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Deciding for Others - Competence (Week 7 - February 27)

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PHIL 2408
Vida Panitch

PHIL2408A February 27, 2014 Week 7 Deciding for Others: Competency – Dab Brock andAllan Buchanan Apatient who possesses the correct degree of decision making competence has the moral and legal right to consent to, or to refuse any and all treatment, even if this refusal may result in harm or even death. 1. What Conception of Competence: A. Standard View: Fixed Minimal Standard • Aperson is ‘globally’competent so long as she possesses relevant capacities at some universally specified level B. Alternative View: Decision-Relative • Competence is always relative to a particular decision. - Aperson is never “globally” competent or incompetent, but only at a particular time relative to a particular task • Various conditions can impede decision making on some matters more than others and for some persons more than others. - Ex.Apatient that has cancer and dementia might float in and out of lucidity and be recognized as incompetent one day but competent the next. How are they to be given the right to make their own decision regarding their cancer treatment? 2. Necessary Decision-making Capacities A. Understanding and Communication: linguistic, conceptual, cognitive abilities necessary for receiving, comprehending, appreciating, and providing information B. Reasoning and Deliberation: able to retain information, draw inferences, and evaluate, understand, communicate relative gains of potential outcomes appealing to values. C. Conception of the Good: able to appeal to and articulate a stable set of values in the process of decision-making, which serve as the basis of choice. 3. What Standard (Degree) of Competence A. Choosing a Standard - Look to Underlying Values • Well-being: what is best for the person (on either hedonic, subjective preference satisfaction, or objective good account) -- (utility) • Self-determination: deciding for oneself has both instrumental value (contributes to well-being) and intrinsic value (good for its own sake) -- (autonomy) • When they conflict: Should we let a person make bad (outcome) decisions out of respect for intrinsic value of self-determination?A high standard of competence protects WB at risk of SD, while a low standard does the reverse. B. Risk-Relative Standard of Competence • No single standard is appropriate: The level must be adjusted relative to the consequences of a decision. The greater the risk (the severity of the expected harms and their probability) the higher a person’s capacities for competence must be 1. Low/minimal: patient consents to minimally invasive but necessary treatment 2. Moderate/median: patient chooses risky but necessary procedure over alternatives at doctor’s recommendation 3. High/maximal: patient refuses minimally invasive but necessary life saving treatment End of life issues – 4 Cases 1. Determining Competence to Refuse Treatment Dax Cowart: As the result of an accident in the summer of 1973, 25 year-old Dax Cowart was badly burned over 65% of his body. Both eyes, both ears and both hands were damaged beyond repair. Large doses of narcotics were required for minimal pain relief; he was bathed in cleansing solutions daily with inadequate pain medication, and the changing of bandages caused him to scream in agony for several hours a day. He pleaded with his caregivers to be allowed to die, and also stated several times that he wanted to kill himself. He had given his mother power of attorney, so his physicians turned to her to obtain consent for all his treatments, even though Dax was determined by two psychiatric evaluation to have full decision-making capacity. His mother was religious and refused to give consent for the withdrawal of treatment. Dax was released from hospital after a year and began law school, but attempted suicide twice before admitting himself into psychiatric care. He has since finished law school, and practices personal injury law. He is happy, but still believes the doctors were wrong to ignore his pleas to die, and is a vocal advocate for the right to die movement. 2. Treatment refusal and non-competent patients Terri Schiavo: A27-year old resident of Florida suffered full cardiac arrest in 1990, and as a result of brain damage caused by oxygen deprivation entered a
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