LINDA C.

GARRO
Department of Anthropology
University of California at Los Angeles

On the Rationality of Decision-Making Studies:

Part 1: Decision Models of Treatment Choice

With reference to both critiques and empirical studies, the theoretical and
methodological grounding of anthropological research on medical decision
making is examined in this article, giving particular attention to the con-
struction and evaluation ofcognitively oriented decision models. A decision-
modeling study carried out in the Mexican village of Pichdtaro (in con-
junction with James C. Young) frames an exploration of some of the ten-
sions and points of contention about the aims and designs of cognitively
oriented studies of decision modeling. While a decision model can provide a
reasonably good guide to an understanding of treatment actions and the
culturally based rationality that underlies them, such models fall short when
they are oriented primarily around predicting treatment accounts. They
should also attend to the jointly cultural, personal, social, and cognitive
constructive processes through which meaning is conferred upon the oc-
currence of illness, [care seeking, decision models, decision making, Mexico]

S tudies of decision making in real-world settings provide an arena for address-

ing the question: Why do people do what they do? Cognitive theories pro-
vide the conceptual backdrop for many, though not all, decision-making
studies. For cognitively oriented ethnographic studies, a frequent starting assump-
tion is that in recurring decision situations where alternative courses of possible ac-
tion exist, members of a group come to have shared understandings, a common set
of standards concerning how such choices are made (Goodenough 1963:265-270;
Quinn 1978; Young and Garro 1994). Applied to the study of illness, cognitive-eth-
nographic studies of medical decision making seek to understand what people do
when faced with illness and typically attempt to account for actions taken to deal
with illness. To gain insight into the relationship between cultural knowledge and
specific treatment actions, careful consideration is given to how people talk about
treatment decisions. Such studies attend to the nature of cultural knowledge
brought to the occurrence of illness, how this knowledge is applied in evaluating
illness, and the process whereby decisions about treatment are made.

Medical Anthropology Quarterly 12(3): 319-340. Copyright © 1998 American Anthropological Association.

319
320 MEDICAL ANTHROPOLOGY QUARTERLY

While not all decision-making studies are cognitively oriented, it is also the
case that not all decision-making studies are overtly concerned with developing
and testing decision models (e.g., Kayser-Jones 1995; Nardi 1983; Sargent 1982,
1989). A common decision-modeling strategy is to build a decision model using
interview data and other information obtained primarily from one sample and then
to validate the model using decisions made by a second, independent sample. In
this article, reference to a decision-making approach or decision-making perspec-
tive refers to an inclusive higher-level category, with a "decision model"—the
more formal representation of the decision-making process that can be evaluated
using actual choices—as a subcategory.
An alternate subtitle for this article is "Pichataro Revisited." Although the ar-
ticle reflects my current thinking, it draws on findings of an earlier decision-mak-
ing study carried out (in conjunction with James C. Young) in Pichataro, a Mexi-
can town where both Purepecha (Tarascan) and Spanish are commonly spoken
(see J. C. Young 1981; Young and Garro 1994).1 This cognitively oriented study
implemented the two-pronged research design described in the preceding para-
graph, separating the data used to construct the decision model from the illness
case histories used to evaluate the model. The Pichataro study provides a base for
exploring the theoretical grounding of decision-making and decision-modeling
studies. The review of relevant literature presented in this article is necessarily se-
lective, but serves to highlight themes and points of debate. An objective is to fur-
ther a discussion of the merits and the limitations of decision-making studies, espe-
cially those that are explicitly cognitive in orientation. To what extent do such
studies open onto an understanding of the rationality involved in making decisions
in a given cultural context?
Some time ago H. Gladwin and Murtaugh observed that "natural decision-
making researchers have various goals" (1984:115). Stating that their primary ob-
jective is to predict behavior to "be useful for policymaking," they note that other
researchers have different goals with some being "interested in finding out the gen-
eral heuristics and procedures widely used in a culture and across cultures to make
decisions" (1984:115). While they regard this objective as "a crucially important
task for cognitive anthropology," it is "somewhat separate" from the concerns that
motivate their work (1984:115). Others see cognition and policy as intertwined,
but they discemibly foreground the policy implications. For example, C. Gladwin
declares that "the goal of decision studies" is to "model how people make real-
world decisions and to identify the specific decision criteria used by most individu-
als in a group in order that policymakers might intervene in the decision-making
process with new policies designed to make things better for the targeted group"
(1989:86). Recent medical anthropological studies that emphasize an applied pol-
icy orientation include Ryan and Martinez (1996) and Bauer and Wright (1996). I
do not review these primarily policy-oriented decision-making studies in this arti-
cle. I focus more specifically on writings that address issues relating to the role of
cognitive theory.
The outline for the remainder of this article is as follows: the first section pre-
sents some broadly based critiques leveled at the theoretical underpinnings of
anthropological studies of care seeking and, at a general level, decision-making ap-
proaches. The second section is a brief overview of theoretical perspectives on de-
cision making, both within and outside anthropology. Both sections highlight
PART 1: DHCISION MODELS OF TREATMENT CHOICE 321

some of the diverse ways scholars think about rationality and decision making,
though it is beyond the scope of this article to delve too deeply into these matters.
Nevertheless, the material covered in these two sections show how the idea of ra-
tionality is "ambiguous," "slippery," and "subject to multiple definitions" (Shore
1996:168-169). A brief sketch of the Pichataro study is presented next, providing a
backdrop for examining some of the tensions and points of contention about the
aims and design of cognitively oriented studies of decision making. Following the
lead of Mathews (1987), the discussion highlights the "framing" of decision situ-
ations as integral to the process of decision making. The companion piece to this
article (Part 2: Divergent Rationalities) explores these issues further in relation to a
study of health care decision making carried out in an Anishinaabe community in
Manitoba, Canada.

Anthropological Critiques of Studies of Care Seeking and Decision Making

The Pichataro study focused on "individuals as purposive actors and rational
decision makers" (Young and Garro 1994:3). Here, rational is used in a manner
similar to that of Quinn (1978:219). Writing about marketing decisions of Mfantse
fish sellers, Quinn states that "such decisions tend to be 'rational,' in the everyday
sense that they are closely considered rather than whimsical or precipitate." By at-
tending to these considerations from the perspective of those who make the deci-
sions, the Pichataro study sought to provide insight into the culturally based ration-
ality underlying treatment actions.
For some commentators, the primacy assigned to individuals and to the con-
cept of "choice" or "option" is problematic because it intimates that "decisions"
are essentially personal and volitional. They argue that the study of decision mak-
ing diverts attention from the influence of the broader political economy, historical
context, and objective social order in constraining treatment actions and giving
form to sources of treatment (Brodwin 1996; Good 1994; A. Young 1981). Al-
though the specific studies targeted remain somewhat ambiguous, Good expresses
concern about the "analytic primacy of the rational, value-maximizing individual"
(1994:39), and asks "why individual decision makers, guided by their personal be-
liefs, are so often the primary focus of investigation and analysis" (1994:47). Good
notes that "decision theories often make empirically false assumptions about the
freedom of individuals to make voluntary decisions, thus reducing attention to
overwhelming social constraints. As a result, decision model research may repro-
duce our conventional, ideologically-grounded understandings of individuals as
rational and voluntaristic actors (cf. A. Young 1980)" (1986:164).
The language of "choice" is also seen to impart a "neutral" or "utilitarian"
stance that seemingly disregards the moral and emotional grounding of illness and
may be inadequate to convey what is at stake in treatment (Brodwin 1996:179). In
characterizing a spectrum of theoretical positions, Kirmayer refers to the domi-
nance of "hyperrationalism," which "minimizes the way that emotions compel
thought, action and emotion" (1992:323-324).
Further, Good (1994:46-47) points to troubling parallels between the anthro-
pological literature on care seeking and Sahlins's (1976) depiction of "subjective
utilitarianism," a variant of a mode of thought that Sahlins refers to as "practical
reason." Concerned with "the purposeful activity of individuals in pursuit of their
322 MEDICAL ANTHROPOLOGY QUARTERLY

