The evolution of functional capacity
Functional Mental Capacity evolved first as a legal concept, arising from the interplay of expert evidence by clinicians and legal judgements and precedents, followed in some jurisdictions by legislation. The law identifies different competencies e.g. testamentary capacity, competency to marry, fitness to plead and stand trial. Decision-making capacity is but one element in the legal classification of competence. Decisional Capacity relates to a person’s ability to perceive, retain and understand information pertaining to the choices at hand, and to use this information to reason about and appreciate the consequences of the choice they may make. Capacity relates to a decision about a person’s capability to carry out a specific act or set of acts. Legal Competency relates to a decision made by a judge about whether a person, under the law, has or does not have the capability to carry out a specific act or set of acts. In this instance the clinician will provide the court with information summarising the person’s decision-making skills and offer an opinion on how these findings may affect the person’s abilities in a specific area. The judge then uses this information, together with legal factors to arrive at a finding of competence or incompetence.
A review of case law literature by Grisso and Appelbaum (1998) [
3] resulted in the so-called ‘four abilities’ model in the assessment of functional mental capacity, namely; the ability to understand the information pertinent to the decision at hand, in keeping with the relevant facts of the decision; the ability to reason with this relevant information so as to engage in a logical weighing and comparison of the positive and negative consequences; the ability to appreciate the significance of the information for one’s own situation; and the ability to make and communicate a decision relating to the decision at hand.
Historically, legislative approaches to incapacitated persons were paternalistic. These approaches have been criticised as not being in keeping with the spirit of the Universal Declaration of Human Rights [
4] and more explicitly in the United Nations’ Convention on the Rights of Persons with Disabilities, Article 3 (a) [
5] which states: “
The principles of the present Convention shall be: Respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and independence of persons.”
In most jurisdictions, modern legislation now includes specific statutory means of protecting the rights of people with mental disabilities, as seen in New Zealand, Ontario, Scotland and England and Wales. All assume presence of mental capacity unless established otherwise. However, all have slightly different definitions for the test of mental incapacity – some require the presence of mental disorder as a first step to define incapacity – as seen in Scottish law [
6], and others view capacity under separable domains [
7‐
9]. Newly published Irish legislation has also changed to a functional approach for capacity assessments [
10]. In this article, we are primarily concerned with the clinical assessment of functional mental capacity. We regard this as a continuum from fully capable to seriously impaired, like any other neurocognitive mental ability or any physical ability. We are not primarily concerned with legal standards or thresholds for competence or incompetence.
Difficulties in assessment of functional mental capacity
The assessment of functional mental capacity is one of the most ethically complex tasks which clinicians are called upon to perform on a routine basis. In every case a patient’s autonomy and right to self-determination must be weighed against a clinician’s judgment that as a consequence of illness, mental disorder or intellectual disability, they may not be capable of acting in their own best interest. Clinicians have an ethical and legal responsibility to demonstrate how an illness, mental disorder or intellectual disability may compromise an individual’s right to autonomy and self-determination when faced with a specific situation. However the reasons for doing this go beyond the assessment of legal competence. Clinicians must assess responses to treatment for many purposes. It is increasingly recognised that functional abilities are the most important outcomes of treatment for mental disorders such as schizophrenia [
2], and functional outcomes are for practical purposes more important than symptomatic improvement. Neurocognitive abilities, social cognition and metacognition all play a part in influencing symptoms and functional outcomes (Fett et al. [
11], Lam et al. [
12], Gallagher & Varga [
13], Lysaker et al. [
14]). Indeed deficits in metacognition may be one of the distinguishing features between schizophrenia and other debilitating physical illnesses (Lysaker et al. [
15]).
In practice the assessment of functional mental capacity can be complex and challenging. The complexity arises not only because of the balancing of responsibilities, but because functional mental capacity is inextricably linked with contextual and situational factors, and also because it is underpinned by a number of sequential cognitive process. In contrast to illnesses, mental disorders or intellectual disabilities, all of which may be static in nature, functional capacity is dynamic and refers to the extent to which patients can apply their abilities to a particular situation and context independently as well as when offered assistance. The cognitive processes which underpin functional capacity include comprehension, appreciation, reasoning, and judgment and difficulties may occur at any step of this process (Grisso and Appelbaum) [
3].
