(This is a work in progress) In medicine a patient has both the ethical and legal right to refuse medical treatment even if denying such treatment are to lead to the patient’s death. At least one of the conditions for the permissibility of such a choice is that the patient, generally speaking, freely chooses it. This broadly means the patient decision was made without external or internal coercion or manipulation. Yet, advances in neuroscience have painted a rich but complex picture of the human decision-making. There are many instances in which a choice appears to be freely chosen but, in fact, is the result of internal coercion. In this post, I want to examine the intersection between patient’s medical decision-making and internal coercion from a psychiatric condition or disorder in cases where psychiatric conditions or disorders become a terminal condition. In these extreme and rare cases a patient’s psychiatric condition or disorder is categorized as being terminal. Campbell and Aulisio (2012) have written on the subject in the context of anorexia nervosa. In that particular case, the patient’s condition and their ciricumstances were enough to warrant categorizing their psychiatric condition as being terminal and allowing the patient to be put into a hospice facility. This case contains many different and relevant ethical issues. However, I want to specific examine whether the issue of whether the patient’s choice to refrain from eating was freely chosen. This investigation is not meant to be viewed as a criticism of the healthcare providers involved, for I believe they made the correct ethical recommendation but rather to consider the ethical implications on decision-making capacity, medicine, and the responsibility of clinicians if the patient’s choice was not freely chosen.
To begin, my inquiry is not aimed at the level of philosophical conceptions of free will, although I do presuppose that to choose freely means a conditional ability to have chosen otherwise and at least some degree of control is fundamental for a person being responsible for an action or behavior (Shepard and Shane 2012; Fischer and Ravizza 1998). I also take freely choosing (volitional control) as constitutive of decision-making capacities in the practice of medicine (Beauchamp and Childress 2009; Jonsen, Siegler and Winslade 2010).
It is not all that surprising that in many cases people lack volitional control over their actions and behavior (Levy 2007; Wegner 2002; Bargh and Chartrand 1999). For example, consider personal self-control, the ability to refrain from certain behavior. In what is referred to as ego-deletion, a person refraining from one kind of action such as not eating a cookie or keeping a straight face while watching a funny video, has a marked decreased ability for self-control in other situations, such as grip strength or problem-solving (Baumeister, et al. 1998; Baumeister 2002; Schmeichel and Baumeister 2004; Vohs and Heatherton 2000). Self-control is only a finite resource. Certain conditions or disorders (Tourette’s syndrome, anorexia nervosa, and in some instances of borderline personality disorder) involve instances where it is not simply a matter of self-control to avoid eating a cookie but a matter of volitional control over doing broader, more intentional actions. For Tourette’s syndrome, anorexia nervosa, and borderline personality disorder, it has been suggested that compulsive impulses build up and, crudely put, override the patient’s volitional control, forcing them to perform certain behaviors or intentional actions. Patients suffering from these conditions or disorders may also only possess a finite amount of volitional control over these intentional actions. So, for example, patients with Tourette’s syndrome at a certain point have to express a tic, while for patients with anorexia nervosa and borderline personality disorder at a certain point they express more complex intentional actions such as not wanting to eat or to ingest or insert sharp objects in themselves (Leckman, King and Cohen 1999; Klein 2012; Kwok, Matorin and Kahn 2012; Campbell and Aulisio 2012; Henderson 2005). For these patients, even though they know that they should eat or that not eating or ingesting or inserting of sharp objects will result in severe health problems and/or death, they still perform these intentional actions. Moreover, these patients may even regard these actions as being authentic and freely chosen decisions of their own accord.
