论家庭在医疗决策中的作用
摘要
病人自主权是病人权利中最为基本的一种权利。病人参与决策、病人自主的医疗决策模式日益取代以医疗父权为基础的医生代为决策的医疗模式。尊重自主也是西方生命伦理学四原则之一。但目前困扰我们的现实和理论问题是：所谓病人的自主权是病人单个人的自主、自决,还是基于家庭的家庭成员的共同决定?是坚持现代西方自由主义、个人主义的生命伦理价值,还是坚持儒家传统中医生、病人、家属之间相互依从、相互协商的生命伦理价值?也就是说,在医疗决策中家庭是否要发挥作用?应发挥哪些作用?怎样发挥作用?
本文首先从中西方医疗史角度考察了家庭在医疗决策中功能和作用演变的历程和规律,分析了影响家庭在医疗决策中发挥作用的文化与社会因素；然后,结合临床实践分析了医疗决策的独特性和复杂性,论证了儒家文化背景下,家庭参与医疗决策的意义和必要性；最后,提出了充分发挥家庭作用,病人、病人家属、主治医生协商对话、共同决策的建议。
通过对中西方医疗史的考察,以及对西方病人自主权的理论与实证研究,发现在中国社会文化环境下,病人自主权利的实现不可能走向西方个人自由主义式的完全独立自主。在中国的医疗环境中,仅仅依靠病人自主的方式是无法充分保护病人的生命健康利益的。在儒家文化背景下,个人是一个以家为核心的有机个人,社会是一个以家为核心的有机体。家庭不仅提供经济支持,而且提供情感支持,不仅承载人的成长和人的再生产等基本职能,更是一个神圣的伦理实体。在生命伦理视阈下,家庭具有关心成长、呵护健康的职责,具有共同负担医疗费用、共同承受医疗后果的功能。因此,让家庭参与医疗决策具有伦理根据。
从本体论来看,病人并非孤立的个体,而是生活在家庭之中的家庭的一员,要对家庭承担义务和责任,所以病人的自主权要受家庭决定权的制约,病人自主其实是在家庭支持、家庭参与和家庭协调一致基础上的自主,是适应儒家文化土壤的病人自主。从德性论来看,家庭是德性的实体,患病绝不是单个人的事情,而是整个家庭共同面临的处境。病人会从家庭寻找和获得经济以及精神上的支持,家庭也会主动地给予真诚的关心和周到的慰藉。从功能论来看,家庭具有医疗决策功能,全家齐心协力,共同参与,同舟共济,才是最好的面对疾病的方式。
家庭参与决策并不是对患者自主权的剥夺,相反,家属的介入是对患病家庭成员的关爱,是对患者不幸与痛苦的分担,是为了更好地实现与医生的沟通。因此,在中国文化背景下,需要着眼于患者与家属的重要关系来重新理解病人自主权。缺乏家属有效参与的病人自主是不完整的,病人需要作出面向和基于整个家庭的负责任的决定和选择,医疗决策除了医生、病人参与之外,病人家属的参与也是须臾不可少的。
最后,结合医疗决策实践,本文提出医生、病人、病人家属共同参与的医疗决策模式：第一,对于患者医疗费用支出对家庭影响较小的治疗性医疗行为,以病人本人的意愿为主,可由病人本人行使签字权。第二,在患者医疗费用支出对家庭影响较大的医疗行为,应征得病人本人和其家属的一致同意。医疗实践中,考虑到患者本人行动、思考的不便,以及为了避免不良信息对患者本人的伤害,患者可以将自己的知情同意权委托给亲属代为行使。这样,家属与医生沟通、商讨之后的医疗决定不仅代表家庭的意愿也代表患者本人的决定。第三,对于非治疗性医学行为应以家属的意见为主,由家属行使签字权。由家属来签字,可以就医疗行为事先在家庭内部充分协商沟通,使决策更合理,有助于协调医患关系,也可以避免家庭内部的矛盾,避免家庭内部的矛盾冲突。第四,病人和家庭都可能做出非理性的医疗决策,一旦非理性的决定危及病人的生命健康时,需要医生行使特殊干涉权,对病人或家庭的决策进行强制干涉,做出有利于病人的决定。
With the rise of human rights movement and advancement of medical technology, more and more attention has been paid to patients' decision-making right. The mode of giving the final decision right to patients has generally replaced the mode based on medical patriarchy. However, we are confronted with the theoretical and practical problems: the so-called patient's autonomy is the patient's self-determination or the joint decision of family members; we should adhere to bioethics value of modern western liberalism and individualism or insist on traditional Confucian bioethics value based on mutual compliance and mutual consultation among doctor, patient and family member. That is to say, should family play a role in medical decision-making? If so, what role should family play and how to play?