own interests and their own satisfactions" and presupposing a "universal Eco-
nomic Man," the role relegated to culture is to provide a "relativized set of prefer-
ences" (Sahlins 1976:102). Consequently, only "the actors (and their interests
taken a priori as theirs) are real" (1976:102); culture "is reduced to an epipheno-
menon of purposeful 'decision-making processes' (as they say)" (1976:86). Al-
though it is never quite clear whether Good's appraisal is intended to encompass
the Pichataro study or not,2 he notes that "utilitarian assumptions often appear in
the common-sense reasoning" in the literature on care seeking (Good 1994:47; see
also 1994:180-181 and Brodwin 1997:82-83). Good goes on to state: "The ana-
lytic conjunction of the utilitarian actor, instrumental beliefs that organize the ra-
tional calculus of care-seeking, and ethnomedical systems as the sum of strategic
actions is uncomfortably consonant with neo-classical economic theories of the
utilitarian actor, the market place, and the economic system as precipitate of value-
maximizing strategies" (1994:47). By suggesting points of correspondence, Good
challenges anthropologists studying care seeking to examine the extent to which
their assumptions and objectives, both implicit and explicit, formulate culture as
"practical reason."
Through their portrayals, other scholars raise objections to the assumed cog-
nitive underpinnings of some anthropological accounts of care seeking and deci-
sion making. Brodwin, for example, notes that his own study "does not isolate
health-seeking as a set of rule-bound observable actions" (1996:191). He situates
his work "away from the utilitarian and cognitive frameworks used by many an-
thropologists to study people's use of medical services in developing countries
(e.g., Sargent 1989; Young and Garro 1982)," frameworks that he says are geared
to portraying "the decision-making calculus that individual care-seekers may fol-
low" (Brodwin 1997:82-83). Writing about "the recent cognitivist shift in the hu-
man sciences," Bibeau depicts the "dominant mechanistic view" as one whereby
"human beings are predominately shaped by 'cognitive blueprints' stored in the
brain in the form of mental maps, scripts, frames, and scenarios that shape actions
of individuals along predetermined lines," which "scientists can leam to 'read' in
order to predict actual behaviors of individuals" (1997:250). As reality is far more
complex than such a view allows, Bibeau urges anthropologists to counteract this
trend by concentrating on the "social grounding of meaning" as revealed by "ac-
tions, interactions, and practices" (1997:250).
Luhrmann observes that the assumption that "people have a coherent clear-
cut set of beliefs" often underlies talk of "rationality" (1989:321; cf. Kirmayer
1992; A. Young 1981, 1982). A corollary assumption is that "people act on their
beliefs, that beliefs are prior to action" (Luhrmann 1989:321; see also A. Young
1981, 1982). Complementing Bibeau's comments about "cognitive blueprints,"
Kirmayer elaborates:

The rhetoric of rationality promotes a naive view of conceptual representations as

propositions directly accessible to consciousness. This allows us the fiction that
people can, quite reasonably, tell us their beliefs. Rationality then inheres in the
logical consistency or coherence of beliefs and in the consistent entailment of our
actions by our beliefs. Western academic psychology is founded on a similar as-
sumption of rationality: states of minds can be correlated with behavior only if we
assume a coherent and stable set of production rules by which intention and belief
are translated into action (Heil 19*86). [1992:330]
PART 1: DECISION MODELS OF TREATMENT CHOICE 323

In opposition to this view, Luhrmann and Kirmayer contend that "beliefs are not
fixed or consistent, for they are often presented to justify some action" (Luhrmann
1989:353; see also Kirmayer 1992:330). Although it is unclear whether verbal dis-
course is to be considered a form of action, Bibeau pushes for the "recognition that
behavior precedes belief, that cultural beliefs are revealed by actions, and that the
belief/behavior relation must be inverted" (1997:250).3 Writing from a different
perspective and research agenda, Boster cautions that much of what researchers
identify as influencing choices may instead be "post hoc rationalizations" (1984:387;
for similar admonitions see Good 1986:166-167 and Bloch 1998:25).
In this article, as well as in its companion, I argue for a view of human cogni-
tion that is both flexible and grounded in social and cultural processes. First, with
reference to the preceding discussion about "subjective utilitarianism," and with
the elusive concept of "rationality" again front and center, I establish that some of
the concerns raised above are more closely associated with normative approaches
to decision making than with the more descriptive approach typically adopted by
anthropologists. The general thrust of the position developed here is that while
there is definitely a pragmatic cast to health care decisions, a decision-making ap-
proach does not necessarily entail a formulation of culture as "practical reason"
grounded in a "utilitarian calculus" in the way that the writings of Good (1994) and
Brodwin (1997:73, 82) suggest.
Theoretical Perspectives on Decision Making
Aspiring to construct theories that will account for all types of choice-making
behavior and traversing diverse fields—including economics, psychology, and ad-
ministrative studies—the literature on decision making is voluminous and intri-
cate. At a very general level, a distinction is often drawn between normative and
descriptive models. As Abelson and Levi explain,
decision models can be oriented toward either how people should choose (norma-
tive models) or how they do choose (descriptive models). When a disparity be-
tween the two exists, it raises issues of human rationality. [ 1985:232]
Normative decision models are prescriptive, structuring decision problems in
terms of probabilities and utilities to reach an optimal decision (i.e., one that maxi-
mizes benefits and minimizes losses or costs). The systematic evaluation of alter-
natives for reaching an optimal decision is seen as a rational process; indeed, it is
seen to represent how one ought to reason. Rationality is thus presumed, with de-
faults leading to the question of "why do people not behave rationally?" (Abelson
1976:61). The normative model, postulating a "universal Economic Man" (and an
internal "rational calculus"), comes closest to the "subjective utilitarianism" posi-
tion put forward by Sahlins. Still, explicitly normative models have not garnered
much support from medical anthropologists (though see Fabrega 1973,1974).
Descriptive decision theorists claim that models of the normative type are not
psychologically plausible, as inferences about underlying mental processes, be-
cause they attribute unrealistic information-processing capabilities to the decision
maker (Quinn 1978; Tversky 1972; Tversky and Kahneman 1974). The normative
"rational" decision process is simply an "idealization that isn't there" (Abelson
1976:61). These theorists argue that instead of probability estimations, complex
decisions are made by relying on procedures that simplify the kinds of cognitive
324 MEDICAL ANTHROPOLOGY QUARTERLY

operations required. Instead of producing prescriptive models of how decisions

might be made on the basis of complex utility calculations, the focus is on discov-
ering how decisions are actually made, on understanding the reasoning process.
Because of simplifying procedures or heuristics, the actual choices made are often
different from those predicted by normative models (Fjellman 1976; Nisbett and
Ross 1980; Simon 1957). A long-standing and influential perspective is Simon's
proposal of "bounded rationality" in which the decision maker constructs

a simplified model of the situation in order to deal with it. He behaves rationally
with respect to this model, and such behavior is not even approximately optimal
with respect to the real world. To predict his behavior we must understand the way
in which this simplified model is constructed, and its construction will certainly be
related to his psychological properties as a perceiving, thinking and learning indi-
vidual. [1957:199]

