Psychiatry and ethics case report refusing treatment bipolar disorder

A 56 years old woman, Fran, was diagnosed with bipolar disorder. She is currently detained under section 3 of the Mental Health Act (MHA) for a manic episode. Concurrently, Fran suffers from diabetes mellitus and eye complication (diabetes retinopathy) due to her uncontrolled blood sugar levels. Her blood glucose was controlled by a combination of diet and insulin. Since admission, under section 3, Fran has complied with the medication prescribed (Depakote) for her psychiatric disorder. However, despite the compliance with Depakote; she is refusing treatment for her diabetes, when recent blood tests have shown very high blood sugar levels. This situation instantaneously raises a major ethical concern. Should Fran receive treatment for her diabetes against her wishes? Or should she be given the right to refuse treatment? If so, is she competent to decide for herself? I would approach this case ethically using the Beauchamp and Childress’ Four Principles and lawfully using the Mental Capacity Act (MCA) 2005.

Over years, the Four Principles framework forms the basis of moral reasoning for biomedical ethics. If we based our decision of treatment for Fran’s diabetes with this approach, there will be contradiction between respecting her autonomy and acting beneficently. Autonomy is a fundamental ethical principle which means freedom from external constraint with the presence of adequate mental capacity (1) (2). In short, it means self-governance (1). Whilst having a mental illness, is Fran competent to make rational decisions? It is crucial to ensure that one’s decision-making capacity is not clouded and remains as an autonomous agent. Autonomy is not a matter of all or none. As in this case, Fran may not be fully autonomous and therefore not legally competent to refuse treatment, but, this does not indicate that her thoughts should be ignored. Making a bad decision does not make it an irrational decision. Fran had expressed her views and wishes clearly that she does not want any intervention for her diabetes. Therefore, in respecting patient’s autonomy, Fran’s needs and values should be respected.

But, the question is whether or not Fran has the capacity to make rational decisions? The nature of mania itself involves changes in cognitive processes (3); and in severe cases, it can include psychotic features (4). Given that Fran was overspending and leaving the bills unpaid prior to her admission whilst having nonsensical believes, it clearly shows that Fran is lack of capacity to make rational judgements. With this, I disregard her as an autonomous agent.

From a legal point of view, the wishes of a competent individual cannot be overridden in his/her best interest. The fact that Fran may be incapacitated, the health care professionals have a duty of beneficence towards her. Beneficence refers to a moral obligation to act for the benefit of others (5). Very often, what the patient perceives as their “best-interest" may conflict with the medical opinion. As in this case, should we allow the principle of beneficence to override Fran’s autonomy? The answer to that lies within how we weigh what is best for Fran. One could argue that Fran could get into major distress if she was given insulin forcefully and may cause her to distrust healthcare professionals. This may then impact on Fran’s mental condition. However, without treatment for her diabetes, Fran’s physical health will deteriorate and may lead to worsening complications of diabetes. Furthermore, one’s physical illness may contribute to his/her mental well-being. Therefore, it is reasonable for healthcare professionals to violate Fran’s autonomy to prevent long-term mental and physical health problems which may require greater medical intervention.

Ultimately, we would like treatment of Fran’s diabetes to be a legal decision. But the MHA, section 3 detainment does not allow treatment of a physical illness in a mentally ill patient. We therefore need to refer to the Mental Capacity Act (MCA) 2005 which aims to act in the patient’s best interest after establishing that he/she lacks capacity (6). Consistent with section 2 in the MCA, Fran’s lack of capacity cannot be established simply by reference to her psychiatric disorder (6). However, her long psychiatric history and her current manic episode are evidence that Fran may be incapacitated. This then calls for a mental capacity assessment. The assessment of one’s capacity has to test all four criteria of “capacity" as defined in the MCA. This includes the ability to understand, retain and weigh the information provided, and also relay his/her decision to others as outlined by section 3 in the MCA (6) (7). Keeping in mind Fran’s psychiatric disorder, it is reasonable to decide that she lacks capacity in making major decisions rationally. It is therefore the healthcare team’s obligation to treat Fran’s diabetes in her best interest. In determining Fran’s best interest, we should also consider views of Fran’s next of kin, Carol, parallel with section 4(7) in the MCA (6). This is to ensure that we have a better insight of Fran’s past and present wishes, beliefs and values. Considering the fact that Fran complied with the treatment for her psychiatric disorder, it may suggest that Fran wishes to get better but due to her lack of capacity, she cannot understand that Depakote does not in any way help to treat her diabetes. Hence, treatment for her diabetes is highly favourable.

In conclusion, using the Four Principles of Ethics with the support of the Mental Capacity Act 2005, it is justifiable to violate one’s autonomy in treating an incapacitated individual. Therefore, if the treatment proposed is in line with Fran’s best interest, I strongly believe that her diabetes should be treated in the context that she is no longer an autonomous agent.

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