In this paper I will show how the medical image, presented to the patient by the physician, participates in medicine's cold culture of abstraction, objectification and mandated normativity. I begin by giving a brief account of the use of anatomical imaging since the Renaissance to show how images have historically functioned in contrast to how they are currently used in medical practice. Next, I examine how contemporary medical imaging techniques participate in a kind of knowledge production that objectifies the human body. Finally, I elucidate how physicians ought to place the medical image within the context of the lived body so as to create a healing relationship with the patient. In all this I hope to show that the medical image, far from a piece of objective data, testifies to the interplay of particular beliefs, practices and doctrines contemporary medicine holds dear. To best treat her patient, the physician must appreciate the influence of these images and appropriately place them within the context of the patient's lived experience.
- Medical imaging
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No image ever exists within a purely neutral field, not matter how hard its originators may think they are trying. Martin Kemp
In March of 2012, the MUSE Center of Photography and the Moving Image in New York featured an exhibit called ‘Seeing Ourselves: The Science and Art of Diagnostic Medical Imagining.’ Curated by two physicians, the exhibit featured work from 60 artists who shared their medical knowledge from an aesthetic standpoint. According to the exhibit's press release,
In diagnostic imaging, the body is examined in detail, piecemeal and irreconciled, described in terms of ‘cuts’ and ‘slices’. The body in pieces, viewed as relics and synecdoches, constitute deconstructed images of humans and problematize issues of creation and re-creation, existence and mortality, integration and dissolution, especially when the images of the dematerialized body are translated from digital code, existing as pure information. There are dire consequences of equating digital reconstructions with the real… Realizing that MRI images are only re-presentations and partial truths empowers us to recognize the political, social, and economic factors that affect the interpretation of these images.1
The images created by the artists are indeed a stunning glimpse into the human interior, meant to inspire as well as complicate the viewer's perception of the human body. The advent of sophisticated medical technology has allowed physicians, patients and now the general public to glimpse further inside the human body, to reveal what skin and bone conceal. As the MuseCPMI attests, these images reveal a truth and a fiction about the human body. Magnetic resonance imaging (MRI), positron emission tomography and computer axial tomography scans show us ‘slices’ of our own bodies, yet it is difficult to reconcile these images with our experience of embodiment. The images are far from neutral or objective; they demand interpretation. But how are we to interpret them? And who has the right to do so?
Most people will not encounter their first MRI in an art gallery, but in a doctor's office. I remember vividly sitting with my doctor years ago, watching as he flipped through MRI scans of my brain and spine. After several months of medical testing to find the source of the numbness that intermittently ran through my legs, this doctor knew almost immediately the secret my body was harbouring. ‘It's MS!’ he declared, almost triumphantly. I was stunned; whatever he saw on those images was lost on me. ‘How can you be sure?’ I asked. Rather than help me interpret the pictures, the doctor became offended, assuring me that he was a specialist and knew what he was looking for.
After over a dozen MRIs, I too would come to see what he saw: the spots, the bright white blotches that should not be there, whose intensity and multiplicity would shape my future. I received several more tests to confirm my diagnosis, but none were as poignant as the image I confronted in the MRI scan. The visual was visceral and confronted me with utter seriousness. Many physicians would later help me to gain the technical expertise necessary to read my magnetic resonance (MR) images, but each was far less helpful in showing me how I ought to understand these images and what they meant for my present and future life.
In what follows, I will show how the medical image, presented to the patient by the physician, participates in medicine's cold culture of abstraction, objectification and mandated normativity. I will begin by giving a brief account of the use of anatomical imaging since the Renaissance to show how images have historically functioned in contrast to how they are currently used in medical practice. Next, I will examine how contemporary medical imaging techniques participate in a kind of knowledge production that objectifies the human body. Finally, I shall elucidate how physicians ought to place the medical image within the context of the lived body so as to create a healing relationship with the patient. In all this I hope to show that the medical image, far from a piece of objective data, testifies to the interplay of particular beliefs, practices and doctrines contemporary medicine holds dear. To best treat her patient, the physician must appreciate the influence of these images and appropriately place them within the context of the patient's lived experience.
