Copyright Terry Bartholomew, 1996. One copy of this paper can be made for the purpose of personal, non-commercial use, subject to proper attribution to the author.




Challenging assumptions about young people's competence
- clearing the pathway to policy?



Terry Bartholomew
Department of Criminology
University of Melbourne

Ph: 03 9344 9462
Fax: 03 9349 4259




Paper presented at the Australian Institute of Family Studies'
Fifth Australian Family Research Conference

Brisbane. November 1996




Terry Bartholomew is currently a tutor and PhD candidate in the Department of Criminology at the University of Melbourne. Thesis topic explores consistency and contradiction in the construction and assessment of young people's competence across a variety of civil and criminal domains.


Abstract

This paper reports findings from a major study in progress which compares the performance of young people and adults on the legal criteria for informed consent in the domain of medical treatment decisions. Data obtained to date indicate that 15 year olds consistently emerge equally competent to legally recognised adults. The research also presents an alternative model on which to base more ecologically valid investigations into young people's decision making competence. Findings outlined here directly challenge the applicability of much psychological decision making research to law and policy, and indicate that current practices may be unfairly limiting the freedom of young people.




Children and adolescents are often prevented from deciding for themselves about many issues which affect their lives. One of the major assumptions underlying such exclusion is the idea that young people are much less competent than adults at making decisions (Ambuel & Rappaport, 1992; Scherer, 1991). In recent times there has been increasing debate over whether this assumption is valid, particularly in relation to adolescents aged fourteen and above (eg. Gardner, Scherer & Tester, 1989; Mann, Harmoni & Power, 1989; Ormond, Luszcz, Mann, & Beswick, 1991).

Recent research into the development of cognitive capacities indicates that adolescents beyond the age of fourteen do not differ significantly from adults in their decision making competence across a variety of domains (Scott, Reppucci & Woolard, 1995), while young people under this age show more variable performance (Ambuel & Rappaport, 1992). This study includes participants who are aged 12, 15, 18 and 21 in order to highlight developmental trends in decision making competence (as defined by legal criteria). A second objective is to identify other ('non-judicial' or 'extralegal') factors which may impinge on the decision making abilities of young people. This latter stage also involves the proposal of an alternative methodological framework on which to base more ecologically valid assessments of decision making competence. The objective of this research is to better inform policy regarding the distribution of rights to young people.

Why focus on decision making competence?

Age is the variable most often used as a reference point when determinations about the 'appropriate' distribution of commodities such as rights and freedoms are being made (Koocher & DeMaso, 1990). An inevitable focus of arguments concerning the distribution of 'adult' rights to young people is the assessment of 'decision making competence', and the importance of reaching a consensus on the age that young people achieve sufficient levels of this variable for them to be legally free to make decisions for themselves (Koocher, 1987; Taylor & Adelman, 1986). To date the law's position on this vital issue has been described as 'ambivalent' (Melton, 1983a), and shows a tendency to waver between the idea of self determination for young people and a more paternalistic position (Ludbrook, 1994). Likewise, legislation regarding the above issues has been shown to vary significantly with time, jurisdiction, and the type of decision in question (Wilson, Della Torre, & Ludbrook, 1995).

Alongside extensive arguments about the competence of adolescents in court arenas, the capacity of young people ('minors' by law) to make autonomous medical treatment decisions has been one of the most contested areas of the 'rights and welfare trade-off' evident in contemporary policy making (Scherer & Reppucci, 1988). Indeed it has been argued that longstanding conflicts between the welfare of citizens, broad social interests in ensuring good outcomes, and cultural views about responsibility and authority are in fact 'nowhere more obvious than in the continuing debate about the competence of children to consent to treatment' (Faden & Beauchamp, 1986: p.293). For this reason the current study focuses on the area of medical treatment decisions in its investigation.

