16卷1期

• Link 原著 Original Article
• 某醫學中心子宮切除婦女自述醫病溝通之探討Physician-Patient Communication Reported by Women of Hysterectomy
• 張珏、張菊惠、胡幼慧
  Chueh Chang, Chu-Hui Chang, You-Hwey Hu
• 子宮切除 ； 醫病溝通 ； 醫師告知
  Hysterectomy ; Physician-patient communication ; Physician's Informed
• 本研究欲探討前往某醫學中心求診之非癌症診斷婦女在面臨子宮切除時，醫病溝通問醫師告知與婦女認知的情形。訪視72位術後3-9個月的婦女，結果發現三成的婦女對疾病診斷、手術範圍認知不正確。889%曾有醫師解釋病情，50.0%曾與醫師討論病情；72.2%曾有醫師說明手術範圍，68.9%曾與醫師討論手術範圍。32.6%的病人在術前並未被醫師告知會合併單或雙側卵巢切除，51.7%的人未被醫師告知子宮切除的範圍涵蓋子宮頸。750%的婦女被告知「過了生育年齡子宮就沒有用了，拿掉沒有關係」，444%被告知子宮切除後的好處，只有6.9%與13.5%的婦女被告知手術對身體與性生活可能會有影響，42%被告知可能會有合併症，其餘則是沒有說或說沒影響。結果得知，醫師告知偏向於手術的好處，而手術風險與可能影響較少提及，婦女對疾病與手術範圍認知不正確，反映出醫師告知的不清楚與不充份。根據本研究結果，建議改善醫學教育，建立婦女健康資源網絡，立法規範醫師告知的責任，敦促醫病溝通中醫師告知的落實。
  Focusing on women of one medical center in Taiwan metropolitan area with non-cancer diagnoses who are faced with hysterectomy, this research investigates the physicians-patients communication about the extent of information provided by physicians, and women's knowledge of hysterectomy. The 72 subjects in this study were women who had a hysterectomy 3-9 months prior to interview. The results showed that 29.2% of the women were unclear of their own diagnosis, 27.8% were unclear of their operations. 72.2%-88.9% of the physicians had explained the operations and disease to their patients, and 50.0%-68.9% had discussed thedisease and operations. Among the 72 women interviewed, 61.1% had either a unilateral or bilateral oopho-rectomy, 32.6% were not advised by a physician to heave the oophorectomny. In the course of physician-patient communication, 75.0% of the women were told that the uterus is useless beyond childbearing age. 44.4% were told the benefits of hysterectomy. Only 6.9-13.5% were told the possible side effects of the surgery, and 4.2% were told the possible complications of the surgery: the rest of the subjects were not told of the possible negative outcomes. Therefore, physicians prefer to tell women the benefits of surgery rather than the risks, side effects and complications of surgery. The facts that women were unclear of their diagnosis and operations reflect the information of physicians supply were unclear and inadequate This research implies a need for improving the medical education as well as developing women's health network, legislating the physicians responsibility of informing patients to improve the physicians-patients communication.
