David and colleagues highlight the gap between the legal and clinical
approaches in the management of patients who have seriously self harmed.
Such clinical scenarios are common, typically occur in a time-pressured
and stressful environment, and cause consternation amongst treating
clinical staff.
Consider the case of an 18 year old woman, who is refusing treatment
after an overdose because her boyfriend has ended their relationship, and
who demonstrates her ability to understand the risks of the overdose, to
retain this information, and weigh up this information, before deciding
that death is preferable to life without her boyfriend. Whilst it could be
argued that she has demonstrated capacity, I would venture that most
clinicians would be uncomfortable withdrawing active care. This discomfort
reflects the clinician's intuitive judgement, and is often hard to put
into words other than that it "feels wrong". The complex interaction of
patient behaviours, intentions and feelings are not easily reducible to a
crisp appraisal of mental capacity, which is too simplistic to address the
real life psychodynamic issues familiar to psychiatrists.
David and colleagues suggested guidance is therefore a timely and
welcome step forward in addressing such complex and emotive issues, and
helping clinicians to navigate through this legal and ethical minefield.
Rapid Response:
Mind the Gap
David and colleagues highlight the gap between the legal and clinical
approaches in the management of patients who have seriously self harmed.
Such clinical scenarios are common, typically occur in a time-pressured
and stressful environment, and cause consternation amongst treating
clinical staff.
Consider the case of an 18 year old woman, who is refusing treatment
after an overdose because her boyfriend has ended their relationship, and
who demonstrates her ability to understand the risks of the overdose, to
retain this information, and weigh up this information, before deciding
that death is preferable to life without her boyfriend. Whilst it could be
argued that she has demonstrated capacity, I would venture that most
clinicians would be uncomfortable withdrawing active care. This discomfort
reflects the clinician's intuitive judgement, and is often hard to put
into words other than that it "feels wrong". The complex interaction of
patient behaviours, intentions and feelings are not easily reducible to a
crisp appraisal of mental capacity, which is too simplistic to address the
real life psychodynamic issues familiar to psychiatrists.
David and colleagues suggested guidance is therefore a timely and
welcome step forward in addressing such complex and emotive issues, and
helping clinicians to navigate through this legal and ethical minefield.
Competing interests: No competing interests