Monday, December 12, 2011

The Morality of Play for the Capitalist Subject

Recently, I’ve been perplexed with what I might call the ‘morality of play’.  By this I mean to ask: how can a politically committed subject living in a capitalist society experience pleasure or play that is not already co-opted or incorporated into relations of power?  Or, more simply, is it possible to imagine a Marxist form of ‘play’ or recreation in a capitalist society?  

Let me start with a simple, personal example: football (soccer) is one of the few enduring passions in my life.  I play weekly, but more importantly I am a supporter of Arsenal Football Club, whose matches I follow keenly and attend whenever I am in London.  As a cultural critic, I am intellectually aware of the problems of supporting/paying what is now more a company than a club; of being transformed from a supporter into a consumer; of, as a result of the creation of the Premier League and its lucrative global satellite TV deals, becoming a distant supporter of a remote club thousands of miles away; and of yielding to the ‘cult of personality’ of the club’s superstars, who I’ve never even met, yet feel like family to me.  I have read, with a painful, knowing grimace, Terry Eagleton’s cutting critique of football as the opium of the people (although I think he underestimates the potential for revolutionary organization by local, fan-owned clubs like FC United of Manchester or AFC Wimbledon, among others).  And yet, like a physician who - knowing all the health risks - continues to smoke, I cannot help but remain glued to the Arsenal, looking forward with such joy and pleasure to matches, around which I carefully plan other events in my life.  Is such pleasure immoral?

The short answer is, of course, yes.  Orthodox Marxist perspectives explain how cultural elements like sports, music, and so forth – especially in their mass produced forms – constitute a superstructure determined by the economic base of the capitalist mode of production.  In their Dialectic of Enlightenment, in which they write about the deceptive techniques of the ‘culture industry’, Theodor Adorno and Max Horkheimer argue that in pleasure, human beings divest themselves of thought.  Although inherently free of domination and discipline, pleasure in the hands of rulers is a rational measure of manipulation, administered to subjects in controlled doses.  In this sense, football is not the only form of pleasure already ‘poisoned’ by power.  One could think of any number of forms of play that are, in the ‘soft’ sense of ideology or the ‘hard’ sense of hegemony, already constitutive of, or at least linked to, techniques of manipulative domination – like going to the movies (cf. Guy Debord’s Society of the Spectacle) or enjoying a post-dinner dessert (cf. Sidney Mintz’s Sweetness and Power). 

Of course, these forms of play are all practices that continually re-constitute us as capitalist consumers, conditioned to find pleasure (and our own postmodern identities) in a way that reproduces the existing mode of production.  Even where we might have options to resist – e.g. via a boycott of a particular product – such resistance is merely a choice already constrained.  If you refuse to buy non-organic milk because of the way in which the drive for profit-maximization has led to the ill-treatment of cows, you have the option of buying organic milk, a purchase that – however moral it may seem – is still a purchase from a profit-making company within a system that exploits labor power (cf. Slavoj Žižek’s First as Tragedy, Then as Farce).  

But what about non-consumptive forms of play?  What are, in this particular historical moment, or conjuncture, the moral stakes of going to a dinner party?  Of having sex?  Of playing pick-up football?  Here, the problem of play arises in a different form, and requires us to think more deeply about the opposite of play or pleasure today: work.  Raymond Williams, in his excellent Keywords, traces the etymology of work before it acquired new connotations under industrial capitalism.  Today, of course, ‘work’ signifies ‘paid employment’, but it used to merely signify ‘activity’.  As a graduate student, when I say, “I need to get to work,” I’m often mistaken to mean that I am employed as an alienated wage laborer, when I simply mean I would like to read or write as part of an activity-process very much my own (one in which I feel I become more rather than less human, and thus ‘need to’ in the Foucaultian ethical sense of self-betterment rather than the sense of labor discipline).  My sense of work, I would like to think, is one that connotes its earlier meaning – merely a form of activity, rather than work in the sense of ‘labor’ that has become a commodity and a class.  And yet my sense of work is by no means dominant.  For the capitalist subject  (which I certainly am, in spite of the less alienating form of my labor), all forms of play – even the non-consumptive – are inextricably bound to the dominant sense of work, as a counter-alienating practice prepared precisely to balance the alienation of capitalist work.  Who doesn’t at times long to come home from work to enjoy a TV show, to make love to a partner, to have a family dinner?  For most of us, these are what we see as our ‘real’ lives, what we do outside of work.

