Professional Documents
Culture Documents
Gross
Table of Contents
TABLE OF CONTENTS........................................................................................................................... 1
PART I: INTRODUCING THE WORK ................................................................................................. 5
THE STUDY OF THE HUMAN ANIMAL ................................................................................... 5
THE THREE PAPERS .......................................................................................................... 8
Surgeons of the Mind ............................................................................................. 8
Experts and 'Knowledge that Counts' .................................................................. 10
The World of Brain Surgery .................................................................................. 11
PART II: THE ARGUMENT AND ITS THEORETICAL COMPLEX ............................................... 13
THE MIND-BODY PROBLEM AND CARTESIAN DUALISM ......................................................... 13
Descartes and After.............................................................................................. 13
The Cartesian Fallacy ........................................................................................... 15
INTRODUCING THE GNOSTIC SPLIT .................................................................................... 17
Phenognosis and Ontognosis ............................................................................... 17
The Body and Embodiment: Closing the Great Divide ......................................... 18
Social Studies of Medicine and the Body ............................................................. 20
The Discourses of Truth: Foucault and Beyond .................................................... 22
INTRODUCING REPLICATED BOUNDARIES ........................................................................... 25
The Gnostic Split and Replicated Boundaries....................................................... 25
Replicated Boundaries: The Professional Grounds .............................................. 26
PART III: SURGEONS OF THE MIND .............................................................................................. 30
INTRODUCTION ............................................................................................................. 30
LOBOTOMY IN MIND: METHODOLOGY .............................................................................. 31
A Historical Approach to the Study of Replicated Boundaries ............................. 31
Reading Psychosurgery ........................................................................................ 32
ON PSYCHOSURGERY ..................................................................................................... 34
CREATING ONTOGNOSTIC LEGITIMACY .............................................................................. 38
'Prehistorical' Sources .......................................................................................... 38
Replicated Boundaries: The Professional and the Legitimate ............................. 40
Building the Heroic Ethos ..................................................................................... 43
The Founding Tale ................................................................................................ 44
Out of the Laboratory .......................................................................................... 46
Men of Science ..................................................................................................... 48
Locating the Mind ................................................................................................ 50
Medicalising the Mind: Symbolic Correlates of Ontognosis ................................ 53
LOSING GROUNDS: AWAY FROM ONTOGNOSIS ................................................................... 57
The Traps of Rhetorics: Facing the Debate .......................................................... 57
The Traps of Science: Methods and Rationalisations .......................................... 58
The Traps of Symbolics: Freeman and the Ice Pick .............................................. 60
FROM THE MEDICAL INTO THE SOCIAL AND BACK AGAIN....................................................... 62
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The use of masculine pronouns and possessives was chosen arbitrarily – the text refers to both
genders
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Before entering the analysis itself, there are two issues that I
would like to address. Both relate to my choice to study the
'Western world'.
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The first paper will serve as theoretical grounds for the overall
analysis proposed in this work. Thus, although heavily drawing on
philosophical insights, its aim will be to build a framework for a
social study of knowledge. In this, I will suggest a conceptual
framing whereby modern Western biomedical practice and research
sees two forms of knowledge coexist and fight for authoritativeness:
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The World of Brain Surgery
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Among the ways in which the problem was tackled, one may
find some that may be viewed as dualist and others as monist.
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Note: some of the material presented here is borrowed from my own Master's Thesis
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drawn from: the history of psychiatry, the clinic, and the surgery
room.
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Introduction
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Reading Psychosurgery
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On Psychosurgery
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or,
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In line with the scheme of this work, I will argue that the
embrace of the practice was based upon one critical component:
the implicit and explicit use of rhetorical, symbolic, and
institutional measures in the creation and maintenance of a
scientific façade. This, I shall claim, will place psychosurgery
within the unquestioned ontognostic truth-basis of medical and
scientific work, thus forming a solid ground of legitimacy.
'Prehistorical' Sources
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the latter will strengthen its efforts to differentiate itself from the
'philosophical therapy' to resemble a more scientific model of
medicine. This quest will be the main drive of psychiatric research
into organic-based cures to mental illness, cures that were believed
to be able to form a bridge over the ever growing gulf between
psychiatry and neurology.
