Medicine and the Body

Simon Williams

• Publisher: SAGE Publications Ltd
• Year: 2003
• ISBN:
  9781446240373
• Edition: 1
• Topic: Ciencias sociales
• Subtopic: Sociología

`An intelligent and informed account of medical sociology. Simon Williams has produced an original and comprehensive sociological statement of the centrality of the body to an understanding of medicine, health and illness. His scope is impressive... It will shape future teaching and research in the field of health and illness? - Bryan S Turner, Professor of Sociology, University of Cambridge

This is a clear, well-written account of medicine, health and the body. Taking recent debates on the body and society as its point of departure, the book critically reexamines a series of embodied issues and emotional agendas in health and illness. Included here are cutting edge discussions and debates concerning:

- the medicalized body

- health inequalities

- childhood and ageing

- the dilemmas of high-tech medicine

- chronic illness and disability

- caring and (bio)ethics

- sleep, death and dying

- the body in late/postmodernity

Written in an accessible, engaging style, with many original and innovative insights, the book will appeal to undergraduate and postgraduate students alike, and to researchers and lecturers with an interest in the embodied agendas of health and medicine in the new millennium.

1

The Biomedical Body: Reductionism, Constructionism and Beyond

In this opening chapter I want to take another look at what, for some seasoned readers, may seem like old, familiar, well-trodden turf: the medicalization debate, that is to say, both past and present. My aim, in doing so, is not simply to throw the ‘limits’ of biomedicine (yet again) into critical relief, reductionist or otherwise, but to turn the glare of the spotlight on the ‘limits’ of sociology itself, particularly its constructionist variants, together with broader ‘imperialist’ debates. Consideration of these issues raises associated questions of crucial importance concerning the nature and status of the biological, within and beyond the sociology of health and illness. It is with these issues in mind that the chapter proceeds in four main ways: firstly, through a revisiting of the biomedical model, including its historical emergence and the so-called ‘orthodox’ medicalization debate; secondly, through a re-examination of the social constructionist and postmodern challenge to the biomedical body; thirdly, through a critical account of the place and function of these sociological critiques themselves, and the ‘limits’ they display; and finally, as a kind of meta-theoretical theme, through a rethinking of the nature and status of the biological within and beyond the sociology of health and illness: one which steers a cautious path between the Scylla and Charybdis of (biological) reductionism and (social) constructionism alike.

Some caveats and disclaimers are perhaps in order at the outset, lest the tone and content of the chapter be misconstrued. Social constructionism, it should be emphasized – which comes in many shapes and sizes – is simply one, albeit an influential, strand of sociology. It cannot therefore be equated or conflated with the sociological enterprise as a whole. Sociology cannot, moreover, in any real sense, be seen as an ‘imperialist’ enterprise, unless we are prepared to equate critique with territorial ‘take-over’, which again is untenable. The ‘limits’ of sociology nonetheless, constructionist or otherwise, are important to face up to – a comment which applies to all disciplines for that matter. Herein lines the rationale or warrant for the line taken in this particular chapter; a reflexive form of sociological housekeeping, perhaps, as a guard against our own self-conceit and deceptions. It is with these caveats and disclaimers in mind that we proceed.

The ‘limits’ of biomedicine: ‘(de)medicalizing’ the body?

What is biomedicine? Is biomedicine neutral and value-free? What are its limits? Have our bodies and lives become ‘medicalized’ through its influence? And what role should sociology play in these and related debates? These are some of the questions which have exercised the minds and bodies of medical sociologists over the years, in more or less (dis)passionate ways. They also provide a useful starting point for the themes and issues discussed in this chapter. First, however, a few preliminary words on changing theories of the body and disease are required as an historical backdrop to the issues which follow.

Changing theories of the body and disease – a brief history

In many respects, Porter comments, the ‘medical history of humanity’ in Europe (from Greco-Roman antiquity onwards) can be depicted as a series of stages which, broadly speaking, involved the systematic replacement of transcendental explanations, positing instead a natural basis for disease and healing (1997: 9). Prior to the ‘age of reason’, for example, supernatural beliefs about malevolent spirits, ideas about evil and divine intervention, and practices of sorcery and witchcraft were highly influential in Christian Europe, retaining a ‘residual shadow presence’ ever since in certain sects and segments of lay and popular culture (Porter 1997: 9). Other, more ‘naturalistic’ beliefs and approaches, in contrast, provided a somewhat firmer basis or grounding for the medical history of humanity to root and flourish. Greek medicine, for instance, in this more ‘naturalistic’ mould, emphasized the ‘microcosm/macrocosm’ relationship in which the healthy body was seen to be in tune via humoral theories of ‘balance’ and the regulation of lifestyle. From Hippocrates in the fifth century BC to Galen in the second century AD, humoral medicine stressed the

analogies between the four elements of external nature (fire, water, air and earth) and the four humours or bodily fluids (blood, phlegm, choler or yellow bile, and black bile) whose balance determined health. The humours found expression in the temperaments and complexions that marked an individual. The task of regimen was to maintain a balanced constitution, and the role of medicine was to restore the balance when disturbed. Parallels to these views appear in classical Chinese and Indian medical traditions. (Porter 1997: 9)

