Course

Thinking through Medicine

Thinking through Medicine.png

Thinking through Medicine

Lydie Fialová

Medicine as an art of healing presents itself in varied and diverse cultural traditions. Its immediate engagement with illness and health, injury, pain, violence, and suffering, allows for unique perspectives on the human condition. The intertwined nature of life and death, the experience of vulnerability and finitude and a tentative sense of something that transcends this finitude, opens a perspective on the uniqueness and singularity of each human life, and yet also the essential interconnectedness of all life. It allows us to reflect on the richness of cultural imagination that captures the physical, emotional, social and spiritual dimension of health and illness in different social and historical contexts. Medicine nevertheless also situates the human condition in the planetary history of life, providing the perspective on human condition from the depth of time. 

 

The aim of this seminar course is to explore some of these various dimensions of medicine, in order to gain a clearer and more nuanced understanding of its role in our own lives and in the lives of communities and societies, as well as in the contexts of a planetary ecological crisis. The course will consider how specific forms of knowledge, practices of care, structures of time, architecture and material culture are transmitted and adapted throughout generations in various cultural contexts. It will also consider the ways in which the environmental and ecological conditions of life have changed as a result of medical and technoscientific processes, and examine the ways in which valuations of ‘progress’ now reveal its toxic dimension. Focusing on the concept of symbiogenesis it concludes with explorations of the geopolitical dimension of health and harm, and the socioecological distribution of pollution and risk in the context of the evolving web of life on this planet.

 

Topics

 

I. Being in the world: embodiment, temporality, interrelatedness.

 

II. The materiality of medical knowledge: on metaphors, animals and corpses.

 

III. The temporality of practices of care: on infants, hospitals and the silence of death.

 

IV. Medicine as an ideology and an instrument of sociopolitical control: on genes, microbes and sexes.

 

V. The symbiotic planet: on mitochondrias, toxins, and the river of life

 

I. Being in the world

 

In this introductory session we shall explore the ways in which we inhabit our lives, our relationships and our world, and how these are transformed by the experience of illness and confrontation with the reality of the finitude of our existence. We shall focus on some of the cultural frameworks of meaning - kinship, religion, medicine, art, nature - upon which people draw in order to understand and interpret this experience of essential vulnerability, of limits, of transience. We will also follow how these different understandings inform,

influence and structure relationships of interrelatedness - between patients, their families, and healthcare givers.

 

The scientific tradition of western medicine operates within positivist ideals of objectivity and methodological reductionism, defining what is considered relevant for medicine, and tends to relegate all what is not -  i.e. 'subjectivity' - to the personal domain. This tension between what is considered objective and what subjective, and how this line is drawn in different contexts, shall be discussed. We will also explore the implications of this distinction: how the subjective, or 'emotional', dimension of illness is negotiated in the interactions of patients and doctors. We will also explore what other aspects of human life

and experience are essentially left out of the concerns of the western medical tradition, and contrast this with other healing traditions that adopt different physiological and cosmological frameworks and which do not necessarily draw these distinctions in the same way. We also consider the phenomena of medical pluralism, eclecticism, and fusion.

 

Key concepts: ethnography, embodiment, temporality, narrative disruption, cosmology, symbolic meaning,medical pluralism.

* LvB: Grosse Fuge, Op. 133, 1827

* Pharmacopoeia: Cradle to Grave. The Wellcome Trust Gallery, British Museum, Room 24

* Carlo Levi: Christ stopped at Eboli. Penguin Modern Classics. 2010

* Robert Murphy: The Body Silent. Norton. 1990

Good, B. (1993) Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge

University Press

DelVecchio Good, Mary-Jo, Paul E. Brodwin, Byron J. Good, Arthur Kleinman (Eds.) (1994). Pain as Human

Experience. An Anthropological Perspective. University of California Press

Fadiman, Anne. (1997) The spirit catches you and you fall down. Farrar, Straus and Giroux

Hinnells, Paul, and Roy Porter (Eds.). (1999) Religion, Health and Suffering. Kegan Paul Intl.

Kleinman, Arthur. (1989) Illness Narratives: Suffering, Healing and the Human Condition. Basic Books

Kleinmann, Arthur. What is Specific to Biomedicine. In: Writing at the Margin. Discourse Between

Anthropology and Medicine. (1997) University of California Press

Lambert, Helen. Health care, hierarchy and the intracultural politics of recognition: Medical pluralism and its

narratives as ethnographic objects. L'Uomo, 2017(1), 157-176.

