The power of implicit (situational) and explicit (written) ‘codes’ about who can touch whom, and when, where and how, in society, extends particularly to healthcare institutions in which certain professionals are granted the right to touch patients in ways not afforded to other people. These are regulated norms, unlike lovers for example, who can make their own on a daily basis. Parents of newborns and young children are expected to have these ‘rights to touch’ as part of proper child-rearing. And physicians are expected to have similar rights as part of their professional role, circumscribed by explicit codes.
Not so for the rest of us. Permission must be given either orally or in writing by post-pubescent children and adults, to allow others to touch them. Even with prepubescent children, teachers for example, cannot touch students outside of school-board regulations that may permit “limited” forms of contact, e.g., hand on the back or shoulder. Male teachers especially cannot hug girl students, and female teachers cannot hug boy students, at least by code. Same-sex hugging is also proscribed, especially towards male-to-male in educational settings. There are clear rules about what constitutes ‘appropriate’ and ‘inappropriate’ touching and sexual harassment within most public institutions and industrial organizations. This extends generally to public open areas as well, but varies by culture.
Anthony Synnott (1993) has charted cultures which are “contact” cultures and “non-contact” cultures according to degrees of ‘tactility’, following from earlier research that showed many people suffer from physical deprivation during their adult lives. He found, along with Argyle, Mead and Montagu, that there are specific cultures which have very low levels of tactility and those which have very high levels of tactility. These he summarized as follows:
South Europeans North Europeans Greeks Scandinavians Turks North Americans Latin Americans Indians Some African cultures Pakistanis
New Guineans Japanese Chinese Upper-class British
Synnott admitted however, that within any of these cultural areas “there is a wide range of individual and sub-cultural variation.” He found that for example, “Californians and Southerners are often more tactile than New Englanders, and francophone Quebecers , than English Canadians. Similarly in Latin America, women in Costa Rica interact closer and touch each other much more often than Columbia and Panama.” This finding, among others, points to how cross-cultural communication can be difficult in a hospital setting. And we have to remember that variations exist according to variables such as age, sex, social class, and religion, regardless of culture of origin.
So how does all this relate to physicians and touching?
Physicians, particularly surgeons, touch people, either with their hands (palpate), a stethoscope (heartbeat), or surgical tools (scalpel, sutures). They understand codes because they, like all physicians in Canada, take the Hippocratic Oath (to practice professional behaviour), and have to submit to ethical standards found within their own professional associations, plus adhere to local hospital policies, etc. They are expected to take the moral high-ground. And they are taught at schools of medicine about liability insurance insofar as it affects their private practice, especially in this case, the “non-qualifiable claims” clauses that may relate to inappropriate touching of patients and possible resulting law suits.
So this seems clear enough. But what about other factors that come into play in the physician-patient relationship? For example, the age, sex, ethnicity, socioeconomic status, situational power/authority, physical appearance, type of illness, patient mobility/immobility, and religion. How do these variables influence how, when, where, and why, patients are touched? Would the fact that the physician was a Latin male, fifty-years-old, single, Catholic, and Chair of the Oncology Department, play a role if the patient was a twenty-eight-year-old female, attractive, single, Muslim, and former beauty pageant winner, with a diagnosed breast cyst? What if the patient was a 92-year-old white British war Veteran, with dementia and severe psoriasis in his groin area, and the physician was a 30-year-old black Lesbian from southern France, and resident dermatologist? Would that have an effect on their interactions re touching of his body?
In either case, who would touch who, where, when, how and why? The possible combinations of ‘causal’ variables appears endless, especially in diverse culures.
Or, would none of these sociological factors have an effect on how the physician treated the patient? How would being a member of a “low contact” or “high contact” touching culture mitigate patient-physician relations?
