lock - 2001 - the tempering of medical anthropology troubling natural categories

7/27/2019 Lock - 2001 - The Tempering of Medical Anthropology Troubling Natural Categories

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MARGARET LOCKDepartment of Social Studies of M edicine and Department of AnthropologyMcGill University

The Tempering of Medical Anthropology:Troubling Natural CategoriesThis article reviews an approach in med ical anthropology that com -menced in the early 1980s and that continues to the present day in whichbiomedical knowledge and practices are systematically incorporated intoanthropological analyses. Discussion then focuses on contributions madeby feminists and medical anthropologists to the literature on medicaliza-tion and resistance, illustrating how the ethnographic approach has beencrucial in critically reconceptualizing and situating these concepts his-torically and cross-culturally. The concept of local biologies is intro-duced in the third section of the article in creating the argument that thecoproduction of biologies and cultures contributes to embodied experi-ence, which, in turn, shapes discourse about the body. Subjective report-ing at menopause provides an illustrative case study of local biolog ies inaction. The final part of the article takes up the question of the moraleconomy of scientific knowledge. Comparative ethnographic work in in -tensive care units in Japan and North America reveals how a moral econ-omy is put into practice in connection with brain-dead bodies and the pro-curement of organs from them. Medical anthropological contributions topolicy making about biomed ical technologies is briefly considered inclosing, [formation of medical anthropology, medicalization, resistance,local biologies, moral economy of science]

When thinking back over the formative years of medical anthropology, it isabundantly clear that from its inception this subdiscipline has beenchronically fractured due in large part to the variety of theoretical andmethodological perspectives taken by its practitioners. These internal rupturescause discomfort and at times heated debate, but they also account for the richnessand diversity so apparent in m edical anthropology and, no doubt, too, for its suc-cess as a vigorous field within anthropology.I have never been overly concerned about either intra- or interdisciplinary turfwars in academia, even though it is well nigh impossible to avoid them. On thecontrary, transcending disciplinary boundaries is one key to the advancement ofknow ledge, in my estimation. Medical anthropologists, given their field of inquiry,M edical Anthropo logy Quarterly 15(4):478-492. Copyright 2001, American Anthropological Association.

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must inevitably be disposed toward communication across disciplines, but this canonly be accom plished successfully if an anthropology of the body, health, illness,and medicine is thoroughly immersed in and informed by cultural anthropology asa whole. Of course, the traffic is two-way, and the parent discipline has much togain by paying attention to its lively offspring.Reciting Genealogies

In writing his review 'The Anthropologies of Illness and Sickness" for theAnnual Review of Anthropology in 1982, Allan Young, in addition to noting theexplosion of medical anthropological articles over the previous decade, set up a ge-nealogy that prior to that time had, in effect, gone unremarked. Not surprisingly, helaid claim to W. H. R. Rivers as a founding father. But he also argued that ethnog-raphers such as Evans-Pritchard, Victor Turner, and Melford Spiro made use ofanalytical frameworks in their research in which episodes of distress and sicknessare conceptualized as vehicles for understanding constellations of associatedknowledge and practices. These include domains of culture not obviously impli-cated in health and sickness. In other words, for these researchers, ethnographies ofillness and distress provide rich material for advancing anthropological under-standing in general.Today this insight is self-evident to many, but in the early 1980s it was, I be-lieve, somewhat of an inspiration for future research and perhaps precluded an un-timely entry of medical anthropology into the doldrums. A great deal of early workin medical anthropology, although clearly important, was limited in scope. Eth-nomedicine was, almost without exception, too narrowly confined to eliciting tax-onomies of disease without considering their application in practice. And analysisof semantic illness networks, while concerned with both conceptual categories andpraxis, tended to be limited to an interpretation of themeanings that individuals at-tribute to illness and how these meanings are informed by culture.It will be recalled that Young argued in the 1982 review essay that a crucialfunction of medical anthropology was not merely to consider the meanings that in-dividuals attribute to sickness but also to lay bare how societal relations producethe forms and distribution of sickness characteristic of any given society. Youngalso insisted, as did Frankenberg (1980), that medical practices are products of ide-ologies and that examination of the unquestioned assumptions embedded in medi-cal know ledge and practice should be incorporated into the terrain of medical an-thropological analyses. Questions about truth claims, power relations, andinequities associated with health, illness, and medicine were brought to the fore inthe same decade that feminist anthropologists w ere raising parallel questions in anoverlapping domain where gender issues were central.TTie 1982 Annual Review contained a second pertinent article, the author ofwhich was Peter W orsley, who argued that "the treating of bodily ills takes place inany culture within a 'metamedicaT framework of thought" (1982:315). This claimfor the existence of an overarching philosophy that guides the basic features ofmedical knowledge, including its organization and practice, provided further in-centive to broaden the horizons of medical anthropology. Worsley argued that in-vestigators should not be seduced into working only in institutions that are obvi-ously part of the "health-care complex," nor should they necessarily start their


