06-06-2007 - S208 Week 10

S208 Week 10 6 June 2007 [Week 9] - Anspach  Cindy raises two critiques  it’s never going to be an even playing field – hospital staff will always have more information  Cindy: I don’t necessarily think one has more than the other  sort of incommensurate forms of knowledge? that incommensurability comes from what?  Cindy: sometimes it’s so embodied, it can’t be articulated  predicting what’s going to happen to anybody is an impossible endeavor  Cindy: so why do we try so hard to do it?  Beth M: technology has outpaced our ability to deal with it. the situation – and thus the conversation – is a product of technology. we haven’t developed technology with an eye toward its ethical ramifications  Amy: I had a problem with the paternalism demonstrated by the physicians  so your experience mirrors Anspach’s  people talk a lot about this sea change that occurred in the 1960s-70s, when medicine went from paternalistic model – where doctors told patient what would be done to him/her – to a model where they now respect patient autonomy, try to provide truly informed consent.. yet so much of what we read questions whether that’s actually happening, and raises the question of whether it’s even possible. what is it that we’re striving for – what’s a realistic goal? what should we be working toward, both in the health care system and in our broader society, re: health, illness, our bodies, what we should try to achieve in our life course? is technology far outstripping our society’s ability to pose intelligent questions – and if so, what do we do? just throw up our hands? become Luddites? as a society, can we really afford to think in those terms?  Amy: ethics is always behind wherever technology is. also left behind has been respect for individuals  are we psychologizing if we fault health professionals? is there a way we can raise the level of analysis beyond that of individuals?  Tania: we’re not rational actors, despite perceptions that we are. Hochschild’s emotion work. perceived notion of rationality.  Martine: going beyond psychologizing, whether it’s the provider or the family member, to the structural character of the health care system, and to the motivations for the types of communications that occur between health care providers and patients  what is it that might be missing that, if we had it, would make the difference? whether it be a piece of information, an ability, etc.  a big part of the problem is that, as John said, the neonate can’t speak for themselves. but if you look at the readings, to what extent does that make a difference?  Cindy: because even if you have a voice, so much is impacted by other factors at the scene

Amy: makes me think of Kleinman talking about ethnography. if the doctors got to know the patients, understood the situation, and helped them weigh what was going on in their lives, I think better decisions could be made together (instead of “the best biomedical outcome is _____”). providers tend to assess risks/benefits based on provider values John: going back to question of what is missing, there’s really no common understanding of the meaning of life or the nature of human existence. people, whether they’re conscious of it or not, are basically trying to reinforce their own belief systems. in a situation like in the intensive care nursing work, where so much of what any individual believes comes into question, there’s a tendency for people to seek out what’s familiar  Beth M: it’s not just the nature of life, it’s the nature of death – and the culpability you hold if you’re responsible for someone’s death  a new phenomenon in history, where one can be held culpable or implicated in someone’s death  it requires affirmative decision-making to do something or do nothing Beth T: going back to Amy, neither decision is wrong. if we would only respect that some people don’t opt for the technological route – and that there’s nothing wrong with it. we have to come to peace about allowing people to have that choice  Cindy: and respecting that they have the choice  Amy: Children’s Hospital in LA takes custody of kids when parents don’t agree with the course of treatment (e.g., Jehovah’s Witnesses won’t allow their children to receive blood transfusions). they do it on a very regular, almost daily basis  Cindy: loss of parental control in the state of California is frightening  Amy: who decided that intervention is the only answer? we have such a fear of death in our culture  our culture is a biomedical culture article looking at dialysis patients with diminished physical function and no chance of transplant. they use metaphors: “no man’s land,” “point of no return.” in the hypothetical case, they would choose not to receive dialysis and instead let go. but yet, every other day, they come in for dialysis. choosing to choose later. the enormity of that decision leads them to choose to choose later.  Krista: they see dialysis as not making a choice, even though it is a decision  that’s how families think about it too. do you want them to consent to the procedures? there’s no realization that, at that moment, you’re being placed on the track, and there’s no easy way to change to another track you can’t talk about life without talking about death. you see Children’s LA taking over parental decision-making because they’re saying it’s rational to act upon technical criteria. when clinicians decide something is a technical decision.. it’s also a social decision, and an ethical and moral decision  Cindy: the personification of technology is now the dominance. the people who have the technical expertise, with no background in education or health care provision.. they’re not devoting their life to humanity, but to the technology/device. it’s very dangerous/insidious, and we’re not realizing that.  Beth M: it’s not just a social decision, it’s also an economic decision. that plays a lot into provider decisions. we’re talking about the most expensive things we do in health care – neonatal and end of life. it’s a money maker and a money drainer, depending on whether 

