This book explores the role that values and value judgements play in assessments of capacity. In doing so, it has attempted to grapple with a fundamental tension that lies at the heart of our capacity legislation. On the one hand, the liberal intuitions that underpin the test for capacity suggest that people ought to be free to make decisions according to their own values and beliefs, no matter how unusual or eccentric these may be. On the other, there are certain beliefs or ways of valuing that we intuitively regard as so abnormal, and so harmful, that we think that far from facilitating decisions based on them, people ought instead to be protected from them. We characterise these beliefs, values, or behaviours as ‘disordered’, yet as the foregoing analysis has shown, the line between the disordered and the eccentric is far from clear cut, being both socially and culturally contingent, and reliant on complex clinical judgements, rather than a matter of objective medical fact.

This chapter will explore how the provisions governing best interests assessments ought to be reformed so as to better ensure that an agent’s authentic desires are being prioritised in decisions being taken about them. The starting point should be that the assessor ascertains ‘so far is reasonably practicable’ the individual’s wishes, feelings, beliefs, and values. This should then be supplemented by a presumption that the agent’s wishes and feelings will be determinative of what is in their best interests, except when giving effect to them will expose the person to a risk of significant harm. Even where the harms are significant, however, there will still be occasions where the agent’s wishes and feelings should nonetheless take precedence; where to do otherwise would involve frustrating their deeply and authentically held beliefs, values, or commitments. This chapter will highlight some of the potential considerations which ought to guide assessors in these circumstances. It will propose that assessors be provided with a list of factors that they must take into account when determining the degree of weight to be ascribed to the agent’s wishes, which reflect these considerations.

The Introduction summarises the core themes of the book and outlines how the argument will proceed over the course of its chapters. It explains why the issue it centres around – namely, how the law grapples with the impact of mental disorder on decision-making – is so important, and why successfully navigating the tension between respect for (and deference to) idiosyncratic values, and protection from disorder or impairment, must be a precondition of England and Wales adopting ‘fused’ mental capacity and health legislation, or a more CRPD-compliant statutory framework. It also explains how the book relates to the existing literature in this area, which has focused in recent years on concerns about the binary nature of the capacity framework, and on the individualistic and rational ‘liberal subject’ on which this framework rests. Finally, it elaborates briefly on some of the concepts which the book will draw upon, in particular what is meant by ‘values’ and ‘beliefs’.

The foregoing discussion has highlighted the fundamental fragility of assessments of capacity, which hinge on a series of complex yet unavoidable clinical judgements about the person’s cognitive capacities and the origins of the beliefs or values that motivate their decision. This chapter will explore the implications of this for best interests assessments and, in particular, the extent to which due weight is currently being given to the person’s authentically held values and beliefs in the assessment of their best interests. Drawing on case law, interviews, and post-legislative scrutiny of the Mental Capacity Act, it will conclude that despite a number of empowering court decisions, the lack of direction contained in the Act on how to apply the MCA has still resulted in different weight being attributed to the agent’s wishes. Moreover, the trend towards greater empowerment has not yet trickled down to decisions being taken on the ground by doctors and care workers, which still remain characterised largely by paternalism and risk aversion. Those undertaking best interests assessments could therefore benefit from a more unified starting point and greater clarity on the factors which ought to influence the degree of weight accorded to the individual’s wishes.

Where the real basis for finding someone to lack capacity is that you consider the beliefs or values that motivate their decision to be distorted by a mental illness, such that the decision is not authentically desired and so is unworthy of respect, this entails a number of empirical and normative claims. This chapter will interrogate these claims by reference to the wide-ranging literature on the nature of mental disorder, and on differing conceptions of autonomy and authenticity (as a component of autonomous decision-making). It will be concluded that while an agent acting on the basis of disordered beliefs or values will often be acting inauthentically (and thus non-autonomously), this will not always be the case, and situations could arise in which there is reason to believe that the agent would endorse or sanction their belief, even knowing it is derived from illness. Moreover, once the shaky conceptual ground on which such judgements must be made is acknowledged, it becomes essential that these judgements are brought out into the open, where they can be subject to appropriate scrutiny.

The law adopts a cliff-edge approach to capacity, drawing a bright line between those who are deemed to have the capacity to make a decision and those who are not. This reflects Enlightenment ideas about the limits of legitimate state authority, according to which substantial justification is required before the state can interfere with the autonomous choices of its citizens. Given its role in distinguishing those who are capable of making autonomous choices (to whom the state defers) from those who are not, it is generally assumed that the test for capacity must be neutral as to the substance of the values, beliefs, or reasons underpinning any given decision, so as to leave proper space for individual autonomy. As a result, the Mental Capacity Act 2005 adopts a process-orientated account of capacity, which focuses on whether certain of the person’s cognitive capacities are intact, and not on the outcome of the decision, or on the substance or origins of values or beliefs which underpin it.

This chapter considers how the law might be reformed so as to better capture circumstances in which an agent’s capacity for autonomous decision-making is being undermined by a disorder or impairment which affects the values or beliefs that the agent applies to the information. It will begin by exploring the merits of including an ‘appreciation’ criterion in the test for capacity, before going on to consider whether more other, more explicit, criteria would be preferable. It will conclude that the challenges inherent in devising a workable legal test lean in favour of the law adopting a more blunt approach which focuses on the origins of the values or beliefs that the agent applies to the information in their decision-making. A new limb of the MCA is therefore proposed, which asks whether the person is unable to make a decision because the values or beliefs by which they evaluate the relevant information have been caused by or altered as a consequence of the person suffering from a disorder, illness, or impairment. Various potential challenges to such a provision will be explored and responded too.