• 系統編號 RN9701-0213
• 計畫中文名稱 探究醫療倫理辨思---醫療倫理辨思的認知架構
• 計畫英文名稱 The Cognitive Structure of Medical Ethical Reasoning
• 主管機關 行政院國家科學委員會 • 計畫編號 NSC95-2516-S038-003
• 執行機構 台北醫學大學 小兒科
• 本期期間 9508 ~ 9610
• 報告頁數 41 頁 • 使用語言 中文
• 研究人員 蔡淳娟; 蔡甫昌; 蔡哲嘉 Tsai, Tsuen-Chiuan ; Tsai, Daniel Fu-Chang; Tsai, Jer-Chia
• 中文關鍵字 醫療倫理; 認知; 倫理辨思; 醫學教育; 評量; 想法發聲
• 英文關鍵字 Medical ethics; Cognition; Ethical reasoning; Medical education; Assessment; Think aloud method
• 中文摘要
醫療倫理是當今醫學教育的重要課題，醫療倫理需要被有效教導與正確評量。好的醫療倫理行為，乃根植於正確的倫理辨思過程(ethical reasoning)，如此才會有正確的醫療倫理抉擇(ethical decision making)，而表現出好的醫療倫理行為。了解倫理專家們的倫理辨思過程，
可以助益教學。本研究乃在探討醫療倫理專家對各種醫療倫理難題的辨思模式，了解各不同專家度醫師的決策差異，探討其決策背後 的原因，以了解學生之不足，作為教導學生與評量其解決醫療倫理難題的能力的準則。研究方法：使用 15 個醫療倫理的難題(ethical dilemmas)，採用 Think aloud method 加上半結構性面談(semi-structured interview)蒐集語音資料，來分析醫療倫理專家的倫理辨思架 構。研究對象為台灣的醫療倫理學專家、住院醫師第二年、及五年級醫學生，對 think aloud method 蒐集的資料作竹字稿，來探究醫 療倫理專家的倫理辨思過程。訪問錄音，撰寫專家描述的解決問題的思路，然後紀錄其知識架構(knowledge structure)與解決問題的方 法分析方法: 分析結果以質性與量化資料報告，受訪者為醫療倫理專家、住院醫師、及醫五學生，人數已達到每個案例均有至少四個 人作答。描述專家的知識架構(Scheme or algorithm)與解決問題方法，其決策則對照加拿大醫學會出版的臨床倫理系列說明，了解在加 拿大與台灣不同文化與社會背景下的專家有之倫理辨思差異，並分析台灣各灣各專家度不同之醫師，其決策與其倫理辯思表現之差 異。結果此研究發現倫理專家在解決倫理困境的辯思架構大同小異，與加拿大的專家意見比較起來，在壞消息的告知、醫療失誤告知、
牽涉兒童的醫療自主權、及無效醫療的處置上有所差異。台灣專家醫師知道理論上的正確作法，但因為種種環境因素，始施行起來有 所落差。對台灣各階層醫師，若只看倫理決策，並沒有差異，但是在說明決策背後的原因、描述執行面上的具體作法、思緒的周密性、
講話的流暢性及顯示的信心，則各階層間有顯著差異。結論: 當今倫理決策存在理論與實際之施行落差，初學者所欠缺的訓練是決策 背後的辯思基礎，不會運用種種倫理原則與法律規範，並缺少施行的實務經驗。將教學與評量重心放在此，可以幫助初學者有效學習
解決倫理難題。
• 英文摘要
Teaching on medical ethics is now an essential component in medical education. Medical ethics should be taught effectively and assessed accordingly. Ethical reasoning is the prerequisite and determinant of proper ethical decisions that result in appropriate ethical behaviors. To understand the cognitive strategies that experts use in arriving at appropriate ethical decisions will help on teaching medical ethics. This study is to determine the experts’knowledge structure and the reasoning strategies applied when confronted with medical ethical dilemmas. The difference of ethical reasoning across different expertise levels is studied. Methods and subjects: The study uses an instrument, composed of 15 vignettes of ethical dilemmas, to elicit think-aloud process and a semi-structured interview. The subject’ s talk is recorded, scripted word by word and then analyzed for their knowledge structure and reasoning strategies. The subjects are ethical experts, year 2 resident and year 5 medical students. Subjects’performance is compared across three expertise levels of expertise. Analysis: The quality data and quantitative results on subj s’performance were reported. The performance among three expertise levels was compared. Results: The study found
experts’knowledge structure and reasoning strategies congruent to each other. However, Taiwanese experts found difficulty to implement the theoretical standards in real practices. The ethical issues with gaps between theory and practice included: disclosure of bad news, autonomy involving children, the use of futile treatment, and the disclosure of medical errors. Novices had weakness on dealing with implementing their decision, the consideration of involved parties and consequences. Conclusion: There are gaps existing between theory and practices. The weakness of novices is to deal with why and how to act on their ethical decision, but not what the decision
