Medical humanities and its entanglements with translation
The increasing specialisation of the different branches of biomedicine, together with their growing social prestige and economic and institutional power, have caused a fragmentation of knowledge, a narrowing of perspectives on health and wellbeing, and a hegemonic relationship with other medicines and other ways of knowing about sickness and health. This reductionism has been identified as a driver of change in the direction of rebalancing between biomedicine and humanities: ‘[...] there has been a paradigm shift away from what might be called medical reductionism to medical holism, where patients are not reduced to diseases and bodies but rather are seen as whole persons in contexts and in relations’ (Cole, Carlin and Carson 2015: 8). In the ‘Introduction’ to Medicine, Health and Being Human, Lesa Scholl presents her project as ‘a conversation between medical practitioners and researchers, alongside humanities and social science scholars, from across the globe, who are concerned about the narrowing of medicine to medical science that has been occurring since the early modern period’ (2018: 2). This monological (and largely monolingual, i.e. mainly in English) limitation of medicine to medical science has affected, in a somewhat negative way, how we currently understand, teach and research medical translation.
The move towards a more holistic, comprehensive and inclusive model of medicine and healthcare, together with a burgeoning interest in ethics and values, is the main driving force behind the emergence and consolidation of the field of medical humanities, more recently also called ‘health humanities’, in academia. In ‘The Almost Right Word: The Move from Medical to Health Humanities’, Jones et al. (2017) offer a detailed discussion on the name the field should adopt. They argue that medicine is but one component of health and wellbeing, and that health humanities is a more encompassing label than medical humanities, because it accurately captures theoretical and pedagogical developments in the education of health professionals. The publication of several peer-reviewed journals such as the Journal of Medicine and Philosophy (since 1976), Journal of Medical Humanities (since 1980), Literature and Medicine (since 1982) and Medical Humanities (since 2000) shows the vigour of the field and the successful expansion it has undergone in the last few decades.
The field of medical humanities provides an interdisciplinary approach to understanding and investigating the effects of illness and disease on patients, health professionals and the societies in which they live and work. Medical humanities includes areas as diverse as medical ethics and law, pedagogy in physician training, medical anthropology, narrative medicine, history of medicine, cultural studies, science and technology studies, sociology, economics, philosophy, literature, theatre, film and visual art. In the introductory chapter of Medical Humanities. An Introduction, Cole, Carlin and Carson (2015: 12) define medical humanities as follows: ‘[...] an inter- and multidisciplinary field that explores contexts, experiences, and critical and conceptual issues in medicine and health care, while supporting professional identity formation’. In The Edinburgh Companion to the Critical Medical Humanities, Whitehead and Woods (2016) synthesise these elements in what they call ‘the three Es’ of medical humanities: Ethics, Education and Experience. Translation and multilingual communication intersect with these main components of medical humanities in a variety of ways, as I shall explain below.
Perhaps the most long-lasting of these intersections is the translation of the works of doctor-writers who have written about the great dramas of human existence and the practice of medicine, such as John Keats, Anton Chekhov, Arthur Conan Doyle, William Carlos Williams, Oliver Sacks, and Nawal el Saadawi. The study, translation, adaptation and staging of the works of playwrights such as Shakespeare (Montalt 2015, 2016), who used the medical knowledge of their time to reflect upon the connections between body, mind and emotions in their characters, is another fruitful area which crosses disciplinary boundaries.
Medical humanities strives to better understand contexts and bring to the fore critical and conceptual issues in medicine and health. In this endeavour, translators are well placed, since they are aware of the usefulness of text genre, a notion that helps them to critically understand language in action and the connection between text and context.
