預立的自主、流動的自主、關係的自主──省思病人自主權利法下預立醫療決定的法律與倫理議題

我國於2019年實施病人自主權利法至今，其中預立醫療決定是落實病人自主權的核心制度，然而國人已經完成預立醫療決定的比例目前偏低，且該法對於預立醫療決定設有嚴謹的程序與形式規定，是否對於病人自主權帶來限制，亦為爭議所在。美國法上關於預立醫療決定的討論顯示，此制度並非全無疑義地等同於病人自主的展現：個人對於將來未知的醫療情境預作選擇，實有決策上的困難；在病人失去意思能力時，若預立的意願與病人當下的利益有所衝突，應以何者為優位也有待辯證。本文認為，預立醫療決定這樣預立的自主有其侷限，個人的自主意願是流動的，以及關係性地繫於與他人之間的理解與互動。基於前述對於預立醫療決定的省思，本文對於我國病人自主權利法上的幾項議題加以分析，包括預立醫療照顧諮商的必要性、病人不符要式表意的評價，以及預立醫療決定在臨床上的執行問題。

Enacted in 2019, the Patient Right to Autonomy Act (the Act) underscores the significance of Advance Directives (ADs) as a pivotal mechanism for upholding patients’ right to self-determination. Despite its implementation, the rates of AD signing in Taiwan remain low. Concerns have arisen over the Act’s stringent procedural requirements, sparking debates on whether these regulations inadvertently constrain patients’ autonomy. An exploration of Advance Directives in U.S. jurisprudence reveals that ADs may not unequivocally serve as the primary means of realizing patients’ autonomy. Decisional challenges arise when individuals must make choices regarding unknown medical conditions, and conflicts emerge when ADs clash with the current interests of incompetent patients. Acknowledging the limitations of precommitments made by ADs, this article posits that personal autonomy is both dynamic, allowing for changing intentions, and relational, emphasizing the integral role of understanding and interaction with others. In addition to reflecting on ADs, this article scrutinizes various issues within the Act, including the mandate of Advance Care Planning, the effectiveness of patient expressions not meeting the Act’s criteria, and the execution of ADs.