The Existential Medicine Network offers a forum and expanding range of resources for all those devoted to challenging the biomedical model of illness from an existential, phenomenological, hermeneutic, anthropological, logotherapeutic, socio-economic, institutional, psychoanalytic, relational and spiritual perspective.

Its aim is also to challenge the universally institutionalised and yet almost wholly unquestioned and un-phenomenological separation between training and practice in ‘psychotherapy’ on the one hand (including existential psychotherapy) and medical training and practice on the other.

It will do so through sharing and contributing to the current evolution of new forms of existential-phenomenological and meaning-based therapy that are relevant to healthcare in all its dimensions – in particular to medical practice and the meaning to be found in the phenomenon of ‘illness’.

Contributions welcome in the form of comments, articles, further links, additions to our bibliography of literature - and case studies in the practice of psychological therapy for chronic or serious illness. To contribute, post a comment or write to peter_wilberg@tiscali.co.uk

'SCIENCE, SALVATION AND BELIEF'



Science, salvation and belief: an anthropological response to fundamentalist epistemologies

From Science, Rationality and Experience by Bryon J. Good  Cambridge University Press 1994


I begin with "an anthropological response to fundamentalist epistemologies"  because of my intuition that there is - quite ironically - a close relationship  between science, including medicine. and religious fundamentalism, a relation­ship that turns, in part, on our concept "belief." For fundamentalist Christians, salvation is often seen to follow from belief, and mission work is conceived as an effort to convince the natives to give up false beliefs and take on a set of beliefs that will produce a new life and ultimate salvation. Ironically, quite a-religious scientists and policy makers see a similar benefit from correct belief. Educate the public about the hazards of drug use, our current Enlightenment theory goes, heralded from the White House and the office of the drug czar, get them to believe the right thing and the problem will be licked. Educate the patient, medical journals advise clinicians, and solve the problems of noncompliance that plague the treatment of chronic disease. Investigate public beliefs about vaccinations or risky health behaviors using the Health Belief Model, a generation of health psychologists has told us, get people to believe the right thing and our public health problems will be solved. Salvation from drugs and from preventable illness will follow from correct belief. 

Wilfred Cantwell Smith, a comparative historian of religion and theologian, argues that the fundamentalist conception of belief is a recent Christian heresy (Smith 1977, 1979). I want to explore the hypothesis that anthropology has shared this heresy with religious fundamentalists, that "belief" has a distinctive cultural history within anthropology and that the conceptualization of culture as "belief" is far from a trivial matter.
A quick review of the history of medical anthropology will convince the reader that "belief" has played a particularly important analytic role in this subdiscipline, as it has in the medical behavioral sciences and in public health (see chapter 2 for more details). Why is there this deep attachment to analyzing others' under­standings of illness and its treatment as medical "beliefs" and practices, and why is there such urgency expressed about correcting beliefs when mistaken? To begin to address this issue, I first describe in a bit more detail the general theoretical paradigm that frames what I have referred to as the "empiricist theory of medical knowledge." I will indicate its relationship to the intellectualist tradition in anthro­pology and to debates about rationality and relativism, showing how the language of belief functions within the rationalist tradition. 

The language of clinical medicine is a highly technical language of the bio sciences, grounded in a natural science view of the relation between language, biology, and experience (B. Good and M. Good 1981). As George Engel (1977) and a host of medical reformers have shown, the "medical model" typically employed in clinical practice and research assumes that diseases are universal biological or psychophysiological entities resulting from somatic lesions or dysfunctions. These produce "signs" or physiological abnormalities that can be measured by clinical and laboratory procedures, as well as "symptoms" or expressions of the experience of distress, communicated as an ordered set of complaints. 