First, this paper explores the function and role of family from the perspective of cultural sociology, among which the structure and function of Confucian social family have been analyzed emphatically. Then, combining with clinical practice, this paper analyses the uniqueness and complexness of medical decision-making. At last, this paper suggests giving full play of the function of family, that is, patient, patent's family and doctor consult with each other and make a joint decision.
By means of theoretical and empirical study of western patient's autonomy, the author finds that in Chinese social and cultural environments, with regard to decision-making right, patients, by no means, enjoy as complete independence from others'intervention as western individual liberalism does. Under Chinese medical environments, patients'life and health will never receive thorough and comprehensive protection via single dependence on their own decision. Family is a small social community on the basis of marriage relationship, kinship relationship and adoptive relationship, which is an independent economic unit taking growth and reproduction of individual as its basic functions. In the perspective of bioethics, family has obligation of caring growth and health, sharing the medical expense and bearing the medical consequences together. As a small social community on the basis of marriage, kinship dnd adoption, family constitutes an independent economic unit whose basic functions mainly consist in people's growth and reproduction. From the perspective of bioethics, it is specific care for individual growth and health and common responsibility for medical expense and consequences that materializes a family's function. Therefore, family participant in medical decision-making does have its ethics basis.
From the point of view of ontology, patient is not an isolated individual, but a member of family with duty and obligation for the family. Therefore, patient's autonomy is constrained by family's decision and should combine with the participant of family members in order to mediate the conflict between concept of human rights and cultural traits. From the perspective of virtue theory, family is the substance of virtue. Getting illness is not just an individual problem, but the situation the family faces. Patient can get economic and spiritual support from family while family proactively gives sincere care and considerate comfort. In the perspective of consequentiality, the best way to face illness is participant together of the whole family. Family participant is not the deprival of patient's autonomy; on the contrary, family intervene intervention makes family bear the burden of decision-making, which is unbearable for patient. Therefore, under Chinese cultural background, patient's autonomy should be understood newly through the relationship between patient and family. The patient's autonomy lacking effective participant is not complete. Patient need make the decision and choice for the whole family. Besides doctor and patient, the participant of patient's family is also essential in medical decision.
In the end, combining with medical decision-making practice, this paper puts forward the medical decision-making mode based on co-participant of doctor, patient and patient's family:First, remedial medical act whose medical expense has little influence over family can be decided by patient himself\herself on the basis of his\her own will. Second, the medical act with great influences of medical expense over family should be approved by patient and family. Third, non-remedial medical act should be based on the family's opinion. Fourth, family decision can be irrational. When family decision may endanger patient's health and life, doctor is obliged to interfere it, that is, exercise the special right of interference to make the choice which is good for patient.
