Competence

Competence is a necessary condition before a physician can accept a patient's treatment consent or refusal. Competence confers decision-making authority on those who are competent, while disenfranchising those who are not (Beauchamp). A determination of patient competence promotes respect for self-determination as well as patient participation in healthcare and other decision making. In most nonemergency situations, those who are legally competent may consent to or refuse healthcare. A patient maintained for years on outpatient hemodialysis, for example, may be allowed to terminate hemodialysis, resulting in death, if the patient decides that he or she can no longer tolerate the stress of the procedure (Neu and Kjellstrand). And based upon religious reasons, a Jehovah's Witness may even refuse a blood transfusion that would otherwise save his or her life. In contrast, the consent or refusal of those who are legally incompetent or clinically incapacitated need not be respected. A psychotic woman who refuses to have a cardiac pacemaker inserted because she believes that others could then monitor and control her activities would not be permitted to refuse this lifesustaining surgical procedure. Competence is usually not a relevant issue in healthcare emergencies, when treatment delay would be substantially harmful to the patient.

Competence and autonomy are often conflated, although their meanings are quite distinguishable (Beauchamp). Competence allows a person to exercise his or her autonomy. One must be autonomous to be competent, yet competent persons may act nonautonomously when, for example, compelled to do so by another person. Further, an autonomous person may act incompetently (e.g., a professional negligent at work).

This entry considers some of the issues in defining, determining, and assessing competence, as well as some of the applications of competence to the field of mental healthcare.

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