醫(yī)療:回到希波克拉底時(shí)代

That Latin maxim1) roughly translated as “above all， do no harm” is a key element of the Hippocratic Oath2).

One of the foundational elements of medical ethics is non-maleficence3)， the notion that when treating a patient， it may be preferable to not do something， or even do nothing at all， if the intervention risks causing more harm than good.

Yet， in our modern era， with its dizzying4) technological innovation， ready access to a cornucopia5) of drugs and impatience driven by the jolts6)-per-minute pace of daily life， the guiding maxim has become: “Do something. Do anything.”

You see it every day in medical practice. No one wants to leave a physician’s office without a prescription or a high-tech test. Everybody wants to be screened so they can nip7) cancer in the bud8) or catch Alzheimer’s9) early， even when this information can do more harm than good.

The Nike “JUST DO IT” and the consumerist philosophy that more is always better may carry the day10) on TV dramas， but it has no place in real-life medicine. Acting swiftly and firmly may provide succour11)， at least temporarily， but every action has an equal and often greater reaction.

We seem—in medicine as in life—to have lost the precious ability to ponder. To wait. To utter the three magic words “I don’t know.” To wisely do nothing until we do know more， or until nature takes its course.

The result is an epidemic of overtreatment that is both financially costly and physically harmful. The reality was exposed in a sobering book by journalist Shannon Brownlee12) entitled Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.

In May， 2011， the Good Stewardship Working Group—physicians who believe good care can be delivered cost-effectively—published a list of commonly used tests and treatments that are unnecessary.

Then， in early December， 2011， a group of academics costed out13) the savings that would come from eliminating a dozen wasteful interventions—a whopping14) $6.8 billion a year in the U.S.

Health-care costs are not on the rise because physicians are going around doing unnecessary heart transplants. Rather， it is the routine use of banal15)—and generally useless—tests that is costing us all a bundle16).

The researchers found， for example， that blood， urine17) and electrocardiogram18) tests are routinely ordered for patients with no related symptoms or risk factors. These are too often done merely to give a patient the sense that the doctor is “doing something.”

Among the most frequently inappropriate practices were those that involved children with minor ailments19): Writing antibiotics20) prescriptions for children with sore throats who didn’t have strep21) infection; recommending unnecessary cough syrup22) for children with upper respiratory23) infections， and ordering imaging tests such as CT scans for kids with minor head injuries (those that did not involve dizziness or loss of consciousness). Again， there are real negative consequences to this kind of overtreatment， including fuelling antibiotic resistance24) and exposing them to potentially harmful radiation.

It’s worth noting that the Good Stewardship Working Group focused strictly on the blatantly25) wasteful.

It deliberately avoided tackling more controversial issues such as PSA26) testing for prostate cancer and mass screening of young women for breast cancer. In those cases， the admonition27) is not for doctors to do nothing， but rather to be more targeted in their interventions. For some young women—those with several risk factors—early screening is appropriate. And for some men， the PSA test can be useful， as can surgery and radiation.

But watchful waiting also has its place. While that terminology is just coming into vogue28)， there is a more long-standing term， clinical inertia29)， though it seems to have more negative connotations.

For example， clinical inertia means having a patient with mildly elevated blood pressure or high cholesterol30) and deciding to not prescribe a drug. Instead， the doctor might encourage him to take a brisk walk each day or lose a few pounds， approaches that would be as effective as drugs and have no negative side effects.

There was a time， not so long ago， when health professionals used this approach much more commonly， rather than immediately reaching for the prescription pad or the diagnostic test. Yet， over time， physicians have been trained increasingly to become technicians， and overly dependent on technology.

Medicine is a science， but it is also an art. At its heart should be the art of listening， and the recognition that not acting is as important as acting.

In the seminal31) work of satire The House of God32)， author Samuel Shem provided a list of commandments for good medical care. The infamous 13th Law of The House of God was: “The delivery of good medical care is to do as much nothing as possible.”

