Toomey, J., Lewis, J., Hannikainen, I., & Earp, B. D.
(2024). The American Journal of Bioethics, in press.
Jennifer Hawkins (2024) offers two cases that challenge traditional accounts of decision-making capacity, according to which respect for a medical decision turns on an individual’s cognitive capacities at the time the decision is made (Hawkins 2024; Appelbaum and Grisso 1988). In each of her described cases (involving anorexia nervosa and grief, respectively), a patient makes a decision that—although instrumentally rational at the time—does not reflect the patient’s longer-term values due to being in a particular psychological state. Importantly, this state does not impair the patient’s cognition, but rather predisposes them to make a decision that conflicts with their own broader values, beliefs, or desires.
Under traditional understandings of decision-making capacity, the patient’s decision in either case must be followed by healthcare providers, insofar as it was made while in possession of the requisite cognitive abilities. But this, Hawkins suggests, is the wrong outcome. Although core cognitive capacities are necessary for decision-making capacity, they are not on her view sufficient. From her perspective, patients who clear the threshold of cognitive capacity are not entitled to have their decisions followed when there is good evidence they are making a serious prudential mistake while known to have a condition that makes people more likely than typical to make such mistakes.
Here are a few thoughts:
This article highlights a crucial topic regarding decision-making.
Traditionally, a patient's cognitive abilities have been the main focus for evaluating their decision-making capacity. This article challenges that notion by introducing the concept of a patient's "true self". It argues that even if a patient has the cognitive ability to make a decision, it shouldn't be automatically respected if it doesn't reflect their long-term values or identity. This emphasizes the importance of understanding a patient's underlying values and goals when making decisions about their care. The article aligns with the idea that people often judge medical decisions based on a patient's "true self," highlighting the complexity of determining a patient's true wishes.
Finally, the article confronts us with ethical dilemmas where respecting a patient's cognitive decision might conflict with their well-being. This underlines the need for a nuanced approach that considers both cognitive capacity and a patient's identity. In essence, this article encourages mental health professionals to move beyond following just cognitive protocols and strive for a more comprehensive understanding of their patients.
