論病人之拒絕維生醫療權：法律理論與臨床實踐   全文下載

On Pat ient ’ s Right to Refuse Li fesustaining Medical Treatment: Theory and Practice

從法律上來說，任何心智健全的成年人基於身體自主擁有一個拒絕醫療權，包括拒絕維生醫療。但當拒絕的結果就是可預期的死亡時，此一拒絕權似乎和生命權形成權利衝突而造成解釋上的困難，究竟是拒絕醫療的自主權優先呢，還是生命權優先？此一問題在過去50年間在世界各國廣受討論，目前在法律及倫理上都有定論，病人基於自主意願而拒絕醫療，雖可能產生死亡的結果，但屬於「自然死」的範疇，合倫理也合法。
在我國，雖然告知後同意法則已經廣泛地被醫界和法界接受，但是否心智健全的病人可以拒絕維生醫療仍有爭議。最新通過的《安寧緩和醫療條例》中，直接明訂末期病人得訂意願書或預立意願書決定是否接受維生醫療，這條是我國法制中首度清楚對維生醫療表態，但卻因為只侷限於末期病人，更添疑霧：是否除了末期病人之外，一般病人不得拒絕維生醫療呢？又，當病人本人無法表達意思時，此一拒絕醫療權得否由家屬或醫師代理行使？如何確保代理人不會權力濫用而損及一些弱勢病人的權利呢？
本篇論文試圖從法律理論及臨床倫理來回答上述問題，旨在探討在我國現行法制下，是否一心智健全的成年病人有一拒絕醫療―包括維生醫療―的法律權利，以及其權利位階。並由此來分析評論今年（2013年）初甫新修訂之《安寧緩和醫療條例》（以下簡稱安寧條例2013）第7條的三項臨床實踐爭議。整篇論文分成四部分。第一部分前言將說明研究動機、研究範圍和研究目的。第二部分從身體自主權出發，談一個心智健全病人拒絕維生醫療權之權利性質與法律位階。在確立病人之拒絕治療權乃是《憲法》保障的基本人權後，筆者進一步在第三部分分析我國安寧條例2013第7條的三個爭議：一、是否只有末期病人才能拒絕維生醫療？二、病人無意識時，家屬如何代理行使此一拒絕維生醫療權？三、醫師以醫囑來「代替」病人決定拒絕維生醫療，合倫理嗎？在最後結論部分，筆者認為，拒絕醫療權是病人自主權的底線，不限於末期病人才能主張；但第一線的醫護人員在尊重病人之拒絕維生醫療權之同時，也應持守其專業精神，確保此一權利之行使，合乎病人本人之自主意願。

In legal discussion of death and autonomy, a typical approach is to begin with a patient’s right to refuse medical treatment. It has long been acknowledged that any human being with adult years and sound mind has a constitutionally-protected right to refuse treatment, including life-sustaining medical treatment (LSMT). Such approach ends in patient’s natural death, a consequence associated with the often-discussed topic of passive euthanasia that was once controversial but now is both legal and ethical. However, the case is not so straightforward in Taiwan. Though the doctrine of informed consent has been widely accepted in both medical and legal professions, it is not clear if or not a competent patient can refuse LSMT. The newly revised Hospice and Palliative Care Act (hereinafter, the 2013 Act) put a new article stipulating that a terminal patient may show a Letter of Intent or Advance Directive to refuse LSMT. This is the first time for Taiwan to have a statute covering the subject of LSMT, but unfortunately, the new law added on confusion rather than clarification. Do non-terminal patients also have a right to refuse LSMT? When the patient is incapable of expressing his intent, can and by what standard should the patient’s family or surrogacy exercise such right? This paper tries to directly answer these questions by exploring in depth the current legal jurisprudence about patient autonomy in Taiwan. In addition, the author critically analyses three possible problems concerning Article 7 of the 2013Act. The paper is divided into four parts. Part One explains the motivation, scope and purpose of the study. Part Two follows the typical approach to start with the right to body integrity, and then discusses the nature and source of patient’s right to refuse treatment. After securing the constitutionality of the right to refuse LSMT, I go into depth in Part Three to examine the three possible controversies associating with Article 7 of the 2013 Act. First, only terminal patients can claim a right to refuse LSMT? Secondly, in case of incompetent, how should the patient’s family to exercise a right to refuse LSMT? Finally, is it ethical for doctors to put an “order” to help incompetent patient to refuse LSMT? In Part Four, the author concludes that the right to refuse treatment is the core of patient autonomy. It is not reserved only for terminal patients and should not be limited by the possible consequence of death.