• 1-12
• 10.6288/CJPH1997-16-01-01

• Link 原著 Original Article
• 影響產婦哺母乳態度及哺乳方式的因素An Exploration on the Factors Influencing the Mother's Breast-feeding Attitude and Feeding Method after Delivery
• 鄧素文、張媚、楊雅玲
  Su-Wen Teng, Mei Chang, Ya-Ling Yang
• 哺母乳態度 ； 哺乳方式 ； 影響因素
  breast-feeding attitude ; feeding method ; influencing factors
• 母乳的優點一直為專家學者所肯定。但自1940年左右，國內外哺母乳率卻不斷下降。民國八十一年起國內開始大力推行母乳哺育。 本研究係以台北某教學醫院527位足月產之產婦為對象。目的在探討產前門診團體衛教及產婦基本屬性等變項中，何者為產婦哺母乳態度的最佳預測因素；及產婦產後及滿月時哺乳方式的最佳預測因素。 研究結果發現在「哺母乳與母嬰身體情況的相互影響」之態度方面的相關因素為就業狀況；在「哺母乳優點及價值觀」的態度方面，其相關因素包括家屬是否贊成哺母乳、醫生曾否鼓勵哺母乳、生產方式及就業狀況；而在「母乳是否可被配方奶粉取代」的態度方面之相關因素包括就業狀況及家屬是否贊成哺母乳。 而影響個案產後所選擇哺乳方式之相關因素包括從前有無哺母乳經驗、對哺母乳優點及價值觀的態度、家屬是否贊成哺母乳、對配方奶粉是否可以取代母乳的態度、及有無參加產前門診團體衛教。至於哺母乳個案滿月哺餵方式的相關因素則包括家屬是否贊成哺母乳及就業狀況。
  Although the advantage of breast-feeding has been recommended, the ratio of breast-feeding had been declining since 1940. Promoting breast-feeding programs has been conducted since 1992 in Taiwan. Antepartal health education was part of the programs. 527 full-term-delivery puerperas were involved in this study. The purposes of this study were to explore the best predictive factors on breast-feeding attitude and feeding method after delivery and on one month after delivery. The results showed that (1) the relavant factor on the first aspect of breast feeding attitude-the mutual influence between breast-feeding and physical condition, was the subject's working status; (2) the family's approval, the doctor's suggestion, the labor pattern, and the working status were significantly related to the second aspect--the attitude about advantage and value of breast-feeding: (3) the subject's working status and the family's approval were the contributing factors to the third aspect--the attitude toward subsititution of formula. Factors affecting the subject's decision on feeding method after delivery included the previous breast-feeding experience, the attitude about advantage and value of breast-feeding, the family's approval, the attitude toward subsititution of formula, and the antepartal group health education. And the relevant factors on one-month-after-delivery feeding method included the family's approval and the subject's working status.
• 13 - 23
• 10.6288/CJPH1997-16-01-02

• Link 原著 Original Article
• 高雄地區大學生健康促進生活型態之預測因子Predictors Contributing to Health-Promoting Lifestyles among College Students in Kaohsiung Area
• 黃毓華、邱啓潤
  Yu-Hwa Huang, Chii-Jun Chiou
• 健康促進生活型態 ； 健康概念 ； 健康行為自我效能 ； 大學生 ；
  health-promoting lifestyles ; health conception ; self-efficacy ; college students
• 本研究以高雄地區三所大學院校562名二年級學生為對象，研究目的在探討健康概念、自覺自我效能、自覺健康狀態及人口學變項對大學生的健康促進生活型態的影響。研究結果可作為今後推展學校衛生教育的依據。研究工具有健康促進生活型態量表、健康概念量表、健康行為自我效能量表、自覺健康狀態量表及基本資料表。預試資料經信度及效度檢定，信度使用內部一致性信度及再測信度；效度使用內容效度、項目分析、因素分析。資料統計方法為皮爾森相關、二因子變異數分析、迴歸分析、線性結構方程式模式分析。結果發現：(1)健康概念、健康行為自我效能、自覺健康狀態分別與健康促進生活型態呈正相關。(2)健康行為自我效能、健康概念、及性別共同預測健康促進生活型態，可解釋之變異量達498.%；健康行為自我效能為最強之預測因子。(3)以結構方程式模式檢驗研究架構，健康行為自我效能對大學生健康促進生活型態的影響力最大，其次為健康概念、性別與自覺健康狀態，可解釋之變異量為50.4%。
  The purpose of this study was to investigate the effects of health conception, perceived self-efficacy, perceived health status and demographic variables on health-promoting lifestyles among college students. A causal model based on Pender's Health Promotion Model was also tested. Five hundred and sixty-two college students in Kaohsiung City were recruited to participate in this study. Five instruments were used to collect data: Health-promoting lifestyle profile, health conception scale, self-rated abilities for health practices scale, general health perception subscale and demographic data form The reliability and validity of these measurements were asessed based on Cronbach's Alpha, test-retest, content validity, item analysis and factor analysis. Data analyses were conducted by means of Pearson correlation, two-way ANOVA, multiple regression and CALIS. The main results indicated as following: (1) Health conception, Self-efficacy and perceived health status were positively correlated with health-promoting lifestyles. (2)According to stepwise multiple regression analysis self-efficacy, health conception and gender were the significant predictors which accounted for 49.8% of variance in health-promoting lifestyle. Self-efficacy was the most powerful predictor. (3) The causal model modified from Pender's Health Promotion Model fitted the data well.
