遵／不遵醫囑？國家偏遠醫療治理與達悟族精神失序者的「混亂敘事」

To Comply or Not To Comply? State Medical Governance and the “Chaos Narrative” of Tao Mentally-Disordered People

台灣為了解決山地離島偏遠地區「有保險、無醫療」的困境，國家提供經費、人力支援偏遠醫療的醫療給付效益提昇計畫，但就實際執行層面來看，達悟人精神失序者不遵醫囑的比例極高，這樣的落差反映相當值得探討的問題。全文從病人敘事的理論分析策略出發，以社會學家Arthur W. Frank「混亂敘事」（chaos narrative）的概念，反省實證醫學的醫療式歸因、健康信念的取徑探討遵醫囑行為的限制。透過田野中蘭嶼達悟族精神失序者的敘事，探究做為少數族群的原住民在國家醫療治理下的特殊病痛經驗。文章分析指出時空限制下的儀式化醫療處置與不平等的醫病關係，以及文化隔閡中對現代精神醫療的不信任，所導致不遵醫囑的普遍現象，呈現國家透過現代精神醫療對原住民社會進行理性治理時的基本困境。不同世代達悟精神失序者分歧、多元的敘事，啟發了我們對疾病、健康、療癒概念的重新思考，有助於我們思考現代精神醫學朝向生物醫學知識典範的霸權，並擴展我們對遵／不遵醫囑現象的認識。本文結論也強調要拉近精神醫療專業與達悟生活世界的差距，必須貼近達悟精神失序者的混亂敘事，深入瞭解達悟社會文化與日常生活脈絡，否則國家提出的醫療方針將會偏離醫療照護的主體，難以實踐醫療照護的真正目標。

In Taiwan, in order to solve the difficult situation of “medical insurance without medical service” in remote areas, including the mountain-lands and outlying islands, the state provides fund and manpower to support “The Integrated Delivery System (IDS).” However, judging from the practical aspects of implementation of IDS, a high rate of mentally-disordered Tao people fails to comply with medical advice. In the light of a discrepancy between State Medical Governance and illness experience of Tao mentally-disordered people, some issues are worth exploring. Drawing on the method of narrative analysis, especially Arthur W. Frank’s concept of “chaos narrative,” my article points out the limitations of two approaches-1) evidence-based medicine approach and 2) health belief approach - in understanding the compliance behavior of mentally disordered people. Based on my fieldwork on Orchid Island, this study aims to explore the special illness experiences of Tao mentally-disordered people-as an ethnic minority group in Taiwan—under the medical governance of the state. The analysis of this study will indicate that non-compliance behavior is a widespread phenomenon caused by ritualized medical management under time and space constraints, the inequalities between the Han’s psychiatrists and the Tao patients, as well as the distrust among Tao people toward the modern biopsychiatry, revealing some dilemmas faced by the rational governance of modern bio-psychiatry of state implemented in Tao community. The divided and diverse narratives of three generations of the mentally-disordered Tao people can inspire us to reflect on concepts of illness, health and healing, helping us critique the current trends of psychiatry toward a hegemonic biomedical-knowledge paradigm, and expanding our understanding about the compliance and non-compliance behavior. In conclusion, this article emphasizes dealing with the gap between the psychiatric profession and the life world of the Tao patient, the need to closely attend to the chaos narratives of Tao people, and an in-depth understanding of the social-cultural contexts in which the Tao patients are situated. Otherwise the IDS proposed by the state will not accomplish its objectives, making it the more difficult for the psychiatric care to be put into practice.