Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients

Abstract

Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15–24 years. The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment, we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched. Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity.

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The American Journal of Bioethics
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Reweighing the Ethical Tradeoffs in the
Involuntary Hospitalization of Suicidal Patients
Adam Borecky, Calvin Thomsen & Alex Dubov
To cite this article: Adam Borecky, Calvin Thomsen & Alex Dubov (2019) Reweighing the Ethical
Tradeoffs in the Involuntary Hospitalization of Suicidal Patients, The American Journal of Bioethics,
19:10, 71-83, DOI: 10.1080/15265161.2019.1654557
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Target Article
Reweighing the Ethical Tradeoffs in the
Involuntary Hospitalization of
Suicidal Patients
Adam Borecky, Loma Linda University
Calvin Thomsen, Loma Linda University
Alex Dubov, Loma Linda University
Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15–24 years.
The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by
the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of
involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this
practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment,
we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched.
Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion
and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to
reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize
and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive
hospitalization of suicidal individuals to those who lack decision-making capacity.
Keywords: decision making; health policy; informed consent; mental health; psychiatry/psychology; professional–patient
relationship
INTRODUCTION
The modern practice of involuntary hospitalization fol-
lows a “dangerousness standard,”commonly interpreted
to refer to an imminent likelihood of suicide, homicide,
or being so “gravely disabled”to represent a likely harm
to oneself. This standard of care has been justified as a
necessary subordination of a patient’s freedom to pro-
mote the patient’s long-term benefit; however, well-
established practices founded on good intentions often
have unrealized harms that undermine the intended ben-
efits. For instance, a subset of suicidal patients might
benefit more from increased freedom rather than from
its sacrifice. The traditional framework of viewing a psy-
chiatric patient’s freedom and well-being as mutually
exclusive may thus be inappropriately narrow for some
patients and may be doing more harm than good. In the
case of the suicidal patient, personal responsibility and
safety may sometimes be reinforcing rather than
in conflict.
We propose modifying the clinical and legal stand-
ards of care to consider cases in which a suicidal patient
might benefit more from enhanced autonomy than from
its sacrifice. To better elaborate such cases and their eth-
ical implications, we begin with an overview of the sui-
cide literature and the practice of involuntary
hospitalization, and trace the emergence of the current
standard of care. For some patients, any protective bene-
fit afforded by involuntary hospitalization may be out-
weighed by the additional stress of hospitalization,
exacerbating the already present suicidal diathesis.
SUICIDE STATISTICS FOR THE UNITED STATES
Suicidality is the most frequently encountered of all
mental health emergencies (Bongar and Sullivan 2013). It
is estimated that one-third of the general (nonclinical)
population have suicidal thoughts at some point in their
Address correspondence to Adam Borecky, Center for Christian Bioethics, Loma Linda University Adventist Health Sciences
Center, Centennial Complex 3227, 24760 Stewart St., Loma Linda, CA 92350, USA. E-mail: aborecky@llu.edu
ajob 71
The American Journal of Bioethics, 19(10): 71–83, 2019
#2019 Taylor & Francis Group, LLC
ISSN: 1526-5161 print / 1536-0075 online
DOI: 10.1080/15265161.2019.1654557

lives and more than 8 million U.S. adults report serious
suicidality in the past year; what’s more, 2.5 million peo-
ple report making a suicide plan in the past year, and
1.1 million report a suicide attempt in the past year
(Meichenbaum 2005). For every person who dies by sui-
cide, more than 30 others attempt it (McIntosh 2012).
The Centers for Disease Control and Prevention (CDC)
reports that in 2014, suicide was the 10th most common
cause of death in the United States and has been steadily
rising. From 1999 through 2013, the age-adjusted suicide
rate for both males and females and for all ages in the
United States increased 24%, from 10.5 to 13.0 per
100,000 population. Hence, a practicing clinical psycholo-
gist will deal with five suicidal patients per month, while
one in two psychiatrists and one in six clinical psycholo-
gists will experience a patient’s suicide in their profes-
sional careers (McAdams and Foster 2000).
Once a punishable wrong, suicide is now largely
viewed as a product of mental disorders that requires
prevention and intervention (Berman, Jobes, and
Silverman 2006); (Harris and Barraclough 1997). Despite
a link existing between suicide and a diagnosis of anx-
iety, depressive, psychotic, or personality disorders
(Olfson et al. 2017), most persons with a mental disorder
do not engage in suicidal behaviors (Bunney et al. 2002).
This fact hints at the implicit difficulty of identifying the
individual patients at the greatest risk. However, on a
population-wide scale, several risk factors are well estab-
lished. For males, the most common method for suicide
involved firearms (55.4%), while poisoning was most
common for females (34.1%). Recent data show that
60.94% of adults with recent suicide attempts were
female, younger than 40 years (80.38%) (Olfson et al.
