의사윤리교육

(1)

의사 의사 윤리교육 윤리교육 , ,

무엇을 무엇을 어떻게 어떻게 할 할 것인가 것인가 ? ?

맹 맹 광 광 호 호 가톨릭대학교

가톨릭대학교 의과대학 의과대학 예방의학 예방의학 교수 교수

(2)

의사윤리교육

의사윤리교육 , , 왜 왜 필요한가 필요한가 ? ?

(3)

No (22.2%)

Yes (77.2%) No response

(0.5%)

0 20 40 60 80 100

Medical Surgical Others

Prevalence

%

* P<0.01

Dept.

* *

N = 940, 11 Univ. Hospital

Prevalence of ethical dilemmas that Residents encountered during their clinical practices. Koh et al, 1998

(4)

의료윤리문제의

의료윤리문제의 유형별 유형별 사례 사례

문제유형문제유형 구체적구체적 사례사례

의사-의사-환자관계환자관계 사실사실 알리기, 알리기, 비밀비밀 지키기, 지키기, 사전동의사전동의 의료개입의

의료개입의 선택선택 치료의치료의 중단, 중단, 인공유산인공유산, , 대리모대리모 임신, 임신, 의료자원의

의료자원의 배분배분 부족한부족한 의료자원의의료자원의 적정적정 배분배분 형질변환기술의

형질변환기술의 임상적용임상적용 유전자치료, 유전자치료, 이종이종 장기이식, 장기이식, 등등 의사와의사와 제약사제약사 등과의등과의 관계관계 리베이트, 리베이트, 과도한과도한 선물, 선물, 등등

(5)

(6)

Non Altruism !

(7)

Doctor & Patient Divided ! Doctor & Patient Divided !

Priority:

Patient Welfare

Priority:

Profit margin

(8)

윤리를 윤리를 무시한 무시한 의학 의학 ( ( value value - - free free medicine)

medicine) 은 은 과연 과연 가능한가 가능한가 ? ?

(9)

Medicine

Medicine ≠ ≠ Science Science

Medicine is not synonymous with Medicine is not synonymous with Science or that it is a branch of it.

Science or that it is a branch of it.

Rather, it is a vocation that is Rather, it is a vocation that is

founded on science.

(10)

The symbol of the The symbol of the

physician,

physician, ‘ ‘ Caduceus Caduceus ’ ’ represents the

represents the bonding and bonding and

intertwining between intertwining between

the forces of the forces of

knowledge and knowledge and

wisdom or

wisdom or science science

and and values values . .

(11)

“ Medicine is the Medicine is the most humane of most humane of

sciences, the sciences, the

most empiric of most empiric of

arts, and the arts, and the

most scientific most scientific

of humanities of humanities ” ”

- E. Pellegrino, NEJM, 1974 –

(12)

Medical Education : Medical Education :

Scientific & Humanistic aspects Scientific & Humanistic aspects

““The ideal medicalThe ideal medical education system is to education system is to educate and train highly competent medical educate and train highly competent medical

practitioners only by ensuring that they practitioners only by ensuring that they

acquire and possess the

acquire and possess the knowledge, skills,knowledge, skills, attitudes, and values

attitudes, and values needed for medical needed for medical practice.

practice.””

-- Educating Doctors to Provide High Educating Doctors to Provide High Quality Medical

Quality Medical Care, AAMC, 2004 -Care, AAMC, 2004 -

(13)

The scientific aspect of medicine The scientific aspect of medicine

in medical education has been in medical education has been strongly emphasized for more strongly emphasized for more

than half a century ever since the than half a century ever since the Flexner Report came out in 1910, Flexner Report came out in 1910,

and in fact, this has greatly and in fact, this has greatly

contributed to the development of contributed to the development of

scientific competence of medical scientific competence of medical

students.

(14)

(15)

(16)

““ I have been told that there are two pillars in medicine –I have been told that there are two pillars in medicine – science and humanism. As basic scientists build up the science and humanism. As basic scientists build up the first pillar during the pre

first pillar during the pre-clinical years and neglect the -clinical years and neglect the construction of the second, students learn to treat

construction of the second, students learn to treat patients as they might treat an experimental mouse.

patients as they might treat an experimental mouse.

Idealistic notions of altruism, honest and integrity that Idealistic notions of altruism, honest and integrity that attracted many to be calling of medicine are mentioned attracted many to be calling of medicine are mentioned in the white coat ceremony, talked about by deans, and in the white coat ceremony, talked about by deans, and actively discouraged through the acculturation process.

actively discouraged through the acculturation process.

This is where transformation must take place This is where transformation must take place””..

-- Chen Kenyon, a secondChen Kenyon, a second--year student at Boston University year student at Boston University School of Medicine (

School of Medicine (AcadAcad Med 78:10:1010-Med 78:10:1010-1014, 2004) 1014, 2004) --

(17)

외국에서의

외국에서의 의사윤리교육 의사윤리교육

(18)

Since early 1980s, medical Since early 1980s, medical

educators have tried to develop educators have tried to develop

strategies for improving general strategies for improving general

professional education and professional education and

promoting humanities curricula promoting humanities curricula

such as altruistic attitudes that such as altruistic attitudes that

those pursuing careers in medicine those pursuing careers in medicine

should possess.

(19)

(20)

(21)

Attributes that physicians need to Attributes that physicians need to

meet society

meet society ’ ’ s expectations of s expectations of

them in the practice of medicine them in the practice of medicine

Physicians must be altruistic.

Physicians must be knowledgeable.

Physicians must be skillful.

Physicians must be dutiful.

