As someone who sees heaven as a giant library filled with unread books by writers she admires, I’m excited about “Go Set A Watchman”, Harper Lee’s highly anticipated sequel to “To Kill A Mockingbird”, published by HarperCollins Publishers on July 14th, 2015.

Following the announcement of the imminent publication, several news articles appeared in print and online, speculating about Harper Lee’s ability to consent to the publication since a stroke in 2007 left her with impairments in vision, hearing and short term memory. The articles raised concerns about whether she was being manipulated following the death of her sister Alice, who was her longstanding advocate. It seemed strange to many that after years and years of maintaining that she would not publish any more novels, Ms. Lee had decided to publish this one, after the chance discovery of the manuscript by her attorney Tonja Carter. As a geriatric psychiatrist who is familiar with situations in which the judgment and decision making ability of an elderly person have been called into question, I realize that this could be a complicated situation in which the truth may be very hard to determine even by people in the center of things, not to mention everyone else, separated from the core situation by time, space, and hearsay.

Cognitive impairment is deceptively easy to miss. Cognition, for one, is not equivalent to memory, and encompasses other domains such as attention, language, visuospatial ability, and executive function. Asking someone the date, location or the name of the President, although important, tests only a few domains of cognition, and perfunctorily at that. It is also understandably hard to accept that someone we care about has cognitive problems. We are, in addition, meaning making creatures, and when someone says something we don’t understand, we often fill in the gaps without realizing that we’re doing so. All this makes the recognition of cognitive deficits by anyone unfamiliar with cognitive testing a challenging process, unless the deficits are glaringly obvious.
However, many of us are acquainted with someone extremely sharp, over the ages of 85, 90, even 95. Certain cognitive changes such as reduced processing speed are common in aging, but people can maintain high intellectual function despite these changes. As brains age, the risk of mild cognitive impairment – minor changes thatare beyond the expected decline for age – increases. These don’t necessarily progress to full blown dementia, though the risk of such progression itself increases with age.
When an elderly person makes a decision that is apparently out of character, it does raise some valid concerns about cognitive status. When I hear that Harper Lee had a stroke, which places her at risk for vascular dementia, I can’t say I don’t wonder about her cognition. It would, however, be grossly unfair, and disrespectful to her, for anyone to judge her state of mind from a distance.
Even if she does have some cognitive impairment, that doesn’t mean that she cannot make her own decisions, or at least some of them, and that she does not grasp the situation at hand.
It is common for psychiatrists, indeed all physicians, to be called upon to weigh in on someone’s “capacity” to consent to, or refuse, a certain medical treatment. This “capacity” is the ability of the individual to make an informed decision. “Capacity” is decision specific – not global – and also time specific, meaning that someone could have the capacity to, say, refuse a blood draw, but lack the capacity to refuse a leg amputation. A person’s capacity or the lack thereof can change with time. This seemingly simple assessment can often be rather complicated, as it is not always easy to know how much someone understands of a given situation, how much they need to understand to proceed with a given decision, whether their decisions are in character or not, and if that necessarily means anything. “Competence”, an allied but different concept, is a legal construct – to execute a will, for instance. It is determined by a court of law, although expert opinion could help sway a decision. Every adult is deemed competent, and capable of making legal decisions, unless otherwise adjudicated by a court of law. Having memory problems, or more broadly, cognitive impairment, doesn’t by itself imply that someone lacks the capacity to make a certain medical decision, or is legally incompetent to manage his or her affairs, though, as one would expect, it is a factor impacting both assessments.
The state of Alabama, acting on an anonymous complaint about elder abuse, interviewed Harper Lee, and was convinced of her competence.
Which leaves us with essentially this : It is hard to know the core truth behind a controversy such as this, but legally, Ms. Lee is competent, and the world stands to gain from this.

If the proceeds from the publication reach her, as they should, the only real risk is that the release of this book is something that Ms. Lee would have never wanted
and isn’t in a position to protest because she doesn’t completely grasp the situation, a risk that would be greater if the book tarnishes her reputation in some way.
People can change their minds, but time can also change their brains. As the world begins to read the book, I hope that the truth, plain and simple, is that Harper Lee changed her mind, and is happy about it.