HEALTH, ILLNESS AND DISEASE - TSpace

TEE RELATSVITY OF SOCIAL CONSTRUCTION: TûWARDS A CONSULTATIVE APPROACH TO UNDERSTANDING

HEALTH, ILLNESS AND DISEASE

Todd Onam Smith

A thesis submitted in conformity with the requirements for the degree of Ph. D.

Graduate Department of Community Health University of Toronto

@ Copyright by Todd Onan Smith (1997)

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ABSTRACT

CONSTRUCTION : THE SOCIAL

TOWARDS A CONSIJLTATIVE APPROACH TO UNDERSTANDING

HEALTH, ILLNESS AND DISEASE

Todd Smith, Ph-D. (1997)

Department of Community Health

University of Toronto

This dissertation constitutes a first step in the development

of what 1 am calling the consultative approach to understanding

health, illness and disease. It primary concern is to outline a

rationale for, and delineate the theoretical tools to help think

about, the relativity of the social construction of disease.

Particular emphasis is placed on the medical construction of

disease, and how medicine constructs some diseases more than it

does others. To this end, a preliminary typology is suggested p p p p p p - - - - - - - - -

for "mapping" the degree topwhich di£ f erent diseases are

constructed. This has implications for the social

constructionist position, and what is referred to more broadly

as horizontalism, because it suggests that medicine, while

certainly constructing diseases, may also be getting at certain

(many) diseases for more or less what they are. It also has

consequences for verticalism - an epistemological and

ontological orientation inforrning rnuch of current biomedicine -

because it challenges, along w i t h social constructionism, the

idea that medicine, or any paradigmatic orientation for that

matter, has special access to the "real" workings of the body.

Finally, various philosophical implications that follow £rom the

relativity of the social construction of disease are discussed.

As 1 see it, developing the consultative approach involves t w o

major projects. The first is to demonstrate the utility of

meaningful interparadigmatic collaboration for achieving better

understanding of disease (and reality, more generally). The

second is to establish the power of a particular communicative

process termed "consultation" for achieving such collaboration.

While, for the most part, 1 leave these two projects for

subsequent study, this dissertation lays the theoretical

foundation for the first. I Say this because, if different

paradigms can (at least potentially) see and penetrate into

(aspects of) reality (or disease, more specifically), then there

is utility, theoretically speaking, in fostering meaningful

interparadigmatic collaboration. And as discussed, different

paradigms (such as medicine and social constructionisrn, as

discussed herein), can indeed (at least potentially s o ) , see and

penetrate. This is confirmed by the relativity of the social

construction of reality (of disease) .

III

1 am privileged to have worked under the guidance of Robin

Badgley. Robin opened the door to the intellectual journey 1

have begun with this dissertation, a journey that both

celebrates and seeks to unify diversity. He was very receptive

to my work and yet extremely penetrating in his analysis of it.

As such, he gave coherent direction to my ideas. He was also

encouraging . Indeed, he was empowering, releasing the potential

within me to academically produce in ways 1 had never produced

before.

1 am similarly grateful to the two other full-time members of

my cortunittee, Ann Robertson and Joan Eakin who, while in many

ways responsive to my ideas, were also helpfully critical of

them. I am grateful to Ann for continuously challenging me to

delve more and more deeply into fundamental thernes, and to Joan

for highlighting issues 1 would have otherwise taken for

granted. 1 am also thankful to them for having prevented me

from t a k i n g on too much while concurrently allowing me

sufficient latitude to explore what 1 conslder to be certain

novelties.

1 would also like to mention Dorothy Pawluch, David Locker and

David Coburn who were al1 present at my defense and who each

raised issues that warrant rnuch attention. Future developments

of this study are bound to reflect their valuable input.

1 am particularly indebted to my family. My father David

Smith and mother Meim Smith, rny father-in-law Pat Lord and

mother-in-law Jean Lord, my two brothers Darron and Brett and

their wives Deb and Maureen, my grandmother Peggy Breckenridge,

and many other members of my family, were al1 so supportive both

emotionally and intellectually, and in some cases, financially.

I've found that writing a dissertation af te r years of

undergraduate and graduate work, is nothing less than an ordeal

for the writer. It is similarly an ordeal for those closest to

him (or ber, as the case rnay be) . There is an overwhelming

tendency amongst everyone to wonder when it will finally be

finished. Happily, my family did not allow that tendency to

overshadow the value they saw in me writing it.

To my dear wife Sandy, and my two boys Grayden and Connor, 1

give special thanks. Of everyone, Sandy was most acutely aware

of rny struggle to finish this dissertation. She was also most

supportive in times of stress. Her input, moreover, was no less

a source of support and inspiration. And as for my boys, who

had no clue about what 1 was doing, they enlivened me by simply

being around.

Finally, 1 want to thank my many friends who took the time to

read my dissertation or sections thereof, to provide me with

feedback, and/or to inspire me in some way. Among them is Ms.

Brenda Radford. One of my intentions for this thesis was to

break with traditional academic writing. Brenda helped me to do

just that. Others include Michael Dragornan, Peter Tamas,

Jonathan Menon, Andrea Robarts, Dan Jaciw and Duncan Hanks.

TABLE OF CONTENTS

m m D m m S ................................................. IV

TABLE OF CONTENTS .............................................. VI

LIST OF TABLES .................................................. X

LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI

CHAPmR 1: INTRODUCTION ......................................... 1 OBJECTIVE ....................................................... 1

S t a t e d Br ie f ly : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 M y Specific Concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In Response to "So What?" 3

INTRODUCTION: CONTEXT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

VERTICAL VERSUS HORIZONTAL APPROACHES TO REALITY . . . . . . . . . . . . . . . 12 . . . . . . . . . . . . . . THE CONSULTATIVE APPROACH: SOME B A S I C ASSUMPTIONS 1 8

U n i t y in Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Consultation and Seeing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3

. . . . . . . . . . . . . . . . . . . . . . . . . In Short (see Table 1 f o r a summary) 28

SUMMARY OF PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER OUTLINE 32

THE IRONY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 SOME DEFINITIONS ................................................. 33

Illness and Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Regarding Truth .............................................. 3 5

JOURNEY NOTES .................................................. 39

INTRODUCTION ................................................. 40

SCIENTISM AS VERTICALISM ....................................... 48 ....................................... MEDICINE AND VERTICALISM 53

Medicine and Naturalist Ontology and Cosmology . . . . . . . . . . . . . . . 53 Medicine and Naturalist Epistemology ......................... 55 In Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VERTICALISM: ONE FINAL EXAMPLE 56

JOURNEY NOTES .................................................. 61 INTRODUCTION .............................................. 62

THE AMBIGUITY OF THINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

SO much . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 THE SOCIAL CONSTRUCTION OF THINGS .............................. 71 Nietzsche .................................................... 71 Rorty ........................................................ 73

................................ Reality as a social construct 78

. . . . . . . . . . . . . . . . . . . . . . The Medical Mode1 as a Social Construct 8 1

Health, Illness and Disease as Metaphors . . . . . . . . . . . . . . . . . . . . . 8 3

SOCIAL CONSTRUCTION, POWER AND MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . 86 Medicalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Foucault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

IN CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 CHAPTER 4 : THE RELATIVTTY OF SOCIAL CONSTRUCTION : THEORY PART 1

J O W E Y NOTES ................................................. 107

INTRODUCTION ................................................... 109

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . THE OMNIPOTENT SOCIAL? 114

THE RELATIVITY OF SOCIAL CONSTRUCTION . . . . . . . . . . . . . . . . . . . . . . . . . 122

REALITY AS CONSTRAINT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

The Body as Constraint ...................................... 129

The Impact of Phenomenal Tangibility ...................... ..,1 33 Revisiting the Paradi gm ..................................... 136 Meanings. Seeing and Constructing .......,.......... ......... 143

TANGIBILITY TYPES ............................................. 146 General Tangibility ......................................... 147 Anomalic Tangibility ........................................ 148 Fabricated Tangibility ................................... 149

Specified Tangibility ...................................... -150

Reality and the Relativity of Social Construction . . . . . . . . . . . 152 Finally . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

SOME ADDITIONAL THOUGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 The Relativity of Relativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -155 Unity Amidst the Diversity .................................. 158

CHAPTER 5 : PARADIGMATIC ARTICULATION. EXTENSION AND

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTENSIFICATION: TEEORY PART II 163

JOURNEY NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 THE DRIVE TO PARADIGMATICALLY ARTICULATE ...................... 167 Introduction .................................................. 167

The Universal Drive to Construct . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Rationalization and Medicalization . . . . . . . . . . . . . . . . . . . . . . . . . . 174 TO Summarize . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

THE DUALITY OF PARADIGMATIC ARTICULATION . . . . . . . . . . . . . . . . . . . . . . 179 Paradigmatic Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1 8 1

Paradigrnatic Intensification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Proactive Intensification and Education . . . . . . . . . . . . . . . . . . . . . 193 Extension, Intensification and Anomaly . . . . . . . . . . . . . . . . . . . . . . 194

PAFWDIGMATIC ARTICULATION AND THE CONSTRUCTION O F . . . . . . . . . . . . . 196 SOME FINAL THOUGHTS CONCERNING PARADIGMS AND THEIR PROCESSES .. 198 CEAPTER 6 : MAPPING THE RELATIVITY OF TEiE SOCIAL CONSTRUCTION OF

DIS-E ....................................................... 205

JOURNEY NOTES ................................................. 205

INTRODUCTION .................................................. 207

The Issue ................................................... 207 Tools for Thinking about the Relativity of Social Construc . . . 208

Things Remember

SOCIALLY-CONCEIVED-DISEASES ...... Introduction ................................................ 221 Hysteria ................................................... .222

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

SOCIALLY-AUGMENTED-DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Certain Infectious Diseases 264

HENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276

CEAPTER 7 : KNOWING AND NOT KNawING ïN DZVERSITY . . . . . . . . . . . . . . . 284

J O W E Y NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 UNIFYING THE CONCEPTUAL DIVERSITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 ASSESSING THE TYPOLOGY ........................................ 290 IMPLICATIONS: TOWARDS THE UTILITY OF INTERPARADIGMATIC

COLLABOMTION ................................................. 306 INTERPARADIGMATIC COLLABORATION BETWEEN MEDICINE AND SOCIAL

... CONSTRUCTIONISM. ......................................... 312

In Summary .................................................. 314 SOME PHILOSOPHICAL IMPLICATIONS - IN BRIEF .................... 315 The Question of Eternal Questions ........................... 317 The Issue of Representation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Truth, Chess and Consultation 323

REFERENCES .................................................... 337

LIST OF TABLES

Table 1. Summary of assumptions as distinguished between the

verticalist, horizontalist and consu l t a t i ve approaches ............... 29

Table 2 . Matching the concepts with the categories of

disease ............................................................................................................................................................ 2 8 6

LIST OF FIGURES

Figure 1: The r e l a t i v i t y of the social construction of

......................................................................................................................................................... phenornena 13 7

Figure 2: The relativity of the r e l a t i v i t y of t he social

......................................................................................................... construction of phenornena 1 5 7

- -

INTRODUCTION

OBJECTIVE

S t a t e d Briefly :

The o b j e c t i v e of t h i s book is t o begin developing what I am

c a l l i n g t h e consultative approach t o understanding h e a l t h ,

i l l n e s s and d i sease . The c o n s u l t a t i v e approach i s con t r a s t ed to

what a r e r e f e r r e d t o as t h e verticalist approach and the

horizontalist approach. ' Broadly speaking, by verticalism i s meant an epis temologica l

and on to log i ca l o r i e n t a t i o n t h a t holds t h a t t r u t h of t h i n g s i s

acce s s ib l e , t h a t r e a l i t y i s pene t r ab l e , but t h a t i t i s so only

v i a c e r t a i n ways and by c e r t a i n i n v e s t i g a t i v e communities. That

is: some can see t h e way t h i n g s are while o t h e r s rnay see th ings

more d i s t o r t e d l y , whi le ye t o t h e r s may not r e a l l y see t h ings a t

a l l . Science and medicine a r e v e r t i c a l i s t i n t h i s s ense

(al though, as d i scussed l a t e r , t h e r e are q u a l i f i c a t i o n s t o

cons ider) . By horizontalism i s meant t h e ep i s t emolog ica l and on to log i ca l

o r i e n t a t i o n t h a t the truth of t h i n g s i s i nacce s s ib l e , and more

r a d i c a l l y , t h a t t h e r e r e a l l y i s n f t any t r u t h "out there" t o

access anyway. I n f a c t , t r u t h , i f anything, i s t r u t h

cons t ruc ted . And so i t r epud i a t e s t h e v e r t i c a l i s t tendency t o

champion c e r t a i n approaches t o r e a l i t y ( l i k e sc ience and

medicine) over o the r s . Soc i a l cons t ruc t ionis rn i s ve ry much

h o r i z o n t a l i s t i n t h i s sense (a l though , a s d i scussed l a t e r , t h e r e

a r e q u a l i f i c a t i o n s t o c o n s i d e r ) .

T h e consu l t a t i ve approach d i f f e r s from bo th t h e v e r t i c a l i s t

and h o r i z o n t a l i s t p o s i t i o n s whi le r e t a i n i n g elements from each.

I t r e j e c t s , along with t h e h o r i z o n t a l i s t , t h e v e r t i c a l i s t

p r e d i l e c t i o n t o exclude c e r t a i n approaches whi le championing

others. It, moreover, shares with the horizontalist a profound

recognition for the socially constructed nature of truth. There

is definitely made truth. We definitely construct truth, reify

it, internalize it and reconstruct it.

Yet, according to the consultative approach, not al1 truths

are constructed truths. With the verticalist position it holds

there is truth "out there" to be known. And like the

verticalist position, it holds we have the potential to approach

- if not to thoroughly penetrate - such truth. We have the

potential to approach - if not to thoroughly penetrate - for example, the way things are with health, illness and disease.

But, the consultationist goes on to Say - and this is the

crucial point - that this potential is not something unique to

any one paradigmatic approach. Instead, it pervades (perhaps in

varying degrees) our paradigmatic diversity. There is,

therefore, tremendous utility in looking to this diversity,

indeed, in facilitating an atmosphere of meaningful

interparadigmatic collaboration. There is tremendous utility in

meaningfully tapping this diversity in order to release the

wealth of possibility to know.

The consultationist, rnoreover, goes on to suggest a par t i cu la r

method for facilitating such interparadigmatic collaboration. To

this end, s/he champions a communicative process termed

consultation.

There are, therefore, two major pro jects involved in

delineating the consultative approach as 1 see it. The first is

to demonstrate the utility of meaningful interparadigmatic

collaboration for achieving better understandings of - for

penetrating more deeply into - reality. The second is to

demonstrate the power of the communicative process of

consul ta tion for facilitat ing meaningf ul interparadigmatic

collaboration so that more adequate understandings of reality

can be achieved.

My Specif ic Concern . . . . . . in this book is to begin the first project. More

precisely, it is to outline the theoretical rationale for taking

the utility of meaningful interparadigmatic collaboration

seriously. My premise is that the utility of interparadigmatic

collaboration stems from the possibility that we (relatively)

see, in al1 our diversity, (perhaps different) things about

reality, about truth. The possibility of seeing, of penetrating

reality as it is, therefore, needs to be established. This, 1

maintain, is accomplished through demonstrating the validity of

the daim: some t h i n g s are more s o c i a l l y c o n s t r u c t e d than

o t h e r s . Taking disease as my focus, my central objective, therefore,

to:

demonstrate the r e l a t i v i t y of t h e s o c i a l ,

medical cons t ruc t ion o f d i s e a s e .

is, moreover, to

and i n p a r t i c u l a r ,

explore the epis temologica l and o n t o l o g i c a l r a m i f i c a t i o n s tha t

follow £rom the r e l a t i v i t y of the social ( m e d i c a l )

c o n s t r u c t i o n of disease.

so doing, and as a particular case study, 1 aim to provide a

t h e o r e t i c a l ra t i o n a l e for the utility of f ostering

interparadigmatic collaboration between medicine and social

constructionism. To actually demonstrate such utility, thus

completing the first project, 1 leave for subsequent research.

In Response to "So What?"

The point behind developing the consultative approach, of

which this book is a first step, boils down to one thing: to

create a more adequate approach for preventing and allevia t i n g

suffering.

The premise is that much suffering is a consequence of, and is

sustained and/or exacerbated by, the imposition of certain

concepts of health, illness and disease, concepts that are

alienating to many, hence inappropriate to the sufferings of

many, hence, inadequate to the alleviation of the sufferings of

many. They are, moreover, inadequate to the seeing of certain

diseases. They do not "get at" those diseases as they really

are.

The problem of alienation is something of which social

constructionism is only too conscious. By defining our bodies

in certain ways, by propounding certain models of disease, by

systematically ignoring or qualifying certain complaints in ways

that conform to its own paradigmatic approach to health, illness

and disease, biomedicine is engaged in the process of

constructing a reality that is, in many ways, oppressive. And

yet, ironically, social constwuctionism is prone to the same

criticisrn. As will be discussed: in its analysis of the

deficiencies of medicine, in its depiction of medicine as a

social arrangement that dominates today; that gets at nothing

foundational - nothing essential about disease nor the workings of the natural in general - despite its claims; that imposes

such nonessentialities on the rest of us, either intentionally

or not; that is, by systernatically repudiating medicine in these

ways, social constructinnism is constructing its own version of

what health, illness and disease are, wittingly or not. It is

itself constructing a reality, a reality, moreover, that

excludes, that imposes, that subjugates, that alienates.

But what if both medicine and social constructionism, despite

their deficiencies, despite their constructions, are hitting

upon certain truths? What if both have something of value to

say about health, illness and disease? What if both see certain

things about the way reality is, about the way certain diseases

are?

(And the p o i n t o f t h i s s t u d y is t o d e m o n s t r a t e the very p o s s i b i l i t y that both d o ! )

Then it would seem advantageous for each to look to the other to

see what it can offer. Then it would seem their meaningful

interparadigmatic interaction would be most beneficial. For

such interaction can only lead to better understandings of

health, illness and disease, and hence better understandings on

how to reduce suffering.

In short (and not limiting things to the relationship between

medicine and social constructionism) :

T h e p o i n t of the c o n s u l t a t i v e approach is to d e m o n s t r a t e the

u t i l i t y o f m e a n i n g f u l i n t e r p a r a d i g m a tic c o l l a b o r a t i o n achieved

through a particular c o m m u n i c a t i v e p r o c e s s t e r m e d

c o n s u l t a t i o n . Through consul t a t i o n , paradigma t i c d i v e r s i t y i s

t apped , more adequate u n d e r s t a n d i n g s o f health, i l l n e s s and

d i s e a s e a r e achieved, a l i e n a t i o n is r e d u c e d , and c o n s e q u s n tly,

s u f f e r i n g is a l l e v i a t e d .

INTRODUCTION: CONTEXT

Now to flesh things out a bit.

In particular, what 1 want to do is outline some of the issues

and major convictions informing this study. Foremost among my

convictions is the principle of unity in diversity as outlined

by Baha'u'llah.

To begin, let me pose a few observational questions:

First, why is it that we have such a systematic need to

envelop ourselves in particular ways of thinking? Second, why

is it that we feel such a pressing need to hold on to and

perpetuate these ways of thinking? Third, why are we so

interested in disassociating ourselves from other ways of

thinking and attacking them by incessantly mining for and

exposing their deficiencies? These are not idle questions;

indeed, they address a reality that continues to permeate our

society at many levels. Think of the masses of students who

enter universities, are exposed to a variety of theoretical

views in a given area, and then find themselves latching ont0

one while devoting their lives to lambasting the others. Think

of party politics: can you recall a time when one party has

officially said of another party's position 'What a great idea!

Let's support it!" Now think of the myriad talk shows that

flood television these days: how often do you see a show in

which a frank yet meaningful discussion between estranged guests

occurs and culminates in a reconciliation of their- differences?

How often do these guests even seriously entertain the

possibility that their adversaries may have a point or two? And

the audience members: how often are they willing to entertain

the same possibility among those guests whom they are

predisposed to slander? If I were to venture perhaps an overly

hasty response to these questions, 1 would Say "never!" To be

fairer, 1 will simply respond "rarely" . Here are a few more questions:

Have you ever had the experience of being exposed to a nurnber

of viewpoints on an issue and, before finding yourself consumed

by one, in allied relationships to some and in hostile

relationships to the others, f ound yourself murmuring "Well,

they al1 make a pretty good case, donft they?" More concretely,

have you ever investigated a variety of available

philosophical/sociologica~ approaches to a given social issue

and, before making a choice among thern which then serves as your

paradigrnatic orientation to understanding and solving social

problems in general, said to yourself "1 can see validity in

each. Do I really need to choose?" Relatedly, have you ever

thought that, although so different and antagonistic in many

ways, Weberian, feminist, Parsonian, Marxist, phenomenological,

hermeneutic, structuralist, post-structuralist and other

approaches to understanding society al1 make at least some sense

- that they each speak to at least some truth about society?

Our general tendency is to devalue such thoughts and feelings of

eclectic sympathy. Instead, a pervasive drive to demarcate, to

hierarchize, to raise one position to lofty heights while

debasing al1 others that would have things otherwise, seems to

exist. There exists a powerful will to paradigmatic mastery.

This is not a new insight. Postmodernists and other critics

have been condemning modernisrn for the drive to dominate and

exclude for a while now. Let's take Lyotard as an example. For

~~otard', modernism is characterized by the quest for truth. It

is an era premised on the belief that we have the ability to

progress towards truth. But it is more than this. Modernism

also privileges some paradigmatic approaches (science, for

example) over others. Some are considered more apt to lead the

way to truth. And their dominance is legitimated by what

Lyotard terms the "metanarrative". Much like Plato's allegory

of the cave3, metanarratives - such as Hegel's dialectic of

Spirit, Marx' s ernancipation of the worker, the Enlightenment

view of humanity progressing and achieving greater and greater

liberty - guide us in our journey. They provide the overarching

criteria for distinguishing between what in fact constitutes

relevant knowledge, and more specifically, what speaks

truthfully about the world and what does not. Consequently,

certain knowledges prevail while others are lost in their wake.

But, as far as Lyotard is concerned, we are moving into a

postmodern age now, and happily so. Postmodernism is

characterized by an increasing incredulity towards, and a

collapse of, the metanarrative and its role as legitimator.

Correspondingly, the classical dividing lines between different

disciplines are evaporating. Knowledge hierarchies are

blurring, totalizing theories are crumbling, and in their place,

diversified, decentralized (and frequently competing) knowledges

are emerging.

Foucault is al1 for this. With Lyotard, he advocates the

"insurrection of s u b j u g a ted knowledgesu4. He is for l i t t l e

stories, localized knowledges, knowledges that, in our quest for

truth, have been suppressed, trarnpled on and disqualified as

naive and insufficient to the goals laid out by the more

totalizing theories (such as science, again), that have managed

to impose themselves and the specific aims they propound.

Foucault employs his genealogical approach5 as a means for

emancipating local knowledges from such tyranny. He explains

that

. . . in contrast to the various projects which aim to inscribe knowledges in the hierarchical order of power associated with science, a genealogy should be seen as a kind of atternpt to emancipate historical knowledges £rom that subjection, to render them, that is, capable of opposition and of struggle against the coercion of a theoretical, unitary, formal and scientific discourse. It is based on a reactivating of local knowledges . . . in opposition to the scientific hierarchization of knowledges and the effects intrinsic to their power: this, then is the project of these disordered and fragmentary

6 genealogies.

Foucault is for diversity, and is so at the expense of unity.

For him, unity is uniformity, constraint and subjugation.

Diversity, contrarily, is liberty - it is to be promoted, celebrated.

Now to be more specific.

Medicine, it is claimed, is one of these totalizing 7 f rameworks . Conrad and schneidere, for example, argue that

western society has seen three major and distinct cosmological

systems in place to help us understand and deal with the world

and its contingencies . Recently, the medical paradigm has

emerged as the third system, supplanting law and its forerunner

religion. Although some would argue that the power of medicine 9 is waning for various reasons , there are others who view

medicine as the chief definer of what constitutes deviance, and

by extension, normality. These others hold that more of life is

being defined and dealt with according to medical interpretation

and practice; that more of life is being understood in terms of

medical conceptions of health and illness. 10 This, among other

things, is what is meant by medicalization, which, for many, has

insidious implications. Medical conceptions are defining our

relationships with Our fellow humans, with the world, and with

ourselves, and doing so in ways that have alienating and

oppressive con~equences'~. Medicine is the latest incarnation of

paradigmatic mastery.

This view is shared by a number of approaches that participate

in the sociology of health and illness, including Parsonian,

feminist, Marxist and post-structuralist approaches, each of

which links the "evolution" of medicine to dominance with

Parsonian analysis shows how the medical profession acts to control rnotivated deviance. Marxist analysis links it with the development of capitalism; the feminists with patriarchy; and the Foucauldian position links it with the development of

12 modern society . Common to them all, however, is some version of the social

constructionist position which in turn "blends elements of these

perspectives. ,,13

Social constructionism, as its name suggests, views medicine

as sirnply that: a social construction. That medicine exists as

the dominant approach to understanding and dealing with those

"deviant" categories we cal1 illness is purely a socio-

historical contingency. Medicine did not have to emerge as it

has. Indeed, it need not have emerged at all. The fact that it

did simply indicates that certain

(patriarchal/capitalist/rationa~ist) interests won out over

others. Medicine is a child of social forces: there is nothing

inherently true nor essential about it: things could be

otherwise.

The popularity of such a view is relatively new within

sociology since it vas not long ago that medicine seemed immune

as an object of social inquiry. According to Wright and

~reacher'~, medical knowledge was, until recently, considered by

many to be self evident - it was, for the most part, taken for granted. Medicine was considered privileged, penetrating into

the realm of disease entities, entities understood to be both

natural and existing "out there". It was considered autonomous

to society given its roots in the modern sciences. As Lock

explains the situation:

For many years social scientists left unquestioned the dominant ideology of their tirne; scientific " f ac t s " were reified, assumed to be pristine and beyond the realrn of social analysis. Anthropologists were particularly blind in this respect, and while they blithely examined the exotic healing ceremonies and rituals of other cultures and situated them in local cosmologies, they stubbornly ignored modern medicine, assuming it to have evolved beyond the superstition, religion, and value laden beliefs so clear to them in traditional medicine. 15

Medicine was believed to hold a unique status by virtue of

having 'special access to the real workings of Nature."16 But for

the social constructionist now,

Medical categories ... are social through and through; they are the outcome of a web of social practices and bear their imprint. When we speak of tuberculosis we are not reading the

label on a discrete portion of nature, 'out therer; we are instead ... employing a social meaning that has been generated by the activities of many different social groups. 17

So, for the social constructionist, medicine is a (if not the)

paramount example of paradigmatic mastery. It has achieved a

towering influence over us all, and yet there is nothing

inherently profound about it. It does not speak to nor address

anything that is essentially true about the world especially

since, according to this view, there is no truth to the world of

which to speak in the first place. And the corollary: medicine

is 'only one of a number of alternative frameworks with no

higher claim to ultimate "truth" than any othcr. l8

The constructionist view can lead to different consequences.

On the one hand, it can lead to despair, since, if there is no

ultimate truth out there to be tapped, then wherein lies the

purpose of existence? This is characteristic of many forms of

existentialisrn. 19 On the other hand, it can lead to a great

sense of freedorn also characteristic of existentialism as well

as other views. No truth means no essential/eternal

requirements which in turn means we can create who and/or what

we want to be. It also means we can discard cosrnological

systems like the rnedical approach and fashion others in its

place, ones which (ostensibly) more aptly suit Our interests.

And we can do this as individuals as tJietzsche2' and ~artre" 22 would have it, or as comrnunities as Rorty would have it.

Notwithstanding the consequences, however, the constructionist

view means a rejection of our tendency to privilege certain ways

of knowing over others based on the modern belief that they

grant us "special access to the real workings of Nature", and

more generally, to ultimate truth.

Now whatrs interesting is that constructionism makes these

clairns about the non-existence of truth, and yet we can ask:

"are not these claims theniselves truth claims?" Social

construction falls into a paradox no matter how you shuffle the

cards. On the one hand it can adopt the superior position that

only it sees the truth - i.e. that reality and truth are socially constructed. But thatfs a contradiction. On the other

hand, it can adopt the humble position - one more in line with its own tenets - that it too is merely a social construction. But then what reason do we have for taking it so seriously? In

either case, social constructionism seems to undercut its own

significance as an approach to dealing with and understanding

other approaches to reality, let alone reality itself. But 1

have to admit that of the two, 1 prefer the latter position

since the former is tantamount to just one more attempt at

paradigmatic mastery, and hypocritically so.

1s there a way out of this conundrtm? 1 think there is . . . but 1 will get to this later. 2 3

VERTICAL VERSUS HORIZONTAL APPROACHES TO REALITY

Let me try and summarize where we are so far. To begin, there

exists this tendency to paradigmatic mastery. There exists this

pervasive drive to differentiate, exclude and subordinate

certain views so that others, in the name of truth, can flourish

and dominate. This is indicative of the modern condition (and

certain historical conditions as well, it should be said), and

is argued by constructionists to be manifestly clear in the case

of medicine. Constructionists of al1 sorts criticize and

repudiate the tendency to erect totalizing theories. For them,

and most clearly in the postmodern formulation, there is no

truth out there to be had. Truth is fabrication. So the

constuctionist seeks the following . S/he seeks to undemine

totalizing theories by highlighting their contingent origins,

and in so doing, to dissolve the traditional hierarchies of ways

to know. In short, s/he is after the liberation and celebration

of knowledge in al1 its diversity. (Whether constructionism is

to remain just one of those knowledges on par with al1 others,

is itself a question. )

Now, before 1 go any further, 1 need to point out that 1 have

been employing the term 'social constructionism" fairly loosely

to this point; 1 have included a number of relatively disparate

theoretical approaches under its umbrella, and perhaps unfairly

so. For instance, although both are very constructionist,

postmodernism24 takes issue with Marxism which it sees as

propounding just one more grand narrativezs to be repudiated.

Moreover, although common to many approaches, social

constructionism is also a unique approach having its own origins

and orientations that one cannot fully reconcile with Marxist,

feminist, postmodern or any other approaches. So, in order to

speak of certain cornonalties between most, if not al1 of these

approaches, 1 will employ the term horizontalist approach.

Moreover, throughout this work, the horizontalist approach is

contrasted with its polarity, the verticalist approach. These

terms are adapted £rom Rortyf s distinction between two estranged

philosophical traditions:

There, then, are two ways of thinking about var ious things. 1

have drawn them up as reminciers of the differences between a philosophical tradition which began, more or less, with Kant, and one which began, more or less with Hegel's Phenomenology. The first tradition thinks of truth as a vertical relationship between representation and what is represented. The second tradition thinks of truth horizontally ... This tradition does not ask how representations are related to nonrepresentations,

2 6 but how representations can be seen as hanging together.

Rorty, as does the social constructionist position outlined so

far, favors the horizontalist approach. For the horizontalist,

there is no absolute truth to be represented, no essential

reality to be accessed; ontologically, there is no essential

"what is". And even if there were, there is no way of

transcending what we create (our language, culture, ways of

knowing) to establish whether or not it is an adequate

representation of (or rnirrors) such a reality;

epistemologically, there is no fundamental way to know about

"what is". As Rorty puts it:

What we cannot do is rise above al1 human communities, actual and possible. We cannot find a skyhook which lifts us out of mere coherence - mere agreement - to something like "correspondence with reality as it is in itself". 2 7

In contrast, the verticalist approach daims we can.

Ontologically, verticalists assume there is something (there is

truth) out there to know. Epistemologically, verticalists also

hold that we can know it and moreover, that there are sorne ways

of knowing that are far superior to others. Hence, the drive

towards paradigrnatic mastery and domination.

What follows are three more ways to distinguish between the

verticalist and horizontalist orientations as 1 intend to use

t h e m . These examples are closely related, but hopefully they

will give a more comprehensive picture of how the two approaches

differ.

1. Regarding essentialism: Verticalists have it that there

are entities out there in the world that have essences - that

there are (as Aristotle sees it) real things made up of primary

characteristics that make them what they are. The point is to

uncover these entities as they are in themselves, thus revealing

how things fit together. The point of inquiry, moreover, is to

converge on an accurate understanding of what those essences

are. Horizontalists, contrarily, hold that no such essences

exist, and that even if they do, we can never know what they

are. Instead, any essence "uncovered" is really an essence

created - created either by a free individual from the

existentialist point of view, or by the

community/culture/language/the powerful from the post-

structuralist (or pragmatist or postmodern, to name a few) point

of view. Essences are simply constructions of convenience.

Illness, for example,

is not a fixed reality waiting to be discovered by the application of more and more precise and standardized methods; rather, illness is socially constructed, and any definition and diagnosis depends on the selection of particular signs and

28 symptoms as relevant.

Illness is nothing more than what we (or the powerful) make it.

Since verticalists are essentialists, they are also

foundationalists. They are foundationalist because they

attribute priority to the real. The body, for example, is given

priority as a real entity. The body impinges and conditions in

various ways. As Turner explains:

Foundationalist frameworks are concerned to understand the body as a lived experience, or to comprehend the phenomenology of embodiment, or to understand how the biological conditions of existence impinge upon the everyday life and rnacro

2 9 organization of human populations . . . Horizontalist approaches, on the other hand, are largely anti-

foundationalist. They have no concern for ontology. Instead,

they put discourse and metaphor in center stage and link them to

the processes of social construction and the exercises of power

in society.

By contrast, anti-foundationalist perspectives conceptualize the body as a discourse about the nature of social relations, or comprehend the body as a system of symbols, or seek to understand how bodily practices are metaphors for larger social structures, or they understand the body as a social construction of power and knowledge in society, or perceive the body as an effect of social discourse. 3 0

2 . Rega~ding human identity: Human identity is a particular

category of essence. Vertical approaches to understanding the

human condition place emphasis on human identity. Although

horizontalist in many ways, Marxism is no exception. The

younger Marx in particular assumes a creative human being that

is alienated frorn his or her creative potential (as well as in

other ways) under the capitalist mode of production.

Consequently, he wants to release the human condition Exom this 3 1 oppressive situation. Most political theory, in fact, stems

frorn certain understandings of human nature, saying basically

that since humans are essentially "X", we need to create a "Y" 32 society to deal with/foster 'X". Micro sociologists of health

and illness, although constructionist in many ways, focus on the

self as well. Their primary concern is with the way in which the

self is affected by the experience of being ill, by the stigrna

associated with illness, etc. 3 3 Horizontalists, and in

particular post-structuralists, on the other hand, repudiate any

notion of an essential self, let alone a universal human

identity. They de-center the self granting it no autonomy.

They approach the self as a product - fully so - of society. 3 4

To make the d a i m that an individual (or humanity) is 'X" is to

create or propound a fiction for the sake of dealing with the

world in a certain way.

3. Regarding progress: Verticalists hold that we are

progressing towards truth. We may have our setbacks; we may get

sidetracked. But in the large scheme of things, we are getting

a better and better handle on the way things are; we are

penetrating deeper and deeper into the way the world works. (We

are obtaining greater and greater knowledge into the realm of

health, illness and disease.) Once again, horizontalists

disagree. They see progress as a fiction. If there is no truth

out there, if there is no essential reality to the world and the

things in it, if there is no universal human identity underneath

a superficial diversity, then there is nothing towards which to

progress, nothing essential that is. The only progress that

exists is one of convenience, one defined according to our

created goals.

Now it should be clear that by "verticalist" and

"horizontalist" 1 am referring to ideal type orientations in the

Weberian sense. 1 am doing this for essentially heuristic

purposes. My analytical concern is the disparity between

horizontalist and verticalist tendencies which are shared in 3 5 varying ways and degrees by different theoretical approaches. 1

think it is accurate to Say that there are certain approaches

that can be categorized neatly as either verticalist in

orientation, or horizontalist. There are others, however, that

cannot be so neatly classified, having some affinities with both

camps. The Marxist and phenomenological approaches are clear

examples. As such, any exhaustive classification of theories as

either verticalist or horizontalist would be forcing the issue.

However, 1 do think the following summary is helpful:

1. Verticalist approaches include: realism, positivism and

other approaches that are more foundationalist, essentialist,

anti-constructionist and modernist in orientation.

2. Horizontalist approaches include: relativism, pragmatism

(as per Rorty) and post-structuralism, al1 of which are anti-

realist, anti-foundationalist, anti-essentialist,

constructionist and more postrnodernist in orientation. 3 6

3. Approaches that have both verticalist and horizontalist

traits include: Marxism, feminism, symbolic interactionism and

phenornenology, among others. As we have seen, Marxism is

verticalist in that it is concerned (at least in some of its

manifestations) with a creative human potential that is

alienated under capitalism. Many feminist formulations share a

similar view, but see patriarchy as the villain. Phenomenology

is also verticalist given its foundationalist concerns. But

each of these approaches is horizontalist in at least one

critical way. Each stresses, to some degree, the social

construction of reality.

THE CONSULTATIVE APPROACH: SOME BASIC ASSUMPTIONS

Tc recap: adopting a purely verticalist orientation means

wanting to penetrate the essence and identity of things; to be

concerned with foundations and how they impinge; to assume

universal and eternal truth; to daim that certain ways of

knowing (science, medicine) are making progress in discovering

the way things are, while other ways of knowing are insufficient

to this task. To adopt a purely horizontalist orientation is to

repudiate al1 these daims. There are no necessary essences,

foundations nor truths. Hence, there are no privileged ways of

knowing. Taken to its relativistic extreme, the horizontalist

approach regards any way as equal to any other. So letf s forget

the modernist p e s t for absolute truth, the horizontalist says.

Letr s celebrate instead the many ways we have of functioning in

the world; and let's ensure, this time, that we sanctify none of

them.

Now for a new approach to these issues.

What fo l lows is a brief overview of some the characteristics

of the consultative approach as 1 see it, which, as concerned

with health, illness and disease, is the subject of this study.

The consultative approach has affinities with both the

verticalist and horizontalist positions, but it is satisfied

with neither. Along with the horizontalist, it does not share

the verticalist drive to totalize and exclude. Instead, it

champions diversity. Along with the verticalist it does not

share the horizontalist daim that al1 truths, essences and

foundations are sirnply social constructions. Instead, it

accepts that truths exist and that we can have some knowledge of

what they are. Social construction does takes place, but it

does not account for everything on its own. So the

consultationist says "let's celebrate diversity", and s/he says

this for the sake of liberation. But s/he says this for another

reason as well. S/he says: "Let's celebrate diversity because

we may each have, in al1 Our myriad ways of knowing, the

potential to shed some light on reality."

This is a pivotal claim. Different ways of knowing are simply

that. They are different approaches each with the possibility

of revealing or penetrating or highlighting, at least to some

degree, certain realities - certain truths out there. There is

no room for unconditional paradigmatic mastery here. Instead,

what is called for is a constant willingness to entertain

diverse approaches to reality given the possibility they can see

certain truths - tmths other approaches rnay miss, ignore, distort. Like (sorne forrns of) horizontalism, the consultative

approach is profoundly interdisciplinary - and more generally,

interparadigmatic - in orientation. But it is so not for

postmodern reasons. It does not disregard the existence of

absolute, nor universals, nor empirical truth, nor our ability

to approach such truth. It accepts their existence and the

possibility, even the feasibility, of their discovery.

And it is for this very reason (to digress a little here),

that we can seriously entertain the social constructionist

position without falling into the trap it has, perhaps

unwittingly, set for itself. Social constructionism has

uncovered a certain truth about the world, namely that social

construction does indeed take place. However, social

constructionism runs into difficulties when it carries its claim

too far by attaching an illimitable status to the reality of 3 7 social construction.

Uni* in Diversity

So diversity is good. But is it sufficient on its own? For

the consultationist it is not. And herein lies the essential

assumption: celebrating diversity is essential, but it is

invariably found lacking unless informed by something else -

unless informed by a spirit of unity. Yet by unity is not meant

uniformity, normalization, or totalization - themes of

modernism. Rather, by unity is meant something more alive than

this, something that responds to and thrives on diversity. What

the consultationist is after is a unity in diversity.

The principle of unity in diversity is appropriated directly

£rom the writings of Baharu1 ll&h3' whose primary teaching is the

oneness of humanity. For him, "the history of humanity as one

people is now beginning."39 We are seeing a trend that has been

gaining greater and greater "momentum during the last hundred

years: the trend toward ever-increasing interdependence and

integration of h~manit~.''~~ This is evidenced by a number of

phenornena, f rom

the fusion of world financial markets, which in turn reflect humanityfs reliance on diverse and interdependent sources of energy, food, raw materials, technology and knowledge, to the construction of globe-girdling systems of communications and transportation. It is ref lected in the scientif ic understanding of the earthf s interconnected biosphere, which has in turn given a new urgency to the need for global

4 1 cooperation.

These processes are forcing us to recognize that we have many

universal commonalities. They are compelling governments to

think globally. The world is shrinking, and it is shrinking

fast. We can attempt to resist the trend, but to what avail?

Instead, perhaps it is time to intensify collective strategies

to address common issues, strategies premised on our fundamental

oneness .

Once again, this oneness is not a oneness of uniformity. Tt

is not about achieving homogeneity. Instead, it is one premised

on a profound regard for the diversity of races, cultures and

creeds that exist in the world. A helpful analogy is to compare

the world to the human body:

Human society is composed not of a mass of rnerely differentiated cells but of associations of individuals, each one of whom is endowed with intelligence and will; nevertheless, the modes of operation that characterize man's biological nature illustrate fundamental principles of existence. Chief among these is that of unity in diversity. Paradoxically, it is precisely the wholeness and complexity of the order constituting the human body - and the perfect integration into it of the body's cells - that permit the full realization of the distinctive capacities inherent in each of these cornponent elements. No ce11 lives apart £rom the body, whether in contributing to its functioning or in deriving its share £rom the well-being of the whole. 4 2

Others have probably used the body as an analogy to understand

the world as a whole. And it is certainly the case that the

analogy has been used to understand society at a national level.

Hegel takes an organicist view of s ~ c i e t ~ ' ~ as do others who 4 4 propound collectivist political theories. Such theories,

however, use the analogy in a way that helps to elevate the

state. Here the individual is considered irrelevant to, or

viewed as a pawn of, society. The "cell" fades in importance.

Contrarily, those who reject the analogy of the body tend

towards the opposite pole. Society, for thern, is nothing more

than a collection of individuals. The individual is paramount.

The c u l t of individualism dominates.

Baha'u'llah shares neither of these orientations. He shares

neither a system's theory approach, for example, nor its

opposite - libertarianism, for example. Instead, his view is

one of reciprocity between society and the individual. The

individual is a trust of society with certain rights and

freedoms that must be guaranteed. Society has a tremendous

responsibility to the individual. But society does not lose as

a consequence. Instead, by nourishing its "cells" it is in fact

nourishing itself. By imbuing the individual with certain

freedoms society is liberating the individual to contribute in

hidher own unique way to the well-being of the whole. In this

way, an otherwise homogenized and moribund body is given

vitality. Releasing creativity, in its diversity, gives life to

the whole, distinguishing "unity from homogeneity or

unifomity. " 4 5

So the diversity of humanity must be tapped. But it must be

tapped in a way that promotes the oneness of humanity.

Much like the role played by the gene pool in the biological life of humankind and its environrnent, the immense wealth of cultural diversity achieved over thousands of years is vital to the social and economic development of a human race experiencing its collective coming-of-age. It represents a heritage that must be permitted to bear its fruit in a global

4 6 civilization.

Unity without diversity is uniformity and lifelessness.

Diversity witnout unity is chaos and ineffectual (even perilous)

to our collective situation and ourselves. Hence the principle

of unity in diversity.

Now, horizontalists Say that diversity has been stifled; that

the individual creativity has been stifled; that humanity has

been stifled. According to Nietzsche, we have been stifled by

the Socratic principle to rationalize, to render everything

subject to reason. In The B i r t h of Tragedy, Nietzsche sees a

powerful struggle running through the ages, namely that between

two forces - the Dionysian and Socratic principles47. The

Dionysian principle of passion represents the "explosive,

ungoverned force of creati~n"~~. But it also represents a force

t h a t has f o r t h e most p a r t l o s t out i n i t s s t r u g g l e with t h e

Soc ra t i c p r i n c i p l e . Passion, f o r example, does not inform a r t

un le s s i t does s o i n conformity with reason. Beauty i s beauty

only in so fa r a s it appeals t o i n t e l l i g i b i l i t y , Nietzsche

rejects t h i s . Nietzsche r e j e c t s the crushing f o r c e of S o c r a t i c

reason. H e denounces it a s u n j u s t l y oppressive, e spec i a l ly

given i t s l a c k of grounding i n anything s u b s t a n t i a l l i k e e t e r n a l

t r u t h . So he c a l l s f o r t h e Superman, one who can shed t h e

f i c t i o n a l garments of reason and t r u t h and exe rc i se h i s /he r

c r e a t i v e capacity t o become.

T h e consu l t a t i ve approach a l s o promotes the need f o r

ind iv idua l becoming. But it does so always wi th the p r i n c i p l e

of un i ty i n m i n d . Without such an o r i e n t a t i o n w e invar iab ly end

up with a n t a g o n i s t i c becomings, then wi th c o n f l i c t , and then

wi th domination a l 1 over again . So, while d i v e r s i t y gives l i f e

t o uni ty , unity i s i n t u r n e s s e n t i a l t o d i v e r s i t y . I t fxees t h e

c r e a t i v e i n d i v i d u a l p o t e n t i a l so key t o i t s own v ivac i ty .

And why wouldn't we want t o be o r i en t ed towards unity, a u n i t y

i n which w e are each f r e e t o exerc i se Our c r e a t i v e p o t e n t i a l s ?

An o r i e n t a t i o n t o uni ty means we a re o r i en t ed t o each o the r . It

means we a r e o r i en t ed towards shar ing with, and learning from,

each o ther . W e a l 1 benefit.

Consultation and Seeing

W e benecit f o r many reasons one of which i s t h a t it i s

poss ib le t h a t each o f us may see, t o some ex ten t o r another, i n

our d iverse ways of knowing, d i f f e r e n t th ings about r e a l i t y .

This, once again , i s a c e n t r a l claim o f t he consu l t a t i ve

approach. From our var ious vantage p o i n t s , some of us rnay see

some things i n r e a l i t y w h i l e o thers may see o t h e r things about

r e a l i t y . Moreover, w e each may see d i f f e r e n t a spec t s of the

same th ing i n r e a l i t y . Some may see hyperkinesis as a d i sease

with b i o l o g i c a l foundations while o the r s may s e e i t as a s o c i a l

construction fabricated in order to individualize what rnay in 4 9 fact constitute a social problem. One may be right and the

other wrong in this case. On the other hand, both may be

penetrating into different aspects of the sarne phenomenon and

hence, different aspects that are true of it. Then again, one

aspect of the phenomenon may have more to it than any other, in

which case one approach may be more revealing (truth bound) than

any other. In any case, we lose if we do not collaborate - we lose the possibility of gaining a more comprehensive insight

into the phenomenon (and the opportunity to more effectively

reduce suffering associated with any "illness") . We lose by

simply promoting diversity.

Turnerr s "strategy of inclusion"50 is along the lines of what I

am talking about. "[His] approach is to think about problems

that interest [him] from diverse starting points. His reason

for this is that "no single paradigm or perspective can ever be

theoretically adequate. "52 In particular, he states that " [el ach

of the major traditions within medical sociology can be

criticized for its limitations and lacunae. "53 So whatr s the

point of adhering to one of them over al1 the others? Why not

draw from each, learn from each? Different paradigms can reveal

different things about phenornena. Turner's approach to anorexia

nervosa is particularly enlightening in this regard. He

demonstrates the utility of using three different, even

disparate, sociological paradigms for revealing different

aspects of this condition.

Anorexia should be approached conceptually and theoretically at three levels ... At the phenornenological level, we may understand loss of appetite as a pseudo-solution to communicative problems between the developing personality and the domestic environment of the overprotective home. At the social level, anorexia is a sick role which provides 'solutionsr to the demands of a cornpetitive middle-class

culture through the secondary gains of the sick role. At the societal level, it is an effect of fashions relating to food, consumption and life-style. Anorexia is peculiarly expressive of the persona1 and social dilemas of educated, middle-class women, because it articulates various aspects of their powerlessness within an environment that also demands their

5 4 cornpetitive success.

Similarly, different approaches are amenable to understanding

dif ferent phenomena. Turner reasons that

sociologists don' t have to choose. . .between levels. For example, it seems perfectly sensible for a medical sociologist to be interested in the question of human pain, and 1 felt that the best approach to that was the work of Merleau-Ponty on phenomenology. However, it was equally sensible for sociologists to be interested in the interaction between doctors and patients, and 1 felt that the legacy of Parson's 'sick role' ... was the most appropriate approach to that level. Finally, 1 felt that neither Merleau-Ponty nor Parsons was adequate for understanding the impact of the state or the environment of social class on the distribution of health and illness globally. 5 s

In brief,

Sociological theory is often written as if one had to choose between competing and incommensurable paradigms. My own view, which could be called methodological pragnatism, is that the epistemological standpoint, theoretical orientation and methodological technique which a social scientist adopts, should be at least in part determined by the nature of the

5 6 problern ai:d by the level of explanation which is required.

The consultative approach is pragmatic in this sense.

