Like most young women of my class and generation, I first became entangled with the medical profession when I reached my reproductive years, originally through the need for contraception. The major contraceptive available at the time was the diaphragm—a low-tech barrier method that required no great medical expertise to administer. But to win the medical profession’s support for the legalization of birth control, Margaret Sanger had conceded the prescribing of diaphragms and other methods of birth control entirely to physicians. So at the age of about eighteen I was forced for the first time into the lithotomy position for, of course, a male gynecologist, to undergo a procedure I found extremely degrading. About a decade later, pregnancy ensnared me into regular monthly doctor visits, culminating a couple of weeks before the birth itself in a pelvic examination performed by the chief of obstetrics at the clinic I attended. No words were exchanged until, when the speculum had been removed from my vagina, I inquired whether my cervix was beginning to dilate. He looked at the nurse and asked in an arch tone, “Where did a nice girl like this learn to talk like that?”
Whether this exam had any effect on my—or, more important, my unborn child’s—well-being, I have no idea, but its emotional impact was instantaneous. I was infuriated. Not only had I read the standard mass market books on pregnancy, but I had recently received a PhD in cell biology and could have gone on and on in what would have seemed to the obstetric chief a similarly obscene fashion. This, I should observe, is the moment I became a feminist in the fullest sense—a conscious woman, that is, and something other than an object or moron. The nurse, to her eternal credit, remained silent and poker-faced.
In the following years, I never questioned the need for regularly scheduled prenatal care, postnatal care, well-baby and then well-child care. I was a good mother and showed up as required for all the vaccinations and measurements of my children’s growth. There were hints along the way, though, that something was going on other than the provision of necessary care. When a pediatrician prescribed my second child an antibiotic for a cold, I asked whether she had a reason to believe his illness was bacterial. “No, it’s viral, but I always prescribe an antibiotic for a nervous mother.” The prescribing was, in other words, a performance for my benefit. Muttering that I was not the one who was going to be taking it, I picked up my baby and left.
If a medical procedure has no demonstrable effect on a person’s physiology, then how should that procedure be classified? Clearly it is a ritual, which can be defined very generally as a “solemn ceremony consisting of a series of actions performed according to a prescribed order.”1 But rituals can also have intangible psychological effects, so the question becomes whether those effects in some way contribute to well-being, or serve to deepen the patient’s sense of helplessness or, in my case, rage.
Western anthropologists found indigenous people worldwide performing supposedly health-giving rituals that had no basis in Western science, often involving drumming, dancing, chanting, the application of herbal concoctions, and the manipulation of what appear to be sacred objects, such as animal teeth and colorful feathers. Anthropologist Edith Turner in the 1980s offered a lengthy and lovingly detailed account of the Ihamba ritual performed by the Ndembu of Zambia.2 The afflicted person, whose symptoms include joint pains and extreme lassitude, is given a leaf infusion to drink, then her back is repeatedly anointed with other herbal mixtures, cut with a razor blade, and cupped with an animal horn—accompanied by drumming, singing, and a recital of grudges the patient holds against others in the village—until the source of the illness, the Ihamba, exits her body.
Does this ritual work? Yes, insofar as the afflicted person is usually restored to his or her usual strength and good humor. But there is no way to compare the efficacy of the Ihamba ritual to the measures a Western physician might use—the blood tests, the imaging, and so on—in part because the Ihamba itself is not something accessible to scientific medicine. It is conceived as the tooth of a human hunter, which has made its way into the victim’s body, where it “bites” and may even reproduce. If this sounds fantastical, consider that, as an agent of disease, a “hunter’s tooth” is a lot easier to visualize than a virus. Sometimes at the end of the ceremony one of the officiants will even produce a human tooth, claiming to have extracted it from the victim’s body. And of course the opportunity to air long-held grudges may be therapeutic in itself.
