Three Kinds of Decision-Making Capacity for Refusing Medical Interventions

Abstract

According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient <i>refusals</i> can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account-what we call <i>comparative</i> DMC. We describe how patients may possess <i>burdens-based</i> DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or <i>goals-based</i> DMC for refusal if they have an overriding goal that is inconsistent with treatment. The <i>overridingness</i> of a patient's objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve.