從Hardwig 的「死亡義務」觀點家庭與醫療決策

Reflections on Family and Medical Decision Making from Perspective of Hardwig’s Conception of a “Duty to Die”

John Hardwig在1997年所發表的文章“Is there a duty to die?”中主張，當病人的生病狀態已經對其家人或重要關係人造成沉重的生理、心理，社會與經濟負擔時，病人或許有死亡義務以免除家人的負擔，成全其福祉。其論證核心建立在「關係自主」(relational autonomy) 與「以家庭為中心」(family-centered) 的醫療決策模式之上。Hardwig 主張一個心智健全的成年病人在進行醫療決定時，必須為他所置身的關係負責，顧及其決定對於家人或重要關係人的影響，尤其在長期照護的身心耗竭與巨額醫療費用壓力下，我們應該反省傳統以病人為中心的醫學倫理觀，承認家人在醫療決策當中的道德相關性，公平考量病人與家人的權益，而在某些情況下當維持或延長病人生命與家人的權益之間有衝突時，為平衡家庭的整體利益或減少家人之犧牲，家庭成員的利益應該凌駕病人利益。本文首先將闡述Hardwig 提出的死亡義務概念，其次則檢視他對於醫療決策與家庭倫理價值的理解及其「以家庭為中心的關係自主」模式證成死亡義務之合理性，最後將提出死亡義務概念對於目前正處於高齡化以及醫療照護成本攀升的臺灣社會有關終末照護、拒絕維生醫療、安樂死與醫助自殺等相關議題的一些可能啟發。

John Hardwig claims in his controversial essay “Is There a Duty to Die” (1997) that one may have a duty to die when her or his illness imposes overly heavy physical, emotional and financial burdens on family members or loved ones. The core of his argument is based on the notion of relational autonomy and family-centered medical decision making model. According to Hardwig, a competent adult patient’s autonomy is profoundly connected to moral responsibility to family and loved ones, and the traditional focus on patientcentered medical ethics, in which patient interests have priority, should be shifted to family-centered medical ethics. In this paper, I shall first delineate Hardwig’s conception of a duty to die. Second, I shall critically examine the plausibility of his understanding of family ethics and values with reference to medical decision making. Finally, I suggest some possible contributions of Hardwig’s idea of a duty to die to the controversies surrounding end-of-life care, refusal of life-sustaining medical treatment, euthanasia and physician-assisted suicide in the rapidly aging society in Taiwan.