Chin J Integr Med 2014 Nov;20(11):876-880
• 876 •
ACADEMIC EXPLORATION Three Basic Modes for Patients' Clinical Decision-Making in China LI En-chang (李恩昌)1, WANG Zhen (王
臻)2, ZHANG Wen-ying (张文英)3, and ZHAO Liang-yu (赵亮宇)1
ABSTRACT In China, there are three basic clinical decision-making modes for patients, namely patients' autonomous decision-making mode, family decision-making mode and patient and family codetermination. They were produced under the unique background of Chinese medicine, Confucian philosophy and law in China. In this paper, the concepts, advantages and disadvantages of these three decision-making modes were analyzed. In addition, some suggestions were put forward for the improvement. The first is that we suggest to establish standards for choosing decision-making modes; the second is to further learn and publicize relevant laws; thirdly, the legal system needs to be further refined; and the last one is to carry out ethical ward round. KEYWORDS patients' clinical decision-making, Chinese medicine, confucianism, patients' autonomous decision-making, family decision-making mode, patient and family codetermination, ethical ward round
Respecting the individual autonomy in medical decision-making is a basic principle of modern bioethics. However, many scholars believe that China is deeply influenced by the Confucianism, thus family decision-making should be the correct mode in patients' clinical decision-making, and a lot of work have been done in order to support this opinion. The authors of this paper originally also had such a tendency of supporting this Confucian based practice. But many cases of family decision-making have brought and continue to cause sufferings and even death to patients. These unfortunate facts are the reason that drove us to think about and research on this subject. In this paper, we propose that there are at least three basic models of clinical decision-making for patients in China. They are patients' autonomous decision-making, family decision-making and patient and family codetermination. Their advantages and disadvantages are analyzed and some improving measures will also be discussed.
Three Basic Clinical Decision-Making Modes for Patients Patients' Autonomous Decision-Making Mode Patients' autonomous decision-making means that patients make independent clinical decisions in the medical process, according to their own medical knowledge, the doctor's diagnosis and the doctor's treatment recommendations or families members' opinions. In this mode, patients are at the center of the
process of decision-making in regard to their medical treatments. They make their decisions based on their understanding or knowledge gained from the doctor's diagnosis, the disease and the doctor's treatment recommendations. Their families may have different opinions about medical treatments, but in the end the decisions are made by the patients. This decision-making mode is primarily focused on the decision makers, the patients themselves. Family members (such as spouse, parents, children, siblings, etc.) and healthcare professionals only have the role of offering options. Patients will/can be treated only after they making their decisions in their own way. In China this mainly occurs in the outpatient care setting for routine diagnosis and treatments. For example, this mode is usually used in some routine treatments of uncomplicated, none life-threatening diseases, some therapies with few side effects or complications, and in patients with clear consciousness.
©The Chinese Journal of Integrated Traditional and Western Medicine Press and Springer-Verlag Berlin Heidelberg 2014 1. Editorial Department of Chinese Medical Ethics, Medical School of Xi'an Jiaotong University, Xi'an (710061), China; 2. Department of Ultrasound Diagnosis of Tangdu Hospital, Forth Military Medical University, Xi'an (710032), China; 3. School of Humanities, Kunming Medical University, Kunming (650500), China Correspondence to: Prof. LI En-chang, Tel: 86-29-82655404, Fax: 86-29-82655404, E-mail: [email protected] DOI: 10.1007/s11655-014-1987-z
Chin J Integr Med 2014 Nov;20(11):876-880
Chinese culture and society has undergone many changes and developments in relation to its politics, economy, and education which in turn has led to a gradual increase in the proportion of patients employing autonomous decision-making in their healthcare choices. Patients employing this mode of decision-making fall into two groups. The first are those who have a "full understanding" and are strongly independent in their thinking. This understanding is gained by the patient's prior knowledge of his or her own body and in many cases they have some knowledge of the relevant medical problems and the consequences of treatments. These patients also have strong independence and thus feel they cannot or should not rely on others to make a decision. On the other hand there are also some patients undergoing routine medical treatments who take into consideration that it is unnecessary to add any trouble or problems to their family by burdening them with decision-making.
