Section 1. South Korean Context
Section 2. Anthropological Perspectives on Aging and Death
1) Discourses on Aging
2) Anthropology of Death and Dying
3) Living with Disabilities and Care in Later Life
Section 3. Anthropology of Institution
1) Anthropology of Institution (focused on hospital setting)
2) Formation of Identity as a Professional Healers (Doctors)
-Disentangling the complexity of end-of-life: Ordinary Ethics and Affect Theory
Section 3. Anthropology of Institution (Focused on Clinical Setting)
Despite ideals of dying at home, the end of life in many industrialized countries takes place in hospitals (Seale 1998; Long 2005). Dying suddenly is relatively uncommon and most elderly individuals succumb to protracted diseases like cancer or organ failure (Lunney et al. 2002). In this context, hospitals frequently serve as the site where medical professionals, patients, and patients’ families make critical decisions about courses of treatment. As such, examining the final days provides a suitable lens for illuminating the relationships among doctors, staff, patients, and their families within the institutional context of a hospital or clinic. In this section of the essay, I will review about discourse on Hospital as an institution. My aim is to elaborate how hospitals have taken away the domain of end of life rites of passage, as people increasingly dying in hospital as Foucault (1975) strongly points out in The birth of the clinic.
Social scientists who were interested in researching hospital were mainly sociologists (e.g., Parsons 1951; Freidson 1970). Sociologists focused on structural and organizational aspects of hospitals as institutional systems. Research on hospitals and clinicians began to become active in the 1990s in Anthropology. This is related to the fact that hospitals have a passive attitude toward social science research and that it is difficult for researchers to enter hospitals. Foucault (1975), in Discipline and Punish, mentioned that the ‘hospital’ as a highly structured, exclusive, and access-denied institution is not a space that researchers can easily access. The literature on hospital ethnography also has reported that hospitals had barriers to anthropologists in terms of accessibility. Anthropologist Margaret Lock notes that researching health, disease, and medicine helps understand the relationships between individuals, society, and culture (Lock 1980). Lock highlights the importance of hospital research as a potent field in understanding them. Along with this, research on hospitals and members within the hospitals began to receive academic attention.
Today, hospitals have become representative places of death in many societies. Notably, in a rapidly aging society, the process of death at the end of life is handed over to the hospital’s task. This has provoked the necessity of studying how end-of-life practices are conducted in the hospital setting. Glaser and Strauss (1965) and Sudnow (1967) first focused on dying process and death in hospitals. Their research is meaningful given that more and more are dying, and this process now occurs in the hospital.
In Awareness of Dying (1965), Strauss and Glaser examined the most recurrent types of interaction between dying persons and hospital staff, together with the strategies used by professionals to handle end-of-life situations and the impact those strategies have on both professional and lay actors, and how the hospital itself is organized. Interaction-related problems often arise at the end of life. In Passing On, Sudnow (1967) argued that death as a social category varies from one hospital to another and from one ward to other wards. Sudnow especially paid attention to how a dying person is treated, how the hospital staff handles the dying process, and how they interact with the deceased’s relatives. In this sense, Sudnow set the stage for current hospital ethnography’s main research topics (i.e., decision making, discourse on good and bad deaths, moral judgment, dying person’s agency, and subjectivity).
Sharon Kaufman’s volume And a Time to Die (2005) deals with end-of-life care. In this work, Kaufman investigates the shape of death in hospitals in San Francisco. What she finds is that the so-called “good death” is elusive for most patients. Rather, a flurry of hospital routines, bureaucratic constraints, advanced technology, and cultural ideals allow for unprecedented management of death and influence the processes of dying. For example, Medicare reimbursement policies mandate that specific forms of care be given or a patient be discharged. Lingering in the hospital and waiting for death to arrive has been excluded as an option. Some of the doctors say, “Dying is not billable.” Instead, there is an unspoken phenomenon of “moving things along” whereby patients are moved from unit to unit, treatment to treatment (Kaufman 2005, 96). In tracing the patterns of interventions, Kaufman documents a pair of “treatment pathways,” one she dubs “heroic intervention” and the other the “revolving door” (97-100).
