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1、Informed Consent and Truth-telling: Changing Realities and Present Challenges,醫生、病人關係的世界性轉變：病人私隱有否限制？,譚傑志教授JOSEPH THAM, MD, PHDSchool of Bioethics, Regina Apostolorum, Rome, Italy,Outline 概要,Truth telling and Informed Consent Historical Background Principlism, Autonomy Multiculturalism Implications
2、for China Advance Directives,病情告知和知情同意 历史背景 原则主义，自主权 多文化主 在中国的应用 預設醫療指示(遺囑),Case: I can put the medicine in his soup, Doctor!“ 案例: “医生，我能把药放进他的汤里让他喝!,J G W S Wong, Y Poon and E C Hui, “I can put the medicine in his soup, Doctor!” Journal of Medical Ethics 2005; 31:262-265. A young man with schizophr
3、enia. His mother had been giving him antipsychotic medication covertly in his soup. Should the doctor continue to provide a prescription, thus allowing this to continue? Truth telling and the balance between individual versus family autonomy.,一个还有精神分裂症的年轻患者 患者母亲长期将安定药物放进患者所食用的汤里 在这种情况下，医生应该继续给患者家属开具
4、处方吗？应该允许此类情况继续发生吗？ 告知真相以及在个人和家庭自主权之间的平衡,4,Case:,65 y.o. Mexican woman, immigrant dx with aggressive late stage ovarian cancer. Poor prognosis. Her family explicitly told MDs that she would not want to hear any bad news. It may cause too much trauma What should the MD do in this case?,Historical Back
5、ground历史背景,Modern Medicine Curing and treatment options Better diagnosis, prognosis Paternalism to Patients rights Appearance of Bioethics Cultural changes in 1960s Scandals and abuses became public Rights movements, distrust with authority figures Legal cases,现代医学 多种处理和治疗方式的选择 更好的诊断及预后 家长式作风对患者权利的影
6、响 生命伦理学的出现 在1960s年代出现的文化改革 医学丑闻和陋习公开化 权利运动，对权威人士的不信任 诉讼案件,6,A bit of history,Abuses Patients rights to know Legal challenges Ethics comes before the law? Protect the patients or protect MDs,濫用 患者的知情權 法律上的挑戰 倫理置於法律面前？ 保障病人或保護醫生?,Principlism 原则主义,Product of modern philosophy 现代哲学的产物 Analytic philosoph
7、y 分析性哲学 Normative ethics 规范伦理 National Commission for the Protection of Human Subjects 1974-1978 Abuses 滥用 National Research Act 1974: 12 commissioners to identify ethical principles (Engelhardts sin of his youth) Belmont Report 1978 Principles 原则 Respect for persons 对人的尊重informed consent 知情同意 Benef
8、icence行善原则risk-benefit ratio 风险-利益比 Justice 公平 subject selection 受试者选择 Quasi-official status 似乎获得官方正式的地位,Principlism 原则主义,Beauchamp and Childress: Principles of Biomedical Ethics Autonomy, beneficence, nonmaleficence, justice Prima facie principles Popularity and practicability: clinics, public poli
9、cy, doctor-patient relationship Presumes common morality Intuitionism or emotivism,Beauchamp 和 Childress: 生命医学伦理学原则 自主权，行善，不作恶，公平 初次印象原则 普及性和实用性：临床，公共卫生政策，医患关系 假定拥有共同的道德标准 直觉主义，动感情主义,Challenges to Principlism原则主义面临的挑战,Tyranny of autonomy Trumping all other principles No consensus Law (Patient Self-d
10、etermination Act 1990) Anti-paternalism, anti-authority Individualism Inadequate: not all choices are good,自主权的 “独断专行” 以其他所有原则为幌子 无法达成一致意见 法律 (患者自主决策法案 Patient Self-determination Act 1990) 反家长主义，反权威主义 个人主义 不足之处：并不是所有的选择都是有好处的,Challenges to Principlism原则主义面临的挑战,Autonomy and informed consent Signing a
11、 paper Reasonable and prudent person standard. Patients right NOT to know? Autonomy and truth-telling Never lie to patient. Truth could never be harmful? Autonomy and family decisions Ambiguity of 4 principles and their secularized context,自主权与知情同意 签署某种文件 合适而谨慎的个人标准 患者拥有“不知情”的权利吗? 自主权与告知真相 永远不向患者撒谎
12、难道真相永远都不会造成伤害吗? 自主权与家庭决策 4项原则的模糊表述以及各自的俗世语境,Challenges to Principlism原则主义面临的挑战,Principlism Neo-casuistry Consensus ethics Engelhardts content-less consensus ethics Contextual ethics Pragmatic ethics Utilitarian ethics Liberalism and nihilism,原则主义 新诡辩论 共识伦理学 Engelhardt 無內容的共识伦理学 背景性伦理学 实用主义伦理学 功利主义伦理
13、学 自由主义和虚无主义,Challenges to Principlism原则主义面临的挑战,Controversial Inhuman and unrealistic Ignores the fact hat the person is not just an isolated individual, but has ties to family, friends, religion, society. Immigrants and multurculturalism: importance of family in healthcare decision-making,富有争议的 不人道而
14、且不现实 忽略了人不是一个孤立的个体，而是与家庭、朋友、宗教、以及社会等紧密相连这一事实。 移民和多文化主义:家庭在医疗决策中的重要性,13,Autonomy,Autonomy = self-determination No more “paternalism” Tyranny of autonomy? Must MD do everything patients request? Eg. female circumcision, etc.,自治=自決 沒有更多的“家長式“ 自主權暴的政？ 醫師必須盡一切病人要求？例如。女性割禮等,14,Challenges,Becomes a piece o
15、f paper How much information is needed? Can informed consent be truly informed?,變成了一張紙 需要多少信息？ 知情同意是真正可以告知情況？,Relational Self 關係性自我,The enhanced patient autonomy approach requires the inclusion of family members in the decision making process. (Surbone, 2006) Patient autonomy = complex concept refer
16、ring to both ones capacity to choose and to ones ability to implement ones choices,得到提升的患者的自主权需要将家庭成员纳入到决策制定过程中来 (Surbone, 2006) 患者的自主权 = 与个人的选择能力以及执行个人选择的能力相关的复杂概念,16,New paradigm,Autonomy as individual self vs relational self Family, other members, etc. Decision making Truth telling Breaking bad news Placebo,自治 = 個人自我還是關係自我 家庭其他成員等 決策 病情告知 壞消息 安慰劑,17,New Paradigm,Do patients want to know bad news? Fear from MD patient Not to let hope die? Deception to maintain hope? When to tell, how to tell (
