医学伦理学：04 医德基本原则与准则

　　1、现代医学目的 （1 1）预防疾病和损伤，促进和维护健康）预防疾病和损伤，促进和维护健康医学最基本的目的医学最基本的目的 （2 2）解除由疾病引起的疼痛和疾苦）解除由疾病引起的疼痛和疾苦传统医学目的的现代保留传统医学目的的现代保留 （3 3）照料和治愈有病者，照料那些不能治愈者）照料和治愈有病者，照料那些不能治愈者 现代医学现代医学 的重要方向的重要方向 （4 4）避免早死和追求安详死亡）避免早死和追求安详死亡传统目的的最大突破传统目的的最大突破 1 医德基本原则 医德基本准则 医德规范体系 第四章 医德基本原则与准则 医德规范体系 一、医德规范体系的概念 二、医德规范体系的构成 三、医德规范体

　　2、系的意义 医德规范体系的概念一一 医德规范体系医德规范体系(System of medical morality)是是 指由所有医德要求按照一定的逻辑关系共同组成的医指由所有医德要求按照一定的逻辑关系共同组成的医 学职业行为规范系统。学职业行为规范系统。 规范就是规矩、标准，即角色要求。规范就是规矩、标准，即角色要求。 医德规范就是医者角色的道德要求。医德规范就是医者角色的道德要求。 医生的角色是什么？医生的角色是什么？ 医德规范体系的构成二二 医德规范体系由医德原则、医德准则和医德范畴医德规范体系由医德原则、医德准则和医德范畴 三个部分组成。三个部分组成。 医德规范体系的意义三三 （一）处于

　　3、医学伦理学体系的主体地位（一）处于医学伦理学体系的主体地位 （二）具有指导医德实践的重要作用（二）具有指导医德实践的重要作用 1. 1.为医务人员提供行为准则，提升其职业精神为医务人员提供行为准则，提升其职业精神 2. 2.维护医疗关系中各方面的利益维护医疗关系中各方面的利益 3. 3.提高医疗行业的社会信誉提高医疗行业的社会信誉 医德基本原则 一、医德基本原则的概念 二、我国当代医德原则 三、欧美生命伦理原则 四、医德基本原则的应用 医德基本原则的概念一一 医德基本原则(Principles of medical morality) 是指医德规范体系中居统帅和主导地位的最高规范， 也可简称为

　　4、医德原则。它是某一医学发展阶段及特定 社会背景之中的医德基本精神的集中反映，是医德规 范体系的构建基础和直接根据，是调节各种医德关系 必须遵循的最高要求。 我国当代医德原则二 社会主义医学人道主义原则的内容包含：社会主义医学人道主义原则的内容包含： 1.1.防病治病防病治病 2.2.救死扶伤救死扶伤 3.3.实行社会主义人道主义实行社会主义人道主义 4.4.全心全意为人民身心健康服务全心全意为人民身心健康服务 Confuciuss principles had a basis in common Chinese tradition and belief. He championed stron

　　5、g family loyalty, ancestor worship, respect of elders by their children (and in traditional interpretations) of husbands by their wives. He also recommended family as a basis for ideal government. He espoused the well-known principle Do not do to others what you do not want done to yourself, an earl

　　6、y version of the Golden Rule. 欧美生命伦理原则三三 生命伦理学萌发于生命伦理学萌发于2020世纪世纪5050年代的美国，年代的美国， 兴起于兴起于6060年代。年代。2020世纪世纪8080年代，生命伦理学年代，生命伦理学 被介绍到我国，体现其基本精神的生命伦理被介绍到我国，体现其基本精神的生命伦理 原则受到广泛重视。原则受到广泛重视。 目前对我国影响较大的美国生命伦理基目前对我国影响较大的美国生命伦理基 本原则有本原则有“二原则说二原则说”、“ “ 四原则说四原则说”、 “五原则说五原则说”等。等。 欧美生命伦理原则三三 生命伦理学二原则说由美国生命伦理学生命伦

