The most general thesis of The Anticipatory Corpse concerns the epistemological understanding of science and humanities in modern medicine: the first model concerns the functional medical knowledge system of the human body, with the metaphysics of efficient causation; the second concerns the functional medical knowledge system of the social or political body which Foucault called biopolitics. Medical science operates with the ideal type of the dead body: “. . . the practices surrounding the care of the dying in our time are built upon this metaphysics of efficient causation, and . . . this metaphysics became possible precisely because medicine’s epistemology became grounded in the dead body, understood as an ideal-type” (21). Biopolitics, translating the functional understanding of the body to the body of polis, operates with the standardization of a so-called “average man,” either pressing the individual into this shape or discovering ever-more deviations from this socially constructed ideal-type. Both models have a de-humanizing effect, evident most strikingly, Bishop argues, in the treatment and/or care for the dying person, because both have no place for the individual grappling with his or her existential questions of life and death. Bishop is especially interested in the question whether spiritual care offers an alternative option.

I. Epistemology

Medical Science: Medical science of the eighteenth and nineteenth centuries as well as their successor—the bio-sciences of the twentieth and twenty-first centuries—treats human life as matter: “Life is the series of functions, and as long as the matter is in motion, there is life.” And: “medicine understands life as function without purpose” (24). The epistemological model of medicine as science (concerned with the explanation of functions of an organism enabling life or with the new construction of organisms) is therefore incompatible with the alternative (Aristotelian) epistemological model of medicine as praxis: as science, medicine is concerned with efficient causation theory, but as a praxis, medicine is concerned with hermeneutical interaction with a patient; this concerns intention-based actions (over against causal effects), the ‘will’ of the patient with her values, convictions, or life-stories. The medical interaction is limited not only by nature (mortality) but also by the limits of understanding someone else’s suffering and pain.

While I support the critique Bishop raises, I am not convinced of his answer. The doctor, Bishop claims, needs to step back from her medical role as a doctor and respond as a human being to the suffering other. But the more radical question is how the two knowledge systems, science/techne and medical practice/praxis, can be compatible; this is a different question than the one asking whether the epistemological framework (techne) can be complemented by a compassionate response to suffering by a personwho happens to be a doctor—with the effect that medical practice as praxis is still not developed further.

Bio-humanities: Bishop analyzes the general shift of the humanities (social sciences, psychology) towards standardized empirical sciences by way of the rise of statistics in the nineteenth century, which conquered the medical humanities only in the twentieth century. The main point is not only the Foucauldian understanding of biopolitics but rather, again, the epistemological framework; the empirical sciences cannot grasp the existential dimension of human life or the individuality of a dying person who does not just represent a particular case.

This analysis is indeed very intriguing. The two “ideal-types”—the “anticipatory corpse” and the “average” “man”—both seem to have a similar effect: to repress the “embodied individual” with her own life-story, her own experiences, her own struggles to address the loss of the “equilibrium” of health.

Biopolitics and spiritual care: Biopolitics is the appropriate term for the disciplining of the human body in different governance practices (the management of the human body and psyche in biomedicine and bio-humanities), which appears to pervade all disciplines concerned with the dying patient. This is—correctly, in my view, identified as medical violence: “we justify the violence of knowing because we believe that we can relieve the human estate of its frailties. The subject forces its object into its categories in order to assist it; yet in the process the person becomes a patient, that is, literally passive to the one who possesses the power of knowledge” (94). Most strikingly, however, the governance of the body has entered spiritual care concepts, too. After theology had given up its own claim to spiritual healing in the nineteenth and twentieth century, Christian pastoral care was designed to create the space and time for patients to be treated as individuals; the process of dying was to be seen as an existential experience of “letting go,” different from a medical problem in need to be fixed; religious rites des passages, e.g. in the form of sacraments or other rituals such as praying were seen as an offer to deal with questions of the existential openness to transcendence rather than as coping strategies. Once “spiritual care” is conceived as yet another element of the bio-humanities (as depicted above), a sociological, functional understanding of pastoral care emerged. Again, I find this an intriguing analysis, deserving thorough discussion in both medical and the theological/ethical scholarship.

II. Ethics: The sovereign patient and the return of the common good

The ethical concept of autonomy and sovereignty of modern self can be seen as the most important condition of the specific modern medical-ethical practice. Biopower, in Foucault’s understanding, requires the active participation of the self who authorizes the very medical actions that will reduce her to a mere organism. But when a persona has been transformed into a body and/or technology-sustained life, we need to decide what to do with it: it is at this point that the “sovereign patient” is “remembered” as the master over her/his life, and asked to consent to her death: “The act of rejecting technology is a choice between death and a meaningless life in the ICU, and similarly, the act of embracing doctor-assisted death is couched as a choice between death and a meaningless life of pain. Both are considered decisions for the same kind of action: a decision maker is acting toward his own death.” Patients’ autonomy is not only medically but also legally established: “The legal apparatus that legitimates the death of the sovereign also affirms for her that this decision really is her own-most. It is what she most desires, for doctors have repeatedly affirmed that it is her decision” (281).

As we have seen in the first part, in the normative epistemological order of medicine, knowledge stems from the “anticipatory corpse.” Now, in the normative ethical order of medicine, the patient’s consent to medical practices is sanctions this transformation of the “gaze”; in the normal practice of medicine (that presupposes a bond of trust between the doctor and the patient) it is almost taken for granted that the patient will go along with the “standard” course of action, justifying the application of the ideal type of the “average man.” However, when it comes to death and dying, why would a patient consent to being regarded (and acted upon) as an organism only? Why anticipate oneself as a corpse?