This work-play complex is connoted best in that heinous expression (unfortunately, too commonly heard in medical school), “Work hard, play hard.” This mode of life creates the perfect circle to maximize productivity – one must do one’s best while at work, and then do one’s best while at play, only in order to be able to perform better at work.  If ‘play’, in the form of religion, sports, music, and so forth, is not taken as a way to rejuvenate our bodies and minds from the labor we perform for others, it at the very least orients us towards searching for life in our limited time off from work, preventing us from organizing work (in the sense of activity) such as the occupy movement (which is itself sustained by economic crisis, unemployment, and lack of opportunity for educated young people).  In Wage Labour and Capital, Marx writes of industrial labor:
[The worker] works in order to live.  He does not even reckon labour as part of his life, it is rather a sacrifice of his life…What he produces for himself is not the silk that he weaves, not the gold that he draws from the mine, not the palace that he builds.  What he produces for himself is wages, and silk, gold, palace resolve themselves for him into a definite quantity of the means of subsistence…And the worker, who for twelve hours weaves, spins, drills, turns, builds, shovels, breaks stones, carries loads, etc. – does he consider this twelve hours’ weaving, spinning, drilling, turning, building, shoveling, stone breaking as a manifestation of his life, as life?  On the contrary, life begins for him where this activity ceases, at table, in the public house, in bed.
[I should mention that today, capitalism operates largely through flexible accumulation, and actively promotes worker autonomy and creativity in some lines of work as a counter-measure against alienation. (cf. Luc Boltanksi and Eve Chiapello's The New Spirit of Capitalism)]

In this notion of ‘play’, even non-consumptive forms of pleasure exist ideologically, as though coming up to gasp for breath in a pool from which there is no escape or exit.  Dinner parties, sexual activity, and all other forms of non-consumptive play remain – to the extent that they do not offer an alternative Marxist hegemony – ways in which the capitalist division of work and life becomes self-affirmed.  They are means of adapting ourselves to a common sense that is not only non-sensical, but immoral within Marxist ethics. (I should say that this type of Marxist asceticism, however similar, should not be confused with the Protestant ethic of capitalism that Max Weber once wrote about.  Indeed, as E.P. Thompson describes in The Making of the English Working Class, trade unionism arose with similar asceticism and self-discipline, which I take to be necessary in any radical political struggle.)           
What would moral ‘play’ then look like for both an anti- or post-capitalist subject?  For an anti-capitalist subject, how can we begin to think of ‘revolutionary’ play in everyday life?  Can we think of ‘revolutionary’ dinner parties, ‘revolutionary’ sex, or ‘revolutionary’ football?  For a post-capitalist subject, for whom that negative connotation of ‘work’ associated with capitalism falls away in place of joy, what happens to ‘play’ altogether?  When labor becomes pleasure, what constitutes play, and what purpose does it serve? 

Friday, November 4, 2011

Capitalism, Violence, and the Problem of the Spectacle

I had the opportunity to observe some events at ‘Occupy Oakland’ on the day of the general strike (Nov. 2).  I have not been involved in the occupy movement and, as an anthropologist interested in social justice, wanted to examine the movement’s rhetoric and actions firsthand.  I reserve judgment or critique on the movement itself, which is still in its early stages.  But, as I explore below, some things I saw and heard reignited my recent conceptual struggle with the idea of violence.  I’m referring mainly to growing discontent with a faction of the occupy movement that has vandalized property and not agreed to use ‘peaceful’ means of protest.  During the night after the occupation of the Port of Oakland, a group of protestors broke windows, threw stones, and started fires.  As far as I know has been reported, the protestors did not hurt anyone or cause damage other than to property.  They have been roundly condemned by police and fellow occupiers alike.

What is violence?  And why does it conjure up such emotional angst among us?  Anthropologists and philosophers have long struggled with this question.  For most of us, violence is that physical or bodily damage - rape, crime, killing, and other acts that violate the dignity of the physical body and property.  Violence brings to mind images of shootings and stabbings, of torture and mutilation, of vandalism and looting.  But of course, violence is much more than that.  Paul Farmer, among others, has popularized the idea of ‘structural violence’, or the violence done by structural processes and social conditions that condemns some to poverty and disease.  It is an idea that could be used to describe the ways in which fluid capitalism creates growing inequality between the richest and poorest, felt particularly during economic crises such as the one that led to the occupy movement. 

