Fundacao Getulio Vargas Escola de Direito, São Paulo 01310-000, Brazil
J Med Ethics. 2020 Aug;46(8):561-562. doi: 10.1136/medethics-2020-106063. Epub 2020 Feb 13.
In a recent paper, Charles Foster argued that the epistemic uncertainties surrounding prolonged disorders of consciousness (PDOC) make it impossible to prove that the withdrawal of life-sustaining treatment can be in a patient's best interests and, therefore, the presumption in favour of the maintenance of life cannot be rebutted. In the present response, I argue that, from a legal perspective, Foster has reached the wrong conclusion because he is asking the wrong question. According to the reasoning in two leading cases and -the principle of respect for autonomy creates a against treatment without consent. Therefore, it is the continuation of treatment that requires justification, rather than its withdrawal. This presumption also works as the tiebreaker determining that treatment should stop if there is no persuasive evidence that its continuation is in the best interests of the patient. The presumption in favour of the maintenance of life, on the other hand, should be understood as an on a factual issue that is assumed to be true if unchallenged. However, the uncertainties regarding PDOC actually give reasons for displacing this evidential presumption. Consequently, decision-makers will have to weigh up the pros and cons of treatment having the presumption against treatment without consent as the tiebreaker if the evidence is inconclusive. In conclusion, when the right question is asked, Foster's argument can be turned on its head and uncertainties surrounding PDOC weigh in to justify the interruption of treatment in the absence of compelling contrary evidence.
在最近的一篇论文中，查尔斯·福斯特（Charles Foster）认为，意识障碍持续时间（PDOC）的认知不确定性使得证明停止维持生命的治疗符合患者的最佳利益变得不可能，因此，维持生命的预设不能被反驳。在本回应中，我认为，从法律角度来看，福斯特得出了错误的结论，因为他问了错误的问题。根据两个主要案例的推理以及尊重自主权的原则，创建了一项反对未经同意的治疗的规则。因此，需要对治疗的继续进行论证，而不是治疗的停止。如果没有令人信服的证据表明继续治疗符合患者的最佳利益，这种预设也可以作为打破僵局的因素，决定停止治疗。另一方面，维持生命的预设应被理解为对事实问题的假定，如果没有受到质疑，则假定为真实。然而，PDOC 的不确定性实际上为推翻这种证据假设提供了理由。因此，如果证据不明确，决策者将不得不权衡继续治疗和不治疗的利弊，而不同意治疗作为打破僵局的因素。总之，当正确的问题被提出时，福斯特的论点可以被颠倒，PDOC 周围的不确定性可以权衡利弊，在没有令人信服的相反证据的情况下中断治疗。