• 24 - 36
• 10.6288/CJPH1997-16-01-03

• Link 原著 Original Article
• 台灣北部地區色情三溫暖之女性性工作者對愛滋病的知識、態度及相關行為之研究A Survey of Knowledge, Attitudes and Practices Concerning Aids among Female Sex Workers from Massage Parlors in Taiwan
• 陳宜民、張麗雅、任一安、傅瓊瑤、周碧瑟
  Yi-Ming A. Chen, Li-Ya Chang, Ian Jen, Chong-Yau Fu, Pesus Chou
• 後天免疫缺乏症候群 ； 人類免疫不全病毒 ； 知識態度行為研究 ； 女性性工作者
  Acquired Immunodeficiency Syndrome AIDS ; Human Immunodeficiency Virus ; KAP Study ; Female Sex Worker
• 性工作者是感染人類免疫不全病毒（簡稱愛滋病病毒）的高危險群之一。而其中無執照的非法女性性工作者常成為愛滋病防治上的死角。本研究乃針對在台北市、台北縣及桃園縣五家色情三溫暖工作的139位女性性工作者，調查其感染愛滋病病毒第一型、第二型與梅毒的情形，以及其對愛滋病的知識、態度與相關行為。結果發現研究對象無人感染愛滋病病毒，但有四人(2.9%)血清梅毒抗體呈陽性反應。在人口學特性方面，40%的研究對象年齡介於30~34歲之問；65%的教育程度在高職以上；29%已婚；23%離婚。 整體而言，女性性工作者對愛滋病的傳染途徑較為瞭解，對不會傳染愛滋病的知識則較為缺乏。在對愛滋病的態度三成份方面，認知態度較偏正向；情感方面，害怕感染愛滋病的態度則視不同情況而有所差異；行為意向方面，則屬中間偏正向的態度。態度三成份之間以情感與意向的相關最強，認知與意向的相關最弱。在愛滋病的相關行為方面，研究對象平均每月工作22天，74%平均一天接客4~6人，60%曾接過外國顧客。此外，只有42%女性性工作者會要求其男友或先生完全使用保險套，顯著低於其與一般顧客之完全使用保險套的比率(94%)。值得注意的是，32%與其男友或先生性交時從未使用過保險套。有25%曾經使用過鎮靜劑、安眠藥或靜脈注射麻醉藥品；76%曾接受過愛滋病毒血液抗體檢查。 在愛滋病的知識、態度及行為三者的相關性方面，愛滋病的知識與整體態度呈正向的關係，尤其是不會傳染愛滋病途徑的知識得分與對愛滋病在認知方面的態度呈有意義的相關。但研究對象的知識得分與其性對象的保險套使用率則呈負相關，尤其是與男友或先生性交的保險套使用情形與知識得分的負相關最佳。不過值得重視的是，在態度上害怕與先生或男友不戴保險套性交會感染愛滋病者，其與先生或男友保險套使用率較高；同時，對愛滋病認知危險性得分高者其主動接受愛滋病血液檢驗的比率亦較高；顯示要改變研究對象的行為，採用改變其態度的技巧可能較增加其愛滋病的知識更為有效。在影響研究對象對愛滋病之知識、態度與行為的因素方面，年齡與愛滋病知識得分有顯著正相關；但年齡愈大與先生或男友的保險套使用率愈低。教育程度為大專者，以及婚姻狀況為已婚者，與接受愛滋病血液篩檢有顯著相關。以上結果，可提供未來針對女性性工作者設計預防愛滋策略之參考。
  Commercial sex workers (CSWs) are at high risk for human immunodeficiency virus (HIV) infection. Because of their illegal status, unlicensed female CSWs deserve special attention with regards to AIDS education and prevention. In this study, 139 CSWs from 5 massage parlors in Taipei City, Taipei prefecture and Taoyuan prefecture were tested for HIV-1, -2 and syphilis infections and surveyed on their knowledge, attitudes and practices (KAP) concerning AIDS. The results showed that none of them had HIV-1/2 infection, while 4 (2.9%) had syphilis. Forty% of them were between 30 and 34 years old; 65% of them had senior high-school and above level of education; 23% were divorced; 29% were married. Although they demonstrated a good understanding of the routes of HIV-1 infection, many still had misconceptions about the infection. In terms of their attitudes toward AIDS, cognition tended to be positive, affection was dependent on the specific situation and conation was neutral to positive. The affection and conation elements of their attitudes had the strongest association and the association of cognition and conation was the weakest. In average, the CSWs worked 22 days per month. Seventy-four% of them had 4-6 clients per day, and 60% of them had foreign clients. In addition, only 42% of the CSWs consistently asked their boyfriends or husbands to wear condoms when they had sex intercourse, which was significantly lower than the rate of condom usage among their customers (94%). Thirty-two% of CSWs reported that their boyfriends or husbands have never used condoms previously. Twenty-five% of the CSWs have taken sedatives and narcotics. Seventy-six% of the CSWs had previously undergone the HIV-l blood test. In this study, there is a positive correlation between knowledge and attitudes toward ADS, especially the association between the knowledge of the ways in which HIV is not transmitted and the cognition element of the attitudes. There is a negative correlation between knowledge and the condom usage rates among those CSW's boyfriends and husbands. Nevertheless, condom usage frequencies by boyfriends and husbands were much higher among those CSWs who stated that they were concerned about contracting HIV-1 infection from their boyfriends or husbands if they did not use condoms. In addition, those CSWs who had scored higher on risk cognition had higher rate of seeking blood test for FIIV-1 infection. Finally, factors which related to the KAP of CSWs, including age, marital status and education level were analyzed. This study may provide valuable information for designing ADS education materials for female CSWs in Taiwan
• 37 - 51
• 10.6288/CJPH1997-16-01-04

• Link 原著 Original Article
• 出生方式對新生兒預後及母親罹病率之影響Effect of Maternal Risk Characteristics on Neonatal Outcome Correlated to Mode of Delivery
• 陳淑貞、藍忠孚、余玉眉、陸振翮
  Shu-Jen Chen, Chung-Fu Lan, Yuh-Mei Yu Chao, Jen-Her Lu
• 高危險妊娠 ； 剖腹生產 ； 母親罹病率 ； 新生兒預後
  High risk pregnancy ; Cesarean section ; Maternal morbidity ; Neonatal outcome
• 無
  This paper explores the associations among modes of delivery, maternal and perinatal outcome and risk factors of pregnancy. We examined medical birth register data of 18539 infants from 18249 deliveries admitted to ten delivery units from Feb. 1992 to Feb. 1993. After controlling the potential confounding effect of maternal and infant characteristics, the outcome measures of different modes of delivery were compared. Incidence of high risk pregnancy was 33.2% (n=6051); in this group, in comparison with vaginal delivery, cesarean section was associated with higher maternal morbidity (11.2% vs 3.4%; p<0.00l.), but lower neonatal morbidity and perinatal mortality (9.4% vs 28%, 0.8% vs 6.2% respectively; p<0.00l). Moreover, multiple logistic regression analysis showed vaginal delivery increased the perinatal mortality (odds ratio: 4.0.95% confidence interval: 2.5-6.2, p<0.01) and neonatal morbidity (odds ratio: 1.8.95% confidence interval: 1.4-2.4, p<0.001) but decreased the materal morbidity (odds ratio: 0.24, 95% confidence interval: 0.18-0.32. p<0.00l). In non-high risk preganancy (n=12198), cesarean section was also associated with higer maternal morbidity (3.7% vs 1.2%; p<0.001), but for neonatal morbidity and perinatal mortality there was no difference with different modes of delivery In conclusion, cesarean section was associated with a better birth neonatal outcome in high risk pregnancy; however, it raised maternal morbidity without improving the neonatal outcome in non-high risk pregnancy.