Beyond the naive, uncritical idea that medical language is uniform, univocal and non-rhetorical, translators tend to be very discerning, both within a given language and between different languages, of its great textual and terminological variability and intentionality. They understand the influence that the situations and contexts in which texts are embedded exert on both ‘original’ writing and translating. Formal and critical analysis of the myriad genres used in medical and health communication in multilingual and multicultural settings is paramount for translators; first, to become aware of the variations between genres, not only in different languages and cultures, but even within the same language and culture; second, to accommodate their target texts to the implicit and explicit norms of what is considered adequate and acceptable in a given context. In addition to the down-to-earth uses of genres in translation practice, such as the use of parallel texts for different purposes, medical humanities can nurture other critical perspectives on genres, in particular their historical and ethical dimensions. Text genres are dynamic rhetorical constructs. The genres we are familiar with today are the result of social and textual developments throughout time. Take, for instance, a biomedical research article. Scientists in the 18th and 19th centuries did not report their findings in the same form as they currently do. What we understand by a research article at present is the result of many diachronic changes that have shaped it structurally and rhetorically into a highly useful tool for creating and spreading knowledge, and also for establishing given conventions that affect writer-reader interactions and hierarchies. In addition to this historical dimension, different text genres have different ethical priorities. Ensuring that experiments can be repeated through the provision of detailed and accurate explanations is a central issue in an original article (OA), but in a patient information leaflet (PIL), comprehensibility and reliability of information take centre stage as ethical priorities, which affect the notion of quality as well as the methods and resources to achieve it.
Communication with the patient is the origin of mainstream medical humanities, which is rooted in ethical principles and is closely linked to patient-centredness. Ethical considerations are important in areas such as access to healthcare through adequate provision of information and means of communication, decision making and informed consent in clinical practice, participation in clinical trials and end-of-life care. In all these areas, communication plays a central role; and, the medical consultation, with its doctorpatient interactions, is the central genre of healthcare in which many of these ethical issues unfold. Expert-lay translation (Askehave and Zethsen 2002), intralingual translation (Zethsen 2009, 2018) and patient-centred translation (PCT) (Montait, 2017a) are developments which are linked with the more holistic and ethically-oriented approach to medicine and healthcare promoted by medical humanities. In PCT, for example, the target patient’s perspective takes centre stage. It aims at empowering patients by making texts comprehensible and empathetic through grammatical, terminological, stylistic, textual and pragmatic choices as well as by the use of non-verbal resources, such as diagrams and drawings. It takes into account educational backgrounds, clinical situation, specific needs, and preferences in the presentation of information of both individual and well-defined subgroups of patients. Intralingual translation (Zethsen 2009) is a fundamental component of PCT, which relies on constant testing and feedback from real target patients (Montait 2017a; Garcia-Izquierdo and Montait 2017).
Another area that intersects with medical humanities’ ethical dimension is translation and multilingual communication in crisis situations - from climate-change-induced disasters to wars and pandemics - in which there is a growing awareness of the moral need to respond in a spirit of international solidarity and collaboration. Translation in crisis scenarios is becoming a global priority. Federico Federici, a leading researcher in this emerging area of translation studies, sees an ‘urgent need to establish a concerted and multidisciplinary debate on the role of intercultural communication in international multilingual missions that respond to emergencies across the world’ (2016: 3). In Intercultural Crisis Communication. Translation, Interpreting and Languages in Local Crises (2019), editors Christophe Declercq and Federico Federici address diverse issues of multilingual, multicultural and multimodal infrastructure in all stages of the crises. This collection includes a contribution in the field of medical translation where three main components are established to plan for the complexity of medical and health communication and translation in such critical situations: logos, ethos and pathos (Montait 2019). Logos (Greek word for ‘reason’, ‘discourse’) refers both to content and communication logistics. The focus is on accuracy, reliability and clarity of the medical content and the terminology of the messages. Paramount here are logistics and accessibility, and more particularly, the rational organisation and distribution of relevant information, the creation of effective messages and coordinated communication, using the most appropriate resources. Ethos (Greek word for ‘attitude’, ‘character’) refers to the set of values and attitudes of a particular individual or group, and the ethical codes that regulate multiple professions (translators, interpreters, doctors, nurses, etc.) and communication in crisis scenarios. Pathos (Greek word for ‘suffering’) brings to the fore personal and collective suffering and empathy. Feelings and emotions should not be overlooked nor removed from the logos and ethos dimensions in multilingual and multicultural communication in crisis scenarios. Medical humanities can contribute to the much-needed multidisciplinary debate on how to respond to crises and enhance the human factor.
