Pragmatics of explanation: Creative accountability in the care of ‘medically unexplained symptoms’

This article describes an emergent reconfiguration of the problem of somatization in contemporary research and practice around ‘medically unexplained symptoms’ among UK-based primary care researchers with a special interest in these conditions. Based on an analysis of clinical research literature and on participant observation in the early stages of a clinical research project, the article explores recent accounts of the role of medicine and doctors in the co-production of somatization, and contemporary efforts to address this iatrogenic dimension by developing and testing clinically effective explanations. In this reconfigured discursive space, the problem of explanation is recast not in terms of the need for a representational, objective truth on the basis of which treatment of one kind or another should follow, but rather in terms of a pragmatic wager whose truth lies in the quality of its clinical effects. In this sense, these explanatory strategies can be characterized as a form of ‘speculative pragmatism’ and may be said to instantiate a form of ‘creative accountability’. The concluding section of the article contrasts this form of pragmatism with the ‘cash-value’ pragmatism implicit in explanatory strategies evident among participants of self-help groups for contested illnesses, particularly in the US. This contrast highlights the constraints that different healthcare systems – or policy environments, broadly conceived – impose on citizens’ ability to re-imagine themselves in ways that might facilitate their potential for growth, transformation and self-care.