As mentioned in my Introduction, and I am delighted to repeat now, the commentaries provided by Calvin Ho and Chua Hong Choon are both excellent. In reading them, some further thoughts were raised for me, and I briefly reflect on these now.
In his legal commentary, Calvin Ho makes a plausible argument that Mr. T has the capacity (and hence the right) to make decisions in his current state about his healthcare, and refers to two legal tests of decision-making competency laid down in the Singapore Mental Capacity Act (2008), which he believes Mr. T would pass. A question arises from each of the legal tests which Ho described.
The first test involves the question of whether there is any “impairment of, or disturbance in the functioning of Mr. T’s mind or brain”. The claim made by Ho is that there is no impairment or dysfunction of Mr. T’s mind or brain. But, this raises a question: what are the functions of the mind? Christopher Boorse suggested that “We may surely assume … that the main function of perceptual and intellectual processes is to give us knowledge about the world” and against this standard “schizophrenia and all other psychoses with thought disorders look objectively unhealthy”.1 Further — and here is the specific point of discussion in relation to Mr. T — does his continuing denial that he is ill (his lack of insight) also constitute such a dysfunction? Is one function of our mind to tell us things about the functioning of our minds — to correct errors, spot illusions and self-deceptions, and respond to beliefs which are odd? If so, then perhaps Mr. T’s lack of insight indicates the presence of a dysfunction.
The second test which (mainly for the sake of completeness) Calvin Ho refers to comprises a list of requirements for decision-making capacity. These are relevant if a dysfunction is identified by the first test. These are:
(1). Understand information given to him;
(2). Retain that information long enough to make the decision;
(3). Use or weigh up that information as part of the process of decision-making; and
(4). Communicate his decision.
These requirements are familiar from other accounts of decision [End Page 222] making capacity, but at least some of these accounts have added a further requirement, “the ability to appreciate the nature of the situation and its likely consequences”.2 This is not merely the ability to understand what one is being told but also the ability “to apply the information abstractly understood to [one’s] own situation”. Potentially, Mr. T would fail this test. He frequently lacks insight into the fact that he is unwell, that is to say, he does not seem to appreciate that the information he is being given is true of him.
I turn now to the clinical commentary by Dr. Chua. What chiefly struck me from this was the determination to engage with the patient as a person. Medication is not the first resort; rather, many other interpersonal approaches can and should be tried first. Medication is of course one aspect of treatment — and in some cases, any hope of any sort of engagement with a patient may rely upon some medical intervention succeeding. Perhaps Mr. T will turn out to be a patient of this kind, who can only be engaged in conversation about his experiences and the state of his mind if he has first taken a course of pills. But it has, over a number of years of speaking to psychiatrist colleagues, been borne in upon me that the psychiatrist himself or herself is a fundamental element of mental healthcare. The psychiatrist is not merely a route to help, the dispenser of prescriptions for pills, but someone with whom the patient can talk to and explore his or her experiences. In short, part of the therapeutic relationship which psychiatrists seek to establish is just a personal relationship. I am sure this is simply obvious to most clinicians and indeed to those who suffer from mental ill health and their caregivers. But sometimes, the obvious is worth pointing out.
Indeed, the desire to engage with Mr. T as a person...