Medicine as Culture: Illness, Disease and the Body

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Deborah Lupton

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    About the Author

    Deborah Lupton is an independent writer and researcher in sociology and cultural studies and Honorary Associate in the Department of Sociology and Social Policy at the University of Sydney. She was formerly Professor of Sociology and Cultural Studies at Charles Sturt University, Australia. She is the author/co-author of 11 academic books and many journal articles and book chapters on a variety of topics, including: the sociocultural aspects of medicine and public health; risk; embodiment; the family and parenthood; the emotions; food; and HIV/AIDS and sexuality.

    Introduction

    Western societies in the early 21st century are characterized by people's increasing disillusionment with scientific medicine. Paradoxically, there is also an increasing dependence upon medicine to provide the answers to social as well as medical problems, and the mythology of the beneficent, god-like physician remains dominant. On the one hand, doctors are criticized for abusing their medical power by controlling or oppressing their patients, for malpractice and for indulging in avarice; on the other, in most western societies, access to medical care is widely regarded as a social good and the inalienable right of every person. Medical views on health, illness, disease and the body dominate public and private discussions.

    Some critics would argue that the medical profession has too much power and too high a social status, people are placing too much trust in medical practitioners and the treatment they offer and the resources devoted to medical technology are disproportionate. In the past two centuries, a range of behaviours from homosexuality to alcoholism have come under the rubric of medicine. With the current obsession for locating the genetic precursor of illnesses, diseases and behaviours, the knowledge base of western medicine has encroached even further into defining the limits of normality and the proper functioning and deportment of the human body. While it cannot be denied that illness and disease are debilitating states, it must be acknowledged that the populations of western societies are vastly longer-lived and freer of pain and discomfort now than at any other time.

    The increasing secularization of western societies, the dependence on rationality and individualism (legacies of the Enlightenment), the increase in average life expectancies and decrease in numbers of deaths from infectious diseases, the turn to biomedicine and science as the ultimate weapons against illness, disease and premature death have all generated ideas and practices which tend to deny the fragility and mortality of the human body. For the populations of western societies, serious illness and death are strange, mysterious, frightening and unexpected events, except perhaps for the very old. Medicine, or faith in medicine, is a creed. There is a set of expectations surrounding health and the body prevailing in western societies: we expect to feel well, without pain or disability, long after middle-age; we expect all children to survive birth and infancy, all women to give birth with no major complications, all surgery and medical treatment to be successful. And for the majority of people, these expectations are indeed met, serving to reinforce them even more strongly.

    However, although medical authority may confer an image of reassuring competence and control of the situation, the notion of the medical practitioner as omnipotent inevitably leads to disappointment and disillusionment when things go wrong, sometimes resulting in legal action against doctors. When the unexpected happens – when early death intervenes, when surgery or medical treatment fails, or produces even worse health, when infants and children die, when illness remains chronic and debilitating – there are few explanations that can provide meaning to the experience. Furthermore, while we continue to look to medicine to provide help when we are ill, we also sometimes express resentment at the feelings of powerlessness we experience in the medical encounter.

    As its title suggests, this book examines the social and cultural aspects of medicine in western societies, seeking to cast light upon the reasons why medicine is characterized by such strong paradoxes, why issues of health and illness are surrounded with controversy, conflict and emotion. What do I mean when I use the term ‘medicine as culture’, as I chose to do in the title of this book? I am highlighting that western scientific medicine is just as much a product of social and cultural processes as are the medical knowledge and practices that have developed in non-western societies.

    ‘Culture’ is a term that appears frequently in the medical literature, but it is typically used to denote non-western cultures. ‘Culturally competent’ or ‘culturally appropriate’ health care has emerged as an umbrella concept that encapsulates the importance of health-care workers such as doctors and nurses being sensitive to the disparities of health status and inequalities in the quality of health care experienced between social class, racial and ethnic groups and working to overcome these through awareness of ethnic and racial cultural differences in health practices and understandings. An objective that is often espoused in the health practitioner literature is that of moving towards ‘patient-centred’ communication, in which each patient's culturally shaped understandings of their body and health or illness states is understood by the workers who deal with them.

