Diverse bodies: the challenge of new theoretical approaches to medical anthropology

Introduction

In recent years, medical anthropology has benefitted a great deal from debates in science studies, and in particular, the focus on knowledge practices (Pickering 1995) and epistemic cultures (Knorr Cetina 1999). At the same time, within anthropology, work exploring post-human orientations – for example, the focus on materiality and the role of objects, human–animal relations and environmental approaches – have invigorated debate not only about how central people should be in our ethnographic accounts, but also from what, or who's, perspective (Viveiros de Castro 1998). Core to all these areas of study has been an increasingly commonplace reference to the word ‘ontology’. Although important differences exist in the use of the term, as a starting point let us say the word concerns not only the status of what is known, but also the status of that which knowledge is based on. This so-called ‘ontological turn’ in anthropology over the last decade is consequently both a theoretical and methodological set of arguments that seeks to provide new insights to old problems (Holbraad and Pedersen 2017).

But surprisingly, these debates have only tentatively been drawn on directly in medical anthropology to explore the relationships between culture, biology, health and medicine. We say surprisingly because the subfield has always had to confront such things as the viability of universal illness categories, how to evaluate the efficacy of local treatments, or the problem of representing the experience of others, especially when they are suffering or in distress. So, by engaging with some of the work from STS and mainstream social anthropology, this Special Issue presents a range of contrasting papers that explore the extent to which such work not only might offer genuinely new analytic approaches to think through established concerns we, as medical anthropologists, have to confront, but also potentially generate new areas for enquiry. But given the imperative of medical anthropology – to engage with illness and suffering with a view to helping alleviate them – this issue of Anthropology and Medicine also extends the arguments to also ask what pragmatic and ethical contributions they might make. Finally, a key matter that the overall collection raises is the extent to which the stale opposition between applied and more theoretical anthropology might be discarded once and for all through arguments that emphasise the cultural basis of even the most fundamental concepts we draw on, including any distinction between knowledge and practice.

One world, many views

To introduce these discussions, let us begin from an obvious starting point. The word ontology is traditionally used in philosophy to refer to the nature of being and existence – to questions of entities and reality itself. This, therefore, distinguishes it clearly from epistemology, which concerns ways to know or study that reality (Hastrup 2004). What should appear obvious from this is that ontology is presented as a resolutely singular word – reality is simply what is, and therefore cannot exist in different forms, even if our knowledge or investigations into it (note the singular pronoun) might lead to a wide variety of interpretations and understandings. Now, we see this straightforward and unproblematic starting point in much of the social sciences through a set of convictions that have been inherited from centuries of Western intellectual thought, and are now so embedded in our everyday thinking that we simply do not notice them. These include that the external world is fixed and singular, that knowledge is cumulative and ever-refining, and that although new techniques and perspectives might raise epistemological questions (concerning how and what can be studied or known about the world), these concerns ultimately have no bearing on the nature or existence of that world, which exists independent to its enquiry. The work of individual disciplines is thereby presented usually as fundamentally one of epistemology – establishing distinct means to know that world by drawing on different methods, techniques, analytical tools and theories.

One can consequently see many of these elements throughout our own discipline. In fact, as we shall argue, that they have served as the basis for a great many contributions anthropology has been able to make to wider debates. Beyond technical matters about how best to know the world, anthropology has always reflected upon what assumptions drive such enquiry, and so has seen its role as one that investigates the cultural perspectives of that world, and the ways in which it is socially constructed: Do people experience time differently? What does someone see if they don't have a word for a particular colour? What might it be like to have a radically different emotional lexicon? And so on. Of course, individual scholars, and different theoretical schools over the years have sometimes taken a clear position on such questions – evoking different degrees of relativism or universalism. But core to all of them is the distinction made between reality and its representation. For example, one can see this in such things as the continued distinction made in anthropological debates between sex and gender, colour and its perception, and of course disease and illness. In this way, our focus has generally been on the degree to which local categories or experiences are universal or not, rather than the apparently nonsensical question of whether reality is universal or not.

