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Illness and culture: learning differences
PATiENl EdUCATjoN COlME[iN~
ANd
ELSEVIER
Patient Education and Counseling 26 (1995) 153-157
Illness and culture: learning differences Nikos Dimou 3 Paraschou
str., P. Psychiko,
Athens
1.5452, Greece
Abstract
A review is presentedof severalaspectsof illnessand culture. Stressingthe importanceof sufferingin life, attention is paid to the influenceof the imageof the world on the relationshipto the diseaseand the doctor. This is illustrated by a belief in fate. Further theoreticalconceptsfrom Kleinman, Helman, Schwederand Sontagare appliedto medical situations.Cultural differencesmay be much more important for the treatment of patientsthan acknowledgeduntil now. Keywords:
Illness;Culture; Suffering; Fate; Medical interactions; Health beliefs -
1. Introduction
2. Suffering
One of the major characteristics of each culture is the way it has dealt with the problems of pain, suffering and death. Every religion, every philosophical doctrine originates from the attempt to provide an answer to the basic questions: Why do we have to suffer, grow old and die? Humans cannot accept these states of being - or non-being - as self-explanatory, natural situations. An outside observer would come to the conclusion that they are not programmed for pain and suffering - but for pleasure and happiness. And still, most of the people, most of their lives, have to face the dark side of things. This, according to Albert Camus, is the basic absurd situation. The world is not tuned to the same wavelength as our wishes. We are not given what we crave for, things seem devoid of any meaning, we shout nobody answers.
Suffering is one of the most important facts of life. According to Buddhist teaching, it is the only pertinent fact we need to know about existence. Every society has tried to face it in its own way. Religions offered explanations and justifications for the existence of pain and tried to conciliate the concept of an omnipotent and absolutely good Deity with the existence of evil, pain and suffering in the world. The basic problem of Theodicy the justification of God - can be formulated as follows: ‘If God is all-powerful, he must be able to prevent evil. If he is all-good, he must want to prevent evil. But evil exists. Therefore, God is either not all-powerful, or not all-good’ [l]. The most obvious consequence of evil, for the human being, is suffering, in its widest possible sense meaning the fact of enduring things. Suffering is something imposed upon us. It converts an active
0738-3991/95/$09.50 SSDI
0 1995 El sevier
0738-3991(95)00769-V
Science
IrelandLtd.
All rights
reserved
154
N. Dimou
/ Patient
Education
being, into a passive recipient of agony and grief. If we divide suffering according to its causes, it could be classified into 2 main groups: (a) Suffering built into the cosmic order (disease, death, natural disasters) and (b) suffering caused by human wrongdoing (e.g. in war). It is the first group that every culture tries to cope with - since man-made pain seems easy to explain (even if it is not easy to avoid). The attitude of a cultural group towards a concrete and very frequent form of suffering, namely illness, is basically determined by its general world-image (The ‘Weltbild’ of the Germans). It is of the paramount importance to comprehend how a culture accounts for suffering, in order to understand the reactions of its individual members to illness - especially to a chronic illness. Some cultures regard suffering as a test imposed upon us by the Deity. It is as if we all existed only on probation and have to pass this test in order to prove ourselves worthy. The ‘Book of Job’ in the Bible illustrates this point very well: Job goes through all kinds of ordeals - but, because of his patience and fortitude, he is not only re-instated but also rewarded at the end. So, if a patient looks upon his illness as a God-sent trial, he may be more persevering and compliant. If he sees it as a part of his fate (the fatalist approach), he will probably remain completely passive - since anything he (or the doctor) does, will not alter the course of things. If again he thinks that being ill is his own fault (the positive puritan attitude), he will fight to ameliorate his condition. 3. Image of the world It is obvious that a patient’s Weltbild influences, in a decisive manner, his relationship to the disease and the doctor. This image of the world is actually the summary of all the things we call culture. It would seem then a good method, before working with a patient, to get acquainted with his cultural background. This is not an easy job. Not only because there is no comprehensive introduction to a foreign culture (I suppose most doctors would expect something concise and practical, like a tourist guide), but also because there are subtle cultural and ethnic differences within the same group. For example, the Jewish culture has given
and Counseling
