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題名:論醫療自主權
作者:李壽星
作者(外文):LEE, SHOW-SHING
校院名稱:輔仁大學
系所名稱:法律學系
指導教授:陳榮隆
學位類別:博士
出版日期:2019
主題關鍵詞:醫療自主權個人自主關係自主告知後同意人格權隱私權自主權代理autonomyrelational autonomyindivisual autonomyinformed consentpersonality rightprivacyguardianship
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摘要
從病人自主權利法的立法說明可以看出病人自主權利法所保障的權利是病人的醫療自主權。各國有關病人醫療自主權的保障,最重要的是「告知後同意原則」,但它是英美普通法的法則,與我國成文法的司法制度,顯然格格不入,而我國目前以告知後同意原則來保護病人的醫療自主權,僅以醫事法律規定的說明義務與病人同意權利,顯然不足。我國在2000年,立法訂定「安寧緩和醫療條例」讓末期病人或其代理人得以拒絕治療及選擇維生醫療,這個條例是我國,也是亞洲第一個成文立法來保障病人的醫療自主權。2016年的病人自主權利法則在立法說明中提出保障「醫療自主權」這個字句,這是我國第一次在法律文檔中確立了「醫療自主權」。醫療自主權是什麼,醫療自主權的內涵為何,醫療自主權的在權利體系的定位為何以及如醫療自主權應該如何保障,必須深入加以探討。
自主是什麼?自主的理論可以從政治哲學,道德哲學,生命倫理學及法律哲學等各種不同的角度來研究,因此有各種同的自主的理論和自主的學說。目前主流學說所討論的都是個人的自主;女性主義和社群主義者提出的則是關係自主、理性自主。主流學說強調自由主義的個人自由,個人的自主則是自由主義的核心。美國崇尚自由與民主,是自由主義的國家,強調個人的自主,但女性主義和社群主義的學者指出,個體和社會是密不可分,個人是組成社會關係的元素;將個體的設定排除於社會背景外,是不切實際的。個人的形成和能力來自於和他人的互動及社會的影響,應該要把社會條件考慮在內。台灣學者另從生命倫理學、東方的醫學倫理與醫病關係,來討論醫療自主的理論,從東方孔孟儒家倫理道德的影響,歸納出臺灣的醫療自主其實不是美國式的個人自主,而是儒家式的醫療關係自主。美國雖是一個自由主義的國家,提倡個人的自主,女性主義和社群主義提出關係自主,對個人的自主提出了改進。因此美國現代的醫療自主是一種關係自主。而關係自主的個人必須有行為能力,因此醫療關係自主也是一種理性的自主。德國從康德的自主理論,也就是康德的理性存有的「意志的自由」理論,導出人性尊嚴的三要素:生命、理性及自主。在康德的人性尊嚴理論下,一個人一定要有理性和自主才有尊嚴,如果沒有理性就沒有自主,沒有自主就沒有尊嚴。未成年的小孩,成年失智喪失行為能力的成年人,沒有完全理性也沒有完全自主。
自主權是德國、美國和我國憲法未列舉的基本權;從德國基本法第一條人性尊嚴及第二條人格發展的文本,可以認定人性尊嚴是德國基本法中先於國家的自然權,德國自主權的保障,是在德國基本法第二條所規定的「人格發展權」,從人性尊嚴的憲法價值,認定自主權是德國憲法未列舉的基本權。德國、美國及我國有關憲法未列舉的基本權,利用憲法解釋違憲審查來確定,其制度與實踐並不相同,美國利用普通法的判例制度,在不同的案例裡面,利用違憲的司法審查,最高法院確定了憲法未列舉基本權的地位。德國則設立獨立的聯邦憲法法院利用案件的裁判結果及內容付予法律的效力而確立基本法未列舉基本權的地位。我國憲法未列舉的基本權,則以司法院大法官會議利用憲法解釋違憲審查,來確定憲法未列舉基本權的地位,我國大法官會議違憲審查有關自主權的解釋,確定了多項自主權的基本權地位,但未包括醫療自主權。
醫療自主權的態樣可從醫病關係來說明醫療自主權的性質及內涵,從醫療的功能與作用來看,醫療自主權包括了幾個態樣:身體自主權,生育自主權,及醫療資訊自主權。德國從德國基本法第二條可導出德國的醫療自主權,它的性質是一般人格權;而美國的醫療自主權,經由多年的憲法解釋違憲審查判例以及學說理論,認定它的性質是憲法上的隱私權。由於美國聯邦最高法院的憲法解釋違憲審查,採美國聯邦最高法院大法官的多數意見,但也尊重不同的少數意見。美國聯邦憲法修正案第5條及第14條規定:未經正當法律程式,不得剝奪任何人的生命、自由或財產。因此在美國的判例中,醫療自主權也有自由權的性質。我國司法院大法官會議解釋自主權,有依德國的人性尊嚴規定,解釋為一般人格發展權,也有依照美國的判例,解釋為隱私權。
有關醫療自主權保障的實務,在德國有倫理層次訂於醫師守則之告知後同意原則,也有成文法訂於民法典的德國病人權利法及醫師的說明義務規定,也有法律效力的聯邦憲法法院的判例。美國則以普通法之先例約束原則用判例來保障憲法上的權利,美國普通法的告知後同意法則,聯邦最高法院己承認病人拒絕治療權是告知後同意法則上的權利也是憲法上半影理論的隱私權,告知後同意法則的理論與實踐由許多的判例結合而成。美國除了普通法以外也有許多聯邦法、統一法及州法的醫療自主權成文法。紐約州的「不施行心肺復蘇法」則是美國也是世界上第一個最完整的自主拒絕醫療的成文法律。臺灣告知後同意原則的實踐,學者與法院均從刑法與民法的法文中分析,導出醫師或醫院的告知或說明義務以及病人或代理人的同意權利,雖然告知後同意是英美普通法的法則,而且我國告知與同意的明文規定是規定於醫事法,而不是民、刑法典。我國的安寧緩和醫療條例,是亞洲最早而且最先進的拒絕醫療自主權的成文法,病人自主權利法之立法說明中明文規定是保護醫療自主權,這是醫療自主權首次出現在臺灣的法律文檔之中,
