Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case. You vote on your decision in the case and, next week, we'll reveal how you all made the call. Bioethicist Jacob M. Appel, MD, JD, will also weigh in with an ethical framework to help you learn and prepare.
The following case is adapted from Appel's 2019 book, .
Carolina is a 60-year-old woman with a history of schizophrenia. She has been admitted to psychiatric hospitals more than 30 times for paranoia, auditory hallucinations, and bizarre behavior. Often, once she is stabilized on medication, her symptoms resolve and she is able to return to the group home where she lives. Yet the medications make Carolina feel "numb" and "stupid," and she is unwilling to take them voluntarily. "I'd rather be psychotic than stupid," she tells one of her psychiatrists.
One time immediately after being discharged from the hospital, when she is still on medication and asymptomatic, Carolina finds a lawyer who helps her draft a document called a "psychiatric advance directive." In the document, she affirms that if she again becomes psychotic, she does not want to receive any medication. She is willing to let the state hospitalize her permanently, if need be, to protect the public and prevent her from self-harm, but she says she does not want to be medicated under any circumstances. She also records a video to go along with the document. "Please don't believe me if I change my mind," she says on the video. "When I'm in the hospital, sometimes I'll say or do anything to get out. But that's not the real me speaking."
Carolina's lawyer arranges for two psychiatrists to evaluate her at the time she signs the document. These psychiatric evaluations are preserved on video. Both evaluators agree that she is asymptomatic and thinking rationally.
As soon as the document is signed, Carolina stops taking her medications and becomes psychotic again. She is taken to a psychiatric hospital where the doctors seek a court order to medicate her forcibly. There is no clear legal precedent on the subject in this jurisdiction.
See the results and what an ethics expert has to say.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Approve a Horn Implantation in Patient's Skull?
Is Doctor Liable for Withholding Patient's Diagnosis From Family?