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Supersizing the Mind. Andy Clark

Posted in books, from the living room, from the reading room, life, neuroscience, personal growth, philosophy, science on April 10, 2009| 6 Comments »

Where does your mind exist? There’s a longstanding “common sense” view that it’s inside your skull. But, it’s becoming apparent, that is far from the whole story. Yes, of course a lot of what we call the mind is related to brain activity and the brain is indeed inside the skull, but many researchers are discovering that just as the brain does not exist in isolation, neither can cognition, behaviour, a sense of self, for example, be understood solely on the basis of brain processes. If we want to understand the mind we have to consider the body in which the brain is embedded. Phrases such as “embedded mind” and “embodied mind” capture the essence of this view, and the more you think about it, the more your realise the importance of the incredible network of connections between the brain and the rest of the body.
I get frustrated by doctors and scientists who act as if we can divide a human being into two components – a body and a mind. Especially when they then use this arbitrary and false dichotomy to actually recommend treatments for people’s illnesses. The “embodied mind” concept binds the body and the mind inextricably. That makes a lot of sense to me. I’ve never met a mind without a body, and the only bodies I’ve met without minds have been in the mortuary.
However, some thinkers, scientists and researchers have pushed the idea of “embedded minds” a stage further. (the difference being that “embodied” is exactly what it says – “in the body”; whereas “embedded” argues for a broad contextual understanding which situates the mind in it’s multiple environments). Andy Clark, who promotes the concept of the “extended mind” is one of the writers who has taken this furthest.

I have three of Andy Clark’s books. The first one I read was “Being There” (ISBN 0-262-53156-9), which was given as a key reference in “Smart World” by Richard Ogle . That book deals with the concept of the “embodied mind”.

Might it not be more fruitful to think of brains as controllers for embodied activity? That small shift in perspective has large implications for how we construct a science of the mind. It demands, in fact, a sweeping reform in our whole way of thinking about intelligent behaviour. It requires us to abandon the idea (common since Descartes) of the mental as a realm distinct from the realm of the body; to abandon the idea of neat dividing lines between perception, cognition, and action.

Being There describes how this concept evolved and lays out the implications of the model. Six years later he published “Natural-born Cyborgs” (ISBN 0-19-517751-7). Here he challenges us to consider just how we, as human beings, extend ourselves outwith the bounds of our physical biology.

For what is special about human brains, and what best explains the distictinctive features of human intelligence, is precisely their ability to enter into deep and complex relationships with nonbiological constructs, props and aids. This ability, however, does not depend on physical wire-and-implant mergers, so much as on our openness to information-processing mergers.

He tracks the evolution of these interactions

….from speech and counting, morphs first into written text and numerals, then into early printing, and on to the revolutions of moveable typefaces and the printing press, and most recently to the digital encodings that bring text, sound and image into a uniform and widely transmissible format…..they constitute, I want to say, a cascade of “mindware upgrades”
What matters most is our obsessive, endless weaving of biotechnological webs: the constant two-way traffic between biological wetware and tools, media, props, and technologies. The very best of these resources are not so much used as incorporated into the user herself. They have the power to transform our sense of self, of location, of embodiment, and our own mental capacities. They impact who, what and where we are. In embracing our hybrid natures, we give up the idea of the mind and the self as a kind of wafer-thin inner essence, the human person emerges as a shifting matrix of biological and nonbiological parts. The self, the mind, and the person are no more to be extracted from that complex matrix than the smile from the Cheshire Cat.

I particularly like this phrase from his concluding chapter in that book –

Our most significant technologies are those that allow our thoughts to go where no animal thoughts have gone before. It is our shape-shifter minds, not our space-roving bodies, that will most fully express our deep cyborg nature.

In his most recent book, “Supersizing the Mind” (ISBN 978-0-19-533321-3), he reproduces the original article which he wrote with David Chalmers, where they both laid out this concept of an “extended mind”. That article alone is worth reading, and, in fact, he recommends you read it first before reading the rest of the book. He juxtaposes the concept “BRAINBOUND” with “EXTENDED”.

According to BRAINBOUND, the (nonneural) body is just the sensor and effector system of the brain, and the rest of the world is just the arena in which adaptive problems get posed and in which the brain-body system must sense and act.
Maximally opposed to BRAINBOUND is a view according to which thinking and cognizing may (at times) depend directly and noninstrumentally upon the ongoing work of the body and/or the extraorganismic environment. Call this model EXTENDED. According to EXTENDED, the actual local operations that realise certain forms of human cognizing include inextricable tangles of feedback, feed-forward, and feed-around loops; loops that promiscuously criss-cross the boundaries of brain, body and world. The local mechanisms of mind, if this is correct, are not all in the head. Cognition leaks out into body and world.

Why is all this important? Well, I think Andy Clark puts it well himself –

This matters because it drives home the degree to which environmental engineering is also self-engineering. In building our physical and social worlds, we build (or rather massively reconfigure) our minds and our capacities of thought and reason.

