The Biotechnical Embrace MARY-JO DELVECCHIO GOOD THE BIOTECHNICAL EMBRACE ABSTRACT. This essay discusses three interpretive concepts that link bioscience and biotechnology to society: the medical imaginary, the biotechnical embrace, and the clin- ical narrative. Drawing on research carried out in the United States and internationally on the culture and political economy of biomedicine, the essay examines these inter- pretive concepts through examples from studies of patients, clinicians, scientists, and venture capitalists engaged in the worlds of oncology and high technology medicine. These interpretive concepts contribute to an understanding of how the affective dimensions of the experience of patients, clinicians and scientists invested in high technology medicine are fundamental to bioscience and biomedicine, and to the political economy and culture of hope. KEY WORDS: biotechnology, clinical narrative, culture of medicine, oncology Cultural and social studies of biomedicine and biotechnology lend them- selves to examining what anthropologists Fischer (1991) and Marcus (1998) have referred to as “multiple regimes of truth,” and thus the call for multi-sited and – implicitly or explicitly – comparative ethnographic research in the areas of science and technology. Although acknowledging the importance of “cultural pasts” and “cultural differences,” Fischer argues that today “it is increasingly artificial to speak of local perspec- tives in isolation from the global system . . . the world historical political economy” and “transnational cultural processes” (Fischer 1991: 526). This formulation echoes recent trends in anthropological studies of biomedicine and biotechnologies, and the whole domain of scientific research and clin- ical culture. Such studies highlight the dynamic relationship, tensions and exchanges between the local worlds in which medicine is taught, prac- ticed, organized and consumed and the global worlds of the production of knowledge, technologies, markets, and clinical standards. Although we may speak about a plurality of biomedicines that are socially and culturally situated rather than about a single unified body of knowledge and practice, such local worlds are nevertheless “transnational” in character – neither cultural isolates nor biomedical versions of indigenous healing traditions. Rather local meanings and social arrangements are overlaid by global standards and technologies in nearly all aspects of local biomedicine. Culture, Medicine and Psychiatry 25: 395–410, 2001. © 2001 Kluwer Academic Publishers. Printed in the Netherlands. 396 MARY-JO DELVECCHIO GOOD COMPARATIVE QUERIES This perspective encourages comparative questions: how do local and international political economies of medical research and biotechnology shape medicine’s scientific imaginary, its cultural, moral and ethical worlds, and the structure of inequalities of use, access and distribution of medicine’s cultural and material “goods”? How do local and international ideologies, politics and policies influence professional and institutional responses to specific needs of particular societies – from the disease plagues of HIV to scarcity and poverty, trauma and civil strife, to public health and profit-driven health service markets? What form does the “polit- ical economy of hope” take? How do the culture of medicine and the production of bioscience and biotechnology “live” in respective societies? Joseph Rouse, an American philosopher of science and society, speaks about American science, about the “openness” of science, arguing for an analysis that acknowledges that “the traffic across the boundaries erected between science and society is always two-way.” Rouse discusses the idea of destabilizing “distinctions between what is inside and outside of science, or between what is scientific and what is social” (1992: 13). Bruno Latour, the prominent French scholar of the biosciences, also contends that “scientific work continually draws upon and is influenced by the culture ‘outside’ science” (Rouse 1992: 13). Although these comments are directed to a long-lived internal debate among scholars of science studies, the concept they propose of two-way traffic across science and society is perhaps all the more striking in biomedicine. The flow of knowl- edge, scientific and medical cultural power, market wealth, products, and ideas is thus not only between local cultures and institutions that create medical knowledge and organize practice, ethics and the medical market, but also between the culture and market of international and cosmopolitan biomedicine and its local variants. The dynamics of the global-local exchange challenge our notions of “universalism” in clinical science and “local” knowledge in clinical prac- tice, stimulating a rethinking of the boundaries not only between science and society but also between “the local” and “the global.” It is with this sense of the transnational fluidity of knowledge and practices, appropriated locally and regionally and integrated into local culture, that I wish to turn to three interpretive concepts that link bioscience and biotechnology to society, and that have grown out of comparative cross-cultural analyses and conversations with colleagues from Europe, Africa and Asia, as well as from my own research in the United States and Indonesia. These concepts are “the medical imaginary,” “the biotechnical embrace,” and “the clinical narrative.” THE BIOTECHNICAL EMBRACE 397 THE MEDICAL IMAGINARY An ethnographic slice through “multiple regimes of truth,” narratives of patient experience and of clinical science, and documents on medi- cine’s political economy, suggests ways in which the affective and imaginative dimensions of biomedicine and biotechnology envelop physi- cians, patients, and the public in a “biotechnical embrace.” The medical imaginary, that