Recent legal developments challenge how valid the concept of mental capacity is in determining whether individuals with impairments can make decisions about their care and treatment. Kong defends a concept of mental capacity but argues that such assessments must consider how relationships and dialogue can enable or disable the decision-making abilities of these individuals. This is thoroughly investigated using an interdisciplinary approach that combines philosophy and legal analysis of the law in England and Wales, the European (...) Court of Human Rights, and the United Nations Convention on the Rights of Persons with Disabilities. By exploring key concepts underlying mental capacity, the investigation concludes that both primary relationships and capacity assessments themselves must display key competencies to ensure that autonomy skills are promoted and encouraged. This ultimately provides scope for justifiable interventions into disabling relationships and articulates the dialogical practices that help better situate, interpret, and understand the choices and actions of individuals with impairments. (shrink)

Editorial introduction to series of papers resulting from a European Commission Project on mental capacity.

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico-legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways (...) for future interdisciplinary research. The terrain can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority. (shrink)

We undertake to bring a phenomenological perspective to bear on a challenge of contemporary law and clinical practice. In a wide variety of contexts, legal and medical professionals are called upon to assess the competence or capacity of an individual to exercise her own judgement in making a decision for herself. We focus on decisions regarding consent to or refusal of medical treatment and contrast a widely recognised clinical instrument, the MacCAT-T, with a more phenomenologically informed approach. While the (...) MacCAT-T focuses attention on individual cognitive performance criteria, an approach oriented by second-person phenomenology brings into view the complex role of time, others and identity in constituting the capacity for individual autonomous judgement. Our phenomenological analysis has consequences both for the practice of capacity assessments and for further research in this arena. Good practice in capacity assessment must attend to decision communities, distributed capacity, and temporal competence, while research on mental capacity will miss the phenomenon if it trains its focus ‘between the ears.’ We illustrate our approach by considering two recent cases of contested capacity: one involving cognitive disability in a dysfunctional decision community, the second presenting the possibility of competent decision-making under conditions of paranoid schizophrenia. (shrink)

A diagnosis of schizophrenia is often taken to denote a state of global irrationality within the psychiatric paradigm, wherein psychotic phenomena are seen to equate with a lack of mental capacity. However, the little research that has been undertaken on mental capacity in psychiatric patients shows that people with schizophrenia are more likely to experience isolated, rather than constitutive, irrationality and are therefore not necessarily globally incapacitated. Rational suicide has not been accepted as a valid choice (...) for people with schizophrenia due in part to a belief that characteristic irrationality prevents autonomous decision-making. Since people with schizophrenia are often seen to lack insight into the nature of their disorder, both psychiatric and ethical perspectives generally presume that suicidal acts result directly from mental illness itself and not from second-order desires. In this article, I challenge notions of global irrationality conferred by a diagnosis of schizophrenia and argue that, where delusional beliefs are unifocal, schizophrenia does not necessarily lead to a state of mental incapacity. I then attempt to show that people with schizophrenia can sometimes be rational with regard to suicide, where this decision stems from a realistic appraisal of psychological suffering. (shrink)

The Mental Capacity Act received Royal Assent on 7 April 2005, and it will be implemented in 2007. The Act defines when someone lacks capacity and it supports people with limited decision-making ability to make as many decisions as possible for themselves. The Act lays down rules for substitute decision making. Someone taking decisions on behalf of the person lacking capacity must act in the best interests of the person concerned and choose the options least restrictive (...) of his or her rights and freedoms. Decision making will be allowed without any formal procedure unless specific provisions apply, such as a written advance decision, lasting powers of attorney or a decision by the court of protection. (shrink)

The Mental Capacity Bill endangers the vulnerable by inviting human rights abuse. It is perhaps these grave deficiencies that prompted the warnings of the 23rd Report of the Joint Committee on Human Rights highlighting the failure of the legislation to supply adequate safeguards against Articles 2, 3 and 8 incompatibilities. Further, the fact that it is the mentally incapacitated as a class that are thought ripe for these and other kinds of intervention, highlights the Article 14 discrimination inherent (...) in this and related legislation. The financial, medical and research interests that underpin the legislation highlight how the legilsation endangers the ulnerable. It appears to be both a responsibility shifting exercise. Most alarmingly of all, efforts to permit non-therapeutic research on the non-consenting vulnerable as well as sterilisation and abortion on those who do not consent suggest that the legislation heralds a new era o gross human rights abuse in instutions around the UK. (shrink)

