Summary
Simon, a widowed father of a single son was brought to the hospital after an attempted suicide. Simon has been suffering severe depression, and treatment with anti-depressants seems to have had no benefit. Once hospitalized, Simon attempted suicide again. This led Simon’s psychiatrist to propose an electroconvulsive shock treatment therapy over a course of two weeks (1).
Discussion
One of the moral dilemmas that are being addressed in this case is: Should the psychiatrist respect the father’s autonomy and allow him to refuse treatment, or should the principle of beneficence take precedence and the treatment be given against the wishes of the Father and Son.
First, we should explore whether or not simon is competent enough to have his autonomy respected. According to Beauchamp and Childress, a person may be declared incompetent if they are unable to give a rational reason for their actions (1). Now this brings into question, is there any rational reason for suicide? To Simon, escaping constant mental distress may take precedence over preserving physical wellness. If this were the case, Simon could be declared competent enough for his autonomy to be respected, and the psychiatrist should respect his decision to refuse treatment; however, from the psychiatrist’s point of view, he could state that Simon’s chronic depression prevents him from understanding relevant information or the consequences of his choice, and therefore would classify Simon as incompetent, and give the psychiatrist reason to apply to the review board to go ahead with the treatment.
Second, we must look at the psychiatrist’s obligation to beneficence. As a healthcare professional, the psychiatrist must take actions to prevent harm and promote good. If the psychiatrist should allow Simon to refuse the treatment, and Simon ends up committing suicide, one could determine that the psychiatrist failed to uphold this principle. But achieving this goal could prove challenging for the psychiatrist. By promoting autonomy through providing accurate information about ECT to the father, the psychiatrist is doing his best to promote good; however, if even after providing accurate and understandable information to both Simon and his son, the pair still refuse treatment and Simon commits suicide, one could say the psychiatrist failed to prevent harm. So at what point does the psychiatrist’s attempts to convince Simon to accept ECT violate Simon’s autonomy through coercion or manipulation?
Personal Response
One might say that Simon’s depression renders him incompetent and temporarily nullifies his right to refuse treatment. But Simon previously agreed to receive anti-depressants, which would not have been prescribed unless Simon had been already been depressed. On that note, is it acceptable to overlook a patients mental illness if their decision could potentially preserve their physical condition as opposed to threaten it? Is someone only deemed incompetent if their actions produce a negative consequence for their healthcare provider? I would say that Simon is indeed in a more severe mental state than when he agreed to take anti-depressants, but not severe enough that he should be declared incompetent and have his autonomy violated.
Furthermore, the efficacy of ECT should be called into question when determining whether or not to respect Simon’s autonomy. While it has been shown that ECT can produce promising effects short-term, chances of relapse still remain high. The common strategy with ECT is that it allows time for anti-depressants to take effect. However, the anti-depressants obviously did not work for Simon before, so the question becomes, would the ECT be enough of a catalyst for the drugs to be effective? The results are conflicting. Earlier studies showed that ECT in conjunction with continued anti-depressant use effectively reduced the symptoms of major depressive disorder with low rates of relapse (2), but some later studies showed that the relapse rates are relatively high. One study showed a 57% relapse in patients receiving ECT and continued antidepressant use in 6 months (3), with another study showing a 51% relapse rate (4). I believe that the high relapse rates of the ECT make it unjustifiable for the psychiatrist to obtain approval for the ECT. The chances that Simon would relapse into depression and be subject to further mental distress should be enough to justify his autonomous decision to refuse of treatment.
References
1. Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. New York, NY: Oxford UP, 2001. 101-40. Print.
2. Gagné, G. G., M. J. Furman, L. L. Carpenter, and L. H. Price. “Efficacy of Continuation ECT and Antidepressant Drugs Compared to Long-Term Antidepressants Alone in Depressed Patients.” The American Journal of Psychiatry 157, no. 12 (December 2000): 1960–65.
