無效醫療問題與全民健康保險醫療給付制度之改革： 以呼吸器依賴病患為例

Abstract

全民健保的實施是我國保障人民生存權及健康權的具體作為，但也從而衍生出無效醫療的問題且逐年加劇。無效醫療的問題反映出生存權及健康權保障界線的衝突，我國仍缺乏有效的價值判斷依據。無效醫療讓病人以極低的健康狀態維持存活，不但造成病人的痛苦與社會的負擔，也耗用可觀的健保資源。二代健保修法後正式將無效醫療明文化，但是卻缺乏判斷無效醫療的準則，因此即使推出一系列政策試圖改善，無效醫療的問題仍無法有效解決。\n二代健保修法後提供「全民健康保險醫療服務/藥物給付項目及支付標準」作為健保給付的法源依據，形式上雖符合明確性的要求，然而實際上無法真確反應醫療的動態過程，也無法作為政策引導及資源分配的工具，更遑論對無效醫療作出明確定義。在全民健保的架構下，制定讓三面關係能夠遵循的醫療指引，才能解決支付標準的不足，並進一步解決無效醫療的問題。本文將參考英國NICE制定醫療指引的程序與方法，提出我國建構醫療指引法制化的建議。\n當醫病關係由父權演變為尊重病人自主，要解決無效醫療，僅有醫療指引是不足的，須在疾病的各階段作適時的介入。在疾病初期，鼓勵病人提早做出「預立醫療決定」；在疾病中期，藉由「醫病共享決策」做出適當的醫療選擇；在疾病末期，則引導病人接受安寧緩和療護。醫療指引在各階段能作為輔助工具，提升病人對疾病的認識，讓病人在自主意願被尊重下做出抉擇，有效減少無效醫療的發生。

The implementation of the National Health Insurance is a concrete act of guaranteeing the right to existence and right to health in Taiwan. But it also bred the problem of “medical futility”, which has deteriorated year by year, that it reflects the conflict of protection boundary between right to existence and right to health. So far, our country still lacks a practical basis for value judgment. Medical futility allows patients to survive in a very poor state of health, which not only prolongs the patient’s suffering and social burden, but also consumes considerable health care resources. The 2nd Generation National Health Insurance Act formally used the term “medical futility”, but it lacked criteria for defining it. Therefore, even if a series of policies were introduced, the problem derived from futile medical care has not been exactly resolved.\n"National Health Insurance Medical Services/Pharmaceutical Payment Items and Payment Standards" was provided as the legal basis of health insurance payment . Although in form it meets the requirements of clarity, it cannot actually reflect the dynamic process of medical care in practice, nor to guide policy development and resource allocation, let alone eliminating the disadvantages of medical futility. Under the framework of the National Health Insurance, it is necessary to formulate medical guidelines for the beneficiary, insurer and contracted medical care institutions to follow, as to make up the deficiency of payment standards and further to solve the problem of medical futility. This article will refer to the procedures and methods of the British NICE to formulate medical guidelines, and put forward suggestions on the legalization of medical guidelines in our country.\nWhen the relationship between doctors and patients has evolved from the patriarchal authority of doctors to respect the autonomy of patients, to resolve medical futility, with only medical guidelines is not enough. There must be appropriate measures to intervene in time at all stages of the disease. At the early stage of the disease, patients are encouraged to make “advance medical decision” early; at the middle stage of the disease, appropriate medical choices are made by “shared decision making”; at the late stage, the patient should be provided with hospice and palliative care. Medical guidelines can be used as auxiliary tools at various stages to enhance patients’ awareness of diseases, let patients make choices under the respected of their own will, and may indeed reduce the incidence of medical futility.