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The Doctor's Dilemma: Is It Ever Good to Do Harm?
原文
1
Medical knowledge changes swiftly, and technological changes make new and expensive investigations and treatments possible that were only theoretical a few years ago. Life has been extended in length, but not in quality, and the debates about end‑of‑life decisions show us how much the notion of a “good life” is bound up with the absence of disease, illness and suffering.
2
The practice of medicine is not purely technical. It involves a relationship between a person who is seeking help, and who may be vulnerable, and a person who has the skills and knowledge to help. Relationships that involve disparities of power, knowledge and vulnerability require some degree of external oversight and regulation. Traditionally, in medicine, this oversight has taken the form of codes of ethics, starting with the Hippocratic Corpus. Today, bodies such as the General Medical Council and the Royal Colleges define the standards of good medical practice.
3
There has been much discussion of how we make moral choices, but what do we mean by a “moral” decision in medicine? Conventionally, we are distinguishing what is clinically and technically possible from whether it is “right” to intervene at all. For example, if a person’s heart stops, we know we can resuscitate them, but should we do so?
4
To answer that question, we do not expect to rely solely on numerical data and we do not anticipate getting an obvious and single answer. We are aware that there may be more than one answer to the question, and those answers may conflict with each other. We will want to get clinical information about the situation: why did the heart stop? Will restarting the heart make things better or worse for that person in medical terms? We will also want to know what the patient thinks about the situation: did they anticipate this? Do they want to be resuscitated? And if we don’t know these things, we will want to ask some questions about how best to make a complex decision if we have not heard the wishes of the person concerned.
5
Moral reasoning differs from those types of reasoning that are purely computational, logical or algorithmic. To answer ethical questions, we engage in a process of reflection and discussion: we begin a discourse that uses the words “ought” and “should”, as opposed to “can” and “must”. If the patient’s heart has stopped because they are losing blood, then a doctor may say: “We must give the patient more blood or his heart will stop, and we can do so because the blood is here and we know it will work.” However, that statement does not answer the question: “Should we resuscitate the patient if his heart stops?” The doctor’s statement about what can be done is not irrelevant, but it is only a part of the reasoning process involved in deciding whether it is right to resuscitate. If the patient had left instructions that they did not want to be resuscitated if their heart stopped during surgery, then the facts of successful resuscitation practice would be irrelevant to what the doctors should do.
6
What we are distinguishing here are facts and values – a distinction developed by David Hume in the 18th century. Hume says that it is a fallacy to think that because things are a certain way (facts), then they should be that way (values). We cannot derive values from facts, but we do evaluate facts and make moral judgments about them, and this reasoning and reflection process is crucial to medical ethical decision-making.
7
For centuries, it was assumed that a good decision ethically in medicine was the same as a good clinical decision. If the doctor did what was medically indicated to benefit the patient, then this was the ethically right thing to do. Although sometimes crudely summarized as "doctor knows best," this approach to ethical dilemmas in medicine is (arguably) less about the doctor's status, and more about the tensions between facts and values.
8
Medicine as a science utilizes a method of study that focuses on consequences of actions, on causes and effects in nature. These facts about how bodies heal, or how drugs work, are sometimes confused with medicine's ethical imperative to bring about good consequences for the patient, or at least reduce harmful consequences. Concerns tend to arise when there is friction between the facts and values.
9
Modern medical ethics developed out of an examination of medical authority after the Second World War, partly in response to the Nuremberg trials of doctors who had used medicine to torment and kill citizens, but also in sympathy with a general increase of attention to the human rights of ordinary people which had previously been denied -- people of color, women and those made vulnerable by illness.
10
Legal cases reflected this change: In one famous instance (Murray v McMurchy, in 1949), while operating on a woman for another purpose, a surgeon tied her fallopian tubes without her consent, because he foresaw that becoming pregnant would be clinically dangerous for her, and that it would also be dangerous for her to undergo two surgical procedures. She sued for negligence and won: It was not disputed that the surgeon was factually correct, in clinical terms, but he had not considered that the patient's own view of herself and her body were essential to the decision-making process. He had focused on facts, and assigned no value to the patient's view, even though it was her body that was being operated on.
11
This case brings us to an important issue in moral reasoning generally, which is how we think about words like "good" or “right" or “best", in relation to a human decision. It is not a question of whether we want doctors to make ethical decisions on a daily basis - it is a fact that this will happen in the world of medical practice. What we want is for doctors to make "good" ethical decisions, or at least the "best possible." We want to know that they have engaged in the type of thinking that takes account of values and personal lived experience.
12
The doctor is empowered to do harm to the patient in pursuit of doing good, and there is a social acceptance that treatment may entail a deliberately imposed suffering that is not the primary intention of the doctor. This acceptance requires a great deal of trust in the medical profession – and doctors are still the most trusted professional group. The trust that makes these interactions possible assumes that doctors will not be the kind of people who exploit vulnerability and exercise influence for their own ends. There is a question here about how society expects doctors not just to be good technically, but to be good personally.
13
There are other accounts of ethical reasoning that may be helpful when thinking about doctors as good people. In his book, Justice: What’s the Right Thing to Do?, Michael Sandel has argued that moral decision-makers need to follow an ethical reasoning process that pays attention to justice and the ways that people weigh the value of their decisions. He argues that impartiality is not always the keystone of justice, but rather that justice processes need to pay attention to what people value.
14
There remains a question about whether it is just and fair to expect a group of people who are chosen for cognitive intelligence and skills in exam-passing to become morally superior individuals. It is often said that doctors are held to a higher moral standard than other people, but how are they trained to that higher moral standard? After the Harold Shipman inquiry, it was recommended that doctors undergo revalidation every five years, but there is no evidence that the revalidation process addresses moral reasoning or the moral identity of doctors. Doctors still do “bad” things, even when they are good people in other ways, and technically good at what they do.
