臺灣《生產事故救濟條例》之質性研究

Abstract

《生產事故救濟條例》（CARA）於2016年6月在臺灣正式施行。作為全球首部針對多類生產事故導入政府資助無過失補償制度之立法，CARA 被視為推動女性健康的重要里程碑。該條例旨在於發生生產事故時，提供即時之經濟救助，以改善女性生產健康結果、降低醫療訴訟率，並促進醫療照護品質之提升。由於該法施行迄今僅約十年，相關影響之研究仍相當有限。因此，亟需更多研究以評估 CARA 之實際成效，藉此為未來政策修正提供參考，同時使臺灣得以成為其他國家可借鏡之制度典範。 因此，本研究透過半結構式訪談之主題分析（thematic analysis）*，從質性研究的角度探討 CARA 施行初期之接受情形，同時分析與生產事故、責難文化（blame culture）、醫師責任、病人自主，以及照護概念相關之論述。研究主持人原先欲探究 CARA 是否能為經歷生產事故之母親及其家庭提供充分且適切之補償／救濟。然而，由於本研究之樣本數有限且分布不均（醫療專業人員 n = 4；母親 n = 1, 3**），研究結果遂轉而呈現醫療專業人員如何理解與經驗 CARA，並輔以一位符合資格母親之經驗敘述，同時蒐集其對制度改善方向之看法。 研究資料歸納出四項主題：（1）CARA 之論述定位仍未明確：受訪者對於條例之目的，以及其欲保護或協助之對象，抱持不同觀點，使 CARA 呈現出一種多元且仍待持續協商之概念；（2）CARA 改變了醫療專業人員之實務運作，但仍存在侷限：受訪者認為條例有助於降低醫療訴訟、改善病人與醫師關係，以及強化病歷紀錄，但同時亦對職場壓力增加表達疑慮；（3）CARA 重新界定責任，但未處理責難之根源：條例改變了責任歸屬與問責機制之實務運作方式，卻未必能解決責難文化、醫療化，以及醫病不信任等根本問題；（4）CARA 或有助於母親於事故後繼續生活，但部分需求仍未獲滿足：受訪者強調，條例所提供之即時經濟補償能為母親創造選擇空間，並協助其走出事故陰影；然而，此種選擇仍受到限制，而母親在支持、說明、整體性照護或正義等程序性與實質性需求方面，亦未必能獲得充分回應。 本研究援引醫療化（Medicalization）、生產場域理論（Birth Territory Theory, BTT）與微觀社會學（Microsociology）三項詮釋框架，提出一套理解 CARA 如何與醫療—法律場域互動之理論架構，並探討其如何重新形塑信任、責任、問責與責難，同時指出其對於事故後母親之支持可能仍不完整。最後，本文針對《生產事故救濟條例》未來修正方向及類似政策提出建議，包括：引入替代性問責形式；檢視 CARA 於矯正正義、分配正義與程序正義之實踐能力；處理責難形成之前因，例如醫病關係中的不信任；以及重新思考《生產事故救濟條例》之照護與補償範圍，特別是加強對母親之程序性與實質性支持。由於本研究為目前已知首篇探討 CARA 之質性研究，且於招募母親受訪者時遭遇困難，未來仍需更多以女性為核心之研究，以進一步深化並拓展本研究初步且探索性之發現。 * 英語為研究者之第一語言。然而，訪談主要以中文進行，並於適用情況下使用英語。研究者與雙語翻譯人員合作，以協助訪談之進行。 ** 本研究共對三位母親進行訪談，然而其中僅有一位母親完全符合招募資格。

The Childbirth Accident Relief Act (CARA, 生產事故救濟條例) took effect in Taiwan in June 2016. The first piece of legislation in the world to introduce government-funded no-fault compensation to a range of childbirth accidents, CARA is a major success in advancing women’s health. The Act aims to enhance women’s childbirth health outcomes by providing timely financial relief in the event of a childbirth accident, reducing medical litigation rates, and promoting improvements in the quality of care. Only enacted ten years ago, little research has been performed on CARA’s impact. More research is imperative to provide insights on the effectiveness of CARA, with the intention to inform future policy reform, all whilst positioning Taiwan as a model for other countries to follow. Thus, through thematic analysis of semi-structured interviews*, this study qualitatively investigated CARA’s early reception while exploring discourse on childbirth accidents, blame culture, physician accountability, patient autonomy, and conceptions of care. The principal investigator initially sought to understand if CARA provides adequate and appropriate compensation/relief for mothers and families who have experienced a childbirth accident. However, due to the study’s limited and uneven sample (health professionals [n = 4] and mothers [n = 1, 3**]), the results instead offer an exploration of how CARA is understood and experienced by health professionals, with an account from one eligible mother, while gathering their input on how CARA can be improved. Four themes arose from the data, as follows: (1) CARA’s discursive framing remains unresolved: participants have various views on CARA’s purpose, and who CARA intends to protect or help, leading to a pluralistic conception of CARA open to future negotiation; (2) CARA changes health professionals’ practice, with limitations: participants' perceptions of CARA’s impact focus on reduced litigation, improved patient/physician dynamics, and bolstered documentation, while voicing reservations about increased workplace pressure; (3) CARA reframes responsibility, but does not address the antecedents of blame: CARA alters the practical operationalization of accountability, while not necessarily resolving fundamental issues of blame culture, medicalization, and mistrust; and (4) CARA may help mothers move on after an accident, but may leave some needs unmet: participants emphasize how CARA’s timely financial compensation creates choice for mothers and facilitates moving on; however, this choice remains constrained, and mothers’ other procedural and substantive needs for support, explanation, holistic care, or justice are not necessarily satisfied. Informed by three interpretative framings —Medicalization, Birth Territory Theory (BTT), and Microsociology, this thesis presents its own theoretical framework for understanding how CARA interacts with the medico-legal landscape; reframes trust, responsibility, accountability, and blame; and appears to not fully support mothers after an accident. This study concludes with suggestions for CARA’s future iterations or similar policies, including introducing alternative forms of accountability; interrogating CARA’s ability to provide corrective, distributive, and procedural justice; addressing antecedents of blame, such as mistrust in patient/physician relationships; and reconsidering the scope of CARA’s care and compensation, especially in increasing procedural and substantive support to mothers. As this is the first known qualitative study on CARA, and faced challenges in recruiting mothers, more woman-focused research is needed to expand on these preliminary, exploratory findings. * English is the first language of the researcher. However, interviews were primarily conducted in Mandarin, and English where applicable. The researcher collaborated with bilingual translators to facilitate the interviews. ** Three total interviews were conducted with mothers, however, only one of these mothers was fully eligible.