Evidence Based Medicine – A Critical Analysis

EVIDENCE BASED MEDICINE – A CRITICAL ANALYSIS

 

In an effort to avoid misconceptions related to lack of objectivity and bias in observation and reporting in clinical diagnosis and treatment, a process of gathering ‘more structured and organized’ evidence in the form of ‘occurrence studies, etiological research, clinical trials, field epidemiological intelligence and intervention, prognostic studies, risk and disease surveillance’ (Jenicek, 2003, p. 32)—named ‘evidence-based medicine’ (EBM-Working-Group, 1992)—has been promoted. The EBM movement can be traced back to a series of lectures given by epidemiologist Archie Cochrane in 1972. Cochrane (1972) argued that too much medical care was using treatments of unknown efficacy and safety, thereby causing harm for individual patients and the population at large. EBM has since become particularly popular with ‘politicians’ and ‘health service managers’ (Evans, 1995, p. 461), more especially because it proposes to guide healthcare decision-making by seemingly rationalising—often naively simplifying—a complex social process (Goldenberg, 2006, p. 2622). EBM holds that the criterion for providing each diagnostic procedure or medical intervention is its effectiveness at national and individual patient level, as demonstrated by biomedical research evidence (Harrison, 1998, p. 19).

 

Evidence-based medicine has been defined as, ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients … it requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patients’ choice’ (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71). The strength of the evidence used in EBM is contingent upon what has been termed, a ‘hierarchy of evidence’ which consists of, in descending order: results of systematic reviews of well-designed studies (the pinnacle of which is the ‘double blind’ randomised controlled trial), results of one or more well-designed studies, results of large case series, expert opinion, and personal experience (Harrison, 1998, p. 20; Pandya, 2008, p. 42).

 

There are, however, fundamental problems with the evidence-based medicine approach for several reasons. Ironically, as highlighted by Cohen and Hersh, ‘EBM is [itself] not evidence-based, because it does not meet its own empirical tests for efficacy’ (2004, p. 197). In fact, Cohen and Hersh go on to point out that for a system that claims to improve patient care by basing clinical decision-making on statistical information derived from clinical trials, there is no evidence (according to the criteria defined by EBM) that this is actually the case (p. 197).

 

Conceptually, I believe the inadequacies associated with ‘evidence based medicine’ go much deeper. For example, according to Davidoff, Haynes, Sackett, and Savage (1995, pp. 1085-1086), the EBM movement centres around five linked ideas: First, ‘clinical decisions should be based on the best available scientific evidence’ (p. 1085). But how does one define ‘best available scientific evidence’ in the light of the construction of meaning, practice, and observation within discursive regimes? Second, ‘the clinical problem—rather than habits or protocols—should determine the type of evidence to be sought’ (p. 1085). And yet, what is regarded as a ‘clinical problem’ and object of inquiry is determined by the habits and protocols that are specific to a given time, place, and disciplinary practice. Third, ‘identifying the best evidence means using epidemiological and biostatistical ways of thinking’ (p. 1085). ‘Thinking’ in ‘epidemiological and biostatistical ways’, far from being confined to objective calculations, involves inductive and subjective reasoning involving numbers. Fourth, ‘conclusions derived from identifying and critically appraising evidence are useful only if put into action in managing patients or making health care decisions’ (p. 1085). Why should putting something ‘into action’, particularly if it is poorly conceived, be a criterion of usefulness? And finally, fifth, ‘performance should be constantly evaluated (p. 1085)’. What ‘performance’ is evaluated? How is it evaluated? What criteria are used, and for what purpose? Indeed, who is considered qualified to speak the ‘truth’? What perspective do they speak from, and to whom?

 

My own experience suggests that clinical decisions are invariably made against a background of cultural and philosophical concepts of disease and health, normality and abnormality. If this is the case (and I firmly believe that it is), by claiming to ‘de-emphasise’ the influences of culture, contexts, and subjective elements from healthcare decision-making, EBM allows selective evidence to be used as an instrument of knowledge and power under the guise of an objective, neutral rationale. In addition, EBM’s ‘hierarchy of evidence’ neglects—or relegates to a lower, less reliable form—qualitative evidence, which includes personal narrative and social preferences, both heavily influenced by historical and cultural contexts.[1] Quantitative evidence alone, in the form of grouped meta-analyses of best research, fails to consider individual patient context in clinical practice. Emphasising and analysing medical description undervalues the subjective experience of the medical encounter. In this, Toombs argues that ‘[t]he importance of understanding the patient’s lived experience should not be underestimated (1993, p. 27) … bodily disruption or impairment … is not so much a simple recognition of specific symptoms … as it is a profound sense of the loss of total bodily integrity’ (p. 90)—Leder terms this sense of corporeal loss ‘the problematic presencing of the body’ (1990, p. 70)—an issue which will be discussed in more detail in subsequent chapters. Further, Gerber et al reason that EBM is caught between presupposing that there is such a thing as an agreed upon concept of disease [or abnormality] while, on the other hand, those practicing evidence-based medicine know that a universally valid definition of pathology cannot be generated (2007, p. 394). Hence, while it is possible to provide a diagnosis of an ‘abnormality’ for a particular clinical case, it is virtually impossible to define a person’s bodily/facial state as being completely ‘normal’ in every context, as I will show later on in this chapter and the next, whereby the concept of the ‘norm’ with regard to the body/the face creates the idea of deviance and, at the same time, prescribes a template for the way the body/the face ought to be.

 

In clinical practice, patients vary significantly from one to the other, but broad-ranging clinical trials do not take this into account (Julian, 2003, p. S2). There is no such thing as, nor could there ever be, an ‘average’ patient.  This is particularly true of surgical patients, where an appropriate trial may be difficult to design, or unethical to carry out (Feinstein & Horwitz, 1997, p. 533). This is because of factors related to the impossibility of ‘blinding’ for the surgeon, as well as the oftentimes irreversibility of the procedure, and the fact that the process of randomisation is likely to jeopardise the surgeon’s credibility in the eyes of the patient by making the surgeon appear indecisive. In my own private practice I would find it difficult to justify using alternative surgical techniques for the sake of experimentation to replace procedures that in my hands have been consistently successful. This is not to underscore evidence-based medicine in toto—far from it. For example, empirically derived data regarding the choice of antibiotic medication for certain types of infection, or the comparison of the results for two types of surgical procedures in similar patients having similar indications for each procedure, can be a powerful tool in the hands of the attending clinician. However, particularly in cases pertaining to cosmetic-based procedures, even when such trials are carried out and reported, Chung et al have shown that the majority of studies in the literature pertaining to cosmetic surgery lack a proper study design and valid sample size estimation, thereby possessing insufficient statistical power to detect a difference between study groups (2002, p. 4).

 

Unfortunately, EBM’s ‘gold standard’ for evidence—the randomised control trial—infers cause and effect relationships from statistical data derived from treatment and outcomes. It is, therefore, less concerned with why a particular intervention is being carried out, than how effective that particular intervention is. It is less concerned with the entity ‘disease’ or the concept of ‘abnormality’, than comparing rival forms of treatment. Put another way, ‘the [EBM] model is therefore probabilistic (that is, one where the cause-effect relationships are inherently uncertain) and empiricist (that is, one where knowledge can only justifiably be derived from past experience)’ (Harrison, 1998, p. 26). In fact, the results of this type of research have a tendency to randomise away clinically important individual characteristics. In practice, what the clinician usually decides, as Pellegrino and Thomasma point out, ‘comes at the end of a chain of deductive and inductive inferences, serially modified by recourse to “facts” and observations—which themselves are usually, to some degree, uncertain’ (1981, p. 123). In the remainder of this chapter, and more so in the next, I will examine in greater detail how what ‘counts’ as the ‘right kind’ of face—as judged by society, but also by ‘expert’-centred groups within society—is historically, culturally, and contextually positioned. Like my SEM studies, ‘seeing’ and ‘knowing’ the face is always situated. It always takes place from a particular perspective.

 

REFERENCES

 

Chung, K. C., Kalliainen, L. K., Spilson, S. V., Walters, M. R., & Kim, H. M. (2002). The prevalence of negative studies with inadequate statistical power: An analysis of the plastic surgery literature. Plastic and Reconstructive Surgery, 109(1), 1-6.

Cochrane, A. L. (1972). Effectiveness and efficiency: Random reflections on health services. Retrieved from London:

Cohen, A., & Hersh, W. R. (2004). Criticisms of evidence-based medicine. Evidence-based Cardiovascular Medicine, 8(3), 197-198.

Davidoff, F., Haynes, B., Sackett, D. L., & Savage, R. (1995). Evidence Based Medicine: A new journal to help doctors identify the information they need. British Medical Journal, 310(6987), 1085-1086.

EBM-Working-Group. (1992). Evidence-based medicine. Journal of the American Medical Association, 268(17), 2420-2425.

Evans, J. G. (1995). Evidence-based and evidence-biased medicine. Age and Ageing, 24(6), 461-464.

Feinstein, A. R., & Horwitz, R. I. (1997). Problems in the ‘evidence’ or ‘evidence-based medicine’. The American Journal of Medicine, 103(6), 529-535.

Gerber, A., Hentzelt, F., & Lauterbach, K. W. (2007). Can evidence-based medicine implicitly rely on current concepts of disease or does it have to develop its own definition? Journal of Medical Ethics, 33(7), 394-399.

Goldenberg, M. J. (2006). On evidence and evidence-based medicine: Lessons from the philosophy of science. Social Science & Medicine, 62(11), 2621-2632.

Harrison, S. (1998). The politics of evidence-based medicine in the United Kingdom. Policy & Politics, 26(1), 15-31.

Jenicek, M. (2003). Foundations of evidence-based medicine. New York; London: Parthenon Publishing Group.

Julian, D. G. (2003). What is right and what is wrong about evidence-based medicine? Journal of Cardiovascular Electrophysiology, 14(Supplement 1), S2-S5.

Leder, D. (1990). The absent body. Chicago: University of Chicago Press.

Pandya, A. G. (2008). Evaluation and design of cosmetic research studies. In P. E. Grimes (Ed.), Aesthetics and cosmetic surgery for darker skin types (pp. 42-48). Philadelphia: Wolters Kluwer; Lippincott Williams & Wilkins.

Pellegrino, E. D., & Thomasma, D. C. (1981). A philosophical basis of medical practice: Toward a philosophy and ethic of the healing professions. New York: Oxford University Press.

Sackett, D. L., Rosenberg, W. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312(7023), 71-72.

Toombs, S. K. (1993). The meaning of illness: A phenomenological account of the different perspectives of physician and patient. Dordrecht; Boston; London: Kluwer Academic Publishers.

Upshur, R. E. G., Van Den Kerkhof, E. G., & Goel, V. (2001). Meaning and measurement: An inclusive model of evidence in health care. Journal of Evaluation in Clinical Practice, 7(2), 91-96.

 

[1]    In their respective papers Goldenberg (2006) and Upshur et al (2001) share my position on these problematic aspects of evidence-based medicine.

