Abstract
Introduction
A few years ago, I participated in developing the medical humanities curriculum at a medical school in London. One of the key documents that I was working on was a ‘case for change’ that argued for the importance of arts and humanities in medical education and practice. In the confines of the medical school, the relation between medicine and medical humanities was taken for granted, for why else would we teach humanities to medical students and junior doctors except to make them better at what they do?
The view that medical humanities lies in an instrumental relation to medicine has been around from the early days of the field and continues to feature strongly, especially at medical schools. This is understandable, for medical humanities originated in the critique of the impact of the scientific turn and medical specialisation on patient care. Doctors were becoming experts in the management of disease but were not as fluent in understanding the patient’s hopes, fears, expectations, and the meanings they draw from their condition and suffering (Cassell, 1984). One of the original impulses was to humanise medicine, and this impulse continues in the development of medical humanities to this day. Engaging with the humanities (literature, history, philosophy), it was argued, can bring a multitude of benefits for medical students and doctors: it can develop the imagination and with it the ability at perspective-taking (Gillon, 1997); it can cultivate understanding, insight, empathy, and from there, the capacity for humane judgment as a fundamental complement to technical judgement (Macnaughton, 2000). Medical humanities has been described as a ‘program of moral development’, medicine’s ‘supportive friend’ (Brody, 2011: 2), and as a ‘source of moral and aesthetic influence upon the daily praxis of organised clinical health care’ (Evans, 2008: 57).
Some humanities educators and scholars who were involved in the early development of the field might consider it a success story that medical humanities is now embedded in many medical schools. Moreover, while there are studies seeking correlations between medical humanities teaching and students’ performance (e.g. Huang et al., 2023), a report examining all health humanities baccalaureate programmes at medical schools in the United States and Canada indicates in no uncertain terms the fundamental importance of the humanities in medical education: ‘the integration of the arts and humanities into medicine and medical education may be essential to meet the needs of a 21st-century world’, and [to] prepare students for critical and creative thinking, identification of internal biases, and ethical reasoning in decision-making processes – all of which are critical skills for participating in the complex system of U.S. healthcare on individual, professional, and collective levels. (Lamb, Berry, and Jones, 2022: 4, 5)
Yet, for all the appeal of this view on the relation of medicine to medical humanities – a relation governed by the instrumentality of the latter to the former – it is a view that lies in tension with another formulation that sees medical humanities, primarily, as an independent research discipline. Here, the instrumental relation is itself interrogated and cannot be taken for granted. For an independent research discipline cannot be limited by the role of a ‘supportive friend’, a helper, or a source of empathy and moral judgement; it has to be able to pursue lines of inquiry and ask new questions that can challenge medicine and broaden the cultural imagination about the concepts and practices that we associate with the ‘medical’. Various suggestions have been offered as to how the relation ought to proceed. Medical humanities should be a ‘disruptive teenager’ that exposes the problems with medicine’s view of human nature; it should move beyond the focus on medical education and practice to re-envision medicine as such (Macnaughton, 2011); it could generate ‘scepticism towards utilitarian models of health and well-being’ and provide ‘a point of resistance to reductive biomedical science’ (Bleakley, 2015: 24); or it could take a more radical path by engaging with critical and cultural theory and, through these resources, move beyond the ‘neoliberal, humanist notion of the individual body-subject … to really explore alternative “collective” and “relational” approaches to “flourishing”’ (Atkinson et al., 2014: 77).
Alongside these debates were discussions on the most appropriate epistemological and methodological bases for the relation between medicine and medical humanities. Should the field adopt a multi-disciplinary approach that respects, and stays within, disciplinary boundaries? Should it adopt a more ambitious inter-disciplinary approach that acknowledges disciplinary boundaries but attempts to integrate knowledge across them? (see Bates and Goodman, 2015; Evans and Macnaughton, 2004; Reiff-Pasarew, 2022). Or should we aim for a more radical trans-disciplinary approach, such as Critical Medical Humanities, that refuses to accept existing boundaries and rejects any limitations posed by instrumentality to medicine? (see Fitzgerald and Callard, 2016). Related to the latter point were debates on the extent to which medical humanities should align itself with the aims of medicine. It has been argued that medical humanities, when it becomes constrained by the ends of medical practice, is ultimately co-opted in its service, ‘defanged’ of its power to criticise medicine (Rees, 2010). Such attempts to prise the medical humanities as an academic discipline apart from medical education and practice have generated a cautionary backlash. It has been pointed out that this academic subject is likely to end up speaking to other academics and would no longer be relevant to medical students and doctors (Downie, 2016: 293). This critique motivated proposals for a ‘practice-based’ medical humanities that holds both ends of the problematic, and finds a way for socio-political and cultural analysis to inform clinical training, practice, and improve patient care (Winning, 2018).
This article is an intervention in these debates. Specifically, I am interested in the sort of relation that should obtain between Critical Medical Humanities and medical practice. My target is an approach to medical humanities that rejects constraint by medical aims and concepts. And the overall aim of this article is to show that it is possible to reconcile radical critique with the ability to influence medical aims and practice. In this sense, my proposal is aligned with propositions for a practice-based medical humanities, but with three major differences. First, in order not to beg the question against Critical Medical Humanities, we have to make the case for the necessity of engaging with medical practice, and we have to do so in terms consistent with the epistemology of Critical Medical Humanities. Second, I demonstrate that what is at stake in these debates is not just the independence of a discipline or the priority of improving practice; in engaging with medical concepts and practices and offering critical interpretations, medical humanities researchers, through this very act, are also challenging the understanding that healthcare professionals and patients have of what they are doing and experiencing. This suggests that there is more at stake than scholarly analysis, for there are ethical and political significances that can be described in the language of recognition and misrecognition. Third, my suggestions as to how a medical practice can be brought closer to a radical analysis appeal to concepts and methodologies associated with a type of philosophical analysis not commonly employed in medical humanities. The benefit of the proposed approach is that it would allow us to do the required work in a careful stepwise manner, which is what is needed in this case.
