Corresponding Author: Graham McCaffrey, RN PhD Email: gpmccaff@ ucalgary.ca Journal of Applied Hermeneutics August 5, 2016 The Author(s) 2016 Compassion, Necessity, and the Pharmakon of the Health Humanities Graham McCaffrey Abstract Health humanities is an emergent interdisciplinary field drawing on existing traditions of using resources from the arts and humanities in the education of health professionals. C ultivation of compassion is often cited, though not without some debate, as a fit goal for the health humanities. In this paper, I undertake a critical reappraisal of the presumed link between health humanities and compassion. Firstly, I propose a model of the health humanities that takes up Derrida’s figure of the pharmakon, as polyvalent medicine or poison (among other meanings). Unlike Derrida, however, I treat the pharmakon as a substance, even when referring to arts and humanities. I then offer examples of negative effects of the pharmakon that both attest to its potency and unsettle comfortable assumptions that it is necessarily benign. Finally, I take up themes from Simone Weil’s reading of the Iliad to propose that necessity may be a useful alternative, or addition, to the ways we think about the goals of the health humanities Keywords health humanities, compassion, empathy McCaffrey Journal of Applied Hermeneutics 2016 Article 13 2 A Drunkard I’ve never been an individual entity. Sixty trillion cells! I’m a living collectivity. I’m staggering zigzag along, sixty trillion cells, all drunk! (From: What ? 108 Zen Poems by Ko Un, 2008, p. 39) Health humanities is a recently marked out interdisciplinary field concerned with the use of resources from the arts and humanities in healthcare, and more broadly in relation to health. Drawing on previous traditions of medical humanities, teaching practices in nursing and other disciplines, and arts based research, advocates for health humanities have staked out bold claims that the humanities can help to counter technical alienation in modern healthcare. There is a debated claim that health humanities help to foster empathy among students and practitioners in healthcare professions. In this paper, I add to the debate using the concept of the pharmakon to propose that if the humanities do indeed have effects, then these must be effects of substance, and effects that are potentially dangerous as well as beneficial. I give examples of the humanities being turned to sinister ends, yet not necessarily thereb y losing their link to empathy, and finally I propose that the goals of health humanities should include not only the stimulation of empathy or compassion, but also the recognition of necessity. Health Humanities Note on Empathy/Compassion I consider empathy and compassion in the modern healthcare context to be functionally referring to the same phenomenon. In the disciplinary literatures, medicine has mostly latched on to empathy and nursing on to compassion, but they both seem to want them to mean a combination experience of emotional identification with another’s subjective situation and purposeful response to said situation. (Compassion isolates suffering, but when empathy is talked about, there is an implicit assumption that anyone appealing to a health professional for help has some order of suffering, so even this apparent distinction is blurry). Since it is actually so difficult to adequately capture in words the complex of emotions, thoughts, reasoning, bodily responses, decisions, and actions that comprise an event of empathy/compassion (and this only gets as far as the compassionate/empathetic actor, never mind what the intended recipient of the act perceives), it is worth bearing in mind that the taxonomic effort may itself be conditioned by the needs of medico-scientific rationalism. There is no consensus definition of empathy/compassion, and a whiff of moralizing essentialism in the literature (McCaffrey & McConnell, 2015), not to mention at times more than a whiff of the quasi-religious (see for examples the grand transformative claims in Armstrong, 2011 and Krnzaic, 2015). Empathy/compassion is not meaningless or irrelevant, but it is a phenomenon of human relating that is complex, culturally and politically inflected, contextual, dynamic and thus deeply interpretable. The strength and significance of the phenomenon are better sought in interpretive dialogue than in claims to final McCaffrey Journal of Applied Hermeneutics 2016 Article 13 3 definition. It is not a purpose of the present paper, then to decide between empathy and compassion, and throughout the body of the paper, I have mostly followed my disciplinary bias (as a nurse) by favouring the term compassion. Amongst recent texts about the health humanities (and in one case, medical humanities), Crawford, Brown, Baker, Tischler, and Abrams (2015) make the most unequivocal connection between humanities and empathy/compassion, describing reading as “a tool for broadening empathy” (p. 56) and more widely arguing that, “attention to literature and the arts can help to develop and nurture skills of observation, analysis, empathy and