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Competence, Consent and Complexity
  1. Ken Boyd

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Consent and competence are concepts central to medical ethics. When first heard of by medical or nursing students they may seem relatively clear and unambiguous in their requirements, and so, for many, even most everyday healthcare purposes, they are. But for medical ethics, like medicine itself, while ‘what ought to be done’ is often an instruction, it can also be a question, and not least when cases, circumstances, or conflicting judgements raise questions about consent or competence the implications of which are far from clear or unambiguous. Two areas in which such questions may arise, psychiatry and identity-changing medical interventions, provide the contexts in which some quite complex questions, about competence and consent respectively, are raised, and thoughtful answers are argued for, in this issue of the Journal of Medical Ethics.

Assessing whether a patient is or is not competent, has or lacks capacity to consent, is a familiar, but also weighty medical responsibility. Established medico-legal criteria commonly enable experienced clinicians to make such decisions with a clear professional conscience: but particularly in relation to chronic mental illness, for example anorexia nervosa or obsessive-compulsive disorder (OCD), matters may be less clear and deciding may be more difficult. Writing in this issue of the Journal, and taking OCD as an example, Guy Widdershoven, Andrea Ruissen, Anton van Balkom and Gerben Meynen (see page 374) examine three different approaches to assessing competence in such complex psychiatric circumstances: (1) the most familiar ‘cognitive’ approach, which ‘focuses on the ability to express a choice, to reason about treatment options, to appreciate a situation and its consequences and to understand …

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