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Thursday Review: “Gesundheit und Krankheit als Bildungsprozess”, Health and Sickness as an Educational Process

A little more than a decade ago, there was a growing sense that the patient was missing from their own care. In Europe, the German-language Journal for Qualitative Education, Counseling, and Social Research called the idea of bringing patients’ biographies into academic study weitgehend brachliegend, “extensively fruitful”. In the US, Rita Charon published her groundbreaking book Narrative Medicine just over a year later.

Too long, patients had simply been objects for study. Different branches of research had begun to converge on the possibilities of a new approach:

Überzeugend weisen sie auf, dass erst im autobiographischen Narrativ, in dem der Kranke als Person zu Wort kommt, der Schlüssel für ein tieferes Verständnis von Kranksein und Heilung liegt.

[The researchers] convincingly demonstrate, that the key to a deeper understanding of illness and healing lies foremost in autobiographical narrative, in which the sick articulate themselves as a person.

The journal felt so strongly about this new area of study, that it renamed itself the Journal for Qualitiative Research.

To commemorate and explain this change, Jörg Frommer and Winfried Marotzki wrote an introduction called “Gesundheit und Krankheit als Bildungsprozess“, “Health and Sickness as an Educational Process”. As an overview, the article lays out common themes for the different research in the volume. As a paper in itself, the article explores the idea of subject and object in medicine.

The main pitfall of modern medicine is erasing the personhood of the patient. That is, handling the human being seeking medical treatment as an object for intervention, and not as an individual with their own existence.

The authors point out that Evidence-Based Medicine (EBM) and what would come to be called Narrative Medicine are equally susceptible to this.

Evidence-Based Medicine runs the risk of turning a person into a data point. Evidence-Based Medicine is certainly useful for diagnosing and, to some extent, personalizing medicine. There is still a need, though, to see the person behind the diagnostic information.

On the other hand, because this discussion is about biography in medicine, it’s important to ask “Whose biography?” and “Who controls how that narrative is told?” In other words, if we practice Narrative Medicine, whose narrative is really important?

The authors emphasize that Evidence-Based Medicine and Narrative Medicine are not incompatible. Neither will they, by themselves, help the other bring a person to the forefront of practice:

Auch heute noch zeigt sich dieses Fach weithin als konservativ-autoritär geprägter Hort von Herrschaftswissen, in dem der behandelte Patient nicht Subjekt ist, sondern ihm lediglich der Status eines „Objekts” medizinischer „Maßnahmen” zugebilligt wird. Daran ändert auch nichts, dass sich unter der Überschrift Evidence-based Medicine ein neues Verständnis medizinischen Handelns durchzusetzen beginnt. Die evidenzbasierte Medizin kann zwar zum Teil gesehen werden als ein Schritt im Prozess der Entzauberung ärztlichen Handelns vom magischen Heilen zum professionellen Handeln unter Berücksichtigung der Individualität des Patienten…

Even today, this area of study appears to be a hoard of oppressive knowledge,* largely formed by conservative and authoritarian tendencies, in which the patient being examined is not a subject, but who is allowed merely the status of an “object” of medical “measures”. It changes nothing, that under the heading of Evidence-Based Medicine, a new understanding of medical activity begins to exert itself. Evidence-Based Medicine can certainly be seen partly as a step in the process of demystifying medical activity from a magical healing into a professional activity taking into account the individuality of the patient…

Other researchers have written about the patient as a subject or object in medicine. The central idea of this introductory article is that this discussion has played out before in another discipline. The lessons learned from that discussion can be applied back to medicine.

Wenig berücksichtigt wurde in dieser Kontroverse um eine angemessene Konzeptualisierung des Verhältnisses der Medizin zu ihren Nutzern, dass ganz ähnliche Problemlagen in den Erziehungswissenschaften thematisiert werden. Dort nämlich wurde und wird — zunächst im Theoriediskurs, und aktuell auch auf der Ebene von Forschungsmethodologie und -methodik —, ein Begriff von Bildung diskutiert, der sich vom klassischen funktionalen und utilitaristisch geprägten Erziehungsbegriff unterscheidet. Ähnlich wie das traditionelle Verständnis der Patientenrolle in der Medizin war der aus Aufklärung stammende Erziehungsbegriff davon ausgegangen, dass es im Interesse einer überindividuellen Ordnung richtig sein k&oml;nne, vom Einzelnen Gehorsam statt Vernunft und mechanisches Funktionieren statt Einsicht zu fordern, und ihm dafür Alltagszufriedenheit statt verunsicherndem Wissen zu ermöglichen. Demgegenüber setzt Bildung im Unterschied zu Funktionalität konsequent auf Reflexivität. An die Stelle von Sozial- und Seinsformen selbst tritt der vielfältige mögliche Bezug des Menschen zu ihnen. In diesem Sinne beschäftigt sich Bildungstheorie

