Christian Science and Competence to Make Treatment Choices:
Clinical Challenges in Assessing Values
International Journal of Law and Psychiatry, Vol. 10. 395-401, 1987
Anne-Marie Pavlo*, Harold Bursztajn**, and Thomas G. Gutheil***
*Staff Psychiatrist, Charles River Hospital, Wellesley, MA.
**Co-director, Program in Psychiatry and the Law, and Clinical Instructor
in Psychiatry, Massachusetts Mental Health Center, Harvard Medical
School, 74 Fenwood Road, Boston, MA 02115, U.S.A.
***Co-director, Program in Psychiatry and the Law, and Associate Professor
of Psychiatry, Massachusetts Mental Health Center, Harvard Medical School,
74 Fenwood Road, Boston, MA 02115, U.S.A.
Reprint requests should be sent to Dr. Gutheil.
The authors acknowledge their indebtedness to Jean Jackson, Elyse Littaye,
and Leslie Levi for their assistance in preparation of this manuscript.
Introduction
The determination of the competency of a patient to accept or reject a
psychiatrist's recommended treatment plan represents an uncertainty-laden
legal and clinical decision. Courts have considered guardianship as a
possible albeit problematic solution to the difficulty posed by the refusal
of treatment by an incompetent patient. The complex role of the physician
has only recently begun to be examined in such cases, particularly when
antipsychotic medication is involved (Gutheil, 1982; Gutheil & Appelbaum,
1982; Gutheil & Appelbaum, 1980; Gutheil,
Shapiro, & St. Clair, 1980; Mester, 1974).
The goal of this paper is to demonstrate through a case study how a clinical
assessment of competency, especially in connection with a patient's values,
may proceed in the context of an emerging therapeutic alliance (Gutheil,
1982). The case in question was especially vexing insofar as the
patient, while psychotic, gave a reason for refusing treatment—belief
in Christian Science—which would ordinarily be considered a valid
reflection of underlying values, and a spiritual choice protected by
the First Amendment.
In attempting to reach the underlying values for incompetent patients,
courts have lately considered substituted judgement (Curran,
1978; Gutheil & Appelbaum, 1985; Gutheil & Appelbaum,
1980), a model of decisionmaking which seeks to determine what the
incompetent patient would have chosen, were he or she competent. An implicit "thank
you" test is therefore established so that an incompetent patient,
when again competent, would theoretically agree with the guardian, clinician,
judge, or other decisionmaker about the vicarious choice and "thank" him
or her for making it (Stone, 1981; Stone,
1974).
The need for an understanding of the patient's values is obvious if this
schema is to work. But how are a patient's values defined? A more crucial
question here is, how may one distinguish between values considered symptomatic
of a patient's psychiatric illness and premorbid "healthy" values?
Religion and Competence Assessment
Issues of religion represent an area of exquisite sensitivity at the intersection
of clinical work, ethics, and law. In a country becoming increasingly
sensitized to issues of religious freedom of expression, the matter of
religious choice and religion is an extremely weighty one. For the clinician,
the knowledge that one person's orthodoxy is another's heresy, and that
one person's true belief is another's pagan superstition, makes the assessment
all the more challenging.
What had to be determined was whether a religious reason for treatment
refusal, offered by this patient at that time, represented a competent
choice based on First Amendment freedoms, or whether it was a symptom
and consequence of his psychopathology, to be given only the weight of
other possibly delusional utterances of the patient. Had the "choice" of
a religion occurred at a time when the patient was competent or only
during an illness? What questions would this timing raise about the patient's
free exercise of his religion? (Flowers, 1984) What
are the implications for competence assessment?
The complexity of the competency assessment with respect to religious
values has already been demonstrated in several court cases (Flowers,
1984; In the matter of the guardianship of Richard
Roe III, 1981). We now examine the clinical issue.
Case History and Hospital Course
Mr. L. was a 30-year-old, Indian male raised in the Muslim faith; he had
had three previous psychiatric admissions and had been diagnosed as paranoid
schizophrenic. He was brought to the Massachusetts Mental Health Center
(MMHC) by the police for striking a passerby on the street. He presented
a psychosis with manic and paranoid features.
Mr. L.'s early development was normal. It is noteworthy that the patient
reports being viewed at age eight by his parents as a "mystic" for
predicting a politician's assassination. Both parents attributed the
onset of his problems to corrective surgery the patient underwent at
age 19 for a reportedly overly prominent jaw; interestingly, his father
saw this as Mr. L.'s only masculine feature, and his mother felt it was
too prominent.
