Korean Journal of Biological Psychiatry

Address for correspondence: Do-Hyun Kwon, LLM Department of Social Welfare, Sungkyunkwan University, 25-2 Sungkyunkwan-ro, Jongno-gu, Seoul 03063, Korea
Tel: +82-2-2072-2961, Fax:+82-2-3676-2204, E-mail: kwondohyun@gmail.com


Introduction

  Since 2013, the Ministry of Health and Welfare of the Republic of Korea has conducted the first suicide survey for all citizens, which can serve as a policy basis for the factors of the increase in the suicide rate in Korea. In 2018, in order to find out the public perception of suicide, the author of this paper added a new question based on the suicide prevention act. Questions about the perception of suicide prevention projects at the national level were newly ref lected. This seems to have laid the foundation for a step forward in the national suicide prevention policy that meets the purpose of the suicide prevention act, which protects people’s lives based on the Constitution by preparing policies at the individual and national level (Article 10 of the Constitution of the Republic of Korea). The incidence of suicide in the Republic of Korea is 25.6 persons/100000 people—more than twice the 12.1 persons/100000 people reported by the Organization for Economic Cooperation and Development.1)

  As emphasized by the Ministry of Health and Welfare of the Republic of Korea regarding suicide prevention and respect for life, Korea has increasingly come to view suicide prevention as a social rather than a personal issue, making it a concern that the broader community must resolve. Therefore, related researchers, medical institutions, and government departments are continually exploring strategies to ensure the efficacy of national suicide prevention programs.

  There is also a growing consensus that any Korean policy for suicide prevention must include a national system for continually managing and treating those who attempt suicide (hereafter, “suicide attempters”). Several national suicide prevention projects include 1) the development of a predictive model of risk factors based on a cohort of suicide attempters and 2) follow-up management for suicide attempters specifically targeting patients admitted to emergency departments. However, an obstacle to such projects is that processes for obtaining consent for the use of personal information make it difficult to register patients. Specifically, if a patient or guardian refuses treatment after the initial registration procedure, follow-up monitoring becomes practically impossible. This barrier is a serious problem because monitoring failures do not simply indicate failures of treatment but also an increased likelihood of depriving the patient of their right to life. In Korea, public health policy agencies repeatedly highlight this concept in response to the ripple effects of suicide; suicide prevention policy requires thorough consideration from both the personal stigma and social welfare perspectives, which has led to many reviews of the relevant policies.2)3)

  I aimed to review analyses of data from the 2018 National Survey on Suicide,4) compiled collaboratively with the Korea Ministry of Health and Welfare and Seoul National University Hospital. This survey explored public opinions of whether exceptions should be allowed to the Personal Information Protection Act to enable national interventions for suicide prevention. The Korean Personal Information Protection Act was enacted on March 23, 2013 to protect the privacy of personal information from the collection, leakage, misuse, and abuse of personal information. It is a law of the Republic of Korea, which is based on Article 17 of the Constitution of the Republic of Korea, and aims to stipulate matters related to the processing of personal information to promote the rights and interests of the people and to further realize the dignity and values of individuals.

  Suicide is treated as a public problem because it inevitably results in conf licts of basic rights. More specifically, suicide impacts the rights of the intervening primary caregiver, of the medical personnel who has a duty to treat, and based on the circumstances for the restriction of basic rights specified in Article 37, Paragraph 2 of the Constitution of the Republic of Korea, the rights of national institutions for maintaining social order and the rights of third parties in the society in which public welfare is affected by suicide attempts.5-8)

  The Personal Information Protection Act stipulates that information may be shared without the consent of the Personal Information Protection Agreement unless there are special provisions in other laws. In particular, Article 15 (3) of the Personal Information Protection Act was newly established on February 4, 2020, relating to matters in which existing personal information can be used without the consent of the privacy officer. This report aimed to identify the extent of consensus in opinions of the national population and review policies for suicide re-attempt prevention from a constitutional perspective to provide an analysis forming the basis for further inquiries into how legislation might best work toward suicide prevention.

