臨床醫(yī)學(xué)倫理

1、臨床醫(yī)學(xué)倫理,Supervisor: 方文貴醫(yī)師Reporter: PGY 江孟舫醫(yī)師,醫(yī)學(xué)倫理定義,人類是非價(jià)值的應(yīng)用，使醫(yī)療照顧具有道德性。包含醫(yī)療行為的道德判斷。 是醫(yī)療照顧環(huán)境中，倫理原則實(shí)際的應(yīng)用。,醫(yī)學(xué)倫理發(fā)展史,1800 B.C. Hammurabi 法典就提到”醫(yī)師”的職責(zé)。 500 B.C.希伯克拉底誓言(Hippocratic oath):內(nèi)容除關(guān)於疾病的觀察、治療、診斷和醫(yī)師們所必須負(fù)擔(dān)的責(zé)任外，也包

2、涵了醫(yī)師的一種宣誓。 1200 A.D. Rabbi Moses Ben Maimon(猶太人)發(fā)表了醫(yī)療法典。 1821 A.D. 英國(guó)公共衛(wèi)生學(xué)家Thomas Percival 著「醫(yī)事倫理規(guī)範(fàn)」出版。,醫(yī)學(xué)倫理發(fā)展史,國(guó)際上其他醫(yī)學(xué)社團(tuán)所制定的各種有關(guān)醫(yī)事倫理的規(guī)則，包括世界醫(yī)學(xué)會(huì)所制定的各種「宣言」，都是依照Thomas Percival原先所採(cǎi)用的文體。 1874 A.D. 美國(guó)的醫(yī)學(xué)協(xié)會(huì)成立，發(fā)表倫理規(guī)章。

3、1984美加醫(yī)學(xué)院規(guī)定醫(yī)學(xué)倫理務(wù)必在課程裡加入規(guī)劃列為必修課程。,醫(yī)學(xué)倫理的基本原則,第一是行善原則(Beneficence)，亦即醫(yī)師要盡其所能延長(zhǎng)病人之生命且減輕病人之痛苦。第二是誠(chéng)信原則(Veractity)，亦即醫(yī)師對(duì)其病人有「以誠(chéng)信相對(duì)待」的義務(wù)。 第三是自主原則(Autonomy)，亦即病患對(duì)其己身之診療決定的自主權(quán)必須得到醫(yī)師的尊重。,醫(yī)學(xué)倫理的基本原則,第四是不傷害原則(Nonmaleficence)，亦即醫(yī)師要

4、盡其所能避免病人承受不必要的身心傷害。第五是保密原則(Confidentiality)，亦即醫(yī)師對(duì)病人的病情負(fù)有保密的責(zé)任。第六是公義原則(Justice)，亦即醫(yī)師在面對(duì)有限的醫(yī)療資源時(shí)，應(yīng)以社會(huì)公平、正義的考量來(lái)協(xié)助合理分配此醫(yī)療資源給真正最需要它的人。,主題,有決定能力者之拒絕治療,案例1,T.O. 太太是 一位64歲的外科護(hù)士,5年前於右胸動(dòng)了癌癥的切除手術(shù). 她在左胸發(fā)現(xiàn)一個(gè)2公分大的硬塊後,再次拜訪他的外科醫(yī)師.她同

5、意 接受一套包括乳癌腫瘤切除手術(shù),放射性治療和6個(gè)月化學(xué)治療計(jì)畫(huà). 在 接受第一次化療後,她經(jīng)歷相當(dāng)大的毒性影響,她通知她的醫(yī)師,表明他再也不想接受任何治療. 經(jīng)過(guò)醫(yī)師和她的兩個(gè)女兒廣泛討論之後,她依然重申他對(duì)於輔助治療的拒絕.,案例2,S.P. 先生, 一 位患有主動(dòng)脈狹窄的病人, 患有心臟病,必須做冠狀動(dòng)脈造影的治療.在聽(tīng)完醫(yī)師解釋治療的急迫性及其利益, 風(fēng)險(xiǎn)以後, 他決定不接受這個(gè)治療.,有決定能力者之拒絕治療,充分告知且有決定能