Constituting the Cosmetic Surgeon

Constituting the Cosmetic Surgeon

ABSTRACT

The human body, in contemporary times, is often seen as a plastic and upgradable commodity which, as a physical resource, can be exchanged for other forms of capital, such as improvements in economic security, cultural status, and social standing. To date, much of the literature pertaining to body image and corporeal modification has centred on the patient as consumer. However, it should be remembered that the attending cosmetic surgeon (as provider) is also a consumer of the Beauty Industry. And it would appear that the role of the clinician in this escalating sociocultural phenomenon has largely escaped closer academic scrutiny. Indeed, it is my contention that the cosmetic surgeon and the bodies they are fashioning have already been fashioned according to a culturally conceived standard, before a single incision or Botox injection has been enacted. My proposed research project will address the question of how individual surgeons—fashioned by bioethical, moral, institutional, and cultural standards … but also fashioning through planning, negotiating, and performing within their specific disciplinary practices—choose among the many treatment possibilities imposed by individual, disciplinary, and broader sociocultural factors. In pursuing this question, I draw on my own expertise as a periodontal and oral plastic surgeon (BDS, MDSc, MRACDS, FRACDS) of more than thirty years’ standing. In addition, my background in visual culture (MLitt) and cultural studies (PhD), as well as my scholarship and familiarity with the works of Foucault, Merleau-Ponty, and Bourdieu would be utilised. While I have briefly touched upon these issues in my recently published book ‘Faces inside and outside the clinic: A Foucauldian perspective on cosmetic facial modification’, there is still much to research, analyse, and discuss with respect to the means by which normalising technologies (in the Foucauldian sense) influence accepted cosmetic practices within the clinical professions.

THE PROJECT

It is difficult to put into words just what a human body is, how it should be, what it can do, and what it means for one body to be ‘wrong’ and another to be ‘right’. It seems to me that written descriptions of the ‘correct’ type of body are far removed from personal face-to-face experience. And yet many individuals and collective groups in society would strongly disagree with me, and argue there are words—and indeed numbers, formulae, and geometrical configurations—that portray the human body in the way it needs to be understood, the way it ought to be, and what it means to have a body shape that differs from prescribed cultural standards.

Initially I will focus on the binary opposition of surface/depth (outside/inside) in relation to what we see’ and know’ in the reading of the body as ‘text’. Essentially, society dictates that there is an implied removal or penetration of corporeal surface structure to reveal an essential depth, moving from the material to the immaterial. In addition, I believe it is important to provide an evaluation of the limitations of ‘objective’ clinical bodily analysis by questioning the validity of so-called hard data in the form of numerical measurements as a means of diagnosing ‘right’ and ‘wrong’ bodily shape, based on ‘evidence’. I will point out the many inadequacies associated with ‘evidence-based medicine’—particularly within the range of cosmetic surgical ‘amendments’—which, as a concept that claims to avoid misconceptions related to bias in observation, is shown to be a highly selective process under the guise of a neutral rationale, and indeed, a way of thinking that is ontologically questionable. I will also argue that templates for ‘normal’ bodily appearance, based on neoclassical canons of corporeal proportions and other purportedly ‘ideal’ body ratios—as used in many of today’s major textbooks on anatomical structures and aesthetic reconstruction—are problematic and potentially misleading with regard to everyday appearances, particularly for those bodies that are found to be in need of ‘correction’. I will point out that the continued acceptance and reinforcement of the guiding principles indicating the type of body we should have are the result of ‘seeing’ and ‘knowing’ within ‘expert’ communities of clinicians and academics that determine the norms and rules for situated ‘webs’ of disciplinary practices contained within a larger discursive regime.

Different writers have referred to such a specialised community as: an ‘institution’ of ‘disciplinary practice’, a ‘field of discourse’, a ‘field or web of significance’, a ‘webbed connection’ of ‘knowledge and power’, a ‘thought collective’ as carrier for a ‘thought style’, a ‘paradigm’ or ‘disciplinary matrix’, and a ‘field of power’. Practitioners within a particular professional ‘field’—cosmetic surgeons, maxillofacial surgeons, and so on—will generally ‘know’ what is important in their particular area of expertise. This being the case, what ‘counts’ as ‘disciplinary practice’ may be described as a set of discourses, norms, and routines that shape the ways in which a field of study … and its related practices … constitute themselves.

In his book The Structure of Scientific Revolutions, Thomas Kuhn casts doubt on the ‘objectivity’ of reported evidence within a designated paradigm, especially if examined by those outside that particular paradigm. Individuals within unlike paradigms (e.g., sociologists Vs cosmetic surgeons) will ask different questions, and demand different answers. For instance, a cosmetic surgeon may acquire knowledge of a certain sort, through their education within a particular paradigm. This in turn is acknowledged and supported by skilled practitioners within that same paradigm. The clinician’s training allows her or him to work successfully within their field of competence, uncritical of the precise nature of the paradigm in which they work, unless threatened by a new paradigm, or the emergence of a new theory that undermines confidence in the prevailing paradigm. Kuhn reports that this ‘is generally preceded by a period of pronounced professional insecurity’. An example of this is when a cosmetic surgeon is faced with the reported results of a particular surgical procedure that enhances the volume of a person’s lips. Rather than contemplating the reasons that brought about the cultural desirability of such a procedure, the surgeon would more likely to be interested in the techniques and materials employed in the procedure, the accuracy and reproducibility of the study’s data, and the stability of the post-surgical anatomical outcome. When faced with the emergence of a new cultural fashion extolling the virtues of smaller lip volume, the surgeon would be inclined to reassess their own ideas and techniques in the light of the newly accepted cultural practice. The reasons for society’s shift from the desirability of full lips to thin lips would demand less critical contemplation than the need to provide a service for which they, the clinician, were trained. As such, the dominant cultural problems related to the supply and demand for facial amendments, augmentations, and enhancements fall outside the puzzle solutions of the surgeon’s disciplinary matrix (paradigm).

There seem to be at least five features which characterise specialised communities such as medical and dental practitioners, surgeons, and similar professions: First, they tell what to value and disvalue and in what order. They also disclose the goals or values to be realised. For example medical schools carry out disciplinary power through the selection of discrete subjects to study, and by normalising students, staff, and administrators by providing an accepted way of thinking about the subject matter in question. Norms and rules are internalised, providing the basis for normalisation through self-discipline and group control. This leads on to a second observation, whereby medical collectives provide ontological guidance as to what will count as disease and abnormality. The third component includes a sociological element in which communities of doctors are sustained by implicit instructions regarding who are strangers and who are members, and the ways in which one should react to each. Under this component, one finds everything from professional associations and journals to binding codes of medical etiquette. The fourth feature of these types of communities is that they provide examples of what it means to know things correctly. These examples usually take the form of favourable experimental results and successfully treated clinical cases, the latter, offering before and after versions of how an ‘abnormal/wrong’ case can be made into a ‘normal/right’ case. This leads us to the fifth component in which specialised communities have implicit or explicit recipes indicating when it is prudent or imprudent to intervene in particular ways, under general notions of usual and customary standards of care or by formally articulating indications for treatment.

Inclusive of specialist medical communities, but with wider ranging implications for society in general, a specialised field is simultaneously a space of conflict and competition. As such, what amounts to the defining content of each field has its own logic for what ‘counts’, what is taken for granted, and how, and in what circumstances, an individual or individuals should act. The ‘conflict’ and ‘competition’ I refer to here, for those within a field (academics, surgeons, pastry cooks, etc.), centres on various forms of capital: economic, intellectual, scientific, cultural, and so on. There are, therefore, many forms of capital, and many types of fields—sometimes overlapping in shared commonalities, and at other times specific in their particularities.

Foucault, in Technologies of the Self (1988), outlines four major discursive and social ‘technologies’—those of ‘production’, ‘sign systems’, ‘power’, and ‘the self—each of which he describes as a ‘matrix of practical reason’ that implies some form of training, and the changing or shaping of individuals within, what he terms ‘truth games’. Foucault makes the point that these so-called ‘truth games’ relate to ‘specific techniques that human beings use to understand themselves’. The interaction of Foucault’s four listed technologies implicates reciprocity between the attainment of knowledge and the practical application of that knowledge, and by engaging with each of these ‘technologies’ (as I intend to do), the nature of their inextricable interdependence soon becomes clear since, while much of Foucault’s work focuses on ‘power/domination’, and later on ‘the self, one is hard pressed to ever find any one of the technologies functioning separately. In fact, I contend that the link between technologies of power and technologies of the self is exemplified by the two technologies least mentioned by Foucault, those of ‘sign systems’ and ‘production’, which contribute in a significant way to what Foucault refers to as ‘government’—the ‘conduct of conduct’, from ‘governing the self to ‘governing others’. All four technologies interact and overlap in varied and dynamic ways. Taken together, they provide tools for exploring the relationships between power, knowledge, subjectivity, and the processes by which individuals act upon themselves in ways that make certain practices possible, and others less likely. All these technologies are needed for the implementation of, and the sustainability of, self practices, including the consumption of the notion of ‘normal ideal’ bodily appearance. In other words, ‘production’, ‘sign systems’, ‘power’, and ‘the self are inseparable when providing an analysis of what everyday bodies do and have done to them.

Given this background, I intend to analyse the clinical encounter itself, and show that the medical consultation has long been regarded as a focal point for more than just the values and perspectives of the patient and the surgeon. It also represents an interface between the medical profession and society. Yet, in an age of consumerism in which there is an abundance of alternative information portraying the body as a surgically malleable commodity, the status of the encounter between surgeon and patient demands added scrutiny. In other words, the medical certainty of the previously dominant ‘paternalistic model’ of the surgeon-patient relationship has, in modern times, been replaced by a more pluralistic model of decision-making, in which rhetorical possibility plays an increasingly important role, and in which corporeal identity is always in a state of potential transition.

There are currently four frequently discussed models of doctor-patient interaction and decision making with regard to treatment: paternalistic, informative, interpretive, and deliberative

Paternalistic: physician makes decisions for the patient’s benefit independent of the patient’s values or desires. Informative: physician provides information, patient applies values and decides. Interpretive: patient is uncertain about values, physician, as counsellor, assists the patient in elucidating his or her values. Deliberative: patient is open to development, physician teaches desirable values. However, for the patient who consults the surgeon seeking cosmetic bodily modification, the clinical reality is that, at any one time during the consultation (and often afterwards), there may be a shift from one model’s framework to another’s, as determined by the changing dynamics of the situation. For example, the informative model may change to the interpretive model once further information is gained and reflected upon by the patient. Similarly, a patient’s values may change due to the influence of a family member or significant other, giving rise to a deliberative perspective. An unexpected finding by the surgeon during the course of the surgical procedure itself may demand that a change from one of the other models to a paternalistic approach be taken. Importantly, a patient is never alone outside her or his social setting, nor is the surgeon. Often the surgeon’s questions are more important for the patient than the answers they give. Some patients demand detailed information, others prefer very little. Some patients like to have a family member with them during the consultation, not so for others. Sometimes patients choose to proceed on to surgery because they like the personality of the surgeon yet have no idea of her or his surgical skills. Even the decor of the surgeon’s waiting room may influence a patient’s decision to select one particular surgeon over another. The phronêsis and mêtis of clinical experience—which entails focussing on specific cases not universal rules, and which allows for flexibility in dealing with changing situations—provides a range of treatment contingencies, which may be adapted to specific circumstances, according to the knowledge and preferences of the surgeon and patient. The ‘one-size-fits-all’ approach is a poor prescription for any patient, let alone for one preparing to permanently change an identifiable exterior part of their ‘identity’. Yet these ‘fashioning’ treatment contingencies, commonly referred to as a ‘range of treatment options’, that are offered by the surgeon, are themselves ‘fashioned’ by factors such as: institutional policies and guidelines; concepts of responsibility and duty on the part of the surgeon; the surgeon’s knowledge and assumptions about the patient’s values and preferences; the surgeon’s knowledge about, and experience with, the treatments available for specific cases; organisational constraints (hospital time schedules, waiting lists, costs etc.); and, in addition to all these factors, the relationship with the patient still needs to be maintained. In other words, the embodied dispositions—the intentional arc—of ‘lived’ ‘wrong(ed)’ bodies must first align with the surgeon’s own frame of reference before any action is taken. Power/knowledge, technologies/techniques, dispositif/disposition, habitus/field/ capital, and so forth, all fashion treatment options just as much as they, in turn, are fashioned, transformed, and become part of medical practice. Surgeon and patient act together to produce the ‘amended’ body by way of a certain mode of complicity in which there is a relationship of the providers and consumers to the system of norms that the corporeal modification aims to fit.