Leslie, Charles, and Allan Young. (1992) Paths to Asian Medical Knowledge. The University of California

Press.

Lindenbaum, Shirley, and Margaret Lock. (1993) Knowledge, Power, and Practice: The Anthropology of

Medicine and Everyday Life. University of California Press

Nichter, Mark, and Margaret Lock. (2002) New Horizons in Medical Anthropology. Essays in Honour of

Charles Leslie. Routledge

Scarry, Elaine. (1988) The Body in Pain. The Making and Unmaking of the World. Oxford University Press

II. The materiality of medical knowledge: on metaphors, animals and corpses

 

Medical knowledge and technologies both derive from and transform research and treatment as well as our understanding of diseases. The process of diagnosis can be understood as a form of interpretation: translating symptoms into distinct categories, correlating these with anatomical structures and pathophysiological processes, and linking them with etiological causes and epidemiological data - processes which all have specific historical trajectories and operate within distinct scientific paradigms. 

 

We tend to consider knowledge as something 'abstract', immaterial, objective. We shall consider how these abstract systems of concepts and classifications derive from the material world. The study of biological processes that constitute life, in cell cultures and organ simulations, relies on models and metaphors that facilitate our understanding of the multiple levels of organisation of living processes, and these metaphors often have a very solid grounding in material culture and social phenomena, such as warfare, writing, and

computing.

 

Historically, medicine has distilled knowledge from the study of corpses and research on animals which entail various degrees of violence, and these - in other contexts transgressive - acts also remain a key component of medical training. The bodies of those available for medical research in pursuit of objective knowledge and 'evidence' have often been those who were socially marginalised and excluded, and a similar pattern is detectable in clinical trials with human 'subjects' (and also in the area of genetic and tissue research and organ transplantations). We will also consider discarded embryos and foetuses as items within

anatomical collections and as objects of medical research, such as the use of their cells and tissues in the development of vaccines. The animals, prenatal - and postmortem - bodies, and 'patients' become biological specimens, objects of medical knowledge and production of 'materia medica'. This process is one of decontextualization and reification and is noteworthy for what is reveals as much as what it obscures. We will examine whether some of these practices of gaining medical knowledge - and power - can be in fact

understood through notions of sacrifice, divination, and gift, which anthropology has studied in other contexts.

 

Key concepts: explanatory models, metaphors, evidence, paradigm, bioavailability, sacrifice.

 

Cohen L. (1999) Where It Hurts: Indian Material for an Ethics of Organ Transplantation, Daedelus 128(4): 135-165.

Copeman, J, Quack J. Godless People and Dead Bodies. Materiality and the Morality of Atheist Materialism. In Social Analysis, Volume 59, Issue 2, Summer 2015, 40–61

Good, Byron J., Michael J. Fischer, Sarah Willen, Mary-Jo DelVecchio Good. (2010) 

A Reader in Medical Anthropology: Theoretical Trajectories, Emergent Realities. Wiley-Blackwells

Landecker, Hannah (2007) Culturing Life: How Cells Became Technologies. Harvard University Press

Lock, Margaret and Vinh-Kim Nguyen. (2018) An Anthropology of Biomedicine. Wiley-Blackwell

Lock, Margaret and Judith Farquhar. (2007) Beyond the Body Proper: Reading the Anthropology of Material Life. Duke University Press

Morgan, Lynn. (2009) Icons of Life: A Cultural History of Human Embryos. University of California Press

Nancy, Jean-Luc. 2008 The Intruder. In: Corpus. Fordham University Press

Petryna, Adriana. (2009) When Experiments Travel: Clinical Trials and the Global Search for Human Subjects. Princeton University Press.

Richardson R. (2000) Death, Dissection and the Destitute. Chicago University Press

Sacks, Oliver. (1999) Awakenings. Vintage

Sharp, Lesley A. (2019) Animal Ethos: The Morality of Human-Animal Encounters in Experimental Lab Science. University of California Press

Sheper-Hughes N, Wacquant L. (2003) Commodifying bodies. SAGE 2003

Tauber, Alfred I. (1994) The Immune Self. Theory or Metaphor? Cambridge University Press 1994

 

III. The temporality of practices of care: on infants, hospitals, and the silence of death

 

Medicine often mediates between life and death, and hospitals and other medical institutions are places where most of us are born - and where most of us are likely to die. Hospitals themselves reflect and materialise various medical classifications and distinctions, such as wards based on different organ systems, spaces of various degrees of purity/sterility, spaces for the dead, for visitors, and the trajectories of different 'kinds' of people through these spaces in time are an interesting way to explore medical culture through ethnography. Contemporary medicine is often criticised for depersonalisation of patients by institutional and bureaucratic regimes, objectification and commodification of care. 

