Mary and Jane

Both of the feature articles in this issue ask about how comprehension intersects with the rights and responsibilities of decision-makers. Both also begin with puzzling cases.

In the lead article, Adrienne Martin draws upon Tom Beauchamp and James Childress's work to give us "Ray," a man who mutilates himself because of his "unusual religious beliefs," and "Mary," who believes that God will make a statistically less successful treatment option successful for her. Martin asks whether Ray and Mary have the ability to make their own health care decisions-an ability usually called competence. In some ways they look competent: they are apparently able to reason clearly, for example. In other ways they seem to lack competence: their conclusions-indeed their premises-are at odds with a correct medical, scientific understanding of their medical problems and treatment. At least from a medical, scientific standpoint, they do not adequately understand their situation.

Martin's recommendation is that we distinguish competence from rational decision-making capacity. To possess a rational decision-making capacity, you have to understand your health problems and treatment options. Because Ray and Mary lack that understanding, they lack decision-making capacity-at least, they lack it in the context of the particular health care decisions at issue. But they do not necessarily lack competence, for other considerations may impel us to accord Ray and Mary the status of being able to make their own health care decisions. In effect, "the ability to make health care decisions" is twofold in Martin's analysis and cannot all be squished under the one heading of competence. There is the personal ability to understand the medical facts of the case, and there is the social status of deciding the outcome.

In the other feature article, Daniel Brudney launches his explorations with the case of Jane, whose chronic drinking has ruined her liver and put her in line for a transplant. According to a widely shared intuition, Jane should wait in line behind people who need liver transplants just as badly as she but who did not ruin their livers through their own behavior. Brudney disagrees. He runs through a variety of conceptions of justice to see how they accommodate this form of punishment (for that's what it amounts to, he argues), and concludes that it is acceptable only under a very limiting condition-namely, that she was fully aware of the consequences of her drinking and knew that it might create a state of affairs in which she would effectively deprive somebody else of a liver transplant.

A colleague of mine often notes that good ethics begins with good facts. Moral decisions that command respect do not, however, as Martin and Brudney both seek to show. Martin finds that a clear medical understanding of one's treatment and prognosis may not be necessary to claim competence, Brudney that a clear medical understanding of the consequences of one's behavior is often not necessary to lay claim to medical resources. Autonomy implies that agents aim at rational decision-making, but lacking that capacity is not grounds for being thrown out of the "Kingdom of Ends."