Disability Studies critiques of existing contemporary environments have been enriched by current discussions in disability theory. The field of surgery, which is a social-scientific body of knowledge and practice that lies at the heart of the "medicalization" of disability, has yet to be scrutinized with the tools of Disability Studies. In this paper, first, using the work of Aimi Hamraie, I examine the field of surgery through a Disability Studies lens, and find that the knowledge deficit, when it comes to disabled patients, is both an ironic and grave injustice. In this examination, I also uncover an entanglement in which the highly embodied nature of surgical practice is used to enrich and develop its own role in the lives of people with disabilities, leading to a potential role for surgery in the contemporary era.
I begin with the observation that there is no surgical textbook chapter entitled anything like "Surgery and the Disabled Patient." Parsing out special populations of concern is common in surgical thinking. A survey of general surgery textbook chapter titles reveals this tendency. "Surgery in the Pregnant Patient," (Mikami, Beery and Ellison 2029-2045) "Pediatric and Adolescent Gynecology," (Strickland 1045-1057) and "Preoperative Assessment of the Older Patient: Frailty," (McAdams-DeMarco and Segey 1159-1162) are common. Surgical epistemology and pedagogy is a complex and dynamic field that is not summarized at one particular locus. Surgical textbooks tend to be conservative, though, reflecting practices and data that have a long history. The surgical textbook, while not a complete accounting of the entirety of surgical knowledge, can be seen as a proxy for one. The central concern of this paper is the lack of a formal understanding and knowledge about disability at the heart of surgery, and that this is a material injustice that actively harms disabled patients.
Though I am concerned with textbook chapters, the formal critique weighed in this paper concerns what I will call the surgical gestalt. The surgical gestalt can be characterized as the comprehensive knowledge and practice of surgery (of which the textbook is just a part). It is gestaltic because it is an assemblage of objects, humans, a built environment integrated with knowledge and political power that is impossible to reduce to its constituent parts. It is gestaltic, too, because it captures a current, contemporary window onto the whole of surgery – it is the surgery of today that is of interest. In addition to the knowledge that is found in textbooks, it includes the subject matter of certifying examinations and "in-service training" examinations of the American Board of Surgery, the built environment in which surgery takes place, the medical equipment that is used, the devices, the entire corpus of research in surgery and the practice that then supervenes on this underlying knowledge and physical structure. The surgical gestalt is surgery, broadly conceived.
The surgical gestalt is oriented heavily towards knowledge, making knowledge central to this critique. Surgical knowledge tends to take a certain form: it comes in small parcels, short nuggets of knowledge, not in discourses, theories or complex systems. Surgeons-in-training or those undergoing boards examination are tested almost entirely in multiple choice format, which reveals the fact that surgical knowledge is broad, not deep. Therefore, absence of certain knowledge can be noted by scanning the gestalt instead of excavating it. The absence of a surgical textbook chapter on disability, then is therefore significant in that it reveals a gap in the gestalt.
Surgery is also highly underdetermined, with much of surgical practice being based on tradition and local and shared experience, rather than on data. The revolution in evidence-based medicine (EBM) brought about by epidemiologists David Eddy, David Sackett, Gordon Guyatt and others, which demands that clinical decisions be made based on evidence from well-designed research has left surgery in a bind. The EBM gold standard randomized-controlled clinical trial is unavailable for most surgeries for reasons of cost, ethics, problems with blinding, and the fact that complex surgical procedures are likely to vary from surgeon to surgeon. For example, in the prominent, highly-referenced surgical textbook, Sabiston Textbook of Surgery, sentences such as "Patients with carcinoids larger than 2 cm, with involvement of the base, or with extension to the mesoappendix should undergo right hemicolectomy with regional lymphadenectomy" (Richmond 1308) and "If the patient is completely asymptomatic 6 hours after a pit viper bite or 24 hours after a coral snake bite and all laboratory results are normal, it is unlikely that envenomation has occurred, and discharge is acceptable" (Norris et. al. 550) go without citations, making the reader rely on the good word of the author and wonder whether there is any evidence for these assertions. This underdetermined nature makes for a practice of surgery that is vast in the variety of its particularities. If one ventures from room to room observing specifically the practices of individual surgeons, one will find significant variation, especially in areas that have not been scrutinized by scientific study. At the core of surgery, though, the key elements of common operations are agreed upon. If an operation is not codified as part of the canon of surgery, it is not considered an operation, but instead either an "innovation" or a deviation from the standard of care.