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Men of Science
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or,
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Moniz, in his book (1936a:40) states over and over again that
the central nervous system (which includes the brain) is the seat of
mental manifestations. The physical is the ontological basis of the
explicit phenomena of the mind:
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This trend soon moved from the field of research to the field of
practice. As noted, ontognosis lies within an overwhelmingly
materialistic episteme where the primal focus of attention is the
body (Eisenberg, 1977; Dew, 2001). This predisposition involves a
form of objectification by which the human body is stripped of its
subjectivity and transformed into a plain object (Babbie, 1970;
Csordas, 1994). An ideal form of these processes occurs in the
operating room.
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This point will be further developed at a later chapter.
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5
The first attempts to incur states of shock for psychotherapeutic ends involved insulin injections. The
technique was relatively short lived.
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The procedure was such that a hole would be drilled into the
patient’s skull (depending on the patient, this would be performed
under local or general anaesthesia), and the device would be
inserted into the frontal lobes of the brain. Then, the steel thread
attached to the leucotome would be manipulated to cut through
the white matter (where neuron cells are linked), and dissociate
'pathological' neuronal connections. Based on Moniz’s reports, we
could abridge the rationale behind the procedure as such:
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This claim is also likely to be based on the fact that the first
patients to undergo psychosurgery suffered from severe psychiatric
symptoms. Since indeed, the intensity and duration of those
symptoms were the main criteria for selection, we can see a large
heterogeneity in the nosological categories of the different patients.
The diagnosis as such, then, had little to do with the decision as to
whether or not proceed with the operation. Moreover, although
countless studies showed that the main indication was the
presence of anxiety and a diagnosis of obsessive-compulsive
disorders (regardless of the severity of the symptoms), the
aggressiveness and agitation of the institutionalised patients still
formed the main criteria for the decision to operate.
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or,
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The Homo Vadum's Brain
He reports:
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These assertions are generally believed to be correct to this day
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Frank, 1946:457:
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Let it be noticed that Frank added in the same paper that "no
cases were considered worse". Indeed, some will claim that the
beneficial effects of the procedure derive precisely from those
personality transformations, without which, the patient could not
have reorganised his psychic scheme (Mayer-Gross, 1949).
Yet, the fear of loss of the human, of the turning into a Homo-
Vadum, did seem to intensify over the last decades. With the
gradual rise in the authoritativeness of phenognosis, the position
towards the Homo-Vadum began to change. Normative functioning
could no longer compensate for the damage inflicted upon the
Homo-Vadum's phenognostic sense of truth. Existential ideals of
self-fulfilment became ever more dominant. The
straightforwardness of the surgical act stood in contrast to the
complexity accorded to human experience: the idea that a crude
'razing' of the brain could alter the multi-dimensional phenomenon
of consciousness led to an overt discomfort. As sentience prevailed
as a discursive force, this formerly amoral scientific endeavour
turned immoral.
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Or:
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Concluding Words
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In the next section of this work, I will hope to show how the
dynamics of more and less phenognostic sources of knowledge
come about in the routine workings of a clinic. This will be based
on a synchronic, rather than diachronic view of the phenomena,
and on a sustained in-situ observation rather than on a more
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where most of the rounds take place. The second floor includes
the haematology inpatient unit. At any given moment one-to-two
neuro-oncology patients are to be found hospitalised, usually due
to secondary complications of treatments. The third floor includes
a large, quite modestly but recently refurbished ambulatory
service. This is where patients are submitted to chemotherapy by
perfusion and return home at the end of the day, after a short
recovery and observation period. The onco-psychological unit is
also located on the floor, with a consultation room of its own. The
team of psychologists usually works with ambulatory patients,
perhaps much more than with hospitalised patients. This might be
explained by the longer life expectancy (and chances of recovery, in
some cases) of the not-yet- hospitalised patients as opposed to the
near-death, and often unconscious, condition of many inpatients.
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also work as general neurologists, they will spend their 'free time'
as 'plain' neurologists.
The first meeting includes the NROs, the head nurse, the
social worker and the neuropsychologist. From time to time, fifth
year medical students are allowed in. The meeting is organised
around a briefing of each NRO on the cases he/she had seen over
the week. Each NRO presents about ten cases, while the others
listen and make suggestions as to treatment options or diagnosis.
This usually happens when the presenting NRO specifically says
that "this is a difficult case" or "that is an interesting case".
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The Patients
The Consultation
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them in the waiting room (and they would not know whether
he/she had arrived) since he/she will typically use the back door
entrance to the clinic. This entrance demands making a small
detour, but allows to remain unseen.