which energizes medicine and makes it a fun and intriguing enterprise, circulates through professional and popular culture. Clinicians and their patients are subject to “constantly emerging regimes of truth in medical science” (Marcus 1995: 3; Cooke 2001), and those who suffer serious illness become particularly susceptible to hope engendered by the cultural power of the medical imagination. The connection between medical science and patient populations and the cultural and financial flow thus becomes deeply woven; the intensity of such connections may be measured in part through the flourishing of disease-specific philanthropies, through NGOs and political health action groups, and through the financial health of NIH ($20.3 billion allotted in the 2001 budget), even under a political regime that promotes tax cuts and small government. Americans invest in the medical imaginary – the many-possibility enterprise – culturally and emotionally, as well as financially. Enthusiasm for medicine’s possibilities arises not necessarily from material products with therapeutic efficacy but through the production of ideas, with potential although not yet proven therapeutic efficacy. An officer of one of the most successful biotechnology firms in America indicated that biotechnology enterprises are in the business of producing ideas about potential thera- peutics, from designer anticancer therapies to the manipulation of damaged genes. So, think about a biotechnology company as a pharmaceutical company. . . . If you start with an idea and you are by definition working on something in the pharmaceutical industry that is likely to fail, . . . 90% of the time. . . . That was one of the myths of biotech. . . . So you are proposing to start a company in which there is a 90% chance of failure, the cost of product development is $500–900 million, and from idea to the time when you have a revenue stream from product development is 12 to 15 years. So your question is really, against that fundamental absurdity, how do you build a business, right? . . . If you start at that purely abstract level, what do you have to sell? You don’t have your product yet, so what do you have to sell to feed the beast that you are about to build? Well, there are only two things that you have to sell: the one is you can sell things that are or look or smell like equity. . . . What’s the problem with that? At the end of the day, the pie is so split up, nobody makes any money on their equity, the dilution is intolerable. So what else do I have to sell? Well, instead of selling pieces of the company, an interest in the home, I can sell pieces of pieces, which I call rights, for example in certain of my discoveries or products, and this is where the pharmaceutical companies come in, and they say we will pay for you to do some research on our behalf, we will take the product that results 398 MARY-JO DELVECCHIO GOOD from it, we the pharmaceutical company will commercialize it and pay you a royalty. So I withstand the dilution, I start generating revenues from collaboration, . . . and then I hand off the more expensive parts of forward integration of manufacturing and sales, I don’t have to take on those burdens. The question then becomes, so call those your children. Keep the family alive by selling your children. The question is, is the nature of your platform prolific enough that in having sold off some of your children, you haven’t sold off all of your future. Because if all you are at the end of the day is getting some royalties, from the 10% of your efforts that didn’t fail, you are never going to be a big company. (Holtzman 2001) Such firms seek to make public the scientific imaginary; until very recently, they have been the darlings of venture capital. (See the business sections of The New York Times and the Wall Street Journal during January 2001– April 2001 for analyses of recent market weakness.) At more mundane levels, Americans live in a world in which the medical imaginary has star billing in medical journalism, television advertisements, and globally popular television productions such as ER. (ER is among the most popular television programs in Indonesia and China.) The imminent discovery of cancer cure, effective genetic therapy, the manufacturing of new and better mechanical hearts, the engineering of tissue and the genetic alteration of pig cells to offset organ shortages, the latest results of clinical trials on AIDS therapies and the effective- ness, cost, and contested patents – all become part of the daily and global circulation of popular, business and medical knowledge. Our vast interests, financial and certainly emotional, in “the political economy of hope” are very evident in daily market reports and public discourses. The circulations of knowledge and of the ethereal products of the medical imaginary are of course unevenly distributed. The robustness of local scientific and medical communities, of NGOs and political health activ- ists, influence how this global knowledge is shared, accessed, and used. (See for recent studies: on Brazil, Bastos 1999; on American research oncology, Cooke 2001; on French science, Rabinow 1999; and on medical missions for high technology treatment of multi-drug-resistant tubercu- losis [MDRTB] and HIV for the poor, Farmer 1999.) Alternative stories, misuses and failures of medicine’s cultural power and possibilities, are also part of the traffic in the medical imaginary: failures (as in prema- turely attempted genetic therapy leading to patient death); fraud (in clinical trials in oncology); discouragement (when promising therapeutics appear ineffective); greed (physicians trafficking in organs, brokering transfers from the poor to the rich). (New York Times, Boston Globe, Organs Watch [http://sunsite.berkeley.edu/biotech/organswatch/] 1999–2000) Yet these tales are set