Symposium Introduction

Hille Haker

Response

To Live Well and To Die Well

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.


  1. Bishop claims both this and the opposite: death seems to be repressed, yet as repressed it is at the core of medicine (and contemporary society), he claims (15); yet: where death is (at the core), life cannot be—hence, it is the anticipatory corpse (not death!) that informs the treatment of life.

  • Jeffrey Bishop

    Jeffrey Bishop

    Reply

    A Response to Hille Haker

    I am intrigued by the fact that my book has been reviewed so favorably and enthusiastically from theological circles. It has been reviewed in a couple of philosophy journals, a couple of medical journals, a few medical ethics/medical humanities journals, and a couple of public policy journals. Yet, there have been nearly more reviews in theological journals than the others combined. Theologians, much to my pleasure, have taken up my challenge at the very end of the book, a challenge stated in the form of a question; Might it not be that only theology can save medicine?It is both odd and, at the same time, the most sensible thing, to think that theologians would be the most vociferous in their praise and response to the book. On the one hand, The Anticipatory Corpse is primarily about medicine, and medicine’s implicit philosophy. Why would theologians be so interested in what is a work of philosophy? On the other hand, it is not such a surprise. After all, theologians like Paul Ramsey, Richard McCormick, and Joseph Fletcher (if he can be called a theologian) first among the first to offer critiques of medicine (both practical and scientific medicine).1 Philosophers were, with a few exceptions, rather late to the game.2 Certainly there are major theologians who have commented on medicine over the years, like Stanley Hauerwas, John Swinton, Robert Song, Lisa Cahill, and the late Allen Verhey. Yet, those voices are not a central part of the engagement with contemporary medicine or its regnant bioethics. The establishment of medicine and bioethics mostly ignore these thinkers.

    In responding to these commentaries on my book, I have become even more convinced that the diagnosis my book makes is correct and that the source of salvation for medicine must come from outside medicine. In this essay, I shall outline what I meant in the final pages of the book, when I said, “Might it not be that only theology can save medicine?” (313).

    * * *

    I am grateful to Hille Haker for her robust engagement of The Anticipatory Corpse. Haker concentrates on my critique of the structural features of health care, and the way in which they shape decisions in a subtle manner. Haker points to two domains that I engaged in the book—organ donation and spiritual care of the sick. I would like to elaborate on another domain—namely physician assisted suicide, which has been sanitized to physician-assisted death. Organ donation and spiritual care of the sick occur within the hospital setting; physician-assisted death requires the sanction of the state. Therefore physician-assisted death carries a more diffuse power with it, and that power is subtle and shapes the imagination of the culture. Take the legislation in the oldest law in the United States that sanctions physician-assistance dying, the Oregon Death with Dignity statute: it was written in such a way as to make absolutely certain that the patient’s decision is her own and to make sure that she has no psychiatric or other reason for requesting death. She has to make a request for assisted death in writing and witnessed by two people. In addition, the physician has the option of referring the patient for psychiatric or psychological evaluation, and she must be referred to at least one other physician for evaluation.

    The patient is assessed at each step to be certain that the decision is really her own. Thus, the legal structure of the request requires the patient to convince her doctors that she is making her own free, informed, and rationally justified decision. At the same time, as she is convincing her doctors, she is also convincing herself that this is the most logical of all decisions. The power behind medicine and the power behind the law confirm for her that this choice is a logical and rational response to the diagnosis. Thus, the social apparatus of hospice care will be fundamentally altered when assisted death is legally sanctioned.  The patient will soon find herself in a situation in which the option for death is always there at hand. Soon she will be forced to defend to herself why she continues to choose to stay alive.

    Put differently, there are logics that are created within the auspices of our institutions. These logics are enabled by social structures and they do contribute to our decisions. These logics bleed over into public reason, creating a public attitude that the only form of compassionate care for those who are “needlessly suffering,” is the option to end it once and for all. In fact, this past summer Archbishop George Carey—a bastion of conservative Christianity—and Archbishop Desmond Tutu both came out supporting legislation in Great Britain that would legalize physician-assisted death, succumbing to the logic of the social apparatuses of the late-modern West.

    Haker notes that the patient comes to identify with the medical gaze, to internalize it. I agree with her conclusion.

    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 do live well and how to die well, in the age of surveillance, measuring, normalization (3).

    The medical-legal apparatus creates our social imaginary; it participates in the constitution of what is possible. Haker hopes to reclaim a different tradition of inquiry, one that focuses on meaning and interpretation rather than explanation. Her therapy for this predicament is not far off from mine. For I claim that within communities that sit at the margins of the late modern West, interpretation and meaning are possible. It is possible for particularity to flourish there, even in our dying, against the tide to homogenize and normalize.


    1. R. A. McCormick, “To save or let die. The dilemma of modern medicine.”  JAMA 229:2 (1974) 172–6; R. A. McCormick, “The quality of life, the sanctity of life.” Hastings Cent Rep 8:1 (1978) 30–36; Paul Ramsey, Patient as Person. New Ed edition ed: Yale University Press, 1974); Joseph Fletcher, Morals and Medicine (Boston: Beacon Press, 1960); Joseph, Fletcher. “Indicators of Humanhood: A Tentative Profile of Man.” Hastings Cent Report 2:5 (1972) 1–4.

    2. John Hyde Evans, The History and Future of Bioethics (New York: Oxford University Press, 2012); Albert R. Jonsen, The Birth of Bioethics (New York: Oxford University Press, 1998).

