网络医疗的发展和思考

随着科学技术、网络技术迅猛的发展,许多互联网业务如网上求医、网上购药、网上保健也日渐火热,成为人们防治疾病的又一手段。网络医疗是网络科技与医疗技术结合的产物,在信息高速发展的今天,它已成为医学交流中一道亮丽的风景线,各国都在不遗余力发展自己的远程医疗系统,这无疑将推动医学模式的进步。然而作为一种新的医疗手段,网络医疗目前仍存在着诸多的弊端和问题,这些问题反过来又可制约网络医疗的发展,因此必须在技术、政策、法律各方面予以完善,使之更好地服务于人类。     

应当建立科学的医疗纠纷技术鉴定体制

现行的医疗纠纷技术鉴定模式年来在解决医疗纠纷中起到了重要作用,但随着卫生改革的进一步深化和法制的日趋健全,以及人们法律意识的不断提高它的缺陷也日益突出。应当建立新的医疗技术鉴定管理体制,鉴定委员会的人员鸺成,增强医疗技术透明度,建立时效制度和回避制度。     

网络医疗发展带来的法律问题

随着网络技术迅速发展,网络医疗以其方便快捷,患者足不出门便可得到一流的医院、最优秀的医生、最先进的医疗服务等,这些深受患者青睐。网络医疗对医学发展将起到不可低估的作用。然而网络医疗在其发展的同时,也存在一些不可忽视的问题。网络医疗在改变传统医患关系模式的同时也带来了一系列诸如保障患者隐私权、保护知识产权、法律关系改变等新的法律问题。这些问题不解决,对网络医疗健康发展,对医患合法权利保护等都会带来不利影响,针对这一系列问题展开论述,提出解决问题的办法。     

Judaism, justice, and access to health care

This paper develops the traditional Jewish understanding of justice (tzedakah) and support for the needy, especially as related to the provision of medical care. After an examination of justice in the Hebrew Bible, the values and institutions of tzedakah in Rabbinic Judaism are explored, with a focus on legal codes and enforceable obligations. A standard of societal responsibility to provide for the basic needs of all, with a special obligation to save lives, emerges. A Jewish view of justice in access to health care is developed on the basis of this general standard, as well as explicit discussion in legal sources. Society is responsible for the securing of access to all health care needed by any individual. Elucidation of this standard of need and corresponding societal obligations, and the significance of the Jewish model for the contemporary United States, are considered.     

医疗纠纷产生的法律根源及对策

当前,我国的医疗纠纷案件逐年增多。卫生立法滞后、违法现象严重、执法不统一、患者法律意识增强、鉴定程序不合理是产生医疗纠纷的重要法律根源。提出的对策：（１） 加快卫生立法,创建良好的法制环境;（２） 完善处理医疗纠纷的法律;（３） 严格执法;（４） 开展法制宣传工作,提高医患双方的法制观念。     

A Historical Overview and Contemporary Expansion of Psychological Theories of Determinism,Probabilistic Causality,Indeterminate Free Will,and Moral and Legal Responsibility

The authors provide a historical overview of the development of contemporary theories of counseling and psychology in relation to determinism, probabilistic causality, indeterminate free will, and moral and legal responsibility. They propose a unique model of behavioral causality that incorporates a theory of indeterminate free will, a concept traditionally assumed to exist by the U.S. legal system, but rejected in counseling theory.     

The Community Response to Rape: Victims' Experiences with the Legal, Medical, and Mental Health Systems

This research examined how the legal, medical, and mental health systems respond to the needs of rape victims. A national random sample of rape victim advocates (N = 168) participated in a phone interview that assessed the resources available to victims in their communities. as well as the specific experiences of the most recent rape victim with which they had completed work. Results from hierarchical and iterative cluster analysis revealed three patterns in victims' experiences with the legal, medical, and mental health systems. One group of victims had relatively positive experiences with all three systems, a second group had beneficial outcomes with only the medical systems, and the final group had difficult encounters with all three systems. Multinominal logistic regression was then used to evaluate an ecological model predicting cluster membership. Community-level factors as well as features of the assault and characteristics of the victims predicted unique variance in victims' outcomes with the legal, medical, and mental health systems. These findings provide empirical support for a basic tenet of ecological theory: environmental structures and practices influence individual outcomes. Implications for ecological theory and interventions to improve the community response to rape victims' needs are discussed.     

