Curlin Farr A, Lawrence Ryan E, Fredrickson Julie
Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, Illinois, United States of America.
PLoS One. 2009;4(2):e4374. doi: 10.1371/journal.pone.0004374. Epub 2009 Feb 4.
We studied how well first-year medical students understand and apply the concept of substituted judgment, following a course on clinical ethics.
Students submitted essays on one of three ethically controversial scenarios presented in class. One scenario involved a patient who had lost decisional capacity. Through an iterative process of textual analysis, the essays were studied and coded for patterns in the ways students misunderstood or misapplied the principle of substituted judgment.
Students correctly articulated course principles regarding patient autonomy, substituted judgment, and non-imposition of physician values. However, students showed misunderstanding by giving doctors the responsibility of balancing the interests of the patient against the interests of the family, by stating doctors and surrogates should be guided primarily by a best-interest standard, and by suggesting that patient autonomy becomes the guiding principle only when patients can no longer express their wishes.
Students did not appear to internalize or correctly apply the substituted judgment standard, even though they could describe it accurately. This suggests the substituted judgment standard may run counter to students' moral intuitions, making it harder to apply in clinical practice.
我们研究了一年级医学生在修完临床伦理学课程后，对替代判断概念的理解和应用程度。
学生就课堂上呈现的三个伦理争议情景之一提交论文。其中一个情景涉及一名丧失决策能力的患者。通过文本分析的迭代过程，对论文进行研究并编码，以找出学生误解或误用替代判断原则的方式模式。
学生正确阐述了关于患者自主性、替代判断以及不将医生价值观强加于患者的课程原则。然而，学生存在误解，表现为让医生承担平衡患者利益与家属利益的责任，称医生和替代决策者应主要以最佳利益标准为指导，并暗示只有当患者无法再表达意愿时，患者自主性才成为指导原则。
学生似乎没有内化或正确应用替代判断标准，尽管他们能够准确描述它。这表明替代判断标准可能与学生的道德直觉相悖，使其在临床实践中更难应用。
