The Narrative Coherence Standard and Child Patients’ Capacity to Consent

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The Narrative Coherence Standard and Child
Patients’ Capacity to Consent
Gah-Kai Leung
To cite this article: Gah-Kai Leung (2020) The Narrative Coherence Standard and Child Patients’
Capacity to Consent, AJOB Neuroscience, 11:1, 40-42, DOI: 10.1080/21507740.2019.1704933
To link to this article: https://doi.org/10.1080/21507740.2019.1704933
Published online: 03 Feb 2020.
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husband”and a history of “intermittent [sic]
depression”(7).
If Harriet fails to meet the criteria of appreciation
and reasoning, as we have argued, the four criteria
suffice to explain the reason that she lacks competence
to consent to ECT. In this respect, the narrative
coherence standard adds nothing at all.
FUNDING
This research is part of the international and interdisciplin-
ary project ENSURE (2016-2019) and is supported by a
grant from ERA-NET Neuron and the German Federal
Ministry of Education and Research (grant num-
ber 01GP1623B).
ORCID
Matth
e Scholten http://orcid.org/0000-0001-8000-8974
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in assessments of mental capacity: An argument for a
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AJOB NEUROSCIENCE
2020, VOL. 11, NO. 1, 40–42
https://doi.org/10.1080/21507740.2019.1704933
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The Narrative Coherence Standard and Child Patients’Capacity to Consent
Gah-Kai Leung
University of Warwick
Aryeh Goldberg (2020) compellingly argues for a
Narrative Coherence Standard (NCS) to bolster exist-
ing methods of assessing patients’mental capacity. But
his account fails to distinguish between the cognitive
abilities of children and adults; consequently, worries
may be raised about the scope of the NCS, in particular
when we consider child patients. In this article, I argue
the NCS cannot plausibly apply to children. Since child-
ren’s self-conception does not arrive fully formed—but
rather is a product of both incomplete cognitive
CONTACT Gah-Kai Leung Gah-Kai.Leung@warwick.ac.uk Politics and International Studies, University of Warwick, Gibbet Hill Road, Coventry CV4
8UW, UK.
ß2020 Taylor & Francis Group, LLC
40 OPEN PEER COMMENTARIES

development and socializing factors—Iclaimchildren
may not possess a sufficiently intimate knowledge of self,
and therefore a sufficiently coherent sense of self, as
Goldberg demands. Therefore, we should either revise
the NCS to accommodate children, adopt an incremental
view of consent, or revert to the relevant form of the
MacArthur competence criteria to establish children’s
capacity to consent.
First, I want to clarify the meaning of “children”.
Following common-sense usage, I define children as
individuals below the standard age of majority of
18 years. By this, I do not mean to suggest a sharp
distinction between the characteristics of childhood
and adulthood (cf. Hannan 2018, 117); for example,
in England and Wales the legal age of mental capacity
is 16 rather than 18 (Mental Capacity Act 2005, 2). I
merely suggest an upper limit beyond which my argu-
ment will not apply. Indeed, this essay may have
implications for adults with a mental age comparable
to young children. However, I do not discuss the
implications of the NCS for such cases at length.
Now, we should review Goldberg’s argument for the
NCS. This is meant to supplement the existing
MacArthur competence criteria, which are: understand-
ing of relevant information; communication of choice;
rational assessment of costs and benefits; appreciation
of consequences (Goldberg 2020). To motivate his
argument, Goldberg presents the cases of Harriet and
Jim to highlight deficiencies in the current medico-legal
framework of mental capacity. On the MacArthur crite-
ria strictly interpreted, Harriet and Jim could justifiably
consent to refuse medical interventions; yet we intui-
tively believe that treatment ought to have continued
for them. Thus, according to Goldberg, the MacArthur
criteria are necessary but not sufficient to establish
mental capacity. (See Goldberg 2020 for a fuller elabor-
ation of these cases as I lack enough space here.)
Consequently, Goldberg adds an extra requirement:
a Narrative Coherence Standard. This turns on the
patient’s ability to develop an intimate conception of
self through a narrative that extends over time
(Goldberg 2020). This therefore enables the patient to
develop mental states—beliefs, attitudes and desires—
that are consistent and importantly coherent with that
narrative conception of self. A patient passes
Goldberg’s narrative coherence test when she shows
how the mental states she has formed about herself—
which fit with her intimate conception of self over
time—are relevant to the medical decision at hand.
I will grant the force of Goldberg’s argument with
respect to adults, but I am not convinced it holds
when we consider children. The NCS demands we
clinically assess what Goldberg calls “the ability to
govern along one’s own self-narrative”(Goldberg
2020, 11), which I interpret as an individual’s capacity
to assemble the chain of events in one’s life experience
into a fully-fledged coherent story. Such an ability to
self-govern depends upon an intimate conception of
the self for Goldberg. Yet children may not possess
sufficient intimate knowledge of self as required for
the NCS. Part of what it means for children to self-
govern is for them to be able to self-reflect, since this
enables children to reject views with which they do
not identify and therefore author their own coherent
self-narratives (cf. Clayton 2012, 354). But it is not
obvious that children have a sufficient capacity for
self-reflection. Furthermore, self-governance requires
that children can distinguish the kinds of goods that
they seek to value in life. The precise goods that chil-
dren consider valuable will be derived from their
intimate conception of self, but inevitably children
will need some guidance as to what goods they ought
to value in the first place (Hannan 2018, 120) and
therefore they will need to be guided as to what con-
ception of self is compatible with whichever goods
they choose to value. If children lack the relevant
developmental capacities for self-governance (such as
the capacity for self-reflection or their ability to distin-
guish valuable goods), then we should doubt their
ability to form coherent self-narratives.
Even if we accept children’s innate capacity for form-
ing coherent self-narratives, as Goldberg’s standard sug-
gests, we might worry about whether they are
independently coherent self-narratives. I define an inde-
pendently coherent self-narrative as one whose values
stand apart from those transmitted through socialization
and are cultivated through self-reflection. But children
cannot form such independently coherent self-narratives
because they are subject to powerful socializing forces, to
the extent that they may even hold a false conception of
self (Harter et al. 1996). One such force is parenting,
which plays a crucial role in the values that children
acquire (Brighouse and Swift 2006, 80, 104; Fowler 2014,
308) and therefore has enormous implications for
children’s ability to form independently coherent self-
narratives. Schools also exert coercive pressure on child-
ren’s worldviews and consequently help determine their
adult life-projects (Schouten 2018,351–35). Given the
pervasive influence of parenting and education in mold-
ing children’s values, it is difficult to tell whether or not
children are merely reproducing certain social norms
through their self-narratives, especially if children do not
possess the adequate self-reflection needed for their val-
ues to stand sufficiently apart from social norms.
AJOB NEUROSCIENCE 41

