临床决策与疾病发展的“度”

临床决策是十分复杂的专业劳动,良好而科学的临床决策取决于众多因素,包括医师的临床经验、知识水平、医师的爱心与责任心、患者病情的复杂性、医疗水平与条件、患者及家属的条件与配合程度等等,辩证法的“度”在临床的良好应用会帮助医师准确地把握病情,给予更加适度治疗;真正的个体化临床决策必须由医师与患者及家属的密切配合才能实现。     

No Blame No Gain? From a No Blame Culture to a Responsibility Culture in Medicine

Healthcare systems need to consider not only how to prevent error, but how to respond to errors when they occur. In the United Kingdom’s National Health Service, one strand of this latter response is the ‘No Blame Culture’, which draws attention from individuals and towards systems in the process of understanding an error. Defences of the No Blame Culture typically fail to distinguish between blaming someone and holding them responsible. This article argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. We demonstrate how healthcare professionals can justifiably be held responsible for their errors even though they work in challenging circumstances. We then review the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, we argue that a responsibility culture has significant advantages over a No Blame Culture due to its capacity to enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.     

Identification and Responsibility

Real-self accounts of moral responsibility distinguish between various types of motivational elements. They claim that an agent is responsible for acts suitably related to elements that constitute the agent's real self. While such accounts have certain advantages from a compatibilist perspective, they are problematic in various ways. First, in it, authority and authenticity conceptions of the real self are often inadequately distinguished. Both of these conceptions inform discourse on identification, but only the former is relevant to moral responsibility. Second, authority and authenticity real-self theories are unable to accommodate cases in which the agent neither identifies nor disidentifies with his action and yet seems morally responsible for what he does. Third, authority and authenticity real-self theories are vulnerable to counterexamples in which the provenance of the agent's real self undermines responsibility.     

Authenticity and Heidegger's Antigone

Sophocles' Antigone is the only individual whom Heidegger names as authentic. But the usual interpretations of Heidegger's ‘authenticity’ (as being-towards-death, taking responsibility for norms, world-historical creation, and a neo-Aristotelian phronēsis) either do not apply to Antigone or do not capture what Heidegger finds significant about her. By working through these failures, I develop an interpretation of Heideggerian authenticity that is adequate to his Antigone. The crucial step is accurately identifying the finitude to which Antigone authentically relates: what Heidegger calls ‘uncanniness' (Unheimlichkeit). I argue that uncanniness names being's presencing through self-withdrawal and that Antigone stands authentically towards this in her responsiveness to the call of being and her reticence at the end of explanation. In conclusion, I consider Sophocles' own creative act, which bequeathed to the West an understanding of being and a vision of how to relate to it authentically. I argue that Sophocles' status as a world-historical creator does not provide a competing picture of authenticity but must itself be understood as responsive and reticent.     

“SLANG”—Sensitive Language and the New Genetics—an Exploratory Study

SLANG—Sensitive Language and the New Genetics—is a concept that arose out of informal discussions between a number of interested parties, both consumers and professionals, who were becoming increasingly uneasy with some of the language commonly used in medical genetics. Some language choices were felt by the authors to be inappropriate for a variety of reasons. Poor language choice may impede an individual's understanding of a genetic condition or important medical information and the chosen words themselves may simply be perceived as discriminatory and even offensive. SLANG is an important concept to explore partly because literature in this area confirms that language choices in medical settings can be of great significance to both patients and families. Studies have shown how language choices impact on professional practice by, as one example, changing the intended meaning of medical information and affecting individual perception of risk and choice which, in turn, may affect individual or familial well-being. In addition language choice has the power to affect how individuals perceive themselves and are viewed by others. This paper presents the results from our pilot study and discusses the implications for health professionals with particular reference to medical genetics settings.     

