American Medicine As Culture

Howard F. Stein

• Publisher: Routledge
• Year: 2019
• Print ISBN:
  9780367003197
• eBook ISBN:
  9780429718625
• Topic: Social Sciences
• Subtopic: Cultural Policy
• Index: Social Sciences

This book situates biomedicine within American culture and argues that the very organization and practice of medicine are themselves cultural. It demonstrates the symbolic construction of clinical reality within American biomedicine and shows how biomedicine never leaves the realm of the personal.

One

MEDICINE, VALUE ORIENTATIONS, AND THEIR MEANINGS

THIS CHAPTER IDENTIFIES CORE VALUES in biomedicine and explores the roles they play in healing relationships. The very identification of who and what should be treated, selection of admissible clinical data, choice of therapeutic modality, and expectation of outcome are themselves based upon value-laden assumptions. The considerable literature on the “health belief model” (see Jette et al. 1981) suggests that patient perception of susceptibility to a disease condition, severity of the consequences of that condition, and efficacy of recommended health action directly influence actual health-related behavior. Likewise, medical anthropologists have long contended that how a person or family diagnoses, defines, and explains the condition of illness determines “what are to him self-evident or necessary treatment pathways” (von Mering 1961: 52; Kleinman 1980). Values not only propel the behavior of patient and family; they likewise direct the action of the medical clinician. In this chapter I explore how values affect clinical thinking, judgment, decisionmaking, and action.

Writers on the subject have repeatedly noted that persistence in treatment, compliance with a clinicians treatment plan, improvement, satisfaction, and so forth have more to do with the patients (or family’s) perception of effectiveness (that one’s expectations of therapy are being fulfilled) and with quality of the healer-client relationship than with the healers theoretical model or specific skills (Ford 1978; Kleinman 1980; Phares 1979; Strupp and Bergin 1969). Yet clinicians highly value those theories, authorities, and techniques that they use to achieve their goals, to organize their inner and interpersonal worlds, and to minimize their anxieties. Patients and families may ascribe the favorable or unfavorable outcome of treatment to the personality of the clinician(s), to their relationship with the clinician, or to the degree of congruence between the clinicians beliefs and theirs. At the same time the clinician may attribute success to his or her paradigm or armory of “tricks” and may explain clinical failure by blaming the patient (or the patients family, social class, or culture). Thus, there may be considerable congruence or disparity between the clinically related values of patient and practitioner. The values of the family, of the medical practitioner, and of the medical specialty to which the practitioner belongs play a vital, if also silent, role in the clinical assessment that takes place reciprocally among clinician, patient, and family. To locate the place of values in medicine, we must identify what values are, which turns out to be inseparable from identifying what they are for in human affairs.

VALUES: BASIC PREMISES AND CLINICAL IMPLICATIONS

Values are standards according to which people aspire to live, “measuring rods” by which they assess where and who they are in relation to who they feel they ought to be. Psychologically, values occupy the superego in the dual sense of serving as ideals and as sources of often severe judgment when one fails to live up to them. They prescribe and proscribe behavior. Values are among the criteria we all hold before (and above) ourselves to determine whether we are “good” or “bad.” Values likewise play a vital role in delineating boundaries between self and other, between “us” and “them”; these identity boundaries often come to haunt patient care in biomedicine. John Spiegel defines three tasks that values perform:

[Values] have an evaluative component—that is, they serve as principles for making preferred selections between alternative courses of action; an existential component, which means that the value orientations help to define the nature of reality for those who hold the given values; and finally, they have an affective component, which means that people not only prefer and believe in their own values, but are also ready to bleed and die for them. For this reason, values, once formed, can be changed only with the greatest difficulty (1971: 190).

Florence Kluckhohn (1953) posits four overarching problem areas of human life—relationships between people, our relationship to nature, our relationship to time, and our relationship to activity—each containing three distinct value orientations that are in turn hierarchically ranked. The “relational” value orientation consists of individualism, collaterally, and lineality. In relationships governed by individualism, the family or group prizes the distinctiveness of each person. In decisionmaking each person voices his or her opinion, and the group decides by majority vote. Collateral relationships place the family or group above the individual; indeed, the individual may be said not to exist. Decisionmaking is by consensus so that a sense of harmonious oneness will prevail. Lineal relationships are ruled vertically in a system of authoritarianism and loyalty, nurturance and dependency, dominance and submission. Stability is preserved as each individual maintains his or her sense of place.