This is the why this way of thinking so exciting. How does our physical environment shape not just our patterns of thought, but our whole sense of personhood? How does it limit, or potentially expand, what we think we are and what we think we can be? Our social world is a fundamentally narrative one. So what are the stories we are told in our societies? And what stories do we choose to tell each other? How does this narratively-constructed world both shape our sense of personhood, and stimulate our imaginations to become something more than we are now?
If all this seems a little esoteric for you, read David Chalmers foreword to “Supersizing the Mind”. You’ll immediately grasp the everyday-ness of all this as he talks about how getting an iphone has changed his life, and, further, how the use of notebooks, and visual cues, can maintain independent living in patients with Alzheimer’s way beyond what would be possible were they to rely on the minds inside their skulls!

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Suffering and good lives

Posted in from the consulting room, health, narrative, personal growth, philosophy, science on March 2, 2009| 5 Comments »

My daily working life is that of a doctor. That only tells you a little because Medicine is a very broad subject and doctoring can require extremely different sets of skills. Sometimes I muse about just what is the job of a doctor? Or what makes for a good doctor? I’m pretty sure it involves trying to understand people better. I’m also pretty sure it involves helping people. It involves never thinking you know everything or that you are definitely right! (I know that’s a surprising conclusion but there’s a difference between being decisive and being certain…..read the linked post for more on this). I think it’s also a common experience that a good doctor is one who gives a damn ie one who cares. However, the specifics of the working life of a doctor depend a lot on the context of the doctor’s work. I made myself a “human spectrometer” to clarify this point.

Human spectrometer

Most health care is created around systems. There are whole departments defined on the basis of their focus on a system – Neurology, Urology, Gastroenterology etc. The focus of a doctor in that department is a particular system of the body. He or she becomes expert in the diseases and disorders of that system and acquires the knowledge, tools and experience to intervene, to either resolve, or to manage those disorders. Some doctors specialise more than this. Move left a little from the system on the spectrometer. We have both medical and surgical specialists who focus on one particular organ, or part of a system, like liver specialists, hand surgeons, and so on, and following that path further left we have biochemists and geneticists who concentrate on the functions right down at cellular, or intracellular levels. Jumping to the other end of the scale, there are the epidemiologists and the Public Health doctors who consider disease at a population level. I’m a great admirer of the work of Prof Richard Wilkinson who makes clearer than anyone else I know just what an impact inequality has on population health. The knowledge, skills and experience he needs to do his job are quite different from those of the hand surgeon. Move left again along the spectrum from the right hand side. There are doctors who focus on families, whose everyday lives involves working with whole families, or parts of families. Then there’s me. Right there in the middle. There are lots and lots of doctors like me. Our days are spent largely in consulting rooms with individual patients. Our approach is a generalist one, not a specialist one. We focus on the person. The skills, knowledge and experience needed to do this kind of daily work is holistic, narrative-based and focused on the ability to listen, to communicate and to understand at an individual level.

So each doctor needs the skills and the knowledge appropriate to their practice but there’s something else all doctors share. We are all trying to relieve suffering.

Suffering isn’t a word you’ll find in medical textbooks (just like you won’t find the words “health” or “healing” in textbooks of clinical medicine either!) but it’s our raison d’etre. You can judge me by it. I judge myself by it. When I go to work any day, I want to relieve suffering. If I interact with a patient and don’t feel that I’ve contributed to a relief of their suffering by my involvement and my actions then I don’t feel I’ve done my job. Dr Eric Cassell’s book, “The Nature of Suffering”, deals with this issue beautifully. He says in this book, and in his others, that he changed his clinical practice by deciding to focus on the issue of the patient’s suffering. In fact he explicitly asks his patients to tell him about their suffering as a powerful way of allowing them to set and declare their agenda and for him to focus his care where it matters. In that book he shows how suffering might lie in an individual patient, but it might lie in their relationships, their family, their workplace or community. You could, in fact, ask that question at any point on the “human spectrometer” above. Just where on the spectrum does the suffering lie?

However, human beings have a complex relationship with suffering. It might even be extolled as something good – “No pain. No gain” “I have to suffer for my art” I’ve read more than one book which considers the place of a serious illness in an artist’s life and puts forward the hypothesis that it was their suffering which enabled them to produce their distinctive, great art. I recently read David Lynch’s book, “Catching the Big Fish; Meditation, Consciousness and Creativity” (which I highly recommend actually!) where he powerfully refutes that argument, claiming that Van Gogh might have had the chance to produce even more and even greater art if he hadn’t had all that suffering to cope with in his life. Suffering gets a good press in many religious teachings as well as in a certain kind of New Age thinking. There are many spiritual practices based on inflicting suffering on the body and there’s even a belief in destiny, or Fate, or karma, which states that if you are suffering it’s because that’s what your soul requires. Even the “quest story” of Arthur Franks, as exemplified in Lance Armstrong’s “It’s not about the Bike” shows how suffering can be a path to growth and development.

I’m not denying any truths which lie in those beliefs. Nor am I claiming to know better. But let me be very clear, as far as I know, nobody, given the choice between a path of suffering and one of bliss, chooses suffering. We only choose suffering if we can see no other way to get to where we want to be. If we can find another way that doesn’t involve suffering we’ll choose it. So, yes, maybe my job involves helping people to make the most of their suffering, or to even get something good out of it, but, my first priority, my prime motivation is to do my best to relieve it.

