- Devotion or Disease?
MV, a fifty-year-old woman, called 911 for help. Police arrived after her husband refused entrance to the paramedics who responded. Once police gained access to the house, they found MV in the bedroom. She fluctuated in her ability to communicate. Her husband would not give them her identification, and the police suspected abuse. A suitcase was on the bed, and police asked MV if she was trying to leave her husband. She could not answer. They decided to send her to the emergency room because she was emaciated and intermittently mute.
MV's medical records indicate that she has schizophrenia. She was admitted to the hospital ten years ago for a similar episode. Her husband confirms that she had recently been treated with vitamins by her family doctor in accordance with the couple's beliefs in Scientology. MV is admitted to the psychiatry unit as an involuntary patient and deemed incapable of consenting to treatment. She has no advance directive or living will.
Early in the course of her treatment, her doctors note that MV is delusional. Much of what she says is incoherent, so they look to her family for help. Her sister tells the health care team about the family's strong history of schizophrenia. She says that MV has never accepted her diagnosis nor believed that she needs treatment. She also explains to them that MV became a devout Scientologist when she met and married her husband, and that this occurred right around the time she was first diagnosed.
MV slowly begins to improve, but she shows no insight into the nature of her psychiatric illness. She is adamant that she does not need antipsychotics and that such treatment could never benefit anyone. This conviction is reinforced by Scientology, and she refuses further treatment on grounds that it would be inconsistent with her religious beliefs. Based on these statements, MV's psychiatrist thinks her patient remains incapable of making her own health care decisions. But because MV is no longer malnourished or dehydrated, her potential to harm herself is greatly diminished, and she can no longer be kept against her will.
Her treatment team encourages MV to weigh all her treatment options, but MV does not acknowledge having any psychiatric problem. The only problem that she will acknowledge is that her husband is abusive: she says he attempted to smother her with a pillow. She will not press charges against him, but she does intend to separate from him. She says she called 911 for help with her domestic abuse, not for medical assistance.
Should MV's health care team respect her treatment refusal?
It behooves us to examine the role religion plays in decision-making ability. It especially behooves us to examine how religion impacts decision-making ability in vulnerable patients.
MV is such a vulnerable patient. She struggles with a psychiatric illness she does not believe she has. She struggles in a marriage that she later admits is abusive. She wants to be an autonomous and independent woman. Her involvement in Scientology may have reflected her desire to autonomously choose a faith that reflected her belief system. Or perhaps, given her vulnerability, she was subtly coerced into her faith by her husband years ago.
Nonetheless, her vulnerability persists. Her family doctor mistreated her psychosis with vitamins, and she deteriorated. Her husband did not cooperate with authorities and was later disclosed as an abusive man. MV arrives in the emergency room in an emaciated and catatonic state. But her call to 911 clearly indicated that she was requesting help.
Despite the complexities of the case, there are several incontrovertible facts. MV is at risk of dying if she returns to her home and continues to get treatment in the community from her family doctor. The decision to enforce hospitalization by making her an involuntary patient is an easy one. She has a documented psychiatric illness and is at risk of death without inpatient treatment. The treatment team likely has one main goal—to provide hydration and nourishment so that she does not die.
When she recovers and becomes more communicative, there will be new and challenging ethical...