How reason for surgery and patient weight affect verdicts and perceptions in medical malpractice trials: a comparison of students and jurors

Jurors' decision-making processes are often influenced by extra-legal factors, including judgments of defendants and plaintiffs. Two studies comparing the decisions of university students with those of community jurors sought to determine if extra-legal factors such as individual differences (including identity as a student or juror participant), the reason for surgery (medically necessary vs. elective), the type of surgery (e.g., gastric bypass, nasal reconstruction) or weight of the patient influenced jurors' decisions and perceptions in medical malpractice suits, such that participants would hold negative perceptions of overweight patients or patients who undergo elective surgeries. Results indicate that students and jurors differ in perceptions of the patient's injury and perceptions of risk, which explains some of the variance in liability verdicts. Students were more likely to find doctors liable, but also were more likely to assign responsibility to patients than were jurors. Patients who had undergone elective surgery were seen as more responsible for their situation - and their doctors were assigned less responsibility - than those who had undergone a medically necessary surgery. Tests of weight bias showed that jurors found overweight patients less responsible for their situation than patients of normal weight, but students showed the opposite pattern. Theoretical explanations are explored and implications discussed.     

消极刻板印象对老年人医疗决策的影响及归因偏差的作用

随着年龄的增长, 对老年人的消极刻板印象和医疗决策逐渐成为了与老年群体越来越相关的两个概念。在此背景下, 很有必要系统地探讨消极刻板印象对老年人医疗决策的效应及其机制。本研究以158名老年人为被试, 通过两个实验考察了消极刻板印象、归因偏差和老年人医疗决策质量间的关系。实验1结果发现, 消极刻板印象负向影响老年人的医疗决策质量, 同时, 归因偏差在刻板印象对老年人医疗决策质量的效应中起到中介作用。实验2结果表明, 减少归因偏差的干预控制可以有效降低刻板印象对医疗决策质量的消极效应。本研究对理解刻板印象效应机制、缓解刻板印象消极效应、以及改善老年人医疗决策质量具有一定的理论意义和实践价值。     

Is Moral Responsibility Essentially Interpersonal? A Reply to Zimmerman

According to Michael Zimmerman, no interpretation of the idea that moral responsibility is essentially interpersonal captures a significant truth. He raises several worries about the Strawsonian view that moral responsibility consists in susceptibility to the reactive attitudes and claims that this view at best supports only an etiolated interpretation of the idea that moral responsibility is essentially interpersonal. He outlines three problems. First, the existence of self-reactive attitudes may be incompatible with the interpersonal nature of moral responsibility. Secondly, Zimmerman questions the significance of the interpersonal nature of moral responsibility, according to the Strawsonian view. Thirdly, he argues that that view may be taken to suggest the wrong kind of priority relation between ‘P is morally responsible’ and ‘it is appropriate to adopt some reactive attitude toward P’. I discuss each of these problems in turn and conclude that Strawsonians can respond to all three problems raised by Zimmerman. The Strawsonian view supports a significant interpretation of the idea that moral responsibility is essentially interpersonal.     

The authenticity of Christian Evangelicals: between individuality and obedience

Based on ethnographic data in a Christian Evangelical church in the UK, the article shows how Evangelical Christians construct their individual and group identity through appeals to authenticity. Authenticity, as it emerges from the local narratives, shares much with philosophical and sociological understandings of it, yet it is articulated within the framework of tradition. By grounding authenticity in Christian tradition, Evangelicals construct an identity which they understand as distinctive rather than morally superior to other moral traditions. Christian authenticity is a moral pursuit that requires obedience—the acceptance of God’s will. This is contrasted with the celebration of individual self-authority that is at the core of Western society. The tension between individuality and obedience to God is the motif that makes Christianity distinctive in the eyes of the informants in this study. It is also the basis for the formation of the Christian self.     

Promoting social responsibility amongst health care users: medical tourists’ perspectives on an information sheet regarding ethical concerns in medical tourism

Background

Medical tourists, persons that travel across international borders with the intention to access non-emergency medical care, may not be adequately informed of safety and ethical concerns related to the practice of medical tourism. Researchers indicate that the sources of information frequently used by medical tourists during their decision-making process may be biased and/or lack comprehensive information regarding individual safety and treatment outcomes, as well as potential impacts of the medical tourism industry on third parties. This paper explores the feedback from former Canadian medical tourists regarding the use of an information sheet to address this knowledge gap and raise awareness of the safety and ethical concerns related to medical tourism.

Results

According to feedback provided in interviews with former Canadian medical tourists, the majority of participants responded positively to the information sheet and indicated that this document prompted them to engage in further consideration of these issues. Participants indicated some frustration after reading the information sheet regarding a lack of know-how in terms of learning more about the concerns discussed in the document and changing their decision-making. This frustration was due to participants’ desperation for medical care, a topic which participants frequently discussed regarding ethical concerns related to health care provision.

