I think we are in agreement that people with all manner of illnesses and conditions can be perfectly able to make reasonable decisions. I do think the question of what standard of rationality continues to be significant. Imagine someone with extremely hyperbolic time discounting, i.e., a bad or obnoxious thing happening now is 1000x worse than the same bad or obnoxious thing happening a week from now, despite the fact that if they happened at the same time they would be equally unpleasant. This could lead someone to prefer a whole range of future terrible outcomes in the interests of avoiding what others would perceive as minor inconveniences in the here and now. It is not hard to construct an argument that this is irrational but it can also be understand simply as a different set of preferences or values.
There are several problems with your example. The first is an epistemic problem. How exactly are you supposed to know whether a patient's apparently biased evaluation of the severity of situations is simply a matter of preferences or a feature of some sort of undifferentiated cognitive abnormality? The other problem is that the whole example misses my point that I don't think it matters if it's merely a matter of preferences if you cannot articulate any rational reason for your preference.
I think to have a coherent idea of rationality here that is going to hold up and be useful you are implicitly positing a sort of teleological model of a person who should instantiate or pursue certain ideal values. Not infrequently when people are making decisions that seem highly irrational (and certainly sounds like this is true in the OP's case), they are essentially pursuing a set of values that differs from that ideal. K.W. Fulford's "dissensus" model can be helpful here.
If someone is simply pursuing different values than I have, that's fine. The issue is, however, that you still have to explain a coherent, understandable process by which you reach your conclusions. Before you claim this is circular, you need to consider the point I made later in this post that you also misunderstood. I asked you a question about whether you think that a mentally ill person incoherently making an important medical decision should be allowed to make that decision. This is a yes or no question. There's no circularity about it. If your answer is yes, then I think you have a generally nihilistic approach to the issue of capacity and we need to have a different discussion. If your answer is no, then we can move on to another issue that I also examined. That issue can be phrased in the form of a question, too: Do you think that a mentally ill person can nonetheless make a medical decision if they seem to understand the issues and thoughtfully provide their rationale? Above, you seem to indicate that this is possible. Assuming you responded "no" to the first and "yes" to the second question, you have indicated that two people in the same circumstances should be treated differently because of how they are able to explain their rationale. By making this distinction, you inherently acknowledge the importance of some form of rationality in considering whether it's ethically appropriate to let someone make a decision.
I have a hard time understanding how you think a basis in some vague sense of "different values" alters whether or not a decision is rational. Are you proposing some concept of subjective rationality? Do you honestly believe that the same argument can be rational or irrational depending on whether a person is basing it on "their beliefs?" This makes no sense. Rationality is not itself subjective. Presumably, if a person is basing their decision on a set of beliefs, that is included in how they lay out their argument. That argument is rational or irrational independent of whether I agree with their beliefs or not. If someone said "I'm an atheist, therefore it is impossible for me to die from COVID," that is irrational regardless of whether I'm evaluating it as an atheist, a Christian, or a Buddhist.
Again, you might make the criticism that the way that rationality is actually evaluated winds up involving some personal judgment of the evaluator, and so different people might come to different conclusions about the rationality of a given position. That is a practical criticism, and does not fundamentally make the case that belief-based positions are in a different category than etiology-based positions such that they deserve different ethical consideration.
At what point do you want to say that the values someone is pursuing are discrepant enough that they fundamentally misapprehend the reality of their situation to some extent and how do we separate that from just radically different sets of preferences (i.e., to be seen as supporting your political tribe being weighted more heavily than potentially dying).
That point is the point at which your political beliefs interfere with a factual understanding of your circumstances or a rational appraisal of your options. How many times do I need to reiterate the same thing. Saying "I'm pro-life and believe that an unborn fetus deserves the same consideration as any other person. I understand that I will die without this medically necessary abortion, but I personally believe that it is morally wrong to make any decision to end the life of another person. As a result, I am refusing the procedure." is dramatically different than saying "I don't want the procedure because even if I don't get it, my baby and I will be fine because I'm a Republican." Both of those decisions cite personal political beliefs, but one is rational and one is not. I happen to personally disagree with both decisions, but the former person likely has capacity to make the decision and the latter likely does not.
