論告知後同意法則於獸醫醫療關係之適用

Abstract

告知後同意法則是指醫師負有法律義務，以病人得以了解的語言，主動告知病人病情、可能診治方法、診治方法的可能風險與利益，以及不治療之後果等，以利病人做出合乎其生活型態的醫療選擇。若醫師未取得病人告知後同意所進行之醫療行為，醫師對該醫療行為所生一切後果應負責。 獸醫醫療領域中，長年習慣上亦有以同意書或口頭方式取得飼主同意，在飼主同意後，獸醫師方得對飼主之動物進行獸醫醫療行為。近年來，「告知後同意法則」一詞亦出現在獸醫醫療糾紛判決之中，且可以歸納出幾個現象。第一，關於獸醫師對於飼主之告知說明義務，獸醫師法或動物保護法雖無明文規定，法院仍會參考醫療法第63條第1項之規定，但實際上獸醫師和獸醫診療機構非醫療法規範之對象。第二，法院認為獸醫師的告知說明義務屬於獸醫醫療契約中從給付義務，若獸醫師未盡告知說明義務，足以致飼主無法獲得充分資訊決定是否要為動物進行獸醫醫療行為時，屬於侵害飼主選擇權之不作為，同時顯未依債之本旨而為給付，屬於不完全給付，具可歸責事由。第三，明確區分未盡告知說明義務與獸醫醫療行為本身有無過失實屬二事，未盡告知說明義務所應負之責任，限於因未盡說明義務，致動物病患承受手術失敗或併發症之結果，而不及於獸醫醫療行為過失所造成之損害結果。 獸醫師-飼主-病患關係，本文又稱獸醫醫療關係，係指在獸醫醫療中三種角色之間的互動關係。以法律觀點來看，因動物病患屬於權利客體，未必有真正的三方關係，但以獸醫醫療觀點來看，獸醫師對於病患的義務仍被認為是首要義務，其原因基於獸醫專業倫理、動物福利與社會契約。本文在探討獸醫告知後同意前，欲先建立獸醫師-飼主-病患關係之原因，主因是在美國法中，告知後同意法則的基礎是建立在醫病關係與忠誠義務的概念之上。 我國告知後同意法則之討論，在「馬偕醫院肩難產事件」後蓬勃發展，在我國的相關討論上以美國法的告知後同意法則與德國法的醫師說明義務為兩大主要發展路徑。我國實務發展過程，逐漸從侵權責任演變為契約責任來處理醫師未盡告知說明義務的問題。目前通說與實務一致認為，醫師違反告知說明義務須與醫療行為過失區分，如果僅違反告知說明義務時，則有兩種情形。第一，如果僅違反告知說明義務時，則侵害病人之自主權。第二，若違反告知說明義務範圍涉及固有風險之說明，且病人受損害結果與固有風險實現有關時，則醫師亦須對該損害結果負責。有學者認為，告知後同意法則的本質即為固有風險的分配。 在探討獸醫告知後同意時，獸醫倫理學家提出，獸醫倫理學的首要問題是：「獸醫師的首要義務是對於飼主還是病患？」如果認為主要義務是對飼主，則獸醫師的角色接近汽車工匠模式。但如果認為獸醫師應以動物病患利益為主要考量，則近似於兒科醫師模式，亦有學者認為獸醫師在上述兩種模式間還有強力病患倡導和弱力病患倡導兩種角色，而獸醫師的角色傾向為何者，將因社會對於動物的態度、動物保護法規與獸醫師專業倫理與獸醫醫療法規的密度有所不同。獸醫告知後同意將會在義務對象兩者之間發揮「道德樞紐」的作用。 獸醫告知後同意之目的具有雙重保護作用，其一是保護飼主選擇權，其二是確保獸醫師履行對於動物病患之忠誠義務。飼主選擇權屬於飼主自主權之一環，係指飼主能自由選擇動物醫療處置的權利。由於自由選擇動物醫療處置涉及飼主自我價值觀，且與飼主人格自律有關，與人格發展有重要影響。基於獸醫師應保護與協助飼主選擇權實現之義務，獸醫師對於飼主負有告知說明義務。另外，獸醫師身為動物病患倡導者，獸醫師有義務向飼主說明並說服採取符合動物福利之動物醫療處置，獸醫告知後同意係為獸醫師履行對於病患忠誠義務之方式。

