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From the sick role to
subject positions: a new
approach to the medical
encounter
Health
Copyright © 1999
SAGE Publications (London,
Thousand Oaks and New Delhi)
[1363–4593 (199901) 3:1]
Vol 3(1): 71–93; 005298
Kathleen Fahy & Philip Smith
University of Queensland, Australia
While Parsons’ theory of the sick role has been widely criticized,
the alternatives that have been proposed are inadequate. Here subject positions theory is put forward as a viable approach to analysing medical encounters, which combines the advantages of sick role theory with those of its
competitors. The approach is demonstrated through ethnographic material
taken from a post-structural feminist praxis research project involving a
midwife researcher and teenage mothers. This shows that actors move
through a variety of subject positions in negotiating medical encounters.
While subject positions theory provides a powerful new way of analysing these
encounters, it is not yet clear how it can be used to challenge medical dominance.
A B S T R AC T
K E Y WO R D S
feminism; medical encounter; nursing practice; sick role; subject
positions
A D D R E S S Kathleen Fahy, Department of Anthropology and Sociology,
University of Queensland, St Lucia 4072, Australia. [Tel: 07 3365 2204; fax: 07
3365 1544; e-mail: [email protected]]
Introduction
For more than 30 years Talcott Parsons’ (1951) theory of the sick role has
endured more criticism than any other work in his oeuvre. Often this critique takes on a shallow and ritualistic quality. Sometimes Parsons’ work is
discussed in depth. But only rarely is the theory of the sick role credited
with any lasting insight. All too often responses to Parsons throw out the
baby with the bathwater. The metaphorical baby in question here is a
coherent and theoretically informed, generalizable model for understanding of the self in relation to social structure and its role in shaping medical
encounters. The bathwater consists of the assorted problems of functionalism: inattention to power, inadequate empirical reference, failure to explore
contingency. In this article we propose a new approach to analysing the
medical encounter. We suggest that subject positions theory holds on to the
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baby while pulling the plug on the bathwater. We begin by pointing to the
unsatisfactory nature of both sick role theory and the competing models
proposed by its critics. Next we outline subject positions theory as a viable
alternative. We then present ethnographic data from a critical feminist
project to demonstrate how subject positions theory might be applied in
empirical research. Finally we reflect on the theoretical and health care
practice implications of our findings.
The sick role and its critics
Although much maligned, Parsons’ theory of the sick role has a number of
potentially redeeming qualities. As Bryan Turner points out, it ‘indicated
the theoretical grounds for an interdisciplinary approach to the nature of
illness by combining elements of Freudian psychoanalysis with the sociological analysis of roles and a comparative cultural understanding of the
importance of illness in industrial societies’ (1992: 137; see also Holton and
Turner, 1986; Turner, 1987). The great strength of Parsons’ original formulation came, we believe, from its foundation in his role theory. Through
combining Freud’s theory of internalization with an understanding of social
structure taken from functionalism, Parsons’ understanding of the ‘role’
effectively combined micro and macro levels of analysis within a voluntaristic model of action (Vukovic, 1979). Specifically the concept of the
socialized role allowed a model of the self to be elaborated which made
space for the collective and structurally prescribed normative constraints
that operate through the individual in shaping interaction outcomes. This,
we believe, remains an important insight into the social forces that shape
medical encounters.
Critics have rarely attained this encompassing theoretical power when
building alternate models for analysing the medical encounter. To our
reading, scholars in the interactionist paradigm have made probably the
most valuable insights into the interplay of self and contingency (e.g.
Goffman, 1962). This grounded focus has provided the basis for a valuable
critique of the empirical inadequacies of Parsons’ work as well as pointing
to the need for a mode of theory that can more flexibly accommodate negotiated forms of self. However, such understandings lack a broader frame of
theoretical reference through which the selves on display in encounters can
be theorized. Because they are rooted in the American pragmatist tradition,
interactionist accounts typically inscribe selves and ‘illness action’ as the
emergent property of local, institutional situations and biographical experiences (Strauss et al., 1963; Dingwall, 1976; Strauss et al., 1985; Corbin and
Strauss, 1987). This insistence on the local and particular means that such
perspectives have yet to produce a powerful, synthetic generalizable model
for the interpolation of selves that can be applied across institutional and
cultural contexts. The implications are fateful when attempts are made to
analyse power in medical encounters (e.g. Kleinman, 1986). The medical
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encounter is often described as the product of interactions and interactional
competencies with only minimal reference to the wider, extra-institutional
structural conditions shaping the selves that work through encounters and
reproduce relations of power (Pappas, 1990). In so far as more general
models are advocated by interactionists, these are limited to methodological strictures and procedures for assembling data (e.g. Denzin, 1989), rather
than broader propositions about the nature of medical power in encounters.
To our reading conversation analytic analyses are no improvement upon
more traditional micro-sociological theories (e.g. West, 1984). While correctly identifying language and concrete micro-sequences of interaction as
absolutely crucial to the operation of medical power, these methods have
no real understanding of the self, replacing a naturalistic mode of analysis
with a seemingly positivistic study of the disembodied utterance (Lynch and
Bogen, 1994).
Structural Marxist accounts of the medical encounter invert the strengths
and weaknesses of the interactionist models. It is now generally accepted
that these offer a robust model of social structure that incorporates power,
but little ability to theorize agency, contingency or the self (Pappas, 1990).
Typically these models propose a variant of the dominant ideology hypothesis in which the patient is trapped by discourses and procedures that
compel obedience. Such analyses are flawed because they provide little
room for theorizing either the shifting identities that run through interactions or the autonomy of culture (e.g. Navarro, 1980; Waitzkin, 1983).
Growing awareness of these problems has seen Foucauldian approaches
provide an increasingly influential alternative for critical sociologists over
the past 10 years. To be sure the focus on institutional discourses and identities marks an important break with the class-based modes of analysis,
pointing as it does towards a more local and cultural understanding of how
selves are constructed and positioned. Yet Foucault’s approach is still relatively insensitive to questions of identity, struggle and contingency (Fraser
1989; Deveaux, 1994). These problems are embodied in the concepts of the
panopticon and the docile body which emphasize mechanisms of conformity and control within the institution. What is left out of the frame here
is not just struggle, ‘resistance’ and the subjective experience of disciplinary
power as is commonly noted. Perhaps more important is the lack of reference to the socially structured wider human experiences and identities
(race-, class-, gender-inequalities, life-history, etc.) that inform particular
encounters within the medical institution (Deveaux, 1994: 227).