Family Decision-Making Mode Family decision-making means that the patients' family members make the clinical decisions for the patients, by considering the doctors' suggestions or the patients' condition. Family decisions in China play an important role in social relations, family dynamics and medical decisions, which has its roots in both Confucianism and Chinese medicine. This kind of decision mode originated from the Confucian thought of more than two thousand years ago. Family has very important roles and in particular the appropriate family structure is important to maintain social and family stability. Parents or elders as the family "managers" must be authoritative, while children or the younger generation should be subservient and abide by the managers' decision. A family, like a small state, should have managers and policy makers, who usually are the elders or parents, and other members need to report to the managers to make the decisions, the support of these is the Confucian philosophy, the so-called "virtue theory", (1) to cement deep human relationship.(2) The family decision-making mode in China is the reflection of that the process of disease treatment is that as if both patients and their family are treated. This way of decision-making is not focused on policy makers to bear the pain but for the patients economy and spirit to bear. Family structure, kinship and
• 877 •
marriage make the patient and family to be one. This decision mode is usually predominant in the treatment of major diseases or in critical care patients with decreased consciousness, dependent status or limited understanding, which therefore requires someone instead of the patient to make the decision. The family as a collective with the managers, decision-making mode is undoubtedly a choice.
Patient and Family Codetermination Patient and family codetermination mode is that in the medical process, the patients actively participate and understand their condition, through discussing with family members and taking doctors' advices, and then make a clinical decision. This requires that the patients and all involved members understand the conditions, on the basis of the doctor's opinions together with other family members, for health care decisions. Generally speaking, this kind of family is different from the Confucian tradition family, in which the family dynamics and structure is a democratic one. All the family members are one, family is like a community, including the patient, the interests of the whole community are involved in the decision. Other members share knowledge, options, opinions, understanding of the disease and treatments and make a common decision.(3) In many modern medical decision-making processes, decisions tend to be made more and more in this way. Wang, et al(4) analyzed the relationship between signatories with patients in 10,777 operation informed consents. The results showed that the signatures by patients were 2,401 cases (22.3%), 5,142 cases (47.7%) by husband/wife, 2,416 cases (22.4%) by parents/children, and 62 cases (0.6%) by brothers or sisters. The above data from different sides reflects the existence of these three modes, of course, in addition to these three decision modes, there are still occasions when decisions are made by hospital staff, with neither patient or family being involved, for example when no family can be found, and the patient has no identity and is unconscious. But these circumstances are not involved in this paper.
Advantages and Disadvantages of the Three Basic Modes At present, the three kinds of medical decision-
• 878 •
making which reflect China's political and economic, cultural and other social situation and are interconnected with each other. In some sense this is alternating between the old and new philosophies, regulations and beliefs. The new beliefs and regulations have not been accepted well, as the old regulations reflect the Chinese medicine and Confucian mode which attach great importance to family opinions. This has resulted in a clash between the modern (Western approach) and traditional (Eastern approach), although this existence has certain rationality, we need to understand the pros and cons of all.
Advantages and Disadvantages of Patients' Autonomous Decision-Making Independent decision-making in both routine examination and treatment is based on the premise of informed consent in medical decision-making. This involves the doctor fully disclosing information about the illness, possible treatments and the patient being actively involved in the treatment plan. This is not only beneficial to patients' autonomy rights, but also an embodiment of social progress, which embodies the doctors and patients to participate in the treatment through informed consent. Chinese law is placing more and more emphasis on the rights and interests of patients in recent years, for example, clauses in "Tort Liability Law of People's Republic of China" and other laws and regulations all have confirmed the patient's autonomy in medical decision-making. These are not only conducive for the patient's knowledge about his own condition, it can assist in better treatment, but also to the harmonious doctor-patient relationship and avoid medical disputes. Thus this is a win-win situation for patients and hospitals. However, disadvantages are possible because the individual decision-making ability may be limited and may lead to treatment delay or inappropriate treatment, which may in turn bring some unfavorable consequences. Secondly, it is possible because there is no soliciting and respect for the opinions of the family members, which may cause family conflicts.