This paper considers concerns that social care research may be stifled by health-focused ethical scrutiny under the Mental Capacity Act 2005 and the requirement for an ?appropriate body? to determine ethical approval for research involving people who are deemed to lack capacity under the Act to make decisions concerning their participation and consent in research. The current study comprised an online survey of current practice in university research ethics committees (URECs), and explored through semi-structured interviews the views (...) of social researchers engaged in or exploring work concerning people who may, under the Act, lack the capacity to make decisions to consent to participate in a research programme. The paper concludes that there was a lack of overt knowledge of and reference to the implications of the Act for research and some concerns that a restrictive focus on health-related scrutiny might prevent social care research from taking place. There was also a degree of creativity shown by social care researchers in responding to changing demands and a wish to assist people in making decisions to participate where possible. (shrink)

The Mental Capacity Act, which received Royal Assent in April 2005, will come into force in April 2007. The Act puts into statute the legality of interventions in relation to adults who lack capacity to make decisions on their own behalf. The aim of this paper is to outline the main features of the legislation and its impact on those health care professionals who provide care and treatment for incapacitated adults. The paper sets out the underlying ethical (...) principles that govern interventions under the Act's powers and briefly explores the legal definition of incapacity and the process by which capacity is assessed. It looks at the governing notion of 'best interests' and at the legal indemnity provided by the Act for interventions that are in the best interests of an incapacitated adult. It contains sections on the Act's main innovations, including research involving incapacitated adults, lasting powers of attorney and the new Court of Protection. It also provides information on advance decisions to refuse treatment. (shrink)

The Mental Capacity Act 2005 gives statutory force to the common law principle that all adults are assumed to have capacity to make decisions unless proven otherwise. In accord with best practice, this principle places the evidential burden on researchers rather than participants and requires researchers to take account of short-term and transient understandings common among some research populations. The aim of this paper is to explore some of the implications of the MCA 2005 for researchers working (...) with 'vulnerable' populations in health and social care settings. The Cyclical Consent Model is described and offered as a process by which researchers might develop good practice when engaged in research involving vulnerable people. (shrink)

"The development of modern diagnostic neuroimaging techniques led to discoveries about the human brain and mind that helped give rise to the field of neurolaw. This new interdisciplinary field has led to novel directions in analytic jurisprudence and philosophy of law by providing an empirically-informed platform from which scholars have reassessed topics such as mental privacy and self-determination, responsibility and its relationship to mental disorders, and the proper aims of the criminal law. Similarly, the development of neurointervention techniques (...) that promise to deliver new ways of altering people's minds creates opportunities and challenges that raise important and rich conceptual, moral, jurisprudential, and scientific questions. The specific purpose of this volume is to make a contribution to the field of neurolaw by investigating the legal issues raised by the development and use of neurointerventions "--. (shrink)

Helga Kuhse suggested in 1985 at a session of the World Federation of Right to Die Societies in Nice, that once dehydration to death became legal and routine in hospitals, people would, on seeing the horror of it, seek the lethal injection. The strategy of legalising passive euthanasia is itself flawed. Laing argues that the Mental Capacity Bill threatens the vulnerable by inviting breaches of arts 2,3,5,8, and 14 of the European Convention on Human Rights. Most at risk (...) are the disabled and incapacitated. Sections permitting non-therapeutic research and non consensual sterilisation are at odds with the Nuremberg Code. New third party powers to dehydrate the vulnerable permit new systemic human rights abuse of a clinical though not historically unfamiliar variety. (shrink)

-/- Following the Mental Capacity Act (MCA) becoming law in 2005, and prior to its coming into force in 2007, there was a sustained effort to train support staff in the many social care settings where this new law was applicable. This training drive was necessary because, prior to the MCA, mental capacity law had evolved in the courts through consideration of a small number of cases that concerned serious medical treatments. These included the withdrawal of (...) artificial nutrition and hydration (Airedale NHS Trust v. Bland [1993]), blood transfusion (Re T [1993]), tissue donation (Re Y [1997]) and the provision of experimental medication for terminal illness (Simms v. Simms and another (2003)). In line with the Law Commission’s recommendations, the MCA extended the application of the law to ‘all acts in connection with care or treatment’ (MCA, Section 5), meaning that, overnight, social care settings and informal family care environments immediately fell within the scope of the legislation. (shrink)

Mental capacity is a foundational concept in contract law, but the term is metaphorical, and a detailed analysis of three representative judicial opinions shows that the explanations that courts give of the term are equally metaphorical. As such, the term illustrates well the cognitivist view that abstract concepts arise through an imaginative but orderly projection from the domain of bodily and social experience. Legal Realists such as Felix Cohen condemned metaphors for their supposed failure to constrain judges, but (...) recent empirical work suggests that metaphorical thinking is indeed constrained, and accordingly thinkers such as Cohen would probably in fact have welcomed cognitive analysis of law, both for its methods and for its substantively progressive disposition. (shrink)

The hospital's clinical ethics committee sought to gauge health-care professionals’ level of knowledge and usage of the Mental Capacity Act 2005 within the hospital trust. The hospital's personnel were asked to complete a 10 part questionnaire relating to the basic contents of the Act. Four hundred questionnaires were distributed and 249 (62%) were returned completed and valid for analysis. A ‘pass-mark’ of 70% (7/10) was assumed; the results showed that 48% of respondents scored ≤50% (≤5/10), 74% of respondents (...) scored <70% (<7/10) and only 24% of respondents scored ≥70% (≥7/10). It was concluded that the Mental Capacity Act 2005 was not being effectively implemented within the Trust. Measures to increase the awareness and usage of the Act have subsequently been instigated. We believe that these measures will improve the awareness and knowledge of the Mental Capacity Act 2005 within the hospital Trust lead to its better utilization. (shrink)

The doctrine of consent is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID-19 patients to consent to emergency medical treatment. We term this the CARD approach.

Background The Mental Capacity Act was enacted in 2007 in England and Wales, but the assessment of mental capacity still remains an area of professional concern. Doctors’ compliance with legal and professional standards is inconsistent, but the reasons for poor compliance are not well understood. This preliminary study investigates doctors’ experiences of and attitudes toward mental capacity assessment. Methods This is a descriptive, cross-sectional study where a two-domain, study-specific structured questionnaire was developed, piloted and (...) digitally disseminated to doctors at differing career stages employed in a large, multi-site National Health Service Trust in London over 4 months in 2018. Descriptive statistics and frequency tables adjusted for missing data were generated and secondary analysis was conducted. Results Participants were predominantly UK trained, female and between the ages of 30 and 44 years. Less than half of the participants reported receiving formal MCAx training. Only one-third of the participants self-rated themselves as very competent or extremely competent. Self-reported MCA confidence was significantly affected by career stage with Consultants with over 10 years of experience reporting lowest confidence. Conclusions This study describes significant variation in practice by doctors and low self-confidence in the practice of MCAx. These results raise concerns that MCAx continues to be inconsistently performed by doctors despite appropriate awareness of the law and professional guidance on best practice. (shrink)

Mental capacities are an essential basis on which people give moral concern to nonhuman animals. Hence, it is important to investigate public perceptions of animal mind and the factors underlying these perceptions. Although research into citizen beliefs in animal mind has been increasing, population-based studies utilizing multivariate methods have been scarce. In this article, public perceptions of animal mind are investigated with a nationwide survey in Finland. Eight animal species positioned differently in cultural categorizations are included in the analysis. (...) Dogs were ascribed the most capacities, followed by cows, pigs, wolves, and elk. Citizens expressed a low belief in the mental capacities of chicken, salmon, and shrimp. Classifying animals as companions, food, and threat influences the perceptions of animal mind. Young age, having a companion animal, valuing societal equality, and concern for animal welfare and for animal utilization are connected to a greater belief in animal mind. (shrink)

This article considers the provisions of the Mental Capacity Act 2005 in respect of advance decisions. It considers the new statutory regulation of advance directives (termed 'advance decisions' in the Act) and the formalities necessary to effect an advance decision purporting to refuse life-sustaining treatment. The validity and applicability of advance decisions is discussed with analogy to case law and the clinician's reasonable belief in following an advance decision is considered. The article assesses the new personal welfare Lasting (...) Powers of Attorney, the situation where an attorney purports to refuse life-sustaining treatment on behalf of the donor, and the contrast between best interests and substituted judgment. (shrink)

In May 2013 a new Assisted Dying Bill was tabled in the House of Lords and is currently scheduled for a second reading in May 2014. The Bill was informed by the report of the Commission on Assisted Dying which itself was informed by evidence presented by invited experts.

