Medicine's Symbolic Reality

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Medicine's symbolic reality

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Arthur M. Kleinman
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Harvard University,
Version of record first published: 29 Aug 2008
To cite this article: Arthur M. Kleinman (1973): Medicine's symbolic reality,

Inquiry: An Interdisciplinary Journal of Philosophy, 16:1-4, 206-213
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Inquiry, 16, 206-13
Medicine's Symbolic Reality

On a Central Problem in the Philosophy of Medicine
Arthur M. Kleinman
Harvard University
Modern socio-cultural studies of medicine demonstrate the symbolic

character of much of medical reality. This symbolic reality can be
appreciated as mediating the traditional division of medicine into biophysical

and human sciences. Comparative studies of medical systems offer a general
model for medicine as a human science. These studies document that
medicine, from an historical and cross-cultural perspective, is constituted as a
cultural system in which symbolic meanings take an active part in disease
formation, the classification and cognitive management of illness, and in
therapy. Medicine's symbolic reality also forms a bridge between cultural and
psychophysiological phenomena; the basis for psychosomatic and socioso-
matic pathology and therapy. This in turn becomes a central problem for
medical theory and for a philosophical reinvestigation of medicine.
'Our language can be seen as an ancient city: a maze of little streets

and squares, of old and new houses, and of houses with additions from
various periods ; and this surrounded by a multitude of new boroughs
with straight regular streets and uniform houses.'
Ludwig Wittgenstein, Philosophical

Investigations, trans, by G. E. M.
Anscombe (Blackwell, Oxford
1968), p. 8.
Wittgenstein's winsome metaphor for scientific language ('straight

regular streets and uniform houses') against ordinary language ('maze
of little streets . . . of old and new houses') applies quite aptly to a
traditional distinction in medical theory: medicine deals with two
kinds of reality, 'scientific' and 'ordinary'; or, put differently, it is
both a biophysical and a human science. Modern medical theory has
concerned itself almost entirely with the wide, well-designed and
clearly mapped suburban avenues of the former, particularly in the
study of disease, its biological substratum, and its determinants,
effects, and control. Often the biophysical root of modern medicine
has been used as the basis for a general critique of the whole of medi-
cine; an example of which is the great amount of consideration given
Medicine's Symbolic Reality 207
to the precise definition of such abstractions as illness and health, a

largely unprofitable endeavor which has characterized much of what
could be called the philosophy of medicine. Only recently has there
been more than superficial and somewhat embarrassed attention
given to medicine as a socio-cultural system, as a practice and a human
reality. Obviously, it is this archaic root of medicine which strikes us as
most like the twisting, narrow, unmapped streets and clutter of old and
new houses of the ancient inner city, Wittgenstein's analogy for the
messy and poorly understood, yet crucial, social and individual
aspects of language. Likewise these sides of medicine, which are now

appreciated for their enormous importance, though not at all clearly
understood, present a challenge to the modern theoretical structure
of medical science, a structure based largely upon knowledge limited
to medicine's biophysical reality.
Recently, the pendulum has swung away from the theoretical
disinterest and even scorn shown by entrenched medical empiricism
for medicine as a human science to a kind of theoretical chaos, as
various social and behavioral science theories are stretched and
forced to fit an elusive medical subject. Even though no sound theo-
retical integration or systematic critique of this enterprise has yet been
forthcoming, there is general agreement that the socio-cultural
approach is beginning to radically remake our understanding of
medicine and, accordingly, we find the traditional dichotomy in
scientific medicine undergoing marked change. Here again, the
quotation from Wittgenstein, who apropos of our subject did speak of
the similarity between philosophical investigations and medical
healing, is most relevant, since he was writing about language as a
mediating reality, and¿ as we shall attempt to adumbrate below, the
realm of symbolic reality would appear to mediate between medicine's
dual roots so as to form a bridging or unifying reality, which itself
becomes a central problem for medical theory.
All of this is the result of several new perspectives on medicine, and
for that matter science generally, which have focused their attention
upon the relation of medicine and science to culture.1 Moreover, these
historical, anthropological, sociological, psychiatric, and medical
field studies have begun to unify their interests around a common
theme, the comparative study of medical systems : that is, appreciation
for the structure and significance of medicine as a health care system in
different cultural settings and historical contexts.2 Recent develop-
ments in the sociology of knowledge, linguistic theory, and structural
208 Arthur M. Kleinman
and symbolic analyses have made important contributions to the

