臺灣博碩士論文加值系統

失能老人除了要面對機能老化導致失能，從衣、食、住、行等無法自我照顧的狀況，還有負擔慢性病及長期的照顧人力、財力、醫療、社會與家庭環境設備等照護資源的支出。當家庭之人力、環境、設施已不敷失能老人的健康照護需求時，失能老人和其照護者都受到沈重的壓力，甚至被扭曲而釀成人間悲劇，以及不當的護照方式。失能老人與其照護者都是弱勢的倚賴者，因此，本文以羅爾斯之差異原則作為照護的基本原則，由此以建立老人和照護者應有的在資源分配上的權利和政府之責任。由此確認滿足失能老人的健康照護的方法，以實質上維護其自由與尊嚴。
本文考察了，丹尼爾斯，納斯邦和姬泰的論述，認同從「依賴者」與「衍生依賴者」提出個體的健康照護需求，與提供每個人在醫療照護上平等機會是公義社會所必備之條件。但本文認為要更進一步從差異原則為基礎，才能確立失能老人和照顧者的權利和合理的照護資源。因為，差異原則關懷最不利者；失能老人屬於最不利者；所以差異原則最能照護失能老人和照顧者，以及他們的需求。
本文並分析丹尼爾斯用以分析健康照護公平性的九個基準，以及參考儒家的觀點，以充實本文以差異原則為基礎的失能老人的健康照護論述。最後，作為一參照的例子，本文從台灣咀嚼吞嚥障礙者的鼻胃管灌食，探討其營養供給模式，對咀嚼吞嚥失能的老人的生命造成的不公義和喪失尊嚴生活的窘境，並從日本護理師模式實施改善措施，確認可以成功移除鼻胃管，恢復經口進食而有的自由與尊嚴。由此建立照護失能老人應有的資源，使老人和照護者得到合理的支援，並享有尊嚴和自由的生活。
本研究除了確認差異原則可以做為長期照護倫理基礎，並可作為推展進食尊嚴的參考模式，以維護失能老人的健康照護需求。本文建議政府在研擬長期照護保險法時，應透過公開對話的審議民主程序，廣納專家、學者、醫療院所從業人員、及相關民間協會與學會組織的意見，來擬定長期照顧政策。

The disabled elderlies, in addition to the encountering organs degeneration, have to face the situation where they cannot take food, clothing, living by themselves, and facing the problem of the heavy burden of the cost of caring for chronic diseases, medical expenses, social and domestic provisions etc. When family could not provide the necessary financial or human resources to take care the needs, disabled elderlies and their caregivers are under heavy pressure, and may even lead to distortions as human tragedy and improper ways of caring. Disabled elderlies and their caregivers are vulnerable dependent persons. Therefore I take Rawls's difference principle as the basic principle of long-term health care, in order to establish the rights of the elderlies and their caregivers the proper allocation of resources and the responsibility of the government. Thereby setting up the basic health care program meeting their needs and maintain their freedom and dignity.

In this thesis, I have examined the discussions between Norman Daniels, Martha C. Nussbaum and Eva F. Kittay, and adopted Kittay’s idea of "dependence " and "derivative dependence ' of the elderlies and their care-takers , and offering them according to their fair equality of opportunities in their medical resources sharing. But I argue that, it need be based on the difference principle, in order to establish and secure the rights of the disability elderlies and caregivers and the sharing of reasonable care resources. For, the difference principle emphasis the caring of the most disadvantaged and disabled elderlies and their careers are among the most disadvantaged. Hence the difference principle could protect them and their needs most appropriately.


I go further for an analysis of the nine benchmarks of just health proposed by Daniels, as well as Confucian ideals of health care, in order to enrich and fortify the difference principle in our treatment of disabled elderlies health care. Finally, as an example, I present the Taiwan case of feeding the disabled through nasogastric tube, who cannot chew and swallow food, and try to show that how the adoption of the principle could make a great improvement in the lives of the elderlies. Moreover, I introduce how the Japanese model by improving the feeding method and removal of the nasogastric tube, could help the elderlies returning to a free and dignity personality by taking food through mouth. Thereby establishing proper care resources, by taking seriously the dependence of the elderly and caregivers, could improve the life with dignity and freedom of the elderlies.

