Choice in Conventional Cancer Therapies
More often than not, cancer patients believe that their choices for therapy are dictated by the findings of pure biomedical science. Cancer patients also tend to believe that biomedical science is a monolith–a huge body of knowledge that dictates what an individual must do with a specific kind of cancer–and that all the information generated by this monolithic science is funneled into the brains of the first physicians they consult. Neither belief is accurate.
Physicians are not handicapped by these illusions when members of their own families develop cancer. Characteristically they get several opinions from different physicians before they make a choice of treatments. What the physician knows–and what is rarely articulated to the cancer patient–is that there are markedly different cultures of cancer therapy within mainstream American medicine. With the word “culture” I refer to the nonscientific assumptions and approaches that physicians bring to the design, direction, and emphasis of cancer treatment.
There are very different cultures of mainstream cancer therapy at the international, national, and professional specialty levels. To make a sound decision on treatment, the cancer patient needs to understand the different approaches undertaken by these cultures. Such knowledge helps cancer patients create a comprehensible map of choice in cancer treatment. Mapping cultures of choice in cancer is a powerful antidote to anxiety about what appears to be a bewildering array of treatment options. We can identify three principal cultures of cancer therapy, each with its own set of options:
1. Cancer therapy within mainstream American medicine. Large differences in treatment exist between surgeons, oncologists, and radiation therapists, with each group naturally tending to favor the contribution of its own specialty.
2. Cancer therapy among complementary approaches to cancer, both in the United States and abroad: treatment varies widely among the practitioners of nutritional therapies, practitioners of psychological approaches, and practitioners of immunological approaches to cancer, to name just a few of these subcultures. (I discuss this area in later chapters.)
3. Cancer therapy among advanced technological-industrial societies.
Remarkable differences exist in the way cancer is treated in England, in France, in Germany, in Japan, and in the United States.
The key point is how profoundly culture affects all approaches–even biomedical systems of cancer treatment. In this section, I explore the choices available to cancer patients within mainstream American medicine. But cancer patients should know that many physicians and scientists in other technologically advanced nations regard American cancer therapy as extraordinarily aggressive, using surgery, chemotherapy, and radiation therapy far more extensively than physicians and researchers abroad believe the evidence warrants.
Our exploration begins, therefore, with international differences in the treatment of cancer, and then in chapters 4 and 5, we turn to the options and choices in mainstream American treatment. In these chapters, I mean to draw your attention to three main points: that American cancer treatments are generally at the “aggressive” end of mainstream cancer care when looked at from an international perspective; that within the community of conventional cancer care, there is an intense debate about the gains achieved through chemotherapy and radiation therapy; and that there are important “cultural” differences among different medical specialties and the treatments offered by different types of hospitals in the United States.
The Crucial Difference: International Variations in Conventional Cancer Therapies
One of the most important pieces of medical information for cancer patients seeking to make truly informed choices among cancer therapies is the high level of variation in the cancer therapies offered by physicians in the different advanced industrial nations. Mainstream cancer therapies differ profoundly in En- gland, France, Germany, Japan, and the United States. Cancer patients should let the significance of this fact sink in. It is not some abstract finding by medical sociologists.
These five nations are all advanced scientific societies. The physicians in each country have access to the same world scientific literature. Yet in each country, doctors treat cancer patients very differently. And American cancer medicine stands out among the rest in one key respect: cancer therapy in America is consistently the most aggressive. This chapter traces the strong evidence that the differences in conventional cancer therapies in advanced industrial nations reflect cultural beliefs more than scientific certainties. Understanding these facts is a crucial step in a cancer patient’s journey to genuine informed choice.
