BackgroundAssessment of capacity to consent to treatment is an important legal and ethical issue in daily medical practice. In this study we carefully evaluated the capacity to consent to treatment in patients admitted to an acute medical ward using an assessment by members of the medical team, the specific Silberfeld's score, the MMSE and an assessment by a senior psychiatrist.MethodsOver a 3 month period, 195 consecutive patients of an internal medicine ward in a university hospital were included and their capacity (...) to consent was evaluated within 72 hours of admission.ResultsAmong the 195 patients, 38 were incapable of consenting to treatment (unconscious patients or severe cognitive impairment) and 14 were considered as incapable of consenting by the psychiatrist (prevalence of incapacity to consent of 26.7%). Agreement between the psychiatrist's evaluation and the Silberfeld questionnaire was poor (sensitivity 35.7%, specificity 91.6%). Experienced clinicians showed a higher agreement (sensitivity 57.1%, specificity 96.5%). A decision shared by residents, chief residents and nurses was the best predictor for agreement with the psychiatric assessment (sensitivity 78.6%, specificity 94.3%).ConclusionPrevalence of incapacity to consent to treatment in patients admitted to an acute internal medicine ward is high. While the standardized Silberfeld questionnaire and the MMSE are not appropriate for the evaluation of the capacity to consent in this setting, an assessment by the multidisciplinary medical team concurs with the evaluation by a senior psychiatrist. (shrink)

Psychiatrists are the health care professionals most frequently called upon to determine the competency of a patient to refuse treatment. The motives for determining competency vary in morally significant ways. This paper explores what I term ‘the ideal motivational situation’ for determining a patient's competency: a desire to respect the patient's autonomy, a desire to promote the patient's overall best interests, and a belief that when these two motives conflict the patient's autonomy should not be dismissed out of hand as (...) a partial patient interest which is naturally outweighed by the totality of his or her interests. I claim that in a liberal, democratic society autonomy ought to trump best interests and be the sole criterion of patient competence. I conclude by offering an essentially aesthetic criterion for determining autonomy. (shrink)

The terms “competency” and “decision making capacity” are often used interchangeably in the medical setting. Although competency is a legal determination made by judges, “competency” assessments are frequently requested of psychiatrists who are called to consult on hospitalised patients who refuse medical treatment. In these situations, the bioethicist is called to consult frequently as well, sometimes as a second opinion or “tie breaker”. The psychiatric determination of competence, while a clinical phenomenon, is based primarily in legalism and can be quite (...) different from the bioethics approach. This discrepancy highlights the difficulties that arise when a patient is found to be “competent” by psychiatry but lacking in DMC by bioethics. Using a case, this dilemma is explored and guidance for reconciling the opinions of two distinct clinical specialties is offered. (shrink)