Technology and Medical Practice

Boel Berner, Ericka Johnson, Ericka Johnson

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317046387
• Edition: 1
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

The advanced technologies being used in diagnosis and care within modern medicine, whilst supporting and making medical practices possible, may also conflict with established traditions of medicine and care. What happens to the patient in a technologized medical environment? How are doctors', nurses' and medical scientists' practices changed when artefacts are involved? How is knowledge negotiated, or relations of power reconfigured? Technology and Medical Practice addresses these developments and dilemmas, focusing on various practices with technologies within hospitals and sociotechnical systems of care. Combining science and technology studies with medical sociology, the history of medicine and feminist approaches to science, this book presents analyses of artefacts-in-use across a variety of settings within the UK, USA and Europe, and will appeal to sociologists, anthropologists and scholars of science and technology alike.

PART 1
Judging Bodies

The discourse of medicine relies on certainty, but the messiness of practice presents ambiguity. This paradox becomes particularly apparent when discussing the normal and the pathological. How do we know what is normal? How can we determine what is abnormal? These are questions inherent in medicine (see Canguilhem 1991, Fausto-Sterling 2000, Oudshoorn 1994, Waldby 2000). However, as the following chapters show, technology can sometimes bring these concepts into focus in interesting ways, highlighting how the (ab)normal is defined in context and through concerted, cooperative work. Technologies can be used to redefine the normal and the pathological for practitioners and patients alike, the starting point for the first three chapters in this book.

In Chapter 1, Celia Roberts presents an analysis of how pubescent bodies are defined in contemporary biomedical discourses. Her critical reading of medical papers, textbooks and media reports examines the changing definition of ‘pathological’ puberty (early, late and undesired puberty), and the increasing numbers of bodies which are being included in that category. Drawing on science and technology studies, social studies of health and medicine and feminist theory, she uses examples to discuss norms and interventions in biomedicine. Roberts’ work is fascinating in that it shows how the definition of pathological is both flexible over time and across cultures, for example, how breast development at age eight is redefined as normal in the US to avoid the costs of mass screening but that breast development at eight is still considered pathological in the UK. Her work also points to disturbing examples of biomedical practices, as when she discusses the hormonal treatments advocated for Gender Identity Disorder, a medical procedure used to delay puberty in children who may possibly wish to change their sex as adults. Roberts demonstrates that Gender Identity Disorder is presented within a discourse of ‘acceptable’ behaviour for girls and boys which pathologizes non-normative gender identities and requires adherence to a narrowly defined script of acceptable behaviours.

Roberts is discussing the construction of pathology, but she shows that medical practitioners are not blind to the changing definition of normal occurring in their practices. Her material indicates that practitioners are aware that norms are not the same as normal, optimal health. Roberts calls for research which also engages parents, teachers and children in examining how everyday puberty is lived and ordered, encouraging us to view puberty as a transition to adulthood rather than leaving it as a question of normal and pathological bodies.

Kerstin Sandell’s study discusses how practitioners grapple with the normal and the pathological in their everyday work practices. Through ethnographic study of routine ultrasound screening, her chapter shows that a distinction between the normal and the pathological is taught and made by midwives in the examination room. Her research presents the details of work that maintain an aura of objectivity around the exam, an exam which serves to decide what abnormalities lay within the jurisdiction of medicine and are thereby treatable.

Sandell’s close ethnographic study of learning practices describe how the work practices of midwives are seen by them as necessary for observing and determining the (ab)normal and teaching this ability to newcomers. Of primary importance is the assumption that an individual midwife’s ability to recognize the normal and the pathological is dependent on his/her exposure to many real foetuses, a cumulative knowledge that grows out of many visual impressions. This plays in stark contrast to the idea of learning the normal through books, anatomies and other text-based material. But learning to see the normal through practice is also dependent on the technological capabilities of the ultrasound machine. Newer, more advanced ultrasounds will potentially enable different views and the discovery of more deviant, ‘abnormal’ scans. How this should be integrated into the existing work practices is a point of negotiation between midwives and obstetricians, but it also involves careful handling of the feedback given to parents during the exam.

Sandell’s chapter presents an interesting material element to establishing the normal/pathological. Within the Swedish practice of state funded, routine, ultrasound scanning in week seventeen, ‘results’ of a normal scan are not saved. Except for the ‘snapshot’ image sent home with the expectant parents, there is no storage of raw ultrasound data, still images or video, that can be referred to later should an abnormality appear. Thus midwives are taught to interpret the scans for the parents using conditional statements like ‘as far as we can see’, or ‘ok for now’. This is in strong contrast to the simulator technologies discussed in Part 2. In Sandell’s research, the normal comprises a tentative position and an absence of materialized representations, which reflects Roberts’ concern in Chapter 1 that there is an overemphasis on the pathological and not enough discussion of the normal within medical practice.

