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0160-7987/X0/0201-ooO3S02.00/0

REIFICATION AND THE CONSCIOUSNESSOF THE PATIENT

MICHAEL T. TAUSSIGDepartment of Anthropology, The University of Michigan,Ann Arbor, MI 48109, U.S.A.

Abstract-The signs and symptoms of disease do something more than signify the functioning of ourbodies: they also signify critically sensitive and contradictory components of our culture and socialrelations. Yet, in our standard medical practices this social language emanating from our bodies ismanipulated by concealing it within the realm of biological signs. I try to show this by means of apatients interpretation of the meaning of her illness. This case study illustrates that in denying thehuman relations embodied in signs, symptoms, and therapy. we mystiiy those relations and also repro-duce a political ideologv in the guise of a science of physical things. This I call reificarion, following KarlMarxsanalysis of the&mmodzy and Georg Luk&s gpplication of this analysis-to the interpretaiion ofcapitalist culture and its mode of objectifying social relations. I argue that in sustaining reification, ourmedical practice invigorates cultural axioms as well as modulating the contradictions intrinsic to ourculture and views of objectivity. In this way disease is recruited into serving the ideological needs of thesocial order, to the detriment of healing and our understanding of the social causes of misfortune.

THE MARXIn PROBLEM: RElFlCATlONBy means of a cultural analysis of an illness and itstreatment in the USA in 1978, I wish to direct atten-tion to the importance of two problems raised byMarxism and by anthropology concerning the moraland social significance of biological and physicalthings. I am going to argue that things such as thesigns and symptoms of disease, as much as the tech-nology of healing, are not things-in-themselves, arenot only biological and physical, but are also signs ofsocial relations disguised as natural things, concealingtheir roots in human reciprocity.

The problem raised by Marxism comes from thefamous essay of Georg LukLs published in 1922 en-titled Reification and the Consciouness of the Prole-tariat, an essay which had explosive impact on theEuropean Communist movement, in good part due toits critique of historical materialism as developed byEngels, Lenin, and the theoreticians of the GermanSocial Democrat Party. In essence, Luklcs chargedthat the concept of objectivity held by capitalist cul-ture was an illusion fostered by capitalist relations ofproduction and that this concept of objectivity hadbeen thoughtlessly assimilated by Marxist critics whowere, therefore, upholding basic categories of thesocial form they thought they were impugning.Lukics attempted to construct a critical sociology ofbourgeois knowledge which assailed the very theoryof knowledge or epistemology which he felt was basicto capitalist culture. The Kantian and neo-Kantianantinomies between fact and value, as much asthe empiricist copy-book theory of knowledge sharplydividing objectivity from subjectivity, were, inLukPcs opinion, tools of thought which reproducedcapitalist ideology (even if they were deployed withina so-called historical materialist framework ofanalysis). The roots of the thought-form which tookthe capitalist categories of reality for granted were tobe found, he argued, in what he called the com-modity-structure, and a chief aim of his essay was to

draw attention to the central importance of the analy-sis of commodities in Marx portrayal and critique ofcapitalism. There was no problem in this stage of his-tory, claimed LukBcs, that did not lead back to thequestion of the commodity structure, the central,structural problem of capitalist society in all itsaspects. Intrinsic to this problem lay the phenomenonof reification-the thingification of the world, persons,and experience, as all of these are organized andreconstituted by market exchange and commodityproduction. The basis of commodity-structure, wroteLuklcs, is that a relation between people takes onthe character of a thing and thus acquires a phantomobjectivity, an autonomy that seems so strictlyrational and all-embracing as to conceal every traceof its fundamental nature: the relation betweenpeople [ 11.It is with the phantom-objectivity of disease and itstreatment in our society that I am concerned, becauseby denying the human relations embodied in symptoms, signs, and therapy, we not only mystify thembut we also reproduce a political ideology in the guiseof a science of (apparently) real things-biologicaland physical thinghood. In this way our objectivity aspresented in medicine represents basic culturalaxioms and modulates the contradictions inherent toour culture and view of objectivity. Rather thanexpound further, I now wish to exemplify these all tooabstract orienting premises by means of a concreteethnographic analysis of a sickness. But before doingso, I have to draw attention to a problem raised byanthropology, namely by Evans-Pritchards classicanalysis of Azande witchcraft published in 1937 [2].

THE ANTHROPOLOGICAL PROBLEM: THEBIOLOGICAL BODY AND THE SOCIAL

BODYIt is surely a truism that the sense of self and of the

body change over time and vary between different3

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4 MICHAEL T.TAUSSIGcultures. in modern capitalist culture the bodyacquires a dualistic phenomenoiogy as both a thingand my being, body and soul. Witness Sartreschapters on the body in Being and Nothingness [3],Of course the physicians who have taken care of me, thesurgeons who have operated on me, have been able to havedirect experience with the body which I myself do notknow. I do not disagree with them. I do not claim that Ilack a brain, a heart, or a stomach. But it is most impor-tant to choose the order of our bits of knowledge. So far asthe physicians have had any experience with my body, itwas with my body in the midst of the world and as it is forothers. My body as it is for me does not appear to me inthe midst of the world. Of course during a radioscopy Iwas able to see the picture of my vertebrae on a screen, butI was outside in the midst of the world. I was apprehendinga wholly constituted object as a this amongst other thises,and it was only a reasoning process that I referred it backto being mine; it was much more my property than mybeing.

As it oscillates between being my property and my.being, especially when diseased, my body asks mequestions which the physician never ask or answer:Why me?, Why now? As Evans-Pritchardobserved, these are the questions foremost in theAzande at~ibution of serious sickness or misfortuneto witchcraft or sorcery-Le. to the malevolent dispo-sition of critically relevant social relationships.Science, as we understand it in our day and age, can-not explain the human significance of physical effects.To cite the common phraseology, science, like medi-cal science, can explain the how but not the whyof disease: it can point to chains of physical cause andeffect, but as to why I am struck down now ratherthan at some other time, or as to why it is me ratherthan someone else, medical science can only respondwith some variety of probability theory which is un-satisfactory to the mind searching for certainty andfor significance. In Azande practice, the issues of-how and why are folded into one another; aetio-logy is simuit~eously physical, social, and moral.The cause of my physically obvious distress is to belocated in my nexus of social relations involvingsomeone elses unjustly called for malevolence. Thisproperty of my social nexus expresses itself in physicalsymptoms and signs. My disease is a social relation,and therapy has to address that synthesis of moral,social, and physical presentation.