The “human-nature” value orientation proposes that we can relate to nature in three distinct ways: mastery over nature, subjugation to nature, and harmony with nature. We can likewise orient ourselves to “time” by preferring the future, the past, or the present. We can prefer three different orientations to “activity”: doing (which emphasizes success, achievement, mastery, improvement), being (which emphasizes spontaneity, the expression of feeling, impulsiveness), and being-in-becoming (which focuses upon personal development, integration, individuation). (See Table 1.1, categories 1 to 4, for an interpretation of these value orientations within American biomedicine.)

Table 1.1Dominant Value Orientations in American Biomedicine

Category	Value (1st order)	Value (2nd order)	Value (3rd order)
1. Relation to People^a	Individual	Lineal	Collateral
2. Relation to nature^a	Mastery over nature	Subjugation to nature	Harmony with nature
3. Time^a	Future	Past	Present
4. Activity	Doing	Being	Becoming
5. Locus of control	Inside (self)	Outside (other)	Between (interactive)

a Based on Kluckhohn and Strodtbeck (1961) and Spiegel (1971).

Dominant values live in uneasy truce with those that are subordinate (Devereux 1967: 209–213). In fact, they are often in conflict with one another in unconscious structure, family relations, and cultural roles. What I am (at the group level, what we are) is intimately connected to what I am not (what we disavow) but am tempted or afraid to be. De Vos writes that “individuals ‘freeze up’ when asked to learn something that might threaten an incompetence that is a protective part of one’s identity, be it sexually or socially defined. For example, many boys and men ‘cannot cook.’ Just as many women and scholars cannot learn to fix a leaky faucet” (1980: 114; see also De Vos 1975a). Values and value orientations are thus far more subtle and dynamic matters than one might at first consider them to be. As a defense against ambivalence, and as a hedge against mortality and fallibility, humans tend to reify values into invariant “they.” One might speak of “serving” values, as though they had a life apart from oneself.

In the context of this discussion of values, consider the quandary voiced by a family medicine intern in dealing with patients whom he found personally, rather than medically, difficult. He was at an impasse about whether to assign dominance to the medical value of caring (personal) or to that of curing (biomedical) as a basis for self-esteem.

When I go to family medicine clinic, it’s my most dreaded day of the week. I don’t mind medically difficult patients. It’s difficult to be direct with patients we don’t like. But there’s little choice here who you see. How do you get rid of patients? Refer? Limit the time of the visit or schedule regular visits? You need a strategy to make them less dependent on you. Am I really doing them any good? Is it the best option they have? Should the physician be satisfied with no change in the patients condition? I’m costing someone money. Is it all I can do? Am I an incompetent physician? I’m not satisfied with the patient’s progress…. It’s frustration when you don’t know whaťs wrong with the patient.

For healers, intervention often seems less an opportunity to help than a compulsion to change others. It is as though they must prove to themselves through their patients that they are able to heal. In this way the patients become an extension of the healers’ fantasied omnipotence. Paradoxically, the value of healing or change can itself interfere with the treatment process. The “need to heal” or “need to change” can become a source of clinical distortion as well as accomplishment (Stein 1982h). A family physician who especially enjoys obstetrics and surgery explained to me:

I like to do a lot of OB [obstetrics]. Theres an end point, and you know you’re done. The woman is pregnant, I deliver her baby, and thaťs a cure. You can see the results of your work, a finished product. I know they say now that pregnancy isn’t a disease, but you know what I mean. I get the same feeling doing surgery, and I know that’s the reason people go into surgery and OB. They want results. They want something to show for it when they’re done. Surgeons like to cut it [the diseased organ or tissue] and be finished. They go in, take out the appendix, and there’s no question they’ve made a cure. A generation ago the patient would have died because they didn’t have surgery and they couldn’t do a cure. It’s so different treating chronic illnesses. You do your goal setting, but end up feeling like a failure because the patient isn’t cured.

This rich, poignant remark clearly establishes the value and personal significance of activity and doing; it also identifies those prized types of biomedical practice (specialties, some of which roles are incorporated into family medicine) through which those cherished values can be realized. Further, it illustrates the image of the physician-as-technician as many physicians’ often elusive highest aspiration.

Doing is not a self-evident activity devoid of context or meaning. If I may oversimplify to make a point, doing means something very different to a peasant fatalist than it does to a boundlessly optimistic capitalist (see Stein 1983c). What is sorely needed in clinical ethnography, assessment, and treatment is careful attention to contending value orientations within medicine. The distinction between an active and passive orientation to problem-solving helps one to understand how individuals or groups experience problems (such as independence-dependence, or initiative-helplessness). Manipulation of the environment (alloplasticity) or manipulation of the self (autoplasticity) can be valued solutions to problems. Such distinctions as act-upon/acted-upon and initiator-of-action/recipient-of-anothers-action are likewise useful in assessing a valued locus of control (Schwartzman 1982). (See Table 1.1, category 5.)