I agree with Bishop’s broader observation: from the physician’s perspective, the required consent to repress the person in the body in order to “work” on the body medically is moralized so that is appears to be the most responsible choice a patient can make in view of the ending of her life: a good death is a death that addresses medical as well as psychosocial and spiritual needs; the gift of life should be given to someone else by donation of one’s organs; in certain situations, life is too much of a burden (for oneself, for others, for society) so that death is the better option. What goes unsaid—and what Bishop has analyzed sharply, is this: The medical “system” morally incentivizes the patient to give permission to the reductive transformation of herself into a body that is examined in light of its own future: the corpse, because medicine does not function otherwise anymore.

And yet: How is it possible that a person will give such consent? Why this sub-jection to the medical institution? And how can a human being, in her role as a doctor, ask of a patient to give such consent? Why this belief in the knowledge system that so clearly represses what it wants to save: namely life?1 The response Bishop gives to these questions follows Foucault: first, it is genealogical (Foucault’s term for the historical analysis of the modern medicine discourse). Bishop gives a thorough account of the “scientification” of medical diagnosis and treatment of patients. Second, it is archaeological (Foucault’s term for the political (polis-related) analysis of the modern state or, as I would rather say, modern institutions). One example may suffice to show what this means ethically: The ethical rhetoric that accompanies organ donation, particularly the rhetoric of the “gift,” can be considered as an explicit or implicit justification strategy for medical practice: the utilitarian principle of ethics—the criterion for the morally justified action is the greatest benefit for the greatest number of persons—connects the utilization of the body with the ethics of the common good. Applied as a social norm this results in the following: at the end of one’s life, one should give up caring for oneself and instead turn to the care for the other: giving one’s life for the common good is no longer “the ultimate gift”—rather, it is the normal expected response to the anticipated transformation of the body into the corpse. According to Bishop, it is the individual’s identification with the medical gaze, encouraged by a medico-social culture that not only has no place for the “dignity of the person” that is sacrosanct to utilitarian contemplations, but that also confuses obligations with supererogatory actions, that creates the social norm of a good dying patient.

Biopoliticshas entered spiritual care concepts, too, which were meant as kinds of another praxis for patients to be treated as individuals, rendering the process of dying as an existential experience of “letting go,” different from a medical problem in need to be fixed. Yet, the very turn to a “spiritual care” concept that seems to be ripped of any thematic religious concern or ritual, may be seen as part of a biopolitical turn of late modern societies (this is Bishop’s interpretation).

Where does all this leave us? Indeed, it seems to me, we need to reclaim “meaning” and “interpretation” in the age of “explanation,” as Charles Taylor and others would claim. We need to re-claim critical, practical reason in the age of instrumental reason. And we need to subject the libertarian utilitarianism underlying most “mainstream” bioethics to a critique of its ethical violence, to borrow a term from Butler: insofar as it ignores the individuality of persons—their life-stories and life-experiences, their imaginations and their own anticipation of death—bioethics does not even touch upon the most important questions of life: how to live well and how to die well in the age of surveillance, measuring, and normalization.

Philosopher, ethicist, and physician Jeffrey Bishop stimulates the critical reasoning of his readers with this provocative volume. I respond to Bishop’s important contribution by addressing some key choices.

“The thesis of this book is that our medical notions about death—notions informed by medicine’s philosophy—have shaped the way medicine cares for patients, and the way patients perceive their dying” (8). Hence, “to unpack notions about death” (19), the volume correlates medical notions to concrete medical practices—i.e., ICU, brain death and transplantations, palliative care, and euthanasia—that occur mostly in rich countries.

Bishop defines medicine as a discipline centered on doing and on its effects (20). Hence, he avoids debating whether medicine is a science or an art; rather, he focuses on notions and on their practical applications. Moreover, medicine’s metaphysics is centered on “material and efficient causation, concerned with the empirical realm of matter, effects, and the rational working out of the causes for the purposes of finding ways to control the material of bodies” (20). This metaphysics depends on medicine’s epistemology “grounded on the dead body, understood as an ideal type” (21). As a consequence, “It is death, after all, that motivates medicine” (15) and the medical truth comes from the dead body (21).

This interpretation of medicine’s metaphysics and epistemology is critically insightful but it can be disembodied if it leaves aside the relational dimension, with high quality interactions, that should characterize any medical practice and medicine as a whole. In such a way, persons and contexts are at the forefront, as well as the struggle for protecting and promoting a good and healthy life. Medicine learns from dead bodies and from death, as Bishop forcefully claims, but this is only the beginning of a very complex learning process that depends on, and is shaped by the multiple interactions that characterize medical practice. At the end of the book this relational richness surfaces by “being moved by the suffering of the other,” by being changed by listening and by caring with humility (311) and uncertainty (313). Context also matters, and meaning is embodied and shaped by communal practices (298).

Otherwise, Bishop’s approach could undermine the importance of one’s experiences, values, beliefs, and the role of one’s relational context. The phenomenological approach that he privileges at the end of his book (289), and the importance that he assigns to social forces throughout the volume integrate Bishop’s critical reflection by making it more comprehensive.

I noticed the contrast between Bishop’s analysis and Christian involvement in health care. Since the beginning of Christianity, the purpose of establishing first hospices and then hospitals was to accompany the sick and the poor when nobody else would care for them at home. Mercy animated this commitment. As Francis of Assisi poetically affirmed, death is a sister, not an enemy. Death is a passage to a happiness and goodness that will never end and it is not experienced as the destruction of meaning.

Bishop’s criticisms of medical notions and practices at the end of life are tailored to Western medicine. They rightly point, however, to the need of reclaiming, first, the rootedness of medical practice within the community. Second, the core of the relational interaction between healthcare professionals and citizens should be the living, not the dead. In other words, the “soul” of medicine and its mission is the living person within the social context. By choosing to discuss selected instances of medical practice centered on the dying and the dead—i.e., ICU, brain death and transplantations, palliative care, and euthanasia—Bishop leaves out, however, other relevant components of medical practice that are centered on communities and on the living. They would contribute to nuance the death-centered focus of medicine that he highlights. Examples are regenerative medicine, alternative medicines, healthy ways of living, preventive medicine, and public health and global health.