There are two problems raised by this account.First, do patients in our society also ask themselvesthe questions that Azande do, despite the disenchant-ment of our age and its incredulity regarding witch-craft and sorcery? Second, have we not falsifiedAzande epistemology, following Evans-Pritchard, indistinguishing the how from the why, fact fromvalue, and immediate from ultimate causes? Unlesswe firmly grasp at the outset that these are not thesalient native distinctions but that they are ourswhich we necessarily deploy in order to make somesense out of a foreign epistemology, we will fail toappreciate what is at issue. The salient distinction tonote is that in Azande epistemology there is a vastlydifferent conception of facts and things. Facts are notseparated from values, physical manifestations are nottorn from their sociai contexts, and it requires there-fore no great effort of mind to read social relations

into material events. It is a specifically modern prob-lem wherein things like my bodily organs are at oneinstant mere things, and at *another instant questionme insistently with all too human a voice regardingthe social significance of their dis-ease.Paul Radin in his discussion of the concept of theself in primitive societies makes the same point. Hesuggests that the objective form of the ego in suchsocieties is generally only intelligible in terms of theexternal world and other egos. Instead of the ego as athing-in-~t~lf, it is seen as indissoIubly integrated withother persons and with nature. A purely mechanisticconception of life, he concludes, is impossible. Theparts of the body, the physiological functions of theorgans, like the material objects taken by objects innature, are mere symbols, simulacra, for the essentialpsychical-spiritual entity that lies behind them [4].As it oscillates between being a thing and my being,as it undergoes and yet disengages itself from reifica-

tion, my body responds with a language that is ascommonplace as it is startling. For the body is notonly this organic mosaic of biological entities. It isalso a cornucopia of highly charged symbols-fluids.scents, tissues, different surfaces. movements, feelings.cycles of changes constituting birth, growing old,sleeping and waking. Above ail, it is with disease withits terrifying phantoms of despair and hope that mybody becomes ripe as little else for encoding thatwhich society holds to be real-onty to impugn thatreality. And if the body becomes this importantrepository for generating social meaning, then it is intherapy that we find the finely gauged tuning wherebythe ratification of socially engendered categories andthe fabulation of reality reaches its acme.In any society, the relationship between doctor andpatient is more than a technical one. It is very much asocial interaction which can reinforce the culturesbasic premises in a most powerful manner. The sickperson is a dependent and anxious person, malleablein the hands of the doctor and the heaith system, andopen to their m~ipulatjon and moralism. The sickperson is one who is plunged into a vortex of themost fundamental questions concerning life anddeath. The everyday routine of more or less uncriticalacceptance of the meaning of life is sharply inter-rupted by serious illness which has its own pointedway of turning all of us into metaphysicians and phi-losophers, (not to mention critics of a society whichleaves its sick and their families to fend for them-selves). This gives the doctor a powerful point of entryinto the patients psyche, and also amounts to a de-structuration of the patients conventional under-standings and social personality. It is the function ofthe relationship between the doctor and the patient torestructure those understandings and that persona-lity; to bring them back into the fold of society andplant them firmly within the epistemological andontological groundwork from which the societysbasic ideological premises arise. In modern clinicalpractice and medical culture. this function is camou-flaged. The issue of control and manipulation is con-cealed by the aura of benevolence. The social charac-ter of the medical encounter is not immediately

obvious in the way that it is in the communal healingrites of primitive societies. With us, consultationand heating occurs in privatized and individualistic

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6 MICHAEL T. TAUSSIGmight be the cause of her disease. it turned out thatshe constantly asked herself why she had it, neverstopped asking herself why?; Why me, Oh Lord,why me?

Her search for explanation and meaning remainsdissatisfied with what the medical profession offers.As we shall see, she demands a totalizing synthesiswhich she herself provides by reading contradictorycultural themes into her symptoms, signs, and pro-gress. These contradictions are exhibited by her reac-tions to the obicer dicta of medical professionals, tothe patterns of discipline enforced by the hospital, andto the conflicts systematically coursing throughsociety in general. Moreover, her mode of under-standing and explanation runs counter to the masterparadigms in our culture which dichotomize mindfrom matter, morality from physical determinism, andthings from the social context and human meaningin which they inhere. In being foreign to acceptedcultural consciousness in these crucial ways, herattempts to provide a synthetic understanding ofphysical things cannot but be tensed and prone toinstability.

Her first response was to say that the cause of hercondition is an unhappy reason. At the age of 15and contrary to her mothers desire, she married afactory worker who soon became unable to supporther and the five children born in the following 5 yearsdue to his alcoholism. She had a tubal ligation fol-lowed shortly thereafter by a re-stagement, and thensix more pregnancies all resulting in miscarriages. Shetook in washing, ironed, and gleaned garbage for bot-tles which she sold. There was rarely money sufficientfor food and she was constantly exhausted andhungry. She would go without food in order to give itto the children who were frequently sick. In turn, shecaught many of their sicknesses, because she was soweak and tired. Life was this endless round ofpoverty, exertion, exhaustion, and sickness. Surelythat could cause polymyositis, she says. You cantake a perfect piece of cloth and if you rub it on thescrub board long enough, youre going to wear holesin it. Its going to be in shreds. You can take a healthyperson and take away the things that they heed thatare essential, and they become thin and sickly. So Imean.. it all just comes together. She has neverapproached her doctors with this idea because Theywould laugh at my ignorance. But it does seem right;that tiredness and work all the time. Take thechildren of India without enough food, dragging theirswollen bellies around, tired and hungry. Surely theycould have this disease too. Only because they haventgot hospitals, nobody knows it.