Whether I can help relieve someone’s suffering or not, the inextricably related goal I have is to help that person to have a good life. The point of relieving suffering is to enable a person to experience a good life. But as suffering is an inevitable thread that winds its way through all lives, a doctor’s job is to help people to have a good life, whether they are suffering or not.

Doctors are not the only people to help others to lead good lives of course, but I do think a doctor who loses sight of this goal, loses sight of what it is to be a doctor.

PS Now you’ll be thinking “ah, but what is a GOOD LIFE?” Me too! (I’m working on a post about this but here’s an earlier one to be going on with)

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More unicorn hunting…more mysteries to unravel

Posted in art, creativity, from the living room, from the viewing room, philosophy, tagged , on March 1, 2009| 2 Comments »

Towards the end of last year I went unicorn hunting. It opened up whole unknown areas for me, not least that of medieval art. I’m still exploring this and learning all the time and, frankly, its awe-inspiring. Well, here’s another part of that adventure. When I read about the unicorn hunt tapestries which are in Cloisters of the Metropolitan Museum in New York (which are being re-created in Stirling Castle), I also read about the Lady and the Unicorn series which are in the Musee Cluny in Paris. I determined to go and see them, and, last week, I did.

One thing about Paris is that everything is further away than it appears on the map! So, although we set off to find the Cluny by opening time of 0915, it was only after stopping for a coffee at the Sorbonne, and scrutinising the map again, that we managed to actually track it down – only a couple of minutes away from where we had stopped.

musee cluny

The Cluny is one of those amazing small museums in Paris (there are many more for me still to discover!). It’s a rambling, ancient building which doesn’t have real corridors, just the occasional narrow passageway or set of stairs. I had come to see the Lady and the Unicorn tapestries so made my way through the various rooms following the signs to the tapestries.

clunyrez

This plan shows you the ground floor. You enter at the far right and make your way to the far left.

The rooms on the ground floor are either very dimly lit to protect the tapestries and ivories on display, or very brightly lit displaying statuary and parts of medieval buildings. One of the rooms has stained glass all around and all backlit which creates a beautiful effect. Having found my way to the staircase to the first floor, I climbed the stairs and walked through a doorway into the specially designed circular room where the unicorn tapestries hang.

clunypremier

The first thing you encounter is a wall. You can choose to enter the space either to the right or the left of the wall. I went right, and entered into a dimly lit room around which were hung the Lady and the Unicorn series of tapestries, five of them, each representing one of our senses. As you stand gazing at the incredible red and blue tapestries, working your way from the one to the next, you reach the furthest right hanging, “touch”, and turn right around and see behind you the largest of the six tapestries, the enigmatic “A Mon Seul Desir” hanging on the freestanding wall you walked around to enter the room. The overall experience is amazing. No photos, no words, will do it justice. You just have to go. For me, the last time I experienced art like this was when I went to see Monet’s Lily paintings in the Orangerie. There’s another place to put on your places I must see list. When you walk into those oval rooms of the Orangerie and find yourself in the middle of those incredible paintings, it’s completely amazing. You feel surrounded by them, enveloped by them, as if you are diving deep down into the art itself. The Orangerie does that, and so does the Lady and the Unicorn room in the Cluny. It’s pervasive and almost overwhelming. There are a few small stools fixed in the middle of the room and I sat down on one of them.

The first tapestry I looked at was “Taste”, on the far left. I don’t know if you have these experiences with art, but I find when I walk through galleries I can appreciate and admire many works but just occasionally one whacks me right in the heart. This tapestry did it for me. I felt my breath catch, my heart leap, and the tears well up in my eyes. I could hardly take my eyes off it. As I looked at the others, one after the other, they too impressed me but I have to say none of the others had the powerful emotional impact of the first. I’ve read a lot about these tapestries since then and it seems this is one of their key features. They bring out different reactions in different viewers. It’s as if there are deep archetypal truths in them and whoever you are, whatever place you happen to be in, in your life, they have the power to touch something in you, to reveal something of your soul. (no photos will convey even a smattering of the power and impact of these tapestries but if you’d like a quick look check out my collection here)

There are so many mysteries surrounding these tapestries. They are just over 500 years old and are quite astonishingly accomplished works of art, but unlike paintings of the same age, no-one knows who drew the original designs, who actually wove the tapestries, who commissioned and owned them, or what message they were created to convey. There are many theories, and Tracy Chevalier, the author of Girl with The Pearl Earring, is one of those to explore them.

Are all the tapestries portraying the same woman? Who is she? And what exactly is going on in the sixth tapestry, referred to as “A Mon Seul Desir”. Whose sole desire? And what is that sole desire exactly? Only in this last, and largest of the series, is she without a necklace, but is she taking it off and placing it in the casket, or is she taking it out of the casket to put it on?

Here are some of the theories. The tapestries were designed by the Master of Anne of Bretagne and woven in the North of France or in Belgium, having been commissioned by the wealthy Lyon family of Les Vistes. The medieval concept of the senses were that there were six. Taste, Hearing, Vision, Taste, Touch and Understanding (otherwise known as the heart or the intellect or, as we might now call it, intuition). It was this final, sixth sense, which controlled all the others.