從美國紐約州Storar及Eichner兩個案例的判決可看出,成年與未成年人的醫療自主權保障不同。未成年人沒有行為能力,基於醫療自權是理性的關係自主,沒有行為能力的未成年其醫療自主權應由父母的親權或法定代理人基於病人最佳利益原則來行使。行為能力與決定能力變成先於自主要素的理性要素。因此各國均訂有人身監護制度。各國的人身監護制度,重點都在保護沒有行為能力的未成年人而訂立行為能力與決定能力的基準。為了保護沒有行為能力的成年人醫療自主權,探求沒有行為能力的成年人在喪失行為能力之前的意志及意思表示,各國都在推動意定代理監護制度,在成年人有行為能力的時候,將本人的醫療意願或醫療決定,以法律規定的成文方式做成委託或信託;成年人一旦喪失其行為能力,代理人即可依照本人的意願,代行其醫療自主權利。未成年人因為心智尚未完全成熟,沒有辦法做出理性的自主,因此未成年人的醫療自主權,要受到父母親權的監護,未成年人成年之後因為智障或身體發展遲緩,沒有完全的行為能力,他的醫療自主權也一樣受到父母親權或法定代理人的監護。
各國所採行之醫療自主權法制,均與其國內的歷史文化以及實務環境有著密切關聯。我國醫療制度從早期的德日制,走到今日的美國制。但是臺灣的法制,還是繼受德日的成文法制。以保護醫療自主權為例,我國法制若無成文法之立法難以保障憲法上的自主權,似應仿照病人自主權利法之立法,將醫療自主權之身體自主權、生育自主權及醫療資訊自主權立專法保護。
English Summary: The Right to Autonomy in Medical Care
From the legislative description of the Patient Right to Autonomy Act, it can be seen that the object guaranteed by the Patient Right to Autonomy Act is the patient's medical autonomy or the right to autonomy in medical care. In the history of the protection of patients' medical autonomy in various countries, the most important issue is the "Informed Consent" principle, which is the doctrine of Anglo-American common law. It is obviously not compatible with the judicial system of Taiwan's statutory law. In Taiwan, informed consent is stipulated in the Medical Care Act, not in the Civil Code. But the court decisions are usually based on the obligations and rights stipulated in Civil Code. In 2000, the legislation established the "Hospice Palliative Care Act" to allow terminally ill patients or their agents to refuse medical treatment and choose palliative medical care. It is the first written legislation in Taiwan and Asia to protect patients' medical autonomy. The Patient Right to Autonomy Act in 2016 puts forward the phrase "medical autonomy" literally in the legislative statement, which is the first time that Taiwan has established "medical autonomy" in a legal file. What is medical autonomy, what is the connotation of medical autonomy, what is the status of medical autonomy in the rights system and how to guarantee it, they must be studied in depth.