In making these connections, the patient elaborateson the connection she has in mind between poly-myositis as muscle degeneration and her life-exper-ience of oppression, of muscular exertion, and ofbodily sacrifice. What seems especially significant hereis that the causes she imputes as well as her under-standing of the disease stand as iconic metaphors andmetonyms of one another, all mapped into the diseaseas the arch-metaphor standing for that oppression.This could well form the highly charged imagery lead-ing to a serious critique of basic social institutions.But, as we shall see, other aspects of the situationmitigate this potentiality.

She then went on to develop the idea that therealso exists an hereditary or quasi-hereditary causalfactor. In her opinion. one of her daughters is possiblyafflicted with the disease, and two of that daughtersdaughters also. She feels extremely close to thisdaughter, to the point where she maintains that thereis a mystical attachment between them, of Extra-Sen-sory Perception, as she says. Even when they are farapart physically, each one knows what is happeningto the other, especially at a time of crisis, when theycome to each others aid. She elaborates on the con-cept that the disease is present in this matriline, mani-festing itself in four distinct stages correlated to thefour ages of the four females involved. In passing, it isworth noting that the males in the family historycome in for little mention with the exception of herfirst husband who is seen as a destructive and evenevil figure. Her immediate social world is seen by heras centered on the history of four generations ofwomen, beginning with her mother who raised thefamily in dire poverty. This characteristic matriline orreciprocating women in the networks of working classfamilies is in this case vividly expressed by the mysti-cal closeness she feels for her daughter, and by themapping of these social relations into the disease as ametaphor of those relations.

The fact that the youngest granddaughter involvedwas seriously ill when a few months of age, and thatthe doctors found an orgasm in her blood, suggeststo the patient the possibility that a foreign-agent orbacterial aetiology plays a part too; the foreign-agentdisappearing into the body to slowly develop the full-blown presentation of the disease at a later date. Theattribution of disease to a foreign-agent would seemas old as human-kind. But only with modern Westernmedicine and the late nineteenth century germtheory of disease did this idea largely shed itself ofthe notion that the foreign-agent was an expression ofspecific social relations. In this patients case, how-ever, the foreign-agent aetiology is systematicallywoven into the fabric of her closest relationships andmetaphorically expresses them.

Finally, the patient develops the idea that Godstands at a crucial point in the causal complex. Shementions that God gave her this disease in order toteach doctors how to cure it-a typical resolution ofthe oppositions redolent in her account of passivityand activity, receiving and giving, crime and sacrifice.She notes that in the Bible it is said. to seek first andthen go to the Lord, meaning, she says, go first to themedical profession and then try out religion. It is thislong march that she has indeed put into practice asmuch as in her working through a theory of aetiology.At this stage of our discussion, she summarized agood deal of her position thus.

You see, protein builds muscle and yet mychildren were lucky if they got protein once a month,and I was lucky. Now I have polymyositis, plus thearthritis, and my daughter has arthritis of the spine,and her little daughter is affected by it, has inheritedit, plus her younger daughter yet. Now there seems tobe a pattern there. You see I was deprived of it andmy children were deprived of it and weve both comedown with a chronic disease. Were not too sure thatshe doesnt have polymyositis. The breakdown of themuscles and the tissues due to strain and work were

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8 MICHAEL T. TAIJSSICI ask her why another patient couldnt help her

walking. She replies. Because she would teach youwrong, when a professional already knows and hasevaluated your muscle strength. And there, uh, youknow automatically that you can trust the nurse. ButBecky hasnt been taught how to grab me or stabilizeme.. . or to tell me which muscle to use to keepmyself from collapsing. So, see, she cant help me pro-fessionally. So our whole friendship has to be ona.. . on a I like you and you like me basis. That tech-nician still has her mind working on far beyond mine.Mine is strictly in trying to accomplish what she hasalready learned and knows.

I ask ; But say the professional teaches you to walkbackwards and forwards between a couple of thingsseveral times a day. Couldnt someone like Becky whoisnt bedridden help you to exercise?

No! Because she doesnt know the extent of yourenergies.

But the professional does?The professional has to figure this out before she

starts the exercises.You yourself wouldnt know the capacity of your

own energy so you could tell?No! No!Here the loss of autonomy to which Ivan Illich

refers in his book Medical Nemesis is strikinglyexpressed [S]. The potential within the patient asmuch as that which exists between patients for devel-oping a therapeutic milieu is agonizingly cut short.The relationship with other patients becomes almostpurely expressive, while the relationship with theprofessionals becomes purely instrumental. As eachtype of relationship is driven to its extreme in puresubjectivity and pure objectivity, so each is threatenedwith self-destruction as it teeters on expressivenesswithout substance, and instrumentation withoutexpression or participation. The replication of ourcultural epistemology into subject-hood and object-hood is here presented in its most naked form. Thesame epistemology is also replicated in the patientsunderstanding, reinforced by the professionals, of theworkings of her body; namely the structure and func-tion of musculature. As opposed to an organic con-ception of the inner dialectical interplay of muscleswith one another and with thought and will, heremuscle function is conceived of atomistically, separatefrom mind and will, and each muscle is objectified assomething separate from the synergistic interplay ofmusculo-skeletal holism. And in her regarding theprofessional as knowing better than she as to theextent of her energies, we may well-regard the aliena-tion of her own senses as complete, handed over tothe professional who has become the guardian orbanker of her mind.This splitting of subjectivity from objectivity asrepresented by patient-good and professionalism, re-spectively, resulting in the capturing of her subjec-tivity by the professional, is as much a result of thepatients inability to develop the mutual aid potentialstill present in the patient sub-culture as it is due tothe relationship between professional and patient. Theformer derives from the latter, and both contraststrikingly with the social relations and culture de-scribed by Joshua Horn for the Chinese hospitals inwhich he worked from 1954 to 1969.

