Purpose: A systematic review and meta-analysis was conducted to identify what factors have been investigated as correlates of the 4 key domains of treatment decision making capacity (TDMC) in people who have experienced psychosis (understanding, reasoning, appreciation, communication) and to provide estimates of the magnitude of these correlations, taking into account study quality. A novel empirical study was conducted to test the hypothesis that variance in psychosis-specific cognitive biases (including the well-established ‘jumping to conclusions’ bias) would account for unique variance in TDMC domains in those with psychosis, after taking into account the known contribution of symptoms and insight. A secondary aim of the empirical study was to examine for the first time the relationship between TDMC and personal recovery in this group, and post hoc analyses of the relationship between cognitive biases, emotional distress and TDMC were also conducted. Methods: Electronic databases were systematically searched for literature on the schizophrenia and psychosis and treatment decision making capacity. Pooled estimates of correlation were estimated for factors with data from three or more studies, and both study and outcome quality were systematically assessed. A cross-sectional observational study was conducted, and individuals with psychosis completed measures of TDMC, cognitive biases, psychotic symptoms and recovery. Multiple regression was used to examine the primary and secondary hypotheses, and mediation analyses were used to conduct the post hoc analyses. Additional data from a parallel study was incorporated to increase power. Results: Twenty-four studies met inclusion criteria for the systematic review and meta-analysis. Low to moderate quality evidence suggested that the ability of people with psychosis to understand treatment-relevant information was strongly associated with overall psychotic symptom severity, verbal cognitive functioning and years of education, but not depression (moderate quality evidence). Low quality evidence suggested reasoning was strongly associated with verbal cognitive functioning and moderately associated with symptoms. Appreciation was associated with symptoms, but it and communication were generally poorly studied. Findings from the empirical study suggest that cognitive biases, and the Jumping to Conclusions bias in particular, predicts a moderate amount of the variance in the understanding and reasoning TDMC domains, but did not add predictive power to a model containing symptoms, insight, and cognition. The appreciation domain was strongly predicted by cognitive biases, insight, and cognition. TDMC was not found to be correlated with personal recovery and post hoc analyses did not find that emotional distress mediated any relationship between cognitive biases and TDMC. Conclusions: The meta-analysis confirms there is a robust association between symptoms and TDMC in psychosis, as currently conceived. The empirical study suggests cognitive biases may be related to TDMC, even after taking into account the contribution of symptoms. Larger studies, perhaps employing experimental procedures, are required to clarify the exact nature of this relationship. The lack of any relationship between TDMC and service-user defined recovery from psychosis is notable, and lends support to those calling for a conceptualisation of TDMC that takes greater account of this concept.

Purpose: A systematic review and meta-analysis was conducted to test key predictions of the widely-studied ‘paranoia as defence’ model (more formally known as the ‘attribution–self-representation cycle’) proposed by Bentall, Corcoran, Howard, Blackwood, and Kinderman (2001), as applied to people with psychosis with persecutory delusions. A novel case series was also conducted to examine the feasibility and acceptability of collaborative psychological assessment and formulation of impaired treatment decision-making capacity (TDMC) among patients with psychosis, and produce preliminary data on safety and efficacy. Methods: With regard to the systematic review and meta-analysis, people with psychosis with persecutory delusions were compared to healthy controls, people with depression and people with psychosis without persecutory delusions (and, if specified, grandiose delusions) on a number of outcomes: externalising attributional bias, explicit self-esteem, implicit self-esteem and discrepancy between implicit and explicit self-esteem. Correlations between paranoia severity and each of these outcomes and self-esteem instability were also examined. In regards to the case series, a formulation of impaired TDMC for 5 patient participants was developed and shared with 13 clinician participants. Acceptability, utility, working alliance and safety were assessed through pre and post self-report and interview measures. Results: Sixty-three studies were included in the meta-analysis and systematic review, of which 33, 36, 10, 10 and 4 were used to test hypotheses on externalising attributional bias, explicit self-esteem, implicit self-esteem, implicit-explicit self-esteem discrepancy and selfesteem instability, respectively. Key model-consistent findings included the following: people with psychosis with persecutory delusions had a greater externalising attributional bias compared to all the other groups and a greater implicit-explicit self-esteem discrepancy than people with depression, and paranoia severity was positively correlated with externalising attributional bias and self-esteem instability. Key model-inconsistent findings included the following: people with psychosis with persecutory delusions had lower explicit self-esteem than healthy controls, and paranoia severity was negatively correlated with explicit self-esteem. There were also some model-inconclusive findings. Regarding the case series, 3 of the patient participants collaborated in the development of their formulation. They found the intervention safe and acceptable, following which they provided a much richer understanding of the factors that may impair their TDMC (Cohen’s d = 2.16). Two patient participants only partially adhered to the intervention protocol, but a psychological formulation was still feasible to produce and no adverse effects were reported. Clinician participants provided a much richer understanding of the factors that may impair the patient participants’ TDMC (Cohen’s d = 1.36; 95% CI = 0.63 to 2.07) after the presentation of the case formulations. Increases in knowledge, confidence and positive attitudes regarding supporting the TDMC of patients were observed. They strongly believed that the formulations cohered with their knowledge of the patient participants and were comprehensive and accurate. Conclusions: The findings of the systematic review and meta-analysis support a ‘weak’ version of the paranoia as defence model, which suggests persecutory delusions are only partially effective at protecting low implicit self-esteem from reaching awareness. The findings of the case series suggest that patients with psychosis, and their clinicians, can be engaged in a collaborative psychological assessment and formulation of factors that may impair their TDMC. Initial data from the case series also suggests this process is acceptable, safe and helpful.

