Metaethical and Pedagogic Issues ST Medical centers are a primary context for医疗服务的地点大多为医疗中心,故医 medical ethics, as well as medical care.疗中心也即医学伦理的主要背景。不论 Whether physicians, philosophers, or是医师、哲学家还是神学家,大多数医 theologians,, most medical ethicists are学伦理学研究者主要在医学院或其附 primarily based in medical schools and属的教学医院工作,他们的主要受众 eaching hospitals, and their principal audiences除了他们的业内同行之外,便是医科学 ae( apart from one another) medical students生及住院医生。这样的背景从一定程度 and residents. This setting partially explains the I上解释了为何在医学伦理学中案例分 primary role of actual case analysis in medical析远多于理论著述。医生和护士可没有 ethics, by contrast with much ethical writing耐心听那些理论论证或是凭空想象出 Physicians and nurses have little patience with的包括了许多世俗伦理的测试用例。 the theoretical dialectic or fanciful test-cases that constitute much current secular ethics Nor do they readily accept the main theoretical他们也不乐意接受主流的理论观点。康 alternatives. The Kantian ideal of persons as德相信,人是理性的,自身即是目的 rational ends-in-themselves is hard to reconcile但这一理论与医务工作者面对的现实 with the reality of patients whose mat却大相径庭一疾病往往会摧毁患者 judgment, sense of self and self-interests, and I的判断力及自我意识,使其无法做出对 dignity are subverted by illness. Likewise, the自己最有利的决定。同样,希波克拉底 scope of the Hippocratic maxim, 'Strive to help的箴言“尽力救治,以无害为先”比功 but above all, do no harm" is far narrower thanI利主义的原则“每个个体作为且仅作为 the Utilitarian principle" veryone counts for|一个”在范围上要狭隘得多。有些医生 one and no more than one" Some physicians会考虑到患者家庭、医务人员或未来患 will give some weight to the welfare of a l者的利益(例如试用新药很难对现有患 patient's family, hospital sta, or future patients者有利),但他们几乎肯定不会考虑患 ( e.g. in drug trials unlikely to benefit current者的朋友、继承人或雇主的利益,尽管 atients),but they will almost certainly ignore这些人可能受到医疗决策的严重影响 the friends, heirs or employers who may be seriously affected by treatment decisions
Metaethical and Pedagogic Issues ST TT Medical centers are a primary context for medical ethics, as well as medical care. Whether physicians, philosophers, or theologians, most medical ethicists are primarily based in medical schools and teaching hospitals, and their principal audiences are (apart from one another) medical students and residents. This setting partially explains the primary role of actual case analysis in medical ethics, by contrast with much ethical writing. Physicians and nurses have little patience with the theoretical dialectic or fanciful test-cases that constitute much current secular ethics. 医疗服务的地点大多为医疗中心，故医 疗中心也即医学伦理的主要背景。不论 是医师、哲学家还是神学家，大多数医 学伦理学研究者主要在医学院或其附 属的教学医院工作，他们的主要受众， 除了他们的业内同行之外，便是医科学 生及住院医生。这样的背景从一定程度 上解释了为何在医学伦理学中案例分 析远多于理论著述。医生和护士可没有 耐心听那些理论论证或是凭空想象出 的包括了许多世俗伦理的测试用例。 