Disability versus futility in rationing health care services: defining medical futility based on permanent unconsciousness--PVS,coma, and anencephaly

All societies must ration health care services in the face of unlimited demand. The concept of medical futility may appear to be an uncontroversial means by which to ration services. Depending upon how it is applied, however, limiting services based on alleged medical futility may violate prohibitions against disability-based discrimination. In particular, use of medical futility to require removal of life-sustaining interventions has been held to violate the Americans with Disabilities Act. The ADA protects both people with disabilities who are conscious and people in unconscious states, such as permanent vegetative state (PVS), coma, and anencephaly. Ultimately, as the number of people in permanently unconscious states increases, our society will have to recognize that consciousness is an essential characteristic defining human beings and determining whether a legal right to unlimited life-sustaining intervention should apply. This article proposes to define medical futility to preclude life-sustaining interventions after a stated period of permanent unconsciousness and to redefine the end of life consistently as neocortical death.     

E Contrario Reasoning: The Dilemma of the Silent Legislator

Summary This contribution offers an evaluation of e contrario reasoning in which the interpretation of a legal rule is based on the context of the law system (contextual e contrario reasoning). A model is presented which will show all the explicit and implicit elements of the argument at work and will also point out how these distinct parts are interrelated. By questioning the content and justificatory power of these elements, the weak spots in the argument can be laid bare. It will be argued that e contrario reasoning inevitably requires a dubious argumentative step, which renders the argument intrinsically weak. The model is applied to a European lawsuit on French cheese.     

Potential for personhood: A measure of life the severely defective newborn,legal implications of a social-medical dilemma

This paper asks for legislation that will remove criminal sanctions from good faith decisions by parents and physicians to allow severely defective newborns to die. In so doing it attempts to bring to satisfactory resolution conflicting points of view in the disciplines of moral philosophy, medicine, and law. This paper argues that euthanasia of severely defective newborns is morally justifiable and legally permissible within reasonable extensions of current interpretations of the Federal Constitution by the Supreme Court. It describes the medical dilemma, evaluates the moral issues involved, and delineates possible legal alternatives.     

对影响“临床决策”负面因素的剖析与探讨

临床决策是医疗实践过程中的中心环节,直接关系到病人的治疗效果。在决策形成和实施过程中受到各方面因素的制约,主要包括两个方面医生自身方面因素,如医生素质、技术水平、决策思维能力等;医生自身以外的因素,如卫生政策、药品及其它医疗器材的流通环节、医保制度、医院经营方针,其它因素如社会、伦理、法律、经济等无不影响着医疗决策的正确实施。因此,要排除干扰,努力实施科学的临床决策,不仅要加强医生本身的素质和技术层面的培养和提高,更需要全社会、患者和广大公众给予理解和支持。     

"管办分离"模式下公立医院出资人制度的探索——以上海申康医院发展中心为例

上海申康医院发展中心是卫生领域推进政事分开、管办分开的一次改革试点,以上海申康医院发展中心为例,分析该模式探索公立医院管理体制改革,建立所有权与经营权适度分离,管资产与管人、管事相结合的市级医院出资人制度,促进市级医院加强内部管理,构建有效的约束激励机制,不断提高医院的营运质量和绩效的成功经验。     

Surrogate medical decision making on behalf of a never-competent, profoundly intellectually disabled patient who is acutely ill

With the improvements in medical care and resultant increase in life expectancy of the intellectually disabled, it will become more common for healthcare providers to be confronted by ethical dilemmas in the care of this patient population. Many of the dilemmas will focus on what is in the best interest of patients who have never been able to express their wishes with regard to medical and end-of-life care and who should be empowered to exercise surrogate medical decision-making authority on their behalf. A case is presented that exemplifies the ethical and legal tensions surrounding surrogate medical decision making for acutely ill, never-competent, profoundly intellectually disabled patients.     