The problem, then, is to rethink the medical encounter in a way that
allows the systematic theorization of the linkages between the self and the
wider social formation, while taking account of contingency, power and
resistance in institutional settings. One way to do this might be to take the
neo-functionalist road (Alexander, 1985) and attempt to rebuild Parsonian
sick role theory in the light of four decades of critique (Glik and Kronenfeld, 1989). Another option would be to abandon the attempt at general
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theory altogether and to undertake grounded studies of the behaviour of
the sick (Levine and Kozloff, 1978). But rather than attempt to reconstruct
the modernist frame of analysis, or shift towards an inductive modality of
social inquiry we suggest that new ways of seeing can come from an
approach informed by theoretical developments in critical postmodernism,
especially those which advance ideas based upon subject positions theory.
In the following section we sketch out the fundamentals of subject positions
theory, paying particular attention to the ways that it can illuminate medical
encounters.
Subject positions theory
Judith Butler’s (1993) work provides a useful account of both the discursive
and the emotional aspects of subjectivity and how these can be described.
She draws on aspects of Lacanian psychoanalytic theory and combines them
with feminist theory of social structure to produce a critical theory of subject
positions. Butler uses this subject positions theory to examine the power
dynamics involved in the formation and reformation of identity and the
spaces that this leaves for agency and resistance. Her elucidation of subjectivity sheds light on compliance and resistance within a power struggle. Consistent with her idea that normative power processes control the assumption
of sexed identities we argue that the same processes operate for the assumption and abjection of other aspects of identity; most particularly the identities assumed by patients, nurses and doctors during interactions with each
other.
For the individual, the process of identification operates to enable certain
identifications and close off others (Butler, 1993). The formation of identity
operates in terms of binaries; one term is enabled and the other is excluded
from acceptable subjectivity; for example, heterosexual/homosexual; lawabiding/criminal; hard-working/lazy; caring/selfish; strong/vulnerable; smart
/stupid. In Lacan’s work, identity is assumed because of the threat of punishment. The fear of punishment is based on knowing the rules or ‘the law’
(Butler, 1993). The law ‘consists in a series of demands, taboos, sanctions,
injunctions, prohibitions, impossible idealisation, and threats’ (Butler, 1993:
107). The ‘law’ defines appropriate and mutually exclusive forms of identification. The law is encoded in the ‘symbolic’ which encompasses language
and symbols, including the body, and is reproduced in interaction.
The foreclosing of the repertoire of identities available to individuals
operates in part through fear of abjection. Butler’s use of the concept of
‘abjection’ is related to but different from that of Julia Kristeva. Kristeva
uses abjection in the sense of pollution: that which is dirty or corrupt and
must be kept outside the body and out of sight (Kristeva, 1982). Butler
draws upon Lacanian theory to designate ‘abjection’ as a degraded or cast
out status within society so that a domain of abject beings is created (Butler,
1993: 243). Abject beings are ‘those who are not yet “subjects” but who form
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the constitutive outside of the domain of subjects’ (Butler, 1993: 3). We
experience the abject as an abyss at the boundaries of our conscious existence. We fear ‘falling into the abyss’ and losing our sense of identity; our
sense of self. The abjected one ‘may not re-enter the field of the social
without experiencing the threat of psychosis; this is felt as fear of the dissolution of the subject itself’ (Butler, 1993: 243). This abject domain, this
site of dreaded identifications, therefore brings with it fear of a symbolic
death so that the subject circumscribes themselves giving up their autonomy
rather than face abjection (Butler, 1993: 3). Thus, rather than seeing the
subject as ‘choosing’ to take on a particular subject position Butler argues
that power works through norms and emotions to generate identification,
abjection and subjectivity (Butler, 1993: 2).
Once an individual takes up an identification (or subject position) there
is a particular discourse which belongs to that identity. For instance, the discourse which goes with the subject position of ‘caring young woman’ is very
different from the discourse which accompanies ‘rebellious tart’. This is
consistent with Derrida’s view that the speaker only ever speaks derivatively (Derrida, 1988). By performing an ascribed identity one is citing the
law. The performance of a particular subject position is the very mechanism of the production and articulation of the norms that demand the
assumption of the identity (Butler, 1993: 14). This means that the more a
particular identity is assumed, and acted out, the more likely it is that this
identity will continue to be socially reproduced.
How does the reiterative power of discourse operate on individuals to
impel them to take on particular subject positions? According to Lacanian theory the subject is fragmented, unstable and constantly shifting but
the conscious subject is unaware of this fragmentation and seeks instead
to feel consistent, whole and integrated (Mitchell, 1974: 26). So individuals
feel the need to present (to oneself and others) a subject which is consistent and non-contradictory (Hollway, 1984). The second reason is that the
subject has a great investment and emotional commitment ‘in taking up
positions in discourse which confer power and are supportive of our sense
of continuity’ (Hollway, 1984: 205). Social structure comes back into the
frame when we acknowledge that the distribution of powerful subject positions, and their precise composition strongly correlates with the distribution of social power more widely and generally operates to reproduce
this power. Consider the range of positions available to women. The traditional, socially prescribed, gendered subject positions for women are
based on a moral ethic of care (Ring, 1994). The discourse of women as
the caring ones has derivative subject positions including being a ‘caring’
and ‘kind’ young woman, a wife, a nurse, a ‘good’ mother, a carer of elderly
or disabled relatives, a grandmother, etc. Caring involves being there,
listening, responding, helping. Such caring often implies the suppression
of one’s own needs, sometimes to the point of self-martyrdom (Haug,
1992).
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The abjected side of the caring dichotomy is the ‘rebellious and selfish’
woman; the whore, the tart, the hag, the scrubber, the crone, the ‘bad’
mother, the wicked stepmother, the witch. This is the subject position which
contains all the discourse to which ‘caring’ women are denied access. This
subject can be free but at the price of being expelled from socially acceptable society and cast into the realm of the abjected and marginalized
(Butler, 1993: 3). Taking on this subject position gives women the power to
say ‘no’ to what they do not want and to ask for, or take, what they do.
However, because ‘rebellious and selfish’ women are rarely recognized as
full subjects, they can be subject to mechanisms of social control or their
subjectivity and agency can be ignored.
Like role theory, the theory of subject positions provides a powerful generalizable theory for exploring the construction of the self in medical
encounters and the ways such constructions might be linked to broader
social structures (e.g. gender and patriarchy in the case of this article).