2017). Other factors include race (suicide rate for black
Americans is consistently less than half the rate for white
Americans) (McIntosh 2012), sexual orientation (gay,
bisexual, lesbian, and transgender individuals have
much higher rates of both attempted and completed sui-
cides than heterosexual individuals) (Haas et al. 2010),
geography (rural suicides are 1.2 times greater than
urban [Bongar and Sullivan 2013], likely due to differing
rates of firearm possession (Nestadt et al. 2017), occupa-
tion (U.S. veterans, whether or not they have ever served
in combat, are twice as likely to die by suicide than non-
veterans) (Kaplan et al. 2007), education level (higher
among adults with no more than a high school educa-
tion) (Olfson et al. 2017), a history of alcohol or drug
abuse, social isolation, and a history of interpersonal vio-
lence (Curtin et al. 2016).
Suicidal behavior is a complex biopsychosocial phe-
nomena that resists attempts to explain it. Diverse
explanations for suicide exist in the literature, ranging
from biological predisposition (Mann et al. 1999), to reac-
tion to humiliation, helplessness, hopelessness, and guilt
(Beck et al. 2006), to an escape from physical or psycho-
logical pain (Jollant et al. 2011).
BRIEF OVERVIEW OF INVOLUNTARY HOLDS
IN AMERICA
The Western legal tradition rarely holds people respon-
sible for the actions of another, except in cases of suicide
and homicide. Therefore, psychiatry is one of the few
areas of medical practice where the use of coercion is
legally and ethically sanctioned under some conditions
(Riecher-R€
ossler and R€
ossler 1993; Salize and Dressing
2004). Two legal principles have historically been used to
justify the civil commitment of certain individuals: parens
patriae, referring to the English Common Law doctrine
by which the government has a responsibility to inter-
vene for citizens who cannot act in their own best inter-
est, and Police Power, which requires that the state
protect the interests of society, even at the cost of
restricting individual liberties (Testa and West 2010). For
suicidal patients, this beneficence-focused model made
the purpose of hospitalization be to observe the patient
so closely that a suicidal attempt would be impossible
(Bongar and Sullivan 2013). Yet for many critics, early
attempts to maximize patient safety went too far in erod-
ing individual liberties.
The 20th century soon began to see a shift on the
continuum away from patient safety toward personal
freedom. As the nation’s mental institutions emptied, the
legal and clinical standard of care moved from the need-
for-treatment model of justifying civil commitment to a
dangerousness model. The dangerousness standard
required that (1) the person have a mental illness before
they can be hospitalized against their will, and (2) the
person had to pose an imminent threat to the safety of
himself or herself or others or be shown to be
“gravely disabled.”
In 1975, the Supreme Court weighed in with
O’Connor v. Donaldson, and upheld the dangerousness
standard of civil commitment and emphasized that “a
finding of mental illness alone cannot justify a state’s
locking up a person against his will …in custodial con-
finement”(Werth 2001). This ruling has been interpreted
in lower courts and legislation to mean that dangerous-
ness to self or others was a necessary additional require-
ment to the presence of mental illness (Werth 2001). This
new standard of admission criteria created new chal-
lenges for clinicians. Courts and professional societies
needed practical guidelines for deciding when an indi-
vidual patient was truly “dangerous”enough to justify
involuntary hospitalization.
One attempt to clarify this question came from the
supreme court. In 1978, Addington v. Texas, the court
looked at the standard of proof required for a clinician
requesting the involuntary hospitalization of a poten-
tially dangerous psychiatric patient. The court acknowl-
edged the clinician’s challenge in predicting with any
accuracy the “dangerousness”of a patient. The court
thereby shifted the burden of proof for an admitting clin-
ician from “preponderance of the evidence”to “clear
and convincing evidence,”but not as high as “beyond a
The American Journal of Bioethics
72 ajob October, Volume 19, Number 10, 2019

reasonable doubt”(Hays 1989). A few years later, in
1983, the American Psychiatric Association (APA) tried
to clarify what type of clinical evidence constitutes “clear
and convincing evidence”and proposed four guidelines
for state legislation. They proposed that in order to be
eligible for civil commitment, a person must (1) have a
diagnosed mental disorder, (2) lack capacity to make a
reasoned treatment decision, (3) have a treatable condi-
tion, and (4) be likely to harm self or others (Stromberg
and Stone 1983). Most of the state laws that currently
exist can be traced, at least in principle, to these APA
guidelines (Werth 2001).
