The Case in Montana

A while ago I shared my appreciation for psychiatrists and psychologists, and the appreciation I’ve found among many for patients’ spiritual concerns.  If you recall (or as you’ll discover if you read the earlier post), that was illustrated by the story of the psychiatrists who regularly consulted me when a foreign-trained medical resident heard a patient say, “If it’s my time to die, if God calls me, I’m ready to go,” and identified it as “suicidal ideation.”

I thought of that story again when I read about a court case in Missoula, Montana (you can read about it here and here).  A woman, identified in court documents as L.K., was diagnosed with Stage I cervical cancer.  She has hesitated to have a hysterectomy.  Reportedly, she made this decision so far in part because she might want to have a child (something a physician has stated is unlikely but possible), and in part for “religious reasons.”

Her “religious reasons” were a matter of concern for one of her physicians and one of her nurses, who between the two of them sent three letters last fall to the Missoula County attorney’s office.  The point of the letters was to question, based on her “religious reasons,” whether she was competent to make the decision regarding surgery and a condition that would eventually be fatal if left untreated.  A medical guardian was appointed, who signed a consent for the hysterectomy.  The surgery was scheduled for last Thursday, but has been postponed by the State Supreme Court to allow an appeal by a public defender.

In a hearing last week, a psychiatrist stated that the patient had “religious delusions,” including that “God had healed her.”  These delusions prevented her from making the appropriate decision to accept the surgery.  The patient, on the other hand, said she did understand her condition and her risk.  She simply wanted to make her own decision on her own schedule.  Her public defender said she is not delusional, but simply very religious, and that forcing this surgery would harm her religious freedom, her physical integrity, and her dignity.

Now, let me say that it is entirely possible that a person might be delusional with religious ideation.  It is possible that is the case with this woman.  However, without actually hearing the conversations, I couldn’t say for myself which I thought was the case.  And while I do have respect for psychiatrists and psychologists, and find that the great majority of them have respect for patients’ religious concerns, there are exceptions.  There are still those who feel that any religious thoughts are by definition dysfunctional.  Again, without actually hearing the conversations, I hesitate to express an opinion.

There is, though, another point from which to consider this.  I have observed that autonomy has become the driving moral principle in health care decisions these days.  This case has in tension the patient’s autonomy with the physicians’ concern for the patient’s best interest (Beneficence).  Now, if and to the extent that this woman is delusional, she may be limited in understanding her own best interest (and I say “to the extent” because decisional capacity isn’t really all or nothing); but if and to the extent that she is not delusional, she has the right to make this decision, even if she ends up dying for it.

That’s really the hard point of the principle of Autonomy for many health care providers.  If we are to allow patients to make their own decisions, we have to respect their right to make even decisions we thing are wrong.  Yeah, we might think a particular decision is wrong, or even crazy; but that doesn’t make the patient crazy in the clinical sense.

We can certainly hope that the judge will give the appeal careful and thorough consideration.  L.K. certainly needs for the review to be thorough, but so do the rest of us.  If it appears that a patient has been declared incompetent only because the patient refuses a treatment, even a treatment that may be life-saving, there is the risk that a court decision may result in loss of rights for many of us.