Medical Humanities Blog

On Empathy & Judge Sotomayor

On the ASBH_Lit&Med listserv, Rebecca Garden solicited views on the flap over Judge Sonia Sotomayor's apparently shocking admission that she views her capacity for empathy as a strong suit of her judicial temperament.  This has provoked controversy.  My comments:

As a lawyer and a medical humanist, it has been difficult for me to make any sense of the certitude with which so many commentators and legal scholars seem to profess that empathy has no basis in judicial decisionmaking.  Such an idea seems so absurd to me I would barely know where to begin critiquing it, although that has never stopped me before.

Several substantive points leap to mind: first, the disdain for the role of empathy in political, moral, and juridical decision-making ought to be situated in context of the general modern emphasis on impartiality and rationalism, and more specifically, in the continued influence of the Langdellian legal formalists (see especially John Austin, not the philosopher of language, but the jurisprudential theorist).  In the latter tradition, it is the rules and principles of decision-making that ought to produce the results, and while their ideas have been mercilessly critiqued, one need look no further than the role the hermeneutics of textualism and originalism play in legal theory and in actual judges' professed methods of decision-making to see its continued influence.

Second, I think the feminist critique of this tradition of impartiality arising from care ethics (in particular, I am thinking of Virginia Held's powerful work on this subject, as well as Alison Jaggar) might be applicable to the notion that empathy has no place in virtuous decision-making.

And third, as suggested by the above, I think the aretaic tradition, and especially the emphasis on phronesis, might provide an excellent theoretical bulwark for arguing that empathy is a crucial component of practically wise and virtuous decision-making.  For those interested, Larry Solum has an extensive research agenda on the idea of a virtue jurisprudence.

Anyway, it has been somewhat disheartening to me to see how many professionals and scholars seem to accept without reflection the meme that empathy has nothing to do with virtuous legal practices and with the conditions for human flourishing, but it reminds me yet again how much I think there is to be gained by suggesting we actively look to the historical humanists as role models.  (I think I am on relatively safe ground in suggesting that for many of the Renaissance humanists, and especially, say, Montaigne, the idea that we can make virtuous legal decisions in the absence of empathy would be absurd.  Montaigne, of course, had extensive legal training and served as a judge for many years.  There is some excellent work connecting all of these themes -- virtue, justice, empathy -- as to Montaigne's life).

Thoughts?

On Kidney Transplantation

One of the most effective and thoughtful critics of traditionally dominant traditions of bioethics practice in the West is Leigh Turner.  Turner recently remarked in an article that an increasing range of voices and approaches is present in bioethics scholarship.  While I spend a fair amount of time on MH Blog spelling out some of my concerns with traditional conventions of such scholarship, it is important to evaluate the broad scope of the work with an eye to Turner's point.  To that end, I am especially pleased to note an article published in the current Hastings Center Report, which epitomizes what Cat Myser has taken to calling an anthropologically or social-science informed bioethics.  The title of the article is Conversations with Kidney Vendors in Pakistan: An Ethnographic Study.

It is available free full-text.  Here is the Abstract:

The growing concern about the shortage of kidneys available for transplantation has led some physicians, economists, and bioethicists to call for monetary inducements and “regulated” organ markets as a way of expanding the number of kidneys obtained from living, unrelated individuals. In contrast, those opposed to the idea of organ sales believe that such practices lead to exploitation of the most vulnerable people in society for the benefit of the privileged. Missing from the literature is in-depth sociological work on the vendors—the men and women who opt to undergo nephrectomy for money—and the on-the-ground realities that frame their decision. Very little is known about the sociological and psychological effects on vendors and on the families and societies they belong to when faced with a situation in which the only way to address financial difficulties is to sell a kidney.

Our aim is to turn the light on those who sell kidneys. Our research provides a “thick” description of the lives of kidney vendors and their families in Pakistan, people who stand at the center of organ commerce and yet have remained largely invisible. We attempt to open a window into their lives, to capture through their narratives what it “means” to them and their families when circumstances compel them to sell a kidney, and the ways in which this act affects connected existences.

This is a wonderful article, full of appropriate and relevant challenges to methodologically individualist and atomistic (see Taylor 1995) approaches to the ethics of kidney transplantation in developing countries.  (Indeed, as the authors note, there are very few analyses of any kind addressing kidney transplantation in developing countries; the vast majority assume developed world contexts, which underscores Myser's work on the whiteness of bioethics).  The anthropological term I mentioned here -- "local moral worlds" -- seems especially relevant to this article, and to unpacking the lived experiences in which the vendors, families, and larger communities inhabit.

Kudos to the Hastings Center Report for publishing such a fascinating, thick analysis, using tools and concepts critical to a rich notion of ethics -- dare I say, a notion of ethics as part of the medical humanities?