Different paradigms see different things (at least potentially),

so what's the point of devoting Our lives to refuting some for

the sake of others? Instead, wouldn't it be more fruitful to

see what each can offer, to take what each can offer, and to do

so with an ever expanding orientation to include as much diverse

knowledge as we can in Our overall approach to phenornena, their

various aspects, and to the world in general?

Assuming the answer is "yes", then other questions emerge,

such as: how is such an orientation to be put into practice?

Or: through what method are we to foster meaningful

interparadigmatic interaction? And: through what method are we

to feel confident that such interaction has the benefit of

getting at and integrating into our knowledge base the truths

the different paradigms are able to highlight, while at the same

time weeding out the deficiencies they invariably harbor? These

questions are reserved for the final chapter of this volume, and

discussed in depth in the next volume. But for the sake of

closure, it should be said briefly that for the consultationist,

there is only one method for this particular job. Not

surprisingly, the method is called consultation.

Here, consultation refers to something other than its ordinary

usage, i . e., a process "of deliberation, advice-seeking, and information-gathering from various sources... "57 Instead, it

denotes a process in which

a small or large number of individuals, representing themselves, institutions, nations, or any other group of people, communicate with one another in an atmosphere of complete unity and frankness. Their purpose is to seek out the truth about the object of their deliberation and to find ways and means in which individual and societal needs for justice, equality, freedom, and progress are met. They also deliberate on ways human conflicts can be resolved without the abuse of power or the manipulation or denial and violation of human rights of any people, whether or not they are directly

58 involved in these consultative processes.

It is, moreover, a process

in which the individual participants strive to transcend their respective points of view, in order to function as rnembers of a body with its own interests and goals. In such an

atmosphere, characterized by both candor and courtesy, ideas belong not to the individual to whom they occur during a discussion but to the group as a whole, to take up, discard, or revise as seems to best serve the goal pursued. Consultation succeeds to the extent that al1 participants support the decisions arrived at, regardless of the individual opinions with which they entered the discussion. Under such circumstances an earlier decision can be readily reconsidered

59 if experience exposes any shortcomings.

Put another way, consultation as described here, is a particular

mode of communication where:

1.the views of everyone, in al1 their diversity, are always

treated as potentially relevant to an issue (to understanding

a phenornenon), and are thus rigorously sought;

2. views are expressed freely but with prudence and with respect

and consideration for others and their views;

3.individuals (and groups) are detached from their own views

such that they see them not as finalities, but rather as

opinions that belong to the group for it to work with, mold or

discard in light of other views and evidence;

4.the ultimate objective is to achieve a unity of thought, but

if this is not attainable, a majority opinion prevails;

5. everyone supports the decision of the group in unity; and

6. the group is able to return to the consultative process upon

evidence of any deficiencies with the decision.

Obviously, consultation requires work on the part of the

individual. For many, it requires an attitudinal adjustment of

massive proportions. Most significantly, it requires an

orientation to otherness, an orientation to "releasing the

potentialities [in their wonderful diversity] latent within the

human consciou~ness"~~.

In Short (see Table 1 for a swnmary)

Verticalists like to think that they can penetrate into

reality and see the way things are. But they clah there are

only certain privileged ways of doing this. Other knowledges

are excluded, subjugated, relegated to minor positions on the

hierarchy, or rendered completely invalid. The approach tends

towards an oppressive uniformity. Horizontalists, on the other

hand, deny any access to truth or that there is even such thing

as truth; everything is a social construction. With this denial

of truth cornes the dissolution of every knowledge hierarchy, and

in their place, the liberation to create ourselves and our own

persona1 or community "truths" (assuming that the corresponding

realization of anomie, of ambiguity, is not too much for us

handle) . So the verticalists are seduced by the quest for truth

(leading to uniformity) while the horizontalists are seduced by

the opportunity for creativity (leading to diversity). The

consultative approach, however, says "why not be seduced by

both?" And if that sounds good, then it says "letf s accomplish

both through consultation, a communicative process founded on

the principle of unity in diversity."

SOMMARY OF PURPOSE

My grand purpose is to provide a rationale for, and delineate,

a consultative approach to understanding health, illness and

disease. This means undertaking two related projects. The

first, is to:

d e m o n s t r a t e the utility of meaningful i n t e r p a r a d i g m a t i c

collaboration f o r ach iev ing bet ter under s tand ings of - for

p e n e t r a t i n g more d e e p l y into - heal th, i l l n e s s and disease

(and r e a l i t y ) . The second is to:

Table 1: S~lmmary of assumptions as distinguished between the

verticalist, horizontalist and consultative approaches.

Essences are

socially

constructed.

REGARD=. . .

ESSENTIALISM

TRUTII

OF REA~ITY

L

UNXTY VERSUS

DIVERSITY

Truth is socially

constructed.

V~TXCALIST A P ~ R O A ~ B

Essences exist.

Truth exists.

Knowledge is

seeing reality.

Only some see

reality.

Unity is good.

Knowledge is

socially

constructed.

Everyone socially

cons t ruc t s

(although some

constructions are

more dominant than

others) .

Diversity is good.'

Essences both exist

and are socially

cons tructed .

Truth both exists

and is socially

constructed.

Knowledge is seeing

and it is socially

constructed. We

a l 1 potentially see

(different things

about) reality in

our diversity. And

w e al1 socially

construct (although

some constructions

are more dominant

than others) .

Unity in diversity

is good.

l Although Rorty is admittedly ethnocentric. See Chapter 4.

demonstra t e the power o f the communicative p r o c e s s o f

consu l t a t i o n f o r f a c i l i t a ting m e a n i n g f u l i n t e rparad igma t i c

c o l l a b o r a t i o n s o that more adequate u n d e r s t a n d i n g s of heal t h ,

illness and disease (and reality) c a n be a c h i e v e d .

As mentioned, the latter 4-5 beyond the scope of this book, as is

the completion of the former. My concern, rather, is simply to

lay the theoretical foundation for the former.

Here is the thinking in brie£:

Different perspectives can be thought of as spotlights,

illuminating different phenornena (aspects) of reality. Sorne may

shine more intensely than others. Some may illuminate more

broadly t h a n others. But it is always possible that each

illuminates something about reality - some truth. So why not

look to each to see what it c m offer? The more light there is,

the more we see and the better off we are.

Underlying this thesis is the principle of unity in diversity.

Through an orientation to diversity, an otherwise singular and

oppressive approach to health, illness and disease

transforms/expands/bifurcates into one more responsive,

flexible, and imbued with greater meaning for all. Through an

orientation to unity, an otherwise scattered and (often)

conflictual diversity is thoroughly explored, and its advantages

integrated for the benefit of all.

This is obviously a case for interdisciplinarity, and more

broadly, for interparadigmatic collaboration. But this case is

being made for very specific reasons. 1 am suggesting, along

with the horizontalist, that the totalizing theories of

modernism are inadequate, and often oppressive. But unlike the

horizontalist, 1 am also suggesting that there is something

beyond social construction out there, something deep, to know,

that it can be known at least to some extent, and that it can be

known in different ways. This means that totalizing approaches

such a s medicine, and s c i ence more broadly, have, i n a l 1

l i k e l i h o o d , and d e s p i t e t h e i r de£ i c i e n c i e s , h i t upon and

exp la ined c e r t a i n t r u t h s . I n f a c t , they may have h i t upon many

truths, deep ly p e n e t r a t i n g i n t o them f o r what t h e y are. But i t

also means t h a t o the r approaches may have done so a s we l l ,

perhaps i n t o o t h e r areas o r a spec t s of r e a l i t y .

T h a t d i f f e r e n t approaches may see d i f f e r e n t r e a l i t i e s f o r more

o r less what t hey are is t h e proposed r a t i o n a l e f o r f o s t e r i n g

i n t e rpa r ad igma t i c co l l abo ra t i on . The p o s s i b i l i t y of

paradigmat ic seeing, t h e r e f o r e , needs t o be e s t a b l i s h e d .

I nva r i ab ly , t h a t i s what t h i s book i s about .

And it begins i t t h u s . It begins by demonstrat ing t h e

v i a b i l i t y o f , and exp lo r ing the r a m i f i c a t i o n s o f , a c r i t i c a l

c l a im made by Turner. 6 1 I t begins i t with an assessrnent of t h e

claim: some things are more socially constructed than others.

For i f t h i s claim is c o r r e c t , i f some d i s ea se s , f o r example, a r e

more (and hence, some less) s o c i a l l y cons t ruc ted than o t h e r s by

medicine, then, t h e o r e t i c a l l y , there i s u t i l i t y i n t ak ing

medicine s e r i o u s l y because i t means medicine may a c t u a l l y see

some d i s e a s e s (more o r l e s s ) f o r what t h e y a r e . Concurrent ly,

t h e r e i s , aga in t h e o r e t i c a l l y , u t i l i t y i n t a k i n g s o c i a l

cons t ruc t ion i sm s e r i o u s l y because i t means s o c i a l

cons t ruc t i on i sm may a c t u a l l y sec some d i s ea se s ( m o r e o r less)

f o r what t hey are. There is, t h e r e f o r e , and t h e o r e t i c a l l y yet

again , u t i l i t y i n each t a k i n g the o t h e r s e r i o u s l y - f o r each t o

cons ide r t he o t h e r a s ( a t l e a s t ) a ( p o t e n t i a l ) source of

va luab le informat ion about t h e t r u t h of hea l t h , i l l n e s s and

d i s e a s e .

Thus, my e s s e n t i a l concern is t o

demonstrate the relativity of the social, and i n particular,

medi cal construction of disease.

I t i s , moreover, t o

' explore the epistemological and antological implications that follow front the r e l a t i v i t y of the social ( m e d i c a l )

construction of d i s e a s e .

CHAPTER OUTLINE

In Chapters 2 and 3 my aim is to outline in more depth what is

rneant by the verticalist and horizontalist approaches

respectively, highlighting medicine and social constructionism

as prime examples, while Chapters 4 and 5 are concerned with

developing the theory informing the consultative approach. In

Chapter 4, I look in particular at the relativity of the social

construction of reality, its viability as a concept, what it

looks like, and its epistemological and ontological

ramifications. In this chapter 1 also introduce a number of the

conceptual tools that are utilized throughout the rest of the

book. In Chapter 5, I continue developing the theory by

addressing in depth the nature of paradigmatic articulation.

Most prorninently, the proposa1 that paradigmatic articulation,

while certainly involving social construction, concurrently

involves the possibility of penetrating into (getting to know in

more depth) reality, is examined. This possibility is pivotal

since it means, once again, that there is, within any paradigm,

(potential) relativity to how different things are both seen and

constructed; since it means that any paradigm can (potentially)

offer (deeper and deeper) insights into reality. In Chapter 6,

the theory is then applied very specifically to medicine in an

analysis of the varying degrees to which a range of diseases are

socially (medically) constructed. This is accomplished with the

introduction of a provisional typology to help think about the

relativity of the social construction of disease. Finally, in

Chapter 7, conclusions are drawn concerning the possibility of

seeing and their implications for the utility of

interparadigmatic collaboration between medicine and social

constructionism. The typology used to demonstrate the

relativity of the social construction of disease, thus

legitimating the utility of interparadigmatic collaboration, is

also assessed and potential weaknesses identified. Finally,

certain phifosophical ramifications are introduced.

1 also begin each chapter with what 1 am calling "Journey

Notes" the purpose of which is to provide brief overviews of

some of the most salient themes to that point, as well as to

introduce the next stage in the discussion.

Before going on, 1 should also point to...

THE IRONY

. . . involved in my focus on biomedicine and social constructionism. The irony stems from the fact that the former

f a l l s within the verticalist tradition as 1 am defining it,

while the latter falls within the horizontalist tradition as I

am defining it. And while the consultative approach as 1 am

defining it, is satisfied with neither, it is in many ways

informed by both - by many of their respective precepts. More

precisely, verticalisrn and horizontalism (specifically, social

constructionism) are drawn upon in order to make a theoretical- p p p p p p p p p p p - p - - - - - - - - - - - - - -

- - - - -

case for the utility of interparadigmatic interaction between

medicine and social constructionism. Even more ironic, and by

extension, they are drawn upon in order to make a theoretical

case for the utility of interparadigmatic interaction in

general, which would include their own interaction. This, no

doubt, is a notion that will vex proponents in both camps.

SOME DEFINITIONS

Illness and Disease

It is common within the sociology of health and illness to set

out a distinction between illness and disease. Whereas the

latter refers to physiological malfunctions, to objective signs

of illness, the former refers to the social psychological state

of the person af fli~ted~~, to his/her subjective awareness of the 6 3 disorder. The distinction is made in order to "avoid

unnecessary confusion between the two realms of culturally

defined and medically defined. problems. "64

However, this distinction doesn't necessarily hold within the

social constructionist literature. First of all, many social

constructionists would protest the stress placed on the

objectivity of disease. There are variations within

constructionism. Some constructionists are much more

constructionist than others.

Some, like Eisenberg, retain a view of disease as a biomedical reality while at the same t i m e recognizing the existence of alternative views of the problem; the latter are the non- medical or "folk" theories of illness. Other investigators are more drastically relativistic [as quoted above] and view the biomedical definitions as only one of a number of alternative frameworks with no higher claim to ultimate "truth" than any other. 6 5

Second of all, when social constructionists s p e a k of illness,

they often s p e a k of it in terms of social conceptions of 'what

is "really" or "basically" wrong with the person. ' 66 Thus spoken, illness refexs to a social designation rather than to an

individual experience (although many would argue the latter is

conditioned, if not determined, by the former) . A comrnon

concern is with the way in which illness designations are both

medically determined and believed to have an objective basis.

It is with this sense in mind, and not the more subjective sense

of the term in mind, that 1 employ the term illness.

And by disease 1 simply mean with Conrad and Kern

"biophysiological phenomena that manifest themselves as changes

in and rnalfunctions of the human body."67 And 1 do so emphasizing

that diseases are phenomena that are, like any other phenomena,

subject to interpretation, and hence, construction by any

paradigm.

Medicine

When 1 refer to "medicinet' 1 am referring to allopathie or

biomedicine as opposed to "alternativer' or "complementary"

medicine; the Western style of medicine that tends to dominate

today . Regarding T r u t h

1 think it is important at this point to emphasize that when 1

speak of truth, 1 place little ernphasis on distinguishing

between essential (foundational, eternal, universal) truth and

empirical or contingent truth. Since my primary aim is to

compare verticalism with horizontalism, the paramount question

is simply whether or not truth as "out there" of any kind exists

and whether or not it can be seen - truth, that is, besides constructed truth. In fact, the distinction between truth and

constructed truth is my primary concern £rom this point until

Chapter 7. In Chapter 7, 1 consider the various kinds of truth,

namely foundational, empirical, pragmatic and constructed truth.

1 "Verticalism" and "horisontalisrn" are terms adapted from a distinction

introduced by Rorty. See later in this Chapter.

2 See, for example, Lyotard (1993).

3 The allegory of the cave is a story meant to legitirnate the importance of

the philosophic/rational quest to transcend the knowledge we obtain through

other means (prejudice, belief, sense experience). The true philosophic goal

is to discover and become one with the realm of immutable truth (the realm of

the Forms ) . Most of us are like cave dwellers, Plato says, content with the

evanescent shadows we see on the walls of the cave. These shadows constitute

what we know. But then some of us are able to break away, to escape this

limited situation and see the light - to see the world of perfection as it is

in al1 its glory. Only true philosophers are able to take this step. See

the Republic pp. 240-243 for more details.

4 Foucault (1980), p. 81. Foucaultrs italics.

5 Foucault's genealogical method is discussed in more depth in Chapter 3.

6 Foucault (1980), p. 85.

7 This is a major theme within the sociology of health and illness. Some of

the more foundational contributions to this view include Conrad and Schneider

(1980); Freidson (1972); and Zola (1978).

8 Conrad and Schneider (1980) . 9 See for example Coburn (1988, 1988a, 1992 1 ; Coburn and Biggs (1986) ; Coburn

et al. (1981) ; McKinlay and Arches (1985) ; and Wahn (1987) . 10 Zola (1978).

11 Feminist sociologists of health, for example, see rnedicine in this way.

As White (1991, p. 51) explains, feminists "have examined medicalization at a

number of levels. Medical textsbooks and journals have been criticized for

their sexist attitudes ... Micro analyses of doctor-fernale patient interactions have revealed the daily workings of sexism...Barrett and Roberts ... analyzed the interactions between male doctors and middle aged fernale patients and

found that 'women were remorsely confirmed in traditional family and domestic

roles and more than one instance of a woman's refusal to do housework

resulted eventually in hospitalization and electro-convulsive therapyf."

12 White, (Iggl), p. 2.

13 Ibid.

14 Wright and Treacher (1982). See their Introduction.

15 Lock (1988). p. 3.

16 Wright and Treache- (1982),-p-. 6 % - - - - - - - - - - - - - - - - - - -

p p p p p p p - - - - -

17 Wright and Teacher, (19821, p. 10.

18 Mishler (l98l), p. 142.

19 A good overview on the subject is provided by Raymond (1991). Pascal's

Pensees gives a specific account of the despair we feel in the face of an

ambiguous existence.

20 Nietzsche, (1969).

21 Sartre (1956).

22 Rorty, (1989).

23 In Chapter 5, to be precise.

24 Which is i t se l f a mishmash of differing views. See Roseneau (1992)

Chapter 1 on this.

25 ... with its emphasis (in some of its formulations) on historical materialism and the inevitable emancipation of the worker and the emergence

of the classless society. These are themes to which Lyotard speaks. See

Sarup (1993) p. 145, for a brief word on Lyotardf s position with regard to

Marxism.

26 Rorty (19821, p. 92.

27 See Rorty in Brown (19941, p. 34.

28 Mishler (1981), p. 148.

29 Turner, (1992), p. 48.

30 Ibid.

31 This theme is particularly prominent in Marx's The German Ideology.

(1970).

32 The political theories of Hobbes (1968), Locke (1988) and Rousseau (1973)

a l1 begin with a theory of humankind in the natural state.

33 See Charmaz (1983; 1987), for example, regarding the impact that chronic

illness has on the sense of self. Goffman's Stigma (1963), is another good

example.

34 See, for example, Foucaultf s History of Sexuality (1978 . 35 That is, my concern is not with the different approaches themselves.

Rather, the different approaches are drawn upon in light of verticalist

and/or horizontalist themes.

36 1 should point out that this relativistic conclusion is not shared by al1

horizontalists. Certain pragmatists, for example, would take issue with such

extreme relativism. Rorty actually disavows relativism regarding some

beliefs as better than others. He States, for example, that '"Relativism" is

the view that every belief on a certain topic, or perhaps about any topic, is p p p p p p p p p p p - - - - - - - - - - - - - - - - - - - - -

as good aspevery other. No one holds this view. Except for the occasional

cooperative freshman, one cannot find anybody who says that two incompatible

opinions on an important topic are equally good.' (Quoted in Bernstein, 1991,

p - 201) . (See also Rorty (lggl), p. 212 for another example. ) Just because

there are no foundations does not mean we have to treat every view equally.

And Rorty certainly does not. As we shall see later, he is in fact quite

ethnocentric. Other horizontalists, however, are avowadly relativist.

Feyerabend, for example, says that ' . . . traditions. . . become good or bad (rational/irrational' pious/impious; advanced/"primitiveW;

humanitarian/vicious; etc.) only when looked at £rom the point of view of

some other tradition. "Objectively" there is not much to choose between

anti-semitism and humanitarianism. But racism will appear viciouz to a

humanitarian while humanitarianism will appear vapid to a racist. Relat ivsm

(in the old and simple sense of Protagoras) gives an adequate account of the

situation which thus emerges. ' (Quoted in Berstein, 1991, p. 200) . 37 Once again, see Chapter 5 for an elaboration on this theme.

38 Baha'u'llah is the founder of the Baha'i Faith.

39 Baha'i International Community (1995), p. 1.

40 Baha'i International Community (l99Sa}, p. 2.

41 Ibid.

42 Bahali International Comunity (19951, p. 4.

43 See Hegel' s Phenomenology of Mind (1969) , for his doctrine of organicism which he employs to understand philosophy, human personalities, societies,

etc.

44 See Marchak (1992) . p. 60. 45 Baha'i International Community, (19951, p. 4-

46 Baha'i International Community, (19951, p. 8.

47 This duality supplanted the Apollian-Dionysian duality that dominated

Greece before Socrates' influence took over. See Zeitlin (l994), p. 18.

48 Zeitlin (1994)' p. 6.

49 Conrad (1975).

50 Turner (1992), p. 235.

51 Ibid, p. 235-236.

52 Turner (1995), p. 211; my italics.

53 Ibid.

54 Turner (1992), p. 220.

55 Ibid, p. 236.

56 Ibid, p. 57.

57 Danesh (1986), p. 116.

58 Ibid.

59 Baha'i International Community (1995), p. 9.

60 Ibid.

61 Turner (1992) . 62 Conrad and Kern (1994), p. 7.

63 Turner (1992), p. 2.

64 Mishler (1981) , p. 142.

65 Ibid, p. 142.

66 Freidson (1970)' p. 209.

67 (1992), p. 7.

JOORNEY NOTES The o b j e c t i v e of t h i s chap te r i s t o e x p l o r e i n some d e p t h the

v e r t i c a l i s t approach t o r e a l i t y , and i n p a r t i c u l a r , t o h e a l t h , i l l n e s s and d i s e a s e .

T h e gist o f t h e c h a p t e r is t h i s : The d r i v e t o uncover - t o m i r r o r r e a l i t y - has captured the

imaginat ion over the c e n t u r i e s . T h e v e r t i c a l i s m s of Pla t o , Descartes and H u s s e r l a r e ment ioned a s examples . Each, i n h i s own way, makes the v e r t i c a l i s t a t t e m p t t o p e n e t r a t e i n t o the t r u t h of t h i n g s . The d r i v e t o p e n e t r a t e , moreover , c o n t i n u e s i n t o t h e present d a y , a drive r e p r e s e n t e d perhaps most p rominen t l y by science.

S c i e n t i s m i s a v e r s i o n o f v e r t i c a l i s m . Assuminq t h e r e is a r e a l i t y t o be uncovered, s c i e n t i s m h o l d s t h a t s c i e n c e i s t h e best way t o uncover i t , to uncover n a t u r e , t o uncover e s s e n c e - t o know what i s " o u t there". S c i e n c e i s t h e r e f o r e cons idered the best form of knowledge t oday .

Medicine is s i m i l a r l y v e r t i c a l i s t - a t l e a s t t h i s is what s o c i a l c o n s t r u c t i o n i s t s h o l d . Premised upon na t u r a l i s t on t o l o g y and epis temology , m e d i c i n e r egards i t s e l f a s h i t t i n g upon objective and u n i v e r s a l t r u t h s concern ing health, i l l n e s s and d i s e a s e , and a s h a v i n g a unique a b i l i t y t o do s o .

Werve heard a lot about the information age recently. We've

heaxd a lot from people like Lyotard that we are moving into a

postmodern era where the quest for "truth" is passé. We hear

that performativity - "the best possible input/output equationw'- is what really counts. The new attitude seems to be

this: whereas before we sought after loftiness, now itf s time

that we got down to earth. Forget eternality; let's deal with

practicality.

The question...now asked by the professionalist student, the State, or institutions of higher education is no longer "1s it true?" but "What use is it?" . . . What no longer makes the grade is competence as defined by other criteria true/false, justhnjust, etc. - and, of course, low performativity in

2 general.

This attitude has implications for power and its augmentation.

Power, Lyotard says, is performativity. Perfomativity

increases with the amount of information at one's disposal. 3

Power, then, is very much related to accessibility to

information and its efficient use.

The performativity of an utterance .. . increases proportionally to the amount of information about its referent one has at one's disposal. Thus the growth of power, and its self- legitimation, are now taking the route of data s torage and

4 accessibility, and the operativity of information.

Performativity is becoming increasingly important. I don't

want to deny that. But 1 don't think w e can conclude that the

search f o r truth is no longer captivating. Our fascination with

the prospect of being able to unearth the essence of things

continues to linger with us, if not to dominate us. The drive

to penetrate reality remains a powerful force in our society.

The conviction t h a t science can lead the way in this endeavor is

still profound. And 1 donlt think Lyotard would unequivocally

repudiate these observations. Indeed, 1 think it is correct to

maintain that he feels we are still in some ways captivated by

this mode of functioning. Otherwise he would not be urging us

to divest ourselves of the grand metanarratives that continue to

inform the quest for truth. 5

A recent cover story in T i m e titled "Glimpses of the ~ i n d " ~

provides a clear example of Our enduring captivation with truth.

Since Plato and before, we have wanted to understand the mind,

to locate it, to categorize it. Plato placed the mind within

the head, Aristotle within the neart, and Descartes somewhere

within the head again, portraying it as an inunaterial entity,

fundamentally distinguished from the materiality that houses it.

The mind has traditionally figured as one of the great subjects

of philosophical inquiry. Now science has made it one of its

many concerns.

Naturally, as a subject of probing scientific scrutiny, the

mind and its qualities (memory, emotion, consciousness) have

been tenaciously linked to materiality. In one scientific view,

the mind is simply a derivative of the brain. Consciousness,

for example, "rnay be nothing more than an evanescent by-product

of more mundane, wholly physical processes - much as a rainbow

is the result of the interplay of light and raindrops ."?

And why not? It makes sense. Take a chunk out of the brain

and funny things happen. Remove a portion of the hippocampus

and you may end up with someone like HM who is able to remember

things prior to surgery, but who is also unable to form any

post-surgery memories. Remove another part of the brain and you

may end up with an individual seemingly normal in many ways, but

who is also systematically indecisive, unreliable, prone to

making bad money investments, and what's more, indifferent to

these problerns. Different sections of the brain seern to be

directly correlated with different aspects of the mind. This is

the clairn that neuroscientists and other scientists are making

based on their use of special technologies such as magnetic

resonance imaging (MRI) and positron-emission tornography (PET) . These technologies ostensibly provide

a window on the human brain, letting scientists watch a thought taking place, see the red glow of fear erupting from the structure known as the amygdala, or note the telltale firing of neurons as a long-buried rnernory is reconstructed. 8

It may be taking things too far to clairn that science is

wholly materialist about the mind. Science rnay not take

materialism to the extent that Dernocritus did, who claimed

everything, even the soul, is made up of diverse eternal

building blocks - atoms - cornbined togethew in various formations. But it is most definitely leaning in that

direction. For many scientists, the mind is rooted in biologyg.

And the corollary they draw is this: no biological account, no

existence. For example: given there is no physical place for

the "self" to exist in the brain, there is no self. This is the

conclusion scientists have corne to after a century of

investigation. The "Time" article ends by saying: "It may be

that scientists will eventually have to acknowledge the

existence of something beyond their ken - something that rnight

be described as the soul. "'O To share a bias of mine, 1 agree.

But for now, scientists are after the physical foundations of

what Descartes originally distinguished as a mental (and

therefore, distinct from physical) substance.

The point of this is to begin to illustrate the verticalist

position as 1 am using it. The verticalist position vis-à-vis

science, for example, says that science can s e e ; science can see

a great deal. It can penetrate into phenomena we previously

held impervious to scientific investigation. And it can do so

with increasing precision and scope. The mind, before so

elusive and subject only to philosophical inquiry, is being

grounded by science. Science is going 'where no-one has gone

bef ore"".

This verticalist drive to penetrate the way things are, to get

at the absolute truth of things, is further revealed in a

special issue of T i m e called "The Frontief s of Medicine. ""

Consider, for example, the title of its introductory essay: "An

Epidemic of ~ i s c o v e r y " ' ~ ; or the position espoused in the same

essay regarding the discovery of the double-helix structure of

DNA :

The entire process of achievement took a major turn toward today's exuberant state in the 1950s. The demonstration of the double-helix structure of DNA by James Watson and Francis Crick in 1953 was the long-awaited key that opened the door to a rich trove of f u n d a m e n t a l biological knowledge. In time this discovery did nothing less than b r i n g to l i g h t the secrets hidden within the membrane of each of the 200 different varieties into which the hurnan body's 75 trillion cells are divided. 14

Or the title of the article devoted to genetics in the same

issue - "Keys to the Kingdom" - and its introductory statement: The discovery and manipulation of human genes - together with the use of special new drugs - are unlocking a future in which the human body promises to confound and defeat its ancient

15 enemies . It seems clear that verticalisrn and the quest for truth remains

a powerful force in our society.

It is, moreover, a force informed by a powerful tradition.

Humanity and its theorists, although not always scientific in

the modern sense, are certainly no strangers to the prospect of

penetrating reality. Take Plato, for instance. If anyone does,

he epitomizes the quest for truth. And his concerns are lofty,

to Say the least. For Plato,

The true lover of knowledge naturally strives for truth, and is not content with common opinion, but soars with undirnmed and unwearied passion till he grasps the essential nature of things . 16 Plato sees two worlds. The first is the material shadow

world, the world of transient things and common opinion. It

concerns him only insofar as it can entrap us and prevent us

from pursuing our main objective in life which is to uncover the

secrets of the real world, the world of the Forms. This is the

world of independent, universal, eternal realities. It is a

world unspoiled by particularity and ephemerality. It consists

of changeless ideas (the perfect good, justice, tree, horse,

color yellow, triangle) of which every corresponding particular

is simply a deficient emulation. It is the world of perfection.

For Plato, there is only one way to access this world, and

that is through reason. The senses misguide us. They leave us

captivated by the shadows of change. They distract us from what

is truly real. But we can know truth because we have all

experienced it. How? Plato believes in the immortality of the

soul and its transmigration. As such, he believes that we have

been reincarnated numerous times. We have therefore been able

to see the other world numerous times, and hence, those things 17 eternal. Thus, knowledge is not about acquisition, it is about

1 E! "rememberingf' or "reminiscing". And how do we rernember? How do

we recover knowledge? Through the practice of reason, and more

precisely, by exercising the Socratic method of questioning. The

Socratic method allows us to give birth to the knowledge latent

within us - to recollect. 19

Our fundamental aim, then , is to be in touch with our

reincarnated soul - the repository of absolute wisdom. It is to

disrobe ourselves of surface changeful knowledges so that we can

penetrate the light of reality.

If it is true, then, we must conclude that education is not what it is said to be by some, who profess to put into a soul knowledge that was not there before - rather as if they could put sight into blind eyes. On the contrary, Our argument indicates that this is a capacity which is innate in each man's soul, and that the faculty by which he learns is like an eye which cannot be turned £rom darkness to light unless the whole body is turned; in the same way the entire soul must be turned away from this world of change until its eye can bear to look straight at reality, and at the brightest of al1 realities which we have called the Good. 2 0

But, in the end, Plato does not universalize our capacity to see

the Good. Instead, he calls for a class of philosopher

guardians, a class both predisposed2' and fully trained to rule

humanity based on its privileged ability to approach Truth.

The history of western thought is filled with verticalists,

filled with personages concerned with the way things are in the

world. Aristotle, Augustine, Aquinus, and Bacon are just some.

So is Descartes. But Descartesf verticalism has a unique

foundation. It begins with the famous egocentric premise:

cogito ergo sum: I think, therefore 1 am. The fact that he

thinks - doubts, understands, imagines - means that he

indubitably exists.

Descartes' original concern is to refute radical skepticism,

the view that we cannot know, and more forcefully, that there is

nothing to know anyway. The world is an illusion. Descartes

sets out to invalidate skepticism by embracing it and pressing

it to its logical conclusions. He designs and applies a rnethod

of radical and systematic doubt through which he discards

anything the existence of which can be questioned in the

slightest. He even posits an evil demon with powers to deceive

him about the most obvious of things . 1 will suppose therefore that not God, who is supremely good and the source of truth, but rather some malicious demon of

the utmost power and cunning has employed al1 his energies in order to deceive me. 1 shall think that the sky, the air, the earth, colors, shapes, sounds and al1 external things are rnerely the delusions of dreams which he has devised to ensnare my judgment . 2 2

But in the end, one thing remains.

In that case 1 too undoubtedly exist, if he is deceiving me; and let him deceive me as much as he can, he will never bring it about that 1 am nothing so long as I think that 1 am something. So after considering everything very thoroughly, I rnust finally conclude that this proposition, 1 am, 1 exist, is necessarily true whenever it is put forward by me or conceived in rny mind. 2 3

So the cogito is his rock solid foundation. It is as

axiomatic to his knowledge of existence as 1+1=2 is to the rest

of mathematics. Upon it he seeks to build the edifice of

knowledge, one made up of clear and distinct ideas. His first

step is to confirm the existence of God (which he attempts

through a few deductive proofs). His second step is to

demonstrate the existence of the external world. Having proved

that God exists and that God is benevolent, he concludes that

God is no deceiver. Anything that we are convinced is t r u e -

that is clear and distinct to us - God validates. Hence, the

fact that we have a clear and distinct belief that the external

world exists means that it is no delusion. The idea of it as a

reality is true since it has been implanted within us by a non-

dece iving God . In short, for Descartes there is truth to be had. It is

"within human powers to arrive at a systematic and true

understanding of nature. . . "24 . And it is to be had through the

exercise of reason the fruits of which are confirmed by God.

Husserl is after certainty in much the same way that Descartes

is. His methods for achieving it are similar as well. Husserl

wants to create a "presuppositionless" philosophy25, a philosophy

oriented to getting at only what is perfectly evident. He seeks

to do so through the method of phenomenal reduction which

involves "bracketing out" or "parenthesizing" anything that can

be questioned as true. By doing this he feels he can reveal the

pith of a phenomenon, disclosing it in al1 its authenticity.

Thus to each psychic lived process there corresponds through the device of phenornenological reduction a pure phenomenon, which exhibits its intrinsic (immanent) essence...as an absolute datum. 2 6

Through phenomenal reduction, Husserl claims he can pierce

through the level of (mental, social) constructions, and get to

the level of "apodicticity" - the level of absolute reality. Like Plato and Descartes, he is after the true essence of

things . Plato wrote in the fourth century B.C., Descartes in the 17th

century and Husserl in the beginning of the 20th century.

That's a spread of well over two rnillennia and yet these

philosophers are the same in a very important sense. They

exemplify an entire philosophical tradition consumed with the

prospect of finding the best way to discover/represent reality.

As Rorty explains,

The picture which holds traditional philosophy captive is that of the mind as a great mirror, containing various representations - some accurate, some not - and capable of

2 7 being studied by pure, nonempirical methods.

Our task is to try and achieve "more accurate representations by

inspecting, repairing, and polishing the mirror, so to

speak.. . ,,28 . But, according to this tradition, certain ways of

polishing the mirror are more suitable than others. Thus,

Philosophy's central concern is to be a general theory of representation, a theory which will divide culture up into the areas which represent reality well, those which represent it

less well, and those which do not represent it at al1 (despite their pretense of doing so) . 2 9 This is verticalism as 1 am using it. There are things out

there to be known, and for some like Plato, Descartes and

~usserl~~, these things are absolute. We can know and accurately

represent them. But some ways of knowing, or representing, are

better than others. The verticalist task, therefore, is to

establish the hierarchy of representational strategies; to

elevate some (or one) as adequate to the task while lowering

(even denigrating) the others. This is what the philosophic

quest has entailed. And the result to date? Most prominently

it is the elevation of science to dominance.

SCIENTISM AS VERTICALISM

'In this century scientism in philosophy" writes Sorell, "has

already had one high point, and it may be enjoying a

resurgence."31 The 1920s were a great tirne for science with the

Vienna Circle working diligently to establish a program for its

unity. Today, science is ernerging to prominence once again,

perhaps dominating the way in which we address reality.

Traditionally, scientisrn has f a l l e n within the empirical - - - - - - - -

t-radrtron, h rradltlon that has repudiated the search for

metaphysical truth - a rationalist enterprise. More recently,

realists with interests in "deeper" issues have emerged within

the scientism camp. So there is controversy within the camp.

Yet both empiricists and realists share a profound concern for

the acquisition of truth, whether it be empirical or

foundational truth. Moreover, both hold that science is the

best way to access truth. Scientism is thus verticalism applied

to science. Consider Sorell's definition:

Scientism is the belief that science, especially natural science, is much the most valuable part of human learning - much the most valuable part because it is much the most

a u t h o r i t a t i v e , o r ser ious , o r b e n e f i c i a l . Other b e l i e f s r e l a t e d t o t h i s one may a l s o be regarded as s c i e n t i s t i c , e.g., the b e l i e f t h a t sc ience i s t h e o n l y valuable p a r t of human learning, o r the view t h a t it i s always good f o r sub jec t s t h a t do not belong t o sc ience t o be placed on a s c i e n t i f i c foot ing. When, a s has happened f requent ly s ince t h e seventeenth century, philosophers claim t o have made morals , or h i s t o r y , o r p o l i t i c s , o r a e s t h e t i c s , o r t h e study of t h e human rnind i n t o a sc ience , t h e y take it f o r granted t h a t f o r a sub jec t t o

become a sc ience i s fo r it t o go up i n the world. 3 2

Scientism makes sc ience the s tandard t o which a l 1 e l s e i s

But l e t ' s g e t more spec i f i c . What exac t ly are t h e claims

being made fo r sc ience? S o r e l l i s o l a t e s f i v e . One i s t h a t

science i s un i f i ed . By t h i s i s meant t h a t t h e laws and

t h e o r e t i c a l tems used by one s c i e n t i f i c theory are t r a n s l a t a b l e

i n t o any o t h e r s c i e n t i f i c theory. They axe in t e r -de f inab le

among t h e o r i e s . Theories a r e t h e r e f o r e conunensurable. A second

i s that sc ience is unr iva led i n i t s a b i l i t y t o p r e d i c t ,

explain and cont ro l . Science can tap i n t o t h e workings of

th ings and it can do s o b e t t e r than anything e l s e . S o r e l l

quotes Hempell on t h i s who says t h a t " the p r a c t i c a l app l ica t ion

of s c i e n t i f i c i n s i g h t s i s giving us an ever i nc reas ing rneasure

of con t ro l over the fo rces of na tu re and the m i n d s of

The a b i l i t y of sc ience t o e x e r c i s e g r e a t e r and g rea t e r con t ro l

i s p a r a l l e l e d by i t s a b i l i t y t o expand i n t o broader and broader

a r eas . I n f a c t , sc ien t i sm holds t h a t t h e reaches of sc ience a re

immeasurable. That i t s knowledge i s boundless. This i s t h e

t h i r d claim, and it i s a d a i m t h a t r i n g s loud and c l e a r with

Carnap who proclaims t h a t \\ [w] hen we Say t h a t s c i e n t i f i c

knowledge is unlimited, w e mean: there i s no question whose

answer is in p r i n c i p l e unattainable by science. ,,35

The fourth claim is that the methods of science guarantee

objectivity and that we are getting closer to the truth about

things. For logical positivists like Ayer, the best nethod is 3 6 one of verification. Any proposition that is meaningful is

either analytically or empirically verifiable. Al1 else is

senseless and not worth pursuing. When a proposition is

analytic it means that it is true by definition. ft is a

tautology. By empirically verifiable is meant that it can be

supported by experience. But - to digress a little - verificationism runs into problems, not least of which is its

own status as a principle. To daim that "[elvery genuine

proposition must be either analytic or empirically verifiable" 3 7 is itself neither analytic nor empirically verifiable. By its

own standards, verificationism is self-refuting.

For realists like Popper, the true method of science is that

of falsificationisrn. Falsificationism is asymmetrically related

to verificationism. The latter is purely inductive in that it

is bent on creating theories - and universal laws - out of the evidence. We must build from the evidence up. But the problem

with this approach3* is that we can never be sure that the

evidence we have is enough. How can we know that things will

not behave dif ferently in the future? How can we be sure that

As will always be As and not Bs? This was Hume's point. Past

events are no indication of what will happen in the future.

Al1 probable arguments are built on the supposition, that there is this conformity betwixt the future and the past, and therefore can never prove it. This conformity is a matter of fact, and if it must be proved, will admit of no proof but from experience. But our experience in the past can be a proof of nothing for the future, but upon a supposition, that there is a resemblance betwixt them. This therefore is a point, which can admit of no proof at all, and which we take

3 9 for granted without proof.

T h e sun ro se today, but what's t o Say t h a t i t w i l l r i s e

tornorrow. That w e assume it w i l l is nothing more t h a n t h a t - an

assumption.

So i f w e can't proceed induc t ive ly , we can proceed through

r e f u t a t i o n . W e can pos i t theories and test them. We can fo l low

modus t o l l e n s . Whereas w e can never decidedly prove a theory

t r u e s i n c e any sample of cor robora t ing evidence, no mat te r how

ex tens ive , i s always f i n i t e , we can unambiguously f a l s i f y a

theory . I t only t a k e s one "bad" i n s t ance t o do s o . So Popper

urges us t o proceed through r e f u t a t i o n . H e urges us t o c r e a t e

t h e o r i e s t h a t a r e f a l s i f i a b l e , and he says t h e more f a l s i f i a b l e ,

t h e better. The bolder , t h e b e t t e r . This , f o r him, i s the mark

how t r u e sc ience advances.

Moreover, i t is t he way i n which we can know w e are g e t t i n g

somewhere. The aim i s t o ge t c l o s e r t o t h e t r u t h . The ex ten t

t o which a theory mi r ro r s t h e t r u t h Popper calls its

v e r i s i m i l i t u d e . The e x t e n t t o which a t heo ry ' s v e r i s i m i l i t u d e

i nc r ea se s depends on i t s a b i l i t y t o withstand f a l s i f i c a t i o n .

The g r e a t e r t h e f i t n e s s of a theory - the g r e a t e r i t s a b i l i t y t o

defy r e f u t a t i o n - t h e more conf ident we can be that it

r ep re sen t s t r u t h .

W e can never make a b s o l u t e l y c e r t a i n t h a t Our theory is not l o s t . Al1 w e can do i s t o sea rch for t h e falsity con ten t o f our b e s t theory. W e do s o by t r y i n g t o refute our theory; t h a t is, by t ry ing t o t e s t it seve re ly i n t h e l i g h t of a l 1 our ob j ec t i ve knowledge and al1 Our ingenuity. I t i s , of course, always pos s ib l e t h a t t h e theory may be false even i f it passes a l 1 t h e s e tests; t h i s is allowed f o r by our search f o r v e r i s i m i l i t u d e . But i f it passes a l 1 these t e s t s then we m a y have good reason to conjecture t h a t our theory, which as we

know h a s a greater t r u t h content t han i t s predecessor, may have no g r e a t e r f a l s i t y content . And if w e f a i l t o r e f u t e t h e new theory , e s p e c i a l l y i n f i e l d s i n which i t s predecessor has been re fu ted , then w e can c l a i m t h i s as one of the ob j ec t i ve

reasons for the conjecture t h a t the new theory is a better approximation to truth t h a n the old theory. 4 O

And it is for these reasons that we can speak of scientific

progress. Why has science progressed? The explanation,

according to Newton-Smith is very simple: Our theories are 4 L getting closer to the truth. New theories are eclipsing older

ones - they are achieving greater and greater verisimilitude. Finally, the fifth claim is that science is beneficial.

Science, given its unlimited ability to approach truth, fosters

progress like no other knowledge form (especially compared to

religion, which is understood to stifle progress42). Its value

to humanity is unique, extensive and profound.

I should emphasize that there are different versions of

scientism. The distinction between logical positivism and its

rival, scientif ic realism, is particularly notable. The former

has nothing to do with metaphysical issues, deep causes,

theoretical entities, etc. Such things cannot be seen nor

experienced. They are, therefore, meaningless and represent

"nothing but sophistry and illusion"43. So positivism insists

that we focus our concerns on that which can be known

experientially. 'With a firm grip on observable reality the

positivist can do what he wants with the r e ~ t . " ~ ~

Realists, on the other hand, are intent upon getting

underneath the surface of things. For them, metaphysical

entities - like electrons and the mind - are real and can be known. We can penetrate and discover them in al1 their

primordial existence. R e a l i s r n is concerned with things both

observable and unobservable.

But logical positivism and realism are similar in fundamental

ways. They both Say that truth exists and that it can be known.

They are both prescriptive. They both Say that truth can only

be known through the methods of scientific inquiry which

guarantee objectivity, and allow us to find "...Truth naked,

relative to no des~ri~tion."'~ Both logical positivism and

realism hold that

[tlhere is a truth of matters, and the methods described by positivists and realists are adequate to the discovery of that truth. This assumes the capacity of the methods of empirical science, construed as guarantors of context independence, to fully reveal the actual character of things. 4 6

Both are verticalist in the purest sense.

MEDICINE AND VERTICAL~SM~'

Now for medicine (modern biomedicine). Medicine is modeled on

the natural sciences and is thus verticalist in orientation. It

revolves around two fundamental claims: 1. biomedical theory is

neutral; and 2. biomedical theory is universal in application.

By the former is meant that it has unique access to the workings

of nature, and more precisely, the body, The latter stems £rom

the former. By the latter is meant that since biomedical

findings are neutral, they speak to universal truths. They are

therefore universal in application.

But things are a little more involved than this. Gordon

provides a u s e f u l picture of the medical approach in her article

"Tenacious Assumptions in Western ~edicine"~'. What f ollows owes

much to her. In particular, Gordonf s depiction of the

naturalism of medicine and the way in which medicine understands

nature (the body) largely in terms of "the canons of the

enlic~htenment"~~ is informative. She divides her presentation

into two areas: 1. naturalist ontology/cosmology; and 2.

naturalist episternology.

Medicine and Natuzalist Ontology and Cosmology

Ontological concerns are concerns with what exists, with what

is real. They are concerns with the nature of being.

Cosmological concerns have to do with the ways in which the

world is put together and ordered.

Medical ontoiogy/cosmology is naturalist which means a few

things. In general, i t means that nature is approached as an

autonomous realm. Illnesses are viewed as entities, or made up

of entities, "out there". The naturalist tendency is to see

diseases independently of anything like culture, morality, the

supernatural, human consciousness, time and space.

To elaborate, consider illness in light of ... 1. Materialism: We have already touched on the dualism of

Descartes. For him, there are two fundamental substances in the

world - one is mental, the other material. The naturalism of

medicine not only perpetuates this division, but gives priority

to the latter. This is an emblematic outcome of the

Enlightenrnent, the tendency of which was to "disenchant" nature

and see it in mechanistic rather than in spiritual terms.

Medicine sees nothing 'divine" about illness. It strips illness

of its "evi l" foundations. Medicine understands illness in

terms of what it sees as the autonomous mechanisrns of nature,

and defines it in terms of materialist indicators (such as blood

pressure) . It understands illnesses by reducing them to

disordered bodily functions. This is physical reductionism.

2. Consciousness: Nature is a reality "out there" according to

naturalism. Thus, diseases are realities 'out there" according

to medicine. They are indif ferent to Our perceptions of them,

and as such, have definite realities. They are things-in-

themselves and to be understood accordingly. As such, medicine

defines illness and health in terms of objective criteria. The

concerns or feelings of patients are irrelevant. To make them

relevant is to conflate thing-in-themselves with emotional

responses to them, objectivity with subj ectivity, materiality

with mentality, "out there" with "in there". It is to rnuddle an

otherwise authentic entity.

3. Atornisrn: Medicine is atomistic which means that it

conceives of the body as little more than the sum of its various

parts. The parts, in their cause/effect relationships, form a

mechanical system which determines the whole. The whole is

therefore derivative of the parts while the opposite is not the

case. This means that the parts (much like the parts of a car)

can be looked at, assessed or dealt with as distinct phenomena.

They can be "decontextualized" and treated accordingly.

4. The Social: Nature is autonomous to social phenomena like

culture, values, morality, society and power. The social gives

rise to diversity, but this diversity is a superficial one. It

is transient and does not correspond to the essence of things.

There is a fundamental sameness to us all, one that underlies

and is indifferent to our diversity. The point is to permeate

the confusion of diversity in order to expose the light of

universality.

As far as disease is concerned this is what taxonomies have

done. Taxonomies are atternpts to mirror the diseases of nature

as they are in-themselves.

5. Time and Space: Medicine is getting better at mirroring

nature's diseases. It is capturing more and more of what nature

and its diseases, in al1 their universality, eternality and

omnipresence, are about. Medicine is on the cumulative path

greater truth, a truth that is neither tirne, nor location

specific.

Medicine and Naturalist Epistemology

Epistemological concerns are concerns about truth (whether

not there is truth) and what/how we can know of it. Naturalist

epistemology assumes there is truth and that there are very

s p e c i f i c ways w e can know of it. Medicine a d o p t s t h i s

epistemology.

Heref s how:

I t s ays t h a t s i n c e t h e r e i s an o b j e c t i v e n a t u r a l r e a l i t y ou t

t h e r e , w e need t o f i nd ways t o r e p r e s e n t it. W e need t o c r e a t e

models, a language, t h e o r i e s , t h a t correspond t o i l l n e s s as it

r e a l l y i s . W e can begin t o do t h i s by tapping i n t o our sensual

knowledge which i s a h i s t o r i c a l . But al though t h i s i s e s s e n t i a l ,

it i s no t enough. To g e t a t na tu r e we a l s o need t o manipulate

it, t o vex it, t o p lace it under a r t i f i c i a l s e t t i n g s and fo r ce

it t o unadu l t e r a t ed presence . This , obviously, i s what t h e

experiment i s al1 about.

But again , t h i s i s no t enough. W e a l s o have t o a l t e r

ou r se lve s when w e a l t e r n a t u r e . W e must disengage ourse lves

from ou r se lve s . W e must achieve adequate d i s t a n c e from Our

b i a s e s , va lues and preconceptions; achieve detachment so t h a t we

can perce ive t h e ob j ec t ( n a t u r e ) f o r what it r e a l l y i s .