Regenerative medicine aims at stimulating the ability of the body to heal and it is creating an alternative medical approach to transplantation needs. Alternative medicines are based on different metaphysical and epistemological approaches, often depending on harmonic relationships with oneself, others, and creation. Lifestyle choices centered on careful nutritional habits, on organic foods bought through fair trade, and on regular exercise are further examples of focusing on the living and on communities in order to preserve health and to prevent disease. In different ways, these examples reveal a holistic and integrated vision of the human body and of bodily functioning where the body is assumed in its not yet fully grasped complexity, and where one’s body is in relation with the surrounding environment.

Moreover, preventive medicine, public health, and global health are ways of practicing medicine where medical knowledge comes from multiple sources and not only from the dead body. Preventive medicine integrates the data concerning infections, diseases, and their effects on individuals and communities. These data can be partly acquired by studying the dying and the dead but, more importantly, by focusing on the living—from lifestyles to working conditions and nutrition—and on human environments.

This synergic attention to all aspects of human life is even more evident in any effort to implement public health and global health. Knowledge of individual and communal ways of living, habits, values, and beliefs matter when the goal is to improve the living conditions of individuals, communities, and of the environment as well as to address what is affecting each one of them—locally and globally. Bishop, on the contrary, critically considers public health an expression of biopower, shaped by the body politic, and aiming at controlling human bodies (41–42).

Besides these medical disciplines, concrete examples of institutions and medical practices centered on the living do exist. My anecdotal experience confirms it. While I was reading Bishop’s volume, I compared it with a forthcoming volume centered on the outstanding St. Mary’s Hospital in Lacor, North Uganda. Since its founding in the early 1960s, this hospital has provided high quality care to millions of patients and to numerous communities. In a context ravaged by the deadly violence of the “Lord’s Resistance Army” (the guerrilla group led by Joseph Kony), the hospital offers medical care centered on the living and integrated in the community. Death and violence are neither shaping the medical notions nor the medical practice.

St. Mary’s Hospital is not an isolated example. The work of Paul Farmer and of “Partners in Health” in Haiti, Rwanda, Burundi, and Russia should be considered too. Farmer’s poignant narratives show how medicine is a collaborative effort where everyone—from the patient, to the healthcare professionals, to the community—play essential roles in understanding what is affecting individuals and communities, and in promoting the quality of living conditions by addressing the social determinants of health. In the United States, free clinics could be further examples of institutional settings that are resolutely centered on providing care to the less well off.

Bishop’s rendering of medicine sounds removed from these accounts. While he portrays a medicine centered on death and generated out of death, these are only a few examples of medical notions and practices shaped on life and on the living. There is no denial of death, and of what death can teach us, but the medical “soul” and its source of knowledge are also life and the living.

Within society, whether in the North or the South of the world, social constructions and institutions shape healthcare systems and influence their moral agents (i.e., healthcare professionals and patients). Hence, Bishop’s rightly focuses on institutional dynamics. His brilliant readings of Michel Foucault’s archeological genealogy and of biopower equip the readers with the needed critical elements to unveil power dynamics. Foucault also seems to guide Bishop in privileging a deconstructive approach centered on unmasking power and control by understanding both as negative and unavoidable, and in denying that the “political” could be a virtuous space (107). In particular, “medicine has become a social apparatus for the control of the dying” (23). The dying, however, are limited to those in ICU and palliative care (19) by leaving out other contexts where one finds the dying (e.g., from homes to wars) and where medicine’s struggle for life and its attention to accompanying the dying might be more evident.

Elisabeth Kübler-Ross’ work falls under Bishop’s criticism too. His comments are insightful and welcome (235). They might be overstated, however. On three counts he dismisses her famous proposal of five emotional transitional stages at the end of life (i.e., denial, anger, bargaining, depression, and acceptance). First, her research methods, findings, and analyses are not considering rigorously scientific. Second, those five stages are categories of social functioning at the service of medical institutions (240–41). In other words, the acceptance of one’s death is praised because it benefits the institutional settings. Third, Kübler-Ross ultimately aims at mastery of death (i.e., at attempting to control the uncontrollable).

One could reply to these poignant critiques from a phenomenological point of view—first, by rethinking what rigorous scientific investigation is and what definition of science is operative in making scientific claims. Particularly at the end of life, emotional responses—and the narratives that accompany them—challenge traditional scientific methodologies. Second, while the acceptance of one’s death could be interpreted in light of institutional purposes and rationales, there are also human and relational dimensions associated with accepting one’s dying and death that go beyond institutions’ logics and dynamics.

Finally, to accept one’s incoming death does not mean to own, to control, nor to master. Since its beginning, the Christian spiritual tradition has affirmed this distinction by reflecting on Jesus’ dying on the cross and on accepting one’s cross. There is neither owning, nor controlling, nor any mastery associated with the experience of the cross. Paradoxically and out of love, even being dispossessed, lost, and vulnerable could lead to accept one’s cross as well as the multiple dimensions of death that the cross can imply in one’s life. Moreover, this acceptance has always being associated with one’s freedom, even when such a freedom is limited and compromised, (e.g., by disease or persecution). Hence, acceptance might neither mean fostering institutional and social conformism, nor assimilation. Accepting one’s dying and death could contribute to strengthening one’s peace, well-being, flourishing, and even happiness. Acceptance is not part of a deadly logic, but it is a living struggle. It indicates that death does not have the last “word” in one’s lived experience.

In a similar vein, Bishop criticizes hospital chaplains who are assessing their patients. He finds this a further example of working on behalf of the institution by fostering institutional compliance (242, 269). This criticism could be nuanced. In higher education, for example, assessment is at the service of the most vulnerable (i.e., the students) to assure that the educational services provided, and the learning experience and environments that these services intend to promote, really deliver what is expected from them. The fine-tuning or the radical transformations that follow any accurate assessment strengthen the quality of the teaching that is offered. In medical institutions, the assessment of chaplains could contribute at delivering the best-needed care to extremely vulnerable persons.

