Modern, scientific medicine has historically objectified people as patients. Indeed, the "modern" and "scientific" elements of it rely on objectification. Modern medicine is founded upon objectification: People become case studies. Their complicated life stories are aggregated into statistics. They're assigned to control or experimental groups, and their individuality melts away.
Medical research as we understand it would be unthinkable without objectification. The techniques I just mentioned are necessary to doing science right, following professional standards. The alternative - drifting in a sea of anecdata - would yield few useful results.
Actually, the alternative might look a lot like the journal articles written a century ago by long-dead German gynecologists. (For my dissertation research, I happily squandered months of my life leafing page-by-page through all the major German medical and gynecological journals and some of the minor ones, spanning about 1905 to 1935.) Typical articles included:
- An outline of a new (and by our lights, scarily unsuccessful and brutal) technique for cesarean section or symphysiotomy.
- Case reports of a needle left behind during surgery.
- Descriptions of rare deformities of the pelvic organs.
- Pictures of pickled uteri.
(And yes, I joined the objectification party while I was working on these journals. I got so I could distance myself from even the photos of disembodied organs, which were mercifully in black and white. I could down a Snickers bar while looking at this stuff. So I experienced from the inside how medical training can create a distance from the suffering person and at least temporarily suspend empathy.)
Singling out medical research would distort the picture, because patients also came to be treated as objects in ordinary practice. This was especially true in teaching hospitals. I've written about how pregnant women in early-twentieth-century Germany were forced to undergo repeated exams by clumsy medical students, and how they were paraded naked in front of a whole auditorium full of observers while in labor. American obstetrics was no better: Women were strapped down while in labor and knocked out, whether they wanted it or not.
Over the past 40 years, under pressure from consumer advocates, feminists, and medical ethicists, medical researchers and practicing doctors have become a lot more sensitive to problems of objectifying patients. Patients with cancer are no longer kept ignorant of their diagnosis and prognosis. These days, expectant mothers are often encouraged to write birth plans - and yes, I realize those plans aren't always heeded, but that doesn't negate the sea change.
One index of objectification is condescension. They're not the same thing, but condescension generally grows out of the practitioner's conviction that he's in a hierarchical relation to the patient; that he's the subject and the patient is the object. And personally, I've seen a major decline in patronizing attitudes among medical practitioners. In the late 1980s, as a young graduate student, I went to my family doctor with complaints of fatigue, nausea, and dizziness. He told me, dismissively, that I was neurotic and overambitious and just needed to chill. (Another doctor diagnosed me with chronic fatigue syndrome, and after roughly 18 months I felt substantially better.) He projected the person of a folksy old-time GP, but I was just a case to him, and as such, he felt free to load me up with stereotypes about smart, ambitious young women. This doctor ultimately got in trouble for inappropriately touching young female patients - demonstrating that medical objectification and sexual objectification can occasionally overlap. He's now long retired, thank goodness.
My recent experiences at the Cleveland Clinic and the OSU MS clinic were the polar opposite. The doctors listened to me and took my complaints seriously. No one implied that I was hysterical or tense or simply a head case. Overall, I'd describe my relationship with my family doctor, ob/gyn, endocrinologist, and the kids' pediatricians as a partnership. We talk to each other frankly, and they listen to me just as much as I listen to them. The kids' doctors are also wonderful about addressing the kids directly and asking them about their preferences. (A penicillin shot or liquid antibiotics? Gee, that's a tough choice for a four year old!)
I realize I'm likely to get better care than average because I'm white, educated, medically literate, fully covered by insurance, and (heaven help me) sometimes a little pushy. But that's not the whole story. For instance, there's one doctor in our pediatricians' group practice who's still completely old-school. He was on duty in the hospital the day the Tiger was born, and he would not shut up about circumcision. In the end he had to respect my refusal to snip. I know he's very condescending toward people who he assumed are less educated. But this fellow is the exception that proves the rule. He's slouching toward retirement, and all the parents I know avoid him whenever possible. He's a relic of the medical past. Patronizing doctors like him are on a gradual path toward extinction.
