Some Further Complexities Attending Medical Evolution

The process accounting for the selection of medical memes, their products, and their integration as institutions, a process complementing biological/genetic evolution, may be provisionally illustrated in a descriptive sense as follows. Using so-called postmodern societies as an example, one can point to a number of different types of institutions that compete with the medical ones. What one could term institutions pertaining to culinary and leisure pursuits (i.e., patterns of thought, feeling, and action that are widely shared pertaining to pleasurable eating and outing) frequently compete with health habits/directives (products of medmemes) involving appropriate foods and lifestyles that

have evolved as part of the healing of certain diseases as well as for the maintenance of health and the prevention of disease more generally. In this instance, then, the implementation of certain medical memes conflicts with the implementation of other memes pertaining to related areas of behavior.

Memes, their products and institutions pertaining to a person's vocation or occupation, and the need for the attainment of success/prestige that attaches to all of this can obviously "compete" with medical memes and their products that enjoin rest, relaxation, and leisure. The medical meme that prepares an individual to expect healing and that has been elaborated during cultural evolution to yield the expectation of dyadic healing (i.e., that enjoins an exclusive reliance on a "doctor-patient" relationship) is now competing with newly developed memes and medmemes the products of which urge and enjoin managed care and group medical practices. The result of this is considerable unrest among patients and doctors and may constitute a transitional point in the social and cultural evolution of medicine.

Escalation of the cost of malpractice insurance and disability/negligence litigation alert one to the fact that medical memes can compete sharply with institutions or memes related to prevailing political and legal concerns. Thus the medical memes and their products that have prepared the doctor-patient relationship in a positive light (e.g., enjoining trust, goodwill, commitment, faithfulness) have come to compete (unfavorably, it would seem) with the effects of newer medical memes about healers and with memes and political institutions pertaining to civil liberties, property violation, and freedom in the pursuit of one's self-interest. This competition obviously leads to problems of medical litigation and in the delivery of medical care, and the effects currently suggest a possible transition point in the social evolution of medicine.

In the are of life preservation and terminal illness, one can see complex changes in the way products of medical memes (e.g., professional norms and ethical imperatives) have continued to operate and function. The environment of evolutionary adaptedness sculpted medical memes that enjoined sickness and healing under conditions of group living during the Early and Middle Paleolithic eras. The biological constraints of this social ecology did not allow for sickness exploitation or healing exploitation; nor did it promote protracted healing in the setting of chronic or serious, progressive sickness. In fact, the medical memes of prehuman and early human groups prepared sick persons and healers to anticipate little care given a context of terminality. Sick persons and significant others prepared and planned for death as part of the SH adaptation. However, as a result of medical evolution during phases of states and civilizations—which involved greater leisure, wealth, complexity of organization, and literate medical knowledge traditions—medical memes and their products evolved to prepare individuals to expect continued care and healing well beyond conditions of health that in earlier periods would have been judged as

wasteful and unnecessarily costly. A related point is that the temptation to exploit sickness became not only possible but also compelling, and although this cannot simplistically be invoked as "causing" unnecessary, heroic medical efforts and treatments in the context of terminality, it nonetheless certainly bears a relationship to the dilemma of planning prudently for death.

Currently, in the modern and postmodern setting, preparedness for sickness and healing has entailed so costly an enterprise that the responsible medical meme (or a set of them) now competes with memes, meme products, and institutions pertaining to savings, income, property, and the like as when individuals or families are forced to consider making costly trade-offs pertaining to treatment of a chronic or terminal disease. And the medical memes obviously "compete" with memes, meme products, and institutions associated with various industries that make use of science and technology.

A final example of how conflict and opposition between medical and nonmedical memes can potentially affect the evolution of sickness and healing can be illustrated for the contemporary period by considering problems associated with the treatment of chronic medical conditions in persons with mental retardation or brain injury who require hospitalization. Very often such patients, in addition to being unable to care for themselves properly, develop disabling symptoms such as aggressiveness, self-injurious actions, and convulsions. It can be appreciated that in a social environment and ecology that was harsh, punitive, and depriving (such as during the evolution of the human line) these individuals would have been the targets of selective infanticide or neglect. Throughout most of history, individuals such as these have generally been provided with marginal care and little or no healing. Over the course of the cultural evolution of medicine, the medical memes and behaviors of sickness/healing that came to institutionalize such social medical practices have become progressively elaborated and changed so that today special organizations and professionals are available whose primary concerns are the problems presented by mentally and neurologically compromised individuals. Parents or guardians are invariably the persons who constitute the first unit of the appropriate healing party for these individuals. In addition, they are morally and legally empowered to make decisions about medication on behalf of such patients because the latter are intellectually compromised and not fully competent in a juridical sense.

