西方医学的最高原则是 no harm. (不能因为治疗而带来附加的伤害。)我的美国儿科医生朋友去中国访问,发现所有的患感冒儿童都要接受抗菌素和吊液治疗。他非常不理解。因为照教科书,感冒前期是病毒所致,主要是对症治疗,治咳嗽,流鼻子,发烧或头痛。少数儿童进入感冒后期,合并有细菌感染有黄痰发烧才需要抗菌素治疗。不能进食的儿童才需要吊液。中国医生这种过度的治疗会给儿童带来附加的伤害,是非常不人道的。
也因为美国医生的水平高且齐,所以在美国只有两种级别的医生:住院医生和住院医生毕业后的主治医生。医院里的一个主治医生在4-8个住院医生的帮助下,管30多张病床。没有任何一个主治医生允许“查“其它的主治医师的“房“。因为大家职业水平都是一样的。美国医院里也有主任,但那是行政职务,与看病没关系。美国医院里的主任也是一个主治医生,也要亲自管30多张病床。美国医院里不养中国那种只管医生不管病人的“主任医师“。在美国没有“能看疑难杂症“这句话。每一个医生都能正确处理自己专业内的100%的问题,无论简或难。所以不存在有人有本事能看疑难杂症,有人没水平不能看疑难杂症的事。美国的西医因为没有中国医疗环境里传统中医的干扰,所以把循证医学(evidence based medical science)发挥到极致。也就是说凡是没有经过当代物理,化学和生物化学证实的东西,一概搁置不理。以至于临床医学在某种意义上带有数学的特点,对于某一种病的解释和治疗只有一个答案,唯一一个最好的答案。对病人来说,同一个医疗问题你问西部加州的医生,或问东部纽约的医生,问城里的医生或问乡下的医生,答案都完全一样。在美国,不鼓励病人为了自己的同一个病去看第二个同科医生。付钱的医疗保险业会认为这是浪费。美国也没有“专家门诊“,因为主治医生的水平是一样的,青年老年的水平也一样,(青年医生的知识还会新一点儿。)没有理由去看老医生要多付钱。中国的病人告诉我,在中国遇到难一点的医疗问题问几个医生,“每个中国医生都有他自己的不同看法“。这就是水平不齐的缘故。
任何一个假的东西一定会祸害国家祸害百姓。中国政府一定没有想到他好心鼓吹的中医中药不久会变成他脖子上的枷锁。比如,中国现在开始解决穷人和农民的医疗问题,大约要花50到70年才能搞定。穷人的医疗问题说起来很简单,就是政府出钱穷人看病。西方国家政府出钱给穷人看病的历史近一百年,很有经验。1960-1963年间任英国卫生部长的波维尔说:“实际上个人能消耗的卫生资源是无限的“。西方总结出在这样一个模式中,穷人对医疗的要求和花政府的钱的欲望一天比一天高。政府对付他们的办法就是告诉穷人除了基本和确切的治疗以外,政府拒付所有的其它医疗项目,但要在法理之中。什么是法,比如我建议用美国的《当代医学诊断和治疗》作诊断和治疗的依据,(中国用的药物会和它不一样)。这本书每年修订一次,2006年已经是第45版。非常实用,明确,内容丰富。中国有中译本。(Current medical diagnosis and treatment, edited by Lawrence M. Tierney, Jr., Stephen J. McPhee, and Maxine A. Papadakis; Lange Medical Books/McGraw-Hill)依据这本书内容,医生要对穷人的疾病作出两种判断:1。区分可治性还是不可治性疾病。如果是不可治的病,比如晚期肝癌,政府除了付钱买止痛药外,一分也不多付。特别是要拒付晚期癌症的各种实验治疗。因为是白花钱没有用。2。在可治性疾病当中要区分有确切疗效的药物和方法和没有确切疗效的药物和方法(比如中药就是没有确切疗效的药物和方法)。政府只付有确切疗效的药物和方法,而且要选最便宜的。其它的选择全部拒付。我这里说的是每一个国家和政府的穷人医疗体系的唯一活命的办法。无论是美国还是欧洲,还是中国,政府想要不破产,就是依“法“告诉穷人这也拒付那也拒付。
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.作者: sunnyyx 时间: 2006-3-14 23:59:19