6、力的人, 偶而也會(huì)拒絕醫(yī)師建議的治療. 如果建議的治療是有選擇性的, 或 是 拒絕治療的後果並不嚴(yán)重, 便不太能會(huì)產(chǎn)生倫理上的問(wèn)題.若該治療為拯救性命或控制嚴(yán)重疾病之必要時(shí). 醫(yī)師幫助病人的職責(zé)是否凌駕病人的選擇自由? 尊重 自主的倫理原則, 在美國(guó)法律上普遍受到支持.,評(píng)論,在T.O. 太太的案例中, 一個(gè)有能力者拒絕治療. 他充分接受告知, 且沒(méi)有顯示出缺乏決定能力. 即使醫(yī)師可能認(rèn)為這將是去除疾病, 延長(zhǎng)生命的好機(jī)會(huì)但T.O.

7、太太自己衡量她的風(fēng)險(xiǎn)和機(jī)會(huì). 她拒絕治療應(yīng)受尊敬.S.P. 先生也具有決定能力. 盡管他拒絕對(duì)他有益的治療也應(yīng)受尊敬.,Physicians’ evaluations of patients’ decisions to refuseoncological treatment,J Med Ethics 2005;31:131–136. doi: 10.1136/jme.2004.008755,Objective,To gain ins

8、ight into the standards of rationality that physicians use when evaluating patients’ treatment refusals,Results,Patients base on personal values and/or experience. Physicians -medical perspective when evaluating patien

9、ts’ treatment refusalsFrom a medical perspective, based on personal values and experience is generally evaluated as irrational, especially when it concerns a curative treatment. An important factor in the physician’s

10、 evaluation of a treatment refusal is whether the treatment refused is curative or non-curative.,Physician evaluate the patient decision,Is it sensible?Responsible?Judicious?On what basis do physicians distinguish be

11、tween their patients’ rational and irrational arguments?,Refusal not base on good reasons,physician’s evaluation of the rationality of the patient’s decision is crucial to their attitude towards the patientif a physicia

12、n thinks the patient’s refusal is not based on good reasons, he or she is often inclined to consider the decision as irrationalkeep trying to convince the patient to accept the treatment.,Physicians emphysis,medical per

13、spective when evaluating what are good reasonsIf refusal was based on reasons related to the kind of tumour, the prognosis, and/or the side effects of the treatment, evaluate these reasons as good reasons and to accept

14、the refusal,Curative treatment,Reasonable chance of cure, a patient’s treatment refusal is often judged as irrational Decision about life or deathThe benefits of being treated are much greater than the price the patie

15、nt has to pay,Patient Age,Physicians find it easier to accept a treatment refusal by an older than a younger patient,Life expectancy,patient with a prognosis of a five year palliative phase, could, by her decision to ref

16、use treatment, shorten her life by several years. That decision is much more difficult for a physician to accept compared with a decision about a palliative phase lasting only a few months,Patient’s perspective,Both medi

17、cal and personal considerations seem to play a role in the patient’s decision, but personal values and experiences predominateSide effects of chemotherapy would prevent them from carrying out these activitiesMeaning of

18、 their life would be gone and quality of life decreased,Patient’s perspective,Some patients indicated they would rather live for a little lesser time than prolong their lives with all kinds of troubles due to treatment,D

19、iscussion,Patients who did not accept their physician’s treatment recommendation weighed the benefits of treatment against the probability and severity of side effects,Medicine, Ethics, andLaw,Competent patient has the

20、right to refuse medical treatmentIssue becomes problematic when a patient’s refusal conflicts with medical opinionPatient expresses a nonrational preference, physicians face a dilemma between their duty to care for a p

21、atient and respect for patient autonomy,Issue become less problematic,‘‘good reasons’’ to refuse a recommended oncological treatment from both the medical and the patient’s perspective based on specific valuesPhysicians

22、 find it less difficult to accept a patient’s refusal of a non-curative treatment even if the refusal is, from a medical perspective, based on irrational groundsplace more emphasis on the patient’s value system,Acceptan

23、ce of patient’s treatment refusal,Acceptance of treatment refusal is important for the physician–patient relationship crucial to his or her attitude towards the patienthe or she is often inclined to persist in convinci