The present research discovers, in addition to the confirmation that the principle of difference can be made the foundation of long-term care ethics, it could also be used to improve feeding method to meet the health-care needs of the disabled elderly. Furthermore, I propose that when the government plans to legalize long-term care insurance, it should take the democratic procedure with dialogues with experts, scholars, pharmacy industry, opinions of societies, communities and associations, in order to form a proper and just long-term care program.

中文摘要............................................................................................................ i
英文摘要............................................................................................................ ii
致 謝................................................................................................................ iv
目 錄................................................................................................................ v
第一章 導論 1
第一節 研究動機 1
第二節 健康照護需求(Health care of need) 、公義(Justice)之研究現況 8
第三節 研究目的、方法與章節架構 30
第二章 羅爾斯公義論與差異原則 33
第一節 羅爾斯公義論 33
第二節 「差異原則」（Difference Principle）的意涵 40
第三節 對羅爾斯公義論的批判 50
第三章 健康照護需求與社會公義 55
第一節 健康照護需求：丹尼爾斯對羅爾斯健康照護之補充 55
第二節 納斯邦(Martha C. Nussbaum)的能力進路 73
第三節 姬泰(Eva F. Kittay)「依賴與照顧」主張 78
第四節 儒家健康照護需求的觀點 83
第四章 從老化、失能之健康照護需求省思長期照護的意義 88
第一節 從老化、失能之影響檢視健康照護需求的意義 88
第二節 從臺灣長期照護之實踐現況檢驗健康照護需求之公義性 99
第三節 失能老人的長期照護與差異原則的關係 106
第五章 以差異原則觀照失能老人之長期照護模式 117
第一節 差異原則與長期照護的本質： 117
第二節 以差異原則觀照臺灣長期照護之營養模式 132
第六章 結論 145
第一節 論文的貢獻 146
第二節 長期照護的未來展望：以差異原則觀照失能老人咀嚼吞嚥的需求 150
參考文獻 153
附錄
附錄一 移除個案鼻胃管及吞嚥訓練作業規範 162
附錄二 2015 年第 十二 屆世界華人地區長期照護研討會-海報論文發表 174

中文專書
李世代，《老年醫學老年照護與老化之一般原則》，臺北：臺灣老年醫學會，2003。
李瑞全，《儒家生命倫理學》。台北：鵝湖出版社，1999。
阿瑪蒂亞森著，任赜、于真譯，《以自由看待发展》。北京：中国人民大学出版社，2002 .
弗蘭克(Viktor E. Frankl )著，趙可式、沈錦惠合譯，《活出意義來 ─ 從集中營說到存在主義》。台北：光啟出版社，1995。
弗蘭克(Viktor E. Frankl )著，鄭納無譯，《意義的呼喚》。台北：心靈工坊， 2002。
亞里士多德著，苗力田、徐開來譯，《尼各馬可倫理學》第五卷。台北：五南圖書出版股份有限公司，頁125，2001年。
歐陽來祥，《吞嚥困難評估與治療》。臺北：心理出版社，2008。
葉淑惠教授，《老人照護指引－長期照護醫療健康小組適用》。台北：華都文化，2010。
瑪莎 納斯邦，丁曉東譯，《詩性正義》文學想像與公共生活。北京大學出版社，頁113，2009。
中文論文
小澤尚子等，「日本實施介護保險的經驗」。《長期照護雜誌》，11(3) ，2007年 頁285-302。
于博芮等，「臺大醫院腦中風中心成立之成效」。《領導護理》，12 (2)(2011)，頁 2-7。
王佳惠等，「長期照護機構建築之歷史演進」。《北市醫學雜誌》，2(4)(2005)，頁311-319.