    I argue that in the context of an analysis of western medicine as a social phenomenon, ‘culture’, more broadly, should be understood as the conglomeration of meanings, discourses, technologies and practices that accumulate around medicine within western societies as well as outside them. The concept of the ‘lifeworld’ is sometimes used by anthropologists and sociologists to describe the everyday sociocultural context in which meaning is generated. In the case of lay people, this term refers to the understandings, concepts and beliefs they bring to the medical encounter, shaped not only by people's encounters with doctors and other health-care professionals but also by such factors as personal experiences, interactions with others, information derived from the mass media and the internet and membership of social class, gender or generational groups as well as racial or ethnic groups. It is equally important to recognize that doctors and other health-care professionals bring their own cultural beliefs to the medical encounter, generated not only by their scientific training but also by other aspects of their own lifeworlds.

    In some Asian countries, people believe that certain illnesses are caused by an imbalance of ‘hot’ or ‘cold’ properties in the body and must be treated with foods and medicines which themselves are deemed to be symbolically ‘hot’ or ‘cold’. In earlier eras, people in western societies understood illness as punishment from a vengeful God for their sins; or as a product of imbalance of the ‘humours’, four types of fluids within the body; or as resulting from exposure to ‘bad air’. Similarly, contemporary western societies have their own symbolic systems of belief which underpin the supposed neutrality of medicine. The white coat worn by doctors is a potent symbol of efficiency and hygiene, while the bleeping medical machines in the hospital setting convey their own meanings of high technological prowess. Certain metaphors and images tend to be used to describe particular illnesses and conditions, people with some medical conditions are assumed to be ‘responsible’ for their illness while others are regarded as blameless. In all these respects and many others, western medicine, and the way in which embodiment, ill-health and disease are understood and experienced in western societies, are inevitably produced by sociocultural meaning systems in ways we do not always recognize. Many of these meaning systems are discussed in this book.

    In the medical encounter, health-care workers and the patients they are seeking to help must make sense of, interpret and share each other's meanings and assumptions. Doctors often find that their patients bring to the medical encounter beliefs and concepts about their illness and embodiment from their own lifeworlds that are incongruent with medical understandings of these phenomena. By bringing together elements of both meaning systems, doctors and patients negotiate authority over meaning. Doctors and other health-care workers, therefore, rather than standing apart from and observing their patients' lifeworlds, actively contribute to and may transform them through their efforts to translate medical knowledge and help patients incorporate this knowledge into their lifeworlds. This exchange of meaning is vital for communication between health-care professionals and patients, so that each understands each other and a shared meaning may be created.

    This book goes some way towards elucidating some of the common meanings related to health, disease and embodiment that may be inherent in lay people and medical workers' lifeworlds, and how they are produced and reproduced. In my efforts to explain elements of western scientific medicine as a sociocultural artefact, the book draws upon scholarship and research published predominantly in the sub-disciplines of medical sociology and sociology of health and illness, the history of medicine and medical anthropology, while also making excursions into the insights offered by the fields of cultural studies and media studies, medical geography and science and technology studies. The discussion is supported with pertinent examples from research studies which have attempted to provide empirical evidence of the lived experience of illness, disease and the medical encounter, and gives due recognition to the macro-political processes which frame, shape and constrain such experiences and knowledge. This book adopts the field of cultural and media studies' interest in mass media and elite cultural artefacts as the sites of the reproduction of meaning, and the poststructuralist concern with discourses (ways of representing and talking about phenomena) and their role in the construction of practices and concepts of reality.

    For the purposes of this book, and for clarity's sake, distinctions have been drawn in the time-honoured way concerning perspectives and paradigms between and within disciplines. However, the caveat is made that such distinctions are, in many cases, no longer as valid or appropriate as once they were. Indeed, one of the strongest points I seek to make is that sociologies, anthropologies, histories, cultural and media studies and even geographic studies of medicine, illness and disease share an intellectual tradition and trajectory based on the same trends and developments in social theory. Over the past three decades or so there has been an increasing propensity for the boundaries between disciplines to blur, particularly among the humanities and social sciences. As a result, it is becoming more and more difficult to ascribe labels to scholarly endeavours. Literary studies, psychoanalytic theory, philosophy, social psychology, cultural studies, linguistics, geography, history, sociology and anthropology have all experienced changes which bring them closer together in their projects.

