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。

     

麻醉科医患沟通现状及认知分析一一我国45家医院联合调查报告——

2017年8月1日~9月30日,在全国45家医院进行了电子问卷调查,旨在从医方角度调研麻醉科医患关系的现状。结果显示在导致医患沟通不畅的原因中除客观因素(病情复杂及疗效不确定)之外,麻醉科医务人员对患者防备心理过重位列首位(37.8%),其次为沟通时间不够(33.4%)、沟通意识缺乏(29.2%)以及沟通能力不足(28.3%),由此可见如今麻醉科医患沟通问题比较突出。建议麻醉科医生通过转变医疗观念,强化沟通意识;掌握语言工具,提高沟通技能;积极向患者科普麻醉学科的进展和局限等综合措施,逐渐改善麻醉科医患沟通现状。

     

医学伦理学发展新阶段的历史使命

每个时代都有每个时代伦理学的主轴。当今医学伦理学面临崭新的境遇,资本、技术、权力和全民健康等问题,已经构成医学伦理学应对和挑战的主要课题。新形势向医学伦理学提出了种种新任务,探索完成这些新任务的政策建议和伦理举措;适应新形势医学伦理学如何加强自身理念的充实、创新和提高;在新情境下如何促进医学伦理学在医学领域内的全面覆盖,让医学伦理学在医学中深深扎根,促进医学技术更好地服务于人民大众的健康,都是开启医学伦理学新征程面临的担当。

     

从伦理辩护到国家权力、个人权利界限的划定——公共卫生领域特殊伦理冲突的和解之道

在流行病防控等公共卫生工作中,为了维护公共健康不得不侵犯传染病患者的个人权利,这是公共卫生领域不同于临床医学的特殊伦理冲突。虽然有学者分别依据“效果论”、“差异原则”和“公共善优先”为公共健康的优先性进行了辩护,但都不能与医学伦理学的个体论视角相融洽。实际上,固守单一的理论视角是伦理冲突和解的最大障碍,只有改变单一视角,才能开启理论的兼容性。伦理辩护必须转化为实践智慧,即必须在公共卫生实践中实现国家权力与个人权利的有序协调,使国家权力和个人权利坚守各自的界限。     

患者的诊治期望值与医患矛盾的关系研究

从患者视角来探索医患矛盾发生的原因,寻找一种有效的医患沟通方法。研究认为医患矛盾的核心问题是患者对诊治期望值的不满意,通过构建以患者诊治期望值为主体的医患沟通方法,发现医生和患者之间对诊治期望值存在明显差异。医生通过对医患之间存在的差异性诊治期望值进行充分沟通,形成医患诊治期望值差异下的共识,建立互信合作的关系,最终实现医患互惠共赢。以患者诊治期望值为主体的医患沟通方法,为避免医患矛盾发生,促进和谐医患关系提供一种新的思路。

     

医患冲突与诚信的缺失

在新的历史条件下,医患冲突表现出更为复杂的特点,从深层次研究医患冲突的原因,诚信的缺失往往被人们所忽视。多数医疗纠纷源于医患双方缺乏诚信,以自我为中心,过分强调经济利益,缺少人文关怀。必须加强诚信道德教育,建立健全信用法律制度,使诚实守信成为人人自我约束、自觉遵守的行为规范。     

Religion and Civic Purpose in Sophocles's Philoctetes

Why should citizens participate in civic endeavors they oppose? In the Philoctetes , Sophocles dramatizes the actions of three interlocutors who struggle for answers to an intractable personal and political conflict amid an existential civic crisis. The characters try several methods to resolve the impasse, specifically deceit, sympathy and appeals to duty. Ultimately, civic religion succeeds in creating unity where other methods of resolution fail. The civic religion framework in the Philoctetes can be seen as Sophocles's statement that resolution of the most extreme political conflicts can be obtained through a combination of piety and reason that respects foundational civic doctrines transcending politics. In this way, civic religion serves to unify political communities divided by self‐interest, intolerance, and desire for revenge while preserving self‐determination and the dignity of free will.     

