Decisionmaking competence and risk

Mark Wicclair criticizes Allen Buchanan's and my claim that determining an appropriate level of competence (Wicclair substitutes "decisional capacity" for "competence", the import of which I note briefly below) for health care treatment decisionmaking involves balancing respecting a patient's self-determination and protecting his or her well-being. The most important implication of this balancing is that a standard of competence should vary in significant part with the effects for the patient's well-being of accepting his or her choice. Wicclair's criticisms take two main forms. First, he considers and rejects four of the positive reasons we offer in support of a risk-related standard. Second, in rejecting our fourth reason he argues that a risk-related standard leads to faulty competence determinations -- too high a standard in some cases and too low a standard in others. If he is correct, there are no positive reasons for adopting a risk-related standard and there are as well specific reasons not to adopt such a standard in order to avoid mistaken competence determinations. My response will address both sorts of criticisms in turn.