白淑芬等，「提昇居家護理個案鼻胃管移除率」。《長期照護雜誌》，17(3)(2013)，頁 315-329。
何怡慧等，「復建期腦中風病患咀嚼吞嚥障礙盛行率及初步篩檢徵象之探討」。《護理雜誌》，61(2)(2014)，頁54-62。
李瑞全，「臺灣醫療健保制度之公平性：一個初步的分析」。《醫學與哲學》，28(12)(2007)12月，頁28-31。
李瑞全，「儒家生命伦理之方向与实践；同情共感与理性分析并进之路」。《中国医学伦理学》，22(6)(2009)。
李瑞全，「醫藥之良好狀態(wellbeing)之分析：生活品質、生活質量與生命質素」。《應用倫理評論》，52(2012)。
經建會，「我國長期照護需求推估及服務供給現況」。《臺灣經濟論衡》，7( 10) (2009)10月。
經建會，「衛生福利的融合綜效──長期照護的前瞻」。《研考雙月刊》，35(2)(2011)。
鄭美雲等，「獨居老人因肝硬化引發個人因應能力失調之護理經驗」。《秀傳醫學雜誌》，11(3-4)(2012)。
經建會，「衛生福利的融合綜效－長期照護的前瞻」。《研考雙月刊》，35(2)(2011)4。
蕭玉霜，「從納斯邦、丹尼爾斯之健康照護需求觀點論長期照護之實踐與挑戰」。《應倫評論》57(2014)。
蕭玉霜，「從狄爾泰詮釋學之人文科學基礎建構護理倫理實踐進路」，《第四屆中央大學哲學研究所校際研究生論文發表會》。中壢：中央大學文學院哲學研究所(2007)。
英文專書
Alasdair C. MacIntyre, Whose Justice? Which Rationality?. Notre Dame: University of Notre Dame Press 1988.
Amartya Sen, The Idea of Justice. Cambridge, Mass.: Belknap Press of Harvard University press, 2009.
Amartya Sen, Equality of What?. S. McMurrin ( ed. ), Tanner Lectures on Human Values, Vol, 1, Cambridge: Cambridge University Press, 1980.
Beauchamp, Tom L., et al., Principles of Biomedical Ethics, 6# edition. New York: Oxford University Press, 2009.
Callahan, Daniel, et al., Medicine and the Market. Baltimore: The Johns Hopkins University Press, 2006.
Ronald Dworkin, The Original Position, in Reading Rawls, ed. Normal Daniels, Stan ford, California: Stanford University Press, 1989.
H. T. Engelhardt, et al., The Foundations of Bioethics. Oxford University press, pp. 87-8, 93-94, 1996,
Eva Feder Kittay, Dependency, equality, and welfare. Feminist studies, 32-43, 1998.
Eva Feder Kittay. Love’s Labor: Essays on Women, Equality, and Dependency. New York and London: Routledge, 1999.
Mary Jo Gibson, et al., Long-Term Care in Developed Nations: A Brief Overview. website URL=http://assets.aarp.org/ rgcenter/health/2003_13_ltc_dv.pdf. 2003,
Kant, Immaneul, The Metaphysic of Morals: Part I The Metaphysical Elements of Justice. Indianapolis: Bobbs-Merrill Educational Publ, translated by John Ladd, p. 35, 1965.
Rosalie A. Kane, et al., The Heart of Long Term Care. New York: Oxford University Press, 1998.
Martha C. Nussbaum, The Fragility of Goodness: luck and ethics in Greek tragedy and philosophy. Massachusetts: Harvard University Press, 2001.
Martha C. Nussbaum, Frontiers of justice: Disability, nationality, species membership. Cambridge. Mass: Belknap Press of Harvard University Press, 2006.
MacIntyre, Alasdair. After Virtue. Third ed.. Notre Dame：University of Notre Dame Press , 2007.
Michael Walzer, Spheres of Justice: A Defense of Pluralism and Justice. New York: Basic, 1983.
National Dysphagia Diet Task Force, National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association. , 2002.
Newhouse JP, Geographic theory of physician location. Annu Rew Public Health, 1990.
