Emmerich Nathan, Gordijn Bert
Medical School, Australian National University, Canberra, Australia.
Institute of Ethics, Dublin City University, Dublin, Ireland.
Theor Med Bioeth. 2019 Feb;40(1):21-41. doi: 10.1007/s11017-019-09478-9.
With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals' disinclination to withdraw it, then the differences between these practices should be taken seriously.
除了少数例外情况，关于撤除和放弃挽救生命治疗的文献认为，撤除或放弃这一行为本身并无任何伦理意义。实际上，关于此事的专业指南甚至更加一致。然而，尽管在说服医疗保健专业人员放弃不太可能带来显著益处的治疗方面已经取得了不小的进展，但显然在撤除治疗方面仍存在一定程度的矛盾态度。鉴于缺乏临床益处意味着治疗患者不仅在伦理上存在问题，而且还消耗了本可满足他人需求的资源，这种矛盾态度令人不安。同样，专业人员长期存在的矛盾态度可能表明这个问题值得进一步关注。在本文中，我们回顾了关于撤除和放弃医疗治疗在伦理上等效性的学术文献。虽然我们并非完全不同意所提出的论点，但我们认为，断言关于撤除和放弃挽救生命治疗在伦理上等效的理论性和脱离实际情况的主张并不能充分阐明与相关临床现实相关的道德问题。我们认为需要一个更广阔的视角，一个基于这样一种理解的视角，即撤除和放弃挽救生命治疗是不同的行为，只有通过更全面地理解它们在医疗保健实践中的地位，才能完全理解其含义。这样一种观点表明，如果要应对因医疗保健专业人员不愿撤除而导致的挽救生命治疗不当延长的问题，那么就应该认真对待这些行为之间的差异。
