預防醫學的哲學與倫理基礎 季瑋珠 預防醫學研究所

公共衛生與預防醫學的基本思考範疇 Public: Individual: The public is primarily comprised of the actions and motives of discrete individual. Collective: The public is primarily conceived as populations within social, economic, and political systems.

公共衛生與預防醫學的基本思考範疇 Health: Mechanic view that emphasizes the traditional medical distinction between disease and non-disease in the individual. The degree to which an individual reaches an equilibrium state with somatic, psychological, and social influences.

公共衛生的決策牽涉的考量 Ontology（本體論）：the nature or essence of reality, of being and existence, the nature of causation. Ethics（倫理）：the nature of rightness and the study of what actions are right actions. Epistemology（認識論）：the study of how knowledge is gained and the general validity of claims to knowledge (how knowledge is gained about causation).

公共衛生倫理的定位 倫理學分類 做對的決定 基本倫理學：終極發問、道德前提、道德本質的論證 應用倫理學： 德行倫理學：倫理教育與發展 個人—醫學倫理屬此類 社會—公共衛生與環境倫理屬此類 德行倫理學：倫理教育與發展 做對的決定

醫學倫理的原則 自主性（autonomy）：尊重個人自決與保護喪失自主性的個人。 仁愛或善意（beneficence）：以個人的福祉為最優先考量與最大程度來增亦個人的健康。 非惡意（non-maleficence）：避免傷害個人，或至少減低傷害。 公正（justice）：以公平、公正態度對待每個人，儘可能公平的分配保健的福利與負擔。

當代重要的政治哲學思想 康德 (Kantianism) vs. 功利主義（utilitarianism） 自由主義（Libertarianism） 馬克斯主義（Marxism）or 社會主義（socialism） 自由平等主義（liberal equality） 社區主義（Communitarianism） 女性主義（Feminism） 多文化主義（Multiculturalism）

康德主義 (Kantianism) 道德責任論 deontology 有絕對的是非對錯 不因結果而改變 人本精神 人是目的不是手段

功利主義（utilitarianism） The morally right act or policy is that which produces the greatest happiness for the members of society. (Bentham) 遠離神權、不問道德、結果主義（consequentialism） 追求效用極大化（maximize the utility） welfare hedonism, pleasure-oriented vs. non-hedonistic mental state utility key word: utility 問題：個人效用的衝突

自由主義（Libertarianism） 自由市場經濟的擁護者，完全相信市場機能可以達成最適當的分配，又稱保守主義（conservatism） Right-wing, capitalism, pursue overall satisfaction Maintain market freedom, limit the use of state for social policy “Minimal state”: protection against force, theft, fraud, or enforcement of contracts, …

自由主義（Libertarianism） Nozick’s entitlement theory: Principle of transfer: whatever is justly acquired can be freely transferred Principle of just initial acquisition: how people own things should be just Principle of rectification of injustice: how to deal with holdings if they are unjustly acquired or transferred

自由主義（Libertarianism） Entitled: having an absolute right to freely dispose, so long as it does not involve force or fraud Liberty > equality Key word: liberty 問題：分配是否真能達到公正（just）？

馬克斯主義（Marxism）社會主義（socialism） Left-wing, perfectionism Communism beyond justice/communist justice: Objection against a juridical community A truly good community has not need for just distribution!

馬克斯主義（Marxism）社會主義（socialism） Like an idealized family: an identify of interests, responding spontaneously to the need of others out of love rather than responding on the basis of rightful duties or calculations of personal advantages（各盡所能，各取所需） Key word: equality 問題：這種理想的社會似乎不存在/社會實驗的失敗

自由平等主義（liberal equality） Rawls: A Theory of Justice, 1971. Principles: Equal right principle: each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all. Difference principle: social and economic inequalities are to be arranged so that they are both to the greatest benefit of the least advantaged, and attached to offices and positions open to all under conditions of fair equality of opportunity.

自由平等主義（liberal equality） Priority rules: 1st priority rule (the priority of liberty): the principle of justice are to be ranked in lexical order and liberty can be restricted only for the sake of liberty. 2nd priority rules (the priority rule of justice over efficiency and welfare): the principle of justice lexically prior to the principle of efficiency and to that of maximizing the sum of advantages, fair opportunity is prior to the difference principle.

自由平等主義（liberal equality） For common goods like basic liberties: Equal liberty > equal opportunity > equal resources 社會契約（social contract）的產生 Key word: fairness

社區主義（Communitarianism） Liberal individuals and state neutrality Self-determination vs. state paternalism Key word: common good philosophical/political/vernacular/liberal, ... 早期的社區發展、社區工作，近期的社區總體營造

女性主義（Feminism） 性別平等與歧視（discrimination）問題、性別刻板印象（stereotype） 世界上大部分的國家是男性主導致定政策 男性的觀點與法則不等於女性 Key word: androgyny or gender-free Gender issue, gender study

多文化主義（Multiculturalism） 尊重文化差異性 跳脫主流文化觀點 Key word: cultural diversity 醫療人類學

最被接受的公共衛生決策哲學 Ontology（本體論）：群體比個人重要，全面健康比身體健康重要 Ethics（倫理）：醫學倫理的四個原則 Epistemology（認識論）：實證醫學，大型隨機分派對照雙盲試驗 問題：paternalistic beneficence，群體與個體的衝突

衛生醫療資源分配的倫理 四種不同的目標 效性（effectiveness）：只注重醫學上的有效性 效率（efficiency）：考慮輸入（input）和輸出（output）的效率 公平（fairness）：平均分配（equal share） 民意（democratic responsiveness）：訴諸社會民意