Okay, so we live in a pretty autonomous society, right? Each person is an individual and gets to make his or her own choices. Do I want to buy a house or a town home? Do I want a Lexus or a Chevy? Do I want chocolate cake or vanilla? (Chocolate, hello!) At the same time, no one is an island and the “independent” choices one makes invariably spreads out to affect others. And in some cases, many others.
This very topic came up recently for me and I thought I’d share because it can be (and was) incredibly thought provoking.
For a little background, there are four “buzz-words” that get bandied about in psychiatry: Autonomy, Non-malfeasance, Benevolence, and Justice. I won’t get into the others here, but you can see which term is number one on the list. Basically, my goal is to collaborate with patients, connect with them, and guide them to their own decisions. Even if I disagree with their ultimate choice!
But when does the idea of letting someone make their own decisions go too far?
Here’s a real life case example to consider. In England, a young woman in her late twenties presented to the Emergency Room after drinking large amounts of a lethal substance. She explained what she’d done to the doctor and she asked that no life saving measures be taken. To her, she had an incurable personality disorder, and as such, life was no longer worth living. And she procured the legal documentation showing that she was of sound mind when she determined suicide was her best option. Acting under the rule of autonomy, she made the decision to end her life. But she also affected several others in that process because she wanted to have company and comfort care while she died in order to ease her passing. So, after what I can only assume was a large amount of debating, perhaps with the legal and ethics teams present as mediators, the hospital complied with the woman’s wishes. They made her “comfortable” and they “let” her die.
As a physician, I’m in the business of keeping people alive, yet I also must give them the opportunity to make their own decisions regarding their health and body. Personally, I don’t know what I’d do if someone came under my care, told me that they did not want life-saving treatment for their suicidal act, and they “proved” to me that they had decision making capacity. Now, I don’t think a personality disorder is a “terminal” illness by any means, but then again I’m not living in that unfortunate patient’s shoes.
Bottom line: Could I “let” someone die right before my eyes knowing that if I saved them, they’d be alive, but their life would potentially be much worse (caustic chemicals do A LOT of damage)? Could I withhold treatment from them, thereby removing any opportunity for them to revoke their death wish? Could I trust that their decision was truly theirs and theirs alone?
Tell me, when we act of our own free will, who else gets to have a say in our decisions?