The Case of Scott Starson

Biomedical Ethics
Group 6
February 26th, 2013

The decision to treat any patient by force poses many questions. There are very few occasions where one might imagine treating a competent person in defiance of his or her express wishes. The moral principle of respect for autonomy coupled with statutes that protect patient rights forbid forced treatment. Yet there remain medical professionals who have disagreed with a patient’s choice and take the matter to court. When considering patient rights it’s important to define the difference between refusing a blood transfusion for religious reasons and refusing medications that affect one’s mental health. A case that highlights the difficulty of determining competence is that of Scott Starson. Starson, who was diagnosed with bipolar disorder, was committed to a psychiatric hospital after having uttered death threats. There, he refused any medication for his disorder as he claimed it would ruin his career as a theoretical physicist. This was a decision that professionals disagreed with. However, the Supreme Court of Canada deemed Mr. Starson competent and able to make his own medical decisions. The main topic of concern is whether doctors should be allowed to impose treatment on a competent patient. Firstly, I will argue the point that every individual should have the right to choose their own medical treatments. Conversely, that those who suffer with a mental health issue cannot always appreciate and make the correct decision when it comes to medical treatments offered to them.
A competent patient should have the right to make their own medical decisions. This statement begs the question – what is competence? Scott Starson was deemed competent, by the Supreme Court, although initially the Ontario Capacity and Review Board upheld the decision that Starson was incompetent. Who is right? To be incapable of choosing one’s own treatment, one must not be able to understand the information and to weigh the risks and benefits in their life. Thus, capacity is not necessarily about best interests, but about the cognitive ability to process information and make an informed decision. In the Starson case, he claimed that taking medication would affect his career; something he holds in the utmost importance. Respect for autonomy and liberty demand that physicians respect a patient’s decision to refuse treatment. “One of the most fundamental principles of Canadian health care theory and law is that, all other things being equal, competent patients have the right to accept or reject any diagnosis, treatment or intervention”. This being said, he had every right to refuse treatment based on the fact that he is a competent patient and able to decide for himself. Why should a professional be able to force upon medication to a patient unwillingly? When a professional doubts a competent patients choice, he or she has a certain professional etiquette to follow. “If all else fails and the physician cannot in good conscience accept the patient’s decision, there is always the option of referring the patient to another physician and withdrawing from the case”. The situation would be radically different if Mr. Starson were an incompetent patient, for instance if he were a child or mentally disabled. In these cases he would be unable to understand what is being said to him and would need a surrogate to make that decision. However he is suffering from bipolar disorder, which is “a condition in which people go back and forth between periods of a very good or irritable mood and depression”. If Mr. Starson thinks that medication for his disorder can potentially ruin his career, than that is his prerogative, his choice to continue his life with bipolar disorder. A professional can’t give any guarantees that medication will cure his mental disorder, so why should he accept or be forced to do that? Dr. O asks some very important questions in his Lesson 8 discussion concerning patients’ rights, “To whom, if to anyone, do we belong? Are we anyone's property? To whom or what does our body belong? Whose body is it anyway? Whose life is it anyway?”Reflecting on these questions, the answer is that every individual is their own person, deemed competent or not. Furthermore, “no one can really know what it’s like to be you or me”, as stated by Dr. O., explains precisely that nobody can fully understand someone else’s decision without actually being them. This is what is happening in Mr. Starsons case, I believe that the physicians are not taking in account that he is looking out for his best interest concerning the overall picture of happiness in his life.
It is argued that competent patients should always have the right to refuse medical help, however patients don’t always appreciate the help that is given to them due to issues such as mental disease that can cloud judgment. In the case of Mr. Starson it was the physicians and professionals who claimed that he couldn’t sincerely appreciate the medical treatments. It seems that Mr. Starsons bipolar disorder is hindering him from reaching out for help. In my experience with mental health diseases, I have seen first-hand that accepting help is very difficult for someone who has not yet accepted the severity of the problem. A lot of focus is turned to the fact that competent patients should have the right to refuse medical treatments. Mental competence can vary in situations, as Dr. O explains; “Competence is task specific. That is, an individual may be competent in one situation or at one task but incompetent in other”. In the case of Mr. Starson, he could seem mentally competent in his work life, but it’s possible that when it comes to medical decisions he does not fully understand the complexity of his disease. In fact, Starson was not his given name, but one he had chosen for himself as part of his delusion that he was a son of the stars. Despite his intelligence, his bipolar disorder caused him to have delusions and could sway his judgement. Dr O. states; “Furthermore, a person may be considered legally competent by the courts (e.g., intellectually and financially competent, yet not considered competent by the medical profession or emotionally and in terms of self-care”. Dr. O’s statement perfectly relates to Mr. Starsons case; the Supreme Court of Canada deemed Mr. Starson competent whereas the physicians did not, proving that competence is extremely difficult to determine. Furthermore Mr. Starson was not deemed criminally responsible for uttering death threats which proves he was incompetent at the time. A competent patient would not be uttering death threats or be court ordered to psychiatric care. Dr. O explains; “So, if the patient is judged to be mentally competent and he insists on threatening someone's life, he could (theoretically) be imprisoned. On the other hand, if he is judged to be mentally incompetent, presumably he can be detained for treatment and perhaps even given an indeterminate "sentence", so to speak.” If Mr. Starson is a competent patient and can make his own medical decisions, as Dr. O explained, shouldn’t he have been imprisoned? He wasn’t because he is a patient who is suffering from a mental disease, and it should be put in account that his disease can cloud his judgment and that a surrogate maybe be better at determining the correct medical help needed.
The main issue of Mr. Starsons case was if he, as a competent patient suffering from bipolar, should be able to decide on his own if treatment is necessary or not. I am a firm believer that if you are competent enough to understand the situation and what you are suffering from, that only you can decide what is best. I agreed to the decision that as a competent patient, Mr. Starson was allowed to decline treatment. However, one must also consider the right to treatment. This is a landmark case for Canada that can be used to impact future generations. When competence is not easy to determine, the ability to improve the quality of life must take precedence. I find that mental health issues is a very sensitive subject when it comes to treatment decisions - the person suffering from it has to be ready and willing to change.

