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Human selves, chronic illness, and the ethics of medicine.

Human Selves, Chronic Illness, and the Ethics of Medicine

One of the rare pleasures of being at The Hearings Center and involved in discussions of medical ethics is that occasionally we are shaken to our philosophic boots. Amidst our deliberations, we come to the sudden and stunning realization that we do not really know what we are talking about. We rediscover that medical ethics hovers over a philosophic abyss.

Fortunately this does not happen often, or we would not be able to carry on with our work. Ordinarily we are like the Harlem Globetrotters of old. We emerge from our offices, the bioethicist's locker room, gather around the conference table, and toss around our cherished ethical principles, autonomy, beneficence, and justice. We twirl them on our fingers, bounce them off our lips, and dribble them through our legs. Ignoring the abyss, we put on a great show and skillfully employ our conceptions, assuming both that they are adequate and that we all know what they mean and imply. This is "Sweet Georgia Brown" ethics, and it is lively, interesting, and usually serves us well. But occasionally the music stops, and we become mired in philosophic quandary.

Consider one of our fundamental ethical values: respect for persons and individual autonomy. We ethically require our health care providers to obtain our informed consent, either direct or substituted, before they practice their medicine on us. But who and what are these professionals finally supposed to respect? Is it our rational decision-making capacities? Our individual bodily integrity and historical, biographical, temporally deep selves? Our lives amidst immediate family and friends? Or our active lives pursued within particular and concrete wordly settings, cultural and natural? How we answer this question importantly determines our particular ethical duties. However, such an answer depends on our conception of a human self, of who we are. This, in turn, determines what in practice we want respected or cared for, and what individual human autonomy, may concretely mean. It is precisely here, with the human self, that we stare into the philosophic abyss. "You would not find out the boundaries of the soul, even by traveling along every path: so deep a measure (Logos) does it have." Thus spoke the presocratic Heraclitus (Fragment 45). After all these years, we still lose ourselves along the footpaths of the soul.

No doubt it is difficult enough to understand the enigmatic Heraclitus, yet there is one thing we can learn from his aphoristic arrows. The understanding of the self is not a matter of scientific or empirical knowledge that can be decided once and for all. It is a task for philosophic or speculative interpretation, and is essentially open-ended. It is a metaphysical question finally requiring bold fights of rational imagination, always tentative, aiming at an adequate conceptual elucidation of who we are and what we experience and endure.

In our ongoing efforts to understand ourselves adequately, we moderns are importantly undermined by recent metaphysical speculation. We poorly comprehend the essential relation of our concrete selves to our organic bodies and to the world abroad. The chief philosophic culprit is arguably the modern conception of "substance," originally fashioned in the great period of substance and genius, the seventeenth century. Here is the crucial point from which critical and speculative reflections should commence.

We must begin, of course, with Descartes and his famous and fateful partition of reality into three types of substance--God, Res Extensa, and Res Cogitans: the Divine Being, extended or physical things, and thinking things. A substance is conceived as that which requires nothing else in order to exist, an entity that can be alone by itself, in need of no other in order to be. For example, a human individual's mind does not require a body in order to exist, nor does a body need a human mind, and God requires neither. Thus a substance is sufficient unto itself and essentially independent of others. Descartes's conception of substance is a descendent of Aristotle, who understood a substance to be a concrete entity that is always expressed linguistically as a subject and never a predicate. It is a concretum that actually supports all particular qualities and attributes and is never present in another concrete entity. A dog may be fierce, but never can be a cat.

