Healthcare and Private Perfections

In his Confessions St. Augustine, contemplating the excesses and indiscretions of his youth famously pronounced the verdict, O Lord, how crooked and sordid, bespotted and ulcerous was I. From Paul to the present, the Church has expressed especial hostility to the pleasures and meanings aroused in the free play of human bodies and brains in the world, and preached mortification of the flesh and faithful obedience as routes to the presumably deeper, more spiritual satisfactions the Church offers instead.

But the Churchs real and ongoing commitment to the address and redress of suffering on earth, to good works as an incomparable path to redemption, constantly and forcefully re-embodies this quest for spiritual fulfillment and confronts the best, most righteous reformers of the Church with quandaries with which their worldview is finally deeply incapable of dealing. It is a hard thing, after all, to try to hold hope and hostility together in a single vision.

A case in point is the claim of Vatican officials last week to decry what they called a religion of health in affluent societies" and then "h[o]ld out Pope John Paul's stoic suffering as an antidote to the mentality that modern medicine must cure all.

To the extent that the Pope is stoically suffering rather than straightforwardly dead a dozen times over by now only because he has made repeated recourse to the most technologically sophisticated medical treatments in human history suggests that the term health is functioning at any rate ambivalently in this Vatican statement.

This becomes clearer still when Maurizio Faggioni from the Vaticans Pontifical Academy for Life makes the sensible point that [w]hile millions of people in the world struggle to survive hunger and disease, lacking even minimal health care, in rich countries the concept of health as well-being figures in creating unrealistic expectations about the possibility of medicine to respond to all needs and desires."

He goes on to expand his point, to say, [t]he medicine of desires, egged on by the health-care market, increases the request for pharmaceutical and medical-surgical services, soaks up public resources beyond all reasonableness."

"Health" is used in two different registers here, one demanded the other decried. On the one hand there is a commitment to the provision of health care to ameliorate unnecessary suffering, but on the other hand there is an almost hysterical hostility directed at what the Vatican decries, portentiously enough, as an unrealistic, superficial, and endlessly distracting religion of health.

The key move that distinguishes the two registers is of course Faggionis conjuration of a reasonableness that seems to translate pretty much into a "moderation" that is a mix of appealing intuitions about fairness, and (to me) rather less appealing intuitions to Puritanism and unquestionable social conventions. Faggionis move will of course be familiar to bioethicists who often like to deploy the distinction between therapy and enhancement to work their way through these same quandaries.

The problem is that distinctions like the one between "therapy" and "enhancement" are ultimately moonshine.

At the heart of the distinction of therapy and enhancement is always a fantasy of the normatively healthy body -- or even the normatively optimally healthy body -- a norm which will inevitably be saturated with parochial cultural and moralistic assumptions mistaken for factual descriptions. And consequently any effort to provide health according to these normative ideals will finally be as prescriptive as it is remedial.

But more to the point, every effort to use such a distinction to inform practice will set in motion forces that inevitably undermine the terms of the distinction itself. It isnt possible to provide health according to any normative ideal without likewise empowering the provision of capacities incompatible with those normative assumptions and thereupon shifting what constitutes the normative in the first place.

Even the most conservatively therapeutic understanding of the ultimate goals of medical science and treatment, a Hayfleckian utopia in which everybody on earth enjoys the robust health and fulsome intellectual capacity of the healthiest among us today as we presently perceive them, as well as lifespans prolonged for all to the extent of the century or so available only to the luckiest among us so far, this still would set in motion a trajectory of scientific and technological development that would provoke unimaginable perplexities into the status of profound biological experiences such as pregnancy, sexual maturation, illness, aging and death.

Already, today, the fresh susceptibility of organisms to prosthetic and pharmacological intervention has transformed the status of "viability," "therapy," "normality," as stable measures of just when lives can properly be said to begin or to end, or as benchmarks against which to leverage intuitions about the proper scope of healthcare practice. So too neuroceutical interventions into memory, mood, and motivation trouble our received intuitions about what enables and constitutes proper consent.

Even the most modest provision of basic and decent health care, and ever more so according to how universally it is provided, will transform, quite possibly beyond recognition, what will count as basic, decent, and normal in the way of our expectations about what bodies properly are and what they are capable of.