15
Medicine needs a way of thinking about ethics that addresses different moral values and intuitions. What remains unclear is how we train doctors to be good people, not just to do good work and make good choices.
翻译
第一段
英文原文
Medical knowledge changes swiftly, and technological changes make new and expensive investigations and treatments possible that were only theoretical a few years ago. Life has been extended in length, but not in quality, and the debates about end‑of‑life decisions show us how much the notion of a “good life” is bound up with the absence of disease, illness and suffering.
润色中文翻译
医学知识日新月异，技术的突飞猛进让几年前还只是理论上的昂贵检查和治疗成为现实。人的寿命被拉长了，但生活质量却并未同步提升；围绕“临终抉择”的争论提醒我们：所谓“美好生活”，在大众心里几乎等同于“没有疾病、没有痛苦”。
逐句讲解
-
Medical knowledge changes swiftly
单词：medical 医学的；swiftly 飞快地
直译：医学知识变化得很快。
润色：医学知识日新月异。
思路：把“changes swiftly”换成中文四字成语“日新月异”，读起来更自然。 -
and technological changes make new and expensive investigations and treatments possible
单词：technological 技术的；investigations 检查、诊疗手段；treatments 治疗
直译：技术的变革使新的、昂贵的检查和治疗成为可能。
润色：技术的突飞猛进让……成为现实。
思路：把“technological changes”意译成“突飞猛进”，语气更强；“make…possible”译成“让……成为现实”符合中文习惯。 -
that were only theoretical a few years ago.
单词：theoretical 理论上的
直译：那些只在几年前还仅仅是理论上的（东西）。
润色：几年前还只是理论上的昂贵检查和治疗。
思路：把定语从句提前合并，中文更顺。 -
Life has been extended in length, but not in quality,
单词：extended 延长；in length 在长度上；in quality 在质量上
直译：生命在长度上被延长了，但在质量上却没有。
润色：人的寿命被拉长了，但生活质量却并未同步提升。
思路：用“拉长”对应 extended，用“同步提升”对应 not in quality，口语化且对比鲜明。 -
and the debates about end‑of‑life decisions show us
单词：debates 争论；end-of-life decisions 临终抉择
直译：关于临终抉择的争论告诉我们。
润色：围绕“临终抉择”的争论提醒我们。
思路：加“围绕”使句式更活泼；“提醒我们”比“告诉我们”更有警示感。 -
how much the notion of a “good life” is bound up with the absence of disease, illness and suffering.
单词：notion 观念；be bound up with 与……紧密相连；absence 缺席、没有
直译：“美好生活”这一观念与没有疾病、病痛和苦难紧密相连到什么程度。
润色：所谓“美好生活”，在大众心里几乎等同于“没有疾病、没有痛苦”。
思路：把抽象的程度副词 how much 换成“几乎等同于”，让句子更接地气；“disease, illness and suffering”合并为“疾病、痛苦”，避免重复。
第二段
英文原文
The practice of medicine is not purely technical. It involves a relationship between a person who is seeking help, and who may be vulnerable, and a person who has the skills and knowledge to help. Relationships that involve disparities of power, knowledge and vulnerability require some degree of external oversight and regulation. Traditionally, in medicine, this oversight has taken the form of codes of ethics, starting with the Hippocratic Corpus. Today, bodies such as the General Medical Council and the Royal Colleges define the standards of good medical practice.
润色中文翻译
行医绝非纯技术活。它是一场“求助者”——往往身心脆弱——与“施救者”——手握技术与知识——之间的相遇。只要双方存在权力、信息与脆弱程度的落差，就必须有外部监督与规矩。传统上，医学用伦理准则来“自我看管”，最早可追溯到《希波克拉底文集》；如今，英国医学总会与各皇家医学院则负责划定“好医生”的底线。
逐句讲解
-
The practice of medicine is not purely technical.
单词：practice 实践、行医；purely 纯粹地；technical 技术的
直译：医学的实践并不是纯粹技术的。
润色思路：中文口语里“纯技术活”很常用，加“绝非”起强调，节奏短促有力。 -
It involves a relationship between a person who is seeking help, and who may be vulnerable, and a person who has the skills and knowledge to help.
单词：involves 涉及；relationship 关系；seeking help 寻求帮助；vulnerable 脆弱的；skills and knowledge 技能与知识
直译：它涉及一种关系，一方是可能处于脆弱状态的求助者，另一方是拥有帮助所需的技能和知识的人。
润色思路：用破折号把双方身份并列，形成“求助者”vs“施救者”的对仗；“往往身心脆弱”比“可能脆弱”更具体，也带同情色彩。 -
Relationships that involve disparities of power, knowledge and vulnerability require some degree of external oversight and regulation.
单词：disparities 落差、不平等；power 权力；external oversight 外部监督；regulation 监管、规矩
直译：涉及权力、知识和脆弱性差异的关系需要某种程度的外部监督和监管。
润色思路：把“require”译成“就必须有”，语气肯定；“落差”比“差异”更形象；“规矩”口语化，对应regulation。 -
Traditionally, in medicine, this oversight has taken the form of codes of ethics, starting with the Hippocratic Corpus.
单词：traditionally 传统上；taken the form of 采取……形式；codes of ethics 伦理准则；Hippocratic Corpus 希波克拉底文集
直译：传统上，在医学中，这种监督采取了伦理准则的形式，最早可追溯到《希波克拉底文集》。
润色思路：用“自我看管”概括 oversight，加引号显得生动；“最早可追溯到”是固定学术表达，简洁自然。 -
Today, bodies such as the General Medical Council and the Royal Colleges define the standards of good medical practice.