The patients often select representatives to convey theiropinions and suggestions to teams of doctors. nurses andorderlies who have day-to-day responsibility in relation tospecific groups of patients. These teams meer daily to planthe days work. Ambulant patients play an active part inward affairs. They take their meals in the ward dining-room and many of them help patients who are confined tobed, reading newspapers to them. keeping them companyand becoming familiar with their medical and social prob-lems. I conduct a ward round in a different ward each dayand as I do so, I usually collect a retinue of patients whogo with me, look and listen and often volunteer informa-tion [9].

The alienation of the patients self-understandingand capacity is all the more striking when we learnthat she has extensive practical experience with physi-cal therapy and that out of the hospital context andaway from the aura of professionals, she does in factregard herself as skilled and powerful in this regard.Speaking about her sprained knee suffered some yearsback she says, And then I had to learn to walk again.Im always learning to walk! I really ought to be well-trained. I could be a therapist.. I trained mydaughter after she had polio. And they refused to takeher at the polio center. I taught her to walk. Her leftside was paralyzed (the same side that the patientalways refers to as her weak and occasionally almostparalyzed side). I learnt from a friend. I used tohave to get up and Id sit on top of her and stretchher hamstrings and stretch her arm muscles andthings and it was 3 months before I got any responseat all. And then one night when I was stretching herhamstrings she screamed because she said that it hurttoo much. Well I sat down and had a good cry.Mother couldnt even continue therapy that night.And from then on, the more it hurt, the more therapyI gave her. And the year from the day that they toldme shed never walk again, I walked back in to thedoctor and I showed her what one person could dowith Gods help. You have to be gentle. And thiscomes from love, compassion, and the desire to helpanother human being. And youd be surprised howreally strong my hands are I never lose the strength ofmy hands. I dont know why. But through all of this Ihave never completely lost my.. my hands.

So, we are faced with a contradiction. And this con-tradiction is just as much present in the hospital situ-ation and in the professional-patient relationship sothat the loss of autonomy and the cultural lobotomi-zation is never complete. For a few days later thepatient refused what was considered an importantpart of her treatment, just as during an earlier stay inhospital she created a wild scene by throwing hercoffee on the floor when the staff refused to give hermore medication for pain.On this earlier occasion she insisted that her painwas increasing. The staff regarded this as secondarygain. The nurses plan was to give support and reas-surance; allow the patient to express her feelings.Monitor emotion regarding status and shift. It is, ofcourse, this mode of perception--monitor emo-tion . . -which so tellingly contrasts with the typeof observation that passes between patients, andwhich should be referred back to my earlier citationfrom Foucault, the perception which

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Reification and the consciousness ol the patient 9does not allow of reciprocity: only the nearness of anobservation that watches, that spies, that comes closer inorder to see better, but moves ever further away, since itaccepts and acknowledges only the value of the Stranger.

Following the innovation and supposedly morehumane problem-oriented approach, which is nowalso taught to medical students, the nurses progressnotes are written up in the form of the different prob-lems the patient has. Each problem is then analysedinto four parts in accord with the S.O.A.P. formula:Subjective (the patients perception), Objective (thenurses observation), Analysis (interpretation of data),and Plan. Soap--the guarantee of cleanliness and thebarrier to pollution! Subjectivity, objectivity, analysis,and plan! What better guarantee and symbolicexpression could be dreamt of to portray. as if byfarce, the reification of living processes and the aliena-.tion of subject from object? And, as one might sus-pect, this formulation is congruent with the need forcomputerizing records and more rationally preparingsafeguards against malpractice suits. The Plan? Givesupport and reassurance. Relate feelings of trust.How much does this packaging of care, trust, andfeelings. this intstrumentation of what we used tothink of a spontaneous human transitiveness andmutuality, cost, according to Blue Cross?

A few days later, the patient complained of morepain, and of her inability to urinate (although accord-ing to the nursing staff she could urinate). The nightfollowing she became angry and threw her coffee at anurse who then called a doctor. He reported; Patienthad a significant episode of acting out. Accused nurs-ing personnel and myself of lying and disrespect. Ex-tremely anxious and agitated. Crying. Had thrown acup of coffee at the R.N. (Registered Nurse). Patientrefused to acknowledge any other precipitating eventor underlying emotion. Husband arrived and calmedpatient down. Psychiatric recommendation with Dr Yand began initiating dose of Haloperidol. Will alsoadd 75 mg/day amitriptiline for apparent on-goingdepressive state with anxiety. (Haloperidol is de-scribed by Goodman and Gillman [lo] as a drugwhich calms and induces sleep in excited patients.Because it produces a high incidence of extrapyrami-da1 reactions it should be initiated with caution.)This is the first time that the doctors notes mentionthat the patient is distressed, although the nursesnotes chart her increasing dissatisfaction going backover several days. The nurses report of the same inci-dent leaves out. for the first time, the S (subjectivecategory) and goes straight to Objectivity:. Patientwas so upset when she was told that somebody saidthat she can get out of bed and use the bedside com-mode. She said that nurse is.. . and for her angerthrew her cupbf coffee on the floor. Crying and wantsher husband to be called because shes very upset.Saying dirty words. Analysis: Patient is very upset.Plan: Dr X notified and patient was told to calmdown since shes not the only patient on the floor,that others are very sick and upset from her noise.Patient claims that she is not sick. Patient quietsdown when her husband came and friendly to thenurses. The next day the doctors notes say that thepatient is quite angry and that her anger takes theform of sobbing and threatening to leave hospital and

warn friends about care here. The day after that, thenurses report that the chaplain talked to the patientfor half an hour so shell be able to release all hertensions, anxiety, and conflict. The chaplain said thatshes angry of something. The Plan notes that thechaplain will come every day and that shes a bit nicerto the staff and courteous when she needs something.The doctors notes describe the patient as stableand thereafter never mention her scene. The nursesreport says that she is still complaining of pain, Sub-jective category, and requesting pain medication,Objective category. As for her anxiety problem theObjective entry says she is talking about how peopledont believe she can do nothing for herself. And thenext day she went home.

