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medical humanities

The Reading Room: The Violet Hour – Great Writers at the End

10 Jun, 16 | by cquigley

 

the violet hour

Katie Roiphe. The Violet Hour: Great Writers at the End. Virago, 2016

 

Reviewed by Professor Robert C Abrams, Professor of Psychiatry, Weill Cornell Medical College, New York

 

A central premise of Katie Roiphe’s The Violet Hour is that the awareness of approaching death is a milestone we all will face at some time and in some form. From there, Roiphe explores how the moment of awareness, the awful prognosis, was confronted by each member of an august selection of writers and thinkers. But it is not only that first acute glimmer of understanding that Roiphe examines, since dealing with death more often than not involves a lengthy, even a lifelong, prodrome, an unwelcome perception that appears slowly and gathers to invade consciousness.

Roiphe’s subjects are persons of uniquely substantial depth, creative visionaries in their own fields—Susan Sontag, Sigmund Freud, John Updike, Dylan Thomas, Maurice Sendak. An interesting aspect of the book is that, when the subject is death, these luminaries are just as avoidant and vexing as the rest of us. One is at first tempted, naively, to believe that what these individuals have accomplished in their lives ought to ease the pain of anticipated death, or enable them to articulate the experience in a way that leads us to greater insight. However, intellectual or artistic stature does little to soften the impact or illuminate the journey—at least for this select group. Instead, Roiphe shows how the nearness of death strikes with terror at one’s narcissistic heart and can derail the psychological homeostasis of almost everyone.

What can be derived from the accounts of these great thinkers is therefore not clarity, but an analysis of how they actually felt as death loomed. In a way, Roiphe’s writers coped with death much as they had lived, in all their contradictory ways. Like strands of spaghetti Bolognese, each story line branches out and swirls around in so many messy directions that the themes can be difficult to untangle and trace. (In fact, compared with their highly variable, tortured pre-death processes, the actual moment of death for these writers seems to have been uniformly anticlimactic; all the complicated action has taken place earlier). So it is that we are shown how Dylan Thomas dreaded death but died in a self-destructive orgy of alcohol and Benzedrine, the culmination of years of punishing abuse of his health. John Updike, on hearing his dire prognosis, turned immediately to poetry, for him a reliable source of consolation, and he kept at it, creating what some have considered his finest work, for as long as his strength allowed.  Susan Sontag did something similar, finding solace under the cover of the intellectual constructs that were her hallmark, except that she fiercely refused to give in or let go; she marshalled all the intellectual force at her command to master her illness and survive it­­, until she simply fell away. Freud was magnificently inconsistent: Freud, the ultra-rational doctor who once famously insisted that “a cigar is just a cigar” could never give up what he knew was rooted in primitive oral gratification and thus knowingly died of smoking-related cancer. Maurice Sendak, who seemed to have imbibed angst prenatally, was completely preoccupied with death and had been preparing for it nearly all of his life.

But thinking about death when it is not proximal is very different from grappling with it in the moment. Death is something for other people, never for oneself, until it isn’t. But up to that moment, it is safe enough to wish for death, romanticize it, flirt with it. When death actually does arrive, it is presented as a full-stop but not necessarily a resolution; one dies, not after living but during it, leaving everything that is unsolved, unsolved. Again, these observations would be unremarkable were it not for Roiphe’s notion that the deaths of such hyper-articulate individuals should be exceptionally revelatory. That in the end her characters are merely ordinary humans contending with the direst possible threat to their existence may be in fact the point.

If The Violet Hour can be a dark, depressing read, it is also a brilliant one, framed in stunning, exquisite prose by an artist-of-a-writer.  Roiphe’s introductory synthesis of thoughts about death could easily stand alone as a splendid thought-piece, and there is a touching personal epilogue at the end. But for most of the book the author is rather coy about her own views of death. For that one must look to her casting choices. Starting with a set of 20th century cultural icons who wrestled with the concept of death and left written records and accounts of witnesses to prove it, her chosen characters add up to a grim group of players, John Updike being the sole possible exception. The others are grim, not only because they are dying, but because of the bleakness they have created for themselves.

It is probably a consequence of Roiphe’s selection of characters that there is missing in this book any serious discussion of hope—Emily Dickinson’s resilient little creature with “feathers.” Hope is too effeminate for the likes of Susan Sontag, who preferred to submit to a brutal stem-cell transplant in lieu of gentle palliation because the transplant offered a slim hope of survival. Hope is too shallow and totemic for Freud, who prided himself on tolerating pain with what Roiphe aptly calls “heroic clarity” instead of mind-numbing analgesics. Hope was off the radar entirely for that 20th-century poet-maudit, the personification of romantic self-loathing, Dylan Thomas. But for us ordinary folk, readers who are death-fearing, moderately self-defeating but not quite blatantly self-destructive, some consideration of hope just might be welcome.

In an influential article in the geriatric psychiatry literature, Sullivan succinctly formulated how “hopelessness at the end of life is not simply the absence of hope but attachment to a form of hope that is lost.” [1] Consistent with the writings of Erik Erikson, [2] this view holds that a dying person must deflect mental energy away from the goal of survival, the currency of which has been divested of all value, to some alternative ethos consistent with his life and personality; this should ideally be something larger in scope than one person’s life, some experience or value that will outlast and transcend the individual, such as intimacy, democracy, art, or salvation. In the absence of any realistic point of future reference, redirection of hope becomes the urgent task to be confronted when one is handed a final sentence of death.

