Course:PSYC537/2010WT1/Vignette3
VIGNETTE 3
You have worked for many years with a client with amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease). ALS is a progressive, fatal, neurodegenerative disease caused by the degeneration of motor neurons, the nerve cells in the central nervous system that control voluntary muscle movement. Although the motor degeneration is usually pervasive, cognitive function is spared. Your client is in the final stages of the disease and has contacted Dr. Jack Kevorkian to arrange for an assisted suicide. Your client shared his plans with you at your most recent session. The client’s family is highly distressed at the prospect of the client committing suicide, think the client is depressed, and have insisted that you intervene to prevent the suicide.
STEP 1: Who are the people potentially affected by decision?
1) Your client
2) The client's family
3) Dr. Kevorkian
4) Yourself
5) Potentially others with ALS (through setting a precedent)
6) Potentially others who wish to commit suicide (also through setting of precedent) (SV)
STEP 2: What are the relevant ethical issues/laws? Which ethical values/laws are in conflict?
There is a conflict between duty to protect, responsible caring, and confidentiality.
The law of Duty to Protect requires the psychologist to attempt to intervene and prevent the client from committing suicide. This, however, conflicts with the principle of responsible caring in the CPA manual. According to this principle, psychologists should respect the ability of clients to make decisions for themselves. It goes further to describe in the value statement that “psychologists should not substitute one person’s opinion about what is in the best interests of another person for that other person’s competent decision making” (page 59). According to this element of responsible caring, the psychologist in this scenario should respect the client’s choice to terminate his life even though his family opposes his decision. Given that the client’s cognitive functioning is intact, there is no reason to doubt that the client’s decision-making is indeed competent from what is described in the vignette.
To complicate this situation further, under the same ethical principle of responsible caring, II.39 states that psychologists should take every reasonable initiative to stop actions by others when they are likely to cause serious physical harm or death. It goes further to recommend that a possible method to do so is to report the action to a family member who can intervene and that this should be done even when a confidential relationship is involved. In accordance to II.39, the psychologist can report the client’s plan to commit suicide to a family member despite that this information was disclosed in a confidential relationship. This brings the ethical value of confidentiality into the conflict as well. If the psychologist follows II.39 and reports the client’s suicide plan to his family member, the psychologist would not be upholding the client’s right to confidentiality. In the same vein, the law of Duty to Protect also clashes with the ethical standard of maintaining the client’s confidentiality.(SC)
STEP 3: How do personal biases, stresses or self-interest affect my choice of action?
- You might be biased against the act of youthenasia and feel it is morally wrong to assist in killing another human being. Alternatively, another bias might be if you see that your client is suffering greatly, you might be inclined to empathize with them and understand their desire to end their life voluntarily, rather than waiting for death to come to them and suffering in the meantime. Also, depending on your personal experiences with family and loved ones, if you have lost someone to suicide, you might be more inclined to side with the family. However, if you have had a loved one suffer through a terminal illness that resulted in a long and painful death, you might be more likely to agree with the client's desired choice of action. Finally, your religious or cultural beliefs might sway to to support or oppose the idea of someone assisting in the suicide of your client. (AA)
STEP 4: Consult with colleagues. --Psychologists must meet a standard of care when performing their professional duties, which is defined as the degree of care which a resonably prudent psychologist should exercise in same or similar circumstances. The failure to meet the standard of care can be considered malpractice. Therefore, an important question the psychologist should ask themselves is what would a colleague do in this situation, without necessarily breaching the confidentiality of the patient when discussing the case with colleagues. However, it is likely that a colleague has not faced such an ethical dilemma before, in which case, consulting with professional consulting service, case laws and previous legal precedents are also good options. (CC)
STEP 5: Develop alternative courses of action.
1) Don't intervene with the client's decision/do nothing
2) Consult with the client and see if they are willing to forgo the assisted suicide and discuss the way they may be feeling, the way the client's family feels and/or any of the following:
a) Perhaps mediate a discussion with the client and their family
b) Perhaps come up with a palliative care alternative to ensure the time they have remaining is optimal.
3) Consult with Dr. Kevorkian without the client to see if he agrees with your assessment of the client's well-being and try to convince him not to go through with the assisted suicide.