The dangerousness standard for the civil commit-
ment of suicidal patients guides both state laws and the
current standard of care for clinicians. Every U.S. state
except for two (Missouri and New Jersey) merely allows
a clinician to involuntarily hold a patient that meets the
dangerousness criteria; they do not require it (Werth
2001). In other words, state commitment statutes allow
clinicians to initiate the commitment process when
appropriate, but do not compel them to do so. These
findings contradict the belief of most clinicians that
when a patient is determined to be at high risk of self-
harm, the therapist is mandated by law to try and get
them involuntarily committed (Werth 2001). However, it
is not state statutes but the standard of care in the pro-
fession that remains the standard by which clinicians are
judged in malpractice courts (Werth 2001). It is to this
standard of care and its ethical implications that we
now turn.
ETHICAL CONSIDERATIONS OF THE CURRENT
STANDARD OF CARE
If the patient is judged to be an imminent risk for sui-
cide, then it is considered legally incumbent upon the
clinician to take a directive role in protecting the patient
from committing suicide (Bongar and Sullivan 2013;
Miller and Hanson 2016; Bongar et al. 1998; Reid 2009;
Berman 2006; Fine and Sansone 1990). This attitude of
provider responsibility for a patient’s life continues to be
assumed by legal experts and the public alike (Firth
2018; Miller and Hanson 2016). A survey of families who
had survived the suicide of a loved one found that “a
majority had considered contacting an attorney and 25%
actually did”(Peterson, Luoma, and Dunne 2002). In
contrast to the almost passive acceptance of a potential
for fatal outcome in physical disease, the mentally ill
patient, it seems, is not expected to die (Friedman,
Nestadt, and Prince 2018). In this way, both the legal
and professional standard of care effectively place the
responsibility for the life of a patient known to be sui-
cidal onto the clinician. This standard may influence psy-
chiatric care to be more defensive, with unintended
consequences that may be harmful to patients (Mulder,
Newton-Howes, and Coid 2016;Ho2014). It is our con-
tention that there are underacknowledged harms in
involuntary psychiatric hospitalization that, if acknowl-
edged, should raise the threshold of hospitalization
higher than what the current publicly supported legisla-
tive standard suggests. Some of these potential harms
are next addressed directly, followed by a discussion of
some of the forces that continue to uphold the
status quo.
There May Be Harms to Suicidal Patients Resulting
From the Use of Coercion and the Loss of Autonomy
The Exacerbation of the Suicidal Illness
Some incidents of suicide both during and immediately
following involuntary hospitalization might be due to
factors such as stigma and trauma inherent in the hospi-
talization itself. Such a suicide has been described as a
“nosocomial suicide”(Large et al. 2014). One study
found a statistically strong and dose-dependent relation-
ship between the extent of psychiatric treatment and the
probability of suicide, with admitted patients having
44.3 times the risk of suicide compared to the general
population, with the majority of inpatient suicides occur-
ring soon after admission (Hjorthoj et al. 2014; Winkler
et al. 2015). Indeed, many other studies confirm that dur-
ing psychiatric treatment and recovery, suicidal behavior
and ideation is increased (Deisenhammer et al. 2016; Qin
and Nordentoft 2005; Powell et al. 2018; Pirkis and
Burgess 1998). These associations are most commonly
explained as the result of selection rather than causation,
with patients with more risk factors for suicide appropri-
ately receiving higher levels of psychiatric care. But this
fact should not ignore the possibility that many factors
inherent in inpatient psychiatric care itself could inde-
pendently contribute to at least some of these suicides.
Psychiatric hospitalization is rife with adverse experi-
ences that could be suicidogenic for vulnerable patients.
The use of and experience of coercion through involun-
tary hospitalization has been connected with feelings of
humiliation, which are a risk factor for the development
of mental disorders, specifically depression (Brown,
Harris, and Hepworth 1995; Rooke and Birchwood 1998;
Farmer and McGuffin 2003). The person who commits
suicide in an inpatient setting is typically frightened,
sad, lonely, disaffected, tired from sleepless nights, and
feels that life is hopeless and futile (Martyn 2000; Mann
et al. 1999; Powell et al. 2018). Other studies show that
involuntary hospitalization can lead to feelings of con-
finement and impaired autonomy (Miller and Hanson
2016; Haglund and von Essen 2005; Rosca et al. 2006),
lower satisfaction with care (Rusch et al. 2014), and
deterioration of care (Kjellin et al. 2004). With increasing
duration of hospitalization, some patients reported
increased suicidal preoccupation after they perceived
humiliation and no lasting improvements from inpatient
therapy (Silverman et al. 1994; Miller and Hanson 2016;
Svindseth, Dahl, and Hatling 2007; Baumeister 1997).
Evidence that involuntary hospitalization can exacerbate
Re-weighing the Ethical Trade-offs
October, Volume 19, Number 10, 2019 ajob 73

these suicide risk factors should lead us to reconsider
how readily it is used as an intervention.
