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d e Ca m p in a s, Ca m p in a s, Bra sil.
An a M a ria Ca n esq u i
Ch r ist o p h e r Pe t e r so n p r ovid e s st im u la t in g clu es fo r th e d eb a te a n d a n a lysis o f p h ysicia n s’ m eta p h o rica l d isco u rse a n d its effica cy (rea l o r virtu al) for en gen d erin g social relation s, ch a n g-in g o r m a g-in ta g-in g-in g eth ica l va lu es g-in th e p ro fession itself, a n d crea tin g or recrea tin g cla ssifica -t io n s fo r p a -t ie n -t s a n d h e a l-t h ca re in s-t i-t u -t io n s. My co m m en ts will fo cu s o n th e la tter a sp ects.
Th e a r t icle, b y a n a u t h o r- a ct o r, st im u la t e s th e d eb a te b a sed o n th e co m p lexity o f th e p lo t a n d t h e d ra m a , a ffe ct in g t h e id e n t it y a n d va l-u e s o f b e in g-a -p h ysicia n in t h e fa ce o f t e ch n i-c a l a n d so i-c ia l i-c h a n ge s in m e d ii-c a l wo r k a n d p ra ctice, m ed ia ted in o u r so ciety b y th e sta te.
As a p r o fe ssio n , m e d ic in e c o n t a in s a h is toricity a n d a con text. As su ch , it ca n n ot b e a n -a lyzed o u tsid e o f th e co n d itio n s th -a t en gen d er it. Ab b ott (1988), a m on g recen t a u th ors of soci-o lsoci-o gica l st u d ie s soci-o n t h e p rsoci-o fe ssisoci-o n s, csoci-o n t e n d s t h a t t h e ke y t o p ro fe ssio n a lism is t h e fa ct t h a t c e r t a in gro u p s a p p ly e so t e r ic a n d a b st ra c t kn owled ge to p a rticu la r ca ses, th ereby co n tro l-lin g t h e m , a lo n g wit h t h e ir q u a lifica t io n s. Th e m e d ic a l p r o fe ssio n is o n e t h a t p o sse sse s a b -stra ct kn owle d ge le gitim izin g its wo rk. Pro fe s-sio n a l m e d ic a l wo r k in vo lve s t h e d ia gn o sis, th eo ry, a n d th era p eu tics o f th e p ro b lem , in a d -d itio n to th e ca p a city to in fe r, i.e., to in ter ve n e in a n d recrea te rea lity.
It is t h r o u gh m e d ic a l so c ie t ie s (ge n e r a l o r sp e cific) a n d e xp e rt co m m it t e e s a n d b a se d o n e t h ic a l c o n s id e r a t io n s t h a t p h ys ic ia n s s e e k t o gu a ra n t e e t h e p r o fe ssio n’s va lu e s vis- à - vis wo rkin g co n d itio n s a n d re la tio n s b o th in stitu t io n a l a n d co n t ra ct u a l, like fe e s, t h e re b y p re -se r vin g wh a t th e y co n sid e r p ro fe ssio n a l d ign i-ty. Th u s, th ere a re a lwa ys con flicts a n d ten sion s b e t we e n e t h ica l va lu e s a n d in t e re st s, n e go t ia -t io n s, a n d a llia n c e s a m o n gs-t p h ysic ia n s a s a grou p u sin g its righ ts to gu a ra n tee th e recogn i-tio n a n d m a in te n a n ce o f its co gn itive a n d co rp o ra t ist st r u c t u re. Pr o fe ssio n a l m e d ic a l re la -t io n s m ove co n -t in u o u sly wi-t h -t h e s-t ru c-t u re o f m ed ica l p ra ctice, with its co n d itio n in g fa cto rs, a n d with th e m a in te n a n ce o r co n q u e st o f p ro -fe ssio n a lism . Th e issu e h e re is t h e d im e n sio n o f t h e p ro fe ssio n’s ju r isd ic t io n , in vo lvin g a c o m p le x c u lt u ra l m a c h in e r y, a s su gge st e d b y Ab b o tt.