Given Descartes's conception, there logically can be only one substance in his metaphysical system, for he conceives the other two types of substance as continually requiring God's power to keep them in being. Thus they are not truly independent in their existence. However, Descartes pragmatically relaxes his metaphysical rigor in order to serve two extra-philosophical masters, the newly emerging natural science and the long established Christian church. The new science required the metaphysical grounding of a thoroughly materialistic and mechanistic nature, the overthrow of Aristotelian "purposive nature." For its part, the church required the metaphysical guarantee of an anatural and nonwordly immortal soul. By conceiving that each type of substance has an essential, "nonsharable" attribute (for example, extension or thought), Descartes is able effectively to get mind and all teleological purpose or final causation out of nature, and all of nature out of mind. In one stroke, Aristotle is vanquished, and the church vindicated. Nature is left with the hegemony of efficient or mechanistic causation and with a mere extensiveness amenable to modern mathematical analysis. Correlatively, this strict "substantial" division of spiritual mind and natural, organic body metaphysically assures the human soul an anatural individuality and immortality. The way is philosophically paved to an other-worldly heaven or hell. Moreover, due to the soul's essential attribute of thought, Descartes is able to conceive the human self as essentially active, as well as being individually one. A res cogitans is an individual, actively thinking thing, essentially characterized by rational thought and willing. It is its soulful or thinking activities.

In the speculative endeavor to conceive our everyday and abiding experience of ourselves, Descartes has won two crucially important principles: that of concrete individuality, integrity, or oneness, and that of essential activity. A self is a concrete, individual actor. But Descartes has to pay a heavy price for his substance metaphysics. We live within the world, experiencing and interacting with other things, including other human and animal organisms. But how can this be? Mental and extended substances have totally different attributes. They have nothing essential in common, and neither needs the other in order to exist. How can there be any real relation or interaction between them? How can we be worldly selves, dynamically involved with concrete, bodily things? Why are we worldly actors rather than little Aristotelian gods, merely thinking thoughts about our thinking? Here Descartes philosophically has to cheat. He posits mysterious machinations in the pineal gland to account for the traffic between mind and natural world, that is, for perceptual experience and bodily action governed by purpose. Thus I am curiously and intimately related to this body that is not mine. We have been saddled with the mind-body problem ever since, the price of Descartes's multiple substances.

Leibniz comes fast upon Descartes's heels. He takes worldly relations seriously and in a brilliant philosophic tour de force endeavors to save Descartes from himself without abandoning a philosophy of substance. We are essentially world experiencers and worldly actors. At bottom, we are nothing but our active experiencing of the world from our particular perspective in the universal scheme of things. The conception of self is deepened and enriched. Not only is the self conceived as worldly, but as essentially temporal. We are memories of the worldly past, anticipations of the worldly future, actively living in the worldly present. Further, our particular and perspectival experiencing of the worldly past, present, and future constitutes our unique individuality, our difference from all other individual world experiencers. In short, the Leibnizean self is an integral or individual one, essentially active, and world related.

However, this adequacy to everyday experience is again bought to a heavy theoretical price. According to Leibniz, we are individual, active, but windowless monads. This means that we are causally unrelated to worldly others. In the end, we only experience ourselves, despite the fact that each self is the experience of the dynamic world from its own perspective. I, by myself, am this world experience. The worldly experience actively issues out of the bowels of myself. When E.F. Hutton speaks, we listen. But Hutton speaks only as within his individual experience, and we hear only as within hours. Actors and sufferers (undergoers) are ontologically isolated from one another. Hutton cannot get his hands on us, nor can we get ours to him. We are all little solipsists, alone by ourselves. But how then can there be a coordination of experience, of actings and sufferings, between these worldly, yet isolated ones? Leibniz's answer is that there is a preestablished harmony between your worldly experience, my experience, and the experience of the innumerable monadic others--a harmony established by the Supreme Monad and Grand Mediator or Go-Between, God.

Again human individuals are conceived as substances, indestructible and immortal. However, beyond more subtle philosophic objections, for those not enamored by the idea of this best of all logically possible gods, this preestablished harmony of isolated immortals seems an extreme metaphysical fudge--a travesty of our sense of finitude, mortality, and dynamic implication in the world. Again it seems that the idea of substance, of that which requires nothing else in order to be, conceptually stands in the way of philosophic good sense.

