Executive Dysfunction as a Barrier to Authenticity in Decision Making

Owen, Freyenhagen, and Martin (2018) present a novel discussion of the meaning of decision-making capacity (DMC). They frame their discussion in the context of deficits in executive function after traumatic brain injury, but their observations and suggestions for expansion of how DMC is appropriately assessed have potential implications for people with other disorders that can potentially affect executive functioning, including those with certain forms of neurodegenerative conditions (such as frontotemporal dementia) and some of those with serious mental illnesses such as schizophrenia or bipolar disorder (Dunn, Lindamer, Palmer, Schneiderman, & Jeste, 2001; Grimes, McCullough, Kunik, Molinari, & Workman, 2000). Although not mentioned explicitly in their article, a key point in considering DMC as conceptualized by Owen et al. is the notion of authenticity of a choice (Brudney, 2009; Kim, 2011; Roberts, 2002). This is essentially the idea that the person has the capacity to make a choice in the particular situation at hand that reflects “who he or she really is”—his or her genuine values and longer standing preferences.

A key point made by Owen et al. (2018) is that the classic definition of DMC, in the 2005 Mental Capacity Act of England and Wales, as well as the widely cited four abilities or dimension model identified by Appelbaum and colleagues, that is, understanding, appreciation, reasoning, and communicating a choice (Appelbaum & Grisso, 1988; Appelbaum & Roth, 1982), is generally interpreted cognitively. But Owen et al. provide a cogent argument that there are subtle components to DMC abilities that are not purely cognitive that may affect authenticity of decisions made.

Through qualitative analyses of interviews conducted with people with traumatic brain injury (more specifically, what they refer to as acquired brain injury and organic personality disorder), Owen et al. (2018) note that, contrary to expectations, the interviewees generally demonstrated intact awareness of deficits associated with their injuries. This level of awareness seems to pass not only the tests of understanding, but those of appreciation (insight). But based on the error analyses, Owen et al. describe three components of DMC that emerge from their interviews that are not immediately apparent in the four dimension model as commonly applied.

1. 1. The ability to have ‘real-time, online’ awareness of deficits and impairments. This requirement goes beyond the broader notions of understanding and appreciation in that it requires the individual to be able to reliably apply such awareness in guiding current behavior. As Owen et al. noted the “awareness was in several instances either unavailable to those patients in the decision situation, or else could not be integrated into the deliberative process” (p. 12). The key notion here is the ability to reliably apply the awareness of deficits in the moment.

2. 2. The ability to detach from and engage with impulses and behavioral cues afforded by the decision situation. In this component, Owen et al. noted that were some patients who showed difficulty stepping back from immediate environmental cues (i.e., to enable a reflective deliberation), and some who could not disengage from the deliberative process itself (i.e., to actually come to a final decision). As with their first criteria, there is a connotation with this second criterion of being able to work adaptively within the moment of the decision-making task.

3. 3. The ability to prefigure a decision situation by being attuned to relevant normative features. Owen et al. are not fully clear in their use of the term “normative,” but their discussion of this component suggests a difficulty some patients may have in assigning or applying valance to possible outcomes—this is similar to the emphasis other authors have made on attending to patients values and preferences, and again speaks to the notion of authenticity of the decisions.

A notable feature of the interviews reported by Owen et al. is that many of the patients were able to speak clearly and cogently about the cognitive and behavioral deficits, for example, noting difficulties with impulse or anger control that developed after their injuries. Yet, even while demonstrating the ability to reflect on and describe such deficits, the very same patients sometimes manifested those same...