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Lecture 2

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Kelin Emmett

Allen E. Buchanan and Dan W. Brock: Standards of Competence • Article talks about the difficulty of the main standards and how it will be examined in order to clarify and defend the decision-relative analysis • There are 3 standards of competence: 1. Aminimal standard of competence  Patient is able to merely express a preference therefore it is not a criterion of competence  It fails to provide any protection for patient wellbeing and is an insensitive to the way the value of self-determination itself varies both with the nature of the decision to be made and with differences in peoples capacities to choose in accordance with their conceptions of their own good 2. An outcome standard of competence  Looks at what the content or the outcome of the decision is. Based on what other reasonable or rational person would chose therefore it is an incompetent choice even though it maximally protects patient’s well-being. The choice fails to adequately respect the patients self determination  This standard ignores the patient’s own distinctive conception of the good and may constitute enforcement of unjustified ideals and other peoples conception of what would be best for the patient  Therefore this standard judges competence by comparing the content of a patient’s decision to some objective standard for the correct decision may fail even to protect appropriately a patient’s well being 3. Aprocess standard of decision-making competence  Based on the process of the reasoning that lead up to the decision and not on the content.  Has 2 central questions: 1. How well must the patient understand and reason 2. How certain must the evaluation be that the person has met specified level of reasoning • Relation of the process standard of competence to expected harms and benefits  There is no single standard of competence. This is true because the degree of expected harm made at a given level of understanding can reason from none to the most serious as well as the value to the patient of self-discrimination can vary depending on the choice being made  Patient may be competent to agree to a treatment but may not be competent to refuse it  Have to look at the net balance of expected benefit  If the patients aims and values are not known, the risk assessment will be done so that the general goals of health care in prolonging life, preventing injury and disability and relieving suffering as against its risks of harm  As the level of competence required increases, the importance of respecting the patients self-determination increases on the assumption that the person will secure their good when they choose for themselves  The patients well-being should be evaluated according to their underlying and enduring aims therefore there is no use of an “objective” standard  When evaluating the patients decision, have to look at how well the patient has understood the nature of the proposed treatment and the possible alternatives, the expected benefits and risk, the reason why this treatment was chosen, and if fits with the persons own underlying aims and goals  Two defects can rise: 1. Factual misunderstanding  Did not understand the nature and likelihood of the outcome, which can be due to a stroke or limitations in cognitive understanding 2. Failure to make decision based patients underlying aims and values  Could be due to depression that has distorted their views and may not actually be what they want  Since there is no objective way to determine a person’s underlying and enduring
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