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An ethical question regarding doctor-patient confidentiality

Suppose a patient has disclosed to his GP that he plans to commit suicide imminently. He is sound of mind (which should rule out any Mental Health Act complications) and does not plan to hurt any third party. The GP suggests counselling services etc. but despite the GP's best efforts, the patient is adamant he will not try any treatment and will commit suicide.

What can the GP do in this scenario? Can he breach doctor-patient confidentiality in an attempt to prevent the patient committing suicide despite i) patient autonomy principles and ii) no third party is at risk of harm? I'm aware the Suicide Act means that suicide is not a crime.

I've tried googling around and the GMC had some guidance, but I couldn't find anything on this specific scenario.

Logically, what I know leads me to believe that the GP is basically powerless to intervene in any way other than by trying to convince the patient to attend counselling/therapy and other support groups, but I'm not sure that's quite right.

Thanks in advance :smile:

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Reply 1
Avatar for Beska
Beska
21
Original post by liam__
Suppose a patient has disclosed to his GP that he plans to commit suicide imminently. He is sound of mind (which should rule out any Mental Health Act complications) and does not plan to hurt any third party. The GP suggests counselling services etc. but despite the GP's best efforts, the patient is adamant he will not try any treatment and will commit suicide.

What can the GP do in this scenario? Can he breach doctor-patient confidentiality in an attempt to prevent the patient committing suicide despite i) patient autonomy principles and ii) no third party is at risk of harm? I'm aware the Suicide Act means that suicide is not a crime.

I've tried googling around and the GMC had some guidance, but I couldn't find anything on this specific scenario.

Logically, what I know leads me to believe that the GP is basically powerless to intervene in any way other than by trying to convince the patient to attend counselling/therapy and other support groups, but I'm not sure that's quite right.

Thanks in advance :smile:


In your scenario, which I am assuming means the patient has stated that they are literally going to leave the surgery and commit suicide, and have a means to do so, have a plan, have made arrangements (e.g. suicide note, life insurance) there are various considerations. The Mental Health Act does apply, and barring all other options (in your scenario, the patient will not listen and is leaving the door) the doctor would likely section the patient under likely section 4 (although happy to be corrected) - in this emergency situation one doctor can make the decision to detain the patient for further assessment and/or detained in the interests of your own health and safety.

Using section 2 (the usual 'section' when people talk about 'section':wink: would likely cause undue delay (you need two doctors, one of which needs to be a specific person with specific training, etc.) and since in your scenario the patient is leaving right now to commit suicide, the delay would potentially cause harm.

The MHA has a 'code of practice' which states:

Factors to be considered in deciding whether patientsshould be detained for their own health or safety include:

the evidence suggesting that patients are at risk of:
- suicide
- self-harm;
- self-neglect or being unable to look after their ownhealth or safety; or
- jeopardising their own health or safety accidentally,recklessly or unintentionally
or that their mental disorder is otherwise putting theirhealth or safety at risk.

This includes if patients have capacity to make decisions (presumably by what you mean by 'of sound mind':wink:.

Section 4 lasts for 72 hours, usually giving enough time for a proper assessment (likely a psychiatrist in this situation) and, if appropriate, escalation to a section 3 which can last up to 6 months. In both cases you cannot refuse treatment.

It is not really an issue of patient confidentiality in the strictest sense. However the GMC do say:

The GMC says in 'Good medical practice':

36. There is a clear public good in having a confidential medical service. The fact that people are encouraged to seek advice and treatment, including for communicable diseases, benefits society as a whole as well as the individual. Confidential medical care is recognised in law as being in the public interest. However, there can also be a public interest in disclosing information: to protect individuals or society from risks of serious harm, such as serious communicable diseases or serious crime; or to enable medical research, education or other secondary uses of information that will benefit society over time.

37. Personal information may, therefore, be disclosed in the public interest, without patients’ consent, and in exceptional cases where patients have withheld consent, if the benefits to an individual or to society of the disclosure outweigh both the public and the patient’s interest in keeping the information confidential. You must weigh the harms that are likely to arise from non-disclosure of information against the possible harm both to the patient, and to the overall trust between doctors and patients, arising from the release of that information.