Lynn Payer, a leading medical journalist, has written a book, Medicine & Culture: Varieties of Treatment in the United States, England, West Germany, and France1 that provides the best single guide to the international cultures of medicine in the United States and Europe. Much of this chapter draws directly on her research. Mark Lipkin, Jr., M.D., director of primary care at New York University School of Medicine, says that Payer’s work “forcefully documents that while practitioners regard themselves as the servants of science, they are often prisoners of belief and custom. …. This [book] will inspire patients to examine and trust their own experience and preferences even if they must go beyond their national borders to see what is possible [emphasis added].”2
Scientific findings in medicine, Payer argues, are necessarily evaluated in different countries through different cultural prisms:
Consider, for example, a study that shows that giving chemotherapy to elderly patients with cancer prolongs their lives by an average of a few months but also causes them severe, intractable, drug-induced vomiting. [Not true for all chemotherapies.] If one believes that length of life is the most important criterion, this study would indicate that such patients should be given chemotherapy; if one believes quality of life is more important it might indicate that chemotherapy should not be given.
In fact, the American authors of this particular paper felt the added months justified a recommendation of chemotherapy; Englishmen who commented on it in the BMJ [British Medical Journal] felt this recommendation was off base. In neither commentary did the authors recommend that patients be asked how they felt about the matter [emphasis added].3
French Aesthetics and the Preservation of Sexual Organs
Payer was first deeply impressed by the role of culture in medicine at a meeting in Strasbourg, France, in 1972 on nonmutilating treatments for breast cancer.
The meeting got off to a roaring start with its organizer, Professor Charles Gros, giving a slide show on the breast and breast cancer in the history of art, referring to the breast as “man’s pleasure” and “woman’s narcissism.” The exhibitors seemed to enjoy the theme–there were breasts everywhere in the exhibition area, including one entire wall of plastic breasts so pointed it seemed that anyone who accidentally pushed against it would receive major puncture wounds. By the third day everyone was booing slides that showed a bad cosmetic result, which seemed as appropriate a response as any in that setting.4
French medical culture, Payer goes on to show, is deeply influenced by the French admiration for thought as a guide to action; a deep concern with the aesthetics of the human body; a strong commitment to the preservation of sexual organs and fertility wherever possible; an obsession with the role of the liver in health; a strong belief in the importance of the vitality of the inner terrain in repulsing illness and the value of “inoculating” exposure to dirt as a way of keeping the terrain robust; and a national commitment to holidays and health spas as ways of rejuvenating the terrain and sustaining health.
As a result of this perspective, the French moved toward lumpectomies and partial mastectomies in breast cancer long before the Americans. Says Payer: “Men, too, are likely to find their sexual and reproductive organs are treated more gently in France than elsewhere. In the United States, for example, cancer of the prostate is often treated by prostatectomy and castration. In France, it is more likely to be treated by radiation therapy and low-dose estrogens or chemotherapy instead of castration.”5
The French concern with aesthetic outcomes was shared, one French physician told Payer, by patients from other Latin countries: “The Latin patients seem to feel that they are not whole as a person after amputation of a hand or a finger,” the physician told her. “It is important for them to have a complete body. But people from the northern countries don’t have the same feelings. They are more interested in being functional than aesthetically pleasing.”6
The French have a deep concern with the terrain–with the vitality of the inner field of the body–a belief that “skews consumption away from antibiotics, which fit the English and American concept of disease as invader, toward tonics, vitamins, and `modifiers of the terrain’…. It favors treatments such as rest and stays at France’s spas as ways to build up the terrain. …. It makes the French leaders in fields that concentrate on shoring up the terrain, such as immunotherapy for cancer.”7 “If the terrain is more important than the disease, it becomes less important to fight the disease `aggressively’ and more important to shore up the terrain. While American doctors love to use the word `aggressive,’ the French much prefer les médecines douces, or `gentle therapies.'”8
This preference for gentle therapies leads the French into much wider use of nonallopathic medicines, notably homeopathy, in which infinitesimally dilute remedies are believed to be increasingly potent as the dilution becomes greater. The French also generally use lower doses of mainstream drugs. “Even the strongest types of drugs may be weaker in France,” says Payer. “The shah of Iran was prescribed chlorambucil for his cancer by his French doctors, and Americans were surprised that he had not been given a stronger drug. …. A belief in the terrain also undoubtedly plays a role in the fact that fewer invasive procedures are used in intensive care units in France than in the United States–with patients doing equally well in both countries.”9
Germany: An Open Medical System with Strong Conventional and Complementary Medical Traditions
Germany is one of the great innovators in the field of alternative and adjunctive approaches to cancer, with strong traditions of naturopathic, herbal, homeopathic, and spiritual approaches to medical care. German cancer patients have, perhaps, a wider choice of cancer therapies than patients in any other modern industrialized country.
