Power, Closure and Medical Collaboration

Will Morris

Culture, Gender and Power Structures in Change

The storm brewing in the training of professionals happens because they are not prepared to accommodate the emerging needs of the cultures in which they operate. The power dynamics are shifting as evidenced in the conflict between men and women in the medical system. Further, patients are demanding more than skilled knowledge about medicine. They want interpersonal skills (Eisler, 1994; Goerner, 1999; Peter Reason, 1991; L. J. Shepherd, 1993).  As an extension of this dynamic, I examine feminine epistemology in relation to power as a possible construct for understanding power differences between medical paradigms.                                                                                                

The dichotomies of male/female, allied healthcare/physician, and hierarchical/heterarchical organizational structures are comparable to dominator and partnership models.  Dominator language that feeds beliefs and assumptions in the power structure is part of the problem.  As a result, people are not free because they function within these systems. Like a frog at the bottom of the well, they have no awareness of life outside the well. Here are some figures that identify gender dominance in the sciences.

Since 1993, there has been some progress and we need much, much more. For example, in 2003 women accounted for only 13% of science professors at M.I.T., up from 8% in 1993. Only 4 women among 32 Harvard faculty members were offered tenure in 2004. Nationally, women account for nearly half the bachelor’s degrees in chemistry and math but only about 10 % of the faculty. Physics continues to be the most male-dominated field among the sciences. Men hold 90 percent of physics faculty positions, and earned 82 percent of the doctoral degrees in 2003. Women scientists in the UK are more successful at achieving a post on their first application, yet 44% of them feel disadvantaged in terms of promotion. Only 14% of men believe women are disadvantaged in terms of promotion (L. Shepherd, 2006).

The Kathleen B. Jones served as Professor and Associate Dean at San Diego State University and served as an activist-scholar within the greater community. For her, women approach authority, ethical dilemmas and decision making with fundamentally different language and logic. “The would-be authoritative female speaks in compassionate tones inaudible to listeners attuned to harsher commands. Hence, in the discourse of the dominant culture, much of compassion is taken as non-authoritative, marginal pleadings for mercy – gestures of the subordinate” (Jones, 1988 pp121). Further, deconstructing the use of rationality as a voice of authority, Jones states,

The radical separation of the realm of cognition from the realm of belief and feeling, arbitrarily restricts authority to formal rules. In addition, the logic of defining authority as a system of ‘conflict resolution’ sees decision making less as consensus building and more as a process of adjudicating completing private claims of self-interest (1988 pp121).

Table 1

This table compares male and female ways of knowing and ethics.(L. J. Shepherd, 1993 pp37-39)

This dominator-dominated world view and its heterarchical counterpart happen within the social networks where individuals operate. These realities engage in the membrane between context and subject; they are composed of both praxis and agency. At the institutional, state and federal levels, empowerment tends towards those agencies that conform to conventional medical practices. This in turn affects the practice of medicine and the resulting social fabric. It occurs at a place between the patient and the practitioner, the insurance company and the clinical interaction and the professional association and the legislative component. “It is a dialectical synthesis of what is going on in society and what people are doing” (Sztompka, 1994 pp217). ‘Gender-holism’ and heterarchical systems provide a solution to these dominant hierarchical and cultural practices (Eisler, 1994).                                                                                                               

The difficulties in the partnership-dominator continuum lie not so much in the fact that the communicating parties use different vocabularies or languages to talk about the same thing, but rather in the fact that they use different structures of reasoning (Maruyama, 1974). In these environments, value laden terms such as ‘evidence-based-medicine’ (EBM) can easily become a moral certainty for dividing the world into the forces of good and the forces of evil.  This then becomes a theme in constructing ‘safe care’ and the protection of the public (Bernstein, 2005). Humans often use different structures for reasoning and this can easily lead to misperception. While evidence based medicine clearly has value, there are limitations because the way we know truth varies based upon gender, social system and history, thus the current theme of randomized controlled trials as the gold standard for EBM miss entire bodies of practice and knowledge. Under these circumstances, “Relatively powerless groups may simply speak in a way that ‘echoes’ the voices of the powerful, either as a conscious way of appearing to comply with the powerful party’s wishes, or as a result of the internalization of dominant views and values” (P Reason & Bradbury, 2006 pp75).

