臺灣運用隔離治療手段防治結核病之實證研究─2009~2011

Abstract

在2003 年SARS 危機中，我們清楚看到傳染病的控制，無可避免地涉及限制人身自 由手段的運用，包括對已感染者的隔離（isolation），以及對眾多無症狀的可能感染者實 施的大規模檢疫（quarantine）。2006 年衛生機關針對降低結核病負擔、回應多重抗藥性 結核病（MDR-TB）興起所提出的「十年減半全民動員計畫」中，亦首度將傳染病防治 法第四十四條所規範的「隔離治療」，納為防治策略的一部份。然而，「隔離治療」對病 人的人身自由構成嚴重的限制與剝奪，如何確保這類手段的合理運用，平衡公共衛生需 求與個人權利保護，是公共衛生與法律交錯領域的重要問題。此一問題之探討，僅就法 規範本身進行法律釋意學的分析，尚未能克盡全功，必須深入認識傳染病本質與特徵、 分析國家公共衛生架構與醫療產業互動，以及從實際法規執行面瞭解其運作，始能完整 而正確地瞭解限制人身自由手段，對傳染病防治工作所帶來的承諾與陷阱。 過去申請人對結核病隔離治療法制面與實際執行面（2006-2008 年）的探討，已發 現隔離治療手段防治結核病，可能並未帶來重大公共衛生利益，且有欠缺成本效益 （cost-effectiveness）、怠於考量較小侵害手段、弱勢族群病人可能不公平地承擔了手段 之負擔等問題。此一研究計畫將延續對結核病隔離治療管制架構的探討，除了將追蹤國 際間其他法域運用限制人身自由手段防治結核病的規範體系與成效外，也將繼續以實證 研究方法，採用質性研究中半結構式訪談方式，訪談臺灣地方縣市衛生局人員，以深入 瞭解2009 年至2011 年，衛生署疾病管制局修正隔離治療要件與流程後，此一限制手段 的實際運用狀況。最後，本研究將應用美國公共衛生法學者Lawrence Gostin 所提出的 公共衛生管制正當性分析架構，包括重大風險、有效性、合理經濟成本、合理個人權利 負擔及公平性等五要件，檢驗臺灣的結核病隔離治療法制，並參考近來司法院大法官會 議第六九０號解釋意旨，嘗試提出傳染病防治法及相關行政法令之修正建議。

In Taiwan’s “Tuberculosis Ten-Year Mobilization Plan,” the health authorities propose to use “isolation care,” authorized under Article 44 of the Communicable Disease Control Act, as part of tuberculosis control strategies to halve the incidence rate by 2015. Despite the importance of reducing the prevalence of this disease, especially given the emergence of drug-resistant tuberculosis, the use of isolation invariably poses restrictions on individual liberty. To justify this intrusive public health intervention, it is important to examine not only the constitutionality of the regulations but also the actual application of the regulatory scheme by the front-line public health officers. In the past two years, my research on the use of isolation on tuberculosis patients during the first three years of the program has found several problems in the regulatory scheme, including failure to gain substantial benefits for public health, lack of cost-effectiveness, omission in adopting less restrictive alternatives, and unfair burden placed on vulnerable groups of patients. This research will follow up the key issues identified by earlier studies through international literature review and semi-structured interviews with local health officers to provide detail of practices during 2009-2011, after Taiwan CDC revised its tuberculosis isolation rules in 2009. By applying the framework for analyzing public health regulation proposed by Lawrence Gostin and with reference to Judicial Yuan Interpretation No.690, this research will offer proposals to amend legislation and regulations governing the use of isolation on tuberculosis patients in an effort to enable the regulatory scheme to maximize health benefits while providing affected individuals with adequate protection.