The point is that we, as anthropologists, have largely concerned ourselves with cultural representations and how people come to make sense of, and live in, the same world differently. Often this approach draws heavily on the notion of ‘belief’ (Palecek and Risjord 2013). For example, anthropologists may well ask how is it that members of a culture believe that a particular ritual, involving certain symbols, might heal the afflicted, or how it is that the involuntary fits of a person are thought to be the result of spirit possession (Fadiman 1997). Anthropology's important contribution has been to incessantly contexutalise such beliefs within the socio-political context and a culture's general cosmology, in order to suggest the underlying logic by which a specific belief makes sense. But as Good rightly points out (Good 1994), using the word belief in this way, although intended to be sympathetic and respectful, has the danger of implicitly elevating the position of the anthropologist as having a different kind of standpoint. Or, to put this another way, by reproducing the idea that ‘they’ have beliefs, there is an inherent risk that this endorses the position that ‘we’ (whether that implies anthropologists, medics, or other collectivities) have, in contrast, ‘knowledge’.

More could certainly be said on this issue in terms of asking what ultimately is the difference between belief and knowledge, or indeed (taking our cue from current concerns in the political sphere) between fact and value (Latour 2004). But here we simply want to emphasise the way in which, although highly productive, this approach has often been a timid way of confronting cultural difference. We regard the approach as a sideways manoeuvre because it permits anthropologists not to have to engage square-on with the more central problem; how can one fully respect alternative claims about the world, take them seriously for what they are, and potentially find ways to reconcile radical differences, without subjugating one with another? Because of this avoidance we have, perhaps inadvertently, not only reproduced, but reinforced, the position that reality itself is fixed and singular. But as a result, we either have colluded with the implicit notion that ultimately ‘we’ know best, or simply have left it to other disciplines to make claims about reality itself.

Extending claims of difference

This emphasis on cultural variation and social construction has, of course, been fundamental to how historically medical anthropology gained its intellectual purchase. It also provided a set of political resources: not only to argue for claims of unity and equality, but equally that cultural variation should be defended and celebrated. In this way, anthropology has always acknowledged a productive tension between relativism and universalism, and thereby challenged voices that articulate one at the exclusion of the other. But appreciating the extent to which different perspectives set up different patterns of rationality that can generate radical alterities has led some to argue anthropology should not only be concerned with questions of epistemology and representation, but broaden its scope to matters of ontology (Henare, Holbraad, and Wastell 2007; Viverios de Castro 1998, 2012). The fundamental challenge is to somehow find ways to acknowledge and accept that what is at stake might be what we take reality to be, rather than just how it comes to be known, perceived or understood. This, then, is a call for anthropology to extend its reach beyond matters of how cultures represent, to asking what are the worlds people live in that they represent.

It is certainly true that weak versions of this move tend sometimes to resemble old, established arguments about cultural relativism, especially when authors slip in to using terms such as ‘worldviews’, which suggests a plurality of perspectives, but leaves a singular world unscathed (Carrithers et al. 2010). However, stronger versions attempt to go further, and argue that by taking what others say seriously one faces a central intellectual and, we would say, ethical choice; either to accept that one version of reality may well be more truthful or accurate than another, or commit to the idea that realities can be different (Holbraad, Pedersen, and Castro 2014). This latter idea is, of course, far from an easy position to adopt. But perhaps that uncomfortableness is its central virtue.

However, this development certainly raises a number of problems. For example, the linguistic basis of a great deal of anthropological engagement from fieldwork to writing can easily fall foul of matters of translation and over interpretation. And beyond this, of course, there will always been concerns that established debates that problematised culture and holism (Strathern 2002) are in danger of being overlooked, and that by attributing distinct realities to discrete cultures simply provides a new means to reify them. These methodological concerns, however, are far from new or specific to debates about ontology. In fact, given anthropology's long-term concern with such matters, one might argue that it is well placed to find innovative ways to make them part of enquiry, rather than obstacles to it.

Ingold (2014) has recently pointed out that participant observation is only an oxymoron if one starts from the premise that subject (participant) and object (that observed) are unconditionally distinct categories. But the history of anthropology has enduringly demonstrated how the distinction between subject and object, or observer and observed, only ever emerge dialectically; in other words, one is always defined by the other. Given this, the methodological value of participant observation should not be curtailed by crude criticism of bias or researcher interaction, because such accusations rest on the assumption that objectivity can exist absolutely and independently (see Daston and Galiston 1992). Rather, participant observation is a means to capture the emergence of an object in relation to the anthropologist as subject. Although this relational aspect of ethnography has, arguably, only become evident in more modern writings (especially since the seminal text Writing Culture, Clifford and Marcus 1986), it has always been a matter that has framed how anthropology should be valued, and hence the kind of claims it makes about the social world.

Readers can hopefully see in this discussion about method that there are also imbedded considerations about ontology. For, if the objective world can only be realised through the subjective engagement of the anthropologist ‘being there’ (Geertz 1988), any a priori, independent existence of the world is called into question. Here again, the same choice we introduced earlier is revisited in a slightly different guise. One can either follow the more usual line of thinking and say all that is at stake is that this particular world cannot have existed prior to its observation. Or one might at least explore the more unorthodox approach that no particular world can exist prior to its observation – because no world can be accorded with the status of existence other than through some kind of interaction with it. We are acutely aware of the sense of uncomfortableness that such a position invokes; after all, most of us spend our lives investing in the idea that the world we inhabit is independent to us. Just the term ‘inhabit’ suggests an environment we are situated in. But the boundary between self and other is increasingly being questioned and destabilised, not only in anthropological writings (Descola 2013), but across a diverse arrange of disciplines and types of enquiry (Haraway 2008). The ontological turn, then, might not only be a result of academic debate about reality and its representation, but also changing sensibilities around how we come to understand and define being human in relation to the world that we interact, and intermingle, with.

Practice and multiplicity

During a recent medical anthropology workshop, in response to one speaker suggesting that no disease category can ever be fully absolute or stable, one of the most sceptical participants suggested that actually there are some states of the body that we all must surely accept are definitive. ‘Take pregnancy,’ he proclaimed. ‘Either a woman is pregnant, or she is not’. At first, this appears to be an incontrovertible example, as most people at the event concluded. But it is important to be vigilant to the extent the language we use to describe the world does not spill over and entirely dictate how we might understand that world to be. In other words, just because our words in English, at least, present a simple either/or option with regard to pregnancy, this should not prevent us from being open to alternative ways of understanding pregnancy that do not follow a simple binary. Ideally, then, we should give sufficient freedom to the world for it to push back and resist how we may want or expect it to be.

The point is, as one starts to reflect on an absolute definition of pregnancy it rapidly becomes more and more uncertain – does it really start from conception, or when a fertilised egg travels down the fallopian tube, or only once it has successfully embedded into the wall of the uterus? And even when it comes to conception; is this when a sperm is able to penetrate the ovum, or when its DNA is released, or when the DNA combines with that of the egg to become a zygote? Clearly, as one zooms in, the notion of a single, definitive event, continually evades our view. But even if such matters of scale and chronology were to be agreed upon – by some pragmatic consensus or coherent theoretical rationale – that is not the end of the issue. From a woman's perspective, the definition of pregnancy may not be driven by some objective external criteria at the microscopic or even molecular level. Instead, she may well regard it as a description of her entire state of being and, indeed, a state of potential. Today, many over-the-counter pregnancy tests are very different technologies to those available a few years ago. They are now much more reliable and sensitive, allowing results much sooner after possible conception. So, whereas a few years ago a woman would not know if she had conceived until a few weeks afterwards, she now can do so after just a few days. The upshot is that she may well now experience joy, trepidation or perhaps regret, earlier. And whereas in the past she would not even have been aware of being pregnant, she may now also have to deal with loss if that fertilised egg fails to thrive early on. The point is that from her perspective, the definition and meaning of pregnancy has altered in a very real and tangible way; the test she has bought not merely identifying if she is pregnant, but actively determining what pregnancy actually is. An illustration like this points to the intersection of both scale and standpoint determining not merely the ‘perspective’ adopted, but also the reality that emerges.

