善終之理論與實踐;Theory and Practice of Good Death

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题名:	善終之理論與實踐;Theory and Practice of Good Death
作者:	林孟蒨;Lin, Meng-Chien
贡献者:	哲學研究所
关键词:	善終;儒家生命倫理學;生命末期;安寧緩和醫療條例;病人自主權利法;good death;Confucian bioethics;terminal death;Hospice Care Medical Act;Patient Autonomy Act
日期:	2024-01-25
上传时间:	2024-09-19 15:57:21 (UTC+8)
出版者:	國立中央大學
摘要:	本論文主題是研究從儒家觀點，如何理解與回應末期病人在生命末期照顧之需求和相關的倫理議題。生命末期是指患有嚴重、持續惡化及不可逆轉的疾病階段；而生命末期照顧則是指從生命末期發生到臨終階段，甚至是往生後的整個歷程，對病人及其家屬的身、心、靈與社會之全方位照顧，而照顧目標則是助其得到善終。深論儒家在生命末期照顧之理路與方法，其論述路徑應從儒家的生命觀、生死觀、疾病觀、照顧病患的應有作為與態度等面向逐一探究，進而建構出更貼近末期病人需求且更臻理想之儒家善終理論。儒家對於個體之死亡自然非常重視，但在諸如生不如死的時候，所面對的是生命能否具有尊嚴地存活下去，能否發揮生命的價值的時候，則死亡並非不可接受。不忍人之心是指不忍生命之受傷害之道德意識，不忍人之心所關切的首先不是自身的自主自律的表現，而是一切生命之受傷害的問題。因此，解除生命受苦乃是儒家生命倫理學的基本取向和關懷所在，也是儒家善終理論的最後依據。在回應臨終病人的情況，目前主要是採用「安寧療護」的方式，以舒解痛苦，安撫病人的心理和精神的需要為主，讓病人以最無痛苦的方式走完生命最後一段的歷程。因為，各種維生醫療的使用，固然讓危急的病人存有一線生機，但當病人已沒有任何治癒的希望，這些醫療處置可能只是延長其瀕死過程，甚至只是增加他們的痛苦。《病人自主權利法》之訂立是為「尊重病人醫療自主，保障其善終權益」。然而此法顯然偏向病人個人自主權利完全摒除了家人的參與。畢竟家人實為親密不可分的生命共同體。家庭共享的自主自律的權利不能只由個人的自主權利所代表，應當也需要與家人共同行使自主這一重要的決定權，即採用「關係式自律」或「倫理關係自律」。此法固然針對家屬可能會對病人決定權有所干涉，但作為共同生活的家人，也應給予一定的法定地位，以參與病人臨終醫療決定的權利。如何使亡者得以安然而去，而在生的家屬心理上、心靈上都能得到安頓，這才是「養生送死無憾」的真正意義。故，安寧療護及病人自主權利法所謂的善終是強調臨終生命品質的善終，而儒家的善終則強調死亡的善終，即壽終正寢，也是所謂的慎終，從平時的修德到死亡盡本分的德性生命的完成。具體而言，即完成傳家任務，使死亡所帶來的親情斷裂得以恢復。所以，在禮俗上才有搬舖的臨終儀式，與家人見最後一面及交待傳家遺言。所謂死得其時及死得其所，目的都在於此。簡要說，就是化人倫為永恒之天倫。一個人臨死時是否得以善終，是人類感到生命是否圓滿，以致一生是否幸福最重要的因素。孟子提出「仁政」、「王道」，即希望能使人人都得到「養生送死無憾」的理想。此中即有社會政治的出發點是如何使人民得以「善終」的期望。此在中國文化的源頭即是一個理想。此如《尚書•洪範篇》即提出「五福」：「一曰壽，二曰富，三曰康寧，四曰攸好德，五曰考終命」。「考終命」，考，老也，終命謂終其正命。就是臨命終時沒有遭到橫禍，身體沒有病痛，心裡沒有罣礙，能安詳且尊嚴離世，這就是「善終」。本文發揮儒家的義理，特別是其中的義與命，性分與參贊天地的道德原則，深入分析和批判當代生命倫理學中對於臨終病人各種死亡的論述，以及參照和提升病人自主權和臨終照護的要點，提出儒家的善終理論如何使得病人在身、心、靈各方面的需求之滿足，和家屬以至醫護團隊等達到生死兩相安的最佳臨終境界。 ;This dissertation presents an analysis of how Confucian hospice care could provide an ethical solution to the needs of terminal patients in order that they could rest in peace. Terminal patients are patients that have serious and painful diseases and in a state that is beyond the curing power of medical treatment. We take hospice care as care that covers the wellbeing of the whole range of patient’s body, mind and spiritual aspects as well as the wellbeing of patient’s family. The wellbeing of the medical careers is also considered an important part of the dying experience and hospice care of the patient. The paper considers first the meaning of hospice in the Chinese tradition as well as in the modern world and why a good and peaceful death is so difficult to obtain by patient, patient’s family and the medical professionals. This paper constructs a Confucian theory of hospice care to meet the needs of a patient so that he or she could have a good time enjoying the last days in this world. Medical professionals have been using palliative as well as hospice care methods covering a much wider sphere of service to patient and patient’s family. I argue and show why the theories of bioethics, with the help of the law of upholding the patient’s right of self-determination, though have helped to solve some of the dilemma of end-of death of terminal patients, they failed to solve their needs so that they could rest in peace. The upholding of patients’ self-determination by law fares no better, because the realization of a good death for a patient is much more than medical treatment. Hospice care does much better, but it could not address the satisfactorily the last wishes of the patient, including his or her psychological satisfaction in family relationship, to be able to express his or her apologies, farewell, love and reconciliation with family members and friends. And last but no less importance is the hope for a better life after death. To satisfy all these needs and understanding the patient’s subjective values requires a full range hospice care grounded in the ethical view and culture of the patient. Confucianism would be a very inclusive approach that covers the quest of the patient in his or her pursuance of a death in peace. This paper tries to present a full picture of Confucian philosophy and ethics with special emphasis on the natural endowments of human life, both moral as well as physical endowments, how to face the difficulties in meeting our best wishes without feeling defeated or neglected in such failures, to see how those ethical, psychological and spiritual elements are understood what constitute one’s good death and how their fulfilment would support the patient throughout the process of dying. In these considerations, Confucianism extends the hospice care for terminal patients involving family, intimate friends and medical professionals as well as friendly and lovely animals, in helping their mutual trust and support through good communications and cooperative activities with other patients and careers in a friendly community. The satisfaction and fulfilment of the last wishes of the patient is primordial for the patient and should be the first target of hospice care. In practice, we try to create a fully peaceful and comforting community so that patients suffer the least with diseases and the pain of leaving loved ones, enjoy the last minutes of self-controlling activities, including eating and drinking, be pacified with enjoyable communal activities, with loving and supportive family interactions, so as not to fear loneliness and desperation in the present life and without hope in the future. In such activities, the patient would live with dignity, wellbeing and high spiritual development and least depress in the advance towards death.
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