Parenting among mothers exposed to ongoing military conflict in childhood: An exploratory study

Mothers living in areas exposed to ongoing military conflict are at higher risk for psychological difficulties, such as posttraumatic stress disorder, than those not living in such areas. The aim of this two-part exploratory study was twofold. The first aim was to examine differences between mothers who grew up under ongoing military conflict in childhood and mothers who did not grow up in affected areas in terms of their levels of differentiation of self and parental self-efficacy (PSE). The second aim was to identify and describe the parenting experiences of mothers who were exposed to military conflict in childhood. In Part 1 of the study, the sample included 120 mothers (half of whom reported on being exposed to ongoing military conflict in childhood). Findings showed that mothers exposed to ongoing military conflict in childhood reported lower levels of differentiation of self and PSE than their counterparts. In Part 2, 10 mothers who were exposed to ongoing military conflict as children were interviewed about their experience as parents and their PSE. Results indicated that the mothers felt their childhood experiences affected their parenting and PSE negatively, resulting in anxiety, difficulty dealing with stress and sometimes posttraumatic symptoms as well as parental patterns of overprotectiveness, separation anxiety and intergenerational transmission of anxiety. The results highlight the consequences of exposure to ongoing military conflict during childhood on levels of differentiation of self and parenting practices.     

Physiological,affective, and behavioral responses to interpersonal conflict among males from families with different levels of cohesion and adaptability

To examine the relation between characteristics of a person's family of origin and cardiovascular, behavioral, cognitive, and affective response to interpersonal conflict, responses of 15 young males from families rated as extreme (EXT) on scales of cohesion (enmeshed or disengaged) or adaptability (chaotic or rigid) were compared to those of 25 young males from families rated as balanced (BAL) on measures of cohesion and adaptability. Subjects participated in two interpersonal role-play conflict situations, one with a male confederate and the other with a female confederate. Measures of heart rate (HR), blood pressure, and indices of both positive and negative verbal and nonverbal behaviors were obtained during each scenario and self-reported measures of positive and negative cognitive self-statements and affective response were obtained following each conflict scene. Results showed that, in contrast to BAL males, EXT males exhibited more negative verbal and nonverbal behavior, less positive nonverbal behavior, higher ratings of state anxiousness during conflict, and higher HR responses during the interaction with the male confederate than the female confederate. These findings suggest that exposure to a family environment with extreme levels of cohesion and adaptability impacts how an individual responds to interpersonal conflict in young adulthood.     

A developmental perspective on psychotherapy process, psychotherapists' expertise, and “Meaning-Making Conflict” within therapeutic relationships: A two-part series

Part I (in this issue)—A Dialectical-Constructivist View of Human Development, Psychotherapy, and the Dynamics of Meaning-Making Conflict Within Therapeutic Relationships— reviews a dialectical-constructivist model of human development and articulates, in the language of that model, how psychotherapy, in general, works. It describes and illustrates three generic processes, which contribute to the frequent successes of an extremely diverse range of psychotherapy theories and practices. This view of psychotherapy focuses on both the client's meaning-making processes and the therapist's meaning-making processes and how they contribute together to effective psychotherapy. Part I also offers a way of understanding what is going on when therapeutic progress is blocked by conflict between the client's and the therapist's meaning-making processes. Part II—Dialectical Thinking and Psychotherapeutic Expertise: Implications for Training Psychotherapists and Protecting Clients from Theoretical Abuse—explores those experiences in which the therapist's own exercise of his or her meaning-making structures, and maintenance of the integrity of his or her theories, has a limiting or destructive impact on the value of therapy to the client. It considers the concept of “theoretical abuse” by psychotherapists as a way of characterizing the most destructive of these experiences. This serves as a rhetorical device for introducing comparisons between these phenomena and the phenomena of sexual abuse by psychotherapists, in terms of dynamics, prevalence, and appropriate strategies for prevention. Part II uses work on the development of dialectical thinking in adulthood to conceptualize how different understandings of the nature of psychotherapists' expertise increase or decrease the likelihood and severity of “theoretical abuse”. Finally, it derives implications for training psychologists and other psychotherapy professionals.