Department of Community and Family Medicine, College of Medicine, Howard University, 500 W Street NW, Washington, DC 20059, USA.
Bioethics. 2010 Mar;24(3):145-52. doi: 10.1111/j.1467-8519.2009.01791.x.
The paper examines the ethical and legal challenges of making decisions for previously competent patients and the role of advance directives and legal representatives in light of the Oviedo Convention. The paper identifies gaps in the Convention that result in conflicting instructions in cases of a disagreement between the expressed prior wishes of a patient, and the legal representative. The authors also examine the legal and moral status of informally expressed prior wishes of patients unable to consent. The authors argue that positivist legal reasoning is insufficient for a consistent interpretation of the relevant provisions of the Convention and argue that ethical argumentation is needed to provide guidance in such cases. Based on the ethical arguments, the authors propose a way of reconciling the apparent inconsistencies in the Oviedo Convention. They advance a culturally sensitive approach to the application of the Convention at the national level. This approach understands autonomy as a broader, relational consent and emphasizes the social and cultural embeddedness of the individual. Based on their approach, the authors argue that there exists a moral obligation to respect the prior wishes of the patient even in countries without advance directives. Yet it should be left to the national legislations to determine the extent of this obligation and its concrete forms.
本文探讨了在奥维多公约背景下，为先前有能力的患者做出决策所面临的伦理和法律挑战，以及预先指示和法定代理人的作用。本文指出了公约中的一些空白，导致在患者的明确先前意愿与法定代理人之间存在分歧的情况下，出现相互冲突的指示。作者还研究了无法表示同意的患者非正式表达的先前意愿的法律和道德地位。作者认为，实证主义法律推理不足以对公约相关条款进行一致解释，需要进行伦理论证来为这种情况提供指导。基于伦理论证，作者提出了一种协调奥维多公约中明显不一致之处的方法。他们提出了一种在国家层面上应用公约的文化敏感方法。这种方法将自主性理解为更广泛的、关系性的同意，并强调个人的社会和文化背景。基于他们的方法，作者认为，即使在没有预先指示的国家，也存在尊重患者先前意愿的道德义务。然而，应该由国家立法来确定这种义务的范围及其具体形式。