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At this point I would introduce myself as Sky Gross, a researcher from the Hebrew University, doing
research on brain cancer and brain cancer patients. I would then ask whether I could sit in the
consultation. All but one patient agreed.
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Family Members
Types of Tumours
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Notwithstanding these comments, it has to be noted that at no point do the physicians use their time
for personal or leisure activities. They are clearly overwhelmed. One cannot but be impressed with
their efforts to keep pace with their extremely demanding schedule.
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The Brain Stem. The area where the brain connects to the
spinal cord is called 'brainstem'. It controls vital heart and lung
functions such as breathing, digestion, heart rate and blood
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The Temporal Lobes. Located on the right and left side of the
brain (near ear level), the two temporal lobes help us distinguish
smells and sounds, and may be involved in the experience fear,
and may impact short-term memory. The right lobe is primarily
responsible for visual memory while the left controls verbal
memory.
Treatment
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Introduction
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Methodology
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At the clinic, this process begins with the first encounter with
the patient. There is a fairly ritualistic intake of new patients,
where the NRO assesses previous findings, gathers clinical history,
and performs a physical examination. If judged necessary,
immediate intervention is considered, albeit only once options are
discussed in conjunction with other experts, such as radiologists
and neurosurgeons, and, if applicable (viz. the tumour is
metastatic), with the primary oncologist. In either case, treatment
options (including, typically in this order: neurosurgery,
chemotherapy, radiotherapy, clinical trials, and palliative care) are
deliberated among a relatively wide array of biomedical
professionals.
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Medicoscientific Diagnosis
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There are two radiology experts: Prof. Soren and Dr. Martin.
Soren is a quiet but impressive man of about 60 year old, with a
beard that gives him the appearance of a wise oracle. Unlike his
junior colleague, he is never turned to by his first name, but rather
with his full title: "Professor Soren". Martin is younger and his lack
of experience is critical: in the field of radiology, tacit knowledge
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or:
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'make true'
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or,
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The Patient
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"A month later she said she felt much better and
stopped telling these overly dramatic stories. When
we looked at the MRI, there was no real
improvement".
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Mechanisms of Integration
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Hierarchisation
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This was the case with Ilya. At the radiology meeting, his
latest MRI took Lise by surprise: "this looks bad…", she told her
colleagues, "It’s amazing, he has no symptoms! This guy walks
around with a ticking bomb in his head, but is completely
asymptomatic…". In other words, the MRI suggested a progression,
while the clinical picture pointed to a more stable and benign
condition. The pictures were unquestionably there, thus the
'anomaly' had to be located at the clinical level, the less
authoritative of the two forms of knowledge. As well put by
Gunderman (2005:342):
Sequencing
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Negotiation
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Peripheralising
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Pragmatism
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was the case with Grushka, a 84 year old woman, whose precise
type and grade of tumour were unknown. The group was
unanymous: she will not have her tumour biopsied, rather, she will
be given something for her symptoms, i.e. a large dose of the most
common steroid used in brain cancer: dexamethazole©.
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or,
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Concluding Words
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and indeed should not, lose sight of the fact that ethos, symbols,
technology, epistemology, and eventually the experts themselves,
do not live in an abstract world of theory, or objective insularity.
They are encroached in the flesh, in the suffering, in the existence
of actual men and women.
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Introduction
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Methodological Notes
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As with all names mentioned throughout this work, this is a pseudonym
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The brain is not just another body part. It is the site in which
all bodily activities, sensual perceptions, cognitive and emotional
processing take place. If, according to some theories, the social is
imbedded in the body (e.g. Frank, 1990; Turner, 1992) and the
body is what is situated in the world (Merleau-Ponty, 1962) the
brain is where 'the world', 'the other', 'the self' all meet. It is where
subjectivity and objectivity ultimately link: a conceptual pineal
gland.
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At a different level, the brain can have primacy over the body,
such as in cases of phantom limb syndrome, when the brain
creates a seeming perception of one's body. This leads amputees to
experience sensations (e.g. pain, tingling) as having their source in
the limb removed. This phenomenon may be explained by the
presence of neuronal representation of the arm or leg at the level of
the brain, which, when cerebrally activated, can 'feel' as the 'real
thing', external to the brain. A related (and, in a way, reverse)
condition is of 'asomatognosia'. This takes place when a person's
limb 'feels' like an external object 'glued' onto one's body, having
nothing to do with his/her perceived 'self' (i.e. Tsementzis, 2000;
Greenberg et al., 2002). In these cases, patients may go as far as
calling this limb by a name, such as 'Joe' or 'Mary' (Sacks, 1985;
Feinberg, 2006). This phenomenon has its source on disorders of
brain activity, again providing a vivid instance of brain's
domination over the body.