It is surely of some importance that the patient wasexamined (sic) by a psychiatrist the morning of thesame day when she later threw her coffee (on thefloor, according to the nurses; at a nurse, according tothe doctor). The nurses report noted that she wascrying and trembling following the visit of the psy-chiatrist, whose own report says that the evidence isstrongly suggestive of an organic brain syndrome.She said it was January when it was December. Thepsychiatrist had just wakened her. She demonstratedsome looseness of associations, at times was difficultto follow as she jumped from topic to topic, and onserial subtractions from 50 she made three errors.Having stated that the evidence was strongly sugges-rive of an organic brain syndrome (i.e. a physical dis-ease of the brain) the psychiatrist in his Recommehda-tions wrote: Regarding the patients organic brainsyndrome. . . In other words, what was initially putforward as a suggestion (and what a suggestion!) nowbecomes a real thing. The denial of authorship couldnot be more patent.

The significance of this episode is that apart fromillustrating yet another horror story of hospitalizationit reveals how the clinical situation becomes a combatzone of disputes over power and over definitions ofillness and degrees of incapacity. The critical issuecenters on the evaluation of incapacity and of feelings,such as pain, and following that on the treatmentnecessary. Here is where the professionals deprive thepatients of their senSe of certainty and security con-cerning their own self-judgement.

By necessity, self-awareness and self-judgementrequire other persons presence and reflection. In theclinical situation, this dialectic of self and other mustalways favor the defining power of the other writteninto the aura of the healer who must therefore treatthis power with great sensitivity lest it slip away intoa totally one-sided assertion of reality, remaining arelationship in name only. The healer attempts tomodulate and mold the patients self-awareness with-out dominating it to the point of destruction, for ifthat happens then the healer loses an ally in the strug-gle with dis-ease. Yet, as illustrated in this case study,a quite vicious procedure precludes this alliance andthe patient is converted into an enemy. It is not, asIllich maintains, for example, that patients lose theirautonomy. Far from it. Instead, what happens is thatthe modern clinical situation engenders a contradic-tory situation in which the patient swings like a pen-dulum between alienated passivity and alienated self-assertion.

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10 MICHAEL T. TAUWGParadoxically, this follows from an ever-increasingself-consciousness on the part of health professionalsto be more humane and to self-consciously allow thepatients definition of the problem a privileged placein the medical dialogue, only to co-opt that definition

in a practice which becomes more rationalized as itbecomes less humanized. This rationalizationamounts to an attempt to wrest control from thepatient and define their status for them by first com-partmentalizing the person into the status of patient-hood, then into the status of thing-hood as opposedto that of a mutually interacting partner in anexchange, and then into the categories of Objectiveand Subjective, working through these reifications byan Analysis and a Plan. The analogy with the rationa-lity of commodity production is complete. As withautomobiles on the assembly-line, so with patientsand with health itself, the difference, the pathos, andthe occasional problem bearing mute testimony to thefact that unlike automobiles, patients do think andfeel, and that sickness is as much an interactivehuman relationship as a thing-in-itself.My intention here is not only to direct attention tothe callousness that results. In addition, we have todeal with the complicated mystification present inhealing in any culture, but which in our own modemclinical setting perniciously cannibalizes the potentialsource of strength for curing which reposes in theinter-subjectivity of patient and healer. In the name ofthe noble cause of healing, the professionals havebeen able to appropriate this mutuality and in a veryreal sense exploit a social relationship in such a waythat its power to heal is converted into the power tocontrol. The problems that ensue, at least as illus-trated in this case study, lie in the very nature of theclinical setting and therefore are especially opaque tothe therapists. As the Chaplain so forlornly noted,Shes angry of something, and this anger stems fromthe contradictions which assail the patient. On theone hand she sees the capacity for mere patients toform a therapeutic community. But on the otherhand,. she denies the flowering of this potentialbecause of her being forced to allow the professionalsto appropriate her discretionary powers, while atanother instant she rebels against this appropriation.The circuit of reification and re-subjectification is in-herently unstable. Health professionalization of thisall too common type does not guarantee the smoothcontrol that the staff demand, let alone what patientsneed. All of which will assuredly be met by yet furtherrationalization and more professionalization.On her later admission to hospital and shortly afterfirst talking to me about patients supporting oneanother, only to claim that it required a professionaltherapist to help her walk, the patient suddenlyrefused the ministrations of the Occupational Thera-pists. She complainted that all her day was taken upwith therapy, that the Occupational Therapist tookan hour a day, and that she had time neither to usethe bedpan, to comb her hair, nor to listen to herreligious music. When Im sick, she declared, Icant work eight hours a day! And yet the wholetheory of my disease and getting better is rest. And soI broke down this morning and I told the Occupa-tional Therapist I had to cut her hour out. Ive got tomake an hour sometime during the day when I can

just relax and not be getting in and out of a chairwhich hurts me severely. Theres no time for anythingof a personal nature.. so the stress and the emo-tional conflict is there. And theres never any time tosolve it by myself. And there was no place. becausethere are only eight hours. I cant put twelve hoursinto eight!Again we see that the passive alienation embodiedin her relation with the professionals, which at firstsight appears to be a fait accompli. registers an abruptrupture, a scene. which ripples panic amongst thestaff.The Occupational Therapists, the Physical Thera-pists and the Social Workers were all deeply upset bythis gesture which they saw as a denial of their effi-cacy and of their jobs. When I asked them why theycouldnt leave her alone for a week, their leader rep-lied, Its my Blue Cross, Blue Shield payments asmuch as hers! So, they drew up a contract with thepatient, nowadays a typical procedure in the hospitalas it is in many U.S. schools.Contracting