4) Don't intervene with the client's decision and consult with family to discuss the client's decision and try to ease the situation from their perspective
5) Depending on the laws in your area regarding assisted suicide, if it is not legal, report Dr. Kevorkian and prevent the client from going through with the assisted suicide. (KA)
STEP 6: Analyze likely short-term, ongoing and long term risks and benefits of each. 1) Risks: The client may go through with the assisted suicide, this will in turn hurt his family, and the family may file a law suit against you. Since you failed to break confidentiality even though the client made it very clear to you they were planning on undergoing assisted suicide it seems likely you would be in some legal trouble and may even lose your liscense Benefits: you don't break confidentiality, you're allowing the client to make his own decision.
2) Risks: the client may still go through with the suicide leading to the risks for option 1 The client may agree not to go through the suicide for the sake of his family despite the fact he may believe its in his best interest and as a result will have to suffer until the very end. Benefits: The client may potentially decide against the suicide protecting you from malpractice, or the client may agree to talk to the family and allow them to be on side with the suicide therefore reducing the risk they will file a law suit against you. You may find a better palliative care option which makes the ending stages a bit easier on the client
3)Risks: Dr. Kevorkian may still go through with your client's suicide resulting in the risks for 1. Benefits: He could potentially change his mind and not go through with the assisted suicide resulting in a happier family and no law suit.
4) Risks: The family may still be very upset over the suicide and they may still file a complaint/ law suit Benefits: They may have more understanding of the client's decision and not sue you
5) Risks: Your client may be very upset that you broke confidentiality, damaging your relationship and potentially affecting his willingness to continue with therapy making the end of his life even worse Benefits: family wont be as upset, wont sue you. (HM)
3) Risks: Even if Dr. Kevorkian decided not to go ahead with the assisted suicide, the client could be quite resentful and upset (especially since the change of plan came about without his involvement). This also stands for option 5.
5) Benefits : Preventing future individuals from finding Dr. Kevorkian’s assisted suicide services, preventing the current situation from taking place for other individuals. (assuming another Dr. is not found to provide these services)
In all cases/options involving a firm stop to the assisted suicide (particularly 5, maybe 3) – Risks: Having a plan for his death may have been giving the client a sense of control over some aspect of his pain and death and a sense of clarity and calm (having come to terms with his circumstances) -- you would have to talk to the client to find out what the motives are. -- In which case, stopping the assisted suicide could lead the client to a complete sense of loss, hopelessness, confusion and even more frustration than prior, fueling his desire for suicide even further. The client may even decide to take his suicide into his own hands, resulting in a potentially dramatically uglier and more painful method of suicide. – In which case, you could still be sued for malpractice. (JK)
STEP 7: Choose course of action after conscientious application of principles.
Assuming that the client's assisted suicide is not scheduled to happen immediately, I think that trying a few different options would be possible.
First, I would arrange to have a follow-up session with the client fairly quickly, to assess for depression and any other physical or emotional symptoms which may be influencing his cognitive abilities. The family may have observed changes in the client's behaviour that I did not witness in therapy, and since it did not seem as though the client had previously discussed ending his/her life, I would want to be sure that the client was considering their options rationally. I also feel it is important that the client's family feel 'heard' in this matter. If I have any doubts as to the client's current cognitive standing, I may refer the client to a physician to rule out any organic causes for depression or cognitive impairments. (All of these things would have to be well documented, due to the risk of being sued for malpractice.) This first step does risk the client becoming frustrated at my lack of apparent support of their choice, however if I emphasize the concern that the family and I have about possible depression, I think that the client will agree with the plan. Should the client be found to be depressed, I would take steps to prevent the assisted suicide and treat the depression (try to contact Dr. Kevorkian and explain that the client is not currently able to make the decision the end their life, inform the client's family that they must keep watch over the client for the time being, create a treatment plan with the client for their depression, refer the client to a psychiatrist for possible medication, etc.,).
Secondly, provided that the client is not depressed and found to be able to rationally consider his/her options, I would want to have a long discussion (more than one session if necessary) about death and suicide with the client, to make sure that they have taken the time to consider everything, including options which may improve their quality of life (as per choice #2, 2b), or even to go through the legal system to try to obtain the legal right to assisted suicide (although the client should be made aware of the previous rulings against assisted suicide in ALS -- see the Rodriguez case from 1993) At each session, it would be important to assess how close the client is to making/attending an appointment with Dr. Kevorkian. If I feel as though the client is still intending to go through with an imminent suicide, I would ask the client if they would feel comfortable having this discussion with one or more members of their family (choice #2a).