 

However, the scope of care is actually much larger than the hospital, and includes informal modes of care in kinship structures, communities, and various formal forms of care provided by other social institutions, and these are often 'gendered'. Life demands care, and severe illness underscores our essential dependence on the care of others. 

 

We will explore these various modalities of care in their temporal contexts, where the horizon might be recovery as in acute conditions, some form of permanence in chronic conditions, or deterioration and death in degenerative and terminal conditions, and ask what these tell us about trust, patience and hope. Specifically in medical contexts, we shall focus on the concept of 'end of life care' as a point of departure to explore the various technologies of treatment and care: in neonatal intensive care units, emergency triage

wards, palliative care units, in the discourse over 'over-care' to be escaped by (assisted) suicide, euthanasia, or 'death by organ donation'. However, we shall also consider death by 'under-care' from the lack of medical treatment or financial means available to provide it. Finally, we follow the discursive transformation of 'patients' as citizens, clients, service-users or customers, and by this examine notions of inequality, solidarity and justice in the political context of health policy, and the implications of these for the particular forms of care-giving.

 

Key concepts: care, temporality, therapeutic spaces, clinical encounters, rituals of healing, technocratic imperative, structural inequality, death.

 

Elias, Norbert. (1986) The Loneliness of the Dying. Blackwell. 1986

Gawande, Atul. (2014) Being Mortal: Medicine and What Matters in the End. Metropolitan Books.

Illich, Ivan. (2000) Limits to Medicine: Medical Nemesis, the Expropriation of Health. Marion Boyars Publishers.

Kaufman, Sharon R. (2005) ....And a Time to Die: How American Hospitals Shape the End of Life. University of Chicago Press.

Kierans, Ciara. (2019). Chronic Failures Kidneys, Regimes of Care, and the Mexican State. Rutgers University Press.

Kleinman, Arthur. (2020) The Soul of Care. Penguin.

Lantos, John D., William L. Meadow. (2006) Neonatal Bioethics.The Moral Challenges of Medical Innovation. John Hopkins University Press

Lock, Margaret. (2001) Twice Dead. Organ Transplants and the Reinvention of Death. University of California Press

Mol, Annemarie. (2008) The Logic of Care: Health and the problem of patient choice. Routledge

Risse, Guenter B. (1999) Mending Bodies, Saving Souls. A History of Hospitals. Oxford University Press

Saunders, C. (2005) Selected writings 1958-2004. Oxford University Press

 

IV. Medicine as an ideology and an instrument of sociopolitical control: on genes, microbes, and sexes

 

Medicine, given its orientation to the ideal of 'health', works also ideologically and thus is prone to becoming an instrument of sociopolitical control. The process of the medicalisation of life, i.e. understanding, interpreting and governing certain phenomena as medical phenomena, carries with itself the commitment to biological reductionism and particular sets of normativities regarding what and who counts as 'healthy'. The judgment that health is more desirable than disease has the potential to become a judgment that healthy people are more worthy, desirable, or valuable than those affected by illness,

disability or any other forms of 'difference', or those who are considered 'products' of 'defective genes'. The expansion of new biological technologies and globalisation increased the power of medicine over the lives of individuals and populations. 

 

We shall examine the effects of human action mediated by medicine on other humans, where exercising technological power over 'nature' turns out to become the power of some

exercised over others, with a focus on reproduction, genetics, and sexuality. We will also explore the appropriation and interiorisation of these practices as 'technologies of the self'. Of particular interest will be the notion of 'life unworthy of living', first coined in relation to infants born with disability, then extended as a response to prenatal diagnostics, and also transposed to other contexts, and claims going in the opposite direction of perfection and enhancement. Given the uniqueness of each human being and the diversity of the human species, what is it that makes certain traits more desirable than others? What social conditions allow and facilitate these preferences for to become culturally dominant and reinforced, both by individuals and regimes of health and political governance? 

 

As an alternative frame of reference, we shall take the 'biological' aspect of medicine into another direction, reimagining human nature as 'animal nature', as a part of the ecology of life. How has this appreciation of the interconnectedness of life, both human and non-human, and intrinsically intertwined with the natural environment, changed the understandings of health, illness and death - taking into account also the detrimental impact of human actions on the conditions for life? Focusing on the concept of 'planetary

health' and on ecological and evolutionary approaches in medical anthropology, we will explore the possibilities for rethinking our understanding of the human condition.

