# introduction

On March 17, 2027, the eligibility criteria for medical assistance in dying (MAiD) is set to be expanded to including those patients whose sole underlying medical condition is a mental disorder (MAiD MD-SUMC) (1). The proposed legislative changes are contentious, and ethicists disagree on whether providing MAiD for relief from suffering caused by mental disorder is morally justifiable (2). Given that MAiD is a legitimate and legal medical procedure within Canada, all patients who meet the diagnostic criteria must be permitted to receive it; anything else verges upon discrimination or other forms of injustice. As such, if a person meets the eligibility criteria for MAiD and holds decision-making capacity, they cannot be denied the procedure. Due to the expanded criteria, MAiD is set to become a more frequent cause of death among Canadians and the expansion to include mental illness as a potentially valid reason for pursuing MAiD presents a specific cause for worry.

Bracketing any concerns about the wider acceptability of MAiD as a practice, the issue that I raise is solely to do with MAiD MD-SUMC. Unlike physical conditions that cause pain and suffering, mental illness has the intrinsic potential to affect one’s ability to understand and appropriately value the consequences of one’s actions and decisions. There is thus a significant risk that a patient who has requested MAiD MD-SUMC may be unable to provide valid consent due to an impaired ability to either: 1) adequately understand the consequences of receiving MAiD or 2) place that consequence within a consistent set of values. The impairment of consent that I am concerned about in this essay is not due primarily to the patient’s cognitive functioning but instead concerns the risk of MAiD MD-SUMC administrations prioritizing the cognitive criterion over the coherence of the MAiD request with the authentic values of the person themselves. This, I will argue, constitutes an important oversight insofar as the consent that is received is not one that is made in full capacity as it overlooks the fact that personal values are a fundamental component of personhood and, therefore, moral agency.

Unlike other issues, taking mental disorder as the sole underlying condition for MAiD requests has the added problem that, “with serious mental illness, the focus of treatment decisions and the source of potential incapacity are one and the same.” (3) This is morally problematic as the severity of the disorder that would justify one of the criteria for MAiD would cause another criterion (consent) to be problematic, if not impossible to obtain. For this reason, the very disorder that would cause the patient to seek MAiD puts them at a high risk of being unable to consent to the procedure. For example, it has been suggested that a number of mental disorders can manifest as a desire for death (4). This complicates the evaluation over whether the desire for death can be truly considered the patient’s own desire or if it should be better understood as the disorder’s interference in the patient’s cognition, which manifests as a transient and misplaced desire that does not reflect the patient’s considered, rational desire (5-7). In line with this concern, depression has been found to be both common within palliative care and “strongly associated” with a desire for death among patients in palliative care (8). Given that we recognize mental disorder as something that ought to be cured, we cannot recognize decisions based in the mental disorder to be true reflections of the person themselves — such decisions ought to be recognized as inauthentic until they are able to be proven authentic.

Due to the complicated interactions between mental disorder and decision-making capacity, MAiD assessors require a more subtle means of evaluating patient decision-making capacity than that which is currently commonly relied upon. Specifically, I am concerned that some capacity assessment evaluations, such as the MacCAT-T, obscure certain components of decision-making in favour of an overly cognitive understanding of capacity. My argument in this paper is based upon a presentation of the factors involved in decision-making, a demonstration that these may be obstructed by mental illness, and a suggestion that more holistic criteria for capacity evaluation be used instead of the excessively cognitive criteria espoused by most commonly used assessment tools. Because of the interplay between these aspects of my argument and the extremely high stakes involved in MAiD assessments, I argue that capacity evaluations (both in general and especially for MAiD requests) ought to incorporate an aspect of narrative assessment by which the patient’s values and self-understanding can be better assessed.
# Consent & the Patient’s Moral
        Agency

When we consider the justification for any medical procedure, the primary limitation on whether a physician may perform a medically advised treatment is the patient’s consent or lack thereof; without the patient’s informed consent to waive certain of their rights, the physician’s act of treatment may, regardless of their intent to help, infringe upon the patient’s right to bodily and personal integrity (9). As I will show in this section, obtaining valid consent depends upon the ability for the person providing the consent to be responsible for their decisions or, in other words, to have moral agency. To quote Doorn at length:

> To meaningfully pursue the right of self-determination, an abstract view on human being does not suffice. If we lack a clear view on human being, every criterion to assess mental competence becomes arbitrary. We need a richer interpretation of the person in which the question of mental competence can be linked to the person’s ability to respond to a given situation in coherence with what he values in life. The human will is closely connected to this life coherence. A proper account of mental competence should therefore be based on a clear view of how one’s conduct or choices reflect one’s deepest values and commitments. In the literature on mental competence, this view is often absent.
> — 10

Doorn’s perspective is closely allied to my own in that it adopts a richer understanding of human willing than the purely cognitive approach to capacity evaluations would suggest is possible.

Given that consent is a requirement for justified euthanasia, we are led to ask about whether a person suffering from a mental disorder severe enough to request MAiD is able to provide true consent. The answer to this question turns on the capacity of the person to make the specific medical decision at hand; namely, do they have the capacity to consent to MAiD? Such a concern requires not merely 1) the non-coerced and informed consent of the patient but also that 2) the request being made is consistent with the patient’s authentic values and self-understanding. These values, however, are rarely taken to have important bearings upon a patient’s capacity. To rectify this oversight, I begin my argument by providing a brief analysis of moral agency and personhood. My reason for doing so is that if we are to determine what it truly means for a person to have capacity, we require a clear understanding of what moral agency itself entails.

Within bioethics, moral agency is often considered to be interchangeable with autonomy (11). However, the sense of autonomy that is often taken to be definitive within bioethics is not autonomy in a robust sense but rather a stripped down “sheer choice” understanding of autonomy that is based in the absence of external coercion (i.e., negative freedom) and is not ethically fundamental (8,12). Indeed, one of the founding figures of bioethics, Albert R. Jonsen, lamented that in our efforts to protect the importance of autonomy within ethical discourse, the principle of respecting autonomy has been reduced to the imperative that, “one merely respects the wishes and choices of every person without passing judgment on further moral grounds” simply because this “shallowest meaning of respect for autonomy is the most readily grasped.” (13) While politically important, this voluntaristic understanding of autonomy is not ethically fundamental because it is not clear why an act of sheer choice should hold any moral value whatsoever unless it is grounded within and expresses the person themselves and is, therefore, no longer sheer choice (12).

Against such reductive accounts of autonomy, it seems that we value autonomy because it is directly connected to the person qua person, rather than because it implies an absence of coercion: an autonomous act is an expression of the person themselves (14-16). Moral agency thus depends upon the ability to ground an act or decision in the specific characteristics of a person. If a decision is not grounded in a person’s character and the values to which they are authentically committed, then we have no reason to morally attribute the decision to them even if they were implicated in the causal chain of actions that brought about the event. If a person is to be self-governing (or autonomous) then they must be able to recognize a set of beliefs, and values as their own and to use these mental contents to pursue the life plan (or narrative) that they have set out for themselves (17). This means that moral agency is concerned with more than the merely intellectual or rational part of the person but must consider the person as a whole. Thus, when we protect a person’s autonomy, what we are trying to protect is a person’s ability to express themselves in their outward actions and decisions.

Granting that moral agency requires a consideration of the person taken as a whole rather than a reductive understanding of autonomy, we must be clear on what aspects of personhood are relevant. Typically, personhood is defined as the ability for a human being to be self-conscious or to possess “a capacity for a first-person perspective.” (18) The first-person perspective of self-consciousness implies the ability to make oneself an object of one’s own understanding, to evaluate one’s self and actions from this third-person perspective, and to alter one’s behaviour according to the person one wants to become (18). Analyzing and adjusting oneself according to one’s moral ideals is the threshold of rational, moral agency (18,19). Because self-consciousness implies that the person can both understand and change themselves according to their self-understanding and their conception of the good, we must recognize that self-consciousness must always be accompanied by a set of values (however basic) by which these acts of evaluation might occur. Indeed, the possession of a stable, minimally consistent and self-affirmed set of values or conceptions of the good are required for decision-making capacity (19). Without having some act, action, characteristic, or state of affairs that one takes as “good,” there is no way to orient one’s practical action and no way to evaluate whether one is acting in a way that one would choose or, ultimately, whether something is (im)moral. It is therefore the evaluative aspect of self-consciousness that enables a person to understand the repercussions of their actions and to judge themselves in line with a moral ideal. This makes self-consciousness (including both self-reflection and self-revision) the necessary and sufficient condition for someone to be considered a moral agent (18,20).

