Book Review

Knowledge, Power and Practice -- The Anthropology of Medicine and Everyday Life

N Engl J Med 1994; 330:1546May 26, 1994

Article

Knowledge, Power and Practice -- The Anthropology of Medicine and Everyday Life
Edited by Shirley Lindenbaum and Margaret Lock. 428 pp. Berkeley, Calif., University of California Press, 1993. $50 (cloth); $15 (paper). ISBN: 0-520-07784-9 (cloth)

Anthropology is training its sights on physicians. The ethnographer, no longer content with studying preliterate cultures and the Gururumba, Bunyoro, Tiwi, or Cheyenne, is subjecting us to critical examination. Be prepared to be startled. There is an uncanny self-consciousness, even dissonance, in having our sophisticated medical practices “uncovered” and contrasted, sometimes to our detriment, with “primitive” systems. Such exercises could contribute to our efforts to humanize medicine -- indeed, anthropology could help us find a universal ethos for medicine. Knowledge, Power and Practice admirably presents the power of such analyses; almost half its 15 essays are written in the mode of traditional cross-cultural studies.

This anthology consists of five unconnected sections, covering the cultural construction of childbirth, the production of medical knowledge, modes of medical understanding, cultural determinants of illness experience, and “body politics.” The essays in the first four sections largely follow a traditional anthropologic format. For instance, Byron and Mary-Jo Good consider the new curriculum at Harvard Medical School as an anthropologic project. In their sensitive exploration of students' reactions to their first encounters with cadavers and patients, we discern the complex interplay of cultural values and psychological reactions in the making of a physician.

To profess, as Alan Young does, that “all knowledge of society and sickness is socially determined” may be regarded as trivially true or as a call for a much deeper and more radical agenda. Some adherents of social constructivism have made contestable claims about how scientific knowledge is produced and developed. The mistaken argument, in its barest outline, is that we engage in value-laden discourse, and since there are alternative social values there must also be alternative constructions of scientific theory and fact. During a period when claims of truth are increasingly being challenged, this is not a trivial matter. The stakes are high, since the growing sense of relativism in all cultural values may be grounded in this discussion. If science has no special claims to truth, does any other endeavor?

This anthology is largely free of such ideological concerns until the last essay, “The Biopolitics of Postmodern Bodies: Determinations of Self in Immune System Discourse,” by Donna Haraway, a well-known feminist critic of established science. She claims that “the immune system is an elaborate icon for principal systems of symbolic and material `difference' in late capitalism.” An immunologist might find such a statement indecipherable, so let me explain. Immunology, according to Haraway, portrays our cultural structure and values because it closely resonates with our own inner and social being. After all, it is the science of self-nonself discrimination. She argues that our own image of selfhood is projected onto immune theory, which might in turn be used to legitimize particular power relations. In a radical turn, Haraway would change the current pervasive depiction of immunology from one of battle to a more humane model. Her point is to expose how immunology depicts relations between diverse kinds as combative, whereas other modes of encounter might be inferred. Immunology has achieved an imperialistic prominence, perhaps matched in intensity “only in the biopolitics of sex and reproduction” in offering us a scientific rationale for declaring not only the scientific basis of difference, but the “natural” state of different kinds. There is us, and then there is the foreign, and the relationship is one of conflict.

I, too, have argued for alternative models (The Immune Self. New York: Cambridge University Press, 1994); what distinguishes my analysis from Haraway's is the effort to incorporate the scientific data themselves. Haraway takes no account of immunology's scientific criteria, nor does she present an alternative scientific interpretation. In short, her critique offers no insight into why adversarial metaphors are scientifically either appropriate or inappropriate and no indication of which observations might be marshaled to construct an alternative theory. Haraway has made an undisguised ideological statement, one with which some might sympathize, but is this anthropology or politics? Science, if it is subject to such deconstruction -- and subsequent reconstruction with a particular political or social orientation -- becomes merely another social construct that serves as a focus of power relations.

The social constructivists jolt us from complacency to reexamine our practices and the very assumptions of our science. This must be welcomed. But to be regarded seriously, the critics must employ a responsible analysis that allows us an objective science that propels our airplanes and cures diabetes. To undermine the legitimacy of scientific objectivity, as some postmodernist ideologues might wish to do, is a dangerous business. I do not deny that the history of science has taught us that the foundations of science can change, reflecting the very essence of scientific development; the truth of today becomes the fiction of tomorrow. Nevertheless, we must proceed with the confidence that we seek a truth, a reality, to which we might relate with increasing comprehension and effectiveness. If we cannot retain our confidence in scientific objectivity in its most grandiose and naive claims, we might at the very least rely on its efforts to attain its own inner coherence and growing power to manipulate nature to our benefit.

Alfred I. Tauber, M.D.
Boston University, Boston, MA 02215