The Doctrine of Informed Consent means that physicians have a legal obligation to inform their patients, in understandable language, about their medical condition, possible methods of treatment, the potential risks and benefits of these treatments, and the prognosis. This enables patients to make medical decisions that correspond with their lifestyle. If a physician performs medical practice without obtaining the patient’s consent, the physician must be responsible for all consequences arising from such medical practice. In veterinary medicine, it has long been customary to obtain the owner's consent through written forms or orally. Only after obtaining the client's consent may a veterinarian perform veterinary practices on the client’s animal. Recently, the term "informed consent" has also appeared in veterinary medical dispute judgments, from which several phenomena can be summarized. First, regarding the veterinarian's duty to inform the client, although there is no explicit regulation in the Veterinarian Act or the Animal Protection Act, courts refer to the provisions of Article 63, Paragraph 1 of the Medical Care Act. However, veterinarians and veterinary clinics are not the subjects regulated by the Medical Care Act. Second, courts consider the veterinarian’s duty to inform as an obligation under the veterinary medical contract. If the veterinarian fails to fulfill this obligation, resulting in the client not having sufficient information to decide whether to undertake veterinary practice, this constitutes a non-performance that infringes on the client's right of choice. It also constitutes incomplete performance, being attributable to the veterinarian. Third, there is a clear distinction between the failure to fulfill the duty to inform and negligence in performing the veterinary practices. The responsibility for failing to inform is limited to the consequences suffered by the animal due to the lack of information, such as surgical failures or complications, and does not extend to damages resulting from negligence in the veterinary practices. The Veterinarian-Client-Patient Relationship （VCPR） describes the interactions among these three roles in veterinary medicine. From a legal perspective, since animals are considered objects of rights, there may not be a truly tripartite relationship. However, from the veterinary medical perspective, the veterinarian’s obligations to the patient are considered primary, based on veterinary professional ethics, animal welfare, and social contract. Before discussing informed consent in veterinary practice, it is necessary to establish the reasons for the veterinarian-owner-patient relationship, primarily because, in American law, the Doctrine of Informed Consent is based on the concepts of the doctor-patient relationship and fiduciary duty. In Taiwan, discussions on The Doctrine of Informed Consent have flourished since the "Mackay Memorial Hospital shoulder dystocia incident." These discussions have primarily developed along the lines of the American law's the Doctrine of Informed Consent and the German law's physician's duty to inform. In the practical development in Taiwan, the issue of physicians failing to fulfill the duty to inform has gradually evolved from being handled as tort liability to contract liability. Currently, both prevailing theories and practices agree that violations of the duty to inform must be distinguished from medical negligence. If only the duty to inform is violated, there are two scenarios. First, if only the duty to inform is violated, it infringes on the patient's right to autonomy. Second, if the scope of the violation involves explaining inherent risks, and the patient suffers damage related to these risks, the physician is also liable for the resulting damage. Some scholars believe that the essence of The Doctrine of Informed Consent is the allocation of inherent risks. When discussing informed consent in veterinary practice, veterinary ethicists raise the primary question: "Is the veterinarian's primary obligation to the client or the patient？" If the primary obligation is to the client, the veterinarian's role resembles that of “Garage Mechanic Model”. However, if the primary obligation is to consider the animal patient's animal welfare, the role is more akin to that of a “Pediatrician Model”. Some scholars believe that veterinarians' roles range between strong patient advocate and weak patient advocate, and the inclination depends on societal attitudes towards animals, animal protection laws, and the density of veterinary professional ethics and regulations. Veterinary Informed Consent serves as a " ethical pivot point " between the obligations to both parties. The purpose of Veterinary Informed Consent has a dual protective function. First, it protects the client's right of choice. Second, it ensures the veterinarian fulfills their fiduciary duty to the animal patient. The client's right of choice, a part of their autonomy, allows them to freely choose the medical treatment for their animal. This freedom to choose involves the client's self-values and personal autonomy, linking to the importance of their personality. Based on the veterinarian's duty to protect and assist the client's right of choice, the veterinarian has an obligation to inform and explain to the client. Additionally, as an advocate for the animal patient, the veterinarian must explain and persuade the client to adopt medical treatments that align with animal welfare. Veterinary Informed Consent is a means for veterinarians to fulfill their fiduciary duty to the patient.