医生与药业的关系:利益冲突重要根源

药业与医生的关系在最近40年日益受到医学界与社会的重视.药业以并不昂贵的馈赠及其他手段,资助学术交流、医学教育和医学研究,深刻地影响着临床医生的行为和诊治决策,从而危及医学的科学性和医学职业精神,加重了病人的负担,且祸及病人健康.药业与医生的这种关系,是道德与金钱关系的赤裸表现,是资本对医学的无情侵略.从道德、法律、行业管理等诸多方面正确规范行业与医生的相互关系,避免当前面临的种种弊端,维护医学的科学性,保护病人与社会公众的利益,刻不容缓.     

维护共同利益：医学道德存在的现实基础

我们为什么需要医学道德 ?作为医务人员处理医患关系的行为准则 ,究竟是一种社会的外在要求 ,还是一种与行业生存、发展有关的内在要求 ,或者是两者兼而有之 ?要准确地回答这些问题并不容易 ,这需要我们去探讨医学道德的本质和存在的现实基础。搞清楚这些问题 ,或许能帮助我们解决在临床医疗道德实践中碰到的各种难题和困惑。1　临床医学道德实践中产生的问题在处理医患关系的矛盾和冲突时 ,社会和医疗管理部门会对医务人员提出这样或那样的道德要求。对此 ,有人常常会问 ,为什么在医患关系中总是要强调维护病人的利益 ?医生是一种职业 ,还…     

医患交往中医生权力异化的道德心理分析

医学职业潜规则流行有诸多原因,但对其流行的一个深层原因——医生权力异化几乎还没被关注。分析医生权力异化的道德心理运作机制,可能为解决医学职业潜规则流行难题提供新思路。在病人方面,避害心理、依赖心理、利己心理和从众效应等是导致医生权力异化的道德心理基础。在医生方面,自利心理、补偿心理和规则意识淡漠等是导致医生权力异化的道德心理基础。基于这些心理机制,培育公民的道德心理、规则意识、法规观念等素质,会有助于解决医学职业潜规则流行难题,助力我国医学伦理学建设及健康中国事业的发展。     

生命医学伦理学视野中的医疗决策——对重庆医生被砍伤事件中医疗决策的道德伦理反思

在生命医学伦理学范式下,医疗决策的核心与关键在其道德正当性。具有道德正当性的医疗决策即使不能将道德陌生人性的医患关系升华为道德朋友,也不会将其恶化为道德敌人。在防止医患关系被异化为道德敌人的价值上,生命医学伦理学的公平和尊重原则优于有利和不伤害原则。对于促成道德朋友而言,医生的人文医疗决策能力要比科学决策能力更重要。只有不伤害或能增进医患信任的医疗决策才是好的和具有道德正当性的医疗决策。医务人员的人文能力是决定医患关系和谐与否的关键所在。为防止医患关系恶化为道德敌人应该建立医生回避制度。     

美国的医学伦理学一瞥

医学伦理学作为伦理学的一个分支,在美国学术界颇受重视,蒂洛的《伦理学:理论与实践》一书对此有专章论述。本文拟根据该书提供的线索,扼要介绍美国学者关于医学道德的主要观点(本文引语,均出自该书),以窥美国医学伦理学之研究概貌,以供国内研究医学道德时批判借鉴之用。(一)研究范围和一般原则蒂洛认为,医学道德实质上与这一问题有关,即如何确立和保持病员、病危者与健康人、医务人员之间的人命攸关的道德关系;以医学道德为研究对象的医学伦理学,不但要研究选择“治疗”手段的道德方式,而且要研究在交往关系中应如何“对待”病人。蒂洛具体列举了医学伦理学的研究所应包括的问题,对无可救药的垂死病人的治疗,停止治疗、听任病人死去(“听任死亡”),征得病人同意杀死病人(“仁慈赐死”),未得病人同意而杀死病人(“仁慈杀死”);对病人的行为控制,     