reconstruction of given medical systems, which in turn have been
compared, either in part or as total structures, historically and cross-
culturally.3 This approach has produced a remarkable body of re-
search findings and offers a phenomenology of medical practice. It is
my intention to bring certain of these findings to bear upon the
question of medical reality. In briefly doing so, I hope to demonstrate
that the study of medicine as a social and cultural enterprise represents
not only a fundamental breakthrough in our understanding of medi-
cine, but also openly invites broad philosophical enquiry into medicine,
something that has been strangely and seriously lacking in the past.
No matter what the perspective — diachronic or synchronie —
medicine is always found to constitute a system. The medical system is
an ordered, coherent body of ideas, values, and practices embedded in
a given cultural context from which it derives its signification. It is an
important part of the cultural world and as such it is constructed, like
any other segment of social reality, by the regnant body of symbolic
meanings. The medical system forms an indissoluble and hierarchical
whole in which healing acts are closely linked with ideas about
disease causation and models for classifying disease. The whole is
oriented toward the problem of effectively dealing with illness. From
this viewpoint, healing is not the outcome of diagnostic acts, but the
healing function is active from the outset in the way illness is perceived
and the experience of illness organized.
Medical systems function along the lines of the cultural dialectic,
relating and treating both individual and social realities. In fact, the
patient for most medical systems has traditionally been both the
individual and his nexus of social relations. The acts of ordering,
naming, interpreting, and offering therapy for illness are aspects of
symbolic reality common to both the sick individual, the healer, and
their society. Medical systems employ different explanatory models
and idioms to make sense of disease and give meaning to the individual
and social experience of illness.4 Meaning and efficacy, until the veiy
recent advent of biomédical technologies which actually control
biochemical, physiological, and psychological processes, have always
been inseparable in medical healing. Medical systems may be crudely
characterized as expressions of the cultural loci of power which they
utilize to explain and control illness.5
A given medical system in its socio-cultural context does consider-
ably more than name, classify, and respond to illness, however. In a
real sense, it structures the experience of illness and, in part, creates

the form disease takes. Disease occurs as a natural process. It works
upon biophysical reality and/or psychological processes, as the case
may be. But the experience of illness is a cultural or symbolic reality.
The experience of illness involves feelings, ideas, values, language and
non-verbal communication, symbolic behavior, and the like. What is
perceived as illness in one culture may not be so perceived in another.
We know a great deal today about typing and labeling of diseases, less
so about symptom choice and culturally specified disease forms, and
just enough about how illness behavior is learned and socialized to

