The loss of subjective reality that arises from the language of biochemistry

In their essay “Learning Medicine” Byron Good and Mary-Jo Good concentrate on “phenomenological dimensions of medical knowledge, on how the medical world, including the objects of the medical gaze, are built up, how the subjects of that gaze – the students and physicians – are reconstituted in that process, and how distinctive forms of reasoning about the world are learned.” (Good and Good, 1993) This statement and the work that accompanies it, is, in many ways, comparable to the work of Friedson. Both pieces examine phenomenology in the creation of clinical reality and the effects this process of clinical construction has upon those who are doing the constructing. 

            In a section subtitled, “Reconstructing Commonsense”, the authors cite a biochemist who states that “Learning a foreign language is a central metaphor for medical education . . . and biochemistry has become the lingua franca of medicine . . . there is a huge vocabulary to be learned . . . and competence in medicine depends on learning to speak and read the language.” (1993)    The authors go on to point out, “the language learned and the world revealed to the medical gaze are closely linked . . . Several aspects of the medical world and the experiences associated with discovering this world may be identified. First, it is wonderfully reductionistic.” (ibid)   In their conclusion, the authors note that,

“The teaching of social science to medical students, however, typically engenders resentment. As they begin to redefine the object of the medical gaze in the language of science and the body, medical students express a nostalgia for the commonsense view of human suffering, fearing that they will lose precisely those qualities they most hoped to bring to medicine.” (ibid)

Therefore, the world of reductionism exists as an axiomatic assumption of American medical culture. Inherent in this ontology is the subject/object dualism that obviates ‘commonsense’ in the medical language and gaze.

            However, a reality based on language does not automatically obviate connection between physically discrete phenomena, as a subsequent section of this piece will reveal; nor must it necessarily elevate physical phenomena over other aspects of reality. Yet this is precisely the cultural preference that must be acknowledged in ‘American-ese.’ “We lack a precise vocabulary with which to deal with mind-body-society interactions and so we are left suspended in hyphens, testifying to the disconnectedness of our thoughts.” (Scheper-Hughes and Locke, 1987) Thus, not only is language heavily relied upon in the construction of quotidian and clinical reality in American culture and medicine, but there is acknowledgement within the discipline of medicine itself that language is insufficient to describe reality. Nor is this limiting aspect of language confined to medicine alone; rather,

 

 

Language permeates all aspects of existence and determines the manner in which phenomena may be organized by a given society of people. As F. David Peat notes,

The implications of a medical reality that is constructed through language places a premium on knowing the limitations and inherent biases of one’s given language. As Benjamin Lee Whorf wrote, “philosophy is grammar writ large.” (Whorf, 1956) Can the effects of one’s ‘cultural grammar’ be acknowledged so that a complementary view can be explored and considered with equal ontological status?   The essential ‘so what?’ in an examination of American cultural grammar and its effects on the construction of quotidian and clinical realities is to state and maintain a certain transparency about the effects of language in shaping reality. That fact that American medicine is reductionistic is not necessarily a limiting factor to either progress within that model, or to integration with other modalities. What is a limiting factor to integration is ignorance of the axiomatic effects of this cultural preference for the reduction and separation of phenomena. It is the world of reflection that is endemic to reductionistic ontology, a ‘double world’ which obviates lived experience which has so hamstrung efforts to integrate American medicine. 

            Friedson’s acknowledgement of the importance of elevating lived experience has huge implications in the scheme to bring integration to American medicine and healthcare. Infusing choice into clinical reality is a major tenet of the shift toward integration. The infusion of ‘authentic existence’ into quotidian reality reveals a crack through which choice may be recognized and exercised. “Authentic existence is not to be found in some kind of mystical experience but in the everyday, where possibilities unfold, where existential choices are made.” (1996) As Friedson notes, inclusion of this ‘authentic existence’ is a feature of Tumbuka reality, upheld by the pre-dualistic state of an ontology created through music. Thus a separation between conceptual, philosophical reality and lived experience is apparently not an issue to the Tumbuka with their axiomatic assumptions of musical ontology. For the Tumbuka healer, “Musical experience is reflexive not reflective: ‘There is no duality of lived experience and music, no double world, no carry-over from one into the other. Genius simply involves living in the tonal sphere as though this sphere alone existed.” (Dilthey, 1985) Thus, the very goals of high-level practice differ because of the axiomatic cultural assumptions of the holistic musicologist on the one hand and the reductionistic linguist on the other. The disappearance of duality is the high-level achievement of the inspired Tumbuka healer where musicology provides the vehicle for transcendence. Music is the ‘language’ of the pre-verbal, pre-dualistic reality in which lived experience is reified over discourse.   In contrast, the cultural reliance on language in the reductionist model carries limiting parameters, which – like social facts – exert a coercive influence in the form of negating lived experience and reifying conceptual discourse. 

