Executive Dysfunction as a Barrier to Authenticity in Decision Making

Transcription

1 Executive Dysfunction as a Barrier to Authenticity in Decision Making Barton W. Palmer Philosophy, Psychiatry, & Psychology, Volume 25, Number 1, March 2018, pp (Article) Published by Johns Hopkins University Press DOI: For additional information about this article Access provided at 26 Mar :15 GMT with no institutional affiliation

2 Executive Dysfunction as a Barrier to Authenticity in Decision Making Barton W. Palmer Owen, Freyenhagen, and Martin (2018) present a novel discussion of the meaning of decision-making capacity (DMC). They frame their discussion in the context of deficits in executive function after traumatic brain injury, but their observations and suggestions for expansion of how DMC is appropriately assessed have potential implications for people with other disorders that can potentially affect executive functioning, including those with certain forms of neurodegenerative conditions (such as frontotemporal dementia) and some of those with serious mental illnesses such as schizophrenia or bipolar disorder (Dunn, Lindamer, Palmer, Schneiderman, & Jeste, 2001; Grimes, McCullough, Kunik, Molinari, & Workman, 2000). Although not mentioned explicitly in their article, a key point in considering DMC as conceptualized by Owen et al. is the notion of authenticity of a choice (Brudney, 2009; Kim, 2011; Roberts, 2002). This is essentially the idea that the person has the capacity to make a choice in the particular situation at hand that reflects who he or she really is his or her genuine values and longer standing preferences. A key point made by Owen et al. (2018) is that the classic definition of DMC, in the 2005 Mental Capacity Act of England and Wales, as well as the widely cited four abilities or dimension model identified by Appelbaum and colleagues, that is, understanding, appreciation, reasoning, and communicating a choice (Appelbaum & Grisso, 1988; Appelbaum & Roth, 1982), is generally interpreted cognitively. But Owen et al. provide a cogent argument that there are subtle components to DMC abilities that are not purely cognitive that may affect authenticity of decisions made. Through qualitative analyses of interviews conducted with people with traumatic brain injury (more specifically, what they refer to as acquired brain injury and organic personality disorder), Owen et al. (2018) note that, contrary to expectations, the interviewees generally demonstrated intact awareness of deficits associated with their injuries. This level of awareness seems to pass not only the tests of understanding, but those of appreciation (insight). But based on the error analyses, Owen et al. describe three components of DMC that emerge from their interviews that are not immediately apparent in the four dimension model as commonly applied. 1. The ability to have real-time, online awareness of deficits and impairments. This requirement goes 2018 by Johns Hopkins University Press

