Feminist ethics and menopause : autonomy and decision-making in primary medical care

The construction of menopause as a long-term risk to health and the adoption of discourses of prevention has made necessary a decision by women about medical treatment; specifically regarding the use of hormone replacement therapy. In a study of general practitioners’ accounts of menopause and treatment in Australia, women's ‘choice’, ‘informed decision-making’ and ‘empowerment’ were key themes through which primary medical care for women at menopause was presented. These accounts create a position for women defined by the concept of individual choice and an ethic of autonomy. These data are a basis for theorising more generally in this paper. We critically examine the construct of ‘informed decision-making’ in relation to several approaches to ethics including bioethics and a range of feminist ethics. We identify the intensification of power relations produced by an ethic of autonomy and discuss the ways these considerations inform a feminist ethics of decision-making by women. We argue that an ‘ethic of autonomy’ and an ‘offer of choice’ in relation to health care for women at menopause, far from being emancipatory, serves to intensify power relations. The dichotomy of choice, to take or not to take hormone replacement therapy, is required to be a choice and is embedded in relations of power and bioethical discourse that construct meanings about what constitutes decision-making at menopause. The deployment of the principle of autonomy in medical practice limits decision-making by women precisely because it is detached from the construction of meaning and the self and makes invisible the relations of power of which it is a part.

Understanding body image disturbance in the promotion of mental health : a discourse analytic study

Health care interventions in the area of body image disturbance and eating disorders largely involve individual treatment approaches, while prevention and health promotion are relatively underexplored. A review of health promotion activities in the area of body image in Australia revealed three programmes, the most extensive and longest standing having been established in 1992. The aims of this programme are to reduce body image dissatisfaction and inappropriate eating behaviour, especially among women. Because health promotion is concerned with the social aspects of health, it was hypothesized by the authors that a social understanding of body image and eating disorders might be advanced in a health promotion setting and reflected in the approach to practice. In order to examine approaches to body image in health promotion, 10 health professionals responsible for the design and management of this programme participated in a series of semi-structured interviews between 1997 and 2000. Three discursive themes were evident in health workers' explanations of body image problems: (1) cognitive-behavioural themes; (2) gender themes; and (3) socio-cultural themes. While body image problems were constructed as psychological problems that are particularly experienced by women, their origins were largely conceived to be socio-cultural. The implications of these constructions are critically discussed in terms of the approach to health promotion used in this programme.

“Lay” theories of anorexia nervosa : a discourse analytic study

Previous studies on lay theories of anorexia nervosa have examined the ‘accuracy’ of lay knowledge, and the identification of factors by family and friends that would encourage early interventions (Huon, Brown, & Morris, 1988, 7, 239–252; Murray, Touyz, & Beumont, 1990, 9, 87–93). In contrast to these approaches, we examine lay theories of anorexia nervosa using a critical psychology perspective. We argue that the use of a discourse analysis methodology enables the examination of the construction of lay theories through dominant concepts and ideas. Ten semi-structured interviews with five women and five men aged between 15 and 25 years were carried out. Participants were asked questions about three main aspects of anorexia nervosa: aetiology, treatment and relationship to gender. Each interview was analysed in terms of the structure, function and variability of discourse. Three discourses: sociocultural, individual and femininity, are discussed in relation to the interview questions. We conclude that, in this study, lay theories of anorexia nervosa were structured through key discourses that maintained a separation between sociocultural aspects of anorexia nervosa and individual psychology. This separation exists in dominant psychomedical conceptualizations of anorexia nervosa, reinforcing the concept that it is a form of psychopathology.

Accounts of experiences of bulimia : a discourse analytic study.

Objectives: To identify the variety of versions of bulimia constructed by participants, to suggest functions and consequences of these constructions, and to examine the sociocultural ideologies evident in participants' discourse. Methods: Ten women and one man were interviewed about their experiences of bulimia. Transcribed interviews were analyzed using a discourse analytic approach. Results: Five dominant ways of talking about bulimia were identified: Individuals were constructed as victims of bulimia, women were constructed as victims of social stereotypes, bulimia was constructed as a damaging action one performs on oneself, bulimia was constructed as a personality trait of individuals, and bulimia was marginalized as abnormal and disgusting. Discussion: Sociocultural ideologies evident in participants' accounts included the valuing of individual will-power and self-mastery and the construction of a mind-body dichotomy entailing the need to control the latter. The analysis emphasizes the importance of considering the sociocultural context within which psychological problems occur.

Helpline Discourse

Helplines are services where callers can request help, advice, information, or support. While such help is usually offered through telephone helplines, web chat and email helplines are becoming increasingly available to members of the public. Helplines tend to offer specialized services, such as responding to computer software queries, or medical and health issues, or seeking information about natural disasters. Further, they may be aimed at particular populations such as children and young people. The earliest research investigating discourse in calls to helplines in social interactional research began in the 1960s with Sacks’ early work on calls to a suicide prevention center. Since then interactional research has produced a wealth of understandings into the mundane and institutional interactional practices through which help is sought and delivered. In addition to discussing the breadth of research into helplines, this entry explores the relationship between philosophies and interactional practices of helpline services.