However, as I say, this is more to do with the MHA than it is confidentiality. If your point is that by sectioning them and involving other doctors etc. you are breaking confidentiality by sharing your concerns, the GMC suggest:

25. Most patients understand and accept that information must be shared within the healthcare team in order to provide their care. You should make sure information is readily available to patients explaining that, unless they object, personal information about them will be shared within the healthcare team, including administrative and other staff who support the provision of their care.

27. You must respect the wishes of any patient who objects to particular information being shared within the healthcare team or with othersproviding care, unless disclosure would be justified in the public interest. If a patient objects to a disclosure that you consider essential to theprovision of safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that information.

Short version/TLDR: The mental health act does apply. The patient is a clear risk to himself and there is power to apply a section 4 for emergency detention to prevent said imminent harm from occurring. The GP isn't powerless as you suggest and if a patient literally told the GP that he is leaving to kill himself, right now, and the GP let them leave with full knowledge of that fact, and the patient indeed does then commit suicide, there is an argument that GP may be acting negligently and not in the patient's best interests.

e: Interesting case here, Rabone case in 2005, where a 24 year old had attempted suicide and had been admitted to hospital voluntarily (not sectioned) but then later went on to leave hospital and commit suicide. The Supreme Court held that the hospital had a duty to take reasonable steps to advert the risk to life in circumstances where they knew of a "real and immediate" threat to that individual". The hospital had violated the duty they had under Article 2 of European Convention on Human Rights (right to life) to protect a patient from committing suicide.
(edited 8 years ago)
Reply 2
Avatar for liam__
liam__
OP
7
Original post by Beska
-


Exactly what I was looking for, thanks for being so comprehensive!

It's very interesting that being suicidal seems to imply that the person may be mentally ill (hence the ability to section under the MHA), however I'm sure many people who have no mental illness travel to Dignitas to end their lives, which seems to be perfectly legal. Indeed, I recall cases in the news where Brits have announced their plans to do this well in advance, and they were not prevented from travelling to Switzerland by the MHA.
Reply 3
Avatar for Helenia
Helenia
20
Being suicidal on its own is not a sectionable condition, but as a GP I think most would be very uncomfortable leaving a patient to just get on with it with no further assessment. Obviously you would explore the patients reasoning and try to make an assessment of their mental health, and if they were continuing to threaten suicide I think contacting the local psych team for advice and assessment would be sensible. Discussing patient care with other medical professionals does not count as breaching confidentiality. Who were you thinking of breaching it with?
Reply 4
Avatar for liam__
liam__
OP
7
Original post by Helenia
Discussing patient care with other medical professionals does not count as breaching confidentiality. Who were you thinking of breaching it with?


I would have thought the police may have to be involved if somebody was being detained against their will under the MHA, which would constitute breaching confidentiality? That was my line of thought anyway.
This same question came up at my mock interview.
But it was role-play and I was the GP and he kept pressurising to give him suicidal drugs.



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Reply 6
Avatar for Beska
Beska
21
Original post by liam__
Exactly what I was looking for, thanks for being so comprehensive!

It's very interesting that being suicidal seems to imply that the person may be mentally ill (hence the ability to section under the MHA), however I'm sure many people who have no mental illness travel to Dignitas to end their lives, which seems to be perfectly legal. Indeed, I recall cases in the news where Brits have announced their plans to do this well in advance, and they were not prevented from travelling to Switzerland by the MHA.


It isn't the symptom of being suicidal per se but rather the fact that the hypothetical patient has said as soon as he's leaving your office he's going to kill himself, he has the means, he's made a plan etc. etc. Realistically I can't see that ever happening like that, but I suppose it's just an example to make a point. That moves it beyond the symptom of suicidal thoughts to it actually being a bone fide threat to the patient's life. Suicidal thoughts are (relatively) common, depending on condition, but usually patients say they won't act on them. Occasionally they say that they might act on them, but that they've not made plans/don't have a method/haven't made a will/etc. I've never actually seen or heard of a case where a patient has come into a GP, for example, and then told the GP that they are suicidal, want to do it, have made all the plans, are going to carry it out imminently. It is theoretically possible though (and obviously must happen). That's the remit of crisis team/mental health liaison/etc who'd likely be the person the GP would call to talk to. The situation is a bit false because I doubt the patient would be really militant and be wanting to storm out (since they've come in to see you in the first place), so you can just sit there and chat with them and then refer to crisis team who will see them relatively quickly in the GP surgery. It's likely that they would do all of the MHA stuff rather than the GP.