How can we compare physical and structural violence?  For most of us, they are both immoral.  But philosophers are not so sure.  Marxists Frantz Fanon and Jean-Paul Sartre believed that violence was critical to ensure political and human liberation for the colonized, who (in the late 1950s and early 1960s) were plagued by an inferiority complex.  Even the liberal Hannah Arendt felt that to take away violence from man would be to dehumanize him.  She opposed violence not to peace or non-violence, but to power.  Those regimes losing power would increasingly resort to violence in order to maintain it.  But violence will always destroy power, never giving rise to it.  Let us then be skeptical about not only the glorification of violence for the grand end of seizing power, but also the revulsion against violence as an inherent evil. 

 First, it is too easy to condemn physical violence.  There is something about the way in which the flowing of blood, the smashing of a window, or the explosion of a gunshot shatters our world.  We become transfixed by the spectacle that it so often produces – pools of blood, destroyed buildings, a dead body – in part because they disrupt our sense of normalcy.  But everyday normalcy is not equivalent to historical normalcy; in the Marxist sense, of course, all history has been a history of class struggle, with violence and revolution inherent to that history.  From a historical perspective, nothing could be more normal than for a movement directed against the wealthiest class to turn to violence against property. 

Does this mean that an event attentive to historical normalcy should be seen as moral?  This is a more difficult question, with several perspectives.  From the point-of-view of the land-owning class, such an event is considered inherently wrong within a bourgeois moral framework in which the protection of property is guaranteed by law and ideology.  Their moral stance is shared by many occupiers from the middle classes who were ‘hurled’ into unemployment after diligently following the rules of achieving the American dream.  From the point-of-view of other more radical occupiers, violence risks alienating potential liberal allies, and becomes a utilitarian question about the efficacy of tactics by which the movement can grow and accomplish specific goals (which seem to still be in the process of formulation).  From a Marxist perspective, one might see the destruction of corporate property as a physical violence fighting against a structural violence.  Yes, a downtown Oakland bank branch seems quite normal and harmless.  It employs local workers and provides a useful service to local residents.  But it is in fact not only symbolic of but also constitutive of a structural violence by which labor power is exploited and finance capital grows – the essential violence done by the capitalist mode of production on workers.  That we aren’t shocked when we walk by a bank branch is because what goes on inside is not earth-shattering shootings or visible torture of people.  Instead, it is a slow violence, an everyday violence, in which the blood and sweat of labor is exploited, hour by hour, dollar by dollar.  
Ultimately, the ethical dilemma in which we are left is this: how does one best respond to the structural violence of capitalism?  The occupy movement has successfully gathered a critical mass of people ready to act, but with very different ideas of what type of action should take place.  I am neither convinced by the violence of some occupiers nor by the non-violence of others.  To close, I draw from Karl Marx’s The Civil War in France (1871).  He was analyzing the reasons for the fall of the Paris Commune – the 1871 takeover of the city of Paris by workers in what was seen as the first ‘dictatorship of the proletariat’.  The socialist occupation was cut short when troops from Versailles re-took the city, crushing the nascent government and executing many of its members.

"...In the economic sphere much was left undone which, according to our view today, the [Paris] Commune ought to have done. The hardest thing to understand is certainly the holy awe with which they remained standing respectfully outside the gates of the Bank of France. This was also a serious political mistake. The bank in the hands of the Commune - this would have been worth more than ten thousand hostages." - Karl Marx, from 'The Civil War in France' (1871)

Perhaps the battle against structural violence consists neither of destroying banks nor of occupying public spaces; historical lessons suggest that occupying banks is an alternative worth considering. 

Monday, October 10, 2011

On Love and Humanism

Che Guevara: With his family, holding his baby (left and/or right?)

I want to explore a fundamental question about the way we treat other human beings.  It is a simple question, but one that ultimately, I think is critical for anyone with humanitarian pretensions, with a desire to ‘save the world’.  It is this: is loving someone compatible with loving humanity?  That is, can you love a single person while also loving people at large? 

French philosopher Jacques Derrida, examining Aristotle’s Eudemian Ethics, once wrote:
It is not possible to love while one is simultaneously, at the same time (áma), the friend of numerous others (to de pollois áma einai phílon kai to phileîn kōlúei); the numerous ones, the numerous others – this means neither number nor multiplicity in general but too great a number, a certain determined excess of units.  It is possible to love more than one person, Aristotle seems to concede; to love in number, but not too much so – not too many.  It is not the number that is forbidden, nor the more than one, but the numerous, if not the crowd.
Depending on your interpretation, it is either impossible to love while one is in love with the crowd, or it is merely impossible to love the crowd – that is, humanity. 

