从医患关系模式的角度分析中国医疗领域中的“自主性原则”

通过调研和访谈从医患关系的模式角度分析了当前中国医疗领域中的“自主性原则”,对医生来说,虽然医生对患者的自主性表示尊重和接受,但很多时候仍将患者自主式作为医生履行职责的障碍;对患者来说,患者也没有将自主视为理想医患关系的要素,反而认为自主在很多情况下会损害自身的利益,提出在西方医疗实践的影响下,医患关系的模式处于传统的家长制和西方的消费主义两种极端模式相重叠的阶段,自主性原则在两种模式中被赋予了截然不同的价值,因而导致了自主性原则在当前中国医疗实践中的两难处境.     

Barriers to accessing health care: the perspective of elderly people within a village community

Many initiatives which emphasise the consumerist stance of patients make the apparent assumption that patients have the knowledge and desire to exercise their consumer rights. This study explores the extent to which there is a consumerist ethos among elderly people in a village community, and the factors which influence the accessing of health care in the community. Using a mini-ethnographic approach, nine key informants were observed and interviewed. Cultural factors were found to influence coping in health and illness, and in legitimising access to primary health care. No informant saw the need to exercise their rights as consumers of health care, suggesting that despite initiatives to involve patients as partners in health care, the hierarchical position of the elderly people in the village is unchanged from the days of the medical model in health care, and is a significant barrier to their use of health services.     

Responsive Consumerism: Empowerment in Markets for Health Plans

Context: American health policy is increasingly relying on consumerism to improve its performance. This article examines a neglected aspect of medical consumerism: the extent to which consumers respond to problems with their health plans.
Methods: Using a telephone survey of five thousand consumers conducted in 2002, this article assesses how frequently consumers voice formal grievances or exit from their health plan in response to problems of differing severity. This article also examines the potential impact of this responsiveness on both individuals and the market. In addition, using cross-group comparisons of means and regressions, it looks at how the responses of "empowered" consumers compared with those who are "less empowered."
Findings: The vast majority of consumers do not formally voice their complaints or exit health plans, even in response to problems with significant consequences. "Empowered" consumers are only minimally more likely to formally voice and no more likely to leave their plan. Moreover, given the greater prevalence of trivial problems, consumers are much more likely to complain or leave their plans because of problems that are not severe. Greater empowerment does not alleviate this.
Conclusions: While much of the attention on consumerism has focused on prospective choice, understanding how consumers respond to problems is equally, if not more, important. Relying on consumers' responses as a means to protect individual consumers or influence the market for health plans is unlikely to be successful in its current form.     

‘A pill for every ill’: Explaining the expansion in medicine use

This paper explores the major factors underpinning the expansion in medicine use over recent decades, using England as an example. It begins by constructing a ‘progressive’ model of the expansion and considers its limitations; it then uses a framework of countervailing powers to examine the contribution of key actors in the field. It examines the commercial orientation of the pharmaceutical industry and the strategies companies deploy to generate demand for their products. It explores the part played by doctors as researchers and gatekeepers to medicines, considering how features of medical knowledge and practice contribute to, rather than curtail, the expansion. It considers the role of the public as consumers of medicines, and the role of governments and insurance companies in both facilitating and controlling medicine use.     

Involuntary autonomy: Patients' perceptions of physicians,conventional medicines and risks in the management of atopic dermatitis

Consumerism is a major force in western health care. It defines the process in which patients should or do play a more active and central role in making informed choices about health and illness. The talk of patients as consumers is closely linked, and is especially pertinent for patients managing a chronic illness. This article presents findings from a Danish qualitative study that set out to broaden the sociological debate on patients as consumers by including patients' perceptions of conventional medicines. In-depth interviews were carried out with 24 people who medically managed their own or their child's atopic dermatitis. The informants were recruited via the Division of Dermatology in a Danish Hospital which was planning an Information Day on atopic dermatitis (AD). The findings reveal how many of the informants who on the surface appear to match the profile of the so called ‘consumer’, by being active, critical, informed etc., in fact prefer to consult a patient-centred medical expert (a dermatologist) with good communication skills, who is able to inform, advise and support on issues of managing atopic dermatitis. These people are not seeking more independence but rather a partnership where responsibility for treatment (medicines) is shared. This preference appears to be closely linked with a sense of insecurity about what an outbreak of atopic dermatitis may lead to and insecurity about the medicines. Ultimately, the findings stress that health care politicians and professionals need to reflect upon patient's wants and needs when designing future health care. Turning health care into self-care may not be an appropriate strategy.     

