病人权利与医患关系

Patientrightsand

Doctor-patientrelationship

病人權利與醫患關係Dr.DerrickK.S.Au

區結成醫生KowloonHospital&HongKongEyeHospital2021/10/10星期日1Theoldestcodeofmedicalethics:HippocraticOath(4thCenturyBC)

Severalpartsoftheoathhavebeenrevisedovertheyears,e.g.-“Toconsiderdeartome,asmyparents,himwhotaughtmethisart;toliveincommonwithhimand,ifnecessary,tosharemygoodswithhim…”“NorwillIgiveawomanapessarytoprocureabortion;”“Iwillnotcutforstone,evenforpatientsinwhomthediseaseismanifest;Iwillleavethisoperationtobeperformedbypractitioners,specialistsinhisart.”2021/10/10星期日2CodeofProfessionalConduct(HongKongMedicalCouncil)

Medicineasaprofessionisdistinguishedfromotherprofessionsbyaspecialmoraldutyofcaretosavelivesandtorelievesuffering.

MedicalRegistrationOrdinance(Cap.161)confersuponthemedicalprofessionconsiderablefreedomofselfregulation,theprofessionisobligedtoabidebyastrictcodeofconductwhichembodieshighethicalvalues,protectspatients’interests,andupholdsprofessionalintegrity.Trustisessentialtothepracticeofmedicine.Therecanbenomedicineintheabsenceoftrust.Thepatient’strustimposesuponthedoctoracorrespondingdutytobetrustworthyandaccountable..hk/code.htm2021/10/10星期日3Ethics:Whatisright?Moral(道德)-comesfromLatin‘mos’(mores);Ethics(倫理)-comesfromGreek‘ethos’Bothhavemeaningofcustoms(風俗),orgenerallyacceptedsocialnormBut‘Whatisright’isnotjustamatterofsocialnorm(e.g.slaverywasasocialnormatonetime)Professionalnormisnotalwaysright,itdoesreviseovertimeWhatislegallypermittedisnotalwaysright2021/10/10星期日4EthicalprinciplesCommonlyquotedethicalprinciples:Autonomy自主原則Beneficence行善原則Justice正義原則Nonmaleficence不傷害原則Theseareusefulbutbythemselvesarenotadequateforethicaldecisionmaking

2021/10/10星期日5RightsThegreatreligionsoftheworldhaveallsoughttoestablishmoralcodesofconductbasedondivinelaw.Theseareoftenconcernedwiththedutiesandobligationsofmantohisfellowhumanbeings,tonature,toGodandthewholeofcreation.

[AncientChinesemoralphilosopherslikeConfucius(孔子)andMencius(孟子)areconcernedwithsimilarmoralissue,thoughnotasapartofdivinelaw]Theideaof'humanrights'isnotuniversal-itisessentiallytheproductof17thand18thcenturyEuropeanthought.Suchsecularconceptionofrightsemphasiseddutiesandprivilegesthatarosefrompeoples'statusorrelationships,ratherthanabstractrightsinthephilosophicalsense.Since1948,withtheUniversalDeclarationofHumanRights,.Respectforhumanrightsisbecomingauniversalprincipleofgoodgovernment.

/main/histof.htm2021/10/10星期日6Rights/ObligationsApairedconcept,forinstance:People/GovernmentPatient/DoctorHumanbeing/fellowhumanbeingsCommonlyquoteduniversalhumanrights:righttolife;righttofreedom;righttoownproperty(limitingwheregovernmentmayintrude);citizenshiprights(voting,nationalityandparticipationinpubliclife);rightstostandardsofgoodbehaviourbygovernments(orprotectionoftheruleoflaw);Othersocial,economicandculturalrightshavebecomeimportantduringthe20thcentury,andraiseimportantandstillcontroversialissuesaboutsocialjusticeandthedistributionofwealth.

/main/histof.htm2021/10/10星期日7WHO:PatientrightsunderstoodasoneaspectofbasichumanrightsWorldHealthOrganisation:Formalizedin1948,theUniversalDeclarationofHumanRightsrecognizes“theinherentdignity”andthe“equalandunalienablerightsofallmembersofthehumanfamily”.Anditisonthebasisofthisconceptoftheperson,andthefundamentaldignityandequalityofallhumanbeings,thatthenotionofpatientrightswasdeveloped.Inotherwords,whatisowedtothepatientasahumanbeing,byphysiciansandbythestate,tookshapeinlargepartthankstothisunderstandingofthebasicrightsoftheperson.

