Death And Embodied Approach 2006%255b1%255d

1 Death, Embodied Approach, and Medicine: Problematizing the Normative Jayanta Bhattacharya [PhD Student, North Bengal Medical College, West Bengal]

With what strift and pains we came into the World we know not; but 'tis commonly no easie matter to get out of it. – Sir Thomas Brown, Letter to a Friend, c. 1680 Death is a part of human experience, a necessary consequence of life that we all must face. Although death is a rite of passage in which we will all participate – as family member, provider, or, eventually, patient – we understand little of what is valued at the end of life. For example, a search of the medical literature published in 1996 identifies 112 papers that contain the keyword “death,” a topic that directly affects everyone. In contrast, a similar search reveals more than 1,000 references pertaining to schizophrenia, a disorder with a population prevalence of about 1%.1 In another study by the same author, a Medline subject search of the core clinical literature (Abridged Index Medicus) identifies only 138 articles (mostly essays and editorials) published from January 1995 to November 1998 on attitudes towards death and only 4 articles on thanatology (the study of the theory, doctrine, and philosophy of death). In contrast, a similar search reveals more than 3,900 articles concerning the polymerase chain reaction, an esoteric laboratory technique.2 In some respects, this century's scientific and medical advances have made living easier and dying harder. Dying patients need to participate in the same human interactions throughout all of life.3 On the part of doctors, we need to attend to the silence that hovers about critically ill patients while they fight for their lives, and to grieve with their survivors. Even if doctors have no such duty to non-patients, grief refers back to the

1

Hobart W. Walling, “Life’s Brief Candle: A Shakespearean Guide to Death and Dying for Compassionate Physicians” in West J Med 1997; 166: 280-284. 2 Walling, “Shuffling Off This Mortal Coil: A Shakespearean Perspective on Death and Dying” in West J Med 1998; 169: 390-395. 3 Karen E. Steinhauser et al “In Search of a Good Death: Observations of Patients, Families, and Providers” in Annals of Internal Medicine 2000; 132: 825-832.

2 patient who, their survivors hope, is not simply dead but lives on in their memories and, even a little bit, in those of others.4 Sir William Osler, one of the pioneering figures of modern medicine, emphasized the scientific aspects of medicine, especially the importance of clinical laboratory examination and postmortem pathologic studies. Also, he wrote to the father of a deceased son, “No doubt before this, the sorrowful intelligence of your son's death has reached you, and now when the first shock has perhaps to a slight extent passed away, some further particulars of his last illness may be satisfactory. He was well aware of his dangerous state. He spoke to me of his home, and his mother, and asked me to read the 43rd chapter of Isaiah, which she had marked in his Bible. I spent the greater part of the morning talking and reading with him.”5 Possibly, we are at the tenuous bridge linking scientific medicine with an embodied approach to death. Needless to say, ravines lie between medical students or would-be-doctors and final goal of doctors in the form of academic, social and emotional challenges, dealing with clinical situations, learning to cope with death and illness and fulfilling that which is expected of them as medical students.6 “The commodization of the healer-sick person relationship as an economic transaction cannot quantify this aspect of relationship, which, as a shared virtue, is not captured by a cost/benefit equation or financial bottom line. It is rather healer’s gift as well as that of the patient.”7 Where We Are Though appearing so irreducible a reality death has changed over time from being a bridgeable separation from the living to an unbridgeable one. Starting its journey from Cartesian dichotomy between mind and body the body is concerned to be not a knowing body, not something active in itself, but rather a known body. Drew Ledder points out that modern medicine is based “first and foremost, not upon the lived body, but upon the

4

M. Rowe, “Morality and medicine: forms of silence and speech” in J Med Ethics; Medical Humanities 2003; 29: 72-76. 5 Shigeaki Hinehora, “Sir Osler’s Philosophy on Death” in Annals of Internal Medicine 1993; 118(8): 638642. 6 Sarah Elise Finlay and Monica Fawzy, “Becoming a doctor” in Medical Humanities 2001; 27: 90-92. 7 Arthur Kleinman, Illness Narrative: Suffering, Healing and the Human Condition (USA: Basic Books, 1988), 54.

