再論病人之拒絕治療權：病人自主權利法施行之後

On the Right to Refuse Treatment: After the Enactment of Patient Right to Autonomy Act

病人自主權利法全面肯認病人自主價值，但在拒絕維生醫療部分似乎只限5類病人且須遵循一定程序要件。究竟一個心智健全的病人是否享有一個不受病程與疾病種類限制的拒絕治療權？本文深入分析病人拒絕治療權之性質及其憲法基礎，輔以美、德比較法制的介紹，並以耶和華見證人信徒之拒絕輸血例子來具體說明病主法相關規定應如何進行合目的性解釋。病人選擇特定醫療（即便是維生醫療）以外的方式面對疾病，這是接受「死亡」可能是其選擇下的「併發症」，和病人以「死亡」作為其主要的選擇截然不同。前者是所有道德社群都承認其合倫理性的「自然死」，後者才是涉及生命法益處分而大有爭議的「尊嚴死」。病主法之性質是在「自然死」範疇下的「輔助自主式立法」，而非「尊嚴死」範疇下的「阻卻違法式立法」。因此（1）病主法第9條、第14條之規定，不應解釋為排他性的強制規定，而是工具性的舉證規定；（2）不符合該規定所訂之預立醫療決定，只要符合「明白及具說服性」之證據強度，足茲確認拒絕治療符合當事人「可推測意願」，在醫師及病人家屬均無爭執下，構成醫師不予或撤除維生醫療的正當理由。根據此一見解，本文最後提出對病人自主權利法的修法建議。

The Patient Right to Autonomy Act (the Act), enacted in 2016 and put into force in 2019, is the first statute in Taiwan formally acknowledging the value of patient autonomy. Nevertheless, the Act paradoxically limits the right to refuse live-maintaining treatment to five categories of patients. Do competent patients have a legal right to refuse any kind of treatment despite the types or stages of their diseases? Is it, as Sun Hsiao-Chih claimed, justifiable to separate the right to refuse treatment to general refusal from special refusal (the refusal of life-maintaining treatment)? This article argues against the separation theory by providing clinical narratives and comparative legal studies. The author further uses the case of Jehovah’s Witness patient refusing blood transfusion to explain the correct and appropriate interpretation of the “no justification” in article 7 of the Act. The paper contests again that patient’s right to refuse treatment, based on the Constitutional right to body integrity, should not and does not have to be broken into general refusal and special refusal. A competent and informed patient’s wish to withhold or withdraw certain treatment, even the life-maintaining treatment, does not necessarily bring about immediate death and should not be viewed as committing suicide. Rather, the refusal implies the acceptance of death as a complication of patient’s choice. Understating the ethical difference between Nature-Death (with moral consensus) and Dignity-Death (with moral controversies), the paper clarifies that the Act is by nature a faciliation-legislation in the field of nature-death, not a privilege-legislation in the field of dignity-death. Therefore, this paper concludes that (1) all the procedural requirements in the Act (art. 9 and art. 14) should not be seen compulsory and exclusive but instrumental for convenience reason; and (2) as long as there is “clear and convincing” evidence to show that a refusal meets the patient’s sincere and real wish, with no disagreement between physicians and families, it constitutes the “justification” of art. 7 for physicians to withhold or withdraw life-maintaining treatment, and accordingly all the action/inaction resulted from should not be held legally liable.