The primary tasks of clinical medicine are thus diagnosis - that is, the interpretation of the patient's symptoms by relating them to their functional and structural sources in the body and to underlying disease entities - and rational treatment aimed at intervention in the disease mechanisms. All subspecialties of clinical medicine thus share a distinctive medical "hermeneutic," an implicit understanding of medical interpretation. While patients' symptoms may be coded in cultural language, the primary interpretive task of the clinician is to decode patients' symbolic expressions in terms of their underlying somatic referents.Disordered experience, communicated in the language of culture, is interpreted in light of disordered physiology and yields medical diagnoses. 

One central goal of the pages that follow is to develop an alternative way of thinking about medicine and medical knowledge, a theoretical frame that challenges this common-sense view while still accounting for our conviction that medical knowledge is progressing, and one that serves us better as a basis for cross-cultural comparisons. To do so, it is important to recognize the epistemo­logical assumptions of this common-sense view, and to appreciate its power. The empiricist theory of medical language is grounded in what philosopher Charles Taylor calls "the polemical, no-nonsense nominalism" of Enlightenment theories of language and meaning? For seventeenth-century philosophers such as Hobbes and Locke, the development of a language for science required a demystification of language itself, showing it to be a pliant instrument of rationality and thought, as well as the emergence of a disenchanted view of the natural world. The development of such a natural philosophy and the attendant theory of language required the separation of "the order of words" from "the order of things”, in Foucault's terms (1970), the freeing of the order of language and symbols from a world of hierarchical planes of being and correspondences present in Renaissance cosmology. What we must seek, Francis Bacon argued, is not to identify ideas or meanings in the universe, but "to build an adequate represen­tation of things" (Taylor 1985a: 249). Thus, theories of language became the battle ground between the religious orthodoxy, who conceived "nature" as reflecting God's creative presence and language as a source of divine revelation, and those who viewed the world as natural and language as conventional and instrumental.

What emerged was a conception of language in which representation and designation are exceedingly important attributes. Such a position was bound to a view of knowledge as the holding of a correct representation of some aspect of the world, and an understanding of the knowing subject as an individual who holds an accurate representation of the natural world, derived from sense experience and represented in thought. Meaning, in this paradigm, is constituted through the referential linking of elements in language and those in the natural world, and the meaningfulness of a proposition - including, for example, a patient's complaint or a doctor's diagnosis - is almost solely dependent upon "how the world is, as a matter of empirical fact, constituted" (Harrison 1972: 33). Although this view has been widely criticized by now, it continues to have broad influence in philosophy, psychology (in particular cognitive psychology and artificial intelligence research), in the natural sciences, and in Western folk psychology. It is associated with an understanding of agency as instrumental action, and with utilitarian theories of society, social relations, and culture as precipitates of individual, goal­-directed action (Sahlins 1976a).

This broad perspective has the status of a kind of "folk epistemology" for medical practice in hospitals and clinics of contemporary biomedicine. A person's complaint is meaningful if it reflects a physiological condition; if no such empirical referent can be found, the very meaningfulness of the complaint is called into question. Such complaints (for example of chronic pain) are often held to reflect patients' beliefs or psychological states, that is subjective opinions and experiences which may have no grounds in disordered physiology and thus in objective reality. "Real pathology," on the other hand, reflects disordered physiology.
Contemporary technical medicine provides objective knowledge of such pathology, represented as a straight-forward and transparent reflection of the natural order revealed through the dense semiotic system of physical findings, laboratory results, and the visual products of contemporary imaging techniques. And "rational behavior" is that which is oriented in relation to such objective knowledge. 

By far the richest discussion of the history of the concept belief is to be found in the writing of Wilfred Cantwell Smith, the historian of religion, whose lectures when I was a graduate student set me to thinking about these matters. In two books completed during the late 1970s, Smith explores the relation between "belief" and "faith" historically and across religious traditions. He sets out not to compare beliefs among religions, but to examine the place of belief itself in Buddhist, Hindu, Islamic, and Christian history. Through careful historical and linguistic analysis, he comes to the startling conclusion that "the idea that believing is religiously important turns out to be a modem idea," and that the meaning of the English words "to believe" and "belief" have changed so dramatically in the past three centuries that they wreak profound havoc in our ability to understand our own historical tradition and the religious faith of others. 

