Preservation of Life and Autonomy

I’ll warn, this is going to be a bit of a dark post. Suicide will be discussed, so read at your own risk.

For my Psychosocial Pathology (diagnostic) class, we had an article reading entitled, After a doomed patient kills himself: A psychiatrist’s reflections” by J Michael Bostwick (Bipolar Disorders 2013: 15: 628-631). So, this article talks about one of the most dreaded aspects about our job as mental health professionals – when a client kills themselves. This is one of those aspects about the job that we all know is possible, especially when you have a client who’s depressed or has thought about suicide, but we tend to not talk about it. I guess the mentality of “it isn’t so unless I speak it” affects all of us, such a good defense mechanism. Most professionals know that this is always possible, and we worry that if it does happen, how are we going to move past it. For many, there will be a period of blaming yourself – what more could I have done to save this individual? There might be denial – they were doomed from the beginning, there was nothing I or anyone could have done. There might even be worry – what are the survivors going to think, am I going to get sued? Out of these fears, some clinicians might decide to hospitalize a client the instant they show any signs that suicide might be lurking. Now, I’m not going to criticize this method; it works for some people, and it’s can be argued that it’s better than having a dead client or being sued for not hospitalizing. However, one thing that we always have to keep in mind is to allow our clients to have and embrace autonomy at all times. In some cases, this might even go so far as to allow our clients the autonomy to choose to end their life. Luckily, I have not had a client commit suicide…yet. My career is still very, very young though, and I have already had clients that I’ve had to pull out that suicide contract and talk about coping skills to prevent them from completing a suicide. But, as one of my professors said, “It’s not a matter of if you’ll have a client commit suicide, it’s a matter of when.” So, thinking now about how I will handle having a client kill themselves will hopefully prepare me for the inevitable future, I do plan to always keep in mind that every client has the autonomy to decide their own destiny, even if this includes taking their own life. Here is one of my favorite lines from this article, as he quotes A. Warsop, and it sums up the dilemma we face when working with people who suffer from mental illnesses and incredibly painful experiences:

“..a physician ‘is forced to reconcile the obligation to save life with the obligation not to infringe [upon] a person’s autonomy.'”

While we must all find a way to reconcile these conflicting pulls, Bostwick later states,

“ must always remain our duty to do our best to fight on the side of life until the bitter end.”

With that, take a look at the article (below), and let me know your thoughts. Hopefully, all of us mental health workers will be able to find a way to work through the emotions we’ll have about a client committing suicide before it happens. I’ll leave you with a paraphrase from the same professor I quoted above that really moved me and gave me a new perspective on suicide:

Everyone has multiple parts, all working towards doing the best they can for us. Sometimes we have a part of us that wants us to end our life. This part is not working against us, rather it knows that what we’re dealing with is too much and it wants us to be free from the pain.

After a Doomed Patient Kills Himself: A Psychiatrist’s Reflections


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