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.