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[筆記] The Rule of Double Effect— A Critique of Its Role in End-Of-Life Decision Making


  • 來源:The New England Journal of Medicine, Volume 337(24), 11 December 1997, pp 1768-1771
  • 作者:Quill, Timothy E.; Dresser, Rebecca; Brock, Dan W
  • 緣起
    1. CV陳醫師:面對這種不可救活的小孩,如果又知道家長也想放棄,我們就不會太盡力,但是面對家長,還是會說我們已經盡力了,讓他們沒有這麼大的愧疚感……
  • 內文整理
    1. What is the "Rule of double effect"?
      1. Effects that would be morally wrong if caused intentionally are permissible if foreseen but unintended.
      2. 可以應用的例子:high-dose opioids to treat a terminally ill patient's pain
      3. 不可應用的例子:physician-assisted suicide, voluntary euthanasia, and certain instances of forgoing life-sustaining treatment
    2. "Rule of double effect"的起源、應用與四大原則
      1. 起源:Roman Catholic moral theologians in the Middle Ages.
      2. 應用:Situations in which it is impossible for a person to avoid all harmful actions.
      3. 原則:
        • The nature of the act must be good, or at least morally neutral
        • The agent's intention:The good effect and not the evil effect
        • The distinction between means and effects(ex.死亡不能是解脫的手段)
        • The proportionality between the good effect and the bad effect
    3. "Rule of double effect"臨床議題之運用
      1. High doses of opioid analgesics:即便末期病人正在死去,在倫理或是法律的考量下,有些醫師還是不敢使用足量的opioid,以免促成病人提早死亡。然而,根據這個道德法則,只要不是“意圖”使病人死亡,即便最後病人因為opioid大量使用的副作用而死,這個行為本身還是被允許的。(目的:relieve the patient's suffering)
      2. Voluntary euthanasia:醫師意圖使病人死亡,明顯違反這個rule
      3. Physician-assisted suicide:協助病人自殺,主要是病人的行動直接致死,而不是醫師,醫師在其中的“意圖”明顯複雜許多,可能包含使病人放鬆、幫助睡眠等等(除死無大事),是否可以直接套用這個道德法則呢?
      4. Terminal sedation:the patient is sedated to the point of unconsciousness in order to relieve otherwise untreatable pain and suffering and is then allowed to die of dehydration.意圖解除疼痛本身是好的,但是死亡究竟是可以預見或者其實也是意圖,就不大清楚(相對地,使用opioid的情形,我們是很不願意病人死亡),不過,至少一點,延長生命的意圖在這種療法下,已經被完全放棄了,據此,這也違背了這個道德法則。
      5. In one large series, 39% physicians who had sedated patients while stopping life support reported that they had done so with the intention of hastening death, in clear violation of the rule of double effect.
    4. 在美國
      1. 刑法規定:Conduct posing a risk to life is permissible if it is justified by the expected benefits. 換句話說,美國刑法針對放棄治療,與這個道德法則看法不同。The law permits clinicians to forgo treatment at the request of a competent patient, even when the expressed purpose is to cause the patient's death.
      2. 在類似的案例中,比如醫師協助病人自殺,或醫師經過病人同意結束病人生命,陪審團通常也不願意判定醫師有罪,顯示多數人已經不完全認同這樣的一個道德法則
    5. "Rule of double effect"臨床運用的問題
      1. The rule originated in the context of a particular religious tradition
      2. The analysis of intention is problematic(Psychology:human intention is multilayered, ambiguous, subjective, and often contradictory.)
      3. In most moral, social, and legal realms, people are held responsible for all reasonably foreseeable consequences of their actions, not just the intended consequences.
      4. Autonomy is a central tenet of Western medical ethics and law.(patients' rights)
    6. 結論
      1. Physicians' care of their dying patients is properly guided and justified by patients' informed consent, the degree of suffering, and the absence of less harmful alternatives to the treatment contemplated.
  • 我的問題
    1. 台灣對於類似的問題如何描述?醫師如何下決定不再救治病人甚至協助病人自殺?完全依病人意願?或者也會有倫理上的兩難?
    2. 台灣醫師的專業素養認知中,這樣的問題是否實際被納入?如果有,那麼台灣醫師所憑藉的判準法則為何?(安寧緩和醫療條例: 末期病人, 自主意願, 自然死)
    3. 台灣的宗教傳統是否影響醫師下決定?
  • 附錄
    1. 生物醫學倫理四大原則
      1. 行善原則(Beneficence):一切以病人的利益為前提
      2. 不傷害原則(Nonmaleficence):將對病人的創傷減小到最低
      3. 自主原則(Autonomy):尊重病人為一個人所該有的尊嚴與自主性
      4. 正義公平原則(Justice):合理地分配醫療資源
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