Hall M A, Berenson R A
Wake Forest University, School of Law and School of Medicine, USA.
Cumberland Law Rev. 1997;28(2):287-314.
This article examines the ethics of medical practice under managed care from a pragmatic perspective that gives physicians more useful guidance than existing ethical statements. The article begins by stating the authors' starting premises and framework for constructing a realistic set of ethical principles: namely, that bedside rationing in some form is permissible; that medical ethics derive from physicians' role as healers; that actual agreements usually trump hypothetical ones; that ethical statements are primarily aspirational, not regulatory; and that preserving patient trust is the primary objective. The authors then articulate the following concrete ethical guides: financial incentives should influence physicians to maximize the health of the group of patients under their care; physicians should not enter into incentive arrangements that they would be embarrassed to describe accurately to their patients or that are not in common use in the market; physicians should treat each patient impartially, without regard to source of payment, and in a manner consistent with the physician's own treatment style; if physicians depart from this ideal, they must tell their patients honestly; and it is desirable, although not mandatory, to differentiate medical treatment recommendations from insurance coverage decisions by clearly assigning authority over these different roles and by having physicians to advocate for recommended treatment that is not covered.
本文从实用主义角度审视了管理式医疗下的医疗实践伦理，该视角能为医生提供比现有伦理声明更有用的指导。文章开篇阐述了作者构建一套切实可行的伦理原则的起始前提和框架：即某种形式的床边配给是允许的；医学伦理源自医生作为治疗者的角色；实际协议通常优先于假设协议；伦理声明主要是理想性的，而非规范性的；以及维护患者信任是首要目标。作者随后阐明了以下具体的伦理指南：经济激励应促使医生最大限度地增进其负责治疗的患者群体的健康；医生不应参与那些若准确向患者描述会令自己难堪或在市场上不常用的激励安排；医生应公正地对待每位患者，不考虑支付来源，并以符合医生自身治疗风格的方式进行治疗；如果医生背离这一理想状态，必须诚实地告知患者；通过明确划分这些不同角色的权力，并让医生为未涵盖的推荐治疗进行倡导，将医疗治疗建议与保险覆盖范围决策区分开来是可取的，尽管并非强制要求。
