A Systems Analysis of Medicine (SAM): Healing Medicine 9783838272672

Citation preview

Ken A. Bryson

A Systems Analysis of Medicine (SAM) Healing Medicine

Series Editors: Alexander Gungov, Friedrich Luft

ibidem

Studies in Medical Philosophy, vol. 6

ISBN: 978-3-8382-1267-8

A Systems Analysis of Medicine (SAM)

The author: Dr. Ken A. Bryson (PhD from the University of Ottawa) is professor emeritus at Cape Breton University, Canada. He has taught at l’Université de Moncton, the University of Ottawa, Saint Mary’s University on ASN television, Wuhan University, China, and le CEGEP Régional de la Côte Nord, Canada. He held a visiting fellow appointment at Saint David’s University, UK, (1996), and a visiting scholar appointment at Huazhong University, China, of science and technology in 2011. He participated in the Rethinking Technology Institute at Pennsylvania State University (1994). He is founding editor of the philosophy and religion special series, Value Inquiry Book Series, Rodopi-Brill (2000–2016), and is a member on several editorial boards. He is a fellow of the Adler-Aquinas Institute. He has published several books and 50 articles in peerreviewed journals.

Ken A. Bryson

This book is a must-read for anyone interested in transforming the impersonal character of the medical experience into a personalized, relational, spiritual, and holistic dialogue about human health. It promotes a holistic vision of the doctor-patient relationship, a medicine that ought to be based on the totality of the human experience rather than on the reductive view of the patient as a person with a certain disease. Ken A. Bryson describes the character of medicine as the gateway to holistic healing and argues that we need to secure the ethical foundation of universal medicine as not relative to a cultural setting, thus establishing the Oath of Hippocrates as the universal gateway to human dignity. This view emboldens us to raise medicine from the level of an impersonal technological encounter with disease to its rightful place as a sacred activity that includes all the levels of the human experience. The book offers practical suggestions on how to accomplish that objective.

ibidem

Ken A. Bryson

A Systems Analysis of Medicine (SAM) Healing Medicine

STUDIES IN MEDICAL PHILOSOPHY  Edited by Alexander Gungov and Friedrich Luft  ISSN 2367‐4377 

  1  

David Låg Tomasi  Medical Philosophy  A Philosophical Analysis of Patient Self‐Perception in Diagnostics and  Therapy  ISBN 978‐3‐8382‐0975‐3   

2  

Jean Buttigieg  The Human Genome as Common Heritage of Mankind  ISBN 978‐3‐8382‐1157‐2   

3  

Donald Phillip Verene  The Science of Cookery and the Art of Eating Well  Philosophical and Historical Reflections on Food and Dining in Culture  ISBN 978‐3‐8382‐1198‐5   

4  

Jean‐Pierre Clero  Rethinking Medical Ethics  Concepts and Principles  ISBN 978‐3‐8382‐1194‐7   

5  

Alexander L. Gungov  Patient Safety  The Relevance of Logic in Medical Care  ISBN 978‐3‐8382‐1213‐5   

6  

Ken A. Bryson  A Systems Analysis of Medicine (SAM)  Healing Medicine  ISBN 978‐3‐8382‐1267‐8 

 

Ken A. Bryson

A SYSTEMS ANALYSIS OF MEDICINE (SAM) Healing Medicine

ibidem-Verlag Stuttgart

Bibliographic information published by the Deutsche Nationalbibliothek Die Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://dnb.d-nb.de.

Bibliografische Information der Deutschen Nationalbibliothek Die Deutsche Nationalbibliothek verzeichnet diese Publikation in der Deutschen Nationalbibliografie; detaillierte bibliografische Daten sind im Internet über http://dnb.d-nb.de abrufbar.

ISSN: 2367-4377 ISBN-13: 978-3-8382-7267-2

© ibidem-Verlag / ibidem Press Stuttgart, Germany 2019 Alle Rechte vorbehalten Das Werk einschließlich aller seiner Teile ist urheberrechtlich geschützt. Jede Verwertung außerhalb der engen Grenzen des Urheberrechtsgesetzes ist ohne Zustimmung des Verlages unzulässig und strafbar. Dies gilt insbesondere für Vervielfältigungen, Übersetzungen, Mikroverfilmungen und elektronische Speicherformen sowie die Einspeicherung und Verarbeitung in elektronischen Systemen.

All rights reserved No part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form, or by any means (electronical, mechanical, photocopying, recording or otherwise) without the prior written permission of the publisher. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

This Book is Dedicated to our Grandson Keanen and his Family; Their Ability to Find Meaning in the Struggle Against Childhood Cancer is Inspirational. And to Exoria and Eliana Campbell, Olivia and Noah MacRury, Jillian, Maria and Bella Bryson

Contents Acknowledgments ................................................................................. 11  Foreword ............................................................................................... 13  Introduction: A Systems Analysis of Medicine (SAM)...................... 19  Chapter One: The STS Toolbox .......................................................... 35  Overview .......................................................................................... 50  Resource.2 ........................................................................................ 58  Technical Programs .......................................................................... 61  Social Community Programs ............................................................ 63  Ethics: Doing the Right Thing .......................................................... 66  The STS Range ................................................................................. 69  The STS Conversation: ..................................................................... 71  Thematic Contrast Issues .................................................................. 76  Bioethics ........................................................................................... 79  Responsible Social Action ................................................................ 83  Characteristics of Successful Social Action...................................... 85  Results .............................................................................................. 88  Conclusion ........................................................................................ 88  Chapter Two: Persons Exist in Relationships .................................... 91  Overview .......................................................................................... 91  A phenomenological analysis of religious faith ................................ 94  What is a person? ............................................................................ 106  Conclusion ...................................................................................... 129  In Summary .................................................................................... 130 

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Chapter Three: Dialogic Spirituality ................................................ 133  Overview ........................................................................................ 133  Introduction..................................................................................... 133  A system-based approach to medicine ............................................ 135  What is spirituality? ........................................................................ 138  Discussion Note .............................................................................. 146  The religious tendency towards good, God, and eternal life manifests itself in the spiritual nature of the person-making process. .. 151  Spirituality and personalized medicine ........................................... 151  Conclusion ...................................................................................... 154  Glossary of Terms........................................................................... 154  Questions to assess broken spiritual associations on the arm of the carbon-self .......................................................... 155  Questions to assess broken spiritual associations on the arm of the social-self. ........................................................... 156  Questions to assess broken spiritual associations on the arm of the internal-self ......................................................... 157  Summary: How to Conduct a Spiritual Assessment ....................... 158  Chapter Four: Why Ethics Matters .................................................. 163  Overview ........................................................................................ 163  Introduction..................................................................................... 163  Ethics regulates relationships.......................................................... 165  Dialogical Ethical Theories ............................................................ 168  The Oath of Hippocrates ................................................................. 174  Abortion .......................................................................................... 176  AMA PRINCIPLES OF MEDICAL ETHICS................................ 180  Social Action .................................................................................. 182  Palliative Care ................................................................................. 189  Case Studies in Healthcare ............................................................. 191 

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Chapter Five: The Absolute Truth Value of Human Death ........... 221  Overview ........................................................................................ 221  Conclusion ...................................................................................... 236  Conclusion ........................................................................................... 239  Works Cited ........................................................................................ 243  Index .................................................................................................... 249 

 

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Acknowledgments My thanks to Stephen H. Cutcliffe for permission to quote the ‘Thematic Contrasts’ from the Science, Technology, Society (STS) Newsletter at Pennsylvania State University. My thanks to Nancy Baker, Manager, Book and Product Editorial Development and Production of the American Medical Association for permission to quote the Principles of Medical Ethics.

 

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Foreword To Kenneth Bryson’s Systems Analysis of Medicine Alexander L. Gungov To see medicine as part and parcel of human life, the medical perspective alone is not sufficient. It is necessary that one both be immersed in medicine and look beyond it so as to capture the entire picture of the human condition. A philosophical perspective on medicine would be an appropriate approach as it connects the specificities of medical care to the entire meaning of being a human and a person. Philosophy is capable of seeing the forest and the trees, as well as the person who is the patient. Moreover, philosophy is capable of a radical change of perspective leading to the realization of the fundamental truth that, in Kenneth Bryson’s words, “the person has a disease, but the disease does not have a person.” Disease is but one of the relationships constituting someone’s personality, which also includes the relationship between patients and their doctor, between patients and their loved ones, between patients and their community/society, and finally, between them and nature. The patient is an ill person who lives in a simultaneous combination of the above relationships and not a particular human being serving as an example (representation) of a given nosological unit in the way medical textbooks describe it. Besides being a patient, every person is involved in a variety of other relationships. Against this multifaceted background of relationships, disease is manifested within the relationship of being a patient. Being involved in many person-forming relationships is the central layer of human personality, that is, the social self, according to Bryson’s analysis. Medicine usually focuses all its efforts on the lowest biochemical layer of a person, the so-called carbon self. This is the ground for the advancement and triumph of the highly sophisticated, but also entirely impersonal, medical technology, and in particular its IT resources. Technology providers are proud of supplying means for health surveillance and control of actual and prospective patients from the stage of statistical disease risk estimation, to prevention measures, diagnoses, and foreseeing prognoses. The patient is reduced to a single atom; he/she is transformed into a subject of mathematically precise calculations. Such an approach

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A Systems Analysis of Medicine

would be opposed and discarded by most veterinary doctors and gifted and experienced clinicians practicing human medicine. To deal with a real patient in the flesh, not only the social-self dimension is indispensable, but also that of the inner self, the rich ensemble of personal awareness including desires, plans, hopes, and worries, as well as self-reflection. The inseparable and harmonized blend of the carbon self, social self, and inner self when viewed through the prism of the relationship of an illness comprise the real patient. Evidence-based medicine is only one of the aspects of medical care. It necessarily needs the supplement of patientcentered medicine. Behind the patient, the person should always appear, leading to person-centered or personalized medicine. Personalized medicine in this book is not understood just as an individualized approach to patients or patient empowerment. Personalized medicine values and treats the person consisting of the above-mentioned three levels of the self. The attending doctor and the entire health care providing system should recognize the difference between curing the carbon self and healing the whole person on the three levels of the self and within the multitude of human relationships. Unlike a mechanic repairing a car in the garage, a physician cannot help but reach the sacred dimension of the patient-person no matter whether the physician or the particular patient are religious or whether the treatment happens to be conducted in a church-affiliated hospital. The sacred meaning of healing a person transcends the fighting and overcoming a specific manifestation of the nosological unit identified in a patient. This process of transcending is realized not in the sense that repairing a car aims at bringing it back to use by its owner or curing an animal with mainstream veterinary medicine aims primarily at avoiding harm to humans. The sacred character of the doctor-patient relationship and of the entire process of healing a person consists in comprehending this person within the whole complex of the person’s relationships and self-awareness. A holistic attitude to a person’s relationships and self-awareness goes beyond the perfunctory social roles and a superficial attitude to oneself. Viewed in such a way, the patient and medicine acquire a sacred character in the sense that the patient is treated not as an isolated individual but is healed as a real person living for and making an impact on his/her family, community, and society. Even extremely lonely people tend to live, at least

Foreword

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potentially, for the sake of somebody else.1 This sacred perspective to medicine is available even to ordinary non-religious humanism. This perspective overcomes the reductionist one-dimensional disposition to the patient and to medicine in general. Humanism, however, is by no means doomed to constrain itself to regarding the human being as the ultimate reality, as is brilliantly shown by Renaissance humanism. Renaissance humanists have no doubts that the ultimate reality transcends the mundane vision of humans but is not solely transcendent. On the contrary, the transcendent has an immanent dimension, elevating humans to the status that exists in ultimate reality. Medicine is definitely concerned with ultimate reality as it deals with health, life, and death. In Bryson’s interpretation, death includes unconcealment of Being. Unlike in Martin Heidegger’s phenomenological analysis, for Bryson, death is not just a reason to concentrate on authentic life but is itself sacred. If the immortality of the soul is assumed, death is a step towards the ultimate reality of Being and, therefore, into the unconcealment of the ultimate reality. However, the ultimate reality does not contradict life since eschaton is not only about the end of this world. Eschaton indicates an opening towards the sacred and divine, towards the transcendence that has descended onto this world and has gained at least partial immanence. Divine grace is exactly such an opening into the ultimate things within mundane time and history. According to the Christian doctrine, the Second Coming and the Last Judgment are not the only way to witness and participate in eschatology and get in touch with the ultimate things. Stepping beyond the unilateral notion of eschatology, which is linked only to the end of linear time, endows the current time and current reality with a sacred dimension available by divine grace and other uncreated divine energies such as love and the light of transfiguration. Medicine heals the body and the soul; it heals the entire person. One does not have to be a Christian who believes that true healing and health are possible only in Christ to perceive that medicine is a sacred science and art, which alludes to the basic dicta of all Abrahamic religions: medicine opposes death, the archenemy of humans, so also that of the benevolent design of their Creator; medicine helps women give birth and collaborates in carrying out the will of God in this respect; it bestows the blessing

                                                             1

The almost impossible cases of total fixation on oneself can be easily judged as a social and psychic deviation.

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A Systems Analysis of Medicine

of life via insulin, dialysis, kidney and liver transplantation, heart and brain surgery, as well as by cancer surgery and various cancer therapies; medicine has destroyed the archenemy in the guise of the plague, cholera, malaria, tuberculosis, hepatitis B and C, etc.; medicine is already powerful enough to preserve life when encountered by such an invincible adversary as HIV/AIDS. Still, patients and doctors should be aware that any human endeavor works only by divine grace and the archenemy will never be brought to naught, as antibiotic-resistant bacteria remind us. According to the Abrahamic doctrine, man is created in God’s image and likeness. God has created man and the world out of his infinite benevolence and love. The capability to love is transferred from the creator to his creatures. Furthermore, in the Christian Trinitarian God, love is the relationship between the three divine persons. Love becomes a pattern of interhuman relationships. The doctor-patient relationship is within the current of these religious examples and it embodies the three divine virtues of faith, hope, and charity (love). The doctor’s attitude to his/her patient is a very special case: on the one hand, a certain distance is necessary as it is obvious that the doctor cannot love the patient as his/her family and will burn out if he/she tries to do so; on the other hand, caring about the patient, the doctor gradually overcomes diseased self-love, and learns to feel balanced compassion and to practice spiritual charity.2 For his/her part, the patient starts feeling a special gratitude which goes beyond any imaginable monetary expression. Within the process of treatment, both the doctor and patient keep hoping for the best development and outcome even when the chances seem to be meager or null; the doctor and patient learn to be humble when it is evident that only palliative or end-of-life care is feasible. The sacred character of medicine provides grounds for metaphysical considerations. Metaphysics is about what transcends empirical reality but also determines it, and in this manner dialectically permeates the mundane empirical world. Metaphysics, claims Bryson, established virtue ethics on which deontological ethics and the Hippocratic oath are founded. Adhering to the Hippocratic oath, the doctor practices divine virtues of compassion, hope, and spiritual charity as well as a certain faith, even if s/he is

                                                             2

This statement could be opposed to the observation that the first concern of doctors nowadays is to avoid litigation, the second is not to seem incompetent but rather smart and trustworthy, and only third is to possibly cure the patient. If this is the case, however, medical practice itself and the society it belongs to suffer a severe malady; therefore, some immediate measures need to be taken to heal them.

Foreword

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agnostic or a staunch humanist.3 The patient does not remain alienated from these virtues although his/her destiny and role seem to be more passive and of secondary importance. Collaborating in healing, both the doctor and the patient surmount the estrangement from God committed in Eden and redeemed at Golgotha. In the science and art of healing, divine kenosis meets human theosis. Medical practice significantly contributes to restoring the sacred image and likeness of persons in the contemporary relativistic and secular globalized world. In the contemporary predicament where manipulation and being manipulated are the prevailing modus operandi and modus vivendi, the sacred elements in the doctor-patient relationship make a healing impact on the entire social climate. This is the reason Bryson’s Systems Analysis of Medicine offers some indispensable light in the clearing leading out of the ethical relativism and spiritual darkness in healthcare and beyond.

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In this particular sentence by “humanist” I mean “atheist.”

Introduction: A Systems Analysis of Medicine (SAM) “…The…World day of the Sick…is an opportunity to reflect on the needs of the sick and … of all those who suffer. It’s also an occasion for those who generously assist the sick, beginning with family members, health workers and volunteers, to give thanks for their God-given vocation of accompanying our infirm brothers and sisters.” (Pope Francis. The Sick and Suffering.)4 A systems analysis of medicine examines the multidisciplinary perspectives of culture, society, politics, economics, resources (academic and community-based knowledge), and medical ethics in the dynamics of the doctor patient relationships. The journey moves beyond a study on disease to a dialogue with diseased patients. The Tri-Council Policy (TCPS-2) on research involving human subjects provides a starting point for my analysis.5 The organizational structure includes Natural Sciences and Engineering Research (NSERC); the Social Sciences and Humanities Research Council (SSHRC), and the Council on Health Research (CIHR) which is of special relevance to this book. The objective of Module 9 of the amended TCPS-2 guidelines is on research involving Aboriginal people of Canada; (1) to understand “there are diverse perspectives on research involving First Nations, Inuit, and Metis communities”; (2) “interpret the Ethics framework in the context of First Nations, Inuit and Metis communities”; (3) “recognize and respect the cultural norms, governance structures and needs of different Aboriginal communities involved in research.”6 I cite these guidelines because they can be proven to the goals of this book. Medicine brings that same care whenever it is guided by the principle of respect for the dignity of persons. This view takes us beyond the perception of the patient as an atom

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6

http://www.presentationministries.com/pope Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada, Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, December 2014. http://www.pre.ethics.gc.ca/pdf/eng/tcps2-2014/TCPS_2_FINAL_We b.pdf accessed 23 March 2018. http://www.pre.ethics.gc.ca/eng/education/tutorial-didacticiel/?

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of disease, to the molecular relationships that characterize us. The view of the patient as disease or isolated entity under-describes the rights of patients to be treated as relational entities. The systems analysis of medicine locates patients in knowledge-based communities. The study of medical ethics assures us that this is the right thing to do, especially at end-of-life, and in transplant medicine. SAM develops an instrument designed to promote the rights of healthcare workers and patients. It moves the medical conversation beyond doctor and patient to include a rejection of ethical relativism and the absence of absolutes or eternal ethical truths in medicine, and it moves away from the impersonal mathematical view of the patient as a disease, and it moves away from the view of the patient as atomistic isolated individual, to include a spiritual, deontological, dynamic, and holistic view of the patient as actively engaged in relations with family, friends, and community. I need to clarify the sense in which a system analysis of medicine is possible to avoid misunderstandings about the role that logic plays in the dialogic character of medicine. The barebones of medicine are about disease, the patient, and the doctor. But the ‘behind the scenes’ elements of medicine are open-ended. They include the patient’s relationships with other persons, family, friends, and community associations along with relationships with the divine and absolute truths. Each element of the systems analysis exists in relationships. Medicine is anchored in a deontological ethics which in turn is embedded in normative ethics. Normative ethics is possible because it is rooted in absolute truth. The metaphysical ground of absolute truth is that the world exists when it could just as easily not exist. It cannot have happened by chance that we are together at this time and space. God must have a plan for creation. Medicine plays a central role in that plan. Both the doctor and the patient exist spiritually as relational molecular entities, not as individual, isolated, a-spiritual atoms. Disease is present as one of the possible relationships that characterize the patient. The cancer that kills us is a good cancer in-itself, but not so good for us. It disrespects human life. We often disrespect nature. Life is a struggle between conflicting forces, our right to life and the rights of the biotic community to survive. The systems analysis of medicine shows us where to draw the line between competing claims. The challenge facing systems analysis of medicine is that we cannot play God and maintain the validity of deontological ethics in the same breath. We enforce the right to life by knowing human limits. We cannot control God or even claim to have a

Introduction

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clear understanding of God’s purpose in creation because God does not conform to human categories. We cannot control other persons. Can we even control ourselves? The attempt to do is destined to fail. The human story is about our imperfections. We are not imperfect beings seeking perfection. We are imperfect beings operating within the limits of the human condition. And while we seek to control our self or at least maintain a reasonably disciplined existence, we are not divine. If I can recognize my imperfections and accept them, I am less likely to be controlled by them. The systems analysis of medicine depends on relationships and the narrative that surrounds our pilgrimage towards health, other persons, and God. Medicine is successful because it is dialogic. Health is a journey. The distinction that Søren Kierkegaard (1813–1855) introduces between subjective and objective truth clarifies the way in which systems analysis of patient relations is possible. Kierkegaard is struggling with the relationship between faith and reason, and what it means to be a “Christian”—I use the word Christian as a metaphor to represent what cannot be expressed through ordinary language, namely the meaning of words like love, compassion, creative intuition and poetry. The journey towards living with our imperfections is not expressed mathematically. The objective thinker knows about God but does not live in a relationship with God!7 The subjective thinker, on the other hand, moves beyond objective truth to enter personal relationship with God. But letting go of reason is a profound source of anxiety. It puts to mind the plight of a tightrope walker working without the safety net. Reason can be so soothing. But it can also create a false sense of values in medicine. The relationship with uncertainty and dependence on God becomes the fixed element required for the possibility of the systems analysis of medicine. It invites us to recognize that we stand in relationship to God, eternal truths, and disease. Patients and doctors are not God, eternal truths or diseases, but they stand in relationship to them and therefore co-opt the spirituality of relationships into a systems analysis of medicine.

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When I was in my late teen I attempted to use reason to decide which of two partners I should date on a regular basis. Coming out of a math class one fine day I decided to rank their attributes on a scale of 0 to 10 with 0 being the least desirable trait and 10 the most. It was a close race, but one came out with more points than the other. My attempt to objectify ‘love’ made sense to me but not to the winner as she told me to ‘get lost.’

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The book’s first chapter builds on an STS method (Science, Technology, and Society) to include social action and the life-giving role of community-based knowledge in medicine. Social action also provides a guide to the development of fresh community-based knowledge as required. The suggestion to treat patients as relational subjects is revolutionary because it builds a bridge between community resources and academic resources. We are not accustomed to think that the deontological character of The Oath of Hippocrates is based on the existence of a seamless web between these two sources of healthcare resources. This book owes much to my students and to a lifetime of research and teaching. I enjoy teaching the usual array of philosophy courses, but especially my years of teaching on death and dying (since 1972) and on ‘Spirituality and Health’ (since 2002) to nursing students. My training and interest in ‘Science, Technology, and Society’ over the course of a quarter of a century at Cape Breton University also tempers the character of this book. The present focus grew out of years of experience with University Research Ethics Boards and finding the correct balance between the classroom and community interest groups. I would be amiss not to make note that my interest in medicine grows from my awareness of the limitations of the human condition as advancing age means more visits to my family doctor, specialists, pharmacists, and community resources. I can now say with certainty that facing the possibility of my very own death through old age is indeed an inspiration to make the best use of the time allotted me. My grandson Keanen’s personal struggles with leukemia leads me to wonder about the meaning of life in the face of unnecessary human suffering. Several thoughts flash before my eye as I join countless others such as Harold Kushner (2004) who wonder why bad things happen to good people.8 Kushner says that “we can’t ask God to make us and those we love immune from disease because God can’t do that.”9 Apparently God cannot create free human beings, on one hand, and simultaneously protect them from disease on the other. Why is human freedom incompatible with the existence of disease? I wonder why a loving and All-Powerful God tolerates the presence of evil in the world. John

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9

Harold Kushner (2004) When Bad Things Happen to Good People. Toronto: Random House of Canada. Ibid., p. 138.

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Hick (1977) interprets the dilemma as the fundamental problem of theodicy; “If God is perfectly good, He must want to abolish all evil; if He is unlimitedly powerful, He must be able to abolish all evil: but evil exists; therefore either God is not perfectly good or He is not unlimitedly powerful.”10 This perennial question is raised again and again by the faithful as they try to make sense of the human condition. The Old Testament Book of Job faces this question as Job is struck with undeserved suffering. Job questions God’s soundness of mind. The Almighty’s reply forces Job to come face to face with his own insignificance. Is that why the innocent suffers? Does human insignificance provide the necessary, and sufficient condition of suffering? Carl Jung’s Answer to Job blames God for the existence of evil. The conversation with Job forces God to face God’s dark side. Jung cites a tradition in which God prays to himself; ‘May it be my will that my mercy may suppress my anger, and that my compassion may prevail over my other attributes.”11 According to Jung, God has two sons; the good son Jesus Christ and the evil son Satan. When God sends Jesus Christ to redeem humankind He also sends Him to redeem Himself against Himself. Jung struggled with the problem of evil and the suffering of innocent victims. Jung’s later work Aion (1951) researches into the phenomenology of the self. Much of the volume is concerned with the figure of Christ (the birth of Christianity and the symbol of the fish) and the problem of evil. The existence of opposites within the self-such as the anima and the animus, good and evil, are recurring themes in Aion (The Collected Works of C.G. Jung, 1969)12. However, for all of Jung’s brilliant insights into the hidden activities of the unconscious, I am raising a philosophical problem, not a psychological issue. Jung’s observations are inductively based on the observations of his patients. Philosophy, however, is a deductive discipline, that is it uses a methodology that moves from universal principles and causes to the analysis of lived life experience. See, for instance my article on Divine Agency and Human Suffering in (AJBT, 2013).13

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John Hick (1977) Evil and the God of Love. London: MacMillan. P. 5. C.G. Jung (1992) Answer to Job. Translated by R.F.C. Hull. London: Ark Paperbacks. P. 60. C.G. Jung. (1969). Aion: Researches into the Phenomenology of the Self. Collected Works of C.G. Jung. Volume 9 (Part 2), Princeton N.J.: Prentice University Press. Ken Bryson (2013). Divine Agency and Human Suffering. American Journal of Biblical Theology. Vol. 15, Issue no. 42.

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A Systems Analysis of Medicine

The problem of disease and suffering in philosophy is analyzed as being an integral part of the human condition and of our death bound subjectivity. Once we are born it is already too late for we begin to die; ‘Doctor, doctor will I die? Yes, my child and so will I.” Death is the result of irreversible and unavoidable cellular breakdown. While increased life expectancy pushes the limit of death into the future, and perhaps at some point nanotechnology will extend life as tiny robots repair and prevent irreversible cellular damage and the death of the organism. However, the second law of thermodynamics informs us that it costs energy to do work. Thus, at some point temporal life must come to an end. We run out of energy because perpetual motion (which is what it takes to reconvert energy loss) is contrary to the ways of human understanding. But personal death is only one instance of evil. What about the other sources of evil. The British Philosopher David Hume (1711–1766) wonders how we can reconcile the existence of an imperfect world with the existence of God; why would the deity not exterminate all evil; why the poor workmanship and frugality of nature, “in all the springs and principles of the great machine of nature”; why the scarcity of survival skills in the animal kingdom; why the profound suffering of animals—why is their pain so intense?14 One of the clearest most logical answers to the problem of evil and the suffering of innocent victims in the context of a loving God is in C.S. Lewis’ observation that it arises because of sin. God is not responsible for human suffering, we are. Lewis says that after the Fall, the organs of the body were no longer controlled by the human will; “(they) fell under the control of ordinary biochemical laws and suffered whatever the interworkings of those laws might bring about in the way of pain, senility and death.”15 God has nothing to do with pain, suffering and death. In fact, His Son Jesus Christ died to put an end to death through His resurrection from death. I can only imagine that God hates death as much as we do. But we brought on the human condition through sin. While the explanation of pain and suffering offers consolation to philosophy, the reality of pain brings us back to the here and now of medicine and how we can best deal with it in our daily experience. I agree in part with the positive character-building

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David Hume (1779) Dialogues Concerning Natural Religion. N.K. Smith. Editor Edinburgh: Oxford University Press. C.S. Lewis. (1967) The Problem of Pain. New York: The MacMillan Company. P. 70.

Introduction

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role that Hick and others assign to suffering. John Hick, and Thomas Aquinas before him (S.T. 1:25:6) invite us to recognize that the proportionality of parts that exists in nature could not be better than it is; “For if any one thing were bettered, the proportion of order would be destroyed, just as if one note were stretched more than it ought to be, the melody of the harp would be destroyed.’16 Could we build character in a world without risk of injury to self and others; is the firefighter that rushes into a burning building to save someone a hero or brave if no risk of personal injury comes from it? Hick’s soul-making explanation for the existence of evil jives well with the Augustinian-Thomistic view of evil and suffering as a privation of good (Aquinas adds ‘normally due to a subject’) and salvific opportunity to atone for the human fall from holiness. We never attain complete holiness in this life but each act of compassion and love we express towards others is a movement in that direction. This sentiment is echoed by Pope Francis when he says that there are two ways of facing the difficulties brought on by suffering; “to look at them as something that blocks you, that destroys you, that detains you, or to look at them as an opportunity. And you can make a choice.”17 The seemingly impersonal nature of medical observation is offset by the spirit of compassion the doctor brings to the suffering patient. The difficulty of expressing hope increases in the face of a terminally-ill patient forcing some doctors to hide behind the smokescreen of empirical data. But the expression of compassion moves the doctor patient relationship beyond despair even in hopeless cases. That possibility is typically the result of an egalitarian dialogue between physician and patient as a shared activity. However, the relationship between doctor and patient is not collegial. They are not friends. The doctor needs to maintain some distance to avoid burn out. The doctor patient connection takes place at two levels. First, they are both social beings in relationships through a set of cultural, societal, political, economic, and ethical parameters as they share a common health concern. Second, the health issue is the backdrop for access to community-based knowledge. I would be amiss not to include a description of health and illness in a system analysis of medicine. The health of a person is the result of all the parts of a human being working harmoniously towards the good of the

                                                             16 17

Summa Theologica 1;25:6 reply to objection 3. https://www.romereports.com accessed 4 March, 2018.

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whole. Disease arises as the breakdown of that dynamic unit as the relationships that individuate persons begin to fail as part divides from part. The total and irreversible disunity of the parts of a person is the death of that human being. Suffering is a byproduct of the disintegration of the organism. Medicine applies itself to reversing the dissolution of the parts that make us integrative organisms. But the irreversible death of some cells is part of aging, as is suffering. We cannot remain totally free from it. The human condition leads to the experience of pleasure and pain, great joy and loss. While we strive to manage pain, the ability to do depends largely on life choices. Aristotle, for instance, thinks wisely that the good life arises out of striking a just balance between goods of body (health and pleasure), goods of soul (intellect and will) and physical goods (wealth and shelter). Too much of a good thing is bad for us; “but to those who desire and act in accordance with a rational principle knowledge about such matters will be of great benefit.”18 Wisdom dictates the pathway to happiness and the good life. But a person’s perception of the role of suffering in the pursuit of the good life can be both a blessing and a curse. Human suffering can enhance the perception of what is valuable in life, but it can also distort reason’s ability to put life in perspective of our ultimate end. Alan Williams (1985) a British health economist suggests that the value of health and suffering can be assessed from the point of view of pleasurable states of consciousness or QALY; “The essence of QALY is that it takes a year of healthy life expectancy to be worth 1, but it regards a year of unhealthy life expectancy as worth less than 1. Its precise value is lower the worse the quality of life of the unhealthy person. If being dead is worth zero, it is in principle possible for QALY to be negative, i.e. for the quality of someone’s life to be judged worse than being dead.”19 End-of-life suffering can be especially threatening to our basic right to personal autonomy as it dims reasoning and therefore informed consent. Human beings are rational, affective, spiritual, relational animals. The good life is populated by all the strings of associations that make us truly personal. These strings include associations taking place at the level of reason and will, namely autonomy, consent, beneficence, nonmaleficence, justice, privacy, secrecy, and con-

                                                             18 19

Aristotle. Nichomachean Ethics. W. D. Ross. Translator. 1.3. 1095 (10). Alan Williams. (1985). “The value of QALY” Health and Social Science Journal. 3 July. P. 14.

Introduction

27

fidentiality. The measurement of good quality of life is challenging, although it includes freedom from unnecessary pain. The Edmonton Symptoms Assessment System (ESAS-R) is designed to measure nine symptoms that are common in palliative care patients (pain, tiredness, drowsiness, nausea, lack of appetite, shortness of breath, depression, anxiety, wellbeing, and other problem-such as constipation). The patient (or Caregiver, if necessary) rates the severity of symptoms on a scale ranging from 0 to 10 where 0 represents the absence of the symptom and 10 represents the worst possible severity.20 In many parts of the world, including Canada, patients in end-of-life care have legal access to euthanasia or assisted suicide. In euthanasia the death causing action is caused by the physician whereas in cases of assisted suicide the death causing action is initiated by the patient. Some physicians find themselves at odds with the current law because of ethical or religious concerns. At first brush it seems that the law is generating (or attempting to generate) an ethical code of conduct that flies in the face of the Oath of Hippocrates. In a democratic society the people that are opposed to euthanasia and assisted suicide (or abortion) can mount a social action to move the political pendulum towards the sanctity of life under all circumstances. The people’s social actions pressure the ruling government to reconsider the law on death causing actions. Catholic churches in the diocese of Sarnia, for instance, conducted a social action in hope of securing 100,000 signatures from the faithful but to date have fewer than required to reverse the governmental decision. The problem moves beyond the force of law. The law does not generate the ethics, the people do! We live in a dangerous world where the proclamation of law on ethical matters corresponds to the will of the people rather than to the will of God. As a result, we live in a culture of ethical relativism (a discussion of this critical issue is found in chapter 4). The goal of a systems analysis of medicine is to shed light on how some of the broken pieces of medicine can be fixed or replaced. To accomplish this goal, we move beyond the conception of the patient ‘as disease’ to include a holistic detail of the individuating relationships that make patients personal. This includes the sanctity of human life. The patient has a disease, the disease does not have the person. We examine the patient’s relationships to locate the place of disease. Not everything

                                                             20

The revised ESAS-R is at http://www.palliative.org/NEWPC/_pdfs/tools/ESAS-r.pdf accessed 23 march 2018.

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is broken about us during life or severe suffering. Everything is broken at death, however. We also look at medicine from the point of view of the doctor’s basic freedom and right to be ethical. The doctor’s right to quality life is often overlooked. We need a constructive criticism of medicine rather than a focus on errors in evidence-based medicine. I am grateful for the dedication and compassionate care of the medical team. My goal in this book is to look at medicine through the eye of philosophy to see if we missed anything. The patient goes to the doctor’s office as a person but is often treated apart from the relationships that characterize personhood. A person is a human being in action. We become persons through our relationships. For this reason, we are equal as human beings, but we are different as persons. While the ESAS-R includes a useful body diagram to help locate the place of pain on the body, SAM identifies pain through the analysis of all the relationships that characterize persons. The following point is discussed in greater detail in chapter two: A person arises out of three basic streams of relationships. The first is that we are the output of organic associations. Disease divides the human organism and leads to personal death if unchecked. The second set of relations takes place at the level of other persons as we enter associations with family, friends and community. The community is an integral part of what it means to be a person. We think of community as an extension of the patient. The role of community is evident as a spokesperson for the needs of the patient. This role becomes increasingly urgent in the age of genetic screening and engineering, cloning, and organ transplant medicine. Medical technology has made the analysis of end-of-life care more complex not simpler. The view of the patient as molecular lightens this load. The third set of associations to characterize us arise at the level of the interior life of psyche. This place is the house of absolute values and eternal truths. Our ethical DNA is inscribed in the human heart. We read in scripture (Jeremiah 31.32–34): “I will put my law within them, and I will write it on their hearts; and I will be their God and they shall be my people. …they shall all know me.”21 These prophetic words from God lay the foundation for the deontological character of medicine, the relational nature of being a person, and the place of spirituality, and ethics in healthcare. This book is dedicated to the task

                                                             21

All references to scriptures are from The New American Bible. Wichita, Kans.: Catholic Bible Publishers, 1985–1986.

Introduction

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of including the role that the spiritual (and religious) belief(s) in the existence of God plays in medicine. For this reason, chapter two examines the phenomenological evidence to support the role of religious faith in the life of a person. We find multiple strings of associations that cluster about the arms of the relationships that make us who we are. These associations carry some links that are broken by the experiences of life. Once the patient identifies a broken link, the process of curing and healing (two distinct focuses) begins through the introduction of fresh connections. The name I have given to the processes of curing and healing is spiritual welding. The religious connection exists in the set of internal associations that characterize being personal. For instance, a negative experience with a church official can result in a wounded belief in the value of religious healing. On the other hand, interpersonal relationships also carry a hotbed of positive and negative associations with other persons. The first path to healing interpersonal conflict is to recognize the nature of our broken associations. Carl Jung claims that we use other persons as hooks on which to tie our negative feelings about our self. Once I succeed in healing my broken associations with others, they appear less threatening to me. The most basic association takes place at the organic level of disease. Physicians are constantly learning about the associations that cause disease and identifying ways to prevent disease from happening. SAM examines all our associations. The view of the patient as a person in relationships is the first step in the process towards holistic healing. This volume opens with a detail of the tools found in the STS toolbox. STS is the study of the interactions between science, technology, and society. The acronym STS represents these interactions as developments in science and technology generate both desirable and undesirable/unanticipated consequences on society. Developments in STS are driven by ethics (doing the right thing) but a problem is raised by numerous descriptions of that standard. The ideal is to successfully anticipate the consequences of developments in science/technology on medicine. The issue opens a Pandora’s box of moral, legal, political, cultural, societal, and economic points of entry. For instance, the socially constructed definitions of health and disease can lead to culturally divisive choices. The maintenance of peace depends on the ability to identify shared values. The ways of nature provide a model to follow. Nature has value because of what it can do for us, but it also has intrinsic value. Medicine has intrinsic value, but it cannot meet all the external demands placed on it (such as euthanasia, and assisted

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suicide) if it means destroying the deontological fabric of medicine. The distinction in environmental ethics between conservation and preservation provides a metaphor we can use for the distinction between the structure of medicine and the demands placed on it. The demands placed on medicine are to conservation as the deontological structure of medicine is to preservation. The etymology of techne as having and controlling patient outcomes is on the side of conservation. Aldo Leopold introduces the idea of conservation in environmental ethics to ensure sustainable developments. We can’t take more out of a system than we put into it. The belief that economic development can take place without regard to the finite nature of our planet and key factors such as increasing population, the depletion of non-renewable resources, soil conservation, increasing industrial production, and the alarming state of our eco-systems puts the ongoing presence of human life on this planet in peril. There is no doubt that these are complex systems, but we have been acting as if the Earth could continue to support a technological mindset driven by greed. The call for conservation provides an urgency to allow the preservation of nature, that is the opportunity nature requires to heal herself. The decision to do so is at the heart of sustainability. It moves beyond conservation to preservation or structure of nature as the root of the possibility of the next generation of humans. The comparison with medicine is that the focus on disease as the primary and exclusive aim of medicine is not sustainable because a person is not a disease. We need to focus on the centrality of personhood. The more medicine becomes technological and impersonal the more it misses out on the dignity and mystery of persons as humans in action. The impersonal character of our age is giving way to increasing violence, protectionism, war, hunger, and death. The dissolution of the family unit—one of the pillars of civilization—is a sign of our troubled times. We expect more from medicine. This is a complex matter because the limits of medicine are dictated by the emphasis we place on the systems of medicine. For instance, economics drives the research agenda while politics decides on the allocation of funds. The priority of these allocations shifts to our socially constructed agendas. The base must be focused on the dignity of the person because otherwise medicine as sacred science will end. Conservation and the pursuit of health is possible because the dignity of the patient is the product of a structured set of relationships. Nature also clings to life because of

Introduction

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structure, but persons are more than the structure of the eco-system. I remember the ‘cabbage patch’ craze of the seventies. The irony is that these precious ‘must have dolls’ were relegated to the level of a cabbage patch. Persons are not cabbage patch material unless they lose the sense of the sacred. Medical technology transitions towards the structure of being personal through the inclusion of the whole person in the doctor patient dialogue. This includes conservation and preservation. Medical techne must also be on the side of sacred structure (preservation) and on the side of fighting disease (conservation) because of the inherent value, dignity, and mystery of each person. Let me explain it this way: without the fight against disease (being able to identify its pathogenesis) we might not survive, in the same way that without the laws of science we might not survive. We need to predict how nature and disease are going to behave. The laws of science and medicine make it possible for us to predict scientific/medical outcomes. We establish proportionality relationships between conditions and property behavior. The possibility of expressing treatment outcomes is raised because disease can be controlled or prevented from destroying health. However, the control of disease implies structure in the same way that the laws of nature attend themselves with regularity because of structure. How else would a disease know that it must observe laws? Nature must be structured in some way. Thus, the focus on the laws of nature without a concern for how nature is structured is destined to fail. Once the structure of nature is destroyed, the laws of science cannot hold. Once we begin to disrespect persons and treat them as disease, we fail. This will become increasingly evident in the next round of medical developments as we move into genetic engineering. Auguste Comte was plainly in error to hold the view that description is the only business of science. Healthcare metaphysics must be based on persons as genus rather than on disease as specific difference. The mystery of human existence includes a connection with eternal life. We read in Paul; (1 Corinthians 15.26) ‘The last enemy to be destroyed is death’. I have no doubt that what Paul is saying about the defeat of disease is based on the resurrection of Christ and the sanctity of the person. The theme is developed throughout the book. The first chapter introduces a method I developed to conduct a systems analysis of medicine. The method is based on basic STS principles:

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how medicine develops as a social, cultural, political, economic, and ethical construct. The key themes in that configuration are relationships, holism, informed citizenship, comprehensiveness, the weighting of cost-benefit assessment, and human values. The developments of medicine enlist the hegemony of good technology which is a letting be of the person as sacred. The view of the person as disease is reductive. The second chapter develops the theme that persons exist in relationships. A person is a human being in action. The first part of the second chapter examines the validity of the claim that some actions are faith based. For that reason, the chapter examines some religious assumptions to determine their role in the patient’s view of medicine. Many see suffering as salvific, many do not. Many see human death as the beginning of a new existence in the afterlife, many do not. It seems clear that medicine cannot function in the absence of some absolute truths. Deontological ethics and the oath of Hippocrates dissolves in the face of cultural relativism. A phenomenological analysis of religious faith reveals that eternal truth exists in history. Faith is founded on a relational view of being human. The second part of the second chapter examines the relationships that make us truly personal. The idea of person as ‘rational-faith-bound-subject’ is rooted in the fact that persons live in relationships. While all persons are humans it is not the case that all humans are equally personal. This is because persons are aware of being in relationship with the divine, other persons, and the environment. The practice of authentic medicine takes place within those parameters. Persons are temporal and eternal-bound subjects in relationships. We are characterized by three main streams of individuating relationships. First, we exist in a multilayered set of carbon-based relationships, as any pregnant person can attest. Second, we exist in a multilayered set of social relationships in family, friends, community, and society-at-large. Community relationships contain medical knowledge. Third, we exist in a multilayered set of human values. The paradigm of the individual as a discrete, separate atom of existence is replaced by values based on all the individuating relationships that make us truly more personal. The third chapter examines the role of dialogical spirituality in healthcare. Persons express a spirituality of imperfection, one that arises out of the trenches of disease and death-bound subjectivity, anxiety, failure, success and triumph. Medicine is a spiritual activity characterized by a skill set and a humanities tradition set of values. Spirituality is our modus

Introduction

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operandi, a means to an end, not an end as such, however. It marks the road to acceptance, courage, wisdom, happiness, hard work, and discipline. Humans are spiritual by nature as our ‘inside world’ seeks to make sense of the ‘outside world’. These two worlds form a unit; they are not disconnected and in the language of phenomenology—as the subjective correlate of consciousness seeks to make sense of its objective correlate. The practice of medicine is based on the concept of intentionality as its objective correlate (disease) reveals the presence of disease as the presence of the temporal in the eternal. Chapter four examines how we are ethical. Why do most of us seek to do good and avoid evil? The evidence of psychology suggests that infants are naturally attracted to the good they see in the outside world. This innate attraction is why we want to be ethical. Although being ethical is a social construct because the interpretation of how we do good changes across the cultural divide, we come together in respecting ways of healing that are different from our own. We share in the attraction to the good but differ in the interpretation of what is good. The success of medical ethics is based on the objective foundation of relational values, and on developments in science/technology. The scientific shift from treating the symptoms of disease to the prevention of disease through genetic screening and engineering creates new ethical relationships we must face and resolve to ensure the ongoing future of personalized medicine. Medicine is not unique in that regard because all developments in science and technology can lead to unwanted secondary consequences. The ability to anticipate and avoid these consequences before they occur is the key to maintaining the ongoing nature of medicine as sacred science. The focus on the patient as a being-in-relationships continues to hold a key role in healthcare. The perception that medical technology interposes distance between the doctor and the patient is at odds with the relational character of a patient’s life in community. The focus on relational values raises the view of disease beyond the range of atomistic measurement to include its effect on other persons. At first brush, disease presents as an obstacle to personal growth but as integral to the human condition it moves beyond the range of empirical observation and measurement to provide holistic treatment outcomes that include community. The belief that medicine focuses on disease alone without concern for healing persons is mistaken. A dynamic

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view of the person suggests that the part acts primarily for the good of the whole person and secondarily for itself. The final chapter is a chapter in search of an absolute base to ground the ethics, the spirituality, the view of the person as a human in action along with other humans in action. It finds the metaphysical foundation to ground the possibility of medical ethics in God’s creative act. Chapter five, therefore, grounds the presence of the absolute in a phenomenological study of being’s unconcealment. The deconstruction of human death reveals that the metaphysics of death points to an activity taking place in being’s unconcealment. The root of the possibility of that activity lies in the primacy of esse. This is the most abstract part of the book, the place where philosophy brings its insights to the medical table. The process of dying is seen to take place as consciousness begins to separate from being’s unconcealment, while human death arises as being’s unconcealment for consciousness ceases. The shift in the ontological ground of esse explains the theodicy of death. The secular nature of death explains the need for palliative care while its sacred character justifies the value of letting terminally-ill patients die. In the grand scheme of things, human death is more than the absence of consciousness; it is the removal of ground in which the possibility of consciousness exists. The death of a person is not the failure of medical technology but the realization of the divine plan as the dead move into the afterlife state of existence, that is, into ‘eternity time’ (not eternal time). This explains the responsibility of medicine not only as science but as sacred science as the final dialogical moment of conversation with the temporal world as the gateway to a fresh dialogic conversation with the sacred in the afterlife state of existence.

Chapter One: The STS Toolbox The parent said; ‘what would it take to make you happy; what do you need to be able to say—yes, this is a very good day’? The child replied, ‘I would be very happy if my wish list was granted.’ Why am I writing this book? I would be happy, if at the end of the day, my wish list for medicine as sacred science was granted; 1. A shift in focus towards the centrality of the patient: A patient has an illness; the illness does not have the patient. 2. The impersonal nature of medical technology is minimalized. 3. A patient is not an individual atom, nor is the doctor, as both exist in clusters of distinct relationships. Healthcare is relational (specialists, pharmacists, social workers, lawyers, psychologists, and community based social action). 4. A person is a human being in action. We are characterized through three main stream of relationships, each one as important as the other (we are dynamic units). 5. The healthcare focus includes all person-making relationships at three distinct levels of observation—the carbon-self, the socialself, and the internal-self. 6. The doctor and the patient bring all their relationships to the medical table as they work through their collective spirituality of imperfections. 7. Community programs serve as a source of medical knowledge. The medical curriculum and the doctor tap into this resource base. 8. Ethical relativism is exposed as being the enemy of deontological ethics and the Oath of Hippocrates. Doctors and patients ought not be forced to decide between their moral conscience and the observance of positive laws. 9. Creation centered medicine is seen to be a sacred science. 10. Medical developments in genetic screening and genetic engineering express reverence for the dignity of the person. The STS Toolbox provides a solution to my problem. I call it a toolbox rather than a method because it provides access to the tools required to transition into the ideal doctor-patient relationship. I do not need all the

35

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A Systems Analysis of Medicine

tools all the time, but they are there to help me unlock and unblock the misery of disease and death, some of the time, depending on the urgency of my dying. One thing I know, I am happier dying in the arms of medicine knowing that all the morphine tools are available in the Hippocratic Toolbox! I have always liked order, even in disorder! A systems analysis is based on a critical review of the necessary conditions of holistic health. The current model of medicine examines symptoms through the determination of an antecedent set of conditions. While a medical explanation can trigger the discovery of a necessary condition of the symptoms, say a cure for cancer, explanation can also be probabilistic. To illustrate the difference between a necessary and a sufficient condition, we can say that cardiac arrest is a sufficient condition of death but not a necessary condition because several factors must be identified before it can be pronounced as the cause of death. Is the patient’s absence of heartbeat reversible, and how long has the patient been in cardiac arrest before irreversible damage to the brain occurs? The Harvard Medical School committee on the study of irreversible coma (1968) list six criteria to satisfy the conditions under which cardiac arrests moves from a sufficient to a necessary condition of death. Briefly summarized these conditions are; (1) total unreceptivity and unresponsiveness to externally applied stimuli; (2) no spontaneous muscular movements or spontaneous respiration or response to stimuli when the respirator is turned off for three minutes; (3) no reflexes—pupils fixed and dilated and no ocular movements, blinking, swallowing, yawning, vocalization, tendon or muscular reflexes; (4) flat electroencephalogram during at least ten minutes of recording, and no electroencephalographic response to noise or pinching; (5) all of these tests shall be repeated 24 hours later with no change; (6) providing that conditions of hypothermia and/or drug overdose are excluded at entry level. The distinction between a sufficient and a necessary condition provides a roadmap to what lies ahead. The goal of systems analysis of medicine is to raise the bar from the view of the patient as disease to the treatment of the patient as relational. We must move beyond the symptoms-based approach of medicine to include the patient’s systems in the mix (history, culture, society, economics, politics, eco-system, and ethics). The explanation and cure of disease is not a sufficient reason for the holistic wellbeing of the patient. The present focus on explanation that we find in medicine is bankrupt. Rapid developments in genetic screening and engineering calls for a shift in which symptoms based medicine must move

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towards the assessment of the new conditions that accompany holistic health, namely other persons (clearest in organ transplant medicine and end-of-life care), the environment (the eco-system, carbon-self, and other animals—xenotransplantation), and the internal-self (reason, will, and the unconscious) a critical area of personal rights such as autonomy, consent, beneficence, nonmaleficence, justice, privacy, and confidentiality). The present chapter examines an STS Toolbox I developed to raise the bar from the discovery of sufficient conditions to the inclusion of a set of conditions we can use to approach the role of the ideal medical practice as providing a necessary condition for the holistic wellbeing of patients. The degree of success is proportionate to the effort we make towards the full use of the toolbox; the more we use the tools, the more factors we discover to raise medicine from the discovery of sufficient explanation of disease to the discovery of the necessary conditions of wellbeing. This set of tools delivers an egalitarian and holistic dialogue between doctor and patient, as well as a path to initiate in-depth responsible social action, if required by either party. Community interest groups are a source of medical knowledge. The strongest evidence of knowledge is frequently available in First Nations communities with their expertise in the healing properties of plants, but also from social action initiatives in communitiesat-large. The mid-wives of pre-medical (scientific) times were the original healers. They knew about childbirth and the healing properties of plants. But they were a challenge to the Church and called witches. The culture of the 15th century Medieval Church lay claims to receiving its healing authority directly from God. The only other source of authority was thought to be the devil. Since the midwives did not receive their healing skills from the church, they must have received it from the devil. They were tortured until they admitted their sin, including having sex with the devil—whose embers according to the Malleus Maleficarum are cold (the Hammer of the Witches). The book published in 1486 is a detailed guide on how to torture witches and was written by Heinrich Kramer and Jacob Sprenger. Fortunately, that STS Tool is no longer in the Toolbox. The task at hand calls on metaphysics to root deontology and the Oath of Hippocrates in firmer ground than the witch trials. We need to use the tools of politics, and economics, and ethics, the cultural will of the people, and the force of social constructs to save medicine from falling under the weight of ethical relativism and the influence of the moment. Developments in medicine take place in history. I see this social construct in my

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own medical history. We live in a fast-moving age. I have a lung disease (COPD or chronic obstructive pulmonary disease. I suppose I should be happy to have made it this long because in 1940, the year of my birth, life expectancy was around 62 years. Medical developments in science and technology have been good to us. But the pace of healthcare has changed. I seldom see a physician. Each year I go for a blood test to measure my creatine level and then a CT scan of my lungs. I see a lung specialist in London hospital who examines the x-rays and the size of lung nodules. This lets me know that they are not cancerous. As for the rest I am on two daily inhalers—Ciclesonide, a corticosteroid, and Tudorza, aclidinium bromide. A pharmacist has my protocol in place and I call for refills. I call in the morning and the inhalants are delivered to my residence later that day. My disease is managed. Society has constructed this process and others like it, so we could be efficient and get on with our busy life. I see my doctor from time to time, usually twice a year, especially as I am prone to pneumonia. In cases of lung infection, I call the pharmacist who faxes my doctor and a prescription for Sandoz-Azithromycin is at the ready for me at the pharmacy. I am surrounded by great doctors, Dr. Vid Singh in Sarnia and Dr. Fortin in London, and a great pharmacist. They know I am compliant and I trust their expert advice. Everyone is efficient, the technicians at the blood clinics, the hospital nurses and staff, and best of all I am not treated as a disease! This change in attitude can only happen through the development of personal relationships. For instance, I know that my doctor has recently experienced a death in his family. I am in sympathy with him, he is a person in relations as I am. We share a common bond in the spirituality of an imperfect world. In Canada, the doctor patient relationship is governed by provincial regulatory boards and the Human Rights Act. But the evolving nature of the doctor patient relationship often moves into unexpected places. The standing clearinghouses to register such change are already in place, but we need responsible social action mechanisms to make the transition from the concerns expressed by doctors and their patients to the regulating bodies. The College of Physicians and Surgeons of Nova Scotia strives to serve “the public by regulating the province’s medical profession in accordance with the Medical Act and its regulations.” All physicians must be licensed by the College to practice medicine in the province. The Provincial Human Rights Code “recognizes the dignity and worth of every person” and its obligation to “provide for equal rights and opportunities

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without discrimination that is contrary to law.”22 Physicians are members of a local community and have the same right as any other citizen. The Toolbox use of a social action processes is intended to protect the rights of all citizens. But on the negative side of developments, we witness the effects of the eroding soils of cultural relativism: In Canada, and in many other countries around the world, physicians are required to support the law-based demands of their patients for abortion, euthanasia, or assisted suicide even when the request conflicts with the doctor’s religious beliefs. The problem does not go away when it is referred to another doctor because the referral makes them complicit in an undesirable outcome—the termination of the pregnancy and the death of the patient. The choice of action is limited: Doctors can refer the matter to their Provincial College of Physicians and Surgeons or to their community for responsible social action by groups of concerned citizens. But why should anyone have to choose between doing what is morally right for them or quitting their job? Strong social action necessarily has local roots. The Toolbox provides a guideline for socially constructed and informed responsible social action which we can examine after the systems have been fleshed out in more detail. The delivery of fair practice for everyone in healthcare is at stake; “The simple understanding that the world we live in and the diseases we suffer from or what we are trying to overcome are not just natural things, but we are also partially socially constructed and need some interpretation will greatly assist us to avoid unwanted consequences.”23 Social action initiatives can be initiated in response to the unwanted consequences of developments in medical science, but also to cultivate and redeploy successful initiatives. Rigorous developments in science moved us from the misguided ways of the Malleus Maleficarum to the inductions and deductions of modern medicine, and from the causal analysis of the symptoms of disease in our day to the removal of their causes before they arise as disease in the future. Although we are making great strides in healthcare today, a problem arises when the impersonal nature of science transfer into the healthcare relationship. How does the Toolbox make med-

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23

College of Physician and Surgeons. Provincial Human Rights Code. Respect for Human Rights http://cpso.on.ca/About-us/Respect-for-Human-Rights accessed February 5, 2018. Alexander Gungov. Patient Safety: The Relevance of Logic in Medical Care, (Stuttgart, Germany: Ibidem Press. Columbia University Press, 2018), 7.

