How to Answer Questions on Consent and Mental Capacity

Doctors face ethical dilemmas regularly, and a large share of them turn on consent: a patient who refuses a recommended treatment, a confused patient on a ward, a teenager who does not want their parents told. Interviewers ask about consent and capacity because they are the mechanism through which autonomy, the first of the four pillars, actually operates. A candidate who can say what valid consent requires and how capacity is assessed can reason through most of these scenarios; one who cannot tends to fall back on "I would respect the patient's wishes" without being able to say when that applies.

They are also testing whether you understand professional standards. Familiarity with the Mental Capacity Act and GMC guidance on consent shows you're preparing seriously for a career where these principles govern daily practice.

Across consent and capacity questions, interviewers mark for:

• The three conditions for valid consent. The patient has capacity, has received adequate information about risks and alternatives, and gives consent voluntarily without pressure.
• The presumption of capacity. Always presume capacity unless there's reason to suspect otherwise, and an unwise decision alone doesn't mean someone lacks it.
• The capacity test, applied to a specific decision. Capacity is the ability to make a specific decision at the time it's required, not a general label.
• What happens without capacity. A best-interests decision, taking account of past wishes, values and beliefs, consulting those close to the person, and choosing the least restrictive safe option.
• The exceptions. Emergencies, where necessary treatment can proceed in the patient's best interests if consent cannot be obtained, and the special rules for under-16s.

Implied and informed consent

Implied consent

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Consent inferred from a person's actions or the situation rather than spoken or written agreement. Appropriate for obvious, low-risk interactions, such as a patient rolling up a sleeve for a blood pressure check, or in emergencies when delay risks serious harm.

Informed consent

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An explicit, voluntary agreement to a test or treatment after the person has received and understood the relevant information (purpose, benefits, material risks and alternatives) and has capacity to decide. Needed for anything more than minimal risk, anything invasive or intimate, or where reasonable people might choose differently.

Material risks are the ones a reasonable person in the patient's position would find significant. Since the Montgomery ruling in 2015, that is the test, rather than what a doctor would choose to mention.

Assessing capacity

To assess capacity, determine whether there's an impairment of mind or brain, and whether because of that impairment the person is unable to do any one of four things:

1. 1.Understand the relevant information
2. 2.Retain it long enough to decide
3. 3.Weigh up the options
4. 4.Communicate their decision

A patient who can do all four has capacity for that decision, however unwise the decision looks. If capacity is lacking, make a best-interests decision considering past wishes, values, and beliefs. Consult those close to the person and choose the least restrictive safe option. Where the patient made a valid advance decision while they had capacity, refusing this treatment in these circumstances, that decision is binding.

Taking consent well

1. 1.Confirm identity and check capacity.
2. 2.Start from what the patient already knows; use plain language and avoid jargon.
3. 3.Explain the proposed treatment, reasonable alternatives and no treatment, with the likely benefits and material risks of each.
4. 4.Check understanding, answer questions, give time to decide, and offer written information.
5. 5.Confirm the decision is voluntary and free of pressure.
6. 6.Document the discussion, the risks covered, the questions asked and the decision.

A spoken answer to "how would you assess whether a patient has capacity?", about ninety seconds:

Bristol asks this as a chain of five questions in one station: implied versus informed consent, consent for a child, the Fraser guidelines, consent from a deaf patient, and advance directives. Most other schools reach the same ground through a scenario.

Things to avoid when answering the question:

Treating refusal as incapacity

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An unwise decision alone doesn't mean someone lacks capacity. The test is about the process of deciding, not the outcome.

Capacity as a label

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Capacity is decision-specific and time-specific. "The patient lacks capacity" without saying for what is a red flag to interviewers.

Skipping the first stage

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There has to be an impairment of mind or brain. A competent adult who disagrees with you does not fail the test.

Consent as paperwork

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A signed form is not consent. The information, the understanding and the absence of pressure are.

Forgetting best interests

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Lacking capacity does not mean the doctor decides alone. Past wishes, family, advance decisions and the least restrictive option all come in.

Not mentioning the law or GMC guidance

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Naming the Mental Capacity Act 2005 and GMC consent guidance shows you know the framework doctors work within.

The five-part consent station is reported at Bristol. Capacity comes up through scenarios at most schools with an ethics station, including the transfusion refusal at Plymouth, the life-support decision at King's and UCL, and the contraception question at Keele, Nottingham, Cardiff and Manchester.