The hospitalization-related stigma is another harm
associated with psychiatric hospitalization. One in five
recently discharged adolescents report feeling signifi-
cantly threatened by potential stigma after their hospital-
ization (Moses 2011). The experience of being
hospitalized can be frightening, demoralizing, and
demeaning; it can induce feelings of abandonment,
oppression, and heightened vulnerability (Miller and
Hanson 2016; Thibeault et al. 2010; Lovell 1995). It can
stigmatize the patient in the eyes of the public and nega-
tively affect help-seeking (Miller and Hanson 2016;
Husum et al. 2010; Sailas and Fenton 2000). Other
authors found that shame and self-contempt about being
involuntarily admitted would render individuals with
mental illness more vulnerable to increased self-stigma
and impaired empowerment, which strongly predicted
poorer quality of life and self-esteem (Rusch et al. 2014;
Thibeault et al. 2010). Moreover, the results of a recent
meta-analysis suggested that the symptoms exacerbated
by a psychiatric admission, such as worthlessness, hope-
lessness, anxiety, and depression, are specifically associ-
ated with inpatient suicide (Large et al. 2011). There is
little doubt that suicide is associated with both stigma
(Schomerus et al. 2015) and trauma (Panagioti, Gooding,
and Tarrier 2012) in the general community. Patients’
integrity and self-determination were undermined by
being dependent and being subjected to control and sur-
veillance (Johansson, Skarsater, and Danielson 2009).
Indeed, hospitalization itself can also exacerbate mental
illnesses by promoting regression and dependency
(Knapp and VandeCreek 1983; Gutheil 1990; Alexander
and Bowers 2004). These findings point to the possibility
that the self-contempt and shame associated with coer-
cive hospitalization may rob some vulnerable patients of
the psychological resources needed to overcome their
mental illness, potentially exacerbating their sui-
cidal tendencies.
Notwithstanding these harms, the influence of ward
atmosphere can also be therapeutic. Johansson and
Eklund (2003) suggest that support from staff, program
clarity, and spontaneity, all components of ward atmos-
phere, are essential for the development of a “healing
alliance”between the patient and clinicians. The locked
door has been related to feelings of safety and security
in some patients (Haglund and von Essen 2005;
Hummelvoll and Severinsson 2001). Improving the
atmosphere of a ward does not always need to come at
the cost of reduced safety. Suicidality is treated by
addressing specific individual needs and by addressing
in general the feelings of alienation and hopelessness
(Martyn 2000). Therefore, to the degree that inpatient
wards can achieve these goals, they should be utilized.
Additional studies of how the hospital milieu influences
suicide risk factors should be undertaken so that the
beneficial elements can be maximized and the harmful
elements reduced.
Damaged Therapeutic Relationship
The concept of the therapeutic alliance and its role in
engaging psychiatric patients in treatment are well rec-
ognized as having a strong impact on treatment outcome
(McCabe and Priebe 2004; McCabe et al. 2012; McGuire-
Snieckus et al. 2007; Priebe and McCabe 2006; Priebe and
Mccabe 2008). Several authors have concluded that coer-
cion was the main barrier to the formation of a thera-
peutic relationship in mental health care (Gilburt, Rose,
and Slade 2008; Overholser 1995; Campbell and
Schraiber 1998; Lidz et al. 1995). Fear of involuntary hos-
pitalization is already a major barrier for individuals
with a mental disorders and substance use disorders
engaging in treatment (Sareen et al. 2007). As it stands,
only 35% of individuals who die by suicide received any
psychological or psychiatric treatment (Britton, Williams,
and Conner 2008). For those with past-year suicide idea-
tion, plans, and/or attempts, the rate of mental health
service use across studies was approximately 29.5%
based on weighted averages (Hom et al. 2015). The use
of coercion in mental health care may be one explanation
of patients’reluctance to seek treatment.
Coercion may also undermine therapeutic efficacy in
patients who are already involved with treatment. The
use of coercion has negative effects on the patients
exposed to it (Sorgaard 2004; Svindseth, Dahl, and
Hatling 2007; Blanch and Parrish 1993; Ranieri et al.
2015) and may delay the treatment progress (Kjellin
et al. 2004). In a study by Sheehan and Burns (2011), a
high perceived coercion score by a patient was signifi-
cantly associated with involuntary admission and a poor
rating of the therapeutic relationship with the therapist
that had the patient admitted. Indeed, individuals sub-
jected to coercion may not engage in treatment and may
avoid future contact with mental health services for fear
of being subjected to involuntary care again (Campbell
and Schraiber 1998). Patients with acute suicidal ideation
often perceive involuntary hospitalization as an attempt
to control them, which may inadvertently increase
thoughts of suicide (Britton, Williams, and Conner 2008).