Let’s step back down from the heights of philosophy to some practical historical and contemporary examples.  In the 1960s and 1970s in America, and arguably even today in many parts of the world, Che Guevara powerfully symbolized a love for humanity.  A doctor and revolutionary who sacrificed his life for the cause of justice, he once famously said, “Let me say, at the cost of seeming ridiculous, that the true revolutionary is guided by sentiments of love.”  For the moment, let’s ignore the problem of Guevara killing his enemies in guerrilla warfare (a problem common to any military struggle that either takes the enemy to lie outside of humanity, or envisions violence as part of the constitution of its own humanity).  Let’s instead focus (perhaps ‘speculate’ is a better word) on the relationship between Guevara’s love for humanity and his love for his family – his father, mother, wife, and children.  Of course, Guevara was quite often separated from his family while attempting to spark Marxist revolution across Latin America and Africa.  His love was distant, as his personal letters reveal:

[To his parents] I have loved you very much, only I have not known how to express my affection.  I am extremely rigid in my actions, and I think that sometimes you did not understand me.

[To his children, from Bolivia in 1966] Right now I want to tell you that I love you all very much and I remember you always, along with mama, although the younger ones I almost only know through photos, as they were very tiny when I left.

[To Dr. Aleida Coto Martínez of the Cuban Ministry of Education] Sometimes we revolutionaries are lonely.  Even our children look on us as strangers.  They see less of us than of the soldier on sentry duty, whom they call ‘uncle.’ 

[To a Spanish woman with the surname Guevara] I don’t think you and I are very closely related, but if you are capable of trembling with indignation each time that an injustice is committed in the world, we are comrades, and that is more important (my emphasis). 

We see in Che’s personal letters the tensions between a revolutionary love for humanity and a love for his family.  He spent so much time away that he and his children became something like strangers to each other.  As much as he sent his love to them through his letters, his fatherly love was absent in everyday life.  And, as he suggests to a Spanish Ms. Guevara, being a comrade was more important to him than being family.  Guevara is not alone in history for dealing with this tension.  Karl Marx, born middle class, became so dedicated to his philosophical work that his family fell into poverty, reliant on the earnings from his colleague Friedrich Engels’ father, a mill owner in Manchester. 

I’m not interested in condemning these historical figures for neglecting their families, nor in attempting to argue that their relative neglect of their families somehow undermines the quality of their philosophy and work.  But the contradiction between a love of one’s family and a love of Man asks serious questions about the meanings of ‘love’ and ‘humanism’.  When we implicitly claim a ‘love of Man’ (literally: ‘philanthropy’), do we mean the same kind of ‘love’ that we would have for a parent, a child, or a partner?  Is a humanist as obligated to a stranger on the street as she is to her mother?  We could argue that she is merely asked to show a certain level of civic respect and responsibility to the stranger.  But, as physician-anthropologist Didier Fassin has shown in his anthropology of humanitarian reason, even this common-sense logic can be torn apart in times of crisis or emergency.  In what he calls the ‘inequality of life’, Fassin points out the underlying inequalities that separate not only aid workers from their beneficiaries, but Western aid workers from local aid workers.  When, for example, imminent danger appears locally, international aid agencies usually evacuate their foreign personnel, leaving (in some cases) local staff to be killed.  This kind of ‘lifeboat’ ethics – in which international aid workers are saved over local ones, or mothers are saved over strangers – contradicts the theory of humanism.  Despite our liberal claims that human beings are born equal and have equal rights, we always privilege those closer to us in some way. 

For those of you with interest or experience in international humanitarian work, this dilemma sounds familiar.  I’ve spoken with many doctors who find it difficult to commit to global health as anything but an idealistic pursuit of young physicians.  Love keeps them tied to friends and family in the United States, making a permanent and wholehearted commitment to global medical work (i.e. a globe of unmet medical need) nearly impossible.  Programs like the Global Health Equity residency at Brigham and Women’s Hospital allow medical residents to train both in Boston and abroad.  But even if their employers are supportive, it can no doubt be hard to convince partners and even young children to move abroad for many months at a time.  This no doubt in part explains the popularity of programs like Operation Smile, which – like military missions –swiftly jet in and out of areas where people do not have access to modern biomedical care.  It’s little surprise that many of these types of organizations (Partners in Health excluded) emphasize intermittent specialized care over the establishment of national and regional primary care networks. 

