【作者】 单巍；

【导师】 朱葆伟； 丛杭青；

【作者基本信息】 浙江大学 ， 科学技术哲学， 2013， 博士

【摘要】 医疗信任(或信任危机)已成为我们当前面临的一个重大的社会问题。它突出地反映在医患冲突中,其背后是某些制度安排的失当。本文试图从理论上研究这一现象,揭示其形成的深层原因和背景,提出重建医疗信任的思路,并且结合一定的实证研究,使其更具实效性。健康是人得以正常生活和工作的基础,而医疗卫生是最重要的社会事业之一,这些都使得医疗信任在社会中具有更重要的地位。医疗事故频发、医疗费用居高不下、医疗资源配置不合理等现象导致了当前中国医疗信任危机的产生。究其根源,则在于我们的医疗卫生系统在一些方面失去了其本应具有的公益性质；同时,部分医生在利益诱惑面前,忘记了自己的职业目标,违背了职业道德。毋庸讳言,危机的形成与医疗卫生体制改革有关。医疗改革通过引入市场机制来解决医疗卫生系统的资源短缺和效率低下问题。改革开放初期,人们对市场的理解较为表面化,对医疗卫生事业的特殊性质也缺乏深入的思考和研究。由此造成了医疗服务的公平性下降、卫生投入缩减和宏观效率低下,以及过度商业化等问题。而现代性制度建立过程中的问题和现代性制度本身的问题交织在一起,形成中国医疗信任问题的特殊情境。医疗信任问题并非中国所独有,随着现代性的深化,以往的信任机制已不足以应对新问题。各国政府在进行医疗改革时,也都致力于在政府和市场两种力量中寻求最佳结合点,以达到公正、共享与效率的统一。在现代性制度的大背景下,重建医疗信任需要从两方面着手：一是从社会和国家的宏观层面上构建起一个以“正义原则”为基础的医疗卫生系统,由此消除信任屏障。这个“正义原则”既包括社会资源分配上的“分配正义”,尤其涉及如何正确处理政府与市场的关系问题,也包括社会各方在交往和商谈过程中的“交往正义”,各方通过平等的交流和商谈,达成初步共识,同时要求参与方共同承担责任和义务;二是在医生职业建设层面上,以互惠原则为基础,通过医生职业的自律和他律机制相结合,以此重建医生的职业理想和规范,在微观层面上建立医患之间的信任关系。在理论研究的基础上,笔者提出以“交往正义”为基础,建立良好的公众参与机制,让公众参与医疗卫生系统的决策制定过程,以此作为重建医疗信任的途径。同时,选取两个典型案例《云南省医疗机构管理条例(草案)》立法听证会和《广州市社会医疗保险条例》网上立法听证会,深入现场调查当前中国公众参与现状,结合国外的经验,提出如何建立良好的交往平台,重建医疗信任。更多还原

【Abstract】 Nowadays, healthcare trust (or a crisis of trust) has been a significant social problem. It is especially reflected in the doctor-patient conflicts, and the fact is some errors of institutional design. This paper attempts to study this phenomenon theoretically and reveal the root cause and background of the formation. Then author proposes the idea of reconstructing healthcare trust, and combines with some empirical researches to make it more effective.Health is the foundation which human is able to live and work, and health care system is one of the most important social undertakings. Consequently, healthcare trust is more important than other in society. There are some reasons led to a crisis of healthcare trust in China, such as Frequently Medical malpractices, the high cost of medical treatment, irrational allocation of medical resources, and so on. Actually, one of the root causes is the lack of public welfare in health care system, and the other one is some medical staff forget their professional ideals and violate professional ethics.To be honest, the crisis of healthcare trust is closely related to China health care reform. The reform adopted the market mechanisms to resolve the problem of medical resource shortages and inefficiencies in China health care system. In the beginning of reform and openness, people comprehend the market more superficially, and did not thoroughly think and study the particularity of health care system. Thus some problems appeared with the reform, for instance the decline in the fairness of health services, the reduction of health spending, macroeconomic inefficiency and excessive commercialization and so on. The problems of establishing the modernistic institution and the problems with the modernistic institution itself are intertwined. That is the special situation in the problem of healthcare trust in China. In fact, the problem of healthcare trust is not only in China but also in other country. Because of the development of modernity, the trust mechanism is not enough to response to new problems. Many national governments are reforming the health care system in different countries. They try to balance government mechanism and market mechanism in order to achieve fairness, sharing and efficiency in health care system. In the context of the modern system, we should rebuild healthcare trust in two ways. First, we should reconstruct the national health care system with ’principles of justice’, and eliminate the trust barrier. The ’principles of justice’ includes ’distributive justice’ and ’communication justice’. Distributive justice means the justice of distribution of social resources, and in particular how to correctly handle the relationship between government and the market. Communication justice means various parties equally communicate and have conversation to make consensus, meanwhile every parties are required to take responsibilities and carry obligations. Second, we should establish reciprocal regulation through the inner-discipline and outer-discipline to manage doctors. Then we can rebuild the doctor’s medical professional ideal and professional codes and establish the trust between doctors and patients.Based on the theoretical study, the author proposes ’communicative justice’ as the basis, to establish a good mechanism for public participation, let the public to participate in the processing of the health care system decision-making. It is a good way to rebuild the healthcare trust. At the same time, the author selected two typical cases to study. One is the ’Yunnan Province Medical Institution Management Regulations (draft)’legislative hearing and other is the ’Guangzhou Social Health Insurance Regulations’ online legislative hearings. Through field investigation, the author survey the current status of public participation in China and concern the experience of foreign countries, then put forward how to establish good communication platform to rebuild the healthcare trust.更多还原