In this original and compelling book, Jeffrey P. Bishop, a philosopher, ethicist, and physician, argues that something has gone sadly amiss in the care of the dying by contemporary medicine and in our social and political views of death, as shaped by our scientific successes and ongoing debates about euthanasia and the “right to die”—or to live. The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, informed by Foucault’s genealogy of medicine and power as well as by a thorough grasp of current medical practices and medical ethics, argues that a view of people as machines in motion—people as, in effect, temporarily animated corpses with interchangeable parts—has become epistemologically normative for medicine.
Of Goods and Practices
Medicine is a good in Western society. Those of us who are engaged in the practices of the good of medicine—especially in light of the status that medicine has achieved—think of ourselves as practicing a good that is virtually unqualified. So, when critiques come, we, the practitioners of medicine, tend to have one of two responses: either outright dismissal of the criticism or a quick attempt to resolve the problem. What follows in this book is another critique of medicine, particularly in its mode of caring for the dying. By “the dying,” I mean those who are in the ICU and in palliative care. I have no doubt that there will be those who will dismiss my critique outright. As for the second group, those who hear the critique and accept it as, at least in part, accurate, they will no doubt attempt a quick remedy, one that fixes the problems that affect a broken medicine. Those remedies will range from a call for better scientific data in order to know better how to care for the dying, to a call for a good dose of humanism in order to solve the problem. The former will emphasize the science of medicine; the latter will emphasize the art of medicine. The former will say that medicine needs better science in order to become, once again, humane; the latter will call for a therapeutic course of humanistic education, a humanities pill to fix what ails us. Yet it seems to me that we have been attempting both fixes for so long that we do not even know where the problem lies.
It is virtually impossible to think about how to solve any problem in medicine without our thinking becoming almost immediately mechanical and instrumental. We already live inside a way of thinking that prevents us from thinking differently; not that thinking differently is impossible, it is just difficult. If we are to prevent all practices in medicine from becoming thoughtless doing, we must once again turn to how we think about what it is that we do. In order to achieve this, however, we must, paradoxically perhaps, realize that all thinking is also a kind of doing. The strict line between theoria and praxis, so prominent in the West, and the strict division between subject and object are, in a way, false ones, but they continue to flourish in our practices. These lines (theory vs. practice, subject vs. object) sit at the very heart of the West, if we are to believe thinkers such as Nietzsche and Heidegger; or perhaps these lines are just an aberration of late Western Scholasticism, or are lines drawn at the Enlightenment. If we accept Foucault’s position—which does not preclude accepting any one of these possible readings on the history of Western thought—we know that there are various kinds of practices implicit in all theoretical endeavors, and at the same time there are implicit theoretical stances in all that we do. Thus, we must think, once again, about what it is that we do by examining critically what we do.
Medicine as a discipline is mostly concerned with doing and with the effects it brings about in the world. Medicine concerns itself with how to pragmatically produce or cause those effects in the world. Or, as Carl Elliott points out, medicine collapses into an unthinking pragmatism, an inane “practice in order to be practical.” Medicine is a practice ordered toward and by its own practicality. Medical information is justified as medical knowledge if one can do something with it in the world. Medicine’s metaphysical stance, then, is a metaphysics of material and efficient causation, concerned with the empirical realm of matter, effects, and the rational working out of their causes for the purposes of finding ways to control the material of bodies; that is to say, medicine’s metaphysics of causation is one of material and efficient causation at the expense of final causes or purposes. Among Aristotle’s four causes, early modern science—including medical science—historically repudiated or, at the very least, minimized formal and final causation and elevated material and efficient causation. Efficient causality reigns supreme in all technological thinking, such that even matter comes to be thought of not so much as a cause, but as the stuff that stands in reserve of power, awaiting knowledge to mold it into what we desire it to be. On this view, matter—the body—has no integrity, except that it is driven by an automaticity and can be bent to our desires. At least since Bacon, it has been understood that knowledge is power gained to relieve the human condition. That is to say, true knowledge can do things with the world. The purpose of knowing—the end of knowing—is to bring about desired effects in a world of immanent cause and effect.
