“醫(yī)改市場(chǎng)化”辨析Medical Reform: How Is It Oriented to or by the Market?

文、譯/林巍

China’s medical reform carried out in recent years has generally been seen as a failure, evidenced in the difficulty of getting medical services, high drug prices, the tension-ridden doctor-patient relationship and so on. Some experts said that all this is attributable to insuf ficient marketization. I think, however, there are many more reasons than this.

[2] When I returned to China after living overseas for more than a decade,it was strange to see the media being flooded by advertisements for various medicines and medical equipment,strikingly different from practice in the West, where doctors provide prescrip-tions for patients to obtain their medicines from pharmacies whose commercial operation has nothing to do with doctors. Chinese doctors, in addition to their routine duties, have to shoulder the task of “drug-provisioning-medicine”to cover the hospital expenses and to ensure wage-raises. This is completely wrong in my opinion.

[3] A doctor’s bounden duty is to treat patients and save lives, which is fundamentally in line with the patients’ desire.Doctors’ rewards and achievability are obtained solely from the effectiveness of their treatment; any other factors intruding into this process will inevitably change the nature of the profession.

[4] Unlike other physical sciences,medicine involves people relations and is seen as a special social culture. The reason for the tense relations between doctors and patients, according to some specialists, lies in the disproportion of doctors to patients, since in many hospitals doctors have to treat several dozens or even more patients every day. While this may be one of the factors, the root cause, in my view, is the patients’ dis-trust of their doctors, who are deemed not to aim at healing them but rather at generating pro fits.

[5] Patients are in an extremely vulnerable position to be ripped off since doctor-patient relations, very much like those of teacher-student and lawyer-defendant, are highly unevenly structured in terms of information and expertise.The “bene fit chain” between the two is thus severed. Unlike other commercial services, curing the sickness to save the patient, involving humanity and human rights, should be bound within government’s responsibilities and should not be entrusted to the market in this regard.What many western countries currently practice is just that, such as in Australia,where 4% of national revenue is allocated to cover everybody’s medicare.

[6] In the West, medicine is a respected and well-paid profession, which contrasts remarkably with the situation in China where doctors have been scolded and beaten, even murdered at will by their patients. No wonder some friendsof mine are stubbornly opposed to their children studying medicine; some medical school graduates have also diverted into other occupations. According to the “l(fā)aws” of the market, the scarcity of medical resources should result in both status and financial appreciation of its providers; the current bizarre situation is completely abnormal, which can only be put down to the government’s rigid medical management of its amount,size, location and so on oriented by the planned economy, where it is hard for the “invisible hand” to play its role.

[7] Also, medical practitioners by nature are self-employed individuals,whose private practice has been proved in foreign countries to be an effective way to improve the doctor/patient ratio under the government’s strict regulation of doctors’ qualifications and medical practice. However, this kind of marketization still seems to be a painfully slow process in China now.

[8] Clearly, the crux of the current medical reform should not be generalized as lacking any market mechanism,but rather a more specific analysis would find that so-called marketization has taken place in the wrong areas. In a way, a more radical reform guided by integrated design is urgently needed, so as to achieve the result of “treating both symptoms and root causes”. ■

普遍認(rèn)為，近年來(lái)的醫(yī)療改革是不成功的，體現(xiàn)在看病難、藥價(jià)高、醫(yī)患關(guān)系緊張等。究其原因，有專(zhuān)家認(rèn)為是其改革的市場(chǎng)化1對(duì)此有許多譯法，除marketization外，還有g(shù)eneral adoption of the market principle、something marketable等，而標(biāo)題更由于“辨析”而具體處理成“Medical Reform: How Is It Oriented to or by the Market?”。不夠。但我卻以為，并非如此簡(jiǎn)單2一般可譯成“maybe not be sosimple”“…that it is not that simple”等，這里稍作變通。。

