Suicide risk? I don't want you.

Why do psychiatrists and other mental health professionals continue to accept into their practices patients who contemplate suicide? Do they want to be heroes? Do they feel too guilty about rejecting someone who "needs" their help?

Know that if a patient kills herself on your watch any survivors and their attorneys will very likely come after the money in your malpractice policy.

Know too that a colleague will gladly testify that if only you had done or not done something you should or should not have done the patient would still be alive today. Licensure boards will do the same. Never mind whether the patient's choice to die had anything at all to do with that for which you were treating them.

Because of these potential devestating consequences, including the emotional impact on yourself, once you know that the patient entertains thoughts of dying you will likely focus the preponderance of your efforts, not on providing the best treatment for the problem, but on preventing a suicide. Consider carefully whether you can keep someone from killing himself. In my community years ago a patient shot himself while in the office with the psychiatrist. Could you have stopped him? Patients kill themselves in psychiatric hospitals. If we cannot prevent those suicides, how can you imagine you have any control over someone between encounters?

Mental health professionals need not accept these risks. We can still ethically decide whom to accept and whom to reject as patients. If judges and juries continue to hold us responsible for the intentional acts of others we can choose not to accept the risk. Consider the consequences if we turned away potential patients whom we judged to carry an unacceptable risk of suicide. Patients would likely soon learn they must lie in order to obtain treatment. Might we add statements to our treatment agreements like, "I have never contemplated or attempted suicide." Would you demand to review prior records for evidence of past attempts or impulses to suicide? If you published on your Web site your policy of rejecting patients with unacceptable risk would they look elsewhere or simply be better prepared to lie.

Might such a change impact people contemplating suicide? Might knowing that mental health professionals might reject them as patients afterward (if the attempt failed) make them less -- or more -- likely to kill themselves? How might a patient react if after the initial evaluation you tell them you will not accept them as a patient? Who will accept them? Will they overwhelm those who do?

Consider making at least a small adjustment in deciding whom to accept as a patient. Maybe if more of us reject them, higher risk patients might not find anyone to treat them, and the courts or legislatures might do the right thing and stop blaming the treaters for the choices of their patients.

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