醫療化理論的後進國批判：以台灣慢性腎病治理的知識、專業與體制轉變為例

The Medicalization of a Latecomer Society: A Critique Based on the Case of Knowledge, Profession, and Transformation of a Medical Regime in Taiwanese Chronic Kidney Disease Governance

台灣慢性腎病防治體制在近十年間迅速建立。相較於以先進國經驗發展的醫療化理論，本文以此案例挑戰其缺乏國際與在地互動面向的盲點，指出其中「自我後進化」的後進國醫療化。本文引入科技與社會研究的科技治理觀點，深入本地脈絡，分析其中的知識、專業策略與體制特質，並藉此批判醫療化理論的全稱式命題。2001年後，面臨透析醫療體制壓力的腎臟專業，藉由政策機制賦予規劃、執行、評估合一的地位，忽視在地現實，以國際統計發展新國病論述並黑盒化充滿爭議的臨床指標，迅速建立慢性腎病防治體制。此體制的影響為：專業上，造成腎臟專業內部分化卻轉變其地位的專業擴權；體制上，惡化既有院所失衡問題；臨床上，對篩檢出的病患支持不足，可能造成「醫源病」。本案例凸顯「自我後進化」的後進國醫療化模式為：計畫導向的政策機制，賦予醫療專業制度機會；醫療專業以片面知識與論述策略，型塑問題與解決方案，以扭轉地位；爭議中的知識則在此過程中，被黑盒化為先進、普遍知識而應用於後進化的在地。

A national chronic kidney disease (CKD) prevention system was established between 2001 and 2011 in Taiwan. Instead of following the theory of medicalization developed in the context of advanced countries, this paper draws on the perspective of technological governance from science, technology, and society studies and analyzes how a medical profession 'promotes' the disease and transforms its status and the medical regime in a latecomer country. This study criticizes medicalization theory for ignoring this latecomer context. Since the millennium, the Taiwanese nephrological profession, faced with financial and professional pressure in the dialysis regime, has promoted a 'new national disease' discourse on the basis of international statistics and the black-boxed clinical index of eGFR. The discourse and index facilitate the implementation of a CKD regime in a project-oriented policy-making mechanism at the expense of ignoring clinical, professional, and social complexities. This regime has the following consequences: It reverses the status of the nephrological profession but causes internal diversification; it worsens the imbalance between hospitals and local clinics; and its insufficient understanding of and support to diagnosed patients might cause iatrogenesis. In conclusion, this study specifies the 'self-latecomerization' characteristics of the profession, knowledge, and policy-making mechanisms of latecomer medicalization.