From the UK
From the UK
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来自英国
DOI：
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发表时间：
2003
期刊：
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通讯作者：
I. Finlay
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文献类型：
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作者：
I. Finlay
EAPC伦理工作组的文件有很多值得称赞的地方。它对安乐死请求的处理方式采取了合理的立场，支持患者进行姑息治疗，但不期望姑息医学专家管理安乐死药物。该文件承认不同的文化和政治背景下，医学实践，如希普曼的谋杀对英国医学的灾难性影响。世界卫生组织最近修改了文件中使用的姑息治疗定义，将姑息治疗的重点放在常规良好临床实践之外。教育工作者尤其欢迎对暂停和撤销治疗的澄清，鼓励公开对话应确保提高对患者需求的认识并将重点放在患者需求上。然而，人们对这些需求却知之甚少。病人需要控制一种基本上完全无法控制的情况，即，当疾病对所有尝试过的干预措施都没有反应时。也许这种对控制的基本需求需要进一步探索患者的术语，而不是医疗保健专业人员的治疗和干预的说法。也许在整个辩论中，有一些重要的问题是从错误的出发点争论的。我们应该把安乐死和医生协助自杀作为两个独立的实体来讨论，还是应该只讨论医生协助死亡？换句话说，病人口服致命剂量的药物，或提供静脉注射，在伦理或意图上是否有分别？我不这么认为。我认为更准确的说法是静脉注射安乐死或口服安乐死;在这两种情况下，医生都与病人进行了同样的讨论，而且在这两种情况下，医生也都提供了药物来诱导死亡。在一种情况下，患者将玻璃杯举到他或她的嘴唇上，在另一种情况下，患者抬起手臂以注射物质。在前者中，口服诱导死亡失败将需要医生进行干预，并使用注射剂量的巴比妥酸盐和肌肉麻痹剂诱导死亡。人们必须问自己，为什么这么少的病人自杀，而且据说他们似乎与那些讨论安乐死的病人不是同一批人。当病人表达“只是想死”的愿望时，病人是在要求死亡以外的东西吗？他或她是否要求对命运有一些控制，任何控制;唯一合理的要求是控制死亡的时间。也许值得花一点时间考虑一下，为什么那些疾病使他们被比喻为“死囚”的病人没有自杀。许多人正在等待，实际上是希望，通过医疗干预获得解脱。然而，每年都有许多人，特别是英国监狱里的年轻人，自杀，他们加入了总登记处死因表中不断膨胀的自杀行列，与其他绝望的人一起，他们无法再活下去。也许自杀是如此根本性的不同，因为它是通过绝望和自我漂浮而自残的终极方式，而安乐死的请求代表了在仍然有能力的情况下重新获得对自己命运的一些控制的需要;有趣的是，荷兰的经验表明，许多安乐死的请求并没有导致致命剂量的药物被管理，但病人觉得如果情况太糟无法忍受，他们可以拥有它。在我们的一生中，我们生活得好像我们掌握了命运;我们觉得我们必须承受我们行为的后果，因此我们的决定是主要的自我决定因素。那些自杀的人则完全相反，他们觉得自己毫无价值，毫无价值，以至于生命没有价值，因此愤怒，自我厌恶和低自尊爆发为自杀。也许欧大理事会道德小组应该重新考虑它们的命名。他们应该清楚，自杀和安乐死是由根本不同的需求驱动的，不应该混淆。安乐死总是医生的同谋，即使不是直接由医生实施，所以口服或静脉注射安乐死比谈论医生协助自杀更准确，更诚实。自杀是自我伤害的终极行为;安乐死是一种绝望的方式来获得对情况的最后一丝控制。安乐死的最终结果是在帮助下自我毁灭。姑息医学2003; 17：137
The document from the EAPC Ethics Task Force has much to commend it. It takes a reasonable stance on the way that requests for euthanasia are to be dealt with, supporting the patient with pallia tive care but not expecting palliative medicine specialists to administer euthanasia drugs. The document recognizes the different cultural and politica l settings in which medicine is practised, such as the disastrous effect on British medicine of Shipman’s murders. The recent World Health Organization modification of the definition of palliative care, as used in the document, has focused palliative care beyond routine good clinical practice. Educators in particular will welcome the clarification around withholding and withdrawing treatment, and the encouragement of open dialogue should ensure a heightened awareness of and focus on the patient’s needs. Yet it is precisely those needs that are poorly understood. The patient needs control over a situation that is by and large quite beyond controlling, i.e., when disease has shown itself non-responsive to all the interventions that have been attempted. Perhaps this fundamental need for control warrants further exploring in the patient’s terms rather than the healthcare professional’s parlance of treatments and interventions. Perhaps there are some important issues in this whole debate that have been argued from the wrong starting point. Should we be talking of euthanasia and physicianassisted suicide as two separate entities, or should we be talking of physician-assisted death only? In other words, is there any difference in ethical terms or in intent if the patient takes the lethal dose of medicine by mouth or proffers a vein for it to be injected intravenously? I think not. I would suggest that it is more accurate to talk of intravenous euthanasia or oral euthanasia; in both instances the doctor has undertaken the same discussion with the patient and in both instances has also supplied the drug to induce death. In one instance the patient lifts the glass to his or her lips, in the other the patient lifts an arm for the substance to be injected. In the former, failed induction of death orally will require the physician to intervene and to induce death with an injected dose of barbiturate and muscle-paralysing agent. One must ask oneself why so few patients commit suicide and anecdotally they do not seem to be the same cohort of patients as those who discuss euthanasia. When the patient expresses the wish of j̀ust wanting to die’ is the patient asking for something other than death? Is he or she asking to have some control, any control over fate; and the only thing that can be asked for reasonably is control over the timing of death. It may be worth for a moment considering why patients whose disease has put them metaphorically `on death row’ do not commit suicide. Many are waiting, indeed hoping, for a r̀eprieve’ through medical intervention. Yet there are many people, especially young men in Britain’s jails, who do kill themselves every year and who join the swelling ranks of suicides in the Registrar General’s tables of causes of death, listed with others whose despair was so great that they could not live any longer. Perhaps suicide is so fundamentally different because it is the ultimate in self-harm through despair and selfloathing, whereas the request for euthanasia represents a need to regain some control over one’s destiny while still having capacity; interestingly, the Dutch experience suggests that many requests for euthanasia do not result in a lethal dose of drug being administered, but in the patient feeling they could have it ìf things get too bad to bear’. All through our lives we live as if we have control over destiny; we feel that we must live with the consequences of our actions and that our decisions are therefore major self-determinants. Those who commit suicide are diametrically opposite / they feel totally worthless and valueless to the extent that life has no value and so the anger, self-loathing and low self-esteem erupt into suicide. Perhaps the EAPC ethics group should reconsider their nomenclature. They should be clear that suicide and euthanasia are driven by fundamentally different needs and should not be confused. Euthanasia is always physician-complicit even when not directly physicianadministered, so oral or intravenous euthanasia is more accurate and more honest than talking of physicianassisted suicide. Suicide is the ultimate act of self-harm; euthanasia is a desperate way to gain the last vestige of control over a situation. Euthanasia has as its final outcome the destruction of self with help. Palliative Medicine 2003; 17: 137