疾病的价值研究

【作者】 张玉龙；

【导师】 陈晓阳；

【作者基本信息】 山东大学 ， 人文医学， 2012， 博士

【摘要】 根据现代医学的发展轨迹和社会的发展趋势,医学正在突破传统的局限,向更加广阔的学科领域发展。同时,医学的社会性更加突出,广大人民群众温饱问题解决之后,对健康的需求趋向全面、个性与多样,生理、心理、环境等方面的整体健康得到空前的关注。生物医学技术面临着批评的强劲之风,对人的冷漠和日益失去对人的关怀,高额的费用令人生畏而止步门前,高消费、高开支、高需求与医学高科技同日而言,有限资源分配的不合理随之而来,甚至出现了技术愈先进,医疗危机却愈严重的极端现象。疾病,作为与健康一道构成生命存在的必然维度,对健康的效用性(无论正负)无疑会成为人文医学的一个聚焦点。关注疾病并且重视病人,研究疾病价值而非单单的对抗、消灭,突出患者心理在疾病产生和诊疗康复过程中所起到的重要作用,都必将扩大人文在医学中的比重,从而筑起医学人文精神重建的坚固堡垒。因此,疾病价值问题研究就成为一个应时而生、势在必探的重要问题,也可以说是当前推动医学人文与医学科学的整合、推进医学教育改革的前沿问题。本研究具有十分重要的理论价值和实践意义。探究疾病,必然从认识和把握疾病的本质入手。疾病遍及整个人类文明史,对于疾病的解读自然历史悠久、观点纷呈,事实上定义疾病一直面临着语义和逻辑上的困境。遵循“从特殊到一般,从具体到抽象”的认知规律,我们首先在“生命别样境遇”这种特殊层次上感知疾病,无论是纵观医学史还是横向中外文化背景下的疾病定义比较,都显示出疾病字面释义的复杂性。当对疾病的解读与生物医学知识、社会结构、文化价值纠缠在一起,就构成了神灵医学疾病观、自然哲学疾病观、自然科学疾病观、进化论疾病观、基因和分子医学疾病观等不同的疾病解释和评价模型。在自然科学领域,采用层次认知结构,出现的是提供疾病及其相应症状的因果关系解释规范；在人文社会科学领域,则采用完备的患病说明,真实的患病经验,清晰的社会角色、体制、充分的疾病经历等进行阐释。其次,是在疾病定义的梳理中,达成对疾病一般的共识：疾病是机体(包括躯体和心理)在一定的内外因素作用下引起的一定部位的机能、代谢、形态结构的变化,表现为损伤与抗损伤的整体病理过程,是机体内外环境平衡的破坏和正常状况的偏离。最后,通过界定本体、推演范畴、探寻原因、讨论标准,提出疾病的本质：本体多样性的呈现。上述过程的展开,实现了对疾病全面而细致的解读,这也是疾病人文研究的逻辑起点。透过密如丛林的价值理论,可以寻求出支撑疾病价值大厦的基础观点,从而推演出疾病价值理论的基本构架。疾病与人密切联系,也是一种文化客观现象,是与价值有关的事实。基于对价值“属性说”、“关系说”的认可,日本创价学奠基人牧口常三郎的价值理论,特别是价值质分正负、量有大小的论述,成为研究疾病价值的哲学指导。以此为基点,我们提出疾病价值的基本释义：疾病对于生命体的一切意义,这种意义包括着疾病正面、负面和零的作用,对于人类来讲既有目的性,也有工具性。疾病价值以疾病与人的关系作为形成基础,其存在依赖于疾病的属性,典型地呈现着主客体间作用力,正、负取向上表现形式多样。在价值理论的指导下,深入考察疾病的价值属性、概述疾病的价值体系,初步构建起疾病价值理论框架。这一构建,既为价值研究开辟了新的空间,也为疾病意义的解析添加新的途径。遵循疾病价值分类规则,以涉身现象学方法为工具,详细解读在疾病价值体系中具有主导地位的直接价值。运用身体现象学理论解析“疾病的主客观叙事”,进而明确患者对疾病意义的体验,从生物、人文两种视角和正负两种性质中,对疾病直接价值概念属性的产生、发展与内涵的确定,内容的阐释进行构建,最后创造性地提出“顺应物种进化规律,实现生命自主”的疾病终极价值学说。在生物维度上,各种类型的疾病对人的躯体、精神等方面造成了各式各样的损伤,妨碍了生命的保存和延长,对主体和他人、群体和社会产生伤害,最终表现为对自由、平等、公平、正义的侵害,充分显示出疾病负价值的“恶”；在人文视野中,疾病带来个体身体失控、熟悉世界丧失、道德判读误解、社会关系紊乱、物质精神财富消耗等负价值的同时,疾病遵从现象学理论,借助“声音”工具,充分展示症状的表面征兆；提示着躯体的尊严,不断激发出潜能和权力；促进医学人性回归,提供社会文明和人类生存的人文关怀维度；引发人性的多元思考,为开阔哲学的视野添置途径；促进对社会文明的审慎批判和多角度反思。疾病直接价值深入研究必将指向疾病终极价值的阐释,达尔文医学观表明,生物进化离不开疾病,疾病是生命进化中必然付出的代价。我们认为,疾病客体对于生命主体追求的终极目标为生命自主,这是疾病价值体系和思想观念的精髓与支柱。疾病在生命中的重要意义和价值指向,自然也要求人类社会懂得如何以自己的心智来理顺和管理疾病带来的无序状态,要从伦理角度来探究以科学、文明的心态对待疾病和生命,引导当代人类重建理性生存方式。疾病的终极价值明确了之后,与其密切相关的间接(工具)价值的梳理随之而来。原本存在于身体内的疾病,却在外部时空中显示出丰富而深刻的文化内涵。解读疾病价值,就必须超越临床生物医学的层面和范畴,在经济、政治、历史、文学、法学等跨学科领域中,展开关注于人体疾患的文化隐喻和社会象征的探讨。对于经济,疾病显示出对经济发展的健康透支,影响人力资本,造成对社会生产力的破坏；影响发展环境,阻碍资源有效使用；影响社会财富聚集,形成高额的经济负担。对于政治,疾病演变为政治控制的附魅,催生了现代医学制度,强化了政治权利；延伸为隐喻或附魅,演变为政治迫害的帮凶；成为稳定政权的附属成果,推动了人道主义政治文化兴起。对于历史,疾病成为反映历史变化的指标,在揭开历史神秘帷幕的过程中,通过疾病往往可以有新的解释；蔓延不可控的重大的疾病,通过影响甚至改变历史的进程,为一个时代烙下深深地印记；疾病在世界历史上,特别是在创造历史的权势或重要人物身上能够起着重要而鲜为人知的作用。对于文学,疾病和疗救成为文学创造母体,存留文学记录中珍贵的临床病史；形成文学视角下独到的医学科学社会评论；促进文学自我疗救新方式的形成。对于法律,疾病作为法律规制下“自然物”,成为保障健康基本人权的必要补充；实现立法科学性和司法有效性的必要依据；促进社会安全与稳定的必要手段。同时,在上述领域疾病产生的价值,无论正负,都具有丰富且重要的启示意义。研究疾病诸价值,最终是为了对疾病价值基本理论的运用和检验,也就是疾病价值的实现。疾病的潜在价值、内在价值转化为现实价值和外在价值,就是促使人类关注自身、反思自身,从而推进生命的涵养,实现人性健康生长和全面发展的过程。完成这一过程,就是将疾病价值的观念、理论,通过多种渠道得到教育对象的接受,从而使得疾病价值得以实现、发挥。在医学教育中,要改革课程设置,强化医学社会学、人文科学等方面的课程,激发学生对社会心理学、文化、道德等领域的兴趣,鼓励学生走出课堂尽早进医院接近和观察患者,培养学生引发患者及其家属的疾病解释模式,要求学生阅读并阐释疾病叙事材料,并加以考核。在医疗系统中,突出自我保健(self-care)理念和行动的推广,重视自我医疗(self-treatment),鼓励病痛的医护和疾病的治疗整合,改变以经济利益、制度效率、职业竞争为特点的医疗卫生系统,促进以疾病为中心的治疗规范的形成。在生命医学研究中,不断扩展医学学术讨论的领域,突破分子、药物等术语的单一束缚,充分重视疾病与病人人性方面的研究,将疾病、痛苦的叙事等术语引进学术范围,实现科学知识与人文知识对疾病的双重呵护。与设计的出发点相呼应,研究在结语中对疾病意义的探寻与生命意义的叩问统一起来。疾病价值展示的疾病(客体)对人类或人类社会(主体)的意义、有用性,是医学人文所追求的一种应然状态,反映了人们关于医学人文的希望和理想、信仰和依托。疾病价值研究对人性的关注,其目标指向从自然本能上说,就是敬畏生命,维护人的生命健康；从社会关系的层面讲,则是关爱生命,提高人的生命质量；从精神本质特征方面阐述,则是自主生命,走向人的终极关怀。更多还原

