Decision-Making Capacity-Reply

In reply Dr MacLean's letter raises important issues concerning limitations of objective approaches to the assessment of competency. We agree that competency assessment ultimately involves a moral judgment, that clinicians need more conceptual clarity regarding competency, and that competency judgments should not be reduced to "a technical medical determination." What should not be overlooked, however, is the important relationship of standardized assessment approaches to the conceptual and moral basis of competency judgments. Clinical assessment of competency to consent is currently a subjective, and even idiosyncratic, process. We previously reported data concerning a lack of agreement among experienced physicians when assessing the competency of patients with mild and moderate dementia to consent to treatment.1More recently, we found that five physicians experienced in competency assessment differed markedly in their competency judgments for patients with mild Alzheimer's disease, but not for older controls. The physicians achieved virtually perfect judgment agreement for