Here, heroic intervention entails high degrees of medical intervention before finally orchestrating and facilitating death. On the other hand, the revolving door involves a pattern of interventions and discharges for chronically ill patients who are deteriorating and approaching death. Both of these pathways proceed along rigid tracks and are difficult if not impossible to escape once begun. More broadly, the pathways display death’s relocation to hospitals where bureaucracy, technology, and medical expertise provide high degrees of control under powerful constraints. Families and patients are overwhelmed, as Kaufman notes and other research highlights (Margolis 2005). Even small parts of the process, such as informed consent, can be arduous and work as a barrier to receiving care (Castro-Vázquez & Tarui 2007). Bowen et al’s (2013) also views these end-of-life studies in relation to practical schemas. According to the article, it becomes clear that hospitals are settings for highly complex social phenomena. Routines, structures, and norms shape the options and processes of decision-making, and thus the practice of medicine.
Over recent history, the medicalization of death has been criticized not only in medical anthropology but also in medical science. ‘Medicalization of Death’ refers to the aspect of excessive intervention in life due to deep intervention of medical technology in life and death. Here, the right to make decisions and autonomy over the lives of patients. It also includes the ethical problems that arise from prolonging dying life, which only adds suffering. To cope with this problem at the institutional level, alternative routes to death have been raised. For example, palliative care and hospice care are the paths for terminal care, and Aid-in-Dying, Assisted Death, and Euthanasia are the paths for death itself. In my, I would like to focus on Palliative care and hospice care, which are the channels through which institutions intervene to provide care.
I also want to focus on the “space” of the hospital. Prentice (2013) stresses the dynamics that space contains as defining space as “intersections of mobile elements” and mentions “space is a practiced place” (p.196). There are several ways to analyze a hospital from its spatial context. I am interested in hospitals as 1) liminal space, which involves Turner’s theoretical concept of liminality, and 2) affective space dealing with a phenomenological approach to the space of the hospital. Research that interpreting hospitals as liminal spaces focus on how people are relocated from their daily lives and taken into a betwixt and between space of being diagnosed, treated, and medicated. The hospitals are believed as places where belonged people’s previous identities are transformed and even stripped bare (D. Long et al. 2008). The key point of the liminal stage is that the existing identities are broken down for new identities to be forged (Turner 1977). Hospital ethnographies adopting the lens of “liminal space” have analyzed how hospitals function to transform and imbue identities to patients. Here, new identities can be varied, such as cancer survivors, a more mobile person, and a rehabilitated person.
Anthropologists have also investigated the idea of “affective spaces” (e.g. Navaro-Yashin 2012), highlighting how paces, objects, and cultural history shape affect and how affect and emotions are attached to material environments. I thought this phenomenological approach to the space is essential to interpret dying patients in the hospital setting. The notion of affective space helps clarify the first person’s direct experience of the environment and how it influences a person’s emotional states, affecting the person’s perception of the surrounding world (De Matteis 2020). The term affect is commonly used in the clinical arena to characterize a patient’s overall state of being and the kind of energy (Lester 2019). However, I would like to approach hospital space more three-dimensionally to analyze space-people interaction further.
2) Formation of Identity as a Professional Healers (Doctors)
More and more people are dying in the hospital means that clinicians who are supposed to survive and treat patients are now taking care of patients’ dying process. In the process of actively changing culture of death, this research focuses on how physicians produce and convey knowledge within the western biomedical institution. In this part of my essay, I aim to delineate on how doctors come to be the people that they are. To achieve this goal, I want to look at the process of physicians forming a specific identity through situated learning in hospitals by questioning how informal and situated learning and embodied skills impact physicians. I want to connect this to my ultimate goal of understanding how the repeated witnessing of and exposure to death affect the formation of a physician’s identity.
Erving Goffman’s concept of the “total institution” is helpful to understand the broader relationship between institution and identity of belonged individuals. A total institution is a place of residence and works where a large number of like-situated individuals cut off from the wider society for an appreciable period of time together lead an enclosed formally administered round of life (Goffman 1968 p.11). The definition of a total institution is delineated in his book, Asylum (1968). Here, Goffman further explains that people within the institution are stripped of their previous identities and must undergo various forms and processes of transforming themselves. In this way, the institution remakes a person’s in conformity with the organization’s expectations for disciplined behavior.
