Suicide

Paramedics are called to the scene of a possible drug overdose by a man who told them that his wife had taken 50 sleeping pills about 15 minutes earlier. When the paramedics arrive, they find the woman waiting for them in the living room. She denies her husband's allegations and states that he is trying to "lock her up" so he can run off with another woman. She refuses transport to the hospital. The paramedics call the emergency department to consult with their base station physician. What should he advise?

Comment: If the paramedics wait until the drugs are absorbed and the patient shows signs of coma and respiratory depression, the risk of the patient's dying is increased.


This case illustrates several important points regarding patient competence and a person's "right" to self-destruction. It is further complicated by the physician not know­ing whether the patient has taken an overdose of sleeping pills or is being manipulated by her husband for ulterior motives.

Commentary

This case seems troublesome because it combines two distinct sources of puzzle­ment. To the traditional conflict between our paternalistic inclinations and our respect for personal liberty, it adds an overlay of extraordinary uncertainty about what is de­scriptively true of the situation in question.

The typical conundrum involving paternalism and autonomy provides a choice between one course of action that is clearly in a subject's best interest and a different course of action that is preferred by the subject. That is the kind of case we would confront if a subject who unquestionably took a lethal dose of sedatives, attempting for bad reasons to commit suicide, then refused, with no signs of mental incompetence, to cooperate with emergency measures aimed at averting death.


In such a case, the pure antipaternalist would counsel respect for the subject's expressed preferences and would disapprove, perhaps with great sadness, of any coercive attempts at rescue. But few of us would carry our respect for autonomy that far. If persuasion fails, we are more likely to support a coercive rescue attempt and hope to sort it all out later.

GOOD AND BAD REASONS FOR SUICIDE


In saying this, I place substantial weight on the hypothesis of bad reasons. I presume there can be good reasons as well as bad; I further presume that it may often be very hard to tell of a given case how good or bad the reasons are. But surely there can be cases in which the reasons are bad and clearly so; in such cases, at least, there is broad support for intervention.

Where the reasons seem compelling, as might be the case with a rational patient who is terminally ill and in intractable pain, we find intervention much harder to justify. For some of us, a categorical injunction against suicide always justifies intervention.


But for those even slightly less doctrinaire, there can be cases where intervention of a coercive kind violates our respect for personal autonomy more than it serves our belief in benevolence. Yet here we do not really have an illustration of the triumph of autonomy over paternalism, for in these cases we are not convinced that intervention really does serve the subject's best interests.

REASONS FOR INTERVENING


Finding such cases, that is, cases that convince us that intervention serves the subject's interests but that incline us all the same to respect autonomy by withholding intervention, is not easy, for although it is true that we recognize a continuum of cases ranging from those in which we unhesitatingly support intervention to those in which we see it as unwarranted cruelty, that continuum does not reveal a shift in our com­parative valuing of beneficence and autonomy.

Rather, it reflects an underlying contin­uum of judgments about the degree to which the subject's interests are violated by self-destruction. We may talk a lot about respect for autonomy and about the right of each person to end his life if he chooses, but our behavior in the face of suicide attempts reveals that we tend strongly to intervene whenever that might be in the subject's interest and to sanction nonintervention only where it seems evident that the subject's interest would not be served by continued life.


Respect for autonomy thus plays a minor role in such decisions, as compared with a utilitarian assessment of expected benefits to be secured by intervention — with the benefit of the doubt accruing heavily to the case for intervention. Why is this so?

In contemplating intervention in a suicide attempt, there are two kinds of mistake we wish to avoid. We want to avoid intervening when we shouldn't, and we want to avoid withholding intervention when we ought to intervene. There is an obvious, radical asymmetry between these two kinds of mistake. The unwarranted intervention may leave the subject offended by the violation of his autonomy as he continues to confront overwhelming despair. But unless he is in protective custody or some analogous situation, his right, such as it is, to end his life remains despite the thwarting of one recent attempt.

When intervention is unjustifiably withheld and the subject therefore dies, all his rights and interests die with him, and there are no second chances for him or for us. This disparity in the seriousness of the two kinds of mistake provides a strong reason to favor intervention — again, if the legitimacy of the underlying disposition to favor utilitarian considerations over pure antipaternalism is assumed.


When we confront a suicide attempt without any specific information about the circumstances that give rise to it, we intervene without misgivings; only a wealth of detailed information about the case could persuade us that to refrain would be appro­priate. A sketchy account of those circumstances would not suffice; we know how fallible our conclusions are about the wellsprings of motivation for drastic action. That knowl­edge combined with our respect for the value of life produces a strong disposition to intervene.

There is another reason, as well. To acknowledge that a would-be suicide has reasoned correctly is to acknowledge that for her, life among us is not worth living. It is to acknowledge that we have failed to respond to her desperation in any effective way. She may be a stranger to us, one for whom we have no specific responsibility.

Yet, we see her plight as constituting an isolation and abandonment that at once shames us and terrifies us. If we agree that her life no longer has value, we tacitly admit our failure to connect with it, to enrich it, to bring value to it. And we suspect that, for one reason or another, more is incumbent on us than accepting that failure.


