Inter-pill-ation and the instrumentalization of compliance
Inter-pill-ation and the instrumentalization of compliance
复制标题
互丸和合规工具化
作者：
J. Dumit
这本由卡尔曼·阿普鲍姆和迈克尔·奥尔达尼编辑的关于顺从的新人类学的合集说明了在当代生物医学的每一个层面上，仔细的、反思的定性研究的持续重要性。依从性本身就是一种评估健康结果趋势的官僚分析，从一系列令人印象深刻的方向和方法进行研究。通过民族志、调查、访谈、修辞分析和叙述技术对护士、医生、青少年和老年患者、非政府组织、家长和大学生消费者进行研究；这些疾病包括癌症、结核病、抑郁症和糖尿病。从这个广阔的网格中，出现了一系列非常一致的见解或预兆，这些见解或预兆表明，一场合规危机是最悲惨的，因为它几乎无法登记。依从性作为一种衡量病人是否遵守规定治疗的措施的有用之处在于，它能够对治疗成功进行索引，从而有助于确保和管理健康。然而，这些人类学家发现，由于其作为一种指标的功能，顺从性本身就被工具化了，有时被用来服务于与健康相去甚远的目标。最令人着迷的是，不仅仅是制药公司和保险公司——资本化药品的标准麻烦——参与这种合规工具化，而且它正在全面发生，严重的精神病患者、结核病治疗者、医生和护士都在这样做。这组文章以一种令人惊讶的方式证实了古德哈特定律（Goodhart’s Law）。古德哈特定律是以这位经济学家的名字命名的，他的发现是：“任何观察到的统计规律性，一旦为了控制目的而施加压力，就会趋于崩溃。”换句话说，当奖励或惩罚的目标是一个指数而不是结果时，行为会迅速转向最大化指数，而不考虑结果。玛丽莲·斯特拉森（Marilyn Strathern）在她关于审计文化的著作中向人类学家指出了这一现象，因为它严重影响了我们自己的学术研究，因为我们被要求达到绩效指标，这些指标很快就会有自己的生命。正如斯特拉森（2000）所说，“这很简单：你把测量系统变成一种装置，它也设定了理想的成就水平。”简而言之，审计措施成为目标。这本书中最可怕的例子是奥尔达尼的发现，直接根据医生的依从性数字奖励医生，几乎会立即使他们的注意力从对患者的最佳护理转移到患者依从性得分的相对价值上。这使得一些病人不值得治疗，而另一些值得治疗
This collection on new anthropologies of compliance edited by Kalman Applbaum and Michael Oldani illustrates the ongoing importance of careful, reflective qualitative research in contemporary biomedicine at every level. Compliance – itself a bureaucratic analytic for assessing health outcome trends – is studied from an impressive array of directions and methods. Nurses, doctors, adolescent and senior patients, NGOs, parents, and college student consumers are researched via ethnography, surveys, interviews, rhetorical analysis, and narrative techniques; and the illnesses considered include cancer, TB, depression, and diabetes. Out of this wide grid emerges a remarkably consistent set of insights, or omens, of a compliance crisis that is most tragic because it almost unregisterable. Compliance’s usefulness as a measure of prescribed treatment adherence by a patient has been its ability to index treatment success, and therefore help in ensuring and governing health. What these anthropologists have discovered, however, is that because of its function as an index, compliance has been itself instrumentalized and made to serve goals sometimes quite far from health. Most fascinating is that it is not only pharmaceutical and insurance companies – the standard bugbears of capitalized medicine – that are engaging in this instrumentalization of compliance, but it is happening across the board, by the severely mentally ill, TB treaters, doctors and nurses. In a surprising fashion, this collection of articles verifies Goodhart’s Law, named after the economist whose finding was that ‘Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes.’ In other words, when rewards or punishments target an index rather than the outcome, actions quickly migrate toward maximizing the index independent of outcomes. Marilyn Strathern pointed anthropologists to this phenomenon in her work on audit culture, as it grossly affects our own academic scholarship as we are asked to meet performance indicators that quickly take on a life of their own. As Strathern (2000) put it, ‘It is very simple: you turn the system of measurement into a device that also sets the ideal levels of attainment. In short, audit measures become targets.’ The most frightening example of this in this collection is Oldani’s discovery that rewarding doctors directly for their compliance numbers almost immediately perverts their attention away from best patient care toward the relative value of that patient’s compliance score. This renders some patients not worth treating and others worth