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Decisions, decisions

April 2021 | by Alan Thomas

Life is full of decisions. Every day we all make many of them. Most are trivial and made without consultation with others: Alpen or cornflakes? Trousers or skirt? Cycle or car to work? But other decisions are more important, and for such decisions we should seek advice. This is the way of wisdom, according to Proverbs 12:15. But from whom should we seek such wisdom?

Like so many technological advances, the internet has brought great blessings. It is hard to explain to younger people how you once booked holidays from magazines and travel agents or had to use very large books to check out facts (they were called encyclopaedias!).

Almost any piece of information you want is out there and available with a few taps on your phone or clicks of your mouse. But information is not wisdom. It is not just that the ‘facts’ may be false and misleading and often harmful. Nor is it the information-overload which makes it hard to grasp what is important, though this too is a problem.

Wise decisions involve the optimum use of available knowledge and thus a judicious use of websites. The biggest problem is the fact that the internet doesn’t know you personally. Your family and friends do. You might seek information and find helpful facts and expertise, but the people to guide us are those close to us. They are the ones to assist you in decision-making.

Each of us lives in a web of relationships – close relationships with family and less close ones with others. This is reflected in the modern concept of personal space which has four zones: intimate zone, for closest family (within touching distance); personal zone for close family and good friends (2-4 feet); social zone, for wider friends and colleagues at work (4-12 feet); public zone (beyond 12 feet).

When we ponder a big decision we should seek advice, especially from those in the intimate and personal zones. If we are thinking of changing jobs, we consult our closest family and trusted friends, especially those with a relevant breadth of experience and contacts.

If someone is struggling to balance the competing pressures of work and home life, we expect them to seek support and advice from those in the intimate zone at home, but also from friends at work in their social zone. We’ve reflected previously in this column that as human beings, maturation of God’s image includes such proper use of such relationships. To try to ignore these is not just foolish but damaging to our personality, and thus to God’s image in us.

Some of our biggest decisions involve our heathcare: to have or not to have this operation? To take this preventive treatment or not? To move to a ‘nursing home’ or remain in my house? For such key decisions we should be wise and seek (and take) advice.

But what happens when mental illness means we cannot make such decisions anymore? Such loss of mental capacity can occur in different mental illnesses, such as schizophrenia and depression. It is most widely recognised as a problem in dementia. All people with dementia will lose mental capacity for decisions.

But not for all decisions, at least not until dementia is very advanced. People with mild dementia can make easy decisions. The difficulty in practice is that most important decisions, including many healthcare decisions, are not easy. To weigh up the pros and cons of moving home requires remembering a lot of information and being able to interpret it correctly. People with dementia lose such abilities.

This is where our intimate and close personal relationships become critically important. We were not made to be alone and we are never wise to make decisions alone. The person with dementia has a particular need of help from those close to her.

The good news is that the Mental Capacity Act (for England and Wales, but the same applies in other jurisdictions) requires doctors and other healthcare decision-makers to seek advice from those close to people with dementia.

When an expert (such as a Professor of Old Age Psychiatry!) deems someone to lack the mental capacity to make a key decision then this expert must discuss the decision with family and friends.

We are required to ascertain what is in the ‘Best Interests’ of the patient. And it is explicit that Best Interests is not simply what the doctor prefers: ‘When working out what is in the best interests of the person who lacks capacity … they must not act or make a decision based on what they would want to do if they were the person who lacked capacity’ (Section 5.7 Code of Practice, Mental Capacity Act).

Best Interests includes finding out what the person would likely have decided based on previous decisions and learning from those in the intimate zone: ‘The person’s past and present wishes and feelings, beliefs and values should be taken into account … the views of other people who are close to the person who lacks capacity should be considered…’ (Section 5.13).

Should she have this benign tumour removed? She doesn’t understand the future problems which will follow from leaving it alone. Should she join the family holiday this year? She doesn’t remember that last year she got lost and distressed.

Her family not only know her but are themselves involved in the outcomes of such decisions. They too will live with the consequences of pain and disfigurement from the untreated tumour and they will have to look after her on holiday.

The Best Interests approach recognises the importance of relationships to our decision making. This fits well with biblical teaching, but it does not fit well with the atomised selfishness of our society. And so problems occur in such key healthcare decisions, not because of what is laid down in legislation such as the Mental Capacity Act, but because this clashes with the powerful doctrine of autonomy. This is especially the case with decisions about end of life care. And this takes us back to euthanasia, which we will consider again next time.