“医改市场化”辨析Medical Reform: How Is It Oriented to or by the Market?

文、译/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 “laws” 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”. ■

普遍认为，近年来的医疗改革是不成功的，体现在看病难、药价高、医患关系紧张等。究其原因，有专家认为是其改革的市场化1对此有许多译法，除marketization外，还有general adoption of the market principle、something marketable等，而标题更由于“辨析”而具体处理成“Medical Reform: How Is It Oriented to or by the Market?”。不够。但我却以为，并非如此简单2一般可译成“maybe not be sosimple”“…that it is not that simple”等，这里稍作变通。。

[2]在海外十余年后回国，有一突出感觉，就是媒体上泛滥3这里的flooded由自然现象转意，更口语化些，其他还可用inundate、widespread、awash等。如：①A visit to Japan may not be necessary to understand how inundated Japanese pop culture is with Western Culture.（无需到日本，便可知道西方的影响在那里的流行文化中有多么泛滥。）②He said he’d seen no evidence of widespread fraud.（他说并未见诈骗泛滥的证据。）③The city is awash with drugs.（该城市毒品泛滥。）的医药广告，与西方形成强烈反差。在那里，医生按病情开药，药行按医生处方供药，根本无需广告，而药价、药售与医生无关。国内的医生则不然，他们还要担负起“以药养医”4其意为“以医生的劳动来实现药品的高附加值，以药品的高利润拉动医院的经济效益，维持医院的正常运转”，直译为to cover hospital expenses with medicine revenue，一般可译成drug-maintaining-medicine，但provision用作动词时有“providing someone or something with …”之意，故用此词。的重任，以维持经营，提高收入。窃以为，这就大错特错了。

[3]医生的天职是看病、医治、救人，在这一点上，医生与病人的根本目的是一致的5有多种译法，如“fundamentally… all agree ...”“be basically consistent with”等，甚至可变通为“after all, …have the same dream and ultimate value”等，取决于具体语境。。医生的回报和成就感，应当仅仅从治疗病人的成效中获得，而一旦掺入其他因素，必然带来根本性质的变化。

[4]医学不是一般的自然科学，要与人打交道，故是一种特殊的社会文化。有专家指出，当前医患关系紧张6亦可译成tentional doctor-patient relationship，或变通为physician-patient relationship has been intensi fied等。的原因，在于医生与病人不成比例；病人耗时费力来见医生，得到的却是几分钟的诊疗，因目前许多医院的医生每天每人要诊治几十甚至更多例病人。固然，这是问题之一，但根本原因在于，病人怀疑医生的目的不纯7不宜简单地译为impure purpose/intention，而是一种不信任（distrust），特别是结合后面的“治病”与“创收”而言。，即不是在治病，而是在“创收”。

[5]医生与病人的关系，正如教师与学生、律师与被告，二者处于专业和信息高度不对等状态，要想从被服务者身上牟利，易如反掌8通常可译为as easy as pie / to turn one’s hand /winking等，但此处根据语境对句式作了较大调整，译出其实质所指为“… in an extremely vulnerable position to be ripped off”，同时将“服务者”具体化为patients，做主语。，所以必须切断二者之间的利益链条。治病救人，固然是一种服务，但却不同于一般的商业性质，而与人道、人权相关联，所以需要政府主要担当职责；在这个意义上讲，医疗不可市场化。在西方主要国家，也正是这样做的，如澳大利亚，政府拿出国民收入的4%作为大众基本医疗保险9通常为medical insurance、hospitalization insurance等，但许多西方国家实行的是medicare制度。，人人有份。

[6]在西方，医生10“医生”平时说成doctor、physician、medical practitioner、surgeon (外科医生)，但指职业时应为profession、medicine等，如：①他的职业是医生，业余写小说。（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，有才华的年轻人通常去学医学、法律及工程专业。）是个备受尊敬、收入颇丰的职业，这又与国内形成强烈反差——医生可以被随意打骂甚至杀害！我的几个朋友，都决然反对子女学医，有的医学院毕业后，也都改行不做医生。这又与市场规律11市场的本质是交换；任何“市场”都是商品市场，其内在的价格机制、供求机制、竞争机制、决策机制等就形成了市场规律。一般可译成market mechanism、market discipline、market forces、market law等，而“按市场规律办事”为按市场规律办事follow/according to market rules/laws等，因这里加引号为 the “laws” of the market，以特有所指。不相符合：既然医生奇缺，医疗资源宝贵，其身价12这里一般是指social status，而“提高身价”为have a rise in social status；因与后面的“精神与物质”相关联，故分解为“in both status and financial appreciation …”以更明确。（精神与物质）应与之俱增才是，但现实却相反。究其原因，是政府控制住了源头，即开设医院的数目、规格、地点等仍是以“计划经济”为主导，那只“看不见的手”仍不起作用。

[7]再者，医生是一种天然13一般为naturally、should be、suppose to be、logically等，这里用by nature指明其工作性质。的个体职业。国外的实践证明，根据供求关系，允许私人医生开业，政府管控医生素质、医疗条件，可以有效缓解医患比例失调，而这在国内又举步维艰14通常指“很难从事”，如：① His move has made life very dif ficult for his employees.（他的这一招使得员工的日子举步维艰。）②经济改革仍将举步维艰，毫无成效。（Economic reform has so far been painful and ineffective.）③The Chancellor could face a rough ride unless the plan works.（除非这个计划能够奏效，否则财政大臣将举步维艰。）这里则用a painfully slow process描述中国当前医改的具体情况。，难以按市场规律行事。

[8]可见，目前医改的症结不能笼统地归结于缺乏市场化15如前所述，不可简单译成lack marketization，而可具体为market mechanism功能。，而应具体分析：不该市场化的市场化了16此句及下句都不宜按字面意思逐字译出，那样不但笨拙，而且难以指明；… has taken place in the wrong areas. 虽显笼统，但含义已明。，该市场化的则没有市场化。所以，对此亟需正本清源，总体调整，从而真正做到“标本兼治”。 □