Sample Ethics Paper on Decision-Making Competence and Autonomy

Decision-Making Competence and Respect for Patients Autonomy


            In western contemporary society, informed consent allows a competent patient to make an informed and voluntary decision about a treatment proposed by the healthcare provider. Healthcare providers are trained to respect patient autonomy as well as decision-making regarding particular treatment. However, autonomy is granted on procedural prerequisites only. A patient may be considered self-governing and competent enough to make decisions when they act freely with proper guidance and understanding to select the most appropriate treatment plan. This disposition does not require patients to hold substantive information about alternative forms of treatment. Therefore, competence among patients is not measured by how much information one possesses about alternative therapies. Medical professionals adopting an account of competence that includes incompetent treatment that patients autonomously make undermines the moral foundation of letting patients make decisions on the most appropriate form of treatment.

            According to the standard analysis of competence, a patient is considered competent enough to make decisions on the most appropriate form of treatment when one has the capacity to understand, make sufficient deliberations and reasoning, able to communicate the chosen decision, and possess a set of interests and concerns that are relevant to the choices they have made (Buchman & brock, 1989). Within this framework, three distinct conceptions are plausible; the first approach holds that a certain minimum degree of understanding and deliberating a patient’s medical needs I order to propose the most suitable treatment course. The second approach holds that competence is relative to the outcomes of the patient’s treatment choice. Culver and Clouser allude that a patient is considered competent when they can make rational decisions on the treatment choice. The third conception of competence posits that competence is relative to the risks attached to the decision made. This approach is commonly referred to as the risk-related conception of treatment. These approaches propose that decision-making ability that defines competence varies from situation to situation among patients. A competency assessment is considered vital only in circumstances where a client objects to the treatment course proposed by the healthcare provider.

Competence Vs. Autonomy

            A patient may be considered competent enough when they have minimal levels of decision-making ability. The degree of decision-making ability of patients is determined by how demanding the decision to be made is considered. If in one situation the choices are easy to make, then the threshold is set on low levels. However, if the decision being made is an intricate one, the standard bar is set high. The determination of how difficult choices are depending on the relevance of the considerations attached to each option. Currently, no account of significance is provided to accommodate all autonomous persons. Such complications are witnessed in instances where two patients are suffering from a similar condition have to make decisions about the most suitable treatment course for presenting conditions. In such a situation, both individuals are required to consider the success rate of the treatment courses provided as well as the conditions they may have to endure during therapy and after therapy. Many other factors affect the decision-making process including the family and environmental backgrounds, the risks involved i the treatment course, the outcomes of the chosen therapies, among other vital issues the healthcare provider and user might consider necessary.

 The same considerations apply in the conception of competence related to the outcomes of a decision made. For instance, the concern that competence refers to the ability to make rational decisions. No account is provided to accommodate all autonomous people in the decision-making process. Instead, the notion of what is considered prudent and not intelligent relies on several competing conceptions. For instance, it may be regarded as rational to refuse lifesaving therapy for one patient while it is irrational in another specific case. In this conception of competence, if a patient autonomously rejects a particular treatment, others may consider course unreasonable, but it remains the most logical thing for the patient. Regarding the account of competence begs questions on the competence levels of the patient to decide on the treatment course because they do not approve of the proposed therapy, which contradicts the conception of rationality. Now this will be considered as disrespect to the patient’s autonomy.

            The risk-related conception faces similar problems of discerning the competence levels of patients. Just like the concept of rationality, the risk related concept is obscure and controversial. As of now, there is no global consensus of what may be considered risky and not risky to everyone. The accounts of competence that assess the decision-making ability among patients take into consideration the risks involved that patients may autonomously reject. Therefore, a patient may be considered incompetent enough to make decisions on the most appropriate treatment course for presenting conditions because of autonomously accepting a different conception of risk and rejecting the involvement of the notion of competence. For instance, if a client is faced with a situation where they have to decide to accept or reject a lifesaving therapy. This situation exceptionally engages an individual in challenging the intellectual pursuits whose primary interest is in life. Although the proposed treatment could be lifesaving, it does not offer an immediate remedy to a presenting condition.

