Students preparing for medical school interviews should have a good grasp of legal and ethical topics that can be applied to their answers. Capacity is a key legal aspect of practising medicine and hot topics that you must have an understanding of before interviews.
This article will explain what capacity is, how it is tested, what happens if someone does not have the capacity, some of the ethical considerations and how to prepare for questions on capacity in medical interviews.
Combine your reading here of medicine interview questions and model answers with medicine interview tutoring or 1-1 mock interviews to ensure even greater success in your interviews.
Capacity in Medicine: A Summary
If someone has capacity, they are able to make a decision about their health
Some things that can affect someone’s capacity include alcohol, drugs, brain injuries, dementia and severe learning disabilities
If someone lacks capacity, a decision about their care must be made in the patient’s best interests, by a healthcare professional
Advance decisions and Lasting Power of Attorneys can be created in order to deal with the lack of capacity in the future
It is important to understand capacity in advance of medicine interviews, as it is a vital part of medical practice
👉🏻 Read more: Ultimate Medicine Interview Preparation Guide
What is capacity?
Capacity refers to someone’s ability to make a decision in medicine.
Healthcare professionals must presume that all adults have capacity unless there is evidence to suggest otherwise.
Here are some important points on capacity:
A patient has capacity until proven otherwise
Capacity is decision-dependent
If a decision is strange and irrational, they may still have capacity.
For someone to have capacity, they must be able to:
Understand the information given to them
Retain the information
Use the information to make a decision
Communicate that decision
The law surrounding capacity comes from the Mental Capacity Act 2005 (MCA).
Capacity is a term that is relevant to patients 18 years old and over. To find out about how children can make decisions about their healthcare, read our article on Gillick's competence and Fraser guidelines.
👉🏻 Read more: Gillick Competence and Fraser Guidelines
How is capacity assessed?
In medicine, capacity is assessed using a two-stage test, often within the context of the Mental Capacity Act (2005) in the UK:
There is a two-stage test for assessing capacity:
The Functional Test - Is the patient not able to make a particular decision?
This test involves determining whether or not the patient is able to make a specific decision at the time it needs to be made. This is not about the decision they make, but their ability to understand and consider the information relevant to the decision. The test examines whether the person can:
Understand information related to the decision
Retain that information long enough to make a decision
Use or weigh that information as part of the process of making the decision
Communicate their decision by any means.
The Diagnostic Test: If the functional test shows that the patient is unable to make the decision, the diagnostic test examines whether this inability is because of an impairment of a number of things including:
Mental health conditions
Unconsciousness
Alcohol
Drugs
Dementia
Delirium
Severe learning disabilities
Brain damage
The capacity can fluctuate over time or depending on the complexity of the decision. Therefore, the assessment should be repeated whenever necessary.
Also, the lack of capacity to make one decision does not imply the lack of capacity for another decision.
It is important to remember that capacity can fluctuate. Just because someone did not have the capacity to make a decision yesterday, does not automatically mean they lack capacity today.
Furthermore, a patient can have capacity for some decisions but not others. An elderly patient with dementia may be able to understand information relating to a blood test and be deemed to have the capacity to consent to this. However, they may not have the capacity to consent to complex surgery.
👉🏻 Read more: Dr Bawa-Garba Case
Capacity: Who Can Assess Capacity?
In a healthcare setting, the responsibility of assessing a patient's capacity usually falls on the healthcare professional who is directly involved in the patient's care at the time of the decision-making process.
The tests explained above should be used.
Sometimes capacity needs to be tested for major decisions, and therefore someone more experienced in assessing capacity may need to be involved.
👉🏻 Read more: NHS Core Values
What happens if someone doesn't have capacity?
If someone doesn’t have capacity to make a decision about their care, the healthcare professionals treating them will have to make the decision for them.
The decision made by the healthcare professional must be in the ‘best interests’ of the patient.
Before concluding that someone does not have capacity, the healthcare professional should take appropriate steps to encourage the person to participate in any decisions that need to be made.
👉🏻 Read more: Common NHS Hot Topics
What are best interests in medicine?
‘Best interests’ are considered when an adult lacks capacity to make a decision. The healthcare professional treating them will instead make the decision, according to what is best for that particular patient.
The healthcare professional must consider the following when deciding what is in the best interests of their patient:
Patient’s past and present wishes
Any beliefs that the patient has that may have influenced their decision if they had capacity
The views of anyone named by the patient as someone to be consulted if they were to lose capacity/be in this position
The views of anyone that care for the patient
The views of any donee of a lasting power of attorney
The above considerations were set out in the MCA.
The healthcare professional should NOT base any decisions made for the patient based on the patient’s appearance, age or any conditions of their behaviour.
👉🏻 Read more: Confidentiality In Healthcare
Advance decisions and power of attorney
If someone lacks capacity, they may have an advance decision or lasting power of attorney. If so, the advance decision should be adhered to if it is for medical decisions that the person would be required to make in that specific situation. If the person has appointed a lasting power of attorney, they will be the person that makes the decisions for the person lacking capacity.