Nor do they readily accept the main theoretical alternatives. The Kantian ideal of persons as rational ends-in-themselves is hard to reconcile with the reality of patients whose mature judgment, sense of self and self-interests, and dignity are subverted by illness. Likewise, the scope of the Hippocratic maxim, "Strive to help but above all, do no harm" is far narrower than the Utilitarian principle, "Everyone counts for one and no more than one." Some physicians will give some weight to the welfare of a patient's family, hospital staff, or future patients (e.g. in drug trials unlikely to benefit current patients), but they will almost certainly ignore the friends, heirs or employers who may be seriously affected by treatment decisions. 他们也不乐意接受主流的理论观点。康 德相信，人是理性的，自身即是目的。 但这一理论与医务工作者面对的现实 却大相径庭——疾病往往会摧毁患者 的判断力及自我意识，使其无法做出对 自己最有利的决定。同样，希波克拉底 的箴言“尽力救治，以无害为先”比功 利主义的原则“每个个体作为且仅作为 一个”在范围上要狭隘得多。有些医生 会考虑到患者家庭、医务人员或未来患 者的利益（例如试用新药很难对现有患 者有利），但他们几乎肯定不会考虑患 者的朋友、继承人或雇主的利益，尽管 这些人可能受到医疗决策的严重影响
In the light of practitioners resistance, some 鉴于从业者的抵制,部分医学伦理 medical ethicists have forsaken ethical theories学家已经放弃了只有单一主导原则的 hat have a single, dominant principle in favor理论,而是选择了借用法理学做法的理 of the jurists tactic of" balancing"several I论,即“平衡”若干无优先排序的原则。 unranked principles. Decisions are to be I通过对每个案例“权衡”目前的若干权 eached by"weighing"for each case the now威原则一一即自主、行善、无伤害,以 canonical principles of autonomy, beneficence,及倘若适当的话,诚信、生命神圣和分 and non-maleficence, and, when appropr配公正一一来做出决定。 veracity. sanctity of life, and distributive Justice Critics find this procedure too dependent or 批评者认为这套程序过分依赖直 individual intuition, and have proposed various觉,并提出了几种解决方案。其中一种 remedies.On one proposal, conflicting general方案将互相矛盾的主要原则具体化,从 principles are" specified"to yield compatib而为某个具体的案例得出一套兼容的 norms for a specific case. On another;the准则。在另一种方案中,主要原则由大 general principles are supplemented or replaced量从“常识”道德引出的禁忌所补充或 by a larger number of prohibitions drawn from取代。在一种“自下而上”由中世纪的 common sense" morality.Ona" bottom up?决疑法所得到的方案中,在道德推理中 alternative drawn from Medieval casuist,itis占中心地位的不是原则而是被详细描 ichly described paradigm cases, not principles.述的范例。其他的方案则完全摈弃原 that have the central role in moral reasoning则,转而主张职业道德(正直诚实、信 Other proposals would dispense with principles托责任、同情心)、“关怀伦理学”的 altogether in favor of professional virtues关注焦点(应需、依赖和信任)和(/ ( integrity, fiduciary responsibility, compassion)或)从与病人、家属及其他相关人员的 the central concerns of" care ethics"(response I谈话中所小心构建起来的“陈述” sensitively constructed from conversations with atients. families and other attendants
In the light of practitioners' resistance, some medical ethicists have forsaken ethical theories that have a single, dominant principle in favor of the jurist’s tactic of "balancing" several unranked principles. Decisions are to be reached by "weighing" for each case the now canonical principles of autonomy, beneficence, and non-maleficence, and, when appropriate, veracity, sanctity of life, and distributive justice. 鉴于从业者的抵制，部分医学伦理 学家已经放弃了只有单一主导原则的 理论，而是选择了借用法理学做法的理 论，即“平衡”若干无优先排序的原则。 通过对每个案例“权衡”目前的若干权 威原则——即自主、行善、无伤害，以 及倘若适当的话，诚信、生命神圣和分 配公正——来做出决定。 