Transcript Medical Ethics Difficult Choices 報告者：林俊龍院長

Medical Ethics
Difficult Choices
報告者：林俊龍院長
NOBLE PROFESSION
GOOD OLD DAYS OF
MEDICINE
• ONE ILL
• ONE PILL
• ONE BILL
Patients Nowadays
• Older
• Multiple complaints and
underlying illnesses
• Physicians employ sophisticated
equipment to reach diagnoses
• Prescribes multiple drugs with
potential interactions.
Subspecialties (1)
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Neurology
Gastroenterology (Hepatology)
Pulmonary Medicine
Cardiology (Invasive, Non-invasive,
Electrophysiology)
• Nephrology
• Endocrinology (Diabetology, Thyroidology)
Subspecialties (2)
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Rheumatology
Immunology
Hematology/Oncology
Infectious Disease
Metabolic disease
Dermatology
Pediatrics
Rehabilitation Medicine
Surgical Specialties (1)
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General Surgery (Proctology)
Endocrine Surgery
Plastic Surgery
Neurosurgery
Orthopedics
Obstetrics-Gynecology
Urology
Surgical Specialties (2)
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ENT (Otolaryngology)
Ophthalmology
Oral Surgery/ Head & Neck Surgery
Cardiovascular Surgery/Vascular
Surgery
• Thoracic Surgery
• Traumatology
HIPPOCRATE’S OATH
To consider dear to me, as my parent him who taught me
this art; to live in common with him and if necessary, to
share my goods with him; to look upon his children as
my own brothers, to teach them this art if they so desire
without fee or written promise; to impart to my sons
and the sons of the master who taught me and the
disciples who have enrolled themselves and have agreed
to the rules of the profession, but to these alone, the
precepts and the instruction but I will preserve the
purity of my life and my art. I will not cut for stone,
even for patients in whom the disease is manifest; I will
leave this operation to be performed by practitioners
(specialist in this art). In every house where I come I
will enter only for the good of my patients.
HIPPOCRATE’S OATH
I will prescribe regimen for the good of my patients
according to my ability and my judgment and never do
harm to anyone. To please no one will I prescribe a
deadly drug, nor give advise which may cause his death,
nor will I give a woman a pessary to procure abortion,
keeping myself far from all intentional ill-doing and all
seductions, and especially from the pleasure of love
with women or with men, be they free or slaves. All
that may come to my knowledge in the exercise of my
profession or outside of my profession or in daily
commerce with men, which ought not to be spread
abroad,
HIPPOCRATE’S OATH
I will keep secret and will never reveal.
If I keep the oath faithfully, may I
enjoy my life and practice my art,
respected by all men and in all times;
but if I swerve from it or violate it, may
the reverse be my lot.
HIPPOCRATE’S OATH
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An art
Like family (sons and brothers)
A teacher
High standard of personal behavior
Refer to specialist
Only for the good of patients
Do no harm
Keeping away from seduction
Confidentiality
• Profession with respect
Medicine
Science
Humanities
Five Principles of Medical Ethics
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A. Autonomy
B. Beneficence
C. Confidentiality
D. Do no harm (non-maleficence)
E. Justice
Oriental (Confucian) Principles
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Compassion
Respect
Righteousness
Dharma (responsibility)
Family
PHYSICIAN-PATIENT
RELATIONSHIP
PURE
AND
SIMPLE
SERVICE ATTITUDE
服務態度
 PATIENT
 CLIENT
 CUSTOMER
 PATRON
 BENEFACTOR
 MASTER
病人
客戶
顧客
主顧
恩人
主人
Bodhisattva
菩薩
Buddha
佛
婦產科---許振興醫師
大林十八羅漢的故事
婦產科---許振興醫師
•陸某某－保險公司主任
•年齡 34歲
•主訴－結婚五年未曾生育，經
血量過多， 有時如自來水般
•診斷－看過中部各大醫學中心，
診斷子宮肌瘤合併嚴重貧血
•醫師建議－全子宮切除
以醫師及疾病為思考導向
•全子宮切除（不到 3小時）
•一勞永逸---醫師沒有負擔
•獨留給病人終生之遺憾
•想生育唯有代理孕母一途
人本醫療為思考導向
•先切除腫瘤，保留子宮 （如何完全切除腫瘤
－ 以不破壞子宮完整之結構）
•如何幫助病人受孕
•如何預防早期流產
•如何預防早產
•如何順利生產
•如何監控腫瘤是否再度復發
•完成生育計劃 再行全子宮及兩側卵巢切除
•時間約需 3 年
人本醫療
• 把快樂、幸福、滿足
留給病人！
• 把問題、責任、壓力
留給自己！
The story
• 41 y/o male patient, admitted to our
ward
• Terminal liver cancer with metastasis
• Owned a restaurant in Thailand
• Had a son with the waitress,
unmarried
• Last wish---- to get married so that
his son can inherit his properties.
