Psychiatric Patient Capacity Evaluations Likely Highlight Other Ethical Issues
July 1, 2025
By Stacey Kusterbeck
If a psychiatrist requests evaluation of a patient’s decision-making capacity, there almost always are additional ethical concerns, a recent study found.1 “These cases are challenging for both patients and providers. Both parties typically have a shared goal to help the patient feel better, but they might disagree on how to get there,” says Brandon Hamm, MD, MS, the study’s lead author and an attending psychiatrist at Northwestern Memorial Hospital.
Even when everyone agrees patients should have autonomy in their decisions, ethical concerns arise about whether such decisions are truly well-informed and carefully considered. “This is where the determination of capacity becomes critical to patients’ care,” says Rohan Shah, another of the study authors and a medical student at Northwestern University.
Hamm, Shah, and colleagues analyzed 145 decision-making capacity cases to assess whether 27 additional ethical context factors were present. The vast majority (93.1%) of cases featured one or more additional ethical context factors. These were the most common:
- The patient was refusing, or not adhering to, inpatient treatment.
- The patient was leaving against medical advice.
- There were concerns about the patient having difficulty obtaining recommended outpatient treatment after discharge from the hospital.
- Clinicians needed help determining the correct surrogate decision-maker.
- Clinicians were considering referring the patient to palliative care or hospice.
- There was a conflict over patient disposition.
“The most distressing cases usually have overlapping and interacting ethical context factors. Navigating these situations requires creativity and openness, collaboration, and willingness to think with the lens of what is the ‘least bad’ option,” says Hamm. Ethics consultants can help to navigate the value-laden challenges that often arise in decision-making capacity evaluations.
“It’s a good idea for psychiatrists to screen for additional ethical context factors in decision-making capacity evaluations,” adds Shah. By doing this, psychiatrists can more readily identify cases where ethics consultation may be helpful. In cases involving psychiatric decision-making capacity, clinicians frequently collaborate with ethicists in these two situations, says Hamm:
- cases involving uncertainty about thresholds for emergency interventions or disagreements about disposition;
- cases where there is concern for preventable harm in patients with questionable capacity.
“Ethics consultations help the team to reach a consensus and also offer moral support to clinicians experiencing moral distress,” says Hamm.
Decisional capacity in medicine is “extremely complicated and often has high-stakes implications for patients and their families,” says Jacob M. Appel, MD, JD, MPH, HEC-C, director of ethics education in psychiatry at Icahn School of Medicine at Mount Sinai and an attending physician at Mount Sinai Health System. Many of these cases have both ethical and psychiatric components. ”All too often, physicians, including psychiatrists, are too quick to apply widely accepted criteria for capacity assessment without investigating the larger context that has given rise to concerns about capacity in the first place,” says Appel.
Substantial data also exist that racial bias, usually unintentional, is widespread in capacity assessments.2 “Some situations, such as those of patients who possess underlying values inconsistent with allopathic medicine, simply are unsuited for the dominant model of capacity assessment currently in use,” says Appel.
In Appel’s experience, ethicists can prove very helpful in asking hard questions about capacity assessments. Ethicists may recognize that an assessment is unnecessary, since the care team is not going to force the care on an unwilling patient regardless of that patient’s capacity status. For example, an elderly patient with a terminal illness may be turning down life-prolonging dialysis treatments without understanding the significance of refusing care. “Clinicians might have a legal right to sedate and dialyze this patient three times a week, but if the patient fought back and it caused great distress, it might be the ethical choice not to do so,” says Appel.
Ethicists can help providers discern which cases are unsuited for traditional assessment models, such as those of Christian Scientists. “An alternative approach for such cases involves a deeper examination of the patient’s underlying values in relation to their current choices,” says Appel.3
Ethicists also can explore with clinicians what the unintended consequences of capacity assessments may be. For instance, refusing a patient’s request to leave against medical advice may have medical benefits, but if the patient needs to leave to pay rent or feed pets at home, there may be other negative results. “Forcing care on a patient in such circumstances can do serious damage to the physician-patient relationship and may deter a patient from seeking care in the future,” says Appel.
In difficult cases, clinicians may themselves want support from ethicists who can reassure them that they are acting within the bounds of accepted ethical norms. Often, physicians are troubled when a patient with decisional capacity makes a choice that the provider finds unsettling. This can happen when a young person refuses potentially lifesaving or life-prolonging care. “Doctors, after all, often consider themselves in the business of saving lives, and many go into the field to do so. Under such circumstances, an ethicist can reassure the physician that deferring to the patient’s autonomy is not only a legal obligation, but also consistent with ethics and decency,” offers Appel.
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
References
1. Hamm B, Shah RM, Hogue O, et al. Quantitative analysis of ethical complexities underlying psychiatric decision-making capacity evaluations: Prevalence and cooccurrence of contributing factors. J Psychiatr Pract. 2025;31(2):95-99.
2. Garrett WS, Verma A, Thomas D, et al. Racial disparities in psychiatric decisional capacity consultations. Psychiatr Serv. 2023;74(1):10-16.
3. Appel JM. A values-based approach to capacity assessment. J Leg Med. 2022;42(1-2):53-65.
Psychiatric capacity evaluations often involve hidden ethical challenges, such as treatment refusal, surrogate ambiguity, and racial bias. Ethicists assist in contextualizing decisions, preserving autonomy, and supporting providers in ethically fraught scenarios involving complex patient values.
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