醫療專業行為獨立性之研究——論美國法上禁止法人介入醫療原則之適用可能性

Abstract

醫療法人是否應維持公益性或公司化，近年來爭議不斷，而醫療專業是否得以不受干預，更與病患權益以及醫療法人公益任務執行有關，為了解醫療專業於我國法制之規範，本文首先透過美國法及相關之英文期刊，介紹美國法上禁止法人介入醫療原則之起源、立法目的、類型及各州州法內容、例外類型及政策轉變。於起源之部分，介紹美國醫學會之設置過程及主張演變，直至後工業時期，因法人介入使醫師專業自主性受到影響，經由維護醫療專業獨立性加以延伸，防止外部人控制、忠實義務分歧、以及過度商業化已經成為公眾政策上支持系爭原則維繫之主要立法目的，在各州法及法院判決中，更常以是否有上述三種立法目的之違反，為爭議是否合法之判斷。本文也歸納出各州常見之例外類型，這些例外容許的法人執行醫療業務型態，包括專業公司、醫院、非營利組織以及健康保險機構等，並介紹禁止法人介入醫療原則之最新發展，以確認是否得以美國法的醫療專業獨立行為規範，確立我國對於醫療專業獨立性之維護，對於財團化之現況提出一解決之途徑。 接續前述美國法之探討，本文進一步探究我國法上醫療法人之規範及現況。首先，我國法上關於醫療法人分為財團法人以及社團法人，在立法目的及主管機關之見解下，目前我國實務上對於醫療法人之定位應為公益性法人；再者，則透過質性研究方法，對於醫療法人之現況進行了解及檢視，分析我國目前實務上醫院運作確實具有受到營利政策影響，醫師對於醫療方式之選擇常需配合醫院政策，並有人情上、行政上之壓力，故於我國醫療法人仍為公益性法人之情形下，應得適用美國法上之禁止法人介入醫療原則關於醫療專業獨立性的三大立法目的，藉由防止外部人控制、減少忠實義務分歧以及防免過度商業化為基礎，確認我國法維護醫學專業判斷之重要性，方得在引進醫學發展所需資金之情況下，以防止外部人控制、忠實義務分歧以及過度商業化為實質要件之限制，減緩醫院財團化之問題。 藉由上述規範與實證研究，本文認為，我國醫療法改革之重點應為醫療專業行為獨立性之維護，即防止外部人控制、忠實義務分歧、以及過度商業化。包括應完善醫療法人之利益迴避機制；再者，應明訂醫療法人之董事會與各醫療機構之負責醫師及其他醫事人員間之關係，避免負責醫師或其他醫事人員執行業務受到董事會、董事長、董事或其他相關人員之不當干預。

Recently, it has been disputed whether the medical professional should maintain charitable or be corporatization. The fulfilling of patient's health and welfare and the charitable task of hospitals are related to the physician’s professional judgment. As a results, this thesis aims to find out the implementation of medical profession in Taiwan’s legal system and the possibility of application of Corporate Practice of Medicine Doctrine in the United States. In chapter two, we introduce the Corporate Practice of Medicine Doctrine (CPMD) including the origins, legislative purposes, types, state law, exception types and policy change through statutes and legal journals. First of all, this article introduce the establishment of American Medical Association and its claim. After the post-industrial revolution, the professional autonomy of physician is seriously affected by the corporate practice and contract practice of corporate. Therefore, extending from the maintenance of the physician’s professional judgment, preventing lay control, divided loyalty and commercialization have become the public policy to support the CPMD. And it has been adopted by most state law and the case law through this years. Although the CPMD has some exceptions and it’s not applied by every state in the U.S., the maintenance of medical professionals is always the primary goal. The third chapter introduce the Medical Juridical Persons in medical care in Taiwan’s law. There are two types of the Medical Juridical Persons, medical care corporate and medical care corporations. Either the medical care corporate or medical care corporations should be charitable in the legislative purpose and the conduct of the authorities. Besides, in accordance with the interpretation of section 2 and 4 of the Medical Care Act, “Physician” should still be the core of Medical Juridical Persons in medical care. In the forth chapter, by using empirical qualitative research methods, we could find out that the current practice of hospital operation was indeed affected by the profit policy. Because of causing pressure to physicians, affecting the physician’s professional judgment, the CPMD has its way. In conclusion, Corporate Practice of Medicine Doctrine in the United States is a principle aiming at preventing outsiders from intervening the decisions of medical professionals. The maintenance of medical professionals is the primary goal all the time. Although there is Medical Juridical Persons in Medical Care in Taiwan’s law, “Physician” should still be the core. With the charitable attitude of authorities by applying the principles of the doctrine, including preventing outsiders’ lay control, divided loyalty and commercialization, it could reduce negative impact of external non-professional intervention of hospitals.