In the following pages, I use the term Critical Medical Humanities (note the capitalisation) to refer to an approach with this name popularised, in particular, by
The article begins by outlining the object of medical humanities, which is the medical
What is the object of medical humanities?
The object of medical humanities is the medical pathway in all its complexity, which is the pathway that takes us to the concepts, frameworks, procedures, and sites of medicine. It might be tempting to start the pathway with the encounter between prospective patient and healthcare professional. But that would be to significantly truncate the pathway to the moment of diagnosis. Much occurs before this moment becomes possible, outlined here in the mental health case: The pathway leading to diagnosis of a mental disorder in a person includes at least the following three crucial steps: first, someone (often though not necessarily the person himself or herself) coming to the belief that the person has a problem, that their mental state and behaviour is in some way problematic; second, construal of the problem as being a mental health problem, or mental disorder (as opposed to being, for example, part of life’s troubles, or a spiritual problem); and third, classification of the mental health problem as being of a particular kind, such as major depression, schizophrenia, or borderline personality. (Bolton, 2010: 328–9)
A point to emphasise is that the understanding and management of adversity, suffering, distress, and disability can proceed along a range of pathways, and that the medical pathway is merely one of those, albeit a dominant one in many societies. For example, in many communities around the world, steps one and two above will lead the person down a different pathway, such as to a Qur’anic healer or a Chinese Medicine practitioner. Both practices are relevant to medical humanities, not per se but because they are possible alternative routes that take us away from the medical pathway. The medical pathway – with its concepts, frameworks, procedures, and sites – is the centre of gravity around which, and in which, medical humanities operates. And no matter how far we deviate from the medical pathway, it remains either explicitly or implicitly a fundamental reference point, for medical humanities is an essentially comparative discipline. When a literary scholar examines constructions of memory loss in 19th-century literature, she might not invoke medical theories or concepts, and so it might appear that there is no comparative dimension. But that is so only because she may assume the reader will be engaging the relevant comparative work in their mind. That is the nature of widespread, dominant ideas, which some medical concepts and theories certainly are: they set the background against which other ideas can emerge as different or radical.
The object of medical humanities is the medical pathway in all its complexity. The object is therefore broader than medicine to include all steps that contain and lead to the concepts, frameworks, procedures, and sites of medicine. For example, what happens at step one above has nothing to do directly with medicine just yet, for what it reflects are folk norms about behaviour and experience; about what is normal, acceptable, abhorrent, worrisome, and all the terms we have to judge each other’s and our own behaviour (these norms can be influenced by ideas that come from medical concepts and theories). Step one is under the purview of medical humanities but only in so far as it stands in relation to the medical pathway broadly conceived.
Medical humanities can examine the medical pathway in a range of ways: longitudinally as the different steps emerge over time; horizontally by taking a particular step or slice of the pathway; across eras and so consider how it has fared historically; across communities and so consider how it fares in different cultures. And within all these possible methodological orientations, there is no shortage of complexities and emerging questions. Indeed, as can be seen in the description of the pathway, each step raises distinctive issues. Step one, among other things, invites us to consider the source of normative judgements about our own and other people’s behaviour: where do these values come from? To what extent are they authentic in my own case? Step two invites us to consider questions about public models of understanding our distress and the extent to which they have become dominated by medical concepts to the exclusion of alternative constructions of identity and personhood. Step three invites us to consider familiar questions about diagnosis, its validity in many cases, the interests it serves, and its cross-cultural portability.
The complexity so far evident in the medical pathway and the questions we can ask about it permit various orientations that we, as medical humanities researchers, can take towards it. Different stances have come to generate different ‘waves’ of medical humanities theory and scholarship. In what follows, I outline the two approaches identified in recent literature.
Orientations towards the medical pathway
The critique of ‘mainstream’ (‘first-wave’) medical humanities
Recent critique of ‘mainstream’ or ‘first-wave’ medical humanities takes issue with what the field had adopted as its primary site of interest – the clinical encounter between doctor and patient (the ‘primal scene’) – and with the epistemological and methodological orientations that govern the relation between medicine and medical humanities (Whitehead and Woods, 2016). As to the first point, the view under critique is that mainstream medical humanities imagines an idealised initial situation, an encounter that begins as a dyad, and which can broaden to include family, community, culture, healthcare system, and whatever else is deemed relevant. But its primary units are the patient and the doctor, with the emphasis on the former’s suffering, the latter’s expertise, and the ethics that should regulate the interaction. Given this understanding of the initial situation, medical humanities approaches are brought to bear upon the clinical encounter, which is often considered to be insufficiently attuned to empathy and lived experience. Inquiry thus begins with a range of binaries such as doctor vs. patient, disease vs. illness, medicine vs. humanities, with each side of the binary contributing distinctive knowledge and perspectives. Within this view, medicine would contribute scientific knowledge, professionalism, and realism, while the humanities would contribute affective attunement and closer attention to subjective experience.
