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Troubled Bodies
Critical perspectives on postmodernism, medical ethics, and the body
By Paul A. Komesaroff Duke University Press
Copyright © 1995 Duke University Press
All rights reserved.
ISBN: 978-0-8223-7978-2
CHAPTER 1
Divide and multiply: culture and politics in the new medical order
Doug White
To whom does one go if unwell? There is a wide choice close to where I live. There are a pharmacist, a newsagent, a firm of doctors, a bunch of assorted practitioners at the local sports medicine clinic, a community health center, several naturopaths, a chiropractor, a transcendental meditation center ("no worries," it advertises), and several psychologically trained therapists, and it is not very far to the nearest public hospital. No doubt this list could be added to, and anyone who lives in an Australian city almost certainly could access similar resources. Of course, there is a prior question before the one of "Where do I go?": How do I know I am unwell? Limitations on advertising by some practitioners means I am not as well advised here. According to locally prominent billboards, I'm not at my best if I get drunk or smoke or go outside without a hat, a shirt, and a slop of some greasy skin covering. Further advice comes from the magazines at the news agency. While I haven't researched this area fully, I think it is quite possible that I am overweight, not well-tuned, and have skin and hair problems and that my sexual aura needs some attention. A woman would, I gather from what I have heard and read, be told of even more health problems.
There is something worth commenting on here. The enormous variety of healthmongers offers a great choice, and this is sometimes equated with a high degree of personal autonomy. No longer do I have to be satisfied with one form of medical practice, as was once the case, in a neatly graded hierarchy: specialist doctors, general practitioners, nurses, chemists. No longer do I have to enter the treatment area through one door, that of the general practitioner. The field is no longer quite so hierarchically structured, and certainly it is not governed by a single mode of theorizing; scientific medicine no longer is the only kind there is. That is how it seems. Yet the past wasn't quite as uniform as I have just presented it. I well remember a member of my family being taken to a faith healer many years ago, and there were all kinds of belief about of the efficacy of certain masseurs and other assorted cranks and quacks. The difference now is that the distinction between "true" medical practice and cranks or quacks is less clear. Nearly all the variety of practitioners now have been to some kind of school, and most have a certificate or diploma to prove it. The variety has probably become a bit greater, but the main difference is that all varieties are now certified. Looking at the customer rather than the provider, it might be considered that it is not an increased range of services that characterizes modern medical times, but increased gullibility. To be kinder, perhaps there is less confidence in any particular form of medical fixing.
Lack of confidence in any particular medical practice is not at all surprising. There are many pressures on us all that make it unclear as to whether we know we are sick or well. An inability to make friends with sexually preferred others might be indicative of unwellness, for which we should seek attention. Everybody gets spots or lumps on their bodies from time to time, but now it's a matter of a life-threatening warning, for who but an expert could tell us that it isn't breast cancer or incipient melanoma? Being a bit tired or irritable would most likely have once been put down to working too hard or having to put up with unpleasant social circumstances; now it might be just as well to see a psychotherapist or a naturopath. And so it goes on. In these circumstances, to which some people are immune, although the degree of resistance appears to be weakening, individual autonomy is rather more like anomie than a desirable state of independence. Uncertainty of meaning and definition is characteristic of both the providers and users of health services.
The great variety of services, and the intensity with which health advice is offered, is not at all in contradiction to an actuality of uniformity and hierarchy. The uniformity underlying the variety is that there is a technical solution to all problems. The intensity of advice, and the number of consumers of this advice, suggests that a great many people have come to believe that they no longer have to put up with any imperfect state. Anything from pimples to a vague feeling of not being treated quite right by the world has a solution. Since, of course, most problems have no solution, or no completely effective one, the opportunity for those offering solutions is endless. But the belief in technical solutions to human problems implies a belief in hierarchy; somewhere, out at the frontiers of science and engineering, a solution must exist. Hence the highest status is given to those with the superior technical skills—people such as brain surgeons, pharmaceutical producers, and genetic engineers (who have recently claimed that the ultimate problem of a limited life span can be overcome).
