Every day around the country, patients are discharged from hospitals without difficulty, as the interests of the hospital and the patient tend to align: both the hospital and the patient want the patient to leave and go to a setting that will promote the patient’s continued recovery. In some cases, however, this usually routine process does not go quite as smoothly. Patients may not want to leave the hospital, or they may insist on an unsafe discharge plan. In other cases, there may simply be no good place for the patient to go. These complex hospital discharge situations often involve ethical, legal, financial, and practical considerations, but the ethical issues inherent in these dilemmas have received only sporadic attention from clinical ethicists at best, leaving patients, providers, administrators, and caregivers unsure about what to do. When the ethical issues are in fact brought to light, analysis usually proceeds based on a consideration of the principles of autonomy, beneficence, nonmaleficence, and justice. However, principled analysis often fails to present patients and providers with a satisfactory solution, as the principles inevitably conflict (for example, when the patient’s autonomous desire to remain in the hospital conflicts with the principles of beneficence and justice). In this paper, I argue that difficult discharges are ethical dilemmas worthy of scholarly attention that goes beyond principlism, and I argue that providers and those involved in discharge planning ought to cultivate what philosopher Alasdair MacIntyre calls “virtues of acknowledged dependence” in order to care for these patients and their families. I first trace the current conversation about difficult discharge and show that the principled approach to resolving discharge dilemmas is not sufficient. I then argue that a new approach is needed, and to that end, I offer practical ways in which MacIntyre’s account of the virtues of acknowledged dependence may help patients, providers, and family members to navigate issues of difficult discharge.

全国各地每天都有患者顺利出院，因为医院和患者的利益趋于一致：医院和患者都希望患者离开并前往促进患者持续康复的环境. 然而，在某些情况下，这个通常例行的过程并不那么顺利。患者可能不想离开医院，或者他们可能坚持不安全的出院计划。在其他情况下，患者可能根本就没有好去处。这些复杂的出院情况通常涉及伦理、法律、财务和实践方面的考虑，但这些困境中固有的伦理问题最多只能得到临床伦理学家的零星关注，让患者、提供者、管理人员和护理人员不确定该怎么做. 当道德问题实际上被揭露时，分析通常基于对自主性、仁慈、非恶意和正义原则的考虑而进行。然而，原则性分析往往无法为患者和提供者提供令人满意的解决方案，因为这些原则不可避免地会发生冲突（例如，当患者自主留在医院的愿望与仁慈和正义的原则发生冲突时）。在本文中，我认为难以出院是值得学术界关注的伦理困境，超出了原则主义范围，我认为提供者和参与出院计划的人应该培养哲学家 Alasdair MacIntyre 所说的“公认依赖的美德”，以便照顾为这些患者及其家属。我首先追溯当前关于难以出院的对话，并表明解决出院困境的原则性方法是不够的。然后我认为需要一种新的方法，为此，我提供了实用的方法，MacIntyre 对公认依赖的优点的解释可能会帮助患者、提供者和家庭成员解决出院困难的问题。