Gordon Self

May 30, 2011

There is a saying in ethics that people might have capacity for making decisions, but have poor judgment. Anyone having raised teenagers will know the truth of this statement, perhaps recalling some of their children's past decisions when good judgment was lacking.

A humble lesson from my own youth bears this out. In 1979 I quit school with only three months remaining in Grade 12, easily passable, instead compelled to enroll in another school of life. Despite loving parents and teachers urging me to finish high school, I put on my backpack and headed for the East Coast.

The choices patients and residents make regarding treatment options may also leave health care professionals at a loss for understanding. A person may leave hospital against medical advice. Or forgo treatment they deem burdensome, such as chemotherapy or surgery, even if it could extend their life.

We need to remember that the person receiving care, not the health care team, is the primary decision-maker. It is our duty to ensure that the person understands their options to help them make a free and informed choice.

As with my own decision years ago, the people in our care may in fact be making a conscious decision to express what is stirring deep within their soul. While I did not have words for it at the time, my decision to quit school was deeply rooted in a spiritual yearning.


There are equally deeply held convictions that factor into our patients' and residents' decision-making that we can often only guess at. Wanting to forgo aggressive treatment to preserve what remaining energy and days a person has left to spend time with family, to reminisce and to pray may make total sense to them. Far from an exercise of poor judgment, such decisions should be respected.

But what if a person's decision-making capacity is lacking, whereby they truly cannot make a free and informed choice, or appreciate the consequences of their decisions?

Suppose, for example, someone intensely grieving the recent loss of a spouse no longer feels life is worth living, and stops eating. They may be clinically depressed and unable to see any hope in their present circumstances.

In this case, is refusing food and nutrition a reasonable, well thought through decision that must be respected? Or does honouring this wish constitute an act of complicity in hastening a person's death?

Application of ethics principles will certainly provide a framework to think through these issues, but not insight into a person's needs, hopes and fears that drive their choices. Good ethics cannot be done in abstraction, without direct conversation with the person receiving care.


Listening at a deeper level in dialogue with those whose mental illness clouds their judgment is a privileged conversation we must have. Last month, the social worker team from the Grey Nuns Community Hospital Mental Health program was honoured with a Mission Award for our organization's value of social justice.

This team demonstrates compassion and willingness to have such conversations, advocating on behalf of their patients to ensure access to appropriate, quality care. Because of their commendable skill in listening, many of their interventions serve to diffuse or prevent ethical conflict.

Earlier this month, Archbishop Richard Smith dedicated the chapel at Villa Caritas, the new 150-bed facility in Edmonton serving seniors with complex medical and mental health needs in honour of St. Dymphna, patron saint of those living with mental illness.


The story of this seventh-century martyr is illustrative of good ethics based on the virtue of Christian hospitality. The people of Gheel, after discovering her body in the 13th century, began to attribute cures and miracles to her. They built an institution to care for those living with mental illness, working to place patients with families to facilitate their recovery and integration back into the community.

This practical expression of hospitality underscores the role of community in healing, and the need to listen deeply to others without condemnation. We can create so much ethical conflict when we judge and fail to appreciate the reason behind the decisions people make, even if appearing lacking in judgment.

As the people of Gheel offered refuge to St. Dymphna and in turn, a place in their community for those living with mental illness, we must be prepared to create a "refuge of compassion," or villa caritas, as it were, for all people. Good ethics demands this practical expression of charity.

(Gordon Self is vice president, mission, ethics and spirituality for Covenant Health and can be reached at