Affect, Value and Problems Assessing Decision-Making Capacity

Valid informed consent to treatment requires that the person giving consent have decision-making capacity or (what amounts to the same thing) must be mentally competent. To date the most influential model for both conceptualizing what capacity is, and for assessing it clinically, is the “four abilities model” developed by Thomas Grisso and Paul Appelbaum. Despite its popularity, however, this framework is flawed. It not infrequently delivers the wrong verdict in certain kinds of cases involving strong emotions and/or problematic values. Given that we want to (a) avoid objectionable forms of paternalism (b) avoid labeling as incompetent those who simply have unusual values and (c) avoid assuming that mental illness entails lack of capacity, it can seem as if there is no good solution to the problems posed by these cases. Nonetheless, there is a way we can proceed while avoiding these moral pitfalls. In this paper I first offer a better way of conceptualizing what it is we are trying to determine in capacity assessments, and then sketch an alternative way to assess capacity that avoids the moral pitfalls while yielding better, more plausible results in the problem cases.