Medical Ethics

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Medical Ethics Difficult Choices

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NOBLE PROFESSION
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GOOD OLD DAYS OF MEDICINE

• ONE ILL
• ONE PILL
• ONE BILL

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Patients Nowadays

• Older
• Multiple complaints and underlying illnesses
• Physicians employ sophisticated equipment to
  reach diagnoses
• Prescribes multiple drugs with potential
  interactions.

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Subspecialties (1)

• Neurology
• Gastroenterology (Hepatology)
• Pulmonary Medicine
• Cardiology (Invasive, Non-invasive,
  Electrophysiology)
• Nephrology
• Endocrinology (Diabetology, Thyroidology)

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Subspecialties (2)

• Rheumatology
• Immunology
• Hematology/Oncology
• Infectious Disease
• Metabolic disease
• Dermatology
• Pediatrics
• Rehabilitation Medicine

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Surgical Specialties (1)

• General Surgery (Proctology)
• Endocrine Surgery
• Plastic Surgery
• Neurosurgery
• Orthopedics
• Obstetrics-Gynecology
• Urology

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Surgical Specialties (2)

• ENT (Otolaryngology)
• Ophthalmology
• Oral Surgery/ Head Neck Surgery
• Cardiovascular Surgery/Vascular Surgery
• Thoracic Surgery
• Traumatology

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HIPPOCRATES OATH

• To consider dear to me, as my parent 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 if they so desire without fee
  or written promise to impart to my sons and the
  sons of the master who taught me and the
  disciples who have enrolled themselves and have
  agreed to the rules of the profession, but to
  these alone, the precepts and the instruction
  but I will preserve the purity of my life and my
  art. 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
  (specialist in this art). In every house where I
  come I will enter only for the good of my
  patients.

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HIPPOCRATES OATH

• I will prescribe regimen for the good of my
  patients according to my ability and my judgment
  and never do harm to anyone. To please no one
  will I prescribe a deadly drug, nor give advise
  which may cause his death, nor will I give a
  woman a pessary to procure abortion, keeping
  myself far from all intentional ill-doing and all
  seductions, and especially from the pleasure of
  love with women or with men, be they free or
  slaves. All that may come to my knowledge in the
  exercise of my profession or outside of my
  profession or in daily commerce with men, which
  ought not to be spread abroad,

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HIPPOCRATES OATH

• I will keep secret and will never reveal. If I
  keep the oath faithfully, may I enjoy my life and
  practice my art, respected by all men and in all
  times but if I swerve from it or violate it, may
  the reverse be my lot.

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HIPPOCRATES OATH

• An art
• Like family (sons and brothers)
• A teacher
• High standard of personal behavior
• Refer to specialist
• Only for the good of patients
• Do no harm
• Keeping away from seduction
• Confidentiality
• Profession with respect

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Medicine
Science
Humanities
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Five Principles of Medical Ethics

• A. Autonomy
• B. Beneficence
• C. Confidentiality
• D. Do no harm (non-maleficence)
• E. Justice

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Oriental (Confucian) Principles

• Compassion
• Respect
• Righteousness
• Dharma (responsibility)
• Family

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PHYSICIAN-PATIENT RELATIONSHIP

• PURE
• AND
• SIMPLE

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SERVICE ATTITUDE ????

• PATIENT ??
• CLIENT ??
• CUSTOMER ??
• PATRON ??
• BENEFACTOR ??
• MASTER ??

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Bodhisattva ??
Buddha ?
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????

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• ????!
• ?????????
• ????!

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The story

• 41 y/o male patient, admitted to our ward
• Terminal liver cancer with metastasis
• Owned a restaurant in Thailand
• Had a son with the waitress, unmarried
• Last wish---- to get married so that his son can
  inherit his properties.

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• 57???, ????
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• 2003-12,??????????,??????????
• ??????, ???????
• 2004-06,????,??,??????????,???????

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The story

• 57 year old male with severe aortic stenosis
• Developed blood stool and found to have colon
  cancer with obvious metastasis
• Seen at Tainan Medical Center and heart surgery
  was advised because the anesthesiologist refused
  to do anesthesia for colon surgery.

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Aortogram Coronary angio

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• ?????
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?????Coronary angio
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??????Chest CT
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??????Abdomen CT
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Dilemma

• Do aortic dissection and valve first, run the
  risk of GI bleeding and clot in valve
• Do the colon cancer first and run the risk of
  cardiac arrest and stroke perioperatively

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?????????,?????
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?????First stage op.
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• 53?, ??????
• 93-05-08 13? ????, ?????
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• 93-05-15 ??????????
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• 93-07-22????????????

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??????--Fistulogram

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• ????????, 6??, ??1000 cc
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• ????

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Conclusion

• ???????? (?xx) ???
• To take care of somebody elses problem
• ?????????
• Tzu-Chi is better

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??--?????

