Lecture 4A - Autonomy, Competence, Consent

Question 1

Is competence assessed for specific decisions or all decisions?

Answer 1

Specific decisions.

Question 2

In the phrase “Competence is the ability to understand and to appreciate the consequences of treatment and non-treatment,” what does “understand” mean?

Answer 2

The ability to explain nature and consequences of treatment and non-treatment.

Question 3

What is the legal order of substitute decision makers?

Answer 3

1. Personal guardians
2. Representatives
3. Advanced directives
4. Temporary substitute decision makers

Question 4

What are the problems with the phrase: “Competence is the ability to understand and to appreciate the consequences of treatment and non-treatment.”

Answer 4

There is a concern that people won’t be taken seriously if they don’t personally really value their own choices. It’s too paternalistic. Often, people haven’t even thought about their own values. It leaves a potential for uncertainty.

Question 5

In BC, competent children can accept or refuse what kind of treatments?

Answer 5

Treatments that have been offered to them, and that the HCP believes are in the best interest of the minor.

Question 6

Competence

Answer 6

The capacity to make an autonomous decision.

Question 7

What does BC law use to test competence?

Answer 7

It appears to use an understanding test, but it can be interpreted as an understanding and appreciation test.

Question 8

What is the legal test to assess competence in practice?

Answer 8

Test if the patient can explain the information in their own words.

Question 9

Are competence laws in BC the same for children and adults?

Answer 9

No. Laws for children are more restrictive than laws for adults.

Question 10

Four elements of valid informed consent

Answer 10

1. Competence
2. Full disclosure of relevant information
3. Voluntariness
4. Consent

Question 11

What is a “personal guardian”?

Answer 11

A court appointed guardian under the Patient’s Property Act.

Question 12

What is the age of consent in BC that established legal competence to make medical decisions?

Answer 12

There is no definite “age of consent”. Competent children of any age have full adult medical decision-making powers (with some exceptions).

Question 13

In BC, what is the presumption regarding competence in children?

Answer 13

All children are presumed competent to make medical decisions.

Question 14

If a patient is incompetent, but competence can be restored in a timely way, who gets to decide?

Answer 14

First restore competence and let the patient decides.

Question 15

How do you begin the consent process?

Answer 15

By identifying the decision maker.

Question 16

How high should the standard for competence be?

Answer 16

It’s can’t be too high and it can’t be “perfectly rational.” It can’t be too demanding or the value of autonomy will be uninteresting.

Question 17

If a patient is incompetent, and competence cannot be restored in a timely way, who gets to decide?

Answer 17

Surrogate decides based on what the patient wants.

Question 18

What does “section 19” say in the Health Care and Care Facility Act?

Answer 18

In your best judgement, make the choice the patient would make.

Question 19

In the phrase “Competence is the ability to understand and to appreciate the consequences of treatment and non-treatment,” what does “appreciate” mean?

Answer 19

The ability to relate a decision to one’s own values.

Question 20

What does Ontario law use to test competence?

Answer 20

The understanding and appreciation test.

Question 21

What is an alternative (to the legal) test to assess competence in practice?

Answer 21

Use a sliding scale of evidence of competence - as the risk associated with the decision increases, evidence of competence must increase as well.

Question 22

In BC, what is the presumption regarding competence?

Answer 22

That all patients are competent unless found to be incompetent.

Question 23

How often does incompetent status need to be reviewed?

Answer 23

It needs to be continually reviewed.

Question 24

Is consent a single datable event, or an ongoing process?

Answer 24

It’s an ongoing process.

Question 25

Informed consent

Answer 25

An autonomous decision

Question 26

Is evident of competence direct or indirect.

Answer 26

Indirect.

Question 27

Weak paternalism requires a theory of ___ and ___ to respect patients’ dignity regarding decisions around their care and treatment.

Answer 27

Weak paternalism requires a theory of competence and informed consent to respect patients’ dignity regarding decisions around their care and treatment.

Question 28

Who decides if the patient is competent?

Answer 28

The patient decides.

Question 29

To what extent must HCPs and substitute decision makers consult and involve incompetent patients in decision-making?

Answer 29

To the greatest extent possible.

Question 30

What does an advance directive do?

Answer 30

It provides consent to or refusal of health care by the capable adult to a HCP.