I bought the guide book in the museum. It’s beautifully illustrated and lays out all the known facts, and the controversial guessed-at facts about the tapestries, but, frustratingly, I feel, makes only half hearted attempts to deal with the luxurious and abundant symbolism in the tapestries.

It’s this last feature which I find so appealing and intruiging. Someone looking at these tapestries in medieval times would see so much more than we do because the culture of that time was incredibly highly skilled at dealing with symbol, metaphor and allegory. In fact, no flower, no tree, no creature in these tapestries has only one possible meaning. Like the Hunting of the Unicorn they can be read in multiple ways. There just isn’t one answer, one interpretation which is the correct interpretation and even now with our somewhat impoverished skills in handling symbol and metaphor, they have the power to touch us really in the depths of our souls.

I’m fascinated. I’m intruiged. I’m hooked. I’ll tell you more if and when I uncover it. Don’t you just love a mystery?

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Reinventing the sacred

Posted in from the reading room, philosophy, science, tagged on February 8, 2009| 1 Comment »

That reductionism is limited, however, does not mean it is not powerful, amazingly productive, and tremendously useful scientifically. We simply need to understand its place, and recognise that we live in a very different universe from that painted by reductionism alone.

So writes Stuart Kauffman in “Reinventing the Sacred” (ISBN 978-0-465-00300-6). I agree with that. As a medical doctor who practices in a field of medicine which values an understanding of patients from a holistic perspective, seeking to know, not just the diseases they might have, but to know the individuals who have those diseases, I find reductionist approaches both useful and insufficient. As Mary Midgley says in “Wisdom, Information and Wonder”,

One cannot claim to know somebody merely because one has collected a pile of printed information about them.

The key point Kauffman seeks to make in his book (he is a complexity scientist) is how our relatively new exploration of complex systems in non-reductionist ways has revealed characteristics which fundamentally change the way we understand reality. The central characteristic is, he feels, “emergence”.

…while life, agency, value, and doing presumably have physical explanations in any specific organism, the evolutionary emergence of these cannot be derived from or reduced to physics alone. Thus, life, agency, value and doing are real in the universe. This stance is called emergence……….Emergence is therefore a major part of the new scientific worldview. Emergence says that, while no laws of physics are violated, life in the biosphere, the evolution of the biosphere, the fullness of our human historicity, and our practical everyday worlds are also real, not reducible to physics nor explicable from it, and are central to our lives. Emergence, already both contentious and transformative, is but one part of the new scientific worldview I shall discuss.

The other major characteristic he describes is how Nature does not conform to “natural laws”, and so the world is not nearly as predictable nor controllable as we have believed (well you only need to read about this year’s economic crises to see that’s true, don’t you!)

Kauffman explains how emergence is a quality of unceasing creativity, and he explains how unpredictability challenges the supremacy of reason as a guide to life. When you first encounter them, these are radical ideas for a scientist, but the more you learn about complexity as a way of understanding reality, the more you realise how reductionism does not equal science. Science is a greater way of thinking than that, and its the modern concepts and methodologies which are expanding science beyond its limited and reductionist constraints. He shows how “ceaseless creativity in the evolution of the biosphere” undermines the Newtonian concept of “natural laws”.

We will soon find its analogues in economic and cultural evolution, which, like the biosphere, are self-consistently self-constructing but evolving wholes whose constituents are partially lawless.

(This book was published in January 2008, and therefore written well before the economic crises of the last year)

This is a radically different scientific worldview than we have known. I believe this new scientific worldview breaks the Galilean spell of the sufficiency of natural law. In its place is a freedom we do not yet understand, but ceaseless creativity in the universe, biosphere, and human life are its talismans. I believe this creativity suffices to allow us to reinvent the sacred as the stunning reality we live in. But even more is at stake……We must come to see reason as part of a still mysterious entirety of our lives, when we often radically cannot know what will occur but must act anyway. We do, in fact, live forward into mystery.

I do resonate with these ideas. Emergence is a fascinating concept. To connect it to the concept of ceaseless creativity and beyond that to the notion of God as Creator is an interesting step. Somehow, though, it doesn’t quite work. I am with him in the awe-inspiring inspiration of ceaseless creativity. I think human beings, other creatures, Nature itself are endlessly fascinating and can, in fact, never be wholly known. But to use “God” symbolically to represent this phenomenon doesn’t work for me. I do like how contemplation of emergence, however, can help us to put reductionism in its place. In fact, reductionism can be more, not less, useful, if instead of trying to understand absolutely everything from that single standpoint, we use it in appropriate contexts and never consider that it gives us the whole “Truth”.

I also resonate with the idea that the acceptance of the inevitabilty of uncertainty makes us aware of the ineffable. In so doing, it makes both the mysterious more real, and reality more mysterious.

