‘Capacity assessments appear subject to bias from the very beginning of the process’
C-L psychiatrists should be wary of racial bias among physicians when responding to decisional capacity placements on patients, say researchers.
The research team studied 181 patient capacity consults requested of the C-L Psychiatry service at an academic tertiary care medical center from 2018-2019 and concluded that “significant racial disparities” exist at the point of requesting capacity consults, which occur disproportionately with Black and Hispanic patients compared to White and Asian patients.
Their as yet unpublished paper Racial Disparities in Psychiatry Decisional Capacity Consults shows that 42.6% of capacity consults at the Mount Sinai Hospital in NYC during the two-year period were placed on Black patients but those patients represented only 17.8% of total inpatient admissions. Hispanic patients represented 26.1% of capacity consults yet only 20.5% of admissions. Conversely, White patients represented only 27.8% of capacity consults while comprising 53.1% of admissions, and Asian patients represented 3.4% of capacity consults while comprising 8.6% of admissions.
The paper says: “These findings bring to light the potential biases introduced with both the initial challenge to a patient’s capacity as well as the subsequent outcomes of the consult. As such, the potential balance of risk vs. benefit, or utility, of these consults in certain populations must be carefully considered.”
It adds: “Psychiatrists should acknowledge the disparate frequency and impact of capacity assessments, which can negatively affect therapeutic relationships between patients, families, and care teams.”
Lead author Omar Mirza, DO, director of C-L Psychiatry at Harlem Hospital Center and assistant clinical professor of psychiatry at Columbia, et al., say patients have the unequivocal right to make decisions regarding their health care through the process of informed consent.
When patients may be unable to consider their options, or appear to be making decisions perceived to be irrational in context of their values, the physician has the unique ability, and possibly the responsibility, to further assess their decision-making capacity.
“This sensitive situation is one of the most common interfaces between Medicine and Psychiatry in the hospital setting, with the psychiatric consultant often called upon to represent the medical establishment’s evaluation of the patient’s capacity.
“Given that studies have estimated that 26% of all medical inpatients do not possess decision-making capacity, it is no surprise that up to a quarter of all inpatient Psychiatry consults are related to this concern.”
Capacity assessments, while intended in theory to protect patient interest, also inherently challenge patient autonomy, thus requiring careful consideration of current approaches to such evaluations, say the researchers.
Even if patients are ultimately determined to be capable of making their own decisions, the assessment process itself has questioned and interrupted their spontaneous ability to act on their own wishes. Given the critical implications of capacity, many hospitals have developed systemic protocols for such determinations.
Appelbaum and Grisso (1988) laid out four criteria for determining decisional capacity: the patient’s ability to communicate a choice, to understand the relevant information, to appreciate a situation and its consequences, and to reason rationally.
“Though the Appelbaum criteria are now widely used and implemented, significant variability still exists among capacity determinations,” say the researchers. “One study used standardized patient scenarios to illustrate that only 33% of experienced C-L psychiatrists using these criteria came to the same conclusion.
“Studies have shown that variables including the physician’s personal values are of some significance in the outcomes of capacity evaluations.”
The researchers go on to say: “While racial/ethnic disparities in health care treatment and outcomes have been discussed as evidence of systemic bias, the overall medical literature has only just begun to interrogate the systems and processes that give rise to such disparities. Given the persistence of such disparities, it is no longer sufficient to merely acknowledge examples of explicit institutional racism … or simply condemn explicit individual biases, such as the unfortunate belief of many physicians that Black patients feel less pain.
“Clinical outcomes that are racially disparate must be identified as symptoms of additional implicit bias, and the relevant clinical methods and policies must be re-examined.”
Significantly, the researchers submitted their paper to Psychiatric Services at the American Psychiatric Association (APA), where it is currently in revision stages. “Psychiatry is far from exempt from such an examination, given its long and troubled relationship with race,” say the researchers. “As the APA has acknowledged, purportedly scientific studies of mental ‘health’ and illness were intentionally used to denigrate, institutionalize, and remove autonomy from marginalized populations.
“From explicit arguments about the mental abilities of non-white patients, to disproportionate diagnoses of mental illnesses, particularly schizophrenia, among the Black population, psychiatrists have consistently been relied upon to legitimize racial discrimination.
“Given this historical medical oppression of racial/ethnic minorities, coupled with documented negative societal attitudes toward their education, intelligence, and decision-making ability, hospital-based physicians’ assessment of capacity warrants significant scrutiny as a structural process highly vulnerable to implicit biases.”
The research team say, to their knowledge, no previous study has assessed for potential racial disparities in capacity consultation and determination—even though “capacity assessments appear subject to bias from the very beginning of the process.”
And they warn C-L psychiatrists: “Simply introducing a capacity consult into the patients’ clinical picture has the potential for harm, as it poses questions regarding their decision-making autonomy and capabilities, with significant implications for the perpetuation and worsening of their vulnerability in the health care system if challenges to their legal autonomy occur at such a disproportionate rate.”
Additionally, the purported worst outcome from a capacity assessment—having one’s autonomy revoked by a capacity assessment, yet subsequently not receiving treatment recommended by the doctors—was most common in this study among Hispanic patients with less than a high school education.
“Ideally, as consults for capacity assessment impose a burden upon patients,” say the researchers, “such assessments would be requested on an objective, bias-free basis, and only when necessary to guide clinical care. In practice, our findings indicate that patients from certain racial backgrounds are subject to such assessments with greater frequency than others. Given the racial/ethnic makeup of the medical profession in the US, and data showing that physicians’ personal values play a role in the outcome of capacity evaluations, providers and institutions should take additional steps to protect patients from such bias.”
Capacity challenges are not benign tools that merely facilitate assessment, they add. “Rather, they are significant interventions that can subject patients to psychological duress. The threat of losing autonomy can prove burdensome to individuals from racial/ethnic communities who already have reasons for distrusting the medical establishment.
“Such assessments, especially if non-actionable, can jeopardize therapeutic relationships and strain alliances between patients, families, and care teams. Psychiatrists cannot be blind to the disparate impact of such assessments even when they might be imposed equitably. Capacity challenges that reflect underlying, systemic racial/ethnic biases in health care serve only to exacerbate existing disparities. Biased capacity assessment can prove a barrier to effective care.”
Among the paper’s mixed-ethnic authors is a member of the Black and Indigenous People of Color community who was attending physician on the C-L Psychiatry service during the study period and contributed to capacity assessments. The team in addition to Dr. Mirza are: Jacob Appel MD, associate professor of psychiatry and medical education, the Icahn School of Medicine; William Garrett, MD, MPH, psychiatry resident, Icahn School of Medicine, Mount Sinai Hospital; Anita Verma, MD, medical director, Partial Hospital Program, Icahn School of Medicine, Mount Sinai Hospital; and Daniel Thomas, MD, medicine resident, Johns Hopkins Bayview Medical Center, Baltimore.