What is an advance decision?
People can make advance decisions to refuse treatment when they lack the capacity to make a decision in the future. It enables health professionals to know what treatments the patient does not want to be carried out if they find themselves lacking the capacity to make this decision.
The specific treatments and specific situations in which you do not want treatment need to be clearly stated in the advance decision.
A common example of an advance decision is the refusal of CPR when someone suffers a cardiac arrest. But other examples include refusal of ventilation and certain medications.
The advance decision must be made when the person has capacity to do so. It has to be written down, signed by the person themselves and by a witness.
What is lasting power of attorney (LPA)?
A person can give someone the power to make decisions about their health and welfare, if they lack the capacity to do this themselves, by creating a health and welfare LPA.
It is important that you understand that the person appointed as the attorney can only make these decisions if the patient is not able to make these decisions for themselves.
The decisions that are covered within a health and welfare LPA include:
Where the person lives
The person’s medical care
The social activities the person takes part in
The care of the person (diet, washing etc)
👉🏻 Read more: NHS GP Shortage and Crisis
Ethical Consideration for Capacity in Medicine
As with all important topics in medicine, it is important to consider how ethics relates to capacity. The four pillars of medical ethics can be applied to capacity and are helpful tools to use when answering questions in your interviews.
Autonomy: Autonomy is promoted by the capacity assessment, as it ensures all adults are presumed to have capacity unless there is significant evidence to suggest otherwise. However, if the capacity assessment is not used accurately, it has the ability to restrict the autonomy of some adults.
Beneficence/non-maleficence: Ensuring that those who do not have capacity cannot consent or refuse to consent to medical interventions limits the amount of harm that can happen as a result.
Justice: The current capacity assessment used ensures that adults are treated fairly. If someone is found not to have the capacity for one decision, it is not automatically assumed that they cannot consent to another intervention. Furthermore, it is ensured that capacity assessments are not based on someone’s appearance or age.
👉🏻 Read more: Answering Medical Ethics Questions
Preparing for a Medicine Interview: Capacity
If you want to study medicine, it is very important that you have an understanding of capacity, especially in relation to consent. See our article on Medical Consent for more information.
Interviewers will not expect you to know the topic inside out, but they will want you to have a good appreciation of how important capacity assessment is.
👉🏻 Read more: MMI Medicine Interview Topics
Medicine Interview Questions on Capacity
Why is capacity assessment in medical ethics significant in medical practice?
What are the procedures followed when someone lacks the ability to make a healthcare decision?
Can you explain the interlinking of capacity and consent in healthcare decision-making?
How might autonomy and beneficence conflict when treating a patient who doesn't pass the functional and diagnostic test for capacity?
In your view, does the current Mental Capacity Act 2005 provide an adequate framework for assessing which patients can make their own medical decisions?
Can you list some factors that might impair a patient's capacity in a medical setting?
How is a patient's capacity assessed in medical practice under the Mental Capacity Act 2005?
What does the term fluctuating capacity in medicine mean, and how can it impact healthcare decisions?
In terms of medical ethics, how would you define best interests when dealing with a patient lacking capacity?
What are some of the ethical challenges in treating a patient who falls under the capacity considerations for patients with dementia or other capacity-impairing conditions?
How does understanding the legal aspects of capacity in medicine help healthcare professionals ensure patient autonomy?
How do we evaluate an individual's ability to make decisions?
What are the four criteria for determining a patient's capacity?
Does capacity remain intact in patients with dementia?
Is it possible for a patient to demonstrate capacity for one decision but lack it for a different decision within the same day?
Can you bring to mind a medical case in which the question of patient capacity became prominent?
Explain the role of an advance decision in a situation where a patient lacks medical decision-making capacity. How does it affect the care plan?
Can you discuss the relationship between Lasting Power of Attorney and medical capacity? How does it come into play during healthcare decision-making?
How does the Mental Capacity Act 2005 guide healthcare professionals when dealing with patients suffering from severe mental health conditions or brain damage?
What ethical considerations need to be kept in mind when determining the best interests of a patient who is unable to make their own healthcare decisions due to impaired capacity?
👉🏻 Read more: 280 MMI Medical School Practice Interview Questions
How to answer questions on capacity in Medicine Interviews
The important things to consider when answering questions on capacity in medicine are:
Remember to explain what is meant by capacity when answering questions on it, as the interviewer needs to know that you understand the relevant terms.
Capacity and consent are closely linked, so make sure you try and incorporate the two when answering questions
It is easy to make your answers on capacity quite wordy and complex, so try to practise answering questions or pinning down a good definition to use in interviews. This will also demonstrate to your interviewer that you can explain complex topics concisely
👉🏻 Read more: MMI Medicine Interview Tips Guide
Capacity Interview Model Question and Answer
Q: How might someone’s capacity be impaired?
A: A person’s capacity can be impaired short-term, long-term, or in different ways over a period of time. However, it is important to note that someone can have capacity to make some decisions and not others, so should always be assessed for different decisions.
