Phenomenological Bioethics

Medical Technologies, Human Suffering, and the Meaning of Being Alive

Fredrik Svenaeus

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351808736
• Edition: 1
• Topic: Economics
• Subtopic: Sustainable Development
• Index: Economics

Emerging medical technologies are changing our views on human nature and what it means to be alive, healthy, and leading a good life. Reproductive technologies, genetic diagnosis, organ transplantation, and psychopharmacological drugs all raise existential questions that need to be tackled by way of philosophical analysis. Yet questions regarding the meaning of life have been strangely absent from medical ethics so far. This book brings phenomenology, the main player in the continental tradition of philosophy, to bioethics, and it does so in a comprehensive and clear manner.

Starting out by analysing illness as an embodied, contextualized, and narrated experience, the book addresses the role of empathy, dialogue, and interpretation in the encounter between health-care professional and patient. Medical science and emerging technologies are then brought to scrutiny as endeavours that bring enormous possibilities in relieving human suffering but also great risks in transforming our fundamental life views. How are we to understand and deal with attempts to change the predicaments of coming to life and the possibilities of becoming better than well or even, eventually, surviving death?

This is the first book to bring the phenomenological tradition, including philosophers such as Martin Heidegger, Edith Stein, Maurice Merleau-Ponty, Jean-Paul Sartre, Hans-Georg Gadamer, Paul Ricoeur, Hans Jonas, and Charles Taylor, to answer such burning questions.

1
PHENOMENOLOGICAL BIOETHICS

Phenomenology of medicine and health care

In what ways is the philosophical tradition of phenomenology able to contribute to the field of bioethics? This is the question I aim to explore in the present book. In using the term ‘bioethics’, my intention is to address not only the classic medical ethical questions revolving around the clinical encounter, but also the type of ethical challenges that arise when medical technologies are used to support and control human life. Phenomenology has been rather absent in the bioethical field up to the present date, but some examples of phenomenology are found in the neighbouring fields of philosophy of medicine and medical humanities and in qualitative studies of medical phenomena carried out in disciplines such as nursing, medical psychology, medical sociology, medical anthropology, and science and technology studies. Phenomenology has also had an impact in certain subfields of bioethics, such as caring ethics, narrative ethics, and feminist ethics. These subfields have played important roles as alternatives to the principle-based bioethics that have developed into the mainstream tradition in the field (Jonsen 1998). This chapter will provide an overview of the different ways in which phenomenology could prove to be useful as a method and philosophical inspiration for bioethics. The possibilities, as will become obvious, are multiple, and to a large extent they still remain to be realized. After providing this overview, I will present my own strategy for bringing phenomenology to work in bioethics by navigating within this field of possibilities.

Phenomenology is a tradition more than one hundred years old of exploring and answering philosophical questions by proceeding from an analysis of what the phenomenologist calls ‘lived experience’; important classics are written by philosophers such as Edmund Husserl, Martin Heidegger, Maurice Merleau-Ponty, and Jean-Paul Sartre (Moran 2000). The starting point for phenomenology is not the world of science, but the meaning structures of the everyday world – that which the phenomenologist calls a ‘life world’. Contemporary phenomenology has branched out into many different disciplines from the tree that started growing in philosophy with Husserl and his successors. Scholars and researchers of art, literature, psychology, sociology, anthropology, pedagogy, history, and, recently, also nursing and medicine, have tried to make use of phenomenology in investigating phenomena of concern in their fields.

The main topic of phenomenology in medicine and health care so far has been bodily experiences – experiences of phenomena such as illness, pain, disability, giving birth, and dying (Meacham 2015; Toombs 2001; Zeiler and Käll 2014). Everybody has a body – a body that can be the source of great joy but also of great suffering to its bearer, as patients and health-care professionals know more than well. The basic issue that the phenomenologist would insist upon clarifying in this context is that not only does everybody have a body, everybody is a body. What is the difference?

