Suicide litigation: from legal to clinical wisdom

Literature on legal aspects of suicide prevention is reviewed to focus on fundamental issues of care. The legal basis of liability is discussed in the context of risk assessment and risk management of suicidal patients. The "four Ds"--duty, dereliction of duty, damages and direct causation--are illustrated. Standards are described at three levels: of the profession, the court and the individual practitioner. Risk assessment is often confused with prediction; the latter is conceptually unsound, and while the former is more sound it is disappointingly imprecise. Despite reliability problems, risk assessment and appropriate management are important, as life itself is involved. Clinicians should be aware that informed consent requires responsibility for suicide prevention to be shared with patients. Such involvement of patients in self-destructive frames of mind raises complex issues. Management issues of both inpatients and outpatients at acute or chronic risk are discussed. Potential pitfalls for clinicians are outlined. Communications with, and the supervision of, other staff must be carefully considered. Families of vulnerable persons or those following bereavement also merit consideration. Patients are entitled to treatment with dignity and liberty--the latter should not be compromised any more than is essential--even when suicide is a possibility. Balancing these difficult issues may be easier if clinicians have a clear awareness of them.