Nicolini Marie Elisabeth
Katholieke Universiteit Leuven, Center for Biomedical Ethics and Law, Leuven, Belgium.
Department for Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, United States.
Front Psychiatry. 2021 Sep 27;12:703709. doi: 10.3389/fpsyt.2021.703709. eCollection 2021.
Physician aid in dying (PAD) based on dementia is a contentious, highly debated topic. Several countries are considering extending their existing laws to include requests in incompetent patients based on a previously written advance directive. Discussions about this issue often invoke a distinction based on disease stage. The Dutch practice uses this distinction in classifications of dementia PAD cases and in guidance for clinicians. This paper explores the problem with this distinction for assessments of persons at the margins of competence. Dutch guidance for clinicians uses an early vs. late-stage disease distinction to refer to requests from competent and incompetent persons. However, the use of disease stages is problematic, both conceptually and empirically. Conceptually, because it goes against very functional model of competence that guidance recognizes. Empirically, because it creates problems for classifying and evaluating patients at the margins of competence. Classification of cases and guidance should be based on competence, not disease stage. This requires rethinking decision-making for patients with dementia. Several possibilities are described, ranging from redefining the scope and role of advance directives in this context to exploring different types of decision-making frameworks.
基于痴呆症的医生协助死亡（PAD）是一个有争议的、备受热议的话题。几个国家正在考虑扩大现有法律范围，将基于先前签署的预先指令的无行为能力患者的请求纳入其中。关于这个问题的讨论常常基于疾病阶段进行区分。荷兰的做法在痴呆症PAD病例分类以及临床医生指导中使用了这种区分。本文探讨了这种区分在评估处于行为能力边缘的人时存在的问题。荷兰临床医生指导依据疾病早期与晚期的区分来处理有行为能力者和无行为能力者的请求。然而，疾病阶段的使用在概念和实证方面都存在问题。从概念上讲，因为它违背了指导所认可的行为能力功能模型。从实证角度看，因为它在对处于行为能力边缘的患者进行分类和评估时产生了问题。病例分类和指导应基于行为能力，而非疾病阶段。这需要重新思考痴呆症患者的决策制定。文中描述了几种可能性，从重新定义在此背景下预先指令的范围和作用到探索不同类型的决策框架。