[2]在海外十余年后回國(guó)，有一突出感覺(jué)，就是媒體上泛濫3這里的flooded由自然現(xiàn)象轉(zhuǎn)意，更口語(yǔ)化些，其他還可用inundate、widespread、awash等。如：①A visit to Japan may not be necessary to understand how inundated Japanese pop culture is with Western Culture.（無(wú)需到日本，便可知道西方的影響在那里的流行文化中有多么泛濫。）②He said he’d seen no evidence of widespread fraud.（他說(shuō)并未見(jiàn)詐騙泛濫的證據(jù)。）③The city is awash with drugs.（該城市毒品泛濫。）的醫(yī)藥廣告，與西方形成強(qiáng)烈反差。在那里，醫(yī)生按病情開(kāi)藥，藥行按醫(yī)生處方供藥，根本無(wú)需廣告，而藥價(jià)、藥售與醫(yī)生無(wú)關(guān)。國(guó)內(nèi)的醫(yī)生則不然，他們還要擔(dān)負(fù)起“以藥養(yǎng)醫(yī)”4其意為“以醫(yī)生的勞動(dòng)來(lái)實(shí)現(xiàn)藥品的高附加值，以藥品的高利潤(rùn)拉動(dòng)醫(yī)院的經(jīng)濟(jì)效益，維持醫(yī)院的正常運(yùn)轉(zhuǎn)”，直譯為to cover hospital expenses with medicine revenue，一般可譯成drug-maintaining-medicine，但provision用作動(dòng)詞時(shí)有“providing someone or something with …”之意，故用此詞。的重任，以維持經(jīng)營(yíng)，提高收入。竊以為，這就大錯(cuò)特錯(cuò)了。

[3]醫(yī)生的天職是看病、醫(yī)治、救人，在這一點(diǎn)上，醫(yī)生與病人的根本目的是一致的5有多種譯法，如“fundamentally… all agree ...”“be basically consistent with”等，甚至可變通為“after all, …h(huán)ave the same dream and ultimate value”等，取決于具體語(yǔ)境。。醫(yī)生的回報(bào)和成就感，應(yīng)當(dāng)僅僅從治療病人的成效中獲得，而一旦摻入其他因素，必然帶來(lái)根本性質(zhì)的變化。

[4]醫(yī)學(xué)不是一般的自然科學(xué)，要與人打交道，故是一種特殊的社會(huì)文化。有專(zhuān)家指出，當(dāng)前醫(yī)患關(guān)系緊張6亦可譯成tentional doctor-patient relationship，或變通為physician-patient relationship has been intensi fied等。的原因，在于醫(yī)生與病人不成比例；病人耗時(shí)費(fèi)力來(lái)見(jiàn)醫(yī)生，得到的卻是幾分鐘的診療，因目前許多醫(yī)院的醫(yī)生每天每人要診治幾十甚至更多例病人。固然，這是問(wèn)題之一，但根本原因在于，病人懷疑醫(yī)生的目的不純7不宜簡(jiǎn)單地譯為impure purpose/intention，而是一種不信任（distrust），特別是結(jié)合后面的“治病”與“創(chuàng)收”而言。，即不是在治病，而是在“創(chuàng)收”。

[5]醫(yī)生與病人的關(guān)系，正如教師與學(xué)生、律師與被告，二者處于專(zhuān)業(yè)和信息高度不對(duì)等狀態(tài)，要想從被服務(wù)者身上牟利，易如反掌8通?？勺g為as easy as pie / to turn one’s hand /winking等，但此處根據(jù)語(yǔ)境對(duì)句式作了較大調(diào)整，譯出其實(shí)質(zhì)所指為“… in an extremely vulnerable position to be ripped off”，同時(shí)將“服務(wù)者”具體化為patients，做主語(yǔ)。，所以必須切斷二者之間的利益鏈條。治病救人，固然是一種服務(wù)，但卻不同于一般的商業(yè)性質(zhì)，而與人道、人權(quán)相關(guān)聯(lián)，所以需要政府主要擔(dān)當(dāng)職責(zé)；在這個(gè)意義上講，醫(yī)療不可市場(chǎng)化。在西方主要國(guó)家，也正是這樣做的，如澳大利亞，政府拿出國(guó)民收入的4%作為大眾基本醫(yī)療保險(xiǎn)9通常為medical insurance、hospitalization insurance等，但許多西方國(guó)家實(shí)行的是medicare制度。，人人有份。

