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.     

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.     

The debate over risk-related standards of competence

This discussion paper continues the debate over risk-related standards of mental competence which appears in Bioethics 5. Dan Brock there defends an approach to mental competence in patients which defines it as being relative to differing standards, more or less rigorous depending on the degree of risk involved in proposed treatments. But Mark Wicclair raises a problem for this approach: if significantly different levels of risk attach, respectively, to accepting and refusing the same treatment, then it is possible, on this account, for a patient to be considered competent to accept, but not refuse, the treatment, or vice versa. I argue that this puzzle does not constitute a genuine problem for a risk-related standard.
To this end I focus on the situation where, of two mutually exclusive options, one is riskier, but offering more pronounced benefit, while the other is safer, but offering less benefit. I argue for this proposition: it can take far less insight to know that the safe option is good than to know that the risky option is better. Now say one is actually informed enough to know that the safe option is good, but not enough to know whether the risky option is better; in such a case one is competent to say yes to that first option (the safe one), but not to say yes to the other. (I argue in passing that Pascal's Wager can be interpreted as having precisely this deliberative structure.)
I thus conclude that cases do indeed exist where one can be competent to say yes but not no, or vice versa; and that it is thus not an anomaly in the risk-related standard that it entails the existence of such cases.     

Risk-related standard inevitable in assessing competence

In a preceding article, Mark Wicclair suggested that where patient preferences clash with the doctor's recommendations, a minimal understanding of the task at hand, rather than the risks involved, should be the basis for standards of patient competence in decision-making (Bioethics 5(2):91-104, April 1991). Skene, Principal Law Reform Officer of the Victoria, Australia, Law Reform Commission, questions Wicclair's minimum standard from a legal standpoint, pointing out contradictions in the effects of such a standard. Skene concludes that legal protection and the education of both doctors and patients are the most suitable safeguards of patient autonomy.     

A response to Brock and Skene

Wicclair responds briefly to articles by Dan W. Brock, "Patient decision-making competence and risk," and Loane Skene, "Risk-related standard inevitable in assessing competence," in this issue of Bioethics. Brock and Skene were responding to Wicclair's essay, "Decision-making capacity and risk," also in this issue of Bioethics. Wicclair had critiqued the arguments of Brock and Allen Buchanan, published elsewhere, concerning standards of competence for health care treatment decision making.     

CONSCIENTIOUS OBJECTIONS IN PHARMACY PRACTICE IN GREAT BRITAIN

Pharmacists who refuse to provide certain services or treatment for reasons of conscience have been criticized for failing to fulfil their professional obligations. Currently, individual pharmacists in Great Britain can withhold services or treatment for moral or religious reasons, provided they refer the patient to an alternative source. The most high‐profile cases have concerned the refusal to supply emergency hormonal contraception, which will serve as an example in this article. I propose that the pharmacy profession's policy on conscientious objections should be altered slightly. Building on the work of Brock and Wicclair, I argue that conscientious refusals should be acceptable provided that the patient is informed of the service, the patient is redirected to an alternative source, the refusal does not cause an unreasonable burden to the patient, and the reasons for the refusal are based on the core values of the profession. Finally, I argue that a principled categorical refusal by an individual pharmacist is not morally permissible. I claim that, contrary to current practice, a pharmacist cannot legitimately claim universal exemption from providing a standard service, even if that service is available elsewhere.     

Reflections on determining competency

Psychiatrists are the health care professionals most frequently called upon to determine the competency of a patient to refuse treatment. The motives for determining competency vary in morally significant ways. This paper explores what I term 'the ideal motivational situation' for determining a patient's competency: a desire to respect the patient's autonomy, a desire to promote the patient's overall best interests, and a belief that when these two motives conflict the patient's autonomy should not be dismissed out of hand as a partial patient interest which is naturally outweighed by the totality of his or her interests. I claim that in a liberal, democratic society autonomy ought to trump best interests and be the sole criterion of patient competence. I conclude by offering an essentially aesthetic criterion for determining autonomy.     

