Decisional Capacity Assessments and Autonomy in Psychiatrically Vulnerable Populations

Abstract: As a routine practice, decisional capacity assessments have become indispensable to clinicians in navigating the refusal of medically recommended care. Within New York State, a major contribution to the integration of decisional capacity in clinical care was the Family Health Care Decisions Act (FHCDA), which stipulates that a capacity assessment must be performed by a neurologist or psychiatrist whenever patients are thought to lack decisional capacity for reasons related to an underlying mood disorder. Though the presumed objective for this provision was upholding the rights of psychiatric patients who might require special protections, the actual result of the FHCDA in NY State is that capacity assessments are routinely fielded to consult psychiatry services whenever a psychiatric history is noted (or suspected) among patients who are refusing care. An unpalatable consequence of this FHCDA provision is that despite the additional scrutiny placed on the medical decision making of psychiatric patients, the law leaves completely undefined what the psychiatrist’s role in the subsequent capacity assessment should in fact be. In this paper, I center on this ambiguity to draw out several different possible interpretations of the psychiatrist’s role in determining capacity, using adapted cases from a clinical ethics consult service. Insofar as these competing interpretations have gone completely unaddressed in the literature, I call for the adoption of professional standards in delimiting the appropriate role of the psychiatrist in capacity assessments and situate the ethical implications of their unsystematized use among vulnerable populations.