Session Three: Vision--Confronting the Margin

Discussion

THOMAS COLE: I had a question for you, Pat, because your language of "care holding open the world" reminded me of Sandra's metaphor for opening the door of death. You began by saying that we can't overcome the cadaver, the very symbol of disengaged reason. And I wanted to ask you, as a nurse, what it was like to be taught to care for a newly dead person? You must have gone through that. And do you think it's possible to care for a cadaver in a way that is not inherently disrespectful? Some of our medical students say that the enterprise is inherently wrong, that it's inherently disrespectful to break apart violently the integrity of the human body. I just wondered what you thought about that.

PATRICIA BENNER: I think if we have a very destructive, disrespectful attitude towards a stranger's body, we also chip away at our own sense of integrity and wholeness. The relational ethic with the cadaver is a really important point.

The film Tom Cole showed us was very powerful in showing the need to disengage and the need not to dehumanize, although in some cases the fascination with being allowed to do what most ordinary people aren't allowed to do comes through. I don't know what to do with that. Western medicine gets so much of its power and vision and efficacy from laying the body bare and from the clinical gaze and from disengagement; and it is currently so silent about the middle terms of the lived life, the social sentient body, the body inscribed with meanings. Being able to find a way to get those middle terms, I think, is very important intellectual work that medicine needs to be doing. And there is something really profound about the practice of dissection that is the perfect enactment of the disengaged reasoning and the treating of the body as unensouled and unworlded and wholly other.

BETTY DAVIES: I just wanted to comment about the idea of disengagement. As you were talking, I had the thought that there are different forms of disengagement or different patterns of disengagement. It seems to me that when a nurse or a physician disengages from the body or from doing any unpleasant task without thinking about the task, that the disengagement becomes a kind of defense mechanism to enable her or him to cope with having to do the task. And that's when the element of personalization or depersonalization occurs. But if we can say, "This was a human person, and let me respect what this person was, but I still have to disengage from this; I have to separate myself from this in order to be able to do it," then that seems to be a different kind of disengagement.

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PATRICIA BENNER: I don't imagine that any of us can get by without the skills of disengagement. But I think that what we want also to learn more about are the skills of engagement. And those are very tricky--not to be over-identified, not to be over-involved. It is incredibly difficult to be the intimate stranger and compassionate stranger in a way that doesn't assume powers that you don't have as a helper, to learn the techniques that are not intrusive. It seems that we need to be able to talk about appropriate disengagement but the positive project remains learning the skills of engagement, the skills of involvement.

TOM COLE: I just want to follow up on that. Another way of thinking about this is, again, to avoid thinking in either/or categories, but to be aware of the necessity of a kind of double movement of consciousness and feeling that depends on what is happening in the moment. In Buberian terms we can talk about the difference between I/it and I/thou relationships. One of the rabbis at my temple thinks that the goal of a good life is to always be in an I/thou relationship. I said to him, "I just don't think thatÕs feasible. You can't always lay your heart open and treat the other person as an autonomous loving self, with whom you reciprocate, because there's just too much work to do in the world. You sometimes have to shake hands and go on your way to the next person."

Another way to think about this is the image of spectator that you were referring to. I had a couple thoughts about that. The anatomical theatres of an early modern era were galleries where people came to view spectacles of dissection. But Adam Smith's ideal of the "impartial spectator" is a person who is capable of good moral deliberation. And the impartial spectator is sympathetic, feels himself or herself linked to others, to the dead and is able to move back into a reflective, more rational mode for decision-making purposes on evaluation. So I think we're talking about moving back and forth constantly, depending on what the other person needs, what the situation demands and what we need. And it takes a lifetime to learn that.

PATRICIA BENNER: I agree, as long as we don't imagine that that atomistic, separate autonomous self is the starting point. The big misconception is to imagine that we start as erratically independent, separate, autonomous beings and then we connect with others, as opposed to the idea that we are constituted by the connections.

