In a Mental Capacity Act (MCA) question about money, a dementia diagnosis or a financial choice others consider unwise is not enough to conclude that the person lacks capacity. The stronger exam move is to ask two linked questions, in order: can the person make this particular decision at this time, with practicable support? If not, is that inability because of an impairment or disturbance in the functioning of the mind or brain? The four functional abilities matter, but a list-only answer can miss the causal link. The UK Supreme Court’s approach is to address decision-specific inability before asking whether it is caused by an impairment or disturbance; some older summaries present the questions in the opposite order.
This article addresses the MCA framework for England and Wales. Legal standards elsewhere, including in the United States, may differ.
Run the test in two passes
First, identify the specific decision and time, then assess functional ability with practicable support. Ask whether the person can:
- Understand the information relevant to the decision, including reasonably foreseeable consequences.
- Retain the information long enough to make the decision—not remember it indefinitely.
- Use or weigh the information as part of reaching a choice.
- Communicate the choice by any means.
Then ask whether any inability to make the decision is because of an impairment or disturbance in the functioning of the mind or brain. It may be temporary or ongoing. A diagnosis such as dementia can be relevant evidence, but it does not decide the question by itself.
An inability in one or more functional areas may satisfy the functional part of the test, but the MCA conclusion also requires that the inability be caused by the impairment or disturbance. Support matters too: do not treat someone as unable to decide before practicable steps to help have been tried.
| Pass | What the question is asking | What is not enough by itself |
|---|---|---|
| Functional ability | Despite practicable support, is the person unable to make this specific decision now because one or more relevant abilities is impaired? | A diagnosis, age, appearance, behaviour, score, or a decision others dislike |
| Causation | Is that inability because of an impairment or disturbance in mind or brain function? | Finding an impairment without linking it to the decision-making inability |
Make the financial decision precise
Managing finances can cover very different tasks, from paying a familiar bill to considering a major transfer. Name the actual decision before assessing it. A person’s ability to handle one complex financial choice does not automatically establish their ability—or inability—to make every other financial decision.
For the decision in the stem, identify what information is relevant. For a proposed transfer, that might include what the transfer involves and the reasonably foreseeable consequences of making it or not making it. The question is whether the person can understand and weigh that information, not whether they choose the option the clinician or family would prefer.
| Vignette clue | How to use it | Avoid this leap |
|---|---|---|
| Dementia diagnosis or low cognitive-screen score | Consider whether an impairment is present and whether further assessment is needed | Concluding that the person cannot make this decision; a screening score is not a capacity assessment |
| A transfer that seems risky or unwise | Explore the person’s understanding of the choice and ability to weigh relevant information | Treating disagreement with family or clinician as proof of inability |
| Difficulty speaking or answering aloud | Check whether another communication method or support helps | Equating speech difficulty with inability to communicate a choice |
| New confusion or drowsiness | Consider whether an acute or temporary problem is affecting decision-making now | Assuming the person’s ability is fixed or that the decision cannot be reassessed |
Family physicians can make the assessment more meaningful by establishing the person’s usual role in similar financial tasks and what has changed. Ask about the timing of cognitive or functional changes, current illness, medication effects, hearing, vision, language, and the conditions under which the person communicates best. Information from someone who knows the person may help clarify baseline function, but it does not replace speaking with the person in an accessible way.
Turn the rule into evidence
When a vignette raises a genuine concern, work through the assessment rather than relying on a label or a single test:
- Specify the decision and time. Replace a broad question such as Can he manage money? with the particular choice the person needs to make now.
- Make the information accessible. Use clear language, allow time, and address communication barriers. Depending on the person’s needs, that may mean glasses or hearing aids, an interpreter, written or visual information, or another communication method.
- Explore the relevant ability neutrally. Ask the person to explain the choice in their own way, what they understand could follow, and what matters to them. Do not require agreement with your preferred outcome as proof of capacity.
- Connect the evidence to the conclusion. If an inability remains despite support, state which ability is affected, what the person could or could not do, and how the inability relates to the mind-or-brain impairment or disturbance at that time. Note what remains uncertain and whether the decision can safely wait for reassessment.
A cognitive screen may contribute useful information, but it cannot substitute for evidence about the decision-making process. Similarly, a family’s worry may be a reason to ask more questions, not the result of the assessment. If the person is found to lack capacity for this decision, best-interests decision-making is a subsequent step—not a reason to change the capacity test to match what others consider best.
A 10-minute retrieval exercise
Retrieval practice means trying to produce the reasoning from memory before looking at notes. That effort exposes whether you remember only the four abilities or can apply the full test, including the causal link.
- Minutes 0–2: Close your notes. Write the two questions in order, then name the four functional abilities.
- Minutes 2–6: Consider three brief variations on a proposed financial transfer: a patient has a dementia diagnosis but no described decision-making difficulty; a patient understands the transfer but chooses an option the family opposes; a patient is acutely drowsy and cannot follow the explanation at that moment. For each, write which part of the test the facts address and what is still missing.
- Minutes 6–8: Check your notes. A diagnosis alone does not establish functional inability; disagreement about the choice does not establish inability to weigh; acute drowsiness may affect a functional ability, but establish an inability despite support and link it to an impairment or disturbance before reaching the MCA conclusion. Consider whether the assessment should occur later.
- Minutes 8–10: Write one sentence for each variation: what can be concluded, what cannot yet be concluded, and what support or information would help. Revisit the exercise later without notes before checking again.
Practical takeaways
- Start with whether the person can make the specific decision with practicable support; then establish whether any inability is caused by a mind-or-brain impairment or disturbance.
- For the functional test, assess understanding, retention long enough to decide, use or weighing, and communication by any means.
- Link any inability to the impairment, consider the person’s support needs, and keep the decision and timing specific.
- Do not infer incapacity from a diagnosis, screening score, communication barrier, or an unwise choice alone.