What is autonomy? The theory of autonomy can be studied from various angles, such as political philosophy, moral philosophy, legal philosophy, bioethics and so on, and there are also different autonomy theories and discussions. At present, the mainstream theory of autonomy is all about individual autonomy, but Feminism and Communitarianism put forward the relational autonomy, in addition to individual autonomy emphasized by the Liberalism. Individual autonomy is at the heart of Liberalism. The United States advocates freedom and democracy, and is a liberal country, emphasizes individual autonomy. Feminist and Communitarianism scholars point out that individuals and society are inseparable, individuals are a link to form social relations, and it is impractical to exclude individual settings from the social background. The formation and ability of the individual comes from the interaction with others and the influence of the society, and should be considered in the social conditions. In Taiwan, the theory of medical autonomy is studied by scholars from bioethics, medical ethics and doctor-patient relationship in Chinese style. From the influence of the Oriental ethics of Confucius and Mencius, they summed up that Taiwan's medical autonomy is not in fact an American-style individual autonomy. It is the Confucian style of medical relational autonomy. The United States is a liberal country, advocating individual autonomy, but Feminism and Communitarianism proposed to improve the individual autonomy and put forward the relational autonomy. Therefore, American medical autonomy is also a kind of relational autonomy in the doctor-patient relationship. Individual in relation with the society must be competent to act as an autonomous person, so the medical relational autonomy of individual must be a kind of rational autonomy. Germany derives three elements of human dignity from Kant's theory of Autonomy, that is, the "freedom of Will" theory of Kant's rational beings: life, reason and autonomy. Under Kant's theory of human dignity, a person must have reason and autonomy to have dignity, if there is no reason there is no autonomy, if there is no autonomy there is no dignity. Underage children, adults who have lost their mental capacity, have no reason and therefore have no rational autonomy.
Autonomy is a fundamental right not enumerated in the Constitution of Germany, the United States and Taiwan. From the text of “human dignity” and “the personality development” of Article I and Article II of German Basic Law, it can be concluded that human dignity is the natural right of the people prior to the legislation of German Basic Law, and the guarantee of German autonomy is the "right to personality development" stipulated in Article II of the Basic Law. From the constitutional value of human dignity, it is recognized that autonomy is the basic right not enumerated in the German constitution. In Germany, the United States and Taiwan, the basic rights not enumerated in the Constitution used the constitutional interpretation and unconstitutional review process to determine its recognition and practice, and their system and practice are not the same. The United States uses the common law system to review different cases, uses unconstitutional judicial review to determine the status of the unenumerated basic rights. In Germany, for its part, has established an independent Federal Constitutional Court to try and review the cases, using the privilege that the judgment and the reasoning are binding as a law to establish the status of the rights in issue. The basic rights not enumerated in Taiwan Constitution are reviewed and recognized by the constitutional interpretation of unconstitutional review by Constitutional Court of the Judicial Yuan. The Constitutional Court has reviewed autonomy of various kinds, recognized autonomy as a basic right in many occasions, but has not included medical autonomy.
The relationship between physicians and patients must be explained in the nature and connotation of medical autonomy. From the function and practice of medicine we assert medical autonomy includes several forms: physical autonomy, reproductive autonomy, and the autonomy of medical information. From the second Article of the German Basic Law, the medical autonomy in Germany can be derived, its nature is the general personality right, while the medical autonomy in the United States, through years of constitutional interpretation of unconstitutional review of the Federal Supreme Court, its nature is the constitutional right to privacy. In the unconstitutional review and the constitutional interpretation of cases in the United States Supreme Court, judgment is decided from the majority opinion. Articles 5th and 14th of the amendment to the United States Federal Constitution provide that “no one shall be deprived of his life, liberty or property without due process of law. Thus, in the jurisprudence of the United States, medical autonomy also has the nature of liberty. In Taiwan the Constitutional Court of the Judicial Yuan had reviewed and interpreted autonomy in several occasions, some were interpreted as the right to development of the general personality in accordance with the human dignity in Germany, some were interpreted as constitutional right of privacy as in the States.