And the other problem I have with both Adam Smith and Kant is that any emotional affinity has to be held in total suspicion and can't count as moral action; rather, what counts as moral for Kant, like Adam Smith, is this reflected, detached, imaginative private consciousness that stands over against private consciousnesses. This is opposed to imagining that one is co-constituted by the social spaces of relationship and that the relationships themselves open up moral possibilities. Moral perception may be dependent on relational skills and emotional affinities. If one doesn't have the schooling of being a loved child or a loving child, maybe many moral possibilities are always going to be closed down to one. And so to imagine that the moral pinnacle is this very privileged, deprived view of the separate, autonomous, reflective intellectual or pure will, I think, is false and misguided.

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GARY LADERMAN: A word that came up several times and offers a rich kind of concept in thinking about all this is "intimacy": intimacy with death and intimacy with the dead. I tend to think historically about how that intimacy with death has changed over time and in America. In the nineteenth century most Americans were intimate with death. It was very much a fact of life, and we were intimate with corpses because bodies were at home, people died at home, and the deathbed scene is one of the key cultural scripts that we have with which to think about the good death and the meaning of death. That intimacy was familial and communal and religious, in terms of who was really intimate with the dying and then with the dead body.

The first part of my book is called, "Intimacy Lost," and the second part is called "Intimacy Regained." I look at--IÕm going back to the denial thesis--the many kinds of conflicting, contradictory, opposing social forces at work in the first part of the twentieth century, and how we lost that older sense of intimacy with the rise of hospitals and the conception that those who are intimate with the dead are doctors, nurses, the medical establishment, and funeral directors. Religion has kind of disappeared. We have a broader split wherein religion is associated with what is supposed to continue after death, a kind of imaginative and spiritual looking at what happens to the soul, whereas the body is left for the new specialists who acquire the kind of intimacy of doctors who are opening up corpses or funeral directors who are embalming them. And in spite of the kind of talk we're hearing today there's a sense in which the history of medicine is founded on this kind of clinical gaze.

So in reference to the medical students who are opening up those cadavers, I see a kind of struggle with being intimate with the corpse. You can only be intimate, I think, with a living thing.

FRANK GONZALEZ-CRUSSI: I think that we should remain open to the various styles of thinking, with respect to just exactly what kind of deference or what kind of respect is owed to the dead, and whether that would preclude dissection or not. I know that in the Christian tradition the body is something despicable, a vessel of rottenness. We are dust and shall return to dust. Not much respect was owed.

And if that kind of thinking were to pervade, it would open the door to all kinds of anatomical dissection, disposal, etc. On the other hand, I know that certain strains of thinking within Christianity and also within Judaism have opposed all manner of post-mortem dissection.

So I think this manner of thinking can change with time, with the prevailing thought. We are raised in a tradition in which you have to show some respect and some reverence. I know that when we are doing an anatomical dissection, it's almost invariable that the person who is actually doing the dissection covers the face of the cadaver. Even though dust we are and to dust we shall return, and this is no longer a person, still you have the face of the person looking at you, and you have the feeling that it is that person, still is that person.

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LAVERA CRAWLEY: What you didn't say and what you spoke to me about in the hallway is how you grew up being exposed to slaughter houses. So the notion of seeing something cut open was not new to you, wouldn't be as shocking, as it would to the medical students who may not have had that situation. As you were just speaking, I was wondering what might happen in future generations of medical students as we move to virtual cadavers, and we get away from the actual human body. What will happen with that?

FRANK GONZALEZ-CRUSSI: I think there is some merit in decreasing the exposure to cadavers. That's my personal opinion. But I know that I'm not alone in this manner of thinking.

The other thing, even more interesting, is what dissection does to medical students. This would probably be the primary concern of an audience like this one. I can see the dilemma that confronts many of you who have to teach humanistic values to medical students. The medical student is exposed about 1% of the time, in a tiny, minuscule portion of the curriculum, to a course that is named "Humanistic Values of Medicine," where the human being is to be explained, not only on the basis of anatomy and physiology but in terms of what that extra thing is that makes a person a human being. So 1% of the time is going to that. And then for the other 99% of the time the body is treated like a machine, the sick body as a machine that is out of order, and there is no reference to this so-called "extra thing" that the human being has.