/genomics/public/patientrights/en/2021/10/10星期日8Fromtheperspectiveofpatients’advocate(病人權益倡議者)社區組織協會:「倡議病人權益是為了保障病人在強調專業知識的醫療制度中，人的自主性及尊嚴不被侵犯。

「經多年推動，病人權益普遍為市民認識及認同，但與先進社會的標準大相逕庭。由於醫護人員與病人關係並不平等、加上醫醫相衛的文化、政府及各醫療機構輕視病人權益，令醫療體系偏離以病人為本的宗旨。市民的知情權、選擇權、私隱權及投訴權未獲充分保障。」.hk/rights/right055_c.htm2021/10/10星期日9WHO:PatientrightscanvaryindifferentcountriesWorldHealthOrganisation(WHO):Patients'rightsvaryindifferentcountriesandindifferentjurisdictions,oftendependinguponprevailingculturalandsocialnorms.Differentmodelsofthepatient-physicianrelationship—whichcanalsorepresentthecitizen-staterelationship—havebeendeveloped,andthesehaveinformedtheparticularrightstowhichpatientsareentitled.

/genomics/public/patientrights/en/2021/10/10星期日10Patient’sCharter(病人約章)Inyear2000,theHongKongHospitalAuthorityproducedaPatient’sChartertooutlinepatientrightsandresponsibilitiesinpublichospital2021/10/10星期日11HAPatients’Charter

–Patients’rightsRighttoMedicalTreatment

(醫治權)RighttoInformation

(知悉權;知情權)RighttoChoices

(決定權

)RighttoPrivacy

(私隱權

)RighttoComplaint

(申訴權)

2021/10/10星期日12HAPatients’Charter

–Patients’ResponsibilitiesGiveyourheathcareprovidersasmuchinformationasyoucanaboutyourpresenthealth,pastillnesses,anyallergies…Followtheprescribedandagreedtreatmentplan,andconscientiouslycomplywiththeinstructionsgiven.Showconsiderationfortherightsofotherpatientsandhealthcareproviders,byfollowingthehospitalrulesconcerningpatientconduct.Keepanyappointmentsthatyoumake,ornotifythehospitalorclinicasearlylaspossible….Shouldnotaskhealthcareproviderstoprovideincorrectinformation,receiptsorcertificates.Shouldnotwastemedicalresourcesunnecessarily..hk/charter/pceng.htm2021/10/10星期日13HongKongMedicalAssociation'sPatients'RightsandResponsibilitiesResponsibilities:Toplayanactiveandresponsibleroleinthehealthcareprocess,youshouldbefranktoyourdoctorsinrevealingyourmedicalconditions.endeavortoco-operatewithanyagreedformofmanagement.bewellinformedbyyourinsurersofthedetailedscopeofcoverageofyourmedicalinsurancepolicies.notrequestdoctorstoissueincorrectreceipts,certificatesordocument,ortomakeincorrectentryintothemedicalrecords.beresponsibletomeettherequiredfeesandchargesforthemedicalservicesprovidedtoyou./english/pubmededu/right.htm2021/10/10星期日14HKMAPatients’rightsRightofinformation.

-Charges -Drugs.RightofrefusalRightofconfidentialityMedicalReports -Publicmedicalinstitutions. -PrivatehospitalsandpractitionersComplaints

