Medicine, Anthropology of
MEDICINE, ANTHROPOLOGY OF•••
Medical anthropology is the cross-cultural study of health, illness, and medical systems. Medical anthropologists describe how the collective meanings, social institutions, and dynamics of political power in a particular society construct local forms of medical knowledge and therapeutic action that are differentially distributed across gender, age, ethnic, and class lines. From hundreds of studies a deeper understanding has been gained of variation in illness beliefs and behavior and of pluralism in healing practices (see, e.g., Good, 1977; Janzen; Kleinman, 1980; Leslie; Lock; Nichter). Yet there are also universals in the mediation of suffering and in the therapeutic process about which the comparative method provides a special insight (see Kleinman, 1988a, 1988b).
Medical anthropologists or anthropologists of medicine (the terms are interchangeable) have brought different paradigms to bear on the study of health and disease. Ecological, political-economic, and applied public-health or clinical perspectives are all to be found in the literature. Yet since the 1970s the most original anthropological contribution is what has come to be called a meaning-centered or social constructionist paradigm.
In this perspective, the central concern is with the way that illness categories and experiences reflect culture, and in turn contribute to social change. Thus, Gilbert Lewis (1975), working with a small-scale preliterate society near the Sepik River of Papua New Guinea, shows how that society's master symbols are reflected in the illness behavior of withdrawal and isolation of seriously sick members and in the "days of shining red" animated by healing rituals. The smells, tastes, sights, sounds, and sensibility of everyday responses to shamans' songs among aboriginals in the Malaysian rain forest and Malays in rice-farming villages (Laderman, 1991; Roseman); of routine coping processes through which Haitian villagers make accusations about the sources of AIDS (Farmer); and of the social as well as personal experience of sadness among Yolmo Sherpas in Nepal (Desjarlais)—all are patterned by deep cultural codes and social structures. Much the same cultural dialectic between persons and collective institutions has been shown to pattern interactions in psychiatric emergency rooms in North America (Rhodes); in the training of medical students to see patients through the lens of biomedical reductionism at Harvard Medical School (Good, 1993); and in the practices of oncologists in Tokyo, Rome, Oaxaca, and Boston (Good et al.).
Global social change has proliferated, not limited, the numbers and types of traditional healers in both richer, industrialized societies and poorer, industrializing ones (McGuire). Industrialization on a worldscale has neither undermined traditional medical beliefs nor foreclosed on folk health practices; yet such global social change has made much less clear the division between traditional and modern. One finds in the so-called East Asian industrial dragons, for example, a greatly complex mesh of attitudes, values, and practices. There is no simple giving way of tradition to Western orientation; indeed, both tradition and Westernization are routinely reinvented. The Japanese may be moving to accept brain death as a marker of the end of human life, and thereby facilitate organ transplantation, which has been severely constrained by Buddhist ideas; but it is a movement strongly contested by large numbers of Japanese who maintain traditional values about death together with the most advanced technological orientation.
Patients and their families, when it comes to serious illness, are pragmatic; they cross back and forth between the professional and folk domains of healthcare. Scientific knowledge has not replaced cultural common sense but been integrated with it (Kleinman, 1980; Nichter). Biomedicine has been the leading edge of a worldwide culture of science, yet in Asian and African societies biomedical institutions and relationships have become indigenized in ways that reflect those societies' master values and particular forms of social life. As a result there are both certain similarities and even greater dissimilarities in the ways professional and lay members of those societies make therapeutic decisions, handle life and death events, respond to chronicity and disability, and negotiate the complexities of care (Laderman, 1983; Last and Chavunduka; Rhodes; Sargent; Young, 1977).
Because of their concern for value orientations and everyday decision making, anthropologists have written about the ethical sides of health and healthcare. For example, Peter Kunstadter (1980) and Morton Beiser (1977) wrote about the ethical quandaries that development projects, including medical ones, introduced into traditional communities, because the services they provide are temporary and therefore raise expectations that eventually will be frustrated. Mary Jo Good and colleagues (1993) and Margaret Lock and Christina Honda (1990) examined the moral exigencies of truth telling about cancer and determining death in biomedicine in Japan. Paul Unschuld (1979) analyzed the corpus of Confucian and traditional Chinese medical writings on ethical issues, and concluded that professional and cultural values of the literati class colluded to control the medical marketplace. Arthur Kleinman (1980) found that healers in Taiwan in the 1960s and 1970s—whether traditional Chinese medical practitioners, shamans, or physicians—were viewed ambiguously: as morally powerful to heal, yet potentially immoral sources of economic gain and even of evil power (sorcery). This finding is rather widespread cross-culturally.
