Veatch R M
Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia 20057, USA.
J Med Philos. 2000 Dec;25(6):701-21. doi: 10.1076/jmep.25.6.701.6126.
While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being.
尽管二十世纪的医学伦理聚焦于医生使患者受益的职责，但下个世纪这一职责将在三个方面受到挑战。首先，我们将越来越认识到，期望医生能够确定什么对患者有益是不现实的。要么当患者的总体福祉才是恰当目标时，他们只关注医疗福祉；要么他们追求总体福祉，这就超出了他们的专业范围。即使在医学领域内，他们也没有依据在医学的恰当医疗目标中进行选择。而且，有许多合理的策略来权衡预期的益处与危害，而医生无法成为在这些策略中进行挑选的专家。其次，越来越合理的伦理体系认识到，在某些情况下，必须牺牲患者的益处以保护患者权利，包括了解真相的权利、要求兑现承诺的权利、尊重自主的权利以及不被杀害的权利。第三，下个世纪的伦理将越来越认识到，必须牺牲一些患者的益处以履行对他人的义务——要么是服务他人利益的义务，要么是其他义务，如信守承诺、讲真话，特别是促进正义。二十一世纪的医生将被视为负有一项新的、更有限的义务，即在道义论伦理原则和外部强加的促进正义义务的约束下，协助患者追求患者对自身利益的理解。结果将是一项对医疗保健消费者忠诚的义务，同时认识到这往往意味着医生不被允许追求医生对患者福祉的理解。