However, we argue subject positions theory offers advantages when it
comes to those bathwater issues of power and contingency. First, the analysis of medical power comes somewhat more easily to subject positions
theory because it is divorced from the consensus-oriented functionalist
paradigm. Second, ever since Lacan’s early work subject positions theory
has focused on the linguistic and symbolic processes through which people
interpolate themselves – and are interpolated – as subjects. As we shall see
this provides a resource for theorizing how cultural structures provide for
both flexibility and constraint in seemingly contingent interactions (Frow,
1985). Third, subject positions theory allows us to analyse the multiple and
overlapping sources of unstable and shifting identities that people draw
upon in interactions. This allows us to move beyond essentialist views of the
unified subject as presented in role theory (and traditional symbolic interactionism), towards a model of self and society which can be more open to
contradictory and competing models of self in interaction. In the empirical
discussion to follow, such a model incorporating shifting selves is able to
illuminate not only the subject positions of the patient, but also the negotiations and identities that are adopted by medical personnel and the sociological researcher.
Subjects, context, methods
The proof of the pudding, as one says, is in the eating, and so to illustrate
the utility of subject positions theory in exploring medical encounters we
draw upon a critical feminist ethnography conducted by the senior author.
The study was conducted in an Australian city. The primary site was the
Women’s Health Centre (WHC); a drop-in, support, advice and advocacy
service for young women aged 12–25. The senior author of this paper is a
midwife who provided a midwifery service for adolescents during the 20
months of field work. When referring to herself throughout this article she
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will use the personal pronoun. A total of 33 young mothers were involved
in the study. Their profile was consistent with the literature on teenage
childbearing, in that they were characterized by poverty and poor educational attainment (Upchurch and McCarthy, 1990).
The analysis and interpretation which follows is a post-structural, feminist account that emphasizes reflexivity, emotion and praxis. In this paradigm, theoretical formulations have a concrete grounding in the immediacy
of the situation being analysed (Fonow and Cook, 1991: 2; Denzin, 1994:
510). This approach is also consistent with Altheide and Johnson’s (1994:
489) idea of ‘validity-as-reflexive-accounting’ which ‘places the researcher,
the topic, and the sense-making process in interaction’ where the focus is
on the process of how meanings are constructed. In the following section
we present two critical incidents involving the use of coercive and persuasive power by health care providers in which I participated as a support
person for the young mother. While I accept that the conceptual separation
of ‘factual’ narration from ‘theoretical’ commentary has been rendered
problematic by postmodern scholarship, I present the data here in a way
that will assist the reader. I distinguish in a provisional way between event
description and later event interpretation. Text in Times roman describes
‘what happened’ while text in italics consists of interpretation, theory and
commentary on events.
Episode one: Cheryl’s experience of vaginal ultrasound
When she was 14 weeks pregnant Cheryl had an appointment for a routine
ultrasound scan. Cheryl was accompanied by one of the social workers from
the WHC who stayed with her during the procedure. When they came back
to the WHC after the scan, Cheryl appeared withdrawn; her face was red;
her breathing was fast and laboured. The social worker who accompanied
her looked downcast and withdrawn. Apparently the doctor had not been
able to get a picture of the foetus abdominally and rather than wait a week
or so he decided to do the ultrasound vaginally. In my view this was not
justified because there was no specific indication for an ultrasound; it was
merely routine.
I invited Cheryl into my room and asked her what had happened. She
answered with eyes downcast as if she was ashamed. She spoke slowly and
painfully. During this time, when she was exploring her responses to the
ultrasound examination I sat quietly. I said things like ‘It wasn’t your fault’.
‘You didn’t deserve it’. ‘It wasn’t fair’.
Here I am enacting the subject position of nurse. I feel comfortable and
unambiguous in taking on this position; it is consistent with my socialization
as a woman and a nurse and is compatible with my feminist principles.
The way in which she spoke is worthy of note. She would say one sentence, or maybe two, and then there would be a silence for two, even three
minutes. And then she would say one sentence or maybe two and then there
would be another silence. Even her crying was interesting, it was not a
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‘full-on’ let-it-all-out type of crying, like I am used to when someone is very
upset as Cheryl clearly was. Her crying was very controlled, very much still
held inside. So although she was crying, there were not many tears and there
was not much sobbing.
Cheryl is a young woman whose mother had long-term mental illness and
who had multiple sexually abusive experiences perpetrated by her school
teacher and two of her brothers. Cheryl does not seem well connected to any
identity. Because of her large build and masculine way of dressing she does
not fit, or want to take on a sexed feminine subject position. It is as if she has
inscribed her body with the message: ‘I’m not a girl, I’m big and strong and
tough, so don’t think about sexually abusing me!’ Cheryl has no work and
therefore no identity as a worker. Cheryl’s identity as a caring daughter is her
only reasonably secure identity but this is contaminated because she also hates
her mother for her mental illness and addictions. Her identity as ‘sister’ is
important to her because she has always cared for her brothers, and still does,
but she also hates and fears them because of their physical and sexual abuse.
Cheryl has a number of abjected identities; mental patient, substance abuser
and sexual abuse victim. None of these identities provide a discourse to assert
her wants and needs in this situation which may explain her initial silence in
the situation and now her difficulty finding the words to say what she feels.
C: He just said – ‘take your pants off’. Oh, he tried to do it on my tummy
but then he said ‘I can’t get a good picture’. So he just said ‘take your
pants off’. No, he said, ‘go to the toilet, take your pants off, come back
and I’ll have to do this vaginally’ [said with anger and resignation].
C: I didn’t want to do it. I was scared. I came back from the toilet shaking.
I just wanted to run. I said to Jenny [the social worker] ‘I’m scared!’ and
Jenny said ‘It’s okay, I’m here’.
The worker from the WHC had taken on the subject position of caring supporter, not advocate.
C: The doctor took this thing, it was shaped like a man’s dick. He held it
over me and put a condom on it. And then he put it inside me [said with
disgust and fear]. Once it was inside me he moved it all around. He
pressed on my stomach at the same time. It just went on and on. He said
a couple of times ‘hold that tight with your muscles while I adjust the
machine’ [said with shame as if Cheryl had to participate in what she was
experiencing as sexual abuse].
C: I was really frightened and tense. I was breathing fast; I felt like I
couldn’t get my breath. I just wanted to punch him. If Jenny hadn’t of
been there I don’t think I could have gone through with it.
This implies that the social worker, by helping Cheryl to stay and submit, was
collaborating with the doctor. Jenny took on a subject position that needs to
be analysed. She assumed a gendered subject position based on the moral
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ethic of caring. She enacted a discourse as ‘being there’ for Cheryl; experiencing with her but not questioning what was happening. By supporting
Cheryl she helped her to ‘cope’. If she hadn’t ‘coped’ Cheryl may have acted
out her fantasy of punching him or walking out. Jenny was submissive to
medical power/knowledge. Jenny’s behaviour was important, even crucial, to
the doctor being able to gain Cheryl’s compliance.
