A person with self-neglect may not fully understand their situation because of a mental condition. If this happens in the US, a judge or group of judges decide that an individual with self-neglect who is not competent can be forced to do what is in his or her best interest. If one is competent, he or she can refuse care (Brockway, 2009).


The case of Mary Northern was the first time that the US courts forced an individual to following the recommendations of APS

The Case of Mary Northern

This was decided by the US courts in 1978 in the case of Mary Northern. Mrs. Northern suffered from self-neglect. When APS first contacted her, she had gangrene in her feet (State of Tennessee, Department of Human Services v. Northern, 1978). Gangrene is a life-threatening condition without amputation. Mrs. Northern was not concerned and refused treatment. Concerned APS agents took the case to court, to force her to have the necessary amputations.

The judges decided that Mrs. Northern was incompetent. When the judges visited Mrs. Northern at the hospital, they asked questions to see if she understood the danger she is in by having gangrene to both feet. Mrs. Northern said that it was soot and dirt that made her feet dark. It was very clear to the judges that she did not really understand or perceive her situation normally (State of Tennessee, Department of Human Services v. Northern, 1978).

Did You Know!
Each state has their own laws regarding self-neglect. Texas and Florida are provided as examples under US State Law

“Incompetency” is difficult to define. It means that a person has a poor ability to remember, reason, or understand the consequences of his or her actions (Competency and Incompetency, n.d.). Legally, it means the person cannot make legally binding decisions (Competency and Incompetency, n.d.). The courts ruled that APS could force her to undergo the necessary medical procedures to save her life (State of Tennessee, Department of Human Services v. Northern, 1978). When a judge rules a patient incompetent, the clinical decision is easier, since we do not allow patients who clearly cannot make informed decisions for themselves to make dangerous or highly risky choices (Selde, 2015; Smith, Lo & Aronson, 2013).

Care Refusal, Competency, and Capacity

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A competent individual is allowed to refuse medical evaluation, treatment. and services

Competent individuals can refuse treatment. In Cruzan v. Director, Missouri Department of Health, the U.S. Supreme Court ruled that all U.S. citizens have a constitutional right to refuse unwanted therapy (Brockway, 2009).

Competency is a legal term, not a medical one. It means that a person has the ability to remember, reason, or understand the consequences of actions (Competency and Incompetency, n.d.). In law, it means the person can make legally binding decisions. People are presumed competent unless determined otherwise by a court. Physicians cannot pronounce an individual incompetent, judges declare individuals incompetent (Morgan & Marcopulos, 2013; Bozinovski, 1998).

Capacity is the ability to understand information about to a decision and to appreciate its consequences. Capacity is specific to an activity. In other words, an individual may have the capacity to do one thing (refuse treatment) but not another (change a will). Having dementia does not necessarily mean that the individual lacks capacity (Bozinovski, 1998).


Bozinovski, S. D. (1998). Self-neglect among the elderly: Maintaining continuity of self. Diane Publishing.

Brockway, L. H. (2009, June 19). Informed refusal: when patients decline treatment. Retrieved January 1, 2017 from

Competency and Incompetency. (n.d.). Competency and Incompetency. Retrieved on January 1, 2017 from

Morgan, J. E., & Marcopulos, B. A. (2013). Capacity evaluations in older adults: Neuropsychological perspectives. In Handbook on the Neuropsychology of Aging and Dementia (pp. 501-509). Springer New York.

Selde, W. (2015, March 25). Know when and how your patient can legally refuse care. Journal of Emergency Medicine Services, 40(3). Retrieved from

Smith, A. K., Lo, B., & Aronson, L. (2013). Elder self-neglect—How can a physician help?. New England Journal of Medicine, 369(26), 2476-2479.

State of Tennessee, Department of Human Services v. Mary C. Northern, 563 S.W.2d 197 (Ten. Ct.  1978).

Last updated: June 7, 2020 at 16:39 pm by
I. M. Abumaria, Doctor of Nursing Practice
Version 2.00