The Role of Money in Consent to Treatment

Voluntary choice is still possible

Photo by Jp Valery on Unsplash

The conditions of informed consent to medical treatment are the following:

1. Capacity. The patient must have decision-making capacity, which involves being able to understand the risks and benefits of the proposed intervention and potential alternatives. Capacity is decision-specific, meaning that someone might have capacity for one decision but not another, depending on its complexity and other factors. For adults, capacity is presumed.

2. Information. The patient must be given all of the relevant information to make the decision.

3. Understanding. The patient must understand the information provided and be able to consider the risks and benefits of each option. Capacity is the ability to understand, whereas understanding is actually performing the risk-benefit assessment.

4. Voluntariness. Consent must be freely given.

Here I’m interested in voluntariness, especially the role that money can play in affecting decisions. People sometimes object to patients making medical decisions when money plays a role. The argument is that the financial aspects of the situation are coercive, so the patient isn’t making a free choice (and, since they aren’t choosing voluntarily, they aren’t giving informed consent).

There are really two separate issues going on. The first is figuring out what constitutes coercion, which I have views about, but which I’m going to ignore here. Even if the concern isn’t coercion per se, we can substitute ‘manipulation’ or some other type of interference. The second issue is figuring out when coercion interferes with voluntariness and therefore invalidates consent to treatment (including MAiD). That’s the root of the objection.

One way to frame the objection is through the following claim:

Financial Coercion: When financial factors play a major role in decision making about significant medical decisions, they are coercive and make voluntary choice impossible.¹

This is one way of capturing concerns about the influence of money on medical decision making, though, of course, there are others. Importantly, I don’t think the financial factors need to be about payment for health care; relevant but non-healthcare expenses can also matter. 

One of its upshots is that certain MAiD choices are coerced. In last week’s MAiD article, I discussed the case of an Ontario woman with multiple chemical sensitivities. People with this condition have environmental allergies that can be triggered by things commonly found in the environment, so they need housing without these triggers to avoid having regular allergic reactions. The woman I discussed received an assisted death after years of trying to find housing she could afford that met her needs.

People who endorse Financial Coercion will conclude that she was coerced into her decision to receive MAiD, since financial factors—her ability to afford chemical-free housing—seem to have played a significant role in her MAiD decision. (However, contrary to what some claim, she didn’t qualify for MAiD because of her lack of housing.) I’ve framed Financial Coercion to include non-healthcare financial factors to capture cases of this sort. On this view, since her decision was involuntary, she didn’t give informed consent and thus shouldn’t have been offered MAiD.

I think that Financial Coercion is false, and I’ll explain why below. But first, let me underline that the situation the woman with MCS encountered is tragic. It’s a tragedy that affordable housing is difficult to find, especially when housing is required to avoid the serious effects of a medical condition. In an ideal world, people wouldn’t face this choice. But this is a housing problem, not a MAiD problem, and the counterfactual where MAiD is banned means that she would have continued to suffer intolerably, probably for years. People should support policies—reduced zoning, increased unit production, more subsidized housing, a government program to help find people with medical conditions suitable housing, etc.—to address the affordability crisis. There’s no contradiction in being pro-housing and pro-MAiD. And, since changing housing access would have completely solved the problem the woman with MCS encountered, whereas banning MAiD likely would have led to years of intolerable suffering, the ethical case for focusing on housing policy instead of trying to ban MAiD is pretty straightforward.

Now to Financial Coercion. Part of the issue is how we distinguish ‘influence’ from ‘coercion’. This distinction isn’t just about cases involving money, but all decision making, and a key factor is whether the individual can weigh the pros and cons of each option and decide in line with their values. If the answer is yes, then that indicates that the choice is voluntary. Also notice that a lack of good choices isn’t, on its own, a sign of coercion or involuntariness. If a cancer patient is given the options of chemotherapy or comfort care (i.e., not treating the cancer), neither option is good, but she can still decide which is the better choice. This is partly why I think that Financial Coercion is too strong. Money certainly influences decisions, but a lack of good options doesn’t mean that all decisions involving money are involuntary.

Another reason to reject Financial Coercion—perhaps the stronger one—is that it leads to implications that I think we ought to reject. Consider the following case:

Alice finds out that she’s pregnant. She’s 21 years old and in university. She’s interested in having a child at some point, but she thinks that now isn’t a good time. In particular, she doesn’t know how she’ll afford to look after a child. She knows that child care (among other things) is expensive, so she’d have to drop out of school. She already has student loans, and her part-time job barely covers her own expenses. Therefore, she decides to get an abortion.²

I think that Alice should be able to have an abortion. She has considered the pros and cons and made a decision in line with her values. In contrast, proponents of Financial Coercion will be against it, since financial factors are playing a major role in Alice’s decision making about a significant medical decision.

While there are obvious differences between Alice’s case and the case of the woman with MCS, money is playing an important role in both of their decisions. So, if we think that the person with MCS made an involuntary choice because of a lack of affordable housing, we should also think that Alice makes an involuntary choice because of a lack of affordable child care. However, I don’t think Alice is making an involuntary choice, so I don’t think the MAiD case was involuntary either.

Now, just as a lack of affordable housing is an injustice that we absolutely ought to address, lack of affordable child care is also unjust (though, in Canada, more is currently being done to address it). But it would be a mistake to argue that we should ban abortions until affordable child care is available for all. Similarly, it’s a mistake to ban MAiD until all social issues are addressed.

In rejecting Financial Coercion, I’m making a pretty narrow point. Financial aspects of a situation can certainly be coercive, but a decision based on these aspects doesn’t, on its own, mean that the person can’t make a voluntary choice.

1. This is formatted as a quotation but I’m not quoting anyone. I’m just not sure how else to format it so it stands apart. But I did discover footnotes!

2. Also not a quotation.