School of Public Health, University of California, Berkeley, California, USA.
J Eval Clin Pract. 2023 Dec;29(8):1251-1260. doi: 10.1111/jep.13864. Epub 2023 May 31.
Fear and anxiety can interfere profoundly with a person's ability to deliberate. Patients sometimes face critical medical decisions while subject to intense emotions which involve catastrophic (or wishful) convictions about the future. Medical teams, and even psychiatrists and bioethicists, lack a model for what to do in such cases. Philosophical accounts of autonomy and the clinical criteria for decision-making capacity derived from them fail to address cases in which emotions do not merely skew judgment but rather block decision-making capacity itself. This paper provides an account of when emotions undermine a person's freedom to deliberate, which is the basis of the capacity for autonomy. People subject to what I call 'concretized emotions' meet the cognitive criteria for decision-making capacity. Yet their emotions dictate their views of reality and prevent them from meeting the basic conditions for deliberation. To deliberate one needs to be able to think through alternatives, and this thinking through alternatives needs to be responsive to evidence. With concretized fear, both the ability to think through alternatives and the ability to respond cognitively to evidence is undermined. The person can engage in apparent deliberation, but her thought processes regarding the feared matter are characterized by the rigid view that things are just as they seem from her emotional view. This paper develops a theoretical and clinical model for a more appropriate and nuanced approach to acting responsibly toward patients subject to intense fear and related emotional states that block their decision-making capacity.
恐惧和焦虑会极大地干扰一个人进行深思熟虑的能力。患者在面对重大医疗决策时，往往会受到强烈情绪的影响，这些情绪涉及对未来的灾难性（或一厢情愿的）信念。医疗团队，甚至精神科医生和生物伦理学家，都缺乏处理此类情况的模型。自主的哲学解释和由此衍生的决策能力的临床标准都没有解决情绪不仅会扭曲判断，而且会阻碍决策能力本身的情况。本文提供了一种解释，说明情绪何时会破坏一个人深思熟虑的自由，这是自主性能力的基础。人们受到我所说的“具体化情绪”的影响，符合决策能力的认知标准。然而，他们的情绪决定了他们对现实的看法，并使他们无法满足深思熟虑的基本条件。要进行深思熟虑，人们需要能够思考各种选择，而这种对各种选择的思考需要对证据做出反应。在具体化的恐惧中，人们思考各种选择的能力和对证据进行认知反应的能力都会受到损害。这个人可以进行表面上的深思熟虑，但她对恐惧问题的思考过程的特点是，她从情绪角度看待问题时，会固执地认为事情就是她所看到的那样。本文为处理受强烈恐惧和相关情绪状态影响而阻碍其决策能力的患者，提供了一种更恰当、更细致的方法，制定了一个理论和临床模型。
