http://www.brainviews.com/abFiles/ImgPet.htm
Simon who is a widowed father of age 53 came to the hospital with mentally unstable mind. He had a severe depression to the point of attempting suicide and wasn’t willing to receive the proposed treatment (1). The dilemma is whether physicians should take Simon’s refusal as a respect for his autonomy and not give the proposed treatment of electroconvulsive shock therapy or value beneficence more and give the treatment despite Simon’s will. Specifying a little bit more, we need to focus on and explore if Simon is competent enough to be considered as autonomous and decide the matter for himself.
In Scotland, the government has introduced an interesting bill to be considered supporting physicians to assist their patients with committing suicide should they desire (2). It has complicated issues and questions involved, such as what are patients’ and physicians’ roles, is it moral to help patients to commit suicide, what is physicians’ job ultimately in helping patients, how do we redefine “helping”, how do we balance between patients’ autonomies and physicians’ need to be beneficent, etc. Applying it to Simon’s case, if we value his autonomy, he not only won’t be treated with the electroconvulsive shock therapy but also will most likely to commit suicide. As a result, doctors may be passively “assisting” Simon to commit suicide. Before we go further and look deeper into whether it is morally better for the doctors to value autonomy over beneficence, it is important to specify what constitutes autonomy and if doctors should respect Simon for his autonomy, if he has any.
According to Beauchamp and Childress, there are three components to autonomy: intentionality, understanding, and noncontrol (3). Simon has intentionality; he doesn’t want the treatment. In addition, although there are influences and resistances exerted by the physicians, Simon remains firm and “noncontrolled”. His autonomy is questionable when we consider his understanding of the situation, though. He doesn’t seem to understand his own situation nor the benefits and possible consequences of the electroconvulsive shock therapy due to the severe depression he has. This ties into assessing one’s competence. Appelbaum and Grisso presented the standards of incompetence including inability to understand one’s situation and its consequences (4). Simon may be able to express his own intentions, but whether physicians should respect his autonomy is debatable because of his current mental condition that hinders his understanding of the circumstances. I say doctors should go ahead and give him the treatment.
Now, the consequences of valuing beneficence over autonomy may be costly. Simon may suffer from permanent memory loss and possibly death in the worst case scenario, not to mention the fact that the treatment only temporarily relieves the severe depression. However, I believe physicians should consider the best solution for the patients always, and in this case, it is treating him with the electroconvulsive shock therapy. They should respect patients’ autonomy, but not when a patient is about to commit suicide because of depression or when the patient himself doesn’t really know much about his own state of mind incapable of making a reasonable decision. In fact, the consequence of valuing autonomy over beneficence is much worse, Simon with his severe depression that doesn’t seem to improve with the current medication, which might lead to his suicide. To give or not to give the treatment is the dilemma. Neither way can satisfy every party involved. Therefore, I believe physicians should make the best choice for the patient who doesn’t meet the criteria of autonomy by giving the treatment to prevent Simon from committing suicide.
References:
1. Waluchow, Wilfrid J., and Elisabeth Gedge. “3.2 Non-Consensual Electroconvulsive Shock Therapy.” Well and Good. a Case Study Approach to Health Care Ethics. By John E. 1926- Thomas. Peterborough, Ontario: Broadview, 2014. 124-31. Print.
2. Russell, Paul. “Pro-assisted Suicide Lobby Making Nonsense.” LifeSiteNews. Life Site, 28 Jan. 2015. Web. 29 Jan. 2015. <https://www.lifesitenews.com/opinion/pro-assisted-suicide-lobby-making-nonsense>.
3. Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. New York, NY: Oxford UP, 2001. 101-40. Print.
4. Paul S. Appelbaum and Thomas Grisso, “Assessing Patients’ Capacities to Consent to Treatment,” New England Journal of Medicine 319 (December 22, 1988)
Jeongseok,
I think you make some interesting points in addressing the dilemma in this case study. I agree that issues of autonomy and beneficence are central to this case. While Mr. S is psychologically troubled, as he is faced with treatment-resistant depression with psychotic features, I would argue that he is emotionally rather than intellectually troubled. His main focus is in ending his life because he views a bleak future. He is able to coherently express how he feels and is adamant in avoiding ECT, despite his withdrawn, agitated nature. While it may seem illogical to consider taking one’s life over trying a possible treatment, it does not make the patient mentally incompetent. Mr. S should still be treated as an autonomous agent. Depressed individuals often feel a loss of control in their life, and if Mr. S’s wishes are not respected, it could exacerbate his depressed symptoms.
In regards to beneficence, ECT does have serious potential risk factors that can cause lasting harm. ECT is also only a short-term solution. Repeated sessions of ECT over an extended period of time can have detrimental effects. I do not think that refraining from ECT is the same as physician-assisted suicide, especially if other treatment plans are underway. Other treatment methods, such as a differing drug regimen or pairing counseling with antidepressants could be less risky and respect Mr. S’s wishes and his son’s concerns. Since Mr. S displays suicidal ideation and intent, increased monitoring to ensure that he will not take his life could be implemented as well. The fact that Mr. S is in an in-patient psychiatric unit may place less emphasis on his autonomy, but ECT should really only be considered as a last resort and only performed with patient or familial informed consent.
Your point is very well taken. The perspective that doctors honoring the patients’ request to not receive the electroconvulsive shock therapy is a form of the doctors “assisting” the patient in committing suicide is very interesting. It is ethical for doctors to practice beneficence in that the welfare of the patient should be the main concern. However, I have to agree with Michelle in that going forth with ECT only solves the depressive problems for a moment. Would ECT be administered regularly? If it is, then that could possibly be more damaging than helpful. There are also other non-invasive alternatives to treating severe depression. Maybe the patients’ refusal to ECT is because it is a surgical procedure. Undergoing surgery is a frightening experience for many and the patient may not see surgery as necessary.