Fall 2003 Volume 16, Number 2	AS I SEE IT: Michael A. Williams, M.D. Lessons from a Neuroethicist's Case Book
	John, a neurosurgery patient, has problems comprehending speech due to a left hemisphere lesion. Unaware of his partial aphasia, a consulting team discusses a needle biopsy with him one morning when his wife is away. John signs the consent form. That afternoon, John has the procedure which his wife doesn't learn about until later.
Jan, a patient with moderate dementia, is found to have normal pressure hydrocephalus. The neurologist recommends shunt surgery. But by virtue of her dementia, Jan doesn't believe the diagnosis and refuses to have surgery. Her husband, family and physician cannot convince her otherwise; yet they're sure surgery is in her interests. It could, they believe, improve the dementia and allow her diagnosis to sink in. They question whether they can take Jan for surgery in spite of her apparent objection. __________________________________________ Decision making capacity, or competency, is an attribute most of us are presumed to have. Yet many patients with neurological and neurosurgical disorders lose that thinking ability. The loss isn't difficult to discern when patients are unconscious, severely demented, or have obvious aphasia, but lack of competency is particularly difficult to identify in cases like John's or Jan's-when cognition is partially impaired. Neurologists and neurosurgeons are commonly faced with the challenges of assessing decision-making capacity, yet there's no simple test for doing so. Not even the widely used Mini Mental State Exam is sensitive or specific enough. Competency includes the abilities to communicate a choice and to understand and appreciate relevant information, such as risks, benefits and likely consequences of procedures. It also includes ability to consider alternatives. It's not unusual for a patient to be competent for one sort of decision-whether blood may be drawn, for example-but not for others, such as whether to undertake surgery. But inattention to patients' competency can result in their undergoing treatment without adequate consent, as in John's case, a situation which could have sparked legal action had harm occurred. Deferring to an incompetent patient's wishes, as in Jan's situation, could mean a patient receives less-than-ideal care and possible harm. Rare circumstances do exist when it's ethically permissible to override a patient's apparent refusal of therapy, and consulting your ethics committee and legal office is strongly advised. Jan, it turned out, was persuaded by her husband to have surgery. When her neurologist saw her three months later, she laughingly admitted she couldn't remember denying her illness. Jan was also thankful that her family and physicians had persuaded her to have the surgery that restored her ability to make decisions. _____________________________________________________________________ Williams is Chair of the American Academy of Neurology's Ethics, Law and Humanities Committee and Co-chair of The Johns Hopkins Hospital Ethics Service _____________________________________________________________________