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Keywords:

  • body;
  • objectification;
  • surgery;
  • participant observation;
  • cancer

Abstract

  1. Top of page
  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References

The article discusses patient objectification from the viewpoint of the objectifying, rather than the objectified party. Resisting a dichotomy between physician-objectifying and ethnographer-humanising, the author portrays objectification not as an essential by-product of professional tendencies, epistemological bases, practical necessities and processes of socialisation but as highly dependent upon context. A further look is given to the settings within which the discursive dynamics of ‘objectivity’ and ‘experience’ come about through artefacts, space, symbols, bodily appearances and so on. The author portrays her relationship with Omer, a brain cancer patient whom she has followed over a period of 18 months and then focuses on her observations of his brain surgery. The fluctuations in the author’s relationship with Omer (as a subject and as a body, alternately) are brought within their immediate contextual elements.

Biography lends to death a new terror. (Oscar Wilde)

The last decades have seen an accumulation of research associating biomedicine’s practices and epistemological bases with stances of depersonalisation and objectification of the patient (Scambler and Higgs 1998, Scheper-Hughes and Lock 1987, Thornquist 1997). Arguably, this tendency toward objectification (Eisenberg 1977, Dew 2001, Mishler 1981, Monrouxe et al. 2009) centres medical forms of attention on the body as a material entity. This body will increasingly become observable through expanding scientific technologies and knowledge and thus evermore given to scrutiny and manipulation as a biological machine (Arney and Bergen 1984, Synott 1992, Walters 2004). Defined as such, the biomedical gaze will give this ‘bodily-body’ precedence over embodied subjective experience, the latter remaining, almost by definition, beyond biomedical epistemological reach (Armstrong 1983, 1984, Babbie 1970, Csordas 1994, Good 1994).

This is perhaps most salient in studies of patient–physician interactions (Fox et al. 2009, Murphy 1990, Toombs 1990, Wiltshire 1999). Across the wide range of literature on the subject, these interactions are typically portrayed as two-voiced dialectics: the voice of medicine and the voice of the life-world. Whereas the former refers to the body in abstract decontextualising terms, the latter conveys a view of patients’ experiences as grounded on their social and personal life as it is narrated from a subjective position (Mishler 1984, Young 1997, Barry et al. 2001). These lines of argument have become the dominant voice in broad areas of social study of biomedicine and the depiction of biomedical epistemology as reductionist and materialistic is by now little questioned.

Drawing its strength from this conceptual scheme is an often implicit assumption that the humanistically inclined ethnographer will apply more sensitivity towards the complex, subjective, personal aspects of human existence. This allows her to point out what she considers excessive attention to its supposedly symmetrical opposite (the ‘bodily-body’). Indeed, in important works studying the body as a site of conjunction between the two spheres (Csordas 1994, Turner 1992), the researcher is typically portrayed as more attuned to the lived aspect of the body, as if a necessary consequence of her position (Berg and Akrich 2004, Featherstone et al. 1991, Haraway 1991). This creates and reinforces a dichotomisation supported by both methodologies and epistemologies. The position of the researcher (taking up from human-centred disciplines) and the position of the (biomedically inclined) physician are split and kept apart.

I here seek to question this dichotomy by depicting a unique set of contexts where the ethnographer herself is swayed towards the objectification of her research subject, a young man afflicted by a deadly brain tumour. I attempt to demonstrate that although one may identify tendencies of objectification in biomedicine, this is neither a constant position nor is it a necessary by-product of the epistemological, historical, technological or even political characteristics of the profession. Rather, the patient’s image is defined and redefined in interactions, alternating object and subject positions, passive and active stances and definitions as either patient or person (Berg and Akrich 2004). Taking this a step forward, I argue that one cannot, and must not, exclude the researcher from these microdynamics. However reflexive and empathetic, the researcher is hardly immune to objectification tendencies. This is an issue that should be thoroughly considered when entering the field: the ethnographer must be aware of the elements that may affect her stance toward her informants; she must be aware of the influences particular contexts may have on the position she will have in the field; her field diary should be considered as an oeuvre of multiple authors: the text, as are the ethnographer’s various states of mind, is but the product of a largely unstable and contingent points of view.

