職災補償的科學與政治：以台灣的精神疾病職業病認定爭議為例

Abstract

議題背景：近年來，隨著新興的勞動體制與工作型態的轉變，工作者的壓力與心理健康問題成為重要的公衛議題；在勞工團體的積極倡議之下，政府也已將工作引起之精神疾病納入台灣職災補償之職業病認定範圍。然而，職業疾病的認定過程中，在資訊不清、風險不確定性與因果難以判斷的情況下，如何公平地給予補償，往往引發勞、資、醫、政等各方的爭議與不信任。在爭議當中，醫學診斷與專家鑑定機制對於因果關係論證與科學知識的詮釋，時常成為各方爭辯的核心焦點。 研究目的：本研究以我國精神疾病認定為職業病的知識爭議與鑑定實務為例，從社會研究的角度，旨在探討知識論述與實務爭議背後的科學知識與權力運作脈絡，如何影響因果判斷與責任歸屬，並進一步釐清當前爭議的根源，並試圖指出當前制度可改善的面向。 方法：2009年2月至2010年5月，本研究訪談14位職業醫學科醫師、11位精神科醫師、2位勞委會承辦相關業務之官員，與3位勞工團體成員。研究亦非正式訪談蒐集資料，並參考醫學會與政府的檔案公告、會議紀錄、政府機關的衛生與勞動統計、判決文書等多元資料。 研究結果：本研究結果包括以下三個面向。首先，本研究以精神疾病的職業病認定爭議為例，凸顯因果關係不易釐清的疾病，由於潛伏期長，暴露危害資料不易取得，若僅依據流行病學與科學原則進行因果判斷，往往不利於處於職場弱勢的工作者；當前精神醫學與流行病學研究過度強調個人危險因子，傾向於譴責受害者。其次，本研究指出，科學知識與證據乃是政策的行動基礎，但科學知識的生產、應用與詮釋往往受到專家所處的社會位置所影響；例如，台灣市場化的醫療生態、社會保險給付制度，以及組織內的利益衝突，深刻地影響醫師對職業傷病問題的診斷認定。第三，研究者檢視職業病診斷與鑑定過程的運作實務，發現目前我國的職業疾病鑑定過程由醫學專業人士主導，但由於國家長期以來缺乏完善的職場健康監測與調查機制，使得鑑定運作過程易受到各種參與者的價值判斷、利益衝突以及政治折衝的影響，不僅扭曲科學評估的專業性，也產生層出不窮的政策爭議與倫理問題。 結論與建議：職業傷病因果關係的確認，並非僅是單純的技術問題，更是涉及職業健康風險如何分配的價值判斷。在職業病認定過程中，職業醫學專家不僅面臨對其專業的質疑與挑戰，也同時面對諸多社會性的價值選擇與利益衝突。針對目前的職業病認定制度，本研究建議可改善以下面向：（1）成立專責於職業傷病診斷、調查與鑑定的公營且獨立運作的機構；（2）認定過程中納入多元利害關係人，包括勞工代表、社會團體、其他專業人士；政府並應匯整公布鑑定案例之內容與統計數據，以透明、公開與負責的運作模式，強化社會各界對此認定過程的信任。職業病認定制度的改善，不僅能保障工作者的健康權益，同時緩和社會衝突，強化政府的公信力與正當性，亦應有助於職業醫學的發展。

Background： In recent years, along with the rapidly changning nature of work environment and employment practices, stress-related health problems in the workplace have become important public health concerns. In response to growing pressure from labor advocacy groups, the government has included work-related mental disorder as one of compensable diseases in Taiwan’s workers’ compensation system. However, due to insufficient exposure data, uncertain health risk and ambiguous causal relationship, the recognition of work-related mental disorder has always invoked controversies and conflicts among medical professionals, employers, employees and government officials. The controversies have mostly centered on the medical diagnoses and causal inferences based on scientific research. Aim：From Social Studies of Science approaches, this study was designed to explore how the power relationships and social context influence the process of recognition of work-related mental disorders This study aimed to provide a better understanding of the nature of scientific knowledge as well as its role in current workers’ compensation system in Taiwan. Methods： During the period from February 2009 to May 2010, the researcher conducted interviews with 14 occupational medicine physicians (of them 6 had been appointed by the Council of Labor Affairs as arbitrators of the Recognition Committee of Occupational Diseases), 11 psychiatrists,2 government officials and 3 labor rights activists. The researcher also reviewed publications, reports, conference proceedings and records, official statistics and court verdicts from a variety sources, including the archives of the government and the medical associations. Results：The results of this study were presented in the following three parts. First, using mental disorders as an example, this study highlighted the problems and limitations of current epidemiologic knowledge, which could hardly support workers’ claims for worker compensation. The limitations were not only due to the long latency of disease and insufficient exposure data, but also due to the dominant individualistic ideology in most epidemiologic research which tend to focus on individual risk factors and lay responsibility of health risk on individuals.Secondly, the results also revealed that the social positions of the scientific experts greatly influence the production, application and interpretation of scientific evidences. For instance, physicians were often discouraged or caught in conflicts of interest when making diagnoses for occupational diseases, because in Taiwan most physicians were employed in market-oriented private sectors. In addition, the current health insurance payment schemes did not provide enough incentives for physicians to make diagnoses for occupational diseases. Finally, the investigation into the reviewing process for occupational diseases also found that the decisions were often made behind closed doors and by a few of medical physicians. However, in the absence of occupational surveillance and investigation mechanisms, these medical professionals actually have limited scientific evidences to rely on. The decisions were often influenced by personal value and intersts or by external political contests. Conclusion：This study indicated that the recognition of occupational diseases involves not only technical issues, but also value judgments concerning the responsibility for health risks in the workplace. When making diagnoses for occupational diseases, medical professionals are often challenged with regard to their professional competency as well as social and ethic integrity. To improve the current systems for recognition of occupational diseases, the author proposed the following: （1）Governments should set up a public-funded and independently functioned institute which is specialized in occupational health services including work health surveillance, health management, and dispute investigation as well as diagnoses for occupational diseases; （2）The decision making process for the recognition of occupational diseases should involve multiple stakeholders, including labor representatives, civil rights activists, and other non-medical professionals. In addition, verdicts and other relevant data should be compiled and disclosed for public’s scrutiny. The improvement of the recognition processes would improve workers’ health right, help to alleviate social tensions and strengthen accountability of the government. It might also help to enhance the development of occupational medicine in Taiwan.