| 摘要: | 目前在臨終照顧上，安寧照顧通常是優先的選擇，雖然如此，仍有少數人為了末期生命的品質，不想自然死，也不想經由臨終鎮靜昏昏沉沉的睡下去，而希望提早死亡，因此有醫師協助自殺的需求。對此需求，存在著立法的合法性與倫理上的爭議。本論文的研究目的主要探討醫助自殺各層面的倫理問題與合法化的可能性。論證醫助自殺是一種醫療行為，它可以成為安寧療護的一環，讓末期病人在臨終照護的選擇上多一種選項，以協助病人達到所期望的生活品質與死亡尊嚴。相較於安樂死，醫助自殺在臨終照護上應該是比較能夠被接受而合法化。在研究方法上，本文以倫理分析為主，並應用臨床研究，作為論證之參考。在意涵方面，醫助自殺不同於一般的自殺。資料分析顯示需求者以末期癌症病人為主，而需求醫助自殺的原因最多為由身體症狀引發的難以忍受的痛苦，還有失去自主性、失去尊嚴等。醫護人員對病人需求醫助自殺的態度與經驗方面顯示，目前為止，大部分的醫護人員反對醫助自殺。本文首先對奎爾醫師所提出的醫助自殺的臨床準則，加以倫理分析，並提出修正與補充，作為未來醫助自殺合法化的標準模式。在末期病人臨終醫療處置方面，本文比較醫助自殺與自然死、自願停止進食與水分、臨終鎮靜與安樂死在倫理上之異同，提出醫助自殺做為臨終照護的一個選項的可能性。本文進而從死亡權的探討，分析學者贊成與反對醫助自殺合法化的理由，個人認為應考量到對病人自律自主權利的尊重，承認病人在末期嚴重病痛之下有放棄繼續活著的權利。只是個別醫護人員卻沒有醫療的義務協助病人自殺。因此病人死亡權的落實，尤其是積極的死亡權部分，必須法律的保障，如此病人不只有道德的權利可以得到幫助，醫護人員也可按其價值選取而決定是否參與協助病人得到醫療的協助。由國家保障病人可依其意願達到死亡的尊嚴。其次，本文最後從儒家的倫理觀點，論述醫助自殺在仁心、不忍人之心與經權原則之下，可以是人道上可被接受的出路。由於儒家思想重視家庭倫理，因此不只病人的自願性，家屬的參與也應受到高度的尊重。在宗教信仰上，台灣多元文化的信仰所形成的生命價值觀，死亡不一定是壞事。只是在醫病關係上，單有仁心仁術不足以協助病人自殺，必須要有良好而持久的醫病關係，病人的需求才不會被扭曲，因此在我國，家庭醫師制度的建立是很重要的。本篇論文的貢獻包括：一、提出醫助自殺可能的臨床準則。本研究嘗試著以奎爾醫師所提的對醫助自殺的七項臨床準則為基準，對照尊嚴死法案，提出醫助自殺可能的法案。二、儒家思想於醫助自殺倫理議題的會通。儒家講求的是醫病家屬的心安，若是末期病人在良好而持久的醫病關係之下，能清楚的了解自己疾病的預後，加上親近家屬的支持，以醫助的方式提早死亡可以緩解病人的痛苦，那麼死亡是「仁」的體現，可以讓病人、家屬心安。其次，若醫助自殺合法化，醫護人員協助病人是「仁心」的表現，仁心的發用，才能讓醫護人員心安。三、在臨床研究方面，本人在台灣醫護的研究與觀察結果發現，在對醫助自殺的接受度方面，醫師與護理人員贊成醫助自殺合法化都不到半數 (醫師占30%，護理人員占39.3%)。但在經驗方面，醫師部分，病人或家屬曾經需求過醫助自殺者達10-14.3%，而護理人員亦達9.2-12.8%。顯然台灣目前醫護人員對協助自殺接受度不高，但少數末期病人卻有這部份的需求。對於未來的展望，本研究認為若病人對醫助自殺的需求要被認同，需要幾方面的配合，包括社會對醫助自殺的認同，醫護人員對醫助自殺的認同，良好的醫病關係和護病關係，還有讓醫助自殺或醫助死亡成為安寧療護的一環。Palliative care is the first choice of terminal care at the moment. However, there are patients who still want to die other than no natural death because of the poor life quality at terminal stage. Nor would they prefer terminal sedation, which put them to a drowsy sleep for a long time. These cases require ‘physician-assisted suicide (PAS)’, which is a legally and ethically debated issue. The aim of my dissertation is to investigate the ethical issue and the possibility of legalization of PAS especially in Taiwan and try to demonstrate that PAS is another type of medical practice, which provides a further choice of palliative care for terminal patients in order to achieve their expected quality of life and dignity. In contrast to euthanasia, PAS is morally more acceptable to be legalized. This dissertation is basically an ethical analysis of the issue with certain references to clinical studies. The meaning of PAS is quite different from ordinary suicide. The evidences showed that people who required PAS were mainly terminal cancer patients. They request PAS due mostly to unbearable physical pains, followed by loss of autonomy and dignity. Most medical practitioners, however, oppose to PAS. In this dissertation, I start from the ethical analysis of reasonable criteria of PAS proposed by Dr.T.E.Quill, and supplement them with some suggestions and modification, which would hopefully provide a standard model for the consideration of legalization of PAS. In terms of the medical care for terminal patients, I compare the differences between PAS and natural death, voluntarily