Innov Clin Neurosci. 2025;22(10–12):52–56.

by Alexandria Nasr, MD; Larrilyn Grant, MD; Jennifer Golida, BS, MS; and Bailey N. Hangen, BS

All authors are affiliated with the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.

Department Editor: Julie P. Gentile, MD, is Professor and Chair of the Department of Psychiatry at Wright State University in Dayton, Ohio.
Editor’s Note: The patient scenarios presented in this article are composite cases written to illustrate certain diagnostic characteristics and to instruct on treatment techniques. The composite cases are not real patients in treatment. Any resemblance to real patients is purely coincidental.

ABSTRACT: Decision-making capacity (DMC) is a core element of ethical and effective clinical care, ensuring that patients can understand, appreciate, reason through, and communicate informed choices about treatment. Accurate assessment of DMC is essential in psychiatric settings, where serious mental illness (SMI) may affect cognition, insight, or judgment, yet does not inherently imply incapacity. This paper examines how implicit, racial, and cognitive biases can influence DMC evaluations and contribute to disparities, particularly for Black and Hispanic patients with SMI. Diagnostic overshadowing, assumptions about insight, and misinterpretation of culturally influenced communication may lead to incorrect determinations of incapacity and undermine patient autonomy. Evidence indicates that while cognitive impairment is a significant contributor to reduced DMC, many individuals with SMI retain the ability to make reasoned treatment decisions. Standardized tools—such as the MacArthur Competence Assessment Tool and related instruments—can improve reliability and mitigate subjective judgment, though current measures lack explicit integration of cultural and racial considerations. This paper highlights strategies to reduce bias in DMC assessments, including clinician education, development of culturally informed protocols, interdisciplinary decision-making, and expanded access to advocacy resources. These efforts support equitable, accurate, and ethically grounded evaluation of patient capacity across diverse clinical populations. Keywords: Decision-making capacity, implicit bias, serious mental illness, capacity assessment, diagnostic overshadowing, informed consent, autonomy, cultural competence

Introduction

Patients are often faced with decisions regarding their clinical care. They may be presented with several options that have varying levels of risks versus benefits. They may, at times, opt out of treatment entirely. As clinicians, how do we know whether a patient can make such a decision safely? How do we uphold the ethical pillar of beneficence while concurrently respecting a patient’s autonomy? Assessing a patient’s decision-making capacity (DMC) is a fundamental aspect of ethical and effective medical care, ensuring that individuals can make informed choices about their treatment. However, these assessments are subject to potential biases that may influence a provider’s judgment, leading to inconsistencies in determining a patient’s ability to consent or choose. This paper explores the impact of such biases on DMC evaluations and examines standardized assessment tools designed to enhance objectivity and reliability in clinical practice, as well as their potential limitations.

What is dMC and why is it important?

DMC refers to a patient’s ability to understand, appreciate, reason through, and communicate choices regarding their medical care. First, a person must understand relevant information about their condition, treatment options, and potential risks. The patient must appreciate the consequences of their illness and the treatment options available. They must be able to reason through these options and alternatives and, finally, express or communicate a choice.¹ It is a fundamental concept in medical ethics and legal standards. Informed consent, as always, is a common first step in determining DMC, where the condition, treatment options, and risks versus benefits are shared with the patient in a manner that is free from coercion.²