Negotiating Ethical Paradoxes in Conducting a Randomized Controlled Trial: Aligning Intervention Science with Participatory Values

In this article, we describe ethical tensions we have faced in the context of our work as intervention scientists, where we aim to promote social justice and change systems that impact girls involved in the juvenile legal system. These ethical tensions are, at their core, about resisting collusion with systems of control while simultaneously collaborating with them. Over the course of designing and implementing a randomized controlled trial (RCT) of an ecological advocacy intervention for girls, called ROSES, ethical paradoxes crystalized and prompted us to engage in critical reflection and action toward the aim of moving away from conducting research on legal‐system‐involved girls and moving toward a more democratic, participatory process of inquiry with girls. Our experience revealed two intertwined paradoxes that ultimately served generative purposes. First, in collaborating with legal system stakeholders, we observed a single story of girls’ pathology narrated for girls, without girls, and ultimately internalized by girls. Second, in reflecting critically on the ethical implications of our study design, it became clear that the design was grounded in a medical model of inquiry although the intervention we sought to evaluate was based, in part, on resistance to the medical model. We describe emergent ethical tensions and the solutions we sought, which center on creating counternarratives and counterspaces that leverage, extend, and disrupt our existing RCT. We detail these solutions, focusing on how we restructured our research team to enhance structural competence, shifted the subject of inquiry to include the systems in which youth are embedded, and created new opportunities for former research participants to become co‐researchers through formal roles on an advisory board.     

减少医师自卫医学行为的对策研究

根据自卫医学行为产生的原因,减少自卫医学行为有两个思路,一个是减轻医师的法律责任,另一个是化解医师在法律责任下所面临的风险。根据第二个思路,应该采取下面的措施:建立医师责任保险制度;建立医疗责任保险制度;实施医疗风险管理;提高医师个人的执业素养。     

加强情商培养 构建急诊和谐的医患关系

急诊科是医院救治急、危、重患者的第一线,也是医患冲突高发的科室,因此善于沟通和交流的高情商成为急诊科医生的必备品质之一;本文从情绪调控、心理学、利益得失、人文素养、语言艺术等角度探讨了急诊科医生情商培养在构建和谐医患关系中的重要作用。     

Being, Doing, and Knowing: Developing Ethical Competence in Health Care

There is a growing interest in ethical competence-building within nursing and health care practising. This tendency is accompanied by a remarkable growth of ethical guidelines. Ethical demands have also been laid down in laws. Present-day practitioners and researchers in health care are thereby left in a virtual cross-fire of various legislations, codes, and recommendations, all intended to guide behaviour. The aim of this paper was to investigate the role of ethical guidelines in the process of ethical competence-building within health care practice and medical research. A conceptual and critical philosophical analysis of some paragraphs of the Helsinki Declaration and of relevant literature was performed. Three major problems related to ethical guidelines were identified, namely, the interpretation problem (there is always a gap between the rule and the practice, which implies that ethical competence is needed for those who are to implement the guidelines); the multiplicity problem (the great number of codes, declarations, and laws might pull in different directions, which may confuse the health care providers who are to follow them); and the legalisation problem (ethics concerns may take on a legal form, where ethical reflection is replaced by a procedure of legal interpretations). Virtue ethics might be an alternative to a rule based approach. This position, however, can turn ethics into a tacit knowledge, leading to poorly reflected and inconsistent ethical decisions. Ethical competence must consist of both being (virtues) and doing (rules and principles), but also of knowing (critical reflection), and therefore a communicative based model is suggested.     

医疗事故处理法律亟待统一规范

目前在我国医疗工作的实践中,医疗纠纷呈上升趋势。然而,解决和处理医疗纠纷与医疗事故的法律、法规尚不移规范统一。随着我国法制的逐步健全,法律,法规的不断完善,医疗事故处理的法律亟待统一规范,以利于全社会遵法,守法,执法的实现。     

加入WTO对医疗服务的挑战及相应对策

加入世界贸易组织（WTO）使我国医疗服务面临新的挑战,如国外医疗机构将进入我国,对公立医院管理体制的冲击等,对此提出了我国应采取的对策如深化医疗卫生体制改革等。