The Silent Omission: Why Avoiding Suicide Questions in Healthcare is a Riskier Strategy Than You Think
For years, some healthcare organizations have quietly been removing a single question from routine mental health screenings – the question about suicidal ideation. Driven by fears of liability, they’ve opted for the seemingly ‘safer’ route of omitting the ninth item on the PHQ-9 questionnaire. But this practice isn’t just ethically questionable; it’s increasingly clear that it’s a misguided attempt at risk avoidance that could actually increase legal exposure and, more importantly, endanger patients.
The Ethical Tightrope: Duty vs. Perceived Liability
At the heart of this issue lies a conflict between two ethical frameworks. The traditional deontological approach, rooted in the philosophy of Immanuel Kant, emphasizes a moral duty to treat patients with dignity and respect, regardless of potential outcomes. This means asking difficult questions, even those that might reveal painful truths. Conversely, the organizations omitting the question are leaning towards utilitarianism – a calculation of maximizing overall good, even if it means potentially overlooking the needs of an individual. While utilitarianism has its place in public health, applying it to a direct question about a patient’s life and well-being fundamentally devalues their inherent worth.
The Data Doesn’t Support the Fear
The most striking aspect of this debate is the lack of evidence supporting the fear of increased liability. Studies conducted during the rapid shift to virtual care during the COVID-19 pandemic, like those from Kaiser Permanente Washington and Stanford Health, have consistently shown no increase in adverse outcomes – including suicide attempts or deaths – following the implementation of full PHQ-9 screenings. In fact, Stanford’s research demonstrated that asynchronous administration of the scale actually improved clinical responses and maintained patient safety. A comprehensive review of the published literature reveals no reported cases of negative legal consequences stemming from asking about suicidality in pre-visit questionnaires.
The Real Legal Risk: Failure to Assess
Ironically, the greater legal risk isn’t asking the question; it’s not asking it. Malpractice experts, including Skip Simpson and Michael Stacy, consistently emphasize that thorough documentation of suicide risk assessments is crucial for legal defense. As they bluntly state, a well-documented chart demonstrating careful consideration of suicidal ideation is a powerful shield against litigation. Omitting the question creates a glaring gap in that documentation, suggesting a lack of due diligence.
Beyond Liability: The Role of Stigma
Why, then, does this practice persist? The answer, experts believe, lies in the pervasive stigma surrounding mental illness. We routinely screen for physical ailments – no one omits the question about chest pain, despite its potential severity – yet a question about suicidal thoughts is often viewed with apprehension. This stigma leads to a perception of patients with mental health concerns as inherently more dangerous, and a fear of being unfairly blamed for a tragic outcome. This is a dangerous and inaccurate assumption.
The Future of Mental Health Screening: Proactive and Integrated
Looking ahead, the trend will be towards more proactive and integrated mental health screening. The increasing adoption of telehealth and digital health tools will facilitate more frequent and accessible assessments. Artificial intelligence (AI) and machine learning will play a growing role in analyzing patient data to identify individuals at risk, but these tools will be most effective when combined with direct questioning and human clinical judgment. We can expect to see a shift from reactive, episodic care to continuous monitoring and preventative interventions. Furthermore, the focus will expand beyond simply identifying suicidal ideation to understanding the underlying factors contributing to mental distress, such as social determinants of health and access to care.
The key to navigating this evolving landscape is to prioritize patient safety, embrace evidence-based practices, and challenge the stigma that continues to hinder effective mental healthcare. Removing the question about suicide isn’t a solution; it’s a dangerous detour that puts patients at risk and undermines the fundamental principles of medical ethics. It’s time to ask the question, document the response, and provide the support that patients deserve.
What steps is your organization taking to improve mental health screening and reduce stigma? Share your experiences in the comments below!