Afterwards, Jenny told me that she felt ashamed that she had not advocated
for Cheryl as she should have done according to the philosophy of YWP. It
is easier, however, to say that one is going to be an advocate than to actually
speak from an advocate’s subject position, a position which, I will argue, is
only available on the abjected side of the dichotomous subject positions available to women.
C: When he started pushing that thing around inside me [pause] I started
to remember all the different sexual abuse I have had [pause] from all
the different men [and boys]. [pause] There were six in all including
Mickey and Jimmy.
Here Cheryl has connected into the identity of sexual abuse victim. When the
doctor invaded her vagina with his technological penis, the memories, both
those in her mind and those encoded in the tissues and muscles of the vagina,
were set loose so that she re-experienced the suffering from previous attacks.
When the co-ordinator of the women’s health centre rang him later he
expressed outrage that Cheryl would think of her experience as one of sexual
abuse. He said that Cheryl should have experienced the vaginal ultrasound
as a non-sexual medical investigation; something not really any different from
other technological investigations. The subject position that the doctor was
expecting from Cheryl was that of the compliant patient; the docile body.
At the time, although I accepted that Cheryl experienced the doctor’s
behaviour as abuse, I was less willing to consider that his behaviour was
motived by the desire to hurt and humiliate her. I thought he was motivated
by money; she was there, he had spent 15 minutes with her; if he didn’t get an
ultrasound, he couldn’t charge the fee. Looking back as a midwife who has
performed vaginal examinations, and who has witnessed countless doctors
vaginally examine women, I now doubt the doctor’s assertion that there was
no element of sexual abuse in what he was doing. The vaginal probe is
‘shaped like a man’s dick’ and the doctor knows this. He makes this clear to
Cheryl because he held it over her as he covered it with a condom when this
could have been done discreetly, out of sight. The fitting of the condom made
more explicit the sexual nature of what is occurring. Also, asking her to help
by holding the probe with her vaginal muscles has erotic undertones that are
normally absent from vaginal examinations which are carefully constructed
as fact-finding missions; nothing else.
Whatever his reasons, he did cause her unnecessary pain, both physical and
psychological. By ignoring her anguish and dispensing with the formalities
of informed consent he took the subject position of ‘bad doctor’ on the
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abjected side of the dichotomy. Good doctors are meant to relieve pain, not
cause it, and when it is caused without good reason this is perceived to be bad.
The ‘bad doctor’ subject position allowed him to conclude the interaction
quickly through dramatizing medical dominance and demanding passive
compliance. The ability of doctors to mobilize this subject position is dependent, in part, upon relatively weak mechanisms of surveillance and accountability for medical professionals. This in turn, is a product of social structural
forces, such as professional autonomy and internal evaluative mechanisms,
whereby doctors regulate each other behind closed doors (Smith, 1992).
Within health care organizations there are no formal or informal mechanisms for raising questions about medical actions. These institutional constraints are compounded by there being no discourses for complaining from
the ‘good’ side of the patient subject position dichotomy. When one acts from
the abjected side of the subject position divide one is threaten with the ‘abyss’
internally and with social punishments externally (Butler, 1993). Outside of
a formal complaint to the Health Rights Commission or a full legal challenge
there is little a patient can do. Perhaps most importantly, there seems to be
nothing the patient can do during the event, without shifting into the abjected
side of the subject position dichotomy – thus risking sanctions by becoming
the ‘bad’ patient.
In the next scenario, we are able to reflect further on these issues when
Cheryl took the difficult and courageous decision to become the ‘bad’
patient.
Episode two: Cheryl’s experience of second stage labour
Cheryl had nominated me as one of three people whom she wanted as
support people during labour. Cheryl and I knew each other very well. We
had had many hours of discussion in preparation for this day; the culmination of which was a written birth plan which specified in advance the type
of birth and forms of intervention which Cheryl wanted. At this particular
hospital birth plans are rare; even rarer is that a labouring adolescent
mother should have a midwife-support person present. The birth plan had
been submitted to the hospital authorities during the ante-natal period and
was now part of her records and therefore available for all staff to read.
By the time I arrived Cheryl had laboured for 12 hours. She was lying in
a large room on a metal bed with a large operating-room light above. Her
feet faced towards a doorway covered by a light curtain. The room is bleak
with a linoleum floor, blank walls and open shelving holding medical equipment. Her mother was sitting beside her, the hospital midwife was also
present. The tape recorder was playing ‘nature’ music in the background.
Cheryl had an epidural block at 6 o’clock and now she was relaxed and pain
free. An epidural block is performed by inserting a fine plastic catheter
through a hole in the person’s back. Having a working epidural usually
means, as it did in Cheryl’s case, that one feels no pain, and all other sensations in the area are either blocked or greatly diminished. Thus Cheryl
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could not feel her legs. She could not tell when her bladder needed to be
emptied and so a rubber catheter had been inserted into her bladder. If a
birthing woman’s sensations of her own body are obliterated by the epidural
(as they were in Cheryl’s case) then she does not feel the baby’s head
descend into her vagina, nor does she feel the urge to push. It is difficult
under such circumstances for a woman to birth her baby naturally. An hour
after I arrived the midwife, let us call her Fiona, did a vaginal examination
and found that Cheryl was fully dilated.
Fiona: We’re going to let the epidural wear off, it’ll take another hour say,
then you’ll feel the contractions again and you’ll feel like pushing
and you’ll be able to push the baby out. [There was no eye contact
between the midwife and Cheryl. She spoke kindly but firmly,
leaving no spaces for questions, objections, or agreement. Cheryl’s
mouth tightened, she closed her eyes and turned her head away.
Fiona left the room.]
Fiona wants Cheryl to have a natural birth. Midwives generally are philosophically committed to natural birth; in part because it is consistent with our
feminine identification with nature and ‘the natural’ and in part because
doctors are not ‘in charge’ of normal births; midwives are the birth attendants.
Because Fiona wasn’t looking or inquiring she had no way of knowing how
Cheryl felt about what she had just said. Fiona’s statement was not a question
or a request for permission, which would require an acknowledgement. She
is merely informing Cheryl of what is going to happen to her. By not asking
for a response the midwife assumes compliance. The discourse of the midwife
is consistent with the subject position of ‘benevolent parent’ which is a natural
manifestation of the etymology of the word nurse: to nurture or nourish just
like a mother (Turner, 1987). Cheryl is not powerless in this situation; she
does have the option of protesting verbally but she does not have the power
to make the midwife top up the epidural. So, although she can protest she is
not in a strategically powerful position.
