The experience of serious illness or injury frequently results in increased vulnerability. In cases in which decision-making capacity is compromised, this vulnerability is compounded by threats to a patient\'s autonomy. This case report presents an opportunity to explore the elaborately entwined relationship between autonomy and vulnerability in patients with severe impairment who are reliant on surrogate decision-makers. Expanded views of autonomy and vulnerability are applied to the case of a young woman with a severe and life-altering spinal cord injury and iatrogenic loss of decisional capacity to illustrate how one can experience enhanced autonomy despite special vulnerability and can be made less vulnerable through surrogate-mediated autonomy. Also revealed is how attitudes and actions of surrogates can potentiate pathogenic vulnerability and disturb the balance between patient autonomy and vulnerability. Through methodical review and robust deliberation, clinical ethics committees can play a stabilizing role in helping distressed care teams reconcile the two.

Respect of human dignity is an unquestionable part of daily clinical routine as well as of evaluations in medical ethics. Some aspects of human dignity are a subject of transformation in the course of a lifetime. If the ability to form a will is reduced, it might be difficult to satisfy the individual perception of a dignified treatment, which is of particular interest in terminal care. As illustrated by the presented case report, moral problems can arise when the patient\'s present verbal or non-verbal expressions are opposed to what is documented or what is estimated by dependants to be the individual\'s will. In clinical decision-making processes, the determination of the will via an advance directive can be overstated, which can go so far that human dignity is reduced to autonomy. A concept of dignity reduced to autonomy misses the point not only of a dignity-centered medical care but also of shared decision-making. In situations at the end of life other aspects, such as authenticity or self-actualization should be considered when respecting the individual\'s dignity. Medicine should as such not marginalize death but provide a care based on principles that focus on human interaction and respect for a comprehensive concept of dignity.
UNASSIGNED: Das Respektieren der Menschenwürde ist zweifellos ein zentraler Bestandteil des klinischen Alltags und von medizinethischen Evaluationen. Manche Aspekte der Menschenwürde unterliegen im Laufe des Lebens einer gewissen Wandlung. Wenn die Fähigkeit zur freien Willensbildung eingeschränkt ist, kann es erschwert sein, den individuellen Vorstellungen einer würdevollen Behandlung gerecht zu werden, was speziell am Lebensende an Bedeutung gewinnt. Anhand einer Kasuistik soll demonstriert werden, welche moralischen Problemstellungen auftreten können, wenn aktuelle Willensbekundungen des Patienten gegensätzlich sind zu dem, was vorausverfügt wurde oder den Angehörigen vertraut ist. Bei der klinischen Entscheidungsfindung kann die Betonung der Willensfestlegung in einer Patientenverfügung so weit führen, dass Menschenwürde auf Autonomie reduziert wird. Ein auf Autonomie reduziertes Konzept der Menschenwürde geht aber am Kern sowohl einer würdezentrierten Medizin als auch der partizipativen Entscheidungsfindung vorbei. Komplementäre Aspekte der Menschenwürde, wie beispielsweise Authentizität und Selbstaktualisierung, müssen berücksichtigt werden. Außerdem sollte die Medizin als solche den Tod nicht marginalisieren, sondern eine Versorgung, die die Prinzipien der menschlichen Interaktion und einer umfänglichen Auffassung von Würde fokussiert, anbieten.

BACKGROUND: Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.
OBJECTIVE: The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.
METHODS: Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER\'s acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.
RESULTS: Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen\'s d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.
CONCLUSIONS: EMPOWER appeared feasible and acceptable, increased surrogates\' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

BACKGROUND: Enrollment into critical care clinical trials is often hampered by the need to rely on surrogate decision-makers. To identify potential interventions facilitating enrollment into critical care clinical trials, a better understanding of surrogate decision-making for critical care clinical trial enrollment is needed.
OBJECTIVE: What are the barriers and facilitators of critical care trial enrollment? What are surrogate decision-makers\' perspectives on proposed interventions to facilitate trial enrollment?
METHODS: We conducted semistructured interviews with 20 surrogate decision-makers of critically ill patients receiving mechanical ventilation. The interviews were recorded and transcribed verbatim, and analyzed for themes using an inductive approach.
RESULTS: Thematic analysis confirmed previous research showing that trust in the system, assessing the risks and benefits of trial participation, the desire to help others, and building medical knowledge as important motivating factors for trial enrollment. Two previously undescribed concerns among surrogate decision-makers of critically ill patients were identified, including the potential to interfere with clinical treatment decisions and negative sentiment about placebos. Surrogates viewed public recognition and charitable donations for participation as favorable potential interventions to encourage trial enrollment. However, participants viewed direct financial incentives and prioritizing research participants during medical rounds negatively.
CONCLUSIONS: This study confirms and extends previous findings that health system trust, study risks and benefits, altruism, knowledge generation, interference with clinical care, and placebos are key concerns and barriers for surrogate decision-makers to enroll patients in critical care trials. Future studies are needed to evaluate if charitable giving on the patient\'s behalf and public recognition are effective strategies to promote enrollment into critical care trials.

