Twitter #moralhorizons
(Med04)
Managing medical uncertainty
Location Old Arts-103 (Theatre A)
Date and Start Time 04 December, 2015 at 11:00
Sessions 2

Convenors

  • Tarryn Phillips (La Trobe University) email
  • John Taylor (La Trobe University) email
  • Celia McMichael (La Trobe University) email

Mail All Convenors

Discussant Susanna Trnka

Short Abstract

We invite papers that explore tension and uncertainty in medical decision-making. How do morality, religion, science, politics, cultural tradition and social change coincide or conflict at the bedside, in the hospital, in the shaman's hut, or in sites of public health intervention?

Long Abstract

Despite the globalisation of western biomedical knowledge and practice, in many places traditional and alternative models of sickness and healing remain popular (and some are even increasing in popularity). Of these, some are in tension with orthodox biomedical approaches, others are considered complementary; but all are sites of contestation. This panel invites papers that explore the factors that influence people's decisions in a medically pluralistic landscape. How do morality, religion, science, politics, cultural tradition and social change coincide or conflict at the bedside, in the hospital, in the shaman's hut, or in communities that are sites of public health intervention? In what ways do power and money circulate when patients, families, care-givers and policy-makers choose one form of treatment or health intervention over another, and to what effect? How are we as social scientists to make sense of these practices? When do we advocate for the maintenance of tradition, and when do we support interventions according to biomedical logic? With a focus on health/illness and medical pluralism in a globalised world, potential topics include, but are not limited to: sorcery and faith-healing; death, dying and palliative care; birth and child-rearing; complementary and alternative medicines; and global pandemics.

This panel is closed to new paper proposals.

Papers

Fitting the 'fluid' into the Gantt chart: the outcomes and moralities of attitude change in medical aid work in Toliara, Madagascar

Author: Cassie Smith (University of Western Australia)  email

Short Abstract

Treatment seeking for club foot in Toliara is inhibited by the belief that incest was the cause. This paper explores outcomes based on solutions that do not attempt to change attitudes, working within the existing system to create a joint project that is locally owned and internationally supported.

Long Abstract

Medical aid, international bilateral funding, philanthropy and research into the health problems of the world's poor is broadly viewed as being well-entrenched within the realm of the good, the moral and the ethically sound. From the perspective of an anthropologist and medical student, this paper argues that there are several challenges to this unquestioned morality. Through case study with an Australian aid organisation (Australian Doctors for Africa), I sought to understand the beliefs, attitudes and understanding of club foot in order to implement a screening and treatment program that had previously been unsuccessful for many years. In Toliara, Madagascar, the collective cultural belief that incest causes club foot, prevents treatment seeking. This paper explores whether it is ethical to try to impact a belief that has existed, that will persist, and that has shaped behaviours and impacted identities, simply because it does not fit in with the aims, structure and projected results? A number of pragmatic solutions that did not seek to alter attitudes, but worked with beliefs to ensure a more sustainable outcome were implemented. This research rationalised the identification of the good, the right, and the ethically sound by working within the existing belief system to create a joint project that was both locally owned and internationally supported. From the fluid (beliefs, attitudes, and culture) to the Gantt chart (structured, micromanaged, shortsighted aims of funding bodies for aid organisations), This paper examines how we as a collective constructed and maintained 'good' aid.

From consumptive to consumer: an offer that cannot be refused

Author: Paul Mason (Monash University)  email

Short Abstract

Consumption, once considered a disease of wasting, has become a commonplace cultural practice. Did a monocausal theory of tuberculosis open the space for the commodification of the body and eventually lead to disease control strategies oriented towards consumerist pharmaceutical interventions?