    • Hille Haker

      Hille Haker

      Reply

      A Reply to Jeffrey Bishop

      While I am very sure that we agree on most aspects of his analysis, I am still not so sure whether I follow Jeffrey Bishop’s conclusion about theology or religious communities.

      Why?

      I am a Catholic theologian engaged day by day with theology, and I am hesitant to add to the image of religious communities resisting mainstream medicine and/or philosophy. In many ways, they are not, and whether this is the solution we are looking for.

      Re. assisted suicide: the Catholic Church, for example, opposes it, but at the same time it is either too weak or to indifferent (or both) when it comes to caring for the very sick. It is an idealized image and wishful thinking that Catholic hospitals or nursing homes are radically different from non-Catholic hospitals. Yes, they may experiment a little more with different forms of care—but they, too, feel the financial constraints, must comply with the rules, make (or must make) compromises, etc.

      The Catholic Church is not exactly know to be a haven for ‘individual autonomy’—but in your example, autonomy becomes the rule of the practice, and hence the individual must show that everything he or she does is indeed ‘autonomous’. I agree about the dynamic. But again: what is the consequence? Not to demand autonomy as condition for any life and death decision? This cannot follow. Rather, it may be better to ‘re-contextualize’ the choices we make: sometimes, there may be better medical treatments available than patients think (under-funding of palliative medicine is well documented); sometimes, however, the best possible medication will not change a person’s determination. But here, ethics needs to ask what the action plans are, how they relate to other forms of suicide, what exactly the burden is for the physicians, etc.—This is a question for medical ethics, for psychological and social ethics—and ultimately for legal ethics. Theology as such should take part in this conversation—but guide the way? I am not convinced.

      I am also hesitant if theology (as academic discipline) were to carry the weight of changing the epistemology. That is the reason why I wanted Jeffrey to explore further the philosophical tradition of hermeneutics as a way to ‘know’ differently. I am convinced that a ‘critical hermeneutics’ (one in discerning the myths, the underlying rules of discourses, which guide and ‘govern’ our understanding) is well able to identify the shortcomings of the two epistemological frameworks Jeffrey addresses. Whether this is done from a philosophical or a theological perspective—both will oppose the reductionist concepts so often used in medicine, medical humanities, and medical ethics.

      And therefore I would like to repeat why I admire this book: It shows historically the effects of the ‘medical gaze’ that is necessary in science; still, it does not work when medicine is considered as a hybrid between science and practice. Furthermore, the book shows how we—bioethicists or medical ethicists—cannot give in to the transformation of individual fates and/or life-stories into ‘particular cases’ of the ‘average man’ (or woman).

      Bioethics must identify the space to address the patient as an individual; it must not function similar to bio-law that necessarily generalizes individual cases.

      There is so much methodological confusion that Jeffrey identifies within biomedicine and biohumanities—that I wonder whether this makes it so tempting to hand it to theologians with the message: “why don’t you fix it?”—I see this happen in several contexts, and I fear that it will not be sufficient. Sure that Jeffrey agrees with that.

    • Jeffrey Bishop

      Jeffrey Bishop

      Reply

      Reply to Hille Haker

      When I suggested that it might be theology that saves medicine, I did not mean that some theologian in an academic theological department would pave the way for a new medicine. Nor did I think that some theologian, say Barth or Bonhoeffer, for example might get us past this problem. I did hope that people would engage my last question asking how major theologians might characterize or help to assuage our contemporary predicament in medicine. Frankly, hearing what Barth or Bonhoeffer or Hauerwas might have to say would be altogether more interesting than the extremely dull bioethics that is produced in the medical academy. I hope that I am not merely abdicating the task to theologians.

      I am in agreement with Hille’s point that Catholic hospitals can be indistinguishable from any other hospital that has to turn a profit in order to offer care at all. However, I think that Hille’s individual/autonomy will not suffice as a fulcrum to do work against the biopolitical apparatus that is modern medicine. (I suspect she and I agree here as well.)

      Hille points me to critical hermeneutic theory. I am certain that a critical hermeneutics will no doubt uncover not only different aspects of human being, living, dying, and thriving, but also different non-reductive forms of knowledge. (In fact, I just read a lovely dissertation on narrative-hermeneutic approach to bioethics,which I hope our student will turn into a book.) Still, I am hesitant to think that philosophers of hermeneutic theory can do much better than physicians, scientists, or theologians.

      What I did mean is that those things deemed as quaint mythologies by the dominant scientific/explanatory world view, might be the source of our salvation. It seems to me that the practices of these marginal communities (most of which would be billed as religious or spiritual) is to interpret their narratives in the context of their present milieu, or rather to interpret their present situation in light of their narrative. These communities are skilled at making sense of the lived worlds of particular persons and do so reasonably well, even while we might quibble with certain dogmatic authoritative statements to which we might ask persons to conform.

      It seems to me that there is something about robust faith communities such that they do give hope and comfort to those who are suffering. They do not eschew the interpretative (and narrative) work to makes sense of human being, living, dying, and suffering such that in our being, living, and even in our dying and suffering, we might find a way to thrive. In fact, the malleability of these narratives through the interpretative task is precisely what gives meaning to particular persons such that thriving is possible even for those who are suffering and dying.

      In the last chapter of The Anticipatory Corpse, before I conclude with the question “might it not be that only theology can save medicine” I attempted to make the case that in late modernity we are stuck between transcendentals of time and space, which are now immanentized now as history and politics. It seems to me that we must turn to traditions and practices. It seems to me that traditions are historical modes of engaging what is at hand; practices are ways of comporting ourselves to others as their needs become manifest. Living traditions and practices of being open to the needs of the other are precisely what liturgical practices enable.