The surgical gestalt, yet, yearns to ground itself in evidence, and generally strives to create new knowledge. There is a history of basic scientists, laboratories and outcomes researchers being housed in University surgery departments. The surgical identity is one of a scientist. The surgical gestalt, then is characterized by underdetermination, but with a striving for knowledge, in the context of a scientific worldview: a certain becoming. In this becoming, as it becomes increasingly determined, surgery should become more aware about how it is situated in contemporary culture and move to incorporate issues of social justice into its gestalt. One such issue is the way that surgery interacts with disabled populations. This determined becoming can be seen as a way of designing the future of the surgical gestalt. I deliberately recognize this congruency with design in order to also recommend the way in which the future is constructed: with a conscious and deliberate attitude in a scientifically- underdetermined environment. In this paper, which I address to both the Disability Studies community and the surgical community, I will consider what emerges when one regards the gestalt using a new materialist, universal design framework, and then go on to consider how the curative impulse of surgery itself might help to ground Disability Studies in materiality.
The surgical gestalt I have described is an environment worthy of critique from the perspectives found in Disability Studies. A central claim of Disability Studies is that it is the disabling physical and social environment that makes an impairment a disability (Shakespeare, 196). The surgical gestalt is such an environment. The absence of learnedness about disability abounds in surgical practice:
Consider, for example, a 19-year-old nonverbal patient with severe autism who becomes violent with the staff on at 2:00 AM on postoperative day one from a bowel resection. The nursing staff calls the surgeons' team requesting a sedative, a benzodiazepine, or anything to make the patient calm down. The surgeon arrives at the bedside and cannot determine whether the patient's pain is out of control, whether he is agitated, confused, whether such agitation is normally part of autistic behavior. The psychiatry team is not immediately available. Drugs do not seem right in this setting, restraints seem even less right, but nothing else does seem right. Surgical knowledge, in all of its particularities and breadth, does not extend to this aspect of postoperative care.
Consider a young woman with a diagnosis of schizoaffective disorder who is addicted to cocaine who presents with an incisional hernia in the lower abdomen and uterine fibroids causing heavy menses and abnormal uterine bleeding. In clinic, she avows that she has given up cocaine, but when she presents for a combined surgery to fix both problems at once, she tests positive for cocaine, so she is sent home. This happens again, and then again. She comes in a fourth time, to the ED, and has incarcerated bowel in her hernia, a problem requiring urgent surgery. The surgeon operates and fixes the problem. She requires a bowel resection. During her postoperative course, the nurses complain that she is difficult and is "narcotic seeking". She won't stay in her room. They call constantly. They feel like she is trying to manipulate them. She is seen as being "out of control." What might be seen as a mismatch between body and environment that could be addressed in the systematic fashion that is characteristic of the surgical approach, is instead seen as a disruptive nuisance.
Consider a thirty-two year old female with severe cerebral palsy who presents with acute cholecystitis. The team prepares her for the operating room and have transferred her from the stretcher to the operating room table. The joints of all four limbs are flexed and fixed in the manner of many patients with severe cerebral palsy. As the team is positioning, the question is asked, "Since cerebral palsy is central, when general anesthesia is induced, will this patients' limbs relax and straighten out?" A wealth of anecdotes, mechanisms and answers returns in answer, but in no one knows. The answer resembles a wealth of other facts, equally central to surgical practice, that are known definitively. This fact is knowable, but absent from the surgical gestalt. The fact that should be in a surgery textbook chapter is that the spasticity probably does go away with anesthesia, but patients with cerebral palsy also often have muscle contractures, joint dislocations and scoliosis (Prosser and Sharma 72-76), which makes positioning a challenge.
