Karlsson et al. BMC Medical Ethics (2018) 19:26
https://doi.org/10.1186/s12910-018-0265-6
RESEARCH ARTICLE
Open Access
Skepticism towards the Swedish vision zero
for suicide: interviews with 12 psychiatrists
Petter Karlsson1* , Gert Helgesson1, David Titelman2, Manne Sjöstrand1 and Niklas Juth1
Abstract
Background: The main causes of suicide and how suicide could and should be prevented are ongoing
controversies in the scientific literature as well as in public media. In the bill on public health from 2008 (Prop 2007/
08:110), the Swedish Parliament adopted an overarching “Vision Zero for Suicide” (VZ) and nine strategies for
suicide prevention. However, how the VZ should be interpreted in healthcare is unclear. The VZ has been criticized
both from a philosophical perspective and against the background of clinical experience and alleged empirical
claims regarding the consequences of regulating suicide prevention. This study is part of a larger research project in
medical ethics with the overarching aim to explore whether the VZ is ethically justifiable. The aim is to enrich the
normative discussion by investigating empirically how the VZ is perceived in healthcare.
Methods: Interviews based on a semi-structured interview guide were performed with 12 Swedish psychiatrists.
The interviews were analysed with descriptive qualitative content analysis aiming for identifying perceptions of the
Vision Zero for Suicide as well as arguments for and against it.
Results: Though most of the participants mentioned at least some potential benefit of the Vision Zero for Suicide,
the overall impression was a predominant skepticism. Some participants focused on why they consider the VZ to
be unachievable, while others focused more on its potential consequences and normative implications.
Conclusions: The VZ was perceived to be impossible to realize, nonconstructive or potentially counterproductive,
and undesirable because of potential conflicts with other values and interests of patients as well as the general
public. There were also important notions of the VZ having negative consequences for the working conditions of
psychiatrists in Sweden, in increasing their work-related anxiety and thwarting the patient-physician relationship.
Keywords: Suicide, Prevention, Bioethics, Public health, Goals, Psychiatry
Background
Suicide is a serious public health problem worldwide [1, 2].
Globally, approximately 800,000 people die by suicide each
year and it is the second leading cause of death among
those aged 15–29 years [3]. In Sweden, approximately 1500
people complete suicide every year, and it is the most common cause of death in males aged 15–44 years [2, 4, 5].
Strategies for suicide prevention exist in most
countries. The WHO presents a goal of reducing the
global suicide rate by 10% before 2020 but also encourages its member states to adopt more ambitious
goals [1]. The WHO argues that suicide prevention
is imperative, that every suicide is a tragedy and that
* Correspondence: petter.karlsson@ki.se
1
Department of Learning, Informatics, Management and Ethics, Karolinska
institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
Full list of author information is available at the end of the article
“every single life lost to suicide is one too many”.
To the authors’ knowledge, Sweden is the only
country with an official goal of reducing the suicide
rate to zero. This is nevertheless of international
relevance, since other countries or healthcare
systems may suggest, or have already suggested,
similar goals [6, 7].
In the bill on public health from 2008 (Prop 2007/
08:110) [8], the Swedish Parliament adopted an
overarching “Vision Zero for Suicide” (VZ) and nine
strategies for achieving suicide prevention. The overarching vision states: “No person should find himor herself in a situation in which they experience
that the only solution is suicide. The government’s
goal is that no person should take his or her own
life”. The nine strategies are directed both towards
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Karlsson et al. BMC Medical Ethics (2018) 19:26
the population and towards individuals. The three
strategies that directly concern healthcare are labeled
[1] “Medical, psychological and psychosocial efforts,”
[2] “To increase the competence of personnel and
other key actors in healthcare and care of persons
with suicide related problems,” and [3] “To analyse
critical incidents [of deaths by suicide in health service contexts] in Lex Maria reports”. The Lex Maria
legislation concerns the healthcare provider’s responsibility to investigate incidents that have or could
have resulted in injuries, in order to improve patient
safety [9–11].
The main causes of suicide and how suicide could
and should be prevented is an ongoing controversy in
the scientific literature as well as in public media
[12–19]. Contemporary scientific theories of the
causes of suicide take medical, psychological and
sociological aspects into account [20]. Epidemiological
research up to this point indicates a high incidence of
mental illness or drug abuse among persons completing suicide [21, 22]. However, the causes of suicide
are complex and it is not established, nor can it be
assumed, that mental illness or drug abuse are necessary causal factors that explain all suicides.
It is unclear how the VZ should be interpreted in
healthcare. On the one hand, it is explicitly stated in
the VZ that suicide prevention in Sweden should be
based on a systematic approach taking all aspects of
people’s social and physical environment into account
[8]. Furthermore, the nine strategies to a great extent
focus on areas outside of healthcare. On the other
hand, empirical studies underscore the importance of
psychiatric illness as a cause of suicide [1, 21, 22].
Moreover, regulations from the Swedish National
Board of Health and Welfare introduced in connection to the VZ recommended mandatory inquiries of
all suicides that occur in relation to healthcare in
accordance with the Lex Maria legislation, which originally concerns incidents due to medical errors [11].
These regulations had the purpose of improving suicide prevention by learning from medical errors, but
could also be interpreted to imply that every suicide
in relation to healthcare in fact is, at least in part,
the result of a medical error. The regulations have
since been changed and it is at present up to healthcare to inquire if a suicide is to be considered the result of a medical error or not, and if so, it is to be
inquired in accordance with the Lex Maria legislation
[9, 10]. It is still the case however, that the VZ states
that all instances of suicide in relation to healthcare
should be investigated by the Swedish National Board
of Health and Welfare. This seems to imply that the
VZ includes an obligation for healthcare to prevent
all suicides.