3 dead or inanimate body.”8 This, the dead, inactive body serves Descartes as a model for the living body. The body exists as one spatial object among other beings. This particular paradigmatic change in perception regarding the body entailed in a change from self as an experiencing subject to a scientific medical text from where we can decipher various meanings of illness and symptoms and extract signs. The clinical gaze of the medical profession was focused on the inner bodily world of the patients. How patients spoke about their ills, symptoms and problems was regarded as best as a pale reflection of the language of the organs and tissues and their pathological changes.9 Hence, the question of an active and agential self was relegated to marginality. Consequently, society has accompanied the dead from being colonized by the scientific world of medicine to being banished from the scene of life. Indian medical studies on the issue of death (and dying) are lacking. To my knowledge, very few clinical, sociological or anthropological studies have been done so far. So, we are to base on Western academic studies to understand the shifting nature of meaning of death, where “increasing attention” is paid “to the way death is managed”10 – not death as such. We shall see later that some extrapolations can be done with respect to India. Harrison’s Principles of Internal Medicine asks (despite the question of “brain death” being settled in US quite sometime back), “How is death to be defined?”11 It does not provide any definition. (Regarding brain death the book speaks of its relevance only in case of organ donation.12) Instead it cautions about over-dependence on technologized care “in hospitals, where the intrusion of life-sustaining apparatuses can so easily detract from attention to the whole person and encourage concentration on life-threateningdisease…”13 How to define death and how to approach it? Harrison’s takes a route different from traditional perception of patient care system to answer these questions. A physician is exhorted to take account of “necessary medical care as well as psychological 8

Drew Ledder, “A Tale of Two Bodies: the Cartesian Corpse and the Lived body” in Body and Flesh: A Philosophical Reader, ed. Donn Welton (Oxford: Blackwell, 1998), 117 (117-130). 9 See David Armstrong, “The patient’s view” in Social Science and Medicine 1984; 18: 737-44, for an insightful analysis on this issue. 10 Gillie Bolton, “Death, dying, and bereavement” (editorial) in Medical Humanities 2004; 30: 49-52. [Emphasis added] 11 Harrison’s Principles of Internal Medicine, 16th Edn. Vol. I, (eds.) Dennis E. Casper et al (New York, Chicago: McGraw Hill, 2005), 4. 12 Ibid, Vol. II, 1630. 13 Ibid, Vol. II, 4. [Emphasis added]

4 and spiritual support that will prevent the isolation and depersonaliztion that can attend in-hospital death.”14 Even, the physician is encouraged to attend the decedent’s funeral. Within a span of 4 years such a change in approach has occurred. Unlike the latest edition, in its 15th edition, published in 2001, only a few lines were devoted to death and dying. Nothing was mentioned about end-of-life care or palliative care. There was conspicuous silence on medical community’s approach to death. Two distinct notes of change are found in the latest edition: a novel (?embodied) approach to deal with the dead, and second, the patient is treated as a “whole person” which is somewhat unique in its representation. In its traditional trajectory the dead had been gradually relegated to a marginal position, particularly in Euro-American culture. American analysts find detectable “Americanness” and the idea of limitless technological progress and denial of death in such analyses.15 In very recent time too while “Learning from the Dying” authors find that “Unfortunately, the ‘hidden curriculum’ of contemporary medicine – especially the hurried, disease-centered, impersonal, high-throughout clinical years – still tend to undermine the best intentions of students and faculty members and the best interests of patients and families.”16 It may quite often sound unfamiliar to us that “Medicine now uses a language in which feelings are generally suspect…In the process of professionalization, emotional language tends to atrophy because physicians are neither encouraged to use it clinically nor educated to enhance it.”17 Placing patient autonomy at the center of ethical decision, “the medical community in United States has proceeded as if this were universally appropriate.”18 In a society that values selfdetermination, many individuals fear that the circumstances of dying will strip them of their personhood and sense of control – “[a]utonomy in patients’ decision making is now the irresistible trend, [though m]any doctors fear this challenge to their own previous secure and powerful autonomy.”19

