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Permitted suicide: model rules for mental health counseling. (Practice).

In mental health practice, no explicit provisions have been made for existing law and codes of ethics to protect freedom and confidences of clients who, due to serious, irremediable ir·re·me·di·a·ble  
Impossible to remedy, correct, or repair; incurable or irreparable: irremediable errors in judgment.

, physical illness, rationally desire to end their lives. This paper makes a case for permitting suicide in these special circumstances special circumstances n. in criminal cases, particularly homicides, actions of the accused or the situation under which the crime was committed for which state statutes allow or require imposition of a more severe punishment. . Starting with an analysis of permitted suicide, the legal background for applying this concept is provided, and ten model rules for permitting suicide in mental health practice are developed.


Physician assisted suicide assisted suicide: see euthanasia.  has recently gained some legitimacy within the medical and mental health communities as a possible option for persons suffering from diseases such as Lou Gerhigs, multiple sclerosis, cancer, and HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States.  (American Counseling Association The American Counseling Association (ACA) is a non-profit, professional organization that is dedicated to the counseling profession. ACA is the world's second largest association exclusively representing professional counselors.  [ACA ACA - Application Control Architecture ], Association for Gay, Lesbian and Bisexual Issues in Counseling, Coalition of Mental Health Professionals, Washington State Psychological Association, 1996; National Association of Social Workers The National Association of Social Workers (NASW) is the largest membership organization of professional social workers in the world, with 150,000 members. The NASW works to enhance the professional growth and development of its members, to create and maintain professional  [NASW NASW National Association of Science Writers
NASW National Association of Social Workers (Washington, DC)
NASW National Association of Social Workers
NASW National Association for Social Work (UK) 
], 1994; Oregon Death with Dignity Act Ballot Measure 16 of 1994 established the U.S. state of Oregon's Death with Dignity Act (ORS 127.800-995), which legalizes physician-assisted dying with certain restrictions. Passage of this initiative made Oregon the first U.S. , 1999; Slome, Mitchell, Charlebois, Benevedes, & Abrams, 1997; Werth, 1996). Nevertheless, contrary to recent correlation studies (ACA et al., 1996), standards of mental health practice invariably in·var·i·a·ble  
Not changing or subject to change; constant.

 treat all suicides as products of mental illness, requiring paternalistic pa·ter·nal·ism  
A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities.
 interventions such as incarceration Confinement in a jail or prison; imprisonment.

Police officers and other law enforcement officers are authorized by federal, state, and local lawmakers to arrest and confine persons suspected of crimes. The judicial system is authorized to confine persons convicted of crimes.
 or detention.

The counseling environment is presumed to offer prospective clients who have a need to work through problems of living, and of dying, a safe haven 1. Designated area(s) to which noncombatants of the United States Government's responsibility and commercial vehicles and materiel may be evacuated during a domestic or other valid emergency.
 in which to do so. Unfortunately, for clients who suffer from severe irremediable medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. , which lead them to contemplate suicide, counseling portends risks of personal freedom and dignity. Counselors should be free to provide a conciliatory con·cil·i·ate  
v. con·cil·i·at·ed, con·cil·i·at·ing, con·cil·i·ates
1. To overcome the distrust or animosity of; appease.

 atmosphere in which to carefully work through end-of-life decisions, and clients should not be dissuaded from enlisting their services (ACA et al., 1996; NASW, 1994; Battin, 1991).

The idea of counselors permitting suicide of a client rather than intervening to prevent it may seem to fly in the face of to defy; to brave; to withstand.
to insult; to assail; to set at defiance; to oppose with violence; to act in direct opposition to; to resist.

See also: Face Fly
 conventional mental health wisdom. Nevertheless, an unqualified standard of intervention fails to accommodate the special circumstances of some clients whose contemplation of suicide is rational and is, therefore, not the result of cognitive dysfunction or mental defect.

This article introduces and defines the concept of permitted suicide. Second, it discusses the legal context for applying this concept to cases of rational clients who seek suicide as relief from the suffering and indignity in·dig·ni·ty  
n. pl. in·dig·ni·ties
1. Humiliating, degrading, or abusive treatment.

2. A source of offense, as to a person's pride or sense of dignity; an affront.

 of serious, irremediable physical conditions. Third, it considers the concept of rational suicide and applies it toward construction of standards for permitting suicide. Last, ten model rules for permitting suicide in mental health practice are proposed in light of the emerging analysis.


Following is articulation of the (necessary and sufficient) conditions under which a mental health provider can be said to have permitted the suicide of a client:

A mental health provider (P) permitted a client (C) to commit suicide Verb 1. commit suicide - kill oneself; "the terminally ill patient committed suicide"
kill - cause to die; put to death, usually intentionally or knowingly; "This man killed several people when he tried to rob a bank"; "The farmer killed a pig for the holidays"
 when (1) C successfully attempted suicide; (2) P reasonably anticipated that C would attempt suicide; (3) P was aware of at least one accessible intervention that could have thwarted C's anticipated suicide attempt suicide attempt, suicide bid nintento de suicidio

suicide attempt, suicide bid ntentative f de suicide

; (4) P intentionally elected not to employ any such intervention; and (5) the proximate cause An act from which an injury results as a natural, direct, uninterrupted consequence and without which the injury would not have occurred.

Proximate cause is the primary cause of an injury.
 of C's death was C's lethal act.

