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。     

Professional Autonomy in Belgium

The Belgian health care system has a few features that may havecontributed to the rising costs of health care: patients' freechoice of physicians, large clinical freedom of physicians, essentiallya fee-for-service remuneration for medical specialists in which the feesare agreed between insurance funds and physicians. The increased medicalconsumption and costs have prompted the state and insurance companies totake measures that limit the professional autonomy of the physicians.Access to medical education, free until 1997, is now restricted. Themedical profession is organized in the Order of Physicians that hasestablished a code of professional ethics that has moral but not legalforce. So far, there is no special legislation for thepatient–physician relationship, though laws on specific issueslike organ transplantation contain duties for physicians. In recentyears a debate is taking place on patients' rights, of which informedconsent is central and gaining importance in medico-legal publications.An analysis of (ethical and legal) regulations concerning thewithholding or withdrawal of treatment by physicians demonstrate thatthe profession still enjoys a large clinical autonomy, though duediscussion with the patient has become more explicitly required. Therespect for professional autonomy is not primarily due to any formalpower that the Order of Physicians would have, but is rather grounded inthe generally high quality of the patient–physician relationshipthat in ethical terms is considered essentially as a confidencerelationship rather than a contractual relationship.     

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.     

医患关系中个人自主的局限与突围——关怀伦理对医疗决策的启示

知情同意和医疗家长主义的改良方式都将自主性理解为一种个人自主,通过对知情同意和改良后的医疗家长主义中个人自主因素的批判性反思,可以发现它们在个人自主的影响下仍然难以解决医疗程序的形式化、医患关系的沉默问题。借助关怀伦理的视角和对关怀关系的分析,表明自主性可以在人与人之间的关怀和支持中实现,并鼓励医生、患者家属对医疗决策的积极参与,促进医患关系的良好发展。因此,关怀伦理对关系的强调将有助于打破个人自主的局限性,并为医疗决策方式带来一种关系转向,也为其提供了一个新的理论基础。

     

Professional Autonomy and the Normative Structure of Medical Practice

Professional autonomy is often described as a claim of professionalsthat has to serve primarily their own interests. However, it can also beseen as an element of a professional ideal that can function as astandard for professional, i.e. medical practice. This normativeunderstanding of the medical profession and professional autonomy facesthree threats today. 1) Internal erosion of professional autonomy due toa lack of internal quality control by the medical profession; 2)the increasing upward pressure on health care expenses that calls for ahealth care policy that could imply limitations for the professionalautonomy of physicians; 3) a distorted understanding of theprofession as being based on a formal type of knowledge and relatedtechnology, in which other normative dimensions of medical practice areneglected and which frustrates meaningful communication betweenphysicians and patients. To answer these threats a normative structureanalysis of medical practice is presented, that indicates whichprinciples and norms are constitutive for medical practice. It isconcluded that professional autonomy, normatively understood, should bemaintained to avoid the lure of the technological imperative and toprotect patients against third parties' pressure to undertreatment.However, this professional autonomy can only be maintained if members ofthe profession subject their activities and decisions to a criticalevaluation by other members of the profession and by patients and ifthey continue to critically reflect on the values that regulate today'smedicine.     

世界医学会《国际医学伦理准则》2022年版修订述评

2022年10月,世界医学会第73届全体大会审议通过了2022年修订版本《国际医学伦理准则》。此次修订历时4年,修订过程的参与度和透明度均有重大突破。新版准则充实了医生对患者的义务,补充扩展了对其他医生、医务人员、学生和其他人员的义务,对社会的义务以及作为医学专业成员的义务。通过对尊重患者的尊严和自主性、知情同意的新要求、良心反对、利益冲突等修订重点和亮点的介绍与评论,对国际医学共同体关注的现代医学伦理问题进行初步探讨,以期加强我国医学伦理理论和制度规范的进一步研究和交流。

     

由临床病例引发对患者医疗自主权的思考

从医务人员视角结合临床病例浅谈患者医疗自主权。阐述患者医疗自主权的概念及涵盖的内容,包括知情同意原则、意定监护、生前预嘱、预立医疗指示、预立医疗照护计划。分析患者医疗自主权在我国实施所存在的阻力,包括受传统孝道束缚、国民对患者医疗自主权的维护意识不强和认知不足、缺乏死亡教育以及医学技术层面等问题。为了有效推广和实施患者医疗自主权,作为医务人员首先要提高自身意识、加强推广力度,其次对于公众要加强死亡教育,另外医患之间、患者与家属之间的交流沟通也非常重要。

     

Re-Evaluating Professional Autonomy in Health Care

Professional autonomy, as the symbol of the traditional freedom ofdecision-making of medical professionals is criticized. This essayexamines the critique. It analyses the underlying assumption that theautonomy of health professionals is incompatible with the need fororganisation and management in order to control rising health carecosts. It is argued that the concept of professional autonomy should beredefined, not through restricting the decision-making freedom ofindividual health professionals, but through expanding the concept intothe sphere of management, so that managers will take responsibility forpatient care.     

关于医疗同意书的若干法律问题的思考

医疗知情同意书与病人知情权密切相关,还涉及病人的自我决定权和隐私权。对知情同意书的本质及其法律效力,签署主体及告知的标准进行了一些探讨。     

The Effect of Relationships on Decision-Making Processes of Women in Harare,Zimbabwe

A preliminary study aimed at investigating the potential impact of relationships on decision-making process and autonomy of women was conducted in Harare, Zimbabwe. The majority of women surveyed (87.6%) were prepared to consult their husbands, whereas only 46.6% said they would consult their relatives prior to participation in health research. Only 6.2% and 11.3% were prepared to keep their participation secret from their husbands their relatives, respectively. Overall, 58.6% were rated as autonomous, 22.5% partially autonomous, and 18.9% were rated as not autonomous. Age, educational level, employment status, and marital status of respondents were significantly associated with autonomous decision-making process.     

