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  • Print publication year: 2010
  • Online publication date: February 2011

3 - Capacity: the gatekeeper for autonomy


The previous chapter showed that, while the law may reject ‘hard’ paternalism, ‘soft’ paternalism (intervention on the basis of incapacity) remains a fundamental component of the law's approach to healthcare decision-making. As several commentators have pointed out, the operation of the capacity requirement may conceal ‘hard’ paternalism or favour societal interests over those of the individual in a way which may, in fact, be more damaging to a person's autonomy in practice that an overt recognition of limits on the right. Accordingly, an understanding of capacity is essential in order to appreciate what the principle of autonomy means at a conceptual level and how it operates in individual cases.

In adopting any principles in respect of capacity, the law makes normative choices. In the words of the United States President's Commission:

[A] conclusion about a patient's decisionmaking capacity necessarily reflects a balancing of two important, sometimes competing objectives: to enhance the patient's well-being and to respect the person as a self-determining individual.

This chapter examines the normative choices which have been made by the law in respect of capacity. It outlines the features of the current legal standard for capacity in England and Wales as set out in the Mental Capacity Act 2005 (MCA) and evaluates these in terms of consistency with the liberal principle of autonomy, which is recognised as providing the basis for the law in respect of healthcare decision-making.

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Feinberg, J., ‘Legal Paternalism’ (1977) 1 Canadian Journal of Philosophy 106
Harrington, J., ‘Privileging the Medical Norm: Liberalism, Self-Determination and Refusal of Treatment’ (1996) 16 Legal Studies 348, 358–62
Brazier, M., ‘Hard Cases Make Bad Law’ (1997) 23 Journal of Medical Ethics 341, 343
Scott, R., Rights, Duties and the Body: Law and Ethics of the Maternal-Fetal Conflict (Oxford: Hart Publishing, 2002), pp. 161–2
Commission, Law, Report on Mental Incapacity Report No. 231 (London: HMSO, 1995), pp. 39–40
Buchanan, A. and Brock, D., Deciding for Others: The Ethics of Surrogate Decision Making (New York: Cambridge University Press, 1989), p. 47
Kopelman, L., ‘On the Evaluative Nature of Competency and Capacity Judgments’ (1990) 13 International Journal of Law and Psychiatry 309
Gunn, M., ‘The Meaning of Incapacity’ (1994) 2 Medical Law Review 8, 14
,Medicine and Biomedical and Behavioural Research, Making Health Care Decisions: A Report on the Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship (Washington DC: US Superintendent of Documents, 1982), p. 57
Mills, J. (London, 1859) in Grey, John (ed.) On Liberty and Other Essays (Oxford University Press, 1991), p. 84
Dworkin, R., Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom (New York: Alfred A Knopf, 1993), p. 225
Rawls, J., Theory of Justice (Cambridge, MA: Harvard University Press, 1971), p. 516
Harris, J., The Value of Life (London: Routledge and Keegan Paul, 1985), p. 201
Beyleveld, D. and Brownsword, R., Human Dignity in Bioethics and Biolaw (Oxford University Press, 2002), p. 117
Bartlett, al., Mental Disability and the European Convention on Human Rights (Leiden: Martinus Nijhoff, 2007), Chapter 6
Keys, M., ‘Legal Capacity Law Reform in Europe: An Urgent Challenge’ in G. Quinn and L. Waddington (eds.) European Yearbook of Disability Law (Oxford: Hart Publishing, 2009)