Methodological notes

  1. Top of page
  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References

Research background

I present my claims using a first-person narrative of my relationship with Omer, a 32-year-old informant encountered as a brain cancer patient in the course of previous fieldwork (Gross 2009a). Conducted in the first half of 2006, this ethnography followed the working of a neuro-oncology outpatient clinic situated in a large hospital (referred to here as ‘Hospital-West’). The team consisted of four neuro-oncologists, a head nurse, a social worker and a neuropsychologist, all taking part in the convoluted processes at the focus of the research, that is, the epistemological dynamics surrounding the case presentation, diagnosis and conceptualisation of disease. Concerned with the ways in which objects of pathology were constructed, I observed routine consultations, doctors’ rounds and three weekly professional meetings: one internal conference, one with radiologists and one with neurosurgeons. Extensive field notes were gathered, along with both formal interviews (transcribed verbatim) and casual exchanges with staff members, patients and close relatives. At the end of these six months of intensive participant observation I begun a year-long follow-up, over the course of which I kept close contact with some of my informants, Omer included. The continuity of these exchanges allowed for a more refined and meaningful rapport to develop. I became Omer’s confidante, and he turned into both a research subject and friend. Yet, while I was growing more intimate with his ‘being-in-the-world’, I also saw his medical condition unfolding: I continued to attend staff meetings, wearing my white coat and browsing through Omer’s medical file. I often heard his case discussed and was thus continuously exposed to the details of the purely biomedical aspects of his condition. Along parallel, yet at times intersecting lines, I followed his ‘illness’ as it was subjectively experienced, while charting his ‘disease’ (Kleinman 1988) as a physical entity with ‘a life of its own’, largely unknown to its carrier. In both forms of rapport, roles were negotiated and renegotiated as contexts shifted, moving from objectifying Buberian I–It relationships to a more personal I–Thou relationship and back again (Buber 1988, Tillmann-Healy 2003). The apex came when I witnessed his brain exposed in the operating room (OR), where the complexities of our relationship reached an extreme.

On auto-ethnography

As considered above, this article presents ways in which the experience of the other as an object may be affected by role definitions, ritualistic practices and overall contextual factors. Since genuine subjective experience is not something that is ‘out there’ but is rather ‘in here’ it can only be reached via introspection. Thus, the use of first-person narrative seemed methodologically most appropriate. Furthermore, considering the complexity and the highly emotional aspects of the research, an intense reflexive stance was unavoidable: both when composing field notes and when rethinking the field in hindsight. My shifting attitude toward Omer was a central concern for introspective analysis, bringing insights impossible to reach without addressing my own thoughts, emotions and embodied states.

Clearly, issues of generalisability and replicability may arise when using auto-ethnographic research. In this, however, the method is no exception to any other form of qualitative research where interpretation and thickness of description are prioritised over quantifiable data (Ellis 1999, Tillman-Healy 2003). My account is inevitably tainted with my interpretative schemes, focusing on concerns that seem to be particularly meaningful and demonstrative of my interpretation (Gross 2009b, Williams 2008). This considered, the narrative form associated with auto-ethnographic work (Richards 2008, Tedlock 1991) allowed me to draw a common thread of meaning around a series of noteworthy moments or events (Mattingly 1998, Polanyi 1985) that best relay my experience and perception of Omer as a subject and as an object. It thus brought coherence and continuity in the sequencing of events and the unfolding of what I believe to be their significations (Ewing 1990, Becker and Kaufman 1995).

The entry into the field

The entry into the neuro-oncology clinic demanded gaining the trust of Professor Tamir. Tamir, the head of the clinic, agreed that my presence could benefit patients’ health and wellbeing, if only by offering personal attention. Also an eager scientist, Tamir gladly co-signed the proposal to the ethical committee and I received formal approval from the hospital’s Helsinki Committee, as is customary in Israeli medical research. This, along with Tamir’s unquestioned authority and charisma, secured me the confidence of the staff. I was accorded access to the innermost stages of their work. All was documented in writing, including signed forms of consent.

