This is taken from my Ethics formal assignment, Semester 1, 2015.
A client has reached a point where they no longer wish to continue cancer treatments and instead wish to die.
Do I take steps to notify relevant bodies of my client’s intentions to die, or do respect their wishes and assist them to live what remains of their life in as fulfilling a manner as possible?
The CCAA (2012) is clear on this:
3.5 The exception to maintaining confidentiality is a client threatening to harm self or another through suicide, homicide, or serious and imminent abuse. It is the duty of counsellors to disclose such information to their supervisors and to the authorities including, where relevant, the Police and the relevant Child Protection Authority in their jurisdiction.
PACFA (2014) is less clear on the topic and more open-ended and flexible. It refers to the need to keep the trust of the client:
3.1.3 Keeping trust
D. Situations in which clients pose a risk of causing serious harm to themselves or others are particularly challenging for the practitioner. These are situations in which the practitioner should be alert to the possibility of conflicting responsibilities between those concerning their client, other people who may be significantly affected, and society generally. Resolving conflicting responsibilities may require due consideration of the context in which the service is being provided. Consultation with a supervisor or experienced practitioner is strongly recommended, whenever this would not cause undue delay. In all cases, the aim should be to ensure for the client a good quality of care that is as respectful of the client’s capacity for self-determination and their trust as circumstances permit.
As can be seen, the PACFA-ethical practitioner could arguably leave the door open for the client to self-determine and respectfully be allowed to self-euthanise.
The Criminal Law Consolidation Act 1935 (1935) speaks to us of suicide. Section 13A(1) of the Act states that “It is not an offence to commit or attempt to commit suicide.” But it is, however, an offence under section 13A(5) to aid, abet or counsel someone else to commit suicide or attempt to commit suicide.
As Dale (2010, p. 31) puts it, “As counsellors our practices are governed firstly by the laws of the land, secondly through our adherence to ethical guidelines and codes of practice set out by the professional bodies to which we belong and thirdly to our own personal views of ethics and morality.” In this instance my membership of CCAA would mean that I would have to notify my supervisor as well as the police and any other relevant bodies.
Having been at the point that forces one to attempt suicide in order to alleviate one’s psychic pain, I have some personal sympathy and empathy with my client. I know that to consider taking one’s own life is not a selfish act, as some have suggested, but is instead an act of great courage. Every fibre of one’s being screams for life; to act upon oneself to draw a veil over one’s life takes immense fortitude and strength. Suicide, especially in a country like Australia where firearms are not easily obtainable, is a courageous and not easy act.
The law holds that I cannot physically do anything to help my client end their life, lest I be charged with manslaughter and being an accessory to manslaughter. But equally I know the pain of depression; also having been a first-hand witness to my wife’s and my mother’s painful, debilitating cancer treatments, I know the suffering that is inflicted upon the cancer victim. From their experiences I know too the feelings they had of being unwell and unable to do anything about it. It is a complete lack of quality of life (QOL) that my client is experiencing.
So do I, the counsellor, take ‘seeking to protect life’ as a supreme ethical cornerstone for my work, or, as Dale (2010) suggests, do I respect client autonomy, even if this means that the client may choose to die? “Do we empathise, explore the suicidal thoughts with our clients and take no action, or do we need (or want) to alert others, most usually the client’s GP, or other medical practitioner, of the perceived danger?” (Dale, p.32).
My own reading of the SA Mental Health Act 2009 (2009) seems to indicate, but I am not a lawyer, that notification is only required if the client has a mental illness; if my client does not, in my eyes, have a mental illness but is instead tired of the pain and lack of QOL and wishes to prolong it no longer, then there are two avenues open to me as I see it. One would be to work with their medical practitioner to increase the dosages and timings of painkiller medications for my client so that pain and discomfort no longer plague him. The other is to allow him autonomy, agency and confidentiality and keep his intentions to myself.
Virtue ethics is not a stance I would have entertained before this course, principally because I had not heard of them. I would have classed myself as a Consequentialist before this course. But Virtue ethics are instructive in this instance of trying to decide what the ‘right’ thing to do is.
