Transcript 價值觀與醫患關係
Slide 1
Ethical Issues in Public Health Care
公共醫療的倫理課題
Dr Derrick Au
Chairman,
the Hong Kong Bioethics Association
Vice-chairman,
Hospital Authority Clinical Ethics Committee
EDB seminar 15.1.2014
1
Slide 2
公共醫療服務 vs.公共衛生
公共衛生 (public health)
公共醫療服務 (public healthcare)
人口 vs. 個人
政策 vs. 服務
例子
2
Slide 3
今天的演講
醫學倫理的關注
在公共醫療服務的倫理課題
決策：怎樣的決定才是「對」的？
醫患關係
個案：在公眾領域曾被報道的事件
3
Slide 4
醫學倫理關注的課題 (部分)
醫患關係中的權利與責任
治療與放棄治療的決定
兩難的醫療決定 (medical dilemma)
與醫療科技有關的倫理問題
稀有醫療資源的分配問題 (allocation of
scarce resources)
4
Slide 5
醫學倫理的原則
尊重(個體)自主 (Respect of Autonomy)
為善 (Beneficence - to do good)
毋損害 (Nonmaleficence – do no harm)
公義、公正 (Justice)
基本原則可供相對客觀的分析和討論，避免
主觀主義和相對主義
5
Slide 6
Public healthcare (公共醫療)
不單照顧個別病人，更須向人群的需要
(population needs)負責。
善用有限的資源
非牟利
有公共衛生的角色
一般性的公共機構的法律與倫理責任
6
Slide 7
處理複雜的具體個案 (臨床)
臨床醫學的指示
病人的意願
(science and
knowledge)
(autonomy and
personal values)
生命質量的考慮
具體處境
(psychological,
Socio-cultural)
(case circumstances,
special considerations)
Adapted from: Sliwa JA et al. Am J of PM&R, Vol 81(9), Sep 2002, pp 708-717. (ADAPTED)
7
Slide 8
怎樣分析個案
有沒有「倫理」問題？(道德上的「應否」的
問題)？
有沒有法例的規定？有沒有適用的機構指引
？
有關個案的已知事實是什麼？有沒有欠缺什
麼資料？
專業的觀點 vs.市民/病人的觀點
醫生的觀點 vs.醫療管理決策的觀點
基本倫理原則如何應用於具體個案？
8
Slide 9
個案一：「愛滋醫生」之死
愛滋醫生墮樓兩月才公佈生前手術千宗 周一嶽：
暫毋須追蹤 2012年3月18日
「愛滋醫生」140病人須驗血 2012年3月27日
「東區醫院一名三十多歲的外科醫生於一月中在寓所墜樓
身亡，其後被證實生前是愛滋病帶菌者，醫院管理局隨即
通知衞生署展開調查，商討跟進工作。愛滋病與醫護人員
專家組主席林大慶教授昨在會議後宣布，將於首階段先為
一百四十名病人進行快速病毒測試及輔導，其後再商討是
否需要進一步擴大跟進範圍。」
9
Slide 10
個案的問題
公眾的「知情權」
個人私隱
衛生署專家組對追踪病人與否的建議
有關個案的已知事實是什麼？有沒有欠缺什
麼資料？
醫學的證據
10
Slide 11
個案二：「13價」疫苗風波
不建議打針卻資助 專家小組矛盾
資助補打
民意大還是科學大？
11
Slide 12
「13價」疫苗的補種問題
7價、10價、13價，還有沒有其他
有沒有效？有效多久 (效益問題effectiveness)
補種疫苗是否需要？
相對風險(relative risk)與絕對風險(absolute risk)
的概念
醫學證據有多清楚？
是否應用公帑資助補種疫苗？(成本效益問題costeffectiveness)
行政/政治決定應否凌架醫學/倫理考慮
12
Slide 13
個案三：罕見疾病的昂貴治療
13
Slide 14
罕見疾病的昂貴治療
兩個患有罕見的遺傳性新陳代謝疾病Pompe
Disease的兄弟在 2010年要求試用一種新面世
的酵素替代藥物，這種藥物未被列入醫管局的「
藥物名冊」(HA Formulary)
考慮因素：
效益、成本效益(cost-effectiveness)、邊際效益
(marginal benefit) 概念
對其他病類病人的公平性
醫學證據 vs. 恩恤考慮
政治/社會角度
藥廠的角色
14
Slide 15
個案四：醫療資源的地區分配
將軍澳產房「難產」(20-10-2002)
15
Slide 16
醫療資源的地區分配
跨區就診問題
醫療設施的分佈與規劃
醫療人手的分配
輪候問題
病人的選擇
16
Slide 17
Ethical Issues in Public Health Care
公共醫療的倫理課題
第二部分
醫患關係：
不同價值觀衍生的不同倫理觀點
EBU seminar 15.1.2014)
17
Slide 18
