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The transplant baby from outer space.

Carol M, age twenty-one, was dropped off at a community hospital by a trucker who promptly disappeared. She had about thirty motel keys from all over the United States in her possession. The staff described her behavior as bizarre, hostile, and noncooperative. The diagnoses of acute abdomen and schizophrenia were made. As she refused surgery, she was referred to a hospital with better psychiatric facilities for evaluation of competency and further treatment.

Upon admission to the second emergency room, Ms. M signed the routine request for treatment with a fictitious name. Such history as could be obtained was notable in its inconsistencies. Physical findings and laboratory data supported the diagnosis of acute abdomen. Five surgical and gynecological specialists agreed that appendicitis was the most likely diagnosis and recommended surgical exploration. Dr. S, the staff psychiatrist on duty, was called to decide whether the patient was competent to give permission for this procedure.

Ms. M was withdrawn and noncommunicative. She sat hunched over, leaning on the examining table, a neat, attractive young girl with blue jeans, pea jacket, and duffel bag piled nearby. When Dr. S brought up the question of surgery, Ms. M said, "If I let them take everything out there won't be anything left in me by the end of the year." She claimed that she had once been treated for similar symptoms "with a hypo," and that that was the treatment she wanted now. She did tell Dr. S she could have surgery only with her father's permission, and provided sufficient identifying information to allow the staff to locate her family by phone in another state.

Her mother confirmed the diagnosis of schizophrenia. Ms. M had already had two prolonged psychiatric hospitalizations involving treatment by psychotropic agents and psychotherapy. In one hospitalization, she appears to have been overdosed, with a resultant phobia about hospitals and doctors. She had disappeared at a point when the family were trying again to obtain inpatient treatment for her. With two physicians always on the line, Ms. M's medical condition was explained to her mother, who requested that any indicated treatment including laparotomy be carried out.

Dr. S decided there was now adequate evidence of a definable mental disorder that impaired Ms. M's judgment sufficiently to keep her from making a rational decision about her treatment. He declared her to be incompetent and called the countyjudge to request permission to admit her and proceed with surgery. During the seven hours it took to complete the workup and obtain legal clearance Ms. M remained voluntarily in the emergency room.

At surgery a right tubo-ovarian abscess was found and a normal appendix removed. After surgery Ms. M was cheerful, responsive, and friendly, although her thought processes were disorganized and the content was clearly delusional - she told Dr. S she was a transplant baby from outer space with 900 siblings in the Mideast. She was started on a psychotropic agent, and Dr. S was reassured that the decision to declare Ms. M incompetent had been justified.

When she was ready for discharge from the GYN service Ms. M agreed to look over the psychiatry unit, although she indicated she did not want further treatment. The psychiatrist who saw her there decided not to request involuntary commitment since she had demonstrated basic survival instincts by getting herself dropped off at a hospital when she developed her abdominal pain. In his opinion, her plan to get in touch again with the truck driver and return to her previous life style was a viable option. When last seen, Ms. M was heading for the freeway with her bag on her shoulder.

How competent must a patient be to refuse treatment? Should Ms. M's refusal of surgery have been honored?


The issue of marginal capacity portrayed in this case puts society on the horns of a dilemma. Unless society allows physicians a relatively free hand in treating patients at the margins of competency, these patients may not receive therapies they need without delay or encumbrance. The cost here is measured in terms of the health, perhaps life, of the patient. On the other hand, allowing physicians such freedom strips patients of their right to refuse treatment. The cost here is measured in terms of patient autonomy and dignity.

As a civil libertarian (former head of the British Civil liberties Union), I believe that recognition of a patient's right to autonomy and self-determination is critically important to preserve her dignity. But, as former head of the National Association for Mental Health in Great Britain, I also believe it does not always serve the person's interests to allow her to refuse treatment that is essential to her health or life. To deny a truly incompetent patient the most beneficial treatment is just as wrong as imposing treatment against the will of a competent patient. In each case the question must be put, Can the patient understand the nature, purpose, and effects of the treatment?