Understanding the natives

Entering the medical backstage was not a trivial task. Considering the highly intricate nature of the field of neuro-oncology and the highly complex terminology used by the experts, there is little way to communicate the real-life work of the professionals without referring, however critically, to these schemes. According to Collins (1994a, 1994b), the lack of understanding of the physician’s life-world (or verstehen) leads to significant biases in ethnographies of medical settings (Bolton 1995). As thickness of description and authenticity may be dependent upon the proper understanding and interpretation of dialogues, objects and procedures, I methodically acquainted myself with the ‘native language’ of neuroanatomy, neuro-oncology and clinical neurology, and acquired more tacit knowledge by continuously watching sequences of both general brain surgery and tumour resection operations.

The story

  1. Top of page
  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References

Prelude

At Tamir’s office Omer’s dossier laid on the table. I saw his name and remembered his case, which was discussed during the last staff meeting. My field notes read ‘Omer Katz is a 32-year-old patient with a grade II oligodendroglioma’; a type of brain cancer carrying a life expectancy for the patient of seven to ten years. He was diagnosed in 1999 and we were now at the end of 2006. Seven years had passed.

The seizure

Our first interview took place at a coffee house near the hospital. Incidentally or not, on this very day, Omer experienced a fully fledged epileptic seizure. This was his first after two years of remission, his first since starting chemotherapy. As we began talking, nothing seemed unusual about Omer, but about ten minutes into the interview he hastily left the table ‘to freshen up’. As far as I could gather, he was emotionally weary at having to recall his experiences. Soon I discovered he had collapsed. Lying on the floor near the staircases, he regained consciousness surrounded by strangers. He called out my name and described me to a passer-by. The latter reached the coffee house and, almost out of breath, told me that one ‘Omer Katz’‘was not feeling well’. Led to the staircases, I made my way through the small inquisitive crowd and approached him in a familiar tone. This moment of intense – and instant – intimacy soon led to a close friendship.

I inevitably found myself helping Omer to the emergency room – the access to which seemed facilitated by the fact that I was wearing (at Tamir’s demand) a white gown. I was led through the back door and no questions were asked. There, we spent the following seven hours together, some in an interview mode, with my recorder lying on the bed between us, as if separating researcher from subject; some engaged in casual conversation, the recorder placed back in my pocket. At one point I was casually asked by the orthopaedist to hold Omer’s arm while she forcefully relocated his shoulder into place; at another, Omer asked me to hold his hand as he laid still. When his family finally arrived, I left. It was as if my shift was over and now theirs began. Yet it all seemed natural, as if finally setting things straight: I was an intimate.

Know it all

The seizure was a clear sign of relapse. As a ‘member of the staff’, I saw the magnetic resonance image (MRI) before Omer did. There was little need for professional deciphering: the tumour had grown considerably; a fact that was enough to explain the seizure. As to my question on this specific episode and its timing, the physicians all ruled out any causal relation between the seizure and Omer’s emotional tension at the time. In other words, the subjective was non grata in this loop of causation: it was the tumour ‘having its will when it had its will’ (as one of the physicians told me). Omer, however, saw his state of mind as a valid, and in this case, dominant, aetiological source: he, as a feeling, experiencing person was at least as consequential in causing the seizure as this ‘lump of cells inhabiting [his] skull’. I myself remained indecisive on the subject.

There was little doubt Omer’s condition was deteriorating physically. As a behind-the-scenes backstage observer I was well aware of that. However, I had to wait for him to find out this unfortunate development as any other patient would: I was not medically qualified to divulge the results and was reluctant to present myself as more informed than Omer himself. For me to convey the results would not only mean a breach of ethics, nor a mere methodological bind. It would have also meant a collapse of the two spheres within which I operated: the professional, biomedical (and thus objectivity-oriented) and the personal, experience-focused (thus perhaps more subjectivity-inclined). At another level, it was the clinical (his seizure) and pathological (the MRI) events that ‘spoke’ of the disease, when Omer still did not (as he was unaware, at least consciously, of his condition). The disjunction became evermore clear: Omer was both a talking organism, sending cues in the forms of signs and symptoms, and an embodied subject, eventually mediating the knowledge of his disease via his conscious self. This double – and very much dualistic – perspective became omnipresent in all exchanges related to him: Omer was both person and patient, subject and body.

