From tech moguls like Bryan Johnson chasing immortality with potions and pills to overreliance on antidepressants, we often see healthcare as simply about finding the right drug – but this is a mistake. While these treatments have their place, philosopher Ian James Kidd argues we’re too quick to reach for invasive scans and prescriptions, which can do more harm than good. In our rush to diagnose, we’ve reduced health to biological functioning alone, seeking neat definitions of disease as mechanical failure. A wider understanding of health, as involving subjective experience and the ways that we make life meaningful, will better prepare us to deal with the uncertainties about our own bodies that come with our mortality.
Scientific medicine has transformed how we experience, understand and cope with our mortality. By “mortality,” I mean the truth that aging, illness, dying, and death are integral to human existence. Our bodies and minds are vulnerable to injury and deterioration due to time, use, neglect, abuse, dangerous environmental conditions, and much more. Notwithstanding scientific medicine’s incredible achievements, I agree with Atul Gawande when he argues that its “most cruel failure” is not helping the aged and sick find and sustain “meaning in life.” Gawande wants to “refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.”
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Illness often makes philosophical issues come “alive” for us.
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The claim that doctors and nurses ought to be concerned with philosophical issues about meaning is popular these days. Barbara Ehrenreich’s last book, Natural Causes, condemns the “epidemic of wellbeing,” the imperative to persist with invasive scans and expensive treatments, rather than seek gentler accommodations to our aging bodies. Her final chapter discusses “the death of the self,” fear and regret at the prospect of an ongoing world we will never know, and reconciling the inevitability of our own death with “joyous” experience of a world that “seethes with life.” Philosophers, too, ask how illness and aging should disturb our sense of how and why to live, as we see in Kieran Setiya’s Life is Hard and Kevin Aho’s One Beat More. The deep relation of medicine to meaning is therefore a common concern of doctors, nurses, cultural commentators, philosophers, and many others.
Illness often makes philosophical issues come “alive” for us. Existentially dramatic questions about “the meaning of life” become suddenly real when the consultant tells us we have only six months left of it. A striking concern of many illness narratives is philosophical uncertainty—Was I a good person? What does it mean to live a good life? What really matters in the end? Questions asked casually in a seminar room become stark demands which cannot be refused. The philosopher Havi Carel, who has a life-limiting lung condition, sees illness as a source of philosophical motivation and insight. Mortality expresses various “facts of life”—finitude, contingency, painful kinds of dependency, and physical and emotional vulnerability. If that is right, existential and philosophical concerns are integral to mortality.
But is Gawande right to think they should be a concern of medicine? Does medical concern for health extend to issues of the meaning of life? I think these philosophical questions often emerge in medical contexts, but cannot be properly asked or answered in the language of science. While medics could be trained to engage with philosophical issues, we can also work towards more collaborative divisions of labour.
Naturalism and disease
In healthcare systems, the dominant conception of “health” is supplied by a set of philosophical ideas usually labelled naturalism. The basic conviction is that health is to be defined in terms of biological functionality. To be healthy, for a naturalist, means that one’s biological functions are being fulfilled, relative to the norms for one’s species and environmental conditions. If bodily systems and processes work, one is healthy—one breathes, digests, and so on, as measured and expressed in biomedical terms. Respiratory activity, for instance, is defined in terms of inhalation, exhalation and oxygen transfer. The inverse is that disease involves failures of functionality. I am ill if I cannot sustain the functionality of my body—if my kidneys cannot filter my blood, or if my lungs cannot exchange gases. At this point, I need surgical or pharmacological interventions.
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Naturalism about health focuses our attention on disease: on definable and locatable biological dysfunctions, expressed in scientific language. What is left out is illness: the first-person experience of disease and biological dysfunction.
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Naturalistic conceptions of health and disease have been extremely successful, practically and epistemically. A history of human achievements must include our fantastic understanding of the human body, made possible by these naturalistic ways of thinking. But naturalism about health and disease has two important limitations. One concerns our understanding of illness, the other our understanding of mortality.
Starting with illness, a characteristic of naturalism is a double privileging. Naturalism, first, privileges a detached, third-person perspective on the world—what some critics call a “spectator stance,” stripped of emotion, individuality, and the froth of subjectivity. In the sciences, this explains a focus on the standardized measurement of a tight set of objectively defined qualities—shape, temperature, atomic numbers, and so on. Second, naturalism in its mainstream forms privileges the language, terms and concepts of the sciences. Its dominant form, “scientific naturalism,” shares the ideal of a detached description of the world, cleansed of the distorting particularities of emotional, social and subjective factors: the ideal of a “view from nowhere,” as Thomas Nagel put it.
For all its merits, naturalism about health focuses our attention on disease: on definable and locatable biological dysfunctions, expressed in scientific language. What is left out is illness: the first-person experience of disease and biological dysfunction. For phenomenologists, the illness-disease distinction matters because it puts back into the picture the first-person perspective. No one experiences a “diseased” body in a neutral, unemotional way. “Reduced lung function” disguises important complexities—anxiety, patterns of fear, the loss of a tacit trust in one’s body one never appreciated until it is diminished. “Breathlessness” is an experience—a suddenly shrinking world, a tight sense of dread, a collapsed sense of agency. As Havi Carel has so eloquently communicated, chronic illness is a transformed experience of embodiment, time, activity, and the world. Being chronically ill includes diminished functionality but is more comprehensive—“a world without spontaneity, a world of limitation and fear: a slow, encumbered world.”