3 22 PPP / Vol. 25, No. 1 / March 2018 beyond the broader notions of understanding and appreciation in that it requires the individual to be able to reliably apply such awareness in guiding current behavior. As Owen et al. noted the awareness was in several instances either unavailable to those patients in the decision situation, or else could not be integrated into the deliberative process (p. 12). The key notion here is the ability to reliably apply the awareness of deficits in the moment. 2. The ability to detach from and engage with impulses and behavioral cues afforded by the decision situation. In this component, Owen et al. noted that were some patients who showed difficulty stepping back from immediate environmental cues (i.e., to enable a reflective deliberation), and some who could not disengage from the deliberative process itself (i.e., to actually come to a final decision). As with their first criteria, there is a connotation with this second criterion of being able to work adaptively within the moment of the decision-making task. 3. The ability to prefigure a decision situation by being attuned to relevant normative features. Owen et al. are not fully clear in their use of the term normative, but their discussion of this component suggests a difficulty some patients may have in assigning or applying valance to possible outcomes this is similar to the emphasis other authors have made on attending to patients values and preferences, and again speaks to the notion of authenticity of the decisions. A notable feature of the interviews reported by Owen et al. is that many of the patients were able to speak clearly and cogently about the cognitive and behavioral deficits, for example, noting difficulties with impulse or anger control that developed after their injuries. Yet, even while demonstrating the ability to reflect on and describe such deficits, the very same patients sometimes manifested those same deficits during the same portion of the interview. In short, awareness/ insight did not translate into ability to actively monitor and control behavioral responses in the moment. An analogous problem is sometimes seen with patients manifesting executive deficits on the Wisconsin Card Sorting Test (WCST), one of the most widely used neuropsychological tests of executive functions (de Assis Faria, Veiga Dias Alves, & Charchat-Fichman, 2015). In the WCST, the examinee is presented with four stimulus cards with patterns that vary in color, form, and number, and is then presented with a deck of cards and asked to sequentially match each card in the deck to the stimulus cards. The examinee is not told about the underlying correct sorting principle; instead, he or she must discover the correct principle for himself or herself based on feedback of correct/incorrect after each attempted match. The examinee is also not informed that the correct principle changes after a certain number of correct sequential responses, but the key aspect of the task is what the examinee does after the correct soring principle changes. Those with executive deficits tend to persevarate to the previously correct (and, therefore, previously reinforced) sorting principle. On occasion, some people who behaviorally manifest persevaration will do so while making verbalizations indicating a cognitive awareness that the rule has changed. That is, some examinees will make verbalizations such as Well, it can t be color any more because you keep telling me incorrect, yet some such individuals still proceed to match the card they are holding to the stimuli based on the principle they just verbally noted is no longer correct. Such behavior exemplifies a disconnection between being able to consciously verbalize a correct concept, and being able to behaviorally alter and guide behavior based on that expressed knowledge. It is, however, a behavior that happens rarely there is, unfortunately, no single test that reliably focuses on assessment of the tendency toward such discordance. However, it is that discordance that seems particularly relevant to the notion that Owen et al. discuss of impaired DMC among those with executive dysfunction. Part of the explanation for the type of error described above on the WCST, in the presence of manifest/verbalized awareness that the sorting principle has changed, is a tendency to be stimulus bound. Stimulus-bound behavior is one form of executive dyscontrol, frequently seen in people with certain forms of frontal lobe injury, in which the individual s behaviors are unduly affected by the immediately present environmental cues rather than internal control or goals (Chayer & Freedman, 2001). As noted by Owen et al., Lhermitte (1986) described a series of case studies of people with executive dysfunction from frontal lobe injuries who evidenced an environmental dependency

4 Palmer / Executive Dysfunction as a Barrier 23 syndrome (EDS). EDS is similar to the notion of the stimulus-bound error described for the WCST. Of note, Lhermitte specifically viewed EDS as a challenge to capacity for personal autonomy. Workman et al. (2000) and Grimes et al. (2000) also pointed out that executive dyscontrol such as stimulus-bound behavior or EDS represent challenges to generally recognized aspects of autonomy, specifically intentionality and voluntariness. At the heart of this argument is what is meant by an authentic autonomous decision? Under the classic model of decisional autonomy by Faden and Beachamp (1986), genuine autonomy has three components: understanding, intentionality, and noncontrol or voluntariness. Understanding requires little further description as it is the focus of the bulk of DMC assessments. But in regard to intentionality they noted that [C]ertain core themes are widely shared in contemporary treatments of intentional action in philosophy and psychology. Chief among these is that intentional acts require plans.... For an act to be intentional, it must correspond to the actors conception his or her plan of the act in question... intentional action is action willed in accordance with a plan. (p. 242; italics in original) Under Faden and Beachamp s model, Noncontrol... entails that there are not external controls on the action (p. 256). Their description of noncontrol is primarily an interpersonal one, that is, wherein an individual s actions reflect the will of another rather than their own. Still, one can see that a tendency to be overly influenced by the immediate environment represents a form of noncontrol, even though not a form of coercion (in that the latter implies an intention of another agent). In brief, the components of DMC noted by Owen et al. seem to fall under the rubric of capacity for willed action, wherein willed has an implication of engagement in a reflective process, to evaluate one s options relative to his or her values and longer term preferences (authenticity), and to guide actual behavior (including decision making and expression of the decision) through the outcome of that choice. Note that what this formulation does not require is that the individual make a choice that the clinician (or investigator) deems correct or reasonable, merely that it is reasoned and matches the individual s values/ preference. A key sentence in the article by Owen et al. is the statement that, in acquired brain injury, it is often the fact of unwise decision making that is the salient factor and overwhelming concern (p. 2). My caution here would be how we define unwise. If unwise is equated with disagreeing with one s physician, then there are obvious problems in ensuring that autonomy is respected. But if an unwise decision is one that is lacks authenticity, then that does seem a relevant and appropriate component of DMC we risk abandoning patients to their rights (Hafen, 1976) if we do not attend to their capacity for authenticity in decisions. There are no quick and easy answer for how to incorporate the notions of authenticity and intentionality into DMC assessment. At the extremes of behavior, choices lacking authenticity may be obvious. But how do we determine an individual s values and preferences when a brain injury may be affecting the his or her expression of those values or preferences? In the opening paragraph, I used the phrase long-standing preferences, but that phrasing is problematic. How long is long enough to be deemed genuine? Would making this a requirement of DMC also intrude with people s right to change their minds about their values and preferences? I have no immediate answer to offer for these questions. However, the examples provided by Owen et al. persuasively demonstrate that a purely cognitive test of DMC, certainly one that focuses only on expressed understanding or general awareness, may lead us to fail in the ethical duty to protect those with diminished capacity for autonomous decision making. Further attention to the measurement of values, the effect of executive dysfunction on the treatment-related (and research-related) consent, and the integration of these concepts into DMC evaluations is clearly warranted (Karel, Gurra, & Moye, 2010). References Appelbaum, P. S., & Grisso, T. (1988). Assessing patients capacities to consent to treatment. New England Journal of Medicine, 319, 25,