The law

The law outlines the standards required for 'adequate' consent, and also dictates when such assessments are required. For this reason the measures utilised in this study are to be based on current legal criteria. Until changes were made in the last decade, the position of most Australian law was that minors (those under the age of eighteen) were not competent to make important decisions for themselves (Wilson et al, 1995). This presumed incapacity included the area of medical treatment decisions.

A more 'child centred' approach was however later adopted in the majority decision of the High Court of Australia in the Marion Case (Secretary, Department of Health and Community Services v JWB [1992] 175 CLR 300). This ruling stated that a minor 'is capable of giving an informed consent when he or she achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed' (1992 175 CLR 300). Specific wordings of criteria vary slightly from state to state, but in Victoria the Common law is yet to be formally qualified and simply requires that judgements of competence to consent to treatment (or to refuse it) be based initially on the treating doctors' opinion of the situation, with an option to refer cases to courts if deemed necessary (Ludbrook, 1994).

Recent key rulings have emphasised that capacity (and not age) is the relevant factor in determinations of competence. Age and maturity are considered relevant only to the extent that they affect the child's capacity (Devereux, 1991). However such statements are misleading as only young people under the age of eighteen must satisfy such individualised competence tests, while adults are presumed competent (Roth, Meisel & Lidz, 1977). Hence, claims that age is not a relevant factor are deceptive. Young people are presumed incompetent and must prove otherwise, while the opposite is true for those over the age of eighteen.

Current standards provided in law for the assessment of such competence are, at best, a general gauge and that they do not provide definitions that are easily transferable into judicial, clinical, or actuarial criteria (Meisel, Roth & Lidz, 1977; Wikler, 1988). Developing the argument that such age based distinctions are based on incorrect (or outdated) assumptions is first contingent on the construction of an instrument which provides a valid operationalisation of existing legal standards. A prerequisite to this task is an adequate definition of competence in this area.

From psychological to legalistic definitions of competence

The development of competence in general life skills has historically been a major point of theoretical discussion in developmental psychology scholarship. The notion of competence as it is referred to in the context of the current paper is more task specific. In legal terms, competence functions as a 'gatekeeping' concept for informed consent assessments (Faden & Beauchamp, 1986). This simply means that competence judgements (in the domain of medical treatment decisions) function to distinguish between those persons from whom consent should be solicited and those from whom consent does not have to be sought (Overton, 1991).

Legal assessments of competence are made difficult by the fact that competence is by nature a continuous variable and legal determinations require binary (yes/no) decisions to be made. For practical and policy reasons, cut-offs must be stationed on this continuum in order to distinguish those who posses sufficient levels of this characteristic from those who do not (Kopelman, 1990). Before this can occur more concrete criteria for measuring the construct must be arrived at.

Measuring competence according to legal standards

Most authors in this area now agree that valid evaluations of competence necessarily involve at least three discrete levels (Faden & Beauchamp 1986). Within an informed consent framework, these levels are (1) the establishment of requisite abilities (as outlined in Common law), (2) the setting of thresholds for these abilities (in most cases, adult levels of performance act as standards), and (3) the construction and use of an empirical test to determine positions on the continuum. The study reported here utilises this model.

In the many efforts to operationalise legal concepts of competence, the selection of relevant abilities, thresholds and tests has often reflected the theoretical, political, and/or moral persuasions of the authors involved (Kopelman, 1990). A certain degree of consensus as to the requisite abilities that represent 'competence' as defined by law has however emerged (Scherer, 1991; Scott et al, 1995). Contemporary researchers and policy interpreters tend to include 'evidence of choice' among the criteria necessary for a valid assessment of decision making competence. This 'low level' test simply requires the participant to express a preference that is relative to the treatment alternatives. Although regarded as a fundamental prerequisite to any judgement of competency, satisfaction of this test is very rarely utilised as a sole criterion. In practice, assessments of competence often involve multidimensional criteria.