‘Me d ica l sla n g’ m a y b e n o t h in g b u t t h e t ip of a very com p lex iceb erg, circu m scrib ed m ere-ly t o wo rd ga m e s fro m wh ich [t h e a u t h o r ] e x-tra cts m ea n in gs a scrib ed to a gro u p o f m ed ica l sp ecia lists, o r a selected set o f situ a tio n s. To go b e yo n d t h e t ip o f t h e ic e b e r g o f wo rd ga m e s a n d p u n s (b o th go o d – a n d ill – h u m o red ), a n d
in o rd er fo r th em to ga in grea ter a m b igu ity, d i-ve rsit y, a n d co n t ra d ict io n , t h e re se a rch n e e d s to rea ch th e con text (b oth sp ecific a n d gen era l) th at en gen d ers, ch an ges, or recreates th e m ea n -in gs ove r t im e . In t h is se n se , o b se r va t io n s b y Hym es (1974) a re p ertin en t in th a t h e p o in ts to t h e lim it s o f re st r ic t in g re se a rc h t o lin gu ist ic fo r m s t a ke n a s a co d e, o r sp e e ch t a ke n in a n d o f itself.
Ru lin g ou t th e au ton om y of d iscu rsive en u n cia te s a lth o u gh it is p o ssib le to p e rfo rm a syn -t a c -t ic a n a lysis o f -t h e wo rd s a n d e n u n c ia -t e s H ym e s re c o m m e n d s a t t e n t io n t o c o n t e xt , t o n e t wo r ks o f so c ia l re la t io n s, in t h e in ve st iga -t io n o f c o m m u n ic a -t ive a c -t ivi-t ie s a s a wh o le a n d t h e ir lin ks a n d d isju n ct io n s, t h u s cre a t in g t h e p o ssib ilit y o f p e n e t ra t in g t h e se t o f ve rb a l in te ra ctio n p a tte rn s, in vo lvin g th e u se s o f la n -gu a ge , t h ro u gh wh ic h m o ve t h e ge n e ra l a n d sp e cific va lu e s a n d re p re se n ta tio n s o f th e ve r y e xist e n c e a n d id e n t it y o f p r o fe ssio n a l so c ia l grou p s.
On e c a n n o t su p p re ss ve r b a l b e h a vio r s o r a n a lysis o f t h e cu lt u ra l syst e m , fu n ct io n in g in tu rn a s a n in tra co m m u n ica tive stru ctu re a lo n g wit h o t h e r co d e s, a llowin g o n e t o re co gn ize o r u n ve il t h e r u le s a n d st r u ct u re o f t h e ve r y cu ltu re o r su b cu lltu re o f sp ecific gro u p s (th e m ed -ic a l p r o fe ssio n , in t h is c a se ), e ve n wh e n t h e cu ltu re m a y b e u n iq u e in its d iversity or d iverse in th e u n iq u en ess o f its va rio u s so cia l a n d p ro -fessio n a l gro u p s. An u n d erta kin g o f th is n a tu re ca lls fo r gre a t e r in vo lve m e n t b y t h e a u t h o r in eth n o gra p h ic resea rch , b a sed o n kn owled ge o f lin gu ist ic st yle s, in o rd e r fo r t h e re su lt t o e n -com p a ss verb a l b eh a viors a n d u ses of la n gu a ge in a co n textu a lized wa y.
It is th u s d ifficu lt to wager on ly on th e sp on -tan eity of cu ltu re, alth ou gh it h arb ors creativity, co n t in u it ie s, a n d b re a ks wit h p re va ilin g st a n -d a r-d s. So cia l a ge n t s b e a r cu lt u ra l m o -d e ls t h a t a re in t e r n a lize d , re ve a lin g t h e m se lve s in t h e ir b e h a vio rs, ge st u re s, sile n ce, r it u a ls, a n d d a ily wo rk a n d in th e verb a l u se o f la n gu a ge (fo rm a l o r in fo r m a l). Sim u lt a n e o u sly, a s p h ysic ia n s, t h e y a re p e r m e a t e d b y t h e h ist o r ica l a n d sp e -c ifi-c -c h a ra -c t e r o f t h e so -c ia l o r ga n iza t io n o f m e d ica l p ra ct ice a n d wo r k a n d t h e ir ju r isd ic-tio n s a n d va lu e s, a lth o u gh th ey m a y b e a b le to gra sp t h e m co m in g fro m o t h e r re fe re n ce s a n d th eir own exp erien ce.
