Medical Ethics Difficult Choices NOBLE PROFESSION GOOD OLD

Medical Ethics Difficult Choices 報告者：林俊龍院長

NOBLE PROFESSION

GOOD OLD DAYS OF MEDICINE • ONE ILL • ONE PILL • ONE BILL

Patients Nowadays • Older • Multiple complaints and underlying illnesses • Physicians employ sophisticated equipment to reach diagnoses • Prescribes multiple drugs with potential interactions.

Subspecialties (1) • • Neurology Gastroenterology (Hepatology) Pulmonary Medicine Cardiology (Invasive, Non-invasive, Electrophysiology) • Nephrology • Endocrinology (Diabetology, Thyroidology)

Subspecialties (2) • • Rheumatology Immunology Hematology/Oncology Infectious Disease Metabolic disease Dermatology Pediatrics Rehabilitation Medicine

Surgical Specialties (1) • • General Surgery (Proctology) Endocrine Surgery Plastic Surgery Neurosurgery Orthopedics Obstetrics-Gynecology Urology

Surgical Specialties (2) • • ENT (Otolaryngology) Ophthalmology Oral Surgery/ Head & Neck Surgery Cardiovascular Surgery/Vascular Surgery • Thoracic Surgery • Traumatology

HIPPOCRATE’S OATH To consider dear to me, as my parent him who taught me this art; to live in common with him and if necessary, to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone, the precepts and the instruction but I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners (specialist in this art). In every house where I come I will enter only for the good of my patients.

HIPPOCRATE’S OATH I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advise which may cause his death, nor will I give a woman a pessary to procure abortion, keeping myself far from all intentional ill-doing and all seductions, and especially from the pleasure of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad,

HIPPOCRATE’S OATH I will keep secret and will never reveal. If I keep the oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

HIPPOCRATE’S OATH • • • An art Like family (sons and brothers) A teacher High standard of personal behavior Refer to specialist Only for the good of patients Do no harm Keeping away from seduction Confidentiality • Profession with respect

Medicine Science Humanities

Five Principles of Medical Ethics • • • A. Autonomy B. Beneficence C. Confidentiality D. Do no harm (non-maleficence) E. Justice

Oriental (Confucian) Principles • • • Compassion Respect Righteousness Dharma (responsibility) Family

PHYSICIAN-PATIENT RELATIONSHIP PURE AND SIMPLE

SERVICE ATTITUDE 服務態度 n PATIENT n PATRON 病人客戶顧客主顧 n BENEFACTOR 恩人 n CLIENT n CUSTOMER

Bodhisattva 菩薩 Buddha 佛

The story • 41 y/o male patient, admitted to our ward • Terminal liver cancer with metastasis • Owned a restaurant in Thailand • Had a son with the waitress, unmarried • Last wish---- to get married so that his son can inherit his properties.

The story • 57 year old male with severe aortic stenosis • Developed blood stool and found to have colon cancer with obvious metastasis • Seen at Tainan Medical Center and heart surgery was advised because the anesthesiologist refused to do anesthesia for colon surgery.

心導管檢查—Coronary angio

Dilemma • Do aortic dissection and valve first, run the risk of GI bleeding and clot in valve • Do the colon cancer first and run the risk of cardiac arrest and stroke perioperatively

完成第一步—First stage op.

瘻管攝影檢查--Fistulogram

Conclusion • 替別人收拾殘局部 (擦xx) 的醫生 To take care of somebody else’s problem • 還是自己的醫院最好 Tzu-Chi is better

Do No Harm (Non-maleficence) • 說易行難　It’s easier said than done • Ｍore people died of medical errors than gunshot • Hospital is a dangerous place

Why? • To err is human 1% chance of making mistakes Wrong identity, wrong part, wrong medication, wrong dosage…….

The Answer • To forgive divine 原諒是神聖的 • Patient safety committee • Double and triple check to reduce the error rate.

89 阿嬤真開心 • 89 year old lady • Loss of appetite, short of breath in last 6 months • Visited medical centers in Taipei • All advised conservative therapy • The eldest son brought her to Dalin because he could not stand the sight of her suffering

The symptoms • Orthopnea, she could not even lie down • Low blood pressure, diaphoresis, profuse sweating with chest tightness • We performed emergency cardiac catheterization and found severe aortic stenosis (gradients of 80 mm. Hg) • We discussed the risks and benefits of surgery • The patient and family agreed to have valve replacement

Justice • Social justice versus economic justice • Equal starting point or same end point? • Unfair world: tall, short; large small; skinny, fat; rich, poor; smart, not so smart, ……

Three Stages of Human Needs • To Survive (存活)Support • To Live (生活)Comfort • To Realize (生命)Education

Age Sex Race Risks Costs Social Factors Benefits

What can we do for patients? Relief Symptoms Prolong Life (Prevent Catastrophe) Risks Versus Benefits

Rapid Advances in Technology • Unrealistic expectations • Make us think, or expect us to be omnipotent • We are not god!

What is the difference between a nun and a nurse ? The nun has to answer to only one god

COMPREHENSIVE 全體性的 FROM HEAD TO TOE 從頭到腳 NOT FRAGMENTED 不是片段的 BODY, MIND, SOUL 身, 心, 靈

The Motto of The City of Hope There is no profit in curing the disease, if in the process, we destroy the soul.

OCCUPATION VS. PROFESSION Occupation: 職業 • To occupy, to take possession • • An activity in which one engages A way of passing the time The principal business of one’s life A craft, trade, profession or other means of earning a living.

OCCUPATION VS. PROFESSION: 專業 (Webster) • The act of taking the vows that consecrate oneself to special religious service. • An act of openly declaring or publicly claiming a belief, faith or opinion.

PROFESSION 專業 • A calling requiring specialized knowledge and often long and intensive preparation including instruction in skills and methods as well as in the scientific, historical or scholarly principles underlying such skills and methods,

PROFESSION 專 • maintaining by 業force of organization or concerted opinion high standards of achievement and conduct and committing its members to continued study and to a kind of work which has for its prime purpose the rendering of public service.

PROFESSION 專業 (SUMMARY) (Webster) • • A belief, faith, or religion Specialized knowledge Long and intensive preparation High standard of achievement & conduct • Society with continued study • Rendering of public service

PROFESSIONAL PRIDE Pride: • A sense of one’s own worth and abhorrence of what is beneath or unworthy of oneself • 引以為傲，不屑為伍。

PROFESSIONAL DIGNITY 專業的尊嚴 Dignity: • The quality or state of being worthy, the quality or state of being honored or esteemed. • Formal reserve of manner, appearance, behavior that accords with self-respect or with regard for the seriousness of occasion or purpose. 尊貴而威嚴態度容貌莊重而不可侵犯

RESPECT 尊敬 SOMETHING YOU COMMAND NOT SOMETHING YOU DEMAND

RESPECT 尊敬 HE WHO DEMANDS RESPECT GETS NO RESPECT

Five Principles of Medical Ethics • • • A. Autonomy B. Beneficence C. Confidentiality D. Do no harm (non-maleficence) E. Justice

Simple solution Patient Centered Medical Care

Convenient 方便性 Compassionate 有愛心的 Comfortable 舒適性 Conservational 環保 Complete 完全性 Cost-Effective 有效益性 Continual 連續性 Community-Oriented 社區性 Comprehensive 全體性 Computer-Based 電腦為基礎 10 C(十全)