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Cited by 16Healthcare Decision-Making and RestraintsEthics and bioethics in healthcareEthics and Legal Issues in Pediatric Healthcare

Should assessments of decision-making capacity be risk-sensitive? A systematic review

Open access
Berens, Noah Clark, Kim, Scott Y. H.·2022·Frontiers in Psychology
DOI 10.3389/fpsyg.2022.897144PMC PMC9277305
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Abstract

Background: The concept of decision-making capacity (DMC) or competence remains controversial, despite widespread use. Risk-sensitive DMC assessment (RS-DMC)-the idea that the higher the risk involved in a decision, the greater the decisional abilities required for DMC-has been particularly controversial. We conducted a systematic, descriptive review of the arguments for and against RS-DMC to clarify the debate. Methods: We searched PubMed/MEDLINE (National Library of Medicine), PsycInfo (American Psychological Association) and Philpapers, updating our search to February 15th, 2022. We targeted peer-reviewed publications in English that argue for or against RS-DMC. Two reviewers independently screened the publications and extracted data from each eligible manuscript. Results: Of 41 eligible publications, 22 supported a risk-sensitive threshold in DMC assessment. Most arguments for RS-DMC rely on its intuitive appeal and practical merits. The arguments against RS-DMC primarily express concerns about paternalism and the seeming asymmetry between consent and refusal; critics of RS-DMC support epistemic, rather than substantive (i.e., variable threshold), risk-sensitivity; counterarguments responding to criticisms of RS-DMC address charges of paternalism and exhibit a notable variety of responses to the issue of asymmetry. Authors used a variety of frameworks regarding the definition of DMC, its elements, and its relation to decisional authority, and these frameworks were significantly associated with positions on RS-DMC. A limitation of our review is that the coding relies on judgment and interpretation. Conclusion: The review suggests that some of the debate about RS-DMC stems from differences in underlying frameworks. Most defenses of RS-DMC rely on its intuitive appeal, while most criticisms reflect concerns about paternalism or the asymmetry between consent and refusal. Defenses of RS-DMC respond to the asymmetry problem in a variety of ways. Further research is needed on the implications of underlying frameworks, the asymmetry problem, and the distinction between epistemic and substantive models of RS-DMC.

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  • Most scholars agree that at minimum, decisions involving greater risk to life require a higher threshold of evidence of adequate mental capacity.

    “most scholars agree that at minimum, decisions involving greater risk to life require a higher threshold of evidence of adequate mental capacity (33, 37, 59, 60).”

    From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [37]

    The Results (‘Views on RS-DMC’; page not provided) define the epistemic view as requiring more evidence of capacity as risk rises and report that 12 of 41 publications endorsed that view alone. They also report that some publications endorsed both views, but do not establish that most scholars endorsed the higher-evidence threshold specifically; 22 of 41 supported a different, substantive view of risk sensitivity. (LLM, conf=0.84)

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Authors
Berens, N. C., & Kim, S. Y. H.
Affiliations
National Institutes of Health (US)
Corresponding author
Kim, Scott Y. H.
ORCID
Venue
Frontiers in Psychology
Publisher
Frontiers Media SA
Published
2022-06-29
Volume
13
Pages
897144-897144
ISSN
1664-1078 (ISSN-L)
DOI
10.3389/fpsyg.2022.897144
PMC
PMC9277305
OpenAlex
W4283699491
Cited by
16
References
51
Citations by year
2026: 2 · 2025: 2 · 2024: 7 · 2023: 3 · 2022: 2
FWCI
0.58
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Psychology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (acceptedVersion)
Funders
National Institutes of Health
Topics
  • Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Ethics and Legal Issues in Pediatric Healthcare
Keywords
decision-making capacity, competency assessment, paternalism

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