We appreciate Dr. MacLean's thoughtful comments regarding the complexity of competence assessment. We agree with him that the current trend toward limited guardianship is an important mechanism for protecting the rights of patients who lack capacity in some areas but retain it in others. We also strongly support his recommendation that health care providers offer counsel and support to patients who, like Mrs. Smith, face difficult decisions. However, we would note that indecision and inconsistency are not evidence of incapacity. Like many patients in her situation, Mrs. Smith may have experienced feelings of profound ambivalence and uncertainty. If so, her vacillation may actually be a powerful argument that in fact she did understand the consequences of her choice. In Lane v. Candura,1 the case that was the model for our survey scenario, the patient's indecision persisted even after the appeals court had upheld her right to refuse surgery. Ultimately, she changed her mind once more and competently consented to treatment. Although the law treats competence as a fact to be determined from the evidence, clinical situations are often fraught with ambiguities that do not yield such determinations easily. Dr. MacLean suggests that competency laws would better reflect these realities if the standard for competence included a patient's ability to make decisions; that is, to recognize, embrace, or make choices based on values. However, this broader standard might undermine, rather than protect, patient autonomy. It would give the state discretion to determine what constitutes a recognizable set of values and an acceptable application of those values. In essence, competence would be determined based on how well, in the view of others, a patient weighs information that she understands. But patients exercise autonomy precisely when they weigh facts to arrive at choices, and they lose autonomy precisely when they are prevented from making choices rooted in their own values, however inscrutable. Professor Drane's sliding scale, which becomes more stringent as the consequences of patient decisions become more serious, suffers from the same problem. By requiring rationality and consistency whenever there are serious consequences, Drane's scale provides, in his words, a means for “setting aside certain dangerous and harmful decisions.”2 In contrast, standards based solely on the concept of “understanding” promote autonomy by allowing patients to determine for themselves where their interests lie and by protecting their choices even when others think they are unfortunate.