But what if we abandon the conception of a human self as a substance? How would things look then? This was Spinoza's attempt to save Descartes from himself and an alternative to Leibniz's universe of monadic substances. Logically, the Cartesian conception of substance requires that there be only one substance, God or Nature, the only one that requires nothing other in order to be. God is causa sui, self causing, sheer atemporal ontological activity, acting out of the necessity of the divine nature. Descartes and Leibniz notwithstanding, all concrete worldly entities are but finite modes or instances of this one infinite activity, not substances themselves. As within the one substance, these finite modes are by ontological necessity dynamically or causally interconnected with one another. If I act, you are affected. You "undergo" or "suffer." You act, and I suffer. ("Agent" and "patient," "activity" and "passivity" are correlative terms.) Each worldly individual is a concrete, finite instance of the interrelated actings and sufferings of the universe. Enduring concrete individuality is not substantially, metaphysically, or immortality secure. Rather it arises from an ongoing and active endeavor to persevere in being in the face of all the dynamic modal others, to which the individual actor is causally related. I only am or exist in my dynamic relations with others. Worldly relations are an ontological necessity, not an embarrassing philosophic puzzle. I exist only as an active, "conative" endeavor to be. An individual conatus, understood as a natural tendency, impulse, or directed effort to keep in being, is the essential me. Thus by necessity, I am an active being or embody a principle of dynamic activity. And it is by this necessary conative endeavor within necessary dynamic worldly relations that by necessity I constitute my individual and unique self, my difference from all modal others.

Here we have a philosophic coherence of three fundamental principles required for understanding a human self--principles of concret individuality (substantial or no), activity, and world relation. It makes philosophic good sense that we are individual world experiencers and worldly actors. We have to be in order to be. According to Spinoza, we are the active experiencing or ideas of our organic body's dynamic implication in the world, and whatever we can actively engender in thought and action from this primordial base. We are a single conative endeavor, physical and psychic, correlative attributes or aspects of a concrete finite mode.

This philosophic success issues from moving beyond the conception of a human self as a substance. Granted, we have to pay a human price. We are confronted with our essential finitude and mortality and have to relinquish traditional Judeo-Christian conceptions and hopes of immortality. (For Spinoza, we share in the eternity of God or Nature only through philosophic understanding.) Moreover, the conception of substance still exacts its philosophic price. In Spinoza's universe, all happens by necessity. Spinoza's one infinite substance exhibits rational intelligibility rather than arbitrary divine willfulness, and this entails a certain, rigorous determinism. Freedom, fully enjoyed only by God, is acting according to the necessity of one's own nature, the success of being active rather than passive in the dynamic interplay of the world, where there is little or no freedom of choice over things. In short, speculative philosophy has not found its final, adequate home, despite Spinoza's certainty that he had discovered the truth.

We have come full circle. Whatever their final adequacy, Spinoza and the presocratic Heraclitus have interesting and significant affinities. Spinoza's "God or Nature" is matched by Heraclitus's uncreated Logos, the Everliving Fire kindling and extinguishing in measures, within which all things have their being. In order to be, the Heraclitian soul, by necessity both a worldly actor and sufferer, must "feed off," actually "live the death" of the dynamically interrelated others than comprise the universe. Things can only exist in dynamic tensions with other things, each existing at the expense of the others. The universe is none other than a cosmic scene of such interrelated warring endeavors to be--a beautiful, well-functioning harmony born of strife. All, directly or indirectly, are at loggerheads with all. All are interlocked with all in the universal, necessary endeavor to "live the death of the other." This is the only way things are or enjoy being; by both encroaching on and being encroached upon. In this ontologically necessary involvement with all others, the soul embodies the universal Logos from its finite perspective within the Logos. This essential connection to the whole universe is why we cannot concretely find the soul out and take its measure. The actor, the acted upon, and the acting--the knower, the known, and the knowing--are one, the Everliving Fire in its dynamic and orderly permutations.

In both Spinoza and Heraclitus, individuality, activity, and relatedness to the worldly other are essentially and more or less coherently conjoined. Speculative attempts to fashion an adequate conception of the human self must follow their lead away from isolated and self-sufficient entities, finally spared the dynamic rigors of worldly existence.

Between ourselves and the philosophic speculations of Heraclitus and Spinoza stand Darwin and the modern theory of evolution. Evolutionary theory, by its inherent logic, places mankind, circumscribed powers of fredom, and ongoing cultural activities squarely and decidedly within the wider realm of nature. Future reflections on the human self must start from this well established, persuasive, and "empirical" premise. To weave together adequately and coherently the fundamental principles of the self--concrete individuality, dynamic activity, and world-relatedness--we must take seriously the fact that we are natural, biological organisms and that our "selves" are intimately and essentially tied up with organic, bodily existence.