 

Key concepts: medicalisation, essentialism, eugenics, normativity, stigma, biopolitics, ecology of health and disease.

 

Connelly, Matthew. (2008) Fatal Misconceptions. The Struggle to Control World Population. Harvard University Press

Dreger, Alice D. (1998) “Ambiguous Sex”—or Ambivalent Medicine?: Ethical Issues in the Treatment of Intersexuality. Hastings Center Report, Volume 28, Issue 3

Kevles, Daniel. (1998) In the Name of Eugenics. Genetics and the Uses of Human Heredity. Harvard University Press

Kohn, Eduardo. (2013) How Forests Think. Toward an Anthropology Beyond the Human. California University Press

Landecker, Hannah. Antibiotic Resistance and the Biology of History. In: Body and Society, 2016, Vol. 22(4) 19–52

McElroy Ann and Patricia K. Townsend. (2015) Medical Anthropology in Ecological Perspective. Routledge. 2015

Rapp, Rayna. (2000) Testing Woman, Testing the Foetus. The Social Impact of Amniocentesis in America. Routledge.

Taussig, Karen-Sue, Rayna Rapp, Deborah Heath. Flexible Eugenics: Technologies of the Self in the age of Genetics. Chapter 3 In: Goodman, Alan, Deborah Heath and Susan Lindee, (Eds.)

Genetic Nature/ Culture: Anthropology and Science Beyond the Two Culture Divide. University of California Press.

 

V. The symbiotic planet: on mitochondrias, toxins, and the river of life

 

Medicine as a system of knowledge and social institution is part of the global fabric of political economy, with often uneasy historical connotations. However, the understanding of the biological nature of human life connects it to other organisms sharing this planet: human body is an ecosystem of cells, bacterias, and viruses, and is connected to ecosystems and the elements – air, water, and soil, which make vital functions possible. Ecological, evolutionary and developmental biology provides a perspective on symbiogenesis, mutual co-creation. Mitochondrias, permanent inhabitants of eukaryotic cells that are at the core of energy

transformations have bacterial origins, and the atmosphere is created by living organisms.

Taking this perspective as a point of departure we can also examine the metabolic exchanges of socialecologies, the alterations of biological, chemical and physical features of the environment as part of industrial processes and the toxicities they produce. This combination of global and planetary perspective allows to study the geopolitical dimension of health and harm and the social distribution of pollution and risk in the context of evolving web of life on this planet.

 

Key concepts: symbiogenesis, environmental and ecological determinants of health, harm, toxic trajectories, injustice.

 

Begon M, Townhead CR. (2021) Ecology: From Individuals to Ecosystems. Wiley.

Boudia, Soraya, Angela N. H. Creager, Scott Frickel, Emmanuel Henry, Nathalie Jas, Carsten Reinhardt, Jody A. Roberts. (2021) Residues. Thinking Through Chemical Environments. Rutgers University Press.

Bowman WD, Hacker SD. (2021) Ecology. Oxford University Press.

Brown, Kate (2020) Manual for Survival. A Chernobyl Guide to the Future. Penguin Books.

Carson, Rachel (2002) Silent Spring. Penguin Classics.

Charbonnier, Pierre (2021). Affluence and Freedom. An Environmental History of Political Ideas. Polity Press.

Chakrabarty, Dipesh. (2021). Climate of History in a Planetary Age. Chicago University Press.

Gilbert S, Epel D. (2015) Ecological Developmental Biology: The Environmental Regulation of Development, Health, and Evolution. Sunderland.

Homburg, Ernst, and Elisabeth Vaupel. Hazardous Chemicals

Margulis, Lynn. (1999) Symbiotic Planet: A New Look At Evolution. Basic Books.

Mittman, Gregg (2010). In Search of Health: Landscape and Disease in American Environmental History, Environmental History 10: 184-209

Mittman, Gregg (2021). The Empire of Rubber. The New Press 2021

Lovelock J, Margulis L. Atmospheric homeostasis by and for the biosphere: the Gaia hypothesis. In: Tellus 1974: XXVI:1-2, 2-10

Swan, Shanna H., Stacey Colino. (2021) Count Down: How Our Modern World Is Threatening Sperm Counts, Altering Male and Female Reproductive Development, and Imperilling The Future of Human Race. Simon & Schuster, NY.