安寧緩和照護之醫護倫理與刑事法律責任的探討

On the Entanglement between Medical Ethics and Criminal Liability in Hospice Palliative Care

謝璧朱(Hsieh,Bizu)

指導教授 ： 盧映潔

國立中正大學/法學院/法律學系/碩士(2012年)

摘要

現代高科技的醫療技術到底是延長了生命？還是延長了死亡？為了促進末期病人的生活品質、尊重其自主決定，安寧緩和醫療條例規定，二十歲以上，具有完全行為能力之人，得預立意願書選擇安寧緩和醫療，在符合不施行心肺復甦術的條件下，得拒絕、終止或撤除心肺復甦術。安寧緩和醫療條例的立法及修正，衍生出人們是否擁有放棄生命的自主權？一個有意識之人的自殺行為，與有意識卻動彈不得而期待他人協助其死亡的心願是否相同？該條例僅適用於末期病人，立法者對於病人自主權是否為有條件的保障？尊重生命與病人自主權如同天秤的兩端，必須取取得平衡，使生命真正的價值與神聖性不致於被破壞而蕩然無存。
適用安寧緩和醫療條例的首先必要條件為被診斷為末期病人，末期病人的定義關係著病人能否接受安寧緩和醫療照護，更涉及病人是否能依其自主決定放棄生命，故而如何定義末期病人是臨床上常見的爭議。安寧緩和醫療條例對末期病人的定義雖然簡單易懂，但卻忽略了醫療的例外狀況以及不確定性，對所謂末期病人的界定，並沒有辦法像機器規格或生產線的標準化。
本論文是以深度訪談法了解安寧緩和醫療的臨床倫理困境。深度訪談主要目的在了解受訪者以本身的語言陳述他們的觀點，根據受訪者日常生活中重複地建構自己的解釋模式中，去發掘他們的現實生活經驗以建立其理論基礎。本研究以六名醫護人員為研究對象，藉由訪談這六名醫護人員，了解我國安寧緩和醫療臨床實務的現況、醫護人員所面臨的困境，以及2011年新修正之安寧緩和醫療條例執行的情形，檢討現行條例之缺失。
現代高科技的醫療技術使自然死與謀殺之間的界線變得越來越模糊，不予或撤除末期病人的維生治療到底算不算安樂死？醫師是否違反了救助的義務？是否屬於醫助自殺的行為？依據美國醫學會（AMA）的倫理準則將「安樂死」視為：為減輕病人無法忍受且無法治療的痛苦，而由第三者為病人施以足以致命的藥劑；「醫助自殺」的定義為：醫師提供病人為終止生命所需的方法及/或資訊，以加速其死亡；「維生治療」指的是可以延長生命卻無法逆轉目前病情的治療。不施行或撤除末期病人之心肺復甦術的結果其實是相同的，在醫學倫理的評價上也沒有太大的差異。2011年修法前，終止或撤除未簽署安寧緩和醫療意願書之末期病人心肺復甦術無阻卻違法事由，可能構成殺人罪或加工自殺罪。而由誰執行拔管行為，對於作為與不作為的判斷，則有不同的結果，若是由對末期病人具有保證人地位之醫師撤除心肺復甦術，醫師的行為屬於違反保證人義務之不作為，故為不作為犯；若是不具醫療義務的第三人撤除末期病人的心肺復甦術，此時該行為人的行為則屬作為而非不作為。終止或撤除心肺復甦術，雖然該當刑法殺人罪或加工自殺罪的構成要件，但若係在符合安寧緩和醫療條例規定之條件所為者，則屬依法令之行為，得阻卻違法。
醫療技術不斷地進步，許多過去無法治癒的疾病都可以得到有效的治療，然而醫療仍有其極限，生命終將走到盡頭，如何平靜安然地死去，似乎越來越遙不可及。國人向來忌諱談論死亡，也因為如此而造成臨床醫護人員在進行病情告知時面臨許多的困難，有時是病人本身害怕聽到壞消息，但更多時候是家屬依照自己的想法猜測病人可能不想知道，也害怕病人可能在得知病情後無法接受，但也可能是因為長期照顧的壓力或是有財產分配的問題，造成家屬不願意讓病人知道病情，也形成台灣家屬的決定權比病人的自主權更為受到重視，加上醫療糾紛越來越多，使醫護人員在採取何種醫療措施時，往往都是以家屬的意願為優先，因為家屬除了是主要的照顧者，更是日後發動醫療訴訟的人。安寧緩和醫療條例的立法與修正一直走在社會風俗之先，在家屬父權思想的影響下，如何讓家屬尊重病人自主權相當困難，種種的問題還有待醫界與法界重新檢討改善。

