Davis John K
The Brody School of Medicine, Department of Medical Humanities, East Carolina University, Brody Medical Sciences Building 2S-17, Greenville, NC 27858-4354, USA.
Bioethics. 2002 Apr;16(2):114-33. doi: 10.1111/1467-8519.00274.
Does respect for autonomy imply respect for precedent autonomy? The principle of respect for autonomy requires us to respect a competent patient's treatment preference, but not everyone agrees that it requires us to respect preferences formed earlier by a now-incapacitated patient, such as those expressed in an advance directive. The concept of precedent autonomy, which concerns just such preferences, is problematic because it is not clear that we can still attribute to a now-incapacitated patient a preference which that patient never disaffirmed but can no longer understand. If we cannot make that attribution, then perhaps we should not respect precedent autonomy--after all, how can you respect patient autonomy by giving patients what they no longer want, even if they never disaffirmed those wants? I argue that whether an earlier preference can still be attributed to a now-incapacitated patient depends on the reasons behind the preference, for a preference includes (and is not merely supported by) the reasons behind it. When the considerations that served as reasons no longer exist, neither does the preference which included those reasons. In particular, if the considerations that served as reasons for the patient exist only under conditions where the patient retains full mental capacity, then once that capacity is lost, so are those reasons and the preference based upon them. I use this analysis of precedent autonomy to ascertain the merits of various approaches to advance medical decisionmaking, including Nancy Rhoden's approach, approaches based on a Parfitian personal identity analysis, approaches based on soft paternalism, and approaches based on the stability and longevity of preferences. Despite the apparent absurdity of respecting patient autonomy by giving patients what they no longer prefer but have never disaffirmed, I conclude with some programmatic remarks on when and why respect for (precedent) autonomy nonetheless requires us to respect former preferences.
对自主性的尊重是否意味着对先前自主性的尊重？尊重自主性原则要求我们尊重有行为能力的患者的治疗偏好，但并非所有人都认同这意味着我们必须尊重现在丧失行为能力的患者先前形成的偏好，比如预先指示中表达的偏好。与这类偏好相关的先前自主性概念存在问题，因为不清楚我们是否仍能将一种患者从未撤销但已无法理解的偏好归属于现在丧失行为能力的患者。如果我们不能进行这种归属，那么或许我们不应尊重先前自主性——毕竟，给予患者他们不再想要的东西（即使他们从未撤销那些意愿），这怎么能算是尊重患者自主性呢？我认为，一种先前的偏好是否仍能归属于现在丧失行为能力的患者，取决于该偏好背后的理由，因为一种偏好包含（而不仅仅是由其支持）其背后的理由。当作为理由的考量不再存在时，包含这些理由的偏好也不复存在。特别是，如果作为患者理由的考量仅存在于患者保持完全心智能力的条件下，那么一旦这种能力丧失，那些理由以及基于它们的偏好也会丧失。我运用这种对先前自主性的分析来确定各种推进医疗决策方法的优点，包括南希·罗登的方法、基于帕菲特式个人身份分析的方法、基于温和家长主义的方法以及基于偏好的稳定性和持久性的方法。尽管通过给予患者他们不再偏好但从未撤销的东西来尊重患者自主性看似荒谬，但我最后提出了一些纲领性的看法，阐述何时以及为何对（先前的）自主性的尊重仍然要求我们尊重先前的偏好。