I don't disagree with you that any of these circumstances could lead to someone making decisions based on a conception of reality probably neither you nor I share. At the same time, I think having or being suspected of having some medical or psychiatric dysfunction should be a necessary but not sufficient condition for physicians to be able to claim particular expertise in evaluating whether or not the people in question have the capacity to make the decision. After all, we should be the ones with the most detailed, extensive, and intimate knowledge of how illness of varying kinds affects decision-making/reason/cognition/whatever.
I would argue that for people making decisions who are not impaired by something we recognize as pathology then the role of physicians in this process is just to provide information and answer factual questions. A potential analogy might be expert witnesses in a trial. Their testimony is of course highly relevant for the court in making its decision about the outcome of the case, but they are not ultimately the arbiters of justice. If we say that we get to determine capacity about medical decision-making in the case of non-medical impairment, then we are saying we are essentially an appeals court in this analogy, getting to scrutinize the reasoning of the lower court and reject it if we think it is unsound on whatever grounds.
But why is it a necessary condition? The issue of capacity is not based in medical or psychiatric science, but in medical ethics. If you want to say that having a medical or psychiatric condition is necessary for someone to be incapacitated, you need to provide an ethically meaningful reason that people with psychiatric or medical illness are entitled to different consideration and different protections against decisions they don't understand than all other people. So far, all you have leveled are practical critiques about doctors not being subject matter experts and potentially having personal biases based on different core beliefs than their patients. Those may be valid criticisms that warrant interventions like additional training for doctors, increased oversight of decisions about capacity, greater accessibility to public defenders to challenge capacity determinations made by doctors, or any number of other changes. They do nothing, however, to justify a position that a person must have a diagnosable condition in order to be incapacitated.
I will reiterate the same point that I've made throughout this thread. In order to ethically justify a diagnosable condition as a necessary condition for a determination of incapacity, you need to make an argument as to why, in otherwise identical circumstances, the class of people with diagnosable conditions warrant different ethical consideration than the class of people without diagnosable conditions. You have, thus far, made no argument on this point. I have made several arguments for why a diagnosable condition does not modify the ethical consideration a person is entitled to when it comes to capacity. These arguments have included:
People with diagnosable conditions and people without are in cognitive states that are fundamentally dictated by the same sets of processes. Irrespective of with what level of granularity we understand the specific processes leading to any one individual's deficits, all of these deficits are the result of some combination of biological and environmental factors. The processes by which individuals come by deficits in these domains broadly similar, so they deserve the same ethical consideration when it comes to capacity.
We don't fundamentally know more about diagnosable conditions than we do about belief-based deficits in rational thought. In fact, there is a decent psychological literature examining extreme or fringe political or religious beliefs. By comparison, we know very little about many of our psychiatric diagnoses, and there is considerable debate about whether some diagnosable conditions are valid at all.
The main reason why most people find it unconscionable to let people make significant medical decisions when they don't understand anything about them relates to the fact that they don't understand them, not what incidental mental disorder they might have. This is also obvious when you consider how it is considered unethical if you fail to obtain informed consent. A patient can be completely cognitively normal, but it's a violation if you let them consent to a surgery without informing them about the surgery. This is unethical because they don't know about what they're consenting to, and as a result they are unable to effectively advocate for their own interests. Taken into the domain of incapacitated individuals, the reason it is unethical to let them make decisions is because they lack understanding/rationality, and thus lack the ability to effectively advocate for their own interests. A person who is so thoroughly influenced by a cult, for example, that they cannot accept the fact that they can die is just as unable to advocate for their interests as someone who is psychotic. Such a person may well have a strong interest in not dying, but if they cannot accept the reality that they can, in fact, die, then their beliefs are interfering with their ability to advocate for their right to continue living in just the same way as someone's mental illness might do the same.
I am pointing out that in this conversation "rationality" and "capacity" are starting to slip closer and closer to circularity. As my old department chair once put it, "all arguments are circular, it's just a matter of how long it takes you to return to the beginning" but we of course want to extend the length of that loop whenever possible.
I have no illusions about being able to re-state all the propositions of a typical medical decision in first-order logic and have the correct decision just fall out. I am also perfectly aware of inductive and abductive reasoning and that medicine is largely conducted on the basis of these two forms far more than deduction. What I was asking was for a commitment about the standards of rationality we are planning to apply to determine capacity that is more detailed than "I personally can follow their chain of reasoning."
At a bare minimum, rational thought requires that a person's conclusion and their rationale for that conclusion bear some relation to one another. I would go further and say that I do think that another person must be able to follow the chain of reasoning.