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icine personal? It seems possible to suggest that medical science is becoming increasingly impersonal and, therefore, that the doctor patient relationship will deteriorate or perhaps disappear as medical doctors give way to trained geneticists. Developments in genetic screening and gene splicing will exacerbate the problem as tele medicine outsources our DNA to a medical laboratory for analysis. The political system is already moving beyond fingerprinting to include DNA samples in police data banks. Can medical facilities be far behind? Developing countries are always one or two rounds of technology behind the rest of the world; it could be the case that personal visits to the doctor’s office will only be possible in the third world. The practice of medicine introduces machines between doctors and their patients. This carries a mixed blessing. Geneticists of the future will engineer a new quality of life for at-risk infants by preventing the onset of disease decades before it arises. This is a good thing, but it opens a Pandora’s box of ethical issues, some of which fly in the face of the Provincial Medical Act and the sacred character of medicine. We always open the Toolbox with a study of the history of the problem under investigation. What is preventing us from realizing the wish list identified in the chapters opening remarks. Ironically, a main problem is the success of science. The invention of the stethoscope by the French physician René-Théophile-Hyacinthe Laënnec in 1816 marks the beginning of an ongoing process where an instrument is interposed between the doctor and the patient. Neil Postman’s Technopoly (1993)24 is highly critical of medicine’s overreliance on technology. He says it leads to several problem areas including the performance of unnecessary surgeries, some of which increase the risk of dying such as Caesarian operations. Caesarians do save lives, but they can also endanger life, especially in non-emergency situations such as when they are performed for the sake of convenience. Another problem is that people usually love to be surrounded by technology. While medical technology is impressive, Postman thinks that it also can be used to protect doctors from unnecessary lawsuits. What patients says about their disease is not as reliable as the technological visualization of disease. Postman claims that the focus on the identification of the disease is more important that the cure itself; “which is why it is possible to say

                                                             24

Neil Postman, Neil, Technopoly. New York: Alfred A. Kknopf, 1993.

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that the operation or therapy was successful, but the patient died”.25 (italics added) No one wants to throw out the baby with the hot water. The community wants to keep the successes of medical technology at hand, but it also wants medicine to treat disease as a subset of what it means to be a person. To borrow from the language of environmental ethics, medicine must be about the preservation of human dignity as well as the conservation of health, healing as about curing, about the human genome as well as about a patient’s relationships with family, friends, and community. To continue the analogy with environmental technology, the conservation of health without the preservation of human dignity is not a sustainable development. The impersonal breakthroughs of medical technology are incomplete without the focus on the underlying metaphysical structure of the person as made in the image of God (Genesis 1:26). The STS Toolbox contains a set of empowering tools to make informed choices about what it means to be a person. It lists the nature of the variables required to sustain a humanities perspective of medicine as dialogic, relational spiritual, ethical, and metaphysical. The toolbox spells out how to incorporate a patient’s societal relationships in the healthcare system. It also enlists the support of existing community programs to meet patient needs. While the STS solution to a problem always begins with the identification and delineation of the problem, the process then moves to the classroom to connect academic technical resources with the non-technical resources and programs that exist in the user community. Medical programs draw on the classroom for technical skills to fight disease, but a patient is also a family member, a friend, or part of a support group, a church, a cause worth fighting for. A recent article on the front page of the Sarnia Journal, November 23, titled ‘Fighting for my Family’ is typical of this focus as Tara Gunn describes her fight with cancer. Tara is a newly married mother of two with stage 4 breast cancer. She says; “I’m blessed to have the best thing to fight for—my family”. She started chemotherapy within a week and underwent a mastectomy in August, but not before having a “Bye Bye Boobie” party with friends. Her relief that the cancer was gone was short lived because another scan revealed that the cancer had spread to her bones. She started reading about other women in her position, just as scared but hopeful. This gave her hope. I fight for my family, she

                                                             25

Ibid., 103.

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says this helps to give her a positive state of mind. She also draws inspiration from a GoFundMe account that friends set up for her to help ease the financial burden of treatment, and a benefit fundraiser is planned for December 16 at the Station Music Hall. I don’t know if she will win the war against cancer, but she has risen above the disease to find hope through family, friends, and a support group for women with cancer. This information is critical to the success of a holistic treatment outcome and needs to be entered into a patient’s medical file along with other relevant STS data discussed in this chapter. If necessary, the patient’s medical history must be amended at the time of hospitalization. This protocol must become part of the medical curriculum for a better fit between this curriculum and a patient’s systems analysis. This comprehensive view provides a better health care model of the patient as a relational, spiritual, holistic, ethical as well as a person fully alive in the dying process. Dying is a personal process, not an event that happens to someone someday. The protocol serves as a normative principle of healthcare. It enlists the community as a source of medical knowledge in the development of programs to provide aid in living in tough times. The blending of academic programs and community initiatives that include societal details in the patient’s healthcare history fills the void left behind by the impersonal character of medical technology. The STS method can be used to provide an approach to healthcare based on the integrative life of the patient without placing undue economic burden on the availability of scarce medical resources. The STS Toolbox is designed to fix the imbalance between the scarcity of medical resources and the constraints of economic limits. The political system strives to reach a fair balance between demand and supply. Organ transplants for cornea, kidney, lung, and heart surgery are first offered to the sickest patients with the best match. Unfortunately, some critical patients awaiting heart transplant do die because of the scarcity of available resources. Unfortunately, health care providers are forced to function with envelopes that contain limited funding, as well as a shortage of donor organs. The regulatory system operates within a limited tax base and the increase of resources for medicine means a decrease of available economic resources to fill other community needs. Those individuals that are healthy oppose the move while those that are sick cry for the implementation of medicine for everyone. All the tools come into play; research into organ transplantation such as xenotransplantation is promising but

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with reservations found within the cadre of cultural and societal expectations. The attempt to make progress in these areas raises serious cultural, societal, political, economic, and ethical conflicts between citizens. My use of the STS method springs in part from a ‘rethinking technology’ summer institute at Pennsylvania State University,26 along with the Ethics and Technology Conference at Guelph University in the late 1980s.27 In the early years our STS course at Cape Breton University was team taught by an engineer (Keith MacLeod) and I as we brought our students to a common classroom to discuss the unintended consequences of technological developments from the multidisciplinary perspectives of engineering and philosophy. The differing constructivist perspectives brought students out of their comfort level to examine the world through a different set of eyes. This proved to be a beneficial experience for everyone. It seems to me that the impersonal state of medical technology today also calls for an interdisciplinary approach between medicine and the tradition of the humanities. The traditional way of thinking about illness is changing because of rapid developments in technology and science. The shift in focus from the analysis of symptoms of illness to the anticipation of symptoms before they arise calls for a radical shift in mind-set about disease. We need to rethink how we are going to conceptualize disease in the future. We need to look at disease through the interdisciplinary lenses of the arts, the social sciences, and the sciences. A few years ago, I had the pleasure of teaching an STS course on chemical dependency with a physician (Dr. T. Crawford), and a psychologist (Dr. G. Carre). The experience

                                                             26

27

The STS program at Pennsylvania University was introduced by Carl Mitcham in 1969 as part of the Engineering program. I was delighted to be invited to join Carl Mitcham and his team at Penn State in the summer of 1994 for a six-week training program titled “Rethinking Technology.” I was one of two Canadians on a 17-member STS study team made up of colleagues from the U.S.A., China, Denmark, Puerto Rico, and The Netherlands. The focus in those early days was on examining scientific and technological developments from the point of view of their unanticipated consequences. The focus was to provide a method the scientific community could use to anticipate and prevent unwanted consequences from happening before it was too late to do so. We met that summer with researchers on the cutting edge of STS notably Albert Borgman, Paul Durbin, Don Idhe, Fred Dretske, Deborah Johnson, Kristin Shrader-Frechette, Langdon Winner, and Ivan Illich, along with the Institute organizers Carl Mitcham, and Leonard Waks. J. Nef, J. Vanderkop, J. Wiseman, H., Ethics and Technology. Ethical choices in the age of pervasive technology, (Toronto, Ontario: Wall & Thompson, 1989), and J. Wiseman, J. Vanderkop, J. Nef, (1991) Ethics, Science, and Technology editors, (Toronto: Thompson Educational Publishing, 1991), 219 p.

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paved the way for the next generation of genetic engineering as we looked at opioid dependency through the eyes of philosophy and theology, medicine, and psychology. Geoff talked about the brain’s receptor cells and the behavior of rats addicted to heroin, Tom talked about the Sydney methadone clinic and the success and failures of some anonymous patients, while I talked about the meaning of being human, spirituality, and medical codes of ethics. The classroom experience reminds me why I became a teacher. We did it on a shoestring budget, laughed and argued a lot, and students loved it. In recent years I have had the opportunity to use the STS method to work with students, band councils, and First Nations communities Elders to solve local issues. The tools contained in the method are used to provide students an informed, responsible blueprint for social action.28 The STS

                                                             28

Over the past quarter century, I used the present model as the cornerstone of STS courses at Cape Breton University and off campus at the invitation of Ann Denny and Leanne Simmons co-directors CBU indigenous studies program. While the school of indigenous studies has a strong presence on campus, I make note of several indigenous communities where the course is taught because of the success of the method. The insight, sincerity and determination of indigenous students provide an ideal atmosphere to demonstrate the applied nature of STS courses. STS studies move beyond the walls of academia to focus on real issues in a local community. The courses were held in seven First Nations communities, namely Eskasoni (We’kistoqnik), Wagmatcook, Waycobah (We’Komaq), Millbrook, Indian Brook (Sipenckati), Chapel Island (Potlotek), and Afton (Paq’nkek). These courses bridge classroom theory and community issues through informed social action. The delivery takes place through a method affectionately known as the ‘STS Wheel’. The ‘Wheel’ is the repository of tools we use to accomplish class goals. It works due to the honesty and hard work of my indigenous students in these communities. Social action outcomes are successful by the very fact of focusing our STS analysis on community issues whether they resolve existing problems or not because at the very least the exercise raises the level of community awareness on these issues. In most instances our work results in positive changes in the community, however. Thus, we meet a key goal of the course to integrate the academic contents of the course (the Wheel) with the real issues found in the communities were the course was taught. My thanks also to the community Elders for accepting my invitation to join us in the classroom to discuss group project presentations at end of term. These presentations provided an opportunity for everyone to reflect on what we did best during the term and where we left room for improvement for the next generation of STS courses. We know that many of our projects had a beneficial effect in the community. At the end of the day philosophy 2222 became as much a community project as an academic course. Thanks to students of my STS class at Cape Breton University (2016) for assisting me with the identification of community resources and programs in First Nations communities: Kaylee Bernard, Jewel Christmas, Kristen Cremo, Mallery Denny, Susy Denny, Mary Googoo, Faith Gould, Alwyn Jeddore, Reanne Jeddore, Mary Johnson, Nikko Marshall, Brianna Paul, Keane Paul, Shaelyn Paul, Tiannie Paul, Kaylene Simon, Treslyn Stevens. A community resources directory of all 13 NS Bands

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toolbox contains all the tools required to ensure that no aspect of a problem is neglected. The method brings a panels approach to the solution of a problem. The first step is to identify the problem to be examined; how is the doctor patient relationship impersonal; why are patients identified with their disease? How do the words personalized, and medicine go together? We begin with a rigorous deconstruction of the problem to prepare a path towards a solution to the problem. Once the solution to the problem is at hand, we proceed backwards and apply it to all treatment options. The next panel examines existing program resources in user communities. These programs mirror patient relationships and are incorporated into treatment outcomes. This approach to healthcare is personalized because it comes from the people as well as from experts in the field. To facilitate this connection, students are invited to think about the connection between academic courses and the possibility of bringing healthcare into the home. This step offers a seamless blend of academic and existing community programs because it brings personal relations into the fold. The role of the social action panel, in part, is to connect academic resources and programs with actual personal issues while drawing on community spirit to promote the development missing resources. The five panels identified in the STS approach to holistic healthcare delivery provide an at hand step by step process for resolving the issues raised in the identified focus. Patient care now moves beyond the limited resources offered in the classroom to incorporate community programs and societal relations that center on healing outcomes and the production of informed, responsible social action towards that goal. In 2017 I published a detailed working paper on the application of the STS method in Indigenous communities29 that serves as

                                                             29

is available through Daphne Hutt-MacLeod, Director of Mental Health, Eskasoni, NS.: 902-379-2910, with updates by Mallery Denny: 902-565-1314. WELA’LIN STS Toolbox: A Guide to STS problem solving and informed social action in Indigenous communities’. In Indigenous Policy Journal. Vol 28, No 1 (2017). This paper includes a 16-page appendix of community resources in Cape Breton First Nations communities. The STS community’s reaction to the interaction between science, technology and society travels both ways. Developments in science and technology do arise because of societal demands, but discoveries in science and technology also affect the direction of society. One of the goals of informed social action is to anticipate and prevent the undesirable and unanticipated second order consequences of technological developments. Once the proverbial horse is out of the barn it is often too late because we cannot expect that we can go on indefinitely with the process of throwing technological fixes at second order consequences. In the democracy, STS social action is one of the more powerful tools we have at our disposal to shape our own future. In my STS courses, we

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a guide for the resolution of issues raised by medical technology. The social action initiative in Native community’s results in the resolution of technical issues like water treatment, soil and water contamination, and other community issues relating to the development of self-help programs in the areas of substance abuse, gambling dependencies, behavioral issues on bullying, and societal problems such as high unemployment, housing, spousal abuse, depression, and suicide prevention, to list some of past issues of concern. An STS problem is one that arises at the intersection of science, technology, and society. This provides the opportunity to move classroom theory beyond classroom walls to meet societal problems as they exist in the environment where we live. In these STS classes theory and problem come together to solve pressing issues by viewing them through the lenses of STS tools, namely society, culture, economics, politics, resources, and eco-systems. These tools along with themes, thematic contrasts, and ethics provide a gateway to the informed resolution of community problems. The method is useful in preventing problems from arising because of the unwanted consequences of scientific developments; they are stopped in their tracks before they surface. The belief in the value of progress directs us to look to science and technology for the solution to real problems. But developments in science and technology can also create new unanticipated problems. In brief, the guide to social action detailed in this chapter is a proven method for anticipating and resolving the second order consequences of technological developments whether in medicine, or any other community issue, before or after the ripple effect technological changes

                                                             examine environmental issues, developments in medical ethics, computer ethics, biotechnology, and the future of work. The social action project is a good introduction to developing a strong voice in these bigger issues. My STS classes form groups of 3 to 5 students to take informed action on a focus area in their local community. Students present the group’s findings to the class during the final week of classes. In the bestcase scenario, a social action project continues to enjoy a life of its own long after the academic course ends. Project outcomes fall into two broad categories, namely, successful or not so successful. There are no failures because at the very least a social action classroom presentation raises the level of awareness about an existing community problem. The grade assigned for social action work is 35% of the final course grade. The community is invited to attend group presentations whenever STS is taught in a native community where participation is manageable. In these cases, the community’s Elders have a voice in the success of the social action and have the right to allocate 5% of the social action grade. The overall grade assigned to a social action project depends on the successful use of the STS method, including the use of thematic contrasts, and the overall transparency of the process as it leads to a resolution of the issues.

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cause in society. It helps us to direct the course of community developments through the production of informed and responsible social action. The panels discussed in Figure One below form a dynamic unit. They are distinct, but they are not separate from the whole. Each panel forms part of a mobile where motion of the one generates motion of the whole. Once a panel is activated it begins to connect the resource and value-added panels with an actual or possible community problem (Focus Panel). The process begins with the identification of a community issue. The next step is to identify the nature of the constructivist perspective or what positive or negative bias someone brings to the classroom (identified as mind-set in the Focus panel). For instance, in 2003, I developed an application of the method to the identification of problems faced by staffs of a vocational school, and in 2008 applied my theory to a published paper on the study of environmental rights.30 A knowledge of the constructivist perspective is essential to the resolution of a problem area because unless we know how someone feels about the issue they bring to the table the attempted resolution of the problem goes around in circles. A phenomenological description of the constructivist perspective is a return to a community experience to gather a comprehensive description of the issues that envelop a focus area. Therefore, it is important to peel through the layers of criticisms against medical technology brought to the table by Postman and others to distinguish fact from fancy. Does medical technology make medicine increasingly impersonal? Does this technology represent the patient as being a disease rather than a person? A fully disclosed point of entry from the point of view of the STS systems, themes, and thematic contrasts serves as the focal point for the identification of how academic and societal relations, community resources and programs lead to the resolution of these issues. Therefore, all available resources and programs (academic and community driven) are filtered through STS lenses (STS Method) as part of a process to generate informed and responsible outcomes rather than ideological interests. The goal of the analysis is to solve the true problem at hand. The Social Action Panel for its part contains a set of guidelines to ensure that the action initiated by a group of concerned citizens is successful, and that community programs are self-examined on a regular basis to

                                                             30

Ken Bryson, Negotiating Environmental Rights. Ethics, Place and Environment, 2008, Vol. 11. Issue 3. 351–366, and Treatment Plan for Clients of Vocational Centers and Special Care Residential Units. International Journal of Philosophical Practice. Elliot Chen. Editor. 2003, Vol. 1. No. 4.

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ensure their viability. No detail is too small to overlook. For instance, the list of checkmarks to action includes a review of the adequacy of scientific investigative skills, the breadth of communication skills, the nature and limits of the medium used to deliver social action. Each panel contains details to serve the goal of informed, just, and fair social action. While some details are more relevant than others to the resolution of a targeted issue, all aspects of a problem are examined to ensure that the right equitable solution is found. We need to anticipate and avoid possible negative outcomes. This is especially important today because we do not have consensus on how to deal with the sorts of ethical consequences that will arise from cross-cultural interests, notably ethical issues. For instance, genetic screening provides medicine with an ability to diagnose the onset of disease before it exists. Genetic engineering, on the other hand, allows us to design human beings in our image and likeness. This possibility allows medicine to eliminate undesirable traits in the human condition without the ability to identify what aspects of the human condition are limitations and therefore undesirable. This is dangerous business that needs to be examined before the horse is out of the barn. In part, medicine is driven by economic resources and cultural biases. Will we have one genomic profile for the rich and another for the poor? How do we decide what characteristics are appropriate for each category of human characteristics? Is being tall or short a defect? Are blue eyes better than brown eyes? Will individuals with the risk genome be an asset or a liability to humans? Would a bank hire an applicant with the genomic predisposition towards risk-taking? Should the social order move towards a political attempt to cleanse humanity of undesirable individuals? Will individuals with a certain genomic profile be unemployable, uninsurable, and unwanted? Should defective newborns be allowed to live, and if so should they be told about their deficiencies? Will proper counselling be made available to them? Who will bear the burden of medical costs? How can we preserve patient confidentiality and privacy in the age of unprotected electronic accessibility for all? Is medicine moving towards designing a new category of human being? Can we protect children’s right to informed consent, if their genetic attributes are fine-tuned before they are born? Who should decide on the best genomic pattern to follow? The problem is that if we don’t ask the question before the fact we will awaken one day to find that the horse has left the barn.

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These questions are designed to awaken us from our dogmatic slumber. Hopefully we can identify and prevent some problem areas. In general, some students enter university with a set goal in mind whereas others do not have any other objective than getting a degree. Thus, the STS toolbox opens in one of two possible ways. It can begin with a study of the academic resource panel, or it can begin with a focus on a problem where the student lives depending on what constructivist perspective they bring to the classroom. In some cases, a focus area only surfaces in later years as students decide on a desirable program of studies. With medicine, however, it seems reasonable to suggests that students already have a general focus area in mind, and some might even have a specialized interest at program entry. The problem with admission into medical school, I think, is economic. The applicant needs to impress the admissions committee that they are bright and dedicated to numerous volunteers causes. Only the rich can do that, because most students need paid work to meet the high tuition fees to medical school. The attempt to identify an academic interest is struck at the beginning of classes. I usually begin with the STS history of randomly selected inventions or a medical cure as a way of seeing how the constructivist perspective plays a role in our scientific inductions. We follow up as we seek to identify the positive and negative impact of these changes on community relations. Students are invited to think about how developments in science and technology affect community relations and problems. Social action groups of 3 to 5 students are populated with students that have different disciplinary interests. This allows students an opportunity to see that the same problem can be viewed from the point of view of many disciplines. The size of a group depends on student numbers in the course. A focus area is always addressed through the lenses of multiple discipline areas. For that reason, students are invited to think about how each course in their academic program connects to their chosen focus area. The first figure below is my attempt to put some order in how the tools are organized in the Toolbox;

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Figure One: STS Panels

Think of the STS panels as forming a circle in search of a solution to a problem. The process of analysis begins with the analysis of a problem (far right panel);

Overview A First Nations social action group objects to the fact that a local substance dependence treatment center focuses exclusively on the scientific behavioral approach to addiction. The center experiences a high client relapse rate. The group wants to introduce a 12-Step program at the center as an add-on to existing resources. The group discusses the idea with community elders and with band council and are encouraged to discuss it with the treatment center. The student group is given permission to schedule a weekly self-help meeting (AA/NA) at the (Eagle’s Nest) center. It was also agreed that clients would be paired with a member of AA/NA upon release so that they would not be going home alone where they could relapse. The treatment center saw this as being a good thing and indeed the relapse rate has decreased since the introduction of AA/NA at the center. This is a successful social action intervention. The social action presented their results to the class and included seniors and invited members of band council and community elders to attend the presentation. Their presentation illustrated how some of the tools in the Toolbox were used. First, they identified the problem and described why it was a problem (high relapse rate). Second, they discussed the STS theme on holism and made known their own constructivist bias that excluding

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other treatment models such as a 12-Step method was reductive. They discussed the cost-benefit of the approach. The risk to some members of the group was loss of privacy about their own struggles with addiction but the cost of losing anonymity was overridden by the benefit of helping others. The group discussed the negative bias that accompanies alcoholism and drug dependency but hoped that the negative attitudes, values and beliefs of people about addiction (the culture) was changing over time. Next, they talked about the ‘society’ tool and how groups and clusters of friends, family, community could be enlisted to help individuals recover from addiction. The group also reported on the economics of the social action initiative and the fact that self-help programs are self-sufficient and run by volunteers. The group also reported on the political benefits of the social action. In this case, positive law and the cost to self and others of driving while impaired. The social action project provided an opportunity to discuss how other tools found in the Toolbox were of benefit to them. The point was made that self-help groups are a powerful resource in their community and that doctors treating addicts should include referrals to these groups as part of the therapy. Cultural programs contain medical knowledge. The referral to the knowledge found in a community illustrates the model that a person (patient/client) is not an isolated atom of individual existence but rather stands in relationship with community. The nature of a person as a human in relationships is discussed in the next chapter while the fact that the spirituality of an addict or anyone broken by the experiences of life is not gone. Spirituality does not vanish, but it can go sour and needs to be redirected towards more holistic outcomes. That matter is discussed in chapter three. The Toolbox also contains a discussion of the ethics of medicine from the points of view of the rights and obligations of doctors. While doctors have an obligation to treat persons in medical need, do they have the right to be selective in who they treat in non-emergency situations. For instance, do they have the right to refuse to treat prospective patients who smoke and drink to excess? These matters are discussed in chapter four on ethics. But at this time, we turn for a more in-depth analysis of the tools found in the Toolbox. Problem Panel: The Panel opens with the study of a local community issue, or with the anticipated negative consequence of a proposed technological development. The first step is to delineate all aspects of the focus area through an in-depth study of the problem at hand. A problem is a deviation from a norm. What is the norm? Why did the problem arise? Be

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specific in deconstructing the problem by including all specifications of the problem such as the what, where, why, how, ethics, and when of the problem history. What gave rise to the problem; was anything changed in the environment that could be used to explain the emergence of this problem. In medicine, several issues demand attention. The first and most basic is the influence of cultural relativism on the practice of medicine. This is an ethical issue. The problem is the deconstruction of the image of the person as sacred because of the ad hoc value of ethics today. At one time, abortion, euthanasia and assisted suicide were not part of the medical practice, but in our day the law makes it necessary for a physician to comply with a patient’s request for abortion or to facilitate the death causing action either directly by initiating the action or indirectly by enabling patients to bring about their own death through assisted suicide. The law forces the physician to choose between personal moral principles and the decision to continue to work as a doctor. Ironically the same law that supports assisted suicide makes it illegal to ‘aid and abet’ someone intent on committing suicide. Cultural relativism undercuts the deontological Oath of Hippocrates but does not provide grounds to maintain internal consistency. Although the Hippocratic Oath is based on the existence of pagan gods, these gods provided an absolute standard to secure a belief in the inherent dignity of human life. In our day the belief in the existence of the God of major world religions replaces the belief in pagan gods, but the absence of unanimous acceptance of divine laws or commandments erodes the concept of human dignity. The foundation of absolute truth is replaced by cultural relativism. The problem with cultural relativism is that we pay ‘lip service’ to essential values such as the Hippocratic Oath. The promise “first do no harm’ is relative to circumstances and therefore does not represent everyone’s best interest. Unless the moral imperative is universal, the marginalized will suffer. Cultural relativism fails by its own canon, as does any ethical theory that seeks to operate in the absence of an absolute standard. The problem of relativism was first enacted by Heraclitus 2500 years ago through the affirmation that change is the only reality. Of course, we can always claim that the affirmation does not apply at certain times, but this view leads to skepticism. Knowledge is not possible. Cratylus, a disciple of Heraclitus would wiggle a finger to acknowledge a question from the master but could not respond because the meaning of the question was undergoing change and therefore the answer to the question would

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become irrelevant. Ironically, the impersonal nature of medical technology as a science mutes the ravages of normative skepticism. The person is dehumanized by being treated as an impersonal disease, but the tradeoff is that mathematics is constant. The addition of 2 and 2 always makes four. All developments in medical technology carry a gain-loss profile because the attempt to quantify human dignity fails. With each new technological breakthrough from the invention of the stethoscope in 1816 to recent developments in Tel-Med care, medicine is becoming increasingly more impersonal but seemingly more successful. Genomic medicine raises the bar to the next level of anonymity. Research in medical technology moves from a symptoms base approach to curing disease to a causal sequencing of genes to anticipate and prevent the occurrence of diseases before they arise. The missing connection and the false sense of success is predicated on the false assumption that a person is nothing but an organism. However, the fact that some disease-free individuals commit suicide or do not want to live blows the whistle on medicine’s reductivism. Barbara Prainsack (2017) senses the urgency of the problem; “In light of current pressures on medicine to become more personalized, using a relational understanding of personhood to shape policies and practices is a much-needed endeavor.”31 We need to design a health care model that incorporates the reality that persons are relational beings. A possible solution is found at the level of community programs where family and friends cooperate to meet the needs of an at-risk individual. That information is required to complete a medical assessment of the patient’s condition at treatment entry. This leads to the third problem examined in this book, namely that the focus on the patient as disease and without constant values, and source of dignity arises because the failure to recognize that medicine has a responsibility as sacred science to treat the whole person. The first step is to move towards a view of the patient’s embeddedness in family, friends, and community. This is clearly the case in organ transplant medicine and in endof-life care. Indigenous communities provide a good example of how life on the reserve takes place at the relational level of cooperation. When a person dies, the entire community comes together to mourn the death. The deceased is waked in the family home by a dedicated group of village women

                                                             31

Barbara Prainsack, Barbara, The “We” in the “Me”: Solidarity and Health Care in the era of Personalized Medicine, Science, Technology, & Human Values, 2017, 1–24.

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who offer prayers for the deceased. The body is never left alone during three days of mourning. Friends of the family prepare food for everyone. Funeral costs are offset by the donation of articles brought to the wake by friends. These articles are sold at a community auction after the funeral so that no financial burden is placed on the grieving family. Scheduled classes are cancelled or deferred during this period. Other examples of relational activities abound in most communities with the development of 12-Step programs to deal with dependencies on drugs, gambling, including sex addiction. A physician, on the other hand, is trained to deal with disease as an empirical condition and therefore needs to seek additional knowledge embedded in our communities. Some community programs such as ‘mindfulness’ groups (meditation, prayer, yoga, reiki …), are effective pain management tools, but we need to connect these resources with the doctor’s office. We need mechanisms to import a patient’s relations into healthcare. The central nervous system cannot tell the difference between a real experience and an imaginary one, but the attempt to imagine external help will not materialize until the doctor connects the patient with that resource. Most patients know the difference between a real family member and an imagined one; programs such as Reiki do play a role in the healing process because they produce measurable results. All things, organic and inorganic seek to maintain themselves in existence. In the 1960s, James Lovelock developed a theory known as the Gaia hypothesis that the biosphere acts like a self-regulating living system to sustain life. The theory has its detractors. Medicine as an important guardian of human health and life has the same spiritual appeal as the Gaia theory, but the impersonal nature of medical technology also has detractors. Spirituality is not the exclusive property of medicine. All academic and community disciplines, resources, and programs are spiritually based, that is they are attracted to the good of healthy living. First, the whole of existence is spiritual, although the term is used primarily about humans. Second, the vision of medicine as sacred science moves beyond spirituality and holism because the possibility of medicine is rooted in the fact that all living things strive to maintain a unity of parts. Consciously or unconsciously all things function as a unity of parts. The practice of medicine even in its most deliberate reductive moments is spiritual, holistic, and sacred despite the impersonal nature of medical tech-

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nology. A phenomenological study of the ultimate ground of the possibility of medicine reveals that we exist in necessary relationship with being’s unconcealment or ontological truth. To apply a theme developed in Martin Heidegger’s phenomenology, the sanctity of medicine arises because of a necessary transition from Dasein to Sein; a Heideggerian Turn in the root of the possibility of doing medicine is found to be contained in the sacred ground of being’s unconcealment. The hegemony of authentic technology suggests a ‘letting be’ of nature. Thus, medical technology avoids reductivism by generating an environment that allows patients to reveal themselves as more than disease. We read in Genesis 1:26 that persons are made in the image and likeness of God. Therefore, medicine is (1) spiritual since it uses technology to eradicates disease, (2) holistic when it views patients as being relational (a patient in relation that has a disease) rather than a diseased organism, and (3) medicine is sacred whenever it recognizes the ontological sanctity of human life as a gift from God. The failure to include these aspects of human existence in the medical model promotes the disorganization of the organism and death. The development of this central vision is a central theme in this book. To that end, I rely on the efficacity of the STS method, as well as on my formulation of the phenomenological method as detailed by Clark Moustakas (1994).32 Philosophy seeks to understand problems through a methodology that in part examines the problem from the point of view of principles of human understanding such as the principle of sufficient reason, non-contradiction, and identity, and the causes of being, namely the efficient, final, and exemplary causes and the material, and formal causes of being. The method includes a definitional, or descriptive analysis of the problem at hand along with a process of enumeration to introduce distinctions in the complex (for instance the distinction between defining or determining what a being is, and describing, or observing what a being does, is made because not all things have universally accepted definitions). In addition, the Socratic method focuses on the examination of all assumptions surrounding a problem. Take nothing for granted. This is also the path of phenomenology as a science free from presuppositions, meaning that all assumptions are examined. Not all unknowns are clearly identifia-

                                                             32

Clark, Moustakas, Clark. Phenomenological Research Methods, (Thousand Oaks, California: Sage Publications Inc. 1994).

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ble, but no aspect of a problem should go unnoticed. Descartes’s methodology is helpful in this regard as we seek to reduce the complex aspects of a problem to its simpler elements. The simple elements are examined individually through a mathematical system of intuition and deduction, analysis, and synthesis. Logic rightly focuses on maintaining internal consistency. An STS analysis of a problem forces the inquiry into why an issue is a problem. The examination of assumptions concerning the problem at hand forces a discussion into why the issue exists as a problem. The process depends in part on a philosophy of the person. In my study of what it means to be a person (we need to agree on what we are before we can fix what is broken about us), I propose that persons are human beings in relationships. In the next chapter we examine the main strings of relationships that define us, namely (1) relationships at the level of the carbon-self; (2) relationships with other persons including pets, and (3) relationships taking place at the level of the psyche, namely conscious and unconscious relations alike. Thus, the examination of a problem area deconstructs the issue into one or more of these streams of person-making associations. In this methodology, the solution to a problem arises by examining a relational stream of associations on each arm of the person-making process, and spotting discontinuities where the need for spiritual welding is required. I would be amiss not to include the history of the great ideas in medicine as a source of insight, as well as a knowledge of the relevant thematic encounters with problems, and tools at hand. Philosophy needs to examine all its assumptions about reality including common sense. To state the obvious, no one of sane mind doubts the existence of the external world, yet the reality of a world existing outside consciousness is indemonstrable! I spent time as a graduate student in philosophy wrestling with a problem that most five-year old take for granted, namely do things exist outside consciousness, but the process of examining assumptions made me more appreciative of the mystery of life. The attempt to prove the existence of things outside consciousness leads to severe epistemological paradoxes. The goal of this STS analysis is to empower medicine by bringing its focus into the light of a patient’s experience. The matter is complex because an informed social action arises through the in-depth study of the elements found in the panels. The Resource.2 panel plays a major role in that solution as is evident in the value of societal relations. A review of some of the issues my students examined in First Nations communities such as fracking, waste water disposal, water treatment, job seeking, high

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unemployment, radiation, poverty, garbage control, bilingual street signage, dog control, drug use disorder, residential school experience, Styrofoam cups, recycling, and agriculture contain a wealth of community- based knowledge that cannot be ignored. The belief that none of these issues is relevant to healthcare is in error because the issues arise where people live. The environment is not outside of us. Community programs provide an indication of the assistance provided to patients in time of sickness. They provide medical knowledge. In STS we think globally but we always act locally. The reason for this is that a problem comes to life in the user’s community, although programs available in foreign communities can be imported for specific tasks if the need arises. We begin the process of examining a problem area by forming small research groups of concerned citizens. In Native communities, a proposed policy is researched and brought to the attention of Band Council. Ideally research groups consist of students with different academic interests such as business, drama, technology, chemistry, biology, medicine, English, Mi’kmaq, physics, biology, anthropology, social work, and philosophy (…) to ensure a comprehensive approach to a focus area. I think that a similar range of interests can be found in medical school. A tentative approach to the problem is then brought to the classroom for wider discussion. Discussion focuses on how each academic discipline relates to the problem area. Students are invited to think about the connection between a community resource, their disciplinary focus, and the problem area. To cultivate this mindset, students are invited to keep a folder of newspaper clippings on the focus area and other materials from the popular press, as well as peer reviewed journal articles that relate to the problem at hand. Selected readings are assigned in the chosen focus area. The next step is to write a detailed history of the problem. Be objective and open to the truth (bias free) because history can be distorted by individuals with an agenda. The victors often write history. History is an interpretive activity, that is I view systems (culture, economics, society, politics, eco-systems) as an interpretive framework to understand history. I do not use systems as a scientific law to predict the course of history. The ideal is to approach the Academic and Programs panels as a reflection of systems theory. For example, computers mirror us, the best and worst of the human condition as we (culture, politics and laws, society, economics) write the software programming for computers. Keep the constructivist perspective in mind, namely flesh out the interests that each member of

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the group brings to the table. Some students attend university because they already have a focus in mind while others come to academia without any clear goal other than to obtain a university degree and hopefully move on to graduate school in some area or other. The final choice of a major, minor or concentration is made at the end of the second year of studies. It seems possible to suggest that on occasion patients also visit a doctor’s office with a hidden agenda in mind. The first step the doctor takes is to develop an open and safe environment for full disclosure. We need to be mindful about the distinction between sex and gender. Sex and gender are often used interchangeably, but they have different meanings in research and therefore applications to medicine (TriCouncil Policy Guidelines);33 “Sex refers to a set of biological attributes in humans and animals. It is primarily associated with physical and physiological features including chromosomes, gene expression, hormone levels and function, and reproductive/sexual autonomy. Sex is usually categorized as female or male but there is a variation in the biological attributes that comprise sex and how those attributes are expressed.” “Gender refers to the socially constructed roles, behaviours, expressions and identities of girls, women, boys, men, and gender diverse people. It influences how people perceive themselves and each other, how they act and interact, and the distribution of power and resources in society. Gender is usually conceptualized as binary (girl/woman and boy/man) yet there is considerable diversity in how individuals and groups understand and express it.”

The distinction between sex and gender has not received the attention it merits but the blurring of boundaries in systems analysis makes it important. For instance, gender expectations contribute to our understanding of the duties of expectant mothers. But not all pregnant women identify as mothers. Not all women are mothers or pregnant. The stereotype image of the mother doctor relationship changes because of socially constructed gender roles.

Resource.2 The panel on social relations is critical to the success of dialogic medicine and healthcare because it expresses all the relations that a patient (or doctor) bring to the medical arena. It includes all the group interactions such

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See Tri-Council Policy guidelines and training module for research with human subjects at http://www.cihr-irsc.gc.ca/e/48642.html

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as families, associations, and institutions that characterize our social face. Community volunteers meet with the patient and healthcare team in the presence of family relations as background noise. The focus is on health and sound moral choice. The value of bringing social relations to the medical table is in ensuring equity, justice and well-being for patients. Social work, and law are two of the allies that promote sound healthcare policy. These policies are designed for human beings. Therefore, the success of the panel operates on definitional understanding of what it means to be a person (chapter 2). The importance of this panel must not be undervalued because it contains the streams of relationships that empower humans as they transition from being human towards being personal. The failure to include this data turns responsibility for healthcare over to the organic arm of being a person and the impersonal character of medical technology. The panel lies at the heart of the distinction between treating a disease or treating a patient with a disease. The absence of societal relations from a patient’s medical profile promotes a healthcare system based on the erroneous view of the patient as an atomistic individual. The well-being of a society depends on making sure that no person-making relationship and no class of citizenry (the poor, minority groups) is left outside societal relations. The exclusive focus on ‘affordable healthcare’ is reductive. Medicine as sacred aims for universal healthcare. Unfortunately, we mistakenly put the emphasis on economic values ahead of human development. The transition to personalized medicine is more than a call for patient empowerment. Mechanisms are already in place in the medical contract between a doctor and a patient to ensure that patient rights such as informed consent, autonomy, beneficence, justice, the right to privacy and confidentiality, are safeguarded. If the patient objects to a doctor’s paternalistic approach to healthcare, the contract with the doctor is not made or is broken. This is not to suggest that a patient’s empowerment trumps a doctor’s skill set. On the contrary, physician and patient each have rights, such as a doctor’s right to not accept a patient if something about the patient’s request runs counter to the doctor’s personal code of ethics. Remember that the doctor also brings personal relationships into the doctor patient dialogue. The point is that although treatment is specific to a patient’s organic condition, including social relations, the doctor’s moral conscience also comes into play. The view of the patient or doctor as an isolated unit is wrong. No one is independent from social relations (Prainsack, 2017); “societies have a responsibility to meet the fundamental needs

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of everybody as well as they can. Such a perspective also affects how we understand individual rights in the sense that their meaning is always shaped by collective responsibilities and shared social practice.”34 The idea of a patient as being a hermetically sealed, autonomous, atomistic individual does not meet the realities of a patient’s lived life. This is especially evident in organ donation, end-of-life care, surrogacy, and the provision of informed consent for at-risk clients, as suggested in the personmaking process (chapter two). The success of social action is dependent on societal relations to generate informed, responsible community programs. The STS method is a conduit for all the resources both academic and community based to solve a medical issue. Students can draw on elective courses to develop imaginative medical background. On the other hand, we can profit from co-op programs as some related work experience translates into academic equivalencies. Community programs contain medical knowledge. Volunteerism in community programs gives medical student an invaluable source of insights into patient relations. The realization that a required community resource does not exists provides the opportunity to fill a perceived need. As the saying goes, necessity is the mother of invention. Ideally hands on experience in a community program can be given academic equivalency in medicine. This vision extends to academia as new courses are constantly being developed by faculty to fill the perceived academic needs of a discipline. In most cases, existing degree programs need to be reconfigured before they can meet the needs of future generations. In the development of future degree or certificate programs it seems possible to imagine that students could work with program advisors to write their own degree contents through the selection of resources (courses and programs) to meet their individual career goals. This is said to widen the existing parameters of university programs to include courses that meet the ever-changing needs of a technological society. The introduction of patient relations in the permutations and combinations of academic courses generates a medical current of fresh and dynamic ideas to meet the changing needs of a patient base. The connection takes place through the interaction between academic curriculum and societal groupings as expressed through community programs (technical and societal).

                                                             34

Barbara Prainsack, The “We” in “Me”. Solidarity and Health care in the era of Personalized Medicine. Science, Technology, & Human Values, 2017, 4.

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Technical Programs Technical programs are developed in medicine to safeguard the well-being of a person as an organic entity. An example of a social action initiative in a First Nations community provides from a study of contaminated ground water. The problem was the pollution of a brook running through a village in Millbrook, Nova Scotia. Some of the children would play in this brook, often leaving toys and tricycles behind, and drinking some of the water. But the water appeared to be contaminated as it was brownish and gave off a strong odor. My students decided to conduct an STS study of the brook as part of course requirements in their STS course. The project was approved by Band Council. The group obtained a brief history of the brook from community elders because nothing was written about it. The pollution of the brook was recent, however. The stream came from the mountain and was always safe to drink in the past. The group wondered what happened to contaminate the brook. Several suggestions were made but no definitive answer was found. The next step was to determine the nature of the contamination. They invited a scientist from the department of the environment to run tests on some water sample. A few days later, the government technician came to the classroom to report that the water sample contained e-coli bacteria along with other contaminants. The research group discussed the findings with the town engineer. They found that a sewer pipe ran parallel to the stream and suspected a break in that pipe. Once they dug it up they found it leaking sewage into the ground water surrounding the outflow valve. A backhoe operator and several other workers repaired the broken sewer outlet. This was a very successful and straight forward social action project, but the polluted stream would have gone unnoticed were it not for the initiative of a small group of concerned citizens. The group did not see a need to conduct a risk assessment as part of their social action initiative because this problem was such a clear-cut case that the benefit to the well-being of children on this reserve far outweighed the cost of repairing the broken pipe. Sometimes a problem is easy to solve. In more complex cases of ground contamination such as fracking, expert witnesses are brought in to assess the situation. The qualification of expert witnesses is usually based on the history of their past successes and failures. The insight gleaned from disciplines such as biology, psychology,

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and economics serve to comment on the connection between building sickness and environmental contamination. The connection might not always be obvious but the challenge in some cases is to find the right connection. Keep the multidisciplinary nature of medical ethics in mind. A course in English literature leads some student to connect a romantic period poem with the beauty of nature. This is contrasted with the possibility of contamination sickness. The philosophy major seeks to make distinctions between conservation and preservation, and perhaps examine academic resources (Resource.1) on environmental rights by raising questions such as ‘do trees have standing rights’ to clean water, namely a right that can be represented in a court of law? A course in industrial design points to research on the effects of waste contamination or less than aesthetically pleasing architecture and building sickness. In this proactive light, each course acquires a fresh new meaning and an existing community resource is identified and used. The success of this mix obviates the value-added dimension of interdisciplinary action in complex cases. Medicine is a complex activity that needs to be recast in similar layers of insight. The mix of academic and community programs (R.1 &.2) breathes fresh air into the life of the academy.35 The development of programs from available resources is an application of the Gestalt principle ‘the whole is always greater than the sum of the parts’ because of the element of organization or as we say in philosophy, the meaning of a text always creates a surplus of the signified over the signifying because of the background noise we bring to it. Programs provide a forum for citizens to add emotion to technology. The belief that medical technology is the exception is wrong because that view leads to a reductive identification of the patient with disease. The emotion of compassion is especially important in medicine, but how is it configured if not by teaching students that medicine is more than biology? Doctors are not mechanics. There is no value free academic or community program. The main points to keep uppermost in mind about academic programs is that they arise out of a gestalt collection of individuals in relationship seeking to find meaning in life (chapter three) deserving of political and economic attention from individuals in charge of universities. The constructivist perspective (the beliefs a stakeholder brings

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Cape Breton University (CBU) houses a center for Indigenous Studies. A guide on Mi’kmaq and Indigenous Studies is found at http://libguides.cbu.ca/Mikmaq. CBU is located in Mi’kma’ki, the ancestral and unceded territory of the Mi’kmaq people.

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to the bargaining table), and the interdisciplinarity character of STS each tell a story on how to maximize benefit for most patients. The importance of being objective in curriculum development whether medicine or law is critical to the successful development of an STS strategy. A more complex STS analysis of ground water and air contamination was undertaken in the Tar Ponds restoration of Sydney Steel. Cape Breton University played an active role in the restoration process as some citizens held marches of concern designed to call governments to move into action on the issue (Liu, Bryson, 2009).36 One of the most toxic sites in Canada was gradually transformed into a beautify green space. Imagine the benefits of transforming individualized healthcare into interpersonal medicine.

Social Community Programs Community programs generate fresh medical knowledge. The purpose of societal community programs is to provide the resources required by a physician to move beyond the visualization of the patient as disease. The societal resources do not substitute for referrals to specialists such as psychiatrists and other healthcare workers but add to them by drawing on the wisdom of social action initiatives developed by society to meet the holistic needs of marginalized citizens. For instance, the treatment of addiction uses several layers of treatment such as detoxification, and counselling including a referral to a community self-help group such as Alcoholics Anonymous or Narcotics Anonymous, and Al-anon. The multi layered, multidisciplinary, approach to addiction medicine healthcare must be factored into the medical curriculum (chapter four). The need to do so is made more urgent by recent developments in medical technology towards genetic engineering. The medicine of the future will most likely treat the symptoms of disease and personality disorders before they arise. Is the addictive temperament of the alcoholic a deficiency in dopamine receptor cells? The case of a genetic predisposition to addiction is made from the fact that 1 in 4 children of alcoholic parents is born with that genomic configuration. How a patient chooses to be autonomous and informed is not easily predicted because of freedom of the will and the imperfections of the human condition, but human freedom is based on

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Fan Liu, Ken Bryson, Sydney Tar Ponds Remediation: Experience to China. Bulletin of Science, Technology & Society. Vol. 29, 2009, 397–407.

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knowledge. The more we know about addiction the freer we are not to be controlled by that predisposition. Social community programs provide an applied resource for academic programs as well as a hands-on referral service that doctors can use to help their patients. The community programs suggested here are available in First Nations communities and provide a useful baseline upon which to draw existing resources or develop new resources through social action. I invite students to draft a list of resources in their own communities. In no order, these are some of the community resources identified by my First Nations students in Cape Breton, Nova Scotia (see footnotes 28 and 29 for additional details); Healing center for women of abuse Healing center for men of abuse After school programs Adult learning programs Programs to eliminate partner violence Parenting programs Anger management Respite care (Alzheimer’s) Teen dating violence Canada’s residential schools: reconciliation (a copy of the final report of the ‘Truth and Reconciliation Commission of Canada’ is available online). Self-help groups (A.A., N.A., O.A. E.A. G.A., S.L.A. co-dependent anonymous, etc.) Women’s well day (free haircut and pedicure) Men’s well day (free haircut and pedicure) Training programs: CPR, First Aid Elders in the community: knowledge, oral tradition, and Mi’kMaq tradition) Fisheries training programs for deckhand, fisheries manager Social assistance (welfare)

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Native alcohol and drug abuse counselling (NADACA) Family services Foster home care (children who need placement, adoption, caring training, foster homes, respite home, protection intake care) Family group counselling Effective parenting course Smoking cessation Healthy weight control Crisis prevention and intervention Mental health care Pre-natal classes Diabetes foot care Dental therapy Respiratory illness (information and support) Chronic disease information One on one community counselling Online computer skills Cyber camps for children Unama’like institute of nautical resources (UINR); formed to address concerns regarding natural resources and their sustainability Community health nurse visits Foot care clinic Teen’s health services Reproductive health Sexually transmitted infections screening

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Ethics: Doing the Right Thing The main discussion on ethics is found in chapter four, but this is an introduction to some of the key points about Toolbox ethics: One of the fundamental areas of concern in ethics is moving beyond ethical relativism to provide an absolute foundation (unshifting) for deontological ethics. This ensures sustainable ethics, that is, a code of medical ethics to protect both doctors and their patients! Whereas, a missed constructivist bias can distort the nature of an intended program, doing the wrong thing also leads to unwanted legal and ethical issues. But what is the right thing to do in healthcare? The Hippocratic Oath is a personal commitment to always act on the side of life. The promise includes honoring the qualitative dimensions of healthcare such as the rights and freedoms of patients, the delivery of compassionate care based on a spiritual assessment of the patient, and the adoption of a holistic attitude towards patients that includes the patient’s significant relationships. We need to ensure that patient rights tied to a systems approach, one based on culture, society, economics, and politics, does not create a neo-colonial approach to ethics. By this I mean the use of systems to legitimate and control an ethics generated by law rather than human nature. We need to ensure that medical ethics is grounded in something to the likeness of the Hippocratic Oath and human nature rather than law and respect the ethical conscience of doctor and patient. The Universal Declaration of Human Rights, adopted by the United Nations in 1948, lists some 29 basic rights and freedoms that serve as “a common standard of achievement for all peoples and all nations.” The declaration of Charter Rights has a profound influence on the legal system local and international, and how we think about respect for persons. In our day, however, the clash of global cultures often leads to violence and war. William James reminds us that we are blind to the feelings of others. A case can be made for the evolution of rights and freedoms in the age of technology. Perhaps we need to issue a call to scholars from all

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countries of the world to reexamine the foundation of rights and freedoms. It seems to me that in our day technology has enlisted the service of politicians to decree what our rights should be, and consequently what course of action to follow to be ethical. But when political laws dictate what to do, people from marginalized cultures have no choice but to act against the ruling politics. They defend their own systems, culture, society, politics, economics, and ethics. This is a reaction against neo-colonialism and the attempt to control and influence foreign systems. Postman’s characterization of the objective physician driven by developments in medical technology practices its own brand of neo-colonialism. Citizens are at odds as to what is right; even citizens of the same country argue for and against abortion, euthanasia, assisted suicide, blood transfusion, xenotransplantation, cloning, genetic engineering, and on and on in the name of Charter Rights! The shrinking global village and the age of instant communication makes matters worse. Christine Pierce and Donald Van De Veer (1995) summarize the issue; “some people do believe in and practice polygamy (Africa, Asia, Utah), polyandry, cannibalism, slavery, bride burning (for insufficient dowries in India), animal and human sacrifices for religious purposes (the Aztecs at one time, the Santerían religion in Florida), eating horses and dogs as a routine part of the diet (Kore, France, China), routine clitoridectomy of young nonconsenting females (Africa) and infanticide of normal female infants (India) routine coercive extraction of bribes to do business (the Near east); many do not.”37 If the problem is caused by depending on majority votes (law) to define the ethics, what is the solution? The Hippocratic Oath locates the source of ethics in human nature rather than in how we vote. Hippocrates, the father of medicine, is driven by a respect for the life and dignity of his patients. He is absolutely right but how could he have known this; he did not arrive at the Oath through the empirical observation of disease, so this normative proclamation of justice and respect for patient rights must have descended upon him from above, that is it must be imbedded in human nature as created by the divine. The distinction between human nature and being a person makes this clear. We read in the Gospel of Mark (2.18–22); “No one sews a piece of unshrunken cloth on an old cloak; otherwise, the patch pulls away from it,

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C. Pierce, and D. Van De Veer, People Penguins and Plastic Trees. 2nd Edition, (Belmont, Cal.: Wadsworth Publishing Company, 1995), 470.

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the new from the old, and a worse tear is made. And no one puts new wine into old wineskins; otherwise, the wine will burst the skins, and the wine is lost, and so are the skins; but one puts new wine into fresh wineskins.” The biblical passage comes to mind because of the connection between human nature and being a person. The ethical standard that governs the morality of how we become more truly personal must fit the ethical structure of human nature. We cannot expect that the ethical constructs of persons are ethical outside the parameters of what we are as a species. While we are equal as human beings we are not equal as persons. This is because a person is a human being in action. A person is the output of relations. To say that the ethics is derived from the law is to argue wrongly that the action decides the ethical nature of the act. This view leads to neo-colonialism. The claim that the ethics is derived from human nature avoids this problem because human nature is what we have in common. Human nature is sacred because according to Genesis 1:26 ‘we are made in the image and likeness of God.’ This view is discussed in chapter two. The morality of human acts is grounded in our human nature as we enter relationship with other persons and the environment. A Charter of Rights and Freedoms governs citizens. In the development of academic research programs; Canadian research agencies adhere to the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS-2). Chapter nine of the Code governs Indigenous research. To preserve Mi’kmaq culture, research questions on the Indigenous way of life must come from the Indigenous communities. Research projects must reflect the will of the Indigenous community and have an applied focus; see “Application for review of research involving humans.”38 Research projects that involve human subjects cannot proceed without approval from the research ethics board (REB). These committees ensure that a research project respects cultural differences and individual autonomy, informed consent, beneficence and non-maleficence, privacy and confidentiality, and social justice in the allocation of scarce resources.

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Tri-Council Policy Statement: Ethical Conduct for Research Involving Human Subjects (TCPS-2). http://www.cbu.ca/wp-content/uploads/2015/07

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The STS Range Let me open with modest philosophic humor I read somewhere; Junior is apprehensive about his very first dating experience and looks to mom and dad for advice. Dad suggests three core points of conversation: (1) likes and dislikes, (2) family, and (3) philosophy. Later that afternoon, junior asks his date (1) do you like noodles? She answers no. Moving on to family he asks her if she has a brother. No, came the reply. Well that leaves philosophy. He thinks for a while and asks his date: well, if you had a brother do you think he would like noodles? I personally would not use that joke if I was a stand-up comic. But some speculative dimensions of philosophy remind me of that first date experience. Students coming to the STS of medicine on a first date can take comfort in the fact that the STS method combines philosophy with engineering, biology with the humanities tradition; no noodles! The STS method, whenever it serves as a dialogic entry to social action is an in-depth study of a problem area through the interdisciplinary lenses of all the disciplines you can fit into the medical Volkswagen, including ethics, history, systems, themes, thematic contrasts, and social action. The interactions between a problem area such as the effect of medical technology on the doctor patient relationship takes place through the lenses of culture, society, politics, economics, and the psychology of doctor patient relationship, along with the looming impersonal character of medical technology. Many of the themes developed at a conference on ethics and technology hosted by Guelf Guelph University (Nef, J. Vanderkop, J. Wiseman, H.) in the late 1980s continue to have relevance today.39 The art of medicine is viewed as technology with special connection to the eco-systems. The connection between human health and the health of the environment is indisputable because we are an extension of the environment. The common technological bond between us is enacted through a focus on disease. This creates space for alternative healing methods. Humans and trees share a common interest in resisting the destructive power of disease and death. Human health is relevant to the good functioning of society, in the same

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J. Nef, J. Vanderkop, J. Wiseman, H., Ethics and Technology: Ethical Choices in the Age of Pervasive Technology, (Toronto: Wall & Thompson. 1989), 6. The themes constitute the basic chapter structure of their volume.

