ASA Decennial Conference - Anthropology and Science

Anthropology, medicine and law: notions of evidence

Contact Convenor: Helen Lambert

Senior Lecturer in Medical Anthropology, University of Bristol

Tel: 0117 9287332.

h.lambert@bris.ac.uk

Panel abstract

What constitutes ‘evidence’ in anthropology? This panel seeks to explore central questions about the nature and applications of anthropological knowledge and the status of anthropology as ‘science’, mainly through work conducted in the broad field of medical anthropology, which has particular relevance for the conference theme.

In recent years medical science and public health have increasingly accepted qualitative research approaches as legitimate strategies for the acquisition of useful knowledge. Paradoxically, Evidence-Based Medicine (EBM) has over the same period grown into a dominant movement, based on a notion of evidence that rests on particular assumptions about the nature and grounds of usable scientific knowledge. These assumptions not only set the limits of what constitutes admissible evidence, but increasingly determine what ideas are considered legitimate to have and pursue within medicine and public health. Anthropologists and other social scientists working in health and medicine are forced to argue for the legitimacy of their assumptions about knowledge within this ‘evidence-based’ framework.

Everyday disciplinary practices necessarily draw on notions of what constitutes legitimate evidence – for example, in evaluating a monograph or refereeing a paper based on ethnographic fieldwork – but these notions remain largely implicit and unexamined in academic anthropology. This panel invites contributors to reflect on these practices and to compare them with science-based notions of ‘evidence’ that are prominent in health research. Such notions are contested by many health practitioners, whose insistence on a place for practice-based comprehension, intuitive skills and experiential knowledge parallel characterisations of ethnographic understanding. Related contributions regarding the way scientific agendas are produced and relationships between the legitimation of particular kinds of ‘evidence’ and the power to define knowledge and knowledge production are also welcome.

Embodied, inter-subjective interactions or disembodied randomised control trials: what constitutes evidence in alternative medicine?

Christine Ann Barry, Brunel University

From the perspective of the biomedical system (Ernst 2000) and the political establishment (House of Lords 2000), randomised control trials comprise the ‘gold standard’ in assessing efficacy of alternative therapies. Such ‘evidence’ is used strategically to reduce potential threat from alternative medicines, feeding into incorporationist and assimilationist policies (Saks 1996). (For example limiting NHS acupuncture to specific biomedically defined diagnosis categories (Campbell 1998).

From anthropology’s perspective, ‘evidence’ includes concepts such as transcendent, transformational experiences (Csordas 1994); inter-subjective consensus (Hsu 1996), giving meaning (McGuire 1988); changing lived-body experience (Busby 1999); and promoting health cosmologies that are consonant with experience (Barry 2003). Methodologies for the collection of such ‘evidence’ include focusing on embodied and intersubjective experience, embedded in context and process, such as that conducted during an ethnography of homeopathy in lay and biomedical settings (Barry 2003).

These two differing notions of evidence are firmly rooted in different cosmologies of the body, health and healing. In theory, the anthropological way of seeing the world has much in common with the philosophical underpinnings of alternative medicine, making anthropological evidence more relevant (Long, 2000). In practice, power dynamics mitigate against anthropologists influencing the biomedical evidence base to include these other types of knowledge.

Barry, C. A. 2003. The body, health, and healing in alternative and integrated medicine: An ethnography of homeopathy in South London. Unpublished PhD Thesis. Brunel University, Uxbridge.

Objectivity in anthropology and law: uses of ‘objective evidence’ in asylum appeals

Anthony Good, University of Edinburgh

This paper examines the position of an anthropologist acting as an expert witness in this jurisdiction.  It explains the circumstances under which expert evidence is sought, and the forms taken by the Œinstructions¹ which anthropologists receive from the solicitors acting for the asylum seeker. It looks at the legal position of a designated expert witness in civil cases generally and in the particular circumstances of an asylum hearing where strict rules of evidence are relaxed; and discusses the constraints and requirements governing the structure of an expert¹s written report.  It then examines the notion of Œobjective evidence¹, in light of the distinctive epistemologies of anthropology and law, and looks at how such evidence is used by the two parties to an asylum appeal.  The anthropologist¹s position is compared with that of a medical expert providing the court with physical or psychiatric evidence on the asylum-seeker¹s condition.

