醫療:回到希波克拉底時代

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，終生執行我職務……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。

醫學職業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概念：在治療病人時，如果某項治療可能產生的負面作用比其產生的積極作用要大，那應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，在當今時代，技術革新令人眼花繚亂，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奏使人們變得毫無耐心。這使得醫學的指導性格言實際上已經變成：“快做點什么，能做的都做。”

這種現象在日常的醫學實踐中隨處可見。沒人想兩手空空地走出醫生辦公室，誰都想拿到一張處方或高科技化驗單。每個人都想作檢查，好把癌癥消滅在萌芽狀態，或者及早發現老年癡呆癥的苗頭，即使這樣帶來的負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”的消費理念也許可以在電視劇里大行其道，但在現實的醫療環境中卻并不可取。迅速而果斷地采取行動也許能提供緊急救援，至少暫時來看是如此，但每個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，我們對待醫療時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。

以上行為導致的結果便是泛濫成災的過度治療，這不僅耗費大量資金，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狀。

2011年5月，促進臨床優質服務組織——該組織的醫生相信能夠以更低的成本和更高的效率來提供醫療服務——發布了一份清單，列出了一些并非必需卻被經常使用的化驗和治療手段。

2011年12月初，一組學者進行了一項估算，如果去掉一些毫無必要的診治項目，全美每年可節省的開支數額驚人——高達68億美元。

醫療衛生費用不斷上漲并不是因為醫生們忙著做沒有必要的心臟移植手術。相反，耗費我們大把金錢的是那些慣用但基本上毫無用處的常規化驗。

比如，研究人員發現，對于沒有相關癥狀或危險因素的病人，醫生也會例行公事似的要求驗血、驗尿以及做心電圖測試。做這些化驗的目的常常只是為了讓病人覺得醫生在“做些什么”。

在最常發生的不當醫療實踐中，對微恙的小孩進行過度醫療是其中的典型：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；給頭部受到輕微創傷(沒有暈眩或昏迷癥狀)的孩子做CT掃描等成像檢查。要再次強調的是，這種過度治療的的確確存在負面后果，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。

值得注意的是，促進臨床優質服務組織關注的焦點僅僅是那些極為明顯的醫療浪費。

該組織有意回避了更有爭議的醫療項目，比如針對前列腺癌進行的前列腺特異性抗原化驗和針對乳腺癌對年輕女性進行的大范圍檢查。對于這些狀況，需要提醒醫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——那些有患乳腺癌風險因素的女性——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可能是有用的，就像手術和放療可能有用一樣。

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

舉個例子來說明。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，醫生決定不給病人開藥。相反，醫生可能會鼓勵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，但卻不會產生任何副作用。

曾經，在并不久遠的過去，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單。但是，隨著時間的推移，醫生們越來越多地被訓練成了技術員，在治療過程中過度依賴技術。

醫學是一門科學，但同時也是一門藝術。從本質上說，它應該是一門傾聽的藝術，是承認不作為和積極作為同等重要的藝術。

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

而自該書1978年出版之后，過度治療的問題已發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。

仿佛我們兜轉了一圈，又回到了希波克拉底治療的時代。他說：“有時候，什么都不做反而是個好藥方。”

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

2.Hippocratic Oath：《希波克拉底誓言》，指的是剛入行的醫生向希波克拉底進行的宣誓，內容涉及醫生職業道德。希波克拉底為古希臘名醫，被稱為“醫學之父”。

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：電視行業術語，指電視行業利用爆笑、暴力、賽車等快節奏畫面來誘發觀眾產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

9.Alzheimer’s：阿爾茨海默癥，俗稱老年癡呆癥，臨床表現為認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》、《紐約時報》等著名媒體發表文章，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……進行估價

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. 產生重大影響的

32.The House of God：《上帝之屋》，作者為精神病醫生斯蒂芬·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70年代的實習醫生在實習期間遭到的心理傷害。小說中有位實習醫生的指導醫生，他教導學生違背醫院的規定，并推薦自己的醫療準則，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