On the Relationship between Competence and Welfare.

Abstract

Pickering, Newton-Howes, and Young (2022) argue for externalism about competence—the view that “welfare judgments are part of judgments about competence” and posit an “explanatory connection” between “decision-making processes and harmful choices” (38, 44). Here, we first attempt to clarify the target of analysis. We then argue that Pickering et al.’s proposal faces a dilemma: either it fails to vindicate externalism, or it collapses into a competing account that they are inclined to reject. For present purposes, we’ll follow Pickering et al. in distinguishing capacity from competence, where capacity is gradable and refers to the extent of a patient’s decision-making abilities (to understand, reason, etc.), while competence is binary and refers to whether a patient possesses sufficient capacity “for them to be able to make a decision” (39). This latter phrase, however, should not be interpreted literally. While there are patients who literally cannot make a decision (e.g. the unconscious), many incompetent patients retain the basic ability to make decisions—i.e. to form and express intentions or preferences concerning their care. The level of abilities required to make a decision is (at least in most cases) significantly lower than that required to make a competent decision. Thus, “to be able to make a decision” should be understood normatively: as roughly equivalent to saying a patient “should be allowed to make a decision.” Competence is thus a matter of having sufficient capacity to count as appropriately having authority over the choice at hand, and hence for one’s decision to determine which option should prevail. Pickering et al. are concerned with the longstanding debate between “internalist” and “externalist” approaches to competence. In a recent systematic review, Berens and Kim (2022, 7) characterize the difference as follows: