Archive for the ‘psychology’ Category

Post-modern Therapy? Balancing Between Appreciation and Critique

I have a respected friend who calls himself a “postmodern therapist.” When I first heard this term, I was intrigued and disturbed (okay, I was more disturbed than intrigued). As you can imagine, everdaythomist is no fan of postmodernism in general, for very Thomistic reasons, but in terms of therapeutic professions (medicine, psychology), it seemed even more of a stretch to label oneself a post-modernist. “Don’t post-modernists reject the existence of a knowable external reality?” I asked him. “How does that philosophical assumption allow you to help a person who clearly has anorexia, for example, or who thinks your coffee table is a monster? Or what about a person who is actually hurting herself, through, say, cutting. Don’t you think a cutter would disagree about this whole non-knowable external reality?” Everydaythomist must also admit that in her head she was also shouting, “Clearly you are wrong! Admit you are a realist, preferably with an Aristotelian-Thomistic bend, and let’s move onto more interesting matters!

Turns out, my friend calls himself a post-modern therapist, at least in part, to help him avoid doing in a therapeutic setting precisely what everydaythomist did in our conversation: declare himself right, declare the patient wrong, and then proceed to define reality for the patient according to a rigid line of truth reasoning. In a therapeutic setting, this narrow perception of “truth” may both assume more about the patient than may be justified, and may actually do the patient harm therapeutically by talking past her. To understand where he comes from in his therapeutic approach, my friend recommended I read Harlene Anderson’s Conversation, Language and Possibilities: A Postmodern Approach to Therapy. I dutifully did so, and I humbly offer my rather naive reflections in response to my friend. Why not just respond in person, you might ask? Because I am taking Anderson’s post-modern approach and recognizing that our debate does not exist in a vacuum, thus I am expanding the concentric circles of our dialogue to include other “voices” that may be at play (that’s you readers. I encourage you post-modern readers especially to jump in and tell me where I may have erred).

Harlene Anderson offers this book as a response to the many bad ways therapy can be and has been done, and she offers an introductory story of a Swedish family with two anorexic daughters to illustrate her point. The daughters both suffered at the hands of their therapists because they were not listened to, they were not cooperative, they were not flexible. In reaction to such hierarchical and over-confident therapists, Anderson offers her own approach as a “collaborative approach” which she conceptualizes as “a language system and a linguistic event in which people are engaged in a collaborative relationship and conversation—a mutual endeavor toward possibility.”

Anderson may be a therapist and may have written a book to help other therapists, but her therapeutic methods are solidly grounded in post-modern philosophical claims which she pretty thoroughly buys into. Post-modern, to Anderson, means embracing social construction, hermeneutics, and narrative. It means recognizing human systems as “language and meaning-generating systems,” reality as language, meaning as something created through language, and truth . . . well, truth is just the meaning one ascribes to an experience and believes (206) (the index does not include an entry for “truth”). Words do not have essential meanings, but meaning is generated through the use of words. She summarizes near the beginning,

Postmodern thought moves toward knowledge as a discursive practice, toward a plurality of narratives that are more local, contextual, and fluid; it moves toward a multiplicity of approaches to the analysis of subjects such as knowledge, truth, language, history, self, and power. It emphasizes the relational nature of knowledge and the generative nature of language. Postmodernism views knowledge as socially constructed, knowledge and the knower as interdependent-presupposing the interrelationship of context, culture, language, experience, and understanding. We cannot have direct knowledge of the world; we can only know it through our experiences. We continually interpret our experiences and interpret our interpretations.

Anderson buys into the post-modern critique of natural and scientific explanations of human systems. As such, she is also an advocate of social construction theories that reject any claim that knowledge reflects an ontological reality but is rather a construction. Anderson does distinguish between social constructivism and constructionism in that the former regards reality as a construction of the individual mind, emphasizing both autonomy and individualism. Anderson aligns better with the latter which de-emphasizes autonomy in favor of “the interactional and communal context of the meaning maker” (44).

