Medicine's Dance with Death

 
 

A physician-philosopher argues that modern medicine is oriented toward the dead body because it is no longer informed by an ultimate purpose for human existence.

In The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, physician-philosopher Jeffrey Bishop argues that modern medicine has adopted a “metaphysics of efficient causation”—a focus on the immediate cause of things that ignores their ultimate purpose. As a result, medicine now takes its bearings from and aims itself toward the dead body, the corpse. This leads to nihilistic attitudes toward the dying, and troubling contradictions and absurdities in our practices.

Bishop’s morbid idea seems strange at first. Modern medicine is characterized by nothing, after all, if not by teams of people working with great energy and at great cost to keep people alive. How can this activity be oriented toward death? Yet once one grasps Bishop’s thinking, one sees evidence for it everywhere.

To understand the idea, it is helpful to remember Aristotle’s concept of the four causes of a thing. Aristotle held that a thing is explained and known by reference to: first, its material cause—that of which the thing consists; second, its efficient cause—that which caused the changes that resulted in the thing; third, its formal cause—that form or arrangement of matter that makes the thing the sort of thing it is; and fourth, its final cause—the purpose for which the thing exists.

Modernity is characterized by a progressive loss of confidence in the relevance of formal and final causes, particularly for living beings. With respect to human beings, our formal cause may be thought of as that which makes us the particular sort of being we are. Our final cause is that purpose or end, that telos, toward which we are directed. In modernity, such causes seem to be merely subjective cultural attributions, and to that extent arbitrary and unreal. Modernity directs attention instead to the more durable causes that remain: material causes (that flesh of which we are made) and efficient causes (that which brings about an effect or change in us). These latter causes inform modern medicine’s view of the body as the pillars of our “metaphysics of efficient causation.” Importantly, they are the causes that science can know and technology can control.

The history of medicine displays this shift of attention and confidence from formal and final to material and efficient causes. Bishop picks up that history in eighteenth-century France, where Foucault’s famous clinic emerged. There patients were subjected to a new and penetrating “medical gaze,” which presumed to use knowledge gained from the new sciences of chemistry and physiology, and especially anatomical dissection of corpses, to see through the fuzzy pretense of the living patient to the sharp reality beneath that pretense. The reality was and is the dead body—the body as it is known through anatomical dissection and scientific abstraction.

The dead body has in this sense become epistemologically normative for medicine, meaning that medicine’s knowledge of the living is derived from the dead body as an ideal type. In the first parts of medical training, students dissect a dead body to ground their knowledge of bodies that are living. In the clinical interview, they carry that idealization forward: Patients, Bishop suggests, are “questioned by the doctor in much the same way that the corpse is questioned by the anatomist, or in much the same way that the functioning body is questioned by the physiologist.”

To this point Bishop joins others in critiquing contemporary medicine for giving in to a scientific reductionism that turns the patient from subject to object, turns the clinician from concern to detachment, and thereby alienates patient and clinician from each other and alienates both from contemporary practices of medicine. That critique has been leveled from many quarters, often in the name of a more humanistic, patient-centered, holistic medicine.

Yet Bishop makes a deeper, more difficult, and more consequential claim: namely, that because medicine has given up formal and final causes for human beings, even its efforts to overcome scientific reductionism fall prey to the metaphysics of efficient causation, which includes a kind of nihilism regarding what it means to live and die well.

When medicine is guided not by any ultimate purpose of human existence—a human telos—but only toward our final terminus, medicine becomes captive to a second aspect of the metaphysics of efficient causation: a politics of efficient control. Bishop points to the famed physiologist Bernard who dismissed questions that ask why (i.e., questions about formal and final causes) as not befitting human capacities. Rather ask how, Bernard insisted, because knowledge of how—knowledge of efficient causation—gives power to make things happen.

The Intensive Care Unit (ICU) provides a paradigm expression of this metaphysics of efficient causation and its politics of efficient control. In the ICU, clinicians mobilize an army of supporting technicians and an arsenal of sophisticated technologies to make things happen. The effectiveness of each action is not judged in relation to whether the action is congruent with some formal or final cause for the human being in question. Rather, the action is effective if it has an effect (e.g., restoring cardiac output, removing electrolytes from the serum, or oxygenating the blood). As a result, in the ICU the patients and even their diseases disappear. All is physiology, matter in motion.

Clinicians and patients alike experience the physiological medicine of the ICU as both degrading and insufferable, often even as life worse than death. But what to do? If the human being is best understood as merely the movement of matter that anticipates the corpse, then actions are not futile so long as they keep that matter in motion. Physiological medicine seems locked into a set of practices that tend to the bizarre and dehumanizing.

To remedy this situation, medicine makes what Bishop calls “the discursive turn.” In reaction to the coldness of technological medicine, medicine turns to an interdisciplinary array of experts to provide a kinder, gentler, more comprehensive approach. The result is what has come to be called “biopsychosociospiritual medicine,” the medicine that seeks to make possible a “good death.”