Yet， since the book’s publication in 1978， overtreatment has reached such tragicomic33) proportions that the satire has melted away， leaving only age-old wisdom.

It’s as if we have come full circle back to Hippocrates， who said: “To do nothing is sometimes a good remedy.”

我愿以此純潔與神圣的精神，終生執(zhí)行我職務(wù)……無論身處何處，遇男遇女，貴人及奴婢，我之唯一目的，為病家謀幸福，并檢點(diǎn)吾身，不作各種害人及惡劣行為……

——選自《希波克拉底誓言》

拉丁語里有一條格言，粗略翻譯過來便是“首要的原則是，不要給病人帶來危害”，這是《希波克拉底誓言》的核心要素。

醫(yī)學(xué)職業(yè)道德中最基本的原則之一是“不為害”。該原則表述的是這樣一個(gè)概念：在治療病人時(shí)，如果某項(xiàng)治療可能產(chǎn)生的負(fù)面作用比其產(chǎn)生的積極作用要大，那應(yīng)該偏向于不使用該治療手段，甚至可以不使用任何治療手段。

然而，在當(dāng)今時(shí)代，技術(shù)革新令人眼花繚亂，各色藥物變得唾手可得，每分每秒都需要新鮮刺激的日常生活節(jié)奏使人們變得毫無耐心。這使得醫(yī)學(xué)的指導(dǎo)性格言實(shí)際上已經(jīng)變成：“快做點(diǎn)什么，能做的都做。”

這種現(xiàn)象在日常的醫(yī)學(xué)實(shí)踐中隨處可見。沒人想兩手空空地走出醫(yī)生辦公室，誰都想拿到一張?zhí)幏交蚋呖萍蓟?yàn)單。每個(gè)人都想作檢查，好把癌癥消滅在萌芽狀態(tài)，或者及早發(fā)現(xiàn)老年癡呆癥的苗頭，即使這樣帶來的負(fù)面作用大于積極作用也在所不惜。

耐克的廣告語“放手去做”以及“更多就是更好”的消費(fèi)理念也許可以在電視劇里大行其道，但在現(xiàn)實(shí)的醫(yī)療環(huán)境中卻并不可取。迅速而果斷地采取行動也許能提供緊急救援，至少暫時(shí)來看是如此，但每個(gè)行動都會帶來等量甚至常常是更大的副作用。

如同對待生活一樣，我們對待醫(yī)療時(shí)似乎都喪失了寶貴的思考能力，我們不愿意等待，也不愿意說出“我不知道”這幾個(gè)奇妙的字眼。在我們了解更多情況或者順其自然之前，也不愿理智無為。

以上行為導(dǎo)致的結(jié)果便是泛濫成災(zāi)的過度治療，這不僅耗費(fèi)大量資金，而且對身體有害。記者莎朗·布朗利在自己所著的《過度治療：太多藥物為何會加劇病情與貧困》一書中冷靜地為我們指出了這一現(xiàn)狀。

2011年5月，促進(jìn)臨床優(yōu)質(zhì)服務(wù)組織——該組織的醫(yī)生相信能夠以更低的成本和更高的效率來提供醫(yī)療服務(wù)——發(fā)布了一份清單，列出了一些并非必需卻被經(jīng)常使用的化驗(yàn)和治療手段。

2011年12月初，一組學(xué)者進(jìn)行了一項(xiàng)估算，如果去掉一些毫無必要的診治項(xiàng)目，全美每年可節(jié)省的開支數(shù)額驚人——高達(dá)68億美元。

醫(yī)療衛(wèi)生費(fèi)用不斷上漲并不是因?yàn)獒t(yī)生們忙著做沒有必要的心臟移植手術(shù)。相反，耗費(fèi)我們大把金錢的是那些慣用但基本上毫無用處的常規(guī)化驗(yàn)。

