12.2 📚 國考版（醫師國考 / PGY OSCE）

對象：M6 / PGY 國考前。倫理是 OSCE 必考站。

12.2.0.1 📌 一頁重點整理 (Cram Sheet)

12.2.0.1.1 🔥 高 yield 6 條
  1. 4 原則：Autonomy、Beneficence、Nonmaleficence、Justice
  2. Informed Consent 5 元素：Disclosure、Comprehension、Voluntariness、Capacity、Documentation
  3. Capacity 4 criteria：理解 / 欣賞 / 推理 / 表達
  4. Withholding = Withdrawing 倫理上 equivalent
  5. Surrogate hierarchy：advance directive → MPOA → next-of-kin
  6. Tarasoff duty to warn 在 specific 威脅時 break confidentiality
12.2.0.1.2 🔢 必背
  • Beauchamp & Childress 4 原則
  • Belmont Report：1979
  • Tarasoff case：1976
  • Capacity 4 elements

12.2.0.2 ⭐ 高 yield 摘要

12.2.0.2.1 4 大原則
原則 內涵
Autonomy 病人自主
Beneficence 為病人 best interest
Nonmaleficence 不傷害
Justice 公平
12.2.0.2.3 Capacity vs Competence
  • Capacity：clinical assessment、decision-specific
  • Competence：legal、court determination
12.2.0.2.4 Capacity 4 Criteria
  1. Understand information
  2. Appreciate consequences
  3. Reason about options
  4. Express choice
12.2.0.2.5 Surrogate Decision-Making Hierarchy
  1. Advance directive / POLST / MOLST
  2. MPOA (Medical Power of Attorney)
  3. Next of kin（spouse → adult children → parents → siblings）
  4. Court-appointed guardian
12.2.0.2.6 Decision-Making Standards
  • Substituted judgment：「what would patient want?」
  • Best interest：if patient preferences unknown
12.2.0.2.7 End-of-Life
  • DNR：心跳停 / 呼吸停不 CPR
  • DNI：不插管
  • Withholding ≠ Withdrawing 心理：但倫理 equivalent
  • Allow Natural Death (AND)
12.2.0.2.8 Confidentiality Exceptions
  • Duty to warn (Tarasoff 1976)
  • Reportable disease（HIV、TB、STI）
  • Child / elder abuse mandatory reporting
  • Subpoena
12.2.0.2.9 Common Cases
Case 處理
Refusal of life-saving tx Respect autonomy if capacity + informed
Family wants secrecy Patient autonomy first
Provider-patient conflict Provider not obligated to non-indicated
Futile care Ethics consultation + family meeting
12.2.0.2.10 Belmont Report 三原則（research ethics）
  1. Respect for persons
  2. Beneficence
  3. Justice

→ Drives modern IRB framework

12.2.0.3 🏆 易混淆對照

12.2.0.3.1 Autonomy vs Welfare 衝突
  • 病人拒救命 → autonomy 優先（如 informed + capable）
  • 但醫師仍要 explore + ensure understanding
12.2.0.3.2 Capacity vs Competence
  • Capacity = clinical
  • Competence = legal
12.2.0.3.3 Withholding vs Withdrawing
  • Both 倫理 OK
  • Withdrawing 心理上難
  • 不要因情緒障礙

12.2.0.4 📝 過去考題類型

12.2.0.4.1 必考
  • 4 原則辨識
  • Informed consent 5 元素
  • Capacity 4 criteria
  • Withholding vs withdrawing 倫理 equivalence
  • Surrogate hierarchy
12.2.0.4.2 OSCE 站
  • 病人拒絕 tx → counseling
  • 末期 family meeting
  • DNR discussion
  • Bad news 告知（SPIKES）
12.2.0.4.3 陷阱題
  • Capacity = competence（錯）
  • Family override patient（錯）
  • Withhold 比 withdraw 更倫理（錯）

12.2.0.5 🎯 自我檢測

  1. Q: 4 大原則？ A: Autonomy、Beneficence、Nonmaleficence、Justice
  2. Q: Capacity 4 criteria？ A: 理解、欣賞、推理、表達
  3. Q: Surrogate hierarchy 順序？ A: Advance directive → MPOA → next of kin → court
  4. Q: Withholding 與 withdrawing 倫理關係？ A: Equivalent
  5. Q: Tarasoff case 主旨？ A: Duty to warn specific identified victim
  6. Q: Belmont Report 三原則？ A: Respect for persons、beneficence、justice

12.2.0.6 📚 想深入請看

⚠️ AI 草稿，未經盧醫師驗證。