Anderson sees broad implications for this philosophical basis in a therapeutic setting. First, the therapist is removed from the pedestal as the “knower” and is instead placed in collaborative dialogue/conversation with the patient (henceforth called “client” since “patient” assumes the person is sick or needs to be treated, which Anderson does not assume). The therapist, rather than diagnosing, is called to take a perspective of “not-knowing,” to suspend all pre-knowledge and judgment in order to properly hear what the client is saying. Attention is given to the client as a story-teller, and the therapist is called to be fully engrossed in the individual before them and the unique narrative they offer (no note-taking, but lots of questions). The therapeutic session is “public” in the sense that the therapist is frank about her own thoughts, prejudices, and biases, and is also willing to share information about herself. Moreover, to the extent that other voices need to be brought into the conversation, they are invited (family, friends). Finally, therapists are called to honor a client’s story, to take them seriously, and to validate them. She tells the story of Lars, a Norwegian seaman who thought he had a chronic disease and was infecting others. The therapist, Harry asks him

How long have you had this disease? . . . As Harry showed interest in Lars’s dilemma and let him tell his story the way he wanted to, Lars began visibly to relax, even to become somewhat animated, and he began to share in Harry’s curiosity. Harry’s intent was not to challenge Lars’s reality or story, or to talk or manipulate him out of his delusion. Harry wanted to learn about it, be sensitive to it, to maintain coherence with it. Colleagues observing the interview were critical of Harry’s question ‘How long have you had this disease?’ They feared the question reinforced the man’s ‘’hypochondriacal delusion.’ A safer, more neutral question, they suggested, would have been ‘How long have you thought you’ve had this disease?’ The not-knowing position, however, precluded the stance that Lars’s story was delusional (138).

Six months later, Lars’s life is back on track and weather he was infected or not was no longer an issue.

This compelling story reveals both the strengths and the weaknesses of Anderson’s approach. Methodologically, it is good to take patients seriously, at least in practice, to give them a chance to speak, to hear their stories, and to be attentive to the particularities of their needs. It is also good to be humble in psychiatric diagnosis. I am reminded of a Mad Men episode from the first season where Betty, Don Draper’s wife, has been seeing a psychoanalyst for some time who says virtually nothing during their sessions until one day he announces “you have a problem with your mother.” In the episode, Betty is upset, and rightfully so. It may be that the doctor is right, but his answer is not only imprudent in its delivery, it is also likely reductionistic. Betty’s problems are much deeper than her mother, and the therapist need only listen to hear that.

But why do we need a post-modern philosophical foundation to encourage prudence in the therapeutic environment? Why must we deny the existence of an objective, identifiable reality independent of human representations? Anderson is not even completely consistent in her application of her post-modern principle. Lars, she thinks, is delusional. He does not have a disease, and his delusion is disrupting his life. She recommends prudence (though she does not use this word) in dealing with a person like Lars, but if he were to jump out of the chair and start assaulting her, claiming that he heard voices in his head telling him to infect her with the disease, I suspect she would not be so enthusiastic about entering into a stance of “non-knowing for the pursuit of collaborative dialogue.” Moreover, Anderson is convinced that her therapeutic stance towards Lars is right, and his previous therapists were wrong. Sounds like a truth claim to me.

The reality and the truth is that Lars really is delusional and his delusions are hurting the people around him. He needs help, and the therapist is the one to provide that help. I can buy that the most effective help a therapist can give is humble and prudent, but I cannot buy the claim that meaning and truth is just a linguistic construct. Surely, there must be a middle ground.

Realism, and the more recent critical realism, tries to forge this middle ground by recognizing that as human beings, we need truth, we have access to reality, and that language indeed communicates meaning but also points to things that really exist (when I say “ow” and point to the paper cut I got from reading the Summa, I am pointing to something that really exists and that I know, namely, my bloody finger). As a result, statements can be true or false depending on the degree to which they correspond with reality, and reality limits the relative meaning that statements can have. As such, we have a criteria for judging the merit of statements and formulating an appropriate response.

I suspect that Anderson’s post-modern therapy is also a reaction to realism, which has been taken to an extreme in our contemporary world by reducing everything to matter, or to biology. Thus, all psychiatric problems have a biological (or a genetic) origin, leaving little room for the dynamic way in which human behavior is shaped in non-material (i.e. linguistic) ways (this relates to an earlier blog post I wrote on metaphysical naturalism. Anderson would critique such naturalism from the opposite perspective in which I have done). But in her reaction, Anderson throws out the proverbial baby with the bathwater (both of which I am still positing exist, as I bet Anderson does to) and lapses into a metaphysical relativism which is just as problematic as metaphysical realism.