14

Ibid, Vol. II, 440. [Emphasis added] Renee C. Fox, “Cultural Competence and the Culture of Medicine” in New England Journal of Medicine 2005; 353(13): 1316-1319. [NEJM hereafter] 16 Susan D. Block and J. Andrew Billings, “Learning from the Dying” in NEJM 2005; 353(13): 1313-1315. 17 John L. Coulehan, “Tenderness and Steadiness: Emotions in Medical Practice” in Literature and Medicine 1995; 14(2): 222-236. 18 Gregory W Ruhnke et al, “Ethical Decision Making and Patient Autonomy: A Comparison of Physicians and Patients in Japan and the United States” in Chest 2000; 118: 1172-1182. 19 “Managing a comfortable death” in Lancet 1996 Jun 29; 347(9018): 1777. 15

5 According to some philosophers “Man was divided into a bloodless intellect and a meaningless vitality (biology).”20 Paul Tillich introduces a distinction between “pathological anxiety” and “existential anxiety” in the broader context of human existence. Death of a patient is not merely disappearance of a bodily existence – as it so frequently happens in our medical world through disappearance of a “case” – but, more importantly, loss of a person embedded in his/her family and social environs. It is being increasingly realized that culture shapes the way we approach our world and affects interaction between patients and clinicians. “Patients may present their symptoms quite differently from what we learned.”21 It is important, however, to be aware of and sensitive to trends that run counter to prevalent Western axioms and dogma and that may contribute significantly to bioethical thinking.22 So, a traditional clinical approach to death based solely on empathy may be illusive for doctors to confront the poignant issue of a dying person who is incidentally a patient. To add, “Empathy can never be validated by formal objective external processes. (Yet – how fascinating – we know there’s a there there, a counterpart to objective reality, the patient’s true emotional state.)…since its validation at best arrives through internal subjective emotional processes, it will remain eternally elusive.”23 We should ask why do such conflicts of understanding, approach and internalization of human problems occur so frequent? Part of the answer may come from Robin Downie reminding us “scientific theories can give no support to believers or to atheists, to determinists or to libertarians…scientific imagination, like its artistic counterpart, must continue to reach out towards new constructions.”24 Another insightful observation may help us to getting at the problem: “The biomedical system replaces …allegedly ‘soft’, therefore devalued, psychosocial concern with meanings with the scientifically ‘hard’, therefore overvalued, technical quest for the control of symptoms.”25

20

Paul Tillich, The courage to be, 2nd edn (with an introduction by Peter J. Gomes), (New Haven, London: Yale Nota Bene, Yale University Press, 2000), 82. 21 Joseph R. Betancourt, “Cultural Competence – Marginal or Mainstream Movement?” in NEJM 2004; 351(10): 953-954. 22 Shimon M. Glick, “Unlimited Human Autonomy – A Cultural Bias” in NEJM 1997; 336(13): 954-956. 23 Lawrence J. Schneiderman, “Empathy and the Literary Imagination” in Ann Intern Med. 2002; 137: 627629. 24 Robin Downie, “Science and the imagination in the age of reason” in Medical Humanities 2001; 27: 5863. 25 Arthur Kleinman, Illness Narrative: Suffering, Healing and the Human Condition (USA: Basic Books, 1988), 9.

