Introduction
Personal choice is foundational to Western culture, from life-changing decisions about marriage to mundane choices like food preferences. We value our freedom to choose so deeply that it often becomes second nature. At the same time, society has long held a responsibility to care for those unable to care for themselves—often by appointing surrogate decision-makers. In psychiatric inpatient settings—particularly geriatric hospitals—questions of consent and autonomy are magnified. Yet, there is limited research on how often surrogate decision-makers are used in these settings or how often patients’ capacity to engage in treatment is formally reassessed. This commentary explores the ethical and legal implications of these gaps and argues that psychologists should play a central role in advocating for routine reassessment of consent capacity, combating institutional paternalism, and promoting the restoration of autonomy where possible.
Brief Historical Overview
The concept of informed consent has its roots in both legal precedent and moral philosophy. From a legal perspective, consent protects institutional integrity and individual rights; from a philosophical view, it upholds a person’s right to autonomy (Faden, Beauchamp, & King, 1986). U.S. Supreme Court decisions such as Cruzan v. Missouri (1990), Washington v. Harper (1990), and Sell v. United States (2003) confirm that while the state has legitimate interests—such as safety or institutional order—these do not automatically override individual autonomy. Instead, any infringement requires procedural safeguards, constitutional justification, and the absence of less intrusive alternatives. These legal foundations support a professional imperative: psychologists need to advocate for the reassessment of consent capacity and challenge persistent paternalism in institutional care.
We also need to be aware that paternalistic attitudes do not shield us from liability. Indeed, as noted in the 2021 decision Bohn v. Providence Health Services—Washington, the court ruled that simply because a provider believes that a person’s caregivers are not acting in their best interests does not give the provider(s) the right to override a person’s (or their caregiver’s) wishes for treatment. In other words, we cannot claim to “know better,” and then impose our views, biases, and beliefs onto patients in their most vulnerable moments.
Defining Our Terms
We should first review what elements are necessary to consider when determining a patient’s ability to consent to treatment. Grisso (1998) outlines four key elements of treatment consent: 1) the ability to express a choice, 2) understand one’s condition, 3) appreciate its implications, and 4) engage in logical reasoning about it. He also cautions that incompetence is functional rather than diagnostic, context-dependent, consequence-sensitive, and subject to change over time. These guidelines remind clinicians that decisional capacity is dynamic and requires individualized, ongoing evaluation. In addition, Grisso emphasizes that the clinician should consider five maxims: 1) incompetence is related to, but not the same as impaired mental status, 2) incompetence refers to functional deficits, 3) incompetence depends on functional demands, 4) incompetence depends on consequences, and 5) incompetence can change.
Building upon Grisso’s criteria for consent capacity, we would be wise to also consider the ethical challenges posed by paternalism. According to Beauchamp & Childress (2019), paternalism directly conflicts with our ethical duty of beneficence since it is, “The intentional overriding of one person’s preferences or actions by another person, where the person who overrides justifies the action by appeal to the goal of benefitting or of preventing or mitigating harm to the person whose preferences or actions of overridden” (p. 231-232). In other words, paternalism occurs when clinicians impose their worldview on patients, assuming they inherently know what is best.
Competing Goods
As noted earlier, there is a longstanding tension between an individual’s right to bodily autonomy and the community’s responsibility to promote safety and well-being. It would be simplistic to suggest that clinicians should focus solely on autonomy without considering our parallel obligation to promote the common good—particularly through interventions that support a patient’s recovery and reduce risk. At the same time, recovery-oriented care frameworks emphasize that self-determination is not only an ethical imperative but also a cornerstone of effective treatment and long-term engagement (SAMHSA, 2012). As with many ethical dilemmas in clinical practice, there is no universal solution to balancing autonomy with beneficence. Instead, it requires ongoing reflection, contextual judgment, and a commitment to upholding both individual dignity and societal responsibility.
While promoting the common good is a foundational aim of healthcare, it can easily be conflated with institutional convenience or risk aversion—especially in settings where staffing, policy, and safety concerns dominate decision-making. Without checks, this can result in routine paternalism disguised as protection. Psychologists, therefore, should act as both ethicists and clinicians, ensuring that interventions claiming to serve the common good do not quietly erode individual autonomy.
Advocacy versus Autonomy
In Being Mortal: Medicine and What Matters in the End, Dr. Atul Gawande insightfully observes that, particularly in work with older adults, our societal values have shifted toward prioritizing safety over autonomy. In practice, this often means that when confronted with choices between supporting an individual’s right to self-determination and restricting that right in the name of safety, we frequently default to the latter. While the impulse to protect others is well-intentioned, it can also reflect a form of unconscious paternalism.
