MULTIPLE REALITIES IN MEDICINE*
In the context of our conference theme - "Competing Paradigms - Crisis or Opportunity?" - two alternatives are indicated. Crisis - because we don't know which paradigm is correct, yet whether we know or not we still must choose one. Or opportunity - because we are convinced that "truth" will emerge out of the competition and contention of differing ideas.
I want to falsify this dichotomy by suggesting a third alternative - an alternative of alternatives, as it were. Perhaps the world is not all of a piece, not just one thing, not a case of either one or the other. I want to suggest that we should think not in terms of competing paradigms, but rather of co-temporaneous multiple realities.
In the following presentation I want to connect the study of conventional and unconventional medicine with a theoretical approach which offers such a non-competitive perspective. The benefits of such a merger are nicely stated by Merton1 in his classic discussion of the reciprocal reinforcement of theoretical conceptualization and empirical investigation.
I will pursue this merger in three steps: First, I will identify some major issues in the field of medicine, issues that, appropriately enough, reflect the confrontation of competing paradigms both within and without the community of medical practitioners. Second, I will briefly summarize portions of the theoretical work of Alfred Schutz2 which, although not usually associated with the sociology of medicine, offers a perspective that is effective in both gaining an understanding and furthering the discussion of these socio-medical issues. Third, I will suggestively illustrate the usefulness of Schutz's ideas in exploring two competing paradigms in medicine today.
MAJOR ISSUES IN MEDICINE
There are a number of major social issues currently being discussed and debated with the medical community. Many of these issues are of far-reaching consequence, and so the discussions have been joined by other interested parties from the larger community. Let me identify three such areas of current controversy and conflict.
(1) Issues regarding the kinds of events which require medical treatment. This includes arguments over conventional versus non-conventional medicine such as marginal medical techniques and practices, and outright quackery. These issues often reflect conflicts between medical beliefs and practices and those that are of a religious, magical, or spiritual nature. These latter are often related to regional, ethnic or cultural variations in folk medicine and various religious sectarian movements.
(2) Issues between medicine and law, including arguments regarding adjudication, both within the medical establishment and between medicine and other social institutions, agencies, or activities. These issues usually center on decision making - who should have the right to make what decisions about whom and under what circumstances.
(3) Issues regarding larger jurisdictional prerogatives. These issues commonly involve conflicts between individuals, institutions, and society-at-large. These issues include differing views regarding definitions of one's body, including rights of ownership and access; the direct or indirect extra-medical uses of medicine; the uniquely privileged position and male-dominated and (to some extent) sexist nature of conventional medical practice in American society.
THE THEORETICAL FRAMEWORK OF ALFRED SCHUTZ
Because these issues eventually impinge on the lives of ordinary citizens in a variety of ways, it will be helpful to turn to a sociological perspective specifically focused on everyday life. Alfred Schutz (1899-1959) was a philosopher-sociologist who is now generally considered to be the founding father of phenomenological sociology. Throughout all of his work, Schutz was primarily concerned with what Natanson3 calls "the discovery in full depth of the presuppositions, structure, and significance of the common-sense world." This common-sense world is the reality which everyone, in the course of their normal rounds as what Schutz called "wide-awake, fully-functioning adults in the natural attitude" take for granted as being there, both for themselves and for others ("who are like us") as well. This reality of everyday life "does not require additional verification over and beyond its simple presence. It is simply there, as self-evident and compelling facticity."4
Schutz developed this "single intuition" into a full-fledged theoretical model. According to Schutz, this "Paramount Reality" is not only the world of working, common-sense, everyday life; it is also the world about which we (i.e., the members of our group) experience the least doubt. It is this reality which imposes itself upon us all with the most urgent, intense, and massive force. It is this frame of reference which is most mutually presupposed and widely shared. It is within this world that we locate and make sense of our individual biographies. This is the world of our typifications and communication with others. It is within this world that we continually grow older. And it is our awareness of this finiteness and inevitability that prompts in each of us a fundamental anxiety regarding our own inescapable deaths.
In addition to this reality - the reality par excellence - there are other, "lesser" realities, finite provinces of meaning into which we are able to, and sometimes must, enter. Schutz designated these other, multiple realities sub-universes of discourse or finite provinces of meaning. For our purposes they can be thought of as alternative paradigms. These provinces of meaning are, in effect, bracketed enclaves of meaning which occur within the Paramount Reality but which refer to some reality "external" to it. Transition from the Paramount Reality into and back out of one of these alternative paradigms, sub-universes of discourse, or finite provinces of meaning is accompanied by an abrupt jerk of discontinuity, the sudden experience of rupture and reconnection. Our everyday experience of "waking up from a dream" is the most common and simple illustration of this shift.5
The sub-universe of dreams is one of the many provinces of meaning Schutz identified. Others include the province of the stage-play, the pictorial world, the fictitious world of the jest, the child's play-world, the province of religious experience, and the world of scientific theory.6
Within each province of meaning, experiences are both congruent and congenial with one another. Each reality, province of meaning, or alternative paradigm is sufficient unto itself. Between the various provinces of meaning there are no formulae of transformation. There is no logic that cuts across the various realities to make them either compatible or comparable. Each province is a distinct and discrete sphere of experience and discourse, although it is possible to shift from one province to another: The curtain rises on the stage and a different reality is thereby invoked.
