competent (for consent purposes): having the mental capacity to understand
information, to deliberate according to values, to weigh the consequences of
one's own decisions, and to communicate one's wishes; a legal determination.
CHOOSING A MEDICALLY UNSOUND COURSE OF ACTION:
THE SUBJECTIVE BEST INTEREST STANDARD
Choosing a medically unsound course of action that would lead to death does not
demonstrate incompetence. In Lane vs. Candura (Mass., 1978), the court found a
woman to be competent to refuse the amputation of her gangrenous leg even though
her train of thought sometimes wandered, her sense of time was distorted, and she
was confused on some matters. The court found that since the individual understood
the alternatives and the consequences of her decision, she was competent to make
her own health care decisions.
The law provides little guidance in defining competence for the purposes of consent,
although there are some basic criteria. (See above.) No state statutes define the
mental status required to consent to treatment, and there are few reported cases on
which to base outcomes. The few cases available indicate that the courts are reluctant
to deprive a patient the right to consent, to second-guess the patient's best interests, or
to judge the appropriateness of the reasons for a patient's decisions. There are two
standards for determining a patient's best interests: the objective and the subjective
standards. (See figure below.) Under the objective standard, it is the medically sound
course of action that is considered to be in the patient's best interests. Under the
subjective standard, allowance is made for the patient who might choose another
course of action. Choosing a medically unsound course of action may not be grounds
for adjudicating incompetence, provided that the patient understands the available
alternatives and their consequences.
PATIENT'S BEST INTEREST
If gangrene develops in the leg, it is in the patient's best interest to amputate the limb.
The patient considering amputation is a dancer who cannot imagine life without
It is not in the patient's best interest, as she sees it, to opt for amputation of the limb.
Figure 1-19. The consent laws allow for both an objective and
a subjective standard of the patient's best interests.