Illusory Consent: When an Incapacitated Patient Agrees to Treatment

Abstract:     
Medical treatment requires informed consent, which in turn requires decision making capacity. When a patient with questionable capacity does not resist treatment, these requirements are often neglected: treatment is administered with no assessment of capacity and no consideration of alternative decision making. A variety of ethical and legal forces contribute to this neglect. The practical effect is that patients are treated when, if they had capacity, they would refuse treatment. This subverts the dominant interest in health care decision making: patient autonomy.

After surveying current law and practice, this article addresses the following issues: (1) when to test patients for capacity; (2) how to test capacity; and (3) what to do when capacity is lacking. The guiding principle throughout is that treatment decisions should correspond as closely as possible to patients' true preferences. On the first question, existing data and new theory are marshaled in support of mandatory capacity assessment in various circumstances. Second, this article argues that standardized instruments rather than physician discretion should be used to assess capacity. Third, when capacity is lacking and the patient does not resist treatment, a familial surrogate should make the medical decision because family predict patient preferences better than doctors.

Number of Pages in PDF File: 55

Keywords: health care decision-making, informed consent

JEL Classification: C11, I10, K13, K32

Accepted Paper Series