    In line with these developments, the scholarly activities which may loosely be gathered under the rubric of the sociology of health and illness have altered focus. There have been two major impetuses fuelling this change. One is the emergence of a growing disillusionment with scientific medicine on the part of both intellectuals and some consumers in the late 20th century. The effectiveness and benevolence of medicine began to be challenged, and so too was its claim to inaccessible and arcane knowledge based on objectivity and political neutrality. The other impetus is the impact of poststructuralist and postmodernist theories, including the release in the anglophone world of the translated works of the French philosopher-historian Michel Foucault, and the growing concern of feminist scholarship with gender and the body. In response to these impetuses, anthropologists, historians and sociologists of health and illness, particularly in continental Europe and Britain, but increasingly so in North America and Australia, began to call into question the claims to ‘truth’ and political neutrality of biomedical knowledge (that which is founded upon scientific principles and understandings). Of particular note is the emergence of the ‘linguistic turn’, or the increasing attention paid to language and discursive processes in the production and maintenance of social life and subjectivity.

    An interdisciplinary perspective, while exciting and stimulating in its breadth, poses its own problems. When one is integrating research and scholarship from a number of disciplines, it can be very difficult to know where to draw the boundaries. One response to this dilemma is the decision to focus this book mainly upon developments in scholarship and research published since 1980. In addition, this text largely avoids discussion of the individual psychological dimension of illness, including the psychoanalytic explanations which have flourished in media and cultural studies and feminist scholarship. Related to this is the decision to omit detailed discussion of mental illness, an area which could itself fill the pages of a book such as this and hence could not be given justice in the space allowed.

    Chapter 1 is an overview of the major theoretical perspectives brought to bear on the sociocultural dimensions of medicine. The chapter reviews developments and paradigmatic changes in medical sociology and the sociology of health and illness since the 1950s, including discussion of functionalism, the political economy perspective and social constructionism. The contributions of medical anthropology and the history of medicine to scholarship are then discussed, as are those offered by the interdisciplinary fields of cultural and media studies and studies of science and technology, as well as medical geography. The chapter discusses the extent to which these sub-disciplines and inter-disciplines have merged in the wake of the poststructuralist and postmodernist movements and demonstrates how a broad appreciation of their differences and similarities assists the understanding of the sociocultural dimensions of medicine, health care and the doctor-patient relationship.

    The remaining chapters build on this theoretical basis to examine more specific dimensions of medicine as culture. Chapter 2 is devoted to examining the body in western medicine, incorporating the insights of prominent contemporary scholars in the humanities and social sciences to understand the sociocultural dimensions of: the sexual and gendered body; public health and the disciplined body; the clean body; the commodified body; food and the body; the dead body; and the body and medical technology. Chapter 3 moves to a focus on language and visual imagery in examining dominant discursive and iconographic representations of medicine, illness and disease. Particular attention is paid in this chapter to the portrayal of illness, disease and death in literature and popular culture and changes in metaphors of the body and illness since medieval times, including the currently dominant machinery and military metaphorical systems, metaphors of the immune system and cancer, and metaphor and gender. Chapter 3 also discusses visual images of people living with HIV/AIDS, the iconography of the interior of the body, and the use of the cultural analysis of representation as a strategy for political activism.

    Chapters 4 and 5 are highly interrelated. Chapter 4 is devoted to examining the lay perspective on health and illness. The chapter traces the notion of the ‘patient’ in the context of changes in the modes of medical treatment over the centuries and then focuses on the effect of the emergence of scientific medicine upon patients' experiences of health care. The chapter also looks at: the ‘sick role’; the moral dimension of illness; the contemporary experience of illness, particularly in the clinical or hospital setting; the effect of medical technology upon subjectivity; and beliefs about illness causation from the lay perspective. Chapter 5 covers in detail issues surrounding power relations in the medical encounter, and is centred on contemporary theoretical debates and research surrounding medical dominance, the doctor-patient relationship, patient dependency and resistance, the nurse's position in medicine and the doctor's perspective on the medical encounter. The chapter also looks at the use of internet-based technologies by lay people, and examines the claims of alternative and complementary therapies and self-help groups that they offer valid alternatives to the alleged problems inherent in the orthodox doctor-patient encounter.