In psychiatric treatment, addressing DMC is particularly important due to the nature of mental illnesses, which can sometimes impair judgment, insight, or cognition. Serious mental illness (SMI) is a term used to describe a group of psychiatric conditions characterized by their serious nature, long duration, and impact on a person’s ability to function in daily life.³ Schizophrenia, bipolar disorder, severe major depressive disorder, schizoaffective disorder, obsessive-compulsive disorder, severe post-traumatic stress disorder, borderline personality disorder, and eating disorders such as anorexia nervosa are examples of SMI.⁴ SMIs often involve profound disturbances in thinking, mood, or behavior, and may include symptoms such as delusions, hallucinations, severe mood dysregulation, or disorganized thinking.⁵ Similar to individuals with intellectual disability, cognitive impairment—rather than demographic considerations or psychopathology—is the largest contributor to limitations in DMC among people with SMI.⁶ It was found that cognitive test scores are predictors of treatment-related decisional capacity in a population of patients with schizophrenia, but the strongest correlation explained only about 25 percent of variance.⁶ This indicates that DMC is nuanced and likely impacted by factors outside of cognition alone. A qualitative study looked at patients with either severe depression or mania and determined that the anticipation of future outcomes in these populations may be fixed, thus leading to failure to perform inductive reasoning, which is an important component in the decision-making process.⁷ With the above factors, these patients may look to substitute decision-makers (eg, a legal guardian, family member, friend, or their provider) to help guide their decisions.⁵

What Are the consequences of bias in DMC assessments?

Racial and ethnic minorities, especially Black and Hispanic patients with SMI, are more likely to be assessed as “lacking DMC” compared to their White counterparts.⁸ This bias may be due to stereotypes and assumptions held by clinicians about the cognitive or functional abilities of individuals based on race or ethnicity. A review conducted by Crapanzano et al⁹ of over a dozen studies revealed that healthcare provider bias against individuals with mental illness does exist and impacts clinical decisions negatively. For example, Black patients with schizophrenia may be more frequently perceived as lacking insight or understanding.⁸ Additionally, expressions of distress or agitation by minority patients might be misinterpreted as evidence of irrationality or incompetence, whereas similar behaviors in White patients may be viewed more empathetically or attributed to situational stress.⁸ Racial biases can lead clinicians to overpathologize behaviors or expressions that differ from their own cultural experiences.

Implicit biases are unconscious attitudes or stereotypes that affect understanding, actions, and decisions.¹⁰ Clinicians may unconsciously associate racial minorities with traits such as noncompliance or lack of understanding, which can negatively impact their judgment of a patient’s capacity.⁸ Stereotypes about certain racial groups being more irrational or violent can also affect how clinicians interpret a patient’s decision-making abilities. A study executed by Yamauchi et al⁴ discovered that patients with a past medical history of schizophrenia increased physician biases and mistakes in decision-making, including whether to offer recommendations for further examinations and whether they expressed an appropriate disposition toward the patient.

The “jumping to conclusions” (JTC) bias occurs when a decision is made based on limited evidence or data. JTC has been related to formation and maintenance of delusions within patients diagnosed with psychosis, longer periods of clinical admission, and poorer clinical outcomes.¹¹ One randomized controlled trial sought to evaluate how the introduction of a psychological intervention could impact DMC in patients with psychosis. It found that the more patients with psychosis were educated on their psychiatric diagnosis and treatment options, the less likely they were to jump to conclusions when making a decision.¹² Subsequently, patients within a psychiatric setting were found to have a greater affinity of expressing appreciation for their medical situation and received treatment and likely consequences, whereas patients within a medical setting showed greater ability of reasoning in regards to received medical information and treatment.⁷ Thus, though impairments in decision-making ability may exist amongst patients with a severe mental disorder, most possess the ability to make adequate decisions about the care of their health and have the capacity to judge risk-reward situations and adequately make decisions about important treatment outcomes.¹³

Clinical Vignette 1

S was a 35-year-old Black male patient who was admitted to the inpatient psychiatric unit for medication adjustments and stabilization for a manic episode. S had a history of bipolar 1 disorder starting in adolescence and marked by episodes of impulsivity, irritability, grandiosity, and auditory hallucinations—these were followed by periods of deep depression. S had a history of multiple hospital admissions with difficulty adhering to medical regimens upon discharge. When he arrived at the medical floor for stabilization, S initially refused to speak with staff about his mood or desires regarding his treatment. A few days later, he was approached by the psychiatric team to evaluate whether he had DMC regarding his treatment.

