Lecture 5: Informed Consent (2) - Voluntariness and Competence

Vocabulary flashcards covering the key concepts, legal definitions, clinical models, and philosophical debates regarding voluntariness, competence, and informed consent from Lecture 5.

Meaningful Consent

Consent that legally and morally authorizes medical treatment, requiring three key elements: the patient must be informed, competent (possessing decision-making capacity), and voluntary (freely given without coercion, duress, manipulation, or undue influence).

Coercion

The invalidation of consent resulting from a medical provider threatening the patient with unwanted and avoidable consequences (such as eviction from a care facility or forced abandonment by a physician) if they do not agree to an intervention.

Warning (versus Threat)

The communication of unavoidable, natural consequences resulting from a choice (such as dying without surgery), which does not coerce the patient, distinguished from an intentional threat of harm.

Third-Party Coercion

Coercion originating from outside actors rather than the clinician, such as a partner threatening abandonment or expulsion from the home unless the patient accepts medical treatment.

Structural Coercion

A condition in which a patient's medical choices are constrained or forced by difficult social circumstances or an unjust absence of social support, such as opting for MAiD because the only alternative is living in a poorly maintained care facility.

Manipulation

An influence on a patient's voluntariness that falls short of coercion by using non-rational techniques to steer decisions, such as selectively withholding information or framing treatment outcomes in an overly positive or negative light.

Framing Effects

A non-rational influence on patient decision-making where presenting logically identical data differently—such as stating a procedure has a 90% success rate versus a 10% failure rate—elicits different choices.

Decision-Making Competence (Capacity)

The present capability of a patient to make their own adequately informed choices regarding treatment, distinguishing those who can authorize care from those whose decisions must be made by a surrogate.

Decision-Relative Capacity

The concept that competence is not an all-encompassing global status, but rather specific to a particular decision at a given time, capable of waxing and waning, and dependent on favorable conditions.

Ontario Health Care and Consent Act (1996)

Legislation establishing that a person is capable regarding treatment if they can understand the relevant information and appreciate the reasonably foreseeable consequences of a decision or lack thereof, while maintaining a legal presumption of capacity.

Four Ability Model (Grisso and Appelbaum)

A clinical standard defining competence through four distinct abilities: expressing a choice, understanding relevant information, appreciating the significance of that information for one's own situation, and reasoning logically through treatment options.

Understanding (Competence Ability)

The ability to grasp treatment consequences and probabilities sufficiently to make a reasonable decision without one's reasons being distorted by delusions.

Appreciation (Competence Ability)

The ability to avoid denial of one's condition and to acknowledge how clinical information and potential consequences apply directly to one's own personal circumstance.

Reasoning (Competence Ability)

The cognitive ability to maintain working memory to compare alternatives, develop a coherent train of reasoning, and understand basic probabilities of outcomes.

Starson v Swayze (2002)

A Canadian Supreme Court ruling establishing that a patient with mental disorder possessed capacity to refuse antipsychotic medication because he recognized his past mental problems, ruling that accepting those problems as an 'illness' was not legally required.

Sliding Scale Approach to Competence

Dan Brock's model in which the required threshold of competence varies according to the net benefit/risk balance: low competence is required for decisions with very favorable balances, whereas high competence is required for decisions carrying severe, unfavorable risks.

Asymmetrical Competence

An implication of Brock's sliding scale framework where a patient may meet the lower threshold of competence needed to consent to a highly beneficial, low-risk therapy, but lack the higher threshold of competence required to refuse that exact same therapy.