Prominent in disability scholarship is the notion that there are alternatives to what is known as the "medical model of disability," which is the view assigned to physicians, healthcare workers and others in the medical culture. Of note, there is no intentional discursive "model" of disability to be found in medicine per se – disability is relatively unexamined within the medical context. The medical model and its dominant alternative, known as the "social model of disability," consider exactly of what the relationship between the disabling impairment and the resulting functional limitation consists (Siebers, 73). In the medical model, the disabling limitation is considered to be based wholly upon the impairment itself; any improvement in the disabling condition will come from materially "fixing" the impairment. "Medicalization" is the paternalistic extension of this view which tends to objectify people with disabilities and infantilize them. The social model suggests that the limitation derives from the built and social environments, and the "lack of fit" between disabled bodies and environment is what matters, not the impairment (Garland-Thomson, 2011, 594). The social model regards the embodied difference as valuable human variation, an "embodied human diversity." (Garland-Thomson, 2011, 603). Many of the social and environmental changes made to the built environment in the twentieth century such as curb cuts and wheelchair ramps, typify social model enhancements to the environment.
It seems ironic that surgery would not incorporate a deliberate and comprehensive study about disability into its gestalt. Disability gives surgeons a mission; broadly defined, what surgeons do is save lives and "fix disability." The critique I weigh here, that surgery actively excludes disabled patients by not formally including them in the surgical gestalt, has likely not been weighed previously because of this mission and identity. Surgery gives much of the medical model its force and thrust; what better way to "correct" a disability permanently than to operate? The examples above purposefully do not include a curative impulse toward the impairment – they are meant to emphasize surgery as an environment. The patients in the examples are disabled, but the surgeries being performed are not being performed to fix the impairment associated with the disability. This characteristic of the examples makes the upcoming analogy between the surgical gestalt and the built environment more apt. I would like to limit the scope of this critique, so far, then, to this type of surgery: the surgery that every human might need to undergo; surgery that has little or nothing to do with the patient's disability. Every human being born with an appendix may one day need an appendectomy.
The social model of disability proposes that disability is primarily a social justice problem – what needs correction is not the body of the disabled person, but rather the social and built environment. Disability, according to the social model, then, is a product of the built and social environment. This move is highly important in Disability Studies, as it shifts the focus of action with regard to the disabled from charity or sympathy to one of justice: in the contemporary era, with what we know about disability, it is simply unjust to build buildings, design things and create environments that are not accessible to the disabled. The surgical gestalt itself is a built and social environment that is congruent to the built and social environment on which social critiques of disability often focus. There is a great deal of body-environment mismatch in surgery, both in the physical structure of things surgical, but also in the learning and knowledge environment of surgery. The resistance to incorporating such details may lay in the fact that surgeons derive mission and identity from focusing very intensively on fixing embodied impairments and haven't expanded concern to encompass the disabled bodies that may present in any other myriad of fashions.
This work shares many fundamental notions and features present in the Science and Technology Studies (STS) literature, especially at its intersection with Disability Studies. When it comes to disability, it seems to grow from the same stalk when it "[attempts] to come to terms with ways of enacting the good society, to demonstrate how other realities could be articulated and enacted," (a view about STS articulated by Galis and Lee (156)). It concerns technoscience and a politically invested construction story about how surgical knowledge comes to be. It invites a socially- and politically-situated analysis that shares features with work by Bruno LaTour and Michel Callon.
I deviate from STS, though, purposefully, since surgical practice seems to proceed, not by science (since the practice is as much "cottage" tradition with casuist elements, as it is science), but by a process more akin to design. Science and technology studies, is, though, entirely and rightly concerned with science and scientific knowledge generation. In this paper, I endeavor to consider the surgical gestalt to be something that is continuously upgrading and being intentionally and consciously reinvented (despite a robust evidence base) so it can be used by surgeons in the ordinary contemporary; in other words, the surgical gestalt is being "designed." A second reason to leave STS for the purposes of this paper is that I am not focused only on knowledge generation, but "gestalt generation", that is the complete knowledge and practice of surgery; a line of inquiry based on new materialism seems much more apt to address this, given such a broad perspective. That said, a future project considering surgery and disability through an STS lens would be a valuable addition to both literatures.