Most of us would readily recognize the Ihamba ceremony as a “ritual”—a designation we would not be so quick to apply to a mammogram or a biopsy. The word carries a pejorative weight that is not associated with, for example, the phrase “health care.” Early anthropologists could have called the healing practices of so-called primitive peoples “health care,” but they took pains to distinguish the native activities from the purposeful interventions of Euro-American physicians. The latter were thought to be rational and scientific, while the former were “mere” rituals, and the taint of imperialist arrogance has clung to the word ever since. As a British medical anthropologist points out:
The old anthropological approach to ritual relied upon a distinction between two kinds of action: that, on the one hand, which was ends-directed and reasonable from the anthropologist’s point of view—and which might be described as related to skill, technique or craft—and, on the other, action which was apparently irrational and, as far as the anthropologist was concerned, did not reveal any such links. Only the second kind of action was to be thought of as ritual.3
Inevitably, a parallel was drawn between the healing rituals of supposedly primitive peoples and the procedures of modern Western medicine. The latter also take place in specially designated spaces and are usually performed by costumed personnel, wearing white coats and sometimes masks, who also manipulate objects generally unavailable to the public at large. In 1956, a time of widespread reverence for the medical profession and its institutional settings, an American anthropologist published an article cunningly entitled “Body Rituals Among the Nacirema”—“American” spelled backward. Describing the hospital as the “temple” where Nacireman healing rituals are performed, the essay recounts that
few supplicants [patients] in the temple are well enough to do anything but lie on their hard beds. The daily ceremonies, like the rites of the holy-mouth-men [dentists], involve discomfort and torture. With ritual precision, the vestals awaken their miserable charges each dawn and roll them about on their beds of pain while performing ablutions, in the formal movements of which the maidens are highly trained. At other times they insert magic wands in the supplicant’s mouth or force him to eat substances which are supposed to be healing. From time to time the medicine men come to their clients and jab magically treated needles into their flesh. The fact that these temple ceremonies may not cure, and may even kill the neophyte, in no way decreases the people’s faith in the medicine men.4
The entire smorgasbord of procedures that make up the traditional “annual physical exam” can be seen as a ritual. Introduced in the 1920s and recommended by the American Medical Association about a decade later, the annual physical loomed as a high-stress hurdle in the life of any health-conscious medical consumer, a trial, so to speak, to determine innocence (health) or guilt (disease). The ingredients of the annual physical are not well defined, and they can take from fifteen minutes to—in the case of the wealthy and hypochondriacal—several days. Yet health insurers required them as a condition of coverage, members of the military were subjected to them, ordinary healthy people were reminded by postcard to show up for them. What follows in the doctor’s office resembles a religious ritual, or even a spectacle designed for entertainment. Commenting on the occasional deployment of clowns to cheer up pediatric hospital patients, one canny observer noted the parallels between these newcomers to the medical scene, “primitive” shamans, and the usual physicians, right down to the “unusual costumes,” and even masks, worn by all of them.5 The patient undresses, the “healer” (or clown or shaman) utters incantations and performs various actions on the patient’s body. Then, in the medical case, comes the “confession,” in which the patient is grilled as to his or her personal transgressions: Do they smoke? Drink? Take illegal drugs? Have multiple sex partners? I made the mistake once of admitting to some nonstandard drug use, years earlier, during college, but the feverish gleam that appeared in the doctor’s eyes, along with a sudden burst of note-taking, convinced me never to mention it to a physician again.
To call something a “ritual” is not to say very much. Human rituals have ranged from human sacrifice to the innocent joys of maypole dancing, from forcible expulsion of a scapegoat from the community to the hearty embrace of a new leader or ally. But to say that a set of actions is a ritual does at least suggest that these actions serve social or cultural purposes other than the immediate task at hand, such as healing the sick or extracting an errant hunter’s tooth. Twentieth-century anthropologists debated the “functions” of the rituals they found native people enacting—whether, for example, they served the individual participant or the group, the average person or, in hierarchical societies, the elite. Many rituals seemed designed to provide reassurance and guidance to individuals during various stages of the life cycle, such as puberty, which may be marked by painful scarification or by gentle celebrations like a bar mitzvah or a fifteen-year-old Latina girl’s quinceañera. Other widespread rituals seemed designed to promote cohesion among individuals within a village or tribe—most obviously through group singing, dance, and feasting. Just as in traditional societies, modern urban people occupy a dense landscape of ritual—rituals of greeting and departure, holiday rituals, rituals associated with weddings, births, and deaths—most of which, most of the time, seem entirely benign. The psychological effect of these familiar rituals is usually to make the participants feel better about themselves and more securely bound to the community.
So what are the intangible effects of medical rituals? Do they “empower,” to use the popular verb, the objects of the rituals—that is, the patients—or contribute to a sense of helplessness and defeat?