KF:
Cheryl, how do you feel about what the midwife just said?
My reason for asking this was to be sure that what Fiona was suggesting was
what Cheryl herself wanted.
C:
I don’t want to feel those pains again [said weakly, plaintively,
Cheryl is not used to getting what she wants or stopping what she
doesn’t want].
This subject position I characterize as compliant but resentful girl-child. This
is Cheryl’s dominant subject position which she has performed throughout
her childhood. Her childhood, it should be noted, was shaped by her mother’s
mental illness which required frequent and prolonged hospitalizations.
Cheryl had no father from the age of four. She experienced multiple instances
of physical and sexual abuse. During all of this Cheryl took on the subject
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position of caring older sister who attempted to keep the family together and
to meet the needs of her younger siblings. She has no expectations of having
her own needs met.
KF:
Well if they top it up the chances are that you’ll have a forceps delivery or a vacuum extraction.
My subject position here is that of facilitator of empowerment. I am reminding Cheryl of the consequences of topping up the epidural to be sure that she
is making an informed decision.
C:
I don’t care, I just don’t want to feel the pain.
Here Cheryl has moved subject position: she has decided to resist and to assert
her desire to have her epidural topped up. Looking back on the transcripts I
now identify this as a pivotal moment. She has become the ‘bad patient’ and
subject position theory predicts that she will be punished.
When Fiona, the midwife came back in, I told her what Cheryl had said.
Without responding she went away (frustrated).
That Fiona didn’t respond implies that she has run out of discourse in the
subject position of ‘benevolent parent’. It could be that on hearing that Cheryl
doesn’t want what she is proposing, Fiona is experiencing ethical conflict and
is thinking about changing her subject position. The subject position of nurse
is highly gendered, being based on caring and nurturance. As nurses and midwives we see ourselves as primarily caring; all our public and professional
discourses promote this as our central value. By promoting a difference
between ‘caring’, and what we claim to be the doctor’s central value ‘curing’,
we seek to create an occupationally located subject position from which to
speak. When we are doing what we think is in the patient’s best interest we see
ourselves as caring. When a patient says that they don’t like what we are doing
it interrupts our discourses as carers; here is an incongruity! What is the
subject to do? There is no way to stay in the subject position ‘caring midwife’
and knowingly override a patient’s wishes. Hence the silence and the withdrawal which provides time for thinking about what to do next.
When Fiona returned she was accompanied by a senior midwife, let us
call her Marian. Ignoring me, Marian spoke directly to Cheryl.
I later heard from another midwife that Marian believed that Cheryl didn’t
really want the epidural topped up but that I was somehow ‘talking her into
it’. In their view, it is not they who are overriding the patient’s wishes, but me.
By these means the midwives in the story are able to stay in the ‘caring
midwife’ subject position and not knowingly override Cheryl’s wishes. This
strategy allows Marian to maintain the subject position ‘good nurse’ as both
an internal commitment and an external demonstration.
Marian: Why don’t we let the epidural wear off, just see how it feels? If you
have a few pushes and you can have the baby, well that’s great, but
if you are too uncomfortable, then we’ll top up the epidural. [Said
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gently. No eye contact was made. Cheryl looked unhappy. She
turned her face away and did not speak.]
SILENCE
Although Cheryl did not reply Marian read her silence as compliance so,
with a gentle pat on the arm, she left the room.
By not pursuing her rhetorical inquiry Marian still doesn’t know what Cheryl
wants. All the words that she used, and the gentle pat confirm for Marian that
she is caring. This allows Marian to present herself as a stable and noncontradictory subject (Hollway, 1984). This is consistent with Lacanian
theory which describes the subject as fragmented, unstable and constantly
shifting, but seeking to feel consistent, whole and unambiguous (Mitchell,
1974: 26). In addition, taking this subject position is powerful, in a way that
finding out what Cheryl wants is not. This is consistent with Hollway’s (1984)
assertion that the subject has a great investment in taking up positions in discourse which confer power. Because she didn’t seek a reply it can be inferred
that Marian wasn’t seeking permission, merely stating a fait accompli.
When occupying a particular subject position, in this case ‘nurse/midwife’
one can only access the discourses that are culturally available for that position (Butler, 1993). Whenever I found myself in the subject position ‘nurse’
(recognizable from the medical/nursing discourse which I was using at the
time) I doubted myself and trusted in ‘higher’ (medical) authority. Having
confidence in one’s own knowledge and understanding are prerequisites to
effective advocacy. I have come to realize that the ‘nurse’ position does not
include discourses about advocacy. This was a difficult awakening for me
because our nursing theories and texts speak of the role of advocate as a subrole of the nursing role. It is interesting that Fiona didn’t doubt that she would
be supported by Marian. This is consistent with the view that whenever one
is occupying a particular subject position one is never doing more than citing
the ‘law’ (Derrida, 1988). In other words, we know what other nurses and
midwives are likely to say because we have learned nursing/midwifery discourses. This is the way that subject positions theory deals with the issue of
double contingency so cogently resolved by the functionalist theory of roles.
Fiona, for example, felt confident that Marian wasn’t going to say ‘What does
the young mother want? Your job is to support her choices’. This adds weight
to my assertion that the discourses of advocacy are absent from the nursing
subject position within this context.
Under the control of medicine, the subject position ‘nurse’ has been
designed to be reciprocal to two subject positions; the ‘compliant patient’ and
the ‘decisive doctor’. The ‘compliant patient’ subject position is that of a trusting and dependent child who, by their faith and gratitude affirm our images
of ourselves as caring and wise. Nurses all recognize and love the compliant
patient, in our informal discourses we call her/him ‘the good patient’. The
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subject position of nurse has not been designed for decision making or advocacy. Decision-making power rests with the ‘doctor’ subject position.
When we were alone again Cheryl turned to me with tears in her eyes: ‘I
really don’t want to feel those pains again’.
KF:
Do you want me to speak for you?
When I reflected on this utterance I could see that it was a pivotal point for
me; I have slid into the more familiar benevolent parent subject position.
C:
Yes please. [When the junior midwife, Fiona, returned I said:]
KF:
Cheryl has thought about it and she really doesn’t want her epidural
to wear off. She knows that this might mean a vacuum extraction or
forceps delivery and she understands what these mean. She just
doesn’t want to feel those pains again.