When t h e s e c r i t e r i a a r e m e t , w e a r e on the way t o obta in ing ,

and hence adequate ly r e f l e c t i n g , t h e t r u t h about r e a l i t y

( n a t u r e ) . 5 0 In Conclusion . . .

. . . na tu r a l i sm inco rpo ra t e s a ve ry s p e c i f i c b l u e p r i n t f o r how

t o know what t r u l y e x i s t s . Biomedicine buys into, is based on,

and pe rpe tua t e s natural isrn. I t t he r eby lays s p e c i a l d a i m over

a s p e c i f i c domain of na tu r e , namely h e a l t h , i l l n e s s and d i s e a s e .

Hence the v e r t i c a l i s m of medicine.

mRTICALISM: ONE FINAL EXAMPLE

One month a f t e r T i m e publ i shed i t s a r t i c l e on t h e b ra in , it

came o u t with ano the r cover s t o r y t i t l e d "The Evolut ion of

~ e ~ r e s s i o n ~ ' ~ ~ . 1 mention t h i s because it provides one more

c u r r e n t example of our con t inu ing v e r t i c a l i s t (and i n t h i s case ,

naturalist), fascination with essences. Human nature is the

pivotal theme of the story.

Wright begins his article by saying that " [a] new field of

science examines the mismatch between our genetic makeup and the

modern world, looking for the source of our pervasive sense of

discontent." This new field of science is evolutionary

psychology, a field that seems to be evolving in the direction

of "mismatch theory". According to this theory, humans are

designed to live under conditions radically different than our

present situation seerns to allow. Because of the disparity

between our natural constitution and the social way of doing

things, the prevalence of many disorders - including depression, clinical anxiety disorder, and suicide - is up. Our present situation is one of social isolation. Our natural

situation is one of social cohesion. We yearn for the latter

but persist with the former. We look forward to watching shows

like Cheers where we can, if only for a fleeting moment, immerse

ourselves in a woxld "where everyone knows your name"; where

life bxings

regular, random encounters with friends, and not j u s t occasional, carefully scheduled lunches with them; where there [are] spats and rivalries, yes, but where grievances [are] usually heard in short order and tensions thus resolved. 5 2

But social transparency prevails. Subways are filled every

morning with emotionless faces staring off into space. Women

and men leave their suburban homes and drop their children off

at daycare £ive days a week only to return home to flick on the

TV. Acquaintances are dodged in the mean tirne. Think of what

the e l e c t r i c garage-door opener has done for uss3: now it is

possible to open the garage from our cars, scoot immediately

into the safety of our homes, and thus avoid the agony of a

courteous chat with our neighbors.

We do these things, but they are not natural. We champion the

free market and cornpetition but w e are really by nature much

more cooperative than that. We promote capitalism and produce

technologies (the TV, cars) thoroughly antithetical to our

natural ways of being. This is what mismatch theory s a y s . And

it says that, as a consequence, we feel guilt and a n x i e t y . If

we could just function in a way that corresponds more closely to

what Our genes require, things would be so much better. If we

could cultivate a n environment of warmth, affection and

camaraderie, we would be so much happier . There is a human nature rooted in our biology, the demands of

which we are systematically ignoring. Because we are ignoring

them, we are more depressed.

These are verticalist daims.

And they are d a i m s , like many others, that horizontalists

relentlessly dispute ...

1 Lyotard (1993), p. 46.

2 Ibid, p. 51.

3 Ibid, p. 47.

4 Ib id .

5 Ib id , p. 4 6 .

6 By Lernonick (1995).

7 Ib id , , p. 3 7 .

8 Ibid. Such technologies a l so l e t u s see the d i f f e r ences between how women

and men think, Women, apparently, use both sides of t h e bxain i n a more

i n t eg ra t ed way than men whose minds seem t o be more compartmentalized.

9 For others , the mind i s equated t o a computer. See i b id .

1 0 Ibid, p. 42.

11 S t a r Trek

1 2 Fa11 ( 1 9 9 6 ) .

13 By Nuland. My i t a l i c s .

1 4 Ibid., p. 7 . My i t a l i c s .

15 By J a ro f f . My italics.

1 6 A s quoted i n Ayer and OrGrady (1994) , p . 354.

17 Raymond (1991), p. 6 .

18 Z e i t l i n (1993), p. 109.

1 9 The theory of r e c o l l e c t i o n i s r a i s e d i n var ious p l ace s . Both t h e Meno and

t h e Phaedo provide good examples. In the former, f o r example, P l a to has

Socrates e l i c i t c o r r e c t answers regarding a geometr ical puzzle frorn a simple

s l a v e boy. Socrates is a b l e to do t h i s only because t h e s lave boy harbors a

p r i o r knowledge of geometry, knowledge he had h e r e t o f o r e forgot ten, knowledge

he ju s t needed t o recover, knowledge stermning from h i s s o u l t s p r i o r con tac t

with t he Forms.

20 A s quoted i n Ayer and OfGrady (1994) , p . p. 3 5 4 .

2 1 P la to a c t u a l l y recommends eugenic planning. For example, i n T h e Republic,

he wr i tes : "It follows £rom our conclusions so f a r t h a t sex should preferably

t ake p lace between men and women who a r e outs tandingly good, and should occur

as l i t t l e a s poss ible between men and women of a v a s t l y i n f e r i o r stamp." (p .

1 7 3 ) .

22 A s quoted i n Ayer and O'Grady (1994) , p. 111.

2 3 Ibid. Not my i t a l i c s .

2 4 S o r e l l ( l g g l ) , p. 29.

25 See Raymond ( l 9 9 l ) , p. 236.

26 Husserl quoted i n Raymond (1991), p. 238.

27 (1980), p. 12.

28 Ib id .

29 I b i d , , p. 3 .

30 I say f o r some s i n c e empirc is ts , who are v e r t i c a l i s t as well , a r e not

a f t e r absolute t r u th . Their concern l i e s w i th t r u t h t h a t can be experienced

through t he senses, through observation. That is, while they repudiate the

metaphysical, they s e e k observat ional t r u t h .

31 (1991), p . 3 .

32 Ib id , , p. 1 . Not my i t a l i c s .

33 1 am not proceeding i n t h e same oxder t h a t S o r e l l p resen ts them.

34 (1991), p . 7 .

35 Quoted Ibid ( l g g l ) , p . 6 . Not my i t a l i c s .

36 See Cottingham (1984), p. 105-111, fo r a b r i e f overview.

37 See Shand (1994), p. 271.

38 O r , r a t he r , "a" problem with t h i s approach. H o r i z o n t a l i s t s r a i s e numerous

i s sues with it. Chapter 3 explores many of them.

39 A s quoted i n Ayer and OfGrady (1994), p. 199. Not rny i t a l i c s .

40 In ibid., p . 357. Not my italics.

41 See Brown (1994), p. 10.

42 Sorel1 (lggl), p. 8.

43 Hume (1990) p. 165.

44 Hacking, (l994), p. 169.

45 Rorty i n Baynes et al. (1987), p. 61.

46 Longino ( l g g O ) , p. 179.

47 1 want to be clear at this point, that the following characterization of

medicine represents a horizontalist, and more precisely, a social

constructionist (within the sociology of health and illness) understanding.

It is difficult to Say how accurate a characterization it really is. For

example, although medicine may incorporate naturalist tendencies, it may be

too categorical to Say medicine is fully naturalist in the sense outlined.

Perhaps the characterization of medicine as naturalist is i tself a social

construction, one (more or less) fabricated for the purposes of social

constructionist analysis into the medical enterprise? This notwithstanding,

the discussion of naturalism which follows is informative, speaking at least

to a tendency within medicine if not to something it unequivocally endorses,

propounds . 48 (l988), pp. 19-56.

49 Ibid, p. 21.

50 Once again, from a constructionistfs point of view..

51 By Wright (August 2 8 , l99S), pp. 32-38.

52 Ibid, p. 35.

53 Ibid, p. 36.

JOflRPJEY NOl!ES Having discussed ve r t i ca l i sm , the o b j e c t i v e of this chapter is

t o explore i n depth i t s a n t i t h e s i s - the h o r i z o n t a l i s t approach t o r e a l i t y , and i n par t icu lar , t o hea l th , i l l n e s s and disease .

Here are some o f the main ideas: Horizontalism repudiates t he mind-as-mirror metaphor so dear

t o ve r t i ca l i sm . I t emphasizes, ins tead , two r e l a t e d po in t s . F i r s t : things a r e ambiguouç and cannot be known a s they are in- themselves; t hey can only be known i n l i g h t of social expec ta t ions , background assumptions; t h e y a r e meaningful on l y when paradigmatically d ic ta ted a s such; t hey mean nothing i n the absence o f perspec t ive . Second: things-in-themsel ves do no t r e a l l y e x i s t anyway (Nietzsche and Rorty, among o ther s , propound t h i s ant i -ontological view) ; th ings are constructed; t ru th is made. Hence, the world need not be a s it i s and can c e r t a i n l y be reconstructed i f we so wish i t t o be.

Having explored these two emphases, Berger's model o f t he social construct ion o f r e a l i t y i s introduced and then elaborated. Special emphasis i s then placed on the m e d i c a l model as a soc ia l construct , and on h e a l t h , i l l n e s s and d i sease a s metaphors of soc i e ta l t ens ions . The role o f power i n soc ia l construct ion i s a l s o emphasized. From various perspect ives - Parsonian, f emin is t and Marxist - medicine is depic ted a s t h e dominant producer of r e a l i t y today. I t is a l s o depicted a s the preeminen t agent of social control today, regula t i n g sociecy through medical i z a t i o n and through the 1 egitima t i o n o f dominant soc i e ta l expec ta t ions . The micro-interaction between doctor and pa t i en t is a l s o discussed a s a major forum for such l eg i t ima t ion .

T h e chapter ends w i t h the Foucauldian approach t o medicine. Foucault says that truth is power manipulated and t h a t medicine a s a "true" discourse - a s one representing the w a y things are with hea l th , i l l n e s s and disease - i s a c t u a l l y a contingent arrangement, one l i nked t o bio-power and i ts emergence t o prominence over t he l a s t couple cen tur ies .

INTRODUCTION

There are two p a r t s t o t h i s in t roduc t ion .

F i r s t , a shor t d ia logue:

It's 12rZ5pm. A verticalist and a h o r i z o n t a l i s t are h a v i n g

lunch together in a university cafeteria. It is a p l e a s a n t

meeting at first.

Verticalist: Hey, d i d you read the a r t i c l e i n t h i s weekf s T i m e ?

Hor izon ta l i s t : Which one?

Verticalist: T h e one about mismatch theory.

Hor i zon ta l i s t : Oh, you mean t h e cover s t o r y about human na tu re

and depression?

Verticalist: Yeah. What did you think?

Hor i zon ta l i s t : Waste of t ime!

V e r t i c a l i s t : What do you mean "waste of time"? How is it a

waste of tirne? I t could be r i g h t you know, and i f it i s , it

says a l o t about t h e problems with our s o c i e t y today and t h e

measures we need t o take t o solve them. 1 mean, i f we a r e by

na ture s o c i a l , t h e r e are a l o t o f changes t h a t we need t o . . . Hor izon ta l i s t : Yah r i g h t !

V e r t i c a l i s t : You c u t me o f f !

Horizontalist: 1 know 1 did, Youfre beginning t o i r r i t a t e m e

with t h a t d r ibb l e . You want t o know what 1 t h i n k ?

V e r t i c a l i s t : I f m n o t sure 1 do, anymore.

Hor i zon ta l i s t : W e l l , 1'11 t e l l you anyway. Mismatch theory says

t h a t human na ture i s i n h e r e n t l y s o c i a l , r i g h t ? T h a t i t s i n

Our genes t o be m o r e gregar ious and cooperat ive . But then 1

ask: Where i s t h i s view of human nature r e a l l y coming from?

What a r e i t s s o c i a l o r ig in s? Are these evo lu t ionary

psychologists a c t u a l l y g e t t i n g a t something profoundly t r u e

about us, o r a r e they j u s t seeing what they want t o see, what

their paradigmatic biases d i c t a t e ? Maybe they have j u s t

happened upon a f r u i t f u l s t r a t e g y t o l e g i t i m a t e another

fiction, even if unwittingly so. And here a r e some more

questions: what role does such a conception of human nature

play? Whose interests does it promote? Maybe it j u s t amounts

to one more attempt at makking some sense of this nebulous

world we live in.. . because, you know, there is nothing more to

this world than that: ambiguity. There is no deep t r u t h to

it . Truth, essence, human nature ... these are al1 fantasies of pragmatic convenience.

[Pause]

Wow! A horizontalist like myself can have a lot of fun with

mismatch theory!

The verticalist grimaces.

Horizontalist : What?

Verticalist: I think 1% going to go have lunch with someone

else now.

T h e verticalist leaves the tab le . The h o r i z o n t a l i s t s h r u g s .

Second, Chomsky versus ~oucault':

Noam Chomsky is another who posits a fixed and universal human

nature. He says that there is "a foundation for whatever it is

that- we 40 w i É h - o u z mental-mpacities; Por I f thërë wërë fiop

such foundation, we could not explain how it is that we are so

capable of learning and using language to the extent that we do,

We could not explain how it is that we can learn to use language

so creatively, producing sentences the likes of which are

totally unique. He says there must be something about our human

nature that allows us to be so linguistically innovative.

To elaborate, Chomsky finds it curious t h a t ,

... having mastered a language, one is able to understand an indefinite number of expressions that are new to one's experience . . . ; and one is able, with g r e a t e r or less facility, to produce such expressions on an appropriate occasion,

desp i t e t h e i r novel ty and independently of d e t e c t a b l e s t imulus conf igurat ions , and t o be understood by o thers who share t h i s s t i l l rnysterious a b i l i t y . The normal use of language is, i n t h i s sense, a c r e a t i v e a c t i v i t y . 3

Chomsky s t r e s s e s t h a t t h e language d a t a w e experience are

minuscule and cannot account f o r t h e prof ic iency w e manifest a s

language users. He exp la ins

The cornpetence of a n adu l t , o r even a young c h i l d , is such t h a t we must a t t r i b u t e t o him a knowledge o f language t h a t extends f a r beyond anything t h a t he has learned. Compared wi th the number of sentences t h a t a c h i l d can produce o r i n t e r p r e t wi th ease, t h e number of seconds i n a l i f e t i m e i s

r i d i c u l o u s l y small. Hence t h e data ava i lab le as input a r e on ly a minute sarnple of t h e l i n g u i s t i c mate r ia l that has been thoroughly mastered, a s indicated by ac tua l performance. 4

So what accounts fo r our language prof ic iency? According t o

Chomsky, there i s a "un iversa l grammar", a "gene t i ca l ly

determined language facu l ty" o r "language a c q u i s i t i o n devicew5

t h a t i s ingrained i n each of us . This device al lows us, when

confronted wi th the d a t a of any language, t o l e a r n , i n t e r p r e t

and use t h a t language c r e a t i v e l y .

T h i s un iversa l grammar i s immanent t o us a l l . But i t does not

c o n s t i t u t e everything t h a t is un ive r sa l ly t rue of us . chornsky6

contends t h a t we a r e fundamentally t h e same i n o t h e r ways a s

we11. For ins tance , he makes the Marxist claim t h a t there i s a

un ive r sa l human need f o r c r e a t i v e work. There i s a l s o a

un ive r sa l human need f o r f r e e inquiry . And l i k e mismatch

theory, he argues t h a t Our present s o c i o - p o l i t i c a l s i t u a t i o n i s

incompatible with such needs. I t is a n t i t h e t i c a l t o human

na tu re , and hence, it i s un jus t .

T h i s is a l 1 very v e r t i c a l i s t of Chomsky.

Enter Foucault.

Foucault will have nothing to do with any of this. He is not

concerned with whether or not there is a human nature. Instead,

he asks questions like: "How it is that we have such a

conception?" and, "What role does it play in our society?" To

posit a human

is suspicious

exist, but if

transcend our

nature is to posit a universal truth, and Foucault

of any claims to universal truth. Truth may

it does, we can never know of it7. We can never

historical/societal situation to achieve eternal

certainty. What we can do, however, is determine the social

origins of truth claims. We can see, for example, how it is

that certain concepts of human nature - as either evil or good,

selfish or altruistic, cornpetitive or cooperative, egocentric or

social, prosaic or creative - emerged and how they have functioned within society.

Foucault's basic technique is to historicize any truth clairn.

Truth is historically conditioned, historically made. It is

truth for that time, truth made by specific socio-historical

circumstances. This is very horizontalist of him. It is also

directly contrary to any verticalist conclusions.

. . . . . . . . . What follows is a relatively in-depth (though, in no way

comprehensive) look at the horizontalist position. Throughout 1

refer to a nwnber of theorists, some of whom are more

horizontalist than others. All, however, have horizontalist

contributions to make, and it is these which provide the focus

of this chapter.

In outlining the position, I find it useful to divide

horizontal emphases into two categories: 1. the ambiguity of

things; and 2. the social construction of things. By "things" 1

mean facts, data, states of affairs, evidence, signs, symptoms,

phenornena, entities, reality, etc. 1 find that the latter

category incorporates the former. 1, therefore, devote more

space to it later in this chapter where special emphasis is also

placed on the social construction of illness and the

relationship of medicine to power.

Now, with the former. . . TBE AMBIGUITY OF THINGS

Francis Bacon compares the mind to "a false mirror, which,

receiving rays irregularly distorts and discolors the nature of

things by mingling its own nature with it."' The mind, for Bacon,

is a cloudy thing; it is full of veils; it harbors different

"idols" al1 of which inhibit us from seeing the world as it

really is. As Bertrand Russell surmarizes, Bacon enmerates

four "idols of understanding":

'Idols of the tribe' are those that are inherent in hwnan nature; [Bacon] mentions in particular the habit of expecting more order in natural phenomena than is actually to be found. 'Idols of the cavef are persona1 prejudices, characteristic of the particular investigator. 'Idols of the market-place' are those that have to do with the tyranny of words. 'Idols of the theaterf are those that have to do with received wisdom of thought; of these, naturally Aristotle and the scholastics afforded him the most noteworthy instances. 9

The senses put us into contact with reality, but that is not

enough. Thatrs just scraping the surface of reality. The idea

iç to go deeper; to uncover how reality really works. But the

mind, on its own, is not up to the challenge.

Bacon goes on to talk about the importance of the experiment

in helping to get a better picture of reality, but that takes us

back to verticalism again. What's important from a

horizontalist point of view is the emphasis that Bacon places on

how the mind can limit/distort/transform what we see.

Horizontalism not only agrees with this, but takes it much

further. Data, for example, are not just data when we get hold

of them. They do not simply appear to us in some unadulterated

lucidity. Instead, they appear to us in ways molded to Our

theoretical, pre judicial, linguistic, mythical, social

expectations. They appear to us in ways paradigmatically

conformed. As we shall see, this is very much Kuhnf s position.

What this means is that the same data can mean different

things to different people/cultures, and in different historical

eras. Hence the problem with induction. Data do not speak for

themselves, nor do they stand unquestionably as some objective

state of a£ fairs. They actually donf t evince anything

meaningful unless they are paradigrnatically recognized as doing

so. To imagine that a single true theory can emerge out of a

given sample of "objective" data is simply nonsense. Instead,

the opposite seems to be the case. Scientists, for example,

. . .invariably describe and explain phenomena in terms of a specific theory which they have invented or constructed. But, formally speaking, an endless number of theories can be constructed to be consistent with a particular body of data, just as an endless number of curves can be constructed to pass through any finite number of points. Logically, the notion of a single correct, or best-supported theory is, to Say the least, an extremely dubious one; but historically it is a notion which scientists routinely and effectively employ, which is indeed essential in scientific research. 10

Likewise, it is possible for any body of data to be described in

terms of any theory: "The data can always be described in a way

which makes them compatible with the presuppositions of the

research tradition. "l'

Ponder the f ollowing:

1. The case of the hatL2:

Imagine you and your friend, upon entering Sandyfs home, find

a gray hat hanging on the banister. You both Say, "Great, Dan

is here." But when Sandy, who has just arrived home herself,

asks why you both have corne to that conclusion, you each give

different answers.

You Say: 'Well, 1 only know one person who wears a gray hat like

that, and its Dan."

But your friend says: "No, the reason I Say its Dan is because

Dan is the only one 1 know who leaves his hat hanging on the

banister like that."

As it turns out, Dan is in the house and he is helping himself

to some left oves Szechwan Chinese food. But the point is this:

The same state of affairs (the gray hat on the banister) is

used in different ways by you and your friend. You each

emphasize different aspects of the same state of affairs, and in

this case, come to the same conclusion. But what if your friend

believed instead that only another friend, Brett, hangs his hat

on the banister? Ln that case, you would each have come to

different conclusions.

A given state of affairs does not stand for anything in

itself. It stands for something only in light of certain

expectations, in light of what Longino refers to as "background

assumptions". Different background assumptions can highlight

the same state of affairs in different ways, and yet lead to the

same conclusions. A given state of affairs (the gray hat is on

the banister) may speak to one person in a way that is entirely

different to the way it speaks to another person, but then stand

for the same conclusion (Dan is in the house). On the other

hand, different beliefs may lead each to draw quite different

conclusions (Dan is in the house versus Brett is in the house)

from the same state of affairs (the gray hat is on the

banister) . Moreover, dif ferent beliefs rnay also take as

evidence completely different states of affairs, once again

leading to either the s m e or to different conclusions. In

Longinors words:

. . . how one determines evidential relevance, why one takes sorne state of affairs as evidence for one hypothesis rather than for another, depends on one's other beliefs, which we can cal1 background beliefs or assumptions. Thus, a given state of affairs can be taken as evidence for the same hypothesis in light of differing background beliefs, and it can be taken as evidence for quite different and even conflicting hypotheses given appropriately conflicting background beliefs. Similarly, different aspects of one state of affairs can be taken as evidence for the same hypothesis in light of differing background beliefs, and they can serve as evidence for different and even conflicting hypotheses given appropriately conflicting background beliefs. 13

To put this al1 another way, a given state of affairs is never

evidentially relevant, even apparent, unless paradigmatically

imbued a s such. (From Sandyf s point of view, the gray hat on

the banister may have no evidential import. For her, the

paucity of left over Chinese food may be the more relevant state

of affairs . )

2. The case of the two sexist pictures:

Although we live in a profoundly sexist society, although the

reaches of patriarchy are insidiously rampant, it remains

interesting to note that some can so easily read sexism into

practically everything they see. Here's an illustration of what

Imagine a picture of a man positioned behind a woman, both of

whorn are portrayed only £rom the waist up. The man is slightly

taller than the woman and a little to her right. They are both

looking straight ahead, each with little emotion on their faces.

There are many ways to interpret this picture. One way is to

see it as a sexist depiction/promulgation of stereotypical male

and female roles. With an inclination to (with background

assumptions that) see sexism in everything, one might rnake the

following interpretation: " H e r e is a typical depiction of a man

playing the protective role- The woman, on the other hand, is

portrayed as the weaker of the two, reliant upon the man for his

presence, strength and guidance. "

Now, imagine a second picture where the positions of the man

and woman are completely reversed. Based on what the first

picture evokes, one might conclude that this second one,

representing the opposite state of affairs, would evoke an

interpretation like: "Here the woman is finally portrayed

holding the more powerful of the two roles; she is watching over

the man who is in turn relying on her for her strength." But

that doesn' t necessarily happen. A new interpretation is made,

al1 right, but it is, like the first, consistent with the

assumption that sexism is omnipresent. This time: "The man is

depicted as setting the direction, leading the way. The woman,

on the other hand, is in her "proper" place, that is, behind the

more powerful man."

These two scenarios are intended to illustrate how background

assumptions can work to make basically the same thing - draw the same conclusions - out of radically different states of affairs. The paradigm is a powerful thing. It has a profound ability to

manipulate what it sees. And this it can do so even to the

point of fabricating sameness out of antithesis - sexism out of

antithesis.

3. The case of Pierre Rivière: 14 This third example comes from Foucault, Pierre Rivière was a

peasant who, in 1835, committed parricide, killing his mother,

sister and brother. While detained he wrote a mernoir recounting

particulars of his life and explaining the crime he comrnitted.

His memoir, however, led to disputes, being as it was

interpreted differently by different groups. On the one hand,

there were the doctors who concluded Rivière was mad, his memoir

providing unequivocal evidence to this end. The lawyers, on the

other hand, drawing upon the same memoir, reasoned he was sane.

The doctors emphasized the strangeness of his behavior while the

lawyers imputed full responsibility to Rivière for his actions.

In other words, the memoir (the evidence) was looked upon as

proof for two fundamentally opposed sets of conclusions. It

spoke entirely differently to the two paradigms.

So m u a . . . . . . for the independence of things l i k e facts, evidence, S t a t e s

of affairs, data (etc. ) , and hence, the phenornena they

ostensibly represent. So much for the autonomy of "objective"

criteria standing for things. So much for what Feyerabend

refers to as the "autonomy principle"'5. For the horizontalist,

facts (etc.) do not stand alone. They are not given. They make

no noise unless evoked by a paradigm. And when evoked, they

speak with a paradigmatic voice.

"There are no f acts, only interpretations . ,16 Facts (etc. ) are paradigmatically laden, and thoroughly sa.

TEE SOCIAL CONSTRUCTION OF TflïNGS

To begin, here is a taste of what two horizontalists - Nietzsche and Rorty - have to Say about reality and our p p p p p p p p p p p p p p p - p - - - - - - - - - - - -

- -

relationship to it. First:

Nietzsche

Nietzsche writes:

Have you not heard of that madman who lit a lantern in the bright morning hours, ran to the market place, and cried incessantly: '1 seek God! 1 seek God!'...'Wither is God?' he cried; '1 will tell you. Ne have k i l l e d him - you and 1. Al1 of us are his murderers. But how did we do this? . . . Who gave us the sponge to wipe away the e n t i r e horizon? . . . God is dead. God remains dead. And w e have killed him . . . There has never

17 been a greater deed ... But he also writes that we have not yet conquered Godf s shadow".

Our long-standing belief in God has had a powerful influence on

us, one w e have no t f u l l y escaped. W e s t i l l funct ion a s i f

the re were t ranscendent t h ings t o t h i s world we l i v e i n . W e

hold ont0 values t r e a t i n g them a s i f they were fundamental t o

the way th ings are and should be. W e seek and propound purpose

t o t h i s world, and search f o r an underlying order t o it. But

the re are no fundamental va lues , t h e r e is no purpose, the re is

no order. "The way" according t o za ra thus t ra lg , 'that does no t

e x i s t . W e t h ink t h a t as s c i e n t i s t s w e have escaped the i n £ luence of

God's shadow. But t h i s too i s f a l l a c i o u s . T o espouse the

o b j e c t i v i t y of sc i ence i s t o be t r ay a lingering metaphysical

f a i t h i n t r u t h e t e r n a l , a f a i t h which r e l i g i o n s share and which

l i nks t r u t h t o d i v i n i t y . But i f God does n o t exist, t r u t h

e t e r n a l does not e x i s t e i t h e r .

So w e must l e t it go. We must l e t t r u t h expire . W e must

expel God's shadow once and for a l l .

This rneans accepting t r u t h f o r what it r e a l l y i s , which i s

nothing more than

A mobile army of metaphors, metonyms, and anthropomorphisms - i n sho r t , a sum of human r e l a t i o n s , which have been enhanced, transposed, and embellished p o e t i c a l l y and r h e t o r i c a l l y , and which a f t e r long use seem firm, canonical , and ob l iga to ry t o a people: t r u t h s are i l l u s i o n s about which one has fo rgo t ten t h a t t h i s i s what they are ; metaphors which a r e worn out and without sensuous power; co ins which have l o s t t h e i r p i c tu re s

21 and now matter on ly as metal, no longer as coins.

I t means accept ing t h a t t r u t h i s nothing more than s o c i a l

const ruct ion, i t s o r i g i n s gene ra l l y f orgo t t en .

And since t h i s is a l 1 t r u t h is , we can c r e a t e the t r u t h s we

want. Why, f o r ins tance , should we be t i e d t o c e r t a i n

mora l i t i e s? Nietzsche f inds what he terms "s lave moral i ty" -

t he moral i ty of C h r i s t i a n i t y - p a r t i c u l a r l y d i s t a s t e f u l . I t has

debased humanity . Human passion, c r e a t i v i t y , magnificence -

these have all been stifled. The morality of Christianity has

ruled for two thousand years and it has achieved nothing,

nothing but mediocrity that is.

Nietzsche wants those of us who can to let it go and to

replace it with his own "master morality." But he knows that is

a burdensorne thing to do. Itrs burdensome to see the world f o r

what it really is - a human fabrication. To repudiate the

inertia of 2000 years of Christianity, to see it as unnecessary?

What a scary thought!** Only the strongest among us c m do this.

So he calls for the superman who can throw out the old, build

and build again the new, and do so making no appeal nor claims

to finality. While the weak pursue shelter within the confines

of commonality and (presumed) eternal morality and truth, while

they live in bad faithz3, the superman shakes free, pursues

his/her own ends and effects hidher own becoming. 2 4

Rorty

Rorty raises a number of related concerns. Put briefly, he

talks about:

1. The Liberal Ironist: Nietzsche calls for the superman;

Rorty calls for the "liberal ironist". Like the superman, the

liheral i rmis t I-s-happy-te embrace khê ambigukty -of exi-sten~~,

and to realize that there is nothing essential about the way

things are. Unlike the superman, the liberal ironist champions

l i be ra l democracy. Rorty thinks liberal democracy is the best

thing going (although there is no transcendental justification

for it). Nietzsche hates liberal democracy - he's of the

opinion that it perpetuates weakness and normality.

But let's dwell on the similarities between the two. By

'ironistr Rorty means

... the sort of person who faces up to the contingency of his or her own most central beliefs and desires - someone sufficiently historicist and nominalist to have abandoned the

i d e a t h a t t h o s e c e n t r a l beliefs and d e s i r e s r e f e r back t o something beyond the reach of t i m e and chance. 2 5

The i r o n i s t i s someone who recognizes t h a t

t h e r e i s no th ing deep down i n s i d e us except what w e have put t h e r e ourse lves , no c r i t e r i o n t h a t we have n o t c r ea t ed i n the course of c r e a t i n g a p r a c t i c e , no s tandard of r a t i o n a l i t y t ha t i s not an appea l t o such a c r i t e r i o n , no r i go rous argumentation t h a t i s n o t obedience t o our own convention. 2 6

There is no t r u t h except t h a t which w e have c r e a t e d .

So on what basis does t h e l i b e r a l i r o n i s t condemn repugnant

t h i n g s l i k e the Holocaust and t h e Naz i regime? On what b a s i s

does s/he r epud ia t e oppression, t o r t u r e , murder? C e r t a i n l y not

by appeal ing t o something divine, abso lu t e o r necessary. Such

t h i n g s do not e x i s t . The i r o n i s t recognizes t h a t h i s / h e r only

refuge a r e t h e values s /he , a s a rnenber of a community, has corne

t o p r e f e r . A l 1 we can do as i r o n i s t s i s compare our own c u l t u r e

and va lues \ \ i n s id ious ly w i th o the r s by r e f e r ence t o our own

s tandards" . 27

One might s a y Rorty is e t h n o c e n t r i c . Well he i s , and he

admits it. 2 8

And from a ph i l o soph ica l po in t of view, t h i s i s a l 1 ve ry

i r r i t a t i n g :

Rorty d iv ide s philosophy i n t o t r anscenden ta l philosophy and 2 9 e m p i r i c i s t phi losophy. The fo rmer i s represen ted by t h e

P l a t o n i s t s whi le t h e l a t t e r i s represen ted by t h e p o s i t i v i s t s .

They a r e d i s t i n c t i n t h a t P l a t o n i s t s a r e metaphysica l ly

o r i en t ed . P l a t o n i s t s a r e a f t e r t r u t h s t h a t t r anscend what

sc ience can r e v e a l . P o s i t i v i s t s , on t h e o t h e r hand, s ee sc ience

as t h e f i n a l r e cou r se . Science d e a l s with t h e ( a l b e i t

temporary) f a c t s of t h i s world, which, p o s i t i v i s t s i n s i s t , i s

a l 1 t h a t can be done. But both s ee themselves as seeking t r u t h ,

not producing i t . They bo th want t h i n g s (our c u l t u r e , f o r

i n s t a n c e ) " to be guided, cons t ra ined , not left t o its own

de vice^."^' Get t ing a t the t r u t h o f t h i n g s g i v e s us that

guidance.

But t h e l i b e r a l i r o n i s t s ays t he r e i s no necessa ry t r u t h t o be

found. There is no "the way t h e world i s . "31 Hence, there is

nothing beyond us t o he lp us g e t on with l i f e . W e on ly have

each o the r , Our community and the t r u t h s w e c r e a t e and dec ide t o

che r i s h . That which w e c r e a t e goes a l 1 the way d o m s o t o 3 2 speak. There is nothing deeper t o t h e worfd, The l i b e r a l

i r o n i s t i s cap t i va t ed by no i l l u s i o n s : t h e r e i s nothing b u t t h a t

which w e c r e a t e .

2 . Science a s a Tool: Drawing on the work of James and Dewey,

Rorty argues t h a t t r u t h is whatever we decide works f o r u s .

Drawing on t h e work of Heidegger, Rorty s t r e s s e s t h a t ne are not

detached observers , but a r e f i rs t and foremost beings-in- the-

world; we a r e coping beings. Truth i s not t r u t h because it

corresponds to some e t e r n a l r e a l i t y . I t i s t r u t h because 'lit

j u s t p l a i n enables us t o tope- ,/ 3 3

It i s w i t h t h i s i n mind t h a t we should understand s c i e n c e .

Science i s simply one more coping s t r a t e g y - al though i t may

seem t o be a good one - a t our d i sposa l . That i s all.

Philosophy has revered it making it t h e model t o which a l 1 forms

of i n q u i r y should conform. But there i s no j u s t i f i c a t i o n f o r

t h i s . I t i s one among innumerable cont ingent vocabu l a r i e s

a v a i l a b l e t o u s . Physics, f o r example, i s a con t ingen t

i n t e r p r e t i v e endeavor: "After each pedes t r i an pe r i od of

science, [physicists] dream up a new model, a new p i c t u r e , a new

vocabulary, and then they announce t h a t t he t r u e meaning o f the

Book [of Nature] has been discovered. ''34 They begu i l e thernselves

i n t o t h ink ing something l i k e " t h i s t ime werve f i n a l l y got Nature

r i g h t . " I n t h e p r a c t i c a l sense they may be r i g h t - now t h e y can

more effectively cope with Nature in ways they deem important;

in the sublime sense, however, they are delusional.

This means there is no reason to presume Galileo discovered a

way to go about things that corresponds more accurately with the

way the world i s than Aristotle's way. What Galileo did do was

"hit upon a tool [a vocabulary] which happened to work better

for certain purposes than any previous tool. " And \\ [O] nce we

found out what could be done with a Galilean vocabulary, nobody

was much interested in doing the things which used to be

done. . . with an Aristotelian vocabulary . "35 As such, we lost

interest in what Aristotle had to offer. Its role as a tool

became obsolete.

3. New Language, New Garne, New Reality: Wittgenstein compares 36 language to a game . His point is that when we are speaking a

language, we use words in much the sarne way that we use, for

example, the pieces in a chess game. Consider the game of

chess. The meaning of any piece (pawn, queen, king, knight)

ernerges entirely £rom the role it has in the game. The same

holds for the words of any language. The meaning of any word

(or concept) makes sense only in light of how it is used in a

particular language. Words derive their meaning not by virtue

of their correspondence to, nor because they stand for,

something. Their meanings are fully exhausted by their

application within the language game to which they belong.

Rorty is tired of the language garne of philosophy. It has

changed over time, but it has also remained consistent enough to

ceaselessly produce problems like "What is truth?", "What does

it mean to be a human being?", "What is the essence of human

nature?", "How can we best represent reality?", etc. It has

obsessed over the mind as the mirror of nature. And it has done

so to no avail. There has been no pay off. So he feels it's

time to let these problems go, tirne to be practical for once.

Rorty suggests t ha t w e t r y t h ink ing i n a new way, one t h a t

al lows us t o "ignore t h e apparen t ly f u t i l e t r a d i t i o n a l

quest ions . "37 He urges t h a t we " s t a r t a f r e s h ~ ' ~ ~ , t h a t we s e t about

c r e a t i n g new vocabularies i n which such problems do no t emerge - i n which they have no meaning. J u s t l i k e d i f f e r e n t background

b e l i e f s h igh l igh t d i f f e r e n t t h ings (da ta , s t a t e s of a f f a i r s ,

e tc . ) , di f f e r e n t vocabularies g ive r i se t o d i f f e ren t problems39.

Creating new vocabularies becomes poss ib l e when w e recognize

t h e r e i s nothing e s s e n t i a l about any vocabulary (language game);

t h a t there a r e no language games o u t t h e r e t h a t speak more

adequately of t r u t h than any o the r ( s i n c e t h e r e i s no t r u t h t o

speak of anyway); t h a t each language game i s productive of i t s

o m " t ruths" . But how a r e d i f f e r e n t language games produced?

Rorty turns t o t h e l i t e r a r y c u l t u r e for answers. 4 0

Poetry and o t h e r l i t e r a r y p u r s u i t s a r e powerful genera tors of

metaphor (novel ways o f using language) . Moreover, t h e metaphor

i s a fundamental source of language game innovation and hence,

of new "truth". 4 1 Imagine, f o r example, a game of chess with

three kings. The game would not be t h e same. The same holds

f o r metaphors and language games. Sometirnes a metaphor catches

on wi thin a c e r t a i n language game. When it does, it l o s e s i t s

metaphoric q u a l i t i e s , it becomes normalized and the language

game a l t e r s . The language game becomes a (moderately? o r

r a d i c a l l y ? ) new t o o l f o r coping.

Now, one might ask whether i t is p o s s i b l e t o ever f u l l y leave

c e r t a i n problems behind. 1s it p o s s i b l e , f o r example, t o ever

succes s fu l ly c r e a t e a language game i n which t h e problems of

t r u t h and essence do not , a t some p o i n t , and i n some way,

emerge? My f e e l i n g is t h a t it i s n o t . But t h a t r s g e t t i n g a

l i t t l e ahead of things . . . 42

Reality as a social constsuct

How about a few points to help summarize where we are so f a r ?

Horizontalists hold that :

1. there is no state of a£ fairs (body of data, evidence, etc. )

that means anything on its own. It acquires meaning only when

paradigmatically imbued; thus

2. the verticalist drive for objectivity is a misguided

pursuit.

Horizontalists also claim that:

3. Truth (essence, purpose to the world, etc. ) does (do) not

exist, although we certainly have our truths; but such

4. truths are nothing more than social constructions; thus

5. there is no reason for incessantly clinging to truths that

do not work for us - that have become tired. Let's be pragmatic

(and in Nietzsche's case, egocentric) and produce those truths

that suit us best. It may be difficult to repudiate the current

and build anew, but it can be done.

. . . . . . . . . . So reality is produced. But how so?

Berger and Luckman state that "[slociety is a human product.

Society is an objective reality. Man is a social pr~duct."~'

put another way by Berger alone: "Society is a dialectic

phenornenon in that it is a human product, and nothing but a

human product, that yet continuously acts back upon its

producer . " 4 4

There is an interactive relationship between human beings and

the society of which they are a part. While society is created

by humans, while it is nothing more than a product of human

consciousness and interaction, humans nevertheless ascribe to it

something far greater than that. They reify it, they treat it

as an exalted thing - a thing transcendent. Consequently,

society becomes coercive of its creators - a force with profound

effects. Humans become victims of their own creation.

Breaking things dom, Berger and Luckman outline three moments

of social construction. These are:

1. Externalization: Externalization is the outpouring of human

beings into the world (which is accomplished through human

interaction, mental activity, physical activity, etc. ) . It is

essential that we externalize. We must fashion Our world since

w e are un£ inished beings4'. We lack a pre-established

relationship with the world, so we create our society (its

institutions, practices, values, etc. ) in an attempt to rnake up

for this lack. To get comfortable.

But we do more than just create. We also imbue our creations

with stability. We clothe them in permanence, granting them an

existence both external to, and indifferent to, us. This we do

for survival reasons. We cannot live knowing that reality is

nothing more than what we have made it . Life, Our existence -

they would have no meaning. So we disguise the contingent

origins of reality. We objectify it, deify it (through

religion, etc. ) . As Turner explains Bergerr s position:

. . . al1 reality is socially constructed, as a consequence of Man's incompleteness, but human beings require stable meanings and cannot live in permanent awareness of the socially constructed and precarious nature of everyday reality, and they are forced to clothe these uncertainties in permanent significance. The precarious nature of the continuously- socially-constructed-world is disguised by the sacred canopy of shared realities. This reality-formation is proved by

4 6 religion.

NOW, 1 should be clear that this is Berger's view, and what

Berger says is not altogether horizontalist of him. Berger

holds (with Gehlen) that it is in our nature to create in order

to redress our inherent lacks. This is too essentialist for

horizontalists like Foucault and Rorty. The former, for

example, would probably want to know how such a conception of

human nature emerged. So, while Berger marries his

horizontalism with more than a hint of verticalism, Foucault

takes things a step further by completely displacing the

meaning-giving essential human subject. For him, there is only

the socially produced subject. 4 7

Anyway, Berger's emphasis on the human need to create and

disguise evokes the second moment of social construction which

is

2. Objectification: Through objectification, the socially

constructed reality (society, institutions, etc. ) takes on a

life of its own. It then confronts the individual as a

reification external to and other than him/herself. Reality is

rendered inexorable. It takes on an appearance of finality when

it is r e a l l y a nothing more than a contingency - a human

product . Finally, there is

3. Internalization: This refers to the process of re-

appropriating reality into our own consciousness. Through

internalization, we make that which we have created an essential

part of us, a determining component of Our subjective being.

Take language as an example. Language is nothing more than a

human product, but we encounter it as an objectivity - as an

entity with a life of its own. We then internalize it and find

ourselves interacting with the world through it.

The justice system prcvides another example. From a social

constructionist point of view, it's intriguing that so many have

such faith in it. A relatively comrnon position, for exa~n~le~~,

is that, while one may not agree with the verdict decided at a

certain trial, one would never question the integrity of the

legal system as a consequence. To do so would be

insurrectionary of him/her. A certain decision rnay be faulty,

but the system - thatfs another issue, one not to be touched.

The system is essential, eternal, true, good, and it must, at

al1 costs, be upheld. To suggest otherwise ... w e l l , only an

anarchist would do that!

But the systern is not essential. It does not tap into

anything necessary about the world. It is purely a human

construct we have corne to deify for our own comfort. It could

be otherwise.

The same holds for medicine. Medicine could be otherwise.

That is, one can see

The Medical Mode1 as a Social Constrvct

... and, building on the themes of Nietzsche, Berger, Foucault and others, this is exactly what social constructionists

propound.

To explain:

I n the previous chapter, 1 outlined the characteristics of

naturalist ontology/cosmology and epistemology. Naturalisrn

constitutes the very specific verticalism of biomedicine. To

review and summarize, this means that 'the medical

profession.. .sees medical knowledge as an assernbly of "proven,

timeless objective facts"'. To continue, it means that the

rnedical world view depends on belief in a reality in which a l 1 is orderly, predictable and stable. A world in which disequilibrium is materially generated (whether by viruses, bacteria, parasites or some other cause), can be empirically observed and externally corrected . . . Above all, it is a world which is knowable, but only by those who honor the rules of the scientific method. 4 9

Moreover, according to the verticalism of medicine,

if science [is] the accurate reading of Naturef s study with eyes undistorted by social interest or cultural prejudice,

[then] medicine [is] the benevolent application of some of what ris] found there. 5 0

Now :

What 1 want to do is outline t h e assumptions of the biomedical

model itselfS1. There is definitely some overlap here, but it is

worth delineating nonetheless.

Assumption :

1. Mind-Body Dualism: The assumption, based on Descartes

conception, is that the mind and body are dichotomous phenornena.

There is no causal interaction between them. s2 This means that

the body should be treated as a thing separate from the

individual.

2. Physical Reductionisrn: Disease is a function of disordered

bodily functions. As such, disease is sought, and addressed,

within the body. Social, psychological and behavioral

dimensions are ignored.

3. The Doctrine of S p e c i f i c Etiology: Each dysfunction has a

specific biomedical cause. This assumption leads t o the "magic

bullet" approach to healing - one dysfunction, one cause, one cure. Hence the abundance of pharmaceutical solutions.

4 The Bady as-a-Machine: T h e body -is viewed a s a o m p l e x - -

biomedical machine. It is made up of parts that need, every

once in a while, to be taken in to the "repair shop. "

5. The Body is the Proper Object of Medical Regimen and

Control: It is assumed t h a t the s i c k body should be given over

to, examined and treated by, the medical establishment. Only

the establishment has access to the relevant knowledge. The

treatment regimen it recommends, therefore, should be complied

~ i t h ~ ~ .

For the horizontalist, there is nothing necessary about this

model. Consider assumption 4. The machine metaphor is

contingent. Other cultures use different ~neta~hors~~ to

understand the body, metaphors which denote different

cosmological beliefs about the world in general. The Chinese

tradition, to cite an instance, understands the body in terms of

a necessary balance between two forces in the world - Yin and

Yang. Western civilization shared a similar view of the body at

one tirne. Aristotle saw the universe in terms of harmony; Galen

saw the body in the same way, positing an essential equilibrium

between four humors within the body (which correspond to the

four elements in the world - air, water, fire and earth) . 55 For Galen, illness emerged with an imbalance among the humors.

Herer s another example:

Fleck argues that the anatomical drawings of the middle ages convey the view of the world of that period - they are about the inevitability of death, Godf s organization of nature, and the human place in the cosmos. This contrasts with modern anatornical drawings which are different in significant ways. Most importantly, the presentation of the body is now that of a mechanical ob j ect . 5 6

Different times and places, di£ ferent world views, dif ferent

metaphors - thatrs the equation. Each body description is a

metaphor for broader cosmological beliefs. It helps us deal

with the body in light of those beliefs. It corresponds to, and

adequately reflects, nothing essential about the body itself.

The machine metaphor, therefore, is but a contingent tool for

coping. The same holds for the other four assumptions of the

medical model. Hence the contingency of the medical mode1

itself.

H e a l t h , Illness and Disease as Metaphots

According to Turner, Berger (and Luchann) does not take his

own conclusions far enough. Berger talks about the social

construction of reâ l i ty , but his primary concern is with social

reality. On the other hand,

a more radical constructionist view of knowledge would Say that knowledge of al1 reality (natural and social) is socially produced. This view would be supported by, for example, the work of Ludwik Fleck.. . who demonstrated that scientific facts are the products of what he called 'thought communitiesf . This point is merely to note that Berger's radical sociology should also be applied to scientific discourses. 5 7

It should, therefore, also be applied to the discourse on

health, illness and disease.

Health, illness, disease, the body ... these are al1 socially produced. They amount to little more than symbolic

manifestations of the values, tensions and anxieties that exist

in society. One can think of them as by-products of an

antecedent socially constructed reality. By the same token,

they can also be seen as metaphors for that realityS8. Such is

the case with the "body as machine" metaphor. Such is the case

with health, illness and disease in general.

Put another way: "Discourse about illness [health and disease]

conveys a message about the whole of so~iety."~~ crawford6' argues

that health and illnesses are not objective entities. Rather,

they axe "categories of Our experience that reveal tacit

assumptions about individual and social reality'? Tapping the

meaning of health, for example, reveals key features in the

structure of social reality, and more specifically, the values

championed by the social group whose reality it is.

Crawford identifies two discourses on health. The first, more

prevalent arnong middle class persons, he calls the discourse of

"health as self control". Within this discourse, being healthy

means being fit and trim. To be so is to celebrate and exhibit

a devotion to values like discipline and being on top of things.

To let your body go is to be out of control. In Crawford' s

words, " [ t] he body and 'personal responsibilityf for health is,

1 believe, the symbolic terrain upon which the desire for

con t ro l and t h e d i s p l a y of c o n t r o l is e n a ~ t e d . " ~ ~ T h e second

d i scourse , more p r eva l en t arnong lower class persons, he c a l l s

"hea l th as r e l ea se" . This conception i s informed by d i f f e r e n t

va lues such as the a b i l i t y t o adopt a c a sua l approach t o

problems along w i t h the a b i l i t y t o do what one wants when one

wants . There is, t h e r e f o r e , nothing f ixed nor e t e r n a l about what i t

means t o be hea l t hy . Heal th iness i s both d e r i v a t i v e o f , and

symbolic o f , wider s o c i a l c ~ n c e r n s ~ ~ .

The same goes f o r both i l l n e d 4 and d i sea se . Disease

c a t e g o r i e s o f t en manifes t s o c i a l cons te rna t ions . Hyster ia is a

c l e a r example. Hys te r i a symbolizes an h i s t o r i c a l example of

p a t r i a r c h a l a n x i e t y over women' s bodies and s e x u a l i t y , both of

which were "seen as t h r ea t en ing t o the moral and s o c i a l f a b r i c

of human s o c i e t i e s . " To go on,

Soc i a l anx ie ty about s e x u a l i t y was d i r e c t e d a g a i n s t women and t h i s anx ie ty has been expressed h i s t o r i c a l l y through a variety of medical c a t e g o r i e s which pinpoint and a r t i c u l a t e the subordinat ion of women t o p a t r i a r c h a l a u t h o r i t y . . . The h i s t o r y of h y s t e r i a is probably t h e most dramatic example of

p a t r i a r c h a l medicine; it most c l e a r l y expresses t h e subordinat ion of women, t h e not ion of s e x u a l i t y a s dangerous and the n e c e s s i t y t o regulate women i n t h e i n t e r e s t s o f s o c i a l

6 5 orde r .