Medicine gives no thought to its metaphysics; it might even deny having one. And it gives no thought to its practices, because medicine is about doing and not about thinking. For Western medicine, and perhaps for all of scientific and technological thinking, the important problem in the medical world is how to manipulate the body or the psyche in order to get the effects that we desire. Bodies have no purpose or meaning in themselves, except insofar as we direct those bodies according to our desires. In this sense Eric Krakauer has said that medicine is the standard-bearer of Western metaphysics. The world—the body—stands before us as a manipulable object, and all thinking about the world or the body becomes instrumental doing; thus, to do good we must manipulate the world and show our effects toward some measureable outcome.
In this book, I shall claim that the practices surrounding the care of the dying in our time are built upon this metaphysics of efficient causation, and that this metaphysics became possible precisely because medicine’s epistemology became grounded on the dead body, understood as an ideal-type. After all, life is in flux, and it is difficult to make truth claims about matter in motion, about bodies in flux. Thus, life is no foundation upon which to build a true science of medicine. The processes of living prevent the possibility of true knowledge about the body. Moreover, in the dead body, in the stasis of death, one can find a firm ground on which to make truth claims. Taking the dead body as epistemologically normative has metaphysical and ethical import, for in doing so, one highlights certain notions of causation over others and deploys practices that shape, direct, and enforce what we call care. The dead body, as the normative body, begets practices that efficiently manipulate bodies and psyches toward the “good” death.
I shall also argue that these practices of the care of the dying hide and mask their power and their force, even while they deploy that power and those forces. These forces both are possible and are deployed because of the implicit metaphysics already held by medicine; that is to say, medicine’s epistemology already holds the world and bodies to be objects that are primarily measureable, even before the measuring. The dead body is the measure of medicine, creating the sense that life is primarily matter ordered to efficiently move within space, both within the space of the body itself but also within the space of the body politic. The dead body as the normative body in medicine creates the conditions for the possibility of the deployment of a metaphysics of efficient causation, a metaphysics of power and control of bodies and psyches. In short, the practices of care of the dying—both ICU care and palliative care—betray the cold ground of their origins.
I shall have to beg the reader’s patience, first as I accumulate evidence for this claim, and second because it is no small thing to entertain the idea that our practices, which are designed to stave off death or to ensure a good death, have dark origins and deploy subtle (and not so subtle) forms of violence. It is no easy thing to turn to medicine’s practices, which all along have been motivated by care and concern, and to acknowledge that the very structures of care and concern created to care for the dying (whether the person is in the ICU or the hospice) cloak death and, in so doing, betray a kind of coldness toward the dying. It will no doubt be hard for us to accept that our practices continue to repeat these violences—even in palliative care—precisely because there is something rotten at the heart of medicine. It is in this sense that medicine has become thoughtless: medicine is primarily about pragmatic doing and efficient control, ordered to utilitarian maximization and its own practicality. In short, medicine’s philosophies of life and death, its technologies of life, and its psychologies of death are founded first in an epistemological move to find a stable place to build its knowledge, namely, the dead body, and second in its deployment of a metaphysics of efficient causation for the mastery of living and dying bodies and psyches.
Medicine embraced the metaphysics of the modern natural sciences. Thus, with the rise of modern medicine, death is pulled out of communal contexts with various mythological, narrative, and liturgical meanings in order to become the ground of medical knowledge, and out of that ground, medicine is able to construct its knowledge. Modern medicine is continually struggling to master death, only to have death return with a vengeance. Death is thus shrouded in technology, hidden in discourse, and finally cloaked in palliative care. And in its return, medicine tries more exhaustively to name it, to shape it, to control its uncontrollable features, only for it to flit away. In this sense, death is medicine’s other, an other at its very heart.
To make the claim that medicine has become a social apparatus for the control of the dying, I shall first have to lay down some philosophical groundwork and declare my own methodological commitments, because, after all, there is no view from nowhere. I take up a thesis articulated by Foucault, which I expand. The thesis, which I have already touched on above, is that in medicine the dead body is the epistemologically normative body, and medicine’s metaphysics is one dominated by efficient causation—the animation of dead matter. While I stand in the Foucauldian tradition of inquiry (if such a thing can be claimed), I do so with significant differences. So, I am not merely naming my sources or giving an account of my use of Foucault. Moreover, it should be noted that Foucault is a master diagnostician, but he is less helpful with therapy. However, Foucault’s insight into the role of space and time, now understood as political space and historical time, in medicine and other disciplines is potent for understanding why contemporary medicine is the way that it is.