Risk-related standards of competence: continuing the debate over risk-related standards of competence

This discussion paper addresses Ian Wilks' defence of the risk-related standard of competence that appears in Bioethics 11 . Wilks there argues that the puzzle posed by Mark Wicclair in Bioethics 5 against Dan Brock's argument in favour of a risk-related standard of competence — namely that Brock's argument allows for situations of asymmetrical competence — is not a genuine problem for a risk-related standard of competence. To show this, Wilks presents what he believes to be two examples of real situations in which asymmetrical competence arises.
I argue that insofar as Wilks equivocates two senses of competence in his examples — namely, competence to perform a task and competence in performing a task — Wilks is unable to illustrate the existence of real situations of asymmetrical competence. By examining the way in which Wilks equivocates two senses of competence in his examples, and by applying the results of this examination to the problem of patient competency within the medical field, I argue that not only does Wilks fail to show that situations of asymmetrical competence exist, but he is also unable to provide a foundation for understating how the risk-related standard of competence can strike a balance between an individual's autonomy and benevolent intervention.
I thus conclude that insofar as Wilks fails to answer the objections raised by Wicclair and others against the risk-related standard of competence, the risk-related standard of competence continues to be undermined by the problem of asymmetrical competence.     

Competence and Ability

It is nearly universally thought that the kind of decision‐making competence that gives one a strong prima facie right to make one's own medical decisions essentially involves having an ability (or abilities) of some sort, or having a certain level or degree of ability (or abilities). When put under philosophical scrutiny, however, this kind of theory does not hold up. I will argue that being competent does not essentially involve abilities, and I will propose and defend a theory of decision‐making competence according to which one is competent only if one possesses a certain kind of rationality in making treatment decisions.     

Ambiguities and Asymmetries in Consent and Refusal: Reply to Manson

John Harris claims that is it ‘palpable nonsense’ to suggest that ‘a child (or anyone) might competently consent to a treatment but not be competent to refuse it.’ In ‘Transitional Paternalism: How Shared Normative Powers Give Rise to the Asymmetry of Adolescent Consent and Refusal’ Neil Manson aims to explain away the apparent oddness of this asymmetry of consent and refusal, by appealing to the idea of shared normative powers, presenting joint bank accounts as an example. In this article, I will argue that Manson's account fails to explain away the oddness. Rather, I will argue that there are ambiguities to which Manson has not paid sufficient attention. In fact, as odd as it may sound, I argue that Manson actually agrees with Harris (at least in relation to the asymmetry of competence). He fails to recognize that he agrees with Harris because he is not careful enough to distinguish between different asymmetries, which I have labelled the asymmetries of choice, permissibility and competence.     

Relationship Between Competence for Transfection and for Transformation

Deoxyribonucleic acid (DNA) extracted from phage SPP1 is highly infectious on Bacillus subtilis competent cells; the efficiency of infection is 5 x 10(3) to 6 x 10(3) phage equivalents per plaque-forming unit. This DNA was used to study the relationship between competence for transfection and for transformation. The experiments were concerned with the frequency of infection and transformation in mutants exhibiting different levels of competence, the effect of periodate on competence for infection and for transformation, the competition between phage and bacterial DNA, the transformation of cells preinfected with phage DNA, and the infection of cells pretreated with bacterial DNA. The data show that B. subtilis cells competent for transformation are also competent for transfection and vice versa; transfection with phage DNA represents, therefore, a simple way to measure the total number of competent cells in a culture. The fraction of competent cells, determined by SPP1 DNA infection, varied from 10(-2) to 7 x 10(-2).     

