In this episode of Psychiatry Bootcamp, Dr. Mark Mullen welcomes Dr. Jacob Appel, psychiatrist, attorney, bioethicist, polymath, and emergency psychiatrist, for a rigorous and clinically grounded critique of the Applebaum-Grisso "Four Abilities Model" of decisional capacity assessment. Dr. Appel traces the model's origins in the 1980s as a patient-empowerment tool, examines how its statutory adoption across more than half of US states has calcified it beyond its original intent, and describes in detail the categories of patients for whom the model systematically fails.
As an alternative, Dr. Appel describes the values-based model, which asks clinicians to identify a patient's current expressed choice, explore the underlying values that have governed the patient's life, and determine whether the two are congruent. He also introduces the consistent preferences approach, which situates capacity within a person's narrative arc rather than a moment-in-time snapshot.nce intervention programs in their own communities.
References:
Irrational People Have Rights Too: Moving Beyond Rationality in Decisional Capacity Assessment: https://pubmed.ncbi.nlm.nih.gov/41801616/
A Values Based Approach to Capacity Assessment: https://pubmed.ncbi.nlm.nih.gov/36638303/
Takeaways:
The Applebaum-Grisso model was designed for patients who temporarily deviate from a Western allopathic baseline.
Documented racial bias in capacity assessment stems in part from the model's privileging of patients who can articulate reasoning in medical-legal language, systematically disadvantaging those with less social capital who may know exactly what they want but cannot express it in those terms.
The values-based model offers a simpler alternative.
Capacity assessment is an intervention, not a neutral evaluation
In states without statutory definitions of capacity criteria, the values-based and consistent preferences approaches are likely protected under the respectable minority
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Chapter:
00:00 Meet Dr Appel01:27 Capacity Model Origins02:21 Four Abilities Breakdown03:26 Standard of Care Law05:46 Why Model Falls Short06:22 Religion Culture Exceptions07:07 Rationality Bias Inequity12:02 Refusing To Engage13:03 More Failure Prototypes15:41 Not Capacity Abolition16:39 Physician Exceptionalism20:51 Values Based Model Steps25:52 Sponsor Break Medlines27:07 Standard Of Care Revisited32:07 Bioethics Teaching Favorites36:50 Genetics Incidental Findings38:52 Closing And Credits
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