Commentary on "Is Mr. Spock Mentally Competent ?"

The notion of competence is simultaneously important and elusive. Louis Charland makes a contribution to our understanding of competence by emphasizing the inescapable role of human emotions. Decision making in the practical, as opposed to theoretical world, points out Charland, is an inseparable mix of cognitive and emotional processes. He correctly notes that in the workings of the brain, these functions are not clearly separated. Unfortunately, Dr. Charland undermines the complexity he manifestly endorses. Is a patient’s emotional decision valid only, as Dr. Charland says, if we judge that it is “appropriate under the circumstances” or is not “devastatingly maladaptive.” In the end, he judges the role emotions play in individual decisions (here the informed consent or refusal of research subjects) by the very cognitive yardstick he urges the reader not to rely on. To understand his mistake, it will be helpful to briefly review the notion of competence.

What is Competence?

Competence is one of the elements of informed consent, the moral and legal principle that guides decision making with regard to both clinical medicine and clinical research. What follows applies both to medical treatment and research. A subject’s decision to participate in research must be made: 1) voluntarily; 2) after he/she receives adequate information; 3) after he/she understands this information; and 4) if the subject is “competent.” Competence generally refers to mental qualities and abilities inherent in the research subject.

Dr. Charland correctly notes that competence should be evaluated in the context of a particular decision, and that it is a threshold concept (either you are competent or you are not.) He confuses things by equating competence with decision-making capacity. One of the key characteristics of competence is that it is a legal determination. Our (U.S.) law assumes that adults are competent until proven otherwise. A determination of incompetence means that the patient no longer has the right or responsibility to make the clinical decision. It must be made by a proxy.

Decision-making capacity is a clinical term. As such it is not at all a threshold concept but rather exists along a continuum from no decision-making capacity (comatose) to full capacity (confident, self-aware, bright, and decisive). Of course, most of us, especially if we are ill and in a strange institution like a hospital, fall somewhere in between the extremes of the spectrum. That is, our worry, pain, ambivalence, physiology (altered by disease or medication), and a myriad of other factors, make us less than ideal decision makers. The critical question is: when along that continuum should our right and responsibility to make the decision be honored or taken away and given to someone else? The answer (in today’s United States) is: you can make your own decision if you are competent; someone else will make it if you are incompetent. (Or, you can’t agree to participate in research if you are not competent to give consent.)

Thus, except at the clinical extremes, competency determination is necessarily reductionistic. That is, wherever along the decision-making capacity continuum you make the threshold judgment about competency/incompetence, there will be patients judged competent with some impairment to their decision-making capacity and others judged incompetent who, nonetheless, have some decision-making capacity that remains.

Competence is, above all, a social construct to help society resolve situations where two valued moral principles, autonomy and beneficence, come into conflict. On one hand, we believe that individual citizens should make their own decisions (unless third parties are harmed). On the other hand, we want to help people and protect them from harm. We seem to have rejected an unbridled paternalism whereby patient autonomy can be trumped by the wiser or more powerful physician/researcher. Therefore, when a patient/research subject makes a decision that is harmful to him/herself, we have but two courses. First, to honor autonomy and let the person expose themselves to harm. Second, to declare the person incompetent, allowing someone else to make the decision (ideally in that person’s best interest). For a judgment of incompetence to be other than a camouflage...