Additionally, we should not assume that children
can develop an intimate knowledge of self before they
are actually ready to do so. If children can be wronged
when they enjoy too little autonomy, they can also be
wronged if we stray too far the other way and assume
they are capable of making decisions to which they can-
not yet reasonably consent (Hannan 2018, 119). This
point is significant in the medical context, given that
choices made in childhood can have wide-reaching
implications when the patient reaches adulthood
(Fowler 2014, 312). Decisions taken prematurely, espe-
cially those based on false or incomplete self-narratives,
may lead to wrongful outcomes downstream.
Given the absence of a fully-developed sense of self
in children, Goldberg might propose we should use a
parent’s or caregiver’s assessment of a child patient’s
sense of self as a reasonable proxy. After all, it is
widely understood that parents or caregivers have
privileged access to the mental contents of children in
their custody, such that they as proxies are capable of
making decisions that will promote their charges’
wellbeing (Fowler 2014, 307).
I have two responses here. First, it is not obvious
that proxies have full unvarnished access to children’s
mental states. A proxy account of a child’s mental state
is even less likely to mirror that of the child concerned,
as it may be affected by either: (a) ambiguity or insin-
cerity on the child’s part; or (b) erroneous memory or
faulty perception on the proxy’s part (Tribe 1974, 959).
Second, even if it were true that proxies had full access
to children’s mental states, it is unclear how relying on
proxy judgements of capacity would overcome the
above worries about the ability of children themselves
to self-govern. It is precisely that children are cognitive
works-in-progress which motivated my initial objec-
tions concerning the NCS’applicability to children.
These responses cast doubt on the ability of proxies to
provide sufficient knowledge of a child’s intimate con-
ception of self, in order to meet Goldberg’s test.
If my argument is persuasive, we should be skeptical
of the NCS’applicability to children. What, therefore,
should be done? We could revise the NCS to account for
children, though it may face further objections not
already mentioned. Alternatively, we might propose an
incremental view of consent, whereby children may con-
sent to an increasing range of things as their intimate
knowledge of self develops. A third response would be to
revert to a suitable version of the current MacArthur cri-
teria. At least one study has indicated a minimum thresh-
old of about 10–11 years old for competence, based on a
modified MacArthur assessment tool (Hein et al. 2014).
This suggests the MacArthur model, appropriately
understood, may already be sufficiently robust to assess
children’s mental capacity. I am somewhat sympathetic
to the incremental view of consent, but I don’thavethe
space to exhaustively discuss all these solutions.
I have argued the NCS currently encounters serious
problems when applied to children. First, children
lack the developmental capacities necessary to acquire
an adequate capacity to self-govern. Second, children’s
intimate conception of self is subject to powerful
socializing forces, which makes it hard to tell where
such an intimate conception of self ends and begins.
Either we should revise the NCS to better handle child
patients, adopt an incremental approach or stick to
the MacArthur model for now.
ACKNOWLEDGEMENTS
I am grateful to Peter R. Wilson and Daniel Mu~
noz for
their helpful comments on this paper.
ORCID
Gah-Kai Leung http://orcid.org/0000-0002-9174-8844
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