台灣臨床倫理困境之解決──由儒家義理做解析

Applying Confucian Principles to the Resolution of Clinical Ethical Dilemmas in Taiwan

台灣的臨床常見家屬介入醫療決策，忽視病人的自主權，形成醫護人員兩難的倫理困境。此與儒家五倫的傳統文化（孝道與家庭凝聚力強）有關，故醫護人員透過了解儒家義理如何影響華人的生活方式與處事態度，以及其對道德價值與生命之解釋，可使醫護人員把家屬介入醫療視為本土文化特有的現象，但病人的意願仍具優位性，因此醫護人員需審慎處理家屬與病人間分歧的意見，以化解倫理困境。本文依儒家義理應用於臨床的解釋，仁是不忍病人受到傷害的心，此心會引發人的行為合乎道德規範之要求；義是指對於違反道德的事心裡會產生厭惡；禮是指醫護專業規範，照護病人的標準作業流程（standard operation procedure, SOP）；智是指對病人的病況進行適切的專業判斷；進階探討「經權原則」：指SOP不適用於病人時，將其作調整以符合病人所需。而「參贊天道與各盡其性分」：則是運用專業照護，使病人延續生命，實現其生命的意義。了解這些義理，醫護人員可以感知自己就是道德的實踐者，因其工作涉及病人的生命，故所有的行事須符合仁的要求，對於身負這樣的天職與重任，在面臨倫理困境時，適時運用儒家義理，可深化照護的價值與意義。 In Taiwan, the family members of patients are commonly involved in medical decision-making, which undermines patient autonomy and presents an ethical dilemma for medical staff. This issue is rooted in traditional Confucian principles of filial piety and strong family cohesion. Medical professionals understand how morality affects the way of life and attitudes of patients, while the interpretation by healthcare workers of patients' moral values is important for providing professional care. Although patients' wishes for their treatment remain important, family intervention in medical treatment decisions is a common phenomenon in Taiwanese culture. Therefore, medical and nursing staff must carefully consider the opinions of patients and their families in order to resolve ethical dilemmas. The following Confucian principles may be applied to clinical interpretation: Ren refers to the empathy felt toward patients who are in pain, which requires that human behavior is in agreement with ethical requirements; Yi refers to the indignity felt toward violations of morality; Ri refers to medical professional norms (standard operating procedures [SOPs]); and Wisdom refers to making appropriate professional judgments regarding a patient's condition. Advanced discussion of the principle of “Flexibility＂ states that when an SOP does not match the needs / situation of a patient, it should adjusted appropriately. The principle of “Counsel Heaven and the best of all＂ implies that medical staff should apply professional care practices in order to prolong the life of patients and help them achieve meaning in their life. By understanding these principles, medical staff may perceive themselves as moral practitioners. Because their vocation involves responsibilities for the patient's life, all of their acts must be consistent with the requirements of Ren. When faced with an ethical dilemma, the timely use of Confucian principles may deepen the value and significance of nursing.