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p h ysician s th em selves, th eir ju risd iction s. Su ch c o m p o n e n t s in c lu d e a u t h o r it y, c o m p e t e n c e , kn owle d ge a n d skill, co m p e t it io n , a n d e t h ica l va lu e s t h a t a re a lwa ys a r t icu la t e d in a n a re n a o f co n flicts, a llia n ces, a n d n ego tia tio n . In stitu -tion s, a s viewed by p h ysicia n s, reta in th is set of elem en ts, su b ject to op in ion s, eva lu a tion s, a n d p la ys o n la n gu a ge , a n d wit h in t h e m t h e c o n -crete wo rk o f d o cto rs o ccu rs.
Resea rch o n m ea n in g is exp a n d ed b y a rtic-u la t in g e n rtic-u n cia t e s fro m t h e d iffe re n t so rtic-u rce s. Th ese a re a lso in flu en ced by th e d ifferen t p o si-tion s of socia l a gen ts in th e system of socia l re-la t io n s a n d vis-à -vis t h e wo r k m a rke t it se lf, in a d d it io n t o ge n d e r, ge n e ra t io n , a n d m e m b e r sh ip in va riou s sp ecia lized societies a n d / or p o -litica l p a rties.
With ou t u n d erstan d in g th is set of elem en ts, it wo u ld b e h a rd to a b stra ctly co n fer th e exclu -sive p owe r o f re sist a n c e t o o r re - c re a t io n o f lan gu age by th e p h ysician s in terviewed . A rea d -e r o f t h is a r t icl-e m a y f-e -e l t h -e la ck o f a b r o a d -e r a n a lysis o f t h e m u lt ip lic it y o f m e a n in gs a s -crib ed by p h ysicia n s to h ea lth ca re in stitu tio n s a n d wh ich th e p a p er lim its to a n esth etists, u n -d ifferen tia te-d in term s of oth er a ttrib u tes. With re ga rd t o o t h e r sp e c ia lize d m e d ic a l fie ld s, a n e st h e t ist s m a y b e a r sp e cific kn o wle d ge a n d skills, ju r isd ic t io n , c o r p o ra t ist b e h a vio r, a n d e t h ic a l o r ie n t a t io n wh ic h m a y o r m a y n o t b e sh a red with th e m ed ica l p ro fessio n a s a wh o le. Oth er in terviews in clu d ed in th e p a p er su g-ge st t h e u se o f p u n s b y m e m b e rs o f o n e o f t h e m e d ic a l a sso c ia t io n s a n d re fe r r in g t o t h e e xp a n sio n a n d xp e n e t ra t io n o f xp r iva t e h e a lt h in -su ra n ce (d o m e stic a n d tra n sn a tio n a l), se r vin g t o co m m o d ify h e a lt h ca re a n d circu m scr ib in g t h e st a t e’s ro le in t h e p rovisio n o f h e a lt h se r v-ice s, t h e re b y a ffe ct in g so m e p h ysicia n s’ in t e r-ests a n d id en tity. Wh ile m ed icin e a s b u sin ess is n o t h in g n e w, wit h in a d iffe re n t h ist o rica l co n -t e x-t -t h e in -t e re s-t s a n d id e n -t i-t y o f p h ysic ia n s we re a lso a ffe c t e d b y a t t e m p t s t o m a ke t h e sta te a m o re a ctive p a rticip a n t in th e p rovisio n o f h e a lt h se r vic e s, wit h t h e re su lt t h a t it [t h e st a t e ] wa s re se r ve d a gre a t e r sh a re o f h o sp it a l a n d o u tp a tien t m ed ica l ca re.
