尊重患者自主权 控制医疗费用支出

从医学伦理学理论和医疗工作实践两个方面探求医疗费用支出居高不下的成因和解决这一问题的方法。医患代理关系中的父权主义和供需关系中的追求医疗服务收益最大化使医疗费用居高不下。在理论上,尊重患者的自主权,采取双方决策机制有利于克服这一成因造成的问题。在实践中,应采用患者介入医疗决策、医保机构审核、促使医患双方信息对称以及道德与法律保障等方式来落实对患者自主权的尊重,这可以在一定程度上有效控制医疗费用的支出。     

Deconstructing paternalism--what serves the patient best?

On the motion that "medical paternalism serves the patient best", this essay reviews current arguments on medical paternalism vs. patient autonomy. Citing medico-ethical texts and journals and selected real-life applications like electroconvulsive therapy (ECT) and the advanced medical directive (AMD), the essay argues that medical paternalism cannot serve the patient best insofar as current debates limit themselves to "who" wields the decision-making power. Such debates side-step "what" the patient's best interests are. The essay further argues through the case of Traditional Chinese Medicine (TCM), and acupuncture in particular, that the current dominant Western school of thought excludes other forms of "alternative" treatment through medical paternalism.     

Paternalism modernised.

The practice of paternalism has changed along with developments in medicine, philosophy, law, sociology and psychology. Physicians have learned that a patient's values are a factor in determining what is best for that patient. Modern paternalism continues to be guided by the principle that the physician decides what is best for the patient and pursues that course of action, taking into account the values and interests of the patient. In the autonomy model of the doctor-patient relationship, patient values are decisive. In the paternalistic model, they are but one among several factors the physician must consider in making a medical decision. Although difficult to practise because of limitations in empathising with another person, modern paternalism remains a way to achieve maximum patient benefit.     

Doctor-patient relationship: from medical paternalism to enhanced autonomy

For centuries, physicians have been allowed to interfere and overrule patient's preferences with the aim of securing patient benefit or preventing harm. With the radical rise in emphasis on individual control and freedom, medical paternalism no longer receives unquestioned acceptance by society as the dominant mode for decision-making in health care. But neither is a decision-making approach based on absolute patient autonomy a satisfactory one. A more ethical and effective approach is to enhance a patient's autonomy by advocating a medical beneficence that incorporates patients' values and perspectives. This can be achieved through a model for shared decision making, acknowledging that though the final choices reside ultimately in patients, only through physician beneficence can the patient be empowered to make meaningful decisions that serve them best. For such a model to function effectively, the restoration of trust in doctor-patient relationship and the adoption of patient-centred communication are both crucial.     

医事法学课程中对父权主义理论的批判与继承

在医事法学课程的教学中不断强调病人是医疗中心的这一观念正瓦解着传统的医疗父权。课程中教师对病人自主权的重视与在实践环节病人自主权仍停留在概念阶段形成了一对矛盾。对父权主义在批判基础上的继承能有助于解决这一矛盾,并能在实践中保护和提升病人的自主权。     

Autonomy in medical ethics after O'Neill

Following the influential Gifford and Reith lectures by Onora O'Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O'Neill in recommending a principled version of patient autonomy, which for us involves the provision of sufficient and understandable information and space for patients, who have the capacity to make a settled choice about medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it against the patient-doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to consider mistakenly that unthinking acquiescence to a requested intervention against their clinical judgement is honouring "patient autonomy" when it is, in fact, abrogation of their duty as doctors.     

从医患关系模式的角度分析中国医疗领域中的“自主性原则”

通过调研和访谈从医患关系的模式角度分析了当前中国医疗领域中的“自主性原则”,对医生来说,虽然医生对患者的自主性表示尊重和接受,但很多时候仍将患者自主式作为医生履行职责的障碍;对患者来说,患者也没有将自主视为理想医患关系的要素,反而认为自主在很多情况下会损害自身的利益,提出在西方医疗实践的影响下,医患关系的模式处于传统的家长制和西方的消费主义两种极端模式相重叠的阶段,自主性原则在两种模式中被赋予了截然不同的价值,因而导致了自主性原则在当前中国医疗实践中的两难处境.     

自主性原则在儒家道德语境中遭遇到的困难

基于调研和访谈的数据,发现当前中国医疗领域中的“自主性原则”在很大程度上得到医患双方的认同和推崇,但同时这种认同和推崇却有着一定的界限.在最重要的医疗决策环节,医患双方都倾向于认为,患者主动地放弃自主权利,由医生作出决定,才是最好的方式.并且在医患双方的心目中,最理想的医患关系模式是具有明显家长制特征的“信托关系”,而不是完全的患者自主.一方面,医生行善与患者自主在儒家的道德哲学中是相互矛盾的,导致行善与自主难以共存;另一方面,儒家生命伦理认为,患者自主在一定程度上构成了对医生品质的否定,因而对于自主性的推崇无法得到文化上的认同.     

加强医学生医患沟通能力培养的探讨

以社会经济发展和现代医学模式转变为背景,从医患沟通能有助于深入了解病情、做出准确诊断、改善医患关系、减少医疗纠纷等方面,阐述了提高医学生医患沟通能力的重要性;并通过分析目前国内外医患沟通教学的现状和存在的问题,提出从培养专业化沟通技能、组建多学科师资团队、采取多元化授课形式、制定系统化考评体系4个方面加强医学生医患沟通能力培养的建议。     

临床麻醉中知情同意的思考

临床麻醉工作中,尊重患者自主权是知情同意的基础,知情同意反映了患者自主权与医学干涉主义之间的相互妥协.在信任基础上的知情同意,是患者自主权的最佳体现,也是对医学干涉主义的尊重,从而为患者的最佳利益服务.     