Caring for unrepresented patients encompasses legal, ethical, and moral challenges regarding decision-making, consent, the patient\'s values, wishes, best interest, and the healthcare team\'s professional integrity and autonomy. In this article, I consider the impact of the aging population and the effects of the social determinants of health and suggest that without preventive intervention, the number of unrepresented patients will continue to increase. The health, social, and legal risk factors for becoming unrepresented require a multidisciplinary response. Medical-Legal Partnerships (MLPs) bring healthcare and legal professionals together to address risk factors and health-harming legal needs. The article discusses the role of MLPs in identifying at-risk individuals, providing preventive interventions, and providing support. I make recommendations and conclude that proactive MLPs offer a sustainable approach to the ethical challenges in caring for unrepresented patients by providing interventions to prevent individuals from becoming unrepresented.

As the incidence of dementia rises, increased utilization of surrogate decision-makers, including legal guardians, is anticipated. This manuscript presents an analysis of resident physicians\' experiences and perceptions regarding requirements, roles, and responsibilities of caring for older adults in need of, or already under, legal guardianship. This is a cross-sectional study, conducted at a tertiary academic medical center. A survey was sent, via Qualtrics, to all emergency medicine, family medicine, internal medicine, general surgery, and medicine-pediatric resident physicians. Eighty-eight out of three hundred thirty-three (26.4%) eligible residents physicians completed the survey. Most (98.9%) reported caring for patients under guardianship, yet many resident physicians reported significant uncertainty regarding the roles and responsibilities of guardianship, including its potential benefits and limitations. They also displayed misconceptions and overconfidence about guardians\' abilities to facilitate disposition, ensure financial security, and assign code status, among other matters. Our study highlights the importance of structured and directed education on the topic of guardianship for medical trainees.

Although people who endorse conspiracy theories related to medicine often have negative attitudes toward particular health care measures and may even shun the healthcare system in general, conspiracy theories have received rather meager attention in bioethics literature. Consequently, and given that conspiracy theorizing appears rather prevalent, it has been maintained that there is significant need for bioethics debate over how to deal with conspiracy theories. While the proposals have typically focused on the effects that unwarranted conspiracy theories have in the public health context, Nathan Stout\'s recent argument concentrates on the impacts that such theories have at the individual level of clinical decision-making. In this article, I maintain that duly acknowledging the impacts of conspiracy theories that raise Stout\'s concern does not require bioethics debate over the proper response to the influence of conspiracy theories in healthcare. Having evaluated two possible objections, I conclude by briefly clarifying the purported import of the response to Stout.

暂无摘要。

Many people with dementia are interested in taking part in research, including when they no longer have capacity to provide informed consent. Advance research directives (ARD) enable people to document their wishes about research participation prior to becoming decisionally incapacitated. However, there are few available ARD resources. This Australian interview study elicited the views of people aged 55 years and older about the content of an ARD form and guidance booklet and processes to support research planning. Participants (n = 25; 55 to 83 years) had interests in dementia research. All participants described the ARD materials as easy to understand, and all expressed willingness to take part in future research. Nearly half believed that an ARD should be legally enforceable, while others saw it as a nonbinding document to guide decisions about their participation in research. Close family members were preferred as proxy decision-makers. The ARD form and guidance booklet may be adapted for use elsewhere.

Food allergy remains a common problem and a lifelong condition for many children. In recent years, food allergy management has increasingly involved conversations about food oral immunotherapy (OIT). Although ethical considerations of autonomy, beneficence, nonmaleficence, and justice implicitly inform these conversations, applying these principles can be complex, particularly in young children. Families of young children assume a role of surrogate decision-maker and must balance immediate risks with the hope of longer-term benefits.
To explore implementation of OIT in children through an ethical lens.
To evaluate OIT through an ethical lens, we conducted a literature search to explore currently published frameworks in this area.
Evaluation of the harm principle, the basic interest principle, and the best interest principle of parental decision-making can be informative. Shared decision-making continues to be central to the process of engaging with patient-family units to individualize the best care, at the right time, and minimize decisional discord. Although OIT is well-positioned to promote health and well-being, challenges to equity, sustainability, and organizational support must be considered to improve access for appropriate patients.
Whereas approaches to food OIT may be tailored to the individual context of each patient-family unit, ethical principles must guide decisions to initiate and continue therapy. Traditional ethical principles of autonomy, beneficence, nonmaleficence, and justice remain cornerstones when considering the ethical context of OIT.