Archive for the ‘Eating Disorders’ Category

“I See You:” Avatar and Prudence

Spoiler alert: If you haven’t seen Avatar, don’t read this post.

People have had a lot to say about the movie Avatar—its pantheism, its overhanded critique of US foreign policy, its hodgepodge of superficial cultural references—but for me, the part of the movie that really stood out was in one of the final scenes where Neytiri, holding Jake in his vulnerable, clumsy, handicapped human form looks into his eyes and says, “I see you.” This motif is woven throughout the movie, as Jay Michelson of the Huffington Post explains:

In the Na’Vi cosmology, what’s really happening is the Ai’Wa in me is connecting with the Ai’Wa in you. This is echoed in their greeting, “I see you,” a direct translation of the Sanskrit Namaste, which means the same thing. (“Avatar” is also from the Sanskrit, though the film plays on the word’s two meanings of an image used in a role-playing game, and a deity appearing on Earth.) As the Na’Vi explain in the film, though, “I see you” doesn’t mean ordinary seeing – it, like Namaste, really means “the God in me sees the God in you.” I see Myself, in your eyes.

I don’t know anything about Sanskrit or the eastern religious traditions on which Cameron is drawing here, but I do know that this motif of “seeing” and its connection with right action and justice has an important foundation in the Thomistic tradition. As Josef Pieper writes in his beautiful little work The Four Cardinal Virtues, the virtue of prudence is the true perception of the way the world really is:

Man’s good actions take place in confrontation with reality. The goodness of concrete human action rests upon the transformation of the truth of real things; of the truth which must be won and perceived by regarding the ipsa res, reality itself.

Bill Mattison picks up the connection between prudence and seeing in his book Introducing Moral Theology: True Happiness and the Virtues. Mattison describes an article by Lorraine Murray in America Magazine called “The Lady in the Mirror.” Murray writes,

I am obsessed with food, but I assure you that I am not fat. I wear a size 10, and the weight charts brand me as “average.” The trouble is that when I gaze into the mirror, a fat lady stares back. I know that I am supposed to be God’s beloved child and I know I should love my neighbor as myself. Problem is, I have such difficulty loving myself because I am always criticizing my body.

Mattison explains,

Given how Murray says she sees herself, it is less surprising that she agonizes over her weight. [Paul Waddell] describes the moral importance of how we see things and claims it is crucial that we have ‘truthful vision.’ Put simply, we cannot act rightly if we do not see rightly. If we do not have an accurate grasp of the way things are, it is impossible to act virtuously. . . Being a prudent person is what enables one to see rightly and translate that truthful vision into action.

In Avatar, Neytiri’s vision, or prudence, is already highly developed. At one point, right before she is about to kill Jake, a seed from the sacred tree of Ey’wa lands on her arm with the outstretched bow and arrow. Her eyes turn to the spirit and back to Jake. She does not yet know what she sees, but she knows that she sees him differently. A similar thing happens when they are arguing about who Jake is. Neytiri complains that she does not know him because she does not see him. At that moment, the same seeds collect all around Jake, covering him. Again, Neytiri’s vision changes. She begins to see Jake. And both times, this vision translates into right action. Neytiri knows the right thing to do because she sees rightly. This is prudence.

But Jake’s vision develops slowly over the film. He must learn to see the truth of reality, and only when he learns to see will he know the right way to act. What is unfortunate about the film is that it traces Jake learning how to see everything but himself. Jake learns to see the Na’Vi and their world rightly, and in turn he learns to treat them rightly. He learns to see Colonel Quaritch for who he really is, and accordingly, can treat him appropriately as an enemy and threat. But Jake never learns to see himself.

Let’s return to “The Lady in the Mirror.” Murray can’t see herself. She has a false vision of who she is, a fat person, and so she does not know how to act rightly. She diets obsessively, abuses herself with thoughts of guilt over an ice cream sundae or piece of fried fish, and looks loathingly at her reflection in the mirror. She can’t act rightly toward herself because she can’t see herself rightly.

