Competence, Capacity, and Informed Consent: Beyond the Cognitive-Competence Model
- Competence, Capacity, and Informed Consent:Beyond the Cognitive-Competence Model
Seules les personnes compétentes peuvent fournir un consentement éclairé en matière de soins de santé. Les approches actuelles définissent essentiellement la compétence en termes cognitifs, omettant ainsi le fait que quelqu'un pourrait être compétent d'un point de vue cognitif sans pour autant avoir la capacité de fournir un consentement valide. Cette étude comporte une théorie plus solide de la compétence, qui comprend non seulement les paramètres cognitifs mais également les paramètres émotionnels et subjectifs. Par la suite, elle différencie la compétence de la capacité et elle indique le rô le utile que cette distinction peut jouer dans un contexte de soins continus et de longue durée. Elle démontre également la manière dont cette distinction concorde avec plusieurs décisions juridiques canadiennes récentes, et elle souligne l'utilité de celle-ci dans l'interprétation et l'application des lois provinciales pertinentes.
Only competent persons can give informed consent to health care. Current approaches define competence in essentially cognitive terms, thereby ignoring the fact that someone may be cognitively competent yet lack the capacity to give a valid consent. I outline a more robust theory of competence that includes not only cognitive but also emotional and valuational parameters. I then distinguish competence from capacity, and indicate the role this distinction can usefully play in the extended and continuing care setting. I also show how this distinction is consistent with several recent Canadian legal decisions, and outline its usefulness in interpreting and applying relevant provincial statutes.
capacité, compétence, consentement éclairé, valeurs, émotions
capacity, competence, informed consent, values, emotions, aging
Over the last 30 years, the doctrine of informed consent has become a cornerstone of health care delivery in the English-speaking world. It is generally accepted that – within very narrow limits that centre in public safety and the competing rights of third parties – patients have the right to accept or reject any treatment and any intervention, even if this means less-than-optimal care or death. It is also accepted that unless there are reasonable indications to the contrary, patients must be presumed to be competent, that they will exercise the right to informed consent in their own person, and that in the case of incompetent patients this right will be exercised for them by a duly empowered substitute decision-maker (Beauchamp & Childress, 2001; Downie & Caulfield, 1999; Engelhardt, 1986; Fremgen, 2002; Garrett, Baillie, & Garrett, 2001; Picard & Robertson, 1996; Stauch, Wheat, & Tingle, 1998; Veatch, 2003). Since lack of information limits the ability to choose, most jurisdictions have developed explicit guidelines about the amount and nature of the information that must be disclosed and the conceptual level at which it must be [End Page 295] pitched (Fremgen; Oates, 2000; Picard & Robertson; Stauch, Wheat, & Tingle).
Clearly, the notion of competence is fundamental to this doctrine. However, in its current form it assumes that competence can be defined in essentially cognitive terms that centre in the conceptual abilities of the individual. That is to say, it assumes that the central determinant in competence is the ability to understand the information that is given and to appreciate its implications. This view is well reflected in the professional literature (Chopra, Weiss, Stinnett, & Oslin, 2003; Earnst, Marson, & Harrell, 2000; Etchells et al., 1999; Grisso & Appelbaum, 1998; Moye, Karel, Azar, & Gurrera, 2004) and in the standard tools that are used to assess decision-making capacity (Folstein, Folstein, & McHugh, 1975; Grisso, Appelbaum, & Hill-Fotouhi, 1997). It is also integral to the law. So, for instance, the Alberta Personal Directives Act, which identifies decision-making competence in terms of capacity, defines capacity as "the ability to understand the information that is relevant to the making of a personal decision and the ability to appreciate the reasonably foreseeable consequences of the decision" (c. P), and Ontario's Mental Health Act defines an incompetent person as someone who lacks "the ability to understand the subject-matter in respect of which consent is requested and able to appreciate the consequences of giving or withholding consent" (c...