The second set of commonly utilised legal criteria for competent decision making concerns the assessment of whether the participant has the ability to understand the facts of their case, the risks and possible benefits of treatment, and the nature of the alternatives to treatment, including choosing no treatment (Scott et al, 1995). Often referred to as the 'comprehension' test, this component is regarded as an integral element of the assessment because its satisfaction is taken to also indicate both intentionality and authorisation on the part of the decision maker (Faden & Beauchamp, 1986).

The third level of competence assessment endeavours to determine whether the reasons supplied for the participant's decision are 'rational'. The 'test of rational reasons' (also known as the 'reasoning' test) relies on assessments of the quality of the participant's thinking and reasoning in arriving at their decision, and is the most subjective, and hence problematic, of all existing criteria (Shafir, Simonson & Tversky, 1993).


Beyond the restricted focus of legal measures

Having outlined the three primary ways in which the decision making of young people and adults is to be compared, it is also necessary to acknowledge the limitations inherent in what Taylor and Adelman (1986) have referred to as the 'descriptive' nature of studies which solely focus on such legalistic standards. Although it is important to draw on the standards outlined in the law in order to make meaningful assessments and comparisons of cognitive capacities, it is also necessary to provide facility for measurement of other (individual and socio-structural) factors which may act as mediators between the latent and actual competencies of young people (Zaslow & Takanishi, 1993).

Put simply, approaches such as the one being utilised here suggest that it is not sufficient to construct rigorous methodological protocols based only on legal criteria when much previous research indicates that adolescents encounter a variety of obstacles which potentially mediate their performance on such tests (Montangero, 1991; Overton, 1991). If young people do in fact perform poorly relative to adults on competence measures, it is necessary to attempt to identify what (intrinsic or external) factors such poor performance may be due to. Such arguments draw fundamental distinctions between terms and constructs such as: competence and performance; capacity and availability; and latent and actual abilities. In this way, responsibility is placed on researchers to identify the causes of young people's performance discrepancies on decision making criteria in order to better inform policy and to enable practitioners to work with young people to enhance their decision making. It is after all a series of simple decisions which lead to such problematic behaviours as smoking, risk taking, drug use, and suicide.

The framework employed here places an emphasis on highlighting environmental, familial, legal, and individual obstacles which may act as 'moderators' of young people's apparent competence. This study includes numerous items which are designed to highlight differences between minors and adults on 'extralegal' variables (ie variables that strict 'legalistic' informed consent criteria are not concerned with, but which are presumed to be indicators or moderators of competence by researchers and practitioners). The objective here is firstly to provide facility to shift the focus of competence measures (and policy) from purely chronological criteria, and secondly to challenge pre-existing ideas about the effect that certain decision making practices (which may be unique to young people) have on exhibited competence.

Some of the most common claims of research that has sought to provide explanations for the apparently poor decision making practices of young people have been: that children and adolescents are worse than adults at perceiving or anticipating the risks of certain behaviours (Jacobs Quadrel, Fischhoff & Davis, 1993); that young people have unrealistic beliefs about their invulnerability (Benthin, Slovic, & Severson, 1993) and that minors are too easily influenced by their peers or their parents when making decisions (Lewis, 1987; Scherer & Reppucci, 1988). Other authors suggest that: young people have undue faith in information supplied by adults and are therefore not good at critically collating information (Lewis, 1981; Mann et al, 1989); and that adolescents are more likely than adults to exhibit 'hypervigilant' decision processes when faced with choices that involve conflict (eg processes which lead to a lack of differentiation between salient and peripheral input in the information search {Janis & Mann, 1977}). Research has also claimed that young people tend to focus too much on short term gains rather than long term implications (Benthin et al, 1993); that children and adolescents lack confidence in their decision making abilities and are therefore not 'committed' to their decisions (Scherer, 1991); and finally that young people exhibit 'inexperienced cognitions' which restrict the potential for a 'vigilant' search and assimilation of information (Mann et al, 1989).

