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新生儿ICU决策中的伦理问题
Ethical Problems in Decision Making in the Neonatal ICU


John D. Lantos ... 妇产科和儿科 • 2018.11.08

在新生儿重症监护治疗病房(NICU)中,关于在伦理上能否不给予或撤掉维持生命的治疗,分歧并不少见。通常,这一困境归结为对身体或认知能力有严重缺陷的人的生命价值的质疑。分歧有时是医师建议治疗,家长拒绝。有时是家长要求继续治疗,而医师认为不适合。在缺氧性脑病1、退行性神经系统疾病2,甚至脑死亡3的情况下,就出现了这样的冲突。这些分歧可能会使医师和护士陷入道德困境,并引发以下争论:单方面做出治疗无用和应该撤掉治疗的决策是否具有伦理正当性4-6。通常情况下,通过医师和新生儿家长的持续讨论、其他家庭成员加入讨论或咨询伦理委员会,可以解决分歧7。大多数重症监护医师学会了如何在这些情况下与患儿家人进行协商。

偶尔,分歧会变得棘手,病例最终诉诸法庭。一些州有指导司法裁决的法规8。美国得克萨斯州、加利福尼亚州和弗吉尼亚州的法律授权医师单方面撤掉维持生命的治疗9-11。相比之下,堪萨斯州、俄克拉何马州和纽约州的法律赋予患者及其家人在分歧中占据主导地位的权力12-14

伦理学家已经建立了一个通用框架来平衡孩子的利益和家长的权力范围。1983年,一个总统生命伦理学委员会首次提出了这一框架,它基于这样一种观点,即医师有责任决定治疗明确有益、无效,还是介于两者之间15。如果医学专业知识表明治疗明确有益,则婴儿的治疗权超过家长为婴儿做出医疗决策的权力。当治疗的益处不那么明确时,伦理学家(和法院)会遵从家长的选择。这一总体框架承认灰色地带不可避免——即在某些情况下,许多选择都是合法的,但通情达理的人对哪种做法正确存在分歧,却又必须做出决策。关于如何定义灰色地带已经写了很多。我在这里没有定义灰色地带,只是简单地承认它们存在。本综述的目的是描述和分析各种策略,这些策略可改善医师与家长合作,从而对社会定义的灰色地带病例做出决策的过程。





作者信息

John D. Lantos, M.D.
From Children’s Mercy Kansas City, Kansas City, MO. Address reprint requests to Dr. Lantos at Children’s Mercy Hospital, 2401 Gillham Rd., Kansas City, MO 64108, or at jlantos@cmh.edu.

 

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