Effectively, Foucauldian ‘truth games’ provide the framework for ‘competitive struggles’ in the name of ‘truth’ across science, medicine, self-care, and other forms of human endeavour. And in spite of the importance of the knowledges of epistêmê and technê in clinical encounters and procedural actions, it is the immediacy and flexibility of phronêsis and mêtis that provide the potential for preparedness and empowerment (especially for the surgeon) ‘to know’ in relation to each new clinical situation. In all of these matters, it is the surgeon who speaks from the asymmetrical position of power and knowledge, through: ‘hierarchical observation’, ‘normalizing judgement’, and the disciplinary power of ‘the examination’ (Foucault 1995). As such, it is the surgeon who must bear the overwhelming share of the responsibility for what ‘truth games’ are put forward and recommended as options in non-life-threatening cosmetic surgery. From my own perspective—having over 30 years of clinical experience behind me—it is not enough to cite the patient’s request (as so many surgeons do) as the overriding determining factor for this or that procedure to be carried out. This does not mean to negate or underscore the patient’s freedom to ‘choose’ a desired treatment within certain constraints. However, in medico-legal and bioethical circles, it is ultimately the surgeon, and not the patient, who is guided by the commonly cited four principles of biomedical ethics, listed by Beauchamp as those of: (1) respect for autonomy (a principle requiring respect for the decision-making capacities of autonomous persons); (2) nonmaleficence (a principle requiring not causing harm to others); (3) beneficence (a group of principles requiring that we prevent harm, provide benefits and balance benefits against risks and costs); and (4) justice (a group of principles requiring appropriate distribution of benefits, risks and costs fairly).These bioethical principles, when measured against situated perspectives—through the theoretical concepts of Foucault, Merleau-Ponty, and Bourdieu—are not without their problems for the surgeon herself or himself, since the uniformity of embodied style conceptualised by the four principles of biomedical ethics listed by Beauchamp, does not exist in the ‘real’ world. Indeed,

there are relational and fluid aspects to people found in and through the matrixes of numerous power relations involving economic, sexual, political, racial, class, and other grids, all of which are integral to their identity as well as their interests, and all of which affect the decisions they make about health care and other matters.

In other words, the biomedical principles detailed by Beauchamp rely on incomplete and naive theoretical assumptions that neglect to consider differences between individuals—between the surgeon and the patient, between the patients they administer, and between the surgeons themselves—that experience and are experienced beyond the limited understanding of health care contexts, and in which embodied intercorporeal connections between the surgeon and the patient are subject to the relational aspects of identity and lived experience for both parties inside and outside the clinic. Indeed, the question induced by the presence of ‘truth games’ in the bioethical delivery of medical services may be stated as: how does the individual patient, but also surgeon, with her/his own unique style of being-in-the-world—produced but also producing, fashioned but also fashioning—choose among the many conditions of possibility ‘truth games’ impose.

Throughout this research project I will proposed that ‘truth’ in what is regarded as the ‘right’ kind and ‘wrong’ kind of bodily shape and appearance is always positioned in relation to an intertwining of situated knowledges that can only ever be partial in the sense that individuals (and in this case cosmetic surgeons) in any contextual circumstance always ‘see’ and ‘know’ in relation to a set of rules, interests, and objectives that illuminate certain ‘things’, and make other ‘things’ less visible, or (in a manner of speaking) in-visible. We are all—inclusive of diagnostic clinicians and surgeons—situated in, and dependent upon, an interplay of surface knowledges (connaissance) and depth knowledges (savoir), whether we are aware of it or not. And in the Modern era, it is from these discursive positionings that we are both constrained through ‘objectivisation’, but also enabled through the creation of the conditions of possibility for ‘self transformation. We, as individuals—with our own values, interests, meanings and motivations (sometimes commonly shared, sometimes uniquely particular)—must also live in and through the discursively determined norms in which we are constituted in our everyday experiences. This living through sociocultural norms, I contend, should not be regarded as passive submission or free acceptance of dominant social values; rather, although bodily appearance is ‘fashioned’ according to particular clinical and social domains of practice, it is also ‘fashioning’ through strategic and negotiated dispositions in which a variety of social agents or factions compete to attain the definition of the social world that is most in-keeping with their respective interests. With the help of the thoughts of Michel Foucault, Maurice Merleau-Ponty, and Pierre Bourdieu, I will argue that versions of ‘the body’ (inside and outside the operating theatre) are destined to oscillate, integrate, and separate in, through, and between elements of the Foucauldian dispositif, and the embodied Merleau-Pontian and Bourdieuian dispositions of specific bodies-in-situation in specific sociocultural contexts. And in the case of the face-to-face clinical encounter—an encounter that requires an admixture of habitual modes of interacting and conscious decision-making—it is the power/knowledge situatedness afforded the surgeon that should ultimately determine the measure of responsibility for any procedural action taken or not taken.

Contemporary Governance in the Clinical Encounter – Paper

Contemporary Governance in the Clinical Encounter –

An Asymmetry of Power, Knowledge, and Responsibility

 

TONY McHUGH BDS, MDSc, PhD, MLitt, MRACDS, FRACDS.

Macquarie University, Australia

Abstract:

 

The clinical consultation encompasses a two-way gaze in which doctor and patient are essentially object and subject at the same time. Inevitably, however, doctor and patient are governed by a different set of rules and a different set of ‘truths’. Indeed, contained within the two-way clinical gaze, there are distinct asymmetries in power/knowledge relations. Through hierarchical observation, normalising judgement, and the examination, it is the doctor who wields the overwhelming share of disciplinary power, and it is the doctor who is guided by the principles of biomedical ethics (problematic though they may be), not the patient. This calls for added responsibility on the part of the doctor to acquire and develop modes of decision-making understood as the logic of practical, individuated, and value-based knowledge (phronêsis) together with intuitive and habituated skill (mêtis). In other words, studying and knowing ‘truth’ in theory (epistêmê), and having the technical ability to carry out scripted tasks to achieve a practical end (technê), are not enough to attain the goal of becoming an excellent clinician. This does not negate the patient’s freedom to ‘choose’ a desired treatment path within certain constraints, however, while still accepting the inevitability of entering into an asymmetry of power and knowledge, it is the doctor’s responsibility to respond to, and care for, the needs and interests of the patient through an interaction of mutual reciprocity that does not reduce either body to the other or to itself.

Introduction

The concept of governance, as described by Michel Foucault, involves a network of power relationships, whereby an effect emerges through the modification of individual and/or group actions upon other actions. This Foucauldian idea or art of governing, which he developed particularly in his lectures at the Collège de France in the latter years of his life, is distinct from the commonly held notion of ‘government’ itself, in which the conduct of an individual or population is regulated through institutions and laws. Foucault’s concept of governance—what he refers to as governmentality—involves, through a network of power, a dynamic interplay between three types of relationships: the relations between individuals and between groups; the communication of information through a system of signs; and, the capacity to modify actions (1982a, pp. 217-218). Foucault writes: ‘In effect, what defines a relationship of power is that it is a mode of action which does not act directly and immediately on others. Instead, it acts upon their actions: an action upon an action’ (1982b, p. 789).

An example of this type of governmentality or ‘technology’ of power can be seen in my own clinic. What invariably transpires in the encounter between the patient and myself is a form of relational disciplinary power, termed by Foucault ‘an anatomo-politics of the human body’ (1990, p. 139). In my capacity as the clinician I satisfy Foucault’s three main instruments of disciplinary power, as described in Discipline and Punish (1995, pp. 170-194).

The first of these ‘instruments’ is ‘hierarchical observation’, which is associated with the interlinking of the observer (the clinician) with the site of observation (the clinic) and the observed (the patient). The clinical setting is ‘an apparatus in which the techniques that make it possible to see induce [sic] effects of power [are enacted] … [It is also a site] in which … the means of coercion make those on whom they [techniques of power] are applied clearly visible’ (Foucault, 1995, pp. 170-171).

The second instrument of disciplinary power is ‘normalizing judgement’ (1995, pp. 177-184), which compares individuals with other individuals, patients with other patients, through ‘deviations’ from what is deemed to be ‘normal’, according to discursively determined perceptual standards. Foucault writes:

[I]t [normalizing judgement] refers individual actions to a whole that is at once a field of comparison … It differentiates individuals from one another … It measures in quantitative terms and hierarchizes in terms of value … It introduces, through this ‘value-giving’ measure, the constraint of a conformity that must be achieved … [I]t traces the limit that will define difference in relation to all other differences … [It] compares, differentiates, hierarchizes, homogenizes, excludes. In short, it normalizes (1995, pp. 182-183).

Normalising judgement is, therefore, also prescriptive insofar as by imposing what is ‘normal’ it renders ‘abnormality’ as ‘difference’ in need of correction. In other words, normalising judgement generates a hierarchy and a set of effective punishments and rewards that can be used to coerce individuals within the hierarchy to pursue aggregate ‘normalising’ technologies (ensuring greater macro-homogeneity) and individual normalising or ‘normating’ techniques (ensuring a coexistence of micro-heterogeneity).

The third instrument of disciplinary power is ‘the examination’:

which combines the techniques of an observing hierarchy and those of a normalizing judgement. It is a normalizing gaze, a surveillance that makes it possible to qualify, to classify and to punish. It establishes over individuals a visibility through which one differentiates them and judges them (1995, p. 184) … The examination, surrounded by all its documentary techniques, makes each individual a ‘case’: a case which at one and the same time constitutes an object for a branch of knowledge and a hold for a branch of power (1995, p. 191).

The principle of the examination generates a critical description of the individual in comparison to the accepted norm. It focuses on the ‘anatomo-politics’ of the patient, in which individuality is introduced into the field of documentation, making each patient a ‘case’, an object of knowledge, and a target for power. However, the examination also combines individual control with systematised ‘truth’ producing technologies for ‘the species body’ (these forms of individualised and systemised control are, together, referred to as ‘bio-power’),[1] establishing a comparative standard for the ‘group’ body, whereby ‘species’ bodies come to be defined—according to the concept of the ‘bio-politics of the population’ (Foucault, 1990, p. 139). Population management (bio-politics) and self-management (anatomo-politics), rather than being discrete entities, operate together ‘by continuous regulatory and corrective mechanisms’ (Foucault, 1990, p. 144) towards the notion of what human bodies should be like. Furthermore, the impact of what Foucault calls bio-power can be seen time and time again in my own clinical practice, whereby my patients and I share a system or ‘commonality’ of knowledge that invariably makes for a ‘taken-for-granted’ clinical encounter, and an effective interaction in which the compliance of my patients is generally assumed. In effect, there is an intrinsic link between the patient and the discursively determined objectivised body that is built on the trinity of power-knowledge-‘truth’. In this ‘[w]e are subjected to the production of truth through power and we cannot exercise power except through the production of truth’ (Foucault & Gordon, 1980, p. 93).

This relationship of power-knowledge-‘truth’ is especially evident in the clinical encounter between the cosmetic surgeon and the ‘aesthetically-inclined’ patient, whereby the clinician may have ‘pathologised’ and ‘abnormalised’ a version of—what many would perceive to be—a ‘normal looking’ bodily appearance, and through which she or he may also have pointed out to the patient that options for attaining a ‘better looking’ body exist, explaining that there are means available for the ‘correction’ of the perceived medical ‘problem’ (McHugh, 2013, p. 87).