In any case, this is actually a separate argument. We can debate how, in practice, we should go about assessing rationality, but this does not really bear on the issue of whether we should treat people with diagnosable conditions and those without differently. Maybe rationality actually has no bearing on whether someone should be able to make a medical decision. Maybe there are completely different criteria that we should be using. None of this actually matters. Fundamentally, what we are arguing is "should people without a diagnosis be protected from their own decisions in the same way that people with diagnoses are?"
Okay this is definitely question-begging. "Are you suggesting that people with invalid grounds for making decisions can make decisions we have stipulated must be made on valid grounds?"
It is not question begging. It is a literal question I am posing to you. Do you think that a mentally ill person without a coherent rationale for their decision should be allowed to make an important medical decision. See my above explanation of how this relates to the relevance of your critique.
I don't think it's as irrelevant as you find it. Our society (and our profession, based on the DSM) has clearly decided that strange beliefs that can be attributed to something that resembles religion are privileged and protected in a way that strange beliefs attributable to something that we have decided is pathology are not. Perhaps you think this is unacceptable and would like it to change. Fair enough, a reasonable discussion can be had there, though I think we run into the problems of physicians also not being particularly expert in theology or the sociology of religion at some point.
The intuitions of most people seem to find a difference here, and since this is a difference entirely dependent on etiology, etiology obviously matters a great deal.
The DSM makes this distinction diagnostically, not with regard to course of action. Cultural beliefs are not diagnoses, but that does not mean that they cannot lead to problems that require intervention. If someone came into your ED and told you that they were going to commit suicide with their cult next week, what would you do? Say you talked with them, several family members, multiple friends, and some of their fellow cult members, and you could find no evidence that they were depressed, no evidence of a personality disorder, no evidence of psychosis, and no evidence of any psychiatric disorder whatsoever. They were also not medically ill. Would you discharge them? Or would you admit them, potentially under some hedgy diagnosis that you don't necessarily fully believe to be accurate, like "adjustment disorder" or "unspecified mood disorder" or whatever?
I'm less confident in the general ability of the average physician to think through an argument carefully. It is not really how we are trained and in fact the learning process often is actively hostile to it. I also think it's not empirically the case that the thought process only gets called into question when there are obvious deficits. A good proportion of the time it seems like it gets called into question when the patient just arrives at an answer contrary to what their treating physicians recommend.
I do apologize for my attempt at humor in invoking logicians, it was meant in jest.
I am personally of the opinion that we should be questioning capacity on anyone who has deficits in understanding or rationality, regardless of whether they agree with the treatment team. I think that the fact that teams only tend to question capacity when the patient disagrees with them is de facto coercive. That said, this is again a practical problem with capacity determinations, not an argument for different consideration of the two groups of patients we've been discussing.
Most modern airliners are designed to be able to land safely even if one of the engines falls clean off mid-flight. My fear is that we get drawn into situations where we see that the engine has fallen off and conclude the patient isn't flying.
Fine, but where does this type of concern end for you? Obviously there are matters about which people can form opinions on the basis of just being a reasonable human being. Some people might have more expertise than others, but for many things we just accept that anybody is competent enough in the subject to form an opinion. The other day, my computer wouldn't turn on and I concluded that was because it was unplugged. Do I need to be a computer engineer to come to that conclusion because it's possible that there was some other technical issue that resolved itself by the time I plugged the computer in?
No this is a specific argument challenging the role of physicians in making decisions when the incapacity comes from something that is not in our wheelhouse. It directly speaks to what I am suggesting the appropriate role for us is in those cases.
Again, I think that it is in our wheelhouse. These are medical decisions, so we're better qualified than anybody else to make these decisions.
And as long as some consideration and processing of available medical information has taken place, I don't think capacity should depend on how good of a medical argument someone makes. If someone has consistently hated physicians and hospitals and wants nothing to do with us because they just don't like our faces and never have, and this person takes in the information we have given and says I don't care, f you doc, you're all scumbags and I'd rather die than be in a hospital, I don't know that that person lacks capacity. Even though they are clearly arriving at this decision verrrrrry differently from how I would be making choices.
It depends on how they're able to explain those decisions. If he can demonstrate that he understands that he needs treatment and will suffer some problematic consequence without it, and nonetheless explains that he doesn't want to be in a hospital and would rather suffer those negative consequences, I might agree with you. If he's not able to demonstrate that he understands any of these things, how exactly are you coming to a conclusion that he has capacity?
