Clinical Ethics and the Necessity of Stories: Essays in Honor of Richard M. Zaner

CLINICAL ETHICS AND THE NECESSITY OF STORIES

Philosophy and Medicine VOLUME 109 Founding Co-Editor Stuart F. Spicker

Senior Editor H. Tristram Engelhardt, Jr., Department of Philosophy, Rice University, and Baylor College of Medicine, Houston, Texas

Associate Editor Lisa M. Rasmussen, Department of Philosophy, University of North Carolina at Charlotte, Charlotte, North Carolina

Editorial Board George J. Agich, Department of Philosophy, Bowling Green State University, Bowling Green, Ohio Nicholas Capaldi, College of Business Administration, Loyola University, New Orleans, New Orleans, Louisiana Edmund Erde, University of Medicine and Dentistry of New Jersey, Stratford, New Jersey Christopher Tollefsen, Department of Philosophy, University of South Carolina, Columbia, South Carolina Kevin Wm. Wildes, S.J., President Loyola University, New Orleans, New Orleans, Louisiana

For further volumes: http://www.springer.com/series/6414

CLINICAL ETHICS AND THE NECESSITY OF STORIES Essays in Honor of Richard M. Zaner Edited by OSBORNE P. WIGGINS and ANNETTE C. ALLEN University of Louisville, KY, USA

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Editors Osborne P. Wiggins Department of Philosophy University of Louisville 40292 Louisville Kentucky USA [email protected]

Annette C. Allen Division of Humanities University of Louisville Humanities Building 303 40292 Louisville Kentucky USA [email protected]

ISSN 0376-7418 ISBN 978-90-481-9189-5 e-ISBN 978-90-481-9190-1 DOI 10.1007/978-90-481-9190-1 Springer Dordrecht Heidelberg London New York © Springer Science+Business Media B.V. 2011 No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osborne P. Wiggins and Annette C. Allen

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2 Keeping Balance in the Face of Death . . . . . . . . . . . . . . . . . Richard M. Zaner

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3 Richard Zaner on Transcendentality, Eidos and Phantasy . . . . . Ronald R. Cox

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4 The Limits of Biomedical Ethics and the Specific Role of Phenomenology in Biomedical Ethics . . . . . . . . . . . . . . . Thomas Nenon

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5 Richard Zaner and “Standard” Medical Ethics . . . . . . . . . . . Stephen Hanson

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6 Bioethics Without Analogy . . . . . . . . . . . . . . . . . . . . . . . Robert Hunt Sprinkle

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7 Phenomenological Nursing in Schutzian Perspective . . . . . . . . Lester Embree

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8 Zaner’s Generative Spirit . . . . . . . . . . . . . . . . . . . . . . . John R. Scudder, Jr. and Anne H. Bishop

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9 Integrity and the Moral Gestalt: Zaner Tells his Mother’s Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Denise M. Dudzinski 10

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Between and Beyond: Medicine and Narrative in Dick Zaner’s Phenomenology . . . . . . . . . . . . . . . . . . . . . . . . Hillel Braude

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Fardels of the Heart: Obesity and the Unbearable Heaviness of Being . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul A. Komesaroff

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The Philosopher as Ethicist, The Ethicist as Storyteller . . . . . . . Arthur W. Frank

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The Ecstatic Witness . . . . . . . . . . . . . . . . . . . . . . . . . . Rita Charon

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¯ row) . . . . . . A Story Teller’s Story: Richard Zaner as Hero (HE Paul J. Ford

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On the Telling of Stories . . . . . . . . . . . . . . . . . . . . . . . . Richard M. Zaner

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Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contributors

Annette C. Allen Division of Humanities, University of Louisville, Louisville, KY 40292, USA, [email protected] Anne H. Bishop Professor Emerita, Nursing Lynchburg College, Lynchburg, VA, USA, [email protected] Hillel Braude Biomedical Ethics Unit McGill University Montreal, Quebec, Canada, [email protected] Rita Charon Professor of Clinical Medicine and the Director of the Program in Narrative Medicine at the College of Physicians and Surgeons of Columbia University, New York, USA, [email protected] Ronald R. Cox Department of Philosophy, San Antonio College, San Antonio, Texas, [email protected] Denise M. Dudzinski Department of Medical History and Ethics, School of Medicine, University of Washington, Seattle, WA, USA, [email protected] Lester Embree Department of Philosophy, Florida Atlantic University, Boca Raton, FL 33431, USA, [email protected] Paul J. Ford Department of Bioethics, Cleveland Clinic, Cleveland, Ohio, USA, [email protected] Arthur W. Frank Department of Sociology, University of Calgary, Calgary, Canada, [email protected] Stephen Hanson Department of Philosophy, University of Louisville, Louisville, KY 40292, USA, [email protected] Paul A. Komesaroff Faculty of Medicine, Monash University, Victoria 3800, Australia, [email protected] Thomas Nenon Office of Provost, University of Memphis, Memphis, TN 38152-3370, USA, [email protected]

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John R. Scudder Professor Emeritus, Philosophy Lynchburg College, Lynchburg, VA, USA, [email protected] Robert Hunt Sprinkle School of Public Policy, University of Maryland, College Park, MD 20742, USA, [email protected] Osborne P. Wiggins Department of Philosophy, University of Louisville, Louisville, KY 40292, USA, [email protected] Richard M. Zaner Anne Geddes Stahlman Professor of Medical Ethics Emeritus, Vanderbilt University Medical Center, Nashville, TN, USA, [email protected]

Chapter 1

Introduction Osborne P. Wiggins and Annette C. Allen

Life is fired at us point-blank. I have said it before: where and when we are born, or happen to find ourselves after we are born, there and then, like it or not, we must sink or swim. . . there is no escape: we have something to do or have to be doing something always; for this life that is given to us is not given to us ready-made, but instead everyone of us has to make it for himself, each his own. . . . Jose Ortega y Gasset, Man and People, quoted by Richard Zaner in The Way of Phenomenology: Criticism as a Philosophical Discipline (1970)

All the essays in this volume were written expressly to honor the work—the teaching and the writing—of Richard Morris Zaner. Like the best teachers, Zaner has encouraged, even provoked, people to think for themselves precisely while he outfitted them with basic conceptual tools for engaging in that thinking. In his writing he has opened up original pathways for approaching both perennial and novel subject areas in philosophy. The contributions to this book reflect in quite creative ways the manifold forms in which Zaner has affected the thought and, indeed, the lives of the authors. We introduce this collection first by briefly sketching Zaner’s professional career. Then we provide an overview of the books he has published. Thirdly, we summarize the individual contributions themselves so that readers may gather some idea of the breadth and insightfulness of these intriguing pieces. Finally, we add some succinct thoughts of our own.

1 Professional Career Richard Zaner received his B.S., summa cum laude, from the University of Houston in 1957. At the University of Houston he studied with Maurice Natanson. Zaner O.P. Wiggins (B) Department of Philosophy, University of Louisville, Louisville, KY 40292, USA e-mail: [email protected] O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_1,  C Springer Science+Business Media B.V. 2011

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went on to complete an M.A. degree in 1959 and a Ph.D. degree in 1961 at the New School for Social Research in New York, receiving the inaugural Alfred Schutz Memorial Award for Dissertation. At the New School he studied with Aron Gurwitsch, Alfred Schutz, Dorion Cairns, Werner Marx, and Hans Jonas, all of whom continued to strongly influence his subsequent writings and teaching. After graduating from the New School he taught at Lamar State College (Beaumont, TX), Trinity University (San Antonio), the University of Texas (Austin), Southern Methodist University (Dallas), and the State University of New York at Stony Brook. In 1981 he became the first Anne Geddes Stahlman Professor of Medical Ethics in the School of Medicine at Vanderbilt University in Nashville, Tennessee. There he established in 1984 the Center for Clinical and Research Ethics. He is presently Anne Geddes Stahlman Emeritus Professor (Zaner 2003).

2 Zaner’s Books Zaner is a philosopher who has persistently remained en route. As the contributions to this volume make clear, he has written on a diversity of topics but with such intellectual penetration that this diversity displays a development and unfolding of ideas rather than a mere multiplicity of them. When defined in the broadest terms, the topics that have ceaselessly occupied him are those of self (or subjectivity), self’s relation to other selves (or intersubjectivity), embodiment of self, the lifeworld, and an array of issues in philosophical method. All of these topics permeate his recent work although this work brings out how essential these topics are for philosophically responsible ethical reflection. Zaner’s approach to the issues that have concerned him has always been phenomenological. Having said this, however, we must quickly add that we mean phenomenology as broadly conceived. Although Edmund Husserl provides his fundamental orientation, Zaner’s first book, The Problem of Embodiment: Some Contributions to a Phenomenology of the Body (1971), already demonstrates his recognition of the need to appropriate insights from Gabriel Marcel, Jean-Paul Sartre, and Maurice Merleau-Ponty in his “phenomenology.” His second book, The Way of Phenomenology: Criticism as a Philosophical Discipline (1970), proves how basic Zaner’s commitment to Husserlian phenomenology is. This volume still furnishes the clearest and most precise rendering of Husserl’s thought available to readers. It first situates phenomenology in its philosophical and historical context, focusing mainly on Descartes, Hume, and Kant. Zaner then delves into the Husserlian themes of the critical examination of presuppositions (both of one’s own and those of other philosophers), self-reflection, the multiple levels of intentional awareness that connect consciousness to and embed it in the world, and methods for opening up the radical standpoint of phenomenological reflection. Zaner extended the Husserlian scope of this study by publishing separately two essays on the method of free variation in phantasy that leads to the disclosure of essential structures of experience (1970b, 1973). His third book, The Context of Self: A Phenomenological Inquiry Using Medicine as a Clue (1981), presents both the full flowering of Zaner’s own original

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phenomenology and a philosophical entryway into the realities of medicine that he will pursue subsequently. The systematic development of his phenomenology still attests to and affirms his rootedness in the thought of his predecessors. Hence the influences of his teachers at the New School, Hans Jonas, Aron Gurwitsch, and Alfred Schutz, are still present, but Zaner regards their ideas as nuggets upon which he expands and takes in novel directions. Marcel and Merleau-Ponty remain prominent, but they too only provide impetus for Zaner’s own creative insights. New figures appear here as well, Erwin Straus, Herbert Plugge, Kurt Goldstein, and Adolf Portmann. Since three of these are physicians and the fourth, Portmann, is a biologist, their roles evince Zaner’s commitment to expanding his phenomenology into the field of medicine and to its central datum, the human body as biological organism. Availing himself of Hans Jonas’s philosophical biology, Zaner discusses the reality of embodiment. This discussion includes “the body uncanny” as this may manifest itself in, say, illness. Embodiment is also conceptualized here as a “contexture,” in Gurwitsch’s sense, and this leads Zaner to coin his own wider notion of a “complexure.” He then explicates his theme of self in terms of its “reflexive” structure. He also addresses disruptions of this reflexive structure of the self as brought to light in Kurt Goldstein’s investigations of brain injury and Gerhard Bosch’s study of autism. The basic self-relatedness captured in the term “reflexivity” leads readily to other-relatedness. Here is where Zaner draws on Schutz’s interpretation of intersubjectivity while greatly extending the latter’s concepts. Gabriel Marcel’s ideas have surfaced throughout the book, and his notion of “availability” receives special attention in the last chapters. Zaner’s full fledged movement into the domain of medical ethics is found in his Ethics and the Clinical Encounter (1988). Demonstrating his continuing commitment to the Husserlian insistence on critically examining presuppositions, Zaner does not at all start as most others in this area do, namely, by assuming that we all have a rudimentary conception of what medical ethics is and how it is typically practiced. Zaner rather takes his readers back to a prior logical premise: the premise prior to the thesis that there is or even could be such a discipline as “medical ethics.” Zaner effects this move back by reviewing the recent history of this discipline and showing how deeply problematic it is; that is, he uncovers how much it presupposes. Zaner searches for a root meaning of “responsibility” in medical caring that renders such caring inherently moral and that at the same time predelineates the path that a medical ethics (or, as Zaner prefers, “clinicallaison ethics”) should follow. This “responsive ethics” takes on more and more definition as the book unfolds. Zaner’s ethics manifests its profound difference from others in its borrowings from Herbert Spiegelberg’s ethics. Rather than placing autonomy at the center of medical ethics, Spiegelberg’s approach allows Zaner to locate the physician’s duty to help the ill or injured person in the accidental or undeserved character of the illness or injury. Toward the conclusion of the book the theory of “clinical-laison ethics” receives further intelligibility when Zaner reinterprets some tenets of Schutz’s philosophy by adapting them to clinical situations. In his two collections of medical-ethical narratives, Troubled Voices: Stories of Ethics and Illness (1993) and Conversations on the Edge: Narratives of Ethics and

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Illness (2004), Zaner relates stories of serious illness and injury in which he himself figures as an ethics consultant. The strong autobiographical element woven into the stories adds to the gripping power of the predicaments they present. Most striking to readers who delve into the narratives convinced that they already know the approach that ethics consultation regularly takes is the deep moral uncertainty which Zaner’s accounts not only portray but also draw the reader into sharing. Zaner’s “responsive ethics” offers a different kind of “ethics consultation.” The usual array of principles, concepts, and rules that ethicists are accustomed to “applying” to the peculiarities of a “case” lose their efficacy as tools of resolution. Zaner does implicitly follow these accepted ethical norms, but they are presupposed as a starting point; they certainly do not imply a solution. The real struggle to arrive at an ethical outcome compels the direct participants to dig down into their underlying moral assumptions. They must bring to the surface what they find most valuable and most meaningful. As Zaner expresses it, Clinical ethics is a disciplined way of helping people understand their conditions, situations, and prospects by helping them (at time, unfortunately, insisting that they) grapple with their own moral beliefs, what they really and truly want and believe is worthwhile. (Zaner 1993, xxi)

“. . .what they really and truly want and believe is worthwhile.” Almost all the ethical systems that have emerged in the Modern period have not ventured to answer that ultimate question. Ethical philosophies of Antiquity, on the other hand, usually sought to do so, aiming as they did at defining the summum bonum of human life. Modern thinkers, however, have regularly argued that what people “really and truly want and believe is worthwhile” transcends the universal prescriptions of morality because they require individual answers, each person ultimately wanting and valuing something different in life. Zaner’s concern does not consist in criticizing this Modern “individualistic” stance. He does, however, realize that when individuals are, as they inescapably are in Modernity, thrown back on themselves, by having to rely on whatever personal resources of value and purpose lie (usually buried) deeply within themselves, the struggle is hard. It is precisely in this struggle that Zaner as clinical ethicist assists. The stories draw us into these struggles straining to reach a resolution, and the reader is gripped by the anxiety of a drama that lurks for all of us only one chance occurrence away—in that moment when the doctor reports, “I’m afraid that the biopsy was positive.”

3 The Contributions to this Volume One of the great pleasures of this volume is the broad sweep it provides of Zaner’s thought. We hope that our overview can aid the reader is acquiring an idea of the whole. The communality of concerns and themes which Zaner’s work has stimulated others to enter becomes apparent in the essays of the contributors. They also, however, display the variety of concerns that Zaner has addressed during his lifetime.

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This collection of essays opens with the voice of the honoree. Zaner’s “Keeping Balance in the Face of Death” is a forcefully moving narrative of an automobile accident in which a 14-year-old passenger is very seriously injured. Zaner has related parts of this story before, in fact as recently as his latest book, Conversations on the Edge (2004). There it is entitled “Broader’s Hill” (Zaner 2004, 89–110). Insisting on the need for the narrator of a story to remain faithful—almost to fulfill a certain kind of moral obligation—to the patient, family, physicians, and other caretakers involved, Zaner returns to and retells the story again in a determined effort to “get it right.” The deeply comatose boy’s medical condition involved such extensive neurological damage that the time arrived at which the decision makers had to make a choice between continuing life support measures—to what purpose? —or to remove them and allow the 14-year-old to certainly die. Zaner’s account focuses on the attending physician who, even if she is not directly the surrogate decision maker for the youth, must nevertheless carry out the decision that the appropriate surrogate reaches. Zaner reveals how this woman, very young and only beginning to assume mortal responsibilities such as these, struggles to come to grips with what she must do and then with what she has already done. Even the death of the boy does not end these painful struggles of conscience. The moral burden of such a deed—and the physician’s honesty in continuing to confront it directly—resounds with striking force in this story. Ronald Cox’s “Richard Zaner on Transcendentality, Eidos, and Phantasy” elucidates the basis of Zaner’s thought in phenomenological philosophy. Readers familiar with Zaner’s writings in clinical ethics may be unaware (or only vaguely aware) of the rational depth and systematic scope of his phenomenological roots. Starting from the contributions to Husserlian phenomenology made by his teachers, Maurice Natanson, Dorion Cairns, Aron Gurwitsch, and Alfred Schutz, Zaner advances this still vital tradition further by expanding its concepts to illuminate its main themes. Cox explicates the main constituents of phenomenological philosophy with a clarity and brevity rarely encountered. We shall leave this clarification to Cox himself and simply note the compass of the phenomenological concepts and methodological procedures he treats: transcendentality, foundedness, free phantasy variation, formal and material universals, legitimating epistemic claims, the multileveled self, intentionality, and the psychological and transcendental epoche. The sophistication of Cox’s rendering of this complex core of phenomenology cannot but leave the reader convinced that it is a philosophy as intellectually refined, logical, and profound as any other contemporary movement. Thomas Nenon’s essay “The Limits of Biomedical Ethics and the Specific Role of Phenomenology in Biomedical Ethics” addresses precisely what its title states: first, possible misconceptions about the current practice of biomedical ethics, and second, what phenomenology can contribute to the field. He begins by pointing to a common overestimation of the influence of the teaching of bioethics on the actual behavior of the students. Nenon explains why it is misguided to view bioethics as able to “solve” ethical problems or “resolve” ethical debates. He sees this view as connected with the assumption that philosophers can (or should be able to) define ethical concepts and principles in terms of their necessary and sufficient conditions

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and then apply these to the problem at hand. Nenon counters that the human intellect more often reasons in terms of typical examples that resemble the topic under examination. After developing these points further, Nenon concludes this section by suggesting that philosophers not seek to function as the sources of ethical norms for medicine. He sees philosophers performing the more modest task of starting from ethical assumptions that remain implicit in the society and making those assumptions conceptually explicit and rationally refining them. Nenon then considers what a phenomenological approach offers medical ethics. He views it as offering a critique and alternative to some of the limitations of other approaches. He cites nine major components of the phenomenological orientation: (1) it resists the reductionistic tendencies in modernity; (2) it insists on contesting received conceptions and assumptions; (3) it employs a first-person perspective so that the patient’s point of view is central; (4) it claims that phenomena are “meaningful” for the patient and others and that consequently this meaningfulness must be sought by those who would adequately understand the case; (5) a phenomenological approach attends explicitly to “context” so that a more comprehensive appreciation of all the items involved is reached; (6) it contends that theoretical cognition is only one mode of awareness and that much of our understanding of ourselves, other people, and the world is non-theoretical and richly composed of thinking, valuing, feeling, and choosing; (7) it attends to the patient’s own experience of his or her “lived body” in addition to the physician’s knowledge of his or her organism as defined in scientific terms; (8) a phenomenological perspective locates the patient’s distress in the experience that his or her embodiment is no longer “normal” although the patient’s understanding of “norm” and its violation is a pre-scientific understanding; and (9) via the appreciation of context, the roles of history and society are recognized as shaping people’s feelings, choices, and understandings and therefore in shaping what they deem acceptable and unacceptable in medical treatment and research. Nenon finds many of these salutary components of the phenomenological approach specifically in Zaner’s “responsive ethics.” As his title suggests, Stephen Hanson’s “Richard Zaner and ‘Standard’ Medical Ethics” addresses the apparent divide that separates Zaner’s form of clinical ethics from “standard” medical ethics. One might broadly characterize this “standard” ethics as analytic or more specifically as “principlist.” Hanson approaches his topic by sketching the apparent distance of the “standard” ethical approach from Zaner’s, the distance that he himself will subsequently seek to overcome. As an important proponent and contributor to it, Hanson provides a clear exposition of the current orientation of “standard” medical ethics. He focuses on the mode of reasoning called “wide reflective equilibrium” that was taken from John Rawls and incorporated into principlism by Tom Beauchamp. He shows how this mode of reasoning can be given greater specificity and plausibility as a procedure for resolving bioethical dilemmas by supplementing it with distinctions, which are necessary in view of our pluralistic society, among “moral strangers,” “moral friends,” and “moral acquaintances.” Although he contends that these three categories are critically helpful in determining the appropriate participants in ethical discussions, Hanson brings out a difficulty inherent in one of them, Who, when the task is that of resolving a particular

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medical ethical dilemma, is justifiably included in the category “moral acquaintances”? Here Hanson finds the bridge to Zaner’s clinical ethics. Hanson points to three theses by which Zaner characterizes his method of “clinical laison” ethics (Zaner 1988, 242–248). He then explains how these Zanerian theses illuminate the procedure for determining whose points of view are relevant in arriving at a resolution of the ethical problem. In this way Hanson answers the question, “In a particular case who qualifies as a moral acquaintance?” Since the three theses that he incorporates into “reflective equilibrium” reasoning lie at the heart of Zaner’s phenomenological approach—developed, as they were, through a reworking of Alfred Schutz’s ideas—Hanson’s essay provides an excellent indication of how a dialogue between Zaner’s ethics and other approaches would be fruitful for both. Robert Sprinkle, in “Bioethics without Analogy,” examines an issue that pervades bioethics although it is an issue that other writers in the field have neglected: the use of analogical reasoning to solve novel problems. Sprinkle explains how analogical reasoning can be both used or misused. He sees this sort of reasoning, with all its pitfalls, becoming more prominent as bioethics has become more public. Activists from different positions can employ analogies from their own chosen traditions to advance either pro or con arguments on a controversial topic. Sprinkle buttresses his point by discussing specific problem-areas in bioethics and showing how analogies are at work. With regard to “end-of-life fights,” the debates have tended toward conceiving of the ethical issues involved as analogous to estate law cases. Hence we now talk about wills properly signed and witnessed, whether executors (surrogate decision makers) have been appointed, or whether there are reasons for not following the will, etc. With regard to “reproductive wrongs,” Sprinkle points out that cells in a Petri dish are conceived by some people as so analogous to full-fledged citizens that other citizens can commit legally punishable crimes against them. This has been maintained despite the obvious disanalogies between cells in a Petri dish and living citizens. Sprinkle also shows how “role revisions” have occurred through positing an analogy between medicine and business concerns. Patients have become “consumers” or “clients,” and doctors, nurses, and other caregivers have become “providers.” Analogical reasoning has resulted in “role denials” too: grandparents have been denied the right to visit their grandchildren if the parents wish to deny them. The conception of rights-holder that Sprinkle finds depositive in this case is a conception that emerged in law during the post-CivilWar Reconstruction era. As a counterweight to the pervasive force of analogies in bioethics, Sprinkle considers John Locke’s “historical plain method” of empirical observation, his advocacy of tenacious fidelity to the directly given. Sprinkle concludes by finding in Zaner’s narratives and clinical ethics a determined “seeing” and careful description of what is itself directly presented. This, Sprinkle thinks, can help us to avoid the pitfalls he has noted in analogical reasoning. Lester Embree, in his “Phenomenological Nursing in Schutzian Perspective,” brings to our attention the influence of phenomenology on nursing, and he does so by framing these influences in terms of Alfred Schutz’s philosophy of the human sciences. Since Zaner himself frequently uses Schutz’s ideas to mark out his own approach, Embree’s analysis in this essay ties into the broad picture of

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phenomenological directions in health care that this collection of essays hopes to furnish. Embree reviews Sandra Thomas’ research study of patients who suffer from chronic pain. Thomas looks especially at how patients subjectively interpret their own lived experience of pain. Since phenomenologically oriented research is an innovation in the field of nursing, researchers must pay critical attention to and further refine the methodology they employ. It is interesting to note that Thomas’ research focuses to two topics which Zaner too considers: the lived body and self in its relationships to others and the ways in which suffering can interrupt those relationships. In addition Thomas examines another prominent phenomenological theme, the subject’s experience of time. Embree’s presentation of this broad field is of necessity highly selective, but it does convey the fruitfulness of a phenomenological approach to nursing and the difference that approach makes. In their “Zaner’s Generative Spirit,” John Scudder and Anne Bishop emphasize Zaner’s ability to “generate” creative thinking in others. They describe how they were able to discover their own original direction in nursing ethics under the influence of Zaner’s unique way of teaching. As they portray it, this way consisted in Zaner’s coaxing and then finally freeing them to explore their own direction rather than providing more didactic communication of ideas or information. They sketch the paths by which the forms of interpersonal relatedness that Zaner calls “vivid presence,” “co-presence,” and “availability” and “empowerment” could transform nursing attitudes and actions. They furnish concrete examples of actual nursing practice that illustrate the decisive differences that these forms of awareness and response can make on patient well-being, even in the face of the approach of death. Definite clues about a Zanerian ethics emerge: this ethics is difficult to formulate in general concepts because the features of personal relationships that he advocates (such as vivid presence, co-presence, and availability and empowerment), when realized in concrete circumstances, bring about an “ethical outcome” that is so unique to the particular medical situation that it cannot be generalized. In her essay, “Integrity and the Moral Gestalt: Zaner Tells his Mother’s Story,” Denise Dudzinski depicts Zaner’s inspiring way of teaching. She explores several themes that pervade his teaching and philosophy. The first is “integrity.” Starting from Zaner’s adaptation of Aron Gurwitsch’s Gestaltist conception of “contexture,” Dudzinski shows how this notion illuminates what is ethically central in clinical consultation. She holds that this understanding of integrity shifts the consultant’s attention away from applying general ethical concepts to the case toward careful attention to its particular details and their—sometimes elusive—interrelations. The purpose of this attentive listening and conversing is to let the true problems of the case emerge, an emergence that would probably never occur without sensitive and often discomforting dialogue. The discomfort is virtually ensured by the phenomenological commitment to highlight the emotional as well as the intellectual aspects of the patient’s situation. Dudzinski then elaborates on the three constituents of the phenomenological method that Zaner borrows from Schutz and adapts to clinical ethical consultation (Zaner 1988, 243–246). She reviews Zaner’s several narratives of his mother’s death and elucidates how his “method” is at work in all of them. First, she discloses how Zaner attends closely to each participant in the

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case while also advancing toward his own ethical comprehension of it. Second, she addresses Zaner’s own sense of guilt for what he later recognizes as the inadequacy of his actions at crucial times. Thirdly, she notes the tentativeness in Zaner’s stories: his own suspicions about the accuracy of his interpretations. She concludes with further reflections on the fruitfulness and uniqueness of what she learned as Zaner’s student. In “Between and Beyond: Medicine and Narrative in Dick Zaner’s Phenomenology,” Hillel Braude shoulders the weighty task of reviewing each of Zaner’s books, beginning with the first, The Problem of Embodiment, and continuing through to Conversations on the Edge, in order to reveal how they singly and cumulatively contribute to the main themes of Zaner’s phenomenology of medicine. Those themes are self, body, intersubjectivity, non-distorted seeing as the primary method, and the central moral significance of universal human vulnerability to illness and death. Not only is Braude’s treatment of themes in all these books striking because of its scholarly insight and thoughtfulness, but his focus on the constant components of Zaner’s reflections reveal to the reader a continuous development in the books that the reader had probably not discerned before. Most instructive are the various connecting strands that Braude weaves together to uncover an order of ideas that can finally be deemed “Zaner’s philosophy.” Braude, like Zaner himself, believes that Husserl’s method of “free variation in phantasy” can disclose diverse constituents of illness and health that other modes of analysis may overlook. Paul Komesaroff’s “Fardels of the Heart: Obesity and the Unbearable Heaviness of Being” develops a distinctively phenomenological portrayal of the manifold dimensions of the lived body, the obese body in particular. This phenomenology is rendered especially vivid by Komesaroff’s incorporation of detailed descriptions of the experiences of his patient, here called “Jo.” He recounts how present-day physicians view obesity, its causes, effects, and treatments. This medical view is poignantly set against Jo’s own first-person depiction of her body as she experiences it, and as she experiences other people experiencing it. The emotional impact of Jo’s reports reveals how much is overlooked if obesity is conceived solely from a medical perspective, however crucial the latter may be for helping to relieve the patient’s suffering. Jo’s story, centered as it is on her obesity and her struggles to control it, show how this aspect of one’s person can circumscribe and define one’s entire life. Komesaroff makes this plausible, however, by providing a phenomenology of the centrality of the body in both health and illness. He supplements his analysis by describing the lived body as a social construction and by unfolding the diverse meanings that fatness, especially the fat woman’s body, has borne in different cultures and historical periods. Finally, Komesaroff describes in meticulous detail the embodied experience of eating food. The transformation of the subject-world relation that eating brings about is graphically presented here. Arthur Frank’s “The Philosopher as Ethicist, the Ethicist as Storyteller” succeeds in drawing from a faithful reading of Zaner’s texts interwoven ideas that a less penetrating reader could easily miss. Frank begins with what Zaner emphasizes as a fundamental fact of our existence: the self’s relations with others are not only the self’s basic access to the world but are also the primary mode of the self’s knowledge

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of itself, i.e., what Zaner would call the reflexive relation of the self to itself through other selves. The fundamental status of this existential fact justifies the dialogical approach to medical situations that Zaner takes. This basic status of intersubjectivity also entails that the role of the ethicist essentially consists in listening to others who seek to get clear about themselves as thrown into this situation. In Frank’s account, the responsibility of the ethicist here centers on his or her role in assisting in the emergence of a story told by the participants. Finally, Frank answers a question with which other readers of Zaner might find themselves left: How exactly does Zaner’s dialogical approach to difficult medical predicaments lead to an ethical conclusion that could somehow be certified as “the right one”? Frank finds the answer precisely in the storytelling by the patient and the other participants. The ethical conclusion and its rightness emerge in the activity of storytelling by these people. The actual telling is a process which, usually after false starts and twisting turns, produces a story with which the tellers can live or at least with which they can face the future with the sense that, however bad the future may be, it is being handled as well as this bad situation can be. The felt rightness of the “fit” between the story and the medical predicament makes possible the decisions that the participants can feel are “right.” Other ethicists might remain uncomfortable with the answer that it is “the felt fit” of the story that signals its ethical rightness. But how else do we judge, as we must if we adhere to the principle of patient autonomy, that the patient or the surrogate has “made the decision on the basis of the patient’s own values”? Rita Charon’s essay, “The Ecstatic Witness,” depicts with powerful lyricism and intellectual insight the transition of the self of the patient that occurs when her body—that essential constituent of selfhood—is diagnosed as seriously ill. The patient is compelled to migrate to that harrowing precipice where all-consuming death stares directly at her, at her in particular. Charon insists on the need for the caretaker to travel there with her. In that way the clinician and the patient—at least for some time—stand on that precipice together, confronting human non-being in its dark inevitability. Such travel with the patient can come about only if the clinician’s body can, at a level below conscious thought, communicate to the patient’s body that togetherness. Of course, much understanding of illness occurs through explicit conversation and exchange of information. However, much also transpires at a stratum of human relatedness that never is and never can be expressed in language. This is the communication of one lived body with another. Charon’s entire effort is aimed at denying any mind/body dualism. Indeed, utilizing Merleau-Ponty’s The Visible and the Invisible, she affirms the possibility of an intimacy of one embodied person with another that comes close to abolishing any duality between them. This is possible because our own lived bodies are realities with which we ourselves possess an intimacy devoid of all duality. We understand our own bodies because at every moment we live them at that level of personal life below language or thought. Hence the clinician can communicate non-verbally with the patient through the clinician’s mode of bodily being with the patient. To clarify her point Charon provides examples of failures of communication at this non-verbal level and their unfortunate consequences.

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Paul Ford’s contribution differs significantly from the others. His title, “A Story Teller’s Story: Richard Zaner as Hero (HE row),” suffices to alert the reader to this at the outset. Ford’s piece does focus on an early—and captivating—part of Zaner’s life-story, and his essay itself takes the form of a story, a story about some of his conversations as a student with Zaner. In addition, there is a Zanerian sort of “meta-”level to Ford’s narrative. There is the Ford who engages in the dialogues and the Ford who reflects on and critically examines the Ford/Zaner dialogues. The conversations begin when Ford sees on Zaner’s office wall a certificate attesting to his “valor and bravery in war,” the Distinguished Flying Cross. Zaner had won the award serving as a gunner on a B26 airplane in the Korean War, and Ford’s surprise and wonder at this award prompts him to ask Zaner about it. Those questions set in motion a series of conversations about Zaner’s actions in the war and the ethical stances to which those actions eventually led him. We leave Ford’s own vivid telling of the conversations for the reader to plunge into. Ford presents the dialogues with an unvarnished directness that makes the reader feel a close-up witness to Zaner’s past and his more recent musings on it. The book concludes, as it began, with an essay by Zaner himself. In his “On the Telling of Stories” Zaner discloses a continuity running through his thought from his early writings to the most recent. He returns to his early concentration on the phenomenology of intersubjectivity, especially that version of it put forward by his teacher, Alfred Schutz. Some readers may not recognize how much of a “return” this refocusing on Schutz on intersubjectivity actually is for Zaner. Almost half a century ago, in 1961, he published an essay in the journal Social Research entitled “Theory of Intersubjectivity: Alfred Schutz.” Although one can only imagine the myriad of directions of thought that the re-engaging now with Schutz on intersubjectivity must trigger in Zaner, he restricts his present discussion to drawing out a tension between two of the directions embedded in Schutz’s account. One direction is rooted in Husserl’s notion of “appresentation.” Although the young Zaner, in 1961, had treated Schutz’s use of this concept as unproblematic, he now finds serious flaws in it. Zaner indicates that the appropriation of Husserlian “appresentation” by Schutz prevents him from providing an accurate description of our face-to-face experience of others. A much more accurate description is found in Max Scheler’s “perceptual theory of the alter ego,” which, interestingly, Schutz himself endorses. Thus an inconsistency seems to reside in Schutz’s approaches to intersubjectivity. Confronting this inconsistency, Zaner deems it imperative to return to Schutz’s insistence that intersubjectivity is not, as Husserl had assumed, a problem at the level of transcendental constitution but is rather a “datum,” a given, in our everyday experience in the lifeworld. Hence Zaner sets out to give fuller meaning to why this is so. His answer again begins with a hint from Schutz. In several essays Schutz asserts the obvious fact that “man is born of woman” as if that fact harbored the potential to resolve many a philosophical puzzle. This fact, it seems, explains why for Schutz the experience of the “We” is so fundamental to our humanity. Zaner concludes that our being “born and brought up by mothers” supplies a basis for understanding that the “we” (including the embodied we) is as fundamental as “I.” From the moment that each of us begins that lifelong journey of becoming who we are, that becoming

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is with others, and the stories we live through in becoming ourselves come forth naturally as stories we tell about ourselves. Story telling appears to be as natural to human beings as their relations with one another. This naturalness of telling stories about oneself and ourselves is what fascinated Zaner as he struggled to make sense of his role as an “ethicist” in a modern hospital. When “the ethics consultant” consults with them, people naturally tell their stories. The first ethical duty of the ethicist in that case is to listen, to listen first of all and then seek to facilitate the emergence of the story. And finally—at least in some cases—the duty becomes that of retelling the story oneself, only this time incorporating one’s own reactions and thoughts as a participant in the unfolding of the self-understanding that is the story. This, however, is not so easy. The realities of illness and the struggles of patients, family members, doctors, nurses, etc. with them are not captured so readily by the expressive force of language. Hence the realities of illness and the words that aim at presenting them converge, if they ever do, only with great effort. And this effort must seek most of all to “get it right.” Only when the storyteller “gets it right” does he or she discover what it was that happened, what it was they all lived through. The thoughtful reader of these essays will be able to detect the multiple paths by which the concerns of the different authors cross, inform, and supplement one another. These paths are so many that we shall not attempt to map them here. However, taken all together in their conversational richness, this collection, we hope, discloses the fruitfulness of the areas that Richard Zaner has explored or stimulated others to explore. In concluding, we wish to acknowledge a doubt that may still linger in the minds of even those readers who have read this collection carefully, namely, a doubt that there persists a genuinely phenomenological viewpoint that encompasses the numerous topics that Zaner interrogates. In other words, despite all the connecting links in Zaner’s thought that we and the contributors to this collection have sought to point out, the reader who surveys the broad span of this thought might still legitimately ask, “How does one start from Husserlian transcendental phenomenology— ‘philosophy as a rigorous science’—and move logically to a narrative ethics focused on suffering and dying patients in a modern hospital? Are all the innovations in Zaner’s works really underpinned by a consistently phenomenological stance?” A reply to these questions must arise from Zaner’s own essay contained here, “On the Telling of Stories.” In this piece he emphasizes the foundational nature of intersubjectivity—our being with others and through others—that grounds our own sense of self and our moral obligations to others. A Zanerian “responsive ethics” is basic because responding to others begins at the beginning, in the processes of pregnancy and giving birth. Later, responding to others often takes the form of telling them stories and of listening to the stories they tell us. Hence one plausible interpretation of Zaner’s writings reveals a thinker who explores the manifold shapes that intersubjectivity can assume. The agony and grief expressed in the stories portray humans at the limit of endurance, striving to make sense of it all. This sensemaking, even in the most troubling of circumstances, is what we humans always try to do.

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Acknowledgments We would like to express our profound appreciation to the contributors to this volume. Readers will easily perceive that these essays, with their depth of feeling and thought, pay powerful tribute to Zaner’s accomplishments and to his gifts of philosophical understanding to them. We too would like to thank Dick for his friendship over many years and for the education he continues to give us. Readers who wish to see more essays that discuss Zaner’s writings on clinical ethics should consult the issue of Theoretical Medicine also devoted to his work (Sadler & Wiggins 2005).

References Sadler, John Z. & Wiggins, Osborne P., editors, 2005, Theoretical Medicine, Vol. 26. Zaner, Richard M. 1961, “Theory of Intersubjectivity: Alfred Schutz,” Social Research, Vol. 28, No. 1, Spring, pp. 71–93. Zaner, Richard M. 1971, The Problem of Embodiment: Some Contributions to a Phenomenology of the Body, The Hague: Martinus Nijhoff. Zaner, Richard M. 1970a, The Way of Phenomenology: Criticism as a Philosophical Discipline, New York: Pegasus Press. Zaner, Richard M. 1970b, “The Phenomenology of Epistemic of Epistemic Claims: And Its Bearing on the Essence of Philosophy,” Phenomenology and Social Reality: Essays in Memory of Alfred Schutz, edited by Natanson, Maurice, The Hague: Martinus Nijhoff, pp. 17–34. Zaner, Richard M. 1973, “The Art of Free Phantasy in Rigorous Phenomenological Science,” Phenomenology: Continuation and Criticism, Essays in Memory of Dorion Cairns, edited by Kersten, Fred and Zaner, Richard, The Hague: Martinus Nijhoff, pp. 239–250. Zaner, Richard M. 1981, The Context of Self: A Phenomenological Inquiry Using Medicine as a Clue, Athens, OH: Ohio University Press. Zaner, Richard M. 1988, Ethics and the Clinical Encounter, Englewood Cliffs, NJ: Prentice Hall. Zaner, Richard M. 1993, Troubled Voices: Stories of Ethics and Illness, Cleveland, OH: The Pilgrim Press. Zaner, Richard M. 2004, Conversations on the Edge: Narratives of Ethics and Illness, Washington, D.C.: Georgetown University Press. Zaner, Richard M. 2003, Curriculum Vitae, http://www.mc.vanderbilt.edu/ethics/zanerhome.html.

Chapter 2

Keeping Balance in the Face of Death Richard M. Zaner

Some years ago, I provided an ethics consult at Vanderbilt University Medical Center that is indelibly marked on my memory. In what follows, I will tell that story, but must first note that, to respect and protect the privacy of all those involved, I have altered all identifying characteristics, with the exception of myself. At the outset of this consult, I learned that a boy, just 14 years old, had without permission taken his dad’s car for a joy ride in the surrounding countryside. He had brought along his close friend and neighbor, the same age. As a result of something that happened while they were driving, it was never clear just what—swerving to miss an errant animal, a chuck-hole in the pavement, a boulder—the car’s wheels cut sharply right, flipping it into an abrupt rollover, and ending up on top of his friend, while the young driver was thrown out when his door popped open and suffered only minor injuries (neither had his seatbelt attached, in this case rather fortunate for him, though not his friend). Jason, the friend, wound up half in and half out of the sun roof, and later, it is not known how long, was resuscitated by an EMS crew who helicoptered to the scene, called by we know not whom nor when. When the crew arrived, he was comatose, not breathing, his face partially submerged in mud, but on initial inspection otherwise remarkably unmarked. He was flown to the local hospital, where resuscitation efforts continued, with breathing tube installed and ventilator initiated. He was then quickly placed on a portable vent and transferred to the trauma service, then to the pediatric unit where, eventually, I was asked to consult. R.M. Zaner (B) Anne Geddes Stahlman Professor of Medical Ethics Emeritus, Vanderbilt University Medical Center, Nashville, TN, USA e-mail: [email protected] Prepared for the inaugural Richard M. Zaner Lecture in Ethics and Medicine, Vanderbilt University Medical Center, Nashville, TN, November 5, 2004. An earlier version was prepared for the Panel, “Rendering the Implicit Explicit: An Interdisciplinary Exploration of ‘Tacit Knowledge’ in Medicine,” The American Society for Bioethics and Humanities annual conference (meeting together with the Canadian Bioethics Society), Montréal, Canada, October 23, 2003. In addition, an expanded version was delivered on April 8, 2004 at a special lecture and book-signing event marking the Chinese translation of the book noted in endnote 3 below, and delivered as the Special Lecture in Ethics, National Taiwan University Medical School, Taipei, Taiwan, April 9, 2004 O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_2,  C Springer Science+Business Media B.V. 2011

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Which went, a small part of it anyway, somewhat as I’ll relate here, although I must leave out most of it. I should mention that a published version of this story has now appeared in my most recent book, Conversations on the Edge, published by Georgetown University Press last January. Even so, I must also say immediately, this remains an especially difficult story to get right in the telling; in what follows, I return to one part of it that has been especially resistant. And, you should know why, or at least something of what I’ve thus far figured out: that it so deeply affected the attending; that it concerned issues that are for the most part raised regarding adults, old ones like myself in particular. Most of these were pretty much unstated while the situation unfolded; unstated, it may be, because the questions raised reach deeply into what makes us human, fallible, yet striving to do the right thing. What those questions are, I’ll allow to come out as I try here, once again, to let the telling of the story guide my efforts. First, I’ll mention one chart note, written by an attending very new to the service and the hospital, and who, for the first time in her career, was faced with the question whether to remove all life supports—a measure recommended by the consulting neurologist after several weeks during which Jason’s devastated neurological status was checked and re-checked. The attending’s prior six-year career had been in solo private practice in a small-town, mainly taking care of babies and children, who mostly didn’t die on her—or, if and when they did die, it was always in a hospital with someone else in charge. She’d never herself done the deed—actual removal of life supports. Her story is compelling, chock-full, too, of silent, maybe unspeakable dimensions. I’ve tried many times to tell my own part of the story—but especially her part has resisted full telling,1 about her bewilderment, her barely constrained anxiety; and, too, my own alarming uncertainty and doubts. Although only a partial telling of the full story, what I’ll relate is very suggestive about the way clinical practice in such situations may actually unfold, and, if told rightly, invokes those silent features in a unique way. What transpired is pretty much, I think, what must be said in the face of serious challenges to any human life, our lives, in the contexts of illness and injury. It arises from that tacit dimension we all know intimately even while we regularly may think we do not—especially when so much seems so unspeakable, unbearable if not impossible to share with others. Yet, there it is, the intricate struggle we undergo when trying to tell such stories honestly; and here is my own suggestion for how we might give voice to those unspoken, often harsh dimensions of our lives and experiences. This physician’s story, like that of the family and, truthfully, my own, I have come to be convinced, when told just so, reveals an important strategy for helping people, patients or families or health professionals, and ourselves, give voice to the seemingly un-sayable and deeply personal traces packed close within “objective” knowledge. If, as we often hear said, the recent trend in evidence-based medicine can be understood as an attempt to root out the reliance on the physician’s personal voice, what I might call the authority of the anecdotal nonetheless may provide a way to reconcile an awareness of the personal aspect in medical knowledge with evidence-based medicine. This attending physician’s responses and actions, I hope

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will become clear, if these are not already clear to you, helped me to appreciate far more just how deeply imbued with personal perspectives and interpretations is every clinical encounter. Even while we seek to be as objective as circumstances permit, we come to realize that masking that personal dimension is not only, in the end, improbable but doubtless even impossible. Roger Rosenblatt’s poignant words thus naturally came to mind: So much of living is made of storytelling that one might conclude that it is what we were meant to do—to tell one another stories, fact or fiction, as a way of keeping afloat. . .We have the story of others to tell, or of ourselves, or of the species—some monumentally elusive tale we are always trying to get right. . . .2

Getting a tale told well and accurately is not at all easy, I’ve learned, certainly not for me. I am constantly brought up against questions that beleaguer, pester, and yet somehow define everything we do and what we are, ultimately. Here in any case is my own effort to respect one crucial aspect of our clinical voice, and thus give it its proper authority. Attending’s note: Pt comatose, no oculocephalic, corneal grimace, flaccid quadriplegia without response to noxious stimulus, pupils non reactive, positive corneal bilaterally, positive doll’s eyes which are improved, no facial droop. Spontaneous breaths began 3/20, no spontaneous movements, severe hypoxic injury. Suggest ethics consult to ensure family understands implications. Given pt’s lack of cough and gag reflexes to maintain airway patency and lack of ability to turn or ambulate, DNR seems appropriate but family upset and refuse, want aggressive pulmonary toilet, and prompt response to any cardiac event continued. Ethics consult requested to discuss issues with family “Damned cars,” this attending said to me one day while we were having coffee a short time after she had asked me to stop by to see this family. “Bad as crack, I’ve often thought, for teens anyway,” she said, vowing to keep her bicycle despite, I thought to myself, the horrendous traffic that had grown only worse over the past few years—and, I must add, not without a twinge of guilt that I’d yet to do that myself. I thought I might ask about the prospect, but she kept talking. “How in the world can any of those people from the donor agency talk about donating Jason’s organs, just tell me that,” she said, quietly but obviously disturbed and puzzled. Her change of topics seemed to mirror the turmoil of her thoughts. “I don’t know how they do it, I know I couldn’t do it; if I’d been the one who had the accident, I’d never do that, you know, donate my organs, though I should, I know, ’cause studies show it works.” She paused, looked over at me, and went on with a stare that defied anything but a nod, “but somehow it all seems so ghoulish. And how about you? You do the same sort of thing, don’t you?” Meaning, I thought the “same sort of thing” donor folks do. Which I don’t, but she wasn’t asking me for an answer, was too wrapped up in her own thoughts. She went right on: “Yet there they are, those parents, I gather they’ve agreed to removing the feed tube, and I’ve got to do that, you know? I have to stop this somehow, don’t I? If it has to be done, I’m the one to do it, right? I mean, we just can’t keep on prolonging the inevitable. The kid’s just about gone as it is, right? But, the feed tube, I can’t just take that away, can I? Can anyone?

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I started to say something, but, like I said, she wasn’t really asking me so much as posing questions to herself. So, I remained silent, looking over at her as she continued. “I know they want it over and done with. If they can’t have Jason back whole and complete, I know they want it over, and so do I, so do we all, for God’s sake, ’cause we’ve gone way beyond the point where that’s even a small point of light. But can a feeding tube be withdrawn?” “Yes, that’s clearly the thing to do sometimes, isn’t it?” I wondered aloud. “From a kid, a minor?” She seemed really baffled. I wasn’t much better off, but I plowed on, anxious, in a sense, to help; she had, after all, called me for coffee. “You know, Dr. Rochelle, you might want to talk about these things with Dr. Arpress, you know who I mean, the pediatric pulmonologist? He’s head of PICU.” “I’ve heard of him, but so far I’ve only just met him in passing, you know, at faculty meetings and such.” “Well, it might be a good thing to go see him, to discuss these issues with another physician, one who has had lots of experience dealing with situations like this one.” “Maybe so, maybe so.” Her eyes grew distant, as if focused on something neither I nor anyone else could see, even though her momentary look at me seemed to want me to do just that. I might have been just imagining things, of course. Then she said, “even though he’s still on the vent, he really doesn’t need it, you know? He could, I think, breathe without the vent. But even if we could d/c that, and I think we can, I don’t think he’d die. We might have to ease things so that there wouldn’t be too much agonal breathing. But remove a feed tube? I’m sorry, but that’s different. Isn’t it?” “But,” I had to ask, “is there any room left for hope? They still do hope, you know?” “No, I suppose not. No hope left. No room. It’s just so damned tough, but I’m still going to give them some more time, somewhere between a few days and . . . and what? Two days? A week? How long will it take without even that nutrition? I just don’t know and they expect me to know, and I have to tell them my best judgment. If I just knew what that was. . . .” Her voice trailed off, her chin crumpling into the palm of her hand. Some staff walked by our table, laughing; one nurse turned around and said, “Hi, Dr. Rochelle. How are you?” She looked up at the nurse, mumbled something even I couldn’t really hear, close as I was. But, she managed a brief smile at the nurse. The group went on by. I looked at her; she was still caught up in her thoughts. “They can’t expect more, I should think,” I said, but she wasn’t listening, hardly heard a word. Even so, I repeated that she really should talk with Dr. Arpress about all this, get some perspective, maybe even some help. She, though, was elsewhere. “Can those parents, much less their other son, understand any of this without being doctors, too, and then wouldn’t they realize that we, that I, just don’t know how long? There’s no way to know? I know that’s the way it is sometimes, just so

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long as you’re not asked to speed things along, and surely hope that’s not on their minds. . .” “Oh,” I blurted out, “I don’t think that’s. . .” But she interrupted, or, rather, just kept on with her stream of thinking out loud. “. . .but I’ve got to put in some drugs, some pretty lethal stuff when you think about it,” and she again looked over at me, the silent question posed there on her face, in her eyes, no need to say it aloud. She went on: “I mean, some drugs to help that poor kid with agonal breathing, but isn’t that, you get down to it, no nonsense: isn’t that no more than killing him? Isn’t that only another way of helping him die, causing his death? Can you put any other face on it?” she again cast a fleeting look over at me. Still not looking for answers to her questions, I thought. “But I have keep the parents and family out of the room, out of the way altogether, they shouldn’t have to see what I think’s going to happen, it won’t be pretty, far as I remember. Damn!” she exclaimed. “I haven’t even seen that sort of thing since residency, you know? Anyway, I know I’ve got to do it, I just want to keep them from seeing the awful part of it. So, can you help with that?” she asked, turning now to me with more directness. She picked up her cup, sipped, her eyes never leaving me. I paused, took a sip, said: “Of course, I’ll do whatever I can, and I’ll talk it over with them, too. Maybe I can find out if they have any questions, any they haven’t had the wits to ask yet.” “So, okay, then, it’s settled, or almost. I’ll give it a couple of days, and you talk with them, that’s fine, that should help . . . . And thanks, too, for putting up with me now.” “No problem,” I replied, and my thoughts had already begun to float off to that still-uncertain, even if soon-to-happen future. We sat there for a bit, sipped our coffees, sort of nodded what we both knew, and I got up, nodded again, she nodded back to me, and I slowly made my way out of the cafeteria entry, knowing well enough, I suppose, what I now had to set up, say, not say. And wondering the while what in the world did I think I was up to, here and now, with this family, their child already locked into some place, whatever, wherever? Later the next day, in the boy’s room, where I had gone to try and find the family, I was brought to an abrupt halt by the scene: the boy, flaccid and unseeing, the feeding tube flexing from his chest off elsewhere, the ventilator chugging quietly, rhythmically, several nurses standing around, all of them hushed as if we were already in a funeral home. A nurse then edged over to one of the nurses from neuro, both at the kid’s bedside, whispered furiously, “He’s almost brain dead for God’s sake, right? God, we can’t let this just go on any longer.” Standing nearby, I could hear the reply, “not quite and isn’t that the whole problem?” “But, my God we can’t kill him, can we?” “Shush,” another nurse, whom I didn’t know, said. Then she said, “the family is right outside the room now.” And someone else’s words coughed up quietly as if from a hollow cave, a voice but whose I couldn’t tell, said “even so we all know that there are times and people willing to act, to do what we all know is the right thing.”

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“The right thing, right? That what you mean?” And someone else, never knowing for sure just who said what, pointed out that the chart was “odd.” Odd how? I wondered, and was answered before I could get the words out: “Well, even with the DNR and DNI, and all the talk from Dad and Mom, you know that there’s no note about the tube or antibiotics or anything else? You know?” “But,” someone said aloud what I was thinking, “do we have any choice?” Then, as most of us were walking out, me to see the family, someone went off to find the attending. But then I heard one nurse still back in the room abruptly let out a sort of sob. And without turning around, I knew, just knew, that everything was over, had to be, people don’t make that sort of noise otherwise, and I then knew that I needed to stay there at the bedside, to witness, for a witness was surely needed at just this time, with that long and impossibly drawn-out dying over all those weeks in that terrible bed, his family standing helplessly along side—wasn’t that so? Jason’s death had been drawn out way beyond anyone’s expectations, beyond even those of physicians more experienced than Dr. Rochelle, the nurses, and obviously much more than I. But that sound, ghastly and eerie, however quietly it was made, well, that had to be the very moment that kept me there. Jason did somehow manage to die, right then, before Dr. Rochelle was able to return to the room, before she would have to face the dreaded task, removing the sole remaining life-line, that feed tube. His lungs, from what the resident later told me, apparently did a tiny jig, little more than make a bit of room for some blood clot plunging through his body’s final arteries, sinking through them until, in the tiny space then nudged open, the clot seeped in and that space closed and it stuck, lodged in that narrow place and his lungs could no longer do what was needed, knowing in their way this had to be—pulmonary embolism, technically, it was said. The family meantime was already grieving deeply out in the hall, waiting and bewildered, stunned by the timing and the horror of it all. And then they came into the room and held onto Jason as, finally, mercifully, that embolism stuck, that artery plugged and then did what had been so desperately needed but could find no one to do that: Jason breathed no more. He died, witnessed by several of us and held by his mother, his brother and father-in-law at her side along with that nurse who had begun these final moments with her deep sob. I stayed on through all this, at the room’s edge, awed. I stayed in that room to witness, watching as that pitifully small body lurched a bit, chest sunk in on itself, and the monitor made its sharp up and down zig and zag line on the monitor— convincing testament that life still lingered there, but only lingered. Barely. Until finally, imperceptibly, the scrolling blip bounced first a little less, then with an almost audibly mournful sound that was no sound at all, it stopped, it flat-lined, no signs of any life, now none, no more. Jason was finally, definitively dead, now. But what is that? What had I witnessed? And what is to be done in the face of it? Dr. Rochelle and I talked later, maybe a week or so later, over a quiet cup of coffee one morning, in much the same place where we had been earlier. I had called her, asked if she was too busy to have some coffee with me. She readily agreed, and we met a few minutes later in the cafeteria; we sat down at a table pretty much by

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itself in a corner. She, like I, clearly was still unsettled by this encounter—especially over all the unknowns and might-have-beens: the accident, the damage to Jason, the family, the failure to get any kind of “closure,” as it is often put even while we know very well that closure seems mostly snake oil masking more than is ever revealed by our insistent search to forget and put behind, yet find some meaning in such events. We dodge, knowing all along we cannot avoid. She, like I, remained stunned by all the inevitable questions that resound inwardly for so long—and we, left wondering whether and why, how and what for, and knowing there are few genuine answers. “That was so hard, you know?” she said, her eyes turned inward. “Yeah,” I could only say, “I know.” Her face told at once more and far less than her words: more, for you had only to look in her eyes to understand her deep sadness, grief and uncertainty; less, for even these words, searching out the unsaid, the unspeakable, succeed in saying what needs saying hardly at all. Yet to try and tell the story, I continue to think, seems much the better way to say anything at all. This telling seems the only way actually able to give that grief its voice. I’m tempted to say its only voice. . .if said rightly. Two things should be acknowledged. First, there are important and difficult questions that stem from the multiple interactions of the people who first invited me, as an ethics consultant, into their situation. On the other hand, there are the too-often unrecognized, obstinate and awkward ethical issues that emerge with the consultant’s involvement. To become involved, whether by invitation or otherwise—like this family who didn’t so much invite me as agree to the attending’s recommendation—ineluctably changes things, and not always making things easier. This is true as much for those who issued the invitation as for the consultant— rarely been noted, perhaps because it is so awkward, seeming even, on the surface, self-indulgent: morally, I myself am then at issue and possibly at risk, like it or not. As I mentioned, I found out, but only indirectly—through Mom, step-dad, aunt, brother, medical chart, several physicians and, later, the boy’s father—something about Jason before the accident: “he loved soccer,” “he was great at math,” “his new girlfriend, Sally, is really pretty;” and, after the accident: “he was hard to get a bp on,” “he looked okay outside, less than what you’d expect, but you knew he’d really hurt himself bad;” and the clincher: “the main part of his brain seems yanked out of its roots, like the stem of a mushroom, frayed but still attached to its top.” I also came to know something about the family, Jason’s daily condition, and other matters more directly, as I talked with family members and their close friends, physicians, nurses, the nurse manager, social worker, chaplain, and others. To become involved in situations like these is invariably to come across countless allusions to numerous “elsewheres:” other ongoing events, people, and relationships (past and present, but also hoped for) which always insinuate just how much is going on I neither know about nor can reckon with in the course of listening, talking, and the rest of it. These hint at and hide details and issues in sometimes perplexing or bristling ways. These shade and set off conversations with everyone involved. Talking with Mom, even though she was very straightforward, I was haunted by indirections and inklings of other times, wisps and whiffs of places and people, clues and tracings faintly suggesting hopes or fears, ghosts of people not there but

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so obviously important for this family, for Jason before the accident—whom I could never meet, yet who were, who may have been, significant for all their lives: for how they feel and think about ethics and God and politics and farms and the weather and movies and school and doctors and hospitals, how they came to believe whatever it is they believe and with whatever passion it may be, secrets never revealed and apprehensions they may have that can’t be spoken aloud. Did it matter that Jason, loving math, was also failing English? That he was caught attempting to steal at a jewelry store earlier this year? That he lost his virginity earlier that same year? That he dreamed of becoming a musician? That he had begun to play a trumpet? That he harbored ill thoughts of his Dad? To be as clear as possible, it’s important to recognize that those of us who engage in ethics consultation (in whatever manner: whether as professor with student seeking advice, or as one of us odd persons working in a hospital) are not ourselves the ones whose original situation occasioned the request for a consult about whatever questions of ethics it may be. When I become involved, it is at someone else’s invitation—a point a consultant forgets at considerable risk; among others, obfuscating significant components of the situation. As with all human action, of course, things may change as the consultant begins and then proceeds; what the consultant proposes may indeed become a more central “issue” than other matters in the situation. Although not (at least initially) of the consultant’s own making, such situations as we may be invited into, for whatever reason, are ineluctably reflexive. By accepting such an invitation, the ethics consultant becomes part of (and thus he or she both influences and is unavoidably influenced by) what is and what is perceived (these are not always the same) as going on. Yet by virtue of that very acceptance of the invitation, the consultant at the same time bears and must accept the responsibility for whatever it is he or she eventually does and says as consultant—including what at some point the consultant may then write, and whatever the form that may take (from chart note to case report to, perhaps, a full analysis—or even narrative such as I’ve presented here). To become involved as an ethicist in a clinical encounter demands that one be focused on the individual constituents (people, setting, circumstances, issues, etc.) for their own sake. Such highly focused, individualizing concern is complex, as it is focused not only on the patient(s) and the veritable world every patient (including family, friends, values, concerns, occupations and preoccupations, etc.) presents; but also on the professionals and their own respective spheres of individual and professional concerns, commitments, values, and the like.3 What does it mean that the ethics consultant must be clinically astute and attentive solely to the individuals—any and all of them: patients, families, friends and acquaintances; as well as the usual variety of professionals: physicians, consultants, nurses, social workers, therapists, etc.—into whose situation he or she has been asked to become involved? The consultant’s concerns are, like any physician’s, at one and the same time diagnostic and therapeutic. Which, among other things, signifies a focused effort to help a patient and family understand what they face when they are confronted with problematic pregnancy, for instance; or to assist a family to

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understand what ethical issues they face when continued treatment for one of their members is thought by their physician to be futile; or to work to gain a physician’s understanding of a patient’s or family’s concerns (which may or may not have been voiced to the physician, or to anyone else before). The ethics consultant seeks to help such people become more aware of their own moral views (which often requires greater alertness about the circumstances and implications they must actually face) so that they can more likely reach decisions commensurate with those views—and eventually, live with the aftermath of whatever decision they may eventually reach. Thus, the consultant’s strict focus is to try and figure out what’s going on and how then one might be helpful—which signifies, in a word, the need for extraordinarily attentive listening and probing with questions. The consultant thus seeks not only to understand but to be understanding: why a request for the consultation came up in the first place, by or from whom it came, much less what is actually learned at the scene about the variety of people, interpretations and views each brings, etc. To help those whose situation it is requires figuring out what they are facing and then helping them to talk about it, to help them articulate their views as a way to help them reach an understanding and, in light of that understanding, to identify and clearly face those options, choices and associated decisions which, after as much discernment and deliberation as time and circumstances permit, seem most consonant with who and what they are within their own life-context—including what they have been and what they hope to become. Whatever else all that signifies, the ethics consultant must be rigorously focused on just these individuals within their circumstances and with their concerns. But, here’s the rub, now that the ethics consultant is involved, that consultant’s perspective on the issues, concerns about the circumstances, and appreciation of the other complexities encountered, are of course informed by his or her own concerns and experiences relevant to the situation now at hand. As with any such situation, however, there is inevitably a strong temptation to forget that this focus includes the issues and concerns of everyone involved and instead have attention diverted to how you or I, the consultant, might see things, and what you or I, the consultant, might decide to do, and the like. Which, of course, is precisely what you should by no means ever do: it is not my decision alone, not my life alone, not my values alone, and to the extent I am unable to put my own concerns and values into the pot to be examined alone with everyone else’s, I have no business consulting with anybody else. “Human language,” Flaubert once remarked somewhere, “is like a cracked kettle on which we beat out tunes for bears to dance to, when all the time we are longing to move the stars to pity.” Which rings true. As do Barry Lopez’s words: “Sometimes,” he said, “a person needs a story more than food to stay alive. That is why we put these stories in each other’s memory. This is how people care for themselves.”4 I like to think that Brian Doyle knew what we were going through: “. . .you think, my god, stories do have roaring power, stories are the most crucial and necessary food, how come we never hardly say that out loud?”5 There is a power in narrative which is plainly unmatched by any other, and it is, I think, because it is, when done rightly, the only way to tell that “monumentally

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elusive tale” that keeps us afloat. Even that first time I looked into Jason’s medical chart, I felt already that daunting sense of moral pathos: how little I will ever know about Jason and his family, the doctors and nurses, the EMS people who first rescued him—is that what they did, “rescue” Jason? How little, yet how immense and imposing are the words that must be used to grab onto the questions they must answer and the issues they must decide, they cannot help but decide. And for me, too, how pitiful will be what I came to know about them, yet how momentous the decisions I was there to help them reach, reach out for, knowing how slight the grounds for making those shattering choices. For Jason of course: his destiny already decided by what happened, sure, but that will never assuage or belie their grief or guilt, nor my sense of failure, of plain inability to help at all. But also for each of them, this family, doctors and nurses as well, each in their own unique ways and within their own singular lives: what vast oceans our words conceal: “outcome,” “result,” “aftermath,” “decision,” “choice,” whose soul-heavings will not ever be finished, over and done with; not really, even though the sheer passing of time will in fact fade sharp edges, heal much, and well. The “once only, once, and no more” (Rilke running through my mind) that happened, here, with this boy, in that car, on that hill, at that time, bathed in that eerie light; here and now, that once-for-all-time happening will yet happen forever, will go on endlessly happening. As, too, doubtless, will my own meanderings in these fields, these ineluctably perilous places where we have our once-and-only lives. “In the immediate world,” James Agee wrote in that incomparable text he published in the late 1930s with Walker Evans’ amazing photographs, Let Us Now Praise Famous Men, . . .everything is to be discerned, for him who can discern it, and centrally and simply, without either dissection into science, or digestion into art, but with the whole of consciousness, seeking to perceive it as it stands: so that the aspect of a street in sunlight can roar in the heart of itself as a symphony, perhaps as no symphony can: and all of consciousness is shifted from the imagined, the revisive, to the effort to perceive simply the cruel radiance of what is.6

Like Agee, I want to do nothing more than let these things and these people be, whoever they are and in whatever way they might (want to) be, with neither dissection nor digestion. I hope I have made it very clear I believe Agee is right. Even while we all must at some point come to realize how hard it is to stand in that “cruel radiance” that is the thrill and sting of every life story.

