DIFFICULT MORAL QUESTIONS
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Question 78: Must a nurse report a patient’s plan to commit suicide?
I quit nursing when we began having our children, but now the youngest is six, and my husband is good with them. I have gone back to nursing part time, working in a home for the aged overnight Friday-Saturday and again Saturday-Sunday. Since many residents need no care at night, my duties are light. When otherwise free, I make a habit of staying with one or another of those who cannot sleep, listening a lot and talking a bit.
Many of these people are extremely lonely, especially at night, and having someone to talk with means a great deal to them. They trust me and tell me all sorts of things, even their deepest secrets. Naturally, many talk about death, and I try to encourage them to take the right attitude. One gratifying thing about my job is that I have been able to encourage several people to get straightened around spiritually. Fortunately, the priest who cares for this home is capable and devout, and when someone is ready to see him, he is always available, friendly, and patient.
The day before yesterday—Thursday afternoon—a chronically depressed resident committed suicide, and when I came in last evening everyone was discussing it. Around three this morning, I was talking with a patient, whom I’ll call Alan, who has no surviving family and never has visitors. He is a fallen-away Catholic; I’ve talked with him several times before, and thought we were making progress. He is undergoing treatment that will be completed in two weeks, and after that will be evaluated for major surgery. He confided that if the surgeon decides to operate, he will kill himself. Naturally, I told him that was not a good idea and he need not be so afraid of the operation.
When Alan entered the home, they changed his medications, and he still has some of the old pills. He showed them to me, and I believe they will kill him if he takes them all at once. As he talked, it also became clear that he has thought the matter through. He does not seem depressed, and his records do not mention any history of suicidal tendencies or any other psychological problem. Ordinarily, I make a note on anything special that comes up and in the morning call it to the attention of Dr. Young, the residents’ primary care physician, when she comes in. My first thought was to do that. But, having confided in me as a friend, Alan expects me not to betray his confidence, and I think he will be very hurt and angry if I do. So, I talked with the priest about Alan without mentioning his name or that he will be evaluated for surgery.
Father was not sure what I should do and suggested I call you. He agrees it would be unfortunate for me to antagonize Alan but also thinks his telling me about his plan was an urgent “cry for help.” May I keep the secret and continue talking with Alan in the hope that he will give up his plan and agree to see the priest? Or must I report what he told me? If so, I could call Dr. Young now or wait until I see her tomorrow morning.
Analysis:
This question calls for judgment to resolve a conflict of responsibilities. Preventing suicide is part of the questioner’s professional responsibility as his nurse, but she also has a serious reason to keep the patient’s secret. She should talk with him tonight, explain that he can refuse the surgery whose prospect he finds repugnant, promise to do what she can to ensure that he receives adequate pain relief, and try to persuade him to give up both his plan to kill himself and his cache of pills. If necessary, the questioner should try to confiscate the pills. If she fails to persuade the patient to give them up, her duty as his nurse and the poor prospects of helping him spiritually argue for reporting what has happened. But if the patient is persuaded and gives the nurse the pills, she should, in my judgment, keep his secret both for the sake of her personal relationship with him and the benefits she hopes to achieve by maintaining it.
The reply could be along the following lines:
I agree with the priest that Alan was crying for help when he told you of his conditional intention to commit suicide. He would not have confided in you had he not hoped to benefit in some way by doing so. However, he may have been seeking various kinds of help: action to prevent his suicide, moral support to carry out his plan, companionship to mitigate his loneliness in facing death, or something else. No matter what Alan wanted, however, it is most important that his intention to kill himself change. If unchanged, that intention not only is likely to be carried out sooner or later, but it endangers his soul. Therefore, no matter what else you do, pray for Alan and ask the priest to join in that prayer.