Suto, al, ‘Capacity to Make Financial Decisions among People With Mild Intellectual Disabilities’ (2005) 49 Journal of Intellectual Disability Research 199
Appelbaum, P. and Grisso, T., ‘The MacArthur Treatment Competence Study I: Mental Illness and Competence to Consent to Treatment’ (1995) 19 Law and Human Behaviour 105
Bellhouse, al., ‘Capacity-Based Mental Health Legislation and its Impact on Clinical Practice: 2) Treatment in Hospital’ (2003) Journal of Mental Health Law24
Owen, al., ‘Mental Capacity to Make Decisions on Treatment in People Admitted to Psychiatric Hospitals: Cross Sectional Study’ (2008) 337 British Medical Journal 40
Shelford, L., Practical Treatise on the Law Concerning Lunatics, Idiots, and Persons of Unsound Mind (Philadelphia: J. S. Littell, 1833), p. 23
Roth, L., Meisel, A. and Lidz, C., ‘Tests of Competency to Consent to Treatment’ (1977) 134 American Journal of Psychiatry 279
Grisso, al, ‘The MacArthur Treatment Competence Study II: Measures of Abilities Related to Competence to Consent to Treatment’ (1995) 19 Law and Human Behaviour 127
Grisso, T. and Appelbaum, P., ‘The MacArthur Treatment Competence Study III: Abilities of Patients to Consent to Psychiatric and Medical Treatments’ (1995) 19 Law and Human Behaviour 149
Jones, M. and Keywood, K, ‘Assessing the Patient's Competence to Consent to Medical Treatment’ (1996) 2 Medical Law International 107
Culver, C. and Gert, B., ‘The Inadequacy of Incompetence’ (1990) 68 The Milbank Quarterly 619
Dworkin, R., Life's Dominion, p. 239. A similar argument may be made about the Kantian view of rationality as morality as described in O. O' Neill, Autonomy and Trust in Bioethics (Cambridge University Press, 2002), p. 85
Stefan, S., ‘Silencing the Different Voice: Competence, Feminist Theory and Law’ (1993) 47 University of Miami Law Review 763¸ 772
Miles, S. and August, A., ‘Courts, Gender and the Right to Die’ (1990) 18 Law, Medicine and Healthcare 85
Lloyd, G., The Man of Reason: ‘Male’ and ‘Female’ in Western Philosophy (London: Metheun Publishing, 1984)
Grisso, T. and Appelbaum, P., Assessing Competence to Consent: A Guide for Physicians and Other Health Professionals (New York: Oxford University Press, 1998)
Appelbaum, P., ‘Assessment of Patients’ Competence to Consent to Treatment' (2007) 357 New England Journal of Medicine 1834
Charland, L., ‘Is Mr Spock Mentally Competent?: Competence to Consent and Emotion’ (1998) 5 Philosophy, Psychiatry and Psychology 67
Somerville, M., ‘Refusal of Medical Treatment in “‘Captive” Circumstances’ (1985) 63 Canadian Bar Review 59, 65–8
Glass, K., ‘Refining Definitions and Devising Instruments: Two Decades of Assessing Mental Competence’ (1997) 20 International Journal of Law and Psychiatry 5, 20–3
Bill, Mental Health (First Report of the Joint Committee on the Draft Mental Health Bill (HL Paper 79–1; HC 95–1) (London: The Stationery Office, 2005), para. 153
Damasio, A. R., Descartes' Error: Emotion, Reason and the Human Brain (New York: Grosset/Putnam, 1994)
Elliot, C., Bioethics, Culture and Identity: A Philosophical Disease (New York: Routledge, 1999)
Rudnick, A., ‘Depression and Competence to Refuse Psychiatric Treatment’ (2002) 28 Journal of Medical Ethics 155
White, B. Cox, Competence to Consent (Washington DC: Georgetown University Press, 1994), p. 132
Breden, T. and Vollmann, J., ‘The Cognitive-Based Approach of Capacity Assessment in Psychiatry: A Philosophical Critique of the MacCAT-T’ (2004) 12 Health Care Analysis 273
Appelbaum, P., ‘Ought We to Require Emotional Capacity as a Part of Decisional Competence?’ (1999) 8 Kennedy Institute of Ethics Journal 377, 385
