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Ethical Issues in Public Healthcare 公共醫療的倫理課題

Ethical Issues in Public Healthcare 公共醫療的倫理課題. Dr Derrick Au ( 區結成醫生 ) Head of Human Resources Hong Kong Hospital Authority. Ethics in Public Health and Health Care Management (EDB 07.6.2012). Ethical principles for clinical cases 臨床上的倫理原則. Commonly taught ethical principles:

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Ethical Issues in Public Healthcare 公共醫療的倫理課題

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  1. Ethical Issues in Public Healthcare公共醫療的倫理課題 Dr Derrick Au(區結成醫生) Head of Human Resources Hong Kong Hospital Authority Ethics in Public Health and Health Care Management (EDB 07.6.2012)

  2. Ethical principles for clinical cases臨床上的倫理原則 Commonly taught ethical principles: • Respect of autonomy尊重自主原則 • Beneficence 行善原則 • Nonmaleficence 不傷害原則 • Justice 公義原則

  3. Clinical ethics in practice臨床倫理原則的應用 • Patient rights病人權利 • Doctor-patient relationship醫患關係 • Health care decision-making 醫療方案的決定

  4. Clinical ethics in practice臨床倫理原則的應用範圍 • Patient rights病人權利 • Doctor-patient relationship醫患關係 • Health care decision-making 醫療方案的決定

  5. Common clinical ethical issues 臨床倫理範圍的常見課題 (部分) • Informed consent 知情同意 • 原則:autonomy,information on risk and benefit,duty of care • Patient privacy 病人私隱 • 原則:autonomy,confidentiality • Life-sustaining treatments 維持生命的治療抉擇 • 原則:autonomy, information on risk and benefit,patient’s best interests

  6. Clinical Ethics • Clinical ethics: A structured approach to assist health care professionals in identifying, analyzing, and resolving ethical issues in clinical medicine. • Some clinical issues of importance: • Informed consent – autonomy vs. benevolence • Truth telling – autonomy vs. nonmaleficence • Confidentiality – autonomy and privacy • End-of-life care – autonomy and risk-benefit • Patient rights – autonomy vs. justice • Risk-benefit – benevolence vs. nonmaleficence

  7. Four-Quadrant method of clinical ethics evaluation分析臨床倫理個案的四格分析方法 A clinical case with ethical problem can be analyzed by considering four aspects of the case Source: Sliwa JA et al. Am J of PM&R, Vol 81(9), Sep 2002, pp 708-717.

  8. Patient’s Charter (病人約章) • In year 2000, the Hong Kong Hospital Authority produced a Patient’s Charter to outline patient rights and responsibilities in public hospital Read more: http://www.ha.org.hk/tmh/patient_charter/index.html

  9. HA Patients’ Charter – Patients’ rights • Right to Medical Treatment (醫治權) • Right to Information(知情權) • Right to Choices(決定權 ) • Right to Privacy(私隱權 ) • Right to Complaint(申訴權)

  10. Issues: Life sustaining treatmentat end of life stage • 《醫院管理局對維持末期病人生命治療的指引》,2002年4月,2012年版本在制定中。 • Ethical considerations involved: • Medical view on what is in patient’s best interests (risk and benefit, quality of life, suffering) • Patient’s informed decision (risk and benefit, values, quality of life, suffering, dignity) • Role of close family members (consensus and conflict management) • Advance directives and Do-not-attempt-resuscitation decisions • Special considerations in decisions related to withdrawing artificial means of nutrition and hydration

  11. Public Health (公共衛生範圍) • Public health practice and policy concerns with issues of illness and disease of populations (關注整體人口或人群的醫療衛生而非個別的醫患關係) • Some ethical issues are unique to public health – conflict between overall health of the public and autonomy of the individual • Immunization (防疫注射) • Mandatory medical reporting and treatment of communicable diseases(強制呈報和治療的規定)

  12. Public Healthcare(公共醫療範圍) • Publicly funded health care is responsible for delivering health service to a population • Many issues are in clinical ethics but some ethical issues are at policy level – e.g. allocation of resources (資源分配的公平性和恰當性) • In health care management ethical issues may be related to health care workers (醫護人員管理上的倫理課題)– e.g. immunization, medical reporting, conscientious objection

  13. Questions raised in case of ‘HIV Doctor’ • The ethical issues : • Privacy/confidentiality vs. ‘Right to know’ of the public (隱私權 vs.公眾知情權) • Mandatory medical reporting (强迫性呈報?) • Restriction of duties (限制臨床醫務工作?) • Discussion

  14. Anti-Drug Driving Law – A&E Doctor’s Role(處理毒駕和醉駕時醫生的角式) • The new law in effect from Mar 2012 allows a doctor to, ‘if he thinks fit’, assist police by taking blood (to check drug/alcohol levels) from patients who are incapable of giving consent at time of presentation to A&E Department • The ethical issues – • Privacy in doctor-patient relationship vs. public interest (公眾利益) • HA policy – neutral or positively facilitate? • Conscientious objection (醫生可否拒絕警方要求?)