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way that the health of the forest relates to the health of the biotic community. Good health is a social benefit to everyone. Disease is the absence of health. A just society depends on equity and the fair distribution of resources to address the health needs of all citizens. Economics, culture, society, and politics all have a role to play in healthcare. The politics of disease can be overrun by economics. Medical errors can also be caused by crooked logic and mistaken inferences (Gungov, 2018). Sloppy logic costs money; “… matters of financing too often subsume the dimension of patient care (…) Of the thousands of medical errors committed on a daily basis, in the bulk of unfortunate clinical decisions, a significant share pertains to various logical flows and epistemological fallacies.”40 The desirability of good health, and correct moral choice play a role in solving the problem of injustice and alienation through the technology of health care and social work. The benefit of this STS approach to medicine lies in the provision of equity, justice, and well-being for the citizens of a given culture. But all choices involve trade-offs because nothing is free. The misdiagnosis of patient symptoms leads to unnecessary surgical procedures and increasingly expensive healthcare costs. A focus on justified costs is an equitable way of allocating scarce medical resources for the benefit of most citizens. However, it does not absolve medicine from its responsibility to respect all human persons. The dignity of human life and a patient’s charter rights to autonomy, consent, beneficence, and nonmaleficence move us beyond economics. Although the misallocation of scarce medical resources is an injustice, whether through sloppy logic, unnecessary medical procedures, misdiagnosis or incompetence, the point is that medicine is not frozen in the soil of economics. Sacred medicine leads to the examination of the metaphysical ground of political systems, jurisdictional laws, and ethics. For instance, the definition of death finds its ultimate ground in metaphysics rather than in biology, or epistemology (chapter 5). In brief, the STS method conducts an in-depth study of medicine as sacred science through the interdisciplinary lenses of ethics, history, systems, themes, thematic contrasts, social action, spirituality, and metaphysics. We need clarity on the constructivist agenda because it can distort the nature of medicine.

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Alexander, Gungov, Patient Safety: The Relevance of Logic. Safety (Stuttgart, Germany: Ibidem Press Columbia University Press, 2018). The quote is from a personal description provided by the author.

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The STS Conversation: Can you pick out what is missing from the following doctor-patient dialogue? Doctor: Hello, how are you? Patient: I have a rash on my hands. Doctor: Examining the patient’s hands … this looks like eczema. It can be caused by stress. Are you new here? Patient: Yes, we moved here from Nova Scotia to be closer to our nine-year old grandson Keanen who has leukemia, and to help his family where possible. Doctor: I can prescribe a pill that will help control the eczema. Anything else? Doctor: Have a good day. Patient: Thank you doctor. The missing ingredient is a missed opportunity to think of the patient in a relational, dialogical interactional way and to discuss the patient’s wellbeing in context of family and friends, and community to uncover a possible source of stress. A patient is not an atomistic individual. The doctor patient relationship must include a conversation about the condition of the patient’s grandson and his family, and how are they doing. Is this what is causing stress in your life or is there something else. Do you have a spouse, are things ok on that front? Do you have financial worries? The systems are touchstones to guide the direction of the doctor patient dialogue. A system is a set of connected parts forming an organized whole. A holistic treatment outcome depends on the successful inclusion of systems analysis in a patient profile. My adaptation of systems includes culture, society, politics, economics, resources, and the eco-systems while the constructivist perspective, ethics, and history provide the guided flight path towards resolution of the problem. The relevance of a given system depends on the patient’s willingness to disclose the information it encloses. For instance,

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the analysis of poverty takes place primarily through the lenses of economics, politics (and law), but the eco-systems also figure in the analysis of this focus area. The Guelph university conference on sustainable developments recognizes the interconnection between variables such as economics, poverty, unemployment, addiction, suicide, domestic violence. This data is as important to medicine as blood pressure and cholesterol readings. The ‘Themes’ column marks places where the wave action of systems analysis reverberates. The culture system, for instance, focuses on communications and warns against problem areas such as ignorance and prejudice. The science/theory resource is philosophy while the technology is education. The value-added component of education is enlightenment and accessibility. The decision to think locally but act globally is an invitation to look at a patient as a being in relations which is a view of disease from the point of view of the connection between the part and the whole. A detailed analysis of the systems or touchstones for dialogical discourse is an integral part of responsible social action. We pause to examine the STS method panel in more detail because this is information is required to appreciate medicine’s nature as sacred science; Culture: this system refers to the set of attitudes, values, and beliefs that surround a focus area. The weighting assigned to beliefs, values, or attitudes in medicine shifts worldwide. It should be noted that the cultural focus in this study is on Western medicine. For a richly colored discussion of STS related research on the culture of health and medicine in East and Southeast Asia see (2018) Science, Technology & Society.41 The discussion of Western medicine is heavily reliant on technology. The focus is on separating patient and disease to produce health. Eastern medicine is holistic and treats disease as being a part of the whole person. Medicine of the West is expensive and mechanistic but does not view the patient as relational. Eastern medicine is less technical but more open to alternative healing techniques. It seems wise, therefore to examine a patient’s medical attitude, value or belief as it exists in a local setting. One of the biggest cultural issues that face us is that we are blind to one another’s way of life.

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Celine Coderey (2018) ‘Drugs’ life: accessibility and use of biomedical drugs in Rakhine State (Myanmar). Coderey makes the useful connection between culture and politics; ‘the resort to unlicensed pharmacists who sell mostly expired inferior or even imitation drugs as a problem arising from lack of government investment in healthcare.’ Science, Technology & Society 23:2 (2018): 1–6.

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Ignorance and prejudice often lead to alienation and war. The solution to reductivism is education and respect for other medical approaches.42 Economics: An article by Marsha Barber (University News, Nov 30, 2016) details how the medical school admissions process is skewed because it favors students with money; “At the medical school my son eventually attended, his classmates had demonstrated skill and initiative to get in. They’d started international charities, competed in sports at the national level, won prestigious academic awards and published prolifically.” Admissions are extraordinarily competitive; “In Ontario, the success rate for getting an offer is less than 10 percent for applicants to many schools. Last year, for example, McMaster University had 5270 applicants for 206 places. Queen’s University had 4686 candidates for 100 places. These admission rates are not unusual.43 The process favors students with money. The newest version of the MCAT is seven and a half hour long. Students who can afford to take the summer off to prepare for admissions exam or who can afford to do volunteer work in far-away countries fare out much better than students who must work summer jobs. At the other end of the spectrum, giving everyone access to affordable healthcare is a major challenge for governments. This is especially the case in the United States and Western European countries, where costs are escalating because of the technological character of medicine. The economic system refers to structures and processes used to meet basic survival needs. This includes goods and services. No one should be unemployed or poor because there is a lot to do and lots of resources we can share. The problem is that in North America we value only one type of work, namely the useful along with good profit margins. The high cost of getting a medical education often leaves out highly qualified candidates. In the STS approach to medicine we strive to attain a fair trade off (thematic contrast) between capitalism and socialism. The STS focus is on combining the twin goals of human development and economic development, that is, the efficiency of developments for all citizens. Our economic resources are often tapped by errors in logic and the misdiagnosis of patient symptoms.

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43

To illustrate the point, a useful guide to research Mi’kmaw language and culture is available at http://libguides.cbu.ca/mikmaqstudies/journal (accessed 12 May, 2016). Marsha Barber. How the medical school admission process is skewed. University Affairs. Nov 30, 2016.

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Polity: the political system addresses a society’s structures and processes for conflict management at the municipal, provincial, and federal levels. Law is an essential component of this structure. Laws that are just promote civil order. Governments need to ensure that all citizens are treated fairly, and that human rights and freedoms are protected. The absence of law leads to violence, repression, and insecurity. While medical codes are principles of conduct rather than laws, they are based on principles contained in the deontological Oath of Hippocrates, the Charter of Rights and Freedom, and the abductive inferences of experiential learning. Resources: a resource is that part of the environment that can be exploited for productive use and economic gain. The depletion of non-renewable natural resources is a great concern, as pointed out by the Club of Rome’s Meadows report in the early 1970s, The Limits to Growth. The focus on sustainable developments refers to developments that can meet present needs as well as the needs of future generations. The future of the current medical paradigm with its focus on disease and the patient as an individual atom will not survive if it does not meet the changing nature of healthcare needs. The sustainable development of medicine depends on the inclusion of responsible social action. (The Resources.2 panel refers to the non-technological medical assets that exist in communities for the wellbeing of its citizens.) Eco-systems: we cannot go blind to the effects of global warming on healthcare. The irreversible consequences that uncontrolled industrial development has on the planet is one of the greater unintended second order consequences of developments in science and technology today. The environment is where we live! The critical condition of the planet today is the result of an ongoing mindset pioneered by Francis Bacon in the 16th and 17th century that ‘nature can be tortured for her secrets.’ The culture of early science acts as if the environment lies outside of us and is boundless. It seems odd to think that anyone today denies the reality of global warming, but that is exactly the stance adopted by some of our world leaders. While Bacon was right to warn against the anthropomorphic explanations of nature in the Middle Ages, he was wrong to hold nature in contempt as if separate from us. Good technology is based on allowing nature

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to heal herself. A strong warning against this mentality was made by Martin Heidegger.44 The attitude (Ge-Stell) of greed condones the disrespect of nature. Rachel Carson’s Silent Spring (1962)45 is a widely recognized pioneer of the environmental movement. In this book she warns against indiscriminate spraying of pesticides and the negative effects it has on birds and wildlife. The chemical industry failed to downplay the significance of this work. The Meadow’s report The Limits to Growth (1972) warned against the dangers that arise out of unsustainable developments in the areas of population growth, agriculture, the exploitation of natural resources, increasing industrial production, and the damage done to ecosystems would result in putting our planet in peril. A twenty year follow up to this report by these scientists showed that no one heeded this warning, however. The Brundtland commission report Our Common Future (1987) concludes in part that global economic developments have not improved quality of life because people appear to be living in worse conditions today than fifty years ago. Vice President Al Gore’s environmental research and podcast An Inconvenient Truth (22 June 2007) successfully raises general concern about the detrimental impact of global warming. However, an annual string of seemingly endless accords among world leaders to take concrete action against green-house gas emissions is going nowhere, especially with President Trump at the helm of US politics. Is Canada moving in a better direction? Recently (3, October 2016) Canadian Prime Minister Justin Trudeau introduced a Carbon tax on carbon emissions, but some Provincial Premiers are upset at the Federal Government for imposing this tax on Canadians without consultation with the Provinces. Ontario’s new ‘Cap and Trade’ legislation has serious financial consequences for Canadian oil refineries. The Sarnia Journal (October 13, 2016) claims that the carbon tax has serious implications for Sarnia because one quarter of the largest producers of greenhouse gas (GHG) emissions in Ontario are in Sarnia-Lambton. Under the legislation, companies that emit more than 25,000 tons of greenhouse gases annually must participate in the cap and trade program. Heavy emitters will be given many credits each year. After 50,000 tons however, they will be required to purchase more credits; ‘the Shell refinery in Corunna, for example, currently

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45

Martin, Heidegger, M. The Question of Technology and Other Essays. Translated by William Lovitt. (New York: Harper Torchbooks, 1977). Rachel, Carson, Silent Spring, (Boston: Houghton Miffin, 1962).

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produces about 170,000 tons of GHG yearly”. The impact on local industry would be devastating. If Ontario set the initial price at $ 18.00 per carbon credit, as some have suggested, it would cost the Shell refinery several million dollars in additional operating costs. If the price is set at $ 50.00 per credit after the first year and the first compliance period ends in 2020, the impact on Sarnia-Lambton industry would be devastating. One of the problems is that these companies must compete against jurisdictions that may not have cap and trade in place. This economic reality is one of the biggest obstacles facing politicians as they seek to legislate laws to reduce GHG emissions. Nothing is free! Perhaps Trudeau acted unilaterally on this matter because of the urgency of the problem and the Premiers’ inability to reach consensus on how to solve the problem of global warming. Some provinces are more dependent on the revenue generated by fossil fuels than others. The effort to reduce unemployment is noteworthy but at what cost? In our day, economic productivity ranks highly on the altar of success irrespective of the negative consequences on the planet and human development. Unfortunately, health care bows to the same economic gods of profit before quality of life. The first step is to raise awareness that a problem exists.

Thematic Contrast Issues This set of tools is my adaption of an undergraduate STS core course at Penn State University and is cited with permission from Stephen H. Cutcliffe (1993).46 Cutcliffe is the editor of the STS History, Science, Technology & Society Newsletter at Penn State University. Grateful thanks for permission to use the material. The ‘thematic contrasts’ provide an essential STS Ge-Stell (to borrow a term from Heidegger) that is maintained throughout this analysis. In my adaptation of the STS method, the attitude expressed in the thematic contrasts prepares the way towards informed and responsible action. The view of medicine as sacred science, therefore, is balanced between two cost-benefit extremes ranging from ‘idiotship, reductionism, and ignorance’, to ‘citizenship, holism, and comprehension’. The noble right path follows on the ethical truth of doing what is right so

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S. H. Cutcliffe, Editor. Pennsylvania State University STS History. Science, Technology & Society Newsletter. Carl Mitcham and Richard Deitrich, Guest Editors. Nos. 95–96. April/June issue, 1993, 19–20.

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that medicine is neither exclusively a focus on disease, or a focus on holism, but a techne imposed on the two that addresses the human condition in all its health care manifestations; Thematic contrast one: Citizenship versus “Idiotship” The word “idiot” derives from the Greek idiotes, persons who did not hold public office or take part in public life, and were therefore ignorant of current affairs. If people refuse to become critically conscious, if they refuse to investigate daily events in order to influence the roles of science and technology, relating such inquiries to their own lives and the lives of others, then they will tend to condone the way things are. Without critical inquiry, “idiots” take the current situation for granted, and cannot discern what in it is a law of nature and what is imposed by powerful people or groups wishing to gain benefits while shifting the related harm to others. An “idiotic” stance makes responsible social action impossible. STS education opposes this sort of “idiocy,” and aims to promote those inquiries that free the citizens of a liberal democracy to participate in public business and exercise responsible action. DEMOCRATIC SOCIETY DEMANDS RESPONSIBLE SOCIAL ACTION.47

Application: the impersonal character of medical technology treats patients as “idiots” and as “disease,” denying them the right to participate in their own health recovery as fully engaged persons. Thematic contrast two: “Holism versus Reductionism” Reductionism limits experience or reality to one or more of its parts, failing to recognize the complexity of the whole. By contrast, holism points toward large frameworks of understanding and multiple interconnections among events. It implies that all events are in some way interrelated, and that THE WHOLE IS GREATER THAN THE SUM OF ITS PARTS. Such concepts as systems analysis, feedback, and self-regulation contribute to achieving a holistic view. Holism does not reject the findings of a reductionist analysis, such as the analysis of a chemical compound into its constituent elements. Indeed, it takes them to be so many more parts to be related within a comprehensive framework. But STS does regard as incomplete inquiries that fail to relate isolated parts to the larger whole. The holistic perspective urges us to work back and forth between comprehensive frameworks and detailed analyses, from unity to diversity—and back again to unity.48

Application: the identification of personhood with human nature is reductionist since it ignores all the relations that individuate persons. We are born human but become persons through our choice of actions (chapter 2).

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Ibid., 19. Ibid., 19.

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Thematic contrast three: “Comprehension versus Ignorance” Comprehension occurs when knowledge is holistic—and judged within the framework of a wide range of values. This theme rests on Synthesis and the principle that there is neither VALUE-FREE KNOWLEDGE NOR KNOWLEDGE-FREE VALUE. The mind always synthesizes knowledge and value, regardless of how “reduced” the knowledge or how limited the value range. Scientific (experimental) knowledge is reduced and based on a narrow range of values, because of the method used to secure it. Non-scientific (experiential) knowledge—i.e., cultural, historical, relational, religious, and traditional knowledge—is more holistic, and includes a wider range of value concerns. The reducing of knowledge by science, and the accompanied narrowing of the value-range, results in limited comprehension.49

Application: medicine and ethics differ in scope and method. Medicine begins its work inductively with the data of observation to express its findings in deductive mathematical language through the instrumentation of medical technology. Its verification of the data about disease takes place in the imagination. Medical ethics’ focus on disease is a branch of environmental ethics and as such begins inductively but moves towards deduction and normative ethics as to its natural term for only in this way can it express the spiritual, always mysterious, and sometimes religious views of the person. Its verification of the data about the patient takes place in the lived life of a real person. Medical ethic’s focus on the whole person (sacred science) is a branch of metaphysics. Thematic contrast four: “Benefits versus Costs” BENEFITS (those things that are good for the well-being of some person or group) versus COSTS (those things which are bad for the well-being of a person or group). With this contrast STS emphasizes the idea of Tradeoffs, and argues that THERE IS NO FREE LUNCH. Such a principle guides us to look for both the benefits and the costs of technological innovations. With regard to this contrast STS does not want to affirm one and reject the other. Science and technology can never be only beneficial and without costs. No benefit can be had without some cost. But STS analysis proposes to increase comprehension of both benefits and costs, to understand the whole, not just one aspect or another, in order to promote more intelligent democratic citizenship in the scientific-technological society.50

Application: The movement towards the implementation of personalized medicine disrupts the doctor-patient contractual model, but it avoids the harm that arises out of treating patient as an atomistic, organic, individual.

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Ibid., 20. Ibid., 20.

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The doctor has a duty of “stewardship” to treat the important needs of persons individually and collectively. We are not generally inclined to associate technological developments with tradeoffs, so this thematic contrast increases our comprehension of benefits and costs to promote more intelligent democratic healthcare in the scientific-technological society.

Bioethics The medicine of the future stands in greatest need of dialogical conversation at all STS levels because it threatens sacred medicine by raising the doctor patient relationship to new dizzying and unreachable heights. This section examines some of the ethical issues that arise in bioethics.51 Medical ethics is a subset of bioethics that deals with doctor patient relationships and medical codes of ethics.52 The main areas of concern include genetic screening and engineering and the development of codes of ethics for the protection of human DNA and life before birth. The study illustrates the need to focus on patient relations and the role of community groups in generating medical knowledge and informed and responsible social action to that end. While the Canadian federal government and the TriCouncil policy on research involving human subjects play a critical role in the protection of human rights, research in genetic engineering invariably moves faster than the ethics. The Canadian Research Ethics Board recognizes the need to minimize harm when doing research on human subjects, “and to ensure that these harms are proportionate to the benefits that might be expected from the knowledge gained from the study.”53 The concern is that the cultural, societal, and economic demand for the development of engineered babies will run ahead of the ethical consequences of the decision to proceed. However, the closer we come to determining the genetic pairing associated with a disease, the closer we are to eliminating the disease before it appears. How can we not make the effort to alleviate the pain

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53

An excellent source of living data is found at http://www.nuffieldbioethics.org See John R. Williams, Christian Perspectives on Bioethics. Amazon.ca: Novalis, 1997. This book is an excellent source on bioethics and other issues in medical technology. 143 pages. Tri-Council Policy Statement: Ethical Conduct for research Involving Human Subjects. http://www.cbu.ca/wp-content/uploads/2015/07 accessed 16 February 2018.

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and suffering by searching for cures to diseases such as cancer, Alzheimer’s, and Parkinson’s? The fact that in our day we have produced a secular image of human nature is cause for concern, however. There are those who do not believe in the existence of God or that human beings are sacred. But the deontological respect we assign to the dignity of the human person is categorical. Persons are treated as ends in themselves. The distinction between rearranging human nature and changing it is critical because the latter treats the human person as a means rather than an end, which is not deontological ethics. The STS toolbox gives us the tools to raise the level of awareness about this problem and produce an informed and responsible social action platform that our trusted leaders can use to govern us. An STS action always begins with a brief history of the problem. Following is a brief history of genetic screening; 1866: Mendel makes the point that not all things are learned … genetics plays a role in learning, that is, information is passed on biologically to children. 1900–1910: The term gene came into accepted use. Sutton found that genes are located on our chromosomes. 1944: Avery makes the discovery that genes are made up of DNA (DeoxyriboNucleic Acid) 1953: Watson and Crick publish a paper in Nature in which they propose that the structure of the DNA can be represented as being a double helix ladder (a two-coil structure). This view is accepted today. 1971: Cohen and Boyer develop the initial technique for recomittant DNA technology. This is the view that that you can take genes from two different living sources and combine them into a hybrid DNA molecule that now carries living DNA from two different sources. 1977: the cloning of Dolly the sheep. Keep in mind that the successful clone happened after something in the order of 227 missed trials resulting in defective sheep. But genetic science ought not ignore the possible harm generated by negative outcomes 1990: the human genome project to map the whole of the human genetic code begins. Multi research labs, government labs and private entrepreneurs map the human genome.

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2000.: J. Craig Venter laboratories is first to complete mapping the human genome. Each human chromosome is made up of 100,000 distinct genes. Each human has 23 chromosomes. The permutations and combination possibilities of genetic configurations are in the millions, but as we begin to narrow the associations linked to cancer and other diseases, at some point, for-profit companies will own patents on genetic combinations and the elimination of diseases. Private labs will have the ability to control the quality of living organisms. Those who can afford the cost of treatment will be free of cancer and other terrible diseases. The poor will be marginalized; will a new class distinction emerge between the disease class and the disease-free class? .

A well-balanced approach to social action examines the issues from the point of view of systems: culture, society, economics, politics and law, resources, and ethics, as well as themes and thematic contrasts. Once the relevant data is collected, we look to academic and community resources to formulate a cost benefit risk analysis of the proposed action to the proposal of an informed and responsible proactive response to the possible threat genetic screening and/or genetic engineering brings to human nature and human dignity. What are the attitudes, values and beliefs of people towards genetic screening? Will some mechanism be in place to offer counselling to individuals with a perceived genetic deficiency? How will insurance corporations and future employers treat genetically disadvantaged individuals? Where is the information stored, for how long, and who has access to it? How are confidentiality and anonymity assured? Will some individuals be stigmatized? Who own genetic information and how is free and informed consent obtained from a genetic sequence? Will pharmaceutical companies have patents on life and therefore an individual’s quality of life, and will the legal system decide who lives and who dies? The societal aspect of an STS analysis includes family, friends, and community. How are they consulted? What are the implications for societal relations? Will entire family and community relations be stigmatized if some citizens have defective or insufficient genetic combinations required for good physical and mental health? The process of mapping the human genome opens the door to genetic engineering. But who makes the decisions about the nature and quality of human life. Is a disease-free baby a better human being? Is being short or bald or having the risk-taking gene an imperfection or is it part of the human condition? Who controls the use of human tissue? Do we have the right to engineer clones for transplant purposes? Can a clone be kept is storage for spare body parts? Are they human or robots? How many cloning attempts are required to produce a successful clone—500 or a thousand

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and what becomes of unsuccessful clones? Are they somewhat human? Can they be sold for profit? Once we become more successful at deciphering all the genetic combinations of disease and have completed the task of detailing the desirable characteristics of a perfect human being, the next question is should we engineer perfect babies? The distinction between somatic and germline genetic engineering is critical because it hovers around the distinction between changing human nature and rearranging human nature. Genetic engineering to correct a defect is good science but genetic engineering to enhance a human characteristic is questionable (in the same way that doping is unacceptable in athletic competition.) Germline engineering is banned because it causes a change in reproductive cells so that the defect is not passed on to an offspring. The process is unethical because it causes a change in what it means to be a human being. It could change the future as we select parts for the next generation from a genomic catalogue. Will that be cash or charge, and yes, we deliver. We face similar issues in the production of genetically modified organisms. In the process of making plants resistant to herbicide spraying, we remove millions of years of evolution and become hostages to the pharmaceutical companies that own the patents on organic life. They decide what lives and what dies, and what we eat. Genetic screening technology presents many opportunities as well as risks. Medicine of the future will no doubt have everyone’s genome on file. The technician will be able to look at your genetic profile and determine what sorts of diseases you might experience in life as well as what your character traits might be. For instance, you might be identified as a risk taker, or you might be found to have a gene that makes you prone to substance dependency such as alcoholism, or you might be found to be at risk for heart disease. The medicine of the future might be able to prevent diseases before they occur. This sounds like a good thing. What are the risks and what are the costs cost of the new medical technology? We need to balance beneficence and nonmaleficence. But of equal importance, is how it affects the human condition. Being human, it seems to me, is a necessary condition of being a person. Being a person, on the other hand, is a sufficient condition for becoming increasingly personal. The critical question, it seems to me, is what direction medicine of the future takes?

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Responsible Social Action A social action refers to an informed and responsible action initiated by citizens of a local community as they seek to offset a threat to their way of life. The fourth thematic contrast ‘benefits versus costs’ reminds us that a proposed social action carries a downside as well as a gain. Therefore, a thoroughgoing risk evaluation and management component is essential to effective social action. The pioneering work of Shrader-Frechette on risk analysis (Risk and Rationality, 1991)54 contains some useful information we need to examine before proceeding with a social action. The three stages of risk assessment are risk identification, risk estimation, and risk evaluation. All parties need to agree on the nature and scope of a problem before they can find a solution to the problem. The solution to a possible risk assessment involves give and take and is usually found in a middle position between insiders and potential victims. Everyone wins something but there is no free lunch. Risk assessment is more than a quantitative measurement of cost-benefit, however. It involves cultural, sociological, economic, political, and ethically weighted factors. The belief that ‘bigger is better’, is not necessarily right, especially if the proposed action negatively affects a community’s quality of life. The attitude, values and beliefs of a people matter. Shrader-Frechette suggests we rank expert opinion based on past successful predictions. Citizens must have informed consent. Further we need to guarantee legal rights to due process and compensation for all unavoidable risks and harms. When results are not certain, we ought to act to avoid the worst possible case. Governments need to fund assessments processes and insure that all sides of a controversy have legal representation. The negotiations should be monitored by a group of experts and ordinary citizens with no conflict of interest in the matter under consideration. It seems possible and even necessary to distinguish between two degrees of social action, one being ‘soft social action’ and the other ‘hard core social action.’ The kind of social action advocated in medicine belongs to the former rather than the latter because of the seamless web between resources available in medical programs and in the user community. Everyone is on board to deliver the best health care possible. The social action required here is one in which doctors become more aware of their

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Karen, S., Shrader-Frechette, Risk and Rationality, (California: University of California Press, 1991).

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patients’ relations and connectedness to community and to the resources that exist or could be developed in that community. Hard core social action, on the other hand involves a process of developing strategies to mobilize people, often in the face of strong resistance. The challenge is to move the people forward by developing multiple levels of engagement to attract supporters. The attraction to a cause depends on emotional appeal. Stakeholders band together because they have a vested interest in bringing about a change. The processes are often challenging (MacKay, 2017); “Asserting popular control over political decision making is of critical importance, as regardless of the organizing we do, some of the processes already set in motion—like climate change, water depletion, and population growth—will invariably present massive challenges to societies worldwide.”55 In the past 25 years, my STS students have conducted hundreds of “soft social action” initiatives in their local communities. Students often tell me that they continue to use their “STS wheel” (a classroom cardboard cutout of the STS tools) in other courses and programs of study such as the B.Ed. The value of STS tools in producing informed social action cannot be overstated. For instance, the use of strikes and product boycotts needs to be governed by responsible and informed citizenship. A great deal of harm is caused to a focus area by irresponsible social action. The STS toolbox provides a useful way to bridge the gap between the gap between the impersonal character of medical technology and the dignity of the person. If philosophy is to successfully mediate the dispute between these two extremes it must find a middle ground between the present medical curriculum and the qualitative programs that exist in our communities. Perhaps this feat can be accomplished through the introduction of fresh courses on spirituality and health in the medical curricula. While such courses currently exist in 75% of medical schools (2014),56 it seems to me that the focus should shift from equating spirituality with the compassionate nature of the health care team towards the sorts of compassionate relations that characterized the patient’s lived life. The challenge that lies ahead is the development and implementation of this model. The following instructions will move us towards this objective;

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56

Kevin Mackay, Radical Transformation. Oligarchy, Collapse, and the Crisis of Civilization, (Toronto: Between the Lines, 2017), 215. C. M. Puchalski, B. Blatt, M. Kogan, A. Butler, Spirituality and Health: The Development of a Field. Academic Medicine, 2014, Vol. 89. No. 1. 11.

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Characteristics of Successful Social Action The primary goal of social action is the development of programs in cooperation with the healthcare community for the benefit of its citizens. These programs are developed as required. We need clarity about what needs to be changed in the current medical model. First, we need to move beyond the disease model of medicine. The patient is not the disease. Second, we need to move beyond the impersonal character of medical technology. Third, we need to move beyond the atomistic representation of the patient. A patient is a person in relationships at three basic levels of operation. The organic face of the patient presents as disease. Thus, medical technology retains its impersonal disease centered perspective of the patient, but also moves beyond this representation. The patient is a being in relationships with other persons, family, friends, community, and the environment. Medicine needs to develop successful strategies to incorporate the relational character of patients into the treatment model. The patient has an interior life and is in relationship with the personal and collective data of psyche. The patient’s interior life is the source of ethical theories. It provides legitimacy to the deontological claims of the Oath of Hippocrates and to the medical codes of ethics. The patient’s presence demands the highest respect and reverence for the sanctity of life. The doctor patient spirituality exists in dialogical relationship as the search for sacred meaning incorporates all dimensions of the doctor patient code of ethics. The doctor is not an atomistic individual but exists in relationship with other doctors, specialists, pharmacists, social workers, church and community belief system as well as with the patient. The doctor’s right to be treated with dignity is as essential to the practice of medicine as is the treatment of the patient as an end in se rather than a means to a selfish paternalistic, disease laden and atomistic isolated view of the patient or doctor as bacteria. In my opinion, the strategy that will be most successful to accomplish this goal is at the educational level of the medical curriculum where a paradigm shift takes place in the doctor patient relationship from the atomistic to the relational view of the patient. That shift empowered by an STS Toolbox incorporates all the relations that individuate persons and thereby includes the spiritual and ethical dimensions of medicine. This shift is not problematic because no emotional opposition exists between the existing model of medicine and the proposed changes. The goal of medicine to treat

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patients with dignity and respect is safeguarded because it raises the doctor patient model of medicine beyond the impersonal characterization of medical technology by including a view of the patient that safeguards the distinction between being human and being truly personal. The strategy to implement this change lies in the discovery of pockets of support in the user community as well as in the medical community itself. People are mobilized by the fact that an operational model of medicine is made even better than before because the ways to make it better are put into place. Strategically it seems that the best chance of success exists by starting the conversion at the local municipal level where doctor and patient both live and work. The fact that a better medical system is seen to be in place at the municipal level will lead to its implementation at the provincial, national, and international levels. In the same way that descriptive ethics, the practice of seeing how ethical principles apply in a local community gives way to normative ethics and the application of these ethical principles to the whole of the medical community. The transformative role of social action in that regard leads to solidarity building between communities. The medical mindset shifts from the patient as atomistic entity to a view of the patient as living in a community of family, friends and of being supported by that community. The patient learns to depend on community health care programs for support and the development of a healthy lifestyle. The doctor learns to refer a patient to community support systems as a way of implementing the vision of the patient as the outcome of several sacred streams of individuating relationships. Change is possible, but it is not always easy. The goal of the social action is to develop a community-based resource to meet the holistic spiritual, and relational needs of a patient or doctor when no such resource is in place, or to augment existing resources. The tools to accomplish successful social action are implemented by community advocacy groups that can feed directly into the medical curriculum. The STS method is comprehensive because it incorporates all the tools needed to do the job whether in the form of quantitative changes and responsible risk benefit analyses, or qualitative changes. The doctor’s office is also a place where a patient needs to feel comfortable about bringing religion into the health care picture. Dialogic medicine is an opportunity for doctor and patient to discuss their most sacred beliefs about God, abortion, euthanasia, assisted suicide and the afterlife state. A Catholic doctor cannot be forced by law to consent to providing

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an abortion for a patient, or to unwittingly participate in an abortion by referring their patients to physicians that do agree with abortion. The principles of medical ethics provide a safe house for a doctor’s religious beliefs, but unfortunately the Canadian law on abortion, euthanasia and assisted suicide force some physicians to choose between their moral beliefs and work. My challenge to medical students is to use the STS Toolbox to reflect on the condition of medicine in their community and to celebrate what works while developing social action mechanisms to raise the medical bar towards the pursuit of holistic, sacred medicine. I have developed four practical variables to measure the success of social action activity: (1) delineation of the focus area, (2) the informed quality of the research, (3) overall characteristics of the project, and (4) results; Focus: How focused is the project? Are problem area and proposed solution stated clearly? Are goals realistic? What steps will bring about the intended outcome? Does the study include an historical perspective of medicine? Have you fleshed out the doctorpatient constructivist perspective (positive or negative bias)? Informed: How informed is the group project? Does the project contain evidence of solid academic research and the availability of medical knowledge from community programs? Are community relations expressed clearly? Have all the consequences of the proposed problem on community been considered? Does the project provide evidence that all aspects of the focus area have been examined (panels, systems, themes, thematic contrasts, history, and ethics)? Characteristics: The overall characteristic of the group project. Are the project goals stated clearly in the presentation? Is there evidence of teamwork? Do you use posters, handouts, video, e-mails, letters, and other communication aids in your presentation? Does the proposed action fit the focus? Is the proposed environment adequate for the delivery of the proposed objective? Do you have research ethics committee approval to proceed with the proposed social action? Have you completed the TCPS 2: Core? Is your questionnaire or survey (if any) approved? Is anyone in

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your community at-risk because of your group project? Do you provide clear evidence that everyone’s rights are respected?

Results Are results clear? Do they provide evidence of meeting the social action objective? What is learned from the proposed interaction between societal interactions, community programs, and the medical program? Are mechanisms in place to ensure the sustained viability of the project? Is the project well received? Did it generate feedback from anyone in the medical community? Are budget managers and politicians prepared to act on its recommendations? Do your recommendations include mechanisms to promote the relational character of persons? Is the overall project a success or a failure? What can we learn from the project? What, if anything, should we change in a follow-up study?

Conclusion The claim that the doctor patient model is negotiated through a compassionate concern for the patient’s disease is not enough in itself. While these are hallmarks of spirituality, some plumbers and carpenters are also spiritual beings, but I would not entrust health care to them. Medicine must move beyond the narrow boundary of the patient as disease to incorporate a patient’s personalized history of community relations into the health care model through a dialogical method of discourse. These personal relations are expressed in systems such as culture, politics, economics, society, and ethics, themes and thematic contrasts. Our relations reveal that what we are as persons-in-the-making is more than the sum of our biological narratives. We can through informed and responsible social action incorporate this fact into the medical mind-set by blending a sensitivity for societal relations into the medical curriculum. Above all we need to look at patients as individuals-at-large. This is possible through a detailed analysis of all the relations that individuate each person. This view is no more difficult to imagine than the view of the patient as seen through the eye of the atomistic disease model. The second chapter examines the three main types of relations that characterize persons, and therefore medical care. This model includes a questionnaire designed to assess the individual health care profile of individual patients. This, I think, provides the missing piece required to generate an authentic spirituality and healthcare profile that can

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be incorporated into the medical curricula. The next chapter opens with a phenomenological analysis of religious faith because faith occupies a central place in the life of most patients. It forms part of the constructivist perspective we bring to the doctor-patient relationship. Further, the spiritual dimension of being human reveals that most people think and hope that death is not the end of personal existence. Religion thrives on the reality of this belief, as does sacred medicine. The nature of the distinction between being human and being a person is examined in the next chapter while the spiritual character of being persons is examined in chapter three. The fourth chapter contains a discussion of ethical principles while chapter five studies the metaphysical foundation of the deontological character of the Oath of Hippocrates. It provides an answer to the question concerning the origin of the sanctity of medicine by rooting it in the sacred ground of creation.

Chapter Two: Persons Exist in Relationships “In light of current pressures on medicine to become more personalized, using a relational understanding of personhood to shape policies and practices is a much-needed endeavor.” (Barbara Prainsack, October 2017)57 “Life is a journey. When we stop, things don’t go right.” (Pope Francis)

Overview The analysis of medicine as sacred science depends in part on a constructivist perspective and what I expect from medicine. Hopefully, others would have similar beliefs and expectations. The first is that I (we) bring our sacred beliefs such as religious faith to the table. I seek to justify my beliefs through a phenomenological analysis of religious faith. Second, I (we) bring a certain view of human nature or more precisely what it means to be a person to that same table. I will use deductive reasoning to justify my view of human nature. Then, I will have argued that medicine is sacred if it meets the needs of the human condition as described herein. What counts as historical evidence? Do we have reason to trust the evidence that Paul gives us in 1 Corinthian 15 on the bodily resurrection of Jesus Christ? Paul has three main things going for him. First, he is a convert to Christianity. Second, Paul is a scholar. Third, he provides evidence for the Empty Tomb narrative from the first-hand eye witness accounts of Peter and James. Three years after Paul’s Damascus road experience he went to Jerusalem to visit Cephas (Peter) to investigate matters concerning the resurrection of Christ. He stayed with him 15 days (Galatians 1:18) and met with the apostle James. What Paul says in 1 Corinthians 15 is based on their first-hand testimony of what they saw. Christ first appeared to Peter and the Apostles, and to ‘the 500 hundred’ and Paul says; ‘lastly to me”. Paul puts himself under oath before God that what he says

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Barbara, Prainsack, The ‘We’ in the ‘Me’. Solidarity and health care in the era of personalized medicine. Sage Journal of Science, Technology, and Human Affairs, 2, 2017.

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is true (Galatians 1:20). Gary Habermas, Distinguished Professor of Apologetics and Philosophy at Liberty University, says that Paul’s Letter to the Corinthians (and Letter to the Galatians) passes the acid test of reliability for most New Testament scholars. The belief in the bodily resurrection of Christ is the prominent view in today’s academy. Habermas says that by normal historical methods of analysis the empty tomb Gospel is true and should be considered biography.58 In my own research on the characteristics of the risen Christ as reported by Mary Magdalene, the Apostles, and the 500, I found that the bodily Christ exhibited a duality of natures as living and other worldly; Christ is somewhat the same and somewhat different; “We (Mary Magdalene and the disciples on the road to Damascus) do not recognize his transfigured body but we know him when he calls us by name or performs miracles. His wounds remain, but they are different (they do not fester). He breaks bread which no ghost can do but he also vanishes from sight, which no physical being can do. Christ appears and vanishes at will. He can be touched by Thomas but not by Mary Magdalene. He is recognized and yet is unrecognizable. He is changed but he is the same… “.59 This account of life after death introduces the possibility of our own afterlife state of existence—a question that continues to fascinate me 50 years after I introduced it to my students in courses on the philosophy and theology of death and dying at Xavier College (now Cape Breton University). I wrote Persons and Immortality (1999) with one problem in mind, namely how to safeguard a person’s identity in the afterlife state, given the decomposition of the body at death? I defended the view of personal immortality and the continuity of a person’s identity in the afterlife state by arguing that the relations that individuate us in this life accompany us into the next life. I justified the belief in the existence of an afterlife state based on the incorporeal nature of mind. If the human mind is not composed of parts, and if human death is the reduction of the body to parts, then the

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Gary, Habermas, The historical evidence for the resurrection of Christ. The Veritas Forum. November 8, 2012. http://www.veritas.org. See also http://www.garyhabermas.com. Accessed 1 April, 2018. Habermass claims that Paul gave his evidence one year after the Cross. Ken, Bryson, What we learn from the resurrection of Christ. Art and Realism (Sztuka i realism): (Festschrift) Commemorative Book, Jubilee Birthday and Scientific Work of Professor Henry Kieresia at KUL. Edited by Fr. T. Duma, A. Maryniarczyk SDB, and P. Sulenta. (Lublin: Polish Society of St. Thomas Aquinas and the Faculty of Philosophy—Catholic University of Lublin, 2014), 771–786.

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mind must survive the death of the body. But the continued condition of immortality is not self-dependent, that is personal immortality is a sufficient condition of being present in the afterlife state but not a necessary condition of immortality. The mind does not contain the reason why it exists rather than not exist. The mind’s existence is not the necessary cause of its immortality. The ongoing existence of a finite entity depends on a necessary condition beyond itself, a condition that exists in the order of existence rather than time or duration. The belief depends on religious faith and the existence of ‘eternity time’ rather than eternal time. Faith is the religious experience of God but is not without logical foundation. I have faith that God is the necessary condition of the existence of the world and all things contained in it. I can adduce arguments for the existence of God and can draw distinctions between the order of time and the order of existence, but at some point, the mind takes a leap of faith to move beyond the realm of personal experience into the existence of a transcendent God as a requirement to make sense of a finite being’s ongoing personal immortality. I have faith in the existence of a loving God, but I need to justify my belief in the validity of the argument from faith. The STS Toolbox leads me to think that my faith comes from my culture. Clearly the faith I have in the existence of a loving God underscores my argument for the ongoing existence of persons in the afterlife state. I developed the philosophy of personal immortality in my Persons and Immortality book to justify my faith in the belief that the afterlife state is an ongoing endless eternal movement towards the loving face of God. In this case the solution to the problem was at hand before the problem arose. It was left unexamined. In this chapter I propose to correct that deficiency by conducting a phenomenological analysis of faith before moving on to discuss the relational nature of persons as sacred beings. My faith assures me that God calls us into eternal life with God. And I am not special. Therefore, I go so far as to say that this same faith assures me that all persons are called to be with the divine in eternal life (unending existence). While I am not prepared to raise Descartes’s methodical doubt anew, because his doubt is untenable, I am wondering if my faith is misleading me; am I asleep thinking I am awake at the keyboard, do my senses deceive me, is some evil genius employing his/her energies towards deceiving me and all (mistaken idiots) who believe in the existence of God and the af-

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terlife state? In STS analysis, an idiot is an individual that does not examine his/her presuppositions. I will examine my presuppositions and while the sceptic might accuse me of being ignorant, I will not be idiotic.

A phenomenological analysis of religious faith The purpose of this section is to argue that the possibility of the deontological Oath of Hippocrates on which medicine founds its ethical belief in the sanctity of human life is based on the existence of God (Creator, Allah, The All) and the presence of at least one absolute truth in history, namely the objective existence of the world. The Oath of Hippocrates collapses without a solid foundation beyond the soils of cultural relativity. As this analysis moves us into the realm of religious faith, it seems necessary to first discuss the matter from the point of view of phenomenology. The phenomenological method as developed by Edmund Husserl serves to examine all assumptions. The application of the method to the examination of religious assumptions is useful because it serves to describe the elements of religious faith expressed in the consciousness of God’s existence. The term ‘intentionality’ that was established by Franz Brentano (1838– 1917) was not original to him. Brentano was reared in the tradition of scholastic philosophy and his doctrine of the intentionality of human acts goes back through Aquinas to Aristotle, where it originated.60 Further, I do not agree that Brentano’s decision to model intentionality on the natural science is acceptable (or that Auguste Comte’s stage based description of science is correct). Description is not the only business of science. In fact, it seems possible to draw a parallel between Husserl’s desire to reveal transcendental subjectivity as the a priori source of all objectivity with an excerpt from the gospel of John 14.23–26 and God’s invitation to enter into subjective relationship; “Judas (not Iscariot) said to him, ‘Lord how is it that you will reveal yourself to us, and not to the world?” Jesus answers that he does not appear to us as an objective phenomenon on a Broadway stage but through the subjective language of the heart; “Those who love me will keep my word, and my Father will love them, and we will come to them and make our home with them.” Thus, we need look not to science but to the recesses of subjectivity to find God. It would be theodicy at a bargain to claim that we find the whole of the divine presence

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See Mortimer, Adler, The Difference of Man and the Difference It Makes. (New York: Holt, Rinehart and Winston, 1967), 215.

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within psyche in an instant, but Husserl likewise questioned himself on the possibility of the reduction and phenomenology at a bargain. The best we can do as we describe the elements of consciousness is make progress towards that goal. Husserl’s ideal is to move towards the personal contents of the correlates of consciousness through a series of steps. Only then do we purify the objective and universal contents of human understanding. The word phenomenology is from phenomena meaning that which appears or presents itself to the senses and to the intellect. Brentano focused on sense and description while Aristotle and Aquinas move beyond the intentionality of perception to include the intentionality of intellectual knowledge. John Deely (1968) recognizes that “(Brentano) fails to distinguish levels or radical grades of intentional existence.”61 Religious faith cannot be dissolved in a solvent, precipitated or centrifuged in any intelligible way. The essence of religious faith lies in the intentionality of consciousness rather than in the phenomenology of perception. Phenomenology is a holistic, organized, methodological study of what appears to the intellect through perception to arrive at an insight into the nature of the manifest, namely of that which shows itself to consciousness. It seeks to reveal something about the nature of the thing-in-itself, that is the phenomena as it exists in its immaterial form in the intellect. The intentional is immaterial and functions as the means to knowledge, not as the term of knowledge. This is based on the distinction between the concept as the process of knowledge and the idea as the term or intended end of knowledge. Knowledge arises through the union of forms; the union between the form of the object known and the form of the knower. Immateriality or freedom from the limiting conditions of matter is a necessary condition of the process. It cannot take place without it. The immaterial that exists in the object of knowledge is different from the immaterial that exists in consciousness. In the object it exists in relation to matter and form while the union of forms that exists in consciousness exists because of the plasticity or transparency of matter (unconcealment of being). The immaterial union of forms takes place as the passive intellect allows the emergence of the unconcealed in the stream of consciousness. The knower becomes many forms but exists as one form in matter as mind and body—an instance of act and potency.

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John, Deely, The Immateriality of the Intentional as Such. The New Scholasticism, XL11, 2, Spring 1968.

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The phenomenological method is descriptive and is free from all unexamined presuppositions. This is not to say that phenomenology calls all things into doubt but rather that it seeks to examine all its assumptions concerning the noetic dialogue between mind and things. Husserl questions himself repeatedly on the possibility of gaining a knowledge of the thing-in-itself. Is the reduction possible; can we see the world through the eye of a five-year old child before the mind starts to flap over the being of things and lodge constructivist meaning in the thing in itself that do not belong to it? The first step is to recognize that consciousness and its object form a unit. I am not outside looking at myself looking at things, but I am that very seeing being seeking to know the thing. Since consciousness and its object form a unit it becomes clear that nothing exists in-itself as such in the second movement of reason (the idea), but only in the conceptual union. The connection with things can be real or imaginary; the point is that there is no cogito without a cogitate. Thus, my phenomenological description of faith is filtered through the lenses of a being with faith in this analysis although it exists in its conceptual modality before analysis begins. We need to filter the contents of consciousness to discern the concept of things from the idea of things. The thing in-itself refers neither to the existence of things outside consciousness nor to the existence of consciousness walled off from things but to a mode of existence superimposed upon the two in such a way as to make the encounter possible. I think that Martin Heidegger sees the problem that way and that his return to Sein from Dasein continues to carry traces of the Dasein in its folds. In that light, consciousness is the noetic encounter from the point of view of the subjective side of the dialogue. But the thing in-itself is the objective side of the noetic correlate. I will therefore not raise the absurd question inspired by some British Empiricists, notably John Locke and George Berkeley, ‘what do things look like when no one is looking at them’ because the noetic correlates do not take a leave of absence. My question, my focus is on seeing what the subjective correlate of consciousness brings to the objective correlate of knowledge. I take comfort in Douglass-Klotz’s translation of the Aramaic text of the Lord’s prayer.62 The translation adds fresh depths to the King James English translation. For instance, ‘bread’ signifies spiritual insight as well

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Neil, Douglas-Klotz, (1990). Prayers of the Cosmos. (New York, NY: Harper & Row Publishers. Inc. 1990)

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as food, while ‘and lead us not into temptation’ morphs into the powerful ‘Don’t let surface things delude us’.63 Christ must be a phenomenologist. The translation is made more vivid through the inclusion of accompanying body prayers. Hopefully the phenomenological method will scape bare the objective correlate of consciousness to uncover what layers of meaning the mind brings to the nature of religious faith before additional harm is done to the fabric of faith. The encounter between the noetic correlates must be harmonious, seamless, and mirror like so that consciousness sees itself in the analysis of faith as the relational correlate of the encounter. To accomplish this objective, the first step is to describe the contents of the subjective and objective correlates of consciousness. We begin with the objective correlate as the focal point of the possibility of objective, verifiable, knowledge. The division between objective and subjective correlates is artificial because the correlates of knowledge are a unit. The objective correlate, as conceived by consciousness is moderated by the unconcealment of things (Heidegger’s Unverborgenheit). Reality shows itself to consciousness in its purity. It sends the subjective correlate of consciousness on a mission to discover truth. However, we will see that the subjective correlate is laced with an inherent structure as well as a constructivist bias towards things. The phenomenological reduction, to add my interpretation to Moustakas’s phenomenology, recognizes the existence of multi layers of intelligibility in being’s unconcealment. The subjective correlate brings its agenda to those layers of possible intelligibilities. The unconcealment of religious faith first presents itself as a gift to reason. The gift manifests itself in two main ways. The first and most basic gift of unconcealment is from the point of view of the primacy of what I shall call esse or the existence of things. The primacy is such that what the subjective correlate identifies as being the essence of things might in fact be reducible to the primacy of existence. What a thing is depends on its existence or to be as precise as possible, to where its existence stops. The existence of the objective correlate outside the subjective correlate of knowledge is indemonstrable. The existence of things demands spontaneous assent. The attempt to proceed otherwise than through the primacy of esse leads to several epistemological paradoxes as discussed in chapter five. The reason for my deferral is that although the primacy of things can

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Ibid., 34–36.

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and does lead to the insight that Creator God must exist, it does so as a truth of reason. In this way, reason is seen to operate hand in hand with religious faith. It should be noted at this point that the choice of religion is relative to the STS systems. The second way faith is a gift is from the point of view of items of religious faith. The subjective correlate of reason is seen to bring a fibrous structure, a way of understanding or of making sense of the world, a spiritual predisposition towards being’s unconcealment. Aristotle opens his treatise on Metaphysics with the exclamation “All men by nature desire to know”.64 This is an innate curiosity or thirst for intelligibility. The subjective correlate is in dialogue with the objective correlate to make sense of being’s unconcealment. Being admits of increasingly comprehensive levels of complexity. Our search for meaning is never satisfied. The subjective correlate appears structured before experience to tirelessly bring its principles of non-contradiction or identity, and of sufficient reason to being’s self-disclosure. Reason expects some measure of success and acts as if the whole of reality was intelligible. The goal of reason is to reduce the whole of reality to increasingly comprehensive identity propositions. But success is partial as the best we can hope for are partial identities. This is because the objective correlate expresses increasingly comprehensive layers of intelligibilities. Each new discovery in medical technology brings partial identities. But the subjective correlate expects that being’s unconcealment will continue to attend herself with some degree of regularity and structure. The work of Emile Meyerson (1859– 1933) into the psychological principles that accompany the history of scientific inductions from their earliest beginnings to their latest developments leaves no doubt about the structure of reason.65 The horizontalization of the ways of reason also reveals that human beings are attracted to the good. Studies on infants as young as three months old show that our attraction to the good is driven by the structure of the human mind. Aquinas says, ‘the good is that which all desire’,66 and gives the name synderesis to this principle of mind. We are structured to do good and avoid evil. The subjective correlate brings this thirst to being’s unconcealment.

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Aristotle Metaphysics. Book 1. Aristotle wrote the work after the Physics. It was left untitled and the early historians gave it the name metaphysics meaning ‘after the physics’. But the meaning of metaphysics has since been used to identify a work that examines the principles and causes upon which the Physics rests. For more details on this structure see my article on Meyerson in the Internet Encyclopedia of Philosophy. St. Thomas Aquinas, Summa Theologica. 1.11:8:1.

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We thirst for good and the existence of a loving God is inherently attractive to us. We are designed to seek God; I think that the existence of a ‘God genome’ explains the perennial addiction to God. This explains medicine’s sacred dimension because the belief in God’s existence appeases our craving for the ultimate meaning of life (chapter 3). It seems possible to put the description of the correlates of human understanding in brackets. First, being’s unconcealment safeguards the objectivity of knowledge. It ensures that what the mind knows in the primary operation of knowledge is the being of things rather than its own mental contents. The concept or conceptual union between the correlates of human understanding provide the means for being’s unconcealment to appear in consciousness before consciousness turns back on itself to become aware of this presence. This ensures that the mind knows being rather than its own mental contents. The presence of the concept or of being’s unconcealment in the subjective correlate of human understanding is followed simultaneously by the production of the idea or something to the likeness of that concept. This is where the structure of the mind comes into play. In other words, the concept is the process or means to knowledge while the idea is the term of knowledge or the actual production of an image of being’s unconcealment. Second, it seems possible to recognize that the structure of human understanding (the subjective correlate of the encounter between consciousness and reality) reveals the natural existence of an insatiable appetite for the intelligibilities of being’s unconcealment within the folds of the subjective correlate. This thirst is driven by the ongoing need to find the ultimate meaning disclosed by being’s unconcealment. The search for the truth of things is open ended. Being is veiled in the garb of contingency as it manifests itself in time and space to consciousness. Each act of human understanding, each breakthrough in medical science and technology is but a payment of rent on the quest to arrive at a full insight into the nature of human beings. The fact that the search for truth is ongoing suggests that the insight found in the truth of being is a profound source of meaning. It would end were it not a source of ongoing comfort to the mind. We are programmed to strive towards the goal of reducing the whole of reality to increasingly comprehensive identity propositions. Being’s unconcealment presents itself as the storehouse of all truth about reality, material and immaterial, sacred and secular, in act and potency. We exhibit a spirituality of imperfection. The thirst of reason to know the whole of reality through being’s unconcealment is comparable to the metaphor of

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seeking to move the Atlantic Ocean with the help of a small cup. While we know that we will never succeed in knowing the whole of reality, we remain convinced that as each cup fills, one less cup of ocean remains in that body of water. We act towards that ultimate end and the ultimate good it promises the intellect. But we attain partial success only and we become aware that only an infinite God as source of ultimate meaning and truth can satisfy our infinite craving for truth. Saint Augustine (354–430) says in The Confessions, “Thou madest us for Thyself, and our heart is restless until it reposes in Thee.”67 Is this claim a matter of faith? If so it stands as a truth supported by the evidence of experience. At birth all humans are attracted to the good and thrive on the invitation of being’s unconcealment to discover the ultimate source of meaning in a being commensurate with infinite meaning. Most persons agree that God is this ultimate source of meaning, although blindness to truth is part of the human condition. This explains the spirituality of imperfection as a movement towards the ultimate source of meaning in God. The natural, innate, desire to do good and avoid evil explains the sacred nature of the Hippocratic Oath. Hippocrates appears to have framed the Oath out of the sacred qualities he found within himself. In our day of ethical relativism, we often appear to be blind to the cravings of our own mind. The decision to always act for the benefit of the sick, to keep the sick free from harm and injustice, and to never deliberately harm anyone is not gleaned in either/or fashion from the subjective correlate of human understanding rather than from being’s unconcealment. The promise to always act on the side of life and to maintain respect for persons is a normative principle, that is, handed down to experience from above and characterized our mode of encounter with the world. The decision to ignore that call is a sickness, that is an absence of a healthy attitude towards creation. We are designed to do good! The search for ultimate meaning of life is generally understood to be spiritual because it can only be satisfied by a transcendent being. The history of philosophy is replete with instances of this sort as Descartes, for instance, introduces the belief in the existence of God, and the fact that God would not deceive us, as a defense of his criterion of truth. Immanuel Kant (1724–1804) goes further by adding the logical deduction that the nature of things in themselves must therefore be

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Saint Aurelius Augustine, The Confessions. 1.1.2, 3–4.

