A person’s sense of reality consists of two parts.
· There is his “model” of reality, which contrasts and connects the objects that exist in his world, and
· There is his conviction that these perceptions are true and extrinsic to himself. Before a model of reality can provide a sense of reality, a person must confirm it through experience: Models of reality are simultaneously “models of” and “models for”.
A sense of reality means, then, imposing order through practical activity, “praxis.” This is any activity which seeks to go beyond the existing situation in order to change it. In praxis, a person uses his model of reality to think about his situation and his wants in order to formulate a subjective plan. He tests the plan against the objectively existing situation in which he finds himself, and with whose objects (animate and inanimate, human and nonhuman) he must work in order to satisfy his wants
The relation of wants, praxis, and the consequence of praxis must not be misunderstood: the desire to satisfy wants is the motive for praxis, but praxis fulfills its ontological role whether or not the wants are actually satisfied.
It should become clear that the notion of “work” which is central to understanding the meaning of medical beliefs and behavior is, if understood from an ontological point of view, a way of describing praxis. There are several reasons why sickness episodes are ontologically important settings.
(1) Episodes of serious sickness rarely lack compelling motives (wants) for action, for forcing people into praxis and for mobilizing audiences: On the one hand there is the medical motive of seeking a remission of symptoms, on the other hand there is the social motive of seeking exculpation for deviant behavior.
(2) Sickness episodes are recurrent events and they affect all members of society.’ This is
ontologically important, because no person ever learns or confirms his sense of reality in a
once-and-for-all event. It must be continually recommunicated to this person and
reconfirmed by him throughout his life (cf. Durkheim 1915:387).
(3) Sickness episodes are able to communicate complex models in a readily recognizable way. Etiologies cast a broad net, implicating objects, qualities, and events in every aspect of life; they sort out these diverse kinds of facts, combine them into relationships that cannot be articulated in everyday contexts, and by juxtaposing (“polarizing”) them with organic processes make
them cognitively impressive.
(4) Finally, sickness episodes (particularly serious-acute ones) are dramaturgical in form. While praxis takes place in many different settings, action that communicates and confirms abstract sociological and cosmological ideas tends to take place (in traditional and tribal societies, at least) in dramaturgical settings. Because these ideas are communicated mainly through expressive symbols, it is also true that these symbols are used most often in such settings. As a dramaturgical event, sickness is episodic in time and focused in space; it is clearly set off from everyday life; there is a sense of audience, for participants are carefully distinguished from outsiders; participants are fit into a small number of highly stereotyped roles that are played according to a more or less fixed program (i.e., with the knowledge and acceptance of a single set of rules) on a field dense with expressive symbols; there is the expectation that events will proceed toward a climax; the episode is marked by a mood infused by extra-ordinary emotions rising out of man’s profoundest fears; and it is sustained by a clearly articulated dialectic of persons and forces that lends a coherence to the world of events and experiences that is lacking or obscure in humdrum situations.
The sickness episode in the West is an extreme type, but by no means an unrelated one, among the sickness episodes played by the world’s peoples. That is to say, while the sick person in the West cannot serve as a model for understanding how sickness is played in other societies, it would be wrong to assume that the technological gulf which separates Western medicine from traditional medicine makes it impossible to compare episodes in these different kinds of societies.
(1) Social institutions in the West have tended to develop into progressively secular forms, and systematic analytic thinking has come to dominate in most aspects of social life over thinking couched inexpressive symbols.
(2) Technological developments in Western medicine have also had important consequences. The great advances in preventive medicine in the West and the appearance of “wonder drugs” have displaced serious-acute ailments from the position of cultural and epidemiological dominance that they previously held, and have left their place to serious-chronic ailments of less dramaturgical potential.
(3) The power to articulate models of reality and to confirm them has passed out of the sick person’s hands and into those of the professional healer.
As Eliot Freidson has observed, the Western medical model is built on a concept of sickness that reflects the healer’s point of view. It describes sickness according to a narrow biophysical determinism that reduces the sick person’s performance to mechanically determined behavior, and makes him more an object than an active participant capable of initiating action and influencing the choice of alternatives during the episode. The active and powerful healer and his passive and object-like client are symbolized in what seems to be a unique combination of ways. The physician demands nakedness, recumbency, unresisting access to body regions that are called “privates” in everyday life, and forbearance of the pain and discomfort which he causes-an assortment of forms that, in the West, is mainly limited to sickness episodes, the rearing of pre-adolescent children, the treatment of “unliberated” women during coitus, and the management of the populations of “total institutions.” The symbolization of sickness in the
West also means alienating the sick person’s volition from the operations of his own body.
The physician probes beneath the body’s surface (and the limits of the known self), into
regions whose secrets and betrayals only he can bring to the surface, and it is his choice
whether this knowledge will be shared with or hidden from his client. Even the sick person’s
consciousness is made superfluous to the episode by the healer’s diagnostic machines (such
as x-rays), by his ability to deal mainly with disembodied parts of his client (such as blood
and urine), and by his readiness to interpose professional deaf-mutes (technicians and nurses)
between the client and himself. Finally, the healer’s regime is absolute, since he leaves his
client (at least middle- and upper-class ones) no place to run. Healer and client share a
system of medical beliefs which both believe is universally relevant and excludes any
alternative explanations of sickness, and both recognize that only the healer fully
understands this system.
In both Western and other societies it seems that “in the face of actual or threatened
disaster, to do something is psychologically satisfying and a way of relieving anxiety;
anything is better than just remaining passive and waiting for it to happen” (Beattie
1964).
Medical beliefs and practices can never explain away sickness or death. Why, then, when they fail to produce a cure, can it be said that they make suffering sufferable?--while serious sickness is an event that challenges meaning in this world, medical beliefs and practices organize the event into an episode that gives it form and meaning.
What does separate them are the different kinds of ontological orders which they affirm. While one works a man-centered cosmos in the grip of anthropomorphized forces, the other moves toward a conception of man autonomous in an indifferent universe.
