The Evolution of Doctor-patient Rapport-from the Perspective of Informed Consent and Co-decision-making

醫病關係因為時代背景的不同，呈現對應式的多樣性表現。回顧醫學史，從古希臘羅馬時期以降，直到中世紀基督教掌握西方世界的政經情勢，再歷經文藝復興，以至於到近代，直到二十世紀，醫師從一開始的主導者之角色，慢慢才有醫師與病人權力分享式的決策模式。在這當中，醫師從幾乎不需與病人溝通；到有學者呼籲由推廣門外漢的專業醫學知識教育，縮短醫師病人知識程度差異，才促使醫師打開對病人溝通的一扇窗。醫病關係由於二十世紀出數起醫療糾紛的訴訟而發生變化，許多法官在審理這些案件中進行很多腦力激盪：首先，法官既要考慮到不去侵犯到醫師的專業權力，而且考量到病人實際受到醫師善意照護禁錮(caring custody)的事實；其次，又要保護病人免於各式各樣新興的醫療處置與手術濫用；最後，並想給予病人某種程度的自由度，於是“知情同意(informed consent)”就在這樣的狀況下誕生。在醫師解釋病情與處置方面，法官並考慮到醫師與病人的專業知識程度之差異。究竟知情同意要在何種情況下必得告知病人，而又要告知到何種程度，這是值得商榷的議題。從另外一個角度看來，不同文化背景的病人，對知情同意、權力分享式醫病共同決策模式，是否有不同的接受模式與程度，本文亦將一併探討。
The rapport of doctor-patient is always the issue for medical society and the public. People care about it because almost all of them suffer from illness off and on in their whole lives. Yet the relationships are changeable from time to time. From the ancient Greek and Rome time, to the tenth century of Christian Age, the decision side was always on the doctor's side. Until the modern time of the last century, the decision model has slowly changed into the hands of both sides. From the perspective of medical history, we learned doctors did not converse much. They were asked to behave themselves, but they were not demanded to explain situations of patients or their decision rationales. But time has changed, through the advances of medical technology; there were overwhelming emerging medical procedures and surgery. Simultananeouly, the concurrent medical legal suits have occurred. The Court Judges had to consider not to violate professionalization of medical physicians, the fact of caring custody, and also to protect patients from being abused of newlydeveloped medical procedures or surgeries. Judges were trying to give patients freedom of autonomy in limited situations. That was a dilemma for Judges at that time. But Judges still tried their best to innovate the "informed consent" for protection of patients from novel procedures or from dangers, and also pushed to communication from doctors to patients at the same time. This article is about these two aspects: the birth of informed consent and co-decision making of doctors and patients.