Compromised Autonomy and the Seriously III Patient
Compromised Autonomy and the Seriously III Patient
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DOI：
10.1378/chest.09-1574
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发表时间：
2010-04-01
期刊：
影响因子：
9.6
通讯作者：
Misak, Cheryl J.
中科院分区：
文献类型：
--
作者：
Tonelli, Mark R.;Misak, Cheryl J.
尊重患者自主性已成为医学伦理的首要原则，以至于已经开发了工具，如指导性指令，试图保持表面上的自主性，即使它已经变得明显和不可挽回地丧失。然而，许多围绕尊重自主的实践错误地假设，自主选择的能力是一个要么全有要么全无的命题。但重病患者可能会保留一些参与医疗护理讨论的能力，但他们的自主性因身体胁迫、认知功能障碍或精神错乱而受到严重损害。自主性受到损害的个人的选择不会像完全自主的人那样具有同样的道德影响力。因此，临床医生不能依赖这样的选择来指导医疗决定，并有义务在采取行动之前对其进行更全面的评估。我们认为，临床医生应该将自主性受损的个体的选择与对患者最佳利益的医学评估进行比较。当病人的选择和最佳利益评估不一致时，为病人的最佳利益行事有时可能会正确地凌驾于病人的要求之上。这种方法在一系列严格限制的情况下，将允许提供和不提供医疗干预，尽管患者提出了相反的要求。《胸腔》2010；137(4)：926-931
Respect for patient autonomy has become the preeminent principle of medical ethics, to the point that tools have been developed, such as instructive directives, in an attempt to preserve a semblance of autonomy even when it has become clearly and irretrievably lost. Much of the practice around the respect for autonomy, however, mistakenly supposes that the capacity for autonomous choice is an all-or-nothing proposition. But seriously ill patients may retain some ability to participate in discussions of medical care yet have their autonomy profoundly compromised by physical duress, cognitive dysfunction, or delirium. The choices of individuals with compromised autonomy do not carry the same moral weight as those of the fully autonomous. Clinicians, therefore, cannot rely on such choices for guiding medical decisions and are obligated to evaluate them more fully before acting. We argue that clinicians should compare the choices of individuals with compromised autonomy to a medical assessment of the patient's best interest. When the patient's choice and the best-interests assessment are discordant, acting in the patient's best interest may, at times, rightly override the requests of the patient. Such an approach, under a tightly constrained set of circumstances, would permit both the provision and the withholding of medical interventions despite patient requests to the contrary. CHEST 2010; 137(4):926-931