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 ResourcesHong 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: 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

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

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

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

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

Four-Quadrant method of clinical ethics evaluation分析臨床倫理個案的四格分析方法

Clinical Indications醫學上的指引

Patient Preference

病人的意願

Quality of Life對生命質量的益處

Contextual Features

具體處境的因素

Source: Sliwa JA et al. Am J of PM&R, Vol 81(9), Sep 2002, pp 708-717.

A clinical case with ethical problem can be analyzed by considering four aspects of the case

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

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 )

Issues: Life sustaining treatment at 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

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 )

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

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

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 ?)

Resource allocation: Brothers with Pompe Disease

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

Challenges of prioritization

醫療資源分配上的「優先」問題

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.

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

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

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.

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

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 ) 。

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。 )

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 。

Thank you for your attention