Review: K. Aho, Existential medicine

Helene Scott-Fordsmand

pp. 2

In contemporary debates in philosophy of medicine medical humanities are gaining ground in a discipline that was for many years dominated by bioethics. Phenomenology, with its focus on human experience, and a long history of interest in illness as boundary cases of human existence, turns up as a tradition with a lot to offer in this context. In their introduction to the Edinburgh Companion in Critical Medical Humanities Whitehead & Woods thus mention phenomenology as one of two key traditions within what can be called second wave medical humanities (Whitehead & Woods 2016, 11). In this spirit, the collection of essays in Kevin Aho’s inspiring publication is an invitation to join the exploration of phenomenology and existential medicine and find new potentials for philosophy of medicine within these traditions.

Existential Medicine is a well-balanced but also composite collection of essays, a rhizome of Heidegger-medicine-hybrids that cover a remarkable amount of ground within the medical sphere. We join the many skilful thinkers who have contributed to the volume in an exploration of the possibilities for phenomenology—and particularly Heideggerian thought—to contribute in manifold ways and in a variety of debates within philosophy of medicine. Readers should not expect the book to give them a clear and stringent definition of the field, nor a coherent “existential view” to use in opposition to other approaches in philosophy of medicine. The individual essays do of course present clear positions and proposals, but as a collection, they invite scholars to explore, broaden and discuss the concepts and methods offered by the phenomenological and existential tradition in light of the revived interest in meaningful lives and human relations.

To set the scene for the exploration, Aho introduces the collection of essays with a brief outline of key concepts in phenomenology that make it particularly relevant for medical debates: embodiment, space and time, affectivity and existence as hermeneutic. Given this introduction it is clear that the ambition of the book is not just to speak within phenomenological circles, but rather the book reaches out to novices in the existential/phenomenological tradition. However, even if the book may aim at the community of philosophers within medical humanities or philosophy of medicine, who have yet to learn the insights and wonders of phenomenology, it has something to offer to a wide range of people, Heidegger scholars included. As a sign of quality in interdisciplinary work, anyone working somewhere in-between the fields of phenomenology and medicine will find valuable insights within the pages of this book, from practising doctors in need of a little food for thought, to experienced phenomenology scholars looking for new perspectives.

The main character in the book is (of course) Heidegger. A key inspiration for taking the subject of medicine up in a Heidegger publishing series is the Zollikon seminars (Heidegger 2001)– a row of seminars held between 1959-1969 on an invitation from Medard Boss. The invitation was motivated by an aspiration to think about medicine outside of the biomedical-technical regime which Boss thought was too dominant at the time, and Boss’ conviction that Heidegger’s work proved valuable for this task. Many of the contributors in the volume agree that it is still the case that medicine is dominated by biomedical-technological regimen, and hence that there is a continued relevance of Heidegger’s work.

The heavy emphasis on Heidegger can seem frustrating to a non-Heideggerian at first, particularly given that some of the key concepts outlined by Aho in the introduction are also well-established as Merleau-Pontian notions. However, the particular focus serves as a helpful unifying principle throughout the essays, whose subjects and approaches may seem otherwise to be philosophical worlds apart. The use of Heidegger thus lets us return to the same concept over the course of many essays.

Surprisingly only a few of the essays in Existential Medicine reference the Zollikon seminars, and if you are not already familiar with them, it remains vague throughout the book—perhaps with the exception of some remarks in Frederik Svenaeus’ and Carolyn Culbertson’s essays—what precisely the Zollikon seminars have to offer. Other of Heidegger’s works and many of his well-known concepts, however, feature prominently in the essays as harbouring important notions for philosophy of medicine. Among these, his works Being and Time (Heidegger 1993) and The question concerning technology (Heidegger 1977) are particularly noteworthy, with notions such as being-towards-death, anxiety, being-with(-others), the they (das Man), and being-at-home recurring in several essays and forming a connecting thread throughout the book. Further, other philosophers from the phenomenological and existential tradition such as Maurice Merleau-Ponty and Hans-Georg Gadamer play a central role in many of the discussions, and a whole range of philosophers, theoreticians, and writers such as Husserl, Binswanger, Sartre, Foucault, Freud, and many more are drawn on in the varying topics treated throughout the book. This multiplicity of voices serves to highlight the ambition of the book to explore the many potentials offered by the phenomenological and existential tradition, rather than merely applying Heideggerian thought to yet another field.