Critics find this procedure too dependent on individual intuition, and have proposed various remedies. On one proposal, conflicting general principles are "specified" to yield compatible norms for a specific case. On another, the general principles are supplemented or replaced by a larger number of prohibitions drawn from "common sense" morality. On a "bottom up" alternative drawn from Medieval casuistry, it is richly described paradigm cases, not principles, that have the central role in moral reasoning. Other proposals would dispense with principles altogether in favor of professional virtues (integrity, fiduciary responsibility, compassion); the central concerns of "care ethics" (response to need, dependency, trust); and/or "narratives" sensitively constructed from conversations with patients, families, and other attendants. 批评者认为这套程序过分依赖直 觉，并提出了几种解决方案。其中一种 方案将互相矛盾的主要原则具体化，从 而为某个具体的案例得出一套兼容的 准则。在另一种方案中，主要原则由大 量从“常识”道德引出的禁忌所补充或 取代。在一种“自下而上”由中世纪的 决疑法所得到的方案中，在道德推理中 占中心地位的不是原则而是被详细描 述的范例。其他的方案则完全摈弃原 则，转而主张职业道德（正直诚实、信 托责任、同情心）、“关怀伦理学”的 关注焦点（应需、依赖和信任）和（/ 或）从与病人、家属及其他相关人员的 谈话中所小心构建起来的“陈述
All of these approaches have theoretical aspe 以上所有方案都带有理论成分,但 and arguments, but the less the explicit appeal愈少试图认真构建及支持道德原则,对 to carefully formulated and supported moral案例分析来说,特殊的哲学训练就显得 principles, the less that special philosophical愈不必要。哲学家当然因他们的思维清 training may seem necessary for case analysis晰、逻辑相关联以及能提出大量恰当的 Philosophers, of course, pride themselves on|间题、做出合适的区分而引以为豪;但 their clarity, sense of relevance, and stock of apt律师也同样如此。而且,医学伦理学家 questions and distinctions,, but so too do I大量地从法学领域借用概念和案例(应 lawyers. Moreover, medical ethicists liberally有关注、作为/不作为、胜任能力;昆 borrow notions and cases from the law(due兰、克鲁赞3、无名婴尸3、乔伊斯·布 care, act/omission,, competence, Quinlan.朗)。不过,由于所受培训及机构职 Cruzan, Baby Does. Joyce brown) There are.位的不同,二者也有区别。比起“法务 wever, differences due as much to training as经理”,哲学家在决断有争议的案件或 to institutional positions: philosophers give less是制定政策时,较少考虑到医疗机构的 weight than do" legal risk managers"to|利益。另一方面,医学伦理学家可能会 institutional interests in deciding contentious I更多地考虑医院及诊所的利益,而生命 cases or formulating policy. On the other hand.伦理学家关注的则是生命的形成、拯救 medical ethicists may give more weight和终结等一般性问题,不论有无医生的 institutional interests and physician practices协助。 than those bioethicists whose concerns are general issues of the creating, saving, an taking of life, with or without physicians assistance he content and methods of medical ethics医学伦理学的教学内容及方法依 teaching varies with audience and locale.ln受众和地点的不同而不同。在哲学系的 philosophy department classes, cases are used课堂中,案例是用来提出一般的、经常 to raise general, often abstract issues of moral是抽象的道德推论和道德理论、中心概 reasoning and moral theory, the definition of念的定义(自主、死亡、因果关系)以 central concepts (autonomy.dath,caus及形而上的假设(人格同一性、身心关 connection), and metaphysical presuppositions I系)。而在大多数的医学院,如此抽象 ( personal identify, body-mind relations ) In的问题则令人兴趣索然,能让师生觉得 most medical schools, there is little appetite for I自己与紧迫的临床问题和身边的案例 such abstract matters, and too little curricular有关的课程也是少之又少。既然如此 time to convince students and clinical没有发生苏格拉底与希波克拉底之间 co-teachers of their relevance to the pressing的对话也就不足为奇了。 clinical issues and cases at hand. We should not be surprised there is no Socratic dialogue with译者注 Hippocrates 1.昆兰( quinlan):指凯伦·安·昆兰( Karen Ann Quinlan)。关于是否应该对植物人终止救助,使其 自然死亡的争议。 2.克鲁赞( Cruzan):指南希·贝丝·克鲁赞( Nancy Beth cruzan)。关于是否应该对植物人终止救助