• 52 - 61
• 10.6288/CJPH1997-16-01-05

• Link 原著 Original Article
• 台灣的乳癌Breast Cancer in Taiwan
• 季瑋珠、 黃俊升、張金堅
  Fei-Wen Liu, Chin-Hua Chiou, Ming-Chin Yang
• 乳癌
  breast cancer
• 臺灣的乳癌發生率及死亡率逐年上升，重要性日益增加。已有的流行病學研究顯示都市、北部地區、外省籍、未婚者、高社經地位、初經早、生育子女數少、初次懷孕較晚、50歲以後體重較重者，罹患乳癌的危險性較高。停經與是否哺乳對乳癌的危險性沒有顯著的影響。病理學方面，乳癌多發生於乳房的外上區，經常有皮膚變化，顯微鏡下最常見者為浸潤性線管癌(infiltrating ductal carcinoma)。臨床表徵方面最常見者為無痛性乳房腫塊，腋下淋巴結腫大，乳頭凹陷，乳頭異常分泌，皮膚橘皮化或下陷等。檢查與診斷方面，大多乳癌為由病人自己發現，但由於國人認知不足，治療時只有19.7%小於或等於2公分。正確的乳房自我檢查應為目前婦女衛生教育的重點。乳癌的診斷方法有乳房X光攝影、超音波乳房檢查、細針抽取細胞檢查等，國內已有的研究顯示超音波乳房檢查敏感度、精確度往往高達80%以上，並不遜於乳房X光攝影；而細針抽取細胞檢查更可直接觀察細胞的變化，降低偽陽性及偽陰性率，幾乎可作為確診工具。乳癌的治療國內目前以修正式的乳房根除術為主，局部切除之保守療法輔以放射線治療，亦有許多醫院在嘗試進行。輔助療法則包括放射線治療（五週內給予4500-5000cGy）、化學治療（CAF，CMF等）、與荷爾蒙治療（tamoxifen，荷爾蒙接受器陽性者效果較佳）。預後方面，第一期的五年存活率高達92.9%，第二期80.5%，第三期48.5%，第四期18.5%；合併手術化學和荷爾蒙治療之五年和十年之局部復發率分別為14±2%與23±4%，唯追蹤流失較多，對預後可能有所高估。腫瘤荷爾蒙接受器、增殖能力、DNA倍子數、淋巴腺轉移的情形是預後之重要影響因素。乳癌之治療因涉及婦女之身體形象，除手術後之身體復健外，心理復健與壓力調適亦為重要課題。根據已有研究的回顧，吾人建議對婦女進行乳癌預防及乳房自我檢查之衛生教育，並對50歲以上婦女每年進行一次乳癌篩檢，在治療上訂定標準化之治療方式，並進行更深入之乳癌之流行病學、篩檢、治療等之本土性研究。
  The incidence and mortality of breast cancer is increasing in Taiwan. Previous epidemiologic studies found that the following women have higher risks: those living in urban area, northern part of the country, Mainlanders, unmarried, having high socioeconomic status, early menarche, low parity, late first full term delivery, and higher body weight after 50 years. Pathologically, breast cancers are more likely to develop at the upper outer quadrant of the breast. Infiltrating ductal carcinoma is the most frequent microscopic finding. Clinically painless mass, axillary lymph nodes enlargement, depressed nipples, abnormal nipple discharge, and skin change are most common appearances. As a result of inadequate knowledge, tumor sizes are usually large when the patients were treated. Only 19.7% of the tumors were not more than 2cm. From previous studies, the sensitivity and specificity of breast sonography are not less than mammography. Fine needle aspiration cytology can get the tissue directly, and has high sensitivity and specificity. It can be viewed as a confirmative diagnostic tool. Modified radical mastectomy is the main stream of breast cancer treatment. Conservative surgery combined with radiotherapy also showed rather good result in early stages. Adjunct therapy includes radiotherapy, chemotherapy and hormone therapy. The prognosis of breast cancer depends on stages. The five-year survival rates of the first to the fourth stage are: 92.9%, 80.5%, 48.5%, and 18.5%. Five- and ten- year local recurrence rates of combined therapy are 14±2% and 23±4%. These rates might be underestimated because of a large number of loss of follow-ups. Hormone receptor concentration, proliferative capacity, DNA aneuploid, and lymph node metastasis are important predictors of prognosis. In addition to physical treatment and rehabilitation, psychological rehabilitation and stress coping are also very important for this disease because of its influence on women's body image. According to the literature reviewed, the authors suggested to promote BSE education, to perform periodic breast cancer screening for women above 50, to establish standardized treatment protocol, and to do more researches on epidemiology, screening and treatment of breast cancer in Taiwan.
