Presentation on theme: "Competence & Capacity ISD II – Psychiatry Nov. 12, 2002"— Presentation transcript:
1 Competence & Capacity ISD II – Psychiatry Nov. 12, 2002 Ethics/Humanities/Health LawAndrew Latus**Some material stolen from Daryl Pullman and Barb Barrowman
2 Objectives Define competence and capacity Discuss their ethical and legal significanceConsider how they apply in hard cases
3 A Case of Apotemnophilia Apotemnophilia = desire for amputation (p. 285)Mr. A., 65 years old, wants to have a healthy limb amputated“I am not happy with my present body, but long for a peg-leg.”
4 Two Questions Two questions: Would it be wrong for a surgeon to perform the amputation?Would you perform the amputation?
5 Capacity vs. Competence These terms are sometimes used interchangably, yet supposedly there’s a differenceWhat is it?
6 Capacity“[T]he ability to understand information relevant to a treatment decision and to appreciate the reasonably foreseeable consequences of a decision or lack of a decision.” (Bioethics for Clinicians)Really a definition of an adequate degree of capacity for medical decision making
7 Capacity vs. Competence Capacity refers to an ability“having capacity”Capacity comes in degreesCompetence refers to a property or characteristic a person possesses“being competent”Competence (relative to a particular decision) is all or nothing.
8 Competence & Competence Defined Capacity = the degree to which one is able to understand the information relevant to a treatment decision and appreciate the reasonably foreseeable consequences of a decision or lack of a decision.Competence = being able to understand information relevant to a treatment decision and to appreciate the reasonably foreseeable consequences of a decision or lack of a decision.We’ll just talk of capacity for remainder of class
9 Capacity for what? Capacity is specific to a particular decision A person may possess the capacity to make some decisions but not othersCapacity can change over timee.g. delirium, drugs, course of illness and treatment
10 A Logical Point About Capacity If you’re worried about a patient’s capacity to refuse some treatment, you should also worry about his capacity to accept itWorries about capacity sometimes go away when the patient comes to accept our recommendation for treatment.E.g., we worry about the patient’s ability to refuse treatment for chemotheraphy but not his ability to accept itThis doesn’t make sense with regard to capacity
11 Why does capacity matter? Two kinds of reasonMoralLegal
12 Moral Reason #1: The Importance of Consent Capable patients are, by definition, able to give informed consent to treatmentThe importance of informed consent is supported both byThe principle of autonomy – respect for persons requires respecting their informed decisionsThe principles of beneficence/non-maleficence – generally, an informed patients is a good judge of what broad sort of treatment is in his/her best interest
13 Moral Reason #2: Beneficence Toward Incapable Patients An assessment of capacity helps us figure out what matters morallyIn the case of an incapable patient, we no longer have recourse to the principle of autonomy.The principles of beneficence/non-maleficence require that incapable people be protected from making decisions that are harmful or that they would not make if capable
14 Why does capacity matter legally? In law, capable patients entitled to make their own informed decisionsIf patient incapable, physician must obtain consent from designated substitute decision-makerAdvance Health Care Directives Act (NL)Presumption of capacity for adultsFor minors, check provincial legislation on mature minors (NB), child welfare act, etc.
15 Aids to Capacity Assessment General impression of capacity from clinical encounterCognitive function testing, e.g., MMSESpecific capacity assessment tools, e.g., ACE
16 Mini Mental State Exam (MMSE) AdvantagesReliableEasy to administerFamiliarProblem:Although cognition and capacity related, they are not identicalDoes not evaluate several cognitive functions (e.g., judgment, reasoning) that are relevant to capacityDoes not address delusions
17 Aid to Capacity Evaluation (ACE) Clinician discloses information relevant to the treatment decision, then evaluates person’s ability to understand this information and appreciate the consequences of his/her decisionDeveloped at U of T’s Joint Centre for BioethicsBased on Ontario’s Consent to Treatment ActPrompts clinicians to probe 7 relevant areas, provides sample questions and scoring
18 Seven Areas to Consider Ability to understand medical problemAbility to understand proposed treatmentAbility to understand alternatives (if any)Ability to understand option of refusing treatmentAbility to appreciate reasonably foreseeable consequences of accepting proposed treatmentAbility to appreciate reasonably foreseeable consequences of refusing proposed treatmentAbility to make decision not substantially based on delusions or depression
19 Some Strengths & Weaknesses Clinically feasible, relatively quickFlexibleUseful format for documentationWeaknessesOnly as good as accompanying disclosureDifficulty of assessing impact of delusions or depressionFactors may interfere with effective communication e.g. language barrier
20 When to Consider Expert Assessment If unsure of assessmentIf patient (or family) challenges findingIf clinician suspects that a decision is based substantially on delusions or depression
21 Trying Out the A.C.E. – Mr. G. Mr. G. (see Bioethics for Clinicians) 42 years oldReceiving treatment for chronic schizophrenia.Unemployed but functions independently in the community.Rarely leaves his apartmentBelieves that his neighbours break into his house and steal his money when he is out,Physician makes house call because Mr. G. is complaining of a sore throatThroat swab reveals an infection.Physician recommends antibiotic therapy
22 Assessing Mr. GClinician explains that the pills are to treat the sore throat but may cause diarrhea or a rash.Asks Mr. G to review the information to ensureMr. G: "You're giving me these pills to help my throat. If I get diarrhea or any skin problems I should stop and let you know."Decision to accept treatment is not based on a delusion, but on a desire for symptom relief.Clinician concludes Mr. G. has the capacity to accept treatment
23 Applying the A.C.E. to Mr. AMr. A. has desired the peg-leg since at least age 10 (p. 288)“Unconsciously such a peg-leg became synonymous with happiness…” (288)“the realization of [my desire for a peg-leg] has become indispensable for my personal happiness…”(288-9)“Naturally over the years I have thought of many arguments against amputation, have … considered them and rejected them... It is not normal. But what is normal and who is normal?” (289)“No one has the right to deny or keep me from this way of life.” (289)
24 A Final Thought About Capacity When it comes to treating religious beliefs as delusions the numbers seem to countMost seem to think that adult Jehovah’s Witnesses have the capacity to refuse, on religious grounds, treatment involving blood transfusionsWhat about singular or rare religious grounds?E.g., what if Barney the Dinosaur, my personal saviour, tells me to seek an amputation?Are we consistent in thinking about religious reasons?
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