Notes 1. Which I finally managed to do, and is included as “Broader’s Hill” in my book, Conversations at the Edge: Narratives of Ethics and Illness, Washington, D.C.: Georgetown University Press, 2004 (translated into Chinese Mandarin, Taipei, Taiwan: PsyGarden Press, 2004). 2. Roger Rosenblatt, “Dreaming the News,” Essay, Time, 149:15 (April 14, 1997) 102. 3. I dwelled on these matters in Chapter Two of my Ethics and the Clinical Encounter, op. cit.

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4. Barry Lopez, Crow and Weasel, North Point Press: San Francisco, CA, 1990, 48. 5. Brian Doyle, “The Greatest Nature Story Ever,” Orion Magazine, found in their online digital edition, http://www.orionmagazine.org/index.php/articles/article/3649. 6. James Agee and Walker Evans, Let Us Now Praise Famous Men (New York: Houghton Mifflin Company, 1939, 1940, 1969) 11.

Chapter 3

Richard Zaner on Transcendentality, Eidos and Phantasy Ronald R. Cox

1 Introduction The body of philosophic work produced by Richard Zaner can be divided into two distinct but deeply integrated and inseparable parts. His earlier work focused on core themes in phenomenology, mostly approached from a Husserlian standpoint, and his later work has dealt with themes in ethics, particularly medical ethics. Within the phenomenological corpus, Prof. Zaner discussed a wide range of issues, but there were three that he returned to again and again. These three are the problems of embodiment, intersubjectivity and the self. These three problems are themselves intimately interrelated, and they are inherently phenomenological ones. Zaner’s book The Context of Self: A Phenomenological Inquiry Using Medicine as a Clue can be seen as the culmination of, and even as a capstone to, all his thinking prior to its publication and as a herald of his shifting focus to medical and ethical themes. These thematic concerns formed a systematic unity such that Zaner’s later focus on the experiences of patients, their perspectives on issues of health, their interactions with medical professionals and how they experience clinical encounters was a natural and, with the benefit of hindsight, a seemingly inevitable step. In focusing on these large themes however, it is possible to overlook Zaner’s very significant contributions to fundamental issues in phenomenology itself that formed the philosophical basis for both his phenomenological and ethical writings. The purpose of this essay is to analyze certain core aspects of the concept of transcendentality as it pertains to phenomenology and as found in the phenomenological writings of Richard Zaner. A significant result of this analysis will be the identification and clarification of an epistemic privilege inherent to transcendental phenomenology, one that is given new emphasis and meaning by Prof. Zaner’s work.

R.R. Cox (B) Department of Philosophy, San Antonio College, San Antonio, Texas e-mail: [email protected]

O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_3,  C Springer Science+Business Media B.V. 2011

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2 Transcendentality in The Context of Self While no simple summary of this work is possible, it is possible to ascertain in a fairly economical fashion the principal idea of transcendentality that pervades its pages. In a critical response to Paul Ricoeur, Zaner writes the following (1981, p. 129): This “talk about” can only be transcendental, and cannot therefore be confused with what it is supposed to justify radically—viz., hermeneutics. It may well be that one must “live in the aura of meaning” of the symbols in order to understand them: but this claim as such is not at the same level as that inquiry, since it speaks to what is transcendentally necessary in order to conduct such an inquiry.

Transcendental phenomenology is at a different level than hermeneutics, radically justifies the latter and speaks to what is transcendentally necessary for hermeneutic inquiry. Again, Zaner says (1981, p. 130), “To repeat: the statements about the hermeneutical task, and the practice of hermeneutics, are not at the same level.” We need not summarize Zaner’s analysis of Ricoeur’s position. Our focus is on this interesting group of claims regarding the nature of transcendental phenomenology. Transcendental phenomenology in the light of these claims is both evaluative and judgmental of hermeneutics, and addresses the conditions necessary for its possibility. The claim that transcendental thought takes into consideration the “necessary conditions for the possibility” of something is recurrent in The Context of Self. The following exemplifies this theme (1981, p. 130): “Now the question here is, ‘how is this possible?’ The quest, in turn, must be a working back ‘to the conditions which make it possible.’ That is, this problematic is manifestly a transcendentally eidetic one.” And shortly after, we find the following (1981, p. 130): It is thus no surprise that Ricoeur “breaks” with his former “phenomenology”: the very questions he poses are no longer the same, they are not transcendental but rather are hermeneutical questions of interpreting “meaning.” This fact renders the very sense of his appeal to “transcendental conditions for the possibility of. . ..” highly dubious at the least.

Yet again, Zaner writes (1981, p. 144): “Still, the transcendental question remains: what are the conditions for the very possibility of being-self?” Citing additional examples of these sorts of references is possible but redundant. Generalizing these claims somewhat, it seems fair to conclude that there are three coordinate aspects to the idea of transcendentality in this work: (1) The first is the theme that transcendentality bespeaks a difference of level between phenomenology proper, i.e. the transcendental-phenomenological attitude, and other thought, which I take to include psychological phenomenology in addition to hermeneutics, but also non-phenomenological and non-philosophical thought as well. (2) Transcendental-phenomenological thought is concerned to explicate the necessary conditions for the possibility of other epistemic inquiry and of other

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affairs, i.e. other phenomena. I interpret Zaner to be asserting that the scope of those affairs with which transcendental thought can be concerned is maximally broad; it includes all things to which a mental life may be intentive. This interpretation is supported by his statement to the effect that (1981, p. 248): “The transcendental condition for the possibility of knowledge and experience thus turns out to be the autochthonous organization of experience according the principle of ‘field’: context, contexture, margin.” Since all affairs of which we are conscious are presented within the field of consciousness, it readily follows that all consciousness of anything at all is subject to the same transcendental condition for its possible occurrence. The concept of transcendentality in The Context of Self is most frequently presented as what we might call “transcendental necessity,” which is to say that phenomenology is transcendental in that it seeks the necessary conditions for the possibility of phenomena. (3) The third aspect of transcendentality or of the transcendental-phenomenological attitude is its epistemic privilege, which is that it provides a radical justification for epistemic claims made in both phenomenology and other areas. Since these three aspects are all essential features of transcendentality, one might expect that they are interrelated to each other. In addition, due to the nature of the claims cited above, these three aspects must be taken as fundamental to Zaner’s concept of transcendentality and of phenomenology. The claim that there is a difference in level between claims made in the transcendental attitude and those not made in that attitude is both interesting and provocative. I believe this claim is an important clue to understanding the other two aspects of transcendentality and of the idea of transcendentality in phenomenology generally speaking. Hence, one investigative path of this essay will be to follow the clues relating to the idea of this difference in level. So what is this difference in level and what does it signify for phenomenological philosophy? In what does the epistemic privilege of radical justification consist and how does it relate to the difference of level? In addition what is the significance of the idea of transcendental necessity mentioned above? How are these three interrelated? I believe that Prof. Zaner answers all these questions. Since this does not occur in a single publication, we must engage in a journey through several works to see the whole picture. We turn first to the task of explicating the idea of transcendental necessity.

2.1 The Two Tasks Mandated by the Idea of Transcendental Necessity There are two aspects to the task of specifying the transcendental conditions of something, i.e. to determining the necessary conditions for the possibility of something, as this is meant within and for the discipline of phenomenology. One aspect of this task is to determine the essence or eidos of that something, and the other is to provide an analysis of the foundedness of it. Let us turn to the latter first.

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2.2 Foundedness To say that one process of intentionality is founded on another means that the founded process cannot occur without the co-occurring of the founding process. However, the founded process may or may not occur given the occurring of the founding process. Hence the founding process is necessary for the founded one to occur. One eidetic relation of founding-founded processes in mental life is that nondoxic positings are founded on doxic positings. Doxic positings are positings of the existence, non-existence, or possible existence of something. Non-doxic or sentic positings include such positings as the positing of moral or aesthetic value. A regressive analysis of the founding-founded stratifications of the processes that comprise the intending to any noema is an essential part of the analysis of the intentiveness to that noema (Zaner, 1970b, pp. 170–174). A thorough analysis of the role of foundedness in phenomenology is well beyond the scope of this essay, so as a matter of expediency, we now hasten on to the other aspect of transcendental necessity in Zaner’s thought.

2.3 Eidetic Inquiry: Free Phantasy Variation and Essences Phenomenology is in its length and breadth a science of essences. It is no overstatement to say that every phenomenological statement is a statement about essences and that every phenomenological investigation is the bringing to light of essences. This means that phenomenology’s aim is to explicate the essential features of mental life, and this in turn means that the methods and procedures of explicating essences is of fundamental significance to it. Prof. Zaner’s essay, The Art of Free Phantasy in Rigorous Phenomenological Science, adds to our comprehension of eidetic insight, and thereby to the specifying of the necessary conditions for the possibility of something (1973, pp. 192–219). Once again, we cannot summarize the essay and must focus on what is germane to our theme. 2.3.1 Initial Comments on Free Phantasy Variation Free phantasy variation is the process of inspecting a range of examples of an essence in one’s phantasy and on that basis attempting to grasp clearly that essence. A few general observations are in order at the outset. Zaner argues, agreeing with Husserl, that the method of free phantasy variation to explicate essences should not be understood as an example of inductive argumentation. Such confusion misses the real point and crucial importance of the method. Free phantasy variation is not an argumentative method per se at all. Second, the emphasis on phantasy makes clear that the method of variation is not limited to considering examples drawn from experience, but is free to use instances supplied by phantasy. Thirdly, of

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significance is that this variation in phantasy is carried out with the awareness of its “free optionalness.” This procedure for the exploration of essences is not restricted to phenomenology, and is used in non-phenomenological and non-philosophical sciences. Zaner mentions its use in geometry. The process used by geometers to produce geometrical idealizations is similar but not identical to the process used by phenomenologists to elucidate essences. Free varying of examples is particularly useful in establishing the outer boundaries of an essence and in delimiting it sharply from other essences. Since the basic idea is that by surveying a number of examples of an essence one can then identify what is common to those examples that pertain to the definition of the essence, the method has a potential use in any science whatsoever. It is important that the consideration of various examples motivates an abstractive leap the result of which is the clear apprehension of the universal in question. The entire process rests to be sure on an initial, indistinct and partial view of the essence to be explicated; else one would not have a beginning point from which to proceed. 2.3.2 Free Optionalness A number of additional points need to be considered here. (1) The process of explicating an eidos begins from the essential necessity that any particular object can be grasped in either of two ways: (a) it can be seen as a particular that is what it is in itself alone and as such is unique, an individual; (b) or, it can be seen as an exemplification of an essence, as an example subsumed under an eidos. Because this is true for all particular objects, it follows that any example of an eidos can be substituted for another example of the same eidos, and so would serve equally well as the starting point for the process of variation. Thus one is free to shift one’s view from any of these examples to any other. That is to say, one may freely choose however one wishes from among the examples of the eidos as the starting point of the variation. In addition, one is free to select other examples, as one wishes and in any sequence, in order to carry out the variation. (2) The beginning point is free from any necessary connection to actuality or actual experience. Rather, one is perfectly free to consider examples from phantasy. This also means then that one could explicate an eidos for which there are no actual examples in existence, providing an eidos of a purely possible something. Hence the process exhibits a free-optionalness in both the choice of beginning point of the variation and in its carrying-out of the variation. The only constraint is that one continues to select examples in the course of the free variation that do in truth stand as exemplifications of the eidos one is seeking to explicate. (3) One is also free to end the process at one’s own discretion, or to go on indefinitely selecting still more examples. Furthermore, one is not compelled by any external circumstance even to begin the process. (4) The objective of the process is to gain an explicit and clear apprehension of the invariant essence that is identical to all the examples considered. It is just the invariance of the eidos, that which is common to all the examples of it that is

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brought to the fore as the result of the process of variation. The essence or eidos is then revealed as that without which the various exemplifications would not be what they are, as examples of the common eidetic form. This is, to quote Husserl, as Zaner does, “the ontic essential form (apriori form), the eidos, corresponding to the example, in the place of which any variant of the example could have served equally well” (Zaner, 1973, p. 196; Husserl, 1968, p. 248). Because this procedure of free variation is not bound by what is given in actual experience and so can freely use instances grasped only in phantasy, the entire domain of the eidetic is opened to investigation. Precisely because this process operates in the realm of the essentially possible rather than the real, it makes possible the exploration of the necessary conditions for the possibility of any phenomena. (5) Zaner notes that it would be incorrect to see the process as it is useful for phenomenology as simply identical to that used in geometry. In addition he quotes Husserl’s comment that the realm of the arts, of poetry and fiction are useful ways to fertilize our phantasy in the pursuit of those essences sought by phenomenology. We will close with the remark by Prof. Zaner that the consciousness of freedom and the possibility of creative thought are essential to the exercise of free phantasy variation, and thereby as well to the eidetic insight that the former makes possible. 2.3.3 Formal and Material Universals While it is obvious that Prof. Zaner’s essay on free phantasy variation makes the process of explicating an essence clearer than before, it might be observed that his essay did not distinguish between the processes of generalization and formalization, i.e. between the two types of universalization. Although this distinction is not made explicitly in that essay, the analysis afforded does provide the basis for a clarification of the two types of universalization. The explication of a universal is called universalization. Generalization is the process of explication of a material universal. For example, if we are using free phantasy variation to clarify the nature of doxic positing, I can freely vary to myself actual and phantasied variants of doxic positings, thereby making the invariant eidos or universal stand out. The analysis provided by Zaner applies directly to the explication of material universals, i.e. to generalization. Formalization is different from generalization, and consideration of the idea of free-optionalness helps clarify that difference. For with regard to formalization, one is not constrained by a material eidos at all, since that sort of eidos is entirely beside the point. Material essences are completely ignored or emptied out, as it were, so that only the form, or what might be called the formal “place holders” are left. One’s freedom to select examples here is unrestrained except that it must still fit the form. To put this another way, when we are performing the free phantasy variation with the aim of explicating a formal universal, I am entirely free to select instances that range across all possible material universals, precisely because all material essences

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are irrelevant to the formal essence. Furthermore, in the process of formalization, one does not ascend or descend a hierarchy of genera and species. Rather one transits from the instance or example to the formal eidos of it in a single leap, a single abstractive jump that removes all material content and leaves only the emptied concept, the form. Hence when considering an example for universalization, I can freely opt to vary in phantasy either in the material or the formal sense. I can for instance look at or phantasy a collection of several apples and attempt to generalize to the material form “apple,” or I can look at the collection and formalize to the formal eidos “set,” or “number,” “three,” or some other formal universal. There is still a constraint to the variations one considers, though the constraint is purely formal. The constraint is just the pure form itself, and that in the first instance is determined by the formal domain within which the formal universal resides. As usual, some free variation will help clarify this. Consider a simple example from formal propositional logic, the conjunctive form denoted by “p and q.” Since the formal domain is formal propositional logic, the field or formal domain is the possible forms of propositions and their relations, as opposed to, for instance, the possible relations between sets. What p and q represent must be propositions. But beyond that, p and q are entirely formal in that any proposition at all may be freely substituted for the p and the q. On the other hand, it would be improper to substitute a set designator, for instance “apples,” or “oranges,” or “quarks” for either p or q since those are not propositions. The process of formalization exhibits the free optionalness of which Zaner spoke. One may freely substitute any proposition at all in place of the p and the q. In other words, whereas in the process of generalization, one may need to consider a definite range of examples, freely varying them to demarcate the limits of the material eidos as completely as possible, that is not required in formalization. Here, one certainly could choose example after example, but they add no expanded sense to the formal eidos in question as happens in generalization. Rather one is completely free to empty the form of all material reference in a single variation, and thereby immediately grasp the formal universal. Awareness of the freedom to make that leap of formalization is an essential part of intuition of formal universals. Husserl wrote about the possibility of developing a pure formal science of relations, which would ultimately be a formal ontology (Husserl, 1968, pp. 48–148). The already developed formal sciences of formal logic, formal mathematics and formal apophantics would find their places within the framework of the pure formal ontology. Husserl believed that the pure science of relations as such was even then in his lifetime under development under the heading of the mathematics of the manifold. Whether that was so has been debated and we surely cannot enter into those questions here. Zaner’s concept of free optionalness extended to the process of formalization clarifies the conditions by which it is possible to proceed in a single leap from a concrete instance to a formal universal and that process significantly differs from generalization.

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2.4 Reflections on Free Phantasy Variation and Its Usefulness The utter necessity of free phantasy variation to the process of clarifying and bringing oneself to the point of being able to grasp or intuit essences is manifest. In addition, the centrality and necessity of essence-seeing as what it is to specify the necessary conditions for the possibility of phenomena is affirmed. This function is then an epistemological one, for it is only in the grasping of essences that genuine knowledge is obtained. One cannot apprehend any particular object in actual or phantasy-experience as merely and only a particular, as an example of no essence at all. Hence any claim to knowledge, any epistemic claim, must be implicitly or explicitly an assertion of an eidetic nature. It must assert an eidetic truth. Under what conditions then is a statement one of eidetic necessity? I.e. under what conditions is a statement transcendentally eidetic? The answer is: precisely when it does explicate an eidos, a material or formal universal. As such this route, free phantasy variation, to eidetic insight is both a powerful tool for investigation and an essential method in phenomenology and all eidetic sciences.

2.5 Some Intermediate Conclusions One aspect of the difference in level question posed above is answered. To provide an account of the necessary conditions for the possibility of any intentional processes is both to give an account of its necessary founding noetic-noematic strata in the stream of mental life, and to explicate its own essence. The process of free phantasy variation is an indispensable part of the method of explication of essences and the prompting of the intuition of essences. To explicate any phenomenon in such a way is then to move our understanding of it to another level. Is this then already to be providing a radical justification for one’s epistemic claims regarding that phenomenon? In what way can epistemic claims be radically justified, in Zaner’s view? More specifically, how are epistemic claims in phenomenology to be radically justified? In order to address that question, it will helpful to turn to Prof. Zaner’s essay on epistemic claims.

3 The Legitimating of Epistemic Claims Zaner’s essay entitled The Phenomenology of Epistemic Claims (1970a, pp. 17–34) is a rigorously argued contribution to epistemology. It contains a crucial truth regarding what it means to speak of radical justification of any epistemic claim in phenomenology, indeed, in any science whatsoever. This also applies more significantly to the elucidation of the epistemic privilege of transcendental phenomenology and thereby as well to clarifying that difference of level that we discovered earlier to be a recurrent theme in Zaner’s writing. We turn then to his analysis of epistemic claims.

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While there is both an outer and an inner contextuality of all epistemic claims, for the purposes of his essay, Zaner focuses on the inner contextuality of such claims. The inner context reveals an eidetic structure whose explication is the goal of his essay. Zaner delineates a number of basic features of any epistemic claim. First, any epistemic claim is expressed in linguistic terms and purports to say something about something. As such any claim sets up zones of relevancy and irrelevancy pertaining to its subject and what is claimed about it. In addition, the making of a claim renders that claim itself open to inquiry. It presupposes the necessary conditions for the possibility that it is a claim to knowledge. This means that every claim is subject to epistemological critique. Specifically, for philosophy, this means that any epistemological investigation as part of philosophy is itself essentially open to critique as well, so that one aspect of the true nature of epistemology as a philosophical discipline must be that it is self-critical. Hence philosophy has the unusual task of accounting for its own possibility, and this is a fundamental dimension essential to philosophy as such. Phenomenology as ultimate epistemology takes this task as one of its most fundamental goals and requirements. Zaner, following Cairns (Zaner, 1970a, p. 20; Cairns, 1973, pp. 239–250), distinguishes between: (1) the mental act of judging; (2) the meaning or sense that is articulated, i.e. the judgment produced; (3) the sentence that expresses the judgment; (4) the physical embodiment of the sentence, the sounds or marks themselves; (5) the objects or states of affairs about which the judgment is made. Judgings are real events that are unique occurrences, whereas the judgment produced is a noematic sense complex that is ideal, i.e. non-spatial and non-temporal. There can be multiple judgings of one single judgment that is identically the same throughout the plurality of judgings. This is only possible due to the ideality of the judgment. The judging process is accurately described as a producing of the judgment. This does not imply that the judgment is an actual component of the judging. To the contrary, the judgment is not located within the mental life that produces it and thereby intends to it. It is not located anywhere at all, since it is ideal. Zaner goes on to emphasize that the judgment bears a unique relation to the affairs that constitute the “subject matter” of the judgment. As a judgment about these affairs, it claims they are of such and such a nature. It predicates some property or feature about the affair or affairs that make up the subject of the judgment. The judgment states a supposition that something or other is true. Zaner uses the term “the supposed state-of-affairs as supposed” or “the claim as claim” to designate the “what” that is alleged or supposed to be so. That the supposal itself purely as supposed is however altogether distinct from what the judgment is about must be clear. For example, the claim that the apple is red must be distinguished from the apple that is the actual object judged about. Zaner expands on the above analysis by pointing out a number of fundamental presuppositions implicit in the making of a judgment. Some presuppositions relate to the intelligibility of the language used to express the claim and of the judgment

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itself. These entail that the terms used to express the judgment bear a sensible context in terms of which the judgment itself, whether eventually deemed true or not, is nonetheless not nonsense. He also points out that judgments as such have an inherent ontological sense, in that they “assert the being of the affairs in question” (1970a, p. 26). And it is this that makes the judgment or claim always subject to epistemic critique. It is legitimate to ask both: (1) Is the judgment accurate in what it alleges to be the case? (2) How is it possible to know that such and such as claimed is the case (or not)? So each and every judgment carries within its inherent sense that it can be evaluated ultimately as true or false. In other words, it is presupposed that it is possible to grasp the intended-to sense of the supposition and the noematic objective sense of the affairs judged about at one and the same time, and thereby also actively judge that those two sense complexes are in agreement, are the same noematic sense complex, or that they are not the same and thus in disagreement. To be sure, such agreement and disagreement can occur in degrees, or various modalities, such as certain, uncertain, more or less certain, and so on. Yet each of those modalities point back to the possibility of complete agreement or disagreement, which is to say, of complete or definitive confirmation of the truth or falsity of the judgment. It is always possible then to form yet another judgment about the coincidence or lack of coincidence between the sense complex, the judgment as supposed, and those affairs themselves that are judged about. In other words it is always possible to form a judgment about the truth or falsity of any judgment. This takes us to several additional and quite crucial presuppositions of any judgment. As a matter of eidetic necessity, the judgment presupposes that the judger has access to the affairs judged about, access that enables both the making of the judgment to begin with and also therefore the evaluation of the truth of it. The presupposition of having access to the affairs judged about themselves then also presupposes the possibility of what can be called “a-having-of-the-affairs-themselves.” This can also be called an intuition of those affairs. The presupposition of a possible having-of-the-affairs-themselves is tantamount to the presupposition of a possible adequate judging of the truthfulness of the judgment. It is possible to judge in a quasi or as-if fashion, to judge fictively. I could quasi-judge, “The planet Saturn is the home of friendly sapient zebras who regularly dine on sapphires.” In such a case, I am fully aware of the quasi- or fictive nature of this judging, and the mode of awareness I have of the affairs the judgment is about a doxic-positing of their inexistence. This falls still within the scope of the above observation regarding accessibility to the affairs judged about. We should also note that fictive judging is quite important in the process of free phantasy variation discussed earlier. Judgments in general presuppose that the judgment is on principle capable of being judged by other individuals in addition to the original judger. The act of judging presupposes the possibility of an audience or a readership capable of grasping the sense of what is supposed, i.e. the judgment. This presupposition arises due to the eidetic possibility that there can be multiple judgings of the ideally

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identical judgment, and that in addition, these multiple judgings on principle could be produced by multiple judgers. Zaner goes on to point out that in the case of judgments made about experience, or for that matter, any form of intentiveness at all, straight-forward intending to the matters judged about is not possible. These sorts of affairs are accessible only by reflection on one’s own mental life and/or mental processes. A having of the affairs themselves in the case in which those affairs are intentional processes cannot be realized by means of sense perceptual experience. The only form of experience by means of which one’s intentional life can possibly be adequately given is reflection. The preceding remark can be extended to any individual intentive process qua noesis and to any noematic sense as intended. It applies therefore to all judgings of judgments that take place in phenomenological investigation, and also to all judgings about mental life or mental processes in philosophy, science and even in the lifeworld. This does not exhaust the content of Zaner’s essay. However it does provide us a vital component of the answer to several questions raised earlier. Once it is combined with insights from The Way of Phenomenology, it will allow us to clarify what the epistemic privilege of the transcendental attitude is, and therewith as well, the genuine sense in which there is a difference of level between transcendental phenomenology and other thought. It will thus provide a final clarification of what it means to justify radically an epistemic claim in phenomenology.

4 Transcendentality in The Way of Phenomenology Zaner’s discussion of transcendentality in this text affords us his most extensive comments on this topic (1970b, pp. 177–195).

4.1 The Multi-leveled Self The discussion focuses on the transcendentality of phenomenology by referring to a certain duality of human nature that is a recurrent theme in his thought and which he here aims to discuss at a fundamental level: the essential reflexivity of the experience of human beings. At one and the same time, I experience myself in dual ways, both as an object among the things of the world about me, and as this self who as subject takes me to be an object all the while also taking me to be a subject. This reflexive multiple awareness of oneself gives one a dual status and this duality is at the heart of the meaning of transcendentality. The world about me is taken as transcendent to me, as other than what I am, and yet, I am now finding myself, as reflecting mental life and ego, also exhibiting a certain transcendence, a transcendence of myself to myself. As a necessary condition for the very possibility of such a dual apprehending of oneself, the self-as-apprehending subject must be at a different level than the self-as-apprehended object, even though these are both different aspects of the very

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same self and mental life. In a discussion of the shortcomings of the Cartesian analysis of reflexivity, Zaner remarks, “By failing to see the eidetic necessity of a status other than worldly or mundane, and inherent in the very experienced duality of subject and object, Descartes failed to make the transcendental turn” (1970b, p. 180). The transcendental turn is effected by recognition of that duality and the difference in level that it entails. Earlier we saw in the criticism of Ricoeur the claim that hermeneutics is at a different level than the transcendental justification of it. Now we see that in the reflexive encounter of self with self there must be a difference of level between the reflective-apprehending and that which is reflectively-apprehended. It is this latter sort of level-difference that I find both most enlightening and suggestive. We need to see to what it is referring and why it is essential to transcendentality in phenomenology. He shows that reflection on one’s own mental life and self, and hence the experience of this reflexive transcendence, is not limited to philosophical or phenomenological thought and it can and does occur in pre-philosophical life. The emergence of the psychological-phenomenological attitude exhibits this critical attitude vis-à-vis one’s own experience, and as phenomenologist I can go on from there to attempting to discern essential features of mental life and the world as experienced by it. Zaner sketches a possible path of development of the psychological attitude starting from the idea of a self-criticism, and its expansion into a network of related phenomenological themes and problems. As one travels that path one will eventually be confronted with a number of experiential consequences of having done so. But in the case where I reflect on myself (in the philosophical sense), this specific disengagement is most unusual, for the disengaging is a ‘stepping-back-from,’ in order to focus on myself. But, (1) this stepping-back is a stepping-back from myself, my own mental life; (2) it is also an action I myself engage in, something which I experience and, by experiencing, experience something else—namely, myself. Hence, (3) I disengage from myself in order to engage myself in myself critically, and this constitutes a complex mode of experiencing and self-experiencing. (Zaner, 1970b, p. 188)

Zaner then says that what makes our inquiry transcendental is “the disclosure of a deeper status of self” (p. 188) in terms of which this sort of reflection is possible and which accounts for the constitution of such reflexive experience in terms of the founding strata of mental life. Here is a reference to a difference in levels and also a clear statement as to what it is. At least one sense of the idea of a difference in level is indeed just that of the relation of founding mental processes to the founded ones. Husserl referred to the phenomenological Ego (i.e., the transcendental ego) as a disinterested onlooker that is “above the naively interested Ego” (Zaner, 1970b, p. 189; Husserl, 1973, p. 35). We see that the difference of level entails that the reflecting transcendental ego must have a superior position to the one reflected on, i.e. it must be above the other. In what way is one aspect of the self above another aspect of the self?

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That reflexive status, since it is apprehended as that by virtue of which any possible reflection, introspection, or autobiographical thinking-over is at all possible cannot, by eidetic necessity, be at the same level or have the same status as the latter. (Zaner, 1970b, p. 191)

The reflecting ego in such a situation is the transcendental ego and the ego reflected upon is the worldly ego. It would seem that these two egos are at different levels, and that one of them has a certain privilege in relation to the other. Zaner rejects any reification of the ego and hence the notion that these are literally different egos. These “two egos” are only two aspects of a single self and are not substances of any sort. The privilege of the transcendental ego referred to here is the same privilege we noted above in Section 2.1 of this essay, i.e. it is the epistemic privilege of having the possibility of radical justification of epistemic claims. Why does that epistemic privilege accrue to the transcendentally reflecting self? Is this privilege the sole possession of the transcendentally reflecting ego alone or of the psychologically reflecting ego as well? It is quite clear from Zaner’s remarks that the self as so conceived is a complex self, a structured self. While this is so, it is also one in which the various aspects of the self are capable of encounter of such a nature that one aspect, the transcendental, knows the others, all the rest of mental life. Based on what Zaner said, the latter apparently does not know the former. So it appears that one aspect of self—the transcendental—is privileged in regard to the others, in that it is a unified aspect of the self that is capable of awareness of the other aspects. This invites turning attention to just that self. As Prof. Zaner words it, “Who is this ‘I’ who thus reflects, explicates, analyzes, and, in these specific modes, experiences himself?” (1970b, p. 192).

4.2 The Knowing Self or the Self that Knows Self At this point we can begin to knit together the answers to the questions we have posed, based on the various insights we have gained from Prof. Zaner’s writings. I propose the following answers: (1) the difference in level mentioned at numerous points by Zaner is a reference to the founding-founded structures of intentional processes that comprise mental life. The founded processes are at a higher level than the founded ones, where “higher” means that they are made possible by the lower ones. Thus, those processes that constitute the transcendental ego or self are founded on other processes that make them possible. More, the mental processes that immediately make those transcendental ones possible are just those involved in instituting the transcendental attitude, i.e. those that effectuate the transcendental epoché and reduction. The transcendental ego is not an entire ego or self and certainly not a separate being or entity. Rather the transcendental ego comprises the intentional

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processes of reflection, description, essence-intuiting, and so on that take place within the framework of the transcendental attitude, and which thereby produce those judgments that make up transcendental phenomenology. (2) The higher level identified above does have an epistemic privilege and that is also part of the sense of the metaphor that it is at a different and a higher level and that judgments produced at that level thus are at a higher level than others. Thus this is the second sense in which there is a difference of levels. (3) The transcendental attitude does have an epistemic privilege as compared to both the psychological attitude and the natural attitude. This privilege is based on two factors: (a) the job of phenomenology is to make justified epistemic claims. The range of topics that form the content of phenomenology is too broad to list here, but all of them relate back to the theme of the explication of the eidetic structures of mental life. Hence, the job of phenomenology to produce eidetic claims involves the producing of judgments regarding both formal and material universals. Since the judgments so made are produced from the transcendental attitude and are about formal and material universals, they therefore describe the necessary conditions for the possibility of those phenomena or affair complexes to which they pertain. This in itself denotes an epistemic privilege: the formation of universal or eidetic claims already presupposes, as Zaner has shown, both the utilization of the processes of free phantasy variation and also, leading directly to the next provision, that the judger has access to the affairs judged about. (b) The epistemic privilege of the transcendentally reflecting ego is not however exhausted by the above provisions. Another epistemically crucial provision was noted above by Zaner. It is that the access to the affairs in question must be appropriate to the state-of-affairs that constitutes the subject of the judgment. The mode of access must be such that the affairs in question can be adequately given if an adequate judgment is to be produced. The mode of awareness in which an affair or affair complex can be adequately intuited would then constitute an epistemically privileged standpoint for the production of judgments relevant to those matters. This means that in order to make true judgments on mental life, there must be an epistemically privileged mode of awareness of it. Hence as Zaner noted, judgments regarding mental life must be founded on reflection on that mental life. Phenomenologists recognize both the psychological and the transcendental attitudes as allowing access to mental life and thus allowing phenomenological investigation and analysis. It seems that, based on what we saw above in this essay, Zaner holds to a privilege of the transcendental attitude with respect to the psychological attitude. Why should that be so? I believe Zaner has provided two reasons for this.

4.3 The First Epistemic Privilege of the Transcendental Attitude In his essay on free phantasy variation, Prof. Zaner says (1973, p. 202): In still different terms, the “starting-point” of free variation must be seen as essentially presupposing the effectuation of the phenomenological epoché and reduction, following

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on which the specifically eidetic epoché and reduction can be effected. The validity of the method of free variation always rests on the apprehension of the intentionality of consciousness and its intended correlates. It is from the apprehension of the noetic-noematic character of any actual or possible experience that the method of free variation begins. Thus, to speak phenomenologically of beginning from affairs taken as examples is always a short-hand: it is intentional experiences with their intended noematic-objective correlates that are to be taken as examples of free phantasy variation. Only because of that “disconnection” and its subsequently established “attitude” (the epoché and reduction) can one properly characterize free phantasy as leading to the originary intuition of essences.

Then, in The Way of Phenomenology, he observes that (1970b, p. 192): “Intentiveness is a sui generis type of relatedness, a thesis in critical philosophy, including within itself its noematic correlate, the ‘tree-as-seen,’ and its noetic correlate, the ‘seeing-of-the-tree.’ ” We can now put these together with what else we have seen to ascertain the first epistemic privilege of transcendental phenomenology. It is that since the job of phenomenology is to produce epistemic judgments that are also eidetic judgments, then those judgments can only be produced on the assumption that the phenomenological epoché and reduction have been effectuated. The effectuation of the transcendental attitude by the transcendental epoché is then the necessary condition for the possibility of the formation of adequate phenomenological judgments. This privilege is however itself founded on the other privilege.

4.4 The Second Epistemic Privilege of the Transcendental Attitude The second privilege of the transcendental attitude is that it provides privileged access to those affairs that make up the subject of phenomenology, namely the intentive processes of mental life. There are two reasons for this privilege. (1) The nature of intentionality: Because the relation between the noesis and the noema is sui generis, it is possible to reflect on it in an adequate fashion only from the privileged standpoint that is the transcendental attitude. Zaner noted that the validity of the free variation process, and hence the legitimacy of the essences thereby intuited, rests on the adequate apprehension of the noetic/noematic intentivenesses themselves. That this is so can be further substantiated by some additional considerations. (2) The field of reflection: We noted above (in Section 2.1. of this essay) that Zaner identified the necessary condition for the possibility of knowledge to be the autochthonous organization of the field of experience into a theme, thematic field and margin structure. Now we should realize that this structural requirement holds for reflective experience and knowledge as well as for straightforward experience. The implication of this requirement is that transcendental phenomenology does indeed have an epistemic privilege in comparison to psychological phenomenology. To understand this is so only requires understanding the difference between the

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transcendental epoché and reduction and the psychological epoché and reduction. So let us state the sense of these two methods precisely. (a) The psychological epoché and reduction: The psychological-phenomenological epoché is the refraining from accepting the existence of anything intended as other than one’s own mental life and self, and also refraining from accepting any causal functional relations between one’s own mental life and self, and anything intended as other than one’s own mental life. The effect of putting the psychological epoché into play is to effect the psychological reduction. The reduction is only the sustaining of the attitude initiated by the epoché. In this attitude, the practicing phenomenologist is thereby focusing attention on the intentional structures of one’s own mental life, without engaging in attempting to account for them in causal terms. In the psychological reduction, one treats all the affairs of which one is or can be aware in the world as other than one’s self and mental life as “appearance phenomena.” Such objects so intended are considered only as what-I-am-awareof, and one’s experience of them is then highlighted as the manner in which I am aware of them. Although putting the psychological epoché into effect means that one does not account for one’s own mental life in natural causal terms, one is still implicitly accepting the existence of one’s mental life, and is also accepting it as being located in the worldly nexus, the worldly causal nexus. This worldly status of one’s mental life and self remains throughout the psychological attitude. (b) The transcendental epoché and reduction: The transcendental epoché is the refraining from accepting the existence and the worldly status of one’s own mental life and ego, along with refraining from accepting the existence of the world intended as other than one’s self and mental life. The transcendental reduction is the sustaining of the attitude initiated by the transcendental epoché. In this attitude, the phenomenologist treats one’s own mental life and ego as only “appearance phenomena.” Phenomenological investigation carried out with the transcendental epoché and reduction in effect is then called transcendental phenomenology.

4.5 Coherence of the Field of Reflection While many of the results of psychological phenomenology and transcendental phenomenology are, for most intents and purposes, the same, there is a significant difference as well. The field of reflection is the noematic field as intended while one is reflecting. The structure of the field of reflection differs for the psychological and the transcendental attitudes and this difference is relevant to the intended noematic sense of the processes reflected on. Within the psychological attitude, one’s own mental life is taken to be a worldly phenomenon, which means that it is taken as part of a causal nexus just as in

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the natural attitude one takes objects of the world to be part of a causal nexus. Furthermore, while the rest of the noematic field of consciousness is taken as appearance-phenomena from the psychological attitude, one’s own mental life and self are not so taken. There is then a thematic division within the reflective field of consciousness. Furthermore, the relation of intentionality is seen from this perspective, from the psychological phenomenological perspective, as crossing that division and thus as affected by it. Since the noetic part of an intending to something as not a part or aspect my own mental life is still part of the natural world causal nexus, but the noematic part is not, the relation of intentionality is presented to the psychologically reflecting self as bifurcated in a fundamental way. So the relation of intentionality as seen from the psychological attitude stands with a foot in two different thematic fields. Given that the noesis and the noema are distinct but inseparable moments of a sui generis relation, this relation itself becomes defined in part by the above identified division when apprehended from the psychological attitude. This does not mean that psychological phenomenology is of no use, or that its findings are wrong or illegitimate. It means instead that certain phenomena are not adequately intuited from that standpoint. It also means that psychological phenomenology does not provide the radical justification of phenomenological assertions mentioned earlier in this essay. If follows that psychological phenomenology is incomplete without transcendental phenomenology. Since the transcendental attitude takes one’s own mental life and self along with those affairs intended to as other than this mental life as appearance phenomena, there is no such division of the field of reflection. The transcendental epoché and reduction refrains from positing the worldly status of one’s own mental life and self and in so doing no longer sees these as part of a natural causal nexus. This means that when one reflects on processes of intentionality that are directed to things intended as not a part or aspect of this same mental life, there is no bifurcation of that intentive process. From the transcendental perspective both the noetic and the noematic aspects of the intentive process are reflectively taken as appearance phenomena. This in turn means that the nature of reflecting intentionalities and the noematic field of reflection from the transcendental perspective or attitude is coherent in a way that the field of reflection from the psychological perspective or attitude cannot be. Thus, the requirement that any epistemic judgment be grounded in an intuition that presents the affairs judged about in an adequate way, and therefore enables one to form a synthesis of identification between the supposed state of affairs as supposed and the affairs themselves, where those affairs are intentive processes, is satisfied only in the transcendental phenomenological attitude. The psychological attitude is still useful, to be sure, but it does not provide the epistemic grounding of some sorts of phenomenological assertions that is possible from the transcendental attitude. Hence, as Prof. Zaner asserts, there is indeed a difference in level between the transcendental attitude and the judgments produced from that perspective and the psychological and natural attitudes and the judgments produced from them.

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5 Conclusion The analysis of the transcendental reflexivity of consciousness as presented in the writings of Richard Zaner shows an epistemic privilege of transcendental phenomenology. This privilege has two key aspects: (1) it is only from the vantage of the transcendental attitude than one is able to grasp reflectively the nature of intentional processes coherently and therefore in a way that makes possible the grasping of the genuine eidos of intentionality; (2) and it is only from the transcendental attitude that the field of reflection can be intended as coherent, under a unified noematic theme, such that there is a unified gestalt contexture of the entire field of reflection. This now also establishes that transcendental phenomenology alone satisfies the requirement that a genuine epistemology be capable of legitimating itself as adequately grounding its own epistemic claims. Utterly central to the recognition of this epistemic privilege is Zaner’s accounts of the transcendental reflexivity of mental life, of the method of free phantasy variation, of the requirements of epistemic claims and of the way these are interrelated. While these elements are parts of transcendental phenomenology as originated by Edmund Husserl, Prof. Zaner has added important clarifications and extensions to them.

References Cairns, D. (1973). “The Ideality of Verbal Expressions,” in F. Kersten and R. Zaner (Eds.), Phenomenology: Continuation and Criticism: Essays in Memory of Dorion Cairns (pp. 239–250), The Hague: Martinus Nijhoff. Husserl, E. (1968). Formal and Transcendental Logic, trans. Dorian Cairns, The Hague: Martinus Nijhoff. Husserl, E. (1973). Cartesian Meditations: An Introduction to Phenomenology, trans. Dorian Cairns, The Hague: Martinus Nijhoff. Zaner, R. (1970a). “The Phenomenology of Epistemic Claims: And its Bearing on the Essence of Philosophy,” in Phenomenology and Social Reality: Essays in Memory of Alfred Schutz, The Hague, Martinus Nijhoff. Zaner, R. (1970b). The Way of Phenomenology. New York: Pegasus. Zaner, R. (1973). “The Art of Free Phantasy in Rigorous Phenomenological Science” in F. Kersten and R. Zaner (Eds.), Phenomenology: Continuation and Criticism: Essays in Memory of Dorion Cairns (pp. 239–250), The Hague: Martinus Nijhoff. Zaner, R. (1981). The Context of Self. Athens, OH: Ohio University Press.

Chapter 4

The Limits of Biomedical Ethics and the Specific Role of Phenomenology in Biomedical Ethics Thomas Nenon

1 The Limits of the Project of Biomedical Ethics as a Philosophical Project Let me first begin by expressing two general reservations I have long held about the project of applied philosophy in general. These have to do not just with applications of philosophy to the sphere of medical decision-making and to debates about public policy or regulations that concern the development and practice of medical treatments and technologies, but to the project of applied philosophy in general—and most especially to that project as it is very often practiced in philosophical debates couched in the language and using the concepts and techniques of Anglo-American analytical philosophy. The first limitation, one that most philosophers who teach ethics recognize, is that I do not believe that courses on ethics are the best way or often even a good way to make people more ethical. I do not think that a course or two on ethics, especially the kind of course that is typically taught as a required course with a relatively large number of students in a lecture hall, is likely to make a person ethical if the combined efforts of that person’s parents, elementary and high school teachers, coaches, relatives, ministers, and peers for over two decades have failed to accomplish that goal; and I think there is even less chance of that happening if the messages conveyed in an ethics course are not consistent with what that person has actually observed, found rewarded, and learned in his or her home, educational and work settings, and in interactions with peers. To use an extreme and perhaps tendentious example: if a law student’s course on legal ethics taught by the philosophy professor or a law professor is not consistent with the actual conduct one has observed in one’s parents in their professional lives, with the behaviors and skills one is learning in other courses, and with the practices and expectations of one’s peers and colleagues in the law firm in which one is serving as an intern, then what is being taught in the T. Nenon (B) Office of Provost, University of Memphis, Memphis, TN 38152-3370, USA e-mail: [email protected]

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course has little chance of having much impact on the student’s actual behavior as a lawyer. If the actual practices of lawyers, and especially of successful lawyers, suggest that a different set of practices is the appropriate practice of successful lawyers, I doubt that anything learned in the class on legal ethics is likely to lead to any significant changes in behavior. If anything, I think they are most likely to teach the student ways to rationalize the practices one is actually learning in all of those other settings and to use the concepts and forms of argumentation one has learned in the philosophy class to sell what is actually unethical behavior as ethical or at least as ethically permissible. The point may seem obvious, but I do not think it is trivial, especially for those of us in academic philosophy departments who perhaps trade on the widely held, but I think misguided expectation that providing the students with a course in ethics will somehow ameliorate, even if not solve what are perceived to be shortcomings in ethical behavior in general, or more often in some specific field. The WorldCom and Enron scandals in the United States were followed by calls for new laws and regulations and for more courses on ethics in the curriculum in colleges of business or for components in existing courses that would increase the awareness of ethical issues for business students. I do not know much about the background of the major players in the Enron and WorldCom scandals, but I do know that most of them professed to be good church-going citizens and that they heard sermons about ethical and moral behavior relatively regularly, that all of them were college-educated and probably had a course or two on ethics sometime in the course of that education, and that all of them prior to the scandal had been quite generous in supporting the usual good causes in their communities, and claimed to the end that this was not really their fault, that they had all been trying to do the right thing and that it was someone else who had misled them or withheld information from them. So I do not think that an ethics course or two would have changed any of the behaviors of the actors who were primarily responsible for the Enron or the WorldCom scandals, and I therefore also do not believe that adding a few courses to the curriculum in business schools or the general education requirements at colleges and universities is a good way to help prevent such scandals in the future. In fact, adding a course on ethics or a chapter to existing courses in the curriculum can very often have precisely the opposite effect. It can suggest that one has done something to correct the problem when one has not. It can serve as a way to let things otherwise proceed as they did before. The danger is analogous to that of allaying a community’s fears about a crime wave by locking up somebody, anybody, even though they were not the real perpetrators. It is not just unethical because it is deceitful and punishes people for crimes they did not commit. It is also dangerous because it leaves the real criminals free to continue what they were doing before. Instead of real solutions, one can too easily opt for easy and relatively cheap fixes like some additional course-work for students who aspire to be professionals in the area one day. The reason I bring this up is that it presents an ethical dilemma for philosophers. It is tempting to offer the public some courses that promise to fulfill a perceived need even when we know that they will not accomplish the intended purpose. We do not need to be the ones making the promises, and the purpose does not have to be the

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one that we intend. It is enough for us to be the beneficiaries of the mistaken belief and to fail to make it very clear that we do not believe that the courses or course units will provide the benefit that others think it will. This is, I should point out, not an admonition aimed just at others, but something that I must remind myself, my students, other faculty members, administrators, and anyone else with whom I communicate now that I have become part of this enterprise by regularly teaching one of those courses. I recall the Dean of our Nursing School who told me several years ago about some of the ethical lapses that she had recently encountered on the part of several of her students in a clinical setting. She said that, as a result, she was considering mandating our course for all of the students in her program. It was a tempting prospect in light of the fact that the general education program at all of the public universities in our state was being changed and this would have been an easy way for the philosophy department to more than recoup the credit hours we were likely to lose through these changes, but I felt that we were ethically obligated to let them know that I think we could not promise to solve her problem or even make some noticeable change in the behavior of unethical people who aspired to be nurses by providing her with the course she wanted for her students. Interestingly enough, though, the faculty in the Nursing School still require some course on ethics and their students most commonly take our undergraduate biomedical ethics course to fulfill that requirement. My second reservation has to do with another common expectation that is often associated with philosophers who specialize in an area of applied philosophy. Some people expect them to be able to “solve” ethical problems or “resolve” ethical debates. The tone of many of the articles by analytically trained philosophers in the standard textbooks on biomedical ethics provides ample evidence that this is no accident, but rather something that is fostered by some of the leading figures in this area and other areas of applied ethics.1 One factor that contributes strongly to this tendency is a certain—I believe misguided—view about how ethical dilemmas and debates arise, and how philosophy can “solve” them. The enterprise of applied ethics as most commonly practiced derives from the assumption, one that goes back at least as far as Socrates, that actions can be classified under concepts and that concepts can be defined. A concept such as justice or piety, philosopher or sophist, expresses a set of necessary and sufficient conditions for something to be that kind of thing. The definition as the answer to the question “What is . . .?” explicitly lays out those conditions that together make up the nature, being, or essence of the thing as that kind of thing. There are some important differences, of course. It is Aristotle who improves upon the theory by distinguishing clearly between substances and their properties and between essential and accidental properties. But in applied ethics, these distinctions do not matter, since it is the project of defining necessary and sufficient conditions of something that is at issue and not whether goodness is a form or a property, nor whether it is an essential or accidental property of human beings and their actions. Accordingly, most of the standard arguments in applied ethics have taken one of two complementary directions. On the one hand, one sorts through the common views about

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certain actions to discover the principles that underlie the classifications of some of them into permitted and others into impermissible, some into demanded and others into optional. The principles are assumed to be able to be captured precisely in terms of necessary and sufficient conditions that relate to salient features of the actions at issue. On the other hand, once one has derived such general principles, there is the issue of explaining which features of a specification that is at issue falls under this principle and not under another one. The overall project thereby hopes to start with clear and relatively uncontroversial cases, then derive the principles that underlie them, and hopes finally to be able to subsume the controversial cases under them (or show why they do not fit) in order to have proven that the controversial cases really are right or wrong, permitted or not, or at the least to show under what circumstance they might be permitted or forbidden. The underlying assumption is that actions are, could be, or should be classifiable in terms of principles that to the extent that these principles express norms, the classification should have an influence on behavior by exhibiting how they fall under those norms that do, can, or should govern human action. It also assumes the principle of excluded middle, i.e. that things either do or do not fall under them, and that unclear cases are unclear because there are features of them that we have not focused on adequately. It assumes that if we did focus on them appropriately, we would be able to see how they fit under one classification rather than another. The abortion debate is a good example. Most people agree that one should not kill another normal person out of convenience. Most people also agree that surgical procedures on one’s own body to alleviate a very burdensome condition are permitted. The debates have then typically revolved around arguments about why the primary facets of abortion are more like one of these uncontroversial cases than the other one. The aim is obviously to solve the hard cases by coming up with univocal, universally valid rules expressed in terms of necessary and sufficient conditions under which one can subsume the hard cases to solve them. In addition to the problem with assumed motivation that I mentioned above, this project poses two additional problems. First of all, it assumes that concepts have sharp edges, i.e. that the terms we use to organize our thinking genuinely are concepts—even if somewhat confused ones—and not types. If we do not make this assumption, then we can understand why hard cases will always remain hard cases and the most that reflection could do is show us not how to solve them, but why they remain intractable. What if the way human thinking actually works is not along the lines of concepts traditionally conceived, but rather in terms of typical examples that serve as guiding points for our thinking but do not operate strictly in terms of necessary and sufficient conditions? In everyday discourse we recognize that robins and sparrows are fairly typical birds and that ostriches are not. We know that a brontosaurus is a typical dinosaur but that some of the smaller flying or gliding animals that lived about the same time are not. If we follow the speculation that birds might have evolved from some of them, then there will at some point in evolutionary history have been some animals that will be hard to classify univocally as lizards or as birds. That does not mean that there is no difference between birds and lizards, but it does mean

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that classing some things cleanly into one of the two classes will be difficult. If we reflect on what we typically mean by birds and what we typically mean by lizards, we can understand why we are tempted to put these in-between creatures into each of the categories and what resists our doing so. No amount of reflection or further research would sole the problem. All it could do is show why it will not be solved. Now maybe there never were any such creatures, but I would suggest that there are problems like abortion that are like them in that they will always remain hard cases and the most we can do is show why. The second problem concerns the nature of the very principles themselves.2 If we all agree about the clear examples of concepts such as prudent, moral, or effective action, then it seems that it would be possible to use reflection to identify some of their common features and investigate which of these features lead us to classify actions under one of these headings instead of its opposite. However, it is important to note that the consensus that these are the relevant features of the concept that unites certain classes of actions will depend upon the choice of examples one takes to be paradigmatic. Persons who have fundamentally different views about examples of justice and injustice will, not surprisingly, come to different views about what justice means because the relevant features of the concept of justice they employ cannot be derived except as common features of their examples. If there is serious disagreement about the examples, it follows that there will normally be serious disagreement about the features that the concept captures and thus about the concept itself. The upshot of all of this is that philosophers cannot manufacture consensus about norms. Where there is an implicit consensus, philosophical reflection can make it explicit. If there are genuine universals and human beings are implicitly aware of them, then the job of philosophy will be to recognize them and make them explicit. If there are implicit assumptions in general practices such as reasoning or dialogue, then the philosopher can bring them out as conditions for their possibility in what some might want to call transcendental arguments. If there are common human needs that find common expression, philosophers might be able to draw them out, but these would be far from a priori conditions that some philosophers like Plato or Kant have hoped to identify. And of course, if ethical norms are the result of an interplay of historical social forces, then philosophical reflection might be able to draw them out and show their relative internal consistencies and their tensions with other norms in other societies or even in the same society. In all of these cases, however, philosophers will not establish the norms but have to work within them. Philosophers can at best take an implicit consensus and make it explicit. But they will not be able to bring about such consensus. And since practical efficacy depends in part upon the ability to draw upon such a consensus, philosophers’ conclusions will have practical efficacy only to the extent that they are able to draw upon the consensus of the society to which they address themselves. If one accepts the analyses presented above, the philosophical reflection in a pluralistic society might well be able to explain many of the controversies that arise within a pluralistic society, but it will not be able to resolve them. Whether the conflicting norms come from different ethnic or national cultures, different religious

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backgrounds, or simply different personal experiences, philosophers will be able to point to them and explain why they result in different conclusions about appropriate actions, but they will not be able to manufacture a consensus about basic norms that does not already exist. So the project of resolving a debate or solving a problem strictly through philosophical reflection and arguments is not nearly as promising as many pronouncements from philosophical “experts” in areas of applied ethics would suggest. That does not mean that there is no place for philosophical reflection in practical fields such as medicine or law. Philosophical theory is an extension and refinement of the practical reflection that can and does guide human actions in people’s everyday lives even in societies that never developed anything like the academic philosophical tradition of systematic and explicit reflection on human actions and the principles that govern them. Such a tradition has emerged after all only at specific historic periods and in specific geographical settings such as ancient Greece or China or various modern European societies. As an individual or group practice, it involves stepping back, looking at one’s actions, asking whether they are prudent, moral, or perhaps even just effective. The aim of such reflection is to improve one’s actions and to make them more prudent, moral, or effective. Thus, just as the original source of philosophical theory, namely, practical reflection, implicitly points toward an improvement of human practices to make them more prudent, moral, or effective, philosophical theory seems to bear within itself an implicit relationship to human practices and is implicitly aimed at improving them. To illustrate the point, one need only recall the names of Heraclitus, Socrates, Plato, Aristotle, or Epictetus from ancient philosophy in the Greek tradition or Confucius or Lao-Tse in the Chinese tradition. In each case, the philosophical project is explicitly directed towards improving human actions and lives and there is no reason why the actions undertaken by health care providers, policy-makers, and patients make in the realm of medicine, for example, should be an exception. I do have one final basic reservation about the project of biomedical ethics as undertaken by philosophers: namely, the tendency of philosophers to think of the problems primarily in philosophical terms, i.e., as general and conceptual instead of practical and specific. Instead of developing this reservation here however, I would like to turn to a different question: namely, the question of why phenomenology might be an appropriate philosophical approach to adopt in undertaking the kind of reflection on medical practice that is appropriate for anyone—including someone trained in academic philosophy—with regard to actions and policies in the field of medicine. We will also see that, coming out of the phenomenological tradition, it has been possible for Dick Zaner and others to overcome some of the traditional shortcomings of biomedical ethics that I have just described.

2 Phenomenological Approaches to Biomedical Ethics The field of biomedical ethics as such is not very old. David Rothman, for example, traces it emergence during the 1960s through the 1980s in response to some generally perceived shortcomings in the way that medicine had come to be practiced

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after the introduction of new technologies, the rise of the large-scale medical research industry, and the increasing distance between health-care providers and their patients as these new technologies and changes in the way that health-care delivery had become increasingly institutionally organized and anonymous.3 The twentieth-century saw the application of modern scientific techniques and technologies to medicine for the first time on a broad scale. As this took place, it gave rise to misgivings about the new direction that medicine had taken and it gave rise to a whole new industry oriented on patients as passive recipients of treatments designed and delivered on the models of science and industry in which individuals increasingly came to be seen as cases, specific examples of biological phenomena, for which scientific treatments are “prescribed.” Another point, not made by Rothman, but one increasingly relevant over the last couple of decades is that even where patients now have come to take a more active role, this is often conceived of in terms of the language of the marketplace: they are “consumers” of health-care services in which they might play a more active, decision-making role, but nonetheless are thought of in terms of a model that uses the language of costs and benefits that is still far removed from models of individual caring relationships and trust that had served as the ethical orientation in medicine in previous ages. In short, the field of biomedical ethics has emerged as an antidote to the tendency to reduce the prevention and treatment of illness and suffering to a specific application of modern scientific technologies and standard marketplace strategies. It is against this backdrop that phenomenology as a philosophical approach is especially well-suited as a conceptual and methodological approach for the analysis and critique of practices and attitudes that neglect the fullness of the experience of need and concern that lie at the heart of medical practice. In this essay I will not go into detail about even those few themes that I will mention. However, I would at least like to name them and say a few words about each of them. These include: • Phenomenology’s program of resisting the reductionistic tendencies of modernity including Husserl’s critiques of psychologism, naturalism, and objectivism and numerous variations on those themes in subsequent phenomenological and postphenomenological figures. These critiques can certainly apply to many of the tendencies in the modern medical industry also. • Phenomenology’s call for a return to “the things themselves” as a call to rethink sedimented opinions, one-side prejudices, and received concepts to rediscover their original sources out of experiences within the life-world. One example of this is the way that Jaspers and Straus used this approach within psychology and psychiatry to reexamine the very categories that were used to classify the various phenomena that are the subjects of those fields. • Phenomenology’s rehabilitation of the first-person perspective and its centrality for philosophy and for human life in general. This helps restore the necessity to take the patient’s perspective into account and to see the patient as a human being with needs and concerns and not just in biological terms. • Its orientation upon phenomena as they present themselves to us as meaningful. One reason why human illness and human health are not simply biological phenomena is that they occur as part of a context of meaning in which they and

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all of their treatments have significance for the persons affected by them and the people that surround them. The awareness in phenomenology of context—conceived of in terms of “surrounding world,” “life-world,” “Bedeutungszusammenhang (context of meaning),” “field of perception” or simply “world” —forms the implicit and normally unthematized background for all cognition and hence for all objects of cognition as they present themselves to us in our experience, even in our scientific experience since modern science is itself a specific context with its own interests, orientation, and limitations. This can help explain why the traditional approaches are much too simplistic and fail to take into account the complexity of the issues at stake in medicine. Phenomenology opposes the reductionistic tendency to isolate the strictly physiological from those contexts in which they occur. The realization that theoretical cognition—thinking and knowing—is not the only or even the primary mode of access to the world and objects within it, but rather that concrete experience involves thinking, willing, and valuing, and that the theoretical attitude may play an important methodological role in philosophical and pre-philosophical reflection and in science, but that one needs to remain aware that experience itself is always much richer than mere thinking. Along with this, the phenomenological tradition from Scheler, through Heidegger, to MerleauPonty and Sartre has stressed the importance of emotions and moods as elements in human experience that are fundamental to how we are and how the world shows itself to us. It is striking, for instance, how Dick Zaner’s work evokes not only the feelings of the patients and their families, but also of the physicians and the clinical ethicists who are part of a decision-making process, and how he tries to understand the actions of the various parties involved in terms of the values and priorities that each of them brings to the situation in which they find themselves. That human personhood is always embodied. In his analyses of even the most basic levels of perception, Husserl pointed out how kinaesthetic awareness is a constitutive element of object awareness. The body is not just a passive receptacle for impressions. Rather proper attention to one’s bodily awareness itself and the active role of bodily motility in object perception opens the way for much broader and richer notions of embodiment and their role in the constitution of ourselves and a world. This is the direction that Husserl takes in his later works and most famously that others such as Maurice Merleau-Ponty have taken within the phenomenological and post-phenomenological tradition. Nam-in Lee has recently shown some of the very important implications of this insight that opened up whole new fields for phenomenological inquiry, such as a phenomenology of the instincts that can be crucial to understanding the phenomena at issue in medicine and biomedical ethics also.4 What is particularly helpful in this approach is the understanding of our embodiment as an essential stratum of our experience, not something apart from it and not something that exists on its own. Out of this attention to the centrality of embodiment for human awareness arise conceptions of normalcy and abnormality as constitutive not just for human consciousness (and human embodiment), but also for the way worlds and the

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objects with these worlds show themselves to us. Phenomenological elucidation of these basic features of the human experience can help us have a better understanding of the consequences of disturbances in the “norm” in our lives, lives that are constantly subject to such disruptions. This was a primary theme, for example, in Erwin Straus’ work. • Finally, the awareness of contextuality can open up a fruitful sphere of research into the historical and social dimensions in the life-worlds that function as the background for feeling, choosing, and believing in our everyday lives. Insights into these backgrounds can be crucial for understanding why people feel, decide, and think the way they do and for understanding their needs and what they will consider acceptable or unacceptable ways of addressing those needs. As I mentioned earlier, up until now, the two leading proponents of a phenomenological approach to biomedical ethics in the United States have been Erwin Straus and Richard Zaner. Even a brief overview of the way that these themes have informed the work of either of them would require more than is possible in any one essay, but would be extremely worthwhile.5 What is interesting about their work is that in each case, they end up stressing the experience of the concretely situated person. For each of them, the question about how best to meet that person’s needs is the central question of medicine and hence of biomedical ethics. This is not just a matter of theoretical knowledge, but rather involves the kinds of skills and attitudes that a caring response to those needs requires. Zaner refers to this as a “responsive ethics”6 within which the medical practitioner is both responsive to the demands of the individual patients and their families and friends in a given situation: the medical practitioner is a responsible agent for them and everyone else with a stake in the outcome of the decisions the caretakers make and the actions they undertake. In the end, the result overlaps to a great extent with a classical virtue ethic, in this case an ethics of responsive and responsible caregivers who learn to recognize the salient moral features of the situation, bring their expertise and knowledge to bear on them along with their sense of compassion and caring, and learn to make good and responsible decisions. It involves developing specific knowledge, skills, and habits, which is why both Straus and Zaner discovered a great mutual affinity to the work of Edmund Pellegrino, another key figure in the development of biomedical ethics over the past few decades, who in this case came from the background of classical philosophy in the Aristotelian/Scholastic tradition.7 I have tried to lay out some of the themes and insights from the phenomenological tradition that can and in several cases have made it a fruitful approach to questions in medical ethics. Both Zaner and Straus demonstrate how the phenomenological tradition, properly understood, points less in the direction of a final resolution of difficult cases in medical ethics through a reflection on universal principles. Rather it can lead to a heightened awareness of the needs of the patient as a whole embodied person who lives, flourishes, but also suffers, and ultimately faces death with a context of meaning that has emotional and value dimensions and is socially embedded. This remains true even when—in the case of some illnesses, be they primarily psychological or physiological—this embeddedness is present only in a deficient

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mode. That is why we see in both Straus and Zaner the importance of the narrative and the individual case, the attentiveness to the story the patient has to tell, and to the difficulty of finding the right words, the right expressions to allow the stories that they have to tell to others about their experiences in the clinical setting in order for others to become better aware of, appreciate, and reflect on the ethical dimensions of decision-making in a health-care setting. This approach ends up placing less stress on the attempt to find a universal, supposedly impartial solution to the kinds of debates that one finds in the standard biomedical ethics textbooks. Rather it seeks to appeal to each reader, each student, each new member of a healthcare profession to be more mindful of the ethical dimensions of decision-making and actions in the healthcare setting by becoming aware of the needs of the concrete person striving to maintain or recover health, facing illness and death as features of human life just as much as health is. Not everyone who takes this approach is a trained phenomenologist or even a trained philosopher. Carl Elliott,8 a physician and bioethicist trained in the analytical traditions, has come to many of the same conclusions and adopted an approach very similar to Zaner’s recent work. Atul Gawande, a very articulate physician who introduces his reader to many of the same themes discussed in biomedical ethics classes, does not try to analyze them in philosophical terms, but instead lets the reader see through his eyes how difficult the choices are that physicians and their patients face. He evokes the importance of dedication and caring on the part of the caregiver who must be genuinely devoted and sensitive to the physical and emotional needs of the patients through a presentation that is at once a non-fictional account and moving literature. This is not to say that the more commonly practiced approaches to biomedical ethics have not achieved much. Over the last 30 years, philosophers in this field have contributed greatly to the development of codes of ethics for medical research and for treatment that have been important to rein in some of the abuses that had previously been practiced by some members of the medical profession, to provide some stability and guidance for practitioners, and to help illuminate some of the fundamental principles that underlie ethical codes and ethical practice in medicine. But in order to avoid overreaching by philosophers into an area where no one, neither the trained academic philosophers nor the physicians, nor public policy makers, or judges and lawyers can come to simple and general solutions for complicated problems and concrete decisions, it is important to be mindful of the limits of their expertise and phenomenological reflection is one way to help achieve that.