Education is another principal interest of mainstream medical humanities. It focuses on new curricula and educational materials, which aim to draw on the perspectives and methods of inquiry of the humanities and social sciences, and bring them into medical and health education (Whitehead and Woods 2016). The link between medical translation and the training of doctors in communication skills can be illustrated in a recent study (Bittner et al. 2016), in which 57 medical students from German universities participated in the following experiment: 25 of them translated medical documents for real patients on a platform6 using plain and understandable language, while the other 30 did not translate such documents. All the students then engaged in communicative interactions in a virtual consultation with six simulated patients, who connected via Skype and evaluated the students’ communication skills. Based on the transcripts of the conversations, an expert conducted a blind assessment of the communication skills of all 57 students. In addition, all participants answered a self-assessment questionnaire focusing on their own communication skills. According to the authors of the study, students in the first group (i.e. those who had translated patient documents) obtained a significantly higher assessment result than students in the second group, which shows that written translation of medical documents for patients is associated with significantly more frequent use of plain, comprehensible language in doctor-patient interactions.
That ‘all the world’s a stage’ is well known in the sociological tradition of Kenneth Burke and his theory of dramatism (1969), and Erving Goffman and his dramaturgical perspective in the study of social interactions (1978), as well as in the sociological understanding of health provision and health communication. In clinical interactions, patients play different roles from those performed by health professionals. Simulated interactions between patients and medical students aimed to enhance the latter’s communication skills have been developed by linguists such as John Skelton (2008). Role-plays have been used in professional development programmes in multilingual and multicultural settings, such as the Building Bridges Programme of the Refugee Council (UK).7 The programme provides a useful model conceived for refugee doctors and nurses wanting to work for the National Health System in the UK that is transferable to other countries (Butt et al. 2019). Role-plays can also be used as a research tool to investigate mediated and unmediated interactions in consultation processes and informed consent. The GENTT (Text Genres for Translation Purposes) research team (Universitat Jaume 1, Spain)8 has used this methodological tool in a number of funded research projects involving doctors, nurses, actors, interpreters, translators and linguists, in order to investigate the multiple dimensions of clinical interactions (non-verbal and verbal language, comprehensibility, ethics, empathy, implicit and explicit norms of the health system, cultural factors and medical content) in multidisciplinary teams.
Efforts to bridge the gulf between biomedical science and experience in the medical humanities can be seen in the distinction between pain and suffering (bodies feel pain but people suffer), as has been argued by Cassell in The Nature of Suffering and the Goals of Medicine (1998), and between disease and illness. Disease happens to bodies and is described and understood through biomedical science, whereas illness refers to what people feel and experience, and is understood through eliciting their stories. It is through language that both patients and professionals are able to shape and express what they experience in their own narratives. This will be explored in the next section in more depth, but first let me conclude this section by focusing on some more recent responses to medical humanities.
In the last few years, mainstream medical humanities has been criticised by some scholars (Viney, Callard and Woods 2015; Whitehead and Woods 2016; Kristeva et al. 2018) on the grounds that it has been limited to a subsidiary role of ‘repairing’, as a soft, ‘subjective’ and cultural supplement to a stable body of ‘objective’, biomedical and scientific knowledge (Kristeva et al. 2018), and that it should be proactive in embracing more fundamental issues of knowledge production. In ‘Critical Medical Humanities: Embracing Entanglement, Taking Risks’, Viney, Callard and Woods (2015) challenge the utilitarian model on which medical humanities is based, i.e. providing a service to biomedical sciences. They argue that it should intervene more explicitly in ontological questions, in particular, aetiology, pathogenesis, intervention and cure, rather than, as has commonly been the case, leaving such questions largely to the domains of life sciences and biomedicine (ibid. 3).
According to these critical scholars, this more radical programme should acknowledge the pathological and healing powers of culture, and consider the body as a complex biocultural fact. Issues of race and ethnicity, sexuality and gender, disability, mental health, technology and media, economics, and social and environmental inequalities are central to the production of medical knowledge as well as to the experience of health and illness (Viney, Callard and Woods 2015). Other key aspects in such a programme are nonmedical notions of health, illness and wellbeing; rethinking of the concept of ‘evidence’ in healthcare; and, the acknowledgement that humanities and social sciences may play a more proactive, constitutive role in shaping such knowledge.
