長期照顧的論戰：從Foucault治理性的概念檢視老人長期照顧

Abstract

台灣人口老化的速度很快，因而從1990年代開始冒現出老人長期照顧的問題，對於治理權力而言，如何治理「老人國」為它的首要任務。本研究試圖將國家治理權力與老人間的關係問題化，探究治理權力如何問題化老人的長期照顧，並在其中又透過如何的權力─知識關係，制定相關政策以導引老人的照顧實作。在如此的意義下，治理權力對於老人圖象與照顧定義的範疇化至關重要。據此，本研究將老人長期照顧論述分為「生活邏輯」與「醫療邏輯」兩種邏輯，藉由系譜學不僅勾勒兩種邏輯的論述鬥爭，分析老人圖象與照顧定義的更迭，也梳理治理權力如何運用老人圖象及照顧定義導引老人長期照顧。據此，本研究有以下的研究發現：首先，在1990年代，生活邏輯與醫療邏輯的鬥爭以「在地老化」與「護理之家照顧論述」間的鬥爭呈現，鬥爭的結果最後以護理之家照顧論述的暫時勝利作收，治理權力以「機構收容」的治理技術，將老人視為病人，聚焦於老人的身體狀況，老人需要醫療監控和生活照顧。接著於2000年代，生活邏輯獲得機會進入政策場域，藉由「生活邏輯的回歸」，促使治理權力的「生活邏輯轉向」，進而常態化為治理的圭臬，依循生活邏輯的治理權力構築出「生活恢復」的治理技術，將老人視為自主主體，注重「生活導引」，自主生活成為老人適宜的生活方式。然而，於2007年後，生活邏輯產生問題，受醫療邏輯與機構照顧論述批評，生活邏輯為了捍衛它的正當性，冒現出有別於生活恢復的治理技術：「預防政治」。預防政治導引老年人口規避長期照顧的風險，因而不僅將老人視為風險主體，老人也作為自主主體，健康促進成為適宜老人的生活方式。當梳理完兩種邏輯間的鬥爭歷史後，本研究批判性指出治理權力與老人心理無效感之關係，並提出「照顧異化」概念，對於治理權力下的照顧實作進行初步反思。最後本研究也批判性地檢視台灣長期照顧治理的問題，並對此提出相關的政策建議。

The elderly population is rising quickly in Taiwan. Therefore, the problem of elderly long term care emerges since 1990s. In this sense, it is important for governmental power in Taiwan to govern “the kingdom of elderly”. This thesis attempts to problematize the relation between governmental power and elderly people, and tries to investigate how governmental power problematizes elderly long term care. In studying this, this thesis analyzes how governmental power uses power/knowledge relations to make long term care policies and conduct practices of elderly care. In this sense, it is crucial for governmental power to categorize image of the elderly and care definition. Therefore, this thesis divides discourses of long term care into two ideal types: “logic of life” and “logic of medicine”. Through the method of genealogy, this thesis not only sketches the discourse struggles between “logic of life” and “logic of medicine” which produce the historical changes in image of elderly and care definition but also analyzes how governmental power uses them to conduct elderly long term care. Based on these assumptions, this thesis has the following research findings. First, the discourse struggle between two logics in 1990s appears in the form of struggle between “aging in place” and “nursing home care”. In the end, the discourse of nursing home care temporarily wins over the discourse of “aging in place”. Based on the temporary victory of “nursing home care”, governmental power utilizes “institutional containment” as governmental technique. This practice of “logic of medicine” focuses on body condition of the elderly. It categorizes the elderly as patients who need detailed medical monitoring and life care. Then, the logic of life gets an opportunity to participate in policy-making in 2000s. This produces “the return” of logic of life, and even results in the “turn” of logic of life in governmental power. Thus, we might find that since 2000s governmental power utilizes “recovery of life” as governmental technique. It takes the elderly as autonomous subjects who need “conduct of life”. In this sense, governmental power focuses on the elderly’s proper way of life and tries to conduct the elderly to lead a autonomous life. However, the logic of life produces many problems after 2007. Therefore, it is criticized by institutional care and logic of medicine. Faced with this situation, logic of life attempts to maintain its legitimacy in long term care field. Hence, it emerges new governmental technique: “politics of prevention”. Politics of prevention conducts the elderly to avoid the risk of long term care. Health promotion becomes the elderly’s proper way of life. We might find that this new governmental technique not only sees the elderly as risky subjects but also autonomous subjects who autonomously promote his/her own health. After sketching the struggle history between two logics, this thesis attempts to point out the relation between governmental power and the elderly’s sense of incompetent. Also, this thesis tries to problematize the long term care practices, and proposes the concept of “alienation of care”. Finally, this thesis examines the governing problems of long term care in Taiwan, and tries to propose relevant suggestions.