Condit ions such as menopause, pre-rnenstrual syndrome and

i n f e r t i l i t y a r e s i r n i l a r examples. Chapter 7 de lves i n t o t h e

s o c i a l c o n s t r u c t i o n of these "diseasesff i n more dep th .

F ina l l y , like h e a l t h , i l l n e s s and disease, t h e body is a

cons t ruc ted phenornenon. This w e have seen, but a s another

example, e ourdi eu^^ shows how t h e body iç shaped and i n sc r ibed

d i f f e r e n t l y by d i f f e r e n t c l a s s e s . The body i s t h e symbolic

t e r r a i n upon which c l a s s d i f f e r e n c e s a r e expressed. Dif f e r en t

class values and activities r e s u l t i n d i f f e r e n t b o d i l y p u r s u i t s ,

and hence, with different understandings of what the body truly

is . As Turner summarizes Bourdieuf s position:

The body. . . is the consequence of (class ) practices . For example, weight lifting articulates working class bodies, while jogging and tennis produce a body which is at ease in the middle-class milieu or habitus. Class practices are i n sc r ibed on the body, which is also a social product of special class activities . 6 7

The body, therefore, is a constructed phenomenon, a figurative

exhibition of a particular class proclivity.

Reality, society, institutional structures, the judicial

system, the medical model, the body, health, illness and disease

are al1 social constructions. There is nothing true nor

essential about any of them. Some (illnesses, for example) are

symbolic articulations of others ( firrnly held beliefs, for

example) - metaphors of justification. Al1 are contingencies.

But, as hinted at in the case of hysteria, there is more to

the equation, and its name is power.

SOCIAL CONSTRUCTION, POWER AND MEDICINE

We are not al1 equal in Our ability to socially construct.

Some have more Say than others. In f ac t , some have much more

Say than others. This seems clear upon examination of the

origins of society, its institutions, its values, laws and

ethics. These have been constructed, for example, from a

predominantly patriarchal point of view. There is no disputing

that. There have been some changes of late such that women may

have become more powerful. But they do not dominate. Nor can

we deny that, historically, women have enjoyed very little Say

in the production of reality. The male reality as objective

reality - this is what women have had to face. This is what

women have internalized.

Now to be more specific.

Medicine is a powerful constructor. Health and illness, at

least in their current formulations are, for the most part,

medically constructed realities. As Freidson puts it: "The

medical profession has first d a i m to jurisdiction over the

label illness and anything to which it rnay be attached,

irrespective of its capacity to deal with it effecti~el~"~~.

Illness is a medically constructed objectivity to which we

generally concede. It is one to which persons thus afflicted 69 feel compelled to subrnit. Thus,

by virtue of being the authority on what illness "really" is, medicine creates the social possibilities for acting sick. In this sense, medicine's monopoly includes the right to create

7 O illness as an official social ro le .

This is clear in the case of mental illness. Goffman, in his

study ~ s ~ l u m s ' ~ , finds that mental illness is a learned social

role. Once labeled ill, patients learn to comply with that

label. There is nothing inherent to the illness. It is a

medical construct full of arbitrary expectations. It is, as

previously quoted, "social through and through. . . the outcome of a web of social practices that bear their ir~t~rint."'~ But it is

perceived otherwise. It is seen a s an objective reality. Once

admitted to the hospital, the patient is expected to act

accordingly, to manifest those behaviors that go along with

his/her label. Generally the patient does. S/he eventually

internalizes what is expected of him/her. The individual

him/herself thus becornes someone new: S/he is him/herself

(re) con~tructed'~.

The same can be s a i d of blind persons . According to ~cott?~,

The disability of blindness is a learned social role. The various attitudes and patterns of behavior that characterize people who are blind are not inherent in their condition but, rather, are acquired through ordinary processes of social learning .

Blind persons acqu i re behaviors t h a t correspond t o dominant

conceptions of what i t means t o be b l ind . This means they

become h e l p l e s s , dependent, d o c i l e , serious-rninded. While b l i n d

persons may begin the rapy wi th a l t e r n a t i v e views of what it

means t o be b l ind , such views a r e d i s c r e d i t e d i n va r ious ways by

t h e prof e s s i o n a l s working wi th them. " [BI y

manipulat ing. . . rewards and punishments, workers a r e a b l e t o

p ressure t h e c l i e n t i n t o r e j e c t i n g persona1 conceptions of

problems i n favor of t h e worker' s own def i n i t i o n s of them. "75

Blindness a s dependency, d o c i l i t y , e t c . , becomes b l indness as

objectivity. The b l i n d person l e a r n s t o see it as such, t o

i n t e r n a l i z e it, t o l i v e it. L i k e t h e menta l ly il1 person, s /he

i s thus , h im/herse l f , ( re ) cons t ruc t ed .

So i l l n e s s e s a r e cons t ruc ted , and with them, il1 persons .

This i ç what l a b e l i n g t h e o r i ~ t s ~ ~ say about deviance7' and deviant

persons. For them, t h e r e is no th ing i n t r i n s i c about any deviant

behavior. Deviant behavior i s simply t h a t which t he (more

powerful i n t h e ) cornmunity has corne t o d e f i n e as dev i an t . T h e

deviant i nd iv idua l i s simply an ind iv idua l who has managed t o

commit a s o c i a l l y determined d e v i a n t a c t , and t o be ef f e c t i v e l y

labeled f o r doing so . Deviance i s a s o c i a l cons t ruc t conferred

upon c e r t a i n i nd iv idua l s . Nothing more. But t he a t t r i b u t i o n

has imp l i ca t i ons . The i n d i v i d u a l suf fers s t i g m a t i z a t i o n , i s

excluded from normal i n t e r a c t i o n s , e t c . . So s /he adap ts , and

does so more o f t e n t h a n not by conforming t o t h e community

expec ta t ion (an apparent o b j e c t i v i t y ) of what t h e dev i an t ac t

means and consequently, what s / h e i s a s a dev i an t . I n l abe l i ng

ternis, s / h e f a l l s i n t o "secondary dev ia t ion" and takes on t h e

new r o l e of "deviant" person.

Back t o medicine.

Medicine dominates over d e f i n i t i o n s of health, i l l n e s s and

d i sease . But t h e r e i s more. The medical paradigm is spreading

its wings. It is becoming the dominant world view through which

reality i tself is being understood/constructed. Some even claim

the medical paradigm is the dominant framework through which we

now organize and make sense of the world7'; that it has become

the home of "truth"; that it has achieved cosmological

ascendance. In reference to Mary Douglas, Wright and Treacher

write :

[Mlodern science and medicine can themselves be understood as cosmologies: as systems of natural symbols which we today use to make sense of the world. Modern medicine, it seems, is not simply a body of knowledge but serves as a set of categories that we use both to filter and construct our experience. 79

Biology, for example, has become "the source of models and

metaphors for twentieth-century thought . "'O But why medicine? Well, one reason may be its (until perhaps

more recently) successful claim to unadulterated knowledge, a

knowledge unaffected by the workings of everyday life. Medicine

is part of a scientific tradition that can apparently penetrate

into objective nature, that can apparently get at things as they

are "deep dom". Thus (and to re-quote) , while The priest can always be countered by advocating atheism or another religion; the [medical] expert, on the contrary, is apparently irresistible; he claims - and it is usually a he - special access to the real workings of Nature; and if he can be challenged at all, then it is only £rom within his own technical discipline and in terms of the criteria there. 8 1

The belief in medicinefs objectivity lends credence to the

medical mode1 and its particular way of seeing (more and more)

of reality.

Medicalization

"Medicalization" is the name given to the process through

which more and more of life is defined and dealt with according

to medical interpretation and practicea2. It is "the process by

which human experiences are redefined as medical problems. "83

While other societies employ religion to explain the ambiguous,

western society relies on biomedicine to fulfill this role.

Impetus for medicalization may occur when a social status does not readily fit within [western] society's cultural systems. When a status is considered ambiguous, deviant, or in some way marginal to social noms and expectations, its legitimacy is questioned, and social rules for its management are arbitrary . . . Relegating such a condition to the health care system has been one way of managing difference £rom the

8 4 nom. . . In fact, social constructionists feel that much of life has been

medicalized - that which is considered deviance in particular. At one time deviance was closely associated with sin; at a later

time it was equated with crime. But now the medical paradigm

has taken over. Now deviance is thought of more in terms of

illness than anything else. 8 5

Indeed, medicalization is an infectious thing. It makes

medical problems out of phenomena that could easily be

understood in different ways. It makes medical problems, for

example, out of what could otherwise be interpreted as social

problems . Consider ~yperkinesis~~: hyperkinesis is a medical

category used to address hyperactive behavior. It is an

individualization of a particular "disorder". But must

hyperactivity be addressed in this way? Maybe the behavior is

better understood as an adaptation to, or symptomatic of, a

"disorder" within the social situation (at home or at school,

for example)? The medical construction is not amenable to such

an interpretation. Consequently, the social aspect goes

unnoticed and remains the status quo. 8 7

Medicalization also makes medical problems out of what could

otherwise be interpreted as a "normal" occurrence. Consider 88 menopause : every woman experiences menopause sometime during

her aging process. What could be more natural? Nonetheless,

medicine treats menopause as an aberration. It treats it as an

estrogen deficiency disease or as an ovarian dysfunction

accornpanied by a variety of physical and ernotional problems.

Menopause is rendered rnedically problematic. But perhaps this

is unwarranted. Look at how other cultures treat it. Chinese

and Indian cultures, for example, see menopause as a good thing, 89 one that frees women from certain burdensome roles. (1 w i l l

examine menopause-as-disease in Chapter 6.)

Moreover, through the drive to medicalize, individual cases of

"normality" are turned into specific cases requiring medical

intervention. Consider Turner' s summary of Bakwin' s study

describing the process by which 942 of 1000 school children were

invariably recommended for tonsillectomy:

Of these children, 610 had their tonsils removed after a preliminary investigation. The remaining children were then examined by another group of physicians and 174 were selected for tonsillectomy. Another group of doctors were then asked to examine the remaining group of children and of these 99 were judged to require tonsillectomy. Yet another group of doctors were employed to examine the remaining children and nearly one-half of these were recommended for the operation. This procedure left 58 children with their tonsils still

9 0 intact.

One wonders what would have happened if the process had

continued. Perhaps no children would have been left with

tonsils intact.

To recap:

1. Medicine dominates the construction of health and illness.

2. More and more of life (and individual scenarios) is (are)

being defined in terms of the medical paradigm.

That's where we are so far. This is the horizontalist

position.

But there is more from the horizontalist position, and it is

this: medicine is an agent of social control. It functions,

perhaps subtly, in the name of social order.

One finds this phenornenon first argued by the structural

functionalist ~arsons~l who clairns that professions like medicine

functions to control deviance. Although a little deviance is a

good thing, he says (as it helps to reaf f i r r n our values), too

much deviance is a bad thing (as it can bring the systern

crashing down). So we need agents of social control to make

sure that the level of deviance in society doesnft get out of

hand . We have two such agentsg2 - the legal agencies and the medical

agencies. Both perform two functions: 1. to isolate deviants so

that the rest of the "normal" population is not infected; and 2.

to rehabilitate the deviants so they can reenter society. The

two agencies differ in the rnanner in which they exercise social

control. The former is more inclined to use force than the

latter. The latter relies more on the enactment of certain

socialized expectations. That is, when sick, w e are expected to

play out an internalized script, to take on what Parsonfs refers

to 2 s the s i x k roh. - Iil-tkis way, the individual i s e f f e c t i v e l y

dealt with, rehabilitated and returned to normal functioning.

To elaborate, according to Parsons, the sick role has two

rights and two obligations. This is how it functions as a

mechanism of social control. These are: Right 1: the individual

is not responsible for his/her ailment. Right 2: the individual

is exempt from carrying out his/her normal activities.

Obligation 1: being sick is not a desirable thing, hence the

individual is obliged to get better. Obligation 2: in his/her

attempt to get better, the individual rnust seek out competent

help, namely medical assistance, and comply with it. These four

components constitute a societally instilled rnechanism that

operates to both manage deviance (sickness) and transform it

into normality. This is essential to a society that thrives on

productivity. Society canrt have too many sick people running

(or rather, lying) around. It needs active people carrying out

their daily obligations if it is to prosper. The sick role

ensures that any individual hiatus due to illness is short and

sweet.

Parson's formulation of the sick role is one way to approach

rnedicine as a systern of social control. And it has its 9 3 problems. Another way is to see medicine as a legitimator of

dominant values in society. From this perspective, medicine

performs the ideological function, for example, of reproducing

capitalisrn by diverting attention from its evils. One way it

does this is by individualizing social problems. This I have

mentioned. However, to put it from a Marxist point of view (in

the w a y White describes it) '': The rnedical profession is seen as central to the control of labor. . .and contemporary theories of disease perforrn an ideological function in stabilizing the status quo. The dominant class supports a conception of illness as an individual phenomenon and denies the salience- ofsocial

p p p p p p p - - - - - - - - - - - - - -

structures in the production of ill-health.

The tensions of capitalisrn are ideologically veiled by medical

practice. Labor is thus fooled and appeased,

And this is accomplished at both the conceptual, as well as at

the everyday micro l e v e l - within the doctor-patient

interaction, in particular. White goes on to explain the

Marxist position, and in particular Mishlerrs findings which

describe how:

. . . doctors strip the patient's information of its social context and redefine it in terms adequate to their technological framework. . . [Tl he dialogue between the doctor and the patient is one in which the doctor asserts the primacy

of the technical and the irmnutability of the social factors that the patient thinks might be a part of their problem. 9 5

Waitzkin cornes to similar conclusions arguing that doctors

"implicitly act as agents of social control ... by rendering public issues into prioate troubles. "96 In Waitzkinf s own words :

In medical encounters, technical statements help direct patient' s responses to ob jectified symptoms, signs and treatment. This reification shifts attention away from the totality of social relations and the social issues that are often root causes of persona1 trouble. 9 7

I corne back to Waitzkin a little later ... Feminists adopt a similar position, but ernphasize instead

medicine's role in perpetuating a patriarchal society. From a

feminist point of view, medicine acts to control women and

subordinate them to patriarchal authority in dif f erent waysge . It serves to legitimate, for example, women as domestic

laborers. It, for example, treats "suburban neurosis with

valium" thus reinforcing "the traditional role of women which

they are seeking to escape. rr 99

One way medicine controls women is by defining women's bodies

from a male perspective. For instance: p p p p p p p p p - - - - - - - -

- - -

Throughout the nineteenth century medical explanations were used to subordinate women . . . [Glynaecology was used to attack the f irst wave of feminism. Obstetricians and gynaecologists located the cause of women's psychological problems in the vagina and castrated women in their thousands. 100

In particular, medicine has created numerous medical categories

such as hysteria, anorexia nervosa and agoraphobia "which both

label [women] and control them ... and which express tensions and the social relations of so~iet~.'~'~' Which, in other words,

express and embody most fundamentally, patriarchal anxieties.

Medicine has been particularly concerned with women's

sexuality. Gynecology t e x t ç l o 2 have consistently def ined normal

sexuality for women in ways quite inconsistent with womenfs

actual experiences. In the 1950s, for example, they held that

vaginal orgasms were "the appropriate re~~onse"'~~ despite their

infrequency. From this it followed that the woman' s sex drive

was inferior to the man's, which in turn supported the view that

the woman should be the more passive of the two during sexual

intercourse. Medicine, and more precisely, gynecology, thus

authorized the view of "woman as passive". Gynecology, from the

feminist point of view, was (and is) "medicine practiced on

women for the benefit of men. "'O4

Another way medicine legitimates patriarchy is by controlling

interventions into women's bodies, Medicine has taken over

women' s 'problems" like ~nenstruation'~~, PMS and menopause. It

also controls intervention into their reproductive capacities.

Childbirth, for example, is a medical concern: to let the mid-

wife handle it, to opt to give birth at home - these would be silly things for a woman to do, even dangerous. 106

Finally, medicine works to legitimate patriarchy during the

micro-interactions between doctors and their patients. The

doctor-patient interaction takes place within the context of

certain societal values and assumpti~ns. They operate on the

basis of those assumptions, and in so doing, reproduce them in

turn. This is something that Waitzkin talks about as discussed

above, although he is not specifically concerned with

patriarchy. To elaborate, he states that

In their encounters with patients, doctors may interpret personal problems and encourage individual behaviors in directions that are consistent with societyfs dominant ideologic patterns. 107

He says that doctors will,

[b] y questioning, by interrupting, and by otherwise shifting the direction of conversation from nontechnical problems to technical ones...exclude certain topics from talk and include

others. Of particular interest here are the verbal techniques that divert attention £rom sources of persona1 distress in the

108 social context.

By diverting critical attention away from the lifeworld, doctors reinforce the ideas that pattern of the lifeworld and rnay help win acquiescence to those features of the lifeworld that patients find rnost disconcerting. 109

This doctors rnay do, although they rnay do so unwittingly.

This doctors rnay also do by modifying their treatment of

certain patients. Sometimes, for example, a male doctor rnay

have a female patient who deviates £rom his particular

understanding of what a woman (her demeanor, pursuits) should be

like. When she does, things can go awry, but more to the

detriment of the patient who is dependent upon her doctor's

valuation of her.

In our society, the man-woman and the doctor-patient relationships recapitulate and reinforce each other, locking male physician and female patient in an asymrnetrical relationship - a relationship in which female patients are dependent on their male physicians' judgments about them as

110 women . When a female patient defies expectation, she in turn threatens

the (ob jectively "out there") man-woman relationship. In

consequence, the physician may react. His negative appraisal of

her rnay lead to an alteration in "the remaining exchange of

information and the delivery of health care" he provides her"'.

In this way the woman is penalized while taken for granted

values and expectations are thus affirmed.

There !

Without claiming to have done so comprehensively, there are

the Parsonian, Marxist and Feminist approaches (stressing their

horizontalism) to medicine and its role as a social control

agent. Now for one more view £rom the pen of ... Foucault

While Chomsky propounds a human nature, Foucault (to put rny

words in his mouth) asks the question: "From whence the notion

of human nature?" His first move is to historicize such

conceptions. His concern is not whether or not there is a human

nature, but rather, how it is that questions concerning human

nature emerge. This we have seen. Chomsky also thinks that

"some firm and humane concept of the human essence or human

natureuu2 is politically indispensable. It iç essential if we

are to work Our way out of Our current plight. So he looks to a

superexcellent knowledge, one that rises above the vicissitudes

of social conflict, one whose light can guide humanity in its

quest for socio-political renewal. For Foucault, there is no

such knowledge.

Foucault says "[tlhe political question . . . is not error, illusion, alienated consciousness, or ideology; it is truth

itself. Hence the importance of Nietzsche. , /113 People like

Chomsky think society is missing the mark. Some Marxists have

it that the worker is alienated in capitalist society; that s/he

is ideologically duped into supporting a system that alienates

him/her. These sentiments assume there is a natural human path

we should be following, a path from which we have severely

deviated as a society. If we could just get back on it things

would be so much better. But there is no such path for

Foucault. Right versus wrong, truth versus falsehood, good

versus evil - in the eternal sense there is no distinction between them. Truth in any form is truth produced. More

specifically, its formulation at any one time is a manipulation

in the interests of power. According to Foucault:

... w e a r e forced t a produce t h e t r u t h of power t h a t Our s o c i e t y demands, of which it has need, i n order t o func t ion : we must speak t he t r u t h ; w e a r e cons t ra ined o r condemned t o confess o r t o discover the t r u t h . Power never cea se s its i n t e r r o g a t i o n , its i n q u i s i t i o n , i t s r e g i s t r a t i o n of t r u t h : it i n s t i t u t i o n a l i z e s , p ro fe s s iona l i ze s and rewards i t s p u r s u i t . I n t h e l a s t ana lys i s , we must produce t r u t h a s w e must produce wealth, indeed w e must produce t r u t h i n order t o produce wealth i n t h e f i r s t place. 114

Truth and power a r e f i rmly l inked . Power feeds on, and is

sus t a ined and fu r the red by, t h e product ion of t r u t h . Truth i s

power extended.

Foucault performs genealogy i n h i s a t t empt t o uncover t h e

o r i g i n s of t r u t h d a i m s , t o determine why they developed a s t h e y

d id , how they were used, t o r e v e a l t h e i r l i n k s t o domination.

Genealogy d i f f e r s r a d i c a l l y from the h i s t o r i a n ' s h i s t o r y . The

genea log i s t makes no t e l e o l o g i c a l assumptions. S/he sees no

d e s t i n y t o humanity nor any purposive rnovement towards any

ul t i rna te goa l . There i s no unfolding o f t r u t h , no progress , no

un ive r sa l s . Ins tead, s /he i s concerned wi th pa ins tak ing ly

i d e n t i f y i n g t h e

acc iden t s , t h e minute dev i a t i ons - o r conversely, t h e complete r e v e r s a l s - the e r r o r s , t h e f a l s e a p p r a i s a l s , and t h e f a u l t y c a l c u l a t i o n s t h a t gave b i r t h t o those t h ings t h a t continue t o e x i s t and have value f o r us; i t i s t o d iscover t h a t t r u t h o r being does not l i e a t t h e r o o t of what w e know and what w e a r e , bu t t h e e x t e r i o r i t y of a cc iden t s . 115

Genealogy r evea l s t he contingency of t h i n g s . When t h e claim:

"Now we've f i n a l l y h i t upon t h e t r u t h ! " i s made, t h e genea log i s t

says: "Don't be deceived i n t o th ink ing t h e r e t s anything deep

about it t h i s time. Last t ime, t h i s tirne, next t i m e . . . i t ' s

doesn ' t much mat ter . Notwithstanding how good it looks , t r u t h

i s only, and always w i l l be, a product ion of circumstances.

Here, le t ' s see how t h i s t r u t h emerged ..."

The same goes for the disciplines, any discipline. Foucault

pays particular attention to the human sciences, which, he says,

have their origins in the Enlightenment drive to find more

rational ways to govern"6. They are the manifestations of "an

aàministered society in which the centralization of information

about citizens is essential for some form of social planning. "Il7

Spawned significantly by radical transitions in demography and

the rise of urban-based industrial capitalism, the Enlightenment

brought with it new govermental concerns. Before, questions

regarding the nature of the state, how to remain in power - these were the primary concerns. However, beginning in the 16th

century, the f ocus changedlla. The individual, his /her relations

with others, the individual as productive and efficient, the

surveying and management of populations - these became the new concerns . And with these concerns emerged a new power in society, one

that revolved around two distinct poles - the human species

(regulating populations) and the human body (disciplining the

individual). The power was bio-power, and it was one that

operated at al1 levels (including micro-interactions like the

doctor-patient encounter), finding extension and legitimization

through the development and consolidation of certain knowledges

and practices (through disciplines like demography, statistics,

epidemiology, psychiatry) . The central issue was how to produce an orderly society of

normalized, disciplined, productive bodies that could be put to

use in the most economic of ways possible"g. This gave rise to

a number of disciplinary technologies, technologies epitomized

by Bentham's ~ano~ticon'~~. It also gave rise to the human

sciences which specialize in identifying deviation, in

determining how pervasive it is, in managing, rectifying and

normalizing it. And this they did (and do) through developing

prescriptions on how to live, prescriptions which, through the

mechanisms of power, we internalize thus determining how we act

and what we come to see as truth. 12 1

Hence, with bio-power the human sciences spawned and/or

developed. With the human sciences, bio-power secured its hold

and flourished, flourishing into the present day.

Foucault also talks in particular about medicinefs link to

power. Turner summarizes Foucault's position on this matter

well:

To understand the nature of modern conceptions of disease, we need to look at the historical emergence of medical categories as separate and distinctive forms of discourse ... Furthermore, it is argued that medicine has its historical roots in the institutional apparatus of social control, and that rnedicine is an important part of what Foucault had in mind by the notion of micro-politics, that is foms of political practice which are decentralized and operate locally through various institutional. settings such as the anatomical theater and the medical clinic. 122

IN CONCLUSION

To be verticalist is to advance the claim that one (or one's

discipline, or onef s epistemological community) knows the way to

penetrate reality and represent it. To be verticalist is to

d a i m authoritative knowledge of the way things are. '23 1t is to

propound the claim: "This is the truth, and this is how to

access it."

There have existed different versions of verticalism.

Theological, philosophical, mythical and scientific verticalism

are examples. The medical version is a sub-formulation of the

latter, and it dominates today. This is what horizontalists

claim. But horizontalists also see medicine as just one more

language gante, j u s t one more discourse formulation, just one

more paradigm caught up in itself.

Medicine is social through and through. Al1 horizontalists

believe this. And they believe, rnoreover, that any label, any

condition, whether it be hysteria, agoraphobia, menopause, AIDS,

diabetes, or l e s i o n , is the construct of socio-historical

conditions. Then there are some horizontalists who propound

something even more disquieting. For them, medicine is nothing

but a contingent arrangement produced (wittingly or not) in the

interests of domination. Its labels, its medical categories,

rnoreover, are contingent tools for the purpose of control, for

the purpose of manufacturing the disciplined (efficient, normal)

individual. Given no ties to power, they Say, there would be no

biomedical "truthff as we know it today.

1 In what follows, 1 am drawing upon Rabinow's (1984) juxtaposition of

Foucault and Choms ky . See Rabinow (1984), p . 3.

Chomsky (1968), p. 100.

Chomsky (1975), p. 123.

Quoted in Ayer and Of Brady (l994), p. 88.

As Rabinow (1984) explains in his Introduction.

Other horizontalists donft even allow for its existence. Nietzsche and

Rorty are good examples, both of whom are discussed in this chapter.

8 See Sorel1 (1991), p. 33.

9 Russel (l993), pp. 528-529.

10 Barnes in Skinner (1991), p. 86.

11 Ibid, p. 92.

12 An example adapted from Longino (1990), pp. 42-43.

13 (1990), p. 43.

14 (1975).

15 (1993), p.26.

16 Nietzsche, See Ayer and O'Grady (1994), p. 318.

17 See Ibid, p. 317.

18 See Zeitlin (19941, p. 5.

19 Nietzsche's protagonist in Thus Spake Z a r a t h u s t r a (1969) . 20 See Raymond (1991), p. 177.

21 See Ayer and O'Grady (1994), p. 317.

22 And it is not only Christianity that he is rejecting, but any system that

propounds a fundamental ontology. Platonism and the Forms would be another

example.

23 Sartre (1956).

24 But where does this leave us? To be strong means to self-create despite

the values, concerns, etc. of others. But doesn't that invariably lead to a

conflict of wills? To the doctrine "might is right"? And if sot doesn't

that lead us into trouble? These are just sorne of the issues that follow

£rom Nietzsche's conclusions. See Zeitlin (1994)' pp. 119 - 125, on this. 25 (1989), p. XV.

26 (1987), p. 60.

27 See Sorel1 (1991), p. 121.

28 See various selections from Rorty (1991) for pointed discussions on his

ethnocentrism.

29 (1987)' pp. 29-29 and 56-57.

30 Ibid, p. 57. Not my italics.

31 Quoted in Geras (1995).

32 Geras regarding Rorty (1995) . 33 (1987), p . 31.

34 Rorty (l982), p. 90.

35 Rorty (1989), p. 19.

36 Wittgenstein (1974) . 37 Rorty (1989), p. 9.

38 Rorty, (1991), p. 36.

39 This is one of Derrida's main themes as well. See Hoy (1991) for a

helpful introduction to Derrida. As well, see Derrida (1981).

40 (1989), p. 2 0 .

41 Ibid, p. 18.

42 See Chapter 7 on this.

43 (1967), p. 6 1 .

44 (1967), p. 1.

45 See Turner (1992), p. 113 on this.

46 Ibid, p. 117.

47 In fact, this is Foucault's major theme. His main purpose "has been to

create a history of the different modes by which, in Our culture, human

beings are made subjects." (Foucault in Dreyfus and Rabinow, 1983, p. 208).

And t h i s i s what he means by "the d e a t h of t h e sub jec t . " Foucault d i sp l ace s

t h e sub j ec t a s a determining e n t i t y .

4 8 One t h a t seemed t o predominate t h e a f t enna th of t h e O . J . Simpson c r imina l

t r i a l .

4 9 Kaufert i n Lock and Gordon (19881, p. 331.

50 Wright and Treacher ( l 982 ) , p . 4 .

5 1 A s summarized by Freund and McGuire (1995). Once again, t h i s i s from the

pe r spec t i ve of s o c i a l constructionism, and more precise ly , as Freund and

McGuire descr ibe it, c r i t i c a l sociology. One may wonder whether o r no t t h i s

d e p i c t i o n i s too extreme - a convenient f i c t i o n f o r the c r i t i c a l s o c i o l o g i s t .

52 Although, as d i scussed i n the previous chap te r , the mind is being thought

o f more and more as a bi-product of t h e brain.

5 3 Parsons speaks t o t h i s . See l a t e r i n t h i s Chapter.

54 Here t h e not ion of metaphor is t r e a t e d d i f f e r e n t l y than Rorty (1989)

treats i t . Rorty s e e s it as something novel, something which, once accepted,

once an habi tua1 p a r t of our speech and way of thinking, is no longer a

metaphor. See p. 18.

55 See White ( l g g l ) , p. 62 .

56 Ib id , p. 59 .

57 Turner (1992), p . 118.

58 One o f Mary Douglasr (1966; 1970) major themes.

59 Herz l i ch and Pierret ( l 985 ) , p . 150.

60 (1984) . p p p p p p p p p p p p p - - - - - - - - - - - - -

6r n id , -pT 627 -

62 I b i d . , p . 81.

63 Pierret cornes t o t h e same conclusion, although she i d e n t i f i e s four h e a l t h

cons t ruc t s : 1. hea l t h - i l l ne s s ; 2 . heal th- tool ; 3 . health-product; and 4 .

h e a l t h - i n s t i t u t i o n . Each construct f i t s i n to a "global system of

i n t e r p r e t a t i o n t h a t s i t u a t e [ s ] t h e ind iv idua l i n soc ie ty ( p . 1 2 ) .

64 Herz l i ch ( 1 9 7 3 ) o u t l i n e s three kinds of i l l n e s s conceptions: 1. illness as

d e s t r u c t i v e ; 2 . i l l n e s s as a l i b e r a t o r ; 3 . i l l n e s s as an occupation. The

conception adopted depends on the i nd iv idua l ' s r e l a t i onsh ip wi th soc i e ty .

E a c h no t i on of i l l n e s s "represents a s p e c i f i c view of i l h e s s , each o r i en t ed

b y d i f f e r e n t conceptions of the r e l a t i o n s of t h e individual t o soc ie ty . " (p .

128) The t h r ee conceptions of i l l n e s s , moreover, correspond t o t h r ee

coherent s t r a t e g i e s each wi th d i f f e r e n t ends: With t he f i r s t , t h e s t r a t e g y i s

not to be ill; with the second, the strategy is to be ill; with the third,

the strategy is to be a good patient.

65 Turner, (1995), p. 90.

66 (1984).

67 (1992), p. 88.

68 See Zola (1978), p. 86.

69 Although, 1 have to Say that this view ignores the potential impact of

human agency, of human defiance, etc.

70 Freidson (l97O), p. 206.

71 (1961).

72 Wright and Treacher (1982), p. 10.

73 Whatrs interesting is that the patient as mentally il1 is legitimated

through what Goffman (1961) refers to as retrospective construction on the

part of the medical s t a f f . Medical s t a f f need to justify the presence of the

patient, the label s/he has been assigned, as well as their role in dealing

with him/her: "The medical elements of the staff ... also need evidence that they are still in the trade they were trained for. These problems are eased,

no doubt unintentionally, by the case-history construction that Fs placed on

the patient's past life, that he finally became very sick, and that if he had

not been hospitalized much worse things would have happened to him ..." 74 (1969).

75 Ibid,

76 Lemert (1993), Becker (1993), and Erickson 1 9 9 3 ) - - - - - - -

- p p p p p p - - - - - - -

- -

77 And "residual deviance". This is Scheff's (1963) term for "unnamable"

instances of deviance. Mental illness i s one such instance.

78 Zola (1978); Conrad and Schneider (1980).

79 (1982), p. 6.

80 Longino (lggl), p. 163.

81 Wright and Treacher (1882), p. 6. My italics.

82 For a more complete characterization, see Zola (1978).

83 Becker and Nachtigall (l992), p. 456.

84 Ibid, p. 457.

85 Conrad and Schneider (1980) . Turner (1995) draws similar conclusions.

86 Conrad (1975).

87 The medicalization of wife abuse is another example. See Stark et al.

(1983), for example. . 88 Kaufert (1988).

See Chapter 6 for a fuller discussion.

Turner (19951, p. 42.

(1939).

see Parson (1959). Wolinsky (1980) Chapter 4, provides a good summary.

Parsons' sick sole concept does not, for example, adequately deal with

things like chronic illness, stigmas associated with certain illnesses,

impairment, etc. It is also based on the assumptions that patient help-

seeking is simple - that the patient actually willingly goes to the doctor

and does not seek help elsewhere; that patients willingly comply with

physician definitions and treatments; that physicians practice universalism

in their treatment of patients. See Galagher (1976), Ronig-Parnass (1981)'

Segall (1976) and Turner (1995: 42-45) for more detailed discussions on the

weaknesses of the sick role concept.

94 White (lggl), p . 27.

95 Ibid, p. 37.

96 Ibid, p. 38.

97 cited in Ibid, p. 38.

98 Ibid, p. 50.

99 Ibid, p. 53.

100 Ibid, p. 51.

101 Ibid, p. 57.

102 Scully and Bart (1978).

10p3pIbid,pp. 218- - - - - -

104 Ibid, p. 219.

105 Although Bransen (1992) would disagree. She argues that the

medicalization of menstruation is very much circumsribed, and the doctorrs

role limited. The degree to which it is circumscribed and the doctor's role

limited varies from genre (ways of talking) to genre. In one genre, for

example, the doctor is seen as critical. In another s/he is seen as

superf luous, etc.

106 An attitude prevalent especially in America. See discussion of childbirth

in Chapter 7.

107 Waitskin (l989), p. 224.

108 Ibid., p. 231. Not my italics..

109 Ibid., p. 232.

110 Fisher and Groce (1985), p. 346.

111 Ibid., p. 361.

112 Quoted in Rabinow (1984), p. 5.

113 Quoted in Ibid, p. 7 5 .

114 (1980), p. 93.

115 Quoted Rabinow (1984), p . 81.

116 See Foucault (1977 and 1 9 7 8 ) .

117 White (lggl), p. 66.

118 1 am drawing upon Rabinow (1984) here.

119 A necessary precursor ta capitalism, 1 should mention.

120 Foucault (1977) . Consider his description of the panopticon (p. 200) : "...at the periphery, an amular building; at the center, a tower; this tower

is pierced with wide windows that open ont0 the i ~ e r side of the ring; the

peripheric building is divided into cells , each of which extends the whole

width of the building; they have two windows, one on the inside,

corresponding to the windows of the tower; the other, on the outside, allows

the light to cross the ce11 from one end to the other. Ail that is needed,

then, is to place a supervisor in a central tower and to shut up in each ce11

a madman, a patient, a condemned man, a worker or a schoolboy. By the effect

of backlighting, one can observe from the tower, standing out precisely

against the light, the small captive shadows in the cells of the periphery.

They are like so many cages, so many small theaters, in which each actor is

alone, perfectly individualized and constantly visible. The panoptic

mechanism arranges spatial unities that make it possible to see constantly

and to recognize immediately." p p p p p p p p - - - - - - - - - - - - - - - -

12i Foücaurt Tiescribes the power process and its effects as follows: "When 1

think of the mechanics of power, 1 think of its capillary fonn of existence,

of the extent to which power seeps into the very grain of the individuals,

reaches right i n t o their bodies, permeates their gestures, their posture,

what they say, how they learn to live and work with other people" (cited in

White (19911, p. 56).

122 (1995), p. 19.

123 Derrida uses the term logocentrism in a similar way. See Fox (1994), p.

8.

CHAPTER 4

THE RELATMTY OF SOC= CONSTRUCTION: TffEORY PART I

JOURNEY NOTES Having o u t l i n e d the major t e n e t s o f t h e v e r t i c a l i s t and

h o r i z o n t a l i s t p o s i t i o n s , t h e o b j e c t i v e of t h i s chapter i s t o beg in t o devel op t he t h e o r y behind t h e consul t a t i v e approach . I t s t a r t s w i t h a demonstration of, and i n v e s t i g a t i o n i n t o t h e r a m i f i c a t i o n s o f , the fo l lowing claim:

Some things are more s o c i a l l y constructed than others. T h i s i s a c la im appropriated from ~ u r n e r ' by which I take t o mean t h a t while some th ings (such a s c e r ta in d i s ease s ) are soc ia l cons t ruc t i ons through and through ( i n t h e interests o f soc ia l o rder , for example), o t h e r s are more t r u e t o r e a l i t y - t h e y more c l o s e l y r e f l e c t t h e way r e a l i t y is, t h e way the natural i s . From t h i s I t h i n k i t is fair t o Say t h a t the degree t o which d i f f e r e n t phenomena are s o c i a l l y constructed i s r e l a t i v e . We can t he re fo re speak of the r e l a t i v i t y o f soc ia l cons t ruc t ion .

To speak of t h i s i s t o be n e i t h e r v e r t i c a l i s t i n o r i e n t a t i o n (i. e . , s t r e s s i n g t h e a b i l i t y o f some compared t o o the r s t o s ee ) , nor h o r i z o n t a l i s t i n o r i e n t a t i o n (i. e., s t r e s s i n g the omnipotence of soc ia l c o n s t r u c t i o n ) . Rather, t o speak o f such r e l a t i v i t y i s t o recognize a n i n t e r a c t i v e and dynamic r e l a t i o n s h i p between r e a l i t y and d i f f e r e n t paradigms, one t h a t v a r i e s wi th t h e s p e c i f i c phenomena under cons truct ion along w i t h the paradigm do ing the cons t ruc t i ng . Neither t h e phenomenon nor the paradigm is omnipotent, b u t then again, n e i t h e r i s impotent .

To p u t t h i s another way, the degree t o which a phenomenon is c o n s t r u c t e d d-egends on_ i_ts t rans lucen t -presencz - - iL s , wha G f - - - - -

term " t a n g i b i l i t y " - along wi th the power of t h e p a r t i c u l a r paradigm doing t h e cons t ruc t i ng t o a c t u a l l y cons t ruc t the way it would have t he phenomenon. Think of the fo l lowing metaphor: r e a l i t y and s o c i a l cons t ruc t ion are i n a t u g o f war with each o t h e r , Sometimes the former ho lds grea ter sway; a t o t he r t imes the l a t t e r predominates. O r t h i nk o f it i n t h i s way: soc ia l cons t ruc t i on t a k e s work. Some t h inqs , however, are e a s i e r t o work w i t h than o t h e r s .

The theme is the r e l a t i v i t y of soc ia l cons t ruc t ion . The p r e c i s e sub jec t mat ter f o r ana l y s i s is t h e d i s p a r i t y between medicine and t h e soc ia l c o n s t r u c t i o n i s t approach t o medicine. T h e former i s l a r g e l y v e r t i c a l i s t i n o r i e n t a t i o n claiming t h a t it h a s privileged access t o t h e way t h i n g s are wi th heal t h , illness and d i s e a s e . Heal t h , illness and d i sease are de f i ned by medic ine . The soc ia l cons t r u c t i o n i s t approach, horizon t a 1 i s t i n o r i e n t a t i o n and b lending i n various ways f e m i n i s t , Marxis t , p o s t - s t r u c t u r a l i s t , and o t h e r concerns, denies any p r i v i l ege t o

medicine. There i s no th ing unadul tera t e d / s a c r e d / p r i v i l e g e d about what med ic ine " f i n d s " and t h u s d e f i n e s a s hea l t h , i l l n e s s o r d i s e a s e . I n s t e a d , any and a l 1 d i s e a s e s are s i m p l y c o n s t r u c t i o n s of a c e r t a i n paradigma t i c p o s i t i o n tha t has m a n a g e d to achieve dominance i n our society. This does no t mean that there is no under ly inq r e a l i t y . I t j u s t means t h a t the a c t u a l wor ld we f u n c t i o n in i s s o c i a l l y c o n s t r u c t e d and c o n s t r u c t e d p r i m a r i l y from a medical p o i n t of v i e w . W e cannot escape our m e d i c a l l y constructed r e a l i t y i n such a way that allows us to see how adequate i t is t o t h e " r e a l " w o r l d . W e can only escape i n t o and c r i t i c i z e medic ine from a l t e r n a t i v e constructed r e a l i t i e s .

M y s p e c i f i c a i m is t o demonstrate t h e r e l a t i v i t y o f s o c i a l c o n s t r u c t i o n , and what such r e l a tivity l o o k s l i k e . Having done t h i s , one can n e i t h e r accept t h e medical nor the s o c i a l c o n s t r u c t i o n i s t approach i n whole. Rather , they should each be understood a s pos s ib l y having valuable c o n t r i b u t i o n s t o make, con t r i b u t i o n s which, when t a k e n toge t h e r , p o s s i b l y crea t e a more adequa t e approach t o understanding and address ing h e a l t h , i l l n e s s and d i s e a s e than e i t h e r one a lone . Taken a p a r t , b o t h g e t c a r r i e d a w a y w i t h t h e i r own p r o j e c t s , both fa11 i n t o the t rap o f p a r a d i p a t i c e x c l u s i v i t y , and no one b e n e f i t s .

INTRODUCTION

[Note: What follows is a short parable i n which three

disparate accounts of the sun are shared. While each account

may (or rnay not) resemble authentic views t h a t have existed o r

do exist, it is not my concern that they necessarily be

representat ional of such views.]

Parable: Three Views of the Sun

Three persons from d i f f e r e n t t i m e s and far o f f places suddenly

f i n d themselves on a beach together . The d a y i s warm and c l e a r ,

and t he sea is calm. They s i t w i t h each o ther i n an t i c ipa t ion

f o r they know - somehow - t h a t they have been summoned for a

purpose. Soon they find t ha t they can ta l k t o each other , th is

notwithstanding they speak d i f f e r e n t languages . S o they proceed

t o converse and do so i n an attempt t o make sense of their

mysterious encounter.

In time they n o t i c e a f i gure o f f i n the distance. They w a i t

i n s i l ence a s the f i g u r e approaches. When she arr i ve s she s i t s

with them. She then nods t o each in t u r n and introduces h e r s e l f

a s t h e I n q u i s i t o r .

Inquisitor: Welcome t o you all. Please, have some food.

She hands them each some bread and dr ink . They finish both

and f e e l rep len ished , t ranqui l and a t home.

Inquisitor: I have brought you here s o t h a t you may be

questioned. I will not keep you l o n g .

B u t the t h r e e visitors would l i k e to s tay l ong and they say

s o . T h e I n q u i s i t o r srniles.

Inquisitor: My ob j ective is simple.

The I n q u i s i t o r waits until the three repos i t i on themselves.

They are i n t r i g u e d , once again, focused. They wait for t h e

Inqu i s i t o r t o continue. She does.

Inquisitor: 1 would like for each of you to tell me what you

know about t h e Sun.

The visitors seem a little puzzled by the r e q u e s t , b u t they

see no reason not t o respond. The Inqu i s i t o r motions t o V i s i t o r

1 who begins.

Visitor 1: The Sun is that resplendent £ire up there that soars

across the sky everyday.

T h e v i s i t o r po in t s t o the sun and t h e n motions its d a i l y

rou t ine . The others follow his ges t i cu la t ions . V i s i t o r 1

cont inues .

Visitor 1: The Gods, in their magnificence, have willed it that

we should have light. So they have given us the Sun.

V i s i t o r 1 becomes s i l e n t and contemplative, and then speaks

again.

Visitor 1: For this wonderful g i f t we should be truly grateful.

Each morning the Sun God awakens to the same entrustment.

He fashions a great fire £rom an immortal flame. You can see

the fire maturing with the d a m as its rays emanate with

increasing intensity and splendor from the ends of the earth.

You can watch i t s flames gradually permeate and then break the

night . And when the fire has grown immense, its light

flooding the heavens, the Sun God lifts it into His mighty

hands and throws it westward. The distance is long and so the

Sun stays with us long, warming us, consoling us. Finally it

falls into the Abyss of the West where the Sun God catches it

and fondles it a s it slowly dirninishes once again to its

immutable essence. He then harbors the £lame through the

night while we sleep in peace, comforted in knowing that He

will, in H i s grace, awaken before long to His momentous task

once again.

The Sun God is truly benevolent.

T h e I n q u i s i t o r smiles and thanks the f i r s t v i s i t o r . She then

motions t o the second v i s i t o r . Visitor 2 is visibly i r r i t a t e d .

Visitor 2: I'm afraid 1 do not share my new friend's beliefs.

What is a l 1 this talk about "gods"? There are no "gods"!

There is only one God, and 1 cari assure you She has more

powers than any Sun god. The world is Her creation. The

stars, the Sun and moon were al1 put into motion by Her

benevolent hand. She fashioned the universe and did so

placing the Earth at the center of Her cosmos. And we - humanity - we are the object of Her omnipresent love. The

rest is in every respect tangential, supplementary to our

existence on Earth.

The sun takes its course from east to west in a perfect

circular motion while the Earth remains transfixed as its

center. We rely on the Sun to be sure. Like my friend has

said, it is a gift to us, one we cannot live without. Our

purpose is to be obedient to that which the Great One has

decreed, to progress within the bounds of spiritual ordinance.

The Sun, with its light and warmth, was created so that we

might do just that in this life.

But it is important to recognize that this is an ernbodied

life. When we die we shed our physicality and are reborn into

a new world. We are born into a world in which we need no

longer rely on the Sun, nor the rain, nor the air. This new

world, my friends, is the world of veridical life. It is the

world of life eternal for which we must al1 prepare. It is

the true home of God.

T h e Sun helps us to spiritually prepare for a glorious

rebir th by providing for essential physical needs. The sun is

a rneans to eternal rapture.

Inquisitor: Thank you. Your views are most welcome.

S h e t u r n s t o V i s i t o r 3 who is l o o k i n g a l i t t l e smug.

fnquisitor: And you, my friend, what can you tell us of the sun?

Visitor 3: Well, to begin, 1 have to admit t h a t what I have

heard here is a little too pietistic for me. In my world

t h e r e are no gods whatsoever - not even one. You want to

account for the Sun, existence, why we are here? Well, let me

give you rny account: you cannot. It is a waste of time to

think you can. The universe j u s t happened. There is no

explanation beyond that. And the Sun, the earth upon which we

live, our existence - the whole package is nothing but one grand serendipity . Now, this accident of a universe we live in holds many stars

one of which is the Sun. The earth revolves around the Sun

and not vice versa, and it does so in an elliptical fashion,

not a circular one. It may seem that the Sun is the one t h a t

is moving, but that is an illusion t h a t stems from our limited

perspective as observers here on earth.

1 can tell you more about the Sun, but before I do, I just

want to emphasize how really unnecessary it is to bekeve in

any god. 1 mean. . . The I n q u i s i t o r interrupts.

Inquisitor: 1 would ask that we stay in keeping with the subject

at hand. Can you tell us anything more about the sun?

Visitor 3: Yes. The Sun is a gaseous bal1 of fire millions of

miles from us. It is massive in that it is many tirnes g r e a t e r

than the earth in size, and yet it is t h e smallest star we

know of.

Visitor 3 is done. There is a pause w h i l e the three look to

t h e I n q u i s i t o r wi th curiosi ty. She l o o k s t h o u g h t f u l . Inquisitor: I want to thank each of you. 1 am g r a t e f u l t o you

for being so forthcoming. You have been borrowed from your

regular lives s o that 1 may be enlightened, and this has been

accomplished.

Heref s what 1 have learned f rom you. 1 see t h a t you a r e a t

variance with each o t h e r . You have each spoken of the Sun,

but i n so doing, you have rendered so much more. You have

a l s o shared accounts of your broader cosmological

understandings. There is much d i v e r s i t y between them. There

i s much d i v e r s i t y between you.

B u t t h i s i s t o be expected a s I'm su re you would agree.

There a re many generations and rnany leagues that separa te you.

You are of d i f f e r e n t worlds. T h i s i s a s p e c i a l place. Here

you can communicate w i t h each other, understand each other.

I n your worlds you cannot. You speak d i f f e r e n t languages, you

have d i f f e r e n t customs, you champion d i f f e r e n t values. I f you

were t o meet under a l t e r n a t i v e circumstances you would be

a l i e n s t o each other and perhaps even becorne enemies. Your

d i v e r s i t y would be a p o t e n t i a l source of mutual t h r e a t . 1 Say

t h i s because h i s to ry has t o l d t h e s t o r y many t i m e s ... Suddenly, the Inquisitor hesitates. She l ooks t h e m over , each

in turn. Then she continues.

Inquisitor: And yet , 1 wonder: a r e you r e a l l y so d i f f e r e n t £rom

each other? Your percept ions , your world views : are t h e y

- r e a l l y sa &ifparate?- qerkaps- tiley-are-. - Your-accoun€spof - thep

Sun would seem t o i n d i c a t e they a r e . But then ... Here. 1 have one more request of you. I would l i k e t o

probe i f 1 may. It seems t o m e t h a t you each va lue t h e Sun.

