Concretized Emotions and Deliberative Incapacity

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Concretized Emotions and Deliberative Incapacity

• Jodi Halpern, MD, PhD
• University of California, Berkeley

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Outline

• Autonomy in current medical practice
• Cases
• Decision-making capacity
• Emotional reasoning
• Concretized emotions
• Clinical and ethical implications

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Kantian Model

• Respect is based on the patients capacity for
  autonomy
• Respect does not require that the patient
  actually exercises autonomy
• Example competent person making critical
  decision by tossing a coin

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Decision-Making Capacity I

• Express a choice
• Understand
• Appreciate
• Reason

Grisso and Appelbaum, 1998
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Decision-Making Capacity II

• Does the patient have a set of values and goals?

Presidents Commission, 1982 Making Health Care
Decisions
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Decision-Making Capacity III

• The capacity to make a rational decision
• A decision is irrational if it involves the
  person suffering evil without adequate reason.

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Outline

• nAutonomy in current medical practice
• nCases
• nDecision-making capacity
• Emotional reasoning
• Concretized emotions
• Clinical and ethical implications

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Emotional Reasoning

• Emotions have cognitive content
• Emotions determine salience
• Emotional views are highly subjective

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Concretized Fear

• Unable to imagine or think that one could feel
  otherwise in the future
• Unresponsive to evidence

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The Capacity for Autonomy

• The ability to think through alternatives
• Responsiveness to evidence

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Inability to See Alternatives

• Cannot shift emotionally
• Cannot imagine things being otherwise
• Cannot see how others could view things
  differently

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Cannot Respond to Insight

• People with emotional biases can usually shift
  their emotional views
• People subject to concretized fear cannot shift
  in response to insight

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Acute and Post-Traumatic Stress Disorder

• Shift into magical thinking
• Sense of a foreshortened future (e.g.,does not
  expect to have a career, marriage, children, or a
  normal life span)DSM IV PTSD

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Fear and the Brain

• The exact conditions that lead to a weakened
  ability to form explicit memories and to regulate
  fear by thinking and reasoning, can also amplify
  fear reactions and enhance our ability to
  implicitly store information about stressful or
  traumatic situations.
• LeDoux, 2002

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The Capacity for Autonomy

• The ability to think through alternatives
• Responsiveness to evidence

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The Existing Approach

• Incompetent override patients decision
• Competent dont interfere with patients
  decision

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Concretized Fear

• Cognitively intact
• Symptom of suffering
• Susceptible to social influence/empathy

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Primary Ethical Obligation

• Restore a minimal capacity for autonomy

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Clinical Empathy

• Emotional resonance
• Curiosity

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How Empathy can be Therapeutic

• Reduces anxiety and helplessness
• Recognizing that one is subject to a frame

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Rethinking Kantian Autonomy for Medical Care

• Structural capacity for autonomy is not the only
  determinant of the moral status of decisions
• We need to look beyond emotional content and
  intensity to identify when emotions are hijacking
  deliberation