Notes 1. One example is the “General Introduction” to the widely used textbook Biomedical Ethics by Thomas Mappes and Richard Degrazia: “In applied normative ethics . . . the task is to resolve particular moral problems—for example, the issue of whether abortion can be morally justified, and, if so, under what conditions. . . . The task of biomedical ethics is to resolve ethical problems associated with the practice of medicine and/or the pursuit of biomedical research.”

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2. This criticism is hardly new. One of the best formulations of it can be found in MacIntyre (1984, pp. 498–513). It is also addressed directly in Zaner’Ethics and the Clinical Encounter (op.cit.), pp. 6–20. 3. Rothman (1991) described convincingly and in great detail how changes in the delivery of medical care and the rise of the modern research industry in medicine led to changes in the way that medical decisions were made and how this eventually led persons and institutions outside of the medical establishment, including public policy makers, lawyers, courts, and eventually professional philosophers to become involved in debates about medical policies and practices and in medical decision-making over the last few decades. 4. Lee (1993). 5. Zaner himself has provided such an account of Straus’ work in his essay “The Discipline of the ‘Norm:’ A Critical Appreciation of Erwin Straus” Human Studies 27 (2004), pp. 37–50. 6. Zaner, Ethics and the Clinical Encounter (op. cit.), pp. 27–28. 7. See, for instance, Pellegrino and Thomasma (1981). 8. Elliott (1999), especially Chapter 7 (“The Point of the Story: Narrative, Meaning and Final Justification”) and Chapter 8 (“A General Antitheory of Bioethics”).

References Elliott, C. (1999) Bioethics, Culture, and Identity: A Philosopher’s Disease, New York, London: Routledge. Lee, N. (1993) Husserls Phänomenologie der Instinkte, Dordrecht: Kluwer 1993. MacIntyre, A. (1984) “Does Applied Ethics Rest on a Mistake?”, The Monist 67, pp. 498–513. Pellegrino, E. and Thomasma, D.C. (1981) A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Profession, London and New York: Oxford University Press 1981. Rothman, D. J. (1991) Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision-making, New York: Basic Books.

Chapter 5

Richard Zaner and “Standard” Medical Ethics Stephen Hanson

To an analytic philosopher, reading some of Richard Zaner’s writings can be strangely challenging. His repeated recognitions, for example, that he was unable to capture in written text “unique events and people. . .quite in the way they were,”1 and his willingness to refer to concepts that cannot quite be encompassed by the words used to describe them—trying to “catch” what actually happened in a clinical case—are quite jarring to one trained in analytic philosophy. One finds oneself wanting to say to the page, “I understand that you cannot remember the exact words of dialogue with the patient’s family; just tell me what is important!” Though this response indicates a difficulty with—perhaps a failure to truly appreciate—Zaner’s point that the context of what happened in the case, and to whom, is a critical part of what “is important” in the case, it is also a symptom of the intersection of differing approaches. Such frustrations can lead to a belief that there is a strong divide between Zaner’s case-focused approach to bioethics and certain theoretical approaches, such as Engelhardt’s principle of permission or specified principlism. Wiggins and Schwartz argue that Zaner’s clinical ethics is “unique” and emphasize this through highlighting the “differences between Zaner’s clinical ethics and what [they] term ‘standard forms of medical ethics.’ ”2 This apparent divide might lead one to think that practitioners of the two types of thinking will have difficulty in communicating with each other, and even more difficulty working together. To think this way would be to discard a very productive union. I was not trained in clinical case analysis in a Zanerian fashion, and in fact have studied more on matters in bioethical theory that Wiggins and Schwartz would likely call “standard forms of medical ethics.” But those “standard forms” of bioethical theory are important at least in part because of the impact that they can have upon clinical case judgment, and so should not only be compatible with methods of case analysis, but should also bring something useful to bear in such analysis. The reverse is true as well, that clinical case analysis should be compatible with, and contribute to, the larger bioethical S. Hanson (B) Department of Philosophy, University of Louisville, Louisville, KY 40292, USA e-mail: [email protected]

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theory. I argue that this sort of symbiotic and mutually supportive relationship does indeed exist between standard bioethics and Zanerian case analysis. I shall explicate just one contribution of Zanerian clinical analysis to more general thought about bioethical theory; in the process of doing so, I also show the compatibility of clinical and theoretical bioethics, as well as further ways in which the two types of thinking about medical ethics can productively interact.

1 Resolution in Clinical Ethics The case consultation is a request from someone involved with a clinical case for assistance in satisfactorily resolving the moral issues involved in the case. Yet this relatively straightforward claim masks an important inclarity. Clinical ethics often confounds two different uses of the term “resolve.” One version of “resolution” often sought in a clinical case is “an agreement upon an action to take in a difficult circumstance.” Such a resolution (or closure) is obtained through negotiation to an intentionally arranged and morally unobjectionable resolution acceptable to the principals in the controversy.3 This achieves resolution of an important sort in clinical care, for it allows the process of caring for a patient to continue forward when it otherwise might not be possible. In many cases of clinical consultation, it may be that this is the only sort of resolution sought. However, a very different version of resolution is possible, and even desirable, in clinical ethics. “Resolution” can also be understood as a means of not only selecting an action to take in a given case, but also justifying it as the morally best action to pursue. This approach to justification is pursued by many theorists of medical ethics, including Tom L. Beauchamp and James Childress in their Principles of Biomedical Ethics.4 In a clinical case, this form of resolution would not only determine the correct or best action to take, but also explain why that action is the right one to take, and provide a valid justification for that decision being correct. For simplicity, I shall refer to this latter version as resolution2, and the prior version as resolution1; in most cases, resolution2 would encompass resolution1, but there would be cases of resolution1 possible that would not meet the requirements of resolution2. Resolution2, when it is possible, provides a significant improvement over resolution1 in clinical ethics. Though a primary desire in most clinical ethics encounters is to discover an action to take that is satisfactory to the patient and his health care providers, as well as any other main participants in the decision (resolution1), it is also important to have good reasons to believe that the decision is not merely a solution of convenience but rather a morally good one. Justificatory theoretical bioethics, in its various different forms, augments clinical bioethics by providing the tools for resolution2. But what can clinical case ethics provide for theoretical bioethics? In fact, the understanding of clinical ethics that Richard Zaner has developed can assist theoretical bioethics with resolving a significant problem that would otherwise hamstring its ability to resolve2 most moral cases. This interchange between clinical ethics and its theoretical underpinnings helps develop a more complete and unified picture of both enterprises.

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First, I briefly explain the process of justification of moral claims by principlebased moral theories, using Beauchamp and Childress’ theory as a model. Then, I elaborate a difficulty that this model has, and provide a recent solution to this difficulty that is currently being developed, called “moral acquaintanceship.” Third, I discuss a potential problem with utilizing moral acquaintanceships in conjunction with principle-based theories in order to justify moral decisions in clinical cases. Finally, I will be able to show how the methods of clinical case ethics that Richard Zaner has developed can resolve this problem with moral acquaintanceships, and therefore can render possible the resolution2 of clinical cases through application of Beauchamp and Childress’ model of specified principles.

2 Justification by Principles in Medical Ethics Principles are often used casually in discussions about clinical cases. For example, respect for patient autonomy will be used to explain why an incompletely dialyzed patient with acute renal failure may leave the hospital against medical advice (AMA), even when his condition suggests that he will have to return to the hospital very soon or die. In a similar way, providing for patient benefit as well as not harming one’s patients can be used to explain why aggressive treatment is not appropriate for a dying patient in significant pain, as well as to explain why higher doses of analgesics are called for even if they might tend to shorten a suffering, terminally ill patient’s life expectancy. Such uses of the principles are not inappropriate, as they help to guide conversation and to enable persons to more clearly articulate the moral matters at hand in a given case. However, these uses also tend to imply that a full justification for the decision to be made has been given through this appeal to general principles, which is not entirely true. Resolution2 of decisions on a principle-based theory is more complicated than just appealing to basic principles. Beauchamp and Childress develop their system of moral decision-making using the four principles of respect for autonomy, beneficence, non-maleficence, and justice as the starting points of theory development.5 The most general form of the principles, the “single-word” labels for them—e.g., “beneficence” or “justice” — are labels for very general norms and the beginning point for moral reflection. By themselves, they cannot justify a particular decision, not least for the reason that multiple “general-norm” labels usually can apply to a given case. For example, one could argue that one should stop the above-mentioned patient from leaving AMA, even if force is required, on grounds that this will prevent a significant harm from coming to him from his incomplete dialysis and progress of his acute disease. Both respect for autonomy and beneficence would seem to apply here, yet produce differing results; other principles might as well. (For example, justice could ground a decision to impose treatment on the grounds that when the patient, very likely, returns in a more severe state to the ER, the time and resources required to treat him will be significantly greater than they would be were he to stay and be treated now.) Consequently, it is clear that simply applying one, or even more than one, principle

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to a case and seeking thereby to ground a decision will not satisfactorily resolve2 a clinical case. The more complete picture of the justification of moral decisions based on principles comes from the joining of the common morality theory from which the basic principles are derived, to a coherence theory of justification along the lines of a Rawlsian reflective equilibrium.6 Rawlsian wide reflective equilibrium is a method of theory development that takes beginning “considered judgments” on basic moral concepts, cases, and the like, and constantly considers and modifies them as needed as new cases, concepts, and moral data are considered. It is “wide” because it encompasses the whole of (in this case) medical ethics; it is “equilibrium” because the entire system must remain in balance, and no claim is taken as in principle unmodifiable as the entire system is continually modified in order to achieve maximal coherence; it is “reflective” because it is the determination of what must be included in the equilibrium, and how, is engaged in through careful and rational consideration. Because this is reflective, one’s beginning points must be carefully considered; it is because of this that these four principles are chosen as Beauchamp and Childress’ beginning considered judgments. There are many different moral theories in existence; but Beauchamp and Childress note that though there can be significant disagreement between the features of these theories, the same basic moral principles are supported by these presumably radically different theories. This is what is meant by the claim that the principles themselves are contained within the common morality: the morality which is in some sense shared by all serious moral persons contains these basic concepts in one form or another.7 For that reason, they can be used as considered judgments for beginning the process of attaining reflective equilibrium. They have been considered throughout much of the history of moral thought, and have remained in some format in virtually every such system. They are not thereby shown to be correct by this historical stability; but they have met the test of time to serve as prima facie plausible starting points. To obtain a reflective equilibrium, the principles are then utilized to address specific moral cases or issues. When there is a potential conflict, as in the patient leaving AMA, the principles are balanced and/or specified with regard to these particular cases or issues, and the procedure is repeated as new ones arise. “Specification” is a term developed by Henry Richardson and adopted by Beauchamp and Childress to describe the way by which adjustment via reflective equilibrium functions as a means of better articulating the norms in question to make them clearly address the cases at hand, and to help eliminate conflicts. A specification of a norm or principle is defined as a focusing of the prior principle by means of “adding clauses indicating what, where, when, why, how, by what means, by whom or to whom the action is to be, is not to be, or may be done or the action is to be described, or the end is to be pursued or conceived”8 in a way that helps to keep the central commitment of the original norm complete. The specification is a modification of the norm, but not, generally, meant to represent a change in its fundamental meaning. Rather, it is a refinement of that meaning. Through this, the principles develop and change, at least in terms of their specificity, and are always understood as both prima facie binding and subject to revision

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as needed.9 Eventually, the principles, and the cases that have been resolved with their assistance, and any further important moral data, will have developed into a fairly complex, coherent system—in fact, they have already been so developed in our own medical ethical history through multiple classic cases, laws, court decisions, and so on. The process is ongoing, but the system can be useful even while it is also constantly under review and possible change. Each new case brings a new moral judgment that needs to be fitted into the coherent whole; but the base of moral rules, principles and judgments in the coherent system also provides a means to resolve2 those new cases. When a particular case can be addressed by appeal to this coherent system without a specific conflict between the principles as they are currently specified, the principles (or, more precisely, the system as a whole) may be utilized to resolve2 the case. The justification for the resolution lies in the coherence of the system which generated the solution to the case. The (more complex, specified and balanced) principles now can be invoked to ground the particular decision made, with their justificatory power coming from the coherent system of which they are a part.

3 Specified Principles in a Pluralistic Society The appeal to the shared common morality as the source of the principles functions as an attempt to address the issue of resolving moral conflicts in a society where persons do not necessarily share similar moral intuitions, theories, or judgments. Beauchamp and Childress argue that in the shared common morality, certain principles—at least these four—are agreed upon by all morally serious persons. Several persons have challenged the truth of this claim10 but even if true, there remains a significant problem for these sorts of theories. Different morally serious persons have different conceptions of the moral world. Consequently, even if they share a common-morality understanding of the importance of the principles, they will not necessarily share the same meaning to those principles. The principle of beneficence accepted by an Engelhardtian libertarian will differ dramatically from that accepted by a Singerian utilitarian. Similarly, Rawlsians will surely not mean the same thing when they discuss justice as will libertarians or utilitarians, and their interpretation of the meaning of that principle, and any specifications of it, will be quite different. Moreover, the specifications selected by those different serious moral thinkers will tend to make the principles diverge rather than converge. Given that different persons specify the principles in the context of rationally differing moral worldviews and/or theories, one can be almost certain that different specifications of the principles will occur. The principles in the common morality might have begun as universally shared, but they will rapidly become unshared through the very process of thoughtful specification of the principles that is required in order to derive a coherent system with which to justify the decisions made via those principles.

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At this point one might argue that, though such a concern is inherent in any coherence theory of justification, the solution is as well. Since claims in a coherence theory are justified by appeal to the coherence of the theory, a more coherent theory should be understood to better justify the claims therein. Consequently, the problem of multiple systems of claims is to be expected, but the solution to this problem is that one should follow the system that is the most coherent. Which one this is might not be immediately obvious, but presumably would become clear as time went on; thus, at this point in the evaluation one should allow persons to specify the principles freely within only basic limits which have already been established through eliminating less coherent systems (e.g., one must grant rights of autonomy to women, persons of color, etc., because no system which fails to do so will be as coherent as systems that do). Sooner or later, the poorer sets of specifications will lead to evidently less coherent theories, which can then be rejected. However, this seems to understate the depth of the moral disagreement in a pluralistic society. Not only are the preferred specifications of principles likely to differ, but so are some of the other judgments with which they are to cohere. Any analysis of a case of commercial surrogate motherhood, for example, must involve views of the notion of human dignity and the purpose and value of reproduction and sexuality that differ widely between different persons.11 Ethical debate about embryonic stem cell research, or animal experimentation, must involve views of what sorts of beings are appropriate recipients of moral standing. To whom or what ought, or even can, one be beneficent? Must one respect the autonomous-like behavior of certain animals? The principles, to the extent they can be used to address these important ideas, will apply differently for persons who hold those different views. Because different rational persons value different things, and value the same things at different levels, there can and will be different specified systems of principles that justify significantly different actions in particular cases. Because these systems seek to cohere with significantly different considered judgments, they are very likely to diverge; but for the same reason there is no reason to think that any theory will necessarily be more coherent. They may, instead, cohere equally well with systems of beliefs that include different basic premises. So, the challenge for a principle-based theory depending upon a blend of a common morality theory and a coherence theory of justification is that, though persons with very similar sets of moral beliefs may hold similar sets of specific principles, the same process of morally serious careful consideration can result in different persons who hold different rational sets of pre-theoretical moral beliefs holding different coherent systems of principles. Consequently, there potentially will be more than one resolution (both type 1 and 2) available to persons in a given clinical case.

4 Moral Acquaintances as a Solution to this Problem This problem may be resolvable through the utilization of the relatively new concept of “moral acquaintanceships.” This concept has been independently developed by Erich Loewy and Kevin Wm. Wildes, S.J., as a means of filling in a theoretical

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gap between what Engelhardt has called “moral strangers,” who are persons who share little in the way of moral understandings, and “moral friends,” who are persons who share much of their conception of the moral world.12 “Moral friends” might also be described as members of a moral community; they are persons who share a robust and full view of the moral world, the rights and responsibilities of persons in that world, and often, their role in their community and who is understood to be the moral leaders and even decision-makers in that community. Communities of Franciscan or Buddhist monks might stand as good examples of moral friends. Moral strangers, on the other hand, share little agreement about the moral world. They can, and often may, understand each others’ positions, but agree with little of the others’ beliefs. They do not have much in common in their ways of understanding the moral world, right and wrong action, or their various rights and obligations. Examples of moral strangers are more difficult to come by, for reasons made clearer below, but one might think of European Christian missionaries and persons holding to the warrior ethic of Native Americans of the Great Plains as examples of moral strangers. The theories derived by Loewy and Wildes approach this division from different perspectives, but they both recognize a significant gap between these concepts of moral friends and moral strangers. They do not deny that the importance of this distinction may be significant, but they note that the breadth of its existence, even in secular Western societies, may be overstated. Moral strangers, who share few moral concepts, may have difficulty justifying any decisions in a given case because different morally serious persons may develop different, comparably coherent, systems of specified principles; but in many if not most particular cases, there will be a significant amount of similarity.13 Most persons are not moral strangers, even if they do not share a rather full conception of what morality means and requires, as moral friends would. They may be, instead, “moral acquaintances,” loosely defined here as “persons who share some, but not most or all, of their set of moral claims and beliefs.” They do not share the rich and complete view of the moral world that moral friends do, nor are they as limited in their overlap as are moral strangers. Persons can be moral acquaintances to a greater or lesser extent, or with regard to a particular issue, while being largely moral strangers with regard to another issue. A Roman Catholic priest, a Methodist minister, and a Reformed Jewish rabbi might all be moral acquaintances; the members of the ACLU could also be seen as moral acquaintances with regard to particular constitutional issues. With this admittedly brief overview as guidance, one can now see the extent to which moral acquaintanceships can assist in resolving2 clinical cases through an appeal to shared, specified principles in a coherent system. Persons may hold differing sets of specified principles, but if they are moral acquaintances, especially with regard to the matter at hand in the given case, they may share sufficiently similar principles with respect to the decision in the case to be chosen that they can come to an agreement on the right solution to the problem. This would resolve1 the case; it is argued elsewhere that if this decision can be based upon shared elements of multiple sets of specified principles that are each, themselves, adequately coherent systems, the decision can also be justified. The case would thus be resolved2.

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5 The Extent of Moral Acquaintanceships Though it requires one, the proof for this will not be argued here, for the point I wish to make follows after this concern.14 For purposes of pursuing that point, allow me to assume that the arguments elsewhere are satisfactory to show that an appeal to the shared specifications of principles shared by moral acquaintances in a given case can satisfactorily resolve2 that case. Even assuming all of this, there is a significant challenge for the proponent of this view, which can be shown by following the history of a case discussion in a medical school class. The case was presented with medical and social details: A 15-year-old Jehovah’s Witness who was 4 months pregnant and had a two-level spondyloptotic cervical spine fracture from an automobile accident 3 weeks earlier.15 She was transferred to the Georgetown University hospital in the hopes that the quadriplegia caused by pressure on the spinal cord could be alleviated or removed by an operation on her injured spine. In addition, she was severely anemic and refused transfusion of blood products. She was unmarried and the father of the fetus was not a part of the case; her parents, also Witnesses, agreed with her decision to refuse blood products. The injury and the additional complexities of the case (her pregnancy, her minor status, and her anemia and refusal of blood products) were apparently unprecedented in the literature. A bloodless procedure was developed, which was thought to be likely to alleviate her symptoms, though not as likely or as successfully as a more traditional procedure involving blood products. The bloodless procedure would require fusion of several of her cervical vertebrae, which would more significantly limit her neck’s possible range of motion than the standard procedure. The case was discussed, including questions of whether the 15-year-old patient was able to make a clear and competent decision to refuse treatment (after evaluation, the health care team believed she was), whether she understood the options available to her and could properly situate her decision in her moral values (after lengthy discussion with her, they believed so), and whether the fetus was at serious risk from the anemia (no) or the procedure (only if a catastrophic bleed were to occur, in which case it was thought neither mother nor fetus could be saved). Accordingly, the bloodless procedure was performed, with significant success. Both patient and fetus survived the procedure, and the paralysis was at least partially alleviated. The decision in the case could have been, and to some extent was, arrived at through and justified by a set of shared specified principles. The patient’s autonomy was respected, as was that of the physicians, though the latter was limited by the need to respect the patient’s autonomous choice. The procedure performed was as beneficent as possible within the guidelines laid down by the patient’s requests; and the patient and fetus were both protected from harm, though that protection was limited by the choice to avoid transfusions. It could be fair to describe the persons involved in the patient’s care (patient, health care team, family, ethicists) as moral acquaintances with regard to the procedure performed, even though they were certainly not moral friends, especially with regard to the choice to avoid blood

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transfusions. They were therefore able to resolve2 this case by appeal to shared moral principles, even though they might not have been able to solve a different case—such as, perhaps, one where the fetus was at significant risk from the patient’s anemia or the bloodless procedure. When this case was presented to the medical school class, several physicians in the audience disputed the decision to eschew the more standard therapy. They argued that the decision to utilize the bloodless strategy was inappropriate, because it overvalued the less-than-full autonomy of a 15-year-old, and provided for her a less effective treatment with a higher risk of (physical) harm for her and her fetus. Clearly, their understanding of the case was less clear than that of those who had actually been a part of the patient’s care; nevertheless, their arguments did not seem to rest upon a fundamental misunderstanding of the case. It seems likely that their moral views, which could be developed as sets of specified principles, were sufficiently different from those of the physicians and family in the case that, had they been part of the patient’s care, the decision might not have been so clearly resolved1 or 2. How, then, to understand the resolution2 of the case as justified by appeal to a moral acquaintanceship, which is now unshared by these new physicians? Had it been resolved2 before being presented to them, only to become unresolved2 at their rejection of the argument? Had it never been resolved2 in the first place, because they (and presumably others) were not moral acquaintances with the patient and her health care team? Or did it remain resolved2 despite these new objections? The broader question herein is one of scope. If individuals such as the physicians who challenged the decision after the fact must be included in the moral acquaintanceship that must be able to justify a decision in order to consider a case resolved2, then clearly this case could not be resolved2, though a resolution1 might have occurred through one or more persons’ recusal from the case. If, on the other hand, their moral views were not required to be a part of that moral acquaintanceship, then the case could be considered resolved2. If justified grounds cannot be found to hold one position or the other on this matter, the moral acquaintanceship argument will be significantly, perhaps fatally, weakened.

6 Zaner’s Insights as a Solution Zaner’s work in clinical ethics can provide such justified grounds. In Ethics and the Clinical Encounter, Zaner presents three theses in his descriptions of his method of “clinical liaison” ethics: Thesis 1: The work of ethics requires strict focus on the specific situational definition of each involved person. Thesis 2: Moral issues are presented solely within the contexts of their actual occurrence. Thesis 3: The situational participants are the principle resources for the resolution of the moral issues presented.16

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These theses, properly understood, can serve as a means to resolve the problems faced by the principle-based theorist looking to moral acquaintanceships to resolve2 clinical cases. For what Zaner has made clear is the extent to which clinical ethics is an intensely contextual and personal matter, requiring careful attentiveness to settings, dialogue, and interactions between the persons involved even to understand the moral matters at hand.17 Any resolution of the case must recognize this, for only in the context of the actual case can one know the matter or resolve (1 or 2) any moral questions that arise from the case. The clinical encounter itself can create a “ ‘mini-culture’ composed of patient, family, health care team, and ethicist” which can delineate a fairly small group.18 Among this group, it may well be possible (as it was in the case above) to obtain a clear understanding of the case and arrive at a sufficient agreement upon moral principles to resolve2 the case. Other persons external to this group might not concur, but they are not a part of this “mini-culture.” What justifies the selection of this group as the appropriate cross-section of persons who must be a part of a moral acquaintanceship in order to resolve2 a case is precisely their proximity to and participation in the case. These persons are properly situated to appreciate the “situational definition of each involved person” (Thesis 1), to apprehend and comprehend the moral values that are “presented solely within the contexts of their actual occurrence” (Thesis 2), and to work with the situational participants who are “the principle resources for the resolution” (Thesis 3). If “[m]oral issues are presented solely within the contexts of their actual occurrence,” so, too, may be their resolutions. If one recognizes the importance of “being in” the case itself in comprehending and working with the moral issues involved in the case, it becomes clear to whom any resolution of a case must be justified. It is those who are intimately connected to the case—those in the “mini-culture” of patient, family, healthcare team, and ethicist, though in some circumstances there could be others involved—to whom the ethical matters of the case are fully comprehensible, and from whom “the principle resources for the resolution of the moral issues presented” must be derived. Those external to this group do not have the connectedness to the case to be able to know the “specific situational definition of each involved person,” and thus cannot appropriately be appealed to in order to resolve2 the case. Moreover, they need not be a member of the moral acquaintanceship needed to justify a case decision by appeal to shared specified principles. The importance of being in the case is not always or perhaps even often recognized or accepted. Consider, for example, the national fervor over the Terri Schiavo case, in which persons in the government, the media, and private citizens around the country opined on the appropriate actions in determining whether her feeding tube should be removed or left in place. Many of these persons did not seem to agree that their views of the case were somehow less appropriate for guiding the treatment in this case. What reason can be given, then, for narrowing the moral acquaintanceship to the “mini-culture” noted above? I believe an answer to this is suggested by a common impression which is fairly clearly explicable by Zaner’s understanding of the contextuality of morality in the clinical encounter, and somewhat puzzling otherwise. I have observed that many

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persons have a particular reaction upon viewing a documentary presentation of the Nancy Beth Cruzan case.19 This video follows the Cruzan family through 5 years of the lengthy medical, moral, and legal process of seeking to disconnect Nancy from the artificial feeding and hydration that they believed, based on her prior statements and knowledge of her values, she would not wish to remain in place. Many clearly difficult and emotional decisions are carefully documented, as is the obvious emotional drain that this procedure has placed on her mother and father, her sister and two young nieces. Even to one who is only a viewer of the film, and not a participant in this struggle, it is difficult and at times wrenching. The extended family’s concern for Nancy shows through in multiple ways, even after she has been in a persistent vegetative state for years. One example may help show this. At one point, Nancy’s sister tells of a time when she came to her parents’ house and knew, from the look on her mother’s face, that something was wrong. Whatever it was that was wrong was so obviously bad that she became upset and refused even to enter the house until she was told the bad news. Even though they were at that time pursuing a legal course of action to allow Nancy to die, her sister’s first thought of what the terrible news could be was that Nancy had died. In fact, the bad news was that the state level courts were deciding against them, and that their legal battle would go on for much longer, but that is not what she feared enough to think of. The frequent reaction that I have in mind occurs about three-quarters of the way into the story. After the Supreme Court decision and eventual lower court reversal allows for removal of Nancy’s feeding tube, dozens of “pro-life” advocates (who have never been seen until now in the film) occupy the hospital in which she is housed in an attempt to force the resumption of her feeding. Even after they are arrested and forcibly removed from the hospital, the group continues to maintain a vigil for days until Nancy’s death outside the hospital in cold and snowy Missouri December weather. They are obviously highly motivated by moral values, which can be seen even if one disagrees with their beliefs. Yet the impression that many persons have upon viewing this is that the protestors, though they have strong moral views of their own, have no real idea what the moral issues at hand in the room upstairs are. This impression may be fed by the largely symbolic actions taken by some—for example, the man who wishes to take a cup of water to his “friend,” Nancy Cruzan, despite the fact that, were he successful, she would likely aspirate and die since she could not swallow. Yet the impression is still strikingly present even considering only non-hyperbolic actions. The protestors’ earnest and intense discussions about the importance of human life and the ways in which it is being diminished by the actions of the Cruzans and the government that allowed their actions to occur involve matters of significant moral note, but appear tragically unrelated to the actual case that has been unfolding for the previous 50 minutes (for the viewer) or nearly 8 years (for the extended Cruzan family). Richard Zaner would likely not be surprised by this impression, for his theses indicate an explicit awareness that the persons outside the hospital and (more importantly) outside the context of the case that had been unfolding over the preceding 95 months would not be fully aware of the moral issues that are fully presented only within that context. Moreover, once one recognizes that these persons are also

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not “situational participants” in the case, one can see that they are not “principle resources” for the resolution2 of the case. A moral acquaintanceship developed in order to justify the decision to cease providing Nancy Cruzan with artificial nutrition and hydration need not include these protestors, no matter how strongly they might wish to impact the decision. They are not truly involved in the context of the case. Conversely, the acquaintanceship must include Nancy’s family and her health care providers.

7 Conclusion With this recognition of the appropriate limitations of a moral acquaintanceship, as justified by the understanding of the source of clinical moral issues in the context of the clinical case and those participating in it, the significant gap left in resolution2 of clinical cases through shared specified principles justified by an appeal to moral acquaintanceship is closed. Zaner’s perception of the unique nature of the clinical case, as opposed to theoretical concepts or public policy, means that decisions in clinical cases can be different for different groups of persons; yet this is not inconsistent with an appropriate understanding of bioethical theory. Instead, it makes it possible for “standard” medical ethical theories to do what they were in significant part intended to do: resolve2 clinical cases.

Notes 1. 2. 3. 4.

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Zaner (2006, p. 657). Wiggins and Schwartz (2005, p. 73). See Beauchamp (1987, pp. 27–48). The same is also true for other theorists, including but not limited to H. Tristram Engelhardt, Jr., Albert Jonsen and other casuists, or Bernard Gert, Charles M. Culver, and K. Danner Clouser’s common morality bioethics. I also believe that arguments about justification similar to those provided herein about Beauchamp and Childress would apply, mutatis mutandis, to these other theorists and their theories, but will not pursue that exploration here. Beauchamp and Childress (2001). Beauchamp and Childress (2001, pp. 398–399, 401–406). The term “wide reflective equilibrium” was coined to describe this mode of reasoning in Rawls (1974–1975). Beauchamp and Childress (2001), pp. 3–4, also p. 404. Richardson (1990, pp. 295–296). Beauchamp and Childress (2001, pp. 14–16). See, e.g., DeGrazia (2003); Engelhardt (1996); Engelhardt and Wildes (1994). Engelhardt and Wildes (1994, p. 145). Engelhardt (1996); Loewy (1997); Wildes (2000). The concepts of moral acquaintances that Loewy and Wildes develop are distinctly different from each other, albeit compatible. Loewy’s and Wildes’s accounts differ in where they locate the similarity. The view discussed herein resembles Wildes’s view more than it does Loewy’s. For those interested in such a proof, one is given in Hanson (2007). The case is taken from Feigenbaum et al. (1997). Zaner (1988, pp. 243–246).

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17. Zaner (1988, p. 245). 18. Wiggins and Schwartz, p. 77. 19. “The Death of Nancy Cruzan.” Frontline, written by Elizabeth Arledge, original air date March 24, 1992. Transcript available at http://www.pbs.org/wgbh/pages/frontline/programs/ transcripts/1014.html, last accessed September 30, 2007.

References Beauchamp, T. L. “Ethical Theory and the Problem of Closure.” In Scientific Controversies: Case Studies in the Resolution and Closure of Disputes in Science and Technology, H. Tristram Engelhardt, Jr., and Arthur L. Caplan, eds. (New York: Cambridge University Press), 1987, pp. 27–48. Beauchamp, T. L. and Childress, J. F. The Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press), 2001. DeGrazia, D. “Common Morality, Coherence, and the Principles of Biomedical Ethics.” Kennedy Institute of Ethics Journal 13(3): 219–230, 2003. Engelhardt, H. T., Jr., and Wildes, K. W. “The Four Principles of Health Care Ethics and Postmodernity: Why a Libertarian Interpretation Is Unavoidable.” In Principles of Health Care Ethics, R. Gillon, ed. (New York: John Wiley & Sons), 1994, pp. 135–147. Engelhardt, H. T., Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press), 1996. Feigenbaum, F., Sulmasy, D. P., Pellegrino, E. D., and Henderson, F. C. “Spondyloptotic fracture of the cervical spine in a pregnant, anemic Jehovah’s Witness: technical and ethical considerations.” Journal of Neurosurgery 87(3):458–463, September 1997. Hanson, S. S. “Moral Acquaintances: Loewy, Wildes, and Beyond.” HEC Forum, 19(4), 207–225, 2007. Loewy, E. Moral Strangers, Moral Acquaintance, and Moral Friends (New York: State University of New York Press), 1997. Rawls, J. “The Independence of Moral Theory”, Presidential Address, Proceedings and Addresses of the American Philosophical Association, 47, 1974–1975, 8. Richardson, H. “Specifying Norms as a Way to Resolve Concrete Ethical Problems.” Philosophy and Public Affairs 19: 279–310, 1990. Wiggins, O. P. and Schwartz, M. A. “Richard Zaner’s Phenomenology of the Clinical Encounter.” Theoretical Medicine and Bioethics 26(1): 73–87, 2005. Wildes, K. W, S.J. Moral Acquaintances: Methodology in Bioethics. (Notre Dame, IN: University of Notre Dame Press), 2000. Zaner, R. M. “On Evoking Clinical Meaning.” Journal of Medicine and Philosophy 31(6): 655–666, December 2006. Zaner, R. M. Ethics and the Clinical Encounter. (Edgewater Cliffs, NJ: Prentice Hall), 1988.

Chapter 6

Bioethics Without Analogy Robert Hunt Sprinkle

The philosophical foundations of bioethics are mostly quite old, but the currently prevailing habits of bioethical argument are not. Clinical developments within the past half century—beginning with the intensive-care unit, mechanical ventilation, cardiopulmonary resuscitation, and renal dialysis—have forced many bioethical questions to emerge most tellingly in adversarial dispute, typically in civil courts, especially in the United States. An expansion of bioethical concern to encompass newer clinical possibilities, such as reproductive manipulation and gene therapy, and major non-clinical problems, such as animal welfare and environmental endangerment, has continued this trend and may have accentuated it. Generations of bioethicists—most noticeably American ones—have focused on legal and quasilegal reasoning and have learned to innovate philosophically within court-made constraints. As jurists do to fit novel claims to familiar rights and rules, they have come routinely to argue by analogy, solving new puzzles by re-cutting key pieces to fit established patterns. I ask if this practice is a sound one and consider both the feasibility and the implications of its conscientious avoidance.

1 Analogy at Its Asymptote The new makes news but is often soon seen as more familiar than initially thought. “What is the new like?” we ask. “Have we seen it before, really? Do we understand it implicitly as a previously unheard variation on an old theme?” These questions are helpful when the “new” to be analyzed follows from a well understood principle. Or when it is a new physiological or behavioral manifestation of a less fully understood yet presumably unchanged nature. But what if principles are not so well understood? Or what if nature actually does change? Or is changed, purposefully? We might again ask “What is this apparent novelty like?” We would seek an analogy R.H. Sprinkle (B) School of Public Policy, University of Maryland, College Park, MD 20742, USA e-mail: [email protected] O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_6,  C Springer Science+Business Media B.V. 2011

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through which we could name the novelty, literally “come to terms” with it, so we could understand our reaction and revise it, as reflection would likely lead us to do. We might transform the new into the recent, and some of us—all of us, now and then—would transform the new into the traditional or anti-traditional, finding cause for approbation, resignation, condemnation, or some mixture of these or other reactions. Our ability to understand the new may be unlimited, but our ability to understand the new in this way—in this analogizing way—probably is limited, at least as to the quality of the outcome, if not the proliferation of the attempts. Our ability to understand the new in this way cannot increase much over time, and, being referential, may actually be decreasing in societies where cultural distinctiveness is fading into a whole. At best, the increase is linear and slow, whereas the increase in the new is geometric, notably in biology, and fast. Understanding the new is complicated further by new understanding itself, in several varieties. Much is being learned about primate and human origins, about the evolution of reason and emotion, and about the mechanisms of attitude and behavior, attraction and repulsion, contemplation and resolution. We are learning a lot about who we are psychologically, including a lot about why we might embrace or reject biological forms of anomaly and innovation. This learning, this look-back into psychogenesis, shows tradition and precedent in a glancing light. We see them differently, sympathetically still but more now as heirlooms in a living room: valuable but, in all candor, less comfortable than might have been hoped. “As heirlooms in a living room”—how has this analogy and others to come found their way into an essay “without analogy”? Because analogies are not all alike nor generally to be shunned. We have inherited an ability to make them and, after a certain age, cannot be considered normal neurologically if we fail to understand them. What is an analogy? Samuel Johnson, in his Dictionary of the English Language, 1755, answered: “resemblance, proportion, similarity of one thing to another.” The Encyclopedia Britannica, in its eleventh and most illustrious edition, 1910–1911, described an analogy this way: “A type of inference whose form is ‘because x is like y in some respects it will be in other respects’. Analogy can be suggestive, and sometimes works, but it is not a deductive proof. The argument from analogy for the existence of God, popular in the 18th-c and 19th-c, maintained that the universe is like a mechanism; therefore just as a mechanism requires a maker, so does the universe.” The Oxford English Dictionary, second edition, 1989, offered a longer and less dismissive account: “A logical resemblance of relations, correspondence of functions, or equality of ratios; an inference that if things agree in some respects they probably agree in others; the drawing of a comparison in order to show a similarity. . . . 7. Logic. a. Resemblance of relations or attributes forming a ground of reasoning. b. The process of reasoning from parallel cases; presumptive reasoning based upon the assumption that if things have some similar attributes, their other attributes will be similar.”

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2 Analogy in Service Nature brims with analogy—with deception, mimicry, empathy, and storytelling, with the conveyance of information in coded and symbolic form, with the making, recognition, and exploitation of similarities. Throughout the range of animal behavior, observation and experiment have shown lessons learned in one case being applied to the solution of a problem arising in another case, insofar as the new is sufficiently similar to the old to elicit a patterned response (Kamil and Roitblat, 1985). We see this analytically and yet may find troubling the notion that animals other than humans—let alone life forms other than animals and molecular structures not themselves alive—could be credited with such behavior. A lizard or a fish may take on an appearance resembling its surroundings (LeBas and Marshall, 2000; Cheney et al., 2007). A honey bee may dance in a pattern directing hive mates to a patch of wildflowers (Leadbeater and Chittka, 2007). A presenting cell may display foreign antigens on its surface, giving other cells a clue to the identity of an impending challenge (Henrickson and von Andrian, 2007). The lizard, fish, and bee may be sentient in some provocatively inclusive sense but not in one prompting an analysis of judgment, justice, or responsibility. Yet the lizard, the fish, and the bee—and the presenting cell—act in ways hinting at commonality in the evolution of analogical reasoning. Closer to everyday experience, nonhuman animals amenable to training have abilities in symbolic logic obvious enough to show that analogical components of our behavioral endowment are widely shared and, in the animals who share them, robustly functional. Certain parrots—like all birds the descendants of dinosaurs—have been found able not just to speak and converse but also to count, to add, and to understand the number zero (Pepperberg, 2006). We may not hold its patent, but we have adopted the analogy as a human trademark. “It was like this!” must have been among the earliest proper sentences. Our ancestors invented stories, took pleasure in telling them, and by telling them learned, remembered, taught, motivated, and warned. Our ancestors drew on walls and skins, enjoying hunts in which they may have taken no part. And they danced, describing hunts yet to happen. They also kept history, interpreting and then reinterpreting events, a constancy of fact no barrier to a revision of meaning. Today we do much the same, even as scholars. In moral philosophy, of which bioethics is an applied subfield, analogies may help explain a question, an answer, or an argument. By changing an argument’s setting or particulars, analogies may help test evidence for adequacy and conclusions for generality. Further, analogies may assist exploration, as thoughtexperiments do in physics, allowing ethicists to play through theoretical problems whose practical counterparts, if any, could be useful to discover. Analogies are so common, so expected, as to have their own careers, becoming subjects of debate (Sundstrom, 1995; Gillam, 1997; Wiland, 2000; Smith, 2002; Deckers, 2007; Campbell, 1992; Caplan, 2005) and objects for collective improvement (Hofmann et al., 2006; Samuel et al., 2006; Johnson and Burger, 2006; Lopez, 2006; Burns,

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2006; Holland, 2006; White, 2006; Neal, 2006). Indeed, moral philosophy without metaphor—analogy’s insistent sibling—has been called impossible, the very basis of moral theory being, putatively, metaphoric. The urgency with which this claim has lately been asserted is explained by concern that a new wave of moral reductionism is propagating, with unexampled force and indulgent funding, from the neural sciences (Johnson, 1993). In moral philosophy’s overlap with economics, the fungibility of the material has become, through monetization techniques of one type or another, the fungibility of the moral—in sum, the apotheosis of the analogy. In biology’s overlap with politics, explanations have moved from analogy to metaphor to policy, quite dangerously. Aristotle’s body politic became Rudolph Virchow’s Zellenstaat [cell state], a pedagogical organ-systems analogy that grew into a theory of political ethics, der Zellenstaat joining Ernst von Haeckel’s German monism to become an aid to ethnonationalism (Sprinkle, 1994). In law, arguments proceed from principle, from precedent, or simply from statute, but often they hinge on the success or failure of a claim that an individual or collective person, or a class of such persons, has a role or a right or an obligation not apparent on plain reading of fact but discoverable by recognition of similarity to other persons, roles, rights, or obligations. Attorneys and judges, like anyone else, may employ illustrative analogies to make a point, but they may also employ dispositive analogies to transform a point, to make it grander or broader or more particular than it would otherwise seem, or to move it, to transpose it (Vandevelde, 1996). Such switching can clarify a predicament or complicate it. In application to bioethics, it has tended toward complication, originally in legal disputes bringing private clinical dilemmas to the attention of a nascent bioethical community, then in political disputes using legal actions to stage cross-border raids in what was becoming a multi-front “culture war.”

3 The Dispositive Analogy in American Bioethics A military tribunal of jurists representing the allies victorious in World War II insisted that everyone participating in research as a subject had to be recognized as a fully rights-bearing and self-determining individual. These jurists, the Nuremberg Military Tribunal, were responding to wartime crimes, but they did not cite wartime pressures as mitigating guilt; rather, they described an investigator’s obligations as personal and undiminished by imposition or delegation, with no reference to circumstance. Precepts of research practice needed more specificity than had been thought necessary prior to the war, so the tribunal supplied that specificity in what came to be called the Nuremberg Code, which itself was soon followed by a clinical complement, the World Medical Association’s Declaration of Geneva, a modernization of the Hippocratic Oath (Sprinkle, 1994, 96–100). The Declaration did contain one figurative, and sisters-deficient, metaphor: “My colleagues will be my brothers.” But neither the Code nor the Declaration contained

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a dispositive analogy. Rather, they asserted identities. Research subjects were volunteers, real ones, and they were patients in the full meaning of the word, as was everyone encountered clinically, without exception. In subsequent alterations of the Declaration, an earnestly sobering phrase, “even under threat,” migrated from one context to another, but it did not disappear. The Code and the Declaration were important to write but probably not hard to write. The prompting events were morally unambiguous, at least from the victors’ perspectives. The technologies involved were not especially advanced. The ethical precepts emphasized in response to the events were already traditional. Presented assertions, once approved internally, were not going to be opposed by any major professional group or by any government or society. While they still must be squared with the foundations laid in Nuremberg and Geneva, bioethical assertions today rarely if ever venture into public with all four of these advantages and often have none. Prompting events now are almost always morally ambiguous. The technologies involved are typically quite advanced and may be the chief source of controversy. The ethical precepts emphasized may be derived from traditions to which objecting activists are genuinely bespoken, or they may be chosen to appeal to traditions, often jurisprudential ones, widely honored beyond the objecting activists’ communities. Presented assertions, if noticed, are almost certain to be opposed by other activists, who may have prepared their rebuttals professionally and expectantly. The appeal of tradition and the appeal to tradition must be distinguished, the latter often being strategic and outside the body of belief and reasoning that constitutes the former. The appeal of a religious, moral-philosophical, or political-philosophical tradition may lead activists to appeal instrumentally to a different tradition, a demonstrably or possibly more influential one, whatever they assess its moral value to be. The search for a promising instrumental tradition—and, thus, the search for a dispositive analogy that might move an argument into that tradition coherently and persuasively—has, in the United States conspicuously, allowed activists “to take bioethics public,” to move it beyond the bedside and out of the laboratory. In this respect, clinical ethics and research ethics have not been alone. They have coevolved with policy ethics broadly, and they have also coevolved with activism itself—environmental-ethical activism being a sometimes painful parallel example (Nees et al., 2003)—during a decades-long “descent” toward professionalization.

3.1 The End-of-Life Fights Beginning in the 1960s, acute intervention and intensive care began producing cohorts of the better-off-dead, as argued first by families appalled at the prospect that a neurologically devastated loved one’s chance to die, if missed, might not return for a grotesquely long time. Withdrawal of life support in some cases was requested, and it was refused. Opposition came from physicians and hospital administrators unwilling to act in a manner inconsistent with their own convictions or unwilling to place themselves in an ambiguous position before the law. As requests

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for withdrawal increased in number, and as some of these requests were granted, the locus of opposition shifted to the governments of states where “mercy killing” had vocal opponents. In retrospect, these opponents, along with like-minded activists elsewhere and dissenting members of requesting families, probably worried most about prognostic uncertainty, about openness to miraculous outcomes being foreclosed by the arrogation of fate by the faithless, about the importance of religious observance especially in death, and about the chance that “pulling the plug” would “open the door” to outrageously abusive scientists and politicians intending to rid society of its useless unfortunates. Yet when they metamorphosed from dilemmas into disputes and then into judgments, verdicts, statutes, and regulations, these withdrawal-of-life-support cases came to resemble estate-law cases with highly eccentric features. Had a will existed, and, if yes, had it been well drawn and witnessed? Had it mentioned withdrawal of life-support? If not, had withdrawal been mentioned privately? Who could be trusted to execute a will, whether explicit or implicit? If it existed and explicitly discussed withdrawal, did a will need to be obeyed, or could it be set aside, and if so under what conditions? Since it could now be a scheduled event, like the induction of labor, when would death be indicated? And, pending a serviceable redefinition of terms, could lifesupport somehow be withdrawn after death? Could the harvesting of organs and tissues be fit into this sequence, and, if not, could death be redefined even more flexibly? Could gifts of life be delivered to graft recipients without the impediment of probate? Could all the agents of expiration—families, physicians, institutions, governments, corporations—be indemnified to their satisfaction? Could answers agreed for adults who were dying be adapted for adults who were not dying? And could they be adapted for children? With patients now transformed, by dispositive analogy, into once-again sentient estate- and graft-bearing citizens, and as the generalizable fates of these citizens were now bound up in legal actions and legislative initiatives, clinical-ethical and moral-philosophical problems were subordinated to contests between courtly champions, as supported or opposed raucously, if not riotously, by groundlings. Activists on each side of the withdrawal issue soon realized that such questions, however far from their central concerns, could—and, because they could, would—become trench lines in a siege they dare not lose. This patients-as-precedents pattern has now many times been repeated, both by accident and by intention and with differing degrees of regret and success. A transposed argument’s future is a function of its new locale. When withdrawalof-lifesupport cases landed in the lap of estate law, precedents applied and set there had to be reasoned first in terms of the body of law involved, not the body of the patient affected.

3.2 Reproductive Wrongs Imaginative reproductive-wrongs activists have advanced embryos and fetuses and even cells in a Petri dish as ostensibly entitled proto-citizens against whom crimes and other indignities are committed, just as against live-born people. Reaching for

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the rights of named children and adults is attractive, for if such a stretch were endorsed then other acts said to be wrong could at last be prevented or avenged. The very implausibility of such a dispositive analogy may explain the need, or anyway the urge, to assert it. Cells in a Petri dish are unlike their putative analogues in every way except molecular genetics and general cellular biology, with embryos and fetuses at later developmental stations along the way to viability, birth, naming, schooling, voting, procreating, and dying. These earliest forms of ourselves are, needless to say, vulnerable, but they are not ourselves, despite their potential. Indeed, their potential can be seen in the gametes that made them and in the molecules that made the gametes. Strangely self-defeating is this analogy’s implication: that good people would of course not value—perhaps even should not value—any human life-form that lacked recognizability as a live-born person, though these are precisely the life forms the activists seek to protect. Equally imaginative reproductive-rights activists have countered that a fetus, if invested with the rights of an adult, might also acquire an adult’s potential for culpability, transforming the fetal-maternal relationship from procreative to parasitic, the implication being that a gravida could terminate a pregnancy in the same self-defensive spirit she would exhibit when purging her gut of worms.

3.3 Role Revisions Structural-functionalist analogies have been the most effectively dispositive of all. Patients have become “consumers” or “clients” and physicians, along with a range of nonphysician clinical coworkers and, by self-description in advertising, corporations and institutions, have become “providers” (Sprinkle, 1997). This transformation served to restrain physician authority—to break “the tyranny of professional norms and standards”—by making more clinicians more interchangeable (Havighurst, 1983) and, so, less formidable in confrontation with corporations and institutions. It also sought to further the notion that patients’ relationships with “providers,” incongruously including insurance companies, were contractual, not in a morally contractual or socially contractual sense but in a legally contractual limited-liability and limited-benefits sense (Sprinkle, 2001). America’s experiment with managed care and managed competition supposedly required that these analogies be accepted, and they were accepted, more than nominally. Yet their acceptance could not make the experiment a success. When consumer meets provider, caveat aeger qua emptor. Similarly, “providers” managing “risk,” meaning their own liability exposure, have read the Nuremberg Code with more interest than the Declaration of Geneva. The Code described acceptable research practices which, if followed, promised protection; the Declaration did not. Protection, then, lay in the transformation of patients into research subjects, the transformation of diagnostic and therapeutic actions into quasi-investigational actions. The documentation of consent—an evermore routinized, off-putting, and disingenuous prelude to an evermore carefully worded list of explicit choices, implicit agreements, potential consequences,

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and robust legal immunities—came to protect informers from the informed and to differentiate interests that supposedly were shared. A parallel role revision was inadvertently predestined in 1996 by the Health Insurance Portability and Accountability Act (HIPAA),1,2 whose Title II, containing ironically named Administrative Simplification (AS) provisions, sought to protect privacy by encouraging and controlling electronic communication of health information. With few patients bold enough to block the transfer of information to health-insurers to whom they have already paid premiums and with harsh penalties specified for violating patients’ privacy in many—but not in all—confusingly differentiated circumstances, HIPAA has done little to prevent to dissemination of private information to corporations but has bizarrely complicated communication with patients’ families (Wilson, 2006), has seriously impeded clinical and epidemiological research (Armstrong et al., 2005; Wolf and Bennett, 2006), and has employed a new class of advisers: “HIPAA consultants.” The sharing of information when it should be shared, as when a credibly identified adult child telephones an intensive-care unit to learn the condition of an acutely ill parent, has become interpretable as a criminal violation of privacy rights (Gross, 2007). This situation could have come about only by “Nuremberging” the patient into an autonomous self-interested decision-maker surrounded by other autonomous self-interested, and therefore potentially threatening, decision-makers. The far more likely possibility, that interests are not confined to self but are shared and that information should then also be shared, has been made an assumption that hospitals, and others, have come to regard as too risky to accept.

3.4 Role Denials A grandparental couple jointly has contributed as much genetic material to a grandchild as has his or her mother or father individually. Nonetheless, the mother or the father or both or any legal guardian has the right to forbid grandparental visitation without showing cause. This according to the United States Supreme Court in Troxel v. Granville in 2000, in whose culmination nine justices assorted their thoughts into six heatedly contrasting opinions coalescing into a six-to-three vote finding, in the words of a four-judge plurality, that a Washington state law “unconstitutionally interfere[d] with the fundamental right of parents to rear their children.” A state’s law had sought to accommodate any petition for visitation that a court might find to be in the best interest of a child. By so doing, though, the law had required the hearing of disputed petitions not only from grandparents but from others, potentially including non-relatives, such as those that might compose non-traditional families.3 This was a hard case, and whether it made bad law is never likely to be agreed by parties with contrary practical interests and differing sympathies. The pivot upon which legal and emotional fortunes turned against Troxel—really the Troxels, plural, a grandparental couple whose son, the father of Granville’s daughters; had died by suicide —was the due-process clause of the Fourteenth Amendment to the United States Constitution: “No state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any state

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deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.” As courts, both state and federal, had reached far more decisions regarding parents than grandparents, the status of parental rights was clearer, and a parents was the one whose federally guaranteed rights were seen as being infringed by a state’s law. Parents were rights holders, and grandparents—now classed with, if not as, non-relatives— were challengers of those rights, rather than asserters of their own parallel rights. Grandchildren’s rights were subsumed under parents’ rights; best interests aside, grandchildren had no right to be visited by grandparents. The analogy drawn by Granville’s advocates had proved dispositive exactly as anticipated, transposing a family in need of reconciliation into citizens in the midst of Reconstruction. A due-process clause in the Fifth Amendment to the United States Constitution had limited the federal government; the due-process clause in the Fourteenth Amendment limited state governments. The Fourteenth Amendment confine state sovereignty within the box of national sovereignty by protecting the rights of all citizens—including former slaves and northerners residing in states of the defeated Confederacy—from the abridgment of privileges or immunities, the denial of due process of law, or the equal protection of the laws. To make this confinement of state sovereignty robust upon reentry of former secessionists into national politics after Reconstruction’s state-by-state conclusion, the Amendment also limited the ability of states to manipulate elections, forbade the election or appointment of anyone who had through rebellion violated an oath to support the federal Constitution, and guaranteed that debts incurred in suppressing rebellion would be honored while debts incurred in making rebellion would not. Family law became a topic of the Fourteenth Amendment only insofar as a state—not the federal government—treated certain of its citizens unfairly. But which citizens? Parents? Grandparents? Children and grandchildren? Here was the only federally judicable question presented by Troxel v. Granville, but the case itself had arisen not because of interest in the relationship between individuals and the states they had come together to create but because of interest in families and the descendants they had come together to procreate. The universality of the dispute existed because the contestants were palpably not atomized autonomous citizens but because they were inextricably related, emotionally as much as genetically. When their family dispute was recast as a property-rights dispute between a state and an owner—a parent “owning” a minor child—then the problem to be solved comfortably became one of federalism. States unhappy with this outcome legislated to allow grandparents to be grandparents while avoiding future federal scrutiny, and the United States Supreme Court, in its own internal wisdom, has so far declined to entertain objections to these efforts (Richey, 2007).

3.5 Entrainment of Bioethical Reasoning Modern experience in the United States has shown that a dispositive analogy’s success can alter advocates’ subsequent strategies. It can also alter bioethicists’

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reasoning, sometimes bending it to a new reality, sometimes breaking it. For example, in 1979, John Fletcher found his own reasoning broken in this way and chose to recast it publicly, writing on “Ethics and Amniocentesis for Fetal Sex Determination” in the New England Journal of Medicine. . . . I personally believe that sex choice is not a compelling reason for abortion. The first moral response of most who think about the issue is close to queasiness. Yet, the issue does not turn on the validity of opposition to abortion for sex choice. The issue turns on the validity of the legal rules on abortion defined by the Supreme Court, which do not require that a woman state reasons in a public or medical forum for early to mid-trimester abortion. No one is presumed to be a public judge of her reasons except herself. Family, friends, counselors or physicians may challenge her reasons if she chooses to confide in them. But the rule is that no public test of reasons is required.

Is this the best rule to apply in abortion? Yes, if one holds, as I do, that the woman’s right to decide is the overriding consideration in the abortion issue. . . . To prevent obstruction of self-determination, it is better to have no public tests of reasons. . . . . . . Although a Supreme Court decision is not itself an ethical consideration, the legal guideline on abortion points beyond itself to the principles of justice and respect for persons. Justice in the modern state requires that women be freed from restrictions on their freedom and opportunity to compete for the social and economic rewards of citizenship. . . . . . . The Supreme Court justices probably did not imagine in 1973 that their decision on abortion was related to the right of parents to choose the sex of children through amniocentesis. However, even if the justices were then aware of the potential use of amniocentesis for this purpose, it did not figure in their reasoning. . . . If the sometimes trivial reason for abortion must be accepted to protect the rights of many women, how could it be acceptable for the same physician to participate in a system that discriminates because of reasons for abortion? To hold to this inconsistency is morally self-defeating and leads to hypocrisy. Furthermore, amniocentesis and laboratory work should be done under the very best of conditions, if done at all. The physician should not be forced to defend an inconsistent policy and practice less than optimum medicine and science. . . . . . . The physician can, if he or she chooses, state an opposing view in moral terms. What the physician should not do is withhold amniocentesis if informed parents desire to proceed. To do so would be to test the parents’ reasons for abortion. The parents may or may not decide on abortion on the basis of the information gained. In any event, that decision remains theirs to make, legally and morally. . . .

. . . Physicians who agree with the social-ethical perspective that informs the legal rules on abortion will finally want to keep faith with the moral intent of the law. Policymakers in this field should now reconsider their obligation to be responsive and consistent in their beliefs. I include myself in the company of those who need to be changed (Fletcher, 1979). One may oppose abortion-on-demand yet still rights to find Fletcher’s forthrightness admirable, and one may welcome abortion-on-demand yet still find his

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accommodation to jurisprudential precedent unsettling. “Justice in the modern state” has often “requiring” reprehensibly. The lesson of Nuremberg was assuredly not to tell physicians to fall into line, take their socialcontractual posts, and vend their services. Yes, the services in question for Fletcher had at last, and for good reasons, been decriminalized, although not overtly with the thought of legalizing the abortion of presumptively normal fetuses—most of them female, if subsequent global experience is informative—for gender preference alone. Could a procedure’s decriminalization mean a physician’s responsibilities had been “demoralized”? No, but they had, arguably, been transposed from one moral presumption to another, from clinical conscientiousness to civic conscientiousness.

