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研究生:李美秀
研究生(外文):Mei-Hsiu Lee
論文名稱:醫療倫理決策模式之研究:莊遜、諾丁與儒家
指導教授:李瑞全李瑞全引用關係
學位類別:博士
校院名稱:國立中央大學
系所名稱:哲學研究所
學門:人文學門
學類:哲學學類
論文種類:學術論文
論文出版年:2013
畢業學年度:101
語文別:中文
論文頁數:177
中文關鍵詞:醫療倫理決策模式莊遜諾丁儒家儒家社群決策模式
外文關鍵詞:medical decision modelAlbert JonsenNel NoddingsConfucianismConfucian community model
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中文論文提要
一個良好的醫療倫理決策模式之所以能被廣泛地應用於臨床實務,以解決日趨複雜的倫理問題,主要是因為其預設的道德根源、人際關係、應用的概念與原則,是能夠切合醫療決策的情況和需求。因此,本文從道德根源、人際關係、應用的概念與原則三方面來分析一個醫療決策的內容,見出其特色。道德根源是一個決策模式之基石,此基石不但說明道德的意義,同時內含相應的人際關係,而基石之分流即是應用的概念與原則。換言之,道德根源是基本的原理,而應用的概念與原則則是將此原理之要義轉化成臨床實際可行之步驟,故三者環環相扣,關係密不可分。將上述三點對任何一個醫療倫理決策模式做分析,即可得知被分析模式之優缺點。
以當前西方臨床上由莊遜所建立的主流的醫療倫理決策模式為例,其道德根源是原則主義之共同道德性,應用的主要概念是:仁愛、不傷害、尊重自律與公義等四個原則。這些原則實預設了西方之個人自由主義。在此背景下,故莊遜的模式以病人之自律為優先。它所預設的人際關係乃是「公民式」的契約關係。醫療決策僅侷限醫師與病人,家屬的參與可有可無。病人的自主權利提高了,但在某些狀況下,將醫療決策權交於因病使判斷力下降的病人是危險的,病人不願透露自己的選取和價值,也易產生棘手的道德兩難議題;而儒家的家庭參與和家庭自律,正能補足莊遜模式之弱點。再者,莊遜公民式的醫病關係顯得很薄弱且未論述應該如何對病人進行關懷以增加醫病間之信任感。儒家自是有家庭的參與,解除病人的孤立無援的困境。而諾丁的關懷倫理學對關懷者與被關懷者間該如何互動有詳細論述,正可適用於臨床實務。
以諾丁的道德根源論點,人與人間之關懷才是道德的基礎,其相應的是關懷式的醫病關係,再延伸出諾丁的醫療倫理決策模式。而儒家義理是以不忍人之心作為道德之根源,關注家庭之人倫關係,現今儒家社群仍舊深受其影響,乃至生
II
活方式與行為,仍隱含著儒家舊有之思想;此在以儒家義理為基礎的社會,常有近乎儒家之醫療倫理決策模式出現。
本文以道德根源、人際關係、應用的概念與原則,分析莊遜、諾丁、儒家之醫療倫理決策模式,再經分析與消融後,截取各家之優點,最後建構「儒家社群之醫療倫理決策模式」,這是一個根據人際間具有的同情共感,建立具有普遍意義的醫療決策模式。其道德根源是儒家之不忍人之心,而此心可以包含諾丁的關懷與莊遜之共同的道德性之要義。不忍人之心是人人皆內在所固有的,是良知良能,較切合我們的道德經驗,由具體的人際關係做開展,較貼切我們的感受與道德判斷,因而人際關係應把家屬納入,因病人體弱,判斷力亦下降,有家屬在旁參與醫療倫理的決策,對病人而言是另一種保護;對諾丁而言,家人位於關懷圈之最內圈,所施予的關懷應比他人來得更多,故諾丁亦會贊成「家庭的自律」。而應用的概念與原則則是會通莊遜、諾丁、儒家之理據後所形成,去除單一理論之缺點,而融合三種理論之優勢,期使此模式對醫療照護品質能提升,同時用傳統儒家之觀點,以迥異西方之角度,重新去審視人的定位,生活與生命之價值與意義,亦能引導臨床醫護人員面對倫理困境時,能順利地進行推理,使得最終的決定是符合倫理的解答。
Abstract
A good medical ethical decision-making model can be widely used on clinical practices to solve increasingly complex ethical issues because the sources of morality, interpersonal relationship, and the moral concepts and principles applied are presupposed to be able to accommodate the conditions and requirements of a medical situation. In this thesis, I employ these three aspects in the analysis of a medical decision model to show its special features. The sources of morality is the foundation of a medical decision model and this foundation explains not only the meaning of morality, but also implies the kind of personal interaction and the moral concepts and principles are derived from this source. In other words, the source of morality is the fundamental principle, and the moral concepts and principles are applied to clinical practice. The three aspects are so interrelated and inseparable and through their analysis we could grasp the advantages and disadvantages of a model. Taking the current western mainstream medical ethical decision-making model created by Albert R. Jonsen as an example, we could see that its source of morality is the “common morality” of principlism. Its main concepts are the four principles, i.e. the principles of beneficence, nonmaleficence, respect of autonomy and justice. These principles of principlism presuppose the liberal individualism of the west. Under this background, Jonsen’s model takes priority the principle of respect of personal autonomy. Personal relation is the typical citizen contractual relationship. Persons involved in medical decision making are limited to doctors and patients while familial participation could be scraped. The self-determination of patients is enhanced. However, under certain conditions, it is risky to leave medical decision making to the patient whose power of judgment is inflicted by the disease. Patient sometimes does not wish to disclose his or her choice and value judgments, and it easily leads to
II
tough ethical dilemmas. Confucian conception of family participation and family autonomy could supplement the shortcomings of Jonsen’s model. Furthermore, Jonsen’s citizen contractual physician-patient relationship is too loose and his model does not respond to the loss of trust between doctors and patients. Confucianism provides family participation to relieve the patient's lonely helpless predicament. While Noddings care ethics has detailed how to improve interactions between the caring and the cared, some of the elements could be applied in clinical practice.