Power and control dominate human endeavors as well as medical notions and practices. Hence, Bishop’s critical comments strongly lead to examine both. In particular, control occurs not only through technology, but it is also mediated by discourses (e.g., in psychology and social sciences) (228). Moreover, control powerfully dominates the dynamics concerning euthanasia in the case of all moral agents involved (i.e., while patients control their own deaths, physicians lose control on their patients and on their practice, 125) and of medical settings (e.g., the ICU, where patients lose their ability to control what is happening to them, 118).

A further example of medical control that Bishop discusses is the “biopsychosociospiritual medicine” (228) because it claims to address “all features of human striving” (228). In doing so, it wishes to provide “total care” (228). But total care is “totalizing care” (309), because the patient is measured according to an understanding of what is truthful that is disembodied, external to the subject, and that is not shaped by contexts, spaces, stories, and experiences. In constructive terms, the path to a more human medicine depends on being connected to one’s personal and social Lebenswelt.

Being born in Italy, I was pleased to read Bishop’s analysis of the main social, political, and legal case of Eluana Englaro that has dominated the Italian scene for years. In discussing this case together with the other high profile case involving Terry Schiavo, Bishop rightly reclaims a space for decision-making and for medical care confined to the home (the oikos) by opposing it to the political. The public political space, often mostly reduced to legal battles, might suffocate the familial contexts where human tragedies are lived and it transforms them in media events. While Bishop’s criticism of both cases is well placed, the risk of demonization of the political context should be eschewed by avoiding considering it solely the reign of the Foucauldian “body politics.” Hence, both civil society and healthcare professionals should keep addressing concerns that promote the common good of citizens and communities. The common good does not aim at assuring social functioning in terms of power dominance and overwhelming control, but it pursues human and social flourishing, even in the case of medical practices and health care institutions.

Bishop is aware that his deconstructive approach dominates the volume and that it should lead to articulating a constructive approach. Hesitantly (285, 309), he unveils his constructive proposal only in the last chapter, by leaving his readers somehow disappointed, longing for a more extensive and articulated proposal to balance his riveting deconstructive stances. In a Foucauldian manner, Bishop’s hesitancy seems to depend on considering his constructive contribution as a further example of a great narrative that should be deconstructed. In any case, he ends with a phenomenological turn focused on the embodiment both of the healthy body and of the diseased body, mourning for “the loss of capacities, potencies, histories, projects, and purposes” (294).

As a theological bioethicist and physician, I would have appreciated a greater attention and engagement with some key voices and positions amidst the abundant theological literature, particularly on hydration and nutrition, by referring to the extensive debates generated in the American theological milieu. The relevance of these debates is not limited at theological circles. The social and political implications of these positions lead to diverse practical approaches addressing the ethical issues associated with nutrition and hydration in patients in vegetative state.

By anticipating my longing for a greater attention to theological literature, Bishop ends by proposing to study figures of saints who cared for the living and for the dying, and he asks: “Might it not be that only theology can save medicine?” (313)—a conclusion that points to a further direction of investigation.

There was no deficiency, but rather an excess, a redoubling, too much rather than not enough discourse, in any case an interference between two modes of production of truth: procedures of confession, and scientific discursivity.

—Michel Foucault, The History of Sexuality Volume 11

Thou only art immortal, the creator and maker of mankind; and we are mortal, formed of the earth, and unto earth shall we return. For so thou didst ordain when thou createdst me, saying, “Dust thou art, and unto dust shalt thou return.” All we go down to the dust; yet even at the grave we make our song: Alleluia, alleluia, alleluia.

—The Book of Common Prayer, 19792

At first, we look upon the image not quite knowing what we have stumbled across. Michel Foucault opens The Order of Things: An Archaeology of the Human Sciences with an extraordinary description of an enigmatic painting—Las Meninas by Velasquez (Figure13). We look alongside Foucault, and slowly we take in the scene: the painter peering out from behind his canvas, the anonymous visitor framed in a doorway, the infanta and her attendants arrayed in the foreground.The latter may be the ostensible topic of the painting, but as Foucault explains, something else entirely is going on. And then our eyes are drawn to the mirror, and to the shadowy figures of the king and queen reflected dimly therein. Las Meninas is, for Foucault, the visual depiction of aseismic shift in thought, the end of the centrality of the royal sovereign and the emergence of man: the sovereign subject in the figure of the spectator, both viewer and viewed, knower and known, the “being whose nature (that which determines it, contains it, and has traversed it from the beginning of time) is to know nature, and itself, in consequence, as a natural being.”4 It is with this configuration of the human being—man framed by what Foucault calls the quasi-transcendentals of life, labor, and language—that contemporary medicine will come to concern itself. And, as Jeffrey Bishop argues in his groundbreaking work The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, it will do so with the dead body of this human being at its focal point.

Bishop begins his genealogy of medicalized dying in America with a striking image of his own, the story of a friend whose experience of illness would inconveniently refuse to follow the carefully sketched trajectories of biopsychosocial medicine. And, in doing so, he gestures towards something else entirely that is going on in the institutions and practices that make up American medicine in the twenty-first century. As he goes on to ask in the Prelude,

Is the kinder, gentler medicine really kinder and gentler? Or is it a mask or a cloak for the cold ground of technological mastery of the living and dying body? Or is it a pall, a death shroud, covering over death, making it more palatable through palliation? Is the biopsychosocial medicine thereby more patronizing than ever, because it promises humanity but cannot deliver without making the patient an object of disciplinary power? (6).

