我国发展电子健康的伦理原则和管理建议

电子健康作为一种全新的医疗保健模式，不仅提高了医疗效率，而且为更多疑难杂症的治疗带来了福音和希望，代表了医疗保健发展的未来。但是，它的发展也会面临许多问题与挑战，如电子健康信息储存的安全性问题、隐私保护问题和卫生资源的分配问题等等。因此，电子健康的研究与发展应遵循一定的规范。我国发展电子健康应该遵循知情同意、安全性、公正、风险一收益以及逐步发展的伦理原则，并从审查、信息储存与信息安全、医患关系、信息传播与隐私保护、效用评估、监督、培训与教育、法律法规等方面提出了管理建议。     

Compelled medical treatment of pregnant women. Life, liberty, and law in conflict

The authors discuss the ethical aspects of the relationship between physicians and pregnant patients involving the reconciliation of maternal-fetal conflict. They analyze the legal aspects of compulsory treatment of pregnant women and its connection with abortion and child neglect law, with the legal status of the fetus, with legal precedents for intervention, and with physician liability for either honoring or disregarding pregnant patients' refusal of treatment that would benefit the fetus. Nelson and Milliken cite the uncertainty of medical diagnostic and therapeutic techniques and the societal values of autonomy and bodily integrity in opposing judicially compelled treatment of pregnant women. They also contend that pregnant women have an ethical obligation to follow those practices and accept reasonable, nonexperimental treatment that will benefit their fetuses.     

Canaries in the mines: children, risk, non-therapeutic research, and justice

The Kennedy Krieger lead paint study received a lot of attention after a US Court of Appeals ruled that a parent cannot consent to the participation of a child in non-therapeutic research. The ruling has raised fears that, if it goes unchallenged, valuable research might not proceed and ultimately all children would be harmed. The author discusses significant aspects of the study that have been neglected, and argues that the study was unethical because it involved injustice and its design meant that the study lacked importance and value. Issues of benefit, risk, and consent are vital, but it is sometimes a mistake to consider these issues before settling questions about justice and the importance and value of a research project. The author concludes by offering a strategy for researchers and reviewers of research to appreciate, in a vivid way, the implications of research participation.     

论大众健康传播医学伦理评价的四个关键问题

在分析健康传播属性的基础上,认为大众健康传播活动既是传播活动,也是医疗保健活动,既要符合传播伦理,更不能违背医学伦理规范,必须进行医学伦理评价。应当由以医学伦理学专家为核心的专业评价队伍作为评价主体——社会公众的代言人,以不伤害、有利、尊重和公正四大医学伦理学原则为标准,对大众健康传播活动的动机和结果进行价值确定和道德决断。     

Balancing rationalities: gatekeeping in health care

Physicians are increasingly confronted with the consequences of allocation policies. In several countries, physicians have been assigned a gatekeeper role for secondary health care. Many ethicists oppose this assignment for several reasons, concentrating on the harm the intrusion of societal arguments would inflict on doctor-patient relations. It is argued that these arguments rest on a distinction of spheres of values and of rationality, without taking into account the mixing of values and rationalities that takes place in everyday medical practice. If medical practice, then, does not follow a single, pure rationality, can it also incorporate the societal rationality of the gatekeeper role? Using a case from general practice, I try to show how physicians may integrate societal arguments into their practice in a morally acceptable way. A version of the model of reflective equilibrium and especially Beauchamp and Childress''s safeguards, may be helpful both to analyse and teach such balancing of values and rationalities. Key Words: Allocation ? gatekeeper ? physician-patient relations ? justice ? balancing ? ethics     

Valve replacement in endocarditis: setting limits in noncompliant intravenous drug abusers

An intravenous (IV) drug abuser underwent repeated valve replacements because of recurrent infective endocarditis. Is it ethically permissible to withhold valve surgery in a recalcitrant, noncompliant IV drug abuser? We believe so, and in our analysis, discuss the principles of futility, rationing, personal responsibility, and justice. Because of her continued drug abuse, the patient is responsible and accountable for the medical consequences. The consequences are that physicians will not be able to provide her with beneficial treatments without disproportionate harm, and that society will no longer be able to provide resources for her treatment without unfairly jeopardizing the availability of resources for other members of society. Although valve surgery does not constitute futile treatment, maximizing and egalitarian principles of societal justice support the withholding of such an expensive intervention. The patient should be jointly evaluated by the physician, social worker, and psychiatrist. The medical team will emphasize patient compliance and willingness to undergo drug rehabilitation, and will offer the first valve replacement. The recidivist abuser with demonstrable non-compliance who sustains a second episode of endocarditis need not be offered another valve. To avoid bedside rationing, we recommend the formulation of such a policy by nations and professional bodies.     