LAVERA CRAWLEY: Comments on that statement?

JOSE ALANIZ: I'm Jose Alaniz, Comparative Literature, at Berkeley. A lot of things, obviously, keep accumulating with each comment. I was reminded of Thomas Lynch's comment that death ultimately doesn't happen to the dead, death happens to the living. And a lot of the hand-wringing and a lot of these moral dilemmas that we go through have to do, of course, with our own sensibilities. Respect for the dead body is actually respect for the person who was before, respect for the family or other things, and also for our own sensibilities.

But I wanted mainly to comment on Dr. Gonzalez-Crussi's bringing up Tolstoy's very careful and very intimate reading and very corporeally based depiction of the dying body in The Death of Ivan Ilyich. I think it's another illustration, though, of the seduction of the representation of the dead body, how it can be taken in some respects for something that is real. In fact, Tolstoy was using that novel to convince his audience to act in a particular way. Tolstoy uses the dying process, and its power, potency, realness, and undeniablity, for political or ideological gain. In fact, he was trying to get people to change their lives, to live in the correct way.

So the main point, I think, is always to think about the representational practices that themselves are depicted in photographs or films [or novels], and to remember that although we are limited in the extent to which we can represent death, we can use its resistant power of representation for other purposes. In that respect, as Sarah Godwin and Elizabeth Bronfen in their work mention, every representation of death is by nature a misrepresentation. It's pointing somewhere else ultimately. And I think the case of Tolstoy is an illustration.

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FRANK GONZALEZ-CRUSSI: I agree with the general gist of the comment. I think that the respect and reverence that's owed to the dead is certainly of a different nature than the kind that is owed to the living. In the operating theater, a surgeon is often cutting a body while listening to music. It has a soothing effect. Many surgeons prefer a little background music while they are taking on the operation. Music, as we were saying out in the hall, would not be permitted in the room where the cadaver dissection is being done. It would be considered irreverent, suggestive of too much levity.

SANDRA GILBERT: I just want to make one comment about what seems to be emerging from this discussion of the body. Really, it seems as though we're going around in circles about this issue of respect for the body. On the one hand there's a long Western tradition in which the body, as Frank has mentioned, is the most abject version of the human being, the ultimate abject spectacle. It's helpless, hopeless, existing, but not existing.

But on the other hand, because it incarnates the mystery of death, it also has this extraordinary nobility. And there is a long literary tradition--for example, a poem by Rilke called "Corpse Washing," a poem by St. Vincent Millay about viewing a body, and a story by D.H. Lawrence called "Odor of Chrysanthemums"--in which a woman looks at her husband's body, in which the body represents utterness, and a nobility, and is in itself completely a mystery.

I also had a question for Patricia. I was so intrigued by your remark that the passage of death and dying has been colonized by the language of choice. I keep going back to that in my mind, and I can't help wondering about that in the context of the debate over physician-assisted suicide and the bioethic story that was told by Jodi Halpern.

PATRICIA BENNER: I have a sense that part of that has to do with a technological self-understanding and a sort of technical view of death, so that if we choose it and own it, it isn't "other." And yet it confronts us with something that is radically other, in that there is a way in which we can't choose it. I'm reminded of a story where a patient had had a heart transplant and was now in the throes of rejection and fulminating multi-system failure. Most nurses could not stand to go into the room. The physicians were very distressed and wanted to discontinue all therapies--the futility discussion. But the wife and husband had had a pact that they would fight together, and that she would fight for him, and that they would fight until the very end. Things had become horrible; he no longer looked like himself, it was "ugly" in the way we talked about yesterday. And so they sent a less experienced nurse in to take care of this patient because the experienced nurses just couldn't stand the travesty of it. And this nurse went in because she was only two years into the practice, and she had known this man and his wife throughout his illness.

