Veatch R M
Am J Law Med. 1984 Winter;9(4):427-68.
The debate concerning the legal and ethical bases of guardian refusal of medical treatment on behalf of incompetent patients often ignores critical distinctions among types of patients and guardians. For example, patients who have expressed preferences regarding treatment while competent are distinguishable from patients who have always lacked the competency requisite to expressing a treatment preference. "Bonded guardians," whose relationship with the patient preexisted guardianship, should have a different role in the decision-making process than "non-bonded guardians," who were strangers to the patient prior to the guardian-ward relationship. This Article proposes criteria for guardian treatment refusal on behalf of incompetent patients. Under the model for guardian decision making presented here, bonded guardians should be preferred over non-bonded guardians, and bonded guardians should be allowed discretion to make treatment choices, limited only by a standard of reasonableness policed by the courts. The Author presents legal and ethical justifications for the bonded guardian's heightened role. Finally, he considers the proper roles of health professionals, hospital ethics committees, and judges in the decision-making process.
关于监护人代表无行为能力患者拒绝医疗的法律和伦理依据的争论，往往忽视了患者类型和监护人类型之间的关键区别。例如，有行为能力时曾表达过治疗偏好的患者，与一直缺乏表达治疗偏好所需行为能力的患者是有区别的。“有联系的监护人”，其与患者的关系在监护关系之前就已存在，在决策过程中应比“无联系的监护人”扮演不同的角色，后者在监护人与被监护人关系建立之前对患者来说是陌生人。本文提出了监护人代表无行为能力患者拒绝治疗的标准。在此提出的监护人决策模式下，应优先选择有联系的监护人而非无联系的监护人，并且应允许有联系的监护人有做出治疗选择的自由裁量权，其限制仅为法院监督的合理性标准。作者阐述了有联系的监护人角色强化的法律和伦理依据。最后，他探讨了医疗专业人员、医院伦理委员会和法官在决策过程中的恰当角色。
