3.3.2 Harm to Self. Educational Objectives. Case. Questions. Mona Gupta, MD CM, FRCPC, MA. Updated December 23, 2013

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1 3.3.2 Harm to Self Mona Gupta, MD CM, FRCPC, MA Updated December 23, 2013 Educational Objectives 1. To consider one's ethical responsibilities in situations where a patient has threatened to harm, or has actually harmed him- or herself in the context of suffering from a mental disorder. 2. To become aware of the relevant medico-legal mechanisms available when one encounters a patient who has threatened to harm or has harmed him- or herself in the context of suffering from a mental disorder. Case Sarah is a 36-year-old woman who is employed as a grade 3 teacher. She is single and has no children. She is brought to the ER of a general hospital by her friend Diane. The triage nurse's notes state that the patient has no real chief complaint. However, Diane spoke to the triage nurse herself, saying that she believes Sarah is thinking of killing herself. Both Sarah and Diane are seated in the examination room. Sarah is dressed shabbily in worn and lightly stained clothing. Her face is gaunt and pale. Her hair is messy. She looks at the physician when she enters, but does not speak. The physician introduces herself and Sarah says "Hi." When asked why she has come to the ER, she points to Diane and says, "It was her idea." Diane tells the physician that she is a colleague of Sarah's. They are friends, but not close. It being the summer they are not seeing each other at work every day, but do get together every couple of weeks. Diane reports that Sarah has two brothers who live in other provinces. Her elderly parents are away on an extended trip. Sarah has a few other friends whom Diane does not know well. Diane became concerned when Sarah stopped returning her calls and s. Eventually she went to Sarah's apartment. Sarah let Diane inside, and Diane noticed that the blinds were drawn and the place was quite untidy. Diane asked Sarah what was going on and she said that she just wasn't feeling much like going out. Diane notes that Sarah is usually quite tidy and well-groomed. She is a quiet person, but is usually more talkative than she is at present. Sarah told Diane that, over the last few weeks, she has only gone out to check on her parents' home. Diane offered to accompany her to her parents' home this week. While there, Sarah took a long trip to the washroom. When Diane went to check on her, she found Sarah examining the contents of her parents' medication cabinet closely. She said quietly, "I could just take all of these pills and end it now." Upon hearing this, Diane insisted on bringing Sarah to the ER. When the physician tries to interview Sarah, she provides short and often uninformative answers. She describes her mood as "Ok." She says she has been eating less, but attributes this to the summer heat, which diminishes her appetite. She does not appear psychomotor retarded or agitated. She denies psychotic and manic symptoms. She becomes irritated when asked her about alcohol and substance use, saying, "It is considered healthy to drink a few glasses of wine each day." When asked how many glasses she drinks, she says three, sometimes four. Sarah looks bored when asked other questions related to depression and responds by saying, "What do I have to say to get out of here?" The physician asks her directly whether she has plans to try to harm or kill herself. Sarah replies, "Well, who would miss me? No one but the cat." When Sarah is asked what kind of support she has in her life, she responds that she is a private person and usually keeps things to herself. She insists that she is not the kind of person who feels comfortable with "shrinks." Questions 1. Q1. What are the primary ethical considerations underlying the clinical approach to cases of actual or

2 potential self-harm? 2. Does Sarah have the right to refuse these interventions? 3. Is Sarah's capacity to make treatment decisions relevant to decisions about intervening in situations of selfharm? 4. What rights to confidentiality does an individual have if he or she has threatened to or has harmed him or herself? Discussion The threat of or actual harm to oneself in the context of a mental disorder is a domain that is governed, in part, by legislation. Each province or territory has a law, usually called the Mental Health Act, that lays out criteria and procedures for hospitalizing someone when he or she has threatened to or has actually harmed him or herself, but is not willing to participate in psychiatric treatment. However, involuntary hospitalization is not the only way to approach this clinical situation. The clinical approach and management options in each individual case, will depend on the weighing of several ethical considerations. Cases of harm to self involve consideration of each of the classic principles of ethics: autonomy, beneficence, non-maleficence, and justice. Even when physicians do draw upon mental health legislation to guide them in involuntarily hospitalizing patients who have harmed or threatened to harm themselves, there are many aspects of this clinical intervention that are not and cannot be specified in legislation. Clinical scenarios are too variable and often too complex to be fully codifiable. The questions that follow explore some of the key ethical