末期醫療決策中的病人自主：以病人為中心的思考

Autonomy in decision-making in the terminal medical care: A patient-centered perspective

本文探討在台灣末期醫療決策討論的臨床現場，病人自主是否確實被適當維護。從文獻回顧以及臨床觀察可知，源於西方個人主義取向自我觀的自主概念，難以完整描述臺灣長輩在臨床醫療現場的自主性展現。近代的臺灣社會，既有華人儒家文化的傳統，也受西方文化的諸多影響，生長其中使人帶有不同程度的個人取向以及社會取向之自我觀。病人真正認可的自主為何，需要個別化地認識與探究。本文回顧自主概念與不同文化的自我觀，說明女性主義的關係自主與東亞儒家哲學的自主原則，因為考量了「關係脈絡」，皆有助擴充個人自由主義式自主概念的不足；同時，也提醒此兩主張雖然都強調「關係脈絡」的重要性，但他們關注的主體不同，前者仍以個人為主體，而後者則以家庭為單位，此一差異源於兩者背後不同的自我觀。有鑑於對病人之自我觀有一定程度的認識，是以適合其文化背景維護其病人自主的必要前提，本文最後回到醫病互動脈絡下看自主議題，並對臨床工作者提出建議。

 

This article focuses on the preservation of the patients’ autonomy in the Taiwanese context. People in modern Taiwan inherit the Confucian tradition and are experiencing the Western cultural influence. Their unique experiences of autonomy in relationships may shed light on how individuals’ autonomy may be preserved in healthcare settings. We reviewed “autonomy” and “self-views” in different cultural contexts and juxtaposed constructs of feminist relational autonomy and East Asian autonomy with that of the individualistic autonomy. Both feminist relational autonomy and East Asian autonomy emphasize autonomy in relationships, but their foci are different: feminist relational autonomy focuses on the individuals, whereas East Asian autonomy focuses on the families. Their differences lie in their different underpinning self-views. For clinical professionals to preserve a patient’s autonomy, they need to understand the patient’s self-view and appreciate individual differences. As the understanding of self-views is a prerequisite to preserve/uphold a patient’s autonomy in one’s cultural context, we further discussed self-views and autonomy in the context of the patient-physician interactions and offered suggestions for clinical professionals.