| 摘要: | 國人基本的健康是政府所需保障之根本權益，就如同其他生存權、自由權一樣重要應受保障。國家的健康照護政策，必須消除先天因素所帶來的健康條件不平等，與外在因素所造成的醫療可近性落差，因為保障全體國民基本的健康條件是當今社會符合公平正義的重要議題。 台灣全民健康保險從84年3月開辦至今已屆滿15年。人民因病而貧，因貧而無法就醫治療的情況確實獲得改善，而在降低民眾就醫財務障礙以及提升民眾就醫可近性等方面均具有相當成效。然而全民健保自實施以來，不斷擴大給付範圍，雖然嘉惠了更多弱勢族群以及重大傷病患者，但也加重了財務負擔。91年全面實施總額預算制度之後，購買醫療服務的方式，由以往回溯性的支付方式改為前瞻性的預先給予額度限制，雖然有助於解決日漸窘迫的財務困境，但在醫療資源有明顯限制的前提下，反而更容易突顯資源分配是否合理與公平的爭議。 隨著世界衛生組織的倡導與推行，「健康是基本人權」已成為當代社會的普世價值。健康照護的功能在於降低痛苦、改善生命品質、得到工作機會與擁有幸福。因為健康照護屬於特殊的社會財，必需優先於其他社會財被滿足，政府負有責任與義務來保障及促進人民的健康。有鑑於台灣當前因調漲保費所引發之輿論爭議，以及全民健保實施15年來諸多弊端，不完善的醫療保健體系無法帶給人民健康只會帶來不幸與痛苦。我們不能坐視醫療資源分配不均，甚至健保財務缺口持續擴大，最後導致全民健保破產的情況發生。 健康保險是第三人付費制度，醫病雙方都有可能不珍惜有限的醫療資源，而產生所謂的道德危機。國家公共政策的推動，無可避免的會牽涉到資源的重新分配，也會影響到社會公平正義的落實。在這過程中可能有人因此受惠，但也可能導致他人的權益受損，因為資源有限會造成公共政策具有資源重新分配的爭議性，而形成利益衝突。然而這往往不是靠政治或經濟手段就能解決的，尤其公平正義是醫療資源分配的核心倫理價值，丹尼爾斯強調「健全的健康照護制度亦是守護社會公義的機制之一」，一切的醫療政策和設施都能以這個原則作為評斷的依據。如果單憑市場機制去制定健康照護政策，根本無法真正貼近人民的醫療需求，畢竟並不是所有需要醫療服務的人，都有能力去購買所需要的醫療照護；甚至城市或鄉下、大型教學醫院或小型區域診所、以及醫護人員的配置多寡，都會影響醫療資源之合理分配以及病人的權利。 本論文即針對台灣全民健保因制度設計不當所引發之倫理爭議；以及一個公義社會所應具備的健康照護政策，就哲學的層面進行研究分析。以丹尼爾斯的健康照護公義理論為依據，來檢視台灣當前健保制度與健康照護政策在醫療資源分配上之公平性。尤其在健保費年年喊漲的同時，健保財務狀況對於全民就醫品質與照護服務影響甚鉅，都是本論文將進一步研究分析的課題。 政府相關單位不該只著重於保費之調整或者不斷的擴大給付內容，是否應先反省健保制度內部結構之不正義，反而造成患者的生命品質長期被忽視與剝奪。畢竟建立一套符合公平正義的健康照護制度，對於政府、醫界與全民都是件刻不容緩的事。而本論文的研究目的，就是希望台灣之健康照護體系能被賦予生命倫理的道德價值，以實質正義取代形式公平，解決長期以來醫療資源分配不均之爭議，並持之以恆的永續發展，才能真正為全民健康帶來福祉。 Health is as important as the survival right and freedom and it is the basic rights of citizen that government should to supply and protect. The national health care policy should aim to eliminate the primary health inequality, and close the gap of medical accessibility. Protect the basic health right of every citizen is an important issue of the new age of social equality. Since 1995, Taiwan government has implemented the national health insurance policy for 15 years. The policy has improved the condition so that people no longer denied of medical treatment because of low social economics status. This policy lowers the difficulties of people obtaining medical examinations or treatments, and helps people getting medical service more easily. But the expansion of national health insurance payment items was too much, since it helped much more patients with rare diseases and helped the patients with low social and economic status, but the resources of national health insurance is over-drawn. Since 2002, the center of health insurance changed the medical service payment system to global budget system. The global budget system narrowed the gap of insurance revenue and reimbursement, but it was objected as the cause of the lowering of justice and appropriateness in such a capped payment system. The crisis is the result of the waste of medical resource by medical service system or patients, at the same time. The public policy of distribution of medical resource also affects justice especially when the resource is limited. Norman Daniels emphasized ‘sound health care system is one of the element of protect social justice’, all medical policy and equipment should be judged by this hypothesis. Since the central value of medical resource distribution is social justice, it should not be considered or solved only by economic management. This study analyzes the health care policy in a justice society by focusing on the ethical problems in Taiwan national health insurance resulted from mal-designed policy. We analyze the justice of medical resources of Taiwan national health insurance policy with Norman Daniels’ theory. As we know, the fees of national health insurance will be raised year by year, our analysis is quite in time, In conclusion, the government and health care organization should review the long-term damage of the quality of patients’ health resulted from the inequality of the national health insurance policy, as well as the raising of insurance premium or the seemingly un-limited expansion of the payment items. Developing an equal and just health insurance policy is the most important and urgent matter for the government, and for the medical care system and all citizens. In this study, we suggest the establishment of a national bioethics commission in national care system, which would help to develop a just policy, solve the controversy about the inequality of the distribution of medical resources, and promote the long-term improvement of health in general. |
