Ziv Amitai, Wolpe Paul Root, Small Stephen D, Glick Shimon
The Chaim Sheba Medical Center, and Israel Center for Medical Simulation (MSR), Tel-Hashomer, Israel.
Acad Med. 2003 Aug;78(8):783-8. doi: 10.1097/00001888-200308000-00006.
Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.
医学培训在某些时候必须使用真实患者来磨练卫生专业人员的技能。但同时也有义务提供最佳治疗，并确保患者的安全和福祉。平衡这两种需求是医学教育中一种基本的伦理冲突。基于模拟的学习可以通过培养卫生专业人员的知识、技能和态度，同时保护患者免受不必要的风险，来帮助缓解这种冲突。基于模拟的培训已在其他高风险行业（如航空、核电和军事）中制度化，以最大限度地提高培训安全性并将风险降至最低。由于成本、缺乏严格的效果证明以及对变革的抵触等多种原因，医疗保健领域在模拟应用方面落后了。最近，国际患者安全运动和美国联邦政策议程营造了一种有利于在医学培训中扩大模拟器使用的氛围，并强调面对经过验证的大型流行病学研究表明因医疗管理导致患者出现不可接受的可预防伤害时，“首先不造成伤害”这一伦理要求。四个主题为基于模拟的医学教育的伦理分析提供了一个框架：最佳护理和培训标准、错误管理与患者安全、患者自主权以及社会正义与资源分配。从患者、学习者、教育工作者和社会的角度对这些主题进行了审视。在可行的情况下使用模拟向所有人传达了一个关键的教育和伦理信息：只要有可能就要保护患者，他们不是为了方便培训而被利用的商品。
