The
Focus of Biological Medicine –
The Clinical Body
The focus of biological medicine
is the ‘clinical
body’.
This clinical body
is not the actual body of any
individual human being – not my body or yours. Instead it is a body
constituted entirely by a body
of knowledge – specifically
the body of knowledge accumulated in the form of medical terms and
textbooks and imparted through medical and clinical training. The
‘gaze’ of the physician derives entirely from this body of
medical and clinical knowledge –
and is directed only at the ‘clinical
body’. It is a purely clinical
gaze
– one which turns the body into an object of medical-scientific
examination and clinical testing.
In his book Medicine,
Rationality and Experience,
medical anthropologist Byron J. Good describes how, in the course of
medical training, the body is progressively depersonalised. In
particular, through their training in anatomy and the dissection of
corpses, medical students begin a process comparable to a type of
extended and intense period of almost cult-like indoctrination –in
the course of which they gradually cease to see a human body as that
of a person
– and cease also to see the interior
of that person as a space of containing personal thoughts, feelings,
memories, fears and desires etc. Instead the person’s interior is
reduced to the anatomical structures revealed by cutting through the
body’s surface.
“In normal reality, the body
surfaces – the skin, the hands, the eyes, the face, the clothing
convey personhood. The interior of the person is his or her thoughts,
experiences, personality.”
Interviewing a medical trainee, Good
cites a student’s own words to reveal how, in the anatomical
laboratory “As the skin is drawn back a different ‘interior’
reveals itself:
“Emotionally, a leg has such a
different meaning after you get the skin off. It doesn’t mean at
all what it meant before. And now the skin, which is our way of
relating to people – I mean touching skin is … getting close to
people – how that is such a tiny part of what’s going on, it’s
like the peel of an orange. And once you get that off you’re in
this whole other world.”
Good remarks that “This whole other
world” becomes the paramount reality in the anatomy lab.
He also reports that “While
participating in anatomy as an observer, I would occasionally be
walking along a street and find myself a body amidst bodies, rather
than a person amidst person. I found myself attending to anatomical
features of bodies I passed, rather than perceiving them as persons
with social characteristics or imagined lives. Students describe
vivid experiences of this sort.”
Through its exclusive focus on diagnosing
and treating the ‘clinical body’, neither the individual’s felt
body, the individual human being
–
nor the individual world of
meaning
in which they live –
actually have any place in
biological medicine at all.
Consequently, biological medicine –
no matter how much treatment it gives to the clinical body –
cannot actually ‘cure’ a
single human being. Instead
only the patient’s illness can do that –
through recognition of its meaning for the patient as
a human being.
Reference: Foucault, Michel The
Birth of the Clinic
The Non-Existent Patient – chronic
illness, cancer and the work of Arthur Kleinman
The terms ‘existential medicine’ or
‘life medicine’ as I also term it, have a very direct meaning in
relation to what is taken as medicine today – biological medicine
or ‘biomedicine’. For the reality is that from the perspective of
biomedicine the patient neither exists
as a human being, nor is seen or understood as having any life
beyond the life of his or her body. This is not a philosophical claim
but one attested by countless patients’ experience of the way they
are treated by their physicians, i.e. precisely not treated as human
beings with real lives and therefore effectively just treated as
living corpses.
In the case of chronic illness, this
paradox of the ‘non-existent patient’ is exacerbated by the way
in which even the patient’s lived bodily experience of illness –
and of its daily effects on their lives – is something which
physicians almost never acknowledge or take any interest in, let
alone seem capable of showing the least bit of empathy for, clad as
they are in the emotional armour of ‘clinical distance’ that has
been drilled into them through their training as the only proper and
‘professional’ bearing to maintain – one which reduces both
patient and illness to a mere anonymous ‘case’ to be ‘managed’.
It should not need emphasising what effects this very bearing has on
the health of the patient, both physical and psychological, given the
experiential, emotional and existential quarantine it places them in
and the loneliness this creates. In contrast, no one has more
articulately acknowledged or given more vivid examples of patients’
daily lived experience of illness – not least chronic illness –
than Arthur Kleinman has in his book entitled The
Illness Narrative – Suffering, Healing and the Human Condition.
