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CHAPTER TWO Social Framing and Diagnosis Corpulence and Fetal Death A neighbor of mine used to encourage her daughters to eat up food they didn’t like by saying “Look at Hanan! If you don’t eat up, you’ll get like her.” And when one of them shouted, “I like Hanan! I want to be like her,” her mother said, to shut her up, “But Hanan will live all by herself. She’ll never have children and nobody will ever call her Mama.” How could I carry a child? Would the fetus have room, or would it be squashed up against my pelvis? How would it get its nourishment, seeing that the food I ate didn’t seem to put any flesh on me? HANAN AL-SHAYKH (1994) Diagnosis is medicine’s classification tool, and as we have seen, it cannot be considered in isolation from human deliberation and agency. Classification is a process that relies on the ability to distinguish same from different: clustering those things that resemble one another in a group, distancing those items that don’t belong. The seemingly natural fit that explains medical categories is nonetheless linked to many social phenomena: what we are technically able to recognize as same or different and what differences we consider to be significant. One might think that the medical diagnosis is embedded with an extra degree of realness in contrast to other categories. Doesn’t the evidence-based system in which medicine is practiced provide some natural proofs to underpin medical classification? There is, of course, a materiality to disease that, on some level, seems logically to repel social construction. Asthma, tuberculosis, and gout are all real in the sense that they have biological markers or clinical features that meet certain standards of evidence. Yet this evidence is not adequate to remove the medical diagnosis from its social frame. I am using the term “social frame” in the same way that Aronowitz (2008) does: as an alternative to “social construction,” a term, he 40 Putting a Name to It argued, that often carries with it confounding antimedical and cultural relativist baggage. Social constructionism emerged as an attempt to break with a positivist approach that considered social facts as measurable entities (P. Brown 1995). The uniform social reality of positivism was replaced by the assumption that ideas are “constructed, negotiated, reformed, fashioned and organized by human beings in their efforts to make sense of the happenings of the world” (SarbinandKitsuse1994,p.3).Implicitinthisapproachistheideathathuman beings are agents, not simply passive entities or disembodied intellects that possess information (Sarbin and Kitsuse 1994). One of the most influential foundational works in social constructionism is Peter Berger and Thomas Luckmann’s Social Construction of Reality (1966), in which they argue that reality, objectivity, and facts are the product of social interactions and appear to be external to individuals only because they are sustained by the practices of many people. Social constructionism contains four key assumptions (Burr 1995). First, it is traditionally critical of taken-for-granted knowledge. It insists that we should be highly skeptical of the idea that observations of the world “unproblematically yield its nature” (p. 3). Knowledge is not, then, simply the reflection of some external reality. Second, social constructionism assumes that the ways we understand the world are historically and culturally specific. How we make sense of the world, the concepts and categories we use, are the product of our history and culture. Third, knowledge of reality is the product of interactions between people. It is through everyday interactions that people make sense of and compose the world around them. “Truth” is therefore the product of social processes involving negotiation between people (p. 4). Fourth, each kind of knowledge, which is produced through social negotiations, then brings about, or invites, different kinds of action. The way we make sense of the world therefore influences what sorts of actions we engage in and how we interact with others. Following these key tenets, social constructionists argue that the proper focus of inquiry is detailed examination of the social practices of people as they engage with each other. A challenge presented to the sociologist of diagnosis by this approach is contained in the argument that social constructionism does not adequately address the tangible physical reality of illness. Best’s “contextual constructionism ” provides one way out. It gives credence to the empirical world, recognizing that the claims and categories and actions of people are...

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