關鍵字

安寧緩和醫療條例 ； 末期病人 ； 心肺復甦術 ； 病人自主權 ； 殺人罪 ； 加工自殺罪

並列摘要

Modern medical technology is to extend life or death? In order to promote the quality of life of terminal disease patients and respect their own decisions, the Hospice Palliative Care Regulation allows adults have to pre-signed hospice living will. A Living Will orders a doctor to use or not to use extreme life-saving measures, such as life support, if you are in an irrecoverable coma or in a "persistent vegetative state." A Living Will is sometimes mistakenly called a Do Not Resuscitate Order (DNR) because most people use this document to stop extreme life-saving measures. However, a true DNR is an order from a physician for other medical personnel to withhold life support. In a typical Living Will, doctors are ordered either to withhold life support or are requested to administer life support.Doctors are also ordered to withhold artificial nutrition or are ordered to give nutrition.It must to trike a balance of respect the right of life and patient autonomy as both ends of the scales, otherwise the true value of life and the sanctity would not be destroyed and disappeared.
To be diagnosed as a terminal disease patient is the necessary condition of apply to the Hospice Palliative Care Regulation.The terminal disease patients can accept hospice palliative care, and according to their own decision to give up the right of life.The definition of terminal disease patients of Hospice Palliative Care Regulation while simple to understand, but it ignores the medical uncertainty. There is no way to as the standardization of the machine to dedine terminal disease patients.
This thesis is based on depth interviews to understand the ethical dilemmas of hospice palliative care.Through interviews two doctors and four nurses to understand the current status of hospice palliative care. The modern medical technology has blurred boundary between natural death and murder.Withholding or withdrawing of a terminal disease patient’s life sustaining treatment, whether be considered euthanasia? The physicians whether breach the aid obligations ? Whether the behavior of the doctor-assisted suicide? According to the ethical guidelines of the American Medical Association (AMA),"euthanasia is the act of a physician or other third party ending a patient's life in response to severe pain and suffering; physician-assisted suicide is the practice of providing a competent patient with a prescription for medication for the patient to use with the primary intention of ending his or her own life.
To terminate or withdraw cardiopulmonary resuscitation of terminal disease patient’s who had not signed hospice living will, could not negates the illegal before the Hospice Palliative Care Regulation had be amended in the year 2011. If the physician terminated or withdrew a terminal disease patient’s cardiopulmo- nary resuscitation (CPR), he may constitute a criminal omission of criminal homicide or assistant suicide crime.
The people have always been taboo to talk about death, because sometimes the patients themselves afraid to hear bad news, but more often are family members according to their own idea speculated the patient do not want to know the truth, so result clinical staff faced with many difficulties.Sometimes it may be the pressure on long-term care or the propertied allocation problem, result family members are reluctant to allow patients to know the condition. How to get family members to respect patient autonomy is very difficult, various issues need the medical profession and the legal profession to re-review and improve.

並列關鍵字

Hospice Palliative Care Regulation ； terminal disease patient ； cardiopulmonary resuscitation ； patient autonomy ； criminal homicide ； assistant suicide crime

參考文獻

10.林東茂，刑法綜覽，一品，六版，2009年。

6.張櫻馨，醫療義務與拒絕醫療權衝突時之刑法評價，國立成功大學科技法律研究所碩士論文，2011年7月。

13.楊琇茹，從病患自主權看病患家屬參與醫療決定之權限，中原大學財經法律學系碩士論文，2004年7月。

2.王皇玉，刑法上死亡之認定---評最高法院九十五年度台上字第一六九二號判決，月旦法學雜誌，第185期，2010年10月，頁257-270。

3.王皇玉，論醫療行為與業務上之正當行為，台大法學論叢，第36卷第2期，2007年6月，頁41-91。