Competence and Mental Healthcare

The presence of a mental disorder does not automatically negate the presumption of a person's competence. Although some severely mental ill persons are indeed incapacitated in many areas of their functioning, most mentally ill persons have only some discrete areas of decision-making incapacity, often confined to episodes of their illness. A paranoid delusional patient who denies that he is mentally ill, for example, may be unable to rationally decide whether or not to consent to antipsychotic medication while he is mentally ill but may have adequate decision-making ability to consent to treatment for diabetes and heart disease. In such a case, the content of the patient's paranoid delusions would be irrelevant to the patient's diabetes and heart disease, and the patient would not deny the fact of his medical illnesses. A patient in a manic episode may be unable to manage his finances because he will rapidly dissipate them, but his decision-making capacity will return as the episode ends. Subtle forms of decision-making incapacity can also arise from mildly altered mood states (depression, hopelessness, anxiety, euphoria), from cognitive dysfunction (impairment in memory or attention from head injury), or from personality traits (guilt, self-punishment, feelings of worthlessness).

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