Patient autonomy and ability to provide consent
Providing help to those who need it and respecting the patient’s autonomy are two fundamental principles in contemporary medical practice. Occasionally, these two principles come into conflict. The patient has the right to refuse treatment (1). This situation is especially complicated when the patient is extremely ill and refuses treatment, and this appears to be irrational.
The patients’ ability to provide consent was not referred to in any of the records. Requirements for such assessment were not added until later. The Patients’ Rights Act now distinguishes between patients who are able to provide consent and those who are unable to do so (1). The ability to provide consent or to make decisions requires mental capacity to understand, assess, decide rationally and voice an opinion. Section 4 – 3 of the Patients’ Rights Act points out some issues that must be reviewed to decide whether the patient is able to provide consent (1). If the patient suffers from physical or mental disorders, senile dementia or developmental disability, this may impair the ability to make competent choices. The grounds for the assessment of the ability to provide consent should be recorded in writing and should be submitted to the patient and his or her next of kin immediately (1).
Previous studies indicate that as a rule, severely depressed patients are able to provide valid consent to or rejection of an offer of electroconvulsive therapy (12), while patients with psychotic depression may have an impaired capacity to make decisions because of cognitive impairment, insufficient understanding or delusions (13).
This raises a number of dilemmas. What about patients who are able to provide consent, but consent or refuse on irrational grounds? How should we relate to such irrational grounds? For example: «I refuse ECT, because no treatment can help me.» Some authors claim that the patient’s right to self-determination should be respected regardless of the irrationality of his or her ideas, unless the patient’s life is at risk (14). So what about patients who are unable to provide consent, but accept the treatment on irrational grounds? «Give me the treatment, because I’m a bad person and deserve to die.» Some would accept this as a valid consent, but is it legitimate?
The study cannot indicate how many consented for irrational reasons or how many were recommended ECT treatment, but refused and were not treated. Refusing treatment is far from synonymous with having insufficient insight. There are numerous examples of patients who do not want electroconvulsive therapy, but prefer conversation therapy, drug-assisted treatment and other measures.
Pursuant to current legislation, electroconvulsive therapy can only be administered on the basis of valid consent or on a plea of necessity (2). It could be an ethical problem, however, that patients who are unable to provide consent fail to receive this treatment until a situation that justifies a plea of necessity occurs.