Autonomy and cultural diseases
If this sketch of the health and illness scene is broadly accepted, the ethical problem can no longer be regarded as one that applies exclusively to the practices of doctors and other medical professionals. Rather, it must now be recognized as a problem pervading our culture and society. The particular problems faced in medical encounters are real and specific, and they need to be resolved as they present themselves. But such resolutions are only partial and inadequate; the context in which such issues arise itself needs theorizing. For example, the question of whether or not euthanasia should be permitted is once again under debate as this article is being written. Nurses, it is reported, by a large majority favor the practice. Perhaps it is the ultimate in caring, somewhat consistent with a slogan I read recently on a young woman's T-shirt, "double suicide is the sublime culmination of love." Doctors, a little more careful of their claim to be the supreme life maintainers, have been more wary of public statements. Perhaps they are waiting for a code of "ethics" on the matter. The Right to Life organization has no doubts about the answer to the question: for them, euthanasia is murder. The issue would hardly arise outside of the context in which there is thought to be a technical solution to all issues. If it was accepted, generally, that people with intractable, terminal conditions must die, the technical issues would become subordinate ones: dying could be allowed, with support and compassion. But as technical means of maintaining existence have become so highly valued, we have no way except that of establishing rules for another set of technical procedures.
Those who possess the technical procedures stand in a hierarchically superior position. Caring, which of all human practices is among those most strongly typified by the reciprocity of loving one another, becomes polluted by the inequality of a power relation based on control of the techniques. The old codifications of religious dogma appear as cultural fossils when brought into relation with the culture that elevates the technical fix. The expectation of autonomy, of control over one's body, which is interpreted as the maximization of happiness, becomes converted into the passing of control to the person with the technical know-how. The question of euthanasia is not a particular question at all; that it is raised for public debate in the current manner is a symptom of a cultural disease, a cultural disease not addressed by those forms of practice which take a symptom as the disease itself.
But many medical encounters, it may be argued, are not at all characterized by the exertion of authority of technical knowledge. Medical dominance is an ideology of which many medical people are aware is held by others, but not themselves. Particularly in the more fashionable locations, like psychotherapy and at the community health centers, the practitioners may go to great lengths to avoid instruction and to avoid decision making. I believe this is not at all what it seems and will attempt to make my point through a couple of examples, one from personal experience and one I just made up. The first example is a dialogue with a doctor on a trivial matter:
Me: I think I need glasses, at least for close-up work.
Doctor: Why ask me, then? If you think you need glasses, you must need them. No one could know better than yourself.
Me: Actually, what I want is a referral from you to a specialist who might tell me more.
Doctor: If you want a referral, then I'll give you one. But I can't see what a specialist could tell you that you can't tell yourself.
Me: Aren't there objective tests for farsightedness?
Doctor: Yes, but it is up to you what you want to use your eyes for. To a jeweler or a watchmaker, farsightedness is a serious matter, but for some other people it doesn't matter at all. Do you read much?
Me: Isn't it worthwhile, if I'm going to have trouble reading, which I do, I should get my eyes checked for other things?
Doctor: O.K., I'll give you a letter for a specialist (which he recommended).
The encounter was pretty harmless. The doctor's authority was used in an attempt to enhance the autonomy of the customer; he might have thought he was engaged in an empowering dialogue. I suspect most people gain knowledge by being told something, but current ideas of autonomy inhibit people from using their authority directly. Authority has to pretend it doesn't exist. Imagine, though, a conversation of a similar structure:
Customer (female): I think my nose is not well shaped.
Doctor: Well, you know whether it is or not. It all depends on what you want to do with it. Noses are many different shapes, and none of them is perfect to everybody.
Customer: I think I'd be more attractive to men if it were a bit better shaped.
Doctor: That all depends on how you want to attract men, or whether you want to at all.
Customer: I'm sure I'm right. Anyway, that is what I want.
Doctor: Well, if that is what you want, I'll write you a letter of referral to a plastic surgeon.
In this conversation, the apparent autonomy of the client is recognized, but it is the weight of the cultural expectation that is actually at work. Doctors could scarcely be expected to act as a counterauthority, if they respect the wishes of those who come to them. But for a long period, this is exactly what doctors did do—that is, represent an authority which at times was in conflict with other authority. The doctor's only claim to authority here is as a voice of the technical solution.
But there are times when it is the case that medical authorities act against what are widely held beliefs. The campaigns against smoking tobacco provide one such example. Since the evidence here is quite overwhelming, there is obviously a case that people should be informed of it. There is a strong case that tobacco should be made unavailable, or permitted in limited quantities, to addicts. The campaign could be directed against the purveyors, as it is with heroin, and this is done to a degree in the case of advertising and sponsorship of sport. In times when authority took a different form, people were not persuaded to have immunization against diphtheria; it was compulsory. Now, the authority has to present itself as directed toward lifestyle, which puts it on the same ground as the advertisers of cigarettes. The campaign against lying unprotected in the sun takes a similar form. Certainly there is a need for public information; there is also good reason for action against the modes of production and consumption that damage the ozone layer. The authority, which presents itself as no authority, is that of preferred lifestyle, and this means its actions on the one hand are limited. On the other hand, it is unlimited, for there is no limit to preferred lifestyle; living is rather hazardous, and the method of exertion of authority even when there is an objective basis for it cannot be clearly distinguished from manipulative advertising or moralpuritanism.
