What is the two-stage test of capacity?

Stage one, from section 2 of the Mental Capacity Act 2005, asks whether there is an impairment of, or disturbance in the functioning of, the mind or brain. Stage two, from section 3, asks whether because of it the person cannot understand, retain, use or weigh the relevant information, or communicate a decision.

Does the Mental Capacity Act apply across the UK?

No. It applies in England and Wales. GMC Decision making and consent 2020 notes that Scotland uses the Adults with Incapacity (Scotland) Act 2000 and that Northern Ireland relies on common law for treatment decisions. The GMC guidance is written to be consistent with all three.

Can a patient with dementia consent to treatment?

Often, yes. Capacity is decision-specific and time-specific, and section 2(3) of the Act says a diagnosis alone cannot establish incapacity. Assess the four functional elements for the decision in question, giving all practicable help first.

Who decides when a patient lacks capacity and there is no attorney?

GMC Decision making and consent 2020, paragraph 89, says the person with lead responsibility for the patient's care decides what is of overall benefit, after consulting those close to the patient and the team, and choosing the option least restrictive of the patient's future options.

What if a patient with capacity refuses life-saving treatment?

An adult with capacity can refuse treatment, and the Act's third principle says an unwise decision is not evidence of incapacity. Explore their reasons, make sure they understand the consequences, document carefully, involve your senior, and keep the offer of treatment open.

Should you delay a decision if capacity might return?

Yes, where the decision can safely wait. GMC Decision making and consent 2020, paragraph 86, says you must consider this, and section 4 of the Act requires a best-interests decision-maker to consider whether the person is likely to regain capacity.

Mental Capacity Act — IMT Interview Ethics Station Answer

Capacity is the most reliable ethics scenario at the IMT interview, and the panel is listening for a legal test said accurately and applied to one patient. The Mental Capacity Act 2005 supplies the test and the principles; GMC Decision making and consent 2020 supplies the professional duty around them.

Key takeaways

Section 1 of the Mental Capacity Act 2005 sets five principles: presume capacity, take all practicable steps to help, never treat an unwise decision as incapacity, act in best interests, and choose the less restrictive option.
Section 2 defines lack of capacity as being unable to make a decision because of an impairment of, or disturbance in the functioning of, the mind or brain, whether permanent or temporary.
Section 3 says a person is unable to decide if they cannot understand, retain, use or weigh the relevant information, or communicate their decision by any means.
GMC Decision making and consent 2020 says capacity is decision-specific and time-specific, and that assessing it is a core clinical skill that does not usually need a psychiatrist.
Section 4 requires a best-interests decision to consider the person's past and present wishes, beliefs and values, and to consult carers, attorneys and deputies.
The Act applies in England and Wales; Scotland has the Adults with Incapacity (Scotland) Act 2000 and Northern Ireland relies on common law for treatment decisions.

What does the Mental Capacity Act say capacity is?

Section 2(1) of the Mental Capacity Act 2005 says a person lacks capacity in relation to a matter if, at the material time, they are unable to make a decision for themselves because of an impairment of, or a disturbance in the functioning of, the mind or brain.

Three qualifications sit beside it. Section 2(2) says it does not matter whether the impairment is permanent or temporary. Section 2(3) says incapacity cannot be established merely by age, appearance or a condition that invites unjustified assumptions. Section 2(4) says the question is decided on the balance of probabilities.

What are the five principles you should state?

Section 1 of the Act lists five principles, and the panel expects all five in order.

A person must be assumed to have capacity unless it is established that they lack it.
A person is not to be treated as unable to make a decision unless all practicable steps to help them have been taken without success.
A person is not to be treated as unable to make a decision merely because they make an unwise decision.
An act done or decision made for a person who lacks capacity must be done in their best interests.
Before acting, regard must be had to whether the purpose can be achieved in a way that is less restrictive of the person's rights and freedom of action.

GMC Good medical practice 2024, paragraph 24, restates the first principle as a professional duty: you must start from the presumption that all adult patients have capacity to make decisions about their treatment and care.

How do you assess capacity at the bedside?

