Roslyn Wallacli Bologh

GroEEding the alienatioii of self and body: acritical, phenomeoological analysis of thepatient in western medicine^

Abstract The treatment of Lbe body as a tiling separate from the social self ismade the object of laqiiky. The implicaliom of tiiis separation areexplored as folloivs: (1) The failure on the part of the medical profes-sion to treat differences in morbiiiity and moKtality rates dij.e to socialclass, pcciipatioB and eiwiionment as an .object, of medical concem; (2)Domination '05/ the iriedical proftissioi}., sBbordinslion of the patient anda corresponctiifi.g sense of entitlement on the part of one and '/utoerabflityon the part of the other; (3) The control of medical knowledge by thepi'ofession for its oWn interests which do not always correspond to Lhepatient's interests; (4) Iliie faflwre to ciomihunicate successfully withpatients; {5} liie intentional avoidance of informing patienis about thenature of or. prognosis for their illness; (6) Exploitation of the patientby the jTiedictl ptEoftssioa.(e.g. umeae&uiy mtgery); (7) The differepcein the 'quaHty .pf caie and attitudes toward patients ac.cordiing to social oiimputed niorf 4iffereiip'Efs anfiong palieijits; (8) The loss of autonomyarid dignity on tJic- part of t ie patient. This state pf affairs is( analysedin terras of tite deftiiitlon of tine pliysticJan as ciirer, the treatment ofmedica.1 knowledge as private property, and the context of a m.arketeconomy.

Given the diversity of theorerical perspectives in sociology and theissues that such lack of consensus gives rise to, it is surprising that onedoes not find the literature in medical sociology reflecting such richnessand such conflict, Malcolm Johnson^ has criticized the paucity oftheoretical developments withm the field blaming it on dominationof a medical perspective

Margaret Gold^ responding to this and similar criticism examined allresearch articles that focus on tlie patient which were published in theJournal of Health and Social Behavior from 1960 through the first halfof 1976. Her work confirmed Johnson's tliesis. She found that thevalue assumptions of the medical profession Influenced, implicitly orexplicitly.^ all stages of the sociological research from defining theproblem and variables through the application of findings to health

Sociology of Health and Illness Vol. 3 No. 2 1981©R.K.P. 1981 0141-9889/81/0302-0188 $1.50/1

Grounding the alienation of self and body 189

policy. It seems reasonable to attribute this state of affairs to fundingsources and the domination of the medical perspective there, to col-laborative research with medical professionals, and to the high prestigeaccorded the medical profession. Those who aspire to share in theprestige of a higher status, or who accept the legitimacy of thatprestige, tend to adopt the manners or in this case the perspective ofthat profession. Gold locates the acceptance of the medical perspectivein the functionalist approach established by Parsons'* which 'holds thatfor society as a whole . . . norms of health, illness and their associatedbehaviors are defined and regulated by the medical system as a legitimateagent of social control'.

The present work attempts a theoretical reformulation of the patientrole relying on a phenomenological and critical perspective that questionsand challenges the values and assumptions inherent in the medicalsystem. As Gold points out, 'the more phenomenological standpointinquires into the processes by which norms and defining powers arecreated. It requires sociological independence from such assumptions,though it does not preclude subsequent agreement or disagreement.'

I reformulate the patient role as a relation of self to body mediatedby the medical profession. Focusing on the relation of self and body,Peter Manning and Horacio Fabrega, Jr' show how the Western medicalsystem contributes to what I call the alienation of self and body. Usinga phenomenological orientation, they make a cross-cultural comparisonof the distinctions made between self and body in three medical caresystems: the Mayan, the Mestizo and the Westem. As they demonstrate,the language of Westem modern medical systems refers to bodiesdivorced of selves. In contrast, the Mayan and Mestizo systems viewdisturbances of the body as symbolic or indicative of disturbancesaffecting the self as a social being — illness as a result of disruptions insocial relations or as punishment for moral transgression.

Western medicine formally divides illness into two types with respectto the self: those that cannot be cured without implicating the selfand those that can. The former become psychiatric cases suffering theburden of a stigmatization that may be as great as that attached tothose illnesses in non-Western medicine deemed the result of moraltransgression. The latter (those that can be cured without implicatingthe sell) constitute the bulk of medical practice. With this division,the alienation of self from body becomes institutionalized in thepractice of treating 'mental' problems by one speciality and 'physical'problems by the other specialities. Non-Westem medicine, by contrast,tends to be less exclusionary or segmented. It treats most illness ashaving a social component. Thus for the bulk of medical practice therethe self as a social being cannot be lost sight of.

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Medical orientation as basis of alienation

One criticism of modem medical practice, then, focuses on the concep-tion of its object - illness or disease — as referring exclusively to thebody with a tendency to disregard the patient as anything but a possessorof the body or illness. It may treat the possessor well or badly; it mayshow compassionate concem or indifference to the possessor. Suchtreatment may be conditioned by market factors. Is there a relativeshortage of patients or of this type of patient or is there an over-supply?* Factors of demand and supply play no insignificant part.