e: As for the assisted suicide point, I have no idea about the finer aspects of the law related to that but I don't think you can be sectioned for conspiracy to commit suicide (for lack of a better turn of phrase), or sectioned because you may or may not consider suicide in the future. I wouldn't feel comfortable with that being a "real and imminent threat" for example.
(edited 8 years ago)
Reply 7
Avatar for Helenia
Helenia
20
Original post by liam__
I would have thought the police may have to be involved if somebody was being detained against their will under the MHA, which would constitute breaching confidentiality? That was my line of thought anyway.

Police aren't necessarily involved unless the person is at risk to themselves in a public place, and I'm not sure a GP counts as that. If they were to leave your surgery you could theoretically call the police to get the patient but I'm not sure what powers they have if the patient isn't mentally ill.

Psych team first, they'd offer advice on both the patient's condition and your position with respect to the MHA.
The MHA only applies to patients with a "mental disorder". In your hypothetical situation, we are told that the patient does not have a mental disorder but that they are planning to kill themselves imminently. If these facts are taken at face value, I don't see that the MHA (or any other legislation) applies.

In reality, of course, it is very hard to tell (with certainty) whether or not a person is suffering from a mental disorder. It is probably arguable that intending to commit suicide is prima facie evidence of some underlying depression or psychosis. The GP is likely to section (even if this is on dubious legal grounds) as that is probably the safest course of action for both the GP and the patient.
Reply 9
Avatar for Ghotay
Ghotay
13
The question comes down to whether suicidality is, by definition, a sign of mental disorder. Practially, I think this comes down to the discretion of the GP. If you WANTED to section them, I'm sure you could manage it. If you wanted to turn a blind eye, I think that would be justifiable too. The circumstances matter a lot here.

A 20 year old man who denies all symptoms of mental disorder, and states that he is going to kill himself with a clear plan for no discernible reason? Yeah, I'd section him.

A 75 year old woman who feels fine, but has no surviving family and tells me calmly that she is 'ready to join her husband'. I'd obviously try to persuade her otherwise, but if she seemed set on it... hey, I might let that one slide.

Probably not the textbook response, but how I personally feel on that matter
GP will normally refer actively suicidal patients to the 'crisis team'. A psychiatric nurse normally makes contact the next day at his home and do a full assessment.

If they are appropriate they are seen daily at home for a time. Most people are then discharged back to the GP or to the local cmht.

The next step up is the day hospital where people go back to there own house at night and go there daily.

If they need psychiatric admission most often they go as voluntary' inpatients. Mental health act is not necessary if you agree with treatment. It is only the last resort of they require admission against there will.

A patient who comes to the GP wants help so will highly unlikely need section. Most of you are not correct with regards to mha. GP cannot and do not 'section' patients. Mostly only psych reg and above are section 12 approved doctors. Section 4 is never used. Crisis team referral is the answer.
(edited 8 years ago)
Just to add to the above - many GP's are section 12 approved, and are frequently used as the second medical signatory when detaining a patient.

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'is of sound mind' 'is going to commit suicide' hmm I don't think so
Reply 13
Avatar for Ghotay
Ghotay
13
Original post by infairverona
'is of sound mind' 'is going to commit suicide' hmm I don't think so


You don't think there are rational reasons to commit suicide? What about that guy in The Godfather II who slit his wrists to protect his family?
Original post by Ghotay
You don't think there are rational reasons to commit suicide? What about that guy in The Godfather II who slit his wrists to protect his family?


Ok first of all that's a film? Hardly relevant. And in theory perhaps, but I don't think the way our legal and medical systems work would reconcile saying someone is of sound mind/competent while also claiming he is going to kill himself. Considering the vast array of other things people are considered not competent for e.g. pregnant women who refuse treatment, people who are religious and refuse treatment, I highly doubt that many doctors would be happy to put themselves on the line by declaring someone who is actively planning to commit suicide as competent. That's just a legal case waiting to happen.

