MonashBioethics ReviewVol. IS No.1

DISCUSSION

January 1996

Should all patients who attempt suicide betreated? A reponse to Savulescu

SUSAN BAll.EY

Lecturer in Nursing, Deakin University

Julian Savulescu believes that some patients who attempt suicide ought to be allowedto die, if they are judged to be sufficiently competent and rational. Savulescurecognises the importance of competence as being pivotal to determining whetherpatients ought to be treated, and draws upon the criteria proposed by Buchanan andBrock! in order to explain the requirement of competence. These criteria are that aperson has the capacity for communication and understanding, to reason anddeliberate, and to demonstrate a consistent and stable set of values.

'David', a 35 year old man suffering from chronic leukaemia, is described as anexample of a situation where, argues Savulescu, it is possible to evaluate that acompetent, rational decision to die has been made, and therefore, treatment should bewithheld. This hypothetical example is compared and contrasted with the well-knowncases of John McEwan and Mrs. N., both of whom were widely judged to makecompetent and rational decisions that would lead to their death.

However, the problem with the case of David and the aspect that renders itdifferent from John McEwan and Mrs. N., is the factor of time. To explain further,David ingested Paracetamol "in a sufficient dose to cause death", which probablymeans that he ingested greater than 140mglkg (therefore if he weighed 70 kg, hewould have had to ingest about 20 tablets) . The clinical characteristics ofParacetamoloverdose in the time from a half half to 24 hours following investion are non-specific,but include nausea and vomiting, a feeling of being generally unwell, pallor andsweating. IfDavid is to be treated, it must be commenced as soon as possible. Within24 hours, evidence of liver toxicity becomes apparent and this will continue on topotentially fatal liver necrosis. The efficiency of the antidote (N-acetylcystine) inpreventing death decreases as the time interval between the initial ingestion and theinitiation of treatment increases. The lowest mortality rate is associated with thecommencement of treatment within 10 hours.2

It is reported that David is lucid and orientated, and that there are no symptomsor signs of major depression or psychosis other than his suicide ideation. His cognitivefunction is apparently normal, and he is informed about what would happen to himwere he not treated. He brings a suicide note with him that explains his perception ofthe inevitability of a future poor quality of life. However, it is arguable that within thetime frame allowable, and with the additional (albeit non specific) symptomsassociated with the overdose, it would be impossible to judge whether David wascompetent or making a rational decision . Although it is reported that David exhibits"no signs or symptoms of major depression or psychosis other than suicide ideation,"the chances are that a thorough psychiatric assessment would not be possible in the

MonashBioethics ReviewVol. IS No.1 43 January 1996

Emergency Department. Furthermore it is widely known that people suffering fromdepression are often observed to be in an uplifted mood once they've made thedecision to die - they feel as though all their worries will soon be over. Also the factthat David actually made it alive to the Emergency Department would plant anotherseed of doubt. because it is frequently the case that people raise the alarm themselvesas they suffer late misgivings or a change of heart about ending their time on earth(and this is despite a suicide note providing superficially plausible reasons for theiraction). Of course, David may have simply had the bad luck to be discovered beforedeath.

Because of the time factor, David's situation is not analogous to that of JohnMcEwan or Mrs. N., because judgements regarding competency in their respectivecases were made over days. In the case of Mrs. N., as I was employed as a clinicaleducator within the particular intensive care unit at the time of her stay, I canpersonally testify that this process was extremely thorough, careful, and involved herfamily. Compared to this situation, it is not possible to understand how therequirement for consistency and stability of values in David's case could bedetermined within the short period of time between his arrival in the department andthe onset of irreparable liver damage.

In asking the question "Is suicide different?" Savulescu makes the comparisonbetween suicide and other forms of self-abuse. However, although alcoholism (hisexample) may ultimately be a one-way trip, it is certainly arguable that an alcoholicdoes not have the same intent associated with his behaviour, nor the same immediacyof ultimate outcome, as the person attempting suicide. Savulescu argues that it isinconsistent that society chooses not to interfere with chronic alcoholics and yetinterferes with people attempting suicide, yet what is actually inconsistent is theanalogy employed here. It would be appropriate to compare alcoholism with obesity orspeeding (or any other "self abuse" behaviours where death is not the purpose of thebehaviour). A more appropriate analogy to this ethical dilemma is that of theresponsibility of actively treating people in an emergency situation who have animmediately life threatening problem (for example, a heart attack or massivebleeding), where the patient is not competent (often because they are unconscious),and where no family are present. The patient mayor may not wish to be resuscitated,but as it is impossible to determine, and as non-treatment will no doubt result indeath, the imperative is to resuscitate. At times, of course, resuscitation results in aprolonged dying process or poor quality of life following recovery, and at times itresults in restoration to wellness. The point is, however, that doctors, nurses andambulance officers working in the emergency setting, without the luxury of timeand/or a crystal ball, must morally and legally attempt to resuscitate.