T h i s is something t o which the t h r e e of you have a l luded i f

not emphasized. Please, be succ inc t and t e l l m e why t h a t is

once again.

The Inquis i tor nods t o V i s i t o r 1.

Visitor 1: The sun provides l i g h t and warmth t o t h e ear th .

Without it we could not l i v e and grow.

Visitor 2: 1 must Say t h a t 1 agree with t h a t . The sun i s that

grea t n a t u r a l phenomenon towards which a l 1 corporeal ex i s tence

yearns. The sun g ives v i t a l i t y t o t h e physical .

Inquisitor: And you?

She l ooks t o Visitor 3.

Visitor 3: There is no denying what my two f r i ends have just

sa id . But what's as ton ish ing is t h a t t h e e a r t h happens t o be

a t exactly the r i g h t d i s tance £rom the Sun. I f t h e e a r t h were

any nearer o r further from it , w e would not exist. A s it

s tands , w e rece ive t h e p rec i se amount of heat w e need from t h e

Sun - that a l 1 th ings need, I should Say. (Although, with t h e

ozone l a y e r th inn ing the way it i s , the Sun f e e l s a l i t t l e

h o t t e r than it should a t times.)

Visitor 3 f i n i s h e s . The Inquisitor b r i n g s a n end t o her

inquiry .

Inquisitor: The sun renders warmth. The Sun renders l i g h t . T h e

Sun makes l i f e pos s ib l e . You al1 be l i eve these t h i n g s , don' t

you?

The t h r e e i n d i c a t e their agreement. They c e r t a i n l y do.

The Inquisitor then surveys her small assembly and nods one

l a s t t i m e i n thanks. And with that, the v i s i t o r s a r e gone.

She then r ises and continues on her way , her face content.

There is oneness, she thinks t o herse l f . Be i t disguised by

fundamental d i s c r e p a n c i e s , there is s t i l l oneness t o be found.

A t l e a s t with certain t h i n g s there is.. . THE OmIPOTENT SOCIAL?

1s everything pure ly s o c i a l cons t ruc t ion? Does medicine have

no foundations i n anything r e a l ? 1s i l l n e s s a fancy of the

times, a play with power? 1s it devoid of anything s u b s t a n t i a l ,

of anything deep, of anything t r u e bes ides made t r u t h ? The

emphatic h o r i z o n t a l i s t answers yes t o each of these questions.

The verticalist answers a definite no. And the consultationist?

S\he s e e s relevance to both sides.

There are degrees of horizontalism, to be sure. Many

constructionists, for example, acknowledge an underlying

biological reality. They concede there is something there,

something other than the social. Wright and Treacher write that

"[iJllnesses really do exist, but as sufferings which have no

necessary, transhistorical, universal shape ...'? Similarly,

Mishler writes that although cultural variation predominates,

"[tlhis does not mean that the same biological processes would

not be observed in different cultures, but that they will be

given different meanings. "3 Lock says the same. While she and

or don' want "to demonstrate the social and cultural character of al1 medical knowledge," Lock expla ins that they

are not denying the existence of real, painful stress and suffering. There is, of course, a biological reality, but the moment that efforts are made to explain, order, and manipulate that reality, then a process of contextualization takes place in which the dynamic relationship of biology with cultural values and the social order has to be considered. 5

Acknowledgments are made. That is not to be denied.

Moreover, there are definitely constructionists who are overtly

essentialist, granting significant weight to the biological, to

the natural. Bryan S. Turner, as shall become very evident

l a t e r in this chapter, is one such constructionist.

But 1 think is it is also fair to suggest that constructionism

can be sornewhat unilateral in its emphasis on the social as

compared to the natural. This is implied by the excerpts above,

but to elaborate, White, for example, in his "Trend Report: The

Sociology of Health and Illness" in 1991, expresses

dissatisfaction with critical sociology which he says "has not

freed itself from the clairns of medicine; it grants primacy to

the biological fact of disease and then adds the social ."6 And

White doesn't want to just add the social. He advocates,

instead, the social constructionist approach in which whether or

not something is a disease (like repetition strain injury), "or

will become a disease, is a political issue, and the outcome,

n o t o f b i o l o g i c a l factors, but social relationships."' He drawç

in particular on the work of Fleck who argues that '" [i]n

sciences, just as in art and in l i f e , o n l y that which is true t o 8 culture i s t r u e t o nature."' Not: that which is true to nature

is true to culture. In White's understanding of social

constructionism, nature is de-emphasized under the sway of the

social. Again: "[tlhe relationship of nature and society ... has moved into the center of the sociology of knowledge, with nature

l o s i n g its privileged epistemological status ."g

And it would seem that other constructionists would agree,

despite their acknowledgment of the biological. Wright and

Treacher, in their initial characterization of the social

constructionist approach, place tremendous stress on the social.

As quoted before, they Say: " [ m ] e d i c a l categories, we would

contend, a r e s o c i a l th rough and t h r o u g h ; they are the outcome of

a web of social practices and bear their irnprint."1° And they go

on to Say: " . . . e v e r y t h i n g i n medicine, however seemingly

technical or recondite, i s regarded as s o c i a l , though no t , of

course, the product of the same forxn of social practice in every

case. "'l Turner also says sornething very similar . Drawing upon

the work of Foucault, he writes:

This epistemology associated with the works of Foucault has radical implications for medical sociology. We can no longer regard 'diseases' as natural events in the world which occur outside the language with which they are described. A disease

e n t i t y i s the product o f m e d i c a l discourses which in turn reflect the dominant mode of thinking (the episteme in Foucault's teminology) within a society. 12

Now, it may be an exaggeration to Say with Fox the following:

Approaches which recognize that there is a nature, but that what is interesting about it is the way that culture uses it to create social relations, are well represented in the SHH? Here, nature is conceptualized as basically ineffectual and able to be bracketed out of the equation. Hence food taboos are seen as a consequence of cultural systems whereby nature is classified, rather than being explicatory of any 'real' danger associated with the foods themselves. 14

. . .by which, in my understanding, Fox is saying that constructionists pay lip service to nature, anà then set it

aside. That the dynamic relationship turns out to be not so

dynamic after a l l . That the relationship is more unidirectional

than any concessions would at first imply, with the social

exercising most, if not a l l , of the sway. That nature is

diminished, ignored. That, indeed, nature is forsaken in the

sweep of social constructionist analysis.

That is, it rnay be an exaggeration to conclude that social

constructionists, generally speaking, trivialize the impact of

nature to the extent that Fox suggests. There is diversity

within the paradigmatic approach, with some granting more weight

to nature than others. Nonetheless, it does seem reasonable to

conclude that £rom a social constructionist point of view

generally, whether or not something is considered a disease is

invariably a social issue. As Rosenberg summarizes it: "disease

is constructed not discovered. "15 Medical categories, moreover,

are contingent (dominant) social arrangements. They are not

adequate representations, of what is "out there".

And it seems reasonable to further characterize the

constructionist approach as calling into question any theory of

illness, and in particular, any scientif ically "correctf' theory

that claims attunernent with the natural. Such theories are

scrutinized for their social origins, which, when found, supply

constructionism with grounds to dismantle their verticalism and

any d a i m s they make to superiority. From a constructionist

point of view, any given scientific theory can be exposed for

its social origins, no matter how sound it may seem. This is

what Foucault's genealogy is a l 1 about. Sirnilarly, this is what

the "strong program" within sociology is about, a position that

holds scientific theorizing is "a social process, consequent

upon interests or non-scientif ic belief S . . . "16 . This means that

a scientific theory is just as contingent as the next (albeit a

lay) theory . "Correct" knowledges, "incorrect"

knowledges ... they al1 amount to the same thing: contingent social arrangements.

Moreover, because medicine has dominated, social

constructionism has paid particular attention to medicine and

its approach to health. And although Fox may be exaggerating

once again, there is definitely some truth to the notion that:

The sociology of health and illness has defined itself, at least in part, through its illustrations of the darker side to caring relationships. The healers are exposed as manipulative and/or oppressive characters, quick to make judgmental and moral evaluations of their patients, or as agents of a deterministic social or political system. . . [FI rom Eliot

- -

Freidscx-onwards there r a n have b e e n few passages emanatping from the pens of medical sociologists which have dwelt on the positive aspects of medical practice ...

. . .Medical sociological critiques of rnedicine articulated with a general disillusion with establishment values and centralized systems: to knock the powerful was trendy and

17 progressive.

Fox goes on to Say that, consequently, an opposition has

resulted

between medicine and health c a r e as the negative, controlling discipline, while the SHH [is] defined (and privileged) as the positive, empowering discipline - on the side of the oppressed and the vulnerable . . . [ an] opposition, which . . . variously

construct[s] a human subject which is essentialist and/or over-socialized or determined. 18

In short, it seems clear that while many constructionists

admit the presence and impact of nature (of biology, of

foundations) - while many are definitely essentialist in orientation, while many acknowledge the foundational - within

the social constructionist approach generally, the social

preponderates over the natural. The dynamic relationship is not

evidentially explored. Instead, the social is explored, and it

would seem, elevated. Moreover, claims to truth about the

natural (about the essential) are challenged and invariably

rendered social contingencies.

My concern, therefore, is to assess very specifically the

validity of this dynamic relationship between the natural and

the social that Lock, Wright and Teacher and others acknowledge,

and to explore, further, what it means both epistemologically

and ontologically to take this relationship seriously. Such an

exploration, I feel, will lead to conclusions that differ

notably £rom those which follow from the constructionist

approach (although not so much that social constructionism does

not figure), as well as radically £rom those which follow from

the anti-foundationalist position, a position that pays no heed

to nature whatsoever, that has no interest in making any avowals

to foundational impact.

Anti-foundationalism, I should make clear, is distinguished

from constructionism by virtue of its disavowal of ontology - of

any concrete prior-to-social reality. Turnerf s distinction is

helpful :

For the sake of clarification, we can say that constructionism is a position within the sociology of knowledge, which claims that our knowledge of reality is the consequence of social processes. There are no discursively autonomous and neutral 'knowledges' of the world: the most 'concrete' facts about

reality are social constructs. Ariti-foundationalism is a form of social ontology which says that there are no 'thingsf or conditions which are not the product of social processes. There are no essential foundations outside ongoing social

19 processes: the most concrete things are social products.

Constructionisrn, in the ideal sense of the term, is concerned

with "knowledge of" things - how "knowledge of" is socially

formulated. Anti-foundationalism places ernphasis on the things

themselves - how the things themselves are socially constructed

Some, like ~errida~', claim there is no independent realrn beyond

that of language and signification. The Saussurian practice of

dividing reality up into signifiers and what they signify

(signif ieds) is fallacious . Everything, for Derrida, signifies . Moreover, signifiers lead to other signif iers ad infini tum.

That is our world. If you logocentricallyZ1 (vertically) think

that youf ve uncovered some impregnable f oundat ion, that you' ve

got a legitimate clah to unqualified presence, guess again: the

foundation invariably slips away. No matter how solid it may

seem at first, it does not - cannot - stand alone. It

incorporates traces from other things. It thus refers on to

other things, which in turn refer on to yet other things, which

in turn refer back again as well as on to other things . . . The world is an endless play of referral. There can be no daims to

solid presence. Presence dissolves within an infinity of

signification.

Reality is a tapestry of signifiers. This is Derridean anti-

foundationalism in brie£. Put more generally, anti-

foundationalism has it that reality itself, not just our

knowledge of it, is (completely ! ) socially determined. With

anti-foundationalism, therefore, the biological is shown little

attention beyond triviality. Ontologically, the world is

(diseases are), constructed. In contrast, with social

constructionism proper, the biological is acknowledged, but

invariably the social is privileged. Epistemologically, the

world is (diseases are), constructed.

However, as Turner goes on to Say, although we can, in

principle, distinguish between constructionism and anti-

foundationalism, it is not uncommon for them to converge. 2 2

Indeed, he feels that ''in practice, these positions are likely

to be held simultaneously. "23 Thus, when 1 refer to the social

constructionist position, 1 refer to it in the ideal type sense

as horizontalist. And 1 do so not feeling too uncomfortable

given the inclination within social constructionism to grant

primacy to the social. thus overlooking the real-social dynamic.

However, 1 do so also noting that 1 am forcing the issue

somewhat, as there is most assuredly diversity within the social

constructionist paradigm - some constructionists (that is, some more than others), do indeed acknowledge (if not truly explore),

foundational impact.

So, once again, my objective here is to investigate the

epistemological and ontological ramifications that follow from

taking the dynamic relationship between the natural (the real)

and the social seriously. Both are considered since, as will be

demonstrated, the how of "knowledge-of" and the nature of "what

is" have consequences for each other. "What is" informs

"knowledge of"; "knowledge of" inf o m s "what is" . Turner asks :

"[aire diseases merely the products of different types of

classificatory procedure? Or are diseases the effects of our

biological and physiological constituti~n?"~~ From what f ollows,

1 Say diseases are both. They are both foundational and

constructed. But there is a qualification: the extent to which

they are both varies from disease to disease. This

qualification has pivotal epistemological, and therefore

ontological, ramifications.

THE RELATMTY OF SOCIAL CONSTRUCTION

The social holds sway. That is definitely granted. But let

me ask again: does it hold al1 of the sway as the anti-

foundationalist holds? In al1 situations? And if it does not,

then how should we understand this dynamic relationship between

the biological and the social that Lock talks about? What does

such a relationship actually look like? My feeling is that

Turner provides the key to these questions when he says "1 see

no reason to doubt the proposition that the body is socially

constructed. However, some things ( 'hysteria ') may be more

s o c i a l l y constructed than others ( 'gout') . " 2 5 The objective of

this chapter is to investigate the validity of such a daim as

well as to b u i l d on, modify and extend it.

To proceed, I employ two terms as heuristic tools: 1. the

paradigm; and 2. the phenornenon.

1. The Paradigm: Kuhn was the first to popularize this term in

his seminal work, The Structure of Sc ien t i f i c ~evolutions~~,

although there was much confusion over what he actually meant by

it. Some have even claimed that he used the term in over 22

different ways2'. Later, however, he came to refer to "paradigm"

in two very distinct ways, the first of which he preferred.

This one c m be referred to as paradigm-as-achievement28. A

(scientific) 29 paradigm in this sense is an "exempiary [way] of

conceptualizing and intervening in particular empirical

contexts . "'O It is a fundamental achievement - an exemplar - that

provides criteria for dealing with new empirical situations. As

Rouse explains, accepting a paradigm is like acquiring and

applying multiple skills. It involves

applying concepts, employing mathematical techniques (not just calculating, but choosing the right mathematics, applying it correctly to an empirical situation, knowing its limitations and approximations, etc.), using instrumentation and other

apparatus, and recognizing opportunities for varying or intervening in particular theoretical or experimental situations. 3 1

It involves "understanding how to treat new situations like old

ones, to do for them what has already been done in the exemplary

case. u3*

This is the narrow sense of the term, but one which, as Kuhn

explains, was also expanded to denote 'all shared group

commitments, all components of what [Kuhn] now wish[es] to call

the disciplinary matrix. "33 This second sense of the paradigm is

the paradigm-as-set-of -shared-~alues~~, which is more global in

scope and includes a group's ideological orientation, a group's

shared set of fundamental beliefs, values, vocabulary and

standards for what constitutes a relevant problem and what its

solution should look like. It is a theoretical world view

incommensurable with others, a view that conditions the way in

which we observe and deal with phenomena.

My use of the term paradigm has similarities with Kuhn's

second use. I use it because, although Kuhn may favor the

first, it is the second that has taken off within the philosophy

of science and, more generally, as part of the horizontalist's

view of things. This view of the paradigm emerges from a

relatively common reading of Kuhn, a reading which Kuhn in many

ways rejects in his 1969 postscript to Structure, much to the

discontent of some. Alan Musgravers reaction is indicative:

Kuhnfs Postscript left me feeling a little disappointed. I find the new, more real Kuhn who emerges in it but a pale reflection of the old, revolutionary Kuhn. Perhaps this revolutionary never really existed - but then it was necessary to invent him. 35

Horizontalists like Rorty prefer the revolutionary Kuhn, the

Kuhn that says science 'creates the world it attempts to

describe"36; the one that says science does so in line with the

paradigmatic assumptions that prevail at the time. The

paradigm, in this sense, has similarities with Wittgenstein's

language games, with Rorty's related emphasis on language and

how it cannot be transcended, with Foucault's discourses, etc.

Horizontalists variously emphasize language, discourse, the

epistemes, the paradigm etc., as the frameworks that guide, if

not determine, understanding and action.

Thus, by paradigm 1 mean to denote a particular framework

within which knowing, addressing and constructing reality

occurs. The paradigm is a lens through which individuals and/or

groups see reality. It is also a tool with which individuals

and/or groups both relate to and fashion reality (and/or more

narrowly, a specific class of phenornena, such as health, illness

and disease) . But my use of paradigm is not to discount the importance of

Kuhn's first use - paradigm-as-achievement. It is not to

discount Kuhn's insight into how new situations, new problerns,

are approached, interpreted and dealt with in light of past

successes. Rather, it is to draw a distinction: Kuhn refers to

past successes as paradigms; 1 refer to them simply as

exempl ars . Moreover, I do not restrict the meaning of exemplars to that

of successes. Rather, I see them as significant experiences in

general, experiences that can, on the one hand, spawn a

paradigmatic approach and then serve as fundamental sources of

paradigmatic justification. To experience oppression in one

situation, for example, rnay lead one to understand and treat

successive situations as oppressive as well. Likewise, a

negative experience with a "minority" may lead one to harbor

prejudicial attitudes towards "minorities" in general. On the

other hand, a paradigm rnay spawn an exemplar. It rnay take hold

of a particular experience (with a minority), paradigmatically

imbue it (see it as typical in a bad way), and then treat it as

lending critical support for the paradigmatic approach

(prejudicial attitudes towards minorities). It may elevate the

experience to the status of exemplar, to the status of pivotal

paradigmatic justification.

2. Phenomenon: By phenomenon I mean simply an event, process

or thing.

REALITY AS CONSTRAINT

To suggest that some things are more socially constructed than

others means to take the dynamic relationship between reality

and social construction seriously. This in t u r n means taking

reality and its impact on the relationship seriously. And there

seem to be good reasons for doing just that. Barnes, (a

constructionist, 1 might add), thinks there are:

[I]t is important not to lose sight of the connection which does exist between knowledge and the real world .. .Hence knowledge is found useful precisely because the world is as it is; and it is to t h a t extent a function of what is real, and not the pure product of thought and imagination. mowledge arises out of our encounters with reality and i s continually subject t o feedback-correction from these encounters, as failures of prediction, manipulation and control occur. 3 7

What follows are some more reasons for taking the impact of

reality seriously.

To begin, let me ask a question: is it possible to m a k e a

boulder of a feather?

Let me be more precise in what 1 am asking: is it possible to

socially construct a feather such that it is understood, related

to, and addressed in exactly the same way that a three ton

boulder is understood, related to, and addressed? 1s it

possible to thoroughly perceive a feather and boulder in exactly

the same way? For t h e m t o have precisely the same meanings

attached to them? Perhaps it is possible. But I would suggest

that it is unlikely. 1 would suggest that it is doubtful that

any paradigm would so construct a feather. Why? Well, most

fundamentally, reality exercises constraints over how it is

understood and what is made of it. It impinges, it dernands. In

a manner of speaking, it has a say. It thus moderates the

extent to which social construction can have its way with it.

Feyerabend says that "Scientists [and, for that matter, al1

members of relatively uniform cultures] are sculptors of

reality. "38 But sculptors need materials with which to work,

otherwise they cannot sculpt. And those materials must retain

properties, otherwise they would not be materials. And those

properties must involve conditions, otherwise they would not be

properties. And those conditions must impose demands, otherwise

they would not be conditions. And those demands must constrain,

otherwise they would not be demands. Hence, social

construction, like sculpting, has its limitations, limitations

which stem directly from the stuff it is constructing.

It follows that the social construction of "feather" has its

limitations. The feather imposes certain constraints,

constraints which allow it to be constructed only so far - within certain parameters, that 1 s . Social construction can

make many things of the phenornenon "feather". It cannot,

however, make it into j u s t anything. 1 doubt - to get back to the example - that it could make of it a boulder. And if it

could, 1 doubt the construction "feather-as-boulderf' would last

very long. Both the feather and the boulder would demand

otherwise (once again, in a manner of speaking) . Their feed-

back, upon encounter, would invariably diffuse any such

construction.

Think of an even more ridiculous example, such as the making

of a rock out of a rainbow. 1s such possible? Considering the

logic presented above, 1 suggest probably not, at least as

regards a sustained construction. Reality (the rainbow and

rock) upon feedback, would demand otherwise,

Social construction orders and manipulates reality . It imbues

phenomena with meanings. But reality and its phenomena (some

more so than others - 1 get to this later) can only be

manipulated so fa r . Reality sets parameters such that social

construction does not proceed unrestrained. It may be that

some, for example, see green as a distinct color while others

see it as simply a variation on the color blue. Green is thus

categorized differently, constructed differently by different

groups or individuals. But there are restraints to its

construction, and thus, to the variation in its constructions.

Green is less likely to be categorized as a variation of red,

for example (unless those perceiving are color blind). And even

less likely is the possibility of it being categorized as a

shape, like a triangle. The fact that it remains a color and

not a shape speaks to the reality of constraint.

The fact, moreover, that different musicians' interpretations

of Pachelbel's Canon and Gigue actually sound more or less

similar, and more or less like Pachelbel's Canon and Gigue as

demanded by the score, speaks to the reality of constraint. Not

too many musicians, 1 would venture, interpret the score -

construct it - to sound like "Mary Had a Little L A . "

Longino says that 'There is "something out there" that imposes

limits on what we can say about it. ' 39 1 agree and paraphrase: There are things out there that impose l i m i t s on our

constructions of t h e m .

Now, it should be emphasized that while reality limits, the

fact that it does necessarily means that it enables as w e l l .

One cannot sculpt unless there is something (with properties,

hence conditions, hence demands, hence constraints ) to sculpt . Real i ty-as-cons training and real ity-as-enabling are two sides of

the same coin. This means, moreover, that reality is

foundational. The foundations of reality (of phenomena) may be

manipulable, somewhat vacuous at times and therefore imbuable,

but they exist nonetheless. If they did not, social

construction could not proceed: it would have nothing to grab

hold of: it would have nothing with which to play. What I am

saying is in line with Gerasr response to Rorty. He writes:

Where one view. . . is that language' s sovereignty over al1 access to the world means there cannot be a way things are just in themselves, the argument put here is that there must be a segment of the world which is already - in itself, and however we rnay then further construct or conceptualize that world - structured, sornewhat stable and dif£erentiated. Otherwise language across the public space with shared symbols would be impossible. 4 O

This view contrasts with the central maxim of Sartrean

existentialism: "existence before essence". By this maxim is

meant that things (existences) have their different essences

only because they are endowed (by us) with t hose essences. This

in turn means that the essences of things are without necessity

and are purely transmutable. We are free to make of things what

we wish of them. The fact that we donf t exercise this freedom

is because the prospect of the inessentiality of things is a

scary one. We think: "If things are not the way they are out of

necessity, then what is the meaning of things? Indeed, what is

the meaning of life?" We feel little comfort with such

thoughts. So we avoid thém and thus avoid Our freedom to

create.

But the question is: can we actually create in the absence of

necessity? Can we create without conditions? Analogously: can

a house be built without materials? If not, then must not those

materials have certain qualities (conditions) that allow them to

be used in certain ways ...q ualities which, if absent, would make

it impossible to build unless other materials (with related, yet

perhaps different qualities/conditions, but with

qualities/conditions nonetheless) were used? If the answer is

"yes" to this last question and "no" to the othe r s , then 1 think

it is fair to draw a few related conclusions:

The freedom to construct is impossible in the absence of (at

least sone) vestige of necessity. 4 1

Social construction is impossible in the absence of (at least

some) phenornenal foundations.

And - dealing with the existentialist claim:

The social assignment/production of essence is impossible in

the absence of (at least some) prior-to-social essence.

Foundational essence conditions constructed essence.

Think of.. . The Body as Constraint

. . . and this al1 becomes more clear. Turner helps t o make it clear.

He writes that :

[I]t would be wrong to construe my sociology of the body as merely a social constructionist viewpoint ... 1 do not believe that rea-ty-is discourse, that is, 1 da not- beLieue t h a t - -

- - - - -

social reality is merely an issue of representation. 4 2

Horizontalism, speaking ontologically, says that is al1 reality

is. This we have seen. It also says that is al1 the body is.

Foucault, in particular, rejects the objectivity of the body and

maintains that the body is nothing but a product of knowledçe,

or rather, that it Y s an effect of practices which embody such

f orms of knowledge. " In particular, Foucault' s

... research fis] concerned with how 'bodies' are produced by discourses and his primary theme Lis] the normalization of the body and populations by the social sciences and the institutions which [articulate] scientific knowledge. 4 3

Turner is not about to reject the impact of knowledge,

discourse, social construction, practices, or what have you.

Their role is profound and he knows it. He insists that the

body is more than a social product. The body has organic

foundations. It has objectivity. It has actuality. The body

is a concrete potentiality that is socially/culturally

elaborated in different ways. In his words, " [tlhe body

provides the foundational potentialities upon which endless

cultural practices can be ere~ted."~~ So the body is both

foundational and anti-foundational; it is both natural and

cultural; it is both objective and constructed.

Take walking or any of the other basic "body techniques" such

as sitting, standing, gesticulating. From culture to culture

one can observe variations in the ways in which people

walk/sit/stand/gesticulate. Walking etc. 'are developed modes

of operation which are specific to given cultures"45. And as

such, they are social constructions. But that is not al1 they

are. Far from it. Remove their organic foundations and what do

you have left? Nothing. Walking, sitting, etc., are better

understood as elaborations on certain commonalties - on certain

foundational (biological) potentialities, that is.

Take sex differences. Turner writes that

. . . even if sexuality is produced by classificatory systems, it still seems to me that male and female bodies are organically, physi~logically~ biochernically different phenomena. 1 know there are problems in classifying biological sex differences. Biological difference is socially produced by the endless reproduction of human beings, but the classificatory systems can be seen as reflections upon differences in natural

46 phenomena.

Classifications produce. Different classifications produce

differently. Thatfs aàmitted. But it is also the case that

different classifications are variations on a foundational

distinction located at the organic level. Natural sex

differences constitute t he potentiality - the stuff - upon which

social construction erects its var ied elaborations of sex

differences. Without the natural, classification could not

ensue. Thus, while there is "a lot of theorizing [that]

entirely emphasizes classificatory processes", the question is:

"classification of ~hat?"~' There needs to be something there,

sornething real to construct, to classify.

Finally, take birth and death. Both are social processes.

Both are elaborated in myriad ways. And yet both are processes

common to us all. They are foundational to us all. The

diversity of social practices associated with them speaks to the

power of social construction. The fact that every culture deals

with them in some way, however, speaks to their foundational

impact.

It also speaks to something else - it speaks to a shared human ontology . Despite the prof ound di£ ferences that exist between

us, "there are fundamental human experiences which are

transcultural or universalistic.. They rnay be addressed in

different ways. They may have different meanings attached to

them. They rnay be variously constructed. But at core, they are

universal.

To sum up: social construction is powerful, but it has no

power unless it is in some way linked to foundations. To

proceed, social construction must have anchors in the stuff of

reality . Or: to work, social construction must have anchors in the

stuff of reality.

Or: to enable coping (coping with nature for example), social

construction must have anchors in t he stuff of reality (of

nature).

This means that coping is possible only because the social has

some attunement with the foundational. And it is for this

reason that I would suggest that a purely pragmatist, or purely

antirepresentationalist, or purely horizontalist approach is

lacking. Rorty says that the pragmatist "drops the notion of

truth as correspondence with reality altogether, and says that

modern science does not enable us to cope because it

corresponds, it just plain enables us to What I am

suggesting is that there is no coping unless there is (at least

some) correspondence with reality. Why? Because coping requires

that there be something with which to cope, which means that

there must be demands with which to work, and thus constraints

within which to innovate. There can be no coping unless coping

is tied in sorne way to, is prernised upon some understanding of,

corresponds to some degree to, the way things are.

Think of it this way. The only reason a sculptor can chisel a

piece of marble is because by doing sor s/he is addressing, upon

impact, sornething essential about the way marble is - the way marble breaks, for example. Indeed, the very act of using a

chisel to chip away rnarble implies some attunement on the part

of the sculptor with this very aspect of marble. Why? Because

if there were no such attunement on the part of the sculptor,

then the sculptor would perceive no distinction between

chiseling marble and chiseling water, for instance. Moreover,

we can be sure that upon taking the chisel to both marble and

water, the sculptor would become immediately attuned to an

essential difference between the two - to an essential

difference between how they each "break". Hence, coping entails

attunement - if only to some extent (if only to the extent of being able to distinguish between the breaking of marble and the

"breaking" of water) .

And to continue: why is it that a sculptor is able to make

"better" chisels (chisels more adequate to the task of chipping

marble)? 1s it not because, upon encounters with the marble - upon blows and chipping - the sculptor becomes more in tune with the way marble breaks? And even perhaps why it breaks the way

it breaks? Indeed, it would seem that the very act of designing

better chisels necessarily involves greater attunement with the

way marble breaks.

The sculptor copes (chisels), therefore, by virtue of (some)

attunement with the foundational (with the way rnarble breaks).

And the sculptor creates better chisels by virtue of greater

attunement with the foundational (with the way marble breaks).

No f oundations, no demands, no coping whatsoever . Coping

entails working within constraints and this in turn entails

attunement with the way things are (if only in some way and to

some degree) . It, rnoreover, entails the prospect of

correspondence, of representation. This becomes more clear with

the following. . . The Impact of Phenomenal Tangibility

Reality cons t ra ins soc ia l cons t ruc t ion . Reality enables

social cons t ruc t i on .

Organic foundations cons t ra in the soc ia l cons truct ion o f the

body. Organic foundations enable t h e soc ia l cons truct ion o f the

body*

That' s where we are so far . But thatr s just the beginning.

This picture needs to be modified somewhat for it is not

complete. In the first place, the power of t h e paradigm t o

construct needs t o be re-emphasized. In the second place, the

power of r e a l i t y t o cons train /enable needs t o be qualified. Let

me proceed with the latter modification first.

It begins as follows:

The power t o cons t ra in /enab le is n o t uni form across phenomena.

Hence t h e relativity of the social cons t ruc t ion of phenomena.

To explain, 1 would like to introduce a new analytical tool,

namely the term tangibility. The sway of social construction is

affected by what is real, and more specifically, by the

tangibility of what is real. The tangibility of a phenomenon

refers to the extent to which the independent-of-social-

"whatness" of a phenomenon is indisputably clear and obvious.

It therefore refers to the extent to which it constrains.

Complete tangibility (full constraint) is never achieved (as

discussed later). But the degree to which it is achieved is

critical in that the ambiguity of a given phenomenon has

consequences for its elaboration. Put another way, the clarity

and "liveliness" (to use Hume's terni in a modified way) of a

phenomenon acts very much like an anchor, reducing in proportion

to its weight as a tangible (constraining) phenomenon, the

degree to which social construction goes about constructing

it ... although . . . (to continue modifying)

. . . this implies a negative linear relationship between tangibility and social construction: the less tangible the

phenomenon (the less it constrains), the more it is socially

constructed. This is fallacious since it means that the

greatest degree of social construction occurs where there is no

tangibility (where there are no constraints) - where there is no

link to what is real. And that is impossible. Links to reality

are essential to social construction. This has been discussed.

So what 1 would like to suggest instead is the following: social

construction is greatest when it concerns semi-tangible (semi-

constraining) phenomena.

(If ve emphasized suf f iciently the relationship between

tangibility and constraint, 1 presume) .

1 suggest this because high degrees of tangibility mean less

latitude for social construction - tangible phenornena are more obvious about what they are; they are more demanding.

Similarly, with zero tangibility social construction is

paralyzed. In this case there is nothing to grab ont0 - there is no basis upon which to create; there a re no demands

forthcoming. With semi-tangibility, however, the condition is

set for extensive (and creative) social construction. The

demands are there but they are very indeterminate, highly

negotiable, extrernely supple.

A n analogy may help:

Imagine a c l a y a r t i s t who we w i l l c a l 1 Sandy, and who, on one

o c c a s i o n i s p r e s e n t e d w i t h a p i e c e o f c l a y . From a f a r , Sandy

l o o k s a t i t o b s e r v i n g i t s d i m e n s i o n s and p o t e n t i a l f o r

m a n i p u l a t i o n . She t h e n p r o c e e d s t o p i c k i t up, and much t o her

d i s s a t i s f a c t i o n , f i n d s t h a t i t i s a hardened p i e c e and t h a t i t

h a s a l r e a d y seen the k i l n . Sandy p u t s i t down and d e s p o n d e n t l y

a c c e p t s i t for what i t i s . I t s hardnes s - its t a n g i b i l i t y -

res t r ic t s Sandy from c r e a t i n g . She cou ld a t t e m p t t o f a s h i o n i t

i n her c a p a c i t y a s a c l a y a r t i s t , o r she c o u l d proceed t o smash

i t a g a i n s t the table i n f r o n t o f her, b u t would either approach

r e a l l y be t o h e r advantage? T h e e f f o r t wouldn't be worth it -

the r e s u l t s would n e v e r conform t o her p a r t i c u l a r e x p e c t a t i o n s

a s a c l a y a r t i s t .

On a n o t h e r o c c a s i o n , Sandy i s p r e s e n t e d w i t h a b u c k e t o f w a t e r

and a s p a r s e s c a t t e r i n g o f c l a y remnants . T h i s t i m e she i s

c o n f u s e d . Her r e a c t i o n : what i s t h e r e t o work w i t h h e r e ? A

very good q u e s t i o n . In t h i s case, Sandy e x p e r i e n c e s non-

t a n g i b i l i t y .

F i n a l l y , on a t h i r d o c c a s i o n , Sandy i s p r e s e n t e d w i t h what she

d e s i r e s m o s t a s a c l a y a r t i s t , a s a c r e a t o r - s o f t moldable

c lay. W i t h zea l and s k i l l , she f a s h i o n s i t t o her s a t i s f a c t i o n ,

shaping it i n conformity t o what she finds meaningful. With

semi-tangibility, Sandy finally gets her way.

In br i e f , semi-tangibility encourages social construction

because it is by definition pliant. A phenomenon with semi-

tangibility is a phenomenon profoundly amenable to social

moldability.

This means that some things are more socially constructed than

others as Turner contends. However, taking things a step

further, 1 would like to modify his contention by suggesting

that the social construction of things is curv i l i near l y r e l a t e d

t o the tangibility of those things (see Figure 1). The greater

the serni-tangibility of those things, the greater their 5 0 amenability to social construction. (Although, as will be

pointed out later in this chapter, even the most tangible things

have some construction to them - having meanings-attached. Hence why the curve is more definite with intangibility).

Revisiting the Paradigm

Now, to re-emphasize the power of the paradigm.

Tangibility is not something necessarily inherent to a

phenomenon. The extent to which any given phenomenon radiates

tangibility (exercises constraints) is in large measure - but in

no way totally - paradigmatically conditioned. The picture 1 have painted so far is one in which social

construction is seen to fil1 the voids that semi-tangibility

creates. With semi-tangibility, the paradigm latches ont0 and

molds, bends, constitutes the phenomenon to its will. But this

assumes the semi-tangibility of the phenomenon is independently

given - prior to social construction. It isdt - it isn't

necessarily, that is.

The paradigm is omnipresent. It is forever there in one form

or another like some perpetual fog, contextualizing our

observations of phenomena and constituting those same phenomena.

Figure 1: The relativity of the social construction of

phenomena. The more semi-tangible a phenomenon, the more

amenable it is to social construction.

Amenability of

Phenomena t O

Social

Construction

Low

Phenomena with: T a n g i b i l i t y Semi-

Tangibility

In-Tangibility

It forms a framework that shepherds (if not determines) both the

investigation of phenomena as well as their social construction.

This was discussed at length in Chapter 3 where it was seen that

illnesses emerge (and fully so from a horizontalist point of

view) in accordance with contextual values and anxieties.

To elaborate, it is useful to draw a distinction between

paradigmatic seeing and constructing, although they are integral

to each other.

Regarding seeing:

A helpful way to think of the paradigm is to compare it to a

lens. This is a common analogy and has been mentioned already.

The world is perceived by different people/groups through

di£ ferent lensesS1. The paradigm is the Lens through which a

group/individual sees.

As such, the paradigm conditions the tangibility of phenomena,

although it does so to some more than to others. As discussed

later in this chapter, certain phenomena (or rather, certain

aspects of phenomena) are rather universally tangible. They are

rather irresistible to any paradigm. For example, not many

would deny the hotness of a burner switched to high upon

accidentally placing a hand on it (except perhaps hot coal

walkers). Not many who would see/construct the hotness of the

burner as coldness, this notwithstanding our paradigmatic

differences. Here the hotness "burns" through the diversity of

paradigmatic fog. It constrains the paradigmatic fog.

But in general: through the paradigm, some phenomena radiate

tangibility, even translucence. Through it others are

distorted, rendered semi-tangible. Through it still others are

made intangible, hidden £rom view. Put another way: phenomena

speak out, but they speak with differing impact. Within the

paradigmatic ear some ring loud and clear, others with static,

and others not at all.

Put y e t ano the r way: a phenornenon r a d i a t e s t a n g i b i l i t y when

t h e paradigm I s i n sync with i t s phenomenal demands, i t s

c o n s t r a i n t s .

Put a f i n a l way: imagine you are enclosed i n a s p h e r i c a l

e d i f i c e of va r i ega ted g l a s s . I n some places t h e e d i f i c e is

t h i n n e r and more t r an spa ren t . I n o the r s i t is v a r i o u s l y

t h i c k e r , dense r , colored. T h i s e d i f i c e is your paradigm. What

you see through the t h i nne r , c l e a r e r s p o t s i s what's t ang ib l e t o

you. What you see through t h e rest i s v a r i o u s l y opaque -

v a r i o u s l y d i s c e r n i b l e , v a r i o u s l y muddled, va r i ous ly s e m i -

t a n g i b l e t o you. Indeed, through some s p o t s you s e e noth ing - you exper ience i n t a n g i b i l i t y .

Regarding cons t ruc t ing :

The power of t h e paradigm t o cons t ruc t is enormous.

~ u h n ' ~ , f o r example, çays that s c i e n t i s t ç a r e h a b i t u a l l y

involved i n what he c a l l s "normal science" - puzz le so lv ing

w i th in a s p e c i f i c paradigrnatic f ramework. B y t h i s he meanss3

t h a t t h e paradigm s e t s ou t t h e r u l e s , the s t anda rds and the

problems t o be solved, and t h e s c i e n t i s t , ab id ing by t h e s e r u l e s

and s t anda rds , embarks on a miss ion t o solve these problems.

What d r i v e s t h e s c i e n t i s t , what chal lenges him/her "is the

conv i c t i on t h a t , i f only he i s s k i l l f u l enough, he w i l l succeed

i n s o l v i n g a puzz le t h a t no one be fo r e has so lved o r solved so

~ e 1 1 " ~ ~ . Moreover, l i k e t he j igsaw puzzle where only one

s o l u t i o n i s acceptable , t h e s c i e n t i s t so lve s t he problem only

when h i s / h e r so lu t i on conforms t o t h e narrow expec t a t i ons of t h e

paradigm. The t r i c k i s f o r t h e s c i e n t i s t t o a r r i v e a t t h i s

s o l u t i o n , s i n c e i t is only t h e n t h a t s/he proves h i s / h e r

b r i l l i a n c e .

Normal science i s about " f i t t i n g " phenomena within the

pa rad igmat ic framework b e t t e r than anyone else has done. It is

consequently about constructing phenomena from the paradigmatic

point of view.

This we al1 do. Through Our paradigms we fashion Our world,

and we do so in different ways. Some phenomena we grab hold of

and then rnold. We understand the Sun, for example, in unique

ways. We attribute to it unique essences. Other phenornena, it

seems, we actually impute into existence. "Finding" biological

foundations for socially constructed deviance, is perhaps one

example. Then there are those phenomena we metaphorically

create. Certain phrases like " t h e is money" and "take it easy"

and "the world is an organism", are cases in point, And those

other phenomena we literally create such as technologies, 55 concrete manipulations of nature.

And once created, these phenomena become integral to each

other and to the world in which we live, thus articulatingke-

forming/shaping, indeed cons t ra in ing , the reality (paradigm)

through which further construction proceeds.

It is useful to distinguish between two types of creations to

make things a little clearer: 1. knowledge-of creations, and 2.

performance creations. The former include al1 those things that

emerge - to some extent or another - out of our attempts to

understand and address reality. Every attempt to penetrate

nature, to uncover its laws, to identify disease as they really

are, to make sense of deviance in light of illness, to confirm

that "such and suchf' is an eternal value, that it appeals to

some eternal truth - every such attempt invariably results in a phenomenal construction of one sort or another, in some degree

or another. A particular illness label like hyperkinesis is an

example of what 1 mean. The label incorporates the attempt to

deal with a particular phenomenon (hyper behavior among school

children) in a certain way (by individualizing the problem).

The latter - performance creations - include, for example, technologies. Technologies are created with the goal "to better

achievef' in mind. Some technologies are created for the sake of

achieving a more accurate understanding of what reality is al1

about. Through them, it is believed, we can penetrate the

workings of nature. Science, for instance, has manufactured an

extensive array of technologies with the aim of "getting at"

phenornena as they are in themselves. These technologies - the microscope, the ultrasound machine, etc. - are the devices through which phenornena are seen and thus understood. Other

technologies are created for the purpose of achieving greater

control and expediency. This is what Lyotard says technology is

created for. In his view, technology ernerges for the sake of

enhancing performativity - it has no necessary relationship to

truth.

Technical devices ... follow a principle, and it is the principle of optimal performance: maxirnizing output (the information of modifications obtained) and minimizing input (the energy expended in the process). Technology is therefore a game pertaining not to the true, the just, or the beautiful, etc., but to ef ficiency: a technical "move" is "good" when it does bette= md/er-expends 3 e s s energy-than another?"

Notwithstanding why they are created, however, technologies

are similar in at least two ways. In the first place, they have

roots in reality in that they are constructed out of knowledges

about reality. They have their roots in knowledge-of-reality

constructions. On the other hand, once created they have

consequences for the way in which we corne to see reality.

Whether created for the specific purpose of penetrating reality,

or for other reasons, they become part of our world. They

become part of the paradigm - itself articulated/modified/transformed by these creations - through

which reality is further understood.

Through technology, for example, the previously exceptional is

transformed into the mundane. Such is the case with artificial 5 7 heart implantation. This is Koenig's point. She begins by

quoting the New York Times which reported on February 18, 1985

that :

Though it was only the second time the Humana team performed an artificial heart implant, there was a sense of the routine. "Boy this is a du11 operation," one of the nurses who had participated in Mr. Schroederfs operations said, according to Dr. Jarvik. "That was great, " Dr. Jarvik said, "because nothing exciting is going on, there didnft seem to be any danger, any risk here."

And then says:

On reflection these remarks seem truly extraordinary. To describe the physical rernoval of a man's ailing heart and its replacement with a mechanical substitute as "routine," indeed, "just a dayf s work, " expresses something of the power of medical technology over the modern imagination.

Technology also has consequences for the way in which

inevitable processes and events are constructed. The impact of

technology on the wayç dying and death are conceptualized is a 5 8 good example. Technclogical along with pharmaceutical advances

have given physicians unprecedented "control over both the

process of dying and the timing of death. Physicians have

become the gatekeepers of dying. Death, now, "is seen as

something that can be controlled, postponed, and potentially

reversed, its timing elective, planned, and managed. This is

in stark contrast to a previous conception of death in which it

was 'looked upon as a familiar and timely "surrender of the self

to destiny". . . Dying, moreover, is something that Y s not

simply a biological "given" [anymore] but is shaped by

physiciansr interpretations of certain cues and inf~rmation"~~ - interpretations which are inf ormed by biomedicineC s cornmitment

to curative therapy and the prevalent assumption that

technological application "will r e s u l t in the alleviation of

suffering and the betterment of the world in general. "63

In short, performance creations, 6 4 along with knowledge-of

creations, condition or constrain the emergence of new

knowledge-of creations. They constitute part of the lens through

which we further see and construct that which we aim to see. In

Berger's tems, they become objectivities we internalize and

which provide the criteria upon which furthes paradigrnatic

discovery/creation of the knowledge-of type ensues.

Meanings, Seeing and Constructing

1 have stressed that things are always socially constructed:

nothing is completely immune from social construction - nothing (semi-) tangible that is. But why do I Say this? 1 Say this

because meanings are always involved with any phenomenon, no

matter how tangible the phenomencn, no matter how clearly the

phenomenon is seen for what it is. With semi-tangible

phenomena, the paradigm goes to work in full force producing

profoundly constructed realities. With tangible phenomena, on

the other hand, the paradigm is more restricted. Tangible

phenomena are bettes seen and are therefore less constructed.

They are less likely to be made into things they truly are not.

But they are socially constructed, nonetheless. Social meanings

are always attached to phenomena no matter how tangible they are

(hence why the curve is the way it is in Figure 1).

Take the Sun as an exarnple. The Sun provides light to the

earth. This aspect of the Sun is perhaps universally tangible.

Indeed, it seems impossible that this aspect could be

constructed otherwise - unless, for some reason, the sun stopped providing light and we were able to survive to witness it.

However, the light of the sun can have different meanings

attached to it. Some, for example, may view it in a positive

way. Someone lying on a beach during a well deserved vacation,

f o r example, rnay cons ide r it a b l e s s ing . Another, however,

a f f l i c t e d w i th sk in cancer due t o spending too rnuch time on t h e

beach, may harbor nega t i ve f e e l i n g s towards it . Here, d i f f e r e n t

meanings are a t t a ched t o t he same a s p e c t , an aspect t h a t i s

otherwise c l e a r l y s een from both pe r spec t i ve s .

Take ano the r example :

Both a daughter and her f a t h e r rnay be wel l aware t h a t h e r

d i r t y shoes a r e on t h e k i tchen t a b l e . They rnay bo th see t h i s

f a c t c l e a r l y . B u t t h e meanings they a t t a c h t o t h i s f a c t rnay

va ry . The former rnay s e e i t a s no b i g deal while t h e l a t t e r rnay

see it a s completely i napp rop r i a t e .

And ano the r example:

From wi th in a p a r t i c u l a r s c i e n t i f i c paradigm, it rnay seem

c l e a r how t o address a p a r t i c u l a r problem of n a t u r e . However,

for t h e neophyte and h i s mentor, the meanings t h e y a t t a c h t o the

s o l u t i o n rnay vary. The neophyte rnay a t t a c h much i n t e r e s t t o i t

while t h e mentor, having had a long and d i s t i n g u i s h e d ca r ee r ,

rnay cons ide r it t r i t e . She rnay have g r e a t e r i n t e r e s t i n new

problems, i n more cha l l eng ing problems.

I n each example, t h e phenomenon ( a s p e c t ) i s understood i n much

t h e sarne a c r o s s pe r spec t ives , o r between persons. The

phenornenon ( a spec t ) i s t a n g i b l e - seen f o r what it i s - across pe r spec t i ve s , o r between persons . Yet, t h e meanings a t t ached t o

t h i s same phenomenon ( a s p e c t ) , vary. And it i s i n t h i s way t h a t

s o c i a l cons t ruc t i on is n e c e s s a r i l y an i s s u e , no ma t t e r how

t a n g i b l e t h e phenornenon ( a spec t ) . So meanings and assumptions can i n h i b i t seeing, i n h i b i t

unders tanding a phenomenon f o r what it i s . Indeed, they can

becorne i n t i m a t e l y involved with a phenomenon, imbuing i t ,

manipulat ing it, and t h u s cons t ruc t i ng it. But meanings can

a l s o p lay a more superf luous r o l e , remaining noth ing more t h a n

meanings-attached t o t h a t which i s seen. This occurs i n the

case of tangible phenornena. And it a l w a y s occurs in the case of

tangible phenomena since meanings in one form or another are

ub iqu i tous . It is in this way that tangible phenomena are

constructed.

A final example helps summarize the main points:

Imagine a hi11 at an incline of 45 degrees. Some see this

t r u t h of the hi11 more clearly than others. Some are more

attuned to the steepness of the hi11 than others: the steepness

is more tangible to them. Consequently, they are less prone to

construct the hi11 otherwise. Those flying in an airplane

directly overhead, for example, rnay not be so attuned to the

steepness of the hill. Upon looking at it out their airplane

windows, they rnay see sornething quite contrary to the reality of

the hill. From their vantage point, it rnay not be so clear to

them what the hi11 is really like. It may be opaque to them,

semi-tangible to them. Indeed, it may not seem like a hi11 to

them at all. And so they rnay construct the hi11 accordingly - they may even flatten it.

Compare them with a group of runners making their way up the

hill. For these runners, the hi11 is indeed a hill. They are

more attuned to the steepness of the hill. Its steepness is

relatively tangible to them. And so their construction of it is

likely to be more in tune with the way things are with the hill.

From the running-paradigmatic-view, the steepness of the hi11 is

better seen and hence less constructed than it is frorn the

airplane-paradigmatic-view . Yet, within the running-paradigrn, constructions can Vary.

While being similarly attuned to the steepness of the hill, the

meanings the different runners attach to it can Vary

significantly. The stronger runners, for example, rnay attach

the meaning "welcome challenge" to the steepness of the hill.

