INTRODUCTION
In the 20th century, life expectancy for the average American
increased from 47 years in 1900 to 83 by the end of the millennium.
Vast improvements in medical treatment, vaccines to eliminate diseases
like polio and small pox, technology to transplant organs, and
machinery to pinpoint malfunction in the human body have enabled an
extended life span for many. Yet, the enhanced ability to prolong life
brings with it the potential for a protracted dying process. In
addition, sophisticated medical technology has contributed to
skyrocketing costs for health care and controversy about allocation of
resources.
Medical cost containment issues and decisions surrounding when it is
time to die have created a practice environment of conflicting
responsibilities and choices for health care clinicians. Biomedical
ethics committees and extensive medical ethics literature have emerged
as signs of increased recognition of the need for ongoing dialogue
about ethical dilemmas. Accomplishments in the area of bioethics
include laws and statues supporting advance directives and informed
consent. These measures have, in principle, empowered competent
individuals to make choices about their own bodies, while relieving
physicians and families of the burden of “playing God” or
guessing what an incompetent patient would have wanted.
Despite such policies that reflect legal and ethical mandates
regarding client autonomy, some patients continue to acquiesce to the
medical “experts” without being fully apprised of their
choices. Social workers in health care may be caught between the
holistic values of the social work profession and the opposing
principles and perspectives of the predominant medical model of patient
care, which often emphasizes treating the body rather than the whole
person. Dilemmas arise where individual self-determination is
juxtaposed with an attitude of paternalism still found in health care
(Greipp, 1996). Social workers, as patient
advocates first and foremost, and as members of an interdisciplinary
team second, must weigh their allegiances carefully when intervening
with clients. This article explores an actual case where a social
worker faced an ethical dilemma which pitted the value of the sanctity
of life against a client's right to autonomy in deciding when to
terminate his life. The ethical quandary encompassed issues related to
a patient's right to self-determination and confidentiality, which
conflicted with agency policies and procedures, the social
worker's responsibility to collaborate with colleagues, and
professional duty to intervene. The social worker's limited
experience in working within the interdisciplinary team further
heightened the dilemma. No doubt, many who read this article will
disagree with the outcome. In reality, the author intentionally used
this questionable decision as a stimulus to continued discussion of
supporting patient choice at end of life and the richness of
perspectives embodied in an interdisciplinary team. Some facts have
been altered to protect the privacy of the client and family and the
professional integrity of health care workers involved.
The four-step ethical decision-making model developed by Joseph
(1985) will be used to frame the process
adopted by the social worker in this scenario. The first step of the
model is to identify the practice situation and the central ethical
dilemma. Second is a review of literature supporting each side of the
conflict. The third step of the model is to identify values and
relevant ethical principles, in this case ethical standards from both
the medical and social work professions, as well as client values.
These values are then placed in hierarchical order of significance to
the ethical conflict. An important part of the model at this point is
to explicate any of the social worker's personal biases that may
influence the decision-making process. In the last
stage—selecting a course of action to resolve the ethical
dilemma—the model requires discernment of options and projection
of the consequences of each choice. Finally, the ethical decision is
stated, along with justification of the resolution (Joseph, 1985).
PRACTICE SITUATION
The social worker involved in the selected practice situation was a
hospice employee rendering professional services to a dying patient and
the patient's family and friends. Hospice services are available
to persons with a terminal diagnosis of approximately six months or
less. An interdisciplinary team of nurses, social workers, chaplains,
home health aides, volunteers, physicians, and complementary therapies
provide care in partnership with patients and their caregivers. Hospice
emphasizes a holistic approach, recognizing that the spiritual and
emotional needs of clients are just as important as physical comfort.
