Howe E G, Lettieri C J
Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA.
Drugs Aging. 1999 Jul;15(1):37-47. doi: 10.2165/00002512-199915010-00004.
This article provides an ethical analysis of the question of whether aged patients' access to health care should be less than, the same or greater than, the access younger patients enjoy, when economic resources are limited. This topic is being urgently considered in the US because managed care is becoming more common and brings with it new challenges to traditional medical ethics, and because the prevalence of the aged is increasing as is the number of patients with Alzheimer's disease (AD). It is also critical throughout the world because new findings suggest that the progression of AD may be retarded or even reversed by providing patients with enriched interpersonal environments. If these findings are valid, it would be inhumane to not consider providing these resources to patients with AD, since these gains would be so meaningful and substantial. Deontological and consequential values influencing this question are presented and evaluated. The theories of Veatch, Callahan and Daniels in regard to allocating health care to the aged are discussed. It is argued that 2 subgroups of aged patients, the isolated and demented, are among the patients worst off because the capacity to enjoy meaningful relationships with others supercedes all others and both groups of patients have lost this capacity. We assert that, on the basis of the principle of justice according to need, these 2 groups of patients' exceptional needs should be prioritised. We then raise the question of whether the majority of the population would be willing to provide these isolated and demented aged patients this care if the new findings proved valid. We conclude that, in light of many people's fear of growing old and dying, and some peoples bias against the aged (particularly in the US), willingness to provide the necessary resources is open to debate. Finally, we provide specific examples of the kinds of interventions which might be optimal for each group of patients. For patients who are cognitively unimpaired, this might be providing home care so that they could remain closer to and in contact with their loved ones. For patients who are cognitively impaired, this might be providing interpersonal support when these patients begin to lose control, rather than applying restraints or using psychotropic medication.
在经济资源有限的情况下，老年患者获得医疗保健的机会应该少于、等同于还是多于年轻患者。在美国，这个问题正受到紧急关注，原因如下：管理式医疗越来越普遍，给传统医学伦理带来了新挑战；老年人以及阿尔茨海默病（AD）患者的数量都在增加。在全球范围内，这一问题也至关重要，因为新的研究结果表明，为患者提供丰富的人际环境可能会延缓甚至逆转AD的病程。如果这些研究结果属实，不给AD患者提供这些资源将是不人道的，因为这些益处将是如此显著和重要。本文阐述并评估了影响这一问题的道义论和结果论价值观。讨论了维奇、卡拉汉和丹尼尔斯关于为老年人分配医疗保健的理论。本文认为，有两类老年患者处于最不利的境地，即孤独的患者和患有痴呆症的患者，因为与他人建立有意义关系的能力比其他任何因素都重要，而这两类患者都已丧失了这种能力。我们主张，根据按需分配的正义原则，应优先满足这两类患者的特殊需求。接着，我们提出一个问题：如果新的研究结果得到证实，大多数人是否愿意为这些孤独且患有痴呆症的老年患者提供这种护理。我们的结论是，鉴于许多人对衰老和死亡的恐惧，以及一些人对老年人的偏见（尤其是在美国），是否愿意提供必要资源仍有待讨论。最后，我们给出了针对每组患者可能最为适宜的干预措施的具体示例。对于认知未受损的患者，可能是提供家庭护理，以便他们能与亲人更亲近并保持联系。对于认知受损的患者，可能是在他们开始失控时提供人际支持，而不是使用约束措施或精神药物。