第一部分涉及的倫理原則和考慮元素
病人利益 (patient’s benefit)
病人權利 (patient’s right)
個人自主 (autonomy)
公眾利益 (public interest)
醫學證據 (scientific evidence)
治療效用 (effectiveness)與成本效益 (costeffectiveness)
專業責任(professional accountability)與機構
責任(organisational accountability)
18
Slide 19
第二部分：價值觀與醫患關係
醫患關係(doctor-patient relationship)
其他持分者 (stakeholders)
價值觀與醫患關係
「病人自主」觀點
「專業主導」觀點
「以病人為中心」
「觀點與角度」？
19
Slide 20
良好的醫患關係
一般指醫生與病人的關係(doctor-patient
relationship) ；現代醫療中亦可包含其他
醫護人員。在公共醫療，臨床服務常以團隊
(clinical team)方式操作。
何謂良好的醫患關係可受價值觀的影響。在
現代醫療，有時亦須要考慮其他持分者(例如
親屬)
20
Slide 21
價值觀與醫患關係：「專業(重新)
主導」
General Practitioner in Glasgow
BMJ Columnist
Blogger: Bad4umedicine.blogspot.com
「現代醫療的框框套套弄得太繁複了。照顧病人，「質素」可
以很簡單。」
‘Modern medicine is overcomplicated and pseudoscientific.
We talk obsessively of structures and organisations, but in
truth quality of care is simple’ (The Dying Deserve Better of
GPs)
「縱壞病人不是好醫生。要什麼就給什麼不是專業責任。」
‘I am wary of the too kind, the too good looking, the too
generous, the too polite, the too thin, and the too earnest—
because they are always fake. Gullibility is a flaw in medicine,
because our job is to give patients what they need, not what
they want.’
21
Slide 22
Des Spence: 醫患關係出了什麽毛病?
‘Despite modern medicine’s supposed so called patient
centredness, the medical model (that all symptoms have
a pathological cause, to investigate, treat, and cure) is
absolutely still the prevailing mindset within medicine…
“you can’t go against the evidence.” The rise of the
superspecialist means absolutism is now the norm not
the exception. The paradox is that medicine is
supposedly more enlightened, but it has never been
more tyrannical, hierarchical, controlled, intolerant, and
dogmatic.’ (BMJ Vol. 344, 25 June 2012)
Question: Liberal or conservative?
22
Slide 23
價值觀與醫患關係：病人(絕對)自
主觀點
Donald M. Berwick (born 1946) is a former Administrator
of the Centers for Medicare and Medicaid Services. Prior to
his work in the administration, he was President and Chief
Executive Officer of the Institute for Healthcare
Improvement (IHI).
On June 18, 2013, Berwick declared his candidacy for
governor of Massachusetts.
三點堅持：
病人的需要最優先 “The needs of the patient
come first.”
「一切先問過我」 “Nothing about me without
me.”
每個病人都是唯一的病人 “Every patient is the
only patient.”
