醫學生面對倫理兩難案例時的心理衝突

醫學生在實習期間遇到倫理兩難問題時，常有多方面的困惑與衝突，過去在這方面的研究偏重在學生對兩難事件的知覺與描述，對於學生內在衝突的性質較少進行探討。研究者主張對於學生內在衝突現象的探討，有助於倫理教育的提升。本研究以「耶和華見證人拒絕輸血」之案例為主題，對醫學倫理課小組討論過程中的學生心理衝突進行研究。受試者為某醫學院六年級學生，共計51 名（男生35 名，女生16 名），並分成5 個小組，各組由一位資深的臨床醫師帶領討論。討論過程約進行50 分鐘，經徵求學生同意後進行全程錄影，錄影資料就各小組的語言內容與類語言特徵騰成逐字稿，再由2 位研究助理依紮根理論進行內容分析，最後歸納出主要的衝突類別。分析結果指出，醫學生討論本案例時的內在衝突可分成三種面向：與醫療有關的倫理原則與專業角色等內在衝突、醫師與不同人際對象間的外在衝突、以及與法律有關的問題。此三種面向共計包含六類衝突：（1）知覺倫理原則衝突時的心理反應；（2）對醫療目的與醫師角色的困惑；（3）身體傷害與心理傷害的對立；（4）同意家屬進行輸血與擔心病人提告；（5）同意病人不輸血與擔心家屬提告；（6）欺騙病患與擔心被發現。根據研究結果，作者提出三項建議以供後續教學之參考，並指出未來值得深入研究的方向。

When confronted with an ethical dilemma during their internship, medical students often feel confused and conflicted in a variety of aspects. Past studies in this area focused primarily on students' perceptions and descriptions about events of dilemma. In contrast, very little discussion has been made about their inner psychological conflicts. In this research, therefore, we studied the mental conflicts experienced by sixth year medical students during small group discussions in medical ethics class. And the main theme of discussion was the case of "A Jehovah's witness who refuses blood transfusions". The subjects (n=51, male=35, female=16) were divided into five small groups, each of the groups was led by a senior clinical doctor. The sessions of discussion lasted about fifty minutes and were fully videotaped with the students' consensus. Linguistic contents and paralinguistic features in the video clip of each group were transcribed. And two research assistants following grounded theory to discover major types of conflicts analyzed the transcriptions. The analysis shows that the mental conflicts which the medical students felt when discussing the case can be categorized into three aspects: (1) inner conflicts about ethics principles and the professional role, (2) outer conflicts between the doctor and other relevant participants, and (3) law-related issues. These three aspects cover six types of conflicts: (1) conflict between different ethics principles, (2) confusion about the purpose of medical practice and the role of a doctor, (3) physical harm versus mental harm, (4) to follow relatives' order versus to be sued by patient, (5) to respect the patient's autonomy versus to be sued by families, (6) to deceive the patient versus to be found out. On the basis of the findings, the authors propose three suggestions as a reference for teaching practice, and point out some directions that worth further research.