Although omitted from Simon's formulation and from most other nonanthro-
pological accounts of decision making, it can be added that such a "simplified
model of the situation" is culturally grounded, as cultural understandings or cul-
tural models frame our understanding of how the world works (Quinn and Holland
1987; see Fjellman 1976:88-89).4 Because they emphasize describing or repre-
senting the culturally grounded decision-making process, anthropological ac-
counts are not overtly concerned with academic controversies about "apparently ir-
rational beliefs" (see Sperber 1982, 1985: ch. 2) as evidenced by the sustained
"rationality debate" (e.g., see discussion in Good 1994:10-14 and Shore 1996). If,
for example, affliction attributed to witchcraft is seen to require a specific form of
treatment, this connection can be incorporated in a decision model or other depic-
tion of the decision-making process. Descriptive decision approaches do not deny
"cultural reason" (Sahlins 1976:170).
Another avenue of inquiry among descriptive decision theorists concerns
how the formulation or framing of a decision situation affects choices made. Psy-
chological experiments demonstrate that different ways of framing the same situ-
ation lead to different decisions (e.g., Tversky and Kahneman 1981). The general
conclusion of these experiments is that "even the most elementary normative prin-
ciples cannot be taken as descriptively valid" (McNeil et al. 1988:567). Although
debates about the nature of human rationality are not absent (see Abelson and Levi
1985:232-235), the general aim of descriptive decision theory is to understand the
reasoning process and not to assess whether reasoning occurs in the right way (see
Stein 1996:17-18).
The oppositional pairing of rationality against irrationality and of reason
against emotion have long structured discussions of human cognition and behav-
ior. Nevertheless, a growing contingent of scholars view emotion as integral to
cognitive processes. Damasio, a neurologist interested in the biological underpinnings
of reason and decision making, maintains that "certain aspects of the process of
emotion and feeling are indispensable for rationality" (1994:xiii). He reviews a di-
verse set of findings (including the psychological experiments on framing men-
tioned in the preceding paragraph) to support his assertion that "emotions and feel-
ings may not be intruders in the bastion of reason at all: they may be enmeshed in
its networks for worse and for better" (1994:xii). Within cognitive anthropology
the interdependence of cognition, emotion, and motivation is acknowledged in a
PART 1: DECISION MODELS OF TREATMENT CHOICE 325

recent definition of cognitive schemas as "learned internalized patterns of thought-

feeling that mediate both the interpretation of on-going experience and the recon-
struction of memories" (Strauss 1992.3).5 Other current work (e.g., the collection
of papers edited by D'Andrade and Strauss 1992) point to the motivational force of
schemas, and highlight the importance of cultural models or cultural schemas (re-
ferring to those cognitive schemas that are generally shared in a cultural setting) in
understanding why people do what they do. Such developing positions hold prom-
ise for studying decision making as a rational process, without dismissing emotion
and without pitting reason against emotion.
The observation that "choices" are not truly volitional and must be under-
stood in relation to historical, political, and economic forces does not mean that a
decision-making perspective is irrelevant.6 Even though what is articulated may
not touch on macrolevel factors, Sargent maintains,

it seems desirable to differentiate the issues of social forces impinging on indi-

viduals (and beyond their domain of awareness) and the decision-making process
in which the individual believes herself/himself to be engaged. That is, people op-
erate on the premise that they do have choices to make, and that they have bases on
which to make decisions. That they may be unaware of all factors comprehensible
to an external analyst does not negate the validity of studying the choice-making
process given the facts, beliefs and values in relation to which the individual acts.
[1982:12]

To the extent that a decision-making entity—whether it be the afflicted individual,

family member(s), or some form of "therapy managing group" (Janzen
1978)—perceives alternative courses of action, a decision-making approach has
the potential to provide insight relating what Goodenough (1964:11-12) has called
the "phenomenal" order, the observable, statistically describable pattern of events,
to the "ideational" order, the standards and principles people have in mind when
producing these events.
A decision-making approach may not be informative when the ensuing action
is an imposed one (see discussion in Good 1994:42-43), although it may be feasi-
ble in such instances to study the process of decision making from the perspective
of those imposing a particular course of action on someone else. While "informed
choice" and the dynamics of power in clinical care settings have generally not been
examined from a decision-making perspective, a study by Kayser-Jones (1995) on
treatment decisions of acute illness in nursing homes draws on the psychological
research on framing. She presents case studies showing how, in situations where
physicians and patients or their families have disparate goals, physicians work to
frame the decision problem relating to treatment or outcome in ways to persuade
family members to adopt goals congruent with those held by the physician.
Although descriptive accounts may be highly variable in form, all can be as-
sessed in terms of their compatibility with theories about psychological processes.
The extent to which a descriptive account accords with social processes and fits the
ethnographic context serves as additional grounds for evaluation. Challenges to such
accounts may be posed by issues raised in the preceding section, such as concerns
about "post hoc rationalizations" and the relationship between cognition and action
(the "belief/behavior" connection critiqued by Luhrmann, Kirmayer, and Bibeau).
326 MEDICAL ANTHROPOLOGY QUARTERLY

When a descriptive account is formalized in a decision model, the ability of

the model to predict independently collected choice data has been used to gauge
how well a model bridges the gap between the phenomenal and ideational orders.
For example, C. Gladwin characterizes hierarchical decision trees as "testable cog-
nitive models" (1989:13). She asserts that a highly predictive model is "assumed to
be an adequate model of the individual decision process for that group of individu-
als" (1989:16, 49).7 While Gladwin's stance is stronger than most, an implicit
premise in a number of studies is that if a decision model, constructed with the aim
of representing the perspective of those actually making decisions, does a good job
of predicting outcomes, it also provides insight into how people actually make
choices. Using the Pichataro study to provide the empirical context, this presumed
connection between prediction and explanation is explored below.

Understanding Treatment Decision Making in Pichataro

Pichataro, with a population of nearly three thousand people, is located in the
highlands of the west-central Mexican state of Michoacan, about 30 kilometers
from the regional market and administrative center of Patzcuaro. Pichatarenos are
primarily maize farmers, with fruit growing, resin collecting, some craft produc-
tion, and temporary migrant wage labor as secondary occupations. Most adults
speak Spanish and Purepecha (Tarascan), although the use of Purepecha among the
young is declining.
At the time of the field research (1975-77), families in Pichataro generally
viewed as available four principal treatment alternatives: (1) home-treatments such
as herbal remedies, locally sold commercial remedies, and dietary avoidances; (2)
treatment by folk curers (curanderas), who used remedios caseros (herbal reme-
dies and other folk curing methods) exclusively;8 (3) treatment by practicantes (lo-
cal unlicenced practitioners of biomedicine who claim varying amounts of infor-
mal or formal medical training) who dispensed a variety of remedios medicos
(typically prescription-type medications); and (4) treatment by a physician. Since
there was no physician in Pichataro, consultations most often took place in
Patzcuaro with private practitioners or at a government-run health center. These
four treatment alternatives contrast significantly in cost. Self-treatment cost little
or nothing; treatment by a physician could amount to a substantial proportion of a
household's resources. For almost everyone, treatment by a physician represented
a heavy financial burden. Curanderas and practicantes were approximately equal
in cost and within the means of most families. While self-treatment was the least
expensive alternative, it was also seen as the least likely to bring about a cure. In
general, physicians' treatments were considered the most likely to succeed, but
there was widespread agreement that for most illnesses either remedios caseros or
remedios medicos can be effective. Many illnesses were understood to result from
the effect of different forces that altered bodily equilibrium. Both remedios caseros
and remedios medicos were seen to rectify disordered bodily states or processes.
Only a few illnesses such as "evil eye" (mal de ojo), "fallen fontanelle" (mol-
lera caida), and witchcraft-related illnesses were considered incurable with re-
medios medicos. The first two could be treated by local curanderas or at home; ill-
ness attributed to witchcraft may be taken to another type of specialist referred to
as "witches" (brujos), who tended to charge extremely high fees for their services.
PART 1: DECISION MODELS OF TREATMENT CHOICE 327

