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Irrational People Have Rights Too : Moving Beyond Rationality in Decisional Capacity Assessment.

Jacob M Appel1

  • 1Academy for Medicine & the Humanities, Icahn School of Medicine at Mount Sinai, 140 Claremont Ave #3D, New York, NY, 10027, USA. jacobmappel@gmail.com.

Journal of Bioethical Inquiry
|March 9, 2026
PubMed
Summary
This summary is machine-generated.

The current "four abilities" model for assessing patient decisional capacity is legally inconsistent and may deny autonomy to patients with longstanding preferences. An alternative values-based or consistent preferences approach is proposed.

Keywords:
CapacityCompetenceDecision-making

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Area of Science:

  • Bioethics
  • Medical Law
  • Philosophy of Law

Background:

  • The dominant "four abilities" model for assessing decisional capacity relies heavily on patient reasoning.
  • This model is argued to be a legal anomaly, inconsistent with other areas of law concerning social and economic decisions.
  • The model may deny autonomy to patients with deeply held preferences who cannot articulate their reasoning.

Purpose of the Study:

  • To critique the "four abilities" model of decisional capacity assessment.
  • To propose an alternative model for assessing decisional capacity.
  • To advocate for a more inclusive approach that respects patient autonomy.

Main Methods:

  • Legal and philosophical analysis of the "four abilities" model.
  • Comparison with legal standards in social and economic decision-making.
  • Development of an alternative model based on values and consistent preferences.

Main Results:

  • The "four abilities" model's reliance on rational thinking is inconsistent with broader legal principles.
  • The model fails to accommodate patients with longstanding, yet unarticulated, preferences.
  • An alternative model is presented, incorporating values-based and consistent preferences approaches.

Conclusions:

  • The "four abilities" model requires significant revision to ensure patient autonomy.
  • A values-based or consistent preferences approach offers a more equitable framework for assessing decisional capacity.
  • Reforming decisional capacity assessment is crucial for upholding patient rights and autonomy in healthcare.