The historical use of medical images
The MuseCMPI's attempt to bring together artistry with medicine recalls an earlier time in Western history when medical images were more explicitly infused with philosophical understandings of the body. Before the use of photography and other more advanced imagining techniques, artists were employed to illustrate human anatomy with masterful detail, but also aesthetic flourish that gave the images a context. Anatomical illustrations, such as paintings, drawings, prints and sculptures have historically served to inspire awe in the public as much as they were used to educate. While the history of anatomical imaging is complex, art historians have recognised a contemporary shift in the use of anatomical images in medical practice. As art historian Martin Kemp notes,
The world of medicine and its associated imagery occupied very different cultural territories from today's professional mainstream. The purpose of anatomical images during the period from the Renaissance to the nineteenth century had as much to do with what we would call esthetics and theological understanding as with the narrower intentions of medical illustration as now understood…the disclosing of the ‘divine architecture’ that stood at the summit of God's Creation remained the central goal of anatomical representation across at least three centuries.2
Believing that the visible nature of God's created order was designed for human understanding, artists and anatomists during the Renaissance sought knowledge through human anatomy, and reconfirmed the ancient model ‘know thyself’ as the human beings’ highest ideal.3 MRI scans, which can only be interpreted by a select few in the medical profession, seem a far cry deeply contextualised and theologically laden illustrations presented in the anatomical artwork Kemp describes.2 If Kemp is right that we have experienced a significant shift in the ways we use and understand medical imagery, we may begin to wonder what caused this shift and what influence this shift may have on the physician's ability to relate medical images to patients’ lived understanding of illness?
As medicine began to establish itself as a profession in the 19th century,i a shift towards more ‘objective’ anatomical illustrations emerged. To reinforce the professionalisation of medicine and its classificatory obsessions, the unadorned style of anatomic illustration, like that in Gray's Anatomy, became the norm.2 As Kemp describes:
The aim was restrictedly practical, avoiding any taint of philosophic anatomy in favor of introducing such verbal and visual descriptions as would be useful for the aspiring surgeon and clinician. The tone of the text is sober to the point of anonymous flatness, while the woodcut diagrams use business-like lines…to achieve a steady register of unseductive description.4
As more ‘practical’ and ‘objective’ illustrations of human anatomy came into fashion, a divide began to emerge between the professions of artist and anatomist in the late 19th and early 20th centuries. Great artists like Matisse and Picasso, while still incorporating human figures in their art, became less concerned with anatomical ‘correctness.’2 At the same time, the use of medical technology enabled physicians to see beyond what the human eye was capable of discerning. The invention of the x-ray in 1895 for example, allowed for an entirely new vision of the human interior. Advancing medical machinery failed to provide an unmediated picture of human anatomy, however. Kemp explains,
Looking and representing are inevitably directed and selective processes, and the putting of them to other eyes and hand caused inevitable problems…This dilemma is particularly severe if we move outside the normal scope of our unaided vision, using such devices as a microscope or X-ray machine. … [E]ven such apparently obvious pieces of mechanical realism proved to be fraught with social frissons, particularly with respect to the portrayal of recognizable individuals and the potentials for voyeuristic viewing. No image ever exists within a purely neutral field, no matter how hard its originators may think they are trying.3
The awe associated with viewing the body in new ways reinforced the body's objectification, tempting its viewers to become voyeurs. At the same time, as the ability to explore the messiness of the human interior became ever more sophisticated, the interpretation of medical images became the sole purview of the medical professional. To establish medicine as a legitimate science, medical practitioners needed to demonstrate that their own viewing practices were objective and distant, rather than voyeuristic.
Today, clinical medicine clearly favours detachment while viewing human anatomy. Imaging technologies, such as CT and MRI scanners, produce images that seem far removed from the bodies we are accustomed to seeing. It has become increasingly difficult for the general public to understand what is being presented in contemporary medical images and how they ought to interpret those images. As we gaze upon the newly charted visions of our interior provided to us by medical technology, we are likely to be confronted with a rather unusual and unrelatable image of our body's interior (dys)function. An MRI attempts to show us a snapshot of our lived interior, but as sociologist Tony Walter notes, careful observation of the body, through stethoscopes, biopsies, MRI scans and other techniques, divide medicine's ‘observed body’ from the ‘subjective body’—the daily, lived experience of the layperson.5 The interpretation of medical images now resides solely within the domain of the medical professional, who must attempt to bridge the gap between the medical image and the real, living body that seeks healing.