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unknowable. The a priori forms of sensibility make the coherence of sensations possible while the transcendental schemata makes pure forms of understanding possible, notably the synthetic a priori judgements of pure reason. Religious faith appears to trace the roots of its very possibility in those same categories of human understanding. While it seems somewhat arbitrary to table an inventory of phenomenological truths on the arms of the subjective correlates of consciousness it seems possible to suggest that each correlate brings its own inherent structure to the table of insight. Nature brings her unconcealment and preservationist perspective to this table. Nature must be structured for how else would she know to follow the laws of science? Science’s ability to formulate laws that nature follows is because of nature, not science. The formulation of laws is possible because nature is structured. This structure in turn makes possible the fact that nature attends herself with some degree of regularity. The role of induction is to observe the patterns of nature and to mathematize observations into the deductive laws of science. Where does the certainty of religious faith come from? The phenomenological reduction of religious faiths to the data of immediate experience begins with the intuition of being and the awareness of standing in the presence of mystery. I am embedded in the mystery of existence and humbled by the poverty of reason. The existence of the world and all things contained in it are given to me in a theory of direct perception. The insight is at the root of the major world religions. Our cultural differences express the mystery of existence through a process of entering relationship with the Creator. All major religions share a common belief in the existence of God, the attraction to the good, and the belief in the existence of an afterlife state. Cultural, societal, political, and economic interests express these beliefs in the many ways the religious connection is understood: Abraham religions (Judaic, Christian, and Islam) to Hinduism, and Buddhism, though I am not convinced that Buddhism is a religious faith. It appears as an attempt to move out of the subjective correlate of consciousness to become one with the impersonal unconcealment of the All of existence. Hinduism is likewise a similar attempt, though methodologically different from Buddhism, to rejoin the ‘Unmanifest’ of existence. This goal appears to resonate well with the Christian ‘let us not be deceived by the surface appearance of things’. Who is right, what is the right path? In my opinion, all religions are right in as much as they make use of symbols and rituals that reflect the cultural bias or constructivist perspective of the faithful. A

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few days ago, I had the opportunity to discuss religion with a Unitarian Lay Minister. He is legally empowered to marry and bury people. I asked why he identified himself as a ‘lay minister’ rather than an ordained minister. He informed me that he does not belong to any organized religion but accepts all of them. He practices kindness lessons among people and seeks to help the poor. The Unitarians appear to be what I understand humanists to be, namely good people willing to accept others in their own unconcealment of faith. This suggests to me that Unitarianism is the lowest common denominator of faith. This is the base zero or purest form of the innate tendency of the subjective correlate of consciousness to do good and avoid evil, but it starts from a common premise shared by all religious cultures. It must be the case that we bring our own cultural, societal, political, economic, systems to the table of doing good as a specification of how to do good. The systems are ways to normalize religious behavior. I am a roman catholic philosopher, born and raised in Québec, Canada, by French speaking roman catholic parents. I was thought to form my own attraction to the good through the rituals and precepts of the catholic church. How else can I explain my belief in the Apostle’s Creed because as a child I lacked the necessary skills to make sense of any of it. Some of the contents of the Apostle’s creed such as the belief in the resurrection of the body were problematic for how that could be me without my body? I am fortunate to enjoy this type of research such matters. The spiritual search for ultimate meaning implies the existence of God. Our hearts are restless until they find God, says Augustine. And if not God then what? It seems possible to suggest that the structure of the intellect reveals a yearning for God. The nature of God is unknowable however since the reality that is God exists beyond the world of experience. However, we populate the reality of God with the existences of this world. My religious faith informs me that God is a Blessed Trinity of Persons or Divine Personalities (Bryson, 2011).68 I need to align the idea of the natural search for the good with the desire to enter relationship with God as the source of the ultimate good to explain how faith feeds my cultural belief in the existence of the Blessed Trinity. I think I can explain this in short order at this time because the issue is discussed in more detail below in the analysis

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Ken, Bryson, An Interpretation of Genesis 1:26. Journal of Philosophy and Theology. Marquette University; Philosophy Documentation Centre, 01/2011; 23 (2): 187–215.

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of what it means to be a person. The natural desire to find the good leads me to three distinct categories of being’s unconcealment. The first is the good I see in nature—trees, rivers, ocean, the sky, sun and moon, clouds, planets; in brief, the good I see in earth, fire, and water, leads me to discover the presence of the divine in nature. I call that presence God the Father. The good I see in other persons, family, and friends, neighbors and strangers, animals and pets. I call that presence God the Son. The good I find in myself, in compassion, forgiveness, and love I call that presence God the Holy Spirit. Thus, the blessed Trinity renders my conception of my search for the ultimate good intelligible. I found an idea that explains my reality It makes sense to me because the idea of a God beyond the experience of my experience is unintelligible. I will hold these views until I find better ones, that is with greater internal consistency. I am familiar with the arguments for and against the existence of God. I research and teach university courses in this area. But the God of the lived life, the God that makes sense to me is the one I can reach through these three outlets. Further, the existence of Christ as human as well as divine gives me a hook I can use to make sense of the inexplicable mystery and gift that God’s unconcealment discloses to the intellect. In the absence of religious faith, reason is at a loss to explain the mystery of existence. Reason is impoverished without faith. My life has less meaning without the evidence of the Blessed Trinity. In the absence of religious faith, I share Albert Camus’ belief that life is absurd. Faith provides the sufficient reason that the subjective correlate requires to function in the face of being’s unconcealment. Reason and faith are not opposed. Faith challenges reason to develop logical explanations that make sense of the mysteries of existence. One of the deepest questions I faced in my career as a Christian philosopher was to make sense of the scriptural claim that we are made in the image and likeness of God (Genesis 1:26). The God of Christian philosophy exists necessarily, not contingently like us. God is omniscient, not a finite intellect like us. God is all loving, not somewhat like us. God is All powerful, not powerless like us. God is ubiquitous, not space/time centered like us. And we could go on, but the point is already clear for how is a finite, mortal, mistake ridden, weak, trial-and-error seeker of truth person made in the image and likeness God? I brought the rational tools of a philosopher and Christian to the seemingly impossible task of making sense of that scripture. I vowed to make sense of it or abandon it, but I am aware

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that arrogance is not philosophical. I welcome the image of the Blessed Trinity in my life because it makes it easier for me to live as a Christian person. In fact, the reality that Jesus Christ, the second person of the Blessed Trinity, is human and divine provides a deity I can recognize as another human person. Christ is just like us in every way except sin. The fact that the three persons or personalities of the divine exist in one God is likewise useful because I could not otherwise have any insight into the nature of God the Father and God the Holy Spirit. Christ is my gateway to the Christian life. In the absence of a belief in Christ I think I would most likely be a Buddhist. I’m not sure that Buddhism is a religion, but I recognize the fact that religion is one of the major tools available to help us find meaning in life or aids to being spiritual entities (chapter three). I also take it that being made in the image and likeness of God mean two different things, otherwise one term would have sufficed. My research into Genesis 1:26 finds that the explanation of the Blessed Trinity is based in part on the loving relationships that exist between God the Father, God the Son, and God the Holy Spirit. The Father loves the Son and the love between the Father and Son generates the Holy Spirit. The relationship is personal, that is, the Father, Son, and Holy Spirit are equal as God but express a distinct personality or manifestation of God. The divine personalities are distinct without being separate from the God of Abraham. It seems possible to suggest that the manifestations of the divine could be infinite as Spinoza argued, but as a Christian philosopher I focus on the reality of God as a Blessed Trinity existing in loving relationships. I take from this study that to be made in the image and likeness of God is to be the output of loving relationships. We are beings in profound personal relationships with the whole of creation. We function in the likeness of God as loving relationships move us into deeply personal relationships towards the image of God. Our defining relationships take place at three main levels to mirror divine relationships. Humans act and react in harmony with the whole of creation to become more deeply personal. This is the ultimate foundation of medicine as sacred science. All existing things are characterized by a process that clings to existence. We resist destruction and send one another on errands to discover the unfolding of creation towards its ultimate intended end, namely the divine essence. All carbon atoms resist destruction and cling to life. Evolutionary progress is designed to function at the output of dynamic loving relationships between all levels of existence.

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The STS toolbox includes a focus on the usefulness of making distinctions, the reduction of the complex to simpler elements, the need to define or describe terms, the examination of all assumptions, and the need for internal consistency in the process of reconstructing the complex from simpler elements. These tools are themselves reducible to simpler elements. For instance, the process of making distinctions invites a distinction between understanding and explaining things. It seems possible to suggest that we can explain what we do not understand. I do not understand the nature of the Blessed Trinity as such, but I can nonetheless have insight into the nature of this mystery through the explanation of human (loving) relationships. I explain war, violence, torture, hate, as an absence of loving relationships. To define an entity is to grasp it in its essence, but to describe it is to talk about what it does. God’s nature is ineffable, but the signs of what God does are all around us and can be described phenomenologically. As a Christian philosopher, I meditate on Genesis 1:26 and wonder what it means to be made in the image and likeness of God. And then as I contemplate the profound mystery of the Blessed Trinity as the word of God provides a connection I can share with others. Looking out my window on a cold January morning I see the brilliant beauty of the rising sun and reflect on the magnificence of creation. How can anyone think that the beauty and harmony of the organized interactions between the carbon atoms of the universe happen by chance? This vision manifests a first insight into the mystery of the Trinity as it inspires me to give thanks to God the Father Creator of the world and all things contained in it and for the privilege of being in the presence of the beauty of nature. And as if that wasn’t enough I experience the love and kindness of God the Son through the presence of other persons in my environment. I thank God for the love, compassion, and forgiveness I find in my relationship with others, and renew my determination to practice my kindness lessons today as I strive to greet other friends and strangers in my environment with this love. And then as if out of nowhere a bird flies past my window in perfect flight looking more like a dove than a seagull and my mind floats from the creative activity of God the Father and the love of God the Son to the blessings of the Holy Spirit. The Holy Spirit fills my heart with gratitude and invites me into the presence of wisdom. At this point the words of the Lord’s prayer ‘give us this day our daily bread’ moves beyond breakfast bread to the wisdom and insight required to avoid the duplicity of surface appearances covering the dark side of evil. The insight moves me beyond

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the illusion and glitz of temptation to find consolation in the discovery of the sacred in the manifest of experience. Our God is a Blessed Trinity of divine personalities in loving relationship with one another. Our God creates us in His image so that our own relationships can now bring us together: I am a carbon atom like all other carbon atoms in the universe, created by the Father to share created space with other physical entities in the environment. The environment is spiritual. I am a social being created by God the Son that I might be a loving and compassionate presence to other persons sharing with them the responsibility of civilization. I am an immaterial soul, Created by God the Holy Spirit and given the wisdom to know that true happiness lies in the cultivation of good moral habits. I fail as often as I succeed in aligning my relationships with the loving relationships taking place in the Blessed Trinity but my ongoing determination to make spiritual progress in that direction is a profound source of comfort. The good news is that God helps us along the way. The theme that permeates this study of the interaction between the correlates of human understanding is that reason and faith are not opposed. However, matters of faith need to be reasonable, especially in the context of religious faith. We are often blind to the values of cultures, societies, economics, and politics different from our own, but a rigorous analysis of these values points to the fact that we share a common bond in the fact that each person is a human being in the making. Everyone swims in a stream of spiritual imperfection. All persons can experience faith because it exists in the fabric of being human. We need to look within psyche to discover what is hiding in the dark of the unconscious. To be blind to one another’s ways is an invitation to take a closer look at being’s unconcealment rather than an opportunity to reject the unknown.

What is a person? My wish list for medicine as sacred science depends on medicine’s success in meeting the needs of a person. While this seems to be a truism, the fact is that unless we have agreement on that score, medicine will find it difficult to rise above the view of the patient as disease, that is to rise above the view of the person as a carbon atom. We draw on the STS Tools to realize the relational structure of persons identified below. Thus, medicine as sacred science is based on the view of humans in relationships, includ-

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ing the faith-based elements that exist in the subjective correlate of consciousness, and the systems-based principles of economics, culture, society, politics, ethics, and metaphysics discussed throughout the book. The idea that persons are separate, individual, atomistic, rational entities is wrong. To deliver a realistic and comprehensive vision of what it means to be a person we must expand the web of personhood to include all the relationships that define us. They move beyond the boundaries of the human as closed thinking thing, a remnant of Cartesians, or organic entity, a remnant of materialism and the view of the person as object of the natural sciences, to include the associations that take place in our interaction with other persons, with the environment, and self-consciousness. The goal of this section is to develop a model of the relational nature of personhood. The utility of the present model in personalized medicine cannot be overstated (Prainsack, 2015); “In its extreme form, personalized medicine implies a radical individualization of medicine in the sense that every person is seen to represent a unique case of health or disease.”69 This shift has wide implications not only for medicine but also for ethics. It moves us beyond the representation of the patient as an atomistic isolated entity into the relational nature of deontological ethics. It sheds light on how to support and promote the autonomy of vulnerable people by casting them into a wide stream of ethical relationships with other persons, the environment and their affective and cognitive connections with these relationships. It provides a realistic and useful model to safeguard human rights by promoting them in all the relationships that define us. The exclusion of one or more of these defining relationships violates the principle of rights and freedoms. The person-making process is an invaluable tool to the defense of the relational, spiritual, holistic, and ethical nature of persons grounded in the existence of eternal standards in history. The existence of the tendency towards the good in each person and the fact that we are created by God to pursue the good is the sine qua non condition of the deontological character of medicine. The model is based on an inclusive view of relations to highlight the importance of all the streams of associations that make us personal. I have used the model successfully in an earlier paper to discuss the rights of at-risk clients, and how best to best to

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Barbara, Prainsack, “Is Personalized Medicine Different? (Reinscription: The Sequel). Response to Troy Duster.” British Journal of Sociology, 2015, 66 (1):28–35.

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meet their needs.70 I distinguish between three classes of needs namely (1) needs of the human body, (2) interpersonal needs, and (3) affective and cognitive needs. While medicine has great success in the fight against disease, the point is that a person is defined by all three streams of relationships and not only the needs of the body. The following model can be used to integrate spirituality, ethics, and cultural values into a medical model that deliver a health care program that is in harmony with the structure of human understanding, comprehensive, holistic, and sacred. The distinction between being human and being a person is often overlooked. It ought not be. We are born human, but we are not equally personal. The reason is that a person is a human being in action. The classical understanding of a human being as a tool making rational animal able to think, feel, interact with others and the environment provides an entry to our nature as relational. We are human at birth, and some would argue that we are persons from the moment of conception because we enter relationships from conception and continue the person-making process at birth through our human actions. We do so through our relationships at three distinct levels of operation. Humans are not persons outside relationships; “‘human relationality is a precondition for subjectivity, not the other way around (…). We are who we are because we relate to others.”71 The first evidence that we are nothing outside relationships is in the elusive character of the “I” of experience. We use the term ‘I” to refer to our self, but it has no ontological foundation outside relationships. The “I” is constructed through a history of personal relationships. It does not exist before relationships. The attempt to grasp the I in its essence fails because it always seems to lie beyond what is recalled. The elusive “I” of relationships is always beyond the stories we tell about it. The problem is that the visualization of an “I” that exists outside relationships is dualistic. Jacques Maritain claims (1954) that the “I” exists in God before receiving a temporal existence;72 “I had (but without being able to say I) an eternal existence in God before receiving a temporal existence in my own nature and my own personality”. Thus, it seems possible to recognize the divine idea

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Ken, Bryson. K. Person as Verb. Satya Nilayam Journal of Intercultural Philosophy. Special issue on human person. Dr. Augustine Perumalil, Editor, 2010, no. 17. 65–95. Barbara, Prainsack, “The ‘We’ in the ‘Me’: Solidarity and Health Care in the Era of Personalized Medicine”. Science, Technology, & Human Values. Sage, 2017, 5. Jacques, Maritain, Approaches to God, (New York: Harper & Brothers Publishers, 1954), 76.

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of the “I” from the point of view of theology, but not epistemology. The “I’ resists definition outside the realm of dualism. I have sought without success to uncover the origin of words like “I”, “self”, “ego”, “and “subject” elsewhere but to no avail. We use these terms to refer to ourselves without knowing their origin or even how they connect to personal experiences. These terms create the illusion of a ‘ghost in the machine’ or detached subject of experiences that observes the human experience. The subject that I am, the person writing this book remains unknowable outside the present activity or history of past activities. The problem relates to the nature of subjectivity as an objective construct of reason. I could tell stories about myself until the day I died and still fail to objectively identify the “I” because it appears to exist beyond the present experience of writing. The self is equally elusive in the traditional view of human nature because a rational animal only exists at the level of operation. The transition into personhood takes place through relationships. The shift of focus to operations illustrates how a human structure springs into action. It acts in a quasi-rational way as seen through its operations. Structure is the metaphysical ground of operations. Rather than focus on the existence of an abstract structure such as self, subject, ego, “I” or human nature, which is without metaphysical reality, why not disclose the nature of the self through a description of the necessary relationships (processes) that characterize being a person? This is not an arbitrary choice. The structured self does not exist outside or beyond the processes that generate it. A shell is empty outside contents as human nature is empty outside personal actions. The distinction between a noun and a verb helps to explain the difference between being human and being a person. A human being is to a noun as a person is to a verb. Human beings are not equally personal, however. The choice of how humans become personal depends on the nature of the systems of experience. However, each person acts in the perspective of the parameters of human nature. This means that a person acts out of the possibilities engineered from the human structure. As we proposed earlier, the phenomenological structure of being rational unveils the existence of faith, reason, an attraction to the good, a desire to survive, a need to find (ultimate) meaning, good, and truth. And this is made possible by the fact that humans are in dialogue with being’s unconcealment. Thus, the medical sciences operate within these parameters and need to incorporate the whole of a patient’s relations into treatment outcomes, including the expression of the divine in personal relationships.

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Ancient logic defines a term through proximate genus and last specific difference. In this setting, men and women belong to the genus animal with the specific difference of being reasonable animals. Life is characterized by self-motion or the movement of the whole by the part. The principle of self-motion is expressed through what the ancients called the soul and the moderns after Descartes identify as the human mind. Thus, the soul acts for the good of the person in relations. Aristotle’s metaphysical biology represents human beings as moving towards their natural end. Motion is the actualization of a being in potency. The human being is in a state of privation with regards to becoming personal. The privation is filled through a choice of action, and the potentiality reduced to act, as the part moves the whole towards its intended end which is eternal life. It seems possible to suggest that the human soul (or mind) rises above the limitations of material things, as is evident from the fact that operation follows nature. The human being does things that no physical thing can do, or that can be explained by an appeal to matter alone. Thus, Aquinas argued that the human soul is dependent on the brain in the order of operation but not in the order of being. This suggests that humans have a brain and a mind at birth, but the evidence of the mind manifests itself as the human becomes a person. While human beings cannot think without a brain, the contents of thought are not reducible to matter. The health of a person depends on an organic well-being but is not reducible to it. Aquinas thought that the death of the body was due to the soul’s departure from the body rather than from the death of the brain. This is because the mind cannot operate without the brain and that the activity of the mind is irreducible to the contents of the brain. The soul is not made up of parts, he says, and consequently cannot be reduced to parts. The existence of a human soul marks the presence of the Absolute throughout persons and gives rise to the ability to act and become personal. But we have the freedom to deny our spiritual nature and remain rooted in secular relationships. This view presents itself as being reductive. It betrays the full range of defining personal relationships. To be in relationship is to move from a state of ‘potency’ such as being human to a state of act such as becoming persons. This is the full sense of person as verb. The human being as a tendency towards relationships sets the stage for the idea of the person as a being in relationships. For the sake of greater clarity, we can identify the parts towards which humans tend as being (1) the carbon-self, (2) other persons, and (3) the

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order of reflexive awareness. From the point of view of the carbon-based existence of persons, we are chemically connected to the environment, biologically connected to other persons, and spiritually connected to God. Our environmental cluster of relations includes the human body, as well as all other bodies and the geography of all extended things; the material world and all things contained in it. The social self, on the other hand, includes all persons (living or not), and the biocentric community as each living thing appears to be endowed with a unique personality. The relations taking place at the level of the internal-self include thought, feelings, faith, and a reflexive awareness of conscious and unconscious processes alike, although the latter manifest through a process of individuation as they only gradually move out of the unconscious into the stream of conscious life through the trial and error experiences of life. A human being becomes a person as the tendency of the human part to act towards the good of the whole springs into action to form relationships with environment, other persons, and the development of self-consciousness. The soul of the person, or mind, is the root cause of self-movement—a movement that includes the basic operations of nutrition, growth, and reproductions, as well as awareness, concrete (here and now) and abstract (self-awareness.) Self-awareness moves beyond the knowledge of concrete, elemental units to encompass knowledge of relationships and the ability to institute and vary the subordination of means towards the attainment of an intended end. Medicine as sacred science is charged with a the responsibility of connecting all the person-making dots. A person is a human being having sprang into action. Some of our person-making associations are freely chosen while others are determined by the carbon-self and other persons. This view of the person provides an inductive base for deductive insight into the function of spirituality, holism, and healthcare ethics (philosophy). The phenomenon of human death is many sided. Epistemology views it as the irreversible loss of consciousness (carbon-self), medical ethics sees human death in the perspective of safeguarding a patient’s right to life (internal-self), and the patient’s relations (social-self), while metaphysics sees medicine as sacred science from the point of view of being’s unconcealment and the ontological ground of life; medicine is sacred because if follows an image of the person in which death is a reversal in the ultimate root of the possibility of life. Death occurs when being’s unconcealment ceases for consciousness. While death

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is the irreversible loss of consciousness from the point of view of epistemology, it presents as the removal of ground in which the possibility of life occurs. From the point of view of the social self, the death of a loved one takes something of the survivor to the grave. This is possible if the concealment in being’s unconcealment is the occasion for a shift towards a fresh round of unconcealment in the after spatial-temporal dimension of human existence. On the other hand, spirituality (chapter three) and ethics (chapter four) are seen to cluster among the strings of relationships that individuate the arms of the person-making process and prepare us to develop the tendency towards the good of this life. The abstract self of medicine does not exist outside these relationships. There is no “I”, “self”, or “subject” of sickness outside these associations. Creating associations creates the self. A change in the associations or relationships that individuate persons produces a change in what it means to be a person. This has far reaching implications, in clinical psychology as well as in medicine. Some of our associations are forced upon us as human beings because they are genetically based and socio-politically driven through the STS factor whereas other associations are freely chosen by us as we mature. The fact that we cling to life motivates us to do spiritual, ethical, and metaphysical welding (through spiritual communion) on our associations. We can now focus on an in-depth analysis of the genealogy of how human beings become persons. The first and most basic association that characterizes us is that we are the product of an environment (Bryson, 2008):73 A part of me is matter arising out of matter. We cling to our geographic identity because we resist destruction. I live in a house or apartment, street or avenue, city or town, province or state, and country. But more than that; I have a personal DNA profile. I am the product of chemical activities taking place in my mother’s uterus, acting out a part predetermined by my zygotic configuration.

The term I reserve for this first formative line of becoming persons is ‘the carbon-self, a term, which seems to me more inclusive than the ‘chemical self’, though this is part of it because I am carbon atoms along with other carbon atoms. My environmental self includes my dependence on nature. I am not outside of nature looking at nature, but I am an integral part of my environment. I am a physical being, matter and energy, along with

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Ken, Bryson, Negotiating Environmental Rights. Ethics, Place and Environment. Vol. 11, issue 3, 2008, 360.

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other extended things in the world sharing with them the challenges of survival. Extension comes from extension; human energy is the output of cosmic energy. Anything that affects my environmental connection defines me. To alter my environmental connection whether through pollution and modifications to natural structures and/or the depletion of non- renewable resources destroys the extended self. Persons resist destruction by maintaining harmonious relationships with nature. Cleaning the environment is a spiritual act because it expresses reverence for all beings, animate and inanimate. It meets my imperative to survive. The tree in my backyard is not an entity that exists outside of me. It bears my footprint; we breathe a common air. Dendrochronology—the study of tree rings—reveals that trees incorporate growth input from their local environment. Trees from toxic environments capture chemical signatures. These tree layers, along with chemical signatures from the whole of my environment define me; they fill me with genes and chromosomes that predispose me towards illness and health. My geographic-self uploads memories of growing up in this or that town, of being here or there. They are an integral part of me as extended being. The environmental self includes my body, my diet, my brain, my external senses, and my central nervous system. I am bladder and kidneys, heart and lungs, with blue or brown eyes, tall or short, fat or thin, brown or white, in this or that place, eating this or that food, in this or that climate, young and old, and to change any of these things is to change who I am. I am the output of environmental associations introduced at birth, as well as of those associations I carve out of the environment as I develop. Health practitioners help me repair my environmental connections using non-traditional healing techniques designed to heal the self as well as restore my unity as an environmental organism. My body obeys the laws of physics that every organism follows. In systems theory, the properties of the part can only be known from the dynamics of the whole. Action and reaction generate equal and opposite forms of energy. I enter life, convert nutrient into energy, my cells add and divide, and I age, die, and something of me returns to the environment. My person as a carbon-self ultimately traces its physical beginnings 13.8 billion years ago to the creation of the universe. I am the product of a universe in motion expanding and contracting according to extremely precise laws. Stephen Hawking (1988) describes the original conditions of big bang science as follows; “Heat had to be exactly as it was because a decrease of heat by as little as one part in a million million would have caused

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the universe to collapse (…) Electro-magnetism and gravity had to be correct to one part in 10 to the 40th the rate of expansion 10 to the 55th density 10 to the 60th and the smoothness of expansion 10 to the 123rd power”.74 I wonder why Hawking’s tremendous insight into the laws governing the expanding universe leads him to conclude in the eternal existence of the universe rather than to creationism? In my opinion, the existence of a universe of infinite duration without a real cause or explanation for its being is a non-starter. Infinite duration invites us to look at time as being infinite. Time in Aristotle’s physics is a measure of change ‘the numbering of anterior and posterior states’ and since the universe continues to expand this is consonant with the infinity of time. Time is a complex problem. It seems possible to suggest that the complexities of time can be deciphered in several ways. Augustine Aurelius a fourth century scholar shows us how the analysis of time can lead to a place in reasoning that flies in the face of common sense. Time, he says, is composed of three main elements—past, present, and future. His analysis of these elements reveals the following paradox: The past no longer exists and is therefore not real or enduring. The future is not yet and therefore, is also unreal. This leaves the present as the only real element of time. The problem, however, is that the present cannot have duration. If it lasted, part of it would lie ahead into the future which is not yet and therefore not real because it has yet to happen. Therefore, the concept time and endless duration only exists in the imaginary world of mathematical abstractions. This view of time as secondary element (the numbering of mathematical entities) is held by the early Greek thinkers such as Aristotle and presumably Hawking. Aristotle’s teachings on act and potency explain that a being must have potency to exist and be deprived of existence before it can exist. This explain why the Greek philosophers viewed the universe as being of eternal duration. The universe could not have had a beginning in time because it would have to exist before it existed which is contradictory. In brief it would pre-exist itself in the state of potentiality to exist before existing. The Greek thinkers, and presumable Hawking do not share in Aquinas’s vision that in the absence of a real cause and sufficient reason for the existence of things, and in the face of the fact that the infinite regress of subordinate causes does not explain why things exist rather than not in the first place, we could not ex-

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Stephen, Hawking, A Brief History of Time, (London: Bantam Publisher, 1988), 127.

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plain why things exist. Yet the existence of the world commands spontaneous pre-discursive assent. The things of our experience do not have sufficient reason in themselves for their existence. Thus, Aquinas (and myself if I may be so bold) conclude that the first cause of things is God. This does not explain why God chose to create the world and all things contained in it, but it does provide evidence for the claim that we stand in the presence of mystery and a bridge to philosophy’s biggest question—why something is there rather than nothing; we face eternity time rather than eternal time. Common sense restores us to sanity as we recover the reality of time. But the matter acquires a fresh sense of difficulty. Cancer, for instance, must be detected just in time before it spreads to the internal organs. The determination of the time of death is also a point of law as the decision to remove a patient from life support can only take place after the patient is pronounced dead. This is especially critical in transplant medicine because the urgent need for organs cannot bias the pronouncement of death. Is there ever an opportune time to decide these matters or does compassionate care blur the boundary between the right and wrong time for medical intervention? Is there a right time for fertility treatment; is age a state or a number beyond which the use of life sustaining technology usurps scarce medical resources; is everyone truly equal or does a patient’s age determine how to maximize benefit for most citizens? How does culture, society, politics, economics, medical resources, and ethics play into the interpretation of the right-time in medical intervention. The resolution of these issues depends on bodily states rather than on time. The view of time as a primary Kantian element invites a biased constructivist approach to medicine. The carbon-self relationship is profoundly personal since it is set in motion by God the Father, Creator ‘of the world and all things contained in it’ (Cannon 5). Persons arise as an extension of the environment, though the mind arises not out of the environment as such but rather as we read in Genesis 1:26—from Amor Dei. The environment is an extension of my personality. Thus, the human brain mirrors the universe while the human mind mirrors divine love. Persons are affected by all extended things (part outside of part) and therefore the formal object of mathematics (extension, size and number) is subject to the measurement of health through medical technology. Persons could not act without a body. The mind comes into play because persons exhibit behaviors that cannot be explained by rela-

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tionships of the carbon-self only. Persons do things that elude other physical things. Human thought violates the laws of the irreversibility of space and time, laws that no physical thing can violate like being in another location without moving an inch. Thoughts are irreducible to the activities going on in the brain. The proof that something else is going on in us is that each person is unique despite our similarities as human beings. All persons have a brain, but we are not equally personal, though together on Earth, perhaps in the same town or country, perhaps not, but most always on the same planet. We are environmental brothers and sisters growing closer in all our connections, as each person brings their skill set or awakening to the table of wonder. In our day, the secular society tends to limit human nature to environmental chemicals only and deconstructs the claim that persons are special, as we appear to enter life test tube like as carbon atoms along with other carbon atoms. The culture is rooted in the shifting sands of cultural relativism. The comforting words of Genesis 1:26 are often reversed in the secular world when a vision of reductive science invites us to create God in our image and likeness. The loving God of major world religions is deconstructed in chemistry labs as human nature and the image of God are reduced to neural energy and dopamine reuptake cycles. Pills and behavior modification are prescribed to change negative emotions into feelings of well-being. The need to probe deeper into the layers of psyche to uncover spiritual roots gone sour is absolved by a behavioral mantra that sings the praises of the external level of observation. No one denies the existence of an environmental self, but a problem arises whenever being human is identified with such associations alone. If religion and science are reuniting in our day it is because human nature is undergoing a revision in which the full dimension of being a person is better understood. Once the environmental self begins to develop in correct perspective, the stage is set for the next phase of personal development—the social self. The social self is the product of associations taking place in relationship with all living things. The first line of influence is the family environment as mother and/or father teach us about love and caring as they strive to meet our basic needs for food and warmth. The social net grows larger as we learn how to interact with significant others; family, friends, people at large, and the whole of the biotic community—animals and plants; The person-making process is refined as we proceed to include the social-self dimension relationships of human nature. Medicine must place

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greater emphasis on these relationships. The intersubjective dimension of being a person includes a carbon-based genetic component in the case of family of origin, as well as a knowledge component, and an affective component. To say that we are connected subjects is to say to the other that we are somewhat the same or at least share a physical connection. But a physical connection does not affirm that we are identical internal states. At least I cannot say ‘I know exactly how you feel’ because your internal state is hidden from me and possibly from yourself. Sartre’s phenomenology of intersubjectivity reminds us that the best we can do is tell stories about ourselves because the internal self is always beyond what is objectified. Further, intersubjectivity is not a union of internal subjects from the point of view of knowledge. The social self is the output of relationships with other persons, albeit at a superficial level. I recognize that we are in the same room, and that we have personhood in common, and that we may have similar likes and dislikes, but it’s guesswork at best. Still, you leave the impression of yourself on me. The impression I have of the other becomes mine since I define my personhood in the light of other persons. Carl Jung reminds us that the other is a ‘hook’ on which I hang my own insecurities. The ‘I’ of intersubjective relations is not a cogito, not a subject nor is it an interior space. In effect, it exists as an abstraction from the relational character of the “I”. It has no ontological status outside relationships. The ‘I’ is a composite of relationships that arise at the intersection of three streams of relationships in reflexive awareness, the face of the other, and the empirical conditions of embodiment. Intersubjectivity is not an encounter with an abstraction because thought represents the other as an extension of my own interiority, an interiority that remains elusive for both of us. The ‘Other I’ is not the encounter between two cogito(s) but arises at the output of a relationship taking place between three streams of associations that constitute the abstracted I (s) of perception. Two hidden ‘I’(s) of experience meet in the individuating relationships of each ‘I’ as an extension of the personalized hidden ‘I’. The ‘I’(s) meet in the physical act of love, as they do in the faith-based act of prayer, and as they do in the compassionate act of caring for the other. The string of love and compassion closes the filters of the cogito towards the other to be with others in the mistaken attempt to be with them as they are in themselves, in their individuating relationships, rather than as a projection of my own individuating relationships. The clearest experience of intersubjectivity takes place at the preconceptual level of in the first glimpse of the conceptual

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encounter in a non-judgmental being with the other, as a dynamic mix of carbon-atom-social atom-internal atom before the reductive ways of reason take place in a second movement of reason and proceed to the production of the idea—something to the likeness of the conceptual union. We are in intersubjective communion through love until the love is questioned, put in brackets for logical analysis. The question why I love the other transforms the relationship between lovers to an inaccessible place beyond the relationship—the home of affective connaturality, and compassionate caring—to a place where love does not exist, but lives. The deepest connection I have with other persons is at the level of affective connaturality. The foundation for the experience of the other as extension of the self is made through love. Love is not knowledge based, however. This is not to claim that we are totally ignorant of the subjective character of the other but that this knowledge is not the basis for this type of intersubjective communion. Philosophers and psychologists have written about all three types of intersubjective connections. A person is the output of a social network comprised of parent(s), sibling(s), relatives, friends, society-at-large, animals and other living things. At birth, the social network is partially defined by culture as we are born into a parental environment and societal structure of family and friends. I cannot choose my parents or siblings, though later in life I can choose my friends. As I mature, I become more aggressive in defining my social environment as I choose where to live and with whom to associate. But I do cannot exist outside a given set of social relationships. I am born into a human structure designed to discover the ultimate meaning of life through associations with other persons in my cultural, societal, political, economic, and ethical environment; (Bryson, 2008) “we live side by side, eating and being eaten, living, and dying, exiting and reentering the living community. We share a common right to life with all other living systems. We inhale and exhale the same air, drink the same water, and walk, swim, fly or climb on common ground. No person exists in the absence of a social face.”75 The connection between the individual and the community does not justify a belief in communitarianism, however. While a person’s social identity and personality is in part molded by community relations, a degree of personal autonomy is placed on associations with the environment and

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Ken, Bryson, Negotiating Environmental Rights. Ethics, Place and Environment. (Vol. 11, Issue 3, October 2008), 360.

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the internal self where all our person-making associations are processed. The emergence of the social-self arises chronologically after the biological self but before the internal-self emerges. The identification of associations gives us a clear distinction of the relations that accompany personal development, but they are somewhat artificial because a person is a dynamic unity of all these relations. For instance, persons must develop a brain and sensory system before they can enter relationships with other persons; they need to experience love and compassion from others before they recognize the connection between God, other persons and love; and they must develop wisdom to recognize self-love as divine love. The structure of the subjective correlate of consciousness leads persons to pursue relationship with a loving God. The nature of a person’s understanding of the divine is relative to that person’s background. For individuals raised in Christian families, the image of the divine is expressed through a belief in the existence of the Blessed Trinity. In the beginning, the nature we assign to God is determined by our parents, but the flexibility of human intelligence allows individuals to express their own image of the divine as they mature and seek to make sense of their individual reality. The relationship with God gives individuals responsibility for their soul. The God of Abraham religions invites the faithful into personal relationship with the divine. Persons reach God through other persons, and the environment. We are taught to love and respect neighbors. Nothing makes the social dimension of Christianity clearer than the divine commandment, “you shall love your neighbor as yourself” (Matthew 22.34–40). How is it possible to love a neighbor as much as I love myself if not through the fact that my relationship with my neighbor is one of the relationships that individuates me? The other must be an extension of me. This sounds selfish, but it speaks of an intentionality of persons dating back to Saint Thomas as he describes the immaterial existence of the other in me. The ‘we’ in ‘me’ forms the “I” of experience. This interpretation of self is missing from the existing medical model. How, then, can medicine care for persons with Alzheimer’s disease, organ transplant, or end-of-life care if not through other persons? The process through which human nature recognizes its dependence on others begins when the person’s self-awareness includes an insight into human weaknesses. The acceptance of my own imperfections allows me to be more welcoming of the imperfections of the

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other. God invites us into personal relationships with others so that together we can strive to build a better world. We never attain perfection but each act of love and compassion marks progress towards that goal. The image of a child seeking to move an ocean with a paper cup illustrates the point. While I have no doubt that the child will not succeed in moving the ocean with this cup, I am nonetheless convinced that each dip of the cup into the ocean brings the child in me closer to that goal. The process of socialization is a continuation of the more basic need to recognize the environment as an extension of the human species. The challenge is very real and perhaps unattainable without a change of heart about our dependence on other persons and the environment for our own development. We need to cultivate friendship with others in the global community to overcome terrorism, war, hunger, poverty, exploitation of other persons and of the environment. We need all the help we can get, including access to religious faith found in the structure of the subjective correlate of consciousness (desire for ultimate good and meaning). Often the structure of the intellect remains in the unconscious recesses of sleep and ignorance and ignores the presence of faith and the desire to do good that lies buried in the layers of consciousness. The natural attraction to God is a case in point. We blur that desire with the trappings of spirituality gone sour. Fortunately, progress towards healthy spiritual development is possible through the phenomenological analysis of the contents of consciousness. I have found two opposite ways to describe the intentionality of persons. One view looks to the other through the eyes of love as Gabriel Marcel says, while the view of Jean-Paul Sartre arms the social self with contempt for others. Sartre’s protagonist Vincent Cradeau exclaims the negativity of other persons by the remark “Hell is just—other people”.76 That statement reveals much about Sartre’s philosophy of human nature. Surprisingly, Sartre is a humanist. He claims that we live in a world without God, structure or reason for existence. We cooperate to overcome the problem of scarcity of resources, but this is a challenge as we are not available to the other in a positive way. In the absence of an objective ethical standard, we are left to our personal circumstances to define standards through freely chosen acts. The other is an obstacle to personal growth, however. They objectify us as they seek to define themselves. We distance ourselves from others. We lock others into compartments. We negate their

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The claim is found in the closing lines of Sartre’s one act play No Exit (1945).

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freedom to define themselves. The feeling is reciprocated, and we naturally go to war. In Sartre’s world it would be better to not exist, but suicide is not an option because it presents the future through which human action acquires meaning. So, we make the best of life in a world without design or promise. Sartre is a Nobel prize winning author and gifted thinker. He appeals to an audience disillusioned by war and the seemingly benign indifference of God. Marcel, on the other hand, also has his experience of the war in hand but uses it to paint a portrait of the social self that is based on an intentionality of loving subjects.77 This means that in loving relationships, we become an extension of each other. Marcel’s ‘we are, therefore, I am’ replaces the anemic subhuman Cartesian belief that I am self-sufficient, therefore, I am. Marcel claims that God has designed us to need each other. He explains that the relationship we have with others is analogous to our own embodiment. I am my body (as opposed to I have a body), he says, means that the other is an extension of me rather than an object to be exploited. In his works, the social claims of denial, infidelity, unavailability, exploitation and despair are replaced by a philosophy of love and availability, fidelity, and God. Where there is God, there is hope. And hope is the fundamental stuff of life. The God that Marcel invokes exists in social relationships. God is present in the caring of the other. Human grief is not an illness; it is a human condition, a broken social-self string that never completely heals over. I can love others and others can love and define me in turn, but the loved one that dies is forever an empty space within me; a vacuum that cannot be filled or fixed by spiritual welding. But there is a light at the end of the tunnel: Gabriel Marcel suggests that the death of a loved one raises us to new heights through the experience of immortality. The death of a loved one carries mixed messages. First, it occasions a break in my person-making associations, but second, it opens the door to new possibilities as the love connection I have to the other is raised to new highs in immortality. This connection between persons must be acknowledged by medicine. The death of a loved one is not a disease or illness and

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For an excellent study of Gabriel Marcel’s philosophy, see Brendan Sweetman (2008) The Vision of Gabriel Marcel. Amsterdam-New York: Editions Rodopi B.V. Value Inquiry Book Series. Vol 193. See also Michael Battle (2009) Reconciliation: The Ubuntu Theology of Desmond Tutu. Pilgrim Pr. Ubuntu; an African concept claims that persons and groups form their identities in relation to one another. It is based on Desmond Tutu’s belief that individuals are unique because they have gifts that others do not have. God has made us to need each other.

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we never completely recover from the loss, but at the same time it opens the door to new relationships. I am in ‘good grief’ if the loss does not control me and provides an opportunity for fresh growth. Marcel’s distinction between problem and mystery focuses on this connection. I do not recover from a relationship based on the problem dimension because it is based on ‘having’. But I do recover from the loss of a loved one if the relationship is based on mystery or ‘being’ present to the other. The relationship I have with a loved one is based on mystery. The loss of health from disease is likewise not only a problem to be solved but a mystery to be lived. The mystery dimension of human existence is best expressed through love. It does not need to satisfy empirical demands to survive. The physical separation of lovers does not end the relationship unless it is based on the problem mentality of denial, and unavailability. Marcel’s philosophy provides a good base for grief counseling but there are other ways of coping with grief. For instance, Asa Kasher’s (Life in the Heart, 2003) presents a warm and poignant alternative to the belief in the continued existence of a dear one in the afterlife state. She writes about how her son Yehoraz lives on in her heart here and now on earth 25 years after his untimely death. She brings witness that the story of his life continues, not in itself, but within the story of her heart; “…those who are loved live in the hearts of those who loved them, and then in the hearts of those who love those who loved them, and so on, endlessly”.78 The story of Yehoraz is not one of passing out of this world, or of passing into another world, but that of a third perspective on death as a life continuing in the heart of a loved one here and now on earth. Sadly, it follows that the memory of the loved one ceases with the death of the lover or when it is no longer passed on to others. The love that parents freely give us serves as a model to emulate as we learn that we too can move out of our fundamental selfishness and care for others. The social self continues to develop over a lifetime of interactions with people worldwide. We learn and develop lessons of kindness; we learn how to be compassionate, and how to be of service to others. We learn to empathize with the pain of the other. The nurse in relationship with cancer patients may or may not have a personal experience of cancer but she can be in touch with her own pain and use that experience as a

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Asa, Kasher. Asa, Life in the Heart. (Journal of Loss and Trauma: International Perspectives on Stress & Coping. 8:4, 2003), 250.

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bridge to the suffering of the other. We learn about resonance, and identification; availability and fidelity, and what Marcel describes as a process of participation. We also learn about hate, resentment, insecurities, jealousy, and other negative emotions. But the choice to use negative or positive emotions as a gateway to the other is our alone. We build a better world as we exchange love for hate, availability for unavailability, compassion for disinterest in all our encounters with other persons. The social self, not unlike the environmental self, engages persons in a lifelong process of becoming progressively more personal. Each day, each hour, each instant of time offers an opportunity to empower other persons; to love others, to be of service to others, as we share with them the responsibility of civilization, the construction of a better world. A person is a dynamic growing human being in action, not a static walled in self. I can use the experiences of the social self to empower or to disempower others, to curse the darkness or to light a candle, as Marcel and Sartre already know. The birth of a human being is a secular marvel and a sacred mystery. The human is a marvel because the complexity of the brain is as deep and complex as the stars, and a mystery because the human mind is incorporeal. A human being arrives on earth fully equipped dependent and independent of matter. The issue raises a key question. How does matter generate non-matter? The first law of thermodynamics assures us that action and reaction are equal and opposite. The ways of human understanding and the principle of sufficient reason lead to an explanation beyond matter, namely to the divine essence to explain the incorporeal nature of the human mind. We do not know the mind of God, but we need to explain the presence of that which cannot be explained by matter. Is the incorporeal feature of the mind part of Genesis 1:26? A fuller investigation into the nature of the internal-self provides an answer to that question. The third and most complex string of associations that characterizes being a person is the internal self. The internal self pre-exists the carbonself and the social-self, although it is dependent on the carbon-self at the level of operation. I am the output of memories, dreams, and thoughts, conscious and unconscious processes taking place in the interior self. To be clear, no pure “I” of experience exists. I am not an interior self that reflects on memories and dreams, but I am that very being now dreaming, now remembering and imagining, thinking and willing, as I act and react to my environment and other persons. These experiences trigger the phenomenon of reflexive awareness as I double back on my relationships to

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become aware of myself as a being in relationships. The internal self is but one of three streams of person-making associations, however. The internal stream exists within psyche as a place to receive, catalogue and generate fresh associations. It provides the glue to fuse associations into a personmaking process. The internal self is placed third in the stream of person-making associations because it arises after the fact of an environmental beginning and a social stream of relationships. The environmental stream arises first because it generates a genetic pathway to the central self. No self-concept exists without the brain. The social arm of person-making then kicks in to provide the emotional content to our behavioral responses to other persons. These emotional responses are fine-tuned by the central self as we learn to institute and vary the stream of relationships established in us by other persons and that we help establish in others. If it is the case that a person cannot think without a brain, it remains no less true that a person cannot think without other persons and the internal self. Some philosophers appeal to the existence of an intangible element in the central sense, others do not. My inclination and indeed fundamental belief is that the human mind provides evidence of the existence of the sacred within everyone. Given that we act as a dynamic unit of all the streams of associations that characterize the process of becoming truly personal, it follows that each person is a spark of the divine-at-work-in-theworld. This suggestion fits what we know about the human mind, love and compassion but the solution to the nature of the internal self remains elusive for how we use mind to understand the origin of mind is elusive. The whole idea of the mind explaining itself is a logical contradiction. Maritain (1954) has a clever way around this dilemma. The mind, he says, cannot think of itself as not thinking. Thus, the “I” that is currently thinking has always existed. I must have existed in the mind of God before receiving my temporal existence; “I had (but without being able to say ‘I’) an eternal existence in God before receiving a temporal existence in my own nature and my own personality”.79 Maritain makes a good point because if the mind is immaterial it must also be eternal, that is, it must not be dependent on matter for its existence. This does not explain why it exists, as we saw earlier, but only that the mind must always exist from the point of view of

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Jacques, Maritain, Approaches to God, (New York: Harper & Brothers Publishers, 1954), 76.

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time. Medicine is sacred science because the doctor patient relationship provides evidence of the existence of eternity time in the temporal. The hylomorphic theory of change does not explain the existence of the human mind since it rests on the defective metaphysical theory that mind arises out of matter or is reducible to it. Aristotle’s analysis of act and potency rests on the fact that the principle of prime matter or substance, depending on the nature of the change, remains the same from the beginning to the end of the change. While Aristotle draws attention to the principle of privation and form before and after the change takes effect, the underlying substrate exists within the potency of matter itself (since matter is in potency to the reception of form to actualize the state of privation). In this way Aristotle refutes Heraclitus and Parmenides while safeguarding the reality of change and the possibility of knowledge. While it is correct to affirm that at death the human soul (the principle of form) reduces itself to the potentiality of matter this is because in Aristotle’s world view the Gods have no interest in maintaining our personal immortality. The eduction of soul from matter is also a non-starter because it depends on the will of the Gods rather than on the structure of the human mind. Thomistic philosophy appeals to the ‘spiritual intellect’ to explain the elusive character of mind. The mind is infinite in its hunger for truth. We are restless seekers of meaning because no finite series of goods completely satisfies us. The spiritual intellect manifests a psychological tendency towards God, or a need to belong to something greater than itself because only God can satisfy our craving for ultimate meaning. The desire to see God is not derived from person-making associations, although the structure of persons reveals a tendency to search for the presence of the eternal in the temporal. This speaks volumes about our species. What is the origin of the drive towards God? Since persons are the output of finite associations, the need to see God can only be explained by the presence of a spiritual intellect designed by God. In logic, the finite brain cannot explain a tendency towards the infinite. The mechanism that triggers our addiction to God must be the presence of the divine within the human psyche. This view affirms the belief expressed in Genesis 1: 26, namely that we are made in the image and likeness of the divine. Thomas Aquinas (Summa Theologica. 84, first part) describes in detail the fact that knowledge begins with the world of experience (the objective correlate of consciousness). The process takes place through several impressed and expressed

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species. Knowledge is the immaterial union of forms as the form of the object known becomes one with the form of the knower. Immateriality or freedom from the limiting conditions of knowledge is at the root of knowledge. There are no innate ideas. First, the object known expresses itself on our five external senses. Each external sense has a proper formal object, that is the sense of touch cannot compensate for the loss of hearing or sight. However, each sense develops extraordinary strength in the absence of an external sense. I remember one of my college classmates who was blind since the age of 7. He could nevertheless recognize someone by the sound of their footsteps. His sense of touch was also developed to the point that he could sense heat from a tiny elevator bulb signaling whether it was going up or down to meet us. But I digress. The data gleaned from the external sense registers on the central sense in the psychic order of awareness. The central sense produces an image of the object known which is stored in memory and imagination. Memory connects the impressed species of sensation with time and space while imagination houses the form of the other without reference to time and space. Imagination is reproductive and creative if it combines the data of external sensation into a new yet to be experienced form. The presence of the form of the other in the brain reduces the agent intellect from the order of potency to the order of act and moves it to examine the species of sensory awareness to set aside individual differences and retain common sensible matter. This is the first movement of reason known as simple apprehension and subject matter of the first degree of abstraction.80 In the production of mathematical abstractions, on the other hand, the intellect sets aside common sensible matter to retain the aspect of quantity from the object known. This is the second degree of abstraction and is a deductive process. Mathematical abstraction is followed by a second type of deductive application as the intellect abstracts from quantity to examine the object from the point of view of existence, causes and principles. This is the third and purest type of abstraction. The philosophy of nature operates at the first degree of abstraction for its observations but moves deductively for its analyses of nature. Aristotle’s theory of act and potency is a case in point. The Stagirite makes use of terms like privation, potency, and act to make sense of the problem of change. No one has seen these terms, but they arise out of his

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For additional detail on the process of abstraction see Aquinas’s commentary Boethius’s De Trinitate; The Division and Method of The Sciences.

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study as principles to explain the state of bodies in motion. He defines change as ‘the act of a being in potency inasmuch as it is in potency’. The reference to ‘the act’ signifies an agent of change while potency is the being before the change occurs. The part of the definition ‘inasmuch as it is in potency’ means that the change is limited by the existent being. Aquinas makes full use of this nomenclature in his rational psychology and metaphysics as he likens the union of mind and body to that of potency and act respectively. The second operation of the intellect is reasoning as the mind seeks to make explicit what is implicitly contained essence of the abstraction arrived at through simple apprehension. Judgement is the third and final operation of the human mind and the locus of truth in Thomistic epistemology as the mind seeks to affirm or deny the real existence of the abstracted concept. The distinction between the mind and brain is critical to understanding why a person is sacred, and therefore why medicine is sacred science. The mind needs a brain to operate but the abstractions of the intellect cannot be reduced to the operations of the brain. The mind produces a surplus of the signified over the signifying. For instance, a blow to my head will affect my thinking but it does not determine what I am thinking as I am being struck. Aquinas draws the argument for the immortality of the soul (spiritual intellect) out of this imagery. The death of the brain is not the death of the person because while the brain is reducible to its parts at death, the mind is not composed of parts and is therefore irreducible to matter (carbon atoms) at human death. The central self is active as well as passive. We process the associations generated in the three streams of person-making associations, while raising them to new heights as we institute and vary fresh relationships towards the attainment of our ultimate end. Our environmental associations are relative to culture, but individuals join in a common search for the transcendent. We are not equally personal because person-making is an individual choice. We aspire to transcendence together as we share in the responsibility of civilization. Unfortunately, we are not always tolerant of others and their cultural differences. This is the irony of world religions that a common thirst for the transcendent, personal and impersonal, should incite persons to war against each other. So, there is something about the inner self that remains a paradox. The irony lies in the fact that the defense of the sacred often misses the presence of the sacred in all individuals. The problem of personal identity in the afterlife state depends on the continuity of person-making associations into that state. I have argued

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elsewhere that the evidence suggests that this is the case. It seems possible to suggest that the internal existence of the spiritual intellect after death returns to a state of eternal duration (eternity time) it enjoyed before birth. The argument rests on the immortal character of internal and social associations, given the nature of human love, and the distinct possibility that God’s love will sustain us in eternity. The belief in the continued existence of an environmental stream is possible because of a central thesis that the significant thing about us is the principle of quantity rather than the actual quantity of this or that body. This means that our continued existence is dependent on the will of God because we remain contingent, spiritual beings on both sides of death. The following chart presents a summary of the geography of knowledge (see my Flowers and Death. Toronto: University Press of Canada, 1985). Illustration: The Geography of Knowledge

Where does medical technology fit in this geography and methodology? Medicine’s formal object is the carbon-self. Its degree of abstraction is inductive and deductive. Medicine is a hybrid body of expertise. Medicine as science employs the methodology of mathematics to express its observation of the relationships between the conditions and property behavior of human carbon atoms. Medicine as an art recognizes that the part of an

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organism functions primarily for the good of the whole and only secondarily for itself. Carbon atoms act primarily for the good of the whole organism. When I am disease free, I feel and think better, and I have improved social relationships. Conversely, the nervous system cannot distinguish between an imaginary and a real experience. Thus, positive thinking affects the disposition of my carbon atoms. Medicine functions as sacred science when it recognizes that a person is much more than the sum of its carbon atoms (holism). Persons need carbon atoms to live but the contents of their affective and cognitive states are irreducible to the activity taking place in those carbon cells. The next chapter expresses this holistic relationship through the spiritual character of medicine or how the ‘inside’ of a person seeks to make sense of the ‘outside’. It provides a map that physicians can use to determine what fits where and why.