New Tables of Contents

Two of my "must-read" journals have released new Tables of Contents.

Topics covered in the new Journal for the History of Medicine and the Allied Sciences include London barber-surgeons 1570-1640, and vivisection, suffragete force-feeding, and responses to scientific medicine in the UK 1870-1920.

Topics covered in the new Medical Humanities include Wittgensteinian approaches to psychiatric diagnoses, phenomenologic and disability studies interpretations of heart transplantation, and a central text in literature & medicine, Middlemarch.

Highly recommended!

On Health Care Costs

We've known since for at least forty years that supply rather than demand is the primary determinant of healthcare utilization (and here again we are discussing healthcare rather than health, which I bring up here only to emphasize the distinction).  Studies surrounding the spate of hospital construction following Hill-Burton demonstrated this perfectly well, as has decades of excellent research from the Dartmouth Atlas.

But, as any medical humanities interlocutor understands, stories can be persuasive in ways that an army of facts and data cannot.  Thus, I want to particularly recommend Atul Gawande's current article in the New Yorker entitled The Cost Conundrum.  No summary would do it justice, as it is a tour de force, even while it simply highlights phenomena that we have known about for decades.  Gawande has been on a particular roll of late, in my view, and this latest article continues his outstanding work.  Here I excerpt a paragraph that Brad F. found revealing:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

Read Gawande.

(h/t Health Beat Blog)

On Medical Humanities Blog

First things first: I passed my dissertation defense.  Assuming I manage to meet the requisite deadlines and get the necessary paperwork completed -- admittedly unsafe assumptions -- I will graduate in August of 2009 with a Ph.D in medical humanities.

Second, I mentioned that changes were afoot at MH Blog.  These changes will not be instituted all at once because, frankly, I don't have the time to do so.  Once I defended, the six projects I had put on hold to concentrate on the defense demanded my immediate attention, and so I have been preoccupied with their requirements. 

There will, however, be changes to MH Blog, and I plan to gradually phase them in over the next few months.  What can readers expect?

When I began this weblog in September 2006, I consciously modeled the format over Larry Solum's wonderful Legal Theory Blog.  Though the quality of the blogging over there puts most of the rest of us to shame, this blog has evolved into something quite different from Larry's masterpiece.  For example, the literature metacrawlers have become much less thorough and less formal, for a number of reasons, mostly pertaining to the enormous scope of interdisciplinary scholarship relevant to the medical humanities (and concomitant resource limitations).

I still enjoy highlighting recently published or forthcoming work that strikes me as important to the medical humanities, and therein is the key to understanding the changes that will come to MH Blog: they will all revolve around me.

Self-deprecating jabs at my own narcissism aside for the moment, MH Blog has never formally been a record of my own academic pursuits and interests.  Over time, the functional separation I tried to maintain between my own work and what I deemed important to the medical humanities eroded, if it was ever perceptible to begin with.  Indeed, as I've noted, no student of the medical humanities can with a straight face maintain the existence of an ontological separation between the subject and the object of investigation (for more on why, read Montaigne).

Therefore, all of the changes at MH Blog will reflect my desire to formally collapse this attempted separation entirely.  MH Blog will, in relatively short order, become intimately connected with my own work and scholarship.  These connections to a greater or lesser extent have already been obvious to the able reader, but I intend to make them more consistent and even more transparent. 

 

This should not result in any dramatic and immediate alterations in the style, the substance, or the format of the posts; but I expect and hope that the differences in how I intend to blog about my work and the medical humanities will emerge from the posts themselves, as any good piece of interdisciplinary work ought to demonstrate.

 

In short, it is as just as Montaigne, who remains the patron saint of MH Blog, says in the emblazoned quotation: It is myself that I paint.

On Ethics & Social Epidemiology

I have noted several times on this blog what I perceive to be a marked lack of development on some of the most complex and difficult ethical questions that attend the social determinants of health. That is, once we accept the premise – which we ought to, based on the abundance and quality of the evidence – that social and economic conditions are primary determinants of health and illness at the population level, what ought we to do from a policy perspective? I have generally been disappointed to find that the answer to this question is frequently assumed, e.g., 'we ought to eliminate inequality.' But a basic tenet of moral thinking is that not all inequalities are unjust. Plato recognized this, as have the majority of the most influential Western thinkers on justice (including Rawls, whose concept of distributive justice expressly delineates between inequalities that are unjust, and those that are not).