That every experience is ‘embodied’ means that the body is a person’s point of view and way of experiencing and understanding the everyday world. Not only can I experience my own body as an object of my experience – when I feel it or touch it or look at it in the mirror – but the body is also that which makes a person’s experiences possible in the first place. The body is my place in the world – the place where I am which moves with me – which is also the zero-place that makes space and the place of things that I encounter in the world possible. The body, as a rule, does not show itself to us in our experiences; it withdraws and by way of this opens up a focus in which it is possible for things in the world to show up to us in different meaningful ways. When I am, for instance, cooking, reading, or talking to my friends, I am usually not attending to the way my body feels and moves; I am focused upon the thing I am momentarily doing; this is made possible, however, by the way my body silently performs in the background. The body already organizes my experiences on a subconscious level; it allows me to experience the things that are not me – the things of the world that show up to my moving, sensing body in different activities through which they attain their place and significance (Gallagher 2005).

Thus phenomenology can be understood as transgressing any dualistic picture of a soul living in and directing the ways of the body like some ghost in a machine. The body is me. But phenomenology, despite its anti-dualism, has also, from its beginnings, been an anti-naturalistic project; that is, the phenomenologist would contest any attempt to reduce experience to material processes only. Experience, to the phenomenologist, must be studied by acknowledging its form and content for the one who is having the experience. Experience carries meaning in the sense of presenting objects in the world to a subject (self, person). It is certainly possible to study experience from the third-person (or, rather, non-person) perspective of science also – we could study the ways light rays trigger nerve firings in my brain by way of the retina when I look at a person right now (if we hook me up to a technological device), but this picture of my brain in action would not be the experience of ‘me seeing her right now’. The picture could catch neither the ‘me-ness’ nor the content of the experience that I am having – this is the first-person perspective of intentionality, which the phenomenologist takes as the starting point of the analysis.

Among the medical themes that can profit from a phenomenological analysis we find not only embodiment, but also related phenomena such as illness, suffering, dying, and giving birth (Aho and Aho 2008; Carel 2008; Leder 1990, 2016; Slatman 2014; Svenaeus 2000, 2011; Zeiler and Käll 2014). One finds elements of such analyses in the works of major classic phenomenologists, such as Husserl, Heidegger, Merleau-Ponty, and Sartre, and even more in some less well-known figures, such as F. J. J. Buytendijk, Hans Jonas, Herbert Plügge, and Erwin Straus, but the idea of a phenomenology of medicine as a distinct field of academic studies is younger than that, maybe thirty years old or so (Spiegelberg 1972; Toombs 2001). Long before that, however, phenomenology had a certain influence in one specific medical speciality, psychiatry, with scholars such as Karl Jaspers (Stanghellini and Fuchs 2013). Jaspers, in his General Psychopathology, published as far back as 1913, famously separated two different angles and frameworks that the psychiatrist needs to explore and combine in his practice: understanding and explanation (Jaspers 1997). This way of describing medical practice is very much similar to stressing the need for a focus upon the lived body and the everyday world of the patient in health care to complement the causal explanations explored by medical science in investigating the body as a diseased organism.

Phenomenology of illness

The contrast between understanding and explanation also mirrors the familiar distinction between illness and disease made in medical philosophy, psychology, and sociology. Illness is the name for the experience of the person being ill, and disease is the name for the pathological processes and states possibly inhabiting his body. Diseases are often taken to be the causes of illness, but the experience of illness can protrude in spite of the doctors’ being unable to detect any diseases; and the illness experience, in turn, can have biological effects, just as the experience of negative stress in many cases leads to diseases and shortens life. Phenomenology of medicine explores the illness perspective – the first-person perspective – without denying the importance and reality of the biological functions of the body – the third-person perspective on diseases. In this way phenomenology is, indeed, anti-naturalist in vehemently denying that the meaning of lived experience could be reduced to patterns of material processes (causal explanation), but it remains material and anti-dualistic in the sense of proceeding from the embodied perspective of the ill person.

The first-person perspective of the ill person – what it is like to be ill in this particular way – is in fact exactly what the doctor explores when entering into empathic dialogue with the patient (see chapter four). When doing so, the doctor (or other health-care professional) adopts a second-person perspective on the experiences of the patient. The second-person perspective on the patient’s experiences is an empathically imagined first-person perspective, in contrast to a third-person perspective on the patient, which is rather a non-person perspective – that is, a perspective that aims to steer free of all idiosyncrasies in a natural scientific way. As we will see, good medical practice consists of navigating in-between the second-person and the third-person perspectives on the patient, combining phenomenological understanding with scientific explanations.