Apply section 3 of the Act. A person is unable to make a decision if they cannot understand the information relevant to it, retain that information, use or weigh it as part of deciding, or communicate their decision by talking, sign language or any other means.

Section 3(2) says a person is not to be regarded as unable to understand if they can understand an explanation given in a way appropriate to their circumstances, using simple language or visual aids. Section 3(3) adds that retaining the information only briefly does not prevent them deciding.

GMC Decision making and consent 2020, paragraph 82, calls this a core clinical skill that does not necessarily require specialist input, and says you should draw reasonable conclusions during your dialogue with the patient. Paragraph 84 says that if you believe a patient may lack capacity, you must assess it using the statutory test.

What does 'relevant information' include?

Section 3(4) says it includes information about the reasonably foreseeable consequences of deciding one way or another, or of failing to decide. So a patient refusing an amputation must be able to weigh what refusal means, not just what surgery means.

What is the worked scenario, answered aloud?

A 78-year-old with pneumonia and a delirium wants to self-discharge at 2 am. Said aloud: I would presume capacity, then assess it for this decision now, because delirium is a temporary disturbance the Act covers. I would explain the risks simply, with a relative present if possible, and check whether he can understand, retain, weigh and communicate.

If he lacks capacity for that decision, I would act in his best interests, consult his family about what he would want, and choose the least restrictive way of keeping him safe. If the decision could wait until morning, GMC paragraph 86 says I must consider delaying it because his capacity may return.

If he has capacity, he can refuse, however unwise I think it is. I would document the assessment and the discussion, offer a safety net and inform the consultant.

How is a best-interests decision made?

Section 4 of the Act sets the checklist. The decision-maker must not decide merely on age, appearance or behaviour, must consider whether the person is likely to regain capacity, and must permit and encourage them to participate as fully as possible.

They must consider the person's past and present wishes and feelings, including any relevant written statement made when they had capacity, and their beliefs and values. They must consult anyone the person named, carers, anyone interested in their welfare, and any attorney or court-appointed deputy.

GMC Decision making and consent 2020 uses the term overall benefit for the same exercise and, in paragraph 88, adds a step candidates miss: first check whether a legally binding advance decision exists, or whether someone else holds legal authority to decide.

What is the trap the panel sets?

The trap is equating refusal with incapacity. The Act's third principle, and GMC paragraph 81, both say you must not assume a patient lacks capacity because they choose an option you consider unwise, or because of their age, disability, appearance, behaviour, medical condition or beliefs.

The second trap is assessing capacity globally. However clear the dementia diagnosis, capacity is for one decision at one time, so a patient may lack capacity for a discharge decision and keep it for a blood test.

When do you escalate, and to whom?

Escalate when the judgement is difficult, when the patient or family disagree with it, or when a decision would restrict liberty. GMC paragraph 85 says to seek specialist input, from psychiatry, neurology, speech and language therapy or liaison nurses, or to discuss with your supervisor, in complex cases and where there is disagreement.

GMC paragraph 90 says that if a proposed option will restrict a patient's freedom, you must consider whether legal authorisation is needed. Paragraphs 92 and 93 route persisting disagreement through an independent advocate, a second opinion, a case conference or a clinical ethics committee, and then the formal legal steps.

How is a capacity answer scored?

The ethics, professionalism and governance area is scored 1 to 5 by each of two interviewers and weighted 1.2, and the communication mark it sits under is weighted 1.6. A 3 is the standard of a competent F2; a 1 anywhere makes a candidate unappointable.

In practice, the marks come from stating the test accurately, applying it to the patient in front of you, naming best interests and least restriction, and saying who you would involve. The verdict matters less than the reasoning.

How this comes up at the IMT interview

At the IMT interview, capacity is set as the station 1 ethics, professionalism and governance scenario, which runs up to five minutes after the portfolio questions, and it also surfaces inside station 2 clinical cases such as delirium, overdose and self-discharge.

Practise saying the five principles and the four functional elements without notes. internalmedicineinterview's question bank of 361 IMT questions includes capacity scenarios with AI-marked spoken practice, so you can hear whether the test came out in order.

Capacity and the Mental Capacity Act