The Fatal Disease

When George, a nineteen-year-old college student, began psychotherapy with Dr. Hightower, he told the doctor that he was suffering from a fatal disease. Two months into therapy George felt that he trusted his therapist enough to tell her that the disease was AIDS.

During the next eighteen months, much of the therapy focused on George's losing battle with his illness and his preparations to die. After two stays in the hospital for pneumonia, George informed Dr. Hightower that he knew he would not survive his next hospitalization. He had done independent research and talked with his physicians, and he was certain that if pneumonia developed again, it would be fatal due to numerous complications and that it would likely be a long and painful death. George said that when that time came, he wanted to die in the off-campus apartment he had lived in since he came to college—not in the hospital. He would, when he felt himself getting sicker, take some illicitly obtained drugs that would ease him into death. Dr. Hightower tried to dissuade him from this plan, but George refused to discuss it and said that if Dr. Hightower continued to bring up the subject, he would quit therapy. Convinced that George would quit therapy rather than discuss his plan, Dr. Hightower decided that the best course of action was to offer caring and support—rather than confrontation and argument—to a patient who seemed to have only a few months to live.

Four months later, Dr. Hightower was notified that George had taken his life. Within the next month, Dr. Hightower became the defendant in two civil suits. One suit, filed by George's family alleged that Dr. Hightower, aware that George was intending to take his own life, did not take reasonable and adequate steps to prevent the suicide, she had not notified any third parties of the suicide plan, had not required George to get rid of the illicit drugs, and had not used hospitalization to prevent the suicide. The other suit was filed by a college student who had been George's lover. The student alleged that Dr. Hightower, knowing that George had a lover and that he had a fatal sexually transmitted disease, had a duty to protect the lover. The lover alleged ignorance that George had been suffering from AIDS.

This scenario has been one of the most agonizing and controversial for the psychotherapists and counselors who consider it at ethics and malpractice workshops. Some believe that Dr. Hightower acted in the most humane, sensitive, and ethical manner; others believe that she was wrong to accept, without more vigorous challenge, George's decision to take his own life. In this sense, it illustrates the dilemmas we face when confronted with a suicidal individual (see Chapter Seventeen). It also illustrates how such issues as confidentiality (see Chapter Sixteen) have been challenged when a specific third party or the public more generally is perceived to be put at risk by a client.

Many would argue that the main goal of therapy when suicide is an issue is to defuse the potentially lethal situation. According to this stance, we have a professional duty to take appropriate affirmative measures to prevent patients from harming themselves, a duty that may include in extreme cases seeking a civil commitment of the patient. However, there has been increasing attention to an alternate view in which the clinician may respect and accept the client's autonomy to such a degree that the client's decision to commit suicide is respected and accepted. Some would accord this "right to die" to any client; others would recognize it only in certain extreme situations (for example, if the client is suffering from a painful and terminal disease). Some would draw the line at accepting a client's decision to commit suicide and taking no steps to interfere with the client's self-destructive acts; others would consider actively assisting the person to die. These agonizing, controversial issues have become especially difficult for some who provide mental health services to those with AIDS (see Pope & Morin, 1990), as in this vignette. As is so often the case, the ethical and clinical issues are interwoven with legal standards. Some states have considered and continue to consider legislation related to the issue of assisted suicide, and the topic continues to be complex and controversial (Carter, VandeKieft, & Barren, 2005; Downie, 2004; Ganzini, 2006; Gostin, 2006; Hamilton & Hamilton, 2005; Herlihy & Watson, 2004; Kleespies, 2004; Okie, 2005; Radtke, 2005; Rosenfeld, 2004; Werth & Blevins, 2006).

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