When concretized emotion-belief complexes derail decision-making capacity

Bioethics

Volumn 26, Issue 2, 2012, Pages 108-116

  Halpern, Jodi ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

Autonomy; Competence; Decision making capacity; Emotion; Fear; Health decisions; Psychiatric assessment

Indexed keywords

ARTICLE; CASE REPORT; CULTURAL ANTHROPOLOGY; DECISION MAKING; EMOTION; ETHICS; FEMALE; HUMAN; MENTAL CAPACITY; MIDDLE AGED; TREATMENT REFUSAL;

CULTURE; DECISION MAKING; EMOTIONS; FEMALE; HUMANS; MENTAL COMPETENCY; MIDDLE AGED; TREATMENT REFUSAL;

EID: 84856049034     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2010.01817.x     Document Type: Article

References (51)

1. Ronald Dworkin gives the example of a Jehovah's Witness whose fear of death drives him to seek a blood transfusion, a choice Dworkin argues is owed respect based on his capacity for autonomy. R. Dworkin. 1993. Life's Dominion. New York, NY: Alfred A. Knopf: 226-227; See also T.E. Hill Jr. 1991. Autonomy and Self-respect. Cambridge, MA: Cambridge University Press: 25-42.
2. R. Dworkin. 1993. Life's Dominion. New York, NY: Alfred A. Knopf: 226-227;
3. T.E. Hill Jr. 1991. Autonomy and Self-respect. Cambridge, MA: Cambridge University Press: 25-42.
4. N. Schwarz. Emotion, Cognition, and Decision Making. Cogn Emot 2000; 14: 433-440
5. J.S. Lerner & D. Keltner. Fear, Anger, and Risk. J Pers Soc Psychol 2001; 81: 146-159.
6. Although the conception of concretized emotion put forth in this paper is my own, and there is no equivalent idea in the psychiatric literature, the term 'concretized' has a relevant use by others. Psychoanalysts have used the term 'concretized' less precisely to describe imputing a subjective feeling to concrete external circumstances. See R.D. Stolorow et al., Psychoanalytic Treatment: An Intersubjective Approach. Hillsdale, NJ: Analytic Press.
7. Note that being depressed or even suicidal does not mean that one lacks the capacity to make a specific medical decision. See for example, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1982. Making Health Care Decisions: A Report on the Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. Washington, DC: Supt. of Docs, US GPO.
8. Genetic Interest Group Ltd, EurogenGuide: Guidelines for health professionals about informed consent procedures in Europe. Available at: http://www.eurogenguide.org.uk/documents/02_educational_materials_for_health_professionals_informed_consent.pdf [Accessed 5 Feb 2010].
9. Dworkin, op. cit. note 1.
10. J. Feinberg. 1986. Harm to Self, The Moral Limits of the Criminal Law. New York, NY: Oxford University Press.
11. Philosophers do discuss additional conditions, such as freedom from controlling influences, as needed for exercising autonomy (as opposed to features that comprise the capacity for autonomy). Perhaps some would argue that concretized emotions act as a kind of internal coercive force. However, under strict definitions of coercion, I would argue that this is not the case.
12. A. Reath. 1998. Autonomy, Ethical. Encyclopedia of Philosophy. London: Routledge:, pp. 586-592
13. J. Hawkins & E. Emmanuel. Clarifying Confusions about Coercion. Hastings Cent Rep 2005.
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17. Buchanan and Brock argue for the importance of a threshold rather than a comparative concept of autonomy. A. Buchanan & D. Brock. 1989. Deciding for Others. New York, NY: Cambridge University Press: 26-29.
18. Grisso & Appelbaum 1998, op. cit. Grisso & Appelbaum 1995, op. cit. Appelbaum & Grisso 1988, op. cit.
19. President's Commission, op. cit.
20. A. Buchanan & D. Brock. 1990. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge, MA: Cambridge University Press; H. Bursztajn et al. Beyond Cognition: The Role of Disordered Affective States in Impairing Competence to Consent to Treatment. Bull Am Acad Psychiatry Law 1991; 19(4): 383-388: 386.
21. Some patients with frontal lobe injuries, for example, may not be capable of valuing. See: A. Jaworska. Respecting the Margins of Agency: Alzheimer's Patients and the Capacity to Value. Philos Public Aff 1999: 28(2): 105-138; L. Charland. Is Mr. Spock Mentally Competent? Competence to Consent and Emotion. Philos Psychiatr Psychol 1998; 5(1): 67-81.
22. L. Charland. Is Mr. Spock Mentally Competent? Competence to Consent and Emotion. Philos Psychiatr Psychol 1998; 5(1): 67-81.
23. H. Bursztajn, op. cit. note 12, p. 383; H.J. Bursztajn, T.G. Gutheil & A. Brodsky. 1991. Affective Disorders, Competence, and Decision Making. In Decision Making in Psychiatry and the Law. T.G. Gutheil et al., ed. Baltimore, MD: Williams & Wilkins: 153-170.
24. H.J. Bursztajn, T.G. Gutheil & A. Brodsky. 1991. Affective Disorders, Competence, and Decision Making. In Decision Making in Psychiatry and the Law. T.G. Gutheil et al., ed. Baltimore, MD: Williams & Wilkins: 153-170.
