In their article, Pickering, Newton-Howes, and Young argue that “a person who is considering or has already made a decision which appears seriously harmful to that person should in some case...

In their article “Three Kinds of Decision-Making Capacity for Refusing Medical Interventions,” Navin et al. (2022) argue that we should recognize two forms of decision-making capacity (DMC) besides...

Should the assessment of decision‐making capacity (DMC) be risk sensitive, that is, should the threshold for DMC vary with risk? The debate over this question is now nearly five decades old. To many, the idea that DMC assessments should be risk sensitive is intuitive and commonsense. To others, the idea is paternalistic or incoherent, or both; they argue that the riskiness of a given decision should increase the epistemic scrutiny in the evaluation of DMC, not increase the threshold for DMC. (...) We respond to the critics’ main concerns by providing a comprehensive account of how risk‐sensitive DMC is coherent, avoids paternalism, and best fulfills the epistemic goal of DMC evaluations. (shrink)

Pickeringet al’s paper argues that the capacity of the decision-maker is the sole consideration in whether a decision should stand, and that the risk of the decision should not be considered. This argument ignores the existence of the player who is of the view that a decision is not wise. This paper argues that patient autonomy is not the sole determinant of whether a person is able to make an unwise decision, particularly in healthcare where there are always others affected (...) by the patient decision. Rather than asserting that patients have an unfettered autonomous choice on clinical decisions this paper argues that these decisions should be looked at through the lens of quality in health care that has proposed four parameters to be balanced; the patient experience, wise use of resources, the effect on public health and the clinician experience. (shrink)

Physician-assisted death (PAD) of patients whose suffering does not stem from terminal conditions has become more prevalent during the last few decades. This paper is focused on decision-making competence for PAD, specifically in situations in which PAD is related solely to psychiatric illness. First, a theoretical analysis presents the premises for the argument that competence for physician-assisted death for psychiatric patients (PADPP) should be determined based on a higher threshold in comparison to the required competence for conventional medical interventions. Second, (...) the higher threshold for decision-making competence for PADPP is illustrated. Third, several real PADPP cases are critically discussed, as an illustration to decision-making competence evaluations that would not have met the higher standard. Finally, a short summary of practical suggestions regarding the assessment of decision-making competence for PADPP is presented. Psychiatrists are called to address the ethical, legal, societal and clinical challenges related to PADPP and should be prepared for its probable expansion. (shrink)

In 2016, this Journal published an article by Rob Lawlor1 on what we might call the acceptance-refusal asymmetry in competence requirements. This is the view that there can be cases in which a patient is sufficiently competent to accept a treatment, but not sufficiently competent to refuse it. Though the main purpose of Lawlor’s paper was to distinguish this asymmetry from various other asymmetries with which it has sometimes been confused,1 Lawlor also presented a brief case in favour of it. (...) Developing an earlier argument of Ian Wilks’,2 3 Lawlor argued that, when the risks associated with refusing a treatment are graver than those associated with accepting it, a higher level of competence may be required to refuse a treatment than to accept it. This claim could have important implications for the law, since determinations of competence often play a central role in determining the lawfulness of refusing or imposing a treatment. Indeed, the acceptance-refusal asymmetry in competence requirements, or something close to it, has played an important role in court judgments.2 However, Lawlor himself suggests that his conclusion will have practical implications only in a narrow range of cases.3 In this issue, Pickering, Giles Newton-Howes and Simon Walker respond to Lawlor’s piece.4 They deny that competence requirements should depend on the level of risk associated with a decision, and thus that there is any basis for the acceptance-refusal asymmetry in competence requirements. Part of the authors’ argument involves contesting the way in which Lawlor uses cases to support his view. In one case cited by Lawlor—and drawn from Wilks—we are invited to consider a whether …. (shrink)

In 2016, this Journal published an article by Rob Lawlor1 on what we might call the acceptance-refusal asymmetry in competence requirements. This is the view that there can be cases in which a patient is sufficiently competent to accept a treatment ( viz., to give consent to it), but not sufficiently competent to refuse it ( viz., to withhold consent to it). Though the main purpose of Lawlor’s paper was to distinguish this asymmetry from various other asymmetries with which it (...) has sometimes been confused,1 Lawlor also presented a brief case in favour of it. Developing an earlier argument of Ian Wilks’,2 3 Lawlor argued that, when the risks associated with refusing a treatment are graver than those associated with accepting it, a higher level of competence may be required to refuse a treatment than to accept it. This claim could have important implications for the law, since determinations of competence often play a central role in determining the lawfulness of refusing or imposing a treatment (eg, in England and Wales under the Mental Capacity Act 2005). Indeed, the acceptance-refusal asymmetry in competence requirements, or something close to it, has played an important role in court judgments.2 However, Lawlor himself suggests that his conclusion will have practical implications only in a narrow range of cases.3 In this issue, Pickering, Giles Newton-Howes and Simon Walker (henceforth ‘the authors’) respond to Lawlor’s piece.4 They deny that competence requirements should depend on the level of risk associated with a decision, and thus that there is any basis for the acceptance-refusal asymmetry in competence requirements. Part of the authors’ argument involves contesting the way in which Lawlor uses cases to support his view. In one case cited by Lawlor—and drawn from Wilks—we are invited to consider a whether …. (shrink)