醫師版倫理敏感度之測量與工具發展

The Development of an Ethical Sensitivity Instrument for Physicians

身為醫療人員若不能意識到倫理問題，就無法適當的察覺倫理問題的發生，並作出合宜的反應。 如何定義倫理敏感度並加以評量，是一個在學理與應用上都很重要的問題。現有的倫理敏感度評量工具 有許多概念模糊之處，針對醫護人員的測量工具更是缺乏。本研究以醫學倫理敏感度為研究主題，並因 應當前評估工具的普遍缺乏，嘗試發展一套適用於醫師的倫理敏感度評量工具。研究者主張倫理敏感度 的測量應該包含「辨、察、想」三個面向，也就是：「辨識醫學倫理議題」、「覺察病人的感受」，及「想像 醫療行為對病人福祉的影響」。在這個定義引導下，本研究發展一份測量醫師倫理敏感度之問卷，並檢驗 此工具對倫理敏感度測量的合適性。期望此問卷之發展，能有助於醫學倫理的教學與研究工作。本研究 共分兩個階段進行，階段一為案例故事撰寫與題項設計。透過專家會議決定重要倫理議題，從不同來源 的112 份案例中挑選具有代表性之倫理議題，編寫案例並設計倫理敏感度測量問卷。階段二為問卷施測 與分析階段。以60 名醫學系學生進行預試，對問卷進行項目分析並進行選題。再以75 名醫學系學生作 為正式施測對象，對此倫理敏感度測量結果進行信度、效度分析，及構面分析。第一階段共編制出六個 代表性案例故事。每個案例皆以三部分組成：（一）辨識倫理議題（共6 題），包含4 題倫理四原則與2 題混 淆題項。（二）覺察病人需求（共7 題）。（三）想像行為後果（共7 題）。第二階段資料分析結果顯示：在正式問 卷的信度、效度議題上，「覺察病人需求」與「想像行為後果」分量表的內部一致性信度分別為0.79 與 0.72。「覺察病人需求」呈現良好的收斂效度與區別效度，但「想像行為後果」分量表的收斂效度與區別 效度則較不理想。構面分析結果支持醫學倫理敏感度應包含「辨、察、想」三個面向。

Without the sensitivity for ethical issues, health care providers are unlikely to aware the occurrence of ethical problems and respond appropriately. The definition of ethical sensitivity and evaluation problems is not only valuable for theoretical concerns but also for clinical and educational application. But many existing instruments were not developed from a clear conceptualization. Instruments for medical use are also seriously lacking. The main theme of this study is medical ethical sensitivity. We tried to develop a suitable instrument for the assessment of the ethical sensitivity because of a lack of tools. We proposed that assessment of ethical sensitivity should include three dimensions: 'ethical issue recognition', 'patient needs awareness' and 'behavior consequences imagination'. Guided by a comprehensive theoretical definition, we attempted to develop an indigenous instrument to evaluate physicians’ ethical sensitivity. The study was divided into two stages. Stage I: two groups of experts were invited to analyze 112 case vignettes collected from different sources. The representative ethical case stories and the instrument for the ethical sensitivity assessment was developed via expert validity accordingly. Stage II：The instrument was administered to 60 medical students as a pilot test for item analysis and to 75 medical students as the main test to explore the reliability, validity and representativeness. In Stage I the inventory contained six representative cases, each case included three parts: (1) ethical issue recognition (4 ethical principle items, 2 confounding items); (2) patient needs awareness (7 items); (3) behavior consequences imagination (7 items). In Stage II the reliability (Cronbach’s alpha) for the subscale of patient needs awareness and behavior consequences imagination were 0.79 and 0.72 respectively, which were both at the satisfactory level. The validity of the subscale of patient needs awareness show good convergent and discriminant validity. The validity of the subscale of behavior consequences imagination was unsatisfactory. The result of the regression analysis and the homogeneity test supported the concept that ethical sensitivity should include not only ethical issue recognition but also patient needs awareness and behavior consequences imagination.