比如，研究人員發(fā)現(xiàn)，對于沒有相關(guān)癥狀或危險(xiǎn)因素的病人，醫(yī)生也會例行公事似的要求驗(yàn)血、驗(yàn)?zāi)蛞约白鲂碾妶D測試。做這些化驗(yàn)的目的常常只是為了讓病人覺得醫(yī)生在“做些什么”。

在最常發(fā)生的不當(dāng)醫(yī)療實(shí)踐中，對微恙的小孩進(jìn)行過度醫(yī)療是其中的典型：給嗓子疼但并未受鏈球菌感染的孩子開抗生素；給上呼吸道感染的孩子推薦無用的止咳糖漿；給頭部受到輕微創(chuàng)傷(沒有暈?；蚧杳园Y狀)的孩子做CT掃描等成像檢查。要再次強(qiáng)調(diào)的是，這種過度治療的的確確存在負(fù)面后果，包括增加孩子對抗生素的耐藥性，以及讓孩子遭受可能有害的輻射危險(xiǎn)。

值得注意的是，促進(jìn)臨床優(yōu)質(zhì)服務(wù)組織關(guān)注的焦點(diǎn)僅僅是那些極為明顯的醫(yī)療浪費(fèi)。

該組織有意回避了更有爭議的醫(yī)療項(xiàng)目，比如針對前列腺癌進(jìn)行的前列腺特異性抗原化驗(yàn)和針對乳腺癌對年輕女性進(jìn)行的大范圍檢查。對于這些狀況，需要提醒醫(yī)生的不是什么都不做，而是在診療過程中更有針對性。對于有些年輕女性——那些有患乳腺癌風(fēng)險(xiǎn)因素的女性——及早檢查是適用的。對有些男性來講，前列腺特異性抗原化驗(yàn)可能是有用的，就像手術(shù)和放療可能有用一樣。

然而，觀察等候療法在治療中也應(yīng)該有一席之地。觀察等候是剛剛流行起來的叫法，事實(shí)上它有一個(gè)存在已久的名稱，叫做臨床慣性，雖然該叫法聽起來更具負(fù)面含義。

舉個(gè)例子來說明。臨床慣性就是指在病人血壓略升高或膽固醇偏高的情況下，醫(yī)生決定不給病人開藥。相反，醫(yī)生可能會鼓勵(lì)患者每天輕松地散散步或者減掉幾磅體重。這些方法可能與藥物治療同樣有效，但卻不會產(chǎn)生任何副作用。

曾經(jīng)，在并不久遠(yuǎn)的過去，健康專家們更多的是采用這些方法，而不是立刻去拿處方本或化驗(yàn)單。但是，隨著時(shí)間的推移，醫(yī)生們越來越多地被訓(xùn)練成了技術(shù)員，在治療過程中過度依賴技術(shù)。

醫(yī)學(xué)是一門科學(xué)，但同時(shí)也是一門藝術(shù)。從本質(zhì)上說，它應(yīng)該是一門傾聽的藝術(shù)，是承認(rèn)不作為和積極作為同等重要的藝術(shù)。

一位名為塞繆爾·謝姆的作者寫了一部影響深遠(yuǎn)的諷刺作品《上帝之屋》。他在書中列出了作為優(yōu)秀的醫(yī)療護(hù)理應(yīng)遵循的一系列戒律。書中臭名昭著的第13條戒律這樣說道：“好的醫(yī)療就是要盡可能地少做事?！?/p>

而自該書1978年出版之后，過度治療的問題已發(fā)展到如今這樣令人悲哀又叫人覺得滑稽的地步。這使得該書含有的諷刺意味消失殆盡，反成了古老的真知灼見。

仿佛我們兜轉(zhuǎn)了一圈，又回到了希波克拉底治療的時(shí)代。他說：“有時(shí)候，什么都不做反而是個(gè)好藥方?！?/p>

1.maxim [#712;maelig;ks#618;m] n. 格言，座右銘

2.Hippocratic Oath：《希波克拉底誓言》，指的是剛?cè)胄械尼t(yī)生向希波克拉底進(jìn)行的宣誓，內(nèi)容涉及醫(yī)生職業(yè)道德。希波克拉底為古希臘名醫(yī)，被稱為“醫(yī)學(xué)之父”。

