much psychiatric research can be carried out with patients whose capacity for consent is unimpaired. The capacity for consent, furthermore, is not all-or-nothing. Hence, even with severely incapacitated patients it may still be possible to obtain valid consent if sufficient care is taken in overcoming the difficulties (see below). It is also important to be aware that even when patients really are incapable of meaningful consent, the ethics of research are not all one way. Proceeding without consent is certainly ethically hazardous. But if a potentially important advance in medical knowledge is at stake, and if, further, the risks of harm are minimal, it could well be unethical not to proceed. There are possible parallels here with the case of children who have not reached a stage of maturity at which they are able to give meaningful consent. Adult patients should not be treated as children, especially if they are severely incapacitated; this (which happens all too frequently even in ordinary clinical care) would be an affront to the dignity of the person concerned. But similar balancing considerations lie behind the justification of research in the two kinds of case: the balancing of responsibilities against rights, of longer term benefits against immediate wishes, of the needs of society against those of the individual. Provided, therefore, a humane and sensitive approach is adopted, and that the agreement of close relatives and other caregivers is obtained, research at least with assenting adult incompetent patients is unlikely to be regarded as unethical. On the other hand, though, it is important that the problems are not underestimated. There is a tendency in published guidelines to play down the difficulties raised by research with incompetent patients, to suggest that they are merely theoretical, or apply only to small numbers and exceptional cases. The Royal College of Psychiatrists' guidelines, for example, while emphasising the importance of the ethical problems raised by incompetent patients, suggest that this 'group is small' since 'to suffer from severe dementia or mental handicap does not necessarily imply incompetence; and incompetence to make one kind of decision does not necessarily mean incompetence to make another kind' (25). Yet this is too anodyne, surely. Even 'mild' dementia (as defined, say, by the 'mini-mental state' examination) (26) may involve failures in such elementary cognitive tasks as remembering a list of three household objects (for example, comb, table, flower) after two minutes, or reciting the months of the year backwards. So that by any 'commonsense' standards (to which, as described above, the assessment of risk is referred by the Royal College of Psychiatrists' guidelines) such patients, let alone those with severe dementia, can hardly be considered competent to make complex decisions about participation in research. As already stated, it is important that the problems in this area are not exaggerated. This is important, if for no other reason than exaggeration could inhibit research with precisely those patients - those most severely incapacitated - who are in greatest need. But denial may not be the best way to facilitate research. It could lead to unsatisfactory (because ill-founded) consideration of the ethical problems in this area, and hence to an increased rather than decreased risk of unethical research practice. Similarly, the fear of litigation is bound to persist so long as the present uncertain state of the law is allowed to continue. This fear, furthermore, is one to which not only researchers, but also the members of research ethics committees are subject, given the responsibilities of the latter in law (Royal College of Psychiatrists' guidelines (27). That the fear of litigation is to some extent justified, is shown by the fact that some commentators, notably those representing organisations concerned to protect patients' rights, have sought to proscribe certain groups from research altogether. MIND, for example, took this position in its evidence to the Royal College of Physicians' Working Party on Research involving Patients. Proscribed patients As a response to the problems raised by research with incompetent adult patients, proscription may be variously