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The VZ has been criticized both from a philosophical perspective and against the background of clinical
experiences and alleged empirical claims regarding
the consequences of regulating suicide prevention.
For instance, it has been claimed about VZ that: (1)
it is unachievable and therefore place an unreasonable
burden on psychiatry [12]; (2) it hinders an open debate on legal euthanasia and physician-assisted suicide
[13, 23]; (3) it may lead to an extensive use of paternalistic coercive measures in healthcare [13, 23, 24];
(4) it is misguided because some suicides, so called
rational suicides, should not be prevented [23]; (5) it
may be counterproductive [23].
This study is part of a larger research project in medical ethics with the overarching aim to explore whether
the Swedish Vision Zero for Suicide is ethically justifiable. The aim of this study is to enrich the normative
discussion of the VZ by investigating empirically how it
is perceived in healthcare. Further, if policies are to be
implemented in practice, it is important to find out what
those who are supposed to implement them think about
them. For instance, if there is a general scepticism towards the policy in question, this may undermine the
feasibility of implementing it. For practical reasons the
main focus of this study was set on psychiatry. In
Sweden, psychiatrists frequently have a consulting role
when suicidality is an issue in the somatic areas of
healthcare. A focus on psychiatry could therefore be expected to cover problems relating to suicidality also
when they appear in the somatic areas of healthcare, and
the study was thus thought to concern healthcare as a
whole. The aim of this study was to answer the following
questions:
(1) How is the Vision Zero for Suicide perceived by
Swedish psychiatrists?
(2) What arguments for and against the Vision Zero for
Suicide occur amongst psychiatrists?
(3) Do Swedish psychiatrists perceive that the Vision
Zero for Suicide has influenced the clinical work in
healthcare and, in that case, in what ways?
Method
Participants and study design
Interviews based on a semi-structured interview
guide [see Additional file 1] were performed with 12
psychiatrists. The inclusion criteria for participation
in the study were: (1) being a specialist or a resident
in psychiatry and (2) having experience of working
with suicidal patients. The aim was to obtain as rich
qualitative data as possible. Thus, participants who
differed in age, experience, area of expertise and
sub-speciality were sought for. Participants were recruited continuously during the project by a mix of
Karlsson et al. BMC Medical Ethics (2018) 19:26
deliberative sampling and chain referral [25–28]. The
number of participants was not set from the beginning but was decided depending on whether further
interviews made any qualitative contributions to the
already gathered material, weighed against a practical
wish to limit the sample size. The final sample included five male and seven female psychiatrists, all
employed in the Greater Stockholm area at the time
of the interview. In total, the participants were working with both in-patient and out-patient care as well
as with teaching, within general psychiatry as well as
with focus on patients with affective disorders,
neuropsychiatric disorders, personality disorders, or
psychotic disorders. The participants’ clinical experience varied from current residency in psychiatry to
having worked as a psychiatrist for 25 years.
The participants were initially contacted by email
and if they were willing to participate they obtained
a document with information about the design and
purpose of the study, including that participation
was voluntary and that consent could be withdrawn
at any time during the course of the study. Verbal
informed consent to participate was then obtained
from each participant and documented in recording
at the time of the interviews, which is sufficient according to the Swedish law. The verbal informed
consent again followed information that participation
was voluntary and that consent could be withdrawn
at any time during the course of the study. The
study was approved by the Regional Ethical Review
Board in Stockholm (Dnr 2015/270–31/5).
Semi-structured interviews
All interviews were conducted by the first author (PK).
The interviews were semi-structured and based on five
main questions with the possibility of adding qualifying
follow-up questions, depending on the course of the
interview [25, 28–30]. The interviews included questions
about the participants’ experiences and perceptions of
the Vision Zero for Suicide (VZ), as well as questions about
their view on rational suicides [see Additional file 1]. The
aim was to get answers to each question, but also to allow
the participants to speak as freely as possible about them
[25, 29, 30]. Hence, the participants were encouraged to
elaborate on the questions or on their initial responses to
them. The interviewer strived not to interrupt the participant while speaking, not to ask leading questions, and to
allow silences [25, 29, 30]. There were a large number of
follow-up questions, and topics were also covered that are
not listed in the interview guide. The interviews were approximately between 45 and 75 min long. The interviews
were recorded with a digital voice recorder and transcribed
verbatim by the first author.
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Data analysis
The analysis was initially performed by the first
author. The first author’s preunderstanding is based
on his professional experience as a physician as well
as being a PhD-student in medical ethics. The coauthors contributed to the analysis from their respective vantage point as philosopher, clinician, or suicide
researcher.
The interviews were analysed with descriptive qualitative content analysis [27, 31]. The terminology suggested
by Graneheim & Lundman was used: ‘subcategories’
refer to the manifest content of the interviews and
‘themes’ to the meaning running through the subcategories on a higher level of abstraction. The analysis was
performed inductively, without pre-set categories or in
relation to any theoretical framework [27, 31]. Though,
with respect to the aim of the study, the analysis was
focused on identifying perceptions of the VZ as well as
arguments for and against it. In this sense the analysis
was purposive.
Initially each participant’s transcribed interview
was read through to get an overall impression of its
content. Next, meaningful units were identified, i.e.
words, sentences and paragraphs expressing a meaning. Thereafter, meaningful units similar in meaning
were given a code, e.g. “There are no rational suicides”. Next, subcategories were created by sorting
codes similar in meaning into the same subcategory.
