- 學位論文
被喚醒的睡眠疾病--台灣睡眠問題的醫療化
Awakened Sleep Disorder—Medicalization of Sleep Disorder in Taiwan
摘要
睡眠是人類與生俱來的本能，如今已逐漸成為醫療體系可介入、處置的生理狀態。從在地醫療體系與西醫地位的消長，到新的醫療專科「睡眠醫學」出現，醫療如何提醒人們正視睡眠的問題？除了醫學知識進步以外，新醫療專科的誕生與發展又和我們的社會文化有什麼樣的互動關係？本研究透過深度訪談法輔以文獻回顧，探討睡眠醫學界的各科醫師（胸腔科、精神科、神經內科、耳鼻喉科）、醫療器材界、和其他醫療體系的醫師，以及失眠與睡眠呼吸中止症的求醫者，從睡眠問題的醫療化出發，挖掘新興醫療發展的社會建構面，透過深度報導呈現睡眠問題醫療化中各行動者的面貌。 新興的醫療專科睡眠醫學界集中處理各種睡眠障礙，從常見的失眠到新疾病睡眠呼吸中止症皆然，並提醒社會正視睡眠問題與公共安全的關係。從醫療化視角看睡眠醫學發展，可以看見，醫療利用睡眠檢查將人們的睡眠經驗界定出正常與異常的界限，成為需要醫療介入、處置的「問題」，而醫師、醫院、醫療器材商和學會組織都參與其中，將睡眠問題一步步醫療化，同時推動睡眠醫療的專業化。制度在此也扮演重要角色，在健保總額制度下，睡眠的醫療發展似乎受限於給付不合理，但這卻也弔詭的成為醫界開發新項目的誘因：不但投入睡眠醫學的醫院總量成長近十倍，醫院的健診中心、坊間健檢機構以及診所更對開發自費項目興致勃勃。 睡眠問題逐步醫療化，因睡眠障礙而求助於醫療專業的人們，有什麼樣的求醫經驗？從他們的經驗我們可以發現，醫療在確定疾病診斷、找出了疾病機轉、提供治療方面有所貢獻。同時，尋求醫療的求診者不但有其個人獨特性、也是具主動性的個體，他們可能遵守醫師囑咐，得到緩解；但預設可普遍使用的治療方式，卻非人人適用。因此有人採取變通策略，讓治療更切合需求；有人則脫離西醫體系，尋求中醫或另類療法。另外還有求診者遇到不當的醫療處置選擇積極「發聲」，或者拒絕被定義為「病人」。這都提醒我們，睡眠問題醫療化的具體表現不但多樣、非單向發展，其結果也無法以黑即白的方式看待，有得亦有失。
並列摘要
Sleep is used to be an innate ability of human beings. From the rise and fall of the dominance of local medicine and western medicine, to the newborn medical specialty “sleep medicine”, medicine has now turned sleep a state examined and treated by medical system. How does the medical system arise our attention of sleep disorder? How does the birth of a clinical specialty relate to our society? Instead of seeing medical development as the solution to health-related problems altogether, this thesis aims to highlight the social construction of disease or disorder by medicine. To reach this goal, I employed in-depth interview and literature review. By interviewing doctors involved in sleep medicine (like chronologists, physiatrists, neurologists and otolaryngologists), doctors from non-western medical system, and people who seek treatment of insomnia or obstructive sleep apnea(OSA), I tried to present the actions of different actors involved in the medicalization of sleep disorder in this in-depth report. Sleep medicine is a newly-shaped medical specialty treating all sleep disorders ranging from common insomnia to new disease OSA. It also arises attention to links between public safety and sleep disorder. From the scope of medicalization, sleep examination is utilized to define normalcy and abnormalcy, turning sleep abnormalcy as problems necessary for medical system to diagnose and treat. This development is a series of actions mobilized by doctors, medical application suppliers and sleep organization. These actors also help build the professional status of sleep medicine. Moreover, the change of local health insurance plays a key role in the medicalizaion of sleep disorder. Under the restriction of coverage of medical treatment, sleep seems to gradually become commodities that medical system is eager to provide. This can be observed from the fast-growing numbers of hospitals involving in sleep medicine, and escalating hospitals, private health screening centers and clinics all work hard to increase services which are not covered by health insurance. As sleep disorder gradually steps into the process of medicaliztion, medical seekers react in different ways. From their experiences, we can see some of them comply with medical advice and thus alleviate their pain or solve their problem, and thus medicalization of sleep disorder do help explain their physical ill-feeling, clarify mechanism of disease and provide remedies. But every unique and active medical seeker has different response. Some of them take alternative medical treatment such as Chinese medicine and alternative medicine, since the common and prevailing way might not meet their needs. In addition, some choose to voice out their dissatisfactory experience of medical-seeking or refuse to be defined as “patients.” According to these medical-seeking experiences, we can see the presentation of medicalization is of various types. It has gains and losses, not an either-or situation.