财务能力(FC)是一种医学法律结构,代表以与个人自身利益一致的方式独立管理其财务事务的能力。因此,FC不仅涉及绩效技能(例如,准确计算硬币/货币,完成支票登记册,支付账单),还涉及优化财务自身利益的判断技能。
From a legal standpoint, FC represents the financial skills sufficient for handling one’s estate and financial affairs and is the basis for determination of conservatorship of the estate (or guardianship of the estate, depending on the state legal jurisdiction). Broadly construed, FC also encompasses more specific legal “financial capacities,” such as contractual capacity, donative capacity, and testamentary capacity. Thus, FC is a very important area of assessment in the civil legal system.
从临床角度来看,足球俱乐部是一种高度认知介导的能力,非常容易受到影响认知(例如痴呆,中风,创伤性脑损伤和精神分裂症)的神经系统,精神病和医疗状况的影响。经济经验和技能在认知正常人之间也有很大差异,并且与教育和社会经济状况的因素有关。家庭,医师,律师和法官越来越询问临床医生,以评估和提供有关FC的临床意见。
随着FC和相关评估工具的概念模型的最新发展,对这一重要的民事能力有一系列新兴的实证研究。
财务能力的重要性
Impairment and loss of FC has important psychological, economic, and legal consequences for patients and family members. Similar to driving and mobility, the power to control one’s finances is a fundamental aspect of individual autonomy in our society. Loss of financial control may result in psychological consequences such as increased feelings of dependency and depression. Declines in FC are also associated with immediate and long-term economic consequences. Failure to pay bills or difficulty in handling basic financial tasks may result in disconnection of services, property repossession, poor credit ratings, and even homelessness. Impaired financial judgment may also result in loss of assets intended for long-term care or inclusion in a will or trust. From a legal perspective, diminished FC is associated with increased risk of financial exploitation in the form of consumer fraud and other scams, as well as greater susceptibility to undue influence by family members and third parties. As noted above, some situations of financial incapacity may reach the courts and result in loss of decisional autonomy and the appointment of a conservator (or guardian) by the court to protect the person and his or her estate.
Conceptual Model of Financial Capacity
Early conceptual formulations of FC were anemic and limited to unelaborated descriptions such as “money management skills” or “financial management skills.” In actual fact, FC is a complex, multidimensional construct representing a broad range of conceptual, pragmatic, and judgmental skills. This multidimensionality is reflected in the concept of limited financial competency recognized across state legal jurisdictions, where an individual may still be competent to perform some financial activities (e.g., handle basic cash transactions, write small checks) but no longer others (e.g., make investment decisions or asset transfers). In addition to multidimensionality, a conceptual model of FC should incorporate the dual performance and self-interest perspectives discussed above. For example, persons with schizophrenia may have adequate financial performance skills but lack FC because they consistently make poor judgments about how to spend their government entitlement monies.
Marson及其同事提出了一个临床模型,该模型以三个日益复杂的水平概念化FC:(1)特定的财务能力或任务,每项都与特定的财务活动领域有关;(2)财务活动的一般领域,在临床上与社区居民老年人的独立功能有关;(3)整体FC或全球水平。FC的这种概念模型当前包括9个域,20个任务和2个全球级别。这9个领域包括基本的货币技能,财务概念知识,现金交易,支票簿管理,银行报表管理,财务判断,账单支付,个人资产和遗产安排知识以及投资决策。如所讨论的,财务活动的每个领域进一步分解为组成任务或能力,强调对与特定领域相关的概念的理解和务实应用。例如,财务概念知识的领域涉及理解诸如贷款和储蓄之类的概念,并使用此信息来选择有利的利率。同样,账单付款不仅涉及了解账单是什么以及为什么应支付账单,还可以准确审查账单并准备邮寄。最后,家庭和法院通常要求临床医生做出有关个人整体足球俱乐部的临床判断。这样的全球判断涉及将有关个人任务和领域级别的绩效,他或她的判断力和线人报告的信息集成。 Such global clinical judgments are particularly relevant for guardianship and conservatorship hearings.
临床评估财务能力的方法
目前,至少有三种评估FC的主要方法:临床访谈,患者/线人评级和直接绩效工具。临床访谈是评估FC的传统,目前是主要的方法。在接受患者(和家庭成员)的采访开始时,临床医生必须首先确定患者的先前或前病前财务经验和能力,这一点很重要。例如,假设一个测试表明难度写支票的人如果他或她从未执行这项任务和/或传统上将这项任务委派给配偶的人,这是不合适的。一旦建立了前虫的经验水平,临床医生就需要确定构成患者当前财务活动的财务任务和领域,并差异地考虑社区中独立生活所需的财务任务和领域。应仔细考虑在特定任务或领域的损害水平。仅需要口头促使启动或完成财务任务(例如,支付账单)的个人与需要实际的动手协助和支付账单监督的个人在质量上不同;反过来,两者都与现在完全依赖他人支付账单的个人不同。
评估FC的第二种方法涉及使用完整的患者和线人评级表。临床医生通常使用观察等级量表来补充其临床访谈。观察评级量表通常由患者和/或知识渊博的线人(例如配偶,父母或成年子女)完成。他们可以提供有关个人当前财务功能以及随时间变化的有价值的“现实生活”信息。但是,目前,FC特定的评级表很少。大多数评级表旨在评估日常生活的基本和高级活动的绩效,因此可能仅产生有限的财务绩效信息。
A weakness inherent in patient/informant rating forms (and also clinical interviews) is reporter bias. Both patients and informants can misestimate a patient’s FC and other functional abilities, owing to a number of factors including lack of insight, denial, and psychiatric issues. Dementia patients and hospitalized elders have been found consistently to overestimate their functional abilities, including financial skills, relative to results of performance-based functional assessment measures. Similarly, even over a short period of time, spousal caregivers of persons with Alzheimer’s disease (AD) can be unstable in their ratings of FC in their spouses. Despite these limitations, clinicians justifiably rely on interviews and informant reports of FC due to their ease of administration, minimal cost, and overall information yield.