The staff and the patient both sign a written con-tract stating, for example, What you do have choicesabout. What you do not have choices about,Objectives, What we will do, What you will do.In this patients case the contract stated as objec-tive, walk 30 feet three times a day. What we willdo, protect two 45 min rest periods. What you willdo, try and walk. The underlying motive, as de-scribed by some theorists of medical contracting, isthat the staff will reward the patient for complyingwith their desires (positive reinforcement), rather thanfalling into what is seen as the trap of the old style ofdoing things which, supposedly. was to reinforce non-compliance by paying more attention to such behav-ior than to compliance. It is, in short, Behaviorismconsciously deployed on the lines of market contractsin order to achieve social control. It is the medicationof business applied to the business of medicine. Re-wards cited in the academic and professional journalsdealing with this subject are lottery tickets, money,books, magazines, assistance in filling out insuranceforms, information, and time with the health careprovider [ 111. It has been found that patients oftenchoose more time with the health provider and helpin untangling bureaucratic snarls so as to obtain in-surance benefits and medical referrals.The very concept of the health care provider, sodisarmingly. straightforward, functional, and matter-of-fact, is precisely the type of ideological Iabellingthat drives patients into so-called non-compliance.The health care provider, in antediluvian timesknown as the nurse, doctor, etc., does not providehealth! Health is part of the human condition, as isdisease, and the incidence and manifestations of bothare heavily determined by the specificities of socialorganization. Health care depends for its outcome ona two-way relationship between the sick and thehealer. In so far as health care is provided, bothpatient and healer are providing it, and, indeed theconcern with so-called non-compliance is testimonyto that, in a back-handed way. By pre-establishing theprofessional as the health care provider, the inher-ited social legacy that constitutes medical wisdom and

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Reification and the consciousness of the patient I1power is a priori declared to be the legitimate mono-poly of those who can convince the rest of us that thiswisdom comes from society and nature in a pre-pack-aged commodity form which they and only they candispense. And in choosing as rewards for non-com-pliant patients help in overcoming the snarls whichthe health care providers provided is to heapabsurdity on deception. But the real pathos in this isneither the absurdity nor the deception. It is that itappears, in our day and age, to be so perfectlystraight-forward and reasonable. This is the mark ofideology; its naturalness. And if its nature is to befound in the realm and language of marketing, so thatmedical culture and healing too succumb to the idiomof business, then we must not be all that surprised.For ours is the culture of business which puts busi-ness as the goal of culture.In the same way that freedom and a specific type ofindividualism came long ago to be asserted with therise of the free market economy, so the introductionof contracting in healing today is seen by its pro-ponents to be a bold blow for the assertion of humanrights, shattering the mystification of the feudalpast when patients complied with doctors commandsout of blind trust. The proponents of contracting inclinical settings also tell us that the doctrine on whichit is based, Behaviorism and the laws of reinforce-ment and extinction, have led to the treatment ofmaladaptive human behaviors, including psychoses,retardation, alcoholism, low work productivity, andcriminality [12].Maladaptation is of course not a thing, but a purelynormative concept travelling under the disguise ofscientific jargon. More often than not it serves in con-texts such as these to smuggle in a particular inten-tion or value by making it appear to be a fact like afact of nature. The assimilation of low work producti-vity. criminality, and psychosis to one another asparts of the same fact, maladaptation, and now topatients who disobey doctors orders, serves toremind us just how colossal a distortion is involvedby reifying social relations so that pointed politicalvulues smuggled under the guise of technical con-structs remain immune to criticism, stamped with theauthority of the hard and impenetrable scientific fact.Once again, the nature of truth is seen to lie in thetruth of nature, and not in some critical way asdependent upon the social organization of facts andnature.In the case of the patient described in this casestudy we might note the following. She had everygood reason for not complying with the staffs orders.This reason was not appreciated by the staff. It wasseen as a threat to their power and to the coffers ofBlue Cross. It was not the case, as the aforementionedauthorities on contracting say, that because she wasnon-compliant she was getting more attention fromthe staff. It was totally the opposite. When she wascomplying she was getting too much attention, and allshe wanted was free time. The immediate cause of herfrustration was intimately related to the bureaucraticpressure of her daily routine. The contracting strategychosen by the staff was thus ingeniously selected tomeet this by further bureaucratizing an agreement,the contract, so as to formally deformalize her timeinto therapy time and free time, time which any

freedom lover would have naively thought was hers inthe first place, anyway, and not something to beowned and dispensed by the staff. The idea that shewas free to choose and contract, and the idea thatcontracting per se is both sign and cause of freedomis as pernicious an illusion that the free time the staffwere granting her was not rightfully hers in the firstplace.The argument in favor of contracting, that it clearsaway the mystifications in the murky set of under-standings existing between doctor and patient, that-itincreases the power, understanding, and autonomy ofthe patient, is a fraud. Moreover, it is a fraud whichhighlights the false consciousness as to freedom andindividualism upon which our society rests. Canautonomy and freedom be really said to be increasedwhen it is the staff which has the power to set theoptions and the terms of the contract? If anything,autonomy and freedom are decreased because theillusion of freedom serves to obscure its absence. Fur-thermore, the type of freedom at stake in the contract-ing amounts to a convenient justification for denyingresponsibility and interpersonal obligations, just as inthe name of contract and free enterprise the workingclass at the birth of modern capitalism was told that itwas as free and as equal as the capitalists with whomthey had to freely contract for the sale of their labor-power. There is little difference between that situation,the capitalist labor market, and the one which con-cerns us wherein the clinical setting becomes a healthmarket and one contracts as a supposedly free agentwith the health care providers so as to grant thelatter the right to appropriate the use-value powerembodied in the healing process.

Far from increasing patient autonomy (as its pro-ponents argue), the design of contracting is unabash-edly manipulative.Requests for lS.min of uninterrupted conversation with nteam member, games of checkers, cards and chess, Biblereading, discussion of current events and visits fromvarious team members are examples of rewards chosen bypatients. Such examples as these imply that patients placeconsiderable value on our interactions with them. It alsoindicates that because patients value our relationships withthem, we are in a powerful position for influencing thechoice of behavior the patient ultimately makes; e.g. com-pliance versus non-compliance [13].