Using your spare time while on duty to visit and talk with lonely patients is the sort of service our Lord commends: “I was sick and you took care of me” (Mt 25.36). By helping patients spiritually prepare for death, you carry on your professional work as a genuine apostolate, caring for each person as a whole, not only for a malfunctioning organism. Your care for patients as persons makes you value your personal relationship with them, and that concern underlies your question. You risk forfeiting Alan’s trust and losing his friendship if you violate his confidences, and unless you maintain your friendly relationship with him, you will be unable to help him spiritually. So, while your duty of confidentiality toward patients who share their secrets with you is not exceptionless, you have a special reason to keep Alan’s secret.
At the same time, his seriousness about committing suicide is shown by the fact that he is not merely talking about it but has a definite plan and the means to carry it out. While saving Alan’s soul is far more important than keeping him alive, preventing his suicide not only must be assumed to be necessary to save his soul but is important in itself and falls directly within the sphere of your professional responsibility. Therefore, I think most physicians and nurses would say reporting what Alan told you is your duty not only to him but to the other members of the team responsible for his care and to the nursing home itself.
Still, since you did not report it this morning and will be seeing Dr. Young tomorrow morning, it seems to me you may wait at least until then rather than call her at once. Meanwhile, you can talk with Alan tonight. In doing so, I think you should discuss the possible surgery that concerns him and try to persuade him to put aside his plan of committing suicide and give you his cache of pills. Pray for guidance and gather your thoughts for this important conversation. I shall sketch out the points I think you should cover, but you must decide what to say and how best to say it as the conversation unfolds.
Perhaps you have too easily accepted the surgeon’s outlook and assumed that, when surgery seems indicated, it must be done, whether the patient wants it or not. But since Alan is living in a home for the aged, I assume he need not try to stay alive in order to fulfill obligations toward dependents or others; since he will have to be evaluated for surgery, I assume its appropriateness will not be immediately obvious; and since he finds the prospect of the surgery very repugnant, I assume it would be quite burdensome for him, not to mention the costs that someone—if only the taxpayers—will have to bear. I strongly suspect, therefore, that he has no moral obligation to accept the surgery, and could rightly refuse it and insist on receiving only palliative care.
If so, and assuming you would refuse the surgery if you were in his place, I think that is the first thing you should tell him. But if you judge that he ought to accept the surgery, I think you should tell him that and explain why—it offers very significant benefits, and the burdens for him will be comparatively insignificant. If he responds by restating his plan to kill himself, I think you may then tell him that he has the legal right to refuse the surgery and cannot be compelled to undergo it. Also, undoubtedly at least part, and perhaps most, of Alan’s motivation to kill himself rather than undergo surgery is fear of pain and suffering. Therefore, in discussing the options with him, assure him you will do everything you can to make sure he receives adequate pain medication and other care necessary to make him comfortable.
Perhaps the alternative of refusing the surgery, or your reassurances, will be sufficient to get Alan to set aside his plan to commit suicide. But he also needs to recognize that suicide is wrong, and that he must surrender the pills he is planning to use. So, whether or not he says he will reject the surgery, I think you should explain why you believe suicide would be wrong and try to get him to give you the pills.
How should you make the case against suicide? Certainly, you should point out to Alan that his life still has value, that he still can do worthwhile things, and that his death would be a loss to you. But more important, I think, is to tell him you believe in heaven and hell, hope he will go to heaven, and fear what might become of him if he kills himself.
Having made the case against suicide as best you can, explain to Alan that, as an employee of the home and only one member of the team that cares for him, you are not free to deal with him as you might deal with an elderly family member you were caring for in your own home. Then tell him that, though he told you about his plan in confidence, you cannot in good conscience let him keep the means for carrying it out. If you did nothing and he killed himself, you would have failed him as his nurse, and would consider yourself at fault for not having prevented his suicide.