3. Rehor, G., A. Conca, W. Schlotter, R. Vonthein, S. Bork, R. Bode, M. Hüll, et al. “[Relapse rate within 6 months after successful ECT: a naturalistic prospective peer- and self-assessment analysis].” Neuropsychiatrie: Klinik, Diagnostik, Therapie Und Rehabilitation: Organ Der Gesellschaft Österreichischer Nervenärzte Und Psychiater 23, no. 3 (2009): 157–63.
4. Jelovac, Ana, Erik Kolshus, and Declan M. McLoughlin. “Relapse Following Successful Electroconvulsive Therapy for Major Depression: A Meta-Analysis.” Neuropsychopharmacology 38, no. 12 (November 2013): 2467–74. doi:10.1038/npp.2013.149.
Although your interpretation of the case is interesting, I would have to say that I disagree with you. Mr. S’s depressive conditions have gotten worse than when he started his antidepressants (shown by the fact that he has attempted suicide). Many would argue that most people who attempt suicide don’t try it a second time, but Mr. S has admitted to preparing to try again. This implies that his life is in danger and in a more emergent state than expected. He simply may not have time to let the drugs come into effect.
Mr. S’s competence is being called into question because he is displaying suicidal behavior. Based on the assumption that people who want to commit suicide are not in their right mind, Mr. S is displaying such character and therefore, we really can’t say that he is acting in his right mind. Therefore, his life is in jeopardy because he is currently not competent to make life saving decisions (like the decision to not take his life).
Joseph,
I found your opinion on this case fascinating. The main problem that I have with your argument is from this statement: “I would say that Simon is indeed in a more severe mental state than when he agreed to take anti-depressants, but not severe enough that he should be declared incompetent and have his autonomy violated.”
By saying that Simon was already in a severe mental state prior to administration of antidepressants, he should have already been considered a suicide risk to begin with. Furthermore, how can anyone be in the position to decide whether or not Simon has progressed into a severe “enough” mental state in order to be considered mentally incompetent?
I agree with your resolution to this case. The trouble that I run into is how you drew the line between mentally autonomous and mentally incompetent.
I have to disagree with you Ann, and fall more on the side of Joseph’s resolution to this case. While most people who fail at their first attempt at suicide do not try it again, I believe the fact that Mr. S did indeed admit to having prepared another attempt does not question his competence but instead simply emphasizes how insanely depressed this man is, and how bad life is for him. While I’m not arguing that suicide is the answer to one’s deep depression, I am arguing that his competence shouldn’t be questioned just because he is depressed. And like Joseph said, the chances that Mr. S falls into a relapse of his depression even after the ECT procedures is enough to justify his decision and respect his autonomy. How can one rank a depressed individual’s mental competence on any sort of scale? At what point does depression have the right to take away one’s autonomy? This distinction is far too difficult to make, but for Mr. S I truly do not believe that the physician can authorize ECT treatments against his will.
While I agree that in some situations attempting suicide could be an indicator of incompetence, I do not believe that this is one case. There are other factors that must be considered including the level of his depression. He tried to help himself by taking anti-depressants, but they did not alleviate his turmoil. I can’t imagine how hard his life must be, but I can tell that it’s not desirable in any way. I do not believe that he is incompetent because he explained his reasons for committing suicide, and he also mentioned how he was prepared to try again. By being able to convey what he is thinking and feeling, he has shown how he understands his mind and is therefore competent.
In this case, I think it is justified for the physician to honor the patient’s decision to not receive the ECT. Given the fact that he has tried various methods to improve his depression and that the remaining family he has has agreed with his choice to deny treatment, there is reason as a physician to respect this. From the doctor’s perspective, the primary responsibility he has is to inform the patient of the treatment and what can be done to improve their health. Also, I think it is important to note the remarkably high relapse rates from ECT. As you said, studies have estimated a 50% relapse rate for those depressed patients after receiving this treatment. If it was an adolescent with their life ahead of them, the same response would not be appropriate; however, the patient here has the approval of his son to deny the ECT procedure.