Abstract
This paper explores the value of a Poststructuralist psychoanalytic model of persons, or “Subjects,” as an expanded frame for the question “Whose consent is it anyway?” The elaboration of the need for this expanded frame, its tenets and its value form the substance of the paper. This frame incorporates the emotional, linguistic, and socio-cultural dimensions that help restore patients and physicians to their full status as persons from their restricted status, in the current dominant theory and model, as unidimensional, rationalistic, medico-legally constructed players; emphasizes their interconnectedness; and, focuses broadly on responsibility as bearing consequences, and not only accountability. This frame does not deny the role and importance of cognition or rationality, it supplements them. It does not supplant rationality, but rather includes it in a view of the person that also includes those other human capacities which are not based on an ideal of pure reason.
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REFERENCES
That which is preconscious is out of immediate awareness but easily accessible, as opposed to the unconscious which is out of conscious awareness and, by definition, difficult to access.
Faden RF, Beauchamp TL. A History and Theory of Informed Consent. New York: Oxford University Press, 1986.
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Although not part of the mainstream bioethics discourse, the notion of voluntariness in psychiatric practice is predicated on being rationally autonomous, or free from a psychiatric disturbance that makes the patient a danger to self (through suicide or severe compromise of self care) or to another (through homocide or physical aggression). Those who are not voluntary in this sense are subject to involuntary hospitalization. This is different than competency. Indeed, a psychiatric patient may be involuntarily hospitalized yet competent to refuse treatment, particularly as competency is task-specific. Voluntariness in this specific sense also reinforces the role of rationality in the ethics of medical decision making.
Pomerantz AS, de Nesnera A. Informed consent, competency, and the illusion of rationality. General Hospital Psychiatry 1991; 13: 138–142.
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There are also problems with their case examples. The case examples focus on women with a history of psychosis. The first makes the assumption that a seventy-four-year-old woman's fears of mastectomy were part of a residual paranoid disorder and “had been aroused by the peculiar latent meaning [italics mine] that a mastectomy held for her: that it would be a stimulus for those round her to withdraw leaving her alone with nothing but death ahead of her” (Appelbaum and Roth: 1464). It may or may not have been true that for this patient this belief was of a psychotic nature, but at the very least one can easily imagine such a fear as non-psychotic. That the diagnosis of a terminal illness should make others withdraw and focus one's attention on imminent death seems a highly non-psychotic fear born out by the common enough behavior of others (including health care providers), and the common enough outcome of breast cancer, with or without mastectomy, especially at the age of seventy-four. In this reading of the patient's fear, the mastectomy symbolizes and makes the diagnosis breast cancer evident to oneself and others.
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For further development of these concepts, see Marta J, A linguistic model of informed consent, Med. Philos. 1996; 21: 41–60.
Faden RF, Beauchamp TL. op. cit.: 268.
Ibid.: 269.
Ibid.: 268–269.
Transference and countertransference refer narrowly to the reactions, based on past experience of other persons, of the patient to the physician or therapist, and of the physician or therapist to the patient, respectively. Katz appears to use these terms in the broader sense to include the reactions and counter-reactions of patient and physician based on their present experiences of each other.
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Dyer AR. Informed consent, autonomy, and paternalism: Respecting the patient in research and practice. In: Ethics and Psychiatry: Toward Professional Definition (chapter 6). Washington, D.C.: American Psychiatric Association Press, 1988.
Ibid.: 88.
Psychoanalytically inspired psychotherapy often integrates elements of other forms of psychotherapy, including cognitive and behavioral therapies, and admits the simultaneous use of pharmacotherapy.
As has been postulated, for example, in the case of anorexic patients.
Pomerantz and de Nesnera. op. cit.; Roth, Appelbaum et al. op. cit.; Appelbaum and Grisso. op. cit.; Appelbaum and Roth. op. cit.
Brody. op. cit.: 9.
Dyer. op. cit.
Faden and Beauchamp. op. cit.
Katz. op. cit.
Lacan J. Fonction et champ de la parole et du langage en psychanalyse. In: Ecrits I. Paris: Seuil, 1966. Translated as: The function and field of speech and language in psychoanalysis. In: Sheridan A. trans. Ecrits: A Selection. New York: Norton, 1977: 30–113.
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Lacan later coined the term “parlêtre,” a neologism composed of the two French words parler (“to speak”) and être (“to be” or “being”), to express the concept of the person as a speaking being, of the person as existing through speech.
The at least initial delight in discovering one's resemblance to another is described by Lacan in “Le Stade du miroir comme formateur de la fonction du Je, telle qu'elle nous est révélée dans l'expérience psychanalytique” (translated as: The mirror stage as formative of the function of the I as revealed in psychoanalytic experience. In Ecrits: A Selection: 1–7).
This is compatible with the notion of first and second orders of autonomy elaborated by Childress after Dworkin (Childress J. Autonomy. In: Veatch RM, ed. Cross-Cultural Perspectives in Medical Ethics: Readings. Boston: Jones and Bartlett Publishers, 1989: 233–240); and with the notion of a third order of autonomy referring to the latent autonomy of the incompetent patient elaborated by Marta and Lowy (Marta J, Lowy FH. Le consentement éclairé: un atout pour la psychothérapie? Revue Canadienne de Psychiatrie 1993; 38: 547–551).
Physicians are obligated (through the Hippocratic Oath, their deontologic codes, and the principle of non-maleficence) to refuse to execute their authorization by a patient for any medically containdicated action the patient may propose as an option, or even as a preferred option.
Conversation and its contents are as tangible as the numbers and pictures of physical medicine which are, after all, only another code, or nonverbal language, representing “reality.”
This article forms part of a larger work-in-progress on an interdisciplinary theory and model of informed consent. The equally important legal, clinical, and pedagogical applications and implications of this approach, though beyond the scope of this article, are an ongoing and future concern.
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Marta, J. Whose Consent is it Anyway? A Poststructuralist framing of the Person in Medical Decision-Making. Theor Med Bioeth 19, 353–370 (1998). https://doi.org/10.1023/A:1009955914018
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DOI: https://doi.org/10.1023/A:1009955914018