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Inquiry: An
Interdisciplinary Journal of
Philosophy
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Inquiry, 16, 206-13
Arthur M. Kleinman
Harvard University
cine, but also openly invites broad philosophical enquiry into medicine,
something that has been strangely and seriously lacking in the past.
No matter what the perspective — diachronic or synchronie —
medicine is always found to constitute a system. The medical system is
an ordered, coherent body of ideas, values, and practices embedded in
a given cultural context from which it derives its signification. It is an
important part of the cultural world and as such it is constructed, like
any other segment of social reality, by the regnant body of symbolic
meanings. The medical system forms an indissoluble and hierarchical
whole in which healing acts are closely linked with ideas about
disease causation and models for classifying disease. The whole is
oriented toward the problem of effectively dealing with illness. From
this viewpoint, healing is not the outcome of diagnostic acts, but the
healing function is active from the outset in the way illness is perceived
and the experience of illness organized.
Medical systems function along the lines of the cultural dialectic,
relating and treating both individual and social realities. In fact, the
patient for most medical systems has traditionally been both the
individual and his nexus of social relations. The acts of ordering,
naming, interpreting, and offering therapy for illness are aspects of
symbolic reality common to both the sick individual, the healer, and
their society. Medical systems employ different explanatory models
and idioms to make sense of disease and give meaning to the individual
and social experience of illness.4 Meaning and efficacy, until the veiy
recent advent of biomédical technologies which actually control
biochemical, physiological, and psychological processes, have always
been inseparable in medical healing. Medical systems may be crudely
characterized as expressions of the cultural loci of power which they
utilize to explain and control illness.5
A given medical system in its socio-cultural context does consider-
ably more than name, classify, and respond to illness, however. In a
Medicine's Symbolic Reality 209
efficacy and provision of meaning for the personal and social experi-
ence of sickness. Efficacy, itself, is a cultural construct. The healing
dialectic has been considered effective when the bonds between the
sick individual and the group, weakened by disease, are strengthened,
social values reaffirmed, and the notion of social order no longer
threatened by illness and death; or when the individual experience of
illness has been made meaningful, personal suffering shared, and the
individual leaves the marginal situation of sickness and has been
reincorporated in health or even death back into the social body.
Healing is the end-point of the medical system, the successful re-
ordering and organizing of the disease experience and, where possible,
its control. Though it is clear that morbidity and mortality statistics,
as well as empirical measures of therapeutic effectivity, do not measure
healing efficacy, little is known about what personal and social stan-
dards of healing efficacy are in modern society, yet these should be
crucial concerns for modern medicine.
Within the form of symbolic reality structured by the system of
medical care, healing has a position situated at the strategic interface
between the cultural systems, the system of social relations, and the
individual. Healing occurs along a symbolic pathway - of words,
feelings, values, expectations, beliefs, and the like which connect
cultural events and forms with affective and physiological processes.
Psychosomatic and sociosomatic correlates are implicit in all medical
healing relationships. Feelings and physiological responses are in some
way linked to socio-cultural reality via early socialization and learning.
Language and other symbolic forms are the most obvious bridge. In
this way, medicine's biological and cultural roots are connected; the
formal, barriers between these realities begin to dissolve if we penetrate
medicine's thoroughgoing symbolic reality. We reiterate that this
symbolic structure is present not only in therapy, where it plays a
patent role of mediation, but also in the social construction and
Medicine's Symbolic Reality 211
cally, medicine, one of the first human sciences and in some ways a
paradigmatic one, is in the tragic process of emancipating itself, via
technicalization of all of its problems, from this vital source.
The study of medicine as a cultural system returns our attention to
the artificial and unfortunate separation of medicine into two distinct
areas, only the first of which has heretofore qualified for scientific
investigation. We have briefly tried to show that we must reconsider
the 'maze of little streets' of the ancient city, medicine taken as a
human reality, if we are to arrive at any general understanding of
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NOTES
1 A leading example of the comparative social study of science is Everett Mendel-
sohn and Arnold Thackray (Eds.), Science and Human Values (Humanities Press,
New York 1972). No single volume is yet available that satisfactorily reviews
the comparative social study of medicine, rather one must turn to a number of
outstanding articles in different areas. The author is presently preparing a
volume entitled Culture and Medicine, which will be a general overview of this
subject.
