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Respecting a Patient’s Autonomy

A Personal Perspective: When a physician should let go.

Key points

  • A suicidal patient is often dealing with depression and may not be thinking clearly.
  • Health care professionals are expected to break confidence when someone is imminently suicidal.
  • When should a patient’s autonomy be respected regarding suicide?

In Parts 1 and 2 of this post (which the reader can access by clicking on the "1" or "2" earlier in this sentence), I describe my patient Jordan, a 19-year-old with cystic fibrosis (CF) who was placed on a breathing machine (ventilator) against his wish during a medical emergency. When he recovered, he said that he was glad that I had not listened to his request. A year later, Jordan told me he was planning to commit suicide because his girlfriend had broken up with him and he had already suffered enough during his life. He had not told anyone else of his plans. I needed to decide whether to intervene by calling the authorities.

Duong Hoang Dinh/Shutterstock
Source: Duong Hoang Dinh/Shutterstock

When I have presented Jordan’s story at medical conferences over the years and surveyed other medical professionals, a large majority have indicated they would have called the authorities because a suicidal patient is often dealing with depression and may not be thinking clearly. Further, health care professionals are expected to break confidence and notify authorities when someone is intent on harming themselves imminently.

When Jordan called me about his suicide plan, I was unsure what to say. This was the first time in my career that I had fielded such a call. I asked him if I could call him back a couple of hours later, as I needed to go to my synagogue where my son was scheduled to read from the Torah. Jordan said that would work for him.

At synagogue, I told my Rabbi about the situation. “Those teenagers,” he scoffed. "They break up with their first girlfriend and think their lives are over. Three weeks later they find themselves a new girlfriend.”

But this was different, I thought. Jordan was not a healthy person who was experiencing heartbreak for the first time. He was a young man who was dealing with a terminal disease, and would not live much longer. He had suffered a lot already, and had good reasons not to become involved in a new romantic relationship. I thought to myself that Jordan was rationally depressed.

It was not an option for me to visit him in person because he lived three hours away. So, when I returned from synagogue, I called him again. He said his feelings about suicide had remained unchanged and he still had not told anyone else of his plans.

I said, “Why don’t you come to the hospital? I will take care of you. We can get the Psychiatry Service involved and they can work with you as well. You can get through this.”

Jordan said he was unsure of what he wanted to do. I continued, “Jordan. Last year I had to make a decision on your behalf whether to put you on the ventilator or let you die. At that time, you were in a coma, so I had to make that decision for you. A verse from the Bible came to my mind that day. ‘I set before you life and death. Choose life.’ I urge you to choose life, Jordan. But this time I am not making the decision for you. This time it’s your choice.”

I had concluded that it was not my right to impose my or society’s viewpoint about suicide on Jordan. I have pointed out to the many medical professionals who disagree that during the previous year they would have honored his wish to die when he was at death’s door because of his lung bleed. Why would we take away his autonomy when he is in a position to decide?

In both situations, I made the choice that I thought would best fit this individual patient, regardless of social expectations. I wish that the medical field could return to such a personal brand of medicine.

Jordan said he would think about what to do overnight, and promised that we could talk again the following morning. When I called him, he said he had changed his mind about committing suicide. He said he felt better and did not think he needed to come into the hospital. Three weeks later, he had a new girlfriend. My rabbi turned out to be right.

Jordan shaved his head around that time. He told me this was because “it’s a new beginning.” He switched universities so that he could be with his new girlfriend. It felt as if he had grown up. Most unfortunately, eight months later, CF finally caught up with him. Jordan died at the age of 21.

Takeaway

My interactions with Jordan have had an important influence on my medical career. I have published articles about parts of his physical and mental healthcare as well as our relationship in 10 different publications. Also, I have shared many of Jordan’s stories with my patients. They have been very instructive and have raised discussions regarding how we can decide difficult dilemmas in our lives.

I believe, as Jordan himself said, that his soul and mine remain linked. I’m fairly certain that he is happy to continue to be making an impact in this living world through the publication of these posts.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.

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