【Abstract】 As the development trend of modern medicine and the society suggests, medicine is breaking through the limitation of tradition and develops towards a wider fields. Meanwhile, the social feature of medicine becomes more prominent, as people’s needs for health besides food and clothing are inclined to be comprehensive, individual and various, and holistic health, including physical, psychological, social and environmental health has caused unparalleled attention. However, the biomedical technique is faced with severe criticism that is concentrated on its apathy towards patients, lack of care, and high charge. Actually, the high tech of modern medicine has brought high expense, high cost and high demands, inevitably causing the inequality of limited resource allocation. More and more advanced medical techniques lead to more and more severe belief crisis. Disease is an essential dimension that comprises life existence with health. For health, its utility, no matter it is positive or negative, is bound to be a focus of humanistic medicine. In stead of just combating or eliminating diseases, it is wiser to pay attention to diseases as well as patients, study the value of disease at the same time, and highlight the important role of patient psychology in disease appearance and treatment. By doing this, the proportion of humanities will be enlarged in medicine and the medical humanistic spirit will be stressed. Therefore, the study on disease value, which will promote the combination of medical humanities and medicine and accelerate the reform of medical education, is an important issue of great necessity. In a word, this study has important theoretical and practical value.To study the disease, it is inevitable to start with recognizing and mastering the nature of disease. Disease can be found throughout the whole history of human civilization. As a result, there is a long history and varied viewpoints concerning its interpretation which is actually faced with the semantic and logic dilemma. Following the cognitive rule, i.e."from specific to general, from concrete to abstract", we’ll first feel the disease as a different situation of life. Looking through the medical history and different definitions of disease under Chinese and foreign cultural background, we’ll perceive the complexity on how to define "disease" Entangled with biomedical knowledge, social structure, and cultural value, the disease interpretation has been divided into various definitions and evaluation models as follows:divinity medical concept, natural philosophy concept, natural science concept, Darwinist concept, genetic&molecular medical concept, etc. In the natural science field, disease is defined with the cognitive level structure as the causal relationship between a disease and its symptoms; in the humanistic science field, it is defined with the patient’s complete condition description, real and abundant disease experience, clear social role and system. Having organized these various disease definitions, this study reached a consensus on "disease":a series of functional, metabolic, and structural changes of an organism (including body and mind) which are caused by certain inner and outer factors, embodied as an injury&anti-injury pathological process, and considered as a balance damage and deviation of the organism environment. Finally, through defining ontology, deducing categories, seeking reasons and discussing standards, this study proposed the nature of disease as the showing of ontology’s variety. During this process, this study achieved an overall and detailed interpretation and proposed the logic beginning of the humanistic research on disease.The basic framework of disease value theory has been deduced from the fundamental concepts of disease value through various value theories. It is assumed that the close relationship between diseases and human beings is a cultural objective phenomenon and a fact concerning value. Soka Gakkai’s founder--Makiguchi’s value theory based on the "property doctrine" and "relation doctrine" is believed as the philosophical guide for disease value research, especially the discussion that the value has positive and negative quality and different quantity. Based on this, the disease value is defined