Long Abstract

The identification of the causative agent of tuberculosis (TB) altered what it meant to suffer from consumption, and catalysed the adoption of medical models of hygiene as a means of prevention. The discovery of antibiotic treatment for tuberculosis some 60 years later, solidified biomedical authority over the disease and simultaneously laid the foundations for the growth of big pharmaceutical companies organised around meeting the health needs of consumers. Medical institutions and social processes, justified by the moral power of germ theory and fortified by the market power of pharmaceutical companies, have slowly transformed consumption, an undesirable disease of wasting, into consumerism, an acceptable commonplace practice for TB control and prevention. In this paper I argue that the isolation of the consumptive ultimately came to characterise the individualism of the consumer, and that this transition has had patterned and differential impacts. Today, as WHO-mandated TB treatment programs are rolled out around the globe, to what degree are new cohorts of patients expected to conform to the consumerist standards of the Western medical model? For a person living with TB in the developing world, medical treatment is an offer they cannot decline. People who are diagnosed with TB are placed under a surveillance system where their consumption of pharmaceutical products is closely monitored. In inculcating and being inculcated by the global medical enterprise, patients are pulled into adopting and reinforcing a biologically reductive narrative of disease and a consumerist model of treatment.

"How much is enough and when should we hospitalise?": newborn screening, MCADD and the medicalisation of breastfeeding

Author: Pauline Herbst (University of Auckland)  email

Short Abstract

The diagnosis of the genetic condition MCADD medicalises newborn feeding, turning it into a site of moral decision-making. Already a space where morality, science, tradition and social practice explosively intersect, feeding becomes a medical solution that staves off serious complications.

Long Abstract

Medium-chain Acyl-CoA dehydrogenase deficiency (MCADD) is an inherited metabolic disorder of fat breakdown that was added to the New Zealand newborn screening programme in 2006. Infections, fasting or vomiting can lead to serious illness with a risk of sudden death. In addition to creating genetically 'disordered' subjects, the diagnosis of MCADD medicalises newborn feeding, turning breastfeeding into a site of moral decision-making. Already a space where morality, science, tradition and social practice explosively intersect, feeding becomes a medical solution that staves off serious complications so long as it is done every few hours. If for any reason the child can't feed, she will need to be hospitalised and fed either intravenously or via a nasogastric tube, a decision usually made by the parent. This paper examines the decision-making of 24 New Zealand mothers navigating the first fraught year of feeding a child with MCADD, revealing a constant tension between what was imagined as best for their child prior to diagnosis, such as exclusive breast-feeding, and post-diagnosis, through the lens of 'disorder'. It explores the moral dimensions of their interactions with the health system both in the lived experience of child-rearing (eg Plunket) as well as the uncertainty around when to hospitalize their children, who in comparison to others on the ward, look healthy and well to staff. These mothers feel a grave responsibility for the life of their children and weigh every parenting decision based on prioritising food intake; navigating a complex moral network of health systems, family and community.

From gasping for air to chronic disease management: the multiple temporalities of asthma and associated healing techniques

Author: Susanna Trnka (University of Auckland)  email

Short Abstract

This paper examines how asthma is defined across multiple temporalities – pharmaceutical, biomedical, and phenomenological. I argue that different understandings and experiences of how asthma symptoms are located in time lead to alternative curative measures.

Long Abstract

This paper examines how asthma is defined across multiple temporalities - pharmaceutical, biomedical, and phenomenological. I argue that different understandings and experiences of how symptoms of respiratory distress are located in time lead to alternative framings of both the illness in question and appropriate curative measures. Asthma has been progressively reconceptualised within biomedicine as a chronic illness that, according to international guidelines, usually requires the daily ingestion of pharmaceutical remedies in order to be held in check. Biomedical delineations of chronicity, moreover, coincide with (but are not the same as) the market-driven logics of pharmaceutical companies who similarly promote understandings of asthma as a long-term, potentially debilitative illness that, in most cases, requires daily management through medication. For a significant proportion of asthma sufferers, however, asthma is not experienced as a chronic condition but as a series of temporary, often powerful and potentially life-threatening, but nonetheless sporadic "interruptions" of everyday life. This paper examines how the disjuncture between phenomenological accounts of asthma and bio-medical and pharmaceutical framings lead some sufferers to question the reasoning and motivations behind diagnoses that highlight chronicity. As a result, some sufferers, moreover, turn away from biomedical solutions, searching out alternative therapies, such as breathing retraining programs (for example, Buteyko) that engage in yet another mode of temporalizing illness, healing, and breath.

