Existential Medicine

Essays on Health and Illness

Kevin Aho

• Publisher: Rowman & Littlefield International
• Year: 2018
• ISBN:
  9781786604842
• Edition: 1
• Topic: Philosophy
• Subtopic: Phenomenology in Philosophy

Existential Medicine explores the recent impact that the philosophies of existentialism, phenomenology, and hermeneutics have had on the health care professions. A growing body of scholarship drawing primarily on the work of Martin Heidegger and other influential twentieth-century figures such as Maurice Merleau-Ponty, Jean-Paul Sartre, and Hans-Georg Gadamer has shaped contemporary research in the fields of bioethics, narrative medicine, gerontology, enhancement medicine, psychiatry and psychotherapy, and palliative care, among others. By regarding the human body as a decontextualized object, the prevailing paradigm of medical science often overlooks the body as it is lived. As a result, it fails to critically engage the experience of illness and the core questions of ‘what it means’ and ‘what it feels like’ to be ill. With work from emerging and renowned scholars in the field, this collection aims to shed light on these issues and the crucial need for clinicians to situate the experience of illness within the context of a patient’s life-world. To this end, Existential Medicine offers a valuable resource for philosophers and medical humanists as well as health care practitioners.

Part I

New Currents in Existential Psychiatry

Chapter 1

The Cure for Existential Inauthenticity¹

Shaun Gallagher

The experience of grief is not uncommon following the death of a loved one. One could ask whether this experience is in some sense a good experience to have. There are cases in which one expects a person to experience grief but there is no such reaction, and one could equally ask whether this is something good. For example, Meursault, the central character in Camus’s existential novel, The Stranger, shows no grief when his mother dies; no grief for the man he murders; no love for his girlfriend:

He [Meursault’s lawyer] asked if I had felt any sadness that day [the day of Meursault’s mother’s funeral]. The question caught me by surprise and it seemed to me that I would have been very embarrassed if I’d had to ask it. Nevertheless I answered that I had pretty much lost the habit of analyzing myself and that it was hard for me to tell him what he wanted to know. I probably did love Maman, but that didn’t mean anything. At one time or another all normal people have wished their loved ones were dead. I explained to him, however, that my nature was such that my physical needs often got in the way of my feelings. The day I buried Maman, I was very tired and sleepy, so much so that I wasn’t really aware of what was going on. What I can say for certain is that I would rather Maman hadn’t died. But my lawyer didn’t seem satisfied. He said, “That’s not enough.” (1989, 65)

Is Meursault an existential hero, anguished about his isolated existence, and struggling with authenticity? Or is he pathological—manifesting the kind of flat affect associated with major depressive disorder (MDD), or autistic or sociopathic behavior? Deutsch (1937), whom Camus could have read on this topic, documents four clinical cases where reaction to the loss of a beloved one was completely absent. She suggests that the omission “of such reactive responses is to be considered . . . a variation from the normal. . . . [And that] unmanifested grief will be found expressed to the full in some other fashion and constitutes a reaction which must be carried to completion” (12).

Today, in contrast, psychiatry, represented by the DSM-5 (APA 2013a), seemingly is going in the opposite direction—if someone does manifest grief, he or she should be considered for a diagnosis of depression. In contrast to the DSM-4 (APA 1994), which specified a “bereavement exclusion” that advised clinicians not to diagnose depression in recently bereaved individuals, the revised DSM-5 removes the bereavement exclusion in order to “facilitate the possibility of appropriate treatment.” This, as some suggest, “medicalizes” grief and encourages over-prescription of antidepressants (Pies 2014).

After reviewing this recent debate about how to treat grief, I examine the classic existential account of authenticity as a kind of anxiety in the face of one’s own possibilities toward death (Heidegger) or toward one’s freedom (Sartre). A confused response to existential anxiety might be to regard it as something that requires medical treatment, and I’ll consider the implications of such a treatment. I’ll further suggest, however, that a better strategy is to pursue a philosophical treatment that shifts the account of authenticity toward a relational phenomenon. Here our consideration of grief can be of help. I’ll conclude by revisiting the grief versus depression distinction.