However, even when physicians treat the patient with respect andcompassionate concem, they direct this treatment to the possessor ofthe body. They do not treat the body itself as a social body withsocially conditioned needs, enmeshed in social relationships andresponding to a particular socially conditioned environment. Amongother things, this means that the class of physicians does not addressitself to the social conditions that contribute to the illness or to thosethat might contribute to curing that social body. In other words, thesymptoms that the patient presents to the physician become treated asmdicators of an underlying illness, disease or injury — some physicalproblem. However, the physical problem, in tum, may be a symptom(or consequence) of some social problem. Epidemiological studies dosometimes point this out. But the separation between epidemiologyand medical practice tends to be bridged only by Departments ofPublic Health and then only in a rather limited way.

The physician class does not address itself to underlying socialproblems nor to the possible social consequences of various altemativemodes of treatment. For example, the physician class treats patients forvarious ailments when it knows (or should know) that those ailmentsare not randomly distributed in the population. The higher rate ofchronic illness and the higher mortality rates that characterize lowersocio-economic groups suggest that these rates are symptomatic of asocial condition - membership in a social class. Yet the aspects ofsocial class that contribute to the morbidity and mortality rates are notsystematically made the object of medical concem and practice. Neitherare the occupational characteristics that seem to be implicated indifferential morbidity and mortality statistics.

The medical profession fails to treat its object — the body, as a socialbody. Similarly, it fails to conceive of its practice as helping the patientor patient class to cure itself. In the orientation of modem medicine,the curing as well as the illness implicate the body but not as a socialbody or self enmeshed in a social environment. Thus the theory andpractice of the medical profession tend to alienate patients from their

Grounding the alienation of self and body 191

bodies by separating their social selves from their illness and from theprocess of curing. Manning and Fabrega, therefore, suggest that 'onesource of the apparently growing sense of a disembodied self, or a self-less body, is modern medicine'.

Structural basis of alienation

The other criticism of modem medical practice, which similarly pointsto the alienation of self and body, derives from a structural analysis ofthe medical profession — its domination and power. Both critiques havein common a concem for the subordination of the patient to the statusof a thing. Whereas Manning and Fabrega attribute the problem to theconception of illness in Western medical knowledge and the practicesthat are implicated in such a conception, Freidson^ attributes theproblem to the control of medical knowledge by the profession forits own interests which do not always correspond to the patients'interests.^

In one case, the practical consequence is a denial or neglect of socialfactors in the diagnosis and treatment of illness. This entails treating thebody as a thing rather than a social being. In the other case, the con-sequence is a conception of the patient as subordinate to the physician.The physician has all the knowledge and makes all the decisions. Thisentails treating the patient as a thing or body and not a consciousbeing capable of learning, understanding and making decisions. Henceprofessional dominance alienates the patient from itself as a conscious,human being. Ivan lllich criticizes modern medicine for this self-alienation of the patient.'

Professional dominance also alienates the patient from the physician.The extent to which the interests of the dominating physician divergefrom and even conflict with those of the patient makes possible theexploitation of patients by physicians for their own ends. The structuralcondition of professional dominance that alienates the patient classfrom itself and from the physician class may be conceived as originatingwith the appropriation by the profession of medical knowledge andmedical resources as its private property. The conception ofthe physicianas curer rather than as resource person or consultant reinforces theprivate property type of relation. A curer, which by definition impliesits other — the one to be cured, has privileged and exclusive access tomedical knowledge, medical technique and other medical resources.Because of the privileged relation to medical resources that characterizesthe physician as curer, the relation of patient to physician must remainone of alienation. This may be contrasted with a conception of physician

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as educator or consultant to patients where the latter cure themselveson the basis of what they learn from the physician.

The treatment of the patient as subordinate and of the ill body as anobject only and not a social, conscious self presupposes the appropriationof medical resources as the domain of the physician class alone. Patientsare denied direct access to these resources — techniques and knowledge.Patients do not learn to cure themselves. Rather they remain divorcedfrom these resources having access only through the dependence onand the intercession of the physician who in turn becomes the curer.

The alienation of self from body, the subordination of patient asbody to physician, with the treatment of the human subject as anobject, has evoked much recent criticism. The focus of such criticismhas included the failure on the part of physicians to successfully com-municate with their patients,'" the intentional avoidance of informingpatients about the nature of or prognosis for their illness" and thedifference in the quality of care given according to social or imputedmoral differences of patients.'^ One may add to these the chargesmade against the profession regarding unnecessary surgery, unethicaland dangerous medical research and medical practice, the conflictof interest between the modem organization and control of healthservices by hospitals and medical centers (and the whole medical-industrial complex) and the needs of the people they supposedlyserve.'^ In addition, the profession has come in for criticism for itsinterest in and preference for medically exciting ailments, 'theinteresting cases' when most patients suffer from 'ordinary' ailments.