Rather than venture into the individual essays of the volume, I will attempt to give an impression of the content of the essay collection by drawing up some noteworthy or common themes worked upon in the book. Not every essay touches directly upon either one of these themes, and many of them include more themes than I will be able to mention here. I have chosen to focus on three trajectories that seem to be of general importance to the area of existential medicine and the crossing of Heideggerian thought and medical practice. First, existential medicine has an important task in its critical engagement with the biomedical model of healthcare and the relation between lived human life and medical science. Second, existential medicine can tell us something about suffering, relief, health, and the role of authenticity in illness. Interestingly, this is treated mainly through issues of sociality in many of the essays. And third, existential medicine can help us understand the relation between possibilities in biotechnological development and the limits of being human.

Human Life ⇋ Medical Science

One of the strong motivations for the growing interest in existential medicine, and medical humanities in general, is a growing awareness of a dissatisfaction with the biomedical model of healthcare. The ultimate promise of biomedical discovery explaining all diseases through the genomics project did not succeed, and suffering is still abundant. Introducing her essay “Losing the Measure of Health”, Culbertson writes of this dissatisfaction as an ironic clash between the amount of success-stories of modern medicine, and the ever more common criticisms and complaints as well as the estranging effects of modern healthcare systems (179).

A strong conviction in medical humanities is that medicine and medical practice has lost something by focusing on generalisable results and universal diagnostic manuals and treatments. This critique of modern medicine is specifically thematised by both Svenaeus and Culbertson in their essays on medicine as a techno-science, i.e. as taken over by technology in ways that Heidegger warned about in The question concerning technology, and later applied to medicine in the Zollikon seminars. In “Heidegger’s Philosophy of Technology and the Perils of Medicalization” Svenaeus develops this critique through Gadamer and quotes from The enigma of health:

“In medical science we encounter the dissolution of personhood when the patient is objectified in terms of a mere multiplicity of data. […] the question is nevertheless whether the unique value of the individual (Eigenwert) is properly recognized in this process” (Svenaeus’ modified translation of Gadamer 1996). (133)

The proposal in medical humanities is for medical personal to turn towards and learn from the humanities as a “science of the particular” (a term I borrow, though slightly modified, from Carlo Ginzburg (Ginzburg & Davin 1980)). Something similar is claimed in existential medicine, where it is held that a turn of awareness towards existential elements of life will re-individualise patients. This idea is expressed throughout the essays in Existential Medicine as a strong reservation toward the reductionist character of modern biomedicine, and the assumption that health is a matter of physiological restauration.