aspects of the clinical approach to self harm, using the preceding case to provide illustrations. Q1. What mechanisms are available to try to prevent Sarah from harming herself? The least restrictive alternative In intervening in cases where someone has harmed or threatened to harm him or herself, one relies on the concept of the "least restrictive alternative" (LRA). The LRA is an ethical concept that has a clinical application. Specifically, the LRA refers to restricting a person s autonomy as minimally as possible in the course of providing care. Patients may be resistant to, or at least ambivalent about, psychiatric interventions. The LRA attempts to strike a balance between the physician's duty to intervene in order to prevent his or her patient from coming to harm, that is to promote beneficence, and the duty to respect an individual's choices, (even if some choices may lack full autonomy because they are influenced by psychiatric symptoms). At the least intrusive end of the spectrum, the LRA may include discharging a patient home with clinical follow-up, if there are suitable supports in place and/or the patient has appropriate supervision, and if the patient has a relatively low risk of engaging in self-harming behaviour. Clinical assessment The guiding ethical principle underlying a clinical assessment where risk of self-harm is a central issue is beneficence. Even if the patient does not want to be in the ER or to be assessed by a physician concerning these matters, physicians have a duty to act in the patient s interest and preventing harm to self is considered on its face to be in the patient s interest. Thus, the physician must attempt to assess the patient as best as possible making use of all the clinical data available. In this case, it is challenging to assess Sarah's risk of self-harm because she is difficult to interview. For example, she elaborates very little when asked direct questions, she becomes irritated with the interview, and she implies that she will say anything (perhaps even things that are not truthful) in order to expedite her discharge. All of these factors make it difficult to conduct a thorough and accurate clinical assessment. However, by taking into account what she does say as well as what she is unwilling to say, some relevant risk factors for suicide can be formulated including: a relatively clear suicide plan being to overdose on her parents medications (although it is hard to tell from the details of the case how well developed her planning is and how lethal the means are); drinking more than moderately on a regular basis, accompanied by lack of insight of this as a problem; and social isolation. Voluntary hospitalization From a clinical point of view it would be reasonable to offer Sarah a voluntary inpatient hospitalization, both because of her risk factors for a suicide attempt and because her mental status is difficult to assess. During an inpatient admission, there would be multiple opportunities to interact with and evaluate Sarah, therefore, it might

3 be possible to conduct an assessment. In addition, Sarah could be prescribed various psychotherapeutic and pharmaceutical treatments to reduce or contain thoughts and feelings of self-harm, and to develop alternative ways of conceptualizing and solving the problems that are currently making her think of suicide as a solution. A voluntary admission would be less restrictive than an involuntary one, allowing Sarah to have the freedom to come and go during an admission, while the treating team attempts to engage her in psychiatric care. In this case, however, Sarah has implied that she does not wish to remain in hospital and is uncomfortable with psychiatrists. She is therefore unlikely to accept a voluntary admission. Her physician must now consider whether an involuntary admission is legally and ethically permissible, and clinically indicated. Involuntary hospitalization Mental health legislation that permits involuntary assessment and hospitalization is informed by the common-law doctrine of parens patriae the notion that the sovereign (or, in our case, the state) has the authority to protect persons from themselves. At the same time, there are authors who have argued that persons should never be forced into hospital against their will that the right to self determination is always more important than any interest that society may have in protecting people from self-harm. In other words, the question of whether people should be involuntarily hospitalized is a classic conflict between the ethical principles of autonomy and beneficence (acting in someone else's best interest). In Canada, from a public policy point of view, beneficence has been deemed to be more important than autonomy in cases where people are at risk of self-harm. This is because it is believed that self-harm generally occurs in the context of mental disorder, and mental disorder diminishes people's abilities to act autonomously. This necessitates the state to act on their behalf through the powers it delegates to psychiatrists. In some cases, it may be legally acceptable to hospitalize a patient involuntarily, but a physician may decide, on ethical grounds, that the person's autonomy should not be overridden. For example, Sarah has already indicated that she does not want to remain in hospital, and has expressed her discomfort with