While the French are obsessed with the state of their livers, the aesthetic shape of their bodies, and the vitality of the inner terrain, the Germans are obsessed with their hearts, both physically and spiritually. Payer quotes Novalis: “The heart is the key to the world.” And Goethe: “He seems to value my mind and my various talents more than this heart of mine, of which I am so proud, for it is the source of all things–all strength, all bliss, all misery. The things I know, every man can know, but, oh, my heart is mine alone!”10
West Germans use six times as many heart drugs per capita as the French and the English. And while outsiders see Germans primarily as authoritarian and efficient, “Germans themselves tend to see their chief characteristic as emotionalism.” Says Payer:
The West German health care system accommodates both the efficient and the romantic aspects of the German character by including both high-tech medicine, such as electrocardiograms and CAT scanners, and “soft” medicine based on the healing power of nature, such as homeopathy and spas. The West German health care system, in fact, accommodates practically everything….ê. “There are 120,000 different drugs on the market in Germany,” Dr. M.N.G. Dukes, then of the Dutch drug regulatory agency, informed me when I interviewed him, “as compared to 1,180 in Iceland. ….”11
Still another legacy of romanticism to German medicine is the healing power accorded to nature, whether it be in the form of long walks in the forest, mud baths, or herbal medicine.
The medical use of spas is even more widespread than in France, and plants are more widely used for their healing powers…. About one fifth of German M.D.’s practice either homeopathy or anthroposophic medicine, as well as Phytotherapie, or plant therapy. These forms of therapy are recognized under the West German health system. …. Under recent drug laws, the alternative medicines will have to be shown to be harmless, but there is no requirement that they be shown to be effective, and their continued use will be decided by commissions composed of practitioners of the particular alternative therapies [emphasis added] ….12
The contrast with American medicine is obvious. In the United States, in theory, new medicines must be proved both safe and effective. In practice, however, there are many controversies over how well this system works. On the one hand, the American system offers considerable protection that Germans do not have against ineffective and sometimes tragically unsafe medicines such as thalidomide. On the other hand, the German cancer patient has extraordinary access to a wide range of cancer therapies that Americans can only explore by traveling to Germany. The German physician, moreover, has authority to use a wide range of cancer drugs in his medical practice, is easily reimbursed for this wide-open medical practice, and can follow clinically the effectiveness of innovative drugs in his practice.
Nowhere, perhaps, is the beauty of German cancer medicine more visible than in its anthroposophical hospitals. Briefly, anthroposophy is a tradition founded by the Austrian philosopher Rudolf Steiner, a Christian mystic, philosophical follower of Goethe, and a student of Eastern, as well as Western, spiritual traditions, which has deep roots in central European folk medicine. Steiner’s followers created a network of schools, hospitals, and homes for the elderly and the retarded throughout Europe and the United States. In America, anthroposophy is best known for its “Waldorf schools” for children.
The anthroposophical hospitals I visited in Germany and Switzerland combine an efficient and effective use of conventional medicine for cancer with intensive use of naturopathic, homeopathic, and anthroposophical remedies. The anthroposophical hospitals are widely known and admired in Germany, and are frequently used by Germans with life-threatening cancer diagnoses. The hospitals are aesthetically beautiful; there is a strong emphasis on treatments that will enable the patient to make the best possible use of his life; and nursing and medical care are strikingly humane by American standards.
Great Britain: Economy, Empiricism, and Freedom for Complementary Medicines
At the Strasbourg meeting on breast cancer that Payer attended
…. one of the British surgeons present pointed out that lumpectomy would tend to be favored by British surgeons for a reason other than its aesthetic results: it’s an easier operation. While an American or French surgeon gets more money for more difficult operations, and would therefore be better paid for performing a radical mastectomy than a lumpectomy, the British surgeon receives the same salary no matter how he treats the disease.