26 (1995)
153- 157
us the most prominent example of the ‘suffering as a test’ theory. On the other hand, the same culture has introduced the notion of sin as a basic cause of human suffering. (Note that the 2 notions are contradictory: Job had not sinned...). Suffering, in that case, is a punishment. Men have to suffer in order to atone for their sins. Especially by postulating the concept of original sin (which has been taken over by the Christian religion), the Jews have created a totally different image. Human beings suffer because they are sinners - all of them, by birth. A similar situation exists within the so-called puritan theory of suffering. A part of puritans believes in pre-destination - meaning that they would tend to adopt a fatalistic approach. Others will be energetic and co-operative. Accordingly, as a basic rule we could propose; Try to assess the mentality and the attitude of every single individual. Do not infer from cultural, and even more, from ethnic generalizations. (For example: the patient is a Turk, therefore, he could be a fully secularized, Europeanized Turk - or a Muslim fundamentalist Turk, two totally different cultural ‘personnae’). When a patient realizes the fact of his disease, the first questions that automatically surface are: ‘Why did this have to be?’ - ‘Why did it happen to me?’ Science can - at the most - explain the biological mechanisms which led to the disease but cannot illuminate the ‘whys’. It is up to religion or philosophy to give some answers, Every single man, whether he is religious or not, has elaborated (or will, at a given moment, elaborate) a theory about suffering - even if it is never expressed and articulated. Even the agnostic has a theory; he believes in fortuitous happening - he postulates that everything is haphazard. His attitude to a chronic disease will definitively be different to that of a fellow-sufferer who believes in the theory of sin and punishment. That personal theory is the key to the understanding of this individual’s attitude. It will be a mixture of prevalent religious and traditional views passed through the personal filter of each single mind. Generalizations can of course always be helpful - as long as they are not applied to individuals in mass procedure. One should also speak less about ethnic differences
N. Dimou
/ Patient
Education
and Counseling
26 (1995)
153-157
155
and more about cultural ones. Within one nation, there usually co-exist many cultures. The latter are the ones that influence an individual’s attitude. Sometimes, even commonplace truths may prove helpful for the understanding of attitudes. In literature, even in fairy tales, the people of the East are thought of as being more passive and submissive than Westerners. This of course has to do with their whole philosophy of life.
There he has made the distinction between the Western human prototype of the ‘active hero’ and the Eastern ‘patient sage’ (‘Aktiven Helden und duldenden Weisen’). One of them wants to change the world, the other just learns to endure. The same philosopher has written the deepest - to my knowledge - analysis of the problem of suffering, in his essay ‘Vom Sinn des Leidens’ On the Meaning of Suffering’ [4].
4. Belief in fate
5. Medical situations
According to the traditional view, the Easterner believes in Fate. He thinks that his future is written down in the ‘Book of Life’. Karma is the Indian word, Kismet the Arabic one. Anything a man may undertake, will not change his destiny. Modern research has confirmed this traditional truth. It has found out that health beliefs concerning locus of control, follow an East-West divide. Westerners accept an internal locus of control that is, they acknowledge that they are responsible for the course of their illness - while Easterners are postulating a totally external locus of control - things are governed from outside: ‘The locus of control construct has led to a large number of studies. One of the more salient results is that persons in Western countries on average are more internal than those in the Far East. Also, people in developing nations are less internal than those from industrial countries. This has to be considered against the background of findings showing that men tend to be somewhat more internal than women and that internals are more achievementorientated’ [2]. It is obvious that when Easterners become developed and achievement-orientated, they will also embrace the Western mentality as far as illness is concerned. So the basic question should not be to what race or ethnic entity does a patient belong - but to what cultural status and system of values. Residence is also not always indicative. A orthodox Hebrew living in New York may be more traditional in his attitude than an Israeli citizen. This discrepancy between East and West has been also studied and commented upon by eminent thinkers. Max Scheler, the German philosopher, has described the difference in his essay (‘Man in the Age of Adjustment’) 131.