Hospice philosophy promotes death with dignity, patient choice, and
quality of life, according to each patient's unique definition
(Greipp, 1996). The hospice program involved
in the ethical dilemma was a member of the National Hospice and
Palliative Care Organization (NHCPO, formerly NHO), which developed a
code of ethics to guide hospice practice in 1996. Neither the hospice
program nor NHCPO supports assisted suicide, suicide, or euthanasia. In
fact, the hospice movement promotes hospice care as a viable
alternative to assisted suicide (National Hospice
Organization, 1990). The client, Allen, was a 62-year-old
married male with metastatic prostate cancer. Shortly after his initial
diagnosis, he refused all life-extending options: surgery,
chemotherapy, and radiation, choosing quality over quantity of life. He
believed that the side effects of any life-prolonging procedure would
diminish his enjoyment of living. Allen was also adamant that he did
not want to become a burden to his family. Two years after the initial
diagnosis, Allen was admitted to hospice care
Allen died 7 months after his admission to hospice. As part of the
scope of emotional and spiritual support, Allen's social worker
contacted the patient and/or family weekly by phone and visited
according to their wishes. On average, the social worker visited three
times a month and the nurse visited twice a week. Allen had refused a
hospice chaplain or volunteer, as he had a large support group of
friends through a 12-step program, in addition to his spouse and adult
daughter. For the first 6 months Allen was able to engage in activities
outside his house, but gradually became dependent on others to drive
him, and eventually found it too much of an effort to leave his home.
Despite being housebound, the patient remained involved with others
through daily phone calls from his support network.
As is sometimes the case in hospice, patients are more comfortable
sharing thoughts and concerns about dying with experienced staff and
volunteers. In keeping with his need to stay in control, Allen openly
discussed his feelings with his social worker and nurse while
protecting family and friends from his fears of dying and his
unwillingness to be dependent on others for his total care.
ETHICAL DILEMMA
Several months prior to his death, Allen revealed to the social
worker that his physician had provided him with the means to end his
life when he deemed his quality of life inadequate. The patient
underscored that his method was such that the cause of death would
appear to be a heart attack and that no one would suspect otherwise. He
acknowledged that he wanted to be in control of his living and admitted
concerns about being a burden to his wife, who was 20 years younger. In
defining quality of life, Allen named factors such as independence,
preservation of dignity, and maintenance of mental faculties. While the
social worker believed it possible that Allen would in the future
follow through with his plan, she chose to maintain confidentiality
regarding the patient's disclosure and the physician's
complicity in providing a method. The social worker did not report to
the nurse, other members of the interdisciplinary team, or the social
work supervisor of the suicide potential, as was required by agency
policy, which would have allowed input from other staff. Nor did the
social worker notify the patient's family members, who were each
considered clients as well. At the end of a lengthy social work visit
where Allen reflected on his sense of peace and completeness, he
remarked to the social worker that he was bidding her a final goodbye.
The social worker was not surprised when she arrived at work on Monday
to learn that the patient had died of an apparent heart attack.
There was little question for the social worker that Allen's
death was the result of a successful suicide attempt. Both Allen, the
doctor, and the social worker made choices that permitted the patient
to end his life according to his own timing rather than waiting for the
natural process of dying to occur. The central dilemma for the social
worker when the patient first stated his intention to commit suicide
and later implied that it would occur was between the social
worker's duty to protect the sanctity of life by actions to
prevent a suicide attempt and her obligation to preserve a
client's right to self-determination by nonintervention, thereby
respecting the patient's autonomy to control the time and mode of
his death. The clinician was responsible for maintaining
confidentiality in the therapeutic relationship and thus supporting
patient autonomy. This duty conflicted with imperatives to adhere to
agency policy and procedures for responding to a potential suicide and
with hospice interdisciplinary team practice to communicate identified
problems to other staff members. Another complication was the
professional value to protect a client from “imminent
danger” or the physical harm implied by the client's plan to
kill himself. One additional confounding factor was the social
worker's therapeutic relationship with the patient's family,
which dictated attention to the well being of family members.
Thoughtful exploration of the ethical dilemma also requires examination
of suicidality as a manifestation of mental illness and as a moral
concern.
HISTORICAL AND CONTEMPORARY VIEWS ON
SUICIDE
Euthanasia and suicide have been the subject of theological and
philosophical debates for thousands of years in the Western world.
Euphemisms for the word suicide, a term first documented in the 17th
century, range from self-deliverance and self-chosen death to
self-annihilation and self-murder (Shneidman,
1973). The connotations of these expressions illustrate the
emotional and intellectual reactions of self-induced death. The ancient
Greeks and Romans held diverse points of view on the morality of
self-inflicted death, which stimulated ethical discourse throughout
subsequent centuries.
The rise of Christianity solidified a negative position on suicide as
sinful and criminal. Although the Bible does not specifically prohibit
suicide, St. Augustine condemned self-murder as a mortal sin according
to the Sixth Commandment, “Thou shalt not kill” (Exodus:
20:13). (St. Thomas Aquinas proclaimed that suicide was a sin, a human
act against natural law. He asserted that killing oneself is an act
that harms the entire community. More importantly, suicide is an act in
opposition to God, who provided life as a gift, and should determine
when a person dies.)
