Biomedical subjects
M Nichter
Publications and source records attributed to M Nichter.
Limitation of medical care: an ethnographic analysis.
This ethnographic study has shown how one attempt to apply ethical principles through a routine procedure failed to fit the clinical context and, in the two cases studied, served to counteract the very foundation these principles were based on--that patients or their families have the right to determine life-and-death decisions regarding code status. The results suggest that the use of well-meaning forms that are intended to facilitate decision making can, in the absence of appropriate guidelines, routinize the doctor-patient discourse to meet bureaucratic needs, narrowing rather than expanding understanding and communication. Bioethical principles implemented in abstraction, apart from the complex intricacies of the doctor-patient-family relationship and the sociocultural influences upon which this relationship is dependent, may be counter-productive to patient interests. As bioethicists and clinicians work to implement the demands of the Patient Self-Determination Act, they will undoubtedly try to forestall legal problems, assure ethical consistency, facilitate auditing, and promote documentation by creating forms. They may look to create inventories, such as the Limitation of Medical Care form described here, or turn to other, less explicit, means of documentation. This study suggests that, in these efforts, genuine attention should be given to patient concerns, not just to the ethical or institutional needs of medicine. This shift in focus from outcome to process can enhance patient and clinician satisfaction, help resolve difficulties in reaching consensus between involved decision makers, and return the power in DNR decision making to patients and families.
Do-not-resuscitate discussions: a qualitative analysis.
The literature to date on Do-Not-Resuscitate (DNR) decision-making is based upon data derived from structured questionnaires, hypothetical scenarios, descriptive epidemiology, or simulated discussions. Lacking in the literature has been a critical examination of the health care professional-patient-family relationship and its impact on decision-making regarding resuscitation. The purpose of this study is to identify and describe organizational and communication factors that affect the process and outcome of DNR discussions and decision-making. Individual and focus-group interviews were conducted with sixteen key informants professionally knowledgeable about resuscitative issues. Thematic analysis of these interviews revealed that a variety of cultural and professional values, as well as previous personal experiences, influenced the assumptions that providers made when engaging in DNR decision-making. Specific recommendations are made to help family physicians identify communication strategies that foster understanding and lead to participatory decisions about resuscitation among patients and families.
Ethnomedicine: diverse trends, common linkages.
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A question of medicine answering. Health commodification and the social relations of healing in Sri Lanka.
Biomedicine although institutionally powerful in Sri Lanka has not been able to depersonalize illness or promote a notion of treatment efficacy disconnected from social relations. An ideology of healing crosscuts the trend toward health commodification. This paper focuses on three concepts fundamental to the interactive dynamics of treatment efficacy: constitution, habit, and power of the hand. A movement between two distinct types of health care seeking behavior is described. One is inspired by finding the right medicine fix, the other by finding a practitioner having a sensitivity toward one's sense of person and all this entails.
From aralu to ORS: Sinhalese perceptions of digestion, diarrhea, and dehydration.
This paper explores popular Sinhalese perceptions of diarrheal diseases and related health care behavior. Also addressed are cultural interpretations of dehydration and perceptions of oral rehydration solution (ORS). The social marketing of ORS is considered. It is suggested that the marketing of ORS be more closely linked to education programs which promote appropriate conceptualization of dehydration. The need to more closely integrate nutrition education and diarrheal management programs is discussed.
Cultural dimensions of hot, cold and sema in Sinhalese health culture.
Attention is focused on those for whom hot/cold and phlegm constitute special health concerns in Sri Lanka. A distinction is drawn between those at special risk to hot/cold and phlegm based on a sense of constitutional vulnerability and those at risk due to temporary illness or expected changes in physiological process. Socialization of the former risk group is considered in light of social labeling theory, while the health behavior of the latter group is highlighted. It is pointed out that a wide range of behavior from folk dietetics to bathing and from water boiling to the taking of birth control pills is influenced by hot/cold reasoning. It is emphasized that the hot/cold conceptual framework serves an integrative function in the traditional health care arena and provides a rationale for participatory action in a health culture undergoing rapid medicalization.
Drink boiled water: a cultural analysis of a health education message.
Water boiling is recommended by health educators in Sri Lanka, and boiled water is given to ill and vulnerable people, but it is not widely consumed by the public. The reasons for this behavior derive from long-standing notions about health care. This study complements one presented some years ago by Wellin, based on the health culture of Peruvians.
Cultural interpretations of states of malnutrition among children: a South Indian case study.
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Clinical anthropologist as therapy facilitator: role development and clinician evaluation in a psychiatric training program.
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Project community diagnosis: participatory research as a first step toward community involvement in primary health care.