Considering Roiphe’s cases from this perspective, she shows how Sontag haughtily spurned everything but survival, and by embracing a losing cause, died sadly, though she left a spectacular record of written reflections. She documents how Freud, who worked until the end, died with little psychological adjustment to make, well aware that he had created an incomparably rich legacy; he also had an heir to his intellectual estate, his daughter, Anna, who was eager to perpetuate it. Only Updike seemed to achieve a meaningful transition; his hopeless prognosis spurred him on to new creative heights and enabled him to return, albeit briefly, to the top of his form as a writer, a peak from which prior to his cancer diagnosis he’d felt he had been slipping. Previously it had been sexual affairs that had seemed to energize his writing; now it was the awareness of death. When he could no longer write, he died.  Neither Dylan Thomas nor Maurice Sendak ever entertained any sustained vision of themselves as surviving, so no such transition applied to them.

Reflecting on the absence of hope in the main body of The Violet Hour should not be taken as a criticism, for Roiphe, by clinging to neutrality and avoiding any position other than that of reporter until the book’s final pages, invites readers to abstract their own lessons from these stories and integrate them in a personal way. And it is fortunate indeed that she does not entirely neglect the critical human need for love, solace and inspiration at the end of life. It had to have been for such a purpose that she cited these beautiful lines written by the terminally ill John Updike:

“To live is good / but not to live—to be pulled down  / with scarce a ripping sound,  / still flourishing, still / stretching toward the sun– / is good also.”

 

References

  1. Sullivan MD. Hope and hopelessness at the end of life. Am J Ger Psychiatry. 2003; 11(4):393-405.
  2. Erikson EH, Erikson J, Kivnick HQ. Vital involvement in old age. New York: W.W. Norton & Company; 1994.

The Reading Room: Salka Valka

27 May, 16 | by cquigley

 

Salka Valka by Halldór Laxness: she needs to be alone

 

Reviewed by David S. Baldwin, Professor of Psychiatry

Clinical and Experimental Sciences Academic Unit

Faculty of Medicine, University of Southampton, United Kingdom

Email:  dsb1@soton.ac.uk

 

Born in Reykjavík in April 1902, Halldór Guðjónsson (he changed his name to Halldór Kiljan Laxness in 1923) lived through almost the entire twentieth century. Raised in an isolated and traditional society, he travelled widely and embraced cosmopolitan modernity, though retained an essentially Icelandic identity. In early life Laxness adhered to staunch revivalist Catholicism, then embraced socialism for thirty years. He subsequently espoused ecological and pacifist causes and addressed philosophical questions reflecting an interest in humanism and Taoism. But the principal achievement of Laxness was the authentic portrayal of sympathetic but struggling characters that symbolised the determined aspirations of the Icelandic nation and marked its long path towards eventual independence from colonialist Denmark (1).

 

Laxness travelled to America in the 1927 summer intending to become a Hollywood screenwriter. Writing to his then wife Inga at the end of that year, he described work on a film script provisionally titled Salka Valka (or, A Woman in Pants): the eponymous protagonist is described as ‘tall and strongly built’ with an expression encompassing ‘rustic virginity, dare-devilry, primitive charm’, and ‘dressed like a fisherman: wide pants, the boot-legs reaching up over her knees, a pipe in her mouth’. The script reflects contemporaneous Freudian concepts of human sexuality and is redolent with surrealist images, such as the final scene in a lover’s cottage where Salka lingeringly unfolds and kisses the leather straps of an Icelandic whip (often made from skin of bull penis) and Laxness imagined the cross-dressing Swedish actress Greta Garbo in the title role (1). Not surprisingly, negotiations with MGM floundered so the script was transformed into a two-part novel: the first manuscript was written whilst visiting isolated Icelandic fishing villages, the second was completed in cosmopolitan Weimar-era Leipzig. These were published a year apart with the support from the national Cultural Fund: the first (O Thou Pure Vine) was well received, but the second (The Bird on the Beach) was chastised by conservatives for its perceived lampoon of boorish ‘upper class’ motivations and criticised by progressives for its caricature of labour movement infighting – the Communist Party leader suggesting Laxness approached socialism as an idealist, with only a bourgeois understanding of the workers’ struggle (1).

 

An English translation of the combined parts of Salka Valka was published in 1936. The English language version has been out of print for many years, but Guðny Halldórsdóttir kindly lent me her copy, which was published in 1973 following revision by her father (2). A previous review commended its saga-like objectivity and clarity, and the masterful portrayal of down-trodden characters whose local quotidian travails seem emblematic of wider persistent human suffering (3): another account praised its Christian symbolism and careful balance of honourable parishioners and devious villains on both sides of the class struggle (4). The themes reflect the author’s perennial concerns with the nature of love, position of women, role of the intellectual, and the lot of common people: many chapters are full of visceral emotions and disturbing sexual acts perpetrated against young women. In a notebook Laxness described his wish to provide ‘tragic perspectives on the incomprehensibility of human feelings’, perhaps drawing on his desolation, anguish and guilt at the end of an affair with an Icelandic woman whilst living in America. But neither review has considered how the progressive emancipation of Salvör Valgerður (‘Salka Valka’) – as she first becomes a prominent local activist, then distances herself from the competing attentions of aggressively preying or dependently needy men – may reflect a growing awareness of her own sexuality.