Dr. A: Good morning, S. I wanted to check in with you about your treatment plan. How are you feeling today?

S: I’m fine. But I don’t get why I’m still here. I feel great—better than ever, actually. I don’t need these meds, and I want to go home.

Dr. A: I understand that you want to leave, but we need to ensure that you’re stable before making that decision. Can you tell me what you understand about your diagnosis?

S: Yeah, yeah. You all say I have bipolar disorder. But I don’t think I need meds to control my mood. I’m just a high-energy guy. I have big plans! And honestly, these meds just slow me down.

Dr. A: That’s what I wanted to discuss. You’ve had several hospitalizations, and each time, stopping medication has led to a relapse. Don’t you think it’s important to stay on them?

S: Look, I know my history. I’ve had ups and downs, sure, but I also know what these drugs do to me. They make me sluggish, and I can’t think straight. I’m not just going to blindly follow whatever you say.

Dr. A: I hear that you don’t like the side effects, but these medications are necessary for your stability. Your elevated mood and grand ideas might be part of your illness. Do you really think you’re able to make the best choice for your health right now?

S: Why do you assume I can’t? Just because I don’t agree with you? I understand what you’re saying—I just don’t think it’s the only way.

Dr. A: Well, based on your history and your current symptoms, I’m concerned that you lack the capacity to make this decision.

S: What? Just because I don’t want to do what you say? That’s not fair. I know the risks. I’ve taken these meds before. I know how they make me feel. That should count for something.

Dr. A: You’ve struggled with adherence in the past, and your symptoms suggest impaired judgment. I have to make sure you’re safe, even if that means overriding your decision.

S: So I don’t get a say at all? You’re not even really listening to me.

PRACTICE POINT: The importance of exploring and working through implicit bias

Dr. A’s assessment did not fully consider S’s ability to understand the treatment options, the risks of not taking medications, or the potential benefits. Thus, he did not engage S in a detailed conversation about the risks and benefits of the medications, nor did he assess S’s ability to retain and weigh this information. Instead, Dr. A concluded that S lacked capacity based on his manic symptoms and previous noncompliance with treatment. It is essential for providers to separate symptoms of mental illness from a patient’s actual ability to make decisions. Providers should make an effort to be aware of their own implicit biases and how these biases may impact future patient interactions.

Alternative approach

Dr. A: I hear that you’re worried about the side effects. Can you tell me more about what concerns you the most?

S: The meds make me feel slow. I don’t feel like myself when I take them.

Dr. A: That makes sense. Some medications do have side effects, but there might be options that work better for you. Would you be open to discussing alternatives?

S: I’d be willing to listen, but I don’t want to be forced into something.

Dr. A: I respect that. My goal is to make sure you have all the information so you can make the best decision for yourself. Let’s go over the risks and benefits together.

Diagnostic overshadowing occurs when a patient’s race or ethnicity influences how their symptoms are interpreted.¹⁴ For instance, a Black patient presenting with agitation may be more likely to be diagnosed with a severe psychiatric condition (eg, schizophrenia) compared to a White patient exhibiting the same symptoms whose distress might be attributed to a medical or psychosocial cause. As a result, the assessment of DMC may be biased by the underlying diagnostic assumptions made about the patient’s condition based on race. Lack of cultural competence among healthcare providers can lead to misunderstandings and misinterpretations of patient behavior, communication styles, and decision-making preferences. Cultural differences in expressing symptoms, understanding illness, or articulating choices may be mistaken for a lack of capacity. For example, language barriers or culturally specific ways of expressing mental distress might be misinterpreted as cognitive deficits or impaired reasoning. Finally, systemic biases within healthcare institutions—such as policies, practices, and legal frameworks—can reinforce racial disparities in DMC assessments. These might include protocols that are not adequately adapted to account for cultural differences or lack diverse representation in decision-making panels. Additionally, minority patients are less likely to have access to advocacy resources, like legal representation or patient advocacy, which can impact the fairness of DMC assessments.