Is Grief or the Absence of Grief a Disorder?

Should we think of the lack of grief (as in Meursault’s case) a disorder, and the presence of grief something good, as Deutsch (1937) suggests? What’s clear is that by the 1960s we get a reversal of this view. G. L. Engel (1961), for example, suggested that grief is actually a disease syndrome: “It fulfills all the criteria of a discrete syndrome, with relatively predictable symptomatology and course” (18). James Averill (1968, 723) follows Engel and considers the presence of grief a psychological disorder involving individual biological disruptions: “Certain features of bereavement behavior are sufficiently uniform to represent a highly reliable syndrome. It is suggested that the concept of grief . . . be limited to this syndrome.”

Consistent with this view, most recently the DSM-5 maintains that rather than the lack of grief, the presence of grief, in such circumstances of loss, is (or is close to) a disorder. This contrasts to the position of the DSM-4 which, in a “bereavement exclusion” clause, advised clinicians not to diagnose depression in recently bereaved individuals—that is, within the first two months following the death of a loved one. DSM-5 removed the bereavement exclusion in order to “facilitate the possibility of appropriate treatment.” Ronald Pies (2014) provides a summary of the debate between proponents and opponents of the bereavement exclusion.

Critics have argued that removal of the bereavement exclusion will “medicalize” ordinary grief and encourage over-prescription of antidepressants. Supporters of the DSM-5’s decision argue that there is no clinical or scientific basis for “excluding” patients from a diagnosis of major depression simply because the condition occurs shortly after the death of a loved one (bereavement). (19)

The DSM-4 distinguishes bereavement from depression but also provides an “override” to the bereavement exclusion—“if the depressed, bereaved patient were psychotic, suicidal, psychomotorically slowed, preoccupied with feelings of worthlessness, or functioning very poorly in daily life” (20).

The American Psychiatric Association (2013b) continues to differentiate grief from MDD: in grief, painful feelings come in waves, often intermixed with positive memories of the deceased; in depression, mood and ideation are almost constantly negative. In grief, self-esteem is usually preserved; in MDD, corrosive feelings of worthlessness and self-loathing are common. In this published statement of the difference between grief and depression, however, the APA fails to mention one of the important differences. Perper (2013, 6) provides the following comparative chart of clinical indicators.

The very first contrast is not mentioned by the APA statement, namely, that grief generally involves a maintained emotional connection with others and the capacity to be consoled by friends, family, and others, whereas, someone who is depressed is extremely “self-focused” and feels like an outcast or alienated from friends and loved ones. There seems to be a real difference in regard to social interactions with others. This is an important point to which I will return.

The Classic Existentialist Conception of Authenticity

For now I set aside this debate about the DSM-5, grief, depression, and so on. Instead, I turn to the issue of existential authenticity in order to set the stage for some further thinking about grief in the final section of this chapter. I’ll focus first on Heidegger’s analysis of anxiety and authenticity; and then turn to Sartre’s analysis.

For Heidegger authenticity is nonrelational; a phenomenon of being-unto-(one’s-very-own-individual)-death revealed primarily in experiences of anxiety. “Anxiety individualizes Dasein and thus discloses it as ‘solus ipse’. . . . Dasein is authentically itself in [its] primordial individualization” (1962, 188, 322). Eigentlichkeit literally signifies something about one’s own, or being one’s own (eigen). As Werner Marx (1987) has indicated, there is no room in Heidegger’s account for the possibility of recognizing that being-toward-death is a condition that we share with others. Indeed, even as the possibility of authenticity seems to be tied to a being-towards a possibility that is said to involve no intersubjectivity at all, that is, being-towards-death, Heidegger characterizes social relations as occasions of inauthenticity. Authenticity consists of being able to withdraw from being lost in the inauthentic crowd and to confront one’s ownmost possibilities.

