Drs. Geppert and Abbott Reply

To The Editor: We appreciate Dr. Balhara’s thought-provoking questions regarding our case conference. In our article, we attempted to illustrate the three domains of an informed consent evaluation: information including the risks and benefits of a proposed intervention, decisional capacity, and capacity for voluntarism. Information and decisional capacity have traditionally formed the cornerstone of most informed consent evaluations. In the case presented in our article, we described a patient who had impaired capacity for voluntarism and subsequently was not able to provide consent for the particular intervention “in accordance with [his] authentic sense of what [was] best in light of [his] situation, values, and prior history” (p. 412). We suggested specific interventions that could quickly and effectively restore his capacity for voluntarism. Dr. Balhara is correct in that a surrogate decision maker would have been appropriate only if the patient had been considered incapable of making a decision, which was the situation prior to our involvement. While optimistic that our approach would have the desired effect, we also recommended contingency planning via a surrogate decision maker “in the event that these factors were unsuccessful in restoring capacity for informed consent” (p. 410). Fortunately, benign and noninvasive recommendations dramatically and effectively restored this patient’s capacity for voluntarism and hence informed consent.