The contemporary medical image and knowledge production
The MR image can be said to be a true representation of the human interior, but it is questionable what kind of ‘truth’ this image represents. For the physician, there is no doubt that the MR image can reveal the true nature of the patient's pathology, but it is perhaps less clear what this truth means for the patient. The physician's education leaves her predisposed to seeing bodies in segments and slices, which are incompatible with the patient's embodied experience of self, and it takes a lot of work to associate the lived body with these ‘true’ images. The MR image is likely to create a sense of dissonance for the patient who cannot reconcile the image with the disruption she has experienced in of her everyday functioning.
With the use of modern medical technology, educators now see images produced from photographic technologies as crucial for teaching students human anatomy. The Visible Human Project for example, has been working for the past two decades to create a digital library of volumetric data so as to represent the ‘complete normal adults human male and female.’6 The project was conceived in 1989, when medical teachers noted the difficulty of conveying visual knowledge to students using only two-dimensional images in textbooks. According to Ackerman, ‘Three-dimensional photographic technologies have been brought to bear on the problem of visualising human anatomy.’6 Once more complicated medical imaging techniques became standard equipment in many hospitals, two-dimensional photographic imagining and even cadaver dissections came to be seen as under-representative of human anatomy. ‘Complete’ knowledge of the human body now demands three-dimensional computer generated images. With these more complex images available, the National Library of Medicine hopes that students will be able to ‘display, rotate, selectively ‘dissect,’ and reassemble normal human anatomy.’6 Medical students can now master the ‘complete’ (normal) human body, without ever having to interact, let alone meet with one!
As we can see, the physician is habituated to see the represented image to stand in for the truth of the body. Just as the physician is taught to see virtual (visible) body as a stand in for the real material body, she is also taught to see the white spots on a MR image as a stand in for disease. The trained physician, taught to see fragments as signifying the whole, sees the essential link between the image, the disease and the patient. As Foucault describes in The Birth of the Clinic, clinical medicine has obscured the traditional meaning of the sign and symptom. Whereas symptoms and signs once pointed towards (but did not completely capture) the essence of a disease and its general prognosis, symptoms are now understood as subjective experiences of illness whereas signs—the physician's trained observations—are now considered objective and true indicators of disease.7 The subjective—in the subjective, objective, assessment, plan (SOAP)-note—is what the patient experiences and is unreliable. The objective is what the physician sees and measures as truth. No remainder exists between the signifier and signified. Physicians can capture the essence of disease by giving words to the truth of what they see.8 According to Foucault, ‘In clinical medicine, to be seen and to be spoken immediately communicate in the manifest truth of disease of which it is precisely the whole being.’7 In other words, medicine now believes that the visible can be truly spoken, which reveals the truth of disease. Physicians no longer need to know how patients subjectively experience disease to diagnose disease.
Foucault calls this particular way of separating the patient's body from her person the ‘medical gaze.’ The medical gaze, which claims to speak the truth of what it sees, is liable to pose a certain kind of violence upon the patient. Gazing into the human interior is hardly a neutral or innocent activity. Foucault queries, ‘to look in order to know, to show in order to teach, is not this a tacit form of violence, all the more abusive for its silence, upon a sick body that demands to be comforted, not displayed?’7 Patients seek medical care in order to be made whole, only to have themselves fragmented and objectified by the physician, often for the sake of teaching younger physicians, or for communicating with other doctors involved in the patient's care. Viewing the body through virtual, representational medical images, such as those in The Visible Human Project, however, obscures the particularity and fluidity of actual human bodies. Medical students are taught to compare all bodies to these phantom everyman bodies, which cannot move, feel or express their subjective needs.
Medical imaging machines, such as the MRI scanner, create computer-generated images representing segments of the human interior. The MRI is a kind of representation of a representation. For most patients, the difficulty involved in interpreting an MRI resides partly in the complexity of the machine itself. The MRI scanner allows us to see the body tissue by aligning the protons in the body's hydrogen atoms. Radio waves are then sent through the body, forcing the nuclei in our body's hydrogen atoms into a different position. When the nuclei move back into place, they emit their own radio waves, which create signals picked up by a scanner. A computer then creates a picture of the body part being scanned based on the location and strength of incoming signals. Bones show up dark on the picture, because they contain relatively fewer hydrogen atoms, whereas fatty tissue, which contains many hydrogen atoms, looks much brighter. Abnormal tissue, such as the tissue formed in someone with multiple sclerosis, can also be seen brightly on the scan.9 While an incredibly precise instrument, the MRI scanner is not simply taking a picture of the human interior. Upon dissection, the surgeon would surely see the pathology of my disease differently than the MR image. One may be left to wonder: in what sense is the image real or true? And in what sense is it a representation?
