Making decisions is not as straightforward as we assume, especially when emotions are clouding our state of mind.
When I chaired the Douglas Institute’s clinical ethics committee the issue of consent came up many times. It is an important issue in psychiatry because the illnesses sometimes force us to make decisions against the will of patients. The issue of autonomy is a sacred cow in medicine. No one wants others to impose their will on us. But many paranoid patients believe medicine is poisonous or intended to harm them. This implies the illness might be affecting their ability to decide.
It is a difficult dilemma to resolve, but judges base decisions on a person’s ability to make a free and informed choice. ‘Free’ means the person is not being forced in any way and ‘informed’ means he or she has all the facts. In psychiatry, both issues can cause problems. With respect to the informed part, most pharmacological treatments have strong and unpleasant side effects. This causes many patients to stop treatment. Unfortunately, Schizophrenia or Bipolar Disorder (two psychotic illnesses in which patients can lose contact with reality) can be extremely harmful to the individuals who have the disease.
It is difficult to fully comprehend the impact of not treating certain psychiatric illnesses. In Schizophrenia, for example, the suicide rate is 100 times higher than in the general population. This implies that for consent to be truly informed a patient must be able to fully comprehend the effects of the medication but also the risks and benefits of treatment refusal.
The free part is also a challenge. Many families and doctors put a great deal of pressure on the patient. This is usually done out of worry for the patient and is certainly understandable. Nevertheless, these people have rarely experienced the effects of psychiatric medication. The ideal we seek is to give the individual as much freedom to decide as possible.
In my private practice, I rarely deal with psychotic illnesses. Most clients are in treatment for depression or an anxiety disorder. Unlike Schizophrenia, medication is not necessarily the first treatment of choice. It is nevertheless very helpful in many cases and can almost be considered a necessity in others. Antidepressant medication can be extremely useful in treating not only depression but most anxiety disorders as well.
In thinking about consent, most clients are highly functional. We rarely question the decision-making process of someone who is not in the throes of a psychotic episode. Yet I am struck by how often decisions are made not on the basis of symptom severity but instead on attitude toward medication. Many people are opposed to the very idea of pills for mood even if they would never question a prescription for an antibiotic.
Many others are worried about side effects. To be fair, there are unwanted side effects of antidepressants so they should not be taken unnecessarily. Nevertheless, most are mild and temporary. For a person to be free to consent, he or she must be able to decide in the absence of fear, a difficult thing to do when facing change. I am constantly struck by how many people base their decisions on emotions and attitudes rather than clinical facts and indications.
This got me thinking about the ‘free’ part of free and informed consent. Are we really free to decide when we are scared or depressed? Doesn’t mood cloud our judgment? And this is not only the issue when we are facing treatment choices. It affects all choices. Decisions to divorce when angry or to have another child when we fall in love can at times be right, but can also turn out to be very wrong. Decisions based on temporary mood states do not always match a decision we would otherwise make when calm.
A good decision usually doesn’t change with our mood. If the decision to divorce still seems right after we have calmed down, then it is probably the right thing to do. A bad decision is one that keeps switching back and forth. This usually means our mood is affecting our ability to make a free choice – one free of emotional coercion.
Here is today’s Métro column:
Free and informed consent
(Source: Consentement libre et éclairé. Journal Métro, March 25, 2014)
SVP, voir plus bas pour la version Française.Consent. It’s a basic principle in decision-making. As adults one of our most sacred beliefs is that, unless we are hurting others, we should never be made to do something against our wills. This applies to relationships, parenthood, school, work, pretty much everything. In a free society consent is king. So let’s look at it in detail.
We generally feel that for consent to be valid it must be free and informed. This means that the person must have all the information before choosing and cannot be forced into one option or another.
Informed
To properly consent, a person must have all the available facts. When taking medication, for example, the person must know the risks and benefits of taking the drug, but also the risks and benefits of not taking it. For example, I must know if a pill has a 10% chance of killing me, but I must also be informed if I have a 50-50 chance of dying from the illness if it goes untreated. I cannot look at the risks of treatment alone, I must also understand the risks of no-treatment. But here’s where it gets complicated. Even with the facts, we have to deal with our emotional reactions to them.Free
We all understand that if someone has a gun to our heads, any contract we sign or any consent we give isn’t very valid. We often think of outside influences when we talk of coercion, but what of fear and despair? Can a terrified person freely consent to anything?In many cases, people struggling with deadly diseases will be depressed and when this happens they will see the world through a negative filter. Pessimism comes with depression. Can people make free and informed choices if their mood is distorting how they see the information?
Then there is anxiety. When we are scared, do we see things the same way as when we are calm? Talk to people about the possible side effects of a medication or tell them about what can go wrong during a surgical procedure and what do you think will happen to them? Will they be truly free to decide when they are being ‘coerced’ by possibly irrational fear?
We rarely take to time to fully consider our decisions in life. Whether it is about our choice of university study, the person we choose to live with, or the treatments we follow, we must examine all the possible risks and benefits of the question at hand as well as the risks and benefits of a refusal. More importantly, we must do so with a mind as free as possible of temporary emotional coercion. To do so, we can wait until our anxiety or despair dissipates a little before deciding, or better yet, we can imagine what we would advise a loved one in the same position. That advice is usually going to be based on logic rather than fear.
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Voici la version Française:
Le consentement est un principe de base de la prise de décision. L’une de nos croyances les plus sacrées est que, à moins que cela ne blesse les autres, on ne devrait jamais nous forcer à faire quelque chose contre notre volonté. Cela s’applique aux relations, à la parentalité, aux études, au travail, à pratiquement tout. Dans une société libre, le consentement est roi. Examinons donc la question en détail.
Nous sommes généralement d’avis que, pour qu’un consentement soit valide, il doit être libre et éclairé. La personne doit donc disposer de toute l’information nécessaire avant de prendre une décision et elle ne doit pas être forcée de choisir une option plutôt qu’une autre.
Éclairé
Pour donner son consentement d’une façon adéquate, une personne doit avoir en main tous les faits pertinents. Par exemple, si une personne prend un médicament, elle doit connaître tous les risques et les avantages de la prise de ce médicament, mais aussi tous les risques et les avantages de ne pas le prendre. Ainsi, je dois savoir que les possibilités qu’un comprimé me fasse mourir sont de 10 %, mais aussi que les possibilités de mourir des suites de la maladie sont de 50-50, sans traitement. On ne peut pas tenir compte uniquement des risques que pose le traitement : il faut aussi prendre en considération les risques posés par l’absence de traitement. Mais c’est là que les choses se compliquent : même en connaissant les faits, nous devons composer avec nos réactions émotionnelles.Libre
Bien sûr, si quelqu’un nous pose un pistolet sur la tempe, tout contrat que nous signerons ou tout consentement que nous donnerons ne sera guère valide. On songe souvent à des influences extérieures, lorsqu’on parle de coercition, mais qu’en est-il de la peur et du désespoir? Une personne terrifiée peut-elle consentir librement à quoi que ce soit?Dans bien des cas, les gens aux prises avec une maladie mortelle sont déprimés et voient le monde à travers un filtre négatif. Pouvons-nous faire un choix libre et éclairé si notre humeur déforme notre vision des faits?
Puis, il y a l’anxiété. Lorsque nous avons peur, voyons-nous les choses de la même façon que lorsque nous sommes calmes? Parlez à des gens des effets secondaires possibles d’un médicament ou de ce qui peut mal tourner au cours d’une intervention chirurgicale. Que croyez-vous qui leur arrivera? Seront-ils vraiment libres de prendre une décision, s’ils sont « contraints » par une peur peut-être irrationnelle?
Dans la vie, nous prenons rarement le temps de bien examiner nos décisions. Qu’il s’agisse de notre choix d’orientation à l’université, de la personne avec laquelle nous décidons de vivre, ou de traitements à suivre, nous devons examiner les risques et les avantages de la question, ainsi que les risques et les avantages d’un refus. Et surtout, nous devons le faire dans un état d’esprit le plus libre possible de toute contrainte émotionnelle. Nous pouvons donc attendre que notre anxiété ou notre désespoir diminue avant de prendre une décision. Ou mieux encore, imaginer ce que nous conseillerions de faire à un être cher dans la même situation. Ce conseil est habituellement fondé sur la logique, plutôt que sur la peur.
Tagged as consent, emotional judgments, free and informed.
Posted in Human nature, Mental health.
Posted on 25 Mar 2014