Changing scenes

As the months went by, more aggressive treatment became unavoidable. Omer went through radiotherapy; he lost his hair patch by patch; he experienced increasing difficulties in communicating properly, focusing his sight and recalling phone numbers; his seizures grew both in intensity and frequency, at this point up to five times a day. Towards the end of the year, he had almost completely lost sensory and motor function on his right side. The Hospital-West team gave up on treatment. Palliative care was all that remained.

The team at Hospital-East, however, were willing to perform one additional surgical intervention to allow the chemotherapy to be more effective. The surgery was to take place a month later. Omer was amused when I first asked him whether I could join in the operation. He dared me to go through this and report on ‘what [he] looks like inside’. Would knowing what his brain looked like add anything to his understanding of himself, or to my understanding of him? Would he have had the same request, had another organ been the target of surgery? On the latter, he responded; ‘it wouldn’t have been that cool.’

The S-day

The difficulties I had in positioning myself in relation to Omer found their epitome during the day of the operation: all seemed to be encapsulated in those hours before, during, and right after Omer’s brain surgery. The morning of the surgery, the pressure Omer’s swollen brain applied on the inner walls of his skull was so severe that he had to keep his eyes shut in agony. The increasing doses of steroids puffed up his face and his 6 foot 3 inch frame gave him the appearance of a giant hamster. I looked curiously, a little detached, at this grotesque figure being wheeled to the OR, his hands nervously patting his skull. On the top of his head were scattered a few bits of fluffy hair and huge bold blemishes. A bulging bump of fatty tissue stood at the centre of a long purplish scar – both remainders of his first surgery, performed seven years before. Throughout, I had to remember to hold Omer’s left hand rather than his right, where he was completely insensitive to touch – I could not subjectively affect the right side of his body which lay there, blind and numb. Yet, from the other side of the bed, to his left, I could press my fingers into his: both of our sensory neurons shooting information up to our brains – the ultimate I–Thou relationship, perhaps. Can we objectify only one side of a person’s body?

In these moments, the clinical details of his case seemed to evade my mind. With him I was at times detached, at others immersed in his experience. He looked at me and, from time to time, made a slight attempt to smile, but raising his heavy eyelids seemed extremely painful. Not able to make genuine eye contact with him, I kept asking myself who this body was, and whether it was at all somebody’s.

I followed the wheeled bed down the elevator together with his parents and sister. Awakening us all from our daydreams, the nurse abruptly halted in front of the surgical area, firmly instructing us not to cross this half-imaginary boundary: we had to say our goodbyes now, here. The family kissed Omer, and asked me, in tears, to take care of him. As I was about to cross into the biomedical realm it seemed they were reminding me he was a dear person rather than a patient.

Passing through an invisible doorway into a brightly lighted corridor, I followed the nurse to the intensive care unit (ICU) where patients were kept and monitored right before and after surgery. Omer’s bed was positioned between two other patients and dozens of high-tech medical appliances. I quietly arranged his pillow – this familiar but futile gesture of concern. Shortly after Omer had signed the consent forms (which he could not read at this point) the surgeon arrived, wearing his scrubs and announced that Omer would shortly be brought to surgery. A nurse showed me to the changing area and handed me carefully bagged sterile uniforms. With the blue nylon pants and shirt in my hands, the nurse found me embarrassed: was I to wear the uniform on top of my current clothes? Perhaps a sign of my position vis-à-vis the field, I was told to take off my daily clothes and wear the uniform on my bare skin. Entering the liminal space of the changing room dressed as a lay person, I remained there virtually naked for a few moments, my identity neither here nor there – I was, after all quite comfortable with both roles, having spent months wearing a white coat. I then wore the uniform, now I wore my uniform. I could feel it on my skin as I unwittingly adopted a slightly different walk (faster than usual) and handled my body differently (less eye contact and a definitely more upright position).