Further condensation of subcategories was done by
arranging and re-arranging them into broader categories. Finally, categories were refined and sorted
into overriding themes. The three levels subcategories, categories and themes thus represent increasing
abstraction and condensation of information. Accordingly, the themes represent the highest level of
abstraction and are the final product of the analysis.
The interest in finding perceptions of and arguments
for or against the VZ rests upon the overarching aim of
answering normative questions about it. This interest
has steered the analysis of the interviews. Accordingly,
overlapping categorization was considered justified if a
reduction of subcategories or categories would have led
to a loss of information that could be of potential normative importance.
Results
The analysis of the 12 interviews yielded 26 distinct
subcategories, 10 higher level categories, and four
themes. The results are presented in Table 1 as well
as in the text to follow. When subcategories are
exemplified by more than one quote, in order to
clarify their meaning, this does not imply greater
importance.
Karlsson et al. BMC Medical Ethics (2018) 19:26
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Table 1 Results of content analysis of interviews with psychiatrists on the Vision Zero for Suicide
Subcategories
Categories
Themes
- Reach for the stars
Benefits in healthcare
Benefits of the VZ
- Increased awareness of suicidality in healthcare
- A good way of supplying resources to suicide prevention
- A positive signal from the authorities
- Decreased shame and increased empathy for suicidal persons
Benefits for the general public
- Increased public awareness of suicide
- Insufficient medical knowledge to treat and prognosticate
Insufficient knowledge
The VZ is unachievable
- Insufficient knowledge for predicting suicide
- Insufficient resources to prevent all suicides
Insufficient resources
- Insufficient legal means for compulsory care
Limitations of compulsory care
- Compulsory care is sometimes counterproductive
- Misdirected focus at the expense of appropriate measures
Wrong focus
- Threat of suicide as an instrument of power
The VZ is
nonconstructive
- Decreased inclination to seek help or share problems
- The VZ supports an unjustified difference between psychiatry
and somatic care
Negative consequences for psychiatry
- The VZ may have a deterring effect on physicians
- The VZ may amplify contradictory tasks
- The VZ may augment the anxiety among personnel
- The VZ may contribute to false views of psychiatric illness
among the public
Wrong message
- The VZ may contribute to false hopes on healthcare among
the public
- The VZ contributes to medicalization of normal psychology
- Thoughts and plans of suicide as comfort and hope
- Conflicting values with regard to the patient
- Conflicting values with regard to others
- Rational suicide
- Assisted suicide
Benefits of the VZ
This theme consists of six subcategories sorted under
two categories, and concerns what the participants
perceived to be potential benefits from the Vision Zero
for Suicide (VZ).
Benefits in healthcare
Some suicides should not be prevented
because the moral cost is too high
The VZ is not
desirable
Certain rational suicides should not
be prevented
I believe in the idea that, that you aim for the stars to
reach the treetops in almost all respects. I think it’s
good to have very high ambitions, if you at the same
time can live with the idea that we may not reach all
the way.
This category represents potential benefits from the VZ
for suicide prevention in healthcare.
Increased awareness of suicidality in healthcare Several participants expressed that the VZ may lead to increased awareness of suicidality among healthcare staff,
which potentially could prevent suicides.
Reach for the stars Two participants explicitly considered goals beyond one’s reach to be a constructive
way of achieving desired results. Several other participants considered utopian goals to be mainly
nonconstructive.
What is positive with the whole thing is that you,
you constantly update this question of suicide and,
maybe that you think about, you consider this
question also in situations where you maybe
wouldn’t otherwise.
Karlsson et al. BMC Medical Ethics (2018) 19:26
A good way of supplying resources to suicide prevention Some participants expressed that the VZ may be
a good way of directing resources to suicide prevention by drawing attention to the problem of suicide.
I mean it’s a good way to supply resources to it, it
illustrates a problem and […] everything that pushes
things in that direction is positive.
A positive signal from the authorities Several participants expressed that the VZ is a positive signal from the
authorities, and that it leads to suicide being taken seriously and as a problem in which the authorities are willing to invest.
We signal that no one should be left to take his/her
own life in a good country. It might signal that
we’re willing to invest in this, that we take it
seriously. It may of course be morally supportive for
personnel in psychiatry and supportive for patients.
Benefits for the general public
This category represents different ways in which the VZ
may have benefits for the public.
Decreased shame and increased empathy for suicidal
persons Some participants expressed that the VZ may
lead to decreased shame connected to suicide and facilitate talking about suicide in general, or increase people’s
empathy with suicidal persons.
So in this way it’s an advantage that you identify this as
a problem and also something that we’re, that we’re
able to talk about. That you don’t, just not talk about
suicide. That it’s too shameful or taboo to even bring up.
Increased public awareness of suicide Some participants expressed that the VZ may enhance public awareness
of suicidality, which in turn may prevent suicides.
If it leads to knowledge. If it leads to the average
citizen daring to ask the right questions when they’re
worried about someone. That schools will take notice
of this. If the vision leads to this, then I think it’s good.
The VZ is unachievable
This theme consists of five subcategories sorted under
three categories and concerns what the participants
perceive as reasons why the VZ is unachievable.
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Insufficient knowledge
This category represents different ways in which a lack
of knowledge is thought to be one of the problems with
the VZ.
Insufficient medical knowledge to treat and prognosticate Many participants expressed that one problem
with the VZ is that current psychiatry has a limited
ability to predict the course of illness, treatment outcomes, prognosis, and optimal choice of treatment for
individual patients. This limitation, including the inability to ease the suffering of certain patients, was
seen as a practical reason why the VZ is unachievable
and as an argument against it.
