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Conditional Preferences and Refusal of Treatment

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Abstract

In this essay, I will use a minimalist standard of decision-making capacity (DMC) to ascertain two cases in the medical ethics literature: the 1978 case of Mary C. Northern and a more recent case involving a paranoid war veteran (call him Jack). In both cases the patients refuse medical treatment out of denial that they are genuinely ill. I believe these cases illustrate two matters: (1) the need of holding oneself to a minimal DMC standard so as to make as salient as possible the patient's own reasons for sometimes unusual treatment denials; (2) the need for clinicians and other relevant parties to exercise great sensitivity toward engaging, on the patient's own terms, idiosyncratic treatment refusals through regard for what I will call the patient’s “conditional preferences.” These are particularly relevant matters when a patient’s DMC is questionable yet he/she registers what may well be his/her settled preferences

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Notes

  1. Pace Frankfurt’s account, endorsement is not necessary for voluntariness since the agent can act freely without any felt desire. Even when he lacks a higher-order desire not to smoke, a person is yet free not to light up because he has control over the action plan (driving to the store, buying a carton, opening it, etc.) that leads up to his smoking. When he acts in the absence of a higher-order desire, he still acts voluntarily. Neither is endorsement sufficient for voluntariness, since an agent can be compelled to act in ways he happens to endorse for reasons beyond his control. If prior states or dispositions—beliefs, desires, or intentions—that he happens to accept are the factors controlling his actions, then he yet remains a mere spectator of his actions rather than the agent who guides them.

  2. So I am assuming the rejection of hard paternalism in these cases for two reasons. First, a robust enough standard of autonomy might warrant hard paternalistic interferences with patients—in the very name of respecting their autonomy (Feinberg 1971; Young 1986). Second, a robust enough standard of autonomy can render soft paternalism extensionally equivalent to hard paternalism whenever an agent’s decisions fall short of exhibiting autonomy so construed.

  3. http://www.thehastingscenter.org/bioethicsforum/post.aspx?id=272&blogid=140

  4. One might object that her false belief that the gangrene is soot just is the kind of delusion that makes actions proceeding from her false belief insufficiently voluntary. So why do I maintain that perhaps this false belief does not incapacitate Northern? She is not trapped by it in such a way that she cannot appreciate warnings as warnings. If, by contrast, she believed the doctors were lying to her about gangrene’s danger because, say, she had a paranoid delusion that they were using her as an experimental subject—then she may be trapped because her current delusional beliefs make her practically unable to control access to reasons that would lead her to trust the doctors and appreciate the gravity of their warnings.

References

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Acknowledgment

The author would like to thank Bruce Brower, Gerald Gaus, Jeanne Hoffman, Eric Mack, James Stacey Taylor, and two anonymous referees for their helpful comments on earlier drafts of this article.

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    William Glod

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Correspondence to William Glod.

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Glod, W. Conditional Preferences and Refusal of Treatment. HEC Forum 22, 299–309 (2010). https://doi.org/10.1007/s10730-010-9133-6

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