Images produced by medical technologies are more often than not seen as an unfettered good by medical scientists and ethicists in contemporary society. The story goes that over the past 25 years a digital imaging revolution has occurred and transformed medicine. By producing images that are invisible to the human eye, physicians are now able to view and diagnose disease in radically different ways. The medical profession has had knowledge of the human body inaccessible to most lay people since its inception, but with the rise of medical imaging it also now has the exclusive ability to produce and interpret images that patients can neither see nor experience.
The public's inability to understand this sophisticated medical technology only thrusts more power back onto the physician. A 2006 study by the US Department of Education shows that 36% of Americans have only basic or below basic skills for understanding health information, meaning at most they had the skills necessary to comprehend short, simple prose or documents.10 Only 12% of people were able to ‘draw abstract inferences’ from complicated texts. Physicians tout medical images as especially helpful for aiding patients in their understanding, but it remains unclear whether most patients are able to grasp the meaning of a MR image. Though little empirical work has been done to see how (and if) patients understand the images being presented, it does not seem like a stretch, given the current data on health literacy, to assume that the vast majority of patients do not know how medical imaging technology works or what medical images represent. The knowledge needed to create and interpret medical images gives the physician tremendous power over the patient, because it allows the physician to be the guarantor of truth.
New insight into the deep inner-workings of the human body provided by medical imaging technology has transformed the physician-patient relationship, but little attention is given to the nature of this changing relationship in bioethics. Whereas once the patient came to the physician to find the source of her disease and to cure it, it is now possible for the physician to view abnormalities unrelated to the patient's motive for seeking care. While the potential for conflict is high when patients find out more than they wanted to know from well-meaning physicians, the medical community's demand for objective data coupled with the public health demand for preventative healthcare has created a consumer market for all kinds of healthcare screenings. Approximately 250 million scans are performed in American hospitals, costing around $100 billion dollars a year.11 Between 1996 and 2010, the use of MRI scans quadrupled.12 The demands made by anxious patients for early-detection screenings has led to serious debate concerning the productive use of medical imaging technology. Patients in our American consumerist society often see healthcare as a right and frequent screenings for a variety of ailments as a mandate. Fierce debate has arisen, for instance, over the recommended ages for receiving mammograms.
Clearly, these new technologies have shifted the way we understand the role of preventative medicine and even how we relate to our bodies. The rise of medical imaging has been accompanied by a prevalent anxiety about the secrets our bodies may be harbouring. We are no longer concerned about our health just when we feel diseased, but seemingly at every moment. Though the medical community has tried to reduce unnecessary medical testing, our collective anxiety reinforces medicine's tremendous power over the public's psyche. Because the production and interpretation of these images resides solely within the medical community's control,ii medicine has reached an ever more powerful and essential place in American life.
What we look for inside the body and what we choose to see there within continues to be infused with cultural meaning, just as it has been for centuries. According to Kemp, ‘The function and the ‘look’ of something are not separate, since any action is hedged around by attitude, hostile and approbatory, and our instinctive visual reaction to any item in a field as highly charged as medicine will be an integral part of the social field within which participants function.’3 The MR images produced and then shown to patients exist within the medical milieu, and in this context, medical images demand our attention and submission. The image of my body produced by the MR scanner must be filtered through the interpretation of the physician who gives the image meaning and context. Given the power of interpretation, I believe that the physician is obligated to help patients understand what this image reveals about their disease, but also what it means for their future life.