The weaker runners, on the other hand, rnay attach to the same

aspect the meaning "unwelcome challenge." Here, they both see

its steepness, and yet attach opposite meanings to it.

Now it rnay also be that these meanings-attached become more

than that. It may be that these meanings have consequences for

how the hi11 is seen. The weaker runners may see it as steeper

than the stronger runners, and thus construct the hill. Yet,

this notwithstanding, there remains an affinity between the

weaker and stronger runners' conceptions of the hill. Although

their constructions of the hi11 may Vary frorn each other, they

share, nonetheless, an affinity they do not share with those

championing the airplane-paradigmatic construction. For al1

runners, the hi11 is a hill. It has perceivable steepness to

it.

Therefore, the hi11 is socially constructed no matter what.

It is constructed if only by virtue of having rneanings-attached.

But some constructions are more attuned to the hillness of the

hi11 than others. Some constructions, that is, are more attuned

with this particular foundational reality.

TANGIBILITY TYPES

My objective, so far, has been to build on Turner's daim that

some things are more socially constructed than others, and

further, that the extent to which things are constructed depends

upon their tangibility: the more semi-tangible they are, the

more amenable they are to social construction. This led

invariably into a discussion of the "how" of tangibility and to

the conclusion that the tangibility of a phenomenon is not

something necessarily given. It is in large measure conditioned

by the paradigm through which it is observed/constructed.

Tangibility, in other words, is a function of phenornenal-

p a r a d i g m a t i c fit, a fit that varies according to both the

phenomenon and the paradigm in question.

This done, what I want to do now is move from the relativity

of tangibility to discuss the various types of tangibility. In

my thinking, four such types are distinguishable (although, most

certainly, there may be more) : general tangibility, anomalic

tangibility, fabricated tangibility and specified tangibility.

General T a n g i b i l i t y

By "general" 1 mean "universal".

Phenornena with general tangibility are phenomena that are

(virtually) indiscriminate radiators of tangibility. They

permeate (ahost) any paradigrnatic fog. They appear focused

(basically) to any lens . They are (essentially) universally

unavoidable. 1 (qualify) for two reasons: 1. because there are

probably no phenomena perfectly tangible - social construction is always an issue; and 2. because there may be some paradigms

that are severely out of tune with them. But 1 would also

suggest that if there are, they are (invariably), only with

great - and perhaps acute - difficulty. Most, if not al1

paradigms are in tune with them ... or... ... with certain phenomenal aspects. Consider once again the

Sun. 1s there any question that the Sun provides the planet

light and warxnth? That if it were to perish, we would perish

along with it - at least in our current state of being? 1s

there any paradigm that would deny such a thing? We can make a

lot of different things of the Sun. We can socially construct

it in many ways. That is something the Inquisitor found in the

simile that began this chapter. But she also found that there

are concurrently aspects to it that seem invariable to us all,

around which our various constructions of the sun seem to

revolve. The two aspects - "provides heat" and "provides light" - seem (at least for the most part) interparadigmatically shared.

Consider the wheel. 1s there any doubt the roundness of a

wheel is what makes it useful as a wheel - that if it were

rectangular, its utility as a wheel would be diminished? And

the shadow. 1s there any doubt that a dense object placed in

front of a light castes a shadow on a nearby surface, and that

it does so every time?

The sun gives light. The roundness of a wheel is essential to

the wheel. Light on an object results in a shadow. These are

al1 tangible things, perhaps even universally so. They,

therefore, hold universal sway. They restrict what we do with

them. They ground any paradigmatic elaboration.

Thus, some (aspects of) phenomena e x e r t ( w e l l -nigh) universal

p u l l .

There are others, however, that exert more distinctive pulls -

that are more paradigmatically specific. 1 would like to

distinguish between two groups of these the first of which are

phenomena with :

Anomalic Tangibility

Let's cal1 these phenomena (or more precisely, once again,

their aspects) anomalies. Anomalies are novel ties, b u t

novelties that can cha l l enge paradigmatic e x p e c t a t i o n s . They

are instances of negative feedback, instances that can ring with

brazen clarity, that can demand with impudence, that can serve

testirnony to paradigmatic fallibility.

Every anomaly is a contravention of paradigmatic expectation.

And yet, it is for that very reason that it achieves

tangibility. As Kuhn explains, "[a]nornaly appears only against

the background provided by the paradigm. The more precise and

far-reaching that paradigm is, the more sensitive an indicator

it provides of anomaly. . . 1/65 . The more precise and far reaching

the paradigm, the more extensively the paradigm is compared with

the world; hence, the greater the likelihood that instances of

bad fit will emerge into view.

Anomalies are not necessarily threatening things. In fact,

they can be quite positive things. They can represent

opportunities for paradigmatic articulation. They can represent

puzzles one can expect to solve if one is ingenuous enough,

discrepancies one can expect to resolve in light of paradigmatic

expectations. Such anomalies are semi-tangible phenomena and

are dealt with as such. Here the paradigm dominates. It takes

these phenomena in, bandies them about, and then spits thern out

paradigmatically articulated. It makes of thern things

paradigmatically meaningful, paradigmatically tangible.

The paradigm, in other words, turns thern into phenomena with

Fabricated Tangibil i ty

On the other hand, and getting back to anomalie tangibility,

some anomalies, are not looked upon so favorably. Some are

truly irritants. And they are irritants because they challenge

the fundamental expectations of the paradigm. This is

dlsturbing and leads the defenders of the paradigm to do al1

they can to account for such anomalies without jeopardizing that

which is fundamental to the paradigm. As Kuhn explains,

defenders "will devise numerous articulations and ad hoc

modifications of their theory in order to eliminate apparent

conflict . " 6 6 To subrnit, to acknowledge the anomalies for what

they indicate, would require a reassessment of what the

defenders have corne to champion. It would jeopardize the very

foundations upon which their (normal scientific) work is based.

It would mean entertaining the severe limitations of their

paradigmatic understandings. These are tough notlons. So

attempts are made to neutralize anomalies, to assimilate thern

within (albeit modified, but not fundamentally so) paradigmatic

expectations, to fabxicate t h e m .

But not al1 anomalies can be successfully assimilated. And

the result? According to Kuhn, the result is paradigmatic

crisis leading to its invariable demise. As Barnes explains

Kuhn's position:

. . . a residue of recalcitrant anomalies may nonetheless persist and accumulate. Such a residue, growing ever larger over tirne, and growing ever more formidable as it resists attempt after attempt to re-assimilate it, may eventually prompt the suspicion that something is miss with the currently accepted paradigm, and set the stage for its demise. 6 7

These anomalies are tangible and glaringly so. They are not so

easily conformed nor ignored. Instead, this time it is the

paradigmatic view that does the conforming, or more precisely

(as Kuhn would have it) the metarnorphosing into something

altogether new.

The second group exerting distinctive pulls are phenomena with

Specif i ed Tangibility

These are phenomena that are relatively tangible to specific

parad igms . When a phenomenon has specified tangibility, it

means that there is a paradigm out there that is uniquely

attuned to its dernands, to its constraints. Certain paradigms

can be "in touch" with certain phenomena, or more accurately,

with certain phenomenal aspects.

Longino, for example, says that background assumptions \\ can . . . lead us to highlight certain aspects of a phenomenon over

others, thus determining the way it is described and the kind of

data it pro~ides."~' She contrasts her position with that of Kuhn

who argues that when an Aristotelian and a Galilean physicist

observe a swinging stone, they see d i f f e r e n t things: "the

Aristotelian sees a body falling with difficulty, a case of

constrained fall, while the Galilean sees oscillatory motion, a

pendulum. But as Longino explains, they are seeing dif ferent

aspects of the same thing:

The A r i s t o t e l i a n b e l i e v e s t h a t t h e n a t u r a l motion of a l 1 i tems (e lements) i n t h e sublunary sphere i s i n a s t r a i g h t l i n e t o t h e i r n a t u r a l p lace . This belief a b o u t mot ion determines what features o f t h e swinging stone are going t o be i m p ~ r t a n t , and c l e a r l y what is important i n t h e s i t u a t i o n is t h a t t h e s t one (whose n a t u r a l p l ace i s a t t h e c en t e r of t h e e a r t h ) even tua l l y cornes t o rest a t a p o s i t i o n which is a s c l o s e t o t h e c e n t e r as it can g e t (given t h a t it is cons t r a ined by t h e s t r i n g of chain) and hence t h a t t h e s tone , swinging, is i n a s t a t e of unna tu ra l motion u n t i l it cornes t o r e s t a t i t s f i n a l p o s i t i o n .

The Ga l i l e an , i n accounting for t h i s same phenomenon, i s

ope ra t i ng wi th t h e impetus t h e o r y of motion t h a t a l r e a d y had a theory of t h e o s c i l l a t o r y motion of v i b r a t o r y s t r i n g s . I n the c o n t e x t of t h i s t h e o r y , f e a t u r e s o t h e r t han those t h a t strike t h e A r i s t o t e l i a n become more i m p o r t a n t , i n p a r t i c u l a r t h e r e p e t i t i v e and o s c i l l a t o r y c h a r a c t e r of t h e s t o n e f s motion. I n t h i s r e spec t t h e motion of t h e s tone i s analogous t o t h a t of t h e v i b r a t i n g s t r i n g and i s g iven an analogous exp lana t ion .

Therefore,

It is no t ... necessary t o Say that t h e A r i s t o t e l i a n and t h e Ga l i l e an a r e see ing d i f f e r e n t t h i n g s . R a t h e r w e can say that they a r e s e e i n g t h e same t h i n g but a t t e n d i n g t o different

70 a s p e c t s o f i t .

Such may be t h e case wi th d i f f e r e n t approaches t o i l l n e s s .

Soc i a l c o n s t r u c t i o n i s t s may be i n touch w i t h how a c e r t a i n

i l l n e s s h a s been cons t ruc ted . Medical e x p e r t s , on t h e o t h e r

hand, rnay have s p e c i f i e d i n s i g h t s i n t o i t s b i o l o g i c a l

foundat ions . Both may be r i g h t . Both may be see ing d i f f e r e n t

a spec t s o f t h e same phenomenon.

S imi l a r l y , d i f f e r e n t paradigms rnay be i n touch with d i f f e r e n t

phenornena. Turner i s of t h e opin ion they are. He says t h a t an

i n t e r p r e t i v e socio logy is amenable t o understanding " s ickness 7 1 and i l l n e s s a t t h e l e v e l of the s o c i a l indiv idual" , whi le

Parson's s i c k r o l e t heo ry sheds l i g h t on t h e i n t e r a c t i o n between

doc to r s and p a t i e n t s . 7 2 Y e t Parson's s i c k r o l e theory f a l l s s h o r t

(a long with the i n t e r p r e t i v e approach) a s i t does not adequa te ly

address another phenomenon, namely the dominance of the medical

profession (which falls short in ways that the former two do

not). To address this, "the sociology of knowledge has proved

to be particularly important and prominent.. . "'3 Finally, to

understand macro-societal processes and the distribution of

health, neo-Marxist or political economy approaches have some

things to Say. 7 4

D i f f erent paradigms see different (aspects of) phenomena for

what they are. At least - to qual i fy - they do so potentially.

And when they do, the phenornena they see are phenomena with

specified tangibility. Thus, unlike with anomalic tangibility,

s p e c i f i e d t a n g i b i l i t y is an i n s t a n c e of p o s i t i v e f e e d b a c k . I t is

a case of mutual affinity between the paradigm and the

phenomenon (aspect). Rather than contravene paradigmatic

expectations, it conf irms them. Where there i s specified

t a n g i b i l i t y , the real-social t u g of war is replaced by a rea l -

s o c i a l embrace of unan imi ty .

Reality and the Relativity of Social Construction

There are times when my four year old son insists there are

monsters in the basement (this is 1997) . When we look together

we establish together that they are no monsters. But invariably

the rnonsters return - they return for him.

1 wonder whose conception, whose construction, whose

representation, is more in tune with the way things really are

on this matter. I would suggest mine is, and I presume most

would agree. But even if 1 am wrong and my son is right, the

same conclusion necessarily follows: one of us is less in tune

with the way reality really is on this matter; one of us is

making much more out of reality than the other.

Hence: the relativity of the social construction of reality.

Whereas Rorty writes . . .

Fossils are constituted as fossils by a web of relationships to other fossils and to the speech of the paleontologists who describe such relationships. If you canrt grasp some of these relationships, the fossil will remain, to you, a mere rock. Anything is, for purposes of being inquired into, "constituted" by a web of meanings. 7 5

... 1 would suggest not exactly. 1 would modify this by saying

instead that anything that exists is more or less constituted by

a web of meanings. In the case of fossils it may be more than

less, while in the case of other things it may be less than

more. But even where it is more than less, there always remains

some (perhaps ambiguous) hint of reality. Notice, for instance,

that in the absence of paleontologist speech, the fossil remains

a mere rock and not a rainbow.

Whereas Hacking says that ... The representations of physics are entirely different £rom simple, non-representational assertions about the location of my typewriter. There is a truth of the matter about the typewriter. In physics there is no final truth of the matter,

7 6 only a barrage of more or less instructive representations.

... 1 would modify this by saying the two situations are not entirely different - they are different in degree. Reality

constrains what we do with it. But it is not unifom in how it

constrains. There is a continuum of constraint here. Sometimes

reality speaks in a more tangible voice. Sometimes its speaks

truth about itself in ways that most, if not all, paradigms can

hardly ignore. The typewriter on the table is a relatively

tangible thing, and perhaps generally so. Can any paradigm

construct it otherwise? Perhaps. But it's unlikely, although 77

meanings will be attached to it. Other times, however, reality

speaks in a less tangible or more semi-tangible voice. When it

does, the paradigm goes to work. It imbues the ambiguous

phenornena, renders them paradigrnatically meaningful, constitutes

them, produces t h e m . Hence the barrage of representations

within physics . And yet other times - to modify even further - reality speaks

with a selective voice. It manifests specified tangibility

where a clarity equivalent to Yhere is a typewriter on the

table" is unique to a given paradigm. Thus, among the barrage

of representations within physics, there may be some that

actually conform quite nicely to reality.

Hence: the relativity of the social construction of reality.

Finally, Turner says chat "ontologies of the body tend to

bifurcate around foundationalism and anti-foundationalism". He

says that the question that divides them is as follows:

1s the fundamental nature of the body produced by social processes, in which case the body is not a unitary or universal phenomenon, or is the body an organic reality which exists independently of its social representation?

The answer, 1 think, is that reality (the body) is both

foundational and anti-foundational. It is both actual and

constructed. As Longino puts it, it is "a product of the

interaction between the external material reality that is "the

world" and our own pragmatic and intellectual [paradigmatic]

needsu7*. And the interaction is a dynamic one. Sornetimes

reality holds sway as it radiates unmistakable (anornalic,

general) tangibility. Then sometimes the paradigm holds sway as

it çoes to work on (imbues, manipulates, constructs) semi-

tangibility. Then there are those instances of close accord

between a singular paradigm and an aspect of reality by virtue

of specified tangibility.

To sum up:

There is this reality out there, but it is a mishmash of

constructions and foundations. From different paradigmatic

orientations, it consists of differently constituted things,

some of which:

Just b a s i c a l l y are the way they are (with s o c i a l meanings attached) . A r e profoundly constructed.

A r e somewha t const ructed.

Hence: the relativity of t h e social construction of reality.

Finally

From a logical point of view there doesnrt seem to be any

other viable conclusion to this matter. Consider the

alternative contention that al1 things are equally socially

constructed. There are distinct problerns with such a

contention. Most preeminently, it is impossible to take such a

contention seriously since the contention cancels itself out.

Since al1 things are equally constructed, the contention itself

is a construction on par with al1 other constructions. It,

therefore, has no serious claim to validity. In fact, the only

way to maintain its validity is to maintain that no things are

socially constructed. If the contention "al1 things are equally

socially constructed" is true - if it is itself not a construction - then it follows, by definition, that nothing is socially constructed; that al1 things just are . And this,

obviously, is false.

Hence: the relativity of social construction of reality.

SOME ADDITIONAL THOUGHTS

Before 1 go ont0 the next chapter, 1 would like to make two

additional points. The first is this:

R e l a t i v i t y i s itself a r e l a t i v e thing.

Let m e explain:

The Relativity of Relativity

The concept goes as follows.

There is an infinity of ways in which any one phenornenon can

be constructed. The relativity between the ways, however,

varies with the extent to which the phenornenon radiates general

tangibility.

Or, the affinity amongst the infinity of ways a phenornenon can

be constructed varies with the extent to which the phenomenon

radiates general tangibility.

To explain, consider the following ideal type (perhaps non-

existent) scenarios (see Figure 2) :

When a phenornenon has complete general tangibility, there is

well-nigh universal paradigmatic attunement with the phenornenon

as it-is-in-itself. Here, besides meanings-attached, the

relativity between the phenornenon's paradigmatic constructions

is nonexistent. Here the phenomenon exudes universal constraint

resulting in a basic similitude between the various

constructions (once again, excepting meanings-attached) - constructions which are really not constructions at all, but

conformities with the phenornenon as it truly is.

General semi-tangibility results in extreme relativity. Here

the diversity between paradigmatic constructions achieves its

greatest magnitude. By virtue of its universal semi-tangibility

each paradigm does with the phenomenon what it wills. Each goes

to work on the phenomenon in its own unique way. Each produces

a distinct construction, a construction very much in accordance

with its paradigrnatic expectations.

General intangibility results in hornogeneity once again. But

the reason for homogeneity, this time, is different. This time

there is nothing to construct. Whereas with general tangibility

there is constraint in the form of unquestionable presence, with

general intangibility there is constraint in the form of lack.

Figure 2 : The selativity of the relativity of the social

construction of phenomena.

Degree of

Relativity

Between

Phenomenal

Constructions

Low

General General General

Tangibility Semi- Intangibility

Tangibility

Here's another analogy t o h e l p c l a r i f y :

Upon e n t e r i n g the c l a s s r o o m , the s t u d e n t s a r e each g i v e n a

piece of c l a y . T h e pieces a r e s m a l l and r o u n d . They a r e h a r d .

L i k e Sandy's f i r s t piece they h a v e each b e e n f i r e d on the k i l n .

T h e s t u d e n t s ' r e a c t i o n s a r e c o n s i s t e n t , a l t h o u g h some a r e more

p l e a s e d t h a n o t h e r s . They r e s p o n d s i m i l a r l y . They a l 1 Say

s o m e t h i n g t o the effect of: "What can 1 t o d o w i t h this? M y

p i e c e of c l a y i s as it i s and t h a t ' s a l 1 there i s t o it. "

The n e x t d a y the same s t u d e n t s a r e g i v e n workab le clay. T h i s

t i m e the s t u d e n t s get t o w o r k , e a c h one i n t e n t on a c t u a l i z i n g t o

the best of h i s / h e r a b i l i t i e s h is /her own u n i q u e a n t i c i p a t i o n s

and s k i l l s . T h e r e s u l t i s a n a r r a y o f d i v e r s e c o n s t r u c t i o n s ,

e a c h o n e imbued w i t h u n i q u e m e a n i n g s .

T h e t h i r d d a y the c l a s s is g i v e n n o c l a y . The s t u d e n t s

c o n c l u d e t h e r e i s n o t h i n g for them t o d o . They l e a v e and go t o

an e a r l y l u n c h .

~ h u s ~ ' :

Genera l t a n g i b i l i t y g e n e r a t e s l i m i t e d r e l a t i v i t y . Genera l s e r n i - t a n g i b i l i t y g e n e r a t e s e x t e n s i v e r e l a tivity. General i n t a n g i b i l i t y g e n e r a t e s l i m i t e d ( z e r o ) r e l a t i v i t y o n c e a g a i n .

The second point i s t h a t t h e r e i s

U n i t y Amidst the Diversity

No mat te r how d i v e r s e our s e p a r a t e understandings, our

paradigrnatic views, Our cosmologies, there is , a t l e a s t with

c e r t a i n t h ings (phenornena, a s p e c t s ) , u n i t y t o be found i n what

we see , know and c o n s t r u c t . T h i s is what t h e I n t e r p r e t e r found

w i t h t h e t h r e e v i s i t o r s who agreed, d e s p i t e t h e i r d ive rgen t

cons t ruc t i ons of it, t h a t t h e sun g ives h e a t and l i g h t and i s

e s s e n t i a l t o l i f e .

What t h e I n t e r p r e t e r d i d n o t conclude, however, i s t h a t while

t h e peoples of t h e world rnay c o n s t r u c t and e l a b o r a t e i n

d i v e r s i t y - i n t h e i r diverse ways of knowing and dealing with

r e a l i t y - t h e y may also see different things for what they are,

precisely because of t he i r diversity. Anomalic and s p e c i f i e d

tangibility are possibilities for any paradigmatic view.

1 Turner (1992).

2 Wright and Teacher (1982) , p. 14. 3 Mishler (l98l), p. 142.

4 (1988).

5 (1988), p. 7.

6 p. 72.

7 p. 76. My italics.

8 p. 60. My italics.

9 p. Il. My italics.

10 (1982), p. 10; my italics.

Il Ibid; my italics.

12 (l995), p. 11; my italics.

13 SHH is the acronym for sociology of health and illness.

14 (l994), p. 14.

15 quoted in White (1991), p. 5.

16 Fox (l994), p. 15.

17 Ibid, p. 70.

18 Ibid, p. 71. It might be said that constructionism (within the sociology

of health and illness), achieves paradigmatic articulation through its

refutation of medicine. To invalidate medicine is to define and extend the

constructionist paradigm. But thatts getting a little ahead of things . . . See Chapter 5 on this.

19 (l992), p. 105.

20 (1976, 1981).

21 Derridar s word.

22 (l992), p. 105.

23 Ibid.

24 Turner (1995), p. 18.

25 (l992), p. 26.

26 (1970).

27 Hacking (1983), p. 10.

28 Ibid.

29 Science is Kthn's focus.

30 Rouse (l987), p. 30.

31 Ibid.

32 Ibid.

33 (1977), p. 319.

34 Hacking (1983), p. 10.

35 In Rouse (l987), p. 37.

36 Brown (1994), p. 33. Not my italics.

37 See Nicholson and McLaughlin.

38 (l993), p. 269.

39 Longino (IggZ!), p. 222.

40 (1995), p. 119.

41 Rorty, perhaps unwittingly, lends support to this view. If it were not

for constructions, he says, deconstruction would be impossible. He says:

"The non-Kantian knows that the edifice will itself one day be deconstructed,

and the great deeds reinterpreted, and reinterpreted again, and again. But

of course the non-Kantian is a parasite - flowers could not sprout from the

dialectical vine unless there were an edifice into whose chinks it could

insert its tendrils. No constructors, no deconstructors." (1982, p. 108)

For deconstruction to proceed, there nust be something w i t h which t o work, to

deconstruct . Well, the same holds true for construction! For construction

to proceed, there must be something w i t h which t o work, with which t o

construct .

4 2 Turner (1992), p. 41.

43 Ibid, p. 52.

44 Ibid, p. 118.

45 Ibid, p. 92.

46 Ibid, p. 256.

47 Ibid, p. 255.

48 Ibid, p. 252.

49 Rorty (1987), p. 30-31.

50 In other words: The more semi-tangible a thing, the more enabling it is.

The more tangible it is, the more restrictive is - restrictive by virtue of

its "concreteness". The more intangible beyond semi-tangible it is, the more

restrictive it is once again - restrictive by virtue of its "lackness". 51 Some of which, incidentally, are more dominant than others.

52 (1970).

53 1 am talking about the "revolutionary" K u h n now..

54 (1970), p. 3 8 .

55 Although, since every creation is understood through the paradigmatic

lens, "concrete" manipultations are concurrently metaphoric constructions.

56 (1993), p. 44.

57 (1988), p. 465.

58 Muller and Koenig (1988) .

59 Ibid, , p. 353. 60 Ibid, , p. 354.

61 Ibid,.

62 Ibid, p. 352.

63 Ibid, p. 367.

64 Daniel Bell (1974 and 1978) affords another example concerning the impact

of technology. In fact, he talks of technological determinism. Very

briefly, he sees the growth of technology as having radical consequences for

society, its n o m s and values. With the emergence of electronic technology

in particular, there takes place, for example, a societal shift from favoring

ascetic workism to championing secular hedonism. Hedonistic consumption

takes over as the nom. Moreover, the importance of obtaining knowledge - of going to university - is emphasized, thus diffusing mass production via

Fordism and similar rneans. Consequently, the middle class takes over as the

revolutionary class, displacing Marx's working class.

65 (l97O), p. 65.

66 (1970).

67 (19911, p. 91.

68 Longino (l99O), p. 216.

69 Ibid, p. 53.

70 Ibid, pp. 53 - 54; my italics. 71 Turner (1995), p. 205.

72 Turner (l992), p. 237.

73 Turner (1995), p. 208.

74 Ibid.

75 Rorty (l982), p. 199.

76 Hacking (1983), p. 145.

77 One may see it in a positive light: It's there poised for work. Another

may see it less positively: It represents work, something s/he is tired of

and wants to get away from.

7 8 Longino (19901, p. 221.

79 Although, it may be l eg i t i rna te ly asked: What about cases in-between? And

what about o u t l i e r s ? I leave such questions for fu tu re w o r k ,

PARADXGtMATIC ARTICULATION, EXTENSION AND m N S I F I C A T I O N : THEORY

PART II

JOClRBEY NOTES To Recap: The point o f Chapter 4 was t o beg in t o o u t l i n e t h e t heore t i ca l

r a t i o n a l e f o r interparadigma t i c c o l 1 aboration, e spec ia l l y between medicine and soc ia l construct ionism. Most s i g n i f i c a n t t o t h i s end was t o provide a t heore t i ca l r a t i o n a l e for t h e p o s s i b i l i t y that d i f f e r e n t paradigms can see. It was argued , moreover, tha t t h i s p o s s i b i l i t y emerges w i t h another p o s s i b i l i t y , namely, tha t some t h i n g s are more soc ia l ly constructed than o thers .

T h e chapter , however, was somewhat involved. Consider t h e fo l lowing summary for some o f the h i g h l i g h t s :

1 . Contra t h e h o r i z o n t a l i s t p o s i t i o n - and more s p e c i f i c a l l y the social c o n s t r u c t i o n i s t p o s i t i o n - there is good reason t o take t he impact o f reality s e r i o u s l y . Social cons t ruc t ion does not proceed unhindered. I t i s constrained by r e a l i t y , l i m i t e d by it, fraught with i t s demands. On t he o ther hand, i t i s by v i r t u e of such cons t ra in t t h a t s o c i a l cons t ruc t ion is a b l e t o proceed a t a l l . Social cons t ruc t ion i s not omnipotent. R e a l i t y cons t ra ins soc ia l cons t ruc t ion; r e a l i t y enables soc ia l cons t ruc t ion . The body, f o r example, both cons t ra ins and enables its social cons t ruc t ion .

2 . Some th ings a r e more s o c i a l l y constructed than o ther s . The degree t o which any phenomenon (o r phenomenal aspect) i s cons t ruc t ed v a r i e s accord ing Ca t h e e x t e n t t o which i t - - -

cons t ra ins . Put another way, phenomenal cons t ruc t ion v a r i e s according t o phenomenal t a n q i b i l i t y - t o the degree t o which the phenomenon man i f e s t s translucence.

3 . O r more accurate ly: t he more semi-tangible t h e phenomenon (or a s p e c t ) , t h e more amenable it is t o social cons t ruc t i on , The more t ang ib l e the phenomenon, the l e s s amenable it i s t o soc ia l construction and the more it i s perceived by the paradigm (doing the perceiv ing) for what i t is. The more i n tang ib l e the

phenomenon, the l e s s amenable i t is to social cons t ruc t ion given i t s absence from paradigmatic view - given i t s u t t e r lack o f cons t ra in t over t he paradigm. There is, therefore, a curv i l i near r e la t i onsh ip between t a n g i b i l i t y and social cons t ruc t ion .

4 . The degree t o which a phenomenon (aspect ) m a n i f e s t s t a n g i b i l i t y is not neces sar i l y given. I t is larqely, although no t determinably, paradigma t i c a l l y condi t ioned. Some phenomena (a spec t s ) seem t o permeate almost any paradigma t i c f o g .

5. Four t a n g i b i l i t y t y p e s a r e i d e n t i f i e d . T h e y a r e : a . phenornena (or phenomenal a s p e c t s ) wi t h g e n e r a l t a n g i b i l i t y - phenomena t h a t a r e u n i v e r s a l l y t a n g i b l e ; b. phenomena w i t h s p e c i f i e d t a n g i b i l i t y - phenomena posi t i v e l y t a n g i b l e t o s p e c i f i c p a r a d i g m s ; c . phenomena with a n o m e l i c t a n g i b i l i t y - phenomena n e g a t i v e l y t a n g i b l e t o s p e c i f i c p a r a d i g m s ; a n d d . phenomena w i t h f a b r i c a t e d t a n g i b i l i t y - phenomena r e n d e r e d p a r a d i g m a t i c a l l y t a n g i b l e .

6 . R e l a t i v i t y i s i t s e l f a re lat ive t h i n g . T h e d i s p a r i t y b e t w e e n the ways i n w h i c h a phenomenon i s v a r i o u s l y c o n s t r u c t e d v a r i e s w i t h the d e g r e e t o w h i c h the phenomenon m a n i f e s t s g e n e r a l ( u n i v e r s a l ) t a n g i b i l i t y * To Continue: T h e t h e o r e t i c a l j u s t i f i c a t i o n f o r i n t e r p a r a d i g r n a t i c

c o l l a b o r a t i o n i s f u r t h e r b a s e d upon a n e x p l o r a t i o n i n t o the paradigma tic d r i v e t o s e l f a r t i c u l a t e . Such a n e x p l o r a t i o n r e v e a l s how i t i s t h a t some t h i n g s corne t o be more s o c i a l l y c o n s t r u c t e d t h a n others.

N e e a c h f e e l a n e e d t o s o l i d i f y , i f n o t t o f u r t h e r , Our very spec i f ic ways o f k n o w i n g . W e a l 1 h a v e a n e e d t o make s e n s e of the w o r l d a t least i n some way and t o perpetuate/develop/sxpand these ways o f k n o w i n g . S o c i a l c o n s t r u c t i o n i s t s a g r e e w i t h t h i s , b u t 1 would a l s o l i k e t o i n c l u d e them under the same o b s e r v a t i o n .

T h i s d r i v e t o a r t i c u l a t e , h o w e v e r , h a s a d u a l i t y t o i t . On the o n e h a n d , i t c a n f o l l o w a n e g a t i v e p a t h , o n e t h a t l e a d s t o paradigma t i c excl u s i v i t y , e x p a n s i o n and m a s t e r y , a d r i v e I refer t o a s p a r a d i g m a t i c e x t e n s i o n . M e d i c a l i z a t i o n i s one very clear e x a m p l e o f p a r a d i g m a t i c e x t e n s i o n . S o is the s o c i a l c o n s t r u c t i o n i s t a t t e m p t t o d i s m a n t l e the m e d i c a l e m p i r e w h i l e l a y i n g o u t i t s own program ( p e r h a p s u n w i t t i n g l y s o ) a s a n a l t e r n a t i v e . On the other h a n d , the d r i v e t o a r t i c u l a t e can f o l l o w a m o r e p o s i t i v e p a t h . I t can r e s u l t i n a g r e a t e r a b i l i t y o f a n y p a r t i c u l a r p a r a d i g m t o see c e r t a i n phenomena ( o r c e r t a i n a s p e c t s t h e r e o f ) . I t can r e s u l t i n p a r a d i g m a t i c i n t e n s i f i c a t i o n . T h u s , w h i l e both m e d i c i n e and s o c i a l c o n s t r u c t i o n i s m p a r a d i g m a t i c a l l y e x t e n d , it i s p o s s i b l e t h a t they i n t e n s i f y a s w e l l . I t i s p o s s i b l e t h a t they d e l v e r e l a t i v e l y d e e p l y i n t o c e r t a i n r e a l i t i e s . 1

These, h o w e v e r , a r e i d e a l t y p e s c e n a r i o s o f a r t i c u l a t i o n t n a t p r o b a b l y d o n o t o c c u r i n i s o l a t i o n f rom each o t h e r . P e r h a p s a m o r e l i k e l y s c e n a r i o is o n e t h a t sees a m i n g l i n g o f these two p r o c e s s e s , w i t h o n e h o l d i n g more s w a y t h a n the o t h e r d e p e n d i n g on the n a t u r e o f the phenomenon i n v o l v e d . I f s o , t h e n t h e p a r a d i g m becomes a n e n t a n g l ed h o d g e p o d g e o f i n t e r c o n n e c t e d i d e a s t h a t r a n g e from r e l a t i v e l y p u r e r e f l e c t i o n s of r e a l i t y t o v e r i t a b l e c o n s t r u c t i o n s .

T h i s i s c r i t i c a l t o the o v e r a l l p r o j e c t o f e s t a b l i s h i n g the u t i l i t y o f i n t e r p a r a d i g m a t i c c o m m u n i c a t i o n , e s p e c i a l l y b e t w e e n m e d i c i n e and social c o n s t r u c t i o n i s m . F o r if t h i s h y p o t h e s i s is r i g h t : i f the d r i v e t o a r t i c u l a t e resul ts i n v a r i a t i o n s i n the d e g r e e t u which d i f f e r e n t phenomena are c o n s t r u c t e d by any one paradigrn (we a r e back t o the r e l a t i v i t y o f s o c i a l c o n s t r u c t i o n t h e m e ) ; if, w i t h i n a n y paradigm, there l i e s the p o t e n t i a l t h a t some " c o n s t r u c t i o n s " , t h r o u g h paradigma t i c i n t e n s i f i c a t i o n , are r e l a t i v e l y t r u e t o reali t y ; i f both s o c i a l c o n s t r u c t i o n i s m and m e d i c i n e , a s they a r t i c u l a t e , are c o n c u r r e n t l y ( a t l e a s t p o t e n t i a l l y ) g e t t i n g a t ( d i f f e r e n t ) t r u t h s about the way things a r e w i t h h e a l t h , i l l n e s s and disease, t h e n i t i s p l a u s i b l e t o s u g g e s t there i s u t i l i t y i n the i r i n t e r p a r a d i g m a t i c c o l l a b o r a t i o n .

INTRODUCTION

Construction is a relative thing.

Yet, the fact is, we do construct. The world we occupy is in

many ways a humanly produced thing. Horizontalism (social

constructionism) has a valid point, one not to be denigrated.

It has - perhaps unwittingly so - hit upon an empirical (or, contrarily, maybe even an eternal?) truth!

Moreover, the drive to construct is a powerful one. I ' m not

one to deny that. We as humans seek perpetuation, development,

legitimation and expansion of our particular ways of knowing and

dealing with the world as discussed in Chapter 3. We seek

paradigmatic articulation. Part of the aim of this chapter is

to outline some of the reasons scholars have given for why this

is. However, 1 would also like to introduce a modification to

horizontalist conceptions of paradigmatic articulation, namely,

the d r i v e t o a r t i c u l a t e has a d u a l i t y t o i t . While on the one

hand it leads to phenomenal construction through a process

termed paradigmatic ex tens ion , it is also possible for it to

lead to phenomenal revelation through a process termed

paradigmatic i n t e n s i f i c a t i o n . This is important because, i t

due t o t h e p o s s i b i l i t y o f i n t e n s i f i c a t i o n tha t there i s

r e l a t i v i t y t o the social cons t ruc t ion of r e a l i t y . Moreover,

is due to t h e p o s s i b i l i t y of i n t e n s i f i c a t i o n that w e might

sugges t t h e r e is utility i n meaningful interparadigma t i c

c o l l a b o r a t i o n . Intensification means getting closer and closer

to the truth. Meaningful interparadigmatic collaboration means

more and more about truth gets shared.

In what follows, 1 begin with a discussion concerning the

nature of paradigmatic articulation, what drives it and what

informs it, and do so highlighting the horizontalist position

(which, incidentally, invariably appeals to verticalist

notions), and its ernphasis on how paradigmatic articulation

results in a constructed world. Having set the stage thus, I

then go on to introduce the innovation of duality. In

particular, 1 suggest that paradigmatic articulation as

described and legitimated by horizontalism is really better

understood as paradigmatic extension, while paradigmatic

intensification is, concurrently, always a possibility.

THE DRJXE TO PARADIGMATICALfiY ARTICULATE

Intzoduction

Why is it that we construct? More precisely, why is it that

we go about articulating the paradigms we hold dear?

Interestingly, scholars, even those firmly propounding

horizontalist views, have made sense of the phenornenon through

appeals to verticalist assumptions. Most basically, they Say

there exists a universal human need to feel at ease with the

world. This concept was introduced in Chapter 3. But

paradigmatic articulation is conditioned by socio-historical

circumstances as w e l l . It is rendered idiosyncratic in terms of

the path it takes and the manner in which it proceeds by virtue

of having foundations in, and being caught up in, a particular

ethos, for example. Rationaiization and rnedicalization can be

understood as particular types of paradigrnatic articulation

specific to the modern drive to dominate in the most efficient,

systematic and regulatory way possible.

The Universal Drive to Constsuct

Theorists like Berger, Sartre and Nietzsche are horizontalist

in orientation - at least in the sense that 1 am using it. They

Say things like the world is a construction, essence is

attributed, truth is made, etc. But their horizontalisms

invariably betray verticalist assumptions.

This is clear with ~ e r ~ e r ~ , as we have seen. To review and

elaborate:

Berger, building on Gelhen among others, begins with the

notion that humans are by nature unfinished beings. We have no

species-specific reality so we go about "finishing" ourselves

through social construction, Social construction is the

inorganic manner by which we countervail our organic

indeterminancies, our natural lacks. It is compensation for an 3 inherently deficient human biology. It is, consequently, an

endless human pursuit.

A n endless human pursuit, moreover, we conceal from ourselves

- something we must inexorably do as far as Berger is concerned.

Otherwise we face something very disconcerting. Otherwise we

face the ambiguity of existence, the contingency of the ways

things are. To see the world as social construction is to

conf ront the ines sent iality of things , to conf ront chaos, to confront anomie. So we wrap that which we have created in

signif icance; we dress it in eternality, ob jectivity. In

Turner' s words :

. . . al1 reality is socially constructed, as a consequence of Man's incompleteness, but human beings require stable meanings and cannot live in permanent awareness of the socially constructed and precarious nature of everyday reality, and they are forced to clothe these uncertainties with permanent

4 signif icance . We mask its arbitrary origins, render solid its frailties. We

legitimate that which we construct.

Or more critically - throwing inequality into the equation - the powerful legitimate that which they construct and impose

5 upon everyone else. And how do they legitimate? One way they

do so is through the production of religion. At least this is

Bergerr s reasoning. Illustrating with a fanciful example, he

If one imagines oneself as a fully aware founder of a society, a kind of combination of Moses and Machiavelli, one could ask

oneself the following question: How can the futu~e continuation of the institutional order, now established e x

nihilo, be best ensured?

That is, while

... al1 the means of power have been effectively employed ... There still remains the problem of legitimation, al1 the more urgent because of the novelty and thus highly conscious precariousness of the new order.

And how is this problem solved? Berger says the answer is

simple. It is

solved by applying the following xecipe: Let the institutional order be so interpreted as to hide, as rnuch as possible, its constructed character.

That is,

Let that which has been stamped out of the ground ex nihilo appear as the manifestation of something that has been existent from the beginning of tirne, or at least from the beginning of this group. Let the people forget that this order was established by men and continues to be dependent upon the consent of men. Let them believe that, in acting out the institutional programs that have been imposed upon them, they are but realizing the deepest aspirations of their own being and putting themselves in haxmony with the fundamental order of the universe. In sum: Set up religious legitimations.

Religion, as far as Berger is concerned, is the supreme

legitimator. Through it, precarious social arrangements are

f i r rn ly established by virtue of their links to divine schemes.

Through it, ambiguities are solidified and discrepancies

elirninated.

Religion legitimates social institutions by bestowing upon them an ultimately valid ontological status, that is, by l oca t i n g them within a sacred and cosmic frame of reference. The historical constructions of human activity are viewed from a vantage point that, in its own self-definition, transcends both history and man. This can be done in different ways.

Probably the most ancient form of this legitimation is the conception of the institutional order as directly reflecting or manifesting the divine structure of the cosmos, that is, the conception of the relationship between society and cosmos as one between microcosm and macrocosm. Everything "here below" has its analogue "up above."

Berger's emphasis on religion is close to what other theorists

say about the role of ideology in general for justifying

contingent societal constructions that appeal to the powerful.

Marx, for example, emphasized how ideology is used by the

bourgeoisie to legitimate capitalism, keeping the proletariat

exploited by ensuring that s/he is ideologically deceived into

thinking that capitalism is the natural way things should be.

Sirnilarly, critical theoxists highlight medicine as the

legitimator today, actively legitimating on behalf of the

powerful both capitalism, and - as far as feminists are 7 concerned - patriarchy .

The early Sartre is another who builds his philosophy on

verticalist assumptions. He is criticized, for example, by

Heidegger and Derrida for privileging the autonomous,

constituting human consciousness, for making the huan b e i n g the 8 center of things. In Derrida's view there is no "Man". There

is no subject. The subject is a fictitious entity, a

construction, a relic of liberal humanism, a "position in 9 language", a mere "ef fect of discourse".

Sartre privileges the human being and hidher freedom.

Contrary to the Platonic view of an autonomous world of perfect

and eternal forms, one indifferent to humanity and its

activities, Sartre says that hurnans are the meaning makers of

the world. That 1 am my own meaning maker. There is nothing

out there that needs to be as it is. 1, for example, am the

architect of any value.

Value...can be revealed only to an active freedom which makes it exist as value by the sole fact of recognizing it as such. It follows that my freedom is the unique foundation of values and that nothing, absolutely nothing, justifies me in adopting this or that particular value, this or that particular scale

1 O of values.

1 am the architect of any essence, of any meaning.

. . . 1 discover myself suddenly as the one who gives its meaning to the alarm clock, the one who by a signboard forbids himself to walk on a flower bed or on the la m... the one finally who makes the values exist in order to determine his action by their demands. 11

1 am the architect of worthy activity.

..,al1 human activities are equivalent . . . Thus it amounts to the same thing whether one gets drunk alone or is a leader of nations. If one of these activities takes precedence over the other, this will not be because of its real goal but because of the degree of consciousness which it possesses of its ideal

12 goal. . . In the absence of anything like God, the inexorable laws of

science, Platofs eternal Forms, I am free to choose rny own

truths, to constitute my own world.

But this is a dreadful freedom 1 have. It is a freedom of

anxiety, of anguish. The infinity of possibilities available to

me, the utter responsibility of total choice that is mine,

choice completely devoid of support or constraint emergent from

any foundation or essentially, is tough to face. The only thing

1 have no choice over is my freedom. 1 am therefore condemned

to be free.

So what do 1 do? 1 seek escape. 1 seek a way out of my

freedom and the anxiety it provokes. And so 1 deceive rnyself

into believing that the world is the way it is because it

reflects the ways things must be. I attribute eternality to

contingency, meaning to human whirn, necessity to human

construction and to the way society is. Through appeal to

society and its "taken-for-granted structureff, I am able to

shield myself

from the naked terrors of [my] condition. The 'okay worldff provides routines and rituals through which these terrors are organized in such a way that [Il can face them with a measure of calm. 13

In other words, I render fundamental the accepted paradigmatic

approach to dealing with the world. 1 flee into what Sartre

calls bad faith, and live, according to Heidegger,

inauthentically.

It might be said, therefore, that construction anew emerges

through self-freedorn exercised; and that construction

a r t i c u l a t e d ernerges though self-freedom denied. The drive to

articulate is consequent upon the human weakness to be at ease

with the world.

Nietzsche despises this weakness, this herd mentality that the

generality of humanity has adopted. He despises commonality,

conforrnity, mediocrity. He despises entities like the state

"where everyone, good and bad, is a poison drinker: the state

where everyone, good and bad, loses hirnself: the state where

universal slow suicide is called - life.''14 Instead, Nietzsche

venerates the solitary individual, the one able to devise

his/her o m virtues, the one who the "good and justff would have

crucified". He venerates the one who can create for

him/herself, the unitary constructor, the anti-superfluous one,

the Superman.

As with Berger and Sartre, however, there is a verticalism

behind Nietzsche's creative horizontalism. In particular,

Nietzsche posits the metaphysical concept16 of a will-to-power

inherent to al1 organisms: "To al1 organic beings, to al1

organisms or bodies - from amoebae to humans - the will to power

i s basic."" T h e concept i s introduced by Nietzsche 's protagonis t

Zara thust ra , who speaks thus:

But t h a t you may understand my teach ing about good and e v i l , 1 s h a l l r e l a t e t o you my teaching about l i f e and about t h e na ture of a l 1 l i v i n g c r ea tu re s .

1 have followed the l i v i n g c r e a t u r e , 1 have followed t h e g r e a t e s t and the srnallest paths, t h a t 1 might understand i t s na ture .

L i s t en now t o my teaching, you w i s e s t men! Test i n e a r n e s t whether f have crept i n t o the h e a r t of l i f e i t s e l f and d o m t o t h e roo t s of i t s hear t !

Where 1 found a l i v i n g creature , t h e r e 1 found w i l l t o power; and even i n the w i l l of t h e se rvan t 1 found the w i l l t o be master. 18

This will-to-power i s a pos i t i ve c r e a t i v e d e s i r e , one tending

towards self-expression, self-becoming. I t i s "an ac t ive

p r i n c i p l e of becorning other , as opposed t o r e a c t i v i t y and

pass ivi ty ." lg B u t it i s a l s o one t h a t has been suppressed under

t h e domination of the Apollo (o r S o c r a t i c ) p r i n c i p l e , and i n

p a r t i c u l a r , under t h e sway of r e l i g i o u s values, standards of

good and e v i l , reason, e t c . The o b j e c t i v e is t o overcome one 's

immersion i n t hese fabr ica t ions of t h e herd ( t h e superfluous,

t h e weak), t he se f ab r i ca t ions t h a t can lead on ly t o mediocrity

and indolence. The ob jec t ive is t o occasion f r e e p lay t o one 's

d e s i r e , t o oner s will-to-power.

In summary: Berger, S a r t r e and Nietzsche a l 1 make foundational

c la ims. O n t h e one hand t h e dr ive t o a r t i c u l a t e emerges from

the need t o avoid uncer ta in ty . Soc i a l cons t ruc t ion emerges out

of t h e powerful human d e s i r e t o f e e l i n sync with t h e wowld, t o

r e s t assured t h a t i t s laws and demands have been mastered. So

w e impute t r u t h s - laws and demands - t o it and then forget t h a t

we have imputed them. W e fo rge t t h e i r o r ig in s and t h a t w e a r e

the constitutors of reality. But Sartre and Nietzsche go on to

Say "let's not forget such things"; and then invite us to "feel

free to create afresh". In fact, Nietzsche, divulging another

verticalist premise (another supposed truth), contends that to

live is to create afresh, to release the inherent will-to-power,

to fashion anew. Al1 else is mediocrity - slow suicide. Rationalization and Medicalization

Weber was another who ernphasized the universal human West for 2 0 mastery over the "contingencies of life". This quest is met

largely through what he termed rationalization, a process cornmon

to al1 of human history and associated very strongly with

religion. Through rationalization, the problematics of

religious beliefs are articulated, accounted for and rendered

intelligible. Or at least so it would seem. In fact, what

really happens is that rationalization creates deeper

contradictions - more pressing anomalies we might Say - engendering an Ympulse for religious innovation. "" (See the Appendix following this Chapter for an elaboration on this

theme) . The theme for now is that while rationalization is a universal

phenornenon stemming from the universal need to make sense of the

world, it has taken a singular path of late, one unique to

western society and informed very specifically by western

rationality - a f omal means-ends rationalityz2. As Turner explains, Weber had it that "the emergence of a modern form of

consciousness . . . is set within a rational tradition. "23 A tradition, moreover, that paradoxically has its origins in

something highly "irrational", i.e. the Protestant, and in

particular the Calvinistic quest for salvational security. A

quest that gave rise "by a process of unintended consequences to

a culture that emphasized reason, stability, coherence,

discipline and world-mastery. "24

It did so in different ways. In the Protestant Ethic and

S p i r i t of c a p i t a l i s m t S Weber explained that it, and in particular

capitalism - one of the rationalizing forces in our tirnest6- emerged out of the Calvinist doctrine which preached

predestination - the view that one had no Say in whether or not

one would be among the saved. But one could have an idea if one

were among the saved through a sign, and the sign was economic

success. So a new ethic developed, one based on the ascetic

standards of frugality, industriousness, and one that encouraged

the rational and methodical pursuit of econornic profit, a 27 pursuit that led to capitalism. Moreover, the Reformation,

through its devaluation of the priest, through its emphasis on

the autonorny of the individual with regard to the church,

through its denial of "the magical efficacy of the sacraments"

thus opening further the door to the world of science, was

a major catalyst in the transfomation of western urban culture that stimulated a new form of rationality characteristic of urban bourgeoisie, a rational culture spreading ultimately to al1 classes and groups within western

2 8 civilization.

According to Weber, rationalization based on this rationality,

has permeated and corne to regulate every aspect of Our lives.

It has, he larnentably concluded, resulted in an iron cage from

which there is no escape. It has resulted in the subordination

of substantive questions of value to that of formal (means-ends)

logic. It has produced a world without meaning, a world without

moral direction, a world dorninated by bureaucracy and the goals

of ef f iciency, order, calculabilityZg . . . . . . and control . Control of the body, for example.