The above conditions define permitted suicide in terms of the intentional omission of a preemptive pre·emp·tive or pre-emp·tive  
1. Of, relating to, or characteristic of preemption.

2. Having or granted by the right of preemption.

 suicide intervention Suicide intervention or suicide crisis intervention is direct effort to stop or prevent persons attempting or contemplating suicide from killing themselves. Current medical advice concerning people who are attempting or seriously considering suicide is that they should . For purposes of these conditions, the variable P refers to any individual or institutional mental health provider having a legal duty of due care to its clients. This includes counselors as well as other mental health professionals such as social workers, psychologists, psychiatrists, and psychiatric nurses. P also includes any mental health facility such as a mental health agency or a psychiatric hospital psychiatric hospital
A hospital for the care and treatment of patients affected with acute or chronic mental illness. Also called mental hospital.

C can be any suicidal client or patient of any such individual or institutional mental health provider. As will be shown, potential candidates for defensible cases of permitted suicide include clients suffering from irreversible physical maladies or diseases causing unmitigated un·mit·i·gat·ed  
1. Not diminished or moderated in intensity or severity; unrelieved: unmitigated suffering.

 (mental or physical) pain and suffering.

Suicide interventions include but are not limited to such specific acts as involuntary hospitalization involuntary hospitalization Forensic psychiatry A civil commitment in which a person is formally confined to a mental health institution, due to mental illness, incompetence, alcoholism, drug addiction, or other, as he/she is deemed dangerous to him/herself or , detaining an individual for observation or evaluation, facilitating or setting up vigils to protect clients from self-destructive acts, contacting the suicidal client's family or contacting authorities such as the police, and referral to another mental health professional or physician (Cohen cohen
 or kohen

(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male.
 & Cohen, 1999). The accessibility of interventions includes interventions that can be performed with reasonable effort, without unduly jeopardizing the welfare and safety of affected third parties or of the professional health care provider, and which can be performed within time constraints dictated by the individual situation.

The intentional nature of failure to execute interventions makes clear that permitted suicide, as a legal category, is not a result of negligence but is rather a deliberate action, backed by considered judgment, and founded upon pertinent criteria. It should also make clear, that a counselor does not permit suicide, as defined, if a present or former client happens to commit suicide without the counselor's knowledge.

The requirement that the counselor reasonably anticipate a client's suicide attempt makes clear that permitted suicide arises in cases in which the harm is foreseeable. There is typically no liability in cases where the harm is not foreseeable. (Winger v. Franciscan Medical Center, 1998). The question of liability arises in cases where the death of the client can be anticipated with a reasonable degree of skill, knowledge, and care ordinarily expected within a given profession (Tarasoff v Regents of the University of California The Regents of the University of California make up the governing board of the University of California. The Board has 26 full (i.e., voting) members:
  • The majority (18 Regents) are appointed by the Governor of California for 12-year terms.
, 1976).

The requirement that the proximate cause of client death be the client's lethal act (condition 5) cannot be derived simply from the fact that the client successfully attempted suicide (condition 1) since the (legal) cause of the client's death may still be the defendant's action. Liability for malpractice and tortious Wrongful; conduct of such character as to subject the actor to civil liability under Tort Law.

In order to establish that a particular act was tortious, a plaintiff must prove that an actionable wrong existed and that damages ensued from that wrong.
 conduct depends, in part, upon the establishment of a causal connection between client harm and the defendant's action (Van Hoose & Kottler, 1985). Such a judgment of causality cannot be founded merely on the discernment that the suicidal act was foreseeable (Nally v. Grace Community Church, 1988; Rowland v. Christian, 1968). Thus a counselor who foresees a client's suicide and does not intervene cannot, by virtue of the foreseeability of harm alone, be held liable for the harm.

The case of permitted suicide as defined is similar to passive euthanasia with respect to proximate proximate /prox·i·mate/ (prok´si-mit) immediate or nearest.

Closely related in space, time, or order; very near; proximal.


immediate; nearest.
 causation (Baird & Rosenbaum, 1989). In the latter, the proximate cause has been deemed to be the disease rather than the medical act or omission such as withdrawal of life sustaining equipment (In re Quinlan, 1976; Cruzan v. Director, Missouri Dept. of Health, et al., 1990). Similarly, in permitted suicide, the failure to intervene may not be the proximate cause. The act of suicide itself can be the proximate cause provided the injured party Noun 1. injured party - someone injured or killed in an accident

victim - an unfortunate person who suffers from some adverse circumstance
 is not insane or bereft of reason and attempts suicide when in that state (Little v. Chicago Hoist and Body Co., 1965; Moss v. Meyer, 1983: Stasiof v. Chicago Hoist and Body Co., 1964).

Permitted suicide in mental health practice may be contrasted with physician-assisted suicide Noun 1. physician-assisted suicide - assisted suicide where the assistant is a physician
assisted suicide - suicide of a terminally ill person that involves an assistant who serves to make dying as painless and dignified as possible
. Permitting suicide involves omission whereas assisting it involves commission (Glover, 1977; Steinbock Stein´bock`

n. 1. (Zool.) The European ibex.
, 1980). In physician-assisted suicide, the physician sets things up in a manner that enables the patient to commit suicide, for example provides the patient with a lethal drug or a means for administering it (In Re Joseph G, 1983; People of the State of Michigan v. Kevorkian, 1994). In permitted suicide, the counselor does not take measures to prevent the suicide.