If the client agrees to a meeting with their family, I would have to think about whether I am qualified to conduct therapy with a family. If not, I might consider asking permission from the client to bring in another therapist who is more accustomed to family therapy. Hopefully all parties involved will have a chance to explain their reaction to the situation, and why they do/do not support the client's suicide. I would also make sure to go over all of their options -- this includes the option of reporting Dr. Kevorkian to the police (if the client identifies the Dr. in the session with the family, and if this is the Dr.'s real name). Ideally the client and the family will come to some consensus, at which point normal therapy would continue with the client.
If the client does not agree to a meeting with their family, I would try to arrange separate therapy for the family members (#4). In this case, I do not think it would be appropriate for me to conduct the therapy with the family, even if I was qualified to conduct family therapy. The family would likely be angry at the situation, and possibly at me, which would interfere with a productive conversation. They, and perhaps also the client, may expect me to speak on behalf of the client, which would not be appropriate.
After all of these steps (or if I know the suicide is scheduled to happen before I have had a chance to go through all of the steps), if the client is still intending to go through with the suicide, and the family is still vehemently opposed, I may have to report Dr. Kevorkian to the police (#4), because assisted suicide is illegal in BC. I would first obtain legal advice, on whether or not I am obligated to report Dr. Kevorkian's activities. If I am not legally obligated to report, I would not, and I would continue to see the client in therapy. If I was in fact legally obligated to report Dr. Kevorkian's activities, I would first let the client know how I was going to proceed, and give them the opportunity for us to have a discussion about the client's feelings, and explain my legal obligations. I would then call the Crime Stoppers anonymous hotline, and report my suspicions that Dr. Kevorkian was performing assisted suicides, without giving out my client's name or the specifics of the case. (AH)
(NOTE: Please add your opinions to this course of action - I am still really torn... AH)
Anita, I think that overall that is a very wise course of action! I would like to add though that depending on the psychological assessment, if the client is not found to be depressed (or otherwise psychologically or cognitively impaired) -- I would discuss further into his motives for wanting to have an assisted suicide. Plans for assisted suicide may provide the client with a sense of well-being (e.g., sense of control over details of his death, peace knowing exact time of end of life). [I think this may well be the case seeing as the client has held on this long and is only seeking assisted suicide this far into the final stages of the disease when death is imminent in any case]. In which case, I would try not to get in the client's way - that however, as noted above, depends on the legal system and if there are any loop holes in terms of my responsibilities to prevent or report. Of course, all this would have to be heavily documented, emphasizing the responsible caring (respect of client's decisions) side of the debate. I would though heavily encourage the client to talk to his family himself (or with my assistance if requested so) to inform them of his plan and to explain his reasons (in spite of their initial resistance and distress), to allow his family a chance to see his side of the decision, to get used to the idea, to mentally and emotionally prepare for the course of events, and to come to terms with his passing, easing the grievance process. This would also allow the family to plan an appropriate last day together. If the family knew, it would also take the edge off of the possibility of a malpractice complaint. & As Anita noted, I would make arrangements to provide the family with their own therapy, during the process as well as following the client's passing. (JK)
STEP 8: Act with commitment to assume responsibility for consequences. -
STEP 9: Evaluate results of course of action. -
STEP 10: Assume responsibility for consequences, including corrections or re-entry into decision making process if still unresolved. -
STEP 11: Take action, as warranted, to prevent future occurrences. ---There are two primary legal issues in the situation of patient suicide: 1) forseeability and 2) reasonable care, in this case, the psychologist has anticipated the suicide and the risk can be seen as relatively high and imminent. So now it comes down to whether the psychologist will take sufficient steps to protect the patient. As a way of managing similar dilemma in future practice, it is very important to use informed consent with suicidal patients for therapeutic and legal benefits. Basically, the informed consent can serve as a foundation of shared understanding regarding the "ground rules" regarding confidentiality and safety during treatment. Psychologists should carefully discuss with suicidal patients all relevant aspects of treatment, including treatment options and goals, threshold rules regarding confidentiality (e.g., possibility of hospitalization, assisted suicide), emergency availability and procedures, thus providing the patient with critical information about the parameters of the therapy. Again, when dealing with the suicidal patient, as when dealing with any patient, the guiding principle should be to keep the benefit of the patient foremost in our mind. Acting in the patient's best interest is a cornerstone in therapeutic alliance, even if the outcome is poor. Through a strong therapeutic alliance with the patient, the psychologist may be able to enlist in treatment those parts of the patient that still want to live. The important thing is to keep the door open for the patients, arranging alternative treatment or providing family therapy. As psychologists, we cannot simply rely on restrictive treatments (e.g., involuntary hospitalization, unwarranted physical restraint) in an effort to protect ourselves from litigation or criticism. (CC)