The lived ill body
Through years of training, the physician has learned to see the part as standing in for the whole: the MR image clearly shows the disease. Taught to objectify and dissect human bodies before he was taught to relate to real living bodies, it is perhaps not surprising that my physician chose first to look at my MRI scans before he decided to have a conversation with me. To know the ‘truth’ of my body, he only needed to view a part of it, unrelated to the whole of my experience. The reliance on medical imaging and lab results by physicians has created tensions when the data collected, rather than the patient's discomfort, is taken as the primary signifier of disease. The medical image, which can present pathology with visual clarity, may in fact exacerbate the tendency of physicians to rely on their own tests over the patient's experience and testimony. The demand that symptoms become reinterpreted as physical signs, (like visible lesions on an MRI) and then translated into objective data, seduces physicians to look past the lived experiences of patients and toward their dissected representations.13
In opposition to the ‘phantom everyman body’ that medical students learn to interpret, patients demand that physicians diagnose and heal their particular bodies. As shown, patients hunger for the diagnostic knowledge produced by medical imaging, and yet are typically unequipped to process the complexity of this medical information alone. This reality makes it all the more important that physicians work with patients to interpret medical images. Helping a patient to understand her MR image involves more than simply explaining the intricate workings of the MRI scanner or even the pathophysiology of the patient's disease, however. Even with this technical knowledge, a patient still might struggle to understand how a disease, spoken about in the abstract, relates to her own body and understanding of self. While it is certainly the case that doctors and patients share some understandings of medicine and culture, we cannot assume the physician and patient are discussing a shared reality when they encounter the patient's illness. In her book ‘The Meaning of Illness’, philosopher and patient with MS, Kay Toombs explains, ‘The physician is trained to perceive illness essentially as a collection of physical signs and symptoms which define a particular disease state. The patient however…does not ‘see’ one's own illness primarily as a disease process. Rather, one experiences it essentially in terms of its effects upon everyday life.’13 Whereas the patient understands illness in its immediacy, through its interaction/coherence with her body, the physician seeks to categorise the illness into ‘objective’ data, abstracting the illness from the patient so as to scientifically analyse it. While the patient and doctor seem to be attending to the same ‘issue,’ each is potentially projecting an entirely different view of the patient's body, and therefore, doctor and patient often fail to share a coherent meaning of illness.
While it is beyond the scope of this paper to provide detailed descriptions of how physicians can better communicate with their patients regarding the interpretation of medical images, I do have some general suggestions for how physicians can begin to bridge the gap between an understanding of ‘the’ body and the patient's understanding and experience of her own ill body. Physicians who wish to help give meaning to patients’ medical images will need to pay particular attention to the ‘lived body’ of the patient, the patient's ‘body image’, and the patient's sense of ‘intercorporeality.’ Beginning with a phenomenological account of the lived body might enable physicians and patients to speak on common ground when discussing illness. When physicians discuss ‘the body,’ they are typically referring to the objective or physiological body. The objective body is one that can be reflected upon and understood as a material object among other objects in the world.13 In most circumstances, however, our experience of inhabiting a body is prereflective, meaning we live without attention to how our body is an object moving in the world. My ‘lived body’ does not experience a separation between body and self, because, of course, I am my body. When all is well and I am able to carry out my projects with ease, I forget about my body, it is invisible to me.
There are two primary ways in which my own body might come into relief: dysfunction and objectification by another. In illness, both of these possibilities are likely to become realities. In the former case, disease is likely to cause my body to function improperly. The numbness in my feet and legs for instance, forced me to notice them. Whereas I normally walk without thought to how my feet and legs move and carry me along, the numbness I occasionally experience causes me to see my feet and legs as objects inhibiting my gait. My taken-for-granted experience of walking can be eclipsed by the new effort it takes me to move.
By the time I was finally diagnosed with MS, however, my initial symptoms had long since dissipated. Still, the battery of medical testing I underwent caused me to continue to objectify my body. I experienced my body as an object when my physicians objectified me. As Jean-Paul Sartre explains, one can experience her body-as-object when she encounters the gaze of the Other.14 When I become aware that the other is looking at me and seeing a physiological body, or an ‘ensemble of sense organs,’14 I learn to see and know myself through the eyes of the Other. As previously discussed, the physician who is taught to view ‘the’ body before she is taught to interact with particular bodies, is likely to perceive the patient's body as an object to be compared to a phantom ‘normal’ body. Toombs writes,
This particular body presented to the physician in the clinical encounter is simply an exemplar of ‘the’ human body and, as such, it may be viewed independently from the person whose body it is. That is, the mechanical workings of this human body are ‘objectified’ in such a way as to render the ‘subjective’ experience of the particular patient explicable in terms of a general, theoretical account of the causal structure of such experiencing.13
As I experience my body being looked upon by the physician who is taught to see me as an instance of some generalised physicobiological entity, I begin to see myself likewise.