The question of authenticity clearly involves our being-with-others. Heidegger is clear that Mitsein (being-with) is part of the very existential structure of human existence. Yet the details of Heidegger’s analysis actually make Mitsein a secondary phenomenon. Despite his claims that being-with has equal primordial status with being-in-the-world, his analysis tends to privilege the individuality of action by making our encounters with others contingent on our already-established concernful involvement with ready-to-hand instruments and worldly projects. One’s encounter with others is “by way of the world” (1985, 239, 242). Thus, we encounter others primarily within the context of the pragmatic affairs of everyday life. Heidegger writes: “Here it should be noted that the closest kind of encounter with another lies in the direction of the very world in which concern is absorbed” (1985, 241). One comes upon others as unavoidably involved in the same way that one is involved in pragmatic contexts. Heidegger offers what one might take to be a very strong statement of the essential nature of Mitsein, namely, that even if we did not encounter others, Mitsein still has to be considered part of the very nature of the individual’s human existence. At the same time, however, one could take this to indicate that others are actually not essential or necessary for Mitsein. Being-with as such does not depend on there being others; Dasein “is far from becoming being-with because an other turns up in fact” (1985, 239). Alternatively, Mitsein seems to mean that Dasein is so taken up by the social dimension, and by the dominance of others, by the Das Man (the they) that it gets lost in a social inauthenticity in which it understands itself as being the same as everyone else—leading to an interchangeability that we find in our everyday relations with others (1962, §47). “We are inauthentic because our self-relations are mediated by others” (Varga 2012, 92).

Dasein, as inauthentic is “not itself,” it loses itself (Selbstverlorenheit); it becomes self-alienated (Heidegger 1962, 109, 166). There is a primacy given to Dasein’s own existence per se, even as being-with, over the actual or possible relations that Dasein could have with others. A number of commentators have seen this as a problem. Karl Löwith (1928), for example, a year after the publication of Sein und Zeit, suggested that Heidegger ignored the role of direct interpersonal contact in his account. Ludwig Binswanger (1962), the existential psychiatrist, made similar criticisms and claimed that the idea that Dasein as being-with left him with “a knot of unresolved questions” (1962, 6). Hans-Georg Gadamer remarks: “Mitsein, for Heidegger, was a concession that he had to make, but one that he never really got behind. . . . [It] is, in truth, a very weak idea of the other” (2004, 23; also see Gallagher and Jacobson 2012; Pöggeler 1989; Theunissen 1984; Tugendhat 1986; Frie 1997).

Although Heidegger emphasizes the “deficient modes of solicitude” in regard to our relations with others, he does not rule out the possibility of authentic relations with others. At the same time, however, he provides no extensive analysis of authentic relations with others. At best, he characterizes such an authentic relation as a “leaping ahead” (vorausspringen), in contrast to “leaping in” (einspringen) where we take over for another that with which he or she should be concerned, and make the other dependent on us. To leap ahead “pertains essentially to authentic care—that is, to the existence of the Other, not to a ‘what’ with which he is concerned; it helps the other become transparent to himself in his care and to become free for it” (158/122). Authentic relations require that I free the other “in his freedom for himself” (1962, 159/122); and likewise that I maintain my own freedom (see also 1962, 344/298). The idea that becoming authentic (understood as a modification of inauthenticity) involves an authentic being-with remains, however, an undeveloped thought in Heidegger, and the major emphasis we find is on the kind of inauthenticity characterized as being lost in the crowd.

Sartre’s analysis of authenticity/inauthenticity resonates with the loneliest aspects of Heidegger’s account. “For human reality to be is to choose oneself, without any help whatsoever, it is entirely abandoned to the intolerable necessity of making itself be—down to the slightest detail” (Sartre 1956, 440–441). For Sartre, authenticity goes hand in hand with autonomy. To whatever extent autonomy, as a realization of one’s freedom, disappears, so too does existential authenticity. Thus Sartre’s (1956) inauthentic waiter has given himself up as an individual in taking up his professional role. To the extent that one considers oneself or treats oneself as a thing, one is “a being of the world, like the ego of another” (1956, 31). Authenticity means not to get lost in the world, or defined by the world (the system, or a project as defined by others), but to act on the radical freedom of choosing ourselves, which involves a lonely “forlornness” (Varga 2012, 86).