  The 2018 National Survey on Suicide was entrusted to Hankook Research Co., Ltd. and conducted between November 21 and December 17, 2018. The target population comprised adults aged 19–75 years. The sampling frame included general enumeration districts from the 2016 Population and Housing Census excluding islands, boarding facilities, and specialized social facilities. The sample was recruited using the 2017 Population and Housing Census results. The survey involved stratified systematic sampling (primary stratification based on administrative districts, secondary stratification based on enumeration district types) and the sampled units were enumeration districts (primary stratification) and households (secondary stratification).

  Proportional allocation was determined relative to the number of households per city/province (with some additional allocation for Sejong-si and Jeju-do). The total sample comprised 150 enumeration districts (10 households per enumeration district) and 1500 households/individuals (1500 people). The survey involved personal interviews, with interviewers visiting house-holds directly and recording responses to the questionnaire. Sampling error at a confidence level of 95% was ±3.1% (using the results of the 2013 survey on national perceptions regarding suicide, calculated based on the mean [1.40] and median [1.48] design effect of the major survey items). The present report was drafted based on an analysis of the part of this survey about perceptions of national suicide prevention projects, compiled by the main author of this report.

  Two questions aimed to measure opinions about allowing exceptions to consent to the use of personal information of individuals who have attempted suicide for the purposes of suicide prevention.

  “As part of the survey on perceptions of national suicide prevention projects, the following is a question about your opinions on allowing exceptions to consent to the use of personal information for the purposes of suicide prevention. In order to protect a suicide attempter, do you think it should be possible in the Republic of Korea to administer suicide prevention without receiving individual consent?”

  Question 1 was designed to address two issues: 1) improving public awareness and setting a foundation for the active domestic implementation of national suicide prevention projects like those used in English-speaking and major European Union member nations, 2) investigating the acceptable scope of exceptions to the process of seeking consent for using personal information. Specifically, part 2) addressed exceptions to the Personal Information Protection Act Article 15, Paragraph 1, Subparagraph 5 to protect the life, body, or material profits of a suicide attempter.4)

  “The following question is about the appropriate scope of suicide prevention management at the national level, assuming that you allow exceptions to the consent process for personal information protection: what do you think is the appropriate scope of suicide prevention management, which can be performed at the national level, without receiving individual consent?”

  The question about the appropriate scope of national suicide prevention management was posed to respondents, who had reported that they would allow exceptions to seeking consent for using personal information for suicide prevention. The question to measure the opinions about the appropriate scope for implementation of a suicide prevention management project, assuming the exception of personal information protection procedures. The question aimed to investigate, first, whether psychiatric care was necessary for suicide attempters in addition to treatment for physical trauma, and second, whether it was necessary to provide preventative psychiatric care management, at the national level, to aid trauma healing of legally responsible guardians and prevent additional suicide attempts.4)

  As shown in Table 1, 79.1% respondents believed that Korea should allow an exception whereby suicide prevention management can be implemented without obtaining individual consent in order to protect suicide attempters (after 1, 2, or 3 or more attempts). Conversely, 20.9% respondents reported that they would not allow this exception under any circumstance. Notably, older respondents were more likely to state that they would not allow this exception. However, 79.1% respondents expressed a positive opinion of suicide prevention management for suicide attempters as an exception to the Personal Information Protection Act.

  Thus, Table 2 reports that the majority (45.0%) were in favor of the “linkage/provision to suicide prevention organizations of information about the suicide attempter or bereaved family.” The percentage of respondents in favor of “psychiatric care for the suicide attempter (one session or multiple sessions)” was 42.9%, and that of those in favor of expanding the target of management to “psychiatric care for the suicide attempter and their guardians (one session or multiple sessions)” was 12.2%.

  Meanwhile, concerning the personal dimension of individuals who reported actual suicide ideation, it is interesting that only 4.8% reported having thought of suicide, replying “Yes” to the question, “Have you received counsel from an expert, such as at a medical institution, a professional counselling organization, or a public health center?” When asked about the main reason for not receiving expert counselling, the most common response was “Because I think it will get better with time” (40.3%), followed by “Because I don’t think it will be solved through counselling” (30.3%) and “Because of how others will see me” (15.3%). Fur-thermore, of the respondents who said that they had not received expert counselling, when asked if they intended to receive expert counselling in the future if the problem recurred, only 32.8% responded “Yes.”

