醫學雙語閱讀：約束病人的道德和法律問題
下面本站小編爲大家帶來醫學雙語閱讀：約束病人的道德和法律問題，歡迎大家學習!
Defining restraintThe New Shorter Oxford English Dictionary defines restraint as 'deprivation or restriction of liberty or freedom of action or movement'. Restraint may occur in the following ways: 定義《新牛津簡明英語詞典》對約束的定義是：“剝奪或限制行動或活動自由”。約束通常表現爲：
- In a physical manner as in the manual restraint of one individual by others;
- By the use of apparatus such as cot-sides to keep a person within a defined area;
- By means of medication that may reduce an individual's capacity for freedom of movement. n 身體約束：他人對個體的體力約束
n 器械約束：如採用牀欄之類的設備將人限制在一定區域內
n 藥物約束：通過使用藥物減少個體的自由或活動能力
- In subtle ways, such as by reducing the heating in certain rooms within a care setting to discourage the use of these areas at specific times.
- Similarly, if a patient requires a walking aid in order to be mobile, removal of the appliance from the patient's reach would be form of restraint. n 技巧性約束：通過巧妙方法，如減少護理區內特定房間的暖氣打消人們使用這些區域
n 當病人移動需要行走支撐時，故意拿走周圍用品，這也是一種約束
An attempt by an individual, or group of individuals, to restrain a person is legally justifiable in certain situations, for example to prevent someone committing a crime. In such instances the minimum means of restraint should be used. The restraint of an individual outside such extenuating circumstances, or the use of excessive force, is unjustifiable. Therefore, it is important, from a legal and moral perspective, to ensure that nursing practice does not involve the unjustifiable restraint of patients. 個人或小組對約束某個個人在特定情況下是合法的，如防止犯罪等。在這些事件中，應使用最起碼的約束手段。若個人約束超出這種範圍，或國量過度使用，便都是不正當的。因此，從法律和道德角度看，重要的是要確保護理實踐不涉及不正當的病人約束。
When might it be considered justifiable to restrain an adult within a health care setting? The right of individuals to freedom is based upon the principle of autonomy: people have the right to make their own decisions, which should be respected by others.
Autonomy is often described as a prima facie principle; this means that, at first sight, the principle appears to be one that should be respected by others. However, further examination may reveal other ethical principles that have an equal, or greater, case for recognition. 那麼，護理部門在什麼情況下約束成年病人才是正當的呢?個人的自由權是以自主性原則爲基礎的：人們有自己作出決定的權利，這種權利應受他人的尊重。
自主性常常被描繪成是一個“當然原則”;也就是說，從第一眼人們就可以看出，這個準則就屬於應該受到他人尊重的那一類。然而，通過進一步考察就會發現，加外還有一些道德準則，他們具有同等甚至更大的認同性。
The ethics of restraint 約束的道德性
The following example illustrates the application of ethical principles in practice.
Anne Martin (not her real name) is 87 years old and has senile dementia. She has been a resident in a care setting for older people for three years, after becoming unable to cope at home because of short-term memory loss and confusion. Her state of mind had resulted in potentially dangerous behaviour, such as wandering from her home and becoming lost, being unaware of traffic hazards when crossing roads and forgetting to eat or drink for several days at a time. In the residential care setting she has attempted to wander outside and, for this reason, a baffle lock is in place at the end of the corridor that leads from her living area to the exit. Although Ms Martin continues to wander, she is unable to leave the premises. 下面例子闡述了道德準則在實踐中的應用。
安尼·馬丁，87歲，患有老年癡呆症。因短暫性失憶和意識混亂在老年護理院住了三年。她的精神狀態已導致其作出了一些有潛在性危險的行爲，如從家出走迷路、過馬路時無交通危險意識、連續幾天忘記吃喝等。在住家護理院時也試圖外出，因爲這個原因，在她起居室通往出口的走廊裏設置了障礙板。雖然馬丁女士繼續漫遊，但已經無法離開這一區域。
While this situation may not be viewed as constituting restraint in the same way that a nurse physically holding on to Ms Martin might be, the arrangement of the environment nonetheless ensures Ms Martin's containment within a restricted area. We may question whether this is justifiable and the following discussion provides one example of how the situation might be examined. 與護士抓住馬丁女士身體相比，這種情形可能並不構成約束，但這種環境安排卻促使馬丁女士拘留在約束區內。那麼，這樣做是否正當，下面的討論爲如何審查這種情況提供了一個例子。