Performance-based instruments represent a third approach to assessing FC. In contrast to clinical interview formats and observational rating scales, performance-based instruments are not subject to reporter bias. Instead, individuals are asked to perform a series of pragmatic tasks equivalent to those performed in the home and community environment. Performance-based measures are standardized, quantifiable, repeat-able, and norm referenced, and thus results can be generalized across patients and settings. These measures, thus, can provide clinicians and the courts with objective information regarding the performance of specific financial tasks that can be highly relevant to the formulation of recommendations and treatment strategies.
Weaknesses of performance-based measures should also be noted. Performance-based measures conducted in a laboratory or clinical office setting cannot take into account either the contextual cues or the distractions within the home environment that may assist or interfere with a person’s abilities to perform everyday financial tasks. These instruments are more difficult and time-consuming to administer. They usually require specialized equipment and training, which can make them costly relative to observational rating scales.
财务能力研究
The lack of conceptual models and assessment instruments specific to FC helps explain the relative lack of clinical research in this important area of civil competency assessment. Only recently have systematic empirical studies of FC been conducted in clinical populations. These studies have investigated patterns of FC impairment in patients with AD and mild cognitive impairment (MCI).
丹尼尔·马森(Daniel Marson)和他的小组的研究表明,轻度和中度广告患者的财务能力受到重大损害。在领域水平上,轻度AD的患者在所有财务活动的所有领域中表现出明显低于正常的老年人对照,但基本的货币技能除外。中度广告的患者在所有金融领域中显着低于对照和轻度AD的患者。
At the task level, patients with mild AD performed equivalently with older controls on simple tasks such as naming and counting coins and currency, understanding the parts of a checkbook, and detecting the risk of mail fraud. However, such patients had difficulty performing more complex financial tasks such as applying financial concepts (i.e., choosing the best interest rate), obtaining exact change for vending machine use, understanding and using a bank statement, and making an investment decision. Patients with moderate AD were substantially impaired on all financial tasks, relative to both normal older adults and persons with mild AD.
在全球范围内,与较旧的对照组相对于对照组和轻度AD患者,中度AD患者相对于较旧的对照表现出严重的损害,并且中度AD患者受到损害。
根据这些初步发现,丹尼尔·马森(Daniel Marson)和他的小组提出了对轻度和中度AD患者的FC评估的初步临床指南:
- 在大多数金融活动中,尤其是复杂的活动,例如支票簿和银行对帐单管理,温和的患者处于损害的巨大风险。应仔细评估和监控保留自主财务活动的领域。
- Moderate-AD patients are at great risk of loss of all financial abilities. Although each AD patient must be considered individually, it is likely that most moderate-AD patients will be unable to manage their financial affairs.
在MCI的人中也观察到FC的下降。相对于正常老年人,有MCI的人在财务概念知识,支票簿和银行说明,财务判断和账单支付领域表现出轻度损害。更具体地说,具有MCI的人在需要实际应用财务概念,理解和使用银行声明以及优先级和准备邮寄账单的任务方面存在相对困难。但是,具有MCI的人的表现要比大多数领域级的财务活动和特定于任务的能力中的轻度广告人的表现要好得多。但是,并非所有患有MCI的患者都表现出这些障碍,这表明该前驱痴呆症组的财务绩效异质性。但是,这些结果表明,尽管金融能力的大幅度(尽管温和)是与MCI相关的功能变化的一个方面,并且可能在MCI患者最终转化为AD中发挥作用。因此,临床医生应随着时间的推移监测MCI的个人FC。
References:
- Griffith, H. R., Belue, K., Sicola, A., Krzywanski, S., Zamrini, E., Harrell, L., et al. (2003). Impaired financial abilities in mild cognitive impairment: A direct assessment approach. Neurology, 60, 449—157.
- Marson, D. C., Savage, R., & Phillips, J. (2006). Financial capacity in persons with schizophrenia and serious mental illness: Clinical and research ethics aspects. Schizophrenia Bulletin, 32, 81-91.
- Marson,D.C.,Sawrie,S.M.,Snyder,S.,McInturff,B.,Stalvey,T.,Boothe,A。等。(2000)。评估阿尔茨海默氏病患者的财务能力:一种概念模型和原型工具。神经病学档案,57,877-884。
- Moye, J. (2003). Guardianship and conservatorship. In T. Grisso (Ed.), Evaluating competencies: Forensic assessments and instruments (pp. 309-389). New York: Plenum.
- Wadley,V.,Harrell,L。,&Marson,D。(2003)。自我和线人报告阿尔茨海默氏病患者的财务能力:可靠且有效吗?美国老年医学学会杂志,51,1621-1626。