23
Slide 24
醫患關係的三種模式
1. Paternalistic (家長式)
2. Contractual (合約關係)
3. Fiduciary (受託關係; Fiduciary duty:
受託責任)
http://www.carroll.edu/~msmillie/bioethics/modelsdocpatrelation.htm
24
Slide 25
醫患關係： 「平衡」觀點
提供資訊
；提供指導
率直；婉言
按照程序；檢視程序
尊重醫學；考慮情景
堅持專業；提防偏執
病人權利；專業責任
25
Slide 26
Thank you for your attention
26
Slide 27
Supplementary materials:
Ethical theories related to
resource allocation and
prioritization
27
Slide 28
Ethical Theory in Prioritization (I)
Most simply, prioritization of health care should be according
to health needs:
Needs as determined by professional assessment
Patient choice weighs little in this approach, as the
underlying value is that of Beneficence
Aims to be neutral to other value judgments (e.g. social
economic background, life-styles)
Limitation: Difficult to compare medical benefits across
different patient groups (e.g. acute thrombolytic service
for stroke vs renal dialysis)
Professional consensus does not automatically translate
into publicly acceptable policy
28
Slide 29
Ethical Theory in Prioritization (II)
Egalitarianism:
Emphasizes equity and equal access
In healthcare, equal opportunity translates into equal
chance to be assessed or triaged, not actually equal
sharing of scarce services
May be problematic when there is critical shortage of
resources (e.g. inadequate vaccine supply in epidemic
situation; obstetric beds for mainland pregnant
women)
29
Slide 30
Ethical Theory in Prioritization (III)
Libertarian principle
The opposite of egalitarianism: emphasizes
personal choice and personal responsibilities
Allows individuals free choice to decide what levels
of health care they would prefer (e.g. opening more
private beds in public hospitals; the idea of having
choice of doctors by paying more)
The society may aid those without sufficient
resources to pay for health care needs on
humanitarian grounds, but it is not provided on the
basis of social justice or patient rights.
30
Slide 31
Ethical Theory in Prioritization (IV)
Utilitarian principle:
Prioritization by cost-effectiveness (e.g. when
introducing new drugs and technology)
Justified by the intention to “maximize health gain”
for a population.
Not all utilitarian theories advocate a “maximizing
principle. A moderate approach is to adopt the
Principle of Proportionality, which implies that some
health care will always be allocated to those with
lesser needs, even though the more needy will receive
more
31
Slide 32
Ethical Theory in Prioritization (V)
Communitarianism:
Considers societal values and local context
Societal values are often implicitly reflected
in ”Macro” allocation levels, e.g. the proportion
of resources to be allocated to take care of the
elderly, the mentally ill, sick children
Challenge: Not easy to engage the community to
assess societal values in the complex subject of
health care resource allocation
Professional views and community views may be
different
Example: end of life decision making – individual
patient decision or consensus building with family?
32
Ethical Issues in Public Health Care
公共醫療的倫理課題
Dr Derrick Au
Chairman,
the Hong Kong Bioethics Association
Vice-chairman,
Hospital Authority Clinical Ethics Committee
