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The assessment of decision-making capacity in patients with acquired brain injury presents a range of clinical and legal challenges. The existing guidance on the conduct of such assessments is often generic; guidance specific to patients with brain injury is sparse and coarse grained. We report on the results of an interview-based study of decision-making capacity in patients suffering from acquired brain injury and organic personality disorder. We identify the clinical and legal challenges associated with the assessment of decision-making capacity in this patient population, review three bodies of relevant research from cognitive neuropsychology and neurophysiology, and draw on phenomenological analysis to identify three distinct abilities that play a role in decision making, but that can be compromised in patients with organic personality disorder. We address the challenge of translating clinical findings into legally attestable results.