As such, to enact governance in contemporary clinical practice is to instil ‘action upon action’, in which clinicians and patients participate in relational exchanges of power/knowledge and practice. In this way, technologies of power[2] intervene to bring individual and group bodies into conformity with culturally accepted norms or standards by ‘invisibilising’ technologies of sign systems and production to the point that structures promoting care of the self appear as orthodoxy or as a ‘taken-for-grantedness’. As such, through relational networks of power, individuals and population groups become, at the same time, objects of power, subjects of power, and the means by which power operates (Foucault & Gordon, 1980, p. 98).

The two-way clinical gaze

From my own perspective as a clinician, the relationship between the clinician and the patient is not limited to the clinician-as-subject and the patient-as-object. With relevance to the clinical gaze, Foucault writes:

The object of discourse may equally well be a subject, without the figures of objectivity being in any way altered. It is this formal reorganization, in depth rather than the abandonment of theories and old systems, that made clinical experience possible (Foucault, 1994, p. xiv).

For Foucault, then, the object-as-patient is equally the patient-as-subject; to which I may add, the clinician is also object, as the patient is subject and object at the same time. Essentially, the assumed asymmetry of a one-way clinical gaze, from clinician to patient, needs to be discounted in favour of the likelihood of the patient turning their gaze upon the clinician—searching for empathy, competence, decisiveness, and so forth (McHugh, 2013, pp. 60-61).

The concept of the two-way clinical gaze also challenges the notion of it being an objective diagnostic act of ‘seeing’ alone in two important respects. In the first instance, Foucault states that the gaze ‘contains within a single structure different sensory fields. The sight/touch/hearing trinity defines a perceptual configuration in which the inaccessible illness [or “abnormality”] is tracked down by markers, gauged in depth, drawn to the surface’ (1994, p. 164). The gaze, therefore, rather than being tied exclusively to the act of vision, also includes other functions such as touching, speaking, and habituated and reflective ways of ‘knowing’. Cognitive scientists are likely to refer to this phenomenon as ‘cross-modal perception’ whereby visual images integrate with tactile and auditory sensory input—as well as procedural and conceptual knowledges—in order to situate, understand, and interact with objects of perception (Seyfarth & Cheney, 2009, pp. 669-670).

This then leads on to another depth characteristic of the two-way clinical gaze insofar as the gaze, in the words of Alcoff, ‘can only function successfully as a source of cognition when it is connected to a system of understanding that dictates its use and interprets its results’ (2006, p. 126). In other words, what is ‘seen’ and ‘known’ by the clinician and patient as a result of the gaze is structured by the conditions in which their own subjectivity is constituted. Governance in the clinical encounter, then, becomes a space embedded in a dynamic interplay, not only within medical networks, but also in, through, and between social networks.

Gender-weighted perceptions

An example of power dynamics in social networks, and their influence on clinical perceptions, can be seen in my own periodontal practice. In the year 2008, I saw in the order of 1,000 patients over approximately 4,000 individual appointments—allowing for multiple visits by the same patient. Of those 1,000 or so patients my records show that only 19 individuals proceeded on to surgical treatment for designated ‘cosmetic only’ reasons.[3] All nineteen of those surgically treated by me in 2008 were female. This tendency for females to heavily outnumber males when it comes to corporeal cosmetic modification is also borne out by statistical data compiled by the American Society for Aesthetic Plastic Surgery (ASAPS-Communications, 2009), which states that there were over 10 million surgical and non-surgical cosmetic procedures performed in the United States in 2008, a five-fold increase in the last ten years. Those aged 35 to 50 underwent 45 percent of the total procedures; ages 51 to 64, 26 percent; and ages 19 to 34, 22 percent. Almost 70 percent of all cosmetic procedures involved the face. Surgery accounted for 17 percent of the total, with non-surgical procedures making up 83 percent. Women underwent 92 percent of the cosmetic procedures, men 8 percent. Surgery involving the face included blepharoplasty (cosmetic eyelid surgery), cheek implants, chin augmentations, facelifts, forehead lifts, lip augmentations, and rhinoplasty. These comprised a third of all cosmetic surgical procedures. Non-surgical cosmetic procedures involving the face included various injectables—the most common of which involved neuromuscular blocking agents (such as Botox), which totalled a mammoth 24 percent of all cosmetic procedures—and facial rejuvenation techniques, such as chemical peels and dermabrasion.

My own clinical findings, and the statistics of the American Society for Aesthetic Plastic Surgery, emphasise the highly-gendered nature (certainly in Western cultures) of cosmetic facial modifications in which females, while sharing corporeal commonalities with males, have certain particularities associated with the way their gender is perceived—by both men and women—that have resulted in the aforementioned differences in the incidence of those undergoing cosmetic surgical modifications. These social particularities, which determine differences between females and males—how they are seen, known, and ‘technologised’—require further investigation, which I shall now venture to undertake, utilising a Foucauldian framework.

In the past there have been two dominant feminist approaches that attempt to explain why women seek cosmetic surgery more so than men. The first of these has to do with the perspective that women are assumed to be objectified by men’s standards of beauty through the ‘male gaze’, thereby constructing representations of the female form that are in keeping with the prevailing cultural norm. As put by Kathryn Pauly Morgan: ‘Actual men—brothers, fathers, male lovers, male beauty “experts”—and hypothetical men live in the esthetic imaginations of women’ (1998, p. 334). According to this interpretation, women assess and adjust themselves on the basis of their perceptions of men’s desires or, perhaps more pertinently, to the patriarchal idea(l)s they have internalised. As such, the meaning of ‘perceptions’—which, I contend, are always partial and situated—in this approach is problematised. The second approach is exemplified in the argument put forward by Kathy Davis whereby cosmetic patients are assumed to exercise a notion of ‘choice’ and agency in self-governing and self-directing their treatment decisions,[4] and in which ‘[c]osmetic surgery transforms more than a women’s appearance; it transforms her identity as well’ (2003, p. 75). In other words, Davis contends that by undergoing cosmetic surgery one not only attempts to conform oneself to the discursively determined ideals of ‘attractiveness’ (or as several of the recipients of cosmetic surgery express as a desire for ‘normality’),[5] it is also an attempt to align one’s surface body with the depth body of an ‘obligatory true self’, which essentially (and paradoxically) imposes upon the individual a measure of depersonalised homogeneity (Negrin, 2000, p. 95; 2008, p. 70).

Both approaches, although appearing to be opposed to one another (i.e., an individual being ‘controlled’ vs an individual exercising ‘choice’), treat the body—as Gagné and McGaughey point out—‘as a passive object that is either inscribed by hegemonic norms constructed by men or used by women as a tool in their social construction of a gendered self (2002, p. 817). Essentially, these two approaches share the premise that cosmetic surgery is a means by which the individual with—what I term—a ‘difference from’ face has the opportunity to conform more closely to the bio-political cultural standard of the ought face.

Realistically, the objectifying gaze, previously referred to as the ‘male gaze’, comes from many sources, not just heterosexual males. In addition to the male gaze, there are also multitudes of other ‘gazes’: the female gaze, the clinical gaze, the gaze of self-surveillance, the ethnic gaze, the photographer’s gaze, the gaze of the social group, the gaze of the imaginary ‘other’, and so on. All these gazes, aside from being disabling through objectification, are also enabling allowing new norms, fashions, cosmetic surgical procedures, and various other means of self-care to come into view. In other words, technologies of power, signification, production, and self-care—in and through elements of the Foucauldian dispositif (texts, actions, objects)[6]—create norms for the female body and feminine subjectivity to follow. These norms are then internalised, embodied, and maintained. Women who claim to exercise agency in these circumstances embark on cosmetic facial modification procedures based on aggregate and individual ‘discursivised’ knowledges of the norm. These ‘fashioned’ knowledges then intervene to create the conditions whereby those targeted—and statistical analyses previously cited for cosmetic surgery suggest that more females than males fall into this category—bring themselves into conformity with particular standards in ways that are taken-for-granted as being ‘freely chosen’. These ‘chosen’ actions are then perceived as legitimate practices of intervention in which situated knowledges play active and productive roles. As such, so-called ‘empowerment’ is complicitly enmeshed in the practice and institution of cosmetic surgery itself, in which new ways of judging the face to be ‘wrong’ are reinforced by new materials and procedures to make the face ‘right’ (Bordo, 1997, pp. 43-57; Heyes, 2007, p. 93). Put differently, seemingly ‘free choices’ for those who embark on regimes of cosmetic facial surgery are manifest because of particular ‘technologised’ ways of ‘seeing’ and ‘knowing’—epitomised by a superabundance of images of flawless, ‘feminine’, female faces—that are taken for granted as being ‘real’. The (dys-figured) consumer of these technologies is then coerced—and in a sense obligated—into becoming con-figured within regimes of ‘truth’ in which the female face is not only medicalised by technologies of domination and the self, it is refigured and redefined within a fluctuating milieu of mediated instability. As put by Jordan, ‘[t]he plastic body is a contested subjectivity whose meaning shapes and is shaped by the ways that the body can be discussed, by whom, and toward what end, as well as the sociopolitical implications of people seeking to make their bodies conform to an idealized image’ (2004, p. 333). Essentially, I agree with Kathryn Pauly Morgan, when she reasons that what seems to be a reflective decision of ‘choice’, and a matter of self-determination, is often an indication of conformity at a deeper level (Morgan, 2009, p. 58).

Analogous to Foucault’s affirmed technologies of sign systems, power, and production, French sociologist and philosopher Pierre Bourdieu appropriates the aforementioned concept of tacit domination within sociocultural representation as symbolic power or symbolic violence. Bourdieu uses the concept of symbolic power to argue that symbolic systems not only provide the means for ordering and understanding the social world, they also act as ‘instruments of knowledge and communication’ and ‘instruments of domination’ (1991, pp. 164-170). Essentially, symbolic power for Bourdieu ‘is the imposition of systems of symbolism and meaning (i.e. culture) upon groups or classes in such a way that they are experienced as legitimate’ (Jenkins, 2002, p. 104). Power relations are hidden by this accepted legitimacy, which allows for successful imposition and systematic production and reproduction of said social practices (Bourdieu & Passeron, 1990, p. 15). The subtlety of this tactic is the fact that control of an individual’s thoughts and actions is made to appear rational and, in many cases, obligatory. For Bourdieu, ‘[t]he distinctiveness of symbolic domination lies precisely in the fact that it assumes, of those who submit to it, an attitude which challenges the usual dichotomy of freedom and constraint’ (1991, p. 51).

 

Asymmetry in the clinical encounter

Contemporary governance in the clinical encounter, for clinician and patient, inextricably implicates certain ‘truths’ in knowledge (general and particular) within relevant professional and social fields. However, contained within these relevant networks, there are distinct asymmetries in power/knowledge relations.

An illuminating account of the ‘shared’ (but unequal) doctor-patient relationship is eloquently described by Victoria Pitts-Taylor who, in trying ‘to establish authority over the meaning of … [her own] cosmetic surgery’, gives an informed and personal perspective on many of the fundamental disparities in the distribution of power, knowledge, and ‘truth’ in the clinical encounter. She writes:

I want to be understood … [yet first] [t]he doctors to whom I presented myself as a prospective patient expected a certain set of attitudes about myself and my body … [Second] [w]hile my cosmetic surgery experience is hardly unique, there are aspects of it that are entirely unique because they are rooted in my own body … I do not experience cosmetic surgery in fully translatable terms; and yet in communicating with others I am expected to employ methods of description that make sense to others [and] [i]n doing so, I comply with already scripted codes of meaning that are set out before me … [Third] my self-narration is shaped by the norms that discipline me … such experiences will be translated to individual selves and to the social world in recognizable templates of norms, diagnoses, and social truths … [Fourth] [t]hese disciplinary effects include … the fixing of my subjectivity. I offer myself as a fixed ‘I’ who can explain myself, and who speaks of having intentionality and agency. But although I am expected to define my actions with reference to an ‘I’ that is stable and foundational, I am actually being produced (2007, pp. 176-178).

