• Ethics

We thank the commentators very much for their reaction to our article.1 We appreciate the theoretical issues they raised concerning the approaches to competence, as well as their discussion of the cases we have presented.

In some cases of mental illness, for example, in severe dementia or paranoid delusions, the line between competence and incompetence is not very difficult to draw. However, in clinical practice healthcare professionals may encounter cases where the line becomes less clear, and the criteria commonly used do not seem to cover the specific problems the patients encounter when deciding about their treatment. This appears to be particularly true for cases of chronic mental illness. Previously, Tan et al pointed at the limits of the cognitive model in patients with anorexia nervosa.2 In our study, we looked deeper into decision-making in obsessive-compulsive disorder (OCD) patients, in order to articulate the challenges, they face when deciding about treatment options. We suggest that in such cases neither the cognitive nor the emotions or values approach enable us to really grasp how competence may be challenged—and supported—in these patients. We propose a practical wisdom approach to competence as an alternative. In what follows, we respond to Crisp and Sullivan-Bissett's thoughtful comments in some detail.

Crisp3 defends a cognitive approach, emphasising that competence requires the ability to reason. In his interpretation of the case of Mary, he argues that her expression that she was ‘fed up’ with treatment can be …