He Wasn’t Thinking Straight. So How Do You Get Through?
Sandeep Jauhar, M.D. New York Times July 11, 2006
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This is a first-person article sketching the author’s experience with a patient refusing cardiac catheterization and the difficulty in the real world of clinical practice of making the judgment of whether a given patient, if obvious signs of psychosis or dementia are lacking, is competent to make the decision to comply with treatment or refuse it.
Dr. Jauhar also discusses the 1978 case of Mary Northern, who was ruled incompetent to make a rational decision about having her gangrenous feet amputated because, while generally sane, she had the psychotic belief that her obviously diseased lower limbs were blackened only because they were dirty.
Dr. Jauhar’s own case, however, is more ambiguous. The exchange between physician and patient is described thusly:
“So you say,” he shot back.
I asked someone to bring in a printout of his blood tests. After I showed him the abnormal cardiac enzyme levels, he sneered and said: “Fine. So you think I had a heart attack.” Clearly, he still did not believe me.
“The best treatment for a heart attack is angioplasty,” I said.
“I don’t want it,” he said, his voice rising. “I told the doctors I don’t want a stent.”
The patient then threatened to leave. Dr. Jauhar reports his judgment that the patient was not competent to make medical decisions because the patient “did not understand his medical condition or its treatment options and the risks and benefits,” an inability to recognize his medical problems which Dr. Jauhar views as the equivalent of Mary Northern’s psychotic view of her condition.
Dr. Jauhar notes that the patient could not be released because “if something happened to him, I would be liable.” When threatened with security, the patient “backed down.” By the next morning he appeared more reasonable, was judged to be competent, and then signed out against medical advice.
Commentary
Dr. Jauhar’s article is, I believe, useful in dispelling the all too common notion that the determination of a patient’s competence is simply a matter of applying legal criteria.
In this case, in fact, I am less confident than Dr. Jauhar that his patient would have been adjudged incompetent by a court, at least those operating in the jurisdictions where I have practiced. Of course, Dr. Jauhar’s database re this patient – and his responsibility for the patient – is infinitely greater than mine, but my dissent may illuminate the problems in determining competency.
Dr. Jauhar’s patient was sarcastic and skeptical, not delusional as was Ms. Northern. He didn’t attempt to explain his situation by expounding an alternative theory that was bizarre or nonsensical. By the written account, at least, he simply didn’t agree with the diagnosis or the recommended treatment. While neither psychosis or dementia is an absolute requirement for a declaration of incompetence, mere disagreement with the physician’s diagnosis or treatment plan is not sufficient evidence of an inability to make ones own medical decisions.
To judge a patient as incompetent to refuse to follow a physician’s recommendations exclusively because the patient denies the validity of the physician’s findings is clearly a circular argument.
On the other hand, I suspect Dr. Jauhar’s concern that “if something happened to him [the patient], I would be liable,” is well-founded.