单词：bodies 机构；General Medical Council 英国医学总会；Royal Colleges 皇家医学院；define 界定；standards 标准；good medical practice 良好医疗实践
直译：如今，诸如英国医学总会和皇家医学院这样的机构界定了良好医疗实践的标准。
润色思路：把“define the standards”意译为“划定……底线”，语气更接地气；“好医生”的底线是意译，但准确传达“good medical practice”的核心含义。
第三段
英文原文
There has been much discussion of how we make moral choices, but what do we mean by a “moral” decision in medicine? Conventionally, we are distinguishing what is clinically and technically possible from whether it is “right” to intervene at all. For example, if a person’s heart stops, we know we can resuscitate them, but should we do so?
润色中文翻译
人们早已热议“如何做道德选择”，可放在医学里，什么叫“道德”决定？按惯例，我们先把“临床技术上能不能做”与“到底该不该做”分开问。举个例子：病人心跳停了，我们明明能把他救回来，但问题是——我们该不该救？
逐句讲解
-
There has been much discussion of how we make moral choices
单词：discussion 讨论；moral choices 道德选择
直译：关于我们如何做出道德选择，已经有了很多讨论。
润色思路：用“人们早已热议”替换“There has been much discussion”，口语化且带时间感；“如何做道德选择”比“我们如何做出道德选择”更简洁。 -
but what do we mean by a “moral” decision in medicine?
单词：mean by 指的是……；moral decision 道德决定
直译：但在医学中，我们所说的“道德”决定是什么意思？
润色思路：把问句提前，用“可放在医学里”作转折，节奏像聊天；“什么叫”比“是什么意思”更口语，读者门槛低。 -
Conventionally, we are distinguishing what is clinically and technically possible from whether it is “right” to intervene at all.
单词：conventionally 通常、按惯例；distinguishing 区分；clinically and technically possible 临床技术上可行的；right 对的、应当；intervene 干预
直译：通常，我们把“临床技术上是否可行”与“到底该不该干预”区分开来。
润色思路：用“先把……与……分开问”形成口语化提问感；“到底该不该”比“是否是正确的”更贴近日常说法。 -
For example, if a person’s heart stops, we know we can resuscitate them, but should we do so?
单词：heart stops 心脏停跳；resuscitate 抢救、复苏；should we do so 我们是否应该这样做
直译：例如，如果一个人的心脏停了，我们知道可以抢救他，但我们是否应该这样做？
润色思路：把“we know we can”译成“我们明明能”，加“明明”突出能力；“但问题是——我们该不该救？”用破折号和反问，制造停顿与冲突感，让读者瞬间感到伦理张力。
第四段
英文原文
To answer that question, we do not expect to rely solely on numerical data and we do not anticipate getting an obvious and single answer. We are aware that there may be more than one answer to the question, and those answers may conflict with each other. We will want to get clinical information about the situation: why did the heart stop? Will restarting the heart make things better or worse for that person in medical terms? We will also want to know what the patient thinks about the situation: did they anticipate this? Do they want to be resuscitated? And if we don’t know these things, we will want to ask some questions about how best to make a complex decision if we have not heard the wishes of the person concerned.
润色中文翻译
要回答“该不该救”，我们既不会只听数字，也不指望有唯一标准答案。大家心里都清楚：答案可能不止一个，还互相打架。先得把临床账算明白：心跳为啥停？救回来是让病人更好还是更糟？接着还得问病人：他早料到会这样吗？他想被救吗？要是连这些都不清楚，那就得再追问：在没听见当事人发话前，这份复杂的决定该怎么拍板才算靠谱？
逐句整句讲解
-
To answer that question, we do not expect to rely solely on numerical data and we do not anticipate getting an obvious and single answer.
单词：rely solely on 仅仅依靠；numerical data 数值数据；anticipate 预期；obvious and single answer 明显且唯一的答案
直译：为了回答这个问题，我们不指望只依靠数值数据，也不期待得到一个明显且唯一的答案。
润色思路：把“do not expect…do not anticipate”合并成“既不会…也不指望”，中文对仗；“numerical data”意译成“数字”，口语化；“唯一标准答案”比“单一答案”更通俗。 -
We are aware that there may be more than one answer to the question, and those answers may conflict with each other.
单词：be aware 意识到；conflict 冲突
直译：我们意识到这个问题可能有不止一个答案，而且这些答案可能互相冲突。
润色思路：用“大家心里都清楚”替换“We are aware”，拉近距离；“互相打架”是口语化比喻，比“互相冲突”生动。 -
We will want to get clinical information about the situation: why did the heart stop? Will restarting the heart make things better or worse for that person in medical terms?
单词：clinical information 临床信息；in medical terms 从医学角度
直译：我们会想要获得关于情况的临床信息：心脏为什么停？从医学角度讲，重新启动心脏会让那个人更好还是更糟？
润色思路：“先得把临床账算明白”用“算账”比喻信息搜集，接地气；把两个问句直接嵌进中文，节奏紧凑，像医生查房时的自问自答。 -
We will also want to know what the patient thinks about the situation: did they anticipate this? Do they want to be resuscitated?
单词：anticipate 预料；resuscitated 被抢救
直译：我们也会想知道病人对这种情况的看法：他们预料到这种情况了吗？他们想要被抢救吗？
润色思路：用“接着还得问病人”承接上文，像对话；“早料到会这样吗？”把 anticipate 口语化；“他想被救吗？”比“他们想要被抢救吗”更短更直接。 -
And if we don’t know these things, we will want to ask some questions about how best to make a complex decision if we have not heard the wishes of the person concerned.