Conclusion How can medicine be faithful to the Hippocratic Oath, if it ignores the sacred nature of human existence. Can we imagine organ transplant medicine or the compassionate care of Alzheimer’s patients, or end-of-life care without talking things over with the patient’s family, and the understanding that persons are designed to do good, to love others, and to search for the ultimate meaning of life? This clearly points to the fact that persons are more than organic entities, although the disposition of the body is important to well-being. The fact that medicine can restart a life derailed by disease, depression, and dying points to its sacred responsibility as science. The relational character of medicine is clear from the fact that persons are the output of relationships with other persons. The importance of treating patients through the lenses of relationships is critical to the success of medicine, now and in the future. Each stream of associations that individuate us is characterized by a plethora of string like associations on each arm of the person-making process. Our medical records need to include as many of these strings of associations as available. This comprehensive medical assessment is required for holistic care. A chart of these associations will provide an at a glance history of a patient’s medical career. The personmaking process does not claim that persons are determined by these relationships alone but clearly what happens in the brain does not stay in the brain. I need a brain and body and relationships with others to think, but the meaning of life is not reducible to those associations. Cognitive and

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affective processes are both dependent on and independent from our associations. The person-making model provides a practical and useful way of thinking about human beings in action. The division of the process into three streams of associations provides a comprehensive map of human beings in action. While the streams of associations are distinct, they are not separate from the whole person. Each stream of associations carries its own distinct features and functions primarily for the good of the whole as though three unique persons exist in one being. I find it interesting that an empirically based concept should mirror the reality of religious faith in the existence of the Blessed Trinity where the streams of associations mirror the existence of God the Father, Son, and Holy Spirit, respectively. This view provides evidence that some aspects of descriptive ethics can become normative and serve as safehouse of deontological ethics.

In Summary The distinction between being human and being a person provides clarity we can use to advantage in healthcare. The model distinguishes between three distinct but interconnected streams of relationships that make individuals unique and respectful. It arms medicine with reasons for viewing patients as sacred. . The first stream of associations: the carbon-self; The focus in this stream of associations is on being’s unconcealment and what it discloses about a patient’s disease. The method is empirical. A human as an organic person in the making includes a focus on DNA, anatomy, biology, diet and the cause and prevention of disease. Genetic screening is paving the way towards identifying the cluster of cell associations that lead to disease while genetic engineering will generate a paradigm change in medicine to prevent disease before the symptoms of disease arise. The second stream of associations: the social-self; The focus in this stream of associations is on loving relations. The patient is viewed as a citizen living in a community of family, friends and neighbors. The systems approach to medicine integrates a patient’s culture, so-

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ciety, politics, economics, and ethics into the treatment plan. The new paradigm empowers medicine to view community as a source of medical knowledge; a necessity for end-of-life care and transplant medicine. The third stream of associations: the internal self; The focus in this stream of associations is on the subjective correlate of consciousness and the sacred contents of mind a patient brings to the medical table. The doctor patient dialogue is secular and sacred because it involves several relationships with other persons, the environment, and the divine. The sacred character of the patient is expressed through the spiritual search for ultimate meaning. The nature of spirituality is the subject matter of the next chapter. The patient needs help to make sense of the sacred and the role of disease and suffering in a human life.

Chapter Three: Dialogic Spirituality Overview The goal of this chapter is twofold. First, to apply the Toolbox to medicine and illustrate how the person-making process makes medicine patient centered as it includes all the relationships that individuate patients. The second goal is to discuss how the application of spirituality as the search for the meaning and role of suffering in life raises medicine to the level of sacred science. The normative connection between patients, spirituality, and ethics is examined in chapter four while chapter 5 provides the metaphysical foundation of medicine as sacred science, that is it secures the foundation of deontological ethics and the oath of Hippocrates.

Introduction Chapter one introduces the STS Toolbox, namely, systems (culture, society, politics, economics, resources, eco-systems, ethics), and thematic contrasts (citizenship, holism, comprehension, cost-benefit analysis), community based medical knowledge (social action), and metaphysics to move towards the vision of medicine as sacred science, as announced in my wish list. Chapter 2 introduces a description of personhood based on three main streams of human activity. Each of these main streams of relationships has a proper formal object, namely, a carbon-based dimension, an interpersonal perspective, and an internal or psychological dimension of action. We populate each stream with its relevant characteristics; the internal self is the home of all innate and a posteriori processes of mind such as the attraction to the good, the quest for sufficient reasons, and the thirst for ultimate good (God or Supreme Being), along with the basic structure of religious faith seeking activities. The carbon-based perspective of the person-making process includes the activities of cell addition and division that take place in the human body along with the whole of the extended world. The social-self processes, on the other hand, includes all relations with other persons, and living-things. Social associations are based on loving others, although negative emotions are also an integral part of the human condition. Further, a person is a dynamic unity of all these relationships. 133

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This is to suggest that any one stream of relationships acts primarily for the good of the whole and only secondarily for the good of itself. We bring all these relationships into the doctor patient visit. The present chapter introduces spirituality as the sacred needle that threads the parts of the method (the Toolbox) into the three streams of relationships that individuate persons. Spirituality is a search for ultimate meaning. The thirst for the meaning of life is found on each arm of the person-making process. The arms of this process are animated or individuated by the STS Tools. This means that the search for meaning as expressed on the carbon-based arm of human action is individuated by culture, society, politics, economics, resources, eco-systems, ethics, thematic contrasts, and metaphysics. The spiritual search for meaning is the sacred lubricant that runs throughout the individuated carbon-self. In similar fashion, the STS Toolbox feeds the social-self arm of person-making while spirituality animates each nook and cranny of our relationships with other persons. The STS Toolbox likewise animates the third stream of person-making as the search for the meaning of life feeds into the deepest recesses of the unconscious mind and consciousness alike. The spiritual search for meaning explains existential restlessness and the ongoing search for an answer to human existence. The suggestion that only God can satisfy our craving for ultimate meaning and happiness explains the sacred obligation of medicine to treat the whole person. What the doctor sees and what we bring to the table of health dialogue is complex. We bring all these relationships because we are the output of all these relationships. To say that no one gets through life alive is more than a groaner. We live a life of spiritual imperfection because of broken associations in the stream of relationships that define us. Spiritual welding is the process of finding fresh meaning to replace the loss of meaning that arises through broken associations due to disease, suffering, grief, aging. The role of the doctor is to attend to the loss of meaning that arises in the stream of carbon-based associations, but the part always acts primarily for the good of the whole. The supposition that persons are carbon atoms only is not only reductive, but an epistemological, ethical, logical, and metaphysical sin of the highest order of incompetence. It overlooks the fact that a person is a dynamic unit of all the streams of relationships that individuate us. It omits the fact that the internal-self- and the social-self and all the elements the Toolbox brings to the medical table helps us to locate and heal the associations that characterize patients as dynamic units. Medicine as sacred science draws its foundation from a

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metaphysics of creation centered spirituality (chapter 5) rooted in the existence of the Blessed Trinity and expressed at the operational level of medicine in a philosophy of nature based on the inductive experience of the person as a human being in action. The typology of the divine as Father, Son, and Holy Spirit mirrors our own experience of God in the meaning seeking, spiritual, structure of persons as carbon atoms, other persons, and the internal-self, respectively.

A system-based approach to medicine History: The first set of tools to achieve the goals announced in my wish list begins with a detailed history the doctor and patient bring into the table of health. The history of modern medicine reveals that the impersonal nature of science and technology has produced a medical arena that is growing increasingly more impersonal. While we recognize that scientific developments always entail a cost benefit transaction between the doctor and the patient, the focus on history lessens the impersonal nature of this relationship. The patient’s history is presumably already available on file, but this is an opportunity to widen it to include a larger tranche of relationships that include family of origin, power of attorney, living will, and end-oflife wishes (life support systems, if any), organ donor card, religious affiliation (such as church, if any), and burial plans. This information is vital to end-of-life care and the determination of a patient’s quality of life assessment. A patient with a family history of dementia and Alzheimer’s might provide a ‘no heroic effort’ directive in his or her file such as a DNR (do not resuscitate). This personal information becomes extremely important to family at the end of life. On the other hand, the doctor should also make relevant aspects of a personal autobiography available to patients. The doctor’s file must contain academic information about areas of interest and qualifications, along with the doctor’s personal views on matters such as abortion, euthanasia, assisted suicide, alcoholism and smoking. Perhaps the doctor could take advice from other doctors on best to populate this profile with the goal of making medicine less impersonal. A third area of history is provided by the medical knowledge available in a doctor patient community. Each doctor’s office must have this list of community resources for referrals, not only to specialists, pharmacists, clergy, psychologist, social workers, but also to access the wide range of self-help groups that are available in most communities (see chapter 1).

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Person-making process: highlights of the main stream of relationships in the lived life of a patient; Culture: is the repository for a person’s attitudes, values and beliefs. It provides a powerful source of psychological insight into patients’ feelings about nature, other persons and themselves. Respect for nature is respect for the human body. Most bodily processes take place without the aid of reason. The immune system, springs into action to protect the body long before the mind gets the message. What is the patient’s attitude towards diet and exercise? The display of respect for other persons could also be widened to include attitude towards the whole of the biotic community. What is my attitude towards pollution. Is cleaning the environment a spiritual activity or do I litter the environment. Greed, addiction, and selfishness are the curses of the age. They direct spirituality into wrong places. This is a complex file, but the doctor must know something about a patient’s culture before prescribing medicine. The attitude of Jehovah’s Witnesses towards blood transfusion is a case in point. Their attitude is that blood is impure once it leaves the human body. Thus, they refuse blood transfusions, including autotransfusion out of religious principles. In most cases the blood that is lost because of surgery is minimal, but even in the hypothetical case of a major loss of blood, their religious belief is such that the benefit of keeping religious principles sacred offsets the cost of personal death. Society: we establish loving connections with a family of origin as well as with friends and community-at-large. We also form connections with animals. The way we frame society speaks volumes about what is happening within ourselves. The observation that a hospital patient does not have visitors suggests a broken association in the person-making process. It also highlights the importance of the connections a person has to a community of origin. Economics: the contrast between human development and economic development provides a glimpse of how we disempower medicine. For the most part, economic conditions regulate entry into medical school, and access to the healthcare system. To assign priority to economic growth rather than to human health in an age of abundant resources is to devalue human dignity. We need to make time in our busy hospitals to be present to patients, but this costs money. Perhaps we can depend more on volunteers to help defray the high cost of healthcare. The attempt to recruit community volunteers to visit the sick places the value of human life above economic

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policy. While hospital administrators are forced to operate with limited funding, society must place more emphasis on community programs to mitigate the limited economic resources accorded to healthcare. Politics: is the process of laws and regulations used to promote liberty and order. Violence, repression, insecurity and civic chaos arise as the outcome of bad government, weak administration, warfare and government control. In the absence of governmental laws directed towards the promotion of human values, the sacred nature of medicine is at-risk. Good governance is founded on an ethics that places value on the dignity of persons (chapter 4). In place of looking to politics to generate the ethics, we need look to deontological ethics to provide a moral framework for patient care that the law can protect. Environment: the environment is where we live, the country, province, city, street, house, and back yard landscape. It includes the whole of our physical space and plays a central role in wellness. To pollute the environment is to poison ourselves. Building sickness expresses the negative effect of a poorly designed building environment on wellbeing. The effect of the environment on us is direct but it can also go unnoticed (indirect). Building sickness is the direct effect of the environment on a person. The effect is indirect when it travels through the body unnoticed. The body sends signals to the brain that something is amiss long before disease strikes. An extreme example of this is noted by Shepard Siegel (1984) in his study of heroin overdose victims. The possibility is that the overdose occurred because the substance was ingested in an unfamiliar environment or other atypical condition. He found this to be the case in some survivors of a heroin overdose; “Two reported that they self-administered the drug in locations where they had never before injected themselves (the bathroom of a car wash and the basement of a candy store (…) some instances of overdose may result from a conditional failure of tolerance when the usual pre-drug clues do not accompany the usual pharmacological consequences.”81 Admission to a hospital or residential unit causes an upheaval in a patient/client’s familiar environment. The change affects the individual’s carbon-self negatively and therefore every possible effort must be made to personalize the new environment. The simple solution is to populate the

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Shepard, Siegel, Pavlovian conditioning and heroin overdose: Reports from overdose victim. (Bulletin of the Psychonomic Society, 22, Results, 429), 1984.

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new environment with items from the familiar environment. This calls for a relaxation of customary institutional rules and regulations and is especially critical to the psychological wellness of individuals in end-of-life care. This is an instance of ‘spiritual-welding’.

What is spirituality? A basic treatise in ethics is that all persons act for an end and all persons act for a good. We want to be happy. Saint Thomas Aquinas says (Summa Theologica 1.11:3:8) that “final and perfect happiness can consist in nothing else than the vision of the Divine Essence.” Spirituality is the engine that drives the person-making process towards this quest for the ultimate meaning of life. Being spiritual takes place in relationships. We express the spirituality of relationships through stories about ourselves as we talk about successes and failures in our relationships. We live a spirituality of imperfection. No one lives out their spirituality on a straight path of success from A to B. A story illustrates the point; one day a young boy arrived home late. His mother asked where he had been. He replied that he came straight home from school. But he neglected to say that he dillydallied along the way and stopped to play with some grasshoppers he found on a neighbor’s lawn and lingered some more to pet a dog before stopping to gather small crushed rocks that lay along the path. Our spirituality follows a similar path as we meander through the detours of life. We never move directly from one level of perfection to another. The goal of this chapter is to examine the ways of spirituality to uncover how it lights up our associations and therefore its role in medicine. Since spirituality is an attribute of the human condition, we expect it to take us places that express a mix of good and not so good outcomes. Thus, the doctor patient relationship, as any other human relationship, is based on a spirituality of imperfection rather than on spiritual perfection. Disease, setbacks and suffering are a normal part of our spirituality. They characterize the way we seek spiritual meaning. The point is how we deal with these experiences and what we do to grow from the experience of imperfection. In our day of instant gratification, it seems possible to suggest that the patient comes poorly prepared to the doctor’s office. The doctor patient dialogue centres on broken carbon-self associations with little or no mention of the other two set of relationships that characterize the person-making process. One of the reasons is the prevailing healthcare paradigm. The doctor’s training centres on a

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carbon-self skillset rather than on a holistic perspective of health. This is also due to the economic constraints placed on healthcare. Ideally, a doctor’s visit could combine a portal to experts in each field of relationships. There are several reasons why this is important. No person exists without individuating relationships. We are persons in the world along with other persons sharing a common environment with them and the responsibility of civilization. We search for the meaning of life together. The word spirituality is from the Latin spiritus meaning breath or life. Spirituality is the inside of a person trying to make sense of the outside world; it directs us towards the pursuit of the higher meaning of life. The pursuit is quite natural to us as we appear to be attracted to the good from birth. The spiritual process is often unnoticed, so we call upon philosophy to establish distinctions between the causes and principles of spirituality. The causes of spirituality are five in number, namely efficient, final, exemplary, formal, and material causes of being. The principles that underlie the structure of human understanding enable us to identify some of the main issues that accompany the study of the role spirituality plays in medicine. The first is the attraction to deontological ethics. John Daniel Wild (1962)82 says that existential restlessness provides an argument for the existence of the ultimate good of life. Saint Augustine makes a similar claim when he says that our hearts are restless until they find God; “My soul thirsts for you, Oh Lord my God (Psalm 63). The explanation is that no finite good completely satisfies our spiritual restlessness. The incessant craving for meaning that exists in our heart continues until we see God ‘face to face.’ Viktor Frankl (1985)83 says that love is the apex of human experience. Frankl’s experiences in an Auschwitz concentration camp during World War 11 taught him a lesson in spiritual survival through the visualization of his wife and the love he felt for her. He did not know where she was or even if she was alive or not but the love he felt for her kept him alive. Stronger individuals did not survive if they did not have this kind of experience. Religion promises this kind of love from God. Religion equates infinite love with God. Moments of intense pressure bring the ongoing search for ultimate meaning into clear light because an existential crisis (disease, divorce, death, Auschwitz) brings spirituality completely

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John, Wild, An Existential Argument for the Divine Transcendence. (Journal of Bible and Religion 1 October, Vol 30, 4), 1962, 269–277. Viktor, Frankl, Man’s Search for Meaning, (New York: Washington Square Press), 1985.

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out of the closet! The pursuit of meaning is an ongoing reclamation of what is best about the human condition. The experience of love is tremendously empowering. Healthy individuals strive to be more loving, compassionate, caring, forgiving, and tolerant in all their associations—qualities we usually associate with spirituality and religion. But the same spiritual search for ultimate meaning can also be directed towards the worst destructive elements of human nature or quite simply the pursuit of disempowering relationships through religious wars. The fact that our relationships never completely satisfy us provides insight into the dynamic character of spirituality, in its victories and failures. My desire for a new bookcase or laptop is not a significant spiritual ambition, but it can turn sour if I steal a laptop or seek to disempower other persons and the environment. The will to enter relationship with God through other persons that share a similar vision is more promising of authentic meaning. In some cases, spirituality is connected more with medicine and healing outcomes than with religion. But the search for the good or the search for the absence of good (the bad), as with the search for God and immortality takes a turn as it becomes clouded with the goals of secular spirituality and the focus on economic development rather than human development; on the use of persons as a means for self-development; on shopping at Walmart in search of the good life; and on pollution of the environment for economic gain. We frame the meaning of life in ways that reflects the best and worst of what it means to be a person. Suffering either blocks or inspires spiritual growth!   The spiritual search for ultimate meaning moves us through the temporal world towards the reality of the unseen divinity of God. While the manifestation of the divine is present in the temporal, the essence of God is unknowable to mere mortals. Our ignorance of the nature God as such is in the realm of the nescient (in contrast with privative ignorance which can be dispelled through study). This explains why the Thomistic arguments for the existence of God begin with the five causes of being and from matters of experience. Aquinas has recourse to the triple methods of analogy, eminence, and negation to visualize the nature of the unseen God. The evidence of reason points to the nature of a divine reality that exists beyond the data of sensation. For Christians, the image of Jesus Christ as human and divine provides some insight into the nature of God or how to enter relationship with God. The nature of God as omniscient, ubiquitous, and all powerful is somewhat like our experience of knowledge, bi-location, and sense of power but also totally unlike these divine attributes.

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God’s nature is only somewhat like human nature. God’s nature is totally unlike the imperfections of human experience. And God is eminently more perfect than any imaginable human perfection. This appears to be the sense of Anselm’s ‘being greater than which none can be found’ but the ontological argument, as fascinating as it is, is laced with the difficulty of moving from the imagination to the reality of a most perfect being. For this reason, the spiritual quest towards God occasions an anxiety of the soul. The experience of suffering compounds the difficulty of visualizing God. The experience of God is accompanied by the ‘dark night of the soul’ as we struggle to discover the vision of the sacred in the ashes of the human condition where suffering and loss are part of life. I think that the anxiety of spirituality exists because we are simultaneously attracted to and repelled by the idea of the divine. We are attracted to it because we appear to be genetically programmed to be attracted to the good. We are repelled by it because we are frustrated in the attempt to visualize the face of God as the divine face exists in se. What is the nature of the ‘I Am who Am’ of scripture? The anxiety of seeing the nature of God overwhelms Job when he comes face to face with God. He is overwhelmed by the reality of the Almighty and falls to his knees in humble contrition for challenging God. But Job witnessed the inexpressible, as do other mystics. Are they any further ahead than anxiety ridden non-mystic types, given that they cannot share their vision? Thomas Aquinas experienced a mystical vision while saying mass, and his response was to stop writing because all the writings of this great genius of the church now appeared like straw to him. What are we to learn from the anxiety that accompanies spirituality? It seems to me that Søren Kierkegaard (1813–1855) faces this problem as he struggles with the relationship between faith and reason in becoming a Christian. However, I think that the distinction he establishes between subjective truth and objective truth is useful even without facing the either/or choice between reason and faith. I take it that the anxiety of spirituality moves us beyond the range of reason to execute a leap into the arms of faith, that is into a relationship with the divine through our associations. The tightrope walker imagery is wonderful because it catches the spirit of walking the rope of faith without a security net once we let go of reason. This explains the challenges facing the phenomenological analysis of religious faith. The Thomistic focus on the reducibility of faith to reason does not change anything because the experience of God’s nature is beyond the scope of human reason. Spirituality leads me to make sense of the divine as ultimate

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source of meaning by totally abandoning the need to make sense of this reality. The abandoning of the tendency to make sense of God’s nature is not the absence or negation of the need to make sense of things. On the contrary, it lies at the metaphysical root of the possibility of making sense of things. The leap into the arms of the Godhead is metaphysical rather than epistemological. We do not abandon the need to make sense of the world because of the epistemic failure to make sense of what lies beyond the range of experience and reason, but because of a reversal in the ground of the possibility of making sense. We abandon ourselves to the mystery of the greatest of all wonders and acquiesce to the truth of the fact that something exists rather than nothing. The primacy of esse functions as a source of inspiration to let spirituality take us where the divinity ordered it to go, namely back to the Almighty. The decision to make use of the causes of being helps us take smaller and more easily digestible bites into the ways of spirituality. Efficient cause of spirituality; the agent or first cause of spiritual action. The primary efficient cause or driving force of spirituality lies in the structure of human understanding. Aristotle’s metaphysics opens with the abrupt statement of a fact; “All men by nature desire to know.”84 We are naturally inclined to know the good we find in nature, other persons, and the internal-self. To say ‘naturally’ is to observe that the desire corresponds to an innate tendency of the intellect to survive. Pain and suffering stand in the way of survival as epitaphs to lost battles (death). We resist destruction. This feature, it seems to me, is congruent with the view of the Blessed Trinity that the Holy Spirit provides the wisdom required to go forth with the challenges of spirituality. We are designed to be spiritually directed towards finding meaning in suffering, as Christ suffered; we are made in the image and likeness of a triune divinity as announced in Genesis 1:26. The secondary efficient cause of spirituality is the human intellect and will as they direct us towards the pursuit of those acts that are in harmony with our tendency towards wisdom or the search for the ultimate meaning of life. Our choice of actions towards the discovery of the ultimate meaning of life leads to the development of moral habits. They become second

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Aristotle, Metaphysics, Book 1, 1, (Chicago: Encyclopedia Britannica, Inc), 1952.

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nature to us because they are in harmony with our tendency towards the good. Thus, the process in which the inside (subjective correlate of consciousness) seeks to make sense of the outside world (objective correlate of consciousness) is skewed by moral habits. The process is enacted in a spirituality of imperfection as we mistakenly pursue unintended goals. Thus, the culpability of moral action is lessened by the ‘dark side of spirituality’ and force of habit. The point is that spiritual energies direct us towards the attainment of the ultimate good as understood by the intellect. The view of the good life changes as we mature. This explains how the spiritual imperative to seek good can be misled by a false sense of the good, or by a correct sense of the good following due intellectual diligence. The spiritual thirst for ultimate meaning is seen to be filled in part by the academic curriculum because of rigorous standards, and in the knowledge medicine gains from community programs. These programs are based on informed and responsible social action. Spirituality is most usually associated with religion. But it is a mistake to think that medicine is a-spiritual. The word religion is from the Latin religare which means to unite or bring together. The religious experience is not in conflict with the healing function of medicine as it seeks to prevent our ‘breaking apart’. Religion focuses on three main beliefs, namely, (1) the tendency to seek the good, which it shares with medicine; (2) the belief in God or Higher Power, which it shares with medicine and the deontological Oath of Hippocrates, and (3) the belief in the existence of an afterlife state, which it shares with medicine as science and the belief in the conservation of mass and energy. The symbols and levels of abstraction are different, however. Medicine is not religion, but it aligns itself with the healing mission of religion. Religion meets the spiritual thirst for meaning when it springs out of historical truth, and faith. Religion is an organized body of culturally sensitive rituals and symbols designed to establish a connection between the faithful and the sacred. While religion is a sufficient cause of spirituality, it does not function as a necessary condition. We are spiritual beings in action even in the absence of the religious connection.85 Medicine is equally spiritual whenever it is holistic by encompassing all the relationships that define us.

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The evidence of our spiritual nature exists in all our human connections. For a detail of spirituality at work in social work, medicine, religion, 12-Step principles, and the arts see Ken, Bryson, The Ways of Spirituality (Sofia Philosophical Review, vol. X, no. 2), 2017.

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Discussion Issues: (1) the innate nature of spirituality is discussed in chapter two and the phenomenological analysis of the subjective correlate of consciousness. (2) spirituality is attracted to the secular (non-religious) dimension of the good (medicine) as well as to the sacred (religious) dimensions of the good. (2.1) it seems possible to suggest that Aristotle’s doctrine of the just means provides a sound way to ensure that the spiritual appetite is not overtaken by the quest for material goods. He distinguishes between physical goods (wealth and shelter), goods of body (health and pleasure), and goods of soul (goods of will—social; such as friendship and honor—and moral goods—such as virtues, justice, fortitude, and temperance, and goods of intellect; Knowledge (practical such as prudence and art), and speculative goods such as wisdom and science. Happiness consists in the pursuit of all these goods in moderation. Medicine as sacred science also strives to achieve a harmonious balance between all the relationships that characterize the person-making process. (2.2) Aristotle does not write about sacred spirituality as understood in religious practice because he thought that death was the end of human existence. He claims that the human soul is reduced to the potentiality of matter at death. The gods are not concerned about us. The religious concern with the afterlife state depends upon the belief that the God of Abraham religions cares about humans and decides to maintain us in existence after our personal death. (3) Finally, a third discussion issue arises over the fact that the goods of our experience are fleeting and do not completely satisfy us. This is used as a base to explain human restlessness and the existence of a personal deity that does satisfy our appetite for the ultimate good in our afterlife state. In my opinion (based on my systems experience of culture, politics, society, economics, and ethics as discussed in chapter one) the personal deity that promises ultimate fulfilment can only be a Blessed Trinity as this view explains in detail our attraction to the good found in nature (God the Father), in other persons (God the Son) and in our own sense of wisdom (God the Holy Spirit). Final cause of spirituality; first in the order of intention and last in the order of execution. The final cause of spirituality is the attraction to the ultimate good of human existence, namely God or a Higher Power greater than self. The unconcealment of the divine beckons the subjective correlate of consciousness to enter relations of love, compassion, availability, and respect for all

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existence with the Blessed Trinity. The Abraham religions (Christianity, Judaism, and Islam) centre on a personal connection with God, while Hinduism is a return to the non-manifested reality (the Unmanifest) of experience that lies beyond the illusory manifestations of daily experience. Spirituality is the empowering force that pushes the faithful through the illusions of temporal reality in search of the true meaning of life. Buddhism, on the hand, is characterized by what we might term an impersonal spiritual drive to move beyond the trappings of the personal ego to attain unification with the All of existence. We attain enlightenment in the vision that nothing lies outside the ego because the ego is dissolved into the all of existence. The process of seeking to be in union with the whole of existence, if attained, ends the existential craving for wholeness. Discussion Issue: examine the connections between spirituality, religion, and medicine. We can be spiritual without being religious, but religion depends on spirituality for its authenticity. We can be cured without being healed, but sacred medicine depends upon being cured and healed. Exemplary cause of spirituality; the spiritual blueprint or architectural design of the spiritual. The exemplary cause of the spiritual is the structure of human understanding. The structure of human understanding reveals the existence of a basic attraction to the good (synderesis), as well as the innate principles of sufficient reason and identity (non-contradiction). The manifestation of these principles takes place through a belief in the regularity of the laws of nature and a belief in the existence of structures. Nature attends herself with regularity and is therefore structured to do so. Discussion Issues: how do we reconcile differences between us. We need to focus on friendship and human development rather than on economic development as the goal of life. The latter is a means to an end rather than an end or ultimate good of life. The attempt to make sense of the outside is otherwise frustrated by the economic agenda of some political systems. The nature of spirituality is often identified with acts of compassion, caring, and availability to the suffering of the other. While the healthcare system is characterized by a caring relationship between doctors and their patients, it seems useful to point out that compassion is a means towards spiritual care and not the end or goal of spiritual care. But this is not to under describe the importance of compassion in health care. Studies on the role of the affective components sympathy, empathy and

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compassion are beneficial to patients while compassion is the most preferred and impactful gift that patients need in end-of-life care. Material cause of spirituality; the subject matter of spirituality. The material cause of spirituality is the human act and the process of becoming increasingly more personal. Persons are attracted to the good found in nature, other persons and the good that exists within the subjective correlate of consciousness. Aristotle makes the case that happiness depends on maintaining a balance between physical goods, goods of the body and goods of the soul. Medicine as sacred science seeks to maintain a balance between the three streams of relationships that individuate persons. In both cases, theory without action is as good as dead: we develop virtue by doing good things (Aristotle), and we maintain wellness by developing harmonious relationships (sacred medicine). Discussion Issue: The person-making process is rooted in culture, society, politics, economics, and ethical standards of moral behavior. The complex nature of STS systems points to the primacy of being informed as a requirement of successful social action. Formal cause of spirituality; the fundamental nature or essence of spirituality. The formal cause of spirituality exists in the structure of human understanding. We appear to be programmed to act towards the pursuit of the (ultimate) good and end of human existence. We are restless because no finite good satisfies the craving for ultimate good. Discussion Issue: the deceptions of appearances. We need to move beyond the surface appearance of things to arrive at the true heart of spirituality. The problem is that our spiritual energies can be plugged into negative sockets as well as positive outcomes. We need to ensure that the way in which we feed our spiritual energies in the pursuit of the good life is in harmony with our human nature.

Discussion Note This section brings together the causes and principles of spirituality, religion, and medicine. While human beings are born spiritual, the spiritual process takes place through our person-making connections. We come into the world as spiritual, eternal-bound human beings, but begin to define our self by our

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choice of actions as we seek to make secular and sacred sense of the world. The internal-self seeks to make sense of the carbon-self, and of the socialself. We are beings that know themselves to exist in relationship. Our spirituality is characterized by two fundamental properties. The first is that spirituality is a process rather than an event. This fact explains human restlessness as each act of making sense of the outside always generates more questions about the human condition. We are ongoing projects in the making towards eternal life. We share with others the responsibility of civilization and the construction of a better world. The second and most basic fact of human spirituality is that we exist as beings towards the resurrection. Thomas Aquinas provides the key to making sense of our spiritual restlessness through an appeal to our relationship with God; “Final and perfect happiness can consist in nothing else than the vision of the Divine Essence.”86 The spiritual challenge is to discover the presence of the Eternal in other persons, the environment, and in the awareness of beings in relationship with the divine. Spirituality, therefore, is a search for ultimate meaning. The search for meaning takes place in the secular world as well as in the sacred world of eternal life. These two worlds are not separate because the latter is only possible through the former. The point is that the Christian philosopher is not satisfied with the spiritual development of a secular world as an end in-itself but only as a means towards the sacred world of meaning. The balance between both worlds is fragile as Paul letter to the Romans attests; I can will what is right, but I cannot do it. For I do not do the good I want, but the evil I do not want is what I do … So, I find it to be a law that when I want to do what is good, evil lies close at hand. For I delight in the law of God in my inmost self, but I see in my members another law at war with the law of my mind, making me captive to the law of sin that dwells in my members87

Our existential restlessness is fed by alternating states of spiritual growth. Do I love my neighbour as myself or is my own spiritual brokenness preventing me from seeing my neighbor as an extension of myself? Do I recognize the presence of God the Father in the environment or do I disrespect nature and contribute to the pollution of the environment? Do I recognize and accept the good that exists within myself or am I overwhelmed by the dark side of my personality? Do I see other persons as a mirror of my own

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Thomas Aquinas. Summa Theologica. ST 1.11:3:8 Paul’s Letter to the Romans 7.18–25a.

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insecurities? Do I dislike others because they remind me of what I dislike about myself, or am I so blinded by my own feelings of greatness that I fail to see the suffering and pain of the other? Am I in a state of sin or grace? Am I attracted to the secular as an end or do I see it as a means towards the sacred? To press the depth of such questions, I invite my nursing students at Cape Breton University to imagine their very own death. This sounds extreme, but it works. I sentence them to death, not because I dislike students but for the sake of shifting the focus towards the brevity of life and the pressing need to prioritize things that matter most. One of the first exercises following a reading of the course syllabus is the death condemnation. I sentence my students to death, not for personal reasons but for the simple fact of being born. The syllabus’s claim that ‘everyone dies someday’ becomes ‘you will die at 5:00 tomorrow morning’. This condemnation is to fix your time of death and to put an end to any anxiety you might have about personal death. Their first assignment is to write about their feelings towards personal death, including the cause of death, and to invite them to detail how they spend the next few hours of life. We discuss their obituaries the following day and it always surprises me to hear that some nursing students cannot imagine their personal death. They write the obituary in the third person, or plan activities such as marrying and having children before their morning death. Some students use humor to describe the cause of their death, but I fail to see how anyone so young can do anything but scream and shout against the injustice and unfairness of dying early. We continue the discussion with a commentary on Tolstoy’s The Death of Ivan Ilyich followed by an introduction to Martin Heidegger’s chapter on death in Being and Time. The goal of the lecture is to suggest that personal death can function as a source of inspiration to make the best of the short time we have on earth. In my most ambitious moments I hope that the exercise provides an opportunity for my students to think about their personal death. The experience builds a compassionate and caring bridge to the suffering of others and provides an opportunity to put life in perspective. The issues that matter most when personal death is at hand are the deeper sources of personal meaning such as love, compassion, honesty, and the ultimate meaning of life. The exercise opens the door to a discussion on the ways of spirituality and the process of making sacred connections with the outside world. The

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word sacred in this context refers to the attitude of compassion and understanding we bring to the suffering of other persons. We share the bond of human suffering, disease, and death with them. Coming face to face with personal death shifts our priorities towards a concern for the most important experiences of life, family, friends, principles, and heroic actions. Being compassionate is the means towards the attainment of the ultimate meaning of life. The priorities of life shift in face of personal death. The concerns of the day move from a preoccupation with the small petty items of life to the bigger picture of human love, compassion, and forgiveness. Prayer is a useful carrier of spirituality. The death condemnation is an instrument of peace although some individuals are dragged away kicking and screaming. The acceptance of the nearness of personal death functions as a positive source of inspiration to “accept the things that cannot be changed, the courage to change the things that can be changed and the wisdom to know the difference.” (Serenity Prayer). The Serenity Prayer finds a place in community 12-Step programs. It takes a lot of inner work to love others as we love our self. We can reframe the Serenity Prayer to reflect this effort: God grant me the serenity to accept the things I cannot change (in myself), the courage to change the things I can (in myself) and the wisdom to know the difference. The prayer changes to ‘us and we’ in some 12-Step groups such as Narcotics Anonymous (NA) but not in Alcoholics Anonymous (AA). Self-help groups practice two levels of acceptance. The first is at treatment entry as the addict accepts the powerlessness of substance (or behavioral) dependence while the second and equally difficult level of acceptance takes place through inner work and the five inventory steps found in these programs. The acceptance of imperfections within self is challenging but it serves as a gateway to the acceptance of imperfections found in others. Typically, the active addict or substance dependent person seeks to control feelings of inadequacy through the use and abuse of a substance of choice. The decision to live in the face of raw emotions without the use of a substance is difficult because it forces the addict to rely less and less on approval from others for feelings of self-worth and more on the acceptance of self as imperfect. Bill W, AA’s co-founder, writes about ‘emotional sobriety’ as a process through which the individual learns to accept and love the self as imperfect. The recovering addict gradually finds acceptance and peace within the inner self. Even the existence of God ‘Higher Power’ is found

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within the self rather than in an external reality. The discovery of a personal God in other persons is an extension of a God found within the self. A second way in which my nursing students learn about the ways of spirituality and the importance of making right choices is by keeping a daily journal of how they find meaning on any given day. Journaling is a great way to uncover how we prioritize the meaning of life. Most of this activity goes on in the dark recesses of the unconscious until we forcibly bring it out into the light of consciousness. All persons are spiritual because everyone seeks to make sense of the world of experience. The students are expected to journal 50 to 60 daily entries each term and to write a 3000-word term paper on the spiritual experience of finding meaning. They are learning about their spirituality and most importantly recognizing it as a measure of internal work and personal growth. A spiritual person is thought to be compassionate, caring, loving, and able to express sympathy and empathy for the suffering of others—qualities which we usually expect to find in nurses and medical doctors. And for this reason, we expect that health care will be holistic. But the reality is that health care workers are trained to fight disease, not spiritual illness. All humans appear to be attracted to the good. Studies on babies find that the attraction to the good is an innate tendency rather than a learned behavior. All persons will display the qualities of compassion, love and concern about the well being of others unless they learn otherwise from society. Thus, the focus towards holistic healing does not come from a physician’s skill set but from personal relations. Spirituality is most often mistaken for religion because of their deep connection. The spiritual is associated with the tendency towards God as the ultimate good of life. Religious beliefs, on the other hand have in common (A) the attraction to the good, (B) the belief in the existence of God, and (C) the belief in the existence of a personal afterlife state with the God of Abraham religions. The clearest expression of the connection between spirituality and religion is found by expressing these three connections on the arms of the person-making process; (1) the carbon-self, (2) the socialself, and (3) the internal-self;

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The religious tendency towards good, God, and eternal life manifests itself in the spiritual nature of the personmaking process. (A) the carbon-self is attracted to the good of life because it resists disunity and personal death. The greater the unity of an organism the greater its health. Medicine plays a major role in the struggle against the destructive force of disease. The ‘we’ in the ‘me’ moves towards the realization of the ultimate meaning of life. (B) But the patient is a being in relationships that has a disease. The patient is not that disease. The fact that a patient has a disease affects relationships with family, friends, neighbors and community-at-large. (C) The patient is a being-towards the resurrection. The destruction of matter is contrary to the ways of human understanding. The individual-in-community that is currently writing this piece cannot think of himself existing outside the relations of community, living and dead. The ‘we’ in the ‘me’ lives on in the deceased ‘me’ as something of the deceased ‘me’ lives on in the ‘we’ of the living. The ‘we’ in the ‘me’ is present in the communion of souls that exists in the presence of the eternal in the temporal and in the presence of the temporal in the eternal. The ‘we’ in the ‘me’ rejoices in the discovery of the ultimate meaning of life in God.

Spirituality and personalized medicine The stream of carbon-based atoms acts towards the good of life by resisting destruction, and by developing the view of others as being an extension of the self and healing the internal self by recognizing the presence of the ‘we’ in ‘me’. Spirituality can go sour in any of these three streams of person-making associations. From the point of view of the carbon-self, spirituality goes sour when the need to fix emotional pain is replaced by dependencies on substance use and/or certain behavioral actions such as undisciplined sexual dependencies and irresponsible gambling habits to fix emotional states. It seems to me that the solution to this problem is best addressed by recognizing that the patient is connected to other persons as well as an environment of choice. Studies have shown that a heroin addict is more likely to overdose when the substance is ingested in a new environment as we saw above. The overdose takes place not because of an increase in the dosage but because the new environment does not give the

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auto immune system time to prepare for the incoming onslaught. Spirituality goes sour when a person uses sex with another person to fix negative emotional states such as depression, anxiety, guilt, fears, feelings of insecurity and lack of self-worth. The point is that the same spiritual tendency that prompts us to act towards the pursuit of the good can mistakenly identify the existence of good in a destructive place. The challenge is to itemize all the strings of relationships that characterize a person. These broken strings exist on the arms of the person-making process. I developed the term spiritual welding a few years ago so that doctors, nurses, psychologists, and social workers could readily identify/cure/heal the place of a broken associations. While it seems evident that many broken strings exist in the carbon-based associations, it seems equally clear that the view of the patient as a person in relationships moves beyond the atomistic conception of the patient to include significant others. Medicine alone cannot fix a broken internal-self. I have in mind the image of a patient that is sent home once the disease is cured, only to commit suicide because of a broken spirituality association in the internal-self. While the nature of the internalself is laced with mystery, it seems evident that some emotional states such as anger, jealousy, fear, and such arise because of a projection through which our own personal insecurities are mirrored in the behavior of the other. What the ‘we’ in ‘me’ dislikes about the other is probably something that I dislike within myself. The anger or resentment I feel towards the other disappears once I am at peace with what goes on within my broken psyche. No one expects to be completely disease free or in a state where a perfect unity of parts exists because age itself causes wear and tear on the organism’s unity. And no one expects to attain perfect peace, a complete healing of the broken self in this life because we are designed to be broken or at least move daily towards brokenness, disunity and death. The point is that we strive to fix our relations, make amends, eat healthier, exercise, and take advise from doctors, social workers, analysts, pharmacists etc., and hopefully an ethicist now and then. One of the tools that helps me most to stay the course on a good spiritual diet is the knowledge of my temperament. Carl Jung’s pioneering work on personality types finds 16 different temperament types expressed

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in the relation between extravert and introvert, sensing and intuitive, thinking and feeling, judging, and perceiving.88 While the goal of a healthy personality is to individuate, that is, to integrate the contents of the unconscious into consciousness, most of us are somewhere on the road towards that objective. The problem is that what happens in the unconscious does so in the ‘dark’ because we are unaware of the contents of the unconscious (that is why it is called the unconscious). The risk of failing to individuate is that we can be controlled by these unknown forces that lie deep within psyche. Let me illustrate with the clash of temperaments that can happen between partners. I am an INTJ type while my partner is an ESFP, my polar opposite. The ESFP function is buried deep within my psyche. I need to individuate, that is, integrate the characteristics of this temperament into consciousness or my way of seeing the world to become a better person. This is easier said than done. In the early days of our marriage these opposite functions were thought to be obstacles to personal growth rather than complementary. They represent different ways of seeing the world (the inside trying to make sense of the outside). In this day, my wife and I can still disagree about issues, but we recognize that we can learn from each other. My temperament type explains why I prefer to meditate on the meaning of the words of the Lord’s prayer rather than rush through a series of prayers. It explains that what is foreign to me such as the sensing and perceiving functions lead me in the direction I must travel to individuate. The knowledge of temperaments also leads me to a fuller understanding and acceptance of why I see the world the way I do. Spiritual growth is slow and often painful as we learn to accept and integrate our personal weaknesses. But the awareness of the process is also a source of strength because it builds a bridge to the acceptance of the other as an extension of self. I would appreciate others coming out of the temperament closet! Carl Jung’s work on dreams contains valuable information for nursing students. The goal of journaling dreams is to become increasingly aware of our personal choices so that the higher goal of finding sacred meaning in life does not get buried under the cover of secular dreams. We read Florence Nightingale to become more aware of the value of sacred goals and how they trump secular goals. In my opinion, the nurses that step

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See Chester, Michael, & Marie, Norrisey, Prayer and Temperament, (Charlottesville, Virginia: The Open Door Inc.), 1984.

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out of their ego to become more attuned to the needs of others are the next generation Florence Nightingale.

Conclusion It seems possible to develop a questionnaire animated by the characteristics of spirituality, religion, and medicine on the arms of the person-making process. The following questions provide a guide for personalized medicine. It arises in part out of an earlier paper ‘Guidelines for Conducting a Spiritual Assessment’ I published in Palliative and Supportive Care (2013).89 Focus: Spirituality, Religion, and Personalized Care:

Glossary of Terms Spirituality is an innate search for the ultimate sacred meaning of life. Religion or religare uses sacred symbols and rituals to establish a connection between the faithful and God. Religion is characterized by the attraction to the ultimate good, a belief in the existence of God as source of ultimate good, and a belief in the existence of an afterlife state. Human Nature is the term used to characterize a rational technological animal made in the image and likeness of God. Person is a process or human being in action. We become personal through action at three main streams of relationships—the level of the carbon-self, social-self, and internal-self. Personalized medicine is spiritual welding, that is a systems analysis of the broken spiritual connections or relational gaps that exist at all three levels of relationships.

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Ken, Bryson, K. Guidelines for Conducting a Spiritual Assessment (Palliative and Supportive Care. Cambridge University Press. Table 1: 3–4), 2013. See also my Spiritual Welding 101. The Yale Journal for Humanities and Medicine. June 27, 2004.

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Questions to assess broken spiritual associations on the arm of the carbon-self Do hospital records include current information about all my person-making relationships? Does my disease affect how I find physical and/or spiritual meaning in life? Do I have concerns about my home environment? Do I have concerns about my body (ventilator, transfusion, organ transplant, burial)? Is my physical care satisfactory? Do I have other physical needs? Am I sleeping OK? Is my appetite OK? Do I have a fear of pain? Am I in pain? Am I physically tired, nauseous, do I have shortness of breath? Are sufficient resources available to meet all my bodily and/or spiritual needs? Do I have a fear of death and of what will happen to my body (cremation/burial)? Are my funeral plans complete? Is my hospital environment OK? Am I embarrassed about my appearance? Does incontinence embarrass me? Do I have enough privacy? Is there anything I miss about nature (sun, rain, wind, sky, trees, ocean)? Do I have financial concerns (adequate insurance coverage or pension income for loved ones)?

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Do I have other physical concerns?

Questions to assess broken spiritual associations on the arm of the social-self. Do significant others know I am sick? Does my doctor have access to my list of significant others for organ transplant purposes, power of attorney, funeral arrangements, surrogacy? Does my condition greatly affect how I find social and spiritual meaning in life? Do I have unresolved social issues? What social relationships are most important to me? Is my family supporting me in my disease? Do I worry about what will happen to my family without me? Is my employer supportive? Are friends and neighbors supportive? Do I have the support of my religious community? Do I belong to a social club, prayer group or 12-Step group? Do I worry about what is going to happen to my pet(s)? Do I need to make apologies or amends to anyone? Do I have unmet religious needs? Does my church community, priest, chaplain, rabbi, Buddhist teacher know that I am sick? Do I have anxiety, guilt, fear, or any other negative emotion I need to discuss with someone? Do I want a visitation (wake), funeral service, cremation, burial, if I die? Do I have interpersonal issues in the hospital environment (privacy, confidentiality, secrecy)? Am I lonely; do I have visitors?

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Are visits from nurses, and doctors becoming less frequent? Am I getting the right message from my caregivers? Is there a special way someone could help me? Is it OK for me to cry and show emotion? Do I have other social concerns?

Questions to assess broken spiritual associations on the arm of the internal-self Does my disease affect how I feel about myself? Are my moral/ethical needs being met? Do I find meaning in suffering? Has God abandoned me? Has my disease generated new emotional problems? Does disease change the way I find meaning in life? How am I coping with my condition? Am I ready for death, or do I have death anxiety? Am I at peace (unity of mind and body, happy or sad)? Do I think that others are acting in my best interest? Are my rights to autonomy, informed consent, beneficence, non-maleficence, privacy, confidentiality, justice (access to scarce medical resources) at risk? What is my quality of life? Do I wish for death? Does the existence of an afterlife state worry me? Do I believe in reincarnation? Do I have good Karma? Are my cultural needs met (attitudes, values, and beliefs)? Am I at peace?

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Do I have any unfinished business, outstanding legal issues or political concerns? Do I have financial worries? Do I have any other unresolved issue bothering me? Do I have religious concerns, fears or doubts? Do I think that God is mad at me? Do I think I am going to die? Am I angry, lonely, or depressed? Do I want to negotiate with God for a longer life? How do I feel about my life; have I accomplished what I wanted to do in life? Do I feel I have done the right thing in life? Do I have any other ethical or moral concerns? Do I have other concerns?

Summary: How to Conduct a Spiritual Assessment The holistic health of a patient/client is identified by observing the fit between spirituality as a search for ultimate meaning and the broken relationships identified on the arms of the person-making process. Assumptions A person is a human being in spiritual action on three individuating streams of relationships; the carbon-self (C), social-self (S), and internalself (I). On (C): all living things resist destruction by acting in harmony with the needs of the organism. Disease is a break in this harmony. The movement towards wholeness is innate. For instance, infants are attracted to the good they find in their environment. This tendency towards the goods of the organism explains human restlessness, and anxiety. At first glance, suffering presents as an obstacle to personal growth. On (S) A person’s search for meaning is nurtured by other persons. We are not outside other persons but form an intentionality of personhood with all human, including the biotic community.

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On (I): the search for the ultimate meaning of life, viz: Augustine and Aquinas root source in God. Viktor Frankl and sacred meaning (love of spouse). Søren Kierkegaard’s subjective truth is the individual entering into relationship with objective truth but doing so without the support of reason—leads to anxiety. Application: 1. Ask patients about their choice of ultimate meaning. 2. A journal is used to record a personal search for meaning. It serves as a bridge to the successes and failures of the other. Healthcare workers must be familiar with their own journey before they can motivate patients/clients to undertake a spiritual journey. Self-knowledge is the social gateway that empowers others to undertake a similar journey. Charting results of the spiritual journey on the arms of the person-making process;. Each arm of p-m holds strings of meaning laden association. The 6 systems (society, culture, polity and law, economics, environment including medical resources, and ethics (healthcare codes of ethics) provide lenses through which patient hospital careers are viewed. Over time healthcare workers develop critical questions to assess healing outcomes. The environmental or carbon-based self; 



can use systems such as the Edmonton Symptoms Assessment Scale (ESAS) to help determine quality of life; Alan Williams suggests the use of Quality of Life Year measurement (QALY). death is not an instantaneous process; carbon-self goes through stages of disunity before in dying.

The social-self; 

parents, siblings, friends, neighbors, person-at-large, and pets. Marcel and Sartre illustrate two different extreme choices on empowering/disempowering other persons.

The reflexive-self and how I assess meaning; 

the spiritual thirst for ultimate meaning takes place through the choice of instrumental meaning. Spirituality can be mistakenly put on a bad diet or false senses of meaning in being misled by the

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Remember to practice your kindness lessons. The following observations on spiritual counselling provide a gateway to a patient centered environment.90 I invite my nursing students to keep a daily log on how they find meaning; the goal is to distinguish between secular and sacred meaning and to uncover the role the latter plays in healing outcomes. 1. Develop listening skills, sensitivity, and compassion. 2. Develop intuition; does body language betray a patient’s true feelings? 3. Do not judge others, meet them where they are coming from. 4. Bring comfort to others as you help them face personal issues. 5. Encourage patients to tell their stories. 6. Zero in on how a patient feels. 7. Loss of meaning is dis-ease accompanied by negative emotions 8. The biggest spiritual problem is reconciliation (others, carbonself, and internal-self) 9. Loss of privacy, unable to look after your bodily needs, loss of dignity, discomfort being naked, no privacy—everyone hears everything, dehumanizing aspect of technology. 10. How do medications affect my patient (disoriented, scrambled, confused?) 11. Loss of autonomy 12. Fear of pain 13. Fear of death 14. A heart condition can lead to grief, loss of hope, depression 15. The awareness of personal shortcomings can lead to depression 16. Why me? am I being punished by God?

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Fr. Colin MacKinnon, Chaplain Cape Breton Regional Hospital, Sydney, NS., and I developed these questions in my Spirituality and Health course for nursing students at Cape Breton University, to ensure greater comfort and care of hospital patients. For additional details on that approach see my article Guidelines for conducting a spiritual assessment. Palliative and Supportive Care. Cambridge Journals Online. (2015), 13, 91–98.

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Loneliness; fear of dying alone—friends bring energy and hope. Use your own stories as a bridge to the pain of the other The patient is angry, crying, facing the insecurities of disease. Do I feel awkward because a patient asked me to pray with them? Log each visit on the streams of associations that characterize the patient’s level of comfort on the person-making scale of well-being (patient’s carbon-self, social-self, and internal-self). Refer to the STS tools to ensure that all aspects of a patient’s relationships are examined. Make sure that the patient finds find meaning in the hospital experience. Always remember that ethics drives the engine of medicine as a science whereas metaphysics and the sense of the sacred raise medicine to sacred science.

Chapter Four: Why Ethics Matters Overview Happiness is measured by spirituality in action as the degree of harmony between our person-making relationships and the search for the ultimate meaning of life merge into ethical unison. The following chapter examines the importance of normative ethics, especially medicine’s dependence on the Oath of Hippocrates.

Introduction It costs money to run a business. Medicine is no exception. A balance sheet will determine the precise cost of running the business by calculating what it costs to open for business each morning and how to offset this cost by calculating the number of patients a doctor must see to make a profit. The cost is high because it includes salaries (nurse, receptionist), rent/mortgage, heat, lights, taxes, and insurance. Further, some physicians refuse to perform certain types of surgeries because of the prohibitive cost of malpractice insurance. The patient sees the doctor because they are sick but insist on maintaining their autonomy and informed consent. They do not want to be harmed. The doctor assesses the patient’s needs but in medicine as elsewhere, business tradeoffs are necessary. We run rational risks. We live in an age of business technology and the doctor reserves the right to refuse to accept certain patients. Other patients are referred to a specialist, or a clinic for bloodwork, or to the hospital for x-rays etc. All this medical business is expensive. How is medicine as sacred science possible in the light of economics? Fortunately, medical technology as business is not incompatible with holistic healing because the cost of doing business is offset by other relationships that characterize the person-making process. The problem arises when the business focus overtakes the process (reductivism). The patient as client brings a cluster of relationships and resources into the doctor’s office. To examine the question ‘how medicine is ethical’ we cast it in the light of shared agency. The moral obligation between doctor and patient is based on a contractual model of shared responsibilities. 163

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We recognize layers of shared moral responsibilities. At the most intimate level, the relationships between family members is based on love and trust. At the other end of the spectrum, the relationship is based on hate and distrust as the Sartrean other stands before us as judge and executioner (‘No Exit’). I would not have wanted Sartre as my doctor! The doctorpatient relationship is somewhere in the emotional middle; compassionate care is a business. There are different types of love (letting-be). The relationship between spouses is based on divine love. Saint Thomas says that the divine persons exist in relationships of love proportioned to the divine essence (S.T. 1:29:4). The love between Father, Son, and Holy Spirit is eternal. Human persons are in an analogical relationship of love because it is proportionate to human nature. Human love enlists a network of mutual sharing of responsibilities. To say ‘I love you’ to the other is to help the other to be fully themselves. The doctor loves the patient since the doctor wants the patient to be fully healthy. Love does not cage the other but helps them grow as a person. In a loving relationship the other is an extension of the self. The teachings of the Blessed Trinity invite us to love others as we love ourselves. I think that something of this divine spirit is predicated analogically of the Oath of Hippocrates. The spirit of compassion is never far away from the doctor’s office, despite its business structure. The doctor and the patient share in the responsibility of health as the concern for patient autonomy, informed consent, beneficence, nonmaleficence, privacy, confidentiality, is not too far removed from the lover’s goal to act in the best interest of the other. The doctor strives to bring about the best health of the patient. This focus moves beyond the view of the patient as disease and source of income to incorporate all the significant relationships that characterize the patient’s history. The doctor patient contract is negotiated in the light of joint agency where the doctor’s ethical and religious beliefs are equally transparent to the patient. The doctor has a right and perhaps the legal obligation to make her/his views known on abortion, euthanasia, assisted suicide. Some doctors, for instance do not recognize alcoholism as a disease, or respect a patient’s right to smoke marijuana (in Canada). Full disclosure is essential to good relationships. Patients, it seems to me, have the obligation to ensure that the doctor’s office has a copy of their ‘living will’ if any, along with other endof-life requests, and all relevant information required in spirit of the Oath of Hippocrates as necessary to meet the demands of a dialogic joint

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agency. The goal of this chapter is to examine the ethical bits and bytes of that process.