Mr. L.'s first psychiatric admission followed suicidal ideation without
psychosis at age 25; an episode of apparent paranoid schizophrenia led
to his second admission after a job rejection for the FBI: Mr. L. then
had the delusion that he was an FBI agent. Between Mr. L.'s second and
third psychiatric admissions he applied for membership in the Christian
Science Church (C.S.) and was rejected.
During his third psychiatric admission he described "praying with
my eyes closed to my mother so that she'd come and take care of me." When
he opened his eyes, he fortuitously beheld the C.S. chaplain, and he
took this coincidence to mean that he was now a Christian Scientist.
He began seeing a C.S. practitioner and refusing to take his prescribed
medications of lithium and haloperidol, but he subsequently fired the
practitioner when the latter opposed his long standing alcohol and drug
abuse. He then became involved with a Christian Scientist who was not
an officially recognized practitioner.
During the subject admission, Mr. L. initially refused medication because
he was a Christian Scientist whose beliefs included healing only through
God. By the third day of the hospitalization he accepted medication,
stating, however, that, "the two of us [therapist and patient] need
to stick together; undercover work is dangerous." When staff applied
for guardianship (based on our conviction that Mr. L.'s claimed membership
in Christian Science was, in fact, delusional restitution after a rejection,
as had occurred with his application to the FBI), Mr. L.'s reaction was
a combination of fear (would his therapist "trick" him into
a prolonged hospitalization?), anger (had his therapist "broken
his cover?"), and relief (he now could "sue the court instead
of his doctor").
Mr. L. provided contradictory views when interviewed by the court lawyer
(an occasion Mr. L. stated he "looked forward to"); he explained
refusing medication because he was a Christian Scientist, while stating
he was taking Haldol because it "helped him." Guardianship
was subsequently obtained for the purpose of deciding about medication.
On the guardian's consent, lithium was begun, and haloperidol was tapered.
Two weeks later, Mr. L. stated the guardianship was "useful" because
the "Court took control and made the decision of medication for
me" which "made me think less about Christian Science and more
about myself." He then questioned whether the "Mother Church
of Christian Science" was "another authority figure for me."
After discharge from the hospital Mr. L. discontinued his treatment relationship
with his Christian Scientist practitioner, although the latter remained
a friend. After an initial acceptance of only family meetings as a treatment
choice, Mr. L. gradually assumed more participation in individual therapy
(2 hr./wk.). He remained in a competent status 9 months after the admission
depicted above.
The course of Mr. L.'s therapy is summarized below.
Course of Therapy
The early phase of Mr. L.'s therapy explored the issues of Christian Science,
particularly the role of this religion in providing a supportive social
setting (though one often concordant with his delusional system) and
the function of the religion as a defense against particular feelings;
the defensive nature of the religion, however, was only appreciated several
months later. Several joint meetings were held with Mr. L., his C.S.
practitioner, and his therapist to evaluate further the role of C.S.
in Mr. L.'s life; the stance of the therapist during this phase was that
of participant-observer, who could side existentially with Mr. L. in
his dilemma as to what could now offer him comfort as his defense of
psychosis was diminishing. This period was accompanied by gradual decrease
in paranoid and grandiose ideation.
Later, Mr. L. shared how comforting C.S. had been, for it apparently had
a male/female deity. (Interestingly, this is also true for witchcraft
in which the patient had an abiding interest; see below.) He agreed during
this period, however, that should he or his therapist notice any increase
in paranoia or other psychotic symptoms, he would resume his medications.
Mr. L. also formulated a "living will" agreement with his therapist
that—should he become psychotic in the future and experience any
delusions concerning medication use (religious or otherwise)—he
would like to be treated with medications in addition to milieu and individual
psychotherapy. He viewed such a "living will" agreement as
giving him both "independence" (which he saw as his "central
problem", especially with respect to his parents), and values separate
from those of his parents.
Several weeks later, Mr. L. shared a diary with his therapist in which
he depicted in detail his involvement with witchcraft and C.S. He noted, "beliefs
can be dangerous; strong beliefs become reality, ominous reality for
the believer... for 1 ½ years I clung to a movement called C.S.
I consider [it now] a delusionary religion, although I had a grand opportunity
for learning Bible."
Witchcraft, in which Mr. L. had been involved before he became a C.S.,
was also interpreted as an escape. This "escape" function recurred
when Mr. L. was undergoing another period of major difficulty involving
doubts about his heterosexual identity and concern over his shyness with
people. At that point he joined and completed a well known local witchcraft
class. He informed the class of his psychiatric difficulties and shared
with his therapist his class notes and reactions to each exercise in
the class. He expressed in therapy much relief that he could find the
subject interesting, without seeing himself as a witch. He stated, "I
don't have to be a witch; I can be myself: shy and lonely, missing my
parents and my sister." The therapist interpreted this sequence
as the patient's demonstration to himself that he could deal nonpsychotically
with quasi-religious issues while subjecting them to therapy exploration.
