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Am J Psychiatry 1994; 151:971-978
Copyright © 1994 by American Psychiatric Association
Depression, competence, and the right to refuse lifesaving medical treatment
MD Sullivan and SJ Youngner
Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Seattle 98195.
OBJECTIVE: The authors explore the possibility that psychiatrists
inappropriately extend their views on suicide by the medically well to
refusal of lifesaving treatment by the seriously medically ill. METHOD: The
legal and bioethics literature on competence to refuse lifesaving treatment
and the possible impact of depression on this refusal is reviewed. RESULTS:
Over the past 20 years, the burden of proof concerning the mental
competence of seriously medically ill patients who refuse lifesaving
treatment has shifted to the persons who seek to override these refusals.
However, in psychiatry a patient's desire to die is generally considered to
be evidence of an impaired capacity to make decisions about lifesaving
treatment. This contrast between ethical traditions is brought into
clinical focus during the evaluation and treatment of medically ill
patients with depression who refuse lifesaving treatment. The clinical
evaluation of the effect of depression on a patient's capacity to make
medical decisions is difficult for several reasons: 1) depression is easily
seen as a "reasonable" response to serious medical illness, 2) depression
produces more subtle distortions of decision making than delirium or
psychosis (i.e., preserving the understanding of medical facts while
impairing the appreciation of their personal importance), and 3) a
diagnosis of major depression is neither necessary nor sufficient for
determining that the patient's medical decision making is impaired.
CONCLUSIONS: Depression can be diagnosed and treated in patients with
serious medical illness. But after optimizing medical and psychiatric
treatment and determining that the patient is competent to make medical
decisions, it may be appropriate to honor the patient's desire to die.
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