On the Alleged Right to Participate in High‐Risk Research

Reigning regulatory frameworks for biomedical research impose on researchers and research ethics committees an obligation to protect research participants from risks that are unnecessary, disproportionate to potential research benefits, and non‐minimized. Where the research has no potential to produce results of direct benefit to the subjects and the subjects are unable to give consent, these requirements are strengthened by an additional condition, that risks should not exceed a certain minimal threshold. In this article, I address the question of whether there should be limits of permissible risks in non‐therapeutic research involving competent and healthy subjects. Some commentators argue that competent and informed individuals should have a right to participate even in extremely risky research and that research ethics committees should never reject studies because they are too dangerous. To use David Shaw's expression, competent volunteers should have ‘a right to participate in high‐risk research’. I argue that this idea is ill‐founded, as it does not take into account the social mission and complex collaborative nature of research practice as well as the inequity of power between researchers and subjects. Imposition of limits on permissible risks for healthy volunteers is justified by the need to protect research enterprise and the need to protect the weaker party, namely the subjects. Also, I suggest that the best way to set boundaries on research risks is to leave the judgment of risk acceptability to research ethics committees.     

Decisionmaking competence and risk

Mark Wicclair criticizes Allen Buchanan's and my claim that determining an appropriate level of competence (Wicclair substitutes "decisional capacity" for "competence", the import of which I note briefly below) for health care treatment decisionmaking involves balancing respecting a patient's self-determination and protecting his or her well-being. The most important implication of this balancing is that a standard of competence should vary in significant part with the effects for the patient's well-being of accepting his or her choice. Wicclair's criticisms take two main forms. First, he considers and rejects four of the positive reasons we offer in support of a risk-related standard. Second, in rejecting our fourth reason he argues that a risk-related standard leads to faulty competence determinations -- too high a standard in some cases and too low a standard in others. If he is correct, there are no positive reasons for adopting a risk-related standard and there are as well specific reasons not to adopt such a standard in order to avoid mistaken competence determinations. My response will address both sorts of criticisms in turn.     

Cell theory, specificity, and reproduction, 1837-1870

The cell is not only the structural, physiological, and developmental unit of life, but also the reproductive one. So far, however, this aspect of the cell has received little attention from historians and philosophers of biology. I will argue that cell theory had far-reaching consequences for how biologists conceptualized the reproductive relationships between germs and adult organisms. Cell theory, as formulated by Theodor Schwann in 1839, implied that this relationship was a specific and lawful one, that is, that germs of a certain kind, all else being equal, would produce adult organisms of the same kind, and vice versa. Questions of preformation and epigenesis took on a new meaning under this presupposition. The question then became one of whether cells could be considered as autonomous agents producing adult organisms of a given species, or whether they were the product of external, organizing forces and thus only a stage in the development of the whole organism. This question became an important issue for nineteenth-century biology. As I will demonstrate, it was the view of cells as autonomous agents which helped both Charles Darwin and Gregor Mendel to think of inheritance as a lawful process.     

Competency and Risk-relativity

In this paper I discuss the view that the appropriate concept of competence is a decision-relative one: that a person may be competent to make one decision but not another. The argument that I present is that neither of the two competing theories supporting the decision-relative approach, internalism and externalism, can provide a coherent explanation of why a person's competence should be thought to be relative to a particular decision. On the one hand, internalism, which regards competence as exhaustively a matter of the person's understanding, fails to identify the specific skills or content that would warrant linking a specific decision with competence, and thus cannot provide an account of decision-relative that parallels task-relative. On the other hand, externalism, which regards competence as a matter of the person's understanding in relation to external elements such as risk, cannot adequately defend why a person's competence to make a decision should 'track' the level of probable harm that results from the decision.     

On a naturalist theory of health: a critique

This paper examines the most influential naturalist theory of health, Christopher Boorse’s ‘biostatistical theory’ (BST). I argue that the BST is an unsuitable candidate for the rôle that Boorse has cast it to play, namely, to underpin medicine with a theoretical, value-free science of health and disease. Following the literature, I distinguish between “real” changes and “mere Cambridge changes” in terms of the difference between an individual’s intrinsic and relational properties and argue that the framework of the BST essentially implies a Cambridge-change criterion. The examination reveals that this implicit criterion commits the BST to the troubling view that an individual could go from being diseased to healthy, or vice versa, without any physiological change in that individual. Two problems follow: (1) the current framework of the BST is ill-equipped to formally embrace Cambridge changes and (2) it is theoretically dubious. The arguments advanced here are not limited to the BST; I suggest they extend to any naturalist claim to underpin medical practice with a value-free theory of health and disease defined in terms of an evolutionary view of biological fitness.     

