MEDICAL ETHICS
The decision-making capacity of a patient with schizophrenia seeking an abortion By Christopher Isennock, MS-3, Mercer University School of Medicine
E
ach year in the U.S., inexperienced and impressionable first-year medical students are outfitted in white coats and gather to recount the Hippocratic Oath, officially joining the ranks of the medical community. Within this oath is found the following words: “If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.”1
These are powerful words for a group of mostly 20-somethings who have not yet learned to wield a stethoscope, let alone honed the skills needed to administer life-saving care. The Hippocratic Oath is one of the oldest documents outlining the principles of medical ethics, and it is a wonderful tradition with which to focus the first moments of one’s medical career. However, during the first two years of education, medical students’ time becomes all but fully saturated in learning the intricate details of human anatomy, pharmacology, microbiology, pathology and histology, and the foundations of medical ethics tend to become overlooked among the great volume of other material. The true importance of these ethical foundations is not fully realized until students transition out of the classroom and into clinical medicine during the third year of medical training ‒ when they are exposed to the many diagnostic uncertainties, conflicts of interest, and competing principles of medical ethics that abound in the real practice of medicine. During this transition, students quickly realize that their decisionmaking capacity and the ethical principles of medicine can no longer take a backseat to other studies but are a crucial factor to consider in every patient’s care. No one ethical dilemma was more pronounced and eyeopening for me than a patient at a federally qualified health center. The resident physician and I were tasked with interviewing a young woman in her 20s who was there to discuss the results of her pregnancy test. The resident explained that she was approximately six weeks pregnant. As I entered her room, expecting to meet eyes with the patient, I was surprised
Christopher Isennock
to see strips of paper scattered about the floor and a somewhat disheveled woman standing with her eyes fixed on the floor. After speaking with the patient for a few moments, it was clear that while she was able to answer my questions, something unseen was drawing her attention away from our conversation. The resident motioned towards the computer screen and my eyes were drawn towards the patient’s medical chart, which indicated that she had been diagnosed with schizophrenia. I can remember the patient’s words clearly: “I already have two kids at home and struggle to pay my bills as is. I don’t think I want to go through with this pregnancy.” In many parts of the country, abortion is still considered a highly controversial ethical dilemma and health care providers must consider the many medico-ethical principles involved in caring for this patient population. My experience with this patient left a lasting impression on me concerning not only the arguments surrounding abortion, but also the ethical principles that give patients the ability to make their own medical decisions at all. Being involved in this young woman’s care would provide me my first opportunity to participate in the determination of a patient’s decision-making capacity in the real world. As defined by Western University Department of Philosophy member Louis Charland, PhD, decision-making capacity incorporates four important components: communication of a choice, understanding, rationale for a given decision, and appreciation of consequences of the choice.2 The first, and easiest, component in this situation to determine was communication of a choice. As described before, the patient had vocally indicated her preference in this situation saying, “I don’t think I want to go through with this pregnancy.” This proves her ability to communicate her choice and satisfied the first element in decision-making capacity. Second, the patient’s understanding had to be assessed. In speaking with the patient during the interview, it was apparent that despite her diagnosis of schizophrenia, disheveled appearance, and somewhat eccentric behaviors, she understood her condition. She expressed an understanding that she was pregnant and understood that in her words, not going through with the pregnancy meant to terminate the pregnancy.
22 MAG Journal
MAG_June_2020.indd 22
6/25/20 11:24 AM
