Gaines (1992b) refers to two discursive modes by which Biomedicine is learned, shared, and transmitted: "embodied" and "disembodied" discourses. Through embodied person-to-person communication and through disembodied texts and images of various kinds, biomedical realities are (re) created over time. Both means have served to (re)produce popular as well as scientific knowledge. But it is noteworthy that science can and does recreate popular knowledge as scientific knowledge. For example, U.S. Biomedicine continues to consider "race" to be a biological reality (Gaines, 1995). This Local Biology, reflected in scientific medical research and practice, has been augmented over the last several decades by the misinterpretation of genetic research results—an unfortunate situation that has reinforced unfounded racial ideologies (Barkan, 1992) and their eugenic overtones (Duster, 1990).
The relatively recent emphasis on "evidence-based medicine" expresses many physicians' dawning realizations that much of their practice, in fact, has not been based on scientific evidence but on medical habits and tendencies, ingrained popular beliefs, and mentor-to-student traditions (e.g., radical mastectomies, low cholesterol diets, circumcision). Medical socialization explicitly and implicitly teaches professional assumptions about biological verities (Good, 1994; Good & DelVecchio Good, 1993) heavily influenced by a variety of sociocul-tural distinctions (Hinze, 1999). These powerful formative processes of socialization (Good, 1994) and those of medical practice employ an "empiricist theory of language" (Good & DelVecchio Good, 1981) wherein what is named is believed to exist independently in the natural world. Nature, too, is believed to exist "out there," independent of the mind of the knower (Gordon, 1988; Keller, 1992).
Through naming and consequent diagnosis, medical language affects and effects transformations of culturally perceived reality. As Gaines and Hahn (1985, p. 6) noted:
That the system of Biomedicine is a sociocultural system implies that Biomedicine is a collective representation of reality. To claim that Biomedicine is a representation is not to deny reality which is represented, which affects and is affected by what it represents. It is rather to emphasize a cultural distance, a transformation of reality; an ultimate reality cannot be known except by means of cultural symbol systems. Such systems are both models of and for reality and action [Geertz, 1973]. Our representations of reality are taken to be reality though they are but transformations, refracted images of it.
Biomedical representations of reality have been based from its inception on what Davis-Floyd and St John (1998) call the "principle of separation": the notion that things are better understood in categories outside their context, divorced from related objects or persons. Biomedical thinking is generally ratiocinative, that is, it progresses logically from phenomenon to phenomenon, presupposing their separateness. Biomedicine separates mind from body, the individual from component parts, the disease into constituent elements, the treatment into measurable segments, the practice of medicine into multiple specialties, and patients from their social relationships and culture. This drive toward separation and classification can obscure the many meanings in the non-linear, non-logical relationships between and among entities.
Nevertheless, Biomedicine's atomistic trend continues to escalate. A few years ago, biomedical researchers were talking excitedly about a "paradigm shift" away from disease-causing organisms to genes. From an anthropological viewpoint, of course, this did not constitute a full ideological paradigm shift but rather an intensification of Biomedicine's separatist approach. Then, in 2001, the Human Genome Project demonstrated that the human genome consists of only 30,000 genes. As a result, the once apparently vast field of genetic explanations of disease suddenly collapsed, and researchers have shifted their focus to proteins in the emerging field of "proteomics."
Biomedicine's separatist tendency results in part from its coming of age during the period of intense industrialization in the West, which led it to adopt the machine as its core metaphor for the human body. This metaphor underlies the biomedical view of body parts as distinct and replaceable, and encouraged the treatment of the patient as an object, the alienation of practitioner from patient, and the discursive labeling of patients as "the gallbladder in 112" or "the C-sec in 214." Patients were not expected to be active agents in their care (Alexander, 1981, 1982); the physician was the technical expert in possession of the uniquely valued "authoritative knowledge" (Jordan, 1993, 1997)—the knowledge that counts.
In the past few decades the Western world has exported much of its industrial production to the Third World, where the process of industrialization continues apace. The West itself has transformed into a technoc-racy—a society organized around an ideology of technological progress (Davis-Floyd, 1992). Thus, Davis-Floyd and St John (1998) describe Biomedicine's dominant paradigm as "the technocratic model of medicine"—a label meant to highlight its precise reflections of technocratic core values on generating cultural "progress" through the development of ever-more-sophisticated technologies and the global flow of information through cybernetic systems. Such developments have generated a new form of medical discourse in which patients themselves are often now expected to be conversant because of the wide availability on the Internet—the ultimate agent in the global flow of information—of even abstruse biomedical information.
Mary Jo Delvecchio Good (1995) has noted the dual emphasis on "competence and caring" that characterizes contemporary biomedical education in some locations. This emphasis reflects the growing valuation within Biomedicine of what Davis-Floyd and St John (1998) have termed "the humanistic model of medicine"—a paradigm of care that stresses the importance of the practitioner-patient relationship as an essential ingredient of successful health care. This paradigm (previously also known as the "bio-psycho-social approach" (Engel, 1980)) replaces the metaphor of the body-as-machine and the patient-as-object with a focus on "mind-body connection" and the patient as a relational subject. The "gallbadder in 112" becomes Mrs Smith, mother of four, suffering from the stress of an unhappy marriage and the looming poverty that will result from her divorce. Kleinman's Illness Narratives (1988a) has made many physicians more aware of the importance of listening to their patients and including their personal and sociocultural realities in diagnosis and treatment. This "conversation-based" approach is augmented by the "relationship-centered care" stressed by the Pew Health Foundation Commission Report (Tresolini et al., 1994) and a new emphasis on "cultural competence" in biomedical training, to which many anthropologists have contributed (see Lostaunau & Sobo, 1997).
Humanism was the central feature of the family practitioner until its near-obliteration by the splintering of Biomedicine into specialized fields that involved minimal practitioner-patient contact, which gained impetus during the 1960s and 1970s. Humanism's renaissance among contemporary physicians has led to the development of more patient-centered approaches to medical education such as the case-study method, in which students are taught through a focus on specific patients instead of a detached focus on disease categories.
Biomedical humanism reflects the technocracy's growing supervaluation of the individual (the "consumer" whose individual decisions affect corporate bottom lines), in contrast to industrial society's subsumption of the individual (the "cog-in-the-wheel") to bureaucratic systems oblivious to individual needs and desires. Humanistic touches range from the superficial—for example the interior redecorating of many hospitals (a prettier and softer environment has been shown to positively influence patient outcomes)—to the deep, such as encouraging parents of ill newborns to hold them skin-to-skin (an effective therapeutic technique known as kangaroo care).
A third transnational paradigm, identified by Davis-Floyd and St John (1998) as the "holistic model of medicine," recognizes mind, body, and spirit as a whole, and defines the body as an energy field in constant relation to other energy fields. Whereas humanistic reform efforts arose from within Biomedicine (at first largely driven by nurses), the holistic "revolution" has arisen since the 1970s largely from outside Biomedicine, driven by a wide variety of non-allopathic practitioners and consumer activism (Fox, 1990). It increasingly incorporates elements of traditional and indigenous healing systems.
At present, a small percentage of physicians worldwide define themselves as "holistic," but in general, biomedical practitioners have been resistant to accepting other knowledge systems as valid, and continue to regard their own system as exclusively authoritative. Nevertheless, as the limits of Biomedicine (which cannot cure many common ailments) become increasingly evident, millions of people in the postmodern world continue to rely on, or are beginning to revalue, indigenous healing systems and to incorporate holistic or "alternative" modalities into their care.
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