Biomedical science and beyond

The biomedical model has been around since the mid-19th century and still dominates 3 our scientific understanding of health and disease. It focuses on the physical aspects of disease (anatomy, biochemistry, physiology, pathology, genetics, etc.) and adopts a positivist stance in its search for objective biomedical truth, mostly ignoring non-clinical factors. It assumes disease to be fully accounted for by deviations from the norm of}} Focusing attention on the creative aspects of the reception of medical texts in other languages and cultures throughout history helps us to think more critically about the dominant diffusionist, instrumentalist and subservient view that reduces translation to no more than a conduit of previous knowledge.

measurable biological (somatic) variables (Engel 1977). Biomedical research provides data which health professionals can use when making decisions of all sorts, giving rise to Evidence-Based Medicine (EBM), which prevails in current approaches to diagnosis and treatment. In the biomedical model, a patient is seen as an object under treatment, a body that is sick and can be managed independently from its mind, family and social circumstances. Biomedicine is presented as a hierarchical, top-down, research-initiated model; it is deemed to be objective, standardised and eschewing cultural and experiential factors. Biomedicine has its own ontological and epistemological norms, and excludes other medicines and forms of knowing and understanding health and disease, such as those with traditional and local roots. In biomedicine, diseases are pigeonholed into categories in which a particular narrative, often predicated on a reductive or mechanistic account, dominates the discourse (Bowman 2014). This can lead to what Carel and Kidd (2014) describe as ‘epistemic injustice’ in healthcare: patients are vulnerable to the privileging of particular ways of describing illness or disease. This occurs, for example, when society as a whole, or health professionals in particular, lack the interpretative framework to understand particular experiences. For instance, this was the case in the 1960s, and later, with sexual harassment. Society did not acknowledge it and the behaviour of the perpetrators was typically tolerated and even excused. As a result, women were victimised, because the wider social context did not label such behaviour as sexual harassment (Carel and Gyorffy2014: 1256).

In the past, translators mainly operated within the framework of biomedicine, owing to its economic and political power and prestige. They focused mainly on expert-to-expert communication, that is, on highly specialised text genres, in which the abstract language of biomedical research excludes the human, lived experience of patients and obscures the fact that where illnesses are unique, disease labels are classificatory terms only (Haggerty et al. 2003). That is why for decades, at least in countries such as Spain, trained doctors with some knowledge of foreign languages were at an advantage in the field of medical translation and led the biomedical translation market, whereas trained linguists and translators tended to be marginalised on the grounds that they did not have the disciplinary knowledge nor the terminological command required to understand and translate biomedical texts in an accurate and reliable way. The development of translation studies as a discipline and the provision of specialised training programmes have meant that more linguists are now involved in biomedical translation. Although these recent developments are encouraging, factual accuracy, conceptual precision, terminological equivalence and adherence to strict textual norms of the biomedical genres continue to be the core concerns of translators working in biomedicine, whether they are health professionals or linguists.

Between 1960 and 1980, George Engel, an American internist and psychiatrist, published a set of papers in which he outlined the limitations of the biomedical model and called for a new, more holistic approach, which he called the ‘biopsychosocial model’. Through this model, he introduced psychosocial factors which would be taken into account without sacrificing the advantages of the biomedical approach, so that patients would continue to be cared for from a disease standpoint, but, additionally, psychological and social information would be given equal standing in the care process (Fane and Rapley 2017). Subsequently, today’s patient-centred care (PCC) took these principles on board. Patient-centred doctors aim at eliciting and understanding their patients’ psychosocial context and perspectives, taking into account their ideas, concerns and expectations

(Epstein et al. 2005). They aim at reaching a shared understanding of the problem with their patients and involve them in decision making and management of their illnesses. Patient-centred care has galvanised some new thinking and prompted responses in translation studies, which I will come back to in the next section.

Two distinct, and sometimes opposing, perspectives constantly interact in clinical communication: that of health professionals, doctors in particular, and that of patients. Or, in Jürgen Habermas’ theory of communicative action (2015), that of expert systems and that of lifeworld (Lebenswelt), respectively. Both have their own particular motivations, expectations, resources, values, conceptual systems, discourses, stories, strategies for public presentation and social roles; and, this dichotomy of socio-professional cultures causes problematic asymmetries that can be understood and bridged in intra- and interlingual translation terms. Intralingual translation, or genre shift (Montalt and Gonzalez-Davies 2007), is particularly relevant in some intergeneric relationships, such as between a Summary of Product Characteristics (SPC, a technical genre describing the properties and officially approved conditions of use of a medicine that forms the basis of information for healthcare professionals) and a patient information leaflet (a genre derived from the SPC typically aimed at patients taking medicines) (Montalt and Gonzàlez-Davies 2007; Ezpeleta-Piorno 2012). It is also relevant in translational medicine precisely because it can help to bridge the gap between experts who write the information they want to convey and their lay readers, who may require a register more suited to their needs.