Anthropological meanings and the hubris of measurement: reclaiming “culture” in health research

Linda M. Hunt, Michigan State University

In the US, the concept of “culture” has recently captured the imagination of a broad cross-section of health researchers, care providers and policy makers. However, this has occurred with minimal input from anthropologists. Instead, popular notions of the cultural “other” have been galvanized into a set of operationalized variables and practice protocols, wherein the objective reality of cultural difference is presupposed, and the work at hand is to uncover and influence discreet chains of cause and effect. In this paper I will consider how the anthropological concept of “culture,” as a complex web of diverse interacting factors, has been transformed by quantitatively oriented health researchers, into a set of normative criteria and algorithms. The epistemological differences between anthropological and clinical ways of knowing which have contributed to anthropologists’ failure to establish an influential voice in this area will be considered and ways that paradigmatic differences might be transcended toward a productive inter-change of ideas will be suggested.

Accounts of the ineffable: quality of life discourses and practices in health care

Chris McKevitt, King’s College London

The effectiveness of medical interventions needs to be demonstrated by measurement of the outcomes achieved by the intervention. For the most part, this entails measurement of aspects of the body (presence/absence of pathology, indicators of function, indicators of bodily performance). Extra-corporeal assessments – largely those which are subjectively evaluated by recipients of services - are also increasingly required. Such assessments include handicap (social function), mood, satisfaction with service delivery and quality of life. 

Outcome assessment responds to the requirement for a rationalised delivery of health care: that interventions work and that they are economically viable. Yet the assessment of subjective outcomes also responds to a political imperative to define health more broadly than the absence of pathology, and a concomitant notion that the subjective views of consumers of health care commodities also constitute evidence of an interventions value or otherwise.

'Quality of life' in particular has become a core concept in western medicine and assessment of individual patient quality of life is increasingly advocated in the evaluation of treatment outcomes and organisation of health care services. It has also been recently suggested that routinely using of quality of life assessment in clinical practice would improve the quality of medical care. However, quality of life is a term that has multiple meanings and there are increasingly myriad approaches to its measurement.

This paper presents findings from a study of the concept of quality of life and its applications in the health care of older people with stroke. Focusing on contrasting definitions of the concept and clinical resistance to quality of life assessment as a form of resistance to evidence based practice, I will argue that ‘quality of life’ as both concept and practice is a symbolic form which uses the language and structure of evidence based medicine to quantify and evoke ineffable elements in the relationship between sufferer healer and society.

Gatekeepers of knowledge and the cultural construction of evidence in mental health systems: some experiences from fieldwork in the west of Ireland

Roberta McDonnell, Queen’s University, Belfast

Bourdieu has well captured the anthropological endeavour by stating that one of the first considerations in the analysis of knowledge is an awareness of the conditions of the generation of knowledge. Past and recent research activity first as a project nurse in a community mental health research team using quantitative survey methods, then as an anthropology undergraduate doing ethnographic research in a mental health hostel in Northern Ireland, brought out some of those contrasting conditions in terms of disciplinary orientation, social and economic context, and methodological philosophies and value systems. Not least is this paradox manifest in the types of questions asked and the uses to which that information will be put. Postgraduate fieldwork in progress entails participant observation in a village and townland area in the West of Ireland, including city and county based professional services and user-led research initiatives. Some of the currently employed evaluation methods for practice efficacy will be described, as well as some of the difficulties encountered during attempts to access aspects of these networks. Understanding the processes involved such as resistance to ‘soft’ i.e. qualitative methodology, has initiated a reflection on the nature of anthropology as a discipline and our positioning within the wide arena of academia, including relations with professional practitioners.