The most striking characteristic of British medicine is its economy. The British do less of nearly everything. …. Should the doctor decide that surgery is necessary, the surgery itself will probably be less extensive: there will be no lymph node dissection for testicular cancer, for example, which Professor Michael Baum of King’s College Hospital referred to as “an antique, barbarous custom.”13
While the French pride themselves on the scope and brilliance of their medical thinking, and take a special pride in the aesthetics and vitality of the body, the English, Payer finds, come from an empirical tradition of focus on details, a public school tradition that taught denial of the body, and a stoic “stiff upper lip” tradition that accustomed them to minimalist medical interventions. “Compared to the French and the Germans,” she says, “the English deemphasize terrain, preferring to place the cause of disease outside their body, or, failing that, in the intermediate position of their bowels. Unlike the French, British doctors do not seem to believe much in building up the resistance, and there is almost a total lack of prescription of vitamins, tonics, cures at a spa, etc.”14
While the British spend a little more than half of what Americans spend on health care, their emphasis is more on relieving and comforting than on cure.
Britain is generally recognized to be ten to fifteen years ahead of Canada and the United States in geriatric medicine. …. Kindness can also be seen in the different interpretation often given to medical studies by the English. Not only are they more skeptical about whether medical treatment is actually doing any good; they are more sensitive to the “soft” side effects that may affect a patient’s quality of life more than the hard ones. …. A British reviewer of a book on cancer chemotherapy noted that in the six hundred-page book there “is too much uncritical listing of drugs found to be `active’ (this so-called activity sometimes achieving very little of real benefit to the patient) and too little discussion of what side effects may mean to the patient and his family, especially psychological effects. The quality of life is hardly mentioned.”
The lesser belief in medicine’s ability to prolong life and the greater belief in medicine’s role in making life nicer are undoubtedly the reason that hospices for the dying grew up first in Britain, not in America. To accept the idea of hospice, one must accept the fact that people die. [Wrote one physician], “in the UK we strive less officiously to keep alive. This is not callousness but stems from a different attitude toward death. American physicians seem to regard death as the ultimate failure of their skill. British doctors frequently regard death as physiological, sometimes even devoutly to be wished.”15
While Payer restricted her study to conventional medicine, Britain is also characterized in the field of complementary therapies by strong traditions of vegetarianism, naturopathic medicine, homeopathy (which she mentions), spiritual healing, and a social tolerance that far exceeds that in the United States for the practice of these and other alternative approaches to cancer.
The United States: An Aggressive Culture and an Aggressive Medicine
“Even as Europeans were developing the simple mastectomy and the lumpectomy as less mutilating ways to treat breast cancer,” Payer writes, “American doctors were advocating the superradical mastectomy and prophylactic removal of both breasts to prevent breast cancer.”
American medicine is aggressive. From birth–which is more likely to be by cesarean than anywhere in Europe–to death in the hospital, from invasive examination to prophylactic surgery, American doctors want to do something, preferably as much as possible. ….
American doctors perform more diagnostic tests than doctors in France, West Germany, or England. They often eschew drug treatment in favor of aggressive surgery, but if they do use drugs they are likely to use higher doses and more aggressive drugs. ….
Surgery, too, besides being performed more often, is likely to be more aggressive when it is performed. This seems to be particularly true when surgery on or near the sex organs is performed. An American woman has two to three times the chance of having a hysterectomy as her counterpart in England, France, or West Germany, and foreign doctors joke about American “birthday hysterectomies,” perhaps without realizing how young the birthday is: over 60% of hysterectomies in the United States are performed in women under forty-four. Besides the policy of some doctors of taking out uteruses routinely in healthy women around the age of forty, often with removal of the ovaries, too, a policy approved by the 1975 edition in one of the leading gynecologic textbooks, many U.S. doctors consider hysterectomy the treatment for many precancerous conditions treated less radically in Europe. When cancer is found, the surgery will be more radical. Prostate surgery will be performed more often than in Europe …. on both younger and older men.16
Payer suggests that this medical aggressiveness reflects the aggressiveness of the American character, and my observations in medicine and in other fields of American endeavor suggest that she is right. Aggressive action is part of the American ethos: football is the most aggressive of national sports; the rate of violent crime is far higher in America than in any of the other industrial democracies; and the rate of incarceration of Americans far exceeds that of any other industrial democracy, rivaling those of the former Soviet Union and the Union of South Africa. Nor does the violence come only from the high violent crime rate of the American underclass. The existence of the underclass reflects American social policies that are startlingly less supportive of its citizens than those of any of the other industrial democracies. In medical insurance, in education, in pregnancy benefits and leave, in job training or retraining, in housing, and in virtually every other field except higher education, the United States does less to take care of its citizens than any other advanced industrial democracy. From the European perspective, much of our foreign policy mirrors the aggressiveness and the “cowboy” mentality that they see reflected in so many aspects of American life.