3.maleficence [m#601;#712;lef#618;s#601;ns] n. 罪行，壞事

4.dizzying [#712;d#618;zi#618;#331;] adj. 使人眼花繚亂的

5.cornucopia [#716;k#596;#720;nju#712;k#601;#650;pi#601;] n. 豐富，豐饒

6.jolt：電視行業(yè)術(shù)語，指電視行業(yè)利用爆笑、暴力、賽車等快節(jié)奏畫面來誘發(fā)觀眾產(chǎn)生的興奮感與刺激感。

7.nip [n#618;p] vt. 阻止

8.in the bud：萌芽狀態(tài)

9.Alzheimer’s：阿爾茨海默癥，俗稱老年癡呆癥，臨床表現(xiàn)為認(rèn)知和記憶功能不斷下降，日常生活能力逐漸減退，并有各種神經(jīng)精神癥狀和行為障礙。

10.carry the day：獲勝

11.succour [#712;s#652;k#601;(r)] n. 救援

12.Shannon Brownlee：莎朗·布朗利，美國著名記者與評論家，常在《大西洋月刊》、《紐約時(shí)報(bào)》等著名媒體發(fā)表文章，代表作即文中提到的《過度治療：太多藥物為何會加劇病情與貧困》(Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer)一書。

13. cost out：對……進(jìn)行估價(jià)

14. whopping [#712;w#594;p#618;#331;] adj. 巨大的，龐大的

15. banal [b#601;#712;nɑ#720;l] adj.

老一套的，平腐的

16. bundle [#712;b#652;ndl] n.

一大筆錢

17.urine [#712;j#650;#601;r#618;n] n. 尿

18.electrocardiogram [#618;#716;lektr#601;#650;#712;kɑ#720;di#601;#650;ɡraelig;m] n. 心電圖

19.ailment [#712;e#618;lm#601;nt] n. 疾病(尤指微恙)

20.antibiotics [#716;aelig;ntiba#618;#712;#594;t#618;k] n. 抗生素

21.strep [strep] n. 鏈球菌

22.cough syrup：止咳糖漿

23.respiratory [r#601;#712;sp#618;r#601;tri] adj. 呼吸的

24.antibiotic resistance：抗生素的耐藥性

25.blatantly [#712;ble#618;t#601;ntli] adv. 公然地；極明顯地；毫不掩飾地

26.PSA：指前列腺特異性抗原(prostate-specific antigen)。prostate [#712;pr#594;ste#618;t] adj. 前列腺的

27.admonition [#716;aelig;dm#601;#712;n#618;#643;n] n. 警告

28.come into vogue：流行起來

29.clinical inertia：臨床慣性

30.cholesterol [k#601;#712;lest#601;r#594;l] n. 膽固醇

31.seminal [#712;sem#618;nl] adj. 產(chǎn)生重大影響的

32.The House of God：《上帝之屋》，作者為精神病醫(yī)生斯蒂芬·貝格曼(Stephen Bergman)，其筆名為塞繆爾·謝姆(Samuel Shem)。該小說出版于1978年，描述的是20世紀(jì)70年代的實(shí)習(xí)醫(yī)生在實(shí)習(xí)期間遭到的心理傷害。小說中有位實(shí)習(xí)醫(yī)生的指導(dǎo)醫(yī)生，他教導(dǎo)學(xué)生違背醫(yī)院的規(guī)定，并推薦自己的醫(yī)療準(zhǔn)則，文中提到的第13條戒律便是其中的一條。

33.tragicomic [#716;traelig;d#658;i#712;k#594;m#618;k] adj. 悲喜劇的