  Thus, suicide is perceived as a social problem and while respondents generally agreed with the national intervention, individuals who report actual suicidal ideation showed inconsistent responses. Paradoxically, in addition to improving public perception, this is the reason why policy improvements are required to prioritize mandatory intervention, not from a personal perspective, but from the perspective of public health and medicine.

  The demographic characteristics of the survey participants were randomized and a total of 1500 adults 19 years of age or older were included. In addition, the ratio of males and females was 50.7% to 49.3%, and the ratio of those over 50 years was 40.5% compared to 59.9% for those under 50 years.

  From a public health perspective, perceptions of suicide prevention in Korea are fundamentally different from those of the right to refuse treatment due to cancer or an unexpected accident, or to refuse life-extending treatment concerning the issue of euthanasia. Suicidal individuals are regarded as demonstrating cognitive behavioral issues by virtue of deciding to end their life. Thus, when a situation arises in which caregivers must determine whether to restrict an individual’s executive autonomy, medical intervention is prioritized.9)

  Korean law stipulates that the right to life as a core value in the protection of all basic rights is considered more important than personal privacy or freedom. Moreover, when considering the ripple effects of suicide, restriction of the basic rights of the deceased (as detailed in the Constitution of the Republic of Korea, Article 37, Paragraph 2) must be viewed regarding public welfare. Given this constitutional interpretation, evidently, policy makers in Korea do not approach suicide simply as a personal problem of the individual citizen.

  Therefore, Korean approaches to suicide necessarily differ from approaches to euthanasia or dignified death. Meanwhile, the 2018 National Survey on Suicide (Ministry of Health and Welfare, 2018) ref lects the desires of the Korean population for the nation to work towards more active suicide prevention policies in the future. Specifically, considering the national population, there is a need to provide suicide attempters with primary intervention for psychiatric illness (the main factor in suicide), and concerning specific intervention methods, there is a need to share information about the attempter and their guardians.

  The Republic of Korea’s Personal Information Protection Act was legislated to provide a more specific implementation of the constitutional confidentiality and freedom of privacy for citizens. Personal information, which is the main object of protection in this law, includes the extent of medical services as sensitive information. Considering the constitutional values of confidentiality and freedom of privacy and the legislative aims of the Personal Information Protection Act, it is clear that patients’ medical information should also be handled sensitively. However, there is considerable scope for contradiction between the protection of a patient’s privacy and other basic rights, such as the right to life and the protection of public welfare and maintenance of public order. Regarding suicide attempters, continuous linkage therapy is the only way to save lives. Despite medical staffs’ continuing efforts to prevent patient suicides, the conclusion of trauma treatment is completed without obtaining consent needed for personal information protection procedures. Therefore, continuous linkage treatment cannot solve these psychiatric problems. Thus, general constitutional deferral must be considered regarding basic rights in Article 37, Paragraph 2 of the Constitution of the Republic of Korea.

  The right to information is the right to recognize and understand whether a condition exists as well as the details surrounding it. In our modern information society, this right to have information signifies the right to access and collect information and to demand its disclosure. The right to know about one’s medical information is guaranteed as an absolute right of patients. Thus, Article 21, Paragraph 1 of the Medical Service Act states that when a patient request to inspect or copy of their own medical information, neither medical personnel nor any person working for a medical institution may deny the request without a valid reason. Paragraph 2 of the same article forbids medical personnel or any person working for a medical institution from allowing anyone other than the patient to inspect or copy the patient’s records, clearly demonstrating that if medical information is personal information pertaining to the one’s self, the patient has the right to possess it.

  However, according to Paragraph 3 of this article, there are certain circumstances in which medical personnel and any other persons working within a medical institution are permitted to allow someone other than the patient to inspect or copy a patient’s records. First, this is permitted when a doctor, dentist, or oriental medical doctor considers it unavoidable for the patient’s treatment. Second, this is permitted when the patient’s spouse, lineal descendant, or designated proxy requests the information while meeting the required procedural conditions. Third, this is permitted in line with the special exceptions listed in the Medical Service Act Article 21, Paragraph 3, Subparagraphs 4–16, in which an individual outside of the patient’s family requires access to information to confirm the right to medical aid or to fulfill the requirements of civil, criminal, or administrative proceedings.