Mistrust of providers or previous negative experiences
may also handicap care by challenging individuals' will-
ingness to fully and honestly disclose symptoms
(Goldston et al. 2008; Moskos et al. 2007). The thera-
peutic relationship between a suicidal patient and a clin-
ician has been emphasized as being critical to restoring a
patient’s sense of well-being and self-worth to address
suicidality (Wettstein 2003; Maris et al. 1992). Coercive
interventions that harm the therapeutic relationship may
thus do more harm than good for suicidal patients.
However, whether a patient was admitted voluntar-
ily or involuntarily is not always a predictor of the qual-
ity of a therapeutic relationship or the perception of
coercion (Gilburt, Rose, and Slade 2008; Sheehan and
The American Journal of Bioethics
74 ajob October, Volume 19, Number 10, 2019

Burns 2011; Thomsen et al. 2018). By reducing patients’
negative, subjective emotions in the admission process, a
clinician can strengthen the chance to achieve better
therapeutic cooperation during the admission and on
possible future admissions (Svindseth, Dahl, and Hatling
2007; Hoge et al. 1997; Hoge et al. 1998). Indeed, there
may be opportunities for interventions to reduce per-
ceived coercion by improving the therapeutic relation-
ship (Sheehan and Burns 2011). The ability of clinicians
to establish and maintain a positive therapeutic relation-
ship can be enhanced through training and supervision
(Gask et al. 2004; Priebe 2000). It is thus important to
balance the immediate clinical benefit of coercive hospi-
talization with the potential damage to the patient’s
future relationship to mental health care (Lidz et al.
2000; Berman 2006).
Inadequate Evidence Exists That a Policy of
Involuntary Hospitalization Is an Effective Method to
Reduce Deaths by Suicide
The assumption that hospitalizing patients involuntarily
is an effective means to prevent suicide in the short term
and overall mental health outcomes in the long term
goes beyond the currently available evidence (Zalsman
et al. 2016). Many restrictive mental health interventions
are based in tradition and theoretical practicality rather
than research (Bowers, Gournay, and Duffy 2000). The
efficacy of closed or locked wards as a suicide preven-
tion technique, for example, is unknown, although it is
known that at least some patients find the experience of
admission to a locked ward distressing (Miller and
Hanson 2016; Large et al. 2014; Hummelvoll and
Severinsson 2001; McAdams and Foster 2000). Formal
one-to-one nursing observation is another widely used
suicide prevention strategy that lacks an evidence base
and is often experienced as intrusive by patients (Miller
and Hanson 2016; Bowers et al. 2008; Manna 2010;
Bowers, Gournay, and Duffy 2000; Hummelvoll and
Severinsson 2001). Furthermore, data indicate that no-
suicide contracts are often ineffective and seen as
manipulative (Drew 1999,2001; Kroll 2000). Even short-
term hospitalization, the gold standard for managing
acute suicidality, is not as effective as it was believed to
be for decreasing suicide or for resolving the patient’s
ambivalence about life and death (King et al. 2001;
Lawrence et al. 2000; Meehan, Kapur, and Hunt 2007;
Zerler 2009; Simon 2006; Silverman et al. 1994; Pokorny
1983). Although the decision to hospitalize a suicidal
patient may alleviate the anxieties of clinicians, family
members, and even the patient, the intervention lacks an
evidence base to conclude that its benefits outweigh
its harms.
Creating evidence-based suicide prevention protocols
is challenging, given the unpredictable nature of suicide,
its low event rate, and the ethical challenge of conduct-
ing clinical trials against the current standard of care.
Bongar and Sullivan (2013) note that, despite decades of
data, there remains a lack of consensus on what signifi-
cance each epidemiological risk factor for suicide has on
an individual patient level. Several ambitious longitu-
dinal studies seeking to predict which individuals in a
cohort would commit suicide proved unsuccessful
(Britton et al. 2011; Pokorny 1983). Indeed, there are no
pathognomonic predictors of suicide or even definitive
“checklists”or psychological tests that consistently pre-
dict suicide completers (Simon 2006; Bongar and
Sullivan 2013). Following a strictly evidence-based plan
of suicide prevention would limit clinicians and policy-
makers to extraclinical actions such as restricting access
to firearms and analgesics, reducing access to hotspots
for suicide by jumping, and increasing school-based
awareness programs or more long-term clinical preven-
tion with pharmacological or psychological treatments
(Zalsman et al. 2016). Absent better evidence-based pre-
diction tools, clinicians have followed trends in clinical
and legal consensus, which have overwhelmingly
favored a low threshold for hospitalization.