Advantages and Disadvantages of Family DecisionMaking Mode Family decision-making mode is usually used when a patient doesn't have the decision-making ability, such as has serious illness or is under the
Chin J Integr Med 2014 Nov;20(11):876-880
condition of unconsciousness. Decision-making by the family on behalf of the patient has the advantage of brainstorm and avoid some adverse consequences. Especially in Chinese medicine treatment, because of the poor economy and medical knowledge, the family could play a collective role, make a better information collection and be beneficial to make more suitable decision for the patient. In addition, this mode can also take into account the interests of the family without causing economic depletion or relations worsening. However, family decisions sometimes may ignore the patient's wishes or violate patient's willings because it inevitably involves economic, social and the personal relationship between family members.(5) Sometimes the family decision may sacrifice the patient's health and even life. As in a typical case, (2) a pregnant woman cohabiting with her boyfriend presented to Beijing Chaoyang Hospital. She was found seriously ill and a surgery was needed emergently, but her boyfriend resolutely refused to sign, which lead to the death of both the woman and unborn baby. This case caused a great sensation at that time, and her boyfriend and the hospital were condemned. The wide discussion, to a certain extent, led to the "Tort Liability Law of the People's Republic of China", which says in medical decision-making, it must add the terms of the written consent of the patients, in order to safeguard the rights and interests of patients. To some hospitals in China, if some severe patients had accidents in the examination or surgery, it is always their family who have medical disputes with hospitals. Therefore, these hospitals tend to have the family members to sign, to prevent the possible trouble in the future. This violates the patient's autonomy in medical decision-making and more likely to delay the treatment or even be life-threatening as in the above case. Although confucianism is at an important place in China, in the new era with rapid social development for over 2,000 years, it does not conform to the requirements of the society development today if still put family above the individual and even above the society. Therefore, we should start with a new ethical view on personal and family in the medical decisionmaking.
Chin J Integr Med 2014 Nov;20(11):876-880
• 879 •
Advantages and Disadvantages of Patient and Family Codetermination
in a strong democratic atmosphere family.
In the patient and family codetermination mode, not only the interests of the family was considered, but also the patients understand their diseases. The patients are informed to a certain extent. Under the current situation of China, family factors should be considered and family members should participate in this important decision-making. As result, this mode now is a better clinical decision-making mode.
Further Learning and Publicizing Relevant Laws
Although the Chinese consciousness is constantly improving nowadays, most patients still have the tendency to rely on the family. This kind of decision-making mode takes the family members' opinions and interests into consideration and lets the patient have the rights to be informed in a certain extent. This mode combines the modern Western medicine emphasizing patient's autonomy and Chinese current reality. Thus it is an ideal mode for medical decision-making in China. However the problem is that there could be some disagreements of the patient and family which might delay the patient's treatment and medical selection, and sometimes make the decision-making cost higher.
Suggestions for Improving Patients' Clinical Decision-Making in China Establish Standards for Choosing Decision-Making Modes We propose that the standards for mode selection are: first, the benefit maximization for patients; second, timeliness, convenience, easy for decision-making without any delay; third, when the family don't agree with the patient, priority should be given to patients' opinions. There is no absolute standard for making a good decision, however, a good decision-making mode should depend on the illness, disease, conditions of patients, family situation, and so forth. Thus, the three modes have their specific situations. Patients' autonomous decision-making is more suitable for outpatient, hospital patients who is the manager of the family, patients with rich medical knowledge or strong independent consciousness. Family decision-making mode is suitable for children, critically ill patients in a coma, elderly with less thinking ability. The third decision mode is suitable for difficult diseases, most surgical patients and patients
As previously mentioned, the coexisting of these three modes, in some sense is the reflection of the influencing of the old laws and regulations during its alternating with new ones. In 1982, the "Rules and Regulations for Medical Work in Hospital"(7) issued by the Ministry of Health, stated that "operation agreement must be signed by the patient's family or unit." However, in 1994, "The Regulations on Medical Institutions" by the State Council stated that "Medical surgery, special examination or treatment in medical institutions must obtain patient's consent as well as the agreement and sign of their family member or relevant party."(8) Laws usually are based on the ethics, the two laws or regulations above both contain the Confucian thinking. In the latter law, patients have the right of agreement and the family member or relevant party have the right of signature, which means many medical decisions are given to the family member or relevant party. However, in 2010, the "Case Writing Standards" and the "Tort Liability Law of the People's Republic of China" began to be implemented, in which the patients now have the rights of both informed consent and signature.(9,10) For example, the "Case Writing Standards" states that "Medical activities must be approved by the patients, the patients themselves need to sign the informed consent form". Although the new rules and regulations have been carried out, the past practice of family member signature still remains. In addition, the legislative intention is to protect the rights and interests of patients, but signed informed consent, from many doctors' view, mainly to protect the doctors. Zhao interviewed four different Chinese seniority doctors, they all agree that informed consent is mainly to protect the doctor, to make them away from prosecution, informed consent is actually the doctor's disclaimer.(11) It was also under the influence of this thought, some hospitals have the patients and their family members both sign for the examinations or operations, which make the patient's autonomous clinical decision-making difficult. Thus, it is necessary for the medical staff and medical institutions to learn more about the relevant laws. The management departments in the hospitals also need to carry out some law enforcement inspection in order to promote
Chin J Integr Med 2014 Nov;20(11):876-880
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the implementation of laws and regulations. In the medical treatment, medical institutions and medical staff should introduce the new relevant laws and regulations so as to let them fully understand and make a reasonable medical decision.