Faden, R. and Beauchamp, T., A History and Theory of Informed Consent (New York: Oxford University Press, 1986), p. 265
Grubb, A., Kennedy and Grubb Medical Law (3rd edn) (London: Butterworths, 2000), p. 627
Gunn, al., ‘Decision-Making Capacity’ (1999) 7 Medical Law Review 269, 273
Richardson, G., ‘Autonomy, Guardianship and Mental Disorder: One Problem, Two Solutions’ (2002) 65 Modern Law Review 702, 705
Stern, K., ‘Competence to Refuse Life-Sustaining Medical Treatment’ (1994) 110 Law Quarterly Review 541, 545
,Consultation Paper of the Law Reform Commission, Vulnerable Adults and the Law: Capacity (LRC CP 37–2005) (Dublin: Law Reform Commission, 2005), para. 7.18
Berg, al., ‘Constructing Competence: Formulating Standards of Legal Competence to Make Medical Decisions’ (1996) 48 Rutgers Law Review 345, 352–62
,Law Commission, Consultation Paper No. 129, Mentally Incapacitated Adults and Decision-Making: Medical Treatment and Research, (London: HMSO, 1993), pp. 18–19
Eastman, N. and Dhar, R., ‘The Role and Assessment of Mental Incapacity: A Review’ (2000) 13 Current Opinion in Psychiatry 557
Bartlett, P., Blackstone's Guide to the Mental Capacity Act 2005 (2nd edn) (Oxford University Press, 2008), p. 51
Wicclair, M., ‘Patient Decision-Making Capacity and Risk’ (1991) 5 Bioethics 91, 103–4, original emphasis
Wilks, I., ‘The Debate Over Risk-Related Standards of Competence’ (1997) 11 Bioethics 413, 418
Brock, D., ‘Decisionmaking Competence and Risk’ (1991) 5 Bioethics 107, 112
Cale, G., ‘Risk-Related Standards of Competence: Continuing the Debate Over Risk-Related Standards of Competence’ (1999) 13 Bioethics 132, 140–1
Buller, T., ‘Competence and Risk-Relativity’ (2001) 15 Bioethics 93, 105–6
Raymont, al., ‘Prevalence of Mental Incapacity in Medical Inpatients and Associated Risk Factors: Cross-Sectional Study’ (2004) 364 Lancet 1421
Wong, J. al., ‘Decision Making Capacity of Inpatients With Schizophrenia in Hong Kong’ (2005) 193 Journal of Nervous and Mental Disease 316
Roth, al., ‘Competency to Decide About Treatment or Research’ (1982) 5 International Journal of Law and Psychiatry 279
Lidz, C. and Arnold, R., ‘Institutional Constraints on Autonomy’ (1990) 14 Generations 65
Lidz, al., The Erosion of Autonomy in Long-Term Care (New York: Oxford University Press, 1992)
Okai, al., ‘Mental Capacity in Psychiatric Patients: Systematic Review’ (2007) 191 British Journal of Psychiatry 291, 294
Secker, B., ‘Labelling Patient (In)Competence: A Feminist Analysis of Medico-Legal Discourse’ (1999) 30 Journal of Social Philosophy 295
Cairns, et al., ‘Prevalence and Predictors of Mental Incapacity in Psychiatric In-Patients’ (2005) 187 British Journal of Psychiatry 379, 383
Wall, al., Systematic Review of Research Relating to the Mental Health Act 1983 (London: Department of Health, 1999)
Stefan, S., ‘Race, Competence Testing and Disability Law: A Review of the MacArthur Competence Research’ (1996) 2 Psychology, Public Policy and Law 31
Estroff, al., ‘Everybody's Got a Little Mental Illness: Accounts of Illness and Self Among People With Severe Persistent Mental Illness’ (1991) 5 Medical Anthropology Quarterly 331, 357
Sherwin, S., No Longer Patient: Feminist Ethics and Health Care (Philadelphia: Temple University Press, 1992), pp. 156–7
Maeckelberghe, E., ‘Feminist Ethic of Care: A Third Alternative Approach’ (2004) 12 Health Care Analysis 317
Lundin, al., The Promise of Hermeneutics (Cambridge: Paternoster Press, 1999), p. 134
Clegg, J., ‘Practice in Focus: A Hermeneutic Approach to Research Ethics’ (2004) 32 British Journal of Learning Disabilities 186, 186