I wholeheartedly concur with Bishop that the answers to these questions are no, yes, yes, and yes respectively, but in this essay I would rather not dwell on how he reaches those conclusions. Instead of a review per se, I would like to offer an experimental riff on some of the themes running through the text. In doing so, I write as a scholar indebted to Foucault who shares the author’s commitments to what John Paul II called the gospel of life, even if we do not share exactly the same ecclesial location. I also write as a new parish priest who prays that the work of praying with and for people who are dying, and of burying the dead, never becomes a matter of “business as usual.”Above all, however, I write in appreciation for the gift that this book represents to a diverse readership that includes those involved with the practice of medicine, those involved in churches, and those who find themselves living and dying in the twenty-first century. That is to say, this book is truly a gift to everybody.

Shortly after introducing the reader to his friend Nancy, Bishop continues the Prelude by introducing the thesis of the text, namely that “our medical notions of death—notions informed by medicine’s philosophy—have shaped the way medicine cares for patients, and the way patients perceive their dying” (6). Elaborating on this statement, he writes:

Not only do the practices surrounding death betray the social structure of medicine, but these practices and these social structures, deployed for the purposes of caring for the dying—betray something deeply held within the psyche of the Western world. In what follows, I shall claim that there is a return of the repression of death, which can be seen in the care of the dying, for death is at the center of medicine, at its core, and even at its cor (heart in Latin) (8).

I believe that this notion of repression—or, at least, of what appears to be repression—is central to plumbing the depths of the moral and theological problem of medicine that Bishop so ably describes. In the course of reading Foucault and his interlocutors with Rey Chow last year, my classmates and I were often reminded that the site of repression, whether actual or perceived, can often be a profoundly fruitful locus of inquiry. For example, as Foucault explains in The History of Sexuality Volume I, what appears to be the repression of sexuality is actually the proliferation of discourses around sexuality, under the pressure of a shift in authority from the church to the state:

[Scientific discourse] was also faced with a theoretical and methodological paradox: can one articulate the production of truth according to the old juridico-religious model of confession, and the extortion of confidential evidence according to the rules of scientific discourse? Those who believe that sex was more rigorously elided in the nineteenth century than ever before, through a formidable mechanism of blockage and a deficiency of discourse, can say what they please. There was no deficiency, but rather an excess, a redoubling, too much rather than not enough discourse, in any case an interference between two modes of production of truth: procedures of confession, and scientific discursivity.5

As Bishop shows in the course of his book, this interference between the ecclesial and the scientific, and its consequent results, is not limited to the matter of sexuality. Rather, the same proliferation of discourses is also at work in the ways that medicine suffers from too much discourse about death—even as it seems at the same time to be unable to speak of it coherently or truthfully.

For Foucault, the collision between the production of truth through confession and through scientific inquiry plays a key role in his version of a narrative of secularization. In one notable essay, “The Subject and Power,”he traces the shift of the simultaneously individualizing and totalizing functions of what he calls “pastoral power”from the ecclesial domain to the regime of the modern Western state. His description of this transition bears quoting at length:

Never, I think, in the history of human societies . . . has there been such a tricky combination in the same political structures of individualization techniques and of totalization procedures.  This is due to the fact that the modern Western state has integrated into a new political shape an old power technique that originated in Christian institutions.  We can call this power technique ‘pastoral power.’ [ . . . ] This form of power is salvation-oriented (as opposed to political power). It is oblative (as opposed to the principle of sovereignty; it is individualizing (as opposed to legal power); it is coextensive and continuous with life; it is linked with a production of truth—the truth of the individual himself.[ . . . ] But all this is part of history, you will say; the pastorate has, if not disappeared, at least lost the main part of its efficacy. This is true, but I think we should distinguish between two aspects of pastoral power—between the ecclesiastical institutionalization that has ceased or at least lost its vitality since the eighteenth century, and its function, which has spread and multiplied outside the ecclesiastical institution. An important phenomenon took place around the eighteenth century—it was a new distribution, a new organization of this kind of individualizing power.6

Rather than liberating humanity from the power of the church and ushering in a new epoch of human freedom, the Enlightenment marked the migration of this power to new contexts, new agents, and new discourses.7 And nowhere would its individualizing and totalizing nature be more clearly seen than in the development of modern medicine.

Foucault continues by describing the resulting change in the meaning of salvation within this new context. Where salvation was once tied to the hope of the resurrection (and thus an acknowledgement of the reality of death), it became a matter of human security, safety, and prosperity (and thus the avoidance or control of death by the sovereign human subject). And it is here that medicine would take its place at the heart of the soteriological project:

We may observe a change in its objective. It was a question no longer of leading people to salvation in the next world but, rather, ensuring it in this world. And in this context, ‘salvation’ takes on different meanings: health, well-being (that is, sufficient wealth, standard of living), security, protection against accidents. A series of ‘worldly’ aims took the place of the religious aims of the traditional pastorate, all the more easily because the latter, for various reasons, had followed in an accessory way a certain number of these aims; we only have to think of the role of medicine and its welfare function assured for a long time by the Catholic and Protestant churches. [ . . . ] Concurrently, the officials of pastoral power increased. [ . . . ] It was also exercised by complex structures such as medicine, which included private initiatives with the sale of services on market economy principles but also included public institutions such as hospitals. [ . . .] Finally, the multiplication of the aims and agents of pastoral power focused the development of knowledge of man around two roles: one, globalizing and quantitative, concerning the population; the other, analytical, concerning the individual. [ . . . ] And this implies that power of a pastoral type, which over centuries—for more than a millennium—had been linked to a defined religious institution, suddenly spread out into the whole social body. It found support in a multitude of institutions. And, instead of a pastoral power and a political power, more or less linked to each other, more or less in rivalry, there was an individualizing ‘tactic’ that characterized a series of powers: those of the family, medicine, psychiatry, education, and employers.8

What Foucault makes clear in this passage is that not only has medicine assumed a considerable proportion of the pastoral and priestly function, but that the church has been involved (intentionally or not) in that process. And, as a result, the church has been hindered in its ability to respond to medicine’s establishment of an incommensurate soteriology. Both Foucault and Bishop (drawing on Foucault) have shown the extent to which medicine offers—and enforces—its own set of answers to the jailer’s fearful and tremulous question in Acts 16:30, “What must I do to be saved?”