It’s tempting to expose humanism as a farcical or at least idealistic ideology, similar to human rights, the United Nations, and so forth.  Great in theory, but doesn’t work in practice.  But why doesn’t it work?  Beyond the geopolitical decisions that undermine these institutions, there is a sense that these concepts require a sacrifice –a self-sacrifice* – that asks too much, that asks us to be superhuman or even nonhuman.  It asks us to place our child’s needs equally next to that of a stranger’s, to forsake a family’s love for a love of humanity.  Certain institutions – the US armed forces, for example – ask their recruits to adopt this philosophy of sacrifice, although usually only temporarily.  Charismatic figures like Guevara sacrificed their love for and desire to be with their families for a love of humanity.  Otherwise we can perhaps only think of machines as capable of responding equally to different individuals. 

I am convinced that it is impossible to love a single person while also loving humanity.  But perhaps more useful than this is to understand that such a contradiction is an eminently modern problem, in part created by webs of responsibility and dependence through the spindle of a globalized capitalist mode of production.  Simply, we would find it difficult to think of ourselves as somehow responsible for the well being of distant others prior to establishing ourselves in relation to them, and in particular, in modes of domination characterized by colonialism, imperialism, class, and so forth.  They are, as I frame them, also problems of a Western intellectual tradition that insists on the equality of Man (contrasting, for example, Indian caste or African networks of patronage).  Even if we were to establish ourselves as dominant to others, it is primarily through the liberal concept of the rights of man born in liberal Enlightenment that we establish the basis for our practice of domination to contradict our ethics of care for others.  Essentially, the idea that we should even be bothered by dominating others is a socially constructed idea. 

I look forward to hearing your thoughts on whether you think one can be truly ‘humanitarian’ while being in love - if we are able to simultaneously love one and love all.  Or does loving one merely expose the farce of ‘humanity’ and the impossibility of being humanitarian? 
*We should be careful to recognize the culturally specific Judeo-Christian roots of the ideas of ‘sacrifice’ and ‘humanity’.  For ‘sacrifice’, recall the Abraham and Isaac parable, in which Abraham’s faith in God is tested when he is asked to sacrifice his son Isaac for God.  For ‘humanity’, we can turn to Auguste Comte’s ‘Religion of Humanity’.  This notion of ‘humanity’ arose as secular rejection of Christianity, put Man in the place of God and calling for his worship.  Despite rejecting the idea of God, ‘humanity’ as a concept is still molded within Christian philosophy. 

Tuesday, October 4, 2011

A Starving African Child: What do you see? How do you feel? What are you going to do?

I apologize.  The picture above is difficult to look at.  It was taken by Kevin Carter, a Pulitzer Prize-winning photojournalist, in 1993 in Sudan, as a starving child attempted to reach a famine relief center.  A vulture lies ominously in the background, waiting for what seems to be a certain death. 

What do you see? 
We’re confronted by images of absolute suffering like these all the time, particularly through charity appeals.  As anthropologist Liisa Malkki has noted, these images often depict the pain of innocent children.  They cannot be child soldiers or espouse any political stance, since this would betray their innocence by implying that they chose to die or suffer for a greater cause.  They can only rarely be replaced by adults, and if so, they are almost guaranteed to be the ‘fairer sex’ that is supposedly naturally nonviolent and loving.  If I sound like the director of a product commercial, making sure that I ‘sell’ the product as best I can, then perhaps there’s more in common between a Christian charity relief appeal and the commercial that follows it on an average cable network.

In 1967, French philosopher Guy Debord wrote an important work called ‘Society of the Spectacle’.  He suggested that, in this age of mass media and consumerism, our senses have been so numbed that reality itself has become mediated through images.  His work is a variation on Karl Marx’s idea of the fetish.  By this, I’m not talking about sexual fetishes (the analysis of which I’ll leave to Freud); rather, I mean that what are social relations between people are replaced by social relations between things.  We may not realize it, but (in Marx’s eyes) we fetishize these human relations everyday.  How many times do we see a fancy car on the street, admiring the car itself without thinking of the people who built it, those who collected rubber to produce its tires, those who dug the oil wells to provide the petrol to make it run?  When we come to relate to things, and not the people behind those things, we become fetishizers and in Marx’s eyes, further away from our humanity. 

