“Health Care: The Critical Importance of Relationships” by Susan Sered

Reference: Sh'ma: A Journal of Jewish Responsibility

Health care policy conversations in the United States tend to coalesce around two axes: economic
and, for want of a better word, human. People of good will may disagree regarding how much money should be spent on health care, yet few disagree that more “human” health care is a good thing. Less clear, however, is who means what by ”human.” Who is responsible for “human” care: doctors, nurses, receptionists, insurance clerks? Does “human” care mean the same thing to members of different cultural or religious groups? Whose humanity are we talking about: the humanity of the patient or of the professional, and if both, do the two sets of “humans” construe
their humanity in the same way? In short, the notion of human care certainly sounds like a beneficent and consensual goal, yet a closer look suggests multiple layers of meaning and nuances that need to be addressed before it is possible to constructively craft effective “human care” policy standards.

In the mid-1990s, under the auspices of the Israel Association for the Advancement of Women’s Health and the Israel Cancer Association, I was part of a research team that interviewed Israeli women who had been treated for breast cancer. During the open-ended and free-form interviews that we conducted, we noticed that many of our informants spontaneously introduced into their answers the language of being human (ben-adam or enoshi). A closer look indicated that the word “human” was most often used in tandem with the Hebrew word “yachas” (relationship, relating, connection). Utterances like, “Yachas is important so that you don’t lose the semblance of humanity (tselem enosh)” signal that, at least for these Israeli women, the meaning of humanity both for caregiver and care recipient lies inside of relationship. As another woman explained, “Connection is the most important thing. If there is no yachas, there is nothing. We, after all, are human beings.” Significantly, our informants gave thought both to their own humanity and to the humanity of their medical caregivers: “He had wonderful yachas. He treated me like a human being.” Or, in contrast, “It was terrible yachas. He isn’t human.”

Using the technique of discourse analysis, we pulled together the many references to “yachas” and “human” in order to get a clearer sense of why these women speak about their humanity in reference to relationship. Why would yachas be invoked as a key consideration in evaluating health care that is, after all, treating a clear and serious medical diagnosis?

Comments by the women suggest that it is through good yachas that individuals become and hold onto an identity and status of being human. This point was often made via invoking an identity or status that is dramatically non-human, such as an object or a number. For example, “Good yachas: A person who makes you feel that he is relating to a person and not to a surgical object.” The issue of being reduced to an object was raised by several women who specified that their concern was with being seen as a mechanical object: “The doctor talks to me like a garage mechanic.” Another woman explained, “Bad yachas: Relating to you like a number and not a person. Like to a machine that part of it is damaged. Without checking the background of the person.” And in rather similar terms, “Good yachas is personal yachas. [When] you are not a number. [When the medical staff] takes interest in what is happening around the person and not only around the disease.” In the high-tech, bureaucratic context of modern medical care, it surely is the case that erasure of one’s human identity is most likely to come in the form of being reduced to a number or a tool — both typically (and legitimately) at the center of most medical practices.

If human identity is lost through attitudes that turn one into a mechanical object or a number, human identity is gained through conversation. “Bad yachas is ‘Don’t ask too many questions. Accept things how they are. You are a number and not a human being.’” Or, as another woman explained, “For him [the doctor], the patient isn’t a person but a disease. He doesn’t let you talk. He always says, ‘Afterwards you can talk,’ but afterwards never comes.”

When I discussed this study with a colleague in the United States, I was told that in her research among American breast cancer patients she also heard more concern voiced around issues of personhood than around the medical procedure or illness itself. Yet, she told me, most typically she heard women speak about their illness and treatment experiences in individual rather than relational terms. A sentiment she repeatedly heard expressed was, “I never would have chosen to have this happen, but now that I have gone through this I know what is really important.” Or, “I have become a better person because of what I went through.”

This language of spiritual or moral invocation was almost never heard when we spoke with Israeli women. Does that mean that the nature of the disease, or even the treatment, was different in the two societies? I doubt it. I think that this difference in discourse reflects different cultural emphases regarding what it means to be human and how one’s humanity is constructed or destroyed. For many or most of the American women with whom my colleague spoke, humanity is primarily conceptualized as an interior spiritual identity that can grow or shrink according to one’s private experiences. For many or most of the Israeli women we interviewed, humanity is primarily conceptualized as a product of relationship, and it can grow or shrink depending upon whether that relationship is characterized by good or bad connection. One is human because one is part of active, reciprocal, multidimensional, and elastic relationships.

Abuse of power, silence, and disregard of the many social roles held by a given individual — all potential experiences in health care — undo one’s humanity. Within the highly technological and bureaucratized setting of modern medicine, a setting in which the sick individual is routinely separated from her family and friends and colleagues (for treatment) and forced into exceptionally hierarchical encounters (with the medical staff), the loss of one’s humanity is as real a threat as the loss of an organ or other body part.

One notion of “human” is not truer, deeper, or more noble than the other. The question for a health care system that strives to give human care is how to go about meeting the challenges of providing human care to individuals and communities who hold quite different notions of what it means to be human. The bottom line, then, from my perspective as an anthropologist, is the obligation to include a wide range of voices in health care policy conversations.

Susan Sered, an anthropologist, is a Fellow at the Center for the Study of World Religions at Harvard University. Her most recent book is Religion and Healing in America, co-edited with Linda Barnes.

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Reprinted with permission from Sh’ma: A Journal of Jewish Responsibility (shma.com), Vol. 33, No. 599, pp. 1-2.

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