Understanding is a fundamental concept in medical ethics. I want to discuss two contrasting senses in which medical treatments require understanding on behalf of the patient. The first of these is very familiar, and much discussed. The second is less so.
The first and most familiar sense in which medical treatment requires a patient’s understanding is that understanding is crucial in determining their capacity to consent. The UK Mental Capacity Act of 2005 states that ‘a person lacks capacity… if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.’ In turn, ‘a person is unable to make a decision for himself if he is unable (a) to understand the information relevant to the decision, (b) to retain that information, (c) to use or weigh that information as part of the process of making the decision, or (d) to communicate his decision (whether by talking, using sign language or any other means).’ As condition (a) makes clear, understanding is legally required in order for a patient to make a decision for themselves regarding their treatment. No understanding, no capacity to decide; no capacity to decide, no possibility of consent.
Psychiatric illnesses present a number of interesting (and troubling) issues here. By their very nature, mental disorders can impair a subject’s capacity to understand their condition or a proposed treatment, thus rendering them incapable of consenting to such treatments. Serious ethical questions arise in evaluating whether, or in what circumstances, it is permissible to administer treatments to such individuals, despite their inability to consent. There has been considerable philosophical discussion of these issues, and I do not intend to add to that here.
I am interested in a second, and far less familiar, sense in which medical treatments may require understanding on behalf of the patient. In some cases, it seems that a patient’s understanding is required not simply to consent to a treatment, but rather to participate or engage in, or even succeed in that treatment. Psychiatry once again provides some pertinent examples. The clearest case for this role of understanding is in the ‘behavioural experiments’ used to generate changes in the patient’s mental state in Cognitive Behavioural Therapy (CBT). From its early stages of development in the 1960s, practitioners were aware of the importance of patients’ understanding in enabling CBT. Orne and Wender (1968), for example, suggested that the success of CBT critically depends on the patient understanding ‘the rules of the game’, that is, the nature and aim of the patient-practitioner exchanges involved in such therapy. They proposed that such understanding should be established through ‘anticipatory socialisation’. It has subsequently become standard to talk about ‘socialisation to the model’ as a key prerequisite for CBT. Wells (1997: 45), for example, describes this as ‘selling the cognitive model and providing a basic mental set for understanding the nature of treatment.’
The role of understanding in such psychiatric treatments contrasts greatly with its role in treatments for somatic illness. In somatic illness, understanding is essential in grounding the patient’s consent to a particular treatment, as we’ve seen above. But once such consent is secured, understanding effectively drops out of the picture as far as the treatment is concerned. Understanding plays no significant role in enabling the patient to undergo such treatments, nor does it determine the treatment’s likely success. Broken legs don’t heal faster once you learn the orthopaedic principles behind plaster casts. Heart bypasses are no more effective for cardiovascular specialists than for laypeople. And yet failure to understand the rationale and principles behind CBT – inadequate ‘socialisation to the model’, as they say – poses a fundamental obstacle for such psychiatric treatments.
As far as I’m aware, there hasn’t been much philosophical discussion of the ethical ramifications of this somewhat unusual situation. I’d be extremely happy to hear from people in comments, however, if you can put me right on this. In the remainder, I highlight two issues that would be interesting to explore further.
First, given the role of understanding in CBT, such treatments place certain cognitive demands on patients. It is an unfortunate fact, however, that many pharmaceutical treatments for psychiatric illness can affect, dampen, or hamper subjects’ cognitive capacities. As such, extremely careful decisions need to be made when prescribing multiple treatments to psychiatric patients. Concurrent pharmaceutical and cognitive treatments might have the unintended effect of reducing the effectiveness of CBT, as a result of the drugs impairing the patient’s capacity for the relevant types of understanding. Obviously the comparative benefits of each treatment would need to be considered in any given case, but a good understanding of this type of interaction is necessary to make informed decisions in the best interests of patients.
Second, potentially problematic issues arise concerning the validity of the cognitive model assumed in any given psychotherapeutic treatment. Suppose that a CBT practitioner adopts a model M of, say, anxiety disorder, which happens to provide an inaccurate representation of the cognitive factors involved in this mental disorder. Through the socialisation process in CBT, patients are required to acquire some understanding of M in order to facilitate their treatment. Let’s further suppose that, in this case, the CBT provides extremely good outcomes for the patient. There is clearly something positive about this situation: by adopting the required position of (putative) understanding, and through mechanisms which have not been specified, the patient recovers well from her anxiety disorder. And yet there is also a lingering sense that something is awry. The patient has been required – as a prerequisite of the treatment – to adopt a particular cognitive model M of her mental illness. But as stipulated, M is inaccurate. What’s the issue here?
One potential worry is that unlike treatments for somatic illness, which of course might also assume inaccurate models, the cognitive model M is likely to provide the basis for ongoing reflection and cognitive self-management on the part of the patient. Unlike the models assumed in somatic treatment, M is likely to be something that the patient ‘takes with them’, if you like, as a tool in their ongoing processes of self-understanding and emotional regulation. Perhaps we shouldn’t worry too much, if adopting this model has good consequences for the subject in the long run. Equally, however, there does seem to be a legitimate concern that this (hypothetical) patient has been furnished with an inaccurate understanding – a working model – of their own mind. Does this seem worse, in some sense, than furnishing them with an inaccurate understanding of the workings of their lymphatic system or knee ligaments? If so, then how so? I should stress that I do not raise this issue because I have any particular doubts about the accuracy of the cognitive models assumed in CBT: for all I know, these models are uniformly sublime in terms of their accuracy. The issue raised is a philosophical one: what ethical issues would arise in the hypothetical scenario sketched above? And how should we address these issues? These seem to me important questions to get right in clarifying the role of understanding in psychiatric treatment.
Orne, M., and Wender P. 1968. “Anticipatory socialization for psychotherapy: method and rationale”, American Journal of Psychiatry, 124, 1202-1212
Wells, A. 1997. Cognitive therapy for anxiety disorders, Chichester: John Wiley and Sons