- AAMC, MSOP, 1998 -

(22)

(23)

(24)

(25)

(26)

(27)

(28)

한국에서의

한국에서의 의사윤리교육 의사윤리교육

(29)

(30)

(31)

Status of ethics education in Korean medical schools , 2003

(맹광호. 의료윤리교육.

(32)

(33)

(34)

(35)

(36)

인턴 인턴 대상 대상 의료 의료 윤리 윤리 교육 교육 실시여부 실시여부

총총 국립병원국립병원 사립병원사립병원 수도권수도권 지방지방

실시함 29 78% 4 25 20 9

실시안함 6 16% 1 5 3 3

무응답 2 6%

계 37 5 30 23 12

(고윤석 들. 의료윤리교육.

(37)

레지던트 대상 의료윤리 교육여부

총총 국립병원국립병원 사립병원사립병원 수도권수도권 지방지방

실시한다 20 54% 2 18 14 6

실시안함 13 35% 3 10 8 5

무응답 4 11%

계 37 5 30 23 12

(고윤석 들. 의료윤리교육.

(38)

(39)

Importance of Role Model

(40)

의사윤리교육 의사윤리교육 , ,

무엇을 무엇을 어떻게 어떻게 할 할 것인가 것인가 ? ?

(41)

““Ethics,Ethics, too, aretoo, are nothing but

nothing but reverence reverence for life

for life. That is what . That is what gives me the

gives me the

fundamental principle fundamental principle

of morality,namely, of morality,namely, that good consists in that good consists in

maintaining, promoting, maintaining, promoting, and enhancing life, and and enhancing life, and

that destroying, that destroying,

injuring, and limiting injuring, and limiting

life are evil life are evil””..

Albert Schweitzer, M.D.

(1875 – 1965)

(42)

의료윤리문제의

의료윤리문제의 유형별 유형별 사례 사례

문제유형문제유형 구체적구체적 사례사례

의사-의사-환자관계환자관계 사실사실 알리기, 알리기, 비밀비밀 지키기, 지키기, 사전동의사전동의 의료개입의

의료개입의 선택선택 치료의치료의 중단, 중단, 인공유산인공유산, , 대리모대리모 임신,임신, 의료자원의

의료자원의 배분배분 부족한부족한 의료자원의의료자원의 적정적정 배분배분 형질변환기술의

형질변환기술의 임상적용임상적용 유전자치료, 유전자치료, 이종이종 장기이식, 장기이식, 등등 의사와의사와 제약사제약사 등과의등과의 관계관계 리베이트, 리베이트, 과도한과도한 선물, 선물, 등등

(43)

(44)

Question is how the Question is how the

medical ethics can be medical ethics can be

taught and evaluated.

(45)

Effective Ethics Education Effective Ethics Education

Begin early and reinforce throughout Begin early and reinforce throughout

the course the course

Fully integrate with the rest of curriculum Fully integrate with the rest of curriculum Teach the student by example (role model) Teach the student by example (role model)

Use more interactive learning methods Use more interactive learning methods

(use of stories, reading assignments, (use of stories, reading assignments, discussions)

discussions)

(46)

(47)

(48)

(49)

Competence Level &

T T - - L Methods of Medical Ethics L Methods of Medical Ethics

KnowKnow

Know how Know how

Show Show howhow

DoDo

Reading, Listening Reading, Listening Story, Case study

Story, Case study Role play, Simulation Role play, Simulation

Demonstration, Role model Demonstration, Role model

Miller

Miller’’s Pyramid of Competences Pyramid of Competence

(50)

(51)

(52)

Importance of Role Model Importance of Role Model

Source credibility

Source credibility – – an important an important principle of adult learning principle of adult learning Role models are effective in

Role models are effective in

inculcating professionalism inculcating professionalism

among learners among learners

How many does your college have?

(53)

The Four Doctors The Four Doctors

((John Singer SargenJohn Singer Sargentt, 1905), 1905) The four physicians who The four physicians who founded Johns Hopkins founded Johns Hopkins

Hospital. The original hangs Hospital. The original hangs

in the William H. Welch in the William H. Welch

Medical Library of Johns Medical Library of Johns

Hopkins University.

From left to right: William From left to right: William

Henry Welch, William Henry Welch, William

Stewart

Stewart Halsted, Halsted, William William Osler

Osler,, Howard KellyHoward Kelly

(54)

한국에서의

한국에서의 의사윤리교육 의사윤리교육 - - 희망과 희망과 도전 도전

희망 희망 : :

- 의사윤리교육의 중요성에 대한 인식 확산

- 의료윤리 교육 및 연구 강화: 한국의료윤리교육학회 - 의대 인정평가 및 병원 심사에서의 윤리교육 강조

도전 도전 : :

- 의학교육 및 전공의 교육부담으로 인한 윤리교육 시간부족

- 의사윤리 교육 전문가 부족

- 지식과 기술 평가 위주의 의사 및 전문의 자격시험제도

- 행위별 진료비 지불제도 및 낮은 수가의 의료보험제도

(55)

The Oak

(Alfred Lord Tennyson, UK, 1809-(Alfred Lord Tennyson, UK, 1809-1892)1892) Live thy Life,

Live thy Life, Young and old, Young and old, Like yon oak, Like yon oak, Bright in spring, Bright in spring, Living gold;

Living gold;

Summer

Summer--richrich Then; and then Then; and then Autumn

Autumn--changedchanged Soberer

Soberer--huedhued Gold again.

Gold again.

All his leaves All his leaves Fall'n

Fall'n at length,at length, Look, he stands, Look, he stands, Trunk and bough Trunk and bough Naked strength.