单词：complex decision 复杂决定；the person concerned 当事人
直译：如果我们不知道这些事情，我们会想追问：在没听到当事人意愿的情况下，如何最好地做出一个复杂决定。
润色思路：用“那就得再追问”形成递进；“这份复杂的决定该怎么拍板才算靠谱？”把“how best to make”意译成“怎么拍板才算靠谱”，既保留“最好”之意，又带出口语里的“靠谱”标准。
第五段
英文原文
Moral reasoning differs from those types of reasoning that are purely computational, logical or algorithmic. To answer ethical questions, we engage in a process of reflection and discussion: we begin a discourse that uses the words “ought” and “should”, as opposed to “can” and “must”. If the patient’s heart has stopped because they are losing blood, then a doctor may say: “We must give the patient more blood or his heart will stop, and we can do so because the blood is here and we know it will work.” However, that statement does not answer the question: “Should we resuscitate the patient if his heart stops?” The doctor’s statement about what can be done is not irrelevant, but it is only a part of the reasoning process involved in deciding whether it is right to resuscitate. If the patient had left instructions that they did not want to be resuscitated if their heart stopped during surgery, then the facts of successful resuscitation practice would be irrelevant to what the doctors should do.
润色中文翻译
道德推理跟纯计算、纯逻辑、纯算法不是一路货。要答伦理题，得先开一场“反思+讨论”的小会：开口说的是“应该”“ ought”，而不是“可以”“ must”。比方说，病人因大出血心跳停了，医生会喊：“必须马上输血，不然心脏彻底罢工，血库现成，咱们也做得到！”——可这番话半点没碰那个关键问：“心跳真停了，我们到底该不该救？”技术可行性并非没用，只是决定“救不救”时只占一票。要是术前病人就留话：“万一术中停跳，别按我回来。”那么再漂亮的抢救成功率，对医生该做的事也瞬间作废。
逐句讲解
-
Moral reasoning differs from those types of reasoning that are purely computational, logical or algorithmic.
单词：moral reasoning 道德推理；computational 计算的；algorithmic 算法的
直译：道德推理与那些纯粹计算、逻辑或算法式的推理不同。
润色思路：用“不是一路货”口语化 difers，突出区别感；把三个形容词并列成“纯计算、纯逻辑、纯算法”，节奏干脆。 -
To answer ethical questions, we engage in a process of reflection and discussion: we begin a discourse that uses the words “ought” and “should”, as opposed to “can” and “must”.
单词：engage in 从事；reflection 反思；discourse 论述；as opposed to 相对于
直译：为了回答伦理问题，我们参与一个反思与讨论的过程：我们开始一种使用“应当”和“应该”而非“可以”和“必须”的论述。
润色思路：把整句改成“得先开一场‘反思+讨论’的小会”，用“小会”形象化 process；中英混排“ ought/ must”保留原词，方便对照，又加引号强调。 -
If the patient’s heart has stopped because they are losing blood, then a doctor may say: “We must give the patient more blood or his heart will stop, and we can do so because the blood is here and we know it will work.”
单词：losing blood 失血；give more blood 输血
直译：如果病人因失血而心跳停止，医生可能会说：“我们必须给病人输血，否则他的心脏会停止，我们可以这样做，因为血就在这里，我们知道它有效。”
润色思路：用“会喊”比“可能说”更生动；“不然心脏彻底罢工”把 stop 口语化、拟人化；“血库现成，咱们也做得到”一句合并，节奏像急诊室里的急促对白。 -
However, that statement does not answer the question: “Should we resuscitate the patient if his heart stops?”
单词：statement 陈述；resuscitate 抢救
直译：然而，这番陈述并没有回答“如果病人心跳停止，我们应该抢救吗？”这个问题。
润色思路：用“半点没碰那个关键问”形象化 does not answer，突出缺口；“到底该不该救”比“我们应该抢救吗”更口语、更有冲突感。 -
The doctor’s statement about what can be done is not irrelevant, but it is only a part of the reasoning process involved in deciding whether it is right to resuscitate.
单词：irrelevant 无关；reasoning process 推理过程；right 正确的
直译：医生关于能做什么的陈述并非无关紧要，但它只是决定是否应该抢救的推理过程的一部分。
润色思路：用“技术可行性并非没用，只占一票”把“not irrelevant but only a part”浓缩成口语表达，一听就懂。 -
If the patient had left instructions that they did not want to be resuscitated if their heart stopped during surgery, then the facts of successful resuscitation practice would be irrelevant to what the doctors should do.
单词：left instructions 留下指示；successful resuscitation practice 成功的抢救技术
直译：如果病人曾留下指示，表示若术中停跳不希望被抢救，那么成功抢救的技术事实对医生应该做什么就无关紧要了。
润色思路：用“留话”替代“留下指示”，口语化；“别按我回来”把 resuscitated 说成老百姓的大白话；“瞬间作废”把 irrelevant 译得既干脆又有画面感。
第六段
英文原文
What we are distinguishing here are facts and values – a distinction developed by David Hume in the 18th century. Hume says that it is a fallacy to think that because things are a certain way (facts), then they should be that way (values). We cannot derive values from facts, but we do evaluate facts and make moral judgments about them, and this reasoning and reflection process is crucial to medical ethical decision-making.
润色中文翻译
我们此刻要分的，是“事实”与“价值”——这套分法来自18世纪的大卫·休谟。休谟提醒：别犯“实然⇋应然”的糊涂，看见“是怎样”就跳去“就该怎样”，那是逻辑陷阱。事实里生不出价值，但我们可以就着事实掂量、评判，再下道德判断；这一连串“掂量+反思”正是临床伦理决策的灵魂。
逐句整句讲解
-
What we are distinguishing here are facts and values – a distinction developed by David Hume in the 18th century.
单词：distinguishing 区分；facts 事实；values 价值；developed 提出、发展
直译：我们在此区分的是事实与价值——这一区分由18世纪的大卫·休谟提出。
润色思路：用“要分的”代替“are distinguishing”，口语且节奏短；“这套分法”把抽象名词 distinction 具体化；“来自”比“由……提出”更像日常说话。 -
Hume says that it is a fallacy to think that because things are a certain way (facts), then they should be that way (values).
