The right to say “no?” Necessary, but in the end inadequate.

Elyn Saks is a powerhouse in psychiatry and the law and an advocate who I admire.  That being said, I disagree with her recent article on Politico.  The answer to the sticky question of consent is not “making it easier to say no” or expanding the way we define competence.  Advances in consent and the right to refuse medications should come through the use of shared decision making and advanced treatment planning.

Consent and the ability to refuse pharmacological interventions by persons with major mental illnesses is a question that continues to challenge social workers, advocates, physicians, and ethicists.    Saks raises some important issues:

  • Mental health treatment has often been authoritarian and, by extension, demeaning.
  • There are many reasons patients may not want to take medications. There are some severe side effects to some psychiatric medications and that the decision to refuse medications can be entirely rational.
  • Patients resent being “forced” to take medications.

I don’t disagree with any of this.  What I do disagree with is Saks contention that making it easier for patients to refuse medications is the solution as it gives the patient a bargaining chip in a negotiation and thus reduces the potential power struggle between patient and provider.  I also don’t think that reframing how we think about competence is the answer. My objection to this article is that it seems to ignore some significant developments in illness management that are based on collaboration and advanced planning. Consent can be much less adversarial.

Shared decision making is finally making inroads into behavioral health and I think show great promise in assisting patients and providers in arriving at mutual goals.  The capacity to make decisions often fluctuates.  When clients are highly symptomatic their capacity to make decisions may be impaired; weeks or months later when symptoms ebb that capacity may return.  The vast majority of patients can participate in decision making to some degree at various times, but there are also times when decision making is just too impaired.  Rather than expand the definition of competence, why not focus on interventions that help clients plan ahead for times when they may be in crisis?

I am an advocate of the recovery model that gives clients greater control.  I also recognize the ethical pitfalls that may accompany recovery oriented services. Fortunately, advocates and researchers have been developing interventions to address those ethical concerns. A great example is the development of consumer oriented interventions like Wellness Recovery Action Plan (WRAP) that expand the control that clients have over decisions when times of crisis emerge.  It is not about making it easier to say “no” or expanding the definition of competence; I’d rather we focus on shared decision making and advanced treatment planning.

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