Download PDF
Semin Speech Lang 2003; 24(4): 275-284
DOI: 10.1055/s-2004-815581
Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Clinical Ethics in the Context of Language and Cognitive Impairment: Rights and Protections

Lynne C. Brady Wagner
  • Spaulding Rehabilitation Hospital, Boston, Massachusetts
Further Information

Publication History

Publication Date:
14 January 2004 (online)

    Permissions and Reprints

ABSTRACT

Ethical dilemmas are particularly complex when a patient has a communication disorder. Questionable decision-making capacity can affect an individual's ability to participate in the informed consent process. When other cognitive impairments as well as language deficits are present, the risk of losing one's right to autonomy is greatly increased. Alternatively, the protection afforded those who are clearly incompetent may be limited if a person appears to have decision-making capacity but is unable to adequately process information. These challenges are illustrated in this article by use of clinical case descriptions. They also serve to demonstrate ways in which speech-language pathologists can provide the expertise needed to assist patients and medical teams in addressing these particular issues and ensuring patient autonomy.

KEYWORDS

Decision-making capacity - competence - neurological communication disorders

REFERENCES

  • 1 Beauchamp T L, Childress J F. Principles of Biomedical Ethics, 4th ed. New York: Oxford University Press 1994
  • 2 Appelbaum P S, Grisso T. Assessing patients' capacities to consent to treatment.  N Engl J Med . 1988;  319 1635-1637
    CrossrefPubMedGoogle Scholar
  • 3 Brady L C, Kirschner K L. Ethical issues for persons with aphasia and their families.  Topics Stroke Rehabil . 1995;  2 84-87
    PubMedGoogle Scholar
  • 4 Tippett D C, Sugarman J. Discussing advance directives under the patient self-determination act: a unique opportunity of speech-language pathologists to help persons with aphasia.  Am J Speech Lang Pathol . 1996;  5 31-34
    PubMedGoogle Scholar
  • 5 McCullough L B, Molinari V, Workman R H. Implications of impaired executive control functions for patient autonomy and surrogate decision making.  J Clin Ethics . 2001;  12 397-405
    PubMedGoogle Scholar
  • 6 Braunack-Mayer A, Hersh D. An ethical voice in the silence of aphasia: judging understanding and consent in people with aphasia.  J Clin Ethics . 2001;  12 388-396
    PubMedGoogle Scholar
  • 7 Freedman M, Stuss D, Gordon M. Assessment of competency: the role of neurobehavioral deficits.  Ann Intern Med . 1991;  115 203-208
    PubMedGoogle Scholar
  • 8 Reid-Proctor G M, Galin K, Cummings M A. Evaluation of legal competency in patients with frontal lobe injury.  Brain Injury . 2001;  15 377-386
    PubMedGoogle Scholar
  • 9 Marson D, Harrell L. Executive dysfunction and loss of capacity to consent to medical treatment in patients with Alzheimer's disease.  Semin Clin Neuropsychiatry . 1999;  4 41-49
    PubMedGoogle Scholar
  • 10 Jonsen A R, Siegler M, Winslade W J. Clinical Ethics, 3rd ed. New York: McGraw-Hill 1998
  • 11 Towner H. In re Martin.  Issues Law Med . 1996;  12 267-271
    PubMedGoogle Scholar
  • 12 Annas G J. Informed consent, cancer, and truth in prognosis.  N Engl J Med . 1994;  330 223-225
    CrossrefPubMedGoogle Scholar
  • 13 Lo B, Dornbrand L, Wolf L, Groman M. The Wendland case: withdrawing life support from incompetent patients who are not terminally ill.  N Engl J Med . 2002;  346 1489-1493
    CrossrefPubMedGoogle Scholar
  • 14 Boyle R J. Determining patient's capacity to share in decision making. In: Fletcher JC, Lombardo PA, Marshall MF, Miller FG, eds. Introduction to Ethics, 2nd ed Hagerstown, MD: University Publishing Group; 1997
    Google Scholar
  • 15 The SUPPORT Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).  JAMA . 1995;  274 1591-1598
    CrossrefPubMedGoogle Scholar
  • 16 Hare J, Pratt C, Nelson C. Agreement between patients and their self-selected surrogates on difficult medical decisions.  Arch Intern Med . 1992;  152 1049-1054
    CrossrefPubMedGoogle Scholar
  • 17 Lo B. Assessing decision-making capacity.  Law Med Health Care . 1990;  18 193-201
    PubMedGoogle Scholar
  • 18 White, B C. Competence to Consent.  Washington, DC: Georgetown University Press; 1994
    Google Scholar
