论生命伦理学的自主性原则

自主性原则是生命伦理学的首要原则,其本质在于个人自主地选择自己的思想和行为.自主分为思想自主、意愿自主和行动自主.自主性原则的思想前提是道义论与后果论.在生命伦理学中,尊重、知情同意、保密和隐私权是自主性原则的具体表现形式.在医疗实践中,自主权的行使必须与具体的情境相结合,其价值才能充分实现.     

论自主性及其在生命伦理学中的意义

本文试图探讨自主性及其对生命伦理学的意义.文章以英国哲学家Onora O'Neill对自主性的质疑为起点,对康德和密尔意义上的自主性概念、以及自主性概念的来源和发展进行分析论证,在此基础上指出,自主性在生命伦理学中所面临的困境,并非如许多哲学家所认为的生命伦理学的自主性与康德意义上的自主性发生了偏离,而是因为在实际运用中自主性的形式与实质被割裂了开来.文章提出,为使尊重自主性原则真正体现保护病人和受试者的利益,不应抛弃形式上的自主性,而应该修复它,并使之更好地体现和服务于实质的自主性.     

论医学伦理学的自主性原则

医学伦理学的自主性原则是对个人的自主和自由的尊重,其核心是对人权的尊重,包含有知情同意、保密、隐私等具体规则。自主性原则是根源于西方强调个性自由和选择的自由主义道德传统,我国古代哲人也提出过相近乃至相同的看法。     

论医学伦理学的自主性原则

医学伦理学的自主性原则是对个人的自主和自由的尊重,其核心是对人权的尊重,包含有知情同意、保密、隐私等具体规则.自主性原则是根源于西方强调个性自由和选择的自由主义道德传统,我国古代哲人也提出过相近乃至相同的看法.     

临床生命伦理视域中的自主

自主原则的提出可以说是临床生命伦理学中最具重大意义的突破.从理论层面上来说,临床生命伦理学中的"自主"既然不同于康德的自主,也不必然是"个人原子主义"的体现.从实践层面上来看,由于医疗服务特殊,病人在认知能力、判断能力及医学知识上与医生存在差别,医生不仅应该在消极的意义上,也应该在积极意义上尊重病人的自主,因此通过有限的干预使病人获得较高程度的自我决定能力是可以得到辩护的.     

尊重自主原则的“自主”之惑——兼论生命伦理学原则的出发点

系统梳理了尊重自主原则的"自主"概念之不同涵义,不仅包括了自由主义阵营内部三种具有代表性的自主概念,而且涵盖了来自现象学、女性主义和社群主义的批评,这些批评也贡献了另一种对"自主"的理解。通过对这些歧义性理解背后原因的探寻,试图重新提出生命伦理学原则的出发点问题。原则主义认为,包括尊重自主原则在内的四原则应以单一普适的公共道德为出发点,但"自主"涵义分歧的现状恰恰表明生命伦理学原则需要从更深的层次上奠基,把握生命伦理学原则的内容及适用范围离不开对原则背后语境的廓清。     

医学伦理学若干原则在教学应用中的是与非

医学生应当注重培养医学人文素质,掌握良好的医患沟通技巧。为促进医学生医学知识与人文精神的融通,应将医学伦理学原则融汇于基础课程和专业课程教学之中。对知情同意原则、最优化原则、保密原则、尊重自主原则等概念进行了科学诠释,结合临床实例,引导医学生客观对待知情同意书、重视最优化原则的选择、理解保密原则、切实践行尊重自主。对知情同意、最优化、保密以及尊重自主等伦理学原则的正确认识与应用,将有利于培养医学生人文素质,建立正确的医师职业价值观念。     

医疗家长主义在何种程度上得到辩护?