We a re a wa re t h a t t h e p u b lic a n d p r iva t e co n figu ra tio n o f h e a lth se r vice s h a s a lwa ys in -vo lve d st a t e in t e r ve n t io n in h e a lt h p o licy a n d rela tio n s with co rp o ra tist in terests, a n a n a lysis o f wh ic h is b e yo n d t h e sc o p e o f t h e se c o m -m e n ts. Tram bliclín icas, m u lam bu latórios, a n d
p ilan tróp icosm a y a lso in vo lve va lu e s p e r t a in in g to th e d egree o f in co rp o ra tio n o f tech n o lo -gie s in m e d ica l a ct s, p o ssib ilit ie s fo r o r lim it a-t io n s im p o se d o n sp e c ia lize d wo r k b y p ra c a-t i-t io n e rs, fra gm e n i-t a i-t io n o f i-t h e ir wo rk (in cre a
s-in gly sh a re d wit h o t h e r h e a lt h p ro fe ssio n a ls), t yp e s o f o r ga n iza t io n a l c o n t r o l o f m e d ic a l p ra ctice, wa ge p o licies, b u sin ess p ra ctices, a n d gre a t e r e xp lo it a t io n , in vo lvin g h igh e r p ro fit m a rgin s, in c lu d in g t h e e a r ly e xp lo it a t io n o f m ed ica l stu d en ts a s la b o r.
A gre a t e r d ive r sit y in t h e in t e r vie ws m igh t h a ve a llowe d fo r le ss sp e c u la t io n a s we ll a s a m e e tin g b e twe e n th e m u ltip le m e a n in gs, re la -tio n s, a n d co n d i-tio n s in th e p ro d u c-tio n o f a n d co n t ra d ict io n s a n d lin ks wit h in m e t a p h o rica l d isco u rse wit h o t h e r fo rm s o f ve rb a l b e h a vio r by p h ysicia n s in th eir rela tion s with h ea lth ca re in stitu tio n s.
Peterso n’s stu d y o p en s u p p ro sp ects fo r a n a lyzin g e t h ic a l a n d m o ra l va lu a t io n a l d im e n sio n s in t h e m e d ica l p ro fe ssio n , a n d q u it e a p -p ro-p ria tely h e -p rovid es u s with clu es a s to th eir p ossib le lin ks with th e con stitu tive d im en sion s o f m ed ica l p ra ctice. Yet h e restricts th e rea d er’s a b ility to gra sp th e wa y b y wh ich d octors tra n s-late in to verb al b eh aviors an d p ractices th e val-u es, p erm an en ce, ch an ges, strval-u ctval-u res, relation s, an d con flicts th at con stitu te th e m ed ical p rofes-sio n a n d t h e ir co n d it io n in g fa ct o rs a cco rd in g to rep resen ta tio n s by p h ysicia n s, wh ich sh o u ld b e th e su b ject o f reflectio n b y th e resea rch er.
St u d ie s su ch a s t h a t o f Do n n a n ge lo (1975) a n a lyzin g p r o fe ssio n a l id e o lo gie s a lo n g wit h ch a n ges in m ed ica l p ra ctice a n d wo rk vis-à -vis th e m a rket, a n d Ca m p os (1988) focu sin g on th e co n t e n t s o f d isco u rse s a n d st r a t e gie s o f m e d -ic a l a sso c ia t io n s vis- à - vis h e a lt h p o l-ic y, h a ve sh own t h e a r t ic u la t io n b e t we e n t h e p r o fe s-sion’s eth ica l orien ta tion a n d d efen se of its cor-p o ra tist in te re sts. Th e se m a y m ove, ch a n ge, o r in stitu te th e m se lve s in te rm s o f b e h a vio rs a n d rep resen tation s accord in g to h ow relation s h ave b e e n stru ctu re d b e twe e n th e sta te a n d so cie ty, with th e h isto ricity o f th e se re la tio n s in Bra zil-ian society as referen ce. An d certain ly, alth o u gh n o t a ll m ed ica l p ra ctitio n ers a ct a s n ego tia to rs of p rofession a l in terests vis-à -vis th e sta te, th ey d o n o t fa il to reflect o n su ch rela tio n s.
