Hopkins Competency Assessment Test

The Hopkins Competency Assessment Test (HCAT) was developed as a brief screening measure for assessing a patient’s capacity to provide informed consent and prepare advance directives regarding medical treatments. As mental health clinicians have increasingly recognized the importance of accurately assessing a patient’s ability to provide informed con-sent, the need for measures to quantify this ability has grown. The HCAT represents one of the first such efforts at developing a standardized approach to evaluating the capacity to provide informed consent by providing a systematic measure of comprehension. Although primarily used in research settings, this measure has the potential to help inform clinical judgments about decision-making competence.

The HCAT, developed by Jeffrey Janofsky, consists of a short description of the informed consent process and the durable power of attorney, followed by six questions (e.g., What are four things a doctor must tell a patient before beginning a procedure?). These questions evaluate the patient’s comprehension of the information disclosed and yield a score ranging from 0 to 10, with scores of 3 or lower signifying inadequate comprehension. In their validation study, Janofsky and colleagues provided interrater reliability for the HCAT by analyzing the ratings of two independent examiners on a series of 16 cases. Not surprisingly, given the simplicity of the scoring system, the authors found a correlation of .95, suggesting a high degree of consistency in HCAT scoring. Other forms of reliability, however, have not been analyzed and are potentially less salient. For example, because the clinical condition of many patients changes over time, test-retest reliability is not necessarily a meaningful index of scale reliability.

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The content validity of the HCAT has been evaluated in several research studies. For example, Jeffrey S. Janofsky and colleagues compared the results of the HCAT with the opinion of an experienced psychiatrist who was not shown the HCAT results. All individuals whom the psychiatrist considered incompetent had received a score of 3 or less on the HCAT, whereas none of the individuals who “failed” the HCAT were considered competent by the psychologist (i.e., a 100% accuracy rate for determination of competence). Barton, on the other hand, found very little concordance between HCAT scores and clinician opinions regarding competence; however, the latter were based on hospital records indicating that a patient had been considered incompetent (which rarely occurred).

Subsequent studies have analyzed the association between HCAT scores and ratings of patient functional impairment, as well as performance on other measures of cognitive functioning. For example, Sorger et al. (2007) found markedly poorer decision-making ability, based on the HCAT, among elderly patients diagnosed with terminal cancer compared with a physically healthy elderly sample, even after controlling for other group differences (e.g., age, gender, etc). Nearly half (44%) of the terminally ill patients studied “failed” the HCAT compared with only 6% of an ambulatory nursing home comparison sample. Moreover, HCAT scores were significantly correlated with other measures of cognitive functioning including the Mini-Mental State Exam.

Despite strong preliminary data in support of the reliability and validity of the HCAT, this measure is rarely used in either empirical research or clinical practice. There are numerous reasons for the limited popularity of the HCAT. Foremost among them is the “generic” nature of the information presented and assessed, focusing on the concept of informed consent and durable power of attorney rather than a specific treatment decision. Clinical evaluations, and much of the emerging research on informed consent and decision-making competence, focus on a patient’s ability to formulate decisions, not simply comprehension of the right to make such treatment decisions. In fact, understanding of informed consent may have little association with the ability to make a rational choice among a set of complicated options. Without tailoring the information disclosed to the patient’s particular medical conditions and treatment options, HCAT scores have relatively little bearing on the patient’s capacity to consent to a specific intervention. These disadvantages are likely the reason why the HCAT has been eclipsed by the MacArthur instruments, which are designed to assess capacity to consent to treatment and research: MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), respectively.

On the other hand, the HCAT has several advantages for clinical research, including brevity, ease of administration, and the generic nature of information presented. Thus, this measure can be easily administered in the context of a battery of assessment instruments (in both research and clinical settings) and is applicable to all patients, regardless of health state or treatment needs. In clinical settings, the HCAT may, with further research, become a useful screening measure that can quickly identify patients who need a more thorough evaluation. Of course, further research is clearly needed before the HCAT gains acceptance as a useful clinical or research instrument. For example, a comparison of the HCAT with more focused measures of decision-making capacity, such as the MacArthur instruments, would help clarify the relationship between the general comprehension of informed consent and the specific decision-making abilities that typically form the basis of such evaluations.


  1. Barton, C. D., Mallik, H. S., Orr, B., & Janofsky, J. S. (1996). Clinician’s judgment of capacity of nursing home patients to give informed consent. Psychiatric Services, 47, 956-959.
  2. Janofsky, J. S., McCarthy, R. J., & Folstein, M. (1992). The Hopkins Competency Assessment Test: A brief method for evaluating patients’ capacity to give informed consent. Hospital and Community Psychiatry, 43, 132-136.
  3. Jones, B. N., Jaygram, G., Samuels, J., & Robinson, H. (1998). Relating competency status to functional status at discharge in patients with chronic mental illness. Journal of the American Academy of Psychiatry & Law, 26, 49-55.
  4. Sorger, B. M., Rosenfeld, B., Pessin, H., Timm, A. K., & Cimino, J. (in press). Decision-making capacity in elderly, terminally ill patients with cancer. Behavioral Sciences and the Law.

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