know that socio-cultural factors are of enormous importance. More
than that, we know that symbolic communication forms a pathway of
sorts between social and cultural events and psychophysiological
reactions.6 Psychosomatic pathology has been well described, but we
are just learning about sociosomatic pathology. The line begins to
blur between ordering the experience of illness and shaping illness
per se. I do not mean merely that psychiatric disorders or psychoso-
matic diseases are in this sense symbolic phenomena, but any disease —
smallpox, leprosy, syphilis, hypertension, cardiovascular disorders,
cancer, etc. — is in part a cultural construct. Disease derives much of
its form, the way it is expressed, the value it is given, the meaning it
possesses, and the therapy appropriate to it in large measure from the
governing system of symbolic meanings.
Medical knowledge is intended to be effective. This can be seen in
the way diseases and their therapies are taxonomized. Medical classi-
ficatory schemes are most often not objective descriptions of empirical
reality. Rather they reflect healing concerns and the theoretical
biases of given cultural and medical ideologies. Classification of
disease is, in fact, the first therapeutic act. Classificatory schemes are
intended to domesticate and make known a 'wild' and unknown
phenomenon, which threatens the very idea of social order and
personal stability, and transform it into something known, named,
and thus manageable. In this sense, ideas of witchcraft as a random
and highly malignant explanatory model are not at all badly matched
with diseases such as endemic malaria and the pneumonia-diarrheal
complex of disorders of infants, which are random and highly malig-
nant. Some diagnostic systems are entirely symbolic, relating specific
illnesses to specific therapies.7 Though much of what we are describing
for medical cognitive systems pertains for the most part to traditional
forms of medicine, there are certainly a number of modern equiv-
alents as students of social deviance and those studying the sociololjy

of medical knowledge, for example, are wont to point out.8
The ring of medicine's symbolic reality is made complete in the
question of healing. Healing is an elemental social function and
experience. It is equally as primary as the gift or exchange relation-
ship, and comprises one of the fundamental forms of symbolic action,
native to all societies. Even a surface examination of healing makes us
aware that medicine begins as a radical form of humanism.9 Tradi-
tionally, medical systems have not made a distinction between healing
efficacy and provision of meaning for the personal and social experi-
ence of sickness. Efficacy, itself, is a cultural construct. The healing
dialectic has been considered effective when the bonds between the
sick individual and the group, weakened by disease, are strengthened,
social values reaffirmed, and the notion of social order no longer
threatened by illness and death; or when the individual experience of
illness has been made meaningful, personal suffering shared, and the
individual leaves the marginal situation of sickness and has been
reincorporated in health or even death back into the social body.
Healing is the end-point of the medical system, the successful re-
ordering and organizing of the disease experience and, where possible,
its control. Though it is clear that morbidity and mortality statistics,
as well as empirical measures of therapeutic effectivity, do not measure
healing efficacy, little is known about what personal and social stan-
dards of healing efficacy are in modern society, yet these should be
crucial concerns for modern medicine.
Within the form of symbolic reality structured by the system of
medical care, healing has a position situated at the strategic interface
between the cultural systems, the system of social relations, and the
individual. Healing occurs along a symbolic pathway - of words,
feelings, values, expectations, beliefs, and the like which connect
cultural events and forms with affective and physiological processes.
Psychosomatic and sociosomatic correlates are implicit in all medical
healing relationships. Feelings and physiological responses are in some
way linked to socio-cultural reality via early socialization and learning.
Language and other symbolic forms are the most obvious bridge. In
this way, medicine's biological and cultural roots are connected; the
formal, barriers between these realities begin to dissolve if we penetrate
medicine's thoroughgoing symbolic reality. We reiterate that this
symbolic structure is present not only in therapy, where it plays a
patent role of mediation, but also in the social construction and
cognitive mapping of illness; in other words it is to be found at all

levels of the medical system.
In studying medicine as a human science this symbolic realm of
ideas and actions becomes a fundamental problem with considerable
practical and theoretical importance. The specific issues questioned
are remarkably different from those emerging out of a concern with
medicine's biophysical aspects, without disparaging the clear impor-
tance of the latter. Indeed, these issues come much closer to giving us a
long-awaited general theoretical critique of medicine. What are real
health needs of individuals, communities, or populations? What are

