二代健保之公義性研究：以丹尼爾斯十項公平性基準為核心

The second generation of health care justice: Daniels of ten benchmarks of fairness

洪煙平(Yeng-ping Hung)

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(2012年)

摘要

全民健康保險法第一條即開宗明義指出全民健保之目的「為增進全體國民健康，辦理全民健康保險，以提供醫療保健服務」。因此全民健康保險之目的在於提供民眾基本的醫療保障。為達到此一目標，在醫療支出方面，必須透過普及的醫療網以提高民眾獲得醫療服務的可近性，並且控制適當的醫療支出成長，另外，在財務收入方面則是必須消除民眾的財務障礙，並維持適當的公平性。
要從生命倫理學的視野檢視社會制度之合理性，實須深切考量約翰．羅爾斯所言：「公義是社會制度的首要價值，就如真理是思想體系的首要價值」，因為，在資源有限的限制下，政策或社會制度如何確立健保系統的資源分配可達公平平等的公義思考，對於健保系統能否獲得合理實踐當是至為關鍵的問題。隨著世界衛生組織的倡導與推行，「健康是基本人權」已成為當代社會的普世價值。丹尼爾斯將羅爾斯的公義理論進一步擴展到健康照護的領域，提供了一個羅爾斯式的「公義的健康照護」（Just health care）理論，以保持和達至公平平等機會(fair equality of opportunity)為健康照護的基本原則，並論證社會應以公平平等機會原則作為健康照護的道德原則，因為健康狀況對個體能否享有公平平等的競爭機會影響很大，因此社會有義務來滿足每一個體的基本健康需求，並且進一步說明社會健康照護政策應該如何公平進行醫療資源之分配。
本論文即針對台灣當前將所實施的二代健保因制度設計不當所引發之倫理爭論；以及一個公義社會所應具備的健康照護政策，就哲學的理論進一步分析，以丹尼爾斯的健康照護公義理論為依據，由十項公平性基準(benchmarks of fairness)，申論一個理想的健康照護體系所應具有的公義分析。並由二代健保制度所引發之爭議，於政策執行面與道德層面上相互牴觸或衝突之處，以生命倫理學的觀點作為進路，並期許建構一個真正符合社會公平、公正、公義之保健體系，進而造福全體國民健康人生。

關鍵字

公平性基準 ； 公義 ； 丹尼爾斯 ； 公平健康照護 ； 全民健康保險

並列摘要

The purpose of NHI is stated clearly from the very beginning that "promoting the health of all citizens, for national health insurance, as to provide health care services" of the National Health Insurance Act. National Health Insurance aims to provide the public with basic health care protection. To achieve this goal, medical expenses must go through a universal health care network to improve the accessibility of the population''s access to medical services, and proper control of health care expenditure growth in the financial income is necessary to eliminate financial barriers to people and maintain appropriate fairness.
In the light of bioethical perspective to rationality of social system, we must deeply consider what John Rawls says: "justice is the primary value of the social system, as truth is the primary value of the system of thought", due to the constraints of the limited resources, how policies or social system establish a health care system of resource allocation reach a fair and equal justice thinking, and when the ability to obtain a reasonable practice for the health care system is critical to the problem.
With the advocacy and implementation of World Health Organization, health is the prevalent human rights that have become the universal values of contemporary society. Daniels further extended Rawls'' justice theory to the areas of health care, and provided a Rolls Justice Health Care (Just Health Care) theory in order to maintain catholic average opportunity (fair in equality of opportunity) for the basic principles of health care; he demonstrated that according to the fair and equal opportunity, the society should base on the moral principles to do the health care because the health conditions are influential to individuals’ competitiveness to possess fair equality. Therefore, the community has an obligation to meet each individual''s basic health needs. We further describe how the social health care policy fairly distributes the medical resources.
This thesis conducts ethical debate for Taiwan''s current implementation of the second generation of health care caused by improper system design; and a just society should be provided with health care policy in the light of philosophical theory. Based on Daniels theory of justice, applying theory of ten benchmarks of fairness to an ideal health care system should have justice. Due to the disputes caused by second-generation health care system, and conflicts or contradictions between policy implementation surface and the moral level, we carry on bioethics’ point of view as a route and hope to build a health system that truly meets social equity, fairness, and justice, and thus benefit all healthy life of citizens.

並列關鍵字

justice ； Norman Daniels ； just healthcare ； National Health Insurance ； benchmarks of fairness

參考文獻

李瑞全（編），2000，《儒家生命倫理學》，台北：鵝湖出版社，再版。

李瑞全，2002，＜生命倫理學五十年（上）＞，《鵝湖月刊》第 330 期。

李瑞全，2003，＜生命倫理學五十年（下）＞，《鵝湖月刊》第 331 期。

陳晶瑩，＜老年人之長期照護＞，《台灣醫學》7 卷 3 期，頁 405。

林郁芬，2009，《柯林頓政府醫療改革推行之研究》（台北：淡江大學美國研究所碩士論文）。