Dilemma
Simon is a financially-unstable, 53-year-old widowed male with one son. Simon was found unconscious in his home in close proximity to an empty bottle of Elavil, a prescribed and controlled antidepressant medication. After being stabilized in a hospital’s ICU, Simon was moved to the Psychiatry Unit for further treatment. Upon observation in the unit, Simon exhibited symptoms indicating severe mental depression; he was disheveled, upset, disconnected from activities, complained of inhibited brain function, suffered insomnia, and exhibited and mentioned suicidal intent. A psychiatrist advised a two-week period containing six electroconvulsive shock treatments (ECT) as a more effective alternative to the previous drug regimen used in treating Simon’s depression. Simon refused the ECT based on the risks involved and his lack of will to live. Simon’s son concurred with his father’s decision and Simon was declared mentally competent despite his depression. Should the psychiatrist appeal to proceed with the electroconvulsive shock treatments or should Simon’s decisions be honored even if they aren’t medically in his best interests (Thomas, et al. 124-125)?
Discussion
ECT is not an uncommon medical procedure, but its use is contested to this day (please learn more about the University of Michigan Health System’s ECT Program). As with any serious medical decision, there are significant risks involving ECT. Its side effects can include short-term and long-term memory loss, confusion, muscle aches, nausea, and other medical complications concerning anesthesia (Mayo Clinic). Besides the concern over these side effects, Simon was declared mentally competent, and therefore able to make decisions regarding his health although he expressed suicidal intent. Per the “three-condition” theory of autonomy (Beauchamp and Childress 104), Simon was (1) intentionally aware of the side effects of ECT and the risks of the procedure, (2) he understood the severity of his situation despite his mental illness and there was no lapse in communication between the patient and doctor, and (3) the only influence or control in Simon’s case was his mental state. These reasons do not provide justification to override his autonomy altogether.
As large as the medical risks of refusing ECT might be, Simon’s competency and valid autonomy must be honored. Simon’s degree of competency may not equal that of somebody with less severe depression than he, but he has been declared within responsible realms to decide on a course of his own treatment. Furthermore, his son wished to proceed with whatever his father chose. The son’s concurrence with his father may lead doctors to believe that the son is confident that his father made his personal choice appropriately and in accordance with reason, although it was not medically advised. The psychiatrist on the case presented possible courses of treatment, advised ECT as the best possible option to treat Simon’s depression, and should not appeal to proceed with the treatment against Simon’s wishes because Simon’s autonomy took priority in the case when he was declared competent. Should Simon’s degree of competency be truly questioned, should his situation worsen or pose an immediate (not potential) harm to others, or should another option of treatment be found, then the psychiatrist is obligated to re-evaluate the situation with new factors. But for now, Simon’s decisions and autonomy should be regarded with credibility.
Works Cited
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009, 2013. Print.
Mayo Clinic Staff. “Electroconvulsive Therapy (ECT) Risks.” Electroconvulsive Therapy (ECT). Mayo Clinic, 19 Sept. 2015. Web. 20 Jan. 2017. <http://www.mayoclinic.org/tests- procedures/electroconvulsive-therapy/basics/risks/prc-20014161>.
Thomas, John, Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 3.2: Non-Consensual Electroconvulsive Shock Therapy.” Well and Good: A Case Study Approach to Health Care Ethics. Peterborough, Ontario: Broadview, 2014. 124-31. Print.
University of Michigan. “University of Michigan Department of Psychiatry.” Electroconvulsive Therapy. University of Michigan, 2016. Web. 20 Jan. 2017. <http://www.psych.med.umich.edu/ect/>.
Hi Elisabeth,
I wanted to bring up a couple points from your blog post. Throughout your post, you indicated that Simon was determined to be mentally competent to make decisions, and that his competency and autonomy should be respected. After reading the case, I would have to disagree with his level of competence. The book never specified whether or not he was mentally competent, and even asked the question “does Simon fall into this category of mentally ill but not necessarily mentally incompetent patients?” in the discussion of the case (Thomas 127).
In the description of the case, I found many points that I thought might be indications of a compromised mental state, and therefore, a decreased degree of competency. For starters, Simons claims of being financially unstable may indeed be conjured ideas. His son claimed that he was “relatively well-off” (Thomas 124). This is an interesting idea, but I don’t know if it should be consider evidence or not because maybe Simon was just hiding the reality of his financial status from his son. I wonder if it would be possible for the Psych Unit to get a hold of financial documents to see if he indeed if in “financial ruin” or if this is an indicator of mental distress.