The presence of a psychiatric disorder alone does not imply a lack of DMC. Rather, an individualized assessment is necessary to ensure that patients are neither unjustly deprived of their autonomy nor placed at risk due to impaired decision-making. Improper DMC evaluations can have significant ethical and legal consequences. If a provider incorrectly determines that a patient lacks DMC, the patient’s autonomy may be unjustly overridden, leading to unnecessary coercion or involuntary treatment. Conversely, failing to recognize impaired DMC can result in harm if a patient refuses necessary care due to impaired judgment. Therefore, ensuring accurate, unbiased, and standardized assessments of DMC is essential in psychiatric treatment to uphold ethical principles, protect patient rights, and ensure appropriate medical decision-making.

Clinical Vignette 2

M, a 32-year-old man, was admitted to the hospital after being found wandering the streets with disorganized speech and signs of psychosis. His family reported a sudden decline in his behavior, believing that people are watching him and becoming suspicious of his close relatives. Dr. J evaluated M in the ER.

Dr. J: Hi, M. I understand you’re feeling very upset right now, and I want to help. What I’d like to do is talk through everything carefully so that we can understand what’s going on.

M (visibly agitated but calmer): I just don’t get why people are watching me. I don’t feel safe. I haven’t been able to sleep, and I think they’re trying to control me.

Dr. J: I understand that you’re feeling like you’re being watched, but I want to explain that sometimes, when we are under a lot of stress or haven’t been sleeping, our brains can cause us to feel or think things that aren’t actually happening. Sometimes, extreme stress or even certain medical conditions can cause us to feel paranoid or disconnected from what’s really happening around us. I want to make sure we take a closer look at all of this, including checking for any physical issues that could be contributing. We’ll do some tests, and in the meantime, I’ll explain the treatment options available. Does that sound okay?

M (calming down slightly): Okay, but how will I know if I can trust you? How do I know that what I’m seeing isn’t real?

Dr. J: That’s a great question. What I’m going to do is make sure we approach this from every angle. We’ll start by looking at your medical history and doing some tests, and I’ll keep you informed about everything we find. If it turns out this is something like stress-related psychosis, we can work on treating that, but I also want to rule out other causes, like medical conditions or substances that could be contributing. We’ll take things one step at a time. You won’t be alone in this.

PRACTICE POINT: The importance of exploring and working through implicit bias

By educating M about the possibility that stress and lack of sleep could be influencing his thoughts, Dr. J avoided the JTC bias. Instead of assuming that M’s symptoms were purely due to a psychotic disorder, he acknowledged the complexity of the situation and explained how a thorough evaluation would be done to determine the cause. Dr. J also involved M in the process and ensured that M felt heard and understood, which helped build trust and decreased his paranoia. Without involving the patient in his care, Dr. J might have assumed that M was too ill to understand what was happening without exploring M’s personal perspective or educating him about his symptoms. By taking the time to explain things to M and involve him in the process, Dr. J reduced the chances that M would feel misunderstood or further distrustful.

Existing assessment tools

Use of standardized assessment tools can help minimize subjective judgments or interobserver differences. The most widely studied and utilized tool is the MacArthur Competence Assessment Tool (MacCAT-1). It is administered by a clinician in a semistructured interview format which evaluates the four main components of DMC. A higher score correlates with stronger DMC. In an Iranian-based population, the MacCAT was found to possess content validity, making it an effective tool with improved interrater reliability.¹⁵ Other validated tools include Assessment of Capacity to Consent to Treatment (ACCT), Hopkins Competency Assessment (HCAT), and Assessment for Capacity for Everyday Decision-making (ACED). While several formal capacity assessment tools can be adapted for use across diverse populations, there is a lack of validated assessments for determining DMC that explicitly include discussions about racial and cultural considerations.