Internet use and the logics of personal empowerment in health

OBJECTIVES: The development of personal involvement and responsibility has become a strategic issue in health policy. The main goal of this study is to confirm the coexistence of three logics of personal empowerment through health information found on the Internet. METHODS: A theoretical framework was applied to analyze personal empowerment from the user's perspective. A well-established Canadian Web site that offers information on personal health was used as a case study. A close-ended questionnaire was completed online by 2275 visitors and members of the Web site. RESULTS: The findings confirm that the development of feelings of competence and control through Internet use is structured around three different logics. This implies three types of aptitudes that are fostered when the Internet is used to seek health information: doing what is prescribed (the professional logic), making choices based on personal judgment (the consumer logic), and mutual assistance (the community logic). CONCLUSIONS: A recurring issue in three logics is the balance of roles and responsibilities required between the individual and the health provider.     

When there is no doctor: reasons for the disappearance of primary care physicians in the US during the early 21st century

Primary care doctoring in the USA today (2007) bears little resemblance to what existed just 25 years ago. We focus on what is likely to unfold in the U.S. over the next several decades and suggest that by about 2025, primary care doctoring in the U.S. could be rare, possibly unrecognizable and even nonexistent. Seven reasons for the probable disappearance of primary care doctoring are identified. The most important reason is medicine's loss of state sponsorship: the U.S. state has shifted from a pluralistic orientation to a New Right approach. With less state protection medicine has become even more attractive for private interests. Six additional reasons include: (1) the epidemiologic transition (chronic diseases reduce doctors to a palliative role and monitoring of incurable conditions); (2) the overcrowded health care playing field (non-physician clinicians are supplanting primary care doctors); (3) the unintended consequences of clinical guidelines (the art of doctoring is reduced to formulaic tasks, easily codified and performed by non-physician clinicians); (4) the demise of the in-person examination (in-person examination is being replaced by impersonal testing); (5) primary care doctoring is becoming unattractive (physicians are dissatisfied, alienated and experiencing income declines. Applications by U.S. graduates to primary care programs continue to decline); (6) patients are not what they used to be (Internet access and Direct to Consumer advertising are changing the doctor-patient relationship). By 2025, many everyday illnesses in the U.S. will be managed via the Internet or by non-physician clinicians working out of retail clinics. Some medical problems will still require a physician's attention, but this will be provided by specialists rather than by primary care doctors (general practitioners).     

“It was fun,it was dangerous”: Heroin,young urbanities and opening reforms in China's borderlands

BackgroundAn unprecedented flow of opiates flooded China's southern regions in the wake of the country's opening reforms in the 1980s. After the Maoist war on drugs had turned the People's Republic of China into an almost entirely drug-free area for three decades, heroin reappeared to become the most widely used illicit substance in the country. As the number of users rose by 1200% between 1988 and 1998, a generation of young people found themselves facing the consequences of addiction.MethodsBased on ethnographic data collected during 13 months of field research among a community of heroin users in the county-level city of Qilin in Yunnan Province, this paper explores the interplay of historical and social factors that led southern China's young urbanities to turn to heroin in the 1980s and 1990s. Towards this end, it draws on a broad array of research methods including the collection of life histories, extensive participant observation, and focus groups among the members of Qilin's local community of heroin users.ResultsI argue that the spread of heroin among southern China's young urbanities should be read as the aggregate outcome of such seemingly disparate factors as the opening of new global routes for the trafficking of opiates, the almost complete lack of Chinese public discourse around drugs in the immediate post-Mao period, the increased individualization of young people's ambitions, desires and forms of socialization, and the rise of a consumerist market economy in the country.ConclusionsBased on the data collected, I claim that the boom in the diffusion of heroin use in post-reform China cannot be described exclusively as a matter of deviant individual behaviours. Rather, it has to be interpreted as a complex social act, which is only understandable when framed within the social and historical context in which it was performed.