 

The novel starts with the mid-winter night-time arrival by boat of eleven-year old Salvör and her unmarried mother Sigurlína at the run-down fishing village of Óseyri. The daughter disembarks first and reassures her mother, ‘in a low deep voice’ which suggests that of a man. They are grudgingly offered a room for the night at the Salvation Army hostel, but the next day their destitute status is acknowledged but not addressed by the local storekeeper, rector or doctor. They return to the hostel and fall prey to the impulsive but persuasive drunkard Steinþor Steinsson, who leads them towards ‘Marbud’, the home of his elderly aunt Steinunn and almost-blind uncle Eyjolfur, where they are offered lodgings. That evening Salvör tells her mother that whilst she was outside Steinþor had ‘grabbed hold of me here and here, and here’, and ‘whispered some stuff in my ear’ but Sigurlína responds inadequately, by asking for mutual understanding between ‘two women’, a response which has a fatal consequence. During the night Salvör is woken by the sound of tussling in the bed, as Steinþor forces himself on Sigurlína: he is repulsed, but only after he whispers a proposition which makes her recoil ‘Almighty Jesus, no! You know you can’t ask me to do a thing like that’. Later, whilst lying awake, Salvör realises she had often lain alone at night whilst her mother was absent, and for the first time appreciates she will have to rely on herself for her future safety: the narrator commenting ‘perhaps one really had nobody but oneself’.

 

The first part ends at dawn on Easter Day, when Sigurlína is found drowned, ‘a little grey oblong piece of flotsam which had been washed up on the sand’. This suicide is the result of a long process which includes remorse for the relationship with a married man which led to pregnancy with Salvör, regret for a subsequent series of damaging sexual liaisons with exploitative men, persistent grief following the death of her two-year old son Sigurlinni from scrofula (tuberculous cervical lymphadenitis: it is later revealed that Steinunn lost many children at Marbud to the same illness), a demoralizing awareness that Steinþor had once again attempted to force Salka into a sexual relationship, and acute anguish following a second desertion by Steinþor, just a few days before their hastily-arranged ‘Hallelujah Wedding’ scheduled for Holy Saturday. Her fragile personality could not withstand such prolonged adversity, without unconditional support from her daughter for whom ‘her mother’s weeping no longer went so deep to the heart as it had done’. During her testimony on entry into the Salvation Army two years before, Sigurlína had told the Congregation of her intention to commit suicide whilst pregnant with Salvör, but attempts at spiritual consolation by vigilant fellow Congregationalists following this nuptial desertion had made no impact: and the position of the often-derided Sigurlína within the wider community had always been marginal. Salvör, just fourteen years old, guarantees the costs of the funeral and walks back to Marbud, alone.

The second part of the novel charts the rise to prominence of Salvör within Óseyri. She establishes a local branch of the seamen’s union to defend workers against managerial exploitation; educates herself through reading political, evolutionist and philosophical texts; and assumes maternal responsibilities for four children once their mother dies. She is praised for being ‘a match for any man alive’. She is tall, erect and high-shouldered, her thick hair cut short with a side-parting; has courageous clear eyes, strong jaw and full lips, firm hands and a deep voice; and wears Alpine hiking-boots, woollen trousers and a roll-neck Jersey sweater which does not conceal the full curve of her firm breasts. She is commended by her childhood crush Arnaldur (by then a Communist agitator) for being a ‘tovarisch’ (Bolshevik comrade worker) icon, but current observers might recognise her portrait as iconographic of something else. She withstands the pleading entreaties and forcible sexual attentions of now-wealthy but still unscrupulous Steinþor, and leaves Marbud after she discovers it was Steinþor who had provided anonymous funds which enabled her to remain there after the death of Steinunn and Eyjolfur. Once aware of the feckless serial infidelity of the impractically idealistic Arnaldur (and despite some lingering affection for him), she reluctantly but determinedly ends their relationship by encouraging him to pursue his dreams in America. At the end of the novel, when the twenty-two year-old Salvör is finally free of unwanted male attention, the narrator compares her solitary precarious existence to the eggs of winter birds resting on narrow ledges on a high cliff-face: but contemporary readers might contend that having rid herself of both barbarous Steinþor and immature Arnaldur, Salvör may not want but certainly needs to be alone. Though with a typical twist, Laxness suggests she may be pregnant: for as Salvör walks past her most long-standing friend, he comments enigmatically, ‘cold weather to be born in’.

The novel therefore carefully illustrates the potentially damaging consequences of parentlessness, childhood abuse, unexpected bereavement and marital desertion; the corrosive effects of social and economic inequality; and the undermining of the aspirations of women by patriarchal institutions. Sigurlína succumbs after accumulated experiences of deprivation and loss, mediated through demoralisation and despair. It is argued that ‘resilience’ represents a process which allows the resumption of development following trauma or other adversity, and contends that ‘bonding’ and ‘meaning’ are important dynamic features which support this process (5). Those with only fragile affiliation or for whom life has lost its meaning (as depicted by Sigurlína) are less buffered against undermining challenges: but the active community engagement of Salvör provides a supportive network facilitating her eventual passage towards probable independence and emancipation.

