Pardon the dry start to this essay but to do this well, some background is needed.
It is not infrequent that a patient may make appear to make a poor decision. The first thing the provider should question is not the patient’s choice, but whether the provider effectively disclosed the necessary information to make an informed choice, and if so, whether they understood that information.
To provide informed consent, or informed dissent (a frequently overlooked equally valid option), a patient must be aware of the risks and benefits of the proposed treatment, as well as risks and benefits of reasonable alternatives. They do not need, for example, to be advised of all that crazy shit that Dr. Oz peddles because it’s easier than having a conscience.1
GIGO. Garbage In, Garbage Out.
The ability to make decisions is known as capacity, and having the capacity to make your own decisions is a fundamental ethical principle of respect for autonomy, or self-determination. Without capacity, autonomy is not possible.
Capacity requires four basic components:
Understanding of the situation
Appreciation for personal relevance
Reasoning, both comparative and consequential
Ability to communicate choices
While Capacity is not Competency, there is definitely some overlap. Competency lies within the realm of legal proceedings, though legal competence is presumed, and to disprove that requires a hearing and proof of incompetence. Capacity must be demonstrated before treatment, and if not clearly present, must be objectively assessed by the practitioner before proceeding.
Capacity is contextual, and may vary significantly for the same patient. While cognition is necessary for having capacity, it does not guarantee it. A patient may completely understand what choices are reasonable for treating a superficial wound, but be completely incapable of the reasoning required for End-of-Life decisions. Capacity is also unrelated to functional ability. For example, a patient can have the capacity to know what they themselves cannot accomplish because of physical impairment.
Here’s a few common scenarios:
Minors do not routinely exhibit capacity, though autonomy is largely dependent on legal constraints
Persons with neurologic or psychiatric disorders may not have capacity, or variable capacity, and have diminished autonomy
Persons under the influence of substances may not have capacity at the time, so they have diminished autonomy
Prisoners have diminished autonomy, requiring institutional protection
Now with that clinical dry part adequately accomplished, there are two current themes running amok. Where am I going and why am I in this basket, as Toto would say?
Pro-Choice
While Planned Parenthood has for years distanced itself from the term “choice,” and they’re not wrong, I believe they have missed a great opportunity. The overarching issue here is autonomy, plain and simple. Do women, pregnant or not, have autonomy, or not? That includes abortion, but also contraception and planning to have children. Planning to have children should most definitely require consequential reasoning, but that is clearly not always the case.
The Left desperately needs to reframe the reproductive rights fight better, and simultaneously more comprehensively. I happen to think it’s a lot easier for conservatives to understand what is at stake when adult women are treated as lacking capacity, on par with minors, the demented, intoxicated, and prisoners. That slippery slope is one helluva road you don’t want to get on. Actually, we’ve been there previously and managed to get off somehow.
By reason of insanity
No, I do not believe Trump is demented. I believe he makes poor choices, constantly, and antisocially pushes limits, or demonstrates complete disrespect whenever possible. Those are features, not bugs. His actions suggest rather that he does not care about dozing off, and knows this comes across as petty attacks rather than substance. Just ask Maggie Haberman, his “psychiatrist.”2 From his general behavior, I strongly suspect he simply does not care about inconveniencing anyone around him by passing gas. This same person then proceeds to the mic and is able to manipulate masses and judges. Sure, at times his capacity may be diminished due to substance use, but that is temporary.
While there are some behavioral health providers who are using their pulpit to pronounce Trump demented, I am most suspicious because I rarely see any alternative explanations offered, and there are many. Rather, the confirmation bias to me is quite clear. Does that mean I think Trump is a decent person? Not at all. Is he in possession of several personality disorders? Probably. But none of that impacts his capacity and autonomy to make bad and sometimes illegal choices.
The law assumes Trump has competency. It would be up to his counsel to prove that he does not. From a medical standpoint, do I believe that Trump has the capacity to be appropriately tried in a court of law? I absolutely do. Do I think he’s nutters on other levels?
https://www.mcgill.ca/oss/article/pseudoscience/dr-ozs-sad-trip-down-rabbit-hole
https://www.politico.com/news/magazine/2022/09/30/maggie-haberman-profile-00059343