Another indicator of possible incompetence that I’d like to make is his lack of sleep and emotional tendencies. In the description of the case Thomas writes that he was “haggard and tearful”. (Thomas 124) Simon was also reported as “neglecting his appearance…[and] woke up most mornings at 4:00 or 4:30 and was unable to go back to sleep” (Thomas 124). Depression and sleep negatively co-interact with each other: “depression may cause sleep problems and sleep problems may cause or contribute to depressive disorders” (“Depression and Sleep”). Either way, it is evident that Simon has developed issues sleeping and seems to be sleep deprived. I’m not sure if there is a large effect (this may be a huge jump in conclusions) but sleep deprivation does effect “overall cognitive function” and if it continues long enough can lead to “increased risk of hallucinations” (Pietrangelo). Saying things like feeling like his brain is ‘rotting’ indicates that he may be experiencing devious thoughts. This fact, coupled with his remorse over his mother’s death 32 years ago and him thinking that if he was there “she would not have died,” which is clearly not true, makes me think that he might not be competent enough to make decisions for himself.
Even if he is determined incompetent, his son still agreed to side with him. However, I think the physician should take the case to court, or do whatever is necessary to override this decision. The son made his decision based on respecting his father’s wishes, but if the father’s wished are irrational, should he respect those wishes? His son also wanted to continue the pill method of treatment because he thought it would be safer. But, considering the suicidal state of Simon, is it really safer? Sure, ETC has potential side effects that can be dangerous, but the mortality rate is very low. Because Simon tried to kill himself using his antidepressant pills, which led him to the Psych Unit, it’s clear that the regime he used to take was ineffective. So who’s to say the new regime of medication will help him? What if it takes the physicians a couple different attempts to find the right regime of medication to help with Simon’s depression…will it be to late by then? Even assuming that this new regime of antidepressants would help him, ECT is a much faster process and could prevent him from suicide. If Simon succeeds in suicide, he will die, so is the safer route actually to give him the ECT treatment?
Another point I wanted to make would be the implications of his suicide, should he succeed. When Simon was caught with the noose made from pillows, he explicitly told the nurse that he would find a way to kill himself “vow[ing] he would try to electrocute himself or find a way to get sufficient pills for an overdose” (Thomas 124). Since he told them he would try to overdose via pills, is it morally right to continue the treatment method of administering pills, knowing that he will probably hoard them in an attempt to later commit suicide?
Finally, there is an indication that his lack of will to live is directly linked to his depressive feelings and sense of hopelessness. Simon said that he “would rather die than suffer like this for the rest of his life” (Thomas 124). I therefore believe that the best course of treatment would be to find a way to override the son, go through the ECT treatment and then medication for 6 weeks, and if after that he continues to have a sense of hopelessness and depression, respect his wishes and not continue with the ECT treatment.
Thanks for your lovely post and I hope to hear your response or any other ideas others have.
Sincerely,
Tori Risner
Works Cited:
Thomas, John E, et al. “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.
“Depression and Sleep.” National Sleep Foundation, sleepfoundation.org/
sleep-disorders-problems/depression-and-sleep. Accessed 28 Jan. 2017.
Pietrangelo, Ann. “The Effects of Sleep Deprivation on the Body.” Edited by
George Krucik, MD, MBA. Healthline, 19 Aug. 2014, http://www.healthline.com/health/
sleep-deprivation/effects-on-body. Accessed 28 Jan. 2017.
Hi Tori!
Thank you for your great comment and for bringing up some complex points of the case. While reading the case, I interpreted the fact that Simon’s son trusted his decisions as basis for his competency. I believe that the actions of Simon’s healthcare personnel suggested that he was competent to make decisions. Even though they did not verbally announce him competent, physicians and the psychiatrist were aware of his condition very shortly after his arrival when his son contradicted what Simon reported about his finances and overall state. With this knowledge and the knowledge of Simon’s actions after his admission to the hospital (suicide attempt, depression, etc.), Simon was still presented with the option for treatment. Doctors deemed him originally capable of making medical decisions for himself. This leads us to the area of doctors doing what they think is best for the patient and also respecting a patient’s autonomy. Doctors only turned to the son for advice when Simon neglected the proposed treatment, not before he declined to comply with their recommendation. These actions of the doctors indicate that they believed Simon was able to make medical decisions regarding himself before he denied the ECT.
Simon’s son, who has known him much of his life, also supported his father’s decisions. Simon’s son may have been emotionally shocked by the ordeal with his father or not in the right state of mind to make decisions given the nature of the situation as well, yet nonetheless wants to respect his father’s decisions. Simon’s actions in the hospital may not appear to be those of what a competent person may be, but in the realm of this case, healthcare personnel treated them as such. Should the doctors of Simon’s case have questioned his ability to make any type of medical decision, recommended or not, given his state? Maybe, but I still believe that Simon’s and Simon’s son’s wishes should be honored until Simon’s condition changes and the treatment plan must be re-evaluated. I hope I provided some extra input on some of your comment’s points!
-Elisabeth Crusey
Works Cited:
Thomas, John, Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 3.2: Non-Consensual Electroconvulsive Shock Therapy.” Well and Good: A Case Study Approach to Health Care Ethics. Peterborough, Ontario: Broadview, 2014. 124-31. Print.