[6]在西方，醫(yī)生10“醫(yī)生”平時(shí)說(shuō)成doctor、physician、medical practitioner、surgeon (外科醫(yī)生)，但指職業(yè)時(shí)應(yīng)為profession、medicine等，如：①他的職業(yè)是醫(yī)生，業(yè)余寫(xiě)小說(shuō)。（He is a doctor by profession and a novelist by avocation.）②In the West, talent youngsters are normally gravitated towards medicine, law and engineering.（在西方，有才華的年輕人通常去學(xué)醫(yī)學(xué)、法律及工程專(zhuān)業(yè)。）是個(gè)備受尊敬、收入頗豐的職業(yè)，這又與國(guó)內(nèi)形成強(qiáng)烈反差——醫(yī)生可以被隨意打罵甚至殺害！我的幾個(gè)朋友，都決然反對(duì)子女學(xué)醫(yī)，有的醫(yī)學(xué)院畢業(yè)后，也都改行不做醫(yī)生。這又與市場(chǎng)規(guī)律11市場(chǎng)的本質(zhì)是交換；任何“市場(chǎng)”都是商品市場(chǎng)，其內(nèi)在的價(jià)格機(jī)制、供求機(jī)制、競(jìng)爭(zhēng)機(jī)制、決策機(jī)制等就形成了市場(chǎng)規(guī)律。一般可譯成market mechanism、market discipline、market forces、market law等，而“按市場(chǎng)規(guī)律辦事”為按市場(chǎng)規(guī)律辦事follow/according to market rules/laws等，因這里加引號(hào)為 the “l(fā)aws” of the market，以特有所指。不相符合：既然醫(yī)生奇缺，醫(yī)療資源寶貴，其身價(jià)12這里一般是指social status，而“提高身價(jià)”為have a rise in social status；因與后面的“精神與物質(zhì)”相關(guān)聯(lián)，故分解為“in both status and financial appreciation …”以更明確。（精神與物質(zhì)）應(yīng)與之俱增才是，但現(xiàn)實(shí)卻相反。究其原因，是政府控制住了源頭，即開(kāi)設(shè)醫(yī)院的數(shù)目、規(guī)格、地點(diǎn)等仍是以“計(jì)劃經(jīng)濟(jì)”為主導(dǎo)，那只“看不見(jiàn)的手”仍不起作用。

[7]再者，醫(yī)生是一種天然13一般為naturally、should be、suppose to be、logically等，這里用by nature指明其工作性質(zhì)。的個(gè)體職業(yè)。國(guó)外的實(shí)踐證明，根據(jù)供求關(guān)系，允許私人醫(yī)生開(kāi)業(yè)，政府管控醫(yī)生素質(zhì)、醫(yī)療條件，可以有效緩解醫(yī)患比例失調(diào)，而這在國(guó)內(nèi)又舉步維艱14通常指“很難從事”，如：① His move has made life very dif ficult for his employees.（他的這一招使得員工的日子舉步維艱。）②經(jīng)濟(jì)改革仍將舉步維艱，毫無(wú)成效。（Economic reform has so far been painful and ineffective.）③The Chancellor could face a rough ride unless the plan works.（除非這個(gè)計(jì)劃能夠奏效，否則財(cái)政大臣將舉步維艱。）這里則用a painfully slow process描述中國(guó)當(dāng)前醫(yī)改的具體情況。，難以按市場(chǎng)規(guī)律行事。

[8]可見(jiàn)，目前醫(yī)改的癥結(jié)不能籠統(tǒng)地歸結(jié)于缺乏市場(chǎng)化15如前所述，不可簡(jiǎn)單譯成lack marketization，而可具體為market mechanism功能。，而應(yīng)具體分析：不該市場(chǎng)化的市場(chǎng)化了16此句及下句都不宜按字面意思逐字譯出，那樣不但笨拙，而且難以指明；… has taken place in the wrong areas. 雖顯籠統(tǒng)，但含義已明。，該市場(chǎng)化的則沒(méi)有市場(chǎng)化。所以，對(duì)此亟需正本清源，總體調(diào)整，從而真正做到“標(biāo)本兼治”。 □