The Vatican insists that all people should have access to "basic health care" but that there is a fantasy of perfect health in the developed world that is driven by unfulfillable desires and so is unmanageable.

It is impossible not to see the force of their point, but it is notoriously difficult to mainstain any such distinction between basic and perfect health that will hold up for long to scrutiny. None of us is in any kind of position to say definitively now just what will be fulfillable or not through the therapeutic address of medicine over the course of our lifetimes.

And, frankly, it seems to me the Church is one of the last places on earth one should look for any kind of reasonableness in working through quandaries of this kind. What are we to make of the way the word desire enters repeatedly into the Churchs discussion of medical practices they denigrate, for example? There seems to me, as it happens, to be a conspicuous continuity between queer practices and prosthetic practices, among them the epochal feminist embrace of reproductive technologies, a field of freedom and emancipation on which the Church has been perhaps the single most significant and consistent opponent of any kind of progress at all.

It is of course true that savage differences in the level of health care available to people in the world both expresses and horribly exacerbates the deep and deepening injustices in the contemporary distribution of wealth both within so-called developed societies, and incomparably more terribly, forcefully demarcating the developed from the developing world.

But at what point will what the Church means by manageable healthcare goals nudge them from a useful and progressive analysis of the instabilities and calamities inhering in this kind of injustice, instead into more straightforward strategies to maintain their own pernicious hold on authority in a secularizing world? It seems very interesting in this connection to notice again that the Vatican describes healthcare in the terms of a rival religion of health when they want to condemn particular healthcare practices and goals as dangerous.

For me, emerging medical technologies enable and demand the universal provision of basic health care, at least the provision of adequate nutrition and basic hygiene and the therapeutic address of treatable diseases, all as a foundational social recognition that the unnecessary suffering of people anywhere on earth diminishes us all while securing basic capacities for everyone on earth unleashes intelligence, creativity, peace, and pleasure for which we are all of us conspicuous beneficiaries.

But I also embrace the inevitable individual recourse to these emerging genetic, prosthetic, and cognitive technologies in prosthetic practices of self-creation and personal perfection.

These are in my view equally indispensable registers of moral and ethical prosthetic practice. They are, as it were, the public and private faces of health care practice. And far from being incompatible, they are to my eyes absolutely interdependent.

Medicine becomes primarily a technique for maintaining and consolidating the control of established authorities whenever it is embraced only to the extent that it provides and imposes a normative standard of health according to those established authorities, all the while policing and repudiating the occasion for deeply destabilizing, subversive practices of personal self-creation that inevitably arise with the emergence of any new technological capacities.

It is an obscenity that big Pharma devotes millions to marketing competing treatments for erectile dysfunction to the developed world while millions die of cheaply treatable diseases in the developing world. But it would also be an obscenity for social and religious bio-conservatives to deny individuals the transformative recourse to emerging consensual practices of genetic, prosthetic, and cognitive medicine. Remember that there is nothing in the least normal or natural about the historically unprecedented level of control human beings have come to take for granted in the present day over their sexual and reproductive capacities. The emerging neuroceutical address of our moods and memories provides the next conspicuous terrain for such fraught individual re-invention.

We can and in fact I insist we must value both the public and private faces of health care practice. Certainly we should not fall for corporate propaganda that would privilege the private over the public, or pretend that only the denigration of public healthcare provision enables desirable prosthetic pursuits of private perfection. But neither should we be bamboozled into a denigration of prosthetic practices of personal self-creation by cynically sanctimonious arguments from social and religious conservative authorities jealous of their power and sensitive to the precariousness of their position in a more secular world.

When a doctor in the Church intones that it is [p]recisely in the handicap, in the disease, in the pain, in old age, in dying and death one can... perceive the truth of life in a clearer way, you can be sure this is not so much the voice of wisdom and modesty and fairness one is hearing, but yet another echo of that immemorial priestly hostility to the life that is lived in bodies. We must hold instead in a single vision an awareness of frailty and suffering as an address that impels us to action, and a grown-up celebration of the pleasures and promises and dangers of new fleshly humanities that have outgrown the old tired and tyrannical crucifixations.