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Competency And Capacity, Drawing The Line Between Competency And Incompetence, Who Should Evaluate Competency?

The determination of competency is a critical one in a liberal democracy as it tries to balance the values of self-determination and the protection of innocents from harm. This determination becomes particularly important in elderly persons for whom chronic illness and mental disability both necessitate and frustrate decisions about medical treatment, about institutional placement, and, sometimes, about the quality of life itself. While there is no "Holy Grail" by which to judge competency (Roth et al.), careful consideration of this important social construct is necessary to maximize patient independence and well-being.

Although American society highly values freedom and autonomy, there are competing values. In the provision of health care, patient autonomy has been a relatively new arrival, coming of age in the rights movements of the 1960s and 1970s. More tried and true for health professionals are the principles of beneficence (to help) and nonmaleficence (to do no harm). Usually these old and new values do not come into conflict. Patients seek the care of physicians in order to relieve or prevent suffering. They voluntarily go to physicians because the latter are professionals with special technical knowledge and practical wisdom about the relief of suffering. In most instances patients exercise their autonomy by asking physicians for advice and then following it. (Youngner).

Sometimes, however, patients and their physicians do not agree about what is best for the patient. Physicians often deal with such conflicts by overriding patients' wishes directly, by force, or indirectly, by manipulation or deceit. This is paternalism; the physician acts unilaterally in what he or she perceives as the patient's best interest. Today paternalism has been, for the most part, rejected. The notion of competence, however, offers a way out of the impasse: in order to exercise freedom of choice and accept responsibility for that choice, a person must have the mental ability to do so. Although freedom of choice is valued, society wants to prevent harm to persons who are inherently unable to make choices.

Competency is one of five elements of the legal and moral doctrine of informed consent that governs the complicated exchange of information about treatment options and the decisions that result from it (Meisel et al.). The other elements are voluntariness, provision of adequate information, understanding, and the making and expression of an actual decision. Competency refers to mental and decision-making capacities inherent in the patient.

Competency is decision- and situation-specific. One person may be competent to make medical decisions but incompetent to handle finances; another may be competent to consent to a chest X-ray but incompetent to agree to complicated surgery. Competency can fluctuate over time. For example, a patient may become very confused when experiencing a high fever, but be quite clear when his or her temperature returns to normal (Appelbaum et al.). Some patients may be found globally incompetent—they lack the capacity to make any important decisions in their lives. In such cases a guardian of person must be appointed.

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