As Carel puts it, chronic illness is the lived experience of disease. The concepts and language of naturalism help us describe and respond to the biological dysfunction, but fall silent concerning the emotional, interpersonal, social, and existential dimensions of illness. Biomedical language is appropriate for describing changes in the condition and capacity of one’s lungs—but not for the experience of our world becoming “slow, encumbered.” For those aspects of illness experiences, emotion and subjectivity are essential and we need a different language. Scientific naturalism, in its familiar forms, does not speak that language. But we can speak others—more autobiographical, phenomenological, and further from science but closer to human experience.
The sensible policy is for us to distinguish disease and illness and assign responsibility for them to different kinds of traditions. Delegation is consistent with cooperation, of course. We must resist the dogged tendency to make one way of thinking our only way of thinking. This means seeking alternatives to naturalism, and alternative forms of naturalism, of a more “liberal” kind. For acute or minor illnesses, naturalistic approaches may be sufficient—not all experiences of illness generate existential anxieties. However, as Havi Carel and Kevin Aho have powerfully demonstrated, writing of their own experiences, philosophical issues are often unavoidable, especially in cases of chronic illness. Certain illnesses will involve transformative experiences, disrupting and undermining our certainties, values, concerns, commitments, and sense of who we are. Such illnesses force us to reflect on “what matters”—and the meaning and significance of human life do not belong to a naturalistic vocabulary. When experiences of illness are chronic or transformative, we must speak other languages, reaching for ways of thinking and talking beyond those of science.
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Disembodied, immortal beings might have anxieties and morals of their own, but they will not be like ours. Humanity means mortality.
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If we take this point seriously, there are different ways to put it into practice. On one ambitious proposal, healthcare—or at least major departments, such as psychiatry—should be radically restructured into something recently labelled “existential medicine.” Other more modest proposals include including more ethics and philosophy into medical education, the use of narrative medicine, and providing patients with “phenomenological toolkits.”
What kinds of proposals are taken seriously, however, ultimately depends on how we think about health in relation to human life as a whole. This brings us to the second limitation of naturalism.
Medicine and mortality
Mortality has two common senses. One concerns death, as when public health experts talk of maternal mortality rates. The other concerns humanity, transience, and the fragility of human bodies and lives—the sense in which the ancients contrasted us with the gods, who are immortal and impervious to the perils of earthly life. Mortality is an integral aspect of human existence. We have a life cycle: a pattern of biological, mental and social development from birth through maturation to eventual death. We anticipate the aging of our bodies, fret about cognitive decline, physical deterioration, and the indignity and disturbances to our confidence and self-identity that follow from age. We build relationships and projects that presuppose bodily and mental capacities, stamina, focus, concentration, and planning abilities.
Mortality is related to the moral and existential realities of a human life—grief and anxiety, courage and despair, compassion and empathy, care, and loving dependence on others. Our bodies and minds fail, break down, and whether they are repaired or collapse depends on the reactions of other people. Big moral concepts like trust and dignity depend on our fragile embodied status. Emotions like sadness, fear and grief make sense because the people we love can be killed or degraded by time, injury, illness, and pain. Disembodied, immortal beings might have anxieties and morals of their own, but they will not be like ours. Humanity means mortality.
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The biological, medical, and philosophical are intricately connected, which is one reason medics and philosophers should collaborate in dealing with them.
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If this is right, then illness has kinds of meaning and significance that are not exhausted by their naturalistic aspects. The biological, medical, and philosophical are intricately connected, which is one reason medics and philosophers should collaborate in dealing with them. Philosophers with illnesses, like Carel and Aho, remind us that the “meaning of life” is not a medical concern or a scientific puzzle. It requires different ways of thinking and a different kind of language. When a person reports that their world has collapsed, that hope is gone, that one can feel no longer “at home” in one’s body, what is needed is engagement with emotions, hopes, and a sense of one’s life-as-a-whole. Asking a radiologist what the cloudy patch on the X-ray means will be an existential question as well as a biological one. How long will I live? Is retirement a likelihood? Can I have children? What shape could my life now take and how do I adapt to what I can now only see as a misshapen life? If such questions are integral to the ways that people process, understand, and respond to medical information, then healthcare systems must offer resources for answering them, or know how to connect with and support the family, friends, religious figures, and others who might play their own roles in that process.
By asking these questions, a person is contemplating their mortality in terms that are essentially philosophical, and, for some, religious. This person is also appreciating that mortality supplies the “total context” for human life. Our emotions, moral concepts, and forms of life reflect our status as mortal creatures. This helps explain why so many people become philosophical when they encounter their own mortality, or that of other people. It is natural for the medical profession to engage with issues of mortality. But those engagements cannot take place properly within the confines of naturalism. Meaning and “what matters in the end” belong to a structure of concerns standing outside the scope of science.
They also require us, as a society, to have better resources for talking about illness, aging, dying and death—something called for in almost every book on mortality I’ve ever read, whether by ill persons, the professionals and loved ones who care for them, or scientists and academics who research illness. Coping with mortality engages our bodies and minds, thoughts and emotions, relations with others, and sense of identity, as well as the discoveries of science and the resources of medicine. Fortunately, we have good resources that can be assembled and promoted; we are not starting from nothing. What matters in the end, for most of us, will be ensuring that the lives we can save are lives of meaning, security, hope, and connection to others.
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