In short, I think my friend is a methodological post-modern therapist, not a philosophical one. Everydaythomist is in no position to tell therapists what to do, but she is in a relative position to judge therapeutic philosophies and ethics. I think my friend likes the idea of listening to clients’ narratives, to deconstructing, at least in part, the extreme therapeutic hierarchy, and to recognizing the individuality and particularity of his clients. But I would encourage my friend to also recognize philosophically and ethically that the client in front of him is real, with real problems and real needs, and the therapeutic task (indeed, the human task in general), is dealing with the real. Just as a person is real, so too can a problem be. Anderson tacitly recognizes the former (hence her emphasis on conversation and collaboration), but not the latter. I see the two as more interconnected.

Part of dealing with the “real,” everydaythomist would also encourage, is recognizing the need for at least some degree of teleology, which even Anderson makes room for in some of her anecdotal accounts. This means recognizing that real things have real purposes (teloi) and that the therapist can be more or less helpful in helping a client achieve these purposes. At one point, Anderson asks a client, “what does it mean to you to be a good mother?” In asking this, she is asking a teleological question, pointing a client to her telos, her end or purpose qua mother. Now, asking the question in itself is teleological—it points the client towards the telos that exists by virtue of the nature of the thing, in this case, the mother. If there are mothers, a teleological position posits, there are good ones and bad ones, and we know the difference by nature if something is not hindering us from this knowledge (like disease). Not that there are not different ways of being a good mother, but there are also clearly bad ways of being a bad mother as well. In many cases, the question itself will suffice for the teleological task (as it does in Anderson’s example, for reasons I would suggest pertain to natural law, but that is a tangent we don’t have time for in this post). But at times, it may require the therapist to softly redirect, as when a client answers something like “It means killing my children that I don’t think are good enough.” A therapist can try and find a prudent response, but prudence demands that the client be pushed a little towards a true telos (or at least restrained for straying too far from her telos).

In conclusion, everydaythomist is still a realist but hopefully has gained a more sensitive appreciation for the way in which post-modern philosophical critiques have contributed both to metaphysical theory and social and ethical praxis. I know that Anderson’s book has at least committed me to the importance of listening and the critical need for conversational humility. And to my friend, I am grateful for these lessons.

Integrating Mind and Matter in Healthcare

A great article in the NYTimes illustrates a major problem in contemporary psychiatric practice–its mind/body dualism. The author Daniel Carlat, who has a book coming out on the subject next month, describes how psychiatric practice has moved over the last fifty years from an exclusive focus on the mind to an exclusive focus on the brain:

Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that “in the first half of the 20th century, American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th century, psychiatry became virtually ‘mindless.’ ” The brainless period was a reference to psychiatry’s early infatuation with psychoanalysis; the mindless period, to our current love affair with pills.

More specifically, writes Carlan, “psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them.”

This is due to a number of factors including the fact that insurance companies “pay nearly the same amount for a 20-minute medication visit as for 50 minutes of therapy” as well as the fact that patients in today’s busy culture are unlikely to want to commit valuable time to weekly therapy. But a big reason for the move to meds over therapy is that the drugs seem to work. But appearances can be deceiving. Carlat writes,

But over the past few years, research studies have shown that therapy is just as effective as medications for many conditions, and that medications themselves often work through the power of placebo. In one study, for example, researchers did a meta-analysis of studies submitted by drug companies to the F.D.A. on seven new antidepressants, involving more than 19,000 patients. It turned out that antidepressants are, indeed, effective, because on average patients taking the pills showed a 40 percent drop in depression scores. But placebo was also a powerful antidepressant, causing a 30 percent drop in depression scores. This meant that about three-quarters of the apparent response to antidepressants pills is actually due to the placebo effect.

Nobody knows exactly how the mysterious placebo effect works, but it is clear that it has impacts on the brain that can be seen as clearly as medication effects. In one study conducted by pain researchers at the University of Michigan, subjects were given an ache-inducing injection of saline into their jaws and were placed in a PET scanner. They were then told that they would be given an intravenous pain treatment, but the “treatment” was merely more saline solution, acting as a placebo. The PET scan showed that the endogenous endorphin system in the brains of the subjects was activated. The patients believed so strongly that they were receiving effective treatment that their brains followed suit. Presumably, a corresponding brain change occurs when depressed patients are given placebo pills.