One thing that stands out about medical procedures, as opposed to so many of the rituals we are likely to engage in, is that they tend to be transgressive, which is to say that they often violate accepted social norms. For example, we do not normally penetrate other people’s “space” or allow others to do that to us, nor do we usually expose our undressed bodies to other people’s inspection. Other, nonmedical rituals may be similarly transgressive, such as those involved in college fraternity and sports teams’ hazings, where the initiate may be required to drink dangerous amounts of alcohol, take off his clothes, and undergo ritualized forms of sexual abuse. Then there are the peculiar rituals associated with the military, such as the drinking rituals of the British army, which include the formation of a “daisy chain” or “ring of soldiers connected through anal penetration.” Participants justify this as a means of promoting group solidarity,6 as could be said, I suppose, of far milder forms of collective rule-breaking as well.
Physicians have an excuse for flouting the normal rules of privacy: The human body is their domain, sometimes seen, in the case of women’s bodies, as their exclusive property. In the middle of the twentieth century, no woman, at least no heterosexual laywoman, was likely to ever see her own or other women’s genitalia, because that territory—aka “down there”—was reserved for the doctor. When in 1971 a few bold women introduced the practice of “cervical self-examination,” performed with a plastic speculum, a flashlight, and a mirror, they were breaking two taboos—appropriating a medical tool (the speculum) and going where only doctors (or perhaps intimate partners) had gone before. Many doctors were outraged, with one arguing that in lay hands a speculum was unlikely to be sterile, to which feminist writer Ellen Frankfort replied cuttingly that yes, of course, anything that enters the vagina should first be boiled for at least ten minutes.7
Well before the revival of feminism in the 1970s, some American women had begun to complain about the heavy-handed overmedicalization of childbirth. In the middle of the century, it was routine for obstetricians to heavily sedate or even fully anesthetize women in labor. Babies were born to unconscious women, and the babies sometimes came out partially anesthetized themselves—sluggish and having difficulty breathing. Since the anesthetized or sedated woman could not adequately use her own muscles to push the baby out, forceps were likely to be deployed, sometimes leading to babies with cranial injuries. There was, however, an alternative, though obstetricians did not encourage it and often actively discouraged it: the Lamaze method, which had originated in the Soviet Union and France, offered breathing techniques that could reduce pain while keeping the mother and baby alert. In the 1960s, growing numbers of educated young women were taking Lamaze classes and demanding to remain awake during birth. By the time of my first pregnancy in 1970, it would have seemed irresponsible, at least in my circle of friends, to do anything else.
We were beginning to see that the medical profession, at the time still over 90 percent male, had transformed childbirth from a natural event into a surgical operation performed on an unconscious patient in what approximated a sterile environment. Routinely, the woman about to give birth was subjected to an enema, had her pubic hair shaved off, and was placed in the lithotomy position—on her back, with knees up and crotch spread wide open. As the baby began to emerge, the obstetrician performed an episiotomy, a surgical enlargement of the vaginal opening, which had to be stitched back together after birth. Each of these procedures came with a medical rationale: The enema was to prevent contamination with feces; the pubic hair was shaved because it might be unclean; the episiotomy was meant to ease the baby’s exit. But each of these was also painful, both physically and otherwise, and some came with their own risks. Shaving produces small cuts and abrasions that are open to infection; episiotomy scars heal more slowly than natural tears and can make it difficult for the woman to walk or relieve herself for weeks afterward. The lithotomy position may be more congenial for the physician than kneeling before a sitting woman, but it impedes the baby’s process through the birth canal and can lead to tailbone injuries in the mother.
So how are we to think of these procedures, which some doctors still insist on? If a procedure is not, strictly speaking, medically necessary to a healthy birth and may even be contraindicated, why is it being performed? Anthropologist Robbie E. Davis-Floyd proposed that these interventions be designated as rituals, in the sense that they are no more scientifically justified than the actions of a “primitive” healer. They do not serve any physiological purpose, only what she calls “ritual purposes.” The enema and shaving underscore the notion that the woman is an unclean and even unwelcome presence in the childbirth process. Anesthesia and the lithotomy position send “the message that her body is a machine,”8 or as Davis-Floyd quotes philosopher Carolyn Merchant, “a system of dead, inert particles,” in which the conscious patient has no role to play. These are, in other words, rituals of domination, through which a woman at the very peak of her biological power and fecundity is made to feel powerless, demeaned, and dirty.
In one sense, childbirth rituals “worked.” The women giving birth were often traumatized, reporting to Davis-Floyd that they “felt defeated”9 or “thrown into depression”: “You know, treating you like you’re not very bright, like you don’t know what’s going on with your own body.”10 Yet, having submitted to so much discomfort and disrespect, they were expected to feel grateful to the doctor for a healthy baby. It was a perfect recipe for inducing women’s compliance with their accepted social role: rituals of humiliation followed by the fabulous “gift” of a child.