Jake is similar. He sees himself as a crippled, as a deficient being because he does not have functional legs. The reason he consents to the colonel’s deal to spy on the Na’Vi, an unvirutous action, is precisely because he sees himself as deficient without his legs, and the colonel promises him “his legs back” if he carries out the mission successfully. If Jake saw himself as a complete and beautiful human being, even with non-functional legs, he would not have been so quick to agree to the colonel’s deal.

While Jake is learning to see the world of the Na’Vi rightly, he still isn’t learning to see himself rightly. His avatar is beautiful, athletic, powerful, and seemingly invulnerable. Indeed, Jake can hardly wait each time he is out of his avatar body to get back in “where things seem more real,” where he gets to lead the Na’Vi into battle, and conquer their great unconquerable mythical bird, and make love to one of the most powerful beautiful Na’Vi ladies.

But in the end, the real Jake is not his avatar. The real Jake is a man, unshaven and unkempt, without functional legs. And Neytiri sees this. As she holds the dying Jake, she tells him “I see you.” This is what love is. Love is not trying to change the other person, to make them perfect, or to focus on their weaknesses. Love is seeing a person for who they are and embracing that person.

But Jake has no such revelation at the end. He doesn’t ever get to look at himself and say “I see you.” He gets his avatar body back. And this is the most unfortunate part of the film. Jake shouldn’t get to have his avatar body at the end. He should have to live among the Na’Vi in his wheelchair, with his respiration mask. He should have to learn how to see himself just as he learned to see the Na’Vi. He should be able to look in the mirror in all of his weakness and vulnerability and say to himself, “I see you.”

Here in real life, we don’t get our avatars. It’s celebrity doppelganger week on Facebook and everybody is posting images of celebrities who they resemble, but in the end, everybody has to go back to being themselves. Murray doesn’t get the model-thin woman she wants to see when she looks at herself. She just gets Lorraine Murray, not a model, but not fat either. And if Murrary wants to be happy, she has to learn how to see herself. Only then will she be able to treat herself right. And this is the most disturbing thing about Avatar–in the end, it’s happy ending keeps us from taking off our 3D glasses, leaving the theater, and seeing the world as it really is, and seeing ourselves for what we really are.

How Neuroscience is Influencing the Bioethical Debate About Compulsory Treatment for Anorectics

Anorexia nervosa is a psychiatric disorder characterized by excessive preoccupation with body size and weight as well as self-deceptive attitudes toward the nature of thinness and emaciation. Treating anorexia is replete with challenges. First of all, treatment is often unsuccessful. Less than 50% of anorectics recover within ten years of the onset of the disorder. About 25% of cases develop into chronicity. Oftentimes, anorexic behavior is replaced by bulimic behavior.

Anorexia is a classic case where the tension between preservation of liberty of the patient and the imperative to treat a severe illness becomes quite acute. In most cases of anorexia nervosa, a well-structured therapeutic program, administered by a multidisciplinary staff experienced in treating eating disorders, is adequate. Even with the best of treatment options, however, avoiding treatment is part of the condition of anorexia. Anorexia is characterized with the obsessive pursuit of thinness and treatment is always aimed at thwarting this goal. The refusal may not be total: many patients accept psychotherapy or family therapy, but may refuse components of treatment likely to increase food intake, reduce physical activity and induce weight gain. In severe cases where anorectic patients categorically deny all treatment oriented toward weight gain, compulsory treatment is usually pursued.

A patient who refuses nutrition despite severe emaciation is generally thought to be behaving without autonomy and is deemed incompetent to consent to treatment. The Mental Health Act Commission allows, “that in certain situations, patients with severe anorexia nervosa whose health is seriously threatened by food refusal may be subject to detention in hospital and further that there are occasions when it is necessary to treat the self-imposed starvation with measures such as involuntary naso-gastric feeding to ensure the proper care of the patient.”

