Donabedian A
J Fam Pract. 1979 Aug;9(2):277-84.
Patient care has two components: technical and interpersonal. The quality of technical management depends on the balance of its expected benefits and risks. The quality of the interpersonal process consists in conformity to legitimate patient expectations and to social and professional norms. Since this conformity is expected to result in social and personal benefit, a unified definition of quality can be derived by including the benefits and risks of both aspects of care. When the patient's health and welfare are judged by professional criteria, and the cost of care is not considered, one has an "absolutist" definition of quality. By contrast, an "individualized" definition accepts the informed patient's valuation of the consequences of care, and includes the cost to the patient as an unwanted consequence. The "social" definition includes monetary cost even when not borne directly by the patient, may place a different valuation on patients and their interests, and pays attention to the social distribution of the cost and net benefits of care. Thus, the physician who wishes to do the best for each patient may be in conflict with what society dictates to be the best of all. The health care professions must resolve this moral dilemma.
技术层面和人际层面。技术管理的质量取决于其预期收益和风险的平衡。人际过程的质量在于符合患者合理的期望以及社会和专业规范。由于这种符合预期会带来社会和个人利益，通过纳入护理两个方面的收益和风险，可以得出质量的统一定义。当依据专业标准判断患者的健康和福祉，而不考虑护理成本时，就有了质量的“绝对主义”定义。相比之下，“个性化”定义接受患者对护理后果的明智评估，并将患者承担的成本视为一种不良后果。“社会”定义即使在患者不直接承担货币成本时也包括货币成本，可能对患者及其利益有不同的评估，并关注护理成本和净收益的社会分配。因此，希望为每位患者做到最好的医生可能与社会认为的整体最佳做法产生冲突。医疗保健行业必须解决这个道德困境。