These illnesses were diagnosed relatively infrequently. Less than 10 percent of the
case histories we collected were considered curable only by remedios caseros. In
addition, such a diagnosis was usually not the first diagnosis made.
The study of treatment decision making in Pichataro consists of two main
parts. The first part centers on understanding what people do when confronting ill-
ness in order to construct the decision model, the second on evaluating the decision
model using illness histories recorded during a series of visits to a sample of families.
As the basis for building the decision model, we attempted to understand the
nature of the knowledge that individuals bring to the occurrence of illness, how this
knowledge is used to make sense of illness, and the process of making treatment
decisions. The fieldwork yielded opportunities to observe how illness episodes un-
fold, serving to enrich, corroborate, and challenge our evolving understandings
and hypotheses about what people do when faced with illness. Informal talks and
interviews were also important sources of information.
In addition, a number of structured interview approaches were employed. We
designed several interview formats to explore cultural knowledge about illness and
its treatment. These included a "term-frame" interview, which systematically
paired illnesses and propositions, and ranking tasks, which explored assessments
of faith in different treatment alternatives for a set of illnesses and judgments of se-
verity for separate sets of illnesses and symptoms. Other interviews were designed
to learn about patterns of care seeking, such as through contrastive questioning
about treatment alternatives, the posing of hypothetical illness situations, and re-
cording family-based case histories of past illnesses.
To minimize the potential for post hoc rationalization of choices, Boster ad-
vises ethnographers to "elicit informants' evaluations of alternatives indepen-
dently of a particular decision situation" (1984:347). The comments and qualita-
tive judgments put forward in the structured interviews (and obtained apart from
actual illness cases) represent a source of information consistent with Boster's ad-
vice. There was considerable convergence among the multiple sources of informa-
tion used in constructing the decision model. While verbal statements about illness
and treatment actions are the underpinning of the model, the resulting repre-
sentation is not simply a distillation of what we were explicitly told. No one told us
"this is how we decide what to do when someone is ill." Rather, the two strategies
underlying the decision model are theoretical inferences, and the decision model it-
self is a formal representation of these strategies which also incorporates con-
straints on choice.
Across a variety of settings, four criteria consistently came up as important
considerations in the choice of treatment: (1) gravity of the illness; (2) whether an
appropriate home remedy is known for the illness; (3)/e (faith or confidence) in the
effectiveness of remedios caseros or remedios medicos for a given illness; and (4)
expense of treatment and the availability of resources.
The decision-making process in Pichataro can be understood with reference
to two basic strategies or general principles which relate these four criteria to ex-
pected orderings in the use of the treatment alternatives. When an illness is not seri-
ous, the general pattern is "cost-ordered," starting with alternatives that are less
costly, and turning to the most expensive alternative, usually the physician, only as
a last resort after the less costly options have been exhausted. The pattern is to try
self-treatment first, unless an appropriate home remedy is not known. If no home
328 MEDICAL ANTHROPOLOGY QUARTERLY

remedy is known, or if illness continues despite home-based treatment, a curandera

or practicante may be consulted. Which one of these is consulted in a given situ-
ation depends on the "faith" one has in remedios caseros or remedios medicos for
the specific illness at hand. How an illness is understood is not fixed; faith assess-
ments may switch from remedios caseros to remedios medicos, or vice versa, often
in response to variable outcomes of different attempts at treatment.
The second strategy, based on "probability of cure" assessments, applies
when illness is considered serious. This strategy favored treatments most likely to
result in a cure; cost is a less important consideration. In most, but not all cases, the
favored alternative is care by a physician. In such instances it is expected that other
alternatives, such as a curandera, would be tried only after recourse to physicians is
unsuccessful.
Of course, as prototypical patterns, exceptions to these two general strategies
are expected, especially when the means are not available to realize a preferred
choice. For example, when a serious illness occurs in a household with scarce eco-
nomic resources, even though the preferred alternative would be the one with the
highest likelihood of cure, economic limitations constrain choices to lower cost al-
ternatives, thereby approximating a cost-ordered sequence. Overall, the most com-
mon constraint on resort to physicians is the perceived inaccessibility of treatment
(e.g., lack of money and/or lack of transportation).
The decision model is a formal statement of these strategies and constraints,
which are represented as a set of rules that specify the combination of considera-
tions that lead to people's decisions to use particular treatment alternatives. These
decision rules should not be viewed as reified constructs in people's heads that de-
termine individual actions, nor should they be seen to presuppose some form of lin-
ear processing or cost-benefit calculus. They are best viewed as a set of hypotheses
for predicting treatment outcomes that can be tested against actual decisions.
While a successful decision model anticipates choices, it is unlikely to anticipate
all choices; there will be some idiosyncratic variability with illness episodes that
do not fit the model. Nor will the model address all events. For example, in this set
of decision rules, resort to a brujo for suspected witchcraft-related illness does not
form part of the decision model. (Although a discussion of how witchcraft comes
to be suspected in cases that defy treatment forms part of the ethnographic ground-
ing, which in turn forms part of the decision-making study.) This omission is not
because such instances do not occur, but because they are so infrequent that the in-
formation needed to incorporate relevant hypotheses in the decision model and to
evaluate them just is not available. (No contemporary cases were collected during
the household visits.) Like other models, a decision model is a simplified repre-
sentation of what happens in the world. In constructing a model, the task is to
account for as many decisions as possible and at the same time strive for parsimony
(see C. Gladwin 1989).
In summary, the decision-making process depicted is one that relies upon cul-
tural and personal knowledge to assess and follow developments in an illness situ-
ation. The course of action adopted, although it may be shaped by real-world con-
straints, reflects these assessments, and the possibility that they, and hence
decisions, may change through time. Verbally elicited information formed the ba-
sis of our understanding of this process, including the decision criteria and the two
strategies portraying their interrelationships. The form of rationality is portrayed as
PART I: DECISION MODELS OF TREATMENT CHOICE 329

pragmatically oriented, but human action is understood "as mediated by the cul-
tural design, which gives order at once to practical experience, customary practice,
and the relationship between the two" (Sahlins 1976:55).

Evaluating the Decision Model

We evaluated the decision model by using illness case histories from an inde-
pendent, randomly selected, sample of households, which was distinct from those
participating in the interviews used to construct the decision model. The 62 case-
collection households were visited approximately every two weeks for a six-month
period. At each visit, we recorded detailed case histories of each illness reported by
members of the household since the time of the last visit.
It is this stage, with the illness case histories used to test the decision model,
where concerns about post hoc rationalizations are most salient. This is not just an
issue for studies of decision making; the potential for the reporting of details to be
reconstructed in such a way as to fit the action taken exists whenever an approach
relies on any type of retrospective assessment, including statistical analyses (e.g.,
judgments of illness severity, diagnoses, and etiological interpretations may be ob-
tained retrospectively [see Weller et al. 1997]), "explanatory model" type ap-
proaches (Good 1986), and the construction of illness narratives (Garro 1994). Al-
though the degree of reliance varies, retrospective information is rather ubiquitous
in the medical anthropological literature, even when the research plan is to closely
follow illness episodes through time.
To date, studies of treatment seeking have not been designed to follow illness
episodes prospectively. Given the practical difficulties of carrying out prospective
studies, it is unlikely that a large number of cases could be followed in a truly pro-
spective manner. In Pichataro, visiting families at fairly regular intervals over an
extended period meant that while some accounts were retrospective, others con-
cerned ongoing illness. In all visits, detailed information about each illness was re-
corded on a day-to-day basis. Our questions aimed to elicit as much information as
possible about the choice of treatment, actions taken to deal with illness, the situation
leading up to the use of a given treatment rather than another, and, in cases of ongoing
illness, other treatments that were being considered in the event the illness continued.
Supplementary data provided another source apart from what was obtained in
actual choice situations and may go some way in addressing concerns about post
hoc rationalizations. For example, in appraising the seriousness of an illness, infor-
mation obtained about a specific case was related to generally shared under-
standings distinguishing three levels of gravity (based on a ranking task judging
the severity of a set of illnesses and symptoms). Relative wealth rankings of the
case-collection households served as an independent criterion of the availability of
economic means (see discussion in Young and Garro 1994:163). For families be-
low the median wealth rank, resort to a physician was scored as an error when
evaluating the decision model unless less costly practitioners were consulted first.
Some of the supplementary information came from the case-collection households
themselves. Brief summaries of illnesses occurring prior to the case-collection pe-
riod were elicited from each family. When similar illnesses were recorded during a
scheduled visit, these summaries provided a basis—separate from what was ob-
tained as part of the case-collection procedures—for assessing preexisting knowledge
330 MEDICAL ANTHROPOLOGY QUARTERLY

of a home remedy and "faith" in treatment for the illness at a household level. Bias
potentially introduced through reliance on these procedures would be in the direc-
tion of indicating the model as failing to account for a given choice, rather than in
the direction of overstating its success rate.
The decision model successfully predicted a high proportion of both initial
and subsequent treatment choices, approximately 90 percent of all treatment ac-
tions. Even when initial home treatments, which represent "a largely routine initial
response to treatment," were excluded from the calculations, the prediction rate is
still more than 80 percent. It was assumed that what remained after excluding in-
itial home treatment involved "active decision making" (Young and Garro
1994:166). These prediction results were interpreted as providing "strong evidence
for the basic validity of the model, and for the contention that the considerations
and assumptions embodied in it represent important aspects of how people actually
make these choices" (Young and Garro 1994:166).9 We also underscored the need for
additional research on "the cognitive bases of the treatment decision-making process,"
in particular on "the dynamics of the faith concept" (Young and Garro 1994:180).