A modern voice denouncing suicide was that of Immanuel Kant. Despite
his support for personal autonomy, Kant stated that suicide, even in
situations of suffering and loss of control, is an irrational action
reflective of lack of self-respect. The philosopher concluded that
suicide is never morally justified under any circumstances:
“suicide is not … abominable because God has forbidden it;
God has forbidden it because it is abominable in that it degrades
man's inner worth below that of animal creation” (Kant, 1997, p. 124). It must be noted that not all
religions universally vilify suicide. Some Eastern cultural rituals
support self-inflicted death as an honorable practice involving
altruistic sacrifice. “Suttee,” the Hindu widow's
fatal leap onto the funeral pyre of her spouse, was an accepted custom
for many centuries (Shneidman, 1973).
Altruistic self-chosen deaths are not unique to eastern religions: Many
saints of Catholicism were martyrs who favored death over dishonor.
Allen, the client in the practice situation, died in the 1990s in the
context of a widening societal debate about an individual's
choices in dying and a more compassionate attitude about
self-intentioned death for terminal patients. Although suicide is no
longer considered a crime in the United States, facilitating the death
of another continues to be prohibited by law. However, defendants are
often acquitted by judges and juries for their acts of mercy.
Physician-assisted suicide, euthanasia, and death with dignity continue
as rallying cries of two decades of controversy regarding a
person's “right to die.” In 1980, Derek Humphry and
others formed the Hemlock Society in the United States to educate the
public on methods to end life. In 1991 Humphry published his how-to
manual for committing suicide, Final Exit. Pathologist Jack
Kevorkian entered the headlines with his suicide machine and faced
criminal charges for assisting persons in terminating their lives. Also
in 1991, Dr. Timothy Quill's New England Journal of Medicine
article and subsequent book, spurred further debate on the notion of
“death with dignity.” Quill outlined narrowly defined criteria for
a physician to participate in aiding a terminal patient's death (1993). In her “Apologia for Suicide,”
Barrington (1987) explains societal disdain
for suicide as mirroring cultural discomfort with the idea of death.
Weir (1986) defines the right to die as the
individual's perogative as an autonomous moral agent to terminate
one's life when quality of life is severely diminished.
Brandt's approach to self-initiated death allows that suicide can
be a rational and morally accepted act; however, consideration of the
well-being versus harm to others must also be included in any decision
to end life (Brandt, 1986).
THEORETICAL PERSPECTIVES ON SUICIDE
Just as cultural, philosophical, and religious perspectives on
self-administered death vary, in the clinical realm, sociologists and
mental health professionals may view suicide as a result of mental
illness, a function of inadequate social integration, or a rational
choice under discrete circumstances. The medical model diagnoses
suicidality as a mental disorder requiring treatment. Karl Menninger
characterized suicide as self-destruction emanating from the
three-pronged nature of human hostility—the wish to kill and be
killed and the desire to die (Purtillo &
Cassell, 1981). Freud visualized suicide as the supremacy of the
death force, thanatos, over its twin life instinct,
eros (Kastenbaum, 1995). A key
concept of psychodynamic theory—ambivalence—is reflected in
the paradoxical nature of suicide, where the individual often moves
toward self-destruction while hoping for discovery and rescue (Shneidman, 1973).
Many health care professionals who acknowledge that suicide can be a
rational decision are careful to qualify this concept with discrete
conditions. Of prime importance is the mental competence of the person
contemplating life cessation. Cognitive functioning and psychological
balance are crucial elements of the capacity to make decisions
regarding life and death. Werth (1996)
promotes the possibility of suicide as a rational decision and presents
situations where mental health professionals may discern that
intervention to prevent a logically considered suicide is
inappropriate. Likewise, Quill (1993) argues
that suicide to alleviate intolerable suffering may be a reasonable
alternative to continued distress. In a contrasting perspective on
anguish in the dying process, Vanderpool (1978) and Barry (1994)
regard suffering as an opportunity for the development of meaning and
virtues such as patience, humility, and courage.
