說謊還是不說謊醫(yī)生的難題

UnitWarm-UpQuestionsIsitevenrighttotellalie?Doyoualwayswanttobetoldthetruth,nomatterhowunpleasant?Arethereanycircumstancesinwhichitisacceptableforadoctortotellalie?Isiteverproperforamedicaldoctortolietohispatient?Shouldhetellapatientheisdying?Thesequestionsseemsimpleenough,butitisnotsosimplytogiveasatisfactoryanswertothem.ToLieorNottoLie—Thedoctor’sDilemmaSisselaBokShoulddoctorseverlietobenefittheirpatients—tospeedrecoveryortoconcealtheapproachofdeath?Inmedicineasinlaw,government,andotherlinesofwork,therequirementsofhonestyoftenseemdwarfedbygreaterneeds;theneedtoshelterfrombrutalnewsortoupholdapromiseofsecrecy,toexposecorruptionortopromotethepublicinterest.Whatshoulddoctorsay,forexample,toa46-years-oldmancominginforaroutinephysicalcheckupjustbeforegoingonvacationwithhisfamilywho,thoughhefeelsinperfecthealth,isfoundtohaveaformofcancerthatwillcausehimtodiewithinsixmouths?Isitbesttotellhimthetruth?Ifheasks,shouldthedoctorsdenythatheisill,orminimizethegravityoftheillness?Shouldtheyatleastconcealthetruthuntilafterthefamilyvacation?Doctorsconfrontsuchchoicesoftenandurgently.Attimes,theyseeimportantreasontolieforthepatient’sownsake;intheireyes,suchliesdiffersharplyfromself-servingones.Studiesshowthatmostdoctorssincerelybelievethattheseriouslyilldonotwanttoknowthetruthabouttheircondition,andthatinformingthemrisksdestroyingtheirhope,sothatthemayrecovermoreslowly,ordeterioratefaster,perhapsevencommitsuicide.Asonephysicianwrote:"Oursisaprofessionwhichtraditionallyhasbeenguidedbyapreceptthattranscendsthevirtueofutteringthetruthfortruth’ssake,andthatisasfaraspossibledonoharm.”Armedwithsuchaprecept,anumberofdoctorsmayslipintodeceptivepracticesthatthattheyassumewill“donoharm”andmaywellhelptheirpatients.Theymayprescribeinnumerableplacebos,soundmoreencouragingthanthefactswarrant,anddistortgravenews,especiallytotheincurablyillandthedying.Buttheillusorynatureofthebenefitssuchdeceptionismeanttoproduceisnowconingtobedocumented.Studiesshowthat,contrarytothebeliefofmanyphysicians,anoverwhelmingmajorityofpatientsdowanttobetoldthetruth,evenaboutgraveillness,andfeelbetrayedwhentheylearnthattheyhavebeenmisled.Wearealsolearningthattruthfulinformation,humanelyconveyed,helpspatientscopewithillness;helpthemtoleratepainbetter,needlessmedicine,andevenrecoverfasteraftersurgery.Notonlydoliesnotprovidethe"help”hopedforbyadvocatesofbenevolentdeception;theyinvadetheautonomyofpatientsandrenderthemunabletomakeinformedchoicesconcerningtheirownhealth,includingthechoiceofwhethertobeapatientinthefirstplace.Wearebecomingincreasinglyawareofallthatcanbefallpatientsinthecourseoftheirillnesswheninformationisdeniedordistorted.Dyingpatientsespecially—whoareeasiesttomisleadandmostoftenkeptinthedark—canthannotmakedecisionsabouttheendoflife:aboutwhetherornottheyshouldenterahospital,orhavesurgery;aboutwhereandwithwhomtheyshouldspendtheirremainingtime;abouthowtheyshouldbringtheiraffairstoacloseandtakeleave.Liesalsodoharmtothosewhotellthem:harmtotheirintegrityand,inthelongrun,theircredibility.Lieshurttheircolleaguesaswell.Thesuspicionofdeceitundercutstheworkofthemanydoctorswhoarescrupulouslyhonestwiththeirpatients;itcontributestothespiraloflawsuitsandof“defensivemedicine,”andthusitinjures,inturn,theentiremedicalprofession.Sharpconflictsarenowarising.Patientsarelearningtopressforanswer.Patients’billofrightrequirethattheymaybeinformedabouttheirconditionandaboutalternativesfortreatment.Manydoctorsgotogreatlengthstoprovidesuchinformation.Yeteveninhospitalwiththemosteloquentbillofrights,believersinbenevolentdeceptioncontinuetheirage-oldpractices.Colleaguesmaydisapprovebutrefrainfromobjecting.Nursesmaybitterlyresenthavingtotakepart,dayafterday,indeceivingpatients,butfeelpowerlesstotakeastand.Thereisurgentneedtodebatethisissueopenly.Notonlyinmedicine,butinotherprofessionsaswell,practitionersmayfindthemselvesrepeatedlyindifficultywhereseriousconsequencesseemavoidableonlythroughdeception.Yetthepublichaseveryreasontobewaryofprofessionaldeception,forsuchpracticesarepeculiarlylikelytobecomedeeplyrooted,tospread,andtoerodetrust.Neitherinmedicine,norinlaw,government,orthesocialsciencescantherebecomfortintheoldsaying,“Whatyoudon’tknowcan’thurtyou.”[776words]譯文:醫(yī)生可也對(duì)病人撒謊嗎？醫(yī)生應(yīng)該告訴病人他已經(jīng)病入膏肓了嗎？這些問題看起來很簡單，但是要給出令人滿意的答案卻并不那么簡單。撒謊還是不撒謊一一醫(yī)生的難題西塞拉?博克為了對(duì)病人有好處一一為了加快病人康復(fù)或不讓病人知道死亡的來臨一一醫(yī)生該不該撒謊？醫(yī)療行業(yè)與法律、政府及其他行業(yè)一樣，往往顯得對(duì)誠實(shí)與否的問題不那么看重，要緊的倒是另外一些事情。譬如，應(yīng)設(shè)法避免可怕的消息造成的打擊，或是應(yīng)考慮恪守保密的諾言，或是需要揭露腐敗行為或促進(jìn)公眾利益等。舉例說吧。一個(gè)46歲的男子，在與家人外出度假之前進(jìn)行常規(guī)體格檢查。雖然他自我感覺良好，但醫(yī)生發(fā)現(xiàn)他患了某種癌癥，6個(gè)月內(nèi)就會(huì)死去。這時(shí)，醫(yī)生該怎么對(duì)他講呢？是不是最好對(duì)他講實(shí)話？要是他問起檢查結(jié)果，醫(yī)生該不該否認(rèn)他得了?。吭摬辉搶⒉∏榈膰?yán)重性縮小到最低限度？該不該將真情至少隱瞞到全家度假之后？醫(yī)生常常面臨這樣的非常緊迫的選擇。他們不時(shí)認(rèn)為，為了病人自身的利益，撒謊很有必要，在他們看來，這種謊言與利己的謊言截然不同。研究結(jié)果表明，大多數(shù)醫(yī)生深信身患重病的人不想知道他們的真實(shí)病情，如果將真情相告，則有可能使他們失去希望，結(jié)果使他們恢復(fù)得更慢或惡化的更快，甚至?xí)詫ざ桃?。正如一位?nèi)科醫(yī)生寫道：“我們這個(gè)職業(yè)，傳統(tǒng)上恪守一條信條，那就是：‘盡可能不造成傷害’，這一信條勝過為講真話而講真話的美德?！庇辛诉@樣一個(gè)指導(dǎo)原則，一些醫(yī)生可能漸漸習(xí)慣于采用他們認(rèn)為對(duì)病人很可能有益而無害的騙人做法。他們可能開出無數(shù)貼安慰劑說一些沒有事實(shí)根據(jù)的打氣話，并歪曲嚴(yán)重的病情，對(duì)那些患者在不治之癥和瀕臨死亡的病人則尤其如此。然而現(xiàn)在有人提出證據(jù)，說明這種欺騙旨在給病人帶來好處的說法是虛幻的。研究結(jié)果表明，與許多醫(yī)生的想法相反，絕大多數(shù)病人確定想知道真實(shí)情況，甚至是嚴(yán)重的病情。當(dāng)他們了解到醫(yī)生沒有對(duì)他們講真話的時(shí)候，他們感覺自己被玩弄了。我們還獲悉，將真實(shí)情況妥當(dāng)?shù)母嬖V病人，能幫助他們與病魔作斗爭，有助于他們跟好地忍受疼痛，減少用藥，甚至在手術(shù)后更快的康復(fù)。謊言不僅不能提供鼓吹“仁慈”欺騙的人們所希望的那種“幫助”他還侵犯了病人的個(gè)人自由，使他們不能對(duì)有關(guān)自己的健康的問題做出明達(dá)的選擇，包括要不要就醫(yī)這一首要的選擇。我們?cè)絹碓揭庾R(shí)到，病人發(fā)病期間，在不知病情或未被如實(shí)告知病情的情況下，他們會(huì)遭到什么樣的不幸。特別是瀕臨死亡的病人一一他們最容易受騙，也最會(huì)被人蒙在鼓里一一因此而不能做出臨終前的種種有關(guān)抉擇：是否要住進(jìn)醫(yī)院或進(jìn)行手術(shù)，在何處與何人度過所剩的一點(diǎn)點(diǎn)時(shí)間，以及如何處理完自己的事物而后與世長辭。謊言也傷害說謊的人，損害他們的誠實(shí)，并最終損害他們的信譽(yù)。謊言還傷害他們的同事，由于病人懷疑有欺騙行為。許多對(duì)病人十分開誠布公的醫(yī)生的工作也因此受到影響。病人的不信任使醫(yī)療訴訟案增多，造成醫(yī)生避免風(fēng)險(xiǎn)的“防御性診治”增多，而這些又進(jìn)而有損整個(gè)醫(yī)療事業(yè)。劇烈的沖突還在出現(xiàn)。病人開始學(xué)會(huì)催問真實(shí)情況，根據(jù)病人應(yīng)享有的權(quán)利