医疗技术评估与决策中风险−获益分析方法的伦理反思

将经济学领域常用的风险−获益分析方法应用在医疗技术领域,为医疗技术评估与决策提供借鉴和指导。然而,从伦理学角度对这一方法进行审视,会发现存在诸多难以定义和应对的困境。按照其属性划分,这些困境大致可以划分为风险−获益分析本身的伦理问题和根据风险−获益分析作出决策所产生的伦理问题两条脉络。对于风险−获益分析中伦理问题的探讨并不是为了束缚医疗技术的应用,而是着眼于技术长期发展与更好地服务人类的目的,尊重人之为人的价值和人与人的平等。

     

智能医学算法决策的伦理困境及风险规制

智能医学呈现出难追溯性、不公平性、过程难以理解性、结果不确定性和数据驱动性的技术特征。上述特征与诊疗场景特性的融合交叠可能诱发医生主体地位被削弱、医患信任危机、医疗资源分配不均加剧以及诊疗结果不确定性增加等风险。为有效防范智能算法的决策风险,在智能医学应用中必须遵循以强化医生主体地位为根本出发点,以降低医患信任危机为主导,以平衡资源分配为方向和以增加诊疗结果确定性为目标的伦理规制。

     

医患共同决策实施现状及策略探析

选取广州地区6家医院共415名患者进行医疗决策参与情况调查。结果发现,60.72%的样本人群认为应以合作形式进行临床决策,且能辩证理性处理医疗决策冲突问题;在医疗实践中,患者个体感知医疗决策参与程度总体较好;多数患者更倾向医患+家属的决策模式,且不同学历患者和不同婚姻情况患者对医疗决策模式的偏好具有统计学差异。推进医患共同决策应厘清医生在共同决策中的角色定位、建构良好的医患互信关系、强化医生共情能力弥合医患差异、重视“家属参与”的重要价值。

     

医患共同决策的具象问题思考——以肺结节诊疗为例

随着健康体检观念的深入及低剂量CT的广泛开展,肺结节的检出率大大提高,而对于其诊断及治疗方案的选择则具有较多的争议,过度诊疗或重视不足都会对患者造成伤害,如何做到正确的诊治从而保证患者的权益,患者的参与及接受程度显得十分重要,医患共同决策(shared decision making,SDM)这一方式在肺结节诊疗过程中的作用不言而喻。通过相关案例初步探索SDM在肺结节诊疗过程中的应用及效果,从而为临床医生及肺结节患者在诊疗过程中提供一种新的思路,也期望这种模式能够得到医患双方的共同认可,减少临床决策中的医患冲突,取得更佳的治疗方案。     

社会价值取向对自我-他人风险决策的影响及其机制

以往关于为自己和代他人决策的冒险行为研究结果不一致,这可能是因为以往的研究没有考虑决策情境和决策者人际特质等因素对于决策行为的影响。社会价值取向(social value orientation, SVO)是一种典型的人际特质,是个体在对自我和他人资源分配时所表现出的社会偏好,通常分为亲社会者和亲自我者。为探究SVO对自我-他人风险决策的影响及其机制,采用为自己和陌生人分别完成多轮混合赌博游戏的任务。结果发现亲自我比亲社会者代他人决策更冒险。用模型量化的损失厌恶和对潜在损失的敏感度部分中介了自我-他人风险决策差异,但只有对他人潜在损失的敏感度部分中介自我-他人决策的SVO效应。说明SVO会影响自我-他人风险决策,且该效应可以通过对他人利益的关心程度起作用,所以在自我-他人风险决策的研究中应将SVO这一决策者的人际特质因素考虑在内。     