重视德性伦理的研究——杜治政医学美德伦理观浅析

杜治政教授是我国当代医学哲学尤其是医学伦理学学科的主要开拓者和奠基人。他直接而清晰地剖析了我国医学伦理学面临的现实危机和道德困境,提出培养医学道德要促进规范伦理与德性伦理的结合,更要高扬医学美德伦理。杜治政教授强调美德伦理首先是医生的美德,美德具有医学伦理学母德的性质,他的医学美德伦理观为我国当代医学道德发展奠定了基础,为解决当今临床实践中的种种现实伦理问题、建立和谐医患关系提供了重要借鉴和有益启示。     

必须守住医学伦理底线

1　医学伦理底线受到市场经济的冲击在医学界 ,医学伦理道德受到了来自市场经济的冲击。在经济利益的驱动下 ,医学道德在许多方面退守到了伦理底线 ,而伦理底线并未被有效守住。病人应当享受医疗权、知情权、不受伤害权、不被欺诈权和隐私权等。保护和实现病人的这些权利 ,是医学道德的伦理底线。这些医学伦理底线是不能被突破的 ,否则 ,医疗行为将完全被利益驱动 ,最终将远离医学目的 ,导致医疗行为与医学目的的背离。1 1　市场经济利益驱动使医学伦理底线受到冲击社会各方面在批评不良医德现象时 ,常常把矛头对准第一线的医生。其实 ,不…     

对医学道德价值的重新界定

我国医疗行业的医学道德教育效果一直欠佳,其原因与我们对医学道德本质的认识存在误区有关.我们应当承认道德的价值是在协调利益关系时维护公平互利性,在处理医患利益关系时也应当建立一种相互平等、公平互利的医德实践理念和机制.     

叙事医学助力医患共同决策

医患共同决策是理想的临床决策模式。它强调医患之间是一种合作伙伴关系,医生与患方之间应彼此交流,相互分享信息,双方同为决策主体,共同选择诊疗方案。但在现实环境下,医患面临诸多的决策困境。叙事医学让医生重视叙事的价值,并要求医生通过关注病人叙事来关注全人、见证病人的痛苦,与病人同在,最终与他们建立归属关系。叙事医学的临床实践有助于化解决策困境,对顺利实现医患共同决策有重要的作用,但需要不断在地化发展。     

论医学教育中的道德情感培育

随着现代医学模式的转变以及医学技术化、市场化的发展,道德情感的作用在医学教育和医疗实践中日渐式微,最终导致医学所倡导的仁爱精神被削弱、医生对病人同情感日趋弱化以及医学神圣性遭遇袪魅。基于医学"仁心仁术"的价值旨趣,道德情感所具有的超功利性、合同性、直接性等功能成为医学为人类谋福利所必不可少的内在精神动力。因此,在现代医学教育中,必须加大对医学生道德情感的培育,通过彰显医学的伦理抱负、开启医学生的伦理觉悟、提升医学生道德情感能力,把道德情感培育融入到医学教育的全过程。     

Conflit d’intérêts et déontologies : l’échec des déontologies existantes et l’improbable (?) succès de la loi

The increasing frequency with which health scandals have come to light since the 1980s has uncovered a great deal of unlawful behavior, both in the pharmaceutical industry and the medical profession, as well as in the world of “experts” (or researchers), along with journalists and specialist media companies. These types of behavior have accumulated and combined to inhibit any reaction from government, thus preventing health policy from playing its role. The State has its share of responsibility in this failure, for having been unable to conserve the impartiality and effectiveness of its administrative actions: it must acknowledge this, which is a whole other problem. However, in the case in point, it is obvious that those texts which must have been breached to allow these health scandals to occur are almost exclusively the result of professional self-regulation, with a wide range of diverse legal values: ethics for the health professions, journalistic ethics, charters between the pharmaceutical industry and media companies, alongside scientific ethical charters. These texts are the result of regulations generated by the professions themselves, drafted to counteract conflicts of interest. The sheer number of cases highlights the failure of these self-regulatory measures, leading to legislation targeting the problem, in particular that of December 29, 2011, which strengthened monitoring in terms of conflicts of interest and penalties against those placing themselves in a conflict of interest situation. Will this legislation, in direct response to the so-called Mediator^® case, be able to succeed where self-regulation failed, swept away as it was by financial considerations? The arbitrations that characterized the drafting of this legislation and the resulting complexity, which affects the decrees, seem to promise many difficulties, particularly due to the scarcity of resources the authorities have to enforce it.     