How to interpret technological ways of knowing the body are also examined in the third chapter. Drawing on ethnomethodological analysis of anaesthesiology practice, Dawn Goodwin and Maggie Mort present accountability being achieved in practice through interactions between people and artefacts. In their examples, public consensus is produced and an intervention is legitimated in the interactions between the technologies of anaesthesiology, the clinical team and the patient’s body. Their examination clearly shows the distinction between the ethnomethodological sense of accountability and the professional one.

In the material they have gathered, Goodwin and Mort first demonstrate how routines and norms signify accountable practice, but then they show that in the messiness of clinical practice, where coherent narratives and routines are sometimes lacking, much work is done by clinicians to make an intervention accountable. They suggest that there are different accountability communities and that policy-makers, practitioners, ethnomethodologists and science studies researchers understand the concept differently. Is accountability a decontextualized ‘account’ open to the judgement of others or something that is interactionally achieved between co-participants? Their work adds accountability into the analytical framework espoused by science and technology studies that views incoherences and disunity in medical practices, knowledge, objects, technologies and bodies. Through ethnomethodological detail, Goodwin and Mort demonstrate how practitioners maintain accountability within a paradigm that expects certainty even when certainty is missing in practice, and how routines and accountability are practised even in the face of ambiguity.

Thus, all three chapters deal with how medical practices incorporate technologies to deal with certainty and ambiguity when creating knowledge about and treatments for the (ab)normal body. In them, technology is sometimes used to judge what is normal and create knowledge about the body, but it does not work alone; it interacts with policy guidelines, practitioners, bodies, patients – even patients’ families – in creating and defining the normal, healthy patient. Incorporating technology into the analysis of these practices forces us to pay analytical attention to the collective, often cooperative and often very repetitive elements of knowing practices upon which an understanding of the (ab)normal relies.

References

Canguilhem, G. [1978] 1991. The Normal and the Pathological. Translated by Carolyn R. Fawcett in collaboration with Robert S. Cohen. New York: Zone Books.

Fausto-Sterling, A. 2000. Sexing the Body: Gender politics and the construction of sexuality. New York: Basic Books.

Oudshoorn, N. 1994. Beyond the Natural Body: An archaeology of sex hormones. New York and London: Routledge.

Waldby, C. 2000. The Visible Human Project: Informatic bodies and posthuman medicine. London and New York: Routledge.

Chapter 1
Defining the Pubescent Body: Three Cases of Biomedicine’s Approach to
‘Pathology’

Celia Roberts

The pubescent body is usually represented as a body in tumult. For both boys and girls, although with quite different inflections according to sex, puberty is understood as a time of profound and irreversible change. For increasing numbers of children in wealthy countries, puberty is also associated with pathology and biomedical intervention. For these children, puberty comes too late, too early or is fundamentally undesired. In such cases, biomedicine offers pharmacological interventions to bring puberty on or to hold it off till later. Puberty thus becomes a medico-technical experience: a coming together of blood, guts and machines in challenging and highly consequential ways.

In this chapter, I tell stories about puberty in order to critically question how pubescent bodies are defined in contemporary biomedical discourses. The chapter is based on critical readings of diverse textual sources, including medical papers and textbooks, media articles and internet resources. My argument suggests that some pubescent bodies – understood as ‘pathological’ – are today becoming sites for seriously consequential biomedical interventions; others – understood to be ‘normal’ – are left to develop without such intervention. Significantly, in the current era increasing numbers of pubescent bodies are meeting established biomedical criteria for ‘pathology’ (and hence intervention). This paper investigates the effects of this change, and how it is being managed. Engaging with Georges Canguilhem’s ([1978] 1991) argument about modern biology’s focus on the abnormal in establishing norms, I suggest that there is much to be learnt from the example of puberty about the status of bodies, norms and interventions in biomedicine today.

Technoscientific Understandings of Puberty

In biomedical textbooks, puberty is defined as the process that produces a body able to sexually reproduce. In the 6th edition of Human Physiology: From cells to systems, for example, Lauralee Sherwood (2007: 739) writes, ‘Puberty is the period of arousal and maturation of the previously non-functional reproductive system, culminating in sexual maturity and the ability to reproduce.’ In an era of ever-increasing rates of infertility, this is a rather uncomfortable definition (did people who cannot reproduce as adults not go through puberty?), but it is one that nevertheless holds. A recent scientific review published in Reproduction, for example, baldly states that ‘Puberty is the attainment of fertility’ (Ebling 2005: 682).

In material terms, puberty is described as the process of developing what physiologists call ‘secondary sexual characteristics’ (breasts, pubic hair, adult genitalia) and of moving into an adult cycle of production of sex cells (eggs and sperm). The biological processes associated with such developments are complex. According to undergraduate physiology textbooks, in late childhood maturational changes and decreased inhibitory mechanisms in the brain increase secretion of gonadotropin releasing hormone (GnRH) from the hypothalamus in pulses during sleep. Over time these pulses become longer until an adult pattern is established. The pulses of GnRH lead to increased secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the anterior pituitary, which in turn increases secretion of either testosterone from the testes or estrogen from the ovaries. It is these well-known sex hormones that ‘arouse’ the dormant reproductive systems, stimulating the development of the secondary sexual characteristics.