St e ffe n (1987) re fe r s t o t h e d ia le c t ic re la -t io n s b e -t we e n p u b lic a n d p r iva -t e m e d icin e in Fre n ch h e a lt h p o licy, o b se r vin g a n id e o lo gica l im p a c t in t h e c o n fr o n t a t io n b e t we e n t h e t wo se ct o rs. Th u s, o n t h e p h ysicia n s’ r h e t o r ica l p la n e, t h e re is n o re la t io n sh ip t o t h e syst e m ’s d u alistic con text. Two id eas or valu es are d irected fo r o r a ga in st th e sta te. On e em p h a sizes a u to n o m o u s u n d erta kin gs, gu a ra n teein g in d ivid -u a l fre e d o m . Th e o t h e r se e s t h e st a t e a s se r v-er a n d gu a ra n to r o f p u b lic in tv-erests.
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ch a d o, 1997), d oes n ot d en y th e con flicts visà -vis t h e id e a l o f a u t o n o m y t h a t p h ysicia n s se e k to p reserve. Wh at rem ain s to b e seen is wh eth er, b y d efen d in g a u to n o m y to geth er with o r sep a -ra tely fro m th e ser vice id ea l (a t th e va lu a tio n a l le ve l), p h ysic ia n s c o n t in u e t o vie w t h e st a t e a n d its ser vice-p rovid in g in stitu tion s a s ser vers o f p r iva t e o r p u b lic in t e re st s, o r b o t h a t t h e sa m e t im e. An d wit h re ga rd t o t h e p r iva t e se c-tor, it rem a in s to b e seen wh ich segm en t of p r i-va te h ea lth in su ra n ce co n tin u es to b e rejected , a s wa s in th e p a st th e segm en t lin ked to corp o -ration s rath er th an m ed ical coop eratives, wh ich a re a lso u n d e rgo in g ch a n ge s to d a y, a lo n g with wh a t u sed to b e p h ila n th ro p ic h o sp ita ls.
ABBOTT, A., 1988. Th e System of Profession s. An Essay on t h e Div ision of Ex p ert La b or. Ch ic a go : Th e Un iversity of Ch ica go Press.
CAM POS, G. V. S., 1988. Os M éd icos e a Polít ica d e Saú d e. Sã o Pa u lo: Hu citec.
DONNANGELO, M. C. F., 1975. Med icin a e Socied ad e. O M éd ico e seu M erca d o d e Tra b a lh o. Sã o Pa u lo : Pion eira .
H YM ES, D., 1974. Fou n d a t ion s in Socio- Lin gu ist ics. An Eth n ograp h ic Ap p roach. Ph ila d elp h ia : Un iver-sity of Pen n sylva n ia Press.
M ACH AD O, M . H ., 1975. So c io lo gia d a s p ro fissõ e s: u m a c o n t r ib u iç ã o a o d e b a t e t e ó ric o. In : Profis-sões d e Saú d e: Um a Abord agem Sociológica(M. H. Mach ad o, org.), p p. 13-34, Rio d e Jan eiro: Fiocru z. STEFFEN, M., 1987. Th e m e d ica l p ro fe ssio n a n d t h e St a t e in Fra n c e. Jou rn a l of Pu b lic Policy, 7:189-208.
La b ora t ório d e Ep id em iologia e An t rop ologia M éd ica , Cen t ro d e Pesq u isa s Ren é Ra ch ou , Fu n d a çã o Osw a ld o Cru z , Belo Horiz on t e, Bra sil. Dep a rt a m en t o d e Psiq u ia t ria e N eu rologia , Fa cu ld a d e d e M ed icin a , Un iv ersid a d e Fed era l d e M in a s Gera is, Belo Horiz on t e, Bra sil.
