Mental Capacity and the Vote: Divergent International Approaches and Shared Problems

On the 7th May this year millions of people went to polling stations (or had submitted postal votes) to choose their representatives in the House of Commons and other public office. These elected representatives make decisions which affect the public; and none are more subject to the implications of those decisions than individuals who receive medical, nursing, or social care. Despite their possible dependencies, research has shown that those in the UK receiving nursing care(Hudson, 1997; Nabi, 2002) or have ‘intellectual disabilities’ (Keeley et al., 2008) are substantially less likely to vote than the rest of the population(around a half or a third as likely, retrospectively).

There are two contrasting national views on whether people who may have limited capacity should be allowed to vote. The UK system is designed to maximise democratic participation through voting. There is no restriction to accessing the vote by those who have any kind of intellectual impairment (The Mental Capacity Act 2005 prohibits substitute decisions with regard to voting), with the exception of those who are detained in psychiatric hospitals as a result of criminal activity. Though, contradictory advice exists, with the Citizens Advice Bureau (ND, online) suggesting that “people who have a severe mental illness and are unable to understand the voting procedure […] cannot vote.” In the United Kingdom the principal remains that all of those who wish to vote are able to do so; in keeping with the UN Convention on the Rights of Persons with Disabilities, where citizens with disabilities have the same political rights as any other citizen (see Keely et al., 2008).

Equal access to the ballot is not practiced in the United States of America, where the prime concern with regard to capacity for decision making rests with the integrity of the ballot. Following a 2001 federal court decision ‘The Doe Standard’(Doe v. Roe, 2001) was introduced which set a requirement for competence in order to vote, those found to lack capacity for making electoral decisions are restricted from voting. Where capacity might be called into question a test might be conducted by a psychiatrist. Appelbaum et al. (2005) reports on the development of a specific test, the Competence Assessment Tool for Voting (CAT-V), which includes criteria to assess the nature and personal impact of voting. Those who are found not to have capacity are denied the right to vote. Subsequent research interest with regards to adaptations of the CAT-V has been seen in Italy (Tiraboschi et al., 2011) and Spain (Irastorza et al, 2011). The practicalities of administering such a test within a short timeframe to all of those who are known to have a condition affecting capacity would seem to be problematic for psychiatrists and allied professionals with limited resources.

The question of whether those who do not have capacity in regard to an electoral decision should vote would seem to be a broad issue with many interested parties, particularly in the light of growing levels of an aging population and rising numbers of dementia sufferers. There exists a more specific problem for psychiatry to consider (at least in an international context)in the practicalities of such a situation, and whether the capacity of a large number of people can be assessed at a time immediately prior to an election.