Noted thanatologist and suicidologist Edwin Shneidman (1973) subscribes to the phenomenon of ambivalence
in a person's attitude toward death. Although he does not consider
psychological life as “rational” or “logical,”
he characterizes the death initiator as someone who believes death is
imminent and commits suicide in order to avoid the negative conditions
of the dying process. In an early psychological study analyzing the
content of suicide notes, Shneidman and Farberow (1959) described a concept similar to self-initiated
death called “surcease suicide,” a “logical”
type practiced by individuals “typically older, widowed, and in
physical pain.” Shneidman suggests yet another condition for
rational suicide, namely that it is a carefully considered and durable
choice devoid of hesitation over time.
In evaluating the practice dilemma, it is important to examine the
fears surrounding the dying process that may precipitate an
individual's action to intentionally terminate life. Simpson
(1979) enumerates fears of the dying process
including pain, discomfort, and loss of control of physical abilities
and/or cognitive functioning, loss of independence, inability to
communicate, and finally, loss of dignity. Schulz (1978) describes the desire to avoid being an
emotional or financial burden to loved ones as a motivation to end life
through suicide. Attention to fears of dying is an important part of
the therapeutic relationship between a clinician and a terminally ill
patient. Quality of life can be enhanced when an individual is able to
verbalize fears and adapt to losses or changes as they occur.
IDENTIFICATION OF SOCIAL WORK VALUES:
DIGNITY AND WORTH OF THE PERSON
A guiding principle in the hospice field is promoting quality of life
for each patient based on his or her unique definition. Empowerment of
the individual is an important tool for facilitating quality of life.
The National Association of Social Workers (NASW) Code of
Ethics enumerates ethical principles related to dignity and worth
of the person which parallel fundamental hospice values (National Association of Social Workers, 1996).
One aspect of the ethical dilemma confronting this social worker was
patient autonomy to commit an act contrary to hospice philosophy and practice.
Biestek (1957, p. 103) describes the principle of
self-determination as “the practical recognition of the right and
need of clients to freedom in making their own choices and decision
… ,” yet cautions that this right is “limited by the
client's capacity for positive and constructive decision making,
by the framework of civil and moral law, and by the function of the
agency.” Support for the client's right to
self-determination could potentially condone actions viewed as posing a
risk to the individual and violating the rules of the agency. The
standard for self-determination stated in the Code of Ethics is
Social workers respect and promote the right of clients to
self-determination and assist clients in their efforts to identify and
clarify their goals. Social workers may limit clients' right to
self-determination when in social workers' professional judgement,
clients' actions or potential actions pose a serious, foreseeable,
imminent risk to themselves or others. (National Association of Social
Workers, 1996, 1.02, p. 7)
Patient autonomy to make life-affecting decisions in health care must
be girded with accurate information about alternatives, comprehension
of the facts of the situation, and explanation of the consequences of
choices. It is the professional's role to ensure that the patients
receive sufficient data to make an informed choice, without influencing
or dictating the final decision (Latimer,
1991). One threat to a patient's right to
self-determination in health care decision making is an attitude of
paternalism, which may be conveyed by a demeanor which implies that the
clinician, not the client, knows “best.” The Hospice Code
of Ethics also includes autonomy as one of the fundamental ethical
principles of health care as “the ability to determine a course
of action for oneself” (National Hospice
Organization, 1996).
Confidentiality, based on an individual's right to privacy and
self-determination, is one of the core principles of the casework
relationship enumerated by Biestek (1957), in
the social work classic, The Casework Relationship. Respect
for the private confidences of a client is a crucial element in
promoting the dignity and worth of the person. According to Reynolds
(1976), individuals will refrain from revealing
intimate information necessary for the therapeutic process without some
implied or explicit assurance that the disclosure will remain private. One of
the precepts of the National Hospice and Palliative Care Organization's
Code of Ethics (1996) is “to
respect and protect the confidentiality of information concerning
hospice clients and families.” Dellinger (1997) delineates the end-of-life intimate
communications that hospice workers may facilitate or witness,
including “revelations, confessions, efforts at reconciliation
and final declarations” (p. 45). Despite its endorsement of the
social worker's ethical responsibility to “protect the
confidentiality of all information obtained in the course of the
professional relationship,” the NASW Code of Ethics (1996) also permits exceptions for “compelling
professional reasons” when “the disclosure is necessary to prevent
serious, foreseeable, and imminent harm to a client or others” (1.07c).
