Suicide Attempts and Treatment Refusals

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