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The Evening of Life
Although philosophy, religion, and civic cultures used to help
people prepare for aging and dying well, this is no longer the
case. Today, aging is frequently seen as a problem to be solved and
death as a harsh reality to be masked. In part, our cultural
confusion is rooted in an inadequate conception of the human
person, which is based on a notion of absolute individual autonomy
that cannot but fail in the face of the dependency that comes with
aging and decline at the end of life. To help correct the ethical
impoverishment at the root of our contemporary social confusion,
The Evening of Life provides an interdisciplinary
examination of the challenges of aging and dying well. It calls for
a re-envisioning of cultural concepts, practices, and virtues that
embraces decline, dependency, and finitude rather than stigmatizes
them. Bringing together the work of sociologists, anthropologists,
philosophers, theologians, and medical practitioners, this
collection of essays develops an interrelated set of conceptual
tools to discuss the current challenges posed to aging and dying
well, such as flourishing, temporality, narrative, and friendship.
Above all, it proposes a positive understanding of thriving in old
age that is rooted in our shared vulnerability as human beings. It
also suggests how some of these tools and concepts can be deployed
to create a medical system that better responds to our contemporary
needs. The Evening of Life will interest bioethicists,
medical practitioners, clinicians, and others involved in the care
of the aging and dying.
Contributors: Joseph E. Davis, Sharon R. Kaufman, Paul Scherz,
Wilfred M. McClay, Kevin Aho, Charles Guignon, Bryan S. Turner,
Janelle S. Taylor, Sarah L. Szanton, Janiece Taylor, and Justin
Mutter
eBook
‘The Explanation You Have Been Looking For’: Neurobiology as Promise and Hermeneutic Closure
The biomedical aspiration of psychiatry has fundamentally reoriented clinical practice since the DSM-III in 1980 and reverberated in the public sphere. Over time, lay public understanding of the causes of mental suffering has increasingly endorsed biological conceptions. In this paper, I explore the sources from which a neurobiological model for mental suffering reaches ordinary people, and investigate its rhetorical appeal, personal appropriation, and consequences. Drawing on interviews and other data, I show that these sources—physicians, popular media, and advertising—share common ontological and moral assumptions. These assumptions, in turn, influence how people take up neurobiological explanation to account for their suffering, and how, paradoxically, they join it to their projects of self-determination. I conclude by considering how, from a phenomenological perspective, a neurobiological account fails to enhance self-knowledge or determination but leads to a hermeneutic dead end.
Journal Article
Toward the Elimination of Subjectivity
We are living in a world being remade in the image of numbers. Everywhere we turn we encounter techniques and technologies of quantification and ubiquitous talk of algorithms, artificial intelligence (AI), metrics, audit, statistics, and more. They have become a part of the fabric of daily life and business, of economic and institutional routine. No domain or discipline is free of their influence or immune to their spreading deployment. The highly touted virtues of this remaking are familiar: increased efficiency and productivity, institutional accountability and responsiveness, health and safety, and ease and convenience. While these are compelling practical benefits, the turn to quantification, indeed its relentless imposition, cannot be explained in terms of merely functional or instrumental value. Deeper ethical and philosophical commitments are driving current ambitions. To bring these commitments into focus, I want to consider some historical context.
Journal Article
All Pathology, All the Time
We live in a medicalized society. We have grown accustomed to hearing that yet another behavior, emotional state, temperament, or bodily experience — some feature of life not previously regarded as a syndrome or disorder or addiction or risk factor — will henceforth be defined and treated as a medical problem. Those unhappy with their shyness or fear of criticism may be diagnosed with social anxiety disorder. Women not sufficiently interested in sex may be diagnosed with female sexual interest/arousal disorder. Kids who do not pay adequate attention to their studies may be diagnosed with attention deficit hyperactivity disorder. (One fifth of America’s twelve-year-old boys have been.) Even homelessness now has a diagnostic code. The number and scope of pathologies grows ever larger. And while some of them surely do capture cases of severe dysfunction, many are what we might otherwise consider normal, even if painful, struggles of life, or just part of human variation: mild inhibitions on life plans, social role conflicts, unpleasant emotional experiences, normal bodily processes. The term “medicalization” implies the capture of these kinds of things. As the psychiatrist Thomas Szasz once observed, we “do not speak of the medicalization of malaria or melanoma.” In theory, it should also be possible to demedicalize features of human experience, much as we can decriminalize certain acts. Demedicalization, however, virtually never happens, even when all we mean by this is raising the diagnostic thresholds so as to reduce the sphere of human functioning deemed clinically relevant. Why not? Why might the domain of pathology be constantly expanding, while the reverse, a contraction, almost never occurs? I want to venture an answer, one that centers on our ever more shrunken and impotent conception of ourselves, of who we are and what we can be.
