The debate over risk-related standards of competence

Bioethics. 1997 Oct;11(5):413-26. doi: 10.1111/1467-8519.00081.


This discussion paper continues the debate over risk-related standards of mental competence which appears in Bioethics 5. Dan Brock there defends an approach to mental competence in patients which defines it as being relative to differing standards, more or less rigorous depending on the degree of risk involved in proposed treatment. But Mark Wicclair raises a problem for this approach: if significantly different levels of risk attach, respectively, to accepting and refusing the same treatment, then it is possible, on this account, for a patient to be considered competent to accept, but not refuse, the treatment, or vice versa. I argue that this puzzle does not constitute a genuine problem for a risk-related standard. To this end I focus on the situation where, of two mutually exclusive options, one is riskier, but offering more pronounced benefit, while the other is safer, but offering less benefit. I argue for this proposition: it can take far less insight to know that the safe option is good than to know that the risky option is better. Now say one is actually informed enough to know that the safe option is good, but not enough to know whether the risky option is better; in such a case one is competent to say yes to that first option (the safe one), but not to say yes to the other. (I argue in passing that Pascal's Wager can be interpreted as having precisely this deliberative structure.) I thus conclude that cases do indeed exist where one can be competent to say yes but not no, or vice versa; and that it is thus not an anomaly in the risk-related standard that it entails the existence of such cases.

MeSH terms

  • Coercion
  • Decision Making*
  • Ethics*
  • Freedom
  • Humans
  • Informed Consent*
  • Mental Competency*
  • Patient Care
  • Patients*
  • Personal Autonomy
  • Reference Standards*
  • Risk Assessment*
  • Risk*
  • Treatment Refusal*