Constructive Processes and Research on Treatment Actions

Although not highlighted in the decision model, the illness cases collected
from households in Pichataro draw attention to constructive processes that illumi-
nate how illness and care seeking are socially and culturally embedded.10 As evi-
denced by a number of illness episodes followed in the case-collection households,
the way an illness is understood may change through time. For example, a child's
illness described simply as diarrea (diarrhea) and treated at home in an initial visit
may come to be seen as an instance of evil eye, successfully treated by a folk
healer, by the time of the next visit. There is considerable variation in the implica-
tions that a proposed diagnosis or interpretation has for the treatment that will be
sought (cf. Abelson and Levi 1985:272). Diagnoses or interpretations may change in
response to variable outcomes of different attempts at treatment (cf. Brodwin 1996).
Assessments about individual illness episodes are integral to the proposed ac-
count of treatment choice for Pichataro. This includes, for example, judgments
concerning the potential effectiveness of remedios medicos versus remedios case-
ros for a specific illness case ("faith" judgments). Evaluations associated with an
illness episode—such as the potential effectiveness of treatment, probable diagno-
sis, cause, and severity—are neither fixed nor defined independent of culture.
Rather, they are emergent and often shifting, reflecting a dynamic process involving
the ongoing application of cultural and personal knowledge. While it is possible to
elicit cultural knowledge about illness and treatment apart from illness episodes,
conferring meaning on and/or assessing actual instantiations of illness depends on
schema-based constructive processes: those "learned internalized patterns of
thought-feeling that mediate both the interpretation of ongoing experience and the
reconstruction of memories" (Strauss 1992:3)." In "coping with familiar yet ever
novel situations" (Bloch 1998:10), there is an "effort after meaning" (Bartlett
1932:44), grounded in schema-based constructive processes. As processes sche-
mas are not static, they actively incorporate incoming information and are modi-
fied by new experiences. Thus schemas are less like "cognitive blueprints" than
cognitive tools that people use to make sense of experience. Schemas serve as
PART 1: DECISION MODELS OF TREATMENT CHOICE 331

guides to actions, guides that may be modified by new experiences. Concepts and
experience, knowledge and action, are complexly interdependent (Luhrmann
1989:353).
In addition, as perhaps first discussed in Frake's (1961) study on the diagnosis
of "skin diseases" among the Subanun, the evaluation of illness may become a "so-
cial activity" that involves negotiating the relevance of culturally shared knowl-
edge about illness and treatment to particular cases (cf. Chrisman 1977). In
Pichataro, speculating about diagnosis, possible cause, and appropriate treatment,
was common. Cultural knowledge serves as a resource, but there are often multiple
explanatory frameworks that may be culturally and/or personally applicable to a
given situation. Further, while theories of decision making are based on the ideal of
an individual decision maker, actual decision making may be grounded in a social
unit(cf.Mathewsl987).
Even though the outcomes of these social and constructive processes are cen-
tral in evaluating the decision model for Pichataro, these processes are themselves
accorded scant attention in the representation of the decision-making process. In-
stead, the focus is on discovering strategies hypothesized to underlie decision mak-
ing and on relating these strategies to treatment actions. As described in the follow-
ing section, some cognitive anthropologists suggest that decision-making studies
rely too much on predicting outcomes and too little on understanding the underly-
ing cognitive process.

Prediction and Understanding in Decision Models

Nardi (1983) and Mathews (1987) are critical of what they perceive as the
tendency for research problems such as decision making to be defined "as nar-
rowly bounded, discrete problem-solving tasks, rather than as problems of general
understanding" (Nardi 1983:697). Nardi finds that decision-making approaches
concentrate on the decision maker's evaluation of external factors (e.g., in medical
decision-making studies, the cost and accessibility of treatment alternatives). She
writes, "Entirely lacking are factors internal to the decision maker, such as his val-
ues, beliefs, aspirations, and ambitions" (1983:698; cf. Sargent 1989:23). Decision
models "emphasize prediction over understanding" (Mathews 1987:55) with the
decision-making process "treated as though it were confined to specifying and or-
dering a few well-defined criteria" when in fact it draws upon "variegated repre-
sentations of knowledge and several ways of utilizing them in the decision pro-
cess" (Nardi 1983:697). Nardi's study of reproductive decision making in Western
Samoa focuses on "discovering the overall scheme of knowledge brought to bear
in everyday problem solving and understanding" (1983:697).l2 Both Nardi and
Mathews (cf. Kayser-Jones 1995; Sargent 1982) emphasize the processual quality
of decision making and the importance of goals and scenarios (the envisioned con-
sequences of a course of action) in framing and working through decisions. Two
papers by Mathews (1982, 1987) are particularly relevant to a discussion of the
Pichataro study and are examined below.
In a book review of the Pichataro study, Mathews (1982) asks whether or not
an ability to predict treatment actions can be taken as evidence that an under-
standing of the cognitive decision process has been achieved. According to
Mathews, "Predicting the points at which people will make decisions based on
332 MEDICAL ANTHROPOLOGY QUARTERLY

assessments of cost or likelihood of cure, however, is not the same as under-

standing how they do so" (1982:177). Although she appears to reduce the interrela-
tionships among the four decision criteria in the proposed orderings for Pichataro
simply to issues of cost or likelihood of cure, Mathews does present an agenda for
additional cognitive research. She proposes that individuals rely on an array of
heuristics ("rules of thumb"), which simplify decision making. Only a few of these
heuristics can be discussed here; additional examples can be found in her review.
For instance, Mathews (1982:182) suggests that for many common and recurring
illnesses, especially at their beginning, people may automatically follow a well-es-
tablished sequence of treatment alternatives (e.g., start with a specific home rem-
edy and then go to a curandera, or start with a specific home remedy, then a differ-
ent specific home remedy and then go to a practicante) rather than make a decision
"on the basis of cost." (Again, this oversimplifies the cost-ordered sequence. Cost
is not the only factor considered in the model. Severity of illness and faith assess-
ments enter into decisions made after initial self-treatment, which as noted earlier
is a largely routine response to illness.) For Mathews, although such treatment ac-
tions may "bear a surface resemblance" to a cost-ordered sequence, the underlying
cognitive process is seen as different. Given that home treatment in Pichataro is
largely a routine initial response to illness, the question becomes to what extent do
more elaborate routine sequences occur. She also suggests that "knowing" a home
remedy may involve cognitive strategies such as drawing an analogy between a
current, distinctive condition and a previous illness. Further, heuristics may play a
role in faith assessments, such as the notion of fixed strategies for certain illnesses,
like evil eye in Pichataro.
There is clearly much to learn by adopting a more "descriptive approach" to
the cognitive processes associated with decision making, even when a model is
highly predictive. But this does not mean that the general principles embodied in
the decision model do not contribute to an understanding of the reasoning process.
Because Mathews (1982) is writing for a book review, she provides only a few ex-
amples to support her argument. Still, the quotations about routine sequences from
her Oaxacan research seem to reflect something like severity and faith assessments
after self-treatment (see p. 182). In the analogy described above that involves a
nonroutine condition, the judged nonseriousness of the illness and the aim to con-
serve scarce fiscal resources contribute to the likely use of home treatment. The de-
termination of a specific remedy by means of analogy can be seen as an additional
cognitive step (and one that the Pichataro decision model is not designed to ad-
dress). Both this example and the fixed strategy proposed for conditions like evil
eye still leave open other questions about the constructive processes highlighted at
the close of the preceding section, such as the processes through which such ill-
nesses are diagnosed or identified. As noted earlier, such diagnoses are usually not
the first to be under active consideration.
In the second paper, Mathews contends that in carrying out decision-making
studies, anthropologists have presumed "knowledge of the goal being pursued by
an informant" (i.e., that there is a "single, standardized goal being pursued by all
decision makers" such as "the goal of being cured") and set the research task as dis-
covering the "routine for selecting among alternative courses of action to realize
that goal" (1987:55). Mathews proposes that many conscious decisions involve an
interplay among multiple, possibly conflicting goals and potential future scenarios.
PART 1: DECISION MODELS OF TREATMENT CHOICE 333

