Research Roundup

In this ethical consideration of capacity, Astrachan et al (2023) introduce a philosophical aspect which is relevant to many health professionals who deal with patients. The presumption of capacity is central to the contemporary doctrine of decision-making capacity (DMC) that helps protect an individual's autonomy.

However, the presumption of capacity is not necessarily straightforward, and the authors consider possible problems. For instance, we can either assume person P has DMC or it is established that P lacks DMC. Let us consider P, who shows signs of impairment and must decide between treatment options X or Y. P is evaluated to determine whether they have the DMC to decide. During the evaluation, P states that they want X. If we presume that P has DMC, then in principle the evaluation should stop and treatment X begun.

But, in practice, this is never done, and as the authors make clear: ‘There is an important distinction between no longer presuming something is true, which leaves open the possibility that it is true or false, and the conclusion that it is true or false.’ Between these two, the authors suggest, is an important unanswered question about what happens during a capacity evaluation, when it is not yet established whether P does or does not have capacity. This unanswered question is explored by the authors.