I wanted to like this book. I wanted it to be a great book. But that’s not where I’ve ended up. I’m grateful to Stuart Kauffman for this work though, and coming from the perspective of a scientist gives his ideas a particular and a unique value. But in terms of “reinventing the sacred”, I think poetry, art, photography, music, and stories do all that so much better. Take a look at the photos of the frozen Scottish countryside I posted earlier, read “Anam Cara” by John O’Donohue, or “The Little Prince” by Saint Exupery, get in touch with what the French call “emerviellement” in your daily life (in the “quotidien“) and tell me if you agree. Yes, the new science of complexity can make us a bit more humble again, has a good chance of firing up our sense of awe, but I think it takes both Art and Philosophy to really put us in touch with the sacred again.

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Myths which improve life

Posted in from the living room, life, narrative, philosophy, writing, tagged on February 3, 2009| 6 Comments »

People often use the word myth as if it is the opposite of the word truth. It’s juxtaposed to reality. You hear that a lot. An explanation about something is dismissed as a myth, meaning that it’s not true, not a fact, that’s it’s unreal. It’s quite strange how we’ve developed this way of using the word myth, because that was never the original meaning of the word. In Karen Armstrong’s “A Short History of Myth” (ISBN 978-1841957036) she says

Human beings have always been mythmakers [because] we are meaning seeking creatures.

Myths then, are a kind of story, a particular kind of story which has the potential to cast light on some aspect of life, some potential to make something clearer, to improve our understanding.

Myths are universal and timeless stories that reflect and shape our lives – they explore our desires, our fears, our longings, and provide narratives that remind us what it means to be human.

Mythology is about enabling us to live more intensely……it expresses our innate sense that there is more to human beings and to the material world than meets the eye.

I think this a key problem for us now at this stage in human development. How do understand both objective and subjective reality? How do we find meaning and purpose in our lives? The great advances of materialistic naturalism (as Havi Carel) would call it, has advanced through a reductionist approach to reality. It’s based on the belief that everything can best be understood by considering the parts, the components, from which it is made. That’s brought great advances in our ways of being able to understand and interact with the physical world, but when pushed to an extreme it creates a world view which denies the importance, even the reality of anything which cannot be measured, counted, or described objectively. That’s created a sense that the life itself has no meaning, that individual lives have no purpose, and that the priorities of living are about accumulation and consumption of material objects. Now the whole system is in crisis. Prime Minister Gordon Brown says we have never been here before and nobody really knows how to progress.

Karen Armstrong says, “Mythology and Science both extend the scope of human beings.” She’s right. these different ways of grasping reality complement each other.

A myth is true because it is effective, not because it gives us factual information. If, however, it does not give us new insight into the deeper meaning of life, it has failed. If it works, that is, if it forces us to change our minds and hearts, gives us new hope, and compels us to live more fully it is a valid myth.

Wouldn’t you like to read myths which did that?

She concludes –

We need myths that will help us to identify with all our fellow beings

We need myths that help us to realise the importance of compassion

We need myths that help us to create a spiritual attitude to see beyond our immediate requirements

We need myths that help us to venerate the earth as sacred once again.

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Making a mark

Posted in from the dark room, life, philosophy, photography on January 26, 2009| Leave a Comment »

Out walking the other day and I came across this mark on the ground,

the other mark

It’s like a butterfly or a flower or something. What was it? Isn’t it strange and beautiful?

Actually I’ve a pretty good idea what it is. Take a look at the other mark which was nearby,

the mark

One of the interesting things about these marks for me is that I find them compellingly beautiful but they are for sure just accidents, unintentional, the unintended marks left while doing something other than making a mark. They aren’t art. They weren’t even created deliberately but they are definitely the hand of a human being all the same.

Everything we do makes a mark, doesn’t it? Has effects we don’t necessarily intend and leaves the world a little changed.

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illness by Havi Carel

Posted in books, from the consulting room, from the reading room, health, philosophy on January 21, 2009| 8 Comments »

I’ve just read “illness” by Havi Carel (ISBN 978-1-84465-152-8). This is an excellent book and as Raymond Tallis says on the back “should be read and re-read by everyone who is professionally involved with illness, who is ill, or is likely to become ill; which is to say, by all of us”. I couldn’t agree more.

Havi Carel teaches philosophy at the University of the West of England. She has developed a rare but extremely serious disease – LAM – which quickly reduced her lung capacity by 50%. She brings her professional philosophical knowledge and understanding to the personal experience of this illness in a way which both challenges the way we think about illness, (chronic illness especially), and provides a useful framework for a positive engagement with such difficult life-limiting experiences as disabling disease.

I would like to see significant changes in the way health care is delivered based on the lessons revealed in this book. We need a fundamental re-humanisation of our ways of thinking about illness in order to bring about a sea change in the way doctors, nurses and other health professionals work.

Havi Carel writes with great clarity. Don’t be frightened off by the fact she’s a philosopher. Despite the fact that she draws on the work of philosophers from Epicurus to Heidegger and Merleau-Ponty (amongst others), there is nothing difficult to grasp or understand in this book. She skilfully uses the works of great philosophers to both illuminate and clarify our thinking about health and illness. Not only does she use clear, straightforward English, but the personal story woven into book makes it a profoundly moving and completely engaging read.