While the assessment of a person’s rationality is pivotal in determining whether they hold decision-making capacity, there is more to truly autonomous decision-making than pure rationality (21). Capacity is bound up with a patient’s ability to form and act upon both cognitive commitments (including understanding, knowledge, and appreciation) and practical/evaluative commitments (including personal values), yet a patient’s evaluative commitments are often omitted from procedural accounts of capacity (12,21-23). Agential decision-making therefore requires that we are able to connect our cognitive commitments with our practical commitments, thereby forming an inferential system of interconnected values, beliefs, and desires that allow us to act meaningfully (12,21). Purely cognitive accounts of capacity are thus defective insofar as they rely upon an inadequate phenomenology of action that takes knowledge and reason to be sufficient to motivate action.

Of course, this concern with the authenticity of medical decisions is implicit in the bioethical emphasis on autonomy. Biomedical ethics typically asserts that it should be the person potentially receiving medical care who makes decisions concerning their care. This conviction is spelled out quite explicitly by Beauchamp and Childress in their definition of autonomy as “a form of personal liberty of action where the individual determines his or her own course of action in accordance with a plan chosen by himself or herself.” (24)

From this brief examination of the relationship between personhood, moral agency, and autonomy, it follows that valid consent requires a person to be self-conscious and to make decisions in light of their authentically held values. Without basing their decisions in their authentic values, it is unclear how a person would be able to judge whether an act is to their benefit or aligns with their desires, even if their intellect is still functioning as it should. The conceptualization of autonomy as merely a lack of coercion that is endorsed by purely cognitive accounts of capacity is therefore insufficient to guarantee the patient’s moral agency, autonomy, or valid consent. If valid consent is to be acquired, moral agency cannot be reduced to intellect but must also include the person’s evaluative commitments. Consent relies not on the abstraction of autonomy understood as absence of coercion but upon autonomy as expressive of the person as a moral agent.
# How Might Mental Disorder Affect
        Decision-Making?

When discussing capacity, it is necessary to recall both that capacity is assumed unless there is reason to doubt it and that mental disorders do not necessarily affect decision-making capacity (25). That said, some scholarship on mental disorder has problematized the ability for those suffering from such disorders to provide informed consent insofar as mental illness may affect their values, desires, and reasoning and thereby impact decision making capacity (9,25-27). Importantly, the impact of mental disorders on decision-making is not limited to the more “obvious” mental disorders such as dementia, schizophrenia, or other psychotic disorders that have been shown to be positively correlated with incapacity. A wide range of “non-psychotic” disorders — such as depression, anxiety disorders, eating disorders, and Parkinson’s Disease, to name a few — may also impair decision-making in a way that is relevant to judgments about medical treatment (28-30). As a person’s evaluative functioning and the consistency of values cannot be extracted from their decision-making capacity, it is possible for their capacity to be affected by severe mental disorder in a way that may not be detectable through purely cognitive evaluation approaches (31). For example, in a study of patients with either schizophrenia or anorexia nervosa, patients were shown to be capable of succeeding at tasks based solely on their rational abilities yet struggle to incorporate certain important information into their decision making; and those suffering from anorexia were capable of coherent decision-making but frequently suffered from distorted values (21). Both patient groups showed that cognitive considerations alone are insufficient to determine capacity because it is not necessarily the cognitive functioning that is impaired by the disorder. Instead, it may be that the evaluative functioning or values themselves that are affected. This then poses a serious problem for decision- making capacity insofar as “if a patient’s values or value system can be traced back to a mental disorder [...] these cannot be considered authentic to the patient himself” (10).