So if the moral basis for eliminating inequality is tenuous at best, perhaps the normatively preferable policy option is "to compress inequality." But how should we do so? Which inequalities should we seek to compress? What is the priority for compression? Health inequalities? Income inequalities? Inequalities in housing conditions? Inequalities in tax policy? Of course, remediation of all of these inequalities are not mutually exclusive, but part of the reason for this is that they seem to be, to some extent, functions of each other. The links between health inequalities and income inequalities are well demonstrated, but there is also good evidence linking housing conditions and health inequalities, and housing conditions and income inequalities, and it seems implausible that the housing conditions that correlate with health and income are unaffected by their distribution (a quick search does not reveal studies directly addressing the question, but I would imagine they exist).

Another example of a difficult question to answer is whether radical redistribution of income normatively (that is, ethically) preferable to remediation educational inequalities? Why or why not? What does justice demand? If justice demands we do both, and that neither is ethically preferable to the other, does the pragmatic policy outlook for each color our perspective on relative priority? (I argue yes).

The point of the above discussion is not to offer any answers, but to suggest that the questions are important. Given my view on this importance, there are few philosophers from whom I learn more than Gopal Sreenivasan, who recently took up a position at Duke University. Sreenivasan writes extensively on the issue of what policies are ethically warranted in light of the best evidence regarding the SDOH. His recent article, published in the fine new journal Public Health Ethics,* tackles the relative vs. absolute income debate (namely, whether health is more properly viewed as a function of relative vs. absolute deprivation). Here is the Abstract:

This paper reviews the epidemiological debate between the relative income hypothesis and the absolute income hypothesis. The dispute between these rival hypotheses has to do with whether an adequate account of the relationship between income and life expectancy requires the definition of 'income' to include any comparative element. I discuss the evidence offered for the relative hypothesis (which answers, 'yes'), as well as two important criticisms that have been levelled against this evidence. I also offer some critical reflections on the debate from a philosophical standpoint concerned with the ethics of population health. Both hypotheses agree that a redistribution of income towards the worst off will improve their life expectancy.

Sreenivasan concludes that there is as yet no reliable evidence in favor of the relative income hypothesis, but also admits to puzzlement as to why it matters. Proponents of both camps accept the strong correlation between income and health, proponents of both camps support income redistribution as a means of improving population health, and proponents of both camps may, he notes, consistently support the idea that psychosocial pathways are key mediators of the effects of social and economic conditions on health.

In any case, Sreenivasan's analysis is penetrating, lucid, and rewards close reading. His work is some of the best available in reflecting from an ethical perspective on the policy implications of the SDOH.

*Disclosure: I recently had a paper published in PHE.

On Stigma

Stigma is a crucial concept in the medical humanities, and few have mined the inquiry for as long and as effectively as Arthur Kleinman.  He has a co-authored editorial(with Rachel Hall-Clifford) on stigma in the current Journal of Epidemiology & Community Health(one of my favorite journals).  Here is the first paragraph:

The concept of stigma has undergone important shifts in definition and characterisation since its initial articulation by Erving Goffman in the 1960s. Here, we contend that the study of stigma has focused too heavily on psychological approaches and has neglected to sufficiently incorporate understandings of stigma and stigmatised individuals as embedded in local moral contexts. What exactly is encompassed by the conceptual umbrella of stigma is far more than a compelling theoretical question, since definitions of stigma directly inform efforts to empirically research and combat stigma.

There are few concepts in medical anthropology I am more attracted to than that of "local moral worlds."  Indeed, it figures prominently, though in slightly altered usage, in my dissertation (more details on the latter forthcoming).  In addition, having read numerous short pieces by Kleinman in various journals over the last few months, I marvel at his ability to pack such meaning and erudition into such small spaces.  Concision is a skill I am still working on, as readers of this blog know full well.

In any case, do read Kleinman and Hall-Clifford.

Extended Deadline: 7th Annual Joint Atlantic Seminar in the History of Medicine

The Call for Papers for the 7th Annual Joint Atlantic Seminar in the History of Medicine has been extended to June 1, 2009!

The 7th Annual Joint Atlantic Seminar for the History of Medicine, will be held the weekend of October 9-10, 2009, and hosted by the Department of the History and Sociology of Science at the University of Pennsylvania in Philadelphia, Pennsylvania.  The seminar is organized and coordinated by graduate students across North America working in fields related to the history of medicine.  Our mission is to foster a sense of community and provide a forum for sharing and critiquing graduate research by peers from a variety of institutions and backgrounds.  For more information, including previous years’ programs, please visit www.jointatlantic.org.

THE CALL FOR PAPERS DEADLINE HAS BEEN EXTENDED TO JUNE 1, 2009.

Graduate students are encouraged to submit abstracts for research presentations on topics related to the history of health and healing; of medical ideas, practices, and institutions; and of illness, disease, and public health, from all eras and regions of the world.  Abstracts should be no more than 350 words and should clearly state the purpose, thesis, methodology, and principal findings of the paper to be presented. Please note that abstracts more than 350 words in length will not be reviewed.
Speakers must be enrolled as graduate students at the time of the conference. Successful proposals will engage with relevant historiographic issues and the potential contribution to scholarship on the history of medicine and health. A panel of graduate students and faculty members from several different institutions will review the abstracts.

