literature about bioethics of suicide in treatment refractory depression?

[bunny cat]

Hi all,
I apologize if there is already a thread addressing this, but I was wondering if anyone can point me in the direction of any good philosophical/bioethical discussions about the physician's approach to a patient expressing SI who appears to have treatment refractory depression. Part of my interest stems from the fact that I'm currently taking our MS4 bioethics course right now, but this has also been something I've been curious about since my psych ED rotation during which we d/c'ed a pt who expressed SI on an almost daily/weekly basis, and if I recall correctly (which I may not be), I thought at least part of the justification was that we were unlikely to change long-term suicide risk in the patient (again, if I recall correctly, the patient was receiving optimal care w/ a h/o of lots of AD trials, ECT, etc, and this was not a case of un/undertreated depression). While I can't wrap my head around the idea of sending someone home who's expressing active SI, I'm not thrilled about the alternative (ie, a pt spends literally the rest of their life on 1-to-1). Would love it if there's a thoughtful discussion addressing this topic. Thanks in advance!

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[kugel]

I'm sure others on this forum (who actually read these things you call..."books") will have better answers, but at our county hospital, we do pretty regularly d/c people who "have little/no likelihood of receiving any additional benefit from locked inpatient care" despite still having SI.

We often do not even admit people with chronic SI. It may sound like a bit of an oxymoron (that's a "dumb bovine," right?) but our philosophy is that there is a demonstrated low risk of actual suicide, since the pt has had SI daily for more than 365 days and has not hurt himself on even one of those. Unless there has been some change in the SI, presence of psychotic symptoms, dramatic new stressor, or some other worrisome change, then he probably does just need support, adjustment or continuation of whatever meds actually help him in any way, and direction to return periodically.

And then, of course, there are those using a complaint of SI to get (enter favorite primary or secondary gain here), whom we refuse to admit, or discharge quickly, because "observations of behavior consistently contradict the complaints of severe depression and the hospital cannot be 'held hostage' by complaints of SI."

 

[VMSmith]

I think something we often forget is how drastic a step it is to involuntarily hospitalize someone. It's not as drastic as incarceration because we're doing it for their benefit (under the parens patria power, where we substitute our hopefully intact judgment for their presumably impaired judgment), but we still are depriving them of their personal liberty and autonomy.

So in order to do so, you need to be reasonably certain that doing so has a significant benefit. If someone is chronically suicidal but not significantly so above their baseline, then there is probably no benefit to hospitalizing them, and therefore depriving someone of their right to personal freedom is not justified.

 

[whopper]

IMHO, there is a small but existing grey area where people want to commit suicide but don't fall under the category of being mentally ill.

For example, imagine someone who wants to die because they feel they've lived their life and that person does not want to experience the effects of a terminal disease they have that will adversely affect them in the near future?

The law, liability, defensive medicine and several other forces push doctors to put that person into a psychiatric hospital. It's a shame.

But to answer your question, I have not seen many sources of literature on this. I did see a movie about an Australian doctor who was teaching people how to perform euthanasia in a safe manner, but at the same time he urged everyone to make sure they were not mentally ill and get medical consultation. Darned, I forgot the name, but it used to be broadcast on the Sundance Channel.

 

[kugel]

The law, liability, defensive medicine and several other forces push doctors to put that person into a psychiatric hospital. It's a shame.

Like the case Whopper mentioned, there are, indeed, times that one could easily argue that the pt is being logical and thoughtful about wanting to die, but I hospitalize him anyway because ...
A) I have a responsibility to protect the hospital in those cases that the law will definitely side with anyone who complains that I should have hospitalized the pt (If the hospital doors close, we can't help anyone)
B) If I don't hospitalize the pt, I might as well just put my license into the shredder and I'll never have the chance to help another pt.

I typically tell the pt both those things, and most understand that it would be foolish of me to do otherwise.

I should note that in those few cases where I get later information, the majority are feeling better (w/o severe SI), and arrive to follow-up appointments (which may indicate that they were not just lying about decreased SI in order to get out of the hospital.