Eijkholt Marleen, Broekman Marike, Balak Naci, Mathiesen Tiit
Unit Ethics and Health Care, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.
Department of neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.
J Med Ethics. 2021 Jan 13. doi: 10.1136/medethics-2020-106943.
A pandemic may cause a sudden imbalance between available medical resources and medical needs where fundamental care to a patient cannot be delivered. Inability to fulfil a professional commitment to deliver care as needed can lead to distress among caregivers and patients. This distress is sometimes alleviated through mechanisms that hide the facts that care is rationed and not all medical needs are met. We have identified three mechanisms that jeopardise accountable and optimal allocation of resources: (1) hidden value judgements that allow rationing under the disguise of triage or prioritisation, (2) disguised conflict of interest between societal and individual patient's needs and (3) concealed biases in the application of medical tools. Under these three pitfalls decisions of resource allocation and who gets treated are handled as medical decisions: normative decisions are concealed and perceived as falling with the realm of medical judgement. Value judgements and moral agency are hidden to offer a 'false sense of medical judgement', while in fact there are several ethical judgements and biases at stake. The three pitfalls entail hidden normative deliberation and are inappropriate for sustainable healthcare delivery and resource allocation. We believe it is necessary to maintain transparency in decision making under conditions of insufficient resources to maintain trust in professional care givers and secure fair treatment allocation. Recognition of the pitfalls, by applying our recommendations, may help to ensure transparent and accountable distribution of care and contribute to public acceptance of the ethics behind rationing.
大流行可能导致可用医疗资源与医疗需求之间突然失衡，致使无法为患者提供基本护理。无法履行按需提供护理的专业承诺可能会给护理人员和患者带来困扰。这种困扰有时会通过一些机制得到缓解，这些机制掩盖了护理是定量配给且并非所有医疗需求都能得到满足这一事实。我们已经确定了三种危及资源合理和最优分配的机制：（1）隐藏的价值判断，即在分诊或优先级排序的伪装下允许进行配给；（2）社会需求与个体患者需求之间的隐性利益冲突；（3）医疗工具应用中的隐蔽偏见。在这三个陷阱之下，资源分配决策以及谁接受治疗被当作医疗决策来处理：规范性决策被隐藏起来，并被视为属于医疗判断的范畴。价值判断和道德考量被隐藏起来，以营造一种“医疗判断的错觉”，而实际上存在多种伦理判断和偏见。这三个陷阱涉及隐藏的规范性审议，对于可持续的医疗服务提供和资源分配而言是不恰当的。我们认为，在资源不足的情况下，决策过程有必要保持透明度，以维持对专业护理人员的信任并确保公平的治疗分配。通过应用我们的建议来认识这些陷阱，可能有助于确保护理的透明和可问责分配，并促进公众接受配给背后的伦理观念。