本文首先从中西方医疗史角度考察了家庭在医疗决策中功能和作用演变的历程和规律,分析了影响家庭在医疗决策中发挥作用的文化与社会因素；然后,结合临床实践分析了医疗决策的独特性和复杂性,论证了儒家文化背景下,家庭参与医疗决策的意义和必要性；最后,提出了充分发挥家庭作用,病人、病人家属、主治医生协商对话、共同决策的建议。
通过对中西方医疗史的考察,以及对西方病人自主权的理论与实证研究,发现在中国社会文化环境下,病人自主权利的实现不可能走向西方个人自由主义式的完全独立自主。在中国的医疗环境中,仅仅依靠病人自主的方式是无法充分保护病人的生命健康利益的。在儒家文化背景下,个人是一个以家为核心的有机个人,社会是一个以家为核心的有机体。家庭不仅提供经济支持,而且提供情感支持,不仅承载人的成长和人的再生产等基本职能,更是一个神圣的伦理实体。在生命伦理视阈下,家庭具有关心成长、呵护健康的职责,具有共同负担医疗费用、共同承受医疗后果的功能。因此,让家庭参与医疗决策具有伦理根据。
从本体论来看,病人并非孤立的个体,而是生活在家庭之中的家庭的一员,要对家庭承担义务和责任,所以病人的自主权要受家庭决定权的制约,病人自主其实是在家庭支持、家庭参与和家庭协调一致基础上的自主,是适应儒家文化土壤的病人自主。从德性论来看,家庭是德性的实体,患病绝不是单个人的事情,而是整个家庭共同面临的处境。病人会从家庭寻找和获得经济以及精神上的支持,家庭也会主动地给予真诚的关心和周到的慰藉。从功能论来看,家庭具有医疗决策功能,全家齐心协力,共同参与,同舟共济,才是最好的面对疾病的方式。
家庭参与决策并不是对患者自主权的剥夺,相反,家属的介入是对患病家庭成员的关爱,是对患者不幸与痛苦的分担,是为了更好地实现与医生的沟通。因此,在中国文化背景下,需要着眼于患者与家属的重要关系来重新理解病人自主权。缺乏家属有效参与的病人自主是不完整的,病人需要作出面向和基于整个家庭的负责任的决定和选择,医疗决策除了医生、病人参与之外,病人家属的参与也是须臾不可少的。
最后,结合医疗决策实践,本文提出医生、病人、病人家属共同参与的医疗决策模式：第一,对于患者医疗费用支出对家庭影响较小的治疗性医疗行为,以病人本人的意愿为主,可由病人本人行使签字权。第二,在患者医疗费用支出对家庭影响较大的医疗行为,应征得病人本人和其家属的一致同意。医疗实践中,考虑到患者本人行动、思考的不便,以及为了避免不良信息对患者本人的伤害,患者可以将自己的知情同意权委托给亲属代为行使。这样,家属与医生沟通、商讨之后的医疗决定不仅代表家庭的意愿也代表患者本人的决定。第三,对于非治疗性医学行为应以家属的意见为主,由家属行使签字权。由家属来签字,可以就医疗行为事先在家庭内部充分协商沟通,使决策更合理,有助于协调医患关系,也可以避免家庭内部的矛盾,避免家庭内部的矛盾冲突。第四,病人和家庭都可能做出非理性的医疗决策,一旦非理性的决定危及病人的生命健康时,需要医生行使特殊干涉权,对病人或家庭的决策进行强制干涉,做出有利于病人的决定。
With the rise of human rights movement and advancement of medical technology, more and more attention has been paid to patients' decision-making right. The mode of giving the final decision right to patients has generally replaced the mode based on medical patriarchy. However, we are confronted with the theoretical and practical problems: the so-called patient's autonomy is the patient's self-determination or the joint decision of family members; we should adhere to bioethics value of modern western liberalism and individualism or insist on traditional Confucian bioethics value based on mutual compliance and mutual consultation among doctor, patient and family member. That is to say, should family play a role in medical decision-making? If so, what role should family play and how to play?
First, this paper explores the function and role of family from the perspective of cultural sociology, among which the structure and function of Confucian social family have been analyzed emphatically. Then, combining with clinical practice, this paper analyses the uniqueness and complexness of medical decision-making. At last, this paper suggests giving full play of the function of family, that is, patient, patent's family and doctor consult with each other and make a joint decision.
By means of theoretical and empirical study of western patient's autonomy, the author finds that in Chinese social and cultural environments, with regard to decision-making right, patients, by no means, enjoy as complete independence from others'intervention as western individual liberalism does. Under Chinese medical environments, patients'life and health will never receive thorough and comprehensive protection via single dependence on their own decision. Family is a small social community on the basis of marriage relationship, kinship relationship and adoptive relationship, which is an independent economic unit taking growth and reproduction of individual as its basic functions. In the perspective of bioethics, family has obligation of caring growth and health, sharing the medical expense and bearing the medical consequences together. As a small social community on the basis of marriage, kinship dnd adoption, family constitutes an independent economic unit whose basic functions mainly consist in people's growth and reproduction. From the perspective of bioethics, it is specific care for individual growth and health and common responsibility for medical expense and consequences that materializes a family's function. Therefore, family participant in medical decision-making does have its ethics basis.
