Toward a Philosophy of Life to Underpin Personhood in Medicine

Toward a Philosophy of Life to Underpin Personhood in Medicine Osborne P Wiggins, Ph.D. Professor, Department of Philosophy University of Louisville Louisville, KY, USA Michael Alan Schwartz, M.D. Clinical Professor, Department of Psychiatry Texas A&M Health Science Center College of Medicine Regional Chair, Department of Psychiatry Texas A&M Health Science Center College of Medicine - Round Rock Chapter in: Kung Bong Koh (Ed): Somatization and Psychosomatic Symptoms Springer, 2013 ISBN: 978-1-4614-7118-9 (Print) 978-1-4614-7119-6 (Online) 2.1. Introduction 2. 1.1. Modern Heritage and the Puzzle about Persons in Medical Practice Hans Jonas has broken new ground in the history of Gnosticism [1] and modernity [2], medical ethics [3], and philosophical biology [4]. He has been embraced by people on the political left and others on the political right. Our presentation draws on his interpretation of modernity and his attempt in his philosophical biology to provide a new path out of some of the dead-ends of modernity. As Jonas knew, these concerns have a direct bearing on how we think about medicine. Modern medicine has enjoyed much success by drawing on those sciences which study the most elementary components of living beings, namely, the sciences of physics, chemistry, genetics, and others. There can be no doubt that these basic sciences do and will play large roles in helping to explain and treat diseases and injuries of various kinds. However, such sciences fall far short in providing for medical practitioners, especially clinicians, a conception of the patient as a living human self that is needed for the practical purposes of healthcare. 2.1.2. Approaches to this Puzzle In its approach this chapter is divided into two main sections: historical background and conditions for life. The two sections are continuous with one another by drawing on the philosophy of living beings developed by Hans Jonas. In historical background , we shall briefly sketch the history of modern conceptions of human life which lead to our present-day puzzlement. This sketch will lead to the recognition of the mind/body problem as the persistent intellectual framework from which we still have not succeeded in escaping. As the new sciences of nature emerged in the 17th and 18th centuries, a philosophical framework for trying to unify the ever-expanding multiplicity of theories and concepts took shape. This framework consisted in a hierarchy of the sciences, each higher level science being theoretically dependent upon the concepts and laws of sciences of the lower levels. This hierarchy of the sciences, however, gave rise to an attempt to simplify them all by proposing an all-encompassing naturalism, the philosophy that all the sciences would (and must) someday be reduced to physics. Reductionistic naturalism has never proven to fully satisfy the modern mind, however; and consequently the mind/body dualism persisted to thwart attempts to see living beings – human beings in particular – as unified wholes. Present-day efforts in medicine to make overall sense of the patient as a person thus encounters road blocks. 2.2. Historical Background 2.2.1.The Modern Hierarchy of the Sciences and Reductionism By placing its confidence in the ability of the physics, chemistry, and other such fundamental sciences to furnish its conceptual base, medicine adheres to an understanding of the relations among the sciences that is at least a century and a half old. In the middle of the 19th century Auguste Comte was the first thinker to explicitly set forth an ordering of the sciences into a hierarchy that is tacitly taken for granted today [5]. According to this hierarchy mathematics is the most fundamental of the sciences. It is the most fundamental because it articulates the formal relations of the elements of any science whatsoever. Founded on mathematics and logically presupposing it is physics. Based on physics and presupposing it is chemistry. Based on chemistry and logically rooted in it is biology. Founded on all of these natural sciences are the social sciences, such as psychology and sociology. The social differ from the natural sciences because the social sciences fall into no particular rank ordering among themselves; logically and conceptually they seem to reside on the same level. Comte claimed that this hierarchy followed two principles: (1) a science was more basic if it was more comprehensive or more inclusive; and (2) a science was more basic if its components were simpler. Hence, to illustrate the first principle, physics was more comprehensive than chemistry because all chemical realities are physical, but not all physical realities are chemical. And, to illustrate the second principle, the constituents of physical realities that physics studies are simpler in their make-up than are the constituents of chemical realities; the elements of chemistry include elements of physics plus something more, something that renders them distinctively chemical. This conception of the hierarchical dependencies among the sciences continues to dominate our thinking to the present day. Because the hierarchy entails that the higher level sciences are conceptually based on the lower level ones, repeated attempts have been made to simplify the overall picture of the universe by showing how the higher level sciences can be reduced to the lower level ones. Now ‘reductionism’ in the sciences can be understood in different senses. The way in which we understand it here is that a higher level science is reduced to a lower level one if the higher level science can be logically derived from the concepts and laws of the science just below it. Ideally such a reductionism implies that all the concepts and laws of all the sciences should be reducible to the concepts and laws of mathematical physics. A less stringent notion of reductionism is very prominent today. It is called ‘naturalism.’ It stipulates that any entity that is not physical, chemical, or biological will ultimately be logically explainable in terms of these natural sciences. In other words, all realities that are not yet considered natural realities will be in the future fully explained by the natural sciences. In other words, the natural sciences will ultimately provide the concepts and laws that explain the whole of reality, even those parts that are now studied by the social sciences and humanities. Moreover, it is incumbent on scientists at work today to search for possible reductionistic connections. For example, neuroscience is today thought to hold out the hope for a reduction of mental processes of all sorts to brain structures and processes, a reduction that would ideally eliminate all need to even use the terms ‘mental’ or ‘psychological.’ Much of the resistance to such a reductionism arises from the fact that thinkers in the social sciences and humanities persist in talking about realities and events that seem to be irreducible. For social sciences to speak of mental processes such as ideas, emotions, purposes, or moods is for them to use a terminology not derived from the natural sciences. Modern-day naturalism has a response to such an ‘unscientific’ way of speaking. Talk about mental events of all sorts is thought by naturalists to be merely a holdover from ‘folk psychology.’ Folk psychology is simply a pre-scientific, common-sensical way of speaking. As genuine science develops, it will progressively eliminate the need to resort to such non-scientific terms, and in their place we can refer to events and structures in the brain. In other words, the vocabulary of neuroscience will entirely replace the words of everyday speech, ‘folk psychological’ words. 2.2.2. The Mathematization of Nature and Mind/Body Dualism The depositing of all words and concepts of mental events into the despised category of ‘folk psychology’ illustrates merely the most recent case of having to find some separate sphere for mind. Since we cannot avoid referring constantly to mental processes, we seek to circumvent our dependence on them by drawing strict lines of demarcation between mental events and ‘true reality,’ i.e., natural reality. We are historically familiar with these determined attempts at strict separation through our troubled heritage of ‘the mind/body problem.’ From the moment Descartes sought to define the external world as res extensa, he had to admit that it bore little resemblance to that other, equally real ‘reality,’ res cogitans [6]. Thus began the dualism of the two metaphysically different realms, physical body and non-physical mind. And, according to some philosophers of the 17th and 18th centuries, not only were the physical and the mental fundamentally different, they were completely separate in their operations and laws. For these thinkers, mind did not determine matter, and matter did not determine mind. On the other hand, some writers sought to locate a point of mutual interaction – Descartes’ ‘pineal gland’ being the most well-known – while still others recognized the hopelessness of the attempt. Descartes also defined the model of pure nature that the new science of nature would study. By defining the metaphysical basis of the physical realm as res extensa, Descartes strips it of all properties except its mathematizable ones. Res extensa means ‘extended thing’ or ‘extended substance.’ By categorizing physical matter as exclusively extended, Descartes defines it as possessing solely geometrical properties. No other properties belong to it. The mathematization of reality had at first to take the form of geometrization because analytical geometry was the most advanced mathematics of Descartes’ time. In other words, what Descartes was saying was that true nature possesses solely mathematical properties. The laws of nature must then be formulatable as algebraic equations and geometrical figures. This set the program for future natural science; one can arrive at the ultimate truth about nature when one can conceptualize its movements and constituents with mathematical formulae alone. All other properties of nature were abstractly disregarded. What happens to these abstractly discarded properties? Do they simply vanish? No, they stubbornly remain in some form that has now, with the abstraction, been rendered mysterious. But at this juncture the usefulness of positing a separate domain of res cogitans becomes clear; everything that was excluded from the sphere of nature can be conveniently deposited in the sphere of mind. Let us cite just two examples of the abstractions that were necessary to constitute the domain of ‘pure matter,’ i.e., matter stripped of all properties except mathematical ones. Our first example of disregarded features is teleology and, with the exclusion of goal-directed behavior, the discarding of teleological explanations. All changes in nature, including alterations in biological organisms, must be explained as the results of antecedent causal conditions. Already Francis Bacon had branded teleological explanations as anthropomorphic fallacies: human investigators were all-too-prone to understand natural events in terms of the human mind. To avoid this, scientists must carefully check this human