      My colleague, Harold Braswell has done an ethnography of hospice care in several settings. One of those settings was in Our Lady of Perpetual Charity, a home for poor cancer patients who are dying. He notes that the Dominican Sisters of Hawthorne provide care that is structured by their life of prayer and eucharist. I do not mean to romanticize what the sisters do. One cannot do justice to the hard work of caring for the dying, by romanticizing it. Yet, there is a sense in which they are engaged in a hermeneutic task that requires them to both tell, and retell their larger narrative of engaging the body of Christ in eucharist and in the other, while at the same time being open to the challenge that the person before them presents to that narrative. A true theologian may be one who prays and works, such that prayer and work are indistinguishable.

Andrea Vicini

Response

A Medical Soul of Life and Living

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.

  • Jeffrey Bishop

    Jeffrey Bishop

    Reply

    A Reponse to Andrea Vicini

    I am, of course, grateful to Andrea Vicini for taking time to read and to engage several of the ideas in The Anticipatory Corpse. Vicini writes that he appreciates that my overall critical analysis of medicine’s metaphysics and epistemology, but he states that my analysis “can be disembodied if it leaves aside the relational dimension . . . that should characterize any medical practice and medicine as a whole”(1). He notes that the dead body is only the beginning of medicine. While I am tempted to say that there is not much that Vicini and I disagree on, there are several things that I think Vicini glosses over. He does not make distinctions between different kinds of medicine. After all, my claim is that, because the beginning of modern, Western medicine is grounded in the corpse (the main thesis of The Anticipatory Corpse), the structures created by medicine constrain the way in which practitioners relate to their patients.

    Vicini notes a contrast between my analysis “and Christian involvement in health care,” pointing to St. Francis, a pre-modern figure in Christian history (1). He notes that I have left out “other relevant components” like “regenerative medicine, alternative medicines, healthy ways of living, preventive medicine, and public health and global health” (2). First, St. Francis is a premodern figure; second, let’s look at the ways in which regenerative medicine, alternative medicine, healthy ways of living, preventative medicine, and public and global health are shaped by contemporary Western medicine.

    One way to look at regenerative medicine is precisely the way that Vicini examines it. Certainly, there are elements of regenerative medicine that focus on stimulating the body’s intrinsic nature to heal (2). Yet, regenerative medicine does not escape the dominant metaphysical assumptions and epistemological stances that dominate medicine. Regenerative medicine also seeks to use the principles of molecular biology along with the drive to engineer tissue and to regenerate human organs, which sounds lovely. However, regenerative medicine does not escape the dominant metaphysics of medicine in which the material and efficient causes of medicine are elevated, while the telos of medicine is immanent to some version of the greatest good for the greatest number of people—which is precisely my critique of modern Western medicine. The efficient mechanisms of technology are not tapping into the body’s intrinsic healing mechanisms so much as it is coercing the body to behave in the ways that we desire.

    Likewise, Vicini praises alternative medicine, which is “based on different metaphysical and epistemological approaches, often depending on harmonic relationships with oneself, others, and creation” (2). Again, the sentiment is lovely. Yet, in the 1990s, the NIH proposed to study Chinese medicine—one of the alternative medicines. Chinese medicine operates on a different geography of the body and on the assumption that the whole is greater than the sum of its parts. Whereas Western science operates on an anatomical pattern grounded in Western notions of the body, and on the idea that we can isolate the molecular basis of herbal medicine, identifying the active ingredient—the part that makes the whole thing work. The animating Western logic is that the whole is the sum of the parts. Western medicine only accepts alternative medicine if it can be transformed into medicine’s own metaphysical and epistemological schema. That will mean that the “harmonic relationships with oneself, others, and creation” that Vicini touts as the good of alternative medicines, lose their power in the drive toward the understanding of efficient mechanism directed at the effective control of the machine body.

    Lifestyle choices, preventative medicine, and public health are also good things if they can be rightly situated. There can be no doubt that shifting a society’s life-style choices could prove to be the simplest and least costly way to ensure the health of society, overall. Usually, these choices are circumscribed by what is available, and at present in the West, these are driven by consumer demand, which is tightly correlated to socio-economic status. Moreover, preventative medicine and public health are prone to the surveillance and panopticon culture of medicine, and each is prone to political and economic control, again serving the immanent telos of the greatest good for the greatest number of people. In short, these factors are not counter-cultural to the medicalized West, but are part and parcel of the biopolitical realities that animate Westernized states bent on controlling bodies like so many cogs in the body of the Leviathan.1

    Put differently, Vicini too readily accepts medicine and thinks that these five domains escape the hegemony of Western materialist medical science directed at efficient and effective of control of the bodies of people, ordered by the greatest good to the greatest number, where the greatest good is defined biopolitically, and perhaps bioeconomically. In short, Vicini essentializes medicine. He conflates Western medicine with medicine as it is practiced in other settings. He states:

    While I was reading Bishops’ [sic] 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” (i.e., 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.

    Searching for a place where my analysis does not work is precisely the thing I called for at the end of The Anticipatory Corpse. I concluded the volume by noting that it is precisely at margins of Western medicine—the places like St. Mary’s—where we might find hope. The medicine at a place like St. Mary’s may indeed be ontologically different from the medicine created at the heart of the West. Vicini risks conflating the practices at St. Mary’s with Western medical practices. These are two different kinds of medicine, because they originate in different metaphysical and epistemological milieux, resulting in different a different set of ethical quandaries. I hope Vicini will strive to show precisely what the differences are in the metaphysical assumptions and epistemological commitments at a place like St. Mary’s, so that we might see a different ethic at work. That is what I meant when I concluded with my question, “Might it not be that only theology can save medicine?” (313). Might it not be that only those practices, those traditions and locations that have resisted Western medical hegemony, can save Western medicine?