Medical pluralism, poverty, or limited access?: Factors that shape hospital use in a developing context

Author: Tarryn Phillips (La Trobe University)  email

Short Abstract

On the Fijian island of Ovalau, health outcomes are relatively poor and use of the hospital is limited and often problematically delayed. This paper examines the weight accorded to ethno-medical beliefs, poverty and limited accessibility as variables that shape treatment-seeking decisions on the island. 

Long Abstract

On the regional  Fijian island of Ovalau, health problems are understood and treated through a range of medical paradigms: Indigenous Fijian traditions, Christian faith-healing, Indo-Fijian  Ayurveda,  Western bio-medical science and public health interventions.  Yet health outcomes remain relatively poor. Many preventable health conditions are caused - and treatable health conditions are exacerbated - by limited or delayed use of the hospital on the island. This paper draws on preliminary ethnographic data to examine the factors that shape and constrain hospital use in a medically pluralistic landscape. In particular, I examine the weight accorded to ethno-medical beliefs, attitudes towards hospitals, poverty and limited transporting options as variables that shape treatment-seeking decisons in this context of uncertainty and medical pluralism.

Gud sik, rabis sik (good sick, rubbish sick): negotiating aetiological uncertainty in Vanuatu

Author: John Taylor (La Trobe University)  email

Short Abstract

Focusing on the local distinction between gud/nomal sik (good/normal illnesses) and rabis ski (rubbish illnesses), the later of which are deemed to be caused by "supernatural" forces, this paper investigates the significance of etiological uncertainty to healthcare seeking behaviour in Vanuatu.

Long Abstract

In Vanuatu, individual illness episodes are typically classified aetiologically, as either gud/nomal sik (good/normal sick) or rabis sik (rubbish sick). While the former term refers to instances in which the cause of an illness is deemed to be primarily material/biological in nature, rabis sik (also used for sexually transmitted infections) refers to illnesses caused by acts of sorcery or manifestations of ancestral sacred/spiritual power often associated with features of the landscape. Occurring in a highly pluralistic healthcare setting, the identification of an illness as either a gud or rabis sik is crucial to how people respond to that illness. Such processes are however often unclear, inconclusive and fraught process, leading individuals and families to navigate between multiple options, including as offered by local healers, "prayer warriors," and Western medicine. This paper presents preliminary findings from a recently commenced ethnographic research project investigating the significance of the sacred/spiritual to illness causation and healthcare seeking behaviour in Vanuatu.

Sustaining hygiene behaviour change in Nepal

Author: Celia McMichael (La Trobe University)  email

Short Abstract

Based on an anthropological evaluation of a ‘WASH’ project in Nepal, this paper identifies the multiple (plural) drivers of hygiene behaviour change, from biomedical health messaging, to emotional drivers, community/volunteer engagement, and elevation of local civic pride.

Long Abstract

This paper investigates drivers of hygiene behaviour change in Nepal. Health and hygiene behaviour change are notoriously difficult to initiate and sustain. Evidence indicates that health messaging is a poor motivator of behaviour change, and hygiene behaviours often drop-away post-intervention when focus dissipates. In Nepal, water, sanitation and hygiene (WASH) present significant challenges to population health. Based on an anthropological evaluation of a WASH project in mid-Western Nepal (conducted in 2014 for Australian Red Cross and with Nepal Red Cross Society), the paper examines the drivers and barriers to sustained hygiene behaviour change such as hand-washing with soap and elimination of open defecation. Many community members reported that improved hygiene behaviour prevents poor health and disease transmission; this suggests that the biomedical model is compelling and widely accepted. 'Biomedical' health messaging, however, was only one of a broad suite of triggers for hygiene behaviour change. Effective strategies included messages with a focus on emotional drivers (disgust, nurture, and affiliation), creation of new social norms, engagement and contribution of local volunteers, and elevation of civic pride related to personal and environmental cleanliness. The paper argues that it is the engagement and activation of pluralistic drivers of hygiene behaviour change, and the engagement and contribution of local volunteers, that have been central to the successes of this WASH intervention in remote Nepal.

This panel is closed to new paper proposals.