„mit der zentralen reflexiven Verortung des Menschen in der Welt, und zwar in einem zweifachen Sinne: zum einen hinsichtlich der Bezüge, die er zu sich selbst entwickelt (Selbstreferenz) und zum anderen hinsichtlich der Bezüge, die er auf die Welt entwickelt (Weltreferenz). Bildung ist aus dieser Perspektive der Name für den reflexiven Modus des menschlichen In-der-Welt-Seins.” (Marotzki 1999, S. 59)

In this controversy regarding an appropriate conceptionalization of the relationship between medicine and its users, it is seldom taken into account that quite similar problems are dealt with in pedagogy. There specifically, a definition of eduction is discussed (initially in theoretical discourse, and currently at the level of research methodology and methods) which distinguishes itself from a definition of child-rearing formed by classical and utilitarian concepts. Similar to the traditional understanding of the patient’s role in medicine, the concept of child-rearing originating from the Enlightenment assumed that it may be right to demand obedience instead of reason and mechanical functioning instead of discernment in the interests of a community order, and thus to make an everyday sense of contentment possible, instead of an unsettling knowledge. Contrasted with this, education emphasizes reflexivity as opposed to functionality. In place of the formation of society or even the self appears the multifaceted, potential relationship of humanity towards those things. In this sense, educational theory concerns itself

with the central, reflexive localization of humanity in the world, specifically, this is twofold: on the one hand, regarding the relationships which we develop to ourselves, and on the other, regarding the relationships which we develop to the world. From this perspective, education is the name of the reflexive mode of humanity’s being in the world.1

The authors set up a dichotomy between two German words that can both translate as “education.” Bildung and Erziehung have very different connotations, though. It feels heavy-handed to translate them as “education” and “child-rearing”, respectively, but it gets the point across.

Bildung is the word that comes to mind when you ask a German speaker about their college education or vocational training. Bildung comes from older German words meaning “form” or “creation”, and is cognate with the German word Bild, which literally means “picture”. An education, then, is how we choose to form ourselves and our own image in the world.

Erziehung, though, has everything to do with children’s manners and behavior. The root word is the verb ziehen, which is literally “to pull”. Even the root word conjures up images of outside forces acting on impressionable young people, forcing them into the mold of adults’ wishes.

Stepping back and asking “What is an education for?” is a surprising way to talk about the patient in healthcare. When Frommer and Marotzki talk about an “educational process”, though, we see that there are some useful questions being asked.

Do we demand obedience of patients because it’s simply utilitarian and in the interest of community order?

The authors’ alternative is centered in reflexivity as opposed to functionality and a potential relationship. A reflexive localization of humanity in the world sounds opaque and theoretical. It boils down to this, though: you are a real person, living among other real people, and when nurtured properly, we can come to know ourselves and our relationship to others in profound and meaningful ways.

It might be true that pharmeceuticals and medical interventions exist because they’re objectively good for us, and for society. Healing, though, and care exist for a deeper purpose. We seek medical treatment to continue to live. We are only cared for when we understand something new about ourselves and our connections to people around us.

The difference is an understanding of biography.


The article reviewed: Frommer, Jörg, and Winfried Marotzki. “Gesundheit Und Krankheit Als Bildungsprozess — Einleitung in Den Themenschwerpunkt.” ZBBS 7, no. 2 (2006): 187–90.

All translations from the German are by Lance Brett Hall.

* The German Herrschaftswissen is a complex word coming from sociology. It literally means “ruling-knowledge,” and a German dictionary defines it as knowledge which helps acquire and retain power.

1 Marotzki, Winfried. “Bildungstheorie Und Allgemeine Biographieforschung.” In Handbuch Erziehungswissenschaftliche Biographieforschung, edited by Heinz-Hermann Krüger and Winfried Marotzki, 57–68. Wiesbaden: VS Verlag für Sozialwissenschaften, 2006.

Featured Image: “A Kadena Middle School student raises her hand…” U.S. Air Force photo by Senior Airman Omari Bernard. VIRIN 170308-F-ZC102-2012.JPG. This photograph was taken by a member of the U.S. military during the course of the person’s official duties. Under United States copyright law, such images are public domain.