Benaroyo, L. and Widdershoven, G., ‘Competence in Mental Health Care: A Hermeneutic Perspective’ (2004) 12 Health Care Analysis 295, 298, original emphasis
Winick, B., ‘The Right to Refuse Mental Health Treatment: A Therapeutic Jurisprudence Analysis’ (1994) 17 International Journal of Law and Psychiatry 99, 100
Wexler, D. and Winick, B., Essays in Therapeutic Jurisprudence (Durham, NC: Carolina Academic Press, 1991)
Wexler, D. and Winick, B. (eds.) Law in a Therapeutic Key: Developments in Therapeutic Jurisprudence (Durham, NC: Carolina Academic Press, 1996)
Slogobin, C., ‘Therapeutic Jurisprudence: Five Dilemmas to Ponder’ (1995) Psychology, Public Policy and Law1933
Behnke, S. and Saks, E., ‘Therapeutic Jurisprudence: Informed Consent as a Clinical Indication for the Chronically Suicidal Patient With Borderline Personality Disorder’ (1998) 31 Loyola of Los Angelus Law Review 945, 978–81
Winick, B., ‘The Side Effects of Incompetency Labelling and the Implications for Mental Health Law’ (1995) 1 Psychology, Public Policy and Law 6
Seligman, M., Helplessness: On Depression, Development and Death (San Francisco: Freeman, 1975)
Winick, B., ‘The MacArthur Treatment Competence Study: Legal and Therapeutic Implications’ (1996) 2 Psychology, Public Policy and Law 137, 151
Dhanda, A., ‘Legal Capacity in the Disability Rights Convention: Stranglehold of the Past or Lodestar for the Future?’ (2006–2007) 34 Syracuse Journal of International Law and Commerce 429
Carson, D., ‘Disabling Progress: The Law Commission's Proposals on Mentally Incapacitated Adults’ Decision-Making' (1993) 15 Journal of Social Welfare and Family Law 304, 313
Fennell, P., ‘Statutory Authority to Treat, Relatives and Treatment Proxies’ (1994) 2 Medical Law Review 30, 36
Green, M., ‘Proof of Mental Incompetency and the Unexpressed Major Premise’ (1944) 53 Yale Law Journal 271
Feinberg, J., The Moral Limits of the Criminal Law: Vol III: Harm to Self (New York: Oxford University Press, 1986), pp. 118–19
deMarco, J., ‘Competence and Paternalism’ (2002) 16 Bioethics 231
Keown, J., ‘Restoring Moral and Intellectual Shape to the Law after Bland’ (1997) 113 Law Quarterly Review 481
Singer, P., Rethinking Life and Death: The Collapse of Our Traditional Ethics (New York: OUP, 1994), p. 75
McGee, A., ‘Finding a Way through the Ethical and Legal Maze: Withdrawal of Medical Treatment and Euthanasia’ (2005) 13 Medical Law Review 357
Brazier, M. and Bridge, C., ‘Coercion or Caring: Analysing Adolescent Autonomy’ (1996) 16 Legal Studies 84
Tan, J., ‘The Anorexia Talking’ (2003) 362 Lancet 1246
Tan, al., ‘Anorexia Nervosa and Personal Identity: The Accounts of Patients and Their Parents’ (2003) 26 International Journal of Law and Psychiatry 533
Tan, al., ‘Competence to Refuse Treatment in Anorexia’ (2003) 26 International Journal of Law and Psychiatry 697
Tan, al., ‘Competence to Make Treatment Decisions in Anorexia Nervosa: Thinking Processes and Values’ (2006) 13 Philosophy, Psychology and Psychiatry 267
Rudnick, A., ‘Depression and Competence to Refuse Psychiatric Treatment’ (2002) 28 Journal of Medical Ethics 155
Dunn, al., ‘To Empower or to Protect? Constructing the “Vulnerable Adult” in English Law and Public Policy’ (2008) 28 Legal Studies 234, 236–8
Enright, M., ‘Choice, Culture and the Politics of Belonging: The Emerging Law of Forced and Arranged Marriage’ (2009) 72 Modern Law Review 331
Herring, J., ‘R v. C: Sex and Mental Disorder’ (2010) 126 Law Quarterly Review 36
Herring, J., ‘Protecting Vulnerable Adults: A Critical Review of Recent Case Law’ (2009) 21 Child and Family Law Quarterly 498