Sometimes it feels more like you carry out something
reminding of witchcraft. In this situation you ought to
perform certain rites in a certain way but you know
that you have no chance whatsoever to take the proper
measures.
They’ve tried every medication in the book, they’ve
tried every therapy. They still get serious
depressions. And I’m powerless and the patient is
suffering. I mean sometimes it’s malignant illness
that we really can’t handle today with the
available science and current knowledge,
unfortunately.
Insufficient knowledge for predicting suicide All of
the participants expressed that one reason why the
VZ is unachievable is a vast lack of evidence on how
to assess suicide risk. The majority of participants
expressed this notion in connection with the Lex
Maria legislation, as it was written at the time of the
interviews, which they perceived as being unreasonable. Further, they emphasized that statistically, suicides will occur also in what are labeled low-risk
groups of patients.
I think it’s very unfair if you’ve been in this
situation where you have made a thorough
assessment of your patient and decided that OK,
you can be on leave during the weekend, at home
with your family, and your dad will pick you up
and so on. And then if you learn that she
committed suicide, then it’s automatically our
fault.
Because if you send people home who have a low risk
of committing suicide, sooner or later for purely
mathematical, statistical reasons, it will happen
occasionally anyway.
Karlsson et al. BMC Medical Ethics (2018) 19:26
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Insufficient resources
The VZ is nonconstructive
This category represents how the participants regard insufficient financial resources as one of the problems with
the VZ.
This theme consists of 11 subcategories sorted under
three categories and concerns what the participants perceive to be potentially negative consequences of the VZ.
Insufficient resources to prevent all suicides A majority of the participants expressed that a lack of resources
in psychiatry is a major reason why the VZ is
unachievable.
Wrong focus
But I also think that this is a little offensive. If you
work in the middle of it all, like I do, and
experience that we are barely covered
[economically] year after year after year. And then
they say that we are going to add a little Vision
Zero here. I don’t give a damn about the Vision
Zero, give us money for more wards, [and] better
healthcare.
This category represents different ways in which the
participants consider the VZ to misdirect the focus of
healthcare.
Misdirected focus at the expense of appropriate measures All participants expressed that a risk with the VZ
is that healthcare will focus on the wrong things, e.g. too
much focus on suicide-risk assessment at the expense of
other potentially therapeutic measures, or failing to meet
needs other than suicidality. More generally the participants emphasized that unachievable goals are nonconstructive, because they increase the risk of unnecessary
or ineffective measures being taken at the cost of more
appropriate ones.
Limitations of compulsory care
This category represents different ways in which the
participants perceive compulsory care and how it is
regulated to be one of the problems with the VZ.
Insufficient legal means for compulsory care Many
participants expressed that even if it would be desirable to commit more people to inpatient care in
order to prevent suicide, this would not be possible
with the current legislation on compulsory psychiatric care.
What happens then, if you hospitalize people –
everybody would not want that obviously – you would
need to hospitalize a lot of people against their will,
and the current legislation does not allow that.
Compulsory care is sometimes counterproductive
Many participants expressed that compulsory care is
the only way for the physician to feel fairly certain
that a patient will not attempt suicide notwithstanding that it is sometimes detrimental to the wellbeing
and treatment of the patient and may even increase
the risk of suicide in a longer time perspective, rendering it potentially counterproductive with respect to
its own purpose.
And an alternative maybe would’ve been to open the
door and then she maybe would’ve run out and
screamed for a bit and then she probably wouldn’t
have taken her own life you see. It becomes, it becomes
like a fish-hook in your hand, the more you try to fix
it, the worse it gets.
And many times people ask questions about
suicidality even when it is not relevant, where you
force the patient into, to talk about it even though you
know it may be counterproductive in some cases. Not
because it might induce more thoughts of suicide but
because it means focusing on the wrong things.
The idea that if we aim for the stars we will reach the
moon, no, then we might just as well, choose to aim for
the moon. That will probably make it easier for us to
choose considerably better means to reach the moon.
When they carried out the Apollo project, no way that
they were planning to go to Alpha Centauri.
Threat of suicide as an instrument of power Many
participants described a tendency among some patients
to use suicide threats to exert power, to get something
they want, e.g. inpatient care or drugs, and that the VZ
may worsen this tendency by reinforcing the threat of
suicide as a weapon of negotiation.
I can’t work as a suicide police […] if my main focus is
that no one can commit suicide then, I for one become
a very neurotic doctor. And then the focus will be
wrong. We will fill up our wards with people who, not
necessarily are the most ill ones but those who I
believe will hurt themselves or commit suicide.
Decreased inclination to seek help or share problems
Many participants expressed that an increased focus on
suicide may have a negative effect on some patients’
Karlsson et al. BMC Medical Ethics (2018) 19:26
inclination to seek help because of fear of compulsory
care.
What happens to their inclination to seek help the
next time it’s bad, if you don’t respect that they have a
wish, within what’s reasonable, to actually be able to
go home with some degree of suicide risk. What
happens then? They will not seek help and if they seek
help they won’t tell the truth.
Negative consequences for psychiatry
This category represents different ways in which the
participants consider the VZ to have potentially negative
consequences for psychiatry.
The VZ supports an unjustified difference between
psychiatry and somatic care A majority of the participants considered it a problem that the VZ contributes to
what they considered an unjustified expectation that
psychiatry should differ from the rest of healthcare by a
responsibility to prevent every death, since no comparable goal exists in other parts of healthcare.