She analyzes transcripts of two conversations in which family members reach de-
cisions about appointing auxiliary personnel for religious festivals in Oaxaca,
Mexico. Mathews's descriptive account points to the interrelationships among
various goals and how they are embedded in scenarios and appraised in reaching a
decision. Who the family members choose as auxiliary personnel "depends ulti-
mately on what they hope to accomplish by having a successful festival which, in
turn, depends on the goals determining their participation in religious service in the
first place" (1987:56). Families differ in assigning priority to one goal over another
in reaching a decision, although they may still try to partially satisfy the goal ac-
corded less priority. Mathews concludes,

Only by investigating how informants represent decisions and structure their solu-
tions can we begin to work toward the formulation of a general theory of human
understanding that will enable us to specify the ways in which individuals use cul-
tural knowledge and personal experience to generate, organize, and select among
goals for the purposes of making a decision. [1987:58].

I do not wish to argue at a general level against Mathews's position; her key
points are cogently presented. However, even though goals per se are not stipulated
in the explanation of treatment choice developed for Pichataro, I submit that they
are encompassed by the two general proposed orderings. Additionally, the goals
and their prioritization are implicit in the statements made by Pichatarefios from
which these orderings derive. Embedded in the two orderings are three goals: alle-
viating sickness, ensuring that a cure is achieved, and minimizing expenditures.
While treatment actions are motivated by the overarching goal of alleviating sick-
ness, the two remaining goals may come into conflict because treatment by a phy-
sician is, in most instances, the alternative judged most likely to achieve a cure and
also the most expensive; self-treatment is judged least likely to lead to a cure and
also the least expensive. Whether one or the other of these goals is prioritized over
the other depends on the severity of the illness. For nonserious illness, the cost-or-
dered strategy emphasizes conserving resources while still attempting to alleviate
the illness. When illness is serious, priority is placed on obtaining a cure. While
constraints on the realization of goals are not featured in the examples Mathews
provides, constraints definitely impact on goals for treatment choices in Pichataro.
Even if the objective of ensuring a cure is accorded priority at an ideational level,
constraints may lead to a situation where minimizing cost assumes greater salience
in determining the reported course of action at the phenomenal level.
I have gone into some detail about implicit goals in the explanation of treat-
ment choice for Pichataro because I want to suggest that Mathews's higher-level
insight about the lack of regard in decision-modeling studies for how individuals
"represent" or "frame" decisions is even more important than explicitly attending
to goals. As Tversky and Kahneman explain, it is "often possible to frame a given
decision problem in more than one way" (1981:453). But it is the framed situation,
and not the process of speculating or converging on a particular framing, that deci-
sion models are set up to handle. Decision models of treatment choice (e.g.,
Mathews and Hill 1990; Ryan and Martinez 1996; Young and Garro 1994) are ori-
ented around accounting for a series of treatment actions. But they generally treat
the framing of decisions either as unproblematic or as a given in constructing and
evaluating a decision model.
334 MEDICAL ANTHROPOLOGY QUARTERLY

As already mentioned, treatment by a physician is considered to be the most

probable source of successful treatment for most illnesses in Pichataro. But certain
illnesses—including evil eye, fallen fontanelle, and other conditions that are seen
as having emotion-based causes—are thought to be particularly amenable to treat-
ment using folk remedies (Garro 1986:363; though only the first two are generally
considered folk-treatment-only conditions). As these understandings are generally
shared, when Pichatarenos refer to an illness with a label such as bilis (bile, associ-
ated with strong emotions), what they are also tacitly conveying is that folk treat-
ment, either at home or by a curer, is an acceptable form of care. In terms of the de-
cision model, judgments that an instance of bilis is not serious, information about
whether a home remedy is known, and if not, information about how past instances
of a similarly framed decision problem were treated in the same household and/or
an evaluation of the effectiveness of folk treatment for illnesses of this type, con-
tribute to the prediction of what form of treatment will be used. The framing or la-
beling of the illness is a critical precondition. The earlier example of diarrhea,
which later comes to be understood as evil eye, supplies the decision model with
two divergent framings that ultimately lead to different treatment predictions for
the two points in time.
That the ability to account for treatment actions in Pichataro depends on so-
cial and cognitive constructive processes through which meaning is ascribed to ill-
ness does not diminish the study's contribution to an understanding of what
Pichatarenos do when faced with illness and why. In part this is because the deci-
sion model is situated in a larger decision-making study. The decision model does
not stand apart from shared cultural knowledge about illness and its care. The aims
were not just to predict treatment actions but to explore cultural knowledge about
illness and care and to understand general principles involved in applying cultural
and personal knowledge to specific instances of illness in relation to existing struc-
tural constraints. For Pichataro, it is the study taken as a whole that provides the
foundation for additional research along the lines that Mathews proposes.

Concluding Remarks
As a framework for exploring the relationship between the phenomenal and
ideational orders, I have brought forward a series of issues raised about decision-
making and decision-modeling studies in the anthropological literature. While a
number of these issues are complex and difficult to resolve, I have suggested some
ways of thinking about them and have emphasized the value of converging data.
With the Pichataro study as a backdrop, I have argued that a decision model can
provide a reasonably good guide to an understanding of treatment actions and the
culturally based rationality underlying such decisions. At the same time, I have
also stressed the need for greater attention to the jointly cultural, personal, social,
and cognitive constructive processes through which meaning is conferred on the
occurrence of illness. In line with the arguments put forward by Mathews (1987),
the position taken here is that decision models do not adequately explain how deci-
sion makers draw upon cultural and personal knowledge in framing decision prob-
lems and structuring their resolution. This is an area for future research.
One issue that has not been raised in this article is whether a decision model is
a general-purpose approach. In the following companion piece, I discuss my efforts
PART 1: DECISION MODELS OF TREATMENT CHOICE 335

to develop a decision model for an Anishinaabe community in Manitoba, Canada.

As in Pichataro, adopting a decision-making perspective as a means to understand
treatment choice was compatible with how individuals talked about actions taken
in response to illness and it proved to be a useful means for learning about the pro-
cess of seeking care. Yet what is learned about the decision-making process does
not support the subsequent steps of developing and testing a decision model. At the
heart of my argument is a claim that the assumptions and form of "rationality" con-
tained in the decision-model ing approach cannot accommodate all aspects of the
version of reality that often guides decisions in the Anishinaabe community.