Likewise, Reamer (1990) notes that the common
belief held in the social work profession is that confidential
information shared by a client can be revealed solely under special
circumstances. Biestek (1957) underscores
that confidentiality is not an absolute right, especially if
preservation of confidentiality conflicts with the rights of other
individuals, the rights of the social worker, or the rights of the
agency through which the social worker is providing services. Moreover,
legal precedents define the relative nature of confidentiality. The
classic court case, Tarasoff v. Regents of University of
California, illustrates a situation where the court determined a
clinician legally bound to report a client's disclosure regarding
intended harm toward another (Dellinger,
1997).
ETHICAL PRINCIPLES: BENEFICENCE,
NONMALEFICENCE, AND JUSTICE
In evaluating a patient situation involving terminal illness and the
possibility of further abbreviating a finite existence through suicide,
the principles of beneficence (to prevent harm and do good) and
nonmaleficence (to not inflict harm) are strongly intertwined. The
imperatives embodied in these principles raise conflicting
responsibilities depending on whether suicide is viewed as a competent
choice to alleviate suffering. Beneficence and nonmaleficence must also
be considered in relation to the patient, the patient's family,
the social worker, the hospice interdisciplinary team, and the hospice
agency. In addition, the impact of the social worker's decision
and the patient's choice on the hospice movement and society
itself are relevant to consider in terms of how they promote good,
prevent harm, and refrain from inflicting harm. Any course of action
based on beneficence or nonmaleficence for one of the actors involved
in the ethical quandary might potentially create harm to others.
The principle of justice is highly valued in the social work
profession and in hospice care. Concepts of fairness and entitlement of
individual rights versus potential harm to others are considerations
that must be weighed in resolving the ethical dilemma. The Hospice Code
of Ethics defines justice as “Fairness: dealing suitably with
individuals; giving individuals what they are due or owed; distributing
benefits and burdens (e.g., of healthcare) fairly” (NHO, 1996, p. 80). Similarly, the social work Code of
Ethics states that in order to challenge social injustice, “Social
workers strive to ensure … meaningful participation in decision making
for all people” (National Association of Social
Workers, 1996, p. 5).
DEVELOPING A HIERARCHY OF VALUES
To resolve the ethical dilemma, the social worker must order salient
ethical values, principles, and duties. A blending of the parallel
intents of the NASW and NHPCO codes of ethics provides a basis for
hierarchical assignment of ethical considerations.
- Self-determination. Nearly three decades ago, the Hospice
movement was founded on the principle of patient choice in dying.
Self-determination remains the keystone of current hospice practice
(Duff, 1979). Likewise, autonomy is related
to the dignity and worth of the person, one of the important values of
the social work profession. An NHPCO publication delineates conditions
for autonomy: “the capacity for understanding, the capacity for
deliberation, and the capacity to make autonomous choices”
(NHO, 1993).
- Sanctity of life. Second in order of importance in the
hierarchy is the value of life and individual and professional
responsibility to protect and enhance life.
- Nonmaleficence. The principle of not inflicting harm is a
crucial guideline in all helping professions.
- Beneficence. Promoting good and preventing harm within the
client system is a prized goal in social work and hospice care.
- Professional integrity and service. These two values are
interconnected in the practice situation and require the social worker
to intervene with the client system utilizing a high level of
professional knowledge and skill and honesty and trustworthiness in
relationships with patients.
- Confidentiality. Maintaining confidentiality is
fundamental to any therapeutic relationship. The social work profession
does not support absolute confidentiality. Maintaining confidentiality
must be weighed according to benefits of individual privacy versus
protection of others from harm.
- Interdisciplinary collaboration. Teamwork is the
foundation of hospice practice. Maximizing the skills of each member of
the interdisciplinary team is achieved through collaboration of
information, perspective, and knowledge (Pellegrino
& Thomasma, 1981).
- Justice. Ensuring that each client served by the hospice
team is offered equal opportunities for resources, information, and
services is a value consistent with the social work profession and
hospice philosophy.
PERSONAL AND PROFESSIONAL BIASES
Attention to the personal and professional biases of the clinician is
essential to systematic ethical decision making. Issues such as the
social worker's personal views on quality of life and sanctity of
life influence objectivity. Although hospice programs and,
theoretically, their agents or staff support patient choice to refuse
or discontinue artificial life-prolonging procedures, it does not
necessarily follow that staff also subscribe to proactive
discontinuation of life itself, preempting the natural course of death.
The social worker's religion and personal and professional
experiences with suicide must be noted.
