Keating R F, Moss A H, Sorkin M I, Paris J J
Center for Health Ethics and Law, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown 26506-9022.
J Am Soc Nephrol. 1994 May;4(11):1879-83. doi: 10.1681/ASN.V4111879.
Decisions to stop dialysis or other life-sustaining treatments for incompetent patients are among the most difficult ethical problems faced by physicians and families. This observation is verified by the large number of court cases and the increasing frequency of ethics consultations on these issues. In such instances, in the absence of an advance directive, the usual practice for physicians is to turn to the patient's family for direction on whether to start, continue, or withdraw the treatment. They do so on the presumption that the family best represents the patient's interests. This presumption may not always be correct. A case is presented in which the family's insistence on continued dialysis was contrary to the patient's previously expressed wishes and the treating physician's assessment of the patient's best interests. It is asserted that, in such situations, after thorough conversation with the family, consultation, documentation, and an unsuccessful attempt to transfer the patient's care to another physician, nephrologists have an ethical obligation and legal right to override the family's decision and to stop dialysis. The ethical obligation is supported by the principles of respect for persons, beneficence, and nonmaleficence. The legal right is grounded in common law and state statutes.
对于无行为能力的患者，决定停止透析或其他维持生命的治疗，是医生和患者家属面临的最棘手的伦理问题之一。大量的法庭案例以及关于这些问题的伦理咨询频率不断增加，证实了这一观察结果。在这种情况下，如果没有预先指示，医生的通常做法是向患者家属寻求关于是否开始、继续或停止治疗的指示。他们这样做的前提是，家属最能代表患者的利益。但这种假设并不总是正确的。本文介绍了一个案例，在该案例中，家属坚持继续透析，这与患者先前表达的意愿以及主治医生对患者最佳利益的评估相悖。有人认为，在这种情况下，在与家属进行充分沟通、咨询、记录，并尝试将患者的护理转交给另一位医生但未成功之后，肾病学家有道德义务和法律权利推翻家属的决定并停止透析。这种道德义务得到了尊重人、行善和不伤害原则的支持。法律权利基于普通法和州法规。