What do YOU see in this picture?  I see a starving African baby, so malnourished and so disfigured as to be hardly human at all.  But what I don’t see are the conditions that created this situation, this thing that shocks us.  As Alex de Waal, a prominent scholar of Africa, has argued, famines are rarely if ever the product of natural causes like droughts, and if they are, they can often be predicted well in advance and addressed via preventive action.  Starvation is a result of human causes, of human actions and relations like politics and violence that turn people into things both in reality and in images.  As I examine below, looking at images in this way forces us to think about our own action or inaction in the creation and perpetuation of suffering.

How do you feel? 
Pictures like these meant to shock, to act on the emotions in a particular way.  Luc Boltanski, an eminent French sociologist, has talked about two emotions generated by this type of image – pity and compassion.  Pity, he argues, is a strictly emotional response that is generated by distant suffering.  It is sentimental, distinguishing only between who suffers and who doesn’t.  It doesn’t stop to ask if the misery is justified or not, but urgently rushes to action against suffering.  Compassion, on the other hand, is less emotional and less distant.  To have compassion requires a face-to-face meeting between the sufferer and the compassionate person, to have a real presence. 

Pictures like the one above are used in a variety of ways, as Susan Sontag reminds us.  They can be employed as propaganda, both by pacifists and war hawks, to end or go to war.  They can shock us into action, usually by donating money to a famine relief fund.  They can become part of an art gallery and turn into what has been called ‘disaster pornography’, in which the image of the suffering of another is exploited for financial or other gain.  Although we all have different reactions to images like these, a common response is that such images can tug on our emotions rather than our reason – they can urge us to feel and to act, not to stop to think and ask questions.  Such was the case during the blockade of Biafra, a secessionist region of Nigeria, in 1968.  The Biafran government, keen to attract Western goodwill to its cause, hired an American public relations firm that exploited images of suffering to aid the Biafran cause.  Rather than helping us understand the conflict, these images merely created for us divisions of good Biafrans against evil Nigerians.  But in such a complex world, should uninformed understandings of ‘good’ and ‘evil’ determine our morals and ethics? 

What are you going to do? 
This is where we come to the real ethical moment – the moment when our sense of right and wrong is challenged.  My own ethics when it comes to suffering is largely dependent on the history of that suffering.  Let me give you an example.  You may have seen a popular appeal from a Christian charity on television that profiles the suffering of a very young Guatemalan girl and asks us to sponsor her school fees. As an American citizen, I find this difficult.  I know that in 1954, the CIA, with the support of Chiquita, orchestrated a coup against the democratically elected socialist president of Guatemala who was trying to institute land reform to help bridge the gap between poor peasants and rich landowners.  I know that the famous revolutionary Che Guevara was in Guatemala at this time, and inspired by the injustice he felt was being committed, later helped overthrow Fulgencio Batista in Cuba, establishing a socialist state that spends more of its money on education than the US and whose current literacy rate is higher than that of the US.  So when I am asked to donate, I am more than a little cynical.  I wonder what might have been if the CIA had not overthrown a democratically elected government.  And I wonder if my own money is being asked to counteract the consequences of that spent by the US government more than fifty years ago.  I take the child to be a fetish – the perfectly innocent thing that demands my action while hiding history and politics outside the picture. 

Another problem with acting on this type of suffering is the form in which I am asked to act – that is, to give money.  Marx, and more recently, Slovenian philosopher Slavoj Žižek, have been critical of these efforts of the middle class to help the exploited poor. 

In the Communist Manifesto (1848), Marx provided a stinging critique of charity:
A part of the bourgeoisie [the middle classes] is desirous of redressing social grievances in order to secure the continued existence of bourgeois society.  To this section belong economists, philanthropists, humanitarians, improvers of the condition of the working class, organisers of charity, members of societies for the prevention of cruelty to animals, temperance fanatics, hole-and-corner reformers of every imaginable kind…The Socialistic bourgeois want all the advantages of modern social conditions without the struggles and dangers necessarily resulting therefrom [that is, the revolt of the working class and poor]. They desire the existing state of society, minus its revolutionary and disintegrating elements. They wish for a bourgeoisie without a proletariat [the working class].