-Publicmedicalinstitutions. -PrivatehospitalsandpractitionersOperations

-PublicandPrivateMedicalInstitutions2021/10/10星期日15HKMA:RightofInformationApatientshouldhaveareasonableandbalancedunderstandingofthesicknessheissufferingfrom.Youmayenquireaboutwhatdiseaseyouhave,ifyouneedanyfurtherexamination,andhowtocurethedisease.Youshouldalsoknowwhattreatmentyouwillreceive,whetherwithdrugsoroperation,anysideeffectsaftertreatment,andthechancesofrecurrence.Inotherwords,inordertoknowmorerelevantfactsaboutyoursickness,youshouldconsultyourattendingdoctor.2021/10/10星期日16IntheU.S.DefinitionPatientrightsencompasslegalandethicalissuesintheprovider-patientrelationship,includingaperson'srighttoprivacy,therighttoqualitymedicalcarewithoutprejudice,therighttomakeinformeddecisionsaboutcareandtreatmentoptions,andtherighttorefusetreatment.Manyissuescomprisetherightsofpatientsinthemedicalsystem,includingaperson'sabilitytosueahealthplanprovider;accesstoemergencyandspecialtycare,diagnostictesting,andprescriptionmedicationwithoutprejudice;confidentialityandprotectionofpatientmedicalinformation;andcontinuityofcare./topic/patient-rights2021/10/10星期日17TheU.S.Patient’sBillofRightsHealthcarereformledtoanemergenceofhealthmaintenanceorganizations(HMOs)andothermanagedhealthcareplans.Therapidchangeinmedicalcaremovedhealthcaredecisionmakingfrommedicalprofessionalstobusinessentities,amovemanyconsidertobedetrimentaltothehealthcareindustryingeneral.Establishingapatient'sbillofrightshasbeentheresponsetothisconcern.TheBipartisanPatientProtectionActof2001hasbeendebatedandpassedbytheU.S.SenateandtheU.S.HouseofRepresentativesandsignedintolaw.2021/10/10星期日18IntheU.S.BillofRightsThesebasicrightsincludetherightto:participateinthedevelopmentandimplementationintheplanofcarebetreatedwithrespectanddignity

beinformedaboutcondition,treatmentoptions,andthepossibleresultsandsideeffectsoftreatmentrefusetreatmentinaccordancewiththelaw,andreceiveinformationabouttheconsequencesofrefusalqualityhealthcarewithoutdiscriminationbecauseofrace,creed,gender,religion,nationalorigin,orsourceofpaymentprivacyandconfidentiality,whichincludesaccesstomedicalrecordsuponrequestpersonalsafety

knowtheidentityofthepersontreatingthepatient,aswellasanyrelationshipbetweenprofessionalsandagenciesinvolvedinthetreatment

informedconsentforallproceduresinformation,includingthemedicalrecordsbythepatientorbythepatient'slegallyauthorizedrepresentativeandhospitalcharges,exceptforMedicaidandgeneralassistanceconsultationandcommunication

complainorcomplimentwithoutthefearofretaliationorcompromiseofaccessorqualityofcare2021/10/10星期日19Whatishappeningto

thedoctor-patientrelationship?Somedoctorsareworriedthatthephysician-patientrelationship,aspecialhumanismmotivatedbytraditionandgovernedbytheethicsofmedicine,maybefouledupbythefiscalandeconomicconstraintslikelytooccurinthehealthcaresystem

-AlvanFeinstein,MD,professorofmedicine,YaleUniversitySchoolofMedicine,NewHaven,Conn.Marwick,Charles.

PreservationofPhysician-PatientRelationshipSeenasIntegraltoHealthCareSystemReformJAMATheJournaloftheAmericanMedicalAssociation.Volume271(12),

23March1994,

pp892-8932021/10/10星期日20WilliamC.Hsiao:WilliamC.Hsiao,PhD,DepartmentofHealthPolicyandManagement,HarvardSchoolofPublicHealth,Boston,Mass.

"Wehavepromotedthediffusionofsometechnologiesthatmaynotbecost-effectiveandencouragedtheiroveruse…""Furthermore,weundercompensateprimarycarephysicians,discouragingthemfromrenderingtheirservices,andlikewise(failtoencourage)theyoungmedicalschoolgraduatestopursueacareerinfamilycare.

"Insteadoftryingtoaligntheeconomicincentivestoimprovecost-effectiveness,wearecreatinganadministrativeorganizationthatwillintrudeonthisverypersonalrelationshipbetweendoctorandpatients,betweenthecaringphysicianwiththetechnicalexpertiseandthepatient,""Isthatthebestwecandotopreservethisuniquerelationship?"Marwick,Charles.PreservationofPhysician-PatientRelationshipSeenasIntegraltoHealthCareSystemReformJAMATheJournaloftheAmericanMedicalAssociation.Volume271(12),

23March1994,

pp892-8932021/10/10星期日21ModelsofDoctor-PatientRelationshipTherearethreedifferentkindsofmodels:1.PATERNALISTIC

(家長式關係)2.CONTRACTUAL

(合約關係)3.FIDUCIARY

(受託關係;Fiduciaryduty:受託責任)/~msmillie/bioethics/modelsdocpatrelation.htm2021/10/10星期日22Fiduciaryrelationshipinperil?Overtheagesthedoctor-patientrelationshiphasbeendefined,throughrulesofethicsandrulesoflaw,asafiduciaryone,asarelationshipfoundedintrust.Whenapatientseeksaphysician’shelpandthephysicianagreestogivethathelp,aspecialcovenantismade.

