Review of Existential Medicine
Existential Medicine: Essays on Health and Illness, by Kevin Aho (Ed.). Lanham, MD: Rowman & Littlefield, 2018, 294 pages, $39.95 USD
In Existential Medicine, authors come together from fields of philosophy, psychology, psychiatry and medicine to revisit the collaboration between the Swiss physician Medard Boss and the German philosopher Martin Heidegger, which culminated in Zollikon Seminars (ZK, 1959-1969). It would be a mistake to assume that this work is the first of its kind since ZK was translated into English in 2001. For many decades, its authors have been busy applying existentialism, phenomenology and hermeneutics in order to better understand health, wellness and patient care. That they have come together with contributions to a single volume is a treat.
Existential Medicine is edited by American philosopher of medicine, Kevin Aho. A cardiac disease patient himself (2018), Aho is responsible for a long list of impressive contributions to the fields of medical and psychiatric diagnosis, as well as the role played by existential modes of being (such as embodiment and temporality), in the experience of illness. His articles could alone supply the chapters for this book, but Aho instead plays the role of coordinator and emcee, introducing his authors and grounding Existential Medicine in the works of Boss and Heidegger. To this end, he reminds his readers how
the [Zollikon] seminars make it clear that human existence (or Dasein) cannot be reduced to measurements from blood tests, cardiographs, and stethoscopes. Existence, rather, is a way of being, an affective, situated and embodied activity. Heidegger’s conception of Dasein, then, is best understood not in terms of “what we are” as if the human being was an objectiv[ely] present substance, but in terms of “how we are”. (p. xii)
Background of Existentialism in Medicine
ZK comprises letters, meetings and conversations had between Boss and Heidegger — the former trying to make sense of the latter’s philosophy and how it might fruitfully be applied to medicine and psychology. After a few exchanges, Boss realizes that Heidegger’s insights must be shared publicly. As Boss reflects in the preface to the German edition: “I did not think it proper to be the only person to benefit from frequent meetings with the great thinker” (p. xvii). He arranged to have his colleagues meet together with himself and Heidegger in an auditorium of the Burghölzi Auditorium of the University of Zurich Psychiatric Clinic. Heidegger eventually admits that that the modern, angular design of the clinic interferes with the dialogues, and they move the meetings to more auspicious settings, such as the private home of Boss. Here Heidegger gave lectures and fielded questions on the difference between beings (what is there) and their being and the significance this has for the practice of medicine and psychology. Just like any western academic who has struggled with Being and Time, Heidegger’s audience of physicians, trained in the still-reigning Modern scientific model of medicine, were understandably nonplussed. Consider, for example, the following exchange:
Martin Heidegger: ...how does bodiliness [embodiment], which is undetermined, relate to space?
Seminar Participant: The body is nearest to us in space.
MH: I would say that it is the most distant. ...Because you are educated in anatomy and physiology as doctors, that is, with a focus on the examination of bodies, you probably look at the states of the body in a different way than the “layman” does. Yet, a layman’s experience is probably closer to the phenomenon of pain as it involves our body lines, even if it can hardly be described with the aid of our usual intuition of space. (pp. 83-84)
The seminars are full of such exchanges — lines of reasoning are developed that seem counterintuitive to the modern scientific mindset. Heidegger continually reminds his participants, “Being cannot be glimpsed by science” (p. 18).
After taking tedious notes during the seminars, Boss worked on his own magnum opus, Existential Foundations of Medicine and Psychology (published in English in 1979). Here he describes a Heideggerian approach to diagnosis and treatment of medical pathology — Daseinsanalysis. For further reading on daseinsanalytic thought in the United States, the reader is encouraged to find the double issue on the topic edited by American psychotherapist Eric Craig, and published by The Humanistic Psychologist (Craig, 1988).
Description of Existential Medicine
In addition to grounding the book in the Zollikon Seminars, Aho introduces his readers to the relevant themes of phenomenological philosophy, the existential modes of embodiment, affectivity, and space and time, as well as a hermeneutic rendering of existence. A far more thorough introduction to these themes can be found in Aho’s previous work (e.g. 2008a, 2008b, 2017, 2018a, and 2018b [in press]) as well as the aforementioned special double issue of The Humanistic Psychologist on Daseinsanalysis.
The book begins with a chapter from phenomenological philosopher and cognitive scientist Shaun Gallagher — a peculiar contribution for a Heidegger series. Gallagher merges a Heideggerian account of authenticity with news from cognitive science presses in order to argue that the psychiatric condition of anxiety is social. He tells his readers, for example, “If Heidegger were a neuroscientist, he might say that Mitsein is hard-wired into the brain…” (p. 10). Such speculation, of course, does not follow the Heidegger of ZK, who explains how “we do not have any possibilities to know how the brain bodies forth in thinking” (p. 197) — a quote acknowledged by Swedish philosopher Fredrik Svenaeus in his contribution to the book, Chapter 9.
