Getting Ill to See a Doctor
“The doctor is the drug.”
“…the drug ‘doctor’ is a
potent one with many unwanted side effects.”
Michael Balint
In a society in which biological medicine
or ‘biomedicine’ is institutionally dominant and ‘mental
illness’ is still tainted by stigma, getting ill and seeing a
doctor remains the principle socially
acceptable way for people who
are consciously or unconsciously
ill-at-ease with their lives to obtain the care and attention they
need or seek.
Precisely for this reason however, a
primary purpose
of illness can be to serve as a principal
communicative medium by which
individuals seek – through the clinical encounter with a physician
– acknowledgement of their existential
dis-ease or life
suffering – one whose origin or ‘etiology’ does not lie in the
biological life of the patient’s body but rather in their life
as such and their life-world
as a whole (including their
work world, family world etc).
However the pre-condition
demanded by the clinical encounter for attaining the acknowledgement,
care and attention that the patient seeks for their existential
dis-ease
is that they ‘present’ the physician with bodily symptoms that
can be neatly fitted in the diagnostic schema of biomedicine, i.e.,
acknowledged as signs of recognised diseases
for which standard biomedical tests and treatments can be prescribed.
If this pre-condition is not
fulfilled the individual risks being classed as a hypochondriac,
malingerer or ‘heart-sink’ patient, i.e., one whose symptoms, old
or new, consistently defy any form of straightforward clinical
diagnosis, despite repeated visits to their doctor, multiple medical
tests or appointments with specialist consultants.
For the individual not
merely to be written off or
classed as a hypochondriac or malingerer, their
own body
knows full well
that it must translate or ‘body forth’ their existential dis-ease
and life suffering in the form of symptoms of an ‘actual’
biological illness or disease capable of diagnostic identification
and treatment.
The word ‘iatrogenic‘ comes from the
Greek words genesis
(origin) and iatros
(physician) and is used to refer to illnesses originating from
medical treatment itself. One of the intrinsically iatrogenic
dimensions of biological
medicine lies in the fact that in many cases patients
do not simply go to doctors because they are ill.
Instead they
become ill
in order to be able to go to
doctors – to create
opportunities through the clinical encounter for the indirect
communication and acknowledgment of their existential dis-ease and
life suffering. This is perhaps the chief purpose and meaning of
illness in the context of the clinical encounter.
Particularly in the case of individuals
who are lonely or isolated, or whose communicative world or abilities
do not fulfil their need to be understood, the clinical encounter
with a physician is sought as something intrinsically
healing – healing simply
because of the opportunity it offers for a tiny
dose of understanding communication –
however medically distorted this ‘understanding’ may be and
however absurdly time-limited the communication itself (in contrast,
for example, to a 50 minute psychotherapy session).
It is the modicum
of human contact provided by the clinical encounter with the
physician or the human care provided by hospitalisation that is most
healing for the patient. In this context, it would be most
interesting to have available statistics showing the number of
patients whose symptoms diminish or even disappear on the very
day of an appointment with a
doctor – feeling better simply through the expectation or
experience of being able to communicate
their suffering with a human being who is, by profession, duty bound
to give them care and attention, take their suffering seriously and
‘understand’ it – even if only in biomedical terms.
Ivan Illich identified three types of
iatrogenesis – clinical, social and cultural.
‘Iatrogenesis is clinical when pain,
sickness and death result from medical care
; it is social when health
policies reinforce an industrial organization that generates
ill-health; it is cultural and symbolic when medically sponsored
behaviour and delusions restrict the vital autonomy of people by
undermining their competence in growing up, caring for each other,
and aging, or when medical intervention cripples personal responses
to pain, disability, impairment, anguish and death.’
To the three types of iatrogenesis
identified and described by Illich one could add a fourth. I call
this ‘communicative iatrogenesis’.
Communicative iatrogenesis arises from
the fact that the required language
necessary to seek and attain understanding communication through
doctoring is the language of bodily illness
itself. For whilst it would
not be usual for a recently bereaved and lonely widow(er) to see a
doctor in order to complain of being ‘heart-broken’ or of ‘losing
heart’ to live, what is
culturally acceptable – if
not normative – is to go to a doctor and complain of pains in the
region of the heart or heart arrhythmias. This is something that
the patient knows. Yet – and this is the key factor – it is also
something that the patient’s body
knows and is capable of responding to – by generating chest pains
or heart arrhythmias. Of course there is such a thing now as
‘bereavement counselling ’. Yet how many prospective patients are
informed or would be inclined to take it up – rather than seeing
the very need for such counselling as a sign of emotional weakness.
Communicative iatrogenesis can be
understood as a fundamental dimension of what Illich himself calls
‘cultural and symbolic’ iatrogenesis – biomedically diagnosable
illness being a culturally determined and also symbolic password
for obtaining the sought-after acknowledgement and communication of
an individual’s life suffering through
that illness and in the
context of
the clinical encounter.
From this perspective, the ‘ordinary’
patient is just as much an individual in need of and in search of
attention, care and communicative understanding as the ‘heart-sink
patient’ or ‘hypochondriac ’. The distinction lies in the fact
that the latter may ultimately fail to fulfil their needs through the
clinical encounter. This is because they lack the central ‘key’
to obtaining the critical ‘password’ to it. This key is their
willingness to let their
own body translate or ‘body forth’ their existential disease or
life suffering – not just in the form of medical symptoms
but in the form of a ‘genuine’ – medically diagnosable –
biological illness or disease.
In considering the origin or ‘etiology’
of illness from an existential and ‘hermeneutic’ perspective
therefore – one that focuses on the meaning
and purpose
of illness rather than its
biological ‘causes’ – we cannot exclude the
existential meaning of the clinical encounter for the patient
and the purpose
that illness serves
within its
biomedical framework, i.e., as a necessary ‘password’ to that
encounter and the opportunity it offers for fulfilling basic
communicative needs.
The idea that becoming ill has a meaning
and purpose is heretical
enough in a cultural climate dominated by biological medicine. The
sad paradox is that in such a culture the relational
healing that patients seek through
fulfilment of their basic human needs – for human contact, care and
understanding communication – can be met only by getting physically
ill. Thus whilst children are
often understood to complain of symptoms or even to somehow
‘actually’ get ill as a way of seeking attention, the culture of
biomedicine demands that adults
do the same thing – simply in order to call
attention to their existential
dis-ease, their life suffering, stress or distress.
1 comment:
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