One notable exception to this general trend away from objectification is medicine's ambivalence toward sexuality. As I've argued before, too many doctors are embarrassed to discuss sexual problems with their patients. This weekend's Well feature in the New York Times offers a fresh example: a prominent ED specialist reports that one in four of his patients who've had a prostatectomy was not aware until after the surgery that he'd never ejaculate again! This embarrassed silence also interferes with patients getting the full scoop on the sexual side effects of antidepressants. The failure of medicine to deal with sexuality is an effect of shame, embarrassment, and ignorance, as these examples show, but it's also a legacy of medical objectification. Seeing someone as merely as a "case" makes it very difficult to view a patient as a whole person with complex needs and desires. The result is condescension, fragmentation, and silence.
While pressure from our culture as a whole are pushing medicine away from condescension and objectification, there are countervailing structural forces. The most obvious of these is pressure to contain costs, which comes from all directions: insurers and HMOs, employers, and the state. Spending time really listening to the patient - as my doctors have done for me recently - doesn't come for free. The specialists will be better able to recoup this; the MS neurologist I saw, for instance, routinely budgets an hour and a half for new patients, and I assume he's got a billing mechanism that will cover his time. I'm pretty sure my family doctor, by contrast, will not be able to bill for all of the time he's given me. Adding insult to injury, just yesterday my university (the only big employer in town) announced they won't consider his clinic in-network anymore as of July 1. While this is likely a gambit to negotiate new rates, the net effect will be to place even more pressure on local primary-care doctors to curtail the time they spend with patients. Rushed appointments are not conducive to seeing the whole "case," much less the whole person.
Another structural counterweight to more enlightened, anti-objectifying medical attitudes is the march of medical technology. Again, the history of obstetrics provides lots of examples. Chief among them is the fetal monitor. Quite apart from the large body of evidence that suggests routine fetal monitoring increases interventions without improving outcomes, fetal monitors also objectify the laboring woman. Her experience - and the well-being of her child - are reduced to lines and squiggles. I'm not a Luddite about this, because I know that fetal monitoring has legitimate uses, even though it's vastly overused. Yet I know it's not just doctors and nurses who sometimes fixate on a mere artifact - the monitor's output - rather than on the whole person. Laboring women and their partners sometimes do the same.
The MRI is a further example of medical technology that can supplant the person, substituting a series of images that risks turning the person into an object. One example of this, ironically enough, is that study of sexual objectification that made a splash in the media earlier this month. While I'm fascinated with functional MRI, I also know that fMRI just shows brain activity in certain areas. What that means is still up to interpretation. And if the researchers are reducing their volunteers to mere images and not conducting lengthy interviews with them (only a questionnaire was mentioned in the media reports), then we can confidently saw that the research subjects are being rendered objects.
Does all of this mean medicine is evil and we should reject medical objectification whenever and wherever it occurs? Not at all. I'm in favor of medicine being more evidence-based. As I mentioned at the start, today is Rare Disease Day, and all of those orphan diseases cry out for more research. (My dad has had Crohn's for 50 years; my husband had an encounter with an obscure but devastating autoimmune neurological disease called MADSAM. My recent brush with the possibility of MS taught me that the unknowns still vastly outweight the knowns, even for such a relatively common disease. So I hope for more research, not less, and I recognize that scientific approaches to medical research will always tilt toward objectification.
But I also favor acknowledging the legacy of unexamined objectification in medicine. We can look at how it operates in specific contexts and weigh whether its costs are worth its benefits. We can analyze the potential of new technologies to fragment and objectify the patient. Simply bringing objectification out of the shadows tends to mitigate its effects: talking about it can make both doctors and patients more aware of it, and this will tend to promote more equal partnerships. And finally, we can hope and lobby for meaningful health-care reform that would limit the power of insurers to dictate that doctors practice medicine in five-minute increments guaranteed to obscure, fragment, and objectify the whole person.