Thepatientagreestotakethephysicianintoherconfidence,torevealtohimeventhemostsecretandintimateinformationrelatedtoherhealth.

Thephysician,inturn,agreestohonorthattrust,andtobecomethepatient’sadvocateinallmattersrelatedtoherhealth,placingherinterestsaboveallothers-includinghisownpersonalorfinancialconcerns.Thelossofthisdoctor-patientrelationshiphasobviousconsequencesforpatients.

Patients,whentheyaresickandthusleastabletofendforthemselves,areleftwithoutatrue,dedicatedadvocateastheytrytonavigatethehostilehallsofthehealthcaresystem,whosechiefconcernistofindwaysofnotspendingmoneyonthem.Lossofthetraditionaldoctor-patientcompactleavespatientsmarginalizedandflounderingwithinthatsystematthetimetheyaremostvulnerable. -BlogofDrRichTheImportanceoftheDoctor-PatientRelationship,andWhyWeCan’tHaveItAnymorePostedonJanuary23,2009

2021/10/10星期日23Paternalisticmodel:

StrengthsandWeaknessesPaternalisticmodel:Thedoctoristheprofessional.He/shegivestheorder,thepatientobeys.Strengths:EmphasizestheexpertiseandknowledgeofthedoctorWeaknesses:IgnorestheautonomyofthepatientIgnoresnon-healthrelatedbutmorallylegitimatevaluesofthepatient2021/10/10星期日24Contractualmodel:

StrengthsandWeaknessesContractualmodel:Thedoctorandpatient"contract"foreachother'smutualbenefit;thepatientdeterminesoragreestothedoctor’sdecisions.Strengths:

HighlightstheautonomyofbothpatientandphysicianAcknowledgescooperative/sharedaspectsofmedicaldecision-makingWeaknesses:No"contracts"developedorsignedinrealdoctor/patientrelationshipsModeldoesn’tallowforattrustingrelationship2021/10/10星期日25Fiduciarymodel:

StrengthsandQuestionsFiduciarymodel:Thepatientconfidentlyentrustshis/herhealthcaretothedoctor,whotakesontheobligationofworkingforthebenefitofthepatient(Fiduciary:relatestoaholdingofsomethingintrustforanother)Strengths:PreservesthefreedomandautonomyofbothpatientandphysicianThelegitimateroleofphysicianknowledgeTheimportantroleoftrustinthedoctor/patientrelationshipQuestionsraisedbyskeptics:1.Patienttrustmaybemanipulatedforfurthereconomicgain.2.Patienttrustmayunderminesconsumer’sawarenessofneedforself-protection3.Seriousillnessandfearofdeathdiminishpatientautonomyandpowertocontractanyrelationship.2021/10/10星期日26WhataboutChineseCulture?TraditionalChinesemedicalethicsemphasizes醫德,basedonvirtuesandmorality,ratherthanrelationshipbetweentwoautonomousindividualsPatientsaschildren(醫者父母心)isrelatedtotheidealimageofabenevolentruler(愛民如子)Itmaybeanalogoustotheconceptofguardianship(監護)inWesternculture2021/10/10星期日27Afewcasesforthought2021/10/10星期日28Case1:RefusaloftreatmentChestphysiotherapyisprescribedforanelderlycancerpatientbytheattendingdoctor,butherefuses.Mustthephysiotherapistinsistoncarryingoutthetreatmentplan?Isitunethicaltogoagainstthepatient’swish(torefuse)?2021/10/10星期日29Case2:AutonomyandfamilymemberApatient’ssoninsistedthatthedoctorshouldnottellhismotherthatshehasbeendiagnosedwithchronicleukemia,otherwisehewilltakeherhomeagainstmedicaladvice.Themotherseemstobegenerallypassiveandsubmissivetotheson’sdecisionsrelatedtoherhealthcareHowshouldthepatient’srightbeaddressed?2021/10/10星期日30Case3:DemandofAlternativeMedicine(另類療法)A20yearoldpatientwithsevereheadinjuryfromtrafficaccidentdidnotimprovewith