Capacity and consent: separating fact from fiction

That we have an ethical and legal obligation to ensure our patients are informed about and allowed to participate in their health care decisions goes without argument.

However, the degree to which a patient can be involved in making decisions ultimately depends on whether we deem them capable to do so, and this ultimately hinges on our skills for assessing capacity.

A recent study conducted by the National Ethics Committee of the Veterans Health Administration in the United States, identified the following 10 common myths that clinicians hold about decision-making capacity and how it is assessed:

1. Decision-making capacity and competence are the same;
2. Lack of decision-making capacity can be presumed when patients go against medical advice;
3. There is no need to access decision-making capacity unless patients go against medical advice;
4. Decision-making capacity is an “all or nothing” phenomenon;
5. Cognitive impairment equals lack of decision-making capacity;
6. Lack of decision-making capacity is a permanent condition;
7. Patients who have not been given relevant and consistent information about their treatment lack decision-making capacity;
8. All patients with certain psychiatric disorders lack decision-making capacity;
9. Patient who are voluntarily committed lack decision-making capacity; and
10. Only mental health experts can assess decision-making capacity.

To truly respect the autonomous choices our patients make, entails that we support their participation in the decision-making to the greatest degree possible.

Perhaps in the time leading up to accreditation and in the culture of promoting ethical healthcare practices, the above list of commonly held misconceptions can act as a catalyst for further education and discussion about the assessment of capacity.

Preventative ethics would suggest that we minimize potential errors from occurring in the clinical assessment of decision-making capacity and debunking these common misconceptions would be a good place to start!

Blair Henry, senior clinical ethics fellow
Clinical Ethics Center and Research Ethics Board, Sunnybrook