    1. Thomas Hobbes, Leviathan. Edited by Richard Tuck (Cambridge: Cambridge University Press, 1996).

Kara Slade

Response

Singing Down to the Dust

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).

Figure 2The 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.

 


  1. Michel Foucault, The History of Sexuality Volume 1 (New York: Pantheon Books, 1978), 65.

  2. The Book of Common Prayer 1979 (New York: Oxford University Press), 482–83.

  3. Diego Velazquez, Las Meninas, 1656.

  4. Michel Foucault, The Order of Things: An Archaeology of the Human Sciences (New York: Pantheon Books, 1970), 310.

  5. Michel Foucault, The History of Sexuality Volume 1: An Introduction, translated by Robert Hurley (New York: Vintage Books, 1990), 64–65.

  6. Michel Foucault, “The Subject and Power,”in The Essential Foucault: Selections from The Essential Works of Foucault 1954–1984, edited by Paul Rabinow and Nikolas Rose (New York: The New Press, 2003), 131–32.

  7.  In noting this shift, I would like to clearly and explicitly state that I am not proposing a nostalgic return to a model of hegemonic Christendom which still holds the figure of Western man at its center, and which would exercise power in ways that are intelligible as power in worldly terms. In Christ, all notions of power and authority are recast in the person and work of the one who became flesh and dwelt among us in the form of a servant. That being said, I would agree with Sam Wells that the prevailing problem of authority in many corners of my own tradition is not so much the overuse of ecclesial authority but the refusal to exercise or even acknowledge it.

  8. Foucault, “The Subject and Power,”133.

  9. Book of Common Prayer, 485.

  10. Rowan Williams, “Death is Real; Death is Overcome,”Dr. Rowan Williams, 104th Archbishop of Canterbury. I commend this sermon to everyone as a model of how to preach the resurrection in the contemporary context.

  • Jeffrey Bishop

    Jeffrey Bishop

    Reply

    A Response to Kara Slade

    I begin The Anticipatory Corpse with two insights from Foucault. Kara Slade brings the book (and us) back into conversation with Foucault. She highlights the way in which medicine, through what I have called the biopsychosociospiritual model, has garnered more and more power unto itself. Whereas the relationship of religion to science has undergone major shifts over the last two hundred years, the movement of religion away from medicine was rather slower. Medicine has only in the last sixty years set itself further apart from religion. What we are seeing, then, is secularization at work.

    In fact, the rise of bioethics finds its origins in theological critique of contemporary medicine of the 1950s–1970s with the work of Joseph Fletcher (if Fletcher can be called a moral theologian, having abandoned the faith at the end of his life), Paul Ramsey, and Richard McCormick.[ref]R. A. McCormick, “To save or let die. The dilemma of modern medicine.” JAMA 229:2 (1974) 172–6; R. A. McCormick, “The quality of life, the sanctity of life.” Hastings Cent Rep 8:1 (1978) 30–36; Paul Ramsey, Patient as Person. New Ed edition ed: Yale University Press, 1974); Joseph Fletcher, Morals and Medicine (Boston: Beacon Press, 1960); Joseph Fletcher, “Indicators of Humanhood: A Tentative Profile of Man.” Hastings Cent Report 2:5 (1972) 1–4.[/ref] Even as recently as 1959, a group of anesthesiologists asked Pope Pius XII whether patients necessitating ventilators, but for whom there was no hope of recovery, could be removed from the machines.[ref]Pius XII, “The Prolongation of Life.” In Death, Dying and Life, edited by Dennis J. Horan and David Mall (Washington, DC: University Publications of America, 1977), 281–87.[/ref] One cannot imagine a group of physicians, qua physicians, asking Pope Francis a question about medical morality. During the 1970s there was a concerted effort to marginalize the “ideologies” of religion from discussions in medical morality and to move to theories of common morality to ground medicine.[ref]John Hyde Evans, The History and Future of Bioethics (New York: Oxford University Press, 2012); Albert R. Jonsen, The Birth of Bioethics (New York: Oxford University Press, 1998).[/ref]

    Even while Western medicine cannot help but deploy its scientism, it has also known that patients are persons, and that they are in need of solace when they are ill. Thus, pastoral ministry in the hospital became a more substantial reality through the rise of hospital chaplaincy. A genealogy of the rise of chaplaincy has not yet been written. Yet it seems to me that the rise of chaplaincy programs in the hospital illustrate several trends in secularization. There was a time when medicine was not so hostile to religion. Through the years, greater numbers of patients were arriving in hospital without pastoral guidance. As H. Tristram Engelhardt, Jr. has noted, pastors would have trained in their particular traditions’ clergy-formation programs or seminaries. Therefore, a Methodist pastor may not know how to minister to a Catholic patient. Thus, there seemed to be a need to create Clinical Pastoral Training programs. So, after ordination, the clergy-person would then have to undergo a different sort of training through Clinical Pastoral Education internships and residencies.[ref]H. Tristram Engelhardt, “Generic Chaplaincy: Providing Spiritual Care in a Post-Christian Age.” Christian Bioethics 4 (1998) 231–38.[/ref] Rather than being a part of a specific tradition, having learned the craft of pastoral ministry for their congregants, the generic chaplain is formed within the structure of the hospital with the ability to minister to all comers with or without faith. The chaplain can be a chaplain to anyone, which may me she can be a chaplain to no one.