Biomedical Reductionism

Various essays thematise the biomedical model in various ways. In line with ideas from medical humanities Svenaeus distinguishes existential medicine from biomedicine by assigning illness experience to the phenomenological or existential realm, that is, subjective experience, as something the biomedical sense of disease cannot inspect or measure (139). Tina Williams & Havi Carel use the term phenomenological exploration in their essay “Breathlessness” (156) as something similar to Svenaeus’ description of the role of phenomenology (as focused on illness experience) to emphasise phenomenology as a hidden resource for medicine, and criticise the lack of attention paid to this element of illness. They argue that the narrowed vision of biomedicine does not only speak against “medicine’s stated commitment to patient-centred care” (157), but also often result in injustices committed against the patient. In “Emotional Disturbance, Trauma, and Authenticity” Robert D. Stolorow criticises the decontextualization of human existence in modern medicine. Particularly in diagnostic manuals, and—referring to Wittgenstein’s notion of family resemblance—argues that the DSM-system reduces complex existential alterations for the individual to non-substantiated essences of pathology (19) (Svenaeus makes a similar remark when discussing the implicit technologisation in diagnostic manuals (144)). Kristin Zeiler, likewise—in her essay “On the Autós of Autonomous Decision Making”, on parental kidney donation—talks of issues around reductionism and decontextualization in the medical idea of autonomy, as a concept based on disembodied subjects who make rational choices expressed in forms of informed consent (97). Drew Leder briefly touches the subject in “What is it to ‘Age Well’?”, in terms of reducing successful aging to an absence of biological change (or at least a minimisation of change) (224). And John Russon & Kirsten Jacobson argue in “Existential Medicine and the Intersubjective Body” that biomedicine overlooks some of the most important issues in treatment of IBD (inflammatory bowel diseases) and HIV. Biomedicine is blind to the element of stigma that is part of living with these diseases, and which entails a range of existential issues. They argue this to the extent where they even seem to be suggesting that biomedical treatment is of lesser importance (identifying existential issues as “the real problem” in HIV and IBD (201)).

By turning critically towards biomedicine, the idea in existential medicine is not (at least in most cases) that medicine as biomedical science should be stopped. In fact—as Aho states in the introduction of the book—one compelling aspects of approaching medicine through Heidegger is that he acknowledges that medical science (i.e. biomedicine) is important, but simultaneously works to problematise assumptions and aspects of medicine as science. Rather than to do away with the scientific aspects of medicine, the idea is, writes Svenaeus, that the techno-scientific side of medicine – often exemplified in biomedical sciences – recognises its limitations, and does not become the dictating force within the discipline (136).

Psyche / Soma

Another related reservation evident throughout the essays, is toward the reified body conception in modern medicine as well as the dualistic subject-object divide—or rather, the psyche / soma—that underpins it. This is not the existential view of the body, as is made clear by Aho in his introduction of the notion of embodiment. Existential medicine does not mean psychiatry, its role is not to care for the psyche while biomedicine cares for the soma. With roots in phenomenology, existential medicine involves the whole existence of a human, life, body, moods, and so on.

In the essays several authors use the well-known phenomenological notion of the body as an “I can” usually associated with the healthy body. Some refer to the Leib / Körper distinction as an approximation of the two views on the body in biomedicine and existential medicine respectively. However, two particular essays in the volume challenge the dualism more directly, namely Slatman and Williams & Carel. In “Reclaiming Embodiment in Medically Unexplained Physical Symptoms”, Slatman argues from the case of MUPS (medically unexplained physical symptoms, such as chronic fatigue) that some diseases cannot be dealt with if we do not find a way to un-rigify the concept of body in our medical language (102 and throughout). The body in cases of MUPS is neither a smoothly lived body, an “I can”, nor a reified biological apparatus, whereby attempts to give meaning to the symptoms fail insofar as there is no proper language. Williams & Carel argue from the case of breathlessness that there are some cases where we have no way of distinguishing physiological and psychological symptoms from each other, as for breathlessness in respiratory illnesses and in anxiety disorders. The two can work interchangeably, simultaneously, they can cause one another, and thus appear as inseparable (150 and throughout). Looking only at the physiological side to understand the symptom (biomedicine) is insufficient, but so is the attempt to divide the symptoms between differing specialities even if including non-biomedical views. Breathlessness is a suspension of conservative medical categories, forcing us to come to terms with a material productivity of cultural aspects in our lives as well as a cultural productivity of the material aspects (formulation taken from Kristeva, Moro, Ødemark et al. 2018).