Therapy, you may be surprised to discover, also leads to empirical changes in the brain.

n an experiment conducted at U.C.L.A. several years ago, with subjects suffering from obsessive-compulsive disorder, researchers assigned some patients to treatment with Prozac and others to cognitive behavior therapy. They found that patients improved about equally well with the two treatments. Each patient’s brain was PET-scanned before and after treatment, and patients showed identical changes in their brain circuits regardless of the treatment.

What this article points out is that the dualistic distinction between mind and matter does not correspond to reality. The “mind” is not some metaphysical entity distinct from and trapped inside the material trappings of the brain. Rather, the mind is matter, or perhaps more specifically, the mind is consubstantial with matter. As scientists like Steven Pinker and Antonio Damasio have illustrated, the legacy of Descartes that there is some sort of “ghost in the machine” is false. The metaphysical “mind,” complete with values, personality, and character, exists substantially in the material components of synapses, axons, and cortex.

We might consider this a development from a more Platonic to a more Aristotelian psychology and biology. Ethically, it challenges us to see how care for the soul cannot be separated from care for the body. We are not spiritual beings who can somehow transcend the trappings of the body with all of its inconveniences, but nor are we purely material beings, as transparent and obedient to the laws of nature as a stone. What is metaphysical in our nature influences and is influenced by what is material.

This new understanding of the nature of the human person, what we might call a philosophical anthropology, needs to influence the way we think of medicine. As Carlat writes,

Clearly, mental illness is a brain disease, though we are still far from working out the details. But just as clearly, these problems in neurobiology can respond to what have traditionally been considered “nonbiological” treatments, like psychotherapy. The split between mind and body may be a fallacy, but the split between those who practice psychopharmacology and those specializing in therapy remains all too real.

For him practically, this has meant a shift to what he calls “supportive therapy” which involves not only prescribing drugs, but also listening to patients, helping them solve basic problems, and offering emotional support. The implications, however, extend beyond just psychiatry to all of medicine. Carlat concludes that good doctoring “involves perfecting all the skills relevant to healing and deploying them when needed.”

This will be a challenge in upcoming years as our health care system becomes more systematized, more reliant on complex care networks dependent largely on electronic patient records rather than a simpler primary care provider/patient relationship. In an of itself, this is not a bad thing and a more efficient system will allow more patients to receive and benefit from healthcare. But doctors need not forget the value of that standard question “how are you feeling?” and most importantly, cultivating a disposition to listen to the response. They may find themselves prescribing fewer meds and getting healthier and happier patients as a result.

Defining ‘Normal’ Behavior: The New DSM and the Old Manuals of Sin

Today’s NYTimes front page features an article on the new Diagnostic and Statistical Manual of Mental Disorders (DSM V), due out in 2013. The DSM is the psychiatric field’s encyclopedia of mental disorders which allows practitioners to determine who is mentally “normal” and who is not.

This is no small deal:

“Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled,” said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth. “And it has huge implications for stigma,” Dr. First continued, “because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”

One concern is that the revisions for the new DSM have “been the subject of intense lobbying by advocacy groups.” Considering the fact that many of the new diagnoses will also come with prescription drug remedies, many worry that the pharmaceutical industry is playing a big role in expanding the diagnostic criteria in order to increase profits from psychiatric drugs. Many of the comments on the NYTimes page note that it seems the new DSM is a matter of politics rather than medicine, or another move by “big pharma” making money by drugging people.

From the EverydayThomist perspective, the problem with the new DSM is that it assumes too much normativity in human behavior. Human behavior is not only incredibly complex, it also varies a lot from person to person. Some children are born with more of a natural tendency toward moderation in food and drink; others are prone to excess. Some children are very shy; others are prone to excessive anger and aggression. Human beings are too diverse to be able to neatly label as “ordered” or “disordered” to the extent that the new DSM attempts to do.