Discussion
The experienced therapist knows how valuable the exploration of a patient's
religious beliefs is—an exploration yielding material of great
clinical richness, as demonstrated in the present case. But clinical
concerns aside, the case raises multiple ethical questions directly bearing
on the question of values and competence. First, the clinician had to
consider whether the choice to refuse medications represented Mr. L.'s
competent values (and was thus a "free choice" in the spirit
of informed consent) or if it was an indication of psychiatric illness
and thus of an incompetent status to make a treatment decision. Mr. L.'s
religious conversion experience (seeing the C.S. Chaplain on opening
his eyes) had been temporally coincident with a psychotic episode; this
raised sufficient questions to lead the clinical staff to elect to petition
for guardianship on the basis of the possibility that the belief was
delusional. This left to the court the curious task of weighing the competency
of a person to profess a specific religion whose precepts stood counter
to treatment.
The last point is particularly noteworthy because any individual's "competence" to
practice his or her established (or even idiosyncratic) religion is almost
never tested or otherwise called into question. The very raising of questions
about this competence might itself be considered an infringement of First
Amendment rights (i.e., to practice one's religion even if "incorrectly").
As noted elsewhere (Gutheil, 1985):
. . . religious choice is often a matter of leaps of faith which
are external to questions of competence to make rational choices.
Second, an argument could be raised as to whether the assessment of Mr.
L.'s competency (either initially by the clinician or later by the court)
was value-free, and as such, unbiased. No decision is "value-free",
however, (Putnam, 1981) and the respective biases and
prerogatives of the legal and psychiatric systems must be acknowledged.
Here, the matter of competence had been thrust upon the doctor-patient
relationship by the legal context of right-to-refuse-treatment litigation.
Thus various competences were being called into question, many for the
first time.
Likewise the question arises whether the clinician's evaluation of Mr.
L.'s values was value-free; that is, whether such distinctions as "mature
values" versus "primitive" or "premorbid" values
are sufficiently objective to be clinically or legally meaningful. The
patient's thanking the clinician as an outcome of treatment does not
settle the issue, even though it meets the explicit "thank you" criterion
described in the introduction. The "thanks" may be mere compliance
or identification with the therapist. Similarly unclear is whether premorbid
values can be unequivocally distinguished from psychopathological/morbid
values.
The primary tool used in the assessment of Mr. L.'s values, namely the
empathic stance, is not itself infallible, as Ferenczi (1941)
and Buie (1981) elucidate. The clinician must test his
or her own sundry value hypotheses frequently by reviewing his or her
opinions collaboratively with the patient in the ongoing process of treatment
(Gutheil & Havens, 1979). But the question arises,
is the outcome of the therapy as well as the formulation of the problem
altered by the inquiry process itself? Let us now briefly address this
question with respect to the differing facets of Mr. L.'s values as they
were appreciated over the 9 month period of psychotherapy.
Mr. L.'s religious values concerning C.S. and witchcraft, as illustrated
in the above case history, served a variety of functions with defensive
and integrative properties, including serving as a primitive superego
or as defenses against underlying psychosis and depression. The highly
conflictual nature of Mr. L.'s values became more apparent as a therapeutic
alliance slowly evolved in the course of therapy.
But does such alliance formation contaminate the patient's value system?
Is the alliance a vehicle for the therapist's imposing his or her own
values on the patient, as noted earlier, through the process of identification?
First, since no one's value development occurs in a closed social vacuum, "contamination" may
be viewed as a normal process. Second, while identification inevitably
occurs, the goal was to maximize the opportunity for Mr. L. to discover
his own values, as well as create new ones; in the process he became
more tolerant of experiencing feelings (particularly anger, sadness,
and loneliness) rather than having to "escape into false identities." Furthermore,
this approach allowed Mr. L. himself to begin to question what were his "true
values"—an essential part of growing up. Lastly, the patient
was able to determine in the course of his treatment how he wanted to
be treated in the future, should he again become incompetent.
Thus, rather than clouding the substituted judgment (what the patient
would have wanted if competent) this exploratory approach realizes that
judgment's actual goal because the motivating spirit of the substituted
judgment determination is the desire to individualize the vicarious decision
as much as possible. This case example illustrates how the evolving therapeutic
exploration within the alliance can produce the most valid empirical
evidence as the basis for this determination, predicated on the state
of the patient at his most mature.
Having shown that the clinical assessment of a patient's values is of
particular importance in the evaluation of competence, we suggest that
this assessment best occurs during the process of clinical administration
and psychotherapy to ensure that an accurate picture of the patient's
values is obtained. Even in the present case, the question remains as
to what extent one can assess patient values without, in the process,
transforming them, as growth occurs in the psychotherapeutic relationship.
