Irrational Capacity: Exploring the complex role of the C-L practitioner when spirituality influences patients to refuse life-sustaining treatment (Bioethics SIG sponsored)

Abstract: When patients make decisions in direct opposition to their medical providers’ recommendations, C-L psychiatrists are frequently asked to determine whether these patients have decisional capacity. This panel will analyze two cases in which the decision-making capacity of the patients was in question due to the patients refusing potentially life-sustaining treatment on the basis of religious beliefs.

Dr. Sterenson will discuss a patient who refused partial foot amputation for a severe infection. The patient was well known to the hospital and seen repeatedly for treatment of weeping foot wounds. Surgery was recommended many times in the past, but the patient refused for unclear reasons. His capacity was never questioned. Psychiatry was consulted when the patient refused surgery because he stated that God told him that he did not need it and that He could heal the patient without intervention.

Dr. Hamm discusses a complex capacity evaluation for a young Black woman at 31 weeks gestation, requesting DNI code status in the setting of respiratory failure secondary to COVID-19 infection. He explores how various factors influenced the patient’s decision making, including her Black Hebrew Israelite identity, experience of divine influence on intuitions, distrust in institutions, and perspectives on COVID-19 legitimacy. In contrast to the first patient, this patient’s spirituality and religious beliefs were an integral part of who she was, and her refusal of care put her life at risk but also the life of her unborn child.

Dr. Harter will discuss the impact of the Rationality Standard in relation to decisional autonomy and the ethical implications of this standard regarding assessments of treatment decision-making capacity. He will highlight the similarities and differences between making decisions based on empirically false claims (treatment refusals based on bad science) and making decisions based on unprovable claims (treatment refusals based on religious beliefs).

Dr. Muskin will discuss the liaison-role opportunities for managing parties who can (or could) be involved. The focus will be on the psychodynamic and multidisciplinary communication issues at play when the referring team questions the legitimacy of patient capacity by focusing on the content of the belief system, with limited insight into transference/countertransferences issues and negative affects that can occur in these situations.

The two patient cases will create a space for panelists and audience members to explore how evaluation of capacitation must consider that idea that religious, spiritual, political, and cultural influences may be non-pathologic drivers of diverse and atypical decision making within a pluralistic society.

This symposium will be provocative and audience members may struggle as they consider such highly personal, emotionally charged issues in medicine. Those in attendance will be encouraged to participate and share their thoughts through polling and active discussion.













Content Contributors:

Diversity, Equity, and Inclusion: This presentation is specifically targeted at the academy's DEI commitments, with a case that explicitly draws attention to the vulnerabilities and communication patterns that are intrinsic to interactions between various dominant and muted co-cultural identities. These include but are not limited to unique standpoints related to age, sex, gender, race, ethnicity, disability, religion.