Lesson 3 – Informed Consent, Substitute Decision-Making, and the Family Centered Approach

* It should be noted that a choice might properly require only low/ minimal competence, even though its expected risks exceed its expected benefits or it is more generally a high-risk treatment, because all other available alternatives have substantially worse risk/benefit ratios.

* Thus, according to the concept of competence endorsed here, a particular individual’s decision-making capacity at a given time may be sufficient for making a decision to refuse a diagnostic procedure when forgoing the procedure does not carry a significant risk, although it would not necessarily be sufficient for refusing a surgical procedure that would correct a life-threatening condition

* The greater the risk relative to other alternatives—where risk is a function of the severity of the expected harm and the probability of its occurrence—the greater the level of communication, understanding, and reasoning skills required for competence to make that decision.

* It is not always true, however, that if a person is competent to make one decision, then he or she is competent to make another decision so long as it involves equal risk.

* Even if the risk is the same, one decision may be more complex, and hence require a higher level of capacity for understanding options and reasoning about consequences.

* The evaluation of the patient’s decision-making will seek to assess how well the patient has understood the nature of the proposed treatment and any significant alternatives, the expected benefits and risks and the likelihood of each, the reason for the recommendation, and then whether the patient has made a choice that reasonably conforms to his or her underlying and enduring aims and values

* Two broad kinds of defect are then possible: first, “factual”