Towards a European understanding of advance decision-making: a comparative, interdisciplinary approach.

病人自主原则强调对病人作为个体的尊重，而不是作为关注的对象；促进先例自治的尝试旨在将这种尊重扩展到那些不再有能力行使自主权的人，从而优先考虑患者的愿望，而不是第三方评估的她的福利。预先决策/指令（ADs）使个人能够在能力范围内做出选择，而这些选择将在未来个人缺乏能力做出同时决策时生效。预先医疗决策发生在一系列情况下，包括与生命终结治疗有关的决定，通常侧重于拒绝维持生命的治疗；涉及与临终关怀无关的身体保健的广告，例如，包括通常包括积极要求治疗（如硬膜外麻醉）以及拒绝治疗的生育计划；以及与精神治疗相关的广告，其中患有严重精神疾病的人列出了他们的治疗偏好。在这两种情况下，AD都可以作为一种重要的机制，传达先前的自主性，弥合丧失行为能力的发生，并提供一个明确的声明，说明患者希望如何接受治疗，或者更常见的是，患者不希望接受何种治疗。预见性决策提供了巨大的希望，可以为那些缺乏能力的人的赋权做出重大贡献，但预见性决策和同期决策之间存在重要的不对称，这可能会破坏AD的法律和道德权威。AD是一种单向的沟通形式，只有当患者缺乏能力，因此无法再讨论替代治疗和护理方案，无法澄清她的愿望，或可能取消她先前表达的愿望时，这种沟通形式才会生效。发生重大问题的原因是，与当时的决策不同，ADs的目的是在未来的一段时间内生效，届时治疗方案的范围和可用的治疗可能发生变化，或者个人的兴趣可能与预期的完全不可预见地不同。此外，可能会出现一些实际问题，包括如何确保退休是自愿的，以及个人有必要的能力作出退休。这些问题与时间和心理距离密不可分，时间和心理距离将AD与应该实施的时间分开，但AD也让人质疑社会对维护生命神圣性的兴趣与患者自决权利之间的相互作用。因此，AD通常受到严格的有效性和适用性要求的约束，这些要求通常赋予负责实施AD的医疗保健专业人员很大的自由裁量权，以确定AD在发生的治疗场景中是否具有约束力。欧洲委员会的人权和生物医学公约（1997）要求考虑病人先前表达的意愿（第9条），要求至少对先例自治有最低限度的考虑。一些欧洲司法管辖区走得更远，试图澄清ADs的地位，并通过对至少一些ADs的重要性和约束性提供法定承认来促进法律确定性。本系列研讨会将考虑一系列欧洲立法对预期决策的回应，试图在提前决策发生的实际背景下探讨这些回应。它将把法律话语与政策和实践话语联系起来，并考虑对预期决策的目的和潜力的共同理解如何有助于起草既反映提交人意图又有可能在以后由医疗保健专业人员实施的ADs。

The principle of patient autonomy emphasises respect for the patient as an individual, rather than as an object of concern; attempts to promote precedent autonomy aim to extend that respect to those no longer capable of exercising autonomy and so to prioritise the patient's wishes over her welfare as assessed by third parties. Advance decisions/directives (ADs) enable individuals to make choices during times of capacity that will take effect in the future when the individual lacks the capacity to make a contemporaneous decision. Advance medical decision-making occurs in a range of situations, encompassing decisions relating to end-of-life treatment, typically focussed upon refusals of life-sustaining treatment; ADs concerning physical health care unrelated to end of life care, including for example birth plans which typically include positive requests for treatments (e.g. an epidural) as well as refusals of treatment; and ADs relating to psychiatric treatment, where individuals with severe mental illness set out their treatment preferences. In each of these situations an AD can act as an important mechanism for conveying precedent autonomy, bridging the occurrence of incapacity and providing a clear statement of how the patient wants to be treated, or more usually what treatment the patient does not wish to be given.Anticipatory decision-making offers great promise and could make a substantial contribution to the empowerment of those lacking capacity, but there are important asymmetries between anticipatory and contemporaneous decision-making that could potentially undermine both the legal and moral authority of an AD. An AD is a mono-directional form of communication that takes effect only once the patient lacks capacity and is therefore no longer able to discuss alternative treatment and care options, to clarify her wishes, or potentially to rescind her previously expressed wishes. Significant problems occur because, unlike contemporaneous decisions, ADs are intended to take effect at a future time when the range of treatment scenarios and treatment that will be available may have changed, or the individual's interests may be radically and unforeseeably different from those anticipated. Moreover, practical problems may arise, including how to ensure that the AD was voluntary and that the individual had the requisite capacity to make it. Such problems are inextricably linked to the temporal and psychological distance that separates the AD from the time at which it should be implemented, but ADs also call into question the interplay between society's interest in upholding the sanctity of life and the patient's right to self-determination. As a result, ADs are usually subjected to stringent validity and applicability requirements, requirements that typically give significant discretion to the healthcare professional charged with implementing the AD to determine whether or not the AD is binding in the treatment scenario that occurs.The Council of Europe's Convention on Human Rights and Biomedicine (1997) requires that account is taken of a patient's previously expressed wishes (Article 9), demanding at least a minimal consideration of precedent autonomy. A number of European jurisdictions have gone further, seeking to clarify the standing of ADs and to promote legal certainty by providing statutory recognition of the importance and binding nature of at least some ADs.This seminar series will consider a range of European legislative responses to anticipatory decision-making, seeking to explore those responses within the practical contexts within which advance decision-making occurs. It will link legal discourse with policy and practice discourses, and consider how a shared understanding of the purpose and potential for anticipatory decision-making may facilitate the drafting of ADs that both reflect the author's intentions and are likely to be capable of implementation by healthcare professionals at a later date.