Just as we were wont to believe that medical carediffered from business, as in Talcott Parsons analysiswhereby the collectivity orientation of the medicalprofession was opposed to the business ethic of self-interest, only to become increasingly disillusioned, sonow we find that even friendship is something to bebargained for and contracted by 15 min slots. Afterall, if health becomes a commodity to be bought andsold, is it any wonder that friendship should likewisebecome a commodity? And if social relations andfriendship become things, like this, it is equally unsur-prising that the subject becomes object to him or her-self so thatthe patients find it very rewarding to improve their own

baseline. This perhaps is the most meaningful reward of all.Improving ones baseline indicates to the patient that he isessentially competing against himself. He views himself as

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I2 MICHAEL T. TAUSSIGthe one controlling his own behavior. This eliminates theneed for increased interaction when the behavior is unac-ceptable. In other words, the patient graphically knows hisbehavior is unacceptable and we as professionals are freeto ignore the unacceptable behavior [14].

ANTHROPOLOGY: THE NATIVESPOINT OF VIEW

If contracting represents the intrusion of onedimension of the social sciences, Behaviorism, intomedical practice so as to improve and humanizemedical care, then Anthropology too has somethingto add; namely a concern with the natives point ofview. The idea here, as put forward by Kleinman et a[.[16] in a recent article in the presitigious Annals ofInter& Medicine, is that disease and illness representtwo different realities and that illness is shaped byculture. Disease represents organ dysfunction whichcan be modified by the pathologist and measured inthe laboratory, while illness is what that dysfunctionmeans to the person suffering it. Cirrhosis of the liver,for instance, can be represented in disease terms; bythe micropathologist in terms of the architectural dis-tortion of tissue and cellular morphology, by the bio-chemist in terms of changes in enzyme levels, and soon. But to the person afflicted with the disease, itmeans something else and this something else is theillness dimension; the cultural significance of theterm cirrhosis, the meanings read into the discom-forts, symptoms, signs, and treatment of the disease,and so on. This is the natives point of view and it willof necessity differ from the doctors disease view-point. Stemming from their reading of Anthropologyand from their own experience with folk medicine inThird World cultures, Kleinman ef al. hold this differ-ence between disease and illness to be of greatimportance. They advocate an addition to the train-ing of medical personnel so that they too will becomeaware of this difference and act on it. This they callclinical social science and its focus shall be with thecultural construction of clinical reality. Learningand applying this shall improve doctor-patient rela-tionships and the efficacy of therapy, overcoming thecommunication gap between the doctors model ofdisease and the patients model of illness. As withcontracting, non-compliance and the management ofhuman beings is of prime concern.Training modern health professionals to treat both diseaseand illness routinely and to uncover discrepant views ofclinical reality will result in measurable improvement inmanagement and compliance, patient satisfaction, andtreatment outcomes I:161.

Elucidation of the patients model of illness will aidthe clinician in dealing with conflict between theirrespective beliefs and values. The clinicians task is toeducate the patient if the latters model interferes withappropriate care. Education by the clinician is seen asa process of negotiating the different cognitive andvalue orientations, and such negotiation may well bethe single most important step in engaging thepatients trust (Kleinman et al. [17]). Like so muchof the humanistic reform-mongering propounded inrecent times, in which a concern with the natives

point of view comes to the fore, there lurks the dangerthat the experts will avail themselves of that knowl-edge only to make the science of human managementall the more powerful and coercive. For indeed therewill be irreconcilable conflicts of interest and thesewill be negotiated by those who hold the upperhand, albeit in terms of a language and a practicewhich denies such manipulation and the existence ofunequal control. The old language and practice whichleft important assumptions unsaid and relied on animplicit set of understandings conveyed in a relation-ship of trust is to be transformed. The relationship isnow seen in terms of a provider and a client. bothallies in a situation of mutual concern. Kleinman etal. demonstrate this democratic universe in which farfrom cleaning up the old-fashioned mystifications asembodied in trust relationships, new mystificationsare put in their place which are equally if not moredisturbing. With their scheme the clinician

mediates between different cognitive and value orien-tations. He actively negotiates with the patient as a thera-peutic ally. For example, if the patient accepts the use ofantibiotics but believes that the burning of incense or thewearing of an amulet or a consultation with a fortune-telleris also needed, the physician must understand this beliefbut need not attempt to change it. If. however. the patientregards penicillin as a hot remedy inappropriate for ahot disease.and is therefore unwilling to take it. one cannegotiate ways to neutralize penicillin or one mustattempt to persuade the patient of the incorrectness of hisbelief, a most difficult task [17]..It is a strange alliance in which one party avails

itself of the others private understandings in order tomanipulate them all the more successfully. What pos-sibility is there in this sort of alliance for the patientto explore the doctors private model of both diseaseand illness, and negotiate that? Restricted by thenecessity to perpetuate professionalism and the iron-clad distinction between clinician and patient, whileat the same time exhorting the need and advantage oftaking cultural awareness into account. these authorsfail to see that it is not the cultural construction ofclinical reality that needs dragging into the light ofday, but instead it is the clinical construction ofreality that is at issue.

THE CULTURAL CONSTRUCTION OFCLINICAL REALITY, OR THE

CLINICAL CONSTRUCTION OF CULTURE?This is where sensitive anthropological understand-

ing truly sheds light. The doctors and the health careproviders are no less immune to the social construc-tion of reality than the patients they minister, and thereality of concern is as much defined by power andcontrol as by colorful symbols of culture, incense,amulets, fortune-telling, hot-and-cold, and so forth.

