「趨生畏死」與「趨樂避苦」之兩難抉擇──「自主意願」：流動且幽微的心靈答案

The dilemma between “living and suffering” and “dying but relieved”: in search of answers from within the soul - approaching patient autonomy with fluidity and subtlety

本文就「自主權利」的概念，首先回顧「自主」與「責任」之對應，其次討論「自主」與「權利」之連結，然後才探究《病人自主權利法》在維護「自主意願」方面的保障與瓶頸，以及實施本法可能遇到的倫理爭議。醫學科技發達，導致眾多重症末期病患與植物人，承受著過度醫療所帶來的深切痛苦，於是，病患的自主權利，開始受到了重視，並且在醫學倫理的討論中，建立了「尊重自主原則」依佛法的「緣起」正觀，病人的「自主權利」，永遠是相對（而非絕對）的選擇自由。因為此中伴隨著或多或少的不確定性，以及「不由自主」的兩大風險：一、病後已無法有效表達當前改變的自主意願。二、執行其自主意願後，無法立即終止痛苦地邁向死亡。然而《病主法》的保障，使病人終究無須面對「他人代替選擇，自己無從置喙」的處境。「畏死」與「懼痛」，這是生命的兩大強烈本能。然而在某些時刻，劇痛之難熬，猶甚於死亡。但是，無限慈愛的力量，也很有可能讓身體衰敗的人，超克「懼痛」之情，產生「努力而活」的感悟。說到底，「自主意願」並非定格不變的產物，反之，隨著當事人的健康狀況、所獲得的支持力量與外在情境的無常變化，「自主意願」經常是一項流動且幽微的心靈答案。

In considering the concept of patients' right to autonomy, this paper first reviews the alignment between autonomy and personal responsibility and the interrelation between autonomy and personal rights. It then investigates the guarantees and obstacles of the Patient Right to Autonomy Act which safeguards patient autonomy. This is followed with a discussion of the potential ethical controversy which implementation of this Act entails. Due to tremendous advances in health care, patients living with terminal illness or occupying persistent vegetative states may undergo severe pain induced by what some may regard as overtreatment. As a result, considerations around patient autonomy arise with increasing frequency and gravity, to the point that they have become a regular topic in discussions of medical ethics. According to the Buddhist view of Dependent Origination, patient autonomy is a relative rather than an absolute freedom of choice due to two significant components of the medical decision-making process--uncertainty and lack of agency. Regarding uncertainty, patients may not be able to consciously address changes to their autonomous wishes (or advance medical directive) once their illness reaches a more advanced stage. As for agency, there are times when, even though their wishes are carried out, patients are unable to receive immediate assistance in dying to end their pain and suffering. Thanks to the Patient Right to Autonomy Act, patients are relieved of the plight presented by being unable to make personal medical choices once they are no longer capable of exercising either conscious deliberation or agency. Fear of death and avoidance of suffering are two strong instincts of life. At times, sharp pain may seem even more unbearable than death. However, the internal strength which arises from practices generating boundless lovingkindness may also encourage individuals with deteriorating health to overcome their fear of suffering and develop the resolve to continue to “do their best to live”. In sum, there is no fixed conclusion regarding patient autonomy. Rather, it often varies due to patients' health conditions, the support they receive, or changes in external circumstances. For these reasons, questions around patient autonomy are often an exploration from within the soul, and characterized by fluidity and subtlety.