Lo B, Steinbrook R
University of California, San Francisco.
Ann Intern Med. 1991 May 15;114(10):895-901. doi: 10.7326/0003-4819-114-10-895.
In a landmark decision, the U.S. Supreme Court affirmed a Missouri ruling that sharply limited family decisions about life-sustaining treatment for incompetent patients. The Court held that the Constitution protects the refusal of life-sustaining treatment by competent patients. For incompetent patients, states may require "clear and convincing" evidence of refusal, specifically for the withdrawal of tube feedings, if such a person were in a persistent vegetative state. The ruling left many clinical questions unanswered, such as whether life-sustaining treatment must be given to terminally ill incompetent patients, whether patients may refuse artificial feedings, and what constitutes clear and convincing evidence of refusal. The decision also has potentially harmful consequences. It may undermine family decision making, encourage cynicism and disregard of the law, and promote defensive medicine. Physicians can minimize such consequences by encouraging patients to provide advance directives, such as the durable power of attorney for health care, by urging legislative action, and by setting national practice standards for decisions regarding incompetent patients.
在一项具有里程碑意义的裁决中，美国最高法院维持了密苏里州的一项裁决，该裁决大幅限制了关于无行为能力患者维持生命治疗的家庭决策。法院认为，宪法保护有行为能力的患者拒绝维持生命治疗的权利。对于无行为能力的患者，如果此人处于持续植物人状态，各州可能要求有“明确且令人信服”的拒绝证据，特别是在撤掉鼻饲管的情况下。该裁决留下了许多临床问题未得到解答，比如是否必须对绝症无行为能力患者进行维持生命治疗、患者是否可以拒绝人工喂食，以及什么构成明确且令人信服的拒绝证据。该裁决也可能产生有害后果。它可能会破坏家庭决策，助长愤世嫉俗和无视法律的态度，并推动防御性医疗。医生可以通过鼓励患者提供预先指示，如医疗保健的持久授权书，敦促立法行动，并为关于无行为能力患者的决策制定全国性实践标准，来尽量减少此类后果。