These attempts to dissolve the distinction between psyche and soma touch upon an interesting meta-discussion: whether existential medicine and biomedicine are and should be thought of as separate elements that work on separate issues, or if not, how the two are connected or integrated. Insisting that the two are completely differentiable categories, seem strange given the acceptance of the concept of embodiment. Arguing that either existential health should be more important than biomedical health or vice versa, as some of the essays in the volume flirt with, seems to uphold a divide between body and self. If we are to take the notion of embodiment as well as the points made by Slatman and Williams & Carel seriously, neither meaning nor bodily function can take preference over the other. The issue at hand is to look for ways to understand the individual life of and meaning of this life for the patient (in order to properly recognise the Eigenwert of the patient), while finding ways to make both existential medicine and biomedicine co-contributors to human health.

Positively surprising after many essays that thematise the faults of modern biomedicine, Culbertson makes the interesting observation that despite all the faults and despite a strong inclination towards the biomedical model in research and education, this is not what goes on in medical practice (186). Doctors have to engage with patients, and even if there is a lot of room for improvement, we already (or still) see existential care being practised.

Anxiety, Sustainable Authenticity, and Sociality

Illness as the Cure

One basic phenomenological observation on the experience of becoming ill, is that the suffering is often connected to a disruption of habitual ways of living, and with that a break of trust in some or many elements of existence (our body, the world, the future, etc.) that would normally be a pre-reflective part of our life. In efforts to understand this break, scholars use the Heideggerian coupling between the mode of being according to the they (das Man)—i.e. a pre-reflectively dominated, normal life before illness—and anxiety as developed by Heidegger in Being and Time. Several of the essays in Existential Medicine engage with the relation between these notions. Anxiety is not—as obvious from its identification with illness—a desired mode of being. However, for Heidegger it gives us the possibility of authenticity, of freeing ourselves through having truly acknowledged our own finitude. In existential medicine then, authenticity – because of its link with a positive way out of illness – becomes linked with existential health.

Essays by Shaun Gallagher, Martin Kusch & Matthew Ratcliffe, Slatman, Williams & Carel, Russon & Jacobson, and Nicole Piemonte & Ramsey Eric Ramsey all touch upon illness as something that breaks with habitual living. Russon & Jacobson bring out authenticity through anxiety as a positive potential in becoming ill, as a moment for patients to “own up to the realities of their own lives” (201). Likewise, Williams & Carel talk about anxiety as an opportunity to reclaim existence as one’s own (154). In both cases, the inclination is that existential health is something that can be separated from or even opposed to physiological health, that is, the idea that serious illness can be seen as a potential to reclaim an authentic life, so that patients can get existentially better even in cases where there are no biomedical cures available.

In “Health Like a Broken Hammer or the Strange Wish to make Health disappear” Piemonte & Ramsey, rightly—I think—approach the somewhat romantic idea of illness as an existential cure for mediocracy from a more sceptical perspective. They write: “it may be the case that one is simply ‘not up for it.’ Illness—and the fatigue, nausea, pain, and weakness that can accompany it—is onerous, and adding to that the expectation that one ought to honestly confront my finitude and allow it to transform me can simply be too much” (213). In their essay (on existential notions of health) they critically investigate the heroic ideal of breaking with the “they-self” (the self embedded in the they) through serious illness to obtain solitary authenticity. They suggest that solitude in illness is not necessarily something to strive for, and the tale of “finding one-self” in hardship can itself, become a symbolic figure that bears resemblance of a they (an inauthentic role, lived by outer expectations more than self-determination) (214). Emphasising Heidegger’s remark that authenticity is not a break with, but a modification of the they (215), Piemonte & Ramsey show the centrality of a they rather than its inauthenticity, in interpreting, making decisions or even understanding the world which we are thrown into. They argue that (existential) health is not a matter of breaking with the they, or not, but a rebuilding of a more authentic belonging in a they, that is not only tied up in illness.

Mitsein, Existential Individualism and Second-Person Phenomenology

In recent years the notion of intersubjectivity and “we” has gained philosophical, or at least phenomenological, influence. Interestingly, despite the prior mentioned importance of re-individualising the patient, a re-occurring theme in the volume is the notion of intersubjectivity, the importance of relations, and the effects of illness on sociality. At times this even amounts to direct criticism of the individualistic traits discernible in the Heideggerian idea of becoming authentic through isolating anxiety (what Gallagher calls existential individualism (10)).

