Individuals with major depression may benefit from psychiatric treatment, yet they may refuse such treatment, sometimes because of their depression. Hence the question is raised whether such individuals are competent to refuse psychiatric treatment. The standard notion of competence to consent to treatment, which refers to expression of choice, understanding of medical information, appreciation of the personal relevance of this information, and logical reasoning, may be insufficient to address this question. This is so because major depression may not impair these (...) four abilities while it may disrupt coherence of personal preferences by changing them. Such change may be evaluated by comparing the treatment preferences of the individual during the depression to his or her treatment preferences during normal periods. If these preferences are consistent, they should be respected. If they are not consistent, or past treatment preferences that were arrived at competently cannot be established, treatment refusal may have to be overridden or ignored so as to alleviate the depression and then determine the competent treatment decision of the individual. Further study of the relation between depression and competence to refuse or consent to psychiatric treatment is required. (shrink)

Competent decision-making is required for informed consent. In this paper, I aim, from a phenomenological perspective, to identify the specific facets of competent decision-making that may form a challenge to depressed patients. On a phenomenological account, mood and emotions are crucial to the way in which human beings encounter the world. More precisely, mood is intimately related to the options and future possibilities we perceive in the world around us. I examine how possibilities should be understood in this context, and (...) how, in depression, decision-making might be compromised. I suggest that, based on this analysis, a specific emphasis and alertness in assessments of competence in depressed patients is called for. In fact, close attention should be paid to the range of future possibilities depressed patients are able to perceive. In addition, providing environmental cues to these patients might be one way of enhancing their decision-making capacity. The practical suggestions arrived at are open to empirical research. (shrink)

Medical decision making by patients is respected as a lawful exercise of free will and agency unless patients are found to lack “competence.” Yet measures of competence in medical decision making typically assess only cognitive abilities. Emotionality is involved in decision making and may affect how far patients’ decisions to accept or refuse medical treatment embody free will. Moreover, neurodivergence, or atypical neurological makeup, is often diagnosed as neurodegeneration, neurodysfunction, neural damage, or neural difference and frequently leads to difficulties in (...) considering the emotional aspects of decisions that standard tests do not measure or disclose. Neurodiversity activists assert that their neural differences are not pathologies to be treated or cured but are alternative ways of being that should be accepted as neuroequal. Nevertheless, who may claim to be neurodiverse is uncertain. We focus on atypical emotionality to consider the limits of neurodiversity in relation to measures of competence, particularly in relation to end-of-life decision making. (shrink)