Give this view of the ‘primal scene’ of ‘first-wave’ medical humanities, two epistemological and methodological orientations have tended to govern its investigation: a multi-disciplinary and an inter-disciplinary approach. The contrast here is between an academic activity that brings together ‘humanities and medical disciplines with a common goal of reflecting on medical practice but with each discipline … retaining its own unique viewpoint and writing from its own literature’ (multi-disciplinarity), and a more radical approach that attempts to ‘integrate the viewpoints of whichever disciplines seem most relevant to the question they are asking in their examination of medicine, its knowledge base, assumptions, and practice’ (inter-disciplinarity) (Evans and Macnaughton, 2004: 3). Advocates of the inter-disciplinary approach argue that a multi-disciplinary one is insufficiently ambitious and precludes real, and messy, contact between disciplines. It presupposes the very boundaries between disciplines that a genuine engagement with medicine ought to question. In this sense, an inter-disciplinary approach is preferable as it seeks to cross boundaries and integrate perspectives so that researchers will not be ‘constrained within the viewpoint of historian, anthropologist or philosopher but will build a perspective that is unique to the discipline called medical humanities’ (ibid.: 3.). The engagement between medicine and the humanities could then generate a medical practice that is more than a science to which an art is tacked, but one that is constituted by both science and art.
Critics of the sort of medical humanities just outlined take issue with the focus given to an idealised initial situation and with the epistemology of inter-disciplinarity. There is no ‘initial situation’, there is no tabula rasa of medical encounter. Every encounter is built upon another that preceded it all the way back (at least) to the emergence of distress and impairment of function that constituted the first step in the medical pathway, as outlined earlier. That is why the object of medical humanities is the medical
This critique extends to inter-disciplinarity and its integrationist intent as an orientation for the field (Fitzgerald and Callard, 2016: 37–8). Critics point out that an integrationist approach remains wedded to a ‘decidedly conservative’ view of disciplines, what they are, and the sort of ‘relations of exchange’ that are allowed across them. More specifically, in the case of medical humanities, an integrationist approach would struggle to ‘radically reconfigure the objects, agencies and practices of clinical attention’ (ibid.: 38). We could say that an integrationist, inter-disciplinary medical humanities operates, at least on an initial basis, with the language, presuppositions, models, and concerns of medicine, with consequent limitations on the autonomy of medical humanities. For if you work towards integration, you have to compromise, and to compromise, you have to accept that the other has claims upon you which you ought to consider, and you have claims over the other which he ought to consider. But to proceed in this way, so the argument goes, is to obscure the origin of these claims and why and how they have come to matter. Given this, critics would probably agree with Rees’s (2010: 269) assessment when he writes disapprovingly of ‘mainstream’ approaches: Medical humanities is what happens when the humanities become constrained by medicine, when the humanities become enlisted in the unrelenting technological and administrative drive to improve the efficiency and utility of medicine. The price of admission of the humanities into medical education and practice is submission to the agendas of medicine and medical ethics, which treats the humanities as a refuge from difficult questions instead of as a crucible of difficult questions.
Proposed alternative: Critical (‘second-wave’) medical humanities
What does the path to an autonomous – in the foregoing sense of autonomous – medical humanities look like? According to Fitzgerald and Callard (2016), we need to move away from an aspiration to integration and towards an aspiration to entanglement. The key move here is to interrogate the ontological status and priority of the existing boundaries of medical and humanistic inquiry, and the concepts that constitute these boundaries. For an inter-disciplinary medical humanities, these boundaries might appear like things that already exist in the social world, the task being to try and integrate them. From the critical stance, this view cannot be true, for boundaries are produced rather than found; they are not, as it were, natural kinds but cultural formations. This kind of argument is often invoked in disciplines that draw on critical theory, and can be understood to comprise the following main steps:
Identify a boundary or concept. Demonstrate that this boundary/concept is not found but culturally formed. Hypothesise as to the knowledge/power dynamics that naturalise the boundary/concept and hide its constructed (normative) nature.