Almost the entire
book would need to be cited to
do justice to it in this regard, so I must restrict myself to a
selection of just a few sections from it:
“The undercurrent of chronic illness
is like the volcano: it does not go away. It menaces. It erupts. It
is out of control. One damned thing follows another. Confronting
crises is only one part of the total picture. The rest is coming to
grips with the mundaneness of worries over whether one can negotiate
a curb, tolerate flowers without wheezing, make it to the bathroom
quickly enough, eat breakfast without vomiting, keep the level of
back pain low enough to get through the workday, sleep through the
night, attempt sexual intercourse, make plans for a vacation, or just
plain face up to the myriads of difficulties that make life feel
burdened, uncomfortable, and all too often desperate. It has always
seemed to me that there is a kind of quiet heroism that comes from
meeting these problems and the sentiments they provoke, of getting
through each day, of living through the long course with grace and
spirit and even humor; sick persons and their families understand the
courage, even if most others do not.
Chronic illness also means the loss of
confidence in one’s health and normal body processes. The asthmatic
can no longer count on unobstructed breathing or a quick end to a fit
of coughing. The epileptic lives under the very point of the sword of
Damocles, uncertain when a fit will come. The sufferer of chronic
sinusitis goes from partially blocked nasal passages on one side to
some obstruction on both sides, then to completely stopped up nasal
passages with fullness, pounding in the ears, and mouth breathing –
which interferes with sleep and causes air swallowing and its effects
(gas, abdominal cramps). The sick person intervenes with nasal
inhalers or oral decongestants. The former are transiently useful,
but over time have less effect and may produce rebound sinus
congestion. The latter may produce abdominal discomfort and lethargy,
and they may worsen asthma. Each time the cycle of symptoms begins,
the sufferer loses faith in the dependability and adaptability of
basic bodily processes that the rest of us rely on as part of our
general sense of well-being. This loss of confidence becomes grim
expectations of the worst, and, in some, demoralization and
hopelessness.”
“For the chronically ill, details are
all. To cope with chronic illness means to routinely scan minute
bodily processes. Attention is vigilantly focused, sometimes hour by
hour, to the specifics of circumstances and events that could be
potential sources of worsening. There is a daily quest for control of
the known provoking agents. Enervating decisions must be made about
when to initiate or terminate an activity, when to move from base
line medication to second level drugs, and when to seek professional
help. And all this occurs in the context of active lives that are
filled with the same pressures, threats, vagaries, and exultations
that make of normal living such a “blooming, buzzing confusion”
(James [1890] 1981, 462). Is it any wonder that exhaustion is one of
the common shared experiences of chronic illness?”
It is in the context of the patient’s
lived experience of illness, together with its effects on their lives
and social relationships, that there arises what is all too often an
almost wholly unseen or unheard need for psychological and
psychosocial support and understanding – not least given the common
experience that chronic illness, whether terminal or not, can often
have a morbidly demoralising
effect on the patient’s relation to life
as such – and even
contribute to their premature death.
Kleinman again:
“...there is a controversial body of
medical and anthropological literature on psychogenic, self-willed,
and voodoo and magical deaths, which suggests that individuals can
come to believe that they are socially dead – a belief shared by
their social circle – and can die in a psychophysiological
reaction. Engel (1968;1971), conducting research at the University of
Rochester, has identified in patients with serious chronic illness a
complex of “giving-up, given-up” that correlates with unexplained
sudden death. Hacket and Weisman (1960; Weisman and Hacket 1961),
working at Massachusetts General Hospital, found that surgical
patients who strongly believed they would die in fact died much more
frequently than other surgical patients … In my experience, fear of
dying … is common among the chronically ill and their families. For
many patients with chronic illness the fear comes as vague, amorphic
ruminations that are crystallized when patients enter a terminal
stage of their disorder or when there is a severe exacerbation of
symptoms. It is important to remember that most patients with chronic
illness do not have an acutely life-threatening problem and that
many, perhaps most, will not die of their chronic illness. Indeed,
there is an old saying among clinicians to the effect that nothing is
as effective at teaching a person how to live a long life as the
experience of chronic illness. For some patients, convictions of
dying or giving up are not delusional perceptions of their current
situation, but rather perhaps early premonitions and remarkably
sensitive recognitions of mortal, though subliminal, bodily changes.