Horacio Fabrega (1990), writing explicitly about an ethnomedical approach to medical ethics, saw biomedicine's ethical preoccupations growing from Greek medicine and the popular morality of ancient Greece. Following many anthropologists, he asserts that in small-scale, preliterate societies, healing and religion are inseparable; thus, for Fabrega medical mores are tied to ritual and theology in these societies. In larger-scale societies—both peasant and posttraditional—the specialized division of labor leads to practitioners who are popularly viewed both as healers and as financially benefiting from the healer's trade. Fabrega argues that all the great non-Western traditions of healers use ethical injunctions to control access to practice and to proscribe certain alternative healers as quacks. He asserts that bioethics is a unique version of medical ethics made possible by the development of biomedicine with its knowledge of biology and powerful biological applications.
Writing for a collection of social-science treatments of bioethics, Richard Lieban (1990), himself an anthropologist, focuses on anthropological interest in the ethical aspects of controversial folk practices—such as female circumcision, differential assistance to male children, and the lack of regulation of folk healers—as examples of what anthropologists can offer to bioethical issues in international health (see also Scheper-Hughes; Korbin; Gruenbaum; Kleinman, 1982). Allan Young (1990), in the same volume, demonstrates the value of ethnographic accounts of the hidden moral dimensions of psychiatric practice in a Veterans Administration unit for treating combat-related posttraumatic stress disorder among veterans who had served in the Vietnam War.
What characterizes anthropological approaches to ethical issues, in medicine as well as other fields, is an emphasis on questions that emerge out of the grounded experiences of sick persons, families, and healers in local contexts. Anthropologists have critiqued universal ethical propositions just as their professional perspective has led them to critique universalist models for economic development. In place of universalist propositions—philosophical or politicaleconomic—anthropologists have focused upon the local interactions of everyday life and the moral issues in which they are clothed. In Isaiah Berlin's (1979) apt metaphor, they are more the fox than the hedgehog. The latter type of intellectual (e.g., the moral philosopher or the psychoanalyst) knows one big thing about the human experience, while the former (e.g., the historian or anthropologist) knows many small, particular things.
The remainder of this entry will adumbrate what anthropological studies tell us about health, illness, and care that is relevant to the practice of bioethics. Starting with a cross-cultural critique of leading bioethical orientations and commitments, the more powerful anthropological contributions will be reviewed, followed by a brief discussion of the possibilities and problems with a culturalist orientation. From the anthropological perspective, bioethics shares with biomedicine several determinative cultural orientations that constrain the standard approach to ethical issues in patient care. The anthropological approach, therefore, becomes particularly useful because of the comparative understanding it offers of often unexamined biases.
The ethnocentrism, psychocentrism, and medicocentrism central to biomedicine are prominent in the standard bioethical approach (see Lock and Gordon; Weisz). Most philosophically trained bioethicists draw on what Charles Taylor (1989) describes as the orthodox sources of the self in the Western philosophical tradition. The great works in that tradition, from those of the Greeks down to the present, assume an individuated self, set off from the collective—single, unchanging, and self-defining. Thereby, inter alia, the autonomy of the person is claimed to be a paramount value along with the ideas of justice and beneficence. From a cross-cultural perspective this intellectual commitment is problematic.
In the major non-Western societies—such as China, India, Japan, Indonesia, and most African societies—few people hold that the isolated individual is the locus of responsibility for therapeutic choice, or that therapy should work to maximize the individuation of the sick person. Rather, there is a paramount sociocentric consensus in which social obligation, family responsibility, and communal loyalty outweigh personal autonomy in the hierarchy of ethical principles. The self is viewed as sociocentrically enmeshed in inextricable social networks, ties that make interpersonal processes the source of vital decisions. More than 80 percent of the planet's population lives in cultures outside of North America and Western Europe or are members of minority ethnic groups outside of the Euro-American majority. That bioethics is able to avoid serious engagement with these alternative ethical traditions must represent one of the last tenacious holds of ethnocentric mentality. Indeed, there is evidence that bioethicists are commencing such decentering cultural engagements (Jennings; Loewy).
