Duquesne University Duquesne Scholarship Collection Electronic Theses and Dissertations Spring 2006 Depression, Volition, and Death: The ffecE t of Depressive Disorders on the Autonomous Choice to Forgo Medical Treatment Matthew utkB us Follow this and additional works at: https://dsc.duq.edu/etd Recommended Citation Butkus, M. (2006). Depression, Volition, and Death: The Effect of Depressive Disorders on the Autonomous Choice to Forgo Medical Treatment (Doctoral dissertation, Duquesne University). Retrieved from https://dsc.duq.edu/etd/370 This Immediate Access is brought to you for free and open access by Duquesne Scholarship Collection. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of Duquesne Scholarship Collection. For more information, please contact [email protected]. DEPRESSION, VOLITION, AND DEATH: THE EFFECTS OF DEPRESSIVE DISORDERS ON THE AUTONOMOUS CHOICE TO FORGO MEDICAL TREATMENT A Dissertation Presented to the Faculty of the McAnulty College and Graduate School of Liberal Arts Duquesne University in partial fulfillment of the requirements for the degree of Doctor of Philosophy by Matthew Allen Butkus, MA DEPRESSION, VOLITION, AND DEATH: THE EFFECTS OF DEPRESSIVE DISORDERS ON THE AUTONOMOUS CHOICE TO FORGO MEDICAL TREATMENT TABLE OF CONTENTS ACKNOWLEDGEMENTS i GENERAL INTRODUCTION iii CHAPTER ONE: We’re Not as Free as We Think We Are – Reductionist 1 and Determinist Ontologies in Human Cognition Reductionism 2 Definitions 5 Concepts/Types of Reduction 9 Challenges to Reductionism 24 The Shift Towards Determinism 44 Determinism 45 Key Definitions in the Determinism Debate 57 Concepts in the Determinism Debate 62 Indeterminism 63 Determinism 79 Libertarianism, Compatibilism, and Challenges to Both 86 Alternative Theories in the Determinism Debate 90 The Resulting Philosophical Model and the Consequences for Cognition 96 CHAPTER TWO: “Rationality” Isn’t So Rational – Automaticity, 98 Backstage Cognition, and Cognitive Heuristics in “Rational” Thought Backstage Cognition, Mental Spaces, and Automaticity 100 Automaticity 103 Conceptual Blending and Mental Spaces 112 Cognitive Heuristics 118 Definitions 126 Specific Heuristics 128 Challenges 142 Complementary/Supplementary Theories 151 Affect and Rationality 161 CHAPTER THREE: Hidden Comorbidities – Diagnostic Criteria of Depressive 173 Disorders and Their Prevalence in Five Common Medical Conditions Depressive Disorders 180 Epidemiology of Affective Disorders 181 Etiologies 199 Treatment 217 Multiple Sclerosis 226 Epidemiology 227 Course of the Illness 227 Rates of Depression 228 Treatment Options 230 Parkinson’s Disease 231 Epidemiology 232 Course of the Illness 233 Rates of Depression 234 Treatment 236 Dementia 239 Epidemiology 243 Course of the Illness 254 Treatment 257 Comorbid Depression 258 Stroke 260 Epidemiology 265 Course of the Illness 266 Depression and Cognitive Dysfunction 268 Treatment 278 Cancer 280 Epidemiology 285 Comorbid Depression 286 Treatment 294 Conclusion 301 CHAPTER FOUR: Of Icebergs and Autonomy – Cognitive Distortions and the 303 Fallacy of Homuncular Autonomy Depressive Cognition 303 Cognitive Distortion and Beck’s Model 304 The Theory of Depressive Realism 314 Which is Right? 335 Autonomy 336 Critiques of Autonomy 339 Homuncular Autonomy Models (Veatch; Faden and Beauchamp; Beauchamp 341 and Childress) Cognitive Autonomy Models (Redelmeier, et al.; Grisso and Appelbaum; Katz; 367 Anderson and Lux) Conclusion 392 Foundational Criteria of Autonomy 393 Medical Criteria of Autonomy 396 Psychiatric Criteria of Autonomy 398 Psychosocial Criteria of Autonomy 398 CHAPTER FIVE: Faces of Choice and Volition – A Case Metric Approach to 401 Assessing Decision-Making Capacity Diagnostic Psychometrics 401 Case Metric 412 Alice 414 Bill 421 Catherine 429 David 437 Eugenia 444 Frank 452 Georgette 458 Harry 466 Irene 473 CONCLUSION 481 APPENDIX: Psychometric Scales 484 BIBLIOGRAPHY 485 ACKNOWLEDGEMENTS First, I would like to thank Adam J. Butkus, Lynne A. Weber, Janet Popeleski, and Douglas J. Sterling, my parents, for everything they have done to help me to get to this point in my life – I cannot list the ways in which I have depended upon them without adding an additional volume to this work. I would like to thank the faculty and clinical staff of Duquesne University, the University of Pittsburgh, St. Francis Health System, and Western Psychiatric Institute and Clinic for the inspiration, knowledge, and resources needed to bring this to fruition. I would like to thank the psychiatric and nursing staff at Mercy Hospital North Shore Campus for two years of clinical experience, allowing me to appreciate the continuity of care issues in clinical psychiatry. I would like to thank David Kelly, Aaron Mackler, and