Closure Theory

Along the lines of dominator-partnership thinking, Weber’s concept of social closure can be used to examine the alienation that occurs when collectives gain and maintain privileged positions in society. Closure depicts a process of domination whereby one group monopolizes advantages by closing off opportunities to another group of outsiders beneath it, which it defines as inferior and ineligible. This concept of closure can be extended where a state’s economic interests in professionalism plays a role in a profession’s rise to dominance and power through the definition of licensing and educational requirements. These objectives are often achieved through totalizing concepts such as public safety – a necessary component of licensure which may also be used to sustain closure. The impact of closure on the availability of Chinese medicine to patients can affect optimal care and lowered cost of care to the culture at large. Practitioners of acupuncture and Oriental medicine are often a last stop resort. The travesty occurs when people die from Cox-II inhibitor pain medications while the National Institute of Health lists studies demonstrating acupuncture efficacy for the treatment of osteoarthritis of the knee (Berman et al., 2004; Hippisley-Cox & Coupland, 2005).                                                                      

Parkin’s four-fold extension of Weber’s closure theory serves as an analytical basis for socio-economic and socio-political control of resources related to services, science and medicine (1974). He articulates four types of closure including exclusion, demarcation, inclusion, and dual. Exclusion exercises hierarchical dominance of inferior social groups by closing off access to opportunities and resources. This occurs through the creation of specific skill sets and entry credentials that protect and secure a privileged access to the market. Demarcation and interdisciplinary control occurs when members of a discipline monitor and regulate closely related occupations defining and controlling boundaries between them. Exclusion suppresses vertically while demarcation does so horizontally. Inclusion refers to subordinate’s attempts to access the advantages of higher level groups.  It can easily be dismissed by the more elite as usurpation. Dual closure occurs when a demarcated group both resists demarcation, and establishes a new sphere of competence with unique exclusions (Hollenberg, 2006).                                                                           

Closure contributes to a sociopolitical and socioeconomic environment where atomization of knowledge and specialization isolates and disconnects people. Morin asks the question, “…what about science? Here, we must realize that this question does not have a scientific answer: science does not know itself scientifically and has no means of knowing itself scientifically” (Morin, 1999, p8). Given this state of affairs, and the fact that these processes are seated within culturally biased epistemologies, how can best decisions be made?

In Summary

Chinese medicine has a history of providing low cost effective health care. Further, there are studies that are beginning to show lower cost of care than the conventional standard of care using acupuncture and Oriental medicine. Community service oriented low cost clinics are supporting the care of underserved populations. The inclusion of acupuncture and Oriental medicine in the Medicare system however, must be conducted in a way that lowers cost of care. The zero-sum of federal health care budgetary resources creates a complicating factor for insurances such as Medicare and Medicade where lowering cost of care can adversely impact the economic interests of certain institutions and collectives.   

Possible solutions are available through models such as ‘cosmopolitan power’ where, in an egalitarian world view possibilities that acupuncture and Oriental medicine holds for the west might occur. Emphasizing a moral application of power with integral and transdisciplinary values that identify with the patterns that connect may bring a transforming power that invites mutuality (Bateson, 2002; Torbert, 1944). These pluralizing and emergent partnership models for culture become possible in the context of a transdisciplinary, transprofessional and transcultural set of communications (Eisler, 1994). “Partnership is not a utopia. It is simply applying our creativity to human interaction” (Eisler, 1994; Montuori & Conti, 2007).                                                                  

There are risks however, in our current state of post-developmentalism.  An egalitarian system of health care is not an inevitable outcome. Rather, as a potential and dynamically evolving set of emerging possibilities, a pluralizing medical culture may generate some solutions for humanity (Sztompka, 1994, pp37).

References

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Berman, B. M., Lao, L., Langenberg, P., Lee, W. L., Gilpin, A. M. K., & Hochberg, M. C. (2004). Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: A randomized, controlled trial. Ann Intern Med, 141(12), 901-910.

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Goerner, S. (1999). After the clockwork universe: The emerging science and culture of integral society. Edinburgh, Scotland: Floris Publishers.

Hippisley-Cox, J., & Coupland, C. (2005). Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: Population based nested case-control analysis. BMJ, 330(7504), 1366-1373.

Hollenberg, D. (2006). Uncharted ground: Patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings. Social Science & Medicine, 62(3), 731-744.

Jones, K. B. (1988). On authority, or why women are not entitled to speak. In I. Diamond & L. Quinby (Eds.), Feminism and foucault, reflections on resistance. Boston: Northeastern University Press.

Maruyama, M. (1974). Paradigmatology and its application to cross-disciplinary, cross-professional and cross cultural communication. Dialectica, 28(3-4), 135-196.

Montuori, A., & Conti, I. (2007). The meaning of partnership.Unpublished manuscript.

Morin, E. (1999). Homeland earth: A manifesto for the new millennium: Hampton Press.

Parkin, F. (1974). Strategies of social closure in class structure. London: Tavistock.

Reason, P. (1991). Power and conflict in a multidisciplinary environment. Complimentary Medical Research, 3(3), 144-150.

Reason, P., & Bradbury, H. (2006). Handbook of action research. Thousand Oaks: Sage Publications.

Shepherd, L. (2006). Lifting the veil--open discussion. In W. M. a. the (Ed.).

Shepherd, L. J. (1993). Lifting the veil. The feminine side of science. Boston: Shambhala.

Sztompka, P. (1994). The sociology of social change. New York: Blackwell.

Torbert, W. R. (1944). The power of balance, transforming self, socirty and scientific inquiry. Newbury Park, London, New Delhi: Sage.