Tunzi Marc, Ventres William
Natividad Medical Center, Salinas, CA.
Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, Little Rock, AR.
Fam Med. 2018 Sep;50(8):583-588. doi: 10.22454/FamMed.2018.821666. Epub 2018 Jun 26.
The practice of modern medical ethics is largely acute, episodic, fragmented, problem-focused, and institution-centered. Family medicine, in contrast, is built upon a relationship-based model of care that is accessible, comprehensive, continuous, contextual, community-focused and patient-centered. "Doing ethics" in the day-to-day practice of family medicine is therefore different from doing ethics in many other fields of medicine, emphasizing different strengths and exemplifying different values. For family physicians, medical ethics is more than just problem solving. It requires reconciling ethical concepts with modern medicine and asking the principal medical ethics question-What, all things considered, should happen in this situation?-at every clinical encounter over the course of the patient-doctor relationship. We assert that family medicine ethics is an integral part of family physicians' day-to-day practice. We frame this approach with a four-step process modified from other ethical decision-making models: (1) Identify situational issues; (2) Identify involved stakeholders; (3) Gather objective and subjective data; and (4) Analyze issues and data to direct action and guide behavior. Next, we review several ethical theories commonly used for step four, highlighting the process of wide reflective equilibrium as a key integrative concept in family medicine. Finally, we suggest how to incorporate family medicine ethics in medical education and invite others to explore its use in teaching and practice.
现代医学伦理学的实践在很大程度上是急性的、偶发的、零散的、以问题为导向的且以机构为中心的。相比之下，家庭医学建立在一种基于关系的照护模式之上，这种模式易于获得、全面、持续、基于情境、以社区为重点且以患者为中心。因此，在家庭医学的日常实践中“践行伦理学”与在许多其他医学领域践行伦理学有所不同，它强调不同的优势并体现不同的价值观。对于家庭医生而言，医学伦理学不仅仅是解决问题。它要求在医患关系的整个过程中，在每次临床接触时，将伦理观念与现代医学相协调，并提出主要的医学伦理学问题——综合考虑所有因素，在这种情况下应该发生什么？我们断言，家庭医学伦理学是家庭医生日常实践中不可或缺的一部分。我们用一个从其他伦理决策模型修改而来的四步流程来构建这种方法：（1）识别情境问题；（2）识别相关利益攸关方；（3）收集客观和主观数据；（4）分析问题和数据以指导行动和行为。接下来，我们回顾几种通常用于第四步的伦理理论，强调广泛反思平衡的过程是家庭医学中的一个关键整合概念。最后，我们建议如何将家庭医学伦理学纳入医学教育，并邀请其他人探索其在教学和实践中的应用。