[e] Just a note I am not a medical professional, I've studied medical law and am doing a medical ethics/law MA so I don't know how in practice this would work but I would imagine if a doctor had a patient come to them saying they are going to commit suicide and then did nothing, that would be negligence. Whether you agree with their reasons for it or not.
(edited 8 years ago)
Original post by infairverona
Ok first of all that's a film? Hardly relevant. And in theory perhaps, but I don't think the way our legal and medical systems work would reconcile saying someone is of sound mind/competent while also claiming he is going to kill himself. Considering the vast array of other things people are considered not competent for e.g. pregnant women who refuse treatment, people who are religious and refuse treatment, I highly doubt that many doctors would be happy to put themselves on the line by declaring someone who is actively planning to commit suicide as competent. That's just a legal case waiting to happen.

[e] Just a note I am not a medical professional, I've studied medical law and am doing a medical ethics/law MA so I don't know how in practice this would work but I would imagine if a doctor had a patient come to them saying they are going to commit suicide and then did nothing, that would be negligence. Whether you agree with their reasons for it or not.


But capacity (i.e. competency) is decided on a decision by decision basis. Very few people have absolutely no capacity to make any decisions. A person may be suicidal but still capable of making decisions in their day to day life and in healthcare decisions.

If you decided they posed an imminent risk to themselves you could only section (I'm talking broad terms here as I don't know the ins and out of the sectioning process) in order to assess them and treat any underlying mental health issue. The section does not extend past that. You could not over ride any of their other decisions, even if they refuse treatment for medical conditions (e.g. diabetes), as long as they have capacity for that decision (i.e. they understand the options and what will happen if they refuse).
Original post by ForestCat
But capacity (i.e. competency) is decided on a decision by decision basis. Very few people have absolutely no capacity to make any decisions. A person may be suicidal but still capable of making decisions in their day to day life and in healthcare decisions.

If you decided they posed an imminent risk to themselves you could only section (I'm talking broad terms here as I don't know the ins and out of the sectioning process) in order to assess them and treat any underlying mental health issue. The section does not extend past that. You could not over ride any of their other decisions, even if they refuse treatment for medical conditions (e.g. diabetes), as long as they have capacity for that decision (i.e. they understand the options and what will happen if they refuse).


My understanding of the sectioning process (in practice) is that once a patient is detained under the MHA they would be detained until they are no longer considered a threat to themselves. Considering that the MCA wording for losing capacity is "an impairment of, or a disturbance in the functioning of, the mind or brain" I would imagine that the patient wouldn't be considered as having capacity anyway, if it was relevant.

I agree with everything you've said so I'm not sure why it's phrased as if to disagree with me, perhaps my first post wasn't clear. I also didn't say that any refusal of treatment subsequently would be overridden?

[e] Again just to reiterate - I only know what answer I would give if this situation was a problem question in medical law/mental health law 101. I don't know how it would work in practice. Either way, I doubt it would ever be considered ok for the doctor in this situation to do nothing
(edited 8 years ago)
Reply 17
Avatar for Ghotay
Ghotay
13
Original post by infairverona
Ok first of all that's a film? Hardly relevant. And in theory perhaps, but I don't think the way our legal and medical systems work would reconcile saying someone is of sound mind/competent while also claiming he is going to kill himself. Considering the vast array of other things people are considered not competent for e.g. pregnant women who refuse treatment, people who are religious and refuse treatment, I highly doubt that many doctors would be happy to put themselves on the line by declaring someone who is actively planning to commit suicide as competent. That's just a legal case waiting to happen.

[e] Just a note I am not a medical professional, I've studied medical law and am doing a medical ethics/law MA so I don't know how in practice this would work but I would imagine if a doctor had a patient come to them saying they are going to commit suicide and then did nothing, that would be negligence. Whether you agree with their reasons for it or not.


Since when can you override the decisions of people who refuse treatment on religious grounds?