Each of these multiple realities is characterized by a distinctive set of common features:
(1) stock of knowledge;
(2) tension of consciousness;
(3) suspension of doubt;
(4) form of spontaneity;
(5) sense of self-experience;
(6) form of sociality;
(7) temporal perspective.
However, "the archetype of our experience of reality" remains "the world of working in everyday life. All the other provinces of meaning may be considered as its modifications."7 As Berger and Luckmann8 state: "consciousness always returns to the paramount reality as if from an excursion." Thus common-sense, every day reality has a paramount and privileged ontological status. It is finally the only way we have of making sure we all know what we're all talking about.
APPLYING SCHUTZ'S THEORY
How will Schutz's ideas help us explore various issues in the field of medicine? I think Schutz's theoretical framework can be used both to reframe the major socio-medical issues outlined above and to expand our understanding of the discussion of conventional and non-conventional medicine.
Schutz's theory of multiple realities is especially germane because it provides a context within which the co-existence of alternative paradigms is a normal state of affairs. The theory locates what is only an apparent conflict among paradigms within a frame of reference of opportunity: Opportunity for increased clarity, insight, and appreciation. More specifically, Schutz enables us to
(1) to accept and respond intelligently to the existence of multiple realities;
(2) to know how these realities work for people and to know under what specific conditions these realities are real;
(3) to conceptualize and understand the simultaneous, contrary co- existence and interrelationships of multiple realities;
(4) to identify problems and issues in ways that will lead to more satisfactory and effective resolutions.
Throughout history, different provinces of meaning or alternate paradigms have significantly dominated the Paramount Reality. The classical distinction between Gemeinschaft and Gesellschaft displays this well. In Gemeinschaft societies, the Paramount Reality was suffused with traditional, received religion; in Gesellschaft societies, the Paramount Reality is permeated by technological science.
History shows that the practice of medicine has also gradually shifted from the provinces of religion and magic toward the province of science. Thus the medical model in modern, Western societies tends to be a scientific one. However, various medical practices and beliefs are still currently arrayed across these various provinces. In Schutz's terms, medicine maintains an enclave in each of these sub-realities. Based upon his own experience, the ordinary man on the street - "the wide-awake, fully-functioning adult in the natural attitude" - may select from among these provinces of meaning the one (or ones) he will shift to in seeking medical treatment or repair.
By way of illustration, let us take the experience of a pain that, to such a typical adult, will suggest the presence of "back trouble". The problem with describing even a hypothetical illness in any specific way is that different provinces of meaning will define the allegedly "same" situation differently, thus protecting their own internal consistency. (One can now begin to see how it is that there are no formulae of transformation between distinct provinces except for a common linguistic system secured in and warranted by a Paramount Reality. This provides a crude solution to what would otherwise be an impossible predicament.)
For his so-called "back trouble" the potential patient might select from orthopedic surgery, chiropractic treatment, Rolfing, acupuncture or acupressure, Reichian or Primal psychotherapy, Zen meditation, physical therapy, or hypnosis. If he is even more radical in his orientation, our man in the street might even join a group (e.g., a religious sect) which provided an alternative Paramount (or Ultimate) Reality that offered divine healing or even defined the condition itself as illusory.
Each of these provinces of meaning have their own criteria of expertise and their own experts. Each is likely to offer a different diagnosis. Each has its own stock of knowledge, and each will accordingly suggest a distinct line of treatment.
However, not all of them will be recognized as equally legitimate or valid, either among themselves or from the perspective of the Paramount Reality. Thus the issues of conflict between conventional (i.e., establishment) medical beliefs and practices and those that are religious, magical, or spiritual in nature can be rearticulated in this broader framework of multiple realities.
Schutz argues forcefully and, I believe, convincingly for taking into account the existence and interplay among such multiple realities as they variously influence human behavior. The conventional medical model of health and disease well subsidized by the Paramount Reality is only one of these realities. Among the wide variety of human activities directed toward diagnosis and cure of human illness, many occur in other provinces of meaning. Members of the conventional medical profession themselves allude to the practice of medicine as both an art and a science. In addition, there is increasingly a sometimes harmonious, sometimes contentious overlapping of the otherwise distinct provinces of medicine and law.
In the course of the Western historical development mentioned earlier, the province of the law also freed itself from the domination of religion. To a great extent it has also remained distinct from technological science and developed an intrinsic and peculiar rationality of its own. Thus we come to the issues of jurisdiction and adjudication.
ISSUES OF JURISDICTION AND ADJUDICATION
To some extent, various provinces of meaning resolve problems of jurisdiction through competition and survival. Freedom of competition seems to vary inversely with conventionality. For instance, in highly secular societies such as ours, mutually exclusive religious paradigms and practices are often granted equal legitimacy, while mutually exclusive scientific paradigms, almost by definition, are poorly tolerated.9 Therefore, both the man in the street and the well-informed citizen (two of Schutz's ideal types) become dependent upon experts in various provinces to make pronouncements regarding legitimacy. In modern societies, the adjudicating province par excellence has become that of the law. In this sense, the law supersedes both religion and science in defining what realities obtain paramouncy.