And I think there is a huge fuss every time someone
dies in psychiatry. If you look at the history of
[a patient’s] illness you might very well think that
it was amazing that this patient survived this long
despite this severe mental illness and [You would
like to hear] ‘what a great job you’ve done helping
the patient this long’ instead of ‘no no no, what
kind of terrible ward are you to let this patient
die?’ I mean you accept that people die from
somatic illnesses but you don’t accept that people
die from, from mental illnesses.
The VZ may have a deterring effect on physicians
Several participants argued that the VZ promotes the
idea that every suicide is a failure on the part of healthcare and that this will discourage physicians from working in psychiatry.
The part of the Vision Zero that implies that every
suicide is a mistake and, I think this scares people
away from psychiatry, because no one is prepared to
take responsibility for saving, saving every one of the
most unsavable persons and always live with this
terror that if someone, erratically – or because it is
impossible to prevent them from [doing it] – takes his
life, you will have to live with that for the rest of your
life, almost as if you had broken the law like a
criminal. So I think it may have a discouraging effect
[…] I don’t think this contributes to attracting the
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talented [colleagues] ones so to speak. No one is
prepared to sign a contract that says that I will
manage preventing everything, always.
The VZ may amplify contradictory tasks Many participants perceived a contradiction regarding preventing
suicides on the one hand and minimizing the use of
coercive measures on the other. The VZ was
perceived as worsening this problem by indicating
that there are no excuses for suicides in healthcare,
an interpretation that the participants felt was supported by the Lex Maria legislation, as it was written
at the time of the interviews.
If psychiatry in a consistent way tries to save these
people’s lives, then psychiatry gets exposed in the
media because of its inhumane methods. So I think it’s
better to, because I mean no one wants to tie people
up and so on…you would really like to just let them
out. But then you’re afraid that then they will commit
suicide and then the shit hits the fan. So it becomes,
it’s a contradictory task when on the one hand you’re,
you’re forced to stop a person from doing a certain
thing, but by coercing them on the other hand you
bring dishonor to psychiatry.
The VZ may augment the anxiety among personnel
All participants expressed that fear of suicide is a major
issue in working as a psychiatrist. Several participants
expressed that the VZ has made this fear greater and
that too much fear of suicide is not constructive but
rather stands in the way of good healthcare.
In psychiatry it means that you coercively detain
people and deprive them of their freedom. Not because
it’s the wisest measure or ethical or what you believe is
the most ethically correct measure but for one reason
only, and that is so that you yourself won’t have to
bear the anxiety that someone may take their life […]
Particularly this question of guilt, which this Vision
Zero signifies is like adding fuel to this kind of
behavior, that you admit [a patient] to coercive care
just in case.
I know that several of my specialist colleagues who
experienced [a patient’s] suicide, have said that ‘well,
if I have to experience this again then, then I’ll stop
working as a psychiatrist and change to something
completely different’ And some of them got symptoms
of PTSD, went to therapy, I mean people felt really,
really bad […] I reached the conclusion that what it
takes then is that we admit everyone who has a risk of
Karlsson et al. BMC Medical Ethics (2018) 19:26
suicide to coercive care, regardless of what they want,
and then we never let them out.
Wrong message
This category represents different ways in which the
participants consider the VZ to be sending the wrong
message to the public, to healthcare, and to patients.
The VZ may contribute to false views of psychiatric
illness among the public Several participants expressed
that the VZ may negatively influence the public understanding of psychiatric illness by implying that psychiatric illnesses are not real illnesses by saying that every
suicide is preventable. The VZ was also thought to potentially increase stigmatization by implying that psychiatric patients are in some way more responsible for their
own suffering than somatic patients.
It’s still not the case that mental illness, everywhere,
is considered an illness, but that it, there might be
something wrong with society or that it is a
sociological concern and that, if someone only had
been kind enough or if someone had helped, things
surely would’ve been different. This is something I
can react strongly against and, I think this plays a
big role in the general stigmatization of psychiatry
and mental illness, that it’s imagined not to be a
real illness.
The VZ may contribute to false hopes on healthcare
among the public Many participants expressed that the
VZ may contribute to too high expectations of what
healthcare can provide in terms of suicide prevention
and treatment of psychiatric illnesses.
I think there are many people who, for different
reasons, want [to promote] a little too romantic idea
of how good our chances are of making assessments
and so to speak how safe the system is.
On the whole it is a problem, both internally and
externally, when psychiatry promises and claims to be
able to deliver things that it cannot deliver.
The VZ contributes to medicalization of normal
psychology Some participants expressed a fear that the
VZ will contribute to medicalization of normal psychological functioning and existential thinking, by implying
that thoughts of suicide are inherently pathological.
We medicalize normal reactions to life.
Page 8 of 13
If you are a human being with an ability to reason
and reflect, then you have a risk of suicide […] If we’re
going to abolish suicide, one hundred percent, so that
it is forbidden, then you almost have to abolish
humanity, you have to lobotomize everything, everyone.
Thoughts and plans of suicide as comfort and hope
Several participants conveyed that thoughts of suicide
can be a source of both comfort and hope for many
patients. Some participants reflected that the VZ signals
that suicidal thoughts are always undesirable and that
this might affect patients negatively.
Many people live with a chronic nearness to suicide.
There are those who have a rope hanging at home
which has hung there for ten years and without that
rope they can’t live. They know that they can go in
there and for a lot of people this has a purpose - I
don’t have to live, I will keep on struggling but I know
I have a way out - If you removed that way out, if you
could, I don’t know what would happen to a number
of them.