medical institutions and medical staff should also be refined, in order to improve the guiding role for patients' medical decision-making, but it does not belong to the scope of this article.
REFERENCES 1. Fan RP. Construct Chinese bioethics—pursuing the
Further Refining the Legal System
brilliance and eternity of Chinese culture. Chin Med Ethics
As mentioned above, in China, these years the relevant legal documents are paying more and more attention to patients' rights. The "Tort Liability Law of the People's Republic of China"(10) has been clear that the doctor must respect for patient's autonomy. These are the legal basis for patient's autonomy. However, some laws are difficult to perform in some medical institutions not only due to the traditional Chinese family thinking and the possible prosecution to medical staff, but also because some laws are less refined, without specific instructions. More research and work should be done to refine the laws.
(Chin) 2010;23(5):6-8. 2. Li EC, Wen CF. Should the Confucian family determination model be rejected? A case study. J Med Philos 2010;35:587-599. 3. Xu HH. Family members jointly decide - Confucian family standard thoughts embodied in clinical decisions. Chin Foreign Med Philos (Chin) 2013;1:9-20. 4. Wang FS, Lu LF, Zhu XY, Liu CL. Who is in the exercise of patients' rights? Analysis of the signature of informed consents in 10,777 cases of surgery. J Med Philos (Chin) 2013;34:40-41. 5. Engelhardt HT, Zhang Y, Zhang DZ. Chinese bioethics should be based on local culture. Chin Med Ethics (Chin)
Carrying out Ethical Ward Round Bioethics in China has presented professional development,(12) the ethical ward round is one of them. The ethical ward round means that hospital ethics committee and the administration department check the implementation of informed consent, autonomy and privacy protection of patients in clinical departments and evaluate the results of examination as well as put forward suggestions for improvement. The earliest Chinese ethical ward round began in Shanghai Shuguang Hospital, satisfactory results have been achieved.(13) Later, some other large hospitals also carry out the ethical ward round, but it has not generally carried out in China.
2013;26:420-425. 6. Confucius, Mencius. The classics. Xi'an: Integrating Ecology Press; 2007:279-280. 7. Rules and Regulations for Medical Work in Hospital. Ministry of Health. 1982. Available from: http://www.yilv.net/ article/fgsd/xzgz/244.htm. 8. Cui XM. The interpretation of article 33 of the "Regulations on Administration of Medical Institutions"—based on "Xiao Zhi-jun" case. J Law Soc (Chin) 2009;12(12):78-79. 9. Ministry of health department. Law of medical accident treatment and supporting file assembly. Beijing: China Legal System Publishing House; 2002:44-54. 10. The Tort Liability Law of the People's Republic of China (EB/OL). Available from: http://www.gov.cn/jrzg/2009-12/26/
Ethical ward round could supervise and promote the implement of patients' informed consent. The investigation by talking directly with patients and their families, going through medical record, understanding the details of treatment decisions and signing procedures could make them determine which mode did the patient choose and evaluate the rationality and possible problems of the decision. These ethical ward round results will be fed back to the department and medical staff so as to improve the patient's rights. In addition, of course, the responsibilities of
content_1497435.htm. 11. Zhao WQ. Clinical practice and reflection of the informed consent in some Chinese. Chin Foreign Med Philos (Chin) 2013;1:21-32. 12. Li EC, Li M, Jia Z, Liu P. 2014 international bioethics forum between UK and China and the professional development of bioethics in china. Bioethics 2014;28:ii-iv. 13. Xi YQ, Zhu KM, Xu BH, Fan MS. Experience of making the medical ethics rounds of the wards. Chin Med Ethics (Chin) 2002;15(6):7-9. (Received June 10, 2014) Edited by YUAN Lin
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ACADEMIC EXPLORATION Three Basic Modes for Patients' Clinical Decision-Making in China LI En-chang (李恩昌)1, WANG Zhen (王
臻)2, ZHANG Wen-ying (张文英)3, and ZHAO Liang-yu (赵亮宇)1