Norman Daniels, Justice and justification: reflective equilibrium in theory and practice. Cambridge: Cambridge University, 1996.
Plato, Republic, translated from the new standard Greek text, with introduction. by C.D.C. Reeve. Copyright by Hackett Publishing Company, Inc, 2004.
Norman Daniels, Just Health: Meeting Health Needs Fairly. New York: Cambridge University Press, 2008.
Peter Singer. Practical Ethics. New York: Cambridge University Press (2nd ed.), 2003.
Rawls, John, A Theory of Justice. Cambridge, Mass.: Belknap Press of Harvard University press, 1971.
Rawls, John, Justice as Fairness: A Restatement, Cambridge. Mass.: Belknap Press of Harvard University press, 2001.
Rawls, John, The Law of Peoples. Cambridge, Mass: Harvard University Press, 1999.
Robert Nozick, Anarchy, State and Utopia. New York basic book, 1974.
R. Ruth, et al., The Concept of Informed Consent. Contemporary Issues in Bioethics, 7th edition (Boston: Georgetown University Press, 2003.
Rowe,J.W. & Kahn,R.L., Successful aging, New York: Dell Publishing, 1998.
Tom L.Beauchamp & LeRoy Walters, Contemporary Issues in Bioethics. 6th ed. (Belmont, CA: Wadsworth, p. 48, 2003.
Thomas Pogge, john Rawls: His life and theory of Justice. Oxford University Press, 2007.
World Health Organization, The Uses of Epidemiology in the Study of the Elderly. Geneva: World Health Organization. , 1984

英文論文
Dalby, P., ”Is there a process of spiritual change or development associated with aging? A critical review of research”, Aging Mental Health, 10(1) (2006), pp.4-12.
Espinoza S., et al, “Frailty in older adults: insights and interventions”, Cleve Clin J Med, 72(2005), pp.1105-12.
Essays on Women, Equality and Dependency”, Hypatia, 17(3) (2002), pp.194-199.
Maslow, A. H. “A Theory of Human Motivation”. Psychological Review, 50(4) (1943), pp.375.
Eva Feder Kittay, “A feminist public ethic of care meets the new communitarian family policy”. Ethic, 111(3)( 2001)a.
Eva Feder Kittay, “When caring is just and justice is caring: Justice and mental retardation”. Public Culture, 13(3) (2001)b.
Gill TM. et al, “Transitions between frailty states among　community-living older persons”, Arch Intern Med, 166(2006), pp.418-23.
Holman, et al., “Promoting adequate nutrition: Using artificial feeding”, Nursing Older People, 17(10), (2006).
Karagiannis, et al. “Effects of oral intake of water in patients with oropharyngeal dysphagia”, BMC Geriatrics, 11(2011), pp.9-9.
Leder, S. B., et al., “Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: Nectar is enough”. Dysphagia, 28(1) (2013), 58-62.
Prabhakaran, S. et al., “Nasoenteric tube complications”, Scandinavian Journal of Surgery, 101(2012), pp.147-155.
Yeh, S. J. , et al., “Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit”. Neurol Sci, 306(1-2) (2011), pp.38-41.
Yeh, S. H., “The effects of aerobic exercise on neuro-related hormones in community dwelling women”, Journal of Medical and Bioengineering, 1(1)(2012).
Yeh, S. H., et al., Effect of 12-week Tai Chi Chuan exercise on peripheral nerve modulation in patients with type 2 diabetes mellitus. Journal of Rehabilitation Medicine, 41(11) (2009), pp.924-929..


