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Where There is no Patient: An Anthropological Treatment of a Biomedical Category

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Abstract

This work anthropologically applies the concept of ‘personhood’ to the Western biomedical patient role, and through cross-cultural comparisons with wellness-seeker roles (e.g. among the Maya of Guatemala and others) it seeks to discern the implications for global healthcare of assuming the universality of the “patient” role. Here, particular ethnographic attention is given to the presumption of the “patient” role in places and situations where, because of cultural and linguistic variation in local wellness-seeker roles and practices, there may be no “patient.” It is hoped that establishing the biomedical patient role (with the clinical expectations, communicative and comportment practices that prefigure it) as acquired rather than intuitive, will help redirect cultural competence to the acquisition of patienthood, broadening it from an endless accrual of cultural inventories by physicians. Also it aims to shift existing biomedical associations of cultural variations in wellness-seeking away from a priori assessments of clinical defiance towards deeper understandings of the kinds of cultural differences that may make the difference treatment outcomes.

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Notes

  1. By citing Kleinman’s classic discussion on what is specific to Biomedicine, I am emphasizing what makes it, as a medical system, distinct from others, rather than denying or ignoring its internal variability. To Klienman’s original observations of distinguishing characteristics, I would add the hegemony of the biomedical ‘‘patient role,’’ which tends to supplant heterogeneity in the disparate wellness-seeking practices (of partial and non-patients) in favor of a homogenous / uniform biomedical patient.

  2. In a-year-and-a-half of research and dozens of encounters I have only one example of a Maya wellness-seeker arriving alone or unaccompanied to biomedical clinical encounter.

  3. The K’iche’ Maya therapeutic encounters that I observed, recorder, and analyzed ranged from interactions with healers, diviners, theurgical herbalist, bonesetters, and sorcerers (see Harvey 2003).

  4. I refer to a “certain sets” of clinical expectations because biomedicine, based on Western science, by definition presupposes consistency, systematicity, and replicability.

  5. Though not Wagner’s original meaning, phenomenologically, treating the body as a “symbol that stands for itself” would mean considering it as “series of appearances” (Sartre 1966) or as an “object of perception” (Merleau-Ponty 1989). In either case, the body would be what it appears to be and/or what is perceived to be, in Western thought, as ontologically individual. This is a phenomenological position rejecting Kantian nominalism that would ask (though perhaps not seek to answer) if there might be a remainder of meaning, something that escapes our signified or concepts, more to the body than is either perceived or perceivable through our language, perception or experience. Noumenalogically, might the body, for example be individual, dividual, neither, fractal, divisible, other, all of these, part(s) of these, or none of these?

  6. Perception here is described as an avoidably cultural act. For perception is caught up in consciousness (in part the direct or indirect perception of phenomena, which is itself, as phenomena, the fruit of perception) and consciousness is embedded in cognition and cognition that is tied to language (the seat of reflexivity) and language is inseparable from culture, and so as Blake put it, “the altering [perceiving] eye alters all.”

  7. The point here is not to verify or deny ethnographic claims of shared experience but rather to question the conditions of the possible in Western social science that autometrically determines what is possible for others based on what is possible for us.

  8. Multiple K’iche’ Maya participants attended both intra-cultural therapeutic and cross-cultural biomedical consultations.

  9. K’iche’ Maya healers, wellness-seekers, and companions may share the sickness. This is further evidenced by the fact that in therapeutic encounters it is very common for all participants to take the prescribed medication (Harvey 2003).

  10. This paper takes a Durkheimian approach to social role. Importantly, Maine differed in his articulation of “social role” from Durkheim, his intellectual predecessor. Durkheim did not involve the individual (or the mortal human being) in his articulation of “social role” precisely because “personhood” (as it later came to be know) for Durkheim was a collective representation that endures beyond the mortal individual. Maine, however, understood status and contract as modes of personhood, linking role inhabitance (the social) with property rights (individual).

  11. One of the many issues that emerge in such cases of a cultural mismatch is where ‘lack’ is perceived and assigned. Are such problems as registration perceived to be located in the Western cultural expectations, in the “un-documented” partial or non-patients, somewhere in between the two, or elsewhere?

  12. The reference here to “sickness” versus what is typically referred to as “illness” narratives (cf. Mattingly and Garro 2000) points to the fact that many of the wellness-seeker narratives that I recorded among the K’iche’ Maya of highland Guatemala were multi-voiced (polyphonic), told by multiple persons as contrasted with the monologic illness narratives of Western patients (for more see the section on “Sociolinguistics and the Patient Role”).

  13. The specific comportment practices referred to here include but are not limited to: removing clothing, submitting to physical examination and clinical procedures.

  14. Dr. Hubert Smith’s now widely criticized physician’s reversion of “therapeutic privilege” allowed physicians to withhold diagnosis from patients sick with fatal illness.

  15. Studies identifying interactional asymmetry in Western doctor-patient interactions seem to suggests that though a definition of patient as “one who endures without complaint” maybe obsolete, communicative practices such as interruptions (Mishler 1997), a lack of access to the “floor” and difficulty introducing new topics (Ainsworth-Vaughn 1998) all have the discursive effect of inhibiting patients from articulating complaints.

  16. By dialectical practice I mean sociolinguistic practices that are themselves produced and which simultaneously produce other practices.

  17. Most research on doctor–patient interactions has been on Western intra-cultural biomedical interactions.

  18. K’iche’ Maya therapeutic models of health care in Nima’ ranged from consultations with healers (ajkunab’), diviners (ajqijab’), socereres (ajitzab’), and herbalist (aj pa q’ayes), and bonesetters (aj pa b’aq).

  19. Unlike the Guatemalan example, the Japanese “surrogate patient,” though entering the examination room and sitting in the chair like a patient, was only prescribed medication if the physician had already previously seen the ‘actual’ patient.

  20. Examples of K’iche’ polyphonic sickness-narratives that sometimes reached cacophony where limited to the q’ijinik (day/light ritual) consultations of Maya ajq’ijab’ (light/day doers) involved in divinatory in healing.

  21. On the possible relation of this micro observation of clinical the expectation of monologic discourses (e.g., in illness-narratives and diagnoses) to a macro biomedical epistemology of monotheism see Kleinman (1995).

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Correspondence to T. S. Harvey.

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This article is dedicated to the memory of Hazel Young, my grandmother, whose encounter with sickness and Western Biomedicine taught me a great deal about what it meant to seek wellness and not be a patient.

The following organizations have supported this research at various stages: the Fulbright Institute for International Education, the Ford Foundation, the University of Virginia, Case Western Reserve University, and University of California at Riverside.

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Harvey, T.S. Where There is no Patient: An Anthropological Treatment of a Biomedical Category. Cult Med Psychiatry 32, 577–606 (2008). https://doi.org/10.1007/s11013-008-9107-1

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