It reminds me of the manuals of moral theology, especially those written at the end of the 19th and beginning of the 20th century which strived to precisely label and categorize every possible sin. This is, however, impossible, as Josef Pieper notes in his most excellent book The Four Cardinal Virtues:

How are we to react to a proposition such as this one, found in one of the most popular handbooks of moral theology: “To look at the private parts of animals out of curiosity, but without voluptuousness . . . is a venial sin”? Not to mention other distortions, it seems that here the limit beyond which casuistry becomes meaningless has been considerably exceeded. Propositions so constructed seem entirely to miss the true purpose and scope of casuistry, which is to provide a tentative approach and an auxiliary means for the practice of discernment. Is it not to be feared that a discernment schooled by such methods will be misguided toward an unrealistic rigidity and a prematurely fixed judgment, instead of toward a sober evaluation of the realities of life; and that this in turn may lead to a total incomprehension of the reality of man as a being who responds to the richly orchestrated world with every power of his soul, and thus reaches his choice?

The pre-conciliar moral manuals were striving toward certainty in their evaluation of human behavior, in much the same way that DSM V seems to be doing. Whereas the moral manuals wanted to define precisely in every possible case what could be considered “sin,” the DSM uses the more contemporary scientifically minded language of “pathology” and “disorder,” but the intent is the same–the desire for rigid and precise criteria to judge human behavior.

A virtue ethics perspective rejects the need for such certainty, recognizing that two people may do the same things, and yet act (in light of circumstances and intentions) in very different ways. As Josef Pieper writes,

It is temperantia, the virtue that realizes the inner order of man in himself, which St. Thomas has in mind when–in contrast to justice, in whose province that which is ‘properly and in itself right’ can and must be determined–speaking of ‘the other moral virtues which refer to the passions and in which right or wrong cannot be determined in the same fashion, because men vary in their attitudes toward the passions,’ he says, ‘therefore it is necessary that what is right and reasonable in the passions should be determined with reference to ourselves, who are moved by the passions.’ But especially in the province of temeprantia ‘we ourselves’ have the choice of innumerable possibilities: for example, to desire halfheartedly or wholeheartedly, to tolerate, to let things take their course, to give in to pressure or to be carried away. ‘Who could determine,’ writes the perceptive Thomist H.D. Noble, ‘who could determine when lack of control ends and where temperance begins?’ St. Thomas says that the realization of temperantia varies too much according to individuals and periods to allow the establishment of hard and fast, universally valid commandments.

Aquinas recognized in the 13th century that there was no such thing as “normal” human behavior. Which is why he referred to the virtues as powers within a person to help her realize for herself within a specific community with specific practices which behaviors would be conducive to happiness. But the problem for a lot of people with virtue ethics is that it leaves too much room for ambiguity, too much room for diversity in behavior which makes human beings, even the most open-minded contemporary human beings, very uncomfortable. So we’ve done away with sin manuals, but have we simply replaced them with an ever-expanding encyclopedia of mental disorders?

What Malcolm Gladwell’s Blink Teaches About Virtue

Malcolm Gladwell’s book Blink provides an anecdotal account of how split-second decisions are made through a process Gladwell calls “rapid cognition” or “thin-slicing.” Gladwell distinguishes this type of rapid cognition from intuition, which he claims is more emotional, claiming that rapid cognition is a distinctly rational process, a type of thinking that simply movers a little faster than ordinary conscious and deliberate decision-making.

One of the most interesting parts of the book deals with first impressions about race, particularly those that happen at a subconscious level. In the chapter entitled “The Warren Harding Error: Why We Fall for Dark, Handsome Men,” Gladwell describes the Implicit Association Test (IAT). The IAT, developed by Anthony G. Greenwald, Mahzarin Banaji and Brian Nosek, measures a person’s attitude on an unconscious level and the immediate and automatic associations a person makes before that person has time to think. In the IAT designed to examine automatic associations with race, a tested individual is timed to see how quickly they associate categories of good and bad adjectives with black and white faces. The test results reveal that the 80% of Americans more quickly pair words like “love,” “peace,” and “joy” with white faces and words like “terrible,” “evil,” and “failure” with black faces. The level of difference is a matter of microseconds, yet is still statistically significant.