Hospital, as an institution, Goffman’s concept of the total institution provides helpful theoretical background. However, it is doubtful that the concept can successfully include actively transforming social change, dynamics of interactions, and the possibility of changing the individual’s notions. As a total institution is a closed social system where belonged lives are organized by strict norms and rules and what happens within it is determined by authoritative few enforcing the rules. This leads to remake a person’s being in conformity with the organization’s expectations for disciplined behavior (Goffman 1961; Foucault 1977). Within this theory, knowledge earned from interactions and informal learning is degraded as the byproduct of the institution’s process of discipline, and an individual’s identity remains stripped and unchanged by own will. It also leaves the question of whether all departments within an institutionalized hospital operate as one unified system. Just as the way a psychiatric ward operates is different from how a pediatric ward works, we need to analyze how Erving Goffman’s concept works in a microscopic environment.
In addition to Goffman’s concept of total institution and its resultant impact on forming identity, I also want to stress that learning in a medical institution is an emotional developmental process, not just a process of information transfer. Psychologist Eric R. Marcus mentions that becoming a doctor describes a state of being and a state of feeling about ourselves that suggests a set of self-representations whose organization and content we call professional identity (Marcus 1999). I think psychological and emotional realms of constructing identity is noteworthy since the hospital is one of the most emotionally charged place both for patients and public health professionals. To deeply understand organization of institutionally and psychologically formed identity and the ultimate professional identity as a healer, it is necessary to pay attention to what and how doctors have been educated and affected formally and informally in becoming professional doctors.
In western medicine, interest in the end of life has only recently started to arise. The medical staff has been educated to restoring a ‘normal’ body by treating a diseased body. For them, death has been an object that must be put off until the end through medical technology and treatment. Institutional hospital’s point of view, death has considered an event to be avoided and a “medical failure” that could put the entire medical institution at risk. Although this is fiction, in The House of God, the way Samuel Shem delineates how doctors deal with dying patients and death is the typical way to be seen in other institutions (Shem 1978). Here, death is depicted as a moment at the end of life rather than as a process that needs to be taken care of.
In many medical institutions, death is introduced in a theoretical way in the first year of study, with lectures on the ethics of body donation for anatomy dissection and deaths of hypothetical patients. However, medical students gain unique insights by visiting patients on wards, spending time with a patient through in-hospital care, and discussing patients dying symptoms with other colleagues. These informal ways of learning “dying” in the clinical setting through dynamic inter-personal interactions and communication exchanges influence the identity formation as healers taking care of the dying process.
As echoed several times in my essay, training to become healers such as doctors involves more than the transmission of knowledge and technical skills. It is more of a complex process where explicit and formal way of learning occur concurrently with tacit and informal way of learning which affects to the healers’ identity, embodied dispositions, and even affects (Bosk 1979; Hahn and Kleinman 1983; Konner 1988; Saunders 2008; Wendland 2010; Holmes et al. 2011; Prentice 2012). Wendland in A heart for the work highlights the importance of local understanding of medical trainees’ experience quoting Arthur Kleinman’s usage of illness narratives. Here, Wendland (2010) advocates that having close attention to the informal narratives of interns and apprentices is essential as they allow us to see moral values of medical work attached to shaped identities. Thus, I want to shed light on the importance of a hidden curriculum. Becoming a doctor involves transforming a layperson into a medical professional and this transformation associates with the process of legitimately peripheral participation at first, becomes deeply engaging member of the community in the end (Lava & Wenger 2009). In this process of professional socialization, hidden curriculum plays an important role. Here, the “hidden curriculum” refers to medical education as more than the simple transmission of knowledge and skills; it is also a socialization process.
Hafferty and Franks (1994) show how the experiences of practice in a clinical context remake young physicians’ values, intuitions, and perceptions. In Bodies in Formation, Prentice (2013) focuses on how trainees become physicians through interactions with other colleagues and patients. Prentice further advocates that medical students and residents learn through practice and it became embodied experience. These embodied skills are essential as physicians also develop higher-level abilities such as intuition and judgment throughout the process.