As a rule, most treatment programs resort to compulsory treatment only as a last resort. Compulsory treatment seems to be justified only by immediate mortal danger to the patient, but may also be pursued based on motives of beneficence within the health care system. Nevertheless, the ethics of compulsory treatment of anorectics is hotly contested issue.

Compulsory treatment for anorexia as well as other conditions assumes that the doctor is right about what is in the patient’s best interest. However, in medicine, prognostic ability is a far cry from an exact science, despite the fact that prognoses are usually given in percentages. Moreover, the prognostic difficulties are complicated in psychiatry, with psychiatrists very often incorrect in their identification of danger to the patient.
Moreover, the pursuit of compulsory treatment usually implies that treating the patient against her wishes will help her. A general principle of compulsory treatment is that one must be reasonably confident that the treatment is going to bring about some beneficial effect. In the case of anorexia, the ethics of compulsory treatment are complicated by the fact that the patient must at some point submit to either treatment or resuming somewhat normal eating patterns. An anorectic cannot spend the rest of her life in a psychiatric ward or on a feeding tube involuntarily. At some point, she must cooperate with therapeutic efforts if she is to recover. Compulsory treatment must both aim for, and have a reasonable likelihood of success achieving a state of voluntary cooperation with the anorectic.

New developments in neuroscience are changing our understanding of the role of the brain in mental illness, as scientists rapidly discover minimally invasive and benign techniques for exploring and altering the brain. Brain mapping technologies like positron emission tomography (PET scans) and functional magnetic resonance imaging (fMRIs) serve to identify the brain areas involved in certain behaviors like self- starvation or performing a given task like consenting or refusing to consent to medical and psychiatric treatment.

Neurotechnology offers more advanced scientific data related to specific cognitive deficits relevant to consent, which has a direct impact on psychiatric diagnostic criteria, providing objective bases, derived from the structure and processes of the brain, for classifying a brain as “abnormal.” Standards for determining competence right now in the clinic are unreliable and based on what is called the “reasonable person standard.” With new neurotechnologies, it may become clearer both clinically and legally what constitutes a reasonable person.

Neuroscientific data is also leading toward a richer understanding of the nature of consent which is based on the idea of “degrees” of competence, rather than a simple threshold. Basically, neuroscience is pointing away from a model of consent that views the capacity to consent as an “all or nothing” sort of thing, and towards a model that accepts more or less capacity. That is, capacity to consent lies on a continuum. On a degree notion of competence, patients are never said to be either fully competent or totally incompetent, but rather, as displaying various and changing degrees of competence to consent at various different times.

Most contemporary models and tests for mental competence do not make adequate provisions for the positive influence of emotions in the determination of competence. Recent advances in the neuroscience of emotion provide compelling evidence that the decision-making process, including the act of giving consent, is not exclusively cognitive, nor can decisional capacity be assessed by purely cognitive means such as the Mac Arthur Competence Assessment Tool (MacCAT-T). Integrating more neuroscience studies on the complexity of the consent process is leading to a “multifactorial and qualitiative account of the components of capacity” which could lead to clinical developments that enhance the necessary components to improve decision-making. For example, fear and anxiety may impair an anorectic’s ability to consent to treatment, which may be enhanced by introducing a known and trusted confidant to the consent process who can engage the patient more successfully on an emotional level.

Although the issue of compulsory treatment, including forced-feeding, for anorectics has been greatly debated on the theoretical in bioethical circles, as Simona Giordano rightly identifies in her book Understanding Eating Disorders, the question of compulsory treatment is also, and perhaps primarily, an “empirical” problem:

People with eating disorders are typically intelligent, and are not at all the stereotypical ‘insane’ person, detached from reality. People with eating disorders are generally skilled, intelligent, and able to run their life in many important ways, like everybody else. It is hard to believe that all of them, when they refuse treatment, are incompetent. Given that we are dealing with intelligent and generally competent people, it seems that one cannot assume a priori that every time a person with eating disorders refuses treatment, she is incompetent. It seems that their incompetence should be assessed, not presumed (193).

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