This ability for mental disorders to affect the decision-making capacity of patients means that patients may be authorized to make treatment decisions that require decision-making capacity while not truly possessing that capacity at the time of evaluation (32). This potential for the symptoms of mental disorder to appear as the reasoned autonomy of the person makes it difficult to discern between an autonomous request for euthanasia and suicidality as a symptom of a patient’s disorder (2,33). While decision-making capacity will, of course, still have to be evaluated on a case-by-case basis, the empirically attested possibility for severe mental disorder to affect a person’s evaluative structure presents a high-risk of impaired capacity and the heightened need for improved capacity evaluations. Actively providing a life-ending treatment to a patient who had no valid ability to consent to such a treatment has the potential to be a grievous failure of the duty to do no harm. Mental disorder thus poses a threat to obtaining morally legitimate consent for any medical procedure and especially one with the finality and ultimacy of euthanasia. When we judge a patient’s capacity, we do so with a two-fold goal of respecting their autonomous decision-making ability and protecting them from harmful decisions made at a time when they do not have the ability to completely judge the options available to them (34). While we ought to respect patients suffering from mental disorder as persons who are typically responsible for and free to make their own decisions regarding their healthcare, attributing capacity to a patient who does not have it is equally or even more harmful than claiming incapacity as we would not protect the patient in a time of vulnerability (33). What is more, in the context of MAiD, our lack of protection for such patients would amount to an active ending of their life; there are few acts of greater moral gravity than this. This is not to say that those suffering from mental disorder should be disqualified from MAiD, but rather that due to the complications that attend upon the mentally ill, we must treat such cases with extreme caution and determine a more holistic way of evaluating the capacity of every patient, and especially those who seek MAiD for mental illness.
# The Limitations of Cognitive-Based Capacity
        Evaluations

The traditional four criteria for assessing capacity (understanding of one’s situation, appreciation of potential consequences, reasoning about options, communication of a choice) has come under scrutiny for overlooking the evaluative basis for patients’ decision-making (35,36). There is a growing sense that the excessive rationalism of some models of decision-making capacity (such as the MacCAT-T) are unable to account for the changes in emotions and values that can be found in some cases of psychiatric disorders wherein the patient’s cognitive ability is not impaired (23,32). The problem is not so much that standard lists of criteria are wrong, but that they omit the importance of evaluative considerations that undergird the patient’s appreciation and reasoning in favour of an overwhelming emphasis on cognitive ability. According to this choice-based form of moral agency, all that is required for a person to be morally responsible for an action is the ability to rationally deliberate between alternative options. Such reasoning may be conceived of as solely “instrumental”, considering neither the authenticity nor content of a person’s actions and decisions provided that the person expresses a general rationality (20). This formal testing relies upon there being an objective “fact of the matter” that is accessible to both patient and analyst and by which the analyst can judge the patient’s correspondence through “observation and measurement via the construction of behaviour indices.” (31) The patient’s cognitive capacity is thus evaluated on the simple empirical ground of their fidelity to the shared experience of the facts of their condition and life. This formal cognitive testing is easily scorable, replicable across different persons and demographics, and due to these criteria, has high reliability across analysts.

The reason for taking such a “procedural” approach to capacity is clear — it provides a strong safeguard against unjustified paternalism on the part of healthcare providers by ensuring that patients can rationally grasp the details of their situation and determine whether they accept to receive a suggested treatment. This, in turn, protects the patient’s ability to make decisions that others may not agree with while simultaneously attempting to protect the patient from making decisions during states of irrationality (21). However useful such formal tests of capacity may be, they are still incapable of testing for other criteria that may be required for an act to be truly attributable to a person and, hence, for which they may be truly responsible. Per Banner, we must recall that “intrinsic to assessing whether a patient is using or weighing information is a normative judgment about the role his value system plays in his decision making.” (31) This is an important consideration. If capacity tests do not test for this more robust conception of capacity, then they are flawed from the start due to their methodological adoption of a sense of the moral person as a disembodied rationality who is not influenced by the their own set of values and motivations (20). Such an account of the patient as a purely rational moral agent is not a realistic portrayal of the way that people actually make decisions. Instead of such a depersonalized, machinic decision-maker, real persons act based on reason, emotion, values, goals, beliefs, and an assortment of other characteristics and personality traits that come together to inform their decision-making. Given how important capacity judgments are for the practice of MAiD, the medical profession requires a stronger evaluative model for capacity.