4 Theories and Fiction In the more rationalistic and dogmatic of his dauntingly numerous works, Galen, to the dismay of practitioners in the more consistently skeptical and empirical wing of the Hippocratic tradition, enhanced or invented theories through which anatomy and physiology might be interpreted and therapies devised. These theories, some of them elaborated almost in defiance of facts he himself had demonstrated or could have demonstrated with just an extra ligature or two, were no match for—and may have restrained—his descriptive and experimental work (Galen, 1963). However, these theories, being more impressive fiction than his competitors could manage, served a rhetorical purpose Galen seemed to value highly, perhaps above objective discovery (Nutton, 2005). These more pejoratively “Galenic” of Galen’s contributions were reflexively credited as far as 14 centuries into the future, until physician-and-anatomist Andreas Vesalius, philosophers Michel de Montaigne and Francis Bacon (Pender, 2006), and a succession of Hippocratic revivalists committed themselves to describing nature as they found it, propelling biology toward a new front in the Scientific Revolution. Major figures among the revivalists were Robert Boyle and two physicians, Thomas Sydenham and his clinical-practice partner, Boyle’s former laboratory assistant, John Locke. The last of these gentlemen was also a philosopher of science and, anonymously, a philosopher of politics and political ethics; he would prove the single most important figure in the development of life-sciences liberalism (Sprinkle, 1994, 29–69). Locke’s Essay concerning Human Understanding contained four books, the last treating Nominalism (Locke, 1975). Here, Locke spoke fervently for clarity in description, for precise nonrhetorical use of words, and against elaborate metaphors and analogies. Sydenham’s neo-Hippocratic “plain and open method” of De Arte Medica survives in Locke’s own hand, Locke often having taken dictation from Sydenham, who intermittently complained of arthritis thought to be gouty. From this “plain and open method,” Locke created the “historical plain method” of empirical analysis and argument (Romanell, 1984), historical in the sense of following clinical and case histories, plain in the sense of analyzing an object or process in its own

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terms and context, from direct experience. What would Locke have made of dispositive analogies, of their pursuit and acceptance, in bioethical disputes? He proved a master of the illustrative analogy in Two Treatises of Government (Locke, 1698), and a master of clinical and laboratory examples in the Essay. But the Essay’s book on nominalism suggested that in the moral analysis of scientific novelty he would not have aimed to involve judiciaries and likely would have thought judges’ judgments on medical questions specious, since anti-majoritarian authority would have conformed them to a non-natural body of law. What would Locke have made of stories? The President’s Council on Bioethics published a book of readings in 2003 and has had trouble keeping it in stock, supplies running behind popular demand. The Council, at its website, has explained its book as follows: Increasingly, advances in biomedical science and technology raise profound challenges to familiar human practices and ways of thinking, feeling, and acting. It is no wonder, then, that bioethics touches matters close to the core of our humanity: birth and death, body and mind, sickness and health, freedom and dignity are but a few of these. From the beginning, human beings have addressed these matters in works of history, philosophy, literature and religious meditation. These works can be invaluable companions as we search for a richer understanding and deeper appreciation of our humanity, necessary for facing the new challenges of our biotechnological age. With this in mind the Council has prepared Being Human: Readings from the President’s Council on Bioethics, an anthology of works of literature that speak to bioethical dilemmas. It contains 95 selections from sources as wideranging as Homer, Tolstoy, Shakespeare, American folk songs, contemporary fiction and poetry, and even a screenplay. Each selection is accompanied by an introduction that directs readers toward its bioethical implications, and provides questions for groups reading together or individuals studying alone.4 The Council’s offering of stories was not simply about “being human.” It was being human. This book was adjunctive; it did not substitute for formality, but it was assembled to make formality more accessible, as analogies can. Unfortunately, a subtextual message could not be ignored: bioethics had confronted the ineffable and reacted analogically, searching existing literature for resonant works of fiction. Thought-provoking, no worse than harmless, and routine in college ethics courses—maybe so. But the stories that really need to be understood are the patient’s own, the family’s own, the community’s own. In biology’s golden age—our age of daily geometric gain in physiological insight, ecological comprehension, and interventional innovation—the uniqueness of those stories has ruined the fit of ready-towear analogies and made judgments by precedent dangerously anachronistic. The best of the past can still help us, but the best of the present can as well.

5 Encountering the Encounter Judgement informed by experience in truly similar cases—or in largely dissimilar cases with instructively similar details—is another matter: not strained analogy, not adapted precedent, just normal clinical science. Even in bioethics, an applied

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subfield of moral philosophy, normal clinical science. Here, the stories told are ones from bedside or research bench, their content not yet understood, their endings still to be improved, but their totality already available as admonition or encouragement. Clinical ethics and life-sciences research ethics are hard to disentangle morally, as they share a motivation: “When impairment occurs without desert, something should be done to help” (Zaner and Bliton, 1991). Clinical ethics encounters the embodiment of that motivation; research ethics sometimes does and sometimes does not, although researchers must always assume that it might. Clinical ethics is thus the more basic of the two. But research, which is designed to clarify the imaginable, continually complicates clinical ethics with unfamiliar possibilities, making clinical ethics also the more applied. This paradox is mitigated by a gift clinical ethics gives to research ethics: “an expanded notion of practical reason within unique situations” (Zaner, 1991). This expanded notion, most diligently explored in our era by Richard Zaner, is at once Hippocratic and phenomenological, principled and nonprincipalistic, inventive and guileless (Zaner, 1966, 1988, 2000). It is the “historical, plain method” come to bioethics.

Notes 1. Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, 104th Congress. 2. U.S. Department of Health & Human Services, Office for Civil Rights—HIPAA; http://www. hhs.gov/ocr/hipaa/. 3. Troxel v. Granville, 530 U.S. 57 (2000). 4. http://www.bioethics.gov/bookshelf/ [last visited 20 November 2007].

References Armstrong, D., E. Kline-Rogers, S. M. Jani, et al., “Potential impact of the HIPAA privacy rule on data collection in a registry of patients with acute coronary syndrome,” Arch Intern Med, 2005, 165:1125–1129. Burns, L., “Banking on the value of analogies in bioethics,” Am J Bioeth, 2006, 6:63–65. Campbell, C. S., “It never dies: assessing the Nazi analogy in bioethics,” J Med Humanit, 1992, 13:21–29. Caplan, A. L., “Misusing the Nazi analogy,” Science, 2005, 309:535. Cheney, K. L., A. S. Grutter, and N. J. Marshall, “Facultative mimicry: cues for colour change and colour accuracy in a coral reef fish,” Proc Biol Sci, 6 Nov 2007. Deckers, J., “Why two arguments from probability fail and one argument from Thomson’s analogy of the violinist succeeds in justifying embryo destruction in some situations,” J Med Ethics 2007 33, 160–164. Fletcher, J. C., “Ethics and Amniocentesis for Fetal Sex Identification,” New England Journal of Medicine, 6 September 1979, 301:550–553. Galen, On the Natural Faculties, Arthur John Brock, trans. (Cambridge, Mass.: Harvard University Press, 1963), book I, sec. xiii, pp. 49–71. Gillam, L., “Arguing by analogy in the fetal tissue debate,” Bioethics, 1997, 11:397–412.

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Gross, J., “Keeping Patients’ Details Private, Even From Kin,” New York Times, 3 July 2007. Havighurst, C. C., “Decentralizing decision making: private contract versus professional norms,” in Market Reforms in Health Care: Current Issues, New Directions, Strategic Decisions 22 (Jack A. Meyers ed., 1983). Henrickson, S. E. and U. H. von Andrian, “Single-cell dynamics of T-cell priming,” Curr Opin Immunol, 2007, 19:249–258. Hofmann, B., J. H. Solbakk and S. Holm, “Analogical reasoning in handling emerging technologies: the case of umbilical cord blood biobanking,” Am J Bioeth, 2006, 6:49–57. Holland, S., “It’s not what we say, exactly, or is it?” Am J Bioeth, 2006, 6:65–66. Johnson, M., Moral Imagination: Implications of Cognitive Science for Ethics (University of Chicago Press, 1993), pp. 63–77. Johnson, S. and I. Burger, “Limitations and justifications for analogical reasoning,” Am J Bioeth, 2006, 6:59–61. Kamil, A. C. and H. L. Roitblat, “The ecology of foraging behavior: Implications for animal learning and memory,” Annu Rev Psychol, 1985, 36:141–169. Leadbeater, E. and L. Chittka, “Social learning in insects—from miniature brains to consensus building,” Curr Biol, 2007, 17:R703–R713. LeBas, N. R. and N. J. Marshall, “The role of colour in signalling and male choice in the agamid lizard Ctenophorus ornatus,” Proc Biol Sci, 2000, 267:445–452. Locke, J., Two Treatises of Government: In the Former, the False Principles and Foundation of Sir Robert Filmer, and His Followers, Are Detected and Overthrown. The Latter is an Essay Concerning the True Original, Extent, and End of Civil-Government (London: Awnsham and John Churchill, 1698), presented as John Locke, Two Treatises of Government: A Critical Edition with an Introduction and Apparatus Criticus, amended reprinting, Peter Laslett, ed. (New York: Mentor Books, by arrangement with Cambridge University Press, 1960 and 1963). Locke, J., An Essay concerning Human Understanding, Peter H. Nidditch, ed. (Oxford: Clarendon Press, Oxford University Press, 1975), Book IV, pp. 525–722. Lopez, J. J., “Mapping metaphors and analogies,” Am J Bioeth, 2006, 6:61–63. Neal, K. C., “Analogical trends in umbilical cord blood legislation in the United States,” Am J Bioeth, 2006, 6:68–70. Nees, D., Green, V., Treadway, K., Lafferty, J., Vanyo, M., Date, P. and Sprinkle, R. H., “Activism, Objectivism, and Environmental Politics,” Environmental Ethics, Fall 2003, 25:295–312. Nutton, V., “The fatal embrace: Galen and the history of ancient medicine,” Science in Context 18(1), 111–121 (2005). Pender, S., “Examples and experience: on the uncertainty of medicine,” Br J Hist Sci, 2006, 39: 1–28. Pepperberg, M., “Grey parrot numerical competence: a review,” Anim Cogn, 2006, 9:377–391. Richey, W., “Supreme Court lets stand grandparent-visitation decision—At issue: whether judges violated the constitutional right of Shane Fausey to raise his child free of undue government interference,” Christian Science Monitor, 27 March 2007. Romanell, P., John Locke and Medicine: A New Key Locke (Buffalo: Prometheus Books, 1984), pp. 144–148. Samuel, G. N., R. A. Ankeny and I. H. Kerridge, “Mixing metaphors in umbilical cord blood transplantation,” Am J Bioeth, 2006, 6:58–59. Smith, B., “Analogy in moral deliberation: the role of imagination and theory in ethics,” J Med Ethics, 2002, 28:244–248. Sprinkle, R. H., Profession of Conscience: The Making and Meaning of Life-Sciences Liberalism (Princeton University Press, 1994), pp. 77–89. Sprinkle, R. H., “Corporatism in Question: A Note on Managed Care,” Report of the Institute for Philosophy and Public Policy, Summer 1997, 17:3, pp. 13–17. Sprinkle, R. H., “A Moral Economy of American Medicine in the Managed-Care Era,” Theoretical Medicine and Bioethics, June 2001, 22:3, pp. 247–268. Sundstrom, P., “Peter Singer and ‘lives not worth living’—comments on a flawed argument from analogy,” J Med Ethics, 1995, 21:35–38.

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Vandevelde, K. J., Thinking Like a Lawyer: An Introduction to Legal Reasoning (Westview Press Law/Methodology, 1996), pp. 86–88. White, G. B., “Analogical power and Aristotle’s model of persuasion,” Am J Bioeth, 2006, 6:67–68. Wiland, E., “Unconscious violinists and the use of analogies in moral argument,” J Med Ethics, 2000, 26:466–468. Wilson, J. F., “Health Insurance Portability and Accountability Act Privacy rule causes ongoing concerns among clinicians and researchers,” Ann Intern Med, 2006, 145:313–316. Wolf, M. S. and C. L. Bennett, “Local perspective of the impact of the HIPAA privacy rule on research,” Cancer, 2006, 106:474–479. Zaner, R. M. and M. J. Bliton, “The injustice of it all: Caring for the chronically ill,” J Clin Ethics, 1991, 2:157–159. Zaner, R. M., “Listening or telling? Thoughts on responsibility in clinical ethics consultation,” Theor Med, 1996, 17:255–277. Zaner, R. M., “Power and hope in the clinical encounter: A meditation on vulnerability,” Med Health Care Philos, 2000, 3:265–275. Zaner, R. M., “Voices and time: The venture of clinical ethics,” J Med Philos, 1993, 18:9–31. Zaner, R. M., Ethics and the Clinical Encounter (Englewood Cliffs, N.J.: Prentice Hall, 1988). “Biomedical ethics and the shadow of Nazism: a conference on the proper use of the Nazi analogy in ethical debate, 8 Apr 1976,” Hastings Cent Rep, 1976, 6:1. “Contested terrain. The Nazi analogy in bioethics,” Hastings Cent Rep, 1988, 18:29–33. The President’s Council on Bioethics, Being Human: Readings from the President’s Council on Bioethics (Washington, D.C., December 2003).

Chapter 7

Phenomenological Nursing in Schutzian Perspective Lester Embree

This is the aim of phenomenology in nursing research—to describe the experiences of others so that those who care for these individuals may be more empathic and understanding of another person’s experience.1 Dedicated to my old friend, Dick Zaner, deep appreciator of narratives of suffering.

1 Introduction At the meeting of the Organization of Phenomenological organizations in Lima in 2005, I urged philosophical phenomenologists to reflect on phenomenology as practiced in disciplines beyond philosophy.2 Since nothing is usually more persuasive for others than a recommender following his or her own recommendation, the present essay results from a reflection on phenomenological nursing. Let me tell how I proceeded. By googling “nursing” in combination with “phenomenology,” “hermeneutics,” and “lived experience,” with the names of major phenomenologists, and by asking some colleagues for help, I easily developed a bibliography of some 1,000 items. Most are in English but some are in Portuguese, Korean, and other languages. I have placed this bibliography in the department for bibliographies of phenomenology in disciplines beyond philosophy of the O.P.O. website (www.o-p-o.net). I can easily imagine that there are many more items for nursing, and I hope they are sent to me to add to that list. I also hope that bibliographies of phenomenology in other disciplines beyond philosophy will accumulate there. There are at least three-dozen such disciplines and philosophical phenomenologists may make up no more than a plurality in our multidisciplinary tradition.

L. Embree (B) Department of Philosophy, Florida Atlantic University, Boca Raton, FL 33431, USA e-mail: [email protected] O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_7,  C Springer Science+Business Media B.V. 2011

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Through my university library I was then able to access probably 700 of these items on line, began to read articles randomly, and was soon quite overwhelmed by the variety, complexity, and the biomedical jargon of the literature thus accessed. I must now admit that I am not prepared at my age to make philosophizing about phenomenological nursing a major new specialty. Nevertheless, I hope this effort will help others. What I am calling “phenomenological nursing” I define as nursing practice and research explicitly influenced by phenomenological philosophy, which in no way precludes nursing’s extensive creative adaptation and development of phenomenology. The history of the phenomenological movement in nursing remains to be written, but a brief sketch can be ventured. A. Davis, “The Phenomenological Approach in Nursing Research” (1973) seems the first clear contribution. By 1980, relevant publications were appearing annually and such figures as D. Allen, P. Benner, A. Bishop, J. Skudder, M. Z. Cohen, N. Diekelmann, N. Drew, S. Gadow, S. Kvale, P. Munhall, C. Oiler, A. Omery, R. R. Parse, F. Reeder, and J. Watson had become prominent. My bibliography includes over 500 authors thus far (most publications have multiple authors), but no doubt there are many more currently writing in phenomenological nursing, including in languages other than English. There was a vigorous debate in the 1990s between the more Heidegger-based and “interpretive” and the more Husserl-based and “descriptive” theorists of nursing. Currently there is some tendency for nursing affected by philosophical phenomenology to be absorbed into a larger coalition sometimes called “qualitative research,” where I hope it can not only resist dilution but also increase appreciation of its distinctive approach. As I wandered about in this amazing new land, I came to wonder why the work of Maurice Merleau-Ponty, the preeminent phenomenologist of the body, was so little drawn upon. Then I found the recent work of Sandra P. Thomas, which significantly relies on that work, and decided it was a good example. In this essay I sketch the theory of cultural science of Alfred Schutz (1899–1959) and then relate some of Thomas’s work to it.

2 The Schutzian Perspective in General In the present section I chiefly draw on my Alfred Schutz Memorial Lecture in 2001.3 Many have unfortunately learned to classify Schutz as a “phenomenological sociologist” and often dismiss him from philosophy on this basis. While there are parts of Schutz’s oeuvre, e.g., “The Stranger” (1944) and “The Homecomer” (1944),4 that are rightly taken as contributions to social psychology if not sociology strictly speaking, the vast majority of his writings are clearly in or on philosophy. When his colleague Leo Strauss praised him as a philosophically sophisticated sociologist for writing “Equality and the Meaning Structure of the Social World” (Schutz, 1964) (CP II), Schutz replied that he would prefer to be considered a “sociologically sophisticated philosopher.”5 His doctorate was in philosophy of law but he did mostly teach sociology and had eminent students in that discipline, Thomas

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Luckmann above all. But he also taught philosophy and was no more a sociologist fundamentally than Merleau-Ponty was fundamentally a child psychologist because he taught in that field for several years. And that Schutz reflected philosophically on sociology no more makes him a sociologist than Carl Hempel’s reflections on physics makes him a physicist, and, in any case, Schutz reflected more deeply on economics than on sociology.6 Schutz’s overall project is best called “theory of the cultural sciences.” I say “cultural sciences” because his scope included the historical sciences as well as the specifically social sciences in the usual signification in the USA today (he often uses “social sciences” in a broad signification that includes the historical sciences) and because the cultural sciences can include primate ethology,7 which “human sciences” cannot. I say “theory” rather than “philosophy” of science because for Schutz the theory of science is regularly done in disciplines beyond philosophy, for, as he says, “It is a basic characteristic of the social sciences to ever and again pose the question of the meaning of their basic concepts and procedures. All attempts to solve this problem are not merely preparations for social-scientific thinking; they are an everlasting theme of this thinking itself.”8 Most often Schutz uses the expression, “methodology,” rather than “Wissenschaftslehre,” but “methodology” has now too often come to denote the application of formal methods in research, i.e., logic and statistics, while “theory of science” and its transform “science theory,” covers not only non-formal as well as formal procedures but also the definitions and basic concepts of sciences for Schutz. There is an implicit difference in Schutz between what can be called “scientific science theory” and “philosophic science theory” whereby the former focuses on just the definition, basic concepts, and procedures of a scientist’s own particular discipline, while in the latter the focus is on these aspects of whole species of science, e.g., the social sciences. Thus, in contrast with Schutz, Max Weber and Talcott Parsons in Schutz’s account focused solely on sociology. The expression, “theory of science” (Wissenschaftslehre), occurs in Schutz. I do not dispute his more usual expression, “methodology,” provided it is comprehended to include far more than statistical technique. As for the relation between science theorists and substantive science, Schutz asserts that, “It is my conviction that the methodologists have neither the job nor the authority to prescribe to social scientists what they have to do. Humbly he has to learn from social scientists and to interpret for them what they are doing” (Schutz, 1996, p. 146), further explaining that, in this role, the methodologist has to ask intelligent questions about the techniques of his teacher [, the cultural scientist]. And if these questions help others to think over what they really do, and perhaps eliminate certain intrinsic difficulties hidden in the foundation of the scientific edifice where the scientists never set foot, methodology has performed its task. (Schutz, 1964, p. 88)

There are three components to science theory for Schutz:

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(1) Where disciplinary definitions are concerned, it may suffice here to say that for Schutz there is a difference between the naturalistic and the cultural sciences, the specifically social sciences focus on living contemporaries while the specifically historical sciences focus on predecessors, and that economics, sociology, and political science are particular social sciences. And the research component in phenomenological nursing can be considered a type of cultural-scientific social psychology. (2) Where basic concepts (Grundbegriffe) for the cultural sciences are concerned, Schutz lists on the first page of his book, for example, the interpretation of one’s own and others’ experiences, meaning-establishment and meaning-interpretation, symbol and symptom, motive and project, meaning adequacy and causal adequacy, and, above all, the nature of ideal-typical concept formation, upon which is based the very attitude of the social sciences toward their subject matter.9 (Schutz, 1967, p. xxxi)

And (3) where methods are concerned there are “definite operational rules”10 that need to be described, something that Schutz does using the expression “postulates,” the most important of which are “subjective interpretation” and “adequacy.” Concerning the latter postulate, he writes, Each term in a scientific model of human action must be constructed in such a way that a human act performed within the life-world by an individual actor in the way indicated by the typical construct would be understandable for the actor himself as well as for his fellow-men in terms of common-sense interpretation of everyday life: Compliance with this postulate warrants the consistency of the constructs of the social scientist with the constructs of common-sense experience of the social reality. (Schutz, 1962, p. 44)

This is not to say that the actor in everyday life must agree with the culturalscientist’s model but only that its terms must be intelligible to her. As for the postulate of subjective interpretation, Schutz writes that, In order to explain human actions the [cultural] scientist has to ask what model of an individual mind can be constructed and what typical contents must be attributed to it in order to explain the observed facts as the result of the activity of such a mind in an understandable relation. The compliance with this postulate warrants the possibility of referring all kinds of human action or their result to the subjective meaning of such action or result of an action had for the actor. (Schutz, 1962, p. 43)

“Subjective meaning” contrasts with “objective meaning,” but Schutz importantly comments that, It was Max Weber who made this distinction the cornerstone of his methodology. Subjective meaning, in this sense, is the meaning which an action has for the actor or which a relation or situation has for the person or persons involved therein; objective meaning is the meaning the same action, relation, or situation has for anybody else, be it a partner or observer in everyday life, the social scientist, or the philosopher. The terminology is unfortunate

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because the term “objective meaning” is obviously a misnomer, in so far as the so-called “objective” interpretations are, in turn, relative to the particular attitudes of the interpreters and, therefore, in a certain sense, “subjective.” (Schutz, 1964, p. 275)

It is through reflection on the subjective interpretation of the subjective meanings of things that a cultural science and even a theory of cultural science can be considered phenomenological. Schutz’s perspective can be summarized as a structure of four levels: The bottom level is that of common-sense thinking and on that level there are the meanings that an action, relation, or situation has for an actor, the partner, and the observer in everyday life. On the second level is the model constructed on the basis of the common-sense constructs by cultural scientist in what can be called “substantive research.” On the third level is the scientific science theory that includes the disciplinary definition, basic concepts, and methodological procedures of the particular science and these refer to the meanings or constructs of the lower two levels. And on the fourth level is philosophic science theory, which is theory of science in which more than one discipline is considered. Philosophic science theory is widest in scope but furthest from the concrete phenomena that are the basis for the whole. This four-level perspective is related by Schutz to economics, jurisprudence, sociology, and to some extent political science in particular as well as the species of the social and even the cultural sciences. On Schutzian grounds it then seems already a philosophical task to explore how phenomenological nursing might be viewed in Schutzian perspective. This is because more than one discipline is in effect considered. But for what it is worth, Schutz seems nowhere to mention nursing.

3 Two Examples of Phenomenological Nursing I now study some of the work of Sandra P. Thomas. As mentioned, my attention was drawn to her work because it relies heavily on Maurice Merleau-Ponty, the phenomenological philosopher of the body, which has curiously been underappreciated in the field previously. Besides the fairly recent book, Listening to Patients: A Phenomenological Approach to Nursing Research and Practice,11 the following brief analysis is based on three articles. One urges the appreciation of MerleauPonty and includes how Thomas herself converted from the quantitative approach to nursing research to an existential phenomenological one.12 Another article nicely outlines the method she advocates,13 while the third (Thomas and Johnson, 2000) conveys research results on chronic pain (Thomas et al., 2000).

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But before I attempt to relate Thomas’s work to Schutz’s science theory, something needs to be said about how these might initially be aligned. Nursing fundamentally relates to people with actual or potential health problems. It often seems better to speak of “clients” than “patients” because, for example, a couple seeking advice about their first pregnancy is not as such sick. Science is, however, involved in what modern nurses do and indeed nursing is often called an “applied science.” This characterization bothers me because it seems to imply that first there is pure scientific knowledge and then it is utilized, whereas not only has nursing been done for thousands of years before the emergence of anything like what we would now call science, but where nurses do not find relevant research in other disciplines, they conduct their own. Hence, I prefer to call modern nursing a science-based practical discipline.14 Much of the underlying science is biomedical, but in phenomenological nursing at least some of it is social psychology of a phenomenological sort.15 In any case, it is the scientific foundation in nursing, often called “nursing research,” that can be considered in Schutzian perspective.16 I will focus on Thomas’s analysis of chronic pain to begin with and then come to include women’s anger. “Chronic pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage . . . without a predictable end and a duration greater than 6 months” (Thomas et al., 2000, p. 686); it chiefly includes lower back pain, and it affects about 25% of the population of the USA. Although nurses who have themselves suffered intense pain are more sympathetic, the literature on interaction between chronic pain sufferers and health care providers “documents paternalistic staff stoicism; labeling of patients as difficult, demanding, manipulative, and addicts; and adversarial relationships between patients and care providers” (Thomas et al., 2000, p. 684). Chronic pain is difficult to treat, clients become weary, discouraged, and angry, they are seldom invited to describe their lived experience of it, but of course they are prepared to say a great deal to those who will listen, e.g., “You can’t think about anything else, really.” “Pain is king. Pain rules.” “The pain just rides on your nerves.” “Pain dominates what you can do.” “Pain is a monster. All I can say is that it’s tormenting.” Pain is a formidable opponent with whom they fought daily. “You’re drowning and you got that will to fight to get ashore . . . to live with chronic pain is a challenge every day.” “I tried to outlast it. I tried to just tough it out. But it was boss.” The dyadic nature of the relationship was succinctly captured as follows: “Now it’s me and this pain. It’s a thing. And you’ve got to fight it continuously.” Feelings ran the gamut from irritability, anger, helplessness, and frustration to profound depression, despair, and exhaustion. (Thomas et al., 2000, p. 689)

It seems that the interactions of care givers and sufferers of chronic pain belong on the bottom level I have described in the Schutzian perspective. For this to work, one first needs to consider the nurses as engaged in practical nursing. Besides these actors and partners, there are observers of the interactions of care givers and clients in practical life, e.g., supervisors and trainee nurses. What is happening on this level is meaningful in more or less subtly different ways for such participants and their subjective interpretations can be sought, the clients in common-sense terms or

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constructs and the nurses in relatively professional jargon. The focus in Thomas’s work is on what patients say, they are interviewed apart from their care givers, but it is easily imagined that she also investigate phenomenologically the care givers of chronic pain sufferers. What pertains to the second Schutzian level is the nursing research that some like Thomas undertake. Individuals are selected and interviews of 1–2 hours are conducted, recorded, transcribed, and interpreted by the leading researcher(s) and then also by an interdisciplinary phenomenology research group; “[t]he insights of group members from other disciplines were particularly valuable in assisting nurse members of the group to continuously bracket (set aside) their prior knowledge of chronic pain phenomena” (Thomas et al., 2000, p. 688). Schutz does not mention but also does not preclude such preliminary interdisciplinary critique, presumably because postmodern challenges to the possibility of objectivity had not yet arisen in his time.17 Thomas’s “phenomenological exploration of women’s anger” contains an outline for phenomenological research projects derived from Pollio, Henley, and Thompson,18 that has five methodical steps, each with a different focus (Thomas et al., 1998, p. 314): (1) In focusing on the researcher herself, the first step includes choosing a topic and undergoing a bracketing interview. “Prior to interviewing and data analysis, each researcher took part in a bracketing interview to set aside personal anger experiences, biases and presuppositions about the phenomenon of women’s anger” (Thomas et al., 1998, p. 313). Johnson adds a commentary on Thomas’s pain investigation in which she expresses doubts based on Heidegger that utter presuppositionlessness can be achieved through bracketing as some nurses have understood it in Husserl. Then she draws on The Phenomenology of Everyday Life (Pollio et al., 1997) for a “positive application of bracketing” and recommends, three strategies for guarding against interpreting texts solely from the perspective of the researcher: (a) the researcher should first describe his or her reasons for conducting the research; (b) the researcher should use the participants’ words as much as possible in the interpretations; and (c) the research should interpret some of the texts in a group setting. (Thomas et al., 2000, p. 701)

In response, Thomas defends Husserl against assertions of utter presuppositionlessness, charmingly sketches what happens in meetings of her research group, claims that “bracketing is a dynamic, iterative process in which the researcher repeatedly cycles through reflection, bracketing, and intuiting,” and then describes the bracketing interview: In the bracketing interview, the researcher has been queried about his or her own lived experience and knowledge of the phenomenon. The resultant transcript has been thoughtfully considered by the researcher and the research group before collection of the interview data. Because the bracketing interview has been analyzed within the group at an earlier meeting, group members are acutely alert to a researcher’s tendencies to impose personal meanings onto the data. (Thomas et al., 2000, p. 703)

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Recourse to an interdisciplinary research group is not mentioned by Schutz, who believes the theoretician to be solitary when theorizing but not when presenting results, but it is difficult to see how he would consider it other than helpful. (Similarly detailed renditions of the subsequent four steps of the method adopted by Thomas cannot be offered in the time available.) (2) In the second methodical step the focus shifts from the researcher to the clients or participants whom she interviews. “Participants were asked to describe what it is like for them to live with chronic pain. Following this initial question, the interviewer sought to elicit richer description and clarification of the narrative” (Thomas et al., 2000, p. 688). Similarly, “Study participants were asked to describe times when they became angry in daily life. Interviews were unstructured and used open-ended questions so that predetermined categories of interpretation would not be imposed” (Thomas et al., 1998, p. 313). Twenty-eight pages in The Phenomenology of Everyday Life are devoted to “Dialog as Method: The Phenomenological Interview”; presumably the clients are called participants there because the interview is dialogical. This seems the best summary statement: The questions, statements, and summaries used by the interviewer are designed to evoke descriptions, not to confirm theoretical hypotheses. The most useful questions focus on specific experiences described in a full and detailed manner. The interviewer facilitates the dialogue by employing questions such as “What was that like?” or “How did you feel when that happened?” as well as by incorporating the participant’s own vernacular when asking follow-up questions. It is typically recommended that “why” questions be avoided when conducting phenomenological interviews. Such questions often shift the dialogue away from describing an experience to a more abstract, theoretical discussion. (Pollio et al., 1997, p. 30)

In the Schutzian perspective, however, the interaction between the client and the nurse researcher is different from that between the client and the care giver if only because the nurse researcher has theoretical purposes, but it is still a social interaction. While there naturally are differences between the client’s vernacular and the care giver’s jargon, this seems best suppressed during interviewing. Nevertheless, there is a difference between the subjective interpretation of the experience from inside, as it were, by the client and the “objective” interpretation being developed from outside by the nurse researcher.19 (3) In the third methodical step the focus is on the transcripts of the interviews. These were read separately by the researcher(s) and then also within the research group, a sense of the whole as well as meaning units are sought, and the “thematic structure” presented to the group for a final critique. The thematic structure of women’s anger experience comprises four main elements . . .:violation, confusion, powerlessness and power. Violations such as unfairness, disrespect, and/or lack of reciprocity in relationships, precipitated a building over time of a confusing mixture of hurt and angry feelings. When these feelings were confined within the body, participants reported feeling helpless and powerless. Paradoxically, when angry feelings were expressed, as in an outburst, participants still reported feeling powerless—and very

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alone. Anger also was described as having the potential for restoring personal power and relationship reciprocity. (Thomas et al., 1998, p. 314)

It is under the influence of Merleau-Ponty that the relations of phenomena researched are then related to the body, self and others, and time. (a) Body Much of women’s anger was described as confined within the body, where it was “an undercurrent, day after day.” Terms such as “simmering,” “stewing,” and “festering” were used to describe the internal agitation. One woman described being “all tensed up inside. It’s like everything on the inside is messed up.” The body hurts: “I can tell if I hold anger for awhile . . . my anger takes the form of stress in my neck. . . Its hidden but my body knows” (Thomas et al., 1998, p. 315). (b) Self and Others Underlying women’s anger were views of self as expanding and contracting. As they told their anger stories, participants described themselves as small/ diminished/virtually extinguished vs. expanded/authentic/strong. Additionally, they described an episodic sense of not self or unrecognizable self which they sought to disown. . . . Another aspect of the life-world is other people. Women’s anger is generated within close relationships. The offenders are intimates, not strangers. Women told stories of self and other, encounters of wife and husband, mother and child, friend and friend. They reported being angry when significant others had let them down in significant ways or expected too much from them. Expressing anger added to the distress rather than giving relief because it “breaks the circle” of relationships, in the words of one participant. Describing how she felt after angry conflict with her husband, she said, “I feel real uneasy. . . I don’t feel like I’m really whole. . . as if my happy little circle with him had been broken.” (Thomas et al., 1998, p. 316)

As for pain, Participants generally kept the secret of having a chronically painful condition because they anticipated adverse outcomes if it were revealed. They perceived other people to have pejorative views of pain patients. They expected skepticism and disinterest rather than sympathy and support. Isolation was thematic in all interviews. Dialogue took place between the study participants and their nonhuman tormentor, the pain, more so than with other human beings. Participants described their pain as imprisoning them. For example, they used terms such as locked off, roped off, and caged off. Pain had somehow reset their interpersonal parameters, creating separation and distance from the world and other people, even family members. They felt that they no longer had much in common with others and no longer “fit in.” (Thomas et al., 1998, p. 692)

(c) Time Finally, the article about chronic pain also contains this about temporality:

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L. Embree The chronicity of these patients’ conditions obviously implies a disease process developing and continuing across a span of time. However, the unit of time that was most consequential to study participants was the moment, a diminutive unit but paradoxically also a lengthy, heavy one that does not correspond to customary notions of clock time. The moment contains not only the pain now but also the perceived possibility of an eternity of suffering, taking “pill after pill after pill.” The pain was ever present: “I haven’t had 2 days pain free in 6 years.” “Constant, can’t never get comfortable. Can’t never rest. Can’t do anything.” “Wake up with it, go to bed with it, every time I move, something hurts.” There is no assurance that the agony of this moment will end, the future is unfathomable. Time seems to stop. Life is on hold, its rhythms disrupted. One participant used the world limbo. Another wondered if he would “ever have a life again.” (Thomas et al., 1998, p. 693)

As these excerpts from thematic structures show, there is, on the one hand, the subjective meaning of the phenomena in question for the participant expressed to a great extent in the terms that participants use and, on the other hand, there are terms and an arrangement that comes from the researcher(s) and amount to what Weber and Schutz call “objective meaning,” although it is, as mentioned, also a type of subjective meaning. And plainly this objective meaning is about the phenomena as subjectively meaningful for the participant(s). (4) In the fourth step, the participant is the focus when findings are reported to him or her. This is where Schutz’s postulate of adequacy would apply and, again, it is not a matter of the participant agreeing with the thematic structure developed by the nurse researcher but of whether the terms in which this structure was constructed are intelligible to her or not. (5) The fifth step consists in the preparation of the final report for publication and the focus then is on the research community, which would at least be fellow phenomenological nurses if not nurses in general. Reflecting on the approach thus outlined one can also extract some of the basic concepts of this phenomenological nursing: bracketing interview, care giver, dialogical interviewing, participants, and thematic structure, and also the distinctive method with its five steps. Thus there is Schutzian style science theory possible on this level as well. There is much more to Thomas’s investigations than there is space to convey, but it is hoped that enough has been said to show what phenomenological nursing is and how it can be related to the science-theoretical perspective that Alfred Schutz related to the social sciences, social psychology and marginal utility economics included.

Notes 1. 2. 3. 4. 5. 6. 7.

Thomas and Johnson (2000). Embree (2007). Embree (2004). Schutz (1964). Schutz Papers, 20 October 1955. Embree (2008a). Embree (2008b).

7 8. 9. 10. 11. 12. 13. 14. 15. 16.

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Schutz (1996, cf. p. 203). Schutz (1967, p. xxxi). Schutz (1962, p. 255). Thomas and Pollio (2002). Thomas (2005). Thomas et al. (1998), 28(2). Concerning practical disciplines such as nursing, see Embree (1994). It is my impression, however, that the phenomenological psychology here could be more cultural-scientific. Cf. Embree (2003). Schutz recognizes applied theory but focuses on theoretical science: “Of course the desire to improve the world is one of man’s strongest motives for dealing with science, and the application of scientific theory of course leads to the invention of technical devices for the mastery of the world. But neither these motives nor the results for ‘worldly’ purposes is an element of the process of theorizing itself. Scientific theorizing is one thing, dealing with science within the world of working is another” (Schutz, 1962, p. 245). Whether it is recognized that videotaping could be resorted to in order to access non-verbal behavior in this approach is not clear. Pollio et al. (1997). I would also observe that in some cultures and ethnic groups there are not just the individual participants but also the immediate families that would sometimes need to be interviewed, perhaps collectively.

References Embree, L., (2008b) “A Beginning for the Phenomenological Theory of Primate Ethology,” Journal of Environmental Philosophy, 5(1), Spring. Embree, L. (2005), “Disciplines Beyond Philosophy: Recollecting a Phenomenological Frontier,” Phenomenology, vol. 5, pt. II, eds. T. Nenon and L. Embree (2007) (Bucharest: Zeta Books), pp. 271–282. Embree, L., (2008a) “Economics in the Context of Alfred Schutz’s Theory of Science,” Schutzian Research, vol. I. Embree, L., (2003) “Gurwitsch’s Theory of Cultural-Scientific Psychology,” Husserl Studies, 19: 43–70. Embree, L., (1994) “Introduction: Reflection on the Cultural Disciplines,” In Phenomenology of the Cultural Disciplines, eds. M. Daniel and L. Embree (Dordrecht: Kluwer Academic Publishers), pp. 1–37. Embree, L., (2004) “A Problem in Schutz’s Theory of the Historical Sciences with an Illustration from the Woman’s Liberation Movement,” Human Studies, 27: 281–306. Pollio, H. R., Henley, T., and Thompson, C. B., (1997) The Phenomenology of Everyday Life (Cambridge: Cambridge University Press). Schutz, A., (1964) Collected Paper, vol. II, ed. Alvid Brodersen The Hague: Martinus Nijhoff. Schutz, A., (1962) Collected Papers, vol. I, ed. M. Natanson The Hague: Martinus Nijhoff, p. 255. Schutz, A., (1996) Collected Papers, Vol. IV, ed. H. Wagner, G. Psathas, and F. Kersten, Dordrecht: Kluwer Academic Publishers, p. 121. Schutz, A., (1967) The Phenomenology of the Social World, trans. George Walsh and Frederick Lehnert, Evanston, Ill.: Northwestern University Press, p. xxxi. Thomas, S. P. and Johnson, M., (2000) “A Phenomenologic Study of Chronic Pain,” Western Journal of Nursing Research, 22: 699. Thomas, S. P. and Pollio, H. R. (2002) Listening to Patients: A Phenomenological Approach to Nursing Research and Practice, New York: Springer Publishing Co. Thomas, S. P., (2005) “Through the Lens of Merleau-Ponty: Advancing the Phenomenological Approach to Nursing Research,” Nursing Philosophy, 6. Thomas, S. P., Smucker, C., and Droppleman, P., (1998) “It Hurts around the Heart: A Phenomenological Exploration of Women’s Anger,” Journal of Advanced Nursing, 28(2).

Chapter 8

Zaner’s Generative Spirit John R. Scudder, Jr. and Anne H. Bishop

Richard Zaner’s creative work evokes generative thinking and ways of being in others. What is generated does not only occur as part of the original encounter but continues to generate well beyond it. Dick became our mentor at a crucial time in the development of our work together. Anne, an experienced and recognized nursing educator, was very interested in pursuing the meaning of nursing but did not know how to go about it. Jack, a philosopher, was interested in ferreting out the meaning of caring practices but with little or no experience in or knowledge of health care practices. Dick helped us to see how our experiences and concerns could be brought together in a quest to make sense out of nursing. He contributed directly to our work through his interpretation of health care and its ethics. Dick’s generative way of thinking and of being has fostered our thought concerning the meaning of being a good nurse and beyond that to the meaning of being and becoming a good person.

1 Generative Interpretation We began our dialogue with Dick concerning health care when we sponsored a conference at Lynchburg College on the relationships between physician, nurse, and patient and asked Dick to speak for the patient. Later, he thanked us for asking him to take the perspective of the patient, because it greatly affected his thought. Fortunately, it also has affected ours. From that time to the present, we have engaged in an intermittent dialogue with Dick by phone, mail, and direct personal encounters. Dick generates our thinking and writing directly by insightful suggestions. When we were working with him on the troublesome conclusion of the manuscript of our first nursing ethics book, he suggested a solution that has affected the way we have written ever since. He had noticed that our work grew out of our dialogue and then was translated into a linear style for publication. He asked, “Why don’t you conclude J.R. Scudder, Jr. (B) Professor Emeritus, Philosophy Lynchburg College, Lynchburg, VA, USA e-mail: [email protected]

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the book with a dialogue between the two of you that explores the ethical meaning of your approach to nursing?” We followed his suggestion and discovered the strength in writing dialogically. Rather than the “one” voice of impersonal or even “we” writing, we were able to speak with two voices – man and woman, philosopher and nurse, but, more appropriately, as just Jack and Anne. On one occasion we engaged in dialogue as Jack and Anne before an academic audience, most of whom knew us well. They encountered not the voice of “one,” not of two familiar scholars, and not even of “we” but of Jack and Anne with their own style and their own views in spirited encounter. The audience broke out in enthusiastic applause and hilarious laughter. Later, we turned toward each other and whispered, “Dick made us do it!” Dick did, however, point out that in treating human relationships, we tended to overstress dialogical encounter and understress Schutz’s we-consciousness. Dick helped us to understand how we-relationships could be intimate and evocative. In we-relationships, according to Dick, we attune to each other to reach a unity and a harmony in which, as Schutz says, “we make music together” (Zaner, 1981, 236). Dick discloses how making music together can reach out beyond harmony. That harmony, according to Dick, will “evoke that wonder over and at ‘our’ common endeavor of working together” and we will experience “a kind of ‘depth’ and . . .‘warmth’ ” (236). The warmth and depth of we-relationships leads us beyond our present relationship with “promises of the ‘still to come’ ” (237) and helps us become more fully ourselves. “The time and space of love, of friendship, of caring, is a time and space at once ‘far’ yet ‘close’: The ‘near’ and the ‘warm’ which are yet something which ‘go beyond’ us, are ‘deeper’ than us. . . . Thus do we prize our love, our friendship, ‘beyond’ even ourselves. For thanks to it. . .‘I’ am fully myself, within the relationship itself wherein ‘you’ are fully yourself” (237). Thus, Dick, as he often does when considering health care, leads us to consider the broader concern of what it means to be a good and fulfilled human being. In following Dick’s suggestion that we think together about the meaning of ethics for our philosophical interpretation of nursing, we found that his clinical approach to ethics spoke forcefully to the nursing ethic we were trying to develop. In his clinical ethics, ethics is intimately connected to the practice of good health care. We had tried to show this in our interpretation of nursing having a moral sense. The primary concern of nursing ethics, in our approach, is to fulfill the moral sense that is inherent in nursing practice. This approach often raises the issue of why ethics and ethicists are needed in health care. We were directly confronted with this issue after reading a paper on our interpretation of nursing ethics at a humanities conference in the Netherlands. A physician came up to us afterward and said, “I really appreciate your interpretation of nursing, but I can’t find a specific need for an ethicist in your approach.” We responded that we doubted that a physician like himself would need an ethicist. He had come all the way from South Africa to the Netherlands to participate in the humanities conference. We observed that we had met few physicians who had the humanistic and moral understanding of health care that he had. We believe, as he

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did, that the primary contribution an ethicist or ethics should make is to help others recognize and pursue the moral sense of their practice. We recognize that ethicists can be especially helpful in cases where physicians or nurses need greater moral understanding than they usually possess. However, the primary function of ethics and ethicists is to help health care professionals recognize and pursue the moral sense of their profession. Dick’s philosophy has helped us interpret nursing as it is practiced rather than how it is projected from a particular philosophy. For example, Dick’s interpretation of the autonomous self made evident the danger of nurses uncritically accepting the current stress on autonomy in nursing literature. The autonomous self is closed in on itself and can think only its own thoughts and its feelings (Zaner 1988, 188). It has no direct experience of others, only sensory information from others that must be reflected upon before its meaning can be grasped and then translated into another form of experience, usually called an intervention. This interpretation of autonomy would make nursing as it is practiced impossible. It eliminates the direct, immediate communication between patient and nurse that is commonplace in and essential to nursing care. His interpretation generated the following response from us. If a nurse can only infer meaning from a person’s bodily movement rather than grasp the meaning from the body’s expressiveness, nursing practice would certainly have to be altered. Imagine trying to turn a patient on a bed with efficiency and care to avoid unnecessary suffering if each grimace, body tension, grunt and moan, was to be taken as a sign from which to infer what was going on inside the body and then be correlated to the appropriate technique inferred from each sign. Instead, most nurses immediately recognize what the patient’s bodily expressions mean and move him appropriately drawing on long years of practical experience. (Bishop & Scudder 1990, 126)

Generative interpretation is different from applied philosophy. We did not apply Dick’s interpretation of the autonomous self to nursing but interpreted nursing in light of his interpretation. Its significance for nursing comes not from the authority of Dick’s philosophical scholarship but from the way that his interpretation enlightens the meaning of nursing for those actually involved in practice.

2 Caring Presence Dick made important contributions to our understanding of caring presence. In interpreting caring presence, we had appropriated Nel Noddings’s interpretation of caring as engrossment and motivational shift on the part of the caregiver. Dick helped us to recognize that a more adequate interpretation of nursing care requires understanding the patient’s perspective as well as that of the caregiver. This was made evident to us in his treatment of vivid presence, co-presence, availability, and empowerment (Zaner 1981, 229–238). Following Dick’s example, we will disclose, with concrete examples, how these ways of caring affected our interpretation of caring presence in nursing.

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2.1 Vivid Presence In one lady’s room, I casually asked how she was doing with her dinner. . .We said a few words and as I was on my way out the door, she said she probably wasn’t very hungry because her chest was “tight.” I was busy but stopped in my tracks and asked her to tell me about this “tightness.” The “tightness” turned out to be chest pain radiating to her left arm. I immediately told the charge nurse who called the physician who ordered oxygen and a medication. . . . (Bishop & Scudder 2001, 58)

The patient’s comment that she experienced tightness evoked vivid presence from the nurse. She, in turn, helped the patient become vividly present to her own body. This enabled the nurse to recognize impending danger and to act on the patient’s behalf. Dick’s concept of vivid presence helped us to grasp the meaning of this encounter between a particular nurse and patient in a way that alerts nurses to the importance of vivid presence in patient care.

2.2 Co-presence Co-presence is different from vivid presence between particular individuals, who are reciprocally related to each other, in that co-presence refers to a mutual relationship in which partners understand each other and share intimacy. Co-present relationships enrich nursing care, as the relationship between nurse Beverly and her patient, Midori, makes evident (Bishop & Scudder 2001, 60). Midori and Beverly faced Midori’s impending death together. They sat in silence with tears streaming from their eyes. Midori spoke first by proclaiming that she wanted to die at home with her family’s not knowing of her impending death. She confessed to Beverly that she felt selfish, asking her to share her burden. Beverly responded by affirming her worth and strength. Later in the day, Beverly returned to wash Midori and take her for a walk. As she washed Midori, she could see her reflection in a mirror. Midori looked weak and helpless, her body constantly straining to stay alive. Beverly knew where in the huge sprawling hospital in the middle of the city there was a place of peace and beauty that Midori would appreciate. A large window that overlooked the busy city in the daytime came alive with flickering lights in the twilight. When Midori absorbed the view in front of her, she commented, “How beautiful!” Beverly held her gently, affirming her love and concern for Midori. Midori, for a moment, forgot her illness and, then, thanked Beverly for helping her through this crucial time of deciding how to spend the last few days of her life. Midori had helped Beverly see nursing in a new way. She realized that the tasks of nursing had come to define her practice. Caring for Midori had shown her “what it really meant to be a nurse” (Dyck 1989, 825). In this case, the patient’s life is enriched through co-presence with her nurse and the patient helps the nurse discover the meaning of her own profession.

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2.3 Availability and Empowerment In Beverly’s relationship of co-presence with Midori, she affirms her availability, and Midori willingly avails herself of Beverly’s care. Through their relationship of co-presence, Beverly empowers Midori to leave the hospital and return home to die with family and friends. In this case, the one cared-for experiences the caregiver as being available and empowering, as Dick contends.

3 Use of Concrete Examples Dick’s two books (Zaner 1993, 2004) that focus on concrete cases help health care professionals to recognize and foster the moral sense of their practice. In these books, Dick moves from clinical cases to the ethical and philosophical meaning made evident by his interpreting and re-interpreting cases. He uses cases that have intrigued him by their disclosure of various shades of ethical meaning and of moral possibilities. Comparing his interpretation of clinical cases that appear in his earlier book with those in his second book discloses how his understanding of those cases has led him to more a more adequate grasp of health care ethics. This may sound strange to those accustomed to beginning with philosophical norms and applying them to clinical cases, but it makes a great deal of sense to those of us who begin with the practice itself as present in concrete care, as we have done in our treatment of nursing ethics and philosophy. It would be overstating the case to say that Dick made us do that, but it is certainly true that Dick encouraged us to cultivate that way of interpreting nursing by helping us learn how to ferret out meaning from concrete experience. One example that we have used many times is the relationship between Beverly and Midori that we have already briefly interpreted. Another is the example of Margie and Mrs. Cooper. We will re-examine this example at greater length here in order to disclose how nursing ethics usually involves continual care of a patient over time in interaction with other caregivers. For this reason, once and for-all solutions to ethical questions or dilemmas, such as “to-treat” or “not-to-treat” or when to pull the plug, are rarely appropriate for nursing ethics. Over a 5-week period, Margie worked with Mrs. Cooper to try to get a satisfactory prosthesis for her. Mrs. Cooper already had a prosthesis for one leg but it fit poorly and had out-lived its usefulness. She entered the hospital to secure a prosthesis for her other leg that had been recently amputated. The physician and others had decided that she was not a candidate for prosthesis and should be placed in a wheel chair. Margie and others had observed that Mrs. Cooper, in spite of her age and some disorientation, was very capable of obtaining objectives, such as walking. Margie worked for weeks to build a consensus that eventually persuaded a reluctant physician that Mrs. Cooper needed a prosthesis for her missing leg rather than a wheelchair. When she gained her new prosthesis, Mrs. Cooper had difficulty

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walking with her worn out inadequate prosthesis on the other leg. Again, Margie worked to convince others to finally get a replacement for the worn out prosthesis. A physician in consultation with a physical therapist made the original “to-treat” or “not-to-treat” decisions concerning Mrs. Cooper. When Mrs. Cooper was given new adequate prostheses, Margie and others worked together to teach Mrs. Cooper how to walk again. Obviously, for Margie, this was not a “to-treat” or “not-to-treat” decision but a continued effort over time to foster Mrs. Cooper’s well being. It is note-worthy that Margie was in no position to make “to-treat” or “not-to-treat” decisions, as is usually the case in nursing. Her moral endeavor involved interaction with many people over time. It involved vision, effort, and steadfast patience rather than a single decision concerning whether or not to treat Mrs. Cooper (Smith 1993, 43–44). The use and reuse of clinical examples by Dick shows how depth of understanding concerning practice and its human meaning can be gained by reexamination of concrete cases. One of Dick’s examples that often has appeared in our work on ethics is the example of Tom. This is an example in which Dick challenges a treat or not to treat ethical decision by working with a patient and others over time, as was the case with Margie. This example helped us to see more fully why clinical ethics is more adequate than applied philosophical ethics for interpreting health care ethics. Dick actually had shared the example of Tom with us prior to his publication of Troubled Voices (1993). Tom, in his late twenties, had been hospitalized numerous times for various problems. He had been born with spina bifida, making him paraplegic and hydrocephalic. With all his other problems, “his kidneys had begun to fail. . . . He staunchly refused to have dialysis. . . . Within a few days, the poisons inevitably built up and dialysis was seriously needed.” When Tom’s physician was out of town, the physician covering decided that Tom’s refusal of dialysis was the result of temporary incompetence and ordered dialysis. When the attending physician returned, Tom “was alert once again – the dialysis had, after all, done its thing – and very disturbed at being forced to have dialysis. In fact, he continued his adamant refusal of any further sessions with the dialysis machine. . . . He said that he had had enough; in fact a lifetime of enough.” When Dick counseled with Tom and his mother, he led him to face issues that he had not faced adequately. “Did he understand the implications of his refusal of dialysis? . . . The thought that he would die without dialysis had, so to speak, sort of sidled past his awareness now and then, but he had not confronted matters squarely. . . . “Trying to learn more about Tom personally, I asked him about his job, one which he obviously enjoyed and in which he took some pride. The numerous illnesses and hospitalizations had eventually required him to quit his job, which more than anything else seemed the source of his depression. He had it all “figured out”: on dialysis he would not be able to hold a job, much less go back to the one he really liked – ergo, life ain’t worth it, so let’s just give up.”

“How can I work when I’ve got to be on that damned machine so much?” Tom asked Dick. Dick asked Tom if he had discussed with his doctor how dialysis would affect his work. Dick suggested that Tom needed to find out much more about

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dialysis and to talk with his former supervisor about the prospects for returning to work. When Tom became aware of the possibility of continuing the work he had found so rewarding, he was willing to continue dialysis. He did, in fact, go back to work at his old job and later when Dick talked with him, he found him “very upbeat, joshing about the machine, joking with his nurse, and offering to come to one of my classes and talk about himself” (Zaner 1993, 47–55). Dick makes evident the inadequacy of the physicians’ treatment of Tom’s case on the basis of whether “to-treat” or “not-to-treat.” He challenged their approach by asking a series of questions that had haunted him. “When Tom first expressed his refusal to undergo dialysis, shouldn’t that have had priority? Did his decline into renal psychosis change the competency with which he chose that condition? The decline, after all, was exactly what one would expect to occur. Within a day or so, he would have lapsed into an irreversible coma and then died. Wasn’t this what he had chosen?” (Zaner, 1993, 55). A fortuitous lack of communication between two physicians kept his decision from being honored, denied his rights, and prevented his death. Dick approached Tom’s case by raising the issue of what would make Tom’s life meaningful enough to endure dialysis rather than raising the issue of “to treat” or “not to treat” based on patient’s rights. Through dialogue with Tom, he discovered that he did not want to end his life but wanted to continue a life that had become, for him as a result of his job, independent and normal enough for him to be happy. For Dick, medical ethics concerns more than whether to treat or not to treat. It concerns “what and who we are, what we hope to be and become, even whether we will continue to be at all” (Zaner, 1993, 137). Reflecting on Dick’s care for Tom helped us recognize that Dick’s clinical ethics spoke more forcefully to nursing ethics than the applied ethics approach that stresses making once-and-for-all decisions concerning big problems. We have attempted to develop an ethic that speaks to how nurses become moral beings through their practice. Nurses rarely face big once-and-for-all decisions like “to-treat’ or “not-to-treat” or whether to pull the plug. Most of the moral concerns of nurses have to do with decisions concerning the way they care for patients day to day. The close and often intimate relationship between nurse and patient is such that it is not difficult to imagine a nurse doing what Dick did to help Tom. Note how similar Margie’s persistent attempts to foster Mrs. Cooper’s well being is to that of Dick’s work with Tom when he was faced with a “to-treat” or “not-to-treat” approach to ethics. Working with Dick, and especially with the example of Tom, made us so aware of the integral relationship between therapeutic care and ethical care that we subtitled our first book on ethics, Therapeutic Caring Presence (Bishop & Scudder, 1996). We came to recognize that therapeutic ethics did not adequately convey the meaning of ethics as integral to health care. Even though we suspect that Dick had similar misgivings, we actually abandoned therapeutic caring ethics because it failed to convey our interpretation of nursing as holistic caring practice. When we sub-titled our revised edition as Holistic Caring Practice (Bishop & Scudder, 2001), the change

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was more than a semantic one. Actually, our re-interpretation placed nursing ethics in such a different context that we consider it as almost another book on nursing ethics. Ethics is an integral part of health care when that care is given holistically to whole persons, as in the case of Tom. Our new subtitle indicates that we now place nursing ethics in the context of our major interpretation of nursing as the practice of caring, an interpretation that has been much influenced by Dick. His generous way of being has encouraged and supported us in our quest to develop a nursing ethic that speaks to nursing practice. His examination of medical cases to disclose ethical meaning helped us to ferret out the ethical meaning in nursing practice. He has shown us how the fundamental concerns of all human beings are evident in ethical considerations of concrete cases.

References Bishop, Anne H. and Scudder, John R. (1990). The Practical, Moral, and Personal Sense of Nursing: A Phenomenological Philosophy of Practice. Albany, NY: State University of New York Press. Bishop, Anne H. and Scudder, John R. (1996). Nursing Ethics: Therapeutic Caring Presence. Sudbury, MA: Jones and Bartlett Publishers. Bishop, Anne H. and Scudder, John R. (2001). Nursing Ethics: Holistic Caring Practice. Sudbury, MA: Jones and Bartlett and National League for Nursing. Dyck, B. (1989). “The Paper Crane” American Journal of Nursing 89(6): 825. Zaner, Richard M. (1981). The Context of Self. Athens, OH: Ohio University Press. Zaner, Richard. (1988). Ethics and the Clinical Encounter. Englewood Cliffs, NJ: Prentice Hall. Zaner, Richard. (1993). Troubled Voices: Stories of Ethics and Illness. Cleveland, Ohio: Pilgrim Press. Zaner, Richard M. (2004). Conversations on the Edge. Washington, D.C.: Georgetown University Press.

Chapter 9

Integrity and the Moral Gestalt: Zaner Tells his Mother’s Story Festschrift for Richard Zaner Denise M. Dudzinski

Richard Zaner is brilliant and eccentric. When I first met him in the early 1990s, he wore purple spectacles like some beloved wizard from Harry Potter. He is something of a wizard, in fact. I studied clinical ethics with Dick while pursuing my Masters in Theological Studies and doctoral degrees at Vanderbilt University. I quickly learned that, unlike some philosophers who are dismissive of theological argument and reflection, Zaner relished the opportunity to both understand theological perspectives and to coax us to unpack our taken-for-granted values. What made him such a remarkable mentor was that the philosophical questioning and debate embodied and enacted his genuine care for us. Dick’s teaching became a way to nurture each of us in our unique circumstances. He asked us to excavate our deepest commitments, both for the intellectual honesty that such an exercise demands and in recognition of our own vulnerability and the vulnerability of the patients and families we would meet. There were many “clinical philosophy” seminars when grief welled as I relayed stories of complex vulnerabilities (including my own) arising from an ethics consultation. Dick and his colleagues, Mark Bliton and Stuart Finder, did not shield us from this grief, sadness, or confusion. Rather they sat still as we underwent it—a profound enactment of trust, friendship, and love. They did for us what we ideally do for those who seek the help of clinical ethicists—they listened attentively, probed boldly and compassionately, and believed that our responses were genuine. The greatest commitment we made to one another was to endure, not to leave, to persist in uncertainty, confusion, helplessness, and burgeoning competence. We were and still are close colleagues. Zaner’s approach to clinical ethics is demonstrated in narratives of his mother’s death. Both exemplify integrity but in different ways. Zaner narrates his mother’s death on two occasions, first in Ethics and the Clinical Encounter (1988) then in Conversations on the Edge (2004). As I will outline here, these stories demonstrate D.M. Dudzinski (B) Department of Medical History and Ethics, School of Medicine, University of Washington, Seattle, WA, USA e-mail: [email protected]

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his commitment to a phenomenological approach to clinical ethics and illustrate many of the philosophical arguments he has made throughout his career including his phenomenological orientation to integrity.

1 Integrity In working with Zaner as a graduate student, a theme emerged in his work that resonated with me—the meaning of integrity in both phenomenological and normative senses. In Context of Self, Zaner describes integrity in a phenomenological sense by explaining Aron Gurwitsch’s notion of gestalt. Gurwitsch writes, “By ‘gestalt’ is meant a unitary whole of varying degrees of richness of detail, which, by virtue of its intrinsic articulation and structure, possesses coherence and consolidation and, thus, detaches itself as an organized and closed unit from the surrounding field” (1964, p. 115). Integrity in a phenomenological sense, concerns the relationship between wholes and parts. Gurwitsch’s notion of gestalt is comparable to definitions of integrity as undivided or unbroken, wholeness, completeness, without any part or element taken away or wanting (Dudzinski 2001, p. 24). Drawing from the work of Aron Gurwitsch, Zaner explains “contexture”, another term describing whole-part relationships that explains why certain themes emerge as prominent within a field of perception. “The ‘whole’ is neither a ‘sum’ . . . nor reducible: it is exactly the system for mutually interdependent and interdetermined constituents”, therefore the whole is autochthonous (Zaner, 1981, p. 80). In other words, a perception is perceived as a whole, with certain features (called themes) emerging more prominently and holding greater functional weight than others (called fields or margins). Gurwitsch writes that “there prevails the particular relationship of Gestalt-coherence defined as the determining and conditioning of the constituents upon each other. In thoroughgoing reciprocity, the constituents assign to, and derive from, one another the functional significance which gives to each one its qualification in a concrete case. In this sense, the constituents may be said to exist through each other . . .” (1964, pp. 134–135). In addition, the theme itself has integrity. Gurwitsch notes that there is an intrinsic intra-thematic structure to the theme (the gestalt-contexture) such that all the constituent components are dependent on one another within the theme (Field 132ff). The relationship between wholes and parts constitutes integrity in a descriptive sense. The person, lets say a patient in a hospital bed, who is the focus of our attention is an enduring unity and has an enduring identity—the parts are recognized as a unique whole over time and under myriad circumstances. Hence, the patient has integrity. In addition, “the patient [matters most as you walk into her room for the first time] not only because you are interested in her as you enter (what Edmund Husserl terms the noetic correlated of the act of consciousness) but also because she captivates your attention (the noematic correlate). [She] is a vulnerable person demanding your notice” (Dudzinski 2001, pp. 44–45). The integrity of your interactions with her depends on respecting her as the center of the moral experience.

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Zaner has written about this in almost everything he has published and it is one of the most important lessons I learned from him. From the standpoint of a clinical ethics consultant, the features of an ethics consultation that draw one’s attention become the theme, and in most instances the patient is thematic. Other aspects of the case (a term for the broader clinical gestalt), while constituting dimensions of the integrity of the situation remain marginal to the patient’s experience or gain significance by virtue of their relationship with the patient. To some degree the integrity of an ethics consultation is related to how the consultant has thematized and investigated features of the case. Influenced by his work in clinical ethics, Zaner extends Gurwitsch’s analysis beyond sensory perception to investigate the gestalt-coherence of embodiment and of moral experiences. Consider Dick’s description of walking into a frail elderly patient’s room. Notice that his description has moral weight because the patient is thematized without jumping too quickly to a normative analysis. In her room, I notice straight-away that everything in the room is arranged in very specific and powerful ways with respect to her. She is the center, everything in the room is there for her, she is the focus of all the equipment, activity, procedures, and for anyone who comes in (nurses, doctors, family, visitors). To walk into such a person’s room is a kind of decentering: here, “you” and “I” matter far less than she. Talk thus centers on and around and regarding her: she is “that-with-respect-to whom” the room is organized at this moment (even while the “same” room will of course be used later by others – who will then also be the centering/de-centering presence). Though unable to talk at first, any talk, even small talk amongst those present in her room, is alerted to and even governed by her presence. What’s going on? What’s wrong? How long will she be this way? What can be expected to happen next? Is there anything we can do? (2000, p. 267)

Zaner’s description resonates with the uninitiated student. The description comforts new students. Even seasoned professional can be shaken and poignantly affected by merely entering a patient’s room. But even more remarkable is that Zaner maintains this fresh perspective twenty plus years into his clinical ethics career. The expert’s sense of “oh, I know what kind of case this is” never shows up in Zaner’s writing, because to do that would be to subjugate the patient to the philosopher’s analysis—which is extraordinarily disrespectful. What Dick taught with subtlety is that when the patient’s vulnerability grabs your attention but you refrain from lingering there for long (say, because it is painful to see her suffer), then you may have failed the phenomenological test of integrity. The theme is the “organizing center” of the experience (a descriptive claim about integrity). When the gestalt-coherence of a situation is determined by the patient and we shift our attention elsewhere, this says something about the integrity of the consultation or about the consultant, more than about the gestalt-coherence of the moral encounter. Reflective of his commitment to integrity—to the particularities of each individual case—Zaner is wary of pat “methods” or depersonalizing tools for clinical ethics consultation because of the risk of imposing philosophical themes instead of allowing the theme emerge (1993). Neglect the emerging “whole” in all its richness and complexity and one commits a phenomenological transgression by

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denying that moral experience is already ordered. It is up to us to discover the order, not superimpose our own. Unlike many other approaches to ethics consultation, where the focus is on the intellectual interpretation of a situation, Zaner taught us to be still and observe when we are afraid, apprehensive or sad, because ethics consultations inevitably evoke such feelings. Zaner, by modeling a phenomenological method, taught me that the emotional and experiential undergoing, so profound in clinical ethics, is as important as the intellectual scrutiny that follows. Zaner’s methodology never segregates the emotional, intellectual, and moral. We undergo them together. After the undergoing, we ‘bracket’ aspects of experiences in order to provide cogent analysis. The way he tells his mother’s story demonstrates the fusion of emotional and intellectual.