It is a film, I just chose an example you might have been familiar with. And it's a pretty realistic example - I'm sure mafia and gangs 'persuading' people to remove themselves from the picture is the sort of thing that actually does happen sometimes. There are lots of reasons I think that suicide could be considered rational, or at least not caused by a mental illness. Consider the Japanese samurai who committed seppukku. To continue to live would have cast horrific shame on their surviving family, so they killed themselves. And what do you think of the monks who sets themselves on fire as a form of political protest?

I agree that it would likely be considred negligent, if it was provable. But if the doctor did not intent to report it, they would probably not document it and so there would be unlikely to be any proof that the patient had shared this plan with the doctor. All I'm saying is that, as with many things in life, this decision would ultimately come down to discretion. And the example I gave above of a little old lady who was 'ready to go' I think is a good example of a case where it would be unlikely for anything to come of it
(edited 8 years ago)
Original post by infairverona
My understanding of the sectioning process (in practice) is that once a patient is detained under the MHA they would be detained until they are no longer considered a threat to themselves. Considering that the MCA wording for losing capacity is "an impairment of, or a disturbance in the functioning of, the mind or brain" I would imagine that the patient wouldn't be considered as having capacity anyway, if it was relevant.

I agree with everything you've said so I'm not sure why it's phrased as if to disagree with me, perhaps my first post wasn't clear. I also didn't say that any refusal of treatment subsequently would be overridden?

[e] Again just to reiterate - I only know what answer I would give if this situation was a problem question in medical law/mental health law 101. I don't know how it would work in practice. Either way, I doubt it would ever be considered ok for the doctor in this situation to do nothing


My point was less to do with the doctor's actions and more to do with the assumption that a suicidal person is automatically deemed incompetent just because of the fact that they're suicidal. They're not.

But like I said, I don't know the ins and outs of a situation like this, so I'll leave it here.
Original post by Ghotay
Since when can you override the decisions of people who refuse treatment on religious grounds?

It is a film, I just chose an example you might have been familiar with. And it's a pretty realistic example - I'm sure mafia and gangs 'persuading' people to remove themselves from the picture is the sort of thing that actually does happen sometimes. There are lots of reasons I think that suicide could be considered rational, or at least not caused by a mental illness. Consider the Japanese samurai who committed seppukku. To continue to live would have cast horrific shame on their surviving family, so they killed themselves. And what do you think of the monks who sets themselves on fire as a form of political protest?

I agree that it would likely be considred negligent, if it was provable. But if the doctor did not intent to report it, they would probably not document it and so there would be unlikely to be any proof that the patient had shared this plan with the doctor. All I'm saying is that, as with many things in life, this decision would ultimately come down to discretion. And the example I gave above of a little old lady who was 'ready to go' I think is a good example of a case where it would be unlikely for anything to come of it


In theory you can't. But it has happened particularly with Jehovah's Witnesses (being the obvious example) and it's much more complicated when they're children, too.

[e] In theory anyone can refuse a treatment as long as they have capacity, for any reason they like. It doesn't have to be a reason we consider 'reasonable' - if you say no and you're competent to say no, then that's that. But, there's tonnes of cases where people who have refused either for religious reasons, are pregnant, various other things have been declared 'incompetent' and given treatment anyway.

Sorry I haven't seen that film so I don't know what happens! I don't think shame on your family would justify killing yourself personally. Definitely not the political protest reason either. But that's subjective. If someone said to me 'I'm going to kill myself because I've brought shame on my family' honestly? I would think they were nuts. I get your point that you can definitely argue suicide can be rational, I'm not sure of my own stance on that though. I agree with euthanasia/PAS but for other reasons I'm still undecided. I read recently there was a nurse who went to Dignitas for example just because she didn't want to grow old, I think she was in her 70s - she was probably 'of sound mind' but I still don't really think that was a rational decision. I suppose there's no argument as to why it's irrational either, though.

True. I hadn't thought about if it would be recorded. It would be hard not to though wouldn't it? If a patient was on the system as having come in, then shortly commits suicide, and the record didn't have anything at all about suicide, I would've thought that would look quite weird (to an outsider) again I don't know how that would work in practice
(edited 8 years ago)

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