the purposes of clinical care ? What is the nature of clinical interpre-
tation and knowledge? What is medical healing? How are medical
ideologies constructed and how do they relate to political ideologies
and social phenomena? How are social sources of power tapped for
explanation and therapy? These questions are of particular signifi-
cance for developing countries, where health structures are being
remade. But certainly, they bring our study of modern medicine to a
deeper level; they expose the infra-structure of medical knowledge
and practice; and they call into question the interests and values
which stand behind medicine.10 If we consider medicine on the plane
of symbolic reality, we rapidly come to think of the medical system
as structured somewhat like a language; we may even think of
'medemes' (similar to phonemes and morphemes) in the comparative
study of medicine, essential units of medical meaning which form the
elements of medical systems and whose relational arrangements
result in the unique configuration of different kinds of medicine. This
analogy suggests that we might be able to describe in a general way
basic relational principles responsible for the structuring of given
medical systems. To do so requires an understanding not only of
medicine as a system, but particularly of a given medical system's
cultural and historical contexts.
Our general medical model confronts the tremendous distortion and
abridgement of traditional purposes in contemporary technological
medicine: increasing technical control has been accompanied by the
separation of efficacy from meaning, progressive dehumanization of
the healing function, so much so that we are seeing traditional healing
activities surface in the wider social structure just as they are dis-
appearing from clinical practices, and systematic attempts to restrict
medicine's symbolic reality to a single discipline, psychiatry, peripheral
to the central core of medical research interests and practices. Ironi-
cally, medicine, one of the first human sciences and in some ways a
paradigmatic one, is in the tragic process of emancipating itself, via
technicalization of all of its problems, from this vital source.
The study of medicine as a cultural system returns our attention to
the artificial and unfortunate separation of medicine into two distinct
areas, only the first of which has heretofore qualified for scientific
investigation. We have briefly tried to show that we must reconsider
the 'maze of little streets' of the ancient city, medicine taken as a
human reality, if we are to arrive at any general understanding of
medicine, or have some success with the tangle of importunate

