Criteria for assessment of patient competence : a conceptual analysis from the legal, psychological and ethical perspectives Citation for published version (APA): Welie, S. P. K. (2008). Criteria for assessment of patient competence : a conceptual analysis from the legal, psychological and ethical perspectives. Universiteit Maastricht. https://doi.org/10.26481/dis.20080905sw Document status and date: Published: 01/01/2008 DOI: 10.26481/dis.20080905sw Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. People interested in the research are advised to contact the author for the final version of the publication, or visit the DOI to the publisher's website. • The final author version and the galley proof are versions of the publication after peer review. • The final published version features the final layout of the paper including the volume, issue and page numbers. Link to publication General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal. If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above, please follow below link for the End User Agreement: www.umlib.nl/taverne-license Take down policy If you believe that this document breaches copyright please contact us at: [email protected] providing details and we will investigate your claim. Download date: 29 Sep. 2021 voor Tristan, Isabelle, Frédérique & Emma Criteria for assessment of patient competence: a conceptual analysis from the legal, psychological and ethical perspectives copyright © Welie, S.P.K. 2008 Eijsden, Limburg (NL) ISBN: 978 90 9023128 0 NUR: 820 doctoral dissertation Universiteit Maastricht, The Netherlands keywords: health law, ethics, legal psychology, Dutch law, health care practice, human research, autonomy, beneficence, informed consent, decision-making, patient-provider relationship, professional standard, representation, patient competence, criteria, human information-processing, patient values, legitimate triggers for competence assessment, recognisable reasons, supportive situation cover images: sequence from “Suske en Wiske: de Sputterende Spuiter” (Vandersteen, 1977, p. 1-2) reproduced with kind permission of Standaard Uitgeverij, Antwerpen, Belgium printed by Fidlar Doubleday Inc. Davenport, Iowa (USA) CRITERIA FOR ASSESSMENT OF PATIENT COMPETENCE A Conceptual Analysis from the Legal, Psychological and Ethical Perspectives PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Maastricht, op gezag van de Rector Magnificus, Prof.mr. G.P.M.F. Mols volgens het besluit van het College van Decanen, in het openbaar te verdedigen op vrijdag 5 september 2008 om 12.00 uur door Sander Peter Karel Welie Promotores: Prof. mr. F.C.B. van Wijmen Prof. mr. J.C.J. Dute (Erasmus MC Rotterdam) Prof. dr. G.A.M. Widdershoven Beoordelingscommissie: Prof. dr. G.M.W.R. de Wert (voorzitter) Prof. dr. H.F.M. Crombag Prof. mr.dr. P.C. Ippel (Roosevelt Academy) Prof. mr.dr. J. Legemaate (Vrije Universiteit) Prof. dr. F.R.J. Verhey Het aan dit proefschrift ten grondslag liggende onderzoek is mede gefinancierd door de Nederlandse Organisatie voor Wetenschappelijk Onderzoek (NWO projectnummer: 41509116). PREFACE The research which resulted in the present dissertation, started with a project funded by the Netherlands Organisation for Scientific Research (NWO; project number: 41509116). It was carried out at the department of health law of the University of Maastricht, and the dissertation was completed at the department of health care ethics and philosophy of the same university, both of which departments have meanwhile merged into the department of metamedica (Faculty of Health, Medicine and Life Sciences). In the course of the re- search, former and present staff members, whose collegiality has been much appreciated, contributed in diverse manners to the process, not in the last place by providing pleasant company. Part of the research was performed within the BioMed I project “Decision Making and Impaired Capacity”. In that framework, the co-ordinating Centre for Philosophy and Health Care (University of Wales) warmly welcomed the author for four weeks as a visiting professor in Swansea, United Kingdom. The employees of a hospital ward for geriatric patients and a nursing home ward for psychogeriatric patients, where empirical research took place (cf. Chapter 3), are thanked for giving the author