On that basis, ask him as your friend to set aside his plan and give you the pills. What if he will not? In telling him that you cannot in good conscience allow him to keep the means of killing himself, you must be truthful; thus, having made that subtle threat, you must carry it out. So, if Alan will not surrender the pills and you can confiscate them without doing him violence, you should take them, while telling him you hate to do it but believe you must. For the same reason, if Alan has hidden the pills or resists your attempt to take them, you definitely ought to report what has happened to Dr. Young as soon as she comes in.
Suppose you get the pills. Should you report what has happened or keep Alan’s secret, at least for a while?
There is a case for reporting. Even if Alan gives you his pills, he might find some other way to attempt suicide. If he tries to kill himself and you have not reported what has already happened, your omission might come to light, particularly if he survived the attempt. In that case, as you may realize, you might be vulnerable to accusations of professional misconduct and civil or even criminal negligence. Because nurses’ rights and duties regarding patients’ confidential communications are ethically and legally unclear, the outcome of any action against you would be unpredictable.
Moreover, members of the team caring for residents in the home doubtless usually share with one another confidential information bearing on patient’s problems. So, though you would be expected not to divulge patients’ confidences to other patients or outsiders, you would be expected to report anything about a patient that might call for attention by others responsible for his or her care. Apart from those who support assisted suicide and euthanasia, most health care professionals would consider anyone’s plan to commit suicide a probable symptom of problems calling for investigation and treatment. You say that Alan does not seem depressed and that his records do not mention any history of suicidal tendencies or other psychological problems. But your past experience and familiarity with Alan’s personality and moods may not suffice for reasonable assurance.255 Despite appearances, he may need psychological counseling and/or medication—matters you are not competent to evaluate.
If Alan refuses to give you the pills and you must confiscate them, that will suggest he probably will go on considering suicide and perhaps eventually attempt it. Moreover, his refusal to hand over the pills would indicate that he probably has not been receptive to your efforts to help him spiritually, so that your confiscating the pills almost certainly will antagonize him. Thus, any prospects your effort may have had will be greatly dimmed. Taking into account your own vulnerability and your professional duty, then, if you must confiscate Alan’s pills, I think you definitely should fully inform Dr. Young tomorrow morning about what Alan told you and the steps you will have taken.
The considerations already articulated, especially with regard to your professional responsibility, may seem to show that your duty to inform Dr. Young will be no different even if Alan voluntarily surrenders the pills. However, you also have a more-than-professional, personal relationship with him, and it is not obvious that you should regard your professional role as the sole determinant of your responsibility toward him. If he responds to your persuasion by giving up the pills, the prospects for him and your relationship with him will be far better than if you must take them from him. Telling the doctor what has happened will violate Alan’s confidences and forfeit his trust, and so will impede your effort to encourage him to receive the sacraments. Moreover, it hardly would be right to restrain him indefinitely so as to prevent him from committing suicide. So, if his plan to do so was deliberate rather than a product of psychological factors beyond his control, the problem really is to get him to repent and face the future with hope, and you and/or the priest probably are more likely than any health care professional to succeed in helping with that.
Two things favor giving the priest Alan’s name and asking him to deal with the problem: he may be more able than you to persuade Alan to give up thoughts of suicide, and, if his attempt goes well, it might lead Alan to receive the sacraments. But Alan, being alienated (“fallen-away”) from the Church, probably is not yet ready to listen to a priest, and if the priest’s contact with him goes badly, you, having violated his confidences and betrayed his trust, may be unable to encourage him to prepare his soul for death. Moreover, the priest may well be less able than you to work with him, for even if he has more experience and skill than you in dealing with people in need of spiritual help, he lacks your established, friendly relationship with Alan. So, I am inclined to think you should not give him Alan’s name at this time.
Therefore, though I realize that some reasonable people will disagree, it seems to me that, if you succeed in persuading Alan voluntarily to surrender the pills, you probably should not report at once what has happened. Instead, I think you should keep his secret and continue talking with him, hoping and praying that he will reaffirm his faith and die with the dignity of a child of God.