Arrieta Valero Ion
Department of Philosophy, ETICOP-IT: Ethics Training in Communities of Practice - Ikerketa Taldea (Research Group), IAS-Research Center for Life, Mind and Society, University of the Basque Country (UPV/EHU), Donostia-San Sebastián, Spain.
Front Psychol. 2019 Aug 14;10:1857. doi: 10.3389/fpsyg.2019.01857. eCollection 2019.
In recent years, several studies have advocated the need to expand the concept of patient autonomy beyond the capacity to deliberate and make decisions regarding a specific medical intervention or treatment ( or ). Arguing along the same lines, this paper proposes a multidimensional concept of patient autonomy (decisional, executive, functional, informative, and narrative) and argues that determining the specific aspect of autonomy affected is the first step toward protecting or promoting (and respecting) patient autonomy. These different manifestations of autonomy are not mutually dependent; there may be patients who have problems in one dimension, while at the same time being fully autonomous in others. Nevertheless, a close interaction has been observed between the various dimensions, and indeed, a phenomenological analysis shows that damage to or a reduction in one aspect of people's capacity for self-government generally affects other aspects of their autonomy, which in turn disrupts their identity and the way in which they see themselves and are seen by others. In this paper, I shall examine some of these interactions and show how they may lie at the heart of the problem of poor treatment adherence in many patients with chronic ailments (where adherence is defined as being the extent to which a patient's behavior over time coincides with the recommendations made by and agreed with their health professional). One example given is that of psoriasis, a chronic skin disease with a very poor adherence record. In Spain, it is calculated that 85% of patients diagnosed with mild to moderate psoriasis fail to comply properly with their treatment, and figures from other parts of the world are similar. Although there are many possible causes for non-adherence among psoriasis patients, assessing their decisional, executive, and narrative capacities and taking appropriate action based on the results may help increase adherence rates.
近年来，多项研究主张有必要将患者自主权的概念扩展到对特定医疗干预或治疗进行深思熟虑并做出决策的能力之外。基于同样的思路，本文提出了一个多维的患者自主权概念（决策、执行、功能、信息和叙事），并认为确定自主权受到影响的具体方面是保护、促进（以及尊重）患者自主权的第一步。自主权的这些不同表现并非相互依存；可能存在这样的患者，他们在某一个维度上存在问题，而在其他维度上却完全自主。然而，已观察到各维度之间存在密切的相互作用，事实上，现象学分析表明，人们自我管理能力的一个方面受到损害或降低，通常会影响其自主权的其他方面，进而扰乱他们的身份认同以及他们看待自己和被他人看待的方式。在本文中，我将探讨其中的一些相互作用，并说明它们如何可能是许多慢性病患者治疗依从性差这一问题的核心所在（其中依从性被定义为患者随时间推移的行为与健康专业人员给出并经其同意的建议相符的程度）。给出的一个例子是银屑病，这是一种治疗依从记录很差的慢性皮肤病。据计算，在西班牙，85%被诊断患有轻度至中度银屑病的患者未能正确遵守其治疗方案，世界其他地区的数据也类似。尽管银屑病患者不依从的原因有很多，但评估他们的决策、执行和叙事能力，并根据结果采取适当行动，可能有助于提高依从率。