The Impact of Depression on Self–Other Discrepancies in Decision Making

Although there is a small but growing body of literature on how people make risky decisions for others and predict others' decisions, results seem to be contradictory. The authors contribute to the understanding of these mixed results by investigating how depression affects self–other discrepancies in decision making and the psychological processes that underlie these discrepancies. In an experiment, depressed and nondepressed individuals read a series of scenarios involving decisions about health, money, and interpersonal relationships. They then indicated which of two options they would choose for themselves or for another person, or predicted which option this person would choose for himself or herself. Finally, participants reported benefits and drawbacks of the decisions (i.e., cognitions) and feelings about risk. Depressed individuals were less prone to bias when they predicted others' decisions than nondepressed individuals. Feelings about risk played a key role in determining the direction and the magnitude of this bias. In contrast, both depressed and nondepressed individuals showed bias when they made decisions for others. This bias affected their decisions in opposing ways and was determined by cognitions. This bias is consistent with literature showing that depression is associated with an increased sensitivity to social risks. The authors provide a theoretical explanation of self–other discrepancies in decision making in depressed and nondepressed individuals and conclude that the results support the assumption that depression is associated with psychological processes whose role is to increase sensitivity to social threats rather than with a more general negative bias in cognitive functioning. Copyright © 2014 John Wiley & Sons, Ltd.     

不确定情境中的决策心理——适应与认知

不确定情境中的决策问题广受经济学家和心理学家关注,但他们对人的决策行为有不同的解释。该简要回顾了经济学和心理学视野中的决策理论,包括预期效用理论、主观预期效用理论和前景理论。主要介绍了“生态理性”观对人的决策心理的研究,着重介绍了研究发现的几种启发式策略,如“一个理由策略”,并探讨了他们在人适应过程中的作用。中最后分析了决策问题的研究现状。     

判断与决策中的锚定效应

versky和Kahneman提出锚定与调整启发式以来,锚定效应在不同领域判断与决策研究中得到广泛验证,提出了不同类型的锚定效应、多种研究范式、心理机制的不同理论观点,以及锚定效应作为有关心理现象的内在作用机制。文章阐述了锚定效应的最新研究进展,提出应深化对锚的种类和形态研究,以丰富的技术手段发展锚定效应神经心理机制研究,系统地进行锚定效应影响因素研究,深入探讨锚定现象对人的心理与行为的正负面影响以及锚定效应与其他有关心理现象间的关系     

风险情景中参照点与管理者认知特征

采用问卷测量的方法探讨风险情景以及个性特征对个体风险倾向的影响。结果显示：(1)成就动机的两个成分,即争取成功与回避失败能够分别预测个体在风险情景中的风险倾向与认知特征;争取成功动机对预测个体机会认知更敏感,而回避失败动机对预测威胁认知更有效。(2)回避失败动机是区分个体风险倾向的关键变量,个体在风险情景中的风险倾向取决于个体回避失败动机的强弱。(3)实验证实了当以“成功”为参照点时,回避失败倾向低的个体,在获益情景中更冒险而在损失情景中更保守;相反,回避失败倾向高的个体,在损失情景中更冒险而在获益情景中更保守。研究表明,结合人格和情景两类变量探讨个体风险倾向的反应模式能够更准确地描述个体行为倾向及其认知特征。这一结论提供了一个可能的思路来解释P理论与刻板模式之间的争执。另外,企业与学生样本在数据的总体趋势上存在相当多的一致性,但在细节上仍然存在差异,因此以学生样本数据进行推论时须要特别谨慎。     

The effectiveness of sources of support in career decision-making: A two-year follow-up

Making career decisions is often difficult and challenging, and one way to advance in the process is to seek help. The present research focused on the various sources of support young adults tend to look for when making their career decision and the factors that affect their actual use of these sources. Study 1 elicited the self-reported help-seeking behavior and the Career Decision-Making Profile (CDMP) from 1071 young adults (ages 18–35) who had already chosen their major(s) at a university. The young adults used sources that were easily accessible, even when they were perceived as being less effective. Additionally, those with less career decision-making adaptability, as derived from the CDMP, tended to seek help more often. Study 2, a two-year follow-up of 296 young adults who participated in Study 1, revealed that getting help reduced the likelihood of changing one’s major.