  • 19 Brady Wagner C L. Withholding and withdrawing tube feeding for persons with dysphagia: exploring complications of advance directives and the obligations of a rehabilitation team.  Topics Stroke Rehabil . 2001;  8 56-59
    PubMedGoogle Scholar
  • 20 Kagan A. Revealing the competence of aphasic adults through conversation: a challenge to health professionals.  Topics Stroke Rehabil . 1995;  2 15-28
    PubMedGoogle Scholar
  • 21 Carney M T, Neugroschl J, Morrison R S, Marin D, Siu A L. The development and piloting of a capacity assessment tool.  J Clin Ethics . 2001;  12 17-23
    PubMedGoogle Scholar
  • 22 Sharp H, Mills K. In response to “The development and piloting of a capacity and assessment tool.”  J Clin Ethics . 2002;  13 165-167
    PubMedGoogle Scholar
  • 23 Sharp H M. A commentary on “Ethical issues for persons with aphasia and their families.” Topics Stroke Rehabil .  1995;  2 84-87
    PubMedGoogle Scholar
  • 24 Kirschner K L. Ethics in practice. Assessing decision-making capacity in a patient with nondominant hemisphere stroke.  Topics Stroke Rehabil . 1994;  1 104-105
    PubMedGoogle Scholar
  • 25 Benson F, Geschwind N. Aphasia and related disorders: a clinical approach. In: Mesulam M, ed. Principles of Behavioral Neurology Philadelphia: F.A. Davis; 1985
    Google Scholar
  • 26 Goodglass H. Understanding Aphasia.  New York: Academic Press; 1993
    Google Scholar
  • 27 Holzer J C, Gansler D A, Moczynski N P, Folstein M F. Cognitive functions in the informed consent evaluation process: a pilot study.  J Am Acad Psychiatry Law . 1997;  25 531-540
    PubMedGoogle Scholar
  • 28 Kim S Y, Karlawish J H, Caine E D. Current state of research on decision-making competence of cognitively impaired elderly persons.  Am J Geriatr Psychiatry . 2002;  10 151-165
    CrossrefPubMedGoogle Scholar
  • 29 Kim S Y, Cox C, Caine E D. Impaired decision-making ability in subjects with Alzheimer's disease and willingness to participate in research.  Am J Psychiatry . 2002;  159 797-802
    CrossrefPubMedGoogle Scholar
  • 30 Dymek M P, Atchison P, Harrell L, Marson D C. Competency to consent to medical treatment in cognitively impaired patients with Parkinson's disease.  Neurology . 2001;  56 17-24
    PubMedGoogle Scholar
  • 31 Krynski M D, Tymchuk A J, Ouslander J G. How informed can consent be?.  <~>New light on comprehension among elderly people making decisions about enteral tube feeding. Gerontologist . 1994;  34 36-43
    PubMedGoogle Scholar
  • 32 Dellasega C, Frank L, Smyer M. Medical decision-making capacity in elderly hospitalized patients.  J Ethics Law Aging . 1996;  2 65-74
    PubMedGoogle Scholar
  • 33 Wong J, Clare I, Holland A. The capacity of people with a “mental disability” to make a healthcare decision.  Psychol Med . 2000;  30 295-306
    CrossrefPubMedGoogle Scholar
  • 34 Kagan A, Kimelman M. Informed consent in aphasia research: myth or reality?.  Clin Aphasiol . 1995;  23 65-75
    PubMedGoogle Scholar
  • 35 Zwiebel N R, Cassel C K. Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies.  Gerontologist . 1989;  29 615-621
    PubMedGoogle Scholar
  • 36 Terry P B, Vettese M, Song J. End-of-life decision-making: when patients and surrogates disagree.  J Clin Ethics . 1999;  10 286-293
    PubMedGoogle Scholar
  • 37 Reimer M. How well do proxies represent the views of cognitively impaired patients?.  AXON . 2000;  21 78
    PubMedGoogle Scholar
  • 38 Sharp H M, Bryant K N. Ethical issues in dysphagia: when patients refuse assessment or treatment.  Semin Speech Lang . 2003;  24 285-300
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Stein J. The ethics of advance directives: a rehabilitation perspective.  Am J Phys Med Rehabil . 2003;  82 152-157
    CrossrefPubMedGoogle Scholar
  • 40 Caplan A, Callahan D, Haas J. Ethical & policy issues in rehabilitation medicine.  Hastings Cent Rep . 1987;  17 (suppl) 1-20
    PubMedGoogle Scholar
  • 41 Powell T, Lowenstein B. Refusing life-sustaining treatment after catastrophic injury: ethical implications.  J Law Med Ethics . 1996;  24 54-61
    PubMedGoogle Scholar
  • 42 Mairs N. Waist High in the World.  Boston: Beacon Press; 1996
    Google Scholar
  • 43 Sharp H M. Ethical decision making in interdisciplinary team care.  Cleft Palate Craniofacial J . 1995;  32 495-499
    PubMedGoogle Scholar
      >