I have taken the subject position of advocate which seems to be located within
the ‘bad’ side of the good/bad midwife dichotomy. I took on this position of
advocate because, I reasoned, Cheryl’s own power is diminished by her
bodily condition. She is in the late stages of labour. Her legs are paralysed
from the epidural. She has a catheter in her bladder. She will need assistance
to birth her baby. Cheryl already has a strong fear of abandonment based on
her experiences in childhood of her mother’s frequent hospitalizations. If I
had not been present I doubt that she would have been able to assert herself
but I should have checked more carefully.
Fiona: Oh, I’ll have to ask the doctor about that.
At this point Fiona runs out of available discourse in the good nurse subject
position. She has to call on other subjects to enter the scene.
Within three minutes the senior doctor, a big man of about 33 years of
age, came in and stood just inside the doorway. Fiona, who had called for
him, stood beside him. I was sitting beside Cheryl’s bed.
Remembering this now I have the image of two forces squaring off against
each other. It is an unbalanced relation; we do not have equal recourse to
power. Cheryl’s source of power is her legal right to control what happens to
her body. This is the sovereign right to say ‘No’ which is set against the discipline of medicine’s coercive forces aimed at producing docile and disciplined
bodies (Foucault, 1980).
The doctor ignored Cheryl and spoke directly to me.
This doctor does not know me and does not introduce himself. Why doesn’t
he introduce himself? It is as if his personal identity does not matter; what
matters is that he is in the doctor subject position. If we had been introduced,
or at least exchanged names he may have had to acknowledge me as a subject.
Doctor: This is inconsistent with Cheryl’s birth plan. [Aggressive, challenging.]
At the time I didn’t understand why he was talking to me instead of Cheryl.
I now assume that the doctor thought that I was trying to control Cheryl’s
actions.
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KF:
Well, no it’s not. Cheryl has never been concerned about medical
intervention and that’s clear in the birth plan. She knows about the
side effects of each of the things that we’re discussing and she
doesn’t want to feel the pain again and she wants you to assist with
the delivery.
My subject position is still that of advocate. I am clear and direct. This is the
discourse of resistance. I speak to him as one equal, adult, knowing, human
being, to another.
As I said the last phrase, ‘she wants you to assist with the delivery’ I felt
a cold fear inside me. I should have stopped speaking at the point where I
said ‘she doesn’t want to feel the pain again’. Nurses and midwives know
that they are not to tell doctors what to do.
It seems to me now that because I had slipped into medical/midwifery discourses this somehow moved my subject position from advocate to nurse. As
this happened I felt fear. As discussed earlier the discourse of advocacy is not
allowed from the subject position of ‘nurse’. The fear is part of the experience
of the abject; of facing the abyss (Butler, 1993). When we move beyond our
habitual identifications we anticipate punishment through disobeying what
Lacan calls the Name of the Father.
When I said that Cheryl wanted her epidural topped up and she wants
medical assistance at the birth, the doctor became angry. He stayed at a distance from us and he continued to ignore Cheryl by directing his comments
to me.
Doctor: There is no reason why she can’t push this baby out.
Here the doctor seems to be arguing with me about the care of the patient; as
if I am a midwife trying to bring about a particular birth outcome. He does
not acknowledge Cheryl’s autonomy nor that I am speaking as an advocate.
This means that the subject position of advocate has not been accepted and
therefore my motives are suspect.
The atmosphere was very tense and I felt frightened, not for me, but for
Cheryl who was at such a disadvantage.
I know that it is a lot easier to stop a doctor from doing something (e.g. a
surgical intervention) than it is to get him to do what you want (e.g. top up
the epidural). This is because the woman only has legal right to say ‘No’, to
proscribe, but no right to prescribe her own medical treatment. Once she
wants something done the power to say ‘No’ rests with the doctor. I was also
very aware that Cheryl was at a bodily disadvantage. It was her body that had,
and would again take the pain. It was her bodily integrity that was threatened
by the birth of the baby. Although it is rare, women sometimes die in childbirth and all women are aware of this. Having the doctor angry at you is a
very frightening experience in such a situation. The gross inequality in power
is clear and the doctor’s distance from Cheryl, combined with his aggression,
are techniques of power which serve to increase the power differential.
Because he was speaking to me I realized that he thought that I was
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influencing Cheryl. So I turned to Cheryl and said in a voice loud enough
for the doctor to hear: ‘Cheryl you’re going to have to speak for yourself,
because the doctor thinks I’m influencing your decision’. And with a fair
amount of courage, I thought, she looked him right in the eye and she said:
‘It was my decision, I don’t want the epidural to wear off’.
Here Cheryl was able to move to an assertive, mature, non-gendered subject
position but she has had very little practice performing this role. I now recognize that she could have done this earlier, probably with coaching from me.
During this time I experienced internal ambivalence. In my subject position
of feminist researcher I was pleased that Cheryl felt empowered to speak
assertively. In my subject position of midwife, in solidarity with the other midwives, I too was disappointed that she wasn’t going to have a natural birth.
This conflict between imposing my own values or promoting the young
women’s own autonomy had been decided earlier in the research process in
favour of promoting young women’s autonomy. However, there was still
some residual inner conflict. This is consistent with Butler’s idea that we need
to risk our sense of coherent identity and embrace multiple and apparently
contradictory identities in the process of accessing more powerful discourses
(Butler, 1993).
At this the doctor became more angry. He took a couple of steps forward
and stood over Cheryl at the end of her bed and looked down on her.
His bodily position in space, in relation to Cheryl’s, seemed to me to be very
threatening. He is a big, strong-looking man and he is using his body to
frighten both Cheryl and me.
Doctor: There is no reason that you should not have a normal delivery. You
are just being selfish. Because of your selfishness the baby could be
injured, even brain damaged. I’ll have to ask the consultant about
that [said in an angry and frustrated voice and, without waiting for
any reaction, he turned around and walked out of the room].
The doctor attacks Cheryl as not being a ‘caring young mother’ which is the
gendered subject position that he thinks she should occupy. He cites ‘the law’
to punish her for taking on the abjected side of the caring/selfish dichotomy
(Butler, 1993: 107).
The consultant must have said it was OK, because the next thing we saw
the junior doctor came in, and topped up the block. The fear stayed with
me however, because, with a working epidural, she may not be able to push
the baby out unaided. Since medicine has the legal monopoly over the use
of forceps and vacuum extractor, if an assisted delivery was needed, then
Cheryl would need the doctors. Cheryl’s epidural was topped up and we did
not see a doctor again for another three hours. At that time the junior
doctor did another vaginal examination and found that Cheryl was fully
dilated as she had been now for at least three hours, but the head had not
moved down the birth canal.
