One contemporary goal for ethnographers is to describe features of that complex relationship in different realms of health care delivery—perhaps especially those arenas undergoing fundamental social change—and to delineate the conditions of possibility that have led to current configurations of the future. What do we make of emerging understandings of time—in contexts of clinical and organizational decision making (which are all about the future) and in situations committed to a rhetoric of medical progress?
This group of articles, based on the Society for Medical Anthropology (SMA) Yale Conference panel “After Progress, After Survival: Improbable Futures in Clinical Spaces” (September 24–29, 2009), explores this question.1 Each article investigates how conceptualizations of the “future” and “progress” perform cultural work in relation to illness, mortality, and ideas about appropriate treatment and life potential.
By focusing on the kinds of futures that emerge in the clinical arena, and by bringing different kinds of clinic spaces into conversation with one another, these articles encourage ethnographers and theorists to build on the studies of the body, technology, and the social impacts of the biosciences and the biomedical research enterprise that have characterized much of the work in medical anthropology in recent years. We hope this collection stimulates other scholars to consider the ways in which the future, time, and progress are lived by health professionals and health consumers and the ways in which those concepts have come to be embedded and deployed within the structures of privatized science, evidence, standards, and the organization of health care reimbursement—everywhere in the world.
The articles in this issue, along with abstracts, are as follows:
Futility in the Practice of Community Psychiatry
The experience of futility among frontline clinicians in community psychiatry is produced by the temporal structuring of their work. All health care providers share the disposition to intervene in the course of disease. Specific notions about the course of severe mental illness are woven into the mission of Assertive Community Treatment (ACT) as well as the treatment plan, a key paperwork tool used to stage daily activities. The treatment plan demands a narrative of progress that ACT workers often find impossible to supply. The gap between the ideal of progress and the realities of practice produce distinctive kinds of demoralization. Drawing from an ethnography of a single ACT team in the United States, this article explores how clinicians encounter, articulate, and attempt to resolve such experiences of futility. It explores their practical strategies to reframe the time horizons of work and thereby restore the sense of their own therapeutic power.
Medicare, Ethics, and Reflexive Longevity: Governing Time and Treatment in an Aging Society
Sharon R. Kaufman and Lakshmi Fjord
The clinical activities that constitute longevity making in the United States are perhaps the quintessential example of a dynamic modern temporality, characterized by the quest for risk reduction, the powerful progress narratives of science and medicine, and the personal responsibility of calculating the worth of more time in relation to medical options and age. This article explores how medicine materializes and problematizes time through a discussion of ethicality—in this case, the form of governance in which scientific evidence, Medicare policy and clinical knowledge and practice organize first, what becomes “thinkable” as the best medicine, and second, how that kind of understanding shapes a telos of living. Using liver disease and liver transplantation in the United States as my example, I explore the influence of Medicare coverage decisions on treatments, clinical standards, and ethical necessity. Reflexive longevity—a relentless future-thinking about life itself—is one feature of this ethicality.
Abandonment and Accumulation: Embryonic Futures in the United States and Ecuador
Elizabeth F. S. Roberts
When frozen embryos are publically debated in the United States, they are most often positioned as having two possible future trajectories: (1) as individual humans and (2) as contributors to stem cell research. Long-term embryo accumulation threatens both of these futures. An accumulated embryo is stuck in a clinic, held back from having an individual future or from contributing to science. There are other kinds of futures, though. For some patients in the United States and Ecuador, where I conducted ethnographic research, future reckoning involves a vision of responsibility toward embryos embedded within a specific family. For these patients, frozen embryo donation to another family or to science constitutes abandonment. The future at stake is not that of an individual embryo’s life, but a group’s future who would abandon one of its own. These patients would rather destroy embryos than freeze them for a future away from their relations.
In Louisiana’s unique, populist-derived charity health system, the self-designation Charity Hospital Baby expresses situational identity anchored in the life cycle and the inversion of racist and authoritative connotations. This article draws on theoretical perspectives of stratified reproduction and the politics of time to examine the controversy in which Babies advocate reopening the Katrina-damaged New Orleans Charity Hospital, and administrators and planners support a new state-of-the-art biosciences district, GNOBED. Babies evoke the present, ethical urgency (kairos) of responding to sickness and disability; GNOBED implies prolonging or saving future lives through biotechnologies under development in accelerated time (chronos). As preservationists and residents threatened with displacement join “re-open Charity” proponents, planners symbolically engage in prolepsis, rhetorically precluding opposing arguments with flash forward of supposedly “done deals.” At stake is nothing less than social death for a segment of this ethnically diverse city.
Finally, João Biehl provides concluding commentary in his afterword, “Homo Economicus and Life Markets.”