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The Story
'Prelude'
The day of our first interview, set at a coffee house near the
hospital, was incidentally the day when Ivan experienced the first
epileptic seizure he had in the last two years. As far as I could
gather from the situation, he was probably emotionally drained
from having to recall his seven years experience with brain cancer
and, ten minutes into the interview he left the table to freshen up
in the bathroom. On his way back, however, he collapsed. Lying on
the floor of the staircases, he regained consciousness surrounded
by strangers, mostly nurses and other hospital employees. As I was
later told, he immediately asked for me, calling out my name and
describing me to the security man. The latter reached the coffee
house and almost out of breath, asked me whether I knew a 'Ivan
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Katz'. "He doesn't feel well" was all he said as he was leading me to
the staircases. I naturally found myself helping him to the
Emergency Room (ER) – the access to which was much facilitated
by the fact that I was wearing my white gown. We were able to use
– unquestioned – the back entrance, usually reserved for staff
members.
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would have merged which has become the two spheres within
which I operated: the professional, biomedical (and thus
ontognosis-oriented), and the personal, experience-focused (thus
perhaps more phenognosis-inclined). At another level, it was the
clinical (his seizure) and pathological (the MRI), which spoke of the
disease, even while Ivan still did not (as he was not, at least
consciously, aware of his condition). The disjunction became ever
clearer: Ivan was both a talking corpse, sending cues in the forms
of signs and symptoms, and an embodied subject, eventually
mediating the knowledge of his disease via his conscious self. This
double, and very much dualistic, perspective became omnipresent
in all exchanges related to him: Ivan was both person and patient,
subject and body.
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A neural weakness on one side of the body, typically leaving the other completely functioning
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Ivan was amused when I first asked him whether I could join
in on the operation. He dared me to go through this, and swore me
to talk to him afterwards about "what [he] looks like inside". I
wondered whether knowing what his brain looked like would add
anything to his understanding of himself, or to my understanding
of him, and as to whether he would have had the same request was
another organ the target of surgery. When I inquired about it, he
responded that "it wouldn't have been that cool". As far as I was
concerned, the baring of the 'organ of the self' bared nothing of his
'self'. I could only speak figuratively, and tong in cheek, on how
large his brain was, as if it reflected his intelligence. Sadly, the size
of his brain had more to do with the space-occupying presence of
the tumour. His brain said nothing.
The S-day
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fact, as Ivan bought his first hat, after having lost most of his hair,
he proudly told me how he "gave the man [the salesperson] a heart
attack" when telling him he was buying it "for the radiations". He
now did not only feel like a cancer patient, he looked like a cancer
patient.
I followed the wheeled bed down the elevator along with his
parents and sister. We reminded ourselves of the evening Ivan, his
mother, and I spent at the hospital inn (where he was staying for
the course of his radiotherapy). There, as we were chatting about
this and that, Ivan ran to the window: Jerusalem was covered with
a white blanket of snow. So little snow ever falls in Israel, that we
were all three captivated by the scene. Reaching the door to the
surgical area symbolised the breaking of our serene silence and
sense of 'normality'. As if suddenly awakening us all, the nurse
abruptly halted, firmly instructing us to be careful not to cross this
boundary and to say our goodbyes now, here. The family kissed
Ivan, and asked me, in tears, to take care of him, as if reminding
me to treat him as a friend, rather than as a patient, even now, as I
was about to cross into the biomedical realm.
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one would a guest in his own home; he called on who turned out to
be the OR head nurse: "This is – what is your name again?...". Once
I have reminded him of my name, he turned to the nurse again:
The nurse handing me the blue nylon pants and shirt found
me a bit embarrassed: was I to wear the uniform on top of my
current clothes? No. I must take off my casual clothing and wear it
directly on my bare skin. Entering the changing room dressed as a
lay person, I remained there virtually naked for a few moments, my
identity in Dantean limbo until I wore the uniform, now my
uniform. I could feel it on my skin as I unwittingly adopted a
slightly different walk (faster than usual) and handled my body
differently (less eye contact and a more upright position). As I
passed through the ICU, I was told by one of the surgeons not to
forget to put the hair cap and mask on before entering the OR.
