Hall M A, Berenson R A
Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1063, USA.
Ann Intern Med. 1998 Mar 1;128(5):395-402. doi: 10.7326/0003-4819-128-5-199803010-00009.
This article examines the ethics of medical practice under managed care from a pragmatic perspective that gives physicians more useful guidance than do existing ethical statements. The article begins with a framework for constructing a realistic set of ethical principles, namely, that medical ethics derives from physicians' role as healers; that ethical statements are primarily aspirational, not regulatory; and that preserving patient trust is the primary objective. The following concrete ethical guidelines are presented: Financial incentives should influence physicians to maximize the health of the group of patients under their care; physicians should not enter into incentive arrangements that they are embarrassed to describe accurately to their patients; physicians should treat each patient impartially without regard to source of payment, consistent with the physician's own treatment style; if physicians depart from this ideal, they should inform their patients honestly; and it is desirable, although not mandatory, to differentiate medical treatment recommendations from insurance coverage decisions by clearly assigning authority over these different roles and by physicians advocating for recommended treatment that is not covered.
本文从实用主义角度审视了管理式医疗下的医疗实践伦理，为医生提供了比现有伦理声明更具实用性的指导。文章开篇提出了构建一套现实可行的伦理原则的框架，即医学伦理源自医生作为治疗者的角色；伦理声明主要是 aspirational（此处未准确翻译出该词的含义，应为“理想性的、倡导性的”），而非监管性的；维护患者信任是首要目标。接着给出了以下具体的伦理准则：经济激励应促使医生最大限度地增进其负责治疗的患者群体的健康；医生不应参与那些自己不好意思向患者准确描述的激励安排；医生应根据自身治疗风格，不论支付来源，公正地对待每位患者；若医生背离这一理想状态，应诚实地告知患者；通过明确划分不同角色的权限以及医生倡导未涵盖的推荐治疗，将医疗治疗建议与保险覆盖决策区分开来是可取的，尽管并非强制要求。
