Ethical Issues
in Public Healthcare
公共醫療的倫理課題
Dr Derrick Au (區結成醫生)
Head of Human Resources
Hong Kong Hospital Authority
Ethics in Public Health and Health Care Management (EDB 07.6.2012)
Ethical principles for clinical cases
臨床上的倫理原則
Commonly taught ethical principles:
 Respect of autonomy尊重自主原則
 Beneficence 行善原則
 Nonmaleficence 不傷害原則
 Justice 公義原則
Clinical ethics in practice
臨床倫理原則的應用
Patient rights 病人權利
 Doctor-patient relationship
醫患關係
 Health care decision-making 醫療方
案的決定

Clinical ethics in practice
臨床倫理原則的應用範圍
Patient rights 病人權利
 Doctor-patient relationship
醫患關係
 Health care decision-making 醫療方
案的決定

Common clinical ethical issues
臨床倫理範圍的常見課題 (部分)

Informed consent 知情同意


Patient privacy 病人私隱


原則：autonomy，information on risk
and benefit，duty of care
原則：autonomy，confidentiality
Life-sustaining treatments 維持生命
的治療抉擇

原則：autonomy， information on risk
and benefit，patient’s best interests
Clinical Ethics


Clinical ethics: A structured approach to
assist health care professionals in
identifying, analyzing, and resolving ethical
issues in clinical medicine.
Some clinical issues of importance:

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Informed consent – autonomy vs.
benevolence
Truth telling – autonomy vs. nonmaleficence
Confidentiality – autonomy and privacy
End-of-life care – autonomy and risk-benefit
Patient rights – autonomy vs. justice
Risk-benefit – benevolence vs.
nonmaleficence
Four-Quadrant method of clinical ethics
evaluation
分析臨床倫理個案的四格分析方法
A clinical case with ethical problem can be
analyzed by considering four aspects of the
case
Clinical
Indications
Patient
Preference
醫學上的指引
病人的意願
Quality of Life
Contextual
Features
對生命質量的益處
具體處境的因素
Source: Sliwa JA et al. Am J of PM&R, Vol 81(9), Sep 2002, pp 708-717.
Patient’s Charter (病人約章)

In year 2000, the Hong Kong Hospital
Authority produced a Patient’s Charter to
outline patient rights and responsibilities in
public hospital
Read more:
http://www.ha.org.hk/tmh/patient_charter/index.html
HA Patients’ Charter
– Patients’ rights





Right
Right
Right
Right
Right
to
to
to
to
to
Medical Treatment (醫治權)
Information (知情權)
Choices (決定權 )
Privacy (私隱權 )
Complaint (申訴權)
Issues: Life sustaining treatment
at end of life stage


《醫院管理局對維持末期病人生命治療的指引》，
2002年4月，2012年版本在制定中。
Ethical considerations involved:




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Medical view on what is in patient’s best
interests (risk and benefit, quality of life,
suffering)
Patient’s informed decision (risk and benefit,
values, quality of life, suffering, dignity)
Role of close family members (consensus and
conflict management)
Advance directives and Do-not-attemptresuscitation decisions
Special considerations in decisions related to
withdrawing artificial means of nutrition and
hydration
Public Health (公共衛生範圍)


Public health practice and policy concerns
with issues of illness and disease of
populations (關注整體人口或人群的醫療衛生
而非個別的醫患關係)
Some ethical issues are unique to public
health – conflict between overall health of
the public and autonomy of the individual


Immunization (防疫注射)
Mandatory medical reporting and treatment of
communicable diseases (強制呈報和治療的規定)
Public Healthcare (公共醫療範圍)


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Publicly funded health care is responsible
for delivering health service to a
population
Many issues are in clinical ethics but
some ethical issues are at policy level –
e.g. allocation of resources (資源分配的公
平性和恰當性)
In health care management ethical issues
may be related to health care workers (醫
護人員管理上的倫理課題)– e.g.
immunization, medical reporting,
conscientious objection
Questions raised in case of ‘HIV
Doctor’

The ethical issues :

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Privacy/confidentiality vs. ‘Right to
know’ of the public (隱私權 vs.公眾知情
權)
Mandatory medical reporting (强迫性呈
報?)
Restriction of duties (限制臨床醫務工作？)
Discussion
Anti-Drug Driving Law – A&E Doctor’s
Role (處理毒駕和醉駕時醫生的角式)


The new law in effect from Mar 2012
allows a doctor to, ‘if he thinks fit’, assist
police by taking blood (to check
drug/alcohol levels) from patients who
are incapable of giving consent at time of
presentation to A&E Department
The ethical issues –


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Privacy in doctor-patient relationship vs. public
interest (公眾利益)
HA policy – neutral or positively facilitate?
Conscientious objection (醫生可否拒絕警方要
求?)
Resource allocation: Brothers with
Pompe Disease
Allocation of Resources – new
treatment for Pompe Disease