Similarly, from an ethnographic perspective, the use of abstract concepts of justice and beneficence as universal ethical principles in decision making is suspect because of the failure to take into account the local worlds in which patients and practitioners live—worlds that involve unjust distributions of power, entitlements, and resources. It is utopian, and therefore misleading, to apply the principles of justice and beneficence to practical clinical problems, unless we first take into account the brutal reality of the unjust worlds in which illness is systematically distributed along socioeconomic lines and in which access to and quality of care are cruelly constrained by the political economy. Beneficent social contracts may make good theory, but they deny empirical experience in local social worlds. Loewy's "beneficent community," which he claims is concerned with minimizing the suffering of its members, is a charming romance; no one lives in such a utopian state. Rather, real communities are sources of suffering at least as much as potential sources of assistance. They do not contain social contracts; but they are filled with different interests, status differences, class divisions, ethnic conflicts and factionalism. Little is gained by instantiating utopian virtues; indeed, much is lost, since illusion and exaggeration distort the practical realities of living.
The third "centrism"—medicocentrism—emerges from comparative studies as yet another bias of standard bioethical discourse. Like biomedicine, bioethics begins with professional definitions of pathology. The disease viewed as pathological physiology, and the professionally authorized array of treatment interventions, define the clinical situation (see Canguilhem). The experience of illness is made over, through the application of ethical abstractions such as those described above, into a contextless philosophical construct that is every bit as professionally centered and divorced from patients' suffering as is the biomedical construction of disease pathology.
The bioethicist, of course, is supposed to take into account the patient's perspective. But by and large the contextually rich illness narrative is reinterpreted (also thinned out) from the professional biomedical standpoint in order to focus exclusively on the value conflicts that it is held to instantiate. The folk categories of patients and indigenous healers are provided with only limited legitimacy. If they can be restated in the abstract terms of the standard bioethical orthodoxy, they are provided a place in the analysis. But if they cannot, then folk categories lose their authoritative imprint to define what is at stake for patients and families.
Take ideas, for example, of suffering—a powerful folk category worldwide. One is surprised to find so many professional ethical volumes in which this word does not appear as an entry in the index. Ethical systems that leave the problem of suffering (and related concepts of endurance and courage) to particular theological traditions cannot adequately engage the human core of illness and care. Here perhaps the standard version of bioethics shares yet another biomedical bias, the rejection of teleology. Biomedicine banishes the concepts of purpose and ultimate meaning to religion; yet most patients and practitioners struggle to make sense of illness with respect to great cultural codes that offer coherent interpretations of experience (cf. Frye).
Medicocentrism also leads bioethicists to construct cases that are centered in the professionally approved institutional structures of biomedicine—such as hospitals or nursing homes—despite the fact that most illness episodes, as social studies reveal, are experienced, interpreted, and responded to in the context of the family. The family—the mundane cultural setting of illness and care, where local social processes are so greatly influential—and the workplace frequently disappear in bioethical discourse, to be replaced by the biomedical staging of more extreme, even exotic value conflicts. Of course, the immense panoply of settings for healing is even less visible or audible in the bioethical construction of clinical reality.
This all too black-and-white portrait of bioethics is intended to draw out and highlight its deep difficulties and their cultural sources. In the practical flow of events, the working bioethicist struggles to overcome the constraints that limit his or her engagement with the obdurate particularity and inexpedient uncertainty of human subjects. And for that very reason he or she will find an ethnographic orientation to be liberating.
In contrast with the bioethicist, the ethnographer begins with the lived flow of interpersonal experience in a deeply particular local world. Not the Western tradition or North America, nor even New York State—which are too unspecified to provide a positioned view from somewhere—but, rather, the Puerto Rican community in the South Bronx, upper-middle-class Scarsdale, a working-class section of Queens, or a network of Russian immigrants in Brooklyn becomes the setting for grounding moral analysis in the concrete historicity, micropolitical economy, and ethnicity of a local world. Even within such a localized flow of experience, perspectives and preferences are further defined by gender, age, and other social categories of persons: for example, the cultural situation of poor women in rural Haiti who are responding to AIDS (Farmer and Kleinman). These indexes of social experience situate groups and their individual members along axes of power such that the forces of macrosocial pressures—economic depression, war, forced uprooting, ethnic conflict, state violence, the organizational control of substance abuse, the social structural sources of chronic illness and disability—are systematically attenuated for some, yet amplified for others. Some become successful or at least are protected; others are victims.