self-reflection” (p. 18). Authors of a textbook of medical humanities make a very similar statement, with reflection repositioned as a means to cultivating empathy: “Medical humanities attempts to cultivate certain key virtues in and values of medicine, such as altruism, empathy, compassion, as well as certain qualities of mind by means of various reflective, interpretive, and reflexive practices ” (Cole, Carlin, & Carson, 2015, p. 10). Jones, Wear, and Friedman (2014) take a more cautious attitude, questioning the easy chain of association that is set up in the literature from humanities, to humanism, to humane. However, while arguing against what they call “the instrumentalist justification” (p. 4) for the humanities, they replace it with “the intellectual practice of the humanities…which encourages fearless questioning…and refuses to accept the boundaries that science sets between biology and culture ” (p. 4). While it is worth questioning the word association trail from humanities to humane, in terms of instrumentality the authors only replace one functional purpose for the humanities in healthcare with a different one, and emphasize intellectuality to boot, which steers back towards the rationality of scientific medicine on its own terms. As an alternate strategy, in this paper I attempt to deconstruct the instrumentality of humanities in healthcare through an exploration of the pharmakon. Pharmakon – Definition and Derrida Pharmakon is a Greek word with multiple meanings, including “drug” so it is the etymological root of the family of words to do with medications: pharmacology, pharmaceutical, pharmacist, and so on. Meanings of pharmakon also include “poison, charm, spell” (Barnhart, 2006, p. 785). Derrida made much use of its polyvalent meanings in his essay Plato’s Pharmacy (1981), where he took up the use of the word in Plato’s Phaedrus in the context of Socrates comparing a written text to a pharmakon. Derrida’s essay is about the ambivalent and fissiparous effects of writing compared to speech and for him the potency of the word lies in “the regular, ordered polysemy that has, through skewing, indetermination, or overdetermination, but without mistranslation, permitted the rendering of the same word by ‘remedy,’ ‘recipe,’ ‘poison,’ ‘drug,’ ‘philter,’ etc” (p. 71). He acknowledged the more literal sense of pharmakon, but even then to establish it as an agent of double meanings and mixed effects: One must indeed be aware of the fact that Plato is suspicious of the pharmakon in general, even in the case of drugs used exclusively for therapeutic ends, even when they are wielded with good intentions, and even when they are as such effective. There is no such thing as a harmless remedy. The pharmakon can never be simply beneficial. (p. 99) Derrida, however, was much more interested in the linguistic play afforded by the use of the word in relation to language and emphasized its dynamic possibilities. “The pharmakon is the McCaffrey Journal of Applied Hermeneutics 2016 Article 13 4 movement, the locus, and the play: (the production of) difference. It is the differance of difference” (p. 127). He used two metaphors to underline the way in which pharmakon gets inside to have its effects, first as housebreaker: “Apprehended as a blend and an impurity, the pharmakon also acts like an aggressor or a housebreaker, threatening some internal impurity and security” (p. 128), then as liquid: …the pharmakon always penetrates like a liquid; it is absorbed, drunk, introduced into the inside, which it first marks with the hardness of the type, soon to invade it and inundate it with its medicine, its brew, its drink, its potion, its poison. (p. 152) Derrida was so taken up with the linguistic possibilities of pharmakon, however, that he insisted that it must be considered “a drug without substance ” (p. 142), “as antisubstance itself: that which resists any philosopheme, indefinitely exceeding its bounds as nonidentity, nonessence, nonsubstance” (p.70). For my purposes, I want to make use of the polysemic vitality of the pharmakon, while insisting on the pharmakon as substance. Presented with a pharmakon, you have a choice whether or not to take it, but once taken it will change you, cell by cell. This is as true for compassion as it is for morphine, as true for reading a poem as it is for Prozac. The neuroscientist Antonio Damasio (2012) has advanced a framework for understanding consciousness that posits an idea of human beings as physically interpretive organisms. Human brains generate images in a constant stream that “are given saliency…according to their value for the individual” (p. 76). Value is der ived “from the original set of dispositions that orients our life regulation, as well as from the valuations that all images we have gradually acquired in our experience have been accorded” (p. 76). Another basic construct for Damasio is that of map making, whereby images are arranged into varied and deeply complex patterns of meaning. In other words, while we have original dispositions rooted in the cellular makeup of human beings and genetics, our horizon of selfhood