 

References 

  1. Guðmundsson H. The Islander. A Biography of Halldór Laxness, trans. by Philip Roughton. MacLehose Press 2008.
  2. Laxness H. Salka Valka, trans. by F.H. Lyon. London: Allen & Unwin, 1973. Originally published in two parts as Þú Vínidur Hreini (1931) and Fuglinn Í Fjörunni (1932).
  3. Magnússon S. The World of Halldór Laxness. World Literature Today 1992; 66: 457-63.
  4. Hallmundsson H. Halldór Laxness and the Sagas of Modern Iceland. The Georgia Review 1995; 49: 39-45.
  5. Cyrulnik B. The Whispering of Ghosts. Trauma and Resilience, trans. by Susan Fairfield. New York: Other Press 2005.

The Reading Room: ‘Making Medical Knowledge’

25 Apr, 16 | by cquigley

 

Making Medical Knowledge

By Miriam Solomon

Oxford University Press, 2015

 

Reviewed by Dr Jonathan Fuller, University of Toronto

 

We should forgive anyone unfamiliar with recent trends in ‘scientific medicine’ for thinking that within scientific medicine there are now multiple medicines to choose from: evidence-based medicine (EBM), translational medicine, narrative medicine, personalized medicine, and so forth. These approaches are not distinct professions in the same sense as allopathic medicine and naturopathy. But just what are the relationships among modern medicines many ‘medicines’?

In Making Medical Knowledge [1], philosopher Miriam Solomon sets out to assess four of these movements introduced over the last forty years: medical consensus conferences, EBM, translational medicine, and narrative medicine. She calls them ‘methods’ to be concise, but notes that they are distinct epistemological approaches, or approaches to (medical) knowledge. Solomon writes that she selected these four methods because of their “dual and paradoxical epistemic character” (p. 14): there is something obvious about each of them (of course medicine should be ‘based on evidence’), as well as something odd (‘evidence-based medicine’ deemphasizes many kinds of evidence, including expert consensus). Given how much time, effort and money is being spent in the name of these movements, a close inspection is certainly warranted.

Solomon’s approach in her book is to examine these methods using an interdisciplinary lens. She situates her study in the realms of social epistemology, philosophy of medicine, integrated history and philosophy of science, science and technology studies (STS), and critical medical studies. She describes her approach as “Naturalistic, Normative, Applied, Pluralist, Social Epistemology” (p. 11); in other words, she aims to describe and evaluate actual medical knowledge and practice using a diverse set of tools, and with a focus on the social. She writes for a broad academic audience, including the medical community.

In the introductory chapter, Solomon argues that “[t]he science/art dichotomy is no longer a fruitful disciplinary divide” or a meaningful way of describing medicine (p. 11). She instead argues that a ‘methodological pluralism’ describes contemporary medicine and its many methods for negotiating knowledge. Solomon then spends three chapters examining medical consensus conferences and group process, two chapters on EBM, one chapter on translational medicine, and one chapter on narrative medicine. The penultimate chapter advances Solomon’s ‘developing, untidy, methodological pluralism’. According to this view, medicine’s epistemological approaches do not have exclusive domains of application; all of the methods she describes are in active use, their domains overlap, they sometimes come into conflict with one another, and there is no “hierarchy of methods” (p. 229) to rescue us when they clash. The final chapter summarizes Solomon’s main conclusions.

Making Medical Knowledge is an excellent and pioneering study of some of the dominant movements in early Twenty-First Century medicine, which – with the exception of EBM – are relatively unexplored by scholars. It provides a good entry point, offering detailed and insightful reconstructions of each method within its historical context, thus satisfying Solomon’s descriptive aim. The historical detail is rich, especially for medical consensus conferences. Solomon is charitable towards each method, and manages to find substance amidst the rhetoric, even for translational medicine, which is especially difficult to pin down and appears at first glance to offer no more than metaphor. She also provides thoughtful criticisms of each method, thus satisfying her normative aim.

Overall, I think Solomon pitches the discussion well for the broad audience she has in mind. The philosopher, historian, sociologist and anthropologist should all find something of interest in her book. I expect that clinicians, especially within academic medicine, will find it fairly accessible. Satisfying the needs of her diverse audience perhaps prohibits Solomon from going into as much depth as some philosophers, historians or social scientists might like. Such is the cost of interdisciplinarity, but it pays off in the form of a study that benefits from its use of multiple disciplinary lenses.

While I generally agree with Solomon’s analysis of each method, I was not fully convinced that an ‘untidy, methodological pluralism’ is the best way to understand the relationships among the methods. Solomon accepts that the methods are often active at different stages of research, but nonetheless argues that they do not fall on a “tidy linear spectrum” from research to practice (p. 206). Yet as her own analysis reveals, translational medicine (research from ‘bench to market’, or ‘T1’) refers to basic medical science research as well as Phase I and II clinical trials, EBM appraises and aggregates the results of Phase III trials, medical consensus conferences make therapeutic recommendations based on the results of Phase III trials or systematic reviews of trials, and narrative medicine (in its integrated form) interprets guidelines and the research literature in the context of the patient’s story. In other words, translational medicine applies to medical research, consensus conferences apply to knowledge dissemination, and EBM and narrative medicine apply to clinical practice. The main purpose towards which each method is put is unique: translational medicine develops new medical technologies, consensus conferences develop consensus statements or clinical guidelines (often pertaining to those technologies), EBM appraises evidence and applies it in clinical practice, and narrative medicine uses narrative techniques at the bedside. Thus, their domains are less overlapping and arranged more linearly than Solomon’s untidy pluralism might suggest.

