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Mental Capacity and the complex nature of decision-making

Kettle being heated on stove

It’s estimated that the average person makes around 35,000 decisions every single day. While this may seem a huge number, many of these are ‘micro decisions’ that we make without even thinking; the sorts of things that might have required great effort during childhood, but which in adulthood require barely any conscious effort at all.

Conscious and unconscious decision-making

Take a moment to consider how you might make a cup of tea…

  • Standing in the kitchen:
    • How do you stand? What muscles do you use?
    • Are you stable/balanced on standing?
    • Do you experience any pain? What sensory feedback do you have?
    • Do you have any mobility issues? How do you use the kitchen environment to support your standing by the kettle?
    • Are there any other adjustments needed?
  • Preparing the drink:
    • Is the kettle gas or electric? Is it familiar?
    • How do you check if it is filled with water? How do you fill it up? Where is the tap and how do you use it?
    • Where do you find tea bags, sugar and milk?
    • Spatial awareness, coordination, visual discrimination and movement decisions
  • Navigating the environment:
    • Once you’ve made your cup of tea, how do you get to your destination? (Again, consider the muscles used and the sequence of events.)
    • How do you then move through the room? What route do you take? What obstacles do you face? How do you overcome them?

Of course, this is a broadly written list, which as an Occupational Therapist I would break down even further in analysis. But it highlights how many of these decisions we take for granted – and this is just the tip of the iceberg! What this goes to show is that even the simplest of tasks involve a great many different thought processes – both conscious and unconscious – to reach the end point, the final ‘cup of tea’.

Changing decisions over time

As humans, we make decisions based upon the sum of knowledge we have accumulated over time. We then process this knowledge and identify the most relevant information to help us make the decision, weighing up known risks and benefits while also taking into account the possibility of the unknown. All of which helps us build a fuller understanding of the situation before deciding how to act.

However, it is perfectly natural that our decisions can and indeed should change over time. After all, what may have been right for us in our early 20s, may not be right for us as we enter middle-age or retirement.

What this reminds us is that any decision made by someone under the Mental Capacity Act (2005) should be regularly reviewed to check they are still happy with their decision and want to carry with the way things are working.

It is also important to remember that any impaired decision-making does not mean that an individual’s thoughts, feelings and wishes are suddenly rendered invalid. Rather, these should all be taken into account as part of any Best Interest decision.

Case law

There are many pieces of case law we could refer to here. However, a recent judgement from Justice MacDonald in the case of North Bristol NHS Trust vs R (2023) really encapsulates the complex nature of decision-making and how it relates to Mental Capacity:

‘Human decision making is not standardised and formulaic in nature in that we do not, at least consciously, break a decision down carefully into discrete component parts before taking that decision. In addition, decisions are always taken in a context, with the concomitant potential for a myriad of other factors, beyond the core elements of the decision, to influence the decision being taken.  This has the potential to make the task of creating a definitive account of the information relevant to a particular decision a challenging one. This difficulty can be addressed however, by acknowledging that in order to demonstrate capacity, a person is not required or expected to consider every last piece of information in order to make a decision about the matter, but rather to have the broad, general understanding of the kind that is expected from the population at large (see Heart of England NHS Foundation Trust v JB [2014] EWHC 342 (COP) at [25]).  Within this context, the Mental Capacity Act Code of Practice at [4.16] states relevant information includes “the nature of the decision”, “the reason why the decision is needed” and “the likely effects of deciding one way or another, or making no decision at all.’ 

Justice MacDonald, North Bristol NHS Trust v R (paragraph 61)

In so writing, Judge MacDonald, links back to the legal requirement of threshold that is known as the ‘balance of probabilities’ that forms an important part of the threshold for capacity. That being that the person being assessed is not expected to have a highly detailed understanding of the decision, but rather to have a broad, general understanding of the sort that might be expected from the population at large.

Find out more

For more information about the threshold for capacity and how we measure understanding please see our extensive collection of guides and resources. We also offer support with complex assessments, as well as training and consultancy services for health and care professionals.  

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