Medical dominance and the illusion of choice
To summarize the argument to this point: there are a very large number of forms of medical practice available currently. They come in three kinds: that which might be called nonprofessional, offered by magazines and the media generally; that which is certified (and it is a characteristic of our times that this certification area has largely replaced older forms of folk medicine, quackery, and so on); and that which is offered by state and quasi-state authorities, in which persuasion aimed at lifestyles has been added to those older forms of public health administration that bring us clean water, unadulterated milk, and mass immunizations. Beyond these directly medical or health practitioners and practices lie various forms of research, of which the highest points are in such things as genetic engineering and the manipulation of bodily chemicals. What all these have in common is the belief that the human body need have cures for disease, as well as remedies for what were once regarded as natural aspects of life and outside medical help, like personal appearance, difficulties in relationships, and so on. Medical practice has expanded beyond its old boundaries and has taken over areas that were the province of others, such as friends, relatives, and religious practitioners. It has been able to do this because of scientific and technical advances and because the dissolution of older forms of relationship between people has opened the way for the technical solution. The apparent great variety of medical practices is superficial and masks a great uniformity. Because what is masked is actually a transformation of the form of life, this transformation is scarcely at the level of conscious understanding and has not been theorized. Moral decisions in these circumstances are likely to be based on an ethical theory derived from earlier times, or on no theory at all.
Health practice was not always like this. The present situation is a relatively recent development. A good deal of thinking about medical practice has been devoted to demolition work on the old structure, and rather little to interpreting the nature of the new situation. Evan Willis in his book Medical Dominance, for example, gives good reasons for not accepting the once well-established hierarchy of health practice, in which medicine defined the legitimacy of others and gained control of the work of other health occupations. Willis is rather less definite and critical about the forms of authority and power that have replaced it. To put this a bit differently, if new levels of practice develop, as has recently been the case in health care, what once existed seems old-fashioned, restrictive, and inhibiting; that which is new seems to be liberating of restriction and inhibition. For example, when the eminent Australian eye surgeon, the late Professor Fred Hollows, suggested that quarantining persons infected with HIV might be an effective way of controlling the spread of AIDS among Australian Aboriginal populations, he was saying something that is completely acceptable within what were once well-established modes of handling epidemics. Only recently, and perhaps still, people with any of a variety of common infections were forbidden to travel to Aboriginal "reserves." Today, although quarantine is still regarded as a legitimate instrument of public health policy, its use is almost completely restricted to the cases of a few exceptionally dangerous, highly infectious diseases. In the case of HIV, it is seen not only as scientifically unsustainable but also as socially objectionable. Indeed, the suggestion above made Hollows the subject of fiercely expressed criticism, those making the criticism against him often calling up images of biblical attitudes toward lepers, to separations of one lot of people from another, and to the formation of boundaries around groups of people.
A practice of quarantine, once consistent with epidemiological understandings and social practices, is no largely longer consistent with social attitudes. From the new level of thinking, it is abhorred. Professor Hollows's comments were not judged in relation to their "efficacy," but in terms of current values. Those with the new perspective seek to remake the whole of social life in their own terms, occasionally exhibiting the smugness and sanctimoniousness which they assume is the quality of those who hold older views. This dominance of the new occasionally creates difficulties for those who are absorbed into it. Not long ago, for example, a group of Muslim women in the Melbourne suburb of Brunswick asked for special time at the local swimming pool, time in which men were excluded. As Muslims, they did not want to expose their bodies to men in general. Currently popular belief implies that people should be able to do what they want, and perhaps should have these rights at the swimming pool. Currently popular belief says that people's autonomy is restricted if they adhere to ideologies and religious beliefs that put boundaries around them. The ethical principle that seems to be at work is that individual autonomy does not include a foundation in any belief, except that of universal individualism.
(Continues...)
Excerpted from Troubled Bodies by Paul A. Komesaroff. Copyright © 1995 Duke University Press. Excerpted by permission of Duke University Press.
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