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According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient  refusals  can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account—what we call  comparative  DMC. We describe how patients may possess  burdens-based  DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or  goals-based  DMC for refusal if they have an overriding goal that is inconsistent with treatment. The  overridingness  of a patient’s objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve.

Three Kinds of Decision-Making Capacity for Refusing Medical Interventions