临床实习生专业教育与医学伦理教育整合的探讨

当前有相当数量的临床学院、教学医院和临床教师仅重视医学生的专业教育而忽视医学伦理教育,专业教育与医学伦理教育严重脱节.应对临床实习生的专业教育与医学伦理教育的培养目标、教育内容、实践过程、教育路径、方式方法进行整合,使医学专业教育与医学伦理教育紧密结合、相互渗透、相互融合、实现整合.     

Sterilization, Catholic health care, and the legitimate autonomy of culture.

Disagreement over the legitimacy of direct sterilization continues within Catholic moral debate, with painful and at times confusing ramifications for Catholic healthcare systems. This paper argues that the medical profession should be construed as a key moral authority in this debate, on two grounds. First, the recent revival of neo-Aristotelianism in moral philosophy as applied to medical ethics has brought out the inherently moral dimensions of the history and current practice of medicine. Second, this recognition can be linked to Catholic morality through Vatican II's affirmation of the legitimate autonomy of culture, including the sciences. A partial precedent for understanding the moral authority of medicine can be found in the recent history of Catholic medical morality, and we further argue that a full contemporary recognition of that authority would weigh against an absolute prohibition of direct sterilizations. Institutionally, we propose the allowance of direct sterilizations in cases where the clinically perceived biomedical good of the patient is at stake.     

From principles to principals: The new direction in medical ethics

Many alternatives or supplements to principalism seek to reconnect medical ethics with the thoughts, feelings, and motivations of the persons directly involved in ethically troublesome situations. This shift of attention, from deeds to doers, from principles to principals, acknowledges the importance of the moral agents involved in the situation — particular practitioners, patients, and families. Taking into account the subjective, lived experience of moral decision-making parallels recent efforts in the teaching of medicine to give the patient's subjectivity — his or her personal experience of being sick or disabled — epistemological parity with scientific medicine's objective, biomedically-oriented view of the person's sickness or disability.Moreover, the shift from principalism to principals signals a growing realization that ethical problems in the profession of medicine are inseparable from its practice. Philosophers and other humanists working in medicine should resist the temptation to institutionalize a professional role as solver of ethical problems, clarifier of values, or mediator of disputes and work instead to help practitioners practice medicine reflectively.     

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.     

完善医学生职业道德培养教育途径

为了提高我国医学生职业道德教育的有效性和实效性,需不断完善和健全现有职业道德培养渠道,并拓展新渠道。在探讨研究国外医学生道德培养途径基础上,博采众家之长,形成以职业道德教育贯穿于专业教育全过程为特征,以职业道德教育与临床医疗实践相结合,以提高医学生自我道德教育能力为目的,适合我国特点的医学生职业道德培养途径。     

临床护理人员的护理伦理知信行素养调查研究——以某三甲医院为例

为了解临床护理人员的护理伦理知识、信念、行为等素养的现状、存在的主要问题及其主要影响因素,问卷调查了某三级甲等医院的1147名护理人员,同时对16名资深护理人员和护理工作管理者进行深入访谈。调查结果显示,尽管多数护理人员在工作实践中能正确践行护理伦理行为,但护理人员的护理伦理知识欠缺,护理伦理教育有待加强;部分护理人员的基本护理（医学）伦理理念尚未建立;“重技术轻人文”的护理理念仍然是影响护理伦理践行的主要因素。临床护理人员普遍有接受有关护理伦理知识和技能培训的需求和愿望。

     

Professional Boundary Ethics Attitudes and Awareness Among Nurses and Physicians in a University Hospital in the Kingdom of Saudi Arabia

This study sought to gauge ethical attitudes about professional boundary issues of physicians and nurses in the Kingdom of Saudi Arabia. Respondents scored 10 relevant boundary vignettes as to their ethical acceptability. The group as a whole proved “aware/ ethically conservative,” but with the physicians' score falling on the “less ethically conservative” part of the spectrum compared to nurses. The degree of ethicality was more related to profession than to gender, with nurses being more “ethical” than physicians.     

托马斯·帕茨瓦尔的医学伦理思想

托马斯·帕茨瓦尔于1803年出版的《医学伦理学》一书是医学伦理学学科诞生的标志。全书采用道德箴言的形式阐述了当时的医学从业人员,包括内科医生、外科医生和药剂师应当遵守的各种道德行为规范,其中主要涉及医生的临床道德义务,医学从业者之间的道德义务,以及一些重要问题,如会诊、费用收取、新的医疗方法和技术应用等的注意事项。这一著作集中体现了帕茨瓦尔的医学人道主义思想,影响了后世医学伦理学的发展方向。     

Were the “Pioneer” Clinical Ethics Consultants “Outsiders”? For Them,Was “Critical Distance” That Critical?

“Clinical ethics consultants” have been practicing in the United States for about 50 years. Most of the earliest consultants—the “pioneers”—were “outsiders” when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became “insiders” very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient “critical distance” for appropriate reflection about the complex medical ethics dilemmas of the day if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field.     

A Defense of Unqualified Medical Confidentiality

It is broadly held that confidentiality may be breached when doing so can avert grave harm to a third party. This essay challenges the conventional wisdom. Neither legal duties, personal morality nor personal values are sufficient to ground professional obligations. A methodology is developed drawing on core professional values, the nature of professions, and the justification for distinct professional obligations. Though doctors have a professional obligation to prevent public peril, they do not honor it by breaching confidentiality. It is shown how the protective purpose to be furthered by reporting is defeated by the practice of reporting. Hence there is no conflict between confidentiality and the professional responsibility to protect endangered third parties.     

