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

Once in a great while comes a book that is of major significance in a professional field. This relatively small book is one of those seminal works. The authors, both nationally known figures in the field of law and mental health, present a very practical guide, written in a clear, concise, and useful manner, to assessing patients' competency to consent to treatment. Dr. Appelbaum has been one of the leading authorities on forensic psychiatry for the last decade or more, and his colleague at the University of Massachusetts Medical School, psychologist Dr. Thomas Grisso, has written extensively in this area. Together, they have accomplished a tour de force in the field of psychiatry and law.

The book should be extremely helpful to all mental health professionals because it gives clear guidelines about complex and often misunderstood legal concepts related to competency and presents case examples to clarify the concepts. Most of all, the authors indicate that their suggestions, recommendations, and conclusions are based on sound principles of law and mental health ethics. Such a grounding is very important because ethics has driven the field of forensic psychiatry and must be a paramount consideration in any discussion involving the rights of individuals, especially those with mental illness. The authors note the vulnerability of mentally ill persons and the danger that authoritarian caretakers may fail to consider their wishes, especially if they are uncertain how to assess patients' decision-making capacities.

Grisso and Appelbaum point out two very important issues. First, a person who is mentally ill is not necessarily incompetent to consent to treatment. Second, the competency assessment must consider more than just the mental illness of the individual; it must take into account the effect of that illness on the individual's decision-making abilities.

The authors reiterate elements of voluntariness in patients' consent. For instance, patients must understand the meaning of the situation in which they find themselves, must be able to consider options and to appreciate their consequences, and must be able to articulate a choice.

The authors clearly state that clinicians cannot assess a patient's competence with a cookbook approach, but must draw on their clinical experiences as they are circumscribed by legal and ethical concepts. Nevertheless, with the support of the MacArthur Foundation, they have developed the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). The instrument is reproduced in the appendix, and its use is discussed in two of the chapters.

Some psychiatrists may be more comfortable than others in using an instrument such as the MacCAT-T to conduct a competency examination. Some would prefer to rely on their clinical experience rather than being bound by an instrument. One is reminded of the McGarry instrument for assessing competency in criminal cases, widely used for several years but less so now. The authors wisely counsel that the MacCAT-T is a guideline to be employed when appropriate. Competency assessors can certainly adopt the instument as an adjunct to clinical experience to be certain that all appropriate questions are asked and responses properly evaluated.

Finally, the authors discuss what to do if the patient is incompetent, covering such matters as advance directives and use of families or the courts as substitute decision makers.

In general, Assessing Competence to Consent to Treatment is an excellent book for psychiatrists and mental health professionals who are called on to evaluate an individual's competency to proceed in either civil or criminal matters and, specifically, to consent to treatment. It is also useful for physicians who are attending patients about whom questions of competency arise. For psychiatrists who are involved in consultation-liaison work, it is an especially helpful book.

One final note: even beyond its usefulness in specific cases, this book is an important contribution to the literature because it underscores the need for the patient's autonomy in decision making as well as the importance of the assessor's role in encouraging the patient's autonomy according to the best principles of psychiatry, ethics, and law.

Dr. Sadoff is clinical professor of psychiatry at the University of Pennsylvania in Philadelphia and is in the private practice of forensic psychiatry.