Physicians and Touching the Human Body: Coming to Terms with Moral Codes and Temptations in the Workplace

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:

Contact                                                                              Non-contact

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…

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

References:

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

 

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BLASPHEMY: What does it mean? Is it still relevant?

Giddens (1992) has pointed out that “In pre-industrial Europe, the most serious crimes, which received the highest penalties, were religious in nature, or were crimes against the property of the ruler or the aristocracy.” (p.146) He goes on to list heresy, sacrilege, and blasphemy as religious based events that were “for a long time punishable by death in many parts of Europe.” (op cit)

Transgressions like fishing, hunting, picking fruit, or cutting down trees or bushes on the lands of the king or aristocracy by the common people, were also capital offenses (not always carried out). “The murder of one commoner by another was not generally seen to be as serious as these others crimes. The culprit often could atone for the crime by simply paying a certain amount of money to the relatives of the victim.” (p. 147)

Blasphemy – speaking irreverently about God or sacred things – (Oxford, 2007), is, in contrast to early Europe, an insignificant or minor offense in Western/European societies today. It occurs in everyday speech as part of normal conversation. Sacred persons’ names are often ‘taken in vain’. “Jesus Christ!”, “For Christ sake!”, “My God!”, “Holy Christ!”, “Mother of God!”, etc., are examples of expletives to draw attention to a circumstance the speaker wishes to emphasize. Some people do not use these terms of course, but many do, mostly men apparently. The repercussions from such usage are, if any, reputational only. And perhaps if asked, an apology often suffices. Sometimes science discovers new information about sacred things or persons that go against traditional beliefs. One anthropologist a few years ago had claimed that Christ lived to be 70 and had three children. More recently, a highly respected British historian claimed that Christ was a myth perpetuated by the Romans to secure compliance among the Jews.

In other parts of the world consequences of blasphemy may entail public lashing, stoning, imprisonment, threats of death, or even beheading. Where tradition or controlled opinion, not facts, is power, and compliance in society is extracted mostly by fear or guilt (a technique of religious leaders), strong reprisals for blasphemy will occur. Enlightenment to the point of having a critical conscience that’s expressible in society without fear of punishment, is one main offshoot of access to higher education. Irreverent comments are treated as hate crimes, which in Western cultures, irreverent comments are treated quite differently.

Blasphemy sanctions may however, extend to non-religious, civil actions to this day. Publicly criticizing a political leader’s family for example, may be construed as a form of blasphemy and even libel, leading to certain fines or brief imprisonments. Freedom of speech has its limits. Note that such freedom varies tremendously to this day throughout the world, and one can only hope that fair and objective consequences of ‘blasphemous’ comments will prevail, as in most democratic regimes today.

Aging and Perspective

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When I think back about high school years, sporting black hair and only weighing 147 lbs, my perspective on life was to see it as wondrous, hopeful, and exciting. My project time frames were short (as far as next week), and my ideas unpredictable.

After the air force, marriage, and university, my perspective started to change considerably, to embrace mortality as a definite thing, and to accept living on an old farm and driving 47 kms twice a day to work in the city, as the way things were meant to be. The loss of our two children within about 11 years of each other, was not.

Then, in my 50s and 60s, after many jobs and more degrees, and especially after also losing friends to cancer, and my parents to a stroke and pneumonia, life seemed precious. Time began to speed up. Health issues further aggravated this encroaching “carpe deum” philosophy, and I suddenly found myself enjoying conversation like never before. Slowing down in every way was looking better. After all, I had taught university long enough, directed several colleges and departments, written over 40 articles and book chapters, and successfully (with blips) raised two healthy daughters, plus re-marrying 13 years ago.

I still live in the country though, and consult, write and cut grass. And have regular ‘happy hours’ whereby I can take a cold beer or a sherry onto the deck, look out over the river, and converse for hours with our long-time close friends who live with us. Statistically, I have 12.7 years left in this current corpus delecti, and my bucket list might be too long. But I am not caring about being dilatory, or not quick-on-the-board-game-draw; rather, I contemplate my perspective on life in hedonistic and altruistic terms. I like happiness from doing what I like doing, and I enjoy helping others who are struggling. I find I read happy books now, not tragedies or sad biographies. I hug my wife every chance I get, and hug strangers if I feel they need it.

So life perspectives change with time and experience, and the aphorism is true…life is what you make it. Mistakes and all, but keeping upbeat is crucial. At 71, I still want to climb a tree.

