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Diversity, Conflict, and Recognition in Hospital Medical Practice

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Abstract

The hospital is a place of encounter between health care providers, patients and family members, the healthy and the suffering, migrants and non-migrants, as well as social and cultural minorities, and majorities of various backgrounds. It is also a space where multiple conceptions of care, life, quality of life, and death are enacted, sometimes inhibiting mutual understanding between caregivers and the cared for, a scenario that in turn may provoke conflict. Through the lens of conflict, we explore in this article the theme of Otherness within the clinic, basing analysis on an ethnographic study conducted in recent years in three cosmopolitan Canadian cities. Daily practices and—on a larger scale—the social space of the clinic become material here for reflecting on recognition (and non-recognition) of the Other as actors in the clinical encounter. The examination of structural and situational conditions that contribute to the emergence of conflict offers an understanding of the diversity of values that pervade the clinic. By way of conclusion, we argue that recognition of diversity, at least on the part of practitioners, is a key condition for the emergence of a pluralist normativity in the social space of the clinic.

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Notes

  1. In line with Weber’s (1946:155) predicament regarding medicine’s bureaucratization, Cassell (2005:40) discusses this issue, where the “art of medicine” (associated with clinical expertise) evolves into the “delivery of medical care,” which refers to a form of scientific medicine where evidence plays a vital role, distancing “care” from the medical role.

  2. This pluralist normativity is inherent to different moral worlds (Boltanski and Thevenot 1991). In the clinic, we could further argue that this plural normativity calls for an internormativity approach (Rocher 1996), where power relations and modes of interactions between different normativities are taken into account.

  3. Authors’ translation.

  4. Authors’ translation.

  5. Saillant and Gagnon (1999) point out that the concept of care is plural, referring to a variety of representations and expectations for both sides. Worms (2012:8) emphasize its political nature: “its moral and social function, its share of violence, its dimension of justice and institution, its creativity […]”.

  6. See The Course of Recognition (2005) for the English translation (David Pellauer), Harvard University Press.

  7. In this sense, recognition precedes knowledge and is achieved through an asymmetric relationship between persons who recognize (or have capacity to recognize) and persons who “deserve to be recognized” (Ricoeur 2004:155). See also Honneth (2004) on this topic.

  8. According to Clifton-Soderstrom (2003:459): “The need for patient voices is a response to modern medicine’s imposition of a scientific language on illness experiences which universalizes persons into general categories before understanding their specificity.” Similarly, almost 30 years ago, Kleinman (1988) and Good (1993) highlighted the importance of patient narratives in the doctor/patient relationship. More recently, however, Kleinman (2013, 2012) has questioned medicine’s capacity to do so.

  9. This is unlike Taylor (1992, 1994), for whom recognition in the Canadian multiculturalist context involves group relations, putting culture and ethnicity at the forefront.

  10. After an exploratory phase (2003–2004), the study Clinical practices in pluralistic context was supported by the Canadian Institutes of Health Research (CIHR 2005–2011) and conducted in a collaborative fashion with anthropologists, doctors, nurses, ethicists (S. Fortin [PI], G. Bibeau, F. Alvarez, D. Laudy, F. Carnevale, M. Duval, F. Gagnon - University of Montreal, McGill University and CHU Sainte-Justine) and many health care providers from the different hospitals taking part in the study (Montreal, Toronto, Vancouver).

  11. Source: Statistics Canada, 2007. 2006 Census, Community Profiles.

  12. We worked with an open-ended interview guide where probing questions gave way to more detailed inquiry as interviewees revealed their experiences and insights on major topics related to practicing medicine (or nursing) in contemporary urban settings. In regards to urban pluralism, our initial questions were: “Montreal (Toronto or Vancouver—depending on research site) is a pluralist city. Do you meet many migrants in your practice? Where do they come from? Does this bring on specific challenges (such as—communication or gender issues, decision making process, consent [and the notion of informed consent], other [end of life, quality of life]—)?”. And in regard to the city (life outside the hospital), “what can you tell me about the social/ethnic relations (or immigrant/non-immigrant relations) in Montreal (Toronto or Vancouver)?”.

  13. Unlike Bluebond-Langner’s (1978) seminal work and Bonnet’s (2011) more recent study, we interacted with the children on only rare occasions, either because their conditions were critical or they were very young.

  14. By symbolic resources, we understand the social recognition of the group to which the patient (and his family) is thought to belong, and the value of this position within a given setting (Taboada-Leonetti 1994).

  15. Compliance understood as consent to a plan of care (Carle 2013).

  16. Participant names have been changed to ensure anonymity.

  17. These two qualifiers are used by caregivers, the word “difficult” being mentioned more often.

  18. This recalls the work of Kirmayer (2012) who highlights that culture is often thought of as a set of features, values, beliefs, and attitudes equally shared by a circumscribed group. This approach favors a reification of difference (or its negation) at the expense of the contextualization of the patient, their history, and their experience of the disease.

  19. The clinic understood as a social space for meetings between the healthy and suffering, migrants and non-migrants, minority and majority groups (the latter being normative in a given environment) of diverse backgrounds (origins, social status, and faiths).

  20. Our interview with Sophia’s mother was conducted in English. Throughout our encounter, she was able to convey her questions, doubts, and frustrations quite clearly.

  21. See Marie-Anne (forthcoming) on this issue.

  22. While the organization of intensive care responds to acute care situations, it is quite another situation for “acute chronic patients,” who depend on reanimation technology and who remain in a very different trajectory of care (Fortin, forthcoming).

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Acknowledgments

This study was funded by the Canadian Institutes of Health Research (MOP - 74673).

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Authors and Affiliations

  1. Department of Anthropology, Université de Montréal, C.P.6128 succ. Centre-ville, Montréal, QC, H3C3J7, Canada

    Sylvie Fortin

  2. McGill University Health Center, Montréal, QC, Canada

    Serge Maynard

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  1. Sylvie Fortin
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Correspondence to Sylvie Fortin.

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Conflict of interest

Sylvie Fortin declares she has no conflict of interest. Serge Maynard declares he has no conflict of interest.

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This study received approval from relevant Ethics Review Boards at all participating institutions. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in this study.

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Fortin, S., Maynard, S. Diversity, Conflict, and Recognition in Hospital Medical Practice. Cult Med Psychiatry 42, 32–48 (2018). https://doi.org/10.1007/s11013-015-9461-8

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