psychiatry more generally. Her physician may conclude that rather than facilitating the assessment, involuntarily hospitalizing Sarah might make her angry and less willing to cooperate, rendering the admission useless and even potentially traumatizing for her. Even if the physician believes that Sarah's lack of desire for psychiatric involvement is a result of a mental disorder (depression) rather a reflection of an autonomous wish, she might argue that involuntarily hospitalizing Sarah would violate her dignity as a person and thus, not be beneficent. Thus, from an ethical viewpoint, every time a physician decides whether to detain someone involuntarily, he or she must weigh a variety of factors. In addition to the criteria laid out in mental health legislation, these include ethical principles, potential consequences to the patient, and his or her own duties as a healthcare professional. Intermediate settings In some communities, there are intermediate settings such as crisis centres with overnight beds. Such places are not hospitals and, as such, do not fall under the purview of mental health legislation. As a result, patients stay or leave voluntarily. However, such centres may be suitable for helping someone who has thoughts of self-harm, or has even acted on such thoughts, to regain a feeling of safety. These centres provide an alternative both to hospitalization and discharge home, when neither plan is suitable or desirable. However, they can also be used when there are no available psychiatric inpatient beds or when an individual physician believes that an available bed ought not to be offered to a particular patient. In such circumstances, the physician is considering the principle of justice by determining what resources an individual patient needs and deserves. As such, these settings also fill a role in "resource allocation at the bedside." Issues related to resource allocation are beyond the scope of this case, but it is noteworthy that even in clinical scenarios where self-harm is the primary concern, ethical considerations regarding resource allocation may form part of the backdrop of clinical decision-making. Q2. Does Sarah have the right to refuse these interventions? If Sarah is being detained against her will in hospital for an assessment then she does not have the right to refuse the detention. Usually a patient may contact a lawyer, although there is little legal recourse if the paperwork authorizing the involuntary assessment has been completed properly. However, once a person has been formally admitted to hospital against his or her will, mental health legislation allows the patient to challenge the involuntary hospitalization through a formal legal process. In many provinces, this will take place before a review board or review panel while in others, the matter is heard before a court. In either case, the Board or Court has the legal power to reverse a decision to involuntarily hospitalize a patient if it believes that the criteria for an involuntary admission were not met or if hospitalization procedures were not followed in accordance with the legislation. A patient who refuses hospitalization poses both practical and ethical challenges to the treatment team. In many

4 settings that accommodate involuntary patients, ward doors are locked to prevent patients from leaving. This can lead to banging on the doors, shouting, and angry outbursts. Patients can also charge the doors and harass or even assault those who do go in and out. If patients' behaviours become unmanageable or dangerous, patients may have to be restrained physically or chemically (or both) and/or secluded. Such measures can leave feelings of moral disquiet amongst staff because of the worry that these measures may negatively affect the patient and/ or other patients sharing the same ward. For example, restraining a patient can be potentially traumatizing if she feels terrified and/or does not understand what is happening. It can also diminish a person s dignity if she feels humiliated by the show of force. The patient may then feel more hostile towards staff and any further proposed interventions. Clinicians may view these circumstances as contrary to their ethical duty to do no harm as well as being clinically counterproductive. Thus, while mental health legislations provides for measures to involuntarily hospitalize a patient, working with an involuntary patient who is actively and physically protesting his or her detention can be distressing for everyone concerned. It may lead the physician to view her actions as violating the principle of non-maleficence. This may be the case particularly with someone like Sarah, who came to the hospital voluntarily but might find herself detained in hospital against her will. Q3. Is Sarah's capacity to make treatment decisions relevant to decisions about intervening in situations of self-harm? Sarah's capacity to make treatment decisions is not relevant to decisions about hospitalization, except in Saskatchewan. In Saskatchewan, a person has to be incapable of consenting or refusing treatment for the disorder that is leading to the involuntary admission. In all other provinces, the decision about hospitalization is made on the basis of self-harming behaviour or threats of self-harming behaviour. This is regardless of the person's capacity to consent to or refuse treatment, even