It is claimed by authors in this area that many of the 'undesirable' cognitions and behaviours listed above are unique to young people, and that these impinge significantly on their exhibition of decision making competence. This study differs slightly from traditional experimental designs which would simply focus on the identification of age differences in the above listed behaviours and cognitions. Instead, a major objective of this project is to ascertain whether the exhibition of these patterns does in fact affect competence scores on legal criteria (an assumption which is usually taken as a 'given'). In this sense the methodology used in this study challenges the applicability of much of the research in this area to direct policy issues.

This study is primarily concerned with (1) testing the assumption implicit in law that adolescents under the age of 18 are consistently less competent at making decisions than those who are over 18, and (2) determining the role that differential performance on the above listed 'extralegal' variables has on competence scores.

The Study

234 subjects had participated in the study at the time of this initial analysis. Although data is still being collected, the analysis reported below refers to only those subjects. The four age groups utilised were 12, 15, 18 and 21. Table one contains a breakdown of the subjects on demographic and other criteria. Participants at the time of reporting had been recruited from a co-educational school, a youth employment centre, a University, and the general public.


Table 1 : Demographic Information


The questionnaire utilised in data collection consisted of three major sections. Section A sought demographic information. Other than containing different vignettes, sections B and C followed the same format. Each contained a story (ie a hypothetical treatment dilemma) describing a situation in which individuals were required to choose between five treatment alternatives to a medical dilemma. Following this were two open ended questions requiring subjects to describe the rationale for their choices, and inquiring about additional information the participant would have sought other than what was provided. These latter items provided the information for the 'test of rational reasons'.

The two sections then included (a) questions about whether the subject had any personal experience with the condition described in the vignette, and (b) a series of five point Likert-type scales which probed subjects about such matters as: (1) the degree to which people such as parents, siblings, friends/peers, and doctors would influence their decision making, and (2) their degree of confidence in their ability to make a good decision in the described situation. Five multiple choice questions assessed the participant's degree of understanding about the information presented.

Situations depicted in the vignettes concerned the choice of treatment for an eating disorder, and a dilemma about whether to take part in a trial for an experimental drug when suffering from a potentially fatal disease. In these vignettes the particular malady, treatment options, and their respective risks and benefits were all clearly outlined. The nature of the two dilemmas was chosen because of the prevalence of eating disorders amongst today's young people, and because the issue of a potentially fatal illness and consent to take part in an ensuing drug trial represents a situation at the more serious end of the spectrum in relation to these types of dilemmas.

In order to be credited with making a choice, subjects were only required to choose one of the treatment options supplied after each vignette. Although a number of these options simply involved the waiver of decision making responsibility to another, and/or a preference to not opt for any treatment, law (and contemporary psychological theory) dictate that any selection within the supplied range must be regarded as an indicator of choice (Furby & Beyth-Marom, 1992). The five multiple choice 'comprehension' items were designed to evaluate subjects' understanding of the information disclosed in the dilemmas and their ability to draw inferences from it.

Table two reports the means and standard deviations for each age group on the comprehension test and the various sub-scales used to assess the reasoning of participants. The 'evidence of choice' criteria is not included here because it was almost universally satisfied.

Table 2 : Means and Standard Deviations on competence measures for four age groups - Dilemma one (D1) and Dilemma two (D2).


Age differences on competence criteria

In initial analyses the socioeconomic status variable was shown to have no significant effects on measures of legal competence. For this reason no further tests were completed on this variable. The 'level of education completed so far' measure correlated so highly with age (r = .91, p < .001) that it too was not entered into any statistical procedures. The rationale behind this decision was simply that the education variable did not appear to be capturing any unique information about the subjects. This high correlation could be mostly attributed to the nature of the age ranges focussed on, and limitations in variability in the current sample.

Standard multiple regression analyses, stepwise multiple regressions, ANOVA's, and chi-squared tests of association were utilised to obtain the results reported below. For reasons of economy of space, only substantive findings will be reported here. Readers who are interested in specific significance values and regression equations are referred to a more indepth reporting of these details in Bartholomew (1996a).