单词：fallacy 谬误；a certain way 某种样子；should 应该
直译：休谟说，因为事物是某种样子（事实），就认为它们应该保持那个样子（价值），是一种谬误。
润色思路：用“别犯‘实然⇋应然’的糊涂”一口说完，把 fallacy 译成“糊涂”，易懂带语气；箭头符号形象化“从事实跳到价值”的陷阱。 -
We cannot derive values from facts, but we do evaluate facts and make moral judgments about them, and this reasoning and reflection process is crucial to medical ethical decision-making.
单词：derive 推导；evaluate 评估；moral judgments 道德判断；crucial 至关重要的
直译：我们无法从事实中推导出价值，但我们可以评估事实并据此做出道德判断，而这一推理与反思的过程对医学伦理决策至关重要。
润色思路：用“事实里生不出价值”把 derive 形象化；“掂量+评判”把 evaluate…judgments 合并成口语动作；“灵魂”代替 crucial，突出“缺它不可”的临床紧迫感。
第七段
英文原文
For centuries, it was assumed that a good decision ethically in medicine was the same as a good clinical decision. If the doctor did what was medically indicated to benefit the patient, then this was the ethically right thing to do. Although sometimes crudely summarized as "doctor knows best," this approach to ethical dilemmas in medicine is (arguably) less about the doctor's status, and more about the tensions between facts and values.
润色中文翻译
千百年来，大家默认“临床好决策”就等于“伦理好决策”：只要医生按医学指征把病人治舒服了，那就是道德满分。这句老话常被粗鄙地翻译成“医生最懂”，其实它真正纠结的并非医生地位高低，而是“事实”与“价值”之间那根永远拉不紧的弦。
逐句整句讲解
-
For centuries, it was assumed that a good decision ethically in medicine was the same as a good clinical decision.
单词：for centuries 千百年来；assumed 被假定；ethically 伦理上；clinically 临床上
直译：千百年来，人们假定医学中伦理上的好决策与临床上的好决策是一回事。
润色思路：用“大家默认”替换被动 assumed，语感更口语；“就等于”直接点破等同关系，句子更脆。 -
If the doctor did what was medically indicated to benefit the patient, then this was the ethically right thing to do.
单词：medically indicated 医学指征；benefit 使受益；ethically right 伦理上正确
直译：如果医生按医学指征去做对患者有益的事，那这在伦理上就是正确的。
润色思路：把“按医学指征去做对患者有益的事”浓缩成“按医学指征把病人治舒服了”，用“治舒服”口语化 benefit；“道德满分”比“伦理上正确”更俏皮，带评价色彩。 -
Although sometimes crudely summarized as "doctor knows best," this approach to ethical dilemmas in medicine is (arguably) less about the doctor's status, and more about the tensions between facts and values.
单词：crudely summarized 被粗俗地概括为；ethical dilemmas 伦理困境；status 地位；tensions 紧张关系
直译：尽管有时被粗俗地概括为“医生最懂”，这种处理医学伦理困境的方式（ arguably）与其说关乎医生的地位，不如说关乎事实与价值之间的张力。
润色思路：用“老话常被粗鄙地翻译成”承接上文，带贬义色彩；“真正纠结的并非……而是……”形成对照句，突出核心；“那根永远拉不紧的弦”把 tensions 形象化，易记且带画面感。
第八段
英文原文
Medicine as a science utilizes a method of study that focuses on consequences of actions, on causes and effects in nature. These facts about how bodies heal, or how drugs work, are sometimes confused with medicine's ethical imperative to bring about good consequences for the patient, or at least reduce harmful consequences. Concerns tend to arise when there is friction between the facts and values.
润色中文翻译
医学这门科学，向来只管“做了啥→得到啥”：身体怎么愈合、药物如何起效，它用因果链条说话。可一旦把这些“自然因果”当成“伦理目标”——以为只要病好、命保，就是功德圆满——概念立刻串线。事实与价值一摩擦，问题才真的起火。
逐句整句讲解
-
Medicine as a science utilizes a method of study that focuses on consequences of actions, on causes and effects in nature.
单词：utilizes 使用；consequences 后果；causes and effects 因果
直译：作为一门科学的医学，使用一种研究方法，专注于行为的后果以及自然界中的因果。
润色思路：用“只管‘做了啥→得到啥’”把“focuses on consequences of actions”口语化、符号化；“因果链条”一句概括，节奏利落。 -
These facts about how bodies heal, or how drugs work, are sometimes confused with medicine's ethical imperative to bring about good consequences for the patient, or at least reduce harmful consequences.
单词：heal 愈合；drugs 药物；confused with 与……混淆；ethical imperative 伦理使命；bring about 带来
直译：这些关于身体如何愈合或药物如何起效的事实，有时会被与医学的伦理使命——为患者带来良好后果或至少减少有害后果——相混淆。
润色思路：用“概念立刻串线”替换 are confused，形象带画面；“功德圆满”口语化“good consequences”，暗含讽刺，突出混淆的荒谬感。 -
Concerns tend to arise when there is friction between the facts and values.
单词：concerns 担忧；arise 出现；friction 摩擦
直译：当事实与价值之间出现摩擦时，担忧往往就会产生。
润色思路：用“问题才真的起火”把 friction 译成“起火”，既保留“摩擦生热”的物理意象，又让“担忧出现”变成可视化的“着火”，短促有力。
第九段
英文原文
Modern medical ethics developed out of an examination of medical authority after the Second World War, partly in response to the Nuremberg trials of doctors who had used medicine to torment and kill citizens, but also in sympathy with a general increase of attention to the human rights of ordinary people which had previously been denied -- people of color, women and those made vulnerable by illness.