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investigations with "named" diseases, given that diseases are cultural construc-tions (1982:327). As Young put it, referring to biomedicine, what is needed is "acritical understanding of how medical facts are predetermined by the processesthrough which they are conventionally produced in clinics and research settings"(1982:277) .

By the time Shirley Lindenbaum and I set about organizing a Wenner Grenconferen ce on m edical anthropology in Casca is, Portugal, in 198 8, w e were able toformulate w ithout too much difficulty com m on key positions taken by the majorityof the participants in their research. A lthou gh several papers continued to make useof a mean ing-centered approach, the epistem ological standpoint of m any can per-haps best be glossed as one in which " biopolitics" are central.

It was striking at Cascais that, when asked to introduce themselves, manypeople insisted that they were anthropologists and not medical anthropologists.Participants affirmed that an anthropological study of health, illness, the humanbody, and medical institutions is no different than comparative research into law,po litics, or econo m ics. N either the human body nor the medical scien ces should beblack-boxed as though epistem olog ically privileged and therefore not available tosocial science investigation. At the conference it became apparent that we wereembarking on a project still very much underway today, namely, a rigorous ques-tioning of w hat are so often assum ed to be "natural" categories of thought and clas-sification. But, clearly, the project was and remains not simply on e of contextualiz-ing the truth claims of science and medicine, but of asking how and why certainrepresentations be com e dominant at specific times and then exposin g the hegem -ony they exert over everyday life and practices associated with health and illness.Th e n ow exten sive literature on the concep t of risk and how it is played out in eve-ryday life is just one exam ple o f this (Brow ner and Press 1996; Crawford 1984;Kaufert 1998; Lock 1998).

It was also evident at the Cascais conference that we had graduated beyondthe common mistake of conceptualizing biomedicine as a monolith. Even moreimportant, perhaps, was that participants had overcome another earlier tendencycommon in medical anthropology, namely, to romanticize and essentialize themed ical institutions and practices of non-W estern societies.Lindebaum and I argued in the book published after the conference that be-cause investigations of human affliction, suffering, and distress are so often inte-gral to the work of medical anthropologists, we are forced with some urgency toconfront the all too familiar dich otom ies o f theory and practice, thought and action,objectivity and subjectivity, and nature and culture (Lindenbaum and Lock 1993).High lighting the ubiquity o f these dicho tom ies is crucial, but beyond that, follow -ing Young, recognition that all medical knowledge and practice is historically andculturally constructed and embedded in political e cono m ies , and further, subject tocontinual transformation both locally and globally is essential.

Today this urgency is magnified as medical anthropologists are increasinglycalled to participate on review boards and ethics committees and to assist with theproduction of gu idelines for issues ranging from em bryo research to genetic eng i-neering and environmental health. In my opinion, this is one of the most difficulttasks ahead o f u s figuring out just what is special and indispensable about an an-thropological contribution to po licy m aking, particularly in connec tion with m edi-cal research. Obviously, simply enjoining sensitivity about cultural pluralism is


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nowhere near adequate to this task. I will return to this point in the conclusion afterreviewing three areas of research that, in my opinion, are important to the furtherdevelopment of the field.There are, of course, many fruitful avenues of past and current research thatcould be highlighted in m edical anthropology; I elaborate on these particular areasbecause, to a greater or lesser extent, my own research intersects with them. Thesetopics, as do others, signal the maturation of medical anthropology as a subdisci-pline that today is contributing substantially not only to theory building in the par-ent discipline but in cross-disciplinary research.