Returning to the case of the patient with anorexia nervosa who decides to stop eating and wants admittance to hospice, the problem becomes clear. It may not be clear that this patient freely chose to stop eating. That this patient did not freely choose to stop eating suggests that she did not have the decisional capacity to decide to consent to go to hospice. If the patient didn’t freely choose then the implications are deep and troubling. In terms of assessing decisional-capacity, it would be difficult to pinpoint the threshold level of volitional control necessary for a patient to be considered as having the capacity to make a choice for a treatment option. In regards to psychiatric conditions or disorders being categorized as terminal, the implication is that clinicians may have a responsibility (an almost unfair burden) to deny what appears to be an autonomous decision to refuse treatment.
Whether or not it turns out to be true that the patient’s decision was freely chosen, considering the implications of the patient’s choice being the result of internal coercion suggests that clinicians, neuroscience, and philosophers need to closer examine the intersection of free will, assessment of decisional-capacity of patients, and responsibilities of patients and clinicians.
REFERENCES
Baumeister, R. F. . "Ego Depletion and Self-Control: An Energy Model of the Self's Executive Function." Self and Identity 1 (2002): 129-36.
Baumeister, R. F., E. Bratslavsky, M. Muraven, and D. M. Tice. "Ego-Depletion: Is the active self a limited resource." Journal of Personality and Social Psychology 74 (1998): 1252-65.
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 6th Edition. Oxford: Oxford University Press, 2009.
Campbell, Amy T. , and Mark P. Aulisio. "The Stigma of "Mental" Illness: End Stage Anorexia and Treatment Refusal." International Journal of Eating Disorders 45 (2012): 627-634.
Fischer, John Martin , and Mark Ravizza. Responsibility and Control: A Theory of Moral Responsibility. Cambridge : Cambridge University Press, 1998.
Henderson, Scott. "The Neglect of Volition." British Journal of Psychiatry 186 (2005): 273-274.
Jonsen, Albert R., Mark Siegler, and William J. Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine . 7th Edition . New York: McGraw-Hill Medical , 2010.
Klein, Carolina A. . "Intentional Ingestation and Insertation of Foreign Objects: A Forensic Perspective." Journal of the American Academy of Psychiatry and the Law 40 (2012): 119-126.
Kwok, Stephanie I. , Anu A. Matorin, and David A. Kahn. "Clinical and Ethical Dilemmas in the Psychiatric Care of Patients Who Norder on the Edge of Being Able to Live Safely and Independently." Journal of Psychiatric Practice 18 (2012): 213-220.
Leckman, J. F., R. A. King, and D. J. Cohen. "Tics and Tic Disorders." In Tourette's Syndrome -Tics, Obessions, Compulsions, edited by D. J. Cohens and J. F. Leckman, 23-41. New York: John Wiley and Sons, Inc, 1999.
Levy, Neil. Neuroethics: Challenges for the 21st Century. Cambridge: Cambridge University Press, 2007.
Schmeichel , B. J. , and R. F. Baumeister. "Self-Regulatory Strength." In Handbook of Self-Regulation, edited by R. F. Baumeister and K. D. Vohs, 84-98. New York: The Guilford Press, 2004.
Shepard, Jason, and Reuter Shane. "Neuroscience, Choice, and the Free Will Debate." AJOB Neuroscience 3, no. 3 (2012): 711.
Vohs, K. D. , and T. F. Heatherton. "Self-Regulatory Failure." Psychological Science 11 (2000): 249-254.
Wegner, David M. The Illusion of Conscious Will. Cambridge: MIT Press, 2002.
Great post! I have suffered from a volitional disorder and witnessed a family member struggle with anorexia, and those experiences have radically altered my perspective on intention and volition. I am still working through how to integrate those experiences into my philosophical and legal framework -- I'm not there yet -- but I'm happy to see someone else thinking about it.
I didn't think much about the issue of volition and intention until I lost some because of OCD/depression (before getting sick I assumed everyone had roughly the same amount of self-control. Therefore criminal punishments -- for instance -- would have about the same level of deterrence for everyone). Boy has my view changed!
Talking to patients (both before and after illness/recovery) about their perceived level of volition could be helpful in this line of research.
Posted by: Nina | 02/15/2013 at 10:43 AM