Take, for example, Shelley Tremain’s (2001) argument against the concept of ‘impairment’. Impairment is a central concept in conventional disability theory. It refers to the physical or mental features of the individual that are associated with limitations in physical and social functioning in a given environment. Disability is an outcome of the interaction between impairments and the environment. Within this view, in order to address the disability, we can modify the environment and/or the impairment, with an emphasis on the former leading us to the social model of disability, and an emphasis on the latter leading us to the medical model of disability. Tremain (2001: 617) takes issue with this view of the concept of ‘impairment’; her argument illustrates the three steps identified above: In the field of Disability Studies, the term ‘impairment’ is generally taken to refer to an objective, transhistorical and transcultural entity of which modern bio-medicine has acquired knowledge and understanding and which it can accurately represent. Those in Disability Studies who assume this realist ontology are concerned to explain why social responses to ‘impairment’ vary between historical periods and cultural contexts … Against these theorists, I will argue that this allegedly timeless entity (impairment) is an historically specific effect of knowledge/power. modes of manipulation that combine a scientific discourse with practices of segregation and social exclusion in order to categorize, classify, distribute and manipulate subjects who are initially drawn from a rather
Fitzgerald and Callard (2016) take this approach to the medical humanities itself. They argue that the traditional topoi of medical humanities represent only one way to perceive the field and what matters within it. The typical research foci of the clinical encounter – the patient’s suffering, illness narratives and experiences, and the doctor’s care and expertise – have so far constituted the ‘essence’ of the field. But the state of being ill, for example, does not by itself – intrinsically, so to speak – call for the application of medical science (or indeed for the remedy of humanistic insight) nor does it necessarily have to be seen as ‘co-located with or coincidental to a body’ (2016: 41). These are derivations from certain ways of interacting with the body and its functioning that have come to constitute our understanding of illness and health. And so, the issue is not that illness and healing are multi-faceted phenomena that cannot be understood from a clinical perspective only, and that require a new, interdisciplinary perspective to be appreciated in their wholeness. The issue is that what get enacted, positioned and understood as moments of suffering, sickness, care, and so on are always in the process of being cut from particular sets of relations. What we need methodologically, then, is a way of thinking, writing and measuring life-states that ‘stays with the trouble’ of these relations and differences. (ibid.: 42)
In summary, critics of ‘first-wave’ medical humanities want to liberate the discipline from pre-existing ways in which the world of medicine has been divided into issues that matter and those that have been pushed back outside medical awareness. They aim to develop an epistemology that can provide increased autonomy to the field, the freedom to ask more radical questions and to locate different sites of interest without being constrained by the concepts of medicine, by the needs of doctors, or by the aspiration to integration with the limitations this poses. On this view of the field, medical humanities is not in service to medicine in the sense of aiming explicitly to improve medical practice or to encourage the development of more empathic doctors. Nor is it there to act as a bulwark against the excesses of reductive biopsychosocial models. For to start with these aims is to constrain inquiry from the outset and lose the possibility of radical critique.
Medical humanities and the agent’s point of view
I agree with the Critical Medical Humanities’ critique of ‘mainstream’ or ‘first-wave’ medical humanities: namely, the problems with the focus on the ‘primal scene’, the limited (and constraining) set of pre-established topoi, and the problems of multi- and inter-disciplinarity in so far as they limit the possibility of radical critique. And I accept that critiquing medical aims, concepts, and practices is an important objective that should be protected and encouraged. But I have concerns about the notion of entanglement – epistemological, ethical/political, and practical – that stem from lack of sufficient constraint by the point of view of agents involved in the medical pathway, including healthcare practitioners and patients. By way of introductory clarification of this claim, we can argue that medical humanities endeavours to show us something about the concepts and practices of the medical pathway that is not immediately available to the agents involved but is provided by a certain kind of critical orientation and analysis. This analysis is not immediately visible and has to be made so, and includes the idea that what is taken to fall under a concept or to constitute the purpose of a practice is not the whole story, and that a different one can be told that takes into account a much broader and imaginative socio-political, historical, and cultural context.
Tremain’s analysis, cited earlier, of the concept of impairment is an example of such an approach and takes itself to have shown that medicine is not just (or even primarily – depending on how far you take the analysis) a caring institution but also a regulatory one. Fitzgerald and Callard’s suggestions also illustrate this approach when they ask, in the hope of stimulating new ways of thinking, ‘what if illness were not imagined, for example, as co-located with or coincidental to a body?’ (2016: 41). This is a powerful notion and one that immediately recalls, in the case of mental health, systemic and family approaches. In the case of, say, heart disease, the idea that illness is not ‘co-located with or coincidental to a body’ will need more work to render it intuitive. For what is at stake are not matters of predisposing and precipitating social and political factors for heart disease (which is standard medical theory), but ontological matters that concern how we should conceive of disease and, more broadly, how we should conceive of human bodies.
The question then becomes how to get these views across to the agents involved in the medical pathway for whom such ideas might not immediately (or at all) chime with what they take themselves to be doing and the beliefs and values that underlie their actions. Of course, it might not be possible to get these views across, owing to the fact that the underlying assumptions and models are so different, which precludes an inter-disciplinary meeting point. A Critical Medical Humanities rejoinder, as outlined in the previous section, would be that we need not constrain our research by the requirement for its results to be immediately applicable or even understandable to agents in the medical pathway, since that is precisely the sort of problem with an inter-disciplinary approach and its drive towards integration, with consequent limitations on radical theory and critique. And, the rejoinder can continue, if the analysis constrained itself by the agent’s point of view, then we might end up with a different analysis, and not a large-scale systemic view and re-imagining that would be much more fruitful.
As much as this is an understandable argument, it is not, for reasons that will occupy the rest of this section, a defensible one. The distance between the critical analysis and the agent’s point of view is significant and appears unbridgeable, and this should bother us. We should try and manage this distance by placing the agent’s point of view at the core of our analyses, and this is for three reasons:
Epistemological reasons: without doing so, the analysis would be incomplete. Ethical/political reasons: without doing so, the analysis could constitute misrecognition. Practical reasons: without doing so, the analysis would have limited to no impact on the behaviour of agents involved in the medical pathway.
Epistemological reasons: Acting under a description
Why do we engage in medical humanities research? At the very least, we aim to understand the medical pathway and, from there, to adopt one of several possible dispositions towards what we have understood; we could, for example, critique, analyse, complicate, deconstruct, (dis)entangle, historicise, politicise. Before we can do any of this, we have to satisfy ourselves that we have understood what we are now working to critique. Understanding the medical pathway might be seen as a relatively straightforward step since most of us have been patients or at least know someone who has. Similarly, familiarity with medical theory and practice is common in the field, either through professional training or education. But the sense of understanding that I intend here cannot be satisfied only through practical experience or intellectual knowledge. To understand a practice, we need to describe it, and description is not a neutral process and will vary between agents engaged in what might appear to be identical practices. To describe a practice, we need to capture the agent’s point of view, which is a description of what the agent takes himself to be doing in the pathway as a whole or at a particular step in it.