Such an example not only illustrates the fact that there are no definitive states or categories relating to the body, but that claims about reality more generally often differ. Studies of science from within and beyond anthropology have drawn on such matters, from detailed accounts of scientific practices in the lab (Latour and Woolgar 1979), to other places, such as the clinic and beyond (Jensen 2010; Mol 2002). One theme has explored the assumption that scientific knowledge is universally applicable – leading, for example, to the idea that human biology is inescapably a local concern and inevitably contingent on a wide variety of social, physical and physiological circumstances (Lock 2001). By committing to the idea of ‘local biologies’ talk of a stable single biological reality is challenged, not simply because it highlights variation but also constant change, as living things and their environments are continual in dialogue with each other (Brotherton and Nguyen 2013). More recently, such areas as social neuroscience and epigenetics have further supported the idea that the social and biological are constantly interacting with each other, leading to continual diversification and difference (Lock 2013; Niewöhner 2011).

But a further area of work investigating scientific knowledge practices has placed particular emphasis on the ways in which they are not merely techniques for representing and understanding reality, but of actually constructing or achieving a reality that can be scrutinised and rendered knowable (Law 2008; Moreira 2004),. World-making, then, rather than world-viewing. A vacuum has to be made in order for its effects to be known; a subatomic particle has to be violently separated in order for it to be observed; an area of tissue has to be stained and placed in a microscope in order for pathology to be identified. Such practices make realities in particular ways. We may be tempted to say, ‘but wait, that reality existed prior to any intervention by the scientist; all you are describing are the necessary means to make things visible.’ Yet arguments from science studies might claim otherwise: these particular things, as they come to be, and hence be known, are always and inevitably the result of particular activities and events. From this position, there is no pre-existing reality other than an undifferentiated potential (what Latour refers to as the multiverse); instead, reality is only that which is made into existence at a moment in time, in a certain location, through a specific set of interactions.

What is key to much of this work is that in contrast to the anthropological debates around ontology that centre on language and communication, emphasis is often placed on human practice. The strength of this is that rather than consider claims of different realities as being intimately associated with how they are symbolically represented, attention is paid to how practice creates reality (Slife 2004). These debates do not merely suggest that realities are practically constructed but that different ontological claims frequently come to be juxtaposed in everyday life. This then introduces something that anthropological debate has tended to sidestep: talking about ontologies is inevitably talking about power and politics (Mol 1999). The juxtaposition of these realities may not always be in terms of cultural differences across large distances, but often the close and proximal ways in which diverse ontologies sometimes contradict, sometimes cohere, and at times manifestly compete with each other. This dimension of the debates about ontology clearly has particular relevance for medical anthropology.

Earlier, we argued that the problem with the notion of social construction is that its remit has always been concerned with representation; how people make sense of their world – a world that, by implication exists prior to, and often independent, of them. But if one accepts that any world is continually co-produced by a wide variety of forces, and that human engagement consists of ‘making’ as much as ‘making sense’, suddenly arguments about construction need not be constrained simply to matters of representation; the world is constructed both materially and semiotically, in combination. Our desk is constructed. The computers we are typing with are constructed. Your feelings are constructed. And so too, are illnesses. To say something is constructed does not mean it is not ‘real’, as a colleague once claimed all ‘postmodernists’ assert; quite the opposite. Things are real because they are constructed. Through a wide range of convergent forces, ranging from the molecular properties of materials (Barad 1998) to the semantic networks that give an object its distinct status (Duranti 2011), there is nothing that can be said to exist prior to its construction. (Clearly, humans don't have to be involved at all in processes of construction – although the realities constructed are ones that, as a consequence, we cannot know about.)

Take tuberculosis, for example; as we conceive it today through our tests and treatments, it is a combination of many different things knotted together. But this current version of the condition is not the same as when Hippocrates described something he called phthisis (Daniel 2006), nor, arguably, is it exactly the same all over the world (Koch 2013). Whilst there may be good grounds to assert sufficient similarity to warrant a standardised biomedical conception of the disease, there may alternatively be valid claims: that the microbacterium varies; that the resulting pathology takes different forms; that dissimilar treatments shape the condition very differently; or that the illness experience is so varied, that a singular term fails to acknowledge the inherent variation. To say TB is constructed is merely to point out the fact that its status as a particular disease object is the result of many different things and processes, including the material and biological, forged into something we may take to be, at present, a singular entity.