Le régime applicable au consentement à l’acte médical des personnes vulnérables que sont les mineurs et les majeurs sous protection juridique est un sujet délicat pour le législateur. Ce dernier doit instaurer une législation conciliant protection de l’intégrité physique du patient, et respect de son autonomie. Le droit positif échoue à trouver cet équilibre. Les mineurs sont privés de leur capacité d’exercice à toutes les étapes de leur vie, quel que soit leur âge ou leur degré de maturité. Elle réserve également un traitement disparate aux majeurs protégés. Leur autonomie variant selon la prise en compte ou non de leur régime de protection par le Code de la santé publique. À ces difficultés s’ajoute celle de l’existence de nombreux actes spécifiquement réglementés dont les règles ne sont pas toujours cohérentes ni compatibles avec les réalités de la pratique médicale. Une réflexion est menée sur les limites du régime actuel ainsi que sur l’élaboration d’une nouvelle législation plus respectueuse de l’autonomie des mineurs et des majeurs protégés. La possibilité de consentir à un acte médical dépendra non pas du statut juridique du patient, mais de son « aptitude à consentir », notion tirée des législations suisse et québécoise. Toutefois, la volonté de protéger l’autonomie du patient ne devant pas conduire à une mise en péril de son intégrité physique, un encadrement de sa capacité d’exercice sera instauré selon que le soin est ou non requis par son état de santé. / The system of Consent to medical treatment for vulnerable persons – whether minors or adults without capacity – is a sensitive subject for legislator. The law has to combine protection of the patients’ physical integrity as well as the respect for their autonomy. The current state of law fails to achieve this purpose. Minors patients are deprived of their right to consent on their own, regardless of their age or level of maturity. Adults without capacity are treated in various ways depending on whether their legal protection is taken into account or not by the Public Health Code. An additional challenge is the existence of various medical acts that depend on specific regulations. Here we discuss the current limits of the law and propose a new system for the consent to medical treatment, which would be more respectful of the autonomy of minors patients or adults without capacity. Consent to medical treatment would depend on the ability to consent rather than on each patient’s legal status, such as stated in legislations from Switzerland or Quebec. However, the will to confer a larger autonomy should not put patient’s physical integrity at risk. Therefore, patients’ capacity for decision-making would depend whether the proposed care is required or not by their health state.