These medical teachings of antiquity remained ‘authoritative’ until the eighteenth century, including what by modern-day standards may be seen as an intimate physician–patient relationship (Porter 1997: 10). ‘Bedside medicine’, at this time, involved an ‘open-ended model’ of bodily processes founded, crucially and characteristically, upon ‘extrapolation from the patient’s self report of the course of their illness’ (Jewson 1976: 228). The ‘sick man’, therefore, in Jewson’s terms, was at the centre of medical cosmology at this time, comprising a unique or peculiar combination of physical, emotional and spiritual factors, incorporated in the symptom complex: one in which mind and body, psyche and soma were integrated as a ‘conscious human totality’ (1975: 227).

The emergence of biomedicine, however, changed all this in a more or less irrevocable way. Important historical precursors here included Vesalius’s anatomical atlas De Humani Corporis Fabrica (1543) and Harvey’s discovery of the circulation of the blood in De Motu Cordis (1628), both of which challenged former Galenic wisdom, thereby paving the way for the subsequent development of a new, more ‘scientific’, hospital-based form of medicine from the late eighteenth century onwards. Within this new form of ‘Hospital Medicine’, the accurate diagnosis and classification of cases came to the fore, based on the four great innovations of structural nosology, localized pathology, physical examination and statistical analysis (Jewson 1976: 229). Disease, therefore – aided and abetted by nineteenth-century inventions and discoveries such as Laennac’s stethoscope in 1819, Pasteur and Koch’s landmark work on micro-organisms in the 1860s, and Röntgen’s X-Rays in 1896 – came to be seen as an objective entity, in which external symptoms correlated with internal lesions within the organs and tissues of the body, in contrast to former generalized notions of disturbances of the body as a whole in bedside medicine. The corporeal surfaces and spoken words of the patient, therefore, gave way to hidden underlying causes, based on detailed physical or clinical examination. Thus, as Jewson puts it, the sick man effectively ‘disappeared’ through the advent of Hospital Medicine, later to be microscopically or micro-organismically transformed, via Laboratory Medicine, into a collection of cells, with medical practice itself, effectively, becoming an ‘appendage to the laboratory’ (1976: 230).

In the short run, it is fair to say, biomedical knowledge and understanding far outstripped its curative potential (Porter 1997). Developments such as the introduction of sulfa drugs and antibiotics in the twentieth century, nonetheless, helped marry this advancing knowledge basis with tangible strides forward in medicine’s own so-called ‘battle’ against disease and premature mortality (Porter 1997: 10). The new genetics, in similar fashion, promises to more or less radically transform the fortunes of medicine, for better or worse, in a new ‘molecular’ era where DNA is clearly no acronym for DO NOT ALTER (see Chapter 8).

The biomedical model, to be sure, has engendered much (heated) discussion and debate within and beyond medical sociology circles, not least concerning its reductionist focus, the ‘machine metaphor’ through with it operates, and the infamous Cartesian mind/body dualism upon which it is premised, so named after the seventeenth-century French philosopher Rene Descartes, whose famous dictum ‘Cogito ergo sum’ (I think therefore I am) drove a wedge between mind and body.¹ As for the key features of this biomedical model, Mishler (1989), in a much cited paper, lists four characteristics – (i) disease as a deviation from ‘normal’ biological functioning; (ii) the doctrine of specific aetiology (specific diseases are caused by specific micro-organisms); (iii) the generic or universal nature of disease, regardless of culture, time and place; (iv) the ‘scientific neutrality’ of medicine – which serve, in effect, as a foil for the sociological imagination itself. Each, that is to say, is open to sociological scrutiny and debate (see the following two sub-sections).

How, then, have sociologists responded to or engaged with these ‘core’ features of biomedicine, and what have their critiques entailed?

The ‘efficacy’ and medicalization debates

It is possible to identify two main, overlapping, lines of critique here, the first (more within biomedicine’s own terms of reference) concerning its ‘efficacy’, the second pertaining to a broader social and cultural critique of modern medicine’s dominance and its (il)legitimate spheres of influence. The former so-called ‘efficacy’ debate will not concern us much here, suffice it to say that McKeown’s (1976) well-rehearsed critique of the limited historical role of medicine vis-à-vis other environmental measures and improved living standards in the decline of infectious diseases² has itself been superseded by the push, echoing Cochrane’s Efficacy and Efficiency (1972), towards evidence-based medicine (Sackett et al. 1997) – medicine, that is to say, based on the ‘best’ available evidence (the gold standard being randomized controlled trials)³ – together with a more ‘open debate’ on medical errors and accountability (see Chapter 9).