What is missing from such assessments of patient capacity is consideration of the patient’s current treatment decision in light of their evaluative functions and underlying values, both of which are central to decision-making (34-37). Yet formal capacity tests are methodologically incapable of testing the authenticity of patient beliefs due to the constitutional difference between the empirically verifiable facts that cognitive tests rely upon and the way in which a person’s values and beliefs are subjectively held and determined. and which are without an empirical correspondent. When it comes to determining the ability of a patient suffering from severe mental disorder to make end-of-life decisions (especially an active request to die), we ought not consult only with other healthcare providers but also with family members and potentially documents made by the patient that might explain their values. This would then enable a more reliable determination of the coherence of the patient’s current decision (which may be caused by the mental disorder) with their person as a whole (34). Considering the person as a whole would require that we include not just their current ability to cognitively assent to a specific treatment but also a more holistic account of the person’s life (2). Such an integration is important insofar as mental disorders have the potential to preclude a person’s assimilation of their life’s history and their long-held values into their current decision-making, thereby impairing their moral agency (14,37). Taking a more holistic, person-centred approach to analyzing capacity may actually make a patient’s decision more intelligible by making breakdowns in their reasoning process more apparent (21).

Despite the importance of understanding a patient’s capacity to make medical decisions, the reliability of capacity assessments has been called into question such that verdicts reached through formal capacity assessments might be considered inconclusive or inconsistent (19,38). Some studies dealing specifically with patients with depression have suggested that these patients suffered no impaired capacity whereas other studies showed that up to 30% of patients did suffer an impairment (28). Again, when relying solely upon the MacArthur assessment, clinicians often come to different conclusions about a patient’s capacity than when the same clinician evaluates the patient without the tool, thereby highlighting a discrepancy between the clinician’s expert opinion and the results of the test (31). In one reported case, a psychiatrist experienced moral distress over the evaluation of a patient (39). The patient, Jim, passed the MacArthur criteria while being unfit to be declared competent to refuse treatment according to the psychiatrist’s own judgment. Goldberg explains that “Jim, despite his adamant refusal of dialysis, had the brief insight to identify his suicidal desire as uncharacteristic, acknowledging that he might well view things differently outside the fog of his depression.” (39) Yet, Jim still expressed his desire to forego treatment. This suggests that the MacCAT-T criteria are missing a means of testing the patient’s ability to govern themselves according to their own self-understanding, criteria that must accordingly be updated (39). As there is this potential for important differences in capacity evaluations that can have very real effects on the legitimacy of patient decisions, the accurate evaluation of capacity is paramount. When it comes to life and death decisions and especially those wherein a medial professional will be ending a patient’s life (i.e., MAiD, PAS, and similar procedures in other jurisdictions), we must have more thorough means of understanding a patient’s capacity to make their own treatment decisions from a position of rationality and authenticity.
# The Potential Role of Narrative in Capacity
        Assessments

As I’ve suggested above, personhood and moral agency are inextricably connected to a person’s values, and these are a necessary component of decision-making. The development of one’s values is thus fundamental to understanding and evaluating decision-making capacity. According to Doorn, “it is more important to see to what extent the patient is able to shape his own life in accordance with the things he values. Not so much rational considerations, but rather the incorporation of moral, social, and ideological values becomes important in this view.” (10) To understand the way in which the patient is able to shape their life or decisions in accordance with their values, we must recognize that personal identity and sense of self are developed through the act of interpreting one’s history over time, culminating in a rich personal narrative (17,40). It then follows that a person’s values, as a component of their personal identity, are a product of this process of self-interpretation; recognizing that they are derived from this narrative process is fundamental to understanding whether a person has decision-making capacity. Following Goldberg, I suggest that a patient’s decision-making capacity is best gauged through analyzing how they construct an autobiographical narrative and whether that narrative is coherent (39). Drawing on Goldberg’s definition, I take “narrative” to be an “imposition of both temporal and conceptual organization onto fragmented, disparate life experiences.” (39) In this account, we are not concerned with tracking the correspondence of the narrative with reality (i.e., its “truth-value”) but with its internal rationality/coherence and the meaning that the patient attributes to different aspects of the narrative. By seeking a narrative explanation for the origin of the values that are underlying the MAiD request, the clinician elicits a greater expression of the patient’s self-understanding than is possible through more typical capacity evaluations. Narrative assessment elicits not only the rational/logical demonstration of whether the patient’s values and decisions align, but also whether the patient understands how their values came to be, the nature of large shifts in their values, and why they hold the values that they currently do.

