Medicine, Health Care and Philosophy

, Volume 4, Issue 2, pp 127–138 | Cite as

Patient decision making competence: Outlines of a conceptual analysis

  • Jos V. M. Welie
  • Sander P. K. Welie


In order to protect patients against medical paternalism, patients have been granted the right to respect of their autonomy. This right is operationalized first and foremost through the phenomenon of informed consent. If the patient withholds consent, medical treatment, including life-saving treatment, may not be provided. However, there is one proviso: The patient must be competent to realize his autonomy and reach a decision about his own care that reflects that autonomy. Since one of the most important patient rights hinges on the patient's competence, it is crucially important that patient decision making incompetence is clearly defined and can be diagnosed with the greatest possible degree of sensitivity and, even more important, specificity. Unfortunately, the reality is quite different. There is little consensus in the scientific literature and even less among clinicians and in the law as to what competence exactly means, let alone how it can be diagnosed reliably. And yet, patients are deemed incompetent on a daily basis, losing the right to respect of their autonomy. In this article, we set out to fill that hiatus by beginning at the very beginning, the literal meaning of the term competence. We suggest a generic definition of competence and derive four necessary conditions of competence. We then transpose this definition to the health care context and discuss patient decision making competence.

autonomy competence decision making incompetence patient rights 


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  1. Appelbaum, P.S. and T. Grisso: 1988, ‘Assessing Patients' Capacities to Consent to Treatment’, N. Engl. J. Med. 319 (25), 1635–1638.PubMedCrossRefGoogle Scholar
  2. Appelbaum, P.S. and L.H. Roth: 1981, ‘Clinical Issues in the Assessment of Competency’, Am. J. Psychiatry 138 (11), 1462–1467.PubMedGoogle Scholar
  3. Appelbaum, P.S. and L.H. Roth: 1982, ‘Competency to Consent to Research: A Psychiatric Overview’, Arch. Gen. Psychiatry 39 (8), 951–958.PubMedGoogle Scholar
  4. Beauchamp, T.L.: 1991, ‘Competence’, in: M.A.G. Cutter and E.E. Shelp (eds.), Competency: A Study of Informal Competency Determinations in Primary Care (Kluwer Academic, Boston), pp. 49–77.Google Scholar
  5. Buchanan, A. and D. Brock: 1990, Deciding for Others. The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press.Google Scholar
  6. Checkland, D. and M. Silberfeld: 1995, ‘Reflections on Segregating and Assessing Areas of Competence’, Theoretical Medicine 16, 375–388.PubMedCrossRefGoogle Scholar
  7. Culver, C.M. and B. Gert: 1990, ‘The Inadequacy of Incompetence’, Milbank Q. 68 (4), 619–643.PubMedGoogle Scholar
  8. Faden, R.R. and T.L. Beauchamp: 1986, A History and Theory of Informed Consent. New York: Oxford University Press.Google Scholar
  9. Gert, B. at al.: 1997, Bioethics: A Return to Fundamentals. New York/Oxford: Oxford University Press.Google Scholar
  10. Klippe, H.v.d.: 1990, ‘Wilsonbekwaamheid in de psychiatrie: zes benaderingen’, Maandblad Geestelijke Volksgezondheid 45, 123–138.Google Scholar
  11. Legemaate, J.: 1992, ‘Criteria voor wilsonbekwaamheid’, NJB 76 (6), 190–193.Google Scholar
  12. Maas, P.J.v.d. at al.: 1991, Medische beslissingen rond het levenseinde. Amsterdam: Sdu Uitgeverij.Google Scholar
  13. Marta, J.: 1998, ‘Whose Consent Is It Anyway? A Poststructuralist Framing of the Person in Medical Decision–Making’, Theor. Med. Bioeth. 19 (4), 353–370.PubMedCrossRefGoogle Scholar
  14. May, T.: 1998, ‘Assessing CompetencyWithout Judging Merit’, J. Clin. Ethics 9 (3), 247–257.PubMedGoogle Scholar
  15. Pellegrino, E.D. and D.C. Thomasma: 1988, For the Patient's Good: The Restoration of Beneficence in Health Care. New York/Oxford: Oxford University Press.Google Scholar
  16. Pepper–Smith, R. et al.: 1996, ‘Competency and Practical MJudgment’, Theor. Med. 17, 135–150.PubMedCrossRefGoogle Scholar
  17. Pomerantz, A.S. and A. de–Nesnera: 1991, ‘Informed Consent, Competency, and the Illusion of Rationality’, Gen. Hosp. Psychiatry 13, 138–142.PubMedCrossRefGoogle Scholar
  18. Roth, L.H. et al.: 1977, ‘Tests of Competency to Consent to Treatment’, Am. J. Psychiatry 134 (3), 279–284.PubMedGoogle Scholar
  19. Welie, J.V.M.: 1998, In the Face of Suffering. The Philosophical–Anthropological Foundations of Clinical Ethics. Omaha: Creighton University Press.Google Scholar
  20. Welie, J.V.M.: 1999, ‘Do You Have a Healthy Smile? Ugliness as a Medical Indication for Dental and Surgical Treatment’, Medicine Health Care and Philosophy 2 (2), 169–180.CrossRefGoogle Scholar
  21. Welie, S.P.K.: 2001, ‘Criteria for Patient Decision Making (In)competence: A Review of and Commentary on Some Empirical Approaches’, Medicine Health Care and Philosophy4 (2), 139–151.CrossRefGoogle Scholar

Copyright information

© Kluwer Academic Publishers 2001

Authors and Affiliations

  • Jos V. M. Welie
    • 1
  • Sander P. K. Welie
    • 2
  1. 1.Center for Health Policy and EthicsCreighton UniversityOmahaUSA
  2. 2.Department of Health Care Ethics and Philosophy (Uns 40)University of MaastrichtMaastrichtThe Netherlands

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