Medicine and pharmacy — facts and myths about the development of an innovative pharmaceutical industry in Poland

Innovation is fundamental to the pharmaceutical industry and a key to improvements in healthcare. Its effectiveness depends on huge, constant investments in research. This innovative industry directly affects the course of studies in healthcare and medicine. Its efforts translate directly into the length and quality of our lives. For several years now, the progress underway in pharmaceutical industry has produced measurable benefits. Doctors have new pharmaceuticals at their disposal, including many types of antibiotics and anti-viral drugs, vaccines and a wide range of drugs which save lives or make them more comfortable. In the near future, ever more efficient cures for neoplastic, rheumatic, neurological, psychic, metabolic, circulatory or respiratory diseases can be expected. Innovation is necessary. The human population is ageing, and the task of an innovative pharmaceutical industry is to keep it in a good condition. The use of innovative drugs can translate directly into lowering the costs of illness. A continuous reduction in spending on healthcare has been observed. The costs of inventing an innovative drug are enormous though (US$ 800 million), and studies on a new drug last between 10 and 13 years. An essential element in recovering the incurred costs and ensuring funds needed for new research is protection by patent. Innovative pharmaceutical companies in Poland are committed to increasing the competitiveness and sustaining the development of not only the market, but also the entire pharmaceutical sector. It is a group of companies of crucial importance to the Polish healthcare system, as it influences improvement in the quality of medical services. Through their investments and spending on research and development, innovative companies accelerate economic growth. In Poland, the innovative pharmaceutical industry is represented by the Association of Pharmaceutical Companies Representatives in Poland (SPFFwP). An earlier version of this paper was presented at an international conference, “The Ethics of Intellectual Property Rights and Patents,” held in Warsaw, Poland on 23–24 April, 2004.     

Casuistry in medical ethics: Rehabilitated,or repeat offender?

For a number of reasons, casuistry has come into vogue in medical ethics. Despite the frequency with which it is avowed, the application of casuistry to issues in medical ethics has been given virtually no systematic defense in the ethics literature. That may be for good reason, since a close examination reveals that casuistry delivers much less than its advocates suppose, and that it shares some of the same weaknesses as the principle-based methods it would hope to supplant.     

The Use of Narrative in Jewish Medical Ethics

Anne Jones has pointed out that over the last three decades, stories have been important to medical ethics in at least three ways: (1). Stories as cases for teaching principle-based medical ethics (2). Narratives for moral guides on what is considered living a good life (3). Stories as testimonials written by both patients and physicians. A pioneer in this effort, particularly in regard to using narratives as moral guides, has been the ethicist and philosopher Stanley Hauerwas. Heavily influenced by virtue ethics, Hauerwas believes that it is a person’s particular narrative tradition that provides one with convictions that form the basis of one’s morality. Befitting a Protestant theologian, he is particularly concerned with the Christian narrative. From a Jewish perspective, there has been much less written on the use of narrative in medical ethics. However, it is a mistake to think that narrative has little, if any, role in Rabbinic ethical decision making. The purpose of this article is to demonstrate the centrality of narrative in the thought of Orthodox Jewish decisors and the problems inherent in this methodology.     

