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Capacity In Healthcare: What It Is And How It's Assessed

Capacity In Healthcare: What It Is And How It’s Assessed

Updated on: December 3, 2023
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Written By Dr Ollie

Every article is fact-checked by a medical professional. However, inaccuracies may still persist.

The concept of capacity in medical ethics refers to a patient’s ability to make informed decisions about their healthcare.

In short, it means whether or not a patient has the mental faculties to make sensible decisions for themselves.

It’s incredibly important in medicine as we, as doctors, always want to do our best for patients while still respecting their personal beliefs.

In this article, I’m going to further explore just what capacity means to healthcare professionals, look at how it’s assessed and explain what happens when a patient doesn’t have capacity.

LEARN MORE: My comprehensive guide to medical ethics also covers medical capacity

What Is Capacity?

Capacity in medical ethics refers to the ability of a patient to understand the benefits, risks, and alternatives to a proposed treatment, as well as their ability to make informed decisions related to their healthcare.

It is an essential aspect of ethical medical practice, as practitioners must ensure that their patients possess sufficient understanding and cognitive abilities to participate in decisions regarding their treatment and care.

Capacity, in this context, can be defined as “a functional determination that an individual is or is not capable of making a medical decision within a given situation” (reference).

This concept is essential in ensuring that patients give valid consent to their medical treatment, which is another fundamental aspect of medical ethics.

Evaluating a patient’s capacity to make medical decisions is a critical responsibility for healthcare providers.

This assessment ensures that patients are respected and involved in their care and that their autonomy is valued.

Why Is Capacity Important In Medicine?

Every patient is assumed to have capacity unless proven otherwise.

This is fundamental to ethical medical practice as it stops doctors from doing whatever they want to patients without their explicit consent!

By evaluating a patient’s capacity, medical professionals are also able to identify any potential barriers to informed decision-making and address these issues to ensure the patient receives the best care possible.

A doctor wearing a long white coat
Doctors can evaluate a patient’s capacity

Additionally, assessing capacity helps medical professionals minimise harm, another cornerstone of medical ethics.

This is essential not only for making treatment decisions but also for determining factors such as whether a patient can provide informed consent for certain medical procedures.

Accurately assessing a patient’s capacity ensures that they are not subjected to unnecessary or harmful treatments based on miscommunication or lack of understanding.

How Is Capacity Assessed?

To assess a patient’s capacity, medical professionals typically consider whether the individual is able to:

  1. Understand the information relevant to their condition and treatment options
  2. Retain that information
  3. Weigh the potential risks and benefits of each option
  4. Communicate their decision back to the medical team

At each step, anything that can be done to aid the patient should be done.

Capacity Assessment Process Pixel Infographic

For example, a blind person wouldn’t lack capacity because they weren’t able to read a treatment information leaflet we wanted to give them- we’d need to give them a copy in braille.

Equally, if a dementia patient is normally more lucid in the mornings, treatment decisions should be put to them then rather than later in the afternoon when they become more obtunded.

This is a really important concept to note- capacity can change over time, so it generally should be assessed at the time when consent is needed for a particular treatment or procedure.

Capacity is also not a static concept.

A person might have the capacity to make some decisions but not others, depending on the complexity and specific circumstances.

A child with Down’s syndrome may have the capacity to decide whether or not they want a blood test but not whether or not they should have life-saving heart surgery.

As a doctor, it’s always key to avoid making assumptions about a patient’s capacity based solely on their age, appearance, or diagnosis.

What Happens If A Patient Lacks Capacity?

When a patient lacks decision-making capacity, the responsibility of decision-making falls on the medical team and appropriate surrogates.

In situations where the patient’s preferences are not explicitly stated, and there is no nominated surrogate, doctors base their decisions on the ‘best interests’ of the patient.

This takes into account the patient’s values, possible outcomes of different treatments, and the associated benefits and risks.

The focus is on what the patient would choose if they were able to make the decision themselves.

In many cases, clinical incapacity may be temporary or fluctuate over time, meaning continuous reassessment of the patient’s capacity to make decisions is required.

It’s crucial for the physician to have open communication with the patient’s family and any surrogate decision-makers.

