关于非自愿治疗的伦理思考：对瑞典精神科医生的访谈
Ethical deliberations about involuntary treatment: interviews with Swedish psychiatrists.
作者信息
Sjöstrand Manne, Sandman Lars, Karlsson Petter, Helgesson Gert, Eriksson Stefan, Juth Niklas
机构信息
Stockholm Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden and Center for Bioethics, Harvard Medical School, Boston, MA, USA.
Academy for care, work-life and welfare, University College of Borås, Borås, Sweden.
出版信息
BMC Med Ethics. 2015 May 28;16:37. doi: 10.1186/s12910-015-0029-5.
BACKGROUND
Involuntary treatment is a key issue in healthcare ethics. In this study, ethical issues relating to involuntary psychiatric treatment are investigated through interviews with Swedish psychiatrists.
METHODS
In-depth interviews were conducted with eight Swedish psychiatrists, focusing on their experiences of and views on compulsory treatment. In relation to this, issues about patient autonomy were also discussed. The interviews were analysed using a descriptive qualitative approach.
RESULTS
The answers focus on two main aspects of compulsory treatment. Firstly, deliberations about when and why it was justifiable to make a decision on involuntary treatment in a specific case. Here the cons and pros of ordering compulsory treatment were discussed, with particular emphasis on the consequences of providing treatment vs. refraining from ordering treatment. Secondly, a number of issues relating to background factors affecting decisions for or against involuntary treatment were also discussed. These included issues about the Swedish Mental Care Act, healthcare organisation and the care environment.
CONCLUSIONS
Involuntary treatment was generally seen as an unwanted exception to standard care. The respondents' judgments about involuntary treatment were typically in line with Swedish law on the subject. However, it was also argued that the law leaves room for individual judgments when making decisions about involuntary treatment. Much of the reasoning focused on the consequences of ordering involuntary treatment, where risk of harm to the therapeutic alliance was weighed against the assumed good consequences of ensuring that patients received needed treatment. Cases concerning suicidal patients and psychotic patients who did not realise their need for care were typically held as paradigmatic examples of justified involuntary care. However, there was an ambivalence regarding the issue of suicide as it was also argued that risk of suicide in itself might not be sufficient for justified involuntary care. It was moreover argued that organisational factors sometimes led to decisions about compulsory treatment that could have been avoided, given a more patient-oriented healthcare organisation.
背景
非自愿治疗是医疗伦理中的一个关键问题。在本研究中，通过对瑞典精神科医生的访谈，调查了与非自愿精神科治疗相关的伦理问题。
方法
对八位瑞典精神科医生进行了深入访谈，重点关注他们对强制治疗的经历和看法。与此相关，还讨论了患者自主权的问题。采用描述性定性方法对访谈进行了分析。
结果
答案集中在强制治疗的两个主要方面。首先，讨论了在特定案例中何时以及为何做出非自愿治疗决定是合理的。在此讨论了下令进行强制治疗的利弊，特别强调了提供治疗与不下令治疗的后果。其次，还讨论了一些与影响支持或反对非自愿治疗决定的背景因素相关的问题。这些问题包括瑞典精神保健法、医疗组织和护理环境等问题。
结论
非自愿治疗通常被视为标准护理中不必要的例外情况。受访者对非自愿治疗的判断通常符合瑞典关于该主题的法律。然而，也有人认为，在做出非自愿治疗决定时，法律为个人判断留出了空间。大部分推理集中在下令进行非自愿治疗的后果上，在这种情况下，权衡了对治疗联盟造成伤害的风险与确保患者接受所需治疗的假定良好后果。涉及自杀患者和未意识到自己需要护理的精神病患者的案例通常被视为合理非自愿护理的典型例子。然而，在自杀问题上存在矛盾心理，因为也有人认为自杀风险本身可能不足以成为合理非自愿护理的理由。此外，有人认为，组织因素有时会导致关于强制治疗的决定，如果医疗组织更以患者为导向，这些决定本可以避免。
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