Conclusions

The overall perceptions of former medical tourists indicate that an information sheet may promote further consideration of ethical concerns of medical tourism. However, given that these interviews were performed with former medical tourists, it remains unknown whether such a document might impact upon the decision-making of prospective medical tourists. Furthermore, participants indicated a need for an additional tool such as a website for continued discussion about these concerns. As such, along with dissemination of the information sheet, future research implications should include the development of a website for ongoing discussion that could contribute to a raised awareness of these concerns and potentially increase social responsibility in the medical tourism industry.

     

What is the process of personal growth? Introducing the Personal Growth Process Model

Personal growth as a process remains vaguely understood. We introduce the Personal Growth Process (PGP) model based on Carl Rogers's organismic valuing process (OVP). The PGP model explains personal growth as a sociocognitive embodied process whereby an individual undergoes multiple mental shifts that make up an ongoing, fluctuating process over the long term, starting from a place of psychological safety. The mental shifts occurring throughout the growth process are broadly categorized as self-awareness, openness towards experiencing and change, existential courage, autonomy/internal locus of control, taking responsibility for the self and others, self-compassion, and compassion towards others. These shifts all represent progress toward well-being, defined here as authenticity, harmony and life-satisfaction. Importantly, the model does not include only individual psychological constructs, but ties the process to one's social environment and common social responsibility.     

Escalation in groups: Focus on information sampling

The purpose of this experiment was to examine if groups escalate more than individuals when information is not distributed to all group members. The experiment also attempted to replicate Bazerman, Beekun, and Schoorman's (1992) findings, that participants with high responsibility escalate more than participants with low responsibility. The task was a modified version of the Heeley Store Case (Bazerman et al., 1992). The dependent measures fell into three categories: rewards, appropriateness of layoff/demotion, and forecasted future performance. The results showed little support for the hypotheses. First, high responsibility participants escalated significantly more than low responsibility candidates for only one of the six measures. This may have been due to the fact that all participants felt responsible for their decisions. For the other dependent variables, the effect was either not significant or in the wrong direction. Second, no significant interaction was found between responsibility and decision-making context (individual, groups with all shared information, and groups with shared and unshared information). We then analyzed the data using a measure of felt responsibility as a covariate. The interaction between felt responsibility and decision-making context was significant only for layoff decision. For all of the other measures, no significant interaction was found. One possible reason why our hypotheses were not supported may have been that the groups felt a diffusion of responsibility. Larger groups may have also demonstrated the effects of group processes more effectively. No clear conclusions can be made regarding the influence of information sampling on escalation. An earlier version of this paper was presented at the 1998 meetings of the American Psychological Society.     

Building esprit de corps: learning to better navigate between "my" patient and "our" patient

Excellence in the care of hospital patients, particularly those in an intensive care unit, reflects esprit de corps among the care team. Esprit de corps depends on a delicate balance; each clinician must preserve a sense of personal responsibility for "my" patient and yet participate in the collaborative work essential to the care of "our" patient. A harmful imbalance occurs when a physician demands total control of the decision-making process, especially concerning end-of-life treatment options. Although emotional factors may push a physician to claim decision-making exclusivity, compounded by a legal framework that overemphasizes individual responsibility, esprit de corps can be preserved through timely communication among clinicians and a recognition that optimal care for "my" patient requires effective team practice.     

Escalation in groups: Focus on information sampling

The purpose of this experiment was to examine if groups escalate more than individuals when information is not distributed to all group members. The experiment also attempted to replicate Bazerman, Beekun, and Schoorman's (1992) findings, that participants with high responsibility escalate more than participants with low responsibility. The task was a modified version of the Heeley Store Case (Bazerman et al., 1992). The dependent measures fell into three categories: rewards, appropriateness of layoff/demotion, and forecasted future performance. The results showed little support for the hypotheses. First, high responsibility participants escalated significantly more than low responsibility candidates for only one of the six measures. This may have been due to the fact that all participants felt responsible for their decisions. For the other dependent variables, the effect was either not significant or in the wrong direction. Second, no significant interaction was found between responsibility and decision-making context (individual, groups with all shared information, and groups with shared and unshared information). We then analyzed the data using a measure of felt responsibility as a covariate. The interaction between felt responsibility and decision-making context was significant only for layoff decision. For all of the other measures, no significant interaction was found. One possible reason why our hypotheses were not supported may have been that the groups felt a diffusion of responsibility. Larger groups may have also demonstrated the effects of group processes more effectively. No clear conclusions can be made regarding the influence of information sampling on escalation. An earlier version of this paper was presented at the 1998 meetings of the American Psychological Society.     