is constantly modified in exchange with social and cultural worlds, to which Damasio, unlike other neuroscientists, accords great respect as the actual realm of human experience. Curiously, he even slips into Gadamerian sounding language, for example when he states, “Our memories are prejudiced, in the full sense of the term, by our past history and beliefs” (p. 142) [italics in orginal]. The idea I am suggesting that we can think of the arts and humanities as mind-body altering substance is not all that surprising. We, as human beings, go to immense lengths to alter our consciousness as we find it. To alter consciousness is to alter the body and vice versa. There is the obvious category of mind/body altering substances, such as alcohol, tobacco, LSD, or heroin, but also foodstuffs (think of comfort food), then the activities we perform to feel good, running and exercise of all kinds (the so-called runner’s high), meditation, yoga, prayer, chanting, dressing up (or down), anything that causes sexual stimulation etc. If this seems to make humanities into more of a drug, then it also makes a drug into more of an idea; we already have a sense from the placebo effect that a drug’s efficacy can be an unstable compound of the drug and the idea of the drug. McCaffrey Journal of Applied Hermeneutics 2016 Article 13 5 Humanities as Pharmakon It is now possible to restate the arts-compassion link in another way: That the arts are another kind of mind/body-altering substance. Putting it more concretely, to posit that reading a novel, for example, is good for nursing students, is to claim it has a distant effect: The student who reads a novel in my course today will be more likely to experience the neurobiological/subjective event of compassion when caring for a patient in six months time. George Steiner, in a polemic partly directed at Derrida, spelled o ut the physicality of art, in this case poetry, and its effects: As the act of the poet is met – and it is the full tenor and rites of this meeting which I would explore – as it enters the precincts, spatial and temporal, mental and physical, of our being, it brings with it a radical calling towards change. The waking, the enrichment, the complication, the darkening, the unsettling of sensibility and understanding which follow on our experience of art are incipient with action. (1989, p. 143) Richard Kearney, in his essay on diacritical hermeneutics, discussed what he called “carnal interpretation” (p. 8) whereby “Every carnal act and organ inscribes its own imaginaire” and “sensation is expression and expression sensation. Flesh is word and word flesh” (p. 8). Or as W.H. Auden put it more succinctly in his elegiac poem on the death of W.B. Yeats: “The words of a dead man / Are modified in the guts of the living” (Auden, 1939/2016). One implication of taking the arts and humanitie s seriously as pharmakon is to see that, like pharmaceuticals, they may have beneficial effects, negative effects, or both, or none at all. A pharmakon is an interpretive substance since it alters perception, however subtly, and perception, or how a person sees the world, affects how she or he acts in the world. The arts and humanities would not matter, and there would be no reason to include them in curricula of health professions, unless they are a kind of pharmakon, an active substance. Pharmaceuticals, as the most literal descendants of pharmakon, are set around with rituals of protection, authority, and propriety. Health care professionals are habitually shocked by the laity’s disregard for correct ritual, which is called non-compliance. The reason for the ritual seriousness is obvious, that pharmaceuticals are known to have real effects on human beings, and their proper use is intended to maximize therapeutic effects and minimize harmful effects, through well- targeted delivery of specific agents at optimal doses: hence the “10 rights” of medication administration (Vera, 2012). The meaning of the effects is, however, interpretable. Modern society has highly sophisticated structures of meaning to endorse what is or is not a desirable effect. During the course of writing this paper, the tennis player Maria Sharapova gave a press conference at which she admitted to testing positive to a performance enhancing drug called Meldonium (Guardian, 2016). It is a drug manufactured in Latvia for short-term treatment of ischemia by increasing blood flow. Sharapova said she had been taking it for 10 years on the flimsy grounds that she has a family history of diabetes. What caught her out, however, was not that her pretext is medically McCaffrey Journal of Applied Hermeneutics 2016 Article 13 6 questionable, but that there was a change in ritual and she missed it. Meldonium was added to the list of banned substances for tennis on January 1, 2016 (Guardian, 2016). To what degree she believed her own dubious rationale is irrelevant, because the structure of meaning for her sport shifted and what had been a matter of indifference (in terms of legality) became redefined as one of culpable harm. The pharmakon of arts and humanities is likewise embedded