Romantic rejection of medical science

Perhaps the most scathing attack on the alienation of patients fromtheir bodies in modem medicine is provided by Ivan Illich in MedicalNemesis. Illich concludes his thesis with the recommendation thatbecause medical care is dangerous to health and reduces the human toan object, people should stop relying on the medical system for theirhealth care. Although critical of this conclusion, reviewers have foundhis thesis an important one that needed to be made and documented.'"The data used to support the thesis and the thesis itself — that medicalcare is dangerous to one's health — is not new. But, the extensive com-piling of the sources into one major work has been recognized as aneeded and important contribution.

However, his recommendation that people regain control and ceaseto rely on the medical system has been met with incredulity, criticismand rejection by most reviewers." Although some object to Illich's

Grounding the alienation of self and body 193

presentation as biased, as ignodng the important contdbutions ofmedical science and therefore doing an injustice to the field, thisobjection fails to deal with the problem that Illich raises. It is certainlyfair and important to point out that there is good mixed with the bad,but this does not resolve the problem that Illich addresses. As his workindicates, it is not a problem of some bad practitioners who should beeliminated or some harmful effects that should be guarded against orcertain dsks that might be minimized, but a problem that is inherentin the character of the system itself.

Illich's thesis is grounded in a commitment to individual responsibilityfor the self as opposed to self-alienation and structured irresponsibility.This raises in a radically posed way the issue of responsibility andprofessional dominance. It is radical in the sense that it makes theproblem of professional dominance not simply a relative matter; thesubordination of patients' interests to professional interests. Rather,professional dominance becomes an absolute evil. The patients give upresponsibility for their own bodies which Illich argues is worse thanforgoing professional medical treatment. The evil of professionaldominance is the expropriation of control over one's body.

It is not simply that professional dominance bdngs with it arrange-ments and practices that suit the convenience of professionals withoutconsideration for the best interests of the patient. Rather, becausetechnical or professional expertise involves the patient's body, notmaking the specialized knowledge available to the patient, means thatthe patient's body becomes separated from the self with a correspondingloss of human autonomy and dignity.

Waitzkin'* rightly points out the individualistic bias in Illich'sthesis: that individuals should reject medical science and take over theirown medical care. He argues that Illich fails to consider the social andparticularly class infiuences on health and the need for social policiesand health programmes.

Despite Illich's individualistic solution to the problem, his workresonates with the sociological problems of alienation and anomieassociated with the division of labour. One can compare Illich's analysisof the alienation of the patient class from itself with Marx's analysis ofthe alienation of the working class.'' Illich seems to be taking aMarxian approach in urging the abolition of medical science as thatwhich mediates and alienates the patient class from its body much asMarx advocates the abolition of capital as that which mediates andalienates the working class from its production. However, Marx's sol-ution was to be accomplished not by the destruction of capital andreturn to an earlier form of production but by the transcendence andsuspension of capital — a moving forward to a new mode of production.

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Illich, the radical critic of modem medicine, tums out to be a romanticmuch like the romantics that Marx criticizes for hearkening back to anidyllic unity that never existed.'* Although a unity existed, it was notidyllic. The earlier unity of self and body, as well as the unity of pro-ducer and product, was a unity mediated by supematural forces orsocial forces in the face of which the individual was powerless.

Unlike Illich, the radical that tums out to be a Utopian romantic,Freidson, the liberal critic of medical practice, tums out to be a revol-utionary if his critique is examined and carried through to its logicalconclusion. For his critique rests on a notion of a professional self-interest which conflicts with the self-interest of the patient. This maybe reformulated as class conflict. The logical conclusion would be theelimination of the possibility of conflicting interests.

Freidson analyses the possibility of exploitation, of using others forone's own ends at their expense. In the case of the exploitation of illness,professionals use the patients' illness for their own ends — research, teach-ing, income, leaming, while depriving patients of medical knowledge andcontrol over their bodies and as Illich stresses, even causing illness. Freid-son's critique of professional dominance, if carried far enough, may bereformulated as a critique of the control over medical knowledge by themedical profession for its own ends. These ends conflict with the ultimategoal of medicine — the care of the patient. This is analagous to Marx'scritique of the control of means of production by the capitalist class forits own ends (profit) which are independent of the goal of production— the sustenance of society.

While Illich alerts us to the exploitation and alienation of the patient,he does not analyse the social conditions that make that possible. Hetreats these consequences as inherent in medical practice, but fails toanalyse the historical rather than natural elements that constitute thismode of medical practice. He does not analyse the social conditionsand presuppositions of modern medical practice, only the consequences.Freidson. on the other hand, provides a framework for analysing thepossibility of exploitation — professional control over medical know-ledge which characterizes modem medical practice. Illich sees the prob-lem aslackof control over one's body, but he fails to provide the groundsfor that lack of control. He locates its source in modern medicine theway the Luddites in the nineteenth century located the source of theirexploitation in machinery, engaging in and advocating destruction ofthe machines."

