Shedding Light on Implicit Processes and the Inherent Vagueness of Decision-Making Capacity

We are grateful to Paul S. Appelbaum and Wayne Martin for their thoughtful remarks on our paper. Among the various aspects that we might address and refute in return, we have decided to focus on just two issues that we believe have potential to advance the debate.

According to Appelbaum, the “assessment of an intuitive process is being predicated on a patient having the ability to reflect on determinants of which he may be completely unaware.” In this passage, he points to an apparently “self-evident paradox.” Also, Martin is skeptical about the assessment of intuitive reasoning ability.

We agree that relying entirely on unarticulated gut feelings is problematic in terms of decision-making capacity (DMC). However, we do not regard the mentioned paradox as unresolvable. It might be true that something that is implicit cannot be explicit, but that the implicit can be made explicit. In this transition—which is, in part, a self-reflective process—intuitions or feelings are experienced, verbalized, and assessed. We are not convinced that the operationalization of reasoning in the MacCAT-T is able to fully account for this process.

Moreover, the assessment of intuitive processes illustrates why the provision of support is fundamentally important in DMC evaluations and should not be separated from the assessment. A counterpart is needed to identify the implicit, unconscious elements and/or help articulate them. Rather than looking at paradigms used in experimental psychology to measure the intuitive reasoning, as Martin proposed, we suggest learning from psychotherapeutic approaches that facilitate the transition from implicit, unconscious processes to explicit content, referred to as clarification-focused interventions (Grawe, 1997).

In psychoanalytic theory, for example, two basic principles have been formulated enabling a grasp of unconscious elements: “free association” on the side of the patient, and “evenly-suspended attention” on the side of the clinician (Freud, 1912). If the patient reports whatever comes into his or her mind without actively censoring it and the clinician listens impartially and attaches no preconceived relevance to single elements of the patient’s discourse, but is instead receptive to the order in which things are said, the fluency and omissions in the speech of the patient, and the manner and emotional tone by which they express themselves verbally and nonverbally, the subtexts in the patient’s speech will become hearable, and implicit elements can be identified (e.g., Mertens, 2015).

Moreover, implicit experiences that have not yet been symbolized in language are often acted out nonverbally, evoking feelings, sensations, and images in the clinician, also known as “counter-transferences” (e.g., Mertens, 2015). Such counter-transferences provide additional insights that can help the patient recognize and verbalize the unconscious elements. Emotion-focused therapy (Greenberg, 2010) offers strategies to empathically foster the expression and articulation of emotions and to direct the patient’s attention to the present through techniques such as paraphrasing, repetition, exaggeration, and mirroring (Engle & Arkowitz, 2006).

We regard it more pertinent for DMC (assuming that the patient understands the medical situation, including the risks and benefits of the treatment alternatives) that the patient is able to assign personal significance and meaning to the situation by means of self-reflection than to (merely) “identify the comparative consequences of the options” (Appelbaum, 2017, p. 327). Moreover, in affirming the potential of these techniques for DMC evaluation, we stress again the importance of addressing not only the definition of relevant criteria but the “how” of the assessment.

Our second remark addresses the commentators’ criticism that the terms intuitive decision making or ability to self-reflect are too vague, poorly operationalized, and therefore incur a potential “risk of arbitrarily designating patients as incapable.” Indeed, it is worth thinking about vagueness in the context of DMC. Along with criteria too generally formulated, a different sort of vagueness is immanent in DMC, which evolves from a requirement to categorize people as either competent or incompetent. Although there are people who clearly fall into one or another category, there are also borderline cases, which are much more difficult to allocate. The question...