“Hammered down on every side” versus “just being positive”: A critical discursive approach to health inequality

Socio‐economic and health inequality are strongly linked and are increasingly perpetuated by discourses of individual responsibility. However, little research from a critical discursive perspective has addressed how people affected themselves may account for this relationship. This research examined the ways in which people who are in debt, unemployed, or in insecure, minimum‐wage employment construct health and negotiate identities around it. Data from semistructured interviews with 6 participants were analysed and 3 main interpretative repertoires were identified: a medical repertoire of health as a lack of illness; health as adopting the “right” behaviours and attitudes; and health as being heavily influenced by external factors, such as income and life circumstances. The analysis focuses on how participants managed the tension between these latter 2 repertoires by adopting various subject positions around health: that it is “slipping” away from them; that it requires motivation; and that it is unattainable. Underpinning this is a “common‐sense” idea of health as something that is worked towards through culturally approved actions and attitudes.     

医务人员的自我保护意识应从实习医生抓起

要想在以后的临床工作中减少医疗纠纷,杜绝医疗事故,保障医疗安全,一名医学生在实习期间,就要开始培养自我保护意识,精湛的医术、良好的医德、高度的责任心和同情心是法宝。只有这样才能建立正常的医患关系,创造一个良好宽松的工作环境和气氛,最终成为一名质量合格、知识结构完整、综合素质全面,能迎接现代医学挑战的医务工作者。     

Self-focused attention,authenticity, and well-being

The purpose of this study was to examine whether two distinct forms of self-focusing tendencies (i.e., self-rumination and self-reflection) predict authenticity, as well as to determine whether authenticity mediated the relationship between these self-focusing tendencies and both life satisfaction and distress. Data of this study were collected from 619 adults through an online survey. The hypothesized model was examined using structural equation modeling. Supporting the hypotheses of the study, after controlling for gender and age, both self-rumination and self-reflection had significant indirect effects on life satisfaction and distress through authenticity. Specifically, participants with a tendency to engage in self-reflection reported higher levels of authenticity, which then was associated with increased life satisfaction and decreased distress. On the other hand, participants who are inclined to self-ruminate reported lower levels of authenticity, which in turn, mediated the effect of rumination on both life satisfaction and distress.     

The role of proxies in treatment decisions: evaluating functional capacity to consent to end-of-life treatments within a family context

Psychology as a profession has entered the arena of palliative and hospice care later in the process than other health care professions. Through the use of Familial Advance Planning Evaluations (FAPEs), however, psychologists can assist individuals and families in facing end-of-life transitions in important ways. Hospice and palliative care philosophy treats the patient and family as the unit of care. End-of-life decision-making is therefore a family matter as well as a normative developmental transition. Yet, little is known about the decision-making process. This paper reviews the literature regarding informed consent, advance care planning, and proxy decision-making and outlines a theoretical model for familial decision-making. Previous models of end-of-life capacity evaluations and family assessments are presented and serve as the basis for a comprehensive assessment of familial decision-making at the end of life. Functional capacity evaluations of individuals at the end of life regarding decisions about life-sustaining medical treatments enable both the individual patient and one identified proxy from his or her family to discuss important issues families may face during medical crises at the end of life. The information gleaned from such evaluations has the potential to assist psychologists and other professionals in designing family-specific interventions to reduce caregiving distress, improve quality of life for dying patients, and ease the transition to bereavement for caregivers.     

正确认识和对待"举证责任倒置"

“举证责任倒置”作为处理民事诉讼中的例外原则运用于医疗纠纷的处理必将对医患关系的根本好转提供有利的措施保证,如何认识和对待“举主责任倒置”是一个崭新的课题,就此,我们谈点不成熟的看法。