As I passed through the ICU I was told by one of the surgeons not to forget to put the hair cap and mask on. These were available only very near the entrance to the OR, an even more restricted area, and consisted of the last garment promising me a place in this in-group. My position as an outsider would be concealed behind these clothes: fully camouflaged, I could then identify myself and be identified as a member of the biomedical team. My inquiring gaze was perhaps all that could distinguish me from the staff.

Under the skin

As I was struggling with the hair cap – reminding me how little I really belonged there – Omer’s bed was wheeled up into the OR and prepped for surgery. I found him unconscious, draped from head to toe, his large blue eyes shut with tape, his bloated face concealed, his body scraped clean and sterilised. As the medical apparatus kept invading his once personal space, he gradually sank into the realm of idle objects – both right and left side of the body. Although he was at the centre of attention, Omer became completely absent and it was in his absence that my role shifted from accompanying him to accompanying the surgeons.

At this point the room was relatively free of tension. The staff moved freely around the room, talking and arranging their equipment in relative leisure. As the actual operation began, the room turned silent. I applied myself as I followed the knife going over the long crescent-shaped scar and an inch further down. The skin was pinned to the sides, allowing the opening of a fist-wide cavity at the centre of the wound. I remained standing over the orifice, surprisingly experiencing little awe or disgust. What seemed to take over me was rather an acute sense of curiosity.

The cutting revealed five pieces of bone stapled to form an odd jigsaw puzzle, a remainder of the previous intervention. As the two junior surgeons removed the white eggshell pieces and dropped them into the stainless steel bowl, a clinking sound broke the silence. By now, only a thin layer of tissue kept the majestic organ in. With a single cut, the brain – swollen and eager to break away – herniated and literally broke out into the open air. The staff showed interest in the unusual extent of the phenomenon. For me, it was as if I could now see – with all the power of the visual – why Omer was under so much pain: his brain was literally about to burst out of the orbit of his eyes. I could empathise with his pain before, yet, somehow, this bulging lump of flesh made it more real.

The peak of surgery

As the team was entering deeper into the body and getting closer to the handling of the brain, the ritualistic aspects of surgery became more dominant. For instance, only then did the head surgeon make his appearance. As if waiting for a bride at the altar, everything had been meticulously laid out for him and all eyes reverently arose to him as he made his entrance. Carefully scrubbed, he took a seat on a tall, throne-like chair covered with a sterilised sheet. The junior surgeon also took a sitting position at this time, on a similar chair, albeit at a less central position, beside (rather than directly behind) Omer’s head. At this point, the OR became silent, still and tense. The lights were turned off, except for a beam of pale light illuminating Omer’s skull. The liquid crystal display screens from which the site of the operation was broadcast to the OR audience were turned on. From one of the screens the head surgeon could observe a live MRI picture of Omer’s brain as he inserted his instruments. So could I.

I knew how the brain looked, but imagined Omer’s would look as if it was Omer’s. After all, this was not the anonymous brain you would see in anatomy class: this was the brain with which I had these I–Thou relations and intersubjective exchanges. This was the brain that cried, laughed, told stories. But as a brain without a person to personify it – it was just meat, sick meat. I was deeply disenchanted.

Seeing the brain without seeing the mind, observing its actuality, its fleshiness, one must concede that in the OR, the mind is nowhere to be found. From where I was now standing, I could see the back of Omer’s head, his open skull and his brain, the material, graspable loci of his subjectivity. I felt I was vicariously picking and probing into him while he lay there, unconscious, and I wondered how deep had I really been allowed in.

Hours went by as the surgeons methodically vacuumed tumour tissue and carefully sealed blood vessels and I became increasingly focused on the physical and biological presentation of the tumour. I felt I had developed a relationship with Omer’s brain; a relationship that was in many ways independent of its carrier, Omer the person. After all, in the course of the last 18 months I had had almost as many direct encounters with Omer’s brain as with Omer himself. This was perhaps most striking when the surgeon showed the latest MRI image on the screen: the tumour’s shape and its shades of grey were all too familiar. I heard myself making a remark that would later puzzle me. Impressed by the tumour’s current size, I said I knew it/he ‘Ever since it [or ‘he’] was this little!’, as if I had been speaking of a child. It/he was, after all, a growing, dynamic organism – whether welcomed or not. The team giggled.