• 62 - 76
• 10.6288/CJPH1997-16-01-06

• Link 原著 Original Article
• 消費者基金會醫療爭議案件之分析研究A Study on Medical Disputes Handled by the Consumers' Foundation in Taiwan
• 劉斐文、邱清華、楊銘欽
  Fei-Wen Liu, Chin-Hua Chiou, Ming-Chin Yang
• 醫療爭議 ； 醫療過失 ； 消費者抱怨行為 ； 爭議處理 ； 消費者保護
  Medical dispute ; Medical malpractice ; Consumer complaint behavior ; Dispute processing ; Consumer protection
• 本研究以消基會歷年來受理之醫療申訴個案進行調查與分析，寄發203份問卷，得有效問卷100份。重要結果：受訪者面對醫療服務上的不滿，所採取的抱怨行為中，以私下抱怨的傾向最強，向消基會申訴的傾向居次。受訪者中以年齡較大、女性病人、曾有策略性互動、該醫療問題造成病人身體殘障或精神失能、家人或親朋認為錯在醫方者，其抱怨傾向較強。雖然受訪者對消產會的服務，整體而言並沒有顯著的期望差距，但若依照其情境加以分析，則認為醫療抱怨風險越高、對醫療服務的實際感受越差、因與醫師承諾不符而認定有問題、所認定的問題為不良反應、該問題造成病人身體殘障或死亡、自評後果嚴重、親朋認為錯在醫方、家人或非此次問題相關的醫事人員支持求償、由參考團體得知消基會醫療中訴單位者，對消基會服務的期望差距較大。本研究並根據調查結果及相關文獻之研究結果，對醫療服務提供者及消基會提出具體建議。
  This study surveyed and analyzed all the cases ever filed complains to the Consumers Foundation because of medical disputes. Out of 203 questionnaires that were mailed out, 100 valid responses were received after two reminding postcards. Important findings are as follows: When dissatisfied with a medical service, the most frequently action taken by respondents was to complaint privately, followed by to report to the Consumer's Foundation. Among the respondents, those ho were older, being female patients, being physically disabled or mentally retarded because of the medical malpractice, having taken strategic interactions, those whose significant others thought the medical staff were to he blamed, had stronger intentions to complain. In terms of respondents satisfaction toward the Consumers' Foundation, the overall difference (gap) between the respondents' expected and actual services received from the Consumer's Foundation was not statistically significant. However, further examination on the respondents' characteristics showed that those who thought the risk to complain was high, those who perceive the medical services were poor, the results were different from what the physician promised, the treatment resulted adversely, the malpractice resulted in disability or death, those who valued the effects were serious, those whose relatives thought the medical stall' were to be blamed, those who were encouraged by their family or other medical practitioners to ask for compensation, and those who knew about the Foundation through their reference group, had worse perceptions about the Foundation's services, Suggestion to medical providers and the Consumers' Foundation were included.