An economic theory of patient decision-making

Patient autonomy, as exercised in the informed consent process, is a central concern in bioethics. The typical bioethicist's analysis of autonomy centers on decisional capacity--finding the line between autonomy and its absence. This approach leaves unexplored the structure of reasoning behind patient treatment decisions. To counter that approach, we present a microeconomic theory of patient decision-making regarding the acceptable level of medical treatment from the patient's perspective. We show that a rational patient's desired treatment level typically departs from the level yielding an absence of symptoms, the level we call ideal. This microeconomic theory demonstrates why patients have good reason not to pursue treatment to the point of absence of physical symptoms. We defend our view against possible objections that it is unrealistic and that it fails to adequately consider harm a patient may suffer by curtailing treatment. Our analysis is fruitful in various ways. It shows why decisions often considered unreasonable might be fully reasonable. It offers a theoretical account of how physician misinformation may adversely affect a patient's decision. It shows how billing costs influence patient decision-making. It indicates that health care professionals' beliefs about the 'unreasonable' attitudes of patients might often be wrong. It provides a better understanding of patient rationality that should help to ensure fuller information as well as increased respect for patient decision-making.     

Economic decision-making in morning/evening-type people as a function of time of day

Decision-making is affected by psychological factors like emotional state or cognitive control, which may also vary with circadian rhythmicity. Here, we tested the influence of chronotype (32 morning-type versus 32 evening-type) and time of day (9 a.m. versus 5 p.m.) on interpersonal decision-making as measured by the Ultimatum Game. Participants had to accept or reject different economic offers proposed by a virtual participant. Acceptance involved distribution of gains as proposed, whereas rejection resulted in no gain for either player. The results of the game showed a deviation from rational performance, as participants usually rejected the unfair offers. This behaviour was similar for both chronotype groups, and in both times of day. This result may reflect the robustness of decision-making strategies across standard circadian phases under ecological conditions. Furthermore, morning-types invested more time than evening-types to respond to high-uncertainty offers. This more cautious decision-making style of morning-types fits with our finding of higher proactive control as compared to evening-types when performing the AX-Continuous Performance Task. In line with the literature on personality traits, our results suggest that morning-types behave with more conscientiousness and less risk-taking than evening-type individuals.     

Blending clinical and technical skills at the bedside

The brave new world will find a richer blending of clinical and technical skill development as scenario-based simulation training emerges on the web. The benefits of competency assessment, standards-based education, and just-in-time decision-making support will help organizations serve the patient with greater skill. This is the bridge to crossing the quality chasm that exists today. And, it is the promise for a safer tomorrow.     

Comparative Risk Assessment Methods and Their Applicability to Dredged Material Management Decision-Making

This article reviews the status of comparative risk assessment within the context of environmental decision-making; evaluates its potential application as a decision-making framework for selecting alternative technologies for dredged material management; and makes recommendations for implementing such a framework. One of the most important points from this review for decision-making is that comparative risk assessment, however conducted, is an inherently subjective, value-laden process. There is some objection to this lack of total scientific objectivity (“hard version” of comparative risk assessment). However, the “hard versions” provide little help in suggesting a method that surmounts the psychology of choice in decision-making schemes. The application of comparative risk assessment in the decision-making process at dredged material management facilities will have an element of value and professional judgment in the process. The literature suggests that the best way to incorporate this subjectivity and still maintain a defensible comparative framework is to develop a method that is logically consistent and allows for uncertainty by comparing risks on the basis of more than one set of criteria, more than one set of categories, and more than one set of experts. It should incorporate a probabilistic approach where necessary and possible, based on management goals.     