Closing up: the last stages

Once the thrust of the surgery over, the head surgeon told the juniors to close him up and left the room. The pieces of bone were placed back and the skin stapled, lights were turned on again and movement became freer. The tension was released, masks were taken off, electronic devices were removed and Omer’s face and body were again visible.

I followed the head surgeon as he went over to talk to Omer’s parents. The despair about the intractability of his condition and ‘the impossible mess the tumour made in his brain’ was reserved to backstage discussions. Not entering into details, he gave a somewhat reassuring impression: Omer had survived and the surgery had bought him some more time. Again, I knew what my informants did not: the surgery was to no avail – this serious and dangerous intervention gave Omer only a few more weeks of palliative care. He awoke with a confused mind and a debilitated body. In many ways, he would remain a lifeless body until his death, yet, unlike in the OR, he would consciously experience every moment of forced passivity.

The story retold

  1. Top of page
  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References

The OR as a space of multiple liminalities

The surgery room is in many ways the epitome of biomedical practice. It is separated both physically and symbolically from everyday life and secluded from the general medical practice of the hospital (Goffman 1961b, Foucault 1975, Moreira 2004, Wilson 1954). This is where the invisible becomes visible, the inaccessible accessible, the inside becomes part of the outside. The OR is also a space where liminal states are omnipresent (Douglas 1966, Turner 1969, Van Gennep 1960). These also include categories where scientific knowledge ceases to exert its conceptual control, namely on life, death and consciousness. Surgery under general anaesthesia calls for a suspension of life and death and a superposition of presence (as an anaesthetised body) and absence (as a conscious person). If, as suggested in the above narrative, full consciousness is the matter out of place (Douglas 1966), it is not only the boundaries in the categories of life and death, inside and outside, that must be reinforced and safeguarded, but also categories of phenomenological sentience versus ontological presence.

As has been well shown in previous studies (Katz 1984, Katz and Kirkland 1988), OR rituals are associated with the need to facilitate the transition between categories of things by clarifying their distinction, most prominently between things that belong (objects) and things that do not belong (subjectivity) in the OR. Thus, subjectivity is curtailed and managed to minimise the soiling of the purity associated with the materialist realm of things. In this shrine of objectivity, the experiencing subject must be subdued (anaesthetised), hidden (draped) and made sterile (disinfected). Along with specific rules and practices, these permit a conversion of the life-world into one object among others that can be dissected and manipulated (Gaines and Hahn 1982, Hahn and Gaines 1985, Hirschauer 1991).

Rituals, however, do more than create boundaries. They also have the power to convert mundane objects into entities that belong to the sacred and are thus less likely to form objects of liminality. For instance, only when transformed from a sentient whole into an operable body can the patient be allowed into the OR (Fox 1992, Katz 1984). The medical personnel also go through processes of transformation: these include scrubbing rituals preceding entry into the operating room and the special attires worn by the staff (Felker 1983, Geest 2005, Moerman 1979). The dressing room creates this hidden space of liminal status where the lay person is transformed into a professional, where insider and outsider identities are interchanged.

The adjacent space of the ICU serves – both spatially and conceptually – as a site of transition where the patient’s ‘operable body’ becomes a ‘normal body’ again (Kaufman 2000) and where danger to the ordering of the orthodox state-of-being is relieved (Landzelius 2001, Van Gennep 1960). As life-world modes of interactions become available (the patient regains consciousness and is able to report on her subjective experience) and biomedical monitoring (for example, of pulse rate and blood pressure) becomes less essential, the patient may be released to the outer circle of the sacred space into the ward. As the patient leaves the liminal state, the surgical team (representing the patient as an operable body) reappears on front stage, where the family (representing the patient in his normal body position) awaits them (Goffman 1961a).

Keeping the subject out: sterility

According to Katz (1984) and others (for example, Cassell 1998), the lengthened minutes of scrubbing immerse the professional into a state of mind by which they perceive the patient as a physical entity interacting with and endangered by other physical entities: germs. Along this line of argument, the roles of listerism and sterility are restricted to promoting practical aims (preventing infections).