因為醫病互動關係的改變，病患自主權在經過歐美數十年來的覺醒與詮釋，並定位於不論是人性尊嚴或是隱私權內涵中之憲法層級，以及在告知後同意於近二十年來引進國內並蓬勃發展之後，病患的自主決定權在現今醫療過程中已經受到相當的重視。青少年也因接近成人的年齡及成熟度，在法律及臨床實務上也逐漸肯認其對於自身的醫療決定擁有自主決定權。然而，兒童不論在法律或是社會觀念之中，均被認定為能力尚未成熟，傳統上認為必須由父母代替其做醫療決定。可是在作者身為一位臨床兒科醫師的臨床實務經驗當中，許多病童往往能表達自己對於醫療決定甚至是臨終決定的自主意見，卻不受到父母或其他成年代理人的採納。 因此，本文將從臨床經驗出發，將所發現許多兒童有能力決定、以及父母無法做出符合兒童利益決定的案例，提出作為本文探討的思考起源。本文主要鎖定未成年人中未滿12歲的兒童進行討論，排除許多文獻早已熱烈討論的青少年人；另外因為立法例上並未賦予未成年人擁有「自主權」，故本文暫不深究兒童法律上的自主權利，而是以探討兒童實質上的「自主性」作為探討的主軸，並以此為未來法律發展的基礎。 本文將首先從「醫病關係的演進」開始，探討一般性「病患自主決定權」之倫理與法律。醫學倫理上涉及包括「生物醫學倫理四原則」以及「告知後同意」；多數國家也將「自主決定權」在法律上定位為憲法層級之人權保障。聯合國兒童權利公約則為現今國際上兒童人權維護的重要指引，也是對於兒童一般自主權正當性的重要依據。至於兒童的自主決定與其決定能力相關，也涉及父母代理決定的討論，故從法律上對於父母子女關係及未成年人保護的討論出發，探討代理決定時的最佳利益判斷，思考兒童醫療決定的問題及衝突，以及在不同年齡適合該年齡得以決定的事項。 在兒童醫療決定上，難題包括為何要重視兒童自主、何人有權決定、如何決定等等，在此議題受到各國重視並不斷發展之下應如何運作。在本文中主要參考了美國以及英國的發展經驗以及建議，提出對於臨床操作的看法。本文認為，可以用兒童醫療「表意權」的行使作為對兒童自主性的肯認，從兒童決定能力的判斷開始，對於具有決定能力的兒童表達其合理意見應充分尊重；若是缺乏決定能力的兒童，則在考量其最佳利益後由父母代理其做出醫療決定。醫療人員基於必須對於病童負責的角色及責任，亦應檢視父母決定是否合理，適時地介入決定以維護兒童最佳利益。 至於在兒童的最佳利益的判斷上，除了要考慮所面對的病況以外，還需要針對兒童未來生理發育和心智發展的影響，整體考量其未來的生活品質；對於臨終的兒童，則應考量是否得到有尊嚴的死亡，此與成年人的思考並無相左。最後，本文將進一步探討較為特殊的臨床狀況，包括面對重症以及急症的病童應如何操作及思考，並重新檢視本文所提出之實際臨床困難案例，建議較為適合的做法，以作為更多臨床個案判斷的參考指引。 / Patients' awareness of self-determination has raised and their rights have been taken into account in clinical consideration because of the change of doctor-patient relationship in recent decades. The right to autonomy was highly positioned at the constitutional level no matter it is contained in the concept of human dignity or the right of privacy. It is also highly valued after “the doctrine of informed consent” was introduced into our country with vigorous development in recent years. Because adolescents’ age and maturity approach adults, they have been recognized to have sufficient ability and right to make their own medical decisions as well as adults. Children, in the general idea of the society, are concerned not to have sufficient decision making ability and therefore need their parents’ help to make their own medical decisions. However, from clinical experiences, many children could not only express their autonomous opinions but even have the ability to consent to their medical treatments, including life-saving treatments. Unfortunately, children’s opinions were usually ignored, and sometimes their parents could not make decisions in their best interest. This study will discuss the patient autonomy of children whose ages are under 12 years old. We acknowledge that children do not have legal “right” to autonomy but they still have their own autonomous expression. The ethical and legal bases of patient autonomy are firstly illustrated, including “the four principles approach to bioethics”, “the doctrine of informed consent”, the legal status of “the right to autonomy” at the constitutional level, and the United Nations Convention on the Rights of the Child which is an international guide to children’s human right. Children’s autonomy is closely related to their decision-making capacity or competence and their age. Furthermore, surrogate decision making plays an important role in children’s affairs. When there is a conflict between the parents and children, the principle of best interest of children should be the leading concern. Regarding the medical decision of children, difficult problems are: why children’s patient autonomy is vital, who has the right to decide, and how to make a decision. I have reviewed the experiences and suggestions from concept leading countries such as the United States and the United Kingdom. I proposed my own viewpoint and suggest some guidelines on the clinical decision process. My opinion is that children’s right to express should be taken as the confirmation of children’s autonomy. For the children with decision making capacity, we should fully respect his rational decision; for the children without it, parents could make the decisions according to the children’s best interest. Medical staffs, including doctors and nurses, also need to reexamine the parents’ decisions suitable for children’s best interest. At the end of the thesis, I re-examine the clinical cases proposed at the beginning of this thesis, to present my resolution to the cases as guides for future clinical situation.