A few years ago, Arnold Levinson and his colleagues found themselves in what he calls an ethical “pickle.”
They’d been compiling reports to distribute to Colorado schools that had participated in a state-wide anonymous survey, where students would answer questions about their drug use, food access and suicidal ideation, among other topics. The researchers had made a practice of sharing a school’s results as a courtesy for participating in the survey, but they didn’t tell them how they stacked up relative to the norm. Until 2013, when an analyst spotted something.
“The first notice came from a statistical analyst and she came to me, she said, ‘Holy moly’ -- in stronger language -- ‘Look at these numbers,’” recalls Levinson, a health behavior epidemiologist with the Colorado School of Public Health.
At a particular middle school, almost a third of students there said they’d seriously considered suicide. Seventeen percent said they had made a suicide plan, and almost as many said they’d attempted suicide. Those were double or triple the statewide rates.
The analyst wanted to know: Did they have an obligation to do something?
“There was no answer right in front of us,” said Levinson. “There was no past practice.”
“To do nothing felt wrong,” he continued. “If you know a group of kids is in harm’s way and you do nothing, how can you live with that?”
At the same time, every course of action came with an upside and a downside.
They could notify the school and tell them outright that their numbers were way worse compared to other schools. But what if the principal chose not to act on that information? Were they supposed to keep track of the school somehow? They could tell the state health department, but that would have broken their promise to keep the school confidential, Levinson explained.
“If we go to the parents, we've not only broken our promise to keep the school confidential, we've also run the risk of freaking them out big time,” he said. “And the school being stigmatized as a ‘suicide school,’ whatever the heck that might be. But all of these things had real risks.”
As Levinson and his colleagues wrote in the latest issue of The American Journal of Bioethics, they’re calling for national health and education groups to devise ethical guidelines on how to handle this kind of data.
"National public health and education associations should produce guidance that clarifies ethical and legal duties owed to schools and students involved in population health-risk surveillance," they wrote.
The Association of State and Territorial Health Officials and the National Association of County and City Health Officials, both of whom were called on in the paper to help provide such guidance, were unable to be reached for comment.
Many states, territories and tribal governments conduct anonymous health surveys among school students as part of the national Youth Risk Behavior Survey. However, they don’t all look at data on the individual school level. That omission, Levinson explained, could also be ethically problematic.
“How many schools are going undetected with very high levels of risks that no one knows about?” he asked.
As the researchers noted, “duty to warn” laws may not apply in these scenarios. A number of court cases have clarified the duty of health professionals to breach confidentiality if lives could be at stake. For example, in the 1970s, a college student killed a peer after divulging his plans to a therapist. California judges ruled that mental health professionals have a duty to warn law enforcement in the face of such imminent threats. Similarly, after the 2012 Aurora theater shooting, Colorado judges ruled that mental health professionals have a duty to warn people and locations if harm may be imminent. But Levinson and his colleagues don’t think those rules apply when it comes to school suicide data, in part because suicide involves self-harm, as opposed to a third party, and because the data can’t indicate whether harm is imminent or not.
In the end, Levinson and his colleagues chose to call the principal of the middle school with alarming statistics. He said they were relieved to find that the principal was prepared to act.
“As it turned out, that school had had a student who had died by suicide and the principal was already worried,” said Levinson. “He had actually agreed to participate in part because he wanted to know: Was this a widespread problem? And if so, he was going to do something about it. And so it turned out we're all on the same page.”
Data from the Centers for Disease Control and Prevention show the Mountain West states have a disproportionately high rates of deaths by suicide. Much of the region has also seen recent rises in youth suicides. According to the United Health Foundation, almost all Mountain West states are among the worst 10 in the nation when it comes to teen deaths by suicide per 100,000 teens.
“COVID is isolating us even more than we already might have felt we were, so this is a time of great challenge,” said Levinson. “The good news is, there are real effective resources out there for people to reach out and contact if they’re worried about themselves, if they’re worried about somebody else.”
If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889) or the Crisis Text Line by texting 741741.
This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUNR in Nevada, the O'Connor Center for the Rocky Mountain West in Montana, KUNC in Colorado, KUNM in New Mexico, with support from affiliate stations across the region. Funding for the Mountain West News Bureau is provided in part by the Corporation for Public Broadcasting.