Decision Making on Behalf of Another: Principals, Agents, and Advance Directives

很多决定都是代表别人做的。例如，家庭成员有时必须代表无行为能力的亲人做出医疗决定。做出决定的家庭成员(代理人)必须选择她认为如果委托人可以自己决定，患者(委托人)会做出的选择。经济学家将这种关系抽象地描述为委托代理问题，其中代理人是决策人，委托人是决策的受益者。在许多情况下，委托人有机会将他的偏好和目标传达给代理人。例如，在代孕保健决策中，这种沟通通常以保健先行指令的形式出现。尽管最近提前指令很受欢迎，但几乎没有证据表明它们提高了代理人预测委托人想要什么的准确性。这样的失败可能是因为(A)委托人可能不完全指定他的偏好，以及(B)代理人可能在解释和应用委托人的目标方面能力有限。目前的研究预测是，当这样的条件适用时，代理人将使用几种启发式或捷径规则中的一种，以便代表委托人做出代理决策。在拟议的研究中探索了四种这样的启发式方法。一个主要感兴趣的问题是，这些启发式规则的使用是增加还是减少了委托人的真实偏好与代理人做出的代理决策之间的一致性。实验1和2将检验委托人的能力、代理人，以及当预先指令增加代理人的代理决策与委托人代表自己做出的决策之间的一致性时。实验3-6检验了四种假设的启发式或策略，当代理人不确定委托人的偏好时，他们将使用这些启发或策略。在投影启发式中，代理使用她自己的偏好作为委托人偏好的指南，有时会导致代理决策更类似于代理自己的偏好，而不是主体的偏好。在受托启发式中，代理人在做出代孕决定时不太愿意承担风险，而更愿意等待利益，而不是她代表自己做出决定(或比代孕母亲代表自己做出决定时)。在干预启发式中，代理人角色比委托人角色(假设委托人任命代理人“做一些事情”，而不是什么都不做)更倾向于积极或激进的干预类选项。在现状启发式中，代理人角色与坚持现状的强烈偏好相关联。最后，与实验1-6不同的是，实验7将以老年内科患者及其指定的家庭成员代理人作为研究的委托人和代理人，将决策心理学的基础研究和应用健康研究结合起来。它有可能阐明哪些启发式方法有助于，哪些阻碍代理人准确地代表委托人的偏好。这一发现可以改善撰写预先指令的做法，并通过指示如何使代孕判断更准确来促进患者的自主权。

Many decisions are made on behalf of someone else. For example, family members must sometimes make medical decisions on behalf of an incapacitated loved one. The family member making the decisions (the agent) has to select the options she thinks the patient (the principal) would make if the principal could decide for himself. Economists have described this relationship in abstract terms as the principal-agent problem, where the agent is the person making decisions and the principal is the beneficiary of those decisions. In many situations, the principal has the opportunity to communicate his preferences and objectives to the agent. In surrogate health care decision making, for example, this communication often comes in the form of an advance directive for health care. Despite the recent popularity of advance directives, there is little evidence that they improve the agent's accuracy in predicting what the principal would have wanted. Such failures could result because (a) the principal may incompletely specify his preferences, and (b) the agent may have limited competence to interpret and apply the principal's objectives. The prediction made in the current research is that when such conditions apply, the agent will use one of several heuristics or short cut rules in order to make surrogate decisions on the principal's behalf. Four such heuristics are explored in the proposed studies. A question of major interest is whether use of these heuristics increases or decreases the agreement between the principal's true preferences and the surrogate decisions made by the agent.Seven experiments are proposed. Experiments 1 and 2 will examine principal competence, agent, and when advance directives increase agreement between the agent's surrogate decisions and the decision the principal would make on his own behalf. Experiments 3 - 6 examine four heuristics or strategies hypothesized to be used by agents when they are uncertain as to the principal's preferences. In the projection heuristic, the agent uses her own preferences as a guide to the principal's preferences, sometimes resulting in surrogate decisions that are more similar to the agent's own preferences than to the principal's preferences. In the fiduciary heuristic, the agent is less willing to take risks and more willing to wait for benefits when making surrogate decisions than she would be in making decisions on his own behalf (or than the surrogate would be in making decisions on his own behalf). In the intervention heuristic, the agent role elicits a stronger preference for active or aggressive intervention-like options than does the principal role (under the assumption that principals appoint agents to "do something," rather then to do nothing). In the status quo heuristic, the agent role is associated with a strong preference to stick with the status quo. Finally, unlike Experiments 1 - 6, which will use convenience samples of lay people, Experiment 7 will use elderly medical patients and their designated family member surrogates as the principals and agents in the study.The proposed research brings together basic research on the psychology of decision making and applied health research. It has the potential to illuminate which heuristics help and which ones hinder agents in representing the principal's preferences accurately. The findings could improve the practice of writing advance directives and promote patient autonomy by indicating how to make surrogate judgments more accurate.