Contagious Disease and Self-Defence

This paper gives a self-defence account of the scope and limits of the justified use of compulsion to control contagious disease. It applies an individualistic model of self-defence for state action and uses it to illuminate the constraints on public health compulsion of proportionality and using the least restrictive alternative. It next shows how a self-defence account should not be rejected on the basis of past abuses. The paper then considers two possible limits to a self-defence justification: compulsion of the non-culpable and over-inclusive compulsion. The paper claims that objections to compelling the non-culpable do not greatly restrict the scope of the self-defence justification. The over-included are, however, innocent bystanders, and methods such as compulsory quarantine, vaccination, and screening are not justified in self-defence. I am grateful to Julian Lamont, Jeff McMahan and Debbie Tseung for their help with this paper. An earlier version was given at the School of Public Health, the University of Texas at Houston; the Auckland Regional Public Health Service; and a conference at the School of Population Health, the University of Auckland. My thanks to the audiences for their comments.     

宗教心理-鬼神心理疾病—濒死体验的诊断与预后

濒死体验是科学现象而不是灵学现象,有初步问卷和最终量表可供筛查和诊断;是心理疾病而不是精神病。美国精神病学学会《精神疾病诊断与统计手册》标定为“宗教—鬼神问题”。除非获得适当的心理治疗与社会心理康复,患者预后不良。     

冠心病诊治中的过度医疗

近年来,过度医疗问题引起了医学伦理学界的普遍关注。过度医疗是一个经济现象,同时也是一个伦理问题．确切的说是一个医学一社会问题。结合冠心病过度医疗的特点,从医学伦理学角度剖析冠心病过度医疗的原因,并提出了医者、患者、医疗机构和社会针对冠心病过度医疗应采取的措施。     

医学伦理学和生命伦理学的学科使命之辨

从古典医德学发展到生命伦理学,催生医学伦理学和生命伦理学两门学科。欧美对于医学伦理学本质解读的经典路径和中国医学伦理学的阐释方式,不能完全反映医学伦理学的全貌,为此需要以动态有机的方式理解医学伦理学范畴。这种理解表明：医学伦理学的学科使命聚焦医学职业道德,是德性伦理和规范伦理的融合,是质料伦理和形式伦理的统一。生命伦理学本质上是为生命科学的运用提供道德正当性论证,将关怀类生命和人类未来生存作为其学科使命。生命伦理学的跨学科建制及其解决范式依托寻求论证和程序合理性,它是对医学职业道德瓶颈的突围,又反哺\"医学职业道德规范\"的制定和执行。     

美德复兴的历程与医学美德的复苏

美德伦理的复兴是20世纪伦理学研究的重要转向和理论图景,国外美德伦理研究以麦金太尔为代表,迈克尔•斯洛特的情感主义美德伦理学最具代表性,国内在译介国外研究的基础上提出美德与规范的互补。在医学领域也开始复兴美德伦理,内因在于美德伴随医学的产生,比规范伦理有更悠久的历史,外因在于扭转社会的去道德化倾向,美德伦理与规范伦理同样重要,甚至某些情况下更重要。但在美德伦理的复兴过程中,也面临着内在与外在的阻力,美德伦理复兴任重而道远。

     

Healing Without Waging War: Beyond Military Metaphors in Medicine and HIV Cure Research

Military metaphors are pervasive in biomedicine, including HIV research. Rooted in the mind set that regards pathogens as enemies to be defeated, terms such as “shock and kill” have become widely accepted idioms within HIV cure research. Such language and symbolism must be critically examined as they may be especially problematic when used to express scientific ideas within emerging health-related fields. In this article, philosophical analysis and an interdisciplinary literature review utilizing key texts from sociology, anthropology, history, and Chinese and African studies were conducted to investigate the current proliferation of military metaphors. We found the use of these metaphors to be ironic, unfortunate, and unnecessary. To overcome military metaphors we propose to (1) give them less aggressive meanings, and/or (2) replace them with more peaceful metaphors. Building on previous authors' work, we argue for the increased use of “journey” (and related) metaphors as meaningful, cross-culturally appropriate alternatives to military metaphors.     

当代中国医德建设与相对主义医学伦理学

当代西方相对主义医学伦理学有许多建树,但也有其致命性的缺陷,这就是否定医学道德的客观绝对性和普遍性医学伦理准则。在引进、介绍了这种学说之后,需要下功夫同它进行对话,即以医德绝对性与相对性辩证统一的原理,对这种学说进行追问,从中借鉴有益的经验和教训,以顺利全面地推进我国当代的医学道德建设。     

多元文化护理的伦理审视

多元文化护理作为当代护理发展的方向, 其伦理内涵植根于后现代主义思潮和对话伦理的理论背景, 并以关怀伦理为基础。无论在中国还是在西方, 有关“关怀”的伦理思想都有丰富的论述, 而以西方女性主义关怀伦理学最为系统。护理学强调关怀, 多元文化护理更是对“关怀”全面而深入的实践。关怀伦理给了多元文化护理诸多启发, 实践多元文化护理应当进一步学会关怀, 实施尊重原则、同情原则、责任原则、宽容原则、情境原则和沟通原则, 体现关怀在知、情、意、信、行方面的具体要求。