Handout 3: Assessing Competence

You will realise by now that value judgements come into medical decisions. You will face situations where the right decision is unclear, you have to use your judgement and EBM won’t help you.

A 36 year old woman, married with 2 children, is admitted with Cushing’s syndrome. Tests show a pituitary adenoma with mass effect. She refuses to have surgery or radiotherapy

Competence is the ability to perform a specific act e.g. decide on a course of treatment. Capacity is a legal term for the same ability.

Your registrar asks you to find the screening tool that ‘decides if she’s competent for us’.

Is she just competent or incompetent? i.e. can patients be tested for competence, applicable to any situation?

Everyone agrees she is doing the wrong thing, including her family. Your consultant reckons that proves she can’t be competent.

What do you think about this? How can a competent person make such a decision? Would you even need to check her competence in this instance?

She may get a lot worse; do you need to prove beyond all reasonable doubt that she is incompetent?

The likely outcome is a worsening of her condition, not death. She wants time to think. A number of your colleagues think she is competent, others disagree.

What does a patient need to decide to make a competent decision?

You tell her about the proposed surgery, why it’s proposed and common side effects. She asks you about no treatment ‘What would happen?’ Don’t tell me about radiotherapy; I don’t want to know.’

Are most people competent? What sort of things might be interfering with her competence?

The husband says to you ‘ you have to show that she has demonstrated her competence. How can you assume that she can make these decisions? Call a lawyer to prove it.’

Is there anything you could do to aid the situation?

A psychiatrist thinks she might be fluctuating in and out of full alertness and is ‘moderately depressed’. She says she will stay in hospital but still doesn’t want the treatment. You want to do something but you can’t give her the definitive treatment.

For further information on Treating People without their Consent:

• the UK Clinical Ethics Network web site has a detailed discussion around these issues.
• Hope T, Savulescu J, and Hendrick J - Medical Ethics and Law : the Core Curriculum. Edinburgh: Churchill Livingstone, Elsevier Science, 2003. The main text book used for the University of Oxford Medical Ethics and Law course provides more details for both teachers and their students.
• Hope T - Medical Ethics; a Very Short Introduction. Oxford: Oxford University Press, 2004.
• Ashcroft A, Lucassen A, Parker M, Verkerk M, and Widdershoven G - Case Analysis in Clinical Ethics. Cambridge: Cambridge University Press, 2005.