Another possible explanation for clinicians’contin-
ued use of involuntary hospitalization for suicidal
patients is the subjugation of therapeutic evidence to
legal pressures. Civil commitment statutes, psychiatric
standards of care, case laws, and managed care protocols
tend to contain “imminence criteria”for patients deemed
to be high risk for suicide (Simon 2006). This means that
failure to properly diagnose clients, take appropriate
protective measures, hospitalize high-risk patients, and
keep them hospitalized until they are no longer at risk
may lead to charges of malpractice. These legal influen-
ces on the standard of care have led to criticisms that
psychiatric practice is becoming influenced by political,
legal, and regulatory factors, rather than scientific evi-
dence (Linde 2010). Clinicians are thus in the precarious
position of being legally responsible for failing at an
extremely demanding task and may reflexively revert to
protective interventions that could be perceived as
unnecessarily controlling or restrictive.
However, the decision to involuntarily hospitalize a
suicidal patient may also come motivated by beneficence
and a genuine desire to help the patient. One source of
evidence overlooked by epidemiological research and
risk prediction algorithms is the personal experience of
an individual clinician with an individual patient in the
context of a therapeutic relationship. Furthermore, there
are highly specific factors in every individual patient
that may precipitate suicidal ideation and that remain
unknown to risk prediction algorithms. This has led
some authors to propose that psychiatry should turn
from dealing in risk scales back toward engagement
with the individual patients and their specific problems
and circumstances, with risk assessments and hospital-
ization being the result of a consensual decision-making
process (Mulder, Newton-Howes, and Coid 2016).
Re-weighing the Ethical Trade-offs
October, Volume 19, Number 10, 2019 ajob 75

With little evidence existing favoring the current
standard of care, evidence for its inadequacy and unin-
tended consequences is growing. Recent decades have
seen an overall trend toward increasing risk of suicide
both during and after discharge from a psychiatric hos-
pital (Chung et al. 2017; Monahan et al. 2001; Lawrence
et al. 2000; Meehan, Kapur, and Hunt 2007). The current
standard of care also has much to gain in securing
engagement and long-term treatment outcomes. One of
the sources of the high suicide rate following hospital
discharge may be a lack of engagement with treatment
on the part of the patient. As it stands, up to 50% of hos-
pitalized suicide attempters refuse recommended out-
patient treatment, and up to 60% drop out after only one
session of therapy (Lizardi and Stanley 2010).
One potential alternative to inpatient psychiatric hos-
pitalization is the practice of outpatient civil commitment
or court-mandated outpatient mental health treatment
(Swanson, Swartz, and Moseley 2017). This practice,
often reserved for adults with severe mental illness,
would guarantee some degree of adherence to outpatient
treatment while avoiding the harms associated with
inpatient treatment. On the other hand, the practice still
involves the use of legal coercion and currently lacks an
evidence base for its efficacy in preventing suicide
(Kisely, Campbell, and O’Reilly 2017). Other interven-
tions that place more of the responsibility for the
patient’s life back with the patient might be helpful in
achieving both a reduction in suicides and improved
engagement with treatment.
The Transfer of Responsibility for the Patient’s Life to
the Clinician May Undermine Therapy by Reducing
Some Patients’Self-Efficacy
Treating the underlying psychological causes of a sui-
cidal crisis may require helping the patient develop an
increased sense of responsibility for their life. In the cur-
rent standard of care, suicide precautions may be used
excessively to protect patients without necessarily giving
them opportunities to make more lasting changes
(Halleck 2012). Involuntary commitment may also
reinforce the notion that the patient is out of control and
needs to be rescued/saved from their suicidal urges. As
a result, the patient’s lack of autonomy and responsibil-
ity for their lives is reinforced (Fine and Sansone 1990).
Meichenbaum (2005) agrees, arguing that if the suicidal
patient relinquishes the responsibility for staying alive to
others, the therapeutic alliance and treatment efficacy
might be compromised. In this way, a patient’s long-
term well-being may be compromised by the sacrifice of
their autonomy in the short term. But such a position
assumes that the patient has the mental capacity to bene-
fit from increased responsibility in the dire moment of a
suicidal crisis. To address this question, we must con-
sider the relationship of suicidality to decision-
making capacity.
Decision-Making Capacity, Competence, and the
Suicidal Patient
It is largely assumed that the presence of mental illness
and suicidality signal the absence of decision-making
capacity (DMC). As Werth (2001) notes, an individual
afflicted with a severe mental disorder may be unable to
pay attention to and assimilate information, or his disor-
ganized thoughts may preclude him from engaging in
anything resembling a rational process. Indeed, another
scholar points out that the complex heterogeneity of psy-
chopathology, irrational cognition, disturbed family sys-
tems, and biological dysfunction that characterize
suicidality makes it difficult to defend a typical suicidal
act as one done autonomously (Berman 2006).