从医疗家长主义在医患关系历史上的发展以及学界的理解来看,它已与传统家长主义概念相去甚远。家长主义干涉的合理与否,在很大程度上取决于是否对主体自主性的提升,以及能否达成和实现病人的意愿和利益。为此,应当注意以提升病人自主性为名而实际违反其自主意愿、背离其最佳利益的情况发生。尊重自主性和有利的原则,当是考量医疗家长主义合理与否的不二法则。     

中国传统医疗父爱主义及其当代价值

中国传统医疗模式强调医生基于患者利益,为患者做主,病人在医患关系中处于被动服从地位。这是由于医生具有专业知识的优势,只有医生才能做出有利于病人的决策。这种医疗模式具有父爱主义的特点,但它同时也意味着对病人权利的忽视。因此,它最终被以尊重自主原则为核心的医疗自由主义传统所取代。但是医疗自由主义在片面强调病人自主性的同时,却忽视了医生的德性,产生了新的医患矛盾。面对今天临床医学实践中的困境,我们有必要重新审视病人自主的至高无上地位以及废弃已久的医疗父爱主义的当代价值。传统医患和谐关系中有很多值得发掘的有利因素,医疗父爱主义有利于增强医者的责任意识,重塑医家美德,从而缓和医患关系,促进医患和谐。     

脑死亡立法的伦理辩护

"脑死亡"立法是必要的并可以得到充分的伦理辩护:尊重人,特别是尊重人的自主性是"脑死亡"立法的伦理基础."脑死亡"立法符合有利和公平的伦理原则,符合功利主义伦理学追求社会利益最大化的目的.但我们在立法时,应尽量贯彻不伤害原则,注意保护患者及其亲属的利益.     

知情不同意

自主原则是医学伦理学的基本原则之一,自主权是患者的基本权利.从临床实践出发,分析了患者知情后拒绝治疗的自主选择与其他利益相冲突的情况,总结了医生尊重患者自主权利的伦理条件,对指导临床实践具有一定的现实意义.     

Precedent Autonomy and Subsequent Consent

Honoring a living will typically involves treating an incompetent patient in accord with preferences she once had, but whose objects she can no longer understand. How do we respect her “precedent autonomy” by giving her what she used to want? There is a similar problem with “subsequent consent”: How can we justify interfering with someone's autonomy on the grounds that she will later consent to the interference, if she refuses now? Both problems arise on the assumption that, to respect someone's autonomy, any preferences we respect must be among that person's current preferences. I argue that this is not always true. Just as we can celebrate an event long after it happens, so can we respect someone's wishes long before or after she has that wish. In the contexts of precedent autonomy and subsequent consent, the wishes are often preferences about which of two other, conflicting preferences to satisfy. When someone has two conflicting preferences, and a third preference on how to resolve that conflict, to respect his autonomy we must respect that third preference. People with declining competence may have a resolution preference earlier, favoring the earlier conflicting preference (precedent autonomy), whereas those with rising competence may have it later, favoring the later conflicting preference (subsequent consent). To respect autonomy in such cases we must respect not a current, but a former or later preference.     

临床麻醉中知情同意的思考

临床麻醉工作中,尊重患者自主权是知情同意的基础,知情同意反映了患者自主权与医学干涉主义之间的相互妥协。在信任基础上的知情同意,是患者自主权的最佳体现,也是对医学干涉主义的尊重,从而为患者的利益提供服务。     

On Replacing the Ethical Principle of Autonomy With an Ethical Principle of Accordance

The author defines and critiques the ethical principle of autonomy. As a concept, autonomy is most aligned with paradigms of counseling that focus on the individual as a psychological entity with moral agency. It is less consistent with frameworks that focus on relationships philosophically and in practice. Autonomy is paradoxical, because it is a consensually defined principle imposed on counseling practice while denying counselors a choice in its application. The author suggests accordance as an alternative ethical principle. Accordance is consistent with relational paradigms of practice and the other relationship‐focused ethical principles in counseling. Accordance fully contextualizes individual responsibility and choice.     

Feminism and Women's Autonomy: the Challenge of Female Genital Cutting

Feminist studies of female genital cutting (FGC) provide ample evidence that many women exercise effective agency with respect to this practice, both as accommodators and as resisters. The influence of culture on autonomy is ambiguous: women who resist cultural mandates for FGC do not necessarily enjoy greater autonomy than do those women who accommodate the practice, yet it is clear that some social contexts are more conducive to autonomy than others. In this paper, I explore the implications for autonomy theory of these understandings of the relation between culture, FGC, and women's agency. I review the range of worldwide FGC practices – including "corrective" surgery for "ambiguous genitalia" in Western cultures as well as the various initiation rites observed in some African and Asian cultures – and the diverse cultural rationales for different forms of FGC. I argue that neither latitudinarian, value-neutral accounts of autonomy nor restrictive, value-saturated accounts adequately explain women's agentic position with respect to FGC. I then analyze a number of educational programs that have enhanced women's autonomy, especially by strengthening their introspection, empathy, and imagination. Such programs, which engage women's autonomy skills without exposing them to autonomy-disabling cultural alienation, promote autonomy-within-culture. This understanding of autonomy as socially situated, however, entails neither endorsement of FGC nor resignation to its persistence.     