The presence of a baffle lock appears to override Ms Martin's autonomy. However, it may be argued that while autonomy constitutes a prima facie ethical principle, in certain circumstances it may be superseded by other principles. It can be argued that in order for an individual to be autonomous, they must possess insight into the potential or actual consequences of their actions. Ms Martin's dementia interferes with her insight and it may be considered acceptable to override her autonomy by reference to the principle of non-maleficence - the requirement to prevent harm. If Ms Martin is allowed to wander out of the care setting she may encounter hazards such as traffic and suffer harm as a result. Interference with her autonomy may be seen as justifiable on this basis. 設置障礙似乎踐踏了馬丁女士的自主性，不過，人們也可以說，當自主性構成了“當然的道德準則“時，在一定情況下，它是可以被其他原則超越的。可以這樣說，一個人要獲得自主權，他就必須具有洞察其行動的可能或實際後果的能力。馬丁女士的癡呆證妨礙了她的洞察力，因此，根據無罪原則，踐踏她的自主性可以認爲是可取的，這是防止傷害的需要。如果允許馬丁女士走出護理區，她就可能遭受危險，如交通事故，最終造成傷害。因此，干涉她的自主性可以說是正當的。
Furthermore, it is arguable that in care settings, there is an ethical requirement not only to avoid harm, but also to create benefit for the client. This principle is beneficence and may also be used to justify restricting Ms Martin's freedom of movement. It may be considered beneficial for Ms Martin to remain within the care environment, in order to maintain both her physical safety and her psychological well-being, because unfamiliar surroundings may cause her distress. The ethical principles of non-maleficence and beneficence might be used as justifications for overriding her autonomy. 再者，在護理機構中，從道德上講，不僅有避免傷害的需要，而且有爲病人帶來好處的需要。這就是有利原則，它也可以用於說明限制馬丁女士活動自由的正當性。馬丁女士留在護理環境內姨了帳有好處，既是爲了保證她的人身安全，也是爲了保持她的精神健康，因爲陌生環境可能給她帶來痛苦。道德的無罪和有利原則可以用以證明踐踏自主性的正當性。
Legal aspects of restraint 約束的法律問題
The another relevant ethical principle is that of justice. The purpose of justice is to ensure that individuals receive that to which they are entitled or deemed to deserve. It may be argued that the restriction of Ms Martin's freedom is unjust. Older adults with senile dementia present problems that are not addressed fully by the UK mental health legislation. Unless Ms Martin is held as an involuntary patient under a section of the relevant act, she is legally entitled to leave the care setting if she so desires. Any attempt to impede her constitutes an illegal restriction of her liberty. 另一個相關的道德原則是公正原則。公正的目的是要確保個人得到有權得到的或被認爲是值得的東西。也許有人會說，限制馬丁女士的自由是不公正的，患有老年癡呆證的老年人，他們的問題在英國精神健康法中並沒有充分的解釋。如果不把馬丁女士歸入相關條款的無意識病人分類中，從法律上講，如果她願意，她就有權離開護理區。任何阻礙都構成了對她自由權的非法約束。
In England, the Bournewood judgement (named after the hospital where the issue arose) by the Court of Appeal in 1998 ruled that patients who lacked the capacity to consent to admission could not be detained within a care setting unless sectioned under the Mental Health Act. 1998年，上訴法庭伯恩伍德審判栽定，缺乏入院同意能力的病人不能被收留在護理機構內，除非將她歸入 精神健康條例中。
Before the Court of Appeal decision it was assumed that people lacking the mental capacity to make an informed choice (people with severe learning difficulties or dementia, for example) could be considered to be content with their admission - as long as they did not show signs of wanting to 'opt out' of treatment. If they were not actively opting out, then it was acceptable for them to be detained in hospital and be treated without a formal detention under a section of the Mental Health Act. 在上訴法庭判決前，人們都認爲，缺乏作出知情選擇的心理能力的人(如患有嚴重學習困難或癡呆的人)，只要他們沒有明顯的“決定不參加”治療的表示，就可以被認爲是同意住院。如果他們沒有主動決定不參加，那麼，根據精神健康條例，將他們留在醫院進行治療，即使沒有正式收留，都是可以的。
The Law Lords looked at two main questions: was the person involved actually detained and, if he or she was detained, was the detention lawful? 高級法官考察了兩大問題：患者是否被實際收留;如果是，這種收留是否合法?