Turner argues that while "Weber's discussion of

rationalization as an historical process can be seen as a

discussion of . . . the emergence of a particular form of

consciousness", it can also be seen 'as the analysis of the

ernergence of new forms of discipline that regulated and

organized the energies of the body. "'O In pre-capitalist

societies, the disciplines targeted human passion. Religion

penetrated into the realm of sexual emotions, imposing

restraints upon them. Then, with the Protestant Reformation,

significant transitions took place. In the first place, there

was an explosion of regulation expanding £rom the specificity of

the monastery to the generality of the household, an explosion

occasioned by the new ethic of world-mastery. In the second

place, regulation took on a new target, shifting from the inner

structures of human emotion to the surfaces of the body, a shift

occasioned by the Protestant disenchantment with the world and

the concomitant focus on the secular. Having their origins in

both religion and the amy, the modern scientific disciplines

developed increasingly rational ways to train, restrain and

discipline the human body by "diet, drill, exercise and

groorning . "31 This is one of Foucault's major preoccupations. As discussed

in Chapter 3, he says that around 17th and 18th centuries, a new

form of power came into being, a bio-power concerned with tne

management and regulation of both the human population and the

human body. There thus emerged a host of disciplines concerned

with the development of technologies that could be applied in a

number of settings - in prisons, in schools, in hospitals - for the purpose of observing, disciplining and producing the body3' - for the purpose of controlling and forging docile bodies

amenable to training, manipulation and improvement3. This was

(and continues to be to this day) accomplished in different

ways: 'through drills and training of the body, through

standardization of actions over t h e , and through the control of

~ ~ a c e . " ~ ~ It was (and continues to be to this day) facilitated

through the systematization of knowledge, through the

development of "examinations, tirnetables, taxonomies,

classifications and registers"35 - through the development of

rational methods of surveillance.

What emerges with bio-power is the rationalized, normalized,

efficient body. Difference is squashed. And this, as we have

seen, bothers Foucault. One can read Foucault as someone

sharing Weber's distress with the ethic of world mastery, an

ethic the basis upon which the historical process of

rationalization has ensued; and Nietzsche's disgust with the 3 6 subjugation of Dionysian passion.

And it is in this light that Foucault understands the

emergence and functioning of medicine. The body is a target and

site of rational disciplinary invasions, the target of myriad

disciplines concerned with its regulation. Medicine is one such

discipline, and a predorninant one at that, emerging with

rationalization and the drive to master and regulate. Its iocus

is the body and its function is that of effecting an efficient

goverment of embodiment . More specifically, its foci include

sexuality, human emotion, social deviance. Its objectives

include control over reproduction, the normalization of emotion

- the determination of normal emotion, that is - and the standardization of illness amenable to bureaucratic management.

Its objective is the management of embodiment through the

medical regimen.

Medicine, in this view, has become the guarantor of social

order. Tt is the latest societal response to the problems of

embodiment and the interaction between embodied persons,

supplanting religion and law and their roles in this regard3'.

The rise of medicine to prominence occurred with the emergence

of the anatomo-clinical gaze. In the Birth of the clinic3*,

Foucault refers to the gaze as the "great break" for medicine.

Through it, patients were objectified, rendered exposed.

Through it, patients were seen in a whole new way. Foucault

says of the autopsy, for example, that "the living night [was]

dissipated in the brightness of death.ff39 In later works, such as

Discipline and Punish, Foucault builds on the theme of the gaze,

describing it more generally as a technology of power through

which the object - the patient, the prisoner, the factory

worker, etc. - is laid bare. The panopticon is Foucaultr s

paradigmatic example of disciplinary technology and the most

efficient employment of the gaze. 4 0 Through the gaze, a

knowledge is achieved which is "codified and organizedff, and

which then "becomes a resource by which the observer develops

bath an expertise, and a control over those s/he observes.fr41

Foucault has it that medicine has developed this expertise and

is in a powerful position to exert control. We are thus seeing

the rnedicalization of society, one that involves the ever-

increasing management of life by medicine in the interests of

regulation and normality.

To Stimmarize

Ironically, theorists - some more up front about it than

others - harbor verticalist assumptions for why it is we construct, perpetuate, legitimate, rationalize, paradigmatically

articulate. We do so to avoid anomie, anxiety, despair. We

paradigmatically articulate to render meaning to the world.

Moreover, some see this as a weakness on Our part, insisting we

should face the ambiguity of our existence and create anew, each

one of us for ourselves. But in so doing they betray once again

a certain verticalism, propounding ideas like the inherent

freedom of the individual, and the individualrs inherent will-

to-powex.

But while paradigmatic articulation may have its vertical

roots, both Weber and Foucault have given reason to suggest that

it is also socio-historically conditioned. Since the 17th

century onwards, for example, a major form of paradigmatic

articulation has come to dorninate the West - rationalization based on formal rationality - one that has foundations in various features of the Protestant Ethic - in the ethic of

world-mastery, for example. Medicalization as paradigmatic

articulation can be understood in a similar way, emerging and

proceeding as a secular answer to the moral problems of

embodiment and its effective regulation.

THE DUALITY OF PARADIGMATIC ARTICULATION

So we construct. We paradigmatically articulate in the

interest of maintaining a meaningful reality, or in the interest

of creating a new (egocentric) meaningful reality. And there

are foundational reasons for why it is we do so. Moreover, how

we do so is socio-historically conditioned. These are sorne of

the themes raised so far, themes 1 have uncritically outlined.

Kuhn says that

scientific theories taken as a group are obviously more and more articulated. In the process they are matched to nature at an increasing number of points and with increasing precision. Or again, the number of subject m a t t e r s to which the puzzle-solving approach can be applied clearly grows with

4 2 t ime .

How? Kuhn explains t h a t

Al1 theories can be modified by a variety of ad hoc adjustments without ceasing to be, in their main lines, the same theories. It is important, furthemore, that this should be so, for it is often by challenging observations or adjusting theories that scientific knowledge grows. Challenges and adjustments are a standard part of normal

4 3 research in ernpirical science. . . Science proceeds for the most part through normal science -

through the articulation of a particular scientific paradigm.

But it is not only science that does this. We al1 do this to

some degree or another. We al1 articulate. We al1

"interpret . . . evidence so that it f its [our] fanciful ideas, eliminate difficulties by ad hoc procedures, push them aside, or

simply refuse to take them seriously. lJ4'

Think of it this way:

We latch ont0 the world in certain ways. We get comfortable

with those ways of latching, come to see them as inexorable, and

then seek to perpetuate them. And upon continued encounter with

the world, we also seek to ex tend Our ways of latching; we seek

to latch ont0 more and more things in line with the particular

ways we have come to latch. And when our particular ways of

latching are challenged, we adjust them. But when we adjust

them, we adjust them more often than not conservatively,

supportively. We make adjustments that will both sustain and

legitimate that which is fundamental to the ways in which we

have come to latch.

Thus, for Kuhn, normal science Y s to a great extent self-

validating: it produces a world in which it is true.. .' 4 5 . More

generally, paradigrnatic articulation is to a great extent self-

validating: we paradigmatically produce worlds in which our

paradigms are (more and more) true. (Unless, of course, we are

strong enough to construct otherwise).

The horizontalist daim is that the ways we do our latching,

the ways we construct, the ways we paradigmatically understand

and deal with the world, get at nothing profound. They are just

ways, ways getting at nothing necessary about the way things

are; ways penetrating into no f oundational truths, no essences,

no realities as-they-are-in-themselves. If anything, they are

the constructors of profundity, essence, reality. And it is on

this point that I would like to introduce a modification, which

is this :

P a r a d i g m a t i c a r t i c u l a t i o n h a s a d u a l i t y tu it. On the one

h a n d , p a r a d i g m a t i c a r t i c u l a t i o n does r e s u l t very much so i n the

( i n c r e a s e d ) c o n s t r u c t i o n of reality. O n t h e other hand, there

is s u f f i c i e n t reason t o a t l e a s t e n t e r t a i n the p o s s i b i l i t y that

paradigma tic a r t i c u l a t i o n can a l s o r e s u l t i n the p e n e t r a tion of

( c e r t a i n aspects of, p e r h a p s ) r e a l i t y . Thus, p a r a d i g m a t i c

a r t i c u l a t i o n i n v o l v e s what 1 shall c a l l paradigmatic extension.

B u t along with paradigmatic extension, it can a l s o involve w h a t

1: skia11 c a l l paradigmatic intensification. 4 6

Paradigmatic Extension

By paradigmatic extension 1 mean very much what has been

highlighted as paradigmatic articulation so far. To be clear,

paradigmatic extension refers to the process of incorporating

more and more phenomena into the purview of the paradigm - into its way of organizing reality. It does so by preying upon

phenomena - particularly those phenomena semi-tangible to it - by taking them in and churning thern about until they obtain

paradigmatic palatability. To paradigmatically extend is to

construct more and more of reality from the paradigmatic point

of view. And when other views are subjugated in consequence, it

is to territorialize reality, to colonize and imperialize. And

this may be consciously done. Paradigmatic extension may

accornpany the conscious belief that one's view is the more

valuable view, if not the only view that matters.

It might be said that the scientism of the scientific

empiricisrn of Carnap and others is a good example of

paradigmatic extension. At the turn of the century there was a

'unity of sciencef movement, one which held that the physical

sciences "enjoyed an implicit unity, one which formalization

would make explicit ... ""; but which also held that the unity

needed to spread. The goal was to extend the methods and

concepts of science to other spheres. This meant that a wider

unity, encompassing the social and human sciences, for example,

"had to be manufactured, by the introduction into previously

unscientific subjects - ethics, for example, or history - the concepts and methodology of established sciences."48 Scientism

is the extension (imposition) of scientific understandings into

areas previously untouched by science, based moreover, on the

belief that such is desirable, even necessary.

The thought behind the forging of this unity - that it is highly desirable for the concepts and methodology of established sciences to be spread, and unsatisfactory for, for example, ethics or history to be left in their prescientific state - captures the scientism in scientific empiricism. 49

Medicalization is a current example of paradigmatic extension.

It is the process by which more and more of life is described

and dealt with in light of the medical paradigm. It is the

process by which more and more phenomena are constructed from a

rnedical point of view and then imposed. We live very much in a

medical reality as a consequence of medicalization. Medicine

has achieved a substantial imperialism. These themes have been

dealt with at some length already, so 1 won't elaborate upon

them here.

Instead, let me turn to something a little more ironic. Those

who criticize medicine for its paradigmatic imperialism may

themselves, wittingly or not, be involved in affecting their own

paradigmatic imperialism. They may themselves be involved l n

affecting their own paradigmatic extension, and doing so through

the denigration of another paradigmatic approach - through the denigration of medicine. 1 am speaking here of my own

discipline - the sociology of health and illness - and in particular, horizontalist sociology by which 1 mean the (perhaps

radical) social constructionist position within sociology.

There are a few issues here:

Focusing on the body, Turner writes (referring to sociology

itself - Ifm not sure 1 would be so general), that

we can safely assume that within sociology there is a broad consensus around the ideas that (1) human nature is infinitely, or at least highly, malleable and plastic; (2) human nature is socially constructed, and as a consequence (3) there is little that one could Say in general about human nature... The body, and especially the female body, is seen to

5 O be a 'fabricationf.. . These are encompassing ideas. These are broad unyielding ideas.

And they are ideas, as has been discussed, that extend to

reality in general. From the social constructionist point of

view (to limit, somewhat, the generalization Turner adopts) , reality is basically a social construction. This is the

paradigmatic approach it has adopted.

Yet, why the general claims?

It is interesting to note that, in practice, social

constructionists tend to highlight social constructionism in

certain cases, for example where "there already exists a

political struggle around the existence of a disease; 'pre-

menstrual tensionf is a classic illustrati~n"~~ as are

AIDS, tran-sexualism, repetitive strain injury, eating disorder, minerf s lung, mental illness and psychosomatic illness generally [ a l1 of which] are areas of constructionist research rather than goitre, gout or gonorrhoeal arthritis. 5 2

It focuses on the politically charged. It invokes social

construction to explain the existence of these specific

conditions. And yet it also makes the general claim that

reality is socially constructed.

It seems that social constructionism (or rather, proponents of

it) is (are) doing exactly the same thing that it claims

medicine and science are doing. It is doing normal science. It

is making compelling arguments regarding certain cases, and then

constructing the rest of reality in light of those arguments.

One could Say that the politically charged cases constitute the

exemplars of the constructionist paradigm. They constitute the

preerninent scenarios of the paradigm. They are the points of

paradigmatic appeal, of paradigmatic justification. They are

the standards that inform further constructionist research into

reality, that fortify i t s extension.

And not just extension, but imperialism. As with rnedicine and

science, social constructionism can have its imperialist 5 3 tendencies. Like other professions, it is not beyond it to

insist upon its 'own claim to authority with something valid to

Say. And so it generates its own terms, develops its own

discourse around the notion that reality is socially

constructed, and then conforms/constructs reality accordingly. 5 5

And it does so in particular by feeding upon that which other

disciplines such as science and medicine, a£ firm. Fox says that

"the natural is simply denied to ensure the ascendancy of the

social/political position. "56 AS discussed before, this may be

too strong a generalization - constructionists generally

acknowledge the impact of the natural. But constructionism

generally does attribute greater weight to social/political

forces than to the natural. By doing so analytically,

constructionism f inds itself on the road to credence and thus,

credibility . But the irony continues, since, can it ever truly be on the

road to credence if by its own d a i m everything is socially

constructed? Wouldnft that mean that social constructionism

itself is a social construction? That it is in no position,

therefore, to make a truth claim? A c l a i m about the w a y things

a r e ? That it is in no position to make the daim "reality is

socially constructed"? And if so, wherefore its credence? Why

take it so seriously? Why not go with something else? With

another discourse? Here we have, it seems, a paradox. 5 7

And yet there is a way out.

The way out, however, does not include the contention that

only social constructionism has got things right. It does not

include the position that "sociology has developed the tools

which provide it with resources to protect it from generating

false pictures of realityu5' - not an uncommon position as Fox

goes on to explain:

Sornehow, sociologyfs analysis of the historical or social factors are the only ones to be free of their own social determination; we are supposed to believe that the sociological analysis is 'methodologically sound' ... In retaining its own d a i m to (social) scientific status, the strong program fails to subject its own discourse to the analysis which it demands of other sciences . . . 59

But that's contradictory. It means that, for some reason or

another, social constructionism is able to tap the truth of

things while maintaining the constructionist notion that there

is no truth to be tapped; that it is has uncovered the truth of

things when there is no such thing as truth. The paradox

remains . And it remains when the not-so-hypocritical-position is

adopted, a position perhaps more common among postmodernists.

Some, like Derrida for example, relativize everything. And in

accordance with that, they relativize their own views,

attributing to them nothing privileged. But in so doing, they

get into trouble in two ways. On the one hand, they undermine

their own position that al1 things are relative. Concurrently,

they irnplicitly affirm the possibility of a particular truth6' - the truth that there is no truth and that a l 1 things are

relative. They irnplicitly affirm a particular ontology. The

paradox thus persists, since, to deny truth is to promote a

particular truth; to deny ontology is to promote a particular

ontology; to deny the verticalist project is to promote a

particular verticalism; to promote horizontalism is to promote a

particular verticalism.

The way out is to let go of the unconditional claim that there

is no truth and that al1 is construction. It is not to deny

that social construction takes place, but to embrace the reality

that some things are more socially constructed than others.

Then the paradox dissolves. Then sociologists are in a

legitimate position to make truth claims (whether they intend to

or not) like:

Society is a dialectic phenomenon in that it is a human product . . . that yet continuously acts back upon its

6 1 producer . What makes power hold good, what makes it accepted, is simply the fact that it doesnf t only weigh on us as a force that says no, but that it traverses and produces things, it induces pleasure, f orms knowledge, produces discourse. 62

... medical ideas of the body and its diseases are ... socially constructed realities that are subject to social biases and limitations. Biomedical ideas are based upon a number of historical assumptions about the body and ways of knowing about the body ... 6 3

As the practice of modern medicine becomes increasingly a technical enterprise, 1t is more incumbent upon us than ever before to recognize that the human body is not a machine, that health and illness are not merely biological states, but rather that they are conditions which are intimately related to and constituted by the social nature of human life. 6 4

Gynecology is a specialty practiced (some Say perpetrated) on women by men and for men. 6 5

Or truth claims like:

The medical mode1 is . . . ( see Chapter 3).

Illness X is a metaphor of society and is therefore a social construction (see Chapter 3) .

* This is how illness X has been socially constructed (see Chapter 6) .

Then it is possible to Say that social constructionism is

en j oying

Paradigmatic Intensification

By paradigmatic intensification 1 mean the process whereby the

(any) paradigm becomes further attuned to (an aspect of) a

phenomenon. To paradigmatically intensify is to further reveal,

to further get at, to further uncover, to further penetrate a

particular reality.

Intensification is always a possibility.

It is always a possibility because tangibility is always a

possibility, and tangibility is always a possibility because

reality constrains. 66

Moreover, the possibility of intensification increases as

tangibility increases. As tangibility increases, the parameters

of possible investigation narrow - they become more directive. Tangibility is both the doorway and the funnel to phenomenal

(aspectual) penetration. The more tangible the phenomenon

(aspect) , the more ajar the door and the more directive the funnel. The more tangible the phenomenon, the more f e a s i b l e its

paradigmatic intensification and the more guided its

penetration.

So paradigmatic intensification is possible. And it's a good

thing it is because if it were not, there would be no reason to

take seriously any claim nor any confirmational analysis.

There would be no reason to take seriously the daim

"illnesses are socially constructed" unless it were possible

that the claim speaks to a certain reality, a reality, moreover,

that happens to be relatively tangible to a certain paradigmatic

point of view. There would be no reason to take seriously any

corroborative analysis to the claim unless there were some

possibility that the analysis penetrates into the "whatness" of

social construction; unless there were some possibility that it

reveals how certain illnesses are socially constructed, how

certain illnesses are metaphors for societal anxieties, how

power produces knowledge of illness not to mention illness

itself, how medicine medicalizes. To Say that illnesses are

socially constructed, that hysteria is a metaphor for

patriarchal anxieties over female sexuality, that medicine is a

dominant producer of illness, and that life is becoming more and

more medicalized is to make t r u t h c l a i m s - to speak to possible

realities. And if they are indeed realities, then to accurately

delve into and analyze them is to intensify.

And isnr t it possible that this is exactly what social

constructionism is doing, at least with regard to certain

conditions (such as pre-menstrual syndrome, menopause,

repetition strain injury, etc. ) ? Isnf t it possible that social

constructionisrn is hitting upon certain realities - tapping into certain tangibilities - and then accurately investigating those realities in more and more depth? In other words, isn't it

possible t h a t soc ia l constructionism is intensifying?

To maintain "no" is to maintain the invalidity of social

constructionism. The validity of social constructionism does

not stem £rom its own paradoxical daim that al1 is

construction. Rather, it stems from the possibility that it

sees a reality - that social construction is a reality; and from

the possibility that it can unveil the "how" of this reality -

how it is that things are socially constructed.

And it is for the same reasons that we can take Foucault

seriously :

Ironically, Foucault makes truth claims about what truth is.

In one spot he says: '"[tlruth" is linked in a circular relation

with systems of power which produce and sustain it, and to

effects of power which it induces and which extends it. f O7 In

another, he says that:

... in a society such as ours, but basically in any society, there are manifold relations of power which permeate, characterize and constitute the social body, and these relations of power cannot themselves be established, consolidated nor implemented without t h e production, accumulation, circulation and functioning of a discourse. There can be no possible exercise of power without a certain economy of discourses of truth which operates through and on the basis of this association. We are subjected to the production of truth through power and we cannot exercise power except through the production of truth. This is the case for every society, but I believe that in ours the relationship between power, right and truth is organized in a highly specific fashion. 68

1 italicize in places to make a point. In making his case

against deep universal truth, Foucault himself appeals to a deep

universal truth. His anti-essentialism/foundationalism is

informed by an essentialism/foundationalisrn - that truth is everywhere, and at al1 times, produced by power. He also

suggests an empirical truth - t h a t there is a "specific fashion"

in which truth, power and r i g h t are organized i n our society

today.

To adopt the Foucauldian position in full, therefore, is to

embrace paradox. It is to champion anti-ontology through an

(albeit implicit) appeal to a certain ontology. So 1 would

suggest that the Foucauldian position in full is erroneous. But

that doesn't mean that 1 think his position should be totally

thrown out. It may be that there is some truth to what he is

saying. It may be that his truth claims about truth are

speaking to a certain reality, be it foundational or empirical.

Moreover, it may be that he has penetrated into this reality,

that through his genealogical approach in particular, he has

penetrated deeply into the workings of power and the ways it

produces truth. It may be that his genealogy has permitted him

to intensify into this particular aspect of truth.

Hence the possible importance of Foucault.

And hence the possible importance of medicine.

That is, is it not possible that there are some things

tangible to medicine? And is it not possible that medicine has

intensified into some of those things? The avid horizontalist

says not a chance. Medicine is just a dominant discourse that

corresponds in no way to a reality "out there" because there is

no reality independent of discourse - the anti-foundationalist

position. Medicine creates its own reality, a reality which

happens to be imposed upon the rest of us. But when you think

of it, it is extremely verticalist of the horizontalist to be so

categorical. Indeed, it is very imperialist of him/her, not to

mention contradictory. To maintain this position is to practice

exclusion, and it is to do so, once again, by promoting a

certain truth: the truth that there is no truth to be accessed

by medicine or anyone else. A truth, moreover, of which only

the horizontalist seems to be aware; a truth only the

horizontalist seems to have penetrated. Indeed, to adopt this

position is to adopt an inconsistent position. It is to

paradigmatically extend, to paradigmatically territorialize, to

pronounce finality while contemporaneously denouncing the meta-

narrative, the dominant discourse, the final word on things.

Thus, to be consistent:

Just as it may be that sociology can see and penetrate, it may

also be that medicine can see and penetrate, albeit into

different phenomena (aspects). It may be, for example, that

medicine has come to grips with various health conditions - with certain acute illnesses, for example - with what they are about,

how they are to be addressed, etc. The success medicine has

enjoyed with certain illnesses suggests this possibility. Its

pragmatic success may have something to do with its

investigative responsiveness to certain phenomenal constraints.

My son, to give a persona1 example, has a congenital heart

condition called aortic stenosis which is defined by a narrowing

of the aortic valve making it more difficult for the heart to

pump blood to the body. The regular condition of the valve is

to have three cusps. With the condition stenosis, however, the

valve may have only one or two cusps, cusps which are thickened

and/or stiff resulting in a valve that is relatively narrow and

less flexible thus limiting the regular flow of blood. The

medical position has it that when the condition is severe, it

needs to be treated, otherwise the heart goes into failure and

the person dies. Now herefs the question: has medicine

constructed aortic stenosis, or has it intensified into a

particular biological reality? Well, I think it is undeniable

that rnedicine has constructed the phenomenon - at least to some

extent. Construction always occurs in some way, and to some

degree. But is it not also possible that medicine has

intensified into the phenomenon as well? 1s it not possible

that medicine has accomplished more than sirnply making this

condition up? It seems reasonable to assume that had my son not

been surgically treated for the condition, he would have died.

That had not his valve been widened through surgery, the blood

flow to the body would have remained obstructed adding undue

pressure on the heart causing it to go into failure. This is

what happens to individuals with severe cases of untreated

aortic stenosis. It may very well be, therefore, that aortic

stenosis is one of those conditions that is relatively tangible

to medicine. While it may be a construction (in some way), it

may also be a construction that reflects very closely a certain

reality, a reality into which medicine has intensified in much

the same way that "reality as socially constructed" rnay reflect

a reality into which sociology has intensified.

Similarly, it rnay be that medicine has penetrated into certain

everyday workings of the body. To give another example:

Within medicine, and science more generally, there is a

distinction made between two types of ce11 division: mitosis and

rneiosis. The former denotes cell division within the body

generally in which two daughter cells obtain identical copies of

chromosomes from the nucleus of the original cell. The latter

denotes ce11 division unique to the ovaries and testes in which

an original ce11 with 46 chromosomes in its nucleus, through two

successive ce11 divisions, generates four germ cells (sperms or

eggs) with 23 unique chromosomes each. Now, once again, herefs

the question: is the distinction not a legitimate one? Does it

not represent an intensification into cellular workings? Or

does the distinction represent simply a construction in the

service of some ideological agenda? 1 think it is fair to

entertain the possibility that medicine (or science more

generally) rnay have penetrated into something true of biological

reality. That it didn't just make this distinction up. That it

really sees something truly different about ce11 division within

the body generally, and within the ovaries and testes more

specifically. And that, while its understanding of these two

processes rnay change in the future, its identification of a

distinction is valid, speaking to a reality, if only

imperf ectly . To conclude "no distinction", in other words,

would be erroneous. In short, is it not fair to conclude that

science rnay have tapped into a specific biological phenomenon in

the same way that social constructionism rnay have penetrated

into a particular social phenomenon?

Rorty says that language (science, the paradigm) is nothing

more than a tool for coping. I would like to suggest that it is

concurrently, at least potentially so, a tool for

intensification.

Proactive Intensification and Education

Intensification is possible. Thatfs the point.

And it is due to its possibility that we can speak of

learning, of education, of acquiring a knowledge of how things

are, which is exactly what the various disciplines, and in

particular the sciences and social sciences, claim they are

about. They are about learning about reality in their various

ways. They are about fur ther intensifying into reality in their

various ways. They are about engaging in various proactive

intensifications. They are about actively penetrating into the

way things are so that things can be known, tapped, utilized,

etc. Hence the potential importance of these disciplines.

Hence the potential importance of medicine. Hence the potential

importance of sociology. 6 9 Hence one of the reasons education is so important, education

being the vehicle through which knowledge intensified is

imparted . . . . . . although - and here is the problem . . . ... education is also the vehicle through which knowledge

extended is imparted.

Within every discipline there lies both the possibility of

proactive intensification and its antithesis, proactive

extension. To medicalize, for example, is to proactively

extend. To medicalize is to actively promote the medical view

as applicable to a growing range of phenornena, and to do so

erroneously. Applying social construction exhaustively to every

illness and disease is another example of proactive extension.

And 1 Say "proactive" extension because 1 want to distinguish

it from reactive extension, extension that occurs despite no

deliberate intent to actively promote a paradigmatic point of

view, Here, extension occurs as a reaction to anomalic

challenge. The proponents of the paradigm react by extending

their paradigrnatic view to envelop the phenomenon and manipulate 7 0

it in line with expectation.

Extension, ~ ~ t r n s i f i c a t i o n and Anomaly

TO this point, 1 have been discussing extension and

intensification as ideal type processes occurring in isolation

from each other. Their mingling is perhaps the more likely

case, however, with one or the other holding more sway depending

on the phenornenon under paradigmatic investigation: the more

tangible the phenornenon, the more likely it is that

intensification will dominate, while the more semi-tangible the

phenornenon, the more likely it is that extension wiil dominate.

But we must also rernember that tangibility is in many ways

paradigmatically conditioned. More precisely, it is in many

ways conditioned by previous paradigmatic activity - by the mix

of antecedent intensifications and extensions into other

realities. ~ h e result is a paradigm made up of a mesh of

concepts, concepts that range in degree from relatively pure

truths (intensifications) to veritable fabrications

(extensions) ,

New it may çeem that extension stifles tangibility, but that

is not necessarily the case. In fact, extension can induce

tangibility and thus lead ultimateiy to its antithesis - intensification. To explain, the paradigm, being a mix of

intensifications anci extensions, can be thought of in terms of

the ratio extension/intensification (e/i). The greater the

ratio, the more the paradigm has extended relative to

intensifieci. The smaller the ratio, the more it has

intensified. ~ o w , consider the following: as e/i increases,

the likelihood of anomaly increases. Anornaly appears against

the paradigmatic background: "[tlhe more f a r reaching and

precise the paradigm, the more the paradigm is compared with the

world; hence the greater the likelihood that instances of bad

fit wil1 ernerge into view." This was said and discussed in

Chapter 4. Now to add: the more erroneously far reaching and

precise the paradigm, the greater the potential for that

reality, upon feedback, to protest. Hence, the greater the

likelihood of anomaly - of anomalic tangibility. The emerging

discontent with medical intervention as a whole can be

understood as a response to the anomalic effects of (discontent

with) medical extension into areas such as chronic illness,

aging, women' s "problems", etc., areas perhaps more adequately

dealt with and understood in other ways.

And with anomalic tangibility there is the possibility of

intensification, intensification of a radical kind, no less.

Intensification that can lead to novel experimentation and to

the articulation of new ways of thinking; that can lead to new

approaches; that can Lead to the reasserting of suppressed

approaches. It can lead to women reclaiming their bodies, to

renewed emphases on preventive health care, to renewed

validations of rnid-wifery, to the promotion of chiropractie -

al1 things that are happening today. It can also lead to legal

action that challenges the prevailing orientation of medical

practice. B r i e f l y , anomalic tangibility can lead to

intensification that foregoes heretofore held paradigmatic

expectations, and around which new paradigmatic expectations

form. It may even lead to paradigmatic shift, to paradigmatic

revolution.

With every paradigm there is the possibility of

intensification. This is so even with highly "extendedf'

paradigms. Extension can breed trouble, trouble that can in

turn prompt or rejuvenate intensification into new corners of

reality.

PARADIGMATIC ARTICULATION AND THE CONSTRUCTION OF A PHENOMENON

Finally, both paradigmatic extension and paradigmatic

intensification can lead to the construction of a phenomenon.

Why? Because both can lead to what 1 shall term

aspectualization, the situation where a phenomenon is understood

in light of one, or some, of its many (~nlimited?~~) aspects - in

light of very specific information about it. This is sornething

I have only alluded to so far.

I would actually suggest that aspectualization, in some degree

or another, is unavoidable. For if it were avoidable, then

total understanding would be possible. Then a perspectiveless

understanding of phenomena would be possible. Then absolute

freedom from paradigmatic constraints would be possible. And I

think we can safely assume that such freedom is rare if not

nonexistent.

Instead, through our paradigmatic ways of seeing the world, of

seeing phenomena, we select some information and exclude other

information. We select certain phenomenal aspects over others,

and then see/construct the world, see/construct phenomena, in

light of those aspects. And to select/exclude is inevitable.

We always do it, Some of us, for example, make heroes out of

good runners because we value good running. It doesn't much

matter that some good runners may also be good at other things,

like inventing cultural theory. Such information we exclude as

we select, indeed, highlight, their running ability - as we

select t h i s aspect of who they are. And yet others among us

make heroes out of cultural theorists because we value incisive

cultural criticism. For us others, it doesnf t much matter that

some of these cultural theorists may also be good runners. Such

information we exclude as we select, indeed, highlight,

theoretical ability - as we select t h i s aspect of who they are. 7 2

Dorothy smithY3 found sornething similar when she gave her

students the assignment of writing about someone they knew to be

mentally ill. She found that her students, in carrying out

their assignment, would actually look for mental illness, and

that they would do so by extracting some information while

excluding other information about their subjects, information

that supported their conceptions of mental illness. In this way

the students defined - constructed - their subjects. The issue, once again, is not whether or not things are

constructed, but rather the degree to which things are

constructed. This, it seems, is conditioned very much by the

extent to which aspects selected fa11 under the sway of

paradigmatic extension as opposed to paradigmatic

intensification. The degree to which phenomena are constructed

depends on the extent to which their aspects selected are

themselves semi-tangible and thus constructed, as opposed to

tangible and t h u s amenable to exploration. In the case of the

former, the aspects are open to profound construction which

means the phenomenon is understood in light of highly

constructed aspects. In the case of the latter, the aspects are

not so amenable to social construction which neans that the

phenomenon is understood in light of aspects both seen and

penetrated into. (And, incidentally, it is in this way that we

need to understand the intensification of phenomena - such really entails intensification into certain of their aspects.)

The former, therefore, is the more constructed of the two

phenomena, while the latter is the less constructed of the two

phenomena.

T a k i n g everything together, the social construction of a

phenomenon from any paradigmatic point of view can be understood

to involve at least three processes:

1. Aspectual Selection: Where some phenomenal aspects are selected (or weighted with more significance) while others

are excluded (or given less weight). This rneans that phenornena are seenkonstructed in light of certain aspects.

2.Aspectual Constntction: Those aspects selected may or may not be tangible to the paradigm. If they are, then intensification can ensue resulting in a phenomenon seen/constructed in l i g h t of aspec t s better and better seen. Here, the social construction of the phenomenon amounts to little more than an issue of aspectual selection (and meaning attachment - see below) . If they are not, however - if they are semi-tangible to the paradigm - then paradigmatic extension ensues resulting in a phenomenon seen/constructed in l i g h t of h i g h l y cons t ruc ted aspects. The result is a phenornenon constructed to a much greater extent. Indeed, in the extreme case, the aspects selected may be little more than social imputations, having little attunement with reality. If so, then the phenomenon itself turns out to be vexy much a construction.

3.Meaning Attachment: No matter how tangible the aspects aspectualized, meanings are always attached to them, and thus, to the phenomenon itself.

So, when we talk about the relativity of the social

construction of phenornena, 1 would suggest that such relativity

results primarily as a consequence of the second process - as a consequence of aspectual construction which is itself very much

a relative affair.

SOM3 FINAL THOUGRTS CONCERNING PARADIGMS AND TBEIR PROCESSES

Now, before 1 go to the next chapter, I just want to mention

one or two things - to offer a few speculations, nothing more - regarding certain allusions made throughout this chapter. The

theme of paradigmatic crisis and revolution is one such

allusion, and is one of Kuhnfs major themes. 7 4

Kuhn, for example, talks about how discovery is seldom an

instantaneous affair. Discovery is a process, he says, one t h a t

passes through three stages. It commences with an awareness of

recalcitrant anomalies, with an awareness that (normal) science

is being violated in some way. It then moves into the second

stage - the stage of extended exploration - if it is felt that the anomalies warrant further investigation and that they should

not be ignored nor relegated to ad hoc explanation. During this

stage, science becomes more speculative, possibly leading to the

third stage, the stage in which the anomalous is no longer t h e 75 anomalous, but the expected. At this point, discovery is

complete. That is, when this occurs there is a paradigmatic

shift, a s h i f t in which the previously anomalous is rendered the

stafidard, the basis upon which, the exemplar around which, a new

paradigm f lourishes . Now, while this is a particularly attractive model, 1 would

l i k e to propose two ways in which it might be modified. In the

first place, there may be certain factors that condition

paradigmatic shift in light of anomalic presence. Power, for

example, rnay play a big role in sustaining a certain

paradigmatic reality despite its ev iden t difflculties - its evident bad fit. In the second volume 1 tackle this and related

issues again.

In the second place, paradigmatic shift may not have to entai1

an a l 1 out shift. A s quoted earlier, Kuhn says that " [a] 11

theories can be rnodified by a variety of ad hoc adjustments

without ceasing to be, in their main lines, the same theories."

To put this another way, it is conceivable that paradigmatlc

shifts of a lesser kind can occur, shifts t h a t do not affect the

essence of the paradigm - that do not affect that which is integral to the paradigm. That do not, for instance, result in

the expulsion of any exemplars.

For heuristic purposes, think of the paradigm in terms of two

levels: a primary and a secondary level. The primary level

refers to the essence of the paradigrn. It consists of those

concepts that make the paradigm what it is. It is the rigid and

enduring quality of the paradigm. It is not so rigid that it

does not develop - articulate - through intensification and extension. This it certainly does. But it is not like t he

secondary level which is the more fluid level, the level of

flux. The secondary level is derivative of the prirnary level,

yet it is more flexible in the sense that it permits sorne

paradigmatic adaptation to phenomenal discrepancies. That is,

it permits what I shall t e m "accommodation."

Accommodation is a special case of extension. So far 1 have

presented extension as the process of incorporating more and

more phenomena into the paradigmatic view by distorting them,

conforrning them, etc.. Accommodation, however, is that aspect

of ext-ension that yields to anomalies, that takes them in

without any major attempts to socially (re)construct them in

line with paradigrnatic expectations. Accommodation thus results

in paradigmatic shifts, but shifts of the minor kind, since the 7 6 essence of the paradigm, its primary level, remains intact.

In this sense, we can think also in terms of primary and

secondary anomalies. Secondary anomalies are phenomena which

present little challenge to the essence of the paradigm.

Through extension they may be successfully reshaped so that they

conform to paradigmatic expectations, or they may be

accommodated since they are perceived as insignificant

challenges to paradigmatic coherence. In the latter case, the

orientation can be summed up as "why bother with them", with the 7 7

result once again being paradigmatic shifts of a minor kind.

But primary anomalies are dangerous. They are like negative

exemplars. They fundèmentally challenge that which is essential

to the paradigm. Consequently, much effort goes into their

conformity since their accommodation entails paradigmatic

demise.

The paradigm, therefore, is both rigid and dynamic. It is

dynamic in three ways: first, it articulates through

intensification; second, it articulates through extension;

third, it undergoes rninor shifts through a s p e c i f i c process of

extension termed accommodation, a process which gives the

paradigm its fluidity. The paradigm is rigid in that it is

incapable of accomodating primary anomalies without finding

itself fundamentally challenged. Moreover, it may be this rigid

quality which, i r o n i c a l l y , conditions its own demise - which facilitates its final act of dynamism - since it is against this rigidity that anomalies are most glaring.

But these, once again, 1 offer j u s t as speculations.

I And it is due to this possibility that w e can speak of "learning". That

is, while it is possible that any knowledge can see certain realities, it rnay

also be that only some, more than others, are actively striving to intensify

- to further penetrate - into what they see, and doing so with some success.

Perhaps the various sciences along with medicine are examples of knowledges

seeking to intensify, and doing so successfully to some extent. Perhaps

social constructionisrn is another example. This is dicussed in more depth in

this Chapter.

2 (1967); and with Luchann (1967).

3 For a good summary of Berger's position, see Turner (1992), p. 113-118.

4 Turner (1992), p. 117.

5 Which is Foucault's point about the knowledge/power nexus.

6 The ensuing quotes are from Berger (1967), p. 33-34.

7 Chapter 3 goes into this in some detail.

8 Boy in Skinner (1991), p. 48.

9 Rosenau (l992), pp. 42-43.

10 (1956), p. 34.

11 Ibid., p. 39.

12 Ibid., p. 629.

13 Berger (l963), p. 147

14 (1969), p. 77. Foucault shares this sentiment, warning us against a l 1

discourses that totalize, normalize and universalize.

15 Ibid, p. 90.

16 Zeitlin (l994), p. Il.

17 Lash (19911, p. 70.

18 Nietzsche (1969), p. 137.

19 Fox (l994), p. 131-

20 Swidler (1993), p. xiv.

21 Ibid, p. xv.

22 See Ritzer (1988), p. 123 for a good summary.

23 Turner (1992a), p. 116.

24 Ibid, p. 116.

25 (1958).

26 The other being bureaucracy.

27 1 should be clear that Weber does not deny the impact of material

conditions, the role of economic circumstances in the emergence of

capitalism. Indeed, one of his major objectives is to demonstxate the

likelihood of a plurality of causes, that one should prioritize neither

economic nor ideologic causes like the Protestant Ethic. As he States in The

Protestant E t h i c : "...it nevertheless cannot be the intention to substitute

for a one-sidedly 'materialist' interpretation of cultural and historical

causes an equally one-sidedly 'spiritualistf interpretation. Both are

equally possible, but both are of equally little service to the interests of

historical tr~th if they daim to be, not preliminaries to inquiry, but its

conclusions." (See Runciman (19871, p. 1 7 2 ) .

28 Turner (l992a), p. 116.

29 Ibid, p. 115.

30 Ibid, p. 117 .

31 Ibid, p. 119.

32 Turner (lggîa), p. 180.

33 This is Foucaultf s major theme in Discipline and Punish (1977) . 34 Rabinow (1984), p. 17.

35 Turner (1992a), p. 180.

36 Ibid, p. 21.

37 See Chapter 3 on this.

38 (1973).

39 Ibid, p. 146.

40 (l977),

41 Fox (1994), p. 24.

42 (l977), p. 289.

43 Ibid., p. 281.

44 Feyerabend (1993) , p. 148. 45 Barnes (1991), p. 92.

46 Longino says something similar to this. She says "both knowledge

extension and truth can guide scientific inquiry and serve as fundamental,

but not necessarily compatible, values determining its assessments," (1990,

p. 36).

47 Sorel1 (lggl), p. 9.

48 Ibid, p. 9.

49 Ibid, p. 9.

50 Turner (1992), p. 104.

51 Ibid, p. 106.

52 Ibid, p. 105.

53 Strong (1979). Strong talks about sociology more generally.

54 Fox (19941, p. 13.

55 It delineates a particular version of the medical model, for example,

squeezing medicine into a particular understanding of what medicine is al1

about - that it is purely naturalistic, for example (See Chapter 2). 56 (l994), p. 13.

57 This paradox is a common criticism of social constructionism.

58 Fox (l994), p. 6.

59 Ibid, p. 16.

&OpR~sgne~~(~992~,-p.90 - - - - - - - - - - -

61 Berger (l967), p. 3.

62 Foucault in Rabinow (198 4 ) , p . 61.

63 Freund and McGuire (1995), p. 5.

64 Lock (1988), p. 8.

65 Scully and Bart (1978), p. 213.

66 This is one of the major points of Chapter 4.

67 In Rabinow (1984), p. 74.

68 (1980), p. 93; my italics.

69 My emphasis is on "knowledge-of" as opposed to the acquisition of trades,

crafts, skills, performativity, etc., al1 of which are important parts of

education as w e l l .

70 Note: Paradigmatic extension, whether proactive or reactive, may not be

seen as such by those who champion the paradigm - by its proponents. Rather,

it may be seen as contributing to the refinement, integrity and coherence of

their particular view. They may see extension as intensification. In this

way they may deceive themselves thus making it possible for proactive and

reactive extension to occur.

71 Here's an interesting set of questions: hon many aspects does it take to

make a phenornenon? Do some phenomena have more aspects than others? Or do

al1 have an infinite number? And here's another question: what makes an

aspect an aspect? What are its parameters? What are the parameters of a

phenornenon? These are important questions each of which rnay imply a weakness

in my theoretical development. However, 1 leave such questions to others to

debate and proceed with the understanding of "aspect" as an ideal type

conceptual tool.

72 One more example would be when kids cal1 one of their classrnates "four-

eyes". Here they are defining him/her in iight of his/her having to wear

glasses.

73 (1978),

74 ( 1 9 7 0 ) .

75 Ibid, p . 53.

76 1 want to suggest, at this point, that paradigmatic fluidity also arises

as a consequence of the uniqueness of different individuals. While

individuals of a particular paradigmatic community share a commonality of

view, they do so most importantly at the prirnary level, at the level of

paradigmatic essence. This is the source-and the fogdatZonof their unity. - p p p p p p p p p p p - - - - - - - - - - -

But at the secondary level, their perspectives may Vary. Different

individuals may accommodate different phenomena into their paradigmatic view.

This results in paradigmatic fluidity across individuals. Moreover, given

the secondary nature of such fluidity, such diversity, the unity of the

paxaaigm, its essence, remains intact.

77 Although, the possibility of there being too m a n y accommodations at the

secondary level should be considered. Perhaps a given paradigm has a certain

tolerance level that is simply greater for secondary anomalies than for

primary anomalies, but one that, nevertheless, is not infinite.

MAPPING THE RELATIVITY OF THE SOCIAL CONSTRUCTION OF DISEASE

JOt3RPilEY NO!l?ES To Recsp: Not o n l y i s i t p o s s i b l e t h a t d i f f e r e n t paradigms s e e d i f f e r e n t

phenornena ( a s p e c t s ) , i t i s a l s o p o s s i b l e t h a t as t h e y a r t i c u l a t e , t h e y p e n e t r a t e more d e e p l y i n t o t h e t h i n g s t h e y see. Hence t h e r e l a t i v i t y o f t h e s o c i a l c o n s t r u c t i o n o f r e a l i t y .

Chapter 1 began by a s k i n g why i t i s we feel such a need t o envelope and perpe tua te Our p a r t i c u l a r ways o f t h i n k i n g ; why i t is, i n o t h e r words, we f e e l such a need t o parad igmat i ca l l y a r t i c u l a t e . Chapter 5 opened by o u t l i n i n g some o f the answers t o t h i s q u e s t i o n . In t e r e s t i n g l y , and i r o n i c a l l y , t h e answers a r e g e n e r a l l y v e r t i c a l i s t o n e s , speaking t o something e s s e n t i a l about human b e i n g s . But w h i l e e s s e n t i a l l y cornpelled, paradigma t i c a r t i c u l a t i o n i s c o n c u r r e n t l y s o c i a l l y cond i t i o n e d . Both r a t i o n a l i z a t i o n (based on formal r a t i o n a l i t y ) and m e d i c a l i z a t i o n , f o r example (the t w o dominant forms o f paradigmatic a r t i c u l a t i o n today, t h e l a t t e r perhaps a sub- ca tegory o f t h e former) have foundat ions i n , and are cond i t ioned by, p a r t i c u l a r s o c i o - h i s t o r i c a l c o n t i n g e n c i e s .

No m a t t e r what i t s o r i g i n s n o r its s o c i a l c o n d i t i o n s , however, t h e e s s e n t i a l p o i n t i s t h a t paradigmat ic a r t i c u l a t i o n has a d u a l i t y t o i t . On the one hand, i t i n v o l v e s paradigmatic e x t e n s i o n . On t h e o t h e r , i t ( p o t e n t i a l l y ) i n v o l v e s paradigma t i c i n t e n s i f i c a t i o n . The former r e f e r s t o the process o f conforming semi- tangib le phenomena i n l i n e w i th paradigma t i c e x p e c t a t i o n s . The l a t t e r refers t o t h e p r o c e s s of p e n e t r a t i n g more d e e p l y i n t o phenomena r e l a t i v e l y t a n g i b l e t o the paradigm. And t h i s may be e x a c t l y what medicine i s do ing - a t l e a s t with regard t o c e r t a i n phenomena. I t may a l s o be what s o c i a l cons t ruc t ion i sm i s do ing . To deny t h e p o s s i b i l i t y o f i n t e n s i f i c a t i o n i s t o undermine t h e s o c i a l c o n s t r u c t i o n i s t paradigma t i c v iew i t s e l f . We can t a k e s o c i a l cons t ruc t ion i sm s e r i o u s l y o n l y by v i r t u e o f the p o s s i b i l i t y that it is i t s e l f p e n e t r a t i n g i n t o a c e r t a i n r e a l i t y : t h e r e a l i t y t h a t r e a l i t y i s (more o r l e s s ) s o c i a l l y c o n s t r u c t e d .

Chapter 5 a l s o d e s c r i b e s what i s r e f e r r e d t o as a s p e c t u a l i z a t i o n - the process o f c o n s t r u c t i n g phenomena i n l i g h t of c e r t a i n a s p e c t s . A major d i f f e r e n c e i n t h e degree t o phenomena a r e c o n s t r u c t e d , t h e r e f o r e , i s t h e degree t o which their r e s p e c t i v e a s p e c t s - a s p e c t u a l i z e d a r e themselves c o n s t r u c t e d . To Continue:

In t h i s chapter, t h e a i m i s t o be more concrete . It is t o demonstra t e w i t h specific cases the relativi t y o f s o c i a l cons t ruc t ion u t i l i z i n g t h e concepts h igh l i gh t ed so far. To t h i s end, a typology of four ca t e g o r i e s represen t i n g different degrees of s o c i a l cons t ruc t ion is o f f e r e d a s an ana l y t i ca l t o o l . While the typology can be applied t o a n y paradigm, it is used a s a framework t o understand the r e l a t i v i t y o f the soc ia l (medical) cons t ruc t ion of var ious diseases.

INTRODUCTION

The Issue

A number of concepts have been introduced so far: phenornenal

tangibility, serni-tangibility, intangibility; generalized,

specified, anornalous and fabricated tangibility; paradigmatic

articulation, intensification, extension and aspectualization.

These have al1 been introduced in light of the clah that

different paradigms may both see and penetrate into various

phenomena - or perhaps more accurately, phenomenal aspects. Other phenomena (aspects), on the other hand, rnay be more

constructed, the results of paradigmatic extension and the

aspectualization of semi-tangible aspects. Hence the central

daim: some things are more socially constructed than others.

The discussion so far, however, has been largely a theoretical

one. In this chapter, my purpose is to apply the theory. In

Chapter 7, 1 provide conclusions and an assessment of rny

application.

To begin, it will be remembered that 1 see the tension between

medicine and social construction as largely an unnecessary

tension, a consequence of both paradigmatic approaches getting

carried away with their own projects, of both approaches getting

carried away with themselves. Medicine daims special and

evolving access to the "whatness" of the workings of the body

and its abnormalities. This is its verticalist claim. Social

constructionisrn counters with the horizontalist claim that the

putative diseases identified by medicine are social

constructions. In rny view, both have sornething - much - to offer, but within limits. And yet, both take their positions

much too far. Both lapse into paradigmatic extension. Both

(needlessly) construct health, illness, disease and the body.

Both (needlessly) construct reality.