To illustrate some of the relevant concepts, consider the following example: you are walking past a dry field under a scorching sun, and you see a farmer kneeling and praying on a mat laid down on the dust. You could have just walked by and assumed, given the time of day, that he is conducting the noon prayer, one of five prayers a day. Instead, you wait till he completes the ritual and ask him: ‘why are you praying now?’ ‘I am asking God to bring about rain’, he answers. An action can be described as intentional if it aims to satisfy a
Getting hold of the intentional description under which the agent acts by no means implies that we have to accept it. We can critique it along, at least, two lines: we can argue that the desire under which the agent acts is not the right one to have in general or in this particular situation; and we could point out that, notwithstanding the rightness of the desire, the action in question will not satisfy it. So, we could respond to the farmer by pointing out that he should not desire rain right now as a deluge is forecast in 12 hours. Or we could point out that praying cannot intervene causally in the weather and that cloud-seeding technology is what the farmer should campaign the government for. We could even go further and offer the farmer a different (better?) description of what he was doing, stating to him that what he is ‘really’ doing is seeking comfort in prayer to cope with impending misfortune. 2 He might, or might not, consider and accept this description, but we were only able to offer it to him once we had captured his own description of what he was doing.
Consider another example, this time from the medical (mental health) pathway. A man is found confused and disoriented in a public place. A member of the public calls the police, who dispatch an ambulance. A Mental Health Act assessment is arranged, and the man tells the psychiatrist and the social worker that for the past four weeks he has been in direct communion with God, that God has spoken to him telling him to get rid of his belongings, to give up his job, to go on a prolonged fast, and to change his life as a way of getting closer to Him. He says that he finally understands what God is and feels on to something significant in his life. He adds that he has been in contact with a Church in his native country and was encouraged to pursue this quest. Following the assessment, he was considered to present with an acute psychosis and was admitted to hospital under the Mental Health Act. He continued to resist all forms of treatment and, a few weeks later, medication was forced on him.
The psychiatrist in this scenario might see herself acting to care for the patient until he gains insight into his psychosis. The patient, on the other hand, is acting in accordance with his experiences and is moving his life to what he believes is a better place. He regards his hospitalisation as an incarceration aiming to undermine his religious quest. For observers of the pathway, it can be seen that neither the psychiatrist’s nor the patient’s descriptions are complete: they do not capture the complexity of the situation or what is at stake in it. Take the description under which the psychiatrist acts. We could critique the desire, not in its aim to care for the patient but in the apparent blind spot as to what ‘care’ should mean in this context, and the extent to which it should take the patient’s values into account. We could critique the practical rationality of the act by pointing out that deprivation of liberty and forced treatment are themselves harmful actions that cannot be justified by the initial desire to care for the patient. We could suggest to the psychiatrist that the description under which she acts, and which shows a disregard for alternative formulations of experience along religious and cultural lines, reflects a kind of ‘medical imperialism’ that promotes a ‘Western’ cultural psychology and its attendant values. 3
In effect, we would be offering the psychiatrist an alternative description of what she is doing. Of course, it is not just an alternative description, for in presenting it, we are also saying that it is a better way to understand what she is doing and so a better way to conduct such actions in the future. She may or may not accept it and allow it to affect her self-understanding, and it may or may not impact future action. But the key point is that by getting hold of two sets of descriptions, one belonging to the agent and reflecting the most proximal motivation for action, and the other belonging to the observer/critic and offering a more distal analytic and contextualised view, we have a more coherent epistemological picture. I would not say a complete picture as this cannot be the case. The practice of offering and sharing descriptions of actions is, in the best of cases, an ongoing dialectical process that, if conducted in the right way, can broaden the viewpoint of all those involved. In the case under consideration, this would mean that any critical analysis of what the agent takes herself to be doing must not ignore the key aspect of the agent’s own description, which is that she is invested in ‘caring’ for the patient. This leads us to the second reason why we must begin with the agent’s point of view.
Ethical/political reasons: Recognition and agential success
Generally speaking, people tend to be committed to the descriptions under which they act, at least initially, and will be tempted to defend them against alternative descriptions offered by others. Whether provided retrospectively or prospectively, the description under which I act offers an account of my values and my capacity at practical rationality. It communicates aspects central to me as an agent, and by putting that description out there in the world, I am also putting my agency to the test. To question my description or to attempt to supplant it is therefore also to question my success as an agent, which might very well be justified, but the point I am emphasising here is that such questioning is taking place. And this applies to the case of the farmer discussed earlier who was offered a rival description by a passer-by, as it does to the case of the psychiatrist who was offered a rival critical/theoretical description of the steps in the medical (mental health) pathway in which she was engaged. In both cases, the farmer’s and the psychiatrist’s success as agents is at stake.