Pitts-Taylor’s narrative emphatically highlights the asymmetrical nature of the power/knowledge relations between doctor and patient in the clinical consultation. And even though I have argued that each individual is both subject and object at the same time—both sharing commonalities as part of an intersubjective ‘interworld’[7]—I must also stress that each ‘player’ in the encounter (surgeon and patient) is governed by a different set of rules, and a different set of ‘truths’.

Through hierarchical observation, normalising judgement, and the examination, it is the doctor who wields the overwhelming share of disciplinary power and knowledge. And as such, and from my own perspective as a diagnostic and surgical clinician, it is inappropriate to cite the patient’s request (as do many of my colleagues) as being the sole determining factor for this or that procedure to be undertaken. This does not mean to negate or underscore the patient’s freedom to ‘choose’ a desired treatment path within certain constraints, however, while still accepting the inevitability of entering into an asymmetrical power/knowledge relation, it is the surgeon’s obligation to respond to, and care for, the needs and interests of the patient, commensurate with the surgeon’s own value-based principles, through an interaction of mutual reciprocity that does not reduce either body to the other or to itself.

Furthermore, in medico-legal and bioethical circles, it is ultimately the surgeon, who is guided by the commonly cited four principles of biomedical ethics (problematic though they may be) and not the patient—these principles being those of: (1) respect for autonomy (a principle requiring respect for the decision-making capacities of autonomous persons); (2) nonmaleficence (a principle requiring not causing harm to others); (3) beneficence (a group of principles requiring that we prevent harm, provide benefits and balance benefits against risks and costs); and (4) justice (a group of principles requiring appropriate distribution of benefits, risks and costs fairly) (Beauchamp, 2007, p. 4).

And here I draw on the work of Arthur Frank and Therese Jones (2003), who elucidate the following insights. For the patient in the clinical encounter, the question is: ‘How do I, acting as a patient, receive treatment without thinking of myself as, in essence, a patient with all the presumptions of passivity and dependence that requires?’ (2003, pp. 185-186). And for the clinician, the question is: ‘How do I, acting as a health care professional, offer my knowledge and skills to others with the necessary requirement of entering into certain relations of power but still care for my own self and the self of the other?’ (Frank & Jones, 2003, p. 186).

This calls for a responsibility on the part of the clinician to acquire and develop habituated modes of intercorporeal existence and decision-making, understood as the logic of practical, value-based wisdom (phronêsis) and intuitive skill (mêtis). In other words, studying and knowing ‘truth’ in medical theory (epistêmê), and having the technical ability to carry out scripted tasks to achieve a practical end (technê), are not enough to attain the goal of becoming a clinician for whom ‘excellence’ becomes internalised as second nature (Kinghorn, 2010, p. 97).[8]

The good clinician

To cultivate the desired form of practical wisdom in which ‘[t]o act is to act on the basis of some value … [and] to act in ways that exemplify our values’ (Frank, 2004, p. 221), Merleau-Ponty tells us that our body inclines us towards an expertise in those environments in which we consistently take part and practice. He writes:

It is knowledge in the hands, which is forthcoming only when bodily effort is made, and cannot be formulated in detachment from that effort … it is the body which ‘understands’ in the cultivation of habit … [t]o understand is to experience the harmony between what we aim at and what is given, between the intention and the performance—and the body is our anchorage in the world (1962, p. 144).

For Merleau-Ponty ‘habit’ is therefore not a mechanical reflex (like a knee jerk), it is a practical skill that is ‘cultivated’ as a form of training in ‘habitual ways of acting in certain situations’ (Burkitt, 2002, p. 224). It is ‘the grasping of a significance’ (Merleau-Ponty, 1962, p. 143) in which our habitual skills are acquired in the process of dealing with ‘things’ in contextual situations, which in turn determine how those ‘things and situations show up for us as requiring our responses’ (Dreyfus, 2002, p. 368). These habituated skills are then ‘stored’ in the body, not as representations in the mind, but as dispositions which, through imitation and repetition in intersubjective experience, become sedimented styles of being-in-the-world.[9] The interconnection of habit (i.e., skilful action) and perception, through sedimentation, make up what Merleau-Ponty refers to as an ‘intentional arc’ (1962, p. 136). And it is this intentional arc that allows for a certain type of corporeal stability or consistency for dealing with ‘things’ in contextual situations, in which past experiences are projected back into the world, and in which an individual’s actions are, to a large degree, experienced as a flow of habitually created skilful activity in response to the sense of the situation according to the stylised intentional arc. Importantly, Merleau-Ponty’s notion of habituality is not opposed to change. In fact, to maintain stability or equilibrium within a changing environment requires our style of being-in-the-world to change. As put by Jack Reynolds:

[T]he body must change … to stay the same would be to induce instability … The suggestion being proposed is that the mode of being associated with a trained individual—and being trained is a state that the body-subject inevitably tends towards for Merleau-Ponty—is such that it renders the undecidability involved in decision-making an increasingly rare state’ (Reynolds, 2002, p. 457; 2004, p. 92).

Cadwallader refers to this process of changing the style of being-in-the-world as ‘stirring up the sediment’ (2010, p. 513). As Merleau-Ponty puts it: ‘By taking up the present, I draw together and transform my past, altering its significance, freeing and detaching myself from it’ (1962, p. 455). In other words, just like an expert driver of a motor vehicle, or an expert chess player, or an expert surgeon, or an expert diagnostician, or an expert teacher, or an expert dancer, the body inclines us towards a skill or expertise in those environments in which we consistently take part and consciously practice so that it becomes ingrained as second nature. Reynolds explains that ‘[o]n mastering a technique, an individual can become accustomed to a situation in such a way that they “understand” how best to decide’ without prolonged decision-making (2002, p. 460; 2004, p. 96).

For the ‘good’ clinician, what were once consciously performed procedures aiming at clinical excellence, through prolonged practice in an embodied context, have become habituated into ‘excellent’ practice as second nature. In a similar manner, the ‘not so good’ clinician, who consistently stylises poorly thought-through actions, is eventually habituated into a regimen of poorly enacted practice. However, as I have alluded to, change is still possible for the clinician who aspires to excellence as second nature in practice by ‘stirring up the sediment’ with a view to reworking habituated activity in a positive manner and by restylising professional modes of practice. Once the correct habitual practices—which comprise not only technical, but also virtuous dispositions—are in place, the clinician is, in a sense, freed up to devote more considered decision-making (i.e. problem or puzzle solving) through conscious reflection, to those situations which demand thoughtful invention and tactical strategising of a more complex nature. And even in those times when reflective deliberation is usually not required, but where the clinician’s faculties are compromised—through stressful situations, or where fatigue is a factor—excellent habituated practices are more likely to result in the appropriate decisions being made, and the correct technical procedures being performed. Clearly, in clinical practice, explicit instructions contained within the four principles of biomedical ethics listed by Beauchamp, or the ability to carry out a technical procedure according to a ‘how-to’ recipe, are no substitute for the ability to respond to unique and unpredictable situations that call for knowledges in the form of phronêsis and mêtis, both grounded and constituted in and through habituated styles of being-in-the-world.

Concluding remarks

 

With the help of the works of Foucault, Merleau-Ponty, and Bourdieu I have argued that, while contemporary governance in the clinical encounter is a shared relationship through mutually overlapping and lived commonalities between clinician and patient, it is inevitably an unequally shared relationship insofar as the rules that govern ‘truth games’ for each specific ‘body-in-situation’ in the relationship differ and are continually in a state of flux. Rather than thinking about the patient, I have argued that the clinician should be thinking with the patient in a relationship in which—because of the asymmetrical distribution of power/knowledge afforded the clinician, in addition to the problematic guiding principles of biomedical ethics—the surgeon must accept the major portion of the responsibility for any procedural action taken, or not taken. Through an appraisal of the acquisition of habituated skills for ‘excellence’ in clinical practice I have argued that studying and knowing ‘truth’ in medical and dental theory, and the following of uniform rules to complete a ‘scripted’ technical task, are no substitute for acquiring the additional knowledges of phronêsis and mêtis, which are themselves grounded in habituated practical experience.

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Negrin, L. (2004). Cosmetic surgery as cultural practice: A review of Dubious Equalities and Embodied Differences by K. Davis. Theory & Psychology, 14(4), 566-568.

Negrin, L. (2008). Appearance and identity: Fashioning the body in postmodernity. New York: Palgrave Macmillan.

Pitts-Taylor, V. (2007). Surgery junkies: Wellness and pathology in cosmetic culture. New Brunswick, N.J.: Rutgers University Press.

Reynolds, J. (2002). Habituality and undecidability: A comparison of Merleau-Ponty and Derrida on the decision. International Journal of Philosophical Studies, 10(4), 449-466.

Reynolds, J. (2004). Merleau-Ponty and Derrida: Intertwining embodiment and alterity. Athens: Ohio University Press.

Seyfarth, R. M., & Cheney, D., L. (2009). Seeing who we hear and hearing who we see. Proceedings of the National Academy of Sciences, 106(3), 669-670.

[1] Foucault proposed two dimensions of his notion of bio-power. One pole, starting in the seventeenth century, focuses on the ‘anatomo-politics of the human body’, the ‘body as a machine’, by seeking to optimise the capabilities of the human body, enhancing its economic utility and, at the same time, ensuring its docility. The second pole, formed somewhat later, focuses on the aggregate body, the species body, ‘the body imbued with the mechanics of life’. In other words, the second pole is one of ‘regulatory controls: a bio-politics of the population’ (1990b: 139), in which there is a diffuse mechanism of power relations concerned with the promotion of, and intervention in, human life. Both dimensions of power in the Modern era are powers of ‘objectivization’, but they also provide the potential for subjective action in relation to a discursively determined corporeal model or norm.

[2] Foucault, in Technologies of the Self (1988, pp. 16-49), outlines four major discursive and social ‘technologies’—those of ‘production’, ‘sign systems’, ‘power’, and ‘the self—each of which he describes as a ‘matrix of practical reason’ that implies some form of training. The interaction of Foucault’s four listed technologies implicates reciprocity between the attainment of knowledge and the practical application of that knowledge.

[3] Oral plastic surgical procedures were carried out on several other patients related to pre-prosthetic requirements and the repair of tissue anomalies caused by disease and/or traumatic injury.

[4] Virginia Braun contends that ‘choice’, agency, and obligation are enmeshed. She argues that ‘[i]n a context where the individual should be a (self-improving) agentic subject, choice rhetoric simultaneously promotes … consumer ‘choice’ to ‘improve’ (Braun, 2009, p. 244).

[5] Negrin points out that ‘while one should avoid being overly dismissive of the reasons people give for their actions [in undergoing cosmetic surgery], at the same time, it is equally problematic to accept such accounts uncritically’ (Negrin, 2004, p. 567).

[6] The methodological function of the dispositif is to allow Foucault to bring together, to order or to arrange, a whole set of heterogeneous elements—some of which are textual and others non-textual, i.e., language-based and non-language-based—to analyse how their interplay and connections result in historical formations that are never constant, or pre-ordained.

[7] Merleau-Ponty refers to as an ‘interworld’ (1962, p. 357), whereby individuals share an overlap or commonality between their perceptions and intentions.

