Book Review

Assessing Competence to Consent to Treatment: A guide for physicians and other health professionals

N Engl J Med 1998; 339:1794-1795December 10, 1998

Article

Assessing Competence to Consent to Treatment: A guide for physicians and other health professionals
By Thomas Grisso and Paul S. Appelbaum. 211 pp. New York, Oxford University Press, 1998. $29.95. ISBN: 0-19-510372-6

The ability of patients to make informed decisions about their care may be compromised by their illness, the effects of medication or hospitalization, or mental disorders such as delirium, dementia, or major depression. If patients are deemed incompetent to make informed decisions, they lose the power to make medical choices and to control their own care. In daily practice, it is physicians who frequently determine whether patients lack decision-making capacity. Assessing Competence to Consent to Treatment is a concise, lucid, wise, and practical book on how to do so.

The first chapters thoughtfully describe the pertinent ethical and legal issues and analyze the components of the capacity to make decisions. The authors emphasize that assessing decision-making capacity requires more than estimating a patient's ability to make a medical choice; the physician must also take into account the demands of the particular decision-making situation and any possible harm that may result from respecting the patient's choice. The book stresses that patients may understand disclosed information and yet fail to appreciate that this information applies to their own clinical situation. For example, patients may not accept their diagnosis or may not believe that they will not benefit from the recommended treatment. In this book, case vignettes are effectively used to illustrate these points.

The next several chapters provide comprehensive, practical information on how clinicians should assess a patient's decision-making capacity. The authors suggest specific questions to ask and provide useful practical advice on how to carry out the interview. Although the authors favor the MacArthur Competence Assessment Tool, which they developed and tested, they acknowledge that physicians may prefer to use other questions. They also make it clear that no threshold score on a standardized instrument can identify patients whose ability to make a decision is inadequate. The level of impairment that disqualifies patients as decision makers should vary according to the likely benefits and risks of treatment.

A few limitations of the book need to be pointed out. The book gives relatively little attention to the ultimate question — how to judge whether the patient's choice should be respected or whether decision-making power should be given to a surrogate. It would be useful to learn more about how to make judgments in difficult situations, such as cases in which patients refuse to cooperate with an interview or hold cultural beliefs about illness that are inconsistent with Western biomedicine. Likewise, they might give more specific advice on how to adjust the standards for assessing decision-making capacity according to the relative risks and benefits of treatment. Clearly there is a danger that such adjustment may be inconsistent or biased and therefore unfair.

The authors stress that these difficult judgments about decision-making capacity should be made by the patient's attending physicians; routine psychiatric consultation or involvement of the courts is neither feasible nor desirable. These decisions require expertise, judgment, and wisdom. This book provides extremely useful guidance.

Bernard Lo, M.D.
University of California, San Francisco, San Francisco, CA 94143