Lim L S
Faculty of Medicine, NUS.
Singapore Med J. 2002 Mar;43(3):143-7.
It seems obvious that in a post-modern, constructivist world where meaning and value systems are often subjective and relative, any absolutist view is likely to be questionable. This is more so if it relates to ethics, the foundations, interpretation and application of which have been and continue to be much debated. So, in addressing the proposition, my efforts were directed at identifying a position that would mediate polarity. I examined the contention that the doctor, because he is better informed, may claim greater acuity and powers of judgment, and its defences against the charge of interfering with individual liberty and autonomy through various arguments such as the harm principle, the welfare, the principle of legal moralism and the appeal to uncertainty. While there is some validity to the arguments proposed, absolute paternalism would seem incompatible with respect for individual rights. How satisfactory, then, is the paradigm shift from paternalism to the independent choice model where the doctor presents neutral statistics as little biased as possible by his own views and judgments and leaves the decision making entirely to the patient or his/her relatives. This clearly had its limitations too. As with much of human experience, the answer would seem to rest in mediating the happy mean. Recognising a distinction between autonomy (self-determination) and independence (total freedom of choice without any interference) allows for a model of qualified independence or "enhanced autonomy" (Quill & Brody, 1996). This is predicated on doctor-patient dialogue, exchange of ideas/views, negotiation of differences, and sharing power and influence for the common purpose of serving the patient's best interest. This model would seem to be a responsible and effective approach to management of clinical dilemmas, as well as one that in its pluralistic approach is consistent with fundamental moral and philosophic propositions. It is by no means flawless, but in an imperfect world, there can be no perfect solution; constant negotiation with the realities--however uncomfortable--is an inescapable fact of life. Actions are right in proportion as they tend to promote happiness: wrong as they tend to produce the reverse of happiness. (J S Mil, Utilitarianism) On that supposition, I submit that guided paternalism is arguably what serves the patient best.
在一个后现代的、建构主义的世界里，意义和价值体系往往是主观和相对的，任何绝对主义观点似乎都值得怀疑，这一点似乎显而易见。如果涉及到伦理道德，情况更是如此，因为伦理道德的基础、解释和应用一直以来且仍在引发诸多争议。所以，在探讨这个命题时，我的努力方向是确定一个能调和两极对立的立场。我审视了这样一种观点，即医生由于掌握更多信息，可能声称自己具有更高的敏锐度和判断力，以及针对通过伤害原则、福利原则、法律道德主义原则以及诉诸不确定性等各种论据对其干涉个人自由和自主权指控的辩护。虽然所提出的论据有一定合理性，但绝对家长主义似乎与尊重个人权利不相容。那么，从家长主义向独立选择模式的范式转变有多令人满意呢？在独立选择模式中，医生尽可能少地受自身观点和判断的影响，呈现中立的统计数据，将决策完全留给患者或其亲属。显然，这也有其局限性。正如人类的许多经历一样，答案似乎在于调和中庸之道。认识到自主权（自我决定）和独立性（不受任何干涉的完全自由选择）之间的区别，就能产生一种有限制的独立性或“增强自主权”的模式（奎尔和布罗迪，1996年）。这一模式基于医患对话、观点交流、分歧协商以及为实现患者最佳利益这一共同目标而分享权力和影响力。这种模式似乎是处理临床困境的一种负责任且有效的方法，而且其多元方法与基本的道德和哲学命题相一致。它绝非完美无缺，但在一个不完美的世界里，不可能有完美的解决方案；无论多么令人不适，与现实不断协商是生活中不可避免的事实。行为的正确程度与其倾向于促进幸福的程度成正比：错误程度与其倾向于产生幸福的反面的程度成正比。（J.S.密尔，《功利主义》）基于这一假设，我认为指导性家长主义可以说是最符合患者利益的。
