傳統上我們所容許的殺人不外乎是：防衛殺人、戰爭和死刑。本文所要探討的是另外一種你我可能更有機會替自己或替他人決定是否要蓄意地結束一個人的生命－那就是，安樂死(euthanasia)。這種蓄意地殺人比傳統上已容許的類型更具爭議之處在於：我們相信殺死一位無辜的人在道德上總是不被容許，或是錯的。然而這樣原則，因醫療技術的進步而遭受挑戰，迫使我們不得不重新思考這原則的理性基礎何在。當患者處於無法減輕的極度痛苦中，這樣的患者如果要求醫師終止治療、撤除維生裝置、提供他致命的化合物或替他注射致命化合物以盡早結束自己的生命，醫師該如何做？在這情況下，遵照患者的要求而結束患者的生命是仁慈還是謀殺。

University of Macau / Faculty of Law

21世紀是經濟繁榮及醫療科技進步的時代，世界各國面對人口結構快速老化、生命延長、慢性疾病遽增，及流感與疾病的可快速傳播，使世界衛生組織的功能逐漸受到重視。台灣各級醫院的病床幾乎都是急性病床，植物人在健保醫療照護體系中，被歸屬於慢性病非重大傷病，並無特殊的減免醫療支出與補助，僅提供慢性病床及有限的居家護理給付。我國自實施全民健保以來，減輕了許多急重症病患家庭的醫療支出，但健保收入在政治因素的介入下，永遠跟不上醫療支出；且健保局預估今（2009）年收支短絀約320多億(健保局，2008)。不免讓我們憂心未來醫療資源的可能枯竭，加上植物人在病情穩定後即需出院，無法長期留在醫院受專業及妥適的照顧，使得植物人照顧家庭在精神及經濟層面更是雪上加霜陷入困頓。為此，內政、社福、衛生等行政部門，實需積極整合介力協助；如此或可與先進國家的長照體系接軌，使植物人照護得到兼具專業、人性與尊嚴的照應。 本研究採用質性研究中的深入訪談法，以台北縣市植物人照顧家庭的12位家屬為訪談對象，以深入探討都會地區照顧家屬難兼具照顧及就業。照顧者是無酬勞的工作，易在身心俱疲下陷於下一個被犧牲者的情境，植物人家庭對植物人照料與甦醒期待及照顧過程裡對自我生命成長價值觀。訪談所得資料，經歸納、分析所得研究結果: 都會地區家庭結構的轉變，使得家庭照護人力不足，何況目前尚無新醫療可預測植物人何時甦醒，況且頭部病變照顧已久植物人再甦醒的機會很渺茫。大台北地區雙薪家庭聘請外籍看護工的型態，確實讓蠟燭兩頭燒的雙薪家庭，減輕了部份照顧人力不足及精神壓力負擔，但此終究非長久之計。但是，如何讓受照顧的植物人，享有品質的醫療與照護，從而體現生命之尊嚴與國家、社會照護、互助的價值，這正是長照體系建立刻不容緩。或許在可預見的將來，因著教育及社會觀念的轉化，我們可以欣然接受安樂死或推行生前醫療契約，坦然接受自己或家人在面對需要長期療護，特別是可能造成植物人情況的事前自在選擇。所以，如何建構可長可久且結合醫療、勞工、社福用以嘉惠老人及植物人之機構，是政府在拼經濟、擴大內需建設及增加就業，不可不亟力擘劃貫徹的重大議題。但這需要政府與民間一起攜手打造，使台灣寶島實現老吾老以及人之老的平和尊嚴人生之樂土。 本研究依據研究結果，提一些建議：一、對家庭之建議：均衡飲食、養成運動習慣、強化家庭生命共同體。二、對醫療團隊：建立醫院網頁、建構植物人疾病成因及預防之道、社工諮商團隊協助家庭以落實社區長期照護系統。三、對學校建議：課程加入生死學課程、強化衛教觀念及基本照顧方式、培養怡情興趣、學習紓解壓力。四、對政府的建議：政府各部會平台資訊聯結化、行政作業單一窗口化、政策宣導口語化、政策推行離島實施而後推廣至全國，應快速實施長期照護系統。 關鍵字：全民健保、植物人、長期照護、安樂死、生前醫療契約 / The 21st century is a time of economic prosperity and technological advancement. However, the world is facing challenges from the problems of the rapidly aging population, increasing longevity, the surging of chronic disease, in addition to epidemics and flues spreading faster then before. Most hospital beds in Taiwan are considered to be “acute hospital beds”, where vegetative patients are considered by the National Health Insurance to be suffering from a chronic disease and not as major illness/injury. There is no extra medical subsidy for these vegetative patients, and only limited payments for home care. Unfortunately, due to the inefficient funding for health insurance, we are concerned that medical resources might become exhausted in the future. Also, a vegetated patient is required to leave the hospital whenever his or her condition becomes stable. They are unable to remain in the hospital for long-term and professional care, which causes the families with vegetated patients to suffer emotionally and economically. Thus, studying ways for vegetated patients to obtain more professional, human, and dignified care is an important issue worthy of research. This study uses an in-depth interview method from quantitative research. 12 families with vegetative patients in Taipei County are the subjects of the interview. In-depth discussions are conducted on the difficulties for families who take care of a vegetative patient, and who have employment in the urban area. The information obtained was categorized and analyzed. 1. Nursing manpower insufficiency Due to the shifting of family structure in the urban area, there are not enough people in the family to take care of the vegetated patient. It is not possible to predict when a medical breakthrough will enable the patient to regain consciousness. Moreover, there is only a slight chance a vegetated patient suffering from head trauma for a long period of time can be revived again. 2. Dependence on foreign nurse aides By hiring foreign nurse aids, the dual-earner families in the Taipei metro area are able to get relief from the burden of caring for a vegetative patient. However, it is not a long-term solution. 3. The need for long-term care. Therefore, it is very important to construct a long-term care system for the vegetated patient to be able to receive quality medical care. Furthermore, Taiwan will benefit from showing respect for life, the importance of social care, and the value of helping each other. 4. Trying new concepts. Perhaps in the foreseeable future, we will accept things such as euthanasia or pre-paid medical contracts due to the changes in education and social attitudes. We might accept that one of our family members might be facing long-term care in the future, so any one of us is able to make arrangements before an unforeseen accident or illness results in becoming a vegetated patient. 5. Co-operation between the government and the people. This is an important issue for the method of constructing a long-lasting system that can combine medicine, labor, social welfare, and benefits for senior citizens and vegetated patients. However, it will take the cooperation of both government and the people to make Taiwan into a peaceful land that will respect their elders and respect life. Some suggestions have been developed as a result of this study: 1. suggestions to families: a balanced diet, exercise regularly, and strengthen the unity between family members. 2. suggestions to the medical team: develop hospital websites, prevent diseases that can cause vegetation, and the social worker consulting team should help families to implement a long-term community care system. 3. Suggestions to schools: add life and death lessons into the school’s curriculum, reinforce the concept of health education and a basic caring method, as well as increase community service, and teach methods for relieving stress. 4. Suggestions to the government: linking information by using a single window to handle all processes, use colloquial language for promoting policies, the policies should first be implemented in off-shore islands before being used in the main island, implement a long-term care system, and provide subsidies to those who hire domestic nurse aids. Keyword： National Health Insurance, Vegetative, Long-Term care, Home care, Euthanasia, Pre-paid medical contract