Autolytic Activity and Its Association with the Development of Competence in Group H Streptococci

Seventeen strains of group H streptococci were tested for their ability to develop competence for genetic transformation, either spontaneously or with the addition of competence factor derived from strain Challis supernatant fluids, and for their ability to autolyze. Autolysis was measured as a decline in optical density after washed cells were placed in a buffer at pH 9. Kinetic experiments showed that, in strains Challis, SBE I/II, WE4, SR 30, and a strain (FW 227) cured of its bacteriophage, competence and the ability to autolyze occurred simultaneously. Since autolysis was observed only in (i) competent cells, (ii) cells that passed their peak of competence, and (iii) those cells that exhibit a potential for developing competence but never go on to transform (i.e., lysogenized Challis cells), it is concluded that, in the group H streptococci, autolytic events are associated with the competent state. Strains that transformed but did not autolyze were not found.     

A polyethnic London carnival as a contested cultural performance*

This article argues that the theoretical problem of the new racism thesis, as originally formulated in the 1980s, was the account of the discursive change it proposed and the role and significance of Powellism in this process. In offering a modification of the thesis I highlight the significance of the use of anecdotal accounts of the plight of ordinary English people in areas of black settlement as central to the re-articulation of racialized common sense in Powellism. I go on to argue that the particular discursive form of the racialized anecdote is one that is developed within Parliamentary debates from at least the mid-1950s onwards and that Enoch Powell is not the author but the elite beneficiary of this ideological work. I suggest that this Commons' sense informs and makes possible the success of the campaign for exclusion of black Commonwealth migrants prior to Powellism, and that Powell fashions his own elite/populist version of such narratives in 1968. Offering an account of racism as a discursive fiction, I argue that the anecdotal form of political racism in post-war Britain is a political and ideological response to the public prohibition on 'race' talk in public space. In offering a tentative theory of post-'race' signification which is consistent with empirical evidence, I argue that the 'moment' of re-articulation of racism in post-war politics is one consistent with the evacuated space of the prohibited notion of 'old' racism.     

Informed consent and nudging

In order to avoid patient abuse, under normal situations before performing a medical intervention on a patient, a physician must obtain informed consent from that patient, where to give genuine informed consent a patient must be competent, understand her condition, her options and their expected risks and benefits, and must expressly consent to one of those options. However, many patients refrain from the option that their physician believes to be best, and many physicians worry that their patients make irrational healthcare decisions, hindering their ability to provide efficient healthcare for their patients. Some philosophers have proposed a solution to this problem: they advocate that physicians nudge their patients to steer them towards their physician's preferred option. A nudge is any influence designed to predictably alter a person's behavior without limiting their options or giving them reasons to act. Proponents of nudging contend that nudges are consistent with obtaining informed consent. Here I argue that nudging is incompatible with genuine informed consent, as it violates a physician's obligation to tell their patients the truth, the whole truth, and nothing but the truth during adequate disclosure.     

Rational desires and the limitation of life-sustaining treatment

It is accepted that treatment of previously competent, now incompetent patients can be limited if that is what the patient would desire, if she were now competent. Expressed past preferences or an advance directive are often taken to constitute sufficient evidence of what a patient would now desire. I distinguish between desires and rational desires. I argue that for a desire to be an expression of a person's autonomy, it must be or satisfy that person's rational desires. A person rationally desires a course of action if that person desires it while being in possession of all available relevant facts, without committing relevant error of logic, and "vividly imagining" what its consequences would be like for her. I argue that some competent, expressed desires obstruct autonomy. I show that several psychological mechanisms operate to prevent a person rationally evaluating what future life in a disabled state would be like. Rational evaluation is difficult. However, treatment limitation, if it is to respect autonomy, must be in accord with a patient's rational desires, and not merely her expressed desires. I illustrate the implications of these arguments for the use of advance directives and for the treatment of competent patients.     