The Oregon Death with Dignity Act of 1999 (as amended from the 1994 Act) legalizes a qualified version of physician-assisted suicide on demand in Oregon. The Act requires attending physicians (or consulting physicians) to refer patients requesting suicide for counseling when, in their opinion, these patients may have a "psychiatric or psychological disorder Noun 1. psychological disorder - (psychiatry) a psychological disorder of thought or emotion; a more neutral term than mental illness
folie, mental disorder, mental disturbance, disturbance
, or depression causing impaired judgment" (3.03). Although counseling refers to consultation with a state licensed psychiatrist or psychologist (3.01(5)), the Act sets a precedent for the role of mental health professionals in the determination of whether nonintervention non·in·ter·ven·tion  
Failure or refusal to intervene, especially in the affairs of another nation.

 or assistance in clients' commission of suicide is warranted.

Recent landmark court decisions recognizing competent clients' autonomy to control the course of their dying also appear to support counselors' nonintervention in certain cases of suicidal clients. In McKay v. Bergstedt (1990), the Supreme Court of Nevada The Supreme Court of Nevada is the highest judicial body in the Nevada state government. This is an elected position. The Chief Justice is elected by the members of the court each year.  found in favor of a 31-year-old mentally competent, nonterminal quadriplegic quadriplegic /quad·ri·ple·gic/ (-ple´jik)
1. of, pertaining to, or characterized by quadriplegia.

2. an individual with quadriplegia.
, Kenneth Bergstedt, who sought to affirm his right to die. Bergstedt, who was able to read, watch television, orally operate a computer, and occasionally use a wheelchair for ambulation am·bu·late  
intr.v. am·bu·lat·ed, am·bu·lat·ing, am·bu·lates
To walk from place to place; move about.

[Latin ambul
, sought to have a respirator respirator /res·pi·ra·tor/ (res´pi-ra?ter) ventilator (2).

cuirass respirator  see under ventilator.
 removed that he had lived with for 23 years.

In Bouvia v. Superior Court (1996), the California Court of Appeals, Second District, found for Elizabeth Bouvia Elizabeth Bouvia is a figure in the right-to-die movement. Her case attracted nationwide attention in this area as well as in medical ethics. History
In 1983, Elizabeth Bouvia, at the age of 25, admitted herself into the psychiatric ward of a California hospital.
, a bedridden bed·rid·den or bed·rid
Confined to bed because of illness or infirmity.
, nonterminal, competent quadriplegic suffering from cerebral palsy cerebral palsy (sərē`brəl pôl`zē), disability caused by brain damage before or during birth or in the first years, resulting in a loss of voluntary muscular control and coordination.  and arthritis, who petitioned the court for the removal of a feeding tube feeding tube
A flexible tube that is inserted through the pharynx and into the esophagus and stomach and through which liquid food is passed.
 involuntarily administered to preempt pre·empt or pre-empt  
v. pre·empt·ed, pre·empt·ing, pre·empts
1. To appropriate, seize, or take for oneself before others. See Synonyms at appropriate.

 her suicide by starvation. The appellate court A court having jurisdiction to review decisions of a trial-level or other lower court.

An unsuccessful party in a lawsuit must file an appeal with an appellate court in order to have the decision reviewed.
 maintained that patients should be able to enlist the assistance of physicians in ending their lives in comfort and dignity.

In a further case concerning the removal of a nasogastric feeding Noun 1. nasogastric feeding - feeding consisting of delivering liquid nutrients through a tube passing through the nose and into the stomach
forced feeding, gavage - feeding that consists of the delivery of a nutrient solution (as through a nasal tube) to someone
 tube from a nonterminal, incompetent patient, the New Jersey Supreme Court, responding to the appellate decision, maintained that, in cases not involving the protection of others, competent patients' interest in directing the course of their own lives should supercede Verb 1. supercede - take the place or move into the position of; "Smith replaced Miller as CEO after Miller left"; "the computer has supplanted the slide rule"; "Mary replaced Susan as the team's captain and the highest-ranked player in the school"  the State's indirect and abstract interest in preserving life (In re Claire C. Conroy, 1985). On the other hand, courts have frequently distinguished between the withdrawal or refusal of artificial means to preserve life and other modes of ending life such as guns, poisons, and knives (Vacco v. Quill Vacco v. Quill, 521 U.S. 793 (1997), is a landmark decision of the Supreme Court of the United States regarding the right to die. It ruled that a New York ban on physician-assisted suicide was not unconstitutional, and preventing doctors from assisting their patients, even , 1997). In Krischer v. McIver (1997), the Florida Supreme Court relied upon this distinction to reverse the decision of a trial court which affirmed the right of a competent, terminally ill Terminally Ill

When a person is not expected to live more than 12 months.

Any gifts given out by the afflicted person at this time may be considered as a dispersion of the estate rather than a gift.
, 35-year-old with AIDS to physician assistance in ending his life. Nevertheless, whether or not this distinction clearly deprives all suicides of legal status is not evident. Suicide by a competent patient suffering from end-stage bowel cancer may be no less defensible than the decision of a competent, nonterminal patient like Kenneth Bergstedt to disconnect his respirator after 23 years (McKay v. Bergstedt, 1990 [Justice Springer's dissenting opinion dissenting opinion n. (See: dissent) ]).

In People of the State of Michigan v. Jack Kevorkian Jack Kevorkian, M.D. (IPA pronunciation: [kɛ.ˈvɔːɹ.ki.ɛn] [1]) (born May 20, some sources say May 26[2], 1928) is a controversial American pathologist.  (1992), Circuit Court Judge David F. Breck denied that there was any morally important difference between assisted suicide and withdrawal of life support. A similar conclusion was reached by the United States Court of Appeals The United States courts of appeals (or circuit courts) are the intermediate appellate courts of the United States federal court system. A court of appeals decides appeals from the district courts within its federal judicial circuit, and in some instances from other  for the Ninth Circuit in Compassion in Dying v. the State of Washington (1996) regarding the right of terminally ill, competent adults to physician-assisted suicide. The Court argued that the line between commission and omission is a distinction without a difference now that patients are permitted to instruct their doctors to terminate life support. The Court concluded that the interest of a competent, terminally ill patient, whose physician is willing to prescribe appropriate medication, outweighs the State's interest in preventing suicide.

In Quill v. Vacco (1996), the Second Circuit Court of Appeals drew the same conclusion in finding a New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
 statute that criminalized physician-assisted suicide to be in violation of the Equal Protection Clause The Equal Protection Clause, part of the Fourteenth Amendment to the United States Constitution, provides that "no state shall… deny to any person within its jurisdiction the equal protection of the laws.  of the Fourteenth Amendment Fourteenth Amendment, addition to the U.S. Constitution, adopted 1868. The amendment comprises five sections. Section 1

Section 1 of the amendment declares that all persons born or naturalized in the United States are American citizens and citizens
. The Court argued that terminally ill patients on life-support systems are treated differently than other terminally ill patients because the former may lawfully hasten death by ending treatment, while the latter may not. The Court maintained that this differential treatment based on such arbitrary elements of the patient's condition, was unfair, discriminatory, and inhumane in·hu·mane  
Lacking pity or compassion.

inhu·manely adv.

The U.S. Supreme Court reversed both the Second and Ninth Circuit Courts' decisions. In Vacco v. Quill (1997), the Court reiterated the distinction between withdrawing life-sustaining treatment and assisting suicide, maintaining that it accorded with fundamental legal principles of causation and intent. Thus, the Court denied that the New York law prohibiting physician-assisted suicide violated equal protection. In Washington v. Glucksberg In Washington v. Glucksberg, 521 U.S. 702, 117 S. Ct. 2258, 138 L. Ed. 2d 772 (1997), the U.S. Supreme Court was asked to review the constitutionality of a Washington state statute prohibiting physician-assisted suicide.  (1997), the Court reversed the Ninth Circuit Court's decision, reaffirming the same distinction by appealing to the long history in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  of legal rejection of physician-assisted suicide. It concluded that the right to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause.

While the Court did not recognize a right to assistance in committing suicide as a constitutionally protected fundamental liberty, it did not foreclose fore·close  
v. fore·closed, fore·clos·ing, fore·clos·es
a. To deprive (a mortgagor) of the right to redeem mortgaged property, as when payments have not been made.

 the possibility of state recognition of a right to assisted suicide. The Court explained that its holding permits continuation of the debate over the legality as well as morality and practicality of physician-assisted suicide. Further, in a concurring opinion Noun 1. concurring opinion - an opinion that agrees with the court's disposition of the case but is written to express a particular judge's reasoning
judgement, legal opinion, opinion, judgment - the legal document stating the reasons for a judicial decision;
, Justice Stevens emphasized that, in particular cases, the distinction between withdrawal of life support and assistance in committing suicide may be illusory, and that the state interest in preserving human life is not sufficient to outweigh the interest of dying patients in assistance to end intolerable suffering and preserve dignity.

In 1996, the American Counseling Association, joined by the Washington State Psychological Association, the Association for Gay, Lesbian, and Bisexual Issues in Counseling, and a Coalition of Mental Health Professionals filed an amicus brief with the U.S. Supreme Court in support of the rulings of the Second and Ninth Circuit Courts regarding terminally ilk competent patients' right to assistance in dying. The brief sought to defend the ability of mental health professionals to adequately assess the competence and rationality of terminally ill clients who have decided upon or have been contemplating hastening death. It sought to lend credence to the idea that such decisions can be rational, voluntary, and consistent with client autonomy, dignity, and self-esteem (ACA et al., 1996). Although the Court did not uphold the Circuit Courts' rulings, the ACA's statement portends change in policy concerning the role of mental health professionals in decisions about assisted suicide.

The National Association of Social Workers (1994) set an earlier precedent for such change with its policy statement on assisted suicide and end-of-life decisions. The document, which was also attached to the aforementioned amicus brief (ACA et al., 1996, Appendix B), stated, "social workers should be free to participate or not participate in assisted-suicide matters or other discussions concerning end-of-life decisions depending on their own beliefs, attitudes, and value systems" (Policy Statement).

In the aftermath of the 1997 Supreme Court rulings, the American Psychological Association The American Psychological Association (APA) is a professional organization representing psychology in the US. Description and history
The association has around 150,000 members and an annual budget of around $70m.
 (APA (All Points Addressable) Refers to an array (bitmapped screen, matrix, etc.) in which all bits or cells can be individually manipulated.

