The prevailing orthodoxy in terms of competency assessment is to test for the presence of certain abilities. Chapter 10 argues that the presence of certain abilities is not enough in cases where the patient refuses a life-sustaining/saving measure that promises to work and does not present obviously onerous burdens. In such cases, the push and pull between dignity and autonomy is most palpable. I argue, however, that we need to know whether the patient has rendered a competent refusal of such measures. Whereas the former refers us to test for certain abilities, the latter refers us to assess the quality of one’s judgment. I argue that, for competent adults (i.e., intact abilities) who refuse means of saving or sustaining their lives with manageable burdens, a higher degree of justification is needed to honor such refusals. Unless such justification is present, we should have epistemic diffidence for the belief that their refusals represent the patient’s stable self.