What, then, happens to the church and to the authority it claims under such a regime? As Bishop points out, it becomes subservient to the real agent of pastoral power, and expected to prove its efficiency and effectiveness under the metrics established by the latter:

Pressure to prove one’s value to the system should be placed in the broad context of the thesis, as described by Alasdair MacIntyre, that the two great values of post-Enlightenment thinking are efficiency and effectiveness. Effectiveness is defined by the domain of the social; efficiency is what does the job quickly and cheaply. The biopsychosocial model, now defined more comprehensively the biopsychosocialspiritual model of medicine, has always been about controlling social function and about promoting medicine’s role in promoting the effective functioning of the body politic. The great high priest who promotes social function within biopsychosocialspiritual medicine is the doctor, and his chief altar boy is the generic chaplain, who has taken on the values of the institutions of health care within the larger sociopolitics of Western society (246).

The depth of medicine’s claim to a priestly function in meditating salvation to the population was highlighted for me by a discussion with Brett McCarty. Viewing some images of early anatomy theaters, we were both struck by the liturgical resonances in the space. (An example may be seen in Figure 2, a contemporary photograph of the anatomical theater of the Archiginnasio in Bologna.) We see the seats for a congregation of learners who would gather around the focal point of the table. And we may well envision the scene of the dissection and the anatomical lectures that took place there, where a body would be broken open in order to gain the knowledge that saves. But, as Bishop points out throughout his text, this is a broken body that remains resolutely dead, and the discourses of death that proliferate around this body presume that death is indeed the last word.

Yet the church has not been a passive spectator in the process of the proliferation of these discourses of death, and in its assumption of control over the way patients understand their living and dying. While Bishop reveals medicine’s exertion of power, he also points to ecclesial complicity in that process, and it is on this convicting note that I would like to end. As pastors, priests, and Christian scholars, we have far too often participated in this process by accepting a role as subservient altar boys (and girls) to the priesthood of the hospital and clinic. And, we have allowed the discourses of the palliative gaze and carefully-managed grief to change our own language and liturgical practice. Nowhere is the latter more evident than in the tendency to recast the liturgical act which my tradition calls “The Burial of the Dead” into a “Celebration of Life”—by which is all too often meant a celebration of the decedent’s past life, not the “sure and certain hope of the resurrection”of which that liturgy speaks.9 There is an unresolvable tension in Christian thought and speech about death, one that necessarily encompasses both Good Friday and Easter, dust and new creation, disconsolate lament at the grave and the song of a full-throated “Alleluia”even there. If, as Rowan Williams suggested in one Easter sermon, “death is real”and “death is overcome,”then Christian proclamation is called to embrace that truth in all its improbable, inefficient particularity.10 Where medicine and its practices have changed the songs we sing as we all go down to the dust, the church is always, already called to sing otherwise.

In a course I teach each spring to fourth year medical students, we read literary works—fiction and nonfiction—that intersect with the medical world our students are entering. Since our focus is on the experience of illness and healing rather than technological mastery, we often engage areas of human life over which medicine can, at most, feign control: suffering, loss, and death. Not surprisingly, the most useful vocabulary of such matters is often “religious,”1 which disturbs some students more than others. A few refuse to enter such fraught conversations at all, while others treat the language with clinical dispassion, bestowing it “the sort of attention we give to strangely shaped shells.”2 On rare occasion, someone who took an undergraduate philosophy course will use the word “metaphysics,” explaining that some people believe there exist things that can’t be measured or proved. The students usually leave the impression that they, however, are too smart—or at least too practical—to waste time on such dead ends.

Oddly enough, these are often the same students who talk at length about the rights of autonomous individuals, a language they find most congenial. When I ask how, outside of positive law that is subject to repeal, they account for the existence of rights, I’m usually told, “Well, that’s different.”3

For these doctors-to-be, then, the set of things that exist but can’t be measured or proved is not empty, though I doubt many would admit to a metaphysics.4 The profession they will soon share with me is an applied science, a pragmatic discipline directed at managing and, ideally, changing the condition of fellow persons for the better, and what does metaphysics have to do with causing change in persons or the world?

Quite a lot, actually, according to Jeffrey Bishop, who argues that medicine has a metaphysics after all, one that has sliced away two of Aristotle’s four causes—formal and final—while enthroning material and efficient cause at medicine’s pragmatic center. Indeed, Bishop writes,

. . . even matter comes to be thought of not so much as a cause, but as the stuff that stands in reserve of power, awaiting knowledge to mold it into what we desire it to be. On this view, matter—the body—has no integrity, except that it is driven by an authenticity and can be bent to our desires (20).

The body, then, understood as a valuable meat machine that’s alive as long as its physiological systems resist death,5 has no end or telos, nothing against which to measure the wisdom or foolishness of any bodily manipulation outside of pragmatic concerns. Other writers have suggested this, occasionally stressing more colorful ways individuals might alter their bodies, such as amputating healthy limbs or building real human wings.6 Bishop, however, is interested in the way medicine as a profession disciplines more mundane individual desires toward certain goals, creating docile bodies.7 It helps to have some familiarity with Foucault’s general argument in Discipline and Punish and especially The Birth of the Clinic,8but Bishop deftly works these complex themes into his narrative.

He extends Foucault’s analysis as well, chronicling the rise of modern medicine through the heyday of vivisection, public health, statistical analysis, the “scientific” reform of medical education, and the rise of technological medicine. Bishop never argues that modern medicine is intrinsically bad. Rather, he calls attention to the ways in which medicine’s social and political ascent uses “death as the stable ground against which life and disease can be known” (58), producing definitions of health, disease, life, and death with respect to physiologic and social measurements, “taken to be a universal norm, against which the individual is both measured and . . . shaped” (85).