The labour had been progressing well, but now, in spite of the uterus
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contracting the head has not descended at all in three hours of second stage.
From the time of full dilation of the cervix until the birth of the baby normally
takes between one to two hours. No one thought that the labour had stopped
progressing because the baby’s head couldn’t fit through the pelvis (which is
sometimes the reason for failure of labour to progress). Cheryl is a big
woman, and as the eventual birth shows, there was no disproportion between
the baby’s head and Cheryl’s pelvis.
The junior doctor said to Cheryl: ‘Look, you’ve got two choices, we can
add a synthetic hormone to the drip to try and strengthen the contractions
and try and push the baby down through the birth canal, though I don’t
think that’s very likely, or I can use the vacuum extractor, you can push, I
can pull and the baby can be delivered now’.
Unlike the senior doctor the junior doctor is enacting an adult, non-gendered,
respectful subject position consistent with emerging reformulations of the
‘good’ doctor.
KF:
(to the doctor) Is it her choice?
Junior doctor: Yes. [So I said to Cheryl: ‘Which of those do you prefer?’]
C:
I want the vacuum extractor.
The junior doctor said OK and began to prepare for the birth. The midwife
came in and started to set the room up for delivery. I left the room to get
Cheryl’s mother because the birth was now imminent. As I came back to
the room I noticed the junior doctor talking to the senior doctor some distance away, down the hall. They both stopped talking and looked at me. I
immediately felt the fear again. I got a sense that something was about to
go wrong.
My sense of foreboding was initiated by the doctors stopping talking and
looking at me. This is consistent with what people do when the unexpectedly
see the person that they are talking about. The looks must have non-verbally
indicated to me that something bad was about to happen. Looking back on
the interaction I suspect that my subject position was being labelled as the
‘witch’ who is training young women to challenge legitimate medical power.
There is some truth is this. I was encouraging young women to take control
of their own bodies and medical destinies. Challenging medical power was
really incidental to this feminist project. However, conflict with doctors
inevitably arose when young women deviated from the ‘good’ patient subject
position in trying to assert their own wants. These unexpected discourses of
self-assertion could not be accommodated within the relatively inflexible
repertoire of citations available in the traditional doctor subject position.
I went back into the room and was beside Cheryl when the junior doctor
came in and said: ‘We won’t be able to put the vacuum extractor on now
because the baby’s head’s got a bit of puffiness on it and if we put the
vacuum extractor on, maybe the cap will slip off and we’ll have a failed
vacuum extraction and if that happens then you would have to have a caesarean section’.
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KF:
I don’t understand, Chris, even if that happened . . . [which
in my experience is highly unlikely because the vacuum
extractor is designed to work in situations where the baby is
a bit stuck and when babies are a bit stuck getting puffiness
on the cap is perfectly normal] . . . even if that happened, you
could use forceps.
Junior doctor: Not with the position that the baby’s head is in [said without
authority, eyes averted].
He is being vague. This is because his assertions cannot withstand my challenges. Now I knew that the position that the baby’s head was occipito
anterior which is the most common position for the application of forceps. I
felt immediately that Cheryl was being punished for having asserted herself.
The senior doctor, now in a position of power, was withholding what Cheryl
wanted. I interpreted this as revenge for his previous loss. I didn’t believe that
the oxytocin was going to make any difference and I could tell from the junior
doctor’s flat tone of voice and the way that he had trouble making eye contact
with me or Cheryl, that he didn’t believe the oxytocin would make any difference. I also sensed that he was embarrassed; that he knew that Cheryl was
being punished and that he felt he had to comply with the wishes of his senior
colleague, even though he didn’t agree and, I thought, felt ashamed of his own
involvement. From this I learned more about the power of the medical ‘fraternity’ and how loyalty to one’s medical colleague is more important than
doing what one perceives to be is the ‘best’ for the patient.
Cheryl was about to give birth. I didn’t want to create a scene. I could have
made matters worse. They could, for instance, decide that she needs a
caesarean section. The power to diagnose, to define what is happening in a
complex practice situation, rests with the doctor. This power to define what is
happening, as previously discussed, really cannot be effectively challenged
from any subject position available to a nurse or a midwife.
Who would support me against two doctors if I tried to somehow ‘make
them’ help Cheryl birth her baby now? There was a slight possibility that the
consultant obstetrician would. If the doctor’s decision was unambiguously
wrong I could have used my subject position as advocate to assert Cheryl’s
legal right to a safe birth. Since the position wasn’t totally clear, then the
doctor had the upper hand. I couldn’t then, nor can I now, think of a subject
position from which to speak which would get Cheryl what she wanted; i.e.
the delivery of her baby by vacuum extraction. If I approached the consultant and he supported the two doctors, which I assessed as highly likely, I
would have nowhere else to turn. And, by appealing to a higher authority I
would have alienated both doctors and both midwives involved in Cheryl’s
care. This could make matters worse for her and for other young mothers
whom I may accompany in the future. I could have appealed to Marian to
intervene but I knew that she knew what was happening. I didn’t have any
evidence that she would help, and by confronting her I could have brought
the veiled conflict between us into the open. Cheryl was too vulnerable, her
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situation too precarious to risk any further escalation the situation. I backed
off.
The epidural block was now not functioning properly and Cheryl was
beginning to be in a lot of pain. The anaesthetist announced that the block
had become ‘one sided’ and so Cheryl was feeling full pain on her right side.
I got the distinct impression that she was going to be required to experience
another couple of hours of blocked second stage labour as a way of punishing me through her. I felt angry and frustrated but I did and said nothing.
I stayed beside Cheryl and tried to be supportive.
This is the same subject position that Jenny enacted in the ultrasound episode.
I was thrown off balance by the ethical dilemma I had confronted, a dilemma
originating in the tension between the subject positions of feminist advocate
and nurse. Not knowing what to do, I had fallen back on the caring nurse
subject position. I became weak and silent. I also felt guilty that I had let
Cheryl down. I gave her the false impression that she could have more control
(be more empowered) over what happened in her labour than she was really
able to have.
By 1 o’clock she had been in labour for 19 hours and in second stage
labour for 5 hours. Cheryl was experiencing her labour pain on her right
side and was crying weakly and plaintively with each contraction. She
looked exhausted, she had been awake for 22 hours. Her mouth and lips
were dry in spite of the sips of iced water and the intravenous infusion. I
was sitting beside her, sad and defeated. At this point the senior midwife
(Marian) came in and said: ‘I’ve had enough of this’ (strongly, with authority). With that, she left the room.