    Of course, with rising health care costs in the 1980s and 1990s, hospital chaplaincy programs were put in a position of having to justify themselves.[ref]G. Fitchett, P. E. Murphy, J Kim, J. L. Gibbons, J. R. Cameron, and J. A. Davis, “Religious struggle: Prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients.” The International Journal of Psychiatry in Medicine 34.2 (2004) 179–96; George Fitchett, Assessing Spiritual Needs (Minneapolis: Augsburg Fortress, 1992); George Fitchett, Spiritual Assessment in Pastoral Care: A Guide to Selected Resources (Decatur, GA: Journal of Pastoral Care Publications, 1993); George Fitchett, “Screening for Spiritual Risk.” Chaplaincy Today (2009) 1–12; George Fitchett, “Health Care Chaplaincy as a Reserach-Informed Profession: How We Get There.” Professional Chaplaincy and Clinical Pastoral Education (2011) 1–7; E. McSherry and W. A. Nelson, “The DRG Era: A Major Opportunity for Increased Pastoral Care Impact or a Crisis for Survival?” Journal of Pastoral Care 41:3 (1987) 201; E. McSherry, “Modernization of the Clinical Science of Chaplaincy.” Care Giver 4:1 (1987) 1–13; W. McSherry and L. Ross, “Dilemmas of Spiritual Assessment: Considerations for Nursing Practice.” Journal of Advanced Nursing 38:5 (2002) 479–88.[/ref] What exactly do chaplains do, they were asked? How do they know when they have been successful in what they do? What added value does the chaplain bring to the patient or hospital? Chaplains were asked to prove their values. Thus, chaplains began to create spiritual assessment tools, first so that they could justify their existence to hospital administrators by measuring what they do. Then they began to justify spiritual assessment in order to promote quality assurance on themselves. These assessment tools usually theorize and operationalize “spirituality” as some sort of psychological coping mechanism, something quite different than administering the sacraments or granting absolution to the penitent.

    Slade, having suffered through a CPE internship understands this (personal communication). The chaplains, if their trade is going to be permitted in the clinic (the hospital) will have to produce scientific discourses of truth, through the deployment of social scientific methods. The pastoral function in the care of the sick has shifted from the institution of the Church to the institution of medicine, resulting in the mutation of the pastoral function into something almost unrecognizable by the Church. Slade’s disconcerting insight is that the goods of medicine have begun to shape what the Church does, at least her branch of it, as it rewrites its funeral liturgy.

    Slade concludes with hope that the Church can somehow take back its role from medicine; “. . . the church is always, already called to sing otherwise” than medicine (6). Her hope for our salvation from the biopolitical apparatus—that is say, from the biopsychosociospiritual medicine—resides precisely where I conclude my book. “Might it not be that only theology can save medicine?” (313).

    By theology, I did not mean those of us who are academics doing what we do best, plying the thought of their favorite scholar. Accepting Evagrius’s statement that a theologian is one who prays, I meant that the theologians that might save medicine are those who pray and work in the care of the sick.[ref]Evagrius Ponticus, The Praktikos: Chapters on Prayer. Translated by John Eudes Bamberger (Collegeville, MN: Cistercian Publications, 1972).[/ref] I meant those communities that pray and engage in Liturgy, and also engage in the care of the sick and dying. I had in mind those groups like the Hawthorne Dominican Sisters, who run hospices around the world.[ref]Harold Braswell, “Death and Resurrection in US Hospice Care: Disability and Bioethics at the End-of-Life” (PhD dissertation, Emory University, 2014).[/ref] These nursing sisters work outside the health care system because they do not qualify as a hospice under these Medicare/Medicaid rules. The grammar of their work is shaped by daily prayer and liturgy as they offer care to the dying. These groups, with their liturgical and health care practices, are perhaps the St. Benedicts[ref]Alasdair MacIntyre, After Virtue, 3rd ed. (Notre Dame, IN: University of Notre Dame Press, 2007), 263.[/ref] and the St. Dominics[ref]C. C. Pecknold, “The Dominican Option.” First Things, October 16, 2014. http:/C:/dev/home/163979.cloudwaysapps.com/esbfrbwtsm/public_html/syndicatenetwork.com4.firstthings.com/web-exclusives/2014/10/the-dominican-option.[/ref] upon whom we have been waiting. They exist at the margins of the West; they are rightly oriented, having first faced Liturgical East.

    • Hille Haker

      Hille Haker

      Reply

      Comment on “Singing Down to the Dust”

      With this turn of the discussion, we begin to discuss the final part of Jeff’s book—and this is as important as the medical epistemology debate we started before.

      Perhaps one must go a little further back, however: before the ‘CPE’ turn of the 1970s, pastoral care centered more on rituals than on communication: in my (Catholic) tradition, this meant it was sacramental. Also, one should note that before the scientific turn of medicine in the 19th century, theology (or rather: religion) was considered to have healing power—today, we would call this the positive effect of “placebo” medicine!
      But then, I would hold, the medical expertise was handed over to the physicians (again: Jeff’s book offers many insights to this history), and it left ‘pastoral’ care in a kind of a limbo.

      The communicative turn of the 1970s tried already to counter the inability of technology to conceptualize the patient as a person or rather, as I would hold, an individual embedded in a particular context and with a particular biography (Wilhelm Schapp, phenomenologist, wrote a book on this with the title: caught in stories or ‘in Geschichten verstrickt’, one of the most important hermeneutical transformations of phenomenology, which Paul Ricoeur would later take up); today, this is echoed in the emphasis on ‘narrative medicine’ and narrative approaches within pastoral care.