• 77 - 85
• 10.6288/CJPH1997-16-01-07

• Link 原著 Original Article
• “組合”乎？“市場”乎？－從台灣變遷中社會的屬性探索全民健保的體制Is It Associations or Market?-In Search of a National Health Insurance Model in Light of Taiwan's Changing Society
• 陳孝平
  Michael S. Chen
• 全民健保 ； 利益團體 ； 競租
  national health insurance ; interest groups ; rent seeking
• 全民健保法的規劃，秉持著「經濟學主義」，在技術層面上相較過去之社會保險有明顯之進步，然而因忽視了「社會面向」及「政治面向」，以致在立法及實施的過程中遭遇到許多橫逆。此緣台灣在解嚴之後，社會力倏忽解放，利益團體風起雲湧，而健保規劃當局未能體察台灣社會的屬性已大異往昔，未致力在法案設計中，建立協和利益衝突的機制，實有以致之。 社會保險因可操作的政策工具有限，而所欲達成的目標眾多，具有「過度認定」的本質：滿足了某些團體，就可能使其它團體的目標落空。在過去威權時代，國家的強制力量可貫徹由官僚制定的政策，然民主化之後，則問題的解決若不是依靠利益團體之問在平等、互惠、長期、持續的原則下協商，就只有委之於市場。前者藉「共治」的機制使利益協和，須有「同舟共濟」的意識；後者雖免於徒須由政府裁斷的問題，然而卻難免產生公平等問題。 「共治」的整合主義模式雖為一相對優良之健保組織模式，然而其前提是該社會必須為一「命運共同體」。若台灣因故無法具備整合主義之條件，或受貿易自由化、產業外移、外勞進入等影響，致無法維護固定的社會疆界，而不能依整合主義建構全民健保模式時，則管理式市場模式即可能成為明知有缺點，但仍不得不接受的最後仰仗。因為捨此而就國家模式，在政府業已無力主導政策時，很可能因無法應付利益團體之索求而陷入財政危機。
  The National Health Insurance Act, passed July, 1994, is a victory of economism and scientism, yet spelled a failure of political economy: Taiwan has entered the post-Confucian era and the civil soiety has unleashed its pent-up power, yet the Act still reserves too many authoritarian elements. In particular, the Act lacks in mechanisms for interest reconcilliation, and leaves too much discretionary power in government's hand. Government, therefore, rendered itself victim of rent-seeking advances from various interests. A social insurance program often features too many goals and too few tools and therefore, while some segments of the population may be served, many more may be dissatisfied. In the past when Taiwan was still under the Martial Law, it was easy to enforce any social policy through the coercion power of the state; yet in a democratized society, the social order can be maintained only through market or a corporatist structure in which negotiations are conducted based on principles of parity in power, mutual benefit, long term, and multi-issue. A market model may be free of direct intervention from the state, but could entail problems of inequality; and a corporatist model can not do without codetermination and solidarity. Corporatism based on codetermination is arguable a better model for social cohesion; yet, the precondition is that the society must be a community of common fate, or a society whose boundaries are fixed. Should Taiwan, under impact of globalization of economy, outflow of industries, and inflow of alien labor, can not keep its boundaries unchanged, the corporatist model might not be feasible. A market model, then, becomes a last resort, since the inability of the state to contain interest contlicts might render a social insurance program a ”welfare trap”.
• 86 - 108
• 10.6288/CJPH1997-16-01-08