[8] Knowing what and why (epistêmê), or knowing how to craft, or to fashion (technê) according to a set of rules and regulations, is no longer sufficient for a full understanding of embodied social practices. What is also required is a pragmatic knowledge in which there is a sense of value-based action in the dynamic process of corporeal interaction; a knowledge which is ‘singular’, ‘idiosyncratic’, and which is ‘generated in the intimacy of lived experience’, and ‘an analysis of values’ (Baumard, 1999, pp. 53-54; Flyvbjerg, 2001, pp. 56-57). The ancient Greeks referred to this form of knowledge as phronêsis. In addition to knowledge as phronêsis, ‘specific situations’ in everyday clinical and social practices are intuitive and ‘tactical in character … these “ways of operating” [are called] metîs’ (De Certeau, 1988, p. xix).

[9] This is not unlike Foucault’s reference to the habituated aspects of meletê or meditatio (an exercise of self-care or training in Greek Antiquity) involving ‘not so much thinking about the thing itself as practicing the thing we are thinking about … ensuring that this truth is engraved in the mind in such a way that it is recalled immediately the need arises … making it a principle of action’ (2005: 357).

Communicating Medical ‘Truths’ – Paper

Communicating Medical ‘Truths’:

A Politics of Negotiation Inside and Outside the Clinic

Tony McHugh, Macquarie University, Australia

 

Health-related information has long been regarded as a focal point for more than just the values and perspectives of the patient and the doctor. This is because the communication of medical knowledge also represents an interface between the medical profession and society, whereby purported medical ‘truths’ that seek to in-form become trans-formed in the process of dissemination, translation, and exchange. In an age in which health-related services and products are increasingly viewed as commodities, and in which there is an abundance of alternative, mediatised information portraying bodies as knowable, controllable, and alterable in discursively specified ways, the relationship between the producer and consumer of medical knowledge must also be problematised as being a negotiable and transmutable entity. Put differently, the medical certainty of the previously dominant ‘paternalistic model’ of the doctor-patient relationship has, in recent times, been replaced by a more pluralistic model of decision-making and bio-political governance, in which rhetorical possibility plays an increasingly important role.

 

Expert ways of seeing and knowing the ‘truth’

 

Medical practitioners within a particular ‘field’—general surgeons, plastic surgeons, diagnostic physicians, dermatologists, gastroenterologists, and so on—will generally ‘know’ what is important in their designated area of expertise. Different writers have referred to such a specialised community as: an ‘institution’ of ‘disciplinary practice’ (Foucault, 1995, pp. 167-168), a ‘field of discourse’ (Foucault, 2002, p. 25), a ‘field or web of significance’ (Engelhardt, 1990, p. 63), a ‘webbed connection’ of ‘knowledge and power’ (Haraway, 1988, pp. 584-588), a ‘thought collective’ as carrier for a ‘thought style’ (Fleck, 1979 [1935], p. 158), a ‘paradigm’ or ‘disciplinary matrix’ (Kuhn, 1970, p. 182), and a ‘field of power’ (Bourdieu & Wacquant, 1992, p. 18).

 

What ‘counts’ as a ‘disciplinary practice’ is described by Anderson and Grinberg as ‘a set of discourses, norms, and routines that shape the ways in which a field of study … and its related practices … constitute themselves’ (1998, p. 330). As an example, they remark that:

it is customary that scholars locate their topics within the field of study in which they write … within a set of previously competing discourses that have contributed to the constitution of the field itself … As we locate our own article within this discursive field, we become part of the taken-for-granted routines and conventions that form our field as a disciplinary practice at the same time that we challenge it (1998, pp. 330-331).

 

Borrowing from Thomas Kuhn’s description of what components make up a ‘disciplinary matrix’,[1] my own clinical practice of periodontics and oral plastic surgery—the measurements I record, the things I look for and ‘see’, and the various other operations and interventions that I undertake—is largely determined by four factors (1970, pp. 182-187). First, there are ‘symbolic generalisations’ upon which my discipline is based. These include the acceptance—within my discipline, and ‘without question’—that diseases and anatomical abnormalities, including their definitions and means of identifying such entities, exist in the oral and perioral region. Second, there are ‘metaphysical paradigms’ or ‘beliefs in particular models’, which dictate shared commitments to such beliefs. For example, the preservation of one’s ‘natural’ dentition depends on a dentally favourable diet and an effective tooth-cleaning regimen, thereby reducing the risk of dental caries and inflammatory periodontal diseases. The disease model based on plaque-related inflammation provides the discipline of periodontics with a preferred or permissible analogy or metaphor, and assists with determining what will be accepted as an explanation for certain clinical phenomena. Third, there are ‘value commitments’ or ‘professional norms’. In periodontal practice these ‘shared values’ include the preservation or enhancement of periodontal attachment levels and bony support around teeth. However, while these values may be widely shared by periodontists, the application of these values may vary considerably, according to individual experience, skill, and judgement. Kuhn remarks that ‘[t]hough they [these shared values] function at all times, their particular importance emerges when the members of a particular community must identify crisis or, later, choose between incompatible ways of practicing their discipline’ (pp. 184-185). The fourth element in the ‘disciplinary matrix’ is the ‘deeper’ meaning of Kuhn’s use of the term ‘paradigm’: that of ‘exemplars’. By exemplars Kuhn means example problems and their solutions that a student encounters from the start of their disciplinary education, progressing through their post-graduate and ongoing professional careers—in textbooks, in assignments and examinations, in published literature, at conferences, and so on. All periodontists, for example, learn to reduce the degree of marginal gingivitis by removing bacterial deposits from the surfaces of the teeth. However, as periodontal training and experience develops, shared ‘symbolic generalisations’ (the first-mentioned element in the disciplinary matrix), are increasingly illustrated by different exemplars, for example: bacterial deposits may be removed by non-surgical mechanical or chemical means; mechanical methods may include the use of scalers, curettes or lasers; pathogenic bacteria may be susceptible to appropriate antibiotic therapy; and surgical debridement of root surfaces may remove plaque that is inaccessible to non-surgical measures. Exemplars are, in effect, concrete solutions to discipline-specific puzzles or ‘problems’. In other words, clinicians solve puzzles based on ‘time-tested and group-licensed’ ways of ‘seeing’, ‘knowing’, and ‘doing’ (p. 189). Kuhn’s criteria, pertaining to a ‘disciplinary matrix’, may be applied to any of the ‘fields’ of ‘expert’ practitioners associated with ‘seeing’ and ‘knowing’ that certain kinds of bodies, their conditions and behaviours are ‘wrong’, and others are ‘right’.

 

In his book The Structure of Scientific Revolutions, Kuhn casts doubt on the ‘objectivity’ of reported evidence within a designated paradigm, especially if examined by those outside that particular paradigm (1970, pp. 126-127). Individuals within unlike paradigms—such as sociologists and cosmetic surgeons—will ask different questions, and demand different answers. For instance, a cosmetic surgeon may acquire knowledge of a certain sort, through their education within a particular paradigm. This in turn is acknowledged and supported by skilled practitioners within that same paradigm. The clinician’s training allows her or him to work successfully within their field of competence, uncritical of the precise nature of the paradigm in which they work, unless threatened by a new paradigm, or the emergence of a new theory that undermines confidence in the prevailing paradigm. Kuhn reports that this ‘is generally preceded by a period of pronounced professional insecurity’ (1970, pp. 67-68). An example of this is when a cosmetic surgeon is faced with the reported results of a particular surgical procedure that enhances the volume of a person’s lips. Rather than contemplating the reasons that brought about the cultural desirability of such a procedure, the surgeon would be more interested in the techniques and materials employed in the procedure, the accuracy and reproducibility of the study’s data, and the stability of the post-surgical anatomical outcome. When faced with the emergence of a new cultural fashion extolling the virtues of smaller lip volume, the surgeon would be inclined to reassess their own ideas and techniques in the light of the newly accepted cultural practice. The reasons for society’s shift from the desirability of full lips to thin lips would demand less critical contemplation than the need to provide a service for which they, the clinician, were trained. As such, the dominant cultural problems related to the supply and demand for facial amendments, augmentations, and enhancements fall outside the puzzle solutions of the surgeon’s disciplinary matrix or paradigm. Anticipating this dilemma, but not providing any specific direction for resolution, Kuhn writes:

[O]ne of the things a scientific community acquires with a paradigm is a criterion for choosing problems that, while the paradigm is taken for granted, can be assumed to have solutions. To a great extent these are the only problems that the community will admit as scientific or encourage its members to undertake. Other problems, including many that had previously been standard, are rejected as metaphysical, as the concern of another discipline, or sometimes just too problematic to be worth the time. A paradigm can, for that matter, even insulate the community from those important problems that are not reducible to the puzzle form, because they cannot be stated in terms of the conceptual and instrumental tools the paradigm supplies (1970, p. 37).

 

Engelhardt describes five features which characterise specialised communities such as medical practitioners, dentists, and so forth: First, ‘[t]hey tell what to value and disvalue and in what order … [they] also disclose the goals or values to be realized’ (Engelhardt, 1990, p. 67). Medical schools, for example, impart disciplinary power through the selection of discrete subjects to study, and by normalising students, staff, and administrators by providing an accepted ‘way of thinking’ about the subject matter in question. Norms and rules are internalised, providing the basis for normalisation through self-discipline and group control. This leads on to a second observation, whereby medical collectives ‘provide ontological guidance … what will count as … disease [and abnormality]’ (Engelhardt, 1990, p. 67). The third component includes a sociological element in which communities of doctors and other health care workers are sustained by implicit instructions regarding who are members of their group, and who are strangers, and the ways in which one should react to the other. ‘Under this component, one finds everything from professional associations and journals to binding codes of medical etiquette’ (Engelhardt, 1990, p. 68). The fourth feature of these types of communities is that they provide ‘examples of what it means to know things correctly’ (Engelhardt, 1990, p. 68). These examples usually take the form of favourable experimental results and successfully treated clinical cases, the latter, offering before and after versions of how an ‘abnormal/wrong case’ can be made into a ‘normal/right case’. This leads to Engelhardt’s fifth component in which the ‘communities … have implicit or explicit recipes indicating when it is prudent or imprudent to intervene in particular ways … under general notions of usual and customary standards of care or by formally articulating indications for treatment’ (Engelhardt, 1990, p. 68).

 

Medical ‘truths’ lost in translation

 

With reference to ways of ‘seeing’ and ‘knowing’ what ‘counts’ as a medical ‘truth’, there are going to be differences of opinion according to the positioning or points-of-view contained within and between scientists, clinical practitioners, various other related fields of academia, and the population at large: each informed, ill-informed, misinformed, and uninformed in certain ‘ways’. As an example of how these differing perceptual systems may operate, Ludwik Fleck, a physician specialising in immunology and serology, outlined in the mid-1930s certain rules pertaining to intra- and inter-collective communication of ideas (1979 [1935], pp. 111-112). For Fleck one particular type of ‘situated’ group is the one grounded in expert or specialist knowledge. With regard to the medical specialties, this would consist of specialist surgeons, cardiologists, paediatricians, and so on. This forms a narrow inner esoteric circle, surrounded by an outer esoteric circle of general experts, such as general medical practitioners, and specialists in certain other areas of health care and related fields. This is then surrounded by an exoteric circle consisting of ‘educated amateurs’ and the public at large (p. 111). The ‘web’ of medical knowledge, therefore, consists of many esoteric and exoteric circles, which intersect and overlap. In my own case, I belong to an inner esoteric circle of periodontists and medical sociologists. However, I am also a member of a small number of outer esoteric and several exoteric circles, both within and outside the umbrella of health care and sociocultural studies. In addition, I am a white (another circle), middle-class (circle), heterosexual (circle), male (circle). Within the clinical specialties and various other disciplines, Fleck’s proposed circles are mutually dependent, since members of the outer circles rely heavily on the knowledge generated by the inner circle of experts; but those within the inner circle also rely on the validation of such knowledge claims by the outer, less specialised groups (Harwood, 1986, p. 180). Fleck’s circles may also be applied to multitudes of intersecting cultural circles,[2] to social groups extending far beyond the ranks of scientists, and health care providers and consumers. And although there may be a dominating ‘commonality’—a general perspective or ‘way of seeing’ in a particular ‘circle’—it is not the only point-of-view influencing knowledge within that circle or collective (Wittich, 1986, p. 318). In this regard, and as put by Donna Haraway, ‘[t]he knowing self is partial in all its guises, never finished, whole … it is always constructed and stitched together imperfectly, and therefore able to join with another, to see together without claiming to be another’ (1988, p. 586). In this way, an individual or individuals possess ‘particularities’ within a field, but also share ‘commonalities’ with others in fields in which the dominant cultural perspective on certain issues within the field may differ from their respective esoteric or specialist expertise.