      Jeff emphasizes the scientific-empirical turn of ‘spiritual care’—this is why I considered his elaboration on the social sciences – as the complement to the medical sciences—so important. It is certainly true that cultural pluralism, the US structure of chaplaincy, and the integration of chaplaincy (now: as spiritual care) into medical practices serves as the background for the current development, which conceives spiritual care as part of the ‘evidence-based’ social science approach—hence working with the model of the ‘average man’.
      In Germany, for example, this turn to spiritual care has not (yet) taken place: Churches, not hospitals, employ hospital chaplains; they are NOT part of the medical team; they represent their denominations, not a general psycho-spiritual care profession. However, there are several attempts to transform the pastoral care model into a spiritual care model, reflecting the US concepts.

      I consider this discussion not only important but central for a critical reflection on healthcare chaplaincy ethics. I call it this, over against the spiritual care model.

      If you are interested what I have done with that in an international project and are still doing, please check one of our books that is available in English (the others are in German): “Medical Ethics in Healthcare Chaplaincy” (http://books.google.com/books/about/Medical_Ethics_in_Health_Care_Chaplaincy.html?id=di2gjMlkipEC) — the book is part of an international project that addresses exactly the question how healthcare chaplaincy can be part of medical ethics without losing its own particular take on illness and suffering, and the patient as a person.

      For the book series: http:/C:/dev/home/163979.cloudwaysapps.com/esbfrbwtsm/public_html/syndicatenetwork.com4.lit-verlag.de/reihe/mehcc

      Thanks to both of you for emphasizing this necessary reflection and the conversation we need to have.

    • Kara Slade

      Kara Slade

      Reply

      A Reply to Jeffrey Bishop

      I am so grateful to Jeff for his thoughtful response, and I think both of us hope that our exchange will provoke discussion—not just among academic types, but also among chaplains. For now, at least, my comments in return will have to be quite brief because I have been waylaid by a very nasty virus. Quite frankly, I am more in the position of *needing* the benefits of contemporary medicine than *critiquing* them. But here we are.

      By far the aspect of my own experience in hospital chaplaincy that I found the most disturbing was the act of charting, or recording, the religious state of the folks I was ostensibly ministering to. It was as if John Wesley’s famous question, “How is it with your soul?” had been bureaucratized and turned into a tool of surveillance. Not incidentally, it was also the means by which the pastoral care department demonstrated its usefulness in delivering the ‘spiritual’ part of the biopsychosocialspiritual care product to the hospital administration. I’d be very interested in hearing Jeff’s thoughts on what happens in the act of charting “spiritual care” as a subset of social work or as a product delivered to the patient within the hospital or clinic.

      It strikes me that something very significant happens in the act of measuring, and recording, the work of chaplains within the framework of medical record-keeping. The technologies of the archive are being brought to bear on what should be some of the most intimate and holy times in the work of Christian ministry—and I think this is not a minor point. I think perhaps it points to the extent to which the technologies of power that pervade the hospital and clinic tend to overwhelm the work of the Church within it, and to force the Church to play by its rules. Chaplains are put in the impossible position of being asked to justify their own existence through acts of archival documentation, and I suspect this is just as bad for chaplains as it is theologically problematic.

      I do have a number of friends who work in hospital chaplaincy (Hi, friends!), and I think I’d want to ask them a not-entirely-facetious question: What would happen if you refused to record your work, to turn it into part of a medical archive? It’s something to ponder, at any rate.

    • Jeffrey Bishop

      Jeffrey Bishop

      Reply

      A Reply to Kara Slade and Hille Haker

      I am happy that both Kara Slade and Hille Haker see the importance of theological engagement with Chaplaincy. I think the task of theological engagement is something that that many chaplains think is necessary, at least those with whom I have engaged.

      However, I have come across several chaplains that seem to want to keep theological engagement at arms length. I can understand that the drive to conform to the institutional structures of the clinic (the hospital is really the clinic par excellance in the Foucauldian sense of the term clinic) continues to drive the work of chaplaincy. The question for chaplains is this: will you conform to the disciplines of the hospital?

Brian Volck

Response

Bodies Without Ends

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.

 


  1. I place the word “religious” in quotation marks to remind myself how recent and characteristically Euro-American is the meticulous and compulsive quarantining of “religion” from all other human experience. See, for example: William Cantwell Smith, The Meaning and End of Religion (Minneapolis: Fortress Press, 1962); Talal Asad,Genealogies of Religion: Discipline and Reasons of Power in Christianity and Islam (Baltimore: Johns Hopkins University Press, 1993); Nicholas Lash, The Beginning and the End of ‘Religion’ (Cambridge: Cambridge University Press, 1996); and William Cavanaugh, The Myth of Religious Violence: Secular Ideology and the Roots of Modern Conflict (Oxford: Oxford University Press, 2009).

  2.  See Simone Weil, “Forms of the Implicit Love of God,” in Waiting for God (New York: Harper and Row, 1951), 184. Weil is writing here about the way in which adherents of one religion may view others, but anyone who’s spent time in a teaching hospital has seen how much the institution resembles a religious temple, with its specially-garbed ministers and acolytes, cleansing rituals, and obfuscatory language. As Stanley Hauerwas writes, “. . . if you want to have a sense of what a medieval Catholicism felt like, become part of a major medical center.” Stanley Hauerwas, “Positioning: In The Church and University But Not Of Either,” in Dispatches from the Front: Theological Engagements with the Secular (Durham, NC: Duke University Press, 1994), 27.