Much of this argument should feel familiar to medical anthropologists. There have always been accounts of how different cultural experiences can manifest in very material, physiological ways that not only escape a common universal medical or biological paradigm, but also resist the usual causal claims of ‘biology first, culture second’. But for many, this current iteration of the debate feels limited by its apparent lack of engagement with subjective experiences such as emotions, and the extent to which the attribution of meaning, often in a diffuse form, might also shape the nature of entities. This is because, whilst medical anthropology has perhaps been as guilty as other areas of social anthropology by amplifying difference and even romanticising otherness, this is set in particular tension with the call to empathise with, care for, and sometimes act on behalf of, others. Our particular orientation consequently invites a complementary kind of politics to those derived from proposing multiple or competing ontological difference: one that might tentatively suggest a common ethics based on empathy and proximity. As a result, the particular focus of medical anthropology– on matters or health, medicine and the body – is not merely an arbitrary site to test out the work, and perhaps the limitations, that a concern with ontology or ontologies might enable. Rather, medical anthropology has the potential to offer some very particular sites of resistance and engagement that have more general consequences.

The collection

As these debates become incorporated into the current discipline, including how it is taught to the next generation of scholars, one might argue that the central value of such discussions is to accept that there may not be a definitive answer. Definitive answers have always been an anathema to anthropology, after all. But unresolved debate can still have real value, opening up space in the intellectual imagination, and hence the worlds that we are able to engage with, demanding a reflexive critique of even our most fundamental categories and assumptions.

The contributions of this Special Issue consequently introduce a specific bundle of contemporary theoretical approaches and terms through papers that are nevertheless grounded in rich, first-hand ethnography. Rather than representing the wholesale import of these ideas, they test out their usefulness and novelty as they are applied to core medical anthropology concerns. More specifically, all the authors have chosen to explore the ontological status of the body, as it is constructed by different fields of biomedicine and beyond. The papers make use of different ethnographic contexts (Brazil, Qatar, the UK, Guatemala, Denmark, the Netherlands) to engage with literature from STS and social anthropology concerning ontology and epistemology, exploring the extent to which they offer new ways to think about the complex relationships between the body, health and medicine, and more general anthropological concerns relating to relativism and representation. They consider different medical concerns (obesity, genetic cancer risk, weight, miscarriage, appetite, death) and question whether a number of specifically Western repertoires have not only shaped medical anthropology but have been centrally productive, exploring to what extent the sub-discipline is inevitably fashioned by its underlying ontological assumptions, and what things might be concealed in the process. Focusing primarily on how human bodies are made and done, the papers adopt a general scepticism as to whether bodies can be conceived of as existing prior to, and independent of, ways of making them known. They ultimately respond to the challenge of attending not merely to what people say and do, but the material and semiotic worlds that saying, and doing, ‘do’, and the multiplicities that might then be produced.

In the first paper of the collection, Emily Yates-Doerr takes up Scheper-Hughes and Lock's well-established work on the ‘three bodies’ (Scheper-Hughes and Lock 1987) to consider how more recent theorising in science studies might reconfigure this classic paper. Through her work on weight in Guatemala, Yates-Doerr (2017) concludes that some bodies are more relevant than others, and that rather than seeking to create better definitions of health and the body we should instead aim towards more fruitful engagements between medical and non-medical practices. The value of this practice orientation and its potential to reconfigure is also taken up by Else Vogel in her paper. Vogel (2017) considers the different types of ‘hunger’ that were constructed during a weight loss course in the Netherlands. Mindfulness coaches recast what Vogel terms ‘normative registers’ by encouraging participants to recognise the many hungers they can have, and what else ‘feeds’ their lives. Vogel suggests that these techniques for drawing out and discerning distinct hungers do not introduce different ‘norms’ but instead have the potential to reconfigure normativity itself.

