物語りに基づく医療(Narrative-Based Medicine)の発展可能性に向けた医療人類学の取り組み : 証言に基づく医療の事例紹介(心身医療におけるエビデンス・ベイスト・アプローチとナラティブ・アプローチ:理論・実践・研究,シンポジウム,第47回日本心身医学会総会)  [in Japanese] Approach to Elaborate on a Key Concept of Narrative-Based Medicine : A Case Study on Witness-Based Medicine in Qualitative Research of Medical Anthropology(Symposium/Evidence-based Approach and Narrative Approach in Psychosomatic Medicine: Theory, Practice and Research)  [in Japanese]

近年,心身医療における物語りに基づく医療(narrative-based medicine; NBM)に関する研究では,病者の語りを質的に分析していく意義が理解されつつある.医療人類学によるNBM研究への貢献の一つは,病いの語りの質的調査において,病者・医療者・調査者間の交感的な関わりを含めた相互作用を理解しようとする点にあるだろう.病いの語りの医療人類学研究では,質的調査の中で生じた相互作用を考慮しつつ,病者の生活世界を精緻に理解しようとするからである.今回の報告では,精錬された病いの語りは病者の証言(witness)であり,その証言が証人である医療者と外部の第三者から確認されていくことが,NBMの実践においてきわめて重要であることを提示したい.本報告における証言は,全人的医療の理解に貢献し,NBM研究における重要な概念と考えられるからである.病者・医療者・第三者の相互作用は,病いの語りを精錬させ,病者が病いの専門家としての自負をもち,医療への過度な依存から脱していく臨床プロセスが確認される可能性がある.ここで問うべきは,病者の個人的経験に関する証言は,心身医療における治療の根拠となるのか,という点であろう.医療人類学は,病者の証言の理解を通して,NBMのあり方について根源的な問いを投げかけている.

Objectives: The purpose of this report is to show a key concept of Narrative-Based Medicine (NBM) through qualitative analysis of interactions between the patient, a doctor and a third person. We will now need to consider a plasticity of illness narratives more closely to understand this interactive relationship. Subjects and method: Illness narratives were collected from 20 outpatients at a clinic in Tokyo. From March 2000 to August 2000, we conducted non-structured interviews intensively to examine illness narratives. The subjects of this study were 5 patients who were placed in the 3rd stage of the Four-stage model (Table 1). This study adopted the qualitative research method from an anthropological point of view because it was necessary to mention the influence of researchers upon their subjects. Results: It has been recognized by our research that there is a process to refine illness narrative (Fig. 1). In the 3rd stage of the Four-stage model, patients become an expert of illness experience while medical doctors remain as a specialist of disease. Furthermore, we examined a key concept in NBM. We found that there are 3 aspects of witness in the 3rd stage (Fig. 2); (I) illness narratives of witness, (II) medical doctor as a witness person for their illness narratives, (III) researcher or family member as a second witness person for doctor-patient relationship. Conclusion: We found that each interaction among 3 aspects could be considered indispensable in order to conduct NBM effectively. It is sure that to witness a patient's daily life is one of the most important elements in NBM. Therefore, we named the interaction among 3 aspects Witness-Based Medicine.