But often, as in my own case, the rituals backfired and left women infuriated by their treatment during pregnancy and childbirth. It isn’t easy to protest from the lithotomy position, but, in effect, growing numbers of women were rising to their feet and refusing the required medical interventions, even opting for homebirths and midwives. By the time my children hit two-digit ages, a nationwide women’s health movement was challenging the misogyny it diagnosed in so much of women’s care—from hazardous contraceptives to a barbarous form of breast cancer surgery, the Halsted radical mastectomy, that left its victims partially crippled. We managed to reform hospital obstetrical practice, winning acceptance for the Lamaze method, demanding and getting more female doctors, and asserting our right to participate in decisions throughout the process.
But just as we made these gains, obstetric care was becoming more intrusive and controlling in other ways. Electronic fetal monitoring during labor became routine even for low-risk births, and when the monitoring was conducted internally, through a probe inserted through the vagina, the woman had to remain bedridden throughout labor. Slight fluctuations in fetal heart rate could set off disproportionate alarm, leading to a shockingly high rate of caesarean sections—30 percent—that began to level off only in 2009. No longer could we place all the blame for the mismanagement of childbirth on “patriarchy.” Women were also up against technocracy, as Davis-Floyd writes, and the idea that any procedure involving wires, drugs, and scalpels was inherently superior to anything that proceeded without technological intervention.
Even at the height of the Women’s Health Movement, we hesitated to extend the feminist critique to those aspects of care that are not specific to women. True, on the academic and New Agey fringes of the movement, there were plenty of women who began to lump together patriarchy, technology, science, and imperialism into a single monolith bent on universal domination. Most of us, though, claimed science for our side, and took it as our mission to restore scientific rationality to a medical enterprise contaminated by sexism. We tended to assume that aside from women’s care, medicine was relatively unbiased and neutral in its social impact.
Not so, argued social critic Ivan Illich in his 1975 book Medical Nemesis, which documented the negative effects of medical care on both sexes, in particular the toll of iatrogenic illnesses, that is, those induced by pharmaceuticals and the medical procedures themselves. Furthermore, he stated that medical institutions represent a vast system of social control, ruled by an “educated elite”:
Medicine has the authority to label one man’s complaint a legitimate illness, to declare a second man sick though he himself does not complain, and to refuse a third social recognition of his pain, his disability.11
Like women, men who were not members of the educated elite—poor or working-class men—often faced a hostile and condescending medical profession. In a 1976 article, sociologist Irving K. Zola offered the case of his own father, a blue-collar worker who was advised by his physician to switch to a “desk job”—as if that were a possibility. Zola, an avid supporter of the Women’s Health Movement, saw male as well as female patients being required to enact a ritual of deference to the doctor and the bureaucracy he was embedded in:
Whether it be horizontal or in some awkward placement on one’s back or stomach, legs splayed or cramped, or even in front of a desk, the patient is placed in a series of passive, dependent, and often humiliating positions.12
According to critical thinkers like Zola and Illich, one of the functions of medical ritual is social control. Medical encounters occur across what is often a profound gap in social status: Despite the last few decades’ surge in immigrant and female doctors, the physician is likely to be an educated and affluent white male, and the interaction requires the patient to exhibit submissive behavior—to undress, for example, and be open to penetration of his or her bodily cavities. These are the same sorts of procedures that are normally undertaken by the criminal justice system, with its compulsive strip searches, and they are not intended to bolster the recipient’s self-esteem. Whether consciously or not, the physician and patient are enacting a ritual of domination and submission, much like the kowtowing required in the presence of a Chinese emperor.
Some physicians, unsurprisingly, see medical rituals very differently. Instead of defending their procedures as scientific and invoking their personal experience as a form of “evidence” every bit as worthy as statistics, they defend ritual as the core of the medical encounter. Patients may care about a “cure,” but they are even more intent on engaging in a ritual. One of the loudest proponents of medical ritual is Stanford medical professor Abraham Verghese, who wrote in a New York Times op-ed that most patients expect certain procedures when the doctor sees them, “and they are quick to perceive when he or she gives those procedures short shrift by, say, placing the stethoscope on top of the gown instead of the skin, doing a cursory prod of the belly and wrapping up in 30 seconds. Rituals are about transformation, the crossing of a threshold, and in the case of the bedside exam, the transformation is the cementing of the doctor-patient relationship.”13
And what is the nature of this relationship? As he expands in a TED talk, it is a relationship based on the patient’s submission to inquiries and physical contact that would normally be seen as rude or, worse, assaultive:
Well I would submit to you that the ritual of one individual coming to another and telling them things that they would not tell their preacher or rabbi, and then, incredibly on top of that, disrobing and allowing touch—I would submit to you that that is a ritual of exceeding importance.14
This is, to say the least, a muddled proposition: Is the ritual necessary to soften whatever discomfort might be caused by the intimacies required for good medical care? Or is it the other way around—that the intimacies are required to heighten the drama of the ritual? Apparently the intimacies may in no way be required for successful care, but patients—always unnamed, of course—demand them anyway. Verghese offers an anecdote about a breast cancer patient who had gone for her treatment to what she judged to be “the best cancer center in the world,” only to return a few months later to the less prestigious facility where she had been diagnosed. He runs into her there and asks, “Why did you come back and get your care here?”
