Authors' reply

Kane et al claim that we ‘collapse all hard capacity questions into a coercion test [which] fails to grapple with the range of clinical sources of “moral distress” and the legal doctrine of informed consent.’ We do not take this position. We identify a narrow set of circumstances that permit capacity evaluators to look past the overt question – does this patient have capacity? – and address the covert but more practically meaningful question – what should clinicians do when the patient declines the treatment recommendation? If it turns out that all parties actually agree that involuntary treatment is not available, feasible or appropriate, then the apparent conflict dissolves.

Nevertheless, Kane and colleagues rightly point out that the determination of whether a treatment is available or ‘medically indicated’ can itself pose an ethical dilemma. Forced treatment is almost always contentious, as it infringes upon people's liberty and autonomy interests. But even voluntary treatments can provoke moral distress if the validity of consent is in doubt or if clinicians regard a requested intervention as futile. Kane et al. seem to suggest that our approach avoids these issues.

On the contrary, we believe that our method puts the focus right where it belongs: on the practical problem of providing involuntary treatment. Capacity status can be an important consideration, but in the most difficult cases, it is seldom determinative on its own. In proposing that capacity evaluators ‘collaborate closely with treatment providers’, we do not advocate that evaluators should abdicate their responsibility to engage in moral discussion about a patient's situation. Nor do we encourage practitioners to make unilateral moral judgements based only on ‘medical risks.’ Instead, capacity evaluators play the vital role of helping treaters recognise the true source of their moral distress. In those cases, referral to broader decision-making bodies such as ethics committees or the courts is appropriate.