一、研究目的 (1). 將針對世界各國相關規範下，早產兒之法律地位進行探討，以釐清現行我國規範對於早產兒法律地位所持之立場。 (2). 促進我國法界前輩更了解照顧早產兒，特別是極早期早產兒所遭遇的醫學倫理困境，能制定更清楚明確的有關極早期早產兒救治的相關法律或更貼切的法律實務判例或見解。 二、研究方法 (1). 文獻探討法，為了解分析照顧早產兒之醫學倫理困境，閱讀中外學者之研究報告、論著等文獻，加以探討。 (2). 歷史比較研究法，蒐集東西方歷史文獻嬰兒生命權利關係之演變資料加以分析；並且比較探討大陸法系及英美法系諸國對相關之早產兒生命權利相關醫學倫理規範及法律規定。 三、研究內容 (1). 早產兒倂發症、後遺症及存活率之情況 (2). 東西方嬰兒生命權利關係之演變史 (3). 照顧早產兒之醫護人員及早產兒家長的困境研究 (4). 國內生命權相關法律規定及醫療法規之分析 (5). 國內外極早期早產兒生命權相關醫學倫理規範及法律規定之分析比較 (6). 更適切之早產兒生命權利法律見解之提出 四、研究結果 經由本研究，基本上理解各國對早產兒生命的尊嚴及生命決定權的醫學倫理規範、法律規定及理論構成，同時也希望藉由此研究能讓政府、社會、法界及醫界對於早產兒生命權利及所遭遇的醫學倫理困境更加重視，我國能制定更清楚明確的有關極早期早產兒救治的相關法律或更貼切的法律實務判例或見解。 / As article 3 of the Universal Declaration of Human Rights prescribes “Everyone has the right to life, liberty and security of person.”, the right to life is the most fundamental human right. However, extremely preterm infants (20 to 23 weeks of gestation) are infants of borderline viability. They are at greater risk for mortality and severe disability. Who can surrogate to make decisions about resuscitation with intensive care or palliative care for them in terms of their best interests? It is a dilemma. There is a potential conflict between palliative care and the general medical duty to save life. It presents complex medical, legal, ethical and social issues for their parents and the health professionals. Until now, it is still out ruled legally in Taiwan. This article focuses on the right to life of extreme prematurity. We will discuss different insights about the right to life of infant from history, culture, society and religion in the world, and analyze guidelines and legal regimes of different countries. Based on that, we can get objective solutions to the right to life of extreme prematurity in Taiwan, as an aid for parents in making ethical and legally based decisions.