The authentic individual is on his or her own. “I emerge alone and in anguish confronting the unique and original project which constitutes my being” (Sartre 1956, 39). For Sartre, as for Heidegger, our relations with others tend to lead us astray from our fundamental project—our unique projection of possibilities upon which we need to act. That is, relations with others tend to be in bad faith. The early existentialist Sartre (similar to Heidegger) does not rule out good faith relations; but neither does he develop an analysis of such possibilities. At best, in Being and Nothingness, we get disclaimers and ambiguous promissory notes.

Even when Sartre finds in Hegel an important realization—that “in my essential being I depend on the essential being of the Other, and instead of holding that my being-for-myself is opposed to my being-for-others, I find that being-for-others appears as a necessary condition for my being-for-myself” (1956, 238)—he immediately gives it up as a model of self-other relations, because the attempt to work out what it means leads directly to the realization that social relations are always inauthentic.

[M]y consciousness becomes as object for the Other at the same time as the Other becomes an object for my consciousness. Thus when idealism asks, “How can the Other be an object for me?” Hegel while remaining on the same ground as idealism replies: if there is in truth a Me for whom the Other is an object, this is because there is an Other for whom the Me is object. Knowledge here is still the measure of being, and Hegel does not even conceive of the possibility of a being-for-others which is not finally reducible to a “being- as-object.” (238)

To be an object is precisely not to be authentic. Sartre then turns to Heidegger to find a better model. But here he seems to miss the direction of Heidegger’s analysis. As Sartre interprets Heidegger, “[t]he Other is not originally bound to me as an ontic reality appearing in the midst of the world among ‘instruments’ as a type of particular object; in that case he would be already degraded, and the relation uniting him to me could never take on reciprocity” (1956, 245). Yet this is precisely where Heidegger does find the other—ontically. Even if Mitsein is an ontological dimension of Dasein, this is not in the same framework of our everyday interactions with others, whom we find out there in the world, precisely among the instruments and pragmatic contexts; even if we treat them as different kinds of objects, they are objects nonetheless. Indeed, Sartre is pulled into Heidegger’s analysis of inauthenticity just at this point:

If I am asked how my “being-with” can exist for-myself, I must reply that through the world I make known to myself what I am. In particular when I am in the unauthentic mode of the “they,” the world refers to me a sort of impersonal reflection of my unauthentic possibilities in the form of instruments and complexes of instruments which belong to “everybody” and which belong to me in so far as I am “everybody” . . . I shall be my own authenticity only if under the influence of the call of conscience (Ruf des Gewissens) I launch out toward death with a resolute-decision (Entschlossenheit) as toward my own most peculiar possibility. (Sartre 1956, 246)

In following Heidegger, authenticity leads to solitude once again. “I emerge alone and in anguish confronting the unique and original project which constitutes my being” (Sartre 1956, 39).

The paradigmatic picture of the existentialist analysis of authenticity, then, is summarized in three points.

1. 1 Authenticity is essentially linked with one’s self, understood as one’s own individuality—one’s lonely anxiety in the face of the possibility of death or self-demise; or more positively, one’s facing up to the possibilities that open from one’s freedom.
2. 2 Inauthenticity involves a denial or running away from one’s ownmost possibilities, one’s freedom.
3. 3 Being-with-others, or being in relations with others, is the common and perhaps unavoidable occasion for inauthenticity. If authenticity is possible, it is not clear how an intersubjective authenticity is possible. Even if Heidegger and Sartre suggest that it is, the suggestion remains undeveloped, and they provide very few details about it.

A Faint Clue from Neuroscience

It’s not often that one turns to neuroscience to clarify or update existentialist themes. Indeed, it’s not clear that neuroscience actually addresses (or can address) the question of authenticity. Nonetheless, neuroscience has studied a number of related phenomena, such as self, freedom, anxiety, and even “mortality salience”—concepts that seemingly underpin the notion of authenticity. Here I’ll mention just one study by Quirin et al. (2011), “Existential Neuroscience: A Functional Magnetic Resonance Imaging Investigation of Neural Responses to Reminders of One’s Mortality.” Quirin e...