CONSIDERATION OF ALTERNATIVES
In the final stage of the ethical decision-making process, the
options for intervention and the likely consequences of each
alternative must be weighed. The relative merits of competing goods and
the effects of possible harm are assessed according to the prioritized
ethical principles and values. In the clinical scenario, the social
worker's options included: (1) supporting Allen's choice to
end his life when he discerned that his quality of life was
insufficient; (2) intervening to prevent a future suicide; (3)
maintaining confidentiality about the patient's future wishes, but
exploring with the patient his motivations and the possible
ramifications of his decision; (4) sharing with the interdisciplinary
team the patient's stated wish to end his life, thus including the
team in the decision-making process.
Supporting the patient's decision to control the timing of his
death would be consistent with ranking self-determination as the
preeminent value in the hierarchy. The second value in the hierarchy,
life, would conflict with respecting self-determination, unless the
sanctity of life is viewed as embodied in the concept of quality of
life. As previously stated, many ethicists consider ending a life of
suffering a moral act which is not contrary to valuing the precious
gift of existence. The social worker's support for the possibility
of patient suicide at some point in the dying process would not
abdicate professional responsibility for intervention to enhance the
patient's physical, emotional, and spiritual well-being in
conjunction with services provided by other members of the hospice
team. Collaboration to promote the patient's quality of life would
imply a series of therapeutic actions recognizing the sanctity of life,
and promoting hierarchical values of nonmaleficence, beneficence,
professional integrity and service, and even justice for the patient.
Confidentiality would also be maintained to protect client autonomy and
to prevent any premature intervention by the hospice team to remove the
patient's option to suicide if efforts had not achieved sufficient
quality of life.
The option to support patient wishes would pose potential harm to the
other parties involved including the patient's family, the social
worker, and the hospice organization. The social worker's
responsibility to prevent and not inflict harm for the other clients,
the family, would be undermined by supporting a patient choice which is
beneficent and nonmaleficient for Allen, but not for his family. The
well-being of the family would depend on their acceptance or rejection
of the patient's choice and their perspective on suicide as a
rational and justified decision or an immoral action. As noted earlier,
maintaining confidentiality in instances of imminent danger, as the
family might interpret the patient's desire to end his life, often
results in legal action. By keeping silent about the patient's
intention to end his life, the social worker would be exposing herself
and her agency to legal liability, a significant harm. The social
worker's professional integrity might be impugned by family
members who felt betrayed and uninformed hospice team members who had
not been informed. The social worker's employer, the hospice
organization, would most likely question the social worker's
professional judgment in not adhering to agency policy. Further
implications for the social worker in supporting the patient's
right to self-determination would arise if the social worker rejected
rational suicide as a moral action. The social worker's personal
and professional well-being would be jeopardized by participation in an
action inconsistent with her belief system. Any publicity which might
arise from legal action by the family would most certainly damage the
social worker's reputation and falsely convey an image of hospice
as a facilitator of assisted suicide. From the standpoint of the value
of justice, families of former hospice clients might feel that loved
ones with a similar wish to end their lives sooner than the biological
process allowed had not been offered a choice by the hospice
organization or the social worker involved. Current and potential
hospice patients or families might either fear or advocate for the
possibility of hospice-sanctioned self-induced death, thus creating
long-term confusion about hospice philosophy. Taking into account the
many potential risks of this first alternative, from a utilitarian
perspective, upholding the patient's right to self-determination
would not allow the greatest good for the greatest number.
In the second option, an alternative to permitting self-inflicted
death is to initiate a suicide prevention plan to promote the value of
life and support death through the natural body process. Although
self-determination is ranked the highest value in the ethical
decision-making hierarchy of principles and values, if suicide under
any conditions is deemed morally wrong or an irrational act regardless
of the patient's competence, responsibilities to prevent harm and
do good would require intervention to prevent the patient from acting
on suicidal intent. In this scenario, divulging private information
would not be considered inflicting evil or harm on the patient because
the greater good would be preservation of the sanctity of life.
Additionally, suicidal intentions would constitute “compelling
professional reasons” for breaking confidentiality (National
Association of Social Workers, 1996,
1.07c).
Nevertheless, in reality, the trusting relationship between clinician
and client would erode, possibly irreparably. Avoidance of patient
suffering could not be guaranteed; however, the hospice team would
offer support to the patient and family in coping with the physical,
emotional, and spiritual dimensions of the patient's illness and
the issue of restricted patient autonomy. Finally, though the patient
would not be afforded “meaningful participation in decision
making,” one aspect of social justice—the general welfare
of past, present, and future hospice clients—would be protected
by consistency in hospice philosophy and practice with respect to
suicide (National Association of Social Workers,
1996). In this instance, from a utilitarian perspective, the
greatest good for the greatest number would occur.