6 We, the Indian medical practitioners, are more conversant with the traditional approach of medicine rather than the recent decentering trends within clinical medicine practiced in Euro-American world. Death, so to speak, has been gradually becoming a medicalized phenomenon, specifically within metropolitan population of India. More number of metropolitan people dies in a setting of institutionalized care. It perhaps points to the medicalization of dying as a physical failure rather than an important event in the life of a patient and family. But, to stress, as an “uncanny double” religious doctrines and belief systems “provide a framework for understanding the human experience of death and dying.”26 Body and Embodiment “Death is inevitably understood and experienced within a complex web of cultural meanings...How does culture shape the experience of …death in clinically meaningful ways…?”27 Our paper will try to focus on this issue through “embodied approach” to death. “Cultural processes include the embodiment of meaning in habitus and physiological reactions, the understanding of what is at stake in particular situations…and the cultivation of collective and individual identity.”28 Embodied approach in itself is represented through an understanding of embodiment which, to our opinion, is an indeterminate methodological field defined by perceptual experience and mode of presence and engagement in the world. This perspective requires that the body as a methodological figure must itself be non-dualistic. While death, on the contrary, in our present dominant social psyche implies termination of a universalized, natural and medicalized body where methodological figure must be dualistic. This universalized natural body is, in its turn, a circumscribed three-dimensional space devoid of any extracorporeal meaning and experiential knowledge. At one end of this spectrum of death perception lies biomedical (or, objective) view of death where perceptual experience of a person has been evacuated. At the other end there remains social (or, put otherwise, embodied) view. Inherent in the first concept is the idea of modernity, progress, reason/rationality and “the notion of a ‘Western conception of self or personhood’ that is 26

Timothy P. Daaleman and Larry VandeCreek, “Placing Religion and Spirituality in End-of-Life-Care” in JAMA 2000; 284(19): 2514-2517. 27 Barbara Koenig and Jan Gates-Williams, “Understanding Cultural Differences in Caring for Dying Patients” in West J Med 1995; 163: 244-249. 28 Arthur Kleinman, “Culture and Depression” in NEJM 2004; 351(10): 951-953.

7 essentialist, autonomous, bounded, stable, enduring, continuous, and impenetrable is itself a selective creation from among the diversity of cultural realities of the past.”29 Michael Sappol shows how in the nineteenth century America the body was extricated free from being a “circulating good…Such a position…defined a crucial aspect of the selfhood of the nineteenth century ‘individual’…the self is excluded from market transactions precisely because in the grammar of exchange, it is assigned the position of subject.”30 The bounded self was the exchanger, not the exchanged. “Death was a haven, a place where the travails of production and exchange ceased and harmony reigned.”31 Another example of different nature like popularization of Academic Hospice program in US may serve to understand death management and dying. Unlike India this program, in its effort to de-institutionalize death and dying, places end-of-life care in a new improvised type of institutional setting.32 It does not really fit to the family setting of a dying patient socially moored in Indian context. The culturally constructed boundaries between life and death are more variable than scientific definitions, based on cellular death or organ system failure. Similarly, cultural practices at the beginning of life shape the definition of death. For example, “Two societies that share the Muslim religion – Egypt and Bali – condone opposite expressions of grief.”33 In Bali, a person mourning must remain calm and cheerful, keeping a strict separation between inner and outer feelings. By contrast, in Egypt a woman who remains “withdrawn, mute, and inactive” for seven years while mourning the death of a child is considered sane and healthy. In making journey from mythos to logos, medicine is authorized with the sole power of producing “true” picture of the body and death. But there is a serious problem about taking this objective scientific picture as the “true” of the “real” world. In this structuration of “true” and “real” picture there is simplification and reductionism. The part that scientists remove is themselves as conscious knowing subjects – not any natural ones per se. This leads to an intricate situation where only the world of medicine 29

C. Jaye, “Talking around embodiment: the views of GPs following participation in medical anthropology courses” in Medical Humanities 2004; 30: 41-48. 30 Michael Sappol, A traffic of Dead Bodies: Anatomy and Embodied Social Identity in Nineteenth-century America (Princeton, Oxford: Princeton University Press, 2002), 38. 31 Ibid, 38. 32 Charles F. von Gunten and True Ryndes, “The Academic Hospice” in JAMA 2005; 143: 655-658. 33 Koenig and Gates-Williams, “Understanding Cultural Difference in Caring for Dying Patient” in West J Med 1995; 163: 246.