stopping of nutrition and fluid, terminal sedation as well as euthanasia, and propose PAS as one possible choice for terminal care. The dissertation deliberates further on the right to death of the patient and the reasons for and against PAS in the literature. I support patients’ right and autonomy in particular their right to die at terminal stage. However, individual medical practitioner has no obligation to assist their patients to commit suicide. Laws should be established for protecting patient’s right to die. By legislation, not only the patients’ moral rights are protected, but medical practitioners could also have the choice to participate or not in PAS according to their personal values. Government has the duty to let patient’s wish for a death with dignity be honored. Furthermore, the dissertation elaborates the Confucian’s view on PAS ,my analysis is based on the basic of Confucian’s conception of the mind of ren or the unbearable mind of other’s suffering and the principle of ching-chuan to show why certain cases of PAS is permissible. Confucianism emphazise family relationship, therefore it is not only the patient’s voluntary decision should be respected, but also their family members’ participation are fully acknowledged. In terms of the pluralistic religious believes in Taiwan, death is not necessarily a bad thing. However, in case of PAS, doctor’s benevolent heart and medical skills may not be enough to carry out PAS for the patients, a long term well maintained doctor-patients relationship is essential. Therefore, in Taiwan, it would be most important to establish a good system of family doctors.The contributions of this dissertation include: (1) The proposal of possible clinical criteria of PAS. By comparing the criteria of Quill’s seven requirements with the Dignity Death Act, I propose a possible PAS for Taiwan. (2) The argumentation of PAS in Confucian terms shows that Confucianism tends to support PAS for terminal painful patients. For Confucianism, it is most important to let the medical practitioners, the patient and patient’s family feel peaceful. Death could be the regarded as the practice of ren if the terminal patient understands his/her own illness, and chooses PAS with family support. This should also be based on a long term well-established doctor-patient relationship, so that all parties feel peaceful for the decision. (3) According to my clinical study and observation on medical professionals in Taiwan, less than half of the physicians and nurses support the idea of legalizing PAS. (30% of physicians and 39.3% of nurses support PAS legalization). 10-14.3% of physicians and 9.2-12.8% of nurses had the experiences of being requested for PAS by patients or their family members. Obviously, although PAS is still not widely accepted by the medical practitioners, some terminal patients demand for this treatment. To carried out patient’ PAS, we need the support of the wider society as well as medical practitioners’ recognition of PAS as part of palliative care. |