On a naturalistic view, illness can be exhaustively accounted for by physical facts alone. This description is objective (and objectifying), neutral and third-personal………Phenomenology privileges the first-person experience, thus challenging the medical world’s objective, third person account of disease. The importance phenomenology places on a person’s own experience, on the thoroughly human environment of everyday life, presents a novel view of illness.

Instead of viewing illness as a local disruption of a particular function, phenomenology turns to the lived experience of this dysfunction. It attends to the global disruption of the habits, capacities and actions of the ill person.

This consideration of the relationship between objective and subjective perspectives is I think central to the development of humane and humanly relevant medicine. Eric Cassell nicely explores this conceptually by unpicking the words “disease” and “illness”, and clinically by asking doctors to encourage patients to talk about their “suffering”. The fundamental shift is a change of perspective from the components of the body, to the socially embedded individual human being. Havi Carel’s consideration of the “biological body” and the “lived body” sets a wonderfully clear perspective from which to understand this.

Normally, in the smooth everyday experience of a healthy body, the two bodies are aligned, harmonious. There is agreement between the objective state of the biological body and the subjective experience of it. In other words, the healthy body is transparent, taken for granted……..It is only when something goes wrong with the body that we begin to notice it.

This is exactly the point made by Hans Georg Gadamer in his excellent collection of essays entitled “The Enigma of Health”. For me, reading his essays completely changed the way I thought about health and illness. Havi Carel has given me a new framework for these concepts and values and I find that very exciting.

One of the most useful parts of this book is the exploration of the idea of “health within illness”. We have a tendency to write off the chronically sick expelling them from the land of the healthy to the land of the ill (as Susan Sontag so clearly wrote). But life’s not like that. Having a chronic illness does NOT mean never being able to experience health again. In the last two chapters of the book, “Fearing death”, and “Living in the Present” she tackles this head on, drawing on advice from Epicurus, Heidegger and the contemporary French philosopher, Hadot. The wonder and the joy of the present is something I’ve posted about before – here and here – both times referring to Hadot in particular. I couldn’t agree more.

Let me finish this short review though by focusing on her other really important point –

Empathy. If I had to pick the human emotion in greatest shortage, it would be empathy. And this is nowhere more evident than in illness. The pain, disability and fear are exacerbated by the apathy and disgust with which you are sometimes confronted when you are ill. There are many terrible things about illness; the lack of empathy hurts the most.

Virtually every day I hear terrible stories of heartlessness and carelessness. Of patients who have experienced a total lack of humane care in the hands of health care professionals. Always those stories shock me. In one way I don’t understand them. Why work in a caring profession if you frankly don’t care? But in another way I blame the system. This exclusive emphasis on the biological body reduces human beings to cases of diseases. By ignoring or belittling the patients’ narratives, or by not paying attention to their subjective experiences of their “lived bodies”, we literally de-humanise our practice.

To think of a human being is to think of a perceiving, feeling and thinking animal, rooted within a meaningful context and interacting with things and people within its surrounding.

It’s time to re-humanise Medicine. This book is an important contribution to that project.

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The unpredictable

Posted in from the reading room, philosophy, science on December 17, 2008| 1 Comment »

Black Swan, author, Nassim Nicholas Taleb, was interviewed recently for Philosophy Now magazine. I happened to be reading it the other day and it came back to my mind as I sat in a train outside Queen Street station for half an hour this morning while engineers attempted to unstick a “points failure”.

My core idea is about the effect of non-observables in real life. My focus is on the errors which result: how the way we should act is affected by things we can’t observe, and how we can make decisions when we don’t have all the relevant information.

I really like his phrase, “non-observables”. It immediately made me think of the Little Prince, and Saint-Exupery’s theme of how what’s invisible is most important in our lives. But that’s not exactly what he means. He’s particularly interested on those events and phenomena which appear unpredictably (for example, by studying swans, you would think one of their characteristics was that they are all white. It’s only when the black one turns up in another part of the world, that you have to abandon that belief). Of particular relevance for this time of year, is his parable of the turkey. The turkey concludes, on the basis of its daily observations, that’s he’s always fed at 9am and that the people who look after him do so very well, that they care for him and want the best for him. It’s only on Christmas Eve that he discovers this was a wrong conclusion.

The scientific method is based on “induction” – using particular observations to generate general laws which then allow predictions to be made. Taleb clearly points out the weakness of this approach.

…..induction presupposes that nature behaves in a uniform fashion, but this belief has no defence in reason.

I also like this phrase of his – “I’m interested in the ecology of uncertainty, not induction and deduction”. The ecology of uncertainty is such a great phrase. How often do we desperately seek certainty in order to make our lives predictable? But it’s a delusion. The world is full of uncertainty. In fact, the more complex the issue, the less certainty we can find. Human beings are complex adaptive systems. We aren’t able to predict, in individual cases, exactly what course a disease will take, nor, whether or not a particular treatment will work.

I’m grateful to Nassim Nicholas Taleb for his work on uncertainty. As science begins to grapple with complexity, scientists are going to have to learn how to handle “the ecology of uncertainty” instead of relying on induction.