Of course, the practice of EBM might sometimes conflict with the practice of narrative medicine (more on this point in a moment). Moreover, the practice of narrative medicine or of EBM might sometimes conflict with the products of consensus conferences: clinical guidelines. Narrative medicine locates individuality in the patient’s narrative, and EBM is often defined as the use of evidence in the care of individual patients [2]. On the other hand, guidelines make recommendations for broad groups of patients, not for individuals.

Solomon presents the example of breast cancer screening for women in their forties to illustrate the various ways that the methods can clash with one another. However, most of the conflict that Solomon describes occurs within each method: among pathophysiologic theories of breast tumour development, among primary studies and systematic reviews with respect to the magnitude of benefit from screening, and among guidelines making recommendations about mammography. While some of the products of EBM (systematic reviews) might appear to conflict with some of the products of consensus conferences (guideline recommendations), the former recommending against mammography and the latter often recommending in favour of mammography, this appearance is illusory. The evidence, on its own, does not have the power to recommend. Conflicts arise among individuals and groups due to their differing interpretations of the evidence and divergent recommendations for which they use the evidence to argue.

Similarly, it might appear that generalized breast cancer screening guidelines conflict with the individualized practice of narrative medicine or EBM. However, even though guidelines make general recommendations on mammography for women in their forties, Solomon notes that the guidelines explicitly state that patients and their physicians should make an individualized decision. There is thus less conflict among the different methods than first meets the eye.

Rather than an untidy methodological pluralism, another way to describe the situation is as follows. Medical research has a dominant aim (‘translation’), and medical practice has a dominant epistemology (EBM). The aim of translation regulates the funding of research, and motivates the use of consensus conferences to disseminate knowledge. Meanwhile, EBM has been embraced by leading medical journals and medical training programs around the world. While medical consensus conferences and clinical guidelines predate EBM, they are now based on the principles of EBM and can be considered EBM tools (the use of evidence-based practice guidelines has been called the ‘using mode’ of EBM [3]). The practice of narrative medicine might sometimes conflict with the practice of EBM. But narrative medicine is a developing movement and approach to clinical medicine, not a dominant one. It does not yet have the political power of EBM. Thus, within research and medical practice, there is more hegemony and less egalitarianism than Solomon’s untidy pluralism perhaps suggests.

Making Medical Knowledge raises interesting questions about the function, theory and practice of medicine’s most influential movements. Modern medicine is a mess of many ‘medicines’, and while it is not the intention of this book to make this mess look tidy, Solomon does succeed in making it intelligible.

 

Acknowledgments

I gratefully acknowledge funding support from the Canadian Institutes of Health Research.

 

Funding

Canadian Institutes of Health Research.

References

  1. Solomon M. Making Medical Knowledge. Oxford: Oxford University Press, 2015.
  2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence Based Medicine: What It Is and What It Isn’t. British Medical Journal 1996;312:71 – 72.
  3. Straus S, Glasziou P, Richardson WS, Haynes B. Evidence-Based Medicine: How to Practice and Teach It. Edinburgh: Elsevier Churchill Livingstone, 2011.

PCMD Medical Humanities Conference 2016

18 Apr, 16 | by cquigley

 

Ian Fussell

Community Sub Dean UEMS

 

In 2002, The Peninsula Medical School (now Peninsular College of Medicine and Dentistry (PCMD)) became the first UK medical school to integrate the medical humanities as core curriculum.

Every year since, year four students engage in a six-month project alongside and mentored by an artist. The culmination of the project is a conference organised by the students displaying and presenting their work.

The work thus created has become increasingly sophisticated over the years, as evidenced by the 2016 conference that just took place in Truro (April 2016). In fact, it was probably the highest quality of work seen to date and would not be out of place at any international medical humanities conference.

The morning session was opened by Professor Alan Bleakly, the current President of the Association for Medical Humanities and a leading world expert in the field. This was a particularly poignant conference as 2016 is the final year that it will be run under the auspices of PCMD following the disaggregation of Exeter and Plymouth Medical Schools. It may have been this, or the unsettled future that the current students are facing, that gave this year’s presentations an extra edge.

Following a superb talk by Alan that encouraged a political voice, we were treated to three songs written and performed by “Dull to Percussion”, a band formed in the “Medical School of Rock” module. The songs were indeed political, satirising the split between the universities and included a protest song aimed squarely at our Health Secretary. Search iTunes or Spotify to listen for yourself, and watch “A Song for a Hunt” go viral.

The day was then jam-packed and it was impossible to experience all that was on offer. The range of skill and talent was breathtaking. We were lectured on the human cost of the western desire for sweetness by students from the anthropology module, and invited to debate “Do Christians make better doctors” by the Christian ethics students. This year a number of new Special Study Units (SSUs) were run. They were also extremely good and included a collaboration with Truro’s Hall for Cornwall team.

The students worked at the theatre, but more impressively wrote a play on mental health in medical students. We were treated to a premiere performance – “Permission to be Human” should be performed at every medical school in the country. There was also a monologue by a shy mature student who helped us understand alcoholism and PTSD in war veterans. The mood was lifted by a hilarious stand up routine; how can dislocating your shoulder be so funny?!

There were a number of writing modules, including poetry. The audience was encouraged to write poems in a short workshop. Another new module was “Writing the Knife”, which generated superb short reflections on memorable clinical incidents. One piece called “Quayside” was outstanding and deservedly won a prize. Read it here https://memorablemedicmoments.wordpress.com/author/memorablemedicmoments/ and add your comments.

