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BODIES in FORMATION

DUKE UNIVERSITY PRESS

Contents

Acknowledgments......................................................1INTRODUCTION.........................................................33ONE "A Fascinating Object"...........................................69TWO Cutting Dissection...............................................103THREE Cultivating the Physician's Body...............................137FOUR Techniques and Ethics in the Operating Room.....................171FIVE Swimming in the Joint...........................................199SIX Enterprising Bodies in the Laboratory............................227SEVEN The Anatomy of a Surgical Simulation...........................253CONCLUSION...........................................................267Notes................................................................277References...........................................................289

Chapter One

With some doctors, I get the feeling they're not seeing the part of me that's not my body. A PATIENT

Take my body. Use it well. Become a good doctor. TAKEN FROM A NOTE WRITTEN BY A FUTURE CADAVER DONOR TO MEDICAL STUDENTS

On the first day of a cadaver demonstration in an anatomy course I took, a student had to leave the laboratory because tufts of hair emerging from the cadaver's ears reminded her of her grandfather. In that moment, the cadaver became a former person, one who reminded the student of someone she loved. For her, the cadaver was no longer a scientific object. This phenomenon is common among medical students: some detail, such as ear hair or a tattoo, brings the cadaver's personhood to the fore, making dissection emotionally difficult. Students also often have strong emotional reactions when they dissect anatomical areas that evoke a cadaver's humanity and personhood, such as genitals, faces, and hands.

Cadavers are persons and things. This ontological duality cannot be resolved, but it can be managed through practices that encourage students to interact with cadavers as persons or as objects. Cadavers remain the most important objects-subjects in a formative rite of passage in North American medical schools: the anatomical dissection. Cadavers help students become physicians, in part by helping them shift from treating bodies as persons to treating bodies as the objects and the subjects of clinical inquiry. Although dissection as a pedagogical practice is in decline, most North American medical students still dissect cadavers in the anatomy courses they take in their first year. Defenders of dissection say the experience provides two benefits for medical students. First, dissection demonstrates a real, if not in vivo, example of the body's structures, and it helps students begin to develop a biomedical stance toward patient bodies. Second, it helps medical students to begin to craft their own bodies as practitioners while they craft others' bodies.

The cadaver often is a medical student's first exposure to medicalized human bodies, to bodily interiors, and to death. Students must grapple with the emotional intensity of destroying a human body. Dissection, whether it takes place in an anatomy laboratory or operating room, requires working against many ethical, legal, and religious traditions that prohibit doing damage to living and dead bodies. Several physicians I spoke with alluded to these taboos, saying what they do would be considered "psychopathic" in any other context. But medical and surgical education, as well as broader faith in biomedicine, makes dissection an important and accepted learning experience. In the past, students kept their feelings about dissection to themselves. Describing the anatomy course he took in the 1940s, Dr. Richard Hunt, a retired anatomist, said, "If you had weird feelings about the cadaver, you never dared tell anyone." Since the 1950s, however, anatomy programs have seen a steady rise in attention to students' affective socialization. Programs at the turn of the millennium do far more to give students opportunities to express their feelings and, in related ways, to engage in practices that summon the cadaver's personhood.

Biomedicine typically takes a "radically materialist" stance toward bodies, diseases, and treatments, approaching humans and their diseases as grounded almost exclusively in biology, excluding other explanatory frameworks (Scheper-Hughes and Lock 1987). Marilyn Strathern argues that biomedical physicians also seek, often in relatively impoverished ways, to "activate the person," who often gets erased amid biomedicine's objectifications of bodies and pathologies (2004, 8). In this chapter, I examine how anatomy training constructs cadavers as persons and as things. I also explore how anatomy courses manage student emotions, how students respond, and how similar constructions of patient bodies as persons and things come into play in clinical settings. Finally, I draw upon anthropological literatures on embodiment and emotion to connect medical training to the cultivation of an affective stance toward patients and their bodies. Students in anatomy laboratories learn to treat bodies within a materialist paradigm, while also cultivating means of engaging the patient's personhood. In other words, students learn to put the cadaver's ontological duality at the heart of what I call "tactical objectification," the ability to objectify the body or call forth the person as needed.

Objectivity and Objectification in Biomedicine

By the early 2000s, many medical schools had cut their anatomy curriculum from a year or more (which was common in the 1950s) to a semester or even a few weeks. Medical school administrators argue that cutting anatomy teaching has enabled them to make room in the packed curriculum for more leading-edge sciences. They also chafe at the cost of running a willed-body donation program that provides medical schools with teaching cadavers. During eighteen months of fieldwork from 2001 to 2006, I interviewed anatomy instructors at four medical schools, took a summer anatomy course, and did participant observation of anatomy courses, dissections, and other activities in two laboratories. Even among programs that remained most committed to traditional anatomy teaching, anatomists and technology builders often discussed the reduction or elimination of dissection at other schools, debated the merits of dissection versus demonstration with previously dissected materials, and considered how they could use imaging and modeling technologies to replace or supplement dissection. The threat to dissection as a pedagogical practice raises questions about what lessons, beyond knowledge of anatomical structures, the dissection holds for students.

Many nonphysicians I spoke with worried that biomedical training alienates physicians from their patients' humanity and that virtual anatomy or virtual dissection might further distance physicians from their patients. They expressed concern that a physician's sense of touch, empathy, or morality might remain underdeveloped without the experience of dissection. Physicians expressed concerns about the effects on medical students of reducing the hours spent dissecting or of eliminating dissection altogether. They argued that trainees must prepare themselves for the emotional rigors of clinical work and acquaint themselves with death and dead bodies.

There is something paradoxical in the notion...