抑郁症患者拒绝非精神治疗:代理决策者应如何代表患者的真实意愿?

IF 1.3 4区 哲学 Q3 ETHICS Hec Forum Pub Date : 2024-01-27 DOI:10.1007/s10730-024-09522-9
Esther Berkowitz, Stephen Trevick
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引用次数: 0

摘要

精神疾病患者,尤其是抑郁症患者,在拒绝维持生命的非精神治疗时,会给临床医生和代理决策者带来复杂的伦理困境。当他们拒绝治疗的行为与他们病前或 "真实 "自我的信念和偏好不一致时,他们做出这些决定的能力就会受到质疑。如果无法证明其行为能力,医疗决定就会由代理机构做出,通常会建议代理机构根据替代判断标准做出决定,或者在无法根据替代判断标准做出决定时,根据最佳利益做出决定。我们建议,如果病人符合广泛接受的行为能力认知标准,但做出的决定似乎并不真实,代理者可以通过遵循 "恢复性代表 "模式来最好地维护病人的自主权。我们将恢复性表述视为替代判断的一个子集,在这个子集中,决策者保留了按照病人本来的意愿做出决定的责任,但要辨别出病人 "最真实的自我 "会做出的决定,而不是推断出病人当前的意愿,因为病人当前的意愿会受到疾病的直接影响。在这里,我们介绍了一个病例,在这个病例中,病人拒绝治疗和之前未确诊的抑郁症导致难以确定病人的真实意愿,并给代理决策者带来了痛苦的负担。我们通过这个病例来探讨临床医生和伦理学家如何才能更好地为代理决策者提供建议,帮助他们做出这些在临床和情感上都具有挑战性的决定。
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Non-Psychiatric Treatment Refusal in Patients with Depression: How Should Surrogate Decision-Makers Represent the Patient's Authentic Wishes?

Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or "authentic" self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, when that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a "restorative representation" model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their "truest self" would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient's treatment refusal and previously undiagnosed depression led to difficulty determining the patient's authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions.

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来源期刊
Hec Forum
Hec Forum ETHICS-
CiteScore
3.70
自引率
13.30%
发文量
34
期刊介绍: HEC Forum is an international, peer-reviewed publication featuring original contributions of interest to practicing physicians, nurses, social workers, risk managers, attorneys, ethicists, and other HEC committee members. Contributions are welcomed from any pertinent source, but the text should be written to be appreciated by HEC members and lay readers. HEC Forum publishes essays, research papers, and features the following sections:Essays on Substantive Bioethical/Health Law Issues Analyses of Procedural or Operational Committee Issues Document Exchange Special Articles International Perspectives Mt./St. Anonymous: Cases and Institutional Policies Point/Counterpoint Argumentation Case Reviews, Analyses, and Resolutions Chairperson''s Section `Tough Spot'' Critical Annotations Health Law Alert Network News Letters to the Editors
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