Beyond Capacity: Identifying Ethical Dilemmas Underlying Capacity Evaluation Requests

Abstract

Psychiatric consultations involving the evaluation of patients' medical decision-making capacity often seem to have little to do with truly compromised patient autonomy. The authors seek to examine hidden ethical dilemmas that lead to capacity evaluation requests. The authors utilize the "principlism" approach to biomedical ethics to illustrate some common moral issues in patient care that are poorly captured by the "autonomy-versus-paternalism" paradigm. Patient autonomy sometimes comes into conflict with ethical imperatives to do "good," to avoid harm, and to deliver care fairly, as well as with the autonomy of others. Consultation psychiatrists are well positioned to unearth these dilemmas and begin to address them. Effective engagement of everyday ethics in clinical medicine is hindered by reflexive resort to capacity evaluations when moral problems arise. Greater attention to matters of values, aggressive urges, and obligations to others can enhance the negotiation of routine ethical dilemmas.