APA - Application Portability Architecture
) formed a Working Group to investigate the role of psychologists in assisted suicide and end-of-life decisions. While this task force decided neither to support or oppose assisted suicide, it recommended, among other things, that the APA monitor change in law, policy, and research on assisted suicide, support education and training for psychologists in critical areas, and periodically revise its official statement on assisted suicide (APA, 2000, Section 4).


As the ACA recognized in its amicus brief to the U.S. Supreme Court (ACA et al., 1996), the question of whether assisted suicide should receive support from mental health professionals depends upon whether such an act, in response to serious illness, can be called rational. This question has recently been addressed in the form of specifying standards of rational suicide (Battin, 1991; Battin, 1995; Siegel, 1986; Werth, 1996). Following are standards derived from these sources:

1. The decision is based upon sound reasoning. The client who is contemplating suicide does not make any logical errors in inferring conclusions from premises; and the premises from which the conclusions are inferred are themselves factually complete and accurate (Battin, 1995).

2. The decision is based upon a realistic worldview world·view  
n. In both senses also called Weltanschauung.
1. The overall perspective from which one sees and interprets the world.

2. A collection of beliefs about life and the universe held by an individual or a group.
. The client does not make any reality claims that cannot be justified within a surrounding culture (Battin, 1995), and the client's claims would be understandable to the majority of other uninvolved un·in·volved  
Feeling or showing no interest or involvement; unconcerned: an uninvolved bystander.

Adj. 1.
 observers from the client's own cultural or social group (Siegel, 1986).

3. The decision aims at the avoidance of pain and suffering. The client's prospective suicide is undertaken to avoid irremediable mental and/or physical pain and suffering that is unacceptable to the client (Battin, 1995; Werth, 1996).

4. The decision is autonomous and voluntary. The client's decision is not inconsistent with, and is supported by the client's own system of personal values and goals, and it is not motivated by pressure or intimidation from others (Battin, 1991; Battin, 1995; Werth, 1996).

These standards assume that the client is mentally competent (ACA et al., 1996). In particular, Standard 1 assumes soundness and reliability of client cognition and perception. This means that rational suicide decisions cannot be the result of psychiatric illness such as clinical depression (Conwell & Caine, 1991; Siegel, 1986).

Standard 1 includes orientation or grasp of basic reality conditions such as awareness of who one is, where one is, and what one is doing or intending to do. It also includes the ability to make inductive inferences based upon adequate evidence (Brandt, 1990). Errors such as prediction based upon an unrepresentative Adj. 1. unrepresentative - not exemplifying a class; "I soon tumbled to the fact that my weekends were atypical"; "behavior quite unrepresentative (or atypical) of the profession"  sample would violate this standard, for example, predicting one's life expectancy Life Expectancy

1. The age until which a person is expected to live.

2. The remaining number of years an individual is expected to live, based on IRS issued life expectancy tables.
 based upon mortality data drawn from just a few individuals.

Standard 1 requires that the decision be based upon complete and accurate information. This requires that the client has taken reasonable steps to insure that he or she has an illness for which there is no cure, and for which no palliative solution is available. Some researchers have also linked consultation with, and consideration of, effects upon significant others as conditions of rational suicide (Greenberg 1982;Werth, 1996). In cases in which the acquisition of complete and accurate client information calls for such consultation and consideration, this appears to be valid. Helping clients to clarify their own true motives, influences, emotions, outlooks, expectations, beliefs, and attitudes regarding suicide can be a complex task. Eliciting such information may also require that counselors raise appropriate questions aimed at exposing such cogent, underlying details (Battin, 1991). Standard 1 also covers the validity of client's deductive de·duc·tive  
1. Of or based on deduction.

2. Involving or using deduction in reasoning.

 inferences. For example, a client who reasoned from the premise, "If I kill myself, then I will escape my suffering," to the conclusion, "If I don't kill myself, then I will not (ever) escape my suffering," would have reasoned invalidly (so-called "inversion" error), since this inference discounts even the possibility of a future cure.

Standard 2 requires that the determination of rationality take into account the client's cultural or social group. For example, while a Jehovah's Witness' rejection of blood transfusions can be justified within a certain religious culture, there is no cultural validation for the schizophrenic who thinks he can fly. This standard also makes clear that client reality is substantially a social construct and that, therefore, assessment of client rationality must take into account the client's surrounding cultural environment (Guterman, 1994; Ginter & Bonney, 1993; D'Andrea, 2000; Ellis, 1996; Rigazio-DiGilio, 1994).

Standard 3 points to the futility of the client's condition due to the irremediable pain and suffering of a serious physical illness. Such conditions include "terminal illnesses, severe physical and/or psychological pain, physically or mentally debilitating de·bil·i·tat·ing
Causing a loss of strength or energy.

Weakening, or reducing the strength of.

Mentioned in: Stress Reduction
 and/or deteriorating conditions, or quality of life no longer acceptable to the individual" (Werth, 1996, p.62). The subjective requirement that the pain and suffering be unacceptable to the client as well as the inclusion of psychological pain signals the need for counselors to relate to clients' suffering phenomenologically, not merely through diagnosis of psychiatric disorders (Schneidman, 1992). The proviso that such pain and suffering be irremediable makes the palpable assumption that palliative care palliative care (paˑ·lē·ā·tiv kerˑ),
n an approach to health care that is concerned primarily with attending to physical and emotional comfort rather
 cannot always alleviate pain and suffering (Washington v. Glucksberg, 1997 [Justice Stevens' concurring opinion]; Werth, 1996).

