Commentary on ‘Competence in chronic mental illness: the relevance of practical wisdom’

Abstract

As this interesting paper well brings out, the assessment of competence to make decisions can be especially difficult in cases of adult mental illness. The paper revolves around two such cases, both involving OCD. Jack realizes his symptoms are peculiar, but resists admission to a psychiatric unit because he prefers not changing his way of life. Later, deep brain stimulation is of some therapeutic benefit, but he is now considering discontinuing treatment. Mary decides to stop treatment based on antidepressants and CBT, and later, on the advice of her psychiatrist, becomes involved in childcare, which provides some health benefits.Au describes three approaches to competence -the cognitive approach (C), the emotions approach (E), and the values approach (V), and suggests that weaknesses in each can best be dealt with by combining all three in a fourth, the practical wisdom approach (P). I shall raise some questions internal to au's critique of the three rejected approaches, and express some doubts about the appropriateness of an Aristotelian model of competence. I shall conclude that the preferable model is a version of C.According to C, a person is competent if she can (i) express choice, (ii) reason, and (iii) appreciate her situation, the consequences of different decisions, and information relevant to her decision. Au rightly suggests that, according to C, Jack is competent to refuse both courses of treatment. But it is not so clear that au is right that C will pronounce Mary incompetent on the grounds that she gives no reasons for her decisions and does not adequately balance the considerations for and against the various courses of action open to her. First, as au. notes, Mary does justify her decision to stop her earlier treatment by saying she was 'fed up'. That sounds like a reason, as does the stress of the treatment to which she later refers. Second, it is not clear that she is sufficiently unaware of relevant facts for her decision to engage in childcare to count as C-incompetent. For example, Mary may hold a narrow view of what constitutes 'therapy', believing nevertheless that the childcare may alleviate some of the symptoms of her OCD.According to E, competence involves a 'positive contribution' from the emotions, something lacking in the case of Mr Spock. (This characterization of Spock could itself be questioned. In Star Trek into Darkness, for example, he sheds tears, and often he seems rather to be a rationalist seeking to repress his emotions rather than a creature of pure reason.) Au rightly points out that E will assess both Jack and Mary as competent throughout. She also correctly implies, when outlining her preferred position, P, that E is defective, in that it includes no role for the appropriateness of emotions. Imagine the case of a Spock who is purely rational except that his decisions are influenced by entirely unreasonable anger. It would be quite implausible to see these decisions as competent, and those of the purely rational Spock as incompetent. Indeed I myself