　　7、理学二原则说由美国生命伦理学 家恩格尔哈特（家恩格尔哈特（H.T. EngelhardtH.T. Engelhardt，公元，公元 19411941年年 ）在）在生命伦理学的基础生命伦理学的基础、 生命伦理学与世俗人文主义生命伦理学与世俗人文主义等著作中提等著作中提 出和阐述。他认为，允许（允诺出和阐述。他认为，允许（允诺 ）原则和）原则和 行善原则是生命伦理基本原则。行善原则是生命伦理基本原则。 欧美生命伦理原则三三 “ “四原则说四原则说”由比彻姆（由比彻姆（T.L. BeauchampT.L. Beauchamp）和）和 查尔瑞斯（查尔瑞斯（J.F. ChildressJ.F. Chil

　　8、dress，公元，公元19401940年年 ）在其）在其 合著的合著的生物医学伦理学原理生物医学伦理学原理一书中提出和阐释。一书中提出和阐释。 他们认为，自主原则、不伤害原则、行善原则、公他们认为，自主原则、不伤害原则、行善原则、公 正原则是生命伦理基本原则。正原则是生命伦理基本原则。 欧美生命伦理原则三三 “ “五原则说五原则说”由蒂洛（由蒂洛（Jacques Paul Thiroux,Jacques Paul Thiroux, 公元年公元年1928192820062006年）在其所著的被西方称为社会年）在其所著的被西方称为社会 伦理决策指南的伦理决策指南的伦理学理论与实践伦理学理论与实践一

　　9、书中提出一书中提出 和论述。他认为，生命价值原则、善良原则、公正和论述。他认为，生命价值原则、善良原则、公正 原则、说实话原则、说实话 （或称为诚实）原则、个人自由原则（或称为诚实）原则、个人自由原则 是基本的伦理原则。是基本的伦理原则。 欧美生命伦理原则三三 在西方，由美国学者比彻姆和查尔瑞斯在西方，由美国学者比彻姆和查尔瑞斯 提出的生命伦理四原则即尊重原则、不伤害提出的生命伦理四原则即尊重原则、不伤害 原则、有利原则和公正原则一直作为伦理决原则、有利原则和公正原则一直作为伦理决 策的首选，并被欧美等许多医学组织视为医策的首选，并被欧美等许多医学组织视为医 生的执业行为依据。生的执业行为依据

　　10、。 （一）尊重原则（一）尊重原则 （二）不伤害原则（二）不伤害原则 （三）有利原则（三）有利原则 （四）公正原则（四）公正原则 一般情况下，应把有利（行善）原则放在优先地位一般情况下，应把有利（行善）原则放在优先地位 予以考虑，其次是尊重（自主）原则、不伤害原则和公予以考虑，其次是尊重（自主）原则、不伤害原则和公 正原则。在出现医德原则冲突时应首先考虑主要原则。正原则。在出现医德原则冲突时应首先考虑主要原则。 当然，基本原则应用的主次顺序不是固定不变的，需要当然，基本原则应用的主次顺序不是固定不变的，需要 依据具体临床问题进行慎重选择。依据具体临床问题进行慎重选择。 欧美生命伦理原则三三 （一

　　11、）尊重原则（一）尊重原则 1.1.含义含义 狭义上的尊重原则是指医务人员尊重病人及其家属狭义上的尊重原则是指医务人员尊重病人及其家属 的人格和尊严。广义的尊重原则，除尊重病人人格外，的人格和尊严。广义的尊重原则，除尊重病人人格外， 还包括对病人自主性的尊重。还包括对病人自主性的尊重。 欧美生命伦理原则三三 （一）尊重原则（一）尊重原则 2.2.尊重原则的内容尊重原则的内容 （1 1）尊重病人的生命）尊重病人的生命 （2 2）尊重病人的人格）尊重病人的人格 （3 3）尊重病人的隐私权）尊重病人的隐私权 （4 4）尊重病人的自主权）尊重病人的自主权 欧美生命伦理原则三三 （二）不伤害原则（二）不伤

