In our healthcare system, parents normally make medical decisions for their kids because, we think, children are not competent to make such decisions for themselves.
This week, we’re thinking about the Limits of Medical Consent. To get yourself in the right frame of mind begin by asking yourself whether it is ever permissible to force medical treatment on a patient against their will? What if they are so emotionally distraught that they can’t think straight? What if they might die without the treatment?
Clearly, there are some people who are not fully competent to make their own medical decisions. But where exactly do we draw the line between the competent and the incompetent? At one extreme, we’ve got children. If a skittish nine-year old kid refuses to let the doctor give her a needed shot, I see nothing wrong with making the kid take the shot. I would do it gently. Maybe turn it into a game. But I would see to it that in the end the kid took the shot. At the other extreme are adults who are just cognitively impaired. For example, a person in a coma can neither grant nor withhold consent. But we don’t deny them care because of that. Here the lack of consent is not even an issue.
Child-like immaturity and a coma-like incapacity are the easy cases. But is it ever okay to compel a fully mature adult, who is not incapacitated, to undergo a medical procedure against their will? There are certainly grounds for denying that it could ever be permissible to do so. Mature adults are autonomous beings. One doesn’t coerce autonomous beings who are not incapacitated.
But I’m not entirely convinced. One may have a duty of beneficence even to a fully autonomous being, it seems to me. And it’s not at all clear that a concern for autonomy ought always trump one beneficence. So, just for the sake of argument, suppose you’ve got a patient with very poor impulse control and very little foresight—a grown-up who has the maturity level of a six-year old. Perhaps the patient keeps promising to change their habits, to make better choices, to come in for treatment, but fails to do so over and over. Arguably, the patient may be in some sense autonomous. But they certainly aren’t being wise. Could it be that one has a duty—a duty of beneficence—to exercise a little well-intentioned paternalism toward such a patience? Such paternalism might be thought to violate the patient’s autonomy. But it would be a violation grounded in beneficence.
No doubt those who fetishize autonomy will insist that at some point, autonomous grown-ups must live with the consequences of their choices, no matter how disastrous those consequences may be. Living with the downside cost of poor choices is just one of the burdens of autonomy! Of course, one could say that in this case we don't have genuine autonomy. The patient isn’t actually a fully functioning autonomous adult, not in reality. And by leaving the patient’s decisions entirely up to them, we’re not in fact respecting their autonomy. We’re helping to make them worse off. We’re doing them serious harm in the name of an illusory respect for a shadow of autonomy.
If you believe in the absolute and trumping value of autonomy, you’ll say that we’d be doing them greater harm if we took away their right to decide. You’d be infantilizing them, denying them their autonomy. But consider a case of another kind that is perhaps more compelling.
Suppose a man loses his wife in a terrible accident in which he too is injured. The man is so grief-stricken that he can’t imagine going on. He refuses urgently needed medical treatment that would keep him alive. Do you force the treatment on him against his will or do you let him die? The easy way out is to say that you would first give him some time get over his grief and then let him decide. But to make my case as hard as possible, I’m just going to stipulate that his injuries are so severe that you can’t wait. If you wait, he dies.
Now speaking just for myself, I’d hope that he eventually gets over his grief. In the meantime, I’d do whatever I can to keep him alive. But what I want to know is why this case seems so different from the first. I do admit that letting a person die because they’re grief-stricken seems much worse than letting an immature adult continue to live an unhealthy lifestyle. But I’m not sure why. Both the grief and the immaturity seem inconsistent with full autonomy. So if there is a reason of beneficence to step in the case of extreme grief, there would seem to be a reason of beneficence to step in the case of extreme immaturity.
Moreover, suppose the grief-stricken patient comes back a year later, fully physically recovered but still in the throes of profound grief. I’m sure I would try to comfort and console him, maybe recommend a good grief counselor to him. But what if he doesn’t want any more counseling. He wants to end his suffering. And he asks me, as his doctor, to help end his suffering. He doesn’t want to live, in other words, he wants me to help him commit suicide.
I’m not sure what I would do. I’m not even sure what I should do. It would be one thing if he were terminally ill. But if he’s physically healthy and asks me to end his life… I don’t think I would…or should… or could… help him die. What he clearly needs is better psychological support, not death.
But the question of autonomy versus beneficence rears its head here too. Or so it seems to me. If we can’t out of respect for autonomy force someone to undergo medical treatment against their will, how can we force someone to live against their will? Why is that any more acceptable than forcing them to undergo medical care against their will?
Not that I know the answer to this question. But if you tune into our episode, at least your thoughts, and possibly your heart too, will be stirred by our amazing guest, Jodi Halpern. She’s thought a lot about these issues.