The word "belief" has a long history in the English language; over the course it has so changed that its earlier meanings are only dimly felt today (Smith 1977: 41-46; 1979: 105-127). In Old English, the words which evolved into modern ‘believe’ (geleofan, gelefan, geliefan) meant ‘to belove’, ‘to hold dear’, ‘to cherish’, ‘to regard as lief’.  They were the equivalent of what the German word belieben means today (mein Lieber Freund is "my dear or cherished friend"), and show the same root as the Latin libet, ‘it pleases', or libido, 'pleasure'. This meaning survives in the Modem English archaism "lief" and the past participle "beloved." In medieval texts, 'leve', 'love', and 'beleue' are virtual equivalents. In Chaucer's Canterbury Tales, the words "accept my 'bileve' mean simply "accept my loyalty; receive me as one who submits himself to you.” Thus Smith argues that "belief in God” originally means "a loyal pledging of oneself to God, a decision and commitment to live one's life in His service" (1977: 42). Its counterpart in the medieval language of the Church was "I renounce the Devil," belief and renunciation being parallel and contrasting actions, rather than states of mind. 

Smith (1977: 44) sums up his argument about the change of the religious meaning of "belief" in our history as follows: The affirmation "I believe in God" used to mean: "Given the reality of God as a fact of the universe, I hereby pledge to Him my heart and soul. I committedly opt to live in loyalty to Him. I offer my life to be judged by Him trusting His mercy." Today the statement may be taken by some as meaning: "Given the uncertainty as to whether there be a God or not, as a fact of modern life, I announce that my opinion is 'yes'. I judge God to be existent." 

Smith argues that this change in the language of belief can be traced in the grammar and semantics of English literature and philosophy, as well as popular usage. Three changes - in the object of the verb, the subject of the verb, and the relation of belief and knowledge - serve as indicators of the changing semantics of the verb "to believe." First, Smith finds that grammatically, the object of the verb "to believe" shifted from a person (whom one trusted or had faith in), to a person and his word (his virtue accruing to the trustworthiness of his word), to a proposition. This latter shift began to occur by the end of the seventeenth century, with Locke, for example, who characterized "belief" along with "assent" and "opinion" as "the admitting or receiving any proposition for true, upon arguments or proofs that are found to persuade us ... without certain knowledge ... " (Smith 1977: 48), and was firmly represented by the mid-­nineteenth century in John Stuart Mill's philosophy. 

Several aspects of the empiricist paradigm relevant to comparative medical studies have become especially problematic, pushing our field in new directions. First, positivist approaches to epistemology and the empiricist theory of language have come under sustained criticism in philosophy, the history and sociology of science, and anthropology. Whichever authors one invokes - Thomas Kuhn, Michel Foucault, Paul Feyerabend, Hilary Putnam, Richard Rorty, or a generation that grew up with these figures - older theories of the relationship between language and empirical reality now seem dated. Rationality and relativism no longer neatly divide the field. Increasingly, social scientists and philosophers have joined in investigating how language activities and social practices actively contribute to the construction of scientific knowledge.

Claims that biomedicine provides straightforward, objective depictions of the natural order, an empirical order of biological universals, external to culture, no longer seem tenable and must be submitted to critical analysis. And for this, the empiricist theory of medical language with its focus on representation will not do; it must give way to alternatives. The role of science as arbiter between knowledge and belief is thus placed into question.

Anthropology's greatest contribution to twentieth-century sociology of knowl­edge has been the insistence that human knowledge is culturally shaped and constituted in relation to distinctive forms of life and social organization. In medical anthropology, this historicist vision runs headlong into the powerful realist claims of modem biology. Enlightenment convictions about the advance of medical knowledge run deep, and although faith in medical institutions has given way to some extent, medicine is a domain in which "a salvational view of science" (Geertz 1988: 146) still has great force. No wonder that discussions of "the problem of irrational beliefs" so often cite medical examples.








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