This approach, however, denies the social grounds of medicine ormachinery. It may be compared to some Hippies' rejection of the modemworld of work by retreating to pre-modern modes. Instead of inquiringinto the roots of modem practice, this view assumes that the practice

Grounding the alienation of self and body 195

can be eliminated by fiat, by rejection, by returning to earlier modes.However, modem practice is a historical, social product. It is purposiveactivity, a response to social or historical conditions.

Medical science, like machinery or the world of work, in so far as ithurts or alienates patients from themselves — their bodies — is groundedin other purposes and needs — those of the medical profession. Thesepurposes and needs, in tum are grounded as well. They do not originatewith individual physicians, but, rather, individual physicians givethem life.

To summarize, modem medical science is utilized by the medicalprofession on behalf of the patient, but the needs of the professiontend to conflict with the needs of the patient class. The problem thenbecomes control over medical knowledge not the acceptance or romanticrejection of medical science. This problem can be reformulated as therelationship to medical knowledge as the private property of thephysician class rather than as social property.

This relationship entails the alienation of the patient class frommedical knowledge, the relative powerlessness of the patient class withrespect to the physician class and a corresponding separation of selfand body.

The language of human entitlement

As a social being, the human is both product and producer of society.All humanly meaningful objects are products of human (social) activityor human life and also producers of human (social) activity or humanlife. They produce human life in the sense that human life for whichcertain objects are meaningful would not exist as such (it would bedifferent) if those objects were different or non-existent. To treat allmeaningful objects as human property or social property as opposedto private property would be to actively realize this.

Such a self-consciously social life would mean that the way thatpeople related to each other, including language, would be different.Individuals would speak a language of entitlement and dependence.

Robert Coles^° describes the sense of entitlement that characterizesthe experiences of privileged children as opposed to the sense of vul-nerability that characterizes poor children. The sense of entitlementcomes from the way in which others relate to them. In the one case,they leam that their position in society brings with it respect and insome cases awe and dependence by others. In the other case, the poorleam that their position in society brings with it contempt or indif-ference and dependence on others. Instead of mutual dependence.

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mutual vulnerability and mutual respect or entitlement, one side orclass feels dependent and vulnerable while the other side or class feelsentitled and invulnerable.

A language of entitlement and interdependence would be one inwhich each respected the other's needs as sufficient justification fora claim to an object. Such a language might best be understood as alanguage that we currently know with respect to emergencies and theclaim to help. In an emergency situation the one in need is entitledto help from others, even strangers. It is considered a human right, andthe aid is considered human decency. The one in need does not feelthat he or she should have to plead for help nor does the one who canprovide aid feel unjustly imposed upon when called on. Neither losesself-esteem.

The relation of the one in need and the other who is able to providethat aid in an emergency situation may be taken as a model of a self-consciously human or social community. Their language is a humanlanguage that is neither the language of supplication nor the language ofcommand. The response is neither the language of condescension northe language of servility. It is the language of entitlement, respect andinterdependence. It differs from the language of exchange which isbased on a calculation of equivalence rather than a recognition of unity.

In a human relationship as described above all property is recognizedas social property although particular individuals possess particularproducts. In the professional-client relationship specialized knowledgemediates the relation. This knowledge is not treated as social propertybut as private property - the property of the physician or professional,llie treatment of medical knowledge as the private property of thephysician class is the foundation of the doctor-patient relationship.A change in the attitude of patients toward medical care as a rightrather than a privilege, as social property not private property, chal-lenges this traditional relationship.

According to the Szasz-Hollander model of doctor-patient relation-ships^' the situation of acute illness, as distinguished from medicalemergencies which correspond to a relationship between parent andhelpless infant and from chronic illness which corresponds to a relation-ship between adults, approximates a patemal relationship of parentto child. The physician sees himself/herself as the beneficent parentwho takes care of the needs of the patient and in return expectsobedience. This relationship separates mind or self from body. Thechild-like patient is assumed to be a body or object without a mind(but with a will), a thing that is an extension of the parent's body,an object that carries out the intentions of the parent's mind justas the hand does what the mind directs it. The patient and by impli-

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cation the child to whom it is compared are things, bodies withoutminds, according to this model. The mind resides with the physician,the body with the patient.

The unity of patient and physician, body and mind, could be accom-plished if the interests of the patient and physician were identical. How-ever, as so many studies have pointed out, this is not the case. Thephysician does not treat the patient's body as the patient would if he orshe had the ability to treat himself or herself, lhis is not to say thatphysicians fail to treat the patient's body as they would treat theirown. The patient's body is not just a sick thing to be treated but isintegrally related to the patient's life which the patient would take intoaccount if he/she were treating him or herself. As things stand now, thepatient's self (social life) is often disregarded in the treatment of hisbody. In fact as Illich's work bdngs out, the patient's life may beruined or damaged from the treatment rather than from the illnessor bodily complaint.

While the patient is reduced to the level of a thing, a body, thephysician is raised to the level of super-human. The physicians' senseof entitlement, which contrasts with the patients' vulnerability, derivesfrom the treatment they are accorded and come to accept as naturaland to be expected. The treatment they receive is one of respect thattakes the form of deference in the literal sense of the deferment ofother needs to the needs and commands of the physicians in their roleas curer of illness. This general deference dedves from their relationshipto the patient. It dedves from the pdodty given to an ill or hurt person'sneeds, that is from the patient as patient.

