1、臨床醫學倫理,Supervisor: 方文貴醫師Reporter: PGY 江孟舫醫師,醫學倫理定義,人類是非價值的應用，使醫療照顧具有道德性。包含醫療行為的道德判斷。 是醫療照顧環境中，倫理原則實際的應用。,醫學倫理發展史,1800 B.C. Hammurabi 法典就提到”醫師”的職責。 500 B.C.希伯克拉底誓言(Hippocratic oath):內容除關於疾病的觀察、治療、診斷和醫師們所必須負擔的責任外，也包涵了醫師的一種宣誓。 1200 A.D. Rabbi Moses Ben Maimon(猶太人)發表了醫療法典。 1821 A.D. 英國公共衛生學家Thomas Perci
2、val 著醫事倫理規範出版。,醫學倫理發展史,國際上其他醫學社團所制定的各種有關醫事倫理的規則，包括世界醫學會所制定的各種宣言，都是依照Thomas Percival原先所採用的文體。 1874 A.D. 美國的醫學協會成立，發表倫理規章。 1984美加醫學院規定醫學倫理務必在課程裡加入規劃列為必修課程。,醫學倫理的基本原則,第一是行善原則(Beneficence)，亦即醫師要盡其所能延長病人之生命且減輕病人之痛苦。第二是誠信原則(Veractity)，亦即醫師對其病人有以誠信相對待的義務。 第三是自主原則(Autonomy)，亦即病患對其己身之診療決定的自主權必須得到醫師的尊重。,醫學倫理的
3、基本原則,第四是不傷害原則(Nonmaleficence)，亦即醫師要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)，亦即醫師對病人的病情負有保密的責任。第六是公義原則(Justice)，亦即醫師在面對有限的醫療資源時，應以社會公平、正義的考量來協助合理分配此醫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歲的外科護士,5年前於右胸動了癌症的切除手術. 她在左胸發現一個2公分大的硬塊後,再次拜訪他的外科醫師.她同意 接受一套包括乳癌腫瘤切除手術,放射性治療和6個月化學治療計畫. 在 接受第一次化療後,她經歷相
4、當大的毒性影響,她通知她的醫師,表明他再也不想接受任何治療. 經過醫師和她的兩個女兒廣泛討論之後,她依然重申他對於輔助治療的拒絕.,案例2,S.P. 先生, 一 位患有主動脈狹窄的病人, 患有心臟病,必須做冠狀動脈造影的治療.在聽完醫師解釋治療的急迫性及其利益, 風險以後, 他決定不接受這個治療.,有決定能力者之拒絕治療,充分告知且有決定能力的人, 偶而也會拒絕醫師建議的治療. 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重, 便不太能會產生倫理上的問題.若該治療為拯救性命或控制嚴重疾病之必要時. 醫師幫助病人的職責是否凌駕病人的選擇自由? 尊重 自主的倫理原則, 在美國法律上普
5、遍受到支持.,評論,在T.O. 太太的案例中, 一個有能力者拒絕治療. 他充分接受告知, 且沒有顯示出缺乏決定能力. 即使醫師可能認為這將是去除疾病, 延長生命的好機會但T.O. 太太自己衡量她的風險和機會. 她拒絕治療應受尊敬.S.P. 先生也具有決定能力. 盡管他拒絕對他有益的治療也應受尊敬.,Physicians evaluations of patients decisions to refuseoncological treatment,J Med Ethics 2005;31:131136. doi: 10.1136/jme.2004.008755,Objective,To gai
6、n insight 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 patients treatment refusalsFrom a medical perspective, based on personal values and
7、experience is generally evaluated as irrational, especially when it concerns a curative treatment. An important factor in the physicians evaluation of a treatment refusal is whether the treatment refused is curative or non-curative.,Physician evaluate the patient decision,Is it sensible?Responsible?
8、Judicious?On what basis do physicians distinguish between their patients rational and irrational arguments?,Refusal not base on good reasons,physicians evaluation of the rationality of the patients decision is crucial to their attitude towards the patientif a physician thinks the patients refusal is
9、 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 perspective when evaluating what are good reasonsIf refusal was based on reasons related to the kind of tumour, the p
10、rognosis, and/or the side effects of the treatment, evaluate these reasons as good reasons and to accept the refusal,Curative treatment,Reasonable chance of cure, a patients treatment refusal is often judged as irrational Decision about life or deathThe benefits of being treated are much greater tha
11、n the price the patient 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 refuse treatment, shorten her life by several years. That deci
12、sion is much more difficult for a physician to accept compared with a decision about a palliative phase lasting only a few months,Patients perspective,Both medical and personal considerations seem to play a role in the patients decision, but personal values and experiences predominateSide effects of
13、 chemotherapy would prevent them from carrying out these activitiesMeaning of their life would be gone and quality of life decreased,Patients 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,Discu
14、ssion,Patients who did not accept their physicians treatment recommendation weighed the benefits of treatment against the probability and severity of side effects,Medicine, Ethics, andLaw,Competent patient has the right to refuse medical treatmentIssue becomes problematic when a patients refusal con
15、flicts with medical opinionPatient expresses a nonrational preference, physicians face a dilemma between their duty to care for a patient and respect for patient autonomy,Issue become less problematic,good reasons to refuse a recommended oncological treatment from both the medical and the patients p
16、erspective based on specific valuesPhysicians find it less difficult to accept a patients refusal of a non-curative treatment even if the refusal is, from a medical perspective, based on irrational groundsplace more emphasis on the patients value system,Acceptance of patients treatment refusal,Accep
17、tance of treatment refusal is important for the physicianpatient relationship crucial to his or her attitude towards the patienthe or she is often inclined to persist in convincing the patient to accept the treatmentpatients experiencing that they are not really free to make their decisions, leading to frustration and miscommunication,Thank for your attention!,