treatment for the very disorder that is leading to the admission. Legally, patients can be forced to take treatment if: a) they are not capable of refusing treatment and b) consent has been provided by the appropriate substitute decision-maker (in most cases a family member and in some cases, a court-appointed decision-maker where this has been put in place). However, as in the case of involuntary hospitalization, there are practical considerations that may influence whether or not involuntary treatment is carried out. Can the treatment actually be administered against the person s will (e.g in the case of psychiatric medication, is the medication available in an injectable form if the person refuses the oral form? Antidepressants, which might be the most suitable treatment for a depressed, suicidal patient, are only available in oral form.) If the treatment has to be given multiple times for it to be effective, which is usually the case, is it feasible to administer the treatment repeatedly if the patient continues to resist? These practical issues may give rise to ethical debate. Having to restrain a patient repeatedly in order to force a medication upon him may seem to be harmful even if the intention is to promote his best interests (such as symptom relief, a return to decision-making capacity, or discharge from hospital). Furthermore, for those patients who suffer unwanted side effects or for whom treatment is only modestly effective, it may seem that involuntary treatment violates the principle of nonmaleficence. Although not legally necessary in most provinces, physicians may believe that the ethical imperative is stronger to admit on an involuntary basis for a patient who lacks treatment decision-making capacity. A patient who refuses treatment will not experience the autonomy-restoring function of treatment. A physician might be reluctant to admit such a patient against her will thinking that nothing therapeutic can be accomplished if she refuses treatment. On the other hand, if the physician is very worried that a patient like Sarah might make an attempt on her life imminently, hospitalization, even in the absence of treatment, might prevent her from acting. Hospitalization in such circumstances would be based on the principle of beneficence. Q4. What rights to confidentiality does an individual have if he or she has threatened to or has harmed him or herself? A person who has threatened or engaged in self-harm does not forfeit any legal rights to doctor patient confidentiality. The physician should strive to respect a patient's request for privacy. With this in mind, physicians should ask patients for permission before consulting friends or family members for collateral history. In the ER setting, however, it may be clinically necessary to seek collateral history, even if a patient is refusing this contact. It may be legally permissible to do so depending on the province. However, even if this contact is legally permissible, out of respect for the trust that is the basis of honest disclosure between doctor and patient physicians should not disclose any information about a patient's treatment or admission to those outside the treating team (e.g. to family members) without the patient's permission. If a patient lacks decision-making

5 capacity, it is appropriate to include substitute decision-makers in all aspects of decision-making, such as discussions of options for preventing self-harm, specific treatments, and discharge planning. Patients themselves, whether capable or not, may also request that substitutes gather information and be involved in planning appropriate interventions. Conclusion While there are legal procedures in place for the involuntary admission of patients who are at risk of self-harm, these are always subject to interpretation at the clinical front line. A variety of clinical and ethical factors might be taken into consideration, including the patient's decision-making capacity, her diagnosis, her social situation, her past history and experience of psychiatric treatment and hospitalizations, the physician's understanding of his or her duties to patients, and the availability of resources including hospital beds. The manner in which physicians weigh up these individual factors may lead to very different decisions in apparently similar clinical cases. This does not pose an ethical problem, provided that physicians are aware of their legal responsibilities while at the same time, making explicit the various values or principles they have considered in deciding how to intervene. Involving the patient as much as possible, and other members of the healthcare team, helps to ensure that the LRA is chosen. If involuntary measures are necessary then they should be focused on the patient's best interests, avoidance of harm, and on making progress toward voluntary (autonomously chosen) interventions as quickly as possible. References 1. Beauchamp T.L. and Childress J.F. Principles of Biomedical Ethics 7th edn. Oxford: Oxford University Press; Chodoff P. Involuntary hospitalization of the mentally ill as a moral issue. In: Green SA and Bloch S,editors. An Anthology of Psychiatric Ethics. Oxford: Oxford University Press; 2006: pp Szasz T. The case against suicide prevention. In: Green SA and Bloch S, editors. An Anthology of Psychiatric Ethics. Oxford: Oxford University Press; 2006: pp