 

Fleck’s epistemological patterns, I posit, may be used as a means for understanding different forms of health-related communication, both inside the clinic and outside the clinic. For instance, with regard to the provision of text for orofacial cosmetic surgery, the inner expert-centred esoteric circle is characterised by journal articles representing ‘intense, fragmentary, personal and critical dialogue within a given field of knowledge’ (De Camargo, 2002, p. 829). Examples of this would be the Journal of Plastic, Reconstructive & Aesthetic Surgery, The International Journal of Oral & Maxillofacial Implants, or the American Journal of Orthodontics and Dentofacial Orthopedics. The outer esoteric circle includes consensus-type or handbook reference knowledge, which is more-or-less a synoptic organisation of the former specialist expositions, described by Fleck as ‘individual contributions through selection and orderly arrangement like a mosaic from many colored stones’ (1979 [1935], p. 119). These would include the Journal of the American Medical Association, the Australian Dental Journal, Lancet, and most student textbooks. And then there is the exoteric ‘lay’ circle that is supplied by information from popular media sources, including the Australian Cosmetic Surgery Magazine, television shows like Extreme Makeover, and certain Internet sites providing experiential feedback. Importantly, ideas that circulate among the various ‘webs’ or ‘collectives’ are bound to change during the process of conversion, resulting in the omission of detail and controversy, and an oversimplification of the intricacies of the concepts involved as the lines of communication move from the inner to the outer circles. This being the case, the complexities and uncertainties contained within the knowledge of specialists is converted by the migration of ideas through the various outer groups and fields into less complex, less critical versions of the inner circle of expert-centred ‘truths’ (Lowy, 1988, p. 145). This, then, may proceed on to popular media presentations, which according to Fleck are:

artistically attractive, lively, and readable exposition[s] with last, but not least, the … [self evident] valuation simply to accept or reject a certain point of view … In place of the specific constraint of thought by any proof, which can be found only with great effort, a vivid picture is created through simplification and valuation (1979 [1935], pp. 112-113).

 

In any exchange of ideas and information between ‘collectives’ or ‘fields’, and with a wider audience outside the predominant, situated ‘way of seeing’, there is always the requirement of translation, transformation, and negotiation of meaning, shaped by a social group (Bonah, 2002, pp. 192-193). And since every individual belongs to several ‘webs’ of communication at once, and in which ‘ways of seeing’ are as a consequence multiplied (Fleck, 1979 [1935], p. 45; Haraway, 1988, p. 586), those in the inner esoteric circle of specialist clinicians are also influenced by their membership of other, non-expert social circles in which ‘knowledge’ is subject to less intense deliberation, scrutiny, and validation. In other words—and to continue with the previous example—the producer and the consumer of facial enhancements, the expert-centred and the user-centred components of the ‘beauty industry’, the encoder and the decoder of media messages, and the inner and outer circles of ‘webbed connections’, are influenced by—but also influence—each other. This being the case, I put forward the premise that the determination of the ‘rightness’ or ‘wrongness’ of particular bodies, faces, conditions or modes of behaviour within and between expert-centred and user-centred communities is subject to multilevel interactions and dynamic interconnections which are not only culturally and historically structured, but are also structuring through embodied perspectives and complicit transactions, since interpretation of information—exoteric to esoteric; esoteric back to exoteric—may bring about a negotiated meaning for what is considered to be the ‘right’ way to look and to be. Such information coming from exoteric ‘lay’ circles, I contend, has the potential to then legitimise ‘expert’ ways of knowing, seeing, and communicating medicalised ‘truths’. One only has to consider the cosmetic surgeon who may be susceptible to (and ultimately believe) mediated messages extolling her or his importance in providing ‘essential’ facial ‘corrections’ for those who deviate from the desired sociocultural ‘norm’; or the dentist, bombarded by media-generated images of ‘whiter-than-white’ teeth, who promotes ‘sparkling Hollywood smiles’ as a means of enhancing the self-esteem of patients who have been stigmatised by discursively-determined visualising practices. In both examples, interpretive exchanges of information between outer and inner circles of medical knowledge have been ‘lost in translation’. In other words, in contrast to Kuhn’s concept of the ‘disciplinary matrix’—which provides a means for solving puzzles largely insulated from external factors except in times of crisis (1970, p. 111)—the notion of overlapping ‘fields’ and ‘webs of connections’ encompasses social factors which provide for a borderless inside/outside perspective in the grounding of medical knowledge which structures, but is also structured by, an intertwining of several different sociocultural influences. To put it more succinctly, when determining what ‘counts’ as ‘truth’ in medical information, what happens inside the clinic has a lot to do with what happens outside the clinic, and vice versa.

 

To illustrate the practicalities of negotiated communication and the governance of bio-political ‘truths’ in the clinical situation, I will now introduce and analyse a face-to-face encounter with one of my own patients. I shall refer to her as Ms K.

 

The case of Ms K

 

Ms K[3]—let us call her ‘K’—is a forty-eight year old woman who has come to my clinic because she ‘hates’ her smile. She has recently undergone a stressful divorce. Her only child has moved overseas, and K is planning to return to the workforce as a marketing and sales representative, a position she held 10 years previously. She has acquired a sum of money as a result of her divorce settlement, and she reasons that it is about time she started looking after herself—‘doing it for me’, as she put it. She flicks through a glossy magazine displaying photographs of a well-known celebrity with a ‘beautiful smile’—a smile she would like to have. She shows the photographs to me and asks: ‘How long will it take before I can have the smile that reflects the way I really am?’ I caution K that I am not able to answer her questions in any detail until a thorough clinical and radiographic examination has taken place.

 

Subsequent findings confirm that K has no significant medical problems, and possesses relatively good dental and periodontal health. She has a single-tooth upper partial denture replacing a central incisor, which she lost a few years previously following a swimming pool accident. During the course of our conversation I learn that K has recently rented a one-bedroom apartment ‘with harbour views’. Not only is K keen to resume her former work position, she also confides to me that she wants to start ‘going out with guys again’.

 

I explain to K that her dental hard and soft tissues are essentially healthy. However, I point out that there are certain ‘irregularities’ that have compromised aesthetic features of her smile. So I ask her: ‘Just what is it that you hate about your smile?’ She says: ‘I can’t stand the colour of my teeth! No one on TV has teeth like these. They’re too yellow, and they make me look old. Can I bleach them?’ I confirm that bleaching is possible. But, I also add that there are other ‘things’ that are ‘wrong’. I take a set of clinical photographs, and on a computer screen I show K what her smile looks like now, and then—with the aid of digital editing—how her smile will look if her teeth are made whiter. She still doesn’t like her smile. And so I focus on certain other features that affect the ‘look’ of her smile. I explain that the tooth on the partial denture does not match her ‘natural’ teeth with regard to colour, size, and shape. In addition, the incisal (biting) edges of the adjacent left and right incisors and canines are uneven. The gingival (gum) margins are also asymmetrical, and they do not harmonise well with her functioning upper lip line. There is also a tissue defect (depression in the gum) where the false tooth fits.

 

K seems to follow what I am showing her, and so I outline what can be done—according to the accepted principles of my specialty—to correct the various ‘abnormalities’ I have diagnosed. If tooth colour is her only concern, the existing teeth can be ‘whitened’—by bleaching, or by placing ‘whiter’ veneers, crowns, and so forth. The denture tooth can also be replaced. If, however, symmetry and harmony of gingival margins and the upper lip line are to be improved—to look more like the magazine images she showed me—as part of a more complex ‘makeover’ of her smile, preliminary surgical intervention will be required. This would include surgical bone resection and recontouring as part of crown lengthening, as well as bone and connective tissue grafting to augment (rebuild) the edentulous ridge. The partial denture may also be dispensed with, by opting for conventional crown and bridgework, or endosseous implant placement (McHugh, 1987, 1994, 1996).

 

During the course of our interaction I realise that merely changing the colour of K’s teeth will not be enough to provide the improved smile that she desires. The edited computer images convince me (and her) of this. And so, further ‘normalising’ image editing is required, this time ‘technologising’ prescribed hard and soft tissue changes in keeping with the templates developed within the esoteric circle of specialists of which I am a member. I show K the revised computer-enhanced version of her smile. I remark that this is the smile I would like to ‘give’ her. It will be her smile, but not the exact copy of the ‘celebrity smile’ that she first indicated to me in the magazine photographs. She accepts this, since the new smile will be her own ‘customised’ smile. However, the thought also occurs to me—though I do not know if I should verbally express it—that K’s desired smile will not secure the position of employment that she aspires to, nor will it ensure that she will start ‘going out with guys’ again. Put another way, K’s perceived accrual of physical capital (i.e. the enhancement of her smile) will not guarantee the intended conversion of her newly gained resources into other forms of capital.

 

Essentially, Foucault’s four major discursive and social ‘technologies’—those of power, sign systems, production, and the self (1988, p. 18)—have interacted to persuade my patient, but also me, into ‘knowing’ the kinds of ‘looks’ she and I desire, need to have, and produce. In my clinical encounter with K these ‘technologies’ are readily apparent: through hierarchical observation, normalising judgement, and the examination (Foucault, 1995, pp. 170-194); through the norms that create the conditions whereby K is brought or brings herself into conformity with particular standards (Foucault, 2007, p. 63); through the image of the ‘beautiful smile’ in the magazine (the signifier) and the concept or meaning that the ‘beautiful smile’ affixes (the signified) (Chandler, 2002, pp. 36-43); through the principal objective of production, which is consumption (Murray, 2010, p. 10); and through the concept that the ‘true self is not necessarily given, but must be created ‘as a work of art’ (Foucault & Rabinow, 1991, p. 351). As an indication of empowerment through the creation of a discursively idealised ought orofacial appearance, these negotiated, bio-political ‘truths’ have been interiorised by K, but also by my own normalised ways of ‘seeing’ and ‘knowing’ within (and outside) my specialist clinical discipline. As put by Suzanne Fraser, these taken-for-granted observations ‘echo a long-standing stereotype in which women compete, and are judged, on the basis of their appearance … in the realm of careers … [and] in the traditional realm of romantic relationships’ (2009, p. 105). And furthermore, in the process of problematising the boundaries of my normalised ways of thinking, I am decidedly unconvinced that K—as a purportedly self-defining agent—is really doing it for herself when she says: ‘I’m doing it for me’—the ‘me’ being some kind of impossible ‘personal reference point untouched by external values and demands’ (Bordo, 2009, p. 23). Indeed, in view of the situatedness of the medico-dental knowledge involved in K’s proposed orofacial transformation, is K realistically able to make an autonomous and informed decision based on a considered and knowledgeable ‘weighing’ of the risks versus benefits for her desired ‘transformation’? I think not! Rather, to a large degree, it is my responsibility to offer my knowledge and skills to K with the necessary requirement of entering into certain asymmetric relations of power, still caring for my own self, but also recognising and caring for K’s ‘self, establishing—as put by Sonia Kruks—‘webs of connections … woven among our differences’ (2006, p. 29).