Journal Article
Depthless: The Soul in Liquid Times and the Need for Freud
Freud is about something important. While features of our contemporary situation make Freud’s view of human nature and culture seem obsolete, they also illuminate what is at stake. Our institutional order is losing its solidity and durability, throwing us back on ourselves and our choices. It is becoming more “liquid,” to use Zygmunt Bauman’s apt metaphor, and fostering a light, depthless way of being and a mutable, non-constraining view of the social world. It is fostering a manner of self-making that involves a detached perspective on our very self and a techne by which we change ourselves through somatic intervention. Freud stood against the tendency to abandon a complex, hermeneutic view of selfhood and the facilitating structures of a cultural order. This was what he was about and what we must recover.
Journal Article
Persons without Qualities
The tremendous excitement for machine learning, predictive analytics, metrics, and their deployment in everything from smart cities to self-driving cars arises from their seeming novelty and the vast new possibilities they promise. Musil, however, whose book was first published in 1930, reminds us that the hopes and trust placed in mathematical reasoning are not so revolutionary, and long-ago mathematics “entered like a daemon into all aspects of our life” (Musil 1953, 40). These aspirations have a history. One of the larger themes of this issue, especially in the opening pieces by Joseph E. Davis and Daniel Doneson, is that what gives the new technologies of quantification their “force,” what makes them compelling and moving, are ethical and philosophical commitments that have been unfolding since at least the dawn of the scientific revolution. The new technologies are an instantiation of these prior commitments—to control our fate, to possess an objective knowledge without a knower, to relieve the human condition—and their most singular expressions yet (and in the fantasy of “strong AI,” their last).
Journal Article
Recovering Old Age
As the outbreak of coronavirus spread this past spring, the world of biomedical ethics exploded with journal articles, consensus statements, and blog posts arguing over the proper criteria for rationing ventilators and other scarce medical resources. The flashpoint came from some of the earliest pandemic guidelines, which appeared to promote discrimination against the elderly — the most likely to die from the disease.In a widely cited statement, published online in the New England Journal of Medicine in late March, bioethicist Ezekiel Emanuel of the University of Pennsylvania and colleagues argued for a strategy for allocating medical resources that would maximize benefits by both “saving more lives and more years of life.” In practice, rationing on the basis of life-years strongly favors young people, who have more years left to live than the elderly and people with disabilities. Given “limited time and information” in an emergency situation, the authors suggested, saving the greatest number of patients who have “a reasonable life expectancy” is more important than improving length of life for those who do not. The overall effect of this strategy would be “giving priority” to those “at risk of dying young and not having a full life.”In response to proposals like this, and to even more directly discriminatory rationing strategies that recommended age-based cutoffs for certain treatments, the U.S. Department of Health and Human Services published a bulletin declaring that rationing based on age or disability would be illegal for any HHS-funded health programs, including Medicare and Medicaid. Similarly, rightly fearing that a focus on maximizing life-years would reinforce cultural bias that values the lives of the young over the old, many conservative bioethicists spoke out against age-based criteria. For instance, according to a joint statement issued by the Witherspoon Institute, all lives should be treated equally, for all are of “inherent, equal, and indeed incalculable value.” A policy preferential to the young would be unethical, and would send the message that society views the lives of its seniors as less valuable, less worth living, and would lead to further devaluation and inequity.
Journal Article
To Fix or To Heal
Do doctors fix patients? Or do they heal them? For all of modern medicine's many successes, discontent with the quality of patient care has combined with a host of new developments, from aging populations to the resurgence of infectious diseases, which challenge medicine's overreliance on narrowly mechanistic and technical methods of explanation and intervention, or \"fixing' patients. The need for a better balance, for more humane \"healing\" rationales and practices that attend to the social and environmental aspects of health and illness and the experiencing person, is more urgent than ever. Yet, in public health and bioethics, the fields best positioned to offer countervailing values and orientations, the dominant approaches largely extend and reinforce the reductionism and individualism of biomedicine.
The collected essays inTo Fix or To Healdo more than document the persistence of reductionist approaches and the attendant extension of medicalization to more and more aspects of our lives. The contributors also shed valuable light on why reductionism has persisted and why more holistic models, incorporating social and environmental factors, have gained so little traction. The contributors examine the moral appeal of reductionism, the larger rationalist dream of technological mastery, the growing valuation of health, and the enshrining of individual responsibility as the seemingly non-coercive means of intervention and control. This paradigm-challenging volume advances new lines of criticism of our dominant medical regime, even while proposing ways of bringing medical practice, bioethics, and public health more closely into line with their original goals. Precisely because of the centrality of the biomedical approach to our society, the contributors argue, challenging the reductionist model and its ever-widening effects is perhaps the best way to press for a much-needed renewal of our ethical and political discourse.
eBook