weakness in themselves and systematically refrain from seeing goal-directed behavior in things. The appearance of teleology was an anthropomorphic illusion [7]. Our other example is the abstraction that systematically disregards values and norms. The fact/value distinction was firmly in place at least by the time of David Hume (1711-1776). Science was ‘empirical’ only to the extent that it studied a nature of pure facts [8]. At this stage, the time of the European Enlightenment, values were not banished; they were simply confined to other disciplines such as moral or political philosophy. The usefulness of this modern dualism cannot be overestimated for the early development of the natural sciences. It allowed these natural scientists to abstract from everything mental, social, political, economic, and religious and to attend exclusively to what remained, matter and the physical forces that determined it. Moreover, natural scientists could apply various idealizations to this matter if applied to the mind and its workings. The most obvious example here is the idealization of strict causal determination. If we assert that the changes in matter are strictly determined by antecedent causal events, we can proceed to seek out these prior events and their law-governed relations to the ensuing changes. However, if we apply this idealization to the investigation of mental changes, we implicitly – if not explicitly -- deny any freedom to the will. If, on the other hand, we conceive of the will as a faculty of the mind alone, then our dualism of mind and matter allows us to place free will in the mental realm and strict causal determinism in the physical. Human thinkers seem, however, to remain unhappy with dualistic systems which so sharply divide reality into metaphysically different spheres. The thinking intellect appears to long for a monism, a single unified system into which all of reality can at least potentially fit. And therefore as dissatisfactions grew more troubling in the early modern period, monisms were proposed: idealism, the monism of mind; and materialism, the monism of matter. But a monism satisfies finally only if it can absorb the other reality into itself. So idealism must explain our persistent experiences of matter as somehow ultimately a mental reality itself. And similarly, materialism works only if it can successfully account for the persistence of our own subjective experiences with purely physical concepts. Each, of course, has proven itself unable to prevail over the other. But it should be remembered that there are versions of ‘naturalism’ prominent today which still strenuously aspire to a monism and seek to account for our subjective experiences as somehow or other merely natural processes in the brain. 2.2.3. Darwinism and the Need to Rethink Life In the middle of the 19th century, Darwin’s theory of evolution disturbed the peace that metaphysical dualism had sought to establish [9, 10]. The Darwinian approach explained the human mind as having evolved through the same regular processes of chance mutation and natural selection that had produced all other living beings. Hence the human mind was incorporated back into the physical domain, and as a consequence the mind required no other explanation than that which natural science could now offer. Natural science was thereby seen as universal: all of reality could be understood in the same basic scientific terms and laws [4]. This universalizing of scientific conceptualization seemed to betoken the victory of metaphysical materialism. If all of reality could be explained by science, then all of reality could ultimately be explained in terms of the most basic constituents that science had uncovered, namely, inorganic matter. Hence we need not speak of ‘mind,’ ‘spirit,’ or ‘soul’ anymore except to demonstrate how even these phenomena could be accounted for fully by a law-governed physical causality. Such a metaphysical materialism, if it could be developed, would signal the victory of what Gabriel Marcel has called ‘the spirit of abstraction’ and what Alfred North Whitehead labeled ‘the fallacy of misplaced concreteness’[11-13]. The ‘spirit of abstraction’ consists in mistaking parts of reality that have been intellectually separated out from other parts of the same reality and treating the abstract parts as actually existing as separate from the other parts. The fallacy of misplaced concreteness goes one step further and seeks to explain all the other parts of reality as produced or caused by this privileged part. The intellectually abstracted part is thus treated as the most ‘concrete’ dimension of reality from which the other dimensions are derived. In metaphysical materialism this is precisely what has happened; the part of reality which is inorganic, purely physical matter, the part studied by physics, has been intellectually abstracted from the other parts of reality and deemed the primary, fundamental, or basic part. Hans Jonas’ approach opposes such a privileging of one part of reality and deeming it the most ‘concrete’ or formative part. Indeed, he opposes all forms of reductionism. And he does this precisely by interpreting the Darwinian breakthrough in a different way. If, in this post-Darwinian age, we must now account for everything living and non-living in a unified system of thought, then we should be able to draw on everything we know about the living and non-living in our account of reality. In other words, the Darwinian victory re-incorporates into our understanding of living beings the entire human realm which materialism had excluded, and it does so with the demand that