()

()

Peter A Singer2003 P210

Peter A Singer2003 P211

Ethical issues
Ethical
Ethical issues bearing upon the rights or
wrongs of human behaviour arise when the
answers proposed to any given question are
uncertain or conflicting.

DJ Roy and N MacDonald. Oxford Textbook of Palliative Medicine.

2nd.ed.1998 P.97

 Ethics

-1990

(Consequentialism) : An action is
morally judged in terms of the
consequences it brings about.
:(Jermy Bentham, ,
1748-1832)
(Utilitarianism):
(the happiness promoted)
(the
greatest happiness for the greatest
number)

(Deontology)

: (Immanuel Kant, , 17281804)

(Categorical
Imperative)

()

()

Search for Evidence:

Evidence-Based Medicine

/(Guidelines)

(
)

(PAS)

2008

(medical futility
(medical uncertainty)
(decision-making)
(Advance Directives)
(assessment of decision
making capacity)
2008


Beauchamp and Childress (1983)
Autonomy
Non-maleficence (doing no harm)

Beneficence (doing good)

Justice

vs.


1. The legal test
2. Gut-feeling test
3. The front-page test
(/ )

4. Role-Model test

- 102008


IDP: Issue, Discussion,
Discussion Plan

Jonsen, Siegler,Winslade. Clinical EthicsA Practical

Approach to Ethical Decisions in Clinical Medicine. 5th ed.
New York, NYMcGraw-Hill;2002.

The Four Topics (four boxes)

Medical indications

Patient preferences
Quality of life
Contextual features

The Four Topics (four boxes)

Medical indications
Patient preferences

Quality of life
Contextual features

The Four Topics (four boxes)

Medical indications
Patient preferences
Quality of life

Contextual features

The Four Topics (four boxes)

Medical indications
Patient preferences
Quality of life
Contextual features

In medical ethics
Beneficence

Nonmaleficence

Jonsen, Siegler,Winslade. Clinical EthicsA Practicall

Approach to Ethical Decisions in Clinical Medicine. 7th
ed.;2010.

Benefit-risk ratio
ratio

the last analysis,

(evaluate it in light of his or

her own values)
Jonsen, Siegler,Winslade. Clinical EthicsA Practicall
Approach to Ethical Decisions in Clinical Medicine. 7th
ed.;2010


1
? ? ??
2
3
4
5

Jonsen, Siegler, Winslade. Clinical EthicsA Practical Approach to

Ethical Decisions in Clinical Medicine. 7th ed. New York, NY
McGraw-Hill2006. ( )

(to the extent

possible I a given clinical setting, set
and reset goals realistically)
Jonsen, Siegler,Winslade. Clinical EthicsA Practicall Approach to
Ethical Decisions in Clinical Medicine. 7th ed.;2010

Indicated or non-indicated

indicated
Jonsen, Siegler,Winslade. Clinical EthicsA Practicall
Approach to Ethical Decisions in Clinical Medicine. 7th
ed.;2010

Indicated or non-indicated
nonindicated:
1.

2.

Jonsen, Siegler,Winslade. Clinical EthicsA Practicall

Approach to Ethical Decisions in Clinical Medicine. 7th
ed.;2010

Non-indicated
3.

4.

indicated

 4415MS
12
MS

urosepsis


indicated for

(adying patient)
(terminally ill patient)
(an incurable patient)

The Dying Patient

non-indicated.
Dying

(dis-integrating),

actively dying or
imminently dying

 in the advanced stage of MS

Deep decubitus ulcers and
osteomyelitis; ()

ICU
ICU
sepsis

in the advanced stage of MS

increasingly stiff lungs, poor
oxygenation. BP 60/40
volume expanders

Arterial O2 saturation: 45%; ABG pH

6.92 ; Anuric, Cr 5.5mg/L (rising).

(futility)

Recommendation
Mr. Care

indicated

Physicological futility

The Terminally Ill Patients

indicated

Terminal

Medicare, Medicaid

terminal

Terminal

(
)


all daily activity
Confused and disoriented, ER
ERunresponsive, high fever,

CXRsuggestive of ARDS; ABG: PO2 35,

PCO2 85, pH 7.02
Cardiac studies: acute anterioseptal MI
Neuro & CM consultants: primary
neuromuscular respiratory insufficiency

callpersonal physician,
ER

ICU?
AMIangioplasty
and stening?
procedures
not indicated ?

Comment

Mr. Care

fibrinolytic therapy or
angioplasty plus stenting
.

Comment (contd)

(support of
compromised function and prolongation of
life)


a)
(unresponsive)

(preference)

[]


b)(prognostic criteria)

functional status

Acute
Acute Physiology and Chronic Health
Evaluation(APACHE):
Evaluation(APACHE) to estimate a patients
risk of dying during an ICU admission.
Modified
Modified Organ Dysfunction Score(MODS):
Score(MODS)
record how many organ systems are
dysfunctional and for how many days


pneumonia, ARDS, AMI => ICU
(extremely low)
(probability)
(certainty)(
)


c)(the

principle of beneficence)

[][
]


d)[

]
[
]

Medical Futility
Futility
Futility
Futility

3
4

5?
6

Singer P.A. ed.: 2003

2
()

6?
7?


1
?
2

3
4?
5?
6?
7?
8?
9?
10()
?

(
)

(PAS)

2008

,,

()()

1.

2.
3.

()
()
6

5
3

7
2
2

(
)

(PAS)

2008

() vs ()

()(CPR)
(ACLS)
()
()
(ECMO)
()
()

(time-limited trials)

1-2

(
)

(PAS)

2008

(double effect)

(best interest)

1.
2.
3.
4.

(
)

(PAS)

2008

 vs
(Euthanasia)

(mercy killing)

()
!!!

 vs
(natural death)
()

!!!

1. /
2.
3.

1.
2.
3.

Responds to patients

Reassuring response

Aggressive response
Judgmental response

Factual response

Empathic response
Questions, Silence

I
II
III
IV
V

()/

(45)

/()
/()

()


(active
dying process)

?
?
?
?


1.
?

: information

2. ?
3. ?

(
)

()
()

()

XXX(
)
/
XXX

Any Question ?