I his essay on inauthenticity, “The Cure for Existential Inauthenticity”, Gallagher notes that the Heideggerian notion of being-with (Mitsein) is underdeveloped. He therefore draws on Merleau-Ponty, Werner Marx, and a range of Heidegger scholars to develop a more full-fletched idea of Mitsein as a relational authenticity, obtainable through shared mortality (rather than solitary confrontation with death). In the subsequent essay Robert D. Stolorow talks about something similar, and calls it “our existential kinship-in-finitude” (24). He develops a notion of relational authenticity based on the idea of a relational home arising through shared “emotional dwelling” (23). In cases of trauma – for which he develops the concept – emotional dwelling means for one to lean into the other’s emotional pain and participate in it, thus, through the relation, helping the other to bear the weight of the trauma enough to find room and time for healing. In this way, Stolorow opens up the idea of sharing anxiety and becoming authentic through communality.

However, what is importantly different between relational authenticity as described by Gallagher and Stolorow, and the they as described earlier is that relational authenticity is bound up in a sharing between individuals recognised as such. The phenomenological we may contain many forms of relations, but the idea of the second person perspective seems to offer something of importance here, although not explicitly used in the volume. A “second person phenomenology” can tell us something about how we relate to others while keeping their individuality in mind. What risks becoming a solitary individualism—authenticity in illness as a confrontation of the I with its own finitude—finds a way through the second-person-relation towards authentic recognition of individuality in a relation, insofar as the you—the other-in-front-of-us—is always a specific you. As such, it seems that even if existentialism has a reputation for freedom through solitude, there is an interest within existential medicine in finding other, perhaps more sustainable ways of authenticity, and existential health.

Slatman also emphasises being-with as a fundamental concept in understanding illness. Turning to Jean-Luc Nancy she goes as far as to reject the individual as a point of origin for sense-making (although not rejecting the idea that medicine should be more sensitive to the sense-making around the individual patient). She builds upon the idea that any meaningful self-conception—and as such any form of authentic selfhood (Jemeinigkeit)—is derived from a fundamental être-avec (Mitsein) or being-together (108), and as such, a medicine that cares for the existence of the individual must care for the relations between individuals. Much the same is touched upon by Zeiler with the notion of “intercorporeality” (83), i.e. being bodies that engage and interact, our bodily selves as always co-constituted by others. Even if we support an idea of bodily autonomy among patients (or donors, as in Zeiler’s essay), it cannot be thought about in isolation from others.

Negative Social Dimensions

Other than relational authenticity and the problem of the they, some of the essays in the volume focus on social problems in illness. Russon & Jacobson argue from a Merleau-Pontian perspective that the body is that through which we come to relate to others, but also that through which others come to relate to us. Changes to our bodies (such as illness) are thus essentially changes in our relation to others (192). They then emphasis the consequences of stigma and problematic social values in relation to illness (much like Drew Leder does in his essay on aging), and argue that an important aspect of existential medicine is to work with changing social values around disease (202). In “The world of Chronic Pain” Kusch & Ratcliffe bring focus on the potential negative social synergy that can arise from the loss of future in cases of serious or all-consuming illness (such as chronic pain). This loss of future, and the loss of the usual trust in the world which follows from serious illness, does – according to them – not only lead to a change in relations, but to a loss of agency in relations, a “self-infantilization” that leaves the patient in an incapacitating downward spiral (65).

The volume thus offers several—at times disagreeing—perspectives on the ways of regaining (or obtaining) existential health, the relation between sociality and illness and the importance of this.

