Health Care Analysis

, Volume 12, Issue 4, pp 273–283 | Cite as

The Cognitive Based Approach of Capacity Assessment in Psychiatry: A Philosophical Critique of the MacCAT-T

  • Torsten Marcus Breden
  • Jochen Vollmann


This article gives a brief introduction to the MacArthur Competence Assessment Tool-Treatment (MacCAT-T) and critically examines its theoretical presuppositions. On the basis of empirical, methodological and ethical critique it is emphasised that the cognitive bias that underlies the MacCAT-T assessment needs to be modified. On the one hand it has to be admitted that the operationalisation of competence in terms of value-free categories, e.g. rational decision abilities, guarantees objectivity to a great extent; but on the other hand it bears severe problems. Firstly, the cognitive focus is in itself a normative convention in the process of anthropological value-attribution. Secondly, it misses the complexity of the decision process in real life. It is therefore suggested that values, emotions and other biographic and context specific aspects should be considered when interpreting the cognitive standards according to the MacArthur model. To fill the gap between cognitive and non-cognitive approaches the phenomenological theory of personal constructs is briefly introduced. In conclusion some main demands for further research to develop a multi-step model of competence assessment are outlined.

MacCAT-T capacity competence decision-making ethics psychiatry 


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  1. Appelbaum, P.S. (1998) Ought we to Require Emotional Capacity as Part of Decisional Competence? Kennedy Institute of Ethics Journal8, 377–387.Google Scholar
  2. Bauer, A., and Vollmann, J. (2002) Einwilligungsfähigkeit bei Psychisch Kranken. Eine Ñbersicht Empirischer Untersuchungen. Nervenarzt 73, 1031–1038.Google Scholar
  3. Bell, R.C. (1990) Analytic Issues in the Use of Repertory Grid Technique. In G.J. Neimeyer and R.A. Neimeyer (Eds.), Advances in Personal Construct Psychology. Greenwich: JAI Press.Google Scholar
  4. Buchanan, A.E. and Brock, D.W. (1989) Deciding for Others: The Ethics of Surrogate Decision Making. New York: Cambridge University Press.Google Scholar
  5. Charland, L.C. (1998) Appreciation and Emotion: Theoretical Reflections on the MacArthur Treatment Competence Study. Kennedy Institute of Ethics Journal8, 359–376.Google Scholar
  6. Dekkers, W.J.M. (1998) Hermeneutics and Experiences of the Body. The Case of Low Back Pain. Theoretical Medicine 19, 277–293.Google Scholar
  7. Drane, J.F. (1985) The Many Faces of Competency. Hastings Center Report 15(2), 17–21.Google Scholar
  8. Elliot, C. (1997) Caring About Risks: Are Severely Depressed Patients Competent to Consent to Research? Archives of General Psychiatry 54, 113–116.Google Scholar
  9. Fitten, L.J., Lusky, R., and Hamann, C. (1990) Assessing Treatment Decision-making Capacity in Elderly. Archives of Internal Medicine 150, 1717–1721.Google Scholar
  10. Freedman, B. (1981) Competence, Marginal and Otherwise: Concepts and Ethics. International Journal of Law and Psychiatry4,53–72.Google Scholar
  11. Grisso, T., and Appelbaum, P.S. (1995) Comparison of Standards for Assessing Patients' Capacities to Make Treatment Decisions. American Journal of Psychiatry 152, 1033–1037.Google Scholar
  12. Grisso, T., and Appelbaum, P.S. (1998) Assessing Competence to Consent to Treatment. A Guide for Physicians and other Health Professionals. New York, Oxford: Oxford University Press.Google Scholar
  13. Helmchen, H., Kanowski, S., and Koch, H.G. (1989) Forschung mit dementen Kranken: Forschungsbedarf und Einwilligungsproblematik. Ethik in der Medizin1,83–98.Google Scholar
  14. Janofsky, J., McCarthy, R., and Folstein, M. (1992) The Hopkins Competency Assessment Test: ABrief Method for Evaluating Patients' Capacity to Give Informed Consent. Hospital and Community Psychiatry 43, 132–136.Google Scholar
  15. Kelly, G.A. (1955) The Psychology of Personal Constructs. New York: Norton.Google Scholar
  16. Kelly, G.A. (1970) ABrief Introduction to Personal Construct Theory. In D. Bannister (Ed.) Perspectives in Personal Construct Theory(pp. 1–30). London, New York: Academic Press.Google Scholar
  17. Markson, L.J., Kern, D., Annas, G., and Glantz, L. (1994) Physician Assessment of Patient Competence. Journal of American Geriatrics Society 42, 1074–1080.Google Scholar
  18. Riemann, R. (1991) Repertory Grid Technik.Göttingen: Hogrefe.Google Scholar
  19. Roth, L.H., Meisel, A., and Lidz, C.W. (1977) Tests of Competency to Consent to Treatment. American Journal of Psychiatry 134, 279–284.Google Scholar
  20. Rutman, D., and Silberfeld, M. (1997) A Preliminary Report on the Discrepancy between Clinical and Test Evaluation of Competence. Canadian Journal of Psychiatry 37, 634–639.Google Scholar
  21. Scheer, J.W., and Catina, A. (Eds.) (1993) Einführung in die Repertory Grid-Technik. Bern: Huber.Google Scholar
  22. Vollmann, J. (2000) Einwilligungsfähigkeit als relationales Modell. Klinische Praxis und medizinethis-che Analyse. Nervenarzt 71, 709–714.Google Scholar
  23. Vollmann, J., Bauer, A., Danker-Hopfe, D., and Helmchen, H. (2003) Competence of Mentally Ill Patients: A Comparative Empirical Study. Psychological Medicine 33, 1463–1471.Google Scholar
  24. Vollmann, J., Kühl, K.-P., Tilmann, A., Hartung, H.D., and Helmchen, H. (2004) Einwilligungsfähigkeit und Neuropsychologische Einschränkungen bei Dementen Patienten. Nervenarzt 75,29–35.Google Scholar
  25. Welie, S.P.K. (2001) Criteria for Patient Decision Making (In)competence: A Review of and Commen-tary on Some Empirical Approaches. Medicine, Health Care and Philosophy4, 139–151.Google Scholar
  26. Welie, J.V.M., and Welie, S.P.K. (2001) Patient Decision Making Competence: Outlines of a Conceptual Analysis. Medicine, Healthcare and Philosophy4, 127–138.Google Scholar
  27. Widdershoven, G.A.M. (1995) Principe of Praktijk? Een Hermeneutische Visie op Gezondheid en Zog. Maastricht: Rijksuniversiteit Limburg.Google Scholar

Copyright information

© Springer Science+Business Media, Inc. 2004

Authors and Affiliations

  • Torsten Marcus Breden
    • 1
  • Jochen Vollmann
    • 1
  1. 1.Institut für Geschichte und Ethik der MedizinFriedrich-Alexander-Universität Erlangen-NürnbergErlangenGermany

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