"临床路径"服务模式的医学伦理学价值

作为一种全新的临床服务模式,临床路径已在我国很多地区进行了尝试,但是,尚未有从医学伦理学的视角进行研究的成果.本文认为,临床路径服务模式有利于"为人民健康服务"医德价值目标的实现,有利于"知情同意"原则的实现,体现着"人本主义"的伦理原则,有利于"公正"伦理原则的最终实现.     

Fault and the allocation of spare organs.

This paper argues that rectificatory justice should supplement distributive justice in allocating priority of access to scarce medical resources. Where a patient is at fault for the scarcity of healthy organs a principle of restitution requires that she should give priority to the faultless. Such restitution is non-punitive, and is akin to reparation in civil law, not criminal law. However, it is doubtful whether such a principle can be fairly applied within the present culture of governmental complicity in cigarette advertising.     

传统医德对当代医德教育的启示

中国传统医德植根于中国传统伦理思想中,其主要思想内涵可以概括为医乃仁术、义为利本、精勤不倦等方面。传统医德的这些优秀成果对于当代医德教育有着多方面的启示,如加强德性教育、加强医德情感的培养、加强社会主义核心价值观的引领作用等。     

探讨病案信息的应用

随着现代信息化的高速发展及社会的进步,病案信息的应用价值也越来越高。病案资料信息的开发利用是科技发展的需要,同时也是目前病案资料管理工作的一个新方向。病案信息的应用价值需要借助病案信息的信息化管理来得以充分实现。为了充分发挥病案信息在社会中的应用价值,本文将从医疗、教学、研究、管理、医疗保险、医疗纠纷等方面探讨病案信息的应用价值。     

Are immune responses pivotal to cancer patient's long term survival? Two clinical case-study reports on the effects of Morinda citrifolia (Noni)

In the State of Hawaii, there are abundant claims of benefit from cancer patients' use of the fruit juice of Morinda citrifolia (Noni). There is no well documented clinical report in peer review journals. The author here studiously examined 2 such claims through interview, review of the medical records and pathology slides. The author concludes that these cases are valuable experiences and hope to stimulate interest in Noni research as an important part of adjuvant immunotherapy for cancer     

“非典”与应激

应激是一种涉及心身两个方面的紧张状态,引起这种状态的刺激物称为应激原,应激源分为社会性、心理性、躯体性和文化性。“非典”成为社会应激源,给人类躯体与心理带来双重伤害,要战胜“非典”,必须同时依靠医学、生物化学、医学心理学、心身医学、行为医学、中医药学等多学科的理论、研究方法和防治手段。鉴于“非典”具有传染性强、病情重的特点,采用支持性心理治疗较为妥当。     

A Closer Look at Health and Disease as Prerequisites for Diagnosis and Prognosis

Health and illness are key concepts of medicine but they also have essential significance for each and every one of our lives. For this reason, social value systems are inevitably integrated into medicine through the concept of health and illness. In turn, medical knowledge and medico-scientific notions are perpetually incorporated into societal perceptions of health and illness. Generally, such integration usually occurs via an extended concept of health and illness, which is to be discussed in the following. To a certain extent, medical and societal notions of health are mutually co-determined. The underlying dynamics deserve a closer look because if health and illness are societal and medical concepts alike this fundamentally impacts on the epistemological and the practical dimension of diagnosis and prognosis as discussed in this volume of Medicine Studies.     

我国医事法学本科人才培养方式初探

医疗纠纷是全世界的问题,这个问题没有随着科技的发展而减少,而是有越来越多的趋势。由于医学科学本身具有极强的专业性,面对大量的医疗纠纷时,一般法律工作者因为缺乏医学专业知识,解决这类问题往往比较棘手。为适应社会需求,近几年国内不少医学院校相继开设了医事法学教育,笔者就国内医事法学人才培养方式做初步的比较分析。     

Coordinating the norms and values of medical research, medical practice and patient worlds-the ethics of evidence based medicine in orphaned fields of medicine

Evidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other things being equal, ethically unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients.     