One example of short-term impairment of capacity is intoxication by drugs and alcohol. Other examples include unconsciousness and delirium. However, a patient can remain unconscious for many days or even weeks if sedated, and delirium can last longer in some patients than others.
Some long-term examples of how capacity can be impaired include brain damage, dementia, severe learning disabilities and mental health conditions. It is important to note that not everyone with these conditions automatically lacks capacity. These individuals should be encouraged to participate in decisions as much as possible.
Some patients experience fluctuating capacity. This can occur in some mental health conditions. These patients will be able to make decisions sometimes, but not others.
It is important to understand the different ways that capacity can be affected. However, healthcare professionals must ensure that all patients are given a fair assessment to enable them to make the decisions that they are able to make.
👉🏻 Read more: MMI Medicine Interview Questions Guide
Frequently Asked Questions
How is decision-making capacity evaluated in healthcare?
The assessment of decision-making capacity in healthcare involves a two-part test - the functional and the diagnostic. The functional test looks at a patient's ability to understand, retain, use and weigh information, and communicate their decision, while the diagnostic test examines the cause of the impairment in decision-making ability.
What are the fundamental elements to determine medical decision-making capacity?
In medicine, there are four essential elements used to determine a person's decision-making capacity. These include the ability to comprehend information, the capacity to retain the information, the capability to use the information to make an informed decision, and finally, the ability to express that decision.
Can you define capacity in a medical context?
In a medical context, capacity refers to a patient's ability to understand, retain, use and communicate information about their condition and the potential risks and benefits of treatment options, thereby making an informed decision about their healthcare.
Why is it crucial to assess a patient's capacity in medicine?
Assessing a patient's capacity in medicine is crucial as it ensures respect for patient autonomy, and is a legal requirement before initiating treatment or care. It's especially important when dealing with high-risk patients who may be incapable of making informed decisions due to various impairments.
Who is responsible for assessing a person's mental capacity in a healthcare setting?
Any healthcare professional involved in a patient's care has the responsibility of assessing the patient's mental capacity, particularly before making decisions about starting or continuing treatment or care.
What does it signify if a person lacks capacity?
A lack of capacity signifies that a person is unable to make an informed decision about their healthcare due to an inability to understand, retain, use or communicate information. This could be due to various factors like mental health conditions, cognitive impairment, or the influence of substances.
What are some factors that could impact a person's mental capacity?
Factors like the influence of alcohol or drugs, states of delirium or unconsciousness, conditions such as dementia or severe learning disabilities, brain damage, and certain mental health conditions could potentially impact a person's mental capacity.
Do all patients with mental health conditions have capacity?
The capacity to make medical decisions does not solely depend on a patient's diagnosis. Some patients with mental health conditions may have the capacity, while others may not. It's assessed on a case-by-case basis.
Can a competent patient refuse medical treatment?
Yes, a competent patient or a patient with capacity has the legal right to refuse medical treatment, even if the decision may seem detrimental to their health.
What's the implication of 'fluctuating capacity' in medicine?
Fluctuating capacity refers to situations where a patient's capacity to make decisions can change over a short span of time, often influenced by their medical condition. It is essential to consider this aspect while evaluating a patient's decision-making capacity.
How is the 'best interest' principle applied when a patient lacks capacity?
When a patient lacks capacity, healthcare professionals must act in the patient's 'best interests'. This includes considering the patient's past and present wishes, feelings, beliefs and values that would influence their decision if they had capacity.
How does capacity relate to informed consent in healthcare?
Capacity is a prerequisite for informed consent in healthcare. A patient can only give informed consent if they have the capacity to understand, retain, weigh the pros and cons, and communicate their decision regarding the proposed medical intervention.
How is capacity assessed in medicine?
Capacity is assessed using the functional test, which looks at whether a patient is able to make a certain decision, and the diagnostic test, which looks at the cause of the inability to make the decision.
What are the 4 elements of capacity in medicine?
The four elements of capacity are:
Can the person understand the information given to them?
Can the person retain the information given to them?
Can the person use that information to come to a decision?
And can the person communicate their decision?
What is meant by capacity?
Capacity refers to someone’s ability to make a decision.
Why is it important to measure capacity?
It is important to measure capacity because it can be a risk to some patients to allow them to make decisions when they are unable to do so.
Who decides if a person has mental capacity?
Any healthcare professional who is caring for the patient.
What does lack of capacity mean?
If someone lacks capacity, it means they do not have the ability to make a decision about their care.
Which issues could affect a person’s mental capacity?
Alcohol, drugs, delirium, lack of consciousness, dementia, brain damage, severe learning disabilities and mental health conditions can all affect someone’s capacity.
Do mental health patients have capacity?
Some mental health patients will have capacity and others will not. Capacity does not depend solely on the diagnosis someone receives.
Can a patient with capacity refuse treatment?
A patient with capacity is allowed to refuse treatment.
Conclusion
Understanding capacity is incredibly important when preparing for medicine interviews. Questions on capacity and consent are a great opportunity to showcase knowledge on legal topics within medicine.
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