In the 1991 article which initiated the debate over risk-related standards of competence in this Journal, I identified several problems associated with them.1 In a subsequent discussion article, Ian Wilks defended risk-related standards.2 He did not address some of my objections, including the following: (1) To attribute decision-making capacity to patients who satisfy only a weak standard may be inconsistent with the concept of decisionmaking capacity as the possession of various cognitive or mental abilities (e.g., a set of more or less coherent and stable values and goals; and a capacity to understand, communicate, reason, and deliberate).3 (2) When patients satisfy only a weak standard, their consent/assent may not warrant concluding that: (a) They have authorized providing or forgoing treatment. (b) They are (partially) responsible for the decision and its consequences. (c) Their decisions are generally reliable indicators of their best interests.4 (3) Proponents of a risk-related standard conflate two distinct questions: (a) Does a patient have decision-making capacity with respect to a particular choice or set of choices? (b) Is it justified to override the patient's decision for paternalistic Mark R. Wicclair (1991), `Patient Decision-Making Capacity and Risk', Bioethics 5, 1991: 91Â±104. 2 Ian Wilks (1997), `The
Bioethics – Wiley
Published: Apr 1, 1999
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