Transcript Capacity and Competence - University of Virginia

Decisional Capacity and
Competence
Walter S. Davis, MD
Director of Education
Center for Biomedical Ethics
University of Virginia
Four Elements of Decisional
Capacity (Applebaum and Grisso, 1995)
 Understanding
 Appreciation
 The
ability to manipulate information
rationally - reasoning
 The ability to communicate a choice
Decisional capacity

The set of cognitive, volitional, and
affective patient abilities that allows the
physician to enter into the consent
compact and ask the patient to make
specific care decisions
Competence
Best thought of as a legal concept
 Determination of
competence/incompetence is done by
court proceeding, and is usually done in
the context of appointing a temporary
(“ad litem”) or permanent guardian
 Medical “evidence” – either records or
real-time testimony – is often presented

Four Functional Abilities in
Decisional Capacity Assessment
The ability to express a choice
 The ability to understand information
relevant to treatment decision making
 The ability to appreciate the significance
of that information for one’s own situation
 The ability to reason with relevant
information to logically weigh treatment
options

Expressing a Choice
Legally a “threshold” issue
 Merely expressing a choice or preference
does not indicate intact decisional capacity
 Clinical interpretation and examples:

– Depression
– Mental retardation
– Communication disorders
Understanding
Most common functional ability used by courts
to determine decisional capacity
 Psychologically and philosophically complex
 Related, in part, to a person’s level of
intelligence
 Clinical interpretation and examples:

–
–
–
–
Schizophrenia
Major depression
Medications
Mental retardation
Appreciation
Acknowledgement or appreciation that
they suffer from the diagnosed disorder
 Acknowledgement of the consequences of
the disease and the proposed treatment
 Clinical interpretation and examples:

– Denial
– Lack of insight
– depression
Reasoning
Logically weighing options
 Clinical interpretation and examples:

– Problem focus
– Considering options
– Considering and imagining consequences
– Assessing likelihood of consequences
– Evaluating consequences based on one’s own
subjective values
– Deliberating