From the point of view of ontology, patient is not an isolated individual, but a member of family with duty and obligation for the family. Therefore, patient's autonomy is constrained by family's decision and should combine with the participant of family members in order to mediate the conflict between concept of human rights and cultural traits. From the perspective of virtue theory, family is the substance of virtue. Getting illness is not just an individual problem, but the situation the family faces. Patient can get economic and spiritual support from family while family proactively gives sincere care and considerate comfort. In the perspective of consequentiality, the best way to face illness is participant together of the whole family. Family participant is not the deprival of patient's autonomy; on the contrary, family intervene intervention makes family bear the burden of decision-making, which is unbearable for patient. Therefore, under Chinese cultural background, patient's autonomy should be understood newly through the relationship between patient and family. The patient's autonomy lacking effective participant is not complete. Patient need make the decision and choice for the whole family. Besides doctor and patient, the participant of patient's family is also essential in medical decision.
In the end, combining with medical decision-making practice, this paper puts forward the medical decision-making mode based on co-participant of doctor, patient and patient's family:First, remedial medical act whose medical expense has little influence over family can be decided by patient himself\herself on the basis of his\her own will. Second, the medical act with great influences of medical expense over family should be approved by patient and family. Third, non-remedial medical act should be based on the family's opinion. Fourth, family decision can be irrational. When family decision may endanger patient's health and life, doctor is obliged to interfere it, that is, exercise the special right of interference to make the choice which is good for patient.
引文
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51 龚群.当代中国社会伦理生活[M].成都：四川人民出版社,1998：130.
52 范瑞平.构建中国生命伦理学——追求中华文化的卓越性和永恒性[J].中国医学伦理学,2010,23(5)：7-8.
53 [美]J·罗斯·埃什尔曼.家庭导论,中国社会科学出版社,1991年版,第5455页。
54 Shek, D T. Family Functioning and Psychological Well-Being, School Adjustment, and Problem Behavior in Chinese Adolescents With and Without Economic Disadvantage. Journal of Genetic Psychology,2002,163 (4):497-500.
55 Olson, D H. Circumplex Model of Marital and Family Systems. Journal of Family Therapy,2000,22(2): 144-167
56 Epstein, Skinner H, Steinhauer P. Family Assessment Measure and Process Model of Family Functioning. Journal of Family Therapy,2000,22 (2):190-210
57 Skinner H, Steinhauer P. Family Assessment Measure and Process Model of Family Functioning. Journal of Family Therapy,2000,22 (2):190-210
58 刘茂松.论家庭功能及其变迁[J],湖南社会科学,2001,(2)：30-34.
59 阮芬儿,陈艳.家庭干预对青光眼患者遵医行为及疗效的影响[J],护士进修杂,2010,25(24)：2288.
60 陈安华,谭建兰,叶兰芬,廖小乔.家庭关怀教育对脑卒中患者遵医行为及生活质量的影响[J],广东医学院学报,2012,(30)264-266.
61 朱清文,方平安,周立智,廖芹,杨源,王小丽.家庭支持对复治肺结核患者院外化疗遵医行为的影响[J],寄生虫病与感染性疾病,2010.8(1)：29-31.
62 叶仁青,周佳.家庭社会功能在糖尿病患者遵医行为的支持作用[J],医学与哲学,2000,21(5)24-25.
63 范瑞平.当代儒家生命伦理学[M],北京大学出版社,2011：P5.
64 KRISHNAN D. In Sickness and In Health:Risk Sharing within Households in Rural Ethiopia[J]. Journal of Political Economy,2000,108(4):668-727.
65 赵忠.我国农村人口的健康状况及影响因素[J].管理世界,2006,(3)：78-85.
66 范瑞平.当代儒家生命伦理学[M],北京大学出版社,2011：P35.
67 Martha Minow,All in the Family & in all Families:Membership,Loving,and Owing,95W.Va.L.Rev.275,307,1992-1993.
68 范瑞平.当代儒家生命伦理学[M],北京大学出版社,2011：P10.
69 Elysa Gordon, Multiculturatlism in Medical Decisionmaking:The Notion of Informed Waiver,23 Fodham Uvb.L.F 1321,1345-1346,1996.
70 李志庭,查学安.浅谈“知情同意”与医疗活动中的签字制度[J],卫生软科学,2004,18(6)：311-313,319.
