報告者：林俊龍院長 medical ethics difficult choices noble profession

報告者：林俊龍院長報告者：林俊龍院長

Medical EthicsDifficult Choices

NOBLE PROFESSION

GOOD OLD DAYS OF GOOD OLD DAYS OF MEDICINEMEDICINE

• 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, Electro

physiology)• 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 OATHTo 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 OATHI 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 PHYSICIAN-PATIENT RELATIONSHIPRELATIONSHIP

PURE

AND

SIMPLE

SERVICE ATTITUDE 服務態度

PATIENTPATIENT 病人病人 CLIENTCLIENT 客戶客戶 CUSTOMERCUSTOMER 顧客顧客 PATRONPATRON 主顧主顧 BENEFACTORBENEFACTOR 恩人恩人 MASTERMASTER 主人主人

Bodhisattva

菩薩Buddha

佛

大林十八羅漢的故事

婦產科 --- 許振興醫師

婦產科婦產科 ------ 許振興醫師許振興醫師•陸某某－保險公司主任•年齡 34 歲•主訴－結婚五年未曾生育，經血量過多， 有時如自來水般

•診斷－看過中部各大醫學中心，診斷子宮肌瘤合併嚴重貧血

•醫師建議－全子宮切除

以醫師及疾病為思考導向•全子宮切除（不到 3小時）•一勞永逸---醫師沒有負擔•獨留給病人終生之遺憾•想生育唯有代理孕母一途

人本醫療為思考導向•先切除腫瘤，保留子宮 （如何完全切除腫瘤－ 以不破壞子宮完整之結構）

•如何幫助病人受孕•如何預防早期流產•如何預防早產•如何順利生產•如何監控腫瘤是否再度復發•完成生育計劃 再行全子宮及兩側卵巢切除•時間約需 3 年

人本醫療•把快樂、幸福、滿足

留給病人！•把問題、責任、壓力

留給自己！

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.

一般外科 魏昌國大林十八羅漢的故事

嚴重主動脈瓣狹窄並大腸癌• 57 歲男性 , 來自台南• 心臟瓣膜疾病 , 三年• 2003-12, 心臟衰竭並急性肺水腫 ,奇美醫學中心住院治療

• 害怕開心手術 , 而選擇吃藥控制

• 2004-06, 解黑血便 ,貧血 ,大腸鏡檢查發現大腸癌 ,即住院安排手術

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.

Aortogram & Coronary angio

• 主動脈瓣狹窄狹窄的麻醉危險性高

• 大腸癌手術因麻醉危險 , 而被迫取消 , 先治好心臟 , 再開大腸癌

• 大林慈濟醫院心臟科林院長

• 心導管檢查• 電腦斷層檢查

心導管檢查— Coronary angio

電腦斷層檢查— Chest CT

電腦斷層檢查— Abdomen CT

專業的考驗 , 團隊的合作先做大腸癌手術之危險

• 嚴重主動脈瓣狹窄可能於手術中或手術後造成猝死

• 奇美醫學中心之建議

先做心臟瓣膜手術之危險

• 必須使用大量抗凝血劑 , 造成大腸癌嚴重出血

• 大腸癌手術前需停用抗凝血劑 , 可能產生心臟瓣膜血栓

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

如臨深淵用單純的心 ,做複雜的事

完成第一步— First stage op.

第三期大腸癌 ,淋巴擴散

術後的照顧 ,後續的治療

還是自己的醫院最好• 53 歲 , 台南慈誠師兄• 93-05-08 13樓 健檢中心 , 大腸鏡檢查

• 大腸息肉 ,疑癌病變• 就近治療開刀 , 奇美醫學中心

• 93-05-15 右半大腸部分切除手術

• 併發症的開始 , “瘻管”

•黃色糞臭分泌物由右下腹引流管傷口流出 ,每兩三個小時必須換藥一次

•奇美醫師並未多做說明 ,換藥再換藥

• 93-07-22 大林慈濟醫院外科門診求助

•

瘻管攝影檢查 --Fistulogram

•第二次手術的困難 , 6 小時 , 失血 1000 cc

•只准成功 , 不准失敗 .