Schizophrenia: Disorganized Type

As one of the sub-types of schizophrenia disorders which affect emotional, social, and perceptual processes, the disorganized type is described as follows:

“In DISORGANIZED SCHIZOPHRENIA, a particularly severe deterioration of adaptive behaviour is seen. Prominent symptoms include emotional indifference, frequent incoherence, and virtually complete social withdrawal. Aimless babbling and giggling are common. Delusions often centre on bodily functions (‘My brain is melting out my ears’).”
W. Weiten.2000. p.428

Twenty years or so ago, one of my sociology undergrad students presented some of these symptoms in class, and on many occasions I had to stop my lecture to determine the sensibility of his questions. He sat at the back of a 75+ class, and I rarely saw him enter or leave the class unless just by himself. I imagined him to be about 21 years old. About fifty present of the time his questions, often spontaneous, were quite surprisingly cogent and informed. It was clear he was “quite bright”, as they say, in some regards.

But on the other occasions his questions were unrelated to the content of the lecture, and he seemed very confused, similar to being ‘high’ on something or other.  It was clear to me that he had a ‘mind altering’ issue, probably (I thought then) from a drug of some kind.

I raise this subject-matter because I sense that this syndrome is more prevalent in society than we are willing to disclose, or know about. From my other experiences in life for example (travel, shopping, family, social events) disorganized schizophrenia manifested itself I’m sure, but was misinterpreted by me as something else. In order for it to be correctly diagnosed, it has to be observable over months.

Treatment options, as with other similar disorders, suggest a combination of medication and cognitive therapy works best.

October 6, 2014

A Cornucopia: The New Job Description

Have you paid close attention to the length of job descriptions these days? Especially institutional, financial and government job descriptions?

Have you tried to read all the way through them and understand what they are really describing and expecting?

At one time, not to long ago, a job description (JD) clearly indicated what it wanted you to do on one page. You filled in the rest on the job because the employer trusted you to grasp and learn, based on initiative and trial and error.

Not today. I read another JD today for a managerial position in a large Canadian corporation, and the JD had 41 distinct company accountables listed, and 19 applicant requirements. One accountability phrase was something like “You will leverage the product characteristics, with third party interventions based on conventional expectations of tactful negotiations and client respect”. What the hell does that mean? And there were 40 more just like it!

Qualifications needed were (and remember this was for a job that paid $62,000 to start): undergraduate degree , but preferably a MBA or equivalent; 5-7 years directly related experience;  ability to direct a team of 7-12 people, and so forth.

So we have to ask ourselves, Why are job descriptions becoming so inclusive, intimidating, and unrealistic in terms of time in any typical day or even week, to do all these things? The answer lies with the assumptions that a) extremely detailed profiles of work activity will cause only the best candidates to step forward, b) the organization will therefore save on unnecessary training costs, and c) the company’s public image will be enhanced by pretense to superiority. The most predictable reaction after reading these impossible lists is to recoil, have another sip, and go for a re-read. Even then, once the task lists are understood in their fullness, a potential applicant most likely wonders “How can I do all this? Especially when realistically makes up 2,3 or 4 job descriptions?”

My Dad was hired as a Superintendent of a tube mill in a large manufacturing company, after he applied from a two paragraph job description. He lasted 38 years.

The ‘Pinky”

You’ve been there. At one of those events or parties where everyone stands around drinking tea with their little finger stuck up in the air, possibly because there’s no where else to put it.

Or perhaps the symbolization of your quite visible pinky denotes social status. Like in Downton Abbey scenes.

Actually, it doesn’t have to be held up in full sight at all. So why do we/some do it? I think the link to Downton Abbey gives us a strong clue. The obvious pinky tells us you are of the ‘cultured’ variety of humans, intent on preserving a particular image in all social settings, especially where there are strangers present of equal or particularly higher social status. Both men and women do it, unless you are a man with a farm or football background or a bricklayer perhaps. No need for pretension among these kinds of chaps. Women are, on the whole, more aware of social conventions than men are, for a whole pile of reasons, not the least of which is that women have wider social circles than men. When I was in high school in the ’50s in Mississauga, Ontario, girls took “Home Ec” classes, and boys took “Shop”. These stereotypical finishing programs equipped us for life as a man or as a woman. One of my girlfriends then, in grade 11, was taught how to set a table and serve tea to a group of other people. This included how to hold a tea-cup properly, namely by pinching the handle between your thumb and index finger. Only two, or possibly three digits were necessary apparently. So this left space for the other two or three.

Since there is a natural tendency to let those fingers ‘float’, raising the pinky works well, almost on its own. It is physically quite comfortable.

And the pinky is the only finger really narrow enough to explore ear and nose orifices, and it also makes a good toothpick after a roast-beef dinner.

So raising it publicly may be a way of advertising its importance. The next time you have a cup of tea, especially if you can’t fit your first finger through the handle, stick your pinky proudly in the air in defiance of coffee lovers who use mugs. Cheers!