Suicide Attempts and Treatment Refusals

Abstract

It is now well established that competent patients have legal right to refuse life-sustaining treatment. When patients are unable to make contemporaneous medical choices, law supports honoring treatment refusals expressed in advance directives. In contrast, just three states permit physician-assisted suicide, and their laws cover only patients with terminal illness. Moreover, in cases involving ordinary suicide, law allows clinicians to intervene to prevent death. What should happen when patient refuses treatment after suicide attempt, either directly or through an advance directive? Should legal officials consider treatment refusal part of suicide attempt and authorize clinicians to intervene, or should they classify refusal as an independent choice that clinicians must respect? The Wooltorton Case A British right-to-die case presented these questions last year. Kerrie Wooltorton was twenty-six-year-old woman with psychiatric problems. She had repeatedly tried to poison but each time doctors intervened to save her life. In 2007, she again took poison and called an ambulance. At hospital, she refused treatment and presented document saying she had come to hospital to avoid painful and lonely death and wanted no lifesaving measures. The hospital staff followed Wooltorton's wishes, and she died next day. British officials conducted an inquest into Wooltorton's death, and in late 2009, Norfolk coroner issued verdict supporting hospital staff's According to coroner, it would have been unlawful for staff to impose treatment without Wooltorton's consent. Although media portrayed Wooltorton as the first person to have used living will to kill herself, (1) coroner focused more on her contemporaneous treatment refusal. Wooltorton's treating physicians said it was that decision that led them to withhold lifesaving measures. (2) The United Kingdom and United States have similar legal standards for decision-making capacity. According to U.K. Mental Capacity Act of 2005, a person is unable to make decision for himself if he is unable (a) to understand information relevant to decision, (b) to retain that information, (c) to use or weigh that information, or (d) to communicate his decision. (3) Physicians in Wooltorton case reportedly took pains to evaluate her decisional capacity, and coroner accepted their judgment that she had issued valid refusal. (4) The United Kingdom and United States also have similar laws authorizing involuntary treatment for persons with mental illness. The U.K. Mental Health Acts of 1983 and 2007 permit compelled treatment that is necessary to protect health and safety of individuals with mental disorders. (5) This can include treatment for symptoms or manifestations of disorder, which presumably includes suicidal acts. Physicians reportedly determined that Wooltorton did not meet criteria for compelled treatment under mental health laws, but psychiatrists have questioned this determination. (6) The Relevance of Causation and Intent Whether coroner focused on contemporaneous treatment refusal, advance directive refusal, or consistency in two choices, Wooltorton case presented line-drawing challenge. Should Wooltorton's treatment choice be invalid because it was part of her suicide attempt? Or should it be classified as legitimate treatment refusal appropriately honored by hospital staff? U.S. courts and legislatures have distinguished treatment refusal from suicide using concepts of causation and intent. The U.S. Supreme Court took this approach in its 1997 Vacco v. Quill decision, when it ruled that patients have constitutional right to refuse life-sustaining treatment, but not right to physician-assisted suicide. (7) In his majority opinion, Chief Justice Rehnquist cited causation as one basis for distinguishing two practices. …