There was so much more to the students’ work, and this short piece cannot cover everything. However, I do want to mention a some other excellent pieces: working with clay exploring the professional masks doctors wear; pottery boxes representing the mess that doctors get into as they progress through their careers; moving and uncomfortable films that depicted a child’s journey through a hospital; the doctors strike shown as a frightening political movement; dopamine photography; a project on how we smell; and life drawing in conjunction with Falmouth Art School. At the end of the day we were “kettled” into a small room, and forced to party…

The aim of this SSU is to develop student’s tolerance to ambiguity. But the SSU achieves much more than this: it helps students develop a community of practice; it also fosters development of resilience and peer support; and importantly, the students have fun while exploring other perspectives on life and illness. I am extremely proud of our medical students and feel very privileged to work with them in this way. I hope that both Exeter and Plymouth continue with medical humanities in their developing curricula.

 

 

 

Ayesha Ahmad: ‘Lahore is an Illusion, Lahore is Everywhere’

27 Mar, 16 | by Ayesha Ahmad

The mango tree faded many shadows ago, its fruit became stones and the branches became a skeleton. Yet, the roots remained, and they embrace the soil in the womb of the earth.

images-1

This was the cradle of my family’s birth.

Now, blood is watering Lahore’s gardens.

In sorrow, I remembered these words given to me a few days ago by my father.

 ‘Lahore is an illusion, Lahore is everywhere’

I wondered about them for sometime afterwards and I did not realise the gift that these words were to become.

more…

Franco Ferrarini: The Past: a Friend or Foe? Different Perspectives from ‘Spectre’ and ‘45 years’.

27 Mar, 16 | by Ayesha Ahmad

The Past: a Friend or Foe? Different Perspectives from ‘Spectre’ and ‘45 years’.

Spectre- directed by Sam Mendes, UK, 2015

45 years- directed by Andrew Haigh, UK, 2015

By Franco Ferrarini, Gastroenterologist and film reviewer

In the words of the French philosopher Henri Bergson: ‘The pure present is an ungraspable advance of the past devouring the future. In truth, all sensation is already memory’. In this view the present, as we usually think of it, is virtually non-existent as the past connects directly with the future. Two recent, but very different films, ‘Spectre’ and ‘45 years’ provide thought-provoking insights into this relationship.

more…

Ayesha Ahmad: Introduction to Global Humanities—Through Creation, Violence Will Die

15 Mar, 16 | by Ayesha Ahmad

Against the backdrop of violence, I have been examining through my research the qualities of our human condition that perpetuate both our survival and our spirit.

As an introduction to an ongoing series on Global Humanities, I will be discussing ways we can counter the dominant narrative of violence.

Our globalised world, or rather, the collective ‘Other’, is met through encounters from suffering—the patients that enter our clinical settings, the individuals that sacrifice their lives to reach the shores of safety, and the images that we only ever see from afar of stories that breathe suffering.

more…

Take Me With You: the Museum of Friendship, Remembrance and Loss

8 Feb, 16 | by cquigley

 

Take Me With You: the Museum of Friendship, Remembrance and Loss

6.00-8.30 pm, Thursday 18 February 2016 at the Chowen Lecture Theatre, Brighton and Sussex Medical School, Falmer Campus BN1 9PX

Museum open from 6.00 pm

Clare Best and Tim Andrews in conversation (+q&a) 6.30-7.30 pm

Drinks reception from 7.30 pm

Museum open until 8.30 pm

 

From Clare Best’s blog:

‘Here is what I wrote in my journal after Tim and I first met in a café in Brighton in January 2013:

Met Tim Andrews in Brighton 16 Jan. Thought on train on way home about some kind of flexible/low-maintenance start to a collaboration. Thought more overnight.

‘Take me with you’ – this is the phrase that kept coming to me in the night. It has connotations of journey, of packing, of accompaniment, of company, of gathering in, of sharing.

I see it perhaps for now as making ‘swaps’ by email of what each of us would take with us to the next world, if we could, if there is one… Things/ideas we hold dear. Then each of us interprets or responds to each other’s chosen thing. And so on.

The items sent might be very fragmentary and abstract. They could be anything: a line from a song, a particular person’s smile, a food, a mood, a book, a film, a favourite walk, a memory, etc etc – it could be literally anything.

So we’d build up a collage, a narrative. And each time we corresponded we’d know each other better, so we would construct a kind of overlapping journal, or a conversation, through what we’d choose and send each other.

And here we are, three years later, with a robust friendship and about 50,000 words written, quite literally, between us – and all kinds of things we’d like to show you.

It’s been a stimulating journey, full of laughter and tears and adventure and tea and cake, and we look forward to sharing it at BSMS on 18 February.

The event is free, but if you’re coming along please register in advance here.

Tim has produced a trailer and has blogged about the project.’

 

Ageing, Embodiment and the Self: A One-Day AHRC Symposium

13 Jan, 16 | by cquigley

The Reading Room: Erik Parens’ ‘Shaping Our Selves…’ reviewed

1 Dec, 15 | by cquigley

 

Shaping Our Selves: On Technology, Flourishing and a Habit of Thinking by Erik Parens. Oxford University Press. 2014. xi+200 pages. Hbk. ISBN: 9780190211745.

Reviewed by Nathan Emmerich, Visiting Research Fellow, Queen’s University Belfast.