Bishop argues that because this biopsychosociospiritual medicine is captive to the same metaphysics of efficient causation, it only delivers a kinder and gentler and therefore more subversive form of the same politics of efficient control. Biopsychosociospiritual medicine wields its control not through the techniques of manipulating the body as matter in motion, but through endless self-reifying assessments.

Take hospice, for example, a system in which I happen to practice medicine. Hospice aims at broad and comprehensive goals such as “quality of life” and “relief of suffering.” The breadth of these aims ostensibly requires systematic assessment and total management from a team of disciplinary experts. These experts must have legitimacy within the regnant regime of scientific medicine, while offering something more than physiological medicine can provide. To do so, they use an array of “scientific” assessments to extend the clinical gaze beyond the walls of the clinic, taking in the entire scope of human care and human experience.

Much as the clinical gaze penetrates the surface of the living body, these assessments promise to penetrate the surface of what the patient, family, and friends can tell. Deploying the tools of statistical science, the assessments categorize all manner of human experience, naming the normal and the abnormal and mobilizing disciplinary powers to “fix” the latter, all putatively for the patient’s good. “These discourses of expert care recreate the very thing that they purport only to promote,” Bishop writes, “namely, a ‘good death.’ A good death is one that is managed in all its facets by those whose expertise defines a good death.”

This pretense of seeing through patients’ and families’ accounts of how they are doing, and using that knowledge to bring about a “good death,” becomes most ironic when it is extended to spiritual care. There biopsychosociospiritual medicine measures spiritual states to categorize them as functional or dysfunctional, then reaches out to discipline and order even the clergy—telling them when and how they can be useful. The result, Bishop argues, is that “whereas the care of the dying, the ill, and the poor was once a handmaiden to the theological virtue of hospitality, now spirituality becomes the professionalized domain of a totalizing medicine.”

In Bishop’s account, the brute physiological medicine of the ICU, and the “holistic” care of biopsychosociospiritual medicine that purports to be its antidote, are two offspring of the same parents: a metaphysics of efficient causation and a politics of efficient control. Both branches of medicine organize and control the way patients live and die, and neither appears to be guided by any meaning or purpose that might be derived from the sort of beings humans are.

Humans are meaning-seeking animals; this vacuum of meaning must be filled. But how can it be filled without appeal to final causes, without appeal to some intrinsic purpose of embodied life? The answer, Bishop argues, is that meaning must be added post-hoc, by virtue of decision.

The antidote to the meaningless efficient control of the ICU technological apparatus and biopsychosociospiritual medicine, therefore, turns out to be a third form of efficient control—the control exercised through sovereign choice. Bishop argues that contemporary medicine elevates patient choice and autonomy in order to sustain the mythos of the autonomous self-giving order to these machines and these disciplines, taking control of them and directing them toward a purpose of the self’s own choosing.

Patients who are too debilitated by their illness to choose occupy a “no man’s land” between life and death, in which not to be able to choose is not to be able to give meaning, for without a decision there can be no meaning in the matter-that-remains-in-motion. For many, and particularly for social liberals, this is life worse than death, and someone must stand in to choose death on behalf of the patient.

To rescue such patients from this life-worse-than-death, many leading ethicists are ready to do away with the traditional distinction between killing and allowing to die. Withdrawing life-sustaining technology from a patient and giving that patient a lethal injection both result in a dead patient, the argument goes. Since both actions are (efficient) causes of death, the act of giving a lethal injection is, all else being equal, no worse ethically than that of removing the ventilator. What makes either action ethical is whether or not the action is chosen by the autonomous self.

The traditional distinction between killing and allowing to die depends on differences in the formal (what kind of act it is) and final (what is the intention) causes of the action. But to many modern minds, formal and final causes seem as irrelevant as the flying spaghetti monster and a geocentric cosmology. Ours is a grown-up metaphysics of efficient causation, and under that metaphysics, a politics of efficient control compels the patient toward a “good death,” even if it is death by suicide. After all, with power to choose comes responsibility. When a degrading death can no longer be avoided, a good death must be chosen.  When death can be chosen, however, living itself becomes a question and a choice. This question and choice are a terrible burden for the dying to bear. Far from being managed, therefore, death returns “with a vengeance.”

Despite his dystopian critique, Bishop closes with a hint of hope. Not a nostalgic hope for the medicine of yesterday. Nor a blueprint for how to fix what ails the medicine of today. Indeed, Bishop is skeptical that any efforts to fix medicine could escape the same metaphysics of efficient causation that leads us to want to fix the problem by making something happen.

Rather, Bishop suggests that medicine can only be renewed through communities and traditions that keep alive, in their bodily practices, the affirmation that being human is more than mechanism, and more than being in control. What are needed, he suggests, are communities and practices that recognize a telos that transcends medicine. “Might it not be that only theology can save medicine?” Bishop concludes. Good question.

Farr A. Curlin, MD, is an associate professor of medicine and the co-director of the Program on Medicine and Religion at the University of Chicago.

 

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