Let us see how these theoretical truths apply to concrete medical situations. Kleinmann has introduced the concept of the ‘Explanatory Model’ (EM) [5], defined as ‘the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process’. These notions are held by both patients and practitioners and ‘offer explanations of sickness and treatment to guide choices among available therapies and therapists and to cast personal and social meaning on the experience of sickness’. There is of course a gap among lay explanatory models, which usually reflect the patients’ mentality and culture and the explanatory models of physicians which are usually based on ‘single causal strains of scientific logic’. Should patient and doctor belong to two wholly different cultural groups, then conflict between both is unavoidable. Commenting on the divergence of Explanatory Models (EM), Cecil G. Helman writes: ‘The ways that lay and medical EMS interact in the clinical consultation are influenced not only by the physical context in which they occur (such as a hospital ward or a doctor’s office), but also by the social class and gender of the two parties involved. The power invested in clinicians by virtue of their background and training may allow them to mould the patient’s EM, to make it fit into the medical model of disease, rather than allowing the patient’s own perspective on illness to emerge’ [6]. It goes without saying that this remoulding of the patient’s model does not help communication. The patient does not recognize - and inwardly does not accept - the explanation given to him by the physician. All the more so, since most of the questions people usually ask themselves when
156
N. Ditnou
/ Patient
Education
they fall ill, can never be satisfactorily answered by a physician. These questions have been codified by Helman into 7 headings. I quote [6]: (1) What has happened? (2) Why it has happened? (3) Why has it happened to me? (4) Why now? (5) What would happen to me if nothing were done about it? (6) What are its likely effects on other people (family, friends, employers, workmates) if nothing were done about it? (7) What should I do about it - or to whom should I turn for further help? The ideal doctor, before starting the (usually automated) answering process, should, with the help of these and other questions, attempt to understand the patient’s explanatory model. Only then will he gain an insight in the patient’s thinking - and only then can he hope to motivate and influence his patient’s behavior and attitudes. Physicians tend to automatically disregard all lay theories of illness causation as ‘old wives tales’. But in treating a chronic disease, it is of paramount importance to understand how the patient sees his condition. It may very well be that in a given culture, a specific disease carries a totally different weight - has a dissimilar image and a divergent connotation I would advise everybody interested in the matter to read Kleinmans’ ‘Social Origins of Distress and Disease’ [7]. According to Richard Schweder, it is: ‘The most important book to be written in medical anthropology for a long time. The work is stimulating, passionate, sophisticated, balanced and theoretically up to date. It sets out an inspiring agenda for the anthropological study of suffering. It raises profound questions about psychic and physical pain, spiritual embodiment, and somatization and about the possibilities of cross-cultural understanding and translation of the subjective states of the ‘other’. It entertains the view that forms of suffering vary across cultures and historical epochs’ [8]. Kleinman advocates a new interactionist and holistic view, which should encompass all the interrelationships between mind, body, society, culture and nature. In his book, he uses neurasthenia and depression as a paradigm for a cultural critique of prevailing medical concepts [7].
and Counseling
26 (1995)
153- 157
In his commentary on Kleinman, Schweder introduces a distinction which is of paramount importance for any cultural analysis of sickness. Extending the basic distinction between illness (what the patient experiences) and disease (what the doctor diagnoses), he distinguishes ‘forms of suffering’ from ‘the causal ontologies or theodicies that are invoked to explain them’. And in a very long parenthesis, he goes on to illustrate what these ontologies or theodicies could be in the case of the neurasthenia - depression analysis: (a) A biomedical ontology of organ pathology/physiological impairment/hormone imbalance, or, (b) a moral ontology of transgression/sin/karma, or, (c) a sociopolitical ontology of oppression/injustice/ loss, or, (d) an interpersonal ontology of envy/ hatred/sorcery, or, (e) a psychological ontology of anger/desire/intrapsychic conflict and defense’. Schweder defines suffering as ‘the experience of disvalued and unwanted subjective states (feelings, sensations, emotions, ideas).’ On the other hand, a causal ontology or theodicy: ‘signifies the events and processes going on in some other order of reality (biomedical, moral, sociopolitical, interpersonal, psychological) that are thought to generate or cause the experience of suffering’ [8]. Physicians have been mostly concerned with the biomedical aspects of this complex. But patients have developed their own lay theories of illness causation - and have given certain illnesses a metaphoric meaning, which creates a totally different universe in which doctors usually feel completely lost. Susan Sontag has given a very perceptive analysis of how, in the course of history, certain serious diseases became metaphors for whatever was wrong or immoral in man’s life [9]. Plague, syphilis, tuberculosis, cancer - and most recently AIDS - have been given a metaphysical, religious or symbolic meaning - which includes many social and personal fears and anxieties. These could permeate the patient’s mind and create problems in his communication with his physician, 6. Conclusion We can imagine that many doctors could feel overwhelmed by the burden imposed upon them,
N. Dimou /Patient Education and Counseling 26 (1995) 153-157
when considering the links between illness and culture. They could react by saying: ‘Well what do you expect me to be when I talk to a patient: A philosopher, a psychologist, an anthropologist, a sociologist, a semanticist, an historian of cultures - and a physician?’ Of course not. But we would expect them to be aware of all these parameters, and always take into consideration that cultural differences may be much more important for the treatment of patients than they have ever acknowledged until now.