8 confronts the world of an autonomous, discrete individual. According to Kenneth Boyd problems “may arise when a metaphor expands in a sphere where it is not challenged or complemented by other equally powerful metaphors, which are also expanding.”34 The particular absence of any metaphors more appealing, convincing, and, as a result, more powerful than therapeutic ones may help to explain why death becomes medicalized in a Western society (and among doctors trained and reared up in this medical tradition across the globe). In his further argument Boyd tells us, “A physically dependent patient who has come to terms with his past life and his approaching death, for example, may well feel, and thus (and because no one else is better placed to judge) be nearer to ‘wholeness’ than ever before.”35 In a non-medicalized position like ours self is rather socially embedded, intersubjective and supposed to be actively engaged with the world. There are expanding metaphors of spirituality, life-after-death and religious beliefs which can stand vis-à-vis death. We can easily assume from this little discussion that a notion of “loss” is absent in advanced biomedical practice inscribed with the idea of advancement over body and disease.36 The disconcerting openness of experience raises a question mark against the conventional assumption that expectancy in the face of death is no longer available to critical thought. The technologization of dying serves to complicate this scenario. It conceals the central existential questions about being and finitude that dying gives rise to.37 This is accentuated by redefining death in the light of “brain death”. Arguably, brain death rests on presumptions of (a) teleological and utilitarian perception of organ donation and transplantation procedure, and (2) a “gift of life” through celebration of immortality. It may possibly entail in a situation when there will be a need of redefinition of death and may “send us on our way down the slippery slope to redefine death in

34

Kenneth M. Boyd, “Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts” in Medical Humanities 2000; 26: 9-17. 35 Kenneth M. Boyd, “Health care ethics, health and disease” in Principles of health care ethics, ed. R. Gillon (Chichester: Willey & Sons, 1994), 812. 36 We would find a rather discordant note in our everyday traditional routine practice of medicine when Jack Coulehan notes the presence of “loss” memorized by one of his sons of the deceased. See, Jack Coulehan “A Model Death” in Ann Intern Med. 2000; 133: 477-478. 37 Franco A. Carnevale, “The Palliation of Dying: A Heideggerian Analysis of ‘Technologization’ of Death” in The Indo-Pacific Journal of Phenomenology 2005; 5(1): 1-12.

9 response to perceived needs.”38 It became imperative for the first time to agree upon a diagnosis of death which could clearly be pinpointed in time, as an event, rather than an indeterminate process. Such a diagnosis would have to be based on a lack of brain function, rather than on the conditions of the heart and lungs, as had been the case since the nineteenth century.39 By focusing on embodied approach to death among others as the anomaly, biomedical and scientific assumptions about death remain unproblematized and, thus, build their normativity. Though in more recent studies it has been revealed that 121 Israeli women with breast cancer found that physicians’ communication about dimensions beyond the clinical affected how they viewed their condition. In another cross-sectional study of 261 house staff, nurses, and attending oncologists it is found that patients with some amount of religious belief had significantly lower scores on items assessing “diminished empathy” and “emotional exhaustion.”40 At its root perhaps lies unstable and culturally variable relation between person and body. Though it must not be confused with spirituality and religious approach, embodied approach to death may help us to destabilize the normative discourse of medicine and death built upon the notion of physical body bereft of any existential meaning. Following Robert Pirsig, if we can lose the subject-object divide that dominates much of our lives, we become at one with what we are doing. This becomes a kind of “atonement”. Through this “at-one-ness” we reconcile our differences, even with physical aspects of our world, and can be said to care about what we are doing.41 Pursuing an embodied approach should be delineated from any representational move where experience or affect may be reduced to language and discourse only. Csordas emphasizes “to work in a ‘paradigm of embodiment’ is not to study anything new or different, but to

