順從、偷渡、發聲與出走：「病患」的行動分析

本文探討台灣「病患」（醫用者）作為一個行動者，在面對需求不滿的情況時種種回應的樣態，以及影響這些異質樣態的原因。我們提出「順從、偷渡、發聲與出走」這個理解醫用者行動的分類概念，然後藉由台灣本土的經驗研究探討，整理出「不限於順從、仍難得發聲」的台灣醫用者行動模式。偷渡、發聲與出走的存在，讓我們看見醫用者參與醫療體系不只限於「順從」的類型，但是最能讓組織迅速有效地面對問題的行動模式「發聲」卻並不常見。接著，我們藉由探索權威知識的形成過程，嘗試解釋影響醫用者行動的關鍵因素，以台灣計畫性居家分娩這個「發聲型出走」的出現做為分析案例。我們發現，從主流的權威知識另立新局，必須有另一套有系統的知識體系。早期居家分娩婦女的宗教信念提供了這樣的知識系統。當邊緣的權威知識想要建立可信度，論述者身份似乎特別重要。早期幾位關鍵產婦的高文化資本，也使這個模式得以迅速建立其可信度。同時，身體經驗成為發聲與出走的資本；產婦以身體理解原有規訓體系的後果，也以身體確認居家分娩的可信度。最後，國際母乳會組織，以其互助的特質，擴展了這些產婦的社會資本，增加其選擇生產方式的資源。我們看見行動者善用其文化資本、身體經驗與社會資本，可能匯集出的能量。這也說明未來要理解台灣醫療體系的樣貌，「病患」的行動角度絕無法缺席。

This paper addresses the issue of how Taiwanese 'patients' (now referred to as medical users) respond when they are dissatisfied with the health care they receive. Based on our revision of Albert O. Hirschman's ideal type of action into an 'acceptance, stealth, voice and exit' analytical framework, we found that users are not simply accepting the status quo. They actively adopting various strategies in response to poor care, yet they seldom voice their dissatisfaction. Thus, the most direct and effective mechanism for expressing discontent does not affect recuperation. To analyze why responses vary and what conditions might increase the potential for voicing concerns, we use the example of planned home birth in Taiwan in the late 1990s to show how the formation of authoritative knowledge impacts action of medical users. We find that religious beliefs provide women with a sold foundation for exploring alternatives to authoritative knowledge. In addition, the cultural capital provided by the first women to participate in home births is serving to strengthen the model's credibility. Furthermore, women's bodily experiences are confirming the negative aspects of hospital births and the benefits of home birth. We also suggest that Taiwan La Leche League chapter is extending the social capital of home birth women and influencing the increased flow of resources to other women who want to give birth to their children at home. The specific social and historical contexts making home birth possible are also discussed. We conclude by stressing the importance of viewing medical users as key actors in the analysis of the medical system.