2 Phenomenological “Method” in Clinical Ethics So what is Zaner’s method? The demand to stick rigorously to the “things themselves” in their own integrity. . . cannot be shunted aside. Without such a notion, one illicitly denigrates the phenomenon either by reductivism (effectively losing precisely what is to be accounted for, by taking it as “really” composed of something ‘lower’) or by a kind of elevationism (taking all things as merely approximately realizations of some “higher” reality, and thus sucking away its very integrity). (Zaner 1981, p. 68)

The commitment articulated above was enacted in every teaching, clinical, or personal encounter I have ever had with Richard Zaner. He embraces Edmund Husserl’s notion of phenomenology, “a ‘scientific self-examination on the part of transcendental subjectivity’ . . . the philosophical discipline of criticism and selfcriticism, carrying out ‘the most extreme radicalness in striving to uproot all prejudice” (1973, p. 197). Likewise he describes phenomenology as “a leading back to origins, beginnings, which have become obscure, hidden, or covered over by other things” (1975, p. 126). As a pre-eminent phenomenologist, he infected me with a desire to describe the complex “thing in itself” that in our work is so often the patient’s well-being in light of an ethical dilemma. In Ethics and the Clinical Encounter, Zaner posits three theses that reflect his allegiance to a phenomenological method. First, “the work of ethics requires strict focus on the specific situational definition of each involved person” (1988, p. 243). Here he refers to Alfred Schutz’s notion of the “subjective interpretation of meaning” whereby one tries to “get at” the way each person involved understands the situation and “endow its various components with sense and meaning” (1988, p. 243). He implores us to be genuinely sympathetic, which means being willing to suffer personally with the weight of another’s grief, despair, and confusion. Consequently his philosophy teaches compassion. Second, “moral issues are present solely within the contexts of their actual occurrence” (1988, p. 244). So by carefully listening and probing, the ethics consultant attends to what is troubling or worrying people, what previous experiences tie in to

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how they feel about this situation, and the impact of setting and circumstance on each person’s perception of the state of affairs. As we will see in Zaner’s accounts of his mother’s death, the fact that an extraordinarily important conversation about his mother’s wishes took place in the setting of the emergency room (ER) impacts the tenor and content of the conversation. Third, “the situational participants are the principal resources for the resolution of the moral issues as presented” (1988, p. 246). Zaner has long distinguished the “moral authority” of ethics consultants from the authority to provide competent ethical analysis in order to inform the decisions made by those with most at stake (patients, health care providers, families, etc.). Those who are most deeply impacted have moral authority and only rarely the ethics consultant (unless the consultant is a patient’s family member, as Dick was in the stories about his mother).

3 Telling Stories of His Mother’s Death In Ethics and the Clinical Encounter, he tells his mother’s story to illustrate his phenomenological method and instruct on its employment in clinical ethics. “For an ethics seeking to be responsive to the actual contexts in which moral issues occur, it is all the more imperative to be fully cognizant of the entire range of facts and interpretations (by each of the participants), as well as the fears and hopes vested in decisions and the aftermath of these decision” (1988, pp. 224–225). In 22 pages, he describes the predicaments faced by his mother and her two sons without revealing that he is one of the sons depicted in the story. In Conversations on the Edge, Zaner retells the story, revealing that the story is about his mother. This story has richer detail and dialogue. Zaner writes, “The story about my mother’s final moments— “The Cruel Clarity of It All” —first appeared as part of a chapter in my earlier book . . ., but I identified neither myself nor my mother, and many details vital to the story presented here were not in the earlier version. I retell it now for many reasons, mainly having to do with my dogged efforts to get it right, so I could work through my guilt and make peace with those troubled and still troubling events” (2004, p. xii). Here are the stark details of his mother’s story. His mother was 74 years old, widowed for 10 years with two grown sons, her eldest living nearby. Dick lived far away. After a difficult recovery from diverticulitis surgery years prior, she developed serious arthritis, causing pain “in every joint”. Treatments either caused severe stomach pain or unbearable side-effects such as shingles. She suffered from emphysema and asthma, and her labored breathing impacted even the most mundane affairs (bathing, walking, dressing, driving). She gradually grew withdrawn, morose, isolated, bitter, and dependent and could no longer recognize the intelligent, outgoing, independent, and caring person she had always been. This unwitting transformation humiliated and upset her. Eventually she could only move from bed to couch to watch TV and had trouble preparing food for herself. She was dependent on portable oxygen and a wheelchair. Independence was one of her most precious values, but now she faced

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and dreaded moving to a nursing home after attempts to live with Dick’s brother were unsuccessful. Having nursed her mother, father, and husband at the end of their lives, she began to dread dying but welcomed death. One morning at the nursing home she was found comatose and barely breathing. After being released from the intensive care unit, she declared that she never wanted to have “those damned machines [ventilator] hooked up to me again, ever” (1988, 227). Dick, his brother, and her physician supported her in filling out an advance directive to refuse “mechanical or artificial means” that would postpone or prolong her dying. Small improvements were met with more setbacks, such as a fall that led to a successful hip replacement. Her mood and ability to care for herself deteriorated, until she became known as a “griper and whiner” at the nursing home. Once again she was found comatose taking shallow and infrequent breaths, and the nurse noticed that the portable oxygen unit had been turned down. She was rushed to the hospital. Dick’s brother arrived at the hospital with her advance directive in hand and was met with hostility and fear by the ER doctor and nurse. Such directives were relatively new; so although they were legal, they were met with skepticism by hospital staff, who, after being confronted by Dick’s distraught brother, insensitively and defensively asked if he wanted to “kill” his mother. When Dick arrived, she was intubated awaiting further tests, and Dick defended his mother’s right to authorize withdrawal of treatment through her advance directive. The doctor, disdainful and fearful of “ethics”, said that since he had already intubated her when the directive was presented, he felt medically and legally obligated to run tests over the next 24 hours before he would be medically certain and therefore willing to withdraw the ventilator. Dick insisted on a neurological consultation, which confirmed massive irreversible brain and brain-stem damage. When the news came in, Dick was alone at his mother’s side. Dick consented to remove the ventilator. He witnessed his mother’s death (1988, pp. 224–242, 2004, pp. 111–141). Zaner writes that his experiment with narrative began in the 1990s (2006, p. 656) but Ethics and the Clinical Encounter was his opportunity to test the waters. He had not, in 1988, embraced the full force of storytelling as a scholarly activity and his way of telling the story resembles the third person accounts seen in medical and bioethics literature. But even then, his penchant for detail made him a rebel. Twenty-two pages of description and analysis exemplifies the rich detail that he long admired and required of himself and his students. In Ethics and the Clinical Encounter he tells his mother’s story as an ethics consultant, not as a son. He is allowed to make this choice because he is both and because we do not require that ethics professors confess in their scholarly writing. It is often appropriate to describe those elements of a consultation which help to highlight the philosophical and pedagogical issues, to analyze from a third party perspective, and to draw lessons relevant beyond the particularities of a particular case. And, as he has said repeatedly, every professional clinical encounter is his story too, since the primary datum is his subjective experience. Perhaps we could see the evolution to narratives coming, given his commitment to phenomenology and the subjective lived experience. Clearly his stories capture the wonderment and perplexity he evoked when adopting Husserl’s epoche, the

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conscious bracketing of the “natural attitude” (the way we engage the world in day-to-day life in which the independent existence of objects, for example, is taken for granted and unexamined) so that one can describe the first-person experience (the noetic) without simultaneously making assumptions about the truth or accuracy of objects of one’s experience (the noematic). This requires a certain honesty and abandon, which we see in his personal stories. Zaner’s copious use of quotations in both accounts demonstrates this commitment. In the first account, he inserts his mother’s words, “why keep up this total charade of life? I’m now . . . the very sort of person I despised, and I can’t seem to help it . . .” (1988, p. 225). While he has already described her as objecting to finding herself “morose, depressed, and bitter” (1988, p. 225), the quotations bring credibility and clarity to the latter description. Not surprisingly, in the clinical arena such quotes are sparse but tend to circulate widely when documented in the medical chart. Zaner makes this very point in “The Cruel Clarity of it All”. “This, [his mother] told her nurse one day—sufficiently impressed by it to make a note of it in her chart—is simply intolerable, just unbearable” (2004, p. 115). In both stories, his mother’s experience of having lost herself and suffering terribly as a result, is the theme of the moral gestalt. Both depict the crisis of corporeal integrity, the sense of bewilderment, loss, and grief that many patients face. Zaner has written extensively on the subjects of embodiment and illness (Cf. Zaner 1979, 1981, pp. 1–107, 1984, 1994). Two themes predominate. First, illness is a crisis of corporeal integrity, a breakdown of one’s sense of oneself. It evokes fear and a sense of being fractured, uncertain, naked, vulnerable, and isolated. “Intrusive and unwanted, illness seems a capricious irruption of our ongoing lives. Marked by a sense of urgency, it presents an underlying threat of compromise and loss. . .” (2000, 267). But Zaner notes that even in illness, there is a wholeness and integrity to the lived experience. In illness as well as in health we experience our bodies as both intimate and alien; however both are experienced more painfully, surprisingly, and acutely when we are ill. In “The Cruel Clarity of it All”, Zaner recounts a conversation with his mom encouraging her to audiotape letters to him. “She said she’d try, ‘But I’m not sure I can even push that button there’, she complained” (2004, p. 117). This is a common but profound example of how her body went from enabling the independent life she cherished to isolating her in a nursing home without the ability to easily move from bed to couch, turn off the television, or simply press a button that connect her to her son thousands of miles away. Every description points to his mother feeling trapped, isolated, and burdened. Although this is a common experience among those facing serious illness, shared experience does not lessen the sadness of solitude and isolation. In describing “clinical-liaison ethics”, he states that it must be “capable of refined description, interpretation, and thematic judgment regarding each of the complex components of clinical situations” (1988, p. 267). He then transcribes part of the tape that his mother made as a kind of letter for Dick. “[H]ow slowly [the day] passes . . . you wonder why I can’t be cheerful about things . . . I’m trying, I really am trying . . . When he [her pulmonary specialist] told me . . . that I’d always have to live

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in a place like this . . . that did somethin’ to me . . .” (1988, p. 268). What follows the transcribed conversations are discussions of the importance of communication—of noticing verbal and non-verbal cues and in trusting what those cues mean in “I-thou” and “we” relationships. These tapes afford him the opportunity to demonstrate how a clinical ethicist keeps the patient at the center of the moral gestalt. Both stories highlight prominent moral themes: how his mother cherishes independence and has lost it, how the struggle for each breath makes her body seem alien to her, how her desires to enjoy her family and protect them from watching her die are foiled. All of these themes relate to Zaner’s publications on embodiment, a phenomenological method for clinical ethics, and integrity. In Ethics and the Clinical Encounter, the aptly titled section “Everyone did what they could, right?,” he bucks complacency, refusing to tacitly accept that the outcome was inevitable and therefore acceptable. Without the reader knowing that he is speaking of himself, he is both understanding and critical of his and his brother’s approach to his mother’s progressive illness. He also ponders the advance directive’s impotence and wonders if he could have improved his mother’s situation. “There was, moreover, ample time for action long before her condition restricted her to the living room couch and TV. . . (S)uch actions designed to explore productive alternatives are not unreasonable” (1988, p. 237). While the hope that “there will always be tomorrow” resonates with everyone, Zaner is not content to rest in the humanness of it. This is another expression of moral and professional integrity. In addition to scrutinizing the actions of everyone involved, he also sympathizes with each person’s perspective. He notes that when various physicians insisted they make their own independent medical judgments about his mother’s condition (i.e. whether or not it was terminal), they were in strict accordance with medical practice. Still he trumpets a frequent refrain—the regrettable reluctance of many health care professionals to squarely face and candidly discuss dying. Opportunities for dialogue abound and the discussions can shape clinical management and greatly minimize suffering. “(T)he hospital’s failure to provide discussions with the family and even with the woman after transfer to the floor [on her first hospital admission] is a grievous flaw in its typical, standardized procedures. Such discussions could have made the eventual aftermath of this case far different and immeasurably better for this family” (1988, p. 239). This statement is written with a professional distance that, as a son, he must have felt painfully, viscerally.

4 Themes in the Narratives The importance of communication has been expressed in Zaner’s philosophical writing, noting our deep and fundamental connection to others. Gabriel Marcel calls this disponibilité, availability to others. This disponibilité or Du-einstellung (Alfred Schutz’s term for the relatedness each of us feels toward others) is the foundation for healing and for clinical ethics consultation, because it is this openness toward others that is the foundation for listening, hearing, empathizing, and helping (2003, pp.195–199).

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In the first story, Zaner is sympathetic to the perspectives of all parties while simultaneously providing a robust normative analysis. A central theme in this story is the role and execution of the advance directive. The fact that it failed to do precisely what it was intended to do warrants ethical scrutiny. “This type of directive carries no legal weight at all in the two places where it is by all odds most needed— nursing homes and emergency rooms” (1988, p. 241). Hence, the document in the absence of institutional mechanisms ensuring that it influence clinical decisions is a sham. In helping his mother complete the form, Dick was trying to ensure that his mother’s wishes would be heeded, that her choices would emerge as the theme in the moral gestalt which captures our attention and then requires moral action. Advance directives allow a silent patient at the center of a moral gestalt to speak, and neglecting that voice is patently disrespectful. Patient wishes continue to be routinely neglected in the clinical arena, often because the execution of medical care seems more pressing from the perspective of care providers. However, since medicine is a moral enterprise, then health care providers must ask at each turn, “Why are we doing this? Should we be doing this? Would this patient want it or benefit from it?” Another theme in the second account is Dick’s sense of guilt. He bravely describes the feelings of many children who encourage aging parents to live in nursing homes. “That is the story I want to tell. Not all of it, not yet. But the quick and harsh . . . [F]or I remain in considerable guilt. . .We [he and his brother] knew her hurt, her pain, her suffering. Yet we not only let her go into that ‘prison’, we— certainly I, for I can and will speak only for myself, lived in a kind of careful ignorance of what had happened to her, or where she was living out her final days and in what miserable condition” (2004, p. 137). What courage it takes to write those words—to traverse the experiences of being a son and a clinical ethicist—to explore the cognitive dissonance and the competing interests, demands and responsibilities. The moral life is messy and clinical ethics consultants are often asked to reveal some underlying order. We can do that through conceptual clarification, but we cannot make grief, sadness, loss, or suffering understandable or neat. But to neglect those aspects of our professional experience would be a kind of lie. And Zaner is committed to telling even painful truths. I hope his readers will listen attentively, as he always did, and that they will sympathize and scrutinize. As he has written, “there are no quick fixes—only the hard work of responsible and imaginative moral reflection” (2001, p. 339). Which brings us to the most painful theme of the second account. In “The Cruel Clarity of it All”, Zaner recounts how he returned from a jog to his wife’s news that “Mom’s had another. She’s back in the emergency room.” “What happened? . . . But why, for heaven’s sake? What’s gone on? When did she do it?” The final question is our first clue that Dick suspects she might have removed her oxygen on purpose so that she could die on her own terms. Later, soon after his mom dies he stammers to the neurologist “well, . . . you see, it crossed my mind and I don’t know what you think . . . I just wondered whether she could have had that sort of stroke while she was still on oxygen, or whether all the damage and such happened after, maybe even because, she was off . . . [T]he nurse [at the nursing home] said she found Mom with

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her portable unit turned off and the, what do you call them? The prongs? The prongs were not in place, not wrapped around her ears, you know? Like they were taken off or something . . .” (2004, p. 132). What strikes me about this passage is how it capture’s Dick’s tentativeness—both the need to know and the fear of knowing. Patients and families are familiar with this paradox. He must have ruminated about this possibility for years, anguishing over what it meant or what precipitated this final act or if she intended it at all. Some 20 years after her death, “there is no doubt in my mind about what happened. She turned off her portable oxygen unit, she pulled off the prongs, she took the sleeping tablets she had apparently hoarded . . . then she lay back down, on her back, and let it happen, waited for it to happen. He concludes, “Bereft of meaningful choice, failed by her body, abandoned in the cracks of the healthcare system, forgotten by friends and left by her sons to a ‘life that isn’t any life, not at all’ my mother took the last, tiny threads of control of her life—and left with as much dignity as could be had” (2004, p. 141). And so concludes his second telling of his mother’s death. The hardest and harshest revealed. And we end where we began. What Dick has done in the two stories about his mother is enact “the philosophical discipline of criticism and self-criticism, carrying out ‘the most extreme radicalness in striving to uproot all prejudice’” (1975, p. 126). In his honesty, faithfulness to phenomenology (which he lauded, enriched and expanded throughout his career), and his commitment to criticism and selfcriticism, he serves as a model for ethics consultation. And he inspires in his readers the awe and wonder with which he approaches every new phenomenon—whether it be the birth of his grandchildren, the death of his mother, or the joys of retirement.

5 Richard Zaner’s Legacy As his student, Zaner had an enigmatic quality—affable, open, and ready to embrace while rarely revealing his own values in class. It was as if he was enacting his commitment to phenomenology by refusing to allow us to simply appeal to the authority of his wisdom and experience. If we analyzed our own lived experiences as novices in clinical ethics, he would guide us without indoctrinating or coaxing discipleship. The result is that his influence is deeply ingrained in my scholarship but I am not simply spinning Zaner’s web—I am making my own with Zaner at the core. This is exactly what Zaner wanted from his graduate students. It was as if the implicit question in every pedagogical encounter was, “Denise, how can I help you become the best of you? What do you need to experience and discover? What challenges must you grapple with? And what acts of kindness and support can I provide as you grow into a professional bioethicist?” Today and forever, I think of Dick Zaner as an intellectual father, with the same affection, awe, and respect I have for my own parents. Zaner began writing intricate philosophical expositions and, after working in the clinical arena, began to shift to story-telling. This shift makes sense to me now that I have been working in clinical ethics for some time myself. As Zaner often says, he

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wants to get the story “right,” which requires repeating verbal and written accounts. In addition, the affective components of ethics consultation are critical, but tend to be overlooked in most bioethics literature. Zaner taught us that it is important that we share our uncertainties and missteps in the interest of our own professional integrity and for the benefit of those who are learning the craft. He did precisely this in telling stories of his mother. Not surprisingly Zaner’s students tell our stories and carry on his practice of telling and retelling (Ford & Dudzinski, 2008).

References Dudzinski, D. M. (2001). The Phenomenology of Integrity: An Essay in Clinical Ethics. Dissertation. Vanderbilt University. Ford, P. J. & D. M. Dudzinski, Eds. (2008) Complex Ethics Consultations: Cases that Haunt Us. Cambridge: Cambridge University Press. Gurwitsch, A. (1964). The Field of Consciousness. Pittsburgh: Duquesne University Press. Zaner, R. M. (1973). “The art of free phantasy in rigorous phenomenological science”, Phenomenology: Continuation and Criticism: Essays in Memory of Darion Cairns. Edited by F. Kersten and R. Zaner. The Hague: Martinus Nijhoff. Zaner, R. M. (1975). “On the sense of method in phenomenology”, Phenomenology & Philosophical Understanding. Edited by Edo Pivˇcevi´c. Cambridge: Cambridge University Press. Zaner, R. M. (1979). “The field-theory of experiential organization: a critical appreciation of Aron Gurwitsch”, Journal of the British Society for Phenomenology 10:3, 141–152. Zaner, R. M. (1981). The Context of Self: A Phenomenological Inquiry Using Medicine as a Clue. Athens, OH: Ohio University Press. Zaner, R. M. (1984) “The mystery of the body-qua-mine”, The Philosophy of Gabriel Marcel. Living Library of Philosophy. Edited by P. Schilpp and L. Hahn. Carbondale, IL: Open Court Publishing Company/Southern Illinois University Press. Zaner, R. M. (1988). Ethics and the Clinical Encounter. Englewood Cliffs, New Jersey: Prentice Hall. Zaner, R. M. (1993). “Voices and time: the venture of clinical ethics”, Journal of Medicine and Philosophy 18, 9–31. Zaner, R. M. (1994). “Body: embodiment: the phenomenological tradition”, Encyclopedia of Bioethics. Edited by W. Reich. Washington, D.C.: The Kennedy Institute of Bioethics. Zaner, R. M. (2000). “Power and hope in the clinical encounter: A meditation on vulnerability”, Medicine, Health Care, and Philosophy 3, 263–275. Zaner, R. M. (2001). “Envisioning power, revisioning life: prominent issues for a phenomenology of medicine”, The Reach of Reflection: Issues for Phenomenology’s Second Century. Edited by Steven Crowell, Lester Embree and Samuel J. Julian. Electron Press, Vol 3, available at http://www.phenomenologycenter.org Zaner, R. M. (2003). “Sisyphus without knees: Exploring self-other relationships through illness and disability”, Literature and Medicine 22:2, 188–207. Zaner, R. M. (2004). Conversations on the Edge: Narratives of Ethics and Illness. Washington, D.C.: Georgetown University Press. Zaner, R. M. (2006). “On evoking clinical meaning”, Journal of Medicine and Philosophy, 31, 655–666.

Chapter 10

Between and Beyond: Medicine and Narrative in Dick Zaner’s Phenomenology Hillel Braude

1 Introduction In a story from his recent collection of autobiographical medical ethics narratives entitled, “When Your’e Dead Anyway, What’s to Live For?” Richard Zaner describes an encounter with a young patient that is revealing about his own work and sense of self as a phenomenologist and clinical ethicist. To take up the story, Zaner is introducing himself to Tom, a brash young man disabled since birth with spina bifida, who is now refusing life-saving dialysis for kidney failure: “Mr. Brown? I’m Dr. Zaner . . .” “Another one? How many of you are they going to send in here anyway? I’ve said all I’m going to say, and that’s that . . .” . . . “Mr. Brown, please let me finish: I’m not ‘another one of them,’ as you obviously think; I’m not a physician, and I’m not about to try and talk you into or out of anything . . .” “Then what the hell are you?” . . . I tried a small smile with a few words to match:” I’m not so sure, now that you ask. I’m not sure you’ve ever heard of people like me before: I’m in ethics, and I’m supposed to try and help you, your mother, and the doctors see if there is some way this impasse, this blockade about dialysis, can be . . .” (2004, 23)

One can discern in this passage an existential anxiety about the status of self. Zaner’s “small smile” is not simply for rhetorical effect, nor a smile of sympathy, but is the knowing smile of a philosopher who has toiled for many years over the question of self in the medical field. Those familiar with Zaner’s oeuvre can visualize him here reviewing in his mind the insight from Gabriel Marcel that he describes in an early work devoted to phenomenology, depicting the human condition as an exigence concretely manifested as a quest, as “a problem which encroaches on its data, which invades them and thereby surpasses itself as a simple problem” (PE, 1964, 5). The answer to this existential challenge appears through Zaner’s role as ethicist, H. Braude (B) Biomedical Ethics Unit McGill University Montreal, Quebec, Canada e-mail: [email protected] With thanks to Smadar Bustan for her insightful remarks on a rough draft of this essay. O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_10,  C Springer Science+Business Media B.V. 2011

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and by the ethical encounter itself. Thus, the professional role of philosopher ethicist that Zaner helped pioneer provides the peg upon which to attach his sense of self. Perhaps, more significantly, it is through being called upon by Tom’s “impasse” that Zaner re-discovers himself as a person. In other words, it is through responding to an ethical call from an-other that Zaner here discovers his own self. This idea receives confirmation the next morning when Zaner returns to speak with Tom and insists on being called by his colloquial name, “Dick”.1 More than simply a philosopher ethicist, Dick is a flesh and blood person, engaged with real people in difficult situations. The philosophical tools that he uses shed light upon and help resolve the impasses resulting from the “thrownness” of the human condition.2 This is possible because for Zaner philosophy is essentially both a “reflective” and a “reflexive” discipline (ibid., 28). The latter is defined as “an eminently personal act, something which only the individual self does from within the inner reaches of his own solitude” (ibid., 29). Dick Zaner embodies this tension between philosophical reflection and reflexive practice. His five decades of work in phenomenology and medical ethics has not been simply intellectual, but mediated through his personal engagement and risk in the clinical face-to-face relation. That Zaner has won the admiration and friendship of stalwarts of the medical profession, such as Eric Cassell and Edmund Pellegrino, demonstrates his ability to talk-the-talk and walk-the-walk as both phenomenologist and medical ethicist. The challenge in responding to Dick Zaner’s landmark contribution in phenomenology and medical ethics is to respect his creative tension between the personal and the intellectual by engaging in an intellectual dialogue about the life-world without reducing it to mere abstraction. Yet, precisely because the self is a problem to itself, I am struck by the inherent epistemological difficulty of reflecting on Richard Zaner’s contribution to the field of phenomenology and medical ethics. This is not simply the result of false humility, but the difficulty in formulating a coherent philosophical response to a human life, especially in Zaner’s case, a life devoted to fleshing out the complexity of the meaning of personal selfhood. Fortunately, that the human condition is a question does not mean that nothing can be said about it. Zaner notes following Marcel that the quest for the human condition becomes directed toward an “indubitable existentiel,” a sort of “existential landmark capable of being designated . . .” (ibid., 8). More fortunately, Zaner himself has provided many of the landmarks for other philosophers and clinicians to follow. However, because of its philosophical and existential depth, Zaner’s rich oeuvre provides much material for further philosophical reflection. The task that I shall attempt to fulfill in this essay acknowledging Zaner’s great contribution to philosophy of medicine and medical ethics is to reflect on the unfolding project undertaken by Zaner in moving from phenomenology to medicine and finally to narrative. Zaner continues to be an unashamed apologist for Husserlian phenomenology, despite the perennial charges of idealism directed against it. Husserl’s emphasis on embodiment provides the link between phenomenology and medicine and helps explain Zaner’s ongoing commitment to the phenomenological project. The contribution of phenomenological writings on the body has been to show that the mystery of human subjectivity is not simply a result of consciousness, of an empty

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cogito, but that consciousness is epiphenomenal to the metabolic, the organic and the physiological. The contents of consciousness are necessarily shaped by its concrete underpinnings. The mystery of the human being results from the chiasm of biological processes with conscious awareness. Phenomenological concern with the body is readily transformed into a critical concern with the “natural attitude” associated with the medical sciences. For this reason, the word “and” connecting Zaner’s work in phenomenology and medical ethics is not incidental. There is a deep self-confessed phenomenological strand intertwining Zaner’s early writings in pure phenomenology with his later writings in medical ethics. Zaner’s background in philosophy is foundational for his work as a clinician. Likewise, the life-world of the clinic has provided the platform for Zaner’s phenomenological gaze. The self-conscious continuity between Zaner’s early phenomenological writings and his later work in medical ethics is evidenced from the titles of his major works. In 1964 Zaner published a groundbreaking phenomenological analysis of embodiment, entitled The Problem of Embodiment: Some Contributions to a Phenomenology of the Body (PE). This was followed in 1970 by The Way of Phenomenology: Criticism as a Philosophical Discipline (WP), which introduced Husserlian phenomenology to an American audience. While Zaner attempted to convey some of the understanding that he had accumulated through personal contact with living embodiments of a great European philosophical tradition—Maurice Natanson, Alfred Schutz, Dorion Cairns, Aron Gurwitsch, Hans Jonas and Werner Marx—from the first, his writings demonstrate the impulse to make an original contribution and not simply to write a “mere textbook” of philosophy.3 The concerns for issues of embodiment and self are retained in and even explain Zaner’s shift from “pure” phenomenology to medical ethics. This “medical turn” is already presaged in, The Context of Self: A Phenomenological Inquiry Using Medicine as a Clue, published in 1981. By this time Zaner had transformed from “pure” philosopher to clinical medical ethicist as first director of the Center for Clinical and Research Ethics and the Ethics Consultation Service at Vanderbilt University. Zaner’s self-conception as a clinical ethicist is clearly evidenced by his next major work, Ethics and the Clinical Encounter (1988), which speaks directly from the realm of clinical experience. Zaner’s most recent writings ostensibly leave the realm of phenomenology for the flowery terrain of narrative. Thus, Troubled Voices (1993) and Conversations on the Edge: Narratives of Ethics and Illness (2004) provide literary stories from years of experience as a clinical medical ethicist. These titles bear testament to the originality and range of Zaner’s investigation of the human condition, remaining faithful to rigorous philosophy whilst engaging the contingent realm of clinical medicine. A number of questions immediately arise through reviewing Zaner’s shift from pure phenomenology to medicine and finally to narrative. Firstly, why the “medical turn?” Zaner’s early concern with issues of embodiment did not necessitate the decision to “abandon” pure philosophy for the realm of medicine. That he did so must be of philosophical significance. Secondly, what does “medicine” signify in Zaner’s phenomenological philosophy? Thirdly, why the turn to narrative in Zaner’s most recent writings? Is this simply the seduction of stories, or does this “narrative turn”

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contain matter of philosophical substance? These questions signify that there is room for further commentary probing the deep connection between phenomenology and medicine. I propose in this essay to answer these questions through re-tracing some of the key concepts that Zaner laid out in developing his phenomenology of medicine. My approach followed here is interpretive and hermeneutical, closely analyzing connections between Zaner’s phenomenological, clinical, and narrative writings. Owing to the size and richness of Zaner’s writings, I am forced to limit the scope of my analysis. I have chosen, therefore, only to concentrate on comparing Zaner’s two early works in phenomenology, The Way of Phenomenology (WP) and The Context of Self (CS), with his most recent compilation of essays, Conversations on the Edge (CE). These texts provide an overview of the whole of Zaner’s philosophical output, linking his earliest philosophical explorations with the perspective gained from years in the clinic. WP is purely phenomenological, presenting an overview of Husserlian phenomenology to an American audience. CS applies phenomenological insights to exploring the nature of medicine, and in turn determining how medical knowledge is involved with aspects of the self. Finally, CE crystallizes Zaner’s phenomenological understanding of medicine and the self in a series of case narratives derived from the clinical context. My concern in this paper is to demonstrate the manner in which Zaner attempts to remain true to Husserlian phenomenology through his medical and narrative turns. CS is a pivotal text in this regard, and Zaner’s reading of three philosophers, Hans Jonas, Aron Gurwitsch and Paul Ricoeur, are central for the development of his mature philosophical theory. Zaner’s Husserlian interpretations of their respective philosophical theories are examined in order to show the development of his method of applying phenomenology to medicine and medical ethics. In particular, I attempt to demonstrate how Zaner conceives of applying Husserl’s concept of free-phantasy variation in the medical context, which is not a departure from the phenomenological method into hermeneutic philosophy, but rather, its culmination! Free-phantasy variation provides the methodology to deal with transcendental subjectivity that puts my own clinical power into question in the face of the other, and forms the basis of medical ethics. It is the key architrave in Zaner’s work that allows for the fine distinction to be made between philosophical reflection and therapeutic practice in a phenomenologically informed clinical medical ethics.

1.1 The Way of Phenomenology Since Zaner constantly affirms the relation between his early training in phenomenology and his later work in medical ethics it is necessary to look within his phenomenological writings to explain his shift from phenomenology to medicine. The continuity between Zaner’s earliest and most recent writings finds confirmation in a passage that is used to introduce both WP and CE, and which suggests a reason for Zaner’s fascination with medicine. Thus, in both volumes Zaner cites a passage by James Agee first published in Let us Now Praise Famous Men, together with startling photographs by Walker Evans:

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For in the immediate world, everything is to be discerned, for him who can discern it, and centrally and simply, without either dissection into science, or digestion into art, but with the whole of consciousness, seeking to perceive it as it stands: so that the aspect of a street in sunlight can roar in the heart of itself as a symphony, perhaps as no symphony can: and all of consciousness is shifted from the imagined, the revisive, to the effort to perceive simply the cruel radiance of what is. (WP preface; CE, xii)

That this passage is quoted in both texts confirms the centrality of Agee’s words for Zaner’s project in phenomenology. Additionally, the hyperrealism of these photographs and associated commentary illustrate Zaner’s fascination with the life and death dramas of the medical realm. Thus, Zaner writes that, like Agee, he wanted in his stories to “do nothing more than let these things and people be, whatever they are and in whatever way they might (want to) be, with neither dissection or digestion” (CE, xii). However, Agee’s paragraph is more than simply a graphic illustration of the “cruel radiance” of the emergency room, but is iconic for the task of phenomenology itself. It resonates with Husserl’s clarion call for philosophers to return “back to the things themselves!” Throughout his writing Zaner has maintained an unwavering commitment to Husserlian phenomenology. It is impossible, therefore, to avoid a diversion through Husserl in reviewing Zaner’s phenomenology of medicine. Fortunately, Zaner himself has provided a succinct review of Husserl’s method in WP. However, because the question-at-hand is not Husserl’s phenomenology, but Zaner’s phenomenology of medicine and medical ethics, it is sufficient to review Zaner’s synopsis of Husserl in order to find explanatory clues for Zaner’s subsequent turn to medicine and narrativity. An apt place to begin this review is with Husserl’s call to return to mundanity and his associated critique of the natural attitude, i.e., the realistic assumptions that underlie everyday life. The phenomenological movement initiated by Husserl is characterized by adherence to a series of methods rather than a set of fixed philosophical principles or categories.4 Spiegelberg has noted in his masterful history of the phenomenological movement that despite constant makeovers, certain constants persisted for Husserl in his philosophy. One “dynamic idea” that remained was Husserl’s “urge to go down to the sources” (ibid., 76). Zaner describes how Husserl sometimes compared himself to an explorer charting out new terrain. He “divided his efforts between soundings, probings, searchings and cartography, with periodic speeches designed to solicit and guide the work of others” (WP, 33). One consequence of this method is that for Husserl only those judgments and descriptions are justifiably acceptable, “which have been framed on the basis of a direct witnessing of the landscape itself” (ibid., 36–37). This element of personal involvement in the phenomenological enterprise heralds another fundamental concept for phenomenology: subjectivity. The main concern of phenomenology is an analysis of the manner in which objects are represented to consciousness. This is as much a concern about the existence of external objects as the intentionality of conscious acts. As Zaner describes: At the same time, however, the investigation must be directed toward what consciousness “means” [“intends”], as well as toward the different ways in which – in accord with the objective, now clearly, now obscurely, now by presenting or my presentifying, now

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symbolically or pictorially, now simply, now mediated in thought, now in this or that mode of attention, and so on in countless others forms, and how ultimately it “demonstrated” the objective as that which is “validly,” “really.” (Ibid., 61)

This emphasis on subjectivity provides the means for a critique of the natural attitude. In particular, Husserl proposed his method of the phenomenological epoché that suspends a naïve metaphysical attitude towards the world, and the phenomenological reduction, intended to thematize the correlation between the outside world and subjectivity.5 Husserl also spoke frequently in terms of the noetic-noematic correlation. Whereas the noesis refers to the act of intentionality regarding an object, the noema refers to the constituted correlate, or the object-as-it-is intended. Husserl’s critical attitude towards everyday assumptions was not meant to undermine their validity, but rather to enlarge our understanding of how knowledge is attained. For Husserl, the natural attitude as well as the positive sciences requires to be tested via the phenomenological method. Husserl differentiated between the “life-world,” in which objects are characterized by their “relative, approximate, and perspectival givenness” and modern naturalistic science that attempts to construct knowledge of the world free from first person experience (ibid., 126). While science attempts to overcome the “naïve” attitude associated with common-sense reasoning, for Husserl the world of the scientist only exists in relation to this prior experience. The result of this phenomenological critique of science is that, “ ‘scientific cognition,’ however, is no longer what naturalism thought it to be—namely, empirical—but is rather the foundational and rigorous effort to disclose, explicate, and analyze the essential features of consciousness and its objects—always considered strictly as correlates” (WP, 61). This critique of scientific empiricism has direct relevance for medical science, the father of the method of empirical observation. Husserl’s privileging of subjectivity and validation of naïve common-sense reasoning established a positively anthropomorphic view of human reasoning conditioned by so-called “empirical man.” This anthropomorphic philosophical anthropology is most obvious in relation to Husserl’s concept of intuition. Husserl regarded phenomenological intuition whereby objects are presented to consciousness, as the “principle of principles” of phenomenology. As noted by Emanuel Levinas in his important study of Husserl’s use of intuition, “The phenomenological reduction is precisely the method by which we are going back to concrete man.” And, “Because of it, we discover the field of pure consciousness where we can practice philosophical intuition” (1973, 146). In other words, the phenomenological method is intrinsically associated with discovering the essence of the human through its critique of empiricism and naturalism. Phenomenology shares this epistemological concern with medicine. Additionally, if phenomenology, as has been observed, has revived Aristotelian intuitive reasoning,6 phenomenology of medicine has revived the Hippocratic synthesis of empirical observation, clinical intuition and wholism.7 In summary, while phenomenology provides the method for the critique of scientific empiricism through a philosophical anthropomorphism, medicine, taking the human condition as its central concern, provides the natural field par excellence where this method can be tested.

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Husserl conceived of his phenomenology as a map that others schooled in his methodology could and should follow. Medicine preeminently concerned with the human condition and the part-whole relation is justifiably included in this field of investigation. This explains the shift from phenomenology as an intellectual project articulated in Zaner’s early writing towards applying phenomenological analysis to the medical life-world in his third groundbreaking work, The Context of Self: A Phenomenological Inquiry Using Medicine as a Clue (CS). This text synthesizes Zaner’s deep training in phenomenology with his awakened interest in medicine. Whilst this text is philosophically mature in its phenomenological method, it may be considered a transitional text for Zaner to develop a philosophical theory of medical practice. As such, it bears the birthmarks of developing ideas, still needing to be tested in the crucible of experience, and to be later articulated in the structure of narrative.

1.2 The Context of Self In CS Zaner develops ideas set out in his first two phenomenological investigations using medical examples as “clues.” The phenomenological meaning of “clues” is already described in WP: How does it happen, it was asked, that objects of any particular type have the sense they have been described as having? . . . By explicating the context of meanings a particular type of object has for or through consciousness, the critical philosopher has before him a crucial set of “clues” (Leitfaden), which “point back” (zuwenden) to the various typical sets or modes of consciousness having that specific type of object as their noematic correlates. The intended object functions as a clue to the synthetic processes which intend it, and tracing out the kinds of syntheses we have mentioned (and other besides) is what is strictly meant by phenomenological “constitution.” (173)

Medicine as a clue is then intended as a specific “noematic correlate” of the mode of consciousness relating to the self. Thus, medicine serves as a privileged theme for the phenomenological philosopher attempting to make explicit the tacit structures of the life-world. In this sense, medicine merely provides convenient material for the phenomenological gaze. Yet, understood in this sense, medicine is no different from any other content of experience presented to consciousness as an object for phenomenological analysis. Is medicine an exemplary “noematic correlate” for Zaner, so that his turn to medicine from pure phenomenology can be interpreted as a continuation of his phenomenological project? Is there not another sense of medicine, in which it “saves the life” of phenomenological philosophy, not only because it allows it to be “relevant,” but also because of the insights it provides for the phenomenological method itself?8 This is because, as Zaner indicates in his introduction to CS, the main question that modern philosophy has to grapple with is that of life.9 While this insight is originally attributed to Dilthey, its validity has been affirmed by development of bioethics in response to radical questions posed by recent medical and biological innovations. Zaner is singular for his persistence in utilizing the

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phenomenological method to enrich medical ethics. His method is novel for both phenomenology and medical ethics. As has been indicated previously, the stakes here are both professional and personal. Thus, the medical examples that Zaner uses here are additionally clues in the sense that they are not yet the fully-fledged examples from his experience as a clinical ethicist that he will draw on in his later writings, and which will be elaborated in the final part of this essay. The two themes that are conjoined in CS are that of the body and the self. This is because, as Zaner claims, both are “two sorts of ‘matter’ which stubbornly resist being taken as merely material” (3). The fundamental phenomenological insight derived from Husserl that the flesh (Leib) is the site of the self provides the first clue as to the relevance of medicine for phenomenology. If WP highlighted the importance of the self, and PE the shimmering presence of the body, CS synthesizes these two themes in a further phenomenological investigation of the embodied-self. As a dialogical process, Zaner’s investigation owes much to other philosophers who he both reveres and critiques. The philosophical heralds of CS include Hans Jonas, Aron Gurwitsch, and Paul Ricoeur. Each of these philosophers provides landmark philosophical insights; yet for Zaner they do not go far enough in touching the radical foundations of the embodied self. In order to understand better the phenomenological path that Zaner has mapped out and thereby explicate his second and final turn, i.e., towards narrative, it is necessary to review each of these philosophers in turn.

2 Hans Jonas and the Phenomenon of Life Hans Jonas’ philosophy of biology has rippled into American bioethics through two former students of his, Leon Kass and Richard Zaner. Yet Kass and Zaners’ reading of Jonas are unusually different. While Kass attributes the influence of Jonas in his opposition to human cloning, through what he calls “the wisdom of repugnance,” Zaner relies on Jonas’ critique of dualism in his phenomenological analysis of the self.10 The essays collected in Jonas’ Phenomenon of Life remain one of the seminal contributions to the philosophy of biology and metabolism. As with many other phenomenological writings, the main antagonist for Jonas’ philosophical rapier is the legacy of Cartesian dualism, denying any intrinsic relation between mind and body. Jonas’ opposition to Cartesian dualism is summarized in a cryptic statement of his, that, “In the body, the knot of being is tied which dualism does not unravel but cut. . . Materialism and idealism, each from its end, try to smooth it out but get caught in it” (2001 [1966], 25). Zaner interprets this statement to mean that, the “union” between mind and body “is ultimately an abortive notion, for its very sense effectively buys into a dualism, if only incipiently.” Instead, there is the “ ‘one’ living body whose ‘extensiveness’ locates it within the actual world (and grounds subsequent knowledge of that world), and whose ‘intensiveness’ is the ‘efforting’ estate of subjectivity” (CS, 11). The organism with its metabolic substrate provides the key ontological structure demonstrating the mind-as-body and body-as-mind. Thought does not precede metabolism, but is consequent to the organism’s “self-organization.” The organism’s

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inwardness is achieved through metabolic activity rendering ingested otherness into sameness. Thus, “Sameness, while it lasts . . . is perceptual self-renewal thorough process, borne on the shift of otherness” (Quoted in ibid., 12).11 While Jonas’ philosophy of the organism is similar to phenomenology in its ontological concerns, Jonas considered his conception accounting for the significance of the ontological notion of “individual” to be beyond the reach of phenomenology (CS, 12–13).12 Zaner, however, contests this anti-phenomenological “bias” and argues that by jettisoning the method of phenomenology, Jonas’ philosophy of biology does not account adequately for the emergence of self.13 In other words, for Zaner, it is not sufficient to account for the emergence of mind from body, but to relate the self back to its embodied being. As Zaner writes, “What happens to my body perforce entails or implicates me” (CS, 52). For Zaner, this further philosophical insight is provided in Aron Gurwitsch’s theory of contextures.

3 Aron Gurwitsch and the Theory of Contextures Zaner’s phenomenology of medicine and critique of Jonas is most indebted to another of his teacher’s Aron Gurwitsch, and in particular the latter’s theory of contextures developed in The Field of Consciousness. As summarized by Zaner, Gurwitsch’s theory attempts to explicate how consciousness makes sense of complex structures of reality, of “wholes,” without “reductively stripping away its very meaning and integrity both as embodying and as biological (“mine” and “other”). (Ibid., 68) This is achieved by distinguishing the theme from the thematic field, and both from the margin (ibid., 75–76). In other words, the noematic object of consciousness is experienced in perspectival relation to various contexts. What is theme in one moment may become thematic field in another, and visa versa. Gurwitsch’s theory of contextures is important because by focusing on actual phenomena of experience it provides a philosophical refutation of the charge of idealism in Husserl’s phenomenology. At the same time, it continues to privilege Husserl’s fundamental concern with analyzing the contents of consciousness. Zaner’s addition is to apply Gurwitsch’s theory of contexture to his phenomenological investigation of the embodied-self, and to expand it to include the phenomenon of life: In a word, these complex contextures are woven together as constituents of an even richer contexture (ever-increasing in its richness). In view of the circumstance that each constituent here is itself an already complex contexture, furthermore, I shall refer to this qualitatively richer one as the complexure of life. . .On the other hand, environing world, consciousness, and embodying organism, form a unique and complex “whole”: whose “parts” are themselves strictly inseparable (albeit distinguishable) contextures: “inseparable” but “distinguishable” in the manner specific to contextures – a “whole” which is the system of intrinsic, functionally correlated references and significances manifested by the constituents. The theory of contexture, now extended and deepened to an extent, gives a clear way of understanding what must otherwise remain an empty formula: the “whole” of a “life” (and its “parts”: body, mind, and, world). (Ibid., 106–107)

The above paragraph posits a radical expansion of the phenomenological method to include the body as a fundamental contexture. Thus, Zaner states that it is

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necessary to distinguish at least three kinds of contexture—noematic, noetic, and the embodying organism. While Husserl acknowledged the importance of the body for phenomenology, Zaner raises it to an equivalent level as the noematic-noetic correlation itself, and medicine provides invaluable examples for this phenomenological investigation. Zaner’s phenomenological reading of the body relies on Kurt Goldstein’s neurological studies on brain-damaged patients to demonstrate how the animate organism as a site of contextures is a complex whole, consisting of “an entire series of differently related sets of members, structures, and patterns of interfunctionings” (ibid., 45). Moreover, because “even an elementary sensory act implicates (as a complex set of “backgrounds”) other bodily members and functions, postures and movements,” the animate organism relates reflexively to itself (Ibid.). As fundamental phenomenological correlates, these three kinds of contextures are inseparable from the question of self. “The ‘problem of self’ is that self is a foundational problem to itself, always and essentially contexturally bound to its body, its mind, its milieu—its life, in short” (ibid., 180). The self as site of these three kinds of contextures is distinguished by self-referentiality. Thus, Zaner distinguishes three kinds of self-referentiality displayed by these contextures, i.e., what he calls the self as “aloneliness,” the self as “effortful possibilizing,” and the self as “other.” It is significant to mention each of these, since they represent the culmination of Zaner’s phenomenological exploration in CS. They will also prove crucial for understanding what is at stake in Zaner’s narrative writing. The self as “aloneliness” refers to experiences that the self experiences in itself. These are of decisive significance in the process of self-awakening. Some of these experiences, common to all people though personally of high significance may be delineated. These include: The encounter with one’s own being-able-to-die or one’s going-to-die; the disclosure that one is alive; the confrontation by self with its own contingency, its own having-been-born without prior knowledge or purpose and without a sense of its having chosen or been chosen . . . (Ibid., 154)

The second self-referentiality refers to the effort the self needs to undergo to position itself in relation to the external environment. “Self is fundamentally a situated or positioned reflexivity oriented towards the environing milieu, which is itself displayed and arranged strictly in complex reference to this reflexively oriented habitus” (ibid., 172). For example, Erwin Strauss’s well known essay on the upright posture describes how the phenomenon of standing upright allows humans the ability to take up a stance in relation to the environment, and thereby frees the mind for cognition.14 If the upright posture demonstrates effortful self-possibilizing in health, the adverse occurs in the presence of illness and disease. The bodily breakages that occur in the context of pathology reveal the pathways through which the self is constructed and deconstructed through the contexture of embodiment: Being thus impaired – unable to “take initiative,” to “choose voluntarily,” to “keep multiple aspects in mind simultaneously,” to “grasp wholes” or “break them into parts” or “compose

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new wholes,” to “plan ahead,” and thus to “detach themselves from the world” – such patients are affected in what precisely constitutes a core moment of their humanity, their essential sense of self. (CS, 177)

The imperative to respond to this damaged self provides one ground for ethics in medicine, and demonstrates the third self-referentiality, of self as other. The question how it is that we know anything about other selves has been a major preoccupation for phenomenologists since Husserl first addressed this question in his Cartesian Meditations. Zaner’s response, drawing on his application of Gurwitsch’s theory of contexture to embodiment is to demonstrate the presence of turning towards the other self in the emergence of self.15 This idea regarding the openness towards the other resonates with Zaner’s earlier phenomenological descriptions of the body. The uncanny otherness of the body, the body as intimate and foreign, the body as source of the self, already presages an opening to the alterity of the other, thus destabilizing the self and bringing it into presence at the same time.16 The theory of contexture reviewed here, particularly as applied to embodiment, provides the theoretical model to explain the part-whole relation that exists in medicine. In turn, medicine provides the context for the analysis of the three kinds of contextures of mind, body, and the external milieu. Medical analysis of bodily rupture confirms the necessity of bodily contexture for the emergence of self. The rupture that occurs in the self through exposure to the suffering of other selves establishes the ethical imperative in medicine. We can see, therefore, the deep connection between phenomenology and medical ethics in Zaner’s phenomenology of medicine. Yet, whilst some major reasons for Zaner’s “medical turn” have now been described, his turn to narrative still has to be examined. To understand this requires an analysis of Zaner’s defense of the phenomenological method against the hermeneutical philosophy espoused by another influential philosopher, Paul Ricoeur.

3.1 Paul Ricoeur’s Philosophy of Hermeneutics It might appear strange at first glance that Ricoeur should occupy a central place in Zaner’s phenomenological analysis of the self using medicine as a clue, since Ricoeur is remembered for his philosophy of hermeneutics. Ricoeur, is, however, deeply steeped in phenomenology, though he departs from it in favor of hermeneutics. For this reason Ricoeur’s philosophy presents a significant challenge to phenomenology. Zaner’s critique of Ricoeur presents a defense of phenomenology against hermeneutics. Yet, the space between them is very narrow, since Zaner himself takes a “narrative turn” in his later writings. This space-in-between phenomenology and hermeneutics finds a particular content through the medical context. Analyzing this space elucidates the full significance of Zaner’s phenomenology of medicine. Freud and Philosophy (1970), a philosophical analysis of psychoanalysis, is the main text of Ricoeur’s that Zaner critiques. This makes sense, since psychoanalysis

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provides a model for the clinical encounter, albeit of a particular kind. Ricoeur’s concern in this work is to provide a philosophical analysis of Freud’s discovery of the unconscious. How can philosophy, premised on rational reflection, account for the presence of the unconscious? What are the implications for moral philosophy of the irrational? Can philosophy still maintain itself in the knowledge that the self is constructed on elusive foundations? The implication, as Zaner writes, is that: Only by a kind of entrapment by or through indirection, apparently, will “self” yield its treasures, enabling us to tell self truly: tell what it is, and how, hence be able to tease out the eidetic core of self by following out the pulses of its movements found in its expressions and works. (CS, 114)

The desire to flesh out the “eidetic core of self” indicates Zaner’s perseverance with Husserl’s eidetic phenomenology. Ricoeur on the other hand, responds to the challenge of psychoanalysis through a theory of symbolic knowledge, and a philosophical hermeneutics of interpretation. Thus, Ricoeur does not contest the presence of the unconscious, but rather that the unconscious attests to the realm of the symbolic, requiring interpretation. For, “it is the very excess of meaning [“overdetermination”] in comparison to the literal expression that puts the interpretation in motion. . .” (Quoted in CS, 116).17 Moreover, the unconscious allows intelligible discourse because it is “turned from the very outset towards language; [desire] nonspoken and the wish-to-speak” (Quoted in CS, 116).18 Additionally, as site of desire the unconscious reveals a mythic structure that is semantically opaque yet essentially systematic: “each symbol belongs to a meaningful totality which furnishes the first schema of the system” (Quoted in CS, 116).19 This opening towards discourse and systematic structure affords the possibility of rational reflection about the symbolic; hence philosophy remains an essential enterprise, provided it recognizes its task as hermeneutical. Reflection has to be hermeneutical, because “I cannot grasp the act of existing except in signs scattered in the world” (Quoted in CS, 126).20 Philosophical hermeneutics, like its phenomenological predecessor, is equally concerned with the structure of the self. The emphasis on interpretation of symbols rather than on discovering the essences of phenomena leads Ricoeur to break with Husserl’s phenomenological method. He questions the suitability of “phenomenological neutrality” to address adequately the symbol, which cannot simply be studied as an object, but requires “participation in what is announced to me” (Quoted in CS, 128).21 Thus, Ricoeur states that, “a hermeneutic method, coupled with reflection, goes much farther than an eidetic method I was then practicing” (Quoted in CS, 128).22 As in other instances, Zaner does not accept these limits to Husserlian phenomenology, and defends it against Ricoeur’s critique, arguing that there is a logical problem with Ricoeur’s hermeneutical philosophy. Whilst Zaner agrees to the importance of the symbolic, requiring indirect methods to discover the treasures of the self, he does not agree that the phenomenological method cannot be extended this far. The problem that Ricoeur faces is to demonstrate how philosophy can be hermeneutical, i.e., have recourse to “intrinsically divisive” symbols, and yet remain

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at the level of conscious philosophical reflection (CS, 118). Zaner considers that Ricoeur’s hermeneutical philosophy participates in symbolic thinking and therefore ultimately must be subsumed to the play of interpretation, whereas phenomenology does not only provide the requisite methodology to discover eidetic essences, but the flexibility to deal with symbolic phenomena. In other words, phenomenology is hermeneutic without becoming hermeneutical. There is a clinical significance in this, perhaps, minor distinction between Zaner’s phenomenology of medicine and Ricoeur’s hermeneutics, both concerned as they are with notions of the self, which ties up many of the themes explored in this essay. Zaner makes the insightful claims that one problem with Ricoeur’s apparent conflation of philosophy and the symbolic is that the “thematization’ provided by philosophical reflection alters the object in question, “from being hitherto not reflected-upon to being reflected upon” (CS, 139). Yet, to remain philosophical this reflection should not really alter the “apprehended” object. It would be absurd for Ricoeur to claim that, “his own reflection on desire of itself indelibly changes desire in its own proper character” (ibid.). Yet, this could be one of the implications of philosophical hermeneutics remaining at the level of the symbolic. An implication of this, which Zaner rejects out of hand, is that the philosopher would then exchange places with the psychoanalyst, and there would in consequence be a confusion “of the tasks of philosophy with those of therapy” (ibid.). The philosopher is not a therapist! What then is the role of the philosopher turned medical ethicist? Is medical ethics a form of applied philosophy, or is it also a form of therapy? This appears to be the fundamental question to answer in distinguishing Zaner’s phenomenology from hermeneutical philosophy, despite both being intrinsically concerned with interpretation and narrative. 3.1.1 Free-Phantasy Variation This concern with interpretation manifests most strongly, not in terms of the phenomenological epoché and reduction, nor in the noetic-noematic correlation, but another eidetic technique derived from Husserl that Zaner calls “free-phantasy variation.” Zaner admits at the end of CS to using free-phantasy variation in his phenomenological investigation, and that it is “far and away the most significant and important phenomenological method, the most powerful and most fruitful” (244). It is surprising that as the most important phenomenological method, free-phantasy variation is only mentioned towards the end of the study, and not in very great detail. Zaner does, however, dedicate a number of essays elaborating his understanding of free-phantasy variation, where again the importance of this method for his phenomenology of medicine is emphasized.23 The centrality of free-phantasy variation is emphasized in the following passage of Zaner’s worth quoting in full: So fundamental is this method that at one point in his early thinking about the matter Husserl insisted that, as he expressed the point, philosophers need to “fertilize” their phantasies to enable them to achieve “observations in originary intuition which are as abundant and excellent as possible.” He mentions in particular using examples from history, art and poetry. That he already at that time clearly understood the implications of the “fundamental insight” is

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evident in what he expressed immediately after that passage: “ ‘feigning’ [‘Fiktion’] makes up the vital element of phenomenology as of every other eidetic science. . .feigning is the source from which the cognition of ‘eternal truths’ is fed” (Ideas I, 160). Keenly aware of how this must have sounded, in particular to critics of phenomenology, in a footnote to this passage Husserl observed with marked sarcasm that such an idea “should be especially suitable for a naturalistic ridiculing of the eidetic mode of cognition”. (Ideas I, 160 n. 14; Zaner, 1973a, 3)24

There is much that is of interest in this paragraph for our present purposes. Firstly, one sees again the emphasis on free-phantasy variation as absolutely fundamental to Husserl’s method. Secondly, free-phantasy variation is a kind of free flow of consciousness that precedes and fertilizes phenomenological intuitions. It is closely aligned with the creative process. Intriguingly, Husserl refers to it as “feigning”, or “Fiktion.” Thus, one sees that phenomenology posits a hermeneutic structure at its heart, even calling it “Fiktion,” whilst distinguishing itself from hermeneutical philosophy. It is the clinical context again that highlights the significance of this distinction. It is obvious, that free phantasy variation lies at the heart of Zaner’s clinical comparisons and phenomenological method more generally. Thus in the one clear definition provided in CS, Zaner writes: The basic key of free-phantasy variation generally is that one explicitly endeavors to consider a range of actual and especially possible affairs as examples of some kind or sort. But with the present issue, the range of examples (which could have been merely possible ones) is of a different order from the more usual sort of examples. Looking carefully at a variety of cases of brain-injured patients, a critical “ability” was made prominent (clinically, but also philosophically) by its very absence (or impairment and relative absence). (245)

Hence, the importance of clinical cases lies in providing the “prominent absence of the phenomenon in question.” These clinical cases are not just important solely for medicine, but in highlighting the relation between free-phantasy variation and the theory of contextures. Thus, Zaner claims that the method of free-phantasy variation is “itself the ‘way,’ the method, for detecting and grasping contextures.” This is generally speaking the emergence of contextures (whole) from what is invariant, and common, the eidos (ibid.). More significantly, it refers to the essence of human life, i.e., “a meaning whose “content” is precisely the “invariantly common” system of functionally significant constituents—human beings (actual and possible) (ibid., 248). At one level, free-phantasy variation provides for Zaner the pre-eminent method of the eidetic science’s analysis of the empirical sciences, including medicine. Yet, the real advantage provided by free-phantasy variation over other phenomenological methods and hermeneutical philosophy is in dealing with the problem of the individual, the n of 1 that has always been the ultimate concern of medical practitioners and the greatest problem to philosophy: In contrast to this usual way of understanding free-phantasy variation, there is something else which is even more interesting to me. This concerns the very possibility of that free-phantasy focus itself: how is it even possible, no longer to attend to the individual example and instead focus on the kind exemplified by that individual? Precisely here is a phenomenological theme that has, I believe, a significance of the first order: it sheds

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important light on the foundations of reflection itself, hence is a central topic for understanding the structures of consciousness and, as I will try to demonstrate, those pertaining to the self and its manifold relationships to consciousness, the embodying body, and still other matters central to the tasks of phenomenology. (Zaner, 1973a, 5)

By being open to any and every human possibility that may be subsumed by consciousness, free-phantasy variation provides the singular phenomenological method for dealing with individual variation and human contingency: Feigning inherently involves a specific shift of attention (. . .), one that is essentially possible as regards any mode of straightforward awareness. The method of free-phantasy variation is not, therefore, restricted to the region of actualities (“facts,” the empeiria), but is rather free to make use of any possible individual (. . .). Feigning is thus a kind of “positional experience of a possible individual” (. . .), for Husserl. (Ibid., 22)

One sees here the importance of free-phantasy variation for Zaner’s phenomenology of medicine. Free-phantasy variation more than any other of Husserl’s phenomenological concepts provides the means of dealing with the contingent aspects of human experience. It again becomes obvious upon reflecting on Zaner’s understanding of free-phantasy variation that his initial turn to medicine and more recent turn to narrative is not a departure from the phenomenological method, but its culmination! Moreover, the problem for medicine of individual physiognomy, and for phenomenology of the individual other prove to intersect through free-phantasy variation. For it is only in fiction that the “prominent absence” of the aspects of self relating to the fundamental human condition can be grasped in their full clarity. For this reason Zaner’s illness narratives are the philosophical culmination of his project in phenomenology and medicine. His “fiction” provides the ultimate test for his phenomenology of medicine, and delineates the outlines of a phenomenological clinical medical ethics. 3.1.2 Conversations on the Edge Dick Zaner should be taken at his word that his “fictional” stories derived from his clinical encounters are deeply phenomenological. Yet, this is not the last word since, as has been seen, the relation between phenomenology and narrative is highly nuanced. In this concluding section, I wish to test Zaner’s theories of phenomenology of medicine against his own narratives of ethics and illness collected in his volume Conversations on the Edge (CE). As indicated by the previous discussion, it is through narrative that the phenomenological method finds its fullest representation in relation to the human life-world. It is commonplace in Zaner’s stories to have references to key philosophers influential for his phenomenology, such as Hans Jonas and Aron Gurwitsch. Similarly, words or concepts bearing philosophical weight, such as “impasse” and “clue”, recur in these narratives. The repetition of key words and concepts a number of times is not an intellectual oversight, but an eidetic strategy arising from the recognition that because objects are presented to consciousness differently at different moments, one can never perceive the totality of any one object. Repetition is an essential strategy for revealing essences, since the same object viewed in different moments

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and from different perspectives to different viewers will reveal itself differently. Yet, because these terms may also be read according to their “everyday” usage, the philosophically uninformed reader will undoubtedly miss the philosophical weightiness of these references. This does not detract from the understanding of the stories, since it is ultimately the experience from which they are derived and not the theory explicating them that is important for grasping the human significance of these stories. More profoundly, since we all have bodies and are selves, the philosophical stakes involved in life and death medical decisions are known to us intuitively, even if we do not all possess the philosophical background required to explicate them. Zaner’s stories are therefore not free from theory. Far from it. The phenomenological method, particularly that of free-phantasy variation is of great significance for the development of these narratives, allowing their “facticity” to be revealed. As highlighted in the discussion of Ricoeur, these stories are not “fiction,” in the sense of being untrue, but “feigning” (Fiktion) in its phenomenological sense, drawing from the deepest founts of the human imaginative possibilities regarding self. Throughout each case, Zaner provides a kind of phenomenological reflection about what is at stake in terms of the self/selves involved in the clinical encounter. This extraordinary attentiveness to different layers of the self-other relation in the clinical context is exemplified in the story entitled, “Hope against Hope,” describing the care of a dying patient, Mrs. Oland. Rather than the traditional ethical concerns of autonomy versus beneficence, Zaner describes a dance of care that he performs with the dying woman: At first, though, this mutual presence seemed more a sort of promise, one that might or might not be fulfilled, depending on what transpired between us. But, because she was terminally ill and I would soon my on my way elsewhere, this clearly remained a mere promise of what could have been. However minimal and temporary, this encounter was deeply textured with our biographies, our lives. Our meeting was dense with anecdotes and tales, their themes embedded in stories that were invited (and could, even might have been elaborated) in every glance and gesture. There was here the promise of sharing that, since impossible, was equally redolent with sadness, a recognition of limitation, borders with sharp edges. (CE, 56)

This phenomenological voice so strikingly portrayed in this paragraph, and others like it make these narratives unique in the clinical ethics literature. They illustrate examples of the phenomenologically trained medical ethicist probing the “complex of reflexively interrelated voices, each with its own complex emotional, volitional, and cognitive tonality. . .” that arises in the clinical encounter (Zaner, 2006, (PV), 287–288). The stories in this collection are striking because they are so deeply personal, reaching a culmination in the story of the death of Dick Zaner’s mother! These are indeed stories on the edge, threatening to infringe the zone of professional detachment. That they do not is testament to Zaner’s mastery of the terrain. Yet, these are more than simply philosophical reflections, but are pre-eminently therapeutic. As Zaner describes elsewhere, the role of ethicist is to focus on the clinical situation and to help patients and families understand their medical conditions and their own

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moral views.25 This understanding may be boosted by philosophical reflection, but is not to be conflated with it. It is in distinguishing between philosophy and therapy that the significance of the method of free-phantasy variation is realized, rather than the traditional phenomenological reduction and epoché. As has been seen, according to Zaner medical examples are philosophically valuable in providing the “prominent absence of the phenomenon in question” (CS, 245). Yet, there is another invaluable role provided by free-phantasy variation that is inherently therapeutic; this concerns the issue of transcendental subjectivity. Maurice Natanson’s insight about certain literature applies equally well to Zaner’s narratives, i.e. that underlying any one of them is the fundamental view that the current of human existence is taken for granted in the lifeworld, becomes thematized in phenomenology, and reconstructed in transcendental subjectivity.26 Transcendental subjectivity, the theme of the self to which objects are presented in consciousness, the true subject of consciousness, is the fundamental concern of the therapeutic encounter. Thus, if one can distinguish a triad of processes within Zaner’s oeuvre, symbolic interpretation, phenomenological reflection and therapeutic engagement, it is the latter that is ultimately concerned with the transcendental subject. The concern with the self characterizes Zaner’s oeuvre from his earliest phenomenological writings to his most recent ethical narratives. The method of free-phantasy variation of all the phenomenological methods is most concerned with this issue of self. This is a result, not only of free-phantasy variation’s flexibility in dealing with the contingent individual, but also because of its relation to vulnerability, the foundation of phenomenological ethics in medicine. This last point becomes evident through the examination of another favorite symbol of Zaner’s relating to the ethics of medicine, i.e. the myth of Gyges. Both in his phenomenological and narrative writings, Zaner returns again and again to the lessons for medical ethics to be derived from this Platonic myth. In book 2 of Plato’s Republic, in the context of a discussion of justice and injustice with Thrasymachus, who argues that injustice is more powerful than justice, Socrates narrates the story of the shepherd Gyges who obtains a magical ring with the power to turn its bearer invisible. With this power of invisibility Gyges succeeds in seducing the queen, killing her husband the king and taking the crown for himself. As Zaner notes, this myth is the antithesis of the Hippocratic ethic. The Gygean “ethic” advocates taking advantage of the vulnerable for our own benefit, since the truth of human relations is power. The radical asymmetry of the doctor–patient relation establishes the temptation for abuse by clinicians, but also grounds the foundation of a medical ethic. There is, however, another interpretation of the Gyges myth not elaborated by Zaner that parallels his phenomenological method. By this I refer to the power of invisibility. Invisibility is one of the superhuman powers, together with flying that forms an eternal human fantasy. But what are these superhuman powers, other than the fantasy of having all of the benefits of a physical body, without any of the material costs? The invisibility of Gyges allowed him to acquire power through bodily force without the risk generally associated with physical action. Stated in Jonas’ language of philosophy of biology, this would be a sheer metabolism without effort, or

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in ethical terms, the conversion of otherness into sameness without being questioned by an ethical alterity. The phenomenologically interpreted medical ethics demonstrates that the ethic of medicine founded upon the acknowledgment of alterity is premised on the possibility of an ethical encounter with an-other, that puts my own power into question. The method of free-phantasy variation provides a method akin to invisibility, i.e., whereby all possibilities can be imagined; yet as opposed to pure materiality this includes the possibility of not being. Free-phantasy variation provides the possibility of taking a stand against the constraints of corporeality as well as of consciousness. This insight needs to be stated, because otherwise one might think that it is only physical constraints that are the source of human suffering. While metabolism and physiology provide the possibility of freedom through human consciousness, consciousness itself may become a burden to the individual, especially through physical disease. Free-phantasy variation provides the possibility of taking a stance against one’s own consciousness. The ability to think of a radically different life, even of non-life, provides the ultimate possibility of transcendental subjectivity. This notion is affirmed in the various stories included in CE, positing the possibility of radical human freedom through taking a position upon and against the constraints of the human condition. While not a naively optimistic position, Zaner’s oeuvre ultimately transcends the phenomenological method he has cultivated so arduously.