What is significant is that at this stage of medicineand the crises afflicting it, such a project shouldemerge. What is happening is that for the first time inthe modern clinical situation, an attempt is underwayto make explicit what was previously implicit, butthat this archaeology of the implicit cannot escape thedemands for professional control. The patients so-called model of illness differs most significantly fromthe clinicians not in terms of exotic symbolization

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Reification and the conscziousness of the patient 13the complacent and everyday acceptance of conven-tional structures of meaning. The doctor and thepatient come together in the clinic. No longer can thecommunity watch them and share in this work.Nevertheless, whether the patient wants to acceptpenicillin or not, whether the rest of us are physicallypresent in the clinic or not, the doctor and thepatient are curing the threat posed to convention andto society, tranquilizing the disturbance that sicknessunleashes against normal thought which is not a sta-tic system but a system waxing, consolidating anddissolving on the reefs of its contradictions. It is notthe cultural construction of clinical reality that is hereat issue, but the clinical construction and reconstruc-tion of a commoditized reality that is at stake. Untilthat is recognize& and acted upon, humanistic medi-cine is a contradiction of terms [20].

but in terms of the anxiety to locate the social andmoral meaning of the disease. The clinician cannotallow this anxiety to gain either legitimacy or to in-clude ever-widening spheres of social relationships. in-cluding that of the hospital and the clinician. for moreoften than not once this process of thought is given itshead it may well condemn as much as accept thecontemporary constitution of social relationshipsand society itself.

Attempts such as those advocated by Kleinman etal. to make explicit what was previously implicit,merely seize on the implicit with the instruments ofmodern social science so to all the better control it.Yet in doing so they unwittingly reveal all the moreclearly the bare bones of what really goes on in anapparently technical clinical encounter by way ofmanipulation and mediation of contradictions insociety.

The immediate impulse for this archaeology of theimplicit, this dragging into consciousness what waspreviously left unsaid or unconscious in medical prac-tice, comes at a time when the issue of the so-callednon-compliant patient (like the illiterate schoolchild)is alarming the medical establishment, now concernedas never before with the rationalization of the healthassembly-line and with rising costs. In this regard, it isa scandal and also self-defeating to appeal to Anthro-pology for evidence as to the power of concepts likethe patients model and the difference between thehow and the why of disease and illness. Forthe medical anthropology of so-called primitivesocieties also teaches us that medicine is pre-eminently an instrument of social control. It teachesus that the why or illness dimension of sicknessbears precisely on what makes life meaningful andworthwhile, compelling one to examine the social andmoral causes of sickness, and that those causes lie incommunal and reciprocal inter-human considerationswhich are antithetical to the bases of modern socialorganization patterned on the necessities of capitalistand bureaucratic prerogatives. As Victor Turner con-cludes in his discussion of the Ndembu doctor inrural Zambia:It seems that the Ndembu doctor sees his task less ascuring an individual patient than as remedying the ills of acorporate group. The sickness of the patient is mainly asign that something is rotten in the corporate body. Thepatient will not get better until all the tensions and aggres-sions in the groups interrelations have been brought tolight and exposed to ritual treatment.. The doctors taskis to tap the various streams of affect associated with theseconflicts and with the social and interpersonal disputes inwhich they are manifested, and to channel them in asocially positive direction. The raw energies of conflict arethus domesticated in the service of the traditional socialorder [IS].

And Lkvi-Strauss reminds us in his essay, The Sor-cerer and His Magic. that the rites of healing rea-dapts society to predefined problems through themedium of the patient; that this process rejuvenatesand even elaborates the societys essential axioms[19]. Charged with the emotional load of sufferingand of abnormality, sickness sets forth a challenge to

REFERENCESI. Luklcs G. Reification and the class consciousness ofthe proletariat. In History and Class Consciousness, pp.8>222. Merlin Press, London, 1971.2. Evans-Pritchard E. E. Wit&r& Oracles and Magic

among the Azande. Clarendon Press, Oxford, 1937.3. Sartre J. P. Being and Nothingness. Abridged edition.DD.279-80. Citadel Press. Seacus. New Jersev. 1956.4. iadin P. Primitive Man OS a Philosophe;, p. 274.Dover, New York 1957.5. Sontag S. Illness as Metaphor. Farrer, Strauss & Gir-oux, New York, 1978.6. Linder R. Diagnosis: description or prescription? Per-cept. Mot. Skills 20, 1081, 1965; cited in Blaxter M.Diagnosis as Category and Process: the Case of Alco-holism. Sot. Sci. Med. If 12, 1978.

7. Foucault M. Madness and Civilization, p. 202. MentorBooks, New York, 1967.8. Illich 1. Medical Nemesis. Caldar & Boyars, London.1975.9. Horn J. Away wirh All Pests, p. 53. Monthly ReviewPress, New York, 1969.IO. Goodman L. and Gilman A. (Eds) The Pharmacologi-cal Basis of Therapeutics, 5th edn, pp. 166-67. Macmil-lan, New York, 1975.11. Boehm Steckel S. and Swain M. Contracting withpatients to improve compliance. J. Am. Hosp. Ass. 51,82, 1977.12. BoehmSteckel S. and Swain M., op. cit., p. 81.13. Boehm Steckel S. The use of positive reinforcement inorder to increase patient compliance. J. Am. Ass.Nephrol. nurs. Technic. 1, 40, 1974.

14. Boehm Steckel S. ibid.15. Kleinman A., Eisenberg L. and Good B. Culture, ill-ness and care: clinical lessons from anthropologic andcross-cultural research. Ann. intern. Med. 88, 1978.16. Kleinman A. et al.. op. cir. p. 256.17. Kleinman A. et al.. op. cit. p. 257.18. Turner V. A Ndembu doctor in practice. In The Forestof Symbols. p. 392. Cornell Uni;. Press, Ithaca, 1967.19. L&-Strauss C. The sorcerer and his magic. In Struc-tural Anthropology, pp. 161-80. Anchor Books, NewYork, 1967.20. I wish to thank Drs Tom OBrien and Steve Vincentfor helping me begin this project, and the members ofthe 1977 Marxist Anthropology seminar at the Univer-sity of Michigan. Ann Arbor, for their comments on anearly draft of this paper.