I realized that she did have the power to get the doctors to help Cheryl. I could
tell from her confident voice that she was about to put a stop to Cheryl’s
suffering.
The junior doctor came within 15 minutes and said: ‘It’s time for this baby
to be born’. Cheryl’s legs were put in stirrups, a resuscitation trolley was
brought in to receive the baby. Fiona and the junior doctor both donned
green gowns and rubber gloves. A metal cap, not unlike the cap of a jam
jar, but made of thick stainless steel was attached to the baby’s scalp inside
Cheryl’s vagina. A thick rubber hose connected the centre of the suction
cap to a vacuum jar. The midwife extracted air from the jar to achieve a
negative pressure between the cap and the baby’s head. A metal chain and
hand grip were also attached to the cap so that when the vacuum seal was
obtained the doctor pulled on the hand grip each time Cheryl had a contraction, while she simultaneously pushed. The baby was born with two contractions. He did not need resuscitation.
Conclusion
The ethnographic material we have presented shows how the display and
reproduction of medical power is an interactional outcome arising from the
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interplay of the repertoire of subject positions mobilized in specific event
sequences. We believe that this tool provides a viable alternative to role
theory. Unlike the models proposed by Parsons’ critics it is a multidimensional approach that allows us to inter-relate the critical issues of
power, contingency, self and social structure without recourse to a one-sided
reductionism which privileges any one of these dimensions. One way of
delineating the relative merits of subject positions theory is to briefly consider how other available theories would have analysed this situation. A traditional interactionist perspective, such as negotiated order theory, would
have been able to capture the dimensions of contingency that characterized
interactions between Cheryl, medical staff and social researcher. But its
analysis would have been largely descriptive in character, largely unable to
define or account for the inequalities and constraints that shaped interactions, largely unable to forge links with wider theoretical traditions and
generalizable models of the social structure. Theorists of medical dominance, whether from Marxist or Foucauldian perspectives, would have
easily located structural and ideological inequalities in the situations we
reviewed. Yet we doubt that these approaches, at least in their currently
available forms, could have made convincing reference to the multiple
selves, symbolic orders and contingent struggles through which inequality
was dramatized, generated and challenged. Power, in a sense, would have
over-determined outcomes to the point where the detail of its reproduction
could be bracketed out as trivial. Parsonian role theory would have likewise
generated a misleading picture of ‘oversocialized’ actors fulfilling their obligations to structural theory. In this way it could have explained Cheryl’s
eventual compliance with medical power and the attempts of medical staff
and the social researcher to do their duty. Yet such an account would have
misread motivations, assumed co-operation rather than investigated contestation, and attributed a false holism to the multiple selves and language
games deployed in a complex and unfolding laminate of events.
Research in the spirit of critical postmodern social theory, such as this,
should not rest content with scoring points against other theories. It is
important that it can suggest patterns for change if it is to have moral intent
(Grosz, 1989; Seidman, 1992). We have demonstrated that shifts from the
subject position of doctor’s assistant to patient’s advocate provide one way
in which radically minded nurses and midwives can confront medical power.
Yet this strategy is not without its problems. Here we identify three such
issues. First, it can lead to moral and ethical difficulties when the patient
makes choices which confront what we might understand to be their own
best interests. Second, there are those challenging, traumatic and paradoxical moments when multiple subject positions come into play within us, each
with its own understanding of what is the best way to proceed. The conflicts
in the data between the researcher’s identities as midwife, nurse and as
radical feminist researcher provide an illustration of this theme. Perhaps it
is only by learning to tolerate this ambivalence, risking abjection and the
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abyss that we can eventually embrace multiple and apparently contradictory identities and thus access more powerful discourses. Third, in the light
of Foucauldian theory it is by no means certain that becoming the patient’s
advocate does not generate alternative relations of power rather than
freeing the patient from medical dominance (Lupton, 1995: 160–1). It is
tempting to try to avoid this dilemma by constructing new subject positions
from which to speak. Yet it is by no means clear that such positions will have
any weight in interactions. Butler (1993) shows that agency cannot operate
externally to the functioning of regulatory norms and that being acknowledged as a subject means speaking through culturally recognized subject
positions. So there are no easy answers to be found by researchers, nurses
and activists simply adopting new subject positions or by looking to hybridity.
But what about the patients? The data presented here suggests that
attempts to take up subject positions that confront medical power are risky
– Cheryl was treated with suspicion and, we suspect, punished for being
rebellious. Cheryl’s experience also shows that attempts to assert personal
sovereignty by moving out of the legitimate subject position of good patient
are liable to be countered by negative labelling and sanctions. Moreover the
range of available subject positions she could adopt was limited. Other
studies suggest that this finding might be generalizable to women outside of
the sphere of the medical encounter. For example, Karen Henwood’s (1993)
exploration of the lives of elderly women found that there were few alternative subject positions available to that of the good grandmother. Those who
rejected an idealized grandmaternal subject position were liable to be categorized as evil maternal figures.
This research suggests that resistance from below through the adoption
of confrontational subject positions can have only mixed effects. The next
step, we suggest, is to think about developing new subject positions from
which doctors and others in positions of medical authority can act. Just as
rape and domestic violence should be thought of as issues for men as much
as for women, so must medical dominance and the doctor subject position
become seen as a problematic issue for medical professionals. Developing
and institutionalizing structures and processes which allow nurses and
patients a voice in questioning medical action and inaction should be a priority. The creation of such institutional structures provides the social
support for the emergence of an expanded range of discourses. Such
support will help patients and advocates avoid experiences of the abject
such as those related in this data. Because subject positions are inherently
reciprocal, it is vital that these changes in discourse arise through cooperation, not confrontation, between doctors, nurses, social researchers
and medical patients.
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Author biographies
co-ordinates the Master of Midwifery course for the University of
Southern Queensland where she is appointed as Associate Professor in Nursing. Her
main research and scholarship interests concern feminist approaches to theorising
and changing the health care systems in ways that are culturally and psychically safe
for patients and non-medical staff. Recent publications have concerned Postmodern,
feminist ethics; Nursing advocacy and burnout; Emancipatory research methodology and the ontology of ‘being’ a midwife as opposed to ‘doing’ midwifery.
KATHLEEN FAHY
PHILIP SMITH is Senior Lecturer in the Department of Anthropology and Sociology
at the University of Queensland. He has published widely in the area of social and
cultural theory. His most recent book is The New American Cultural Sociology
(Cambridge).
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