M a ria Eliz a b et h Uch ôa
Th e a r t ic le b y Ch r ist o p h e r Pe t e r so n is h igh ly st im u la t in g. Th e a u t h o r gra d u a lly in t r o d u c e s u s to Ca rio ca m e d ica l ta lk a n d in vite s u s to re fle c t syst e m a t ic a lly o n it s m e a n in g a n d c o n -st r u c t ive p ro c e ss. Th e a n a lysis o f sla n g a n d p u n s cu rren tly u sed b y p h ysicia n s in th ree sp e-c ifie-c a re a s (a e-c q u isit io n o f kn o wle d ge , p h ysi-cia n - p a t ie n t re la t io n sh ip , a n d t h e h e a lt h sys-t e m ) d ra ws o u sys-t a n e sys-t wo rk o f m e a n in gs lin kin g scien tific m ed ical d iscou rse, Hip p ocratic eth ics, a n d m e d ic a l p ra c t ic e in t h e c u r re n t Bra zilia n con text.
Asso c ia t io n s, c o n t ra d ic t io n s, a n d b re a ks ch a ra cterize th e a u th or’s com in g a n d goin g b e -t we e n -t h e -t e x-t a n d -t h e c o n -t e x-t e vo ke d b y i-t , a n d wh ich , p a ra d oxica lly, it h elp s to crea te. On
th e on e h a n d , citizen s’ u n iversa l righ t to h ea lth c a re a n d t h e d u t ie s o f a n o n - d isc r im in a t o r y m ed ica l p ra ctice, a n d o n th e o th er, th e sca rcity a n d p o o r d ist r ib u t io n o f re so u rce s fo r h e a lt h , gen era tin g co n tra d ictio n s p erm ea tin g th e co n -text o f m ed ica l tra in in g a n d p ra ctice.
Th e in va sio n o f m e d ic a l p ra c t ic e b y t e c h -n o lo gy fo st e r s t h e d e ve lo p m e -n t o f a p r iva t e, e n t re p re n e u r ia l m e d icin e. Th e d ism a n t lin g o f p u b lic h ea lth ca re ser vices a ggra va tes in eq u a l-it y a n d re in fo rce s t h e su b o rd in a t io n o f h e a lt h c a re p ro fe ssio n a ls t o h e a lt h p la n s. Disp a ra t e a ccess to h ea lth services, p h ysicia n s’ d ep ro fessio n a liza tio n , a n d tra n sgre sfessio n o f p ro fe sfessio n a l e t h ic s e m e r ge in t h e ga p e st a b lish e d b e -t we e n -t h e o r y a n d p ra c-t ice. Au -t o n o m y, d u -t ie s, a n d resp o n sib ilities b eco m e th e a ttrib u tes o f a m o d e l fo r id e a l p ra ct ice wh ich is in cre a sin gly e st ra n ge d fr o m t h e m o d e l m a d e p o ssib le in p ra ctice.
Th e q u e st io n ra ise d so o ft e n b y m e d ic a l st u d e n t s c o n c e r n in g t h e t yp e o f d o c t o r s t h e y wa n t , sh o u ld , o r c a n b e c o m e va n ish e s in t h e con text of lea rn in g th e kin d of m ed ica l p ra ctice t h a t is p o ssib le in re a lit y. To re fu se su ch p ra c-t ice m e a n s c-t o re fu se re a lic-t y, c-t o e xclu d e o n e se lf fro m th e lea rn in g p ro cess, fro m in tegra tio n in to h ealth care services a n d th e exercise of m ed -icin e. To a ccep t it is to in frin ge o n p ro fessio n a l eth ics, to lose on e’s righ ts, to com p rom ise. Con fron ted with th e con tra d ictory d em a n d s of th e -o r y a n d p ra ctice g-ove rn in g th e p r-o fe ssi-o n , th e fu tu re p h ysicia n n ot with ou t con flict, of cou rse m u st le a rn to strike a b a la n ce. Co n tra d ictio n s, ten sio n , a n d d isco m fo rt a cco m p a n y th is lea rn -in g p ro ce ss a n d su b se q u e n t m e d ica l p ra ct ice. Th e c o n fr o n t a t io n b e t we e n t h e id e a l m o d e l d icta te d b y th e co d e o f e th ics a n d th e p o ssib le m o d el d icta ted b y rea lity crea tes a n im p a sse.