ABSTRACT In China, there are three basic clinical decision-making modes for patients, namely patients' autonomous decision-making mode, family decision-making mode and patient and family codetermination. They were produced under the unique background of Chinese medicine, Confucian philosophy and law in China. In this paper, the concepts, advantages and disadvantages of these three decision-making modes were analyzed. In addition, some suggestions were put forward for the improvement. The first is that we suggest to establish standards for choosing decision-making modes; the second is to further learn and publicize relevant laws; thirdly, the legal system needs to be further refined; and the last one is to carry out ethical ward round. KEYWORDS patients' clinical decision-making, Chinese medicine, confucianism, patients' autonomous decision-making, family decision-making mode, patient and family codetermination, ethical ward round
Respecting the individual autonomy in medical decision-making is a basic principle of modern bioethics. However, many scholars believe that China is deeply influenced by the Confucianism, thus family decision-making should be the correct mode in patients' clinical decision-making, and a lot of work have been done in order to support this opinion. The authors of this paper originally also had such a tendency of supporting this Confucian based practice. But many cases of family decision-making have brought and continue to cause sufferings and even death to patients. These unfortunate facts are the reason that drove us to think about and research on this subject. In this paper, we propose that there are at least three basic models of clinical decision-making for patients in China. They are patients' autonomous decision-making, family decision-making and patient and family codetermination. Their advantages and disadvantages are analyzed and some improving measures will also be discussed.
Three Basic Clinical Decision-Making Modes for Patients Patients' Autonomous Decision-Making Mode Patients' autonomous decision-making means that patients make independent clinical decisions in the medical process, according to their own medical knowledge, the doctor's diagnosis and the doctor's treatment recommendations or families members' opinions. In this mode, patients are at the center of the
process of decision-making in regard to their medical treatments. They make their decisions based on their understanding or knowledge gained from the doctor's diagnosis, the disease and the doctor's treatment recommendations. Their families may have different opinions about medical treatments, but in the end the decisions are made by the patients. This decision-making mode is primarily focused on the decision makers, the patients themselves. Family members (such as spouse, parents, children, siblings, etc.) and healthcare professionals only have the role of offering options. Patients will/can be treated only after they making their decisions in their own way. In China this mainly occurs in the outpatient care setting for routine diagnosis and treatments. For example, this mode is usually used in some routine treatments of uncomplicated, none life-threatening diseases, some therapies with few side effects or complications, and in patients with clear consciousness.
©The Chinese Journal of Integrated Traditional and Western Medicine Press and Springer-Verlag Berlin Heidelberg 2014 1. Editorial Department of Chinese Medical Ethics, Medical School of Xi'an Jiaotong University, Xi'an (710061), China; 2. Department of Ultrasound Diagnosis of Tangdu Hospital, Forth Military Medical University, Xi'an (710032), China; 3. School of Humanities, Kunming Medical University, Kunming (650500), China Correspondence to: Prof. LI En-chang, Tel: 86-29-82655404, Fax: 86-29-82655404, E-mail: [email protected] DOI: 10.1007/s11655-014-1987-z
Chin J Integr Med 2014 Nov;20(11):876-880
Chinese culture and society has undergone many changes and developments in relation to its politics, economy, and education which in turn has led to a gradual increase in the proportion of patients employing autonomous decision-making in their healthcare choices. Patients employing this mode of decision-making fall into two groups. The first are those who have a "full understanding" and are strongly independent in their thinking. This understanding is gained by the patient's prior knowledge of his or her own body and in many cases they have some knowledge of the relevant medical problems and the consequences of treatments. These patients also have strong independence and thus feel they cannot or should not rely on others to make a decision. On the other hand there are also some patients undergoing routine medical treatments who take into consideration that it is unnecessary to add any trouble or problems to their family by burdening them with decision-making.