  15. Resource allocation: Brothers with Pompe Disease

  16. Allocation of Resources – new treatment for Pompe Disease • In 2010, two brothers with Pompe Disease pleaded for use of a new enzyme replacement therapy. The new drugs are not yet in HA formulary and the evidence for its benefit is not yet strong enough for inclusion • The ethical issues – • Potential benefit vs. cost-effectiveness in treatment of rare conditions with poor prognosis • Compassionate treatment and its implication on equity

  17. Challenges of prioritization 醫療資源分配上的「優先」問題

  18. Applying ethical theories to prioritization (I) • Prioritization to promote personal choice: • This is a Libertarian (自由主義)principle. • Advocates a system which can maximize personal liberty, including allowing individuals free choice to decide what levels of health care they would prefer. • The society may aid those without sufficient resources to pay for health care needs on humanitarian (人道主義)grounds, but it is not demanded on the basis of social justice.

  19. Applying ethical theories to prioritization (II) • Prioritization emphasizing equity and equal access: • The underlying ethical theory is Egalitarianism (平等主義). • Most ethicists would interpret this to mean equal opportunity (機會平等). • In healthcare, equal opportunity translates into equal chance to be assessed or triaged, not actually equal sharing of scarce services

  20. Applying ethical theories to prioritization (III) • Prioritization by cost-effectiveness(成本效益原則): • Justified by the intention to “maximize health gain” for a population. • This is a Utilitarian principle (功利原則). • Not all utilitarian theories advocate a “maximizing principle. • A moderate approach is to adopt the Principle of Proportionality(合適比例原則), which implies that some health care will always be allocated to those with lesser needs, even though the more needy will receive more

  21. Applying ethical theories to prioritization (IV) • Prioritization to reflect societal values: • The underlying ethical theory is Communitarianism(社群原則). • Stresses the importance of local context and societal values (社會的價值觀,例如重視家庭、敬老、關心弱勢社群、重視公平和個人責任).. • Does not favour automatic adoption of universalistic principles (e.g. International guidelines). • 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 find appropriate mechanisms to involve the community in the complex subject of health care resource allocation. • Caution: Professional consensus and community views may be different.

  22. Applying ethical theories to prioritization (V) • Prioritization according to health needs(按客觀評定的需要而作分配): • Needs as determined by assessment • Patient choice weighs little in this approach, as the underlying value is that of Beneficence and Non-maleficence • Aims to be neutral to other value judgments (中立的價值觀e.g. social economic background, life-styles) • Limitation: Comparing medical benefits across different patient groups (e.g. CABG冠心血管搭橋手術vs renal dialysis「洗腎」). is difficult • Caution: Professional consensus does not automatically translate into publicly acceptable policy

  23. Waiting list: Health service prioritization in practice(「輪候」作為例子) • 醫生的診治時間也是「有限的醫療資源」(scarce healthcare resources) • 急症室「分流」(triage),不全是先到先得,而是依病情緩急輕重分類 • 戰地救援的triage :輕傷者最後救,但最嚴重的不一定最先救,因為太嚴重的救不活。戰地「分流」的倫理原則是「整體效益最大化」(maximize benefit),基礎是「功利原則」。急症室不會先考慮效益。 • 公共醫療注重「成本效益」(cost-effectiveness) ,但不可一味追求「整體效益最大化」,否則老年及弱勢病人得不到合適比例的治療(proportionality原則)。

  24. Health service prioritization in practice • In practice, some criteria of prioritization are less controversial and more acceptable than others. • It is generally considered acceptable to prioritize according to patient needs and risk-benefit. • It is usually not acceptable to adopt moral criteria (以道德判斷來編配優次一般並不可取 e.g. “unhealthy life styles is irresponsible there for should not get as much health care.”) • Age-based prioritization is usually not justifiable, except where there is evidence that it is a good proxy to predicting care need or medical outcome. (直接以年齡來編配優次一般並不可取。) • Completely random allocation is usually not adopted unless resource constraint is not an issue. (完全隨機的編配優次一般並不可取,除非該服務並不緊絀。)

  25. Selected references • Medical ethics: http://en.wikipedia.org/wiki/Medical_ethics • 百度百科/醫學倫理: http://baike.baidu.com/view/34513.htm • 抗疫倫理:http://uk.oneworld.net/article/view/122604/1/562 • Public Health Ethics:http://depts.washington.edu/bioethx/topics/public.html • 鎏金頌:醫療資源分配. 考腦筋分配資源點至啱? http://www.hkjc.com/chinese/news/images/Audience_Handout_May2010.pdf • (工具書)杜治政、許志偉主編《醫學倫理學》,鄭州大學出版社,2003。

  26. Thank you for your attention

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