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Today, an amazing day

Posted in from the dark room, life, philosophy, photography on November 10, 2008| 12 Comments »

Platform 3 rainy morning

I took this photo while standing on a cold, wet platform waiting for a train to take me to work.
This is not an unusual experience. It’s not a rare experience. It’s very easy to bury your head into your shoulders, stand and shiver, and just wish you were somewhere else.

This year I’ve been reading some contemporary French philosophers, Jean-Philippe Ravoux, Pierre Hadot, and Bertrand Vergely. I’ve not read much, but both in interviews they’ve given and in the few books of theirs which I’ve read, I’ve found that they all three mention two common concepts. The two concepts are captured by these two French words – “quotidien” and “emerveillement”.

Quotidien means daily, but not just in the sense of “daily paper”, or “daily bread”, but in the sense of the “everyday”, of daily life. You’ve probably read a lot about the importance of living in the present. It’s certainly a common theme in Eastern philosophy, but it’s also a very common theme in the work of Western self-help writers and psychologists. Both the concept of the present, and that of the “quotidien”, concentrate us on a period of time – the period of time in which we are most alive. I find the concept of the present a little tricky. It’s very hard to pin down. You only have to breathe out and the present has already become the past. So we tend to stretch the boundaries of the present outwards from a moment to a period of time lasting maybe a few minutes, or hours, or even a day or number of days. The more we stretch the boundaries though, the more what we call the present loses its power. I like the French term, “quotidien”. It’s a period of time I can grasp. It’s today. Every day. It’s the time period in which we are alive, our conscious time, the time when we can act.

The second word, “emerveillement”, is about an attitude towards something. It means a state of wonder, of marvel, even of amazement, or awe. Probably the best way to understand this is to think about the way children engage with the world. Young children find the world a fascinating place. Think of how much fun a child can have even with the packaging in which a present is given. The world really is an amazing place. Ceaselessly fascinating. It’s just that on a day to day basis we slip into autopilot, and as we stumble through our days like zombies, our lives literally pass us by.

So here’s the alternative. Today, this very day, let something catch your attention, and just pause for a moment and wonder. That’s what I did as I stood on that windy, rainy platform. I noticed the lights and the way they reflected on the concrete and the rails. I noticed the row of lamps on the opposite platform, and their reflections stretching into the distance. And I saw the green light glowing at the end of the platform, signalling GO. Green for go. Green, the signal to start. The day was beginning. Another amazing day.

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The Logic of Care

Posted in from the consulting room, health, philosophy on August 16, 2008| 2 Comments »

logic of care

The Logic of Care by Annemarie Mol, Professor of Political Philosophy, University of Twente, Netherlands ISBN 978-0-415-45343-1

Every now and then I read something which challenges my thinking. This is one of those books. The subtitle of the book is “Health and the Problem of Patient Choice”. I thought, “what problem?”, by which I mean isn’t it just a “good thing”? Aren’t we hearing this mantra increasingly often? That the way ahead for health care is to increase patient choice? Wasn’t this even what was implied by my post about the shift in power from doctors to patients? Yet, one of the commenters on that post made me feel immediately uncomfortable because they highlighted the issue of patients being seen as “customers”, which just doesn’t feel right to me. In fact, I’ve often felt I’m a bit out of step with new terminologies because I don’t like “patients” being referred to as “clients” or “customers” or any of the other preferred modern terms! However, right from the outset, Annemarie Mol questions our “logic of choice” – not only in health care, but in society more generally. She points out that in society, the emphasis on choice is not all that it seems. If, like me, you haven’t thought much about this before, this questioning of “the logic of choice” is challenging…..

“Sociologists have emphasised that all humans are born naked and helpless and depend on others for their survival for years. Even as adults Westerners are independent – all the more since they no longer cultivate their own food, sew their own clothes, or bury their own dead. Some sociologists have studied how in actual practice people in “free societies” make their choices. They have found that making choices takes a lot of energy, energy that not everybody has to spare or likes to spend on it. They have also found that “we” end up choosing remarkably similar things. Indeed, some scholars have argued that autonomy is not the opposite of heteronomy at all. Instead, they say, making people long for choices and invest a lot in making them, is a disciplining technique.”

“A second widespread way of doubting the ideal of choice is to point out that when it comes to it almost nobody (ill or healthy) is any good at it. It is difficult for all of us to weigh up the advantages and disadvantages of one uncertain future against another.”

As she points out, when somebody is acutely ill, they aren’t in a position to make choices. Instead, she says, what they need most is care. She shows how the logic of choice presupposes which finite and distinct products, instruments, outcomes, and so on are on offer. Having chosen, the patient awaits the promised outcome. In the logic of care the emphasis is on actions, interactions and processes. It isn’t about outcomes, it’s about experiences, or ways of living.

“Care is not a limited product, but an ongoing process”

“….consumers can help each other with their choices and they may buy as much kindness and attention as they can afford. However, and this is my point, in one way or another a market requires that the product that changes hands in a transaction be clearly defined. It must have a beginning and an end. In the logic of care, by contrast, care is an interactive, open-ended process that may be shaped and reshaped depending on its results. This difference is irreducible. It implies that a care process may improve even though less product is being supplied.”