In 2010, two brothers with Pompe
Disease pleaded for use of a new enzyme
replacement therapy. The new drugs are
not yet in HA formulary and the evidence
for its benefit is not yet strong enough for
inclusion
The ethical issues –


Potential benefit vs. cost-effectiveness in
treatment of rare conditions with poor
prognosis
Compassionate treatment and its implication
on equity
Challenges of prioritization
醫療資源分配上的「優先」問題
Applying ethical theories to
prioritization (I)

Prioritization to promote personal choice:

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This is a Libertarian (自由主義)principle.
Advocates a system which can maximize
personal liberty, including allowing individuals
free choice to decide what levels of health care
they would prefer.
The society may aid those without sufficient
resources to pay for health care needs on
humanitarian (人道主義)grounds, but it is not
demanded on the basis of social justice.
Applying ethical theories to
prioritization (II)

Prioritization emphasizing equity and
equal access:



The underlying ethical theory is Egalitarianism
(平等主義).
Most ethicists would interpret this to mean
equal opportunity (機會平等).
In healthcare, equal opportunity translates into
equal chance to be assessed or triaged, not
actually equal sharing of scarce services
Applying ethical theories to
prioritization (III)

Prioritization by cost-effectiveness(成本效
益原則):

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Justified by the intention to “maximize health
gain” for a population.
This is a Utilitarian principle (功利原則).
Not all utilitarian theories advocate a
“maximizing principle.
A moderate approach is to adopt the Principle
of Proportionality(合適比例原則), which implies
that some health care will always be allocated
to those with lesser needs, even though the
more needy will receive more
Applying ethical theories to
prioritization (IV)

Prioritization to reflect societal values:
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The underlying ethical theory is Communitarianism(社群原則).
Stresses the importance of local context and societal values
(社會的價值觀，例如重視家庭、敬老、關心弱勢社群、重視公平和個人
責任)..
Does not favour automatic adoption of universalistic principles
(e.g. International guidelines).
Societal values are often implicitly reflected in ”Macro”
allocation levels, e.g. the proportion of resources to be
allocated to take care of the elderly, the mentally ill, sick
children.
Challenge: Not easy to find appropriate mechanisms to involve
the community in the complex subject of health care resource
allocation.
Caution: Professional consensus and community views may be
different.
Applying ethical theories to
prioritization (V)

Prioritization according to health needs(按
客觀評定的需要而作分配):

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Needs as determined by assessment
Patient choice weighs little in this approach, as the
underlying value is that of Beneficence and Nonmaleficence
Aims to be neutral to other value judgments (中立的
價值觀e.g. social economic background, life-styles)
Limitation: Comparing medical benefits across
different patient groups (e.g. CABG冠心血管搭橋手術
vs renal dialysis「洗腎」). is difficult
Caution: Professional consensus does not
automatically translate into publicly acceptable
policy
Waiting list: Health service prioritization
in practice (「輪候」作為例子)

醫生的診治時間也是「有限的醫療資源」(scarce
healthcare resources)

急症室「分流」(triage)，不全是先到先得，而是依病情
緩急輕重分類
戰地救援的triage ：輕傷者最後救，但最嚴重的不一定最
先救，因為太嚴重的救不活。戰地「分流」的倫理原則是
「整體效益最大化」(maximize benefit)，基礎是「功
利原則」。急症室不會先考慮效益。
公共醫療注重「成本效益」(cost-effectiveness) ，但
不可一味追求「整體效益最大化」，否則老年及弱勢病人
得不到合適比例的治療(proportionality原則)。
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Health service prioritization in
practice
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In practice, some criteria of prioritization are less
controversial and more acceptable than others.
It is generally considered acceptable to prioritize according
to patient needs and risk-benefit.
It is usually not acceptable to adopt moral criteria (以道德判
斷來編配優次一般並不可取 e.g. “unhealthy life styles is
irresponsible there for should not get as much health care.”)
Age-based prioritization is usually not justifiable, except
where there is evidence that it is a good proxy to predicting
care need or medical outcome. (直接以年齡來編配優次一般並
不可取。)
Completely random allocation is usually not adopted unless
resource constraint is not an issue. (完全隨機的編配優次一般
並不可取，除非該服務並不緊絀。)
Selected references
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Medical ethics: http://en.wikipedia.org/wiki/Medical_ethics
百度百科/醫學倫理: http://baike.baidu.com/view/34513.htm
抗疫倫理：http://uk.oneworld.net/article/view/122604/1/562
Public Health
Ethics:http://depts.washington.edu/bioethx/topics/public.ht
ml
鎏金頌:醫療資源分配. 考腦筋分配資源點至啱？
http://www.hkjc.com/chinese/news/images/Audience_Hando
ut_May2010.pdf
(工具書)杜治政、許志偉主編《醫學倫理學》，鄭州大學出版社，
2003。
Thank you for your attention