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