All abstracts should be submitted electronically (either as a MS Word document or as text in the body of an e-mail) to Marissa Mika, Program Chair, at jasmedconf@gmail.com.

It is not clear at this time whether or not we will be able to provide financial support for travel to participants. However, we will make every effort to provide accommodation for presenters. We urge students whose papers are accepted to seek financial support from their home institutions to participate in the seminar. Registration for the conference is free.

____________________________________________

Alas, it is unlikely that I will be a graduate student in October 2009, so I am not eligible for presentation here, but nevertheless is highly recommended as a unique forum for graduate students to gather and present their work in the history of medicine.

(h/t H-SCI-MED-TECH)

Call for Papers: Disability and Life Writing

Call for Papers

Special Issue of Journal of Literary and Cultural Disability Studies
(JLCDS)

Human Conditions: Disability and Life Writing
Guest Editor, G. Thomas Couser

Papers welcome on any aspect of this broad topic.  I wish to encourage
breadth across time, across cultures, and across media: thus, “life
writing” should be understood to include non- print media (such as blogs)
and even non- written forms of representation, such as documentary film,
YouTube videos, and more.  The following questions, then, are meant to be provocative and suggestive, rather than exhaustive.

• How have recent developments in media affected representation of disability?
• How has the growth of self- publishing (which effectively bypasses any editorial gate- keepers) affected representation of disability?
• Are new categories of disability being represented? How “representative” (inclusive) is the representation of disability in life writing? That is, has life writing showcased some disabilities or impairments and tended to eclipse others?
• Are developmental disabilities adequately represented, both
  qualitatively and quantitatively, in life writing?
• Also, how diverse is the representation of disability in life writing in terms of ethnicity, race, and national origin? How does the  representation of disability in life writing vary from nation to nation, culture to culture? That is, have some cultures been more receptive to it than others?
• Is there significant disability life writing before Helen Keller’s?

Pre- submission inquiries welcome.

Proposals to G.T.Couser@hofstra.eduby 1 September 2009, complete
papers by 14 February 2010.

Professor G. Thomas Couser
(rhymes with browser)
Founding Director, Disability Studies
Department of English
204 Mason Hall
Hofstra University
Hempstead, NY 11549
(516) 463- 6743

(h/t Kelly Hills, Lit&Med_ASBH Listserv)

________________________________________________

Friend of MH Blog and erstwhile guest-blogger Kelly Hills notes:

This is an interesting topic, and something that I've thought about off and on - especially seeing your connection with the disability blog carnivals.

 
Something that "they've" said about the internet, for about as long as I can remember, is that it "allows" people who might never meet up with one another in real life to find one another and reaffirm and support what "normal" society may consider odd choices or decisions. Obviously this was originally applied to fetishes and kinks that a lot of folks would consider socially unacceptable ("oh the internet is just validating your strangeness!"), but over the years I've seen it applied to just about everything - including vaccination fears and people who want to embrace disabilities much further than the medical community, including those who're downright offended at the idea that medicine is seeking to "cure" them (I'm thinking in particular of neuro issues here).

I wonder if the internet is making it easier for voices that might have not been heard, otherwise, to congregate and create larger groups with more power/voice, which turns around to at least get them noticed, if not lend credence to the ideas that they are promoting.

Thoughts?

Roy Porter Lecture, Prof. Shigehisa Kuriyama: A Strange Convergence of Fears--Interpreting the Comparative History of Blood and Guts

'A Strange Convergence of Fears - Interpreting the Comparative History of Blood and Guts'
THE ROY PORTER LECTURE
Professor Shigehisa Kuriyama
(Harvard University)

Wednesday 27 May at 1730
Harrie Massey Lecture Theatre, 25 Gordon Street, London WC1 UK

Traditional Chinese medicine is typically cast, today, as an alternative 'other' to modern Western medicine: critics and advocates alike stress the alien unfamiliarity of its vision of the body. Professor Kuriyama proposes, on the contrary, to spotlight a basic, yet neglected convergence. He will argue that by becoming modern, Western medicine also became in a sense more East Asian, and urges that one key to this convergence lies in the entwining of money and the body.

Registration required. To download the notice for this lecture in pdf format, please click here:

http://www.ucl.ac.uk/histmed/downloads/events/neale_rsp.pdf

For information on other events at the Wellcome Trust Centre for the History of Medicine at UCL, please see our website:
http://www.ucl.ac.uk/histmed/events/events

Posted by Prof. HJ Cook, Director, WTC, h.cook@ucl.ac.uk

(h/t H-SCI-MED-TECH listserv)