the opportunity to gain a perception of the way in which the concept of patient competence is dealt with -or, rather, does not play an important part- in daily health care practice. The Dutch National Foundation of Patient Advocates in Mental Health Care, the author’s current employer, kindly allowed a two-week study leave in order to make the manuscript ready for being printed. The author greatly acknowledges Standaard Uitgeverij for its permission to reproduce a sequence from “Suske en Wiske” on the cover. Lastly, Chapters 2 through 7 have been published previously in the fol- lowing journals and books (see below for bibliographic information). The author wishes to express his gratitude for the permission granted by the publishers of these journals and books to reprint these publications in this volume in slightly modified format and, in case of Chapter 6, English translation. Chapter 2: Welie, S. P. K., & Berghmans, R. L. P. (2006). Inclusion of patients with severe mental illness in clinical trials: Issues and recommendations surrounding informed consent. CNS Drugs, 20(1), 67-83. v vi WELIE • CRITERIA FOR ASSESSMENT OF PATIENT COMPETENCE Chapter 3: Welie, S. (2008). Patient incompetence in the practice of old age psychiatry: The significance of empirical research for the law. In G. Widdershoven, J. McMillan, T. Hope & L. v.d. Scheer (Eds.), Empirical Ethics in Psychiatry (pp. 231-247). Oxford/New York: Oxford University Press. Chapter 4: Welie, J. V. M., & Welie, S. P. K. (2001). Patient decision making competence: Outlines of a conceptual analysis. Medicine, Health Care and Philosophy, 4(2), 127-138. Chapter 5: Welie, S. P. K. (2001). Criteria for patient decision making (in)competence: A review of and commentary on some empirical approaches. Medicine, Health Care and Philosophy, 4(2), 139-151. Chapter 6: Welie, S. P. K. (2002). Wilsbekwaamheid in de gezondheids- zorg. In: P. J. van Koppen, D. J. Hessing, H. L. G. J. Merckel- bach & H. F. M. Crombag (Eds.), Het Recht van Binnen: psy- chologie van het recht (pp. 85-106). Deventer: Kluwer. Chapter 7: Welie, S. P. K., Dute, J., Nys, H., & Wijmen, F. C. B. van (2005). Patient incompetence and substitute decision-making: An analysis of the role of the health care professional in Dutch law. Health Policy, 73(1), 21-40. Maastricht, Sunday 29 June 2008 TABLE OF CONTENTS Preface .................................................... v Table of Contents...........................................vii 1. Overview ................................................1 S.P.K.Welie 1.1. Introduction .......................................1 1.1.1. Initial sketch of the subject matter .................1 1.1.2. Lack of clear, unambiguous criteria ...............1 1.1.3. Multi-disciplinary approach ..................... 2 1.1.4. Outline of this dissertation .......................4 1.1.5. Starting-points: task-specificity and legal consequences according to the Dutch Civil Code ...4 1.1.6. Research questions .............................5 1.1.7. Methods .....................................8 1.1.8. Central thesis .................................8 1.1.9. Focus on the care context (as distinct from the research context) .............................9 1.2. Structure of this overview ............................9 1.3. The background of two competing ethical principles ......10 1.3.1. Historical background .........................10 1.3.2. Beneficence ..................................11 1.3.3. Autonomy ...................................12 1.3.4. Informed consent .............................14 1.3.5. Relevance of patient competence as a function of the weight of autonomy ..........................14 1.3.6. Three stipulative definitions .....................15 1.3.7. Possible errors in competence assessment .........15 1.4. Legal framework...................................15 1.4.1. Legal regulations .............................15 1.4.2. Legal consequences of patient competence versus incompetence ...............................16 1.4.3. The odd exception of the (Dutch) Special Admissions into Psychiatric Hospitals Act ........17 1.5. Various criteria for assessment of patient competence .....18 1.5.1. Statutory definition of patient competence .........18 1.5.2. Three kinds of standards discussed in the literature. .18 1.6.