Indeed, the medical and the social constructionist paradigms

are very much at variance, with medicine insisting upon its

being able to see diseases and the like, and social

constructionism insisting upon the unfounded imperialism of the

medical point of view (which, apparently, it s e e s - a verticalist claim, ironically) . The doorway to meaningful

interaction between them is consequently very much closed. But

if there is relativity to the social cons t ruc t ion of things - if

t h e r e i s r e l a t i v i t y t o the medical cons t ruc t ion of disease, for

example - t hen , the l o g i c goes, t he re are grounds t o f l i n g the

door wide open. There are grounds for each to look seriously to

t h e other for insight. Why? Because the relativity of the

medical construction of disease rneans two things. I t means: 1.

medicine may see and intensify into certain diseases, or aspects

thereof, relatively well - their physiological reality, for

example; and 2. social constructionism may see and intensify

into other diseases (and some of the same diseases), or aspects

thereof, relatively well - their socially constructed reality,

for example.

So, taking disease as the focus, the aim of this chapter is to

examine the social, and more particularly, the medical

construction of disease. Various conditions are assessed and

categorized according to the degree to which they a r e socially

(medically) constructed as diseases.

Tools for Thinking about the Relativity of Social Construction

As discussed, social construction is always a factor. There

exist no phenomena - of which there is at least sorne social awareness - fully disconnected from paradigmatic assumptions, that have no links to social meanings. The i s s u e , rather, is

t h e e x t e n t t o which paradigma tic assumptions/meanings infiltra t e

the phenomenon, imbue the phenomenon, cons t ruc t the phenomenon.

Relatedly, the issue is the extent to which paradigmatic

assumptions/rneanings debar seeing and intensification into the

phenomenon. Among the theoretical claims made so far is that

the more tangible the phenomenon to a paradigm, the more clearly

it is seen by the paradigm, the less amenable it is to

construction by the paradigm.

To demonstrate and better understand the relativity of social

construction, the following typology is offered as an analytical

tool in which four phenomena types are distinguished:

1. phenomena that are socially conceived, referred to here as

socially-conceived-phenornena ;

2. phenomena that are socially manipulated, referred to here

as socially-manipula ted-phenomena;

3. phenornena that are socially augmented, referred to here as

s o c i a l l y - a ugmented-phenornena;

4. phenomena that are socially transfixed, referred to here as

soc ia l l y - t rans f ixed-phenornena . These should be understood as ideal type categories, and the

entire scheme as a useful - and preliminary! - device for mapping the degree to which phenomena are constructed, with the

first category including the most constructed phenomena, and the

fourth the least constructed phenomena. (In fact, the fourth

category consists only of intangible phenomena or non-existent

phenomena. Any phenomenon perceived is a phenomenon constructed

somehow, and to some degree, as already said. There are no

perceivable phenomena impervious to social construction.)

It is according to this scheme that 1 demonstrate the

relativity of the social construction of disease. You will

remember that by disease 1 am utilizing Conrad and Kern's

definition which is that diseases are "biophysiological

phenomena that manifest thernselves as changes in and

malfunctions of the human body."' More broadly, 1 also refer to

"disorder" in order to incorporate malfunctions of the

psychological kind.

The problem, however, is that not everything we cal1 "disease"

conforms so well to disease in the sense defined. In fact, no

diseases are purely thus. Al1 diseases are constructed to sorne

extent or another. Al1 diseases are made sense of in terms of

social assumptions. Yet, the point once again, is that some

diseases are more socially constructed than others. This means

that some diseases correspond less well than others to

"malfunctions of the body" although, to those constructing them,

to those reifying them, they appear to correspond equally. In

fact, some diseases are o n l y what 1 s h a l l refer to a s " d i s e a s e s "

mean ing they have no v e r i f i a b l e and/or l e g i t i m a t e claim to

" m a l f u n c t i o n of the human body". This does not mean that, as

social constructions, the real biological does not figure.

Indeed it often does. But it figures more often than not as an

effect of the construction reified. Once constructed, such

"diseases" can produce serious physiological disorders. Here:

kill the social construct and the physical dies with it.

Then there are diseases that are diseases in the sense

defined, that have veritable roots in the biological. While

they are definitely constructed (to some extent), they are

constructed more or less in line with their realities as

diseases, as malfunctions. Here: kill the social construct and

the physical remains, only to stimulate the birth of another(?)

social construct . In any event, utilizing the typology above, I distinguish

between four types of disease constructions:

1. diseases that are socially conceived, or s o c i a l l y -

conceived-diseases;

2. diseases that are socially manipulated, or socially-

m a n i p u l a t e d - d i s e a s e s ;

3. diseases that are socially augmented, or socially-

augmented-diseases;

4. diseases that are socially transfixed, or socially-

transfixed-diseases . with the first category representing the most constructed

diseases (being only "diseases" with little or no correspondence

to the definition), and the fourth representing the hast

(encapsulating intangible on non-existent diseases).

And by these categories 1 mean the following:

1. Socially-conceived-àiseases. Socially-conceived-diseases

are social reifications manufactured out of the semi-tangible.

Where there is ambiguity, there is extensive amenability to

social construction. Hence, whexe there is physiological

ambiguity, where these is ambiguity about whether or not the

physiological constitutes a disease, there is extensive

amenability to social construction. Here, the physiological

(or, more broadly, the body) is constructed. Social (medical)

meanings imbue and pervade ambiguous physiological (corporeal)

realities making of them abnormalities, physical "diseases" or

psychological "disorders" with which to reckon.

Socially-conceived-diseases emerge as the ambiguous natural is

suf fused with the social (with medical assumptions/meanings) . This means that socially-conceived-diseases are stand-ins for

the social. They are social (medical) anxieties manifested and

imputed into the real, into "malfunctions of the bodyff. They

are "diseases" thoroughly social in constitution, social

epiphenomena reified through paradigmatic extension as the real

thing . This is not to Say that they are not associated with

physiological (or psychological) suffering. They often are.

But such suffering is, in many circumstances, better understood

as a consequence of the construction rather than visa versa.

Those "afflicted" buy into socially-conceived-dises as

d i s e a s e s , and "live out" their physiological (or psychological)

prescriptions. In this way, the constructed disease produces

real suffering. (1 Say this, however, with some reservation

since 1 do not want to totally discount the fact that such

"diseases" can also emerge through the attempt to explain

instances of real suffering; "diseases" which, when once

constwucted, induce more suffering.)

This raises an important distinction: socially-conceived-

diseases should not be confla ted with socially produced

diseases. Both emerge through the social, but while the former

refer to epistemological constructs with ontological

ramifications (and thus, invariably, physical ramifications in

the form of suffering), the latter refer to afflictions

generated through exposure to deleterious social arrangements

(in the way that silicosis or lung cancer emerges through

exposure to certain noxious work conditions in minesi; or in the

way that insufficient socioeconomic conditions lead to higher

rates of illness3) . When speaking of socially produced diseases,

the (more or less constructed) categories we use to designate

and understand them are generally taken for granted.

2. Socially-manipulated-diseases: There is a profound

qualitative disparity between socially-conceived-diseases and

socially-manipulated-dises. Socially-conceived-diseases have

no verifiable (or, to put it more forcefully, veritable) roots

in malfunctions in the physiological. Socially-manipulated-

diseases, on the other hand, are clearly diseases in that they

are rnalfunctions of the biological. Upon experience, there are

few, notwithstanding Our diversity, who would see or construct

them, otherwise. Socially-manipulated-diseases have generalized

tangibility as diseases (so defined). They permeate basically

any paradigm as diseases. The social, in other words, is

constrained by them. The social cannot so easily make of them

rainbows, or feathers, or rocks, for example. As diseases, they

are too dernanding, too evident, too tangible for that.

But while it is relatively tangible that they are diseases,

they nevertheless remain highly ambiguous phenornena. The actual

"whatness" of them - of what they are about, of how to deal with

them, of the why of them - is deeply semi-tangible. They are consequently shoe-ins for social construction. As evident

threats to health, to the well-being of society, there quickly

emerges an active social attempt to make sense of and address

them. Through paradigmatic extension once again, the social

goes to work on them, latching onto them (or rather, ont0 their

semi-tangible aspects), imbuing them, conditioning them. In so

doing, it invariably manipulates tkem in line with (dominant,

medical) social anxieties.

3. Socially-augmented-dises. A socially-augmented-disease

is a disease that is in certain ways socially "filled-out"

(exaggerated) , and/or "added-on-to" (supplernented) . In the

first sense, the disease is constructed through

aspectualization. More accurately, aspects belonging to it are

socially exaggerated to the point where they basically becorne

the disease. Aspectualization, to be sure, is not unique to

this category. Socially-conceived-diseases and socially-

manipulated-diseases are understood most significantly in light

of certain aspects - in light of certain aspects-aspectualized.

The difierence, however, is that socially-augrnented-diseases are

also understood in light of relatively tangible aspects, aspects

paradigmatically intensified into, aspects less infused with

paradigmatic assumptions/meanings than in the case of socially-

conceived and socially-manipulated-diseases. But they are

aspectualized nonetheless.

Socially-augmented-diseases in this sense are diseases with

certain (intensified into) aspects selected, highlighted, while

others are concurrently eclipsed (relegated to the background,

screened from paradigmatic perception).

Augmentation also involves "adding-to" or supplementation.

Again, the degree to which social assumptions/meanings

infiltrate the disease, distort it, etc., diminishes with its

tangibility. With socially-augmented-diseases, there is little

to no such social infiltration. Rather, the social either

exaggerates a tangible aspect, and/or attaches meanings to the

disease, meanings that remain ancillary to it. In this second

sense, meanings do not get in the way of paradigmatic seeing and

intensification. Rather, here, socially-augmented-diseases are

diseases with meanings-attached, nothing more.

Now, there is probably no such thing as an socially-augmented-

disease in this second sense alone. Any disease perceived is

likely, and at very minimum, a disease both socially

supplemented and aspectualized. Why? Because one can never see

everything there is to see about a disease, or any phenornenon

for that matter. Aspectualization is always a factor. The

issue, rather, is simply the extent to which aspectualization is

a factor (not to mention the degree to which the aspect

aspectualized is constructed as opposed to seen).

4 . Socially-transfixed-diseases. A disease devoid of any

construction whatsoever, a socially-transfixed-disease is either

intangible or nonexistent.

Some Things to Remember

Before I proceed to examples of the various disease types,

there are a few caveats that need to be stated up front. It is

only with these in mind that 1 can comfortably urge you, the

reader, to continue reading. They are the following:

1. The schema, the typology, is meant as a preliminary tool. 1

alluded to this already, but it is important to be clear.

1 am not about to daim that the schema constitutes the

definitive tool for representing the relativity of the social

construction of disease. Rather, the schema is offered as a

provisional tool to assist with seeing the relativity of the

social construction of disease which is the main point. 1 clairn

for it nothing more than j u s t one way of mapping the variable

degree to which social assumptions/meanings infiltrate and

construct different disease phenornena. Its strengths and

weaknesses as a tool, and the extent to which it accurately

encapsulates different diseases, will be taken up in Chapter 7.

2 . The four disease categories represent ideal types. Thus,

when 1 assign disease X to category N, 1 do so with the

understanding that the placement is, to some degree, forced.

There are probably no diseases that fit p e r f e c t l y within any one

of the categories, except the fourth, especially since the

schema itself is tentative. Any disease assigned, for example,

will jncorporate aspects perhaps better placed within other

categories, or somewhere in between two categories, or

otherwise. So, when I assign disease X to category N, 1 do so

only because, upon reflection, t h e category seems most relevant

to understanding its construction as a total phenornenon. When 1

categorize a disease, 1 am doing so in light of what seems most

prominent about the phenornenon in the degree to which it has

been socially constructed, especial ly when compared to other

diseases . Thus, a socially-manipulated-disease is relatively

more socially manipula ted than a socially-augmented-disease; a

socially-conceived-disease is relatively more socially conceived

than a socially-manipulated or socially-augmented-disease, etc..

As mentioned above, 1 plan to spend some time discussing the

merits and otherwise of these categories in Chapter 7.

3. The diseases do not represent a cross-section. In what

follows, I am not concerned with representing each disease type

with an abundance of diverse examples. I see tremendous value

in the attempt to categorize the many diseases (or "diseases")

that exist according to this, or to some other more adequate

typology, characterizing the relativity of the social

construction of disease. However, my primary purpose at this

time is to simply demonstrate the relativity of the social

construction of disease. And this, I think, can be accomplished

with one or two examples £rom each category which is al1 1

present in this chapter. Indeed, the goal would be achieved by

simply demonstrating disparity in the degree to which t w o

diseases are socially constructed. Once again, other diseases

(or "diseases") will be considered in Chapter 7.

1 should also point out that most of the examples 1 use centre

around womenfs conditions or conditions of sexuality as their

analyses as social constructions are plentiful within the social

constructionist literature. The problem, as indicated before, is

that such examples are prone to be treated as the exemplars of

the social constructionist paradigm, as justifications for the

clairn that al1 diseases are social through and through. But 1

draw upon them nonetheless to demonstrate very clearly that such

is not warranted. In the first place, as we shall see, other

diseases are less constructed than they are. In the second

place, there is variation in the extent to which they are

themselves constructed. For these reasons, 1 have chosen to

make them the focus of my analysis in this chapter.

4 . The disease placements are provisional. My placements are

necessarily provisional due to my own inclination to see,

organize and construct according to my own paradigmatic point of

view. To daim for my placements anything more solid than

provisional status would be tantamount to claiming that I can

see the way diseases are socially constructed, the degree to

which they are constructed, etc. It would be tantamount to my

claiming unadulterated access into this particular reality. Now

it may be that 1 am seeing this reality and am accurately

placing diseases into the appropriate categories of social

construction. The possibility of my seeing and representing the

reality of the social construction of disease does exist. But

it is only a possibility. My placements should, therefore, be

understood as constituting a submission subject to refinement,

modification . . . maybe even total rejection. What follows is an

initial attempt at something new, and so 1 make no claim to

expertise in the area.

I affirm this especially since, for the most part (and this is

important), rny analyses are informed by the sociological

literature concerned with health and illness. But 1 would also

suggest that while my analyses are guided by this literature,

they are not determined by it . If they were, then 1 would

probably not be atternpting to demonstrate the relativity of the

social construction of disease. Instead, 1 would Say my

analyses are guided by my own paradigmatic framework which is

definitely informed by the sociological, and in particular, the

constructionist literature, but within which the constructionist

approach is considered inadequate on its own, manifesting as 1

see it, many ironies.

Some of these ironies 1 have already highlighted in previous

chapters, especially in Chapter 5. In the present chapter,

however, examples abound as I draw so heavily on the

sociological/constructionist literature. For instance, you will

note that while the avid constructionist says everything is

construction, that truth does not exist, etc., truth claims of

the following nature are nevertheless made:

A. this is how disease X is constructed;

is" and "knowledge of" as discussed in Chapter 4. The "what" of

a disease has implications for what we come to know of it;

similarly, what we come to know of it has implications for the

"what" of it - for how it occupies a place in Our world, for its

essence. Yet, there is also the possibility - indeed, the

likelihood - that in what follows (and previously) , 1 needlessly conflate(ed) the ontological with the epistemological. This, 1

suggest, is a (potential) difficulty that is not resolved here,

but something that definitely requires attention.

1 also want to be clear concerning the contrast 1 draw between

disease and 'disease". As 1 see it, they are (ontologically?)

very different. By the former I mean a veritable malfunction of

the body (as defined above). In the case of the latter, 1 mean

a condition irnputed into existence with no veritable status as

"rnalfunction of the body", but one perceived/treated/lived as

such nonetheless. (Perhaps this means that epistemologically

they hold the same status? Although the episternological. informs

the ontological . . . ) . The distinction, 1 fee l , is somewhat

cumbersorne, but for the time being 1 leave it as such and

relegate it to further work, or to others, to refine.

6 . Medicine is the focus but not a w i l l i n g , nor a singular,

villain. Various analyses of the medical construction of

disease tend to depict medicine as intentionally seeking ways to

define more and more of reality from a medical perspective.

Sometimes it even cornes across as if medicine is involved in

some sort of a conspiracy to this end, in this way buttressing

its dominance and/or controlling us al1 on behalf of society.

Maybe this is the case at times. Generally speaking,

however, I t h i n k i t is more u s e f u l t o t h i n k of medic ine a s

engaged i n s o m e t h i n g we a r e a l 1 e n g a g e d i n : p a r a d i g m a t i c

a r t i c u l a t i o n . And this involves, either wittingly or not, both

paradigmatic extension as well the possibility of paradigmatic

intensification. The only real differences between the medical

approach and other paradigmatic approaches is that 1. medicine

happens to be more dominant at this time than other approaches,

especially vis-à-vis health, illness and disease; and 2.

medicine is the focus of this analysis. Social constructionism

could just as easily be the focus of a similar analysis. Any

paradigm could be the focus of a similar analysis. Any paradigm

could be exposed, in the way medicine is here, for its

deficiencies and strengths as an articulator.

This is important since, based on the analysis that follows,

one may easily form the impression that I harbour an implicit

hostility towards medicine. Let me be very clear that 1 harbour

no such hostility. If my analysis is trenchant, it is so

because 1 am dealing - at least for the most part until 1 get to socially-augmented-diseases - with what 1 see (in my own limited

way) as palpable examples of how medicine has extended. Medical

paradigmatic extension figures as the primary subject of rny

critique, not the medical paradigm as a totality. For there is

much more to the medical paradigm than its extensions, much more

to it (at least potentially s o ) that is worthwhile. This should

be clear given the discussion in Chapter 5 and elsewhere. In

short, extension is the problem as far as I am concerned, and my

specific focus (case study) throughout the bulk of this chapter

happens to be m e d i c a l extension. This is not to isolate

medicine as somehow uniquely deficient nor villainous since al1

paradigms e x t e n d , w i t t i n g l y or n o t , and could, as said, easily

be the focus of a similar analysis.

I should also be clear that, for the most part, 1 treat

medicine as an ideal type category. 1 do this for the sake of

simplicity, but because 1 do, 1 am also not being totally fair.

For there is diversity among those who champion the medical

paradigm at core, as there is among those who champion the

social constructionist paradigm, or any paradigm. There is

diversity manifested if only at the secondary paradigmatic level

(see Appendix 1 post Chapter 5) . Some physicians, for example,

would no doubt take issue with the general stance medicine has

adopted and propagated, as I understand it, concerning certain

diseases (or "diseases") . ..*......

With these caveats in mind, consider the first category

SOCIALLY -CONCEIVED-DISEASES

to which I assign the greatest level of social construction.

Introduction

As discussed in Chapter 4, social construction can proceed

only when it has something with which to work. To construct

something out of nothing, out of intangibility that is, is

impossible. Even at this level of social construction, this

deepest and most profound level, there is something with which

social construction is working. This is the level at which

phenomena are literally socially constructed; the level at which

phenomena are socially contrived out of other phenomena, semi-

tangible phenornena; the level at which paradigmatic extension

holds full sway.

Here, that which is contrived is a stand-in for that which

remains otherwise unarticulated. And it is the contrivance that

is reified. The facade, in other words, is ascribed its own

reality and thus becomes the real (to those who construct it).

The facade is objectified as something that exists "out there".

As such, it has real consequences, with those who buy into it

"playing outff the disease and thus manifesting the appropriate

(physical, psychological) symptoms. As such, the construction

of disease translates into the production of disease.

Certain "diseases" fit this description, being manifestations

of particular social anxieties or paradigmatic assumptions.

Clear examples abound. Menopause 1 suggest is one, being a

present day social elaboration of particular corporeal semi-

tangibilities, an elaboration that combines these together into

a disease. Hysteria - being more of an historical example while

in some ways still current - is anothex, and perhaps even more profoundly so than menopause (suggesting variation within this

category in the degree to which different diseases are socially

constructed), having no foundational roots in biological

dysfunction whatsoever. Its roots lay in the (supposedly)

"irrational" (woman) body from which the "diseasef' is

constructed, and the biological imputed. Both are products of

medical paradigmatic extension, extension inf ormed by broader

social values.

In what follows, I discuss hysteria first, and then menopause.

In Chapter 7, 1 allude to other conditions that may fa11 into

this category.

Eysteria

The history of hysteria is a debatable subject. Foucault bas

its o r i g i n s largely in the 19th century medical discourses on

sexuality. Others insist instead that the condition can be 6 traced back to early Egyptian and Greek times. And there are

still others who argue that hysteria has been given a history

that does not in fact exist, being erroneously attached in more

recent centuries to the tradition of suffocation of the womb as

expounded upon by Hippocrates. As in^^ puts it: Nineteenth-century hysteria, a parasite in search of a history, grafts itself by name and lineage ont0 the centuries- old tradition of suffocation of the womb, thus making Hippocrates its adopted father .

Classical hysteria, therefore, "is in reality but a mare's nest,

a spurious entity invented by later physicians in the Middle

Ages and Renaissance and legitimated a f t e r the event by medical

223

historians. "' In Kingf s view, \' [il t is tirne that father disowned

his hybrid child. "' No matter w h a t its historical origins, however, one fact

remains indisputable: the "disease" hysteria was (and still

by some) invariably tied to (presumable) corporeal

abnormalities, abnormalities, moreover, unique to women.

Landouzy in 18461°, for example, clairned that:

There is an organic cause f o r this affliction, the great majority of recorded cases with pathological evidence showing some type of lesion of the female reproductive apparatus, and particularly the uterus and ovaries.

It was not until Charcot and Freud that the biological basis for

hysteria f e l l into serious disrepute. But even then, the

condition was inexorably tied to the female constitution, and in

particular, to female sexuality.

Keeping Kingf s reservations in mind, what follows is a brief

history of the condition as generally told £rom the

constructionist position. Its status as a disease is then

assessed.

Most argue that the term "hysteria" derived from the Greek

w o r d "hystera" which means uterus or womb. 11 In its beginnings

as a disease, the condition - characterized by uncontrollable

crying, moodiness, tantrums, fainting, etc. - was believed to have ultimate foundations in certain aberrations of the womb.

It w a s therefore, treated a s a uniquely female disorder.

The earliest evidence of hysteria actually cornes from Egyptian

society, where it was identified in the oldest known medical

papyrus dating £rom around 1900 BC. The papyrus dealt

specifically with hysterical disorders and their requisite 12 treatrnents. Here, as it would be for centuries to come, the

condition was tied directly to the womb. Considered an

independent organism able to wander throughout the body, the

womb was held to cause various disturbances when estranged £rom

its normal position, and inducing hysterical disorders when

colliding with the brain. Any cure, therefore, worked to return

the womb back to its proper place.

Cure for this anomalous displacement could be attempted from two directions: the wornan's sexual parts could be fumigated with fragrant substances to attract the migratory uterus from below, or vile-tasting and foul-smelling potions could be ingested to drive the deviant womb back from above. 13

Also implied in the papyri was the connection to "abnormal"

sexual activity which lead to womb wandering. 14 Through sexual

abstinence and, thus, lack of pregnancy, the womb became dried

out inducing it to take flight from its home, The implied cure,

therefore, was pregnancy, a condition that ensured female well-

being. "(Plregnancy was normal, desirable and indeed a

necessary rnedical condition for women in order to preserve their

sanity. ,# 15

The notion that a women's sanity was linked to her sexuality,

to her role in society, and in particular, to her reproductive

system, is a consistent "theme that runs through the history of 16 the disease". Beyond implication, it was firmly implanted in

the Greek medical undeirstanding. Here, as with the Egyptians,

hysteria was once again viewed as a disease of the wandering

uterus applying pressure on the brain (which, incidentally, was

believed to be located within the heart and diaphragm). So

displaced, it provoked, arnong other symptoms, convulsions. This

time, however, the treatments prescribed were very specifically

sexually oriented. While scent therapy, irritant pessaries and 17 herbal concoctions were suggested, the treatments considered

most effective were intercourse, rnarriage and pregnancy. Where

normal sexuality oriented to pregnancy within the confines of

marriage was lacking, hysteria invariably presented.

This , o s t e n s i b l y , was Hippocrates view, a l though King' s

r e s e r a a t i o n s , once aga in , are important t o cons ider . According

t o King, while Hippocra tes c e r t a i n l y t a l ked of the wandering

womb, he d i d not a t t a c h ' hys te r i a" t o t he range of symptoms he

i d e n t i f i e d . I n f a c t , he placed g r e a t e r emphasis on t h e symptoms

themselves, and when he did group them, he grouped them

according t o t h e part of t he body t h e womb happened t o be

v i s i t i n g . Moreover, Hippocra tes did not recommend marr iage and

pregnancy f o r any th ing bu t hypochondria ( ano the r d i s e a s e of t h e

womb). The unders tanding t h a t he recommended it as a cure f o r

h y s t e r i a i s simply an e r r o r i n r e t r o s p e c t i v e i n t e r p r e t a t i o n . I n

King' s words :

It can be seen t h a t t h e Hippocra t i c t e x t s do indeed work by d e s c r i b i n g symptoms r a t h e r t h a n g iv ing a s i n g l e d i s e a s e name t o t h e s e chap t e r s , and that where they group symptoms and t h e r a p i e s t o g e t h e r t h e y do so according t o t h e p a r t of t h e

body t o which t he womb i s be l i eved t o have moved. O f these

t h e r a p i e s , t h e recommendation of marriage/pregnancy occurs only i n t h e d i s c u s s i o n of womb movement t o t h e hypochondria i n Diseases of Women.. .which ends by saying t h a t , a f t e r fumigation, the patient should s l e e p with her husband: "release £rom t h i s d i s ea se , when she is pregnant . "la

P la to a l s o p r e s c r i b e d marr iage and pregnancy as cures f o r t h e 19 wandering womb. H e wrote i n t he T i m a e u s t h a t :

The womb i s an animal which l ongs t o genera te c h i l d r e n . When it remains ba r r en t o o long a f t e r puberty, it is d i s t r e s s e d and s o r e l y d i s t u rbed , and s t r a y i n g about i n t h e body and c u t t i n g o f f the passages o f b rea th , it impedes r e s p i r a t i o n and b r i ngs t h e s u f f e r e r i n t o the extremist anguish and provokes a l 1

2 O manner of d i s e a s e s be s ide s .

Moreover, (as Turner exp l a in s P l a t o f s position), " [t] h e s e

d i s tu rbances cont inued u n t i l the womb was s a t i s f i e d by i t s

reproduct ive func t i on . "2'

Galen sha red much the same p o s i t i o n , although he introduced

some key innova t ions . 22 H e , l i k e t h e o the r s , l inked h y s t e r i a t o

women's reproductive activity, to deficiencies in sexual

intercourse and reproduction. But his reasons for doing so were

different. From b i s perspective, there was no such thing as a

wandering womb. Instead, sexual abstinence resulted in the

retainment of female "seminal secretions . . . within the womh bringing about putrefaction, contamination and finally

hysteria. "23 He also suggested that men could experience

hysteria, a notion that was later disavowed given the f i rm

conviction that hysteria was ultimately and causally tied to the

uterus . The link between hysteria and reproduction certainly had its

recesses. The Christian view leading up to the Renaissance, for

example, propounded the alternative notion that hysteria was

linked to the devil or to evil spirits. Of particular interest

here was the connection made between hysteria and witchcraft, a

position, "largely sustained by a virulent rnisogyny . "24 Consider,

for example, the not so uncommon attitude towards women as

expressed in Witches' Hammer, a work written in the fifteenth

century by Dominican monks :

What else is woman but a foe to friendship, an inescapable punishment, a necessary evil, a natural temptation, a desirable calamity, a domestic danger, a delectable detriment, an evil of nature, painted with fair c o l ~ u r s ! ~ ~

From such a perspective, one could only expect women to be in

league with the devil. Here, every woman was a potential

witch. 26 Every woman including Elizabeth Jackson who, in 1602,

was accused by another woman Mary Glover for the latter's

hysteria, and in particular, for her convulsions whenever

Jackson came near her. Jackson, who in an heated exchange with

Glover, wished upon Glover an evil death, was subsequently

convicted for her witchcraft, the apparent cause of Gloverfs

hysterical episodes. She was convicted, moreover, despite

Doctor Edward Jorden's efforts to disabuse those who were "apt

to make every thing a supernaturall work which they do not

unde r s t and". 27

The Christian view at this time, also held sexual behavior in 2 8 low regard, it being itself an evil act. Intercourse,

therefore, was no cure for hysteria.

Later, during the Renaissance and the Classical age, the link

between hysteria and the womb was further effaced, but for

different reasons. Leonardo Da Vinci with his drawings of

anatomy, Gabriele Fallopio's contributions concerning

reproduction, Harvey' s discovery of the circulation of blood,

al1 served to discount any links between the womb and hysteria.

Links, instead, were found elsewhere. Of particular note was

the connection made to female psychology and a womanfs

constitution as espoused by Willis and Sydenham in the

seventeenth century, both of whom "questioned the uterine

explanation of hysteria"Zg. In their view, women were more

likely to be afflicted with hysteria due to their more delicate

constitutions and inabilities to deal with difficulty. They

considered women more delicate because they saw thern as less

'dense and firmly organized" internally than men, thus allowing

any out of balance "animal spirits" within them to traverse and

produce disorder with ease. 30

" T h a t is why [hysteria] attacks women more than mentff writes Sydenham, "because they have a more delicate, less f i rm constitution, because they lead a softer life, and because they are accustomed to the luxuries and commodities of life and not to sufiering.

As before, patriarchal morality came into powerful play,

suffusing the female body and thus constructing the phenornenon

hysteria.

It is a similar moral stance that informed the work of

Philippe Pinel in Paris in the early nineteenth century, who

constructed his own version of hysteria. 32 In fact, Pinel

attributed a purely moral, and more specifically, sexual, origin

to hysteria. In his view, hysteria emerged as a physiological

and psychological response to deviant sexual activity. The

cure, once again, was normal sexual activity - marriage. (Pinel

also advised productive work as a cure. ) It was, moreover,

under his influence that an increase in the number of (supposed)

women hysterics occurred, with doctors becoming more and more

"provoked and outraged by what they perceived as female

treachery, malingering, and irmn~rality."~~ This lead to a

"medical reaction so violent that extreme rernedies such as

ovariectomies and clitoral cauterization were advocated by

certain specialists in cases of intractable hysteria. "34

Then ~ h a r c o t ~ ~ appeared on the scene in the late nineteenth

century, and did so suggesting the unique innovation that

hysteria was, at least in part, a learned disorder, a mimicked

disorder. He also suggested, like Galen, that men could

experience hysteria. But it was Freud's contribution that

changed the face of hysteria forever. It was also his

contribution that, despite his intentions, ultimately destroyed

hysteria as a disease. As Rousseau and Porter put it, "Freud

was not the beginning of anything new in the history and

conception of the condition but rather the end of a long wave. rr 3 6

Freud's chief contribution lay in the idea that "the symptoms

of hysteria were symbolic expressions of unresolved

psychodynamic conflicts and were typically sexual in nature. " j 7

Whereas, previously (and even in the nineteenth century as

observed at the beginning of this section), hysteria was held by

many to have an organic base, Freud (as did Charcot), found its

cause in the psychological. For psychological disorders devoid

of an organic base could nonetheless produce physical symptoms.

One could get parlor from anger, or heart palpitations from 38 fear, etc. . And one could get hysterical symptoms from the

repression of sexual conflict. Thus, with Freud the

pathological imagination of women, the pathological sexual

imagination of women, took over as the etiological agent of

hysteria . The problem, however, was that Freud's analyses of his

hysterical patients were overwhelmingly informed by particular

assumptions concerning female sexuality, assumptions which,

obviously, he took for granted. In his analyses, Freud

constructed away supposedly aberrant notions of sexuality,

notions that didn't sit well with the "patriarchal fantasies of

fernininity and female s e x ~ a l i t ~ " ~ ~ he championed. This is

evident in the case of Dora (who, incidentally, he recognized as

having been unsuccessful in curing) . As explained by Moi:

There are ... ideological tendencies to sexisrn at work in his text. Freud, for instance, systematically refuse [dl to consider female sexuality as an active, independent drive. Again and again, he exhort[ed] Dora to accept herself as an object for Herr K. Every time Dora reveal [ed] active sexual desires, Freud interpret [ed] them away, either by assuming that Dora [was] expressing masculine identification . . . or by supposing that she desirerd1 to be penetrated by the male. 4 0

According to Freud, Dora was actually aroused by Herr Krs (a

friend of her father's) pursuit of her. Her (hysterical)

problern lay, at core, in her inability to acknowledge it. 4 1

Thus, towards the end of the nineteenth century, hysteria

remained in large measure tied to the sexuality of wornen - to her deviances from the n o m s of sexual practice. While, with

Freud it was no longer tied to a wandering womb, it was firmly

tied to female corporeality and the supposed psychology that

goes with it. In this way, it was also tied to the roles she

was expected to play in society, to her specific roles as

reproducer and wife. This means that single, divorced or

widowed women, or women pursuing education or careers, were

highly susceptible to hysteria. They were the "superfluous"

among women in society because such pursuits/roles prevented

them £rom engaging in "normal sexual activity designed to bring 4 2 about reproduction". And as the superfluous, they were likely

to become the hysterical.

The implication of this medical mode1 was that women could only lead healthy lives in so far as they were sexually connected to a man in a lawful marriage which had the aim of reproduction. Sexual relations outside marriage were associated with another sexual disorder, namely nymphomania. The medical theory of the hysterical woman supported the status inequalities between men and women, supported the medical analysis of the social and psychological values of pregnancy inside marriage, and finally acted as an argument against further education for women on health grounds. A protracted period of education would delay the necessary functions of reproduction and satisfaction inside marriage and therefore professional women were particularly exposed to the

4 3 damaging implications of delayed pregnancy.

Hysteria in the 19th Century, with its varying etiology over

the years, is best understood as a descendant - one confirmed and re-confirrned (one constructed and re-constructed), in

different ways - of broader patriarchal values and concerns. It

was also a synibolization through which patriarchal concerns were

both rnanifested and worked-out. This understanding is further

evidenced by the dramatic decline in hysterical behavior since

the turn of the century, a decline most likely fostered by

social restrictions on various behaviors generally associated

with hysteria, such as thrashing about and fainting. Whereas,

in the 19th century it was fashionable to faint, the 20th

century began to see it as socially inappropriate. 4 4

This decline also lends credence to one current idea that

hysteria should be seen as a learned social role rather than a

disease entity 'out there". In one sense, for example, hysteria

can interpreted as a role that women adopted as an expression of

revolt against the impossible (patriarchal) situation they were

compelled to incessantly endure.

The hysteric's symptom-statements [were] ironic exaggerations of the Victorian ideal female stereotype. They [said], in effect: "You want me to be sickly, passive, and dependent? Watch me - 1'11 do it better than you believed possible - and youf 11 be sorry!" For carried to hyperbolic heights, stereotypical female modes of behaviour [were] inconvenient and irritating to those who [held] power . . . 4 5

And in Doraf s case:

[the] symptoms, seen as i ron ic communications, fulfill [ed] their purpose admirably. The aphonia: "1 cannot speak: 1 am woman, 1 have no Say. So 1 will Say nothing." The malaise . . . 1 am inactive, uninvolved, because 1 am unable to take initiative." The stomach pains: '1 am in pain, in the very region that defines me as a woman, and 1 need to be taken care of." And the suicide gesture: ' I ' m just a woman - maybe I shouldnrt be allowed to live. 46

On the other hand, the hysteria role can also be read as a being

a declaration of defeat, or

the realization that there is no other way out. Hysteria [was] . . .a cry for help when defeat [became] real, when the woman [saw] that she [was] efficiently gagged and chained to

4 7 her ferninine role.

In either case, hysteria was not a disease inexorably tied to a

womanfs natural constitution. Instead, it was a role played-out

in reaction to an oppressive social situation. Hysteria was not

a disease "out there" that afflicts the sexually deviant woman.

It was a social construct lived by wornen who found in it

(consciously or not) a method by which to manifest the

intolerability of their social situation. This does not mean

that t h e physical was not involved. It often was, but as

syrnptoms that emerged through immersion in the role.

Since Freud, less and less credence has been invested in the

idea of hysteria as a disease. In 1952, for example, with the

publication of the first version of the Diagnostic and

S t a t i s t i c a l Manual of Mental Disorders, the "disease" did not

appear, having been deleted in the precursor manual, the Mental 4 8 Disorders Diagnostic Manual . As Libbrecht indicates, this

institutionalized the trend beginning around the dawning of this

century, a trend spurred on by the likes of Dubois in 1904 who

clairneci that "within a few years the concept of hysteria will

belong to history ... t h e r e is no such disease, and there never

has been"; and Gaupp who in 1911 exclaimed tha.t: " [nlowadays the

cry is ever louder: away with the name and the concept of / 4 9 hysteria: there is no such thing. . . . This does not mean that

the diagnosis is no longer made. It still is. But when it is

made, it is made with some regret, and more often than not, as a

means by which to avoid confrontation with ignorance. Faced

with symptoms that cannot be made sense of, there are doctors

who "find an easy way out in relegating them to a category, to a

diagnosis, \hysteriar . . . " 5 0 As Ey puts it, making I would suggest

sornewhat of a bold over-generalization:

Every doctor knows in his clinical experience that he is bound to fa11 back on the magic word hysteria, and at the same time is loath to do so, because it has so little definite meaning. In fact, we are al1 obliged to make use of it when we are faced with paradoxical clinical manifestations which do not coincide wi th the pathology with which we are familiar, and which do not fit into the framework of illnesses which to us are 'real illnesses', which obey the general laws of anatomy and physiology. 5 1

Even though pathological changes cannot be demonstrated,

hysteria is still "ernployed as if it refers to a disease.. . "52

Here, hysteria is a spurious entity constructed, conceived, as

a stand-in for medical inadequacy. Here practitioners extend,

conforming the anomalous in order to safeguard (what they see

as) paradigmatic integrity, relegating it to the psychosomatic.

Such, to elaborate upon this medical phenornenon, is not only

the case with hysteria. For example, when physicians cannot

locate the cause of a complaint, when they are unable t o deal

with it in line with their medical training, some may very well

respond by psychologizing the complaint. The result is a unique

sort of construction, a construction of something that is

potentially real in nature, real in the body, into the

psychosornatic, even the morally depraved. In Kirmayerfs words:

" [t] he diagnosis of a psychosomatic condition transforms the

real into the imaginary, the innocent into the culpable . "53

Conditions are dismissed as imaginary, pseudoseisures,

pseudoangina, etc.; and patients are described as histrionic,

malingering, crocks, hypochondriacs, hysterics, psych cases, 5 4 etc.

Consider the following example: 5 5

A thirty-four year old professional woman with low back pain continues working despite her family doctorfs prescription of strict bed rest. Her doctor describes her as 'a workaholic, a driven perfectionist." She endures one year of pain with little changes in her life-style. Eventually, her pain worsens and she undergoes tests which dernonstrate a collapsed intervertegral disc. A neurosurgeon operates on her spinal column to decornpress t h e pinched nerve root. The patient feels better immediately after the operation but within a few days has recurrent pain. Without performing an examination, the surgeon tells the family doctor that he has corrected the back problem so there should be nothing wrong and suggests that the problem is "behavioral." He refuses to see the patient and advises she seek psychiatric help. (ft is subsequently found on myelogram X-ray that the patient has a new nerve r o o t compression from a re-extruded disc.)

The patient's expression of pain is discounted, psychologized.

Why? Because, for this doctor, it does not conform to the

biomedical mode1 within which he is immersed. In the first

place, the patient did not conform to expected standards of

behavior - she lived with the pain for a year without doing

anything about it. In the second place, she complained of pain

after the cause was ostensibly removed. As Kirmayer sumarizes

the case:

The disease revealed by the physical examination and technical instruments is at once more real and more important than the patient's subjective distress. The rational order of medicine eclipses the bodily-felt reality of the patient. If biology provides no rationale for suffering then medicine can wash its hands of the patient who must be responsible for her own recalcitrant problem. 5 6

This statement too, generalizes the response of medicine. And

it is not clear that such generalizations are fair. Not al1

doctors respond in such ways. However, the physician in the

above examples does. He articulates his biomedical paradigm,

extends it. And he feels compelled to do so. In the face of

anomaly - distress with no perceived biological cause - he feels compelled to make sense of it, to construct it in line with the

assumptions he has available to him, and in particular, with the

assumption of individual responsibility. He paradigmatically

extends the semi-tangibility with which he is faced. In this

way he leaves his biomedical world intact, and his failure to

address his patientf s pain, rationalized. His maneuver acts 'to

maintain the rationality and coherence of the biomedical world

view. . . ,,57 Moreover, his maneuver imposes an assumption that may

not apply - t h a t may be inappropriate - as evidenced by the

subsequent discovery of a new nerve root compression.

Now, 1 want to be clear. I am not suggesting that

psychosomatic illnesses do not exist. They probably do exist.

And 1 am not suggesting that physicians unequivocally or

purposefully misrepresent problems in line with their

assumptions when identifying patients as psychosomatic. What I

am suggesting, however, is that the attribution psychosomatic

illness may be inappropriate in certain cases, being nothing

more legitimate than a transformation of the anomalous into the

paradigmatically conformed. The attribution is much more common

among patients, for example, whose conditions challenge and

confuse the medical model, whose conditions, for example, are

"characterized by chronic, relapsing, and unpredictable course,

often with a poor prognosis"; whose conditions are "less

controllable by conventional medical treatments . In the face

of individual anomalies, clinicians may very well

respond ... by increasingly "psychologizing" the condition - Le., by shifting responsibility for etiology of £lare-ups [for example] to patientsf emotions, personality, or early psychological experiences. 5 9

And it is this "psychological" condition which is then

objectified, which is then made a part of reality.

Moreover, it is the emotions, the personality and the early

psychological experiences that are objectified as the causes of

the condition, that are "split off and reified as impersonal

causal agents responsible for the patientf s illne~s."~~ These

emotions, personalities and psychological experiences become the

reality, the reality, moreover, to which patients often succumb.

Patients often corne to explain '"their chronic ill-health by

def ining themselves as too "obsessive, " as "perfectionists, " as

"anal, " as "sensitive, " or as people who "hold to rnuch in"' . 6 1 Hysterics, similarly, fa11 into their prescribed role.

To sum up: Slavneyf s62 approach to hysteria is, 1 think,

particularly valuable. In his view, we need to see hysteria

from a variety of perspectives to see what each reveals. He

talks in particular about four perspectives within the field of

psychiatry - the disease perspective, the dimensional perspective, the behavioural perspective and the life-story

perspective. From the viewpoint of the disease-perspective,

however, which demands an etiology, he concludes there is

nothing much to see. It reveals little if anything about the

condition. Wandering wombs are a fabrication, and in their

absence, nothing else, no malfunction, no broken part, exists . Thus, we cannot conclude that hysteria is something someone has.

Still, it may be sornething sorneone is or does, by playing out a

prescribed role, for example. In any case, medicine, in having

claimed d i s e a s e (1 am speaking historically) for hysteria, 6 3 exceeded its \'compass". In "trying to Say everything, it . . . made

insupportable claims. " 6 4 In other words, it p a r a d i g m a t i c a l l y

extended and imputed into e x i s t e n c e a f a b r i c a t i o n . I t c o n c e i v e d

a c o u n t e r f e i t .

And this, I am suggesting, describes much of the history of

hysteria. While individuals have c e r t a i n l y behaved

"hysterically", the "disease" hysteria was little more than a

social construct created to rnake sense of certain aberrant

behaviors, a manifestation of particular social anxieties

exercised through medicine, a product of paradigma tic extension

inforrned by patriarchy, a product, moreover, emergent through

the social infiltration of women' s (threatening and semi-

t a n g i b l e - £rom this perspective) corporeal existence, and prescriptive of the role certain "deviant" women played out. As

such, hysteria was a socially-conceived-disease, the

manufactured fruit of a particular medical articulation that

went the way of extension.

These are strong claims, and they are premised rnost

significantly on the notion that there was (and is) nothing

biologically foundational to hysteria-as-disease. That is, the

construct hysteria-as-disease boasted no ties to veritable

malfunctions (besides the patriarchal notion that femaleness was

i t s e l f malfunction, which, of course, it was (and is) not) . Then again, perhaps 1 am too q u i c k to dismiss the biological

here. Maybe there was (and is) something foundational to

hysteria, something that underlayed it, some malfunction that

sought expression. But even if there was, let me suggest that

it was highly ambiguous, ambiguous in the sense that there was

nothing about the body that cried "malfunction" in the way that

it cries "malfunction" with TB, or heart attacks, or scurvy, or

strokes.

Relatedly, there is the issue of causality: did hysterical

malfunctions originate in the body, or were they produced

through living-out the hysterical role? (Or another option:

maybe they both originated in the body, and were produced

through living-out the hysterical role. . . . ) As noted, I take

the latter position. But let me note as well that my position

betrays a (potentially unwarranted) bias on my part, one that

may require further justification.

Menopause

Unlike hysteria, menopause is clearly associated with an

underlying biological reality. The reality that aging occurs,

that fertility loss occurs, that the cessation of menstruation

occurs, is undeniable. 65 1, therefore, consider rnenopause-as-

disease as less a construction than hysteria which, for me,

indicates variation within the category socially-conceived-

diseases. For this reason, 1 have decided to include it as an

example.

Menopause has ties in biological processes that really occur,

unlike a wandering womb. And yet, from a sociological point of

view, "menopause is a social construct and not a separate, 6 6 independent, biological entity". More specifically, the

disease menopause (referred to as an estrogen deficiency disease

or as an ovarian dysfunction6'), is a social construct. 6 8 ~t is a

"disease. " As Kauf ert and Gilbert put it : " . . .menopause can be interpreted as the imposition of a structure and a set of

boundaries on a reality that is essentially a m ~ r ~ h o u s " ~ ~ - on a

reality that is essentially semi-tangible. Questions like: how

should we address this reality? Does it constitute a disease or

just a normal part of life? are addressed, and essentially so,

in line with social assumptions. Such questions are not

answered so clear ly by the phenornenon itself, as in the case of

AIDS as we shall see, or stroke. In other words, menopause-as-

disease can be interpreted as the product of the social, of the

medical paradigmatic pervasion of real physiological processes.

It is, as with hysteria, a disease conceived through

medicalization, through paradigmatic extension by proponents

championing the medical model. This becomes clear when

contrasted to the alternative notion of menopause-as-normal as

discussed below.

When you think of it , the construction menopause-as-disease is not surprising. As a reality it demands attention, affecting

the "lives of women in a pronounced way. . . by ending menstruation and the ability to conceive . . . " Viewed in this way, "it seems

both predictable and logical that menopause should take on

special significance in the specific cultural traditions in

which the process takes place. "70 It is logical that, in our

society where medicine plays such a significant role, it should

take on the special significance of disease. And this it

certainly has.

Consider the following medical descriptions of the condition: 7 1

"The postmenopause should be regarded as a sex-linked endocrine deficiency disease which requires careful

evaluation, management and follow-up." (An Australian gynecologist )

The menopause Y s a hormonal deficiency state and, like al1 endocrinopathies, should be managed as vigorously as need be and without a necessary limitation of time." (Dr. Don Gambrell, Professor of Endocrinology and Obstetrics at the Medical College of Georgia)

And there are a plethora of other examples such as:

The menopause is an inevitable consequence of aging in the woman. Evidence demonstrating the adverse effects of the accompanying loss of ovarian hormone secretion has made the treatment of the menopause a major therapeutic and preventive health issue. 72

Kaufert et al. characterize this medical position well:

Within the language of medicine .. . menopause has been given many of the characteristics of a disease. Reading the medical literatuxe, a physician will find patients defined as menopausal in much the same fashion as they are labelled diabetic or arthritic. Symptoms are attributed to menopause just as they are attributed to gall bladder disease and stomach ulcer. In the literature, menopause is a condition to be diagnosed and treated. The phrases used to describe menopause, such as "ovarian f ailure" or "estrogen def iciency, " create an impression of pathology, which is heightened by menopause being blamed for an increase in the risk for coronary heart disease, osteoporosis, and urinary incontinence. Physicians are told that they must act preventively and protect their patients by replacing the lost estrogen. Al1 these words - diagnosis, prevention, treatment, symptoms - signify disease in the lexicon of medicine. 7 3

Having quoted this, we are faced with the question of how fair

such a statement is. Perhaps it makes too much of a

generalization where generalization is not wholly warranted.

Does the idea of menopause-as-disease really pervade the medical

establishment to the extent the above statement implies?

Such reservations notwithstanding, there remains little doubt

that the construct menopause-as-disease has received much

credence within the medical paradigm. And so rny focus is: why

treat it as a disease? The answer is quite simple as implied

already. The notion of menopause-as-disease fits well within

the rnedical view, a view that tends to dominate. Lt, moreover,

"irnplies a concrete medical course of action.ff74

On the other hand, medicine certainly did not always recognize

menopause as a disease. The mid-life women seeking medical

assistance for her troubles was commonly treated not so long ago

as a "stateless refugee" one denied "citizenship in the land of

the sick. ff75 She was a hypochondriac, a person devoid of any

legitimate claim to complaint. She was frowned upon, often

patronized.

But this al1 changed. The mid-life woman has become

medicalized, and her disease made the focus of a massive medical

undertaking. She has become the prime sub j ect for intervention

while the remainder of her life is characterized as problernatic

and dependent upon medicine for a return to normality. At least

much of medicine has corne to depict her life as such.

Statements such as the following, made as recently as 1994, are

indicative:

As the "baby boomers" are approaching mid-life and looking at menopause and andropause looming on the horizon, our society is suddenly demanding that the medical profession focus its attention on the golden age of life. Nearly one third of a womanf s life is now spent beyond the age of 50. In this context, we felt it was imperative to address specifically, and in a comprehensive rnanner, the rnedical issues which

76 pertain to the menopause.

The fact that the above is quoted in the preface to a book

titled Comprehensive Management of Menopause containing articles

by a range of medical experts that in large measure (but with

some notable exceptions), support and/or take for granted the

idea of the need for medical management, is even more