網路資訊
中央健康保險局，<全民健康保險醫療服務給付項目及支付標準>，website, URL=http://www.nhi.gov.tw/Resource/bulletin/5549_1040106%20103%E5%B9%B4%E8%87%A83%E6%94%AF%E4%BB%98%E6%A8%99%E6%BA%96%E5%85%B1%E5%90%8C%E6%93%AC%E5%AE%9A%E6%9C%83%E8%AD%B0%E4%B9%8B%E6%94%AF%E4%BB%98%E6%A8%99%E6%BA%96%E4%BF%AE%E6%AD%A3%E6%A2%9D%E6%96%87%E7%B8%BD%E8%AA%AA%E6%98%8E%E5%8F%8A%E5%B0%8D%E7%85%A7%E8%A1%A8(%E9%A0%90%E5%91%8A).pdf, 2014, pp.18-20,(2014/07/23瀏覽)。
中廣新聞，〈釘妻案判9年，王敬熙喊為什麼不是死刑〉，臺灣性別人權協會，website URL= http://gsrat.net/news/newsclipDetail.php?ncdata_id=6940，2011年9月12日（2014/02/23瀏覽）。
中廣新聞，<釘妻案判9年，王敬熙喊為什麼不是死刑>，臺灣性別人權協會， URL= http://gsrat.net/news/newsclipDetail.php?ncdata_id=6940, 2011,（2014/02/23瀏覽）。
王顏和譯，<國際機能、失能和健康分類>，衛生署委託「國際健康功能與身心障礙分類系統-兒童與青少年版推動計畫」99M4073，URL=http://www.pmr.org.tw/icf/download/ICF.pdf, 2010. （2015/10/23瀏覽）.
內政部統計處，<內 政 統 計 通 報，104年第29週，104年6月底人口結構分析>， URL= http://sowf.moi.gov.tw/stat/week/list.htm, 2015, (2015/9/23瀏覽) 。
內政部統計處，<101年底我國老人長期照顧及安養機構概況>，內政統計通報，一○二年第十一週， URL=http://www.moi.gov.tw/stat/news_content.aspx?sn=7230, 2013,（2013/12/23瀏覽）。
世界衛生組織，<世界衛生組織法>，URL= http://apps.who.int/gb/bd/PDF/bd47/CH/constitution-ch.pdf?ua=1 （2014/02/23瀏覽）。
世界衛生組織，<維也納人權宣言>URL=http://www1.umn.edu/humanrts/chinese/CHl1viedec_BIG5.html（2013/03/23瀏覽）。
《孟子》本文引用之經典原文係採數位經典網站， URL= http://www.chineseclassic.com/13jing/montzu/ch01_1.htm(2013/10/23瀏覽)。
《荀子》〈非相〉本文引用之經典原文係採數位經典網站， URL= http://www.chineseclassic.com/13jing/montzu/ch01_1.htm(2013/10/23瀏覽)。
國家發展委員會，<中華民國人口推計（103 至 150 年）>， URL= file:///C:/Users/syh2271766/Downloads/103%E7%89%88%E4%BA%BA%E5%8F%A3%E6%8E%A8%E8%A8%88%E5%A0%B1%E5%91%8A0903final.pdf (2015/5/23瀏覽) 。
臺灣長期照護專業協會，<機構品質監測指標>， URL=http://www.klchb.gov.tw/KLCHB/_uploadS/news/news/3115/file/7fc0223d-98d6-423c-a8a7-c4531d544f77.pdf. 2007, (20140523瀏覽)。
衛生福利部，<長期照護服務網計畫（第一期）－102年至105年>，頁7-8， URL= http://b009.ttu.edu.tw/ezfiles/45/1045/attach/12/pta_17295_2794991_98353.pdf, 2010,（2014/02/23瀏覽）.