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the person has insurance. people are given a price tag on their decisions – whether or not they pay them – and that’s a huge driver of what ends up happening. people are impacted by whether they’re respected, but there’s also the economics – an immense pressure on the system  economists conduct willingness to pay surveys. in the hypothetical, people always want things. for many environmental changes, people don’t want to pay out of their own pocket – but in the moment of the medical decisions, people actually often do opt for medical services the Ong article from last week demonstrates that it’s not just “who should” or “who ought,” but in fact we do think that re: immigrant bodies entering our borders, the existing citizenry can make claims. in effect, that’s the health system Ong describes. we can make certain claims, and they have certain obligations to the nation-state everything requires a consciousness about it that’s kind of overwhelming and historically a different condition of living altogether Amy: I disagree that providers make decisions based on economics; economics impacts the system, but when an intervention is possible, providers don’t look at what kind of insurance the patient has. ERs and ICUs have to admit patients whose lives are threatened. admins may see insurance, but providers do not  Beth M: I heard that providers are informed that patients are uninsured  Tania: I know of people who have been told not to receive services because they couldn’t pay  Amy: but for ERs, for life-threatening situations – where much of the money is spent – this doesn’t happen, and in fact can’t happen because it’s against the law Nayan Shah’s Contagious Divides: Epidemics and Race in San Francisco's Chinatown Erica: girl taking sugar pills to fight cancer  Kleinman brings up issue.. in cultural anthropology, people had/have to grapple with issue of understanding “the native perspective” from their own moral universe. there are no universal moral ethical constructs that all societies abide by. yet on the other hand, trying to balance that with this nihilistic cultural relativism. if you can come up with a framework that morally legitimizes any decision, then anything goes. is there a way we can intelligently and considerately say that not everything is okay, while acknowledging there’s a wide variation? Williams; Kerr and Cunningham-Burley Martine: Williams draws on two understandings of the body in medical sociology – phenomenological and social constructionist. I wonder where symbolic interactionism’s theoretical perspectives fall within that continuum  Romi: I found the phenomenological perspective seemed more interactionist  John: I see SI as a bridge between the two. SI is the how of how phenomena turn into a social construction.  Beth T: I didn’t think of it as a bridge, but I thought of it as lying between the two SI – as does social constructionism and phenomenology – the theoretical rubric it lays out is often broader and more wide-ranging than the specific ways it’s been taken up in the literature. even though there are many versions of social constructionism – people who take