 

On the face of it Shaping Our Selves is about the way biomedical technologies, such as neurochemical enhancements and reconstructive surgeries, can be sued to alter and mould the human body and mind. However, the author has previously addressed both of these topics. What is on offer here is, first, a consideration of the way the ethical analysis of these technologies are characterised by polarised positions and, second, an account of binocularity. This latter is a metaphor and names a habit of thinking that, if adopted more generally, purports to promote a greater degree of mutual understanding between different sides in these debates.

Parens’ strategy is to demonstrate that participants in these debates do not simply disagree but have differing intellectual orientations, or lenses, through which they consider the matters at hand. Such disagreements are, therefore, a result of a fundamental incompatibility, even incommensurability, that lies at the heart of opposed ethical perspectives. Parens proposes that if we wish to increase our understanding of the matters at hand we should attempt to consider them by thinking in a binocular, as opposed to monocular, manner. Whilst he thinks that in the final analysis, and when deciding to act, we must lapse into monocularity (p.158), he maintains that when trying to fully understand the issues we can and must oscillate between different ‘lenses’ if we want to fully comprehend the issues at hand.

The binocular metaphor works because Parens is able to divide bioethics – or, at least, the literature on the topics he discusses – into two opposing and mutually incompatible camps each of which adopts different stances on a variety of matters. The camps are those of the enthusiasts and the critics. Those who inhabit these camps have, he says, two different kinds of ethical stances, each of which is associated with two different sets of conceptual ‘lenses.’ When he suggests binocularity involves oscillating between different perspectives it is these conceptual lenses he has in mind. This endeavour can be compared to the way our vision flips between seeing a duck and a rabbit in Wittgenstein’s famous example (p.39).

Thus, the purpose of binocularity is not to help us to see further and with greater clarity or to see in greater depth, at least not insofar as seeing in greater depth means developing a more detailed appreciation for the dimensions of a ‘monocular,’ ‘singular’ or ‘unified’ ethical picture. Rather it names a habit of thinking about different, mutually incompatible approaches to ethical arguments. The aim is not to adjudicate the arguments, to effect some kind of reconciliation or to uncover some sort of ‘third way’ compromise – although, particularly when one begins to think about substantive policy, this latter may in fact result. The avowed aim is, instead, to sensitise us to our own ethical partiality and, in so doing, to encourage us to become less combative and more bipartisan in our thinking. It is Parens’ hope that we will become less rigid in maintaining our ethical stances and, in so doing, become less concerned with winning ethical arguments and more concerned with developing a greater understanding of the issues.

It is a laudable aim and Parens’ discussion contains a great deal of insight into and appreciation for the essentially political problem of engaging in contemporary ethical debate in a mutually respectful manner. Nevertheless, there are some questions to be answered. For example, Parens divides bioethicists into enthusiasts and critics, roughly those who embrace emerging biotechnologies and those who are more cautious and critical of its potential impact. The characteristic perspectives of these two groups is fleshed out by a series of conceptual binaries, one of which is the idea that enthusiasts see biotechnology as ‘value-free’ whilst critics see it as ‘value laden’ (Chap. 4). Whilst this might be true of bioethicists like Julian Savulescu and John Harris, it is not clear that this applies to others who are positioned in this camp, such as James Hughes (p.60 & 95), Andy Clark (p. 81) and Donna Haraway (p.81). Indeed it is also not clear that these latter techno-enthusiasts – and other comparable figures such as, for example, Steve Fuller – would have much sympathy for the relative simplicity of utilitarian accounts. Equally, one could suggest that utilitarian bioethicists would no doubt find Haraway’s or Fuller’s thinking needlessly complex.

One can make a similar point about those who adopt a more critical stance. In Parens view the inhabitants of this camp include outright bio-conservatives such as Leon Kass (p.51), as well as more moderate conservatives such as Dan Callahan (p.15), Michael Sandel (p.60), and Hans Jonas (p.67). However, it also includes many if not most, sociologically inclined bioethicists such as Illina Singh (p.58), Jackie Leach Scully (p.136), and Tom Shakespeare (p.136), none of whom could really be considered anything but liberal in their general outlook. Whilst one might take this as suggesting there is a distinct problem with Parens binary nomenclature, it is important to note that he rejects the idea that the enthusiasts and the critics map onto standard political divisions of progressive liberals and traditional bio-conservatives (p.52).

Given the evident and significant differences between the perspectives held by those Parens groups into enthusiast and critic, we might consider Steve Fuller’s recent suggestion that the notions of left wing and right wing are undergoing an ‘axial rotation.’ Fuller’s thinking indicates that we should reframe these basic political differences in terms of ‘up wing’ and ‘down wing.’ The latter is associated with the ‘precautionary principle,’ something often espoused by those Parens has termed critics. In contrast the ‘up wingers’ are associated with the ‘proactionary principle’ or ‘imperative,’ an idea that stems from the enthusiasts’ reaction to the precautionary principle. Whilst they come from very different perspectives, Parens (the critic) and Fuller (the enthusiast) have, it seems, independently divided the world in very similar manners, indicating that their ideas have some degree of validity.