Family Decision-Making Mode Family decision-making means that the patients' family members make the clinical decisions for the patients, by considering the doctors' suggestions or the patients' condition. Family decisions in China play an important role in social relations, family dynamics and medical decisions, which has its roots in both Confucianism and Chinese medicine. This kind of decision mode originated from the Confucian thought of more than two thousand years ago. Family has very important roles and in particular the appropriate family structure is important to maintain social and family stability. Parents or elders as the family "managers" must be authoritative, while children or the younger generation should be subservient and abide by the managers' decision. A family, like a small state, should have managers and policy makers, who usually are the elders or parents, and other members need to report to the managers to make the decisions, the support of these is the Confucian philosophy, the so-called "virtue theory", (1) to cement deep human relationship.(2) The family decision-making mode in China is the reflection of that the process of disease treatment is that as if both patients and their family are treated. This way of decision-making is not focused on policy makers to bear the pain but for the patients economy and spirit to bear. Family structure, kinship and
• 877 •
marriage make the patient and family to be one. This decision mode is usually predominant in the treatment of major diseases or in critical care patients with decreased consciousness, dependent status or limited understanding, which therefore requires someone instead of the patient to make the decision. The family as a collective with the managers, decision-making mode is undoubtedly a choice.
Patient and Family Codetermination Patient and family codetermination mode is that in the medical process, the patients actively participate and understand their condition, through discussing with family members and taking doctors' advices, and then make a clinical decision. This requires that the patients and all involved members understand the conditions, on the basis of the doctor's opinions together with other family members, for health care decisions. Generally speaking, this kind of family is different from the Confucian tradition family, in which the family dynamics and structure is a democratic one. All the family members are one, family is like a community, including the patient, the interests of the whole community are involved in the decision. Other members share knowledge, options, opinions, understanding of the disease and treatments and make a common decision.(3) In many modern medical decision-making processes, decisions tend to be made more and more in this way. Wang, et al(4) analyzed the relationship between signatories with patients in 10,777 operation informed consents. The results showed that the signatures by patients were 2,401 cases (22.3%), 5,142 cases (47.7%) by husband/wife, 2,416 cases (22.4%) by parents/children, and 62 cases (0.6%) by brothers or sisters. The above data from different sides reflects the existence of these three modes, of course, in addition to these three decision modes, there are still occasions when decisions are made by hospital staff, with neither patient or family being involved, for example when no family can be found, and the patient has no identity and is unconscious. But these circumstances are not involved in this paper.
Advantages and Disadvantages of the Three Basic Modes At present, the three kinds of medical decision-
• 878 •
making which reflect China's political and economic, cultural and other social situation and are interconnected with each other. In some sense this is alternating between the old and new philosophies, regulations and beliefs. The new beliefs and regulations have not been accepted well, as the old regulations reflect the Chinese medicine and Confucian mode which attach great importance to family opinions. This has resulted in a clash between the modern (Western approach) and traditional (Eastern approach), although this existence has certain rationality, we need to understand the pros and cons of all.
Advantages and Disadvantages of Patients' Autonomous Decision-Making Independent decision-making in both routine examination and treatment is based on the premise of informed consent in medical decision-making. This involves the doctor fully disclosing information about the illness, possible treatments and the patient being actively involved in the treatment plan. This is not only beneficial to patients' autonomy rights, but also an embodiment of social progress, which embodies the doctors and patients to participate in the treatment through informed consent. Chinese law is placing more and more emphasis on the rights and interests of patients in recent years, for example, clauses in "Tort Liability Law of People's Republic of China" and other laws and regulations all have confirmed the patient's autonomy in medical decision-making. These are not only conducive for the patient's knowledge about his own condition, it can assist in better treatment, but also to the harmonious doctor-patient relationship and avoid medical disputes. Thus this is a win-win situation for patients and hospitals. However, disadvantages are possible because the individual decision-making ability may be limited and may lead to treatment delay or inappropriate treatment, which may in turn bring some unfavorable consequences. Secondly, it is possible because there is no soliciting and respect for the opinions of the family members, which may cause family conflicts.