Along the way, questions medical science can’t answer are discarded as irrelevant or left up to the private individual—questions such a why physiologic phenomena happen rather than how, or what “changing the condition of fellow persons for the better” really means. Whenever medical science appears to overstep its authority in naming and claiming what it can control, some corrective social response will be proposed, typically with a nod to bioethics’ chief talisman, “autonomy,” thereby reassuring all parties that the patient is still in control, at least within well-defined bounds.

Foucault, of course, has his critics, but even if one concedes that “panoptic” social surveillance has largely given way to seduction as the primary disciplinary mechanism,9 or believes that a robust form of patient autonomy still exists in the modern hospital, I struggle to find a clear line in practice between coercion and cooption.10 As an attending physician once told me during my internship, “If you’re not a little disturbed by what you, as a doctor, can get your patients to agree to, you’re not paying attention.”

I’m not suggesting that physicians bully or seduce patients in a conscious exercise of raw power. Most medical professionals, including the medical students I teach, enter their field with a desire to help others and are then educated into seeing some behaviors as more helpful than others. That education, however, is riddled with assumptions about what is or is not healthy, desirable, or acceptable—in many cases more firmly founded on bourgeois, liberal, and consumer patterns of behavior than on empiric data. And even when my medical advice is more or less evidence-based, I have a clear power advantage over my patients and families through the specialized practical knowledge I acquired over years of training and my so-called professional objectivity.

For example, three year-old Tamika is on my inpatient service at the hospital, having been admitted overnight after two days of fever, vomiting, and increasing weakness. Her mother has never seen Tamika so ill before. The primary care physician who knows the family best does not round at the hospital, so they must trust strangers—professionals who know many things but have only just met Tamika and her mother—at a time of great stress and uncertainty. Tamika had a number of invasive tests performed in the Emergency Department and continues to receive fluid and antibiotics through an IV, but her clinical condition is worsening.

I enter the room, reminding Tamika’s mother that I introduced myself on rounds earlier this morning. I re-examine the patient, noting her quick pulse, pale, sweaty skin, and exhausted appearance. I explain to Tamika’s mother what I think is going on, taking care to explain words like “sepsis” and “shock.” I tell her what we—the medical team and I—are going to do immediately, including another bolus of fluids through the IV and a change in antibiotics for expanded coverage. I also explain that Tamika may very well need transfer to the Intensive Care Unit if she does not respond rapidly to our stepped-up therapy.

Tamika’s mother asks me about the risks of her illness and therapies. I answer as best I can, quoting statistics from large studies when possible, knowing that she cares far less about what happened to the last three hundred patients than what will happen to her only daughter. I restate my plan to be sure she understands before requesting and receiving verbal consent to proceed.

Throughout this idealized vignette—a fictional composite of real encounters—I’ve portrayed my actions and intentions as professional, knowledge-based, compassionate, even “holistic”—behaviors I hope to model for my students and residents. I do not, however, suffer from the delusion that the result of this encounter can be described as “informed consent.” I know certain details, as Tamika’s mother likely does not, of the pathophysiology of septic shock, the likely causative microorganisms, and what might go awry with our invasive technology. Yet, even if Tamika’s mother shared my medical knowledge, I have no direct access to the emotional and spiritual significance of her daughter’s life so far, nor of this current, severe illness. Were I to inquire about Tamika’s mother’s metaphysical commitments or the end toward which she and her daughter are living, some of my colleagues might find my “holistic” concerns charmingly quaint. Others will remind me that the hospital employs social workers and chaplains trained to attend to such matters with their research-validated spiritual assessment tools.

Stripped to its barest essentials, the encounter can be summarized this way: the mother of a very ill child turns to me, a stranger, for help because I possess practical knowledge of the human body, knowledge that gives me power which she must trust and accept—or not. If she accepts my medical authority and advice, we will proceed toward what I hope is a satisfactory outcome. If she says “no,” I will try to understand her reasons and work to change her mind.

When I was a pediatric intern, learning to give medical advice to patients, I was taught the theoretical importance of autonomy, with which medical providers reassure ourselves we’re not, thank God, like those paternalistic doctors of the past. In the above vignette, the decisions to be made are, for me at least, rather clear, and the scope of patient autonomy rather limited: Tamika’s mother wants her to be well, and I’ve just told her how we can do that. If, however, we were discussing end of life decisions or what might constitute futile treatment if continued, the choices would be less obvious and the scope of autonomy rather more difficult to define. In this case, were the mother to speak and behave in ways the medical team finds unhelpful, she’ll likely be considered “a difficult patient,” possessed of “unrealistic expectations,” and making “unreasonable demands.”

What appeals to individual autonomy typically efface is the degree to which biomedicine has already shaped both the question asked of the patient and the technologically driven answers she is invited to choose from. As Bishop puts it:

The myth of our culture proclaims autonomy and the individual as sovereign, all the while hiding the fact that we are constituted not as sovereign subjects but as subjects of the social and philosophical power structures that shape our lives. Our cultural and communal myth, the story we tell ourselves about ourselves, is the myth of the individual. (216)

The word “myth” is used here to signify a shared, foundational narrative as well as a commonly believed falsehood. Bishop shows how standard whiggish accounts of the rise of modern biomedicine season their histories with various fables and just-so stories. Among these is the counterfactual belief that, as late as the 1800s, anatomists robbed graves to circumvent Church prohibitions against autopsy and human dissection, even though human dissection had been part of medical education in Italy since the thirteenth century and, over time, throughout Europe. As Foucault writes, this mythology permitted early nineteenth century founders of the medical clinic to see themselves as part of an “anatomical church militant and suffering.”11 As with any political entity seeking to establish and expand its power, “Medical Science” elevates itself with narratives that demean or demonize potential rivals by selecting or creating an Other and then scapegoating it.12

