Abstract：
The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1-4.
摘要：
几十年来，作为临床知情同意过程的一部分，对医疗决策能力的评估一直被认为是生物伦理内务处理问题。然而在实践中,现实与医学文献中所描述的和医学教育中所描述的几乎没有相似之处。大多数关于知情同意的文献都将医疗决策能力作为同意过程的前提。也就是说,临床医生必须首先确定患者是否有能力，只有这样，临床医生才能与患者进行其余的知情同意。这种两步方法的问题在于，它在实际实践中没有意义。我们将知情同意过程中的医疗决策能力评估视为螺旋楼梯，不仅仅是两步，要求临床医生不停地盘旋，取得进展,直到他们到达他们需要的地方:1。临床医生从大多数成年人的能力开始，有时根据先前的患者接触对能力进行临时评估。2.然后，他们开始对当前情况和干预方案进行知情同意.3.接下来,他们必须在这个过程中重新评估能力。4.之后,他们继续知情同意。5.如果容量还不清楚，他们重复1-4。
