Competency and The Capacity to Make Treatment Decisions

Introduction

In this paper I will discuss the case from the perspective of Hebert, Dworkin and Dresser. Then I will give my opinion as to how the doctor and the son should proceed.

Hebert

Hebert defines competence as “an assessment of functional capacities”. A set of guidelines can be set to determine whether someone is competent or not. These are, the rationale behind a choice must be sound, the patient must understand their current state, and the patient must be aware of all the possible outcomes of their decision. If a patient fulfills all the guidelines, they are fully competent, and they must be involved in the decision-making process. By these guidelines, Mr. K is not competent because he is unaware of what his current state is. His son took him to the home because he was unable to care for Mr. K any longer, as it is often the case with Alzheimer’s patients, since it can make a person more prone to incidents like fires due to forgotten food in the oven or heightened aggression towards people. The latter seems to be the case with Mr. K since he has been violent towards some of his caretakers at the home. Mr. K believes that the reason why he has been taken to the home is not due to his illness, but because his son wants to simply get rid of him. If Mr. K understood his condition, he would understand that he could harm himself or others and that it is better for him to go to the home.

As Mr. K is incompetent a substitute decision maker must be chosen. This place will be taken by Lawrence, his son, and it is important to determine if he is making decisions based on what his father would have wanted to do when he was competent. As in case 6. 6, where the husband kept the wife alive because he was unable to let her go, despite her previous wishes. If the son starts doing things based on what is best for himself instead of Mr. K, then he should either be reminded what a substitute decision maker ought to do, or a different person should be designated to make decisions. Although Mr. K is incompetent he should be involved in the decision-making process because of beneficence, and justice. In terms of beneficence, everybody including, Mr. K would be benefited from him being involved. Mr. K is suspicious that people are conspiring to get rid of him as he is afraid of being a burden and being abandoned by his son. In response Mr. K acts out. If he was involved, his suspicion would decrease at least a little bit, and maybe he would stop being as aggressive. The caretakers and the son will benefit by having less issues with Mr. K and he will be calmer with his day to day activities. Regarding justice, it is fair to the patient to tell him what is going to happen to him. Regardless of the course of treatment, Mr. K will go through a difficult time. Mr. K needs to be part of the decision making when determining the best palliative cares since after all he is the one that will feel the pain. The advance directive must also be taken into consideration, but it must be revised. Someone needs to read what the advance directive says exactly. If the advance directive does say something along the lines of what the son says, then one must determine what is meant by “heroic measures”.

According to Duhaime’s Law Dictionary a heroic measure is any artificial measure without which a person would die. In this case, chemotherapy is an artificial method that would allow Mr. K to live longer. Thus, treating him for his prostate cancer would go against his advanced directive. One should also consider that Mr. K never said what kind of situation he had in mind when writing the advance directive. He could have been thinking of a situation when he was unconscious. Since he is conscious now, and although he is not competent, it is fair to discuss with him what he may have meant.

Dworkin and Dresser

“Experiential interests” are things we enjoy doing, like watching tv on a rainy day, while “critical interests” are rooted more deeply within us, for example, someone’s dream that someday they will have children. Together they sum to make us live happy and fulfilling lives. Although our critical interests play a more important role, for example, someone may have a broken bone which causes an experience of pain, but the hopes of being healthy make the experience bearable. Minds are very complex, and so everybody has different definitions of what they consider to be their valued critical and experiential interests. It is therefore a matter of respect for someone’s autonomy to respect whatever they value. Someone who has written an advanced directive has done so because of their interest in not living through certain experiences. As is the case with Mr. K, who does not want to be kept alive by heroic measures. This could be due to a fear of feeling discomfort by the treatments or any ailments that occur to him. Since this advance directive exists, the doctor and Lawrence should respect it and not treat the cancer, but let the father die naturally of cancer. The advance directive left by Mr. K seems very mysterious. It is unclear what the actual contents of it are since the son probably does not know all the contents of the directive. Since the context in which the advance directive are unknown different reactions can occur. If Mr. K made the advance directive in the presence of a lawyer and demonstrated that he was a competent person when making the decision, then the advance directed may be respected.

On the other hand, if Mr. K did not demonstrate competence then his directive is not better than him deciding on treatment as an incompetent adult with Alzheimer’s. In addition, one must determine if Mr. K made the advance directive under no pressure. If anybody in his family pressured him in any way to write the advance directive, then following the advance directive is an absolute violation of the autonomy of Mr. K. Patients with dementia are not less complex than a person who is healthy. Although their interests may not be the same as what they were when they did not suffer from the illness. A patient with Dementia still feels emotions in the same way any other person does, and in the case of a patient that is in a terminal condition, like Mr. K, it is important to keep this in mind. The son and the doctor need to ask Mr. K whether he is feeling comfortable, if his pain is increasing or decreasing, and he must be told why and what is going to be done to him.

Critical Analysis

In my opinion, Mr. K is incompetent to make decisions himself. This is because I think he is in a state of confusion. I don’ believe that a decision can be made if somebody lacks certainty. Ambivalence can facilitate coercing the patient. If Mr. K was competent he would be able to understand why he is in the home. Instead he becomes aggressive and refuses to accept that his son is not going to pick him up. I believe that his inability to understand that his son has left him there is caused by the Alzheimer’s. If his memory loss is advanced enough for him to forget an almost daily reminder that his son will not come back, then he does not have the mental capacity to decide if he will be treated for cancer. I also agree that he does not pass Hebert’s guidelines for determining competence. Regardless of his being incompetent, Mr. K should be part of the decision-making process. I agree with Hebert in that it would be unfair if Mr. K was kept in the dark about his treatment. Mr. K is already in a scary situation, if secret decisions are added to his life without him knowing why will only make the situation worse. In addition, I agree with Dworkin in that only Mr. K knows what his current experiential interests are. He is the only person that can voice what he is feeling. Lawrence, the son, needs further evaluation before being chosen as substitute decision maker. I cannot decide whether the son is trying to get rid of his father or is trying to do what is best for him. As Hebert says, a substitute decision maker must do what is best for the patient. The son shows signs that he is tired of some of his father’s behavior. For example, he seems to deem his father incompetent because of his inability to follow directions to the bathroom. I fail to find any correlation between one’s ability to obey and competence.

Finally, I believe that the advance directive is too ambiguous to be followed immediately. I think a lawyer needs to review it, there needs to be an investigation as to whether it was made in a legal way. For example, one would not consider a contract binding if it was signed by someone who was under the influence of alcohol. One must determine if the directive was made by a competent person. If it was then I believe that the advanced directive must be followed since as Hebert and Dworkin say, it respects his autonomy.

Conclusion

Mr. Kennedy is incompetent to make a decision regarding his health, his son needs to be deemed competent before making any decisions regarding his father’s health, and the advance directive left by Mr. K needs to be analyzed, but if it was made by a competent person, it must be followed.