The VZ is not desirable
This theme consists of four subcategories sorted under
two categories and concerns what the participants perceive as reasons why the VZ is not desirable even in
theory.
Some suicides should not be prevented because the moral
cost is too high
This category represents different ways in which the participants consider the VZ, except from potentially having
negative consequences, to be in direct conflict with
other important values.
Conflicting values with regard to the patient Many
participants expressed that a problem with the VZ is that
in some situations, preventing suicide is less justified, for
example, when healthcare is unsuccessful in alleviating
the patient’s symptoms and further measures, such as
compulsory care or medication, risk inflicting more
suffering.
The more treatment-refractory a person turns out to
be, I mean, the more years that have passed of
compulsory care and medication and all possible
things without [the patient] getting better, it only gets
worse, the more I think you should question if it’s
actually meaningful. Because it has no intrinsic value,
but it should aim for making the patient feel better
and getting well, and if it doesn’t it only does damage.
Karlsson et al. BMC Medical Ethics (2018) 19:26
Conflicting values with regard to others Many participants give examples of the VZ being in conflict with the
interests of other people. Examples evolve around children’s rights, family policy, surveillance, alcohol restriction, and situations where society has an interest in
applying legal measures, e.g. legal sentences, economic
penalties, and eviction, that are associated with an increased risk of suicide.
There was always a discussion if you should, so to
speak, take [the patient’s] her child away or not.
Because then you knew she would attempt suicide
immediately. In such situations [the patient] she
managed to disarm the whole system that aspired to
protect the child. Because no one wanted to press the
death-button so to speak, so the child did fare ill in
that way and probably still does.
To what extent should you be allowed to fail in life
[…] If you’re sentenced for a crime, the suicide risk
also goes up sky high the following months. If you go
bankrupt same thing, the suicide risk goes up sky high.
If you’re evicted from your home, same thing. So there
are several examples of failures or shameful situations
in life that we know to be associated with a high risk
of suicide. Then of course it would be possible to
simply stop sentencing people for a lot of crimes.
Certain rational suicides should not be prevented
This category represents different ways in which the
participants considered the VZ to not be desirable in
theory, by arguing that certain rational suicides should
not be prevented.
Rational suicide Many participants spontaneously
brought up what they perceived as rational suicides,
without being asked about this. Rational suicide was
used as an argument for why the VZ is not a desirable
goal.
In some way it [the VZ] implies that every suicide is
wrong even though many people suggest that there is
the rational suicide. And there are also those [cases]
that may be somewhat rational as well as having
elements of psychiatric illness but not to the extent
that you could prevent them anyway. And this is
something that, it’s political suicide, interestingly
enough, should one say that in public, that we have to
accept certain suicides.
Assisted suicide The participants expressed both the
idea that legalization of assisted suicide could have a
Page 9 of 13
suicide preventive effect, as well as the opposite idea that
it would rather be a way of facilitating suicide.
There are also people who should be allowed to take
their own life […] different people with ALS and
Huntington and things like that. Then it’s obvious, it’s
totally, it’s a shame for this country that it’s not legal
for people like that to be able to get euthanasia.
Discussion
Though most of the participants mentioned at least
some potential benefit of the Vision Zero for Suicide, the
overall impression was a predominant skepticism towards it. Some participants focused on why they consider the VZ to be unachievable, while others focused
more on its potential consequences and normative implications. Accordingly, the analysis of the interviews
yielded themes that reflect these different focuses. An
overarching impression is that the participants shared
the belief that the number of suicides should and could
be reduced, but that the VZ nonetheless, for different
reasons, is not desirable.
Unachievable, nonconstructive or counterproductive
All participants considered the VZ to be unachievable.
The major reason was a lack of reliable methods for
suicide risk assessment. This is consistent with a recent
report from the Swedish agency for health technology
assessment and assessment of social services (SBU),
“Instruments for Suicide Risk Assessment” from 2015,
which concludes that “none of the included studies provided scientific evidence to support that any instrument
had sufficient accuracy to predict future suicide with
80% sensitivity and 50% specificity” [32]. The report
supports the participants’ notion that in order to reduce
the numbers of suicides, the methods for prediction of
suicide need to be substantially improved.
The VZ was considered to be unachievable also because of limitations of contemporary psychiatry: current
clinical methods are not effective enough to save every
person at risk of suicide. This, too, is consistent with the
existing literature [33]. A related concern was that the
VZ will contribute to the general public underestimating
the severity of psychiatric illnesses or overestimating the
ability of healthcare to treat these illnesses. These shortcomings may then lead to decreased public trust in
psychiatry.
Some participants expressed a fear that increased
focus on suicide may have problematic clinical effects or
may even be counterproductive to its own purpose.
First, it may decrease some patients’ inclination to seek
help because of fear of compulsory care. Second, it may
decrease some patients’ trust in healthcare by signaling
Karlsson et al. BMC Medical Ethics (2018) 19:26
that only suicidality is important. Third, a focus on suicidality at the expense of other psychiatric problems
may for some patients lead to suicidality later on, without guarantees that they will seek help when they eventually are suicidal. Fourth, it may put the psychiatrist in
a weakened position since it strengthens the patient’s
chances of using suicidal behavior as a weapon of negotiation. Fifth, an increased focus on suicidality does not
necessarily mean better suicide prevention. Some participants expressed that the current implementation of suicide prevention in healthcare places too much emphasis
on mandatory suicide risk assessments and that this is
not an effective way of preventing suicide. Moreover,
they expressed that mandatory risk assessments take
time from other potentially therapeutic activities, may
have a negative impact on the psychiatric consultation
and may disturb the patient-physician relationship by
thwarting the consultation. Beyond these concerns, it
may be added that even if not counterproductive, it is a
normative question whether prioritizing suicide risk over
other psychiatric problems in general is ethically
justifiable.
