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The Anticipatory Corpse: Medicine, Power, and the Care of the Dying
by Jeffrey P. Bishop
University of Notre Dame Press, 2011
(410 pages, $35.00, paperback)
reviewed by Raymond Barfield
Jeffrey Bishop is a physician and a philosopher, and only someone who is both could have written this book. The Anticipatory Corpse is a diagnosis of medicine's malady, and unfortunately Dr. Bishop has some bad news for us: "There is something rotten at the heart of medicine" (22). Bad news about a disease can be hard to take, but it can also be a relief to see more clearly what is actually wrong, and this was certainly my experience of reading the book as a physician.
Bishop has written ten chapters, and nine of these are diagnosis. By the time he gets to the last chapter, he is aware of what his patient has been through during the explanation of the ailment. He writes, "My reader may have tired of critique by now," and as a physician who has had to tell many patients that medical therapy is limited, he no doubt also understands the impact on the patient when he finishes that sentence by saying, "yet I hesitate to be constructive" (285).
That is a tough thing to hear after 284 pages of diagnosis, but his reasons for hesitating are ultimately both humble and hopeful. They are humble because Bishop knows that he himself has been formed (and harmed) by the ill system he just diagnosed, and any good doctor knows when he or she needs to call on others to help with a problem beyond his capacity to solve. The reasons are hopeful because, even though Bishop does not think that medicine can heal itself in isolation, he does believe there is a resource for genuine help, and he mentions it in the last sentence of the book: "Might it not be that only theology can save medicine?" (313).
Many of Bishop's readers will be baffled by that last sentence, but once his critique is understood, the concluding sentence makes enormous sense. Drawing heavily on Foucault's genealogical assessment of contemporary medicine in The Birth of the Clinic, Bishop spends the first three chapters establishing a thesis that he acknowledges will be provocative, though he asks the reader to hear him out: it is the dead body that is epistemologically normative for medicine, and it is through the dead body that we come to understand the bodies with which medicine engages.
By "body" Bishop means both the bodies of patients and the "body politic," which has altered our understanding of what constitutes "death" in order to perpetuate the "good" of the citizens of this political body. Though his critique extends into the political place of medicine, the formation of physicians is at the heart of his diagnosis, and he thus cites medical schools as the engine that perpetuates the illness.
The Malformation of Physicians
So how are physicians (mal)formed, according to Bishop? Here is a paraphrase of his argument:
A relatively normal person goes to medical school. He meets his first patient in anatomy, and the patient is dead. The formation of his imagination has begun. He diligently learns where various molecules reside—liver molecules, kidney molecules, lung molecules. Then he moves to his second course, physiology. Here, he learns two things. First, he learns what it looks like for molecules to move in the right direction. But more importantly, he gains a definition of "life"—life is molecules moving, and moving in the right direction. Next, he studies pathology, which is the science of molecules going rogue and moving in the wrong direction.
He learns about that as a set-up for the most important lesson of all. Once he finishes pathology, he goes to the wards and learns medical and surgical techniques for fixing rogue molecules that are moving in the wrong direction or threatening not to move at all (definition of death). Now he has a definition of his vocation: he is supposed to make rogue molecules move, and move in the right direction. And then he graduates from medical school and has his definition of life and vocation reified in residency by physicians who were formed in the same way, and who hold enormous power over his present and his future.
The language Bishop uses to explicate this process is the language of Aristotelian causality. Physicians are imaginatively formed to think in terms of material causality and efficient causality, to the exclusion of final causality. They are trained to respond to rogue physiology, without reference to purpose, goals, or any sense of a genuine human telos—why we are doing this.
The Body as Machine
Chapters four through eight assess the rippling consequences of this approach to formation. In chapter four Bishop gives us a powerful account of the "autonomous self" and of the shift of "sovereignty" to an individual patient, essentially reducing the physician to a technology dispenser guided not by any sense of purpose, but only by "a patient's choice." This shift, poignantly, has been impossible to resist philosophically by physicians formed to view life and vocation in terms of efficient and material causality, rather than final causality; metaphysics, Bishop insists, matters in medicine.
Chapters five and six give an account of the ways in which the definition of death has changed in service to the growing project of organ transplantation. When the body is defined in terms of efficient causality alone, it is essentially reduced to a machine, and its parts are interchangeable. Once there is no longer an "autonomous, decision-making person"—the only definition of person that fits the background metaphysics of modern medicine—associated with the machine that is the body, what would be the reason not to harvest machine parts for another machine that might continue to be able to support an autonomous, decision-making person? Where would medicine fit the idea that, say, religious vigil and the arts of dying might hold value that compete in some way with the harvesting of organs?
These chapters set up a discussion of Terri Shiavo and others in a persistent vegetative state. Bishop's account and criticism of the behaviors and justifications of both "liberals" and "conservatives" are astonishing. They astonish not only in their philosophical subtlety, but also in the kinds of things they name as lost in the debate—grief over the unavoidability of the tragic, for example.
The Evolution of Palliative Medicine
When Bishop turns to palliative medicine, in his penultimate chapter, entitled "The Palliative Gaze," he sets us up for the paucity of solutions he will offer in his final chapter. The reason this chapter is such an effective prelude to not giving a "solution" is that it assesses the history of palliative medicine's evolution and its current state compared with, for example, Cicely Saunders's original vision of hospice.
Palliative medicine now has its own "evidence-based" journals generating generalizable knowledge that does not depend on the particulars of individual persons; it has its own board certification and national meetings; it has become just another medical subspecialty, one that medically manages the dying process and the subsequent grief with confident expertise.
And this is the point. For many of us, our first exposure to palliative medicine and hospice was an experience of something refreshing that perhaps answered some of the hard-to-name problems within medicine. But this "solution" has been subsumed by medicine and now has the very same problems it was meant to address.
Exactly the Right Question
For this reason, in his last chapter, Bishop cautions us not to just rush in and "fix the problem" using whatever resources are ready-to-hand in medicine. Medicine is too broken to fix itself. What is needed for the healing of medicine is the kind of framing discourse that re-immerses us in the larger reality of our world. And in this larger reality Bishop includes curiosity about why we are here in the first place, who we are, what we ought to be, and where we are going.
Medicine begins with the dead body as normative, but it has no account of the hope and wonder that the threshold of death introduces us to, nor of the gift of being present to the ill, the suffering, and the dying. Where would medicine ever find the kind of transformative frame that makes new sense of its understanding of life, death, vocation, and love?
There is one very fine possibility that is well worth exploring, but Bishop—and all of us in medicine—will need a lot of help from outside medicine if we are to heal. And with the proper humility of someone who cannot offer us the answer, he ends with a question, but it is exactly the right question: "Might it not be that only theology can save medicine?" •
Raymond Barfield is Associate Professor of Pediatrics and Christian Philosophy at Duke University in Durham, North Carolina, where he directs the Pediatric Quality of Life and Palliative Care Program, and a new Duke initiative called Theology, Medicine and Culture. He is the author of The Ancient Quarrel Between Poetry and Philosophy (Cambridge University Press) and a forthcoming book of poetry called Life in the Blind Spot.