71 丁春艳.由谁来行使知情同意的权利：患者还是家属[J].法律与医学杂志,2007,14(1)：29-34.
72 丁春艳.由谁来行使知情同意的权利：患者还是家属[J].法律与医学杂志,2007,14(1)：29-34
73 方红丽,张桂青.“知情同意”实施难原因研究综述[J].中国医学伦理学,2006,19(2)：55-57
74 丁春艳.由谁来行使知情同意的权利：患者还是家属[J].法律与医学杂志,2007,14(1)：29-34
75 邹劲林,莫湘琼,李振东等.医患共同参与医疗决策对胃癌术后机体恢复的影响[J],中国慢性病预防与控制,2012,20(4)：449-451.
76 Martha Minow, All in the Family & in all Families:Membership, Loving, and wing,95W.Va.L.Rev.275, 307,1992-1993.
77 刘朝晖.手术签字制度再引争议：谁有权利为生命负责[J].医院领导决策参考,2009,(3)： 20-22.
78 张涛.病人的知情同意与医生的特殊干涉[J].中国医学伦理学,2001,(8)；8-9.
79 吕英杰.“肖志军拒签案”医生的刑事责任分析[J],政治与法律,2008,(4)：129-133.
80 家属拒医院剖腹产建议后母婴双亡[N],新闻晨报,2008.06.25,A13版.
81 曾义.抢毯危重应人的.家属同意研究[D],长沙：中南大学,2011.
1. Gerald Dworkin, Can You Trust Autonomy? HASTINGS CENTER REPORT, March-April,2003.
2. Sutherland HJ, Llewellyn-Thomas HA, Lockwood GA, et al. Cancer patients:Their desire for information and participation in treatment decisions[J]. Journal of the Royal Society of Medicine,1989,82 (3): 260-263.
3. Charles C, Whelan T, Gafni A. What do we mean by partnership in making decisions about treatment[J]. Br Med J,1999,319(9):780-782.
4. Ong LML, De Haes JC, Hoos AM, et al. Doctor-patient communication.-a review of the literature [J]. Soc Sci Med,1995,40 (7):903-918.
5. Hack TF, Degner LF, Dyck DG. Relationship between preferences for decisional control and illness in formation among women with breast cancer:a quantitative and qualitative analysis. Soc Sci Med,1994, 39:279-287.
6.蔡昱.论患者亲属在医疗决定中的作用——兼与李振良教授商榷[J],北京：民商法论丛,2008,(41)：329-335.
7.李振良,李肖峰,徐康平.患者亲属——医疗决定的重要主体[J],大连：医学与哲学,2007,(1)：4-7.
8. Agatha Lambris, Informed Consent for All? Not Quite! A Comparison of Informed Consent in the United States and Japan,7Femp. Int.1 & Comp. L. J.,2003
9.安德烈·比尔基埃等主编《家庭史1》(上册),生活·读书·新知三联书店,1998年版,第15页。
10. THOMAS, SHANNON生命伦理学基础[A]E长沙：湖南科技术出版社,1996.1-15
11.土丽艳,郭照江。知情同意原则与文化背景[J]中国医学伦理2001,(5)：30-31
12.陈树林,李凌江.知情同意中病人自主权与传统医疗父权的冲突[A].医 学与哲学：2003.24[6]45-48
13.孙笑侠,郭春镇.美国的法律家长主义理论与实践[J].西北政法学院学报.2005.(06)。
14.李霁,张怀承,患者权利运动的伦理审视.中国医学伦理学.2007,12
15.邱翔.有限医疗家长主义及其辩护.湖南师范大学.硕士学位论文.2008.6
1 6.朱明兰等,西方国家病人自主权概况及浅析[A].医学与哲学.2012.33(12)
17.王圣军.病人权利托付的医学伦理学意义[A].自然辩证法研究.2001.18(5)
18.雷锦程.病人自主性与家庭本位主义之间的张力[A].医学与哲学.2008.29(3)
19.《圣经·马太福音》8：16。
20.马克思恩格斯全集：第1卷[M].北京：人民出版社,1995.P60.
21.马克思.1844年经济学哲学手稿[M],北京：人民出版社,1985：P53-54.