Standard 4 authenticates the decision as the client's by requiring consistency with basic values (Battin, 1991; Cohen, 1986; Macklin, 1982). Such decisions cannot result from mental disorders mental disorders: see bipolar disorder; paranoia; psychiatry; psychosis; schizophrenia. , prescribed medications, substance abuse, or external social or economic pressures (ACA et al., 1996).

In applying standards of rationality, counselors should not confuse fundamental value disagreement with cognitive dysfunction, fallacious thinking, or false premises. (Appelbaum & Gutheil, 1991, p. 223). On the other hand, an inconsistency or other logical failure in the client's belief system might be challenged according to according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 the client's own value system.

Training and Consultation

Consonant with the aforementioned standards of rationality, counselors must possess an adequate grasp of technical skills required for assessing client competence and rationality, including familiarity with pertinent cognitive modalities (Carney & Hazler, 1998) and assessment tools (Agresti, 1990; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Hill & Spengler, 1997; Hinkle, 1990). Counselors also have a duty to consult with at least one other independent professional having such expertise (APA, 1992,1.20a; ACA, 1995, C.2.e; AMHCA AMHCA American Mental Health Counselors Association , 2001, 1.n; Oregon Death with Dignity Act, 1999). Consultation with a philosophical counselor trained in applied logic and critical thinking may also be of significant confirmatory value (Cohen, 2001). Further, both primary counselor and consultant(s) should agree that the client is competent and rational. Otherwise the irreversibility and finality of the decision militates against permitting the suicide.

Waiting Period

Proposals for legalization LEGALIZATION. The act of making lawful.
     2. By legalization, is also understood the act by which a judge or competent officer authenticates a record, or other matter, in order that the same may be lawfully read in evidence. Vide Authentication.
 of physician-assisted suicide have typically required a waiting period before lethal medication can legally be prescribed by physicians. For example, the Oregon Death with Dignity Act of 1999 requires a waiting period not less than 15 days after the patient makes the initial verbal request (3.08). One rationale for the wait is to provide patients an opportunity to rethink the decision and thus to change their minds.

This rationale also applies in the case of counselor-permitted suicide. In this case, at the time of verbal expression Noun 1. verbal expression - the communication (in speech or writing) of your beliefs or opinions; "expressions of good will"; "he helped me find verbal expression for my ideas"; "the idea was immediate but the verbalism took hours"
verbalism, expression
 of intent to commit suicide, the client could be asked to sign a unilateral no-suicide agreement to stay alive until the client has had an opportunity to work through the matter carefully and rationally with the counselor (Wubbolding, 1996). This waiting period should afford the counselor time for consultation, time to assist the client in working through any other unfinished business, including notification of next of kin The blood relatives entitled by law to inherit the property of a person who dies without leaving a valid will, although the term is sometimes interpreted to include a relationship existing by reason of marriage. Cross-references

Descent and Distribution.
, and time to confirm pertinent data such as medical reports.

Since the process of successfully working through the issues surrounding the suicide decision may depend upon a number of variables--the complexity of these issues, number of sessions per week, and client cooperation in disclosing pertinent information--standardizing the waiting period can be problematic. Counselor and client might instead negotiate the length of the waiting period, although a minimum wait might be established. Thus, a 15-day minimum waiting period could be required. Clients who refused to sign a no suicide agreement for an agreed upon Adj. 1. agreed upon - constituted or contracted by stipulation or agreement; "stipulatory obligations"

noncontroversial, uncontroversial - not likely to arouse controversy
 duration could still be subject to paternalistic intervention, depending upon the counselor's assessment of the risk of client suicide.

Notification of Next of Kin

Respect for client autonomy may, in some instances, militate against mil´i`tate a`gainst´

v. t. 1. To argue against; to cast doubt on; - used in reference to facts which tend to disprove a hypothesis; as, the absence of a correlation of budget deficits with inflation militates against any causal relation
 dictating such recourse, as when client and family are estranged es·trange  
tr.v. es·tranged, es·trang·ing, es·trang·es
1. To make hostile, unsympathetic, or indifferent; alienate.

2. To remove from an accustomed place or set of associations.
. While counselors have a responsibility to carefully explore notification issues with their clients prior to a determination of the rationality of a suicide decision, there should be no unconditional requirement for clients to notify family (Oregon Death with Dignity Act, 1999, 3.05).

Method of Delivery

The method of delivery (manner of administering suicide) must also be broached if the counselor is to facilitate a client's thorough inspection of suicide. Counselors should accordingly familiarize themselves with the pertinent facts about the various methods of self-administration, including types of drugs, lethality of dosages, and the efficacy of different methods.

Further, while counselors cannot legally prescribe lethal drugs or administer paraphernalia (for example, give clients plastic bags), the line between permitting and assisting the client in committing suicide may be questioned (Young, 1989). For example, does a counselor assist suicide by providing the client with literature on self-administration (for example, giving the client a copy of Derek Humphrey's book, Final Exit) or by providing the client with the Hemlock hemlock, any tree of the genus Tsuga, coniferous evergreens of the family Pinaceae (pine family) native to North America and Asia. The common hemlock of E North America is T.  Society's Internet address There are two kinds of addresses that are widely used on the Internet. One is a person's e-mail address, and the other is the address of a Web site, which is known as a URL. Following is an explanation of Internet e-mail addresses only. For more on URLs, see URL and Internet domain name. ?