Savulescu believes that there are many reasons why we are reluctant to letpatients who attempt suicide die, suggesting that it may'still be thought of as a crimeor a sin, or a symptom of mental illness. I would argue that it is not a 'reluctance ' assuch, but that it is wrong to allow someone to die where there is reasonable doubtabout their competence to make this irreversible decision.

1. Buchanan, A. & Brock, D. Deciding for others. Milbank Q 1986; 64 Suppl 2: 17-94.2. Linden, C., & Rumack, B. Acetaminophen Poisoning. in Tintanalli, J., Krome, R. & Ruitz, E. (Eds.)

EmergencyMedicine, McGraw-Hili Inc. USA., 1992, pp.S93-S97.

MonashBioethicsReviewVol. IS No.1

Response to Bailey

JULIAN SAVULESCU

44 JanlWY1996

Sir Robert MenziesScholar in Medicine, Centre for Human Bioethics, MonashUniversityand VISiting Fellow,Subfacultyof Philosophy, Universityof Oxford,U.K.

Bailey is right to claim that the case of David differs from the cases of McEwan andMrs N. In the former, competence would have to be determined in hours, in the latter,it was evaluated over days. Is this relevant?

Bailey's claim seems to be that we cannot evaluate, over several hours, thecompetence of a person who has taken a panadol overdose and who may be nauseated.,vomiting, pale and sweating. That is an empirical claim. She provides no evidence tosupport it.

Let's assume that this claim is true (though I myself doubt it). What follows?Bailey concludes that health care providers "working in the emergency setting,without the luxury of time and/or a crystal ball, must morally and legally attemt toresuscitate ." For this conclusion to follow, a much stronger claim would have to betrue. It would have to be true that it is either conceptually impossible to evaluatecompetence over a period of hours or that, as a matter of empirical fact, such anevaluation is impossible given the limitations of human judgement, the skills ofgathering the relevant psychological information and so on. I cannot see how either ofthese claims is true. My claim was a conditional one, if competence can be evaluatedthen it should be evaluated. I said that if there is no time to evaluate the competence ofa patient who attempted suicide, that patient should be treated. It seems to me possiblethat there will be cases in which such evaluation is possible. If David is not such anexample, my argument is directed towards these others.

Indeed, there seems to me to be one class of patients in whom such evaluation iseminently possible: patients who have been successfully resuscitated after a suicideattempt. Some of these go on to repeat an attempt of suicide. If a patient issuccessfully resuscitated after a suicide attempt, we should make an effort to evaluatewhether he or she continues to want to die after regaining competence. There seems tome less justification in resuscitating a patient a second time who has expressed acompetent desire to die in the past, and has demonstrated resolve by taking steps toend his/or her life at least twice.

The general issue of evaluating whether a person competently desires to diecould be assisted by encouraging the use of advance directives. This might beparticularly useful in those who have attempted suicide, but have been successfullyresuscitated and clearly competently now desire to die.

Bailey claims that my analogy between suicide attempt and alcoholism is"inconsistent". This is based on a difference in "intent" or "purpose". Bailey seemsattracted to the intention/foresight distinction, or doctrine of double effect. I myselffind nothing attractive in that doctrine. Her own "more appropriate analogy" ofattempted suicide is of an incompetent person who has suffered a life-threateningheart attack. This case begs the question: the very issue is whether the person whoattempts suicide is competent. The more appropriate analogy should be of a personwho has had a heart attack and who is of questionable competence. If it were possible(within time constraints) to evaluate the competence of a patient who has suffered a

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heart attack, we should do so, since if the patient is competent, we should seek his orher consent for treatment. The patient might refuse, in which case it would beunethical to administer it, and a battery in law.