Schneiderman L J, Faber-Langendoen K, Jecker N S
Department of Family and Preventive Medicine, University of California, San Diego School of Medicine, La Jolla.
Am J Med. 1994 Feb;96(2):110-4. doi: 10.1016/0002-9343(94)90130-9.
The medical futility debate is usually framed as a conflict between physician and patient (or surrogate) over the right to decide whether a particular life-saving treatment is futile and should not be attempted. Arguments on behalf of physician-determined futility emphasize the limits of physicians' obligations; arguments on behalf of patient-determined futility reflect concerns over the potential erosion of recent gains in patient autonomy against medical paternalism. Underlying the arguments of those pressing for "value-free" definitions of medical futility and unlimited obligations of physicians to patients may be fears of covert rationing and patient abandonment. Often overlooked in this debate, both at the bedside and in public commentary, is the ethical duty of the physician to redirect efforts from life-saving treatments toward the conscientious pursuit of treatments that maximize comfort and dignity for the patient and the grieving family. To supplement the limited terms of the futility debate with an ethic of care, physicians should lead in advocating greater awareness of the ethics of care in doctor-nurse interactions, institutional facilities, insurance policies, and public education.
医疗无效性的争论通常被视为医生与患者（或代理人）之间就决定某种特定的救命治疗是否无效且不应尝试的权利所产生的冲突。支持由医生判定无效性的论点强调医生义务的限度；支持由患者判定无效性的论点反映了对患者自主权近期对抗医疗家长主义所取得的成果可能受到侵蚀的担忧。那些迫切要求对医疗无效性进行“无价值判断”定义以及医生对患者承担无限义务的人，其论点背后可能存在对隐蔽配给和患者被遗弃的恐惧。在这场争论中，无论是在床边还是在公众评论中，常常被忽视的是医生的道德责任，即把努力从救命治疗转向认真追求那些能为患者及其悲痛的家人最大化舒适和尊严的治疗。为了用关怀伦理来补充无效性争论的有限范畴，医生应带头倡导在医患互动、机构设施、保险政策和公共教育中提高对关怀伦理的认识。