we now see the living world as a unified whole. Hence we seem to be called on to develop a theory of this unitary whole which is life in both its mental and physical dimensions. Still it seems we cannot heed this call. We cannot because we in the West have inherited a centuries-long understanding of life that is dualistic, and this heritage is not easily discarded. Just as in the past the unacceptability of dualism has led merely to the reduction of one side to the other, to either materialism or idealism, so today the most popular attempt to construct a monism is naturalism which is nothing other than materialism in a new guise. This leaves the reality of life, most obviously human life, inconceivable except by reducing it to one monism or the other. And it is human life, in illness and health, which centrally concerns medicine. What medicine needs is a non-dualistic, a post-dualistic, theory of life. Hence the question arises of how to develop such a theory. Obviously we must fully appreciate what the separate sciences have taught us, but we should view them all, the natural sciences, the social sciences, and the humanities, as equally important contributions to the general theory. And yet it is the sprawling multiplicity of these disciplines that must be overcome. Overcoming it will require overcoming the one-sidedness and exclusivity that limits each. What should be the starting point of our inclusive, unified philosophy of life? Beyond abstract theories, an indispensable beginning for the development of a non-dualistic philosophy of life can be found in the directly and constantly felt reality of being alive in ourselves. This determines our starting point because here we can claim privileged access: since we are living beings ourselves, we know what it means to be alive from our own first-hand experience. Every moment of our lives we directly experience life, life in ourselves and in others. Our most intimate experience of life is in our own individual lives. But this constant experience of our own being-alive makes it possible for us to make sense of the being-alive of other people and, to some extent, of animals. We move beyond abstract theories here because we cannot imagine a datum more concrete than the experience of ourselves in our constant living reality. Direct reflection on this experience reveals to us the basis of any other experience of life. And such a concrete given is certainly more basic than any of our theorizing about life [14]. Quite independently of Jonas, the zoologist Adolf Portmann has put forward the same idea. In order to develop a non-reductionistic view of all forms of life, Portmann writes, “…we must, then, also emphasize – more than what is usually done –what we owe to the knowledge of our own inner life for the understanding of all animal existence. There is also a continuous stream of interpretation flowing from our own experience into our biological work with animals, a stream that can only come from that special wellspring of our own experience. This subjectivity should not be perfunctorily deemed suspect for being all too human, but, rather, should be made use of in a meaningful way. The vision of life looking down from above, from the point of view of the human being is a necessary complement to the attempt at building from beneath, to proceeding from the simplest forms” [15, p6]. Hence we should be able to start from both sides -- from the side of what science can tell us about inorganic, organic, psychological, and social realities and from the side of our own direct experience of life in ourselves and in others – and show how these realities meet in the living being. If dualism is to be discarded, then we must strive for a unified understanding of life, an understanding that fully appreciates both the natural processes of the organism and the inward-felt experiences of being-alive. Hence, aiming at their intersection, we shall reason from both directions. We do this in the confidence that life is ultimately one reality, however complex. Human beings are psychosomatic wholes, and therefore a theory that reintegrates psyche with soma can be developed as long as no component of the whole is short-changed. We shall search for features that characterize life as such, whether ‘objective’ or ‘subjective.’ These features of living beings in general emerge, in our view, as conditions for being alive. If the organism ceases to meet the conditions we shall outline, it will cease to live. Hence they might be called ‘necessary conditions of life.’ We shall now, drawing on Jonas, attempt to describe some of these vital conditions [4,11]. 2.3. Conditions for Life In this second part of the chapter, we employ the method sketched just above and seek to lay out conditions for being alive that are found in both the mental and the more physical dimensions of life. These conditions are the following: (1) the necessity for living individuals to constantly act in order to sustain their ongoing existence; (2) the separateness of the individual living being from its environment while at the same time maintaining an openness to the environment and engaging in transactions with it; (3) the necessity for the organism to undego constant change while always making a sameness of self throughout this change; (4) the directedness of the organism’s activity toward its own future being, hence the teleological orientation of organic processes; (5) the origin of feelings in higher life forms. These five conditions of life can serve as a framework within a unified conception of the person which for the purposes of medicine includes both the more physical and the more mental dimensions of patients. 