The first purpose of the current study was to test whether young people beyond the age of 14 showed similar levels of competence to adults in their ability to satisfy informed consent criteria. It must be remembered here that any findings of no significant differences between the 15 and 18 year old subjects on competence measures are in support of this notion, because 18 year olds are legal adults in this domain. Support for this proposal was obtained on the theoretical measures of reasoning in both scenarios, the comprehension test, the evidence of choice test in both dilemmas, and the 'amount of relevant additional information sought' measure in dilemma two (a component of the rational reasons test). On all of these criteria, the performance of 15 year olds did not differ significantly from that of 18 year olds, while that of 12 year olds was much less consistent.

These results support the findings of researchers such as Mann et al (1989), Ambuel and Rappaport (1992), Melton (1983a, 1983b), and Overton (1991) among others, who found significant differences between the performance of young people under the age of fourteen and those over this age, but no differences between this latter group and legally recognised adults on competence measures. The consistency in these findings is especially notable because of the different designs, subject pools, and problem contents evident in the above listed studies. Such findings are also consistent with recommendations made by the American Psychological Association to the US Supreme court in 1987 (in the form of an amicus brief ). Following their review of the available literature, the APA submitted a controversial document which asserted that 'current evidence indicates that there is no quantitative or qualitative differences between the reasoning powers of adolescents over the age of 14 and those of legally recognised adults' (cited in Gittler, Quigley-Rick, & Saks, 1990; p.132). These findings add weight to common suggestions that around the age of 14, a notable transition occurs in adolescent cognitive operations.

A number of findings in relation to the competence criterion of 'rational reasons' do challenge the above assertions however. Measures such as the 'total number of relevant probes' made by subjects in the bulimia scenario, and (in the fatal disease dilemma), 'the presence of faulty or undesirable reasoning processes', and 'the number of valid reasons given for the decision', all indicated significant differences between 15 year old subjects and legally recognised adults. On these measures, 15 year olds were much more aligned with the 12 year old group. These latter results are not in agreement with the idea that by the age of 15 young people are as good as adults at making decisions.

One possible reason for the lack of consistency with previous research that is evident on these particular items, may be that the measures of competence employed here were more multidimensional in their orientation than those utilised in much previous research. This would have had the effect of highlighting very specific elements within the test of 'rational reasoning' that adolescents differed from adults on. The unitary nature of 'rational reasoning' measures in past research (and much practice) may have concealed such specific distinctions (Scott et al, 1995). By dividing the 'test of rational reasons' into a variety of both qualitative and quantitative components, and coding these in a way which facilitated in-depth analysis, the current study's measures of 'rational reasons' may have simply been more sensitive to such discrepancies. Issues such as these dictate that the substantive issue to be addressed in future discussions involving the 'test of rational reasons' is the need for more explicit definition of the construct in question and the criteria for its satisfaction. Only after the law has clearly outlined specific criteria and thresholds within this component of competence testing, can proper standardisation and quantification occur. Until these refinements are made, it will be all the more difficult for young people to prove their competence, or to 'disprove their incompetence' as they are required to do in current law.

In order for a decision maker to be deemed competent, they must be able to supply 'rational reasons' that highlight the subjective utility of the chosen outcome. However, explicit details concerning the number of reasons necessary for satisfaction of this test, the necessary extent of their external (or objective) theoretical validity, and instructions about how to balance the existence of both rational and irrational reasons during assessments are not elucidated (Devereax, 1991; Faden & Beauchamp, 1986). In contemporary research, concerns about the lack of such assessment guidelines have also been demonstrated by the practitioners who are required to make such competence determinations (Bartholomew, 1996b).

In relation to the overall criteria of 'rational reasons', the above issues make definitive statements about the legal competence of adolescents problematic. There is no doubt however that on all other legal criteria of competence, 15 year old subjects in the current sample were as competent as legally recognised adults.