RESPECTING AUTONOMY WITHOUT DISCLOSING INFORMATION

There is widespread agreement that it would be both morally and legally wrong to treat a competent patient, or to carry out research with a competent participant, without the voluntary consent of that patient or research participant. Furthermore, in medical ethics it is generally taken that that consent must be informed. The most widely given reason for this has been that informed consent is needed to respect the patient's or research participant's autonomy. In this article I set out to challenge this claim by considering in detail each of the three most prominent ways in which ‘autonomy’ has been conceptualized in the medical ethics literature. I will argue that whilst these accounts support the claim that consent is needed if the treatment of competent patients, or research on competent individuals, is to respect their autonomy, they do not support the claim that informed consent is needed for this purpose.     

Great apes' risk-taking strategies in a decision making task

We investigate decision-making behaviour in all four non-human great ape species. Apes chose between a safe and a risky option across trials of varying expected values. All species chose the safe option more often with decreasing probability of success. While all species were risk-seeking, orangutans and chimpanzees chose the risky option more often than gorillas and bonobos. Hence all four species' preferences were ordered in a manner consistent with normative dictates of expected value, but varied predictably in their willingness to take risks.     

Biosynthesis of vitamin B2: diastereomeric reaction intermediates of archaeal and non-archaeal riboflavin synthases

The dismutation of 6,7-dimethyl-8-ribityllumazine catalyzed by riboflavin synthase affords riboflavin and 5-amino-6-ribitylamino-2,4(1H,3H)-pyrimidinedione. A pentacyclic adduct of two 6,7-dimethyl-8-ribityllumazines has been identified earlier as a catalytically competent reaction intermediate of the Escherichia coli enzyme. Acid quenching of reaction mixtures of riboflavin synthase of Methanococcus jannaschii, a paralog of 6,7-dimethyl-8-ribityllumazine synthase devoid of similarity with riboflavin synthases of eubacteria and eukaryotes, afforded a compound whose optical absorption and NMR spectra resemble that of the pentacyclic E. coli riboflavin synthase intermediate, whereas the circular dichroism spectra of the two compounds have similar envelopes but opposite signs. Each of the compounds could serve as a catalytically competent intermediate for the enzyme by which it was produced, but not vice versa. All available data indicate that the respective pentacyclic intermediates of the M. jannaschii and E. coli enzymes are diastereomers.     

Is gene therapy a form of eugenics?

If, as I believe, gene therapy is in principle ethically sound except for its possible connection with eugenics then there are two obvious ways of giving a simple and straightforward answer to a question such as this. The first is to say "yes it is, and so what?" The second is to say "no it isn't so we shouldn't worry". If we accept the first of the above definitions we might well be inclined to give the first of our two answers. If on the other hand, we accept the sort of gloss that Ruth Chadwick gives on Galton's account, "those who are genetically weak should simply be discouraged from reproducing", either by incentives or compulsory measures, we get a somewhat different flavour, and one which might incline a decent person who favours gene therapy towards the second answer.     

‘I cover myself in the blood of Jesus’: Born Again heritage making in Sierra Leone

This article concerns the risky terrain of heritage management in Sierra Leone and its navigation by devout Born Again Pentecostal Christians. It engages with the ever‐expanding Born Again movement and its narrative of rupture, on the one hand, and the increasingly visible heritage sector and its focus on cultural continuity, on the other. These positions appear irreconcilable: one experiences the past as a dangerous satanic realm, the other as a valuable resource. However, as this article explores, they frequently meet in the workplace as many heritage professionals are also Born Again believers. I am interested in this meeting‐point as demonic channels and godly practices converge. I argue that Freetown's Born Again heritage professionals do not succeed in their roles despite their religion, but because of it.     

Gene control of developmental competence in Aspergillus nidulans

Conidia of Aspergillus nidulans placed in liquid nutrient medium germinate to produce hyphae that grow for a day or more as undifferentiated colonies. After 20 hr of growth, but not before, such colonies become responsive to induction and develop conidia-bearing structures (conidiophores) after being placed onto the surface of media-saturated membrane filters. Thus the time at which these colonies become developmentally competent is 20 hr. A mutant has been isolated which is indistinguishable from the wild-type strain except that it becomes competent to be induced 2 hr before the wild-type strain. At least one gene controlling competence has been characterized as a chromosomal allele. We have therefore been able to measure the time at which a growing colony becomes developmentally competent, and have shown that competence is under genetic control.