Ross Lainie Friedman
Carolyn and Matthew Bucksbaum Professor of Clinical Medical Ethics; Professor of Pediatrics, Medicine, Surgery, and the College; Associate Director of the MacLean Center for Clinical Medical Ethics; and Codirector of the Institute for Translational Medicine at the University of Chicago in Chicago, Illinois USA. Lross@ uchicago.edu.
J Clin Ethics. 2019 Fall;30(3):232-239.
In their thoughtful critiques of my article "Better than Best (Interest Standard) in Pediatric Decision Making," my colleagues make clear that there is little consensus on what is (are) the appropriate guidance and intervention principles in pediatric decision making, and disagree about whether one principle can serve both functions. Hester proposes his own unitary principle, the reasonable interest standard, which, like the best interest standard from which it is derived, encourages parents to aim for the great, although Hester tempers it with a pragmatic principle that allows consideration of cultural and family values and practical, financial, social, or psychological circumstances. I reject the aspirational guidance principle because it is too demanding, and I also reject the notion that this pragmatic condition "gives permission for others to extol parents to give reasons" for their decisions, because it allows too much interference into the family and its decision making. Whereas the other respondents and I focus on whether and when third parties should intervene in the doctor-patient (surrogate) relationship, Navin and Wasserman mistakenly redefine intervention to include physicians' behaviors that attempt to influence parents, ignoring the integral role of shared decision making-a bidirectional discussion in which physicians help patients (surrogates) select among reasonable medical options through education, and, when necessary, motivation or persuasion. Diekema and Salter focus on the harm principle for intervention, ignoring other conditions in which intervention may be appropriate and institutions other than the state that may intervene. Paquette's overly narrow interpretation of who has positive obligations to children fails to ensure that a child's basic interests and needs are met. Finally, Bester claims that the "need to choose the available option that best promotes or protects the child's basic interests" is akin to a focus on best interests. But constrained parental autonomy does not require parents to choose the option that best promotes a child's basic interests. Rather, it requires respect for broad parental discretion about how they raise their child unless their decisions fail to promote the child's basic needs and interests.
在对我的文章《儿科决策中优于最佳（利益标准）》的深刻批评中，我的同事们明确指出，在儿科决策中哪些是合适的指导和干预原则，几乎没有共识，并且对于一个原则是否能同时发挥这两种功能也存在分歧。赫斯特提出了他自己的统一原则，即合理利益标准，它与从中衍生出来的最佳利益标准一样，鼓励父母追求最有利的结果，不过赫斯特用一个务实的原则对其进行了调和，该原则允许考虑文化和家庭价值观以及实际、经济、社会或心理状况。我拒绝这种理想主义的指导原则，因为它要求过高，而且我也拒绝那种认为这种务实条件“允许其他人要求父母为其决定给出理由”的观点，因为它允许对家庭及其决策进行过多干涉。虽然其他受访者和我关注第三方是否以及何时应介入医患（替代者）关系，但纳文和瓦瑟曼错误地重新定义了干预，将其包括医生试图影响父母的行为，而忽略了共同决策的重要作用——这是一种双向讨论，医生通过教育帮助患者（替代者）在合理的医疗选择中进行选择，必要时还包括激励或劝说。迪凯马和索尔特关注干预的伤害原则，而忽略了其他可能适合干预的情况以及除国家之外可能进行干预的机构。帕奎特对谁对儿童负有积极义务的解释过于狭隘，无法确保儿童的基本利益和需求得到满足。最后，贝斯特声称“需要选择最能促进或保护儿童基本利益的可用选项”类似于关注最佳利益。但受限的父母自主权并不要求父母选择最能促进儿童基本利益的选项。相反，它要求尊重父母在抚养孩子方面的广泛自由裁量权，除非他们的决定未能促进孩子的基本需求和利益。