Aimi Hamraie's "New Materialist Practice"
Aimi Hamraie's analysis of Universal Design provides a fruitful pathway for incorporating a social model perspective into the surgical gestalt. Universal Design is a movement in architecture and design that broadly recognizes that contemporary design should not exclude bodies with varying abilities and disabilities. Universal design has been successfully and iteratively incorporated into Disability Studies, representing an ideology of inclusion and flexibility throughout a wide range of applications from technology to education. Hamraie has argued that Universal Design brings an epistemological and methodological approach to contemporary models of disability, establishing a "new materialist practice" in Disability Studies (Hamraie 2012). Hamraie's project characterizes Universal Design as a phenomenon that is grounded in the thought that it "frames a regime of intelligibility in which the built environment is inseparable from knowledge about the bodies of the potential users of space" (Hamraie 2012). Using this Hamraiean notion of universal design will be instructive when applying a social model perspective to the surgical gestalt.
Hamraie points out that Universal Design responds to three "epistemic regimes in design" (Hamraie 2012). It represents an epistemic technique that is based on academic research, it responds to thinking that is "at once intentional and intuitive" and it responds to the "normate template". These concepts have value when considered in the current project.
The first epistemic regime to which Universal Design responds is the multiplicity of epistemic methods that have been used to generate new knowledge in design (Hamraie 2012). The fact that it is based on academic research makes the Universal Design concept fit well with the aims of surgery. While much of surgical practice has not been scrutinized by research, surgery yet aspires to ground itself in scientific, academic research. Evidence of participation in research by medical students is necessary for acceptance into most surgery residency programs. A scan of the faculty promotion criteria for most medical schools reveals a preponderance of criteria for research over clinical activity or teaching. To have an abstract accepted to the American College of Surgeons Clinical Congress, it must be about basic science, health sciences, laboratory research, educational research or outcomes – there is no room on the program for any thought that is not considered "research" (100th Clinical Congress Abstract Program Submission Site).
Surgery is not entirely bereft of scientifically-derived knowledge about disability. Frank Johnson, Walter Longo, Katherine Virgo and others have published a series of studies investigating the outcomes of many general surgical, urological and vascular procedures and diagnoses in patients with spinal cord injury (Ahmed et. al., Brandes et. al., Strauther et. al., West et. al., Jacobs et al., Stratton et. al., Longo et. al.). Elizabeth Pendo has made the point that recent efforts to break down barriers between disabled patients and healthcare at the federal level failed to take into account the way that the built and physical environment remains a significant barrier, twenty years after the passage of the American with Disabilities Act (1057). Payal Shah and colleagues have surveyed disabled adolescents to determine their overall level of comfort with contemporary gynecologic services and offer solutions (101-104). Though there is evidence of concern for disabled patients in surgery, much remains unknown about how specific disabilities interact with surgery in the pithy way that surgeons are confident about so much else. It is this type of research that should be added to the agenda to broaden the surgical gestalt: an expansion in the focus of research to take into account a more complete set of human beings.
Second, Universal Design responds to thinking that is at once "intentional and intuitive." (Hamraie 2012) Hamraie points out that designers are often thinking intuitively, and "research" in that context refers to "the designer's drawings, studies and models that explore possibilities for a design" (Hamraie, 2012). Design "researches potential futures by solving problems within the status quo" (Hamraie 2012). Universal Design improves design in this regard, allowing a broader, more scientific methodology to enter in to the design function. Once again, surgery has a similar approach and would therefore benefit from Universal Design influence in a congruent way. Though much of surgery is practiced according to algorithm, routine, standard of care, an evidence base, and tradition, the surgical gestalt allows for a good deal of intuitive thinking and creativity in the status quo. The surgical endeavor is too complex to allow the entire gestalt to be formalized and its underdetermination allows "experts" to arise who base their assertions on personal experience, training and shared experience in community with other surgeons. When it comes to caring for the disabled, the entirety of the endeavor is intentional and intuitive – one cannot easily resort to one's training, look something up in a textbook or access an evidence base. There is nothing in the gestalt that formalizes an approach to the postoperative care of the autistic patient, the preoperative positioning of the patient with cerebral palsy or the distinct perioperative needs of a patient with schizoaffective disorder.