Each local world is characterized by what is at stake for its members. That structure of relevance—compared to a belief or a convention—gives to the meanings of illness and to treatment expectations the sense of something much closer to natural law. Families hold the world to be a certain way as an article of fundamental faith in local reality. In the infrapolitics of family, workplace, and community, which is empirically discoverable, the processes of strategic negotiation and interpersonal engagement over what is at stake can be properly regarded as processes through which a local moral order is constituted and expressed. Culture, then, is built up out of the everyday routines and rhythms of social life. It is the medium of experience, for example, in which one person's chronic pain affects an entire work unit, a family member's Alzheimer's disease is shared as an illness reality by the entire family, and cancer care is negotiated among parents, child, and professional care providers.
Hospitals, clinics, and disability programs also are grounded in the particularity of local worlds, as is the bioethicist. The ethnographic task for the practicing bioethicist, then, becomes the discovery of the meanings and relationships in distinctive local worlds, and their actual impact on particular patients, families, and practitioners. This is a kind of cultural analysis of moral conflicts and negotiations over plans and practices that make up the flow of everyday living. As part of this ethnographic work, the bioethicist needs to elicit the perspectives of the participants and place them in the contexts of family, workplace, and medical system. The bioethicist's involvement should be to facilitate communication and to help negotiate conflicting orientations. In this work, it is necessary to protect the participants from the dehumanizing imposition of hegemonic principles. This focus on the positioned, intersubjective perspectives of participants in a local context is a radically different vision of how to proceed with the ethical analysis of a case than that which originates in a philosophical quest for an illusory transpositional objectivity, a synthesis valid for an entire context, which in the anthropological vision is the problem, not the solution (Sen).
More specifically, anthropological analysis draws attention to the institutional context of ethical decision making (see Bosk; Fox; Mizrahi). Social institutions—a particular type of hospital, a clinic for alternative care, or a religious facility—refigure ethical issues in terms of efficiency and other technical criteria that make up everyday social routines. Hence, the special characteristics of a Veterans Administration hospital, a university-based teaching hospital, a military hospital, a member of a for-profit hospital chain, or a highly cost-conscious HMO constrain the day-to-day social processes that create the local moral order. What is at stake for a resident in training in a teaching hospital—generating new knowledge, securing a place in the academic hierarchy, and so on—is noticeably different from what is at stake for a senior physician at a small community hospital. The difference signals a distinctive institutional context for deciding what level of treatment is routine, which kinds of issues will be highlighted as ethical problems, when families will be involved, and so on. Quite obviously, such institutional contexts will also be distinctive cross-culturally.
In Japan, even in a university teaching hospital, the practice has been not to disclose to patients that they are suffering from cancer but to allow key family members to decide if and when the truth will be told. In China, family members will stay in the hospital with the patient to do the nursing, prepare meals, and make all the major decisions, even for the family head when he is seriously ill.
In Zaire and Senegal, members of the kinship-based therapy management group, including perhaps the doctor and the nurse, will decide if the patient is to be part of a research protocol (Beiser). In a Seventh-Day Adventist mission hospital run by American staff in Borneo, the structure for identifying and resolving a moral dilemma draws on a religious ideology that suffuses the institutional context in a manner that greatly differentiates this hospital from nearby hospitals run by transplanted Javanese Muslims or local animists. The responses of North American and Chinese psychiatrists to depressed patients in the United States and China have been compared with respect to their decidedly different institutional contexts for determining what kinds of therapeutic behaviors represent good care and what kinds of moral messages will be given and received in the patient-doctor interaction (Kleinman, 1988b). Renée Fox and Judith Swazey (1984) have shown how physicians in a Chinese hospital draw on both Confucian views and Communist ideology to authorize local patterns of ethical decision making that challenge North American orientations. And cultural historians disclose how bioethics in North America has emerged out of the social problems and responses of a particular era (Rothman).
Besides cultural critique and comparison, what practical contributions can anthropology make to bioethics? The cultural formulation of diagnostic and therapeutic issues clearly should be as significant to the consulting bioethicist as it frequently can be made to be for the consulting physician, especially when the patient and family come from cultural and ethnic backgrounds that differ from those of their professional caregivers, or when the setting is outside North America (Kleinman, 1982). That formulation involves systematic steps in placing the illness and treatment experience in the culturally grounded context of family, work, and medicalsocial welfare systems, through the application of a mini-ethnography—a description and interpretation of how those settings affect, and are affected by, the illness. Cultural formulation identifies lay and professional explanatory models, compares them for evidence of cultural bias or conflict, and sets out a process of negotiation to assure cultural sensitivity (see Helman, 1984; Kleinman, 1988a; Rogler). These are technical procedures that should be part of the repertoire of the bioethicist. Ethnographic knowledge of the core ethical orientations and social patterns of different communities will be especially significant in planning and implementing medical research in ethnic minority and non-Western settings (Christakis).