These were available only very near the entrance to the OR, an
even more restricted area, and consist of the last piece of garment
promising me a place in this in-group. My position as an outsider
would be hidden behind these clothes: fully camouflaged, I could
then identify myself and be identified as a member of the
biomedical team.
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In Hebrew, the 'it' and the 'he' are interchangeable
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tension was released, masks were taken off, cables and electronic
devices were removed, and Ivan's face and body were again visible.
Just a Story
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separate the OR from a 'messy' outside world where body and mind
are meshed up (and where forms of knowledge can be confused as
well); Third, with spatial definitions, which create clear boundaries
between areas of objectification; Finally, with components such as
clothing, language and technology associated with this stance. I
shall now discuss each of these.
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not. In more concrete terms: the more one would treat the patient
as an object, the more one would be required to be sterile, that is,
to abide to this "stylisied, arbitrary, repetitive, and exaggerated"
behaviour (Katz, 1981:349).
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Anaesthesia: Subduing Phenognosis
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Or, as in Ivan's case, the anaesthesiologist
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15
This is also when the team's sense of humor was more readily exercised. However, I must admit, that
never in reference to Ivan. I was not impressed that this was merely due to my presence.
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Going Native
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I again use the masculine stance here, so as not to impair the readability of the text
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From his 17 very own birth and throughout his infancy, the
human being learns to regard himself as distinct from the
surrounding world. This is when he realises himself as a subject
facing objects, including his own body (Mead, 1934). This type of
objectification is an inevitable consequence of the gnostic split, as
it binds attempt to understand the 'other' as a subject. According
to Western tradition, there would be two ways of 'knowing the
world': the phenognostic first-person perspective which provides
subjective certainty, or the ontognostic third-person perspective
which has been made secure by scientific method. In either way,
whether experienced first-hand or scientifically ascertained, the
other will seem as an object, as well may be one's own body
(Gallagher, 2000).
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Here again, based on considerations of style and readability, I will use the masculine form
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Conclusions
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Long before the 1990's 'decade of the brain', long before the
neuroscientific revolution of the 1960s, the cerebral organ has
raised considerable interest from both medical and scientific
endeavours (Hyman, 2000). As has been well addressed
throughout this essay, the brain indeed holds peculiar attributes
which makes it such a fascinating object of study: It is, after all,
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Many New Age movements will take this stance even farther.
These may go as far as to portray 'experience' as not only a
legitimate source of Truth and as holding strong authoritativeness.
Phenognostic sources may have predictive elements, may be able to
alter an ontognostically-known 'reality' and work beyond the forces
of the world-out-there (in ways considered 'supernatural', i.e.
beyond ontognostical metaphysics). In many cases, when scientific
evidence will not support a claim based on subjective experience,
the latter will be considered superior. Science, for example, may
have a strong case against the probability of the divination of the
dead. The believer, however, will claim that, as it felt true to an
experiencing individual – it IS true. Here again, two sources of
truth will interact and fight for authoritativeness, and now both
will share a common battle ground: Modern Western
epistemological culture. This social and cultural phenomenon
should stand among other areas of concern in which contemporary
social scientists are engaged.
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RReeffeerreenncceess
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Black, D. N., Stip, E., Bedard, M.-A., Kabay, M., Paquette, I.,
& Bigras, M.-J. (2000). Leucotomy Revisited - Late Cognitive and
Behavioural Effects in Chronic Institutionalized Schizophrenics.
Schizophrenia Research, 43, 57-64.
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Clarke, A. E., Mamo, L., Fishman, J. R., Shim, J. K., & Ruth,
J. (2003). Biomedicalization: Technoscientific Transformations of
Health, Illness, and US Medicine. American Sociological Review, 68,
161-194.
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Goodwin, D., Pope, C., Mort, M., & Smith, A. (2003). Ethics
and Ethnography: An Experiential Account. Qualitative Health
Research, 13(4), 567-577.
Goodwin, D., Pope, C., Mort, M., & Smith, A. (2005). Access,
Boundaries and their Effects: Legitimate Participation in
Anaesthesia. Sociology of Health and Illness, 27(6), 855-871.
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Kesey, K. (1973). One Flew over the Cuckoo's Nest. New York:
Viking Press.
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Popper, K. R., & Eccles, J. C. (1977). The Self and its Brain:
An Argument for Interactionism. Berlin: Springer.
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