Marx is referring to the fact that the upper classes who give charity rarely understand how their own actions contribute to the suffering of the working class.  Žižek states this case well, calling this the ‘liberal trap of “humanitarian help” ‘.  This trap is a type of ethic that permits a ruthless pursuit of profit as long as it is counteracted with charity – avoiding the issue of complicity and co-responsibility for the misery of the poor.  Žižek points us to the case of George Soros, who made his billions through hedge funds (an exemplary form of capitalist exploitation) and yet is strongly dedicated to philanthropy.  According to Žižek, Soros gives away with one hand what he stole with the other.  This type of hypocritical charity is not limited to the megarich.  At Berkeley, I am constantly reminded how we are asked to consume in order to solve problems of poverty through campaigns like the anti-HIV ‘(Red)’ or the anti-domestic violence movement ‘Shop till it Stops!’.  In promoting consumption as a solution to poverty, we forget that consumption (as part of the capitalist mode of production) is also a cause of poverty.  Not only that, but we end up coming to the aid of another by engaging with things, fetishes.  Buying a t-shirt substitutes for self-sacrifice, political change, or face-to-face help for another human being. 

I am, no doubt, cynical about charity.  But I have trouble with the idea of rationally explaining away the suffering before me.  Can I really dismiss it as a hypocritical appeal, turning away a child just like that?  As with my patient, I’m confronted by the immediate suffering before me and the structural inequalities that create it, and which are perpetuated by a ready acceptance to act in ethically questionable ways.  By consuming to save this child, I implicitly underwrite the system of production that produces this suffering, agreeing to wipe away the historical and political inequalities that have created such misery.  But what do you do when a suffering child asks you for money to go to school?  Or a mentally ill homeless man asks for spare change to buy a meal?  Is it unethical to give them money, thereby letting the government off the hook of providing free public education, healthcare, and low-cost housing for all?  Is it unethical to point to structures, politics, and histories to divest myself of personal responsibility for the child or homeless man? 

I don’t have an answer.  I’d like to hear from you to understand how you react to images of suffering, and what you do.  This is indeed a serious ethical dilemma of individual bourgeois responsibility for suffering in the world.  For some, like Kevin Carter, it is a matter of life or death.  The photographer was so haunted by, among other problems, the images of suffering he encountered that he committed suicide in 1994, a little over a year after taking this iconic picture. 

Thursday, September 29, 2011

Reflections on the Ethics of Practicing Medicine

Like many aspiring doctors, I imagined myself working to serve the underprivileged, to ‘help humanity’ by dedicating my life towards health for all.  I wanted to use the privilege of my position to help those less fortunate, those struggling with poverty, inequality, and injustice. 

But after two years at Harvard Medical School, I became quite disillusioned with the possibility of putting this vision into practice.  In this post, I want to share with you some of my frustration with medicine – both the American system and the discipline itself – that brings to light some fundamental ethical problems that haunt me and others.  It was this frustration that led me to enter a program in medical anthropology in which I have been exploring these issues and trying to find fresh ways of doing medicine that are ethical and just.

Many of you are no doubt aware of the ways in which American healthcare perpetuates inequality.  Without a single payer national healthcare plan, many of our nation’s poor (and middle class) do not have adequate access to healthcare.  We spend far more money on expensive treatments of preventable disease than on cheap, effective public health measures.  Despite far outspending many countries on healthcare, our health outcomes are no better, if not worse.  While our technological advancements in genomics are leading us into age of ‘personalized’ medicine, we still don’t have the ‘impersonalized’ structures in place to guarantee even basic healthcare for all.  As a medical student, I saw these problems daily: observing costly procedures to insert cardiac stents in people living in a culture of over-eating and under-exercising, or watching homeless patients getting pushed back out onto the streets once their acute medical problems had resolved.  It can be difficult to remember you are performing a ‘humanitarian’ job when you sometimes create or perpetuate more problems than you solve.

At their core, these are structural problems that could be solved with a shift in budgetary priorities to reflect a commitment to prevention and equality.  This is an important problem that policy makers, physicians, and activists across the country have rightly dedicated their lives to.  But what I find more disconcerting in everyday practice as a physician is not necessarily the structures in which we practice medicine, but the underlying ideologies and assumptions that accompany our practice. 

Let me paint a picture of what I’m referring to.  In many adult primary care clinics, but especially ones that serve low-income patients, depression and mental illness is a common diagnosis.  Depression certainly has biomedical causes and can be traced to chemical imbalances in the brain.  But, more than medicine would like to admit, depression (as physician-anthropologist Arthur Kleinman and others have shown) can be a product of social and cultural problems.  It is no surprise that a single, immigrant mother who has just lost her job should be prone to depression; like the way we think of PTSD, depression can be a normal reaction to an abnormal situation.  As doctors, we are torn between the structural problems of the world and the suffering patient before us.  In prescribing an SSRI, we may relieve the tremendous pain of our patient; yet are we merely papering over the cracks of socioeconomic injustice and inequality, providing (almost literally) the ‘opium’ to the masses once described by Karl Marx?  In acting bioethically to our patient (that is, following the Hippocratic Oath and standard medical practice), are we acting unethically with respect to the broader suffering and problems of the world?  In providing loving care to our patient, are we underwriting the very violence that wrought so much suffering onto our patient? 