22.[美]孙隆基《中国文化的深层结构》,桂林：广西师范大学出版社2004年版,第13-14页。
23.恩格斯：“家庭、私有制和国家的起源”,《马克思恩格斯选集》(第4卷),北京：人民出版社1972年版,第61页。
24.[德]黑格尔：《法哲学原理》,范扬、张企泰译,北京：商务印书馆1982年版,第258节,第253页。
25.[德]黑格尔：《精神现象学》(下卷),贺麟、王玖兴译,北京：商务印书馆1997年版,第9页。
26.许娘光：《宗族、种性、俱乐部》,华夏出版社,1990年版,第164页。
27.关培兰、石宁.中美家庭伦理观比较[J].道德与文明,1998,(5)：32-33.
28.颜氏家训
29.紫阳朱氏宗谱·朱子家训
30.李桂梅.中国传统家庭伦理文化的特点[J].湖湘论坛,2002,(2)：85-87.
31.龚群.当代中国社会伦理生活[M].成都：四川人民出版社,1998：130.
32.范瑞平.构建中国生命伦理学——追求中华文化的卓越性和永恒性[J].中国医学伦理学,2010,23(5)：7-8.
33.[美]J·罗斯·埃什尔曼.家庭导论,中国社会科学出版社,1991年版,第5455页。
34. Shek, D T. Family Functioning and Psychological Well-Being, School Adjustment, and Problem Behavior in Chinese Adolescents With and Without Economic Disadvantage. Journal of Genetic Psychology,2002,163 (4):497-500.
35. Olson, D H. Circumplex Model of Marital and Family Systems. Journal of Family Therapy,2000,22 (2):144-167
36. Epstein, Skinner H, Steinhauer P. Family Assessment Measure and Process Model of Family Functioning. Journal of Family Therapy,2000, 22 (2):190-210
37. Skinner H, Steinhauer P. Family Assessment Measure and Process Model of Family Functioning. Journal of Family Therapy,2000,22 (2): 190-210
38.阮芬儿,陈艳.家庭干预对青光眼患者遵医行为及疗效的影响[J],护士进修杂,2010,25(24)：2288.
39.陈安华,谭建兰,叶兰芬,廖小乔.家庭关怀教育对脑卒中患者遵医行为及生活质量的影响[J],广东医学院学报,2012,(30)264-266.
40.朱清文,方平安,周立智,廖芹,杨源,王小丽.家庭支持对复治肺结核患者院外化疗遵医行为的影响[J],寄生虫病与感染性疾病,2010.8(1)：29-31.
41.叶仁青,周佳.家庭社会功能在糖尿病患者遵医行为的支持作用[J],医学与哲学,2000,21(5)24-25.
42.范瑞平.当代儒家生命伦理学[M],北京大学出版社,2011：P5.
43. KRISHNAN D. In Sickness and In Health:Risk Sharing within Households in Rural Ethiopia[J]. Journal of Political Economy,2000, 108(4):668-727.
44.赵忠.我国农村人口的健康状况及影响因素[J].管理世界,2006,(3)：78-85.
45. Elysa Gordon, Multiculturatlism in Medical Decisionmaking:The Notion of Informed Waiver,23 Fodham Uvb.L.F 1321,1345-1346,1996.
46.李志庭,查学安.浅谈“知情同意”与医疗活动中的签字制度[J],卫生软科学,2004,18(6)：311-313,319.
47.丁春艳.由谁来行使知情同意的权利：患者还是家属[J].法律与医学杂志,2007,14(1)：29-34.
48.方红丽,张桂青.“知情同意”实施难原因研究综述[J].中国医学伦理学,2006,19(2)：55-57
49. Martha Minow, All in the Family & in all Families:Membership, Loving, and wing,95W. Va. L. Rev.275,307,1992-1993.
50.刘朝晖.手术签字制度再引争议：谁有权利为生命负责[J].医院领导决策参考,2009,(3)：20-22.
51.张涛.病人的知情同意与医生的特殊干涉[J].中国医学伦理学,2001,(8)：8-9.
52.吕英杰.“肖志军拒签案”医生的刑事责任分析[J],政治与法律,2008,(4)：129-133.
53.家属拒医院剖腹产建议后母婴双亡[N],新闻晨报,2008.06.25,A13版.