Advantages and Disadvantages of Family DecisionMaking Mode Family decision-making mode is usually used when a patient doesn't have the decision-making ability, such as has serious illness or is under the
Chin J Integr Med 2014 Nov;20(11):876-880
condition of unconsciousness. Decision-making by the family on behalf of the patient has the advantage of brainstorm and avoid some adverse consequences. Especially in Chinese medicine treatment, because of the poor economy and medical knowledge, the family could play a collective role, make a better information collection and be beneficial to make more suitable decision for the patient. In addition, this mode can also take into account the interests of the family without causing economic depletion or relations worsening. However, family decisions sometimes may ignore the patient's wishes or violate patient's willings because it inevitably involves economic, social and the personal relationship between family members.(5) Sometimes the family decision may sacrifice the patient's health and even life. As in a typical case, (2) a pregnant woman cohabiting with her boyfriend presented to Beijing Chaoyang Hospital. She was found seriously ill and a surgery was needed emergently, but her boyfriend resolutely refused to sign, which lead to the death of both the woman and unborn baby. This case caused a great sensation at that time, and her boyfriend and the hospital were condemned. The wide discussion, to a certain extent, led to the "Tort Liability Law of the People's Republic of China", which says in medical decision-making, it must add the terms of the written consent of the patients, in order to safeguard the rights and interests of patients. To some hospitals in China, if some severe patients had accidents in the examination or surgery, it is always their family who have medical disputes with hospitals. Therefore, these hospitals tend to have the family members to sign, to prevent the possible trouble in the future. This violates the patient's autonomy in medical decision-making and more likely to delay the treatment or even be life-threatening as in the above case. Although confucianism is at an important place in China, in the new era with rapid social development for over 2,000 years, it does not conform to the requirements of the society development today if still put family above the individual and even above the society. Therefore, we should start with a new ethical view on personal and family in the medical decisionmaking.
Chin J Integr Med 2014 Nov;20(11):876-880
• 879 •
Advantages and Disadvantages of Patient and Family Codetermination
in a strong democratic atmosphere family.
In the patient and family codetermination mode, not only the interests of the family was considered, but also the patients understand their diseases. The patients are informed to a certain extent. Under the current situation of China, family factors should be considered and family members should participate in this important decision-making. As result, this mode now is a better clinical decision-making mode.
Further Learning and Publicizing Relevant Laws
Although the Chinese consciousness is constantly improving nowadays, most patients still have the tendency to rely on the family. This kind of decision-making mode takes the family members' opinions and interests into consideration and lets the patient have the rights to be informed in a certain extent. This mode combines the modern Western medicine emphasizing patient's autonomy and Chinese current reality. Thus it is an ideal mode for medical decision-making in China. However the problem is that there could be some disagreements of the patient and family which might delay the patient's treatment and medical selection, and sometimes make the decision-making cost higher.
Suggestions for Improving Patients' Clinical Decision-Making in China Establish Standards for Choosing Decision-Making Modes We propose that the standards for mode selection are: first, the benefit maximization for patients; second, timeliness, convenience, easy for decision-making without any delay; third, when the family don't agree with the patient, priority should be given to patients' opinions. There is no absolute standard for making a good decision, however, a good decision-making mode should depend on the illness, disease, conditions of patients, family situation, and so forth. Thus, the three modes have their specific situations. Patients' autonomous decision-making is more suitable for outpatient, hospital patients who is the manager of the family, patients with rich medical knowledge or strong independent consciousness. Family decision-making mode is suitable for children, critically ill patients in a coma, elderly with less thinking ability. The third decision mode is suitable for difficult diseases, most surgical patients and patients
As previously mentioned, the coexisting of these three modes, in some sense is the reflection of the influencing of the old laws and regulations during its alternating with new ones. In 1982, the "Rules and Regulations for Medical Work in Hospital"(7) issued by the Ministry of Health, stated that "operation agreement must be signed by the patient's family or unit." However, in 1994, "The Regulations on Medical Institutions" by the State Council stated that "Medical surgery, special examination or treatment in medical institutions must obtain patient's consent as well as the agreement and sign of their family member or relevant party."(8) Laws usually are based on the ethics, the two laws or regulations above both contain the Confucian thinking. In the latter law, patients have the right of agreement and the family member or relevant party have the right of signature, which means many medical decisions are given to the family member or relevant party. However, in 2010, the "Case Writing Standards" and the "Tort Liability Law of the People's Republic of China" began to be implemented, in which the patients now have the rights of both informed consent and signature.(9,10) For example, the "Case Writing Standards" states that "Medical activities must be approved by the patients, the patients themselves need to sign the informed consent form". Although the new rules and regulations have been carried out, the past practice of family member signature still remains. In addition, the legislative intention is to protect the rights and interests of patients, but signed informed consent, from many doctors' view, mainly to protect the doctors. Zhao interviewed four different Chinese seniority doctors, they all agree that informed consent is mainly to protect the doctor, to make them away from prosecution, informed consent is actually the doctor's disclaimer.(11) It was also under the influence of this thought, some hospitals have the patients and their family members both sign for the examinations or operations, which make the patient's autonomous clinical decision-making difficult. Thus, it is necessary for the medical staff and medical institutions to learn more about the relevant laws. The management departments in the hospitals also need to carry out some law enforcement inspection in order to promote
Chin J Integr Med 2014 Nov;20(11):876-880
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the implementation of laws and regulations. In the medical treatment, medical institutions and medical staff should introduce the new relevant laws and regulations so as to let them fully understand and make a reasonable medical decision.
