Center for Ethics in Health Care, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA.
J Med Ethics. 2011 Jun;37(6):339-43. doi: 10.1136/jme.2010.038950. Epub 2011 Feb 2.
There are two contrasting views on the decision-making for life-sustaining treatment in advanced stages of dementia when the patient is deemed incompetent. One is to respect the patient's precedent autonomy by adhering to advance directives or using the substituted judgement standard. The other is to use the best-interests standard, particularly if the current judgement on what is best for the incapacitated patient contradicts the instructions from the patient's precedent autonomy. In this paper, I argue that the protracted clinical course of dementia over many years requires the extended perspective of a progressive decision-making process-extended in both social space and time. The ongoing debate between these two competing views has missed this perspective by focussing on an exclusive disjunction between the competent former self and the incompetent current self. Drawing on theories of situated cognition in cognitive science, I will show that the cognition of a demented patient can be viewed as extended and embodied by her supportive social environment. As the disease progresses, the content of the mind of a demented person becomes partially constituted by such external resources along with her diminishing intrinsic mind. With this understanding, medical decision-making for a demented patient can be construed as a temporally and socially extended practice. A collective decision-making body consisting of the patient, her family and surrogates, and the clinician, should make progressive decisions as a whole over years of the disease course. Finally, I will provide a practical example of how this proposal can be applied in clinical practice.
当痴呆症进入晚期且患者丧失能力时，对于维持生命的治疗决策存在两种截然不同的观点。一种观点是通过遵守预先指示或使用替代判断标准来尊重患者先前的自主权。另一种观点是使用最佳利益标准，特别是如果当前对丧失能力患者的最佳判断与患者先前自主权的指示相矛盾。在本文中，我认为，痴呆症多年来的漫长临床过程需要一个渐进决策过程的扩展视角——在社会空间和时间上都进行扩展。这两种相互竞争的观点之间的持续争论忽略了这一视角，而是将重点放在有能力的前自我和无能力的当前自我之间的排他性不连续上。通过借鉴认知科学中情境认知理论，我将表明，痴呆症患者的认知可以通过她的支持性社会环境得到扩展和体现。随着疾病的发展，痴呆症患者的思维内容部分由这些外部资源以及她不断减少的内在思维构成。有了这种理解，对痴呆症患者的医疗决策可以被构建为一个具有时间和社会延伸性的实践。一个由患者、她的家人和代理人以及临床医生组成的集体决策机构应该在疾病过程的多年中作为一个整体做出渐进式决策。最后，我将提供一个实际的例子来说明如何将这一建议应用于临床实践。
