The Divergence of Psychiatric and Medical Decision-Making Mechanisms for Patients Who Lack Capacity and Its Lasting Impact on the Delivery of Psychiatric Care

Abstract

Modern medical ethics utilizes an informed consent process that emphasizes patient autonomy by respecting the decisions of patients who have capacity. When patients are incapacitated, decision making for patients who require medical and psychiatric care is often handled differently. When incapacitated patients require medical care, surrogate decision makers are allowed to make decisions immediately and for the duration of incapacitation, with limited court involvement (“treatment-driven” or “best interests” model). In contrast, for psychiatric treatment, most states utilize “rights-driven” models in which an incapacitated patient who would benefit from psychiatric treatment cannot be admitted or treated absent an additional judicial finding of “dangerousness” or “grave disability” (“danger to self”) sufficient to justify civil commitment. The divergence of psychiatric and medical decision making for incapacitated patients began in the 1960s when the basis of most mental health law was established and continues to impact the delivery of present-day psychiatric care. [ Psychiatr Ann. 2024;54(5):e146–e150.]