in structures of meaning, and rituals of usage, because it too carries the potential for potent effects that may be judged desirable or harmful. To illustrate this point, I propose three strong counter examples to the uncomplicated assumption in the health humanities that exposure to works of creative imagination has positive effects. Poetry written by jihadists, and by Radovan Karadzic, the Bosnian Serb leader during the civil war in the 1990s, are examples of art expressly in support of destructive ideologies. However, they are also examples of art that makes appeal to compassion. The third example, of the Goethe Oak, is a brutally ironic example of the possibility that the arts and humanities may have absolutely no effect on ethical behaviour. ISIS, War Crime, Goethe Oak Father, I have travelled a long time among deserts and cities. It has been a long journey, Father, among valleys and mountains, So long that I have forgotten my tribe, my cousins, even humankind. These are lines from a poem by Osama bin Laden, (quoted in Haykel & Creswell, 2015, p. 6), in which he recounts his journeys from country to country through the persona of his young son, Hamza, and then explains in his own voice the reasons for their travails. First of these is the need to respond to “a world where the suffering of innocents, particularly Muslim innoce nts, is ignored and ‘children are slaughtered like cattle’” (Haykel & Creswell, 2015, pp. 6-7). He then goes on to blame the “Zionists” (p. 7) for their attacks on Muslims, and Arab regimes for their failure to come to their defence. There is an unmistakable appeal to compassion in the poem, to recognize the sufferings of children, and then to take action to relieve their suffering. It is crucially, however, an absolutely selective compassion from which the invitation to care for the suffering of one category of people is accompanied by murderous rage towards other kinds of people. Haykel and Creswell (2015) put jihadist poetry into wider contexts of the popularity of poetry in parts of the Arab world, and its place as part of jihadi culture. They argued that poetry has a function in establishing the self-proclaimed ISIS Caliphate as “a fantasy world of fluctuating borders where anything can happen, including the recapture of past glories” (p. 9). While from the outside, it is easy to dismiss jihadi poetry as mere propaganda, it is more than that within the structures of meaning by which Islamists seek to legitimize themselves, their values, and their actions. My second example of the potentially dangerous effects of a humanities pharmakon is the work of Radovan Karadzic, who was found guilty of genocide at the International Court in the Hague in March 2016 (International Criminal Tribunal for the Former Yugoslavia [ICTY], 2016). Before the breakup of Yugoslavia and the outbreak of war, Karadzic was a psychiatrist and poet, McCaffrey Journal of Applied Hermeneutics 2016 Article 13 7 apparently at the confluence of healthcare and humanities. His poetry, however, was an outlet for his Serb nationalist politics, which brought him to the leadership of the self-declared Bosnian Serb Republic in 1992 and to a new career of ethnic cleansing of Bosnian Croats and Muslims (BBC, 2014). Surdukowski, a doctoral candidate in law, wrote a paper for a legal journal before the start of the war crimes trial in 2009, arguing that the prosecution could “use Karadzic’s texts and affectations to warrior poetry in the pretrial brief and in admitted evidence” (Surduko wski, 2005, p. 677). His article’s title memorably begins with the question, “Is poetry a war crime?” (p. 673). If the examples cited in the article are anything to go by, Karadzic’s poetry has little literary merit, but is intended to valorize a narrative of victimhood and heroic revenge: When the time comes for gun barrels to speak, For heroic days, valorous nights, When a foreign army floods your country, And wreaks havoc and causes damage in it, That condition must be righted: Then you roam your homeland on foot, And your boots fight side by side with you. (Cited in Surdukowski, 2005, p. 685) Here again, however, the poetry has a different sense within a structure of meaning where historical memory, identity, and narrative poetic tradition are connected to a living cultural context. I do not know whether Karadzic’s poetry ever was admitted as evidence into his trial; probably there was no shortage of other kinds of evidence that made it superfluous. The question in Surdukowski’s title is meant seriously, however, acknowledging the power of poetry as incitement to action via impassioned response. W.B. Yeats interrogated himself on this same question when he asked rhetorically in his poem The Man and the Echo (1938/1982, p. 393): Did that play of mine send out Certain men the English shot? It is the real possibility of incitement to action that makes a pharmakon of the humanities, and the moral indeterminacy of the action as such that holds out potential of both benefit and harm. My third counter example of the link between humanities and empathy runs in a different direction. The Goethe