Situating M edicalization an d Resistance 'Medical anthropologists, particularly when studying gender issues, havedrawn consistently on theories initially set out in sociology or political theory,where use is made of the now familiar concep ts of ideology, hegem ony, medicali-zation, and resistance, among o thers. During the 1970s and 1980s, medicalization(a concept first formulated by Irving Zola) was usually used to convey the idea of aunilateral imposition of power over the bodies of unsuspecting target groups, mostoften patients (Conrad 1992; Zola 1972). In the early feminist literature it was fre-quently assumed that enlightened individuals should resist medicalization and that

one function of the social sciences was to raise consciousness about the inappropri-ateness of, for example, a medicalized childbirth or menopause (MacPherson1981; Rothman 1989).Together with historians and sociologists (Conrad 1975; Laqueur 1990), an-thropologists have tracked the creation of diseases and disease-like states (Cohen1998; Lock 1993; Martin 1987; Young 1995). These studies have shown repeat-edly how, with medicalization, attention is deflected away from the social arrange-ments and political forces that contribute to the incidence of distress and disease

and to the experience of life cycle transitions. Subjectivity and symptom reportingare subsumed into medical pathologies and standard deviations from medicalnorms, and the focus of attention is on the bodies of individuals, who are essen-tially m ade responsible for their own condition.Ethnographic research has shown, however, that the responses of individuals,families, and communities to medicalization are complex and perhaps best de-scribed as pragmatic. Individuals are not inevitably made into victims of medicalascendancy (although this clearly happens at times) but act most often on what isperceived by them to be in their own best interests. Contributors to two books con-cerned primarily with gender and reproduction edited by Ginsburg and Rapp(1995) and Lock and Kaufert (1998) show that women are by no means alwayspassive vessels with respect to medicalization, laboring under the constraints ofhegemonic, undisputed cultural norms. This is not necessarily the case even whenthe lives of individuals are severely constrained by structural violence and there islittle scope for individual agency. Nor are women inherently suspicious of newtechnolog ies; on the contrary, technology is very often embraced as enabling, par-ticularly in connection with infertility (Becker 2000; Kielmann 1998) and in bring-ing about reproduction in lesbian households (Lewin 1998).

Findings such as these suggest that the concepts of medicalization, resistance,autonomy, and agency need refinement. For example, when women actively seek


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out and make use of biomedical technologies, this may not be evidence of inde-pendent agency on their part, although often it is or is claimed to be the case (Lopez1998). Biomedical technologies can assist women in achieving a modicum of inde-pendence from oppressive circumstances, or they may permit them to fulfill per-sonal desires, often to have a child. However, w om en's behavior can equally wellbe due to a desire to "please" others (certain feminist anthropologists may be sorelytempted to label this as false consciousness) or, alternatively, to untoward pressureexerted by others. It is clear that women frequently respond to the expectations ofpartners, extended families, women's groups, or communities rather than singlc-mindedly pursuing what might bring about their own personal desire or comfort(Abel and Browner 1998; Handwerker 1998; Lock 1998; Pearce 1995). At times,too, women are actively coerced into being recipients of medical interventions.In these circumstances, physicians, the usual scapegoats singled out by an-thropologists as aggressive medicalizers, may try to protect patients from abusivefamilies and probable iatrogenesis. For example, I have come across physicianswho refuse to test patients for the gene recently associated with an increased riskfor late-onset Alzheimer's disease, even though certain families are now demand-ing that the test be done. Because no treatment is available and there are no recom-mended suggestions for behavioral changes, these physicians argue that medicali-zation is inappropriate and resist the pressure placed on them by families (SergeGautier, personal communication 2000). On the other hand, public demand frominterest groups for increased surveillance and medicalization is sometimes suc-cessful, as has been the case w ith AIDS and breast cancer activists (Kaufert 1998).The complexity of responses to medical technologies and medicalization cannot beteased out without an approach that is sensitive to the situated exigencies of theeveryday worlds of informants and their relationships within families, communi-ties, and local political groupings.