A major impression from the interviews is that there
was a great deal of anxiety among the interviewed psychiatrists that patients will complete suicide. The participants reported considerable psychological suffering and
morbidity among personnel facing patients’ suicides;
they felt that the VZ has worsened these anxieties. Several participants perceived the task of trying to limit the
use of compulsory care and at the same time preventing
every potential suicide as contradictory; the lack of clear
directives on how to balance these tasks added to this
frustration. Furthermore, these problems may, some
participants maintained, deter people from working with
psychiatry and invite resignation in others. This result is
consistent with points raised in the debate in the
Swedish medical journal, Läkartidningen, where one of
the arguments against the VZ was that it places an unreasonable burden on psychiatry [23].
Comparing psychiatry with somatic healthcare
The participants expressed that the VZ has several problematic implications for the understanding of psychiatric
illness and for psychiatry. There was also a widespread
sense of unfairness with regard to the Swedish Lex
Maria legislation [11]. This legislation originally addressed critical incidents caused by medical errors, and
regulations from the Swedish National Board of Health
and Welfare – to which the VZ is linked – stated that all
instances of suicide in relation to healthcare should be
investigated accordingly. As mentioned these regulations
are now changed. Nevertheless, the participants perceived the VZ as a liability mainly because it was perceived to imply that every suicide is a failure on the part
Page 10 of 13
of healthcare. This problem was elaborated by the participants in three principal ways: (1) it implies that
psychiatry could successfully save the life of all of its patients if certain measures are taken, in contrast to somatic healthcare, in which a certain amount of mortality is
accepted with reference to current limitations of medicine; (2) in a contradictory way it implies a difference
between psychiatric and somatic illness: psychiatric patients are less responsible for their own wellbeing since
suicide is considered a failure on the part of healthcare,
and at the same time more responsible since they are assumed to be able to choose not to complete suicide,
given that psychiatry acts in a certain way; (3) it implies
that suicidal ideation is always pathological. Some participants expressed a concern that the VZ will contribute
to the medicalization of normal human psychology as
well as to increased shame and stigmatization of suicidal
patients. These results echoed the debate in Läkartidningen, in which one argument against the VZ has been
that it will increase shame and stigmatization of suicidal
persons by implying that thoughts of suicide are always
wrong. Again, this is a way by which the VZ is thought to
be potentially counterproductive; the option of suicide itself is sometimes thought to be protective against suicide.
It is also noteworthy that the participants again alluded to
a major discussion in the bioethical literature, namely the
medicalization of normal human psychology [34].
Although a huge area in modern biomedical ethics
[35], a further discussion of whether or not psychiatric
and somatic illnesses are equal in all relevant respects is
beyond the scope of this paper. It is important to note,
however, that if healthcare treats psychiatric and somatic
patients differently, and if there is a difference in the
responsibility of healthcare professionals for mortality in
the respective groups, arguments are needed to justify
these differences.
Undesirable because of ethical conflicts
Several participants expressed arguments why the VZ is
not desirable because it conflicts with other important
values. First of all, they emphasized that measures aimed
at treatment or suicide prevention, e.g. compulsory care
and medication, sometimes inflict further suffering on
the patient. They also emphasized that inpatient care is
the only way for the responsible physician to be fairly
certain that a patient will not attempt suicide, at least in
the short term. However, they also expressed that the
element of coercion itself often lowers the chances of
therapeutic success and, further, that the level of unnecessary coercion is considerable and that it is fairly
common to overuse coercive care ‘just in case’, in fear of
the patient attempting suicide. The VZ was thought to
inappropriately amplify these tendencies by increasing
the focus on suicide.
Karlsson et al. BMC Medical Ethics (2018) 19:26
One way of justifying measures that are potentially
harmful is by reference to the aim of decreasing future
suffering or saving or prolonging life. Thus, the more
unlikely the wanted outcome is (prolonged life or decreased future suffering), the weaker the justification.
The claims that psychiatry is not successful in treating
all its patients and that compulsory care can be potentially harmful are fairly uncontroversial. Previous research indicates that suicide risk is perhaps the most
important issue for justifying compulsory psychiatric
care [36], explaining to some degree the participants’
concern that the VZ may increase the use of coercion in
healthcare. However, the question whether the VZ actually
does so is an empirical one yet to be answered. Further
empirical questions yet to be answered are whether compulsory care on current rates in fact lowers the suicide
rates, and whether increasing the use of compulsory care
would be counterproductive to suicide prevention. These
uncertainties pose challenging problems for answering
ethical questions regarding the justification of compulsory
care as a method of suicide prevention. Suffice it to note
that these considerations again point towards the question
of what means are justified in order to achieve suicide
prevention. It is also interesting to note that these claims
are consistent with the cited debate in Läkartidningen,
where one argument against the VZ has been that it may
be counterproductive by increasing the use of compulsory
care. The results in this study shed some light on why the
VZ could have such an effect [23].
A different argument why the VZ is not desirable
given by some participants was that it may be in conflict
with the interests of the general public, e.g. in the areas
of children’s rights, family policy, surveillance, alcohol
policy, and in instances where society has an interest in
applying legal measures associated with increased risk of
suicide, such as legal verdicts, economic penalties, and
eviction. This argument again points towards the question of what means are justified to achieve suicide prevention, but this time alludes to values other than those
of the patient.