Of course, changes in patient values alone are insufficient to justify a judgment of incapacity (22). It is a normal part of human life for our values to change over time and the simple alteration of values cannot be taken to indicate that the new values are inauthentic. What we ought to be concerned with when dealing with MAiD requests based upon mental illness is whether the values displayed in the request are actually attributable to the person; in other words, whether the desire for MAiD is authentic. The innovation of the narrative approach to capacity evaluations is that the physician can question the origins of the patient’s current values by asking “Why?” questions and see if the patient can provide a coherent narrative for how these values and decisions originated. In the event of a seeming shift in patient values, a clinician can then determine whether the new values can be ascribed to the patient’s person by testing whether the patient can provide a coherent narrative of how the shift in values came about. If the patient can provide such a coherent narrative, then, providing that the patient satisfies the typical MacArthur criteria, the clinician can confirm the patient’s decision-making capacity regarding the decision at hand. If the patient cannot provide a coherent narrative regarding their altered values and reasoning about the decision at hand, then the clinician cannot confirm the patient’s decision-making capacity. It should thus be clear that evaluations of “narrative coherence” are tracking something different than the canonical MacArthur criteria. Whereas the MacArthur criteria are concerned with ensuring that the patient is cognitively capable of making the decision in question, the narrative approach to capacity evaluation is concerned with ensuring that the decisions are made authentically.

The important thing about the narrative approach is that it is able to assess alterations within a patient’s values and beliefs and draw attention to incongruities that may indicate a lack of self-understanding or self-awareness in an important area. This does not in any way indicate that alterations in values and beliefs are themselves to be discounted or indicative of incapacity but simply that the patient ought to be able to provide a coherent narrative of how these changes came about. If no narrative explanation is forthcoming, the clinician may continue to work with the patient through various forms of psychological counselling to help elicit a greater degree of self-understanding or expression, thereby eliding any a priori disqualification of the patient’s decision-making capacity on the basis of a clinical diagnosis. Instead, the narrative approach that I’ve suggested seeks to foster relational autonomy while also safeguarding those patients whose decision-making capacity is affected by their mental disorder. Using the narrative approach to capacity evaluation provides a means of actualizing Doorn’s suggestion that capacity evaluation be used to “foster the patient’s capacity to respond to his own situation and to form his will” through inquiry into the patient’s own reasoning, values, and self-understanding (10). This method of ongoing narrative evaluation means that a patient who, at one point in time, is unable to provide a coherent self-narrative may at a later time be capable of providing such a narrative. That is, a patient suffering from a mental disorder may request MAiD MD-SUMC, be denied it on the basis of incapacity, and then, at a later time, be found to have full decision-making capacity and be approved for the treatment on the same basis that they initially applied for MAiD. The key difference would be that the patient would be able to place their decision to seek MAiD within a coherent account of their life, experiences, values, beliefs, and relationships; in short, within a coherent narrative.

It should be noted that this narrative approach aims to be non-stigmatizing towards persons with mental illnesses; there is thus the possibility for a narrative approach to capacity evaluation that justifies rational suicide (39). Through assessing the patient’s ability to narrate the development of or change in their values, a narrative approach to capacity evaluation would allow patients suffering from long-term mental illnesses to be eligible for MAiD MD-SUMC. The patient would explain why their values had shifted and thereby show that their MAiD request was not based in the symptoms of their illness but in their considered, authentic values and self-understanding. The goal of the narrative approach to capacity evaluations is simply to assess the patient’s ability to provide a coherent narrative, not to provide a normative judgment of the narrative. The objective is an assessment of the process by which a decision is made rather than an assessment of the content of that decision; in this way, the evaluation remains neutral in its judgment of patient decisions. What the narrative is assessing is the patient’s ability to 1) grasp the cause-and-effect relationships between agents and events within their life, 2) reflect upon their own values and beliefs and how they may have changed or remained the same. Narrative allows one to place objects, people, and events in a causal sequence through explaining their relevance to the narrative conclusions. This is not an abnormal method of elucidating causal relationships but is the central method involved in any historical inquiry; and it allows us to grasp causal relationships that are less certain because more complex than what simple “if X, then Y” statements can express. Such “mechanistic” causal statements are rarely sufficient when it comes to moral agency and, in such cases, describing the causal relationship in terms of teleological orientation is the only plausible option. While standard evaluations of rationality, such as the MacArthur criteria, are useful in assessing whether patients can understand basic cause/effect relations, they cannot test for whether the patient’s own evaluation of these relations is true to themselves.