What the IAT most significantly reveals is that unconscious attitudes and the behaviors which those attitudes give rise to may be completely incompatible with a person’s conscious values. Even those who consider themselves very enlightened in matters of race still overwhelmingly tend to have an implicit preference for whites. Gladwell himself, who is half-black, was found to have a “moderate automatic preference for whites.” As he notes in the chapter, he considers himself an enlightened and progressive individual on the matter of race relations, with a strong conviction that blacks and whites are equal. Gladwell’s point, however, is that just knowing of cognitively assenting to the idea that the two races are equal does not tell the whole story. He writes,

Our attitudes towards race and gender operate on two levels. First of all, we have our conscious level. These are what we choose to believe. . . . which we use to direct our behavior deliberately. . . . But the IAT measures something else, our attitude toward racism on an unconscious level. the immediate, automatic associations that tumble out before we have had time to think. We do not deliberately choose our unconscious attitudes . . . [and] we may not even be aware of them. The giant computer that is our subconscious silently crunches all the data it has from all the experiences we’ve had the people we’ve met, the lessons we’ve learned, the books we’ve read, the movies we’ve seen . . .and it forms an opinion. That is what is coming out in the IAT. The disturbing thing about the IAT is that it shows us that our unconscious attitudes may be utterly incompatible with our stated values.

The IAT does not just reveal what we subconsciously believe, which a virtue ethicist like myself would call a “disposition.” It is also a predictor of how we behave. A person with a subconscious preference for or dispositional tendency towards whites will in conversation lean in towards black people less, stutter more, and become visibly tenser. These subtle cues can have a major impact on our social engagements. Gladlwell cites law professor Ian Ayres’ study of racial discrimination by Chicago car dealers which found that car dealers gave the lowest initial offer to white men, and the highest initial offer to black men. Even after 40 minutes of negotiating, black car shoppers were still offered prices nearly $800 times higher than the initial offer made to white shoppers.

Much more disturbing is the discussion of Amadou Diallo, a black man who was shot 41 times by four cops who saw him standing on the street corner in the South Bronx late at night. Gladwell argues that these cops, though probably not explicitly or even consciously racist, displayed certain racially-motivated automatic implicit associations that caused them to make a prejudicial, and in this case, lethal split second decision:

The officers, observing Diallo on the stoop, sized him up and in that instant decided he looked suspicious. That was mistake number one. Then they backed the car up, and Diallou didn’t move. [Officer] Carroll later said that “amazed” him: How brazen was this man, who didn’t run at the sight of the police? Diallou wasn’t brazen. He was curious. That was mistake number two. Then Carroll and [officer] Murphy stepped toward Diallou on the stoop and watched him turn slightly to the side, and make a movement for his pocket. In that split second, they decided he was dangerous. But he was not. He was terrified. That was mistake number three.

Seven seconds later, Diallo was dead, shot 41 times, wallet in hand. When the four cops went to trial and were found “not guilty,” there were protests against what was widely perceived as a racial injustice. It seemed that these four cops were clearly guilty of overt racism that motivated them to shoot an innocent man. Gladwell, however, interprets the situation differently. He argues that these four cops, due to past experiences both personally and professionally with black people caused them to automatically and implicitly associate black people with danger, much more quickly than they might associate white people with a threat. These cops were habituated to automatically conclude that a black man in a dangerous New York neighborhood reaching into his pocket meant trouble, and their automatic implicit associations cost an innocent man his life. Gladwell’s point in describing these racial anecdotes is that even if we do not think of ourselves as racist, and even if our consciously held values hold that blacks and whites are equal, our split second decisions or “thin-slicing” activities, as Gladwell describes them, may indicate deep-seated, racist tendencies.

So what do we do about our subconscious, split-second tendencies to prefer whites over blacks? We cannot, as Gladwell argues, simply try to develop our conscious values. That is, we cannot just think more that blacks and whites are equal. Gladwell considers himself a consciously tolerant person and still, his IAT indicates an unconscious preference for white people.

“I’ve taken the race IAT on many occasions and the result always leaves me feeling a bit creepy. At the beginning of the test, you are asked what your feelings towards blacks and whites are. I answered, as I am sure most of you would, that I think of the two races as equal.”

Gladwell’s theory about rapid cognition or thin-slicing indicates that it is not enough to make certain conscious changes in attitudes or values, but must also acknowledge the subtle influences that can alter our subconscious, thereby undermining our conscious attitudes. Gladwell argues, however, that by taking control of the environment in which rapid cognition takes place, one can also control rapid cognition and prevent or lessen the mistakes made.

