Introduction
In this paper, the article presents and evaluates the concept of decisional competence as advanced by Alan Buchanan and Daniel Brock. The paper argues that decisional competence is a valid view that is critical to understanding people, especially patients in healthcare settings where autonomy and wellbeing are promoted and protected. In its presentation, the paper explains the core elements of the competence view advanced by the two authors and their reasoning for these views. In its second part, the presents a rival perspective and argues in favor of the decisional competence as suggested by Buchanan and Brock. In the last section, the article offers an objection that a person with a different perspective may hold and corresponding response to the perspective.
Core elements of Decisional Competence
Alan Buchanan and Daniel Brock suggest that competence in decision-making is determined by one’s ability to perform a certain task at a specific time under specified conditions. Imperatively, they posit that competence is the capacity to make decisions but such capacity cannot be complete without the existence of certain conditions. Buchanan and Brock state that one can have the ability to make decisions at particular time but lack the capacity at other moments (Buchanan & Brock, 1989). A competent person possesses linguistic, conceptual and cognitive abilities and can communicate. The authors also suggest that a competent person has a stable and consistent conception of good practices and can weigh the different priorities. The authors also argue that while abilities which contribute to one’s capacity may vary, people should be judged to be one side of the line or the other based on if they are considered as capable of deciding for themselves or requiring their decisions to be made by surrogates. Imperatively, competence is a threshold idea and not a comparative concept since decision-making ability, skills and capacities are essential in analyzing the requirements for informed consent in life situations.
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Secondly, Buchanan and Brock posit that competence is based on standards or values that justify the emphasis on decision-making capacity by individuals. These two values include the promotion of one’s wellbeing (beneficence) and respect for their self-determination (independence or autonomy (Buchanan & Brock, 1989). Thirdly, the authors emphasize that competence is a value choice and not based on scientific determination. However, a decision can be a better or worse choice based on whether one reflects on the values at stake, has a clear understanding of their desired goal in determining competence and can predict the effects of having the threshold at higher or lower degree. They suggest that decisions should be made at higher level since the risk increases as the expected harm may be great and contain higher probability. Buchanan and Brock recommends a decision-relative competence standard instead of a fixed minimal capacity (p.377). They offer reasons for their preference and perspective. They argue that it reflects the manner in which people make judgments of competence in different areas of life, it is enhanced by practical demands of the informed consent doctrine or principle, and it concurs with the basic legal framework. Further, it reduces incompetence judgments in certain situations as opposed to making them global, and finally, it enables people to have better balancing of the two primary values of wellbeing and self-determination.
Rival View or Perspective
While the decision-making competence presented by Buchanan and Brock is laudable, Jukka Varelius offers a different perspective. Varelius argues that such conception undermines the moral ground of allowing autonomous persons, for instance, in healthcare settings, to make informed choices about their treatment (Varelius, 2011). Again, Govert den Hartogh argues that people must recognize the multi-dimensional aspect of having threshold conditions of competence (Den Hartogh, 2016). The implication is that people should reject both the threshold concept of competence and the distinction between what the author terms as hard and soft paternalism. Competence allows for levels and one’s competence should be marked instead of stating that they are not competence enough to make decisions regarding their life, especially in critical care in healthcare settings. While it is acknowledged that one is competent based on their abilities to understand and possess a set of values and concerns to their decisions and have the capacity to communicate their choice, those without one of these abilities should not be considered as incompetent to make decisions. Further, a person’s autonomy is abstract since decision-making abilities are influenced by those close to them and their environment.
Imperatively, the concept of competence advanced by Buchanan is not only demanding but also place the person at a vulnerable position (Den Hartogh, 2016). For instance, if a person’s competence is based on what those close to person believe as autonomous values, one may be considered as competent if they can make decisions in manners that others think they should. In such instances, the concept of decisional competence is self-defeating since it is apparent that surrogate decision-making process will prevail. As such, there will be no respect for one’s autonomy. Further, the concept is demanding since, for instance, how would healthcare providers acquire knowledge regarding patient’ values that they should have before making competent decisions? It should be noted that in healthcare settings, health providers understand that their patients do not misunderstand the kind of treatment that they propose to ensure that they are safe and not harmed (Varelius, 2011). It follows that such objections are not only valid but require a clear understanding of the decisional competence as proposed by Buchanan and Brock.
Analysis of the Original Argument
Buchanan and Brock argue that competence is the ability to make decisions irrespective of the hard situation that one may face. Competent persons have the capacity to communicate and express their opinions based on their value system that should be respected by all people (Buchanan & Brock, 1989). The implication is that Buchanan and Brock are not ignoring the fact that other conditions influence decisions but rather, the person must weigh the alternatives and choose the best outcome. It does not imply that those close to them cannot influence their decisions. However, it would be impractical to suggest that when one makes a decision after getting views from others, they are incompetent and do not have the capacity to make better choices. Buchanan and Brock emphasize that there are three critical attributes required for effective decision-making; understanding and communication, stable set of values, and logic and deliberation. For instance, logic and deliberation implore on one to understand the effects of their decisions and seek relevant views in regard to these consequences so that they can opt for the best choice.
Response to Objection
The above objection mirrors a narrowed way of evaluating what Buchanan and Brock presents. The authors state that competence faces hurdles and such hurdles can only be tackled when people possess values and adhere to them, particularly in healthcare settings where concepts like informed consent shape discussions between healthcare providers and patients and their families. When one argues that the decisional competence is too difficult to be practical, it demonstrates that people may not ascribe to values that allow them to make informed decisions or choices (Buchanan & Brock, 1989). However, practical situations demonstrate that people do not make decisions in a vacuum but are influenced by their abilities, skills, environment and views from those close to them. While the concept of competence may acquire a binary feature, it needs people to understand that it is a threshold concept that encourages observation of values, good practices, and overall ability of decision makers to have correct choices.
Conclusion
In this paper, I have argued that decisional competence is a valid perspective that allows one to understand how people make choices and the impact of these choices. The paper has evaluated and presented the core features of Buchanan and Brock concept of decisional competence and argued that decision-making tasks require an adequate understanding, better reasoning and enhanced communication for all stakeholders. The paper defends the original argument presented by Buchanan and Brock and objects rival positions presented by two different authors.
References
Buchanan, A., & Brock, D.W (1989) Deciding for Others: Competency. Pdf.
Den Hartogh, G. (2016) Do we need a threshold conception of competence? Medicine, Health
Care and Philosophy, vol. 19, pp.71-83. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805723/
Varelius, J. (2011) Decision-Making Competence and Respect for Patient Autonomy . Res
Cogitans , vol.1, No.8, pp.33-42.