Texts "Con and Pro" : The Early Modern Medical Controversy over Tobacco

The habit of "drinking smoke" , meaning tobacco smoking, caused a true controversy in early modern England. The new substance was used both for its alleged therapeutic properties as well as its narcotic effects. The dispute over tobacco continues the line of written controversies which were an important means of communication in the sixteenth and seventeenth century Europe. The tobacco controversy is special among medical controversies because the recreational use of tobacco soon spread and outweighed its medicinal use, ultimately causing a social and cultural crisis in England. This study examines how language is used in polemic discourse and argumentation. The material consists of medical texts arguing for and against tobacco in early modern England. The texts were compiled into an electronic corpus of tobacco texts (1577 1670) representing different genres and styles of writing. With the help of the corpus, the tobacco controversy is described and analyzed in the context of early modern medicine. A variety of methods suitable for the study of conflict discourse were used to assess internal and external text variation. The linguistic features examined include personal pronouns, intertextuality, structural components, and statistically derived keywords. A common thread in the work is persuasive language use manifested, for example, in the form of emotive adjectives and the generic use of pronouns; the latter is especially pronounced in the dichotomy between us and them. Controversies have not been studied in this manner before but the methods applied have supplemented each other and proven their suitability in the study of conflictive discourse. These methods can also be applied to present-day materials.

A Narrative Study of Patient Encounter Accounts of Physicians, Nurses, and Medical Receptionists after Two Decades of a Paradigm of Patient-Centered Care

Despite recent well-known advancements in patient care in the medical fields, such as patient-centeredness and evidence-based medicine and practice, there is rather less known about their effects on the particulars of clinician-patient encounters. The emphasis in clinical encounters remains mostly on treatment and diagnosis and less on communicative competency or engagement for medical professionals. The purpose of this narrative study was to explore interactive competencies in diagnostic and therapeutic encounters and intake protocols within the context of the physicians’, nurses’, and medical receptionists’ perspectives and experiences. Literature on narrative medicine, phenomenology and medicine, therapeutic relationships, cultural and communication competency, and non-Western perspectives on human communication provided the guiding theoretical frameworks for the study. Three data sets including 13 participant interviews (5 physicians, 4 nurses, and 4 medical receptionists), policy documents (physicians, nurses, and medical receptionists) and a website (Communication and Cultural Competency) were used. The researcher then engaged in triangulated analyses, including N-Vivo, manifest and latent, Mishler’s (1984, 1995) narrative elements and Charon’s (2005, 2006a, 2006b, 2013) narrative themes, in recursive, overlapping, comparative and intersected analysis strategies. A common factor affecting physicians’ relationships with their clients was limitation of time, including limited time (a) to listen, (b) to come up with a proper diagnosis, and (c) to engage in decision making in critical conditions and limited time for patients’ visits. For almost all nurse participants in the study establishing therapeutic relationships meant being compassionate and empathetic. The goals of intake protocols for the medical receptionists were about being empathetic to patients, being an attentive listener, developing rapport, and being conventionally polite to patients. Participants with the least iv amount of training and preparation (medical receptionists) appeared to be more committed to working narratively in connecting with patients and establishing human relationships as well as in listening to patients’ stories and providing support to narrow down the reason for their visit. The diagnostic and intake “success stories” regarding patient clinical encounters for other study participants were focused on a timely securing of patient information, with some acknowledgement of rapport and emapathy. Patient-centeredness emerged as a discourse practice, with ambiguous or nebulous enactment of its premises in most clinical settings.

Could Staying Human in Medical Training Help Make Medicine Humane? Review of Allan D. Peterkin, Staying Human During Residency Training

Compte-rendu / Review

Strengthening argumentation in medical explanations by text planning revision

Explanations are an important by-product of medical decisionsupport activities, as they have proved to favour compliance and correct treatment performance. To achieve this purpose, these texts should have a strong argumentation content and should adapt to emotional, as well as to rational attitudes of the Addressee. This paper describes how Rhetorical Sentence Planning can contribute to this aim: the rulebased plan discourse revision is introduced between Text Planning and Linguistic Realization, and exploits knowledge about the user personality and emotions and about the potential impact of domain items on user compliance and memory recall. The proposed approach originates from analytical and empirical evaluation studies of computer generated explanation texts in the domain of drug prescription. This work was partially supported by a British-Italian Collaboration in Research and Higher Education Project, which involved the Universities of Reading and of Bari, in 1996.