The transition from medical school to clinical residency is a massive shift from the formal schooling of the classroom to situated learning in a hospital. Moreover, the transition from residence to more experienced specialized physicians also involves a massive shift. Thus, I thought it is necessary to specify the levels of the process of becoming a clinician. Also, the way surgeons are trained completely different from other clinicians, such as pediatricians or internal medicine doctors is trained differently even after they finished their residency. Thus, I thought we should not underestimate the fact that transformations and training can be a life-long process.
Additionally, as the importance of multidisciplinary teamwork is emphasized within the medical institutions today, clinicians’ situated learning continues regardless of period or specialty. Medical staff not only meet people in their department, but they also interact with other interdisciplinary staff from other departments. Thus, we should consider that their forms of learning and building sociality are situated in a constantly transforming process. This characteristic is noticeable in hospice and palliative care wards where multidisciplinary medical staff work together. This produces following research questions worth studying. 1) How can we capture the doctor’s “learning method” and “knowledge acquisition process” from the anthropological perspective in the changing medical culture that demands continuous learning due to dealing with frequent death and requiring interdisciplinary teamwork? And 2) what significance does this research have in the reality of increasing deaths in hospitals?
Historically, there have been various empirical and theoretical approaches to find answers for these questions. For example, in Making Doctors: An Institutional Apprenticeship, Sinclair (1997) describes how physicians come to be the people they are. Here, Sinclair highlights Bourdieu’s concept of “dispositions” and “habitus.” This means that whether a student is in a formal teaching setting such as a classroom or not, “many of the most vital ways of thinking and acting are transmitted from practice to practice simply through contact of the one who is learning with the one who is teaching (Sinclair 1997 p.21).” This once again shows the importance of “who” these physicians interact with. Also, as a physician, Mahood (2011) mentioned the importance of informal learning. He argued that much of the socialization occurs in corridors outside formal learning environments. This informal setting becomes “sticky knowledge,” which is more memorable than the explicit formal curriculum (Lingard et al. 2002). In other words, this research highlights the importance of studying the sphere of sociality formed within the hospital and knowledge that occurred from the informal environment. Through this, we should not only criticize the medicalization of death but also pay attention to the newly formed sociality through the event of death from the place where death is most frequently witnessed. Once again, this shows the necessity of further studying how death is being discussed through informal interaction.
The other factors that I consider essential regarding forming professional identity is embodied practice and its embedded habit-body relations. Prentice (2013) argues that surgeon’s repeated practice aggregate and condense after period of time and become bodily habits. Years of cultivation such habits leads to professional skills, which accompany spontaneous and habitual judgment making (2013. p.195). In a deeper level, for Merleau-Ponty, “habit” is a ‘‘rearrangement and renewal of the body image’’ through which the body becomes ‘‘mediator of a world’’ (2002, p.164). The skilled body is the body that is habituated to particular action and control to believe in particular ways through practice (Mahmood 2005).
I believe how doctors form their professional identity as healers are an essential topic to analyze end-of-life culture within the clinical setting. Doctors are inevitably exposed to institutional and human/ nonhuman environments, which continuously affect forming a particular identity. In this part of the essay, I tried to unpack how those sources have impacted identity formation. Based on these theoretical backgrounds, I want to understand my main interest in how the repeated witnessing of and exposure to death affect the construction of a physician’s identity in the Hospice and Palliative care ward located in an Institutional hospital.
A hospice and palliative care ward is a space that houses patients that are nearing death and in which people provide care for such patients. The wards are operated in a completely different manner from that of conventional spaces in hospitals. The members of the ward are also organized in a different manner as the multidisciplinary team members provide total care for patients with terminal cancer and their families. In this way, these people build different sociality and networks and are exposed to a new form of situated learning that affects shaping unique identity. Since the hospital and the staff inevitably influence the quality of life of terminal patients, it is necessary to further research on interaction, the process of learning, and ultimately embodied practice of caregiving.
 Buchbinder (2018) argues that in the United States, perspectives on aid-in-dying (AID, also known as assisted suicide) reflect contested cultural values surrounding dependency, disability, and care, as well as suffering, choice, and autonomy.
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