All day long the physicians were talking in clinical discourse to this wife about the ejection fraction, the multi-system failure, etc., etc. And this nurse is taking care of the man, and she is feeling very sad, and she says, "I don't want to remember him like this." And she starts reminiscing about his sense of humor and about the different things that happened on the unit. Well, reminiscing is a kind of leave-taking ritual. And so she goes on, "Tell me about how you met, and tell me about your life together." And this reminiscing continues. And the woman then says, "If I turn off the drips, how long will he live?" And the nurse responds, ÒWell, I think no more than a few minutes.Ó

The wife then walked out of the room, came back in five minutes or so, and said, "Turn off the drips, but don't stop the ventilator."

For me, that story is an example of the way choice language doesn't really capture the issues of letting go, and also that we can do everything and death will still occur. There is a way in which we imagine that death is not quite natural.

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JOHN GILLIS: There's a term here that I guess maybe I haven't been attentive to in the literature, but this concept of "intimate strangers" really intrigues me. Is that something relatively new in the literature?

PATRICIA BENNER: It's been around, and it's also been talked about as a kind of pathology, that maybe you are intimate with strangers but you don't have a life. So, I mean, that is one kind of pathology. But you can turn it around and look at people with very robust, lovely lives, but who have this capacity to experience solidarity and make connections. I think it's part of the social tradition of the compassionate stranger that you be compassionate not only to those in your family but to other human beings as well.

JOHN GILLIS: Well, the reason I ask is that--and I think my fellow historians here would confirm this--the presence of strangers was a normal phenomenon up to, really, the late nineteenth century. Sometimes in rather bizarre ways, the deathbed scene would be crowded with people. And then comes along the institutionalization of death, and this circle was narrowed. In fact, what seems to have happened is that one group was privileged over every other: the family, the next of kin. What I'm hearing here opens up a very interesting area of speculation for me, that the next of kin may not always be in the best position to attend the dying person. I think we've had several narratives that have suggested this. And I'm beginning to wonder why. It seems that while the next of kin will go on living their world--that's your term--the person dying is about to leave that world, and in some sense needs permission to leave that world. The next of kin are likely, in a deathbed situation, to want to sustain the roles and expectations and petty tyrannies that always prevail in family life. This is the curse of intimacy. This is its strength, but it's also its curse. But the dying person may need permission to assume the role of the slightly deviant, the quirky individual. After all, this is the last moment, and maybe that's a right that we should all reserve to ourselves at this point. And here, with the intimate stranger, is a wonderful opportunity for that looseness of relations to come into play.

So it seems to me this comes back to detachment and intimacy. It is clear to me that detachment and attachment are vital in these circumstances. But we shouldn't overplay either of these. It's important to keep in the situation a certain looseness but also a certain comfort of the known: the unknown and the known.

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PATRICIA BENNER: I was thinking of Jim's description of Fran, the love object. And I could just imagine her, and imagine myself in situations like that, where somehow you're still able to hold open joking and very concrete particularities, and that you're really able to meet someone in your common humanity. For the one dying, there's no risk involved. For the one caring, there's really no great risk involved. And you can connect on this human level. And I think it's a wonderful cultural possibility and one that we ought really to hold open and sustain.

LAVERA CRAWLEY: We have time for maybe two more questions.

MICHAEL WITMORE: The terms "detachment" and "intimacy" seem to be defining different sorts of vision. They're different from other terms like "mind," "body," "knowledge," "understanding." I'm wondering what difference that particular pair makes. And I'm wondering if you have any sense of whether there's a term that encompasses both.

PATRICIA BENNER: Detachment and intimacy. That's a really good question. I'm sure they should not be oppositional, should not be dichotomous. There's a way in which if you've just merged and you have no recognition of the other as other, then you can't have intimacy either. So I think we need metaphors like "dance." We're a little impoverished on language for relationship. But I like the notion of putting detachment and intimacy on a continuum and not seeing them as mutually exclusive or in opposition.

LAVERA CRAWLEY: I think we can go on and on here, but time has run out. My thanks to all the panelists and to all of you.

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