5 24 PPP / Vol. 25, No. 1 / March 2018 Appelbaum, P. S., & Roth, L. H. (1982). Competency to consent to research: A psychiatric overview. Archives of General Psychiatry, 39, 8, Brudney, D. (2009). Choosing for another: Beyond autonomy and best interests. Hastings Center Report, 39, 2, Chayer, C., & Freedman, M. (2001). Frontal lobe functions. Current Neurology and Neuroscience Reports, 1, 6, de Assis Faria, C., Veiga Dias Alves, H., & Charchat- Fichman, H. (2015) The most frequently used tests for assessing executive functions in aging. Dementia and Neuropsychologia, 9, 2, Dunn, L. B., Lindamer, L. A., Palmer, B. W., Schneiderman, L. J., & Jeste, D. W. (2001). Enhancing comprehension of consent for research in older patients with psychosis: A randomized study of a novel consent procedure. American Journal of Psychiatry, 158, 11, Faden, R., Beauchamp, T., & King, N. (1986). A History and Theory of Informed Consent. New York: Oxford University Press. Grimes, A. L., McCullough, L. B., Kunik, M. E., Molinari, V., & Workman, R. H. (2000). Informed consent and neuroanatomic correlates of intentionality and voluntariness among psychiatric patients. Psychiatric Services, 51, 12, Hafen, B. C. (1976). Children s liberation and the new egalitarianism: Some reservations about abandoning youth to their rights. Brigham Young University Law Review, 1976, 3, Karel, M., Gurra, R.J., & Moye, J. (2010). Reasoning in the capacity to make medical decisions. Journal of Clinical Ethics, 21(1), Kim, S. Y. (2011). The ethics of informed consent in Alzheimer disease research. National Review of Neurology,7, 7, Lhermitte, F. (1986). Human autonomy and the frontal lobes. Part II: Patient behavior in complex and social situations: The environmental dependency syndrome. Annals of Neurology, 19, 4, Roberts, L. W. (2002). Informed consent and the capacity for voluntarism. American Journal of Psychiatry, 159, 5, Workman, R. H., Jr., McCullough, L. B., Molinari, V., Kunik, M. E., Orengo, C., Khalsa, D. K., & Rezabek, P. (2000). Clinical and ethical implications of impaired executive control functions for patient autonomy. Psychiatric Services, 51, 3,