Alex RKIn this conversation, I talk to Dr Chloe Beale about the uses and misuses of capacity in the context of responding to suicide risk. Warning, we do get quite deep into the issues involved.
The paper by Wren Aves we discuss is: “If you are not a patient they like, then you have capacity”: Exploring Mental Health Patient and Survivor Experiences of being told “You Have the Capacity to End Your Life”. Psychiatry is Driving Me Mad. 2022. DOI:10.13140/RG.2.2.34386.84163
The paper by Dr Lucy Series Chloe mentions is: “The ‘you’ve got the capacity to choose to kill yourself’ phenomenon, and what we can do about it,” available here.
A paper by Chloe which looks at some of these issues is “Magical thinking and moral injury: exclusion culture in psychiatry,” available in the BJPsych Bulletin here.
My legal take on these issues is here.
Excellent discussion, thanks for posting.
It was interesting to consider the ‘you have capacity to kill yourself’ phenomenon as an updated version of ‘positive risk taking’. I also wonder, in the context of personality disorder, if it is an updated manifestation of the previously held view that it is untreatable.
I thought Alex’s question about what the test of capacity is here is key … and Chloe’s conclusion that clinicians should not just impose their will on patients is also crucial. Those two points suggest to me that it is possible that a person CAN have capacity to end their own lives, within the structure of the MCA. I think as professionals/society we should be open to the position that, even if we disagree with the person’s decision, think it unwise etc, suicide CAN be the right outcome for that individual, anathema as that may seem. Some people’s suffering is unbearable, treatment can be ineffective and we need to acknowledge that.
There was no critique of capacity as a concept to adequately bear the weight of such decisions, which was a bit disappointing, and whether there might be alternative approaches in paradoxical self-destructive/help-seeking behaviour. Instead, the proposal was more training. But if we don’t have a clear idea on what the test of capacity is in these situations, then what training are people receiving?
Also trying to distinguish between a decision around care/treatment and a decision to end one’s life is okay in an abstract or legal context, but those decisions aren’t mutually exclusive in practice. The CARING act might be to prevent someone ending their life e.g. through hospitalization, including amounting to a DoL. Therefore a decision to end one’s life is also not outside the scope of the MCA.
My impression is that clinicians, whether consciously or not, are often working backwards in these situations, from what is the best proportionate action in that person’s interests (probably the interests of the service as well)… if actions that override consent are felt to be disproportionate, then the conclusion is that the person HAS capacity to decide. I appreciate this is not how the MCA is designed, or how people have been trained, but speaks to the MCA being linear and elegant in theory but not in practice.
More research, as suggested, seems like the best next step.
Perhaps there is an element missing from the capacity test, viz : Does the person have the ability to put the decision into effect?
Being able to decide whether or not you should stop smoking or drinking or using drugs or lose weight is not the same as being able to put that decision into effect. You might make several ‘resolutions’ to quit but lack the ‘willpower’ to resist temptation or to overcome distressing withdrawal symptoms. When you ask your GP for help, you are not sent away with the unhelpful advice “You have the capacity to decide whether or not to quit.” You have already made that decision. What you are asking for help to put the decision into effect. Y0u are given a prescription for nicotine patches, or methadone, or referred to a support group or hypnotherapy service etc.
Perhaps it is the same with suicidal thoughts. If someone has come to hospital or to their GP seeking help, it is not because they lack the rational faculty to decide whether or not to resist the suicidal impulse. Asking for help shows they’ve already made that decision. Perhaps what they lack is the ability to put into effect that decision to resist the suicidal impulse.