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A model for clinical counseling with the terminally ill client who considers premptive suicide

14 December 1990


The increasing use of life-extending medical technology creates a dilemma for
some individuals who, when diagnosed with terminal illness, consider preemptive suicide as an alternative to other forms of dying. At this point, psychology as a profession has no standards of practice for providing counseling to such individuals other than those standards which have been developed for treating depression and suicide generally. A review of historical attitudes toward suicide highlights the alternation between permissive and proscriptive social norms. Discussion of the many ethical dilemmas confronting the therapist in this area focuses on the need to find an appropriate balance between respecting patient autonomy and respecting the therapist's duty to warn against harm. A model is proposed by which professional therapists can assist terminally ill clients in making decisions about the manner and timing of their own deaths. The model approaches preemptive suicide as one of several alternatives that might be chosen by a mentally competent, terminally ill patient. A framework is developed within which the patient can make this decision in an orderly and emotionally appropriate way while allowing the therapist to exert continuing clinical judgment regarding the psychological health and needs of the patient. In order to address the need for informed consent, a variety of special arrangements and agreements need to be made between clinician and client, the most important of which involve discussing the use of coercion and creating mutual understanding about what defines the welfare of the client. Procedures are described for assessing the patient's general mental status and for insuring that the patient has an adequate and accurate grasp of the medical facts. A process is then described for constructing and evaluating a wide range of
alternatives to preemptive suicide which the patient may consider. The inclusion
of physicians, family members and others who may contribute to this discussion is encouraged. Activities are described through which the patient may bring
responsible closure to the life which is ending, including the tasks of parting from family, friends and the clinician. A brief discussion of the model focuses on ways in which it might engender productive discussion of these issues among
professional psychologists .


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