How does it happen then that the patient as patient has less respectshown him or her than does the doctor as doctor? Some could arguethat this is a feature of the economic class position of physicians —they earn a great deal of money and have gone through an extensiveand rigorous educational process the requirements for which are quitecompetitive. However, neither the medical student nor the wealthynon-professional patient is accorded the respect within the medicalsystem that the physician receives and correspondingly expects, althoughthe first case exemplifies the same extensive education and the secondcase great wealth. Thus it is not necessadly the economic or educationalaspect of social class that accounts for the great respect accordedphysicians and their corresponding sense of entitlement.

The paradox of the doctor-patient relationship is that on theone hand the respect accorded the physician dedves from the valueplaced on human life and well being — the health of the patient — and,therefore, dedves from the patient. On the other hand, the value of thepatient seems to decline to the same extent that the value of the

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physician dses. This inverse relationship requires explanation. Orrather, what requires explanation is the forgetting that the value of thephysician does derive from the patient. How does this come to be for-gotten? How is it that the physician comes to be highly valued whilethe patient becomes devalued? How is it that the source of the phys-ician's value, the unity of patient and physician, is forgotten?

I propose that the answer to this is in three interrelated parts. First,the definition of the physician as curer. Second, the treatment ofmedical knowledge as pdvate property. Third, the context of a marketeconomy.

Physician as curer

The physician as curer can be reformulated as a scientific magician.Although the roots of the physician's magic are in science, he/she stillremains in essence the curer, the one able through magic (knowledge orskill) to cure the patient. I pair science with magic, although the twoare usually considered opposites, because medical science is not treatedas a general human capability, a knowledge and technique developedin history. Instead it is treated as if it were beyond the human, a powerthat is not available to mere humans but only to select beings — thescientific magicians or physicians.

The power to cure is not treated as a human power, a histodcallyproduced human power, like other human powers, but a super-humanpower, one that is bestowed on certain select beings. Yet it is wellknown that medical science is a social product, not a supernaturalphenomenon. What do I mean by claiming that it is treated as a super-natural phenomenon? I mean by this that in place of modern medicalknowledge as the source of the cures, understood as a social product andtherefore a general human capability, the physician is seen as the sourceof the cure. This conception bdngs with it the implication that thehuman as human cannot cure himself or herself but requires a super-human force which resides with the physician. My grounds for thisclaim lie with the treatment of the patient as incapable of curinghimself or herself. The physician supplies the patient with techniquesbut not knowledge, with pills but not understanding. Hence he/shesupplies the patient with the equivalent of superhuman forces from theperspective of the patient. The patient treats the physician as the bearerof such supernatural forces by not expecting to learn what is knownabout the illness or cure. Rather, the patient expects the physician tocure the patient magically.

However, this analysis could not be wdtten if it were not already

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generally known that the physician is not the bearer of supematuralpowers; that the ability to cure illness is a historically developedhuman power. This knowledge accounts for much of the ambivalencewith which physicians are regarded. It is the core component of muchof the humour about physicians as is well documented in any collectionof 'Get Weir cards."

The contradictory conception of the physician as both human andsuperhuman provides the possibility of transcending the modemdoctor-patient relationship. This possibility only occurs with modemmedical practice because pre-modern medical practice was often basedon medicine as a supematural force.

The question becomes how is it that the physician is treated as asuperhuman being, a curer, when it is known by all that he or she isnot? How is it that the value of the physician is directly inverse to thevalue of the patient qua patient?

Medical knowledge as private property

Why does the physician appear as a different type of being from thepatient? Why is one made to be more than human — a curer — with thecorresponding diminution of the other as less than human - a case?

1 propose that this differentiation comes from the treatment ofmedical knowledge as the private property of the physician class. Ifmedical knowledge were treated as social property instead of privateproperty, physicians could not take responsibility for the cure as theynow do. Of course, this sense of responsibility is limited to what theycan be expected to accomplish on the basis of their limited humanknowledge and ability. However, it is still a responsibility for the cure,and it is assumed by the physician and not the patient. Once the patientaccepts medical treatment by the physician, including following his orher directions, then the responsibility for the cure belongs to the phys-ician. Only if the patient actively refuses the treatment does he or shetake responsibility to some extent for the consequences.

However, despite IUich's data on iatrogenic illnesses - those causedby treatment itself - a general refusal of medical treatment is a self-defeating and self-destructive way of asserting human responsibility.Illich makes a case for the patient doing just this. However, Illich missesa fundamental point. There is another way in which the patient canrecover his or her sense of human dignity, his or her sense of self-responsibility. That is not by becoming subject to the forces of naturebut by relating to medical science and to the physician as himself orherself a physician albeit a less knowledgeable one, as well as a patient.

