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Transcript
臨床醫療倫理 Ethics in Clinical Practice Ming-Been Lee, M.D. Departments of Psychiatry and Social Medicine College of Medicine National Taiwan University 醫學的真諦 醫學是關係的科學 ◎病 人為中心 ◎家庭為單位 ◎社區為基礎 醫學以人文為基礎 傳統:人的尊嚴、利益與價值 現代:人與萬物 和諧共生 優質的醫療 聖 專業技術 專業倫理 專業溝通 Terminology Morality Ethics Law Bioethics Medical Ethics Objectives of Medical Ethics Education: To Teach 1. Humanistic and ethical aspects of medical career; 2. Personal moral and professional moral commitments; 3. Foundation of philosophical, social, and legal knowledge; 4. Medical reasoning; 5. Interactional skills to apply insight, knowledge and reasoning to clinical care. 醫學倫理理論、原則與規則 理論 原則 行善 效益論 (Utilitarianism) (beneficence) 不傷害 (nonmalefice nce) 規則 1.關懷,保護病人的權利 2.預防及排除可能的傷害 3.幫助他人,造福人群 1.不能傷 害病人 2.不能侵害病人的權利或 幸福 3.平衡利害得失,使痛苦 減至最低 醫學倫理理論、原則與規則 理論 原則 公正 (justice) 義務論 (Deontological Theory) 規則 1.分配正義 2. 福利正義 3. 法律正義 1.誠實 ( respect for 2.守密 autonomy) 3.知情同意 4.尊重隱私 尊重自主 Medical Ethics: Principles 1. Autonomy 2. Beneficence 3. Non-maleficence 4. Justice Medical Ethics: Rules Informed Consent Confidentiality Truth telling Veracity Privacy: Limited Parties Involved in Clinical Ethics Staff-patients Staff-family Staff-staff Staff-society Third parties Health Care Ethics Team. Model of Staff-Patient relationship: a Good manners Keep secret: third parties, legal, using computers Informed decision making Patient’s right and responsibility Justice: Resource allocation, Minimal justice High-tech medicine Special issues: AIDS/ICU/organ transplantation Clinical Ethics: Three Obligations to Patients Give the best care that we can Be honest Be trustworthy Principle of Autonomy Rational individuals should be permitted to be self-determined. Patient’s autonomy VS rights and needs of others . Respect for Autonomy Patient’s body integrity. Patient’s control over touching, manipulation, invasion, medication, or other intervention. Patient’s right to authorize beneficient act. Informed Consent Show respect for self-determination. Function as a corrective process to paternalism. Provide opportunity and encouragement to become more active in decision making. A PROCESS rather than a Document. Consent Process Provision of information Comprehension Voluntariness Consent Active authorization rather than passive consent Required Discussion 1. Define problems 2. Exact nature of proposed treatment 3. Alternatives 4. Prognosis with and without treatment 5. Risks and benefits of treatment and alternatives 6. Serious risks even if unlikely 7. Any question patient may have General Process of Case Analysis 1. The Case: Review of fact. 2. Identification of ethical problems. 3. Determine reasonable alternatives. 4. Consider the option in relation to ethical Principles and Context. 5. Propose a resolution. 6. Consider your position critically. 7. Action required: Do the RIGHT thing. Interactional Skills Education Support 常用的溝通技巧 關係的建立 非言語溝通技巧 言語溝通技巧 Establishment of Rapport 1. Listening by 3rd ear 2. Sensitivity 3. Empathy □ Concern □ Respect □ Acceptance □ Warmth □ Genuineness □ Understanding 4. Confidence 非言語溝通技巧 ● 動作 ● ● ● 空間 語助詞 觸摸 Major types of kinesic nonverbal communication Gestures Facial Expressions Gaze Supportive Technique Abreaction 1. 2. Clarification 3. Praise 4. Reassurance 5. Suggestion 醫療 態 度 能:專業技能、溝通合作 心:同理心 1. 尊重 4. 體諒 2. 關懷 5. 坦誠 3. 接納 6. 溫馨 後SARS : 從關懷出發 Safety Appreciation Reflection Support 苦 海 慈 航 I Q EQ CQ MQ