Definitions

Generically, "competence" means simply the ability to perform a particular task (Beauchamp), although it has often been used loosely in several senses. In healthcare contexts, competence is the capacity to make autonomous healthcare decisions (Morreim). In most accounts of competence, competence is specific to the task or issue, since a person may be able to perform one task but not another. Few people are globally competent or incompetent. Since one's abilities change over time, in either direction, competence is also specific to time. Abilities may also be a function of the conditions or the situation in which they are tested or the person who tests them.

Competencies, of course, relate to all areas of function (Grisso). While competence to consent to healthcare or research is of primary concern in the present context, issues are often raised about a person's ability to work, manage personal finances, make a contract, write a will, live independently, drive a car, marry and divorce, parent a child, or testify in court. In legal contexts, competence questions arise in civil actions as well as in criminal litigation (competence to stand trial, commit a crime, enter a plea, or be sentenced) (Bonnie). Legal competencies implicate past decision making (e.g., competence to write a will), present decision making (e.g., competence to stand trial), or future decision making (e.g., competence to manage one's financial affairs).

A person's competence may be questioned in more than one area. In the case of a mother with cancer and a psychotic depressive disorder who is separated from her husband, for example, questions may arise about her capacity to parent her children, manage her finances, and consent to medical or psychiatric care. If she were employed, questions may arise about her ability to function at work if she failed to meet deadlines or otherwise fulfill her job duties due to a medical or psychiatric disorder. Her or her husband's attorney may question her ability to consult with her attorney and participate in the divorce litigation.

This contextualized, decision-specific notion of competence may be contrasted with a more generalized conception that reflects the general legal and moral autonomy enjoyed by most adults in contemporary Western cultures (Wear). Many more adults are considered competent under the general conception than the task-specific one; therefore, establishing that a person is incompetent is more difficult under the former than the latter.

"Incompetence" has come to mean the loss in court of a person's legal right to function in some particular area. Such a narrow legal definition of competence or incompetence contrasts with the more common clinical use of incompetence according to which a person has a legal right to function but is unable to do so. Clinical and legal competence may not correspond. An elderly, demented person, for example, may have the legal right to drive a car or make his or her own healthcare decisions but may no longer be substantially able to do so. Similarly, an adolescent may not be legally competent to consent to healthcare but may be clinically or functionally able to do so.

The increasingly prevalent view is that individuals have various specific abilities or capacities as well as incapacities, each along a continuum. A person is considered incapacitated when the person is no longer able to perform that specific function and incompetent when a court has so ruled. Legally, there is a presumption of competence, which may be overcome when the court is presented with adequate evidence of incapacitation. In the clinical literature, however, competence refers either to an individual's capacities (a descriptive definition) or to whether that individual's particular capacities are sufficient to render legal decision-making authority to him or her (a threshold definition).

Finally, although competence usually refers to a person's abilities, it may also refer to his or her actions or behavior (Beauchamp). For example, a person of general competence may autonomously choose to act incompetently in a given situation (e.g., intentionally fail an examination).

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