The Mental Capacity Act (2005) was designed to protect and empower patients with impaired capacity. Despite an estimated 40% of medical inpatients lacking capacity, it is unclear how many patients undergo capacity assessments and treatment under the Act. We audited the number of capacity assessments on the general medical wards of an English-teaching hospital. A total of 95 sets of case notes were reviewed: the mean age was 78.6 years, 57 were female. The most (...) common presenting complaints were feeling ‘unwell’ (n = 25) and confusion (n = 24). In all, 52 patients had conditions, such as delirium (n = 26) and dementia (n = 15), which often impair capacity. Capacity was assessed in seven (7.4%) patients, all of whom disagreed with the medical team about their treatment. The number of documented assessments fell short of the estimated rate of incapacity, suggesting that some means of improving capacity assessment in busy medical environments is required. (shrink)

Cases of severe and enduring Anorexia Nervosa (SEAN) rightly raise a great deal of concern around assessing capacity to refuse treatment (including artificial feeding). Commentators worry that the Court of Protection in England & Wales strays perilously close to a presumption of incapacity in such cases (Cave and Tan 2017, 16), with some especially bold (one might even say reckless) observers suggesting that the ordinary presumption in favor of capacity ought to be reversed in such cases (Ip 2019). (...) -/- Those of us who worry that such trends and proposals amount to (or at least pose a serious threat of) wrongful discrimination on the grounds of disability nevertheless feel the pull of judging many SEAN service users to be incapacitous with respect to decisions regarding (perhaps amongst other things) treatments involving feeding, artificial or otherwise. But it is difficult to get to grips with exactly what their incapacity consists in. Many such service users seem able to understand, retain, use and weigh information, and express a decision (i.e. they seem, prima facie, to satisfy the ‘MacArthur’ criteria). At the very least, they do not, generally. (shrink)

The Mental Capacity Act 2005 has put the assessment of mental capacity for decision-making at the forefront of psychiatric practice. This capacity is commonly linked within philosophy to autonomy, that is, to the idea, or ideal, of self-government. However, philosophers disagree deeply about what constitutes autonomy. This contribution brings out how the competing conceptions of autonomy would play out in psychiatric practice, taking anorexia nervosa as a test case. © 2009 Elsevier Ltd. All rights reserved.

The Mental Capacity Act 2005 placed for the first time research concerning adults lacking mental capacity upon a statutory footing. However, while the legislation which regulates the inclusion of such adults in ‘intrusive research’ safeguards researchers and research participants alike some controversy remains as to its implementation. This paper focuses upon two specific issues raised by the legislation. First, what constitutes ‘intrusive’ research and whether all issues concerning research involving adults lacking mental capacity should (...) be referred to NHS research ethics committees. Secondly, the role of one of the statutory safeguards–the ‘consultee’. These are individuals who are to be consulted regarding the inclusion of adults lacking mental capacity in research. It contrasts the ‘personal’ and ‘nominated’ consultees and considers whether there is a risk that the legislation may result in a new ‘quasi profession’ of consultees in the future. (shrink)

This article challenges the neo-Darwinist physicalist position assumed by currently prevalent naturalizing accounts of consciousness. It suggests instead an evolutionary understanding of cognitive emergence and an acceptance of mental capacity as a phenomenon in its own right, differing qualitatively from, although not independent of, the physical and material world. I argue that if we accept that consciousness is an adaptation enabling survival through immediate individual intuition of the world, we may accept this metaphysics as a given. Methodological focus (...) can then shift to investigating the, as yet untheorized, nature of consciousness itself as capacity/interconnectivity/potential. The article accepts Joseph Margolis's recent advocacy of a pragmatist approach that is "natural but not naturalizable" , that is, an anti-reductionist as opposed to an eliminativist position, but it seeks to develop this position further and to give it new direction. (shrink)