The direction is corrected, however, in Chapter 2, written by American philosopher and psychoanalyst Robert Stolorow. Stolorow begins by criticizing decades of phenomenological psychopathology research for failing to question the validity of the diagnoses set forth by the American Psychiatric Association. For example, a phenomenological account of depression that begins with the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V; APA, 2013) criteria has already begun with certain expectations about what counts (or does not count) as psychopathology and is therefore insufficiently phenomenological. Reminiscent of Heidegger, Stolorow argues that “the DSM is a direct descendent of Descartes’s metaphysical dualism” (p. 18). For an alternative, he recommends a conception of psychopathology that is based on the existential modes of affectivity and sociality.
In Chapter 3, American philosopher Anthony Vincent Fernandez deftly teases apart the subtle difference that Heidegger makes between ontic and ontological, that is, the “ontological difference.” In Being and Time, Heidegger differentiates between fundamental structures of human existence (such as temporality, attunement and situatedness) and their various modes. As a fundamental structure of existence, temporality is always a dimension of human being and is therefore ontological. Within this ontological structure, there can be many different ontic modes — such as experiencing the world as moving slowly or quickly. You and I can experience the same subway trip as fast or slow, depending on where we are going and how much time we have to get there, but for each of us this experience is always within the ontological structure of temporality — that does not change. Fernandez explains that phenomenological psychopathology has focused primarily on the shifts in ontic modes of being, but he suggests that they must also seriously consider the possibility that for some, the ontological structures themselves may also be altered. For example, traditional phenomenological psychopathology would understand that the depressed person is still situated within an affective milieu (mood or attunement) but that the particular mode has a deflated quality. Fernandez argues how, in some cases, persons with severe depression are actually experiencing a breakdown of these ontological structures, such as the loss of affective attunement with the world and with others (citing Fuchs, 2013). The possibility of such a breakdown would be profoundly consequential to the phenomenological understanding of depression.
Philosophers Martin Kusch and Matthew Ratcliffe make a unique contribution to the volume in Chapter 5. Kusch does not speak as a philosopher but as a chronic pain patient. Ratcliffe, who specializes in the philosophy of medicine, provides an analysis of Kusch’s experience. After a routine dental surgery, Kusch began to experience what became a lifetime of chronic dental pain. He describes the many specialists he visited and the various ways of being treated like a set of dental x-rays. The combination of these two perspectives results in an existential analysis of chronic pain as well as an indictment against the depersonalizing treatment of patients by specialists and health management organizations.
If the personal narrative and analysis given in Chapter 5 is not the highlight of the book, then that distinction would have to go to Fredrik Svenaeus in Chapter 9. Svenaeus gives a damning critique of medicalization in the practice of contemporary medicine and the latter’s reliance on technological developments. Heidegger was famously cautious regarding technology, careful to point out that it must be useful for human beings and not the reverse. What Svenaeus calls the “perils of medicalization” (chapter title) can be summarized by the following quote:
The annihilation of human being, not as biological being, of course, but as a being-in-the-world, is therefore a problem and danger that stems from choosing the scientific method as the only one relevant in medicine. …[T]he danger is that the scientific attitude finds a dominating hold by way of the technology that makes the attitude in question harder to critically scrutinize and complement with the phenomenological point of view. (p. 136)
When medicine is effective in extending the life of a human being by ten years, what does this mean? When defined biomechanically, a beating heart is all that is required to keep someone living, but what kind of “life” is this? If living is defined scientifically, then technologies may be employed to this objective. These, however, do not and cannot touch the existence [Da-sein] of the person.
Svenaeus urges his readers to re-examine the goals of medicine and particularly what is meant by health the way hermeneutic philosopher Hans Georg Gadamer has done in his famous Enigma of Health. Health is not the success of medical science but the state in which one is unaware of health. Health “cannot be produced by the doctor using technical and scientific skills” Svenaeus reminds us, “rather, health must be re-established (p. 139).
Existential Medicine does not end without reference to Heidegger’s (1927) famous broken hammer, made by American professors Piemonte and Ramsey in Chapter 14. Like the weight and heft of a hammer that only becomes apparent when the latter becomes broken as a tool, the authors argue that human beings only become aware of health when it breaks down. Their attention then shifts to the notion of authenticity when dealing with a traumatic illness, describing the possibility that an inauthentic mode of being might be understandable. For example, instead of meditating on the full implications of a stage four cancer diagnosis, a patient may reasonably choose to pretend nothing is wrong and follow-along with the behavioral expectations of “the they [people].”
