Dill A E
Department of Sociology, Brown University, Providence, RI 02912, USA.
Soc Sci Med. 1995 Nov;41(9):1289-99. doi: 10.1016/0277-9536(95)00211-o.
This paper uses ethnographic data to examine ethical dilemmas in discharging elderly persons from the hospital. The focus is on two elements significantly influencing that process, the patient's decisional capacity and the involvement of family members in decision-making. Within the field of bioethics these issues have been discussed in terms of factors compromising the autonomy of the patient and the interdependency of family members. An ethnographic analysis demonstrates how several assumptions in bioethical approaches to these issues are problematic. First, bioethical discussions generally neglect social and structural factors that condition discharge decision-making. The rationality and mental capability of the individuals making decisions are presumed to exist independently of those persons' social contexts; they are also assumed to be concrete properties amenable to objective assessment. Bioethical models further assume that 'the family' is an identifiable ontological unit that exists independently of the setting in which decisions are made and that interdependency is a concrete attribute of familial relations. In contrast, this study shows how discharge planning is an event produced by the interplay among diverse interests. The structure of the discharge planner's role and processes of collective decision-making shape how medical staff perceive and define patients' decisional capacity and the involvement of families. This points to unintentional and unrecognized ways in which the patient's choices and control over decisions can be restricted. The analysis supports attempts to develop bioethical models based on socially grounded principles recognizing the importance of both autonomy and interdependence in long term care decisions.
本文运用人种志数据来审视医院老年患者出院时的伦理困境。重点关注对这一过程有重大影响的两个因素，即患者的决策能力以及家庭成员在决策过程中的参与度。在生物伦理学领域，这些问题一直是围绕损害患者自主性和家庭成员相互依存性的因素来讨论的。一项人种志分析表明，生物伦理学在处理这些问题时所采用的几种假设存在问题。首先，生物伦理学讨论通常忽视了影响出院决策的社会和结构因素。人们假定做出决策的个体的理性和心智能力独立于其社会背景而存在；这些能力还被假定为可进行客观评估的具体属性。生物伦理学模型进一步假定，“家庭”是一个可识别的本体论单位，独立于决策所处的环境而存在，并且相互依存是家庭关系的一个具体属性。相比之下，本研究展示了出院计划是由多种利益相互作用产生的一个事件。出院计划者的角色结构和集体决策过程塑造了医护人员对患者决策能力以及家庭参与度的认知和界定方式。这指出了患者在决策方面的选择和控制权可能受到限制的一些无意且未被认识到的方式。该分析支持基于具有社会基础的原则来开发生物伦理学模型的尝试，这些原则认识到自主性和相互依存性在长期护理决策中的重要性。