This paper considers the meaning of the term ‘intrusive research’, as used in the UK Mental Capacity Act 2005, in relation to studies in which an informant is asked to provide information about or on behalf of a person who lacks capacity to consent, and who is not otherwise involved in the study. The MCA defines ‘intrusive research’ as research that would legally require consent if it involved people with capacity. The relevant ethical principles are that (...) consent should be sought from people who would be affected by a piece of research and that this requirement should be implemented proportionately. The critical question, for investigators and research ethics committees, is: would provision of the personal information specified in the research protocol significantly affect a person whose capacity is not impaired? If the answer to this question is ‘no’, then the study falls outside the definition of ‘intrusive research’, and the MCA does not apply. (shrink)

This paper considers the meaning of the term ‘intrusive research’, as used in the UK Mental Capacity Act 2005, in relation to studies in which an informant is asked to provide information about or on behalf of a person who lacks capacity to consent, and who is not otherwise involved in the study. The MCA defines ‘intrusive research’ as research that would legally require consent if it involved people with capacity. The relevant ethical principles are that (...) consent should be sought from people who would be affected by a piece of research and that this requirement should be implemented proportionately. The critical question, for investigators and research ethics committees, is: would provision of the personal information specified in the research protocol significantly affect a person whose capacity is not impaired? If the answer to this question is ‘no’, then the study falls outside the definition of ‘intrusive research’, and the MCA does not apply. (shrink)

This article sets out a scenario highlighting some of the issues to be faced by NHS hospitals when dealing with patients who may require treatment under the Mental Capacity Act 2005. The article sets out matters to consider when dealing with patients in A&E, assessments of best interests, emergency treatment, lasting powers of attorney and transferring patients to nursing homes. All of these matters come under the remit of the Act.

At the time of writing, euthanasia for psychiatric conditions is legal in Belgium and the Netherlands, in cases that are judged to involve unbearable and untreatable suffering. There is a difference between ‘euthanasia’ and ‘assisted suicide’ or ‘assisted dying’. Although I will refer for the most part to ‘psychiatric euthanasia,’ my points apply equally to assisted dying. Even where these practices are legal, they are highly controversial. One case, in particular, received considerable media attention. In the Netherlands, on January 26, (...) 2018, a 29-year-old woman called Aurelia Brouwers ended her life... (shrink)

In 2014 the Essex Autonomy Project undertook a six month project, funded by the AHRC, to provide technical advice to the UK Ministry of Justice on the question of whether the Mental Capacity Act is compliant with the United Nations Convention on the Rights of Persons with Disabilities. Over the course of the project, the EAP research team organised a series of public policy roundtables, hosted by the Ministry of Justice, and which brought together leading experts to discuss (...) and debate the issues. A one-day public conference was held at the Institute for Government in July. In September 2014, the EAP research team submitted its findings to the Ministry of Justice. (shrink)

In 2014 the Essex Autonomy Project undertook a six month project, funded by the AHRC, to provide technical advice to the UK Ministry of Justice on the question of whether the Mental Capacity Act is compliant with the United Nations Convention on the Rights of Persons with Disabilities. Over the course of the project, the EAP research team organised a series of public policy roundtables, hosted by the Ministry of Justice, and which brought together leading experts to discuss (...) and debate the issues. A one-day public conference was held at the Institute for Government in July. In September 2014, the EAP research team submitted its findings to the Ministry of Justice. (shrink)

The Mental Capacity Act is an impressive piece of legislation that deserves serious ethical attention, but much of the commentary on the Act has focussed on its legal and practical implications rather than the underlying ethical concepts. This paper examines the approach that the Act takes to best interests. The Act does not provide an account of the underlying concept of best interests. Instead it lists factors that must be considered in determining best interests, and the Code of (...) Practice to the Act states that this list is incomplete. This paper argues that this general approach is correct, contrary to some accounts of best interests. The checklist includes items that are unhelpful. Furthermore, neither the Act nor its Code of Practice provides sufficient guidance to carers faced with difficult decisions concerning best interests. This paper suggests ways in which the checklist can be developed and discusses cases that could be used in an updated Code of Practice. (shrink)

