老龄化社会近亲属医疗代理的现实困境与治理优化

Practical Dilemmas and Governance Optimization of Next-of-Kin Medical Proxy in an Aging Society

摘要: 我国已迈入深度老龄化社会，高龄失能、认知衰退、空巢老年群体规模持续扩张，近亲属医疗知情同意代理成为老年就医场景的常态化制度安排。该模式是家庭养老模式的延伸，适配人口高龄化背景下医疗服务与家庭照护的协同需求。但受家庭结构原子化、空巢化加剧、传统养老伦理偏差、社会公共服务配套滞后等因素制约，当前近亲属医疗代理普遍存在亲属决策分歧、责任推诿、漠视老人真实意愿、代理权责失衡、空巢老人应急决策缺位、医患及家庭矛盾频发等现实问题。本文以实地问卷调查、深度访谈获取的一手实证数据与典型案例为核心支撑，结合家庭类型化分析、医学与法学双重决策能力评估标准，系统阐释近亲属医疗代理的社会内涵与存在合理性，深度剖析其运行困境与深层成因，构建适配老龄化趋势的规范化治理体系，从认知重塑、制度完善、平台搭建、基层监督、医疗机构规范、顶层协同六个维度提出可落地的优化路径与试点方案，旨在切实维护老年群体健康权益与人格尊严，完善老龄健康基层治理体系，为推进积极应对人口老龄化国家战略落地提供实践参考。

Abstract: China has entered an era of deep population aging, with a growing number of elderly people facing advanced age disability, cognitive decline and empty-nest living. Next-of-kin medical proxy for informed consent has become a normalized arrangement for elderly medical treatment. As an extension of the family pension model, this mechanism adapts to the practical needs of medical services and family care under population aging. However, affected by family structure differentiation, empty-nest phenomenon, biased traditional pension concepts and lagging social supporting services, the current next-of-kin medical proxy system faces prominent problems, including divergent decision-making and mutual buck-passing among relatives, neglect of the elderly’s genuine will, unbalanced proxy rights and responsibilities, emergency decision-making vacancy for empty-nest elderly, and frequent family and doctor-patient conflicts. Based on first-hand empirical data and typical cases obtained from questionnaires and in-depth interviews, combined with typed family analysis and dual medical-legal evaluation criteria for decision-making capacity, this paper systematically expounds the social connotation and rationality of next-of-kin medical proxy, analyzes its practical dilemmas and underlying causes, and constructs a standardized governance system. It proposes practical optimization paths and pilot plans from six dimensions to safeguard the legitimate rights and dignity of the elderly, improve the grassroots governance system for aging health, and provide references for the implementation of active aging strategies.