Documenting the pragmatism of individuals is not to argue that the micro-physics of power, dominant ideologies, culturally constructed orthodoxies, and he-gemonies are not at work. Numerous informants, wherever their location, exhibitpragmatism, cynicism, or ambivalence about medical interventions, at least someof the time. But unquestioned participation in medical and other bodily practices isalso visible everywhere.Individual desire is frequently informedsometimes over-determinedbythe mystification associated with political regimes, religious organizations, or cul-tural aesthetics. Perhaps the most pervasive example of this is that, worldwide,governm ents of all kinds are deeply involved in the politics of contraception, abor-tion, population management, and birth. Sometimes women and their partners re-sist the normative order with respect to these interventions; at other times theycomply because they have no choice (Anagnost 1995; Barroso and Correa 1995;Kligman 1995). In other circumstances the majority of women apparently thinkthat medicalization coincides with their own best interest. Browner and Press(1996) have shown how , until relatively recently, American women valued subjec-tive knowledge over biomedical recommendations during prenatal care although,in contrast, technological intervention was welcomed during labor. Over the pastseveral years this situation has changed, and as the state of California (in commonwith other locations) has become increasingly involved in the promotion of prenatalgenetic screening, many women now think of these tests as indispensable to the


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high-quality prenatal care they desire (Browner and Press 1995). On the otherhand, the Inuit strongly resist medicalization when they give birth, in large part be-cause this has usually involved routine "evacuation" from the Arctic to urban terti-ary care hospitals in the Canadian south (O 'Ne il and Kaufert 1995).Reconstructions of narrative accounts by informants provide invaluable andoften moving insigh ts. They also reveal the complexity and range of responses ofindividuals, but they rarely capture the full range of political interest at work withmedicalization and the normalization of health, illness, and reproduction. For onething, individuals do not usually have knowledge about the history of technologiesand their selective adoption by the public over time. Nor are individuals usuallyaware of how the application of technologies tends to change as professionalknowledge and interests change . But people are increasingly able to reflect criti-cally on their own situation and that of those around them, as their narratives makeabundantly clear. Paradoxically, medicalization has actually promoted such reflec-tion by presenting peop le with choice, although globalization rather than medicali-zation per se has no doubt been the major driving force for change. The result isthat older hegem onies have crumbled, only to give way to new ones, most often inthe form of know ledge that comes under the rubric of science. Some forms of careand treatment modalities associated with these new hegemonies are highly effec-tive, others are not. What is most noticeable is that new forms of subjectivity areemerging globally as, increasingly, people everywhere adopt the concept of riskand become familiar with the disease nosologies of biomedicine. At the same time ,pluralism and cross-fertilization among medical knowledge and practice flourish.Multisited ethnographic research forces some reflection about the hegemo-nies that social scientists are in danger of perpetuating, particularly when grandtheory is crudely put into practice. One contribution of medical anthropology is tomonitor concepts and categories frequently used in the social, medical, andepidemiological sciences, bioethics, and feminist theory. W e cannot function with-out concepts and taxonomies, but when applied as though universally objective,they enable the proliferation of scientific truth claims that often fit poorly withlived experience. Such claims can best be challenged and modified or even de-posed using the ethnographic method, in which professional, political, advocacy,and popular knowledge and practices are all subjected to interrogation.Local Biologies

Medical anthropology has long been thought of as a specialty that can poten-tially transcend the nature/culture divide embedded in m odernist thinking. My owneffort in this direction was to create yet another concept, that of "local biologies"(Lock 1993). This concept does not refer to the idea that the categories of the bio-logical sciences are historically and culturally constructed (although this is indeedthe case) nor to measurable biological difference across human populations.Rather, local biologies refers to the way in which the embodied experience ofphysical sensations, including those of w ell-being, health, illness, and so on, is inpart informed by the material body, itself contingent on evolutionary, environ-mental, and individual variables. Embodiment is also constituted by the way inwhich self and others represent the body, drawing on local categories of knowledgeand experience. If embodiment is to be made social, then history, politics, language,


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and local knowledge, including scientific knowledge to the extent that it is avail-able, m ust inevitably be implicated. Th is means in practice that, inevitably, kn ow l-edge about biology is informed by the social, and the social is in turn informed bythe reality of the material. In other words, the biological and the social are copro-duced and dialectically reproduced, and the primary site where this engagementtakes place is the subjectively experienced, socialized body. The material bodycann ot stand, as has so often been the case, a s an entity that is black-boxed and as-sum ed to be universal, with so much sociocultural flotsam layered over it. The ma-terial and the social are both contingentboth local.