He suggests that we have a responsibility to not only alter our conscious values, but also to alter our environments in such a way to develop our rapid cognition to make the best possible split-second decisions. People’s results on the race IAT change if they expose themselves to images and verbal information about black people with positive connotations prior to taking the test. People who look at a picture or read a story about Martin Luther King, Jr. right before taking the IAT, for example, register much less implicit racial prejudice than other test takers. More practically, Gladwell suggests that putting ourselves in environments that expose us on a regular basis to racial minorities can alter our stereotypes of them and thus alter our unconscious automatic reactions to them. Thus, despite the fact that racial and other implicit attitudes operate on both a conscious and unconscious level, Gladwell seems to think that we are still morally accountable for even those automatic associations not governed by conscious choice.

Although Gladwell does address any theory of virtue or the moral psychology underlying a virtue ethic, his description of rapid cognition illustrates a remarkable parallel in contemporary psychology with what Aquinas calls a habit [habitus]. More remarkably, Gladwell inadvertently illustrates how habits—both good and bad—can be developed not through rational control over attitudes and behaviors, but by the subtle interaction between a person and her environment. Changing a bad habit, therefore, is not just about conscious effort. Any smoker can tell you this. A person who tries to quit smoking despite the fact that her friends are all smokers and much of her social engagements revolve around smoking is likely to be unsuccessful, no matter how hard she tries to change her habit. Rather, she must also change her environment. She must put herself in situations where she cannot reach for a cigarette for pleasure or stress-relief; she must surround herself with non-smokers, and engage in activities where smoking is contrary to enjoying the activity, like long bike rides. In short, developing virtue through habituation is as much about trying to make conscious dispositional changes as it is about putting ourselves into situations where we don’t need to try.

Additionally, if we take Gladwell’s book seriously, we must conclude that we are habituated in ways which we do not intend all the time. We may read fashion magazines and think that we approach these enlightened about body satisfaction and weight, but simply exposing ourselves to these magazines over and over again, whether we realize it or not, habituates us to associate beauty and desirability with thinness, as I wrote about here. We may think that we can watch overtly violent or sexually explicit films and not become influenced to be more violent or more lustful, but Gladwell’s research (and virtue ethics) says otherwise. We may live in an overwhelmingly white and middle-class neighborhood and think of ourselves as racially unprejudiced, but I bet the IAT would say otherwise. What Gladwell’s book teaches us is that our moral development is much more dynamic than we consciously recognize.

The Re-Emergent Interdisciplinary Nature of Scholarship

One of the complaints about scholarship these days, especially in the humanities but also in the natural sciences, is that each discipline has become so specialized, that it has become irrelevant to those on the outside. Young scholars in PhD programs are continually pushed to the marginalia in the search for new and original topics, and the dissertations they churn out are frequently so obscure and specific that nobody would read them except the author and their board.

My goal in this post is not to complain about over-specialization in scholarship but rather to suggest that over-specialization is not the way of the future. David Brooks’ op-ed in the New York Times this week, entitled “The Young and the Neuro,” addresses the necessarily-interdisciplinary nature of contemporary research being conducted in the humanities, and especially in cognitive neuroscience, which fuses the fields of bioetechnology, psychology, economics, as well as political science and ethics. Scholars involved in this emergent field are actually transversing disciplines, all in the hopes of trying to figure out how and why people interact in the way that they do.

The new interdisciplinary nature of such scholarship is a reaction against the reductionism we saw in the earlier part of the century, especially in the wake of new knowledge about genetics. A funny side note: in yesterday’s NYTimes crossword puzzle, one of the clues (33 across) was “essence of a person, one might say.” Not to spoil it for you, but the answer is DNA.

The research Mr. Brooks discusses challenges this notion that DNA actually is the essence of a person. People like Christopher Hitchens and Richard Dawkins and E.O. Wilson wanted to use genetics to explain the essence of all human behavior. Ethics, once considered a branch of philosophy, entered into the natural sciences as scientists hypothesized and rapidly worked to confirm that one’s genetic constitution could explain why you as a person behaved the way you did. This field became known as sociobiology–the systematic study of the biological basis of all forms of behavior.