The potential gravity of recommending that a court find a person incompetent – i.e. denying that person the right to an autonomous choice, means that assessments of functional mental capacity can be lengthy and onerous. In such an assessment, the clinician must take account of the patient’s mental illness (or otherwise), cognitive function and social attitudes, as well as collateral information from a reliable informant where possible. Furthermore, the information shared by the clinician during the assessment of functional capacity should be such that it is easily understood by the person whose mental capacity is being assessed. This holds true even when the assessment is not for a medico-legal purpose.
Although psychological science has produced objective measures of cognitive capabilities, which can be usefully applied to capacity evaluations, it would be wrong to determine capacity solely on the basis of cognitive testing. This is because cut-off scores for a particular individual faced with a particular competency question can never be determined in advance. Moreover, the results of cognitive assessments are proxies and thus one step removed from the ultimate issue of whether a patient can understand, reason, appreciate and make and communicate a decision based on the unique demands of a particular situation. All of these factors can be more holistically and directly assessed using clinical interviews with the patient and informants. However, in contrast to cognitive assessments which have established psychometric properties, the reliability and validity of unstructured clinical interviews is unknown and unmeasurable.
Research by Volicer and Ganzini [
16] showed that psychiatrists, psychologists and geriatricians do not adhere to a uniform approach for the purpose of assessments of functional capacity. Their work supports the idea that physicians’ competence assessments are often subjective and inconsistent (Marson, McInturff et al.) [
17].
Case law [
18,
19] internationally has increasingly placed emphasis on the patient’s right to all material information pertaining to a particular proposed treatment, in order to make an informed decision. However, if a person is suffering from a psychotic illness, it is foreseeable that sharing too much information about treatment options may overburden the person’s capacities to make an informed treatment decision, as demonstrated by Kennedy, Dornan et al. [
20]. It follows that decision-making in other domains would be similarly affected. Furthermore, other illnesses such as dementia would have similar deleterious effects on decision-making ability.
There are a number of structured professional judgement tools which have been developed for assessment of functional mental capacity, the majority of which are based in Decision Theory [
21]; that is identifying the values, uncertainties and other issues relevant in a given decision, its rationality, and the resultant optimal decision. Perhaps the best-known of these in a forensic arena are the MacArthur Competence Assessment Tools for Consent to Treatment [
22] and Fitness to Plead [
23]. In a psycho-geriatric setting, other tools have also been devised, e.g. The Hopkins Competence Assessment Tool [
24]. Fazel, Hope and Jacoby [
25] have also published a structured approach to the assessment of mental capacity to complete advance directives, emphasising a patient centred approach. A key feature of these assessment tools is that they provide clinicians with a structure for carrying out their own interviews thus improving transparency, reliability and objectivity. For example, in addition to using a validated functional capacity interview in a complementary and concurrent fashion, clinicians can use capacity instruments as a template to structure their own judgment by substituting the specific idiosyncratic question facing their patient into the structure of the instrument. Used in this manner a structured professional judgement approach to assessing functional mental capacity capacities could facilitate clinician’s ability to communicate their opinions in legal settings and to reduce the potential for idiosyncratic differences between experts. More importantly, the assessment of functional mental capacity as a treatment outcome can become a reliable and valid measure. One recent study employed the MacArthur instruments as outcome measures in a controlled trial of cognitive remediation therapy for psychosis (Naughton et al. 2012) [
26]. In addition to improved transparency of clinical decision-making, functional capacity instruments are useful to identify targets for treatment and to measure change. The extent to which functional mental capacities change over time is of great importance when considering the legal and human rights protections necessary for mentally incapacitated patients, including those detained and treated under mental health legislation.
Although functional capacity assessments are often specific to the decision in hand, in practice clinicians are most often required to make decisions regarding a patient’s capacity to manage their finances, to consent to medical treatment and to make welfare decisions concerning living independently. Currently there is no single instrument to assist clinicians when assessing functional capacity in these three domains. No single instrument has a framework that is readily transferable to idiosyncratic situations. Because of the routine nature of these tasks a valid and reliable functional capacity assessment in these domains would be particularly useful to help clinicians structure their judgments.
In examining these tools, we noted the need for a different form of rating of functional mental capacity, in order to take account of its continuous rather than binary form.