Discussions should focus on providing key information about the patient’s medical condition, available treatment options, and the potential repercussions of various decisions.

Through this collaborative process, the healthcare team can ensure that decisions made on the patient’s behalf align with their desires and as far as possible respect their autonomy.

The Mental Capacity Act (2005)

The Mental Capacity Act (2005) is a significant piece of legislation in the United Kingdom that provides a legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to do these acts or make these decisions for themselves.

The act was implemented on 1st April 2007, following its royal assent on 7 April 2005.

Before the introduction of the Mental Capacity Act, matters concerning an individual’s mental capacity were dealt with under common law, which consists of accumulated judgments from individual cases.

The Mental Capacity Act sought to clarify and build upon these existing principles, thereby offering a more structured approach to assessing mental capacity.

At the core of the act are five key principles, designed to serve as guiding factors for healthcare professionals in their decision-making processes:

  1. A person should be assumed to have the capacity to make a decision unless proven otherwise
  2. An individual must be provided with appropriate support and assistance to make an informed decision
  3. A person has the right to make an unwise decision and must not be considered as lacking capacity solely based on the decision they make
  4. Actions and decisions made on behalf of someone lacking capacity should be in the person’s best interest
  5. Any actions taken must be the least restrictive option in terms of the individual’s rights and freedom of action

In practical terms, the Mental Capacity Act aids healthcare professionals in navigating the often-complicated ethical issues that arise when treating patients who are unable to make their own decisions.

Examples of such situations include withholding life-sustaining treatment, determining the best course of action for a patient’s long-term care and addressing advanced treatment decisions.

Personal Beliefs And Capacity

An important aspect of the concept of capacity is understanding the role personal beliefs play in a patient’s decision-making process.

Personal beliefs and values can greatly influence one’s decisions, including choices related to healthcare.

It is essential for healthcare professionals to respect the autonomy of patients and their right to make decisions based on their beliefs, even if those decisions seem illogical or irrational to others.

Respecting a patient’s personal beliefs and capacity does not mean, however, that healthcare providers should blindly accept decisions that may seem unreasonable.

Instead, the provider has an ethical obligation to ensure that the patient fully understands their situation, the potential consequences of their actions, and available alternative options.

In some cases, a patient’s seemingly irrational decision might actually reflect a lack of capacity to make informed decisions.

In such circumstances, healthcare providers should assess the patient’s understanding of the situation and provide any necessary support or interventions to ensure an appropriate level of capacity is achieved.

Challenges In Determining Capacity

Although the process of determining whether a patient has capacity or not might seem quite straightforward, in practice there are often a number of challenges you can face as a healthcare professional.

One of the primary challenges in determining capacity is the varying levels of cognitive ability among patients.

Some may have fluctuating capacity due to temporary or reversible conditions, while others might experience a progressive decline due to chronic or degenerative illnesses.

This variability can create difficulties for healthcare providers in assessing an individual’s decision-making capability at any given moment.

Additionally, cultural, linguistic, and educational differences can impact assessments of a patient’s decision-making capacity.

Different backgrounds might influence how individuals approach and express their decision-making processes.

For instance, while some cultures emphasise individual autonomy, others might give more weight to collective decision-making and family authority.

These variations can lead to misunderstandings and misinterpretations, complicating assessments of patients’ capacity.

Lastly, external factors such as stress, anxiety, or pain can also impact an individual’s capacity to make informed decisions.

As a doctor, you have to take these factors into account and consider whether temporary interventions or treatments could improve a patient’s decision-making abilities.

Final Thoughts

An adult with the capacity to make decisions about their own treatment is what the medical ethics pillar of autonomy rests on.

Patients have to be able to understand and appreciate what’s going on in order to make meaningful treatment decisions.

If you take anything away from this article, I hope that it’s the concept of capacity is fluid- it can vary depending on the person, decision and even time of day.

There’s no such thing as either having ‘capacity’ or not, it all depends on the circumstances and indeed who’s evaluating the patient.

About the author
After studying medicine at the University of Leicester, Dr Ollie now works as a junior doctor in London. His interests include medical education and expedition medicine, as well as having a strong belief in the importance of widening access to medicine.