Th e embod iment o f the coproduction of local bio log ies and culture is, by defi-nition, internalized and individualized. Humans are unique in terms of both theirgenetics and their lived experience, and, to this extent, embodiment is personal.Paradoxically, most embodied experiences are shared by us allpain, immuno-logica l responses to infection, the biological ch anges of aging , hormone secretions(although these last tw o are inevitably m odified by se x), and so on. But even thesemost basic of biological events are contingent, as numerous studies have shown(see, for example, Good et al. 1992; Lock et al. in press; Worthman 1995). Thiscon tingen cy is due to individual b iology and, of course, to language and the social,environmental, and political contexts in which individuals live. Nevertheless,some types of embodied experience are relatively common across groups of peo-ple, due in part to shared environm ents, histories, language, beh aviors, and values.Other contributing factors are biolog ical attributes com m on to a proportion of indi-viduals w ho liv e in clo se proximity to one another and wh o have a reasonably closeshared biological ancestry.

Continuous migration from prehistoric times, accelerated today with globali-zation, ensures that people who share biological attributes are widely dispersed.Even so , until late in the last century, the majority o f peop le other than those livingcl ose to major historical trade routes tended to l ive out their live s within a short dis-tance of their birth place. Biological attributes are used by population geneticistsand others to ascribe people to populations that are not, of course, congruent withself-defined ethnic groups or com m un ities. But the very fact that scientists are in-terested in docum enting features of inclusion and exc lusion based on biological at-tributesformerly, through anatomical taxo nom ies, blood typing, and so on, andnow by means of DNA samplinghas made it relatively easy for prejudiced com-mentators to decon textualize the alw ays provisional typ ologies of population biol-ogy and conflate them with social groupings to produce and naturalize a racistrhetoric. Certain population geneticists and biological anthropologists have actu-ally encouraged this type of conflation (sometimes inadvertently), as the ongoingcriticism by anthropologists of the Human Genome Diversity Project makes clear(Harry and Marks 199 9; Jackson 1999 ; Lock 199 9).

Under the circum stances it is not surprising that recognition of b iologica l dif-ference, and therefore of local biologies, has been anathema to many social scien-tists, but, given the speed with wh ich the new gen etics is revealing the com plexityof bio logica l difference, to dogge dly ignore these findings would be singularly un-wise. Apart from anything else, the outrageous claims made by a few geneticistswho appear with disproportionate frequency in the media to talk about the way inwh ich the new gen etics will bring about the good life for us all need urgently to becountered (Lock in press c) .


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It go es without saying that there is no simp le relationship between local b iolo -gies and societies, nation states, ethnicity, communities, or even families. Never-theless, em bod ied subjectivity is shaped to some extent by the contingency of localbiologies that can be partially shared across groups of people. These biological at-tributes may contribute to the creation of powerfiil, even hegemonic, discourse inconnection with health, distress, illness, and life cy cle transitions. When I con sid-ered comparative research findings from Japan and North America in connectionwith menopause, such discourse appeared to be at work, and I felt compelled tocreate a concept of local biologies in order to interpret the data (Lock 1993). Bydrawing on such a concept, m y hope was to prevent the Japanese findings from beingtreated as so much exo tica and at the same time to challenge the dominant d isease-like medical mod el of the end of m enstruation.It is recognized by m any govern ments that as the proportion o f older peop le inthe population increases, research into the possib le effects of the end of menstrua-tion on the health of women as they age is of importance. Aging and its potentialcost to health care system s are of enorm ous po litical interest. Medical kno w ledgeabout menopause has been created in large part out of the symptom reporting andexperiences of small samples of women in clinical situations, almost all of themliving in Europe or North America. Most of these women have gone to visit doc-tors because of their physical and emotional distress. In addition, many of them