ObjectiveTo examine health and social care professionals’ understanding of the legislation governing research involving adults lacking mental capacity in England and Wales.MethodsA cross-sectional online survey was conducted using a series of vignettes. Participants were asked to select the legally authorised decision-maker in each scenario and provide supporting reasons. Responses were compared with existing legal frameworks and analysed according to their level of concordance.ResultsOne hundred and twenty-seven professionals participated. Levels of discordance between responses and the legal frameworks were high (...) across all five scenarios. Nearly half of the participants provided responses that were discordant in all scenarios. Only two participants provided concordant responses across all five scenarios.DiscussionParticipants demonstrated a lack of knowledge about the legal frameworks, the locus of authority and the legal basis for decision-making. The findings raise concern about the accessibility of research for those who lack capacity, the ability to conduct research involving such groups and the impact on the evidence base for their care.ConclusionThis is the first study to examine health and social care professionals’ knowledge and understanding of the dual legal frameworks in the UK. Health and social care professionals’ understanding and attitudes towards research involving adults with incapacity may warrant further in-depth exploration. The findings from this survey suggest that greater training and education is required. (shrink)

The Mental Capacity Act 2005 came into force in England and Wales in 2007. Its primary purpose is to provide “a statutory framework to empower and protect people who may lack capacity to make some decisions for themselves.” Examples of such people are those with dementia, learning disabilities, mental health problems, and so on. The Act also gives those who currently have capacity a legal framework within which they can make arrangements for a time when (...) they may come to lack it. Toward this end, it allows for them to make advance decisions or to appoint proxy decision makers with lasting powers of attorney. (shrink)

In 2014 the Essex Autonomy Project undertook a six month project, funded by the AHRC, to provide technical advice to the UK Ministry of Justice on the question of whether the Mental Capacity Act is compliant with the United Nations Convention on the Rights of Persons with Disabilities. Over the course of the project, the EAP research team organised a series of public policy roundtables, hosted by the Ministry of Justice, and which brought together leading experts to discuss (...) and debate the issues. A one-day public conference was held at the Institute for Government in July. In September 2014, the EAP research team submitted its findings to the Ministry of Justice. (shrink)

The mental capacity Act 2005 (MCA; Department of Constitutional Affairs 2005) was partially implemented on April 1, 2007, and fully implemented on October 1, 2007, in England and Wales. The MCA provides a statutory framework for people who lack decision-making capacity (DMC) or who have capacity and want to plan for the future when they may lack DMC. Health care and social care providers need to be familiar with the MCA and the associated legal structures and (...) processes. The MCA is supported by a Code of Practice (Department of Constitutional Affairs 2007), which was developed after extensive consultation and includes case examples. Those involved in the assessment of DMC and the application of the MCA should .. (shrink)

The mental competence of people requesting aid-in-dying is a key issue for the how the law responds to cases of assisted suicide. A number of cases from around the common law world have highlighted the importance of competence in determining whether assistants should be prosecuted, and what they will be prosecuted for. Nevertheless, the law remains uncertain about how competence should be tested in these cases. This article proposes a test of competence that is based on the existing common (...) law but which is tailored to cases of assisted suicide. The test will help doctors, other health professionals and lawyers determine whether the suicidal person was able to competently request assistance. Such knowledge will help to reduce some of the current uncertainty about criminal liability in cases of assisted suicide. (shrink)

Mackenzie Graham has made an important contribution to the literature on decisionmaking for patients with disorders of consciousness. He argues, and I agree, that decisions for unresponsive patients who are known to retain some degree of covert awareness ought to focus on current interests, since such patients likely retain the kinds of mental capacities that in ordinary life command our current respect and attention. If he is right, then it is not appropriate to make decisions for such patients by (...) appealing to the values they had in the past, either the values expressed in an advance directive or the values recalled by a surrogate. There are two things I wish to add to the discussion. My first point is somewhat critical, for although I agree with his general conclusion about how, ideally, such decisions should be approached, I remain skeptical about whether his conclusion offers decisionmakers real practical help. The problem with these cases is that the evidence we have about the nature of the patient’s current interests is minimal or nonexistent. However—and this is important—Graham’s conclusion will be extremely relevant if in the future, our ability to communicate with such patients improves, as I hope it will. This leads to my second point. Graham’s conclusion illustrates a more general problem with our standard framework for decisionmaking for previously competent patients, a problem that has not been adequately recognized. So, in what follows, I explain the problem I see and offer some brief thoughts about solutions. (shrink)