My observations, however, suggest that these rituals cannot be explained away by simply turning to the germ theory. In addition, the levels of objectification (by different professionals, at different stages) and the demand for elaborate scrubbing seem to correlate with each other. The ‘precise and beautifully choreographed ritual’ of scrubbing (Cassell 1998: 91) involves transformative practices in relation to the experience of surgery (Landzelius 2003); namely, in keeping a view of the body as belonging to the world of matter, whether germs are involved or not. In more concrete terms, the more one treats the patient as an object, the more one is required to be sterile, that is, to abide to this ‘stylized, arbitrary, repetitive, and exaggerated’ behaviour (Katz 1984: 349). Along this continuum, the head surgeon (who encounters Omer only at the stage where his skull is already open) would stand on one end with myself and the anaesthesiologist (who had outside exchanges with Omer at the ICU) the other. Distancing rituals and objectification came hand in hand.

Anaesthesia: subduing subjectivity

The effect of anaesthesia on objectification is undeniably powerful. When sedated a person’s state of wellness is defined in terms of pulse rates or levels of oxygenisation shown on computer screens (Collins 1994a). By eliminating the patient’s subjective presence, anaesthesia creates a lifeless body to be manipulated, as if in the absence of its ‘owner’. In submitting herself to sedation, the patient will convey her faith in the expertise of the surgeon as a ‘worker of the body’ into whose hands she can literally place her own existence.

It is precisely at this point when the critical spectator turns absent, that the team is able to make the transition to a backstage form of interaction (Goffman 1961a, Hindmarsh and Pilnick 2002, Pilnick and Hindmarsh 1999). Backstage the language becomes more technical and inside information is more freely communicated – including, as in this case, alarming news on the patient’s prognosis. At one point, for instance, while Omer was deeply sedated, the head surgeon called me over and showed me, right on the surface of the exposed brain, the extent of the damage, announcing as if of a matter of fact that ‘the tumour [was] enormous’ and that Omer’s prospects of survival were grim. Omer himself was absent (that is, anaesthetised) as his death sentence was declared.

Going native

According to many scholars (for example, Becker et al. 1961, Fox 1979, Goffman 1961a, Smith and Kleinman 1989, Walters 2004), medical education includes the teaching of clinical detachment or ‘role distancing’ from patients as human beings. It allows physicians to not only treat the patient more objectively or to be less sensitive to awkward and at time repulsive tasks, but also to refrain from developing emotional – and often, emotionally stressful – attachment to patients (Frank 1995, Francis and Lewis 2001, Good 1994, Hafferty 1988, Leder 1992). Although I had not been inculcated with such distancing techniques acquired by socialisation, I was fully able to sustain viewing the surgery without suffering an extreme emotional response. Distancing cannot merely be a skill taught in medical school, nor is it simply a form of tacit knowledge acquired through practice. When undertaking the task of surgical intervention, the specific rituals and symbolic elements work to suppress feelings of identification and compassion. This was effective not only in the medically socialised participants but in the lay observer as well.

Alternating objectification and theories of mind

  1. Top of page
  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References

Objectification is often seen as a mere fault in the practical and epistemological bases of biomedicine. One can also, however, regard it as an inherent feature of daily interaction, as an ordinary and perhaps unavoidable, part of one’s exchanges with the world. Whereas the former view relates to the more detrimental effects of referring to another as an object, the latter returns to the philosophical fundamentals: can the other really be seen, experienced and understood as a subject?

In philosophy this problem engendered the notion of the theory of mind (ToM). Although one can only be confident of one’s own subjective presence (as experienced at first-hand), human beings do ascribe minds to others and do so in accordance with particular ToMs (Carruthers and Smith 1996, Premack and Woodruff 1978, Whiten 1991). Put otherwise, one sees others as subjects if and only if they hold characteristics deemed to belong to a ‘minded’ thing. This may include animals squeaking in pain when tortured or exclude entire categories of human (and non-human) forms of existence, such as comatose patients (or ‘vegetables’ accordingly), or foetuses (or ‘unborn babies’, accordingly).