　　12、害原则 不伤害原则（不伤害原则（Principle of non-maleficencePrinciple of non-maleficence）是）是 指，在医务人员的整个医疗行为中，无论动机，还是结指，在医务人员的整个医疗行为中，无论动机，还是结 果，均应避免对病人造成伤害。果，均应避免对病人造成伤害。 欧美生命伦理原则三三 （三）有利原则（三）有利原则 有利原则（有利原则（Principle of beneficencePrinciple of beneficence）是指）是指 把有利于病人健康放在第一位并切实为其谋利益的把有利于病人健康放在第一位并切实为其谋利益的 伦理原则。伦理原则

　　13、。 欧美生命伦理原则三三 （四）公正原则（四）公正原则 公正原则（公正原则（Principle of justicePrinciple of justice）是指以形式公）是指以形式公 正与内容公正的有机统一为依据分配和实现医疗和健康正与内容公正的有机统一为依据分配和实现医疗和健康 利益的伦理原则，即具有同样医疗需要以及同等社会贡利益的伦理原则，即具有同样医疗需要以及同等社会贡 献和条件的病人应得到同样的医疗待遇，反之，不同的献和条件的病人应得到同样的医疗待遇，反之，不同的 病人则分别享受有差别的医疗待遇。病人则分别享受有差别的医疗待遇。 欧美生命伦理原则三三 医德基本准则 一、医德基本准则概

　　14、述 二、医德基本准则析要 三、医德基本准则的实现 医德基本准则概述一一 医德基本准则（Medical morality code）是指 构成医德规范体系主体部分的具体医德规范，也可简 称为医德准则。它是依据一定的医德理论和原则制定， 医务人员在具体、典型的医学情境中应该遵循的职业 行为准则，是用以调整医学实践中各种具体人际关系、 直接评价医学行为善恶的主要尺度。 医德基本准则的作用医德基本准则的作用 1.1.医德基本准则是医德规范体系中的构成主体医德基本准则是医德规范体系中的构成主体 2.2.医德基本准则是进行医德评价的直接尺度医德基本准则是进行医德评价的直接尺度 3.3.医德基本准则是实施医

　　15、院管理的重要依据医德基本准则是实施医院管理的重要依据 4.4.医德基本准则是养成医学伦理素质的关键环节医德基本准则是养成医学伦理素质的关键环节 医德基本准则概述 一一 医德基本准则析要二 （一）我国权威文献举要（一）我国权威文献举要 （二）国外医德文献举要（二）国外医德文献举要 （三）医德基本准则析要（三）医德基本准则析要 医德基本准则析要二 （一）我国权威文献举要（一）我国权威文献举要 1.1.医疗机构从业人员行为规范医疗机构从业人员行为规范 以人为本，践行宗旨。以人为本，践行宗旨。 遵纪守法，依法执业。遵纪守法，依法执业。 尊重患者，关爱生命。尊重患者，关爱生命。 优质服务，医患和谐。优质

　　16、服务，医患和谐。 廉洁自律，恪守医德。廉洁自律，恪守医德。 严谨求实，精益求精。严谨求实，精益求精。 爱岗敬业，团结协作。爱岗敬业，团结协作。 乐于奉献，热心公益。乐于奉献，热心公益。 医德基本准则析要二 （一）我国权威文献举要（一）我国权威文献举要 2.2.中国医学生誓词中国医学生誓词 健康所系，性命相托。健康所系，性命相托。 当我步入神圣医学学府的时刻，谨庄严宣誓当我步入神圣医学学府的时刻，谨庄严宣誓: : 我志愿献身医学，热爱祖国，忠于人民，恪守医德，我志愿献身医学，热爱祖国，忠于人民，恪守医德， 尊师守纪，刻苦钻研，孜孜不倦，精益求精，全面尊师守纪，刻苦钻研，孜孜不倦，精益求精，全面