The physician who is willing to engage her patient in a conversation about the patient's lived body and understanding of illness might help to mitigate the dissonance that is created when a patient begins to experience her body as an object. A physician might begin the process of giving meaning to the patient's illness by reversing the order of her gaze. Rather than looking first to the medical image, then to the disease, and finally to the patient in front of her—as my physician did—the physician might instead begin with the patient's lived experience. Showing and explaining illness, while important for medical training, is insufficient for the patient who seeks to be comforted and made whole. Toombs claims, ‘If the physician is sensitive to the patient's interpretive understanding of illness, he or she can act as an arbiter of meaning—perhaps enabling the patient to modify or change an inappropriate interpretation of the situation.’13 Rather than primarily discussing how disease affects generalised normal bodies, the physician ought to begin with how the patient understands illness and how she anticipates living with illness.
Next, the physician needs to uncover how the medical image coheres or disrupts the patient's previously held identity or ‘body image.’ According to Maurice Merleau-Ponty, one's body image is the way that one experiences her embodied-self as mediated through the perceptions of others and her interactions with her world.15 Building upon Merleau-Ponty's work, Gail Weiss suggests,
Images of the body are not discrete but form a series of overlapping identities whereby one or more aspects of that body appear to be especially salient at any given point in time…body images…are copresent in any given individual, and…are themselves constructed through a series of corporeal exchanges that take place both within and outside of specific bodies.16
The MR image is likely to create tensions with how a person relates to her body and to her environment, because it puts forth a new image of the body a patient must contend with. Even though I live with few symptoms as a result of my MS, my body has learned to function differently as a result of my diagnosis and my evolving body image. Because the MR image serves, in part, to predict the future course of my disease, rather than move effortlessly through the world, I now reflect upon the ‘taken-for-granted’ habits of my body more actively than ever before. For example, whereas I may have overlooked a simple trip as I walk, I now question if my failed gait is a symptom of my MS. (A neurologist recently explained to me that ‘normal’ people should never trip, further exacerbating my fears.) Whether or not this is the case, I have learned to associate nearly all my bodily failings with MS. Set against the context from which I am able to project my present and future bodily functioning, I now perceive a long hallway as a potential obstacle, rather than a pathway. My once unconscious movement through the world has been disrupted by the newly acquired knowledge I have gained about common MS symptoms, even though I remain uncertain as to which of my bodily failings are truly caused by my MS. More often than not, I cannot help but see my body as an instantiation of the MS body.
By discussing with the patient how the medical image interacts with the patient's body image, the physician can begin to give context to the image and help the patient navigate the meaning she associates with illness. When confronted with new body images, Weiss claims,
These body images will inevitably be in tension with one another, but, by communicating with one another through the ‘body image intercourse’… they allow us to negotiate productively the turbulence of our corporeal existence, a turbulence that cannot and should not be abjected from our body images, since it is precisely what enables us to meet the vicissitudes of bodily life.16
Physicians may be able to help patients negotiate their ‘corporeal turbulence’ by discussing the multiple and varied ways they see their other patients live with MS. Ironically, though they are taught to relate all bodies to a generalised normal body, physicians are in a unique position to help situate the effects of illness on different lived bodies. Physicians are often privy to many instantiations of ‘abnormal’ bodies by virtue of their profession. If the physician has other patients with the illness being diagnosed, she likely has many living examples of particular ill patients. The physician ought to be able to convey to the anxious, newly diagnosed patient the myriad of ways in which various individuals embody their illness and how those individuals are able to negotiate the turbulence that arises when their bodies malfunction. By presenting patients with multiple body images—multiple ways in which other patients experience and live with their illness—patients might be less likely to visualise a future in which illness and disability are world threatening.