[2] [3] [4] [5] [6] [7]
References [I] Hick J. The Problem of Evil. The Encyclopaedia of
[8] [9]
157
Philosophy. Vol. 3. New York: Macmillan, 1967, pp. 136-141. Berry JW, Poortinga YP, Segall MH, Dasen PR. Cross Cultural Psychology. Cambridge: Cambridge University Press, 1992, pp. 12. Scheler M. Der Mensch im Weltalter des Ausgleichs. Philosophische Weltanschauung. Munchen: Lehnen Verlag, 1954, pp. 89- 118. Scheler M. Liebe und Erkenntnis. Miinchen: Lehnen Verlag, 1955, pp. 29-68. Kleinman A. Patients and Healers in the Context of Culture. Berkeley: University of California Press, 1980. pp. 104-118. Helman CG. Culture, Health, and Illness. London: Butterworth-Heinemann, 1993, pp. 95. Kleinman A. Social Origins of Distress and Disease. New Haven: Yale University Press, 1986. Schweder R. Thinking Through Cultures, Harvard: Harvard University Press, 1991, pp. 313. Sontag S: Illness as Metaphor. New York, 1978.
ANd
ELSEVIER
Patient Education and Counseling 26 (1995) 153-157
Illness and culture: learning differences Nikos Dimou 3 Paraschou
str., P. Psychiko,
Athens
1.5452, Greece
Abstract
A review is presentedof severalaspectsof illnessand culture. Stressingthe importanceof sufferingin life, attention is paid to the influenceof the imageof the world on the relationshipto the diseaseand the doctor. This is illustrated by a belief in fate. Further theoreticalconceptsfrom Kleinman, Helman, Schwederand Sontagare appliedto medical situations.Cultural differencesmay be much more important for the treatment of patientsthan acknowledgeduntil now. Keywords:
Illness;Culture; Suffering; Fate; Medical interactions; Health beliefs -
1. Introduction
2. Suffering
One of the major characteristics of each culture is the way it has dealt with the problems of pain, suffering and death. Every religion, every philosophical doctrine originates from the attempt to provide an answer to the basic questions: Why do we have to suffer, grow old and die? Humans cannot accept these states of being - or non-being - as self-explanatory, natural situations. An outside observer would come to the conclusion that they are not programmed for pain and suffering - but for pleasure and happiness. And still, most of the people, most of their lives, have to face the dark side of things. This, according to Albert Camus, is the basic absurd situation. The world is not tuned to the same wavelength as our wishes. We are not given what we crave for, things seem devoid of any meaning, we shout nobody answers.
Suffering is one of the most important facts of life. According to Buddhist teaching, it is the only pertinent fact we need to know about existence. Every society has tried to face it in its own way. Religions offered explanations and justifications for the existence of pain and tried to conciliate the concept of an omnipotent and absolutely good Deity with the existence of evil, pain and suffering in the world. The basic problem of Theodicy the justification of God - can be formulated as follows: ‘If God is all-powerful, he must be able to prevent evil. If he is all-good, he must want to prevent evil. But evil exists. Therefore, God is either not all-powerful, or not all-good’ [l]. The most obvious consequence of evil, for the human being, is suffering, in its widest possible sense meaning the fact of enduring things. Suffering is something imposed upon us. It converts an active
0738-3991/95/$09.50 SSDI
0 1995 El sevier
0738-3991(95)00769-V
Science
IrelandLtd.
