Is Suicide Foreseeable?
By Judy Regan, MD, JD, MBA, and Lauren Smith, JD

Suicide is the third leading cause of death for people ages 15 to 24. A recent study by the Centers for Disease Control showed a decline in suicide among youth 10-24 years of age from 1990 to 2003 but a sharp eight-percent increase between 2003-2004; this was the largest single-year increase in 15 years.

Historically suicides were considered illegal acts in which the youth bore the sole responsibility. More recently, however, suicide has been considered to be “a superseding intervening cause” that can break the causation chain of events leading to the death. Both legal theories made it difficult to establish that a physician could be liable for a youth’s suicide. However, some courts are now finding it is a jury question as to whether a youth’s suicide was a foreseeable consequence of a physician’s alleged medical negligence and thus not a superseding, intervening cause.

The Court of Appeals of Tennessee just recently visited this topic in the case of Drake v. Williams, No. M2007-00979-COA-R3-CV, slip copy, (Tenn. App. 2008). In Drake, a 24-year-old began exhibiting signs of depression and alterations of his mental state. After being evaluated by his family physician, he was placed under the care of a psychiatrist who diagnosed him as having a major depressive disorder, single episode, severe. The patient was admitted to the treatment center and began taking medication. A low level of suicidal ideation was noted and he was placed on suicide precautions. While the patient’s psychosis and mental state fluctuated during his 18-day stay at the hospital, his psychiatrist believed his condition was improving and allowed his discharge on the condition that he stay with his parents. Eight days after his discharge and despite his perceived improved behavior and general condition, he committed suicide by shooting himself with his father’s gun.

Thereafter, the deceased’s parents initiated a medical malpractice wrongful death action against the psychiatrist alleging the psychiatrist breached a duty of care to the deceased. The trial court ruled in favor of the psychiatrist, finding the suicide was a superseding, intervening cause of death. The parents appealed and the Tennessee Court of Appeals reversed the trial court’s decision, finding that it was, indeed, a jury question as to whether the deceased’s suicide was a foreseeable consequence of the psychiatrists’ alleged medical negligence and not a superseding, intervening cause.

To be a superseding, intervening cause, the intervening act must be “1) sufficient by itself to cause the injury, 2) was not reasonably foreseeable to the negligent actor, and 3) was not a normal response to the negligent actor’s conduct.” It is obvious that suicide is sufficient by itself to cause the injury. Whether suicide is reasonably foreseeable or a normal response to the negligent actor’s conduct are the deciding questions in a medical malpractice case and, indeed, questions the courts throughout the country and in Tennessee are more inclined to present to a jury as a question of fact.

In Williams, White v. Lawrence, the Tennessee Court of Appeals cited to a general negligence case that was decided in favor of the defendant when discussing the issue of foreseeability. In Rains v. Bend of the River, 124 S.W.3d 584 (Tenn. Ct. App. 2003), a handgun and ammunition retailer was sued by the parents of a young man who purchased a gun and ammunition from the defendant and proceeded to kill himself with it. The court found in favor of the defendant, holding that the clerk who sold the gun had no reason to foresee that this particular customer was going to kill himself. The Rains court, however, noted three exceptions to the application of the independent intervening cause in suicide cases: “1) circumstances in which the defendant’s negligence causes delirium or insanity that results in self-destructive acts, 2) custodial settings in which the custodian knew or had reason to know that the inmate or patient might engage in self-destructive acts, and 3) special relationships, such as a physician-patient relationship, when the caregiver knows or has reason to know that the patient might engage in self-destructive acts.” It appears then that the physician-patient relationship, specifically the psychiatrist-patient relationship, is one that is unique and that the courts address with particular scrutiny, as the physician is seen as having a better perspective and more knowledge as to the patient’s mental health.

Given that suicide is a leading cause of death in young adults and over half of practicing psychiatrists will lose a patient to suicide at some point in their career, it is evident that medical malpractice litigation regarding a suicide will continue. Despite the consideration that suicide in many cases can occur without warning (and therefore be unforeseeable), the judicial system seems to be unwilling to consider that factor without first considering whether the psychiatrist or physician had any knowledge that the suicide was a possibility. Therefore physicians, particularly psychiatrists, should perform suicide assessments on their patients, document their findings and take appropriate actions to ensure their patient’s safety when applicable.

References:
1. Jeffrey S: Suicide in Youth and Young Adults Spiked in 2003-2004: CDC Report. Am J Psychiatry 164:1356-1363, 2007.
2. See Williams, White v. Lawrence, 975 S.W.2d 525 (Tenn. 1998) (holding that reasonable minds could differ as to whether the decedent’s act of suicide was an independent intervening cause of his death), Jacoves v. United Merch. Corp., 9 Cal. App.4th 88 (Cal. Ct. App. 1992) (cited in Williams and holding that the foreseeability of the patient’s suicide was a triable issue of fact for the jury to consider).
3. Smith AR, et. al: Revisiting Impulsivity in Suicide: Implications for Civil Liability of Third Parties. Behav Sci Law 26(6), 2008.

Dr. Regan is an associate clinical professor of psychiatry at Vanderbilt University School of Medicine and an associate with North, Pursell & Ramos, PLC, in Nashville. Ms. Smith is an associate with NPR.