The Impact of Specific Psychotherapist Beliefs Regarding Managed Care on Prospective Psychotherapy Clients

The purpose of this study was to investigate the separate impact of each of thirteen therapist beliefs that, presented collectively, were previously found to have a significantly negative impact on prospective clients' attitudes toward managed care psychotherapy (Pomerantz, 2000). Participants in this study initially completed a brief questionnaire measuring their willingness to enter psychotherapy and their expectations regarding psychotherapy under managed care. Participants subsequently completed the same brief questionnaire again after being instructed to imagine seeing a hypothetical psychologist and being presented with the psychologist's supposed beliefs regarding managed care (which were actually derived from survey data by Murphy et al., 1998). Results suggest that almost every discrete therapist belief had a significantly negative impact on participants' attitudes toward managed care psychotherapy. Several specific therapist beliefs produced particularly salient negative effects. Implications regarding ethics and informed consent are discussed.     

2013版《赫尔辛基宣言》对我国知情同意的借鉴

为提高患者 (包括受试者) 权益保护水平, 世界医学协会2013版《赫尔辛基宣言》将知情同意作为单独部分予以规定, 区分知情同意能力、增加告知研究结果、强化知情同意主体法律地位。我国自2008年“李丽云事件”发生后已对知情同意制度进行修订, 但其签署过程中仍存在以作用取代目的、自主权尚未受到充分保护、告知程序内容不完善、医患沟通欠缺等问题。因此, 应借鉴2013版《赫尔辛基宣言》规定, 加强医患双方法律教育、明确知情同意主体能力、规范知情同意签署过程、提高医务人员沟通能力, 以切实保护患者知情同意权。     

酒依赖与酒文化

在医疗过程中,无法取得患者的同意时,通常由他人代其做出同意。但是,代为同意人在代为做出同意时,必须以患者本人的最佳利益为原则。在判断患者的最佳利益时,可以借鉴英国《心智能力法2005》的规定,通过对诸因素的评估,来综合决定何谓患者的最佳利益。我国在制订和修改代为同意的相关规定时,应该考虑如何借鉴英国的规定,制订符合我国国情的代为同意制度。     

论医疗活动中知情同意与委托代理之间的平衡

为分析医疗活动中知情同意的现状与问题并探讨解决方法, 论证了患者知情权难以理想实现以及自主同意权的盲目性问题, 分析了知情同意的泛化与形式化趋势, 以及知情同意对医生保护作用的有限性。认为委托代理制度有助于解决这些问题, 即医患双方通过签署委托代理书, 患者让渡一部分决定权给医生, 医生根据自己掌握的信息决定是否为患者采取相应措施。遵循自愿原则、动态原则与合法性原则有助于选择知情同意与委托代理间的最佳平衡点, 可以更好地保护医患双方的权益。但实施委托代理制度尚存诸多问题, 有待进一步分析与探讨。     

Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients

Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15–24 years. The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment, we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched. Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity.     

The Curious Case of the De-ICD: Negotiating the Dynamics of Autonomy and Paternalism in Complex Clinical Relationships

This article discusses the response of our ethics consultation service to an exceptional request by a patient to have his implantable cardioverter defibrillator (ICD) removed. Despite assurances that the device had saved his life on at least two occasions, and cautions that without it he would almost certainly suffer a potentially lethal cardiac event within 2 years, the patient would not be swayed. Although the patient was judged to be competent, our protracted consultation process lasted more than 8 months as we consulted, argued with, and otherwise cajoled him to change his mind, all to no avail. Justifying our at times aggressive paternalistic intervention helped us to reflect on the nature of autonomy and the dynamics of the legal, moral, and personal relationships in the clinical decision-making process.     

我国公共卫生中的伦理学问题

在公共卫生研究中重点探讨了伦理审查、研究对象选择、知情同意、保护研究对象隐私、对研究对象的适当补偿等方面的伦理学问题;在公共卫生实践中重点探讨了传染病防治、疾病监测、计划免疫、疾病筛查及卫生资源配置领域中的伦理学问题。重视这些问题并参照一定的伦理学原则将有助于解决问题,更好地促进公共卫生事业的发展,促进人群健康。     

谈医疗行为中患者知情同意权的实现

目前,关于患者的知情同意权的讨论引起了众多医院管理者的关注。对知情同意与医疗行为的矛盾冲突进行探讨,提出医疗行为为中实现患者知情同意的对策及伦理原则。     

Informed consent and the use of placebo in poland: Ethical and legal aspects

The concept of informed consent was one of the most fruitful ideas that deeply changed the relationships between physicians and their patients from paternalism to respect for the personal autonomy of subjects needing professional medical care. The great progress in medicine, also involving the pharmaceutical industry, has created an increasing need to perform different clinical and experimental trials. The evolution of clinical research in the last decades has influenced strongly the design of these studies. One of the most important changes in this field has been the use of placebo groups in double-blind controlled studies. The controversies have involved not only the use of placebo when standard or proven treatment was available, but also some specific problems concerning the procedure of obtaining informed consent in such trials. This paper briefly presents the evolution of informed consent in Poland as well as different ethical and legal problems concerning informed consent and the use of placebo controls in clinical trials. An earlier version of this paper was presented at an international conference, “Placebo: Its Action and Place in Health Research Today,” held in Warsaw, Poland on 12–13 April, 2003.