论中国 ≪民法典≫框架下医疗代理决策权的法律界定与制度完善

Despite the Civil Code’s patient-centered design, bedside practice reveals a persistent threefold imbalance. First, family members’ views often override the patient’s expressed choices, particularly under time pressure and amid fragmented documentation. Second, designated proxies—including appointees and voluntary guardians—are routinely sidelined in operations, reversing the intended priority of application. Third, the operational triggers for “incapacity” and “ethically inadvisable disclosure” remain underspecified. Clinicians lack shared, auditable criteria for determining when capacity is absent, when disclosure would be harmful, and how those determinations should be recorded. This ambiguity invites discretionary drift, inconsistent notes, and gaps between consent, proxy activation, and ex post review. This study uses doctrinal interpretation in tandem with comparative analysis and close readings of two cases: the 2017 Yulin maternity case and the appellate decision in (2009) Xi Min Er Zhong Zi No. 46. On a unified terminology scaffold, it builds an operational model that links trigger criteria to the priority of application and, ultimately, to procedural safeguards. It then translates that model into an executable reform program spanning administrative coordination, hospital governance rules, information-system fields, tiered staff training, and metric-based evaluation. Illustrative data elements include a capacity-assessment timestamp, trigger rationale, and the proxy’s identity and legal basis. On the electronic health record (EHR) face sheet, new fields would include whether a proxy exists, evidence type/ID, scope of authority, validity period, proxy contacts, and the verifier and timestamp. Training sequences are matched to specific roles, and evaluation emphasizes timeliness and documentation completeness (process-oriented metrics) rather than clinical endpoints. Proportionality constrains risk: interventions are no more restrictive than necessary, with residual disputes channeled to calibrated ex post remedies. The analysis affirms the patient as the primary consent holder. A proxy may act only when decision-making capacity is demonstrably absent or disclosure is ethically inadvisable, and, in either case, no less restrictive alternative is available. In such cases, the hierarchy places the designated or appointed proxy (including a voluntary guardian) before the statutory next of kin. Substantively, the substituted-judgment standard prevails; where the patient’s likely wishes cannot be determined, the best-interests standard applies. Procedurally, a closed-loop safeguard is required: two-physician written assessments of capacity and “inadvisability, ” ethics committee review when criteria are met, and full documentation with time-bound ratification within 24–48 hours to regularize proxy activation. Taken together, this work converts abstract principles into a workable flow from inadvisability or incapacity to proxy activation. It grounds the primacy of the patient or a clearly designated proxy in publicly verifiable authorities, and reframes patient-rights protection as auditable hospital governance.