Whilst Parens’ division of bioethicists, and those who labour in associated fields, into enthusiasts and critics stands up to scrutiny, some of the associated binaries seem less robust. For example, he holds that enthusiasts see technology as value-free whilst critics hold that it is inherently value-laden (chap. 4). However, even if these individuals are not bioethicists per se, this division can be supported when we consider enthusiasts like Haraway, Clark and Fuller. Furthermore, given the scope of this division, what might it mean to propose that we oscillate between the view that our techno-scientific achievements are value-free and the view that they are value-laden? Parens asserts that “no thoughtful person would want to choose between thinking that technology is value-free and thinking it is value-laden” (p.93). Whilst I am not a true Scotsman, I certainly aim to be a thoughtful person and, as such, I fail to see why one should not ‘choose’ or, rather, conclude that all human technology is value-laden. In my view the alternative position is fundamentally flawed.

This is not to say that I cannot appreciate the arguments, the motivations and, to a degree, the value of arguments that presume that technology is value-free. Nevertheless, I cannot take them as seriously as work conducted from what I consider to be the more defensible perspective. Given that Parens is not proposing binocularity as a ‘grand, meta-lens’ (p.9), ‘cure or solution’ (p.10), or ‘panacea’ (p.172) perhaps this is all that is required when oscillating between competing, contradictory and incommensurable points of view. If so, one could think that what Parens is proposing is a mode or style of interaction between those with differing ethical stances and perspectives. Whilst he is not suggesting we abandon the pursuit of singular or monocular ethical perspectives, arguments and accounts, he is questioning how we ought to conduct ourselves when speaking across such divisions. One might, then, take him to be offering an ethics of the public square or, to put it another way, attempting to find a common socio-political space from which we can give proper consideration to divergent but genuinely held ethical perspectives. As such ‘binocularity’ is a kind of political stance, built upon the recognition that the neutrality of liberalism is not the same as liberalism being value free (p.49).

Whilst it is not discussed, at least not in any detail, Parens’ approach can be seen as insisting on the value-laden nature of the public square, our political debates and, for that matter, our ethical discourse. One can, I think, see this as predicated on the assumption that applied or practical (bio)ethics is, in essence, a contemporary political technology, one that bolsters the apparent neutrality of liberalism. As such it would seem that binocularity is predicated on the assumption that human technologies are not value-free, but inherently value-laden. Binocularity is, then, something that conforms to the worldview of the critics. However, it is not clear how well it might sit with those enthusiasts who cleave to the notion that technology is, or can be, value-free and that ethics is, or can be, considered in an ‘objective’ matter to be pursued through adopting an ‘impartial’ stance (p.23). If my analysis is well-founded, it is not clear to me why Parens’ putative opponents, the enthusiasts, would think the binocular approach worth considering; it seems to be founded on a set of values that seem anathema to their favoured approach.

In the chapter ‘Closing Thoughts’ Parens details how, when he embarked on his first major project at the Hastings Centre, he adopted a ‘high reason’ approach to (bio)ethical analysis of enhancement and did so against his own academic training and intellectual inclinations (p.161). Given that Parens identifies with the critics’ camp, one can see this as an attempt to adopt the stance of his opponents, the enthusiasts. Whether this was done to prove them wrong on their own terms or, as is more likely, something that naturally resulted from the process of entering a new field, of being a newcomer who naturally tries to fit in and find his feet by conforming to the rules of the disciplinary game, is not relevant. What matters is that the approach adopted by Parens belonged to his opponents. Whilst one cannot fault him for it – it was through doing so that Parens was able to fully develop his own ethical stance – it is nevertheless illuminating. In this light one might consider if Parens’ metaphor of binocularity fails to fully challenge his opponents; if, despite his intentions, it cedes too much ground to the enthusiasts thereby allowing their style of monocular ethics to flourish and, ultimately, maintain its position of dominance.

Against this one can, I think, point to an underdeveloped aspect of Parens’ account. On the one hand he claims binocularity runs against the grain of “the first law of thinking dynamics” (p.40), as conducting intellectual enquiries using more than one lens requires more effort than monocular thinking. However, towards the end of the book, Parens discusses a couple of cases that reveal the way in which ordinary individuals often appear to be thinking in a binocular manner and, furthermore, seem to be doing so with relative ease (p.149-151). If this is the case it seems to belie the notion that “we can’t actually think with any two lenses at once” (p.39). As the notion of lens is, here, a metaphor for ‘conceptual framework’ we should, I think, acknowledge that monocularity is a product of thinking from within specific disciplinary perspectives and may not be something that troubles everyday human reflection, at least not to the same degree.

To be clear, monocular disciplinarily has served us well. Nevertheless, given that the notion of ethical expertise or, at least, moral authority is widely rejected, then we should consider the positive and negative consequences that disciplinary rigour in the field of ethics has had for the way we understand our ordinary or everyday ethical thinking. Read as a plea to further reconnect academic ethics, and the study of meaning questions more generally (p.4), with lived experience as – for example, those working in feminist and disability ethics have done – and a broader, humanities based, understanding of human being, Parens’ argument takes on greater significance; it indicates that further reflexive development of this field of enquiry is possible. Indeed, consistent with this thought, Parens suggests that we are at the beginning of a ‘second wave’ in enhancement debates, one that exhibits a greater degree of binocularity (p.9 & 175). If what Parens calls the second wave is, as I suspect, marked by a relatively sophisticated and interdisciplinary approach to bioethical analysis, then his binocular habit of thinking may offer a much needed guide as to how such scholarship might be collectively understood and, ultimately, pursued in such a way as to contribute to and participate in the common good or, in Parens terms, human flourishing in the broadest sense.

 

 

 

 

 

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