Following the work of the French philosopher Michael Foucault, both biological and social theories of health and illness were finally come under closer scrutiny. For Foucault, knowledge was not in itself universal in nature and it could not be abstracted from particular points in history when new paradigms were set. In his book, The Birth of The Clinic, Foucault uses as an example two descriptions of a hysteric, set in different points in history. One when bedside medicine was the general practice and one, more recent, as clinical medicine becomes the dominant theory.
In his first description, when bedside medicine was the dominant way of thought, it was accepted that a fault in the body was caused by a disharmony in the spiritual sphere of the patient. The doctor, was seen as something as a wise. In his second episteme (Foucault 1973), because of the rise of technology and hospitals, medicine had become a rationalised process where a disease was considered as a breakdown in a much-studied mechanism (‘machine’)- the body. What Foucault is trying to illustrate is how the changing medical approach and the views of disease can be seen as a product of particular ways of viewing the body- the clinical gaze (Foucault, 1973). In other words, each episteme can only be seen and understood in its historical perspective, with its own dominant paradigm.
Between 1879 and 1900 the causative agents of at least 22 infections were discovered. At the end of the 18th century, the clinic formed a focus for medical training and it emphasised clinical observation, bedside teaching and physical examinations. This approach was promoted by the invention of the stethoscope in 1819 and by developments in pathology, which meant that disorders became localisable to distinct areas of the body and were not anymore attributed to just general disturbances in the body. With this new ‘clinical gaze’, with an emphasis on detailed clinical observation and examination was viewed as giving rise to the belief of solid invariable reality of the body. The body was now viewed differently.
Bentham’s panopticon was a revolution in the way one thought of how power was being exercised. In the book Discipline and Punish, Michael Foucault uses Bentham’s panopticon to show how this shift to disciplinary power is based round the idea of controlled surveillance. The panopticon has a central guard cell and round it, is a circle of cells. The theory is that being under such close surveillance should affect and therefore improve the prisoners’ idea. The idea is not weather the guard is really there or not; it is the feeling of being surveilled that makes the prisoner correct himself.
Armstrong picked such ideas and applied them to his idea that treatment in medicine is about social control and regulation through surveillance- similar to that of Bentham’s panopticon. For Armstrong the shift from sovereign to disciplinary power are in medicine, where they are represented by the shift from bedside to clinical medicine. Fundamentally Armstrong is saying that the notions at heart of biomedical knowledge (such as the body and disease) are maybe to be questioned. Such concepts as the body and disease the, selves are in actual fact; open to a multiple range of visions and interpretations in the way they are to be dealt with. Therefore the progression of medical knowledge, from bedside to clinical medicine, is viewed as a shift in gaze. If this idea is to be accepted, biomedical knowledge becomes a product of forced culture. Naturally, the question as to how much/ how far the clinician has constructed the reality of medical knowledge, springs to mind. And to answer this, we will look at those aspects in the clinical model that are questionable from a social constructionist view.
For social constructionists, for example, the clinical method of personal history, diagnosis, testing and treatment is very subjective, as doctors may vary in their decisions according to their own personal experiences. Medicine students are obviously influenced by the rhetoric at university, but it is only once they enter the field and actually practice medicine, that they are able to create throughout their experiences their potential as doctors. Another example of this may be the concept of medical fashions where we may notice that in different countries, doctors study different organs as the source of identification of disease. Here, the body is viewed differently in different countries. In France the point of commencement is blood pressure, whereas for the Germans it is the liver. For the British on the other hand, chilblains are a source for main complain. But fashions also mean that certain practices go in and out of fashion themselves. Tonsillectomy for example, which is rarely practiced today, had a very big moment in the mid-seventies where it was practiced frequently.
Also, social constructionists see the wearing of white coats, masks and surgical gowns, as something ritual and symbolic in nature. Research on the wearing of white coats in hospitals was conducted and found that while students were wearing them 100% of the time, only 2% of consultants actually do. This shows that the act of consultants not wearing coats is symbolic in that it assures his position of autonomy and knowledge.
Students and nurses, being the only ones wearing coats promote their inferiority while surgeons will do their ward rounds n suits rather than coats. So as to give the impression that he is a well respected member of society that can be trusted. We may go further and say that the entire process of dressing can be seen as symbolic in that it reassures patients as to not to worry about the subjective uncertainties in medicine. Armstrong notes how important this passive blindness is in the power relation and trust between the doctor and patient.
Also, by viewing the body as a mechanical model, anything that is outside the standard norms is considered as ‘defective’ and therefore is sectioned accordingly. For social constructionists, everything is symbolic and bound to culture. From diagnosis to disease, everything is constructed on subjective power relations, which means that this does not only apply to medicine but can be expanded to any aspect in the life of the individual.
To evaluate social constructionist theory we must not look at its relativism in nature but rather, at its ideological roots. By arguing that there is no universal, independent reality, the social constructionist discards all methods and categories we use to file knowledge. They separate theory from methodology. But more importantly, by claiming that there are multiple realities, paradigms and discourses, they don’t affront the subject of which one is best. For them to judge which theory may be of best use would be impossible in the first place as this would involve the practice of objective scientific knowledge which by definition, for them is impossible. Therefore the biggest criticism can be made here. If there are multiple realities but the social constructionist won’t tell us, which is best, how are we supposed to get better and improve health generally? Although the biomedical model may have many flaws to it, there is no doubt as to the amount of problems it is able to overcome so as to maintain health, it’s still one of the best theories we have around.
BIBLIOGRAPHY
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Armstrong, D., Political Anatomy of the Body, Cambridge University Press 1983
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Bury, M., The Sociology of Health and Illness, Routledge 1991
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Bury, M., Social Constructionism and Development of Medical Sociology, 1986
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Foucault, M., The Birth of the Clinic, Tavistock 1973
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Foucault, M., Discipline and Punish, Harmondsworth 1979
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Jewson, N., The Dissapearance of the Sick Man, Sociology 10. 1976
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Scambler, G., Sociology as Applied to Medicine, Balliere Tindall 1991
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Seale, C., Medical Knowledge: Doubt and Certainty, Open University Press 2001
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Smith, B., The truth that never hurts: writings on race, gender, and freedom, Rutgers University Press 1998
