Suicide is a difficult subject, both ethically and legally. Challenges, conflicts, and dilemmas can arise that influence the care and treatment of patients. Addressing these problems requires both competence and knowledge about ethical and legal issues related to suicidal ideation and behaviors.
Healthcare providers are facing more and more challenging and complicated ethical situations. From and ethical standpoint, when the welfare of the patient is compromised, healthcare providers must act in the patient’s best interest.
To guide ethical practice, four ethical principles are commonly cited: (1) beneficence (do good), (2) nonmaleficence (do no harm), (3) autonomy (control by the individual), and (4) justice (fairness). However, these traditional bioethical principles can be confusing when applied to the ethics of suicide care. A healthcare providers’ duty to do no harm can contradict a suicidal patient’s autonomy regarding end-of-life decision-making, leading to ethical dilemmas for the provider (Montreuil et al., 2021).
Recent studies have examined the lived experiences and perceptions of various healthcare providers caring for suicidal patients. These studies highlight the various emotional and ethical challenges that accompany caring for this patient population. Two recurrent themes include a desire for additional training on suicide care and concern about the lack of evidence-based clinical guidelines to assist in suicidal patient management (Montreuil et al., 2021).
Ethics-related stress is nothing new. Many nurses and other frontline workers have long perceived limited respect for their work and describe increased dissatisfaction with their work situations. According to the National Council of State Boards of Nursing, nearly 100,000 nurses say they are considering leaving the profession for other jobs.
Although the COVID-19 pandemic has exacerbated many of these trends, it is often not the root cause of the problem, nor are the issues isolated to the United States. In fact, the main drivers of nurses’ intent to leave are frequently identified as more durable issues or problems, such as insufficient staffing levels, desire for higher pay, not feeling listened to or supported at work, and the emotional toll of the job (Martin et al., 2023).
- Morality: personal values, character, or conduct of individuals within communities and societies.
- Ethical principle: a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action.
- Code of ethics: describes the obligations, values, and ideals for a profession.
Montreuil et al., 2021
Ethical Issues During COVID
COVID-19 has been a uniquely traumatic experience for the health workforce and their families, pushing them past their breaking point. We owe them a debt of gratitude and action. And if we fail to act, we will place our nation’s health at risk.
Surgeon General Vivek Murthy May 23, 2022
During the COVID pandemic, nurses and other healthcare providers were faced with uncertainty and trauma. This was related to caring for patients with COVID-19, inadvertently killing patients due to crisis workloads, contracting COVID-19, the risk of transmitting COVID to family members, and job loss. Political unrest and financial upsets also contributed to a feeling of uncertainty (James et al., 2023).
The COVID pandemic subjected people to serious restrictions of their liberties: quarantine and mask requirements, vaccine mandates, closed borders, curfews, and restrictions on free movement. Events and gatherings were banned, and visitors were denied access to healthcare facilities, even when spouses, family members, and friends were seriously sick or dying. Contact tracing required people to reveal personal information and many people were prevented from attending school or going to work (Biller-Andorno and Spitale, 2022).
Ethical issues related to equity and fairness—especially access to scare resources such as healthcare services, equipment, medications, and vaccines—became complex issues at every level and in every country. Key considerations emerged related to maximizing utility, nondiscrimination, fairness, and protection of vulnerable groups (Biller-Andorno and Spitale, 2022).
The pandemic and its management put high demands on public trust. Particularly in the early phase, there was a lack of evidence related to infection rates, treatments, preventive measures, case fatality rates, or risk factors. The lack of high-quality evidence contrasted with the abundance of mis- and disinformation, especially on social media (Biller-Andorno and Spitale, 2022).
Healthcare professionals experienced situations that violated their moral codes and values. They were asked to make difficult ethical decisions that often ran counter to their training and their fundamental concern for the wellbeing of their patients. They often had to set aside patient care to perform other tasks related to the pandemic. They had to keep up to date with public health guidelines, such as when to place COVID-19 patients in isolation, when to sedate them, or admit them to intensive care. Some of these practices went against the moral principles underpinning ethical care. The severity and gravity of the pandemic led to ethical conflicts and chronic stress, emotional exhaustion, depersonalization, and a lack of personal fulfilment (Muñoz-Quiles et al., 2022).
