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Am J Psychiatry 1995; 152:1033-1037
Copyright © 1995 by American Psychiatric Association
Comparison of standards for assessing patients' capacities to make treatment decisions
T Grisso and PS Appelbaum
Department of Psychiatry, University of Massachusetts Medical Center, Worcester 01655, USA.
OBJECTIVE: This study investigated the proportion of psychiatric and
medical patients who are impaired in their decision-making abilities in
relation to each of several major legal standards for determining
competence to consent to treatment. METHOD: The subjects were hospitalized
patients with diagnoses of schizophrenia (N = 75), major depression (N =
92), and ischemic heart disease (N = 82) and equal numbers of community
comparison subjects matched on age, race, gender, education, and
occupation. Three instruments measuring abilities related to the legal
standards for competence were administered to each group. Impaired
functioning was defined as scores two standard deviations below the means
for all subjects combined or lower. RESULTS: Although similar percentages
of subjects with impaired performance were found for each of the measures,
different groups of patients were identified as impaired depending on the
measure used. The proportion of patients identified as impaired increased
when compound standards were used, i.e., when impairment was defined as
poor performance on any of two or three measures. Despite previous
suggestions that the legal standards might form a hierarchy of
rigorousness, the data did not support this hypothesis. CONCLUSIONS: Choice
of standards for determining competence, including compound standards, will
affect the identity and proportion of patients classified as impaired.
Clinicians should be aware of applicable standards in their jurisdictions.
Use of compound standards requires independent evaluation of performance on
abilities related to each relevant standard, because standards do not
appear to be hierarchical. Policies relating to the characterization of
persons as incompetent must be fashioned with caution.
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