從美國紐約市結核病拘禁法令 評析臺灣結核病隔離治療制度

Abstract

結核病是目前全球最嚴重的傳染病之一，多重抗藥性結核病（Multi-Drug Resistant Tuberculosis, MDR-TB）之興起，更是結核病防治工作的新挑戰。為控制結核病對公眾健康的風險，從一九九○年代以來，拘禁（detention）已成為阻斷感染、確保病人完成治療，避免抗藥性之發展與傳播的公共衛生手段之一。其中最著名的例子，即是美國紐約市面對結核病反撲與多重抗藥性結核病流行，於一九九三年修正結核病防治法令，運用多元的介入手段，包括直接觀察治療（Directly Observed Treatment, DOT）及拘禁，成功地使發生率重新回到下降趨勢。臺灣自二○○六年起與世界衛生組織同步推動「結核病十年減半計畫」，衛生機關亦開始運用傳染病防治第四十四條授權下的「隔離治療」權力，要求病人於指定醫院接受治療至解除隔離為止。雖然限制人身自由以控制傳染病，具有醫學上及法律上的合理性，但強制性地將病人與他人分離、限制其行動自由於一定場所，係對個人自由之嚴重侵害，運用此介入手段之正當性值得探討。為此，本文以美國紐約市的結核病拘禁法令為借鏡，檢討分析目前臺灣傳染病防治法授權下的結核病隔離治療制度。本文發現，目前以傳染病防治法第四十四條、第四十五條為法源、加上衛生主管機關之行政命令所建構之結核病隔離治療制度，存在許多缺陷，包括管制手段欠缺定義、權力範圍不明確、手段要件標準過於寬鬆、隔離治療場所適當性不足，缺乏公正審查與有效救濟機制以防止權力濫用等問題。這些制度上缺陷弱化了衛生機關利用限制人身自由手段以降低結核病風險、促進公眾健康的正當性。

Tuberculosis remains as a major global public health concern. The emergence of multi-drug resistant tuberculosis (MDR-TB) has brought new challenges to global efforts in reducing the burden of tuberculosis. In combating the tuberculosis epidemic, the detention of patients has been used by health authorities since the 1990s in attempting to avert transmission, ensure completion of treatment and prevent development of the drug-resistant form of tuberculosis and its subsequent spread. As a parallel project to the Stop TB plan led by the World Health Organization, Taiwan adopted and implemented a Ten-Year Mobilization Plan in 2006 to halve tuberculosis incidence rates by 2015. For the first time, the health authorities started to use the power of “isolation care” authorized under Article 44 of the Communicable Disease Control Act to require patients to submit themselves to designated hospitals for treatment. Although using personal control measures to fight against communicable diseases is a common form of public health intervention, forcible separation of individuals from others and depriving them of their liberty of movement constitute a serious intrusion on individuals’liberty and therefore need to be carefully scrutinized. In attempting to determine whether Taiwan’s tuberculosis isolation care scheme is sufficient in controlling risks and providing adequate protection for patients’ right to liberty, this article analyzes the tuberculosis isolation care laws and regulations and finds that the regulatory framework, including the legal authority empowered by Articles 44 and 45 of the Communicable Disease Control Act and related administrative rules and guidelines, have shortcomings. The unclear definition of “isolation care,” the ambiguity of the interpretation of “necessity,” improper criteria for the use of isolation care on infectious and noninfectious patients, inadequate detention sites, failure to provide impartial review and patients’ right to access to courts review, and the lack of enforcement procedure all contribute to doubts about the justifications of the current tuberculosis isolation care scheme.