54.曾义.抢毯危重应人的.家属同意研究[D],长沙：中南大学,2011.
2 Sutherland HJ, Llewellyn-Thomas HA, Lockwood GA, et al. Cancer patients:Their desire for information and participation in treatment decisions[J]. Journal of the Royal Society of Medicine,1989,82 (3):260-263.
3 Charles C, Whelan T, Gafni A. What do we mean by partnership in making decisions about treatment[J]. Br Med J,1999,319 (9):780-782.
4 Ong LML, De Haes JC, Hoos AM, et al. Doctor-patient communication:a review of the literature[J]. Soc Sci Med,1995,40 (7):903-918.
5 Charles C, Whelan T, Gafni A. What do we mean by partnership in making about treatment? Br Med J,1999, 319:780-782.
6 陈晓阳,曹永福.医学伦理学[M].济南：山东大学出版社,2002.
7 Hack TF. Degner LF, Dyck DGRelationship between preferences for decisional control and illness in formation among women with breast cancer:a quantitative and qualitative analysis. Soc Sci Med,1994,39:279-287.
8 蔡昱.论患者亲属在医疗决定中的作用——兼与李振良教授商榷[J],北京：民商法论丛,2008,(41)329-335.
9 李振良,李肖峰,徐康平.患者亲属——医疗决定的重要主体[J],大连：医学与哲学,2007,(1)：4-7.
10 Agatha Lambris.Informed Consent for All? Not Quite! A Comparison of Informed Consent in the United States and Japan,7Femp.Int.1 & Comp.L.J.,2003
11 安德烈·比尔基埃等主编《家庭史1》(上册),生活·读书·新知三联书店,1998年版,第15页。
12 刘宇鹏,万献尧.浅谈临终医疗的双重效应原则[J].医学与哲学(临床决策论坛版),2008,29(2)：4-6.
13 THOMAS, SHANNON生命伦理学基础[A]E长沙：湖南科技术出版社,1996.1-15
14 土丽艳,郭照江。知情同意原则与文化背景[J]中国医学伦理2001,(5)；30-31
15 陈树林,李凌江.知情同意中病人自主权与传统医疗父权的冲突[A].医学与哲学：2003.24[6]45-48
16 孙笑侠,郭春镇.美国的法律家长主义理论与实践[J].西北政法学院学报.2005.(06)。
17 李霁,张怀承,患者权利运动的伦理审视中国医学伦理学.2007,12
18 邱翔.有限医疗家长主义及其辩护.湖南师范大学硕士学位论文.2008.6
19 朱明兰等,西方国家病人自主权概况及浅析[A].医学与哲学.2012.33(12)
20 王圣军.病人权利托付的医学伦理学意义[A].自然辩证法研究.2001.18(5)
21 雷锦程.病人自主性与家庭本位主义之间的张力[A].医学与哲学.2008.29(3)
22 陈树林,李凌江.知情同意中病人自主权与传统医疗父权的冲突[A].医学与哲学：2003.24[6]45-48
23 THOMAS, SHANNON生命伦理学基础[A]E长沙：湖南科技术出版社,1996.1-15
24 《圣经·马太福音》8：16。
25 《圣经·马太福音》9：32-33。
26 《圣经·马太福音》9：2-7。
27 《圣经·马太福音》8：5-13。
28 《圣经·马太福音》8：17。
29 孙笑侠,郭春镇.美国的法律家长主义理论与实践[J].西北政法学院学报.2005.(06)。
30 李霁,张怀承,患者权利运动的伦理审视.中国医学伦理学.2007,12
31 邱翔.有限医疗家长主义及其辩护.湖南师范大学.硕士学位论文.2008.6
32 朱明兰等,西方国家病人自主权概况及浅析[A].医学与哲学.2012.33(12)
33 王圣军.病人权利托付的医学伦理学意义[A].自然辩证法研究.2001.18(5)
34 土丽艳,郭照江。知情同意原则与文化背景[J]中国医学伦理2001,(5)；30-31
35 雷锦程.病人自主性与家庭本位主义之间的张力[A].医学与哲学.2008.29(3)
36 马克思恩格斯全集：第1卷[M].北京：人民出版社,1995.P60.
37 马克思.1844年经济学哲学手稿[M],北京：人民出版社,1985：P53-54.
