In this provocative episode of Psychiatry Boot Camp, Dr. Omar Mirza discusses the limitations and potential harms of the standard Applebaum-Grisso criteria for decisional capacity.

Dr. Mirza argues that the current medicalized focus on cognitive abilities (understanding, appreciation, reasoning) can inadvertently subvert patient autonomy. The conversation traces the legal evolution of informed consent, from Schloendorff to the Nuremberg Code, and introduces radical alternative frameworks: Dr. Jacob Appell’s Values-Based Assessment and Dr. Mirza’s own "FREE WILL" model.

This episode challenges clinicians to view the capacity assessment not as a benign measurement, but as a potent intervention with significant risks, advocating for a humble, approach that prioritizes the "dignity of risk" over institutional paternalism.

Takeaways:

Shift from Assessment to Intervention: Capacity evaluations should be reconceptualized as "challenges" or "interventions" rather than benign measurements, acknowledging their potential to damage the therapeutic alliance and cause iatrogenic harm.

Values Over Cognition: The traditional cognitive model fails to account for a patient’s personal values; a Values-Based Assessment investigates discordance between a choice and a patient's longitudinal values rather than just their ability to justify the choice.

The "Respectable Minority" Rule: Medicolegally, physicians may meet the standard of care by following a "respectable minority" opinion, allowing for the use of emerging, viable alternative models to the dominant Applebaum standards.

Addressing Power Asymmetry: Capacity assessments often function as a "colonial act" or a "flex of power" that only exists within hospital boundaries, disproportionately impacting those with lower socioeconomic status or different cultural perspectives.

The "FREE WILL" Framework: A mnemonic for clinicians to navigate the legal (Foundation, Reason, Everyone, Expectation) and clinical (Want, Investigation, Listen, Logical solution) levers of capacity.
Dignity of Risk: Respecting autonomy means allowing for "unwise" or risky decisions that are consistent with a patient's identity.

REFERENCES:

The CL Psychiatrist: Decisional Capacity: Autonomy vs. Beneficence (Graphic Novel by Dr. Mirza): https://www.amazon.com/CL-Psychiatrist-Decisional-Capacity-Beneficence/dp/0990827763

Zürcher T, Elger B, Trachsel M. “The Notion of Free Will and Its Ethical Relevance for Decision-Making Capacity.”: https://pubmed.ncbi.nlm.nih.gov/31068168/

Mirza OF, Appel JM. “Capacity Reconceptualized: From Assessment Tool to Clinical Intervention.”: https://pubmed.ncbi.nlm.nih.gov/36825923/

Appelbaum PS. “Assessment of Patients’ Competence to Consent to Treatment.”

PubMed: https://pubmed.ncbi.nlm.nih.gov/17978292/

Perske R. “The Dignity of Risk and the Mentally Retarded.”: https://pubmed.ncbi.nlm.nih.gov/5059995/

SUPPORT OUR PARTNERS:

⁠⁠⁠⁠⁠⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months)

Cozy Earth: Start the New Year off right and give your home the luxury it deserves, and make home the best part of life. Head to http://www.cozyearth.com and use my code BOOTCAMP for up to 20% off. And if you get a Post-Purchase Survey, be sure to mention you heard about Cozy Earth right here!

Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/

For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Sales@Human-Content.Com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠

Connect with HumanContent on Socials: @humancontentpods

Produced by: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Human Content⁠

Learn more about your ad choices. Visit megaphone.fm/adchoices