problems besetting modern medicine. Since Plato, there has been a
persistent and more or less unspecified ideal in the West of an anthro-
pological medicine, a kind of medical science and practice that would
be concerned unashamedly with such problems as human nature and
other critical aspects of philosophical anthropology, a medical science
conceived of in radically human terms, just as medical systems have
traditionally been structured, and taking its place as an essential part
of the human sciences. Though such an enterprise has nowhere been
realized, we now seem to have before us a 'royal road' for system-
atically exploring medicine in these terms; comparative studies in
medicine offer enormous support for the appreciation of medicine as a
form of symbolic reality, a new direction which has already begun to
challenge modern medical theory and which could well become a
central problem for a philosophical reconsideration of medicine.
NOTES
1 A leading example of the comparative social study of science is Everett Mendel-
sohn and Arnold Thackray (Eds.), Science and Human Values (Humanities Press,
New York 1972). No single volume is yet available that satisfactorily reviews
the comparative social study of medicine, rather one must turn to a number of
outstanding articles in different areas. The author is presently preparing a
volume entitled Culture and Medicine, which will be a general overview of this
subject.
2 The reader is referred to the following paradigmatic studies of different systems
of medicine: for traditional Chinese medicine, Pierre Huard and Ming Wong,
Chinese Medicine (World University Library, New York 1968); for primitive
medicine, Victor W. Turner, The Forest of Symbols (Cornell University Press,
New York 1967); for folk medicine, John M. Ingham, 'On Mexican Folk Medi-
cine', American Anthropologist, Vol. 72 (1970), No. 1, p. 76; for ancient Greek
medicine, Pedro Lain Entralgo, The Therapy of the Word in Classical Antiquity,
ed. and trans, by L. J . Rather (Yale University Press, New Haven 1970) ; for
modern medical systems, Eliot Freidson, Profession of Medicine (Dodd, Mead &
Co., New York 1970); for culture contact and transformations between tradi-
tional and modern systems of medicine, R. C. Croizier, Traditional Medicine in
Modern China (Harvard University Press, Cambridge, Mass. 1968), Charles
Leslie, 'Modern India's Ancient Medicine', Transaction, Vol. 6 (1969), No. 8,
p. 46, and Alexander Alland, Adaptation in Cultural Evolution (Columbia Uni-
versity Press, New York 1970). Recently, the Wenner-Gren Foundation has
conducted an interdisciplinary conference on the comparative study of Asian
systems o£ medicine, which is soon to be published. In October 1973 the first of
several international conferences on the comparative study of medical systems
will be held at the University of Washington and will deal with Chinese medicine
and scientific medicine in China, as well as theoretical issues in comparative
medicine; it is to be followed by a conference on African medical systems.
3 On the sociology of knowledge, see Peter Berger and Thomas Luckmann, The
Social Construction of Reality (Doubleday, New York 1967) ; and Burkart Holzner,
Reality Construction in Society (Schenkman, Cambridge, Mass. 1968), both of
which are made relevant for medicine in Freidson (1970). On the relation of
modern linguistic developments to the study of medical systems, see Claude
Levi-Strauss, 'The Effectiveness of Symbols', Structural Anthropology (Doubleday,
New York 1967), pp. 181-202; and S. J . Tambiah, 'The Magical Power of
Words', Man, Vol. 3 (1968), No. 2, p. 175. Examples of symbolic and structural
analyses applied to medicine are found in : Clifford Geertz, 'Ethos, World-View
and the Analyses of Sacred Symbols', in Alan Dundes (Ed.), Every Man His Way
(Prentice-Hall, Englewood Cliffs, New Jersey 1968); Victor W. Turner, 'The
Syntax of Symbolism', Philosophical Transactions of the Royal Society of London,
Series B (1966), 251, p. 295; and Nur Yalman, 'The Structure of Sinhalese
Healing Rituals', Journal of Asian Studies, Vol. 23 (1964), p. 115. For modern
ethnographic approaches to medical systems, see: Charles O. Frake, 'The
Diagnosis of Disease among the Subanum of Mindanao', American Anthropologist,
Vol. 63 (1961), No. 1, p. 113; and L. B. Glick, 'Medicine as an Ethnographic
Category', Ethnology, Vol. 6 (1967), p. 31. Historical and cross-cultural com-
parisons of elements of medical systems are exemplified by Michel Foucault,
Madness and Civilization (Mentor Books, New York 1965); and Mary Douglas,
Purity and Danger (Pelican Books, Baltimore 1970). Alland (1970) attempts to
compare whole medical systems in his evolutionary framework. General com-
parisons of Asian, African and Western medical systems are found in: Robin
Horton, 'African Traditional Thought and Western Science. I', Africa, Vol. 37
(1967), No. 1, p. 50; Pierre Huard, 'Western Medicine and Afro-Asian Ethnic
Medicine', in F. N. L. Poynter (Ed.), Medicine and Culture (Wellcome Institute
Publications, London 1969); and T. A. Lambo, 'Traditional African Cultures
and Western Medicine', in Poynter, Medicine and Culture.
4 See Horton (1967).
5 Glick (1967), p. 34.
6 Cf. Heinz Werner and Bernard Kaplan, Symbol Formation (Wiley, New York
1967), pp. 15-54; K. I. Platnov, The Word as a Physiological and Therapeutic
Factor (Foreign Language Pub. House, Moscow 1959), pp. 16-38; and Marcel
Mauss, 'Les Techniques Du Corps', Sociologie et Anthropologie (Presses Universi-
taires de France, Paris 1950).
7 Victor W. Turner, 'Lunda Medicine and the Treatment of Disease', Rhodes-
Livingstone Museum Occasional Papers, Vol. 15 (1964), pp. 4—5.
8 Freidson (1970), pp. 205-23.
9 See Pedro Lain Entralgo, Doctor and Patient (World University Library, New
York 1969).
10 Cf. Jürgen Habermas, 'Knowledge and Human Interests: a General Per-
spective'. Appendix to his Knowledge and Human Interests (Beacon Press, Boston
1971).

Medicine's Symbolic Reality

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This article was downloaded by: [McGill University Library]

On: 05 September 2012, At: 13:10