The Issue of Competence
The notion of competence becomes a troublesome concept as soon as we recognize that it comes with two quite different meanings, variably emphasized in the literature, and these two conceptualizations pull us in quite different directions.
On the one hand, competence is seen as a status concept. Both the law and the new ethos tend to instruct us that it should generally be presumed, and such generally unassessed status confers numerous privileges and rights on patients who are presumed to have it—for example, the right to informed consent and the right to refuse treatment. To presume competence in patients is thus protective of patient freedom and autonomy. This presumption also advances our concern for efficiency because it rejects the need to perform a detailed assessment of the average "alert and oriented" patient as to whether he is capable of performing, or has actually performed, the cognitive and participatory tasks already detailed. Finally, competence in the status sense is clearly an either-or sort of notion. Patients either have such status or they do not.
On the other hand, competence is also seen as an ability or capacity notion in that a competent patient is deemed to have sufficient ability or capacity to participate in medical decision making. This sense of competence, particularly given the reflections in chapter 3 on diminished competence and the barriers to it, is a spectrum concept. Competent patients fall within a wide range, from the marginally competent to those who are particularly informable, knowledgeable, and reflective about their situation and prospects. A capacity sense of competence thus tends to remain up for grabs however much we are instructed to presume competence in the usual patient, absent significant counterindications. This is so because the patient might still fail to have or exercise sufficient ability in any given instance of information acquisition or decision making.