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Ethical and Legal Considerations

Confidentiality

Confidentiality is of central importance in any therapeutic relationship as it provides the foundation for the development of trust and protects clients’ rights to privacy. Confidentiality is not absolute however. When suicide risk is suspected, clients and their parents/caregivers need to understand that the clinician will take specific actions- including telling parents- to protect and promote the client’s safety. Clients need to be explicitly told that their privacy will not be protected under these circumstances. Clients and their family members should always be fully informed about the limits to confidentiality at the outset of treatment. These principles and the rationale behind them should be re-visited throughout the course of treatment, especially during periods of crisis and heightened suicidal ideation.

Other exceptions to confidentiality include:80

  1. When there is an imminent danger to an identifiable third party
  2. When you suspect abuse or neglect of a child
  3. When a disclosure is ordered by the court or required by other legislative acts

Ontario's and British Columbia's information and privacy commissioners recently produced a Practice Tool to support decision-making in situations where individuals may be at risk of suicide. A quote from this document makes our ethical and legal responsibility unambiguously clear, “… life trumps privacy, and our laws reflect that reality.”

For a copy of the tool go to http://www.oipc.bc.ca/pdfs/Policy/ipc-bc-disclosure-edu.pdf.

Informed Consent

Thoroughly informing clients and their parents/caregivers about the treatment process is an ethical and legal requirement. Taking time “up-front” to explicitly outline the treatment process, including: limits to confidentiality, the rationale for treatment including any risks or benefits, as well as treatment alternatives is an essential element of providing competent clinical care.

When working with younger children, we have an ethical obligation to treat children with dignity and respect which means providing them with as much information as they are deemed capable of absorbing. This has been referred to elsewhere as “assent” to treatment (instead of consent)81

Elements of Informed Consent61

  1. Statement about the purpose and nature of treatment
  2. Specific therapeutic goals and procedures
  3. Alternative choices
  4. Risks/benefits
  5. Potential duration
  6. Costs/method of payment
  7. Cancellation policy
  8. Limits to confidentiality
  9. Clinician qualifications
  10. Boundaries
  11. Complaint procedure

Protection from Harm

If a youth, aged 16 or older, is assessed to be at imminent risk for suicide and is refusing to be admitted to hospital as a voluntary patient, it may be appropriate to consider involuntary hospitalization in a designated mental health facility.

All four criteria, as outlined in the Mental Health Act, for admitting someone as an involuntary patient must be met. These are:

  1. The person is suffering from a mental disorder that seriously  impairs their ability to react appropriately to his or her environment or to associate with others
  2. The person requires psychiatric treatment in or through a designated facility
  3. The person requires care, supervision and control in or through a designated facility to prevent the person’s substantial mental or physical deterioration or for the person’s own protection or the protection of others
  4. The person is not suitable as a voluntary patient

Children under age 16 may be admitted by their parent or guardian as voluntary patients under the Mental Health Act if the admitting physician and director agree. It is recommended that such children be admitted under the Mental Health Act, rather than the Hospital Act because the Mental Health Act provides direction on admitting children and youth and protects their rights by providing for regular reviews and access to a Review Panel.

For more information on the Mental Health Act in BC.

If a child or youth is judged to be at risk for self-harm and the parents/caregivers are unable/unwilling to provide consent to treatment, then the youth may be “in need of protection” based on the Child Family and Community Services Act. Steps for making a report to child protection authorities, as outlined in the BC Handbook for Action on Child Abuse and Neglect should be followed.