Three concepts of patient competence

In the principles of informed consent we state that each person ought to be free to make his or her own decisions regarding his or her life and health — provided that he or she is mentally competent to do so. Here, the concept of competence plays a crucial role. Where one is competent our moral goal is to promote his or her freedom; if he or she is not, our priority must be to protect and help him or her. In this paper I discuss three different notions of patient competence. The first, rational competence, concerns the basic ability to make a decision. The second, performance competence, concerns one's ability to make decisions and perform skills in ways that measure up to certain external standards. The third, reflective competence, concerns one's ability to identify and critically to scrutinize one's own values — one's ability, that is, to formulate and to evaluate one's own internal standards of decision and action. This richer analysis of the concept of competence enables us to formulate more precisely the moral difficulties we face when competence is impaired.
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