New Technologies and Being-Towards-Death

The relation between medicine and technology comes up in several essays. As already touched upon, it is specifically prominent in the criticism of medicine as techno-science. Beyond Svenaeus and Culbertson, who discuss the notion of technologisation, technology comes up in the form of biotechnology and related to ethical debates. Tara Kennedy developpes an intriguing Heideggerian theory of bioethics in order to evaluate new medical technologies in “Heideggerian Ethics and the Permissibility of Bio- and Nano-Medicine”. She bases her ethics proposal on the notion of dwelling, as an opposition to the technological enframing and drive to mastery. She importantly adds that it is not an anti-technology ethics (165): as with biomedicine, Heidegger was not against technology, but rather cautious with the modes of operation it brings about and its effects on humanity. The ethics of dwelling is an ethics of care, humility and openness towards disclosures of being. Although the theory—like many other ethical theories—turns out to be somewhat vague and ambiguous when applied to actual cases, it reveals something important about the techno-scientific approach to medicine, and also manages—I think—to deepen the understanding of some common intuitions around bioethics without turning to naturalism.

Biotechnology also comes up in Adam Buben’s essay “Heidegger, Curing Aging, and the Desirability of Immortality” on the promise of immortality. Here the Heideggerian notion of being-towards-death—that features in relation to anxiety throughout the volume—is a central phrase of discussion. Buben re-interprets the notion as unrelated to actual death but rather dependent on human temporality as restricted. He writes “one does not so much fear death as feel anxious in the face of one’s limited, but still significant, capacity for choice and action” (125). Thus, we should not fear immortality as a threat to our humanity, at least not for the sake of losing our being as being-towards-death.

As the notion of being-towards-death figures in many of the other essays in light of illness as something that makes actual death more acutely present, Buben’s reinterpretation is intriguing for its unspoken consequences for the common coupling between illness, being-towards-death and authenticity. Unfortunately, the volume does not allow the various essays to relate to each other. Although many authors reference each other’s prior work, there is no direct interaction between them. I am curious as to what consequences the Buben reading would have for Williams & Carel, for instance, and if these consequences are something that Buben will want to accept in order to stick to his proposal. Several other papers would have been intriguing to hear comment on each other, Kusch & Ratcliffe and Slatman for instance, or Leder and Svenaeus, and reactions and discussions between them will be something to look forward to.

Final Remarks

In my attempt to summarise some broader trajectories, I have neglected to mention the essays of Anthony Vincent Fernandez and Dylan Trigg. These are the two most abstract essays in the volume, and also the two that speak most directly to scholars already within the field. Fernandez’ essay, “Beyond the Ontological Difference”, gives a very thorough analysis of the misunderstanding of the ontological difference in Binswanger’s Daseinsanalysis, and the consequences this misconception still has in current phenomenological discussions of psychiatry. Trigg’s essay, “From Anxiety to Nostalgia”, treats the difference in temporality of anxiety and nostalgia, and despite that, their interconnectedness. These phenomena have some relevance in psychiatry, but the most interesting aspect—I think—of the analysis is its insights on human inclination towards conservativism in times of existential challenge, and the connection one can make—and in fact Trigg does make—to current western politics.

For the essay collection Aho has managed to curate a book that touches upon an impressive range of philosophical and medical fields. Particularly it is enjoyable that the collection has such a strong emphasis on illnesses that are typically considered somatic, thus succeeding in moving existential medicine beyond the psychiatric realm within which the use of philosophy—and particularly the use of existential philosophy—in medicine is sometimes stuck. The book is divided into four parts: (1) New currents in existential psychiatry, (2) Phenomenologies of anxiety, pain, and death, (3) Ethics, medicalization, and technology, and (4) Existential health. If you are reading the book for a specific purpose or with a particular focus, take care with staying too strictly within parts. Many of the essays might as well have been placed under different part-headings, with some of their key-points relating clearly to essays in other parts of the book. If you are on a tight timeline use the outline of the volume at the end of the introduction to select relevant essays rather than chose by title. Valuable insights, thoughts and dilemmas on a variety of topics and concepts, however, pop up here and there, so reading the entire volume is definitely recommendable.


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