Furthermore, high percentages of individuals who die by
suicide had been diagnosed with a mental illness, par-
ticularly with major DEpression (Blumenthal 1988;
Bongar and Greaney 1994; Harris and Barraclough 1997).
In one large-scale study of suicides, interviews with fam-
ily members and other collaterals revealed that the over-
whelming majority of suicides were associated with
affective or alcohol-related disorders, suggesting that
impaired cognition was present (Robins 1981). In view of
this evidence, many argue that the purpose of involun-
tary hospitalization is to alleviate an acute, transient sui-
cidal illness to restore an individual’s ability to make
autonomous decisions (Berman, Jobes, and Silverman
2006; Johansson and Eklund 2003; Reid 2009). These find-
ings suggest that so-called “rational suicides”made by
fully autonomous individuals are rare at most.
Other commentators object to the equation of severe
mental illness with the absence of DMC. Grisso, Grisso,
and Appelbaum (1998) argue that even the diagnosis of
severe mental disorders such as major depression or
schizophrenia is not sufficient to conclude that a person
is mentally incapacitated. Recent authors echo this point,
suggesting that even suicidality may not necessarily be
driven by mental illness, lack of legal competence, or
lack of mental capacity (Ho 2014; Britton, Williams, and
Conner 2008). Decision-making capacity must be deter-
mined clinically on an individual basis and cannot be
assumed based on diagnosis, the presence of suicidality,
or the refusal of treatment (Stromberg and Stone 1983;
Appelbaum 2007). It has been argued that more attention
should be paid to isolated cases of incompetence, rather
than assuming global irrationality of suicidal patients.
Indeed, one recent literature review found that the fre-
quency of clinical judgments of lack of DMC in
depressed individuals varied greatly according to the
acuity of illness (Cholbi 2009). The lack of consensus in
the literature on the decision-making capacity of suicidal
patients makes the a priori assumption of its absence
ethically dubious.
The clinician may even attempt to cultivate increased
autonomy in a suicidal individual with therapeutic inter-
ventions before automatically resorting to hospitaliza-
tion. Even if a suicidal state is often characterized by the
The American Journal of Bioethics
76 ajob October, Volume 19, Number 10, 2019

lack of critical thinking (Baumeister 1990), actively dis-
cussing options with patients may help them generate
alternatives that enhance their decision-making capacity
(Britton, Williams, and Conner 2008). Such an approach
that acknowledges an individual’s choices and provides
them with the opportunity to take responsibility for their
lives may enhance their natural self-protective tendencies
(Britton, Williams, and Conner 2008). Several therapeutic
techniques show promise for effectively resolving a sui-
cidal crisis while preserving patient autonomy.
Treating Suicide Without Coercion
Treatment modalities that acknowledge a suicidal
patient’s rationality and the importance of self-efficacy
may be more effective than hospitalization in some
patients in reducing suicidal behaviors. Self-determin-
ation theory (SDT) and dialectical behavioral therapy
(DBT) provide a framework through which the value of
a patient’s perceived autonomy, competence, and
relatedness is used to increase treatment engagement
and improve treatment outcome during a suicidal crisis
(Britton, Williams, and Conner 2008; Jobes and Berman
1993; Linehan et al. 2006; Omer and Elitzur 2001; Orbach
2001). In many cases, suicide is related to a sense of
helplessness and lack of perceived autonomy (Miller and
Hanson 2016; Filiberti et al. 2001; Hendin et al. 2006).
Improved treatment outcomes have been found to result
from the cultivation of autonomous motivation and per-
ceived competence in depressed patients (Kennedy,
Goggin, and Nollen 2004; Williams et al. 1998). Another
retrospective study of a suicide assessment strategy uti-
lizing these techniques found that patients resolved their
suicidal crises in less time and used less health care in
the 6 months following the crisis than did clients receiv-
ing treatment as usual (Jobes et al. 2005). This evidence
supports the notion that at least some suicidal patients
may benefit more from interventions that maximize their
autonomy, rather than transferring responsibility to the
clinician via hospitalization.
Several therapeutic modalities have been studied for
reducing suicide risk in emergency situations, when the
traditional response has been to hospitalize. Ketamine
and other rapid-acting antidepressants may fulfill their
initial promise to reduce suicidal ideation in acutely sui-
cidal patients in the emergency setting (Duman 2018).
Other therapeutic techniques may also explore and
address individuals’ambivalence about killing them-
selves in the acute setting (Britton, Williams, and Conner
2008; Brown et al. 2005; Jobes and Mann 1999). Safety
planning interventions (SPIs), administered to acutely
suicidal individuals in emergency departments (EDs),
followed by telephone follow-ups to monitor suicide risk
and support treatment engagement, were found to
reduce suicidal behavior and increase treatment engage-
ment compared to care as usual (Stanley et al. 2018).