The book concludes with a shift in focus to elder care. In Chapter 15, American physician and philosopher Drew Leder explores the question of what it means to “age well” — reminiscent of Joan Erikson’s chapter on Gerotranscendence (Erikson & Erikson, 1998, pp. 123-131). The modern medical model, Leder argues, “associate[s] later life with a series of potential diminishments to be defeated: sickness, destitution, disability and the loss of enjoyment” (p. 225). These, he explains, might be replaced with examples of what he calls “aging well.” For example:
elderhood may be a time to reap the wisdom accumulated over decades of experience; explore new territories; meet and surmount extreme challenges; become more vulnerable, and thereby more compassionate; turn to matters of the spirit with an urgency or maturity that was lacking in youth; and so on. (pp. 225-226)
To demonstrate these possibilities, he introduces four historical, cultural, spiritual and religious archetypal elder figures: Contemplative, Contributor, Compassionate Companion and Creative: “four ways to see the elder anew while avoiding ageist presumptions” (p. 226).
The link between humanistic psychology and attempts to existentially humanize medicine goes back nearly a century with neuropsychiatrist Kurt Goldstein (1934/2000) — the person responsible for the now humanistic concept of “self-actualization.” Goldstein understood the existential dimension of all medical practice. He explains, for example, how any “medical decision always requires an encroachment on the freedom of the other person” (p. 341). He continues, “With the concepts of freedom and responsibility we enter into the spiritual sphere and seem to remove ourselves from natural science” (p. 342).
This is what Aho and his authors accomplish in Existential Medicine. Their words, echoing those of Heidegger, Boss and the contributors to the special issue on Daseinsanalysis (Craig, 1988), remind the readers of this society of an important area where humanistic practitioners, scholars and researchers — those who are sensitive to the existential dimension of human being — are needed today.
Health psychology, with its mission to integrate psychology with biomedicine, is not headed in the direction of the solution of the problems in contemporary health care — at least not as far as the authors of Existential Medicine are concerned. Furthermore, with the emphasis on biomedicine creeping into every facet of psychological and psychiatric practice, who is left to take seriously the experience of illness? This task has evidently fallen to the minority of philosophers and physicians who have continued to find the collaboration between Heidegger and Boss an important one.
Posted Tuesday, Sept. 4, 2018
Patrick M. Whitehead, PhD, teaches psychology at Albany State University in Albany, Ga. His existential-phenomenological approach to general psychology has been published as an anti-textbook (R&L:2016. He studied existential humanistic psychology (MA, 2011) and phenomenological psychology (PhD, 2014) at the University of West Georgia under the guidance of Christopher Aanstoos. Whitehead also organized parts of his master’s thesis into a monograph titled Education in a Postfactual World: From Knowing to Understanding (Brownwalker, 2018). His PhD thesis has been organized into a monograph titled Expanding the Human: Posthumanism, Nonhumanism and Humanistic Psychology (Lexington Books, 2017).
Aho, K. (2008a). Medicalizing mental health: A phenomenological alternative. Journal of Medical Humanities, DOI 10.1007/s10912-008-9065-1.
Aho, K. (2008). Rethinking the psychopathology of depression: Existentialism, Buddhism, and the aims of philosophical counseling. Philosophical Practice, 3(1), 207-218.
Aho, K. (2017). A hermeneutics of the body and place in health and illness. Place, Space, and Hermeneutics, 5, 115-126.
Aho, K. (2018a) Neurasthenia revisited: On medically unexplained syndromes and the value of hermeneutic medicine. Journal of Applied Hermeneutics, article 6, 1-14.
Aho, K. (2018b). Temporal experience in anxiety: Embodiment, selfhood, and the collapse of meaning. Phenomenology and Cognitive Science, DOI-10.1007/s11097-018-9559-x.
Aho, K. (in press). Notes from a heart attack: A phenomenology of an altered body. In C. Faulk & E. Eriksen, (Eds.), Phenomenology of the broken body. London: Routledge.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th ed. Washington: APA.
Boss, M. (1979). Existential foundations of medicine and psychology. New York: Jason Aronson.
Craig, E. (1988a). Psychotherapy for freedom: The daseinsanalytic way in psychology and psychoanalysis. The Humanistic Psychologist, 16(1), 1-278.
Erikson, E., & Erikson, J. (1998). The life-cycle completed. New York: W.W. Norton & Co.
Fuchs, T. (2013). Depression, intercorporeality, and interaffectivity. Journal of Consciousness Studies, 20(7-8), 219-238.
Gadamer, H. (1996). The enigma of health. J. Gaiger and N. Walker (Trans.). Stanford, CA: Stanford University Press.
Goldstein, K. (2000). The organism. New York: Zone Books. (Original work published in 1934)
Heidegger, M. (2008). Being and time. J. Macquarrie and E. Robinson (Trans.). New York: Harper Perennial. (Original translation published in 1962)
Heidegger, M. (2011). Zollikon seminars: Protocols—conversations—letters. M. Boss (Ed.). F. Mayr & R. Askay (Trans.). Evanston, IL: Northwestern University Press.