38 马克思恩格斯选集：第1卷[M].北京：人民出版社,1995.P118.
39 马克思.1844年经济学哲学手稿[M],北京：人民出版社,1985：P79.
40 [美]孙隆基《中国文化的深层结构》,桂林：广西师范大学出版社20¨04年版,第13-14页。
41 恩格斯：“家庭、私有制和国家的起源”,《马克思恩格斯选集》(第4卷),北京：人民出版社1972年版,第61页。
42 [德]黑格尔：《法哲学原理》,范扬、张企泰译,北京：商务印书馆1982年版,第258节,第253页。
43 [德]黑格尔：《法哲学原理》,范扬、张企泰译,北京：商务印书馆1982年版,第258节,第255页。
44 [德]黑格尔：《精神现象学》(下卷),贺麟、王玖兴译,北京：商务印书馆1997年版,第9页。
45 李桂梅.略论中西家庭伦理精神[J],湖南师范大学学报(社会科学版),2005(2)：20一23.
46 许娘光：《宗族、种性、俱乐部》,华夏出版社,1990年版,第164页。
47 关培兰、石宁.中美家庭伦理观比较[J].道德与文明,1998,(5)：32-33.
48 颜氏家训
49 紫阳朱氏宗谱·朱子家训
50 李桂梅.中国传统家庭伦理文化的特点[J].湖湘论坛,2002,(2)：85-87.
51 龚群.当代中国社会伦理生活[M].成都：四川人民出版社,1998：130.
52 范瑞平.构建中国生命伦理学——追求中华文化的卓越性和永恒性[J].中国医学伦理学,2010,23(5)：7-8.
53 [美]J·罗斯·埃什尔曼.家庭导论,中国社会科学出版社,1991年版,第5455页。
54 Shek, D T. Family Functioning and Psychological Well-Being, School Adjustment, and Problem Behavior in Chinese Adolescents With and Without Economic Disadvantage. Journal of Genetic Psychology,2002,163 (4):497-500.
55 Olson, D H. Circumplex Model of Marital and Family Systems. Journal of Family Therapy,2000,22(2): 144-167
56 Epstein, Skinner H, Steinhauer P. Family Assessment Measure and Process Model of Family Functioning. Journal of Family Therapy,2000,22 (2):190-210
57 Skinner H, Steinhauer P. Family Assessment Measure and Process Model of Family Functioning. Journal of Family Therapy,2000,22 (2):190-210
58 刘茂松.论家庭功能及其变迁[J],湖南社会科学,2001,(2)：30-34.
59 阮芬儿,陈艳.家庭干预对青光眼患者遵医行为及疗效的影响[J],护士进修杂,2010,25(24)：2288.
60 陈安华,谭建兰,叶兰芬,廖小乔.家庭关怀教育对脑卒中患者遵医行为及生活质量的影响[J],广东医学院学报,2012,(30)264-266.
61 朱清文,方平安,周立智,廖芹,杨源,王小丽.家庭支持对复治肺结核患者院外化疗遵医行为的影响[J],寄生虫病与感染性疾病,2010.8(1)：29-31.
62 叶仁青,周佳.家庭社会功能在糖尿病患者遵医行为的支持作用[J],医学与哲学,2000,21(5)24-25.
63 范瑞平.当代儒家生命伦理学[M],北京大学出版社,2011：P5.
64 KRISHNAN D. In Sickness and In Health:Risk Sharing within Households in Rural Ethiopia[J]. Journal of Political Economy,2000,108(4):668-727.
65 赵忠.我国农村人口的健康状况及影响因素[J].管理世界,2006,(3)：78-85.
66 范瑞平.当代儒家生命伦理学[M],北京大学出版社,2011：P35.
67 Martha Minow,All in the Family & in all Families:Membership,Loving,and Owing,95W.Va.L.Rev.275,307,1992-1993.
68 范瑞平.当代儒家生命伦理学[M],北京大学出版社,2011：P10.
69 Elysa Gordon, Multiculturatlism in Medical Decisionmaking:The Notion of Informed Waiver,23 Fodham Uvb.L.F 1321,1345-1346,1996.
70 李志庭,查学安.浅谈“知情同意”与医疗活动中的签字制度[J],卫生软科学,2004,18(6)：311-313,319.
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