Abstract

The prevailing orthodoxy for competency assessment is to test for the presence of certain abilities. This article argues that the presence of certain abilities is not enough when a patient refuses a life-sustaining/lifesaving measure that promises to work and does not present obviously onerous burdens. In such cases, we need to know whether the patient has rendered a competent refusal of such measures. Whereas the former refers us to test for certain abilities, the latter refers us to assess the quality of one’s judgment. Although such a thesis has been entertained previously (for example, Freedman), I reformulate the argument by applying two well-accepted epistemological criteria for justified belief. I argue that a competent refusal of such measures requires that the judgment be based on reasons. This basing condition turns on (or kicks in) in what I refer to as high-stakes contexts—contexts in which the patient’s life will end by respecting the refusal, and, by not respecting it, the patient undergoes a lifesaving and minimally burdensome treatment.