© 2017 Vitaly LEKHTSIER
2017 – №2 (14)
Key words:cognitive medical anthropology, medical choice, medical pluralism, decision-making model, divergent rationality
Abstract:Medical choice is a quite natural subject for medical anthropology as the latter has discovered and described the phenomenon of medical pluralism. The article elaborates on the medical pluralism studying methods proposed by modern cognitive medical anthropology via one of its most outstanding representatives, Linda Garro. This sphere of medical anthropology focuses on the individual choice of health systems or practices. Linda Garro’s books and articles include both results of empirical studies of medical choice and a profound reflection on its cognition principles. The article analyses the collection of works «The Ethnography of Health Care Decisions» (Social Science & Medicine, Volume 16, Issue 16, 1982) where Garro acted as collector, editor and author, and her book «Medical Choice in a Mexican Village» (1994) co-authored with Young. In the book Garro and Young introduce such notions as the «study of medical choice», «decision-making approach», «model treatment decision making» and explain the medical decision making in a Mexican community Pichátaro based on the anthropologists’ empirical studies.
The article pays particular attention to the analysis of Garro’s methodologic work «On the Rationality of Decision-Making Studies» (1998) which explains the basic principles of cognitive medical anthropology, its subject matter and goals and contains detailed arguments of cognitive medical anthropologists’ opponents with responses to them. The study focuses on such problems as the freedom of choice and how it is influenced by the social background, the correlation of action and belief, the difference between normative and descriptive approaches to rationality, inter-influence of culture and personal experience in decision making, methods used by anthropologists to reduce «post hoc rationalization». One of Garro’s key ideas is linked with the concept of «divergent rationality» which allows variability in decision making, different ways of applying culturally available schemes by people in case of illness. Linda Garro uses it to support the methodological options provided by medical choice model in case of chronic conditions which were the subject of Garro’s research in a Canadian community. The article also talks about narrativist concept of illness and treatment which, according to Garro, is a logical follow-up of the medical choice topic.
Medical choice is an integral topic for medical anthropology as the latter has discovered and described the phenomenon of medicalpluralismsetting forth the individual treatment choice practices which are classified by anthropologists in different ways. The subject of medical pluralism can be studied from the point of view of critical medical anthropology. As a rule it implies the stories of structural prevalence or even monopoly of a particular medical system, of the medicine for social elites and the medicine for the poor. The emphasis on the individual treatment choice itself is made in cognitivemedical anthropology– an approach that appeared on the wave of «cognitive revolution» of the 1950s. However, as a most prominent follower of the approach, Linda Garro, states, it has not so far obtained clear disciplinary boarders.
Let’s settle on the works of Linda Garro whose books and articles include both empirical studies of medical choice and a profound methodological reflection on its cognition principles.
First of all, we need to consider a collection of works called «The Ethnography of Health Care Decisions» (Social Science & Medicine Volume 16, Issue 16, 1982) where Garro acted as the collector, editor and author. The volume represents a great variety (including geographical variety) of medical and anthropological studies of health care decisions in a number of countries. It dwells into analysis of standards people use to choose alternative health care services. While some authors come up with cultural beliefs as the main factor influencing medical decision-making, others write about social and economic aspects. Linda Garro’s article «Variation in the choice of treatment in two Mexican communities» co-authored with James C. Young is dedicated to the results of their collaborative study of the two neighboring rural communities in Mexico: one of these communities – Pichátaro – had restricted access to sources of biomedical treatment, while the inhabitants of the other – Uricho – had a good access to free services of the Western biomedicine. The auhtors were testing the hypothesis that medical decisions and people’s beliefs were interrelated, and came to the conclusion that there is no direct correlation and the differences in medical care seeking are coming from the differences in the access to medical care without necessarily changing the set beliefs.
The same issue (however in a much larger scope and in a more detailed way) is presented by Garro in her book «Medical Choice in a Mexican Village» (1994). The whole study is dedicated to the people of Pichátaro community. The book systematically introduces and explains such notions as the «study of medical choice», «decision-making approach», «model treatment decision making». The authors describe all the treatment alternatives in Pichátaro in details. One of the principal conclusions contained in the book is that medical decision is determined by how people assess the severity of the acute illness. The people of Pichátaro resort to the Western medicine when the illness is considered life-threatening. Otherwise materialfactorsbecome decisive and people prefer self-treatment or going to folk curers or «practicantes». This allows the authors to identify medical decision making.
Later on, Garro returns to this subject in her large-scale work published in two parts: «On the Rationality of Decision-Making Studies: Part 1: Decision Models of Treatment Choice» and «Part 2: Divergent Rationalities» (Medical Anthropology Quarterly 12(3), 1998). In this work Garro explains the main principles of cognitive medical anthropology, its subject matter and goals. Here she also replies to detailed objections made by cognitive medical anthropology opponents. In particular, they question the individual, free and strong-willed nature of treatment decisions, criticize lack of attention to the political economic context of those decisions as well as the objective social order. The opponents also set forth the idea that the people’s believes do not precede their actions and the factors which are considered important by anthropologists are just post hoc rationalizations. In response to that Garro emphasizes that people act assuming that they do have a choice, they are probably not aware of all the factors but while they see alternatives we can study the decision-making process. Those decisions presuppose emotions as well, so the rational/emotional opposition is irrelevant.
Garro notes that the counter-theses set forth by cognitive medical anthropology opponents are based on normativeapproach to rationality while cognitive medical anthropology is relying on its descriptivemodel. The descriptive decision-making model is a formalizedsimplified idea of the decision strategies applied by people themselves. Garro describes a number of empirical methods of data collection and then testing the models identified at the second stage of the research – these methods reduce the effect of retrospective «post hoc rationalization». Among Garro’s important ideas is that of continuous, ever-changing nature of people’s assessment of a particular illness or treatment outcome. She also concludes that cultural knowledge and personal experience correct each other in the practice of medical decision-making.
The second part of the work tells about another field research carried out by Garro in Anishinaabe community in Canada. This part gives an account of chronic conditionsand a different level of Western medicine accessibility. Analyzing the options of decision-modeling for people with chronic conditions, Garro relies on the concept of «divergent rationality» introduced by R.A. Shweder. This kind of rationality allows decisions’ variability and multiple ways in which people can apply culturally available schemes to particular cases of illness. People are likely to apply different treatment choice strategies at the same time. A number of examples provided by Garro is a perfect illustration of this concept. Garro supposes that medical decision models in communities like Anishinaabeshould be more complicated than those in Pichátaro.
The issue of culture and individual illness experience correlation is examined by Garro in the framework of cognitivist problematics – narrative concept of illness and treatment phenomena. This approach is represented in collection of articles called «Narrative Representations of Illness and Healing» (Social Science & Medicine. Volume 38, Issue 6), composed by Garro together with Cheryl Mattingly. The volume outlines and employs different research perspectives in the analysis of illness and health narratives. One more key publication on the subject is Garro and Mattingly’s collaborative project «Narrative and the Cultural Construction of Illness and Healing» (2000). In her article «Cultural Knowledge as Resource in Illness Narratives: Remembering through Accounts of Illness» Garro raises a question of correlation between something we rememberand something we knowor between things that are knownand things that are remembered. Methodologically Garro is relying on a wide range of distinctions outlined by cognitive psychology. The article has been structured as the compilation of the data obtained during field research carried out in different periods of time, including the research in Anishinaabe. Garro’s narrativist research illustrates and provides evidence for the concept of «divergent rationality».
This concept may be broadened (under condition of extra theoretical efforts) to the treatment choices made by people in modern big cities.
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