Success as an agent cannot be achieved just by acting on my intentions in the social world and satisfying myself with the result. I might believe that I have succeeded, but others might not think that I have. For example, I might believe that I am a world-class pianist and every day at midday I play a concert at the piano at the train station to entertain the passengers. No one, apart from me, recognises that I have the ability I claim to have, and no one accepts my reasons for playing the piano at the train station or my self-confessed identity as a world-class pianist. In fact, some might even go so far as suggesting that I might be ‘delusional’. Successful agency requires much more than sincerity; it requires participation in social interactions where my self-understanding and reasons for actions are tested and retested, and by which they can be recognised or mis-recognised. Broadly speaking, one’s success as an agent requires that others (1) recognise me as having the social status and identity I attribute to myself; (2) recognise the deed as falling under the act-description that I invoke; and (3) recognise me as acting on the intention I attribute to myself. In general, this success requires that I am taken by others to have the intentions and commitments that I take myself to have, and so
Such recognition, as we know all too well from current debates surrounding various aspects of our social identities, is not always forthcoming. Many of the ongoing social struggles for recognition surrounding mental health identities, and gender and racial categories, illustrate the tension between individuals’ own formulation of their shared identity and the mainstream, dominant view that often fails to recognise, and so fails to correspond, to how people see themselves. We can, at this point, get drawn into complex discussions as to how this tension can be approached: should we, for example, repair social relations such that the recognisees receive the recognition they demand for their identities, or should we reject the identities in the terms they are presented since they are incoherent or morally objectionable? To be able to address such a question, there is much else that we need to examine first, including: the normative force of demands for recognition in general; the ethical, political, and psychological harms of misrecognition; the justification and adjudication of specific demands for recognition; the role of ideology in the politics of recognition; and the limits and nature of social responses to misrecognition. 5 For the purpose of this article, we need not examine these issues, for all I want from the foregoing argumentation are three points:
First, to question someone’s success as an agent by doubting the validity of their identity and reasons for action is an ethically and politically significant manoeuvre that can constitute misrecognition. Second, the framework of recognition is not limited to particular areas of our social life and extends to all social interactions in which claims and counterclaims are made pertaining to identity and reasons for action. Third, this framework also captures what we, as medical humanities researchers, do when we engage with the medical pathway; we are implicated in mutual relations of recognition (and misrecognition) with the variety of agents that populate the pathway, including healthcare professionals, service users, and patients.
The first two points, I assume, are straightforward. The third requires unpacking or, rather, specification of the scope of the argument which, as stated, might appear to implicate all academic and intellectual interventions in ethical/political concerns with (mis)recognition. Here, we need to distinguish between (a) what a discipline says about the agents it studies, and (b) what researchers writing from a discipline (or several) say to each other about their respective accounts of the agents they study. The former is a direct account of what the agents are up to, be they farmers praying to bring about rain or psychiatrists wielding the power of the Mental Health Act under the justification of ‘care’. They are the sort of accounts that are offered by anthropologists as well as medical humanities researchers when they speak directly about the object of their research. These analyses are within the scope of (mis)recognition as they often contain rival accounts of agents’ reasons for action and question their success as agents.
As to point (b) above, when researchers debate their respective accounts and venture into second-level discussions on epistemology and methodology, we would not want to say that such exchanges should be understood as occurring within the scope of (mis)recognition. This would suggest the unintuitive view that when scholars debate a theoretical point and disagree, they are misrecognising each other, where such misrecognition is an ethically and politically significant event that can be described in the language of injustice. This could stifle and limit debate and would distract us from the issues at stake. The reason this view is unintuitive is that scholarly debate proceeds in light of the implicit understanding that we are engaged in a social activity where ideas are questioned and better ones are considered. Participants in scholarly debate recognise each other as playing that ‘game’ together and accept its parameters or, at least, are able to subject the parameters themselves to debate as well. This frees us to disagree with each other without this raising an ethical or political concern about misrecognition.
However, when we theorise directly about the object of our research and the agents that populate it, point (a) above, we cannot suppose that we are engaged with them in a scholarly ‘game’. Our analysis of what the agents are doing pushes against their own view, yet the agents do not always share a scholarly interest in our analysis, or its theoretical heritage or assumptions, including the often-challenging concepts and ideas that we propose. For this reason, our analysis would not be seen as a legitimate move in a scholarly exchange – as our colleagues might see it – but as a rival account of what the agents are doing. As I said before, we do not have to accept the agent’s description, and we can certainly critique it, but we need to acknowledge that what we are doing places us within the sphere of recognition and misrecognition.
Practical reasons: The dialectics of change
The third reason why we must place the agent’s point of view at the core of our analyses arises from the foregoing epistemological and ethical/political arguments. First, the epistemological point: in order to capture the agent’s point of view – which is fundamental to understanding the practice and to a more coherent epistemological picture – we need to acknowledge that agents act under a description, and the first step must be to get hold of that description. Second, the ethical/political point: we need to register that by offering rival descriptions of the agents' actions, we are questioning their success as agents, which places our analyses within the scope of (mis)recognition. Combined, these two arguments have a key implication, which is that medical humanities cannot distance itself from medical
Another way to phrase this question is to ask: what do we do after we find ourselves in possession of two rival descriptions and are motivated by the need to negotiate within a framework of recognition? To answer this question, we first need to outline the relation in which the rival descriptions stand to each other. The first description is offered by the agent involved in the medical pathway as a description and justification of her actions; the second description is offered by the observer/critic and represents an alternative description that is taken to capture the agent’s actions in their broader context. Both descriptions can and do learn from each other. The critic’s descriptions can be enriched by intimate knowledge of the complexity of the agent’s actions and motivations; the agent’s descriptions can be enriched, and their actions improved, by understanding the context in which they practice, including its socio-political significance. There is, then, a mutuality by which both points of view can develop further. As I noted earlier, in the best of cases, the practice of offering and sharing descriptions of actions is an ongoing dialectical process that can broaden the viewpoint of all those involved, but only if conducted in the right way. In seeking to bring the agent’s and critic’s descriptions closer to each other, we cannot merely negate the rival description and offer ours; we must somehow preserve its key elements even as we attempt to supersede them in the description that we offer.