            While American medical students at Harvard are learning to speak and think and construct a clinical reality based on reductionism and the reification of physiology, the Tumbuka healer is busy constructing a clinical reality that emphasizes connections between things and a belief in things unseen. “Although technically illegal, (accusations of witchcraft) were so numerous that they were taken as a common part of everyday life . . . that was associated with darkness and hidden forces, with things that were unseen, concealed, and thus evil.” (Friedson) While the ‘grammar’ of reductionism leads American medical students to construct and reify a physical world with physical causes for disease and illness, the world of the Tumbuka is inherently suited to treat a different array of illnesses. “All around them they see evidence of people suffering from illnesses caused by witches and spirits . . . indigenous healers are believed to be the only health care providers able to help with these kinds of illnesses.” (ibid) The dichotomization between spirit/mind and body that characterizes biomedicine has little competition to challenge its belief structure; yet no insignificant evidence points to the dissatisfaction of patients who, through intuition or hard practical experience within the American medical system, sense the shortcomings of such a histological approach (Astin, 1998) and who, like the Tumbuka, recognize a role for the spirit healer. What would it take for American culture to admit such a role within the ranks of the healthcare professionals? In order for the spirit healer to find work, the patient-population must maintain a notion of the numinous in everyday life and not merely buy into a reification of corporeal structure. In other words, in order to move outside of histology (or even psychology) into spirit healing, there must exist a social fact which defines and contains a collective spiritual reality. A good example of this exists in Tumbuka culture where “for the Tumbuka dreams are real. . . not taken as a fiction of the mind but as a reality of the soul . . . For the Tumbuka, there is no sharp demarcation between the reality of waking consciousness and the reality of dreams . . . both have the same status of reality.”    (Friedson)  Friedson makes a careful distinction between ontological status and reality. “Having the same status does not mean, however, they share the same reality . . . they (Tumbuka) clearly differentiate between the reality of waking consciousness and dreams. They do not however, dichotomize between the two into real and unreal . . .these two realities have an equal ontological status.” (ibid) The possibility that qualitatively different aspects of reality may be equal in ontological terms is not a feature of the reductionist model. As Good and Good explain,

“A critical experience for most medical students (is) where they see physiological responses to various chemicals introduced into a living animal . . . (which) serves as the architecture for developing medical knowledge . . . (this) quickly becomes the only reasonable way to think . . . physiology elaborates this world in the language of mechanism and function.” (1993)

 

In addition to the above assertion that ‘physiology quickly becomes the only way to think,’ there is great significance in realizing the breadth of this characteristic cultural assumption. Michael Taussig writes about this same issue concerning a lack of alternative ontologies in American medicine, saying that they are “denied by an ideology or epistemology which regards its creations as really lying ‘out-there’ – solid, substantial things-in-themselves . . . this illusion is ubiquitous in our culture.” (2003) Thus it is not only that reductionism is itself a uniquely discernable ontology, it is also the case that a feature of reductionism is to deny comparable status to any alternative ontological world-view save one which reflects reductionism. This is a tricky and more subtle point than it may at first appear. Where the subtlety of this notion is either understood, and thus reconciled, or misapprehended, and thus perpetuated, is to be witnessed in one’s example, the lived experience, of one who works at integration. Therefore, this issue is of singular importance to the integrative specialist and will be the focal theme of my ethnography.  

            This very issue is dealt with in a subsequent passage in Taussig’s piece, illustrating the essential ‘so what?’ and the pivotal implication to the integrative specialist. It is the “denial of authorship, the denial of relationship and the denial of reciprocity of process to the point where the manifold armory of assumptions, leaps of faith and a priori categories are ratified as real and natural.”(ibid) This essential theme of the ‘denial of authorship and reciprocity’ is given far too little weight in the debate between personal agency and social structure as cause/solution to illness and disease; and will thus be a primary theme of the ethnography in section four. For the integrative specialist, it is authorship and reciprocity that holds the key to reconciliation between the holistic sensibility (with its axiomatic assumption of social relationships and their role in health and illness) and the reductionist, commodity model (with its steadfast and inherent denial of such a sensibility). 

