A patient's decision must be informed and free, and he/she must be competent either to consent to or refuse treatment. Rather than selecting a single standard of competency, a sliding scale is suggested that requires an increasingly more stringent standard as the consequences of the patient's decision embody more risk. The standard of competency to consent to or to refuse treatment depends on the dangerousness of the treatment decision. Three different standards are correlated with the psychiatric abnormalities that are most likely to undermine them. A model with guidelines for use is provided to aid the physician who is called on to make a determination of competency.
KIE: The author proposes a three-level sliding scale for physicians to use in determining the capacity of patients with diminished mental capacities to consent to or refuse treatment. Since his goal is to promote informed and free participation in treatment decisions by competent patients while protecting incompetent patients from the harmful effects of a bad decision, the stringency of the standard of competency at each level is related to the dangerousness of the treatment decision. The three standards are also correlated with the psychiatric abnormalities that are most likely to undermine them.