Finally, by presenting multiple body images to patients, physicians may begin to introduce a healthy sense of ‘intercorporeality’ that exists between bodies and within our own bodies. By ‘intercorporeality’ I mean the ways in which our experience of being embodied is mediated through our interactions with other bodies.16 How one understands her own illness is always already filtered through the context in which others present illness to her as well as the ‘cultural imaginary’ that narrates illness to the public. Given that the dominant narratives about chronic illness are likely to be negative, it is important that the physician expand the patient's images as well as her imagination. Studies shows that patients newly diagnosed with MS often feel overwhelmed by the mere thought of impending physical impairment and as a result, isolated themselves from ‘the world of MS’ and those who inhabit it.17 While most people are able to cope with the early stages of MS, few believe that they will be able to do so when the disease becomes severe, causing many to feel anxious and distressed about their futures. The reality, however, is that the majority of those who actually experience further significant impairment are able to cope with those circumstances as well.17 Knowing others who embody the patient's same illness, physicians are in a unique position to undermine the dominant narrative that supposes that MS is the ‘bad thing’ that happens to a person, which inevitably leads to severe disability and poor quality of life. Physicians can thus help resignify illness to their patients by shedding light on the need for expanded intercorporeality. Because MS is such an unpredictable disease, many physicians may be wary of predicting what effects it may have on particular individuals and may resist providing examples of what could happen. Weiss suggests, however, that holding together multiple body images (as opposed to having only one coherent and static image) can enhance rather than diminish our sense of bodily integrity.16 Helping patients to incorporate their ill-identity into their body image, and helping them connect their bodies to other bodies (conceptually and perhaps even more literally if the physician is able to refer patients to MS groups) may ultimately help patients productively cope with illness.
Physicians themselves must be willing to introduce conversations concerning meanings, values and lived experiences. Patients are unlikely to initiate such conversations or share their fears about the future with their physicians. According to Toombs,
Invariably patients assume (often incorrectly and certainly unreasonably) that their physician knows and understands what [the patient's] personal value system is and, further, that in making clinical decisions the physician is doing so not only in light of the clinical data but additionally with regard to this personal value system. Patients, therefore, rarely explicitly communicate their values to their physicians. Physicians, on the other hand, may deem it inappropriate, irrelevant, or intrusive to task patients about their values and may judge the clinical data alone to be sufficient to determine what is in the patient's best interest.13
Indeed, the ability to make an informed decision about one's healthcare may demand just these kinds of ‘values’ conversations. The physician must attempt to relate to the patient's lived experience, rather than on her scientific understanding of illness, so as to help the patient articulate the meaning of illness as it is lived out, and anticipated, in her everyday life. It is in these sorts of conversations where the healing relationship between patient and physician begins.
Every visual image has its function and exists within a context. Gone are the days when the professions of artist and anatomist easily cohered, but this does not mean that medical images are easily divorced from their sociopolitical contexts and implied meanings. Those who view an MRI in an art gallery may be swept up in its beauty, whereas those who view such an image in the examination room might find the image horrifying. The artist and the physician, however, exert a certain authority and power over the image they help to construct. What we see in the image must be interpreted, lest we fail to grasp its essential meaning for our lives; a meaning that the artist and the physician would be remiss to let us ignore. Physicians ought not to forget what the gallery curator so easily admits: ‘Realising that MRI images are only representations and partial truths empowers us to recognise the political, social, and economic factors that affect the interpretation of these images.’
A wide array of medical technology allows physicians to see into the human body with startling depth, but the images these technologies produce can reinforce the cold clinical gaze, which associates the patient only, or at least primarily, with her objectified body. The knowledge produced by these images can be wielded over patients in dominating and alienating ways. Taught to see disease in an objective and data-driven fashion, the physician is likely to neglect any attention to the patient's subjective experience of illness and its meaning for her life. The physician's duty to heal demands that she engage in a process of mutual interpretation with her patient to discover what the image signifies to each. This is particularly true when we realise that healing means more than curing and suffering can be produced by the mere threat of future impairment.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i The AMA was founded in 1847.
↵ii Recently, some companies have begun offering 10 min CT body scans, but these have been sharply criticised by physicians who fear their use is limited without physician follow-up. See for example The Almanac article ‘Health and Fitness: Examining the Body Scan: Stanford researchers advise people considering body scans to proceed with caution—and eyes wide open. February 2005. http://www.almanacnews.com/morgue/2005/2005_02_09.hfscans.shtml accessed 6/21/12.
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