All rights
reserved
154
N. Dimou
/ Patient
Education
being, into a passive recipient of agony and grief. If we divide suffering according to its causes, it could be classified into 2 main groups: (a) Suffering built into the cosmic order (disease, death, natural disasters) and (b) suffering caused by human wrongdoing (e.g. in war). It is the first group that every culture tries to cope with - since man-made pain seems easy to explain (even if it is not easy to avoid). The attitude of a cultural group towards a concrete and very frequent form of suffering, namely illness, is basically determined by its general world-image (The ‘Weltbild’ of the Germans). It is of the paramount importance to comprehend how a culture accounts for suffering, in order to understand the reactions of its individual members to illness - especially to a chronic illness. Some cultures regard suffering as a test imposed upon us by the Deity. It is as if we all existed only on probation and have to pass this test in order to prove ourselves worthy. The ‘Book of Job’ in the Bible illustrates this point very well: Job goes through all kinds of ordeals - but, because of his patience and fortitude, he is not only re-instated but also rewarded at the end. So, if a patient looks upon his illness as a God-sent trial, he may be more persevering and compliant. If he sees it as a part of his fate (the fatalist approach), he will probably remain completely passive - since anything he (or the doctor) does, will not alter the course of things. If again he thinks that being ill is his own fault (the positive puritan attitude), he will fight to ameliorate his condition. 3. Image of the world It is obvious that a patient’s Weltbild influences, in a decisive manner, his relationship to the disease and the doctor. This image of the world is actually the summary of all the things we call culture. It would seem then a good method, before working with a patient, to get acquainted with his cultural background. This is not an easy job. Not only because there is no comprehensive introduction to a foreign culture (I suppose most doctors would expect something concise and practical, like a tourist guide), but also because there are subtle cultural and ethnic differences within the same group. For example, the Jewish culture has given
and Counseling
26 (1995)
153- 157
us the most prominent example of the ‘suffering as a test’ theory. On the other hand, the same culture has introduced the notion of sin as a basic cause of human suffering. (Note that the 2 notions are contradictory: Job had not sinned...). Suffering, in that case, is a punishment. Men have to suffer in order to atone for their sins. Especially by postulating the concept of original sin (which has been taken over by the Christian religion), the Jews have created a totally different image. Human beings suffer because they are sinners - all of them, by birth. A similar situation exists within the so-called puritan theory of suffering. A part of puritans believes in pre-destination - meaning that they would tend to adopt a fatalistic approach. Others will be energetic and co-operative. Accordingly, as a basic rule we could propose; Try to assess the mentality and the attitude of every single individual. Do not infer from cultural, and even more, from ethnic generalizations. (For example: the patient is a Turk, therefore, he could be a fully secularized, Europeanized Turk - or a Muslim fundamentalist Turk, two totally different cultural ‘personnae’). When a patient realizes the fact of his disease, the first questions that automatically surface are: ‘Why did this have to be?’ - ‘Why did it happen to me?’ Science can - at the most - explain the biological mechanisms which led to the disease but cannot illuminate the ‘whys’. It is up to religion or philosophy to give some answers, Every single man, whether he is religious or not, has elaborated (or will, at a given moment, elaborate) a theory about suffering - even if it is never expressed and articulated. Even the agnostic has a theory; he believes in fortuitous happening - he postulates that everything is haphazard. His attitude to a chronic disease will definitively be different to that of a fellow-sufferer who believes in the theory of sin and punishment. That personal theory is the key to the understanding of this individual’s attitude. It will be a mixture of prevalent religious and traditional views passed through the personal filter of each single mind. Generalizations can of course always be helpful - as long as they are not applied to individuals in mass procedure. One should also speak less about ethnic differences
N. Dimou
/ Patient
Education
and Counseling
26 (1995)
153-157
155
and more about cultural ones. Within one nation, there usually co-exist many cultures. The latter are the ones that influence an individual’s attitude. Sometimes, even commonplace truths may prove helpful for the understanding of attitudes. In literature, even in fairy tales, the people of the East are thought of as being more passive and submissive than Westerners. This of course has to do with their whole philosophy of life.
