醫學倫理諮詢及其在臺灣之應用

Ethics Consultation and Its Implementation in Taiwan

倫理諮詢在生物科技快速往前推進的時代裡，已變成醫學倫理上重新強調的要點。美加先進國家至少有百分之七十五以上的醫院都已提供有倫理諮詢的服務，來幫助醫事人員，病患及家屬從事日愈複雜艱難的醫療抉擇。1982 年Baby Doe 事件加速了建立醫療諮詢機制的必要性之認知，1992 年美國主掌健康照護機構之認可的組織，要求所有的醫院必須提供給病人及健康照護者倫理教育的課程及活動，而且各醫院也紛紛陸續成立了醫學倫理委員會以應對越來越複雜的醫療難題。雖然醫療倫理諮詢已變成一個潮流，但諮詢機制，過程及責任卻沒有完全釐清，醫學倫理委員會通常把教育當作委員會的重要任務，因為醫療諮詢缺乏訓練有素的專家使提供該服務有力不從心之嘆。倫理問題通常錯綜無比，基本上它不只是醫療的問題，也是社會的、教育的、價值思維的、人際關係的、法律的、經濟的，因之要提供一個完善的諮詢機制必須有長期的準備與週全的機制。誰可以提出諮詢？如何從事諮詢？它與法律的關係又是如何？醫師能當諮詢師嗎？醫院裡的哲學家其定位又是如何？等都是問題。本論文以台灣目前醫院裡的諮詢情況做了一個調查，一般的認知是台灣在這方面有所欠缺有待加強，而各醫院的醫學倫理委員會也應扮演新的角色，試圖填補諮詢上的缺口。本論文對倫理諮詢的理論作些簡述，討論它的過程與諮詢記錄的思考，也同時做了一些建議。

Ethics consultation is a new emphasis in bioethics that has gradually gained its weight along with the rapid development of biomedical sciences. Recent survey in North America estimated that over 75 percent of all hospitals provide such a service either formally or informally. The Babe Doe case has propelled the establishment of Infant Care Review Committee to offer counsel and review in cases involving disabled infants with life threatening conditions. In 1992, the Joint Commission on Accreditation of Healthcare Organization required that all health care organizations set up some mechanism for the consideration of ethical issues arising in the care of patients and must provide education to caregivers and patients on ethical issues relating to health cares. These developments have somehow added the incentive to a wide spread establishing of medical ethics committee and the likes in hospitals in the last two decades. Although bioethics consultation has become a trend in bioethics movement in recent years, there has not been much guidance on the design or responsibility of such a service. Medical ethics committee has placed ethical education as the main function of the committee yet in clinical setting ethics consultation can be more practical and effective as majority of health professionals are not trained bioethicist to deal the unexpected issues by the bedsides. With such a mechanism, health professionals and patients can easily access the needed help to facilitate decision-making, save precious time and avoid ever-growing dispute and tension. This trend, however is still controversial as some, based on the uneasiness of people to request for a consultation, argue that the ethical dilemma a health professional or a patient experiences, is personal in nature and should not be anyone else’s business except their own as the principles of autonomy and confidentiality uphold. In addition, some insist that the recommendation provided by the consultation may be unsound, ethics experts may receive undue deference, procedures may be unfair, consultation may not be timely, the problem may be beyond the scope of the ethicists…etc. Despite of all these arguments and doubts, ethics consultation has been promoted not only as a positive ethical help to all but also as a supplementary assistance to the inefficient mediation and counseling services and the bloated legal system.