Many of the reasons given ostensibly to justify treatment without consent are insufficient. The fact that Carol M had a diagnosis of schizophrenia, or any other major mental illness, does not in itself justify a finding of incompetency. Even her delusional system and need for psychotropic medication does not render her incompetent. A person with a serious mental illness may be competent for certain purposes or during certain times, but incompetent for other purposes or at other times. A psychotic condition with delusions, while it may impair a person's judgment about a variety of decisions she must make in life, need not deprive her of rationality in respect to medical treatment. Nor does the fact that her decision differed from the judgment of her doctors mean that she is incompetent. Finally, the fact that she may have appreciated the intervention after the fact and thanked her physicians (Alan Stone's "thank you" theory) does not prove that the decision to treat was the proper decision.

Nevertheless, the facts of the case suggest that Carol M's refusal of surgery was properly overridden. The relevant facts are that there were serious questions about her capacity to consent; her closest family member requested treatment, five specialists determined that treatment was important to her physical health; she was assessed to be incompetent by mental health professionals who were not involved in her treatment; and a court concurred that she was incompetent and in need of treatment. These authorities judged that she did not truly understand the health risk she faced, and we are given no facts with which to conclude that they were incorrect.

It may be that a more sensitive approach, trying treatments more consistent with Carol's wishes, would have been preferable - always presuming this "less intrusive" approach would not have resulted in an irreversible deterioration in her health. It would, however, be callously insensitive to Carol's humanity not to provide her with treatment essential for her health and well-being.


This is a case in which the behaviors of the patient needed interpretation as much as her symptoms needed diagnosis and treatment.

First, it is evident that there was never a question of whether to perform the surgery or select an alternative treatment more in keeping with the patient's expressed wishes. Had the patient been prepared to agree to surgery, the question of her competence to authorize it would not have been raised. It was her refusal of surgery that initiated a search for "other" evidence of incompetence, and the discovery of previous diagnosis of schizophrenia "permitted" Dr. S to declare her incompetent and seek the court order.

The confirmation of incompetence to consent found in the patient's delusional postoperative state is another disturbing aspect of this case. Many patients, otherwise normal in mentation, who enter a hospital for surgical treatment experience what has earned its own name - hospital psychosis. We see no attempt to distinguish between that possible diagnosis and the diagnosis of underlying, persistent schizophrenia of a degree that would render the patient wholly incapable of a valid consent. Evidence obtained post hoc and used to justify a decision before surgery to deprive a patient of her autonomy smacks of a kind of opportunism.

Her remark about obtaining her father's permission cries for interpretation, yet seems to have been ignored. This remark was made before incompetence was declared, and so should have been viewed as either a request for the counsel of a trusted family member or as designating a proxy decisionmaker. Even when the history of involuntary associations with hospitals and physicians was discovered, the fact of her voluntarily seeking medical help despite a strong aversion to hospitals and physicians, together with a reasonable interpretation of her remark about her father's permission, should have been grounds for respecting her particular way of making decisions instead of circumventing it.

Her attempt to choose an alternative therapy, based on her past experiences, does not seem to have been seriously explored with the patient or to have been considered by the medical staff. Dr. S's dismissal of her request to be treated medically rather than surgically, finessed through the "finding" of incompetence, renders moot Ms. M's own experience with her medical history, her own wishes, her own wisdom as to the events transpiring in her own body.

Could not a bargain - and a useful one - have been struck by agreeing to start Ms. M on a nonsurgical course of treatment with antibiotics and ice packs, closely monitoring her symptoms and signs, provided that she would seriously consider surgery? In that way the long hours of waiting for legal clearance could have been put to good use, according this patient the dignity of treatment that she was prepared to accept and perhaps thereby strengthening her trust and confidence in the medical team. Instead, we are left with a patient whose intermittent autonomy is further undermined and whose trust in her ability ever to exercise it authoritatively in a medical setting has once more been betrayed.
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Title Annotation:includes commentaries
Author:Gostin, Larry; Hull, Richard T.
Publication:The Hastings Center Report
Date:Jul 1, 1992
Previous Article:The nurse as patient advocate.
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