Decisional capacity in patients with acute delirium.

A Rawlsian approach
Authors: Sorin Hostiuc1, Ionu Negoi1, Eduard Drima2
Abstract
Delirium is characterised by a temporary, usually reversible, cause of mental alteration; it can occur at any age, but
affects most often the elderly. Delirium patients may also present acute psychotic episodes, which might make them
decisionally incompetent. In order to assess decisional capacity, Fan et al developed a two-stage approach, that tries to
analyse (1) the presence of delirium, using the Confusion Assessment Method, and (2) a proper analysis of the
decisional capacity. Often, in patients with decreased decisional capacity, physicians must assess which ethical
principle should respect first the principle of autonomy, whose practical implementation is informed consent, or
beneficence the good of the patient, irrespective of the its declared wishes. In this poster we will look at the issue of
decisional capacity in patients with acute delirium from a Rawlsian point of view, and will try to give an answer based
on what is just to respect the autonomy of the patient, or the moral duty to do good to the patient.

After Rawls, the principles of justice should be developed with the
aid of a theoretical concept, coined Original Position, in which the
persons who develop these principles are under a veil of ignorance,
which hides everything particular about them. By not knowing
anything about them (age, gender, religious orientation, social
status, diseases, and so on), the principles generated under this veil
will have a maximal degree of fairness. No social class will be
privileged, no social or ethnic group, no particular subgroup of
patients, and so on. Therefore, the decisions that will be taken will
try to maximise the overall benefits in the population.
Rawls believes that, under this veil of ignorance, the deciding party
will develop two fundamental principles, which should primarily
regulate the distribution of social and economical advantages:
1. Each person has an equal right to basic liberties, compatible
with fundamental liberties of every other person in that
population. Fundamental liberties include the right to vote, to be
elected, self-determination, the liberty of personal property and
the liberty not to be arbitrarily arrested.
2. Inequalities should be distributed in such a matter that: (a) they
should generate a maximal benefit for the least advantaged
members of the society (the difference principle), and (b) the
chosen positions should be available to all in the conditions of
an equality of opportunities.
In patients with mental health disorders who need medical or
surgical interventions, is often needed a complex analysis of
decisional competence, due to their often fluctuating decisional
capacity.
The decision of performing a medical procedure is left to either
the patient or a proxy/physician, depending mainly on two
principles:
Threshold up to which decision making
should be left to the patient
Autonomy
Beneficence
References
Rawls, J. (2009). A theory of justice. Harvard university press.
Hostiuc, S. (2014). Consimtamantul informat. Cluj-Napoca: Casa
Cartii de tiin.
Fan, E., Shahid, S., Kondreddi, V.P., Bienvenu, O.J., Mendez-Tellez,
P.A., Pronovost, P.J., and Needham, D.M. (2008). Informed
consent in the critically ill: A two-step approach incorporating
delirium screening*. Critical Care Medicine 36, 94-99.
If the decrease of autonomy is moderate, the decision should be left
to be taken by a proxy/physician only if generated medical
beneficence is high (e.g. the patient needs a liver transplant and he
refuses for bogus reasons, and if he clearly expresses his wishes to
live).
If the decrease of autonomy is significant, the decision, according to
this classical approach, is left to the proxy/physician, irrespective of
the degree of beneficence the procedure generates (yellow circle).
Autonomy is considered by many philosophers/bioethicians/
theologians a fundamental characteristic of humanity - autonomy, or
the potential to be autonomous is often defined as a threshold criteria
to separate human from other beings.
By removing the decision making competence in patients with a low
decisional capacity we generate a maximal medical benefit for them
(we take medical decisions, which may impact positively their quality
of life), which apparently respects the second Ralwsian principle..
However, the overall beneficence of the patient might be negatively
affected:
it may lead to a decrease in the trust in that physician in particular,
and in the overall medical body in general
it devalues the patient as a human being
medical decisions are often taken by patients based not only on the
potential medical benefit, but also on other considerations:
wellbeing for other family members, social or economic
considerations, and so on.
We must also take into account the often fluctuating decision making
capacity - even if at a specific time the patient does have a
significantly decreased decisional capacity, in only days it can be
fully restored.
Conclusions
Therefore, we believe that, in order to respect both Rawlsian
principles, we should allow psychiatry patients to take medical
decisions irrespective of their decisional capacity as long as it is
present (even if very decreased).
Proxy decision making should be left only for the instances in which
the patient clearly has no decisional capacity or if the decisional
capacity of significantly decreased and the medical benefit is
significant.
1. Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, 2.
University of Medicine and Pharmacy, Galai, Romania
Correspondence to: sorin.hostiuc@umfcd.ro