            A further concept that is endemic to the holistic musical ontology is the concept of ‘illness as teacher.’ Friedson shares accounts not only of other healers who must heed the ‘call of healing’ by responding to personal illness, by embracing a path of healing for themselves and others; but also his personal journey in which, submerged in the cultural reality of the Tumbuka, he finds a hidden pattern of meaning within his experience. Friedson tells the reader, “In Western medical theory, illness is judged negatively, but for the Tumbuka some illnesses have a positive value attached to them . . . it is a necessary component in the creation of the prophet healers known as nichimi, extremely valuable and highly regarded members of their society.” (1996) Here is the cultural valuation of ‘illness as teacher’ and also the continued elevation of lived experience over theory and discourse.

            A great healer in Tumbuka society is not merely a well-read student with good grades and perfect attendance; rather, the prized physician in the experiential, musical ontology is one who knows his/her craft through doing, through having experienced illness and vanquished it or assimilated it as an ally in the path of knowledge that healers of all cultures tread in seeking mastery of their craft. Friedson himself experienced a similar awakening to ‘illness as teacher’ when he reveals, “when I look back on these episodes from a distance . . . there seems to be some kind of relationship between my symptoms and the circumstances of my work – a resonance between my internal state and external actions, and the dynamics of the vimbuza affliction.” (1996)

            The reification of interconnectivity and holistic awareness that is captured by Friedson’s ethnography is in direct contrast to the commodity model which so effortlessly obviates social facts of connection. In Reification of Consciousness Taussig explains the tenets of such a model and its deeper implications. Whereas Friedson reports that it is not uncommon among the Tumbuka people for a relative to take on an illness - an almost absurd notion in American medical culture – Taussig makes the reader aware of the near-total obfuscation of social relationships to disease-cause that is built in to the commodity model of medicine and healthcare. “The patient’s so-called model of illness differs most significantly from the clinician’s not in terms of exotic symbolization but in terms of the anxiety to locate the social and moral meaning of the disease. The clinician cannot allow this anxiety to gain legitimacy or to include ever-widening spheres of social relationships.” (Taussig)

            Last of all the contrasting features that I will explore in this comparison of the Tumbuka musical construction of reality and American medicine’s reliance on language for establishing the ‘one-track’ mind of physiology is the concomitant passivity that is required of the patient in the reductionist methodology. Michael Taussig reports on the pathologizing of patients, the dynamics of which the medical profession seeks to obfuscate through technical language. But, as he points out, “Health care depends for its outcome on a two-way relationship between the sick and the healer. In so far as health care is provided, both patient and healer are providing it, and indeed, the concern with so-called noncompliance is testimony to that.” (2003)  The patient who comes to see the physician in the American commodity model of healthcare is expected and even required to be passive in order that the physician, who holds a vested interest in the labeling of the patient’s disorder, can come to terms with the prescribed treatment and act it out upon the patient/object/disease entity before him/her. Consider that this is all taking place in a cultural milieu that, as Hans Baer points out, reifies personal agency as a legacy of the founding of America. 

“Within the U.S. context, biomedicine incorporates certain core values, metaphors, beliefs and attitudes, that it communicates to patients such as self-reliance, rugged individualism, independence, pragmatism, empiricism, atomism, militarism, profit-making, emotional minimalism, and a mechanistic concept of the body and its repair (Stein 1990). For example, U.S. biomedicine often speaks of the war on cancer . . .in the case of cancer treatment, U.S. biomedicine manifests a pattern of aggression that seems in keeping with the strong emphasis in American society on violence as a means for solving problems.” (Baer, 2003)

 

The paradox revealed by examining the statements by Baer on the one-hand and the ethnography of Taussig on the other is that while American culture reifies strong individualism, that same agency finds no outlet in the reductionist, commodity model of medicine and healthcare. Here is the ‘double-world’ writ large; a split between theoretical concepts and lived experience, which manifests amidst the unique combination of social facts and cultural assumptions in American ontology. Reductionism may be a cultural axiom. But a commodity model of medicine and healthcare that obviates the possibility of reconciling patients and healer/physicians through ‘irreconcilable conflict of interest’ (Taussig) is a social fact, a coercive force and a choice that only becomes recognizable as a choice in the moments when authentic existence emerges within clinical or quotidian reality, when the sacred finds expression within the profane. (Eliade, 1963)