a University of Otago Bioethics Centre and Otago Community Hospice.
Am J Bioeth. 2018 Aug;18(8):20-31. doi: 10.1080/15265161.2018.1485758.
When shared decision making breaks down and parents and medical providers have developed entrenched and conflicting views, ethical frameworks are needed to find a way forward. This article reviews the evolution of thought about the best interest standard and then discusses the advantages of the harm principle (HP) and the zone of parental discretion (ZPD). Applying these frameworks to parental refusals in situations of complexity and uncertainty presents challenges that necessitate concrete substeps to analyze the big picture and identify key questions. I outline and defend a new decision-making tool that includes three parts: identifying the nature of the disagreement, checklists for key elements of the HP and ZPD, and a "think list" of specific questions designed to enhance use of the HP and ZPD in clinical decision making. These tools together will assist those embroiled in complex disagreements to disentangle the issues to find a path to resolution.
当共享决策失败，且父母和医疗服务提供者之间存在根深蒂固且相互冲突的观点时，就需要伦理框架来寻找前进的道路。本文回顾了关于最佳利益标准的思想演变，然后讨论了伤害原则 (HP) 和父母酌处权区 (ZPD) 的优势。将这些框架应用于复杂和不确定情况下的父母拒绝，会带来挑战，需要具体的子步骤来分析大局并确定关键问题。我概述并为一种新的决策工具辩护，该工具包括三个部分：确定分歧的性质、HP 和 ZPD 的关键要素检查表，以及旨在增强 HP 和 ZPD 在临床决策中的使用的“思考清单”。这些工具将共同帮助那些陷入复杂分歧的人理清问题，找到解决问题的途径。