With Omer’s growing tumour and the rising dosage of his medication, his grotesque appearance made him less and less resistant to this form of objectification. In this sense, his draped inertness in the OR had a dramatic effect. In terms of humanness, being attached to non-biological apparatus – such as physiological monitors and a stereotactic helmet – further turned him into a form of cyborg: the mechanical extending to his own body and his body into the mechanical.

Of further bearing was the sense of him as being reachable or responding to communicative stimulation, such as touch, sounds and words. Not only was his ability to perceive and acknowledge his surroundings affected by the disease, but so was his capacity to respond, depending on the level of pain he was experiencing, as well as on the extent of deterioration in his cognitive and language skills. In fact, in the midst of his disease, his girlfriend left the condo they shared, unable to continue a relationship with what/whom, according to her own ToM, was ‘a wreck’ rather than ‘the man she knew and loved’.

Objectification is thus intimately linked to the extent to which any ToM is inclusive of one or another form of personhood. This of course, goes much beyond biomedical socialisation and well into the examination of broader sociocultural forces still to be explored.

Concluding words

  1. Top of page
  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References

Modern western culture has always held an intricate view of the body. While it is also considered as one object among others, the body is assigned a singular status as the locus of a subjective consciousness (Lanigan 1995a, 1995b, Sartre 1956, Merleau-Ponty 1962). Approaching this conundrum, social studies have repeatedly shown how biomedicine, as a dominant discourse of modernity, tends to refer to the body in terms of matter, discarding the mind (Cartwright 1995, Lock 1997, Martin 1994).

The OR has its own rituals that are in many ways extensions and intensifications of biomedical epistemologies, practices and symbolic elements. These involve the transformation of a life-world into an object that can be manipulated through the absorption of the patient into a small, depersonalised, objectified body part (Hirschauer 1991, McNay 1991). Little progress has been made, however, in understanding how this stance of ‘objectification’ is experienced by the objectifying party – here, the researcher – rather than by the objectified party that is, the patient. It is precisely this experience that is portrayed in this article.

Often defined in terms of a loss of human concern over another, the term objectification is overwhelmingly used in a pejorative tense. Here, however, I sought to show how it might be an unavoidable part of biomedical work. Neither is it limited to biomedical settings or exclusive to physicians. Ethnographers, in particular, often sway from objectification to empathising positions (Fabian 1983, Clifford and Marcus 1986, Pratt 1986, Wiltshire 1999), as they do not merely observe, nor do they merely participate in transformative rituals – they also experience them and are phenomenologically affected by them. I have thus suggested an interpretation of exchanges in biomedical spheres that points to the inherent tension between the two tendencies (objectification and empathy), two roles (physician and ethnographer), two perspectives (biomedical and personal), and two phenomenological states. Indeed, it seems that, depending on the symbolic and ritualistic setting, even the most empathetic actor oscillates between these two attitudes, experiences and forms of rapport. This influence can impinge on good research if left unrecognised. It is not only at the stage of recalling or communicating fieldwork but in its very course that these points should be considered. To which team do I feel ‘I belong’ and how does this affect the saliency I attach to different phenomena? When and how is my subject – or, for that matter, my informant – becoming an object? Am I more or less empathetic in one or another context? What signals am I sending to the participants, consciously and unconsciously? How does this affect the ways my fieldwork takes it course? In this article, this understanding was sought by voicing my own experience of the effects settings, rituals and symbolic elements and their effect on the view I had on the object and subject of research: the patient’s brain and the growing tumour on the one hand; and Omer the person on the other. I must conclude, however, that it is now only the latter that truly remains in my thoughts.

One day, finite projects – and lives – come to an end, and we must leave the field. (Tillmann-Healy, 2003: 729)

Acknowledgement

  1. Top of page
  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References

This writing is dedicated to Omer and his family, without whom these insights could not have been reached and shared.

References

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  2. Abstract
  3. Methodological notes
  4. The story
  5. The story retold
  6. Alternating objectification and theories of mind
  7. Concluding words
  8. Acknowledgement
  9. References
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