as all the meanings that disease has posed on life, including positive, negative, and zero meanings, and they are of purpose and utility for humans. This value is formed on the basis of the relationship between diseases and humans. Its existence depends on the disease property, typically showing the force between the subjective and objective and the variety of positive and negative orientation. Instructed with this assumption, this study explored the value property of disease and summarized the value system of disease, thus initially establishing the framework of disease value theory. By doing this, this study has opened a new window for value research and added to new ways of analyzing disease value.Following the categorization rule of disease value and the embodied phenomenology way, this study made a detailed interpretation on the direct value that takes a dominant position in disease value system. This paper applied body phenomenology to analyze "the objective and subjective narration of disease", clarified patient experience on disease meanings, determined the birth, development, and connotation of direct value of disease from two perspectives, i.e. biological and humanistic, and two natures, i.e. positive and negative, built the related explanation, and creatively proposed the ultimate value of disease that "it is inevitable to follow the species evolution law and realize the independent life". From the perspective of a living creature, every type of disease causes injury to human body and mentality, prevents life from existing and prolonging, hurts the subjective, others, groups and society, does harm to freedom, equality, equity, and justice, fully showing the "evil" of the negative value of disease. Humanistically speaking, while disease brings about physical disorder, loss of familiar world, moral misunderstanding, disorder of social relationships, cost of material and spiritual wealth, disease fully shows the external symptoms with the phenomenology theory and "sound" tool; disease indicates the dignity of body and arouses potential and power; disease promotes the return of humanity and provides humanistic care as social civilization and human existence; disease stimulates multi-perspective thinking on humanity and adds to ways of broadening philosophical view; disease promotes the cautious judgment and reflection on social civilization. Research on the direct value of disease leads us to the explanation of the ultimate value. Darwinist medical thought indicates that the evolution can’t be separated from diseases which are necessary cost the evolution should pay. It is assumed that the essence of disease value system and related theory lies in the disease objective’s ultimate pursuit for the life subjective, i.e. the independent life. The important meaning and value orientation of disease in life require human society to know how to overcome the disorder disease brings, explore scientific and civilized ways to treat disease and life from the perspective of ethics, and guide contemporary humans to rebuild rational way of living.After clarifying the ultimate value of disease, this study started to discuss the indirect (tool) value that is closely related with the ultimate value. Disease exists in the body, but it possesses rich and clear cultural connotation out of the body. To interpret the disease value, we have to exceed the clinical biomedical boundary and explore the cultural metaphor and social symbol concerned with disease in such fields as economy, politics, history, literature and law. With regard to economy, disease makes an overdraft on the healthy development of economy, damages social productive forces by affecting human resource, influences development environment by impeding the effective use of resource, affects the accumulation of