Notes 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Ibid., 2. This is a term derived from the German existentialist philosopher, Martin Heidegger (1962). Zaner, R. (1970, pp. xi–xii). See, Spiegelberg, H. (1965 pp. 5–6). For a very good discussion on Husserl’s concept of the natural attitude and the epoché, see Zahavi (2003, pp. 44–46). See, Cobb-Stevens (1990). For the relation between intuition and Hippocratic reasoning, see, Castiglioni (1934) and Braude (2006). Cf. Toulmin (1973). See page 3. See, Kass (1997). For Zaner’s quite different views of cloning see, Zaner (1998, Summer, 2003). See, Jonas (1966), p. 79. See, Jonas (1966), p. 79. See, CS, p. 12. Strauss (1966). See, for example, the following enigmatic passage in CS: Yet this self-relatedness cannot be “itself” without the presence within its very self relatedness—which, in turn, is not “itself” without the first self-relatedness. The self as self-relatedness is as such related to the other self as itself a self-relatedness to itself, and as such to the self. Thus self-relatedness requires the presence of the other self. The “power” of the other self is precisely the “empowering” of self in its self-relatedness, and is thereby also a “self-empowering.” Seeking the other is finding that the other self is already present (Ibid., 202).

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16. This ethical theory is remarkably similar to that developed by Emmanuel Levinas. Other than both working in the phenomenological tradition, there does not appear to be any direct influence of Levinas on Zaner’s ethical theory. 17. See, Ricoeur (1970), p. 19. 18. See, Ricoeur (1970), p. 457. 19. See, Ricoeur (1970), p. 40. 20. See, Ricoeur (1970), p. 46. 21. See, Ricoeur (1970), p. 31. 22. See Ricoeur (1970), p. 458. 23. See, Zaner (1973a, b, 2006). 24. This passage is from an unpublished manuscript of Zaner’s expanding his concept of freephantasy variation written about in previous articles. (Private correspondence with author.) 25. See, Ibid., 290–291. 26. Natanson (1998).

References Braude, H. D. (2006). The Invisible Thread: Intuition in Medical and Moral Reasoning. The Committee for the History of Culture. Chicago, University of Chicago. Castiglioni, A. (1934). “Neo-Hippocratic Tendency of Contemporary Medical Thought.” Medical Life XLI(3): 115–146. Cobb-Stevens, R. (1990). Husserl and Analytic Philosophy. Dordrecht/Boston/London, Kluwer Academic Publishers. Heidegger, M. (1962). Being and Time. New York, Harper & Row. Jonas, H. (2001 [1966]). The Phenomenon of Life: Toward a Philosophical Biology. Evanston, Illinois, Northwestern University Press. Kass, L. R. (1997). “The Wisdom of Repugnance: Why we should Ban the Cloning of Humans,” The New Republic 216(22): 17–26. Levinas, E. (1973). The Theory of Intuition in Husserl’s Phenomenology. Evanston, Illinois, Northwestern University Press. Natanson, M. (1998). The Erotic Bird: Phenomenology in Literature. Princeton, NJ, Princeton University Press. Ricoeur, P. (1970). Freud and Philosophy: An Essay on Interpretation. New Haven and London, Yale University Press. Spiegelberg, H. (1965). The Phenomenological Movement: A Historical Introduction. The Hague, Martinus Nijhoff. Strauss, E. W. (1966). “The Upright Posture,” Phenomenological Psychology. New York, Basic Books: 137–165. Toulmin, S. (1973). ‘How Medicine Saved the Life of Ethics,’ Perspectives in Biology and Medicine 25(4): 736–750. Zahavi, D. (2003). Husserl’s Phenomenology. Stanford, CA, Stanford University Press. Zaner, R. (1964). The Problem of Embodiment: Some Contributions to a Phenomenology of the Body. The Hague, Martinus Nijhoff. Zaner, R. (1970). The Way of Phenomenology: Criticism as a Philosophical Discipline. New York, Pegasus. Zaner, R. (1973a). “Examples and Possibles: A Criticism of Husserl’s Theory of Free-Phantasy Variation”. Research in Phenomenology 3: 29–43. Zaner, R. M. “Examples and Possibles,” Unpublished manuscript, private correspondence with author. Zaner, R. M. (1973b). “The Art of Free-Phantasy Variation in Rigorous Phenomenological Science,” Phenomenology: Continuation and Criticism, Essays in Memory of Dorion Cairns. F. Kersten and R. Zaner, Eds. The Hague, Martinus Nijhof: 192–219.

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Zaner, R. M. (1998). “Surprise! You’re Just Like Me! Reflections on Cloning, Eugenics and Other Utopias,” Biomedical Ethics Reviews: Cloning. James M. Humber and Robert F. Almeder. Eds. New York, Humana Press, Inc.: 103–151. Zaner, R. M. (2004). Conversations on the Edge: Narratives of Ethics and Illness. Washington, D.C., Georgetown University Press. Zaner, R. M. (2006). “The Phenomenon of Vulnerability in Clinical Encounters,” Human Studies 29: 283–294. Zaner, R. M. (Summer, 2003). “Finessing Nature,” Philosophy and Public Policy Quarterly 23(3): 14–19.

Chapter 11

Fardels of the Heart: Obesity and the Unbearable Heaviness of Being Paul A. Komesaroff

And send us prying into the abyss, To gather what we shall be when the frame Shall be resolved to something less than this Its wretched essence; It is enough in sooth that once we bore These fardels of the heart – the heart whose sweat was gore. Lord Byron, Childe Harold’s Pilgrimage: Canto the Fourth [H]uman affliction is an appeal to be cared for and taken care of[;] it thereby requires the afflicted person to put himself or herself. . . in the hand of others. It is essentially a trust relationship that is evoked, and it is trust in a special sense: namely, trust in the context of initial, vital vulnerability and diminishment of selfhood. . . [T]hose to whom this appeal is addressed. . . are called on precisely to be responsive to just this specific afflicted person in his or her very condition and responsive for his or her actual well-being and life. . . Richard Zaner, Ethics and the Clinical Encounter (1988, p. 310)

Health problems related to excessive weight or obesity have acquired major importance in modern Western societies. In Australia it is said that nearly two thirds of people are overweight and about one third are obese. A long list of health problems is attributed to or associated with excessive weight and the economic cost is said also to be great. Both the causes of the high prevalence of obesity and the most appropriate responses to it are the subject of intense debate but appear to include increased availability and aggressive marketing of convenience foods, processed foods of high energy density, increased use of motor cars, automation in the workplace, and increased time spent in passive entertainment pursuits. The responses to this modern plague include a search for new pharmaceutical treatments and public health campaigns directed towards encouraging people to P.A. Komesaroff (B) Faculty of Medicine, Monash University, Victoria 3800, Australia e-mail: [email protected]

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reduce their energy intakes and to exercise more. There has been a huge increase in commercial enterprises selling medical therapies and weight loss programs, even though the evidence shows that these are at best minimally effective. Additional measures under consideration include banning food advertising and marketing to children, imposing food and physical activity requirements on schools, and controlling availability of convenience foods and drinks. While it may well be associated with significant and increasing health problems there are key assumptions that are often overlooked. One major gap is the absence of voices of the people living with obesity themselves. This essay for it is a contribution to redressing this lacuna. My understanding and insights are derived from my conversations with many of my patients and with one in particular, whom I will call “Jo”.1 Before I proceed further, therefore, I would like to introduce her to you. Although Jo was only thirty eight when I met her a couple of years ago, she had already had a long life. What struck me from the very first was her deep sense of sadness and tiredness. She had spent a lifetime battling weight issues, medical problems, family conflicts, financial worries. All she wanted, she said, was to be able to rest and be happy. When she was growing up Jo had thought of herself as an ordinary kid. The family lived in the Western suburbs: they weren’t well off but they weren’t poor either. It was not a close family. Her parents’ marriage was unhappy and sometimes marred by her father’s violent behaviour. There was little sharing of emotion. In fact, Jo reflected that she never saw either of her parents cry, and she felt that neither of them was ever aware of the personal pain and suffering she endured. It was not until puberty and she started putting on weight that she began to think of herself as different. Whether it was her weight that separated her from her classmates or her sense of being different that led to her weight gain she could not decide. However, her memories of high school were dominated by a sense of alienation and exclusion, and sometimes frank humiliation. What she experienced then continued throughout her entire life. When she was 16 her weight was already 80 kg and by 20 it was 100. it continued to increase inexorably, especially after her pregnancies. By the time she was 30 she weighed 160 kg and on her 39th birthday she registered 203 kg. The extreme weight ravaged her body: she suffered from diabetes, heart disease, severe breathing problems and painful arthritis and could walk only with great difficulty, with the help of two sticks. Jo and I talked at length about her struggle, her hopes and deep fears, and her body. We talked about what it is like to live within an obese body. Of course, this is a bad way to put it. I experience my body not primarily as an object among others in the world, or as a thing that I occupy. Rather, I am embodied, in the sense that I live my body, not just that I have one.2 My lived body is just not an objective, physiological body. It is rather the condition and context through which I am able to have relations

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with objects. My body is immanent and transcendent. I live it, as it is experienced by me. It provides the horizon which establishes my place in the world and makes possible my relations with other people and other things. My body is my being in the world. It is the means by which I obtain knowledge and generate meaning. It constitutes the field within which I establish my cohesion and identity as a subject, the basic schema of orientation, the centre of my systems of coordinates.3,4 My body, therefore, is not the means by which I experience the world; it is not a mere property of my personality or individuality; it is not a collection of organs and tissues subject to health and disease. At least, it is not just these things: it is also who I am and how I exist in the world. It defines and shapes my self representations, my sources of sensuous pleasure and my relationships with others. My body is private: indeed, it is the very meaning of private. It is also my link to other bodies. My flesh is not a pure object: it is a component of the medium within which I interact with others and set my personal course.5 Different meanings are made possible through fluctuations or perturbations in the bodily schema. It is not just a matter of meaning either: the mutated manifold transforms the very conditions of knowledge and experience.6 There has been extensive discussion about the lived experience of the sick body,7 the sexed body8 and the disabled body.9 To take the last example, Kay Toombs has written about the experiences of people with disabilities, drawing on her own experience of multiple sclerosis. She describes in detail the disruption of the lived body engendered by the loss of mobility. This includes a change in the character of surrounding space, an alteration in one’s taken-for-granted awareness of (and interaction with) objects, the disruption of corporeal identity, a disturbance in one’s relations with others, and a change in the character of temporal experience. The loss of upright posture is of particular significance since it not only concretely diminishes autonomy but affects the way one is treated by others.10 What about the lived experience of the obese body? I will let Jo speak in her own words: My body, she says, feels alien to me. It is as if it is not my own any more. When I was a girl I was nimble and lithe. I loved dancing and I was the fastest runner in the class. I was always running everywhere. They couldn’t stop me. Now it is painful for me even to stand up from sitting. I have to use two sticks to walk. Even the simplest daily tasks require effort. Sometimes it is too much to be worth it. I can’t sit in most chairs. I haven’t gone to a movie in years. Everything I experience is through the lens of my fat. I once looked up “heavy” in the dictionary and found that almost all the terms applied to me: my body is slow, obdurate, ponderous, cumbersome, lumpish, ungraceful, oppressive, stodgy, inert. When I go to Target to buy a T-shirt the shop girl looks me up and down with undisguised contempt. When I go to the doctor for a Pap smear I sense his revulsion as he approaches me, lying on the couch. I try to shrink away, to look small. I imagine my liquid fat dribbling down the legs of the couch, forming an embarrassing, filthy puddle on the floor of his spotless surgery.

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Sometimes I try to imagine my body to be a kind of thin body, bigger than most, but able to pass as thin. I try to block out my bulges, rolls and dimples, my fleshy spillages. I try not to look at myself in mirrors or shop windows. I bind myself up in elastic underwear, wrap myself in dark colours, trying to hide my body from myself and from the gazes of others.11 In public, no matter what I wear, I feel naked. I can see what people are thinking. The first thought that passes through their heads when they look at me is “fat”. Last week I was in the train and someone exclaimed loudly to his companion so that I could hear, “The trouble with fat people is that they take up too much space!”. In the supermarket people standing next to me in the queue always scrutinise what I buy. I always buy good food now – much better than most. I only eat organic food and I am a vegetarian. I have watched every morsel, counted every calorie, that has gone into my mouth since I was 16. I don’t eat MacDonald’s or drink Coca Cola. But I can see what they are thinking: “She is a glutton. She lacks control. I bet she’ll eat all that tonight. . .”. It is well documented that obesity is a social construction. This is true in both a more and a less obvious sense. The average weight has increased in developed societies because of increased availability of food and decreased exercise. At the same time, the meanings and values attached to body size and shape have also changed, with time and culture. In the West and in many other societies fat bodies used to be regarded as aesthetically pleasing and sexually desirable.12 In the early twentieth century, for example, the slender woman was regarded—in the words of a contemporary text—as the “type of women men should shun when choosing a life companion”.13 Such women, the writers went on, were “man haters”. Their sexual development is arrested in early youth, as evidenced by “flat chests, narrow hips, bloodless and thin or peaked features . . . and a lack of that warmth and softness that attracts and holds the affections of men”.14

Many cultures have regarded fat as a desirable and aesthetically pleasing characteristic. Fatness is often a mark of social status for men and of marriageability in women. Large bodies are seen as soft and well-tended by a prosperous, caring community.15 They are also seen as sexually responsive and desirable. Rebecca Popenoe16 has shown how, for example, the “laboriously fattened, voluptuous, immobile” bodies of Azawagh Arab women embody ideals of sexual desire, kinship, religion and health. The women control the fattening process and with it establish their own social and sexual power. In Azawagh society the beauty ideals attached to fatness are actively embraced by both sexes as an effective means of preserving the identity and solidarity of the community and the well-being of the individuals within it. Fatness, therefore, may be a signifier of beauty and health, opulence and prosperity, power, sexual availability, dependent and domestic femininity and community well-being.17 Obesity, on the other hand, is none of these things. It is not widely recognised that the concept—and indeed the word itself—are of relatively recent origin. The word “obese” first appeared in English in the seventeenth century,

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as opposed to the word “fat”, which goes back at least a thousand years earlier. Obesity is a form of fatness that is linked to a series of moral and cultural valuations. It refers to excess and has progressively become linked to disease and other socially undesirable characteristics. Over time, the word has accumulated a congeries of connotations, which now include social transgression, greed, psychological maladjustment, impoverishment, untrustworthiness, self-indulgence and hedonism.18 Studies have shown that physicians describe their obese patients as weak-willed, ugly and awkward.19 Furthermore, as Jo has found many times, social discrimination against obese people is active and widespread. Because obesity is a social construct it is not surprising that, as in previous health issues configured at the cultural level as epidemics or plagues,20 it has been used in the service of larger social, economic, and political projects. Bodies’ surfaces and boundaries are continually crafted within social fields of inequality.21 The feminist author Susan Bordo has argued that flesh gendered feminine is devalued in the pursuit of productive individualism and virtuous self-mastery.22 Katherine Le Besco23 has shown how meanings surrounding identities are produced on the basis of body size which in turn produces social stigma. “Negotiating questions of fat identity”, she writes, “involves a fluid, alternating pattern of invocation and refusal of mainstream tropes of health, nature, and beauty”.24,25 (C)urrent discourse surrounding body size and shape has worked to incorporate the protests of fat people against their own bodies; when civil rights are being demanded on the basis of genetic subjection of fat people, the fat body is effectively rendered uninhabitable.26

It is important to emphasise, however, that the various meanings of fatness are not just of purely theoretical interest, a curiosity of linguistic usage. These meanings are actually realised in the social flesh: they are engraved in bodies, which carry the traces of evolving traditions, fashions and aesthetic styles, and they result in real pain, real suffering and too often, real despair. Jo is not just a mind in a body, as in a box, and a body in the world. Her world itself is flesh. Her body is not “in” the world and the world is not “in” her body, ultimately. The world neither surrounds her flesh nor is surrounded by it. There is reciprocal insertion and intertwining of one in the other.27 Jo’s body is at once an organon of knowledge and the source of the valuation of things. As the philosopher Maurice Merleau-Ponty has said: There is a strict ideality in experiences that are experiences of the flesh: the moments of the sonata, the fragments of the luminous field, adhere to one another with a cohesion without concept, which is of the same type as the cohesions of the parts of my body, or the cohesion of my body with the world. Is my body a thing, is it an idea? It is neither, being the measurant of all things.28

Contrary to the assumptions of contemporary medical discourse, the body is not a machine and is not subject to machine-like causality. There is no simple causal route by which the social forces are played out within people’s bodies. The pathway from society to the inner schema of the body, from history to flesh, from culture to the lifeworld, is tortuous and complex. Let us return again to Jo.

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Jo could not remember a time when she was happy. She had always felt she was the black sheep of the family. She was somehow different – more sensitive, less interested in sport. She liked music and would spend hours by herself as a young teenager. She was always lonely. More than her sister she was disturbed by her parents’ problems and can recall the shame she felt when a school friend visited and witnessed a violent argument in which her mother threatened her father with a knife. She longed to be like the other girls and to be regarded as attractive to the boys. Sometimes her friends tried to help her, but on one occasion this turned to disaster. When she was sixteen she went out on a blind date with a boy who was four years older than her. He took her to a pub, got her drunk and then took her home and raped her. Confused and ashamed, feeling sullied and defiled, she confided in no-one. She became more of a recluse, her only source of physical pleasure being food. Soon after, she left school. She had never been very good at studying and the constant humiliation made each day a painful experience. Her parents were too involved in their own problems to care much. She took up an apprenticeship at a horse stable and lived alone in a hut at the back of the stables. She was the only girl and the other apprentices, failing to make headway with her sexually, continued the pattern of ridicule and humiliation, often hitting her over the head in a gesture of contempt. This was a period she remembered as one of absolute desolation. The only mitigation was the kindness she experienced from her boss and his family. The boss’s wife was the first to suggest a diet. At her suggestion Jo visited a doctor and was given instructions about what she could and couldn’t eat. She described how much she wanted to lose weight, how much she just wanted to be normal. When the doctor told her what to do it seemed so easy. But in reality it wasn’t easy at all. Her dependence on food was too strong. Despite her best efforts she couldn’t resist the hunger. During the day she would try not to think of food by trying to focus on her work. During the night she would lie awake, sad and alone, trying to ignore the vast chasm in her stomach aching for the comfort of food, any food. Her whole body seemed to shout at her, command, compel her, to eat. It would often reach the point where she could think of nothing else. She would turn on the television, try to think of things she would like to do, places she would like to visit, but it was often of no use. Sometimes she would go for a whole day, or nearly a day, eating almost nothing. She would get to ten o’clock at night and think to herself that she had made it: one day, one small accomplishment, perhaps a few grams less in weight. That, at least, would be an achievement of sorts. There was not much else to be proud of. Sometimes she would get to ten o’clock and feel so bereft, so lonely, so sad, that without knowing how or why she would find herself at the local Seven Eleven shop, buying a couple of pies and two cans of Coke. She would devour them, like a junkie taking a hit. The comfort was instantaneous but only momentary. Afterwards, she would inevitably feel more humiliated than ever, totally abject, defiled and negated, absolutely nothing.

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How does a society enter a body? How does it shape our flesh? How in the lifeworld, the intimate domain of immediate experience, sensuous and social, are the structures of our bodily experiences and meanings composed and then given corporeal reality? Perhaps the most primordial of lifeworld experiences is that of the enjoyment of food. In spite of the fact that in modern medical and cultural discourses eating is presented as a purely functional and physiological activity, from earliest memories it evokes rich and diverse significations. One does not have to invoke the ritual of fasting practised in virtually all cultures and all the major religious traditions, or the use of the hunger strike as a political weapon by Mahatma Gandhi, Bobby Sands, Daniel Berrigan, the Suffragettes and many others as proof of this. One only has to reflect on the mundane act of eating itself. The most powerful way in which cultural and social influences are imprinted on the body is through the experience of eating. Medical discourse has focused on the physiology of energy metabolism and hunger, and modern social and public health campaigns have sought to change eating attitudes and behaviour. However, eating is not a purely mechanical activity that can be modified at will according to dictates issued by doctors or policies promulgated by public health practitioners. The meanings of eating, and the habits and practices associated with it, evoke some of the most elemental and primal experiences of an individual and are closely bound up with their senses of personal and psychic identity. To understand these meanings, it is necessary to examine in detail what is involved. Let us reflect, therefore, on the mundane process of eating. Here I am at breakfast. I am hungry. I know that I am hungry, because I am separated from the world. I am separate and needy, because I am human. I can see that the world stretching out before me exists to satiate my hunger. I experience the anticipation of the meal. My attention focuses and my senses grow more acute as I respond to the site and smell of the food: the toast, the egg, the orange juice. I arrange the food on the plate and adjust my position in my chair. I exclude other sensations. I place a morsel of the egg and toast in my mouth. The taste wells up, spreads through my mouth, suffuses my body. I feel slight contractions in my pharynx and upper abdomen. I savour the experience, try to hold the moment. I experience with pleasure the various textures, the crunching sensation, the mixture of flavours. During enjoyment, as Emmanuel Levinas says, I am a hungry stomach without ears. I concentrate on my own pleasure. While I am savouring this mouthful of food, there is no physical distance between me and the world. I become my sensations. “The objects of the world, which for thought lie in the void, for sensibility—or for life—spread forth on a horizon which entirely hides that void”.29 This sensibility is my experience of otherness, of “the elemental”. In the satisfaction of need the alienness of the world that founds me loses its alterity: in satiety the real I sank my teeth into is assimilated, the forces that were in the other become my forces, become me (and every satisfaction of need is in some respect nourishment).30 I repeat my actions. I am now chewing methodically. I swallow and trace the passage of the macerated food into my upper pharynx and then I lose it, to discover a sense of fullness in my stomach. I establish a comforting rhythm, involving my

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jaw, my tongue, my hands and my throat. I repeat the actions without thinking—in fact, it takes some effort to stop. The rhythm is reassuring, calming. The external environment has receded from my consciousness. My whole body is focused on the gustatory experience. I am embraced by it, consumed by the act of consuming. In enjoyment, to quote Levinas again, I am absolutely for myself. I am alone without solitude, innocently egoist and alone. Not against the Other, not “as for me” but entirely deaf to the Other, outside all communication and all refusal to communicate.31 The signification of the gustatory and the olfactory, of eating and enjoying, has to be sought on the basis of the signifyingness of signification, the one for the other. . . . It is a passivity more passive still than any passivity that is antithetical to an act, a nudity more naked than all “academic” nudity, exposed to the point of outpouring, effusion and prayer. It is a passivity that is not reducible to exposure to another’s gaze. It is a vulnerability and a paining exhausting themselves like a haemorrhage. . .32

After a time I am aware of a fullness in my stomach, but the plate still beckons. The hand mouth actions continue without my conscious intervention. The sense of pleasant fullness may be exceeded. Even if I am not really concerned about my weight I connect the act of eating with a sense of weightiness. Each mouthful connotes a sense of excess. I have a mental image of obese persons, not myself, but others. The disapproval associated with eating—overeating—surrounds me. I feel a mixture of guilt, pleasure, excess, self-betrayal. I am suffused with a variety of sensations, not all of them consistent: pleasant satisfaction, comfort, reassurance, shame. When I am in the process of satiating my hunger my relationship with the world changes. When I eat, I am not distant from the world: I am absorbed in it. I am overwhelmed with it sensually. I taste it and feel it and enjoy the developing sensation of satiation. This is my absorption in the element, and my first experience of the world’s otherness.33 Jo and I have reflected many times on the question: What is the space one seeks to fill by eating? One thing is clear: it is rarely, if ever, a physiological space. Rather, it is a space of meaning and values. It is a space to be filled by a caring, nurturing relationship with the world and with others. It is a space to be filled by solidity, comfort, gentleness and reassurance. The “body naked and indigent identifies the centre of the world it perceives”, says Levinas. It conditions it by its own representations of the world “and is thereby torn from the centre from which it proceeded, as water gushing forth from rock washes away that rock”. The body indigent and naked is not a thing among things. It is “the very reverting. . . of representation into life, of the subjectivity that represents into life which is sustained by these representations and lives off them”.34 The world I constitute nourishes me and bathes me. It is aliment and “medium”.35 Eating is an activity of meaning that is both intensely personal and deeply social. In fact, there is a surplus of meaning. Representation consists in the possibility of accounting for the object as though it were constituted by a thought, but there is an overflowing of meaning that arises in relation to alimentation. The surplus over

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meaning is not a meaning in its turn, simply thought as a condition—which would be to reduce the aliment to a correlate represented. Eating. . . is not reducible. . . to the set of gustative, olfactory, kinaesthetic, and other sensations that would constitute the consciousness of eating. This sinking one’s teeth into the things which the act of eating involves above all measures the surplus of the reality of the aliment over every represented reality, a surplus that is not quantitative, but is the way the I, the absolute commencement, is suspended on the non-I. The corporeity of the living being and its indigence as a naked and hungry body is the accomplishment of these structures. . .36

The eating process is a sensual one, and indeed, the model for all enjoyment and satisfaction. However, something can go wrong in the moment of pure sensibility.37 Instead of the element serving as an access to satiation and pleasure it can deliver me abstractly over to otherness, into pure empty sensibility.38 Faceless and losing itself in nothingness, my body can become inscribed in the fathomless depth of the elements.39 Darkness is the very play of existence which would play itself out even if there were nothing. There is a density, an atmosphere, a field in which I become immersed, which omits the actual objects that would have this density, which lies outside the breath of existence or the field of familiar forces.40 Jo was all too familiar with both the ecstasy and the agony of eating. For her, eating was a source of solace. Her layers of fat provided insulation against the assaults of the inexorable harshness of the world. Her expanding body was her panoply, her shield. It protected her, but paradoxically, it also exposed her. Not only was it a shield to hide behind: it also stripped her bare. It rendered her completely naked, exposed to anyone who merely glanced at her, who could in an instant read her inner fears, her passions, her weaknesses, and her pain. As with other major illnesses throughout history, the obese body is a nodal point for conflicting lines of force: for negative surges, humiliation, disease metaphors, decay and abandon, resistance, opposition. It is a palimpsest for diverse meanings, the site of cultural inscriptions which are not always clearly legible and not always consistent. It is a kind of cultural lightning rod—a focus of fear and fantasises, aspirations and ambitions. It may be regarded as the site of plenitude, or luxury, or wealth or power: that is, it may be at the heart of the social order and its institutions. It may also be the site of excess, of the absence of control, of abandon, of unrestrained libido. The obese body may therefore be marginalised, outcast, darkly threatening the imminent breakdown of internal and external control. Jo never finished the apprenticeship. After a couple of years she left the stables and drifted a bit. She worked in various jobs and had a couple of unsuccessful relationships from which she ended up with two children. She tried alcohol and speed, but they didn’t do much for her. She thought a lot about death and wondered about killing herself, but she never tried anything. When she was thirty eight she teamed up with Damien, who was ten years younger and himself had problems with depression and drugs. However, he truly cared for her and committed himself to the care for her children, who were now teenagers. He suggested that she seek specialist help and on her GP’s advice she came to see me.

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By this time her medical problems were far advanced and she had great difficulty breathing as well as walking. But what upset and humiliated her most was her inability to care for herself at the most mundane level. She needed help from Damien or one of the children to dress, wash, or even clean herself after going to the toilet. In addition to her deep personal demoralisation she now also felt that she was failing her family. It had been one thing to have betrayed herself; she now felt that she was also betraying the only truly caring relationship she had ever experienced. She was desperate to seek a solution. We discussed surgery. The image of the surgeon’s knife slashing at her skin was almost unbearable, but she suppressed her revulsion and spoke with a surgeon, only to find that there would be no way she and Damien could afford the thousands of dollars needed to proceed. Jo had over many years grown to hate her body. She was not alone. For every one else it also seemed to be an object of abhorrence and disgust. She was in fact often taken aback by the intensity of the attacks on her, as she was merely going about her daily business. It was as if they thought that she was attacking them, as if she posed a threat against which they had to defend themselves. She could not understand how, raw and vulnerable as she was—her only defence, her pathetic and ineffectual defence, being her thick layers of adipose tissue—how she could be encountered as menacing, as a figure of abhorrence and dread. The obese body—like all bodies—is not just one body but many. It is the biological body, the body of organs and tissues, of health, sickness and disease. It is also the social and cultural body, the body of affect and emotions, the body of love and hate, of imagination and dreams, of hope and dread, of guilt, of sin, of sexuality and passion, of scandalous transgressions, of dark secrets and unspoken desires. It is the body of forces and densities, of drives and inner, unknown spaces.41 The body of medicine is one of the proudest achievements of reason and the Enlightenment. In this canon the body is made up of spaces and volumes. It is presented as entirely finished, completed, strictly limited, and is shown from the outside as something individual. That which transgresses its limits is excluded, hidden, or moderated, including sexual life, eating, drinking and defecation, which are transferred to the private and psychological levels where their connotations become narrow and specific, torn away from a direct relation to the life of society and to the cosmic whole.42 It is self sufficient and speaks in its name alone. In the medical discourse, death is only death, it never coincides with birth; old age is torn away from youth. All actions and events are interpreted on the level of a single, individual life. They are enclosed within the limits of the same body, limits that are the absolute beginning and end and can never meet.43 The body of science is the full, multifarious body attenuated and purified of all its inconvenient and carnal excrescences. The elements that reason sought so assiduously to subdue, however, could not be extirpated altogether. Instead, they were forced underground, into more arcane social and psychological locations, from which they continued to wage an obdurate war of resistance. Historically, one of the manifestations of these recondite remnants of pre-Enlightenment reason was the figure of the grotesque body, which erupted from time to time in carnivals and other

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events when social discipline was momentary loosened.44 The obese body is one of the contemporary forms of this arcane space. The grotesque body provided all the elements that were lost when the rational, medical body was constructed: the merging of life and death, the continuity with the ancestral body, which is renewed in the next generation, and with other fleshly bodies. It was a body in the act of becoming, never finished, never completed, continually built and created, and subject to unlimited transformation. It swallowed the world and was itself swallowed by the world. It ignored the impenetrable surface that closed and limited bodies as separate and completed phenomena. In the contemporary age, the bulges and eruptions, the rolls of fat, the uncontainable surfaces and volumes of the obese body, suggests “uncontained desire, unrestrained hunger, uncontrolled impulses”, a refusal of regimentation and subjection.45 In this sense, the obese body is a body opposed to science, standing against science, and by its nature resisting the epistemological and social discipline imposed by scientific thought and the practices that accompany it. As a component of the grotesque the obese body offers a gesture of resistance to the totalising sway of science and medicine. But, as every obese person knows, this is not a war of liberation. In the contemporary world the other of science and knowledge is experienced not as pleasure and creative enjoyment but as shame and revulsion, as disgust and horror, as abjection. Abjection and the grotesque are two sides of one coin. They reflect the same characteristics of the obese body: its ambiguity, and the fact that it does not respect borders, positions and rules. As abjection, the obese body disturbs identity, system and order. It is a place not where meaning is created but where it collapses, where “I” am not.46 The abject, obese body presents a life-threatening negation that must be radically excluded. The abject is the in-between, what defies boundaries, a composite resistant to unity, the threat of unassimilable non-unity.47 The experience of abjection is frequently described not only by those observing obese bodies but by the obese people themselves. The following description by Julia Kristeva evokes Jo’s poignant descriptions of her own corporeal experience: (There is) a weight of meaningless, about which there is nothing insignificant, and which crushes me.48 There looms. . . one of those violent, dark revolts of being, directed against a threat that seems to emanate from an exorbitant, outside or inside, ejected beyond the scope of the possible, the tolerable, the thinkable. It lies there, quite close, but it cannot be assimilated. It beseeches, worries, and fascinates desire, which, nevertheless, does not let itself be seduced.49

In the classical account of Mary Douglas, filth and defilement exist on the border of identities and threaten the unity of the ego. Revulsion and disgust are referents to those things that cannot be controlled, which refuse to be bounded, are anomalies that cause profound cultural anxiety. The rolls of fat, the flab, the surfeit of tissue, the seepages and discharges, signify the disorder that threatens whenever the injunction to consume is taken too literally and the precarious balance of psychic and social discipline breaks down.50 The boundaries between the pure and the dangerous are largely conventional: today, the obese body stands on the side of danger.

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Abjection is, therefore, systematically generated deep within the culture. There is an inescapable need for objects of revilement. They help maintain social solidarity and guarantee psychological coherence. Like other plagues before it obesity exquisitely epitomises the fears and terror deep within the contemporary social imaginary. In the public sphere of contemporary society fat bodies have assumed the function of the abject: as “that which must be expelled to make all other bodily representations and functions, even life itself, possible”.51 They take up the burden of representing the horror of the body itself for the culture at large. They symbolize the inevitable death and decay of all bodies, the inexorable fate of all carnal matter. Jo’s body bore the stigmata of her sad life. There is a cruel and ironic parallel between her body, the merciless reception of it, the medical consequences and the facts of her social and emotional life. Jo was by now unable to undertake even the most meagre of physical actions. When surgery had been excluded all that was left was the strategy that had failed her all her life: resisting the compulsion to eat. It was futile, and we both knew it, but she promised to try it all the same. On one occasion over three months her weight fell by 5 kg. We tried to maintain a façade of hopefulness. The next time, however, her weight had gone up again. She was increasingly remorseful and full of self blame. She had tried to break out of the circle of hopelessness. But the forces against her had been too powerful. She knew she was beaten, or at least that she couldn’t win. She asked about the effects of stopping her medications. I explained what the role of each one was. She assured me that she was not suicidal and would not attempt to take her own life. She knew that she was caught in a trap, that the wound in her flesh was deep and immedicable. She was an innocent bystander to her own tragedy. I last saw Jo just before Christmas. She was happier than usual and talked optimistically about the forthcoming family celebrations. But she failed to attend her next appointment a month later. Her husband rang later that day to say that, tragically, he had found her dead beside him in their bed that morning. It appeared that she had died of natural causes. The obesity epidemic is not merely a crisis of health outcomes or health care costs. It is a symptom of deeper processes within medicine and the culture. The obese body is not just a body of health, sickness and disease. It is many bodies, including the bodies of society and culture, the emotions, imagination, sin, and sexuality. It is a space of excess, of surplus of meaning, of resistance against the relentless, unpitying forces of the apparatuses of science and culture. It is also a site of sadness, of humiliation, of loss, of abject defeat. Our bodies are not just objects in the world. We are, to be sure, flesh and blood, atoms and molecules, hormones and electrical impulses. But we are also flows, movements, strata, segments, intensities, aligned and linked in heterogeneous, disparate, discontinuous unities.52

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This has been the story of one body, a body that was ravaged, abused and, until the end, uncared for. This essay is dedicated to Jo herself and all those who suffered with her.

Notes 1. This essay is based on the experiences of a real individual but also draws on stories provided by a number of other people. Some factual details – including Jo’s name – have been changed for reasons of confidentiality. 2. Merleau-Ponty M. Phenomenology of perception. London: Routledge & Kegan Paul, 1962, p.70. 3. Husserl E., Cartesian meditations: An introduction to phenomenology. Trans. D. Cairns. The Hague, Martinus Nijhoff, pp. 116–117; Husserl E., Ideas pertaining to a pure phenomenology and to a phenomenological philosophy: Studies in the phenomenology of constitution. Trans. Rojcewicz and A. Schuwer. Dordrecht, Kluwer Academic Publishers, 1989, pp. 165–166. 4. Schutz A., and Luckmann T. The structures of the life-world. Trans. by Richard M. Zaner and H. Tristram Engelhardt, J London : Heinemann, 1974, pp. 222–226. 5. Grosz E. Volatile bodies, Bloomington: Indiana University Press, 1994, p. 102. 6. Bodily control is an expression of social control. The social system seeks progressively to disembody or etherealise the forms of expression (Mary Douglas: The two bodies in Natural Symbols. The social body and the physical body). 7. Zaner RM. Conversations on the edge: Narratives of ethics and illness. Washington, D.C., Georgetown University Press, 2004; Zaner RM. Ethics and the clinical encounter, op. cit. 8. E.g. Grosz E. Volatile bodies, op. cit., and Butler J. Gender trouble: Feminism and the subversion of identity. New York: Routledge, 1990. 9. E.g. Toombs SK. The meaning of illness: A phenomenological account of the different perspectives of physician and patient. Dordrecht; Boston: Kluwer Academic Publishers, 1992. 10. Toombs SK. The lived experience of disability. Human Studies 18: 9–23, 1995. 11. Cf. Murray S. (Un/Be)Coming Out? Rethinking Fat Politics, Social Semiotics, Volume 15 Issue 2, 2005, 153-163. 12. Jutel A. Weighing Health: The Moral Burden of Obesity. Social Semiotics Volume 15 Issue 2, August 2005, 113–125. 13. Wood, GP., and EH Rudduck. 1923. Vitalogy or encyclopedia of house and home. Chicago, Ill.: Vitalogy Association. Quoted in Jutel ibid. 14. Wood and Rudduck, op. cit., p. 861. Quoted in Jutel ibid. 15. Mauss M. The gift: Forms and functions of exchange in archaic societies. Trans. by Ian Cunnison. New York, Norton, 1967. 16. Popenoe R. Feeding desire: Fatness, beauty, and sexuality Among a Saharan people. London, Routledge, 2004. 17. Gremillion H. The cultural politics of body size. Annual Review of Anthropology. 34, 2005, 13–32; see also Jutel A. op. cit. 18. Polivy, J., D. Garner, and P. Garfinkel. Causes and consequences of the current preference for thin female physiques. In Physical appearance, stigma and social behavior, edited by CP. Herman, MP. Zanna and ET. Higgins. Hillsdale, N.J, Lawrence Erlbaum, 1986. 19. Maddox GL, and V. Liederman. Overweight as a social disability with medical implications. Journal of Medical Education 44, 1969, 214–220. 20. Sontag S. Illness as metaphor. London, Penguin, 1991. 21. Butler J. Gender trouble: Feminism and the subversion of identity. New York, Routledge, 1990; Butler J. Bodies that matter: On the discursive limits of “Sex”. New York, Routledge, 1993.

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22. Bordo S. Unbearable weight. Berkeley, University of California Press, 1993, p. 142. 23. Braziel JE and Le Besco K. eds. Bodies out of bounds: Fatness and transgression. Berkeley: University of California Press, 2001. 24. Losano A. and Risch BA. Resisting venus: Negotiating corpulence in exercise videos. In Braziel JE and Le Besco K. eds. Op. cit., p. 123. 25. The most obvious of these is the medical one. In the medical interpretation obesity relates to dietary management. According to Bryan Turner this “emerged out of a theology of the flesh, developed through a moralistic medicine and finally established itself as a science of the efficient body” (Turner B. The body and society: Explorations in social theory. London, 1984, Sage, p. 3). 26. Le Besco K. “Queering fat bodies/politics”. In Braziel JE and Le Besco K eds. Bodies out of bounds, op. cit., p. 76. 27. Merleau-Ponty M. The visible and the invisible, edited by Claude Lefort, trans. by Alphonso Lingis. Evanston [Ill.], Northwestern University Press, 1968, p. 138. 28. Ibid., p. 152. 29. Levinas E. Totality and infinity, translated by Alphonso Lingis. The Hague, Boston, M. Nijhoff Publishers, Hingham, MA, 1979, p. 135. 30. Ibid., p. 128. 31. Ibid., p. 134. 32. Ibid, p. 127. 33. Levinas E. Otherwise than being. Trans. by Alphonso Lingis. The Hague, Boston, M. Nijhoff, Hingham, MA, 1981, p. 72. 34. Totality and infinity, p. 127. 35. Ibid., p. 128. 36. Ibid., p. 128. 37. Levinas E. Existence and existents. Trans. by Alphonso Lingis, The Hague, Martinus Nijhoff, 1978, pp. 56–58. 38. Ibid., p. 57. 39. Totality and infinity, p. 158. 40. Levinas E. There is: Existence without existents. In Hand S, ed. The Levinas reader. Blackwell, London, 2001, p. 35. 41. Deleuze G., and Guattari F. A thousand plateaus: Capitalism and schizophrenia. Trans. by Brian Massumi. Minneapolis, University of Minnesota Press, 1987, p. 30. 42. Bakhtin MM. Rabelais and his world. Trans. by Helene Iswolsky. Cambridge, Mass., M.I.T. Press, 1968. 43. Ibid. 44. Ibid. 45. Bordo S. Unbearable weight. Op. cit. 1993, p. 189. 46. Julia Kristeva, Powers of horror: An essay on abjection. Trans. by Leon S. Roudiez. New York, 1982, p. 26. 47. See Lechte, J. Julia Kristeva. London, New York, Routledge, 1990, pp. 157–167. 48. Kristeva J. Powers of horror, p. 2. 49. Ibid., p. 1. 50. Douglas M. Purity and danger: An analysis of concept of pollution and taboo. London: Routledge, 2002. 1966, p. 2. 51. Kent L. Fighting abjection. Bodies out of bounds, op. cit., p. 135. 52. Deleuze G. and Guattari F., op. cit., p. 152.

Chapter 12

The Philosopher as Ethicist, The Ethicist as Storyteller Arthur W. Frank

What is he doing there? This question animates most of Dick Zaner’s bioethics essays. His presence in the hospital baffles people, and not the least charm of Zaner’s writing is that he shares their bafflement. Zaner visits the parents of premature twins; the babies have multiple problems and probably will not leave the hospital alive. “I searched for words to console, reassure, commiserate, unsure until the last moment what could possibly be the right words at a time like this” (Zaner, 2004, p. 4).1 Much to Zaner’s own surprise, he introduces himself as a philosopher: “the words that came out sounded bizarre to me” (2004, p. 4). “ ‘A philosopher?’ Jim [the father] demanded, his admirable candor providing all the inflection he needed. ‘What in the world is a philosopher doing here?’ A not unreasonable question, I thought and said so, wondering what, indeed, I was doing there” (2004, pp. 4–5). This chapter is about what in the world Zaner has been doing for all these years, being a philosopher in hospitals, principally at Vanderbilt. The question nags him, even as it perplexes and provokes those whom he visits, attends to, and serves. Sometimes, people’s perplexity is polite, but more often, Zaner is met with provocation: “ ‘Mr. Brown? I’m Dr. Zaner. . .’ ‘Another one? How many of you are they going to send in here anyway? I’ve said all I’m going to say. . .’ ‘Mr. Brown, please let me finish: I’m not “another one of them,” as you obviously think; I’m not a physician, and I’m not about to try and talk you out of anything. . .’ ‘So what and who are you then, Mr. Dr. whatever?’ I tried a small smile with a few words to match. ‘I’m not so sure, now that you ask. I’m not so sure you’ve ever heard of people like me before: I’m in ethics, and I’m supposed to help you, and your mother, and the doctors see if there is some way this impasse, this blockade about dialysis, can be. . .’ ” (2004, p. 23)

A.W. Frank (B) Department of Sociology, University of Calgary, Calgary, Canada e-mail: [email protected]

O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_12,  C Springer Science+Business Media B.V. 2011

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Zaner is “in ethics” and he is “supposed to help,” but what do those phrases mean, as a practice of applied philosophy? This chapter’s question echoes what patients ask Zaner and what he repeatedly asks himself: “All this time, that inward, whispering voice kept up its insistent challenge: ‘what am I doing here?’ ” (1993, p. 3).

1 Being a Philosopher The introduction that Zaner blurts out, surprising himself—“I’m a philosopher” (2004, p. 4)—expresses the truth of where he begins, and often where he ends. Zaner is a philosopher before he enters the hospital rooms in which he works, and his ruminations on what has happened in those rooms turn back to philosophy after he has left. Others write in detail about Zaner’s philosophy, but the briefest introduction to how philosophy orients Zaner’s bioethics seems necessary. Zaner’s ethics is less a philosophical position than it is a practice: something he does more than something he thinks or believes. This practice begins with a selfconscious suspension of thought, a silence. “To enter such a scene”—which could be the room of parents whose newborn twins face death, or the room of a man who is refusing to continue dialysis—“with the idea of trying to help is to be faced with the prominent need to sort things out: what’s going on and what might be done for it? This cannot be done beforehand: one never knows in advance which issues must be dealt with” (2006, p. 288, emphases added). The tradition of a presuppositionless beginning can be traced back through Husserl to Descartes, but my concern is only to underscore Zaner’s discipline of refusing prior assumptions, whether these are medical reports or bioethical principles, in order to attend to what is there. Which is, first and foremost, the patient, usually in a bed: “To enter the room was to enter her room. I noticed straightaway that, even if she didn’t orient to me, everything in the room, including me, was oriented to her in very specific and powerful ways. She was the center. . .” (2004, p. 57, original emphases). Such observations are a bare beginning, but this beginning is necessary as a kind of clearing. Too many voices compete for the ethicist’s attention: the physicians or nurses who made the referral, the patient’s family, the patient, bioethical colleagues and established ways of thinking. First, these voices must be suspended, provisionally silenced; first, Zaner has to experience the room as if he had never entered such a room before. Nothing beforehand. Then comes dialogue, the relations of self and other. “Seeing Tom is seeing Tom seeing me. Hearing him, I hear myself and know myself hearing him” (2004, p. 35). The self knows itself only in relation to other selves. Thus, bioethics is never about the patient in the singular, but rather it is always about relationships: “to address that actual, ongoing relationship itself, attending to each of the integral constituents within that temporally unfolding contexture” (1999, p. 107). These relationships are complex; patients find themselves in relationships comprising strangers, self, body, and family (1994, p. 217; see also 2004, p. 83). Decisions about therapeutic abortion, following genetics consultation, provide the most obvious examples of the shared, relational nature of ethical decision-making:

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With these [genetic] tests, we witness a change in the very sense of what we understand by “moral agent”: the single, isolated individual. . . Rather, the new moral agent is something somehow larger, more complex: both she and her husband and their developing fetus, all together. Yet, not even that is sufficient. For at stake is also his brothers and sisters, who need to know as much as he does and for their children’s sake. Even more, there are his first and second and third cousins. . . (1993, p. 103)

So the relational web expands, including also the medical workers who have performed the test and who now wait upon the couple’s decision, and who will have to perform the procedure, if it is chosen, and then have to live with their own moral consequences of those actions. The nature of relationships is that each participant makes the other’s participation possible. Here, as often in Zaner’s writing, he returns to Schutz: “In Alfred Schutz’s lovely phrase, she and I were face-to-face with each other, making music together. . .” (2004, p. 56). Conversation is Zaner’s medium of making music together. In this dialogical music making, each is responsible not only for his or her own part, but also for being the partner whom others need, if they are to play their parts as best they can. That is the foundation of Zaner’s bioethical practice. It is humans’ possibility and our responsibility. What is he doing there? The philosopher as ethicist reminds people that they can proceed—they can go forward in this dangerous world—only if they move with attention and respect for others. The ethicist is there to remind people whose habits of thought posit the separated individual that the “new moral agent” is “somehow larger” (1993, p. 103). Finally, Zaner remains a philosopher in the singularity of his pursuit for clarity. Zaner recalls asking his then-future teacher, Aron Gurwitsch, “why he himself had ‘gone into’ philosophy. His response was stunning: he pounded the table at which he had lectured, sending papers flying, and proclaimed loudly: ‘To be clear, Herr Zaner, to be clear!’ ” (2006, p. 285, n. 1, original emphases). Zaner the bioethicist avoids pounding on tables (plenty of others in medical centers do enough of that). Working in hospitals teaches him how elusive clarity is, always subject to later revision. It makes a difference, after a couple makes a painful decision whether to abort their fetus that clinical tests suggest is radically impaired, when the autopsy shows that the aborted fetus actually did have all the problems that medical tests had predicted—though with some margin of potential error—and would not have lived long after delivery (1994, p. 236). But such clinical evidence cannot be taken as moral certainty, for the simplest of reasons: the life that would have been lived under the auspice of an alternative decision can never be known. Herein lies the task of applied philosophy: how to achieve sufficient clarity in the inevitable absence of certainty? What kind of clarity is that?

2 Being an Ethicist What is he doing there? He is working in a hospital, on call to consult when medical treatment is complicated by interpersonal conflicts, or by difficult choices among alternative courses of action, or by fear of liabilities ranging from lawsuits to bad

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press. He is there to help people—both medical staff and patients—to make decisions that their professional training and life experience have not prepared them for. He is there in part because the human condition is marked by dilemmas, and in part because technology creates options and thus dilemmas faster than received wisdom can offer common-sense responses. Hospitals are places where moral vocabularies seem perpetually unable to keep up with what circumstances require. Before all else, Zaner is there to listen: “I wanted. . . to listen internally and intensely. . .” (2004, p. xi). Listening begins with receiving a referral, and it intensifies on entering a patient’s room. Listening continues when Zaner writes about what happens, often years later. Zaner listens for what families need to hear themselves saying. He listens so that people can hear themselves and thereby recognize themselves through the medium of his listening. Zaner’s objective as an ethicist—“to help them to think clearly” (1994, p. 213; see also 2006, p. 290) begins with the most intense listening. What Zaner hears are people who are struggling to make what he calls “the best of bad choices” (1993, p. 71). “But that’s awful,” says the mother of a critically impaired fetus. “What do you do when none of the choices are good ones?” (1993, p. 70, original emphases). As always, Zaner is candid about his limits: “I didn’t know then, and I’m not sure I know now, just how to respond to that question. It is the kind of question that cuts to the moral quick” (1993, pp. 70–71). Yet, this is the kind of question that Zaner confronts in almost every consultation: situations defined by none of the choices being good ones. Yet inaction is not an option either. As Zaner often explains to patients, not to act is to take one kind of action because a fetus continues to develop or kidneys continue to fail. People who have become patients are not simply confronted with situations in which none of the choices are good ones. They are also confronted with a form of decision-making that is new to them. In philosophical terms, couples and families are suddenly required to think outside their stock of knowledge (1994, p. 218). The typifications that have been sufficient to make sense of the world and the taken-for-granted assumptions that have sufficed to guide decisions are, with terrible suddenness, no longer adequate (1994, p. 231). “Coming across this obstacle, we must do something different to find a solution. We have reached what was described by Plato as an a-poria, an acute impasse. What must we do to resolve the dilemma?” (1993, p. 139). The “we” in the sentence just quoted refers, on my reading, to patients, families, medical staff, bioethicists and philosophers all, as each confronts this “acute impasse” from his or her personal and professional position. Each brings different resources to this confrontation, but all share the ultimate inadequacy of their respective resources. That shared lack is their common vulnerability, but to repeat Schutz’s metaphor, it is also their potential capacity to make music together, albeit a sad music. For vulnerable humans, the question of what to do, pressing as it is in hospitals, leads to asking what Zaner calls “the really basic ethical questions” that all persons, however implicated, eventually must ask: first, “who am I?” and then its relational complement, “who are you?” (2004, p. 83). These questions cannot be answered beforehand—again, Zaner’s first principle of nothing beforehand—but as

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close as humans can get to answers will be revealed in the process of responding to the aporia, the medical crisis that is also a moral crisis. Here we reach the heart of Zaner’s ethical method, and what sets him apart from many of his bioethics colleagues. Zaner’s method, contrary to the interventional ethos of most professions and the time pressures of medical managers, is “letting people be” (2004, p. 15; see also 1993, p. 44). What Zaner means is not what bioethicists call autonomy. Zaner works in enlightened medical settings where patients already have that. Patients’ problems are what to do with the autonomy they have. How to be autonomous is a problem when none of the choices are good ones, and people are operating outside their stock of knowledge, typifications, and takenfor-granted assumptions, including the assumption that in any dilemma, there has to be at least one good choice. Letting people be does not mean leaving them alone to make decisions using their own resources. It is already established that those resources are inadequate to the task that confronts them. The ethicist remains with people, listening and asking questions, “to help [patients and families] to think carefully about their situation in light of their own beliefs” (1994, p. 213; see also 1993, p. xxi). But it can be a shock for people to realize that “their own beliefs” are not sufficient guidance to the issues they face. They need someone to listen to them while they talk their way into new beliefs, founded on the old ones, but supplementing and revising them considerably. In the crises during which Zaner meets patients, these people must discover what their beliefs are, as they struggle among the best of a set of bad options. This struggle eventually depends on the extent to which all the participants can help each other to disclose the complementary questions: who am I? in relation to who are you? In this struggle of dialogue toward disclosure, the ethicist is participant, facilitator, and witness. The ethicist may shape the struggle, but he or she does so knowing that what ultimately counts is not what she or he says, but what patients and families can be guided to say to each other and to believe about themselves. Ultimately, the ethicist will be shaped by the history of struggles that become his or her biographical sedimentation What guides people in their struggles is another apparent principle that quickly turns into a question: “wanting to do the right thing” (1993, pp. 1, 28, 148). “But that doesn’t seem right,” a patient objects to one of her (bad) choices (1993, p. 62). Right is already in her moral vocabulary as a resource, yet the situation is pushing the boundaries of what right means—what counts as right when none of the choices are good. Eventually, syntax itself breaks down: “The right thing, right, thing, right?” (2004, p. 105). In the fractured world of bioethics consultation, the right thing is simultaneously, aporia, resource and telos. People’s need and desire to do right makes their situation deeply troubling. Their sense of right is their bedrock—as when a family member tells Zaner, “you got to tell that doctor that Martha’s got to be done right, taken home. . .” (1993, p. 28, original emphases). Doing right is what people want to be able to claim at the end. And some typification of right is what people have to work with, seeking that end. Zaner makes no pretense at having any authority to declare what the right thing is. That refusal marks another separation from some of his colleagues who understand

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their role as adjudicating rightness. Lacking either template solutions or decision algorithms, Zaner asks himself what he does bring, in what capacity he is there: “First, was I any different from any good friend? Second, even if there was something distinctive about my being a philosopher, just what was that?” (1993, p. 21). And then the almost inevitable question, as a refrain, “What in the world is a philosopher doing in the hospital?” (1993, p. 21). To which Zaner’s eventual answer, in practice if not in principle, seems to be: the philosopher becomes a storyteller.

3 The Ethicist as Storyteller What is he doing there? The ethicist is helping people to tell the stories in which their decisions might ultimately seem good enough. And, he is living the stories that he will tell, later, when he seeks to honor these people’s struggles. Most briefly put, the ethical value of stories is to clarify. Stories are the means and medium by and through which people seek to discover what counts as right, or sufficiently right, in their current situation. That situation is anything but clear, and telling stories about what is happening brings as much clarity as may be possible. This value, indeed this necessity, of stories to bring clarity is not uncontroversial, as many ethicists prefer to privilege principles and to avoid stories as deceptive in their particularity and emotion. So the case for narrative is worth specifying: until people tell stories about themselves, until they put themselves into a story that represents them, they do not know what is going on, and they cannot make the decisions that need to be made consciously, lest things happen by default. Zaner writes of a couple who must make decisions about what will be the brief lives of their premature and badly impaired twins: “how much Jim and Sue needed to tell their story” (2004, p. 9). The how much is imperative. Until Jim and Sue tell their story, they have no basis for thinking about what they must do. Their eventual decision makes sense only when it follows as part of a narrative in which one thing follows another according to a logic that is recreated in each story.2 The people who tell their stories in bioethics consultations generally do not like what things have followed which other things; Jim and Sue despair that premature births followed a too-short gestation. But that is the story they find themselves part of, and their unavoidable task is to plot the next move in that story. Zaner’s crucial insight into the practice of bioethical consultation is that as much as Jim and Sue need to tell their story, the story is not already there, waiting to be told. Thus, Zaner adds to his statement about Jim and Sue’s need to tell: “Or, at least, to tell a story, since you may never be all that certain, I suppose, just which one will or even needs to come out” (2004, p. 9). Stories, on this account, are not representations of events that have transpired and been held in memory, awaiting telling. Stories “come out,” much as Zaner’s unplanned introduction of himself comes out (“the words that came out sounded bizarre to me” (2004, p. 4)). Zaner is not a Freudian, but he recognizes an Id-like quality in some speech: words just come out, unbidden, and sometimes sound bizarre to a human who is endowed with the capacity to hear him or herself, and to

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react as a listener to his or her own speech. The work of ethics consultation is to help move the story from words that come out to words and actions for which speakers can feel responsible. This work does not take place easily or quickly. Perhaps my favorite line in all Zaner’s writing is when he observes: “Sometimes, in fact, it takes a lot of telling before you get it right” (2004, p. 9). There it is again, this word right, provoking the question: what, or maybe when, is right? The answer, or more accurately, a response, goes back to the observation above that people like Jim and Sue tell a story; that is, they tell one among a number of possible stories, each representing a different take on the situation they are in. What takes a lot of telling is finding the story that fits. The fitting story is that in which people discover what their values are, as they traverse this strange terrain where previous benchmarks seem to have little use in guiding action. The turn to stories addresses a problem of applying ethics that can be summarized this way. Words like right, or phrases like their own values, exemplify what Ian Hacking (1999) calls elevator words: any attempt to specify what they mean will invariably lead, through a process of one word being defined by another, back to the word that started it all. Asking what right actually signifies leads to working through a sequence of words, probably including values, and eventually ending up back at right. At the end of chasing what decision is implied by doing the right thing, a bioethics consultation ends with the justification that X ought to be done; why? Because X is declared to be this elusive right thing. But the right thing has not predicted X; on the contrary, X has filled in what the right thing is, in the present situation. The hard truth of Zaner’s decades of experience is that people’s own values prove to be of little use when specified in the abstract. They become working values only when—and analytically oriented bioethicists might shudder at this phrase—what is decided upon feels like it fits the values (or vice versa, reversibility being the process).3 To rephrase Zaner’s statement in terms of Hacking’s metaphor: it takes a lot of telling to get off the elevator with a feeling that words like right and value now have sufficient content to enable action. Surely there must be more; there must be outside principles that offer some check on the validity of this narrative loop. In Zaner’s most analytic writing, when he is the furthest from stories about people in actual consultations, I think he wants some external criteria that can be appealed to. But in his stories, no such criteria seem available, and none seems necessary. Take, for example, the primal rule that orients most ethical systems: Thou shall not kill. But at what level of fetal disability does therapeutic abortion count as killing? That is the question people struggle with in several of Zaner’s stories. Does discontinuation of life support count as killing? Is it “playing God” to discontinue life support, or was it playing God to have started that life support in the first place? The nature of the ethical aporia is that either principles are in conflict, or else what counts in the application of a principle—why the principle indicates acting this way rather than that—is not clear. Zaner is not concerned to mount a principled defense of narrative as a means of ethical decision-making. His argument seems entirely pragmatic: stories are the most available means to do the

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work of helping people reach a decision. After a lot of telling, people can get it right enough to be able to live with their decisions for the rest of their lives. And Zaner never forgets that people will live with their decisions for the rest of their lives. Recognizing that people tell one among a number of possible stories does not mean that Zaner as ethicist would stand by while they told any story. If stories are flexible, insofar as a number of stories could adequately represent a situation, they also carry a strong sense of moral responsibility. “My gift to Jim and Sue was listening; their gift to me was their story, the one they slowly understood took care of them when they desperately needed to be taken care of” (2004, p. 9). This cycle of giving and responding continues when Zaner eventually writes the stories we readers receive. These written stories seem a necessary final act to his ethics consultations. “And because of that [the couple’s gift to him], I took on the burden of telling their story, an obligation from their gift to me” (2004, p. 9). Stories, as what makes and keeps relationships moral, “harbor the powerful tug of ‘obligation’ and ‘responsibility’ ” (2004, p. 9). Responsibility is why not any story will suffice: “If I tell a story, I sense that I have a responsibility, among other things, to get it right, to make sense, to be clear, as well as to tell my tale in an interesting way” (2004, p. 9). This statement, however, risks more elevator words: responsibility leads to right, sense, clear, interesting; to what are these words accountable? What grounds them? Here Zaner is at his most circular, but also perhaps at his wisest: “I have a responsibility to be faithful to what my story is about” (2004, p. 9). Does faithful get us off the elevator, or simply take us up one floor from responsibility? I would argue we do get off the elevator, not perhaps in a philosophical sense, but as a pragmatic effect of the stories themselves. Consider two moments in Zaner’s stories. In one, medical staff and family are struggling with a difficult decision about end-of-life care. The right thing is in dispute. “But just as someone went off to find Dr. Rochelle, I heard the nurse back in the room abruptly let out a sort of sob. And I knew, just knew, that everything was over, had to be, people don’t make that sort of noise otherwise” (2004, 105, emphases added). People die; stories end, just end. And those who have lived intensely within the story just know that ending, not only that it happened, they know how right it was (or not). That same just knowing, and knowing in having been there through it all, grounds what it is to be faithful to what the story is about. Here I must claim the privilege of knowing something about Zaner’s writing process. For him too, it takes a lot of writing before he can believe he has been faithful. The complementary moment is when a woman who decided to have a therapeutic abortion returns to Zaner’s office, a couple of years later, bringing him cookies. She tells him: “That was really hard, so very hard. Sometimes I wonder if I’ll ever get over it. It still hurts. I suppose it will always hurt” (1993, p. 71). She goes on to tell him how she and her husband now have another child, two months old. “I think I’ll just love him all the more,” she says, “knowing that [her husband] and I did everything we could to save our first” (1993, p. 71). That story too has ended, although as in every story, one sort of ending is another beginning. This woman can never live the alternative life in which she decided against therapeutic abortion, but she can feel she “did everything we could.” And her life goes on, having another

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child, making cookies. It is a story, not the story, and there can be no moral certainty, but it feels like everyone has been faithful to what the story was about.

