預立指示之倫理分析及可行性探討

NONE

段秀玲(Hsiu-Ling Tuan)

指導教授 ： 李瑞全

國立中央大學/文學院/哲學研究所碩士在職專班/碩士(2006年)

摘要

人類不但活得更長，人口中高齡人口佔大部分；也發展出許多新醫療科技，增進、延長並改變生命。人口急遽老化影響到對於死亡、臨終，與為醫療作決定的態度。
台灣「安寧緩和醫療條例」2002年12月11日公布，「安寧緩和醫療條例」的特色，在將生命自決權交回患者手中，使醫療工作範圍從生、老、病擴及到死亡，協助人們學會面對死亡。綜觀整個法案內容，主要是規範末期病人得拒絕心肺復甦術，得預立意願書，以及得預立醫療委任代理人。
預立意願書是針對個人因為受到末期疾病侵襲，因而無法作出或表達這些決定的情況所設計，為的是要傳達一系列預先的指示。這項當病人有行為能力時完成的預立意願書或預立醫療委任代理人的預立指示，在當病人無行為能力為自己的醫療作決定時產生效用。
在健康照護與延長生命上最重要的問題就是何時、對誰、用什麼方式、甚至是否拒絕治療或非自願的治療。同樣的，一個有行為能力的人可以經由預立指示關心並決定自己未來的狀況。
本文首先檢討預立指示在生命倫理學上的理據，主要申論預立指示與自律原則和諮詢同意原則之關係，及預立指示所涉及之行為能力與代理人之授權問題。
預立指示常是由病人心中有某些期待或對治療情況預作假設而作了一些指示，但此假設因著有行為能力的人藉由預立指示公布自己未來的決定，卻忽略了一旦病人實際上的狀況和預作假設有所差異時，預立指示可能會出現道德上的風險。因此，本文進一步分析人格同一性對預立指示之道德權威之挑戰。本文基本上認為，縱使人格有變，預立指示仍然有效。至於當事人之行為能力的要求則視於其要決定的事項之嚴重性。因此，本文贊成以滑動折算策略作為行為能力之判斷方式。
由於預立指示是否有進行諮詢同意的過程，病人所作的預立指示則出現包括1、執行上的疑慮2、無行為能力判定標準的問題3、代理人替代判斷的兩難一些倫理的爭議。
本文並探討預立指示之風險、口頭指示之有效性、及申論建立有效的預立指示的一個模式。最後本文分析代理人在判斷上的問題及解決的方法。

關鍵字

自決權 ； 諮詢同意 ； 自律 ； 預立醫療委任代理人 ； 預立意願書 ； 預立指示 ； 行為能力 ； 人格同一性

並列摘要

Improvements in advanced medical technologies have increased and lengthened the lifespan of human beings and changed the way of life. In addition, the issue of rapid aging population certainly affects people’s attitude about their facing death, approaching the point of death and making decision for certain medical treatment.
Taiwan’s “Hospice Palliative Care Act” was promulgated on December 11th, 2002. Its distinguishing features are to return the right to self-determination back to the patients and expand it to cover the scope of medical treatments from birth, aging, sickness to death, as well as assists the patients in facing death. The main point of this Act is to allow terminal patients to refuse to undergo the cardiopulmonary resuscitation (CPR), to make a living will, and to appoint the durable power of attorney.
This study first reviews the principles and bases of the advance directives in bioethics, in particular the relationship between advance directives, the principle of automony and the principle of informed consent, as well as the competence that advance directives involved, and the authorization of the durable power of the attorney.
Advance Directives usually are those directives that patients made due to their expectations or assumptions on the future medical conditions. These directives announce the decisions of the patients with respect to their future. However, the use of these directives overlook the fact that directives based on assumptions can sometimes lead to regretful decisions when the actual outcome differs from the assumptions and leads to moral risks. Hence, this essay analyses the challenge of the personal identity to the moral authority of the advance directives. Basically, this study indicates that even with a change in personal identity, advance directives are still effective. Therefore, the author supports the use of the sliding scale strategy for competence.
It is critical that whether informed consent was well taken care of in the advance directives, advance directives made by patients that may lead to controversy: 1) Questions in execution. 2) The issue of the criteria of incompetence. 3) Difficulty in judgment made by the durable power of attorney.
This dissertation also investigates the risks involved in advance directives, the effectiveness of verbal directives, and the establishment of a valid example for advance directives. At last it will analyze the problems and solutions on the judgments made by the durable power of the attorney.

並列關鍵字

advance directives ； durable power of the attorney ； living will

參考文獻

黃勝雄等著，2000，《天使的眼睛》，花蓮：門諾醫院。

鈕則誠著，2004，《生命教育-倫理與科學》，台北：揚智出版社，初版。

蔡甫昌著，2002，《醫學倫理與家庭醫學》，台北：台大醫學院社會醫

（安寧緩和醫療條例）

李瑞全、朱健民、葉保強著，2005，《應用倫理學與現代社會》，台北：