The ability to value: An additional criterion for decision-making capacity

In the United States, the dominant model of decision-making capacity (DMC) is the "four abilities model," which judges DMC according to four criteria: understanding, appreciation, reasoning, and communicating a choice. Some critics argue that this model is "too cognitive" because it ignores the role of emotions and values in decision-making. But so far there is no consensus about how to incorporate such factors into a model of DMC while still ensuring that patients with unusual or socially disapproved values still have their autonomous decisions respected. In this paper, we aim to give an account of the role of values in decision-making which can answer some of the lingering questions about capacity. In the current literature, defenders of the inclusion of values in DMC tend to propose solutions which focus on the distorted or incoherent attributes of the values themselves. We argue that shifting the focus onto valuing as an ability is a better solution and that a complete picture of capacity includes understanding, appreciation, reasoning, communicating a choice, and the ability to value. On the basis of a conceptual analysis of the necessary conditions for autonomous decision-making, we derive a conception of the ability to value. On our account, the ability to value has four components: the possession of values, the ability to access those values, the ability to engage in practical reasoning with one's values, and the ability to act on the result of that reasoning. We describe the positive components of the ability to value, some indicators of impairment, and some implications of our account.