    The last substantive chapter, Chapter 6, reviews feminist scholarship as it has been applied to the sociocultural analysis of medicine and health care. In so doing, the chapter picks up some of the issues and debates canvassed in earlier chapters. It discusses the development of the medical specialization of gynaecology and its implications for the ways in which the female body has been constructed historically, and then examines in detail: power struggles; discursive definitions and theoretical debates around contraception and abortion; menstruation and menopause; prenatal screening technologies; assisted reproduction technologies; and childbirth and motherhood. The brief conclusion following Chapter 6 serves to bring the dominant themes and arguments of the book together and looks at ways in which a sophisticated sociocultural awareness of the discourses and imagery relating to medicine, health and embodiment may contribute to the expansion of alternative ‘ways of seeing’.

  • Conclusion

    As western medicine continues to dominate other social arenas, the paradox of its benevolence, its ability to save lives and its miraculous properties versus its capacity to support social inequities, to cast villains and victims and to entrench power differentials, becomes ever more evident. These contradictions are constantly apparent when discussing the role played by medicine in society, and have been particularly pertinent for women and other marginalized groups, to whose social position medicine has historically contributed. In this book I have attempted to depart from the approach to medicine and culture that tends to view non-western societies' medical discourses and practices as socially constructed, but which fails to recognize that the medical apparatus bringing together various discourses, practices and objects in western societies is equally a product of social and cultural relations and systems. I have demonstrated that in western societies, as in all other societies, issues of embodiment, health, illness, disease and death are inextricably interlinked with social and cultural processes; that is, the biological dimensions and medical understandings of these phenomena cannot be extricated from the sociocultural settings in which they are known and experienced.

    The recent renewed attention to ways in which the body is constituted by medical discourses and practices has brought to the fore one of the most contentious and important debates in social theory: that which examines the respective roles of structure and agency in the lives of individuals (Turner, 1992: 159). Macro-theorists in the sociology of health and illness, particularly those embracing the political economy approach, have traditionally emphasized structure over agency when analysing the role played by medicine in the lives of people. In contrast, other social theorists who have taken a micro-perspective have emphasized individual agency in the medical setting, or the ways in which people can shape their own destinies and give meaning to their lives. This book has argued for a bringing together of these theoretical perspectives in ways that maintain a recognition of the distinctive contribution made by each approach while at the same time acknowledging the points at which they merge. Although the poststructuralist understanding of the integral contribution of language and discourse in shaping notions of reality has sometimes been criticized for reducing the agency of social actors under the power of language, this book has demonstrated that there is the possibility of resistance as long as attempts continue to be made to access or develop alternative discourses from which individuals may construct subjectivity.

    Awareness of the manner in which disease categories and treatment practices are developed and institutionalized to the exclusion of others is of critical importance to understanding the social role of medicine in any culture. In demonstrating the dynamic and relative nature of medical knowledge, such insights provide space for the resistance to dominant forms of knowledge. In exposing the social bases of medicine, health care and illness states, by showing how they are not necessarily given or ‘true’ but are subject to change, the social constructionist perspective renders these phenomena amenable to negotiation, allowing the opportunity for alternative ways of thinking and speaking that avoid taken-for-granted assumptions and stereotypes. For marginalized groups, such challenges have assisted their quest to be heard. For example, if people living with HIV/AIDS can insist that they be considered survivors rather than passive invalids by rejecting the term ‘AIDS victims’, if menopausal women can successfully argue that the ceasing of menstruation is a new, liberatory dimension of womanhood rather than the death of femininity, if people with disabilities can point out that the spaces in which they are forced to move limit their capacities, then the bodily experiences and practices around these processes can be transformed.

    Writings influenced by social constructionist perspectives have also had the important effect of challenging researchers in the humanities and social sciences themselves to be reflexive, to examine their own position of power and claims to truth in the research and writing process. Foucault (1984b: 74) has contended that it is the role of the scholar to expose the mechanisms by which ‘truth’ is constituted, and in whose interests it works, and thence to be in the position of ascertaining the possibility of a new politics of truth. This argument may be usefully extended to the context of bodies in medicine. Scholars interested in the sociocultural dimensions of illness, disease and the body in medicine need to be aware of the potential of their writings to contribute to oppressive, constraining and stereotypical discourses that support confining dualisms such as Self/Other, masculine/feminine, sick/well, rational/irrational, active/passive, productive/wasteful, nature/culture, disorderly/ controlled and moral/immoral, and to use their understanding of the socially constituted nature of knowledge to allow space for the production of novel, multiple knowledge about bodies in the medical setting that avoid either/or distinctions.

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