medical institutions and medical staff should also be refined, in order to improve the guiding role for patients' medical decision-making, but it does not belong to the scope of this article.
REFERENCES 1. Fan RP. Construct Chinese bioethics—pursuing the
Further Refining the Legal System
brilliance and eternity of Chinese culture. Chin Med Ethics
As mentioned above, in China, these years the relevant legal documents are paying more and more attention to patients' rights. The "Tort Liability Law of the People's Republic of China"(10) has been clear that the doctor must respect for patient's autonomy. These are the legal basis for patient's autonomy. However, some laws are difficult to perform in some medical institutions not only due to the traditional Chinese family thinking and the possible prosecution to medical staff, but also because some laws are less refined, without specific instructions. More research and work should be done to refine the laws.
(Chin) 2010;23(5):6-8. 2. Li EC, Wen CF. Should the Confucian family determination model be rejected? A case study. J Med Philos 2010;35:587-599. 3. Xu HH. Family members jointly decide - Confucian family standard thoughts embodied in clinical decisions. Chin Foreign Med Philos (Chin) 2013;1:9-20. 4. Wang FS, Lu LF, Zhu XY, Liu CL. Who is in the exercise of patients' rights? Analysis of the signature of informed consents in 10,777 cases of surgery. J Med Philos (Chin) 2013;34:40-41. 5. Engelhardt HT, Zhang Y, Zhang DZ. Chinese bioethics should be based on local culture. Chin Med Ethics (Chin)
Carrying out Ethical Ward Round Bioethics in China has presented professional development,(12) the ethical ward round is one of them. The ethical ward round means that hospital ethics committee and the administration department check the implementation of informed consent, autonomy and privacy protection of patients in clinical departments and evaluate the results of examination as well as put forward suggestions for improvement. The earliest Chinese ethical ward round began in Shanghai Shuguang Hospital, satisfactory results have been achieved.(13) Later, some other large hospitals also carry out the ethical ward round, but it has not generally carried out in China.
2013;26:420-425. 6. Confucius, Mencius. The classics. Xi'an: Integrating Ecology Press; 2007:279-280. 7. Rules and Regulations for Medical Work in Hospital. Ministry of Health. 1982. Available from: http://www.yilv.net/ article/fgsd/xzgz/244.htm. 8. Cui XM. The interpretation of article 33 of the "Regulations on Administration of Medical Institutions"—based on "Xiao Zhi-jun" case. J Law Soc (Chin) 2009;12(12):78-79. 9. Ministry of health department. Law of medical accident treatment and supporting file assembly. Beijing: China Legal System Publishing House; 2002:44-54. 10. The Tort Liability Law of the People's Republic of China (EB/OL). Available from: http://www.gov.cn/jrzg/2009-12/26/
Ethical ward round could supervise and promote the implement of patients' informed consent. The investigation by talking directly with patients and their families, going through medical record, understanding the details of treatment decisions and signing procedures could make them determine which mode did the patient choose and evaluate the rationality and possible problems of the decision. These ethical ward round results will be fed back to the department and medical staff so as to improve the patient's rights. In addition, of course, the responsibilities of
content_1497435.htm. 11. Zhao WQ. Clinical practice and reflection of the informed consent in some Chinese. Chin Foreign Med Philos (Chin) 2013;1:21-32. 12. Li EC, Li M, Jia Z, Liu P. 2014 international bioethics forum between UK and China and the professional development of bioethics in china. Bioethics 2014;28:ii-iv. 13. Xi YQ, Zhu KM, Xu BH, Fan MS. Experience of making the medical ethics rounds of the wards. Chin Med Ethics (Chin) 2002;15(6):7-9. (Received June 10, 2014) Edited by YUAN Lin