Oak was an oak tree in central Germany, where Goethe reputedly wrote poetry while enamored of a local noblewoman. Through its association with the great poet, it became a symbol of German humanism and civilization. In 1937, the Nazis built the Buchenwald concentration camp at the site, and they chose to build around the oak since to them it symbolized a link between German high culture and their own ideology. To inmates of the camp, however, it stood as a positive symbol of a German culture that preceded, and would survive the aberration of Nazism (Neumann, 2000, pp. 178-9). The Nazis’ appropriation of the Goethe Oak had nothing to do with the content of his work, and was a grotesque reading of themselves as readers of Goethe, whereby “civilization” is apportioned by race and language, and not by the quality of relationships within a whole society. The symbol of the Goethe Oak standing in Buchenwald ruptures the assumption of a straightforward link between humanities and humane- McCaffrey Journal of Applied Hermeneutics 2016 Article 13 8 ness. The examples above point to the potency of arts and humanities as substance, and as reminder of the possible differential effects and uses of the pharmakon. Compassion, Contingency, and Weil’s Necessity “They talk about a life of brotherly love show me someone who knows how to live it.” (Dylan, 1979) The argument so far does not disprove or discount a connection between the humanities and empathy or compassion, but it does complicate the connection and counters the tendency to assume it is automatic. I retain a conviction that the arts and humanities do have a place in nursing education and research, but that there is a space for re-examination of why that should be so. Not only is the pharmakon of the humanities a substance of polyvalent goals and effects, but the target of compassion is itself inherently unstable. Compassion is a fugitive experience, a human response that may or may not emerge in any given situation. A healthcare system, however, has to provide a threshold of consistent response, which has to include technical competency and ought also to include a flexible responsiveness to individualized needs, based on understanding of individual histories and experience. That, I believe, is both an ethical imperative and a practical one since we know by now that technical capability alone is not a ll there is to helping people improve or maintain health. Objectifying people does not help. If the presence of compassion cannot be guaranteed, however, nor can it be dismissed. There are claims in the nursing literature on compassion that it is something more like a steady state virtue humming in the background (Bradshaw, 2009; McCaffrey & McConnell, 2015). That, however, is to stray from definitions of compassion that more or less agree it requires the particular stimulus of another’s suffering. A constant outpouring of compassion, presumably in response to a constant awareness of suffering, is a condition of saintliness which I will not say does not exist, but I suggest is sufficiently rare that we can discount it for the practical purposes of running a complex modern healthcare system. The variation that some people possess a disposition towards compassion, which will be triggered appropriately on each and every occasion it is called for, is somewhat more attainable but again, I would suggest, beyond the reach of most of us. If compassion is not reliable as a resource for healthcare providers, it does not therefore follow that it can be dispensed with altogether as one physician author (Faust, 2009) suggested, in favour of observab le, external signs of k indness. If compassion cannot be summoned to order, by the same token, it cannot be refused when it does arise. If compassion is not a necessary condition of providing high quality healthcare at any given moment, nor does it make sense to deny that it may deeply enhance an interaction or that the ideal of compassion may furnish a sustaining sense of meaning for the practitioner. In practice, however, compassion is best considered as a contingent event and as such, contingency should be brought into the remit of arts and humanities. Contingency, however, implies its opposite : necessity. Compassion as a contingent event, and the arts and humanities as pharmakon, unstable but offering as at least one of its effects a route into imaginative understanding of, and feeling for the other, both require context for their McCaffrey Journal of Applied Hermeneutics 2016 Article 13 9 appearance in human life. Simone Weil’s reading of Homer’s Iliad offers one way into articulating the context, the background for the contingencies of compassion and artistic effect. She arrived at her conception of necessity in contrast to force. For her, the Iliad demonstrated the fundamental significance of what she called force, which she saw as malign since it is always directed towards the objectification of human beings. She saw force as the e ncompassing theme of the Iliad, appearing in almost every relationship and most vividly of course in warfare. Thus she calls the Iliad “the purest