social wealth by forming high cost. In the field of politics, disease becomes the enchantment of political control, gives the birth of modern medicine system, and intensifies political power; disease becomes metaphor or enchantment and changes into the accomplice of political persecution; disease evolves into attached fruit to solid regime and promotes the rise of humanistic politics and culture. For history, disease is an indicator of historical changes, it could provide new explanations for the unveiling of mysterious historical changes; once out of control, severe diseases could leave a deep marking to an era through changing the historical course; disease is found to have cast important and little-known influence on history-creating figures in human history. For literature, disease and treatment are considered as parents of literary creation because of their record of clinical history, promote the formation of medical social remark from the perspective of literature and the birth of new ways of literature self-treatment. For law, as’a natural item’under the legal regulation, disease is a necessary complement to the healthy security of basic human rights, a necessary ground to realize the scientific legislation and effective judicature, and a necessary means to promote social security and stability. At the same time, all the values disease produces in the above fields, no matter it is positive or negative, have rich and important indications.The study on disease value is aimed to employ and testify the disease value theory, i.e. to realize the disease value. The potential and inner values of disease respectively turn into realistic and outer values. During this process, human beings watch and reflect on themselves to improve the life quality, thus realizing the healthy growth and overall development of humanity. To accomplish this process, we need to have the concept and theory of disease value accepted by the education targets so as to make disease value meaningful. With regard to medical education, we shall reform the course arrangement, intensify such courses as medical sociology and humanistic science, stimulate students’interest in social psychology, culture and ethics, encourage them to approach and watch patients in hospital, train them to establish disease explanation model of patients and their family members, require them to read and explain disease narration materials with assessment. In the health care system, we have to highlight the promotion of self-care concept and activity, stress self-treatment, encourage the combination of pain care and disease treatment, change the contemporary health care system that is featured with economic benefits, system efficiency, and career competition, and promote the formation of disease-centered treatment. In biomedical research, we should continually broaden its academic fields, break through the boundary of terms, e.g. molecular, medicine, pay much attention to disease and patient humanity, introduce such terms as disease, painful narration, etc., and have disease cared by both scientific and humanistic knowledge.To echo with the starting point, this study discussed the meaning of disease and life in the conclusion. The display of meanings and utilities that disease (objective) brings to human society (subjective)in disease value is a qualified status that medical humanity has pursued and a reflection of hope, faith and trust humans have posed on medical humanity. From the perspective of natural instinct, the attention disease value research pays to human nature is a reverence for life and health; from the perspective of social relationship, this attention is a care for life and human life quality; from the perspective of spiritual nature, it is an independent life and an ultimate concern about humans.更多还原