一般外科
魏昌國
大林十八羅漢的故事
嚴重主動脈瓣狹窄並大腸癌
•57歲男性, 來自台南
•心臟瓣膜疾病, 三年
•2003-12,心臟衰竭並
急性肺水腫,奇美醫學
中心住院治療
•害怕開心手術, 而選
擇吃藥控制
•2004-06,解黑血便,貧
血,大腸鏡檢查發現大
腸癌,即住院安排手術
The story
• 57 year old male with severe aortic
stenosis
• Developed blood stool and found to have
colon cancer with obvious metastasis
• Seen at Tainan Medical Center and heart
surgery was advised because the
anesthesiologist refused to do anesthesia
for colon surgery.
Aortogram & Coronary angio
•主動脈瓣狹窄狹窄的
麻醉危險性高
•大腸癌手術因麻醉危
險, 而被迫取消, 先
治好心臟, 再開大腸
癌
•大林慈濟醫院心臟科
林院長
•心導管檢查
•電腦斷層檢查
心導管檢查—Coronary angio
電腦斷層檢查—Chest CT
電腦斷層檢查—Abdomen CT
專業的考驗, 團隊的合作
先做大腸癌手術之危險
先做心臟瓣膜手術之危險
• 嚴重主動脈瓣狹窄可
能於手術中或手術後
造成猝死
•必須使用大量抗凝血劑,
造成大腸癌嚴重出血
• 奇美醫學中心之建議
•大腸癌手術前需停用抗
凝血劑, 可能產生心臟
瓣膜血栓
Dilemma
• Do aortic dissection and
valve first, run the risk of GI
bleeding and clot in valve
• Do the colon cancer first
and run the risk of cardiac
arrest and stroke
perioperatively
如臨深淵
用單純的心,做複雜的事
完成第一步—First stage op.
第三期大腸癌,淋巴擴散
術後的照顧,後續的治療
還是自己的醫院最好
•53歲, 台南慈誠師兄
•93-05-08 13樓 健檢中
心, 大腸鏡檢查
•大腸息肉,疑癌病變
•就近治療開刀,奇美醫
學中心
•93-05-15 右半大腸部
分切除手術
•併發症的開始, “瘻管”
•黃色糞臭分泌物由
右下腹引流管傷口
流出,每兩三個小
時必須換藥一次
•奇美醫師並未多做
說明,換藥再換藥
•93-07-22大林慈濟
醫院外科門診求助
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瘻管攝影檢查--Fistulogram
•第二次手
術的困難,
6小時, 失
血1000 cc
•只准成功,
不准失敗.
•運心轉境
Conclusion
•替別人收拾殘局部 (擦xx)
的醫生
To take care of
somebody else’s
problem
•還是自己的醫院最好
Tzu-Chi is better
骨科--劉耿彰醫師
大林十八羅漢的故事
叛逆與成長--骨科劉耿彰醫師
本人多處骨折
小朋友股骨骨折
小朋友術後
本人術後 (1)
本人術後(2)
六個月後關節纖維化
(Arthrofibrosis)
關節固定太久
結痂
活動不良
關節鏡解離術
術前
術前
術後
復健之辛苦
媽媽的陪伴
復健師的用心
志工菩薩--師姐的關懷
終於有了進步
癒合
功能正常
行動自如
喜悅---找到了家與路
Do No Harm
(Non-maleficence)
• 說易行難 It’s easier said than
done
• Ｍore people died of medical
errors than gunshot
• Hospital is a dangerous place
Why?
• To err is human
1% chance of making
mistakes
Wrong identity, wrong part,
wrong medication, wrong
dosage…….
The Answer
• To forgive divine
原諒是神聖的
• Patient safety committee
• Double and triple check to
reduce the error rate.
89 阿嬤真開心
• 89 year old lady
• Loss of appetite, short of breath in last 6
months
• Visited medical centers in Taipei
• All advised conservative therapy
• The eldest son brought her to Dalin
because he could not stand the sight of her
suffering
89歲 阿嬤真開心
•因為阿嬤很喘,無法平躺,我們在
勉強做完心導管後,連夜進行急診
主動脈瓣膜置換手術
•術後復原快速,於三週後平安出
院
The symptoms
• Orthopnea, she could not even lie down
• Low blood pressure, diaphoresis,
profuse sweating with chest tightness
• We performed emergency cardiac
catheterization and found severe aortic
stenosis (gradients of 80 mmHg)
• We discussed the risks and benefits of
surgery
• The patient and family agreed to have
valve replacement
Justice
• Social justice versus economic
justice
• Equal starting point or same
end point?