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Similarly, the physician divests himself or herself of the superhumanresponsibility of curing the patient by relating not as a curer to anill body but as one physician to another who is less knowledgeableor experienced. Thus physicians would treat patients with sympathyfor their plight and respect for their abihty to learn and cure them-selves. The patients, in tum, would treat the physicians with respectfor their learning and sympathy with their plight of trying to relaytechnical information to one whose knowledge is inferior and whosemental and physical state is disturbed.

To the extent that the professional class deprives the patient classof property in medical knowledge, the patient class is reduced to a non-human, that is a thing or body without intelligence. At the same timethat the patient class is exhorted to respect and accept medical knowl-edge as a human product (as opposed to a superhuman gift or charisma),there is little possibility for the patient to treat medical knowledge asa human product. Consequently, the human patient becomes less thanhuman and medical knowledge becomes more than a human product —a superhuman thing — and the physician becomes the agent of thesupernatural, himself or herself more than human.

Medical practice in a market economy

Why does the physician class treat medical knowledge as private prop-erty? Why does the class not conceive of itself only as a party to superiorknowledge and skill rather than conceiving of itself as a curer? Whydoes the patient class treat the physician as curer instead of as possessorof superior knowledge and skill? Why is medical knowledge treatedas the pdvate property of the physician class? What does the physicianstand to lose by raising the patient to the level of student physician?The advantages that can be lost are all associated with a market economy.If the patient succeeds in understanding the illness and the cure, and ifthis knowledge is freely available to all, the income of the physicianbecomes threatened. Physicians could lose substantial income if theydid not maintain an exclusive monopoly over medical knowledge.

The problem of professional dominance and the corresponding self-alienation of the patient is grounded in a market economy and cannotbe eliminated without eliminating the condition of a market economyitself. The problem reduces itself to one of eliminating the marketas a mechanism for determining income. This means that incomewould have to be independent of the numbers of patients treatedand their willingness or ability to pay. This concept differs from HealthMaintenance Organizations (prepaid group practices) where the number

Grounding the alienation of self and body 201

of patients who pay a fixed amount in advance determines the phys-icians' income.

However, the fee is the one power the patient has in affecting physicianresponsibility, as Szasz cogently points out.^^ With the elimination ofthe patient's power over the purse strings, what guarantees physicianresponsibility? Why not an increase in insensitivity to the patient if thephysician is not dependent on the patient for income? Conceptually,we have seen that the physician requires the patient in order to be aphysician. Hence, if the physician wants to practise medicine, he/sheis dependent on the patient even if not for income. The sense of inter-dependency and mutual responsibility has to be the starting point ofall practice.

Szasz has argued that physicians' loyalty is likely to go to whoeverhires or pays them. If the physicians are paid by an employer, theloyalties of such a 'company doctor' will be to the company. Similarly,if the govemment employs the physicians, their loyalty will be givento the govemment. This raises the problem of the social factors thatimpinge on the relationship.

Parsons^" points out the role of the physician In Hcensing illnessbehaviour — the forgoing of ordinary role performance. In having thepower to impel others to suspend ordinary expectations regarding theordinary role responsibilities of the patient, the doctor-patient relation-ship becomes more than a relation between the two parties. Therelationship mediates other relations between the patient and others orbetween the patient and his or her other roles — parent, wife, worker,neighbour.

Parsons explicates the role of physician as arbiter of whether or notindividuals can legitimately suspend their responsibilities while main-taining their status as accepted and acceptable members. In so doingParsons's analysis implicitly assumes a natural or universal conflictbetween individual and societal interest with respect to individualscarrying out their role responsibilities. It is assumed that individualsmay try to shirk responsibility and, therefore, they must be examined

.by an expert who will determine whether they are legitimately unableto perform their duties.

In contrast to Parsons's analysis I would contend that the conflictbetween individual and society should be treated as historically specific,as generated by a situation in which individual interests and socialinterests are not identical. It is interesting that Szasz uses the exampleof Russia to demonstrate the situation of a state-employed physicianwhose loyalty, therefore, goes to the state. In that situation, neitherpatient nor physician can completely trust the other. The physicianmust be careful to be sure that the patient is not a govemment 'plant'

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testing the physician's thoroughness in not allowing workers to shirktheir responsibilities. The patients cannot trust the physician to givethem the benefit of any doubt.

What is interesting in this example is that the govemment's mterestwhich is supposed to represent a general social interest, conflicts withthe supposed individual interest. If the individual interest and thegovemment interest do not coincide this can only mean that social lifeitself is divided, is composed of opposing tendencies represented on theone hand by the worker and on the other by the government. To theextent that there are private interests that are opposed to social interests,to the extent that the individual's needs are not recognized as thecommunity's needs and vice versa, the means of producing social lifeare controlled by some to the active and intentional exclusion ofothers. This means that the means of producing social life are appro-priated as the private property of one class on whom the other class(es)depends for its subsistence.

As long as a relationship is mediated by private property, such thatonly one side has access to and control over that which the other sideneeds (a situation of private property) the relationship will be a tenseand ambivalent one.