and loveliest of mirrors” (1940/2005, p. 183). She defined force as “that x that turns anybody who is subjected to it into a thing” (p. 183, italics in original). Weil does not talk about empathy or compassion in her essay. She does not address whether or not we as readers should identify with characters in the Iliad for better or worse, or whether we would be any better off for doing so. She does, however, claim to find elements of thought that have been lost to modern societies. O ne is that force invites retribution and that individuals can move precipitately and unpredictably from perpetrator to victim, and become objectified either way. Instead of a recognition of the relationships between things, “conceptions of limit, measure, equilibrium, which ought to determine the conduct of life are, in the West, restricted to a servile function in the vocabulary of technics” (p. 195). In modern society (our modern society, not Weil’s mid 20t h century modern society), measure does indeed have a servile function in that it is supposed only to be a data processing tool, and yet the vocabulary of technics is so dominant that we are often put in the position of servants to the servile. The Francis Report (2013) in the UK about the mid-Staffs hospital, where flagrant neglect of patients ran rife, showed that staff were spellbound by outcome measures while literally failing to see the faces of suffering patients. Weil remarks that “prestige, from which force derives at least three-quarters of its strength, rests principally upon that marvellous indifference that the strong feel toward the weak, an indifference so contagious that it infects the very people who are the objects of it” (p 199). It also says something about how healthcare interactions are influenced by the prestige of technical medicine itself carrying both professional and patient along in its powerful undertow. Weil nonetheless finds a redemptive aspect in the Iliad in rare “moments of grace” (p. 208) when Homer describes tenderness between husbands and wives, parents and children, or even mutual respect on the battlefield. “It is in this that the Iliad is absolutely unique, in this bitterness that proceeds from tenderness and that spreads over the whole human race, impartial as sunlight” (p. 208). The poem’s bitterness “is the only justifiable bitterness, for it springs from the subjection of the human spirit to force, that is, in the last analysis, to matter. This subjection is the common lot, although each spirit will bear it differently, in proportion to its own virtue” (p. 211). She elsewhere used the phrase “the hand of necessity” (p. 201) for this subjection to matter. In another of her works, Weil wrote that, “The sun shines in the just and on the unjust…God makes himself necessity. There are two aspects of necessity: it is exercised, it is endured: the sun and the cross” (2002, p. 43). Necessity is “the re lationship of things” (p. 48) and for her, “Obedience is the only pure motive” but “obedience to necessity and not to force” (p. 49). Here Weil appears to be making a distinction between the necessity that is “the relationship of things” (p. 48) and force which the subjection to matter played out in human action. Force admits of exceptions to itself when people are able to connect to the even more fundamental power of necessity, as Gadamer wrote, “over and above our wanting and doing” (1960/2004, p. xxvi). The pharmakon of the arts and humanities as substance reminds us of the same necessity, the same McCaffrey Journal of Applied Hermeneutics 2016 Article 13 10 subjection to matter, even when we are most tempted to fly away with the language of the spirit. It can at its worst be used to incite resort to force, but it can otherwise bring us back to the necessity we all share, “the relationship of things” (Weil, 2002, p. 48) in which we live and die. Out of this necessity, at times, appears the contingent event of compassion. Conclusion There is no final conclusion, if conclusion means a new definition of health humanities, a new curriculum, a new moral imperative towards making health professional more empathetic. If anything, I have tried to inject some irony into the health humanities, a sense of the tragic that the scientific wo rldview so conspicuously (and dangerously) lacks, because it enjoins us to wait for science to fix everything – including the problems science created – while life rushes onward regardless. If poetry can be likened to a drug, likewise a drug can be likened to poetry. Both are “modified in the guts of the living” (Auden, 2016). There remain vexed questions of how best to administer the pharmakon of the health humanities to students who have widely divergent degrees of receptivity or compliance. While a didac tic novel like Still Alice (Genova, 2009) has obvious relevance to students learning about people with dementia, it is poor literature. Nonetheless, it does have traces of Weil’s necessity, the brute materiality of a decaying brain lived out in a character, albeit a two-dimensional one for much of the novel. 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