The third epistemic regime considers the use of the normate body as a template. The critical term "normate" was invented by Rosemarie Garland-Thomson to mean "the severely able-bodied […] phantom figure who is the imagined user of buildings designed outside of the guiding principles of universal design" (Garland-Thomson, 2012). The "normate template", a critical term invented by Hamraie, then, indicates a design strategy that considers only the normate in its substrate. Evoked by Hamraie to elucidate this term are the Vitruvian man of Leonardo and the Modulator of Le Corbusier, examples of "perfect" geometric embodiment. These forms exist, according to Hamraie because traditional design does not have a research apparatus that would allow a richer model of the human being, and therefore must rely on a picture. Hamraie sees Universal Design as being a new anthropometry in which "human bodies and behaviors become legible proofs of the normate template's inadequacies for designers." (Hamraie, 2012)
Surgery, though it does not have a "template" as specified as those in the history of design, does have a particular human form "in mind" as a substrate. Consider the classic of anatomy studied by first year medical students: Netter's Anatomy (Netter). Not only are the anatomic pictures depicting gendered beings of Vitruvian perfection, but the textbook commonly depicts only the most common variant of a portion of anatomy when even non-negligible variants exist. All plates reveal a human with two arms, two legs and completely unambiguous genitalia, never "unruly" nor "heretical." (Fausto-Sterling) They reveal a hepatic vascular anatomy that is present in only 60% of patients (Sicklick, D'Angelica and Fong), without comment on other common anatomies.
The normate template of surgery is not only anatomical. Surgeons expect a patient who understands and adheres to postoperative instructions, to communicate, and to endure pain. This approach may be appropriate for beginning medical learners, in whom a simplified anatomical template is useful in mastering a complex initial knowledge. For practicing surgeons, though, who singularly profess knowledge as the core good of the profession, and who open their practices to any human being who might walk in through the door, it is not. Applying Hamraie's new anthropometry to the surgical gestalt, in its social and material components, could have wide-sweeping and transformative effects on surgical knowledge and then on surgical practice. Instead of the normate template of the first year medical student, surgeons should embrace a wider variety of human forms onto which a more complete gestalt can be molded. A Universal Design-based method of expanding the surgical gestalt would allow an expansion of formalized knowledge that takes this variety of forms into account.
Using Universal Design as a guiding light for improving the surgical environment for disabled patients has the potential to be a new materialist practice in surgery. Universal Design, though, understood at its fullest, requires designs and the built environment to be accessible to all potential users of that design or space. While it is possible to envision a space that is accessible to all possible bodies, some disabilities may take a form that does not fit in even a broadly encompassing design. To encompass all possible humans into a space could therefore be characterized as a radical notion. Such a radical goal should not obliterate the drive to create designs and built environments that aim toward this ideal. In surgery, too, one might argue that is impossible to develop and formalize an approach to surgical care that addresses any potential disability. It is favorable, then, to think of an aspirational Universal Design approach to the surgical gestalt that aims at a richer notion of Universal Design without being discouraged by an unachievable asymptote.
A Universal Design-based effort to fill in missing disability elements of the surgical gestalt then, will be a complex project that will need to be approached intentionally and deliberately. A textbook chapter entitled "Disability and the Surgical Patient" would just be a beginning. A research program should be developed with stakeholders from across the disability spectrum in lead positions; knowledge is socially situated and a research program should be guided by first-hand accounts. In this era in which patient-centered medicine is emphasized, surgery is struggling to understand what patient-centeredness is and how and can be practiced. A recognition and mapping of the socially constructed spaces of surgery would be a good starting point, with a paradigm case being the relationship between surgery and disabled populations.
Complex Embodiment and the Curative Impulse
I have so far only considered the situation in which the surgical gestalt acts as an environment. I will now consider the curative impulse in surgery when directed toward the disabled population. I will define the curative impulse in surgery as the compulsion to intervene surgically on bodies with therapeutic intent. The curative impulse is at the heart of the medical model of Disability Studies: the knee-jerk impulse to fix, or "cure," the impairment. As I have noted, surgeons derive much of their professional mission and identity from operating on disabled persons with an intent alternately regarded as either normalization or improvement of function.
In what follows, I argue for a role for a curative impulse in surgery, albeit transformed by the gestaltic sea change that I have proposed. Work in contemporary Disability Studies makes room for such a role. Susan Wendell has made the point that changes in the physical and cultural environments will not improve the situation of some people with disabilities. She writes:
In most postmodern cultural theorizing about the body, there is no recognition of – and, as far as I can see, no room for recognizing – the hard physical realities that are faced by people with disabilities. …We need to acknowledge that social justice and culture change can eliminate a great deal of disability while recognizing that there may be much suffering and limitation that they cannot fix (Wendell 45).