The technical term for this is ‘sublation’, which has the twofold meaning of preserving and putting an end to something. 6 It denotes the process by which a concept can develop into a more complex one by passing through its opposite. It reflects a dynamic, rather than a fixed, development of the understanding. The first moment in this dynamic is when the understanding of a particular situation appears to be stable and comprehensive. In the second moment, the moment of instability, a certain one-sidedness or restrictedness is revealed in the deployed concept. It fails to account for key aspects of the situation and so is negated and passes into its opposite. In the third moment, the opposition between the two concepts is grasped, and their unity results in a transition to a more developed concept. Sublation preserves the first concept in a more complex form while putting an end to its initial one-sidedness or restrictedness. It thereby keeps the concept ‘alive’, as it were, in all future determinations while iteratively developing the understanding. In the following case-study, I demonstrate how the notion of sublation can play a role in developing the understanding of agents involved in the medical pathway, in line with a critical analysis of the practices they are engaged in.
Case-study: Care, paternalism, and insight in psychiatric practice
We are back with the psychiatrist mentioned earlier, who authorised detention and forced treatment on a patient undergoing what he believed to be a ‘religious experience’, and what the psychiatrist believed to be ‘psychosis’. She took herself to be acting under the motive of care for a patient that she regarded as lacking insight into his illness and its effects. From a distal perspective that is able to capture more of what is relevant, the critics could see that, in this instance (at least), psychiatry is disregarding cultural and religious understandings of experience in favour of a medical view that reflects scientific and secular preoccupations, values, and models of the human. The motive of care is also put into question given that the interaction does not consider what the patient would want ‘care’ to mean in this context. The critics could point out that what is happening is captured better not by the view that the psychiatrist is treating illness under a motive of care, but that she is medicalising socially unwanted behaviour under a motive of control. Moreover, the interaction places the burden of the problem wholly on the patient and fails to problematise potentially exclusionary or oppressive social norms.
I intentionally present these views as categorically opposed, and perhaps even (apparently) unbridgeable, in order to illustrate the challenge. If we are motivated to bring these views closer to each other within a framework of recognition, then we cannot just leap from one view to the next. To do so would not leave the psychiatrist with much to go by to change an already existing understanding and practice. There is much work that needs to be done in a careful stepwise fashion that seeks to develop the psychiatrist’s views without merely negating them. The notion of sublation, as illustrated below over a few initial stages, can be helpful in negotiating a meaningful transition of views. It is important to bear in mind that the process can be observed and analysed from several perspectives; my focus, however, remains on the side of the critic trying to bring the agent closer to their point of view – a perspective that fits with a critical analysis of the medical pathway.
The first stage begins with the psychiatrist’s view that she is caring for the patient by providing a diagnosis and authorising involuntary admission and treatment. For the critics, the psychiatrist’s view is restricted, one-sided, and does not account for all aspects of the situation. Crucially, it does not account for the fact that the patient rejects that what is done to him can be described as ‘care’, rather than abuse through coercion. If we were to take at face value the patient’s view as one more fact about the situation, then it becomes apparent that what is happening includes the management of social deviance via medical concepts and authority. The critics, at the very least, question the simple desire to ‘care’ as there is clearly much more going on that also recalls the desire to ‘control’. If we were to mediate these two views – which requires that we preserve the element of ‘care’ even as we negate it (i.e. sublation) – we would have the notion of caring-control, or paternalism. The concept of paternalism sublates the concepts of care and control.
Now that we have the concept of paternalism, the second stage begins with the psychiatrist’s view that progressing with caring-control requires the patient to develop a new understanding of his predicament. Given that the patient’s current views, and their underlying mental states and behaviour, have caused the problems that led to the clinical encounter, the patient needs to think differently about what has happened in order to make progress with the problems that led to the encounter. The basis of this new understanding is that the patient needs to develop insight into the fact that he is ill. Insight, in psychiatry, is defined as ‘awareness of having a mental disorder, of its symptoms and of its implications’ (Lincoln, Lullmann, and Rief, 2007: 1). Illness-insight is framed in diagnostic and psychobiological terms, and the patient’s refusal to accept a medical formulation of his predicament is labelled as ‘lack of insight’. For the critics, the psychiatrist’s view is restricted and one-sided as it rejects the patient’s own religious narrative. In this sense, the notion of illness-insight (and its alleged absence in the patient) is a barely disguised cover for the priority of the medical narrative as a route to caring-control.
If we were to mediate these two views, then what is carried through from the psychiatrist’s view is that some sort of new understanding of, or insight into, the situation is required. But what we have learnt from the critics is that this cannot be at the expense of the patient’s narrative; i.e. the notion of illness-insight cannot do the required work here since it demands from the patient to abandon his own narrative. Sublation then requires a notion by which the patient can still develop insight into his predicament without having to abandon his religious understanding. The notion of ‘social-insight’ can realise these two requirements. In contrast to illness-insight, which promotes a psychopathological understanding of the patient’s experiences (thereby denying his own narrative), social-insight focuses on the social interactions that excluded the patient and activated the medical response in the community. The patient’s mental states and behaviours are no longer the primary focus, which now shifts to people’s
Even though the concept of social-insight has allowed us to bring social judgements into the picture, the patient’s mental states and behaviours continue to be understood as the trigger that activated the medical pathway. The burden of the problem is still wholly upon the patient, even if the psychiatrist has ceased to push the narrative of illness upon him. Accordingly, there are many more steps that need to be taken before we can arrive at the view where the psychiatrist is able to problematise the social judgements themselves and see that they might be exclusionary or oppressive. Given this, the next stage must facilitate the realisation that the source of the problem can be seen from both sides; that social norms, too, are implicated here, and not just the patient’s mental states and behaviours.