Normally the lived body remains in the background of our experience, and our attention is instead focused on the things in the world that we are engaged with. In Merleau-Ponty, to mention the most well-known ‘body phenomenologist’, we find penetrating descriptions and conceptual analyses of such everyday experiences that are bodily in nature even though we are not focused upon the body: seeing, listening, walking, talking, reading, and the like (Merleau-Ponty 2012). In some situations, however, the body calls for our attention, forcing us to take notice of its existence in pleasant or unpleasant ways. This experienced body can be the source of joy, as when we enjoy a good meal, play sports, have sex, or just relax after a day of hard work. However, the body can also be the source of suffering to its bearer, as when a person falls ill or is injured and experiences pain, nausea, fever, or difficulties in perceiving or moving (Leder 1990; Zaner 1981). When I have a headache, an example most famously explored by Sartre in Being and Nothingness, the pain in question invades my entire world – my attempts to concentrate, perceive, communicate, move, and so on (Sartre 1992; Svenaeus 2015a). If the doctors examine my body with the help of medical technologies they may be able to detect processes going on in my brain and the rest of my body that are responsible for the pain in question, but they will never find my headache experience, the feeling and meaning the pain has for me in my ‘being-in-the-world’, to speak in a phenomenological idiom invented by Heidegger in his magnum opus, Being and Time (1996). The hyphens are put in place by Heidegger in order to stress that a person (other terms used here are ‘self’ or ‘subject’), in experiencing and doing something, is always immersed in the things at hand. Consequently, things that we encounter in the world are first and foremost ‘tools’ (in German, ‘Zeuge’) that are ‘ready to hand’, according to Heidegger (1996: 66 ff.).

The concept of tool in Being and Time is introduced as Heidegger is analysing what he calls the ‘being-there’ – ‘Da-sein’ – of human beings as a ‘being-in-the-world’ (1996: 41 ff.). What is a world in the phenomenological sense? It is the pattern of meaning, the horizon in which we come to see things as such-and-such things. No phenomenon shows up alone; it is always embedded – temporally and spatially – in a background pattern that makes it possible for the object to stand out and show itself to us with a certain significance. The things of the world attract our attention from out of such meaning patterns: a chair can only show up within a room, on the floor, in front of a wall, beside the table at which we eat while sitting on it, and so on.

One of Heidegger’s most important observations in Being and Time is that such ‘showing itself to us’ is as a rule not played out in the manner of our being conscious of objects in the world, in perceiving or thinking about them. The most basic access, rather, relies on our handling the stuff of the world in various ways to attain things. The chair is not first and foremost an object with such-and-such a shape and colour; it is something to sit on, and we approach it in such a way when we take a seat or offer it to somebody else in inviting her for a cup of coffee. The similarities and differences between the limbs and organs of the lived body and the ‘outer’ tools of the world will be an important subject in later chapters of this book, when I aim to explore the ethical conundrums that arise when we are able to transfer organs and tissues between bodies, or even to create fleshy ‘body tools’ in the laboratory (Diprose 2002; Malmqvist and Zeiler 2016; Sharp 2007; Slatman 2014; Waldby and Mitchell 2006).

The difference between the first-person and the third-person perspective is an important one. The first-person perspective makes it possible to understand not only how human experience is meaningful and material simultaneously, but also how the body belongs to a person in a stronger and more primordial sense than a pair of trousers, a car, or a house does. The body is not only ours, it is us; and this insight will, as mentioned, have important repercussions in facing ethical dilemmas associated with technologies that make it possible to keep a human body alive when the person, whose body it is, appears to be permanently gone (chapter seven). How should we treat and look upon such bodies? How should we consider the possibilities of using parts of such bodies to help other persons in need of new organs? A phenomenological take on embodiment is also helpful in understanding pregnancy and the way medical technologies are involved in assisted reproduction and maternal care (chapter six). How can phenomenology inform our views about embryo and stem-cell research and about abortion? How can it inform our views about the ethical dilemmas having to do with choosing what (type of) children should be born?

