醫療化的實作本體論：臺灣慢性腎病衛教實作的體制分析

The Ontologies-in-Practice of Medicalization: A Regime Analysis of Chronic Kidney Disease in the Taiwanese Health Education System

醫療化（medicalization）是醫療社會學的重要概念，既有研究已指出其知識、制度、社會互動及實務意涵，但甚少分析臨床實作。本文以科技與社會研究的實作本體論與體制分析觀點，分析臺灣慢性腎病（Chronic Kidney Disease, CKD）臨床衛教實作，凸顯醫療化過程中衛教實作體制的本體論意涵。2002年起臺灣腎臟醫學會預設普遍客觀的「腎絲球過濾率」診斷，大力推動CKD防治。面對本地多元醫療選擇，衛教實作並不只是傳授知識、規訓病患，也並非如醫學會等拓展知識類屬、專業擴權或社會控制過程時「否定、禁止」另類醫療，而是承認病患的另類醫療與社會主體性，以「維繫、競爭」為主要策略，在多種連結與整合佈署中社會化CKD，形成新臨床與日常實作體制，探討在本地實現CKD疾病現實。正視在地體制脈絡的實作本體論分析，正視看似普遍的疾病如何實現於在地，可在理論上彰顯醫療化的本體論層次，亦有助於擴充醫療化的在地適用性。

Despite well-established medicalization theory, clinical practices and their specific local ontological constitutions are generally understudied. Drawing on regime analysis from science, technology, and social science studies, this paper examines how nursing practices enact the biomedical realities of chronic kidney disease (CKD) in Taiwan, and discusses their ontological implications. In order to address CKD in the daily lives of patients, nurses use a ＂maintain and compete＂ subjectification strategy by linking and integrating existing clinical and social practices. They connect their patients' social, interactional, cognitive and motivational modes of existence by reinterpreting complex medical indexes and clinical guidelines into simple language, help their patients make necessary adaptations in their daily lives to deal with CKD, address institutional and practical problems, and supervise the use of alternative therapies. This examination of the making of a new ontological infrastructure in clinical nursing practices extends the theoretical scope and local application of medicalization theory.