Welie J V
Center for Health Policy and Ethics, Creighton University, 2500 California Plaza, Omaha, NE 68178, USA.
Med Health Care Philos. 2001;4(2):169-83. doi: 10.1023/a:1011450017960.
In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the "power of attorney"), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The ever more common aversion of best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit.
在文献中，通常区分出三种为无行为能力患者的护理做出决策的机制：生前预嘱、代理人的替代判断（代理人可能持有也可能不持有“委托书”）以及最佳利益判断。几乎普遍认为，第三种机制是这三种中最糟糕的，只有在前两种机制不可用时才会采用。在本文中，我主张采用最佳利益判断。对最佳利益判断日益普遍的反感带来了一种风险，即医疗保健提供者会退出决策过程，将患者（或其家庭成员）弃于这些关于生死的最艰难决策之中。我在本文中的方法主要是否定性的，也就是说，我批评生前预嘱和替代判断所谓的优越性。后两种机制之所以具有所谓的优越性，是因为它们据说是道德中立的，而最佳利益判断则代表患者进行价值判断。我认为，经过仔细审视，生前预嘱和替代判断并非道德中立；事实上，它们通常依赖于最佳利益判断，即使这些判断没有明确表达出来。
