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Previous Volume 358:644 February 7, 2008 Number 6 Next

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To the Editor: In his Clinical Practice article on the assessment of patients' competence to consent to treatment (Nov. 1 issue),¹ Appelbaum invokes the ability to reason as a central criterion for capacity. I consider this ethically troublesome. The criterion that can replace reasoning, with fewer unintended consequences, is consistency over time.² Capacity has more to do with acting characteristically than with acting reasonably.

Appelbaum concludes, for the case presented, that "psychiatric consultation should be considered" because of the possible presence of early dementia or depression, despite acknowledging that neither condition rules out capacity. Capacity is presumed for all adults, like the presumption of innocence in a criminal trial. When in doubt, capacity should be assessed by those who best know the patient. Hence, the primary care physician is usually better able to assess capacity than is a psychiatric consultant. When additional input is needed, a more patient-centered alternative to psychiatric consultation is available at most teaching hospitals — namely, an ethics consultation.

Jeffrey P. Spike, Ph.D.
Florida State University College of Medicine
Tallahassee, FL 32306-4300
jeffrey.spike{at}med.fsu.edu

References

1. Appelbaum PS. Assessment of patient's competence to consent to treatment. N Engl J Med 2007;357:1834-1840. [Free Full Text]
2. Spike JP. Assessment of decision-making capacity. In: Aronson C, Brummel-Smith K, eds. Reichel's care of the elderly. 6th ed. New York: Cambridge University Press (in press).

Although Spike would favor application of a consistency standard rather than reasoning, this is not generally accepted¹ — for good reason. Consistency with past behavior is a difficult determination,² especially for unprecedented decisions (e.g., amputation); moreover, a consistency standard risks denying patients the right to choose differently today than they have in the past.

Paul S. Appelbaum, M.D.
Columbia University College of Physicians and Surgeons
New York, NY 10032
psa21{at}columbia.edu

References

1. Berg JW, Appelbaum PS, Grisso T. Constructing competence: formulating standards of legal competence to make medical decisions. Rutgers Law Rev 1996;48:345-371. [ISI][Medline]
2. Gutheil TG, Appelbaum PS. Substituted judgment: best interests in disguise. Hastings Cent Rep 1983;13:8-11. [ISI][Medline]

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