In this paper I discuss the view that the appropriate concept of competence is a decision‐relative one: that a person may be competent to make one decision but not another. The argument that I present is that neither of the two competing theories supporting the decision‐relative approach, internalism and externalism, can provide a coherent explanation of why a person’s competence should be thought to be relative to a particular decision. On the one hand, internalism, which regards competence as exhaustively a (...) matter of the person’s understanding, fails to identify the specific skills or content that would warrant linking a specific decision with competence, and thus cannot provide an account of decision‐relative that parallels task‐relative. On the other hand, externalism, which regards competence as a matter of the person’s understanding in relation to external elements such as risk, cannot adequately defend why a person’s competence to make a decision should ‘track’ the level of probable harm that results from the decision. (shrink)

This discussion paper addresses Ian Wilks’ defence of the risk‐related standard of competence that appears in Bioethics 11. Wilks there argues that the puzzle posed by Mark Wicclair in Bioethics 5 against Dan Brock's argument in favour of a risk‐related standard of competence — namely that Brock’s argument allows for situations of asymmetrical competence — is not a genuine problem for a risk‐related standard of competence. To show this, Wilks presents what he believes to be two examples of real situations (...) in which asymmetrical competence arises. I argue that insofar as Wilks equivocates two senses of competence in his examples — namely, competence to perform a task and competence in performing a task — Wilks is unable to illustrate the existence of real situations of asymmetrical competence. By examining the way in which Wilks equivocates two senses of competence in his examples, and by applying the results of this examination to the problem of patient competency within the medical field, I argue that not only does Wilks fail to show that situations of asymmetrical competence exist, but he is also unable to provide a foundation for understating how the risk‐related standard of competence can strike a balance between an individual’s autonomy and benevolent intervention. I thus conclude that insofar as Wilks fails to answer the objections raised by Wicclair and others against the risk‐related standard of competence, the risk‐related standard of competence continues to be undermined by the problem of asymmetrical competence. (shrink)

Informed consent is valid only if the person giving it is competent. Although allegedly informed consents are routinely tendered, there are nonetheless serious problems with the concept of competence as it stands. First, conceptual work upon competence is incomplete: the concept is unanalyzed and no logic of competence has been identified. It is thus virtually impossible to reliably discern who is competent. ;Traditional work on competence has explicated three dichotomies from which the necessary conditions for the possibility of competence will (...) be identified, viz., that competence is either a global or a specific notion; is present in varying degrees or in virtue of a threshold; and may or not include appeals to consequences. Past efforts have failed to notice a fourth dichotomy: competence as an affective or cognitive notion. Failure to designate the appropriate arms of these dichotomies is responsible for there being, at present, no reliable test for competence. The inadequacies of a highly regarded particular test for competence, the mental status examination, are examined in light of this failure. ;Competence is located within the rule-governed practice of informed consent. That practice and hence, competence, is justified through a Kantian analysis of respect for persons. This analysis reveals that the logic of competence requires assessment in terms of specific rather than global concerns; degrees of ability rather than a threshold; both cognitive and affective abilities; and no appeal to consequences. ;Based upon the analyses of consent as an example of decision making within the practice of informed consent and of respect for persons, the capacities which jointly comprise competence are identified. These are the capacities to receive, recognize, and retrieve information; to reason about, relate to oneself, and rank options; to choose among alternatives; and, under certain circumstances, to defend one's choice. ;Identification of the logic of competence and explication of and justification for the capacities that comprise competence to consent provide a conceptual foundation for the crucial concept of competence that the informed consent process currently lacks. It should facilitate construction of a test for competence. (shrink)

Aims: To assess patient receipt of written information. To ensure patients understand the written information about a resuscitation policy and to determine whether they disapproved of or had concerns about the policy. Methods: All admissions to four wards of the hospital were approached for an interview. A set questionnaire was asked by one of 2 interviewers. Results: 72% of 572 admissions were interviewed. Refusal accounted for only 2 of the people not interviewed. 11% were unable to advocate for themselves by (...) reason of mental incompetence, inability to communicate or impairment secondary to their illness. Of the 401 interviewed only 49% recalled receiving the patient information booklet. Few patients (17%) recalled reading the information in the patient information booklet. They were all then given the paragraph about the hospital’s resuscitation policy. 352 were asked their understanding and only 61% demonstrated that they understood the paragraph. 91% of all 401 patients approved of the hospital having the option of DNR orders. 31% of people however had concerns related to DNR orders. These are discussed. Conclusions: Many acutely unwell patients are unable to advocate for themselves. Written information is a poor method of communicating with patients. There was limited receipt of the information and many misunderstood the paragraph about the hospitals resuscitation policy. There was a wide range of patient thoughts and concerns expressed. (shrink)