Many healthcare professionals experienced frequent ethical conflicts accompanied by intense concern and distress. These ethical conflicts were related to a lack of resources and a sense of powerlessness. Frequent exposure to potentially harmful events often increased depression, anxiety, psychological distress, and poor sleep quality (Muñoz-Quiles et al., 2022).
Training in ethical conflicts and moral deliberation in teams is one of the key strategies needed to address day-to-day care and to handle future situations that are similar to the COVID-19 pandemic. Building moral resilience and developing the ability to maintain or restore personal integrity in the face of moral adversity is a valuable personal resource in response to moral and ethical conflicts (Muñoz-Quiles et al., 2022).
What every single lawyer does is send for the records and goes through the records with a fine-toothed comb. Many cases fall into a category I call ignoring the obvious. Ignoring the obvious is often reflected in either inadequate suicide assessments or risky medication practices. And again, as you've heard over and over, no matter how good the care, if it isn't written down it didn't happen.
Susan Stefan, 2019
Nurses can be reprimanded or have their licenses revoked for not following the Nurse Practice Act in the state they are practicing. They can also be held legally liable for negligence, malpractice, or breach of patient confidentiality when providing patient care. Legal issues can arise related to failure to assess, insufficient monitoring, failure to communicate, and failure to follow protocols (Ernstmeyer and Christman, 2021).
Laws allowing full scope of practice for nurse practitioners and greater ease of practice for RNs have been associated with lower population-level rates of suicide and homicide. These findings suggest that laws favorable to full nursing practice have a protective relationship to population health, including injuries (Choi et al., 2020).
Reasonable and Prudent Care
Reasonable and prudent care means a nurse uses good judgment in providing nursing care according to accepted standards and that another nurse with similar education and experience in similar circumstances would provide. In the context of suicidal behaviors, reasonable and prudent involves:
- Systematically assessing and formulating risk.
- Protecting the patient from self-harm.
- Developing a treatment plan to reduce assessed risk.
- Implementing the treatment plan.
- Evaluating progress and revising or modifying treatment plan as needed.
- Recognizing the need for follow-up and continuity of care.
Standard of care is a legal concept that describes what is expected of a reasonable and prudent healthcare practitioner. It means a provider is reasonably competent and reasonably aware of suicide literature. It means a provider has done a systematic suicide assessment, getting all the information needed to protect a patient. Professional judgment can fall below the accepted standard of care when the nurse or clinician:
- Kept poor records.
- Has no documented reasoning.
- Did not “think on the record.”
- Has no reasonable explanations for the failure to intervene and protect the patient.
- Engaged in standard care (everyone does it) v. standard of care.
Simpson, Berman, Stefan, 2015
To avoid the risk of jeopardizing—or even losing a nursing license—it is essential that nurses (and nursing students) follow the scope and standards of practice set forth by their state’s Nurse Practice Act as well as their organization’s policies, procedures, and protocols (Ernstmeyer & Christman, 2021).
For patients who screen positive for suicide ideation and deny or minimize suicide risk or decline treatment, obtain corroborating information by requesting the patient's permission to contact friends, family, or outpatient treatment providers. If the patient declines consent, HIPAA permits a clinician to make these contacts without the patient's permission when the clinician believes the patient may be a danger to self or others.
Sentinel Event Alert, The Joint Commission, Issue 56, February 24, 2016
Patient confidentiality is a major legal consideration—especially in the event of a co-worker’s suicide or suicide attempt. Every person has the right to have personal, identifiable medical information kept private. This right is protected by federal regulations under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA regulations extend beyond medical records and apply to patient information shared with others (Ernstmeyer & Christman, 2021).
Posting to social media sites has the potential to put nurses and other healthcare providers in legal jeopardy. Information related to co-workers, patients, patient care, or the healthcare organization should never be posted on social media. Healthcare workers (and students) who violate this guideline can lose their jobs, may face legal action, or can be disciplined or expelled from their nursing program (Ernstmeyer & Christman, 2021).