A "capacity spectrum" is more suitable than a binary approach for determining whether someone should make their own treatment decisions, argues Adrian Pecotic.

In most countries, laws enable mentally ill people to be detained and medicated without their consent. In these places, the possibility of involuntary commitment colours every interaction with mental health systems, especially for those afflicted by the most serious disorders. The vital importance of one’s autonomy ensures the possibility of its loss will be a subtext of every appointment and check-in.

"Criteria are so broad they cannot capture variations in the severity and nature of symptoms experienced by different individuals... Psychiatrists should be required to show exactly what underlying capacities are inhibited by the disorder."

Mental health laws set out criteria for when a patient loses the right to refuse treatment. [Editor's note - these laws often 'compete' with human rights laws and conventions] Almost all jurisdictions commit patients when necessary for "the health or safety of the patient or for the protection of other persons" (UK Mental Health Act). Laws in most US states employ similar language, as do laws in Canada. A second common standard is a psychiatrist’s determination that a patient is incapable of making "a rational and informed decision as to whether or not to submit to treatment" (Texas Health and Safety Code). In the UK, a separate law, the Mental Capacity Act, covers incapacity to make medical decisions, while Scotland’s Mental Health Act includes both criteria. These laws protect people whose disorder causes a loss of the capacity to make treatment decisions. Without a way for psychiatrists to mandate treatment, debilitating symptoms may go untreated for months or years.

Sectioning powers are overused 

With these successes come many failures stemming from the overuse of involuntary commitment. The criteria are so broad they cannot capture variations in the severity and nature of symptoms experienced by different individuals. Statutes about the "health or safety of the patient" invite interpretations that judge a mentally-ill patient to be endangering herself as soon as she disagrees about whether to take medication. The same decision can motivate an appraisal that the process of making the decision was not “rational and informed.” The way the laws are written makes it too easy to act on a presumption that someone in the midst of a manic or psychotic episode cannot make responsible treatment decisions.

These issues call for a closer examination of what it means to possess the capacity to make responsible decisions. Decision-making requires many distinct abilities. One must decide on a goal, assess the situations, generate options, and perform many more mental tasks in the lead up to acting. Motivated by the amount of relevant factors, Adina Roskies, a Dartmouth College philosopher, argues that decision-making is not a unitary capacity, but “a constellation of capacities.” Looking at the many underlying capacities allows questions about a person’s ability to act responsibly to be answered in a nuanced manner. Problems with one capacity, say, “the ability to rationally assess… intentions” will have different impacts than difficulties with “inhibiting... responses.”  All these possibilities for variation suggests the capacity to make responsible decisions is a spectrum, not all or nothing.

Psychological capacities  

This view of decision-making clashes with the mental health laws we’ve seen. Those legal frameworks separate people into two distinct categories: those with the capacity to make responsible decisions and those without it. A spectrum is more suitable than a binary approach for determining whether someone should make their own treatment decisions. Each person’s illness presents a unique cluster of symptoms that interact with the psychological capacities involved in choice in different ways. Some symptoms, in some people, might interfere with one but not the other underlying capacity, and therefore inhibit decision-making in a particular way. The presence of a mental illness doesn’t show someone is unable to make treatment decisions responsibly. We need to consider how the illness impacts the capacities connected to choice.  

Consider two people undergoing manic episodes and neither want to take antipsychotic drugs. Both have many of the typical symptoms of mania, such as increased energy, irritability, and out of character behavior. Left untreated, these symptoms can persist for up to six months and, in future episodes, may become more intense and disruptive. Episodes may also last longer. Despite this, the first person worries about the side-effects of such medications and is concerned about long-term dependency. The second person doesn’t want drugs because of beliefs induced by an additional, common, symptom of mania — a delusion of grandiosity: e.g. he has special telepathic powers that drugs will interfere with. Since this delusion forms part of the reasoning for refusing medication his assessment of relevant circumstances isn’t accurate.

When such an important underlying capacity is diminished to so great an extent, involuntary treatment is likely appropriate. What’s crucial is someone without an understanding of the situation cannot consent to treatment or to the risks of not taking medication. In contrast, the first individual is aware of the risks and benefits of both options, so can consent to both. The current laws do not encourage attention to these differences. Instead, psychiatrists should be required to show exactly what underlying capacities are inhibited by the disorder.

Once we treat capacity as a spectrum rather than an either-or, it opens up possibilities for giving patients rights tailored to the capacities they possess.  Perhaps the bipolar person with grandiose delusions retains excellent impulse control, and can have substantial freedom of movement because of it. The other might lack impulse control, meaning that monitoring by friends, family, or professionals is prudent. People have their own, unique, illnesses that affect different capacities in different ways. A step might be necessary in one case, but a violation of rights in another. Laws guiding psychiatric practice should be better at telling the difference.

Using a more nuanced understanding of the capacity to consent to treatment can balance the competing goals of mental health legislation. On the one hand, we want to give patients as much autonomy as possible. On the other, psychiatrists need to be able treat those whose refusal to take medications is induced by disorder, not genuine desire. Attending to the impact of symptoms on the “constellation of capacities” that contribute to choice affords people as much autonomy as possible. Legislation that establishes clear and exact standards for the revocation of consent, and other rights, will go a long way towards assuaging fears of unjustified commitment. If people who need to interact with the mental health system are aware of the grounds on which determinations of capacity are made, decisions no longer look so arbitrary. There can be less guardedness around mental health professionals, and hopefully, better treatment outcomes as a result of that trust. 


Adrian Pecotic is a former Research Fellow at Georgia State University’s Neuroscience Institute. He recently completed an M.A. in Philosophy with a concentration in neuro-philosophy.


Opinions expressed in Mental Health Today's blog section are those of the contributing author.