　　17、发展；发展； 我决心竭尽全力除人类之病痛，助健康之完美，维我决心竭尽全力除人类之病痛，助健康之完美，维 护医术的圣洁和荣誉。救死扶伤，不辞艰辛，执著护医术的圣洁和荣誉。救死扶伤，不辞艰辛，执著 追求，为祖国医药卫生事业的发展和人类身心健康追求，为祖国医药卫生事业的发展和人类身心健康 奋斗终生。奋斗终生。 医德基本准则析要二 （一）我国权威文献举要（一）我国权威文献举要 3.3.临床医师公约临床医师公约 第一，全心全意为人民健康服务，为我国社会主义医第一，全心全意为人民健康服务，为我国社会主义医 疗卫生事业服务；疗卫生事业服务； 第二，医术上精益求精，团结协作，保证医疗质量，第二，医术上精益求精

　　18、，团结协作，保证医疗质量， 努力进取创新；努力进取创新； 第三，维护严肃、严格、严密的医德医风，廉洁行医，第三，维护严肃、严格、严密的医德医风，廉洁行医， 抵制一切不正之风；抵制一切不正之风； 第四，提倡敬业尊师，积极扶植后学，努力提高临床第四，提倡敬业尊师，积极扶植后学，努力提高临床 服务艺术；服务艺术； 第五，积极开展卫生科普工作，提高群众防治疾病知第五，积极开展卫生科普工作，提高群众防治疾病知 识和自我保健意识。识和自我保健意识。 医德基本准则析要二 （二）国外医德文献举要（二）国外医德文献举要 1.1. 希波克拉底誓言希波克拉底誓言 The Hippocratic Oath The H

　　19、ippocratic Oath is an oath historically taken by physicians and other healthcare professionals swearing to practice medicine ethically and honestly. It is widely believed to have been written either by Hippocrates, often regarded as the father of western medicine, or by one of his students. The Hipp

　　20、ocratic Oath is one of the most widely known of Greek medical texts. It requires a new physician to swear upon a number of healing gods that he will uphold a number of professional ethical standards. English Translation, version 1 Apollo Physician and Asclepius and Hygieia and Panacea and all the go

　　21、ds and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and

　　22、to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who ha

　　23、ve signed the covenant and have taken an oath according to the medical law, but to no one else. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody if asked for it, nor

　　24、 will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. Whatever houses I

　　25、 may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in

　　26、 regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about. If I fulfill this path and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I

　　27、 transgress it and swear falsely, may the opposite of all this be my lot. English translation, version 2 I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agre

　　28、ement: To consider dear to me, as my parents, 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; and that by my teaching, I will impart a knowledge of this art to my own sons, and

　　29、 to my teachers sons, and to disciples bound by an indenture and oath according to the medical laws, and no others. I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will give no deadly medicine to any one if asked, nor sugge

　　30、st any such counsel; and similarly I will not give a woman a pessary to cause an abortion. But I will preserve the purity of my life and my arts. 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, specialists in

　　31、this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or men, be they free or slaves. All that may come to my knowledge in the exercise of my profes

　　32、sion or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life. T

　　33、he Oath has been modified multiple times, in several different countries. One of the most significant revisions is the Declaration of Geneva, first drafted in 1948 by the World Medical Association; it has since been revised several times. I solemnly pledge myself to consecrate my life to the service

　　34、 of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; the health of my patient will be my first consideration; I will maintain by all the means in my power the honor and the noble traditions of the medical pr

　　35、ofession; my colleagues will be my brothers; I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from the time of conception, even under threat, I will not us

