Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.
Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.
J Med Ethics. 2018 Apr;44(4):226-233. doi: 10.1136/medethics-2017-104414. Epub 2017 Oct 25.
It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making.
在医学伦理学家中，普遍认为能力是知情同意的必要条件。在这种观点下，如果患者没有能力做出特定的治疗决策，那么该决策必须基于事先指示或由替代决策人代表患者做出。我们将其称为能力模型。根据联合国人权事务高级专员的一份最新报告，联合国残疾人权利公约（CRPD）第 12 条对能力模型提出了全面否定。高级专员在此采用了残疾人权利委员会提出的对第 12 条的解释。根据这一解释，CRPD 第 12 条规定，不得以决策能力受损为由剥夺精神残疾人士做出治疗决策的权利，并要求用支持性决策取代所有替代决策制度。在本文中，我们详细阐述了 CRPD 第 12 条对精神残疾人士的六个不利后果，并提出了另一种前进的方式。所提出的模式结合了能力模型和支持性决策的优势。