Given clinical realities and the length of time required to do the sort
of extended competency evaluation described, our case might support use
of a "best interest" model to guide immediate emergency treatment
of the presumed incompetent patient (Gutheil & Appelbaum,
1985); later, should the patient continue to suffer from incompetency
requiring medical intervention, the clinician may provide the court with
the data for a realistic application of the substituted judgment standard.
Note that both best interests and substituted judgment are time honored,
common legal models for vicarious decisionmaking; our only innovation
here is their sequential use as described.
Our proposed model for a biphasic assessment of competency ("best
interest" standard first, later substituted judgment) (Gutheil & Appelbaum,
1982; Mills, 1980) is consistent with recent clinical
(Bursztajn, Feinbloom, Ham, & Brodsky, 1981) and judicial
(Harnish v. Children's Hospital, 1982) recognition
of the importance of informed consent in medical treatment. Some practical
advice on this process is addressed elsewhere (Gutheil,
1987). In those cases where the patient's competence begins to be
restored, the second phase of competency assessment may involve the use
of the therapeutic alliance to help the patient express his now competent
choices in the form of a truly informed living will (Appelbaum,
1979; Gutheil & Appelbaum, 1982).
References
-
Appelbaum, P. S. (1979). Michigan's sensible "living
will." New England Journal of Medicine, 301, 788.
-
Buie, D. (1981). Empathy: Its nature and limitations.
Journal of the American Psychoanalytic Association, 29, 281-307.
-
Bursztajn, H., Feinbloom, R., Hamm, R., & Brodsky,
A. (1981). Medical choices, medical chances.
New York: Delacorte Press.
-
Curran, W. J. (1978). The Saikewicz decision.
New England Journal of Medicine, 289,499-500.
-
Ferenczi, S. (1941). Confusion of tongues
between adults and the child. International Journal of Psycho-Analysis,
30,225-231.
-
Flowers, R. B. (1984). Withholding medical
care for religious reasons. Journal of Religion and Health, 3, 268-282.
-
Gutheil, T. G. (1982). On the therapy in clinical
administration: Part two. Psychiatric Quarterly, 54,11-17.
-
Gutheil, T. G. (1985). Medication refusal
on religious grounds: Clinical, legal and ethical concerns. Cura
Animarum, 37,21-27.
-
Gutheil, T. G. (1987). Clinicians' guidelines
in assessing and presenting subtle forms of patient incompetence
in legal settings. American Journal of Psychiatry, 143,1020-1023.
-
Gutheil, T. G., & Appelbaum, P. S. (1980).
Drug refusal: A study of psychiatric inpatients. American Journal
of Psychiatry, 137, 340-347.
-
Gutheil, T. G., & Appelbaum, P. S. (1980).
Substituted judgment and the physician's ethical dilemma: With special
reference to the problem of the psychiatric patient. Journal of Clinical
Psychology 41, 303-305.
-
Gutheil T. G., & Appelbaum, P. S. (1982).
Clinical handbook of psychiatry and the law. New York: McGraw-Hill.
-
Gutheil, T. G., & Appelbaum, P. S. (1985).
The substituted judgment approach: Its difficulties and paradoxes
in mental health settings. Law, Medicine, and Health Care, 13,61-64.
-
Gutheil, T. G., & Havens, L. L. (1975).
The therapeutic alliance: Contemporary meanings and confusions. International
Review of Psycho-Analysis, 6,467-481.
-
Gutheil, T. G., Shapiro, R., & St. Clair,
R. L. (1980). Legal guardianship in drug refusal: An illusory solution.
American Journal of Psychiatry, 137, 347-352.
-
Harnish v. Children's Hospital Medical Center.
387 Mass. 152. (1982).
-
In the Matter of Guardianship of Richard
Roe III 421 N.E. 2d. 40 (Mass. 1981).
-
Mester, R. (1972). Psychiatrists' reaction
to their patients' refusal of drugs. Israeli Annals of Psychiatry
and Related Disciplines, 10, 373-381.
-
Mills, M. J. (1980). The rights of involuntary
patients to refuse pharmacotherapy: What is reasonable? Bulletin
of the American Academy of Psychiatry and the Law, 8, 313-334.
-
Putnam, H. (1981, March). The fact-value
dichotomy. Paper presented at Harvard University.
-
Stone, A. A. (1974). The right to refuse
treatment and the psychiatric establishment. Psychiatric Annals,
4, 22-42.
-
Stone, A. A. (1981). The right to refuse
treatment. Archives of General Psychiatry, 38, 358-362.