(PS9-18) Moral Dilemmas in Suicide Risk Assessment: A Qualitative Study of Emergency Department Clinicians

Abstract Text: Suicide risk assessment is both a clinical challenge and a morally complex process. Clinicians must balance patient autonomy with the duty to prevent harm, navigating complex ethical priorities. While research has examined risk factors for suicide and the ethics of using involuntary hospitalization to prevent suicide (e.g., Large et al., 2014; Madsen et al., 2020), less attention has been given to the moral weight of these decisions and the systemic factors shaping them. Understanding these dilemmas is essential for developing clinical standards that support ethically sound, harm-reducing clinical decision-making rather than placing the burden solely on individual providers. We conducted qualitative interviews with 20 emergency department (ED) clinicians tasked with routinely making these decisions, analyzing their experiences with suicide risk assessment and hospitalization decisions. Using a thematic analysis approach, we identified key ethical concerns, including the involuntary nature of hospitalization, concerns about potential iatrogenic effects, systemic pressures influencing discharge decisions, and the challenge of withholding hospitalization for patients seeking admission primarily due to housing insecurity rather than imminent suicide risk. When asked broadly about challenges in hospitalization decisions, 40% of participants explicitly described moral dilemmas. Clinicians described ethical challenges inherent in deciding to hold people against their will, and in deciding which people who are homeless will have the benefit of housing for the night due to the severity of their mental health concerns. Systemic pressures also played a significant role, with clinicians describing instances where resource limitations forced them to discharge patients despite lingering concerns about safety. One clinician expressed this frustration, stating, "We will discharge people, and they go right across the street to CVS and get a razor just to prove how wrong you were in discharging them." These findings underscore that suicide risk assessment is not exclusively a clinical task but also an ethically complex process in which clinicians must weigh competing harms with limited systematized guidance regarding these ethical factors. The goal of medical care is to minimize harm and maximize benefit, and our findings highlight the range of potential harms that individual clinicians are considering with respect to hospitalization decisions for suicide risk. Our results imply that suicide risk assessment protocols may be improved with the inclusion of systematized guidance focused on these ethical considerations. Future research should focus on interventions that enhance this component of suicide risk assessment to support providers in aligning decisions with both risk-related and ethical components of intervention selection.