  To protect citizens’ right to privacy, the Constitution of the Republic of Korea guarantees freedom from invasions of privacy in citizens’ private lives (Article 17) and communications (Article 18). In modern information societies, personal information has become an object of collection and transmission. There are increasing cases where private information that an individual may not want revealed is unavoidably publicized or collected and managed by another party. This situation has resulted in increased demands for privacy protection. Freedom of privacy is the freedom of an individual to lead a private life, and confidentiality, which is the same as the right to privacy, signifying freedom from one’s private life being unjustly disclosed. Freedom of privacy includes protection from the state interfering or forbidding a citizen from freely building a private life.10)

  In summary, the basic rights protected by Article 17 of the Constitution of the Republic of Korea limit freedom of privacy to freely building and maintaining the privacy of one’s personal life.11) The inviolability of privacy refers to the right of an individual to maintain the secrecy of private and other confidential matters involving personally protected interests.12) The freedom to enjoy a private life by one’s own free will is referred to as the inviolability of freedom of privacy. Moreover, an individual has the right to decide whether to disclose their private life to anot her party.

  In the Republic of Korea, Article 4-of the Mental Health Act (ACT ON THE IMPROVEMENT OF MENTAL HEALTH AND THE SUPPORT FOR WELFARE SERVICES FOR PSYCHIATRIC PATIENTS, Act No. 16377, Apr. 23, 2019) states that the Minister of Health and Welfare should establish a plan for national mental health projects every five years. Likewise, Article 7 of the Suicide Prevention Act states that the Minister of Health and Welfare should establish a master plan for the prevention of suicide every five years, focusing on early identification and intervention systems at relevant ministries for mental health patients and suicide attempters. However, because there is no implementation plan for the master plan, there is a shortage of expanded legislative revisions and systematic management for plan implementation.13)

  Specifically, the law was revised such that based on the emergency hospitalization system in Article 50 of the Mental Health and Welfare Act, when an individual suspected to be mentally ill presents a threat to the health and safety of themselves or others, they may be subjected to emergency hospitalization with the consent of a medical doctor or police officer, even without the consent of a guardian. Even if the individual has not visited an emergency room, this could be interpreted strictly as a conflict of basic rights, as far as the individual’s physical freedom is restricted.

  Indeed, when the national suicide prevention management program is invoked, the conf lict with the Personal Information Protection Act emerges as a major legal debate. It is approached differently from emergency hospitalization because, unlike the emergency hospitalization system, it does not cause an immediate physical restriction of basic rights; sensitive information can be processed, either by policy or technology, in ways that sufficiently maintain confidentiality, and finally, even if only to prevent the abuse of emergency hospitalization according to the Mental Health and Welfare Act. For example, Block-chain security technology can provide enhanced resilience, encryption, auditing, and transparency by covering confidentiality, integrity, and availability, the three elements of CIA (Central Intelligence Agency). Digital Blocks are updated only through the consent of all participants who manage this information by identifying medical staff conducting suicide prevention research and operating subjects managing participants’ identification information such as certificates and controlling access to patient information based on this. It is possible to intercept, modify, or delete data.14)

  There is an urgent need to guarantee the validity of Articles 14 and 20 of the Suicide Prevention Act. More specifically, Article 14, Paragraph 1 of the Republic of Korea’s Suicide Prevention Act reads as follows: “Article 14 (Measures for Assistance to Persons Likely to Commit Suicide and Promotion of Mental Health) (1) The central government and each local government shall create an environment in which appropriate medical services can be provided to persons at risk of suicide due to a mental disorder.”15)

  One issue here is, because the law specifies “persons at risk of suicide due to a mental disorder,” the range of people is severely restricted because of insufficient linkage to psychiatric care for individuals who actually attempt suicide due to, for example, refusal to consent to the use of personal information by the individual or their guardians. Additionally, the latter part of Article 14, Paragraph 1, states the requirement to create an environment in which appropriate medical services can be provided but the specific scope of appropriate medical services is not defined, which raises questions about its validity for the prevention of suicide. Hence, it is suggested that, considering the severity of psychological trauma caused by suicide and suicide attempts, this should be converted to mandatory psychiatric treatment with the assumption of national support.

  There have been continual suggestions to revise the enforcement decree of the same law to expand the provision of treatment to include not only the patient but also their guardians. Therefore, based on the results presented in the survey, the following two guidelines in accordance with Korean legal interpretation.