And she was reluctant to tell me. She said, “The cancer center was wonderful. It had a beautiful facility, giant atrium, valet parking, a piano that played itself, a concierge that took you around from here to there. But,” she said, “but they did not touch my breasts.” Now you and I could argue that they probably did not need to touch her breasts. They had her scanned inside out. They understood her breast cancer at the molecular level; they had no need to touch her breasts.15
Here the defense of medical ritual verges creepily on the excuse commonly offered by sexual assailants: “She was asking for it.”
None of which is to say that human interactions—including rituals and touch—play no role in health care. Think of the mother’s kiss that magically relieves a toddler’s boo-boo or the reassurance that emanates from a concerned and kindly health care provider. Our bodies are not cadavers; they are inhabited by our minds, through which we are connected to other humans and animals both living and dead. Strengthen those connections and we are likely to feel better. Threaten or sever them and the result could be fatal, as in cases of “voodoo death,” widely observed in traditional societies, where a person who has received a death curse or broken a powerful taboo dies within a day or so for no apparent physical reason.
There is hard evidence for the efficacy of ritual displays of concern in the form of the well-documented placebo effect: Patients given a sham treatment—say, a sugar pill—are more likely to feel better than those given no treatment, real or fake, at all. In one study, those who received a fake treatment along with care described by the experimenter as “very schmaltzy,” with elaborate expressions of concern (“I’m so glad to meet you”; “I know how difficult this is for you”) while being touched on their hands and shoulders, did better than those who had been given their placebo in a more brusque and impersonal fashion.16 This result was attributed by some to “positive thinking”—if you expect that an intervention will help, it probably will.
But then the experimenter, Ted Kaptchuk of Harvard Medical Services, eliminated the effect of positive expectations: He and his team told a subgroup of patients that what they were being given was in fact a placebo, “like a sugar pill.” “Not only did we make it absolutely clear that these pills had no active ingredient and were made from inert substances, but we actually had ‘placebo’ printed on the bottle.” To the researchers’ surprise, the patients who knowingly took the placebo experienced improvements comparable to those who took a real, FDA-approved medicine for their condition (irritable bowel syndrome). “These findings,” says Kaptchuk, suggest “that there may be significant benefit to the very performance of medical ritual.”17
Physicians who, like Verghese, emphasize the importance of the medical encounter as a ritualized interaction may take comfort from these placebo studies. From a scientific standpoint, though, they cast yet another awkward light on the epistemology of medicine. The idea, going back at least to the turn of the twentieth century, had been that medical procedures were entirely rational, with each step dictated by well-tested biomedical principles. Everyone acknowledged a role for incalculable factors like “schmaltz” or “bedside manner,” but this role was thought to be auxiliary to the main event—the surgery, administration of pharmaceuticals, or interventions of scientifically proven value. But if what the patient really needs, at least in some cases, is attention and some display of concern, why is the practice of medicine limited to laboratory-trained physicians operating in massively capital-intensive medical institutions?
Well, it could be argued that science, or the veneer of science, is required to make a ritual acceptable to modern, educated people, who are unlikely to be impressed by drumming and animal horns. The Ihamba ritual may be the culturally appropriate way for the Ndembu people to express concern for an afflicted person; Westerners require the trappings of big science—imaging machines, centrifuges, and sterile, or at least blank, interior rooms. But to my knowledge no one has tested this proposition. Would it help to add cut flowers, soothing music, and friendlier faces to the conventional medical encounter? Does all the equipment have to be real, or would cardboard imitations do just as well? And if the real point of medical ritual is to demonstrate social support for the patient, surely we could do so in ways that are less grotesquely expensive, as well as less stressful and demeaning.