With regard to the practice of the protection of medical autonomy in Germany, there are ethical rules the same as informed consent doctrine in the Code of Physicians, as well as the German Patient Rights Act and the physician's obligation to inform which is set out in the German Civil Code. Decisions in the German Federal Constitutional Court also play an important part. The United States, for its part, uses jurisprudence to safeguard constitutional rights by the principle of precedent - stare decisis in common law. The Federal Supreme Court has recognized that a patient's right to refuse treatment is a right of informed consent and also a constitutional right of privacy by the penumbra theory. Case law theory and practice are combined with statues in many jurisprudences. In addition to common law, the United States also has many statue laws, uniform laws and state laws to protect medical autonomy. New York State's "Do Not Resuscitation Act" is the first United States and the world's first and most complete statue law to refuse medical intervention. Taiwan has practiced the principle of informed consent for a long time, scholars and courts derived the duty to inform and the right to consent from the text of Civil Code and Criminal Code which do not have any phrase of informed consent. Instead, informed consent principle is only stipulated in medical laws, and the informed consent doctrine is the law of Anglo-American common law doctrine. Taiwan's Hospice Palliative Care Act is the first and most advanced statue law to refuse invasive medical treatment and life-sustaining treatment in Taiwan and Asia. The legislative statement of the Patient Right to Autonomy Act in 2016 explicitly states to protect “medical autonomy” of patient, which is the first time that “medical autonomy” has appeared in Taiwan's legal files,
As can be seen from the judgements in Storar case and Eichner case in New York State Supreme Court, the protection of medical autonomy between adults and minors was different. Minors have no capacity, based on medical autonomy being a rational relational autonomy, medical autonomy of incapacitated minors should be exercised by parental authority or legal proxy on the basis of the principle of best interests. Therefore, capacity and decision ability become the rational elements before the autonomous elements in the theory of human dignity. In the world, nearly every country has a personal guardianship system. The system of personal guardianship in various countries focuses on the protection of incapacitated minors and the establishment of benchmarks for capacity determination. In order to protect the medical autonomy of incapacitated adults and to explore the will and wish of incapacitated adults before they are incapacitated, many countries are establishing the arbitrary guardianship system. Durable power of attorney means, when adults are competent, their medical will or medical decisions shall be entrusted in a written manner prescribed by law; once an adult loses his or her ability to act, the proxy or agent may represent and decide in accordance with his or her own wishes. For minors because the mind has not yet fully grown, there is no way to make rational autonomy, so the medical autonomy of minors must be supervised by parental authority. Adults of mental retardation or slow physical development, do not have full capacity, his medical autonomy is also subject to parental authority or legal representative custody.
The legal system of medical autonomy adopted by various countries is closely related to the historical culture and practical environment. In Taiwan, medical system has gone from the early German and Japanese system to the American system today. But Taiwan's legal system is still subject to the statutory jurisprudence of Germany and Japan, not including the common law system in the US. Taking the protection of medical autonomy as an example, it is difficult to protect the constitutional autonomy rights without the legislation of statutory laws in Taiwan. It seems that the physical autonomy, the reproductive autonomy and the autonomy of medical information which are included in medical autonomy, should be protected by the legislation of statues on each of the independent rights of the patients.
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(二) 學位論文
王小星,從臨終末期病患生命權與自主權觀點探討不予或撤、止維生醫療之法律爭議,國立成功大學法律學研究所碩士論文,2012年。
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王皇玉,醫療行為於刑法上之評價─以患者之自我決定權為中心,台灣大學法律學研究所碩士論文,1995年。
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吳宜亭,論心智障礙者之強制治療和權利保障─以國際人權法下之自主原則為核心,國立清華大學科技法律研究所碩士論文,2010年。
李宏文,論子女最佳利益原則,台北大學法學系碩士論文,2004年。
林修睿,學術自由下研究倫理的建構與應用:以生物資料庫對原住民基因採集為例,國立成功大學法律學研究所碩士論文,2015年。
邱琪雯,醫師告知義務法律責任之再研究─以是否負刑事責任為中心,中原大學財經法律學系碩士論文,2006。
洪榮彬,資訊時代之資料處理與資料保護─以德國聯邦個人資料保護法制為中心,輔仁大學法律學研究所碩士論文,1993年。
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馬興平,論資訊隱私權的保護-從釋字第603號解釋出發,國立中正大學法律研究所碩士論文,2008年。
張志明,美國聯邦最高法院與德國聯邦憲法法院墮胎判決之比較研究,國立政治大學法律學系碩士論文,1999年。
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陳品錚,論人性尊嚴之憲法意義—以德國基本法第一條第一項為基礎,國立中正大學法律學研究所碩士論文,2010年。
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曾美雪,母胎關係與墮胎:自由女性主義、關懷倫理學之論點與儒家之新視野,國立中央大學哲學研究所碩士論文,2006年。
楊琇茹,從病患自主權看病患家屬參與醫療決定之權限,中原大學財經法律研究所碩士論文,2004年。
葉千慈,論監護人、保護人及醫療委任代理人之互動關係-以成年監護制度之人身照護事項為中心,嶺東科技大學財經法律研究所碩士論文,2018年。
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二、英文
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Diana T. Meyers, Being Yourself: Essays on Identity, Action, and Social Life, Lanham, MD: Rowman and Littlefield, 2004.
Diana T. Meyers, Decentralizing Autonomy. Five Faces of Selfhood, in Anderson, J. and J. Christman, eds., Autonomy and the Challenges of Liberalism: New Essays, Cambridge: Cambridge University Press 2005.
Diana T. Meyers, Intersectional Identity and the Authentic Self. Opposites Attract! In Mackenzie and Stoljar eds., Relational Autonomy Feminist Perspectives on Autonomy, Agency and the Social Self, New York: Oxford University Press, 2000.
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