This is a different kind of dispute than that between various provinces of meaning, each of which may contain its own medical enclave. The province of law, however, does not pretend to the practice of medicine in any manner whatsoever. The very pronounced and current dispute between traditional law and conventional medicine centers around which of these two provinces of meaning will take precedence in determining the everyday, taken-for-granted content of the Paramount Reality. While the law and medical science seem to be of equal stature, the Paramount Reality in Western secular societies is increasingly ultimately bounded largely by legal definitions and decisions, often whether or not these are rooted in scientific warrant.
APPLICATION TO A PARTICULAR CASE
Having painted Schutz's theory in with rather large strokes, I want to briefly show how it is useful by demonstrating that we are dealing with alternative, multiple realities in comparing conventional and non-conventional medicine. Non-conventional medicine is typically defined as a deviant practice.10 Conventional medicine is closely associated with the scientific model,11 although Wissman and Angle12 have shown that this does not mean that it is internally free from competing paradigms. The broad category of unconventional medicine includes many widely differing alternative paradigms. Utilizing DeVries'13 discussion of midwifery, the conventional and non-conventional medical practices associated with pregnancy and birth do, in fact, suggest that we are dealing with alternative realities. Each of these different sets of practices:
1. meet Schutz's criteria for constituting an alternative reality or finite province of meaning;
2. contrasts markedly with the other set;
3. cannot readily be transformed into, reconciled with, or made comparable to the other set.
The paradigmatic differences between conventional and non-conventional approaches to pregnancy and birth medicine can be readily charted according to Schutz's seven basic common features of reality (listed earlier). The table below clearly demonstrates their contrasting characteristics.
TREATMENT OF PREGNANCY
Characteristics of Reality
Expression in the
Expression in the
Stock of Knowledge
Professional training, scientific information, artificial chemical remedies
First hand experience, folk wisdom, natural remedies
Tension of Consciousness
Anesthetized, away from or out of the situation.
Focused awareness, involved with the situation.
Parent suspends doubt in scientific criteria, external authorities, eventualities
Parent suspends doubt in empathetic assistance, folk wisdom, internal sensations
Form of Spontaneity,
System of Relvances
Pulling by others, patient and baby as objects to be manipulated
Pushing by mother, active participation by father & child, mother and child as self-determining subjects
Self as marginal, sub-ordinate, blurred self-awareness
Self as central, super-ordinate, focused self-awareness
Impersonal, mother as recipient, bureaucracy dominant
Highly personal, mother as initiator, family dominant
Standardized, external timetable, availability of personnel and facilities
Physiological inner duree, when the baby is ready without reference to external criteria
This brief analysis is clearly a preliminary exploration of Schutz's theoretical framework. I hope it will serve as a brief introduction to his theory of multiple realities or alternative paradigms as well as a stimulus to others to attempt its further application.
* Revision of a paper originally presented at the annual meeting of the Pacific Sociological Association Spokane, WA, April 1978
1 Robert Merton, Social Theory and Social Structure. New York: The Free Press, 1957, pp.85-117.
2 The most complete statement of Schutz's contribution to sociology (and philosophy) is found in Alfred Schutz, Collected Papers, Volume 1: The Problem of Social Reality; Volume 2: Studies in Social Theory; Volume 3: Studies in Phenomenological Philosophy (edited and introduced by Maurice Natanson). The Hague: Martinus Nijhoff, 1967.
3 Natanson's lucid and succinct summary of Schutz's work appears in Ibid., Volume 1, pp. xxv-xlvii. The quote is from p. xxv.
4 Peter Berger and Thomas Luckmann, The Social Construction of Reality: A Treatise in the Sociology of Knowledge. Garden City, N.Y.: Doubleday-Anchor, 1967, p. 23. This work is a direct intellectual descendent of Schutz's and also contains an excellent summary of his perspective.
5 Ibid., p. 21.
6 Schutz, 1962:231
7 Schutz, 1962:233
8 Berger and Luckmann 1967:24
9 Thomas Kuhn, The Structure of Scientific Revolutions. Chicago: University of Chicago Press, 1962.
10 L. Kay Gillespie, "Quackery: Conventional and Unconventional Considerations." Paper presented at the Pacific Sociological Association Meetings, Sacramento, California, 1977.
11 Rene Dubos, Mirage of Health. Garden City, New York: Doubleday-Anchor, 1961.
12 David Wissman and John Angle, "The Conventional and Unconventional Ophthalmology of Myopia." Paper presented at the Pacific Sociological Association Meetings, Spokane, Washington, 1978.
13 Raymond G. Devries, "Conventionalizing the Unconventional: A Study of Midwifery." Paper presented at the Pacific Sociological Association meetings, Spokane, Washington, 1978.