•運心轉境

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

大林十八羅漢的故事

骨科 --劉耿彰醫師

叛逆與成長 --骨科劉耿彰醫師

本人多處骨折

小朋友股骨骨折

小朋友術後

本人術後 (1)

本人術後 (2)

六個月後關節纖維化 (Arthrofibrosis)

關節固定太久結痂活動不良

關節鏡解離術

術前

術後術前

復健之辛苦

媽媽的陪伴

復健師的用心

志工菩薩 --師姐的關懷

終於有了進步

癒合

功能正常

行動自如

喜悅 ---找到了家與路

Do No Harm (Non-maleficence)

•說易行難　 It’s easier said than done

• Ｍ ore people died of medical errors than gunshot

• Hospital is a dangerous place

Why?• To err is human

1% chance of making mistakesWrong 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

89 歲 阿嬤真開心

•因為阿嬤很喘 ,無法平躺 ,我們在勉強做完心導管後 ,連夜進行急診主動脈瓣膜置換手術

•術後復原快速 ,於三週後平安出院

The symptoms• Orthopnea, she could not even lie down• Low blood pressure, diaphoresis, profus

e sweating with chest tightness• We performed emergency cardiac cathet

erization and found severe aortic stenosis (gradients of 80 mmHg)

• We discussed the risks and benefits of surgery

• The patient and family agreed to have valve replacement

Justice• Social justice versus economic ju

stice

• 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

Risks Benefits

Costs

Age

Sex

Race

Social Factors

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 nunnun and a nurse nurse ?

The nun has to answer to only

one god

醫療三部曲•下醫醫病 (身 )•中醫醫人 (心 )•上醫醫國 (靈 )

COMPREHENSIVE COMPREHENSIVE 全體性的全體性的FROM HEAD TO TOE FROM HEAD TO TOE

從頭到腳從頭到腳NOT FRAGMENTED NOT FRAGMENTED

不是片段的不是片段的BODY, MIND, SOUL BODY, MIND, SOUL

身身 , , 心心 , , 靈 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. PROFESSIONOCCUPATION 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. PROFESSIONOCCUPATION VS. PROFESSION

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.

PROFESSIONPROFESSION 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,

PROFESSIONPROFESSION 專專業業• maintaining by 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.

PROFESSIONPROFESSION 專業專業 ((SUMMARY) SUMMARY) (Webster)(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 PRIDEPROFESSIONAL PRIDEPride:

• 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 DIGNITYPROFESSIONAL DIGNITY專業的尊嚴專業的尊嚴

Dignity: • The quality or state of being worthy, t

he 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 RESPECT 尊敬尊敬SOMETHING YOU

COMMAND

NOT

SOMETHING YOU DEMAND

RESPECT RESPECT 尊敬尊敬

HE WHO DEMANDS RESPECT GETS

NO RESPECT

保險公司保險公司 醫師醫師

病人病人

政府政府

THIRD PARTY

護士護士醫事人員醫事人員

家屬家屬

保險公司保險公司 醫師醫師

病人病人

政府政府

志工志工

護士護士

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

10 C(十全 )

Convenient Convenient 方便性 方便性 CompassionateCompassionate 有愛有愛心的心的

Comfortable Comfortable 舒適性 舒適性 ConservationalConservational 環環保保

Complete Complete 完全性 完全性 Cost-EffectiveCost-Effective 有效有效益性益性

Continual Continual 連續性 連續性 Community-OrientedCommunity-Oriented 社區性社區性

Comprehensive Comprehensive 全體性 全體性 Computer-BasedComputer-Based 電腦為基電腦為基礎礎

The most beautiful smiles are the patients’

越南義診

甘願做To Care with Compassion

歡喜受To Give with Joy

加入慈濟Join Tzu-Chi

加入人醫會Join TIMA

新加坡慈濟人醫會林深耀醫師•林醫師從 2002年 8月發現患上胰臟癌後，經過開刀、化療等艱苦治療過程

•熱愛生命 在困境中呈現生命偉大光輝的一位勇者

•人的生命不在乎長久，而是在乎做了什麼。所以蠟燭的長短不重要，在乎的是這支蠟燭能不能發光。

•人間眾生不離生老病死，人世的短暫就如一朝風月，稍縱即逝；而莊嚴的大愛精神卻如萬古長空，將是永遠存在。

人生如蠟燭 要點燃方能造福

Life is like a candleIt lights only when it burns 一切因緣生 因緣聚 因緣成

The karmic affinity

brought us all together

It Matters Not Long or Short

The candle is burning

The EndThe End