The third stage begins with the psychiatrist’s view that social-insight is a useful notion in that it allows us to sidestep the question of the patient’s narrative and creates the basis for helpful interventions under the overall aim of caring-control. It allows us to focus on interventions geared towards conflict resolution, and it allows the patient more autonomy, since by knowing that certain behaviours and interactions are likely to take him down the medical pathway, he can endeavour to control these behaviours, thereby minimising conflict (see Rashed, 2020: 610–12). For the critics, the psychiatrist’s view is restricted, one-sided, and does not account for all aspects of the situation. Specifically, social-insight as a route to caring-control places the burden wholly on the patient to self-censor, and no burden on society to be more accepting. In other words, it suggests that it is only the patient who needs to develop social-insight, which is to develop an understanding of how his behaviour violates certain norms and expectations. The opposing view is that the community itself needs to develop an understanding of how its norms and expectations routinely exclude certain mental states and behaviours, together with the corresponding possibility of controlling these judgements. If we were to mediate these two views, then what is carried through from the psychiatrist’s view is that some notion of ‘control’ via social-insight must still inform the situation. But control cannot be one-sided and must involve ‘control’ of social norms as well as control of one’s behaviours, the balance of which needs to be worked out at later stages. Here, we have arrived at the notion of
As can be seen, achieving a transition of views via the notion of sublation is a laborious process that can only proceed dialectically in small steps. I have only demonstrated three steps, and there are many more required before we can arrive at a manifestation of the practice that speaks to the multitude of relevant socio-political, cultural, and historical considerations. This methodology, though it may appear complex and is certainly slow, is necessary for negotiating radical differences in epistemology and values, and it can succeed if there is sufficient goodwill and an appreciation of the importance of consistency on all sides. It shows a way to reconcile critique with medical practice without losing the radicality of the former or the ability to influence the latter.
Conclusion
The relation between medicine and medical humanities has been a topic of debate for several decades. Resistance to the dominant view whereby medical humanities lies in an instrumental relation to medicine has led to assertions of independence from medical aims and practice. Only an autonomous medical humanities, critics argue, can challenge medicine and broaden the cultural imaginary about the concepts and practices of healthcare. The question of the relation between such an autonomous discipline and medicine is what occupied me in this article. The focus was on the proposal for Critical Medical Humanities, an approach that defines itself against paradigms of multi- and inter-disciplinarity, seeing in both – to a greater and lesser extent, respectively – a nod to, and a limitation by, medical concepts and boundaries. In contrast, Critical Medical Humanities seeks to liberate itself from the existing ways in which sites of interest have been determined by medicine, thereby having the freedom to ask new questions and offer radical critique and analysis. In this sense, Critical Medical Humanities is a welcome paradigm, for medicine can certainly learn from its distinctive epistemological perspective and the imaginative socio-political, historical, and cultural analysis and contextualisation that it can offer.
However, a key problem stands in the way of sharing this knowledge, which arises from lack of sufficient constraint by the point of view of agents involved in the medical pathway, such as healthcare professionals and patients. This prevents the medical humanities analysis from having meaningful uptake into, and influence upon, the medical pathway. Proponents of Critical Medical Humanities could object to the latter point by arguing that this way of thinking is a return to the paradigm of instrumentality to medicine. To get around this objection, I have argued in this article that Critical Medical Humanities (and medical humanities more generally) must place the agent’s point of view at the core of the analysis, not for instrumental reasons but for epistemological and ethical/political ones that could lead to instrumental gains. And so, the relation between medicine and medical humanities that I am proposing in this article is not defined or justified by instrumentality but by the nature of the interaction.
Epistemologically, we need the agent’s description of what they take themselves to be doing in order to complete the dimensions of our knowledge. It places us in a position where we can offer critique of the practice and propose alternative descriptions of agents’ actions. The juxtaposition here is between the agent’s own proximal, ‘front-line’ description and the medical humanities’ distal and contextualised analysis, both of which need each other. Ethically and politically, once we offer the agents alternative (and better) descriptions of what they take themselves to be doing, we are questioning their success as agents and so are implicated with them in relations of recognition and misrecognition. If we wish to negotiate these interactions within a framework of recognition, then we cannot step away and claim that we are not interested in practice, for we have already made an ethically and politically significant intervention and proposed a view on changing the practice
With the necessity of engaging with the agent’s point of view established, I proposed a methodology, a dialectics of change, aimed at achieving a meaningful transition of views. This includes the views of agents in the medical pathway who can learn from the medical humanities’ analysis, and the views of medical humanities researchers who, by capturing the descriptions under which the agents act, can become better acquainted with their motivations, values, and aims. Reconciling radical critique with medical practice is therefore a process that will touch the views of all those involved. Here, I find it apt to conclude with Sari Altschuler’s (2018: 199; emphasis added) welcome advice: we should insist that the humanities’ distinct ways of knowing have enriched and can continue to enrich medicine and the health professions … Incorporating the humanities into health care and health research in this way will require
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