2.3.1. The Need for Self-Preservation The existence of every living being is sustained through metabolism. Unlike inorganic matter, the very being of a living entity is contingent upon its own ceaseless activity. As a result the existence of the organism from moment to moment is its own dynamic achievement. Inorganic matter need not actively do anything in order to endure as the being it is, but organisms must. This inescapable need to persistently bring about their own continuation through their own metabolic functioning proves that organisms are threatened beings: if they do not actively achieve and repeatedly re-achieve their own reality, they die. Ceaselessly dependent on their own functioning for their survival, organisms hang suspended over the abyss of non-being. Hence we can acknowledge one of the conditions that necessarily define life: always threatened by non-being the organism must constantly re-assert its being through its own activity [2, 4]. 2.3.2. Enclosed within the Self and Open to the World This activity, however, must be an organized activity. Metabolic processes are structured processes, and it is this very structure of the processes of the organism that must be maintained as such. When the structure fails to determine the direction of the processes, the organism dies. Accordingly, the identity of the organism depends on the maintenance of its internal structure. We might even say that the identity of the organism is the identity of the structure. This becomes even more obvious when we note that the components that constitute the organism are constantly changing. The material components of the organism come and go, but it is important that the organism remains as the same one. To ‘remain as the same one’ is to maintain the same structure even in the midst of constant change of components. In order to maintain this constant change of its components, however, the organism must to some extent be open to its environment, the ultimate source of the components. We are now in a position to appreciate another one of the distinctive conditions of being alive. Living beings are both enclosed within themselves, defined by the boundaries that separate them from their environment, while they are also ceaselessly reaching out to their environment and engaging in transactions with it. This vital feature is found even in the single cell [2], and it continues in different forms all the way up to social institutions. On the one hand, the cell membrane determines the cell’s boundaries: the reality of the cell extends no farther than this membrane. And indeed these boundaries must be maintained if the cell is to continue to be. Hence the membrane must maintain the separation of the cell from the rest of reality. Death consists in the loss of this separation. This need to remain bounded and distinct from that which is outside is observed at all levels of life. From the single cell, through the different organs of animal bodies, to the level of human beings as whole persons, ‘self’ and ‘other’ are definitely distinguished. This distinction between self and other is demonstrated most clearly, of course, in the immune system. The immune system is geared to detect what is non-self; and once this detection of otherness occurs, the immune system actively opposes the invader. On the other hand, the membrane is semi-permeable so that the cell may continually exchange its material with realities outside of it. Literally through its membrane the cell metabolically carries on transactions with that which is not itself. Indeed this transaction with other entities is necessary if the cell is to maintain its existence; the cell is physically dependent upon the outside for its continuation in being. This dependency on what is not itself in order to survive evinces the organism’s neediness; lacking self-sufficiency, the living being must of necessity acquire the means for its existence from its environment. However, this unavoidable exposure to the environment, born out of need, manifests again the riskiness of organic existence. The environment can prove harmful and even deadly. The alien and uncontrollable nature of the environment poses an additional threat to the already precarious venture that is organic life. Hence the cell is enclosed within its own boundaries in order to maintain its separate and autonomous being while it is also open, constantly engaging in transactions with outside realities and indeed even exchanging its own matter with them. 2.3.3. Change and Sameness Through the metabolic exchange of material components the cell undergoes ceaseless change in its physiochemical make-up. But this change is, as we have seen, an organized change: it is determined by the internal structure of the cell. Through the change, then, the cell maintains its own separate identity while it also changes the physicochemical parts that compose it. It is both in flux and stable. Maintaining its stable identity through constant turnover in its material constituents, the being of the organism is both independent of and dependent on these constituents. Some material constituents are always necessary for the existence of the organism; hence the dependence of the organism. But since these constituents will eventually be exchanged for others as the organism continues to live, the organism is independent of precisely these constituents, i.e., of whichever constituents compose it at any given time. We can therefore recognize one of the other conditions of life in organisms; they are both dependent on the material components that constitute them at any given moment and independent of any particular groupings of these components across time. These conditions of dependence and independence always define organic existence [2]. 