Rational non-interventional paternalism: why doctors ought to make judgments of what is best for their patients.

This paper argues that doctors ought to make all things considered value judgments about what is best for their patients. It illustrates some of the shortcomings of the model of doctor as 'fact-provider'. The 'fact-provider' model fails to take account of the fact that practising medicine necessarily involves making value judgments; that medical practice is a moral practice and requires that doctors reflect on what ought to be done, and that patients can make choices which fail to express their autonomy and which are based on mistaken judgments of value. If doctors are properly to respect patient autonomy and to function as moral agents, they must make evaluations of what their patients ought to do, all things considered. This paper argues for 'rational, non-interventional paternalism'. This is a practice in which doctors form conceptions of what is best for their patients and argue rationally with them. It differs from old-style paternalism in that it is not committed to doing what is best.     

医患关系紧张的思考和对策

和谐的医患关系是获得良好医疗效果的基础,和谐的医患关系有利于我国医疗卫生事业的健康发展。近年来,日趋紧张的医患关系严重冲击着医疗服务市场,医疗纠纷和医患矛盾是当前社会热点问题之一,频发的暴力伤害事件,成为困扰医院发展和管理的重大问题。同时目前紧张的医患关系也不利于建设和谐社会,文章阐述了医患关系的定义、医患双方的权利和义务、医患关系的实质。本文从医患双方缺乏足够的尊重与信任局势、医患纠纷增多的现状、医院恶性暴力事件增多的趋势、职业＂医闹＂参与恶性事件的现象等方面研究了目前医患关系的种种不和谐现状;从目前医疗体制、医方存在问题、患方存在不足、社会普遍存在信任缺失方面分析了医患关系不和谐的原因,从建立能被社会各方接受的解决医患纠纷的途径、医院加强法制教育、增强有效沟通技巧、树立医院正面形象等角度探讨了解决医患关系的一些对策。     

Paternalism, family duties, and my Aunt Maude

Using the case of his elderly great-aunt as an example, a physician raises the question of obligations toward elderly persons who refuse treatment that could improve the quality of their lives. Miles' aunt, blind, frail, and confined to a nursing home, refused cataract extraction that could restore her sight. Her family and physician scheduled the surgery, prepared to call it off if the aunt objected. The extraction was performed, the aunt's sight was restored, and her enjoyment of and participation in life increased significantly. Miles argues that the insistence upon autonomy and the proscribing of physician and family benevolence can be as abusive of patients as excessive paternalism. "As an absolute," he quotes, "autonomy reveals an impoverished view of how we live and are sustained in moral communities."     

Existential autonomy: why patients should make their own choices.

Savulescu has recently introduced the "rational non-interventional paternalist" model of the patient-doctor relationship. This paper addresses objections to such a model from the perspective of an anaesthetist. Patients need to make their own decisions if they are to be fully autonomous. Rational non-interventional paternalism undermines the importance of patient choice and so threatens autonomy. Doctors should provide an evaluative judgment of the best medical course of action, but ought to restrict themselves to helping patients to make their own choices rather than making such choices for them.     

医患冲突现象的文化基础分析

本文从社会现象文化基础的视角出发,对当前医患关系存在的“主体撕裂”“价值撕裂”“行为撕裂”现象进行了客观描述和分析,并据此对中国式医患冲突做出初步判断,明确从医学文化视角看,当前医患关系虽已“撕裂”,还未“断裂”,尚可“医治”.在此基础上,本文以唯物辩证的思想为指导,对当前医患关系冲突现象进行了医学文化基础原因的深入分析,认为医学文化的社会基础要素、医学文化的自身基础要素的内在冲突是我国医患关系恶化的重要因素.文章明确提出了医学文化的4个社会基础要素和9个构成要素的理念,并且提出了解决医患冲突、重建医患关系的“5个和谐”之道,以弥合医患裂痕,实现医患和谐.     

如何培养医学生构建和谐的医患关系

临床实习教学是高等医学教育的重要组成部分,随着当前医患关系的紧张,医疗纠纷的增加,培养临床医学生构建和谐医患关系的能力对提高教学质量具有重要的现实意义。和谐互信的医患关系不仅有利助于培养高素质的医学人才,而且有助于医学事业的和谐发展、有助于更好的服务患者,有助于和谐社会发展。本文就临床教学活动中构建和谐互信的医患关系的重要性及我院如何培养临床医学生构建和谐医患关系的途径加以论述。     

关于构建和谐医患关系的实践思考

如何构建和谐的医患关系是当前急需解决的重要问题。从医患关系不和谐现状入手,对医患关系的性质做了再思考,从医务人员角度进一步分析其成因,并探讨了构建和谐医患关系的对策：切实增强对医德医风重要性的认识;坚持以患者为中心的办院方向;建立医德医风约束机制等。     

对市场经济背景下医患信任危机的思考

本文论述了在市场经济背景下紧张的医患关系缘于医患双方信任危机,并分析了导致信任危机产生的因素。思考市场经济背景下如何建立医患双方信任关系,我们认为通过加强医务人员医德教育,明确医疗活动中医患角色,加大力度打击“医闹行为”,媒体正确引导舆论促进相互信任的产生,从而能有效减少医疗纠纷,创建和谐医患关系。     

改善医患关系的重要途径——患者满意度测评

近些年,我国医患关系处于紧张状态,已经影响到了医院的正常运营及发展。如何改善医患关系,引导医患关系走向和谐发展,是当前医药体制改革过程中面临的问题和挑战。本文分析了医患关系的现状和改善医患关系的基本途径,探讨了通过患者满意度测评改善医患关系的途径,意在帮助医院提高服务质量,改善医患关系,增强竞争力。