Although not always formally trained in ethics, consultation-liaison (C/L) psychiatrists and psychosomatic medicine physicians who practice in general hospitals frequently see cases laden with ethical questions. In a 2006 survey of members of the Academy of Psychosomatic Medicine, the majority of respondents reported that management of bioethical dilemmas had a significant effect on their work; capacity evaluation and informed consent made up the majority of the issues.1 In fact, evaluation of the patient’s decisional capacity is one of the most common consultation requests in acute hospital settings. In such situations, the primary team and other hospital staff (eg, case manager, social worker) often look to psychiatry to provide the recommendations that can affect the patient’s course of treatment and outcomes.
This article provides a practical framework that can guide C/L psychiatrists through solving problems of capacity and informed consent.
The 4 principles
The 4 cardinal principles of biomedical ethics—autonomy, beneficence, nonmaleficence, and justice—are widely accepted as standard ethical principles in medicine.2 The conflict between autonomy and beneficence/nonmaleficence often leads to distress among health care professionals, as well as patients and their families, and frequently manifests in psychiatric consultations for evaluation of the patient’s capacity to make medical decisions or to refuse recommended treatment. This is especially true when the clinician feels strongly about the need to intervene to maximize outcomes but the patient disagrees. Although the clinician turns to capacity evaluations to address his or her own discomfort and distress, the true underlying moral dilemma stems from the conflict between a patient’s autonomy and the physician’s paternalism.3
In assessing capacity to provide informed consent, remember that informed consent comprises 3 critical elements: providing information (ie, full disclosure), decisional capacity, and voluntarism capacity (ie, ability to make a decision, free from coercion).4
Appelbaum5 outlined decisional capacity and its 4 standards:
• Ability to communicate a choice
• Ability to understand information necessary for the specific decision at hand
• Ability to appreciate the implications and significance of the provided information or the choice being made
• Ability to reason by weighing and comparing options as well as consequences of the potential decision
Wright and Roberts6 advocate the use of the “Four Topics Method”7 to help with ethical decision-making strategy for patients in a medical setting. With this algorithm, each case is analyzed through 4 aspects:
• Medical indications
• Patient preferences (and the patient’s decisional capacity)
• Quality-of-life issues
• Contextual features or external factors that may affect the patient’s care
In addition, Wright and Roberts recommend Drane’s “sliding scale” model, which modulates the threshold to determine the patient’s decisional capacity based on risk to benefit ratio of the decision, to help with the analysis. For example, the greater the risk associated with the patient’s treatment refusal, the lower the threshold for deeming the patient as not having decisional capacity.
Two typical cases that might arise are presented in the case vignettes. They describe relevant ethical dilemmas and their formulations, and demonstrate how a C/L psychiatrist can work through each case using the “Four Topics Method.”
Ms A is a 73-year-old with diabetes, hypertension, and end-stage renal failure. She is receiving hemodialysis and has had above-the-knee right lower extremity amputation. She is brought to the hospital after a fall. This is the third similar presentation to the hospital during the past 2 months.
The evaluation reveals malnutrition, dehydration, and early-stage bedsores. Ms A is evaluated by a social worker and a physical therapist; both recommend a skilled nursing facility as the most appropriate placement for her. However, the patient fervently refuses this option, and psychiatry is called in to evaluate her capacity to make decisions.
Ms A is found to be alert and fully engaged, with bright affect and a linear and goal-oriented thought process. She explains that she has been independent her entire life and that she values her independence very much. She states that she “would rather die than live anywhere else rather than [her] own home.” She understands that she is in poor health but is willing to engage additional services at home to address any health concerns. If that isn’t enough, she “would rather go home and suffer the consequences than be placed in a nursing home.”
The C/L psychiatrist finds that although the hospitalist and associated clinicians believe that Ms A’s decision is poor and places her at high risk for recurrent complications and readmission, Ms A has the capacity to make decisions regarding her discharge. The team is advised to work closely with the patient to maximize her supports at home.
This case demonstrates a common conflict between a patient’s autonomy and the physician’s duty and drive to provide beneficence. Physicians often feel overprotective of patients when confronted with what they feel are unsafe decisions. They begin to question the patient’s decisional capacity. Paternalism exists when a physician believes that he knows better than the patient what is in the patient’s best interests and places the patient’s medical good above all else.3 However, it is the physician’s responsibility to respect the patient’s values and to understand the impact of medical and psychosocial interventions, keeping in mind the patient’s particular cultural/attitudinal context. It is important to continue to closely work with the patient to find the best solution, even if the work is distressing, because the physician feels that the patient is making the wrong decision.
Dr Sher is an instructor in the department of psychiatry and behavioral sciences, Stanford University and attending psychiatrist on the psychosomatic medicine service at Stanford Hospital, Stanford, Calif. Dr Lolak is Associate Professor in the department of psychiatry at The George Washington University and Director of Psychiatric Consultation Service at The George Washington University Hospital, Washington, DC. The authors report no conflicts of interest concerning the subject matter of this article.
1. Bourgeois JA, Cohen MA, Geppert CM. The role of psychosomatic-medicine psychiatrists in bioethics: a survey study of members of the academy of psychosomatic medicine. Psychosomatics. 2006;47:520-526.
2. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th ed. New York: Oxford University Press; 2009.
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6. Wright MT, Roberts LW. A basic decision-making approach to common ethical issues in consultation-liaison psychiatry. Psychiatr Clin North Am. 2009;
7. Siegler M. Decision-making strategy for clinical-ethical problems in medicine. Arch Intern Med. 1982;142:2178-2179.
8. Naik AD, Dyer CB, Kunik ME, McCullough LB. Patient autonomy for the management of chronic conditions: a two-component re-conceptualization. Am J Bioeth. 2009;9:23-30.