For Noddings, care between persons is the source and foundation of morality. In medical situation, caring is the basic physician-patient relationship, and from this we could derive Noddings’ medical decision model. Confucianism takes the mind of empathy as the source of morality and emphasizes human ethical familial relation. Presently, Confucian communities are still deeply affected by this philosophy, and their life style and behaviors still embody these old Confucian thoughts. Therefore, in a society that takes Confucianism as the basis, it always shows certain Confucian elements in its medical decision model.
The paper employs the framework of moral sources, personal relation, and moral concepts and principles in the analysis of the medical ethical decision models of Jonsen, Noddings and Confucianism and after some detailed analysis, it tries to construct a Confucian community medical ethical decision model. It is a medical decision model built upon interpersonal empathy with universal significance. In this new model, we take the Confucian moral empathy as the source of morality which could contain Noddings’ caring and the common morality of Jonsen’s model. The mind of empathy is an inherent and intrinsic feature of every person. It is our inherent conscience and moral capability, and it fits closely with our moral experiences and judgments. As the patient is usually weak and dependent, the capacity for judgment naturally decreased, hence family participation in medical ethical decision is
III
legitimate and a kind of protection for the patient. According to Noddings’ care ethics, family members are in the innermost circle of caring and would provide much more care than others. Hence, Noddings may also approve Confucian family autonomy. In this model, we absorb the concepts and principles of Jonsen, Noddings and Confucian theories into a well-founded model. It tries to remove the shortcomings of each single theory and merges the advantages of three theories in order to improve the quality of medical care. Furthermore, it employs the Confucian point of view and reconstruct the situations of human being, the meaning and value of life. It constitutes a different model and could provide a workable model for medical professionals to solve probable moral dilemmas, so as to arrive at the best ethical solution for the medical professionals, the patient and the family.

目 錄
第一章 導論 1
第一節 研究目的、動機與方法 2
第二節 當前的醫療倫理決策之主流模式 7
第三節 道德根源、人際關係和應用的概念與原則三者與醫療倫理決策
模式的關係 11
一、道德根源之意義 12
二、人際關係 18
三、應用的概念與原則 22
第四節 對未來臨床實務之貢獻以及論文章節與結構 24
第二章 莊遜的臨床倫理決策模式 26
第一節 莊遜的模式之倫理學背景:原則主義 26
一、道德根源 27
二、人際關係 28
三、應用的概念與原則 29
四、理論的限制 31
第二節 莊遜的臨床倫理決策模式之要義 34
一、道德根源 34
二、人際關係 35
三、應用的概念與原則 36
四、理論的限制 55
附錄 60
第三章 以諾丁的關懷倫理學建立一個醫療倫理決策模式 61
第一節 諾丁的關懷倫理學理論:以關懷為中心 61
一、諾丁的關懷理論之先驅 61
二、諾丁的關懷倫理學之道德根源 64
三、諾丁的關懷倫理學之人際關係 66
四、諾丁的關懷倫理學之應用概念與原則 69
五、諾丁對原則主義之批判 77
第二節 諾丁的關懷倫理於臨床實務之應用 80
一、醫護人員看見病人不適時:內心所湧起的「我必須」 80
二、護理人員與病人的不平等相遇 81
三、被關懷者—病人 82
四、關懷者—醫護人員 83
五、關懷與行動 85
六、結論 86
第三節 諾丁的醫療倫理決策模式 87
一、諾丁之醫療倫理決策模式之要點 89
二、典型案例之應用 94
第四節 諾丁的關懷倫理之優缺點 99
第四章 儒家醫療倫理決策模式 102
第一節 儒家倫理學之基本觀念 102
一、道德價值根源:孔子的「仁」與孟子之「不忍人之心」 103
二、人際關係:五倫與家庭共同體之關係 107
三、應用的概念與原則 112 第二節 儒家醫療倫理決策模式之架構 117
一、第一序之決策 118
二、第二序的決策 121
第三節 案例之應用 124
第四節 儒家醫療倫理決策模式之缺點與優勢 129
第五章 以莊遜、諾丁與儒家為根基所建立的臨床倫理決策模式 133
第一節 融合莊遜、諾丁與儒家之臨床倫理決策模式 133
一、道德的根源 134
二、人際關係 136
三、應用的概念與原則 138
第二節 案例之應用 146
第三節 對當前臨床應用之反省 153
一、對現行的臨床倫理困境之反思 153
二、對傳統臨床倫理決策模式之突破與啟發 158
三、對學生與臨床醫護人員面臨實務工作時之生命教育之貢獻 159
四、促使學生與臨床醫護人員對倫理困境之相關知識的挹注 159
參考文獻 161



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