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

许多决定是代表别人做出的。例如，家庭成员有时必须代表丧失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）必须选择她认为病人（委托人）会做出的选择，如果委托人可以自己决定的话。 经济学家将这种关系抽象地描述为委托代理问题，代理人是决策者，而委托人是这些决策的受益者。 在许多情况下，委托人有机会向代理人传达他的偏好和目标。 例如，在代理医疗保健决策中，这种沟通通常以医疗保健预先指令的形式出现。 尽管最近流行的预先指示，有很少的证据表明，他们提高代理人的准确性预测什么的委托人会想要的。 这种失败的原因可能是：（a）委托人可能没有完全说明他的偏好;（B）代理人解释和适用委托人目标的能力有限。 在目前的研究中所作的预测是，当这些条件适用时，代理人将使用几个代理或捷径规则之一，以使代理人的代表的决定。 在拟议的研究中探讨了四种这样的化学方法。一个主要的兴趣问题是，是否使用这些代理增加或减少委托人的真实偏好和代理人作出的代理决策之间的协议。 实验1和2将检查主要的能力，代理人，当预先指示增加代理人的代理决定和决定的主要代表他自己的同意。 实验3 - 6检查四个provisistics或策略假设被代理人使用时，他们是不确定的主要的喜好。 在投射启发式中，代理人使用自己的偏好作为对委托人偏好的指导，有时会导致代理人的决策更类似于代理人自己的偏好而不是委托人的偏好。 在信托启发式中，代理人在做出代理决策时，比她代表自己做出决策时（或者代理人代表自己做出决策时）更不愿意承担风险，更愿意等待利益。 在干预启发式中，代理人角色比委托人角色更倾向于积极或积极的干预式选项（假设委托人指定代理人“做某事”，而不是什么都不做）。 在现状启发式中，代理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以老年患者及其家属为委托人和代理人，将决策心理学的基础研究和应用健康研究结合起来。它有可能阐明哪些代理商帮助和哪些代理商阻碍代理商准确地代表委托人的偏好。 本研究结果可改善预嘱书写的实践，并借由指出如何使替代判断更准确，促进病患自主性。

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.