What are the limits of cultural analysis, cross-cultural comparison, and the sensibility to variation and differences that come under the term cultural relativism? While epistemological and even ontological relativism—willingness to entertain the idea that there is no single form of knowledge or being in local worlds—will seem defensible to many, ethical relativism of the radical variety—the idea that there are no ethical standards cross-culturally—will not. Are such practices as infanticide of female children in South Asia, ritual murder of elderly women accused of being illnesscausing witches in East Africa, and rationing of care based on color status under apartheid acceptable because the dominant group says they are? Clearly, this would be an unacceptable conclusion. Behind it lurks the terrible transmogrification of medicine under the Nazis, when biomedical ideology and technology, dominated by Nazi values, prepared the way for the death camps (Kleinman, 1988b; Proctor).
The anthropological argument advanced in these pages is for elicitation and engagement with alternative ethical formulations, a constrained relativism; it is for affirmation of differences, not automatic authorization of any standard or practice as ethically acceptable because it is held by some people, somewhere (Shweder; Wong). The limit to ethical relativism is that the bioethicist must compare alternative ethical formulations with those ethical standards he or she holds for the evaluation of a particular problem in a particular context. The outcome of such an evaluation could be acceptance or rejection of the alternatives or of the bioethicist's own standards, or some form of negotiation and compromise.
The idea of radical cultural relativism is unacceptable to all but a small group of diehards. It is, moreover, a serious misinterpretation of what ethnography, cultural analysis, and cross-cultural comparison have contributed: the idea that before we apply an ethical category we hold to be universal, we had better understand the context of practice and ideas that constitute a local moral world. The job should be to situate a bioethical problem in that local ethos in order to understand what is at stake for the participants, what is contested, and thereby to offer a cultural formulation of conflicting ethical priorities. That having been done, there are at least three further steps. First, we need to systematically compare local and professional bioethical standards for that particular problem; second, we need to negotiate that part of the difference on which both parties deem it ethical to compromise; and third, where a cross-cultural ethical conflict cannot be so resolved, both parties should specify the nature of the problem for further adjudication (Kleinman, 1982). This ethnographic strategy does not commit the deep error of assuming that "all goods, all virtues, all ideals are compatible, and that what is desirable can alternately be united into a harmonious whole without loss" (Williams, p.xvi). Compromise and negotiation may not resolve ethical conflicts; and even where they do, some losses must occur. The quest is not for integration and unification, but for multicultural pluralism.
Where possible, it is the obligation of the bioethicist not only to respect the specific views of others and to affirm the validity of the process of alternative moral formulations, but also to develop deep knowledge about those viewpoints and to test those alternative categories and practices for potential ways to resolve ethical conflict. This ethnographic approach emphasizes the process of engagement and negotiation with the lived moral orientations of others; it attempts to minimize the application of those bioethical standards that derive from the Western philosophical tradition, to settings for which they lack coherence and validity. In all other areas of cross-cultural research and practice this is the established procedure. This approach also protects the responsibility of the professional bioethical consultant not to accept value decisions that contravene human rights and other pannational moral conventions. But it makes this universalist responsibility the final stage in a process of cultural translation that gives priority, initially at least, to alternative worlds of experience interpreted in their own terms. Perhaps the cardinal contribution of the medical anthropologist to bioethics is to deeply humanize the process of formulating an ethical problem by allowing variation and pluralism to emerge and receive their due, so that ethical standards are not imposed in an alien way; rather, these standards will then be realized as the outcome of reciprocal participatory engagement across different worlds of experience.
arthur kleinman (1995)
SEE ALSO: Alternative Therapies: Social History; Body: Cultural and Religious Perspectives; Death: Cultural Perspectives; Health and Disease: Anthropological Perspectives; Human Nature; Medical Ethics, History of; Medicine, Sociology of; Mental Illness: Cultural Perspectives; Women, Historical and Cross-Cultural Perspectives
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