Bryan Chambliss for their patience and direction in bringing this dissertation to fruition. I would like to thank William Klein for allowing me to bounce ideas off of him prior to writing, as well as for exposing me to elements of cognitive psychology I had not read or researched that were directly germane to the discussion contained within. I would like to thank Barbara Kucinski for exposing me to and clarifying elements in biopsychology and psychoneuroimmunology of which I had only surface familiarity. I would like to thank Matthew Bundick for guidance in concretizing my hitherto ad hoc education in psychology. I would like to thank Richard and Jennifer Schiavoni and Matthew Gourley for too many late evenings and dinners, which prevented my mental breakdown. Finally, I would like to thank Raymond Klavon, who is, without a doubt, the most patient and kindest person a graduate student could ever hope to have as a landlord. i In doubt his Mind or Body to prefer, Born but to die, and reas’ning but to err; Alike in ignorance, his reason such, Whether he thinks to little, or too much: Chaos of Thought and Passion, all confus’d; Still by himself abus’d, or disabus’d; Created half to rise, and half to fall; Great lord of all things, yet a prey to all; Sole judge of Truth, in endless error hurl’d: The glory, jest, and riddle of the world! -Alexander Pope An Essay on Man It is a wonderful feeling to recognize the unity of a complex of phenomena that to direct observation appear to be quite separate things. -Albert Einstein Letter to Marcel Grossman The mind is inherently embodied. Thought is mostly unconscious. Abstract concepts are largely metaphorical. These are three major findings of cognitive science. More than two millennia of a priori philosophical speculation about these aspects of reason are over. Because of these discoveries, philosophy can never be the same again… Philosophical sophistication is necessary if we are to keep science honest. Science cannot maintain a self-critical stance without a serious familiarity with philosophy and alternative philosophies. Scientists need to be aware of how hidden a priori philosophical assumptions can determine their scientific results. This is an important lesson to be drawn from the history of first-generation cognitive science, where we saw how much analytic philosophy intruded into the initial conception of what cognitive science was to be. On the other hand, philosophy, if it is to be responsible, cannot simply spin out theories of mind, language, and other aspects of human life without seriously encountering and understanding the massive body of relevant ongoing scientific research. Otherwise, philosophy is just storytelling, a fabrication of narratives ungrounded in the realities of human embodiment and cognition. If we are to know ourselves, philosophy needs to maintain an ongoing dialogue with the sciences of mind. - George Lakoff and Mark Johnson Philosophy in the Flesh GENERAL INTRODUCTION The Nature and Purpose of this Dissertation Since its inception, medical ethics has concerned itself with balancing several key concepts – the patient’s best interest, both psychosocial and medical; the patient’s legal rights and autonomy; the authenticity of the patient’s decision, i.e., narrative concerns that the patient’s choice be reflective of her values, etc. As is the case with any pluralistic system, these concepts are complementary at times and conflicting at times. Significant efforts to determine just how to proceed in any given case result, both in academic circles, in which theories clash and value structures rise and fall, as well as in clinical cases, in which academic language gives way to clinical context and lives hang in the balance. These values have been stressed in different manners at different times – before the advent of medical ethics as a field in itself, the physician-patient relationship was defined in paternalistic terms. The physician, being the source of medical knowledge and prognostic wisdom, had an air of authority which one dared not question. Decisions were top-down, in the manner of a general commanding his soldiers, and were rarely questioned. While the patient’s concerns were counted, what was in their medical best interest carried the day. This perspective evolved over time, and a different model of physician-patient interaction emerged. Patient advocacy found legal and philosophical recourse in autonomy models which stressed the ability of a patient to choose the treatment she wanted, and patients’ rights became more than an ephemeral concept. Decisions proceeded on egalitarian terms, in which the patient and the treatment team reached an accord – the patient’s medical best interest was now simply one factor