Department of Family Medicine, University of Wisconsin, 1100 Delaplaine Ct., Madison, WI, USA.
J Gen Intern Med. 2012 Feb;27(2):238-40. doi: 10.1007/s11606-011-1903-6. Epub 2011 Oct 5.
Medical decision-making involves choices, which can lead to benefits or to harms. Most benefits and harms may or may not occur, and can be minor or major when they do. Medical research, especially randomized controlled trials, provides estimates of chance of occurrence and magnitude of event. Because there is no universally accepted method for weighing harms against benefits, and because the ethical principle of autonomy mandates informed choice by patient, medical decision-making is inherently an individualized process. It follows that the practice of aiming for universal implementation of standardized guidelines is irrational and unethical. Irrational because the possibility of benefits is implicitly valued more than the possibility of comparable harms, and unethical because guidelines remove decision making from the patient and give it instead to a physician, committee or health care system. This essay considers the cases of cancer screening and diabetes management, where guidelines often advocate universal implementation, without regard to informed choice and individual decision-making.
医学决策涉及选择，这些选择可能带来益处，也可能带来伤害。大多数益处和伤害可能发生，也可能不发生，而且即使发生，也可能是轻微的或严重的。医学研究，尤其是随机对照试验，提供了事件发生概率和严重程度的估计。由于没有普遍接受的权衡利弊的方法，而且自主的伦理原则要求患者知情选择，因此，医学决策本质上是一个个体化的过程。因此，追求普遍实施标准化指南的做法是不合理和不道德的。不合理是因为对益处的可能性的重视程度超过了对可比伤害的可能性的重视程度，不道德是因为指南将决策权从患者手中夺走，交给医生、委员会或医疗保健系统。本文考虑了癌症筛查和糖尿病管理的案例，在这些情况下，指南通常主张普遍实施，而不考虑知情选择和个人决策。