38

Margaret Lock, “Displacing Suffering: Redefining Death in North America and Japan” in Social Suffering, eds. Arthur Kleinman, Veena Das and Margaret Lock (Delhi: Oxford University Press, 2000), 222. 39 Margaret Lock, “The Quest for Human Organs and the Violence of Zeal” in Violence and Subjectivity, eds. Veena Das, Mamphela Ramphele and Pamela Reynolds (Delhi: Oxford University Press, 2001), 271295. 40 Alan B. Astrow and Daniel P. Sulmsay, “Spirituality and Patient-Physician Relationship” in JAMA 2004; 291(23): 2884. 41 Robert Pirsig, Zen and the art of motor cycle maintenance (London: Corgi, 1974). Quoted in R. G. Evans, “ Patient centred medicine: reason, emotion, and human spirit? Some philosophical reflections on being with patients” in Medical Humanities 2003; 29: 8-15.

10 address familiar topics…from a different standpoint.”42 He also argues that this does not mean that scholarship must deny biology, but that it must bring biology into the problematic of cultural and historical change.43 Kevin O’Neil argues how death in America changed radically from the midnineteenth to the early twentieth centuries through a trajectory when dying did not mean an unbridgeable separation from the living, rather all suggested continuity between living and dead to a milieu when death meant a bridgeable separation with the living.44 “The exile of the dead” began with insinuation of commerce into the world of dead. Along with, there was sea change in medical understanding. Modern biomedicine, with its roots in a Cartesian and dualistic mechanical view of mind and body, through its scientific and technical success could be viewed as determining not just the knowledge, but skills, attitudes, and moral values deemed necessary in the good physician. In a population selected for convergent thought an overwhelmingly reductionist view of modern medicine may sit quite naturally.45 Unfortunately, a situation arises where “many physician find it easier to define success in terms of life and death than to try to determine what sort of existence is meaningful to an individual patient.”46 So, it is no wonder that atrocity stories are central to people’s talk about their encounters with the medical profession.47 In a recent American review we find “Over the past century dying has become increasingly institutionalized. In the early 1900s most people died at home, but by the middle of the 20th century the majority of deaths in industrialized nations occurred in health care institutions.”48 As a result many people dying in institutions have unmet needs for symptom amelioration, physician communication, emotional support, and being 42

Thomas Csordas, “Embodiment and Cultural Phenomenology” in Perspectives on embodiment (cited below), 143-162. 43 Csordas, ibid, 156. 44 Kevin O’Neil, “Disciplining the Dead” in Perspectives on Embodiment: The Intersection of Nature and Culture, eds. Gail Weiss and Honi Fern Haber (New York, London: 1999), 213-231. 45 R. G Evans, “Patient centred medicine: reason, emotion, and human spirit? Some philosophical reflections on being with patients” in Medical Humanities 2003; 29: 8-15. 46 Timothy Gilligan and Thomas A. Raffin, “Whose death is it, Anyway” in Ann Intern Med. 1996; 125(2): 137-141. [Emphasis added] 47 Geoffrey Baruch, “Moral tales: patient’s stories of encounters with health professions” in Sociology of health and Illness 1981; 3(3): 275-295. 48 John M. Teno et al, “Family Perspectives on End-of-Life Care at the Last Place of Care” in JAMA 2004; 291(1): 88-93.

11 treated with respect. Family members of decedents who received support at home were more likely to report a favorable dying experience.49 By taking a careful look at the differences of feeling of decedents and family members we can assume that death and dying bring different meanings to doctors and patients. Why this difference? “There are many reasons…but most of those reasons are rooted in a medical philosophy that is focused almost exclusively on curing illness and prolonging life, rather than on improving the quality of life and relieving suffering.”50 This emanates from the fact that the culture of biomedicine has designed death as a negotiated event when “approach to death has, in theory, by painting itself into the cold corner where culture is no longer deemed relevant, done away with all meaning…”51 Though, it is understandable that being sensitive to and responding to the emotional state of dying patients is important because psychological factors can influence the prognosis and especially the quality of life.52 This tradition of biomedicine (of Western cultural origin) has “denied death so completely…that dying was irrelevant to physicians, patients, families, and others.”53 Interestingly, the denial of death was not a common theme even in the 16th century England. Shakespearean plays bear evidence in support of it. “Most characters” in Shakespearean dramas “are well aware of their mortality, and many do not hesitate to face death.”54 This situation gradually and relentlessly changed over about four centuries to a culture of denial of death. A novel image of death has been imported thereafter. “The white man’s image of death has spread with medical civilization and has been a major force in cultural colonization.”55 Mechanical death has conquered and destroyed all other deaths. Conclusion

