Exemptions and Patient Competence

When evaluating a patient in a clinical context, two central principles of modern medical ethics come to the fore, what are known as the beneficence and autonomy principles. The beneficence principle deals with patients’ good. Doctors must act in ways that are good for the patients in their charge. The autonomy principle, on the other hand, deals with patients’ rights. According to it, doctors must respect the right of every individual of autonomy over their own person—that is, they must respect patients' decisions about their medical care. 

Of course, these two principles can, and often do, come into conflict, especially in cases of anosognosia, or lack of awareness that one is mentally ill. The right thing to do in these cases is both complex, and highly contextualized, though the consensus in the literature seems to be that paternalist action—acting for the sake of a patient’s good regardless of their will—is pro tanto wrong, even if all things considered justified. In these cases, I argue, the burden of proof falls on the clinician (or philosopher) to provide such justification when dealing with competent patients.

This raises the question, what does it mean to be a ‘competent’ patient? Is there anything about mental illness generally, or anosognosia in particular that causes people to fail to meet such criteria? One obvious place to begin thinking about this is with Strawson’s work on our common practices of treating others as responsible agents. As is well known, Strawson presents us with two kinds of cases in which we do not commonly treat others as responsible agents. First, there are those who we recognize as agents, who may not have the right kind of knowledge about or control over the situation in question. These people are excused. Second, there are the much less discussed and perhaps less well understood individuals who simply fail to be appropriate targets for our reactive attitudes. These people are exempt.

Interestingly enough, Strawson's characterization of those toward whom we take this stance are, roughly, children and those with mental illness (we need not follow him in calling this second group 'warped', 'deranged', or 'neurotic'!). Despite its intuitive appeal, however, it's not clear to me that mental illness universally absolves one of responsible agency, or that it exempts one from patient competence and the respect of clinicians. A so-called kleptomaniac, for example, may not be reasons-responsive when it comes to taking things she does not own, but nonetheless perfectly capable of being a collaborative partner as regards her medical care.

I think that the right way to go about this is actually to drop the notion of exemption, and instead opt for a more complicated picture. Different mental disorders present different challenges to reasons responsiveness in different domains, and not all of those may be relevant to determining an individual patient's competency. Moreover, we must be careful about the danger of construing denials that one is mentally ill as mental illness, as in the recent case of Kamilah Brock.

(Perhaps, as extra fuel for this philosophical and ethical fire, we may consider this recent case, of a man whose rights and wishes are being respected.)

Comments

[Eddy Nahmias]

Hi Natalia, interesting post. I wonder if Strawson would disagree with anything you suggest here--or rather whether he'd be happy to have us try to develop more fine-grained accounts of when agents should be exempt or excused. He never actually uses any variations of the words 'exempt' or 'excuse' in his 1962 essay (did Watson introduce them?), but he does say, "I must deal here in crude dichotomies and ignore the ever-interesting and ever-illuminating varieties of cases." I read him as presenting the objective and participant stances as two ends of a spectrum, and we struggle to find the right place to land on that spectrum when we interact with people who display various degrees and types of excusing or exempting conditions, including people with mental illnesses and indeed children. Perhaps his talk of the "hopeless schizophrenic," the "systematically perverted," and the "warped or deranged" was aimed to lead us to consider the far end of the spectrum to help us see what he meant by the objective stance, cases where "you cannot reason with him [at all!]"

Having said all this, I do think Strawson just gestured us in the right direction, but his own distinctions between what we now call excuses and exemptions are problematic (or at least incomplete). He just wanted us to get out of our metaphysical conniptions and get back on track to talk of "the moral sentiments" and the reactive attitudes and moral practices that "express our nature." (These complexities are nicely illustrated in the case you link to of the man behind the yellow door, especially the attitudes and actions of the man's parents and ex-wife.)

[Fritz Warfield]

I don't find it at all obvious that competence for medical decision making should be linked to philosophical accounts of responsibility. What's that connection supposed to be?

Also: in the medical context competency assessments are standardly relativized to a particular treatment context. That is, rather than being across the board competent-or-not assessments of a patient, such assessments are of a patient for purposes of a particular issue or proposed treatment. So of course for various assessments confirmed kleptomania wouldn't preclude a patient from being judged competent (though perhaps for some it would). Am I misunderstanding something?

[Natalia Washington]

Hi Eddy! Yes, I think Watson introduced the excuse/exemption language, but I figured that at Flickers I better start from the source! Even if we agree to run over the excuse exemption distinction though, I wonder how much of the responsible agency=competence line we should take as the right direction. The devil is in the details, of course, but do you have any initial thoughts?

No, Fritz, I think your confusion is right on track… I think the story is supposed to go like this: take the extreme case of someone experiencing florid psychosis who appears to be a danger to themselves and others. What is it about this person that makes it ‘obvious’ (if it is at all obvious) that violating the autonomy principle, by for example, administering medication or restricting freedoms, is justified? There are some commonplace responses that sound distinctly Strawsonian, like ‘He isn’t himself’ or ‘that’s his disease talking’, which call rationality or reasons-responsiveness into question in similar ways as those responses which are supposed to absolve agents of responsibility. One might think, then, that what these justifications are latching onto is the idea that what makes one competent to make medical decisions are the same characteristics or capabilities which enable agency. If that’s right, then trying to find out how different psychological conditions impair agency will be important for determining competence.
That being said, if there are systematic differences between folk and philosophical ideas about competency, and clinical ideas, I’d love to hear more!