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?????--???????
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??---??????
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Do No Harm (Non-maleficence)

• ???? Its easier said than done
• More people died of medical errors than gunshot
• Hospital is a dangerous place

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Why?

• To err is human
• 1 chance of making mistakes
• Wrong identity, wrong part, wrong medication,
  wrong dosage.

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The Answer

• To forgive divine
• ??????
• Patient safety committee
• Double and triple check to reduce the error rate.

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89 ?????

• 89 year old lady
• Loss of appetite, short of breath in last 6
  months
• Visited medical centers in Taipei
• All advised conservative therapy
• The eldest son brought her to Dalin because he
  could not stand the sight of her suffering

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89? ?????

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The symptoms

• Orthopnea, she could not even lie down
• Low blood pressure, diaphoresis, profuse sweating
  with chest tightness
• We performed emergency cardiac catheterization
  and found severe aortic stenosis (gradients of 80
  mmHg)
• We discussed the risks and benefits of surgery
• The patient and family agreed to have valve
  replacement

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Justice

• Social justice versus economic justice
• Equal starting point or same end point?
• Unfair world tall,short large small skinny,
  fat rich, poor smart, not so smart,

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PROFESSIONAL DIGNITY
?????
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Three Stages of Human Needs

• To Survive (??)-Support
• To Live (??)- Comfort
• To Realize (??)-Education

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Age Sex Race Social Factors
Risks
Benefits
Costs
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What can we do for patients?

• Relief Symptoms
• Prolong Life (Prevent Catastrophe)
• Risks Versus Benefits

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Rapid Advances in Technology

• Unrealistic expectations
• Make us think, or expect us to be omnipotent
• We are not god!

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What is the difference between a nun and a nurse
?

• The nun has to answer to only
• one god

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?????

• ???? (?)
• ???? (?)
• ???? (?)

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COMPREHENSIVE ????
FROM HEAD TO TOE ???? NOT FRAGMENTED
????? BODY, MIND, SOUL ?, ?, ?
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The Motto of The City of Hope

• There is no profit in curing the disease,
• if in the process, we destroy the soul.

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OCCUPATION VS. PROFESSION

• Occupation ??
• To occupy, to take possession
• An activity in which one engages
• A way of passing the time
• The principal business of ones life
• A craft, trade, profession or other means of
  earning a living.

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OCCUPATION VS. PROFESSION

• PROFESSION ?? (Webster)
• The act of taking the vows that consecrate
  oneself to special religious service.
• An act of openly declaring or publicly claiming a
  belief, faith or opinion.

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PROFESSION ??

• A calling requiring specialized knowledge and
  often long and intensive preparation including
  instruction in skills and methods as well as in
  the scientific, historical or scholarly
  principles underlying such skills and methods,

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PROFESSION ??

• maintaining by force of organization or concerted
  opinion high standards of achievement and conduct
  and committing its members to continued study and
  to a kind of work which has for its prime purpose
  the rendering of public service.

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PROFESSION ?? (SUMMARY) (Webster)

• A belief, faith, or religion
• Specialized knowledge
• Long and intensive preparation
• High standard of achievement conduct
• Society with continued study
• Rendering of public service

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PROFESSIONAL PRIDE

• Pride
• A sense of ones own worth and abhorrence of
  what is beneath or unworthy of oneself
• ????,?????

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PROFESSIONAL DIGNITY?????

• Dignity
• The quality or state of being worthy, the quality
  or state of being honored or esteemed.
• Formal reserve of manner, appearance, behavior
  that accords with self-respect or with regard for
  the seriousness of occasion or purpose. ?????
  ???????????

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RESPECT ??

• SOMETHING YOU COMMAND
• NOT
• SOMETHING YOU DEMAND

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RESPECT ??

• HE WHO DEMANDS RESPECT GETS
• NO RESPECT

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THIRD PARTY
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Five Principles of Medical Ethics

• A. Autonomy
• B. Beneficence
• C. Confidentiality
• D. Do no harm (non-maleficence)
• E. Justice

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Simple solution

• Patient Centered Medical Care

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3 C

• Consummer electronics
• Computer
• Communication

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Diamond - 4 C

• Carat
• Color
• Cut
• Clarity

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10 C(??)
Convenient ??? Compassionate ????
Comfortable ??? Conservational ??
Complete ??? Cost-Effective ????
Continual ??? Community-Oriented
??? Comprehensive ??? Computer-Based ?????
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The most beautiful smiles are the patients
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????
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???To Care with Compassion

• ???
• To Give with Joy

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????Join Tzu-Chi

• ?????
• Join TIMA

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????? ???????Life is like a candleIt lights
only when it burns

• ????? ??? ???
• The karmic affinity
• brought us all together

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It Matters Not Long or Short

• The candle is burning

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Thank You
The End