The urgency to conclude that simply being a professional ‘protects’ you from inappropriate touching, is offset unfortunately, by actual cases of malpractice involving inappropriate touching/sexual harassment (lower rates in Canada, much higher rates in the US). Going to Google Scholar will show the reader examples of Canadian infractions of touching code infractions. See also:
https://www.thestar.com. April 29, 2016. ‘Sexual touching’ case highlights a loophole for doctors guilty of abuse…
http://www.cbc.ca/news/canada/manitoba/doctors-discipline-patient-boundaries. ‘Disciplined doctors’ often given 2nd chance to practise…
Written and implicit codes do work the vast majority of the time. Tort law, costs, hospital ethics committees, and codes of conduct extract compliant, and it yet should be firmly stated that no profession (medicine, teaching, police, military, accounting, real estate, engineering, and so forth) is post facto exempt from behaviour sanctions. Nor are private citizens, exempt from the laws of the land.
But the context of traditional medical care (and physiotherapy or chiropractic), in which patients have to take their clothes off either in part or totally, and dress in a flimsy gown in order to be examined more thoroughly, transforms the prior dressed, more egalitarian state, into a state of complete subservience, body vulneability, and expected conformity. The power balance shifts to ‘doing what the doctor asks’ (or nurse) and defers to his or her expertise. The patient by definiion, becomes a temporary social ‘deviant’, and is expected to play the ‘sick role’ (Parsons). This state of dependency makes the patient vulnerable, protected situationally by an often non-visual or buried-in-adminstration “Patient’ Rights” code. This doctor-patient situation can be made worse when medical ethics and organizational ethics come into conflict (Hall). Or especially when there are multiple physicians attending to one patient, not to mention the whole corps of ‘ancillary staff’ behind the scenes -which multiplies the possibilities of things going wrong (as well as going right). Illegitimate touching can be like background noise at a rock concert; no one notices.
As the main communication of reassurance and healing, touch can be central to a physician’s role. But it can be controlled beyond codes immediately known to the physician, as in the case where a husband unexpectedly accompanies his wife into the examining room, where religious values of modesty and/or patriarchy override the physician’s usual degrees of freedom.
Western society suffers from a lack of tactility. We don’t touch each other enough in a non-sexual way. Older people for example, who are isolated from the community or live alone, particularly are susceptible to the mental and physical health hazards from not being touched. Physicians readily have this opportunity of redress with the elderly. Nonetheless, this patient group is not where most problems occur, when they do occur. It most often occurs in situations where there is opportunity and motive for sexual assault involving younger patients. Following moral codes every day, and while being vigilant about liability, is the bane of physicians’ modus operandi. Being careful can haunt one, to the point of much raised anxiety, especially as often found in recent medical school graduates. More normalized touching in society that is free from sexual implications, may reduce among everyone, inappropriate touching, simply through body acceptance and familiarity.
“Touch is many things, and has many meanings; it is magical and cosmic, healing and therapeutic, a product of merchandising technique, a prime mode of communication, soothing or arousing, loving or murderous, creative, polluting, energizing, an expression of power, and also occasionally a problem in individual, cross-gender and cross-cultural communication. It is essential for human physical, emotional and intellectual development, yet also strangely taboo.” (Synnott: 180)
Finally “We need to understand that we have for too long neglected and overlooked the importance of tactile communication not alone in the development of the infant and child, but also in the development of the adult” (Montagu, 1979: 335)
Perhaps it’s time we all incorporated more touching into our lives, but within the margins of legality, respect, need, and care.
TL Hill, PhD Medical Sociologist
Argyle, Michael. (1978). The Psychology of Interpersonal Behaviour. 3rd edn. Harmondsworth: Penguin Books
Hall, Robert T. (2000). An Introduction to Healthcare Organization Ethics. New York: Oxford
Mead, Margaret. (1956). Sex and Temperament in Three Pimitive Societies. New York: New American Library/Mentor Books
Montagu, Ashley. (1978). Touching: The Human Significance of the Skin. 2nd edn. New York: Harper Colophon Books
Parson, Talcott. ((1975). “The sick role and the role of the physician reconsidered.” Milbank Memorial Fund Quarterly, 53: 257-278
Synnott, Anthony. (1993). The Body Social: Symbolism, Self and Society. London: Routledge