NOTES

Acknowledgments. I thank Robert Whitmore for constructive feedback on earlier ver-

sions of this article. I also gratefully acknowledge the insightful and helpful comments of the
manuscript reviewers. The fieldwork in Pichataro was funded by a grant-in-aid from the
Wenner-Gren Foundation for Anthropological Research, and by Alcohol, Drug Abuse, and
Mental Health Administration National Research Service Awards Nos. 1-F31-MH-O55OO-
01 and 5-F31-MH-0O55OO-02 from the National Institute of Mental Health (all awarded to
James C. Young).
Correspondence may be addressed to the author at the Department of Anthropology,
University of California at Los Angeles, 405 Hilgard Ave. Box 951553, Los Angeles, Cali-
fornia 90095-1553.
1. The field research took place during twelve months' residence in Pichataro during
1975 to 1977 and during the summer of 1980. In the remainder of this article and the com-
panion piece, the most recent printing of the book will be cited (Young and Garro 1994). The
book, bearing the name of James Young, was first published by Rutgers University Press in
1981.1 often refer to this study using the name of the community, Pichataro.
2. In Good 1994 see the last paragraph on page 46 followed by the first full paragraph
on page 47; see also page 181 and footnote 21 on page 190.
3. Reading Bibeau brought to mind Spiro's (1987) views on the internalization of cul-
ture and its relation to behavior. According to Spiro, individuals may come to learn about,
understand, and believe cultural systems but "a cultural system may be said to be internal-
ized" only when it comes to "engage their minds and influence their action" (quoted in
Strauss 1992:36-37). This topic will berevisitedin Part 2, the companion article to this piece.
4. In the medical anthropological literature, an illustrative application of the "bounded
rationality" concept can be found in Finerman 1995.
5. The phrase "thought-feeling" comes from Wikan (e.g., Wikan 1989). Bartlett, a
psychologist, who is credited with introducing the concept of schema to cognitive theory,
also first highlighted the importance of affect to schematic processes (e.g., Bartlett
1932:206-207), although this insight has often been overlooked (see Garro n.d.).
6. A more explicit focus on political, economic, and historical considerations would
undoubtedly contribute to an understanding of treatment actions in Pichataro as well as in
other settings. But it does not supplant what can be learned through other approaches. For
example, in Pichataro there is significant variability in the use of different treatment alterna-
tives within families. Is it possible to explain why family members resort to different alterna-
tives at different times without recourse to cultural understandings? On a separate but related
issue, it is not the case that anthropological studies of decision making view the individual as
a completely free and unfettered decision maker. In the first place, it is only those alterna-
tives that members of a group view as possibilities that become incorporated in a decision-
making account. Further, a decision-making perspective is also concerned with perceived
constraints. For example, constraints, such as cost and accessibility in the decision model of
336 MEDICAL ANTHROPOLOGY QUARTERLY

treatment choice for Pich£taro (Young and Garro 1994), lead to the predictions of the cir-
cumstances under which a less preferred source of treatment is "selected."
7. Although she does not provide further elaboration for this point, it is a difficult one
to defend. In the case of Gladwin's proposed hierarchical decision structure, whether the in-
dividual-level cognitive process even approximately follows a hierarchical order is an open
question. It is one thing to state that "tree models use more realistic assumptions about indi-
viduals' cognitive capacities than do linear additive decision models" (Gladwin 1989:11),
and quite another to assert that the tree model captures cognitive processes at an individual
level.
8. The usage offolk follows the definition given by Press: " 'Folk medicine' should be
strictly limited to describing systems or practices of medicine based upon paradigms which
differ from those of a dominant medical system of the same community or society
(1980:48).
9. Here it should be noted that the implications of a highly predictive model are a bit
more modest than what Gladwin (1989) claims, especially in regard to representing cogni-
tive process.
10. Statistical modeling approaches have been proposed as alternatives to decision
modeling (e.g., Chibnik 1980). When applied to treatment decision making, however, one
significant limitation of prediction-oriented statistical models is that they do not adequately
capture the processual nature of illness and care seeking (Mechanic 1979; Weller et al.
1997:225-226). With the objective of discovering statistically significant patterns of asso-
ciation between the use of treatment alternatives and the independent variables examined,
such statistical models focus on a decision outcome and not a sequence of outcomes (see
Kroeger 1983; Stoner 1985 for reviews). A recent study by Weller et al. (1997) comparing a
multivariate modeling approach and a decision-modeling approach can be used to illustrate
this point. In describing the research situation, the authors write: "Seeking a cure for illness
on the Pacific Coast of Guatemala is a dynamic process and throughout the process, a series
of sources and treatments may be sought" (1997:231-232). Nonetheless, the analysis using
the two approaches, as well as their comparison, is confined to the prediction of the initial
treatment alternative used. Because subsequent treatment choices are not independent of
preceding actions, initial treatment actions are studied since these alone are amenable to sta-
tistical analysis. But a limited ability to predict an initial treatment action is incomplete as an
account of care seeking; the initial treatment used cannot stand for an illness episode. It is
also perhaps worth noting that except for dichotomous judgments of severity, none of the
variables in the multivariate modeling analysis pertain to how individuals confer meaning
on an occurrence of illness, nor is this a particular focus in the interviews used to build the
decision model. Whether multivariate models are able to deal with "ideational" aspects (e.g.,
"faith," etiological assessments), which have formed part of other decision models and are
often featured in descriptive anthropological accounts of care seeking in medically plural-
istic settings, remains an open question.
11. As schemas can have motivational force (D'Andrade and Strauss 1992), such a
view can accommodate Kirmayer's position that emotions "determine not what is logical to
do to achieve certain ends but what ends are most pressing in a given situation" (1992:330).
12. Nardi's use of the term model comes close to the concept of a cultural schema or
cultural model even though Nardi's paper predates the 1987 volume edited by Holland and
Quinn devoted to developing this concept.

REFERENCES CITED

Abelson, Robert P.
1976 Social Psychology's Rational Man. In Rationality and the Social Sciences. S. I.
Benn and G. W. Mortimore, eds. Pp. 58-89. London: Routledge and Kegan Paul.
PART 1: DECISION MODELS OF TREATMENT CHOICE 337

Abelson, Robert P., and Ariel Levi

1985 Decision Making and Decision Theory. In The Handbook of Social Psychology,
vol. 1. L. Gardener and E. Aronson, eds. Pp. 231-309. New York: Random House.
Bartlett, Frederic C.
1932 Remembering: A Study in Experimental and Social Psychology. Cambridge:
Cambridge University Press.
Bauer, Mark C, and Anne L. Wright
1996 Integrating Qualitative and Quantitative Methods to Model Infant Feeding Behav-
ior among Navajo Mothers. Human Organization 55:183-192.
Bibeau, Gilles
1997 At Work in the Fields of Public Health: The Abuse of Rationality. Medical An-
thropology Quarterly 11:246-252.
Bloch, Maurice
1998 How We Think They Think: Anthropological Approaches to Cognition, Memory,
and Literacy. Boulder, CO: Westview Press.
Boster, James S.
1984 Inferring Decision Making from Preferences and Behavior. An Analysis of
Aguaruna Jivaro Manioc Selection. Human Ecology 12:343-358.
Brodwin, Paul E.
1996 Medicine and Morality in Haiti: The Contest for Healing Power. Cambridge:
Cambridge University Press.
1997 Politics, Practical Logic, and Primary Health Care in Rural Haiti. Medical Anthro-
pology Quarterly 11:69-88.
Chibnik, Michael
1980 Working Out or Working In: The Choice between Wage Labor and Cash Crop-
ping in Rural Belize. American Ethnologist 7:86-105.
Chrisman,Noel
1977 The Health Seeking Process: An Approach to the Natural History of Illness. Cul-
ture Medicine and Psychiatry 1:351-377.
Damasio, Antonio R.
1994 Descartes' Error. Emotion, Reason, and the Human Brain. New York: Avon Books.
D'Andrade, Roy, and Claudia Strauss, eds.
1992 Human Motives and Cultural Models. Cambridge: Cambridge University Press.
Fabrega, Horacio F.
1973 Toward a Model of Illness Behavior. Medical Care 11:470-474.
1974 Disease and Social Behavior: An Interdisciplinary Perspective. Cambridge, MA:
MIT Press.
Finerman, Ruthbeth
1995 "Parental Incompetence" and "Selective Neglect": Blaming the Victim in Child
Survival. Social Science and Medicine 40:5-13.
Fjellman, Stephen M.
1976 Natural and Unnatural Decision-Making: A Critique of Decision Theory. Ethos
4:73-94.
Frake, Charles O.
1961 The Diagnosis of Disease among the Subanun of Mindanao. American Anthro-
pologist 63:113-132.
Garro, Linda C.
1986 Intracultural Variation in Folk Medical Knowledge: A Comparison between Cur-
ers and Non-Curers. American Anthropologist 88:351-370.
1994 Narrative Representations of Chronic Illness Experience: Cultural Models of Ill-
ness, Mind and Body in Stories Concerning the Temporomandibular Joint (TMJ). So-
cial Science and Medicine 38:775-788.
338 MEDICAL ANTHROPOLOGY QUARTERLY