Like many hormone stories, this story of sexual development maintains an understanding of sexual difference as binary (see Roberts 2007). Stories of puberty in girls focus on the estrogen-producing ovaries, and stories about boys focus on testosterone-producing testes. In relation to boys, for example, Sherwood (1997: 739) writes that ‘Testosterone is responsible for growth and maturation of the entire male reproductive system.’ In a section on girls, she states ‘GnRH begins stimulating release of anterior pituitary gonadotropic hormones, which in turn stimulate ovarian activity. The resulting secretion of estrogen by the activated ovaries induces growth and maturation of the female reproductive tract as well as development of the female secondary sexual characteristics’ (Sherwood 2007: 762). It is important to note, however, that girls also experience changes in androgen secretions at puberty. In pubescent girls, these ‘male’ hormones are linked, Sherwood (1997: 762) explains, to the growth of pubic and underarm hair, overall growth and ‘the development of libido’. Similarly (although much more ‘surprisingly’ for biomedicine), estrogen also affects male sexual development. ‘Recent findings suggest’, Sherwood notes (1997: 742) ‘that estrogen plays an essential role in male reproductive health; for example, it is important in spermatogenesis and surprisingly contributes to male heterosexuality. Also, it likely contributes to bone homeostasis.’ Such ‘surprises’, as I argue elsewhere, stem from a long history of understanding sexual difference as binary and even oppositional, and have no basis in physiological reasoning or material evidence (Roberts 2007, see also Oudshoorn 1994, Fausto-Sterling 2000).

The hormones released in puberty do stimulate significant biological differences between women and men’s bodies, namely, ovulatory and menstrual cycles in women and continuous sperm production in men. The differences between these sets of processes are much discussed: Sherwood (1997: 752), for example, concludes that ‘Female reproductive physiology is much more complex than male reproductive physiology. Unlike the continuous sperm production and essentially constant testosterone secretion characteristic of the male, release of ova is intermittent, and secretion of female sex hormones displays wide cyclic swings’. Her use of the non-technical term ‘swings’ – a word often associated with emotional lability – references a wide-spread cultural interpretation of this difference: women are often understood as moody and fluctuating because of their sexual physiologies, whilst men are seen as constantly desiring and stable. Such differences are, as Sherwood’s writing shows, built into discourses of puberty and thus into children’s lives at very young ages.

Blood, Guts and Mysterious Machines

Despite this physiological knowledge of the ‘blood and guts’ constituting it, puberty remains, as physiologists Palmert and Boepple (2001: 2367) write, ‘a long-standing mystery’ for biomedicine. The two key elements constituting this mystery are described in a review article written by a group of pediatricians and published in Endocrine Reviews (Parent et al. 2003). Firstly, in humans there is extraordinary variety in the timing of puberty in the current era (’a 4–5 year physiological variation in age at onset’) (Parent et al. 2003: 668) and a similar variation in the timing of puberty across historical periods. In Europe, for example, age at puberty for girls dropped from 17 in 1830 to under 14 in 1960 (Parent et al. 2003: 673, see also Ellis 2004: 926). Secondly, what actually causes puberty to start remains uncertain. In their introduction, Parent et al. (2003: 668) write that ‘puberty results from the awakening of a complex neuroendocrine machinery in which the primary mechanism is still unclear’. According to these clinicians, then, puberty constitutes a profound paradox: a machine with incomprehensible mechanics (which could, logically, only be a kind of alien entity).

Aliens aside, the use of a machine metaphor to describe the pubescent body is unsurprising. As several authors have argued, from the 18th century on, such metaphors have been ubiquitous in biological discourses (see for example, Canguilhem [1978] 1991, Stacey 2000, Waldby 2000). In relation more specifically to reproduction, anthropologist Emily Martin ([1987] 1992) describes biomedical texts’ reliance on cultural discourses of factory-based production in describing menstruation. Menstruation is figured as a kind of failure of purpose (to conceive) and as producing disgusting waste. ‘Menstruation’, she argues, ‘not only carries with it the connotation of a productive system that has failed to produce, it also carries the idea of production gone awry, making products of no use, not to specification, unsaleable, wasted, scrap’ (Martin [1987] 1992: 46). Such descriptions, Martin suggests, are linked to understandings of gender and work. The reference to menstruation as failed activity resonates with the 19th and early to mid 20th century idea that women are supposed to be at home reproducing the species, ‘providing a safe, warm womb to nurture a man’s sperm’ (Martin [1987] 1992: 47).

In contemporary biomedical discourses of puberty, mechanical discourses are particularly strong when genes are invoked as stimulating hormonal cascades. Palmert and Boepple (2001: 2364), for example, argue that ‘The mechanism(s) underlying the relative suppression and the subsequent pubertal activation of hypothalamic GnRH secretion is unknown but of critical importance. Further understanding of the maturation of GnRH secretion and pituitary responsiveness is vital to understanding the mechanism(s) behind the broad variation in the ...