Where social life is mediated by private ownership of the means ofproducing that form of life, individual needs and social needs are notidentical. In that case, there is a division between those who possessthe means of producing and reproducing social life and those who, asmembers of that form of life, have no control over the means of pro-ducing it thus making alienation and exploitation possible. This becomescontradictory when those members who are subject to a form of lifewithout having control over it are posited as free individuals capable ofconsciously and rationally shaping their lives.

'Consciously and rationally shaping their lives' means that they canchoose among alternatives and can freely form contractual arrange-ments with others. By being posited as free, 1 mean that the form oflife requires that they be free. For example, the form oflife of patient,requires that the patient be able freely to choose or reject a physician,to cooperate consciously with the physician. Hence for that form oflife, the patient is posited as a free, conscious individual. The form oflife becomes contradictory when the individual is posited as free andthen has no control over the conditions of that form oflife.

The problem of the alienated patient cannot be overcome untilmedical knowledge becomes social property in practice. In theory weall know that medical knowledge is a product of society (of history).But how can the social character of medical knowledge realize itselfin practice? Only when the patient class struggles to gain power over

Grounding the alienation of self and body 203

medical knowledge can this occur. This means that the physician classmust cease to be a class in the sense of possessing medical knowledgeas its own pdvate property. Physicians would have to cease beingcurers. lhis means that those who go into the medical profession mustbe trained as advisers and not as curers. Becoming a physician wouldmean learning to help others to make medical decisions for themselvesand to cure themselves.

Physicians' interest may continue to diverge from that of patients.An 'interesting case' may hold more challenge and be more rewardingthan a common chronic illness. However, by eliminating exclusivecontrol over medical resources, patients can see to it that their needsare not overlooked. This can only occur with the abolition of privateproperty in medical knowledge. Whatever confiict between physicianself-interest and the self-interest of patients that would remain ordevelop would not be irreconcilable because neither group would havethe power to exclude the other from participating in decision-making.For instance, physician self-interest in professional prestige dedvedfrom research and teaching might be accompanied by indifference tothe needs of the community or the patient. However, with equalparticipation by patients, decision-making regarding allocating medicalresources could not be made according to physician interest exclusively.Rather, all medical resources would have to be treated as social propertynot pdvate property, hence no one group could dominate exclusively.

Conclusion: towards a unity of self and body

This theoretical reformulation of the doctor-patient relationship as arelationship of alienation contrasts with a relationship of self-realizationwherein each party realizes itself. As opposed to realizing itself, as afree, conscious being, the patient must deny its human capacity to learnand develop, to understand and treat its body. Thus modern medicalpractice is a contradictory thing. Its aim is to serve and help the patientthat it posits as a human subject, but its means for accomplishing this,its treatment of the patient as object, contradicts its end.

This analysis of the alienation in the patient role and the grounds ofthat alienation has ramifications for practical activity and for futureresearch. The practical activity suggested by the analysis is one ofcomplete involvement of patients in all aspects of treatment includingthe allocation of resources. This means patients will not have a sub-ordinate position to professionals. Of course, this will entail struggle ofpatients with professionals as well as struggles within the patient classand struggles within the professional class. Such struggle, however.

204 Bologh

does not result from theoretical analysis but already exists. It is theclass struggle given with the division between patient and physician.

Complete involvement of the patient class includes control overhospital boards of directors, allocation of resources, and the right tofull explanation and education regarding the illness, the body, and thetreatment. Such education may also involve making available or improv-ing means of gaining knowledge other than by exclusive rehance on thephysician. One such possibility is through peer groups or self-helpgroups composed of patients, ex-patients, and/or patients' relatives inaddition to consultations with professionals. The development orincreased use of a patient advocate position may also be helpful.

Struggles to realize these possibilities already exist as can be seenin the various social movements related to health care. Particularlyimportant has been the women's movement. This analysis has provideda theoretical framework for understanding these movements as sharingthe same grounds; the alienation of patients from themselves, of selffrom body, that occurs with the appropriation of medical knowledge asprivate property.

To conclude, non-alienating medical practice requires the abolitionof the division between those who possess medical knowledge andtechnology and those who are subject to it. Self-consciously socialindividuals^* would replace class individuals and would re-unite theself and body not as a unity given with nature unmediated by medicalscience (an un-selfconscious or non-historical unity) nor as a unitymediated by the supematural, but as a historical unity, a unity that isproduced by the struggle of patients to gain control over their bodiesby re-appropriating medical knowledge as a social product instead oftreating it as the private property of a profession. This means eschewingthe traditional sociological conception of a profession which views theclient as inherently incapable of learning to treat itself.

If the client is inherently incapable of leaming the technical knowl-edge necessary for treating itself, then it is only natural that suchknowledge appear as the private property of the profession. Such hasbeen the implicit and explicit sociological perspective which thisanalysis challenges. With the increasing educational levels of the popu-lation, the growth of consumer advocacy groups, and the use of massmedia, such incapacity on the part of the patient seems less and lessviable as ideological support for the domination of professions.