Very often those responsible, although well intentioned, do not grant permission for an identified treatment plan. Reasons given are such things as opposition to a specific psychoactive agent, dislike or distrust of physicians, or disagreement on principle with the medical team's assessment of diagnosis or need for treatment (despite having brought the patient for hospitalization).

The result of such an impasse is that the patients are often discharged improved (when permission is granted to pursue an alternative, less than optimal

plan) only to subsequently fail to maintain improvement. That family or guardians are not able to provide a therapeutic setting in the home very often precipitates a readmission just as much as do the limitations inherent in the initially chosen, less than optimal treatment plan.

The readmission initiates a new round of appraisal and discussion that all too often has the same end result as the original hospitalization. A third, "objective" or neutral party who could provide the permission to implement the needed treatment is difficult to obtain in such cases. Other relatives are reluctant to intervene and hospital or social welfare personnel and administrators are unwilling to take responsibility and seek a juridical resolution for the permission to conduct an optimal treatment. The end result of dilemmas such as these is prolonged hardship and agony for patients (as well as their often well-meaning relatives, who are forced to cope with the intractable symptoms) and repeated, costly hospitalizations that consume resources and compromise the welfare of other patients who could be effectively cared for with the inefficiently squandered resources.

In the above example, then, what takes place is a clash in the operation of medical and nonmedical memes and their products and integration as institutions of the society that come to bear in the care of certain classes of patients. This can be conceptualized in terms of opposition among memes. The family, which constitutes the most "natural" segment of the healing audience, brings into play a set of memes (involving spiritual, religious aspects of caring and responsibility) and medical memes (reflecting their interpretation of the sickness) that conflicts with medical memes of the professional members of the healing audience. Similarly, there is a clash between medical memes and political and ideological memes regarding the definition of personhood and autonomy/individuality as these come into play in sickness and healing. The prevailing political memes make it difficult for individuals (relatives, friends, or legal personnel of the hospital) to seek juridical responsibility to ensure optimal treatment. In a free, democratic, and individualistic society, persons (or in special circumstances, relatives) are the ones required to make decisions regarding their sickness and healing, and professional members of the healing audience are reluctant or unable to intervene (except in matters of life and death, which most often do not strictly apply in the circumstances outlined). The result of these clashes in medical and nonmedical memes and their phenotypic effects and integration as institutions is a failure to achieve the consensus that is required for therapy.

The above scenario is not unlike dilemmas such as those that daily confront families and medical personnel that bring to the surface questions of euthanasia, assisted suicide, and efficiency in the use of medical resources. The dilemmas are a staple theme in bioethical conferences and in the writings of health economists.

Several points need emphasis. Medical memes program and prepare indi-

viduals to orient, think about, and behave in medically relevant ways. Medical memes integrated with medical genes are anchored by biological evolutionary processes but have always been influenced by purely cultural and social conditions. How sickness and healing are configured and played out in a society reflects the biology of the SH adaptation and the way that the neurocognitive machinery for it is developmentally modified. The scenario for sickness and healing in relation to serious disease and injury has changed dramatically. The changes are the result of social and cultural evolution of medicine and society. As societies and medical systems evolve and complexify, competition among what have been termed medical and nonmedical memes (and their products and integration as institutions) create medical quandaries. In a more specific sense, inconsistency and opposition in medical and nonmedical memes surrounding certain categories of sickness and healing interfere with and militate against the implementation of others. The result could be termed medical stasis or medical devolution. The inefficient use of some resources because of such maladaptations hinders optimal resolution of medical problems and advances in the treatment of others of the society. These are examples of structural constraints in the social system of medicine, in the way of constructing sickness and healing. Such a state of affairs also conforms to what Anthony Giddens (1984: 373) terms "contradiction": "Opposition of structural principles, such that each depends upon the other and yet negates the other; perverse consequences associated with such circumstances."

Clearly, policies are needed to more effectively and efficiently deal with a range of medical problems associated with sickness/healing as this is configured and played out in contemporary "postmodern" society. The failure to effectively resolve such dilemmas, which entails careful deliberation of and decisions pertaining to choices among moral, political, spiritual, and economic directives, hinders the evolution of effective policies regarding sickness and healing. At the base of these impediments or maladaptations (Rappaport 1979) in the social system of medicine are conflicts and quandaries surrounding the meanings and values of memes, healmemes, and their products.