润色中文翻译
当代医学伦理的诞生，是二战后人们对“医学权力”的一次大检讨：一边是纽伦堡审判把“医生用治病之名折磨、屠杀平民”的血债搬上台面；另一边，有色人种、女性、病弱群体长期被剥夺的人权也开始被看见。旧账与新仇一起烧，才把现代医学伦理逼了出来。
逐句整句讲解
-
Modern medical ethics developed out of an examination of medical authority after the Second World War
单词：developed out of 源于；examination 检讨、审视；medical authority 医学权力
直译：现代医学伦理源于二战后对医学权力的审视。
润色思路：用“诞生”替换 developed，带生命感；“大检讨”比“审视”更具历史冲击力和口语色彩。 -
partly in response to the Nuremberg trials of doctors who had used medicine to torment and kill citizens
单词：in response to 作为回应；Nuremberg trials 纽伦堡审判；torment 折磨；citizens 平民
直译：部分是对纽伦堡审判的回应，那些医生利用医学折磨并杀害平民。
润色思路：用“把血债搬上台面”概括 trials，画面感强；“治病之名”点明 medicine 被滥用，语气辛辣。 -
but also in sympathy with a general increase of attention to the human rights of ordinary people which had previously been denied -- people of color, women and those made vulnerable by illness.
单词：in sympathy with 共鸣；general increase 普遍增长；denied 被剥夺
直译：同时也与对普通人权关注的普遍增长相呼应，这些权利此前曾被剥夺——包括有色人种、女性和因疾病而脆弱的人。
润色思路：用“旧账与新仇一起烧”把“also in sympathy”转成情绪叠加；“被看见”口语化“attention increase”，突出终于受到关注；“逼了出来”呼应 developed，让伦理学的出现带被迫、催化之感，富有动感。
第十段
英文原文
Legal cases reflected this change: In one famous instance (Murray v McMurchy, in 1949), while operating on a woman for another purpose, a surgeon tied her fallopian tubes without her consent, because he foresaw that becoming pregnant would be clinically dangerous for her, and that it would also be dangerous for her to undergo two surgical procedures. She sued for negligence and won: It was not disputed that the surgeon was factually correct, in clinical terms, but he had not considered that the patient's own view of herself and her body were essential to the decision-making process. He had focused on facts, and assigned no value to the patient's view, even though it was her body that was being operated on.
润色中文翻译
法律很快给这股新风投了赞成票。1949 年名案“默里诉麦克默奇”里，医生借其他手术之便，顺手把女方输卵管给扎了——理由十足：怀孕对她太危险，开两刀更危险。女方告医疗过失，赢了。没人否认医生的“医学算盘”打得精，可法庭认死理：她怎么看自己、怎么看自己的身体，是决策里绕不过去的价值；眼里只有“事实”却不给“她的想法”半点分量，就算拿的是手术刀，也照样侵权。
逐句讲解
-
Legal cases reflected this change:
单词：reflected 反映；change 转变
直译：法律案件反映了这一变化。
润色思路：用“投了赞成票”把 reflected 形象化，暗示法律站在新风向一边，口语鲜活。 -
In one famous instance (Murray v McMurchy, in 1949), while operating on a woman for another purpose, a surgeon tied her fallopian tubes without her consent
单词：famous instance 著名案例；operating 动手术；fallopian tubes 输卵管；without her consent 未经她同意
直译：1949 年著名案例“默里诉麦克默奇”中，医生为女方做其他手术时，未经同意结扎了她的输卵管。
润色思路：用“借其他手术之便，顺手给扎了”把事实一句话说全，节奏紧凑，带口语贬义。 -
because he foresaw that becoming pregnant would be clinically dangerous for her, and that it would also be dangerous for her to undergo two surgical procedures.
单词：foresaw 预见；clinically dangerous 临床危险；surgical procedures 外科手术
直译：因为他预见到怀孕对她临床上有危险，且让她经历两次手术也危险。
润色思路：合并成“理由十足：怀孕对她太危险，开两刀更危险”，用“开两刀”口语化，又保留因果逻辑。 -
She sued for negligence and won:
单词：sued 起诉；negligence 过失
直译：她以医疗过失起诉并获胜。
润色思路：加冒号后接解释，保留原文节奏；“赢了”口语干脆。 -
It was not disputed that the surgeon was factually correct, in clinical terms,
单词：not disputed 无争议；factually correct 事实正确；clinical terms 临床角度
直译： surgeon 在临床角度事实正确，这一点无争议。
润色思路：用“没人否认医生的‘医学算盘’打得精”形象化，算盘比喻计算精准，带俚语风味。 -
but he had not considered that the patient's own view of herself and her body were essential to the decision-making process.
单词：considered 考虑；essential 不可或缺
直译：但他没考虑到患者对自己及她身体的看法在决策过程中不可或缺。
润色思路：用“法庭认死理”转换主语，突出法律视角；“绕不过去的价值”比“不可或缺”更有口语分量。 -
He had focused on facts, and assigned no value to the patient's view, even though it was her body that was being operated on.
单词：focused on 聚焦于；assigned no value 赋予零价值
直译：他只聚焦事实，对患者的看法赋予零价值，尽管被手术的是她的身体。
润色思路：用“眼里只有‘事实’却不给‘她的想法’半点分量”形成对仗；“就算拿的是手术刀，也照样侵权”一句收尾，既点明后果，又带警示节奏。
第十一段
英文原文
This case brings us to an important issue in moral reasoning generally, which is how we think about words like "good" or “right" or “best", in relation to a human decision. It is not a question of whether we want doctors to make ethical decisions on a daily basis - it is a fact that this will happen in the world of medical practice. What we want is for doctors to make "good" ethical decisions, or at least the "best possible." We want to know that they have engaged in the type of thinking that takes account of values and personal lived experience.