Rather than taking a lead from Mol's ‘praxiology’ as Yates-Doerr and Vogel do, Sahra Gibbon draws on the work of Margaret Lock to consider the different sorts of ‘local biologies’ that are articulated in Brazilian cancer genetics (Gibbon 2017). Diverse ontologies of ‘the body’ and ‘the biological’ are materialised in the clinics she attends and in the accounts she draws out. These intersect and cohere in different ways so that there are more than one but less than many ‘local biologies’ at stake. While Gibbon's work focuses on these multiple bodies within her fieldwork location, in Susie Kilshaw's paper, it is precisely the location itself that constructs the ontological multiplicity she examines. Through work on pregnancy and loss in Qatar, Kilshaw (2017) suggests that different contexts construct different foetuses; foetuses have multiple realities dependant on their situatedness rather than biological value. Through detailed descriptions of foetuses alive, at different stages of development, lost, and disposed of, Kilshaw weaves together these different multiplicities and the consequences they have for the women involved.

In contrast, Maryon McDonald's paper sees the limits of the turn to the ontological. She locates her argument through historical developments in anthropology, and in particular, the links and disjunctions between ‘the Oxford School’ of Edwin Ardener and contemporary authors such as Viveiros de Castro and Mol. To these developments, McDonald (2017) adds her own work on dealing with death and cadavers within biomedicine – for medical students undertaking dissection, in organ donation practices, and in the ways a body is declared ‘dead’. While biomedicine recognises different ways in which death is ascertained, she nevertheless argues that medicine seeks to reify death as a universal notion, actively seeking a ‘mono-realist singularity’. She argues we should take this ambition seriously, as well as something we should treat ethnographically. This differs from the direction taken by Bodil Just Christensen, Line Hillersdal and Lotte Holm in their own engagements with biomedicine (Christensen, Hillersdal, and Holm 2017). They instead suggest that ontological approaches can offer opportunities for collaboration between anthropology and medicine and space for interdisciplinary developments. Coming from different disciplines, yet all working on bariatric surgery in Denmark, Christensen, Hillersdal, and Holm (2017) examine how the concept of ‘appetite’ was a key concern but constructed differently. Through the experiences of collaboration, they reconceptualised appetite as a ‘fractional object’ with multiple relations and enactments; a turn that then allowed alternative exploration of scientific and anthropological practices within the field.

Collectively, these papers give ethnographic examples of a theoretical reconfiguring in practice. Across them, ontologies are located in particular spaces – through Yates-Doerr's work, we see how particular equipment and measurements construct particular ontologies in clinical and non-clinical spaces; Gibbon seeks to locate biological ontologies in relation to emotional and ancestral constructions; while for Kilshaw, it is the very location of her object of study that constructs its ontological position. Multiple ontologies are drawn out in many of the papers also, and may compete (Vogel), are more or less easy to reconcile (McDonald), or can be themselves productive for medical anthropologists undertaking interdisciplinary work (Christensen et al.). Rather than advocating situated specificity that would resist wider comparison, the ontological locatedness and multiplicity detailed in each instead point to particular politics at play. By focusing on how these ontologies are ‘done’ rather than what they ‘are’, the contributions explore how ontological categorisations might have wider implications for such things as morality and status (Kilshaw); which or whose ontologies take precedence and ‘count’ (Vogel, Christensen et al., Yates-Doerr); how different realities relate to, or reinforce, wider inequalities (Gibbon); ways in which acknowledging different ontologies might lead to a more careful medical anthropology (Yates-Doerr, Christensen et al.); and to what extent the ‘ontological turn’ might be considered a political move within medical anthropology itself (McDonald).

As a result, the focus of this Special Issue thereby also becomes political and ethical, raising new questions and finding alternative spaces of engagement for medical anthropology and their interlocutors. The value of the collection is accordingly not merely to contribute to the development of theory but to propose ways of engaging with wider forms of human experience and the worlds they are coupled with. By drawing closely on detailed accounts, the issue explores in what ways broad conceptual debates open up the specifics of an ethnographic encounter in radically new ways, or whether what they really do is catalyse a more nuanced and contemporary awareness of established debates and concerns.

Disclosure statement

No potential conflict of interest was reported by the authors.