Demographic variables which affect competence

The second aim of the current study moved beyond strict legal domains and sought to identify demographic variables (other than age) which predicted competence scores. Consistent with the widespread belief that there are many demographic variables which act to inhibit or enhance competence (and the ability to provide informed consent), a number of significant findings emerged. Personal experience with a similar medical condition, the gender of the subject, and the language spoken in the home affected performance on a number of the criteria for competence. Personal experience with a situation was highly correlated with age, but did maintain statistical significance following stepdown analyses. This variable was only a significant predictor of competence measures within the Bulimia scenario. As would be expected, those who had a degree of personal contact with an eating disorder consistently provided more reasons for their treatment decisions and sought greater amounts of valid additional information than those who did not.

The language spoken in the home was a significant predictor of both the subjects' overall comprehension total, and the number of undesirable reasoning processes that their answers revealed. Those from homes where English was not spoken performed less well on the comprehension scale, and were more likely to show questionable reasoning in their rationales for treatment choices in the fatal disease dilemma. Such findings may not however be due to differences in decision making competence per se, but could conceivably be due to the fact that the questionnaire involved a significant amount of reading (and writing), and subjects from non-English speaking households may have been disadvantaged by this approach. Concerns such as these highlight the problem of using 'pen and paper' tests of competence, as they maximise the potential for confounding variables such as literacy, cultural specificity, and the subject's preparedness to respond to open ended items to enter the experiment.

Similarly, those from non-English speaking households may be more likely to rely on experts such as doctors, or to defer to significant others. Although such behaviours influence the scores obtained on the above criteria, these approaches may not necessarily represent unproductive decision making methods or coping styles. Further, such tendencies to be more deferent to experts may be indicative of cultural norms. Again, the importance of what Meacham (1991) refers to as 'contextualising' competence assessments emerges as a significant consideration when comparing the performance of subjects with different demographic/cultural profiles (p.43).

Females were found to be significantly more likely than males to fulfil positive reasoning criteria with their answers to scenario one. Although the aforementioned increased likelihood that females had some form of personal experience with an eating disorder may be an important consideration in this instance, an alternative explanation is that males and females may have different styles of searching for information, weighing options, and/or justifying their decisions. These differences may manifest themselves in differential performance on very specialised measures of competence. Such sex differences in cognitive style and preparedness to supply justifications have been identified previously in decision making literature, and hold their own ramifications for practitioners (Baron, Granato, Spranca & Teubal, 1993; Benthin et al, 1993).

The types of decision making patterns which limit competence

The final objective of this project was the identification of extralegal decision practices which emerged as significant contributors to scores on competence criteria. Simply put, the question at hand is one of identifying the decision making practices (eg reliance on friends, family etc; favouring short-term goals over long term goals) which were predictors of performance on competence measures.

In the first scenario, the subjects' self reported confidence in their decision making ability, and their reported reliance on the advice of peers and experts all emerged as significant predictors of various measures of 'rational reasoning'. In the second more serious dilemma, the subjects' self reported confidence again predicted a subtest of rational reasoning. These findings alone have many ramifications. Although adolescents may differ significantly from adults on factors such as their reliance on parents, experts, and siblings for advice, such behaviour does not appear to limit their capacity to make competent judgements according to legal criteria.

According to the present findings, most extralegal variables which are commonly presumed to be mediators of competence do not explain significant amounts of variation on competence measures. For this reason research designs such as the present one challenge the underlying assumptions of much psychological research into decision making prowess. Psychological study in this vein usually focuses on differences between young people and adults on such (extralegal) criteria as their level of reliance on peers, their preparedness to be influenced by short term goals, and their changeability etc. Any differences which are noted between the two groups are then used as evidence of young people's inferior decision making abilities. Findings such as these are then often used in judicial and policy environments as justifications for the denial of rights to young people.