Training Synergies Between Medical Informatics and Health Services Research: Successes and Challenges

Stanford''s two decades of success in linking medical informatics and health services research in both training and investigational activities reflects advantageous geography and history as well as natural synergies in the two areas. Health services research and medical informatics at Stanford have long shared a quantitative, analytic orientation, along with linked administration, curriculum, and clinical activities. Both the medical informatics and the health services research curricula draw on diverse course offerings throughout the university, and both the training and research overlap in such areas as outcomes research, large database analysis, and decision analysis/decision support. The Stanford experience suggests that successful integration of programs in medical informatics and health services research requires areas of overlapping or synergistic interest and activity among the involved faculty and, hence, in time, among the students. This is enhanced by a mixture of casual and structured contact among students from both disciplines, including social interactions. The challenges to integration are how to overcome any geographic separation that may exist in a given institution; the proper management of relationships with those sub-areas of medical informatics that have less overlap with health services research; and the need to determine how best to exploit opportunities for collaboration that naturally occur.Training in medical informatics and health services research has been closely linked at Stanford University for almost two decades. Although the close linkage was deliberate, it was facilitated by historical circumstances, in particular the common academic structures in which both programs arose. In this paper, we describe some of that rationale and history, identifying the areas of overlap that we have pursued in coordinating the training opportunities for graduate students and fellows in both areas of study. As we shall note, the synergies have been great, and in some cases trainees have collaborated closely on research while also taking some of the same courses. We believe that these interactions can be a model for the design of training programs that encourage scholarly interactions between medical informatics and health services research. Although our initial charge was to describe both the successes and failures in integrating the programs, we found that we could not identify any outright failures and that it would be better to delineate the complexities and challenges that we have faced in bringing together these two disciplines.     

Medical education and society.

As health care changes under the pressures of restraint and constraint our vision of the future of medical education should be based on the medical school's responsibility to the community. The medical school is "an academy in the community": as an academy, it fosters the highest standards in education and research; as an institution in the community, it seeks to improve public health and alleviate suffering. The author argues that to better achieve these goals medical schools need to become more responsible and responsive to the population they serve. Medical schools have been slow to accept fully the social contract by which, in return for their service to society, they enjoy special rights and benefits. This contract requires that medical educators listen to the public, talk honestly and constructively with government representatives and assess the needs and expectations of the community.     

走向生命关爱的公正伦理——平价医院凸显医疗公正的伦理探析

医疗公正的表象是医疗资源分配的公正，实质是社会公正的正义，从根本上说是生命公正。平价医院的诞生有助于缓解“看病难、看病贵”问题，凸显了医疗公正的伦理价值，进而有利于实现社会的真正和谐。     

Children, Gillick competency and consent for involvement in research

This paper looks at the issue of consent from children and whether the test of Gillick competency, applied in medical and healthcare practice, ought to extend to participation in research. It is argued that the relatively broad usage of the test of Gillick competency in the medical context should not be considered applicable for use in research. The question of who would and could determine Gillick competency in research raises further concerns relating to the training of the researcher to make such a decision as well as to the obvious issue of the researcher's personal interest in the project and possibility of benefiting from the outcome. These could affect the judgment of Gillick competency if the researcher is charged with making this decision. The above notwithstanding, there are two exceptional research situations in which Gillick competency might be legitimately applied: (1) when the research is likely to generate significant advantages for the participants while exposing them to relatively minor risks, and (2) when it is likely to generate great societal benefit, pose minimal risks for the participants and yet raise parental objection. In both cases, to ensure that autonomy is genuinely respected and to protect against personal interest, Gillick competency should be assessed by an individual who has no interest or involvement in the research.     

有限性财政支持和负责任的选择:福利国家后的卫生保健

福利国家在医疗保健的金融资助上片面追求公平、公正、平等。坚持医疗保健享有权的公平、公正、平等虽然符合世俗道德,但不符合情理和伦理学要求,并且会误导政府制定出财政上无法持续、医疗经费支付不合理的保健政策,把医疗保健作为福利来对待从而加重国家和个人的经济负担,而不能全面保障国民的保健需求。从国家政策和个人的选择、医疗保健项目与自我使用的权利和可利用的资源、享有权与道德风险、享有权与政治风险、国家福利制度与制药企业间、医疗技术的进步与医疗成本、医学进步与老年人口增长七个方面全方位探讨医疗保健与人的状况的有限性的关系。建议:发展中国家应该审慎研究发达国家的医疗保健政策,但绝不能照搬;他们需要建立和制定符合自己国情的医疗保障体系和政策,使国民享有全面的医疗保障;为了保障医疗财政支持的可持续性及全面保障国民的保健需求,应建立健康储蓄账户,并以强制性购买灾难性健康保险作为补充,对于一些贫穷的地方或地区,由国家支付经费为其建立健康储蓄账户,形成以家庭为单位的医疗经费支付单位,这样可以避免医疗保健享有权的五大危害:过度消费、政治风险、资源不足的风险、风险转移、哲学风险。