EDB seminar 15.1.2014
1
Slide 2
公共醫療服務 vs.公共衛生
公共衛生 (public health)
公共醫療服務 (public healthcare)
人口 vs. 個人
政策 vs. 服務
例子
2
Slide 3
今天的演講
醫學倫理的關注
在公共醫療服務的倫理課題
決策：怎樣的決定才是「對」的？
醫患關係
個案：在公眾領域曾被報道的事件
3
Slide 4
醫學倫理關注的課題 (部分)
醫患關係中的權利與責任
治療與放棄治療的決定
兩難的醫療決定 (medical dilemma)
與醫療科技有關的倫理問題
稀有醫療資源的分配問題 (allocation of
scarce resources)
4
Slide 5
醫學倫理的原則
尊重(個體)自主 (Respect of Autonomy)
為善 (Beneficence - to do good)
毋損害 (Nonmaleficence – do no harm)
公義、公正 (Justice)
基本原則可供相對客觀的分析和討論，避免
主觀主義和相對主義
5
Slide 6
Public healthcare (公共醫療)
不單照顧個別病人，更須向人群的需要
(population needs)負責。
善用有限的資源
非牟利
有公共衛生的角色
一般性的公共機構的法律與倫理責任
6
Slide 7
處理複雜的具體個案 (臨床)
臨床醫學的指示
病人的意願
(science and
knowledge)
(autonomy and
personal values)
生命質量的考慮
具體處境
(psychological,
Socio-cultural)
(case circumstances,
special considerations)
Adapted from: Sliwa JA et al. Am J of PM&R, Vol 81(9), Sep 2002, pp 708-717. (ADAPTED)
7
Slide 8
怎樣分析個案
有沒有「倫理」問題？(道德上的「應否」的
問題)？
有沒有法例的規定？有沒有適用的機構指引
？
有關個案的已知事實是什麼？有沒有欠缺什
麼資料？
專業的觀點 vs.市民/病人的觀點
醫生的觀點 vs.醫療管理決策的觀點
基本倫理原則如何應用於具體個案？
8
Slide 9
個案一：「愛滋醫生」之死
愛滋醫生墮樓兩月才公佈生前手術千宗 周一嶽：
暫毋須追蹤 2012年3月18日
「愛滋醫生」140病人須驗血 2012年3月27日
「東區醫院一名三十多歲的外科醫生於一月中在寓所墜樓
身亡，其後被證實生前是愛滋病帶菌者，醫院管理局隨即
通知衞生署展開調查，商討跟進工作。愛滋病與醫護人員
專家組主席林大慶教授昨在會議後宣布，將於首階段先為
一百四十名病人進行快速病毒測試及輔導，其後再商討是
否需要進一步擴大跟進範圍。」
9
Slide 10
個案的問題
公眾的「知情權」
個人私隱
衛生署專家組對追踪病人與否的建議
有關個案的已知事實是什麼？有沒有欠缺什
麼資料？
醫學的證據
10
Slide 11
個案二：「13價」疫苗風波
不建議打針卻資助 專家小組矛盾
資助補打
民意大還是科學大？
11
Slide 12
「13價」疫苗的補種問題
7價、10價、13價，還有沒有其他
有沒有效？有效多久 (效益問題effectiveness)
補種疫苗是否需要？
相對風險(relative risk)與絕對風險(absolute risk)
的概念
醫學證據有多清楚？
是否應用公帑資助補種疫苗？(成本效益問題costeffectiveness)
行政/政治決定應否凌架醫學/倫理考慮
12
Slide 13
個案三：罕見疾病的昂貴治療
13
Slide 14
罕見疾病的昂貴治療
兩個患有罕見的遺傳性新陳代謝疾病Pompe
Disease的兄弟在 2010年要求試用一種新面世
的酵素替代藥物，這種藥物未被列入醫管局的「
藥物名冊」(HA Formulary)
考慮因素：
效益、成本效益(cost-effectiveness)、邊際效益
(marginal benefit) 概念
對其他病類病人的公平性
醫學證據 vs. 恩恤考慮
政治/社會角度
藥廠的角色
14
Slide 15
個案四：醫療資源的地區分配
將軍澳產房「難產」(20-10-2002)
15
Slide 16
醫療資源的地區分配
跨區就診問題
醫療設施的分佈與規劃
醫療人手的分配
輪候問題
病人的選擇
16
Slide 17
Ethical Issues in Public Health Care
公共醫療的倫理課題
第二部分
醫患關係：
不同價值觀衍生的不同倫理觀點
EBU seminar 15.1.2014)
17
Slide 18
第一部分涉及的倫理原則和考慮元素
病人利益 (patient’s benefit)
病人權利 (patient’s right)
個人自主 (autonomy)
公眾利益 (public interest)
醫學證據 (scientific evidence)
治療效用 (effectiveness)與成本效益 (costeffectiveness)
專業責任(professional accountability)與機構
責任(organisational accountability)
18
Slide 19
第二部分：價值觀與醫患關係
醫患關係(doctor-patient relationship)
其他持分者 (stakeholders)
價值觀與醫患關係
「病人自主」觀點
「專業主導」觀點
「以病人為中心」
「觀點與角度」？
19
Slide 20
良好的醫患關係
一般指醫生與病人的關係(doctor-patient
relationship) ；現代醫療中亦可包含其他
醫護人員。在公共醫療，臨床服務常以團隊
(clinical team)方式操作。
何謂良好的醫患關係可受價值觀的影響。在
現代醫療，有時亦須要考慮其他持分者(例如
親屬)
20
Slide 21
價值觀與醫患關係：「專業(重新)
主導」
General Practitioner in Glasgow
BMJ Columnist
Blogger: Bad4umedicine.blogspot.com
「現代醫療的框框套套弄得太繁複了。照顧病人，「質素」可
以很簡單。」
‘Modern medicine is overcomplicated and pseudoscientific.
We talk obsessively of structures and organisations, but in
truth quality of care is simple’ (The Dying Deserve Better of
GPs)
「縱壞病人不是好醫生。要什麼就給什麼不是專業責任。」
‘I am wary of the too kind, the too good looking, the too
generous, the too polite, the too thin, and the too earnest—
because they are always fake. Gullibility is a flaw in medicine,
because our job is to give patients what they need, not what
they want.’
