1. Jakub Zawiła-Niedźwiecki University of Warsaw
Competence – a problem for research in mental health that asks for novel approach.
Jakub Zawiła-Niedźwiecki
University of Warsaw

2. Agenda Mental health – a worldwide public health issue
Competence as a practical and theoretical issue for research ethics
Existing tools and criteria
External influences on competence
Competence as a set of sub-skills of the mind-brain
‘Narrowing’ the thinking of competence

3. Mental health – public health issue
Lack of scientific knowledge on biological mechanisms
Lack of effective treatments
Poor understanding of key concepts in mental health
Global ’epidemic’ of mental issues

4. Mental health – the need for more knowledge
Lack of scientific knowledge on biological mechanisms
Lack of effective treatments
Poor understanding of key concepts in mental health
Global ’epidemic’ of mental issues

5. Competence as basic notion for the bioethical considerations
Competence is related to philosophical notions of personhood, moral agency
The dominant bioethical framework of principlism assumes some form of competence
Competence
Informed consent
We know what it is when we show clear examples, but can we explore and operationalise the borderline further then normally philosophically possible?

6. Another type/level of competence?
Decision maker’s
Competence ?
Surrogate decision
Patient’s
Competence
Pseudo-competence, haven’t considered it properly yet.

7. Competence in research vs. competence in clinical settings
1. Is there a valid difference for the phenomenon of competence between the two settings?
2. Clinical ethics sometimes discerns between capacity to consent and capacity to refuse, is it relevant in research context?
If 1. then 2., if not 1 then not 2.
I don’t think that 2 and 1. Is is only a matter of quality of proof or certainty.

8. Competence in research vs. competence in clinical settings
Can’t we just recruit clearly incompetent patients for the purpose of research and get proxy consent?
Well no.
Violation of extremely personal space
It is debatable if there is a duty to participate in non-beneficial research. If no then proxy decision makers wouldn’t be acting in subject’s best interests
Even if there is such duty it’s not sure if incompetent patients can have duties – there is connection between competence and moral agency

9. Psychiatric classifications and competence
Having a DSM/ICD ‘label’ affects self-image, social position, and perceived capacity to make decisions
Mental health consumers are considered a vulnerable population prone to influence and pressure
Large scale surveys as late as 1990’s showed that vast majority (72%) of MD’s considered all patients under particular ‘label’ to be incompetent
Sensitivity and specificity of even standardised testing in this part of medicine is very low
 1999 study showing that only 20% of patients with dementia would be considered competent, but only 78% of healthy volounteers would be considered competent

10. Traditional formulation of competence criteria
Experts try to identify following particular abilities:
Capability of receiving and reproducing pertinent information
Possessing of a set of values and goals
Ability to reason about choices
Ability to express a consistent choice
Many authors phrase them using universal quantifiers and expressions such as: all relevant, all foreseeable.
This is a compilation from various sources
Can we seriously say any of us fulfils the criteria?
Is it possible to set thresholds within the criteria – can one have a set of values and goals partially?
What about healthy individuals that don’t fulfil either of the criteria?
Major requirements on education and skills possessed – all the reading ability research in 1980’s.

11. Existing tools MacArthur Competence Assessment Tool and others
But gold standard is still expert opinion!
Empirical research on the topic since 1980’s – starting with literacy skills
Appelbaum, P. S., & Grisso, T. (1995). The MacArthur Treatment Competence Study. Law and Human Behaviour, 19(2).
Expert opinion can strongly vary, there are empirical studies showing as high as 40% dissenting opinions in blind tests.
He expressed concern over her ability “not to feel coerced or pressured or manipulated into sexual activity” and over “the trust placed in AB not to abuse his position” -> strongly biased by beneficence or best interests thinking

12. What influences competence?IQ
Language and literacy skills
Education
Emotional status
Physical health
Biochemistry (pharmaceuticals, foods, intoxicants etc.)
Cognitive biases
Social position
Setting and means of assessment
Amount of time spent on the decision …
non-native language use!
Affects = doesn’t necessarily mean it only diminishes it!

13. Influences - continued
Pharmacological influences can be both positive and negative. It could be postulated that even in routine matters we would need to get the subject into some sort of „standard biochemical equilibrium”
Source: Stoppe (ed.) 2008

14. New approach Mind/brain functions Competence Executive Memory
Attention
Communication
Emotive
Mind/brain functions

15. New approach Bundle concept of agency
Ability to develop more objective tools
Aimed at conceptualising partially competent subjects and their cooperation in decision-making process
Setting criteria for particular mental functions for each decision
Evaluating mental functions through psychometric tests
Establishing capacity for a particular decision

16. Competence with assistance
New approach
Competence with assistance
Executive
Memory
Attention
Communication
Emotive
Mind/brain functions
Proxy

17. Summary
Separating cognitive evaluations from context of particular decision
Removing as far as posible, within existing tools, influence of education, social context etc.
Keeping the idea that one has to have capacity to make a choice at a particular time and in particular situation
Partial and assisted competence

18. Thank you