In this book we will return many times to how one could approach and better understand various forms of human suffering in health care by way of phenomenology and the importance such analyses carry for bioethics. Medical-ethical dilemmas revolving around issues of providing information and obtaining consent occur in situations involving people who are vulnerable, dependent, and out of control because they are suffering. To understand not only why but also how these people suffer is necessary to be able to help them. Empathy on the part of the health-care professional is a matter not only of informing patients about their medical condition and respecting their ability to make decisions about the medical care they are offered, but also of understanding and helping persons who suffer. As we will see in chapter two, suffering is an existential issue that occurs when we become alienated from the things that are most important and dear to us in life. Empathic understanding of human suffering in health care will in most situations need to proceed beyond medical body matters into everyday life matters and issues concerning persons’ self-understanding. New medical technologies pushing or changing the forms and limits of human self-understanding as such raise further questions of responsibility when they are tested or implemented on a societal level.

Phenomenological bioethics

Phenomenological bioethics can be regarded as the part of the phenomenology of medicine and health care that focuses on ethical dilemmas arising in connection with understanding and helping suffering persons, and in connection with dealing with medical-technological dilemmas involving human bodies and their parts. Since phenomenological philosophers in the process of their explorations of lived experience and the life world of human beings have already developed various types of ethical arguments, phenomenological bioethics could, indeed, turn to these philosophers and make use of their moral reflections more or less directly in bioethics (Drummond and Embree 2002; Sanders and Wisnewski 2012). Since we find many different types of ethical analyses in the works of phenomenologists, the choices would then come down to whom, among the master phenomenologists, to follow. Such phenomenological heritages are already at work to some extent in fields such as caring ethics, feminist ethics, and narrative ethics.

As mentioned above, in addition to these heritages, phenomenology has entered bioethics via the philosophy of medicine and medical humanities in studies of such themes as illness, empathy, and medical technology. What follows will provide an overview of how the points of connection between phenomenology and bioethics should be considered. My main concern is the question of what it may mean to do bioethics in a phenomenological manner, and the aim is to offer a structure that can encompass many different understandings of phenomenological bioethics by offering a generous interpretation of both concepts. Phenomenology will be considered to be a tradition that is related to existentialism, hermeneutics, and post-structuralism, and such neighbouring schools will be included in my overview at certain points. The ways in which phenomenological bioethics is related to older traditions that have influenced phenomenology as well as bioethics will also be taken into account to some extent, mainly in the case of Kantian ethics and Aristotelian virtue ethics.

Different understandings of phenomenology in medicine and health care

Proceeding from the way the term phenomenology has been used in studies in and of medicine and health care, at least three different understandings of the concept might be discerned. These three, more or less established, understandings of phenomenology are helpful in drawing a map of phenomenological bioethics.

The first, and probably most dominant, understanding of phenomenology in medicine concerns giving adequate and detailed descriptions of experiences and situations of importance. A doctor may speak about ‘the phenomenology of a case’, for instance. This is certainly a correct and important understanding of phenomenology, but as has become obvious already from the brief overview above, it is insufficient for grasping the full meaning of the concept. The second understanding of phenomenology, less well known in medicine, is that phenomenology is a research programme in philosophy starting out with Husserl in the early twentieth century and including not only philosophers such as Heidegger, Merleau-Ponty, and Sartre, but also names such as Max Scheler, Edith Stein, Hans-Georg Gadamer, Karl Jaspers, Hans Jonas, Paul Ricoeur, Charles Taylor, Emmanuel Levinas, Hannah Arendt, Michel Foucault, Jacques Derrida, Jean-Luc Nancy, and many others. According to such an understanding, phenomenology is not only a descriptive but also a theoretical and conceptual endeavour. The third understanding of phenomenology common to studies in and of medicine and health care is phenomenology in the sense of a qualitative research method – a method inspired by the philosophical tradition of phenomenology in which the researcher aims to give voice in an unbiased way to the experiences of research subjects. The phenomenological method can be applied in gathering and analysing empirical materials consisting of interview transcripts, video recordings, field notes, diaries, and so on. This is a common understanding of phenomenology in nursing research and other fields of empirical health-care studies.

The three understandings of phenomenology obviously have much in common, and they support each other in offering a more complete account of what phenomenology is about in medicine and health...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgments
• 1 Phenomenological bioethics
• 2 The suffering person
• 3 The body uncanny
• 4 Empathy and the hermeneutics of medicine
• 5 Medical technologies and the life world
• 6 The beginning of life
• 7 Surviving death
• References
• Index