According to the Oregon Death with Dignity Act of 1999, the attending physician must "[d]ispense medications directly [italics added], including ancillary medications ..." (3.01(L[A])), or, with the patient's written consent, provide a written prescription to a pharmacist "who will dispense the medications to either the patient, the attending physician or an expressly identified agent of the patient" (3.01(L[B])). Providing literature about how to commit suicide does not appear to involve making a means of suicide available directly, since the literature itself is not a lethal instrument. Whether it may be regarded as an indirect means analogous to a physician's prescription is unclear.

A physician's prescription of a legally regulated drug removes a barrier to obtaining the drug that would otherwise have blocked the patient from (legally) obtaining it. In contrast, providing a client with information about self-administration (or providing information about how to obtain such information) does not likewise remove any such barrier. The client does not need legal authorization from anyone to (legally) obtain the information.

While there is no First Amendment protection of literature rendering directions on the commission of a crime (Rice v. Paladin Paladin

archetypal gunman who leaves a calling card. [TV: Have Gun, Will Travel in Terrace, I, 341]

See : Wild West
, 1997), self-administration literature exists in the public eye and seems to enjoy such a constitutional safeguard. It is nevertheless legally suspect as to whether counselors who intentionally make such literature available to clients who are contemplating suicide are guilty of a crime.

A number of state penal codes provide that anyone who assists another in the commission of suicide is guilty of a felony (Cal. Penal Code, Sec. 401; Texas Penal Code, Sec. 22.08; Oregon Penal Code, 163.125(b); New York Penal Code, 125.15(3); Florida Penal Code, 782.08). Some states have also criminalized attempts at assisting suicide (for example, Texas Penal Code 22.08(a)). It is suspect as to whether counselors who provide directions to clients on the commission of suicide with full knowledge of the intended use of such information will be deemed in violation of such laws.

While counselors must not counsel clients to commit suicide (NASW, 1994), competent clients should not be prevented from assessing the facts about the use (and misuse) of different modes of self-administration. Imparting such knowledge to clients does not mean that the counselor endorses or recommends any of them. To criminalize crim·i·nal·ize  
tr.v. crim·i·nal·ized, crim·i·nal·iz·ing, crim·i·nal·iz·es
1. To impose a criminal penalty on or for; outlaw.

2. To treat as a criminal.
 counselors' cooperation in a process of rational inquiry subverts the counseling mission of client empowerment. Clients who irremediably ir·re·me·di·a·ble  
Impossible to remedy, correct, or repair; incurable or irreparable: irremediable errors in judgment.

 suffer from physical maladies are thereby deprived of the opportunity to think rationally and according to their own ethical lights about how they might want to die.

Nevertheless, counselors should avoid imparting information about means of self-administration until they deem clients sufficiently rational and at a stage in their deliberations where it would be useful to pursue such discourse. Counselors must exercise constraint in providing such information when it is not necessary to clients' present deliberations, when there are more immediate issues that must be resolved first, or when counselors have reason to think that their clients might prematurely use the information to end their lives.

Medical Diagnosis

A further restriction may be that of limiting permissible nonintervention to cases of terminally ill clients (Oregon Death with Dignity Act, 1999, 2.01). On the other hand, as discussed (under legal background), courts have permitted withdrawal of life support in cases of rational patients who were not terminally ill (McKay v. Bergstedt, 1990). Further, as explained (under Methods of Delivery), medical assistance such as that of making legally regulated, lethal drugs available to suicidal clients through prescription goes beyond merely permitting suicide as herein defined and may thus warrant additional safeguards.

A patient whose release from irremediable pain and suffering hinges upon the removal of a respirator may be no more in need of pain relief than a patient who is not so dependent (Quill v. Vacco, 1996). Further, the suffering, suicidal client who is nonterminally ill is required to suffer for an indefinite period of time while the client deemed terminally ill may have only a projected maximum wait of about 6 months (Oregon Death With Dignity Act, 1999,1.01(12)). Thus nonterminally ill clients may be required to suffer longer precisely because they are not terminally ill. If the rationale in the one case is release from pain and suffering or a death with dignity--the exercise of autonomous control over one's destiny--then the disparate treatment of these cases is inconsistent.

Medical Documentation for Diagnosis

Whether the illness in question is terminal is distinct from whether it is incurable and irreversible. The incurable and irreversible nature of the disease is a medical fact that must be sufficiently documented by counselors before they are warranted in permitting suicide. Otherwise the counselor violates a duty of due care by not acting according to professional and legal standards of knowledge, skill, and diligence that have been established for the protection of clients (Cohen & Cohen, 1999; APA, 1992, 2.01(b)).

Current standards of documentation pertaining to end-of-life decisions commonly require the medical determination of a qualified, primary physician as well as confirmation by an independent, qualified consulting physician (see, e.g., Health Care Advance Directives, 1999, Florida Statute 765.306; Oregon Death With Dignity Act, 1999, 3.01, 3.02). The counselor whose client is contemplating suicide due to an incurable and irreversible disease, needs accordingly to request these records from the primary physician after the client has voluntarily signed a written release of information granting their legal transfer to the counselor. If the client refuses to release these records to the counselor, then proper documentation for permitting client suicide does not ensue, and the counselor's duty of due care requires the counselor to take reasonable measures to prevent the suicide.