In my own clinical experience, this dynamic is commonplace. For example, a staff member recently voiced concern about a proposed discharge plan, stating that it was “not safe enough.” While her reaction was rooted in genuine care, it reflected a broader tendency to prioritize perceived safety over an individual’s expressed preferences. Ultimately, such positions—however well-meaning—can erode a person’s right to live according to their values and choices.
As board-certified specialists, we are uniquely positioned to recognize and challenge this subtle but pervasive form of paternalism. Through reflective practice and advocacy, we can help ensure that the individuals we serve retain meaningful opportunities to make decisions about their own lives, even when those choices carry risk.
A Call to Action and Interdisciplinary Collaboration
As board certified specialists we are often leaders in our respective fields. With that mantle of leadership comes the responsibility to ensure that we are consistently advocating for patients to receive treatment where they have a say in the matter. In my experience, there has been a troubling tendency toward marginalization rather than inclusion, with a focus on imposing solutions rather than genuinely listening to patient voices. The easier path involves imposing our own preferences, feelings, and judgments onto patients, typically under the assumption that we know best. However, taking this path without careful consideration risks infantilizing those we seek to help. The more difficult, yet closer to our values as a profession, is to ride the potential roller coaster of serious mental illness with our patients and work together to form a treatment plan. It would make sense that for a field that prides itself on empathy that this latter choice would be our first impulse.
In that vein of working together to form a treatment plan, we as board certified specialists have the opportunity and responsibility to advocate that our patients are routinely reassessed during their treatment. Granted, in many settings, psychologists lack the authority to override psychiatric and medical decisions related to treatment consent, even when a patient’s improved stability is evident. Nonetheless, we are often best positioned to observe shifts in cognition and decisional capacity. As such, we need to assertively document these changes and advocate for reassessment. This advocacy cannot occur in isolation—it needs consistent collaboration with interdisciplinary partners. Though differing clinical priorities may cause tension, psychologists can lead efforts to center patient autonomy in all treatment decisions.
Promoting patient autonomy within inpatient psychiatric settings cannot be accomplished in isolation. Psychologists need to collaborate closely with psychiatrists, social workers, nurses, and other members of the treatment team to ensure that patients’ rights and preferences are routinely considered. While psychologists may not always have final authority over decisions related to treatment consent, they are uniquely positioned to assess cognitive and decisional capacity, monitor changes over time, and advocate for reassessment when appropriate. Constructive collaboration involves more than case discussions—it requires a shared commitment to ethical care, clear communication, and mutual respect for each discipline’s expertise. Differences in training and clinical focus can sometimes create tensions—for example, when psychiatric and/or medical providers emphasize symptom management while psychologists may focus on insight and capacity-building. Navigating these differences calls for diplomacy and ongoing dialogue, with the psychologist serving as both consultant and advocate. In this way, interdisciplinary collaboration becomes not just a logistical necessity, but a vital avenue through which patient autonomy can be meaningfully upheld. Finally, as part of our leadership role, psychologists can also encourage systemic reforms—such as protocols mandating periodic reassessment of consent capacity—as part of institutional policy and interdisciplinary practice standards.
Conclusion
Advocating for patient autonomy is a critical responsibility inherent to our roles as board-certified specialists. While paternalism may stem from genuine intentions to protect vulnerable individuals, it is essential that we continually challenge this stance by actively reassessing patients’ capacity to consent. Doing so not only respects the fundamental dignity of the individual but also aligns our practice with the core values of our profession—empathy, empowerment, and ethical responsibility. As board-certified specialists, our ethical obligations extend beyond the therapy room. They include challenging entrenched norms, educating colleagues, and promoting policies that safeguard autonomy. We should ensure that capacity is never treated as a fixed status, but as a recoverable function—and that the right to choose is not suspended indefinitely in the name of care and safety.
References and Recommended Readings for Future Learning
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
Bohn v. Providence Health Services – Washington, 484 P.3d 584 (Alaska 2021).
Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990).
Faden, R. R., & Beauchamp, T. L. (1986). A history and theory of informed consent. Oxford University Press.
Gawande, A. (2014). Being mortal: Medicine and what matters in the end. Metropolitan Books.
Grisso, T., & Appelbaum, P. S. (1998). Assessing competence to consent to treatment: A guide for physicians and other health professionals. Oxford University Press.
Nelson, T. D. (Ed.). (2017). Ageism: Stereotyping and prejudice against older persons (2nd ed.). Bradford Books.
SAMHSA (Substance Abuse and Mental Health Services Administration). (2012). SAMHSA’s working definition of recovery: 10 guiding principles of recovery. U.S. Department of Health and Human Services. https://store.samhsa.gov/sites/default/files/d7/priv/pep12-recdef.pdf
Sell v. United States, 539 U.S. 166 (2003).
Washington v. Harper, 494 U.S. 210 (1990).
William McKenna, PsyD, ABPP
Board Certified in Serious Mental Illness Psychology
Correspondence: wmckenna7@gmail.com