Winter 2004 Volume 16, Number 2	AS I SEE IT: David M. Blass Lessons from a Medical Ethicist's Case Book
	We offer the following hypothetical case to highlight some of the challenges inherent in medical decision-making for a patient suffering from depression.

Mr. S. was a 75-year-old retiree who had been fairly debilitated for five years because of ischemic cardiomyopathy. Then, a heart failure episode required repeated hospitalizations and he declined significantly. The elderly man experienced anergia, lessened interest in activities, and a 20-pound weight loss. He ruminated about his illness and was frequently sad and self-deprecating. He became dependent upon his family for food, medicine and personal care. When his cardiologist prescribed needed changes in medication, Mr. S. wanted no more of it. He was worn out from the disease, he declared. He felt it was time to surrender. The cardiologist suspected depression, but was uncomfortable in challenging a patient's autonomous decision. Mr. S.'s family, however, while respectful of his wishes, insisted he see a psychiatrist. Finally, Mr. S. came to Hopkins' geriatric psychiatry clinic. He was diagnosed with severe major depression, was admitted, and, after a proper course of antidepressants, returned to his baseline mood. Once at home, Mr. S. benefitted from his family's efforts to increase his socialization and activity. He lived for another year with normal mood and high quality of life until he succumbed to heart failure. Mr. S. said how very grateful he was for being encouraged to accept psychiatric care. This simple vignette illustrates two points about medical decision-making. First, major depression, even though it may not always render patients incompetent to make decisions, can skew perspective so that they cannot see the value of life. They may make unsound medical choices. Then, the depression itself infringes upon autonomy. Although it is tempting to interpret a patient's depressive symptoms as a natural response to advanced medical illness, the more accurate interpretation is that they're a product of psychiatric illness. A psychiatric consultation can help clarify this. Second, although the course of the patient's underlying cardiac disease could not be altered, his environment and daily routine could readily be adjusted to improve his mood, optimism and quality of life. Because of advanced illness, Mr. S. had become isolated from activities and social connections that previously sustained him. It's all too easy to underestimate the influence non-medical factors have on medical decision-making. Yet they're of great importance when discussing treatment options with a patient. Blass, an assistant professor of psychiatry and behavioral sciences, is a faculty affiliate of the Phoebe R. Berman Bioethics Institute at Johns Hopkins. He is also a member of The Johns Hopkins Hospital Ethics Service.