The issue of rational suicide was discussed extensively
by the participants, giving rise to several interesting
questions. It is the authors’ ambition to present the results from these discussions in a separate article. Here,
with respect to the aim of this article, only a brief account of these results will be made: Several participants
recognized the possibility of rational suicides, typically
exemplified by cases in which an individual suffers from
a severe somatic illness without hope of improvement
and associated with considerable suffering. Some participants expressed that severe, chronic psychiatric illness,
too, could serve as a rationale for suicide. The participants conveyed that what makes these questions difficult
is not so much the question of whether rational suicides
Page 11 of 13
exist, but rather that there is a considerable “grey zone”
in which the wish to die can be considered partly rational and partly irrational. Further, that it is either impossible or extremely difficult to assess the rationality of
a patient’s suicidal thoughts. One possible interpretation
of these statements is that the participants tended to
consider the possible existence of rational suicides as
less relevant from a clinical perspective; the vast majority of suicidal patients are considered irrational
until the opposite can be proven. These results are in
line with previous research on psychiatrists’ views on
rational suicide [36].
Importantly, the approach of presupposing irrationality
is problematic since suicide prevention then comes into
potential conflict with respect for autonomy – as is the
case when suicidal patients are considered irrational,
and thereby non-autonomous, “by default”, i.e., without
prior consideration. Respect for autonomy is considered
very important in healthcare legislations in most Western
countries. An important question arises: does the VZ
protect important values to the extent that disregarding
autonomy in these cases is justifiable?
Strengths and weaknesses
This study includes a relatively large number of interviews with psychiatrists who differ in age, experience
and area of expertise. The result is rich and varied,
which was also the aim of the method, and we consider
this to be one of the strengths of the study. Nonetheless
the applied chain referral recruitment of participants
may have led to a selection of participants with similar
perceptions of the Vision Zero for Suicide. However, the
richness and variation of the material speaks against that
this would be the case. The results cannot be used to
infer any general conclusions on how common certain
perceptions and arguments are among Swedish psychiatrists, and there is a possibility that more interviews
would have yielded yet other understandings and arguments not found in this material. However, since the
aim of the study was to enrich the normative discussion
on the Vision Zero for Suicide by examining perceptions
and arguments among Swedish psychiatrists, the results
constitute an empirical knowledge base. If the normative
discussion can be improved by these results, it may be
relevant also for other countries in setting goals for
suicide prevention.
Conclusions
Though most of the participants mentioned at least
some potential benefit of the Vision Zero for Suicide,
there was a predominant skepticism towards it. The VZ
was perceived to be impossible to realize, nonconstructive or potentially counterproductive, as well as
Karlsson et al. BMC Medical Ethics (2018) 19:26
undesirable because of potential conflicts with other
values and interests of both patients and the general
public. Contradictory tasks and unclear directives on
what means are morally justified in suicide prevention
were held to be especially troubling concerns by the participants. Moreover, the VZ appears to be perceived as
having negative consequences for the working conditions for psychiatrists in Sweden, by increasing psychiatrists’ anxiety and thwarting the patient-physician
relationship.
Additional file
Additional file 1: Interview guide containing questions about the
participants’ experiences and perceptions of the Vision Zero for Suicide
as well as questions about rational suicides. (DOCX 15 kb)
Abbreviations
VZ: Vision Zero for Suicide
Acknowledgements
Financial support from the Swedish Research Council and from the Swedish
Research Council for Health, Working Life and Welfare is gratefully
acknowledged (2014-4024). The funders had no role in study design,
collection and analysis of data, manuscript preparation, or in the decision to
submit the manuscript for publication.
We would also like to thank the participants of the study who generously
gave their time and shared their thoughts and experiences in order to
contribute to this research.
Funding
Financial support from the Swedish Research Council and from the Swedish
Research Council for Health, Working Life and Welfare (2014–4024).
The funding body had no influence over any part of the study.
Availability of data and materials
The datasets generated and analysed during the current study are not
publicly available because it would risk compromising individual privacy of
the participants. The interviews also contain patient cases in such detail that
identification could be possible, which is a further reason why the data is
not publicly available.
Authors’ contributions
PK, NJ, MS and GH contributed to the conception and design of the study.
PK conducted and transcribed the interviews. PK did the first analysis of the
interviews. NJ and DT contributed to additional analysis. All authors
contributed to interpretation of the data. PK wrote the first version of the
manuscript. All authors contributed to revising the manuscript critically in
several steps. All authors have read and approved the final draft.
Ethics approval and consent to participate
The study was approved by the Regional Ethical Review Board in Stockholm
(Dnr 2015/270–31/5).
The participants were initially contacted by email and if they were willing to
participate they obtained a document with information about the design
and purpose of the study, including the following consent to participate
statement: “Note that your participation is completely voluntary and that
you, if you agree to participate, can withdraw your participation without
presenting any reason for doing so. You also have a right to contact us at
any time if you want to withdraw your participation. Participation in the
study will not affect your employment or your professional position. No
reward for participation will be obtained”. Verbal informed consent to
participate was then obtained from each participant and documented in
recording at the time of the interviews, which is sufficient according to the
Swedish law. The verbal informed consent again followed the consent to
participate statement as presented above.
Page 12 of 13
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
Department of Learning, Informatics, Management and Ethics, Karolinska
institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden. 2National
Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska
institutet, Granits väg 4, 171 77 Stockholm, Sweden.
1
Received: 18 September 2017 Accepted: 16 March 2018
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