have had hysterectomies. These patients are not representative, and until very re-cently, virtually no research had been don e in conn ection with the subjective ex pe -riences of m iddle-aged w om en as a w ho le as they go through this life cy cle transi-tion. A great deal of medical knowledge about menopause is produced andcirculated, therefore, without reference to the lived experience of the majority ofwom en and, as such, is biased, in particular with respect to the frequency and typeof symptom s reported (Lock 199 3).Despite these shortcomings, the professional organizations of gynecologistsin the United States, Canada, Australia, most European countries, and elsewherehave made blanket recommendations that virtually all women once past meno-pause should take powerful horm one replacement therapy (HR T) until the day theydie. These recommendations, which in effect make the body of a 30-year-old thenorm for all women, are designed to counter what are believed to be the long-termconsequences of "estrogen-starved bodies/' including an increased risk for heartdisease, osteoporosis, and Alzheimer's disease. But these recommendations rideroughshod over the considerable variation in incidence of these diseases acrosspopulations and socioeconomic groupings of women and also over the iatrogeniceffects that many wo m en exp erience when taking the medication. They a lso ignorethe fact that the epidemiological studies on which the recommendations are basedare hotly contested in terms of both methodology and significance of findings.There is by no m eans a consen sus that HR T w ill reduce the risk of heart disease orAlzheimer's, and there is considerable concern that its long-term use will increasethe risk of breast and ovarian cancer. Som e experts are belatedly sug gesting m odi-fications to this regime (Santoro et al. 1999). Aside from anything else, because"compliance" of women is so low (approximately 15 percent of all involvedwo m en in North Am erica), it is clear that something is amiss.

In order to counter received medical wisdom on this subject, survey researchwa s carried out in the m id-1 98 0s with over 1,300 wom en in Canada, nearly 8,000


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in the United States, and over 1,300 in Japan, aged 45 to 55 inclusively, all drawnfrom the general population. This research indicates strongly that the menopausaltransition is not a difficult time for the majority (A vis and M cK inlay 19 91 ; Kaufertet al. 1992; Lock 1993). Of more significance for the present argument is that, inJapan, women going through konenki (the term usually glossed as menopause) re-port very few of the "classical" sym ptom s of m enopau se, nam ely, hot flashes andnight swea ts. Through exte nsive open-ended interviews with over 100 wom en andother confirmatory exercise s, I con cluded that this difference has little to do w ith alack of willin gn ess to coopera te w ith the researcher. Nor is it to do with shyn ess onthe part of wo m en about reporting sym ptom s (as is often assum ed to be the case bymedical audiences). The fact that no clear and unambiguous signifier exists inJapan ese that refers ex clu sive ly to hot flashes in female midd le age does not appearto be a major stumbling block either (but see Zeserson 2 00 1). T ho se relatively fewwomen in the study (12.5 percent) who had experienced hot flashes talked aboutthem unambiguously, suggesting that the difference between Japan and NorthAm erica is quantitative, not qualitative, but nevertheless statistically significant.

Japanese doctors deal every day with middle-aged patients who se symptomsand experiences differ quite markedly from those that medical texts written inEurope or North America tell them are "normal" for menopause (Lock 1993).W hen I carried out this research, virtually no Japanese d octors listed the hot flashas a "typical" symptom. After exposure to conferences and reading the proceed-ings of International Menopause Society meetings and other sources, a few ofthese doctors have come to believe that the problem lies with Japanese womenthem selve s, w ho simply do not pay "proper" attention to their bod ies. The majorityprefer to hypothesize that a biological difference sufficiently markeddue per-haps to environment, diet, or gen eticsr esults in a subjective exp erience at the endof menstruation for many Japanese women that is different from that commonlyexperienced by w om en in North Am erica. On the basis of m y research findings, Iam in agreement with these physicians and conclude that these embodied experi-ences produce an effect on (but do not determine) the production of medical andpopular discourse in Japan.

