Correspondence

Patients' Competence to Consent to Treatment

N Engl J Med 2008; 358:644February 7, 2008

Article

To the Editor:

In his Clinical Practice article on the assessment of patients' competence to consent to treatment (Nov. 1 issue),1 Appelbaum invokes the ability to reason as a central criterion for capacity. I consider this ethically troublesome. The criterion that can replace reasoning, with fewer unintended consequences, is consistency over time.2 Capacity has more to do with acting characteristically than with acting reasonably.

Appelbaum concludes, for the case presented, that “psychiatric consultation should be considered” because of the possible presence of early dementia or depression, despite acknowledging that neither condition rules out capacity. Capacity is presumed for all adults, like the presumption of innocence in a criminal trial. When in doubt, capacity should be assessed by those who best know the patient. Hence, the primary care physician is usually better able to assess capacity than is a psychiatric consultant. When additional input is needed, a more patient-centered alternative to psychiatric consultation is available at most teaching hospitals — namely, an ethics consultation.

Jeffrey P. Spike, Ph.D.
Florida State University College of Medicine, Tallahassee, FL 32306-4300
jeffrey.spike@med.fsu.edu

2 References

1. 1

   Appelbaum PS. Assessment of patient's competence to consent to treatment. N Engl J Med 2007;357:1834-1840
   Full Text | Web of Science | Medline

2. 2

   Spike JP. Assessment of decision-making capacity. In: Aronson C, Brummel-Smith K, eds. Reichel's care of the elderly. 6th ed. New York: Cambridge University Press (in press).
   

Author/Editor Response

As I state in the article with regard to psychiatric consultation, “treating physicians may have the advantage of greater familiarity with the patient and with available treatment options. Psychiatric consultation may be helpful in particularly complex cases or when mental illness is present.” That ethics committees sometimes play helpful roles offers no reason to alter that judgment.

Although Spike would favor application of a consistency standard rather than reasoning, this is not generally accepted1 — for good reason. Consistency with past behavior is a difficult determination,2 especially for unprecedented decisions (e.g., amputation); moreover, a consistency standard risks denying patients the right to choose differently today than they have in the past.

Paul S. Appelbaum, M.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032
psa21@columbia.edu

2 References

1. 1

   Berg JW, Appelbaum PS, Grisso T. Constructing competence: formulating standards of legal competence to make medical decisions. Rutgers Law Rev 1996;48:345-371
   Web of Science | Medline

2. 2

   Gutheil TG, Appelbaum PS. Substituted judgment: best interests in disguise. Hastings Cent Rep 1983;13:8-11
   Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Gerben Meynen. (2011) Depression, possibilities, and competence: A phenomenological perspective. Theoretical Medicine and Bioethics
   CrossRef

2. 2

   Gerben Meynen. (2010) Free will and psychiatric assessments of criminal responsibility: a parallel with informed consent. Medicine, Health Care and Philosophy 13:4, 313-320
   CrossRef

3. 3

   Michael Koelch, Anja Prestel, Hanneke Singer, Ulrike Schulze, Joerg M. Fegert. (2010) Report of an Initial Pilot Study on the Feasibility of Using the MacArthur Competence Assessment Tool for Clinical Research in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Journal of Child and Adolescent Psychopharmacology 20:1, 63-67
   CrossRef

4. 4

   Gerben Meynen. (2009) Exploring the similarities and differences between medical assessments of competence and criminal responsibility. Medicine, Health Care and Philosophy 12:4, 443-451
   CrossRef