The dichotomy between active and passive underlies the dominant physician images of doer, fighter, and technician and the value orientations of individualism, mastery over nature, future orientation, and internal locus of control. Although this polarity is a value distinction, it is also a deeper, or “meta,” organizing value. The wish and ability to “take charge”—over another person, over a situation, over a procedure—contrast with the feeling of being at the mercy of another, paralyzed into inaction, unable to do anything in the face of death. The quest to dominate medical situations expresses this search for ways to be active, to keep the upper hand, to enlist others (patients, their families, medical consultants, one’s clinical staff) to work at one’s behest. One young resident explained:

We want to give service, but we sure don’t want to feel used, manipulated in return. I don’t know what’s worse, to get sued by a patient or to feel burned, a sucker, for doing what you thought was right. So then what do we do? We start to practice defensive medicine, assuming that everybody’s out to get us, to try to talk us out of meds or into unnecessary surgery. You always try to keep one up on your patients. That’s no good, for you get just as bad as the patients you mistrust. I guess I’ve just got to be more careful so that the manipulators don’t take advantage of me. … Some patients dare you to try to take their disease away. They really drive you crazy if you try to cure them. Take away one symptom, they come back at you with another one, as if they’re trying to beat you at some game. I like the kind of patient who wants to get better. They’re good compilers, and you don’t have to worry about what tricks you’ve got left up your sleeve to outsmart them. Why can’t we dissect every medical problem like we did in anatomy?

The distinction between active and passive is less clear-cut than might be expected. Lurking behind the dread and conscious renunciation of the passive position (clinical manifestations of which are listening, waiting, “going along with nature,” doing nothing) is a deeper wish for the forbidden pleasures of passivity (fulfilling dependency wishes, being taken care of). Because of its strength, this second wish must be disavowed all the more ardently. A foundation block underlying the doer identity of the biomedical physician is, if I might put it in a formula, “A doctor is not a patient.” A doctor is one who, in taking care of others and their ailments, manages the patienthood of others and resists the lures and dangers of passivity. The avowed role obligation of patients is to use the socially acceptable transitional state of patienthood in order to become again an active member of society.

Physicians often make value compromises, tempering some professional values and standards in order to enhance others. A family physician in the Great Plains contrasted his practice style with that of academic physicians in the university hospital:

At the university hospital, they’re purists when it comes to treating kids who come in with congestion, flulike symptoms, no fever, but whose moms insist on antibiotics. For the purists, the rule of thumb is, “No antibiotics without ear involvement [infection].” If the ear isn’t red, the kid isn’t going to get antibiotics no matter what the mom says. She might say, “My regular doctor’s always given us antibiotics when Johnny’s got like this” or “My mother always got antibiotics for me when I had the flu.” But the purists don’t budge. I’ve seen people leave mad, not getting what they came in for.

I’m more liberal with antibiotics. As a doctor, I’m offering a service to people. We’re selling a service by being doctors. You wouldn’t think of going back to a clothing store where you went to buy something and they wouldn’t sell it to you. “I’ll get it somewhere else then,” that’s what you’d say. It’s the same with patients; they’ll continue going to another physician until they get what they’re after. If what I give them isn’t going to harm them, why shouldn’t I give it to them? Some other time, they’ll be back for something I can treat them more scientifically for.

Here, “pure” (biomedical orthodoxy, or officially correct way to think) contrasts with an implicit “impure” (compromise), which the physician illustrates to mean offering the patient a “service” that assures patient satisfaction and, as importantly, the return of the patient for later service. This pragmatic, patient-pleasing intervention is distinct from the equally pragmatic but empirical decisionmaking and action discussed in the Introduction. In the radical empirical model of decision-making, the physician acts prophylactically as if a specific biomedical process were occurring and could be remedied by the cour...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• List of Tables and Figures
• Preface
• Acknowledgments
• Introduction: An Anthropological Interpretation of American Biomedical Culture
• 1 Medicine, Value Orientations, and Their Meanings
• 2 Medical Metaphors and Their Role in Clinical Decisionmaking and Practice
• 3 Medicine, Moralism, and Social Control
• 4 The Influence of Group Dynamics on Clinical Thinking and Practice
• 5 Money and Medicine: An Identity Problem
• 6 Socialization and the Process of Becoming a Physician
• 7 The Self of the Physician: Links Between Culture and Personality
• Conclusion: Implications of an Anthropological Approach for the Study, Teaching, and Practice of Biomedicine
• References
• Index