This is one dilemma of practicing medicine that I would refer to as the problem of ‘superstructure’.  Marx wrote about superstructure as encompassing all those institutions and practices that perpetuated a fundamentally unequal capitalist mode of production.  For Marx, superstructures in society were meant to placate the masses and prevent them from organizing revolution to take over the means of production.  His classic example was the church – the place where workers were taught to endure misery in this life for reward in Heaven.  Today, I fear that the hospital is taking the place of the church, keeping workers in good condition while allowing what are essentially social problems to be seen as medical problems. 

A second, and arguably more fundamental dilemma, is what I would call the problem of ‘biopolitics’.  ‘Biopolitics’ is a term popularized by French philosopher Michel Foucault and, put simply, refers to the ways in which populations are managed or controlled.  This may sound menacing, but biopolitics can sometimes be quite beneficial to society and its individuals: the practice of having a yearly health exam, of not being allowed to smoke in buildings, of understanding the importance of eating right and exercising regularly – these are all effects of biopolitics.  They save money and lives, improving the quality of life of all.  Yet they are not entirely non-violent practices.  Being a doctor who encourages people not to smoke, who urges them to have yearly physical exams, and who suggests ways to get more exercise is to have an unquestioned sway in influencing others, to be guides for others on how to live.  If not social coercion, it is a persuasion, a way to tell others ‘this is right, this is wrong, and you should believe me because I wear a white coat.’  It uses expertise and authority to dictate ethics to others. 

Allow me to quote from a 1784 essay by philosopher Immanuel Kant, in which he attempts to answer the question of ‘What is Enlightenment?’:
It is so easy to be immature. If I have a book to serve as my understanding, a pastor to serve as my conscience, a physician to determine my diet for me, and so on, I need not exert myself at all. I need not think, if only I can pay: others will readily undertake the irksome work for me. The guardians who have so benevolently taken over the supervision of men have carefully seen to it that the far greatest part of them (including the entire fair sex) regard taking the step to maturity as very dangerous, not to mention difficult.
In my reading, Kant implies that having others like physicians determine your sense of ethics is a sign of immaturity, a symptom of imprisonment within the chains of ignorance, awaiting to be Enlightened.  We are far too happy to allow doctors to supervise us, rather than to declare ourselves mature enough to supervise ourselves.  I do not mean to suggest that doctors are involved in brainwashing or controlling patients via bioethics; Foucauldian anthropologists like Paul Rabinow have been careful to show the consensual and beneficial ways in which biopolitics are practiced.  What worries me is that the very practice of guiding patients creates social difference between the patient and physician.  In daily practice, I draw on a specialized body of knowledge to solve problems that others cannot solve for themselves.  In this process, I re-iterate my medical maturity over their medical immaturity.  Even as I am on leave from medical practice while in graduate school, I am sometimes asked by my colleagues for medical advice, and in the very practice of guiding them I exert a type of domination over them.  Even if it is benevolent, it produces inequality and creates an ethical problem for me.  I would term this the dilemma of ‘Enlightenment’ – the product of dividing (quite rationally) an enormous body of knowledge into various systems of interconnected labor, making patients dependent on physicians to help decide what is right and wrong for their bodies and health. 

If you’ve gotten this far with me, I thank you for reading.  If you’ve (quite reasonably) skipped to this last paragraph for a little summary of what I have to say, here it is: bioethics go beyond problems of deciding who gets care when there are limited resources, or whether physician-assisted suicide is a legitimate medical practice.  It transcends too the material problems of our healthcare system and its inability to provide healthcare for all.  What I’ve suggested are two ethical dilemmas that we often ignore – the ways in which doctors brush social problems under the carpet of medicine (the dilemma of ‘superstructure’) and the ways in which relations of social domination are established by the practical confinement of medical knowledge to an elite few (the dilemma of ‘enlightenment’).  I happily welcome comments on these problems, both from practicing medical students and physicians on how they negotiate and attempt to transcend these troubling dilemmas to remain ‘ethical’ doctors, as well as patients who rely on physicians to solve the problems of their bodies and lives.