1. Jakub Zawiła-Niedźwiecki University of Warsaw
Kępiński, philosophy of mind, an inquiry into some limits of patient’s autonomy
Jakub Zawiła-Niedźwiecki
University of Warsaw

2. Agenda Naturalistic reading of Kępiński
Kępiński and his view of medical science and practise
Problem of competence as both scientific and ethical problem
Kępiński’s criticisms of psychiatric methods as related to current criticisms of methods in competence assessment
Using Kępiński’s notion of informational metabolism and his criticisms of medical practise plus modern cognitive models towards more scientific view of competence

3. Reading of Kępiński in naturalistic and biomedical framework
Usually interpreted through humanistic, personalist philosophy
Partially due to association with John Paul II
He can be read within framework of modern biomedical science and naturalistic philosophy
Assuming: principalist ethics, evidence-based medicine, cognitivist-computational model of the mind, natural science/philosophy divide - much of Kępiński’s work can be still used

4. Reading of Kępiński in naturalistic and biomedical framework
Homunculus Fallacy – Kępiński’s belief in “control centre” is not justified in modern models, but is not central to his ideas and can be safely rejected
30% utilisation of the brain fallacy
Current reading of Kępiński has to correct for his work mostly being pre-scientific from before the EBM, modern philosophy of the mind and cognitive psychology era
Kępiński was distrustful of statistical methods in medical science, but his most known contribution (KZ-syndrome) was arrived at using statistics
Kępiński A. KZ-syndrom. Próba syntezy (1970). W: Kępiński A. Rytm życia. Kraków: Wydawnictwo Literackie; 1972, s. 92–106.

5. Kępiński’s idea of medical science and practise
Basic science as only one of the tools of clinical medicine
Tests, tools, statistical correlations are tools of the trade not the whole of medicine
There is no biological/psychological division
The mental is as biological as physiology
Organisms and organs are interrelated systems that need to be treated as a whole, regardless of nature of the problem
There is crucial epistemological content to doctor-patient relationship

6. Kępiński’s idea of medical science and practise
Writing before EBM movement he rejects ‘magical thinking’ of some doctors and distrusts methods without scientific basis
In psychiatry this means scepticism about psychoanalysis and other methods without strong evidence

7. Competence as basic notion for the bioethical considerations
Whole construct of informed consent is based on an idea of rational, comprehending agent making the decisions
Competence is related to philosophical notions of personhood, moral agency
The dominant bioethical framework of principialism assumes some form of competence
We know what it is when we show clear examples, but can we explore and operationalise the borderline further then normally philosophically possible?

8. Language Competence Competency Capacity Capability
DMC (Decision making capacity)
Ability to provide consent
Possesion of reason
Confused ethico-legal language, bioethical vs. medical vs. psychiatric language
Some authors speak about actual competence or competence in non-legal sense, and this is part of thinking in some jurisdictions e.g. Poland.
Change over time, is it even possible to separate the two languages?
Schneider and Bramsedt 2006 paper
Large variation of the populations and possible research being carried out on them e.g. elderly – dementia, schizofrenics, affective disorders, addictions, eating disorders, bodily identity-disorder and so on and so on.

9. Existing tools MacArthur Competence Assessment Tool
But gold standard is still expert opinion!
Heavy reliance of experts on Mini Mental State Examination [MMSE]
Empirical research on the topic since 1980’s – starting with literacy skills
Appelbaum, P. S., & Grisso, T. (1995). The MacArthur Treatment Competence Study. Law and Human Behaviour, 19(2).
Expert opinion can strongly vary, there are empirical studies showing as high as 40% dissenting opinions in blind tests.
He expressed concern over her ability “not to feel coerced or pressured or manipulated into sexual activity” and over “the trust placed in AB not to abuse his position” -> strongly biased by beneficence or best interests thinking

10. Psychiatric classifications and competence
Having a DSM/ICD ‘label’ affects self-image, social position, and perceived capacity to make decisions
Mental health consumers are considered a vulnerable population prone to influence and pressure
Large scale surveys as late as 1990’s showed that vast majority (72%) of MD’s considered all patients under particular ‘label’ to be incompetent
Sensitivity and specificity of even standardised testing in this part of medicine is very low
 1999 study showing that only 20% of patients with dementia would be considered competent, but only 78% of healthy volounteers would be considered competent

11. Psychiatric classifications and competence
Data from MacCAT project and related research shows that only small population of gravely ill patients provides all the difference between mental health consumer population and general public.
Patients denying their diagnosis / illness – how it affects competence and the IC procedure?
It is a common symptom among mental health issues that a patient is denying the symptoms or the way they are labelled.
Patients denying their diagnosis can we even get informed consent from them and would it be ethical to do so? Can it be worked around with the study design.

12. Existing tools - criteria
Experts try to identify following particular abilities:
Capability of receiving and reproducing pertinent information
Possessing of a set of values and goals
Ability to reason about choices
Ability to express a consistent choice
Many authors phrase them using large quantifiers and expressions such as: all relevant, all foreseeable.
This is a compilation from various sources
Can we seriously say any of us fulfils the criteria?
Is it possible to set thresholds within the criteria – can one have a set of values and goals partially?
What about healthy individuals that don’t fulfil either of the criteria?
Major requirements on education and skills possessed – all the reading ability research in 1980’s.

13. What influences competence?IQ
Language and literacy skills
Education
Emotional status
Physical health
Biochemistry (pharmaceuticals, foods, intoxicants etc.)
Cognitive biases
Social position
Setting and means of assessment
Amount of time spent on the decision …
non-native language use!
Affects = doesn’t necessarily mean it only diminishes it!

14. Influences Source: Stoppe (ed.) 2008
Pharmacological influences can be both positive and negative. It could be postulated that even in routine matters we would need to get the subject into some sort of „standard biochemical equilibrium”
Source: Stoppe (ed.) 2008

15. What Kępiński has to say on competence?
Nothing directly
He values highly:
Doctor-patient relationship
Honesty and truth-telling
Patient involvement

16. What Kępiński has to say on competence?
Indirectly:
Critique of confusing diagnostic tools with diagnostic process
Subjective, first person perspective on diagnostic process in psychiatry
Criticises confusing nosology with ontological reality – in this it would mean case DSM classification with incompetence
Assessment of a patient requires looking at whole patient: body and mind, also in competence assessment

17. Informational metabolism
Idea of informational metabolism enables conceptualisation of the mind as a set of interrelated functions that can possibly be measured analogously to biochemical metabolism
Source: Kokoszka (1999)

18. New (?) approach
Establishing required levels of informational metabolic processes for particular decision prior to assessment
Assessment of the processes
Holistic judgement of patient’s competence based on above assessments as supportive data for the assessing expert

19. What does it change?
Separating cognitive evaluations from context of particular decision
Removing as far as possible, within existing tools, the influence of education, social context etc.
Keeping the idea that one has to have capacity to make a choice at a particular time and in particular situation

20. Thank you