A recent Ethics Column described the difference between decision making capacity (DMC) and legal competency. In this article, we discuss DMC in everyday treatment decisions. A primary principle of medical ethics is respect for people. To uphold this principle, we have an ethical obligation to ensure that patients are informed about, and allowed to participate in, choices regarding their healthcare.
These choices involve four main elements:
- Understanding relevant information
- Appreciating the choice and its consequences
- Reasoning about treatment options
- Communicating a consistent choice
Determination of DMC, therefore, leads to an understanding of whether a person can make their own decision or someone else is empowered to make decisions for them. How do we do this?
In determining DMC, we are assessing the process someone uses to make a decision, not whether the final decision is correct or wise (or we agree with it). It involves assessing each of the four elements above.
DMC is a concept that addresses the ability of a person to make a specific decision at a specific time. For example, if a person is incapacitated due to an acute illness, they may lack the DMC to guide their present medical care. However, when they begin to recover, they may regain their capacity. Similarly, DMC is not an all-or-nothing endeavor; a patient may lack the DMC to make a decision regarding a complicated medical intervention, but may be fully capable of making decisions regarding participation in various therapies. Their capacity to understand relevant information is related to the type of information, as well as the possible consequences. Finally, the individual has to communicate their consistent choice in a way that is understood by others.
All aspects of DMC are dependent on staff at every juncture in a patient’s care. It is essential for staff to create an environment where a patient can participate in and focus on their involvement in decision making to the best of their ability. From helping a patient schedule an intake appointment to performing a medical procedure, we all have a role in understanding and supporting patients’ DMC.