Competence

1
Competence Capacity

• ISD II Psychiatry
• Nov. 12, 2002
• Ethics/Humanities/Health Law
• Andrew Latus
• Some material stolen from Daryl Pullman and Barb
  Barrowman

2
Objectives

• Define competence and capacity
• Discuss their ethical and legal significance
• Consider how they apply in hard cases

3
A Case of Apotemnophilia

• Apotemnophilia desire for amputation (p. 285)
• Mr. A., 65 years old, wants to have a healthy
  limb amputated
• I am not happy with my present body, but long
  for a peg-leg.

4
Two Questions

• Two questions
• Would it be wrong for a surgeon to perform the
  amputation?
• Would you perform the amputation?

5
Capacity vs. Competence

• These terms are sometimes used interchangably,
  yet supposedly theres a difference
• What is it?

6
Capacity

• The ability to understand information relevant
  to a treatment decision and to appreciate the
  reasonably foreseeable consequences of a decision
  or lack of a decision. (Bioethics for
  Clinicians)
• Really a definition of an adequate degree of
  capacity for medical decision making

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Capacity vs. Competence

• Capacity refers to an ability
• having capacity
• Capacity comes in degrees
• Competence refers to a property or characteristic
  a person possesses
• being competent
• Competence (relative to a particular decision) is
  all or nothing.

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Competence Competence Defined

• Capacity the degree to which one is able to
  understand the information relevant to a
  treatment decision and appreciate the reasonably
  foreseeable consequences of a decision or lack of
  a decision.
• Competence being able to understand information
  relevant to a treatment decision and to
  appreciate the reasonably foreseeable
  consequences of a decision or lack of a decision.
• Well just talk of capacity for remainder of
  class

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Capacity for what?

• Capacity is specific to a particular decision
• A person may possess the capacity to make some
  decisions but not others
• Capacity can change over time
• e.g. delirium, drugs, course of illness and
  treatment

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A Logical Point About Capacity

• If youre worried about a patients capacity to
  refuse some treatment, you should also worry
  about his capacity to accept it
• Worries about capacity sometimes go away when the
  patient comes to accept our recommendation for
  treatment.
• E.g., we worry about the patients ability to
  refuse treatment for chemotheraphy but not his
  ability to accept it
• This doesnt make sense with regard to capacity

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Why does capacity matter?

• Two kinds of reason
• Moral
• Legal

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Moral Reason 1 The Importance of Consent

• Capable patients are, by definition, able to give
  informed consent to treatment
• The importance of informed consent is supported
  both by
• The principle of autonomy respect for persons
  requires respecting their informed decisions
• The principles of beneficence/non-maleficence
  generally, an informed patients is a good judge
  of what broad sort of treatment is in his/her
  best interest

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Moral Reason 2 Beneficence Toward Incapable
Patients

• An assessment of capacity helps us figure out
  what matters morally
• In the case of an incapable patient, we no longer
  have recourse to the principle of autonomy.
• The principles of beneficence/non-maleficence
  require that incapable people be protected from
  making decisions that are harmful or that they
  would not make if capable

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Why does capacity matter legally?

• In law, capable patients entitled to make their
  own informed decisions
• If patient incapable, physician must obtain
  consent from designated substitute decision-maker
• Advance Health Care Directives Act (NL)
• Presumption of capacity for adults
• For minors, check provincial legislation on
  mature minors (NB), child welfare act, etc.

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Aids to Capacity Assessment

• General impression of capacity from clinical
  encounter
• Cognitive function testing, e.g., MMSE
• Specific capacity assessment tools, e.g., ACE

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Mini Mental State Exam (MMSE)

• Advantages
• Reliable
• Easy to administer
• Familiar
• Problem
• Although cognition and capacity related, they are
  not identical
• Does not evaluate several cognitive functions
  (e.g., judgment, reasoning) that are relevant to
  capacity
• Does not address delusions

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Aid to Capacity Evaluation (ACE)

• Clinician discloses information relevant to the
  treatment decision, then evaluates persons
  ability to understand this information and
  appreciate the consequences of his/her decision
• Developed at U of Ts Joint Centre for Bioethics
• Based on Ontarios Consent to Treatment Act
• Prompts clinicians to probe 7 relevant areas,
  provides sample questions and scoring

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Seven Areas to Consider

• Ability to understand medical problem
• Ability to understand proposed treatment
• Ability to understand alternatives (if any)
• Ability to understand option of refusing
  treatment
• Ability to appreciate reasonably foreseeable
  consequences of accepting proposed treatment
• Ability to appreciate reasonably foreseeable
  consequences of refusing proposed treatment
• Ability to make decision not substantially based
  on delusions or depression

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Some Strengths Weaknesses

• Strengths
• Clinically feasible, relatively quick
• Flexible
• Useful format for documentation
• Weaknesses
• Only as good as accompanying disclosure
• Difficulty of assessing impact of delusions or
  depression
• Factors may interfere with effective
  communication e.g. language barrier

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When to Consider Expert Assessment

• If unsure of assessment
• If patient (or family) challenges finding
• If clinician suspects that a decision is based
  substantially on delusions or depression

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Trying Out the A.C.E. Mr. G.

• Mr. G. (see Bioethics for Clinicians)
• 42 years old
• Receiving treatment for chronic schizophrenia.
• Unemployed but functions independently in the
  community.
• Rarely leaves his apartment
• Believes that his neighbours break into his house
  and steal his money when he is out,
• Physician makes house call because Mr. G. is
  complaining of a sore throat
• Throat swab reveals an infection.
• Physician recommends antibiotic therapy

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Assessing Mr. G

• Clinician explains that the pills are to treat
  the sore throat but may cause diarrhea or a rash.
  
• Asks Mr. G to review the information to ensure
• Mr. G "You're giving me these pills to help my
  throat. If I get diarrhea or any skin problems I
  should stop and let you know."
• Decision to accept treatment is not based on a
  delusion, but on a desire for symptom relief.
• Clinician concludes Mr. G. has the capacity to
  accept treatment

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Applying the A.C.E. to Mr. A

• Mr. A. has desired the peg-leg since at least age
  10 (p. 288)
• Unconsciously such a peg-leg became synonymous
  with happiness (288)
• the realization of my desire for a peg-leg has
  become indispensable for my personal
  happiness(288-9)
• Naturally over the years I have thought of many
  arguments against amputation, have considered
  them and rejected them... It is not normal. But
  what is normal and who is normal? (289)
• No one has the right to deny or keep me from
  this way of life. (289)

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A Final Thought About Capacity

• When it comes to treating religious beliefs as
  delusions the numbers seem to count
• Most seem to think that adult Jehovahs Witnesses
  have the capacity to refuse, on religious
  grounds, treatment involving blood transfusions
• What about singular or rare religious grounds?
• E.g., what if Barney the Dinosaur, my personal
  saviour, tells me to seek an amputation?
• Are we consistent in thinking about religious
  reasons?