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

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

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

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

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)

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

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

7. 處理複雜的具體個案 (臨床) Adapted from: Sliwa JA et al. Am J of PM&R, Vol 81(9), Sep 2002, pp 708-717. (ADAPTED)

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？

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。」

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

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？

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cost-effectiveness) • 行政/政治決定應否凌架醫學/倫理考慮

13. 個案三：罕見疾病的昂貴治療

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

15. 個案四：醫療資源的地區分配 • 將軍澳產房「難產」(20-10-2002)

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

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)

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 (cost-effectiveness) • 專業責任(professional accountability)與機構責任(organisational accountability)

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」？

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)

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.’

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?

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.”

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

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

26. Thank you for your attention

27. Supplementary materials: Ethical theories related to resource allocation and prioritization

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

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)

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.

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

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?