This is not to say that Europeans are entirely critical of American culture. Many Europeans feel hemmed in by their population densities and the myriad regulations that go hand in hand with their strong systems of social support. They are fascinated by the freedom they see in American society, by a culture where people are free to make or lose everything, and where life seems to take place on a dangerous high wire without a safety net.
But the main point here is that, from the perspective of most educated Europeans, the aggressiveness of American medicine in general, and American cancer medicine in particular, is a perfect reflection of one of the major themes in American culture and the American national character. So they would be loathe to accept automatically an American oncologist’s recommendation of an aggressive course of therapy without comparing these recommendations with those of a cancer specialist at home. And they would also see the trend toward even more aggressive therapies in experimental cancer research as a further expression of this American obsession.
Payer traces aggressiveness in American medicine back to Benjamin Rush, physician and signer of the Declaration of Independence, who opposed an “undue reliance upon the powers of nature in curing disease.” The early medical texts echoed Rush with observations that “desperate diseases require desperate remedies” and that “mildness of medical treatment is real cruelty.”17 Incidentally, these are explicitly the views of the mainstream of American oncologists today.
According to Payer, this aggressiveness in medicine was found in surgery, where “frontier surgeons” pioneered radical operations “which, they bragged, Europeans had been too sensitive and timid to perform. …. American surgeons attributed their successes in part to a frontier stoicism lacking in effete Old World practitioners; European critics denounced the American practice as an example of frontier barbarism and cruelty.”18
It is not difficult to argue that the aggressiveness of American medicine has found its purest expression in cancer therapy. However, some elements of aggressiveness in cancer therapy have peaked. The hemicorporectomies of the 1950s, pioneered in the United States, in which patients were cut in half to save their lives, are no longer performed. Radical mastectomies in general have given way to less radical surgeries for breast cancer. As a clinical and research issue in cancer, a greater interest is arising in quality of life, and an increasing number of studies compare shorter chemotherapy treatments with older and more arduous ones.
So the picture is complex. But, at the same time that some of the most aggressive approaches to cancer have peaked or begun to subside, other extraordinarily aggressive treatments have arisen to take their place. The growing application of bone marrow transplants together with total body irradiation is an example. This is a set of procedures in which the patient is given a combination of therapies that are essentially lethal, and then aggressive efforts at rescue are made.
I am not passing judgment on the efficacy of the quintessential American aggressiveness in cancer therapy. Aggressive therapies can undoubtedly save lives in some cases. But I have found an international perspective on cancer treatment to be of real value to thoughtful patients seeking to evaluate their options.
Cancer in Japan: The Denial of Cancer, Germ Phobia, Constitutional Theories of Causation, and the Alliance of Conventional and Complementary Medicine
Cancer patients in Japan are rarely told of their diagnosis by their physician. The physician, instead, tells the family, which decides whether or not to tell the patient and, in most cases, elects not to. A leading Japanese physician explains: “Human beings react very strongly to the notion of death. We should let the patients spend the rest of their short lives without anxiety; we therefore should not inform the patient of the cancer verdict.” This particular doctor sees the American practice of telling cancer patients their diagnosis as caused largely by the American physicians’ fear of malpractice suits.19
Even when medical school faculty members develop cancer, their colleagues do not give them the diagnosis. Moreover, patients at the National Center for Cancer Research in Tokyo and at regional cancer centers are not told. Emiko Ohnuki-Tierney recounts: “A doctor at the National Center for Circulatory Diseases told me that patients believe that, whereas all other people there may be cancer patients, I am somehow an exception.”20
These observations come from a gem of anthropological research by Ohnuki-Tierney, called Illness and Culture in Contemporary Japan: An Anthropological Perspective. As in Europe, medical pluralism is much more widely and deeply sanctioned in Japan than in the United States, so that biomedicine exists side by side with a rich array of traditional forms of health care–notably the folk medical tradition of kanpo, and the great religious and spiritual traditions of Shintoism, Buddhism, Confucianism, and shamanism. These traditions penetrate and deeply influence the biomedical systems of allopathic care in Japan.
