Judy Z. Segal

Strategies of influence in medical authorship

The notion of a rhetoric of science argues that scientific writing is not unproblematically neutral and objective, but rather laden with both theory and value and necessarily persuasive. The nature of persuasion within the profession of medicine is studied here through an analysis of rhetorical strategies at work in medical journal articles. (All articles are on the subject of functional headache and appear after 1982 in such journals as the Journal of the American Medical Association, The Lancet, The New England Journal of Medicine and Headache.) The analysis is organized using the Aristotelian categories of invention (the discovery or creation of arguments), arrangement (their organization in the most persuasive order) and style (including such matters as the use of the passive voice and the avoidance of figurative language). The result of the analysis is a comprehensive inventory of strategies medical authors use in order to influence their peers. The inventory provides a vocabulary and a procedure for analysis of medical rhetoric in general; that is, it goes some way to enabling a medical metadiscourse. The analysis further suggests that rhetorical studies, as a discipline, has much to contribute to medicines project of examining its own assumptions and scrutinizing its own dominant paradigm. Identifying rhetorical strategies at work in medical journals is one way to articulate medical values and to understand them as instruments of action within the profession.

Public Discourse and Public Policy: Some Ways That Metaphor Constrains Health (Care)

Since the terms of the health policy debate in the United States and Canada are largely supplied by biomedicine, the current “crisis” in health care is, in part, a product of biomedical rhetoric. In this essay, three metaphors widely identified as being associated with biomedicine—the body is a machine, medicine is war,and medicine is a business—are examined with a view to the ways in which they influence the health policy debate, not only with respect to outcomes, but also with respect to what can be argued at all. The essay proposes that biomedical language itself be foregrounded as the constitutive material of public discourse on health policy.

The Sexualization of the Medical

The medicalization of sex is part of an already-in-place discursive problem that can be illuminated by looking at efforts to sexualize the medical. “Erectile dysfunction,” “female sexual dysfunction,” and their real and imagined pharmacopia, do not constitute the medicalization of sex; they are effects of sex already having been—to borrow a term from Peter Conrad (1992)—healthicized. The equation of sex and health, as cultural common sense, has made health seem like the natural discourse for thinking about sex in the first place. Reversing the terms of this special issue, and using the methodology of rhetorical analysis, this article looks at the person with cancer as a sexualized subject—someone whose health is represented as intimately tied to his or her sex life. It suggests that, in public discourse—and notably in movies and on television—sex is the comic ending of the illness narrative. In light of this narrative move, the ability to have good sex joins the ability to be positive and cheerful as a (Western) cultural imperative of illness experience, in general, and cancer experience, in particular. Public representations of illness virtues often fail, then, to answer realistically the compelling question, “How shall I be ill?”

lIlness as argumentation: a prolegomenon to the rhetorical study of contestable complaints

The resources of rhetorical theory, the classical theory of persuasion, can be marshaled to help physicians evaluate patient complaints for which there is no corresponding objective evidence and which rely, therefore, on the persuasiveness of patients to be taken seriously (contestable complaints). An appropriate focus for the evaluation of such complaints is argumentation itself: what, in the absence of objective evidence of disease, counts as a good argument for a patient to be eligible for medical attention? How do patients convince physicians that they are ill and in need of care – and, conversely, how do physicians convince patients, when the need arises, that they are well and not good candidates for medical intervention? Two rhetorical concepts are especially productive for the analysis of argumentation. One is kairos, the Sophistic notion of contingency, and the other is pisteis, the Aristotelian catalogue of persuasive appeals. A focus on types of arguments directs attention away from types of patients (difficult, suspect, malingering and so on), and provides a more neutral means of judging claims to illness.

Naming Migraine and Those Who Have It

Medical language has implications for both public perception of and institutional responses to illness. A consensus panel of physicians, academics, advocates, and patients with diverse experiences and knowledge about migraine considered 3 questions: (1) What is migraine: an illness, disease, syndrome, condition, disorder, or susceptibility? (2) What ought we call someone with migraine? (3) What should we not call someone with migraine? Although consensus was not reached, theresponses were summarized and analyzed quantitatively and qualitatively. Panelists participated in writing and editing the paper. The panelists agreed that “migraine,” not “migraine headache,” was generally preferable, that migraine met the dictionary definition for each candidate moniker, terms with psychiatric valence should be avoided, and “sufferer” should be avoided except in very limited circumstances. Overall, while there was no consensus, “disease” was the preferred term in the most situations, and illness the least preferred. Panelists disagreed strongly whether one ought to use the term “migraineur” at all or if “person with migraine” was preferable. Panelists drew upon a variety of principles when considering language choices, including the extent to which candidate monikers could be defended using biomedical evidence, the cultural meaning of the proposed term, and the context within which the term would be used. Panelists strove to balance the need for terms to describe the best science on migraine, with the desire to choose language that would emphasize the credibility of migraine. The wide range of symptoms of migraine and its diverse effects may require considerable elasticity of language.

Medication adaptation headache.

The purpose of this editorial is to challenge the choice of the term ‘medication overuse headache’ (MOH). MOH is not a new concept, but the name remains controversial. Although it is an improvement on previous labels such as ‘drug abuse headache’ and ‘rebound headache’, there is still more work to be done. Our criticisms of the portrayal of MOH are scientific and, broadly speaking, moral. We survey possible terms and their implications and make a recommendation. A recent review article states that MOH is ‘an avoidable disorder’ (1). The current diagnostic criteria (International Classification of Headache Disorders, second edition, 2004 [ICHD-2]) are:

Sex, drugs, and rhetoric: The case of flibanserin for ‘female sexual dysfunction’:

In August, 2015, the US Food and Drug Administration approved Addyi (flibanserin) for the treatment of Hypoactive Sexual Desire Disorder in premenopausal women. Ten months before that, the FDA had held a Patient-Focused Drug Development Public Meeting to address the ‘unmet need’ for a pharmaceutical to treat that condition. I attended that meeting as a rhetorical observer. This essay is an account of persuasive strategies used on, and then by, the FDA, as it considered approving a drug that was not convincingly either safe or effective. The essay turns on three texts: the ‘Even the Score’ pro-drug campaign that informed the patient-focused meeting, the text of the meeting itself, and the FDA’s own published report of the event. I describe how a pharmaceutical company (Sprout, then owners of flibanserin) recruited, and then ventriloquized, both health professionals and members of the public to pressure the FDA to approve a sex drug for women – claiming that not to do so was evidence of sexism. I argue, with rhetorical evidence, that the case for approving flibanserin had already been won before Sprout submitted its application.

The View from Here and There: Objectivity and the Rhetoric of Breast Cancer

In 2007, I wrote an essay on breast-cancer narratives and their public function; in 2012, I wrote another essay on the same topic. In 2009, I was diagnosed with breast cancer. This chapter takes up the shift between essays in my authorial position: I did not, for example, slip, with my diagnosis, from objectivity to subjectivity. Moreover, just as personal illness narratives are not innocent of cultural values or simply subjective, so accounts of neutral-seeming experts about cancer are not free of ideology or politics or desire, and are not simply objective. This chapter uses rhetoric as a theoretical framework for approaching questions of objectivity both in research and in cancer discourse.