Medical Ethics

MEDICAL ETHICS

The decision-making capacity of a patient with schizophrenia seeking an abortion

By Christopher Isennock, MS-3, Mercer University School of Medicine

Christopher Isennock

Each 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 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.

Although she did not have detailed knowledge of each procedure available to her, in my opinion it was not necessary for her to do so to satisfy the understanding provision, as she understood the basics of the situation she was in and that there were termination options available. Thirdly, we must deal with the question of her ability to rationalize her choices. The concept of reasoning is often left vague in discussions of decisional capacity, yet consistency and the ability to derive conclusions from premises are often used as criterion for rationalization of a decision. 2 The patient demonstrated her ability to derive conclusions from premises as she indicated that in order to relieve the financial burden of having another child, she wanted to terminate the pregnancy. Whether or not her diagnosis of schizophrenia would affect her consistency in making that choice over time is more difficult to determine, as we only saw the patient on that one day.

“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. ”

The remaining component of decision-making capacity, appreciation of consequences, is more abstract to determine and physicians are often left with some ambiguity in doing so. According to Dr. Charland, appreciation of consequences means that “subjects must be able to appreciate the nature and meaning of potential alternatives – what it would be like and ‘feel’ like to be in possible future states and to undergo various experiences – and to integrate this appreciation into one’s decision making.” 2 Clearly, this is the deepest level of understanding of the four criterion and means that patients must be able to imagine themselves in different outcomes based on their choices.

One common way to assess a patient’s ability to appreciate the consequences of their decisions is to get them to describe what it would be like to live with the various outcomes of their decisions. But in this instance, the patient was not walked through the potential options and outcomes of her decisions. Therefore, I speculate that it did seem that she was able to appreciate the consequences of her choices, although I wish that we had done a more thorough job assessing this. I believe that this conclusion is supported by the reasons behind her choice.

Her primary concern was that the pregnancy would result in financial hardships. In order to provide this reasoning, she must have been able to place herself into the frame of mind of what it would be like to have another child and could therefore appreciate the consequences both having and not having a baby. Although we did not explicitly walk through potential scenarios to assess her ability to appreciate the consequences of her decision, I believe that she did successfully meet the final component in decision-making capacity, rendering her capable of making her own medical decisions. There is also support for the patient’s decision in the literature. In a meta-analysis of decision-making capacity in schizophrenia, researchers found that “impairment in capacity is not a distinguishing feature of schizophrenia.” 3 This means that a diagnosis of schizophrenia alone cannot be used to remove someone’s decision-making capacity. Furthermore, the researchers found that the “majority of people with schizophrenia were deemed to have adequate decision-making capacity” and that only around 18 percent of patients with schizophrenia were found to lack decision-making capacity. 3 Therefore, determining a schizophrenic patient’s decisionmaking capacity must be done on a case-by-case basis. The transition from textbook to clinical medicine challenges third-year medical students to realize the importance of the ethical foundations of medicine and marks a monumental step in their journey to becoming health care providers. During this time, students begin to appreciate that real-life medicine is much less black and white than the medicine practiced in textbooks, and it often involves competing ethical principles of medicine. My experience with the young woman with a history of schizophrenia seeking an abortion strongly exemplified this fact to me. This experience taught me that decision-making capacity is nuanced and can be difficult to establish, especially in a patient who is at risk of having impaired decisional capacity. Despite this potential challenge, determining a patient’s decisionmaking capacity is a foundational part of a physician’s duties and is not one that can be overlooked.

References

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3. Miles, S. H. (2004). The Hippocratic Oath and the Ethics of Medicine. New York: Oxford University Press, 2004. Charland, L. C. (2015). Decision-Making Capacity. The Stanford Encyclopedia of Philosophy (Fall 2015 Edition). Retrieved from: https://plato.stanford.edu/archives/fall2015/entries/ decision-capacity. Jeste, D. V., Depp, C. A., & Palmer, B. W. (2006). Magnitude of impairment in decisional capacity in people with schizophrenia compared to normal subjects: an overview. Schizophrenia bulletin, 32(1), 121–128. https://doi.org/10.1093/schbul/sbj001.