N.d. The Remembered Past in a Culturally Meaningful Life: Remembering as Cultural,

Social and Cognitive Process, unpublished MS.
Gladwin, Christina
1989 Ethnographic Decision Tree Modeling. Newbury Park: Sage Publications.
Gladwin, Hugh, and Michael Murtaugh
1984 The Attentive-Preattentive Distinction in Agricultural Decision Making. In Agri-
cultural Decision Making: Anthropological Contributions to Rural Development.
Peggy F. Barlett, ed. Pp. 115-136. Orlando, FL: Academic Press.
Good, Byron
1986 Explanatory Models and Care-Seeking: A Critical Account. In Illness Behavior
A Multidisciplinary Model. S. McHugh and T.M. Vallis, eds. Pp. 161-188. New York:
Plenum.
1994 Medicine, Rationality, and Experience: An Anthropological Perspective. Cam-
bridge: Cambridge University Press.
Goodenough, Ward H.
1963 Cooperation in Change. New York: Russell Sage Foundation.
1964 Introduction. In Explorations in Cultural Anthropology. W. H. Goodenough, ed.
Pp. 1-24. New York: McGraw-Hill.
Heil, John
1986 Does Psychology Presuppose Rationality? Journal of the Theory of Social Behav-
ior 6:77-87.
Janzen, JohnM.
1978 The Quest for Therapy: Medical Pluralism in Lower Zaire. Berkeley: University
of California Press.
Kayser-Jones, Jeanie
1995 Decision Making in the Treatment of Acute Illness in Nursing Homes: Framing
the Decision Problem, Treatment Plan and Outcome. Medical Anthropology Quarterly
9:236-256.
Kirmayer, Laurence J.
1992 The Body's Insistence on Meaning: Metaphor as Presentation and Representation
in Illness Experience. Medical Anthropology Quarterly 6:323-346.
Kroeger, Axel
1983 Anthropological and Socio-Medical Health Care Research in Developing Coun-
tries. Social Science and Medicine 17:147-161.
Luhrmann,T. M.
1989 Persuasions of the Witch's Craft: Ritual Magic in Contemporary England. Cam-
bridge, MA: Harvard University Press.
Mathews, Holly F.
1982 Illness Classification and Treatment Choice: Decision Making in the Medical Do-
main. Reviews in Anthropology 9:171-186.
1987 Predicting Decision Outcomes: Have We Put the Cart before the Horse in Anthro-
pological Studies of Decision Making. Human Organization 46:54-61.
Mathews, Holly F., and Carole E. Hill
1990 Applying Cognitive Decision Theory to the Study of Regional Patterns of Illness
Treatment Choice. American Anthropologist 92:155-170.
McNeil, Barbara J., Stephen G. Pauker, and Amos Tversky
1988 On the Framing of Medical Decisions. In Decision Making: Descriptive, Norma-
tive, and Prescriptive Interactions. David E. Bell, Howard Raiffa, and Amos Tversky,
eds. Pp. 562-568. Cambridge: Cambridge University Press.
PART 1: DECISION MODELS OF TREATMENT CHOICE 339

Mechanic, David
1979 Correlates of Physician Utilization: Why Do Major Multivariate Studies of Physi-
cian Utilization Find Trivial Psychosocial and Organizational Effects. Journal of Health
and Social Behavior 20:387-396.
Nardi, Bonnie A.
1983 Goals in Reproductive Decision Making. American Ethnologist 10:697-714.
Nisbett, Richard, and Lee Ross
1980 Human Inference: Strategies and Shortcomings of Social Judgment. Englewood
Cliffs, NJ: Prentice-Hall.
Press, Irwin
1980 Problems in the Definition and Classification of Medical Systems. Social Science
and Medicine 14B:45-57.
Quinn, Naomi
1978 Do Mfantse Fish Sellers Estimate Probabilities in Their Heads? American Eth-
nologist 5:206-226.
Quinn, Naomi, and Dorothy Holland
1987 Culture and Cognition. In Cultural Models in Language and Thought. D. Holland
and N. Quinn, eds. Pp. 3-40. Cambridge: Cambridge University Press.
Ryan, Gery, and Homero Martinez
1996 Can We Predict What Mothers Do? Modeling Childhood Diarrhea in Rural Mex-
ico. Human Organization 55:47-57.
Sahlins, Marshall
1976 Culture and Practical Reason. Chicago: University of Chicago Press.
Sargent, Carolyn
1982 The Cultural Context of Therapeutic Choice: Obstetrical Care Decisions among
the Bariba of Benin. Dordrecht, Netherlands: D. Reidel.
1989 Maternity, Medicine and Power. Reproductive Decisions in Urban Benin.
Berkeley and Los Angeles: University of California Press.
Shore, Bradd
1996 Culture in Mind: Cognition, Culture, and the Problem of Meaning. New York:
Oxford University Press.
Simon, Herbert A.
1957 Models of Man: Social and Rational. New York: John Wiley.
Sperber, Dan
1982 Apparently Irrational Beliefs. In Rationality and Relativism. M. Hollis and S.
Lukes, eds. Pp. 149-180. Oxford: Basil Blackwell.
1985 On Anthropological Knowledge. Cambridge: Maison des Sciences de l'Homme
and Cambridge University Press.
Spiro, Melford E.
1987 Collective Representations and Mental Representations in Religious Symbol Sys-
tems. In Culture and Human Nature: Theoretical Papers of Melford E. Spiro. B. Kil-
borne and L. L. Langness, eds. Pp. 161-184. Chicago: University of Chicago Press.
Stein, Edward
1996 Without Good Reason: The Rationality Debate in Philosophy and Cognitive Sci-
ence. Oxford: Clarendon Press.
Stoner, Bradley P.
1985 Formal Modeling of Health Care Decisions: Some Applications and Limitations.
Medical Anthropology Quarterly 16:41-46.
Strauss, Claudia
1992 Models and Motives. In Human Motives and Cultural Models. R. D'Andrade and
C. Strauss, eds. Pp. 1-20. Cambridge: Cambridge University Press.
340 MEDICAL ANTHROPOLOGY QUARTERLY

Tversky, Amos
1972 Elimination by Aspects: A Theory of Choice. Psychological Review 79:281-299.
Tversky, Amos, and Daniel Kahneman
1974 Judgment under Uncertainty: Heuristics and Biases. Science 185:1124-1131.
1981 The Framing of Decisions and the Psychology of Choice. Science 211.453-458.
Weller, Susan C , Trenton R. Ruebush II, and Robert E. Klein
1997 Predicting Treatment-Seeking in Guatemala: A Comparison of Health Service
Research and Decision-Theoretic Approaches. Medical Anthropological Quarterly
11:224^245.
Wikan, Unni
1989 Managing the Heart to Brighten Face and Soul: Emotions in Balinese Morality
and Health Care. American Ethnologist 16:294-312.
Young, Allan
1980 The Discourse on Stress and the Reproduction of Conventional Knowledge. So-
cial Science and Medicine 14B: 133-146.
1981 When Rational Men Fall Sick: An Inquiry into Some Assumptions Made by
Medical Anthropologists. Culture, Medicine and Psychiatry 5:317-335.
1982 The Anthropologies of Illness and Sickness. Annual Review of Anthropology
11:257-285.
Young, James C , and Linda C. Garro
1982 Variation in the Choice of Treatment in Two Mexican Communities. Social Sci-
ence and Medicine 16:1453-1465.
1994[1981] Medical Choice in a Mexican Village. New Brunswick, NJ: Rutgers Uni-
versity Press.