Finucane T E, Harper M
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Clin Geriatr Med. 1996 May;12(2):369-77.
For ethical decision-making near the end of life, autonomy is the moral North Star. At the same time, for some treatments, the burdens so clearly outweigh benefits that physicians may make a judgment not to offer the treatment. This is often clearer in surgery. A person with colon cancer and metastases may not insist on resection of the metastases. For some reason, some treatments have escaped these logical constraints. Attempted resuscitation of a dying patient is a good example. The circumstances in which a physician may make choices on behalf of a competent, terminally-ill patient without consent, and even without notification, are hotly debated, but data suggest that physicians do so frequently. Patients who lack capacity present even more difficult challenges. Advance directives, when available, can be extremely helpful, but even with them difficult problems can remain. If advance directives have not been established, family and close friends are an obvious source of guidance. Their legal role varies in different jurisdictions; in practice, they are crucial in bedside decision-making. Guardianship and alternatives to it remain a poor last resort. Euthanasia is a very difficult problem. We believe it is semantically misleading to lump under the term "passive euthanasia" those circumstances where potentially life-sustaining treatment is withheld or withdrawn. The tension between patient autonomy and medical common sense remains unresolved within the "futility" controversy. The authors believe it serves no purpose to discuss carefully with dying patients propositions that are nonsense. At the same time, physicians must not confuse decisions about quality of life with judgements about treatment effectiveness. We believe that what many, although not all, dying patients want are physicians with intelligent compassion who can take care of them through the dying process.
对于临终时的伦理决策而言，自主性是道德的北极星。与此同时，对于某些治疗，其负担明显超过益处，以至于医生可能会做出不提供该治疗的判断。这在外科手术中往往更为明显。患有结肠癌并伴有转移的患者可能不会坚持切除转移灶。出于某种原因，某些治疗却摆脱了这些逻辑限制。对濒死患者进行心肺复苏就是一个很好的例子。医生在未经同意甚至未告知的情况下，为有行为能力的晚期患者做出选择的情形备受争议，但数据表明医生经常这样做。缺乏行为能力的患者带来的挑战更大。预先指示若能获取，会极有帮助，但即便有了预先指示，难题可能依然存在。如果没有确立预先指示，家人和密友显然是指导的来源。他们的法律角色在不同司法管辖区有所不同；实际上，他们在床边决策中至关重要。监护及替代监护措施仍是不得已的下策。安乐死是个非常棘手的问题。我们认为，将 withhold 或 withdraw 维持生命的治疗的情况归为“被动安乐死”这一术语在语义上具有误导性。在“无效治疗”争议中，患者自主性与医学常识之间的紧张关系仍未得到解决。作者认为，与濒死患者仔细讨论无意义的提议毫无意义。与此同时，医生绝不能将关于生活质量的决策与关于治疗效果的判断相混淆。我们认为，许多（尽管不是所有）濒死患者想要的是富有智慧同情心、能在临终过程中照顾他们的医生。