Moreover, the patient will rely on hospital care besides inhibiting the pursuit of intellectual development, which accords meaning to the patient’s life. In this situation, the patient may choose against the treatment. This decision may be informed by the belief that death will not take away anything of significance to their lives, but will relieve them from troubling and dependent entities. In this case, the decision of whether to undertake or not to undertake the treatment course may be considered less risk decision rather than a high-risk decision.

            On different grounds, a patient suffering from similar conditions and faces the same dilemma of going for or rejecting a lifesaving treatment course may opt for the treatment. The patient may consider the interests of the other patient i intellectual pursuit pretentious. The primary benefit of this particular client may be centered on living life and shallow relationships with society. Undergoing the treatment course proposed by healthcare professionals offers a chance to continue with life, although not at full capacity. However, the treatment may also fail as it is not guaranteed. Therefore, for this case, the decision of accepting or rejecting the proposed treatment is a high-risk choice. Additionally, the conception of competence is incompatible, as it does not account for what is risky to different patients, therefore, infringing on patients’ autonomy. Whenever the understanding of competence and notion of risks involved contradict the view of an autonomous patient, the independence and autonomy of the patient are undermined. 

            Different versions of the risk-related conceptions propose that high-risk decisions require higher decision-making ability than low-risk choices. This version recognizes the complexity in making some decisions in various instances and situations of different patients. The complexity of individual decisions depends on the factors considered important to specific choices. However, there is no universal guide of what is deemed to be acceptable for all autonomous individuals. Therefore, trying to adopt the concept of relevance that differs from that of an independent patient is likely to stir conflict in respect of patient’s autonomy. The proponents of the risk-related conception of competence determine competences based on the findings of evaluating a patient’s decision-making process. This places centrality to the criteria by which evaluation is performed. In an instance that the criteria used to determine a patient’s decision-making ability differs from the demands of an autonomous patient for adequate decision-making, the notion of competence undermines the respect for patient’s autonomy.

 This approach suggests that the conception of competence be based on the autonomous values and concerns of an individual patient whose decision-making ability is in question. This argument posits that evaluating the decision-making ability of a patient should take into account the features of the situation and the options one must take into account to make a competent decision depending on what the autonomous individual perceives essential. For instances from the case of administration of a lifesaving therapy, it is not necessary that a patient be able to make the complicated calculations on the implications of the proposed therapy. However, the most important factors are not in the discomfort of the treatment. To be able to make competent decisions, it is essential that clients understand the considerations that according to her autonomous values and concerns are relevant to the decision being made.

Criticism and Possible Objections

            Critics of the conception of competence as proposed by Buchanan and Brock argue that it is too demanding to be practically viable. The big question that emerges is could medical professionals have adequate prior knowledge of the patients’ values that are required of persons making competence evaluations. Because retrieving and accessing information of what patients’ value may be complicated, it is okay to conclude that in practice, healthcare providers should ensure that patients do not misunderstand the nature of proposed treatments for presenting cases. For providers who may not have adequate information about the clients they are working with, it may be necessary to make consultations with the families or support collaborates who may have adequate information on the individual’s autonomous values.

            While there are risks associated with seeking independent information from other patients besides the clients themselves such as intentionally providing wrongful information to gain access to assets and money, it is critical for healthcare providers to find the most trusted source to inform decisions after that. However, such extremes are necessary on exceptional cases rather than procedural rules. It is essential to recognize the patient’s autonomy as an essential value in healthcare, and such incidents do not provide a leeway for healthcare providers to undermine a patient’s autonomy in the presence of adequate information. Further criticism emerges if a patient’s competence is evaluated based on information provided by close relatives and friend on their autonomous values, a patient may be considered competent only if she acts and decides depending on the way others think things should be. This makes the patient’s competence dependent on the thoughts of others. The proposed remedy to approaching a patient’s competence is a hidden form of surrogate decision making compared to the account of competence that pays adequate respect for the patient’s autonomy.


            In light of the above considerations, decision-making competence should be addressed in terms of the autonomous values of individual patients whose competence is being evaluated. Despite presenting differing views of how competence should be perceived offers crucial practical insights. The prevailing methods of assessing patient’s competence to make decisions on treatment courses do not consider individual patient’s values, and concerns, which ought to be complemented along the lines demonstrated in the new developments


Buchanan, A.E. & D.W. Brock: 1989, Deciding For Others: The Ethics Of Surrogate Decision-Making. New York: Cambridge University Press.