Appreciation and Emotion: Theoretical Reflections on the MacArthur Treatment Competence Study

Abstract

When emotions are mentioned in the literature on mental competence, it is generally because they are thought to influence competence negatively; that is, they are thought to impede or compromise the cognitive capacities that are taken to underlie competence. The purpose of the present discussion is to explore the possibility that emotions might play a more positive role in the determination of competence. Using the MacArthur Treatment Competence Study as an example, it is argued that appreciation, a central theoretical concept in many contemporary approaches to competence, has important emotive components that are seldom sufficiently recognized or acknowledged. If true, this means that some leading contemporary accounts of competence need to be revised in order to make more adequate provision for the positive contribution of emotion.

It is generally agreed that emotions can influence mental competence negatively. This occurs when they disrupt and impede the cognitive capacities that are held to underlie competence (see, e.g., Appelbaum and Roth 1982; Buchanan and Brock 1989, p. 56; Culver, Ferrell, and Green 1980; Elliott 1997; Bursztajn et al. 1991). But is this the only manner in which emotions affect mental competence? With few exceptions, the prevailing view appears to be that it is. ¹ However, a closer look at leading developments in contemporary emotion theory suggests otherwise.

In this paper, I will argue that, in addition to their negative role, emotions also have an important positive role to play in competence. This is partly because the “cognitive” capacities that are thought to underlie competence actually include emotion. The strategy is to argue that appreciation, a central theoretical concept in competence, requires emotion. The specific concept of appreciation I will examine is taken from the MacArthur Treatment Competence Study (Appelbaum and Grisso 1995; Grisso et al. 1995; Grisso and Appelbaum 1995). The reason for this choice is that the MacArthur study is one of the most thorough and sophisticated discussions of mental competence to date and its underlying theoretical assumptions are representative of much work in the area. For the purposes of this paper, competence will be defined as decision-making capacity and construed as a threshold concept (Buchanan and Brock 1989, pp. 18–20). In other words, either one is competent, or one is not. It is also possible to construe decision-making capacity as a matter of degree, but that will not be the sense in which I use the notion here. Finally, I also take competence to be decision-relative, meaning that “. . . a person may be competent to make a decision at a particular time, under certain circumstances, but incompetent to make another decision, or even the same decision, under different conditions” (Buchanan and Brock 1989, p. 18).

Before proceeding further, it is important to emphasize that the point of the present discussion is not to propose a specialized notion of “emotional competence” to replace or to compete with competence as it is understood traditionally. Rather, it is to motivate the case for the thesis that an adequate account of appreciation must take into account the positive contributing influence of emotion. Moreover, the point is not to argue that the MacArthur account of appreciation should be rejected. Instead, the idea is that its theoretical premises need to be extended to include emotion as a positive contributing factor in competence. Thus, the purpose of this investigation is to enrich the theoretical presuppositions of the MacArthur Study, not to dismiss them. Finally, the class of decisions under consideration are decisions to consent to or to refuse medical treatment, although the arguments proposed are also relevant to decisions to participate in clinical research. What makes emotion particularly relevant to these two classes of decisions is their fundamentally practical nature (Freedman 1981, p. 64). Whether emotion might be relevant to more theoretical decision-making tasks is something I will leave aside for now (but see, e.g., Simon 1967).

Understanding and Appreciation in the Macarthur Study

In the MacArthur study, competence is comprised of four elements: (1) understanding, (2) appreciation, (3) the ability to manipulate information rationally, and (4) the ability to communicate a choice...