Conscientious Objections

Because suicide is a form of action that may be proscribed PROSCRIBED, civil law. Among the Romans, a man was said to be proscribed when a reward was offered for his head; but the term was more usually applied to those who were sentenced to some punishment which carried with it the consequences of civil death. Code, 9; 49.  by counselors' religious or personal morality, it is understandable that some counselors may be averse to the idea of ever permitting clients to commit suicide. However, standards of practice require that counselors avoid imposing their values on clients (AMHCA, 2001, 1.e.2; ACA, 1995, A.4.b).

While more extensive study of attitudes of mental health professionals toward supporting client suicide is indicated, there is evidence suggesting that only a minority of counselors would oppose according at least some clients the option of suicide (Fenn, 1999; Werth, 1996). Nevertheless, counselors who are unable to counsel clients effectively due to value conflicts or personal problems should assess the situation, seek consultation, and where necessary, make appropriate referral (NASW, 1997,1.06.a; APA, 1992,1.13.c; ACA, 1995, A.11.c, AMHCA, 2001, 1.q). Further, professional standards do not release counselors from a duty to protect a client to whom referral is made (AMHCA, 2001, 1.p; ACA, 1995, A.11.a). This would require taking reasonable measures to protect the safety of a suicidal client prior to continuation of counseling with the referral or in the event the client declines the referral.


The following rules for permitted suicide can be gleaned from the foregoing discussion:

1. Pursuant to standards of rationality (as herein defined), the counselor validates the client's decision to commit suicide and obtains at least one independent, qualified, confirmatory assessment.

2. In applying standards of rationality, the counselor is mindful of any personal value disagreement he or she may have with a suicidal client and does not confuse these differences in the client's values with cognitive dysfunction, fallacious thinking, or false premises.

3. The counselor facilitates the client's free and rational exploration of suicide without attempting to cajole (language) CAJOLE - (Chris And John's Own LanguagE) A dataflow language developed by Chris Hankin <> and John Sharp at Westfield College.

["The Data Flow Programming Language CAJOLE: An Informal Introduction", C.L.
, intimidate, or otherwise influence the client's election of suicide.

4. At the time of verbal expression of intent to commit suicide, the counselor requests that the client sign a unilateral, written, no-suicide agreement to stay alive for a negotiable waiting period of no less than 15 days. If the client declines to sign the agreement, the counselor assesses the risk of client suicide and acts accordingly to prevent it.

5. The counselor is knowledgeable about the various methods of self-administration, including types of drugs, lethality of dosages, and the efficacy of different methods. While the counselor may impart such information as appropriate to the client's free and informed exploration of the issue of self-administration, the counselor neither advises nor encourages the use of, nor provides clients with any such means of, self-administration.

6. The counselor avoids the rendering of information on self-administration prematurely, unnecessarily, when the counselor considers the client to be incompetent, or when the counselor has reason to doubt the client's ability to act responsibly with regard to this information.

7. The counselor requires sufficient documentation of the incurable and irreversible nature of the client's disease pursuant to the client's signing of a written release of appropriate medical records. Sufficient documentation includes validation of the incurable and irreversible nature of the client's disease as provided by a qualified physician, and confirmation thereof from a qualified, independent consulting physician.

8. The counselor who has a conscientious objection to permitting suicide of any client, including rational ones, carefully assesses the situation and, mindful of client safety, refers the client to a qualified counselor who does not have any conscientious objection to the same.

It is important to note that, in the context of the above rules, rational does not equate to morally justified according to a particular conception of morality. It refers to the evidentiary basis of a judgment rather than to a substantive moral principle. To be rational in this sense is to base one's judgment on logically sound reasoning. As Rule 3 makes clear, accepting the rationality of a suicide does not mean that one agrees with it morally.

The proposed model rules anticipate and address some of the legal arguments (discussed herein) against permitted suicide. As suggested (under legal background), there have been significant professional and legal strides toward recognition and protection of competent individuals' right to control their own demise in the face of irremediable pain and suffering.


Seriously and irremediably ill clients, who rationally seek suicide to end suffering, warrant the same legal protection afforded other groups of rational, competent persons against involuntary hospitalization, detainment, surveillance, and other forms of coercive practice. In such cases, paternalistic intervention by counselors defeats the counseling missions of client empowerment and promotion of client welfare and undermines clients' dignity and trust by using clients' own confidential disclosures to subvert their autonomy (Cohen & Cohen, 1999). Where the standard rationale for suicide intervention does not apply, counselor permitted suicide according to rules resembling those herein set forth provides a viable remedy to undue abridgments of personal freedom, welfare, dignity, trust, and autonomy.


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Elliot D. Cohen, Ph.D., is a professor of Philosophy and chair, Department of Humanities, Indian River Community College Indian River Community College (IRCC) is a community college based in Fort Pierce, Florida which serves the counties of Indian River, Martin, Okeechobee and St. Lucie. It has branch campuses in Okeeconbee, St. Lucie West in Port St. , Fort Pierce, FL. He is also editor of International Journal of Applied Philosophy.
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Author:Cohen, Elliot D.
Publication:Journal of Mental Health Counseling
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Date:Oct 1, 2001
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