Current findings indicate that variation on many of the standards that psychological research commonly focus on does not appear to influence decision making competence as assessed by legal criteria. This expanded model highlights the lack of validity evident in extrapolating developmental differences in decision making style into notions of decision making competence and thus into rationales for the denial of rights and freedoms. Although legal criteria do not include many of the extralegal variables included here, the assumptions which have driven policy in this area have certainly drawn on psychological research which did. For that reason, ecologically valid research in this important area needs to include facility to test such assumptions.

The fact that the 'confidence in own ability' variable consistently emerged as a significant and independent predictor of competence raises an interesting causal question regarding law and policy. Mann et al (1989) have noted that confidence in decision making is a vital prerequisite to 'commitment' to choices already made, and to feelings of self determination. It has been claimed by these authors that the law as it stands limits opportunities for young people to 'practice' decision making, and thus to increase their confidence in their own abilities. It is further claimed that limiting the autonomy of young people promulgates a self fulfilling prophecy of learned helplessness, where young people know that they are not free to decide major issues for themselves, that their decisions are not binding, and that their registrations of dissent can be (and often are) easily over-ruled. This process sets in motion a reluctance on their part to make decisions (Shafir et al, 1993; Scherer & Reppucci, 1988), a lack of commitment to their own choices (Janis & Mann, 1977), and/or a tendency (particularly in mid adolescence) to react against the decisions of adults simply out of frustration (Koocher, 1987; Berndt, 1979). Such behaviours are often regarded as evidence of the inconsistent and 'emotional' nature of young people's decision patterns by policy makers and researchers (Offer & Schonert-Reichl, 1992). However, whether these patterns of behaviour emerge as responses to the structural limitations placed on young people's autonomy, or whether they are in fact manifestations of fundamental shortcomings in their decision making abilities, is a causal question beyond the scope of the current piece.

Our system's current approach of limiting opportunities for young people to harm themselves is indicative of the 'health protection model' of rights administration. Unfortunately, one direct result of the presumption of incompetence that this model is based on is a lack of legitimate opportunities for young people to: (1) prove themselves as good decision makers, (2) practice their decision making skills, and (3) to enhance their confidence in their own decision making abilities. Thus it could be argued that findings regarding the variable of 'self reported confidence' in the current study reveal as much about our current system as they do about young people themselves.

The fact that many of the identified significant extralegal predictors were sufficiently independent of age to gain entry to regression equations predicting performance on competence measures, and the emergent importance of the 'personal experience' variable in predictions of competence, emphasise the importance of a broader scope of analysis in future investigations of competence. Although it must be noted that age has most certainly emerged as the dominant predictor of competence, distinctions between the 'consistently competent' and the 'rarely competent' have not appeared in positions consistent with where the law presumes them to be. Young people below the age of 18 (and above the age of 14) appear to be being deprived of rights that their performance on competence tests indicates they are entitled to.

The Future

Just as it is important to show caution when generalising findings from a limited sample of adolescents to the wider population, it is also imperative that findings of competence on one narrow aspect of decision making not be generalised to other situations. The results of any competence assessment are given meaning only as a function of the context in which the need for assessment arises, and with due acknowledgment to the domain- specific nature of the construct (Koocher & DeMaso, 1990). Treatment decision making competence does not appear to be a consistently applied trait. Changes in the context, form, and nature of a decision are likely to significantly influence subjects' reasoning and choices (Shafir et al, 1993). The different predictors which were identified as significant across the two separate dilemmas in the current study are testament to this.

Although this study has provided much information regarding the effects of demographic and extralegal variables on medical decision making competence, it must be noted that the percentages of variance explained in most final regression equations (approximately twenty to thirty percent) indicate that, although equations are highly statistically significant, these input variables are by no means the definitive predictors of performance on competence measures. Future studies would be well advised to proceed in the direction of the current study by seeking to identify additional variables which act as mediators or enhancers of such performance because it is obvious that, until now, only a small percentage of these have been identified.

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