Banner has criticized approaches that rely upon the internal rationality of a person’s reasoning process as a test for capacity (such as the narrative approach) on the grounds that we do require a normative evaluation of the content of the person’s decision, not just its form (31). She suggests that there is an “appropriate response” that a patient ought to have to information concerning their situation, and if they do not have the appropriate response, then this is evidence of a lack of decision-making ability (31). Per Banner, analyzing whether a person is making a decision in full capacity requires a normative evaluation of their decision which evaluates whether they are appropriating and using the information given to them in a way that they ought to (31). Yet this need not imply any judgment about the conclusion, only that the patient is using the information in a way that does justice to its major normative implications and includes these implications in their deliberations. The narrative assessment allows us to understand whether the patient is placing sufficient normative weight on the information prior to a decision being actualized. While Banner may be correct that information ought to be weighted appropriately, this is not an indication that the end-result ought to be uniform among all persons or that a decision made against the wider consensus is irrational. Indeed, many normative systems, such as virtue ethics or natural law theory, reject there necessarily being only a single “right answer” to any morally charged situation. This means that Banner’s suggestion would have to assume a normative framework (and its concomitant axiology and understanding of a good human life) within which the patient’s weighting of information would be situated and judged. According to Rawls, “a modern democratic society is not characterized simply by a pluralism of comprehensive religious, philosophical, and moral doctrines but by a pluralism of incompatible yet reasonable comprehensive doctrines. No one of these doctrines is affirmed by citizens universally.” (41) Given that no such “comprehensive doctrine” is ubiquitously held by the pluralistic citizens of Canada, Banner’s demand to judge the outcome of the patient’s deliberative process according to a determinate moral standard is untenable. Instead, the narrative approach to capacity assessment can test the internal rationality of the patient’s deliberative process and then aid in determining whether the patient is acting consistently with their own authentically held values and beliefs.
# Conclusion

Most will agree that there must be restrictions or guidelines on who qualifies for MAiD and under what conditions they qualify. While decision-making capacity is paramount to any refusal of or request for treatment, it is widely agreed that when the stakes of a medical decision are significant, higher thresholds of capacity are required to make that decision (8). Because MAiD entails the willed death of a person, opting for MAiD may require a higher threshold for capacity (25). My contention is that current means of evaluating who qualifies for MAiD are inadequate to deal with requests for MAiD MD-SUMC. Given that the mental disorder is sufficiently severe to cause suffering serious enough to bring a person to pursue MAiD, there is good reason to question whether the mental disorder may have negatively affected the patient’s capacity to consent to such a serious procedure. The problem is that consent requires not only that one possess adequate decision-making capacity but, as I’ve argued, is fundamentally about the authenticity of the values guiding the patient’s decision-making. My concern is that in trying to uphold the autonomous decision-making of patients suffering from mental disorders, we may actually betray their true convictions, beliefs, and values; in short, betraying their true moral agency. Due to this possibility, I’ve argued that we need a more subtle form of capacity assessment that enables greater understanding of whether the values guiding the patient’s request for MAiD are authentically their own and are not a symptom of their disorder. I believe that the narrative approach to capacity evaluation that I’ve sketched here can promote the more holistic type of assessment that is required for determining the patient’s decision-making capacity. While it will have to be fleshed out in greater detail, I hope to have contributed to the discussion surrounding the complexity of decision-making capacity, mental disorder, and end-of-life care.

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