The biggest problem with clinical epidemiology and the logic of choice approach is the unpredictable nature of reality.

“……diseased bodies are unpredictable. It follows form this unpredictability that care is not a well-delineated product, but an open-ended process. Try, adjust, try again. In dealing with a disease that is chronic, the care process is chronic too. It only ends the day you die.”

“Do not just pay attention to what technologies are supposed to do, but also to what they happen to do, even if this is unexpected. This means that good professionals need to ask patients about their experiences and attend carefully to what they are told, even if there is nothing about it in the clinical trial literature. There won’t be. The unexpected is not included in the design of trials. The parameters to be measured are laid out in the first stage of a clinical epidemiology research project. If doctors and nurses want to learn about the unexpected effects of interventions, they should treat every single intervention as yet another experiment. They should, again and again, be attentive to whatever it is that emerges.”

This unpredictability undermines the logic of the dominant approach to medicine –

“The scientific tradition that is currently most prominent in health care – that of clinical epidemiology – has not been designed to deal with the unexpected effects of interventions. Tracing these requires that one be open to surprises. Since unforeseen events cannot be foreseen and unidentified variables cannot be counted, other research methods are needed to learn more about them. Promising among these are the clinical interview and the case report. In good clinical interviews patients are granted time and space to talk about what they find striking, difficult or important. The diverse and surprising experiences are carefully attended to. Case reports in their turn are stories about remarkable events. They make these events transportable so that others may learn from them.”

And the answers are to be found in stories – in listening to patients and professionals and to reporting what is learned.

“The ideal of patient choice presupposes professionals who limit themselves to presenting facts and using instruments. In the linear unfolding of a consultation, a professional is supposed to give information, after which the patient can assess his or her values and come to a decision. Only then is it possible to act. However, care practices tend not to be linear at all. Facts do not precede decisions and activities, but depend on what is hoped for and on what can be done. Deciding to do something is rarely enough to actually achieve it. And techniques do more than just serve their function – they have an array of effects, some of which are unexpected. Thus, caring is a question of “doctoring”: of tinkering with bodies, technologies and knowledge – and with people, too.”

I like her emphasis on doctoring instead of technologies and products –

“I want to talk of doctoring. Within the logic of care engaging in care is a matter of doctoring. Doctoring again depends on being knowledgeable, accurate and skilful. But, added to that, it also involves being attentive, inventive, persistent and forgiving.”

And of her emphasis, not just on good communication –

“Good communication is a crucial precondition for good care. It also is care in and of itself. It improves people’s daily lives.”

…..not just communication, but “conversations” –

“Good conversations in a consulting room do not take the shape of a confrontation between arguments, but are marked by an exchange of experiences, knowledge, suggestions, words of comfort.”

“Let us doctor, and thus, in careful ways, experiment with our own lives. And let us tell each other stories. Case histories. Public life deserves to be infused with rich stories about personal events.”

Life is complex. Health is complex. It cannot be reduced to events, interventions, targets and outcomes. Patients are not consumers. The model of markets, goods, services, purchasers and providers may well NOT be the best one for health care. This is not least because people with chronic diseases need attention for life, but also because we all have a variety of different values and priorities which, themselves, will vary through the evolving different contexts of our lives.

“Clinical epidemiology has developed clinical trials as research tools to inquire into the effectiveness and effectivity of treatments. Clinical epidemiology itself however, relates to patient choice in an ambivalent way. Sometimes it indeed presents its trials as tools that increase knowledge of the “means” that doctors have at their disposal, suggesting that the “ends” can be established elsewhere. At other times, however, clinical epidemiology casts patient choice as superfluous. For if trials show which treatments are more effective and efficient than their alternatives, there is no further need to make decisions. Just go for the treatments the trials show to be best! To the adherents of this line of thought, it is a great puzzle: why do professionals not comply? Why do they refuse to implement the results of front-line clinical trials? There is a lot going on here, but let me just note that this question fails to recognise that the parameters explored in trials, their measures of success, do not necessarily map onto the ends that patients and their doctors may want to achieve. If there are different treatments, the question is not just which of them is more effective, but also which effects are more desirable. The question is not just which treatment has the greatest impact on a given parameter, but also which parameter to measure. In chronic diseases “health” is out of reach, so it is not obvious which parameter to go for. Different treatments may well improve different parameters. Or, to put it in the terms used in the logic of choice: not all technologies serve the same ends and not all ends are equally worthwhile to everyone concerned.”

“Some diseases can never be cured, some problems keep on shifting. Even if good care strives after good results, the quality of care cannot be deduced from its results. Instead, what characterises good care is a calm, persistent but forgiving effort to improve the situation of a patient, or to keep this from deteriorating.”

And, finally, I completely agree with her emphasis on acting – on what we DO

“The logic of care is not preoccupied with our will, and with what we may opt for, but concentrates on what we do.”

“Rather than taking you for a spectator of your life, they expect you to play a leading part in it. Thus, in the logic of care it is not the noun that is crucial, life (an object that can be judged), but rather the verb, to live (an activity of which we are the subjects).”

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