Continuing along the lines of autonomy, I wonder what you (both) think would happen if Simon didn’t have a son or any other immediate family? More specifically, would there be more grounds to attempt to force him to undergo the treatment because his autonomous decision is not enough on its own without a family member backing him up?
There is substantial evidence that patients with depression and anxiety are much less likely to comply with recommended treatments. One study states that, “the odds are 3 times greater that depressed patients will be noncompliant than that nondepressed patients will be noncompliant” (DiMatteo et. al 2101). Evidence like this suggests that there may be grounds to claim that Simon’s mental state (specifically his severe depression) is interfering with the decision making portion of his autonomy in a significant way.
Regarding whether or not the caregivers should try to take this to court, I still don’t think there is a sound, compelling reason that will convince the courts that he has compromised autonomy. If the doctor strongly believes that the best or only remaining treatment option is to give Simon the electroconvulsive shock treatments, then, at a minimum, he would need to convince the son to agree and be willing to support that decision in court. Even if the son is convinced, without Simon deciding that he wants the treatments, there is no guarantee that the court will force Simon to undergo treatment.
Citation:
DiMatteo, M. “Depression Is a Risk Factor for Noncompliance With Medical Treatment.” JAMA (2000): 2101-107. Web.
Hi Jack,
The point of absence of other family members that you bring up is very interesting. I didn’t interpret Simon’s son as “backing up” his father’s decision in this case. If Simon’s son had disagreed with Simon’s decision, I don’t think that the psychiatrist would have had any more authority or incentive to go ahead with ECT therapy. The influence of family members on medical decisions, however, must be recognized. This point is brought up in an article by Dr. Anita Ho that was assigned as reading this past week, and it does a good job of creating awareness of family consideration in medical decisions. Given the circumstances surrounding this case, however (even if Simon’s son had been in favor of ECT), I agree with you in that the court would not necessarily be able to force Simon to undergo treatment.
Thanks,
Elisabeth Crusey
Hello everybody,
I agree with Elisabeth’s point that the physician does not have the authority to force Simon to undergo ECT treatments. However, there are two more dimensions to this case that I wanted to bring up in this discussion.
My first point has to do with the topic of understanding and rationality in informed consent. While it is quite clear that Simon knows what ECT is, there is a good chance that he has a skewed understanding of its side effects. As has been mentioned by several sources that we have read and discussed on the topic of ECT, this procedure is highly controversial because of its grotesque portrayal in the media and in popular culture. Thus, it is quite likely that Simon is using this pseudo-evidence as the basis for his decision making in his depression treatment. If I was the physician, I would make every effort to demonstrate that ECT is really nothing like the media portrayal, and then I would request his consent once more to confirm that he had the best possible understanding of what his options were given the circumstances.
The second point I want to make has to do with the duty of the physician regardless of what Simon decides. Physicians’ professional morality, and common morality, dictates that people that have the capacity to help others ought to do so. The physician still has the duty to make every effort to help Simon, who is threatening suicide. Thus, if he refuses to take the ECT, and the court refuses to force him to, then the physician needs to appeal to have him stay in the psych ward so he can receive more intense care for what seems to be severe depression. While this may sound incredibly paternalistic, I believe that it is necessary to institutionalize this patient because he has already attempted suicide with the anti-depressant pills. Thus, to give him more pills would be to give him the means to commit suicide, which he attests is a likely scenario to unfold.
While autonomy is important, it is definitely prima facie. The principle of “do not kill” definitely takes precedence. While Simon’s autonomy will be violated in every situation described in my suggestions, I believe that not letting him die is more important than respecting his autonomy. To let someone decide to be taken off of life support is one thing, but to let a middle-aged person who has warning signs of diminished competence go off and commit suicide without attempting to intervene and save him is another.
Hello Thomas,
Thanks for bringing up the points regarding Simon’s socialization and preconceived notions towards the idea of undergoing ETC. I agree that these possibilities may have influenced Simon’s decision, but don’t believe that Simon’s doctor should be basing his competency or autonomous choice off of the potential of outside influence through media. He should, as you mentioned, be sure to reduce as much bias surrounding ETC as possible and provide an objective view of the treatment plan. Regarding your second point, I’d be interested to know the protocol in such case. There is no way to know if he intends to truly commit suicide and if he would use the pills to do so, but the physician must act in the best interests of the patient. Do you know what kind of realm the physician’s decision-making privileges lies under concerning duty versus autonomy? I have a hard time agreeing that not letting him die is more important than respecting his autonomy (letting him die also translates to speculation about his possible suicide, which we can’t even be sure of), so I’d genuinely appreciate any other sources you could give to help me understand more. That being said, looking out for Simon’s best interests is everyone’s priority. It’s simply unclear what his best interests are.
Thank you!
Elisabeth Crusey