Japanese acco unts about the end o f m enstruation sound bizarre to most NorthAmericans and Europeans because emphasis is usually given to stiff shoulders,dizziness, and other nonspecific symptoms. It is tempting to Orientalize this dis-course and dismiss it as anomalous. The danger, of course, is that the white Euro-American body remains the gold standard and the medical model of a universalmenopause survives intact. Research conducted in Hong Kong, Singapore, Tai-wan, China, Korea, the Philippines, Thailand, Malaysia, and Indonesia reveals lowreporting of hot flashes and night sweats (see Lock and Kaufert 2001 for details).Some of this research is m ethod ologica lly weak, but the relative consistency of theresults is nevertheless suggestive. In a comprehensive study in the Yucatan,Be yen e (1 98 9) found no reporting of these symptom s.

In all, these data strongly sug gest that it is not appropriate to conceptualize theend of menstruation as an invariant biological transformation modified by culturealone. Sim ilarly, it should not be assumed that postmenopausal w om en are equallyat increased risk for heart dis ea se, o steo po rosis, and other Jate-onset chronic dis-eases. The coprod uction of biolo gy and culture are implicated in emb odied experi-ence and its expression, and this effect has a tendency to be manifested in similar


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ways in individuals where culture and shared biological attributes are fairly con-gruent.In sum , differences in local bio logie s partly accoun t for but do not determine

the cultural construction of menopause and, where relevant, its medicalization.There is no doubt that biological and genetic determinisms must be rejected out-right. But it is also necessary to reject those equally deterministic argum ents for thesocial and cultural construction of the body and related medical practices in whichthe material body is black-boxed. Truth claims about the body demand contextu-alization and critical appraisal, but to ignore the reality of biology entirely and itsinterdependence with history and culture is shortsighted in the extreme. Some re-newed bridge-building with certain biologicakanthropo logists seem s to be in orderif w e are to m ov e forward.The Moral Economy of Scienti f ic Knowledge

A further area of research where medical anthropologists have a great deal tocontribute intersects primarily with the interests of historians and sociologists ofscience. Lorraine D aston, a historian of science, argues for recognition of a moraleconomy of scientific knowledge and practices.1 B y moral economy, she does notmean that ideologies and political self-interest inevitably penetrate the scientificendeavor (although frequently they clearly do). Nor is she arguing that scientificknow ledge is socially constructed. Daston su ggests that even though moral econ o-mies in science "draw routinely and liberally upon the values and affects of ambi-ent culture, the rewording that results usually be com es the peculiar property of sci-entists" (19 95 :7). Daston is writing about "truth" claim s made in con nection withobjectivity, m easurem ent, replication, and so on, and also about the probability sci-ences and the making up of populations of people designated at risk (see also,Hacking 19 86 ,199 2) . By moral economy, Daston m eans "a w eb of affect-saturatedvalues that stand and function in a well-defined relationship to one another"(1995:4).

For some time now a good number of medical anthropologists have beencomfortable writing about "cultures of b iome dicine" or som ething approximatingto this. Empirical evidence suggests that biomedical knowledge and practiceshows significant variation in different geographical locations, and, moreover, dif-ferent emphases and competing arguments among subdisciplines of biomedicineare well recog nized. On e w ay to account for these differences is to argue that bio-medicine is shaped by values; that medicine is not the epistemologically free en-deavor that it claims to be. The "tribe" of moderns, writes Latour, similar to pre-moderns, "projects its ow n social categ ories onto Nature" (19 93 :47 ). Bu t in settingthings up this wa y, Latour m akes use o f a dualistic opposition b etween modern and"premodern" between the W est and the Rest.

Daston's resort to moral economies is insightful because such economies arebuilt into the scientific endea vor wherever it is located. Ev erywh ere scientists re-sort to them, whether they live in Papua New Guinea, Moscow, or Argentina. Forexa m ple, Japan ese, Ame rican, and Canadian neu rologists undertake essentially thesame tests and measurements, use the same logical arguments, and draw the sameinferences to make a diagnosis of irreversible loss of consciousness in patients(known familiarly as brain death) (Lock 2002). The same moral economy of