25. Note that while the claim that emotions are intentional states is relatively uncontroversial, there is a lively ongoing debate in philosophy about the nature of these intentional states, that is, whether emotion occurrences themselves are highly cognitive, involving full-fledged beliefs, or are, on the other end of the spectrum, complex somatic perceptions of danger, loss of a loved one, etc. For the purposes of this paper I will remain agnostic about this debate.
26. J. Prinz. Is Emotion a Form of Perception? Can J Philos Supplement 2006; 32; 137-160;
27. S. Doring. The Logic of Emotional Experience: Noninferentiality and the Problem of Conflict Without Contradiction. Emotion Review 2009; 1(3): 240-247;
28. C. Calhoun & R.C. Solomon, eds. 1984. What Is an Emotion? Oxford: Oxford University Press: 3-40.
29. A.T. Beck. The Current State of Cognitive Therapy: A 40-Year Retrospective. Arch Gen Psychiatry 2005; 62:953-959; R.A. Gould et al. A Meta-analysis of Treatment Outcome for Panic Disorder. Clin Psychol Rev 1995; 15(8): 819-844.
30. R.A. Gould et al. A Meta-analysis of Treatment Outcome for Panic Disorder. Clin Psychol Rev 1995; 15(8): 819-844.
31. The language of 'determining salience' comes from Ronald de Sousa. See de Sousa. 1987. The Rationality of Emotions. Boston, MA: MIT Press; see also P.Goldie. 2000. The Emotions, A Philosophical Exploration. New York, NY: Oxford University Press.
32. De Sousa. 1987. The Rationality of Emotions. Boston, MA: MIT Press; see also P.Goldie. 2000. The Emotions, A Philosophical Exploration. New York, NY: Oxford University Press.
33. Ibid; R. Wollheim. 1999. On the Emotions. New Haven, CT: Yale University Press; C. Calhoun & R. C. Solomon op. cit. note 16.
34. J. Neu. 1980. Jealous Thoughts. In Explaining Emotions. A. Rorty, ed. Berkeley CA: University of California Press: 449.
35. Now, to say that the emotional view is unrelenting does not mean that the person can never get relief from the view. Ms. G was able to 'escape' and relax during a guided imagery in which she imagined being at the beach on a lovely day. However, as soon as she returns to thinking about her life, her fearful view dominated her thoughts.
36. People do not literally think through every decision this way, imagining every possible outcome - that would be impractical. We all make many daily decisions based on policies from previous deliberation. Yet in making such a personal and important decision as whether to go on with one's life, the ability to imagine alternatives and thus to apply one's values in a vivid way seems particularly important.
37. Raz discusses two examples of people whose autonomy is rendered practically non-existent by the lack of options in their external circumstances: a person stuck in a well and a person chased by a beast.
38. J. Raz. 1986. The Morality of Freedom. New York, NY: Oxford University Press: pp. 373-374
39. For example, if the only way to save my son's life is to donate a kidney, I cannot genuinely imagine my real self in a future in which I chose not to donate. For an account of 'volitional necessity,' see H. Frankfurt. 1998. Necessity, Volition and Love. New York, NY: Cambridge University Press.
40. H. Frankfurt. 1998. Necessity, Volition and Love. New York, NY: Cambridge University Press.
41. Thanks to Maria Merritt.
42. L. Sanders. 2003. Diagnosis: Back Pain-Mottled Vertebrae-Anxiety. New York Times Magazine 19 October: 29-30.
43. I use the term 'effects' rather than 'benefits' because the concept of benefit already involves questions of values/subjectivity. See J. Halpern. Can the Development of Practice Guidelines Safeguard Patient Values? J Law, Med Ethics. 1995; 23: 75-81.
44. J. Halpern. Can the Development of Practice Guidelines Safeguard Patient Values? J Law, Med Ethics. 1995; 23: 75-81.
45. J. Halpern. 2001. From Detached Concern to Empathy: Humanizing Medical Practice. Oxford: Oxford University Press.
46. Personal communication, Director of Disability Student Services, University of Illinois, Urbana.
47. Beck pp. 953-959
48. R.A. Gould et al., op. cit. note 17, pp. 819-844
49. H. Silverman. The Role of Emotions in Decisional Competence, Standards of Competency, and Altruistic Acts. J Clin Ethics 1997; 8: 171-175.
50. Halpern, op. cit. note 32. Patients have written about the process of recognizing that their emotions were preventing them from seeing options, and thus seeking help with their decisions; C. Schneider. 1998. The Practice of Autonomy: Patients, Doctors, and Medical Decisions. New York, NY: Oxford University Press.
51. C. Schneider. 1998. The Practice of Autonomy: Patients, Doctors, and Medical Decisions. New York, NY: Oxford University Press.