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Background The commonly-accepted “biopsychosocial model” does not always lend itself to the kind of pragmatic decisions that many clinical situations demand of physicians. Objective The authors attempt to identify and close gaps in the biopsychosocial model that hinder its application in certain real-life clinical situations. Method The authors review some of the current and historical literature on the development and application of the biopsychosocial model, and argue the shortcomings of this modality in various clinical situations. Results The authors present three dicta to guide clinicians toward relevant areas of inquiry: 1) Think neuroanatomically; 2) Think existentially; and 3) Think “dirty;” that is, understand that patients and physicians sometimes work toward different goals. Discussion These dicta form an addendum to the biopsychosocial model, identifying and filling three specific, commonly-encountered gaps in that paradigm, which, ironically, is usually considered all-inclusive.

Background The 4-abilities model of decision-making capacity is vulnerable to constricted application and teaching. Objective The authors attempt to assert the fundamentally clinical nature of capacity evaluations, while acknowledging that the concept of decision-making capacity must be legally grounded. Methods Relevant aspects of clinical care are examined and emphasized as they apply to the evaluation of capacity for medical decision making. Results Accessing patients' maximal abilities, attending to noncognitive aspects of choice, and identifying diagnostic explanations for patients' difficulties are important components of these assessments. Discussion The evaluation of medical decision-making capacity is not a purely forensic task; it is enhanced by an approach that bridges the clinical-forensic divide.

Background Psychiatric consultations involving the evaluation of patients' medical decision-making capacity often seem to have little to do with truly compromised patient autonomy. Objective The authors seek to examine hidden ethical dilemmas that lead to capacity evaluation requests. Method The authors utilize the "principlism" approach to biomedical ethics to illustrate some common moral issues in patient care that are poorly captured by the "autonomy-versus-paternalism" paradigm. Results Patient autonomy sometimes comes into conflict with ethical imperatives to do "good," to avoid harm, and to deliver care fairly, as well as with the autonomy of others. Consultation psychiatrists are well positioned to unearth these dilemmas and begin to address them. Discussion Effective engagement of everyday ethics in clinical medicine is hindered by reflexive resort to capacity evaluations when moral problems arise. Greater attention to matters of values, aggressive urges, and obligations to others can enhance the negotiation of routine ethical dilemmas.

The commonly-accepted "biopsychosocial model" does not always lend itself to the kind of pragmatic decisions that many clinical situations demand of physicians.The authors attempt to identify and close gaps in the biopsychosocial model that hinder its application in certain real-life clinical situations.The authors review some of the current and historical literature on the development and application of the biopsychosocial model, and argue the shortcomings of this modality in various clinical situations.The authors present three dicta to guide clinicians toward relevant areas of inquiry: 1) Think neuroanatomically; 2) Think existentially; and 3) Think "dirty;" that is, understand that patients and physicians sometimes work toward different goals.These dicta form an addendum to the biopsychosocial model, identifying and filling three specific, commonly-encountered gaps in that paradigm, which, ironically, is usually considered all-inclusive.