世界医学会《国际医学伦理准则》的诞生与发展：一项历史的回顾

《国际医学伦理准则》是世界医学会代表性伦理规范之一。世界医学会成立于第二次世界大战结束之际,是国际重要的医学专业组织,致力于制定体系化的伦理规范对个体医生提供道德指导,也对世界各国医学会、政府和国际组织提供帮助。《国际医学伦理准则》于1949年诞生,70余年来历经4次修订不断完善,2022年最新修订版做出了重要调整,中国参与了最近一次修订工作。历史性地分析《国际医学伦理准则》,有助于进一步理解当代医学职业精神的特征,深入认识世界医学会的伦理治理体系,也对推进中国医学伦理学规范建设有借鉴性意义。

     

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。     

2000年～2009年《医学与哲学》(人文社会医学版)内容分析

对2000年-2009年<医学与哲学(人文社会医学版)>刊发的论文进行内容分析,将论文分为医学伦理学、医学哲学和医学人文学等19个大类,分别统计了各分类下的论文数量情况.并对论文的关键词著录情况进行统计分析,统计内容包括10年间刊发论文的关键词数量分布和高频关键词数量.     

《医学与哲学》临床决策论坛版2011年主要栏目选题

临床决策研究如何预防（或减少）医疗差错;预防医疗差错的机制;医疗差错监控体系的建立医学整合：临床专业科室应以“内外科”划分还是以“系统器官疾病”划分？疾病诊治的多学科协作模式;临床学科整合的形式与途径     

更高的伦理标准与更多的利益冲突——《赫尔辛基宣言》008年的修订

2008年,世界医学会大会通过了<赫尔辛基宣言>的最新修订.2008年版的宣言在安慰剂的使用、实验后利益的分配和研究结果发表等3个条款的修订中不但没有放弃过去的立场,而且提出了更严格的要求,进一步加强了对受试的保护,从而坚持了更高的伦理标准.也正因为如此,此次修订后也在医学研究的各方中产生了更多的利益冲突.     

Conflict of interest issues in informed consent for research on human subjects: a South Asian perspective

Health research for progress in the control and conquest of disease afflicting man is unquestionable. Concerns arise when motives other than the advancement of scientific knowledge and benefit for individuals and society are the driving force behind clinical trials. These conflicts of interests become even more pronounced when dealing with populations rendered vulnerable by virtue of poverty and ignorance. South Asia with its teeming millions represents one such region. This essay examines the reasons that make this population vulnerable to exploitation. Informed consent in the process of research is an area where such conflicts are prone to arise. In order to ensure that conflicting interests of researchers and funding agencies are kept in check, the processes of informed consent and ethical review of research need to be strengthened. Suggestions are put forward to modify the consent process to match the needs of South Asia and to strengthen the ethical review process for safeguarding the rights of the study subjects. But perhaps the most important safeguard against exploitation is the virtuous researcher himself with noble intentions. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002.     

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。     

The Professional Autonomy of the Medical Doctor in Italy

This contribution deals with the issue of the professional autonomy ofthe medical doctor. Worldwide, the physician's autonomy is guaranteedand limited, first of all, by Codes of Medical Ethics. InItaly, the latest version of the national Code of MedicalEthics (Code 1998) was published in 1998 by the Federation ofprovincial Medical Associations (FnomCeO). The Code 1998acknowledges the physician's autonomy regarding the scheduling, thechoice and application of diagnostic and therapeutic means, within theprinciples of professional responsibility. This responsibility has tomake reference to the following fundamental ethical principles:(1) the protection of human life; (2) the protection of thephysical and psychological health of the human being; (3) therelief from pain; (4) the respect for the freedom and the dignityof the human person, without discrimination; (5) an up-to-datescientific qualification (Art. 5). The authors underline that autonomyis an anthropological – and consequently ethical –characteristic of the human person. Different positions on autonomy inbioethics (individualistic, evolutionistic, utilitarian andpersonalistic models) are explained. The relation between theprofessional autonomy of the physician and the autonomy of the patientand of colleagues is discussed. In fact, the medical doctor isobliged: (1) to respect the fundamental rights of the person,first of all his/her life; (2) to ensure the continuity of thecare, even if he can only relieve the patient's suffering; (3) tomaintain, except under certain circumstances, professional secrecy andconfidentiality regarding patients and their medical records. Moreover,the physician cannot deny the patient correct and appropriateinformation. He/she should not perform any diagnostic or therapeuticactivity without the informed consent of the patient and the medicaldoctor must give up medical treatment in case of documented refusal ofthe individual. Furthermore, the medical doctor has the right to raiseconscientious objections if he/she is requested to perform medicalactions that are contrary to his/her conscience or medical opinion,unless this attitude would seriously and immediately harm the patient.Regarding the relationships with colleagues, the physician is obliged tosolidarity, mutual respect, and care of sick colleagues. Finally, theauthors discuss the Italian legislation affecting the physician'sprofessional autonomy: (1) the SSN health care Acts; (2) theso-called Charter for Public Health Care Services; (3) the Acts onprivacy; (4) Good Clinical Practice.     

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。     

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。

     

The Peace Work and Witness of the Churches in the German Democratic Republic and the World Disorder of the 21st Century

This article is an edited translation of an address given in Erfurt, Germany, on 12 May 2019, to celebrate the 90th birthday of Heino Falcke, dean (provost) of Erfurt from 1973 until his retirement in 1994. Falcke, who was also a member of the working group on Church and Society of the World Council of Churches, played a central role in developing the theological and ethical response of Protestant churches in the German Democratic Republic (GDR) to the threats to peace in a nuclear age. This was expressed in the “renunciation of the spirt, logic, and practice of deterrence.” This article seeks to set out the insights from the peace work and witness of the churches in the GDR against the background of the “world disorder of the 21st century.”     

医疗机构口头告知不宜扩大

口头告知界定的不明确给医疗机构及其医务人员带来了困扰。知情同意和告知义务虽被越来越多的医疗机构和公众关注,但对于告知方式并没有过多的注意,医疗机构因为口头告知导致损害赔偿的案件也不鲜见。本文探讨了医疗告知含义、医疗告知的多种方式,通过口头告知的利与弊来提出口头告知不宜过于扩大化。     

浅论医患关系中的权利冲突——以医师的诊疗权与患者的知情同意权为例

现实中医患关系呈现给人们的似乎是永远纠缠不清的利益,掩盖了医惠之间模糊的、缺失的权利。实质上引发医患矛盾的主要原因不是利益而是权利的冲突,从医师的诊疗权与患者的知情同意权的角度出发,分析了医患关系中权利冲突的成因及其表现,提出了相关解决的方法。     

紧急救治规则研究

现行法律规定之下的紧急救治规则缺失调和患者生命权、健康权与知情同意权冲突的机制,对紧急情况的判定标准也不一,“不能取得患者近亲属意见”的解释依旧不明。此外,也没有相应机制保障紧急救治情形下的医疗欠费问题。为了完善紧急救治规则,有必要建立事先医疗指令制度,并以“不利因素比较说”为标准判定紧急情况,进一步再明确“不能取得患者近亲属意见”的具体内容。再者,为了有效解决紧急救治情形下的医疗欠费问题,提高医务人员因承担患者所欠医疗费用而降低的救治积极性,有必要建立征信机制和保险机制。