　　36、e my medical knowledge contrary to the laws of humanity; I make these promises solemnly, freely and upon my honor. simplest 医德基本准则析要二 （二）国外医德文献举要（二）国外医德文献举要 2.2.日内瓦宣言日内瓦宣言 在允许我成为医界一员的时：在允许我成为医界一员的时： 我郑重地保证自己要奉献一切为人类服务；我郑重地保证自己要奉献一切为人类服务； 我将会给予我的师长应有的尊敬和感谢；我将会给予我的师长应有的尊敬和感谢； 我将会凭着我的良心和尊严从事我的职业；我将会凭着我

　　37、的良心和尊严从事我的职业； 我的病人的健康应是我最先考虑的；我的病人的健康应是我最先考虑的； 我将尊重所寄托给我的秘密，即使是在病人死去之后；我将尊重所寄托给我的秘密，即使是在病人死去之后； 我将会尽我的全部力量，维护医学的荣誉和高尚的传统；我将会尽我的全部力量，维护医学的荣誉和高尚的传统； 我的同行将会是我的兄弟姐妹；我的同行将会是我的兄弟姐妹； 我将不容许年龄、疾病或残疾、信仰、民族、性别、国籍、政见、人种、我将不容许年龄、疾病或残疾、信仰、民族、性别、国籍、政见、人种、 性取向、社会地位或其它因素的考虑介于我的职责和我的病人之间；性取向、社会地位或其它因素的考虑介于我的职责和我的病人之间

　　38、； 我将会保持对人类生命的最大尊重；我将会保持对人类生命的最大尊重； 我将不会用我的医学知识去违反人权和公民自由，即使受到威胁；我将不会用我的医学知识去违反人权和公民自由，即使受到威胁； 我郑重地、自主地并且以我的人格宣誓以上的约定。我郑重地、自主地并且以我的人格宣誓以上的约定。 医德基本准则析要二 （二）国外医德文献举要（二）国外医德文献举要 3.3.新世纪医学职业精神：医师宣言新世纪医学职业精神：医师宣言 Medical Professionalism in the New Millennium: A Physician Charter The charter is the product

　　39、 of several years of work by leaders in the ABIM Foundation, the ACPASIM Foundation, and the European Federation of Internal Medicine. The charter consists of a brief introduction and rationale, three principles, and 10 commitments. The introduction contains the following premise: Changes in the hea

　　40、lth care delivery systems in countries throughout the industrialized world threaten the values of professionalism. The document conveys this message with chilling brevity. The authors apparently feel no need to defend this premise, perhaps because they believe that it is a universally held truth. Th

　　41、e authors go further, stating that the conditions of medical practice are tempting physicians to abandon their commitment to the primacy of patient welfare. These are very strong words. Whether they are strictly true for the profession as a whole is almost beside the point. Each physician must decid

　　42、e if the circumstances of practice are threatening his or her adherence to the values that the medical profession has held dear for many millennia. Preamble Professionalism is the basis of medicines contract with society. It demands placing the interests of patients above those of the physician, set

　　43、ting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physici

　　44、ans, which depends on the integrity of both individual physicians and the whole profession. Fundamental Principles Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physici

　　45、anpatient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle. Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions abo

　　46、ut their treatment. Patients decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care. Principle of social justice. The medical profession must promote justice in the health care system, including

　　47、the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. A Set of Professional Responsibilities Commitment to professional compet

　　48、ence. Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure

　　49、that appropriate mechanisms are available for physicians to accomplish this goal. Commitment to honesty with patients. Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not m

　　50、ean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur. Whenever patients are injured as a cons

　　51、equence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured partie

　　52、s. Commitment to patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with persons acting on a patients behalf when obtaining the patients own

　　53、 consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitm

　　54、ent to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others). Commitment to maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships b

　　55、etween physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose. Commitment to improving quality of care. Physicians must be dedicated to continuous improvement in the quality of healt

　　56、h care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care. Physicians must actively participate in t

　　57、he development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for health care delivery. Physicians, both individually and through their professional associations, must take re

　　58、sponsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care. Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and

　　59、adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity

　　60、entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession. Commitment to a just distribution of finite resources. While meeting the needs of individual patients, p