  3.  For the record, I’m not arguing that rights don’t exist, only that an allegedly post-metaphysical age has “. . . a lot of ‘splainin’ to do,” regarding the origins and ontological status of universal rights. Jacques Maritain shares an overheard quip in his introduction to a UNESCO document on human rights: “. . . someone expressed astonishment that certain champions of violently opposed ideologies had agreed on a list of those rights. ‘Yes,’ they said, ‘we agree about the rights but on condition that no one asks us why.’ That ‘why’ is where the argument begins.”[footnote] Jacques Maritain in Human Rights: Comments and Interpretations, Allan Wingate, ed. (New York: UNESCO, 1949), 9–17 (accessed online at http://unesdoc.unesco.org/images/0015/001550/155042eb.pdf ). For a secular account of rights that has its cake and eats it, too, see Richard Rorty, “Human Rights, Rationality, and Sentimentality,” in On Human Rights: The Oxford Amnesty Lectures, Shute and Hurley, eds. (New York: Basic Books, 1993), 111–34.

  4. I suspect it would be equally as difficult persuading them that measurability does not necessarily imply existence. For an example of how much can go wrong in measuring what one wants to believe exists, see Steven Gould, The Mismeasure of Man, (New York: WW Norton and Company, 1981), especially the chapter, “The Real Error of Cyril Burt,” which is a rather technical deconstruction of “g,” or “General Intelligence,” but well worth the effort.

  5. Julien Offray de La Mettrie (1709–51) was a French Enlightenment materialist, physician, and philosopher, whose most famous work was L’homme machine, translated as, “Man, the Machine” or “The Human Mechanism.” Marie François Xavier Bichat (1771–1802) was a French anatomist and early founder of histology and anatomical pathology who defined life as “the sum of the functions by which death is resisted.”

  6. See Carl Elliott, “Amputees by Choice,” in Better than Well: American Medicine Meets the American Dream (New York: WW Norton and Company, 2003), 208–36; and Lauren Slater, “Dr. Deadalus: A Radical Surgeon Wants to Give You Wings, Harper’s, July 2001.

  7. See Michel Foucault, Discipline and Punish: The Birth of the Prison (New York: Vintage Books, 1995).

  8. Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (New York: Vintage Books, 1994).

  9. See, for example, Zygmunt Baumann, “The Postmodern Uses of Sex,” Theory, Culture, and Society 15, no. 3 (1998): 19–33.

  10. Aldous Huxley, in his foreword to the 1946 edition of Brave New World, wrote A really efficient totalitarian state would be one in which the all-powerful executive of political bosses and their army of managers control a population of slaves who do not have to be coerced, because they love their servitude” (accessed online athttp:/C:/dev/home/163979.cloudwaysapps.com/esbfrbwtsm/public_html/syndicatenetwork.com4.wealthandwant.com/auth/Huxley.html).

  11. Foucault, Birth of the Clinic, 126.

  12. In large academic presentations in my current hospital and medical school over the past fifteen years, I have heard speakers assert the following without evidence or qualification: that Christians systematically burned ancient medical texts for fear of pagan origins, that American eugenic sterilization was an exclusively religious phenomenon, that maltreatment of disabled persons results from a belief in Original Sin, and that psychiatrists are poorly paid because the Catholic Church forced Descartes to write that the mind and the body are completely separate entities. As there is ample evidence that Christians have done very bad things over the past two millennia and that some were complicit in the above mentioned processes—at least those that actually happened; see, for example, Christine Rosen,Preaching Eugenics: Religious Leaders and the American Eugenics Movement (London: Oxford University Press, 2004)—it’s disappointing to hear highly-credentialed, educated persons indulge themselves in simplistic white hat vs. black hat tales.

  13. “A Definition of Irreversible Coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” Journal of the American Medical Association 205 (1968): 337–40.

  14. Presidents’ Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research,Defining Death: Medical, Legal and Ethical Issues in the Determination of Death (Washington, DC: US Government Printing Office, 1981).

  15. Bishop examines accounts by Mita Giacomini, “A Change of Heart and and a Change of Mind? Technology and the Redefinition of Death in 1968,” Social Science & Medicine 44, no. 10 (1997): 1465–82 and Margaret Lock, Twice Dead: Organ Transplants and the Reinvention of Death, (Berkeley: University of California Press, 2001), in support of the brain death-transplantation linkage; and Calixto Machado, et al.,“The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants,” Journal of Medical Ethics 33, no. 4 (2007): 197–200, which challenges the association. In his book, Bishop carefully explains why he finds the former accounts persuasive.

  16. Robert Spaemann, “Is Brain Death the Death of a Human Person?” Communio 38 (Summer 2011): 326–40.

  17. See John Paul II, “To the Participants in the International Congress on ‘Life Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,’” March 20, 2004 (accessed online:http:/C:/dev/home/163979.cloudwaysapps.com/esbfrbwtsm/public_html/syndicatenetwork.com4.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html); The Congregation for the Doctrine of the Faith, “Responses To Certain Questions Of The United States Conference Of Catholic Bishops Concerning Artificial Nutrition And Hydration,” August 1, 2007, (accessed online:http:/C:/dev/home/163979.cloudwaysapps.com/esbfrbwtsm/public_html/syndicatenetwork.com4.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20070801_risposte-usa_en.html ); Pius XII, “The Prolongation of Life,” in Death, Dying, and Life, edited by Horan and Mall (Washington, DC: University Publications of America, 1977); and John Paul II, Evangelium Vitae (Washington, DC: US Catholic Conference, 1995).

