A Broader Notion of Competent Decision Making in Respect to What Is in the Best Interests of Patients Affected by Anorexia Floris Tomasini (bio) Keywords anorexia, autonomy, capacity, competence, refusal of treatment, suffering Simona Giordano (2010) claims that whether or not anorexics should be allowed to die should not primarily depend on their competence, but on the extent of whether the condition can be alleviated. This implies two outcomes. First, that if an anorexic has a reasonable chance of recovery, competent refusal of treatment can be overridden. Second, that if an anorexic has no realistic chance of recovery, patient refusal needs to be upheld—not, exclusively, on the basis of patient’s decision-making competence, but on the basis of their prolonged and unnecessary suffering. Giordano is right, in my view, to suggest that there are good moral grounds to uphold patient wishes to refuse life-saving treatment, when the condition is intractable or, in her words, practically ‘untreatable,’ so that there is no realistic end to their prolonged suffering. Although I agree with Giordano’s thesis, I believe she makes too much of a potential and controversial conceptual tension between competence and suffering and too little of how they may be complementary. Part of the problem with Giordano’s exposition of her case is that she leaves the concept of medical competence implicit. Competence is a composite term and can be subdivided into three further subcategories: capacity, information, and voluntariness. By far the most important conceptual subcategory in the composite meaning of competence is the capacity or ability for patient decision making in relation to their best interests. One reason why mental capacity is so important is that it involves the other two constitutive categories that make up competence. This can be demonstrated by the following syllogism that might plausibly demonstrate mental capacity of a patient to reach a competent decision. a. Understand and retain information relevant to the treatment decision. [End Page 155] b. Believe it. c. Weigh up the relative risks and benefits of the treatment. d. Arrive at a clear choice Clearly, a and b involve the ability to be ‘informed,’ stressing the importance of information and ones capacity to process it, while b (to some degree), c and d (to a greater degree) involve voluntariness. There may be three reasons why Giordano has underestimated the importance of competence and its potential conceptual complementarities to suffering. The first might have to do with an inadequate grasp of the composite meaning of the concept. That is to say, medical competence, most importantly, is about a patient's capacity or capability of understanding what is in their longer term interests. Whereas Giordano implies the importance of this in her article, through her inclusion of an example where the short-term interests of anorexic to refuse treatment maybe overridden, for the sake of their longer term interests (which they may later understand), she does not explicitly relate it to capacity as an aspect of competence. The second might have to do with a lack of understanding of the subtlety of the concept; that is, capacity of understanding must be distinguished from actual understanding. This makes the criterion more flexible and less open to the abuse of medical paternalism, where any shortfall of understanding by the patient to the received medical/therapeutic wisdom can be a reason to judge a patient to be incompetent. This is an important development, because if capacity is interpreted in the right spirit, it gives the patient more autonomy to disagree with medical opinion, as long as the patient can be judged to be able to reach some sort of rational conclusion from premises (e.g., see the case of Re C (Adult: Refusal of Treatment) [1994] All ER 819. pp. 819–25 [Kennedy and Grubb 2000]). In the case of anorexia this may, under certain circumstances, lead to a patient refusing treatment, if it can be demonstrated that they are able to reach a different conclusion based on different values. Third (and finally), Giordano seems to be operating with an overly divisive set of moral criteria, in which patient suffering as a further criteria might, controversially, be at odds with any finite judgment about...
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Mar 15, 2011
M Sutrop 
Open Access