 

Models of negotiated interaction

 

In this clinical encounter with K, I may well have taken the option of a ‘paternalistic’ approach to medical care: ‘to discern what is in the patient’s best interest[s] with limited patient participation … [assuming] that the patient will be thankful for decisions made … even if … she would not agree to them at the time’ (Emanuel & Emanuel, 1992, p. 2221). If, however, I were to follow the ‘informative’ doctor-patient model, I would provide K with facts relevant to her concerns, but rely on her own values to determine the treatment she wanted. This model assumes that K’s values ‘are well defined and known’ (Emanuel & Emanuel, 1992, p. 2221), and that factual content is the only thing that K requires to make her decision. Another possible interactive approach, the ‘interpretive’ model, is similar to the ‘informative’ model, insofar as K is provided with information on the nature of her ‘abnormalities’, potential risks, and the benefits of the various types of interventions available. However, in this model, I try to interpret K’s values, and ‘elucidate and make coherent’ these for her, thereby assisting her in her decision regarding the best form of intervention for her needs. In the interpretive model ‘the physician works with the patient to reconstruct the patient’s goals and aspirations, commitments and character’ (Emanuel & Emanuel, 1992, p. 2222). And finally, there is the ‘deliberative’ model which, as defined by Emanuel and Emanuel (1992), is similar to the ‘interpretive’ model, except that: ‘Not only does the physician indicate what the patient could do, but, knowing the patient and wishing what is best, the physician indicates what the patient should do’ (p. 2222). In effect, I decide what the treatment for K should be, and guide her to accept it, but I do so by taking her values and preferences into consideration.

 

The problem I have with all these models is that they do not allow for the shifting complexities and practicalities of the decision-making process in a ‘real life’ clinic. In everyday practice, decision-making actions are likely to reflect a ‘hybrid model’ whereby the perspective taken at the beginning of the consultation may well change during the course of the encounter to suit the needs of the individual patient (Charles, Whelan, & Gafni, 1999, p. 781). For example, the ‘paternalistic’ model assumes that K has the same knowledge and values as me—a decided impossibility. The ‘informative’ model relies on me supplying the ‘relevant facts’ for K to make a decision, but how do I know what ‘facts’—imbued with subjective and prescriptive elements—are ‘relevant’ or ‘true’ for K in the first place? In addition, it would be highly unlikely for me to be sure that I could interpret K’s values objectively. And this is also the case for the ‘deliberative’ approach, which relies on an even more intimate and objective knowledge of K’s values—a knowledge that is always partial, situated, and never neutral. Clearly, whatever the case, there is going to be an asymmetry of power and knowledge in the clinical encounter.

 

Ms K coda – Concluding remarks

 

It transpired that K eventually accepted the more comprehensive treatment plan I had presented to her. This included pre-restorative oral plastic surgery to provide improved ridge form, gingival margin symmetry, and orofacial harmony. Conventional crown and bridgework followed according to plan, and the resulting ‘customised’ smile was pleasing to both K (the patient) and me (the clinician). Did K do this for herself? Did the enhancement of one of K’s anatomical parts result in a feeling of bodily wholeness and happiness? Did K’s ‘true self’ smile feel authentic? Did K’s accrual of physical capital result in the desired conversion into other modes of capital (vis-à-vis career enhancement and a romantic relationship)? The answer to all these questions from K’s perspective would probably be: ‘yes’ … and, for me: ‘maybe … maybe not’. K did get the job she wanted, but I suspect that her previous experience in the sales and marketing industry helped her considerably. K also found a romantic interest—an old boyfriend from schooldays who reappeared in her life by chance at a meeting of the local historical society. Was it her ‘new’ smile that drew him in? I suspect not … but who am I—the consumer, just as much as the producer of K’s negotiated ‘smile’—to judge?

 

References

 

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Bonah, C. (2002). ‘Experimental rage’: The development of medical ethics and the genesis of scientific facts – Ludwik Fleck: An answer to the crisis of modern medicine in interwar Germany? The Society for the Social History of Medicine, 15(2), 187-207.

Bordo, S. (2009). Twenty years in the twilight zone. In C. J. Heyes & M. Jones (Eds.), Cosmetic surgery: A feminist primer (pp. 21-33). Farnham, England: Ashgate.

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Chandler, D. (2002). Semiotics: The basics. London: Routledge.

Charles, C., Whelan, T., & Gafni, A. (1999). What do you mean by partnership in making decisions about treatment? British Medical Journal, 319(7212), 719-720.

De Camargo, K. R. J. (2002). The thought style of physicians: Strategies for keeping up with medical knowledge. Social Studies of Science, 32(5-6), 827-855.

Emanuel, E. J., & Emanuel, L. L. (1992). Four models of the physician-patient relationship. Journal of the American Medical Association, 267(16), 2221-2226.

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Fleck, L. (1979 [1935]). Genesis and development of a scientific fact. Chicago; London: University of Chicago Press.

Foucault, M. (1988). Technologies of the self. In L. H. Martin, H. Gutman & P. H. Hutton (Eds.), Technologies of the self (pp. 16-49). Massachusetts: University of Massachusetts Press.

Foucault, M. (1995). Discipline and punish: The birth of the prison (A. Sheridan, Trans. 2nd Vintage Books ed.). New York: Vintage Books.

Foucault, M. (2002). The archaeology of knowledge (A. M. Sheridan-Smith, Trans.). London; New York: Routledge.

Foucault, M. (2007). Security, territory, population: Lectures at the Collège de France, 1977-78 (G. Burchell, Trans.). Houndmills, Basingstoke, Hampshire; New York: Palgrave Macmillan.

Foucault, M., & Rabinow, P. (1991). The Foucault reader. London: Penguin.

Fraser, S. (2009). Agency made over? Cosmetic surgery and femininity in women’s magazines and makeover television. In C. J. Heyes & M. Jones (Eds.), Cosmetic surgery: A feminist primer (pp. 99-115). Farnham, England: Ashgate.

Haraway, D. (1988). Situated knowledges: The science question in feminism and the privilege of partial perspective. Feminist Studies, 14(3), 575-599.

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Kuhn, T. S. (1970). The structure of scientific revolutions (2nd ed.). Chicago, Ill.: University of Chicago Press.

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McHugh, A. T. (1996). Nice legs … ‘shame about the face! Paper presented at the Northern Suburbs Dental Study Group Meeting.

Murray, J. C. (2010). Technologies of power in the Victorian period: Print culture, human labor, and new modes of critique in Charles Dickens’s Hard Times, Charlotte Bronte’s Shirley, and George Eliot’s Felix Holt. Amherst, NY: Cambria Press.

Wittich, D. (1986). On Ludwik Fleck’s use of social categories in knowledge. In R. S. Cohen & T. Schnelle (Eds.), Cognition and fact: Materials on Ludwik Fleck (pp. 317-323). Dordrecht; Boston: D. Reidel Publishing Company.

 

 

[1]        In the postscript of the 1970 edition of The Structure of Scientific Revolutions Kuhn responded to charges of vagueness in his use of the word ‘paradigm’, substituting the term ‘disciplinary matrix’. He ‘suggest[s] “disciplinary” because it refers to the common possession of the practitioners of a particular discipline; “matrix” because it is composed of ordered elements of various sorts, each requiring further specification’ (1970, p. 182).

[2]        Such ‘cultural circles’ may be variously described as ‘collectives’, ‘fields’, ‘webs’, and so on.

[3]             This patient’s name and certain aspects pertaining to her description have been altered to protect her anonymity.

Seeing what is known, knowing what is seen: A perspective from inside the clinic

It has been said that in order to ‘see’ we must first ‘know’ what we are looking at. The physician’s perspective in clinical diagnosis is a good example of this, insofar as specialised communities, such as those in the fields of medicine and dentistry, have their own logic for seeing and knowing what ‘counts’, what is taken for granted within their discipline, and how and in what circumstances they should act. I draw on my own experience as a diagnostic and surgical clinician, scanning electron microscopist, and a practicing visual artist to illustrate that ‘seeing’ is always situated. As an example, I analyse an anthropomorphised Mona Lisa to demonstrate that while the painting itself has not changed appreciably since it was completed in the early sixteenth century—apart from the ageing of its material components—people’s attitudes towards it, and the perceptions and knowledge that shape an observer’s interpretations of, and responses to, the painting and its subject, have varied considerably. In a similar manner, I argue that for the diagnostic physician, what is often taken as visibly self-evident can be recognised as the product of a specific perceptual process or practice, rather than the natural result of human sight.

“Faces Inside and Outside the Clinic” by Tony McHugh – BOOK LAUNCH

Dept of Media, Music, Communication and Cultural Studies

Macquarie University, NSW, Australia.

‘Faces Inside and Outside the Clinic: A Foucauldian Perspective on Cosmetic Facial Modification’.

First: This book integrates my own first hand clinical (diagnostic and surgical) experience with logical theoretical (philosophical and sociological) argument in the discussion of facial/bodily ‘rightness’ and ‘wrongness’.

Second: The factors surrounding considerations (inside and outside the clinic) for cosmetic facial modification are discussed with reference to medical, visual, and cultural analyses.

Third: Faces Inside and Outside the Clinic highlights the need for clinicians to realise that claims of medical and scientific ‘objectivity’ in disciplinary knowledge are always ‘situated’, and must be heavily qualified. In addition, clinicians must be prepared to take the greater share of the responsibility in the face-to-face clinical encounter when assessing the need for patients to proceed (or not to proceed) on to cosmetic facial/corporeal modification.

Fourth: Faces inside and outside the clinic provides end-users in the quest for facial/corporeal enhancement a perspective on the nature of, and their position in, what has been termed the ‘face game’: a game in which identity, appearance, and meaning have merged.

Fifth: This book will appeal to graduate and undergraduate clinicians and academics in health-related sciences; contemporary philosophy, cultural studies, and sociology scholars and students; and affiliated providers and consumers of the ‘beauty industry’.

Contemporary governance in the clinical encounter: An asymmetry of power, knowledge, and responsibility

The clinical consultation encompasses a two-way gaze in which doctor and patient are essentially object and subject at the same time. Inevitably, however, doctor and patient are governed by a different set of rules and a different set of ‘truths’. Indeed, contained within the two-way clinical gaze, there are distinct asymmetries in power/knowledge relations. Through hierarchical observation, normalising judgement, and the examination, it is the doctor who wields the overwhelming share of disciplinary power, and it is the doctor who is guided by the principles of biomedical ethics (problematic though they may be), not the patient. This calls for added responsibility on the part of the doctor to acquire and develop modes of decision-making understood as the logic of practical, individuated, and value-based knowledge (phronêsis) together with intuitive and habituated skill (mêtis). In other words, studying and knowing ‘truth’ in theory (epistêmê), and having the technical ability to carry out scripted tasks to achieve a practical end (technê), are not enough to attain the goal of becoming an excellent clinician. This does not negate the patient’s freedom to ‘choose’ a desired treatment path within certain constraints, however, while still accepting the inevitability of entering into an asymmetry of power and knowledge, it is the doctor’s responsibility to respond to, and care for, the needs and interests of the patient through an interaction of mutual reciprocity that does not reduce either body to the other or to itself.