49

Teno, ibid, 88. [Emphasis added] R. Sean Morrison and Diane E. Meier, “ Palliative Care” in NEJM 2004; 350: 2582-90. 51 Margaret Lock, “Displacing Suffering: The Reconstruction of Death in North America and Japan” in Social Suffering, eds. Arthur Kleinman, Veena Das and Margaret Lock (Delhi: Oxford University Press, 2000), 213. 52 E. T Creagan, “Attitude and disposition: do they make a difference in cancer survival?” in Mayo Clinic Proc1999 Feb; 72(2): 160-164. 53 Annete T. Carron, Joanne Lynn and Patrick Kenney, “ End-of-Life Care in Medical Textbooks” in Ann Intern Med. 1999; 130: 82-86. 54 Hobart W. Walling, “Life’s Brief Candle” in West J Med 1997 Apr; 166: 280-284. 55 Illich, Limits to Medicine - Medical Nemesis: The Expropriation of Health (London New York: Penguin Books, 1977), 180. 50

12 It has got definite implications for Indian perception the body, death and dying. Through insinuation, replication and reproduction of scientific, medicalized images of dying process “societies are confronted with new circulations of technology and capital and new hierarchies of embodiment as their forms of marginalization within a world system of shift…”56 Consequently, “the ‘ageless’ individual body becomes marked: age comes to matter.”57 Medicine becomes concerned with management of age and, as a consequence, death and dying – not the person. So, a situation comes up when we often miss an analysis of the embodied, speaking person taking up an existential position in the world. What is forgotten that we have bodies but we are not bodies, that the body is an agent, not a resource. These presume a nature of death as a calculable real identity that can be entrapped and refined into a reserve of objective “death knowledge.” These strive to arrive at a stance of certainty and security toward death. Despite this calculablity of death blurring the position of the unanticipatable in knowledge, any attempt to objectify the body and its demise (with phenomenological and existential meanings) can never be fully contained within an objective, measurable, cognitive framework. It is well to remember that the healing power of medicine must ultimately succumb to mortality and that dying patients need our honesty and respect at least as much as impersonal technological imposition. Physicians too facing the end of their lives share similar sort of anxiety and gloom like their patients. “Plunged into the realm of patients with lifelimiting diseases, their eyes open to the gnawing anxiety, creeping gloom, and maddening arbitrariness of illness, as well as frustrations, indignities, and frank dangers of the health care system.”58 Thomas Nagel in his seminal essay “What is it like to be a bat” calls this particular human attribute as “the subjective character of experience.”59 He argues, “every subjective phenomenon is essentially connected with a single point of view and it seems inevitable that an objective, physical theory will abandon that point of view…no presently available conception gives us a clue how this could be done.” Death is such an 56

Lawrence Cohen, No Aging in India: Modernity, Senility and the Family (Delhi: Oxford University Press, 1999), 302. 57 Ivan Illich, Limits to Medicine (London New York: Penguin Books, 1977), 288. 58 Erik Fromme and J. Andrew Billings, “ Care of the Dying Doctor: On the End of the Stethoscope” in JAMA 2003; 290: 2048-2055. 59 Thomas Nagel, “What is it like to be a bat” in The Philosophical Review” LXXXIII, 4 (October 1974): 435-440.

