What we owe patients when fear undermines autonomy: Concretized emotions and the incapacity to deliberate.

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.