  18. If I understand Peter Singer correctly, he sees the PVS-brain death distinction as lacking practical significance. While Singer rejects brain death criteria for reasons similar to those presented by Bishop, he argues that a persistent vegetative state means the person who once existed has ceased to be. In the absence of previously expressed wishes to the contrary, Singer would argue that such a patient can and perhaps should be euthanized. See Peter Singer, Practical Ethics (Cambridge: Cambridge University Press, 1993) and Rethinking Life and Death: The Collapse of Our Traditional Ethics (New York: St. Martin’s Griffin, 1996).

  19. Wendell Berry, “Health is Membership,” in Another Turn of the Crank (Washington, DC: Counterpoint, 1995), 90. Later in the same essay, Berry anticipates some of Bishop’s argument when he writes, “The body alone is not, properly speaking, a body. Divided from its sources of air, food, drink, clothing, shelter, and companionship, a body is, properly speaking, a cadaver, whereas a machine by itself, shut down or out of fuel, is still a machine.” Ibid., 94.

  • Jeffrey Bishop

    Jeffrey Bishop

    Reply

    A Response to Brian Volck

    It is gratifying to find the thesis of The Anticipatory Corpse confirmed by Brian Volck, a practicing physician. I should say that the book was written because there was something that I felt amiss during my training and then in the years of my practice. In a way, the book was an attempt to diagnose the malaise that I had felt all those years. Volck points out precisely how easy it is for a student to be seduced by medicine’s language, just as I had been, even while the malaise persisted.

    Medical students are some of the easiest students to teach. We were (and they are) driven to succeed, and the condition for the possibility of success is conformity to the structures of medical education and the content of that education. When presented with conundrums, usually in the form of perplexing ethical issues, it is easiest to just let the absurdities that we encounter go and to appeal to the traditions of medicine, like autonomy and informed consent, which Volck notes are just-so fictions meant to allow medicine to function smoothly. Never mind that we all know the right medical answer and we are taught motivational interviewing to convince patients of what the right answer is. In what way does autonomy reign supreme, and how does a patient give consent if we are attempting to convince our patients what is the best medical answer? There are other absurdities, such as when presented with a case, and for us she is a case, like that of Jahi McMath; we know it is absurd that she is dead to her physicians and to state of California, and yet she is alive to her family and the caregivers that care for her. Such were the absurdities of my education, and the education of all medical students. To deal with these, I had to dig, and dig deeply, to find what permits otherwise really smart people to hold to such absurd positions even against readily available countervailing sense experience. Such is the power of medicine; it is able to convince otherwise intelligent people against reason and sense, to make our social constructions come to life.

    Volck captures the thrust of my argument precisely, and with the erudition of both a man of letters and a man of science. There are two points that Volck has brought clearly into relief for me. The first point illustrates a point of clarification that I should make. The second demonstrated how vague my conclusion is.

    First, Volck’s framing of the thesis of The Anticipatory Corpse, even while he captures it well, demonstrates that I should have been a bit more careful with my language around the use of Aristotelian causation. I stated that material and efficient causes are elevated over formal and final causes. Though I never directly claimed that medicine completely drops formal and final causation, I left that impression. What I should have said is that the Western Enlightenment project severely curtailed formal and final causation, making them immanent and elevating material and efficient causes over the now immanent formal and final causes. Formal causes essentially become the laws of physics, which is really no more than power (energy) relationships between objects; final causes, that for the sake of which something is done, become the greatest good for the greatest number of people.

    Second, and more importantly, Volck brings into clear relief what I meant by the rather vague ending of The Anticipatory Corpse. I end with a series of questions that open to theological engagement; the final question, which is really more a statement, is: “Might it not be that only theology can save medicine?” Volck interprets rightly that I mean that local religious communities, engaged in practices of care may serve as a source for renewal, because they can relativize the normalizing power of medicine. Volck notes that local religious communities might promote 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 (9).

    Volck (much like Slade) wisely notes that this call might be too large for American Christianity, where Churches “resemble convenience samples of atomized individuals . . .” and where medical science holds such a central role in the everyday lives of these individuals. Volck captures concisely and precisely what I mean. It is in local parish communities, where particularities are celebrated over the generalization of medical science, where interpretation and meaning are possible over against the stale and thin truth making of the social sciences.

    Conclusion

    I am suggesting that the hospice beds should sit at the entrance of the Church near the baptismal fount. Parishioners, even small children, can greet their fellow parishioners as they enter the Church, where the practices of care of offered and received in plain view, and where the care of the failing body is a reminder to us all that we must give and, yes even receive care if we are to be the body of Christ. I do realize that the totality of healthcare cannot be delivered in the parish. Still, I am reminded of a woodcut image of the interior of the Hôtel Dieu in Paris dating to about 1500. It captures a scene in which the sick are being cared for by brothers and sisters; doctors, monks, and nuns minister to patients. The Eucharist is being shared with patients and the resurrected body of Christ animates the work of the kingdom.

    The historian Gary Ferngren has shown that the Christian Church thrived in Greco-Roman culture because it challenged the logic of the dominant culture. Christians cared for disabled children, where the Romans practiced exposure. The Christians remained in localities where epidemics were rampant, risking their lives. The chief virtue of the Benedictines, hospitality, would give birth to the hospices, hospitals, hostels, and hotels of Europe.[ref]Gary B. Ferngren, Medicine and Health Care in Early Christianity. (Baltimore, MD: Johns Hopkins University Press, 2009).[/ref] Christianity transformed Greco-Roman culture. I am not calling for some nostalgic return to the good old days. I do, however, think that it is possible that the Church can once again contain the world within it, and that it should strive to do so. Lord, I believe in that possibility; help my unbelief in that possibility.

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