Tuesday, September 15, 2015

Ethics and suicide: Are we paying attention to the important issues?

by Victoria Saigle and Eric Racine, Ph.D.

Eric Racine, Ph.D.

Victoria Saigle is a graduate student at the Institut de recherches cliniques de Montréal's Neuroethics Research Unit. She is a completing her MSc in Experimental Medicine at McGill University through the Biomedical Ethics Unit. 

Dr. Eric Racine is the director of the Neuroethics Research Unit at the Institut de recherches cliniques de Montréal and holds academic appointments in the Department of Medicine and the Department of Social and Preventive Medicine at Université de Montréal and in the Department of Neurology and Neurosurgery, the Department of Medicine, and the Biomedical Ethics Unit at McGill University. He is also a member of the AJOB Neuroscience Editorial Board.

Discussing suicide can be difficult in clinical, public, and academic settings because many people have strong intuitions about which, when, and whether voluntary death is appropriate. However, discussions about suicide are largely absent from bioethics scholarship. Considering that suicide is among the ten most common causes of death worldwide and the second leading cause of death for individuals aged 15-29 (World Health Organization, 2014), it is surprising that more attention is not devoted to this topic.

Victoria Saigle
Ethical dilemmas related to suicide intersect with important questions in research ethics, clinical ethics, and public health ethics. However, we discovered in recent work that the majority of ethics scholarship on voluntary death focuses either entirely on physician-assisted dying (PAD – a term we are using here to describe many different acts in which a physician helps to hasten death at a patient’s request) or consists of philosophical arguments about the acceptability or rationality of suicide. Though interesting, these topics do little to address the challenges and lived experiences of suicidal individuals, their families, suicide researchers, or health professionals. Below, we will delineate aspects of suicide that deserve more attention.

From a research ethics standpoint, multiple studies have reported the challenges of conducting research with individuals who are, or who were previously, suicidal. Likewise, recruiting the loved ones of someone who has died by suicide can be difficult
(Mishara & Weisstub, 2005; Moore, Maple, Mitchell, & Cerel, 2013; Omerov, Steineck, Dyregrov, Runeson, & Nyberg, 2014). While it is important to exercise great care and sensitivity when involving these individuals in research, efforts should be made within ethics scholarship to examine what factors contribute to suicide research challenges and to develop solutions when possible. Not doing so risks building barriers to research in an area in need of more evidence. Complications posed by the involvement of suicidal individuals and their families in research should be addressed, rather than ignored.

Similarly, suicidality in clinical settings raises a wide range of ethical issues that deserve attention. For example, health professionals may not have received adequate training to deal with suicidal individuals (Osteen, Jacobson, & Sharpe, 2014) or they may be unsure whether breaking confidentiality is appropriate if their patients disclose suicidal ideations (Barrett, 1997). This can lead to unsettling situations in places like emergency departments, where uncertainty is the norm and time is in short supply. Knowing how to respond to repeated attempts of suicide or to situations where there is evidence that the decision to commit suicide was preplanned may also be challenging for clinicians, whose training teaches them to prevent harm. Protecting the well-being of clinicians who interact with suicidal populations, examining organizational responses to suicide disclosure in clinical settings, and ensuring that the interactions between health care professionals and their suicidal patients are appropriate are all examples of issues that could be addressed within clinical ethics.

Finally, further attention should be paid to the strategies used to detect, address, and prevent suicide at a national level. Many people view suicidality to be a symptom of mental disorders, and it is estimated that roughly 90% of individuals who die by suicide have an underlying mental illness (Turecki, 2014). This presumption that the wish to end one’s life and mental illness are related is not novel. In fact, some have suggested that ethical dilemmas in suicide research are often unaddressed because researchers believe that suicidality is a symptom of mental illness that can be removed by curing the underlying disorder (Stanley, 1986). At the moment, treating the presumed mental illness is the most predominant public health strategy for suicide prevention (Mishara & Chagnon, 2011). However, different ways of conceiving of the linkage between mental illness and suicide can lead to the adoption of different prevention strategies. For example, if it is assumed that mental illness causes suicidality directly, treating the mental illness may be the primary method of suicide prevention. If, on the other hand, suicidality is seen as the result of complications one endures due to a mental illness (e.g. unemployment, social problems), then education and efforts to reduce stigma about mental disorders may become the primary strategy (Mishara & Chagnon, 2011). It is important to consider if more than one prevention method should be used and/or if the emphasis on curing mental illness as the sole form of suicide prevention further stigmatizes the act and makes it harder for those experiencing suicidal ideation to seek help (Mishara & Chagnon, 2011).


In sum, it seems that ethics scholarship about suicide neglects many practical ethical issues that are raised by suicide. Our purpose here is not to pass judgment on whether suicide is always right or wrong, moral or immoral, but to draw attention to the fact that these discussions sometimes eclipse more common issues that deserve more attention than they currently receive.

References
Barrett, N. A. (1997). The medical student and the suicidal patient. Journal of Medical Ethics, 23(5), 277–281.
Mishara, B. L., & Chagnon, F. (2011). Understanding the Relationship between Mental Illness and Suicide and the Implications for Suicide Prevention. In R. C. O'Connor, S. Platt, & J. Gordon (Eds.), International Handbook of Suicide Prevention: Research, Policy and Practice: John Wiley & Sons, Ltd.
Mishara, B. L., & Weisstub, D. N. (2005). Ethical and legal issues in suicide research. Int J Law Psychiatry., 28(1), 23-41.
Moore, M., Maple, M., Mitchell, A. M., & Cerel, J. (2013). Challenges and opportunities for suicide bereavement research: the experience of ethical board review. Crisis, 34(5), 297-304.
Omerov, P., Steineck, G., Dyregrov, K., Runeson, B., & Nyberg, U. (2014). The ethics of doing nothing. Suicide-bereavement and research: ethical and methodological considerations. Psychological Medicine, 44(16), 3409-3420.
Osteen, P., Jacobson, J. & Sharpe, T. (2014) Suicide Prevention in Social Work Education: How Prepared Are Social Work Students?, Journal of Social Work Education, 50:2, 349-364
Stanley, B. (1986). Ethical considerations in biological research on suicide. Ann N Y Acad Sci., 487, 42-46. 
Carter v. Canada (Attorney General), 2015 SCC 5, (2015). Retrieved from: https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do
Turecki, G. (2014). The molecular bases of the suicidal brain. Nat Rev Neurosci, 15(12), 802-816.
World Health Organization. (2014). Preventing suicide: A global imperative (pp. 1-92). Switzerland: World Health Organization.


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Saigle, V. and Racine, E. (2015). Ethics and suicide: Are we paying attention to the important issues? The Neuroethics Blog. Retrieved on Retrieved on , from http://www.theneuroethicsblog.com/2015/09/ethics-and-suicide-are-we-paying.html

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