Tales Publicly Allowed: Competence, Capacity, and Religious Belief: What Should We Make of Someone Whose Beliefs Prevent Her from Accurately Understanding Her Medical Needs and Care? Should That Person Still Make Her Own Health Care Decisions? in Fact, She Probably Lacks Decision-Making Capacity. but That Does Not Mean She Is Not Competent

Article excerpt

Fear of power invisible, feigned by the mind, or imagined from tales publicly allowed, religion; not allowed, superstition. And when the power imagined is truly such as we imagine, true religion.

--Thomas Hobbes, Leviathan

In their classic text, Principles of Biomedical Ethics, Beauchamp and Childress describe a puzzling case:

   A man who generally exhibits normal behavior
   patterns is involuntarily committed to a mental institution
   as the result of bizarre self-destructive behavior
   (pulling out an eye and cutting off a hand).
   This behavior results from his unusual religious
   beliefs.... [H]is peculiar actions follow "reasonably"
   from his religious beliefs.... While analysis
   in terms of limited competence might at first appear
   plausible, such an analysis entails that persons
   with unorthodox or bizarre religious beliefs are less
   than competent, even if they reason clearly in light
   of their beliefs. (1)

Let's call the man in this case "Ray." Ray's case is puzzling because Beauchamp and Childress, like many other prominent bioethicists, want the concept of competence to do double duty: to pick out a certain set of rational decision-making capacities, and to serve the "gatekeeping" function of distinguishing persons who should be permitted to make their own treatment decisions from those whose decisions should be made by a surrogate. (2)

There is wide agreement that the relevant set of capacities includes at least the capacities (a) to understand one's diagnosis and crucial facts about one's treatment options, such as their risks and prognoses; (b) to appreciate how those facts apply to oneself; and (c) to reach and communicate a decision in light of that understanding, appreciation, and one's own values. In brief, the relevant capacities are those specific to the task of making a treatment decision. Although we sometimes speak of "global" capacity, in truth all capacity is task-specific--the specificity of the task can range from very broad to very narrow. We are sometimes inclined to call a person who is not capable of making everyday decisions like what (or whether) to eat "globally incapacitated," but as many commentators have pointed out, even a person who is incapable of leading any kind of independent life may yet be capable of performing many individual tasks. And conversely, a person who is capable of making most everyday choices may be incapable of performing a specific task like making a treatment decision. Furthermore, each of these capacities should be seen as an ideal, and we may vary how tightly we hold a patient to these ideals, depending on the situation and on what is at stake. For example, when very little is at stake in a patient's treatment decision, we may not require that the patient exhibit a very deep and probing capacity to understand the diagnosis and treatment options in order to be considered "capacitated" to make the decisions.

A person who passes the competence gatekeeper thereby has a certain status; he should be dealt with in a certain way. Here we may distinguish legal competence and moral competence. In both, the core idea is that a competent patient should be permitted to make his own decisions; neither his caregivers nor a surrogate should make decisions for him unless he wishes them to. The difference lies in whether he has this status as the result of a court's decision or as a matter of morality. I take it that commentators like Beauchamp and Childress are primarily concerned with competence as a moral status, and this will be my focus.

Beauchamp and Childress imply that people who have this status have it because they are capacitated in the way described above. In this, they exemplify the common view that capacity is both necessary and sufficient for having the status of a competent decision-maker. Indeed, "competence" and "capacity" are often used interchangeably. I will argue, however, that they differ in important ways. …