Clinical Vignette 3

The patient, H, was admitted to the hospital for depression. She was approached by Dr. R.

Dr. R: H, I’m here to discuss your treatment options, but I need to understand if you’re able to make decisions for yourself right now. You seem very down, and I’m concerned that you may not be able to make the best choices at the moment.

H (in a flat tone): I don’t really care what happens. I don’t want to talk to my family. You just decide. I don’t have the energy to think about it.

Dr. R: Given how depressed you are, I think it might be best if I make decisions for you. You seem too upset to decide for yourself.

H: I don’t want you to make decisions. But I don’t know…I’m tired, and I don’t care about anything anymore.

Dr. R determined that H lacked DMC based on her mood and unwillingness to engage, concluding that it would be in her best interest to involve family in decision-making.

Practice Point: Use of screening tools to minimize bias

The MacCAT is a structured, validated assessment tool used by clinicians to help determine whether a patient has DMC or not. By using the MacCAT, Dr. R could formally assess H’s ability to understand her options, appreciate potential outcomes, reason through her choices, and express a choice. After working through these components, Dr. R determined that, while depressed, H still had the capacity to make decisions about her care. Using a validated tool like the MacCAT reduces the potential for bias or assumptions about a patient’s ability to make decisions based solely on their emotional state or appearance. When used properly, the MacCAT helps ensure that the patient’s autonomy is respected, even in the context of severe depression. It prevents unnecessary paternalism by encouraging shared decision-making and empowerment of the patient in their treatment.

Alternative approach

Dr. R: H, I want to make sure we’re approaching this in the best way for you. There’s a tool called the MacCAT that helps us assess decision-making capacity. It’s a structured way to understand whether someone can make medical decisions for themselves. Would it be okay if we worked through it together?

H (shrugs): Sure. Whatever.

(Dr. R proceeds with the MacCAT assessment, evaluating H’s ability to understand her treatment options, appreciate the potential consequences, reason through her choices, and express a decision.)

Dr. R: H, from our discussion, I can see that while you are feeling very depressed and withdrawn, you do understand the treatment options available, their risks and benefits, and how they apply to your situation. You also are able to express a consistent choice, even if you feel uncertain. Based on this, I believe you do have the capacity to make decisions about your care.

H (softly): So…I can still decide what happens?

Dr. R: Yes, you can. I know it’s hard right now, but your voice matters. If you’d like, I can help you think through the options and support you in making a decision that feels right for you.

H (pauses, then nods slightly): Okay…maybe just tell me again what my choices are.

Dr. R: Of course. Let’s go through them together.

(Dr. R begins reviewing treatment options with H, ensuring she remains engaged in the decision-making process.)

Conclusion

Determining whether a patient has the capacity to make their own treatment-related decisions is a nuanced task. There are several considerations that need to be addressed by clinicians to uphold ethical pillars while providing the best possible care to patients. In this paper, we explored factors that can impact DMC in patients with SMI and explored potential biases that can alter outcomes.

So, what can we do? We can strive to implement regular training programs to help healthcare providers recognize and address implicit biases that may affect DMC assessments. This training should include specific modules on cultural competence and acknowledgment of the impact of race and ethnicity on clinical decision-making. We can encourage the use of interdisciplinary teams, including members from diverse racial and ethnic backgrounds, to provide balanced perspective in DMC assessments. This could include cultural liaisons or community representatives to help bridge gaps in understanding and interpretation. We can instill best-practice strategies aimed at ensuring patients with mental illness or SMI are empowered to make adequate and appropriate decisions regarding their healthcare and subsequent treatment. We can use validated assessments tools. However, as discussed, this is an area that needs to be expanded in the future to assist providers in reflecting on their own implicit biases and how they may impact DMC determinations. Finally, we can strive to ensure that all patients, especially those from minority populations, have access to advocacy resources, such as patient advocates or legal counsel, during DMC evaluations.

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