Capacity in Medicine - Medicine Ethics and Interview Questions

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:

1. Understand the information given to them
2. Retain the information
3. Use the information to make a decision
4. 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:

1. The Functional Test - Is the patient not able to make a particular decision?
   1. 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:
      1. Understand information related to the decision
      2. Retain that information long enough to make a decision
      3. Use or weigh that information as part of the process of making the decision
      4. Communicate their decision by any means.
2. 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:
   1. Mental health conditions
   2. Unconsciousness
   3. Alcohol
   4. Drugs
   5. Dementia
   6. Delirium
   7. Severe learning disabilities
   8. 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

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 happens if a patient lacks capacity? Best interests explained

‘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

Capacity and medical ethics: autonomy, beneficence and justice

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

Capacity interview questions for medical school

1. What does capacity mean in medicine?
2. Why is capacity assessment in medical ethics important in medical practice?
3. What are the procedures followed when someone lacks the ability to make a healthcare decision?
4. Can you explain the interlinking of capacity and consent in healthcare decision-making?
5. (Hard, unlikely) In your view, does the current Mental Capacity Act 2005 provide an adequate framework for assessing which patients can make their own medical decisions?
6. Can you list some factors that might impair a patient's capacity in a medical setting?
7. In terms of medical ethics, how would you define best interests when dealing with a patient lacking capacity?
8. What is the link between autonomy and capacity?
9. How do we evaluate an individual's ability to make decisions in medicine?
10. What are the four criteria for determining patient's capacity?
11. Is it possible for a patient to demonstrate capacity for one decision but lack it for a different decision within the same day?

👉🏻 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:

1. 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.
2. Capacity and consent are closely linked, so make sure you try and incorporate the two when answering questions
3. 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 assessment questions: model interview 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

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.

Check out our Medicine Interview Tutoring and Interview Question Bank which has over 400 medicine questions and answer guides for your practice.