润色中文翻译
这起案子把道德推理的共性问题甩到我们面前：说到“好”“对”“最佳”，咱们到底拿什么标准往人身上套？医生天天都得做伦理决定，这不是“要不要”，而是“必然发生”。既然拦不住，我们就要求他们做得“靠谱”，至少是“当下最好”。想放心，就得确认他们脑子里真把“价值”和“病人的活生生经历”算进去了。
逐句讲解
-
This case brings us to an important issue in moral reasoning generally,
单词：brings us to 引我们到；issue 议题；moral reasoning 道德推理
直译：此案把我们带到道德推理中一个重要议题。
润色思路：用“把……甩到我们面前”口语化，带突然感，突出案例冲击力。 -
which is how we think about words like "good" or “right" or “best", in relation to a human decision.
单词：in relation to 关于；human decision 人的决定
直译：即我们如何理解“好”“对”“最佳”这些词，当它们涉及人的决定时。
润色思路：用“拿什么标准往人身上套”把抽象思考具体化，带动作感，易懂。 -
It is not a question of whether we want doctors to make ethical decisions on a daily basis - it is a fact that this will happen in the world of medical practice.
单词：on a daily basis 每天；medical practice 医疗实践
直译：这不是我们是否想让医生每天做伦理决定的问题——这是医疗实践中必然发生的事实。
润色思路：用“这不是‘要不要’，而是‘必然发生’”形成对仗，节奏明快，强调不可回避。 -
What we want is for doctors to make "good" ethical decisions, or at least the "best possible."
单词：good ethical decisions 好的伦理决策；best possible 尽可能最好的
直译：我们想要的是医生做出“好”的伦理决策，或至少是“尽可能最好”的。
润色思路：用“做得‘靠谱’，至少是‘当下最好’”口语化，“靠谱”对应 good，“当下最好”对应 best possible，接地气。 -
We want to know that they have engaged in the type of thinking that takes account of values and personal lived experience.
单词：engaged in 从事；takes account of 考虑；lived experience 亲身经历
直译：我们想确认他们已进行那种兼顾价值与个人亲身经历的思想过程。
润色思路：用“脑子里真把……算进去了”把抽象思维过程说成打算盘，通俗形象；“活生生经历”比“亲身经历”更具画面感。
第十二段
英文原文
The doctor is empowered to do harm to the patient in pursuit of doing good, and there is a social acceptance that treatment may entail a deliberately imposed suffering that is not the primary intention of the doctor. This acceptance requires a great deal of trust in the medical profession – and doctors are still the most trusted professional group. The trust that makes these interactions possible assumes that doctors will not be the kind of people who exploit vulnerability and exercise influence for their own ends. There is a question here about how society expects doctors not just to be good technically, but to be good personally.
润色中文翻译
医生被“授权”在行善途中可能伤人——社会默认：治疗带来的蓄意痛苦，只要大夫本意不坏，就可接受。这份默认把巨额信任押在医学界身上；而医生也确实仍是公众最信得过的群体。信任背后有个假设：他们不会利用病人的脆弱给自己谋好处。于是，社会真正要问的是：我们怎样才算“技术好”，同时“人品也好”？
逐句讲解
-
The doctor is empowered to do harm to the patient in pursuit of doing good,
单词：empowered 被赋予权力；in pursuit of 追求
直译：医生被赋予权力，在追求善的过程中可能对病人造成伤害。
润色思路：用“被‘授权’”加引号，突出被动许可；“行善途中可能伤人”把抽象 harm/good 具体化，四字对仗，易记。 -
and there is a social acceptance that treatment may entail a deliberately imposed suffering that is not the primary intention of the doctor.
单词：social acceptance 社会认可；entail 必然带来；deliberately imposed suffering 蓄意施加的痛苦；primary intention 首要意图
直译：社会认可治疗可能带来并非医生首要意图的蓄意施加的痛苦。
润色思路：用“默认”替换 acceptance，更口语；“蓄意痛苦，只要大夫本意不坏，就可接受”把长句拆成两步，逻辑清晰。 -
This acceptance requires a great deal of trust in the medical profession – and doctors are still the most trusted professional group.
单词：a great deal of trust 大量信任；professional group 职业群体
直译：这种认可需要对医学界的大量信任——而医生仍是最受信任的职业群体。
润色思路：用“把巨额信任押在”形象化 require；“公众最信得过的群体”比“最受信任的职业群体”更口语。 -
The trust that makes these interactions possible assumes that doctors will not be the kind of people who exploit vulnerability and exercise influence for their own ends.
单词：interactions 互动；exploit vulnerability 利用脆弱；for their own ends 为自己谋利
直译：使这些互动得以可能的信任，假定医生不会是利用脆弱、滥用权力为己谋利之人。
润色思路：用“信任背后有个假设”承接上文，像聊天；“给自己谋好处”口语化 for their own ends，易懂。 -
There is a question here about how society expects doctors not just to be good technically, but to be good personally.
单词：expects 期望；technically 技术上；personally 人品上
直译：这里的问题是社会如何期望医生不仅在技术上好，而且在人品上好。
润色思路：用“我们真正要问的是”把 there is a question 转成主动提问；“技术好”与“人品也好”并列，简洁对照，朗朗上口。
第十三段
英文原文
There are other accounts of ethical reasoning that may be helpful when thinking about doctors as good people. In his book, Justice: What’s the Right Thing to Do?, Michael Sandel has argued that moral decision-makers need to follow an ethical reasoning process that pays attention to justice and the ways that people weigh the value of their decisions. He argues that impartiality is not always the keystone of justice, but rather that justice processes need to pay attention to what people value.
润色中文翻译
想让医生成为“好人”，还可以借其他伦理视角。迈克尔·桑德尔在《公正：该如何做是好？》里提醒：做道德决定，得把“正义”拉进来，看大家究竟在意什么。他认为，公正不等于冷冰冰的“不偏不倚”，而是得认真掂量人们心里那杆秤到底称什么。
逐句讲解
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There are other accounts of ethical reasoning that may be helpful when thinking about doctors as good people.
