醫療資源包括疾病治療、健康照護等資源，而國家政府負有義務保障和促進人民的健康，所以台灣實施全民健康保險，目的是疾病的風險分擔，以醫療給付為主。但因健康照護資源稀少，要以國家機制適當的分配資源來達到社會的公平正義。 本文探討有「治療必要性」與「美容整形」爭議的醫療項目，並以全民健康保險法相關於唇顎裂療程之給付情形為例。唇顎裂相關議題的探討，涉及醫療資源的分配；而醫療資源分配的原則，涉及健康與疾病的理解。所以第二章根據波斯亞提出之「物種正常功能」理論，對疾病的定義做一義理分析。波斯亞的生物統計理論是分解性的觀點，而世界衛生組織的疾病分類手冊，採納社會環境的因素考量，屬於整體性的觀點。第三章說明醫療資源分配的公義原則，主要以羅爾斯和丹尼爾斯的觀點來說明。丹尼爾斯辯護羅爾斯的契約理論，主張公平均等機會原則。第四章比較各國的保險制度，台灣實施全民健康保險，荷蘭是社會保險和私人保險混合，而美國是市場機制的保險制度。但不論是何種保險制度，面臨的倫理問題都相同，也就是如何建構一個公平分配資源且提供均等就醫機會的健康照護制度。第五章討論醫學化的語言。因為醫學是一種社會體制，疼痛、畸形和功能紊亂都具有社會的意義。 現代社會的趨勢是「以封面判斷一本書」，所以本文主要分析先天或後天顱顏傷殘對於患者就學與就業之機會的影響，做為討論「醫療必要性」與「美容整形」差異的基礎，再以此差異上的區分說明保險給付的公平原則。 The medical resources involved medical treatments and health care. The governments have been entrusted with the duty of protecting and promoting health of population. In Taiwan, the target of the National Health Insurance Program is the share of risk of diseases, and the main business is medicine coverage. But the medical resources are scarce, we must take the public mechanisms to allocate resources to get justice of society. This thesis explores the distinctions between “medical necessity” and “cosmetic surgery”. And discusses the insurance coverage of cleft lips or/and palates. The issue of cleft lips or/and palates involves the allocation of medical resources, and the principles of allocation involve the comprehension of disease and health. Chapter two describes the definitions of disease. The biostatistical theory of Christopher Boorse belongs to the analytic perspective. While the World Health Organization issued a manual for the classification of Impairments, Disabilities and Handicaps (ICIDH), this work employed mainly social and humanistic concepts belonging to the holistic perspective. Chapter three concerns justice of allocation, in terms of two representative scholars. Norman Daniels defends John Rawls’ contractarian theory and holds the principle of equality of fair opportunity. Chapter four goes comparing the health insurance programs of Taiwan, Holland and the United States. The basic ethical problem is how to structure a health care system that fairly distributes resources and provides equitable access to health care. Chapter five discusses the languages of medicalization. Since medicine is a social institution, the pains, deformities and dysfunctions are given a social valence. This thesis studies diseases and disorders that damage the mouth and face. The initiative would require health insurance plans to cover medically necessary corrective reconstructive surgery for congenital defects.