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up social constructionism differ greatly on the importance they attribute to the physical body – the way the social constructionist literature has evolved has been heavily influenced by Foucauldian discourse. the literature to date sets itself against a phenomenological perspective that insists on placing bodily experience at the center. the way that Williams lays out the two different literatures.. don’t conflate the perspectives with the way they are taken up in the literature. the literature tends to take up a much more narrow part of the bigger spectrum that social constructionism can be. you can think of social constructionism the theoretical perspective as encompassing many different versions of social constructionism; yet the literature on social constructionist applications to the body – the way that specific scholars have taken up social constructionist perspectives vis-à-vis the body – take up only a small part of that spectrum. the social constructionist literature on the body has been faulted for being top-down, very inscribing of people, seeing the body more on a surface level, seeing what institutions and ideologies and cultural norms do to bodies.. yet there is nothing necessarily about social constructionism itself that couldn’t take up a more bodily level of experience. in a similar way, symbolic interactionism has been faulted for not taking up issues of power. when you start to talk about how things could be otherwise, how anything can happen in a given interaction.. the emphasis on these theoretical tenets of how society works emerges in large part as a reaction to structural functionalism, which was a more scripted notion of how society operates. symbolic interactionism – people interacting with one another are in the process of building up society all the time. much more open-ended notion of how society comes to be. the way people have taken up symbolic interactionism in empirical studies – if that’s going to be your emphasis over how top-down institutions tend to structure people (from the functionalist school) – you can see how there’d be a relative neglect of power. if your emphasis is more going to be on the open-ended nature – to counter more top-down approaches to how society is built up – you are, relatively speaking, going to neglect issues of power. but there is nothing within SI itself that doesn’t argue that some ritualized aspects of interactions have a scripted quality that could be used to explore issues of power. just because it hasn’t been taken up doesn’t mean the theoretical perspective isn’t capable of it  social constructionism has been faulted for not taking up bodily experience and meaningmaking  the Berger and Luckmann we read re: the social construction of knowledge – that kind of straddles both SI and social constructionism. that’s why you have to be careful about saying that social constructionism is this, that, or the other thing. Berger and Luckmann present a social constructionist-inflected view of symbolic interactionism. on the one hand, their explicit goal was to look at the sociology of knowledge. the way it had been taken up before was as less formal knowledges. Berger and Luckmann look at it as everyday knowledges, the knowledge one needs to navigate through the world; this is the way everyday reality can be seen as built up and constructed  I think what Williams was trying to argue – that social constructionism doesn’t pay attention to the biological body – doesn’t mean you have to jettison social constructionism as a theoretical approach. is social constructionism fundamentally opposed to seeing the body in a biological, lived, visceral kind of way? he’s trying to raise that question. is there common ground between these perspectives? maybe the phenomenological approach has gone as far as it can. maybe the problem is that these perspectives have gone so far in

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diametrically opposed directions. maybe this is not the most productive way to look at it. we’re trying to get away from and beyond these binaries. when you look at the importance of discourse, of text. the constructionist literature on the body, emphasizing the importance of the body as text.. they’re arguing that version of social constructionism – that says there is no importance of reality that is outside of language – that one representation of Foucault’s theoretical approach.. it’s not theoretically interesting, things cannot come to be until we can give voice to it and express it. language is a central means by which we apprehend things, by which we make reality. can there be experience without language? is it the case that discourse isn’t involved in “real” things that happen to us? Cindy: the Foucauldian notion of the panopticon conflicts with my understanding of his assessment of words circumscribing our understandings of reality  he doesn’t mean language and words so literally. our sense of things, our understanding of reality.. there is no notion or conception that is outside language, outside some means of expression. does it make sense to build a whole universe – of an approach to life and death, and the ethical framework of what is to be done in a situation – upon what is an unanswerable question (the question of what is going on in the body, what one’s intentions are)? some of this week’s articles are more prescriptive; others raise questions. Williams offers a potential way out  Tania: “need to recover a new non-reductionist way”  Martine: if the body is completely a text and discourse determines possibilities, where does action come in? at the same time, there are spaces where social constructionism has brought the body in in many ways, pointing out the two extremes/approaches.. on the one hand, social constructionism casting the body as a discursive construction, and on the other hand phenomenology.. just the act helps us to avoid taking up just one approach or the other dualism of theory and practice – they have to be one and the same. whatever corporeal reality is going to look like may differ from site to site and based on what questions you ask. each theoretical perspective will sensitive you to a different set of questions, which is not to say those sets of questions are incompatible. maybe we need to construct what the common ground is going to be “writing out” vs. “writing in”: the body as constructed reality. is there a reality that is not constructed? by focusing on the body as this fabrication, this surface text – it’s a construction of what. the way social constructionists have taken up the body, that’s not a question they even entertain. in some ways, talking about the body, just in theory, how much does that actually do for us? Kaufman never problematizes the body, yet it is present everywhere in her work ethnography tries to get inside a culture, inside a world, to find out how that world works. what’s on the horizon for medical sociology, social constructionism, symbolic interactionism? the political economy of medicine is so complicated, and we’re all kind of complicit in it. where is there leverage to intervene? how might things be otherwise?

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to the extent that we get caught up in biomedicine and how it’s a pervasive way of looking at the world, are we in fact further empowering it? Krista: what’s left of life? what’s the point of talking about what we’re talking about? how does it transform society, and how we perceive and act toward one another?