The Professional Autonomy of the Medical Doctor in Italy

This contribution deals with the issue of the professional autonomy ofthe medical doctor. Worldwide, the physician's autonomy is guaranteedand limited, first of all, by Codes of Medical Ethics. InItaly, the latest version of the national Code of MedicalEthics (Code 1998) was published in 1998 by the Federation ofprovincial Medical Associations (FnomCeO). The Code 1998acknowledges the physician's autonomy regarding the scheduling, thechoice and application of diagnostic and therapeutic means, within theprinciples of professional responsibility. This responsibility has tomake reference to the following fundamental ethical principles:(1) the protection of human life; (2) the protection of thephysical and psychological health of the human being; (3) therelief from pain; (4) the respect for the freedom and the dignityof the human person, without discrimination; (5) an up-to-datescientific qualification (Art. 5). The authors underline that autonomyis an anthropological – and consequently ethical –characteristic of the human person. Different positions on autonomy inbioethics (individualistic, evolutionistic, utilitarian andpersonalistic models) are explained. The relation between theprofessional autonomy of the physician and the autonomy of the patientand of colleagues is discussed. In fact, the medical doctor isobliged: (1) to respect the fundamental rights of the person,first of all his/her life; (2) to ensure the continuity of thecare, even if he can only relieve the patient's suffering; (3) tomaintain, except under certain circumstances, professional secrecy andconfidentiality regarding patients and their medical records. Moreover,the physician cannot deny the patient correct and appropriateinformation. He/she should not perform any diagnostic or therapeuticactivity without the informed consent of the patient and the medicaldoctor must give up medical treatment in case of documented refusal ofthe individual. Furthermore, the medical doctor has the right to raiseconscientious objections if he/she is requested to perform medicalactions that are contrary to his/her conscience or medical opinion,unless this attitude would seriously and immediately harm the patient.Regarding the relationships with colleagues, the physician is obliged tosolidarity, mutual respect, and care of sick colleagues. Finally, theauthors discuss the Italian legislation affecting the physician'sprofessional autonomy: (1) the SSN health care Acts; (2) theso-called Charter for Public Health Care Services; (3) the Acts onprivacy; (4) Good Clinical Practice.     

Moral responsibility and respect for autonomy: meeting the communitarian challenge.

The principle of respect for autonomy has come under increasing attack both within health care ethics, specifically, and as part of the more general communitarian challenge to predominantly liberal values. This paper will demonstrate the importance of respect for autonomy for the social practice of assigning moral responsibility and for the development of moral responsibility as a virtue. Guided by this virtue, the responsible exercise of autonomy may provide a much-needed connection between the individual and the community.     

The Porosity of Autonomy: Social and Biological Constitution of the Patient in Biomedicine

The nature and role of the patient in biomedicine comprise issues central to bioethical inquiry. Given its developmental history grounded firmly in a backlash against 20th-century cases of egregious human subjects abuse, contemporary medical bioethics has come to rely on a fundamental assumption: the unit of care (and the unit of value) is the autonomous self-directing patient. In this article we examine first the structure of the feminist social critique of autonomy. Then we show that a parallel argument can be made against relational autonomy as well, demonstrating how this second concept of autonomy fails to take sufficiently into account an array of biological determinants, particularly those from microbial biology. Finally, in light of this biological critique, we question whether or to what extent any relevant and meaningful view of autonomy can be recovered in the contemporary landscape of bioethics.     

Professional Autonomy in the Health Care System

Professional autonomy interferes at a structural level with the variousaspects of the health care system. The health care systems that can bedistinguished all feature a specific design of professional autonomy,but experience their own governance problems. Empirical health caresystems in the West are a nationally coloured blend of ideal type healthcare systems. From a normative perspective, the optimal health caresystem should consist of elements of all the ideal types. A workableoptimum taking national values into account could be attained bygovernance structures that also introduce elements from other ideal typesystems. Thus a normative approach to medical practice guaranteeing anessential degree of professional autonomy for a relationship of trustbetween the patient and the physician, could be combined with anefficient and equitable allocation of health care resources.