Unlike the French–and like the Germans and Americans–the Japanese have a deeply phobic response to germs and dirt, but they carry it further than anyone else. When Japanese children come into the house after playing outside, they take off their shoes, wash their hands, and frequently gargle. Many Japanese adults wear a kind of surgical mask when outside, especially in winter, to protect themselves from germs. In public libraries, stickers inside book covers state, “Before and after reading, wash your hands well,” and “Do not lick your finger to turn pages.” At Japan’s National Institute for Cancer Research, all books returned by cancer patients are wiped with alcohol before others can use them. Some Japanese leave used books in the sun so that sunshine will kill the germs. The Japanese are reluctant to use secondhand clothing for fear that it may carry germs.
From these and others observations, Ohnuki-Tierney builds a powerful picture of the Japanese germ theory that permeates both Japanese culture and its medical institutions. She persuasively locates this theory in the Japanese tradition of protecting the purity of inner space (the inner self or private home), while expecting and often accepting a dirty and impure exterior space (the world outside the home).
But if germs carry disease, the more fundamental cause of illness, the Japanese believe, is a series of imbalances created by changes in the weather or seasons, or by exposure to cold foods. In this view, the Japanese occupy an intermediate position between the French and German concern with the vitality of the terrain and the English tendency to minimize concern with the body. Essentially, the Japanese are concerned with inner vitality, but they see that vitality as being deeply affected by outer, natural influences.
At the same time, Americans see the Japanese as having amazingly little interest in the psychological factors of disease, in general, and of cancer, in particular. Instead, the Japanese see the inner cause of illness in terms of taishitsu, the constitution with which one was born, and jibyo, the “carrying illness” that goes along with this constitution and which may become acute on aggravation. As Ohnuki-Tierney points out, the focus on physical as opposed to psychological sources of illness performs a social function in “eliminating the possibility of blaming another person for misfortune.”21
Japanese have a very high incidence of abdominal cancer, a fact that is generally attributed to certain aspects of their diet–and there is certainly reason to believe their diet is a major contributing factor. But it is also interesting to note that “in terms of illness the greatest attention by far is given to the abdomen, including the stomach and intestines.” Traditionally, the abdomen, or hara, is considered the seat of the soul (recall that, for Germans, it is the heart). The haramaki is a long piece of material traditionally wrapped around the abdomen to protect it. Ohnuki-Tierney lists many Japanese expressions that involve the abdomen: “To heal the abdomen” means to wreak one’s anger on someone; “the worm in the abdomen is not satisfied” means that one is angry; “to read the abdomen” means to read someone’s thoughts; and “to show the abdomen” means to be candid with someone.22
Kanpo, the Japanese traditional folk medicine, was introduced in Japan from China in the sixth century. It uses acupuncture and moxibustion (burning small cones of mugwort on different parts of the body), and plants and animal medicines. It was suppressed once in the nineteenth century and again by the occupation forces at the end of World War II. Today, its use is growing. Ohnuki-Tierney describes her personal experience with kanpo:
Before I left for fieldwork in Japan in 1979, I was told by my gynecologist that I had multiple fibroids requiring “immediate surgery.” …. In Japan, I decided to be a participant observer and asked Dr. I to prescribe herbs for me, although I was not a believer in kanpo. I took his medicine, consisting of twenty herbs, for three months. Upon my return to the United States I surprised my doctor, who found none of the fibroids. Even if we take into account other factors that may have contributed to the disappearance of the growths, it would be hard to deny the real “medical efficacy” of the treatment.23
Ohnuki-Tierney then goes on to report that Dr. I rarely prescribes surgery, even with cancer, because, in his view, the shock to the body increases the imbalances and the operation may spread the cancer.24
The critical point about the use of kanpo in Japanese medicine is that it is widely seen as complementing biomedicine, while in the United States, as Ohnuki-Tierney points out, alternative medicine largely operates in opposition to biomedicine. Thus biomedicine in Japan is seen as more effective with pathogen-specific, organ-specific, and acute conditions, while kanpo is more effective with a wide range of chronic conditions.