2.3.4. The Organism’s Teleology and the Basis for Value As we have said, the metabolic activity of the organism is geared toward sustaining the existence of the organism. This being geared toward the sustaining of its own being shows that the metabolism of the organism is ‘for the sake of’ its own continuation in being. The being that the transactions are geared toward preserving is the organism’s future being. The metabolic functioning is for the sake of bridging the temporal gap that separates the organism in the present from its own existence in the future. In slightly different terms, metabolic activity serves the temporal enduring of the organism. Hence it is temporal duration that poses the main threat to the organism’s contingent existence; the question of whether the organism will endure from moment to moment remains unanswered until the future becomes the present and the organism still lives. And the threat can be defeated only if the activity of metabolism is sustained. Life is thus teleological: the present activity of the living being aims at its own future being [10,16]. If we can speak of the metabolic transactions of the organism as occurring ‘for the sake of’ the organism’s future being, this means that at some fundamental level the organism posits its own continuation in reality as ‘good.’ In other words, the organism posits its own existence as having a positive value. Value is thus built into the reality of being alive; it is organic life itself that places value there. It is not human beings and certainly not human agency that introduces value into an otherwise value-free universe. Living beings themselves, by striving to preserve themselves, already signal that, at least for the being involved, its own life is good [3, 4,17]. We can see, then, that the values that motivate medical practice are grounded in organic life itself. While only human beings can develop and practice medicine, it is not human beings who introduce into the world the values that call for and justify it. The same would be true for suffering and pain, at least for those organisms that can feel. Felt suffering and pain are posited by the organism feeling them as bad. Hence the moral need to relieve and even eradicate pain through medical treatment arises at the most basic levels of life, even if only human beings can recognize this value as a moral requirement and develop the medical techniques to respond to it [3,4]. 2.3.5. The Origin of Feeling in Higher Life Forms Since we have mentioned feeling, we would like to conclude by indicating its importance for any philosophy of life. Although it is difficult to pinpoint the precise level, at some level of life the organism’s relationship with the world becomes a relationship of feeling; many organisms are sensitive to elements in their environments. Again this applies to individual cells as well as to conglomerates of cells and whole organisms. Sensitivity is the first glimmering of subjectivity in organisms, if we may apply the word ‘subjectivity’ to even the most primitive and elemental kinds of feeling. Moreover, as we move up the living kingdom to more and more complex organisms, sensitivity too becomes more complex, and at a certain point we can speak of organisms perceiving items composing the environment. It would, of course, be difficult to mark the progressive difference between an elemental sensitivity to the outside and an actual perception of it, for any form of felt sensitivity may already count as an experience, at least of a very basic sort. Our point here is, however, that the first glimmerings of subjectivity arise relatively early in the phylogenetic scale. And once subjectivity appears, it grows in complexity, refinement, and acuity. ‘Mind,’ then, is certainly not the exclusive privilege of human beings. It is not even the exclusive possession of the higher animals. Mental life begins where sensitivity to the outside is felt [3]. This birth of subjectivity marks another aspect of the selfhood of living beings. For as subjectivity grows and becomes more complex, the organism is able to sense its environment across spatial distances and to feel a desire for things across time. If we add to this subjectivity the movement of the organism’s body, then the living being can move across the spatial distances and pursue objects as long as desires for them are felt. With growing experience and motility, then, living beings confront a world that grows in its spatial extent and its temporal duration. Mind renders organic world-relatedness richer and more encompassing, even if this larger exposure to the outside also expands the realm from which threats to life can emerge [3]. 2.4. Conclusions Medicine’s laudable attempt to orient its activities toward the patient as a person encounters the problem that confounds all such attempts in the modern era; the centuries-long persistence of mind/body dualism renders it extremely difficult to conceive of persons as integral wholes. Obviously if such a re-conceiving of patients is to serve medicine, it must incorporate what we know from present-day biology and other natural sciences as well as what we know about persons as psychological and spiritual beings. The way we have suggested for incorporating the two facets is to reason from both points of view at once and to thereby uncover conditions for life found in each. 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