In the gray zone of serious but not life-threatening chronic illness,
such perceptions may be accurate reflections of extraordinary
psychophysiological sensibility. For most, however, such a sixth
sense responds to emotional reactions, personality type, life
situation, and even cultural background (for example, Jews have been
shown to be more fearful of symptoms and the threat of death than Old
Yankees) (Zborowski 1969; Zola 1966). If there is a single dimension
of illness that can teach us something valuable for our own lives,
then it must be how to confront and respond to the fact that we will
all die … There is no better example of what I mean than the sick
person’s coming to terms with death.”
The patient’s experience of
demoralisation
– not just through illness itself but through empathic failure on
the part of physicians, lends great appropriateness to Kleinman ’s
use of the term Remoralisation
to suggest the aim of a wholly new type of “medical psychotherapy”
– akin to what I call Life Medicine. By ‘medical psychotherapy’
he did not mean any standard or standardised form of therapy – and
certainly not psychiatric treatment of a sort which pathologises
a patient’s possibly quite morbid or death-preoccupied psychical
states – but rather a type of therapy which instead recognises
patients’ needs for psychological understanding and psychosocial
support as something no less and in some ways even more
important to their health, both psychological and
physical, than any form of biomedical care and treatment (which is
anyway usually given in clinical settings wholly alien to and
separate from the intimate context of the patient’s own personal
life – therefore further alienating
the patient from that life). However, as Kleinman writes on
‘Remoralisation’:
“Instilling or rekindling hope in the
chronically ill patient (and often in the family, too) is an
essential, though poorly charted, clinical domain. Of course, there
are models of short-term psychotherapy. But these have not been
widely translated into the care of the chronically medically ill (for
an exception, see Karasu and Steinmuller 1978)… Care for the
psychological needs of the chronically medically ill is a field with
few markers, like those unexplored portions of the maps of ancient
times that carried the ominous warning, “From here on dragons!”
The fact that even short-term counselling
of any sort is usually only given as a form of ‘palliative care’
to those patients seen as terminally ill, i.e. on a fast-track to
death,
symbolises a complete failure to recognise and respond to the
psychological dimension of illness as such – and chronic illness in
particular – in a patient’s life,
and that quite irrespective of however long or short that life may
turn out to be. Indeed, from the perspective of Life Medicine, it may
be hypothesised that illnesses becomes ‘chronic’ precisely
through the persistent – chronic – failure to offer the types of
‘medical psychotherapy’ that I call ‘Life Doctoring’.
Another symbol of this failure is the way
in which diagnoses of cancer in
particular have become so culturally charged with morbid
connotations. It is as if one particular type of disease has become
artificially singled out as
a symbol for the way in which illness in
general can come to gradually
‘colonise’ – to invade and pervade – ever more areas of a
patient’s life
– doing so in the same way that cancer cells can come to
‘metastasise’ to colonise different parts or organs of a
patient’s body. This symbolism would also explain the
disproportionate amount of money spent on ‘cancer research’ –
as well as on expensive but largely ineffective and often life
damaging
forms of cancer treatment. It is as if the ‘C’-word has, in
Freudian terms come to both ‘condense’ and ‘displace’
important dimensions of illness as
such – which continue to go
almost wholly unrecognised in their significance, having to do with
both the patient’s lived experience of illness and with the
personal, social, economic and cultural life contexts in which it
both arises and is experienced.
In highlighting such contexts, Kleinman
offers a stark account of how a poor black female patient (Mrs.