Teaching Medical Law in Medical Education

Although the teaching of medical ethics and law in medical education is an old story that has been told many times in medical literature, recent studies show that medical students and physicians lack confidence when faced with ethical dilemmas and medico-legal issues. The adverse events rates and medical lawsuits are on the rise whereas many medical errors are mostly due to negligence or malpractices which are preventable. While it is true that many medical schools teach their students medical law and ethics, there are wide variations in what is being taught because there is no universally agreed syllabus. Yet the knowledge of medical law and ethics is closely relevant to the medical profession and that failure in abiding the law may result in serious civil or even criminal consequences. While this paper does not propose to lay detailed analysis of the relevant areas of law or ethics, it proposes to cover some legal areas so as to highlight and bring to attention the need for a medical law and ethics course. This article also considers the problems faced and recommendation as to future directions to be taken with respect to teaching medical law and ethics. It concludes with a suggested course outline for the teaching of medical law and ethics.     

Getting Beyond Form Filling: The Role of Institutional Governance in Human Research Ethics

It has become almost a truism to describe the interaction between research ethics committees and researchers as being marred by distrust and conflict. The ethical conduct of researchers is increasingly a matter of institutional concern because of the degree to which non-compliance with national standards can expose the entire institution to risk. This has transformed research ethics into what some have described as a research ethics industry. In an operational sense, there is considerable focus on modifying research behaviour through a combination of education and sanctions. The assessment of whether a researcher is ‘ethical’ is too often based on whether they submit their work for review by an ethics committee. However, is such an approach making a useful contribution to the actual ethical conduct of research and the protection of the interests of participants? Does a focus on ethical review minimise institutional risk? Instead it has been suggested that ethics committees may be distorting or frustrating useful research and are promoting a culture of either mindless rule following or frustrated resistance. An alternative governance approach is required. There is a need for a strong institutional focus on promoting and supporting the reflective practice of researchers through every stage of their work. By situating research ethics within the broader framework of institutional governance, this paper suggests it is possible to establish arrangements that actually facilitate excellent and ethical research.     

药品回扣引起的伦理学思考

药品回扣是市场经济冲击医疗服务产生的赘疣,成为社会关注的焦点。通过伦理的视角审视这一现象,认为药品回扣严重腐蚀了医生的精神灵魂,加剧了医患矛盾,增加了医患纠纷,造成医患之间的信用缺失,破坏了公平合理的医学伦理学原则,应对此严加治理,保障患者的正当权益。     

Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care

Although the medical profession's codes of ethics have rightly been criticized for having claimed authority to decide questions of medical ethics for society, codes continue to provide crucial guidance to the individual clinician in matters of ethics. Examination of the code of the American Psychiatric Association (APA) shows that while it emphasizes the psychiatrist's fiduciary responsibility to individual patients, it ignores the crucial dimension of stewardship responsibilities to society. As a result, the ethical pronouncements of the APA have thus far been of little use to clinicians with regard to the major issues posed by managed care. In contrast, the code of the National Association of Social Workers considers the ethics of social institutions as well as those of individual practitioners, and advises clinicians on how to manage the inevitable and legitimate tensions between fiduciary and stewardship commitments. Until the APA extends the scope of its ethical vision, it will not be able to help clinicians struggle constructively with the question of how it is possible to "care about patients" and "care about money."     

The hyperreality of clinical ethics: A unitary theory and hermeneutics

Medical ethics nowadays is dominated by a conception of ethics as the application of moral theories and principles. This conception is criticized for its depreciation of the internal morality of medical practice and its narrow view of external morality. This view reflects both a lack of interest in the empirical realities of medicine and a neglect of the socio-cultural value-contexts of medical ethical issues, including the creative development of a broader philosophical framework for a practicable medical ethics. Several alternative approaches and conceptions have been proposed. The unified clinical ethics theory, developed by Graber and Thomasma, is an interesting attempt to synthesize these alternative approaches. It correctly identifies as the crucial problem the present disconnectedness of medical ethics from theoretical philosophy as well as the practice of medicine. In this paper, however, it is argued that the unitary theory should take more serious attention to the hermeneutic character of medicine as well as ethics. This implies that the unitary theory must in fact transform itself into aninterpretive clinical ethics theory. The theoretical characteristics and practical consequences of an interpretive theory of medical ethics are discussed in the present paper.