• Unfair world: tall,short; large
small; skinny, fat; rich, poor;
smart, not so smart,……
Three Stages of Human Needs
• To Survive (存活)Support
• To Live (生活)Comfort
• To Realize (生命)Education
Age
Sex
Race
Social Factors
Risks
Costs
Benefits
What can we do for patients?
Relief Symptoms
Prolong Life (Prevent
Catastrophe)
Risks Versus Benefits
Rapid Advances in
Technology
• Unrealistic expectations
• Make us think, or expect
us to be omnipotent
• We are not god!
What is the difference
between a nun and a nurse ?
The nun has to
answer to only
one god
醫療三部曲
•下醫醫病 (身)
•中醫醫人 (心)
•上醫醫國 (靈)
COMPREHENSIVE
全體性的
FROM HEAD TO TOE
從頭到腳
NOT FRAGMENTED
不是片段的
BODY, MIND, SOUL
身, 心, 靈
The Motto of
The City of Hope
There is no profit in
curing the disease,
if in the process, we
destroy the soul.
OCCUPATION VS. PROFESSION
Occupation: 職業
• To occupy, to take possession
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An activity in which one engages
A way of passing the time
The principal business of one’s life
A craft, trade, profession or other
means of earning a living.
OCCUPATION VS. PROFESSION
PROFESSION: 專業 (Webster)
• The act of taking the vows that
consecrate oneself to special
religious service.
• An act of openly declaring or
publicly claiming a belief, faith
or opinion.
PROFESSION 專業
• A calling requiring specialized
knowledge and often long and
intensive preparation including
instruction in skills and methods as
well as in the scientific, historical
or scholarly principles underlying
such skills and methods,
PROFESSION 專
• maintaining by
業force of
organization or concerted opinion
high standards of achievement and
conduct and committing its
members to continued study and to
a kind of work which has for its
prime purpose the rendering of
public service.
PROFESSION 專業
(SUMMARY) (Webster)
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A belief, faith, or religion
Specialized knowledge
Long and intensive preparation
High standard of achievement &
conduct
• Society with continued study
• Rendering of public service
PROFESSIONAL PRIDE
Pride:
• A sense of one’s own worth
and abhorrence of what is
beneath or unworthy of
oneself
• 引以為傲，不屑為伍。
PROFESSIONAL DIGNITY
專業的尊嚴
Dignity:
• The quality or state of being worthy,
the quality or state of being honored
or esteemed.
• Formal reserve of manner, appearance,
behavior that accords with self-respect
or with regard for the seriousness of
occasion or purpose. 尊貴而威嚴 態
度容貌莊重而不可侵犯
RESPECT 尊敬
SOMETHING YOU
COMMAND
NOT
SOMETHING YOU
DEMAND
RESPECT 尊敬
HE WHO DEMANDS
RESPECT GETS
NO RESPECT
病人
家屬
THIRD
PARTY
政府
保險公司
醫事人員
護士
醫師
病人
志工
政府
保險公司
護士
醫師
Five Principles of Medical Ethics
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A. Autonomy
B. Beneficence
C. Confidentiality
D. Do no harm (non-maleficence)
E. Justice
Simple solution
Patient
Centered
Medical
Care
Convenient 方便性
Compassionate
有愛心的
Comfortable 舒適性
Conservational 環保
Complete 完全性
Cost-Effective 有效益性
Continual 連續性
Community-Oriented 社區性
Comprehensive 全體性 Computer-Based 電腦為基礎
10 C(十全)
The most beautiful smiles
are the patients’
越南義診
甘願做
To Care with Compassion
歡喜受
To Give with Joy
加入慈濟
Join Tzu-Chi
加入人醫會
Join TIMA
新加坡慈濟人醫會林深耀醫師
•林醫師從2002年8月發現患上胰臟癌後，
經過開刀、化療等艱苦治療過程
•熱愛生命 在困境中呈現生命偉大光輝的
一位勇者
•人的生命不在乎長久，而是在乎做了什
麼。所以蠟燭的長短不重要，在乎的是
這支蠟燭能不能發光。
•人間眾生不離生老病死，人世的短暫就
如一朝風月，稍縱即逝；而莊嚴的大愛
精神卻如萬古長空，將是永遠存在。
人生如蠟燭
要點燃方能造福
Life is like a candle
It lights only when it burns
一切因緣生 因緣聚 因緣成
The karmic affinity
brought us all together
It Matters Not
Long or Short
The candle is
burning
The End