Porter’s somewhat ironic remark that ‘medicine’s finest hour is the dawn of its dilemmas’ (1997: 718) is indeed apposite in this context. As Renee Fox comments, in her revisiting of ‘medical uncertainty’:

shifts in multidimensional ways, long-standing sources and manifestations of uncertainty have been reactivated, accentuated, or modified and new ones have formed. It is with extensive uncertainty about its state of knowledge and accomplishments, its future directions and limitations, and with a mixture of confidence and insecurity, that modern Western medicine is approaching the twenty-first century. (2000: 422)

These tensions, dilemmas and debates in turn, feed into the second broader set of sociological issues concerning the social and cultural critiques of modern medicine and its ‘expansionist’ tendencies. Again a number of overlapping lines of thought and points of criticism may be identified here. Mishler (1989), for example, returning to the ‘core’ features of the biomedical model identified above, takes issue with each of these specific assumptions. ‘Deviant for whom?’ he asks, with respect to the first criteria of ‘normal’ biological functioning. The doctrine of specific aetiology is likewise problematic – no one-to-one correspondence can be assumed between pathological agent X and disease Y – as is the notion that manifestations of disease are somehow transhistorical and transcultural. The key issue upon which much sociological debate has turned, however, concerns the very notion that medicine, as a ‘scientific’ enterprise, stands ‘outside’ social relations. In contrast, it is held, medicine is an institution of social control. Parsons (1951) may have been the first to grasp this issue, in his classic formulation of the ‘sick role’ (see Chapter 9). It was left to others, nonetheless, to fully formulate the sociological critique at stake here, of which the so-called ‘medicalization thesis’ is a prime expression. ‘Medicine’s monopoly’, Freidson states, ‘includes the right to create illness as an official social role’ (1970: 206). Zola, in similar fashion, notes how medicine, in ‘nudging aside’ if not ‘incorporating’ the more traditional institutions of law and religion, is becoming the ‘new repository of truth, the place where absolute and often final judgements are made by supposedly morally neutral and objective experts’ (1972: 487). This, he argues, is a largely ‘insidious’ and often ‘undramatic’ accomplishment by ‘medicalizing’ daily life; a process in which the labels ‘healthy’ and ‘ill’ become ‘attached’ to an ever-increasing part of human existence (1972: 487). Manifestations of this ‘attaching’ or medicalizing process, Zola claims, are evident in at least four concrete ways: (i) through the expansion of what in life is deemed relevant to the good practice of medicine; (ii) through the retention of near absolute control over certain technical procedures; (iii) through the retention of near absolute control over certain ‘taboo’ areas; and (iv) through the expansion of what in medicine is deemed relevant to the good practice of life (1972: 488).

Perhaps the most radical formulation of these issues is provided by Illich (1975), whose thesis on the ‘medicalization of life’ and the associated issues of medical nemesis has engendered much discussion and debate over the years. The medical establishment, Illich boldly proclaims, has become a ‘major threat to health’. By transforming ‘pain, illness and death from a personal challenge into a technical problem, medical practice expropriates the potential of people to deal with the human condition in an autonomous way and becomes the source of a new kind of un-health’ (Illich 1974: 918). These debates surrounding the so-called ‘iatrogenic’ consequences of modern medicine – be it clinical (medical complications/drug side-effects, for example), social (the artificial need for medical products) or structural (the undermining of peoples’ autonomy and competence) – are well rehearsed.⁴

Suffice it to say that Illich himself is open to criticism on a number of counts. Navarro (1975, 1980), for example, from a neo-Marxist perspective, takes issue with both the explanations and solutions proposed by Illich to these iatrogenic problems, qua medical nemesis. Illich’s resentment of the industrialization of all fetishism (including medicine), Navarro asserts, ends up fetishizing the very process of industrialization itself (1975: 359–60). The professional power and dominance of medicine, moreover, is an illusion, with medicine itself labouring under capitalism, the interests of which it represents and reproduces in numerous ways. Power relations within the bourgeois order, from this perspective,

were the ones which determined the forms and nature of medicine, it led to scientific inquiry where the aim of that inquiry was the discovery of the cause or micro-organism, and the instrument of that, inquiry was the microscope. By focusing on the microcausality of disease, however, science ignored the analysis of the macrocausality, i.e. the power relations in society. (Navarro, 1980: 541)

These contentions find echoes in Taussig’s (1980) own elegant writings on processes of reification and the consciousness of the patient. Drawing upon Marx’s analysis of the commodity and Lukäcs’s application of this approach to the objectification of social relations, Taussig highlights a situation in which human relations embodied in signs, symptoms and therapy are denied, thereby mystifying these very relations and reproducing political ideology in the guise of a science of physical ‘things’. Medical practice, from this viewpoint, is an important way of maintaining the ‘denial as to the social facticity of things’, instead taking on a ‘life of their own’ severed from the ‘social nexus’ within which they are embedded (T...