Consider, for example, a person with chronic, intractable pain. The totality of the impairment, in this patient, is so fully and physically within the patient's body that a change in the built or social environment will do little to alleviate it. It must be a medical therapy (a material one) that will be needed to alleviate the pain – in the form of a pill to swallow or a surgical procedure to undergo.
When viewed in this framework, a space is opened for a potentially legitimate role for a curative impulse in surgery when it comes to disability, while avoiding "medicalization." Medicalization, here, is the tendency by physicians to define, control and continuously "normalize" the bodies that present before them. The challenge for surgery will be to account for and distinguish between "both the negative and positive valences of disability" (Siebers, 25) and to incorporate this distinction into practice in a truly patient-centered fashion. To achieve this, a move from the medical model towards the social is needed. I have posited that the entirety of the surgical endeavor, its knowledge and cognitive aspects, and its physical ones, should be construed as an environment worthy of critique. If disability is not then entirely socially constructed, and there are aspects of disability that are physically embodied, surgery might be able to interact with some impairments with helpful intent and have a positive effect on disabled populations. The strong curative impulse in which surgery is rooted results in a more complex engagement with disabled populations for which a binary medical/social model will be inadequate. Incorporating a focus on disability in the surgical gestalt will have interesting and certain effects on this curative, non-environmental aspect of the gestalt as well.
If, for example, the surgical gestalt is progressed in the way I have described, surgeons will gain a new, richly material-discursive understanding of the lived experience of people with disabilities. Since surgeons come in close contact with all varieties of human bodies then the clinical encounter itself is likely to be transformed and the impulse trained on emancipation rather than cure. Even more, the impulse itself could be modulated to the preferences of patients – when emancipation is sought, the impulse takes that form and when cure is sought, it takes the form of cure. Such a transformation would go far beyond contemporary progressive versions of cultural competency such as Metzl's "structural competency" which requires adding competencies and didactics to an already-packed medical school curriculum (Metzl, 131). Instead, surgeons will have a material understanding of disability through the lived experience of those people with disabilities with whom they interact. Indeed, the degree to which allowing surgeons with disabilities to enter practice has yet to be explored in this context.
Medical care without medicalization has a history in Disability Studies. Susan Wendell solves the problem of cure being closely associated with the medical model by conscripting who counts as being disabled in the social model. She promotes the notion that the social model should be applied to a group called the "healthy disabled," a group that is "stable and "not ill". Medical care (and for our purposes, surgical care) then, is indicated for the disabled populations that are not in this subset (Wendell, 17-18). Tom Shakespeare allows and encourages role for the medical without medicalization for people with disabilities, based on the observation that "disability is a complex phenomenon, requiring differing levels of analysis and intervention, ranging from the medical to the socio-political" (202).
Most apt is Irving Zola's recognition that disability is a universal experience of humanity (Zola, 401-406). Elisions can arise and spectra can be realized when such an all-encompassing view is taken. Disability is integrated through a continuity of ever-changing lives, moving into some lives early on and some at the end. For some, disability is a permanent aspect of life, but for others, the durability of disability is a shifting thing. Certainly there is a role for surgery in quotidian life – where surgery is integrated into what might be thought of as "non-disabled" lives. Where along this spectrum the dividing line lies separating the surgery of the non-disabled from a legitimate role for surgery in the temporarily disabled to a mindless practice of normalization can only be determined by a process like I have described above. Imposed on this could be another continuum, in which the exterior is elided with the interior. What is seen as environment more generally can be thought of continuously with surgical care. The environment becomes more personal as local environments are tailored to lessen the disabling nature of the impairment, to wheelchairs and prosthetics, to implantable prosthetics, then more invasively implanted devices like stimulators and cochlear implants. The asymptote, then is the surgery that is done without implanted technology, but consists of the realignment of bones and nerves, resection of tissue and the placement of suture. The blurred distinction between disability and non-disability and between environment and surgery then sets a fertile, non-binary context for the development of a more developed "curative impulse".
