Hastings Center Report

In her interesting and suggestive article, "Tales Publicly Allowed: Competence, Capacity, and Religious Belief," Adrienne Martin begins with a case that Tom Beauchamp and I discuss in Principles of Biomedical Ethics. The case involves a person she calls "Ray," who generally acts normally but who has been "involuntarily committed to a mental institution as the result of bizarre self-destructive behavior (pulling out an eye and cutting off a hand) [because of ] his unusual religious beliefs." Martin argues toward two conclusions: "that capacity and competence come apart, and that there may in some circumstances be reasons to allow an incapacitated person to make her own treatment decisions," including, but not limited to, religiously based decisions.

Martin raises important questions about capacity and competence and how to view and treat religiously based beliefs and practices in health care. Her arguments merit close attention; ultimately, though, I find them unconvincing.

Her second conclusion involves an argument that some religiously based decisions are "incapacitated," but that our sociocultural respect for religious beliefs and practices leads many bioethicists to view decision-makers as both capacitated and competent to make their own decisions. Martin's otherwise valuable contribution to this important topic is marred by unnecessary and unwise conceptual gymnastics and by serious misinterpretations both of Principles of Biomedical Ethics and of the broader bioethical discussion.

Martin insists on a sharp distinction between capacity and competence, the former having to do with rational capabilities and the latter with moral status as a decision-maker. She writes that "Beauchamp and Childress exemplify the common view that capacity is both necessary and sufficient for having the status of a competent decision-maker." While capacity and competence are closely intertwined in our analysis, we do not hold that capacity is necessary and sufficient for competence in her sense of the term. There may be reasons for allowing a person of diminished capacity to make decisions in some cases and for not allowing a person with full capacity to make decisions in other cases. If a person has the specific capacity to make a decision, then according to our conception, that person is competent to make that decision. However, such a person does not have an absolute right to make that decision, and others do not have an absolute duty to respect that decision. Such a right or a duty is, at most, only prima facie. For instance, a person's right to decide may be legitimately overridden in order to prevent some, but not all, harms, costs, and burdens to others.

Martin also misstates the way Beauchamp and I approach religious beliefs and practices in the context of health care. Martin claims that Beauchamp and I, like many others, fall into a "trap": We want to respect religious beliefs and practices, particularly by nonintervention or noninterference, and in order to do so, we hold that religiously based decisions must be "capacitated" (her term).

That is a trap, but we don't fall into it. In my judgment—and I do not claim to speak for Tom Beauchamp on this point—even though a policy that automatically treats persons with unorthodox or bizarre religious beliefs as less than competent is indefensible, some people with those beliefs are indeed incompetent in certain cases, and Ray may be one. If so, then weak paternalistic interventions (based on Ray's limited capacity and his risk of harm) would be warranted. But even if we reach a different conclusion about his capacity, we should not rule out the possibility of a strong paternalistic justification for intervention. (Indeed, later in Principles of Biomedical Ethics, we discuss a very similar case and indicate that a strong paternalistic intervention can be justified in that case, even though it violates a substantial autonomy interest because it conflicts with the religious views "central to the patient's life plan.") Furthermore, when a person is seriously maiming himself, as in this case, forcible intervention is warranted because of the heavy burden and costs such injuries impose on others.

The central point is just this: if a policy implies that those who have unorthodox or bizarre religious beliefs are less...