'Community participation' and 'bottom up planning' have become fashionable themes in international health circles. However, in the absence of sociocultural perspective these themes remain largely rhetoric. In this paper, a deprofessionalization of social science is advocated in the service of participatory research as a first step towards community involvement in primary health care. Deprofessionalization is suggested as an adjunct to, not a replacement for in-depth professional social science research. An exploratory community diagnosis of health project conducted in rural south India is described. During the project, lay researchers received rudimentary social science field training and collected data on health behaviour deemed important to health planners as well as the health concerns of the community. Illustrative data, generated by the project is presented on the rural poors' utilization of government health facilities, their attitudes towards Primary Health Centre staff, and their ideas about how a proposed community health worker scheme could best serve them.
Paying for what ails you: sociocultural issues influencing the ways and means of therapy payment in South India.
The dynamics of payment for therapy to traditional healers and cosmopolitan practitioners in rural South India is focused upon as a means of better understanding health care seeking behavior, patient-practitioner relationships and interactions, treatment decisions and referral. Payment to traditional practitioners involves the ideal of moral bonding while payment to cosmopolitan practitioners remains largely non-moral. Charging for therapeutic consultations through medicine costs and the layperson's means of estimating the cost of therapeutic services and regimes are investigated as factors influencing practitioner shopping, the practice of medicine, and the dynamics of prescription writing. The meaning and process of payment are identified as issues influencing both micro and macro, moral and pragmatic aspects of health care and health economy.
The ethnophysiology and folk dietetics of pregnancy: a case study from South India.
The contingency between notions of ethnophysiology and the folk dietetics of pregnancy are examined in a region of South India. Attention is focused on lay perceptions of essential body processes and health concerns during pregnancy. Preventive and promotive health strategies employed during pregnancy by the rural poor which involve diet are considered. The tendency for rural South Indian women to prefer smaller babies and the relationship of this preference to dietary behavior are considered in relation to both concepts of the appropriate quality and quantity of food to eat during pregnancy and the concepts of baby space and baby strength. Nutritional ramifications of alternative food consumption patterns are considered. The importance of understanding indigenous health concerns and notions of ethnophysiology when introducing public health programs is highlighted by a discussion of why many pregnant women are reluctant to comply with iron sulfate, tetanus toxoid, and vitamin therapy as currently presented by primary health care staff.
Negotiation of the illness experience: Ayurvedic therapy and the psychosocial dimension of illness.
The negotiation of the illness experience by ayurvedic vaidya and South Kanarese patients suffering from specific sources of psychosocial distress is examined in light of the cultural patterning of illness and communication within the clinical context. The negotiation process is initiated by the posing of rhetorical questions about somatic and affective states and structured by a conceptual framework which relegates such states to humoral interrelationships. By establishing a humoral explanatory model for an illness episode or affective state which takes into account environmental and constitutional factors over which one has little control, responsibility is mollified and dialogue about personal problems eased. A comparison of the interaction between ayurvedic practitioners and patients and astrologers and clients is made in this regard. The socially integrative and adaptive consequences of ayurvedic therapy is considered vis a vis a portrayal of a popular vaidya therapy for a number of illnesses associated with the somatization of psychosocial stress.
Idioms of distress: alternatives in the expression of psychosocial distress: a case study from South India.
This paper focuses attention on alternative modes of expressing distress and the need to analyze particular manifestations of distress in relation to personal and cultural meaning complexes as well as the availability and social implications of coexisting idioms of expression. To illustrate this point the case of South Kanarese Havik Brahmin women is presented. These women are described as having a weak social support network and limited opportunities to ventilate feelings and seek counsel outside the household. Alternative means of expressing psychosocial distress resorted to by Havik women are discussed in relation to associated Brahminic values, norms and stereotypes. Somatization is focused upon as an important idiom through which distress is communicated. Idioms of distress more peripheral to the personal or cultural behavioral repertoire of Havik women are considered as adaptive responses in circumstances where other modes of expression fail to communicate distress adequately or provide appropriate coping strategies. The importance of an 'idioms of distress' approach to psychiatric evaluation is noted.
The layperson's perception of medicine as perspective into the utilization of multiple therapy systems in the Indian context.
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The semantics of addiction: moving beyond expert models to lay understandings.
Five expert discourses on addiction purport to explain the phenomenon of the semantics of addiction. An assessment of the burgeoning use of this term by the lay public, however, reveals a plethora of socially contextualized and culturally mediated meanings related to addiction that are generally not considered by expert models. Addiction has meanings that index the loss of self-control and individual responsibility, as well political and moral meanings and meanings that index social modes of consumption, the range and limits of normative behavior, and the constitution of deviance. The category of addition interacts with other socially produced categories, including "drugs" and "desires," and implies an unfolding history linked to specific cultural conventions of what is proper. This paper briefly reviews expert debates over the meanings of addiction and explores the semantics of how this term is used in both popular discourse and among those who use substances associated with physical addiction. In addition, some of the more interesting theoretical issues this discussion brings to light are highlighted, with the intent to identify issues warranting future research that will broaden the study of addiction.