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第 67  期

論壇專文
Invited Papers

  (81)
「趨生畏死」與「趨樂避苦」之兩難 抉擇──「自主意願」:流動且幽微的 心靈答案
The dilemma between "living and suffering" and "dying but relieved" : in search of answers from within the soul - approaching patient autonomy with fluidity and subtlety
作者 釋昭慧
Author Chao-hwei Shih
關鍵詞 病人自主權利法不確定性不由自主緣起畏死懼痛
Keywords Patient Right to Autonomy Act, uncertainty, lack of agency, Dependent Origination, fear of death, avoidance of suffering
摘要 本文就「自主權利」的概念,首先回顧「自主」與「責任」之對應,其次討論「自主」與「權利」之連結,然後才探究《病人自主權利法》在維護「自主意願」方面的保障與瓶頸,以及實施本法可能遇到的倫理爭議。



醫學科技發達,導致眾多重症末期病患與植物人,承受著過度醫療所帶來的深切痛苦,於是,病患的自主權利,開始受到了重視,並且在醫學倫理的討論中,建立了「尊重自主原則」。



依佛法的「緣起」正觀,病人的「自主權利」,永遠是相對(而非絕對)的選擇自由。因為此中伴隨著或多或少的不確定性,以及「不由自主」的兩大風險:一、病後已無法有效表達當前改變的自主意願。二、執行其自主意願後,無法立即終止痛苦地邁向死亡。然而《病主法》的保障,使病人終究無須面對「他人代替選擇,自己無從置喙」的處境。



「畏死」與「懼痛」,這是生命的兩大強烈本能。然而在某些時刻,劇痛之難熬,猶甚於死亡。但是,無限慈愛的力量,也很有可能讓身體衰敗的人,超克「懼痛」之情,產生「努力而活」的感悟。



說到底,「自主意願」並非定格不變的產物,反之,隨著當事人的健康狀況、所獲得的支持力量與外在情境的無常變化,「自主意願」經常是一項流動且幽微的心靈答案。


Abstract In considering the concept of patients'right to autonomy, this paper first reviews the alignment between autonomy and personal responsibility and the interrelation between autonomy and personal rights. It then investigates the guarantees and
obstacles of the Patient Right to Autonomy Act which safeguards patient autonomy. This is followed with a discussion of the potential ethical controversy which implementation of this Act entails.

Due to tremendous advances in health care, patients living with terminal illness or occupying persistent vegetative states may undergo severe pain induced by what some may regard as overtreatment. As a result, considerations around patient autonomy arise with increasing frequency and gravity, to the point that they have become a regular topic in discussions of medical ethics.

According to the Buddhist view of Dependent Origination, patient autonomy is a relative rather than an absolute freedom of choice due to two significant components of the medical decision-making process—uncertainty and lack of agency. Regarding uncertainty, patients may not be able to consciously address changes to their autonomous wishes (or advance medical directive) once their illness reaches a more advanced stage. As for agency, there are times when, even though their wishes are carried out, patients are unable to receive immediate assistance in dying to end their pain and suffering. Thanks to the Patient Right to Autonomy Act, patients are relieved of the plight presented by being unable to make personal medical choices once they are no longer
capable of exercising either conscious deliberation or agency.

Fear of death and avoidance of suffering are two strong instincts of life. At times, sharp pain may seem even more unbearable than death.However, the internal strength which arises from practices generating boundless loving-kindness may also encourage individuals with deteriorating health to overcome their fear of suffering and develop the resolve to continue to “do their best to live”.

In sum, there is no fixed conclusion regarding patient autonomy. Rather, it often varies due to patients’ health conditions, the support they receive, or changes in external circumstances. For these reasons, questions around patient autonomy are often an exploration from within the soul, and characterized by fluidity and subtlety.
《病人自主權利法》之倫理、法律、社會與政策意涵:引言
/ 李瑞全    Shui-Chuen Lee
1
自主與善終
/ 尉遲淦    Chi-Kan Ywi
29
從儒家的觀點省察病人自主權利法的限制:以永久性植物人為例
/ 黃漢忠    Hon-Chung Wong
43
從一位醫師的角度來看病人自主權利法
/ 陳秀丹    Shew-Dan Chen
65
病人自主決定權與「涉艾信息」告知規則的建構
/ 胡曉翔    Xiaoxiang Hu
77
從北京首例冷凍胚胎案看患者自主權
/ 田文鳳、張新慶、張群芝、杜華英    Tian Wen-Feng, Zhang Xinqing, Zhang Jing-Zhi, Du Hua Ying
91
佛教生死觀在預立醫療照護諮商的應用
/ 李明書    Ming-Shu, Lee
107
突然「不想死」錯了嗎?──從尊重自主原則到尊重自主死亡權利的道德疑慮
/ 周琬琳    Wanling Chou
125
臺灣《病人自主權利法》的倫理分析
/ 林孟蒨    Meng-Chien Lin
141
由「病人自主權利法」立法歷程論生命自主權之限制
/ 陳俊志    Chun-Chih Chen
157
論台灣病人自主法: 家庭干涉如何刺激病人自律
/ 許文鳳    BunRong Kouy
187
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