Perspectives in Biology and Medicine

RITUALS AND ROLES IN MEDICAL PRACTICE M. L. ELKS* There are many ritual aspects to medical care. First of all, the nature of the usual diagnostic process mirrors many classic healing and initiation rituals. From the patients' point of view, the psychological responses to diese stereotypic experiences may add to die process of healing, especially for major illnesses. The healer may assume care roles, such as mother, mentor, or magus. And as the latter, part of die physician's efficacy is in die psychological ritual effects. In medical school and graduate training, physicians-to-be are put through a multi-year initiation ritual that inculcates them to the habits and dominance required ofthe magus-healer. In practice, physicians recapitulate the ritual practices tiiey have been taught. This nonrational aspect of the science should not be abolished but should be appreciated and nurtured. However, we should also be wary of dictates of ritual behavior diat can prevent needed changes in our practice or create an irrational push to procedures solely for the psychological effects. Although medical professionals often call medicine "a science and an art," in die United States medical education tends to focus on the science and give lesser emphasis to die aspects of "art" [I]. A mindset strongly influenced by Descartian mind-body dualism is at the core of American medical diought and teaching, in spite of many recent articles and books addressing the interpersonal and social issues of die art of medicine. Medical educators have often been reluctant to examine the role of symbolic and psychological issues in die practice of medicine. In diis paper, I examine the rituals and roles of medicine in the context of die healing effects of rituals and roles of die patient and on die initiation and professional identification of the practitioner. A better understanding of these issues can help us to be more effective practitioners and healers. * Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock , TX 79430.© 1996 by The University of Chicago. All rights reserved. 0031-5982/96/3904-0962$01.00 Perspectives in Biology and Medicine, 39, 4 ¦ Summer 1996 | 601 The Medical Encounter as Ritual Healing Ritual practices involved in primitive, native, folk, faith, and "new age" healing are well described and documented [2-19] . Ritual healing ceremonies often involve elements ofone or more ofthe following processes: isolation , a formal series of questions or recitation, divination, night journey or quest, and symbolic loss or physical trials. The first element, isolation, highlights one of the many similarities between healing rituals and initiation rituals, in which isolation is often prominent. In many African native traditions, isolation and/or retreat to a sacred place is prominent [9], and isolation from society, often in a sacred place with stylized contact with the healer, is characteristic of shamanistic practices [4] . In addition, healing rituals often involve a series ofquestions in a formal structure or a specified incantation. Both seasonal and healing rituals involve purification (as by fire, water, or the changing of garments) and stereotypic actions and objects that alter time flow—that remove time and location from the ordinary to the sacred [10]. Contrasts between darkness and light/fire are often an aspect of ritual purification ceremonies [6] . For many native American Indian tribes, including the Aurohuaca Indians of the Colombian Sierra Nevada and the Inca of Peru, confession is a necessary prelude to healing [11, 12] . For many traditions, confession is followed by dances, chants, and physical challenges or trials [13]. Another element characteristic ofhealing rituals is some aspect of divination —of learning the truth by examining the patient and the signs: The treatment [by the Shaman] . . . may include the "laying on of hands," the manipulation of the affected parts of the body, and, of course, ritual singing and dancing. [14] Then thejanka feels the pulse of the patient with his left hand and pulls the fingers of the patient's hand with his right hand . . . mutter[ing] the name of some god or spirit. . . . Thejoints of die patient's fingers often crack in the process of pulling, and it is by counting the number of cracks tiiat the janka is able to discover which superhuman force brought about...