Against Externalism in Capacity Assessment—Why Apparently Harmful Treatment Refusals Should Not Be Decisive for Finding Patients Incompetent

Click to increase image sizeClick to decrease image size

This article refers to:

Harmful Choices, the Case of C, and Decision-Making Competence

DISCLOSURE STATEMENT

Savulescu is a Partner Investigator on an Australian Research Council grant LP190100841 which involves industry partnership from Illumina. He does not personally receive any funds from Illumina. Savulescu is a Bioethics Committee consultant for Bayer.

Notes

1 Note that seeming to be seriously self-harmful and being seriously self-harmful are not the same concept and they may come apart in reality. If paternalism can be justified, it will typically involve overriding another’s decision, presumed to have been reached incompetently, “for their own good.” It is important, then, that it is really their own good that is being promoted by the decisional override, not their merely apparent or assumed good based on, e.g., the beliefs or values of someone else. See later discussion.

2 We take an “imprudent” decision to be one that is harmful to the patient herself, all-things considered and on balance, which is equivalent to saying that the decision is contrary to her overall best interests. Importantly, we assume: (a) that these interests are themselves determined, to a large extent, by the patient’s own adequately considered, accurately informed beliefs and values, and (b) that having one’s primarily self-affecting decisions respected—commensurate with one’s level of autonomy or capacity—is itself a significant part of well-being (Veit et al. 2021).

3 There is, of course, a major ongoing debate about whether it is ever appropriate to dichotomously designate persons (even with respect to certain decisions) as “competent” versus “incompetent” rather than, say, variably able to make or contribute to adequately justified decisions—if sufficiently supported—on their own behalf. Following Pickering et al. (2022), we will frame our analysis in terms of a dichotomous assessment of competence/incompetence insofar as this remains a dominant paradigm, and to align the structure of our argumentation with theirs.

Additional information

Funding

Julian Savulescu, through his involvement with the Murdoch Children’s Research Institute, received funding through from the Victorian State Government through the Operational Infrastructure Support (OIS) Program.