All of these approaches have theoretical aspects and arguments, but the less the explicit appeal to carefully formulated and supported moral principles, the less that special philosophical training may seem necessary for case analysis. Philosophers, of course, pride themselves on their clarity, sense of relevance, and stock of apt questions and distinctions, but so too do lawyers. Moreover, medical ethicists liberally borrow notions and cases from the law (due care, act/omission, competence; Quinlan, Cruzan, Baby Does, Joyce Brown). There are, however, differences due as much to training as to institutional positions: philosophers give less weight than do "legal risk managers" to institutional interests in deciding contentious cases or formulating policy. On the other hand, medical ethicists may give more weight to institutional interests and physician practices than those bioethicists whose concerns are general issues of the creating, saving, and taking of life, with or without physicians’ assistance. 以上所有方案都带有理论成分，但 愈少试图认真构建及支持道德原则，对 案例分析来说，特殊的哲学训练就显得 愈不必要。哲学家当然因他们的思维清 晰、逻辑相关联以及能提出大量恰当的 问题、做出合适的区分而引以为豪；但 律师也同样如此。而且，医学伦理学家 大量地从法学领域借用概念和案例（应 有关注、作为/不作为、胜任能力；昆 兰 1、克鲁赞 2、无名婴尸 3、乔伊斯•布 朗 4）。不过，由于所受培训及机构职 位的不同，二者也有区别。比起“法务 经理”，哲学家在决断有争议的案件或 是制定政策时，较少考虑到医疗机构的 利益。另一方面，医学伦理学家可能会 更多地考虑医院及诊所的利益，而生命 伦理学家关注的则是生命的形成、拯救 和终结等一般性问题，不论有无医生的 协助。 The content and methods of medical ethics teaching varies with audience and locale. In philosophy department classes, cases are used to raise general, often abstract issues of moral reasoning and moral theory, the definition of central concepts (autonomy, death, causal connection), and metaphysical presuppositions (personal identify, body-mind relations). In most medical schools, there is little appetite for such abstract matters, and too little curricular time to convince students and clinical co-teachers of their relevance to the pressing clinical issues and cases at hand. We should not be surprised there is no Socratic dialogue with Hippocrates. 医学伦理学的教学内容及方法依 受众和地点的不同而不同。在哲学系的 课堂中，案例是用来提出一般的、经常 是抽象的道德推论和道德理论、中心概 念的定义（自主、死亡、因果关系）以 及形而上的假设（人格同一性、身心关 系）。而在大多数的医学院，如此抽象 的问题则令人兴趣索然，能让师生觉得 自己与紧迫的临床问题和身边的案例 有关的课程也是少之又少。既然如此， 没有发生苏格拉底与希波克拉底之间 的对话也就不足为奇了。 译者注： 1. 昆兰（Quinlan）：指凯伦•安•昆兰（Karen Ann Quinlan）。关于是否应该对植物人终止救助，使其 自然死亡的争议。 2. 克鲁赞（Cruzan）：指南希•贝丝•克鲁赞（Nancy Beth Cruzan）。关于是否应该对植物人终止救助
使其自然死亡的争议 3.无名婴尸( Baby does):美国无名婴儿尸体的常 用化名。无名婴儿尸体常常被处理,无强制上报程 序,无完善的全国档案,导致大量婴儿失踪案件悬 而未决,犯罪率攀高 4.乔伊斯·布朗( Joyce Brown):指乔伊斯·帕特丽 夏·布朗( Joyce Patricia BrowN)。反对强制收容 治疗街头流浪精神病人案例
使其自然死亡的争议。 3. 无名婴尸（Baby Does）：美国无名婴儿尸体的常 用化名。无名婴儿尸体常常被处理，无强制上报程 序，无完善的全国档案，导致大量婴儿失踪案件悬 而未决，犯罪率攀高。 4. 乔伊斯•布朗（Joyce Brown）：指乔伊斯•帕特丽 夏•布朗（Joyce Patricia Brown）。反对强制收容 治疗街头流浪精神病人案例