Philosophy 230
Some Answers to Study Questions:  Buchanan and Brock's "Deciding for Others:  Competency"

Note:  While some of the study questions are factual, others are evaluative.  The evaluative
questions can obviously be answered in a variety of ways, and you should not hesitate to
develop your own ideas.  Be sure to get back to me if you have any questions about
these answers.

1.  The authors argue, first, that the concept of competency (in the context of health-care
decision-making) must be a threshold concept.  This means that competency must be seen
as "all-or-nothing" rather than a matter of degree.  In other words, the answer to whether
someone is competent must be 'yes' or 'no'.  The reason for this is simple:  the purpose
of determining a patient's competency is to determine whether her health-care decisions
(for example, her refusals of treatment) will be respected.  Since this is a 'yes-or-no' question
(we cannot 'to some extent' abide by a patient's refusal of treatment; we either abide by it or
we do not), our concept of competency must also be 'yes or no'.

The authors go on to argue that competency should be understood as decision-relative.  That is,
a patient's competency should be understood to be relative to specific decisions, so that a patient
might be competent to make one decision, yet not competent to make another.  The proper question
to ask, when evaluating a patient's competency, is not "Is this patient competent" but rather "Is this
patient competent to make this decision?"  The authors defend this view of competence by
emphasizing that different decisions will make different demands on a patient's ability to
communicated and understand and to reason and deliberate--the underlying capacities relevant
to competency.  Some decisions, for example, are so straightforward that even a patient
with quite limited abilities could competently make a decision; other decisions will involve
a variety of complex alternatives and significant evaluation of probabilities.  Thus a patient
might be competent to make some decisions but not others.

2.  The authors highlight the capacities to communicate and understand and to reason and
deliberate.  They also point out that a patient must have a "set of values" or priorities (370
7th ed.).  Communication and understanding are obviously relevant because in order
for patients to make decisions about their care they must be able to understand the relevant
facts--the diagnosis, the main alternatives, etc.  They must also be able to communicate their
questions and their wishes.  With reason and deliberation the authors have in mind such things as the
ability to make inferences, to think about probabilities, and to compare alternatives.  Finally,
a patient must have a "set of values" or priorities--something must matter to him.  These values
do not have to be fully worked out or even fully consistent, but without any values at all the patient
would not see any reason  to make one choice rather than another.  (It is only because I value being
alive and healthy and free of pain, for example, that I would  agree to have an appendectomy for
appendicitis.)

3.  The "fixed minimum threshold" conception of competence specifies one single standard of
competency that will apply across the board.  A patient who meets the standard would be
deemed competent to make any decision, regardless of its risk or complexity; a patient who
did not meet the standard would be deemed incompetent to make any decision, regardless
of how low-risk or simple it was.  The authors think that this makes little sense.  Since health-
care decisions carry varying degrees of risk and make varying demands on a patient's
abilities to communicate and understand and to reason and deliberate, it makes more sense to
adopt a decision-relative concept of competence.  They point out that one further advantage
of a decision-relative concept is that it allows a determination of incompetence to be
restricted to one decision--a patient could be deemed incompetent to make a particular decision
without being deemed simply incompetent.

4.  One of the main potential problems for their view lies in their emphasis on the relevance of
risk in determining a patient's competence.  That is, they argue that the riskiness of a patient's
choice should in part determine the standard we use to determine whether the patient is competent
to make that choice.  The standard for competency should be higher, they think, in cases in which
the patient seems clearly to be making a decision that is not in her interest.  Of course, the patient
might well meet even this higher standard and be deemed competent, but the purpose of raising
the standard in such cases is that it makes it easier to justify paternalism in cases in which the
patient's choice seems clearly foolish.

I can see what the authors have in mind here, but this move leaves me uneasy.  All of the problems
that Goldman raised for paternalism, for example, will be relevant here.  According to whose
priorities is the patient's choice being deemed foolish?  I think the authors are right to suggest
that the standard for competency must vary from decision to decision.  It makes sense to
raise the standard for complex decisions that make greater demands on a patient's abilities.  But
to raise the standard in order to make it easier to override what is (in our view) a patient's
foolish choice--I think this goes too far in undermining a person's basic right to self-determination.