4 The Storyteller as Witness When, in the story just told, Zaner hears the nurse’s sob, he knows more than that death has happened. “I then knew or felt I should have stayed on, if nothing else, as a witness, for a witness was surely needed at just this time, with that long and agonizing process, that impossibly drawn-out dying over all those weeks in that terrible bed” (2004, p. 105). The final obligation of the ethicist, the obligation ultimately fulfilled in writing the story, is to be a witness. Zaner writes repeatedly about the value of the presence of the ethicist on the clinical scene. Before the ethicist says anything, “being present as an ethicist is of itself a trigger for very crucial conversations” (1993, p. 46). “To serve as ethicist is to be the occasion for these people—patients, family, doctors, nurses, and other providers— to undergo the disquiet and hardship of reflection and deliberation” (1993, p. 147). Again, the crucial importance of listening is to enable people to hear themselves tell their own stories: “to hear themselves think out loud, and to be heard, hoping that they will be able to get through it all with integrity and with the realization that while they might have acted differently they at least will have a strong sense of having done the very best they could in the circumstances—with all the uncertainty and suffering that entailed” (1993, pp. 71–72, original emphases). To get through it all with integrity requires a witness because integrity is a dialogical achievement; integrity must be recognized in order to be. Zaner repeatedly tells patients that he is there not to judge them, yet another fine line is evident. The presence of the ethicist does trigger, even mandate, an intensity of reflection that people might not muster without that ethicist. There is judgment involved, albeit— and crucially—judgment of process and not of outcome. The ethicist is the witness to people’s stories, allowing them to be heard, but the ethicist’s presence is also a check on the range and responsibility of those stories. That presence defines the fine line that prevents a story from being any story. Last but hardly least, the ethicist is a witness to chance. Both what brings people to hospitals and what happens to them once there depend crucially on chance. “But I knew then and know now how chancy such things are, how it could so easily have happened very differently from the way it did. I knew our lives are willy-nilly lived out in the midst of chance. . .” (2004, p. 100). This vision of life as chancy supports humans’ mutual identification—the other’s bad luck could just as easily be my own—and it leads to tolerance in how people respond to their troubles.4 Most of all, the vision of life as chancy underpins the belief that any story could always be otherwise. People literally take their chances: they take up chance, shape it into stories, and among those stories, they try to find the right thing to do. If we humans are lucky, we find someone to share this process with us: “We are enabled to be what we are only within these complex and mutual relationships with others. . .” (1993,

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p. 145). The ethicist offers him or herself to victims of chance, creating a relationship that has, as all relationships have, its own distinct possibilities for what it enables people to be.

5 Coda: On Broader’s Hill What’s he doing there, on that stretch of country road? He looks for skid marks where the road curves, he tells different versions of the story, each a possibility. He measures the variation between these stories. He tries to understand something he knows is beyond understanding: the death of two boys, who, as the saying goes, had their whole lives before them. Then, nobody knows why, there is an accident on Broader’s Hill, and they are dead. There are ethics issues—termination of life support, potential for organ donation—but these do not require Zaner to be out on this road, studying the scene. “I can almost feel the sizzle of hot metal, smell the reek of leaking gasoline and the stink of smoking tires and exhaust. . . It’s almost as if I were actually there, witness to the horror and quite as unable to do anything to stop it as I would have been had I actually been there” (2004, p. 101). What drives him out there? What do these imaginations serve? Maybe this: Zaner is compelled by his disquiet over “how pitifully little will be what I come to know about them,” these people whom he helps to make such momentous decisions (2004, p. 110). Zaner drives out to Broader’s Hill to know a little more, especially more beyond language: what it sounded like and smelled like. He suspects language, having heard too much medical terminology: “Vast oceans our words conceal: ‘outcome,’ ‘result’. . .” (2004, p. 110). Yet, language makes stories possible, and stories make moral life possible. Zaner wants, if for the briefest moment, something beyond the stories; he wants the experience, the being there, before some story sorts it out, this way or that. That moment, if he can grasp it, will keep his stories faithful. Why is Zaner out on Broader’s Hill? To be clear, fellow vulnerable humans, to be clear.

Notes 1. All subsequent references in this chapter refer to Zaner’s writing, unless specified. 2. I say recreated to recognize that while people tell stories that are very much their own, they tell these stories within genres they themselves did not create, using character types, plot structures, tropes and common-sense narrative conventions that are not at all their own, but which they recreate in each act of storytelling. 3. Zaner’s conceptualization of moral decision-making seems to anticipate recent work by psychologists using experimental methods to study how people actually arrive at moral judgments. Steven Pinker (2008), summarizing Jonathan Haidt, writes: “People don’t generally engage in moral reasoning. . . but moral rationalization: they begin with a conclusion, coughed up by an unconscious emotion, and then work backward to a plausible justification” (original emphases; see also Appiah, 2008, pp. 149–150 for a complementary account). If I understand Zaner, he would say that people need to tell stories in order to become able to articulate and act upon a

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conclusion that they might have begun with, but that they could not yet say, and this storytelling requires the presence of a bioethicist as witness, less judge than anchor. 4. Zaner’s concept of life as chancy is complementary to Arthur Kleinman’s (2006) emphasis on life as inherently dangerous, and morality as an attempt to humanize that danger.

References Appiah, K.A. (2008). Experiments in Ethics. Cambridge: Harvard University Press. Hacking, I. (1999). The Social Construction of What? Cambridge: Harvard University Press. Kleinman, A. (2006). What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. New York: Oxford. Pinker, S. (2008). “The Moral Instinct” [On-line]. Available (July 6, 2008): http://www.nytimes. com/2008/01/13/magazine.13Psychology-t.html. Zaner, R.M. (1993). Troubled Voices: Stories of Ethics and Illness. Cleveland: Pilgrim Press. Zaner, R.M. (1994). “Experience and moral life,” in E.R. DuBose, R. Hamel, & L.J. O’Connell (Eds.). A Matter of Principle? Ferment in U.S. Bioethics (pp. 211–239). Valley Forge, PA: Trinity Press International. Zaner, R.M. (1999). “Afterword,” Human Studies, 22: 99–116. Zaner, R.M. (2004). Conversations on the Edge: Narratives of Ethics and Illness. Washington: Georgetown University Press. Zaner, R.M. (2006). “The phenomenon of vulnerability in clinical encounters,” Human Studies, 29: 283–294.

Chapter 13

The Ecstatic Witness Rita Charon

These feelings propel me beyond myself, take me out of myself, beyond my own concerns of the moment, toward Tom [a young patient in renal failure]. They are an elemental and literal ec-stasis; to be myself before Tom is to be beyond myself, always already with him. Richard Zaner, Conversations on the Edge, 33

1 The Precipice of Illness Illness insists on the transit of the self. Unbounded by dumb health, the self in illness—either the self of the sick person or the self who ministers to the sick person—finds itself not only freed to but required to move into altered states. When serious physical or mental illness befalls the body, the self must travel outside its ordinary boundaries onto daring expeditions into the unknown. We know this, if only from memoirs written by seriously ill people, yet we tend to underestimate both the reach of such travel and the impossibility of return. When one cares for a seriously ill person—either as a doctor or nurse, a chaplain or ethicist, or a relative or friend—he or she similarly is launched onto perilous travel outside the self, not simply into the awareness of the fragility of health but more fundamentally and transformingly and irrevocably into an identity with that ill person and hence into a subject position from which one must own up to not only the certainty of the self but also the certainty of its end. Richard Zaner captures this phenomenon in his use of Hegel’s idea of ecstasia. Understood as an experience of alterity in the face of another’s presence—or perhaps an experience of self-recognition in the face of another’s alterity—ecstasia R. Charon (B) Professor of Clinical Medicine and the Director of the Program in Narrative Medicine at the College of Physicians and Surgeons of Columbia University, New York, USA e-mail: [email protected]

O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_13,  C Springer Science+Business Media B.V. 2011

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affirms mutual constitution through intersubjective contact. When Zaner visits the patient he calls Tom, he finds that he is called outside of himself toward this young man with renal failure who decides to discontinue his life-maintaining dialysis (Zaner, 2004, p. 33). Zaner is summoned out there onto the precipice where one must stand in order to face or even choose death. There is no way save coming close to death himself that Zaner could have stood on that precipice. As a clinician, if one can claim that position for the bioethicist, Zaner is granted the privilege to visit this precipice while healthy, a rare dispensation indeed. This precipice, perhaps the “edge” that Zaner had in mind in entitling his book, is ordinarily reserved only for the dying—not their parents, not their children, not their lovers. Oddly, and this is the subject of this essay, the clinicians who care for the dying can gain admission to the precipice. Indeed, they cannot do their work (some of them don’t know this) without standing out there. Here is where the work is done. Here is where the clinician must stand, not in an act of bravado but in an act simultaneously of duty and of love. This fact is traceable to the body. Death is a mortal event. Death comes to the body, and then concentrically or secondarily to the mind, the self, and the soul should it exist. The portal of death—like the portal of the self—is the body. This fact distinguishes the curators of the body from other associates to those who are ill or dying such as friends or relatives or lovers. Because the clinician gets the situation with the body, the ill or dying person can establish a parity with him or her. Often, it is the clinician who tells the person about the situation, perhaps dosing the knowledge in metabolizable units, perhaps coming clean with it all at once, perhaps (and this is most common) staggering out of the obscurity of an illness into the glare of the diagnosis and its prognosis, either gradually or in fits and starts, along with the person whose life is being threatened. That is to say, these two—say, the doctor and the patient—are finding out about the horrible business together, hand, as it were, in hand. What can draw clinician and patient near to one another in these situations is, primordially, that each has a body. It seems to me a central although under-articulated or yet invisible aspect of the clinical relationship. Mortals both, their alliance transcends the transitory fact that one is ill and one is well, or that one uses words like sweating and peeing and the other uses words like diaphoresis and voiding, or that one suffers pain and illness while the other suffers uncertainty and defeat. (This alliance is not made between the psychoanalyst and the analysand or between the Zen master and the contemplative, not because of the absence of physical touch in these other practices but because the material body is not at stake in their dealings. This contrast, in my mind, illuminates the heightened or at least idiosyncratic power of the medical situation.) Through the alliance made possible by their mutual possession of a mortal body, the clinician and patient find a key to the situation of illness—and, perhaps, as this essay will suggest, to the wider situation of health as well. The ground of alliance between the ill person and the clinician is the ground of the self-telling body. Not the body of pleasure or of sex, of fashion or of sport, the body present in my office (I am a general internist) is the body that can tell of

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itself, including its beginning and its end, encoded, if not in consciousness, at least in its genetic helix. These other bodies can delight in their senses or their bliss; they can display their beauty or their strength. In contrast, the self-telling body is in contact with a more fundamental self—the self that exists in the forecast of its non-existence. This self/body confronts the purified fact of being mortal, of living in time, of the difference between being alive and not being alive. In a 1915 condolence letter to Sir William Blake Richmond, whose young wife has been killed in a motorcar accident, Henry James depicts the savage and meaning-canceling certainty of death: “To have been what she was, with that flawless distinction, all the years, with this black atrocity waiting, makes one ask what is the sense of life?” (Plante, 1994, p. 92). What the black atrocity waits for is the distinctive body on which the self depends for its presence, its location. It is the body of bones and organs as it is the body of family and relation. Without this body, the self cannot be uttered. Without this body, the self cannot enter relation with others. Without this body, the self is as abstraction. Religious scholar John Hull, who became blind in mid-life, says that without vision, “I often feel I am a mere spirit, a ghost, a memory. . . . This is such a profound lostness” (Hull, 1990, pp. 25, 145). And so, by definition, because we are mortal, this body brings to its self a black atrocity waiting, the atrocity that will end it. It cannot but be. If this is the body encountered in our clinical practices, we have duties toward it that exceed getting the ldl under 100 or keeping the bone density ship-shape. Our duties toward the body—at least in the long view toward both its distinction and its extinction, the view that recognizes that the body both proclaims and makes finite the span of the self—entail both the corporeal and the lived experience. More and more, I see that the bridge between those two poles—actually, the very planet whose expanse constitutes and culminates in the two poles—is a narrative one. Without the narrative planet, there would be neither corporeality nor lived experience, only thingness and existence. With it, a unity between the subjective and objective experiences of both patient and clinician can be achieved in our clinics and surgeries. The reductionism that plagues medicine nowadays obscures the gravity—and the potential bliss—of that unity. Despite clinicians’ necessary but misleading fragmenting habits of mind—the gallbladder in 302, the guy with the neck, the appy—medicine has the power to recognize the singularity of both those who seek care and those who provide it. The power and the bliss are to be found through the narrative transactions of routine care.

2 Giving an Account of Oneself One way to probe the self-telling that occurs in health care is to treat it as an instance of what Judith Butler terms “giving an account of oneself” (Butler, 2005). Neither a trivial recitation of symptoms nor a chance to scold against poor health habits, the medical transaction, given seriousness and skill on both sides, permits a consequential creative process of self-exposure and, sometimes, self-creation. Although

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neither Butler nor the sources upon whom she relies in developing her framework of self-telling—Foucault, Nietzsche, Hegel, Arendt—start from the premise of medical treatment, their primordial questions of subject emergence and self-composition take on an eerie illumination when asked in the presence of illness. It is as if Butler and her colleagues and mentors enter the room in which we sit by one door while we doctors and patients enter it through the door in the opposite wall, and yet we find ourselves together contemplating the opacity of self to self, the forces—moral accountability, accusation, punishment, poeisis of the self—that summon the subject to self-knowledge or self-generation, the mutuality of recognition in relation, and the sociality of subject formation in both what is known and what cannot be known by the self about itself. How, Butler asks, does the subject declare its singularity? How does it escape from sameness into distinction? To put it in Hannah Arendt’s words, “[T]he specifically human act must at the same time contain the answer to the question asked of every newcomer: ‘Who are you?’ ” (Arendt, 1998, p. 178). Not “what are you?” but “who are you?”, the question that impresses the singular self seeks not common elements but exactly those that are never but once exposed. By this train of thought do the philosophers of subject entail the body as that which enables exposure, the requirement for recognition in the sociality. In her Arendtian approach to speech, action, and self-constitution through narration, Italian phenomenologist Adrianna Cavarero writes that “existing consists in disclosing oneself within a scene of plurality where everyone, by appearing to one another, is shown to be unique. They appear to each other reciprocally—first of all in their corporeal materiality and as creatures endowed with sensory organs. Put another way, the language of the existent assumes the bodily condition of ‘this and not another’ ” (Cavarero, 2002, p. 20). The body, here, solves a problem of self-revelation. The body is convenient to the philosopher of subjectivity, for it declares unchallengeably that this one differs entirely from that one. The body permits the personal manifestation, the appearance to another’s sensate receptors, the concrete proof of being the one and only self. However, for those clinicians and patients who enter the room from the door in the opposite wall trailing behind them diagnostic and therapeutic decisions for one and pain and suffering for the other, the body is the problem. Happily, now, or at least productively, we can see that the problems of the body—disease, pain, mortality—carry within them solutions to the problems of the self, if only as prizes of consolation. The body’s frailty and evanescence is (or at least is a necessary condition for) its flawless distinction, for persons are either well or ill in their own unique combinations. These two fields—philosophy of the subject and clinical medicine—find in one another their opposing but completing poles, the filling of their lack. Having found one another, they can rest—at least provisionally sated, planetary, entire. We can look now more closely at how this works. In the oddest way, when we tell of our bodies, we find out about ourselves. The woman seeking in vitro fertilization is telling of her barrenness and by that virtue telling of her yearning and yet-objectless love, a hypothetical love that, however unreal, declares her

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reality—a childless mother with a desire whose fulfillment will render her newly who she has always been yet to be. Or the middle-aged man after a big right-sided hypertensive stroke who can move neither left arm nor left leg, whose masculine vitality defined him before the stroke, who is now wheel-chair bound and terrified, and who rediscovers health when he falls in love with his home health attendant. These stories have charge. Even the more pedestrian health concerns whose stories I hear in the office are charged with the self—the stress fracture in the runner’s foot, the chest pain in the woman tending to her father dying at home of end-stage heart disease, the rash in the teen-ager afraid that her mother will find out about her sexual activity. Neither instrumental steps toward pathophysiological diagnosis nor relational steps toward psychotherapeutic alliance, the stories enact a body’s movement through life toward self-recognition, enabling that body’s inhabitant to watch the life and, therefore, to understand it. The Norwegian country hermit in Per Petterson’s novel Out Stealing Horses finds that he knows how to do a lot of practical tasks at his cabin by the lake by simply letting himself do them, “as if the secret lies in how the body behaves toward the task at hand, . . . in fact as if what you are going to do already exists in its finished form, and what the body has to do when it starts to move is to draw aside a veil so it can all be read by the person observing. And the person observing is me” (Petterson, 2005, pp. 75–76). This description pertains, I suggest, to not only how one learns to accomplish mundane tasks like using a chainsaw (or, rather, learns that he already knows how to do these tasks) but also to how one learns to accomplish self-becoming tasks like conceiving a child or getting used to hemiplegia. These clinical stories are not mere accounts of trouble. The telling of them makes the trouble knowable (or perhaps the knowing troublesome). The stories manifest or even incarnate the trouble, and, so, make visible and knowable the life beyond or despite it. How much graver and how much more is there at stake in situations of terminal illness. When a patient, like Zaner’s patient Tom, faces death in the short future, the black atrocity has become visible. It has a face. Tom knows that he will die of renal failure. It is the very facing, or more accurately the coming to have a face, of his black atrocity waiting that occurs on the precipice.

3 Listening for the Self-Telling Body In the enfacement of the black atrocity, patients like Tom may appreciate the help of a skilled and accompanying witness, someone who can stand with him or her, on the precipice, during the wait. Another way to put this thought is that patients like Tom may appreciate having a listener to receive the accounts they give of self. I have cared for a woman for many years for hypertension, scoliosis, and severe arthritis. Some years ago, I began to suspect that her cognitive powers were in decline. She is a writer and editor, creative and highly intelligent, altogether independent in life. Eventually, she became able herself to recognize her slowly deepening memory loss, even though she would get angry with me when I probed this area of her health.

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I had her see a neurologist who specializes in dementia. When I asked what the specialist told her, she said, “Dr. Carlson thinks I have Alzheimer’s, but I don’t think so.” She looked long and hard at me, and during that stare, I realized and accepted my duty toward her. It is to wait with her on her precipice, while the dementia comes toward us. I will watch with her, not knowing if my being there with her will alter her wait. On her next visit to me, she brought a copy of a manuscript she is currently writing, proof of her current and sustained capacity to accomplish deep and meaningful work. It included the poem “The New Colossus” written by Emma Lazarus as the dedication for the statue of the New York harbor, with these lines: Not like the giant of Greek fame, With conquering limbs astride from Land to Land; Here at our sea-washed, sunset-gates shall stand A mighty woman.

In order to stand with someone on such a precipice, the watcher/listener needs not only the wherewithal to interpret the many languages of the body—rales of the lung, murmurs of the heart, forgetfulness on the mental status exam, low sodium on the chemistry panel—but also, having inhabited his or her own body and having taken stock of the fact of mortality, the capacity to admit that life most certainly will end. Part of the equipment for the clinical listener is exactly the courage to perceive and to confess that life will end. This is not an easy courage to come by. Many healthy people who work among the sick avoid this knowledge. They act as if they have developed immunity to disease by virtue of their close contact with it. Or, knowing that they don’t smoke, drink, eat McDonald’s, or pay for sex, they trust that they will be spared this lung cancer, this cirrhosis, this heart failure, this AIDS. Others rationalize, or believe along religious or mythical lines, that there is not really an end to life, just perhaps a change in its state. Most commonly, clinicians simply lower the head and plow onward in diagnosis and treatment of diseases without coming to terms with the meanings of illness, deaths of patients experienced either as personal defeats—errors, ignorance, failures in judgment, under-vigilance—or as the consequence of unfortunate but temporary and correctable lacunae in scientific knowledge. But those who work among the ill and do develop their own awareness of death can listen for the self-telling body. Not only might they hear this body tell of asthma or dementia or colon cancer. They will hear it tell of being lost in the cosmos, like a dropped star or a rogue planet. They will hear it tell of being shorn off, the jagged endings, the stumps of life. They will hear it tell, in rage and sorrow, of the leer of the disease that comes for it, from nowhere, landing at random in the midst of life, disfiguring it, replacing its warmth and liveliness and meaning with nothing but cold pain in an empty future. Even though they will also hear of faith and family and endurance and hope, they will hear of these other things that are hard to receive. The dyad in which these things can be told and received is the dyad of not just two selves but two selves accompanied by their bodies. There need to be two selftelling bodies there, each of whom owns up to its mortality, in order for the account of self to be given and also received. Each self-telling body, through its capacity for

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vision and tactility, is an exemplar sensible, in Merleau-Ponty’s terms, as set forth in his chapter “Intertwining—The Chiasm” from The Visible and the Invisible: It is that the look is itself incorporation of the seer into the visible, quest for itself, which is of it, within the visible. . . . [A]ll this means: the world, the flesh not as fact or sum of facts, but as the locus of an inscription of truth: the false crossed out, not nullified. . . . The body interposed is not itself a thing, an interstitial matter, a connective tissue, but a sensible for itself . . . which offers to him who inhabits it and senses it the wherewithal to sense everything that resembles himself on the outside, such that, caught up in the tissue of the things, it draws it entirely to itself, incorporates it, and, with the same movement, communicates to the things upon which it closes over that identity without superposition, that difference without contradiction, that divergence between the within and the without that constitutes its natal secret. (Merleau-Ponty, 1968, pp.131 [editor’s note 1],135–136)

Of course, we have learned a great deal about the experience of embodiment from the phenomenologists, including Zaner. We have learned a great deal about illness from those phenomenologists, like S. Kay Toombs, Drew Leder, Michael Schwartz, and Osborne Wiggins, who have shone the lights of their philosophy on the fates of the ill. Mreleau-Ponty’s symphonic statements guarantee a place for his tradition within medicine by demonstrating its power to bridge the philosophy of subject and clinical medicine, declaring the almost inexpressible unity between body and self. Elsewhere, I described the body as the copulative term between self and world (Charon, 2006, p. 89). Merleau-Ponty’s vision dramatizes how profound are both the abysses and crossings enacted by and through the body. What have we here in our sensory/sentient body (the word has simply no alternative, for every possible synonym—instrument, dwelling place, objective correlative, frame—diminishes it) is the simultaneous fullness of time, space, material, metaphor, self, and relation. This fount of being, indeed, is raised to another power when there are two of them involved. Merleau-Ponty continues: As soon as we see other seers, we no longer have before us only the look without a pupil, the plate glass of the things with that feeble reflection, that phantom of ourselves they evoke by designating a place among themselves whence we see them: henceforth, through other eyes we are for ourselves fully visible; that lacuna where our eyes, our back, lie is filled still by the visible, of which we are not the titulars. (143)

The now-dyad is not simply doubled in intensity and complexity; with two bodies intertwined, it becomes a fresh, an unsigned system. Any two bodies, present for one another, become a cosmos of reflexive endowment and intensification of meaning—self-meaning and other-meaning simultaneously and necessarily. The bodies of passion, of birth, of work, and of play enjoy, or at least draw on, their liminality while the very borders between them bristle with turrets of sightings interiorly and exteriorly. In So Long, See You Tomorrow, novelist William Maxwell represents the semi-autobiographical plight of a young mid-Western boy whose mother dies in the 1918 flu epidemic, leaving him to comfort his grief-ravaged father: My father was all but undone by my mother’s death. In the evening after supper he walked the floor and I walked with him, with my arm around his waist. I was ten years old. He

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would walk from the living room into the front hall, then, turning, past the grandfather’s clock and on into the library, and from the library into the living room. Or he would walk from the library into the dining room and then into the living room by another doorway, and back to the front hall. Because he didn’t say anything, I didn’t either. I only tried to sense, as he was about to turn, which room he was going to next so we wouldn’t bump into each other. His eyes were focused on things not in those rooms, and his face was the color of ashes. (Maxwell, 1996, p. 8)

The 10-year-old figures out, with his body, where his father’s body-hence-self is heading in the space and time of grief. Who ever thought that this other-directed proprioception—the boy is dancing with his father in this sadness-saturated scene— could be the vehicle of filial love? What is extraordinary is not that it happened but that the artist Maxwell is acute enough to represent it in his aesthetic work. This very same proprioceptive act of “walking-with,” or rather the failure to do it, becomes the source of the little boy’s deforming and life-long regret. Around the time of his mother’s death, his playmate Cletus lost his father to a gruesome suicide. The protagonist unexpectedly meets Cletus years after the double deaths in a high school corridor: One day during the first week or so of school as I was hurrying along a corridor that was lined with metal lockers I saw Cletus Smith coming toward me. It was as if he had risen from the dead. He didn’t speak. I didn’t speak. We just kept on walking until we had passed each other. And after that, there was no way that I could not have done it. . . .I think now— I think if I had turned and walked along beside him and not said anything, it might have been the right thing to do. (Maxwell, 1996, p. 51)

Morality here is informed and enforced corporeally. The thing to have done to honor the second death would have been the thing that seemed right in honoring the first death. It is as if the boy had had encoded in the very quadriceps of his legs and the rotator cuffs of his shoulders the code of conduct with which to ethically answer death. I turned to Maxwell’s novel to figure a dyad of selves in which two bodies tell of themselves and so can learn of the other, corporeal actions (walking, focusing of the eyes, color of the skin) declaring lived experience. But what, then again, when one body is that of the ill person and the other body is that of the person trained to be of help in that illness? We sense the again seemingly unutterable turn of the helix of complexity in this situation where the material of the body is in question. We remember that the body’s material chiasmata—the biological intersections of neurological tracts or genetic material—as well as the phenomenological crossings of the sensory and the sentient endow the self with its mysterious unity. As the optic chiasm bestows peripheral vision and the chromosomal chiasm offers the site of genetic mixing during reproduction that yields genetic variety, the body’s chiasmata both ground us and let us exceed that ground. But disease and that which it heralds threatens it all. The body succumbs to its peril, while with the self does the peril abscond. What feels to be beyond the reach of words here is not only the situation between the two bodies sitting, say, in the

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shabby clinic office where I see my patients in Manhattan or in any emergency room or labor & delivery suite or hospice where a sick person expects help from a trained one. Beyond the situation itself, what feels unutterable is the failure, spelled out by disease, of the very solution to the problem of living. The primary failure enacted in disease is, by virtue of the body’s frailty, the threat to the unity between body and self and the consequent exposure of the mortal closeparenthesis. The current clinical situation also, sadly, seems to dramatize the failure of the well member of that dyad to comprehend the fragility of the contact, the breadth of the chasm, the height of the stakes involved in the meeting. We clinicians simply do not yet comprehend what is being asked of us at those bedsides—not of us as thinkers or diagnosers or treatment-mongers but as bodies situated within the pull of the gravity of the ill body of another. It is to consider this that we are being summoned by Zaner and his colleague phenomenologists. When Zaner writes about the clinical relationship qua relationship, he points to the intersubjective necessity that both participants be present. Borrowing terms from Arthur Kleinman (“empathic witnessing”) and Ortego y Gasset (“tak[ing] the others into account”), Zaner paints a dialogic picture of two persons, situated side by side: “What is obvious about any human encounter is even more fundamental to the clinical situation: one enters or is party to them with ‘what I am’. . . . To dialogue with another, there is nothing for it but to be oneself. . . . Conceived as dialogue, the clinical event is essentially [an] open . . . encounter between two human beings, one of whom appeals for help and the other of whom professes the ability to give it” (Zaner, 1990, pp. 304, 308, 321, 322). The one appealing for help, at least help with illness, exposes his or her situation with the body. In John Banville’s novel, The Sea, the first-person narrator’s wife Anna is dying of an unnamed cancer. The couple come home from the visit to the doctor, who spelled out her condition as terminal: This was not supposed to have befallen her. It was not supposed to have befallen us, we were not that kind of people. Misfortune, illness, untimely death, these things happen to good folk, the humble ones, the salt of the earth, not to Anna, not to me. In the midst of the imperial progress that was our life together a grinning losel had stepped out of the cheering crowd and sketching a parody of a bow had handed my tragic queen the warrant of impeachment. She put on a kettle of water to boil. . . .Abruptly she went slack and sat down heavily, extending her arms before her along the table in a strange, desperate-seeming gesture, as if in supplication to some unseen other seated opposite her in judgment. (Banville, 2006, pp. 15, 16)

In what the narrator calls an “agonized inarticulacy,” this couple lives through and beyond Anna’s gruesome death, the death that was not supposed to have come to them. Their desperation, inarticulate, is containable and expressible in Anna’s unforgettable bodily gesture. Can such desperation be registered by a clinician sitting nearby, perhaps indeed the one imagined to be sitting opposite Anna in judgment? If he or she can perceive and interpret such actions of the ill body, perhaps that which must be told can be

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heard, and the teller can be recognized. Here is the birth of expression. MerleauPonty continues, “It is as though the visibility that animates the sensible world were to emigrate, not outside of every body, but into another less heavy, more transparent body, as though it were to change flesh, abandoning the flesh of the body for that of language” (Merleau-Ponty, 1968, 153). Clinicians have but half the equipment they need if they can only say to Anna, “You will die of your cancer” or to Maxwell’s narrator, “Your bereavement for your mother, having been symptomatic for more than six months, is pathological.” Stephen Henry, Robert Dittus, and Zaner suggest that clinicians can “mov[e] beyond evidence-based medicine” toward a “recognition that clinician-patient interactions are central to medicine” by developing and prizing Michael Polanyi’s tacit knowledge, that “taken-for-granted knowledge at the periphery of attention that allows people to understand the world and discern meaning in it” (Henry et al., 2007, pp. 292, 294). Polanyi realizes that tacit knowledge comes from the body, that there are “bodily roots of all thought, including man’s highest creative powers. . . . Our body is the ultimate instrument of all our external knowledge, whether intellectual or practical. In all our waking moments we are relying on our awareness of contacts of our body with things outside for attending to these things” (Polanyi, 1983, pp. 15–16). In the paper called “Medicine and Dialogue” published in 1990 and cited above, Zaner was not yet including the body of the doctor in the picture but was, rather, enjoining the doctor to include more than the body of the patient in his or her view. By the 2007 essay, however, Zaner invites the clinician’s corporeality to enter the picture, by invoking Polanyi’s tacit knowledge. The body of the clinician is the source of the knowledge necessary to say to Anna, “Your palms-up desperation moves me to try to understand your predicament of rage and loss” or the Maxwell’s protagonist, “Imagine, then, putting your arm around the waist of Cletus in the Chicago corridor; at least you know now, from your own life, what would have helped him and you.” I am not imposing the duties of spiritual advisor and psychoanalyst on the hapless general internist in the shabby clinic. Instead, I am suggesting realms of effective care that can be provided to our patients, if only we attend to both bodies in the room.

4 Aesthetics, Illness, and Taking Care I have been using fictional scenes to represent the nodal points in this essay to make a point about aesthetic works. What have the novels of Per Petterson, John Banville, and William Maxwell done for me in envisioning this set of concepts about health and illness? These aesthetic projects have not only reported on situations of bodily states. The novelists’ works of art have singularly represented these situations, in entirety, in forms that do not speak of but rather attest to that which they treat. The novels do not paraphrase the situations they represent. They manifest them. As literary critic Cleanth Brooks wrote so long ago in The Well-Wrought Urn (in his chapter called “The Heresy of Paraphrase”): “The poem, if it be a true poem[,] is a

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simulacrum of reality—in this sense, at least, it is an ‘imitation’—by being an experience rather than any mere statement about experience or any mere abstractions from experience” (Brooks, 1947, p. 213). Like other aesthetic works, these novels—by virtue of their forms—enable me to witness the sublime. Mont Blanc, Shelley’s “Mont Blanc,” Cezanne’s Baie de Marseilles vue de l’Estaque, the Bach Toccata in D minor are all avenues through which I can be transported to and expose myself to and hence appreciate a heightened beauty, a heightened and otherwise unavailable truth. These appreciations enlarge me as seer, as the visible is now incorporated into me in our Merleau-Pontian mutual pact: It is that the thickness of flesh between the seer and the thing is constitutive for the thing of its visibility as for the seer of his corporeity: it is not an obstacle between them, it is their means of communication. (Merleau-Ponty, 1968, p. 135)

Now. The same process applies to accounts of illness. In a revolutionary 1999 essay, British sociologist Alan Radley suggests that illness narratives written by patients are not mere records of events but, rather, are accounts of self given by the sufferer (of the sort that Butler writes) that ascend to the status of aesthetic works. Such accounts are . . . essentially exemplifications of a way of living. This means that they do more than report events which the person has suffered, or even provide an account of the author as principal player in the story. . . . [T]his is achieved through a portrayal of how to live with illness, rather than by a specification of events or actions alone. It is in the course of this portrayal that there is a transformation of the mundane world of disease and its treatment essential to an understanding of suffering. This presentational act of ‘showing forth,’ summarized here as exemplification, has been proposed as key to all aesthetic acts. (Radley, 1999, p. 779)

Radley includes illness narratives written by patients in the universe of aesthetic works. I wish to enlarge this category to include also accounts of illness written by care-givers, both professional and personal. In both cases, the texts—whether written by the ill person on the precipice or those chosen to stand there with him or her—are not simple records but aesthetic works that represent these situations. As such, they have the capacity to enable the witness to “engage in an aesthetic act, in which the countenancing of the sublime is achieved in the light of horror and of pleasure” (Radley, 1999, p. 780). It is this turn of the helix that brings the clinical witness to undergo not only the visible and the painful but also the ecstatic. I don’t think Zaner achieved his ec-stasis by visiting or brooding about his patient Tom. In order for him to have traveled both outside of himself and then into contact with Tom, I think Zaner had to represent Tom. I think it was in the act of writing about Tom, representing this patient’s predicament for himself and, perhaps, for us, his readers, that Zaner achieved the position of the ecstatic witness. Furthermore, he had to write about Tom not as an anonymous clinical case but in the genre of a rich, thick, singular narrative, personalized both in the direction of subject and the direction of author. The reader has got to know that this text is about Tom and written by Zaner in order for the text to do its work.

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Before I mount more conceptual evidence to buttress these hypotheses, I must include a “Methods” section to describe the sources of my evidence in having reached these tentative conclusions. My colleagues and I in the Program in Narrative Medicine at Columbia have been coaching writing seminars in clinical settings now for years. We meet regularly with groups of doctors, nurses, and social workers on the adult in-patient oncology unit, the pediatric oncology service, and the AIDS/HIV clinic. Some of these seminars include patients and family care-givers. We gather social workers from all areas of the hospital and ambulatory settings, from the liver transplant service to the Surgical Intensive Care Unit to the domestic violence clinic. We work with students in physical therapy, pastoral care, and medicine; with residents in medicine, pediatrics, psychiatry, and family medicine; and with faculty from a broad array of clinical departments. We hold intensive three-day narrative medicine training workshops that attract health care professionals, literary scholars, writers, and patients from all over the world. We are planning advanced training for graduates of our basic workshops and are developing a Master’s degree in Narrative Medicine from Columbia. During training, we ask participants to write about their practices in a variety of genres and approaches. Sometimes the writing is done prior to the session, whereas at other times, we devote the first 5 or 10 minutes of the seminar to private writing. The texts produced are, typically, astonishing. The power and craft of the poetry or prose no longer surprise us. When our writers read aloud to their colleagues what they have written, they often are unaware of what they have done in the acts of representation. One woman, a social worker and psychotherapist, wrote about having made a house call to visit a dying patient who was unable to get to the therapist’s office. In naturalistic prose, the writer sketches the living-room scene with precision and sensual detail. When she read her text aloud, a skilled listener wondered why there was such a detailed description of the couch in the living room and the colors and pattern of the patient’s dressing gown. It was only as we all struggled to answer the question, “What is the genre of this text?” that the author realized that she had created not a character sketch or a memoir or even a premature obituary; she had created a still life. What the author responded to and therefore represented was, perhaps, the stilling of life, the fact that the patient still lived, and also to the balance and beauty, like Cezanne’s pears and apples, as well as the grave sadness held by the composition of this fading life. This realization mattered not only for the aesthetic work produced but also and simultaneously for the author, the listeners, and—should the text be shared—for the patient who is the subject of and inspiration for the artistic work. This group of readers gave this psychotherapist something of value by virtue of having recognized the genre of her hastily written paragraph about care. These methods offer evidence that these texts written by health care professionals about their practice are also aesthetic works. They are not paraphraseable utterances but rather are exemplifications, proofs that something was witnessed and then represented, that something was undergone. Not mere reports against forgetfulness, these texts achieve something of value. As Henry James writes in the Preface to The Golden Bowl, “To put things is very exactly and responsibly and interminably to

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do them” (James, 1909b, p. xxiv). It is in the act of putting, or representing, that the clinician transforms the experience with the sick person from a chaotic formless occurrence of illness and death into something visible by virtue of its form. By writing, the writer confers form on erstwhile formless situations. This is the source of its power. The form of a written text includes its genre, diction, imagery, narrative strategy, temporality, allusions—all the things a close reader looks for in any text. Even altogether inexperienced writers rely on these formal elements in writing, for there is simply no way to write a sentence but with metaphors, a temporal structure, words, and a voice. There is no text from nowhere, and there is no formless text. One result of writing something out is that, indeed, it gets out of the writer. Freud said long ago that he wrote things down in order to get rid of them, but that is no longer the last or even a particularly useful idea nowadays. Creating aesthetic works is not an exercise in emesis or evacuation, no matter how satisfying the purge might feel. Rather than chaff to discard, the material of the writing has to be exteriorized so as to be made visible and audible. This is what our writers are after. The writing lets the formless wormy situation “out” of the writer/clinician by granting it form, and, once and only once clothed in form, the situation can be seen, examined, and recognized by the writer and his or her readers/listeners. This is the part that is newly coming into view. The form cannot be declared without a seer-who-declares, for the seer/declarer has an obligatory role in making the seen visible. It does not become visible on its own for others except by being seen and represented by one seer. From the train window, I see a black-asphaltsurfaced parking lot filled with old-fashioned full-sized yellow school buses, each marked with its number in large black numerals. There must be over a hundred of them squeezed into and almost over-flowing the small lot. They are parked in a topsy-turvy manner, as if left hurriedly by their drivers, making them appear abandoned and yet still warm with life. I smile to recall Bus #37 out of the garage in Mount Ivy, which I myself drove while finishing up my pre-med courses at Rockland Community College. I have available to myself in a flash the satisfying feeling of parallel-parking my bus, of yanking closed with my right hand on the chrome swivel handle the accordion door after the last straggling sixth-grader boards, of parking with my buddy school bus-drivers, dressed in our bell-bottom jeans and shaggy teeshirts, in the breaks between the grammar school run and the junior high run. I then or at the same time recall the buses I rode to high school, the girls from St. Charles and the boys from Bishop Hendrickson, the flirting that went on, the invitations to the prom given, received, accepted, rejected, hoped for, not heard. These memories of myself as a 24-year-old hippie and a 14-year-old Catholic school-girl collide, coloring the view of the school buses today, viewed as a late 50s year old professor on her way to give a lecture. These buses, I am trying to say, are seen by me— and now by you—in a way that only I can see them. My view of the buses is mine and mine alone. It is my animation of them which both limits and rescues them— limiting them to my idiosyncratic perspective and rescuing them, for you, from their otherwise doomed oblivion. There has to be a seer as the receiving vessel in order for the visible to be first contained and then made viewable for others. It is in the transit through the

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meaning-making apparatus of the seer that that which is seen becomes visible. I do not mean to sound spooky or mystical here. Indeed, I am perhaps being unduly material. The process of making visible that I am proposing is akin to the biological processes of alimentation and tissue growth. A cascade of events has to take place, more or less in sequence. The subject is espied by the seer. The seer interiorizes the seen. Within the interior of the seer, something happens and the seen achieves, perhaps slowly and perhaps instantaneously, a meaning. This meaning can be appreciated either by the seer or by others only if it is expressed out of the seer, and the only way it gets out is by being given form. Again to turn to my mentor, Henry James: “Art deals with what we see, it must first contribute full-handed that ingredient; it plucks its material, otherwise expressed, in the garden of life. . . . But it has no sooner done this than it has to take account of a process . . .that of expression, the literal squeezing-out, of value” (James, 1909a, pp. ix–x). So any work of art and perhaps anything at all communicated by one person to self and to others begins its life in the world as something seeable or conceptualizable, say, a parking lot of school buses. The seer sees it, plucks it, and submits it to a process of extracting from it, rather like juice from a lemon or milk from a nipple, its value or its meaning. This inspiration, this occasion of thought or reflection, this objective correlative, is waiting in the world, hushed in anticipation, a work in potential, the latent needing to be animated by the seer/declarer in order to take its place in the world of the real. Without the expression, the seen is squandered. It leaves the self without having had any impress. It is as if unseen. It is not enough to see it. It must be represented. And once the seen is made visible and audible by virtue of being represented, it can do things for all concerned. Radley focuses on the ability of the written text to connect author with reader: “[T]he performative unfolding of the account, its reading, initiates the reader into an aesthetic/ethical relationship with its object” (Radley, 1999, p. 791). Acts of reading clinically inspired texts in narrative medicine settings—either by the reader holding the book, the colleague at a seminar listening to writer reading aloud, or indeed a writer rereading his or her own text—predictably initiate the reader into realms first of experience and then, quickly, of relation. Beautifully, in appreciating the text’s form, the writer and readers/listeners bow their heads together toward the object, thereby nearing one another in trying to grasp the meaning being represented. It is as if the reading initiates a contact between writer and reader, one that was not there before. We find (and are now trying to document in controlled studies) impressive gains in team congruence and transparency as a consequence of narrative writing training. Suddenly the nurse knows what the child life therapist goes through; the oncologist understands the plight of the chemotherapy nurse who disagrees with heroic treatment but yet must administer the aggressive medicines. The well (and this is really what we are after) can glimpse, as a unity, the sick person living a life now around illness, the betrayal of disease, the espied end of life. Catching sight of this is what is required of the ecstatic witness. This catching sight, with all the pain and terror and horror involved, is what grants admission to the precipice of illness.

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5 A Mutual Corporeality What, though, of these two self-telling bodies? Radley proposes about the illness account that “while how it is told is clearly important, understanding what is being said owes everything to our being embodied readers, for whom issues such as horrors and the sublime extend well beyond what can be said in words” (Radley 1999, p. 787). Here again, echoing Merleau-Ponty and our novelists, the witness/receiver/reader of the account of illness relies on his or her corporeal equipment as vessel for what is given by the teller of self. Both writer and reader at some levels have to bodily enact the horror and sublime of these narratives. I am not thinking about the frisson of recognition along the back of the neck as the clinician sits with a psychotic patient or of the sympathetic twinge in the corresponding part of the listener on hearing of a particularly impressive pain. I am instead thinking about the ways in which the clinician/listener’s body becomes the transducer of knowledge that bypasses words altogether and is registered directly on the sensate soma. We don’t know how we knew these things about the other except that the knowledge is somehow beamed—from one body to the other—without the intermediate of spoken word. I think of a description I wrote some years ago of a young man, a new patient in my practice: A young man came in to see me, referred by his wife who had been my patient for some time. She said that he had been enduring bothersome symptoms for years, but had not wanted to subject himself to a medical evaluation. The patient, a muscular man of serious demeanor and stiff carriage, described severe abdominal pain, terrible difficulty with digestion, and bowel symptoms which interfered dramatically with his work performance and his leisure time. I wondered at his stoic acceptance of these intrusive symptoms for many years, and I noticed the pressure with which he held himself in during our conversation. It was then time for the physical examination. Instead of changing into the cotton gown as I had asked him to, my patient stood hunched over the stainless-steel sink near the examining table, fists clenched, head bowed, his back to me, motionless. I knew not what was happening, but I knew not to move. I sat at my desk, quarter-turned away from him, gaze slanted down, arrested by the force-field of his stillness. We were part of a tableau, wordlessly enacting what, it came to me, must be an old truth. When he spoke, it was to say, “It’s because of what happened the last time I was at the hospital.” And so I knew to use great caution, slowness, and gentleness in touching him, so that performing the physical examination could be not an assault but an effort to help. (Charon, 2006, p. 12)

A more recent example comes to mind. A patient rather new to my care came in needing emergent care of a serious skin ulcer. She is a woman in her fifties who has lived with multiple sclerosis for many years. For about 10 years, she has been wheelchair-bound. She had recently been admitted to hospital for a serious pulmonary illness that required a long and tumultuous intensive care unit stay and eventual placement of a tracheostomy and chronic dependence on oxygen and a night-time respirator at home. Recently, she was discharged from the nursing home where she had been forced to live for six months following the debilitating

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hospitalization. Although glad to be alive, she was despondent about living in an institution, and so it was, with tremendous joy, that she moved back to her little apartment in Washington Heights. I had been assigned to her as her “community physician,” without whom she would not have been allowed to leave the nursing home, and so my care was of some importance in her maintaining her independence. I remember my surprise when I first met her. She gave me a wonderfully discordant view of frailty and vitality—a woman swollen by steroids sitting in a motorized wheelchair, two oxygen tanks, and copious plastic tubing connecting her tracheostomy to the oxygen who was dressed in a vibrant floral-print dress and wrapped in a lush blue-green shawl. Her expression, I remember, was one of joy, interest in all she took in, as if hungry for all the living she could possibly do in every instant. On our first meeting, she had impressed me with her intellect, her survivorship, and her willingness to take risks to safeguard her independence. She was in my office this day with a worsening decubitus ulcer on her back that needed expert care. I did not know what to do for it. Undertrained in wound care, I felt anxious, aware that this skin condition could require re-hospitalization were it not properly cared for and embarrassed that I, as a general internist, did not know what to do for her. I must have seemed unhappy with her being there because of my discomfort with the clinical problem. I remember asking the nurse in my clinic to help me. She didn’t know what to do either, but she gave me the beeper number for the wound care specialist over in the hospital. Meanwhile, I was feeling more and more irritated, put out, unhappy with the situation and no doubt conveying my distress to the patient. Finally, the wound care specialist answered her page and expertly advised me not only in what to do that instant but also warmly welcoming me to make rounds with her in the hospital to brush up on my clinical knowledge of wound care. Then and only then could I truly be with the patient. I remember that her wheelchair sat her quite high off the floor, almost throne-like. Once the clinical uncertainty left me, it felt as if I “came back” into myself. It was a very odd feeling—as if my clinical brain had been traveling outside of my body, seeking answers to these vexing questions, humiliated that I didn’t know what to do, and therefore rendering me unavailable to my patient. But once I found the answers I needed, the brain came back home with a start, reconstituting my entire self within my body. I was able—and this was a very sudden shift—to be at the patient’s disposal. I remember I drew my office chair up alongside her high wheelchair so that we were shoulder to shoulder, even if I was lower down than she. And then I just sat there, relaxed, hands in my lap, breathing quietly. I felt at her disposal, able now to enter into her climate or to let her climate enter me. And as soon as I did that, I think maybe asking something about how things were going in her apartment, she began to cry. She expressed fear about her illness, rage that the multiple sclerosis wasn’t enough but had to have this lung problem added to it. She was desperately afraid she’d have to return to the nursing home. None of this feeling-state had been available to me when my clinical brain had been flying around looking for answers

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to wound care questions, leaving my body as if beached and useless. With the return of body/self unity, I could contact her in her distress. These two clinical examples seem to suggest that the patient’s body was talking to mine or mine to the patient’s. In the first case, clinically relevant knowledge came to me not through conscious thought but through proprioceptive nerve endings that made me aware of my own bodily position in the room, while in the second, my body was the transmitting instrument that proclaimed my being at the patient’s disposal. It feels like a following of Zaner’s precepts that, in the clinical relationship, “one enters or is party to them with ‘what I am’. . . . To dialogue with another, there is nothing for it but to be oneself.” Or, again, it may be an illustration of what Merleau-Ponty points to in Phenomenology and Perception: Whether it is a question of another’s body or my own, I have no means of knowing the human body other than that of having it, which means taking up on my own account the drama which is being played out in it, and losing myself in it. (Merleau-Ponty, 2002, p. 231)

How, then, are we to think about a system in which both participants in the clinical transaction have to be present, corporeally, for the full measure of contact to be achieved? It seems that this train of thought brings us to the complex and almost embarrassing question of the erotics of illness. If, borrowing literary scholar David Morris’s usage, I use the word eros to connote the realm of unruly desire and the non-thought known (what is typically called the unconscious), I mean to turn the corner toward not spiritual mumbo-jumbo but rather toward the experience of interiority that precedes and constitutes language. Making the point that medicine, at least in its Asclepian past, has always incorporated the realms of appetite and erotic soma along with its Hippocratic rationality, Morris writes recently, “Asclepius points toward an ecstatic past, when healing occurred via dreams and visions imparted by a god, filling worshippers with an otherness that the new guild-centered pragmatic Hippocratic tradition . . . needed to forget” (Morris, 2007, p. 426). Western medicine has worked hard to sanitize itself of anything that might suggest such ecstasy, for the messy body always brings with it unseemly singularities and appetites and uncovers fraught boundaries that are easier avoided than properly navigated. But to renounce the erotic is to surrender whole continents of meaning and contact. Morris continues, “An Asclepian medicine suited to an era skeptical of Greek gods might reinterpret eros as a power that invokes desire (as distinct from knowledge), that credits intersubjective experience (as distinct from objective data), and that values bodily presence (as distinct from meaning). This interpretation of eros embraces recent innovations in narrative medicine and in mindful practice” (Morris, 2007, p. 434). It is not enough to welcome the self-telling body of the patient into the consulting room. We need also to welcome the self-telling body of the clinician there, even at the risk of welcoming what was outlawed by Hippocratic or rationalized medicine because of its potential dangers. Gradually, through the generosity and wisdom of such teachers as Merleau-Ponty, Henry James, Richard Zaner, and our novelists, we are beginning to glimpse the potential bliss of a medicine fortified with attention and

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representation. Once we admit that our texts are, indeed, aesthetic works, and once we own up to the mutually corporeal dimensions of any form of care for physical and mental illness, then we are opening the door to a health care that gives voice to the sufferer while giving heart to the ones who care for the sick. Instead of the dire situation described decades ago by Elaine Scarry (Scarry, 1985), in which there existed no language for pain and the one suffering had to, by definition, suffer alone, we are coming to recognize the methods that power us to contact, in verbal and corporeal language, the pain of others. We stand, then, on the precipice of illness with those for whom we care, aware of the abyss of illness and death before us while trying to cross the abyss of interiority/exteriority between us and the patient who suffers. We give ourselves up to the transit of the self, in part by being willing to let the visible of the suffering transit through us to be clothed in form. With our own modest powers of attention and representation, we express that which we see, letting ourselves and others— including the person whose suffering inspires these actions—gaze at the meaning of that which can be seen. In the intertwining of self-telling bodies that are at once instrumental, aesthetic, and even erotic, we hope to create chiasmata that endow us all with knowledge of, experience with, and transit through and beyond our own bodily capsule toward the planetary ecstasy of being, simply, human.

References Arendt, H. (1998). The Human Condition, 2nd edition. Chicago: The University of Chicago Press. Banville, J. (2006). The Sea. New York: Alfred A. Knopf. Brooks, C. (1947). The Well-Wrought Urn: Studies in the Structure of Poetry. New York: Harcourt, Brace & World. Butler, J. (2005). Giving an Account of Oneself. New York: Fordham University Press. Cavarero, A. (2002). Stately Bodies: literature, philosophy and the question of gender. Ann Arbor: University of Michigan Press. Charon, R. (2006). Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press. Henry, S.G., Zaner, R.M., Dittus, R.S. (2007). “Moving beyond Evidence-Based Medicine,” Academic Medicine, 82: 292–297. Hull, J. (1990). Touching the Rock: An Experience of Blindness. New York: Vintage Books. James, H. (1909a). The Novels and Tales of Henry James: The New York Edition, vol. 21. The Ambassadors. New York: Charles Scribner’s Sons. James, H. (1909b). The Novels and Tales of Henry James: The New York Edition, vol. 23. The Golden Bowl. New York: Charles Scribner’s Sons. Maxwell, W. (1996). So Long, See You Tomorrow. New York: Vintage Books. Merleau-Ponty, M. (1968). The Visible and the Invisible. Evanston, IL: Northwestern University Press. Merleau-Ponty, M. (2002). Phenomenology of Perception. London: Routledge Classics. Morris, D. (2007). “Un-forgetting Asclepius: An Erotics of Illness.” New Literary History 38: 419–441. Petterson P. (2005). Out Stealing Horses. St. Paul, MN: Graywolf Press. Plante D. (1994). “The Secret of Henry James,” The New Yorker 28 (November 1994): 91–99. Polanyi, M. (1983). The Tacit Dimension. Gloucester, Mass.: Peter Smith. Radley, A. (1999). “The Aesthetics of Illness: Narrative, Horror and the Sublime.” Sociology of Health & Illness, 21: 778–796.

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Scarry, E. (1985). The Body in Pain: The Making and Unmaking of the World. New York: Oxford University Press. Zaner, R.M. (1990). “Medicine and Dialogue,” The Journal of Medicine and Philosophy 15: 303–325. Zaner, R.M. (2004). Conversations on the Edge: Narratives of Ethics and Illness. Washington, D.C.: Georgetown University Press.

Chapter 14

A Story Teller’s Story: Richard Zaner ¯ row) as Hero (HE Paul J. Ford

1 The Distinguished Flying Cross: Part I (or Moral Authority) I look around his office as I wait to meet with this teacher-ethicist. On the wall behind his door, I notice the standard academic patchwork of framed bits of recognition. A certificate of successful Ph.D. completion. An award from the University Medical Center for dedication and work in “Medical Ethics.” A diploma saying “Masters of Arts.” All things seem right in the world, until my eye catches the words “Flying Cross.” Is it real? Is it a type of ironic humor? As I sit waiting for Professor Zaner to finish jotting a note on my research paper, I more carefully examine the wall. This framed certificate recognizes valor and bravery in war. It is a “distinguished” flying cross, which seems pretty rare to me. In my years of working under the guidance of this graduate school professor not a word had been breathed about this honor. No reference to it appears in any of his biographies on jacket flaps of his book. Is this real? I know he served in Korea but I just assumed it was a desk job of some kind. Finally, he turns his thick grey beard in my direction. “So, what are we talking about today?” I am too absorbed in my new found symbol of action and gallantry to respond that our meeting is supposed to be about my dissertation work. “Isn’t a Flying Cross pretty significant?” I respond, unconsciously ignoring his initial query. “That’s a distinguished flying cross. It is pretty significant in terms of medals. I was a B26 gunner in Korea. Do you know what a B26 is?” His voice has taken on an odd reminiscent quality. I shake my head indicating that I did not know

P.J. Ford (B) Department of Bioethics, Cleveland Clinic, Cleveland, Ohio, USA e-mail: [email protected] Note: The narrative portions of the below were written somewhere around 1999 when I was a PhD student at Vanderbilt University. For the purposes of this book I have collected them together, lightly edited them, and created some connecting descriptions. I have attempted to keep as much language and content as it originally was in order to preserve the sense of the conversation. The present day reflections are from 2007 when I put this chapter together.

O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_14,  C Springer Science+Business Media B.V. 2011

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about the plane. He slaps his knee and laughs. “Christ! I haven’t thought about these things in ages. . . The B26 wasn’t even supposed to be able to get off the ground. . . .” He trails off a little. “You know, I had to shoot upwards at people some times.” “You mean shoot up at people in other planes, right?” “No. I shot at people and trucks on hilltops. We would fly in the valley and would see them above us and I would shoot at them.” He pauses a minute in reflection and then continues with energy or perhaps tension. “I saved the squadron’s ass one time. That’s why they gave me that medal. We were flying in as a squadron. You see there is a lead plane that flies in to draw enemy fire so the anti-aircraft installations can be spotted. That was to be our plane on this mission. I destroyed thirteen installations myself. It wasn’t ‘till later we realized our plane was full of holes.’ I’m a pacifist now.” The last sentence was delivered in a remarkable flat and matter-of-fact kind of way. Before responding, I pause for a moment after this last declaration. “What is your take on Kosovo then?” “Violence never solves anything.” He responds in a resolute but sad voice. Last week, yesterday, or even a few moments ago this answer would not have been very satisfying. However, here is a man who knows what he is talking about. A shift has occurred in my understanding of him and his words. He is a bona fide war hero, a person who has survived the brutality of conflict and come out as a moral philosopher. I have never met a hero before. He has experienced violence and did violence to others in the name of war. . . he’s now a pacifist.

1.1 Post Meeting Reflections Senator XXX was held for 3 years as a prisoner of war in Vietnam and is now supporting the use of ground troops in Kosovo! This is the by-line for an upcoming nightly news story. The story turns out to show this senator saying he thinks ground troops are necessary for the resolution of the Kosovo conflict. “The killing of innocent people must stop and an air campaign just won’t let us reach our objective.” This man has experienced war and prison internment. Yet he is willing to have others go into the same perils. My mind turns back to my professor in contrast to this senator. One says use force; one says never use force. My thoughts return to a conversation of many years past which occurred during an election year. It was a conversation with a fellow undergraduate at the time. “You say this American presidential candidate purposefully avoided serving his country during war time? Isn’t your president supposed to be the Commander in Chief of the armed forces? So, if this guy becomes president, he could send people into combat to do something he was previously unwilling to do himself?” Incredulous I ask my American friend. “That’s right. But he was sticking up for his beliefs. You have to understand the politics around Vietnam. It was different.” She tries to help me to understand.

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I say in a very astute manner, “I doubt this guy will win. With Americans so patriotic and stuck on being a super power, I doubt they will put in a guy like that when Bush oversaw the success of the Gulf War.” “Wait and see. I think he will win.” She replies prophetically. “But how could he ever send military people into combat? Who would listen to him? He doesn’t have the moral authority, does he?”

1.2 Responding in a “Zanarian” Way? Zaner encourages me to write my short narratives that capture difficult issues. So, I write the above and send it to him. I sent it with great discomfort and anxiety given his masterful writing, his status as my teacher, and the deeply personal nature of this story. In reading this, he might identify my weakness in storytelling or even worse, he might be offended. The next part captures the meeting in response to my first narrative. Again I felt compelled to write about the encounter.

2 Bearing His Cross (or Distinguished Flying Cross Part 2) “So what do you think of it?” I ask nervously. One of my professor-mentors slides a copy of my short narrative Distinguished Flying Cross back to me. “It’s fascinating to read about myself and our conversation.” He smiles. “Some interesting stuff. What do you make of it?” I look back at him. “Actually I have more questions than anything. I mean you’re a pacifist. . . Is the cross an actual medal or just that certificate I saw?” “You know there wasn’t even a ceremony for the cross. They didn’t actually present the medal to me. A year later when I was in college, I remembered I had been awarded it; 3rd highest medal1 they give and there wasn’t even any ceremony. At least for the smaller medals, like 50 missions medal, they had a ceremony and shook my hand. So, I wrote the service. They checked their records. Sure enough I was supposed to have one. They mailed the cross and that certificate.” I nod, realizing how odd it is to have pomp and circumstance for minor medals and nothing for such a high honor. He continues to speak. “A few years ago I pinned that cross right here on my chest. . .” he proudly puffs out his chest and taps his left breast. “. . .went down to Atlanta and marched in protest against the Gulf War. I put all my medals on and my wife and I demonstrated against the war.” “Wow,” I reply in a stunned state. When he had tapped his chest in seeming pride, I had been sure he was going to say he was honored or something to display his valor. Rather, the mock posturing and the “as if proud” seemed to be a way of saying to me that he retrieved the medal and wore it in order to tell the government what they can do with their wars. “Ummm. Back to Kosovo for a minute. You’re clearly against war, demonstrating and such. How do you solve a problem like Kosovo?”

