A Values-Based Approach to Capacity Assessment

Abstract

The dominant approaches to assessing patients for decisional capacity in the clinical setting, the “four skills” and “sliding scale” models, emerged in the 1970s and 1980s against a backdrop of medical paternalism and reflect their origins in law and forensic psychiatry. They privilege rationality and require the ability to defend one’s decisions with knowledge and argument. Unfortunately, these approaches place a heavy burden upon patients who may hold preferences consistent with their underlying values but may not possess the education or reasoning skills necessary to meet the heavy burden imposed by current capacity standards. This article reviews the shortcomings of the dominant models. Then the article proposes a novel value-based approach to capacity assessment that places primary emphasis upon the patient’s underlying and longstanding values and the concordance of those values with the patient’s current wishes and preferences.

Keywords:

• capacity
• sliding scale
• competence
• psychiatry
• mental health ethics

Notes

1 John Patrick Shanley, Doubt: A Parable, New York: Dramatist Play Service, 22 (Theatre Comm’cns Grp., 2005).

2 Melanie Tervalon & Jan Murray-García, Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education, 9 J. Health Care Poor Underserved 117, 117-18 (1998).

3 See Jennifer Anderson Juarez et al., Bridging the Gap: A Curriculum to Teach Residents Cultural Humility, 38 Fam. Med. 97 (2006); see also Sunila J. Prasad et al., Cultural Humility: Treating the Patient, Not the Illness, 21 Med. Educ. Online 30908 (2016).

4 See Loren H. Roth et al., Tests of Competency to Consent to Treatment, 134 Am. J. Psychiatry 279, 279-84 (1977); see also Paul S. Appelbaum & Thomas Grisso, Assessing Patients’ Capacities to Consent to Treatment, 319 N. Eng. J. Med. 25, 1635-38 (1988); see also Barton W. Palmer & Alexandrea L. Harmell, Assessment of Healthcare Decision-Making Capacity, 31 Arch. Clin. Neuropsychol. 530, 530-40 (2016); see also James F. Drane, The Many Faces of Competency, 15 Hastings Ctr. Rep. 17, 17-21 (1985); see also Allan E. Buchanan & Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision-Making (Cambridge Univ. Press 1990).

5 I am indebted to my colleague, Omar Mirza, for using the term “capacity challenge” to describe what is generally referred to as a capacity evaluation.

6 Mohr v. Williams, 95 Minn. 261, 104 N.W. 12 (1905).

7 Schloendorff v. Soc’y of N.Y. Hosp., 211 N.Y. 125, 105 N.E. 92 (1914).

8 Salgo v. Leland Standford Jr. Univ. Board of Trustees, 154 Cal. App. 2d 560 (1957); see Lydia A. Bazzano et al., A Modern History of Informed Consent and the Role of Key Information, 21 Ochsner J. 81, 81-85 (2021).

9 Loren H. Roth et al., supra note 4; see Loren H. Roth et al., The Dilemma of Denial in the Assessment of Competency to Refuse Treatment, 139 Am. J. Psychiatry 910, 910-13 (1982).

10 See Roth et al., supra note 4.

11 Id.

12 Thomas S. Szasz & Marc H. Hollender, A Contribution to the Philosophy of Medicine: The Basic Models of the Doctor-Patient Relationship, 97 AMA Arch. Intern. Med. 585, 585-92 (1956); Thomas S. Szasz, William F. Knoff, & Marc H. Hollender, The Doctor-Patient Relationship and Its Historical Context, 115 Am. J. Psychiatry 522, 522-28 (1958); President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 42 U.S.C. § 300v (1982).

13 Alan Meisel et al., Toward a Model of the Legal Doctrine of Informed Consent, 134 Am. J. Psychiatry 285, 285-89 (1977).

14 See Roth et al., supra note 4.

15 Appelbaum & Grisso, supra note 4.

16 See Drane, supra note 4; see also Buchanan & Brock, supra note 4; see also President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 42 U.S.C. § 300v (1982).

17 See Appelbaum and Grisso, supra note 4.

18 See Drane, supra note 4; see also Buchanan & Brock, supra note 4.

19 See Roth et al., supra note 9.

20 See, e.g., P.B.H. § 2980..

21 Howard Owens, When Is a Voluntary Commitment Really Voluntary?, 47 Am. J. Orthopsychiatry 104, 104-10 (1977). See Appelbaum and Grisso, supra note 4.

22 Grace B. Olin & Harry S. Olin, Informed Consent in Voluntary Mental Hospital Admissions, 132 Am. J. Psychiatry 938, 938-41 (1975).

23 Charles M. Culver & Bernard Gert, The Inadequacy of Incompetence, 68 Milbank Q. 619 (1990).

24 Id. at 619. See Charles M. Culver, Philosophy in Medicine: Conceptual and Ethical Issues in Medicine and Psychiatry (Oxford Univ. Press 1982).

25 See Drane, supra note 4; see also Mark R. Wicclair, Patient Decision-Making Capacity and Risk, 5 Bioethics 91, 91-104 (1991).

26 Walid Michael Nassif, Assessing Decisional Capacity in Patients with Substance Use Disorders, 18 Current Psychiatry 35, 38 (2019).

27 See Appelbaum and Grisso, supra note 4.

28 Miranda v. Arizona, 384 U.S. 436, 469 (1966).

29 Adrian M. Owen & Martin R. Coleman, Detecting Awareness in the Vegetative State, 1129 Annals N.Y. Acad. Sci. 130, 130-38 (2008). See Martin M. Monti et al., Willful Modulation of Brain Activity in Disorders of Consciousness, 362 N. Eng. J. Med. 579, 579-89 (2010).

30 Id.

31 Jacob M. Appel, Toward a Psychodynamic Approach to Bioethics, 71 Am. J. Psychoanalysis 58, 58-66 (2011).

32 See Appelbaum & Grisso, supra note 4.

33 David J. Rothman, The Shame of Medical Research, 47 N.Y. Rev. Books 60, 60-64 (2000).

34 George S. Mellgard & Jacob M. Appel, Death, Taxes and Uncertainty: Economic Motivations in End-of-Life Decision Making, 17 Clinical Ethics 90, 90-94 (2021).

35 See Appelbaum & Grisso, supra note 4.

36 Larry May, Challenging Medical Authority: The Refusal of Treatment by Christian Scientists, 25 Hastings Ctr. Rep. 15, 15-21 (1995).

37 Carol Levine, When Parents Choose Prayer over Medicine, Should Courts Step In?, 14 Hastings Ctr. Rep. 3, 3-4 (1984).

38 Terry Rabinowitz and Ryan Peirson, “Nothing Is Wrong, Doctor”: Understanding and Managing Denial in Patients with Cancer, 24 Cancer Invest. 1 68-76 (2006).

39 Id.

40 See Appelbaum & Grisso, supra note 4.

41 Adamson v. California, 332 U.S. 46, 63 (1947).

42 See Roth et al., supra note 9.

43 David Kapley et al., Mental Health Innovation vs. Psychiatric Malpractice: Creating Space for “Reasonable Innovation”, 5 Faulkner L. Rev. 131 (2013).