COMPETENCE,PRACTICAL RATIONALITY AND WHAT A PATIENT VALUES

According to the principle of patient autonomy, patients have the right to be self‐determining in decisions about their own medical care, which includes the right to refuse treatment. However, a treatment refusal may legitimately be overridden in cases where the decision is judged to be incompetent. It has recently been proposed that in assessments of competence, attention should be paid to the evaluative judgments that guide patients' treatment decisions. In this paper I examine this claim in light of theories of practical rationality, focusing on the difficult case of an anorexic person who is judged to be competent and refuses treatment, thereby putting themselves at risk of serious harm. I argue that the standard criteria for competence assess whether a treatment decision satisfies the goals of practical decision‐making, and that this same criterion can be applied to a patient's decision‐guiding commitments. As a consequence I propose that a particular understanding of practical rationality offers a theoretical framework for justifying involuntary treatment in the anorexia case.     

Review of Potential Environmental and Health Risks of the Nanomaterial Graphene

Several future applications have been suggested for the nanomaterial graphene, and its production is increasing dramatically. This study is a review of risk-related information on graphene with the purpose of outlining potential environmental and health risks and guide future risk-related research. Available information is presented regarding emissions, environmental fate, and toxicity of graphene. The results from this study indicate that graphene could exert a considerable toxicity and that considerable emission of graphene from electronic devices and composites are possible in the future. It is also suggested that graphene is both persistent and hydrophobic. Although these results indicate that graphene may cause adverse environmental and health effects, the results foremost show that there are many risk-related knowledge gaps to be filled and that the emissions of graphene, the fate of graphene in the environment, and the toxicity of graphene should be further studied.     

Risk and relative social rank: positional concerns and risky shifts in probabilistic decision-making

Although research indicates that individuals generally favor certain prospects over those whose outcomes are more variable, risk-aversion does not characterize human decision-making across domains. Here, we use an evolutionary perspective to explore the role that concerns with relative position play on preferences for certain versus probabilistic outcomes. Our evolutionary-based hypothesis predicts that concern with relative position will lead to increased risk when (1) the higher variance outcome offers the potential to render one better off than social competitors, but the lower variance outcome would not, (2) the choice is in a decision domain affecting one's ability to solve adaptive problems reliably present in human social life, and (3) the decision is being made about a gain rather than a loss. The current study (N=239) found support for these predictions, demonstrating that such positional concerns reverse the well-documented certainty effect in domains predicted in advance by the theory. Our findings highlight the important role played by social comparisons in individual decision-making and preferences for risk.     

Ergodicity-breaking reveals time optimal decision making in humans

Ergodicity describes an equivalence between the expectation value and the time average of observables. Applied to human behaviour, ergodic theories of decision-making reveal how individuals should tolerate risk in different environments. To optimize wealth over time, agents should adapt their utility function according to the dynamical setting they face. Linear utility is optimal for additive dynamics, whereas logarithmic utility is optimal for multiplicative dynamics. Whether humans approximate time optimal behavior across different dynamics is unknown. Here we compare the effects of additive versus multiplicative gamble dynamics on risky choice. We show that utility functions are modulated by gamble dynamics in ways not explained by prevailing decision theories. Instead, as predicted by time optimality, risk aversion increases under multiplicative dynamics, distributing close to the values that maximize the time average growth of in-game wealth. We suggest that our findings motivate a need for explicitly grounding theories of decision-making on ergodic considerations.     

