The moral principle of autonomy is one of the four major principles of bioethics. Despite its monumental influence over the beliefs and choices of bioethicists, physicians, and patients’ families, it is difficult to specify the exact definition of this complex principle. In Principles of Biomedical Ethics, Beauchamp and Childress examine a variety of theories surrounding autonomy. In order to apply the principle of autonomy to any case, we must understand what makes a choice autonomous and who is able make an autonomous choice.
The Three Condition Theory of Autonomy outlines terms that are necessary for a choice to be deemed autonomous. An autonomous act must be intentional, have been executed with understanding, and without controlling influences over the action (Beauchamp and Childress). Using this basis, I would like to now apply this idea to the case of Simon, a 53 year old who is depressed and is denying Electroconvulsive Shock Therapy (Thomas, Waluchow & Gedge). The moral issue lies in deciding whether or not the psychiatrist should petition to force the Electroconvulsive Shock therapy and go against the principle of autonomy. In this case we must decide if the principle of autonomy should be placed higher than the principle of non-maleficence. His decision was intentional as his action to refuse treatment is in accordance with his wish to be left alone (Andre). Also, his decision is not being influenced by any outside source. Which leaves the issue of if he understands the severity of refusing his potentially life-saving treatment.
It is difficult to determine in his depressed state if he fully understands the probable outcome of his life without the electroconvulsive shock therapy. Due to the complex nature of depression and our incomplete understanding of its influences over the brain and decision making skills, we are unable to determine if Simon is competent enough to understand his actions. In a similar case to Simon, Paul Henri Thomas tried to deny electroconvulsive shock therapy, however the court ruled he was incompetent to make his own decision. By allowing the deciding factor to be the competence of the patient, there is almost a guarantee that the patient will receive the treatment. In the eyes of physician, if a depressed patient is competent, they will accept the therapy, and if they deny the therapy, they are incompetent, and therefore the therapy should the forced upon them (Andre). This paradox makes Simon’s case difficult, however we have another person’s opinion to help us make a decision: Simon’s son.
The presence of Simon’s son, and his ability to be his proxy for his therapy choices greatly reduces the complexity of this ethical dilemma. Simon’s son is intentional in his actions, is not being influenced by an outside source (besides the patient himself), and understands the risk associated with the electroconvulsive shock therapy. My decision in this case is to respect the autonomy of not only Simon, but also his son. While it may be difficult as a physician to see a patient forgo a possibly life saving therapy, ultimately in this specific circumstance, they must support the patient.
Works Cited:
Andre, Linda. “Deciding Competence.” Ect.org. N.p., n.d. Web. 27 Jan. 2015. <http%3A%2F%2Fwww.ect.org%2Fnews%2Fcatch22.html>.
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009. Print.
Thomas, John, Wilfrid Waluchow, and Gedge, Elisabeth. Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Broadview Press Ltd., n.d. Print.
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In this case, I believe the scenario involved the son operating under numerous misconceptions of the ramifications and side effects of ECT, which means he is not acting with understanding, and potentially that his actions under the outside influence of the media or whatever was the source of his misinformation about ECT. Does this affect the doctor’s acceptance of the son’s competence in making this decision and the ultimate decision of whether or not treatment should be undertaken?
That is a fair point, and I do believe that the doctor should inform and educate the son on the true side effects and risks of ECT. However, there is a point that after the son has been fully educated and informed of all correct information that he is the proxy for his father, and his decision should be respected. I see no grounds for forcing the ECT treatment on the man.
Genevieve,
I think you make a compelling argument by analyzing Beauchamp and Childress’s theory of autonomy, incorporating their theory into the case at hand, addressing all sides of the moral dilemma, and by discussing the proceedings of a similar case. I agree that we continue to increase our awareness and understanding of depression through research, but it is challenging for me to equate a depressed patient with mental incompetence. It is clear that Mr. S views his life to be one that is not worth living, he dwells on a tragic incident in his past, and he overestimates his proximity to financial ruin. Depression often leads to suicidal ideation, feelings of guilt, and a fixation on negative aspects in one’s life. While taking all this into consideration, Mr. S does not want ECT because he would rather be left alone and escape his life. I think he is aware that ECT is proposed as an effective treatment option, but also feels defeated, as his course of antidepressants was unsuccessful in alleviating his depression. It seems irrational to have thoughts of ending your life when human instinct is survival, but does suicidal ideation make a person incompetent? Is it possible that the stigma surrounding mental illness is playing a role in this case? I think the discussion would be very different if it involved a cancer patient who is refusing further surgery to remove a tumor.
I agree that the ultimate decision may lie in Mr. S.’s son if there is question about Mr. S.’s autonomy. Even after being reassured by the physician of the minimal risks of ECT and educated on the effectiveness of the procedure, Mr. S.’s son remains firm in his decision to refuse ECT. I agree with your decision to respect the autonomy of both the patient and his son.
Autonomy is a dicey issue, especially when the refusal of life saving treatment is present and there is the complications of mental illness involved. As a society we tend to have a bias against mental illness and seek to treat it immediately. Calling someone mental, crazy, etc… all imply that that person lacks competence. Therefore I would like to question your decision because socially speaking his son is also under the influence of this bias and is not necessarily competent. You are saying in this case that the son can act as a mediator for consent between the doctor and the patient because he is competent. Yet the patients competence is called into question because of his emotional instability. His son is facing his father probably dying. The son’s mental state is most likely not the most stable and thus his competence should also be called into question as he is also emotionally unstable in this situation. It is hypocritical to deny someone competence due to being in a turbulent mental state and yet have someone else who is in just as an emotional state to be competent. Furthermore there is the bias of society involved. Our society pushes preserving life above all else and that mental illness is something that can be solved. This is the bias you brought up that the doctors will have but wouldn’t that bias also be present in the son especially with the doctor pushing the son to give his father treatment. Thus the sons decision is neither fair nor competent if you use the arguments to deny the competence of the father or to ignore the doctors decision.