MIES biblioteka

Naujausi A B C D E F G H I J K L M N O P R S T V W Y Z

Metai: 1992
ISBN: 0521311969
Leidykla: Cambridge : Cambridge University Press
Brūkšninis kodas: 4036704
Ieškoti VUB kataloge

     This book is the most comprehensive treatment available of one of the most urgent and yet in some respect most neglected problems in bioethics: decision making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part two applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly, and psychiatric patients.
     The authors` approach combines a probing analysis of fundamental issues in ethical theory with sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike.

Preface xi
Introduction 1
I. The question 1
II. The history of the problem 2
III. Ethics and the law 4
IV. Ethics and public policy analysis 5
V. The method 7
VI. The plan 9
Part one Theory 15
Chapter 1: Competence and incompetence 17
I. The concept of competence 18
A. Competence as decision-relative 18
B. Global Conceptions of competence 20
II. Capacities needed for competence 23
III. Competence as a threshold concept, not a comparative one 26
IV. Standards of competence: Underlying values29
A. Promotion of individual well-being 29
B. Respect for individual self-determination 36
C. Conflict between the values of self-determination and well-being 40
V. Contract with a single value foundation – individual self-determination as sovereign 41
VI. Deciding on standards of competence 47
VII. Different standards of competence 48
A. A minimal standard of competence 49
B. An outcome standard of competence 49
C. A process standard of decision-making competence 50
VIII. Relation of the process standard of competence to expected harms and benefits 51
Table 1.1: Decision-making competence and patient well-being 53
IX. Relation of refusal of treatment to determination of incompetence 57
X. Contract with a fixed minimum threshold conception of competence 59
XI. A two-step model of patient decision-making authority – the competence of the decision-maker and the rationality of his or her choice 65
XII. Operational measures in the medical setting 70
A. Use of formal tests to determine competence 71
B. Importance of informal evaluations of competence 73
XIII. Competence determinations in nonmedical settings 75
XIV. Varying standards of competence 77
A. Difficulties raised by determinations regarding the incompetent`s finances 78
XV. The need for institutional policies for the determination of competence 84
Chapter 2: The primary ethical framework:
Patient-centered principles 87
I. The need for an ethical framework 87
II. Underlying ethical values 89
A. The scope of the competent patient1s right to refuse treatment 90
B. Limitations on the competent person`s right to refuse care or treatment 92
III. Guidance principles 93
IV. Conflicts among guidance principles 96
V. The advance directive principles 98
A. The case against always giving priority to advance directives 101
1. Practical problems 101
2. Moral objections103
B. Conclusions: The scope and limits of the moral authority of advance directives 110
VI. The substituted judgment standard 112
VII. Scope and limits of the moral authority of substituted judgment 117
VIII. The best interest principle 122
A. Beyond the scope of the best interest principle: Permanently unconscious patients 126
B. The individual`s interest in the good of others 132
C. The dependence of the patient`s well-being on institutional options and other`s interest in the patient 133
IX. Authority principles: Who should decide? 134
A. The family as decision-maker 136
B. Disagreements within the family 138
C. Physicians and judges as decision-makers 139
X. Intervention principles: Attempts to specify conditions that rebut the presumptive authority of the family 142
A. Challenges to the family as decision-maker 147
B. The institutional ethics committee 148
Chapter 3: Advance directives, personhood, and personal identity 152
I. The value of advance directives 152
II. The moral authority of advance directives 152
III. Loss of personal identity 154
IV. How much psychological continuity is enough? 159
V. Surviving interests 162
VI. The distinction between the surviving interests of a self that no longer exists and the surviving interests in the persisting self 165
VII. Attempts to raise the threshold for psychological continuity 169
VIII. A compromise position 178
IX. Conclusions concerning personal identity 184
Chapter 4: Distributive justice and the incompetent 190
I. The need to qualify the patient-centered approach 190
II. The relevance of guidance principles to questions of distributive justice 191
III. Incompetence, moral status, and rights of distributive justice 193
A. The permanently unconscious; Minimal interests 194
B. The severely and permanently demented: Truncated interests 196
IV. Rationing health care: The role of physicians and surrogates deciding for incompetents 200
V. The moral responsibility of families toward elderly incompetent individuals 207
Part two Applications 213
Chapter 5: Minors 216
I. Noninfant minors 216
A. The current legal presumptions of incompetence 216
B. The concept of competence 217
C. The developmental evidence about children`s decision-making capacities 218
D. Determining a standard of competence 224
E. The values at stake in the competence determination 225
F. The child`s well-being 226
G. The child`s self-determination 229
H. The parent`s interest in making decisions concerning their children 232
I. Children`s cmpetence and children`s decisional authority 234
J. The legitimate interests of parents and the best interest principle 235
K. The variable standard of competence 237
L. Implications for medical practice and legal policy regarding children`s competence 240
II. Newborns 246
A. The correct guidance principle: Bet interest, not substituted judgment 246
B. The nature of the infant`s interests 247
C. The interests of others 259
D. The fundamental moral status of infants:
A radical challenge to the decision-making framework 260
Chapter 6: The Elderly
I. The magnitude of the problem 267
Table 6.1: Share of U.S. population over 64 years of age, 1900, 1940, 1960, 1975, and 2000 269
Table 6.2: Distribution of U.S. elderly population by age-group, 1950, 1975 and 2000 269
II. How incompetence is determined, formally and informally, and by whom, in various settings 271
A. Determining competence to make medical decisions 272
B. Formal determinations of incompetence for decisions concerning finances and places of residence 280
III. How surrogates actually decide for those elderly individuals who are considered to be incompetent 289
IV. Some important trends in recent case law 290
V. Advance directives and other planning approaches:
Who uses them and how effective are they? 295
A. Livings wills 296
B. Durable powers of attorney 297
1. General durable power of attorney 297
2. Durable power of attorney for health care 298
VI. Summary 306
Chapter 7: The Mentally ill 311
I. Decisions about involuntary hospitalization or commitment 312
A. The historical context of involuntary commitment 312
B. Patient-centered commitment – danger to self versus need for care and treatment 317
C. Society-centered commitment – dangerousness to others 325
II. Decisions to refuse treatment by involuntary committed patients 332
A. The historical context of treatment refusal by involuntarily committed patients 332
B. An ethical framework for treatment refusal by involuntarily committed mental patients 336
1. Persons dangerous to others 336
2. Persons dangerous to themselves or in need of care and treatment 342
III. Some residual issues in decisions for the mentally ill 347
A. The least restrictive alternative condition 347
B. Advance directives by the mentally ill 350
C. Involuntary outpatient commitment 358
D. Special limits on surrogate consent for “inhumane” treatments 361
Looking forward 366
Appendix one : Living trust and nomination of conservatorship 370
Appendix two: Durable power of attorney for health care 374
Notes 387
Index 413

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