The fundamental clue to ourselves is our organism's metabolic mode of existence. We can only be by ever-becoming and by having essential and necessary truck with the world. Our particular and concrete individuality is woven out of our active dealings with the world in which we live, the issue of ever recurrent conative endeavors to maintain an individual integrity in the face of worldly others.

Our personal identity, our unique and more or less permanent stamp, is essentially related to these conative, "striving" activities. Personal identity is the issue or mating of definite form and individual activity. In our multifarious dealings with the world, we come to act in characteristic and definite ways. We develop individual habits of bodily movement, feeling, and thought. We engender particular abiding passions and interests, which range over the whole gambit of humanly organic life. Such habits or characteristics, developed in the past, continue to inform ongoing bodily actions, emotional life, and thinking endeavors. All these are activities of a more or less integrated, dynamic, and temporally deep self. The enduring character of my recurrent activities is my personal identity, my difference from all others, that which is qualitatively the same about me in my endeavor to be and to remain a concrete individual one.

In short, I speculatively conceive the self as a wordly actor-sufferer, essentially in dynamic flux as opposed to substantially secure, fundamentally temporal as opposed to atemporal or out of time, and "by nature" worldly as opposed to having origins elsewhere.

This has definite implications for the ethical practice of medicine, particularly for professionals involved with chronic illness and rehabilitation. Those who have suffered an incurable illness or permanent impairment have been touched to the quick. They can no longer act in formerly characteristic ways. Their dynamic selves, with their personal identities, have suffered more or less radical, irretrievable losses. Out of the ashes of the old self must, if possible, be evolved a new self, dynamically active, integral, and worldly. This ought to be a primary concern of medical practice, which cannot deal merely with the body, as if "res cogitans" or soul were not intrinsically involved. Nor can ethical obligations be discharged by merely gaining informed consent from patients or families. For the "true self" is not merely a rational, decision-making self, essentially untouched by worldly and bodily vicissitudes. Through initial trauma and abiding consequences, the worldly conative self is by necessity undergoing a sea change. In the midst of such agonizing change, who is the "I" who can be truly informed and know precisely what it wants? Consider a professional baseball pitcher who has recently and permanently lost the use of his arm, a football player paralyzed from the neck down, a cellist ravaged by the progressive debilitation of multiple sclerosis, a philosopher undermined by a major stroke, a young public attorney and father of four denied an active and responsible life by "locked-in syndrome," or a mother who through enduring mental or physical disability can no longer care for her children. What do they want for themselves? How could they possibly say until we have aided them in evolving a regenerated self, in developing new characteristic and satisfying worldly activities, if this is possible at all?

It would be ethically perverse to focus singlemindedly on informed consent and autonomy in decision-making. Rather, our ethical concern should center on the present and future real possibilities of the suffering worldly actor--on what he or she might possibly do now, on the support of family, friends and health providers, on social services, and on how the world might be altered to facilitate his or her worldly activities.

In sum, ethical responsibility and obligations depend centrally on the nature of the object of ethical concern. The ethics of medicine depends crucially on the nature of the patients medicine serves. This, if you will, is a call to arms. It is a call to medicine, philosophy, and medical ethics to take ourselves seriously and to recognize who we are and what we need. The worldly actor requires a concrete realm of meaningful and significant action, not just respect for the truncated autonomy of freely answering yes or no to procedures. Acute medicine may get away with being relatively unconcerned with the worldly self, for the patient will soon return intact to his or her familiar world. Not so with chronic or rehabilitation medicine, where the patient often must discover both a newly active self and a new world in which to act. Human organisms and their concrete worlds can never be disjoined, for we are more than mere "thinking substances" or isolated monads, as traditional and still subtly influential modes of thought would have it.

Strachan Donnelley is director of education at The Hastings Center.
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Author:Donnelly, Strachan
Publication:The Hastings Center Report
Date:Apr 1, 1988
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