While professionals would have extensive knowledge applicable to allor many different types of cases, chents should be capablfe of leamingfrom the profession whatever is pertinent to their own needs.

This analysis assumes the human capacity for leaming. It does not gointo the particular practical problems that this may entail. However,

Grounding the alienation of self and body 205

beginning from such a perspective allows one to inquire into the sub-jective (conceptual) and objective (structural) presuppositions of thepatient in Westem medicine. We have seen how the status of patientpresupposes and (re)produces the alienation of self and body.

Received: February 1980 Department of Sociology and AnthropologyAccepted: August 1980 St John's University, New York

Notes

1 I wish to thank Hans Baer for reading and commenting on an early draft ofthis paper. Thanks also to Phyllis Zumatto.

2 M. Johnson, 'Medical Sociology and Sociological Theory', Social Science andMedicine, vol. 9, no. 4/5, pp. 227-32, April/May 1975.

3 M. Gold, 'A Crisis of Identity: The Case of Medical Sociology', Journal ofHealth and Social Behavior, \o\. 18, no. 2, pp. 160-8, June 1977.

4 T. Parsons, The Social System, Chicago: Free Press, 1951.5 P. Manning and H. Fabrega, Jr, 'The Experience of Self and Body: Health and

Illness in the Chiapas Highlands', in G. PsathsLS, Phenomenological Sociology,New York: John Wiley, 1973.

6 See B. Ehrenreich and J. Ehrenreich, The American Health Empire: Power,Profits, and Politics, New York: Random House, 1970.

7 E. Freidson, Profession of Medicine, New York: Dodd, Mead, 1970.8 See also J. C. Quint, 'Institutionahzed Practices of Information Control', in

E. Freidson and J. Lorber (eds). Medical Men and Their Work, Chicago: AldineAtherton, 1972; F. Davis, 'Uncertainty in Medical Prognosis, Clinical andFunctional', in E. Freidson and J. Lorber (eds). Medical Men and Their Work,Chicago: Aldine Atherton, 1972, among others.

9 I. Illich, Medical Nemesis: The Expropriation of Health, London: Calder &Boyars, 1976; also published by New York: Pantheon Books, 1976.

10 B. Korsch and V. F. Negrete, 'Doctor-Patient Communication', ScientificAmerican, vol. 227, pp. 66-74, August 1972.

11 Quint, op. cit.; Davis, op. cit.; A. Shiloh, 'Equahtarian and Hierarchical Patients:An Investigation Among Hadassah Hospital Patients', in E. Freidson andJ. Lorber (eds). Medical Men and Their Work, Chicago: Aldine Atherton, 1972.

12 D. Sudnow, Passing On: The Social Organization of Dying, Englewood Cliffs:Prentice-Hall, 1967.

13 Ehrenreich and Ehrenreich, op. cit.;D. Kotelchuck, iVo^nosu Afe aHve.' Crisis inthe Health Care System, New York: Random House, 1976; G. Kinkead,'Humana's Hard-Sell Hospitals', in Fortune (November 17, 1980), pp. 68-81;A. Strauss, Where Medicine Fails, New Brunswick, Dutton, 1973, including thefollowing articles: C. Nanry and J. Nanry, 'Professionalization and Poverty ina Community Hospital', J. A. Roth, 'The Public Hospital: Refuge for DamagedHumans', E. Markson, 'A Hiding Place to Die', A. Shiloh, 'Sanctuary or Prison- Responses to Life in a Mental Hospital'.

14 L. Thomas, 'Rx for IUich', New York Review of Books, vol. XXIII, no. 14,pp. 3-4, 1976.

206 Bologh

15 H. Waitzkin, 'Review of Medical Nemesis: The Expropriation of Health', Co«-temporary Sociology: A Journal of Reviews, vol. 5, no. 4, pp. 401-3, 1976.

16 Ibid.17 K. Marx, Gnindrisse: Foundations of the Critique of Political Economy,

London: Penguin Books and New.York: Random House, 1973.18 Ibid.18 G. Weissman, 'The Tides of Anti-Science', The Sciences (January/February

1977), pp. 28-31.20 R. Coles, Privileged Ones. Volume V of Children in Crisis, Boston: Little

Brown, 1978.21 T. Szasz and R. Hollander, 'A Contribution to the Philosophy of Medicine:

The Basic Models of the Doctor-Patient Relationship', A.M.A. Archives ofInternal Medicine, vol. 97, p. 585, May 1956; cited in Samuel W. Bloom TheDoctor and His Patient, New York: Free Press, 1965.

22 R. W. Bologh, 'Alienation and Anomie in the Patient Role: Sources of Ambiv-alence and Humor in Comic Get Well Cards', Sociology of Health and Illness,vol. l ,no. 2, September 1979.

23 T. Szasz, The Myth of Mental Illness, New York, Harper & Row, 1974.24 T. Parsons, op. cit.25 R. W. Bologh, Dialectical Phenomenology: Marx's Method, Boston, Routledge

& Kegan Paul, 1979, p. 9, 263-74.