Miyaji N T
Department of Public Health, Kyoto Prefectural University of Medicine, Japan.
Soc Sci Med. 1993 Feb;36(3):249-64. doi: 10.1016/0277-9536(93)90008-r.
The perceptions of American doctors about their practice regarding truth-telling in the care of dying patients were examined based on semi-structured interviews with 32 physicians in a teaching hospital. The doctors inform patients of their disease using three basic styles; 'telling what patients want to know', 'telling what patients need to know' and 'translating information into terms that patients can take'. These styles are supported by five basic normative principles; 'respect the truth', 'patients rights', 'doctors' duty to inform', 'preserve hope' and 'individual contract between patients and doctors'. These styles and principles suggest that physicians adhere to the recent trends of American medical ethics based on informed consent doctrine, and give the impression that patients have control over obtaining information. But close analysis of their accounts shows that physicians still hold power to control information through their management of the information-giving process. The styles and principles are flexibly interpreted and selectively used in the process so that they facilitate a discourse which justifies, rather than eliminates, the information control. Clinical contexts of information control are analyzed by examining dissimilar manners of providing information about treatment as opposed to prognosis. Physicians give less, and vaguer information about prognosis, citing its uncertainty and lesser relevance to future actions as reasons. Information about treatment is more readily shared in order to counterbalance the negative impact of the news on patients. The analysis reveals that the way doctors control information is closely related to the way they handle aspects of the reality of clinical practice, such as physicians' own emotional coping, institutional and legal constraints, and power relationships among patients, doctors and other care-givers. Situating the findings in the historical context of normative discourse in American medicine, discussion focuses on the issues of trust and power of doctors. The humanistic role of the doctor, although suppressed in the currently dominant, contractual ethical framework, is still powerful in doctors' narratives. It expresses doctors' commitment to patients while preserving their authority. Implications of the individualistic approach to the doctor-patient relationship are also discussed.
基于对一家教学医院32名医生的半结构化访谈，研究了美国医生对其在临终患者护理中告知真相做法的看法。医生们采用三种基本方式告知患者病情：“告知患者想知道的内容”、“告知患者需要知道的内容”以及“将信息转化为患者能够理解的表述”。这些方式得到五条基本规范原则的支持：“尊重真相”、“患者权利”、“医生告知义务”、“保持希望”以及“患者与医生之间的个人契约”。这些方式和原则表明，医生遵循基于知情同意原则的美国医学伦理最新趋势，给人的印象是患者能够掌控信息获取。但仔细分析他们的叙述会发现，医生仍可通过管理信息传递过程来控制信息。在这个过程中，这些方式和原则会被灵活解读并选择性运用，从而促成一种为信息控制提供正当理由而非消除信息控制的话语。通过审视提供治疗信息与预后信息的不同方式，分析了信息控制的临床背景。医生提供的预后信息较少且更模糊，理由是预后具有不确定性且与未来行动的关联性较小。为了抵消这一消息对患者的负面影响，治疗信息会更轻易地被分享。分析表明，医生控制信息的方式与他们处理临床实践现实方面的方式密切相关，比如医生自身的情绪应对、制度和法律限制以及患者、医生和其他护理人员之间的权力关系。将研究结果置于美国医学规范话语的历史背景中，讨论聚焦于医生的信任和权力问题。医生的人文角色尽管在当前占主导地位的契约伦理框架中受到压制，但在医生的叙述中仍然强大。它在维护医生权威的同时表达了医生对患者的承诺。还讨论了个人主义医患关系方法的影响。