We also see in her plight a possible plight of our own. It isn't that we expect to face despair or even think there is any significant chance that we will. It is the mere possibility that reminds us of the dependence of our well-being on our relationships with others and, in that reminding, impels us to acknowledge a relationship with her and a commitment to try to help her.

ADDITIONAL PROBLEM OF UNCERTAINTY IN THIS CASE


In this case, all these features are present. In addition, there is the uncertainty about whether the suicide attempt is real, as the husband claims, or fictional, as the wife asserts. There is no problem here unless we would intervene if given confirmation that the husband's account is true. For the pure antipaternalist, therefore, the disagreement between husband and wife has no bearing on the case. The proper judgment is insensitive to information about which one is lying; the case against intervention is robust, given that the wife declines to cooperate with the paramedics.

For the rest of us, the dispute is relevant. If we could confirm that the wife's account is true, we would advise the paramedics to depart, leaving the unhappy couple to soldier on in their marital battlefield as best they can. It might be worth a parting admonition that they need a social service agency or mental health professional, rather than a paramedic, but there would be no remaining question of taking the wife away against her will.


If we could confirm the husband's account, I presume that, for reasons of the sort discussed above, we would favor intervention. There are practical problems here, to be sure. If the wife is passively resistant, neither consenting nor engaging in battle, she can simply be carted off to the hospital. If she is well-defended and actively opposing the rescue attempt, there may be little choice but to wait until the drugs blunt her belligerence.

There is surely a question about how much personal risk a paramedic should be expected to undergo in the attempt to rescue a hostile subject; if the wife fights them off with slings and arrows, they can hardly be faulted for letting self-protective caution override their desire to get her quickly to a hospital. The case description emphasizes that delay will reduce the chances of saving the woman's life. With other things being equal, this provides a reason for acting swiftly and for coercive intervention rather than delay in the name of respecting autonomy.

But other things are not equal if the woman, in fighting back, poses a serious threat to the paramedics. In that case, the judgment about what to do would be heavily dependent on the details of what is happening at the time. The case description tells us nothing of such details.


What it does tell us is that we have no confirmation of either the husband's or the wife's story. We do not know which story is true, and yet we must decide how to respond. What are the costs we would like to avoid in this situation?

If the wife has not attempted suicide, a despicable fraud has been perpetrated against her by her husband. If, in addition, she is hauled away by the paramedics, injury will have been added to insult, as her autonomy is overridden not to her benefit but contrary to it. That is a seriously undesirable outcome, which is why it is so frustrating to be unable to discern which of the two conflicting stories is true.

Yet, if the wife has taken the pills, an even worse outcome is in prospect. If we hesitate, because of uncertainty, until the symptoms are visible, the woman may die. And given our reasons in favor of intervention — except in extraordinary cases of a character we have no reason to think is present in this case — we dread the thought that our hesitancy could be a substantial contributing cause of a preventable death.

In confronting this case, the paramedics should first do all that can immediately be done to determine the truth. If they detect inconsistencies in the stories of husband or wife, a bit of pressure on those points might prompt revision of the false story. If they do not, the husband can be warned of certain discovery and a liability to prosecution or to civil litigation for fraudulent appropriation of services if his story is false.


If he stands his ground, the paramedics should confirm his willingness to assist them and to accompany them to the hospital. If it appears that he simply wants them to take his wife away, that would cast doubt on his veracity. Finally, the paramedics should attempt to persuade the wife to go with them to the hospital, on the grounds that if her story is true, and her husband accompanies them, she has little to lose and vindication to gain.

It is useful to be explicit about the difference between the situation in which we know the wife has taken the pills and the situation in which there is uncertainty. In the first case, we intervene, but at the cost of overriding the women's expressed preferences.

We recognize that as a cost, but it is one we are willing to incur as the necessary price of avoiding the least desirable outcome. If we intervene without being confident that the woman is at mortal risk, we do so with the same objective. What makes the case different is that the cost may be much greater.

We may be overriding her expressed preferences, in unwitting complicity with her malevolent husband, when she is not even at risk. Even so, the radical asymmetry between the two kinds of mistake remains. The cost of intervention may be much higher, but it is still the price that must be paid to rule out the most disastrous outcome.


I believe that this account reconstructs the way we generally think about intervention in suicide attempts; I also believe it is a correct way of thinking. It is compatible with acknowledging the possibility of rational suicide and with recognizing instances in which intervention must be withheld. And it is defensible not merely on utilitarian grounds of maximizing human welfare but also on grounds of maximizing autonomy, for many of those whose suicide attempts are thwarted go on to lead well-functioning, autonomous lives.

APPEALS TO THE LAW


It is, of course, relevant what legal constraints apply to the case. If prevailing law prohibits coercive intervention in such cases, the paramedics face a choice between abandoning their rescue attempt and proceeding at some legal peril.

Since the case description is silent on the matter of applicable laws, it is impossible to assess their proper impact on the disposition of the case. In any event, the question of what the law allows, encourages, permits, or forbids should not be asked in the initial stages of determining what ought to be done. Rather, it is best to identify, if one can, what course of action is supported by the strongest moral case and only then to inquire whether that determination requires correction in light of the law.

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