The fourth option available was for the social worker to trust in the
collective wisdom of the interdisciplinary team in order to resolve the
dilemma. This action would protect the social worker from sole
responsibility for such a weighty decision but would also open up the
possibility of direct confrontation of the patient's wishes and
revelation of the social worker's breach of confidentiality.
ETHICAL DECISION AND JUSTIFICATION
Despite the social worker's own discomfort with the idea of
suicide, she chose to respect the self-determination of her patient by
acting on a third option, that is, to maintain confidentiality while
also directly addressing the implications of future suicide. The social
worker's intention was not to dissuade the patient from his
choices, rather to encourage him to fully examine the alternatives and
the possible consequences for family. If Allen still chose to end his
life, the social worker would explore with him whether his means of
ending his life was indeed guaranteed to succeed in painlessly
terminating life and in being undetectable as suicide. This clinician
recognized that prostate cancer can create an uncomfortable dying
process or a more certain physical decline where the patient is
dependent on others for total care. For Allen, the choice to avoid
likely dependence and possible discomfort by ending his life appeared
to be a rational decision. The social worker also recognized a duty to
mitigate any harm to the other parties involved, including the family,
the hospice team, and the hospice organization. She also sought to
protect her reputation, with the belief that the professional skill
that she had acquired through her experiences in hospice should not be
undermined for current and future patients. Lastly, the social worker
identified the detriment to the hospice movement in setting a publicly
acclaimed precedent of sanctioning patient suicide. The social
worker's professional knowledge that most hospice patients, even
those who fear a painful death and mention self-inflicted death,
ultimately die comfortably, solidified her resolve to prevent the
patient's action from becoming public knowledge.
The social worker adopted a teleological rationale for her
determination to support Allen's right to chose. For each
decision, which proceeded from resolution of the central dilemma, the
social worker made choices and selected interventions by weighing the
consequences. To support the value of sanctity of life, through her
weekly counseling sessions and in collaboration with the hospice nurse,
the social worker used her professional knowledge and skill to
encourage and empower the patient to maximize his quality of life.
Allen's ambivalence and fears about the dying process were
addressed to ensure that any decision would be informed and rational.
As the patient's pain increased, the hospice team alleviated
Allen's discomfort. Rather than ending his life when he first
needed assistance and care, the patient allowed others to assist him.
The social worker helped him to recognize the gift of giving that he
had bestowed on loved ones that wanted to care for him. Allen waited
until he was close to losing his ability to implement his suicide
method to end his life. He firmly believed that he should protect his
family from any added turmoil which raising the issue of suicide might
create and thus chose to not include them in his deliberations. The
social worker ascertained with the patient that his means of
self-administered death would be “fool-proof” and, in fact,
discovered that the patient's physician prescribed the needed
medication prior to the patient's admission to hospice.
The consequences of actions taken to resolve the ethical dilemma were
that a patient died with minimal suffering and in a manner consistent
with his own values of quality of life. Other parties involved were
protected from harm by their lack of awareness of the patient's
decision. For the social worker, as a human being who valued the
precious life of Allen and as a professional dedicated to enhancing the
final stage of life, the ethical conflict was not easily resolved. The
clinician made her decision based on the unique circumstances of
Allen's life and illness, upholding the patient's
self-determination to make a decision even when it conflicted with
agency policy and the social worker's beliefs. That Allen's
circumstances were unique has been borne out in the social
worker's subsequent experience.
In years since Allen's death, the social worker continued to
encounter patients who raise self-administered death as a possible
course of action. In each of these cases she intervened to address
issues of depression, anxiety, ambivalence about death, and fears of
the dying process. She also informed patients and families at the time
of her first visit that important information revealed to one member of
the interdisciplinary team was shared with other members. In most
instances, further intervention to prevent suicide has not been needed.
For the exceptions, the social worker has collaborated with hospice
team members to institute a plan for suicide prevention, while
exploring and validating the patient distress surrounding the
conditions the patient finds intolerable. Even in these situations,
through vigilant management of physical symptoms, increased sedation,
or counseling related to emotional or spiritual distress, most patients
appear to experience minimal suffering.