There he has made the distinction between the Western human prototype of the ‘active hero’ and the Eastern ‘patient sage’ (‘Aktiven Helden und duldenden Weisen’). One of them wants to change the world, the other just learns to endure. The same philosopher has written the deepest - to my knowledge - analysis of the problem of suffering, in his essay ‘Vom Sinn des Leidens’ On the Meaning of Suffering’ [4].
4. Belief in fate
5. Medical situations
According to the traditional view, the Easterner believes in Fate. He thinks that his future is written down in the ‘Book of Life’. Karma is the Indian word, Kismet the Arabic one. Anything a man may undertake, will not change his destiny. Modern research has confirmed this traditional truth. It has found out that health beliefs concerning locus of control, follow an East-West divide. Westerners accept an internal locus of control that is, they acknowledge that they are responsible for the course of their illness - while Easterners are postulating a totally external locus of control - things are governed from outside: ‘The locus of control construct has led to a large number of studies. One of the more salient results is that persons in Western countries on average are more internal than those in the Far East. Also, people in developing nations are less internal than those from industrial countries. This has to be considered against the background of findings showing that men tend to be somewhat more internal than women and that internals are more achievementorientated’ [2]. It is obvious that when Easterners become developed and achievement-orientated, they will also embrace the Western mentality as far as illness is concerned. So the basic question should not be to what race or ethnic entity does a patient belong - but to what cultural status and system of values. Residence is also not always indicative. A orthodox Hebrew living in New York may be more traditional in his attitude than an Israeli citizen. This discrepancy between East and West has been also studied and commented upon by eminent thinkers. Max Scheler, the German philosopher, has described the difference in his essay (‘Man in the Age of Adjustment’) 131.
Let us see how these theoretical truths apply to concrete medical situations. Kleinmann has introduced the concept of the ‘Explanatory Model’ (EM) [5], defined as ‘the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process’. These notions are held by both patients and practitioners and ‘offer explanations of sickness and treatment to guide choices among available therapies and therapists and to cast personal and social meaning on the experience of sickness’. There is of course a gap among lay explanatory models, which usually reflect the patients’ mentality and culture and the explanatory models of physicians which are usually based on ‘single causal strains of scientific logic’. Should patient and doctor belong to two wholly different cultural groups, then conflict between both is unavoidable. Commenting on the divergence of Explanatory Models (EM), Cecil G. Helman writes: ‘The ways that lay and medical EMS interact in the clinical consultation are influenced not only by the physical context in which they occur (such as a hospital ward or a doctor’s office), but also by the social class and gender of the two parties involved. The power invested in clinicians by virtue of their background and training may allow them to mould the patient’s EM, to make it fit into the medical model of disease, rather than allowing the patient’s own perspective on illness to emerge’ [6]. It goes without saying that this remoulding of the patient’s model does not help communication. The patient does not recognize - and inwardly does not accept - the explanation given to him by the physician. All the more so, since most of the questions people usually ask themselves when
156
N. Ditnou
/ Patient
Education
they fall ill, can never be satisfactorily answered by a physician. These questions have been codified by Helman into 7 headings. I quote [6]: (1) What has happened? (2) Why it has happened? (3) Why has it happened to me? (4) Why now? (5) What would happen to me if nothing were done about it? (6) What are its likely effects on other people (family, friends, employers, workmates) if nothing were done about it? (7) What should I do about it - or to whom should I turn for further help? The ideal doctor, before starting the (usually automated) answering process, should, with the help of these and other questions, attempt to understand the patient’s explanatory model. Only then will he gain an insight in the patient’s thinking - and only then can he hope to motivate and influence his patient’s behavior and attitudes. Physicians tend to automatically disregard all lay theories of illness causation as ‘old wives tales’. But in treating a chronic disease, it is of paramount importance to understand how the patient sees his condition. It may very well be that in a given culture, a specific disease carries a totally different weight - has a dissimilar image and a divergent connotation I would advise everybody interested in the matter to read Kleinmans’ ‘Social Origins of Distress and Disease’ [7]. According to Richard Schweder, it is: ‘The most important book to be written in medical anthropology for a long time. The work is stimulating, passionate, sophisticated, balanced and theoretically up to date. It sets out an inspiring agenda for the anthropological study of suffering. It raises profound questions about psychic and physical pain, spiritual embodiment, and somatization and about the possibilities of cross-cultural understanding and translation of the subjective states of the ‘other’. It entertains the view that forms of suffering vary across cultures and historical epochs’ [8]. Kleinman advocates a new interactionist and holistic view, which should encompass all the interrelationships between mind, body, society, culture and nature. In his book, he uses neurasthenia and depression as a paradigm for a cultural critique of prevailing medical concepts [7].
