This week, we’re thinking about the Limits of Medical Consent. To get yourself in the right frame of mind begin by asking yourself whether it is ever permissible to force medical treatment on a patient against their will? What if they are so emotionally distraught that they can’t think straight? What if they might die without the treatment?

Clearly, there are some people who are not fully competent to make their own medical decisions. But where exactly do we draw the line between the competent and the incompetent? At one extreme, we’ve got children. If a skittish nine-year old kid refuses to let the doctor give her a needed shot, I see nothing wrong with making the kid take the shot. I would do it gently. Maybe turn it into a game. But I would see to it that in the end the kid took the shot. At the other extreme are adults who are just cognitively impaired. For example, a person in a coma can neither grant nor withhold consent. But we don’t deny them care because of that. Here the lack of consent is not even an issue.

Child-like immaturity and a coma-like incapacity are the easy cases. But is it ever okay to compel a fully mature adult, who is not incapacitated, to undergo a medical procedure against their will? There are certainly grounds for denying that it could ever be permissible to do so. Mature adults are autonomous beings. One doesn’t coerce autonomous beings who are not incapacitated.

但我并不完全信服。在我看来，一个人甚至对一个完全自主的人也可能有行善的义务。而且，对于自治的担忧是否总是应该胜过一项慈善事业，这一点也不清楚。所以，为了讨论的方便，假设你有一个冲动控制能力很差、预见性很差的病人——一个只有六岁小孩那么成熟的成年人。也许患者一直承诺改变他们的习惯，做出更好的选择，来治疗，但一次又一次地失败。可以说，病人在某种意义上是自主的。但他们肯定不明智。难道一个人有责任- - -行善的责任- - -对这样的耐心表现出一点善意的家长式作风吗?这种家长式作风可能会被认为侵犯了病人的自主权。但这是一种基于慈善的违反。

No doubt those who fetishize autonomy will insist that at some point, autonomous grown-ups must live with the consequences of their choices, no matter how disastrous those consequences may be. Living with the downside cost of poor choices is just one of the burdens of autonomy! Of course, one could say that in this case we don't have genuine autonomy. The patient isn’t actually a fully functioning autonomous adult, not in reality. And by leaving the patient’s decisions entirely up to them, we’re not in fact respecting their autonomy. We’re helping to make them worse off. We’re doing them serious harm in the name of an illusory respect for a shadow of autonomy.

If you believe in the absolute and trumping value of autonomy, you’ll say that we’d be doing them greater harm if we took away their right to decide. You’d be infantilizing them, denying them their autonomy. But consider a case of another kind that is perhaps more compelling.

假设一个男人在一场可怕的事故中失去了他的妻子，他自己也受了伤。这个人非常悲伤，他无法想象继续下去的情景。他拒绝接受能让他活下来的迫切需要的治疗。你是违背他的意愿强迫他接受治疗还是让他死去?最简单的方法是告诉他，你会先给他一些时间来克服他的悲伤，然后让他决定。但为了让我的案子越艰难越好，我就假定他的伤势非常严重，你不能再等了。如果你再等，他就会死。

Now speaking just for myself, I’d hope that he eventually gets over his grief. In the meantime, I’d do whatever I can to keep him alive. But what I want to know is why this case seems so different from the first. I do admit that letting a person die because they’re grief-stricken seems much worse than letting an immature adult continue to live an unhealthy lifestyle. But I’m not sure why. Both the grief and the immaturity seem inconsistent with full autonomy. So if there is a reason of beneficence to step in the case of extreme grief, there would seem to be a reason of beneficence to step in the case of extreme immaturity.

Moreover, suppose the grief-stricken patient comes back a year later, fully physically recovered but still in the throes of profound grief. I’m sure I would try to comfort and console him, maybe recommend a good grief counselor to him. But what if he doesn’t want any more counseling. He wants to end his suffering. And he asks me, as his doctor, to help end his suffering. He doesn’t want to live, in other words, he wants me to help him commit suicide.

I’m not sure what I would do. I’m not even sure what I should do. It would be one thing if he were terminally ill. But if he’s physically healthy and asks me to end his life… I don’t think I would…or should… or could… help him die. What he clearly needs is better psychological support, not death.

But the question of autonomy versus beneficence rears its head here too. Or so it seems to me. If we can’t out of respect for autonomy force someone to undergo medical treatment against their will, how can we force someone to live against their will? Why is that any more acceptable than forcing them to undergo medical care against their will?

Not that I know the answer to this question. But if you tune into our episode, at least your thoughts, and possibly your heart too, will be stirred by our amazing guest, Jodi Halpern. She’s thought a lot about these issues.