It is suggested that some of the responses encountered during this fieldwork project can be understood as having their origin in attitudes to the nature of practice-relevant ‘evidence’, that is to say how ‘scientific’ the research is considered to be, and therefore how useful in terms of clinical practice and service policy.  If ‘science’ is taken in its broadest sense as meaning all or any form of knowledge then it must be asserted that anthropology is of course, a science. But the term ‘science’ has taken on a more restricted meaning, with an assertion of greater objectivity and thus more acceptability as ‘evidence’ – in particular when this ‘evidence’ will shape clinical practice and social policy. User-led research initiatives seem also to have adopted a highly structured and quantified method for their investigations, though incorporation of tagged-on ‘qualitative’ elements is becoming more evident in both professional and service-user ‘tools’.

Yet there is still a sense that the crucial influence of symbolic meaning systems in the formation of human experience remains unaddressed and this is relevant to both ‘service user’ experiences and actions, and to how they are interpreted and responded to by both their immediate social relations, wider social networks and health care professionals. It is here that anthropologists have the greatest potential for input into the multi-disciplinary arena of mental health service provision and theory and policy development. In that arena however, the anthropological slant has arguably (aside from small pockets of activity), not made significant waves in terms of  mainstream health care research, policy and practice, as has e.g. experimentally-based clinical psychology. The extent to which this state of affairs may be due to internal debate regarding the nature and orientation of the discipline of anthropology is the final consideration of this paper.

Evidence in medicine, anthropology and the other medicine

Harish Naraindas

Both anthropology (and the social sciences in general) and medicine are interstitial disciplines compared to disciplines like either physics or literature. Since both deal with mind and body, or with fact and value, they have been unable to decide ever since the enlightenment whether their method of constituting their enquiry should be quantitative (fact) or qualitative (value). The history of the social sciences bear testimony to this schizoid birth and the constant swing between the two poles leading to two different notions of what constitutes admissible evidence. Hence anthropology can be opposed to medicine, or each can re-duplicate the division within themselves leading to a fractal cycle.  

Ethnology and anthropology between them have traditionally been the other of science in so far as their provenance has been belief rather than knowledge. And medical anthropology till late either skirted notions of efficacy in the other (its traditional provenance) medicine, or put it down to belief.  It is only of late that notions of efficacy have had to confront the possibility that efficacy may not be either due to ‘unbridled empiricism’, or the product of belief, but may be based on knowledge. Or that efficaciousness may be neither contingent on practice, nor (only) on superstitious belief, but based on a theoretical corpus either as text or as embodied practice.

This by no means has made things easier. It has meant what it has meant for the last two hundred years: that these other theories are false. Hence the intractable problem of chronic pain in pain clinics in the West, which is increasingly handled by acupuncture, is explained not by theories that gave birth to the therapy but by medical theories of the release of endorphins that mute pain. But nowhere is there the attempt to grapple with how ‘false’ theories can give birth to the right ‘technique’. Part of this conundrum comes from notions of what constitutes admissible evidence, which in turn is based on certain founding theories of the body and the world.

Practitioners of alternate medicine and their patients play out this schism between evidence and efficacy in the contemporary world. I examine the case of one such practitioner to show that patients, as ‘carriers’ of orthodox medicine, often want evidence not only of cure but also of diagnosis and prognosis. They also want evidence of the fact that they have been properly examined.  And they want evidence that the prescription (and cardinally proscription) in its ‘entirety’ has therapeutic value. This duel between doctor and patient, based on doubt and scepticism, comes from the fact that most patients in the contemporary world have particular conceptions of evidence given to them through a long and thorough socialisation. Through a set of case studies I will problematise these contrasting notions of evidence. I will attempt this through the case of a patient who sued my practitioner for negligence and invoked the authority of another practitioner to do so. 