However, this judgment was subsequently overturned by the House of Lords, on the basis of the common law principle of 'necessity', by which health care staff are able to act in the best interest of an individual who would otherwise experience significant pain and suffering. 不過，這種審判隨後就被上議院根據不成文法的“必要”原則推翻了，根據這一原則，在個人可能遭受重大危險和痛苦的情況下，保健護理人員能夠採取行動保護個人的最大利益。
There is a problem for the care team because, while restraint of Ms Martin may constitute an infringement of her legal right to freedom of movement, permitting her to wander - in the knowledge that she may come to harm - could constitute negligence. In order for a charge of negligence to be upheld in law, the following three conditions must prevail: 護理小組卻會面臨一個問題，限制馬丁女士的自由可能構成對行動自由這一合法權利的侵犯，允許她出走—在明智其可能受到傷害的情況下—也可能構成過失。但是，要使過失指控在法律上成立，就必須滿足下列三個條件：
- A duty of care must exist. Within an officially designated care setting staff do owe a legal duty of care to patients/residents;
- The duty of care must have been breached. It is arguable that, since staff are aware that Ms Martin has a diminished sense of danger, they should ensure that she does not wander unattended. In the event of her coming to any harm the staff would be viewed as having neglected their duty of care to Ms Martin;
- Significant harm must have been sustained as a direct consequence of the neglect of the duty of care. n 必須有護理職責。在正式指定的護理機構內，護理人員對病人/居住者擁有合法的護理職責;
n 護理職責必須受到違反。既然護理人員知道馬丁女士危險意識下降，他們應該保障她不會在沒有陪同的情況下外出。如果她受到傷害，就可以認爲護理人員忽略了對馬丁女士的護理職責。
n 重大傷害必須是由護理職責失職所直接造成的。
For the care team Ms Martin's situation presents a dilemma. On the one hand she is legally entitled to leave the premises and any effort to physically restrain her may be regarded as assault, while on the other hand if she leaves the premises and comes to any harm the staff may be guilty of negligence. 馬丁女士的情況使護理人員處於兩難境地。一方面，馬丁女士有離開上述區域的合法權利，對馬丁女士的任何人身約束都可以被看作是侵犯;另一方面，如果她離開上述區域受到傷害，便是護理小組的失職。
The best option is probably to justify the restriction of Ms Martin's autonomy in the light of her diminished insight into the potential consequences of her actions. The care team may argue that the purpose of the baffle lock is to prevent harm and that they are acting in what they perceive to be Ms Martin's best interests. 最好的辦法是，鑑於馬丁女士對其行動潛在後果認識能力的下降，對其自主性的約束應合法化。護理小組可以表明，障礙的目的是要防止傷害，最大限度地保護馬丁女士的利益。
Further issues 幾點思考
There are other aspects of the situation which have to be taken into account: 還有幾個方面應該加以考慮“
- The use of a baffle lock may be acceptable in order to ensure Ms Martin's safety, but not if the purpose of its installation is to allow management to reduce staffing levels;
- Optimum staff-to-resident ratios would permit a member of staff to accompany Ms Martin in order to ensure that she does not come to any harm when she wishes to leave the premises; n 爲保障馬丁女士的安全，可以使用障礙，如果只是爲了減少護理人手便於管理，就不得設置這種障礙;
n 最佳護-患比允許一位護理人員陪伴馬丁女士，以確保她想要離開上述區域時不受傷害;
- Another consideration is that Ms Martin is not the only resident whose freedom may be restricted by the presence of the baffle lock. The needs of other residents should also be taken into account before using this measure. Such an assessment may be carried out using the same ethical principles that helped to determine whether the restraint of Ms Martin was justifiable; n 另外也要考慮到，馬丁女士並不是唯一的自由受限患者，在採用這一手段時，也應考慮其他患者的需要，可以應用相同的道德準則進行評估，這些道德準則有助於確定約束是否公正
- In areas where baffle locks are justifiable, a written policy and procedure should be formulated by management to explain to staff, residents and their visitors the rationale for the use of the locks. This should also clearly identify the measures that should be taken to ensure that residents who do not need this form of protection are able to leave and enter the area as they please. n 在障礙合法的區域，應由管理部門制訂正式規章和程序，向護理人員、患者及訪問者說明使用障礙的原因，同時明確應採取的措施，確保無需這種保護的患者能自由離開和進入。
Conclusion 結論
This case study demonstrates that restricting a person's movements may not concur with commonly held perceptions of restraint as comprising dangerous behaviour on the part of the individual being restrained or those who are in a position to restrain.
It should also have highlighted the complex situations in which restraint may be required and the ethical principles that may be applied to support or discourage its use. 本案例研究表明，對受約束個人或作出限制者來說，限制一個人的活動不可能與大衆的對約束的認識一致。
同時也應強調需要約束的情況的複雜性，強調可以適用於支持或反對使用約束的道德準則。