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“It’s gone way beyond the point where any of my suggestions would do any good. Now I say get the people together who start these things and let them fight it out. Get Clinton and Milosevic in a ring to duke it out themselves and leave everyone else out of it.” A kind of half-serious expression plays over his face before it turns grave again. “Paul, if they are going to get involved in conflicts they need to at least commit to it and get it over with. The air bombing is not going to get what they want done. It is like in the Gulf War. They didn’t solve anything. My son was in one of the units poised on the road to Baghdad when the attack was called off. They didn’t commit to solving the problem.” “Your son is in the military? How did he get enlisted?” “I don’t know why, but even when he was young he was attracted to military recruiters. We wouldn’t even let him play with toy guns. Whenever he got a B-B gun as a gift, I would store it in the attic. At seventeen he came to us with a paper to sign that would allow him to enlist early. He was intent on paying for his own college, even though he could have attended this university for free since I work here. He told us, ‘you have always said I needed to make my own decisions. Well, I have thought this out and this is what I want to do.’ There was nothing my wife and I could do but to let him enlist.” “How about you? Were you drafted?” “God no! I signed up. . . I had JOHN WAYNE in my eyes!” He waves his hand near his face as he emphatically proclaims, “I was going to be a HEro.” (The last word with extra emphasis on the “he” sounding something like “HE¯ row.”) This is the ultimate irony. He got what he wanted, but realized it was something no one ought to want. He became a legitimate war hero, but realized John Wayne movies show nothing about the price of gaining this status. Stars reflected in his eyes when he entered the war, now he bears the cross of that war. This burden prompted him to demonstrate against violence. Added onto the weight of his experiences, he underwent the further cost of seeing his own son go into conflict. A parent’s concern for a soldier must be grave, for a parent who has experienced killing in a war it must be even grimmer. Once again, I am reminded of the fact that this professor does not list the distinguished flying cross on his resume or his book jackets. Does he see himself as a hero, and if so what accomplishments listed on his resume might give him this status? Who are his heroes now, as opposed to before the war?

3 Bearing His Cross: After Meeting Reflections To what extent do experiences give an individual some type of moral authority? Experiences of war appear to give very powerful understandings for those who are willing to be attentive. However, this does not mean that everyone who experiences war is reflective on those events. Conversely some who have not experienced war can reflect on other’s stories or through using their own imagination/intelligence to come to moral decisions. In each of the three above cases in the original story,

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individuals are in a position to be listened to. They have their own motive and reasons for taking the positions they do. It seems that their experiences alone do not give them moral authority.

3.1 Continuing the Dialogue with Zaner I send the following email with the above second story attached: Dr. Zaner, Twice now you have managed to bore yourself into my head. The only way I know how to exorcize your voice is to write about it. I blame you for this on at least two accounts, you have encouraged me to be attentive to the oddities of interactions and demonstrated the necessity to reflect on these elements. Once again, I realize this story does not capture how the conversation actually went, but it is simply a way in which my thoughts can be given voice. Paul.

So, I send the new story to him. Later, we meet after he has read it. The below is the third and final encounter, which I again felt necessary to write. 3.1.1 A Stealth Flight (or Distinguished Flying Cross Part III) “Okay Paul, what are we up to today?” The “war hero” asks in his usual way. “I wanted to talk to you about that philosophy article you gave me to read; and to check to see if you had read my second story?” I add this last part in a timid manner. I feel the nervousness of facing someone who has read a story about a conversation I have had with him. Maybe I have gotten the conversation completely wrong. I hope that he replies as positively to this latest story as he did to the first one about his distinguished flying cross. His reading of that story really sparked a great conversation between us. He picks up the pages, leafs through them, and looks up. “Interesting, I think I might use some of this stuff in my writing. So, what else is it that we are talking about?” “So, the piece is okay?” I ask, trying to get more feedback. “Sure, its fine. Oh, before I forget, did you see that mini-series the last two nights. . .” “You mean the one on the gulf war syndrome?” I ask, hoping he is staying somewhere close to the topic of the story I had given him. “Yes. That’s the one. You didn’t tape it by any chance, did you? It had some fascinating stuff in it that I didn’t know. I wanted to get a copy of it but my tape jammed the first night. I only recorded the second night.” “No, actually I didn’t get to see the program.” “You know, I met some of the people who were portrayed in the show. That was really a brave piece to put on television—because of all the politics involved.” He continues by talking about his son’s military unit’s position in Iraq relative to a chemical plant explosion, the government cover-ups, and the horrible birth

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defects attributed to the syndrome. Once he finishes with his discussion of gulf war syndrome and its politics, we talk briefly about the philosophical piece he had suggested I read. As I am readying to leave, he again picks up my story from his desk. “Are you going to write any more about this?” He asks this in such a way that I cannot tell if he is encouraging me or forbidding me to continue writing about his experiences and our conversations. “Well, I’m not sure if I will write more. Maybe. It all depends on how things strike me. The stories just come out.” “If you do write more, I want to read it. You have written some things here that I hadn’t realized before.” There is now a reflective tone in his voice. “So, you don’t mind if I continue to write about our conversations,” I gingerly query. “Not at all. That’s fine.” He pauses and glances at the last page. When he speaks again, his voice trails off. “It just brings up so many memories when I read this stuff.” He seems quiet, subdued, and troubled. Silence and sparsity of words have marked this encounter. A kind of stealthy mood has come over him. I detect little hints of his reaction to my story in his body language. However, much is left unsaid. I cannot be sure whether this recipient of the distinguished flying cross is even able to speak his responses to my stories, but there are responses present. “I have written a great deal on this subject, but it is still all sitting in the computer. I’ve never done anything with it.” This is his parting shot before I leave. It seems he has previously tried to speak that unspoken element, but never to his satisfaction or at least not to a point where he wants to share it. I am still left wondering about numerous questions. Who are his heroes now? What in the previous story has caused the flow of those memories he mentioned? How can I understand the silence of a professor who often describes himself as having “verbal diarrhea?”

4 Now to the Present Day Dick Zaner writes powerful narratives about himself interacting with others that reveal something about the contextures of medical encounters. In his medical narratives, Zaner often places himself as a key reflective player. He usually tells of being a stranger in the medical environments and meeting strangers to talk of bodily intimacies. The above exchange provides a retelling that may enrich the contextual understanding of the central figure in the Zaner narratives, while also celebrating his teaching and methods of exploration. It is a story of my learning to pay attention to the person with whom I am interacting. It is about a willingness of an ethics consultant to lay bare his intimate past to a trainee in the same way he asks patients and healthcare providers to do so during consultations. Finally, there is an openness to let a student attempt to capture and develop skills in telling stories of encounters in useful ways. Look to the titles of several of Zaner’s narrative texts Conversations on the Edge: Narratives of Ethics and Illness, Troubled Voices: Stories of Ethics and Illness and Ethics and the Clinical Encounter. These titles point to the socially strange and

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awkward interactions that are edgy encounters that are troubling. But the question is for whom are they edgy and troubling. In hearing and reading a story about a patient being faced with pregnancy termination in an uncertain circumstance, Zaner makes this exceedingly clear. Again the title succinctly makes the point: “But How Can We Choose?” It is always about the “we” in the stories. Not a “we” of equal responsibility or of equal suffering, but yet a “we” fully engaged in the circumstance. The story I have told above is that type. It is about Zaner, his son, the people on hills in Korea, and about me in my growth. I see this imprint of reflectivity and of being part of the story on many of Zaner’s students. In the stories his students write there are many examples of such reflexivity and attention to the embedded teller attempting to help. One example that prominently demonstrates this is the collection of case narratives he inspired Denise Dudzinski and me to collect. More than a third of the 28 cases have authors who have directly studied with Zaner (These include stories by such people as Agich, Bliton, Finder, Dudzinski, and Rosell). His narrative contributions and influence will continue to propagate to future generations because of his willingness to both tell stories and encourage others to do so. Zaner’s influence and contribution to clinical ethics has been invaluable in many respects. The most striking for me has been his work in telling rich interpersonal stories and encouraging others in their endeavors. Of course by implication I have already made my position clear about Zaner as a Hero. His courage and dedication to patients, healthcare providers, and students begin to explain this. His complex, edgy, uncomfortable, troubling stories demonstrate his admirable willingness to bear a cost in his helping others. Zaner’s war medal provides some information about his past and present. But, his response and moral reflection on these experiences set him as an important role model. These elements “distinguish” Zaner in so many ways.

Notes 1. Although in the original, I indicate it to be the 3rd highest. Although a very high medal, it is in fact slightly lower than that.

References Ford. P.J., Dudzinski. D.M. eds (2008) Complex Ethics: Cases that Haunt Us. Cambridge: Cambridge University Press. Zaner RM. (1988). Ethics and the Clinical Encounter. Prentice Hall. Zaner RM. (1993). Troubled Voices: Stories of Ethics and Illness. The Pilgrim Press. Zaner RM. (2004). Conversations on the Edge: Narratives of Ethics and Illness. Georgetown University Press. Zaner RM. (2008). But How Can We Choose? in Complex Ethics Consultations: Cases that Haunt Us. eds Ford PJ, Dudzinski DM. Cambridge University Press.

Chapter 15

On the Telling of Stories Richard M. Zaner

“In three words I can sum up everything I’ve learned about life: it goes on.” —Robert Frost

1 By Way of Prelude: A Song Before I Dance I owe much to those who have generously contributed to this collection; not only for their kindness in doing so, but also for their enduring insights, many of which have helped me immeasurably over the years to reach an understanding of phenomena otherwise beyond my ken. Reading these writings has confirmed this time and again, and I am deeply grateful for their words and intelligence. I have been warmed by the personal notes, charmed by their stories, captivated by their sensitive reasoning. Here, I want to give something in return, well beyond my past writings. I often promised myself that I would sometime try and show how the various stages along my life’s way have, one and all, been cut from the same cloth. Discerning the unifying themes of my life’s work has not been all that ready-tohand, not even, perhaps especially, for me. Still, as I have thought about these matters the past few years, several things have become a bit clearer to me. The themes that long preoccupied me since I became involved in the world of clinical and research medicine, were given a first expression in several essays I was asked to write,1 in which I tried to tie in my concerns for medicine and clinical R.M. Zaner (B) Anne Geddes Stahlman Professor of Medical Ethics Emeritus, Vanderbilt University Medical Center, Nashville, TN, USA e-mail: [email protected] This is based, somewhat remotely, on my “Afterword” for Richard M. Zaner (guest Editor), “Performance, Talk, Reflection: What Is Going On In Clinical Ethics Consultation?” Special Issue for Human Studies, 22: 1 (January 1999), with Introduction and Afterword, pp. 1–3, 99–116. (Published simultaneously as a separate hardcover book by D. Reidel, Holland and Boston, 1999.)

O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1_15,  C Springer Science+Business Media B.V. 2011

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ethics with my long commitment to phenomenological reflection. While I think those attempts were worthwhile, they did not probe those core themes at all sufficiently. I want now to try this one more time, as perhaps my best way to return the honor those who contributed these essays have done for me.

2 First Movements of the Dance As I view my writings now, there are three themes at their center: first, the phenomenon, “my body;” second, since “mine” (along with “my”) focuses that phenomenon, there is the theme of “self” (“me-myself-I”) on which to dwell; and, third, two closely connected issues want to be clarified: the contexture of body/consciousness/self that was the center of earlier studies (especially The Context of Self)2 ; and, as several whose work has always been close to me, Alfred Schutz and Kierkegaard, emphasized, that complexure, as I termed it, cannot stand by itself but is always “with the Other.” Briefly, then, embodiment, reflexivity, and intersubjectivity have been the guiding themes of my work—and on that basis, explorations into especially revealing forms of sociality (such as those displayed in clinical encounters). Trying to be clear about that nexus of issues, questions of method have been central as well, but at the same time are far more complex and tricky than I first thought. Indeed, although I have written a good deal about method over the years,3 the fact is that it remained somewhat opaque, even when I seemed to get all the words in their right order. In a sense, my first serious inroad into the real question of method came only when I found myself writing narratives in the effort to make sense of my experiences as a clinical ethics consultant or “ethicist”. It was while engaged in this form of writing, that it gradually became clear that that long-preoccupying cluster of issues had also been methodically addressed in a novel and highly suggestive way. There are several aspects of this; I’ll take them up one at a time.

3 Dancing with Another as We Grow Older Together Without exploring the matter nearly as much as I think he should, Alfred Schutz nevertheless set out the basic framework for what I came to believe. I tried to lay this thematic out in my Alfred Schutz Lecture several years ago.4 Schutz, I noted there, was especially troubled by Husserl’s frequent insistence that intersubjectivity should be understood fundamentally as a “problem” at the transcendental level. As Schutz emphasized: “it is in no way established whether the existence of Others is a problem of the transcendental sphere at all. . .or whether intersubjectivity and therefore sociality does not rather belong exclusively to the mundane sphere of our life-world.”5 And, in his essay on Max Scheler, he similarly insisted, “the idea of a transcendental community of monads requires additional metaphysical assumptions which cannot be warranted by a philosophy whose idea it is to be a rigorous science.”6 Rather than “problem of constitution,”

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intersubjectivity is instead “a datum [i.e., a “given:” Gegebenheit] of the lifeworld”7 —which is precisely what Schutz probed in his many writings. Although Schutz set out to explicate this theme, it nonetheless remains unclear just what he meant by calling it a “datum.” This is odd, moreover, when it is appreciated how heavily he depended on Husserl for explicating this thematic— in particular the notion of “appresentation”—since with this approach the Other is in a clear sense always, so to speak, essentially out-of-reach and thus an always-tobe-reached, and is thus “given” only indirectly, by way of some other affair that is then taken as “standing for” or “making present” what is itself not capable of being directly “given.” The oddity I have in mind was acutely noted by Eugen Fink in their fascinating exchange after Schutz’s critique of Husserl during the Husserl Colloquium at Royaumont in 1957. Of particular interest for me is Fink’s terse comment, “I can never and in no way originarily apprehend what is “within,” what it is that acts in the living body of the Other (das-Im-Leibe-Walten des Anderen).” Because of this, he concluded, this appresentation is characterized by “non-redeemability” (Einlösbarkeit). This suggests, Fink emphasized, that Husserl’s notion of appresentation as regards the apprehension of the Other can only be “metaphoric—and unsuccessful at that. . . .”8 Accordingly, if appresentation is the way in which the Other is given and apprehended, there is then truly a “problem,” indeed, a plethora of serious ones. For example: if Fink is right and what is appresented (the Other) is only “metaphoric” and therefore is strictly in-accessible, then in principle how would one know that there is anything at all to which the metaphor points and through it is appresented? What connection could possibly hold between what is appresented and what appresents? In his response to Fink, Schutz immediately embraced Scheler’s “perceptual theory of the alter ego,” as he termed it, and went on to assert his own long-held notion that there is (one should probably instead say “there just has to be”) a special form of appresentation by means of which the Other is apprehended: “indicative symbols” such as gestures, facial expressions, language, and bodily actions. As in any symbolic consciousness, Schutz thought, in apprehending the Other, “the symbol alone is present, whereas that which is symbolized is only appresented.”9 To which, it is obvious, the same sorts of severe problems ineluctably arise. Now, several things are noteworthy here. First, Fink’s distinction is far more interesting than Schutz seemed willing to admit, for if Husserl’s usage is, as Fink alleges, merely an unsuccessful metaphor, one can surely wonder whether the root relation to and experience of the Other is appresentational in any sense. More to the point: although it is surely true that many encounters with Others involve many types of appresentation, the question is whether what Schutz termed the Du-einstellung (“thou-orientation”) is itself appresentational. Second, consider his comment about Scheler. On the one hand, Fink neither mentioned Scheler nor did his remarks relate to what Schutz had in mind: symbols as appresentations. So why would Schutz have been prompted to endorse Scheler at just this point? Indeed, if Scheler is correct in own analysis of this phenomenon,

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Schutz’s endorsement would seem inconsistent with Schutz’s own view of such “perception” as symbolic in any sense. What Schutz noted there and elsewhere is fascinating, nevertheless, on its own—for what it says about his thoughts on intersubjectivity, and the light it may shed on the phenomenon itself. More on all this as I make my way into these issues.

4 The Primal Dance: Being Born There are several clues to figuring out what Schutz might have meant by calling intersubjectivity a “given” and not a “problem.” On the one hand, long fascinated by Scheler’s ideas, he consistently embraced Scheler’s “perceptual theory of the alter ego:” I do indeed apprehend my wife’s joy in her smile, grasp my friend’s anger in his upraised fist, etc.—or, in his own example, “ “I and You,” We see the flying bird.”10 Only if the two of us are, if you will, always-already-with and oriented toward each other within a living present does his crucial notion of Du-einstellung at all make sense, which means that it can not itself be a form of appresentation, no matter how “special” one wishes to make it. There is a significant clue here—a good deal more speculative, but very intriguing. After insisting in his critique of Husserl that intersubjectivity is a given and not a problem, he wrote: “As long as man is born of woman, intersubjectivity and the we-relationship will be the foundation for all other categories of human existence.” Accordingly, everything in human life is “founded on the primal experience of the we-relationship,” which, though he didn’t explicitly say so, must surely be the experience of being born—or in his phrase, being “born of woman.”11 Since all “other categories of human existence” are founded on this primal experience of being born, be it noted, intersubjectivity was for Schutz “the fundamental ontological category of human existence in the world and therefore of all philosophical anthropology.”12 In the Scheler essay, Schutz’s remark—made almost in passing, it seems— is just as fascinating. Pointing out first that there is one taken for granted assumption which no one doubts, not even the most ornery skeptic, he wrote: “we are simply born into a world of Others.” Then he abruptly announced: “As long as human beings are not concocted like homunculi in retorts but are born and brought up by mothers, the sphere of the “We” will be naively presupposed.”13 Here, too, it is reasonable to surmise that what is “naively presupposed” is precisely that “primal experience” of being “born of woman” and (he added here) being raised by mothers—as opposed to being “concocted. . .in retorts.” I know that although what I’ve said thus far is a mere abridgment of the wealth of Schutz’s ideas, I have to leave it at this here. In a sense, what has long resonated for me in Schutz’s writings is his wonderfully descriptive yet deceptively simple language, in particular certain enchanting, provocative, always highly suggestive terms: “living present,” “living presence,” and being “face-to-face,” which I had examined in earlier studies. Now, what fascinates are others of his potent notions,

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so much Schutz’s native air: “making music together,” “growing old together,” the “mutual tuning-in relationship.” What are these all about? Other passages also have much the same charm, but one in particular strikes me as vital to understanding Schutz, even while it is very dense—that delightful exchange with Eugen Fink after Schutz presented his critique of Husserl at the Husserl-Colloquium in April, 1957. As I noted earlier, Fink picked up on Schutz’s discussion of the Husserlian notion of “appresentation,” and noted a fundamental difference between two types, one that is “redeemable” (einlösbar) and the other not. A well-known example of the first would be seeing a book from “this” side as having another, appresented, side; then if one turns the book over what was at first only appresented is now presented—it is “redeemed” or “fulfilled,” which is rather like making good on a promise. As distinct from this type, Fink pointed out, are supposed appresentations where that redeemability is absent in principle. The experience of the Other is the clearest case in point, since, he emphasizes, “I can never and in no way originarily apprehend what is “within,” what it is that acts in the living body of the Other—I can never “redeem” this appresentation.” It is because of this, Fink points out, that Husserl’s notion of “appresentation” in such cases is, he says, only “metaphoric—and unsuccessful at that. . . .” It is Schutz’s response to this that I find intriguing. Matters are more complex than what Fink had indicated, for there are visually perceived affairs whose appresented other aspects cannot in principle be actualized. Schutz mentioned the inside of the earth, but other examples are easy to come by: I will never be able to see the other side of the moon, even though it has been seen by some astronauts and will be seen by others. He puts these aside, however, emphasizing instead Scheler’s “perceptual theory of the alter ego:” . . .we directly perceive in the smile of the Other his joy; in his folded hands his praying. I would like [then] to modify somewhat Fink’s thesis that it is impossible to bring another’s appresented inner life to perceptual presence by saying that I can apprehend the Other’s inner life only by means of indicative symbols (his gestures, his facial expressions, his language, his actions), that I can apprehend it only by appresentations. Indeed, it is a peculiarity of symbol-relationships in general that the symbol alone is present, whereas that which is symbolized is only appresented.14

5 Tripping a Light Fantastic Fink’s argument that Husserl’s usage is but an unsuccessful metaphor, suggests that, while there clearly are any number of appresentational apprehensions relative to Others—typically I see your wearing a suit as appresenting certain social characteristics, for instance—the root relation to and experience of the Other (the Du-einstellung) is not appresentational in any sense. I think Fink had the better part of the argument. Schutz, in the end, continued to accept Husserl’s appresentational approach, even while he just as forcefully rejected the Husserlian notion of transcendental intersubjectivity.

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First, a note about the way in which intersubjectivity was discussed by Schutz. I’ve already hinted at a buried assumption. Perhaps more obvious in Husserl’s work, as Schutz saw clearly, it was both shared yet not shared by Schutz: the notion that the human sphere consists of persons each of whom supposedly has a sort of “inside” and, if that’s so, then there has to be an “outside.” I am quite aware that I may verge on heresy here. Even so, there are in Schutz’s writings a number of odd, even enigmatic ways of describing the interrelating of Other and Self, and Self with itself. For him, the “self” (or, variously, “mind,” “subject,” “consciousness,” and the like) is consistently regarded as being “inner”—in a quite literal way as somehow inside self’s own body, and the embodying body is regarded as having an “outside” thanks to which what is “inside” is able to be “expressed” (literally pressed to the body’s “outside”) and thus experienced and known by the Other. Knowing or experiencing the Other by Self is then essentially a matter of working backward, so to speak—not unlike Dilthey’s notion for understanding historical phenomena: outward manifestations of inward life—from what the Other does or displays on its body, that is, its “outside.” The Other “presses to the outside” what is within its own inner durée—which, as events on the “outside,” on his bodysurfaces, are or can be then taken by Self as “clues” or “indicative symbols” that “appresent” the Other even while the Other’s “inside” remains essentially opaque. Since what is inside cannot in principle be apprehended for and as itself except by the Self whose inside it is, or who is coextensive with that inside, it thus turns out that knowing and experiencing Other by Self is and can only be a matter of interpretation of symbols. The Other remains therefore considerably problematic even while Schutz insists that nothing is more certain within daily life. Yet, not even the Self is capable of directly apprehending itself, for Schutz: since that can occur solely in reflection, which it essentially caught up in the temporal durée, Self appears solely as past, never in the vivid present. As I noted in my Schutz Lecture, there are other complicating features of his understanding of intersubjectivity. I must again leave those aside here, and attend instead to several crucial assumptions that mark his understanding: (1) that Self can know itself only as past and is thus inaccessible to itself in any immediate and direct way; and (2) that the inner sphere somehow exhibits itself only in somewhat recondite ways—indicative symbols would be one such way—which are interpretable in the present by the Other, but what is symbolized in principle is never capable of being directly experienced by the Other. Thus is Self directly accessible neither to itself nor to the Other—Scheler’s notion that I see my wife’s love in the way she touches my cheek, can only be deceptive or, at most, a matter of symbolic interpretation. This view invokes a second crucial assumption—one which was at the heart of Schutz’s ideas almost from the beginning, deriving, I suspect, mainly from his reading of Bergson’s concept of “inner durée.”15 At one point Schutz takes pains to emphasize the resulting paradox: “in [one] sense each of us knows more of himself than of the Other;” yet, “in a specific sense the contrary is true. . . .I know more of the Other and he knows more of me than either of us knows of his own stream of

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consciousness.”16 Self experiences the Other’s overt acts in a vivid present, whereas both of us can grasp his own inner life only as past, and that of the Other only as appresented in symbols. If we follow Schutz’s own guides for understanding how intersubjectivity is at all possible, we are left with little more than what Fink insists is “metaphoric. . .and unsuccessful at that.” Yet, each Self does indeed experience the Other in a sense directly and immediately, although only by means of what seems little more than an artifice, even trickery, albeit unintended. Sartre’s well-known charge of “ontological optimism” (leveled at both Hegel and Husserl) seems equally apropos for Schutz—who, to make matters even more fascinating, himself makes pretty much the same charge against Husserl and Scheler. There can be in Schutz’s own terms no simultaneity between two subjective streams of experiences; thus, intersubjectivity seems at best an impossible dream—a dance, if you will, which despite appearances cannot be realized: there can be no “growing old together.” Doing a “light fantastic” is mere fantasy. In fact, Schutz himself seems at one point to recognize just this result: “fully successful communication is nevertheless unattainable. There still remains an inaccessible zone of the Other’s private life which transcends my possible experience.”17 In the plainest terms I can find, however, the very notion of the “unattainable” is at best incoherent in Schutz’s own framework, just as is the notion of the “inaccessibility” of a private life other than Self’s. I mean: if it is accepted that the inner durée or “inside life” of Self is essentially closed to the Other, since the Other can in no way whatever apprehend Self’s inner life but only what may be “ex-pressed” as symbols in the “external world”—if all that is accepted, then the very notion of “fully successful communication” is unsinnig, as is the idea that it is “unattainable,” and that there is “an inaccessible zone of the Other’s private life.” The entire argument is severely compromised even further by his postulate that the same is true of Self, that it apprehends itself only as “past” and is thus Other to itself, is essentially alienated. Which, finally, makes the very notion of the body as a “field of expression” dubious at best. Underlying Schutz’s analysis and motivating those sorts of questions is a rudimentary assumption: that genuine intersubjectivity is ultimately a matter of having the Other’s subjective life in the very way the Other has it. Which, it is clear, cannot be true for the very good reason that it would mean that the otherwise crucial distinction between self and other collapses. The same must be true for my relation to myself: so to speak, if I am an other to myself (I reflectively apprehend only a “past me”), it also seems his assumption that experiencing the Other can only be a matter of being-inside the Other. The Other (whether as “thou” or “you”) is in the end just another “me,” albeit inaccessible in a different way. And why? Because Schutz simply took for granted that it is sensible to suppose not only that there is the Other, but that the Other is a being who, “like “me”,” is endowed with an essentially private sphere that yet transcends my and thy possible experiences; hence, “I,” like Others, am Other to myself, and can be known by myself only symbolically.

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6 Intermission And yet, I hesitated as I explored these issues once again; and yet: the magic of our daily lives—despite Schutz’s many arguments—is that all those oddities, infelicities, paradoxes, and even absurdities make not the least difference. We go right on believing in the Other, the common world, and the rest of it: we “take for granted.” Thus, to use one of his finest examples, when you and I see a bird in flight, there really and truly is, we take for granted, just one bird and we, you and I together, see it, point to it, talk about it. When a child is killed by an onrushing auto, her parents haven’t lost two children—as it were, “his” and “hers;” they have lost but one and they not only grieve, each in his and her own way, but they share as well a common grief and loss. Schutz, of course, went to considerable lengths to detail precisely how it is that commonsense life overcomes the skeptics: that remarkable artifice, taking-forgranted. We have to wonder, it’s clear, about that pervasive, constitutive feature of everyday life—“taking things for granted”—what is that really all about? Significantly, it is at just this point, both in the Scheler essay and that on Husserl, that Schutz makes those intriguing assertions noted earlier—more announcements, really, than anything else. Apparently thinking about just this question in Structures of the Life-World, Schutz remarked that, although I grasp myself only in the past-tense, I do not reflectively grasp an “absolute beginning.” I have been told that I was born. I “know” this. I can also locate my birth on the basis of a syllogism which is dependent on my knowledge (all men are born, I am a man; therefore, I was born). I cannot locate my birth in my inner duration—quite apart from the antinomies which would then result. I can deduce it only as an original “return” to a world transcending and independent of it.18

There may be a point to the musings of skeptics: how do or could I ever become aware of my having been born? Does my having been “born of woman” constitute the “primal experience” and is “ontologically” the foundation for all other human categories? It is surely the case that little in human life is as descriptively intimate and close as the fetus in the mother’s womb, or their bonding, when it occurs, just prior to and immediately at birth. But how should these be understood? Philosophers have written and chatted, at times incessantly, about death, and said almost nothing about birth. Has something crucial been missed in these discussions?

7 Method: A Sort of Dance Meta-movement I suggested in my Lecture that, if, Schutz expressly contends, the Other is always apprehended appresentationally—through gestures, facial expressions, language, and actions (“indicative symbols”)—so, too, would Self then experience itself by means of appresentations, albeit different from the way the Other is grasped. This may not be as far-fetched as it might sound, for even Schutz went to great lengths

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to argue that “all appresentational references are means of coming to terms with experiences of transcendences,”19 or, as he was later to suggest, we “cross limits” and “boundaries” by means of such appresentation20 —whether by means of marks, indications, or signs (transcendences within paramount reality) or the more potent symbols that come into play with respect to “experiences which transcend paramount reality.”21 Clearly, not only my own birth—that “primal (ontological) experience”—but so far as being “born of woman” is constitutive of “all other categories of human existence,” my Self as well, then—which yet transcends my grasp of it in any event, being always grasped as “past”—are able to be brought within “reach” solely through those specific types of appresentation Schutz analyzes as marks, indications, signs and symbols. Although he never expressly proposed this idea, it strikes me as fundamentally consistent with his views to suggest that for him both the experience of Self and of the Other occur thanks solely to these remarkable indirections.22 Beyond those rather brief ruminations, however, Schutz did not apparently make very much of his own intriguing observations about that “primal experience” of being born—all the more astonishing if one thinks of the emphasis so often given to the blunt end of all things, death—which also preoccupied him, but is unhelpful for explicating that primal experience. While he reflected at least some about death, so far as I can determine he never took up that other fundamental shaping of human life, birth. In fact, in a clear and compelling way, it is the primal experience of being (or having been) born that constitutes the crucial other side, if you will, of the central experience of growing old together. We could not experience ourselves as aging, as growing older, if we did not begin to be—so to speak, come at some always-alreadyongoing time in our lives to find ourselves as having-already-been-thrust-into life: birthed and thereby “worlded.” From these considerations several conclusions seem to me inescapable. First, Schutz and Scheler are in a sense quite correct: being human is a matter of being born human; hence, birth is a powerful, if oddly ignored, phenomenon deserving close study. Even the merest dip into these still opaque waters convinces me that Marcel was also quite correct: to be (human) is to become (human).23 Becoming “human” requires a sequence of developmental stages whose primary characteristic is that these stages are set within ongoing interrelationships with highly specific Others, the mother most especially. We are at the outset of our lives truly alwaysalready-with mother; always-already-within the literal embrace of her own body, literally, from the earliest stirrings of semen-penetrated ovum to the full infant immediately prior to birth. Accordingly, as Schutz saw with remarkable if also undeveloped insight, intersubjectivity is in no sense a “problem” to be solved, but to the contrary is the fundamental “given” of and within the dense reality of human life. What he did not, however, probe were the implications of this “primal experience.” Instead, as noted, he reverted to a quite different phenomenon entirely, appresentation, seeking then to resolve what was in any case no problem in any coherent sense calling for a solution. In the most straightforward terms, Self is from the outset of its life strictly with (even within) the primal Other, its mother.

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From these considerations it directly follows that the crucial phenomenon is precisely that set of interrelationships, the principal language of which is, first, what I will term nested embodiment. It is within the nest of pregnancy that self first comes to be, and its language is first and foremost that of intimate touch—even, if you will, a sort of “all-touching” that alone comes from being within the womb, that unique nest of my own life. Second, that form of embodied “speaking” continues into the early years of childhood and even later, into adulthood through such gesturing as kissing, holding, punching, pushing, pointing, and the like. Third, that development of embodied language becomes quickly and firmly set within the bounds of spoken language and gestural displays. I mean, the core of human development is a sort of embodied moving which develops as a dance of talking and listening, in the most concrete form of all: mother (later, father, siblings) telling baby, that is, giving baby ways by which it gradually comes to understand the fundamentals of being a person in a world populated with other humans, each of whom is also, as Marcel put it, on the way (être en route). Telling those “ways” is telling stories: narrative is the way, the method for elucidating the fundamentals of human life within its own human milieu, just as it is the principal form of evidence for the Other as such. The Other is “s/he who tells and listens,” just as Self is “s/he who listens and tells.” In just this sense, I think, to be human is to be gifted both with my life and the sense of myself as “on the way,” in the process of happening. The primal Other is precisely the mother, who “gifts” me with myself (gift of life from pregnancy, birth); and, later, “gifts” me with herself (through words and dramatic gestures: stories). Being born is accordingly constitutive of what and who I, any I, am; I am not merely, then, a “being-toward-death,” but even more fundamentally a “being-from-birth.”24 Being-born is thus at once radical injustice and yet radical debt and responsibility: without being asked, I am gifted not simply with life but with self-conscious life, which I did not chose and doesn’t automatically know itself, but must needs ask and seek itself first of all. I am indebted for my being to the primal Other (mother), and responsible thence for proper recognition of that and of becoming myself—which is itself always a task in process, and even when not always accomplished, done within the nexus of our growing old together. As I thought about how I might address that central set of themes of my work, then, what came back to me, not surprisingly, I suppose, are many of the several thousand clinical encounters25 that engaged me over the 22 years of my tenure at Vanderbilt University Medical Center.26 I was regularly struck by how those many people seemed invariably so anxious to tell their own stories. The turn I took, in the early 1990s, to writing stories, to narrative, was, I can now say, both natural and, as I have come to understand these matters, significant for taking account of the sphere of human affliction and the various ways in which others seek to help those who cannot help themselves. The people whom I met in these clinical encounters sought not only to tell me and others what they were going through, with all their uncertainties and ambiguities, but wanted me to listen while at the same time helping them articulate their sense of themselves and their beliefs. Being sick or seriously injured not only solicits telling. It also seems to go about this almost of itself; let someone come in to a hospital room

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to visit, for instance, and a story is off and running—all the more so if the visitor chances to mention that he or she has been ill, and even more if the illness is like that the patient has at that moment. All of this, I now am convinced, occurs naturally within the nest of relationships that is human life, whose initial and initiating “nest” is what is normally called “pregnancy”. When you enter into a clinical encounter, you confront a veritable chorus (sometimes riot) of voices, each anxious to be heard—at times oddly subdued but just as often, a confusing muddle, even an aggressive anarchy. Of course, you soon learn that each tale needs to be told in its own way, differently, depending, in part, on whose point of view is adopted (created, invented, or whatever), or what it was about one or another situation that seemed especially intriguing or important—at least while I might have been trying to tell that tale cleanly and clearly, and most of all fairly. One thing, though, seems obvious: all of these tellings and yellings are efforts— some still tentative, others more vigorous—to make sense of things and in the end, of ourselves, of our lives. “Sometimes,” in Barry Lopez’s powerful words, “a person needs a story more than food to stay alive.”27 As Roger Rosenblatt wrote, So much of living is made of storytelling that one might conclude that it is what we were meant to do—to tell one another stories, fact or fiction, as a way of keeping afloat. . .We have the story of others to tell, or of ourselves, or of the species—some monumentally elusive tale we are always trying to get right. . .28

In Brian Doyle’s compelling terms, listening to one another, “. . .you think, my god, stories do have roaring power, stories are the most crucial and necessary food, how come we never hardly say that out loud?”29 I hope, earnestly, that in my own efforts to tell stories, I got each tale right. For now, I am hopeful that what I’ve tried to say in a more academic way does those narratives, and all those I have yet to tell, justice; that what I say about those situations and encounters is fair and honest.

8 The Dance Concludes with a Song The stories patients tell (and others of us involved with them) invariably arise from the themes intrinsic to practically every clinical encounter—more accurately, from those encounters in which we all understand that much is at stake, much to be won (by “successful” treatment) and much to be lost (when everything has been done and rescue, cure, or restoration is no longer possible). At the core of these clinical events is an encounter with our own, even my own, mortality and the circumstances which make that especially exposed and exigent: questions of dying and death, loss and grief, and how people deal with them. It is not easy for any of us to discuss such situations in any case; they are all the more awkward and difficult to talk about when an intimate other is faced with such an extreme situation: someone close and dear is dying or faces severe compromise, is in great pain with relief only barely in sight, if at all. It is for most of us next

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to impossible when the individual in question is yourself, myself. When faced with such situations, Ronald Blythe’s terse comment about Tolstoy’s The Death of Ivan Ilych comes to mind: that the character of Ivan reveals the “plight of a man who has a coldly adequate language for dealing with another’s death but who remains incoherent when it comes to his own.”30 Faced with the prospect of my own dying— say, on receiving a diagnosis of serious cancer—I am struck dumb, without words or wits to withstand the onslaught of the unspeakable. But, it has also seemed to me, faced with the pending death of a loved one—wife, husband, child, sibling, mother, father—so are we so often struck dumb as well. Facing not-being, we know the profound inability of language and the blunt bewilderment of finitude.31 We rarely if ever have the right words ready to hand, if we ever have them, to talk candidly about dying, loss, grief, profound sadness, fear, dread—the inner tremblings of the soul. Instead, we fumble and mumble, waiver and stall for time and still more time waiting for our minds to be made up, somehow settled—by the sheer passage of time, or the push of circumstances. Until, often as not and with a sigh of detectable relief, we revert to talk about nature or God: rather than make our own decisions, we talk about letting “nature take its course”, or send out desperate, prayerful pleas to one or another deity, thinking that things are surely out of our hands—God’s will or blind nature, yet, merely mask the needed making of a decision, or the resolve to make sense of things. Beyond the exigencies of discussing ethical questions openly with those who actually have to face them and perhaps helping them find some way to settle on some course of action or other—be they patients, doctors, nurses, family members, or any other—there is also, if we are honest, the arduous chore of putting that talk into written form at some point, into words that go beyond while yet truly capturing the moment, words that will convey the actual sense and feel of those disturbing situations. It is so very difficult, we then realize, to write without obscuring, concealing, masking, or even forgetting to mention precisely what was vital for ourselves and others as we then strived to understand what we were going through. James Agee said it best, in Let Us Now Praise Famous Men, that remarkable work he and Walker Evans were once commissioned to write and publish, in order to talk about, much less write about, unique individuals facing themselves across the awesome horizon of their own unique lives and deaths: For in the immediate world, everything is to be discerned, for him who can discern it, and centrally and simply, without either dissection into science, or digestion into art, but with the whole of consciousness, seeking to perceive it as it stands: so that the aspect of a street in sunlight can roar in the heart of itself as a symphony, perhaps as no symphony can: and all of consciousness is shifted from the imagined, the revisive, to the effort to perceive simply the cruel radiance of what is.32

But Agee was even more emphatic about the point I am trying to express here with as much directness as I can. His first words about the project the U.S. Department of Agriculture commissioned him to write, along with Evan’s extraordinary photographs—pictures and words about poor white dirt farmers in the South—give the compelling challenge to any who would dare write about people in times of utmost distress:

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It seems to be curious, not to say obscene and thoroughly terrifying, that it could occur to [anyone]. . .to pry intimately into the lives of an undefended and appallingly damaged group of human beings, an ignorant and helpless rural family, for the purpose of parading the nakedness, disadvantage and humiliation of these lives before another group of human beings, in the name of science, of “honest journalism” (whatever that paradox may mean), of humanity, of social fearlessness, for money, and for a reputation for crusading and for unbias which, when skillfully enough qualified, is exchangeable at any bank for money (and in politics, for votes, job patronage, abelincolnism, etc.). . . .33

Just this challenge has haunted all my writing, though I have intended neither science nor art nor journalism, as it haunts every clinical situation. Whether writing as phenomenological philosopher, armed and seasoned with all those epochés, or as clinical ethicist talking with and listening to a critically ill patient—and, later, trying to make sense, phenomenologically or clinically— the harsh question refuses to go away: Is it ever possible to perceive anything simply “as it stands,” especially while you are yourself there, too, dancing and singing, talking and listening dans le milieu des choses? And, supposing it can be accomplished, somehow: behold the perceiving of things while standing in their midst, how then to talk with colleagues, of all sorts, much less, later on, to write about those very things—without dissection, or analytic examination, neither absorption nor digestion, but straightforwardly, without clouds or shadows or anything else obscuring—to say what must be said, and say it so that you get it right? Can any of us “stand” in the face of that “cruel radiance of what is” and tell it like it is? How can we, after serious listening and observing, talk or write, when what we must talk and write about is so unique, so singular in its immediacy and potency, and for that very reason seems, contrary to everything we hope to do, so utterly unrecoverable? What amazing trust must be placed in listeners and readers, to understand this ungetaroundable quandary?34 How put the unconditional into words, tell the unqualified uniqueness of individual people and their actions, emotions, relationships, circumstances? And how then go on to write about these very encounters—standing then at still another remove from their utter immediacy—without obfuscating or distorting the very things that mattered most while we were still enmeshed in the moment, in the circumstances that have left such deep marks, still haunting us as we try to figure it all out. . .in writing? It was as I was dwelling on these matters that stories began to occur to me and as I tentatively began to write them, it became increasingly clear to me that just these narratives held the key that connected my earlier work with what I slowly began to call clinical ethics. My job, if you will, I understood now to have been this: helping those who invited me to become involved in their lives to locate, articulate and pursue, as far as time and circumstances allowed, the specific questions posed by their conditions, but also by their fears and hopes; it was also imperative for me to learn to elicit and listen to their voices, however awkward and incomplete the stories they then told—and, as I later learned, to share something of my own stories with them.35 Narration, then, became the heart of my clinical endeavor—a point expressed very well by Paul Komesaroff:

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The major concerns expressed in the public debates about medical ethics ignore many of the most important issues. They ignore, for example, the finely textured and subtle nature of the interaction between doctor and patient and the social context in which it occurs. They ignore the manner in which problems are formulated within this relationship and the ways in which the various possible courses of action are identified. Most importantly, they ignore the delicate ongoing process of negotiation and compromise that characterizes human relationships in general and in particular underlies any therapeutic interaction.36

Or, in Agee’s admirable bluntness: is it not “obscene and thoroughly terrifying. . .to pry intimately into the lives of an undefended and appallingly damaged group of human beings”? The question is humbling; I offer here only a few deliberations—along with, I should add, an invitation to look into narrative, for instance, Rita Charon’s splendid book,37 to appreciate this challenge.

9 The Ardor of the Dance Expressed differently, our experiences are thoroughly storied, even while most of the time and for various reasons, they are only partially told. I can now say more clearly what I’ve been driving at: while the kind of clinical conversational attunement that is focused on patient experience and self-interpretation has only begun to be more appreciated in the health care professions,38 especially medicine, precisely this discipline is the central feature of clinical ethics consultation. In different terms, to be oriented, understanding and sensitive in any clinical involvement, ethicists have to be as precise and careful in attending and listening as the physician who auscultates a heart or palpates a spleen.39 Clinicians are led to believe that symptoms are clues to disease, evidence of a “natural” process, a physical entity that has yet to be uncovered—incorporating, Arthur Kleinman says, a positive tendency to “regard with suspicion patients” illness narratives and causal beliefs.”40 In this respect, unlike physicians (focused on the patient’s body and the patient) and unlike patients (focused on their condition), the clinical ethics consultant must be wholly unlike any “naive realist,” contrary to what Kleinman alleges: akin to a more reflective Sam Spade, perhaps, ethicists must bring a clear-headed, strong reflective presence to clinical situations, to ensure that the fundamental questions of moral worth are not avoided, but are instead at the very center of every clinical conversation and decision. The patient and family, but also the physician and nurse, and others who may become involved and influence the course of a patient’s condition, thus exhibit interpretive methods quite as much as any one else. They are, in Kleinman’s words, like “revisionist historians,” “archivists,” “diarists,” even “cartographers,” who constantly search their pasts for present meaning, record the minutest difficulties on the map of the changing terrain of ongoing illness, and focus on the “artifacts of disease (color of sputum, softness of stool, intensity of knee pain, size and form of skin lesions).41

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Phenomenologically oriented clinicians, if I may so put it, are hunters and gatherers at the same time, they are seekers and collectors of the stories which make up every clinical encounter. Beyond hunting for, gathering, and listening to, and learning to understand such stories, they are also witnesses and guarantors, ensuring that every clinical narrative has its chance to be told and receives its appropriate hearing. I must not ignore what I believe is a crucially important feature of writing, especially narrative writing: in a word it is, or can be, a way to discover and understand the sense of what was going on in the initial situation now being told. Consider only those moments of initial writing when we are trying to get our thoughts clear, trying to find adequate and accurate ways of expressing what went on in a particular encounter. Those initial, always laborious moments of writing seem most of all a kind of unearthing of initial sense, when we try out first this or that expression, phrase, or word, and listen to whether it says rightly what is on our minds regarding this or that moment in a clinical conversation—that we’ve “got it right.” In doing so, I have found that this, so to speak, wandering through and then mining of the field of expression is a significant part of explicating the sense of the event I am trying to “tell.” To appreciate that such phases of writing are, in truth, moments of genuine discovery, is to acknowledge as well that even that much-sought-for final version, the one designed for full public display in some published form, may itself continue to be a kind of discovery. If this is granted, then the status of the writer must be similarly reconsidered: rather than simple “data-gatherer,” much less mere recorder of facts and collector of clues, the sense of writing-as-discovery suggests that the writer is more inquirer than recorder, more interrogator than settler of disputes, more in the posture of one still learning than one of having-already learned. I want to emphasize, too, that every moment of consulting must, as I understand these matters, be shared—impressions discussed, initial judgments tested, implications explored, the “lay of the land” properly told. Conversations and writings need to be continually submitted to others, for their understanding but also for their critiques. Understood in these terms, writing may be one aspect of a more general method. Pursuing this notion, we might note that the initial piece of writing often has the form of a narrative, often truncated and terse and sometimes delightful and charming. My “way” of writing has evolved, for better or worse, into this: a seemingly untidy mixing of straightforward story-telling with periodic reflections. I do it this way because, put most succinctly, I must: that is what happens in these encounters, by everyone involved and not merely by me. We not only act and interact; we also think and talk about it; and as our actions are only sometimes “right on,” so for our thinking—and, therefore, our telling of the story, our trying to get it right. So, I find myself mixing up what otherwise may seem very different ways of writing— factual reporting, narrative relating, reflective evoking—but I do so because it is all intimately part of what must be told. “That,” Rosenblatt keenly observes, “it is what we were meant to do.” Indeed, to conclude, I am constantly seeking that “monumentally elusive tale” which every clinical encounter evokes. If that is true, then writing about my encounters can only be a voyage of continual discovery. With the beacon of Agee’s example as my guide—for all his lamenting,

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he did after all go on to write, at incredible length and masterfully, even if he was prying “intimately into the lives of an undefended and appallingly damaged group of human beings”—I too find myself having to enact my own sort of prying, hoping that, a little like Agee, I may gradually discern each of the situations that follow, “centrally and simply, without either dissection into science, or digestion into art, but with the whole of consciousness, seeking to perceive it as it stands,” so that I may perchance, “perceive simply the cruel radiance of what is”—the telling of which, I believe, can only be a story, accompanied, however painfully, with the obbligato of continual reflection.

Notes 1. See, for instance, “Experience and Moral Life: A Phenomenological Approach to Bioethics,” in E. R. DuBose, R. Hamel and L. J. O’Connell (Eds.), A Matter of Principles? Ferment in U.S. Bioethics, The Park Ridge Center for the Study of Health, Faith, and Ethics. Valley Forge, PA: Trinity Press International. 1994, pp. 211–239; also “Phenomenology and the Clinical Event,” in M. Daniel & L. E. Embree (Eds.), Phenomenology of the Cultural Disciplines, Dordrecht, Boston, London: Kluwer Academic Publishers, Vol. 16 Contributions to Phenomenology, 1994, pp. 39–66; finally, “Interpretation and Dialogue: Medicine as a Moral Discipline,” in S. Galt Crowell (ed.), The Prism of Self: Essays in Honor of Maurice Natanson, Dordrecht & Boston: Kluwer Academic Publishers, 1995, 147–168. 2. The Context of Self, Athens, OH: Ohio University Press, 1981. 3. Especially The Way of Phenomenology. New York: Pegasus Press (Bobbs-Merrill), 1970 (O.P.); also, “On the Sense of Method in Phenomenology,” in: Phenomenology and Philosophical Understanding. E. Pivcevic (Ed.). London: Cambridge University Press, 1975, pp. 122–138; “The Art of Free Phantasy in Rigorous Phenomenological Science,” in: Phenomenology: Continuation and Criticism: Essays in Honor of Dorion Cairns. F. Kersten and R. Zaner (Eds.). The Hague: Martinus Nijhoff, 1973, pp. 192–219; and “Examples and Possibles: A Criticism of Husserl’s Theory of Free-Phantasy Variation,” Research in Phenomenology 3 (1973), 29–43. 4. “Making Music Together While Growing Older: Further Reflections on Intersubjectivity,” The Alfred Schutz Memorial Lecture, October 17, 1997, Lexington, KY, co-sponsored by The Society for Phenomenology and the Human Sciences, The American Philosophical Association, and The Center for Advanced Studies in Phenomenology, Inc., Human Studies 25: 1–18, 2002. 5. Alfred Schutz, “The Paradox of the Transcendental Ego,” Collected Papers IV, Dordrecht, Boston, London: Kluwer Academic Publishers, 1996, p. 191. 6. Alfred Schutz, “Scheler’s Theory of Intersubjectivity and the General Thesis of the Alter Ego,” in Collected Papers, Vol. I, Phaenomenologica #11, The Hague: Martinus Nijhoff, 1967, p. 167. 7. Ibid., p. 82; as he pointed out at the end of his Royaumont talk, “the clarification of the sense-structure of intersubjectivity and of the world accepted-by-me-as-objective is, and remains, a legitimate task for phenomenological constitutional analysis” (“The Problem of Intersubjectivity in Husserl,” Collected Papers, vol. III, op. cit., p. 84). 7. Schutz, “The Paradox of the Transcendental Ego,” Collected Papers IV, Dordrecht, Boston, London: Kluwer Academic Publishers, 1996, p. 191. 8. Eugen Fink, “Discussion” of Schutz, “The Problem of Transcendental Intersubjectivity in Husserl,” in Collected Papers, III, op. cit., p. 85. 9. Schutz, “The Problem of Transcendental Intersubjectivity in Husserl,” op. cit., p. 87 (emphasis added). On this, see also Schutz, “Symbol, Reality, and Society,” in Collected Papers, I, op. cit., esp. pp. 313–319.

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10. Schutz and Luckmann, Structures of the Life-World, Vol. II, Evanston: Northwestern University Press, 1989, esp. Schutz’s outline for of this great work, pp. 256, 299–300. See also my The Context of Self, op. cit., esp. pp. 224–231. 11. Schutz, “The Problem of Transcendental Intersubjectivity in Husserl,” op. cit., p. 82. 12. Ibid., p. 82. 13. Schutz, “Scheler’s Theory. . .,” Collected Papers, I, op. cit., p. 168. 14. Schutz, “The Problem of Transcendental Intersubjectivity in Husserl,” op. cit., esp. pp. 313–319. 15. See Henri Bergson, Time and Free Will, New York: Humanites Press, 1971. 16. Schutz, “Scheler’s Theory. . .,” op. cit., pp. 174–175. 17. Schutz, “Symbol, Reality, and Society,” Collected Papers I, op. cit., p. 326. 18. Schutz and Luckmann, Structures of the Life-World, Vol. I, op. cit., p. 46. 19. Schutz, “Symbol, Reality, and Society,” Collected Papers, I, op. cit., p. 328. 20. Schutz and Luckmann, Structures of the Life-World, Vol. II, op. cit., p. 131. 21. Schutz, “Symbol, Reality, and Society,” Collected Papers, I, op. cit., p. 329. 22. Schutz remained convinced that, although “the self experiences itself as the originator of [its] ongoing action and, thus, as an undivided total self,” all these “correlated essentially actual lived experiences. . .are inaccessible to all recollections and reflections. . ..” (Schutz and Luckmann, Structures of the Life-World, Vol. II, op. cit., p. 298.) He did have some doubts about whether the working self is “alone” capable of experiencing all this modo praesenti, however (ibid.). 23. See Gabriel Marcel, Le Mystère de l’être, tomes 1 et 2, Paris: Éditions Montaigne, 1951. 24. Christina Schües has broached this topic, “The Birth of Difference,” Human Studies 20: 2 (April, 1997), pp. 243–252, although there is much that is problematic in what she suggests. 25. I must note that almost a quarter of these clinical consultations were done during the 4 years of the clinical ethics program my colleagues and I at the Vanderbilt Center for Clinical and Research Ethics set up in 1990 and ran at a local hospital, St. Thomas; the program was then run by a staff brought in by St. Thomas for that purpose, and continued at least until the time of my retirement (July 2002). 26. From all I can figure out of my many years in this field (I first became, as they say, “involved” in 1971 as the first Director of Social Sciences and Humanities in Medicine at the State University of New York at Stony Brook), I was one of the very first of us non-physicians to venture into the halls and rooms of hospitals as an “ethics consultant”, or “ethicist” (the sibilant name coined for us by physicians). In 1982, I was asked by the head of Vanderbilt Hospital’s Medical Board to set up a service and after some time trying to figure out how this could be done, it was formally instituted in 1984 by simple fiat: the hospital director at the time, Norman Urmy, sent out a memo appointing me as “ethicist,” which was approved, after several extraordinary meetings, by the Medical Board. During my tenure at Vanderbilt, where I first engaged in this practice from 1981 until my retirement in 2002, my best estimate is that I was involved in over 2000 clinical consultations, with issues raised for me by patients, physicians, nurses, and a host of others in the hospitals and clinics at Vanderbilt and other institutions. Many arose from the work I and my colleagues did at St. Thomas Hospital, in Nashville. In my later years, quite a number were with patients involved in one or another research protocol (such as the justly well-known first in utero surgical repair of spina bifida lesions, which gained world-wide attention; my involvement was principally to design, with my colleague, Mark Bliton, an effective and sensitive process for obtaining informed consent from the mothers- and fathers-to-be who came seeking “anything” that might help their still unborn babies), including several intense sessions with both us. However, the bulk of consults were with those hospitalized in the more usual sense, due to illness and/or injury, or the debilitating effects of genetic anomalies. An early essay is my “Is “Ethicist” Anything to Call a Philosopher?,” Human Studies7: 1 (1984), pp. 71–90. 27. Barry Lopez, Crow and Weasel, San Francisco, CA: North Point Press, 1990, p. 48. 28. Roger Rosenblatt, “Dreaming the News,” Essay, Time, 149:15 (April 14, 1997), p. 102.

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29. Brian Doyle, “The Greatest Nature Story Ever,” Orion Magazine, found in their online digital edition, http://www.orionmagazine.org/index.php/articles/article/3649. Brian Doyle is the editor of Portland Magazine at the University of Portland, in Oregon. 30. Ronald Blythe, Introduction, Leo Tolstoy, The Death of Ivan Ilych. New York: Bantam Books, Classic edition, 1991, p. 10. 31. See especially Arthur Frank, “Experiencing Illness Through Storytelling,” in S. Kay Toombs (Ed.), Handbook of Phenomenology and Medicine, Dordrecht & Boston: Kluwer Academic Publishers, 2001. 32. James Agee and Walker Evans, Let Us Now Praise Famous Men, New York: Houghton Mifflin Co., 1939, p. 11. 33. Ibid., p. 7. 34. See my “The Phenomenon of Trust in the Patient-Physician Relationship,” in E.D. Pellegrino (Ed.), Ethics, Trust, and the Professions: Philosophical and Cultural Aspects. Washington, D.C.: Georgetown University Press, 1991, pp. 45–67. 35. See my “Listening or Telling? Thoughts on Responsibility in Clinical Ethics Consultation,” Theoretical Medicine 17:3 (September 1996), pp. 255–277. 36. Paul Komesaroff, “From Bioethics to Microethics: Ethical Debate and Clinical Medicine,” in Paul A. Komesaroff (ed.), Troubled Bodies: Critical Perspectives on Postmodernism, Medical Ethics, and the Body. Durham and London: Duke University Press, 1995, p. 66. 37. Rita Charon Narrative Medicine: Honoring the Stories of Illness, New York: Oxford University Press, 2006. A special issue of the Journal of Applied Communication Research will be devoted to this book, based on the symposium at the National Communication Association on her book, and in which I was honored to participate. 38. See Stephen G. Henry, MD, Richard M. Zaner, PhD, and Robert S. Dittus, MD, MPH, “Viewpoint: Moving Beyond Evidence-Based Medicine,” Academic Medicine, 82(3), March 2007, 292–297. 39. Eric Cassell, Talking With Patients, Talking With Patients, two volumes, Boston: MIT Press, 1985, p. 4. 40. Arthur Kleinman, The Illness Narratives: Suffering, Healing and the Human Condition, New York: Basic Books, 1988, p. 17. 41. Ibid., p. 48.

Author Index

A Agee, J., 24, 122–123, 204, 206–208

K Kristeva, J., 149

B Beauchamp, T. L., 6, 58–61 Bordo, S., 143 Butler, J., 167–168, 175

L Levinas, E., 124, 131, 145–146

C Cairns, D., 2, 5, 35, 121 Cavarero, A., 168 Childress, J., 58–61 D Douglas, M., 149 F Fink, E., 195, 197, 199 G Gurwitsch, A., 2–3, 5, 8, 108–109, 121–122, 126–136, 155 H Husserl, E., 2, 11, 30, 32–33, 38, 44, 52, 88, 93, 108, 123–126, 128–129, 131–133, 151, 154, 195–197, 199–200, 208–209 J Jonas, H., 2–3, 121–122, 126–127, 133, 135

M Marcel, G., 2–3, 114, 119–120, 201–202 Merleau-Ponty, M., 2–3, 52, 88–89, 91, 95, 143, 171, 174–175, 179, 181 N Natanson, M., 1, 5, 121, 135 P Popenoe, R., 142 R Ricoeur, P., 28, 38, 122, 126, 129–136 S Scheler, M., 11, 52, 194–201 Schutz, A., 2–3, 5, 7–8, 11, 87–97, 100, 110, 114, 121, 155–156, 194–201 Spiegelberg, H., 3, 123 Straus, E., 3, 53, 128 T Thomas, S., 8 Toombs, S. K., 141, 171

O.P. Wiggins, A.C. Allen (eds.), Clinical Ethics and the Necessity of Stories, Philosophy and Medicine 109, DOI 10.1007/978-90-481-9190-1,  C Springer Science+Business Media B.V. 2011

211

Subject Index

A Autonomy, 3, 10, 59, 62, 64–65, 101, 134, 141, 157 B Beneficence, 59, 61, 134 Bioethics, 5, 7, 15, 57–58, 71–83, 112, 125–126, 153–159 C Cartesian dualism, 126 Chiasm, 121, 171–172, 182 Clinical ethics, 4–7, 57–59, 65–66, 75, 83, 100, 104–105, 107–111, 114–116, 134, 191, 193–194, 205–206 Clinical-liaison ethics, 65, 113 Consciousness, 2, 24, 29, 32, 41, 43, 52, 100, 108, 120–121, 123–125, 127, 132–133, 135–136, 146–147, 167, 194–195, 198–199, 204, 208 Context, 2, 6, 23, 27–29, 35–36, 51–53, 57, 61, 66–68, 75, 82, 106, 108, 121–122, 125–126, 128–129, 132, 134–135, 140, 194, 204 Contextuality, 35, 53, 66 E Ethicist, 4, 9–10, 12, 22, 66, 100, 114–115, 119–121, 126, 131, 134, 153–163, 165, 185, 194, 205 Ethics consultant, 4, 12, 21–23, 109–112, 115, 194, 206 F Face-to-face relation, 120 Flesh, 120, 126, 130, 141–143, 149–150, 171, 174–175 Free-phantasy variation, 5, 30–34, 36, 40–41, 44, 122, 131–136, 208

G Gestalt, 8, 107–117 H Hermeneutics, 28, 38, 87, 122, 129–132 I Integrity, 8, 107–117, 127, 161 Intentionality, 5, 30, 41, 43, 123–124 Interpretation, 3, 9, 12, 17, 23, 61, 90–94, 99–101, 103, 105–106, 110–111, 113, 122, 130 Intersubjectivity, 2–3, 9–12, 27, 194–199, 201 J Justice, 47, 49, 59, 61, 73, 78, 80–81, 135, 202–203 L Lifeworld (or life-world), 2, 11, 37, 51–53, 90, 95, 120–121, 124–125, 133, 135, 143, 145, 194–195, 200 Lived body, 6, 8–10, 140–141 Lived experience, 8, 87, 92–93, 112–113, 116, 141, 167, 172 M Margin, 29, 41, 96, 108–109, 127, 147, 155 Meaning, 3, 11, 17, 21, 27–28, 35, 37, 51, 53, 60–61, 73, 75, 77, 88–91, 94, 96, 99–106, 108, 110, 120, 125, 127, 130, 132, 141, 146–147, 149, 167, 170–171, 174, 178, 181, 206 Medical ethics, 2–3, 5–6, 45–55, 57–69, 105, 119–123, 126, 131, 133, 135–136, 185, 206 N Narrative, 3, 5, 7–9, 11–12, 22–23, 54, 94, 107, 112, 114–116, 119–137, 158–159, 167, 175–179, 181, 187, 190–191, 194, 202–203, 205–207

213

214 Nursing (nurses), 7–8, 12, 19–22, 24, 47, 87–97, 99–106, 109, 112–113, 115, 154, 161, 176, 179–180, 204, 209 P Phantasy, 2, 5, 9, 27–44, 122, 131–136 Phenomenology, 2–3, 5, 7, 9, 11–12, 27–32, 34–35, 37–38, 40–43, 45–55, 87–88, 93–94, 110, 112, 116, 119–137, 181 R Radical (radicalness), 2, 28–29, 34, 37, 39, 43, 60, 110, 116, 125–127, 135–136, 149, 155, 202 Reflective equilibrium, 6–7, 60 Reflexivity (reflexive), 3, 10, 22, 37–39, 81, 120, 128, 134, 171, 191, 194

Subject Index S Self (selfhood), 2, 10, 27–33, 37–40, 95, 108, 120–122, 125–126, 128, 169–174, 194, 198–202 Social construction, 9, 142 Story, 5, 8–12, 15–17, 21, 23–24, 54, 67, 107–117, 119, 134–135, 158–162, 175, 185–191, 203, 207–208 Subjectivity, 2–3, 9–12, 27, 110, 120, 122–124, 126–127, 135, 146, 168, 194–199, 201 T Thematic field, 41, 43, 127 Transcendental, 5, 11–12, 27–44, 49, 110, 122, 135–136, 194, 197 W “We” relationship, 100, 114, 196