Ethics regulates relationships Codes of medical ethics are inextricably tied to moral and conventional rights. We are born human but become persons as we enter relationships. Human rights arise through these relationships. To respect the dignity of persons is to respect the relationships that make us truly personal. Our rights are anchored in the existence of metaphysical absolutes. The deconstruction of absolutes leads to ethical relativism, the devaluation of personal relationships, and the loss of human rights. The belief in absolutes includes the religious belief in the existence of a personal divinity. We enter relationship with God through other persons and the environment. The Trinity is a manifestation of God in relationships. To be made in the image and likeness of God is to become one with other persons and the environment through love. This view explains why persons are sacred and why they are treated as an end in themselves rather than as means to an end. This absolute secures the foundation of medical ethics. We are special because God loves us first. Our human rights derive their force from the absolute truth that we are made in the sacred image of a loving God. The removal of this absolutes from medicine reduces the Oath of Hippocrates to ethical relativism where moral issues arise through human construction rather than divine decree. Ethical relativism opens a Pandora’s box where medicine’s code of ethics is interpreted to suit the secular needs of people. In that case, medicine is secular science rather than sacred science. It subsequently has no formal ties with God or any objective code of ethics, rules of conduct other than the relativistic demands of the people. In our day medicine loses its sacred appeal whenever it is built on the shifting sands of an image of the person that commands no reverence because the medical house has no objective foundation. We need to be clear about why we are special and act accordingly. We need to be clear about what it means to be human and about how we become persons. We become personal through participation in the sacred relationships of the divine. We cannot be ethical until we connect divine relationships with our own experiences. This much we do understand about personal relationships: We are necessarily connected to the environment. The environment and persons form an indissoluble unity. The organic matter of the world is an extension of our own

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organic matter. We are carbon atoms existing alongside other carbon atoms. The universe is unfolding, expanding and contracting in ways that parallel our own cellular complexities. The activities of the human brain provide us with a mirror image of what is happening in the universe. We are the nanotechnology of the universe. This is God the Father at work in us through the expanding and contracting universe. To pollute and destroy the environment is to pollute and destroy the human persons because it destroys one of the basic relationships that make us truly more personal. Good medicine is good because it recognizes this absolute connection with the environmental. The attempt to move beyond our nature, to go against human nature lays the seed of our own molecular destruction. The Son of God is also an absolute that allows us to recognize our loving connection to other persons through the Oath of Hippocrates. Medicine is successful because it encompasses all the relations that individuate patients into the treatment model. The other is an extension of me. The union that binds us is love. To love the other is to say to the other you shall not die because you live on in me and through me. The person is not now or ever an individual isolated atomistic datum of existence. To deconstruct the patient as a separate entity is to destroy the fabric that grounds the possibility of society and civilization. Medicine cannot operate in the false pretense that a patient presents as a separate entity, separate from family, friends and community. To separate a patient from community is to produce an abstraction that has no ontological reality. The claim that the I can exist apart from others is false. We learn this lesson from René Descartes. When Descartes calls the existence of the world into doubt and proceeds to announce his clear and distinct perception of himself as a thing that exists whenever it doubts is mistaken because it is founded on an untenable premise. To call the existence of the world into doubt is to destroy the very existence of the thinking self. The self cannot exist without its object any more than the molecular self can exist without its relational foundation in community. God the Son is an absolute given that is required to secure the possibility of the relational model of medicine. The dignity of the person is also rooted in the sanctity of the human heart where the qualities of love and compassion are born in the ways of the divine. This is God the Holy Spirit at work in us and through us. Medicine’s focus on compassion is nonexistent without the absolute. Cultural relativism does not and cannot safeguard the fabric of medicine and the delivery of compassionate care. How dare the laws of the land deconstruct human nature by removing the sacred

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entrails of what makes us persons without putting the sanctity of medicine and the Oath of Hippocrates in peril. In peril, nay that hardly cuts it because it is more than in peril, it ceases to exist! The political illusion today is that money is the new absolute. Medicine demands its authentic deontological ethics, its compassionate care of others, its sacred rituals and symbols, its holistic care of patients in relationships, its soft social action, but it can only deliver the sacred promise expressed in the Oath if it maintains a grip on why we are special, and how the divinity provides an absolute standard to keep medicine as sacred science. The absolute empowers us to retain an image of the person that is sacred, it empowers us to respect persons as end in themselves, and it prepares us to meet the next revolution in medicine—genetic screening and engineering. The medicine of the future will enable us to treat patients before they become sick by diagnosing the genetic combinations that generate illness. But unless the vista of the absolute is maintained, medicine will devolve into an assembly line as technicians sit side by side with other technicians to install parts in the human model each year. Perhaps our diet will shift from proteins to solar power as we become less divine and more robotic. The experiences of the Second World War led to the development of the Universal Declaration of Human Rights, adopted by the UN General Assembly on 10 December 1948, as the international community vowed to never again allow atrocities like those of that conflict to happen again. The cornerstone of the Universal Declaration of Human Rights lies in the belief in the dignity and worth of the person. The development of spiritual principles of conduct to safeguard the sanctity of human life is a logical outcome of this belief. The Commission agreed on a pluralist approach to why the person is sacred and therefore in the nature of ultimate reality. Hernán Santa Cruz of Chile, member of the drafting sub-committee captures the spirit of the world gathering as he wrote; “I perceived clearly that I was participating in a truly significant historic event in which a consensus had been reached as to the value of the human person, a value that did not originate in the decision of a worldly power, but rather in the fact of existing—which gave rise to the inalienable right to live free from want and oppression and to fully develop one’s personality.”91

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http://www.un.org/en/sections/universal-declaration/history-document/index.html accessed 26 January 2018.

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The Declaration of Human Rights, it seems to me, is founded on a deontological belief in the value of normative standards to safeguard and promulgate the highest values of the human condition. While the DHR was drafted by representatives from all regions of the world its primary value lies in its appeal to the human condition rather than law. This is because of the different legal and cultural backgrounds of these representatives. The medical community participates in a like-minded belief in the value of a deontological code of ethics based on the sanctity and dignity of human life rather than on law and economics as such.

Dialogical Ethical Theories Ethical theories are grouped into four main types with arteries in each category to help guide moral conduct. The first group of ethical headings is placed under the heading of normative ethics which are a priori or deductive and move from the top down so to speak. Descriptive ethics as well as professional codes of conduct arise from hands-on experience in the field. Aristotle’s virtue ethics, Aquinas’s natural law ethical theory, Kant’s deontological ethics, and Mill’s utilitarian ethics are instances of normative ethics. The doctor patient relationship moves among these forms of normative ethics. Clinical medical ethics is not unrelated to factors in environmental ethics and bioethics. Natural law ethics claims that the morality of an act is based on human nature, that is an act is moral if it is in harmony with that nature. Human nature is a dynamic concept. Natural law derives its force from the Eternal Law which is the law of the divine governance of things. The text of Genesis 1:26 announces that we (human beings) are made in the image and likeness of God. A person is a human in action. The claim celebrates free will and the choice to enter person-making relationships. The morality of an act depends on the degree of conformity between the choice of associations and human nature. Thus, human nature expresses the ontological ground of the possibility of ethical behavior whereas the person-making process actualizes that possibility. The development of positive laws that are in harmony with human nature safeguards the possibility of ongoing spiritual goal as we move towards our intended end. The purpose of law is to promote moral rules of conduct to protect the rights of individuals as they strive towards the common good of a society. The law applies the ethical standards of human nature, it does not

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create the ethics. Law derives its ethics from systems theory. Unfortunately, in our day the culture of ethical relativism appears to direct the course of medical ethics. It becomes increasingly difficult to safeguard the universal, deontological, character of the Hippocratic Oath in the pluraculture. This creates a problem as we seek to apply normative ethics to the person-making process in such a way as to promote the life and health of the person worldwide. But natural law ethics cuts across all cultures because it is based on human nature and what it means to be a person. On this ground, we find no justification for hate and violence among nations. Deontological ethics does not affirm euthanasia and assisted suicide although positive law takes it upon itself to enact legislation to justify these end-of-life options. The law of the land founds its judgements on these matters based on the will of some individuals and the secular interpretation of quality of life. While the proponents of natural law ethics disagree with that view of suffering and the meaning of life, some members of a democratic society advocate alternative normative standards such as consequentialism as they strive to maintain a course of action that appears to be in the best interest of most citizens. This process is in harmony with the scarcity of medical resources and the need to maximize benefit for most citizens. Deontological ethics, on the other hand, proclaims that we ought to act out of duty and respect for the moral law irrespective of consequences. Immanuel Kant provides two tests of moral action; (1) “I ought never to act except in such a way that I can also will that my maxim become a universal law”, and (2) “Act in such a way that you always treat humanity, whether in your own person or in the person of any other never simply as a means, but always at the same time as an end.”92 The fact that some Jehovah Witnesses refuse a needed blood transfusion even if it means personal death is a case in point. Some beliefs are worth dying for. Natural law and deontology base their ethical claim on a belief in the existence of God. Not everyone believes in the existence of God, however. Jean-Paul Sartre, for instance bases his ethics on humanitarian ground as we agree to come together to overcome the scarcity of goods. At first brush the principles of Humanitarianism and Unitarianism appear to be cut from the same cloth.

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Immanuel, Kant, Groundwork of the Metaphysics of Morals. H.J. Paton (trans.), (New York: Harper & Row, 1964), 70 and 96.

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Bill, a Unitarian minister is one of the kindest persons I know. Bill follows his bliss by acting towards the pursuit of the sacred good as directed by spirituality through acts of compassion, kindness, and sharing with persons less fortunate. Happiness is a measure of the harmony between the person-making process and the search for sacred meaning. The following praiseworthy principles are affirmed and promoted by the Unitarian fellowship: “(1) the inherent worth and dignity of every person; (2) justice, equity, and compassion in human relations; (3) acceptance of one another and encouragement to spiritual growth in our congregation; (4) a free and responsible search for truth and meaning; (5) the right of conscience and the use of democratic process within our congregations and in society at large; (6) the goal of world community with peace, liberty, and justice for all; (7) respect for the interdependent web of all existence of which we are a part.”93 The Unitarian practice of ‘virtue ethics’ is open to all truth values through acts of kindness, and compassion towards everyone. Bill, as all Unitarians, is open to all truth values, all beliefs, including the absence of beliefs. Why is it that the deontological character of the Oath of Hippocrates seemingly collapses in the face of Bill’s Unitarian gospel? Is not the Oath based on a similar respect for the dignity of other persons? This paradox, it seems to me is based on the appearance of a deficient metaphysics that would otherwise lead to chaos and skepticism. The paradox is explained through an application of the STS Toolbox. Unitarians accept a universal view of all systems, thematic contrasts, themes, and ethics. Their view of the absolute is inclusive. Perhaps they are unaware that their metaphysics of the person is rooted in an all-inclusive vision of God. If the Unitarian gospel was relativist, it would ultimately promote disorder rather than order, division rather than unity, which it does not. The rejection of absolutes leads to ethical relativism. The fact that Unitarianism is not relative to the core confirms the structure of mind detailed in chapter 2. The universal tendency towards the discovery of the ultimate meaning of life and the desire to do good provide empirical evidence of the existence of an absolute. The denial of the existence of the absolute ground of ethics suggests that we are not always aware of the psychological processes that animate our scientific inductions. Sometimes the culture of relativism gets in the way of the truth.

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www.uusarnia.com accessed 3 March, 2018.

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We read in scripture that Jesus cast out demons. But some in the crowd said that He did so by Beelzebub, the ruler of the demons. The Gospel (Luke 11.14–23) reports that “Every kingdom divided against itself becomes a desert, and house falls on house.” This is cultural relativism at its worst. If Satan is divided against himself, how will his kingdom stand? Relativism is the curse of the age because it grants equal value to all truths and opinions including the absence of truth. If the Unitarian principles on the worth, and dignity of the person along with the cry for justice stands the test of time it must be because we view these principles through the eye of an absolute standard such as the existence of God, and the ultimate triumph of good over evil or the role of the Church in these matters. But how is the ‘inherent worth and dignity of every person’ measured in the absence of an absolute standard, as is seemingly the case in cultural relativism? The cultural relativists must accept that at least one truth is absolute, namely the possibility of their claim. Saint Paul’s letter to Timothy makes the point; “…having itching ears they will accumulate for themselves teachers to suit their own liking and will turn away from listening to the truth and wander into myths.” (2 Tim 4:3–4). The Hippocratic Oath is an instance of deductive ethics, specifically deontological ethics and is based on solid metaphysical ground (the belief in the existence of absolutes). Descriptive ethics, on the other hand, is inductive as it moves from the ground up as we learn to do the right thing from experience. Professional codes of conduct such as the association of computing machinist, engineering, and architectural ethics fall into this category. Common sense etiquette, the use of precedents to determine points of law, and the observed choices that a people make in their community also provide instances of descriptive ethics. In time, descriptive ethics leads to the establishment of normative codes of behavior that professionals are expected to follow in their chosen area of work. We learn from game theory that a positive first move is always the best course of action to follow. The doctor’s decision to respect the dignity of patients is returned with the kindness and admiration from patients and thereby confirms the beneficence of the Hippocratic oath. Perhaps Hippocrates formulated his Oath after many years of medical practice? The next group of ethical theories falls under the umbrella of applied ethics. This type of ethical theory is growing in use as the global community strives to reach agreement on public policy. The challenge is to respect

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national cultural boundaries while being respectful of international cultures. The DHR seeks to avoid neo-colonialism, that is controlling weaker countries so that citizens are not free. The goal is to develop sound healthcare policy for everyone. R. Gillon (1994)94 establishes four principles of medical ethics as respect for autonomy, beneficence, nonmaleficence, and justice. The principle of beneficence directs the nurse’s action to the promotion of good; described as what is best for a patient. This includes the patient’s right to privacy, secrecy and confidentiality. The patient is not to be harmed (nonmaleficence). The principle of justice promotes a just and fair allocation of scarce medical resources. Further, spiritual centered care is based on compassion, empathy, and expressions of kindness towards the patient, as is holistic medicine (carbon-self, social-self, and internal-self). The application of ethical principles must also be seen to include a focus on the relational nature of patients and clients, that is their societal connections with family, friends, and community resources. Applied ethics usually leads to the development of a normative ethics and the establishment of ethical standards in a discipline, although these developments can be painfully slow. The development of environmental ethics is a case in point. While the Global Green Charter was established in 2001, we have yet to reach global agreement on controlling carbon emissions. The focus in our day appears to be on economic development rather than human development. Medical ethics fuses with bioethics and serves as a subset of environmental ethics. The hope of medical ethics is that the shift towards an all-inclusive view of patients happens quicker than developments in environmental technology. Environmental ethics also includes engineering ethics, and journalistic ethics. I think that the model we use to negotiate environmental ethics as a tradeoff between the rights of persons and the rights of the environment go hand in hand. A human being’s organic connection to the environment functions as an extension of the human person. The ongoing existence of human rights is dependent on the (structural) conservation of the environment’s unity or right to life, ontological truth (to enlist a hegemony that follows the clarity of nature), ontological goodness (nature is pleasing to the human appetite for order and harmony), and beauty (integrity, harmony, and clarity of nature). The negotiation between

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R., Gillon, Medical Ethics: four principles plus attention to scope. BMJ 1994 July 16; 309 (6948): 184–188.

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personal rights and the rights of the environment is based on cost-benefit accrued to both parties. For successful negotiations, the environment must be seen to have standing rights that can be represented in a court of law. Any award to the environment granted by the courts must be seen to go to the environment, such as land restoration awards. Personalized healthcare is founded on the principle of respect for persons seeking medical assistance, and the ethics of research involving human subjects as detailed in the Belmont Report (18 April 1979).95 The agreement between the doctor and the patient must be negotiated as both parties bring their constructivist perspective to the medical table. The distinction between four main types of medical models illustrates how the joint responsibility of doctor and patient is served best. (1) While the original version of Hippocratic Oath is a valued and sacred oath (see below) it is seen to be paternalistic. The (1982) formulation less so. (2) The Engineering model of medical ethics: the avoidance of paternalism does not shift authority to the patient. They do not have the training that a physician brings to the table. Acquiescing to a patient’s demand for drugs has hurt the health industry. Much harm comes from a doctor too eager to fill a patient’s demands for narcotics and anti-bacterial medication. (3) the Collegial model is an equally inappropriate vehicle for patient care. The doctor and patient are not ‘best friends’ working to solve health problems at the golf course; (4) the contractual model is desirable because of its flexibility, professionalism, and dialogical character as long as the dialogue is egalitarian. The conversation brought to the doctor patient meeting is based on validity claims and not on the power structure. The doctor and patient discuss a proposed treatment method and outcome, but if either party dislikes the terms of the arrangements, the contract is not made or is broken. Patients have the right to seek a second opinion, and doctors have the right to refuse to accept a non-compliant patient for treatment. The contractual model offers each party the opportunity to make known their ethical, societal, and cultural views. The onus is on patients to ensure that all their societal data is made known to the healthcare team. The patient brings a history of personal relations consisting of societal groups, cultural atti-

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On July 12, 1974 the US National Research Act was signed into law, thereby creating the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The report was issued on 30 September 1978 and published on 18 April 1979.

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tudes, political (legal) parameters, and economic concerns into the contractual model. This is the place to iron out ethical choices before striking the contract between doctor and patient. The contractual vision of the doctor patient relationship provides the best platform to negotiate ethical protocols. While a doctor’s and nurse’s professional training is based on the inductive observation of a patient’s reported symptoms, it seems that the best ethical protocol will be based on utilitarian principles of ethics. The patient’s ethical approach to the medical contract is, I think, normative while the doctor brings empirical observations of the disease to the proposed contract in that it appears to descend from above to meet the doctor’s empirical observations. In addition, the doctor is guided by a spiritual attraction to the good of healthy outcomes.

The Oath of Hippocrates From the point of view of normative ethics, all newly qualified doctors pledge adherence to ‘the Hippocratic Oath’. Hippocrates of Kos (460–377) BCE is generally recognized as the father of medicine. While clinical medicine is based on observation and rational deductions, rather than on myth, the origins of medicine appear to be grounded in theology and the doctrine of creation ex nihilo (out of nothing) of the ‘chaos,’ (possibly water) as a divine primordial condition. Elements of theological beliefs are present at the earliest beginnings of medicine. Hippocrates was influenced by Pherecydes of Syros (580–520) BCE who believed in the theory of metempsychosis which is the transmigration of the soul, usually in the form of reincarnation. Cicero and Augustine claim that Pherecydes held the first teachings on the immortality of the soul. While his work has not survived, the reasons for reincarnation are usually associated with the process of becoming better persons. This explains in part why the Hippocratic Oath places strong emphasis on ethical ideas like respect for the sanctity of human life, duties of confidentiality and secrecy, avoiding harm, justice, respect for the teachers of the art of medicine, and solidarity with peers; I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own

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sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion (italics added).With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!96

How does Hippocrates know to think about the sacred character of medicine, and why does he subscribe to the benevolence of nature? While theological influences could play a role in the Oath, I think that the simplest explanation is found in the structure of human understanding and the natural attraction to the good discussed in chapter 2. He was influenced by the Pythagorean theory that nature is composed of four main elements, namely earth, air, fire, and water. In an analogous way, he thought that the body was made up of four fluids (black bile, yellow bile, phlegm, and blood). Disease was the result of an imbalance between those fluids. The physician had to reinstate the healthy balance between these fluids. While the techne of medicine is empirical, the desire to promote life by restoring balance to the body is not empirical. Nor is the belief in the benevolence of nature empirical. The phenomenology of medicine gives witness to a dialogue between the (deductive) subjective and (inductive) objective correlates of consciousness. The practice of medicine is a mode of dialogue imposed on these two correlates in such a way as to restore the organism’s health. Hippocrates’s contribution to medicine is immense. Asclepiades of Bithynia (124–40 BCE) was the first physician to establish medicine in Rome. He did not accept the theory of a ‘benevolent nature’, however. He relied primarily on the clinical observations of nature. Following the Atomist school of thought, Leucippus and Democritus

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The text of the Hippocratic Oath is available under the creative commons attributionsharelink license. For additional details see https://creativecommons.org/licenses/bysa/3.0/

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were able to resolve the seeming contradiction between the views of Heraclitus (change is the only reality) and Parmenides (change is an illusion) through a doctrine of the displacement in space of fundamentally identical and immutable particles—in the same way that the same letters of the alphabet can be arranged to compose a comedy or a tragedy depending on the place they occupy is space. Asclepiades appears to have imported this first atomic theory of matter into medicine to explain disease through an alteration of the place occupied by molecules in the human body. He was first to speak about what is known today as molecular medicine (objective correlate of consciousness), but he also introduced the friendly, compassionate, care of patients (subjective correlate of consciousness). He favored healing therapeutic methods such as a healthy diet, physical exercise, and massage.

Abortion The direct termination of the life of the unborn is one of the consequences of ethical relativism. The failure to recognize the connection between normative ethics, Charter rights and law is a source of confusion and division. The abortion controversy in Canada is a case in point as the debate between a woman’s legal right to abortion in the first trimester of pregnancy and the Church’s teachings against abortion rages on. The Federal government’s decision to make agreement on a woman’s ‘reproductive rights’ a central issue in the current round of job grants has alienated the Church from applying for these grants (CSJ 2018) to hire students this summer. Marilyn Gladu MP, Sarnia-Lampton, objects to the exclusion on the ground of Charter rights; “the attestation itself appears to be in violation of the charter rights of individuals under the freedom of religion of faith groups to hire those who follow their faith. A court challenge against the Liberal government is in the works because it is seen to “discriminate in granting funding to any Canadian organization under the Charter rights granted to Canadians.”97 The governmental requirement raises the possibility of civil dissent. Some Canadians are against abortion for ethical reasons while others object to abortion on the grounds of religious faith and the protection it ought to receive under charter rights and freedom of reli-

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The Federal Express. M.P. Marilyn Gladu. Sarnia-Lambton. Vol 2. Issue #4 Winter 2018.

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gion. I think that the confusion is based on the failure to distinguish between deontological ethics and the situational ethics of the day. In a democracy, unfortunately, the law is driven by the political will of the people, not by normative ethics. In our day, ethical relativism is seen to trump the absolutism of deontological ethics. But the principles of Charter Rights are based on normative ethics, as is the Oath of Hippocrates. The application of Charter rights to resolve the abortion issue is based on ethical relativism or the changing whims of the people. Therefore, our age stands for a representation of the person that commands no reverence. The confrontation between Charter Rights and the will of some (marginalized Christians) was bound to happen and worse yet, destined to continue to happen to whomever is marginalized by ‘the will of the people’. The problem is compounded by the fact that this situation extends to medical ethics (and other areas of ethics) as the deontological foundation of medicine gives way to the ad hoc ways of politics. The move flies in the face of human dignity as the individual is seen to be treated as means to political power rather than as the dignified champion of charter rights (and trust in God) contrary to the medical principles of the AMC, CMA, and Worldwide codes of medical ethics. Clearly the policy puts the cart before the horse and is sowing the seeds of its own inevitable dissolution as is to be expected when you build a foundation on the dirt of ethical relativism. Canada is a secular nation; Justice Bertha Wilson says that the Charter protects a woman’s rights (S.7) to an abortion. The U.S. Supreme Court similarly affirms the legality of a woman’s right to have an abortion on the grounds of the woman’s constitutional right to privacy (Roe V Wade, 410 U.S. 113, 22 January 1973.) In 1988, the Supreme Court of Canada struck down Canada’s abortion law as unconstitutional under the Charter of Rights and Freedoms for infringing on a woman’s right to life, liberty, and security. However, a dilemma arises for doctors who oppose abortion on religious or ethical grounds. The law puts them in a conflict of interest with their Charter Rights “with respect to freedom of conscience, freedom of religion, freedom of thought, freedom of belief, and freedom of expression.”98 They are forced to choose between two evils—the loss of a job or being unethical and in violation of the principles of the Hippocratic Oath.

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David Raes (February 1, 2018). Editorial. Liberal government has misfired on summer job grants. The Sarnia Journal (note: the Sarnia Journal is an award-winning weekly newspaper).

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Further, the Canadian Liberal government’s policy that grant workers must support abortion rights if they want to access tax payer funding this summer (2018) reflects the bias of law makers rather than the ethical view of Canadians. It undermines social cohesion, and the religious belief shared by many in the Islamic, Jewish, and Christian communities on the sanctity of human life. The failure to distinguish between the methodology of ethics, the Charter of Rights, and positive law remains a principal source of confusion. The normative character of deontological ethics is deductive whereas the force of Charter rights and the promulgation of laws relating to the Charter arise from the inductive examination of empirical evidence. We expect to find that the structure of a just law reflects a proper balance between deductive and inductive principles. We expect that deductive principles will descend to animate the particular experience of some individuals. But what we find in place is an artificial ethical construct where the right thing to do depends on most people. The politics substitutes for the ethics! What we expect from medicine is an interdisciplinary blend of inductive and deductive processes that recognize the primacy of co-principles. The deontological basis of human dignity is not grounded in the observations of medicine, while the empirical nature of disease is not rooted in the deductive claims of deontological ethics. Each perspective is important as it brings its insights to the table of dialogic medicine so that together they generate a humanistic medicine that is at once true to science and true to the Oath of Hippocrates—sacred medicine. The controversy surrounding abortion revolves around three additional interrelated issues—the religious view, the viability of the fetus, and the determination of when a fetus is a person. The Roe V Wade ruling on a woman’s right to abortion applies to a fetus in the first trimester of life, that is before the fetus is viable or capable of a meaningful life outside the mother’s womb. Rapid developments in science and technology make it increasingly difficult to maintain a precise cut off point for viability. A person is more than the sum of measurable parts. Whereas in an earlier day everyone knew more less when a fetus was viable, today we can maintain the life of a fetus independently of the mother. The religious view, on the other hand, is losing ground in our secular society where fewer than 20% of the population attend church on a regular basis. In my opinion, the strongest case against abortion is strengthened by including a third argument for a fetus’ right to life, namely that the fetus is a person because it

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is seen to engage the person-making process from conception. The decision to examine these issues based on interdisciplinarity is critical to the following argument because it makes use of the distinction in philosophy between being human and being a person as we saw in chapter 2. We are born human but become spiritual persons through our actions. Our personal actions take place in three streams of associations. The first and most basic set of relations take place at the level of matter and energy. The organic relations of the fetus are evident from the first measurable moment of conception as the cells of fertilized egg spring into action through the addition and division of cells (miosis and mitosis). The fetus’ DNA connection to its parents is evident from the beginning of life. The second set of relations takes place through interactions with other persons; the fetus’s social connection to the mother begins at the outset to establish a lifelong bond. Many women who had abortions regret the act years later, including the original petitioner Jane Roe (Norma Leah McCorvey Nelson). She became a member of the anti-abortion movement in 1995 and supported making abortion illegal until her death in 2017. The third set of relations that transforms humans into persons take place at the level of the psyche. The fetus gives evidence of self-awareness after the fact of birth but the processes that accompany self-awareness must likewise begin at conception given the evidence for the existence of innate ideas and the infant’s natural attraction to the good. These relationships make us truly personal from the first moment of our temporal beginning. The evidence suggests that pre-verbal infants (3-month-old) are attracted to the good ‘puppet’ and avoid the nasty ones. Thus, the fetus’ right to life and security of the person is guaranteed under the principles of deontological ethics, the Charter, and law, contrary to the current interpretation of the law. Society has an obligation to ensure the safety of women as well as the fetus by providing resources to pregnant women. Threats to a pregnant woman’s safety often translate into an unwanted and undesirable threat to the safety of her fetus. The humanities tradition of medicine seeks to provide aid to women with unwanted pregnancies by finding viable options to abortion. Some of these resources are found in the academic disciplines like sociology, psychology, and economics, and in our communities. In principle, the medical profession today continues a long-standing tradition of providing compassionate care and respect for the human dignity and rights of patients. The physician regards responsibility to the patient as paramount. The following principles of medical ethics, revised

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June 2001, copyright 2016, appear here with permission from the American Medical Association (AMA).99

AMA PRINCIPLES OF MEDICAL ETHICS Preamble The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following principles of medical ethics are adopted by the American Medical Association as standards of conduct to define the essentials of honorable behavior for the physician. They are principles rather than laws. Principles of medical ethics I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

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AMA Principles of Medical Ethics (2001). https://www.ama-assn.org/sites/default/files/media-browser/principles-of-medical-ethics.pdf accessed January 18, 2018.

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VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. IX. A physician shall support access to medical care for all people. The 2001 text of the AMA code removes the reference to the pagan deities found in the Oath of Hippocrates but retains the focus it places on developing ethical statements for the benefit of the patient. It serves as a guide of ethical conduct for physicians. The short statements contained in the code represent an attempt to “balance the dynamic tension between professional standards and legal requirements.”100 That decision is incorporated in Principle V to maintain a multidisciplinary commitment to medical education, and in Principle VI on providing the freedom to choose whom to serve. The existence of an ethical conflict between doctor and patient is reason not to accept that individual as patient, except in cases of emergency. The Principles of Medical Ethics “are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.”101 The environment of medical practice remains open to the introduction of new science and technology, and “socioeconomic changes in the organization of medical practice.” (italics added). The vision of the patient as a person-in-community-relations provides an instance of this sort of change. In my opinion, this change is required to shed light on the rapid developments taking place in medical technology; “aspects of human cloning, conflicts of interest in clinical trials, ethical considerations in encouragement of donation of cadaveric organs for transplantation, interactions with and inducement from the pharmaceutical and medical device industry, electronic communications with patients, and issues of privacy

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101

The Ochsner Journal (2003). The Code of Ethics of the American Medical Association. P. 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399321/ accessed January 19, 2018. Ibid., p.2.

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and confidentiality of patient’s personal medical information.”102 Developments in biotechnology introduce new STS systems issues about informed consent, patient autonomy, privacy, confidentiality, education, counselling. The Nuffield Council on bioethics provides a forum for ongoing discussion on these issues.103 One of the hot button issues in our day is privacy. Personal privacy is a social issue as we learn from the action of Cambridge Analytica as they successfully harvested 87 million Facebook profiles for political use in the Trump-Clinton campaign for President of the U.S. George Orwell’s 1984 is right, ‘Big Brother’ is watching us all the time. Deontological ethics will continue to struggle to accommodate this complexity until we shift from ‘atomistic ethics’ to ‘relational ethics’. Our moral decisions have consequences on our families, friends, and communities. For instance, the invasion of the individual’s privacy has consequences for all the individuals in that person’s social relationship profile. Medical ethics strives to be apolitical, although it seems difficult if not impossible to isolate politics from related STS systems such as culture, society, economics and the availability of medical resources. However, the atomistic view of ethics fails to include all the elements of the STS Toolbox. The spirit of the AMA code is to ensure that ethical policy is not subject to ‘the tide of popular vote.’ At the end of the day, new developments in medical ethics shall change the nature of the doctor patient relationship from treating the symptoms of disease to predicting the onset of disease in the developing fetus and the consequences of this discovery on the family of origin and community-at-large. The ripple effect is felt on all components of the STS Toolbox.

Social Action The Canadian Medical Association Code of Ethics (October 15, 1996, and most recent 2004), expresses its code in greater detail but in the same spirit; the CMA lists 43 points whereas the AMA’s briefer text is expressed in 9 points as we saw above. The CMA details are divided into 5 areas of responsibility: General Responsibilities, Responsibilities to the Patient, Responsibilities to Society, Responsibilities to the Profession, and Responsibilities to Oneself. The goals of the AMA and CMA are driven by

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Ibid., p. 3. For an in-depth discussion of these issues see the Nuffield Council on Bioethics: http://www.nuffieldbioethics.org

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the same deontological belief in the sanctity of human life that led to the development of universal rights of persons. The website for the World Declaration of Geneva offers a modern declaration of the Hippocratic Oath while maintaining the basic standards of human rights and freedoms declared by the United Nations in 1948. The WMA founded in 1947 ‘to establish and promote the highest possible standard of ethical behavior and care by physicians’; the site includes a link to the Declaration of Helsinki on research involving human subjects; the Declaration of Tokyo on guidelines for physicians to help prevent torture; and the Declaration of Taipei on a protocol for research on health databases, Big Data, and Biobanks.104 Medical code of ethics provide principles that are based on the structure of the human mind. They are not legal documents. The suggestion that the Code may set out different standards of behavior than does the law does not mean that medical principles are above the law. On the contrary, “physicians should be aware of the legal and regulatory requirements for medical practice in their jurisdiction.”105 This is the reason why the possibility of conflict between medical principles and regulatory legal requirements arise and force some doctors to choose between their personal beliefs and work. For instance, the Province of Ontario does not provide legislation to protect physicians and healthcare providers who, in conscience, refuse to participate in medically assisted suicide or euthanasia. The reason that some doctors object to the law is clear enough. In euthanasia the death causing action is initiated by the doctor while in assisted suicide the action is initiated by the patient but both end in the direct termination of a human life. Working together with many Catholic partners and other faith communities, the Coalition of HealthCare and Conscience is at the time of this writing petitioning the Ontario government to protect the conscience rights of healthcare providers and to lobby for adequate palliative care in Ontario. The passage of Marilyn Gladu MP’s Bill C-277 on palliative care in Canada by the Canadian House of Commons is moving in the right direction because the proposed Bill C-277 (Marilyn Gladu MP) is asking the government to fund palliative care as an option for patients seeking euthanasia or assisted suicide. However, it fails to solve the wider issue of the ethical

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See https://www.wma.net/wp-content/uploads/2016/11/Decl-of-Geneva-v2006.pdf. Accessed January 21, 2018. Code of Ethics of the Canadian Medical Association. October 15, 1996 and most recent 2004. Preface. https://www.cma.ca/En/Pages/code-of-ethics.aspx accessed January 21, 2018.s

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dilemma that arises when a doctor is mandated by law to act in a manner that violates that doctor’s ethical and religious beliefs. The office of the Bishop of the Catholic Diocese of London (Bishop Fabbro,2018) issued an invitation to all parishioners to raise their voice in unison against the Ontario government’s abuse of power; “Despite more than 30,000 letters sent to Members of Provincial Parliament (MPP), this campaign (against doctors, nurses, and health care workers forced to participate in assisted suicide and euthanasia) did not achieve its desired goal at the present time Ontario still does not have legislation that adequately protects the conscience rights of health care workers who are opposed to cooperating in actions that would cause the death of their patients. Health care workers in our province are being forced to choose between their careers and their conscience.”106 Physicians and other caregivers are forced to participate in euthanasia and assisted suicide against their will because when they object against it they are forced to refer patients to compliant doctors. This makes them unwilling accomplices to an action they deem to be unethical and against their religious beliefs. This places the universal deontological primacy on the value of life (and the structure of reason) at odds with the reality as the State deems that some forms of human life are less valuable than others. The issue has the support of the CMA Code of Ethics; “Seek help from colleagues and appropriately qualified professionals for personal problems that adversely affect your services to patients, society or the profession.”107 The request by some citizens for the development of palliative care services in Canada offers an alternative for patients facing the prospects of euthanasia or assisted suicide at the end-of-life, but it does not completely solve the ethical conflict facing doctors. While some patients sign DNR (do not revive) orders years before the need to do so arises, the request is usually not in conflict with deontological ethics and the Oath of Hippocrates. Dying is a process and in some cases medical intervention would be of no significant benefit to the patient; “The key consideration in making the judgment will be to determine whether the benefit of resuscitation outweigh the burdens.”108 However, the deontological mandate to

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R., Fabbro, Bishop, Diocese of London. Office of the Bishop. (Letter to the faith community, 16 January, 2018). Code of Ethics of the Canadian Medical Association. (10 March 2001). Responsibilities to Oneself. Item 43. For additional detail on the Catholic perspective on DNR orders see; https://www.cat holiceducation.org/en/science/ethical-issues/going-too-far-with-dnr.html

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‘first do no harm’ is disrespected when some individuals find themselves in declining health and put undue pressure on doctors for an end-of-life solution to their low quality of life. The principle governing cases where a patient is allowed to die at end-of-life-stage when no cure exists does not violate any ethical principle. Only a third of the Canadian population has access to adequate palliative care. These individuals are being denied real choices on end of life issues. The Coalition for HealthCare and Conscience provides clear evidence of the need to think of patients as being in community relations. The community is rising to meet the needs of patients that cannot and do not speak as atomistic individuals. In my opinion, the conflict between deontological principles and the law will be exacerbated by new developments in genetic screening, genetic engineering, cloning, and xenotransplantation since we are now in the age of biomedicine and ethics. Personalized medical ethics, therefore, takes us outside the narrow atomistic view of the patient to include standards to incorporate all significant community relationships. This brings us to the front of a basic distinction between curing and healing, and an application of the person-making process. Two main points are made about curing disease. The first is that it takes place on the arms of the carbon-self. The second, is that curing is a process rather than an event. The fact that dying is a process rather than an event points to the deficient nature of the atomistic view of the patient. Even a death caused by decapitation is a process, although an extreme example, it points to a condition of the patient (sans tête) now incompatible with the continuance of life, but not yet dead as such. The length of time it takes to die depends on the cellular complexity of the organism. The individual in cardiac arrest has minutes to go before irreversible damage is caused by the lack of oxygen (anoxia) required to maintain the higher thought functions of the brain. The first part of the brain to die is the highly developed neo cortex followed by the death of the mid brain and brain stem. The death of the patient is almost universally accepted as being whole brain death. The delicate ethical issues we face in organ donation is to agree on the condition when the person is pronounced dead but before the death of the internal organs takes place. The decision includes family. The issue moves us beyond empirical observation to the Hippocratic Oath’s focus to be on the side of life in relationships. This explains why the practice of euthanasia and assisted suicide are not uni-

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versally accepted. They move medicine away from quantitative assessments of the empirical evidence to a qualitative judgement about quality of life relationships. But the methodology of medicine is currently illsuited to that purpose. The agenda is driven by an atomistic view of the patient. In the case of euthanasia, the death causing action is initiated by the physician while the process of assisted suicide is initiated by the patient by pressing a switch or device to activate the ingestion of nitrous oxide or some other death causing chemical. The physician and the patient rely on law to make the call. But the law is not a substitute for ethics. The belief that euthanasia or assisted suicide are ethical is culturally based, that is depending on the law’s interpretation of citizen rights. An STS systemsbased definition of quality of life moves beyond this reductive view to include culture (attitude, values, and beliefs), society (the patient as a being is relations with family and friends), economics, and a deontologically based ethics to place the focus on the sanctity of human life. Does David Lamb (1992) sense this reductivism when he suggests that the scarcity of donor organs for transplant purposes needs to move the definition of death outside the established norm to include putrefaction of the body?109 This approach reassures him that death shall not be pronounced prematurely for the sake of procuring donor organs. The definition of death moves beyond the observable and measurable conditions that accompany death to include social ethics. The basis of social ethics is a patient’s community relations and therefore has the support of law. The force of law comes from social ethics; the law does not generate the ethics! The Hippocratic Oath is based on deontological ethics and the belief in the primacy of life. This view enlists the service of law to underwrites the enactment of the protocol. However, the secular society often seeks to write the ethics of life on the platform of political laws. Unfortunately, the impersonal character of medical technology, if left to itself, constructs an image of the sacred in the likeness of the secular. As a result, human life is not considered to be sacred. In our day, developments in science and technology appear to generate an image of the divine in our likeness. Modern technology engineers an image of humans in which the sense of the sacred is lost. Once the sense of the sacred disappears we plunge headlong in a

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David, Lamb, Death and personal Identity. In David Cockburn, editor, Death and the Value of Life, (Lampeter, UK: Saint David’s University, 1992) Trivium 27, 43–56.

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political system where economic development trumps human development, as law rewrites the ethics to protect greed and selfish desires, justify war, violence, and the loss of respect for the marginalized. The mantra of secular medicine becomes the development of a superior race, with diminished protection for the at-risk members of society, as the genetic selection of desirable human traits replaces the war crimes of the past. The state has an important role to play as custodian of the people’s health, individually and collectively. Political intervention and ‘stewardship’ become an issue not because politics writes the ethics but because life is sacred. State intervention is warranted where an individual’s actions affects others.110 The main ethical principle in matters of public health is from Stewart Mill’s normative ‘harm principle.’ Stewardship is the claim that liberal states have a duty to look after important needs of people individually and collectively. The challenge facing medicine is to construct an image of the person based on social ethics rather than on the economic principles that govern organic citizens. The desire to enact a patient’s social relations into the medical system speaks volumes about our social nature; “Everyone has duties to the community in which alone the free and full development of his personality is possible.” (Universal Declaration of Human Rights, 1948.)111 A right implies an obligation. Therefore, the healthcare system has the obligation to treat patients as embedded in a community of relationships where many citizens object to the deconstruction of the sacred in human nature. The healing dimension of medicine focuses on the whole patient, including spirituality, and relations. However, the process of healing is initiated by the patient, from the patient, and for the patient either directly or through the intervention of community groups. The healthcare team is receptive to patient data by including all the relations that individuate persons in the treatment outcome. It seems to me that the best way to accomplish that holistic outcome is to ensure a harmony between medical technology and all the relations that individuate patients. Thus, the diagnosis and cure from disease must be in harmony with all the relations that individuate patients, along with their spirituality, including how they find

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For a discussion of public health and the responsibilities of the State see Nuffield Council (2007) Public health: Ethical Issues. The full report (225 p.) is available for download or purchase at [email protected] Article 29.1 (1948) Universal Declaration of Human Rights. http://un.org/en/universaldeclaration-human-rights/ accessed January 17, 2018.

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meaning in life, and their religious beliefs, if any. This is accomplished by observing the objective correlate of consciousness, namely what the patient’s complete medical history, qualitative and quantitative elements alike, disclose about the patient. In other words, the patient’s medical history must be inclusive. The molecular portrait of a patient arises as a process of recording each atomic detail on the arms of a patient’s individuating relationships. The primary responsibility for providing the additional data derives primarily from patients but the directives for doing so is part of a treatment plan. The resources available in the user community are to be included in the treatment plan. The inclusion of community resources in treatment outcomes serves as an academic resource for healthcare professionals. The use of these resources promotes the best intertest of patients by ensuring access to all resources while protecting the doctor’s right to practice medicine. The professional medical care of an individual’s health is a duty that a doctor undertakes rather than a right a citizen acquires in a liberal state. This is accomplished by including the availability of community resources in the medical curriculum. Doctors have the duty to provide the best care available to patients, while patients have the right to expect an inclusive level of healthcare from their doctors. In this way the obligation to provide holistic healthcare is safeguarded through the inclusion of the significant relationships that individuate patients. It seems to me that community programs can be harvested as a useful data bank to identify some of a patient’s support systems or community relations. This source of public data adds to the personalized family relations the patient includes in the hospital chart. The arms of the person-making process are clearly distinguished by the personal and public information patients makes available in their medical history. A scan of each stream of defining person-making associations reveals at a glance a patient’s carbon-based profile, social-self profile, and the associations that characterize the internal-self. The strings of associations that individuate a patient’s medical career include spiritual questions on the meaning the patient ascribes to life, along with a string of associations on a patient’s personal relations, including healing groups, and internal-relations usually of a religious nature or an activity that replaces religion such as the Unitarian focus on the importance of acts of kindness, helping the poor, and so on. The internal self populates these relationships as the seat of intellect and will, including the innate tendencies discussed

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in chapter 2, and therefore of ethical beliefs concerning personal autonomy, informed consent, beneficence, non-maleficence, privacy and confidentiality at the individual level, and justice, equity, and fairness at the level of the State. Medicine must not only be thought to be ethical it must be seen to be ethical less it serves as a neo-colonial enterprise to further the ambitious ends of a political agenda.

Palliative Care Palliative care provides a case in point to prove the primacy of deontological ethics in medicine. Bill C-277, the framework on palliative care in Canada Act cleared the Senate and received Royal Assent on December 12, 2017; “It (the Act) requires Canada’s health minister to develop and implement a framework to give all citizens access to palliative care through hospitals, home care, long-term care facilities and residential hospitals. It will also dictate training for doctors, nurses and home-care workers, and list services covered from pain control to emotional and spiritual counselling (italics added).”112 Bill C- 277 became a reality in Canada thanks to the tireless work of its chief proponent Marilyn Gladu MP. The provision of palliative and hospice care was pioneered by Dame Cecily Sanders at Saint Christopher’s Hospice, London, England, in the 1970s. Individuals approaching the end of their life have the option of receiving palliative care which, in my opinion, offers a viable alternative to assisted suicide, and euthanasia. Hopefully the implementation of the Act in Canada will follow the British model concerning the focus on pain management, the feeding of compassionate care, and relaxed institutional regulations. An article by R. E. Neale in the Archives of the Foundations of Thanatology (1971) provides additional details on end of life care at St. Christopher’s Hospice.113 The only patient that presents a problem at St. Christopher’s is the one that doesn’t die! The focus shifts from saving life to ending life in a loving environment free from pain and life-prolonging measures. Feeding is done by hand; it might take several hours or several minutes, but the end goal is to provide human contact. Most individuals

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Troy, Shantz, Gladu scores legislative win, The Sarnia Journal, Thursday, December 21, 2017. Cover story. Robert E., Neale, Between the Nipple and the Everlasting Arms, (Archives of the Foundation of Thanatology. Volume 3, Spring) 1971. 21–31.

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do not want to die alone. The process of sharing this kind of human warmth depends a great deal on volunteers for its success. The connection between medical ethics and environmental ethics casts the dialectical relation between doctor and patient in new light. From the point of view of phenomenology, we can describe the doctor-patient’s ethical horizon as containing a mix of normative ethics and clinical medicine. Medicine must always be on the side of life, as on the side of morally acceptable laws to regulate the just and fair distribution of scarce medical resources to promote the health maximization of (most) citizens. The guiding ethical principles that professionals can refer to are autonomy, informed consent, beneficence, non-maleficence, privacy, truthfulness, and confidentiality, secrecy, justice, fairness, equality, and entitlement. In brief, distributive justice, rights-based justice, and respect for morally acceptable laws are expressed on the platform of a patient’s actual life in a community. These moral principles apply value to the practice of clinical medicine. The desire to think of a patient as an abstraction is unacceptable. The doctor brings environmental resources to the fore by observing the nature of the disease, the scarcity of medical resources, the patient’s quality of life, along with input from the specialist, pharmacist, family and significant others, social worker, psychologist, chaplain, and additional resources as required, such as dietician, respiratory technician, and healing techniques such as Reiki, massage therapy, music therapy. Social ethics moves dialectically from above on the arms of these correlates. The focus on individual rights now shifts to meet the other as an extension of the self. This means that the light of individual rights is recast in the light of social rights. This view calls for a reinterpretation of subjective truth because it is seen to exist in relationship with objective truth. The process begins with internal work as patients redefine themselves in the context of family, friends, society, and other social groups. The weld between the correlates of consciousness is possible through systems analysis (culture, society, politics, economics, resources) as a conduit between the rights of the individual and the rights of other persons. This means that the contractual model between doctor and patient must be amended to include the proposed model. Without the contract there is no stability (conservation) which is a necessary part of society. Members of a democratic society must agree to render the authority required by law to assure the union of the individual with the collective, as required by the nature of the person-making process. This view provides a holistic account of the person as a human

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being in action, while guaranteeing that the ethical primacy is assigned primarily to the patient as a person and only secondarily and derivative sense to the patient as a human being. The law needs to be framed in a way that protects why and how human beings become personal. The distinction between curing and healing is examined using the person-making process. The following case studies provide examples where curing and healing take place simultaneously. In some case it seems possible to cure without healing whereas in end-of-life cases the focus shifts to healing.

Case Studies in Healthcare Over the years, I developed a strategy to promote the autonomy and rights of at-risk-clients. The strategy makes use of the distinction between being human and being a person as the latter incorporates three main streams of relationships that characterize how humans enter action thereby becoming more personal. We become personal as the output of relationships taking place at the level of the environment, including where we live, work, eat, and sleep. The environment includes everything physical or organic about us, including our genome, as we saw earlier. This plays a powerful role in defining us, therefore, we need to ensure that it is incorporated into a treatment plan. For instance, a body builder at risk because a traumatic head injury would be familiar with a body building gymnasium, weights, mirrors, and such that featured as part of the regimen before the brain injury. Treatment seeks to reproduce parts of that environment as an integral aspect of the client’s relational modality, beginning with something as simple but essential such as having a full body mirror in his treatment room. Second, the social environment plays an equally positive role in who we are as persons. The client’s emotional history of care, compassion, love and hate before the injury shapes the client’s recovery. The client’s family, friends, neighbors and community play an essential role in the patient’s relational profile. Third, the client’s psychological profile plays an essential role in the treatment plan. It provides a valuable source of data into how to deal with depression and any other condition that affects autonomy and informed consent through the identification of standards or eternal truths in the life of a patient. Patients or clients in recovery or treatment need to stay in touch with the presence of the absolute in psyche. The fol-

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lowing test cases make use of one or more of these definitional relationships to highlight how a client’s rights are put at risk because of injury and provide insight into how to advocate for the best treatment modality for a client or patient. The model helps us to see the injury from the patient’s point of view. The choice of treatment is weighed against nonmaleficence and beneficence. The possible harm that can accrue to a patient or client from a procedure or treatment plan cannot be greater than the harm that would otherwise accrue from the existing condition. The factors that play into the treatment process are based on the deontological fact that the patient or client is treated with dignity and as an end in se rather than a means to an end. They include the presence of an absolute or eternal truth in the equation to secure the legitimacy of deontological ethics (the tendency to do good and seek meaning). They include the patient or client’s relational profile as identified through the three streams of relationships that individuate persons. They are based on a holistic dialogical process between doctor and patient or patient’s legal representative to secure informed consent. They strive for transparency as required to protect a client’s right to personal autonomy and the ability to direct personal outcomes in good times as in times of risk. They strive to draw upon community resources as well as academic and other professional resources available to a client to ensure the delivery of the best care available. They strive to be fair and just in the light of the scarcity of medical resources and the healthcare rights of other patients. The following cases describe four at-risk scenarios. In the first case, Keanen a nine-year old boy is being treated for leukemia. His prognosis is good. The second case makes more explicit use of the personmaking process because of its complexity. Kendra, a 29-year old female, is bi-polar and schizophrenic. She is aggressive; staffs fear she might injure herself or others. The third is a case about depression. Janet, a 24-year old female goes to hospital in search of treatment for a minor injury. She is sent home after a brief examination. She returns home and commits suicide. The fourth case is about opioid and alcohol dependency and illustrates the need to incorporate community into the treatment plan.

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Case 1: Keanen’s Story Keanen, a nine-year-old boy was diagnosed with acute lymphoblastic leukemia in 2015.114 His parents met with the healthcare team to discuss the impact of the disease on them. The medical model in place at London Hospital, London, Canada, is based on the idea of the patient in relations with doctor, specialist, social worker, pharmacist, family, friends, school, and other children with cancer. Keanen attends camp for children with cancer (Oochigeas or camp Ooch); “where kids with cancer can just be kids”. He loves camp activities and the many volunteers that make it possible. Keanen and his family also appreciate the welcoming spirit and facilities made available freely at Ronald MacDonald house for sick kids. In the beginning, Keanen’s parents did not understand the need for a model that views children with cancer as patients in relationships, but the benefit of doing so soon became apparent to them. Living with a child that has cancer is a learning process for the family. The impact of the disease is on the whole family. Counselling is available to the family as needed to make sense of the impact the disease would have on the whole family. They were told to ‘buckle up’ because life as they knew it before cancer would change. The healthcare team gave them the tools they would need to get through it. They met with a pharmacist to understand the side effects the medicine would have on Keanen. The team provides access to family activities such as camping to give the family time to bond. Keanen went to special camps for kids with cancer where he was well cared for by doctors, nurses, and counsellors on site. This also gave him the opportunity to bond with other kids with cancer. He learned that he was not different. He was not alone. But he was different at home. Living with cancer became the new normal for him and his family. Keanen’s time away gave the family time for respite care from the world of daily medicine and worry. Children with cancer are treated differently at home and school. Trying to moderate

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The details surrounding Keanen’s hospital experience are provided by his mother Dr. Mikelle Bryson-Campbell. Keanen’s father, Craig, found out about their son’s condition by telephone. The impersonal nature of a telephone call from a physician (on the next floor in the same hospital) is a never to be forgotten experience of pain for the father that could have been softened somewhat by a doctor’s compassionate face to face visit. No one wants to be informed by telephone that their 8-year-old child has cancer, and this is an area where something positive can be done to improve healthcare delivery. The realization that the doctor patient experience is relational (Keanen’s family relationship), followed by the awareness that we live in a spirituality of imperfection is an opportunity to learn and grow from our mistakes and improve the quality of the doctor patient relationship.

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discipline between the negative effects of the medication on Keanen and bad behavior remains a challenge. The challenge is to find the proper balance between what aspect of Keanen’s behavior can be controlled and what must be reprimanded is difficult. Whenever Keanen goes on steroids, he becomes teary and emotional. He knows this about himself and often gets mad at himself over it. However, Keanen is a bright normal boy and on occasion he no doubt uses cancer as an excuse for being bad. It’s important to set up boundaries because in a couple of years Keanen will be cancer free (we pray) and he’ll be back to normal life without excuse for noncompliance. How do you raise a child with cancer? The oncologist advises on the benefits of treating Keanen as a normal child. Keanen is expected to go to school even at the risk of getting the flue. He is in his second year of treatment and takes chemo pills at home. He goes to the hospital once a month for blood tests, or a spinal tap, but goes at once if he has an infection and his neutrophils are dangerously low. His immune system walks a fine line between the efficiency of treatment and warding off disease. Keanen is beginning to recognize the signs of low blood neutrophils whenever he is overly tired or has frequent nose bleeds. He knows that his body’s ability to stop bleeding is challenged by cancer. Keanen and his family see light at the end of the tunnel because January 2018 begins the third and final year of aggressive treatment for cancer. The prognosis for recovery from his type of childhood leukemia is excellent, and he will be taxed with the burden of relapse and annual check-ups for the rest of his life, he is one of the lucky ones to have the voice of an excellent support team to walk with him on this journey. The model of the patient as a person in relations must find its voice in all areas of medicine, renal dialysis, transplant medicine, palliative care, and with the advent of bioethics—the medicine of the future. While the process of itemizing the variables that individuate Keanen’s conditions on the arms of the person-making process would be of some benefit, I have reserved this way of filing data for the next case—a member of a vocational center day program. IN KEANEN’s OWN WORDS Hi, my name is Keanen. I am going to tell you about my big day. I was in Cape Breton at my grandma and poppa’s. We went to sleep. I didn’t know what was coming that night. At 12:00 A.M. I woke up crying in pain. So, my dad drove me to the hospital. We had to wait for 3 hours in the waiting room. When it was after the doctor said I was

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fine. When we went back home to Sarnia, I was getting more and more tired, and in more and more pain so my dad took me to the hospital again. This is in the Sarnia hospital and they said I had something wrong. So, I went in an ambulance to the London hospital. They are good with cancer. When we got there, they said I had cancer. I stayed at the hospital for 2 months. But I missed school for about 80 days. Side effects, I got chubby, sleepy and constant pain mostly in my back. Sometimes I think it’s not bad and sometimes I do. Note: 3 days after writing this, Keanen was admitted to intensive care with an infection of the lungs and blood (Sepsis)—a potentially life-threatening condition.