Techniques that target a patient’s motivation and respon-
sibility may also help reduce suicidal behavior in the
long run by enhancing treatment follow-up and engage-
ment (Lizardi and Stanley 2010). Others have found that
when clinicians are more supportive of autonomy,
patients perceive themselves as responsible for their
behavior and may become more invested in their treat-
ment, leading to better engagement and better outcomes
(Ryan and Connell 1989; Joiner et al. 2003; Johansson,
Skarsater, and Danielson 2009).
Shifting the management of suicidal patients toward
greater autonomy is not without risk. Clinicians may
need to tolerate a higher level of risk to provide effective
therapy and help patients learn to manage their self-
destructive urges without resorting to hospitalization
(Fine and Sansone 1990). Many proponents of self-deter-
mination therapy models still reluctantly argue for the
need of involuntary hospitalization for some suicidal
patients as a last resort (Miller and Hanson 2016; Britton,
Williams, and Conner 2008). Perhaps a better indicator
for whether a suicidal patient should be involuntarily
hospitalized is in the clinical determination of a patient’s
decision-making capacity. While determining the cap-
acity of patients with mental illnesses such as depression
is not always clear-cut, capacity criteria carry much more
clinical utility than the unacceptably high false-positive
rate of current suicide risk assessments.
CONCLUSION
We suggest that the assumption that increasing patient
autonomy would increase suicides is built on overconfi-
dence in the predictive value of psychiatric risk assess-
ments and a tendency to minimize the personal costs of
psychiatric treatment, rather than on evidence for the
efficacy of coercion. The evidence reviewed in this article
suggest that a shift away from coercive protectionism
may even have positive effects on a patient’s immediate
survival, future treatment engagement with mental
health care, and long-term psychological outcomes.
Policies that preserve the autonomy of mentally ill
patients with decision-making capacity may be required
to bring about the appropriate shift in the current stand-
ard of care.
A policy that limits involuntary hospitalization to
those who cannot make their own decisions about their
own health will maintain the benefits of autonomy on an
individual’s mental health while preventing the add-
itional harms brought by coercive incarceration. For
example, state legislation could uphold the current dan-
gerousness-to-self standard for psychiatric hospitaliza-
tion but limit a clinician’s power by also requiring the
absence of decision-making capacity before coercive
force is used. Using an incapacity requirement may
improve the care for suicidal patients for several reasons.
(1) It would likely reduce the number of suicidal patients
involuntarily hospitalized, thereby reducing the exposure
of these individuals to the harms of hospitalization and
harms to the therapeutic relationship with their provider.
Re-weighing the Ethical Trade-offs
October, Volume 19, Number 10, 2019 ajob 77

(2) It would eliminate the stigmatizing ethical asym-
metry between mental health and the rest of medicine
by allowing all competent patients to refuse unwanted
treatment. (3) It would return responsibility for compe-
tent patients’lives back to the patient, potentially
increasing self-efficacy and reducing suicidal behavior.
(4) It would also remove the legal conflict of interest for
clinicians who are incentivized by malpractice prece-
dents to err on the side of hospitalizing a suicidal
patient. (5) Clinical assessment of decision-making cap-
acity, though still imperfect, would provide a more
quantifiable standard suicide risk assessments for deter-
mining whether a patient should be involuntarily
hospitalized.
The right of a competent person to refuse medical
treatment, even if doing so leads to harm, is fundamental
to our common morality. But in the context of mental
health policy, would tilting the scale toward personal
autonomy over the preservation of life in suicidal patients
imply a fundamental shift in the values of medicine? If
implemented, would this policy be the first step down a
slippery slope toward the full endorsement of euthanasia
for psychiatric patients, as seen in some European coun-
tries? There is evidence that when a state takes a legisla-
tive step toward removing barriers to suicide, such as
legalizing physician aid-in-dying, there is an increased
rate of total suicides relative to other states (Jones and
Paton 2015). Rather than arguing for a fundamental shift
from valuing life to valuing autonomy, we suggest that
more lives might be saved by scaling back the use of coer-
cion in psychiatric practice. Rather than diminishing the
value of human life, our proposed changes may bolster
the dignity of patients and the value of their lives by
engaging them as competent individuals. Evidence in the
form of empirical studies would be needed to test whether
making this change to mental health policy would influ-
ence suicide rates or rates of hospitalization. But given ris-
ing suicide rates nationwide, the lack of evidence for the
efficacy of the current standard of care, and mounting evi-
dence of the harms of coercion, it is time to expand the
search for potential solutions. 䊏
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