Flowers) suffering from a whole range of intense worries and life
pressures is reduced in her
clinician’s cursory medical report to a mere case of chronic
hypertension, i.e. high blood
pressure – one for which the ‘cure’ is simply medications and a
reduction in salt intake. Kleinman ’s transcript of a consultation
between this patient and her physician (Dr. Richards) shows the
latter’s obsessive focus on the purely bodily dimension of her
condition as opposed to its life dimensions – and his complete
failure to register the most obvious temporal and symbolic links
between them – even when these are made quite explicit by the
patient herself (and underlined in the sections from the transcript I
cite below) as well as impatiently interrupting any talk about
pressures in her life before she can even begin to say more about
them. Kleinman introduces the transcript by describing the patient as
a human being with a life outside the consulting room: being a mother
of five, periodically unemployed but now working as a poorly paid
waitress, having a partially paralysed mother, an unemployed pregnant
daughter with a history of drug problems, a brother in prison whom
she is afraid will also get involved with drugs, his 12-year old
daughter who has problems of truancy and minor delinquency and, last
but not least, a ‘friend’ she refers to – Eddie Johnson – in
reality, her long time male companion, recently killed in a barroom
brawl.
Some extracts from Kleinman ’s
transcript:
Dr. Richards: You said you had headaches?
Mrs. Flowers: Sometimes I think my
life is one big headache.
These here ain’t been too bad. I’ve had ‘em for a long time,
years. But in recent weeks they been badder than before. You see,
a year ago last Sunday,
Eddie Johnson, my friend, you know, Uh huh, well, he died.
And….
Dr Richards (interrupting): Are the
headaches in the same place as before?
Mrs. Flowers: Yeah, same place, same
feelin’, on’y more often. But you see Eddie Johnson had always
told me not to bother about…
Dr. Richards (interrupting again and
changing the subject): Have you any difficulty with your vision?
Mrs. Flowers: No.
Dr. Richards: Any other problems?
Mrs. Flowers: My sleep ain’t too good,
doc. I think it’s because…
Dr. Richards (interrupting again…): Is
it trouble getting to sleep?
Mrs. Flowers: Yeah, and gettin’ up real
early in the mornin’. I been dreamin’ about Eddie Johnson. Doin’
a lot of rememberin’ and cryin’. I been feelin’ real lonely.
Dr. Richards: Any other problems? I
mean bodily problems?
Mrs. Flowers: No, ‘cept for tired
feelin, but that’s been there for years. Dr Richards, you
think worryin’ and missin’ somebody can give you headaches?
Dr. Richards: I don’t know. If they are
tension headaches, it might. But you haven’t had other problems
like dizziness, weakness, fatigue?
Mrs. Flowers: That’s what I’m sayin!
The tired feelin’, it’s been there some time. And the pressure
makes it worse. But I wanted to
ask you about worries. I got me a mess o’ worries!
And I been feelin’ all down, as if I just couldn’t handle any
more…
Dr. Richards: … Right now why don’t
we do a physical exam and see how you’re doing?
Mrs. Flowers: I
ain’t doin’ well. Even I can tell you that.
There’s too much pressure
and it’s makin’ my pressure
bad.
Dr. Richards: Well, we’ll soon see how
things are going.
Mrs. Flowers spells out the connection
she clearly senses between pressures in her life that are getting too
much for her and “my pressure” – her diagnosed hypertension.
Dr. Richards clearly does not. Hence in his medical record Mrs.
Flowers all but ceases to exist
as a human being and reduces the worries and pressures in her life
to a set of numbers. I cite from Kleinman ’s record of this medical
record:
39 year-old black female with
hypertension on hydrochlorothiazide 100 mgs. daily and aldoment 2
grams daily. Blood pressure now 160/105. Has been 170-80/110-120 for
several months, alternating with 150/95 when taking meds. Has
evidence of mild congestive heart failure.
No other problems.
“No other problems.” One
can hardly think of a phrase that, in the context of this far from
untypical medical record, more blatantly exposes the complete
separation between the life of
the human
body and the life of the human
being that lies at the very
foundation of biological medicine.
Note:
though biomedicine has, since Kleinman wrote his book, grudgingly
come to realise the relation between ‘stress’ and hypertension,
this has led to words such as ‘stress’ and ‘stressor’
becoming loose ‘umbrella terms’ – as a result of which they
too grant permission to ignore
the highly individual nature
and meaning of events and
circumstances affecting the health of specific patients and calling
for recognition from physicians.