Aesthetic of the cryptic - gathering evidence amongst families of the disappeared in Southern Sri Lanka

Alex Argenti-Pillen, University College London

This paper discusses how the careful deconstruction of evidence is a powerful tool of survivor hood amongst victims of political violence in Sinhala Buddhist rural communities. I argue that this lack of evidence is not merely linked to the fact that institutional frameworks (judicial, medico-scientific), that construct evidence for elite populations in Sri Lanka, are not available in the rural slums. Nor can this tendency to avoid the authoritative presentation of evidence solely be linked to a culture of repression or extreme violence. Examples from the linguistic repertoire of people from the village of Udahenagama show how the cultural construction of authorship and of the relationship between speaker and interlocutor precludes the emergence of collective knowledge about the atrocities of the civil war. I argue that this style of knowledge production about wartime events plays a crucial role in the containment of widespread violence. In this paper I frame the systematic deconstruction of evidence in the everyday life of post-war communities in Southern Sri Lanka within a wider cultural debate on the aesthetic of the cryptic in South Asian cultures (see Malamoud, Jamous, Heesterman). I furthermore discuss how this aesthetic necessarily influences the construction and presentation of an ethnographic analysis. .

Alex Argenti-Pillen 2003 Masking Terror. How Women Contain Violence in Southern Sri Lanka. Philadelphia: Pennsylvania University Press.

Questioning sex in a South African township: reflections on the nature of ethnographic and 'qualitative' evidence

Kate Wood, University of London

Qualitative methods have increasingly been accepted in public health as legitimate strategies in the acquisition of useful knowledge, alongside quantitative approaches. Their importance in sexual health research has been emphasised by the HIV/AIDS epidemic, whose complexity has demanded nuanced social analyses of practices relating to sexuality and risk-taking. Public health-oriented research that makes use of qualitative methods to explore 'local' sexual practice, experiences of sexual ill/health and responses to HIV/AIDS continues to rely heavily on 'self-reported behaviour' produced from one-off interviews or 'focus group' encounters. While anthropologists have contributed to this body of research, ethnographic methods continue to be under-utilised. This paper reflects on the kind of evidence produced by long-term ethnographic approaches to sexual health, asking how this compares to evidence arising out of the application of short-term qualitative methodology. It draws on the author's experiences of both research strategies before and during doctoral fieldwork on sex and violence with South African township youth.

The social sensitivity of sexual matters, the exceptionally private nature of many aspects of sexual lives and the social riskiness inherent for individuals in exposing their experiences and positionings mean that while sexual health researchers are heavily reliant on narrative accounts and spoken dialogue as sources of evidence, interpreting such evidence is fraught with danger. Analyses based on qualitative methods have tended to be slow in recognising and addressing this.  

Using specific examples from fieldwork, the paper describes how understanding of the complexity and inconsistency of public and private talk about sexual practice deepened with ongoing participant observation. Long-term ethnography revealed this to be a setting in which coded ambiguity and contestation featured prominently in talk about sex and violence. The generation of evidence relating to practices that were so vulnerable to public censure, and on which personal questions of reputation and identity were in important ways dependent, was heavily influenced by the specifics of context, and by the nature of the relationships cultivated between the ethnographer and her informants. Ethnographic approaches allowed practices of secrecy and exposure in relation to sex and violence, and the gendered nature of these, to be revealed. This in itself offered possibilities for the generation of understanding. Young men's talk about their violent practice, for instance, displayed elaborate discursive strategies that shed light on wider processes of moral mapping in which notions of blame, legitimacy and the displacement of responsibility featured prominently.

The paper suggests that the weaknesses contained in short-term qualitative approaches relate to their acceptance of narrative evidence at face value, their inability to interrogate in depth the complex politics of language relating to sex and violence in order to generate understanding, and their effacement of the importance of the researcher's positioning in the production of evidence.

Discussants: Ursula Sharma, Sophie Day & Stephanie Schwandner-Sievers