单词：accounts 表述、视角；ethical reasoning 伦理推理；good people 好人
直译：还有其他关于伦理推理的表述，在把医生当作好人来思考时可能有帮助。
润色思路：用“还可以借其他伦理视角”代替 there are other accounts，口语且带“工具感”；“想让医生成为‘好人’”直接点题，亲切易懂。 -
In his book, Justice: What’s the Right Thing to Do?, Michael Sandel has argued that moral decision-makers need to follow an ethical reasoning process that pays attention to justice and the ways that people weigh the value of their decisions.
单词：moral decision-makers 道德决策者；pay attention to 关注；weigh the value 权衡价值
直译：桑德尔在其书中主张，道德决策者需遵循一种关注正义及人们如何权衡其决策价值的伦理推理过程。
润色思路：用“得把‘正义’拉进来，看大家究竟在意什么”把 pay attention to justice & weigh value 合并成两句口语，节奏轻快；书名保留英文，方便读者查找。 -
He argues that impartiality is not always the keystone of justice, but rather that justice processes need to pay attention to what people value.
单词：impartiality 不偏不倚；keystone 基石；justice processes 公正程序
直译：他认为，公正并不总是以“不偏不倚”为基石，而应关注人们重视什么。
润色思路：用“冷冰冰的‘不偏不倚’”形象化 impartiality，带贬义；“认真掂量人们心里那杆秤到底称什么”把 what people value 译成具体动作，通俗生动。
第十四段
英文原文
There remains a question about whether it is just and fair to expect a group of people who are chosen for cognitive intelligence and skills in exam-passing to become morally superior individuals. It is often said that doctors are held to a higher moral standard than other people, but how are they trained to that higher moral standard? After the Harold Shipman inquiry, it was recommended that doctors undergo revalidation every five years, but there is no evidence that the revalidation process addresses moral reasoning or the moral identity of doctors. Doctors still do “bad” things, even when they are good people in other ways, and technically good at what they do.
润色中文翻译
问题还没完：凭“脑子灵光+会考试”就把一群人挑出来，再指望他们个个成道德标兵，这公道吗？人人都说“医生道德门槛得更高”，可门槛怎么砌？连环杀医案后，英国规定五年一次“再注册”，却没人证明这流程能修补道德推理或身份认同。技术全优、平时人也不坏的医生，照样可能出“坏事”。
逐句讲解
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There remains a question about whether it is just and fair to expect a group of people who are chosen for cognitive intelligence and skills in exam-passing to become morally superior individuals.
单词：remains a question 问题仍在；just and fair 公正；cognitive intelligence 认知智力；exam-passing 应试能力；morally superior 道德更高
直译：问题仍在：期望一群因认知智力和应试技巧被选中的人成为道德更高的人，是否公正？
润色思路：用“凭‘脑子灵光+会考试’就把一群人挑出来，再指望他们个个成道德标兵”把长句拆成两段口语，带引号强调选拔标准；“这公道吗？”短问收尾，像日常质疑。 -
It is often said that doctors are held to a higher moral standard than other people, but how are they trained to that higher moral standard?
单词：held to 被要求；higher moral standard 更高道德标准
直译：人们常说医生被要求比其他人更高的道德标准，但他们如何被训练到这一标准呢？
润色思路：用“人人都说‘医生道德门槛得更高’，可门槛怎么砌？”把抽象 standard 译成具象“门槛”，动词“砌”带建筑画面，易懂。 -
After the Harold Shipman inquiry, it was recommended that doctors undergo revalidation every five years, but there is no evidence that the revalidation process addresses moral reasoning or the moral identity of doctors.
单词：inquiry 公开调查；revalidation 再注册；addresses 处理；moral identity 道德身份
直译：Shipman案调查后，建议医生每五年再注册，但没有证据表明该流程处理道德推理或医生的道德身份。
润色思路：用“连环杀医案后”替 inquiry，一句话交代背景；“却没人证明这流程能修补”把 addresses 译成“修补”，带工程感，暗示漏洞仍在。 -
Doctors still do “bad” things, even when they are good people in other ways, and technically good at what they do.
单词：good people 好人；technically good 技术好
直译：医生即使在其他方面是好人和技术高手，仍可能做“坏事”。
润色思路：用“技术全优、平时人也不坏的医生，照样可能出‘坏事’”把三句信息并成一句，口语对仗，突出“好人+好技术≠不出坏事”的悖论。
第十五段
英文原文
Medicine needs a way of thinking about ethics that addresses different moral values and intuitions. What remains unclear is how we train doctors to be good people, not just to do good work and make good choices.
润色中文翻译
医学界缺一条能兜住各种价值、各种直觉的伦理思路；更闹心的是——到底怎么把“人”教好，而不仅是教他会干活、会选对选项？
逐句讲解
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Medicine needs a way of thinking about ethics that addresses different moral values and intuitions.
单词：addresses 处理、应对；moral values 道德价值；intuitions 直觉
直译：医学需要一种伦理思维方式，能够处理不同的道德价值与直觉。
润色思路：用“兜住各种价值、各种直觉”把 addresses 译成口语里的“兜底”，含“全部包住”之意，形象轻松。 -
What remains unclear is how we train doctors to be good people, not just to do good work and make good choices.
单词：remains unclear 仍不清楚；train 训练；good people 好人
直译：仍不清楚的是我们如何把医生培养成好人，而不仅仅是做好工作和做出正确选择。
润色思路：用“更闹心的是”承接上句，情绪升级；“把‘人’教好”与“会干活、会选对选项”形成鲜明对比，口语对仗，突出“育人”比“育技”更难。