Bibliography www.econcordia.com, Biomedical Ethics Website, Lesson 4 & 8, video and slides
Kludge, E. (2005). Readings in Biomedical Ethics. A Canadian Focus. Toronto: Pearson Prentice Hall.
U.S. National Library of Medicine. PubMed Help. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth.
McLachlin, B. (2005) Judges of the Court. Retrieved from http://www.scc-csc.gc.ca

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[ 1 ]. http://www.scc-csc.gc.ca/court-cour/ju/spe-dis/bm05-02-17-eng.asp. Supreme Court of Canada Speeches
[ 2 ]. Eike-Henner, W. Kluge. Readings in Biomedical Ethics: A Canadian Focus. Chapter 6, page 146.
[ 3 ]. www.econcordia.com, biomedical ethics website. Lesson 4, slide 14
[ 4 ]. http://www.ncbi.nlm.nih.gov/pubmedhealth. U.S. National Library of Medicine
[ 5 ]. www.econcordia.com, biomedical ethics website. Lesson 8, Dr. O’s Lesson 8 Notes.
[ 6 ]. www.econcordia.com, biomedical ethics website. Lesson 8, Dr. O’s Lesson 8 Notes.
[ 7 ]. www.econcordia.com, biomedical ethics website. Lesson 4, Dr. O’s Lesson 4 Notes.
[ 8 ]. http://www.scc-csc.gc.ca/court-cour/ju/spe-dis/bm05-02-17-eng.asp. Supreme Court of Canada Speeches
[ 9 ]. www.econcordia.com, biomedical ethics website. Lesson 4, Dr. O’s Lesson 4 Notes.
[ 10 ]. www.econcordia.com, biomedical ethics website. Lesson 4, Dr. O’s Lesson 4 Notes.