and Counseling
26 (1995)
153- 157
In his commentary on Kleinman, Schweder introduces a distinction which is of paramount importance for any cultural analysis of sickness. Extending the basic distinction between illness (what the patient experiences) and disease (what the doctor diagnoses), he distinguishes ‘forms of suffering’ from ‘the causal ontologies or theodicies that are invoked to explain them’. And in a very long parenthesis, he goes on to illustrate what these ontologies or theodicies could be in the case of the neurasthenia - depression analysis: (a) A biomedical ontology of organ pathology/physiological impairment/hormone imbalance, or, (b) a moral ontology of transgression/sin/karma, or, (c) a sociopolitical ontology of oppression/injustice/ loss, or, (d) an interpersonal ontology of envy/ hatred/sorcery, or, (e) a psychological ontology of anger/desire/intrapsychic conflict and defense’. Schweder defines suffering as ‘the experience of disvalued and unwanted subjective states (feelings, sensations, emotions, ideas).’ On the other hand, a causal ontology or theodicy: ‘signifies the events and processes going on in some other order of reality (biomedical, moral, sociopolitical, interpersonal, psychological) that are thought to generate or cause the experience of suffering’ [8]. Physicians have been mostly concerned with the biomedical aspects of this complex. But patients have developed their own lay theories of illness causation - and have given certain illnesses a metaphoric meaning, which creates a totally different universe in which doctors usually feel completely lost. Susan Sontag has given a very perceptive analysis of how, in the course of history, certain serious diseases became metaphors for whatever was wrong or immoral in man’s life [9]. Plague, syphilis, tuberculosis, cancer - and most recently AIDS - have been given a metaphysical, religious or symbolic meaning - which includes many social and personal fears and anxieties. These could permeate the patient’s mind and create problems in his communication with his physician, 6. Conclusion We can imagine that many doctors could feel overwhelmed by the burden imposed upon them,
N. Dimou /Patient Education and Counseling 26 (1995) 153-157
when considering the links between illness and culture. They could react by saying: ‘Well what do you expect me to be when I talk to a patient: A philosopher, a psychologist, an anthropologist, a sociologist, a semanticist, an historian of cultures - and a physician?’ Of course not. But we would expect them to be aware of all these parameters, and always take into consideration that cultural differences may be much more important for the treatment of patients than they have ever acknowledged until now.
[2] [3] [4] [5] [6] [7]
References [I] Hick J. The Problem of Evil. The Encyclopaedia of
[8] [9]
157
Philosophy. Vol. 3. New York: Macmillan, 1967, pp. 136-141. Berry JW, Poortinga YP, Segall MH, Dasen PR. Cross Cultural Psychology. Cambridge: Cambridge University Press, 1992, pp. 12. Scheler M. Der Mensch im Weltalter des Ausgleichs. Philosophische Weltanschauung. Munchen: Lehnen Verlag, 1954, pp. 89- 118. Scheler M. Liebe und Erkenntnis. Miinchen: Lehnen Verlag, 1955, pp. 29-68. Kleinman A. Patients and Healers in the Context of Culture. Berkeley: University of California Press, 1980. pp. 104-118. Helman CG. Culture, Health, and Illness. London: Butterworth-Heinemann, 1993, pp. 95. Kleinman A. Social Origins of Distress and Disease. New Haven: Yale University Press, 1986. Schweder R. Thinking Through Cultures, Harvard: Harvard University Press, 1991, pp. 313. Sontag S: Illness as Metaphor. New York, 1978.