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A Narrative Coherence Standard for the Evaluation of Decisional Capacity: Turning Back the Clock

In the target article of the present issue, Goldberg (2020) challenges the traditional four criteria for the evaluation of clinical decision-making capacity (understanding, appreciation, ability to reason, communication of decision) by arguing “that clinicians and bioethicists who evaluate decisional capacity face questions far deeper than the mere presence or absence of a patient’s informed consent” (7), and that “an additional standard beyond the existing cognitive criteria – to be called the Narrative Coherence Standard” is needed (9). Goldberg’s argument reflects what is sometimes considered a “narrative turn” in parts of medicine and particularly in medical ethics over the last two decades (see Charon and Montello, 2002). We agree with what we take to be the central premise of that movement, i.e., that a focus on patients’ narratives can be important in helping clinicians to achieve better understanding of their patients and assisting patients to view their current situations in the broader context of their lives. As Bruner (2002) has suggested, narratives open up a space for self-reflection and self-construction by requiring persons to make sense of their experiences. “Becoming involved in storytelling seems to bring together emotion and thinking, or the essentials of both, in intuitive and analytical reasoning, fostering self-reflection and ultimately self-understanding” (Hermann et al. 2017, 321). However, a number of authors have also pointed to the limits of narrativity for biomedicine and the medical humanities, particularly with regard to the “frequently unexamined assumption that all human beings are ‘naturally narrative’” (Woods, 2011, 73). In his article “Against Narrativity,” Galen Strawson takes issue both with the thesis that, in the words of Oliver Sacks, “each of us constructs and lives a ‘narrative’... this narrative is us, our identities,” and the normative, ethical claim that we ought to live our lives as a story, exemplified by Marya Schechtman’s claim that “a person ‘creates his identity [only] by forming an autobiographical narrative – a story of his life,’ and must be in possession of a full and ‘explicit narrative [of his life] to develop fully as a person’.” (Strawson, 2004, 428). The former contention is empirically incorrect, whereas the latter unjustifiably demands that persons impose a narrative on their lives or be seen as less than fully human. Notwithstanding these problems, Goldberg (2020), reflecting the current enthusiasm for narrative approaches, identifies what he takes to be deficiencies in the current approach to assessing decisional capacity and identifies a requirement for narrativity as the corrective. We note, however, that neither of the patients he briefly presents supports a clear case for the inadequacy of the dominant approach to capacity assessment and hence the addition of a narrative criterion. An elderly, depressed woman who believes she is “not worth helping” and apparently discounts the potential impact of the proposed treatment fails to appreciate both the nature of her situation—as a human being, she is indeed worth helping—and the effect of the choices before her, and should be found incompetent under the current criteria. A young, homeless man who arrives in an emergency room in renal failure, “lethargic, with imbalanced electrolytes” (he is later also described as depressed) seems unlikely to meet criteria for decisional capacity, although without further details it is difficult to know with certainty. Putting aside these specific cases, there are indeed clinical situations in which the current criteria for decisional capacity seem at first sight to be insufficient. As an example, it is known that emotions have a crucial function in decision making. For instance,