2 The reader is referred to the following paradigmatic studies of different systems
of medicine: for traditional Chinese medicine, Pierre Huard and Ming Wong,
Chinese Medicine (World University Library, New York 1968); for primitive
medicine, Victor W. Turner, The Forest of Symbols (Cornell University Press,
New York 1967); for folk medicine, John M. Ingham, 'On Mexican Folk Medi-
cine', American Anthropologist, Vol. 72 (1970), No. 1, p. 76; for ancient Greek
medicine, Pedro Lain Entralgo, The Therapy of the Word in Classical Antiquity,
ed. and trans, by L. J . Rather (Yale University Press, New Haven 1970) ; for
modern medical systems, Eliot Freidson, Profession of Medicine (Dodd, Mead &
Co., New York 1970); for culture contact and transformations between tradi-
tional and modern systems of medicine, R. C. Croizier, Traditional Medicine in
Medicine's Symbolic Reality 213
Modern China (Harvard University Press, Cambridge, Mass. 1968), Charles
Leslie, 'Modern India's Ancient Medicine', Transaction, Vol. 6 (1969), No. 8,
p. 46, and Alexander Alland, Adaptation in Cultural Evolution (Columbia Uni-
versity Press, New York 1970). Recently, the Wenner-Gren Foundation has
conducted an interdisciplinary conference on the comparative study of Asian
systems o£ medicine, which is soon to be published. In October 1973 the first of
several international conferences on the comparative study of medical systems
will be held at the University of Washington and will deal with Chinese medicine
and scientific medicine in China, as well as theoretical issues in comparative
medicine; it is to be followed by a conference on African medical systems.
3 On the sociology of knowledge, see Peter Berger and Thomas Luckmann, The
Social Construction of Reality (Doubleday, New York 1967) ; and Burkart Holzner,
Reality Construction in Society (Schenkman, Cambridge, Mass. 1968), both of
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which are made relevant for medicine in Freidson (1970). On the relation of
modern linguistic developments to the study of medical systems, see Claude
Levi-Strauss, 'The Effectiveness of Symbols', Structural Anthropology (Doubleday,
New York 1967), pp. 181-202; and S. J . Tambiah, 'The Magical Power of
Words', Man, Vol. 3 (1968), No. 2, p. 175. Examples of symbolic and structural
analyses applied to medicine are found in : Clifford Geertz, 'Ethos, World-View
and the Analyses of Sacred Symbols', in Alan Dundes (Ed.), Every Man His Way
(Prentice-Hall, Englewood Cliffs, New Jersey 1968); Victor W. Turner, 'The
Syntax of Symbolism', Philosophical Transactions of the Royal Society of London,
Series B (1966), 251, p. 295; and Nur Yalman, 'The Structure of Sinhalese
Healing Rituals', Journal of Asian Studies, Vol. 23 (1964), p. 115. For modern
ethnographic approaches to medical systems, see: Charles O. Frake, 'The
Diagnosis of Disease among the Subanum of Mindanao', American Anthropologist,
Vol. 63 (1961), No. 1, p. 113; and L. B. Glick, 'Medicine as an Ethnographic
Category', Ethnology, Vol. 6 (1967), p. 31. Historical and cross-cultural com-
parisons of elements of medical systems are exemplified by Michel Foucault,
Madness and Civilization (Mentor Books, New York 1965); and Mary Douglas,
Purity and Danger (Pelican Books, Baltimore 1970). Alland (1970) attempts to
compare whole medical systems in his evolutionary framework. General com-
parisons of Asian, African and Western medical systems are found in: Robin
Horton, 'African Traditional Thought and Western Science. I', Africa, Vol. 37
(1967), No. 1, p. 50; Pierre Huard, 'Western Medicine and Afro-Asian Ethnic
Medicine', in F. N. L. Poynter (Ed.), Medicine and Culture (Wellcome Institute
Publications, London 1969); and T. A. Lambo, 'Traditional African Cultures
and Western Medicine', in Poynter, Medicine and Culture.
4 See Horton (1967).
5 Glick (1967), p. 34.
6 Cf. Heinz Werner and Bernard Kaplan, Symbol Formation (Wiley, New York
1967), pp. 15-54; K. I. Platnov, The Word as a Physiological and Therapeutic
Factor (Foreign Language Pub. House, Moscow 1959), pp. 16-38; and Marcel
Mauss, 'Les Techniques Du Corps', Sociologie et Anthropologie (Presses Universi-
taires de France, Paris 1950).
7 Victor W. Turner, 'Lunda Medicine and the Treatment of Disease', Rhodes-
Livingstone Museum Occasional Papers, Vol. 15 (1964), pp. 4—5.
8 Freidson (1970), pp. 205-23.
9 See Pedro Lain Entralgo, Doctor and Patient (World University Library, New
York 1969).
10 Cf. Jürgen Habermas, 'Knowledge and Human Interests: a General Per-
spective'. Appendix to his Knowledge and Human Interests (Beacon Press, Boston
1971).