The discourses on induced abortion in Ugandan daily newspapers : a discourse analysis

Background: Ugandan law prohibits abortion under all circumstances except where there is a risk for the woman's life. However, it has been estimated that over 250 000 illegal abortions are being performed in the country yearly. Many of these abortions are carried out under unsafe conditions, being one of the most common reasons behind the nearly 5000 maternal deaths per year in Uganda. Little research has been conducted in relation to societal views on abortion within the Ugandan society. This study aims to analyze the discourse on abortion as expressed in the two main daily Ugandan newspapers. Method: The conceptual content of 59 articles on abortion between years 2006-2012, from the two main daily English-speaking newspapers in Uganda, was studied using principles from critical discourse analysis. Results: A religious discourse and a human rights discourse, together with medical and legal sub discourses frame the subject of abortion in Uganda, with consequences for who is portrayed as a victim and who is to blame for abortions taking place. It shows the strong presence of the Catholic Church within the medial debate on abortion. The results also demonstrate the absence of medial statements related to abortion made by political stakeholders. Conclusions: The Catholic Church has a strong position within the Ugandan society and their stance on abortion tends to have great influence on the way other actors and their activities are presented within the media, as well as how stakeholders choose to convey their message, or choose not to publicly debate the issue in question at all. To decrease the number of maternal deaths, we highlight the need for a more inclusive and varied debate that problematizes the current situation, especially from a gender perspective.

The social construction of child maltreatment: the role of medical practitioners

• Summary: This paper explores how medical knowledge in child protection practice operates, in conjunction with social work knowledge and legal knowledge, as a social process of constructing meaning as ‘maltreatment’ (or not) in which the physical body of the child and perceived abnormalities represent ‘evidence’. Through discourse analysis of two case studies, this paper makes explicit and problematizes the social processes by which meanings are given by medical practitioners, social workers, police and parents to material experiences, the preference given to some meanings over others, and the econsequences of particular meanings for children and families and social work practice.

• Findings: Medical, social and legal knowledge are not neutral but embedded in power relations. The case studies show, through a sociological analysis of professional practice in child protection, how preferred versions of knowledge and meaning may override or dismiss alternative meanings, with particular consequences for parents and children and for practice outcomes.

• Applications: The case studies offer opportunities by which critically to engage with child protection knowledge, policy and practice in keeping with contemporary approaches that advocate dialogue, critical reflection and reflexivity, so that professional knowledge and professional power may be deployed constructively rather than oppressively.

Medication communication through documentation in medical wards: knowledge and power relations

Health professionals communicate with each other about medication information using different forms of documentation. This article explores knowledge and power relations surrounding medication information exchanged through documentation among nurses, doctors and pharmacists. Ethnographic fieldwork was conducted in 2010 in two medical wards of a metropolitan hospital in Australia. Data collection methods included participant observations, field interviews, video-recordings, document retrieval and video reflexive focus groups. A critical discourse analytic framework was used to guide data analysis. The written medication chart was the main means of communicating medication decisions from doctors to nurses as compared to verbal communication. Nurses positioned themselves as auditors of the medication chart and scrutinised medical prescribing to maintain the discourse of patient safety. Pharmacists utilised the discourse of scientific judgement to guide their decision-making on the necessity of verbal communication with nurses and doctors. Targeted interdisciplinary meetings involving nurses, doctors and pharmacists should be organised in ward settings to discuss the importance of having documented medication information conveyed verbally across different disciplines. Health professionals should be encouraged to proactively seek out each other to relay changes in medication regimens and treatment goals.

Parochialism or self-consciousness? Internationality in medical history journals 1997-2006

Research councils, universities and funding agencies are increasingly asking for tools to measure the quality of research in the humanities. One of their preferred methods is a ranking of journals according to their supposed level of internationality. Our quantitative survey of seventeen major journals of medical history reveals the futility of such an approach. Most journals have a strong national character with a dominance of native language, authors and topics. The most common case is a paper written by a local author in his own language on a national subject regarding the nineteenth or twentieth century. American and British journals are taken notice of internationally but they only rarely mention articles from other history of medicine journals. Continental European journals show a more international review of literature, but are in their turn not noticed globally. Increasing specialisation and fragmentation has changed the role of general medical history journals. They run the risk of losing their function as international platforms of discourse on general and theoretical issues and major trends in historiography, to international collections of papers. Journal editors should therefore force their authors to write a more international report, and authors should be encouraged to submit papers of international interest and from a more general, transnational and methodological point of view.

Race and discourse analysis: Building a dialogue in health service research and health care settings

Using a framework for discourse analysis developed by Van Dijk, the investigator will pinpoint the pathological forms of discourse on race, defined as 'race talk' in three professional domains: health services research, public health provider organizations, and literature on multiculturalism. Attention will then turn to developing an analytical strategy for building more meaningful dialogue on race. The retrieval of potential resources for dialogue will be drawn from the third domain. Analysis will focus on enhancing the prospects of converting 'race talk' into dialogue. This will be accomplished by characterizing the normative preconditions as formal procedural requirements for dialogue and then supplementing these conditions with others related specifically to race. From here, the practical implications of combining procedural requirements and resources in each of the domains will be considered. Finally, the author will attempt to determine how these selected resources might be employed to transform 'race talk' in practice and lay the groundwork for a dialogue of understanding. ^