Finally, a profound difference exists between the experience of illness in Japan and that in the United States. Many Japanese still choose a hospital because it is in a favorable direction from their house. The average hospital stay is 42.9 days, as compared with 8 to 16 days in the United States and Europe. The hospitalized patient wears his own nightclothes. A prominent physician told Ohnuki-Tierney that requiring hospital nightclothes would cause legal suits “against this abrogation of human rights, and it would be in all the newspapers.” Family members help with the patient’s care and frequently cook the meals: “One doctor stated emphatically: ‘We certainly cannot expect a sick person to eat the hospital food, which is not edible even for a healthy person.'”25
Thus the hospitalized patient keeps his identity in many important ways, and is surrounded by a network of caring family members and friends. Says Ohnuki-Tierney,
In the United States, where the sovereignty of the individual is sacred, the patient role ironically denies individualism, at least symbolically. …. In sharp contrast, the patient role in Japan reinforces individual identity. …. For both men and women, there is an implicit and sometimes explicit expectation on the part of the patient, approved by family members and doctors, that hospitalization is a form of “vacation,” a reward for hard work.26
Is One National Approach to Cancer Better than Others?
Approaches to cancer therapy in all five countries are remarkably different from one another, and would lead to very different personal experiences of cancer. For the American cancer patient, the bottom line is that the system of cancer therapy in the United States is by far the most aggressive of any advanced technological nation. This aggressiveness cannot be attributed to science, which is equally accessible to biomedical cancer specialists in the four other countries.
Does the aggressiveness of American cancer therapy extend life for some cancer patients at an acceptable cost in terms of its effect on the quality of life? For some cancer patients, it certainly does. For others, it equally certainly does not. Very few studies accurately assess the difference in outcomes among these five nations for specific cancers. In general, there is no known difference between the efficacy of one national medicine and another.
Quite apart from the differences between nations in cancer care, it is important to realize that no other industrialized nation has separated conventional biomedicine from other practices to the extent that the United States has. In the early part of the century, biomedicine achieved an overwhelming hegemony in the United States that has effectively marginalized–and often criminalized–other systems of cancer care. In Europe and Japan, biomedicine never achieved a similar level of complete hegemony, with the result that medical pluralism flourishes more widely abroad. This means that a wider range of choices are available for cancer patients elsewhere, as well as a greater freedom for physicians to experiment with integrating therapies from different traditions, if they so choose.
1 Lynn Payer, Medicine & Culture: Varieties of Treatment in the United States, England, West Germany, and France (New York: Holt, 1988). Copyright Ø 1988 by Lynn Payer. Quotations reprinted by permission of Henry Holt and Co., Inc.
2 Ibid., back cover.
3 Ibid., 31.
4 Ibid., 35-6.
5 Ibid., 53.
6 Ibid., 54.
7 Ibid., 62.
8 Ibid., 65.
9 Ibid., 66.
10 Ibid., 74.
11 Ibid., 77-8.
12 Ibid., 96-7.
13 Ibid., 101-2.
14 Ibid., 118.
15 Ibid., 120-1.
16 Ibid., 124-6.
17 Ibid., 128-9.
18 Ibid., 129.
19 Emiko Ohnuki-Tierney, Illness and Culture in Contemporary Japan: An Anthropological View (New York: Cambridge University Press, 1984), reviewed by Michael Lerner in Advances 2(2):77-80 (Spring 1985). This and all following quotes are from the review.
20 Ibid., 77.
21 Ibid., 78.
22 Ibid., 78.
23 Ibid., 78.
24 Ibid., 78.
25 Ibid., 79.
26 Ibid., 79.