Dementia and legal competency

The legal competency or capability to exercise rights is level of judgment and decision-making ability needed to manage one's own affairs and to sign official documents. With some exceptions, the person entitles this right in age of majority. It is acquired without legal procedures, however the annulment of legal capacity requires a juristic process. This resolution may not be final and could be revoked thorough the procedure of reverting legal capacity - fully or partially. Given the increasing number of persons with dementia, they are often subjects of legal expertise concerning their legal capacity. On the other part, emphasis on the civil rights of mentally ill also demands their maximal protection. Therefore such distinctive issue is approached with particular attention. The approach in determination of legal competency is more focused on gradation of it's particular aspects instead of existing dual concept: legally capable - legally incapable. The main assumption represents how person with dementia is legally capable and should enjoy all the rights, privileges and obligations as other citizens do. The aspects of legal competency for which person with dementia is going to be deprived, due to protection of one's rights and interests, are determined in legal procedure and then passed over to the guardian decided by court. Partial annulment of legal competency is measure applied when there is even one existing aspect of preserved legal capability (pension disposition, salary or pension disposition, ability of concluding contract, making testament, concluding marriage, divorce, choosing whereabouts, independent living, right to vote, right to decide course of treatment ect.). This measure is most often in favour of the patient and rarely for protection of other persons and their interests. Physicians are expected to precisely describe early dementia symptoms which may influence assessment of specific aspects involved in legal capacity (memory loss, impaired task execution, language difficulties, loosing perception of time and space, changes in mood and behaviour, personality alterations, loss of interests and initiative). Towards more accurate determination of legal competency the psychometric tests are being used. The appliance of these tests must be guided with basic question during evaluation: "For what is or is not he/she capable?" In prediction of possible dementia development, the modern diagnostic procedures are used as help for potentially demented individuals in order to plan own affairs and by oneself determine future guardian. This ensures the maximal respect and protection of rights among persons with dementia in order to independently manage life one step ahead of progressive illness. Finally, it is to be distinguished medical concept of legal capacity which is universal and judicial concept which is restricted by rules of national legal system differing from country to country.     

Medicolegal considerations in the initiation and termination of resuscitation in Canada.

Medicolegal issues in cardiopulmonary resuscitation (CPR) and emergency cardiac care were considered in the United States by the National Conference on Cardiopulmonary Resuscitation in 1985. This paper discusses these issues in the Canadian context. Although there is little legislation or case precedent in Canada to guide providers of CPR in decision-making, there appears to be little risk of liability or prosecution for competently rendered care. Providers should be cautious in withholding or withdrawing resuscitative measures from incompetent patients when brain death has not occurred and cardiovascular unresponsiveness has not been demonstrated. However, resuscitation may be withheld when a competent patient refuses it or if there is another medically and legally valid reason to do so.     

Combining multiple quantitative and qualitative goals when assessing biomanufacturing strategies under uncertainty

This paper reports how financial and operational results from bioprocess simulations can be combined with other criteria pertinent to decision-making predictions to provide a more holistic approach to the evaluation of biomanufacturing alternatives. The classical additive weighting method, which is a multiattribute decision-making technique that can account for both the quantitative and qualitative parameters that ultimately need to be considered, is used. Its application is demonstrated through a case study that addresses whether start-up companies should invest in a stainless steel pilot plant or use disposable equipment for the production of early phase clinical trial material. The technique is extended to allow for uncertainty in parameters. An illustration of its use to compare alternatives based on cumulative frequency curves of the aggregate scores is provided. For cases where it is difficult to discriminate between the options, plots of risk versus reward are shown to be useful for identifying the best alternative based on the risk preference of the company's management.     

Incorporating uncertainty and social values in managing invasive alien species: a deliberative multi-criteria evaluation approach

The management of Invasive Alien Species (IAS) is stymied by complex social values and severe levels of uncertainty. However, these two challenges are often hidden in the conventional model of management by “value-free” analyses and probability-based estimates of risk. As a result, diverse social values and wide margins of error in risk assessment carry zero weights in the decision-making process, leaving IAS risk decisions to be made in the wake of political pressure and the crisis atmosphere of incursion. We propose to use a Deliberative Multi-Criteria Evaluation (DMCE) to incorporate multiple social values and profound uncertainty into decision-making processes. The DMCE process combines the advantages of conventional multi-criteria decision analysis methods with the benefits of stakeholder participation to provide an analytical structure to assess complex multi-dimensional objectives. It, therefore, offers an opportunity for diverse views to enter the decision-making process, and for the negotiation of consensus positions. The DMCE process can also function as a platform for risk communication in which scientists, stakeholders, and decision-makers can interact and discuss the uncertainty associated with biological invasions. We examine two case studies that demonstrate how DMCE provides scientific rigor and transparency in the decision-making process of invasion risk management. The first case regards pre-border priority ranking for potential invasive species and the second relates to selecting the most desirable policy option for managing a post-border invader.