衛生福利部，<長期照顧服務法>，webside,URL=http://www.mohw.gov.tw/MOHW_Upload/doc/1%E9%95%B7%E6%9C%9F%E7%85%A7%E9%A1%A7%E6%9C%8D%E5%8B%99%E6%B3%95_0051321001.pdf, 2015, (2015/06/23瀏覽)。
蘋果日報，<68%民眾贊成安樂死 醫界反對>URL= http://www.appledaily.com.tw/appledaily/article/headline/20110923/33688790/, 2011年9月12日,（2014/02/23瀏覽）。
衛生福利部統計處，<102年老人狀況調查報告>， URL=http://www.mohw.gov.tw/cht/DOS/Statistic.aspx?f_list_no=312&fod_list_no=4695 , 2014,（2014/12/23瀏覽）。
《禮記》〈禮運〉本文引用之經典原文係採數位經典網站， URL= http://www.chineseclassic.com/13jing/montzu/ch01_1.htm(2013/10/23瀏覽)。
護理健康照護司，<長期照護十年計畫成果>，衛生福利部URL= http://www.tii.org.tw/fcontent/mi-20111201/file/%E5%8F%B0%E7%81%A3%E4%BA%BA%E5%8F%A3%E8%88%87%E9%86%AB%E7%99%82%E7%B5%B1%E8%A8%88%E8%B3%87%E6%96%99.pdf, 2012, (2014/05/23瀏覽)
護理健康照護司，<長期照護十年計畫成果>，衛生福利部， URL=http://www.tii.org.tw/fcontent/mi-20111201/file/%E5%8F%B0%E7%81%A3%E4%BA%BA%E5%8F%A3%E8%88%87%E9%86%AB%E7%99%82%E7%B5%B1%E8%A8%88%E8%B3%87%E6%96%99.pdf, 2012, (2014/05/23瀏覽)。
聯合國，<老齡問題維也納國際行動計劃>，聯合國老齡化議題， URL=http://www.un.org/chinese/esa/ageing/vienna.htm, 1982,（2011/5/23瀏覽）。
聯合國，<聯合國老人綱領>， URL= http://www.un.org/chinese/esa/ageing/principle.htm.（2011/5/23瀏覽）。
WHO, “Active Ageing A Policy Framework”, URL= http://whqlibdoc.who.int/hq/2002/WHO_NMH_NPH_02.8.pdf, 1991, 2002,（2011/5/23瀏覽）
聯合國，<維也納人權宣言>， URL= http://www.ohchr.org/CH/Issues/Documents/other_instruments/06.PDF, 1993,（2011/5/23瀏覽）。
臺灣長期照護專業協會，<長期照護歷史軌跡>，臺灣長期照護專業協會， URL=http://www.ltcpa.org.tw/about/aboutus-304.php, 2010,（2013/02/23瀏覽）。
日本摂食嚥下リハビリテーション学会医療検討委員会，<訓練法のまとめ>http://www.jsdr.or.jp/wp-content/uploads/file/doc/18-1-p55-89.pdf, 2014,（2013/12/23瀏覽）.
摂食嚥下リハビリテーション学会，認定士制度，2014，URL= http://www.jsdr.or.jp/ (2014/12/23瀏覽)。
Amartya Sen, Equality of What? Tanner Lectures on Human Values, Delivered at Stanford University, 1979, Website, URL= http://tannerlectures.utah.edu/_documents/a-to-z/s/sen80.pdf (2015/01/23瀏覽)
Daniels, Norman, “Justice and Long-Term Care: Need We Abandon Social Contract Theory?” WHO, Ethical Choices in Long-Term Care: What Does Justice Require? URL=http://www.who.int/mediacentre/news/notes/ethical_choices.pdf, p.71, 2002,（2011/5/23瀏覽）.
Kittay, E. F., “Can Contractualism Justify State-Supported Long-Term Care Politics? Or, I’d Rather Be Some Mother’s Child A Reply to Nussbaum and Daniels”, WHO, Ethical Choices in Long-Term Care: What Does Justice Require? URL=http://www.who.int/mediacentre/news/notes/ethical_choices.pdf. p. 77-78, 2002,（2011/5/23瀏覽）.
E. F. Kittay. “Love’s labor, Labor: Essays on Women, Equality, and Dependency”.( New York and London: Routledge), P.29, 1999, URL=http://www.doc88.com/p-6961875539873.html（2014/12/23瀏覽）
Martha C. Nussbaum, “Long-Term Care and Social Justice: A Challenge to Conventional Ideas of the Social Contract?” WHO, Ethical Choices in Long-Term Care: What Does Justice Require? URL= http://www.who.int/mediacentre/news/notes/ethical_choic es.pdf. p.35-36;56, , 2002,（2011/5/23瀏覽）.