Department of Philosophy, Oakland University, Rochester, Michigan, USA
Department of Foundational Medical Studies and Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA.
J Med Ethics. 2022 Mar;48(3):189-192. doi: 10.1136/medethics-2020-107078. Epub 2021 Feb 19.
The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases (eg, Alzheimer's disease). That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions.
指定代理人的能力（CDS）不仅仅是另一种医疗决策能力（DMC）。具有 DMC 的患者可以表达偏好、理解与该选择相关的信息、认识到该信息对其临床状况的重要性，并根据其目标和价值观来推理他们的选择。相比之下，即使患者无法理解自己的状况或推理他们的选择的相对风险和收益，他们也可能拥有 CDS。患有进行性认知疾病（例如阿尔茨海默病）的患者可能会丧失 DMC ，因为 DMC 需要复杂的手段-目的推理，因此许多或大多数类型的医疗选择都可能缺乏 DMC 的患者可能仍然拥有 CDS。也就是说，认知能力严重下降或患有精神疾病的患者仍然可以理解代理人的作用，对潜在的代理人表示偏好，并能够为这种选择提供某种理由。此外，代理选择有许多合法和相关的理由，与 DMC 的推理标准不一致。不幸的是，如果判断患者缺乏 DMC，许多患者将无法指定代理人。当这些患者拥有 CDS 时，这种做法在伦理上是错误的，法律上是可疑的，并给医疗机构带来了不必要的负担。
