「知情放棄」與「空白同意」合乎自主原則嗎？論病人自主之性質

Are "Informed Waiver" and "Blanket Consent" Acceptable Exceptions to the Principle of Autonomy? On the Nature of Patient Autonomy

10.6424/JLE.200912.0097

楊秀儀(Hsiu-I Yang)

自主 ； 告知後同意 ； 知情放棄 ； 空白同意 ； autonomy ； informed consent ； informed waiver ； blanket consent

生命教育研究

1卷2期（2009 / 12 / 01）

97 - 122

繁體中文

本文藉著研究告知後同意的兩種例外「知情放棄」與「空白同意」來探討一個在 病人自主理論上非常根本的問題：自主是權利還是義務？「知情放棄」乃指病人在知道其有決定權的情況下主動放棄其決定權之行使，而 將一切決定交由醫師，空白同意則是指在相關資訊並不充分，甚至不具備的情況下就預先同意，作了決定。這二者都偏離了正統的自主原則──在充分的資訊下自主作決定，是否在倫理上可以接受？本文分析自主義務的可能論述，主張即便肯認病人有道德上的「自主」義務，但 這只是一個「對己」義務，而非「對他義務」，因此可以依照病人的自由意願不履行。在臨床治療的醫病關係中，病人的「知情放棄」並不違背自主原則；另外從法社會學的「中間幹部理論」來主張關於人體檢體之再利用，必須允許某種形式的「空白同意」，才能真正落實尊重自主原則。

The ethical and legal doctrine of informed consent has a very strong metaphor that information is power. Therefore, it is believed (or at least claimed) that the power imbalance between doctor and patient caused by information asymmetry can be adjusted by empowering patients with physicians' duty to disclose. Nonetheless, clinical experiences often show that information does not necessarily bring about knowledge, and knowledge does not necessarily bring about right choices. While informed consent forms become ever lengthier, more and more people doubt such information-dumping really promotes patient autonomy.This paper asks a basic question: can a competent patient waive his/her right to autonomy? Is patient not only entitled but also obliged to autonomy? In more specific, can a patient/subject decline his/her right to know or/and right to make a choice and delegate it to the physician/researcher? Is autonomy in nature a right or a duty?This paper tries to answer these questions by exploring two scenarios: patients' informed waiver in a clinical setting and human subjects' blanket consent in a research setting. The author anatomizes the bioethical concept of autonomy into two identifiable rights: right to know and right to make a decision, both, I argued, under certain condition are waivable.

1. 楊秀儀(2004)。救到死為止？從國際間安樂死爭議之發展評析臺灣「安寧緩和醫療條例」。臺大法學論叢，33(3)，1-44。
   連結：
2. 楊秀儀(2007)。論病人自主權－我國法上「告知後同意」之請求權基礎探討。臺大法學論叢，36(2)，229-268。
   連結：
3. 楊秀儀(2002)。病人，家屬，社會：論基因年代病患自主權可能之發展。臺大法學論叢，31(5)，1-31。
   連結：
4. Salgo v. Leland Stanford Jr. University Board of Regents, 317 P.2d 181 (Cal. App. 1 Dist 1957)
5. Schloendorf v. Society of New York Hospital, 211 N.Y. 125, 105 N.E. 92 (1914)
6. Cruzan v. Director, Mo. (1990). Dep't of Health, 497 U.S. 277
7. Annas, G. J.(Ed.),Grodin, M. A.(Ed.)(1992).The Nazi doctors and the Nuremberg Code: Human rights in human experimentation.New York:Oxford University Press.
8. Annas, G. J.,Glantz, L. H.(1986).The right of elderly patients to refuse life-sustaining treatment.Milbank Quarterly,64(Suppl. 2),95-162.
9. Beauchamp, T. L.,Childress, J. F.(1983).Principles of biomedical ethics.New York:Oxford University Press.
10. Beecher, H. K.(1966).Ethics and clinical research.The New England Journal of Medicine,274,1354-1360.
11. Berlin, I.(1969).Four essays on Iiberty.New York:Oxford University Press.
12. Friedman, L. M.(1990).The republic of choice: Law, authority, and culture.Cambridge, MA:Harvard University Press.
13. Friedman, L. M.(1977).Law and society: An introduction.Englewood Cliffs, NJ:Prentice Hal1.
14. Gaylin, W.,Jennings, B.(2003).The perversion of autonomy: Coercion and constraints in a liberal society.Washington, DC:Georgetown University Press.
15. Gordon, E.(1996).Multiculturalism in medical decision making: The notion of informed waiver.Fordham Urban Law Journal,23,1321.
16. Kass, L. R.(1992).A right to exit?.Hastings Center Report,22(6),44.
17. Katz, J.(2002).The silent world of doctor and patient.Baltimore, MD:Johns Hopkins University Press.
18. Knouse, J. N.(1991).Cruzan: The Supreme Court and the right to die.Loyola Law Review,36,1111-1124.
19. Mansoo N. C.,O''Neil1, O.(2007).Rethinking informed consent in bioelhics.New York:Cambridge University Press.
20. McLean, E. D.(1991).Living wil1 statutes in light of Cruzan v. Director, Missouri Department of Health: Ensuring that a patient's wishes will prevail.Emory Law Journal,40(4),1305-1341.
21. Minow, M.(1991).The role of families in medical decisions.Utah Law Review,1991(1),1-24.
22. Morreim, E. H.(1995).Balancing act: The new medical ethics of medicine's new economics.Washington, DC:Georgetown University Press.
23. Pellegrino, E.,Thomasma, D.(1988).For the patient's good: The restoration of beneficence in health care.New York:Oxford University Press.
24. Schneider, C. E.(1998).The practice of autonomy: Patients, doctors, and medical decisions.New York:Oxford University Press.
25. Taylor, C.(1992).The ethics of authenticity.Cambridge, MA:Harvard University Press.
26. Taylor, J. S.(Ed.)(2005).Personal autonomy: New essays on personal autonomy and its role in contemporary moral philosophy.New York:Cambridge University Press.
27. Warren, B. J.(2000).Pennsylvania medical informed consent law: A call to protect patient autonomy rights by abandoning the battery approach.Duquesne Law Review,38,921.
28. 李太正(1997)。從最高法院86年度臺上字第五十六號判決談錯誤診斷及醫師說明義務。司法週刊，851。
29. 李明濱(1997)。病人自主與知情同意。醫學教育，1，377-388。
30. 孫美華(2005)。碩士論文(碩士論文)。桃園，長庚大學醫務管理學研究所。
31. 楊秀儀(2008)。告知後同意之倫理法律再思考。月旦法學，162，1-15。
32. 楊秀儀(1999)。誰來同意？誰作決定？－從告知後同意法則談病人自主權之理論與實際：美國經驗的考察。臺灣法學會學報，20，367-410。
33. 楊秀儀(2000)。論醫療傷害賠償責任適用消費者保護法之爭議。民法七十年之回顧與展望紀念論文集，臺北:
34. 蔡美娟(1998)。我的抗癌歲月。臺北:遠流。

1. 林信銘、王志堅(2010)。權利或犯罪？從法哲學的觀點論刑法對自殺及其協助行為的評價。生命教育研究，2(2)，1-32。
2. 林耀盛,何雪綾(2020)。末期醫療決策中的病人自主：以病人為中心的思考。應用心理研究，72，91-130。