Virtue ethics are normative ethical philosophies that place their emphasis on ‘being’ rather than ‘doing’. Through ‘right being’ I am more likely to be ‘right doing’. As Aristotle said in the Nicomachean Ethics (2002), the chief human good is happiness, achieved through the development and display of wisdom and reason, and balancing the components of courage, moderation, open-handedness, munificence (i.e. spending in proportion to the occasion), greatness of soul, honour, mildness of temper, conversational excellence and technical skill-based excellences (Stewart, 2010). Progression towards these goals leads to general human excellence. For me as a counsellor to display the Aristotelian virtues would require of me the following:
- Courage to possibly disagree with my supervisor and ignore the CCAA code of ethics 3.5 and not notify the police or other relevant bodies;
- Moderation in balancing my responsibilities under CCAA’s code of conduct versus the needs of my client;
- Open-handedness in my dealings with my client, my supervisor and me;
- Somehow to display ‘megalopsychia’ (Aristotle, 2002) or greatness of soul which, according to Curzer (1990), is ‘greatness and self-knowledge’;
- The display of Honour in my dealings with all of my clients, colleagues and others;
- Mildness of temper;
- Conversational excellence; and
- Excellence in my tradecraft.
These are virtues worth striving for, in my humble opinion. They call on me to do my best in all circumstances, and to apply phronēsis, or ‘practical wisdom’ (Hinman, 2013).
What I would do
I would attempt to exercise and display the Aristotelian virtues by letting my client exercise autonomy. I would not encourage them to suicide, but would instead encourage them to seek out palliative care; such providers are better skilled than I in meeting the needs of the soon-to-be-deceased. I would of course discuss the case with my supervisor but I would not be swayed from allowing my client the respect due to them, which comes attached with notions such as autonomy and self-agency.
And as in the first case study, I would document everything.
Aristotle. (2002). Nicomachean ethics: Translation, introduction, and commentary. Oxford: Oxford University Press.
CCAA. (2014). Code of ethics. Retrieved from: http://ccaa.net.au/images/documents/CODE_OF_ETHICS_Sept_2014.pdf
Curzer, H. J. (1990). A great philosopher’s not so great account of great virtue: Aristotle’s treatment of ‘Greatness of Soul’. Canadian Journal of Philosophy, 20(4), 517-537. doi: 10.1080/00455091.1990.10716503
Dale, S. (2010). Where angels fear to tread : An exploration of having conversations about suicide in a counselling context. Newcastle upon Tyne: Cambridge Scholars Publishing.
Government of South Australia. (1935). Criminal Law Consolidation Act 1935. Adelaide: Government of South Australia Retrieved from http://www.legislation.sa.gov.au/LZ/C/A/CRIMINAL%20LAW%20CONSOLIDATION%20ACT%201935.aspx.
Government of South Australia. (2009). Mental Health Act 2009. Adelaide: S.A. Government Retrieved from http://www.legislation.sa.gov.au/LZ/C/A/MENTAL%20HEALTH%20ACT%202009.aspx.
Hinman, L. M. (2013). Ethics: A pluralist approach to moral theory (Fifth ed.). Boston, USA: Wadsworth.
King, I. (2008). How to make good decisions and be right all the time: Solving the riddle of right and wrong (Kindle ed.). London: Bloomsbury Academic.
Miner, M. H. (2006). A proposed comprehensive model for ethical decision-making (EDM). In S. Morrissey & P. Reddy (Eds.), Ethics and professional practice for psychologists (pp. 25-37). South Melbourne: Thomson.
PACFA. (2014). Code of Ethics: The ethical framework for best practice in counselling and psychotherapy. Retrieved from: http://www.pacfa.org.au/wp-content/uploads/2014/10/PACFA-Code-of-Ethics.pdf
Stewart, A. E. (2010). Explorations in the Meanings of Excellence and Its Importance for Counselors: The Culture of Excellence in the United States. Journal of Counseling & Development, 88(2), 189-195.
Wikipedia. (n.d.). Ethical non-naturalism. Retrieved 28th May, 2015, from http://en.wikipedia.org/wiki/Ethical_non-naturalism