Case 2: Caring for at-risk clients Kendra115 is a young woman in her late 20’s who is verbal and has a moderate to mild mental challenge. In her early twenties she began to exhibit symptoms indicative of mental illness. She has been diagnosed as having a bipolar disorder as well as paranoid schizophrenia. She currently attends a vocational center through the week. She has had several recent hospitalizations for aggressive self-destructive behavior. She currently presents as very confused and unpredictable. She recently came into her day program and related to staff that she attempted to stab herself in the abdomen with scissors at home. She has also repeatedly told staff that other participants have called her names (slut, whore, and pig). There is nothing to indicate that this is factual. She is very fixated on her father who does not live with the family. He has diagnosed mental illness and at times will promise to visit her and just not arrive. He will also repeatedly tell her to stop talking foolishly or he won’t come back to visit her. Mother will also tell her that if she doesn’t “smarten up” her father will never visit her again. While attending her vocational program during the day, she will walk over to the sink to grab a glass of water and pour it on staff, participants, or herself. Regularly after she has had her lunch she will continuously tell staff that she wants to leave and go home. Some of her medication is supposed to be given at noon but her mother will not send it to the Vocational Center to be administered. She becomes increasingly agitated, yelling and making attempts to leave the room where staffs are supervising her. She lives alone with mother. Mother repeatedly changes medications and states all the current situations are attention getting behaviors; she blames the “full moon and PMS” for everything. Mother has frequently refused to come to the Center to pick up her daughter when she is very agitated. The mother has

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Thanks to Debra MacLean, Director, North Side Adult Services Center for providing the case. I discuss this case in Person as Verb. (2010).

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removed her daughter from hospitalizations earlier than doctors would wish. Staff Concerns: The client is becoming increasingly agitated, unpredictable, and disruptive to everyone around her. Concern is great that she will injure herself or someone else very soon. She also repeats the same sentences over and over and louder and more insistently. The client’s medical and social conditions put her rights at-risk. Only some of the conditions of the client’s treatment plan are fixed. The question facing staff is how to act in her best interest. Staffs draw freely for the tools available in the STS Toolbox. Guiding Principles: Vulnerable persons are individuals whose diminished competence and/or decision-making capacity and/or physical challenges make them less likely to be autonomous, have informed consent, or be able to directly input into choices that are in their best interest. However, at-risk clients have the same universal rights as other citizens; the declaration of human rights is based on a belief in the absolute value of individuals and the principle of a just society. The protection of human rights is the cornerstone of a true democracy, one in which free and informed citizens direct their own outcomes through representative government. The challenges facing staffs is to ensure that Karen does not injure herself or anyone else in her environment. Training for staffs includes developing awareness of the ways in which they might unwittingly discriminate against a client’s rights. Feedback loops are put in place to ensure that the client is given the opportunity to input into the decision-making process. The practice of holding regular training programs for staffs is guaranteed by the implementation of section 24 of the Human Rights Act of Nova Scotia; “to develop a program of public information and education in the field of human rights to forward the principle that every person is free and equal in dignity and rights without regard to race, religion, creed, color or ethnic or national origin.”116 The expression of the mandate to care for vulnerable persons is typical of what happens in democratic societies. In similar light, the Tri-Council policy statement on the ‘ethical conduct for research involving humans’ is likewise intended for the protection of

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Human Rights Act of Nova Scotia. Chapter 214, amended 1991. Section 24, number b. p. 11.

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individual rights that could be compromised by academic research.117 We live in a world where personal freedoms are put at risk through the unintended consequences of scientific research. We need full disclosure to balance the harms and benefits of scientific research on research subjects. Residents of group homes and special care centers are especially at-risk because of their inability to provide informed consent. They are therefore entitled to special protection against abuse, exploitation or discrimination on the grounds of duty-based principles of fairness and dignity. Minimal risk is commonly defined as follows; “if potential subjects can reasonably be expected to regard the probability and magnitude of possible harms implied by participation in the research to be no greater than those encountered by the subject in those aspects of his or her everyday life that relate to the research, then the research can be regarded as within the range of minimal risk.”118 The need to minimize harm translates into the design of special procedures for the care of residents in these units. The harms must be proportionate to the benefits that might be expected from the knowledge gained from the study. We demand high standards of care throughout the system. Following is an accepted list of clients’ standing rights, that is rights that have legal standing in a court of law. Codes of ethics generate laws to enforce guiding principles of autonomy as the right of individuals to direct their outcomes, freely chosen or through the appointment of surrogates empowered by law to act in the best interest of their at-risk clients or patients. In addition, the privacy and confidentiality of clients is required to ensure autonomy. The right to informed consent is the need to be informed of the consequences of a treatment choice. Consent is critical to autonomy. The right to privacy or to limit access to personal information includes a right not to be touched, or observed, unless conditions warrant it. Confidentiality or secrecy limits knowledge about an individual. Further, all patients and clients have the right to quality life, although ethical theories differ on the determination of when life is worth living or whether it is worth living to preserve certain states of body and mind. A good quality of life usually includes a state of existence free from pain, in the presence of pleasurable states of consciousness. Patients/clients have a right to their

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The Tri-Council policy statement on ethical conduct for research involving humans is located at http://www.nserc.ca/programs/ethics/english/policy.htm Ibid., Article C.1, p.1.5.

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values, attitudes, and beliefs without fear of reprimand from staff, unless they present as a risk to the common good. The social good of the community trumps the good of the individual. Anonymity is the belief that all clients/patients have a right to protection from undesired attention, while solitude is the right to enjoy a lack of physical proximity to others. Further, justice and fairness are especially relevant rights in the age of scarce medical resources. The person-making profile of an individual client or patient is designed to capture tradeoffs between competing ethical claims while safeguarding the ‘we’ in the ‘me’ of personal care. The process of identifying all variables that cluster on the arms of a patient profile calls for a sharp eye less anything significant is missed. For instance, it might be the case that the clients’ restlessness peaks at certain times of day depending on certain variables. The goal is to establish connections between restlessness and such triggers. Some of these associations can be missed so the first task is to be as detailed as possible in listing all factors that exist in the life of the client. I am providing a sketch here of the tools found in the STS Toolbox to illustrate the process that staffs can apply to individual cases. 1. The environmental self: The empirical circumstances of the case include a detail of all the circumstances that surround the case; when does the disruptive behavior occur, where does it take place, why is it a problem, is it a diet problem, how are decisions being made, what are the alternatives, should the client be removed from this environment …etc. An attempt is made to catalogue all variables of a physical nature, including the use of prescription drugs, diet, exercise, the physical outlay of the client’s living space, clothing, and other stimulus. The focus is on an interdisciplinary approach to how the environment defines us. The successful management of at-risk clients also depends on budgetary constraints since the services of a counselor, psychologist, sociologist, physician, therapist, lawyer, biologist, dietician, are not always at the ready because of limited access to funding. Staffs must discuss the medication issue with the doctor and greater responsibility ought be assigned to staff to ensure stability in the client’s use of medication. 2. The social self: the first line of inquiry takes place at the level of family. The client lives alone with mother. Mother repeatedly changes medications and states that all the current situations are attention-getting behaviors; she blames the ‘full moon’ and ‘PMS’ for everything. Mother often refuses to come to the center to pick up her daughter when she is

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very agitated. She also removed her daughter from hospitalization earlier than the doctors had wished. Staffs need to meet with the mother to assess her motivation. The father daughter relationship is also a source of concern. If the daughter’s safety is at risk in this stream of associations she should be removed at once from a vocational center and assigned to a residential unit (group home). Staffs also need to investigate the ‘name calling’ experience. Every person in this community, staffs and clients, is significant to Kendra’s mental health. Social determinants create stress factors that can be interpreted as symptomatic to the client’s state of mind. The way we view other persons speaks to us about what is going on in our own psyche. We use others as hooks to hang our own fears and dreams. Always look at the big picture and not at the patient as an atom separate from others. Look at the social determinants of health. A symptom speaks to us about the patient as an atom, but social determinants view the patient as molecular being in relationship with other persons. A symptom might be the result of broken relationships with other persons. What is the patient’s social determinants? Stress factors usually bring in physical symptoms. 3. The internal self: The client’s condition of paranoid schizophrenia blurs the distinction between real and imagined experiences. The point is not to determine if the client is telling the truth about name-calling but why she feels this way. The process I suggest we follow in this case is to hold a round table meeting of clients to discuss this situation. The next step is to ask Kendra to describe her feelings about the name calling. This provides an opportunity for Kendra to share her feelings about the name calling in an open forum. I have no doubt that other clients will apologize to Kendra, if the name calling is real, but more than likely the reality of the name calling is fictional. Still the exercise serves the purpose of providing an opportunity for Kendra to vent her feelings, which I think is therapeutic. In a moral universe, ethics ought to work hand in hand with the laws of the land. The client is at-risk in her family of origin and therefore must be moved to safer grounds, ethically and legally. The strategic agenda of the Law Commission of Canada recognizes this guiding principle since it advocates basing law on relationships. The Commission thereby places the centrality of relationships at the core of ethics as well as law. The Commission identifies four broad types of relationships, namely, “personal relationships, social relationships, economic relationships, and governance

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relationships.” Law is the means for channeling ethical responsibilities towards clients. We begin with an assessment of quality of life. The client’s social frame is poor. Staffs need to talk with the client’s mother and father before adjusting that frame. Staffs make judgments about a client’s quality life to plan management. But the care plan is enacted in accordance with Provincial standards. These (legal) standards are fettered by the circumstances of the case, namely, the client’s health, age, religious beliefs, family situation, and the availability of resources. Once the case is put in context, the expectation of services (ethical) is discussed with the client’s mother and father before changes can be made to the social frame. This process assures us of the best possible fit between the needs of the client and the conditions that surround the case. The level of care is expressed through a personalized person-making chart. The associations are governed by contract, but they are seen to be ethical as well as legal. The associations are seen to maximize return on investment of scarce resources, Provincial standards, ethics, and law meet in the expression of a realistic social frame for the client. The client’s psychological and environmental frames are instituted and varied in accordance with a similar “push pull” process. Staffs can unknowingly introduce mixed messages into a client’s life. A restless client could be receiving conflicting signals from others (new staff, other clients), the environment (rearranging a client’s room without warning), or even from her own brain (changes in medication, diet). Staffs can check to ensure that the care they offer clients is consistent. For instance, the way a client meets new part-time staffs during summer holidays is inconsistent with the development of a healthy social self. I ask my students ‘how would you feel if one morning you awoke to find someone new in your living room’? New staffs need an introduction to clients. The view of the individual as becoming a person offers more promise than the view of the individual as being human since it is more transparent. A central trait of interpersonal relationships with clients of vocational centers and residential units is genuineness. Carl Rogers emphasizes the importance of being genuine. He describes the social frame as the client’s reciprocation of the therapist’s attitudes. If staff bring an attitude of acceptance to the social frame, clients are more likely to feel comfortable. If clients are not allowed the opportunity to input into the treatment plan, they are less likely to be at peace. The panel objective is to be integrative

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and constructivist; to view the problem from the perspective of relevant disciplines, and from the client’s point of view, respectively. The complexities of the case are identified by asking several key questions. The process always begins with a thorough inventory of the client’s history and systems analysis as detailed in the first chapter. (1) What are staffs concerns? What are the issues and how can fresh relations be struck to meet those concerns? For instance, will moving the client from a vocational center to a residential unit meet some of these concerns? (2) What are the effects of each alternative? (3) Who are the people involved (include a list of family, other clients, staff, and other professionals)? (4) How is the treatment decision being made (what medical model is used i.e. paternalism, collegial, engineering, or contractual)? Is everyone that is being affected by the decision consulted (in a democracy, everyone that is affected by a decision should be consulted)? How does staff express the client’s best interest? (5) Why are the client’s rights at-risk (why is this issue problematic)? Does the decision-making-process safeguard the client’s rights? (6) When is the client at risk? Note the time and circumstances that accompany a client’s disruptive behavior. Does she become agitated before meals, before medication is given, at bedtime, etc.? (7) Where does the behavioral problem occur? The resident’s total environment is a critical component of the person-making process. (8) Do staffs have access to the required resources? Since treatment is labor intensive, the resource category includes the availability of staff. This is a budget issue. (9) Ask a co-worker to confirm your observations. An STS Toolbox is at-hand. Once the associations between doctor, specialist, pharmacist, counsellor, staffs, ethics, law, and the best interest of the client are expressed on the arms of the person-making process, we begin the task of instituting new relations or varying old ones as required. Since staff focus is on non-aversive (non-punishing) behavior change, clients learn to modify their behavior through the positive consequences of doing so rather than out of the negative consequences of not doing so. The goal is to establish positive associations that allow clients the opportunity to behave responsibly. The process respects the client’s rights to autonomy and informed consent. On the other hand, punishment is rarely effective since it enlists a confrontational attitude between individuals. It sends a signal of being out of control (in sharp contrast to the loving, nurturing environment we expect will arise out of healthy associations). The focus

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shifts from passive learning (operant conditioning) to active learning (trial and error) as the client’s person-making profile fills with data. In the psychological frame, we find that the associations that accompany the client’s condition of paranoid schizophrenia blur the distinction between real and imagined experiences. Her belief of being vilified by a resident is real to her, even if imagined. It is met by enlisting more input on the conditions surrounding the event. The what, when, where, and such of the incident provide an opportunity to vary that relationship. If, for instance, the client is allegedly victimized at a certain time of day, then, a shift in the timing of the event can result in a changed outcome. The focus on psyche includes the client’s religious life. Although the case study does not provide details here, staffs should make the appropriate inquiries to determine if their client’s spiritual search for sacred meaning, and religious needs are being met. A client’s spiritual or religious experience is an integral component of holistic healthcare. Is the client generally happy? This question provides insight into the alignment between the client’s search for meaning and her person-making profile. What else can staffs do to help? What can the client do for herself? The therapeutic value of play and art is well known. The client’s focus on self can properly be directed outward through play, constructive recreation, dancing, working with clay, painting. Such activities have a potential to unleash healing, spiritual energies of the psyche. This energy is creative, restorative, and it is important to access it and allow it to do its healing work. The essential characteristic of the social frame is that we need others to become more truly personal. However, relations with others can become askew and destroy a healthy concept of self. The client is experiencing real problems in her relations with mother, father, and other clients. The first consideration is for the welfare of the client. If she is at-risk in her present social frame, then, that association must be changed, and the client integrated into new associations. The client’s mother is controlling (she uses medication and the daughter’s father to control her daughter). Staffs need to meet with the mother to understand her motivation. Does the mother distrusts staff; if so, why? The contractual model suggests that mother, daughter, and staff are entitled to an opportunity to settle their differences. The daughter should only be removed from the family of origin, if she is at risk. Still, with consent from all parties the client might move from a vocational center to a group home. The relationship with the father also needs mending.

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Staffs might agree to the use of a self-help process to address the client’s paranoia. In this event, feelings trump reason. The equality of participants is critical to the success of such groups. In the early stages, a staff member can choose to lead a group, but gradually move away because these groups are not led by anyone in particular. They acquire a life of their own. Group work takes place in a nurturing setting where the focus is placed on feelings, emotions, and the equality of the participants. Group autonomy is valued. Resonance and identification provide an opportunity for individuals from different walks of life to speak in single voice. The client’s opportunity to voice her concerns over the name calling in this kind of a social setting will help other clients understand what she is going through. They will reach out to her as they become more able to identify with her and connect their own feelings of being victimized with her struggle for self-respect. The client’s rights can then be expressed through new associations. For instance, can she be put back on a regular (common) schedule of activities? The completed person-making guide provides a detailed history of the patient’s profile and makes all relations visible at a glance while providing a scale to assess a client’s progress. This simplifies staff’s objectives and goes a long way towards ensuring that all the client’s personal relation needs are met. Case 3: Will someone please help me? Janet, a 24-year-old single and unemployed female suffers from frequent bouts of anxiety and depression. She experiences severe chest pains and goes to emergency to be admitted for treatment. She is examined and released after a few minutes. Janet goes home and kills herself. The case attracts national attention. Was the emergency doctor negligent? The medical team followed protocol as it bandaged the patient’s injury and sent her home. However, holistic care suggests that a patient is more than a biological organism. Either staffs failed to access the patient’s file, or more than likely they were not trained to recognize signs of depression. The suggestion to follow a person-making protocol that examines all three streams of associations that individuate persons, might have saved her life. For instance, a referral to a community support system for persons with depression could have brought a (female) volunteer to the hospital and the patient would not have gone home alone. Healthcare workers require training beyond the walls of academia to connect with these community resources.

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They contain medical knowledge. Staffs require access to the patient’s comprehensive medical history, and to the community’s list of resources. I am not suggesting that community resources replace psychiatric help, but rather that such resources do complement what is currently taught in the medical curriculum. Janet has a known history of depression and attempted suicide. This is also a clear signal that we urgently need guidelines on the treatment of depression. It is doubtful that persons suffering from depression, or other at-risk condition, can be autonomous, and while the law is unclear on the involuntary placement of these at-risk patients, a referral to a community resource makes it less likely that a patient will suicide. The members of a like-minded community support system will want to help because of the help they received and because of the tendency towards good and the importance of finding meaning that animate everyone. The literature on suicide prevention and help lines suggests that the first line of defense is to buy some time, that is, ask the individual to put suicide off for an hour or two. This provides the opportunity to rethink the intended act and indeed to access community resources. The hospital emergency unit is often overworked and understaffed, especially in the early morning hours. Perhaps no one wants to disturb the sleep of an on-call doctor after a 24-hour shift? Medical training must include a holistic approach to disease, one that includes community outreach programs and the view of the patient through multiple lenses in streams of relationships rather than as organic, atomistic entities. The hospital staff feels vindicated because they found nothing medically wrong with Janet but that’s because they set the bar too low. Is this the faulty healthcare reasoning that Postman (Technopoly, 103) has in mind when he says of beliefs voiced in medical practice; ‘the operation or therapy was successful but the patient died;” and “wherever doctor strikes have occurred, the mortality rate decreases” (105). No one takes comfort here, but this is an opportunity for action. Drop-in spaces for at-risk individuals are available in most cities today in church basements and community centers. They operate through government grants, corporate and community donations, and fundraising, but also operate on a volunteer basis. Self-help or 12-Step groups provide a safe environment to meet individuals with similar emotional problems to discuss coping skills, and life-giving techniques. In communities worldwide, there are hundreds of different self-help groups based on the 12-Step principles of Alcoholics Anonymous. Their success is based in part on the resonance and identification between group members. Healing takes place

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at the emotional level offering complementary approach to the valuable services of counsellors, social workers, psychologists, and doctors. The absence of a support group in a community is an occasion for its development through informed and responsible social action as discussed in Chapter 1. Some support groups are relatively unknown. For instance, little is said about a support group for individuals with a life after life experience, that is, for individuals whose near-death experience is so rich that they find it difficult to resume ordinary life on earth? The resource is developed to meet a need. A few days ago, I saw a television report on a community assistance program developed to meet the at-risk needs of criminals likely to commit murder or be murdered in the coming year. The idea sprang out of a statistical report on the number of projected murders likely in the Chicago area each year. A community group was formed to meet with each criminal in their community to inform them that because of their history they were likely at-risk to kill someone or be killed that year. The group was formed independently of the police because most criminals are uncomfortable working with the police. The group’s motivation is based on love of neighbor. They do not come to judge and condemn the criminal but to express personal concern about the statistical probability that the criminal could harm someone or be harmed in the coming year. The net effect on this community is a 20% reduction in the homicide rate last year. The success of the intervention depends on a prisoner’s willingness to make suggested changes in lifestyle like leaving gang membership. One ex- drug dealer stopped dealing drugs and now works a regular job. He reports changing his lifestyle and feeling much better about himself though the income from his current salary is much less than before. Case 4: Substance Dependency119 The opioid crisis and other forms of substance dependency in our day calls for responsible social action. The program Alcoholics Anonymous or Narcotics Anonymous, since alcohol is also a drug, are successful 12-Step programs that medicine can use to help opioid addicts and alcoholics recover from substance dependency. These programs are self-supporting and community driven. The foregoing study begins with the analysis of two

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Part of this material first appeared in my article (2018) The ways of spirituality. Sofia Philosophical Review.

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complementary scientific approaches to substance dependency before focusing on a community based social action response to dependency. The literature on the treatment of alcohol use disorder falls into three broad complementary areas. The first is based on total abstinence and traces its origin to Bill W. and Dr. Bob S. (Anonymous, 1935).120 The question whether Anonymous is a program that focuses on living sober rather than on recovery from addiction is a moot point because the literature on the success of controlled drinking is mixed. The second treatment modality is based on the organic (carbon-self) scientific study of brain chemistry and the brain’s reward center, serotonin release and dopamine receptor cells, while the third approach to alcohol use disorder is based on clinical psychology, namely positive reinforcement, and behavior modification. The second and third approaches seek to promote problem-free moderation, although abstinence from alcohol appears necessary for individuals with more severe symptoms. While total abstinence can be a desirable condition of recovery, the success of treatment does not depend on it. D. L. Davies in the early 60s and Mark and Linda Sobell in the early 70s pioneered the behavioral treatment of alcohol use disorder. Although the debate about the possibility of the alcoholic’s ability to drink in moderation is far from settled, their research prepared the way for the ongoing study of addiction. The distinguishing characteristic that separates the abuse of substance from the dependence on it to function depends on a subjective criterion. In our day, Keith Humphrey, Professor of Psychiatry at Stanford University School of Medicine, and Robert Miller, psychologist and Distinguished Professor Emeritus of psychology and psychiatry at the University of New Mexico, Albuquerque, are spearheading fresh approaches to the study of alcoholism. Dr. Miller is the author of numerous studies on alcohol and drug abuse including ‘Integrating spirituality into treatment’, and ‘Controlling your drinking’. He developed a ‘Feeling-State’ protocol that is open to the ways of 12-Step programs while making room for other harm reduction treatment modalities such as CRA and CRAFT (community reinforcement and family training). Dr. Miller suggests that the solution to alcohol and drug abuse should come from clients in their community setting rather than the counselor. He says that the job of the counselor

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A.A World Services Inc. Alcoholics Anonymous. Third Edition, (New York City: Alcoholics Anonymous Publishing), 1976.

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is to help people find the motivation for change. The CRA method developed by Robert Meyers also suggests that the client must decide whether sobriety is more rewarding than drug use. CRA makes drug use less rewarding by allowing its negative consequences to occur. The focus is on helping a client find positive reinforcement for not drinking or using a substance in moderation. Whether the client’s treatment focus shifts to abstinence or moderate drinking depends on the distinction between substance abuse and dependency. In an interview conducted by W. White, Dr. Miller reports that individuals who have a less severe problem appear to be more successful in controlling their drinking than others with more severe symptoms as they often had more success with abstinence rather than moderation, “not because they tried moderation and failed but they found it difficult or not worth it.”121 Dr. Miller developed CRAFT as an extension of CRA to include community reinforcement and family training in helping a client discover the rewards of moderation or total abstinence depending on the distinction between problem use and dependence. This process, it seems to me, is fully consonant with a 12-Step community-based program as the doctor and the patient-in-community relations share insights to promote health. Other researchers in the alcohol field include Dr. Humphrey who is policy advisor to the White House on the prevention and treatment of addictive disorders, and Andrew J. Saxon M.D. an academic with numerous publications in the field of addiction. Dr. Saxon is Director of the addiction psychiatry residency program at the University of Washington where he teaches in the department of Psychiatry and Behavioral Sciences. His research focus is on the brain’s reward circuitry and offers an alternative to the Anonymous program. The approach seeks to develop a treatment of alcohol use disorders that centers on the role of the brain’s dopamine receptors, and the genetic characteristics of alcoholics such as impulsiveness. The medical model is meeting with some success because the total abstinence from alcohol use advocated by Anonymous is not for everyone, or even the best course of action to follow in all cases, although the medical model might enjoy more success if it included the connection between the individual and the community. Statistics from AA world headquarters

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W., White, “The Psychology of Addiction Recovery; An Interview with William R. Miller Ph.D.” Emeritus Distinguished Professor of Psychology and Psychiatry. Center on Alcoholism, Substance Abuse, and Addiction (CASA). The University of New Mexico, 2012. www.williamwhitepapers.com accessed March 9, 2016, 13–14.

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in New York City reveal that approximately 27% of individuals that seek help in AA are sober at the end of the first year, but this implies that 73% of addicts fail to find sobriety in 12-Step programs. This is not to suggest that all alcoholics fail to find sobriety in Anonymous after a relapse, but the point is that a treatment modality that incorporates the doctor’s referral to community resources might improve the addict’s chance of success. A program on alcohol-drug misuse that aired in 2016122 on CBC television suggests that 87% of individuals that cannot maintain abstinence from alcohol beyond the first year in Anonymous can nonetheless achieve some degree of sobriety through medical intervention and therefore will reduce the risk of harming themselves if they seek that help. Suzuki borrows the tile Wasted for his program from a book written by Pond and Palmer (2013).123 In that book, Michael Pond, an alcoholic therapist (by his own admission), promotes harm reduction as his method of choice for the treatment of alcohol use disorder. Pond expresses strong, personal dissatisfaction with the Anonymous program, in part because of its alleged focus on the negative emotions of guilt and shame associated with ‘relapse’. He suggests that the experience of shame following relapse leads some individuals to suicide. In my opinion, the problem appears to arise because the term relapse lacks specificity. For instance, Dr. Miller’s tongue-in-cheek assessment of the issue is on how many drinks and what length of time between drinks constitutes a relapse?124 At the same time, if Pond’s point is taken seriously, the community can and should examine the possible connection between relapse, guilt, and suicide. Turning the ability to control the negative effects of drinking alcohol over to God or Higher Power is core to 12-Step programs. But some professionals find it impossible to let go of control. Miller’s view, on the other hand, is entirely consistent with the goal of harm reduction but not with Anonymous’ focus on abstinence. As if to settle matters, the scientific community claims that alcoholics inherit ge-

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David, Suzuki, D. Wasted. The Nature of Things. CBC television, Jan. 20, 2016. Michael, Pond, and M. Palmer, Wasted. An Alcoholic Therapist’s Fight for Recovery in a Flawed Treatment System, (Toronto, Ont.: Greystone Books Ltd. University of Toronto Press), 2013. W., White, The Psychology of Addiction Recovery; An Interview with William R. Miller Ph.D., Emeritus Distinguished Professor of Psychology and Psychiatry. Center on Alcoholism, Substance Abuse, and Addiction (CASA). The University of New Mexico, 2012. www.williamwhitepapers.com accessed March 9, 2016.

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netic traits that make them more susceptible to impulsiveness. The explanation proffered in Wasted is that alcoholics have fewer dopamine receptor cells than non-alcoholics and presumably fail to activate the brain’s reward circuitry without external stimulants. The detoxification process puts alcoholics at risk because the brain rewires itself to depend more on itself and less on alcohol. Several drugs such as Ativan (Benzodiazepine) are used to treat anxiety disorder during this period of transition. Medicine provides anticonvulsant medication such as gabapentin to reduce the risk of dying from rapid convulsions (DTs). The narcotic antagonists Naloxone (NLX), an opioid blocker and medication, and Naltrexone (NTX) reverse the effects of an overdose of heroin or some other types of pain killers. Naltrexone blocks dopamine receptor cells and its slow release effect reduces the craving for alcohol for a period lasting up to 30 days. Naltrexone is available in liquid injectable form in the U.S. (Vivitrol) but is only available in capsule form in Canada. Naltrexone acts directly on the brain’s reward pathway and reduces the addict’s impulsive behavior. University communities are beginning to address the opioid crisis by stocking naloxone kits to block today’s fentanyl crisis and relapse from heroin use. Petra Schulz, an instructor in community health and community studies at MacEwan university is a co-founder of the grass roots movement ‘Moms stop the Harm’.125 She says that her son’s death from a drug overdose could have been prevented. We need better education, and drug policy reform at the Federal level, not ‘tough love’. MacEwan University’s Wellness Centre became a distribution center for naloxone in the fall of 2017. Also, the community’s focus on spirituality appears to have a positive influence in moderating impulsive behavior. First, the community recognizes that we have an opioid crisis. Second, the community promotes the development of safe shelters for addicts and advertises that naloxone kits are available to block, and reverse overdose trauma caused on dopamine receptor cells by heroin, fentanyl, and other opioids. It seems possible for drug counselors to recommend the use of whatever model works best for their client. The first step, as always, is to construct a complete person-making profile of a client. At the end of the day, the path to recovery depends on a cost/benefit ratio in which a client weighs the negative consequences of alcohol use against the benefits of

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Michael Roncic, Harm reduction policies gain favor on campuses. University Affairs. UA/AU, April 25, 2018.

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reducing consumption, or in some cases total abstinence from alcohol. Following Dr. Miller’s experience in the alcohol field, the client decides the best course of action rather than a counselor or other experts in the field of alcohol addiction. But we need to develop a culture of community awareness to promote recovery from addiction. One major difference between the Anonymous program and the cost/benefit model is that Anonymous is based on spiritual recovery and the discovery of help in a community of addicts. Miller finds that spirituality is hardly possible during the first year because the individual must first attend to higher needs such as health and employment. But health depends on spirituality! Addicts live in a community, not in the clouds and will not get on with life until they regain a will to live without drugs. Perhaps they can learn about spirituality from addicts in recovery through spirituality? A doctor treating a patient as if the patient did not live somewhere focuses on controlling disease and therefore on controlling a patient’s health outcome. However, a patient’s spiritual energies can be redirected towards healthier ‘carbon capping’ outcomes. The focus on redirecting spirituality is urgent in the Anonymous program and indeed functions as the necessary condition of recovery. The individuals that seek help from AA do so because the severity of symptoms undermines the autonomy and consent required to redirect spiritual energies. The AA claim “We were powerless over alcohol…” presents as a blockage to personal growth. The program of Alcoholics Anonymous is spiritual and community based to the core. Treatment begins with the doctor’s assessment and care of the patient’s condition and continues with a referral to a community-based treatment program such as Alcoholics Anonymous. Community based recovery from dependency focuses on finding a solution to negative emotions and the user’s low self-esteem. Abstinence from alcohol use is but a means to that end. The medical, clinical focus on harm reduction alone is incomplete because it misses the possibility of community-based recovery. The community-based structure of 12-Step programs: The spiritual ability to find meaning in the alcohol related experience of the other is integral to the success of 12-Step programs. The spiritual character of A.A. arises out of the strength that its members get from sharing stories about their experiences with alcohol. They are brought together because they identify with their common inability to control drinking and the decision to turn the unmanageability of life over to a Higher Power. This means that their spirituality arises out of letting go of control. It does

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not move from point A to point B in clear and distinct steps, but rather follows a circuitous path in which God is at work in their life. Alcoholics in recovery trust God to do for them what they could not do for themselves. Theirs is a spirituality of brokenness, or imperfection. The spirituality of A.A. draws from a rich history of spirituality (Kurtz & Ketcham, 2002); “…we can recognize the contributions of such spiritual geniuses as the Hebrew prophet Jeremiah and the Greek philosopher Socrates, of church fathers such as Ignatius of Antioch, of the desert Fathers and Mothers of the monks basil and Gregory, of the saints Augustine and Benedict and Francis of Assisi, of mystics such as Julian of Norwich, of reformers as diverse as Calvin and Luther and Caussade, of the rabbinic commentators and the Baal Shem Tov, of William James and Carl Jung, of the brothers Niebuhr and D. T. Suzuki… .”126 The addict’s need to attain perfection is mistakenly sought in the instantaneous, immediate and false sense of perfection that arises from drug use; “Breaking through that denial and confronting reality is what members of Alcoholics Anonymous mean by ‘hitting bottom.’”127 The practice of a spirituality of imperfection arises through the addict’s recognition and acceptance of personal powerlessness and failure. The ideal of a perfect state of bliss is replaced by the reality that spirituality operates within the weaknesses and strengths of the human condition. Bill Wilson, the co-founder of the Anonymous program, views the spirituality of imperfection as dependent on the awareness of what Herbert Spencer called ‘God-consciousness’ (Anonymous, 1976).128 But God-consciousness is open to a variety of meanings to enable the spiritual awakening promised in the Anonymous program. The way in which spirituality connects with a 12-Step program is different from the connection between spirituality and other 12-Step applications because the spirituality practiced in A.A. is tailored to the special needs characterized by substance or behavioral dependency (addiction). The parameters of recovery from alcohol dependency bring out an essential characteristic of spiritual growth. While this application extends to other dependencies whether behavioral such as sex or gambling dependencies, or other substance-based problems

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E., Kurtz, and K. Ketcham The Spirituality of Imperfection. Storytelling and the search for meaning, (New York, N.Y.: Bantam Books, 2002) 6. Ibid., 169. Herbert, Spencer, 1976. A.A World Services Inc, Alcoholics Anonymous. Third Edition, (New York City: Alcoholics Anonymous Publishing, 1976), 570.

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such as opioid dependency, the use of a 12-Step method to overcome addiction is historically first in line since it was introduced in 1935 by Bill Wilson and Dr. Bob Smith. Based on the metaphysical structure of spirituality the essential character of the Anonymous program clusters about the arms of a person-making process, namely the carbon-self, the social-self, and the psychological-self. In this case, the social-self is the first line of contact since it opens the door to the possibility of healing the associations that exist in the other two strings of person-making relationships that individuate us. Alcoholics in recovery tell their personal stories about ‘what it was like; what happened, and what it’s like now.’ The fellowship works through resonance and identification with personal stories. 12-Step programs have no explicit connection to organized religion, although the spiritual thread is present in both. Spencer’s descriptive ‘Godconsciousness’ is sufficiently vague to incorporate both camps. The visualization of God by individuals in recovery provides insight into the nonreligious aspect of spirituality. The active alcoholic expresses a need to find the meaning of life but uses alcohol to fix negative emotions. Thus, 12-Step spirituality opens as an attempt to reverse false spiritual starts or non-life-giving spiritual connections. Too much dependency on a ‘Higher Power’ can also be a source of sour spirituality. It can become addictive. Leo Booth (1991) claims that “Religious addiction does exist; it is a disease like any other addiction; and it can and should be treated by the same methods used to treat other addictions.”129 No point going from the frying pan to the fire; while religious spirituality plays a negative role in freeing the faithful from sin and guilt, it can play an equally negative role if God becomes a scapegoat for the inability to take personal responsibility for a wrongful course of action. The practical view of God in 12-Step programs is that at treatment entry God is found in the community of recovering addicts. The progressive nature of recovery suggests that this is a prerequisite to finding God elsewhere. Historically, the first introduction of a 12-Step program intended for personal recovery from substance and/or behavioral dependency is found in the Twelve Steps of Alcoholics Anonymous (1935). While the Oxford Group’s focus on spirituality and recovery predates Anonymous, and influences its development, the Oxford Group’s intent is primarily to provide

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Leo, Booth, Fr. When God Becomes a Drug, (New York, N.Y.: Penguin Putnam Inc)., 1991, 38.

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a religious experience rather than a spiritual recovery. This fact points to an important distinction between spirituality and religion. Furthermore, AA’s spirituality arises out of deflation of the ego at depth rather than in the practice of the Oxford Group’s philosophy of absolute purity, honesty, unselfishness, and love. Dr. Silkworth, one of Bill W.’s early mentors gave him solid advice (A.A. World Services Inc. 2005)130 when he told him not to focus on the Oxford Group’s four absolutes when dealing with alcoholics because their spirituality is not of an evangelical type. Rather the focus on personal growth arises from the ashes of the alcoholic’s deflated ego; “deflation at depth is the foundation of most spiritual experiences.” Without that bit of advice, the AA program might not have come to light. The development of 12-Step programs would not take place without community. It begins following Bill Wilson’s spiritual experience in Towns Hospital in 1934. He saw something that day that made him realize that he had to connect with another alcoholic to resist the urge to get drunk. The ‘other alcoholic’ is Dr. Bob Smith—A.A.’s co-founder. That fateful meeting is described in Alcoholics Anonymous Comes of Age: a brief history of A.A. (1979).131 They talked for hours, each able to identify with the other’s craving for alcohol. And together they were able to stay sober. But they also realized the need to grow their meeting by spreading the web of talks with other alcoholics who wanted what they had. They found a third person wanting help with an alcohol problem, and a fourth and so on. The community movement which Bill W. and dr. Bob N. began in 1935 has grown to 2,103,184 members in 118,305 groups worldwide as of 2016.132 This community-based resource has expanded to more than 100 applications from alcohol dependency to include other emotional problems where resonance, identification, and the desire to do something about the problem is the only requirement for entry. They turn to each other and through others discover the existence of a source of power greater than their now deflated ego. Doctors treating patients with alcohol problems or other abuse issue must connect with this community-based resource as a fit be-

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W., Silkworth, W., A.A World Services Inc. Alcoholics Anonymous Comes of Age; A Brief History of A.A. (N.Y.: Alcoholics Anonymous Publishing, 2005), 68. Alcoholics Anonymous Comes of Age: a brief history of A.A. (New York: Alcoholics Anonymous World Services Inc. Eight Printing), 1979. Statistics are from https://www.aa.org/assets/eng_US/smf-132_en.pdf accessed 27 March 2018.

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tween academic medical resources and the patient’s relational connections. Alcoholism is a sickness and a moral problem, and it therefore does not recognize class boundaries. It can affect anyone and appears to have a genetic profile that is passed on to one of every fourth child of alcoholic parents. One of the first professional groups was formed in 1943. Father Edward Dowling was one of the first priests to approach the problem of the alcoholic through A.A. It was felt at the time that priests in A.A. needed to know about other priests in A.A. Priests, doctors, psychiatrists, lawyers and other professionals are reluctant to join A.A. Because of what they do. Alcoholic professionals are less likely to seek outside help because they have good paying jobs and have the respect of society. This makes them less likely to look for respect within themselves. The first priest-member joined Alcoholics Anonymous in 1943. He has been instrumental in carrying the message to clergy in need of help with alcohol abuse. He recognizes the need to for professors familiar with alcohol dependency to pass on the message to seminarians through lectures and the publication of articles on alcohol use; “We think a real contribution along these lines would be to (…) assist us in writing more articles on alcoholism, even to the extent of composing some sort of text that might be useful in seminaries throughout our country.”133 And if in seminaries why not in medical classrooms? Resources are at hand in communities worldwide. The alcoholic’s willingness to search for a power higher than self (Second Step) depends on the admissibility of a First Step, namely the admission of personal powerlessness and unmanageability over the use of alcohol. Carl Jung, a spiritually minded analytical psychologist, recognized the relational function of ego deflation when he directed one of his patient (Roland H.) experiencing problems with alcohol use to meet with Bill W’s group of friends in recovery.134 The active alcoholic, it seems is otherwise seeking sacred meaning in the wrong places. The use of alcohol to find sacred meaning fails. Jung’s referral is highlighted in a letter he sent to Bill W. on January 30, 1961; “Dear Mr. Wilson, I had no news from Roland H. anymore and often wondered what had been his fate (…) alcohol in Latin is ‘spiritus’ and you can use the same word for the highest

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Alcoholism A Source Book for the Priest. 1960. National Clergy Conference on Alcoholism. Rev. Ralph S. Pfau. Founder and Secretary of NCCA. Introduction. (1957) p. 12. s Carl, Jung, Letter to Bill W. http://www.silkworth.net/aahistory. (Jan. 30, 1961). Accessed August 20, 2015.

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religious experience as well as for the most depraving poison.” The spirituality that animates recovery appears to emanate out of the Jungian imagery of the ‘wounded healer’, a spirituality that exists deep within the realm of personal pain. In Jungian analysis spirituality arises out of the integration of the contents of the unconscious into consciousness (individuation) rather than in the outward pursuit of perfection. The depths of personal failure serve as a source of strength as illustrated through the immortal lyrics of Leonard Cohen;135 Ring the bells that still can ring Forget your perfect offering There is a crack, a crack in everything That’s how the light gets in.

That view aligns with Anonymous’ focus on five personal ‘inventory’ Steps because recovery from substance dependency is contingent on selfawareness. That belief is consonant with the experience of Søren Kierkegaard (1813–1855) and William James (1842–1910) as they both appear to draw spiritual strength from their personal struggles with depression. In this case the focus on personal brokenness marks a significant departure from the spirituality of Kierkegaard and James because healing takes place through a community group of like-minded friends. The clearest expression of the central role of spirituality in recovery is expressed in Anonymous’ 12th Step; “Having had a spiritual awakening as a result of these steps …” Thus, a ‘spiritual awakening’ implies that the alcoholic had otherwise misdirected spirituality until that point. This is to say that the individual in recovery becomes aware of the need to redirect spiritual energies after the fact of the previous eleven Steps. Adherence to the Twelve Steps is prescribed as a necessary condition of recovery from dependency. Further, the 11th step’s suggestion that the need to ‘improve conscious contact with God…’ is integral to righting spirituality, signals the pivotal role of God or a Higher Power in personal recovery. The word ‘recovering’ might be a more appropriate characteristic of the spiritual

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Leonard, Cohen, Anthem. Lyrics. http://www.azlyrics.com/lyrics/leonardcohen/anthem.html Accessed March 3, 2016.

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awakening than ‘recovered’; the A.A. program promises ‘spiritual progress’ rather than ‘spiritual perfection.’136 Thus, ‘spiritual awareness’ refers to an ongoing process of recovering from alcohol dependency rather than a cure for a medical condition. This marks a clear break from the medical and psychological models. The study of these steps reveals that recovery is contingent on the discovery of a Higher Power (Step 2) and the willingness to turn ‘will and life’ over to the care of that Power (Step 3). The nature of the Higher Power is unspecified, as expected from a non-religious movement. Members will take from this concept what they need to recover from dependency. It begins with the group experience and continues with helping others seeking help with addiction. The only requirement for membership in Anonymous is the Third Tradition: a ‘desire to stop drinking.’137 The 12-Steps are suggested as a necessary condition of recovery. While the nature and function of the Higher Power is unspecified, the individual is invited to enter relationship with it or turn control of substance dependency over to God so that God can do for the individual what was otherwise unattainable. The action of Steps 2 and 3 is presented as a necessary condition of recovery. This is the first indication that spirituality could have a transcendental character but not necessarily so. The Anonymous program is designed for atheists as well as theists. It arises out of the individual’s relationship with whatever Power the individual identifies as being ‘greater than self.’ No reference to the God of religion is made or intended. The ongoing process of spiritual awakening (steps 4 through 11) subsequently appears to be contingent on the ongoing effort to remove whatever obstacles stand in the way of relationship with the nature of the Higher Power as identified by the individual in recovery. However, the insight into the nature and function of the Higher Power evolves as the individual experiences a spiritual awakening. Five blockages to ongoing recovery and spiritual awakening (personal deficiencies, defects of character and shortcomings) are addressed from Steps 4 through 5–6–7, and 10, while two other impediments to spiritual growth are found in blocked relationships with other persons (steps 8 and 9). Shaming others who do not or cannot maintain sobriety is not part

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137

A.A World Services Inc. Alcoholics Anonymous. (Third Edition. New York City: Alcoholics Anonymous Publishing), 1976, 60. A.A. World Services, Inc. Twelve Steps and Twelve Traditions. (New York N.Y.: Alcoholics Anonymous Publishing), 2006, 139.

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of steps 8 and 9. On the contrary, the Anonymous program is based on the resonance and identification between alcoholics, not on shaming others but on accepting others as they present themselves. A high percentage of alcoholics do relapse during the first year because of the power of alcohol dependency, but as they learn from individuals with long term sobriety they are not alone to fail the first time around. The AA slogan ‘live and let live’ captures the essence of the relationship with others, and the door to the AA community is kept open to anyone with a desire to stop drinking. Further, the other in recovery is a gateway to divine help. The 11th Step provides an opportunity to deepen the relationship with a Higher Power. The focus of the ‘inventory steps’ is on inner work as the release from the bondage of substance and/or behavioral dependence progressively gives way to the discovery of an alternate source of sacred meaning. The net effect is a ‘spiritual awakening’ and the realization of several promises. While the promises contained in Anonymous are expressed throughout its pages, the greatest concentration of promises is found on two pages of that volume. The promises arise as the beneficial outcome of cultivating the spirituality found in the teachings of this program. The emotional benefits of 12-Step spirituality include the discovery of a new sense of freedom, happiness, and serenity; “…that feeling of uselessness and self-pity will disappear (…). Our whole attitude and outlook upon life will change. Fear of people and of economic insecurity will leave us (…). We will intuitively know how to handle situations which used to baffle us.”138 These emotional changes happen because of the sacred bond with the group, the adherence to spiritual principles, the discovery of God in and through other persons, and the gradual healing of mental states. Anonymous promises recovering addicts that the negative emotions of the past such as the fears, insecurity, and guilt that arise out of mishandling spirituality and past emotional challenges will give way to a new sense of belonging. The belief in the existence of a Higher Power and the individual’s willingness to change provide a promised map to recovery. The act of entering personal relationship with a Higher Power—usually expressed through other persons in recovery—puts life’s issues into clearer perspective. That outcome is promised in the Anonymous fellowship; “Are these extravagant promises? We think not. They are being fulfilled among us—

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A.A World Services Inc. Alcoholics Anonymous. (Third Edition. New York City: Alcoholics Anonymous Publishing), 1976, 83–84.

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sometimes quickly, sometimes slowly. They will always materialize if we work for them” (italics added.)139 It seems possible to affirm that spirituality plays a dual role in the Anonymous programs; not only as a tendency towards meaning but also a tendency to unmask what stands in the way of sacred meaning; “We recovered alcoholics are not so much brothers in virtue as we are brothers in our defects, and in our common striving to overcome them.”140 The spirituality of Anonymous is characterized by a process that begins with the recognition and admission of failure (the crack in Cohen’s Bell). This is an explanation of how an emotional blockage provides a spiritual opportunity for personal growth. The experience of ego deflation and failure prompts some addicts to seek out a source of sacred power outside the self. The Higher Power morphs into a God of their understanding. The process of recovery gradually leads to a spiritual awakening. This sets the stage for an alternate substance free search for meaning. Spirituality in this instance is the awareness that the promise of a meaningful life is at hand without the use of alcohol (or any other minds altering substance or behavior). The spiritual awakening and the ensuing physical sobriety ushers in a new era of personal growth otherwise beyond the reach of the individual. The process paves the way for a spirituality now unblocked from dependency to step into the light of recovery to the discovery of new meaning in life. Bill Wilson says; “…sobriety is only a bare beginning; it is only the first gift of the first awakening.”141 The published stories of alcoholics in recovery confirm that promise.142 The distinction between God’s nature and God’s attributes highlights a main difference between the spiritual character of 12-Step programs and the spiritual character of religious beliefs. It seems possible to suggest that the addict’s first introduction to a 12-Step program should focus on the existence of God as such (Higher Power) rather than on divine attributes. The reason for this suggestion is that the addict’s experience of what God does is generally negative. Perhaps the Augustinian religious tradition carries the same negativity as a spiritual weakness turns into a source of

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141 142

Ibid., 84. A.A. World Services, Inc. As Bill sees It. (New York: Alcoholics Anonymous Publishing), 1998, 167. Ibid., 8. A.A World Services Inc. Alcoholics Anonymous. (Third Edition. New York City: Alcoholics Anonymous Publishing), 1976, 453–561.

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grace? A spiritual maturity is required to enter a positive relationship with God. The addict’s God consciousness is laced with negative emotion because the relationship with God does not appear to produce a plan that includes the ongoing use of the drug of choice. God does not provide the peace required to maintain an addict’s continued drinking. At first brush it seems that God is not all loving and all powerful. So that idea of God is abandoned. The movement towards recovery calls for a revolutionary change of relationship with God. The addict that seeks recovery must first learn to accept that a life without substance use is possible, and second that this is carried through by developing a challenging relation with a seemingly uncaring God. The recovering addict gradually develops a clearer vision of God as ultimate good. At the end of the day, the suspension of belief in the attributes of God followed by a belief in the pure existence of God generates a rich source of spiritual insight. At some point in recovery the individual’s willingness to trust this unknown source of power is filled with glimpses of God’s attributes as God fulfills the spiritual promise of recovery found in the AA program. At that point the addict might be ready to raise spirituality to the next level by seeing God at work in the personmaking process. The spirituality of an addict in recovery whether from substance dependence or a negative religious experience is purer than unblemished religious spirituality because it emerges out of the depths of a personal hell. While the view of alcoholism and opioid dependency as disease finds its explanation in the brain’s dopamine receptors and the brain’s reward circuitry, it seems that the higher road to mental health is integrative. For instance, the Mayo clinic’s successful approach to alcoholism moves beyond the organic structure of persons to include a focus on the spiritual.143 The success of the medical model depends on the view of the patient as disease but perhaps medicine can attain greater success by reclaiming its foundational roots in the ancient art of healing and living life in the Agora. The next chapter examines the ultimate ground for my advocacy of medicine as sacred science.

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Mayo Clinic. See http://www.mayoclinic.org/disease-conditions. Accessed June 28, 2015.

Chapter Five: The Absolute Truth Value of Human Death Overview The proof of the sanctity of human life exists in God’s creation of the world and all things contained in it as given in a philosophy of direct perception. The existence of the world is indemonstrable, but it provides an absolute foundation for deontological ethics. It also points to the poverty and majesty of medicine; the dignity of the person and the limits of measurement. What does human death have to do with the absolute ground of medicine? We are death bound subjects and while medicine controls disease and the process of dying, it is powerless before the metaphysical reality of human death. The distinction between the epistemology of human death and its metaphysical ground plays a significant role in the distinction between death and dying. While the pronouncement of human death is based on the irreversible loss of consciousness, the ground of the possibility of this absence points beyond itself to a reversal in being’s unconcealment and the possibility of life. From the point of view of epistemology, death is the irreversible absence of consciousness. From the point of view of metaphysics, human death is a reversal in the possibility of the presence and absence of consciousness. This is evident from the fact that being’s unconcealment contains the ground of the possibility of truth. The metaphysical structure of human death is traced to a concealment in being’s unconcealment. The concealment of being is not the annihilation of unconcealment. Personal death does not annihilate God’s creative act for that individual. Theology points to a reversal in being’s unconcealment in the afterlife state of existence and the face to face encounter with God. But the nature of this encounter is beyond the scope of the present inquiry. The metaphysical nature of death points to the presence of an absolute truth that is given freely to medicine and empowers it as science, but the realization of this truth also discloses the nature of medicine as sacred science. Medicine as science observes, measures, and controls the process of disease and dy-

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ing. Its material focus is the carbon-self relations of the human body. However, medicine as sacred science operates in the evidence of the absolute mystery of human existence and the gift of medicine as is evident from the foundational character of the Oath of Hippocrates. Its material object as sacred science is the whole person as a spiritual organism. The carbon-self exists in relationships with the whole of the person-making process and the mystery of human existence. The root of the possibility of medicine helps us to control dying but that control ceases at human death. The analysis of the metaphysical ground of this realization introduces us to the poverty and majesty of medicine. What would happen if the focus in Christian theology shifted from a Fall-Redemption account of biblical history to a creation centered theology? Matthew Fox (1983) thinks that the shift away from a theology centered on sin is overdue; “To teach original sin and never to teach original blessing creates pessimism and cynicism.”144 At first brush, the focus appears ill advised because of the richness of the Old and New Testament account of the ‘Fall’ of Adam and Eve, and the Incarnation of Jesus Christ, God’s only Son, and of His death and resurrection to redeem us from sin. I cannot imagine my spiritual life unfolding without the Gospel stories of Mark, Matthew, Luke, and John. I cannot imagine my ability to make sense of who God is without the image of Jesus Christ who is God, and like us in every way except sin. The image of Christ as human provides an example I strive towards but never attain fully in prayer life. The Gospel of Fall and Redemption through the mystery of the incarnation and the credibility of a Son at once divine and human provides a solid foundation for a lived faith; a belief system that makes sense to me. It points to the possibility of personal salvation as a gift from the divine while allowing plenty of room for my Augustinian tears of contrition as I face my human weaknesses and resolve to do better; nay, do better because the possibility of doing so has been bought by the blood of Christ. Why then raise the question what would happen if the focus in Christian theology shifted toward a creation centered theology? I do so to build on the already solid cornerstone foundation laid by Christ, not to detract from it or fail to give thanks for the possibility of personal salvation bought by Christ.

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Matthew, Fox, Original Blessing, (Santa Fe, New Mexico: Bear and Company), 1983, 19.

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I think that the very first insight that comes from a creation centered spirituality is the awareness of standing in the presence of mystery and the reality of personal salvation. Rejoice for you are gifted with personal existence and eternal life with God the Blessed Trinity. These words are layered with meaning as I begin a process that leads to the well of mystery to savor the gift of being’s unconcealment. As I peel away the layers of grateful existence, the first thing I notice is the primacy of creation. The words of Canon 1.5 First Vatican Council (1869–1870) have never run truer than in creation centered spirituality; If anyone does not confess that the world and all things which are contained in it, both spiritual and material, were produced, according to their whole substance, out of nothing by God; or holds that God did not create by his will free from all necessity, but as necessarily as he necessarily loves himself; or denies that the world was created for the glory of God: let him be anathema.145

Canon 1.5 gives tribute to God for creating the world and all things contained in it. We do not know why God chose to create rather than not create and the world is therefore a blessing, a gratuitous gift from the Creator God the Father. The philosophy of creation centered spirituality puts the focus directly on the primacy of esse as the objective correlate of consciousness. Being’s unconcealment is given directly to consciousness in a theory of direct perception. The existence of the objective correlate outside or away from the encounter between the subjective and objective correlates is dualistic, and inconceivable. We are part of the dialogical encounter and not outside looking on. The analysis of our subjective correlate takes place as consciousness falls back on itself to allow us to reflect on the structure of esse. The unconcealment of esse reveals the existence of a multiplicity of things, of different species of being and of differences within each species. The world of things shows itself to us. To the objection that the primacy of esse is not a first indubitable truth because consciousness and its object form an inseparable unit, the answer lies in the distinction between the concept and the idea. The plurality of existing forms is given to consciousness spontaneously before the reflexive activity of consciousness takes place. The term Aquinas reserves for this encounter is the concept. The concept is the means to knowledge. It springs into unconcealment and dialogue with the objective correlate of

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Canon 1.5. (1869–1870), On God the Creator of All things. First Vatican Council. https://www.ewtn.com/library/councils/v1.htm accessed January 2018.

