Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals

by Thomas Grisso

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Author: Thomas Grisso

Publisher: Oxford University Press

Hardcover:
ISBN 10: 0195103726
ISBN 13: 978-0195103724

One of the most challenging tasks facing clinicians today is the assessment of patients' capacities to consent to treatment. The protection of a patient's right to decide, as well as the protection of incompetent patients from the potential harm of their decisions, rests largely on clinicians' abilities to judge patients' capacities to decide what treatment they will receive. However, confusing laws and the complicated ethical issues surrounding the concept of competence to consent have made the process of competence assessment intimidating for many clinicians. Health professionals--physicians, medical students, residents, nurses, and mental health practitioners--have long needed a concise guidebook that translates the issues for practice. That is what this book accomplishes.
This volume is the product of an eight-year study of patients' capacities to make treatment decisions--the most comprehensive research of its kind. The authors describe the place of competence in the doctrine of informed consent, analyze the elements of decision-making, and show how assessments of competence to consent to treatment can be conducted within varied general medical and psychiatric treatment settings. The book explains how assessments should be conducted and offers detailed, practice-tested interview guidelines to assist medical practitioners in this task. Numerous case studies illustrate real-life applications of the concepts and methods discussed. Grisso and Appelbaum also explore the often difficult process of making judgments about competence and describe what to do when patients' capacities are limited.
A timely, practical handbook relevant to every medical specialty, Assessing Competence to Consent to Treatment will benefit a wide array of medical practitioners--including physicians, medical students, residents, nurses, and other allied health professionals--who need to assess the mental competence of patients in their everyday practice. It will also interest ethicists and moral philosophers, as well as geriatricians and clinical psychologists working with cognitively impaired patients.

From The New England Journal of Medicine

The ability of patients to make informed decisions about their care may be compromised by their illness, the effects of medication or hospitalization, or mental disorders such as delirium, dementia, or major depression. If patients are deemed incompetent to make informed decisions, they lose the power to make medical choices and to control their own care. In daily practice, it is physicians who frequently determine whether patients lack decision-making capacity. Assessing Competence to Consent to Treatment is a concise, lucid, wise, and practical book on how to do so.

The first chapters thoughtfully describe the pertinent ethical and legal issues and analyze the components of the capacity to make decisions. The authors emphasize that assessing decision-making capacity requires more than estimating a patient's ability to make a medical choice; the physician must also take into account the demands of the particular decision-making situation and any possible harm that may result from respecting the patient's choice. The book stresses that patients may understand disclosed information and yet fail to appreciate that this information applies to their own clinical situation. For example, patients may not accept their diagnosis or may not believe that they will not benefit from the recommended treatment. In this book, case vignettes are effectively used to illustrate these points.

The next several chapters provide comprehensive, practical information on how clinicians should assess a patient's decision-making capacity. The authors suggest specific questions to ask and provide useful practical advice on how to carry out the interview. Although the authors favor the MacArthur Competence Assessment Tool, which they developed and tested, they acknowledge that physicians may prefer to use other questions. They also make it clear that no threshold score on a standardized instrument can identify patients whose ability to make a decision is inadequate. The level of impairment that disqualifies patients as decision makers should vary according to the likely benefits and risks of treatment.

A few limitations of the book need to be pointed out. The book gives relatively little attention to the ultimate question -- how to judge whether the patient's choice should be respected or whether decision-making power should be given to a surrogate. It would be useful to learn more about how to make judgments in difficult situations, such as cases in which patients refuse to cooperate with an interview or hold cultural beliefs about illness that are inconsistent with Western biomedicine. Likewise, they might give more specific advice on how to adjust the standards for assessing decision-making capacity according to the relative risks and benefits of treatment. Clearly there is a danger that such adjustment may be inconsistent or biased and therefore unfair.

The authors stress that these difficult judgments about decision-making capacity should be made by the patient's attending physicians; routine psychiatric consultation or involvement of the courts is neither feasible nor desirable. These decisions require expertise, judgment, and wisdom. This book provides extremely useful guidance.

Review

"A clinical masterpiece. Drs. Grisso and Appelbaum have written a practical, clinical gude to assessing an individual's competence to consent to treatment. Their scholarly reviews and focused clinical vignettes make this volume an essential element of all physicians' personal libraries."--Thomas N. Wise, M.D., Chairman, Department of Psychiatry, Georgetown University

"...an insanely competent exercise in logic and clarity."--The Journal of Clinical Research Best Practices

"Every few decade comes a book so influential that the history of the entire field is divided into 'before' and 'after'. Assessing Competence to Consent to Treatment is such a book: a clinical, legal, and scientific accomplishment so complete that it will be the odd reader who does not turn the final page and think, 'this is what scholarship should be.' A staggering accomplishment!"--John Monahan, Ph.D., Doherty Professor of Law, University of Virginia

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