Tobin Siebers points out that embodiment is at once central to the field of Disability Studies but also "appears as a bone of contention in disability studies because it seems caught between competing models of disability." (Siebers, 25) On one hand, the medical model seems so imbued with embodiment that the social determinants of disability are ignored. On the other hand, the social model so emphasizes the disabling environment that it leaves out embodiment altogether. Siebers's theory of complex embodiment is put forth as a way for Disability Studies to acknowledge the necessarily embodied nature of disability, and for society to recognize and value disability "as an important form of human variation" (Siebers, 25).
In addition to suggesting a theory of complex embodiment, Siebers goes further to suggest that the medical and social models should not be thought of as static, but rather have the potential to be mutually transformative. Siebers draws from Iris Marion Young's work when looking at the mutually transformative nature of complex embodiment. In Young's, "On Female Body Experience: 'Throwing Like a Girl'", she makes the important claim that "throwing like a girl" is not based on any physical difference between girls and boys, but rather girls are "physically handicapped" because they "learn to live out our existence in accordance with the definition that patriarchal culture assigns us, we are physically inhibited, confined, positioned, and objectified" (Young 153). Young's point here is that situated knowledge and identity not only manifests from one perspective or another (here femaleness) but from the physical embodiment of the person. The social representation, then, influences the experience of the body. The theory of mutual transformation makes the claim that influence not only works this way, but flows the other direction as well: The body influences the social manifestation. In Siebers's view, this bidirectionality of determination gives people with disabilities "greater knowledge and control over their bodies in situations where increased knowledge and control are possible," broadens standpoint theory to allow a richer theory of intersectionality, and can free Disability Studies from the postmodern constraint of a pure social construction model (Siebers 27-30).
While Siebers' goal is to reintroduce necessary embodiment into the dominant social model of disability studies, this current project might be seen to approach complex embodiment from the opposite direction, bringing a necessary social transformation into the highly embodied surgical gestalt; taking the hyper-embodied view of disability in surgery and using concepts of universal design and notions of complex embodiment to open up to a practice of surgery that takes both embodiment and social determinants into account. Resisting binaries and embracing the social is one step in developing such a bi-directionality.
This work of Hamraie, Young, and Siebers who intend to trouble the purely social model of disability have a home and a laboratory in surgery, where the material is very present and the social as yet has gone largely unexamined. Surgery should proceed in several ways. First, funding should be sought to allow researchers in surgery to include patients who do not tend to the mean or fit in the routinely small number of broad demographic categories (e.g. "black", "female", "low income"). Second, textbook editors in surgery should invite surgeon authors with expertise in disability to write chapters regarding pre-, intra- and postoperative care of the disabled patient. Surgical trainees should be held accountable for this knowledge by certifying boards like the American Board of Surgery. Third, leaders in surgery should bring about a culture change that recognizes current injustices when it comes to disabled patients, and seeks to improve them. Fourth (to bring a concept from STS, which I sidestepped earlier) as Vasilis Galis has suggested more broadly, surgery must outgrow its position as an "institution of industrial modernity" (Gleeson, 2001, 254) and become a "hybrid forum" (Callon 2009) which can open spaces in which diverse groups (consisting, perhaps, of surgeons, politicians, patients and patients with disabilities) can become active in co-creating the future surgical gestalt along with traditional surgical scientists (Galis, 834-35). Finally, researchers should recognize intersectionality: that injustice can compound when a patient is not only disabled, but also part of an otherwise underserved or understudied group and that such patients deserve particular scrutiny. Such a project would not only make surgery better by including a focus on disabled patients, but open up the surgical gestalt to a more creative becoming and possibly even manifest the ideas of Hamraie, Young, and Siebers in an environment that includes a rethink of the curative impulse in surgery when it comes to disability.
In this paper, I have revealed a deep irony – on one hand surgeons are professional experts on disability and gain much of their mission from fixing disability. On the other, there is a gap in the gestalt where there ought to be a rich, formal knowledge about disability. This may result from the focus on disability as something totally embodied – as a physical defect that leads to impairment that, when "fixed," can lead to a more full and complete existence. This incommensurate state does not naturally resolve. Wendell's observation that social and cultural change may not be able to benefit all people with disabilities seems to leave room for the possibility that something can be gained by addressing the impairment itself.
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