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consciousness at the pre-discursive, pre-thematic process of knowledge. The concept awakens the subjective correlate of consciousness to reflect on the encounter and produce something to its likeness. The concept functions as the exemplar of consciousness while the activity of reason produces the idea of the objective correlate of consciousness. The significance of the process of knowledge is twofold. First it introduces the essence or nature of things to consciousness. Thus, it must be the case that the essence or nature of things is reducible to their existence. Essence arises as a limitation of existence. In other words what something is depends on its existence as a given datum or the objective correlate of consciousness. The production of the idea, on the other hand, is the product of the subjective correlate of consciousness as it examines things and provides distinctions between existents and observes varying degrees of difference between existents. In ordinary language we refer to these distinctions as the degrees of knowledge. The activity of simple apprehension, and reasoning provides insight into the nuances of essence or the nature of things. Being’s unconcealment sends us on errands to discover the nature of disease as limitation rooted in the simultaneous primacy of esse. The second thing we notice is that there are grades of perfection in nature. The world of things reveals grades of existence ranging from inanimate matter, to animate matter in the form of plants animals and human beings. We notice degrees of perfection and imperfection or disease in each species of things. While our species is human nature, we are not equally personal. While our species gives evidence of reflexive awareness, the animal species does not do so. This is to say that animals are not reflexively aware of themselves whereas humans are aware of being aware. Some living things exhibit the power of sensation and awareness whereas others such as plants do not possess sensory powers. The attempt to prove that animals are reflexively aware or that plants have sensations sins against Occam’s razor because it fails to reduce the explanation of behavior to its simplest terms. We can explain the most sophisticated behavior of animals based on stimulus-response and classical conditioning and while this also explains some human behavior, it cannot explain the whole of it. The objective correlate of consciousness also conveys the contingent nature of esse to the subjective correlate of the noetic encounter. We learn that things come into being and pass away. The awareness of our very own finitude is simultaneously a source of empowerment and a source of anxiety for our species. Consciousness cannot think of itself as not thinking or

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someday not existing. The awareness of creation centered spirituality is simultaneously a source of awe and a source of despair because we do not, nay cannot control it. We are attracted by the good of existence, as we strive to bridge the gap between the inside and the outside of reflexive awareness to find the ultimate meaning of life. We are logical beings in search of sufficient reasons to explain why we exist rather than not exist. A partial answer lies in subjective truths and the leap into relationships with all living things. Religious faith is appealing because it offers an explanation pleasing to reason. Matthew Fox’s vision is that creation centered spirituality is more inviting than the Fall Redemption spirituality of sin. Point well taken, but I am pondering the theology of creation spirituality through the eye of philosophy. While the same structure of human understanding enters dialogue with being’s unconcealment, would the need for the redemptive story be as clear to us in the absence of the fall? Perhaps the struggle against suffering (not giving in to our deceptive attraction to the good) would be lost to evil without the story of the Cross. Would the humility of Christ as a God who does not seek equality with God be lost on us? Would the divine courage to face personal death and the human need for salvation be lost to us? How would the forgiveness of sin be possible in a creation centered spirituality? How would we explain our limitations? My focus at this point is on the metaphysical structure of human death and what it teaches us about relations, and so I leave the development of these important questions to theologians. However, I take comfort in the rich Aramaic text of the Lord’s prayer. The English translation of the prayer is by Douglas-Klotz (1990).146 The material in parenthesis is from the Good News Bible with the Apocrypha (1986);147 The interpretation of the translation is mine. O Birther! Father-Mother of the Cosmos, (Our Father who art in Heaven) Focus your light within us; make it useful: (Hallowed be thy name)

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Neil, Douglas-Klotz, Prayers of the Cosmos: Meditations on the Aramaic Words of Jesus, (New York: Harper Collins Publishers), 1990. I strongly recommend this insightful book. Good News Bible with the Apocrypha, (Toronto, Canada: Canadian Bible Society), 1986, Mt 6:9–13.

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The translation offered by Douglas-Klotz is far richer than the seemingly anemic biblical translation. The first line of the prayer “O Birther” conveys the idea of God as Creator of all things both material and immaterial ‘under the cosmos.’ This is the first indication that the teachings of Jesus can be interpreted through creation centered spirituality because of the unity of all things. The ‘Birther’ calls us to meditate on creation and enter divine union (reign of unity) with the Birther. For this to happen, human will (and the person-making process) must accord with the divine will. The prayer asks Birther for the insight (bread is food for the whole person in relationships) needed for union with the divine, and the wisdom required not to be deceived by the surface appearance of things (temptations of the secular world), and free us from what holds us back that we might enter fully into all our person-making relationships. The Lord’s prayer, it seems to me, is an invitation to reflect on human limitations that they might become a source of strength as befits our spirituality of imperfection. The call is to plumb the depths of the unconscious in the spirit of Jung’s call to individuation because ‘what happens in the dark controls us.’ The Aramaic text of the Lord’s prayer is an awakening to the power of creation centered spirituality in the sense that the relation with the Birther is the most essential of all personal relations. This is not to overlook things of this world. On the contrary, the invitation is to recognize the divine in all our earthly relations, namely God the Creator in the environment, other persons and the internal-self. This is the source of

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Hippocrates’s Oath and the insight that all life is precious. While Hippocrates scoped beliefs about pagan gods for this insight, current research into the history of the Cross reveals the existence of Christ as that God! Thus, creation centered spirituality underwrites Hippocrates’s celebration of life. That view is familiar to us because all humans in action, all persons called into spiritual union with the divine. The structure of the subjective correlate of consciousness reveals the innate attraction of humans towards the ultimate good, along with the innate tendency to see God at work in all things through the regularity and structure we expect to find in nature. The regularity of nature springs from its structure and is a sign of perfection. The reducibility of essence to existence is equally a signpost of the perfection that exists in all things. The greater the degree of unity, truth, goodness, and beauty of the existent, the greater the perfection of being. Also, the reducibility of essence to existence assigns ultimate primacy to God’s act of creation. God creates the world and all things contained in it from nothing. The nothing is not the absence of something because an absence acquires meaning in relation to an anterior presence of which it is privation. Creation is the act of giving existence where nothing existed, not even in potency. Creation does not take place in space and time or in the nothing of space and time. Space and time appear in existence simultaneously with being and time to follow the laws of contingent things as they expand and contract to form planets. The claim that essence arises as the extrinsic limitation of existence is unacceptable because it gives rise to the real distinction between essence and existence. This is Plato’s eternal world of form. The reducibility of essence to existence resolves the problem of the eternal world of Greek philosophy. The world of essence does not exist as a principle of limitation because potentiality cannot be thought to lie in eternal wait for God’s creative act. The essence of a being arises at the place where its existence ceases. For the same reason, William Carlo (1966) says that formal causality is reducible to efficient causality; “formal causality is the limitation and determination of efficient causality to the production of this kind of being.”148 In order to express what we mean by the ultimate reducibility of essence to existence, Carlo (1966) uses the following metaphor of water being poured out of a pitcher; “simultaneously with a sudden drop in temperature. Under freezing conditions, it becomes a solid before it

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William, Carlo, W. (1966) The Ultimate Reducibility of Essence to Existence in Existential Metaphysics, (The Hague: Martinus Nijhoff), 1966, 107.

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strikes the ground. The liquid existence is possessed of its dimensions, its own limitations. The shape it assumes is the determination of its own substance. Essence is not something extrinsic to existence which limits and determines it in the same way that a pitcher shapes its recipient liquid, but essence is the place where existence stops. There is nothing in water which is not water. There is nothing in an existent which is not existence.”149 In somewhat similar light, Martin Heidegger’s claim that being is bordered by nothingness (the clearing) which allows being to step out of the clearing as the possibility of truth. In simple language, the desk I sit at is bordered by the nothing. Were it not the case, the desk would extend into infinity and would no longer be a desk. Thus, the nothing plays into the existence of the something, and must also define it. For this reason, being’s reclaim of unconcealment must be at the root of the possibility of death as the absence of consciousness; it must be the nothing that surrounds the something of life.. Creation centered spirituality places the focus on the creative act and the primacy of being’s unconcealment over the reflexive awareness of that truth. It arms the subjective correlate of consciousness with the truth that being’s unconcealment unfolds for us on the instalment plan in harmony with our hunger for truth. We bring different gifts, different appetites to the truth of being. The subjective correlate of consciousness brings all the interests of the pluraculture to the banquet of being’s unconcealment. That is why we have doctors, lawyers, plumbers, carpenters, and philosophers in this world. The doctor is given the same invitation to the banquet of holistic truth. But the current reductive skill set of medical school dulls the thirst for the mystery of existence and often under values the sanctity of human life in all its dimensions. No one is blind to the fact that we are beings in relations. We move towards perfection because we are not perfect. What does this have to do with human death? A great deal as we saw earlier. Death is not an instantaneous process. It takes time to die. It happens in stages. Somatic death is the irreversible cessation of cardiac and respiratory systems. Fortunately, the process is reversible although the human brain begins to die in the prolonged absence of oxygen (anoxia). We have billions of brain cells and lose something in the order of 100,000 brain cells a day (on a good day), more on a bad day. Irreversible brain damage

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Ibid., 103.

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begins to accrue without oxygen and after 3 to 4 minutes the process of dying enters cellular or brain death. The first part of the brain to die is the higher oriented function of the brain responsible for feelings and reflexive awareness. This is followed by the death of the mid-brain and brain stem. The third definition of death includes the death of all functions of the brain, including the brain stem. Rapid developments in science and technology have created confusion about when to pronounce death. The patient on life support is in a condition that could be incompatible with the continuance of life if the internal organs fail. The patient must be pronounced dead before being taken off life support systems. But once the pronouncement of death is made the organs of the deceased can be harvested. David lamb suggests a fourth definition of death to include putrefaction, less the urgent need for donor organs hasten the pronouncement of death. In fact, the same individual can be pronounced dead or alive in different parts of town depending on the availability of medical services, and a host of human factors including the age and condition of the patient and the time of day (more people are pronounced dead in the early morning hours). The pronouncement of death is an important moment to make sure that the patient is viewed as a person in relationships. What does all of this have to do with the Hippocratic Oath? A great deal because the four definitions of death discussed in this chapter are seen from the point of view of the subjective correlate of consciousness, only. We need to keep in mind the fact that the objective correlate of consciousness also plays an important role in the pronouncement of death as we saw in chapter 2. For as long as we live we are in dialogue with being’s unconcealment. The distinction between dying and death is critical. While dying is the absence of consciousness, human death is the absence of both the objective corelate of consciousness as well as the subjective correlate of consciousness. At human death, being’s unconcealment ceases for consciousness. Being’s unconcealment exercises its primacy over consciousness by refusing to be for consciousness. Human death is a metaphysical reversal in the ground of consciousness. Death is not the absence of consciousness (the subjective correlate) but the removal of the root of the possibility of consciousness. Death is not the cessation of all functions of the entire brain but the cessation of the possibility of cessation (absence of life). The presence of the sacred in medical science is clear. We need to personalize medical technology to remind ourselves that we are not the creator of the world and all things contained in it as we bow before the mystery of the divine Birther. We do not know

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why the Creator chose to create rather than not create. Life is a gift. But it seems to me that human death is a reversal in creation as the Birther reclaims the gift of existence. The attitude of being in the presence of the Sacred, it seems to me, goes a long way towards rethinking the value of euthanasia and assisted suicide. The challenge facing us is to use medical technology animated by a profound sense of the spiritual to fight for quality of life, not raise the specter of death as an epitaph to remind others of lost battles in the quest for quality of life. I have argued elsewhere that the conversation between the subjective and objective correlates of consciousness does not end at death.150 The claim that personal death arises because God choses to annihilate being’s unconcealment for that person is contrary to the ways of reason. The evidence gleaned from deductive analysis (philosophy, and mathematics) suggests that human death is the occasion for a reversal in the dialogue between the subjective and objective correlates of consciousness in the same way that movement of one end of a stick moves the other end of that stick. We learn from quantum physics that a subatomic explosion creates two particles that fly away from each other with opposite spins going in one direction and the other. They separate from each other at a speed greater than the speed of light. The observation of one of the particles causes the spin of the other to change direction even at great distances.’ The fact that looking at the spin of one particle causes a change in the spin of the other confirms the dynamic unity of the correlates of consciousness. Metaphysics and mathematics work hand in hand to verify the existence of a necessary connection between the subjective and objective correlates of consciousness.151 But insufficient focus has been placed on the play taking place in the objective correlate of consciousness at death. It might be the case that human perception begins to fail at end of death, not only because of the subjective correlate of the dialogue with being but also because of a play in being’s unconcealment. Flowers do not appear to be as bright during the final moments of dying because being’s unconcealment

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151

Ken, Bryson, Christian metaphysics and human death. Journal of Philosophy and Theology. 27, 2 (2015) 259–288. The phenomenon baffled Einstein who taught that information could not travel faster than the speed of light. He labelled it ‘spooky action at a distance.’ Kofler, J., and O. Meyer-Streng. 2013. “Spooky Action at a Distance” in the Quantum World Shortly Before the Final Proof. http://www.mpq.mpg.de/4860668/13_04_15. Accessed January 12, 2018.

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is beginning to withdraw its truth from consciousness. Perhaps God is preparing us for death through a gradual reversal in the primacy of esse. The gradual reversal is possibly accompanied by a shift in being’s unconcealment. It seems logical to hypothesize that at death, the unconcealment of being emerges to fullness as being discloses itself fully to the subjective correlate of consciousness. Being’s unconcealment if total because it takes place outside the parameters of space and time in the eternal order of the possibility of existence. The subjective correlate of consciousness likewise undergoes a revolution as the concept and the idea change places in the life of reason. The subjective correlate grasps the idea of beings unconcealment fully at the first moment of the intuition of being. The spiritual body undergoes a Kantian reversal as the idea of being’s unconcealment lights up the dialogue. The body glows in happiness and insight as it moves eternally towards the face of the mighty Birther of cosmos. It seems reasonable to suggest that persons in the afterlife state pick up where the moral habits acquired in this life leave off. A second argument to demonstrate the primacy of existence and the fact that we stand in the presence of mystery comes to us from the analysis of time. Heidegger’s phenomenological analysis of time is directed towards the process of uncovering the meaning of Dasein’s standing in the presence of being’s unconcealment. But it does not get off the ground, so to speak. While temporality serves as the horizon for laying bare the character of Dasein’s projects, it moves ahead of itself to question the root of the possibility of the inquiry. Heidegger’s question about metaphysics ultimately leads to the root of the possibility of Dasein’s questioning the meaning of being. The project undertaken in Being and Time could not be finished without Heidegger’s consent or assent to the primacy of esse; a leap beyond the order of temporality. Heidegger could not do so without betraying his metaphysical roots in ‘alêtheia’ (unconcealment), namely the question of the meaning of being uncovered by the pre-Socratics interpreted anew through Dasein as project. Heidegger gives us a vivid description of Dasein’s being-in-the-world (temporality, care, death, understanding …) but shifts the focus from the Being of being and of their grounds to a study of the essence of truth. Heidegger’s writings after ‘the turn’ become somewhat less systematic and more interpretive of philosophical and literary texts, especially of ways of framing being by the pre-Socratics,

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Descartes, Kant, Hegel, and Nietzsche. Descartes, for instance, frames being through the ‘cogito’; Kant through the a priori forms of perception and of understanding. Aquinas frames being from the point of view of the creative act and the primacy of esse. Time is central to the study of metaphysics. The view of human death as being a reversal in being’s unconcealment places emphasis on temporality to suggest that time itself is temporal. Heidegger hints at mysticism but does not take the final metaphysical leap into the arms of existence as divine gift. It seems to me that metaphysics cannot use metaphysics to analyze the possibility of metaphysics. The question raised through the horizon of time will always be unfinished until the investigation uncovers the root of the possibility of being’s unconcealment in the view of human death as reversal of the root of the possibility of unconcealment. Death is the death of death if the root of the possibility of finitude happens at death. Thus, death is a source of inspiration, not only because it reminds us of finitude, but because it transforms the question of being to the awareness of living in the face of the mystery of existence. The mystery lies in the realm of the nescient; a mystery which cannot be solved or dismissed. The mystery is paradoxical because it calls for spontaneous assent. No one doubts the existence of being, but the existence of being is indemonstrable. We are simultaneously powerless and powerful before death because death is simultaneously timely and untimely, a source of inspiration and a source of despair and it appears personal and impersonal because when death comes we are no longer. Thus, death is not an experience of the living, but it serves as a powerful reminder that we stand in the presence of the sacred mystery of existence. Let me explain in more detail through a fuller analysis of time as secondary element. Last January 1, 2018, people worldwide knew it was a new year. But what is the meaning of ‘new year’? Most of us already know what it means until we start thinking about it. A calendar year is a unit of measurement; the year 2018 comes after 2017 and before 2019. If Aristotle is correct, we measure time by numbering anterior and posterior states of change. Big bang science claims that the universe has been expanding for 13.8 billion years. This makes sense, though we depend on the truth of science to make that claim. Science fiction (and some philosophers) entertains us with the possibility of going back in time and meeting our parents before they are born. And some wonder about the status of time itself; does time have a beginning or an end? The expanding universe generates space

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and time ahead of itself as it continues to expand and contract in the folds of interstellar space. At some point in time, the big crunch of thermal equilibrium puts the current process at an end and possibly generates another big bang, which possibility is raised by the first and second laws of thermodynamics. But once we abandon common sense logic, the meaning of time is elusive. Aurelius Augustine, a fourth-century scholar and saint, explains that time is an illusion. The elements of time are past, present, and future. But as we take a closer look at the ontological status of these elements we find the Aristotelian view of time to be on shaky grounds. The elements of time are the past, the present, and the future, as everyone knows. But the past no longer exists, therefore it’s not real. The future is not yet, therefore it’s not real. This leaves the present as the only ground for belief in the reality of time. But the present cannot last as some aspect of it will be cast into the future which is the unreality of the not yet of change. Therefore, time does not exist or at least it does not have a solid claim to existence as a primary metaphysical datum of existence. This explains why Aristotle thought time was eternal. His teachings on act and potency can be used to confirm the eternal dimension of time. He says that if time came into being from non-time, it must have been in state of privation and potency from the point of view of possible existence. The world must likewise be eternal because a thing—being or time—cannot preexist itself, that is exist before it exists. This explains why the early Greek thinkers thought that things could not have a beginning in time. They had no conception of the God of Abraham as Creator of the world and all things contained in it. Perhaps time is a primary element rather than a secondary element, that is a structure of human understanding which along with the spatial representation of reality is required to transform the plethora of sense impressions into organized sensations. For instance, the device on which I work sits on a desk next to a lamp, and notes. But the desk knows nothing of this until my perception of space and time, the innate forms of understanding, transforms unrelated things-in-themselves into a meaningful proposition. Perhaps the God of creation uses a divine blueprint to similar effect in creating the world and all things contained in it. The genius of Thomas Aquinas is to recognize that although the existence of the world can be eternal in the order of time and duration we still must explain why it exists in the order of existence. The things of our experience do not have a sufficient reason to explain why they exist rather than not exist. Aquinas

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argues that infinite regress in the order of causality does not provide a sufficient reason for the existence of things. At some point the ways of reason require an explanation to why things exist. The explanation is found in the Uncaused Cause, The First Act, the biblical ‘I am who am’ to account for the existence of a contingent world. The existence of the early Greek eternal procrastination suddenly mutates into reality and the world of things parades before consciousness. The creative act transforms the eternal into eternity time. Being and eternity time signify a different mode of existence, not more or less potency and time. The third and most comprehensive argument for the existence of the unprovable world stems from the attempt to pull it out of the realm of consciousness. The attempt at a global deduction of reality from rational principles alone leads to severe epistemological paradoxes as the work of Emile Meyerson demonstrates. Meyerson builds an additional layer of structure on Kant’s synthetic a priori judgements to arrive at the point of his ‘the plausible propositions of science as I explain in greater detail elsewhere.’152 The additional layer comes from two innate principles of reason, namely the principles of legality (or lawfulness) and identity. The first makes the claim that we expect nature to attend herself with some degree of regularity. The second innate principle of reason, the principle of identity, supports the claim that to think is to identify. It introduces a structure (support) for the laws (rapports) of science. Thus, legality implies causality as the relationships of nature would not attend themselves with regularity in the absence of its structure. But the principles of reason lead to an epistemological paradox. In round one, the principle of identity leads to the production of increasingly comprehensive identity propositions. Knowledge is acquired through the successes of nature as it reduces the complex and diverse data of sensation to identity statements about reality. For instance, we associate the behavior of properties with a set of antecedent sufficient conditions which reason has identified to explain the behavior. The statement ‘water boils’ deconstructs to the identification of antecedent conditions and consequent property behavior. When the conditions affecting the properties of the substance water is 100 degrees Celsius and the atmospheric pressure is 76 cm. of mercury, then the properties of that

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Ken, Bryson, The Metaphysics of Emile Meyerson: A Key to the Epistemological Paradox. The Thomist: (A Speculative Quarterly Review. Volume 37, Number 1), January 1973, 119–132.

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substance are observed to boil. The problem arises as the ways of identification lead to progressively comprehensive identity propositions. The goal of reason is to reduce the whole of reality to the Parmenidean one out of which all diversity is emptied. The places at which reality resists the identification of reason saves the day, however. Meyerson calls them ‘irrationals’ of science such as transitive action. Sensation is itself irrational. But this second movement of reason leads to skepticism and the claim that reality is unknowable (Meyerson agrees with Kant). Meyerson brings the deductive activity of reason to a place between the devil and the deep blue sea. His decision to fuse the elements of the paradox into the plausible propositions of science is a compromise. It gives rise to the distinction between the desire to identify (explain) the whole of reality and the realization that partial identities (plausible propositions) is all we get. The need to identify reality whenever we think about nature, including common sense, gives way to the partial identities. The plausibility of propositions is a stretch for Meyerson because in final analysis he says that reality is unknowable. The dilemma offers proof of the inability of reason to deduce reality from rationalist principles. The attempt to do so leads to absurdities: knowledge is possible, but it ought not be. The problem arises because Meyerson (Descartes and Kant before him) begin to philosophize with an activity of reason rather than with the being of things. Reality arises as the output of an activity of reason or in Meyerson’s words, as a place to lodge sensations in their absence; “I have had a mixture of sensation … I know that these sensations may come back; consequently, to satisfy my causal tendency, I suppose that these sensations exist during the interval. Now since, by hypothesis, they do not exist within me, they must exist somewhere else; there must be, therefore, a ‘somewhere else’ a non-ego, a world exterior to my consciousness.”153 Therefore, either the existence of reality is an extension of spatial reasoning, which leads Meyerson to solipsism, or it is unknowable in itself (as is the Kantian noumenon). Descartes begins his philosophy with an activity of reason and experiences a similar dilemma. Since there can be no interaction between substances (mind and body) whose attributes (thought and extension) are mutually exclusive, the stage is set for either idealism or

                                                             153

Emile, Meyerson, Identity and Reality. Translated from the French by Kate Lowenberg, (London: MacMillan), 1930, 360.

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positivistic epistemology. Thomistic epistemology avoids this dilemma by rooting his philosophy in a metaphysics of existence.

Conclusion “Faith is like that: if good works do not go with it, it is quite dead.” (James. 2:17).154 Medicine acknowledges that it stands in the presence of the mystery and sanctity of human existence. God’s creative act guarantees the existence of an absolute truth that serves as a beacon to remind us of the ultimate mystery and sanctity of life. William Laine Craig arrives at the same conclusion, though his analysis of the origin of the universe travels through a mathematical path of permutations and combinations to arrive at the conclusion that God exists (1998);155 Since He created the universe from nothing, we know that He must be enormously powerful, if not omnipotent. Since He brought the universe into being without any antecedently determining conditions and fine-tuned it with a precision that literally defies comprehension, He must be both free and unimaginable intelligent, if not omniscient. Moreover, the fact that the entire known universe, from the smallest elementary particles to the most distant stars, was designed in such a way as to be a suitable environment for the existence of human life on Earth suggests the astounding conclusion that He must have some special concern for us. (italics added)

Two things are certain. First that the existence of a world outside consciousness is indemonstrable. Second, the existence of a world outside consciousness commands our spontaneous assent. Therefore, we stand in the presence of at least one absolute fact. The world exists! This one immutable truth lays the cornerstone for the belief in the possibility of normative ethics and secures the deontological character of the Oath of Hippocrates. This is not situation ethics. This is not assigning truth value to the relativity of culture. The deductive process is drawn directly from the

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155

The Letter of James 2:17. The Jerusalem Bible. Internal evidence suggests that James’s Letter was written either before the Galatian-Romans in A.D. 49, or as a rejoinder to what Paul had written about relating faith to works and be placed at 57 or 58. William, Lane, Craig, Scientific confirmation of the cosmological argument. In Louis P. Pojman. Editor (1998) Philosophy of Religion, 3rd edition, (Belmont California: Wadsworth Publishing Company), 1998, 40.

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intuition that God must expect us to behave appropriately towards the existence of the world and all things contained in it. This indubitable assumption provides reasonable grounds for the view of medicine as sacred science. Ethical relativism collapses under the weight of its own shifting foundation as it fails to acknowledge the existence of that indubitable truth, including the relativism of its own affirmation of relativism. Now is the day when relativism and skepticism fail. We discovered the existence of at least one truth that cannot be doubted, God is! In the absence of that truth, the existence of the contingent world is without a sufficient reason for its existence and could just as easily not exist as exist while existing which is contradictory. In the presence of this truth the belief in deontological ethics and in the innateness of the spiritual tendency towards the ultimate meaning of life is secure. The phenomenological analysis of how we think makes sense of the spiritual search for ultimate meaning. The elements of faith are systems based, however, that is, they owe their descriptive contents to a set of cultural, societal, political, and economic shaping influences, as we know from the STS Toolbox. The root of the possibility of the existence of contingent things (the world of human experience), therefore, moves us beyond human understanding and yet empowers us to unite faith and reason in a single moment of intuited insight. It inspires us to enter human relationships with the love and compassion that arises from being created in the image and likeness of the suffering divinity that is Christ. No one doubts that the world is real or that it exists outside consciousness. But philosophy as radical interrogation of the whole of reality must examine its assumptions. Can we prove that the objective correlate of consciousness is real or that it exists independently of consciousness? The complex answer is that the attempt to do so leads to epistemological paradoxes. The synthesis of the arms of a paradox is fraught with difficulties as the history of philosophy from Descartes to Kant, Hegel and Meyerson make known. Therefore, it must be the case that the existence of reality and its unconcealment to consciousness is a gift that commands spontaneous assent (or should I say not so spontaneous because the insight arises only after reason recognizes its paucity, as the Oracle at Delphi makes known). We stand in the presence of a gift, the sacred gift of existence! The gift stands us in the presence of the mystery of existence and the sacred mission of medicine to respect the complexities of the gift of life. Medicine without this vista of the absolute is reductivism. The challenge

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facing us is to discover and honor this presence in the relationships that individuate persons. In Summary; The Oath of Hippocrates is an expression of reverence towards creation and a sacred pledge to respect the God given gift of healing and to always use it to promote the sanctity of life. Hippocrates’ belief in the existence of pagan gods is replaced by a belief in the existence of the loving and caring God of Abraham. It also allows for the existence of different visions of the divinity. This explains the universal possibility of being compassionate towards those persons and animals that are at-risk. The one-legged seagulls are always the first ones I feed on my morning walks. God must have a plan for creation otherwise God would not have created the world and all things contained in it. This explains why we are spiritual by nature as we strive towards uncovering the ultimate meaning of life. We often go astray because ours is a spirituality of imperfection. God must have given us intellect and will to direct our own outcomes. This explains why we respect autonomy and informed consent. God gives us the gift of faith (secular and religious). This explains the need for humility and respect for the human condition in the developments of medical technology. God must love us. This explains beneficence and nonmaleficence. The God of Abraham is a Blessed Trinity of divine personalities. This explains our need to love one another, the environment, and ourselves because we are made in the image and likeness of God. God created a world in which all things are in relationship. This explains the person-making process and the dialogical character of medicine. God must have wanted us to participate in the history of civilization and the construction of a better world. This explains the need for justice and fairness in sharing resources, and the focus on human development along with economic development.

Conclusion The first chapter opened with a wish list; 1. A shift in focus towards the centrality of the patient: A patient has an illness; the illness does not have the patient. 2. The impersonal nature of medical technology is minimalized. 3. A patient is not an individual atom, nor is the doctor, as both exist in clusters of distinct relationships. Healthcare is relational (specialists, pharmacists, social workers, lawyers, psychologists, and community based social action). 4. A person is a human being in action. We are characterized through three main stream of relationships, each one as important as the other (we are dynamic units). 5. The healthcare focus includes all person-making relationships at three distinct levels of observation—the carbon-self, the socialself, and the internal-self. 6. The doctor and the patient bring all their relationships to the medical table as they work through their collective spirituality of imperfections. 7. Community programs serve as a source of medical knowledge. The medical curriculum and the doctor tap into this resource base. 8. Ethical relativism is exposed as being the enemy of deontological ethics and the Oath of Hippocrates. Doctors and patients ought not be forced to decide between their moral conscience and the observance of positive laws. 9. Creation centered medicine is seen to be a sacred science. 10. Medical developments in genetic screening and genetic engineering express reverence for the dignity of the person. The application of the STS Toolbox contents to the doctor patient relationship arrived at positive recommendations to improve the delivery of healthcare. The process was filtered through the lenses of systems (history, culture, society, economics, politics, resources, eco-systems), ethics, thematic contrasts (citizenship, holism, comprehension, and cost-benefit), and metaphysics (creation centered theology and human death). The examination of the doctor patient relationship through the eye of history clarifies the importance of providing a history not only of the patient but also of the doctor’s interests, and of the medical knowledge available in the 239

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patient’s community. The focus on society drew attention to the need to move away from the view of the patient as an individual atom to include all the social relationships that individuate persons. The analysis of culture providers insight into the set of attitudes that accompany how the doctor and the patient think about health, along with the values (religious and ethical) they bring to the table along with their personal beliefs. The study of politics and law allowed us to examine how ethics arises and why deontological ethics and the Oath of Hippocrates is at-risk in the absence of an absolute foundation in the dignity of the human person. The study of economics also provides insight into ways in which the medical experience is limited by economic development. The study of thematic contrast ‘comprehension versus ignorance’ brought out the nature of the spirituality of imperfection into clearer light, while the focus on ‘holism versus reductionism’ reminded us of the importance of incorporating a holistic vision of the person-making process in healthcare. Persons are human beings in action in three main streams of individuating relationships. The contrast between cost and benefit, on the other hand, reminds us of the challenge facing us in the allocation of scarce medical resources and the critical importance of protecting patient’s rights by providing a foundation in the doctor patient relationship for the provision of informed consent, autonomy, beneficence, nonmaleficence, justice and fairness, secrecy, privacy, and the confidentiality of healthcare records. The following observations are combined in the realization of this vision; 1. The shift towards the relational character of medicine reveals that disease is but one of the strings of associations that characterize the person-making process. The distinction between curing and healing moves the treatment protocol beyond the level of patient as disease. 2. The process of detailing the relationships that individuate the doctor and the patient personalizes medicine. 3. A detail of the relationships that characterize the patient’s social stream provide data essential for organ transplant medicine, endof-life care, including religious views on abortion, euthanasia, and assisted suicide. 4. A detail of the relationships that characterize the doctor’s internal stream of associations make known the doctor’s relevant personal and ethical views.

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5. The doctor patient relationship is widened to include the family of relationships available to healthcare. 6. The doctor and the patient are seen to share in the search for sacred meaning through a spirituality of imperfection. 7. The patient’s community relations are seen to be a source of medical knowledge. The doctor’s office provides a list of relevant community resources for patients. 8. God’s creative act and the primacy of a theory of direct perception provides the objective metaphysical ground required to root deontological ethics and the Oath of Hippocrates in objective soil. Human death is seen to be an action taking place in being’s unconcealment. 9. The phenomenological analysis of the human mind reveals the sacred nature of human nature and underscores medicine’s role as sacred science. 10. The evidence for human dignity is found in the fact that human relationships are analogous to the relationships of love expressed in the Blessed Trinity. And the most urgent for last, the need for action. The ‘citizenship versus ‘idiotship’ thematic contrast calls us to initiate responsible, informed, social action. The social action begins in our lived communities where we know who lives where and how they can be contacted. Citizens know what resources are available, and what resources are needed to raise the healthcare bar, and how to use political processes to bring about necessary change. The character of medicine as dialogic, holistic, spiritual, ethical, deontological, and community based offers a comprehensive view of how to improve the delivery of healthcare. My hope is that this book contains a useful guide to that end.

Works Cited Adler, Mortimer. The Difference of Man and the Difference It Makes. New York: Holt, Rinehart and Winston, 1967. A.A. World Services Inc. Alcoholics Anonymous. Third Edition, New York: Alcoholics Anonymous Publishing, 1976. ___________________Alcoholics Anonymous Comes of Age; A Brief History of A.A. New York: Alcoholics Anonymous Publishing, 2005. ___________________Twelve Steps and Twelve Traditions. New York: Alcoholics Anonymous Publishing, 2006. ___________________As Bill sees It. New York: Alcoholics Anonymous Publishing, 1998. Aquinas, Saint Thomas. Summa Theologica. Translated by Fathers of the English Dominican Province. Chicago, Ill: Encyclopedia Britannica, 1952. __________________. Boethius’s De Trinitate; The Division and Method of The Sciences. A. Maurer, translator, Toronto: Pontifical Institute of Medieval Studies, 1958. Aristotle. The Works of Aristotle. Translated by W. D. Ross, Chicago: Encyclopedia Britannica, Inc., 1952. Augustine, Saint Aurelius. The Confessions. Translated by Edward Bouverie Pusey, Chicago: Encyclopedia Britannica, Inc. 1952. Barber, Marsha. “How the medical school admission process is skewed”: University Affairs. Nov 30, 2016. Battle, Michael. Reconciliation: The Ubuntu Theology of Desmond Tutu. Ubuntu: Pilgrim Pr. 2009. Booth, Leo, Fr. When God Becomes a Drug. New York: Penguin Putnam Inc., 1991. Bryson, Ken. “Divine Agency and Human Suffering”, American Journal of Biblical Theology. Vol. 15, Issue no. 42, 2013. ___________ “STS Toolbox: A Guide to STS problem solving and informed social action in Indigenous communities”, Indigenous Policy Journal. Research Notes, vol 28, No 1, 2017. ____________ “Christian metaphysics and human death”, Journal of Philosophy and Theology. 27, 2, 2015, 259–288. ____________ “The Metaphysics of Emile Meyerson: A key to the epistemological paradox”. The Thomist. volume 37, no.1, January 1973, 119–132.

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___________ “Treatment plan for clients of vocational centers and special care residential units, International Journal of Philosophical Practice. Elliot Cohen, editor, vol. 1. No. 4, 2003. ___________ “What we learn from the resurrection of Christ”, Art and Realism (Sztuka i realism): (Festschrift) Commemorative Book, Jubilee Birthday and Scientific Work of Professor Henry Kieresia at KUL, edited by Fr. T. Duma, A. Maryniarczyk SDB, and P. Sulenta. (Lublin: Polish Society of St. Thomas Aquinas and the Faculty of Philosophy – Catholic University of Lublin), 2014, 771–786. _____________ “An interpretation of Genesis 1:26”, Journal of Philosophy and Theology. Marquette University; Philosophy Documentation Centre, 01/2011; 23 (2), 187–215. _____________ “Person as Verb”, Satya Nilayam Journal of Intercultural Philosophy. Special issue on human person. Dr. Augustine Perumalil, editor, 2010, 65–95. ___________ “Negotiating environmental rights”, Ethics, Place and Environment, vol. 11. Issue 3, 2008, 351–366. ___________ “The ways of spirituality”, Sofia Philosophical Review, vol. X, no. 2, 2017, 1-38. _____________ “Guidelines for conducting a spiritual assessment”, Palliative and Supportive Care. Cambridge University Press. Table 1: 3–4, 2013. _____________ “Spiritual welding 101”. The Yale Journal for Humanities and Medicine. June 27, 2004. Carlo, William. The Ultimate Reducibility of Essence to Existence in Existential Metaphysics: The Hague: Martinus Nijhoff, 1966. Carson, Rachel. Silent Spring. Boston: Houghton Miffin, 1962. Coderey, Celine. “Drugs’ life: accessibility and use of biomedical drugs in Rakhine State (Myanmar). Science, Technology & Society 23:2, 2018, 1–6. Cutcliffe, Stephen, H. editor, “Pennsylvania State University STS History”, Science, Technology & Society Newsletter. Carl Mitcham and Richard Deitrich, Guest Editors. Nos. 95–96. April/June issue, 1993, 19–20. Deely, John. “The immateriality of the intentional as such”. The New Scholasticism, XL11, 2, Spring 1968. Douglas-Klotz, Neil. Prayers of the Cosmos, New York, NY: Harper & Row Publishers. Inc. 1990. Fox, Matthew. Original Blessing. Santa Fe, New Mexico: Bear and Company, 1983.

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Index

127, 129, 130, 135, 139, 140, 145, 146, 148, 150, 151, 154, 157, 158, 159, 160, 161, 172, 177, 179, 184, 185, 191, 192, 194, 198, 200, 201, 202, 203, 216, 217, 221, 223, 224, 227, 228, 229, 230, 231, 232, 233, 235, 236, 237, 238, 239, 241 beneficence 68, 82, 171, 172, 238 bioethics 79, 168, 172, 182, 185, 187, 194 Blessed Trinity (and God) 15, 16, 17, 19, 20, 22, 23, 24, 27, 28, 34, 37, 41, 52, 55, 68, 80, 86, 91, 93, 94, 98, 100, 101, 102, 103, 104, 105, 107, 108, 111, 115, 116, 119, 120, 121, 123, 124, 125, 128, 130, 134, 139, 140, 142, 143, 144, 147, 149, 150, 151, 154, 157, 158, 159, 160, 164, 165, 168, 170, 171, 177, 208, 211, 212, 215, 216, 217, 218, 221, 222, 223, 225, 226, 230, 233, 236, 237, 238, 241, 243, 245, 246 Boethius 126, 243 brain 16, 36, 44, 110, 113, 115, 119, 123, 124, 125, 129, 137, 166, 185, 191, 200, 206, 207, 209, 219, 228 Brundtland, Gro Harlem 75

A  abortion 27, 39, 52, 67, 86, 135, 164, 175, 176, 177, 178, 240 absolute 20, 28, 32, 34, 52, 66, 94, 165, 170, 171, 191, 192, 196, 213, 221, 236 abstraction (and degrees of knowledge) 117, 126, 128, 143, 166, 190 afterlife 32, 34, 86, 92, 93, 101, 122, 127, 143, 144, 150, 154, 157, 221, 231 AMA 180, 181, 182 Aquinas, St. Thomas 25, 92, 94, 95, 98, 110, 114, 125, 126, 138, 140, 147, 159, 168, 223, 232, 233, 243, 244 Aristotle 26, 94, 95, 98, 110, 114, 125, 126, 142, 144, 146, 160, 168, 232, 243 Aurelius Augustine 100, 114, 233, 243 autonomy 26, 37, 58, 59, 68, 70, 107, 118, 157, 160, 163, 164, 172, 182, 189, 190, 191, 192, 197, 201, 203, 210, 238, 240

B  Bacon, Francis 74 being (and esse) 13, 15, 17, 21, 24, 25, 28, 31, 32, 33, 34, 35, 44, 47, 50, 53, 55, 59, 60, 61, 63, 67, 70, 71, 72, 78, 80, 81, 82, 83, 85, 86, 88, 92, 93, 95, 96, 97, 99, 100, 101, 103, 104, 105, 108, 109, 110, 111, 112, 114, 116, 117, 118, 122, 123, 124,

C  Carlo, William 227, 244 Carson, Rachel 75, 244 cellular 24, 166, 185, 229 citizen 39, 130, 186, 188 Club of Rome 74

249

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community 13, 14, 19, 20, 22, 25, 28, 32, 33, 35, 39, 41, 42, 43, 44, 45, 46, 47, 49, 50, 51, 53, 54, 57, 60, 61, 62, 63, 64, 65, 68, 70, 71, 79, 81, 83, 85, 86, 87, 88, 111, 116, 118, 120, 130, 133, 135, 136, 143, 149, 151, 156, 166, 167, 168, 170, 171, 172, 181,184, 185, 186, 187, 189, 190, 191, 192, 198, 199, 203, 204, 205, 206, 207, 208, 210, 212, 213, 215, 217, 239, 240, 241 compassion 16, 21, 23, 25, 62, 103, 105, 117, 119, 120, 123, 124, 144, 145, 148, 149, 150, 160, 164, 166, 170, 172, 180, 191, 237 concept (and idea) 30, 32, 33, 50, 52, 60, 78, 95, 96, 99, 102, 107, 108, 110, 114, 118, 121, 124, 127, 130, 141, 168, 193, 202, 205, 216, 219, 223, 224, 226, 231 confidentiality 27, 37, 48, 59, 68, 81, 156, 157, 164, 172, 174, 182, 189, 190, 197, 240 consciousness 26, 33, 34, 56, 94, 95, 96, 97, 99, 101, 107, 111, 119, 120, 125, 131, 134, 143, 144, 146, 150, 153, 175, 176, 188, 190, 197, 211, 212, 215, 219, 221, 223, 224, 227, 228, 229, 230, 231, 234, 235, 236, 237 consent 26, 37, 48, 59, 68, 70, 81, 83, 86, 157, 163, 164, 182, 189, 190, 191, 192, 196, 197, 201, 202, 210, 231, 238, 240 conservation (and preservation) 30, 31, 41, 62, 143, 172, 190 constructivist 43, 47, 49, 50, 57, 62, 66, 70, 71, 87, 91, 96, 97, 101, 115, 173, 201

correlate 33, 96, 97, 99, 100, 101, 103, 107, 119, 120, 125, 131, 143, 144, 146, 176, 188, 223, 224, 227, 228, 229, 230, 231, 237 Craig, W.L. 81, 193, 236 cultural relativism 32, 39, 52, 116, 171 Cutcliffe, Steven 11, 76, 244

D  death, definitions (heart, cortical brain, whole brain, putrefaction, metaphysical) 15, 22, 24, 26, 28, 30, 31, 32, 34, 36, 38, 39, 52, 53, 55, 69, 89, 92, 93, 110, 111, 115, 121, 125, 127, 128, 136, 139, 144, 148, 149, 151, 152, 155, 157, 159, 160, 169, 179, 183, 185, 186, 205, 209, 221, 222, 225, 228, 230, 231, 232, 239, 241, 243 deontology 37, 169 Descartes, René 56, 93, 100, 110, 160, 166, 232, 235, 237 dialogic 20, 34, 41, 58, 69, 164, 178, 241 direct perception 101, 221, 223, 241

E  economics 19, 30, 36, 37, 46, 51, 57, 62, 66, 67, 69, 70, 71, 81, 88, 106, 107, 115, 131, 133, 144, 146, 159, 163, 179, 182, 186, 190, 239 eco-systems 30, 46, 57, 69, 71, 75, 133, 239 environment (and ethics) 32, 37, 46, 52, 55, 57, 58, 61, 68, 69, 74, 85, 87, 105, 107, 108, 111, 112, 115, 116, 118, 119, 120, 123, 131, 136, 137, 139, 147,

Index 151, 154, 155, 156, 158, 159, 160, 165, 172, 181, 189, 191, 196, 198, 200, 201, 204, 226, 236, 238 ESAS-R 27, 28 eternal truth 21, 28, 32, 191, 192 ethical relativism 17, 20, 27, 37, 66, 100, 165, 169, 170, 176 ethics 16, 19, 20, 27, 28, 29, 30, 32, 33, 34, 35, 36, 37, 41, 44, 46, 51, 52, 59, 62, 66, 67, 68, 69, 71, 78, 79, 81, 85, 86, 87, 88, 107, 111, 115, 130, 131, 133, 137, 138, 139, 144, 159, 161, 165, 168, 170, 171, 172, 173, 174, 176, 178, 179, 180, 182, 183, 185, 186, 188, 189, 190, 192, 197, 199, 200, 201, 236, 239, 241, 245 euthanasia 27, 29, 39, 52, 67, 86, 135, 164, 169, 183, 185, 189, 230, 240 existence (primacy of ) 21, 22, 24, 25, 29, 31, 32, 34, 51, 52, 54, 56, 80, 89, 92, 93, 94, 95, 96, 97, 99, 100, 101, 102, 103, 104, 107, 108, 109, 110, 111, 112, 114, 116, 119, 120, 122, 124, 125, 126, 128, 129, 130, 134, 139, 140, 143, 144, 145, 146, 149, 150, 152, 154, 157, 165, 169, 170, 171, 172, 179, 181, 197, 213, 217, 218, 221, 223, 224, 225, 227, 228, 230, 231, 232, 233, 234, 235, 236, 237, 238

F  faith (philosophic and religious) 16, 21, 32, 89, 91, 93, 94, 95, 96, 97, 98, 100, 101, 102, 103, 106, 107, 109, 111, 117, 120, 141, 143, 176, 183, 184, 222, 225, 236, 237, 238

251

Frankl, Viktor 139, 159, 245

G  genetic engineering 31, 35, 44, 63, 67, 79, 81, 82, 130, 185, 239 geography of knowledge 128 Gladu, Marilyn 176, 183, 189 God (and the Almighty) 15, 16, 17, 19, 20, 22, 23, 24, 27, 28, 34, 37, 41, 52, 55, 68, 80, 86, 91, 93, 94, 98, 100, 101, 102, 103, 104, 105, 107, 108, 111, 115, 116, 119, 120, 121, 123, 124, 125, 128, 130, 134, 139, 140, 143, 144, 147, 149, 150, 151, 154, 157, 158, 159, 160, 165, 168, 170, 171, 177, 208, 211, 212, 215, 216, 217, 218, 221, 222, 223, 225, 226, 230, 233, 236, 237, 238, 241, 243, 245, 246 good (and evil) 20, 22, 24, 25, 32, 33, 34, 35, 38, 40, 46, 50, 53, 54, 69, 71, 73, 78, 81, 82, 93, 98, 100, 101, 102, 105, 107, 109, 110, 111, 112, 120, 122, 124, 128, 129, 130, 133, 138, 139, 141, 142, 143, 144, 145, 146, 147, 150, 151, 152, 154, 157, 158, 160, 164, 166, 168, 170, 171, 172, 174, 175, 179, 192, 195, 197, 204, 214, 219, 225, 226, 227, 228, 236 Gore, Al 75 Gungov, Alexander 13, 39, 70, 245

H  Hawking, Stephen 113, 114, 245 health (and illness) 13, 14, 15, 19, 21, 25, 29, 30, 31, 35, 36, 41, 42, 43, 53, 54, 59, 65, 66, 69, 72, 76, 77, 81, 83, 84, 86, 88,

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91, 107, 110, 113, 115, 121, 134, 135, 136, 139, 144, 145, 150, 151, 154, 164, 167, 169, 173, 175, 180, 181, 183, 187, 188, 189, 190, 195, 199, 200, 207, 209, 210, 219, 239, 240, 246 Heidegger, Martin 15, 55, 75, 76, 96, 97, 148, 228, 231, 232, 245 Hick, John 23, 25, 245 Hippocratic Oath 52, 66, 67, 100, 129, 169, 171, 173, 174, 175, 177, 183, 185, 186, 229 holistic 14, 20, 27, 33, 36, 37, 42, 45, 51, 54, 62, 63, 66, 71, 72, 77, 78, 86, 87, 95, 107, 129, 139, 143, 150, 160, 163, 167, 172, 187, 190, 192, 202, 203, 228, 240, 241 Hume, David 24, 245

I  internal self (and psyche) 117, 119, 123, 124, 131, 133, 151, 188, 199

J  James, William 66, 211, 215 Job 23, 141, 245 Jung, Carl 23, 29, 117, 152, 153, 211, 214, 226, 245 justice 59, 67, 68, 157, 170, 171, 172, 198, 238, 240

K  Kant, Immanuel 100, 168, 169, 232, 234, 235, 237, 245 Kierkegaard, Søren 21, 141, 159, 215 knowledge (concept and idea) 52, 95, 126, 144, 234 Kushner, Harold 22, 245

L  Lamb, David 186, 245 Leopold, Aldo 30 Lewis, C.S. 24, 245 Lovelock, James (and Gaia hypothesis) 54

M  MacKay, Kevin 84 Marcel, Gabriel 120, 121, 123, 159, 247 Meadows report 74 medical model (paternalistic, engineering, collegial, contractual) 55, 85, 108, 119, 173, 193, 201, 207, 219 mind 21, 23, 42, 43, 47, 49, 56, 57, 62, 68, 78, 80, 88, 92, 93, 95, 96, 97, 98, 99, 100, 105, 110, 111, 115, 123, 124, 125, 131, 133, 136, 147, 152, 157, 170, 183, 197, 199, 204, 229, 235, 241

N  naloxone 209 natural law 168 nonmaleficence 26, 37, 70, 82, 164, 172, 192, 238, 240 nursing 22, 148, 150, 153, 160

O  organism 24, 26, 28, 53, 55, 113, 128, 151, 152, 175, 185, 203

P  Pennsylvania State University 11, 43, 76, 244 person-making process 56, 60, 107, 108, 112, 116, 124, 129,

Index 133, 136, 138, 144, 146, 150, 151, 152, 154, 158, 159, 163, 168, 170, 179, 185, 188, 190, 191, 192, 194, 201, 212, 219, 222, 226, 238, 240 phenomenology 23, 33, 55, 94, 95, 96, 97, 117, 175, 190, 245 politics 19, 30, 36, 37, 46, 57, 66, 67, 69, 70, 71, 72, 75, 81, 88, 106, 107, 115, 131, 133, 137, 144, 146, 177, 182, 187, 190, 239 Pope Francis 19, 25, 91 Postman, Neil 40, 47, 67, 204, 246 Prainsack, Barbara 53, 59, 60, 91, 107, 108, 246 privacy 26, 37, 48, 51, 59, 68, 155, 156, 157, 160, 164, 172, 177, 180, 181, 189, 190, 197, 240 problem 23, 24, 27, 29, 35, 39, 40, 41, 45, 46, 47, 49, 50, 51, 52, 55, 57, 61, 67, 68, 69, 70, 71, 72, 73, 76, 80, 83, 87, 92, 93, 96, 108, 114, 116, 120, 122, 126, 127, 141, 146, 151, 153, 160, 163, 169, 177, 189, 198, 201, 206, 208, 213, 227, 235, 243 psychology 33, 44, 61, 69, 112, 127, 179, 206

R  relations (and associations) 29, 55, 95, 112, 121, 136, 152, 153, 159, 171, 190, 202, 203, 219, 226 relativism 35, 52, 165, 170, 171, 177, 237, 239 religion (and religious faith) 29, 32, 67, 86, 89, 91, 93, 94, 95, 97, 101, 102, 103, 104, 106, 116, 120, 130, 133, 140, 141, 143, 145, 146, 150, 154, 176,

253

177, 188, 196, 212, 213, 216, 237 research ethics board (REB) 68 resources (community and academic) 13, 19, 22, 30, 41, 42, 44, 45, 46, 47, 50, 54, 58, 60, 62, 63, 64, 65, 68, 70, 71, 73, 74, 75, 81, 83, 86, 113, 115, 120, 133, 135, 136, 152, 155, 157, 159, 169, 172, 179, 182, 190, 192, 198, 200, 201, 203, 208, 214, 238, 239, 241 resurrection 24, 31, 91, 92, 102, 147, 151, 222, 244, 245 rights 20, 37, 38, 47, 51, 59, 62, 66, 67, 70, 74, 79, 83, 88, 107, 157, 165, 168, 172, 176, 177, 179, 180, 183, 186, 187, 190, 191, 192, 196, 197, 201, 203, 240, 244

S  Sartre, Jean-Paul 117, 120, 123, 159, 169, 246 Satan 23, 171 science 15, 17, 29, 30, 31, 33, 34, 35, 38, 39, 40, 43, 45, 46, 49, 53, 54, 55, 70, 72, 74, 76, 77, 78, 80, 82, 94, 99, 101, 104, 106, 111, 113, 116, 125, 127, 128, 129, 130, 133, 135, 143, 144, 146, 161, 163, 165, 178, 181, 184, 186, 219, 221, 229, 232, 234, 237, 239, 241 Smith, Dr. Bob 24, 212, 213, 245 social action 22, 27, 35, 37, 38, 44, 45, 46, 48, 50, 56, 60, 61, 63, 64, 69, 70, 72, 74, 77, 79, 81, 83, 84, 85, 86, 87, 88, 133, 143, 146, 167, 205, 239, 241, 243 society 13, 14, 16, 19, 27, 29, 32, 36, 45, 46, 51, 57, 58, 59, 60, 63, 66, 67, 69, 71, 74, 78, 79, 81, 88, 107, 115, 116, 118, 131,

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133, 136, 137, 144, 146, 150, 159, 166, 168, 170, 178, 180, 182, 184, 186, 190, 196, 214, 239 spiritual welding 29, 56, 121, 152 spirituality 21, 28, 32, 34, 35, 38, 44, 51, 54, 70, 84, 85, 88, 99, 108, 111, 120, 131, 133, 134, 136, 138, 139, 141, 142, 143, 144, 145, 146, 147, 148, 150, 151, 154, 163, 170, 187, 193, 205, 206, 209, 210, 211, 212, 215, 216, 217, 218, 219, 223, 225, 226, 228, 238, 239, 240, 241, 244 STS Toolbox 35, 37, 41, 42, 45, 85, 87, 93, 133, 170, 182, 196, 198, 201, 237, 239, 243 substance dependence (and addiction) 50, 51, 54, 63, 72, 99, 125, 136, 206, 207, 210, 211, 212, 216, 219 suffering (and evil) 22, 24, 25, 26, 28, 32, 80, 123, 134, 138, 141, 145, 148, 149, 150, 157, 169, 204 sufficient and necessary condition 23, 36, 82, 93, 95, 143, 210, 215, 216, 234 systems 19, 20, 25, 30, 31, 36, 39, 42, 47, 57, 58, 66, 67, 69, 70, 71, 74, 77, 81, 86, 87, 88, 98, 102, 107, 109, 113, 118, 130, 133, 135, 144, 145, 146, 159, 169, 170, 182, 186, 188, 190, 228, 237, 239

 

T  technology 13, 28, 29, 31, 32, 33, 34, 35, 38, 40, 41, 42, 43, 45, 46, 47, 49, 53, 54, 55, 57, 59, 62, 63, 66, 67, 69, 72, 74, 77, 78, 79, 80, 82, 84, 85, 86, 98, 99, 115, 128, 135, 160, 163, 172, 178, 181, 186, 187, 229, 238, 239 The New American Bible 28 thermodynamics 24, 123, 233 thing-in-itself 95, 96

U  Unitarian 102, 170, 171, 188 unity 54, 77, 113, 119, 133, 151, 152, 157, 165, 170, 172, 226, 227 universal 23, 52, 59, 95, 167, 169, 170, 183, 187, 196 Utilitarian (and consequentialism) 169

V  Venter, Craig, J. 81

W  Williams, Alan 26, 79, 159, 247 Wilson, Bill (Bill W.) 177, 211, 213, 214, 218

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