But Bishop’s analysis of the 1968 Harvard Medical School Report of the definition of brain death13 and the 1981 President’s Commission document, Defining Death,14 masterfully uncovers the mythology and effaced motivations in the American development of “brain death” as a clinical entity. Bishop rightly begins with a description of the President’s Commission’s printed cover, in which three stylized figures attend to a hospital bed surrounded by a machine and IV pole, yet the two white-coated men look as though they’re closing a coffin, the female figure looks far less like a nurse than a nun, and the IV pole, with its dangling red bags of blood, takes the form of a cross. But his careful reading of the document itself undoes a myth I was taught in medical school, namely that the concept of “brain death” was developed in response to growing public fear that doctors kept patients alive against their previously stated will with the aid of sophisticated technology. Note how what I was taught underwrites narratives emphasizing the rise of autonomy over against the imposition of burdensome medical care. As Bishop demonstrates, however, a precise definition of the moment of death becomes a pressing practical problem with the development of new transplantation technologies.15 It’s what the body can still be used for once the wetware has failed, rather than the person’s intrinsic purpose or end, that makes the exact timing of death so important.

Yet in defining death with brain criteria, medicine employs a metaphysics that locates personhood in the autonomous choosing functions of the cerebral cortex and assigns somatic integration and physiologic regulatory function to the brainstem, while creating novel philosophical puzzles such as how a patient is understood to be dead while she remains on life-support until her usable organs are harvested. As philosopher Robert Spaemann points out, the science behind the definition of brain death has, since the concept’s proposal, proved dubious, while the underlying metaphysical assumptions have, if anything, grown more convoluted.16 As if to prove Bishop’s argument that medicine treats the dead body as normative, brain death criteria provide a set of clinical signs and tests to distinguish life from death without persuasively establishing what the difference between life and death truly is.

Questions raised by medicine’s implicit metaphysics are sometimes addressed politically, typically with appeals to autonomy or personal sovereignty. This politicization can turn ugly, as in the public squabbles over the fate of Terri Schiavo. It can also have strange effects on theological discourse, as in certain Vatican statements defining the administration of food and water to a patient in a permanent vegetative state (PVS)—even via artificial means—as obligatory. These recent pronouncements appear to reverse or at least significantly revise previous official Catholic statements on the difference between ordinary and extraordinary means of patient care.17 PVS is not synonymous with brain death, but the politics and metaphysics carry over across similar conundrums medical technology makes possible and proposes to solve.18

For a physician like me, the most pressing issue raised by Bishop’s analysis is “What’s to be done?” This is, however, precisely the sort of question that medicine, which claims to be a self-correcting system, thrives on. Even if every hospital, research facility, and regulatory body conceded that medicine is built upon an unstated metaphysical foundation in which the dead body is normative, Bishop’s challenge will undoubtedly be co-opted in ways similar to the absorption of Dame Cicely Saunders’ modern hospice movement, leading to the redefinition of a good death as one fully managed by experts and regulated by the state in accordance with the individual’s culturally-derived preferences. As Bishop writes, “Under a metaphysics of efficient causation, it is inevitable that palliative care will become, under the governance of the state, the place where death is caused, as the final effect in an immanent series of cause and effect” (278). Note, he adds later, “. . . that no assessment has been created in which researchers have shown that what the patient and family most need is a respite from healthcare professionals” (284).

What Bishop suggests is at once simpler and far more revolutionary. I believe he’s onto something important when he makes a Levinasian turn to the ongoing encounter with the suffering other as calling the physician—as opposed to a body mechanic or patient manager—into being, and that the shared language, practices, and ends that make this “being-there-with” possible are only learned in community. He stops short of saying that these communities are necessarily “religious,” but I know of few other places where such conversations are possible. Though medicine, like the state, declares itself to be both above and larger than “religion” or “sect,” this alleged universality is the result of exclusion, a strictly enforced embargo on questions which “society,” as opposed to a particular community, claims it can do without.

Perhaps a helpful response to Bishop’s analysis is to promote in these local, particular communities—church, synagogue, or mosque—an awareness that the questions and answers medicine proposes are neither sufficient nor definitive, a “hermeneutic of suspicion” toward any care plan or solution that stresses technologically managed individual autonomy over communal interdependence, and a renewed observance of those liturgies and practices that honor the communally understood ends of bodies more than their efficient function. This is a tall order for religious bodies in the United States, especially for a culturally accommodated Christianity, but that has the practical advantage of giving us something to do for the foreseeable future.

As for doctors, like me, we might begin by re-imagining families like Tamika’s as (at least possibly) situated in a community rather than as individuals who may need their spiritual concerns managed with the help of a social worker or non-denominational hospital chaplain. While I’m seeing patients on morning rounds, I have to remind myself—since nothing else in the hospital will—that, in the words of Wendell Berry, “the community—in the fullest sense: a place and all its creatures—is the smallest unit of health and that to speak of the health of an isolated individual is a contradiction in terms.”19

Finding functioning communities may take some sleuthing where churches, voluntary associations, and neighborhoods increasingly resemble convenience samples of atomized individuals, nor are all communities necessarily healthy. Going out of my way to situate my patient in community will take time, complicate my interactions with the family, and almost certainly reduce my efficiency and productivity. Nevertheless, the isolated sovereign self is overmatched by the social power of medicine, and to do nothing more than reassure my patients that the choice is up to them is at least an act of omission in my professional duty, if not active abandonment.

In any case, Jeffrey Bishop has delivered modern medicine an ethical challenge too important to leave to the doctors and hospital administrators. Furthermore, the language of modern medicine, with its buried assumptions and effaced metaphysics, must be called out and enriched with older words and more fitting grammar. If the church truly understands itself to be the living Body of Christ, it will act accordingly, reclaiming at least for its professed members the proper ends toward which our individual but interdependent bodies are committed.