In recent years, biomedical science has diversified into Personalised Medicine (PM) and Translational Medicine (TM). PM springs from the notion that, in biomedical and pharmacological terms, one size no longer fits all. PM can then be defined as targeted medicine. What at first sight might seem a radical move towards patient-centred care is, in fact, a biomedical model that uses characterisation of individuals’ phenotypes and genotypes (e.g. molecular profiling, medical imaging, etc.) for tailoring the right therapeutic strategy for the right person at the right time, and/or to determine predisposition to disease, and/or to deliver timely and targeted prevention. Personalising therapeutic strategies, and pharmacological treatment in particular, does not necessarily mean reinforcing patient-centred care or including the psychosocial factors mentioned above. No matter how much PM individualises diagnosis and treatment, it is still very much within the biomedical paradigm of muta ars. Patients are still the individual recipients and beneficiaries of biomedical innovation, the silent bodies that passively receive the targeted cure based on the best possible biomedical evidence. Biomedical translators are there to facilitate this impersonal, detached, and ‘neutral’ flow of information and knowledge. Their main objectives are to target specific groups of patients, or even to convey individualised diagnoses, prognoses and treatments.

Translational Medicine (TM) goes a step further than either Evidence-Based Medicine (EBM) or PM. It aims to transform scientific discoveries arising from laboratory, clinical or population studies into new clinical tools and applications that will hopefully bridge laboratory and clinical practice, and improve human health by reducing the incidence of disease, morbidity and death. It is focused on ensuring that proven strategies for disease treatment and prevention are eventually implemented within a patient population. Ensuring this translatability of knowledge involves encouraging the flow of information from the laboratory to the clinic (‘bench to bedside’), and from the clinic back to the laboratory (‘bedside-to-bench’). TM is based on the notion of knowledge translation (KT), whose aim is to bring pure scientific knowledge from ‘bench to bedside’, by testing its validity in clinical practice, while at the same time keeping the scientific knowledge ‘intact’ throughout the process of translation across various social fields and sectors of the healthcare system (Engebretsen, Sandset and 0demark 2017). KT reflects a subordinate and mechanistic view of translation as no more than a conduit for knowledge dissemination, in which true scientific knowledge remains ‘uncorrupted’ after crossing multiple social, cultural and linguistic barriers. In translational terms, the ‘target culture’ (that of clinical practice and the sphere of the patient) is subordinated to the ‘source culture’ (that of biomedical research). The aim of the translation is to be a hermetically sealed container and a safe carrier of the original message from the source to the target culture. Engebretsen, Sandset and Odemark (2017) critique TM in the following terms:

We maintain that KT relates to the ‘original scientific content’ as a double supplement. On the one hand, KT offers new approaches to the communication of scientific knowledge to different groups in the healthcare system with the aim of supplementing a lack of knowledge among clinicians (and patients). On the other, it demonstrates that a textual and cultural supplement, namely a concern with target audiences (clinicians and patients), is inevitable in the creation of an ‘autonomous’ science. This creates an inherent paradox in existing KT models - while these models presuppose that the principal duty of adequate KT is to implement the original scientific message in new social contexts and textual forms without altering its content, the same models, paradoxically, also state that it is through translational modifications and adaption to new audiences, i.e. through synthesis and development of guideline recommendations, that the message becomes scientifically trustworthy. Hence, translation both threatens and fulfils the original scientific message.

This paradox reflects the current entanglements between biomedicine and translation, and the need to think about them in critical terms. Further research is needed to expand the critique to the ‘bedside-to-bench’ dimension of TM. Translation-oriented research and critical thinking are also needed to address the issue of patients reporting outcomes in clinical trials through genres such as PRO (Patient Reported Outcomes). The patient is not only the recipient of a treatment in a clinical trial, but also plays an active role by contributing feedback in the form of personal experience on issues of interest to the pharmaceutical company. This subjective data, called health outcomes, is of vital importance in determining the benefits and risks of a drug, providing better understanding of diseases, improving adherence to a course of treatment and, most importantly for pharmaceutical companies, obtaining approval for a drug.