13 irreducible, subjective, human experience shared by doctors, health care providers, family and community members and others. No amount of clinical care and empathetic drive to protocolize an end-of-life care can substitute or replicate this experience of loss. At this particular point, embodied approach problematizes the normalizing/normative discourse of death; it makes a place for cross-cultural variation and belief. Death does not remain an “other” of life60; it becomes an integral part of human existence. Death is fundamental to the nature of being human. Every culture and society has its own knowledge of death and support system for it.61 Scholars have emphatically argued “the interaction of the traditional value-of-life ethos, certain religious beliefs, and the stark realities of medicine at the end of life, has most commonly resulted in an arbitrary “line in the sand”…”62 Along this line of argument, this “arbitrariness” leads to euthanasia debate, possibly, always tilting towards medical authority and patient autonomy. David Healy reminds us, “The relatively rapid transformations in our understanding of death reflect our capacity to make myths and to embody these myths in command and personal memories. This myth making capacity seems even more active – and perhaps even more needed – in our modern scientific era.”63 Whither myth? A new medical myth of “gift of life” after brain death or something traditional sustained by any given society? As Boyd and Illich have shown, a medical approach must not replace the specific approach to death of a given society contained within its matrix rather it should try to learn from it which is evident from ongoing debates taking place among reflective academicians and general practitioners around the globe. Our Indian experience should join this debate to impart more meanings to the process of embodiment. Otherwise, “We become distanced from our body and unable to create personal relationships or respond to the lives of others. It is as much the continuity of emotion as the continuity of memory and consciousness that gives us that unique phenomenon we call personal identity.”64 Thomas F. Tierney points out that at this late point in the twentieth century (now 21st 60

Veena Das has also discussed on this issue with a different perspective in her Critical Events: An Anthropological Perspective of Contemporary India (Delhi: Oxford, 1999). 61 Ivan Illich, Limits to Medicine. 62 Sharon I Fraser and James W Walters, “Death - whose decision? Euthanasia and the terminally ill” in J. Med. Ethics 2000; 26: 121-125. 63 David Healy, “The Hour of Our Death” (Book Review) in British Medical Journal 2003; 327: 230. 64 A V Campbell and M Willis, “They stole my baby’s sole: narratives of embodiment and loss” in Medical Humanities 2005; 31: 101-104.

14 century), however, there seems to be on the horizon another shift in the status of death. Contrary to traditional thought, it may be neither fear nor anxiety about death. “Rather, such a revaluation might be triggered by a fear that that medicine, in its attempt to defeat, or at least defer, death, will impose a prolonged and undignified life.”65 Embodied approach to death makes us aware of an engagement that defines a mode of intersubjective perception and attention to the distress of another – not a fear of undignified life. It can help to the formation of a subject lived by memory and may produce the experience of non-subjugation to clinical detachment. Life has an aim, and human beings, at least to some extent, can acquire knowledge to deal with the workings of an orderly universe. To quote Heidegger, “Death here enters the domain of foundational mindfulness…to put the question of being above all onto its ground…”66 In a recent article in New England Journal of Medicine Jerome Groopman reflects on his first son’s death which for him and his wife was, for the first time in their lives, not a “great case”. “There was no intellectual pleasure in solving a clinical puzzle, no charge of exhilaration from the drama of the operation. Instead, there was terror, raw and palpable, as we realized how close we had come to burying our first son…It could easily have been me.”67 He reflects medicine “has split into two streams – a current of marvelous biology and an undertow that pulls at the soul.”68 For him “it is hard to imagine that these two streams can ever again flow as one.” We realize it is hard for us too if we are not too obsessed with hard scientific straightjacket of medicine. We all experience empirical reality, the reality of our own senses. This is what an embodied approach to death talks about.

65

Thomas F. Tierney, “The Preservation and Ownership of the Body” in Perspectives on Embodiment: The Intersection of Nature and Culture, eds. Gail Weiss and Honi Fern Haber (New York, London: Routledge, 1999), 233-261. 66 M. Heidegger, Contributions to Philosophy: (From Enowning), tr. Parvis Emad and Kenneth Maly (Bloomington: Indiana University Press, 1999), 201. 67 Jerome Groopman, “A Great Case” in NEJM 2004; 351(20): 2043-2045. 68 Ibid, 2045.