What Does It Take to Make a Decision?

28 Dec

The Washington Post reported yesterday that “a psychologist who examined one of the defendants on trial at Guantanamo Bay in connection with the September 11th terrorist attacks concluded that the high-value detainee was incompetent, raising questions about his fitness to stand trial.”  Cases like these raise the question of how exactly psychologists and psychiatrists determine whether a person is competent to make a decision.  The issue also comes up in medical care.  For instance, can a patient suffering from severe mental illness be forced to take medications to treat his condition even if he refuses to do so?

Mental health professionals use 4 criteria to decide if a person is competent to make decisions about his medical care.  The first is whether the person can clearly communicate a choice about his health care.  The second criterion is that the person can understand relevant information about his health condition.  The third requirement is that the person is capable of using information, such as what his physician says, to reach an accurate perception of reality.  Lastly, a person must be able to reason among the choices in medical treatment with which he is presented.

To systematize the evaluation of decision-making capacity, physicians often use a validated instrument called the MacArthur Competence Assessment Tool for Treatment (MacCAT-T).  It generates numerical scores using the 4 previously described decision-making criteria. 

In the past, it was commonly presumed that people with psychiatric disorders like depression lacked the ability to make reasonable decisions about their health. What these patients wanted was not taken into account when doctors made choices about their care.  As Paul Appelbaum writes,  “During a century and a half of widespread institutional care of mentally ill in the United States, the power of physicians to prescribe most forms of treatment for committed patients went unchallenged.  Generations of patients were thus routinely subjected to bleeding, purging, cold baths, whirling chairs and lobotomies.”  In recent decades, however, research has revealed that the presence of a psychiatric disorder does not necessarily mean a person is incapable of making reasonable decisions about their medical care.  For instance, using the MacCAT-T to measure decision-making capacity, one study found that only 20-25% patients hospitalized for depression had impairment with regard to at least one element of decision-making competence.  In addition, a number of important legal cases have established that patients with psychiatric disorders must be granted a much greater amount of autonomy in their decision-making than was previously recognized.  

The work of psychiatrist Paul Appelbaum has played an important role in shaping medicine’s approach to assessing decision-making capacity.  Appelbaum has an interesting New York Times article on the medical and legal history of the issue linked here.


Posted by on December 28, 2013 in Uncategorized


6 responses to “What Does It Take to Make a Decision?

  1. Cleo1117

    December 28, 2013 at 11:03 pm

    So, it’s Paul Appelbaum whom we have to thank for the closing of state mental hospitals virtually turning the mentally ill out to live in the streets. The multitude of homeless people should speak volumes to the followers of Appelbaum. He was wrong and society including the mentally Have been harmed.


      December 28, 2013 at 11:21 pm

      I take your point about the negative consequences of allowing people with severe mental illness to live outside of care facilities. Although I’m not an expert on this matter, it is my understanding that deinstitutionalization resulted in an increase in homelessness. However, I don’t believe it’s fair or accurate to the lay the blame for this at the feet of Paul Appelbaum. As he explains in his article, it was the advent of effective medications for previously untreatable conditions such as schizophrenia, as well as important legal and political changes that resulted in deinstitutionalization. One of Appelbaum’s important contributions is helping to delineate a standard process for determining whether a patient has decision-making capacity. Here is a link to a New England Journal of Medicine article he wrote on the subject:

      • Cleo1117

        December 29, 2013 at 12:55 am

        I am glad that you get my point. Yes great strides have been made with medications. Many people have been helped, people who have the resources and support to get and take the proper meds. Again, many do not have that luxury. Closing the institutions, giving the mentally Ill no where to turn but to family (who often suffer varying degrees of the same illness) or the streets has done nothing to help. People who are homeless cannot get medication. People without adequate insurance cannot continue a medication treatment plan and often stop the medication resulting in regression. Even those on Medicare with plan D pharmacy cannot afford a long term therapy of drugs. My own targeted therapy drug for cancer is 10,000 per month and adjusted as pharmacy. If I didn’t have excellent retirement insurance then I would just have to die sooner. This is the same choice facing the mentally ill; they have no help for getting effective treatment. We need our state hospitals. We also need to take care of these ill people even if it means they cannot live free just to fall deeper into a black hole.


    December 29, 2013 at 10:01 pm

    Thanks for your insightful comment.
    In his book, The Age of Melancholy, Duke Psychiatry Professor Dan Blazer describes how the deinstitutionalization that occurred with the advent of effective psychiatric medications was supposed to have been accompanied by community clinics to help patents manage their conditions and the use of these meds. Instead, it has become increasingly difficult for even middle class people to find psychiatrists since so many have stopped taking insurance due to poor reimbursement.

  3. markps2

    January 2, 2014 at 3:27 am

    Regarding deinstitutionalization. a majority of the population did recover.

    “The American Journal of Psychiatry (Vol. 144, No. 6, p. 718-735) showed that 62 percent to 68 percent of those former back ward patients showed no signs at all of schizophrenia”

    APA: New hope for people with schizophrenia

    A growing number of psychologists say recovery is possible with psychosocial rehabilitation.
    Monitor Staff
    February 2000, Vol 31, No. 2 Print version: page 24

    Regarding medications.

    [In 1955, there were 355,000 adults in state and county mental hospitals with a psychiatric diagnosis. During the next three decades (the era of the first generation psychiatric drugs), the number of disabled mentally ill rose to 1.25 million. Prozac arrived on the market in 1988, and during the next 20 years, the number of disabled mentally ill grew to more than four million adults (in 2007.) Finally, the prescribing of psychiatric medications to children and adolescents took off during this period (1987 to 2007), and as this medical practice took hold, the number of youth in America receiving a government disability check because of a mental illness leapt from 16,200 in 1987 to 561,569 in 2007 (a 35-fold increase.)
    The astonishing increase in the disability numbers during the past fifty years raises an obvious question: Could the widespread use of psychiatric medications–for one reason or another–be fueling this epidemic?]robert whitaker

    If the meds/drugs were working , the numbers of ill persons would be going down.

    “A slave is he who cannot speak his thoughts.” Euripides (484-406 B.C.)
    That is what the drugs do, make people slaves. You take them for a day, a week, or the rest of your life and see how you feel on them.

    “Involuntary mental hospitalization and the insanity defense should be seen for what they are: symmetrical symbols of psychiatric power. In the one case, the psychiatrist “accuses” the innocent; in the other, he “excuses” the guilty.” T.Szasz

    “It is better one hundred innocent Persons should be found guilty and suffer (psychiatric drugs and psychiatric prison), than that one guilty Person should escape.” says Psychiatry.

    This is the reverse of ” it is better one hundred guilty Persons should escape than that one innocent Person should suffer” said by Benjamin Franklin.
    “In physics, we use the same laws to explain why airplanes fly, and why they crash. In psychiatry, we use one set of laws to explain sane behaviour, which we attribute to reasons (choices), and another set of laws to explain insane behaviour, which we attribute to causes (diseases/brain chemical imbalances).” Szasz

    Sanity comes from inside a person, not from the outside.

  4. markps2

    January 2, 2014 at 3:28 am

    The American Journal of Psychiatry (Vol. 144, No. 6, p. 718-735) showed that 62 percent to 68 percent of those former back ward patients showed no signs at all of schizophrenia


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