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)

According to a standard account of patient decision-making capacity, patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical c...

Metaphysicians, ethical theorists and philosophers of law squabble endlessly about what it is for a person to act — or perhaps even to ‘will’ — more or less freely. A vital issue in this controversy is how we should analyse two obvious but surprisingly problematical contrasts. The first antithesis is between things we do because we are forced, and deeds we perform because we want to — sometimes after having discovered preponderant reasons in their favour. The other polarity is more (...) general. In most situations, if I act on my desire, I act more freely than if I had not had the desire. But what if my attitude is the product of childhood conditioning — or later brainwashing, brain surgery, hypnosis, behaviour modification, alcoholisim, narcotics addiction, neurosis, psychosis or worse? Then isn't my autonomy diminished? What is it about these latter desires, or their origin, that differentiates them from their unthreatening congeners? (shrink)

If a person is competent to consent to a treatment, is that person necessarily competent to refuse the very same treatment? Risk relativists answer no to this question. If the refusal of a treatment is risky, we may demand a higher level of decision-making capacity to choose this option. The position is known as asymmetry. Risk relativity rests on the possibility of setting variable levels of competence by reference to variable levels of risk. In an excellent 2016 article inJournal of (...) Medical Ethics(JME), Rob Lawlor defends asymmetry of this kind by defending risk relativity, using and developing arguments and approaches found in earlier work such as that of Wilks. He offers what we call the two-scale approach: a scale of risk is to be used to set a standard of competence on a scale of decision-making difficulty. However, can this be done in any rational way? We argue it cannot, and in this sense, and to this extent, risk relativity is a nonsense. (shrink)