1. Decisional Capacity and Competence
Walter S. Davis, MD
Director of Education
Center for Biomedical Ethics
University of Virginia

2. Four Elements of Decisional Capacity (Applebaum and Grisso, 1995)
Understanding
Appreciation
The ability to manipulate information rationally - reasoning
The ability to communicate a choice

3. Decisional capacity
The set of cognitive, volitional, and affective patient abilities that allows the physician to enter into the consent compact and ask the patient to make specific care decisions

4. Competence Best thought of as a legal concept
Determination of competence/incompetence is done by court proceeding, and is usually done in the context of appointing a temporary (“ad litem”) or permanent guardian
Medical “evidence” – either records or real-time testimony – is often presented

5. Four Functional Abilities in Decisional Capacity Assessment
The ability to express a choice
The ability to understand information relevant to treatment decision making
The ability to appreciate the significance of that information for one’s own situation
The ability to reason with relevant information to logically weigh treatment options

6. Expressing a Choice Legally a “threshold” issue
Merely expressing a choice or preference does not indicate intact decisional capacity
Clinical interpretation and examples:
Depression
Mental retardation
Communication disorders

7. Understanding
Most common functional ability used by courts to determine decisional capacity
Psychologically and philosophically complex
Related, in part, to a person’s level of intelligence
Clinical interpretation and examples:
Schizophrenia
Major depression
Medications
Mental retardation

8. Appreciation
Acknowledgement or appreciation that they suffer from the diagnosed disorder
Acknowledgement of the consequences of the disease and the proposed treatment
Clinical interpretation and examples:
Denial
Lack of insight
depression

9. Reasoning Logically weighing options
Clinical interpretation and examples:
Problem focus
Considering options
Considering and imagining consequences
Assessing likelihood of consequences
Evaluating consequences based on one’s own subjective values
Deliberating