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objectivity with respect to this diagnosis (even though it is disputed within themedical w orld to som e extent) is at work here.Culturally informed values come into play one step later, when a large

number of Japanese neurologists express reluctance to declare unilaterally that abrain-dead patient is no longer alive and has no individual rights or interest. Brain-dead patients whose ventilated bodies are measurably alive cannot be counted asdead in the estimation of both these neurologists and a large portion of the Japanesepub lic. Only ten procurements o f organs from brain-dead donors have taken placein Japan since brain death was legally recognized less than four years ago .American and Canadian intensivists for their part, with some exceptions,think o f brain-dead patients as no longer alive even though the body lying in front

of them con tinues to breathe, is warm, m etabo lizes nutrients, excretes, and exhibitsother signs of "life." If an individual is diagnosed with an irreversible loss of con-sciousness, then that "person" is no longer alive, no matter how lively their body.Such entities have no interests, are cadaver-like, and can be counted as good-as-dead, and, w ith prior permission, organs can be procured from them. Of course, notall involved families feel the same way, and a good number of intensivists struggleat times to justify their logic to them selves (Lock 20 02 ).Recognition of moral economies permits us to pose radical questions about

scientific kn ow led ge , its production and application, and its methods of relegatingother methodologies, including ethnography, to the sidelines. Ethnography makesit possible to examine the way in which scientific knowledge is selectively de-ployed in different global contexts by drawing on morals and value systems thatare historically, politically, and culturally informed. That we moderns have neverbeen mod ern, as Latour argues, is important to recognize. But m edical anthropolo-gists bring another insight to the table: that people everywh ere are increasingly, forbetter or worse, partially modern.Another o f Latour's (1 99 3) insights about the current proliferation of hybridsis extremely important for medical anthropological research, in my opinion, as isthe related concept of cyb orgs proposed by H araway (1 99 1) . By researching boun-dary objects, hybrids of nature and culture, and technohuman complexes, insightsabout the scientific "work" that is needed to sustain beliefs in neutrality, objectivity,and progress beco m e most apparent. Here m edical anthropo logists join forces withhistorians and sociologists o f science to tackle som e of the most pressing questions ofour day involving moral conundrums requiring debate (see, for example, Brodwin

2000; Ho gle 1999; Latour 1999; Lock et al. 200 0; Timmermans 1999).In closin g, I return very briefly to medical anthropology in action and to ourrole with respect to po licy making, ethics comm ittees, and so on. For several yearsnow, anthropology has been go ing through the culture wars, with opponen ts argu-ing for and against the worth of culture as a concept. I find culture (used reflexivelyand in conjunction with a political/economy framework) a necessary concept formost research projects, especially when culture is explicitly made to do work bythe particular peop le or institutions that one is studying .When it comes to interdisciplinary committee work, I am more circumspectabout its use . An argument that draws on differing valu es is les s likely to be inap-propriately essentialized than is the culture concept and is-of more assistance inopening up discussion about comparative epistemologies and unexamined assump-tions in the world o f science and policy making. My experience with a government


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committee brought together to create guidelines for human embryo research, forexample, has been that the task of the anthropologist is above all to question thelanguage and orthodoxies of bioethicsof dignity, autonomy, "informed" con-sent, and so on. This language, grounded in individual rights and designed to pro-tect patients and "health consum ers" from exploitation, paints comm ittee mem bersmore often than not into a tight corner. Because attention is bound up with ques-tions of virtue, it be com es we ll-nigh imp ossible to consider the politics and moraleconomies so deeply implicated in the new biomedical technologies as they areloosed on society with ever-increasing rapidity. Very often, too, questions of thepoverty of individuals, communities, and of some governments, that is, of equityand unequal acc ess to health techn ologies of aH kinds, are ignored. If social scien-tists do not raise these issu es, then they w ill likely not be considered by m any com -mittees, even though they have been called together specifically to predict the soc ialimpact of various of the new biomedical technologies. Medical anthropologistshave much to keep them oc cupied.

N O T ECorrespondence may be addressed to the author at Department of Social Studies of

Medicine, McGill University, Montreal, Quebec, Canada.1. Daston' s use of moral economy is not indebted, she insists, to its original use by E. PThompson (1991). I would argue that some useful connections can be made between thesedifferent uses of the concept, but space does not permit elaboration (but see Lock in press b ).

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Acceptedfor publication March 29, 2001.

lock - 2001 - the tempering of medical anthropology troubling natural categories

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