Guideline 1: legal interpretation of the Personal Information Protection Act for suicide attempters

  In Korea, there are inevitably situations where conf lict arises between various basic rights due to the relationship between the state and medical institutions in sole possession of personal information and deceased individuals who have provided their medical information for research or therapeutic purposes through legitimate consent procedures for using personal information. Medical information, especially mental-health related information, which is the focus of this report, is more carefully protected due to its sensitivity, and the particular environment in Korea, where there are concerns of social prejudice against those with mental illnesses. In other words, even if the use of mental health-related information offers significant public benefits, either from a commercial or a sociopolitical perspective, consent to use personal information is emphasized, based on the severe harm that could be caused by any disclosure of that information.16)

  If it were possible to collect or use mental health-related medical information, which majorly impacts individual’s social life, based solely on unilateral decisions by a medical institution, without the consent of the patient, it would naturally lead to substantial concerns about infringements on basic rights, including not only confidentiality of privacy but also rights of property and reputation. However, actually seeking to refer a suicide attempter in the emergency room to psychiatric care, treatment is often refused or terminated from the stage of seeking consent for using personal information, ultimately leading to loss of life due to suicide re-attempts. Therefore, I propose the principle of proportionality as a constitutionally conforming legal interpretation to allow, without patient consent, the mandatory, not optional, registration of patients who visit the hospital with a history of attempted suicide to be treated as an exception to the procedures for protection of personal information, to protect the patient from the risks of potential suicide through follow-up investigations.17)

Guideline 2: the principle of proportionality on Human Right

  The principle of proportionality is a legal interpretation that accounts for the conf lict between the basic rights of the suicide attempter, their guardians, the medical personnel, and the state.
If the suicide attempter is recognized to present a clear risk to themselves, even if not to others, this mandatory registration could be allowed as an exception to the Personal Information Protection Act solely to protect the patient’s right to life. In addition to the patient’s right to life, the exception could be allowed to protect the right to life of medical personnel, given that treatment cannot be delayed for some patients with mental illnesses. If, due to the nature of treatment, it is determined that the symptoms of the illness can only be alleviated through longterm sustained follow-up rather than fragmentary or one-time treatment, it can be considered that the duty to treat takes priority over the protection of personal information.

  Tracking suicide attempts through follow-up surveys with those who attempt suicide is known to reduce future attempts. In the Republic of Korea, only patients who have agreed to under-go psychiatric treatment including documented case information and cases covered by the Personal Information Protection Act are eligible for follow-up. In Korea, despite the considerable efforts of medical personnel to prevent suicide, it is difficult to guarantee even minimal treatment and access to psychiatric care for patients who are admitted to the emergency department for attempted suicide. The suicide rate cannot be expected to decrease in a medical system where, after the treatment for trauma, it is impossible to provide continued treatment to resolve psychiatric issues without consent to use personal information by the patient or his/her guardian. According to the constitution, by applying the principle of proportionality to psychiatric care, and preparing criteria for prioritizing psychiatric treatment for suicide attempters as an exception to the protection of personal information, I hope that it will be possible to guard the patient’s rights to life and good health, while also protecting the physician’s duty to treat.

  Ultimately, this study demonstrated that suicide is perceived as a social problem and that there was general agreement with national intervention; however, individuals who report actual suicidal ideation showed inconsistent responses. Paradoxically, this might be the reason why policy improvements must prioritize mandatory intervention, not from a personal perspective, but from the perspective of public health and medicine. Moreover, due to policy limitations, I did not present specific guidelines for clinical ethics. Therefore, this requires further research from a policy perspective.

Limitations
  Though this study uncovered several insights about suicide and health policy in Korea, it is limited by the fact that it did not survey suicide attempters, but rather members of the general public. This limitation may have resulted in a lack of input from those patients and former attempters. The need for further investigation is evident and future scholars should conduct surveys of national management systems to target suicide attempters.

Acknowledgments
  The Author received survey data support costs from the Ministry of Health and Welfare of Korea in 2020 and having no conf licts to declare.

Conflicts of interest
  The author has no financial conf licts of interest.

ORCID iDs
  Do-Hyun Kwon  https://orcid.org/0000-0001-9789-3308