Centre for Ethics in Medicine, Population Health Sciences, Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
BMC Med Ethics. 2021 Jun 1;22(1):68. doi: 10.1186/s12910-021-00636-0.
Best interests is a ubiquitous principle in medical policy and practice, informing the treatment of both children and adults. Yet theory underlying the concept of best interests is unclear and rarely articulated. This paper examines bioethical literature for theoretical accounts of best interests to gain a better sense of the meanings and underlying philosophy that structure understandings.
A scoping review of was undertaken. Following a literature search, 57 sources were selected and analysed using the thematic method.
Three themes emerged. The first placed best interests within the structure of wider theory, noting relationships with consequentialism, deontology, prudential value theory, rights and political philosophy. The second mapped a typology of processes of decision-making, among which best interests was ambiguously positioned. It further indicated factors that informed best interests decision-making, primarily preferences, dignity and quality of life. The final theme considered best interests from a relational perspective.
Characterisation of best interests as strictly paternalist and consequentialist is questionable: while accounts often suggested a consequentialist basis for best interests, arguments appeared philosophically weak. Deontological accounts, found in law and Kantianism, and theories of political liberalism influenced accounts of best interests, with accounts often associating best interests with negative patient preferences (i.e. individual refusals). There was much more emphasis on negative interests than positive interests. Besides preference, factors like dignity and quality of life were held to inform best interests decisions, but generally were weakly defined. To the extent that preferences were unable to inform decision making, decisions were either made by proxy authority or by an intersubjective process of diffuse authority. Differing approaches reflect bifurcations in liberal philosophy between new liberalism and neo-liberalism. Although neither account of authority appears dominant, bias to negative interests suggests that bioethical debate tends to reflect the widespread ascendancy of neo-liberalism. This attitude was underscored by the way relational accounts converged on private familial authority. The visible connections to theory suggest that best interests is underpinned by socio-political trends that may set up frictions with practice. How practice negotiates these frictions remains a key question.
最佳利益是医学政策和实践中无处不在的原则，适用于儿童和成人的治疗。然而，最佳利益概念背后的理论基础尚不清楚，也很少有明确的表述。本文通过考察生物伦理文献中的理论观点，来更好地理解构成理解的意义和潜在哲学。
进行了范围界定审查。在文献搜索之后，选择了 57 个来源，并使用主题方法进行了分析。
出现了三个主题。第一个将最佳利益置于更广泛理论的结构中，注意到与后果主义、义务论、审慎价值理论、权利和政治哲学的关系。第二个绘制了决策过程的类型学，其中最佳利益的定位模棱两可。它进一步指出了告知最佳利益决策的因素，主要是偏好、尊严和生活质量。第三个主题从关系的角度考虑最佳利益。
将最佳利益严格描述为家长式和后果主义是值得怀疑的：尽管这些观点常常暗示了最佳利益的后果主义基础，但这些观点在哲学上似乎很薄弱。在法律和康德主义以及政治自由主义理论中发现的义务论观点影响了最佳利益的观点，这些观点通常将最佳利益与消极的患者偏好（即个人拒绝）联系起来。对消极利益的重视远远超过了积极利益。除了偏好之外，尊严和生活质量等因素也被认为会影响最佳利益决策，但通常定义较弱。在偏好无法指导决策的情况下，决策要么由代理权威做出，要么由分散权威的主体间过程做出。不同的方法反映了新自由主义和新自由主义之间的自由哲学的二分法。尽管两种权威观点都不占主导地位，但对消极利益的偏见表明，生物伦理辩论往往反映了新自由主义的广泛盛行。这种态度在关系观点趋同于私人家庭权威的方式下得到了强调。与理论的明显联系表明，最佳利益是由可能与实践产生摩擦的社会政治趋势支撑的。实践如何协商这些摩擦仍然是一个关键问题。
