Institute of Medical Information, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100020, China.
School of Public Health, Peking University Health Science Center, Beijing, 100191, China.
J Bioeth Inq. 2022 Mar;19(1):163-175. doi: 10.1007/s11673-021-10159-3. Epub 2022 Jan 11.
As patient autonomy expands, a highly controversial issue has emerged. Should the advance directives (ADs) of refusing life-saving treatments or requesting euthanasia of persons with dementia (PWDs) who express changed minds or are often in a happy state be fulfilled? There are two autonomy-related positions. The mainstream position in philosophical discussions supports the priority of ADs based on precedent autonomy. Buchanan and Brock, and Dworkin represent this view. The other position supports the priority of PWDs' current wishes based on minimal autonomy represented by Jaworska. By rethinking the theoretical and practical challenges of the two positions and their arguments respectively, the paper concludes that in such a scenario, the priority of ADs is morally indefensible, and it is also challenging to establish minimal autonomy defend the moral priority of PWDs' current wishes. For PWDs whose past values, beliefs, and preferences fade away but who retain apparent intrinsic sentience of well-being, a modified defined quality-of-life (QoL) approach serves as another reasonable basis in their medical decision-making, and the ADs and the QoL should be further merged to reduce the uncertainty of the grey zone.
随着患者自主权的扩大，一个极具争议的问题出现了。对于表达过改变意愿或经常处于幸福状态的痴呆症患者（PWDs），他们的拒绝救生治疗或请求安乐死的预先指示（ADs）是否应该得到执行？存在两种与自主权相关的立场。哲学讨论中的主流立场支持基于先例自主权的 ADs 的优先级。布坎南和布罗克以及德沃金代表了这种观点。另一种立场支持基于 Jaworska 所代表的最低自主权的 PWDs 当前意愿的优先级。通过重新思考这两个立场及其论点在理论和实践方面的挑战，本文得出结论，在这种情况下，ADs 的优先级在道德上是站不住脚的，而且也很难确立最低自主权来捍卫 PWDs 当前意愿的道德优先级。对于那些过去的价值观、信仰和偏好逐渐消失但仍然保留明显内在幸福感的 PWDs，一种经过修正的明确生活质量（QoL）方法可以作为他们医疗决策的另一个合理依据，并且 ADs 和 QoL 应该进一步合并，以减少灰色地带的不确定性。