21
Slide 22
Des Spence: 醫患關係出了什麽毛病?
‘Despite modern medicine’s supposed so called patient
centredness, the medical model (that all symptoms have
a pathological cause, to investigate, treat, and cure) is
absolutely still the prevailing mindset within medicine…
“you can’t go against the evidence.” The rise of the
superspecialist means absolutism is now the norm not
the exception. The paradox is that medicine is
supposedly more enlightened, but it has never been
more tyrannical, hierarchical, controlled, intolerant, and
dogmatic.’ (BMJ Vol. 344, 25 June 2012)
Question: Liberal or conservative?
22
Slide 23
價值觀與醫患關係：病人(絕對)自
主觀點
Donald M. Berwick (born 1946) is a former Administrator
of the Centers for Medicare and Medicaid Services. Prior to
his work in the administration, he was President and Chief
Executive Officer of the Institute for Healthcare
Improvement (IHI).
On June 18, 2013, Berwick declared his candidacy for
governor of Massachusetts.
三點堅持：
病人的需要最優先 “The needs of the patient
come first.”
「一切先問過我」 “Nothing about me without
me.”
每個病人都是唯一的病人 “Every patient is the
only patient.”
23
Slide 24
醫患關係的三種模式
1. Paternalistic (家長式)
2. Contractual (合約關係)
3. Fiduciary (受託關係; Fiduciary duty:
受託責任)
http://www.carroll.edu/~msmillie/bioethics/modelsdocpatrelation.htm
24
Slide 25
醫患關係： 「平衡」觀點
提供資訊
；提供指導
率直；婉言
按照程序；檢視程序
尊重醫學；考慮情景
堅持專業；提防偏執
病人權利；專業責任
25
Slide 26
Thank you for your attention
26
Slide 27
Supplementary materials:
Ethical theories related to
resource allocation and
prioritization
27
Slide 28
Ethical Theory in Prioritization (I)
Most simply, prioritization of health care should be according
to health needs:
Needs as determined by professional assessment
Patient choice weighs little in this approach, as the
underlying value is that of Beneficence
Aims to be neutral to other value judgments (e.g. social
economic background, life-styles)
Limitation: Difficult to compare medical benefits across
different patient groups (e.g. acute thrombolytic service
for stroke vs renal dialysis)
Professional consensus does not automatically translate
into publicly acceptable policy
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Slide 29
Ethical Theory in Prioritization (II)
Egalitarianism:
Emphasizes equity and equal access
In healthcare, equal opportunity translates into equal
chance to be assessed or triaged, not actually equal
sharing of scarce services
May be problematic when there is critical shortage of
resources (e.g. inadequate vaccine supply in epidemic
situation; obstetric beds for mainland pregnant
women)
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Slide 30
Ethical Theory in Prioritization (III)
Libertarian principle
The opposite of egalitarianism: emphasizes
personal choice and personal responsibilities
Allows individuals free choice to decide what levels
of health care they would prefer (e.g. opening more
private beds in public hospitals; the idea of having
choice of doctors by paying more)
The society may aid those without sufficient
resources to pay for health care needs on
humanitarian grounds, but it is not provided on the
basis of social justice or patient rights.
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Slide 31
Ethical Theory in Prioritization (IV)
Utilitarian principle:
Prioritization by cost-effectiveness (e.g. when
introducing new drugs and technology)
Justified by the intention to “maximize health gain”
for a population.
Not all utilitarian theories advocate a “maximizing
principle. A moderate approach is to adopt the
Principle of Proportionality, which implies that some
health care will always be allocated to those with
lesser needs, even though the more needy will receive
more
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Slide 32
Ethical Theory in Prioritization (V)
Communitarianism:
Considers societal values and local context
Societal values are often implicitly reflected
in ”Macro” allocation levels, e.g. the proportion
of resources to be allocated to take care of the
elderly, the mentally ill, sick children
Challenge: Not easy to engage the community to
assess societal values in the complex subject of
health care resource allocation
Professional views and community views may be
different
Example: end of life decision making – individual
patient decision or consensus building with family?
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