If the sociobiologists would have stuck to ethics, they would not have ruffled very many feathers. But sociobiologists also had to attempt to illustrate how genetics could even explain the great metaphysical questions faced by humankind such as the nature of the soul and the existence of God. What happened in the wake of such books like The God Delusion was a widespread religious reaction against science, especially science that extolled genetics as a causal mechanism or used the dreaded word “evolution.” This religious antithesis to the new work in biology, genetics, and evolution became another form of reductionism. Instead of using science to explain everything, the “theologians” and preachers and ordinary believers wanted to use God to explain everything.

Here is what both sides missed. Different fields explain different phenomena and answer different pressing questions raised by human beings. This was something Aquinas (drawing on the Greek heritage of Aristotle) recognized in distinguishing the practical from the speculative intellect. The practical intellect deals with the natural world, the world that is contingent, subject to decay and change and evolution. The practical intellect deals with sense data derived from sensuous consciousness, that is, with this particular human being, this particular triangle, this particular action.

The speculative intellect is concerned not with the contingent, but with the necessary, the universal, the unchanging. The speculative intellect is concerned with the immaterial. It wants to know not “this particular triangle” but rather, what is the essence of “triangle?” What is the universal form that makes particular triangles come into being? The speculative intellect is not concerned with this particular action, but rather with the question of causation–what are the universal forces that causes anything at all to happen?

The practical intellect deals with what Aristotle called the practical sciences: physics, ethics, politics. The speculative intellect deals with the mother of all science: metaphysics (literally, “above or beyond the physics.”) Aquinas recognized in light of his theological preoccupations that even this neat division was not truly in accordance with reality with the recognition that theology was both speculative (metaphysical) and practical (ethical and political). That is, our study of God is primarily speculative but imminently practical. Theology is speculative because it deals principally with divine things which are immaterial, but secondarily practical because it is concerned with human acts insofar as these acts lead the person to beatitude. So even theology, the premier metaphysical pursuit becomes interdisciplinary in Aquinas’ work. The larger part of the Summa theologiae (“sum of theology”) deals with practical matters, what we would now call ethics.

But Aquinas’ ethics are a theological, and hence, interdisciplinary ethics. His ethics are most certainly theological in the sense that all human acts must be properly considered as part of the life in the spirit. Charity, the most important theological virtue, is the form and mother not just of the theological virtues, but of all the virtues, including the human or moral virtues of prudence, justice, temperance, and fortitude. Thomas’ sum of theology shows how biology, anthropology, politics, ethics, economics, metaphysics, and theology are interwoven, each answering different particular questions in order to draw the really important conclusions concerning why we (humans) are here on this earth, what we are supposed to be doing while we are here, and where we are ultimately meant to end up.

In Aquinas’ day, he could be a theologian, an ethicist, a political scientist, an economist, and an anthropologist, but such “renaissance men” were thought to have been long-extinct in the contemporary period in light of the increasing specialization of each of the disciplines. We assumed that to really know anything in the wake of the proliferation of knowledge that followed the modern scientific, industrial, and technological revolutions, you had to be a specialist.

What Brooks’ article indicates to my Thomistic eyes is that we are beginning to re-recognize the important ways in which the practical and speculative concerns overlap, the dangers of reductionism, and the importance of interdisciplinary pursuits in drawing the right sort of conclusions about the questions we are asking. As Brooks points out, we now know the important influence that genetics has on our behavior. But we are beginning to recognize also how complementary processes of social interactions and culture influences genetics and physiology. He writes,

All of these studies are baby steps in a long conversation, and young academics are properly circumspect about drawing broad conclusions. But eventually their work could give us a clearer picture of what we mean by fuzzy words like ‘culture.’ It could also fill a hole in our understanding of ourselves. Economists, political scientists and policy makers treat humans as ultrarational creatures because they can’t define and systematize the emotions. This work is getting us closer to that. . .

The hard sciences are interpenetrating the social sciences. This isn’t dehumanizing. It shines attention on the things poets have traditionally cared about: the power of human attachments. It may even help policy wonks someday see people as they really are.

The challenge faced by young scholars like myself is no longer how to get my questions and my language specific enough to generate a new idea. Rather, young scholars are faced with the new challenge of how to gain a broad enough base of knowledge to re-ask the really old questions without dabbling too much, or drawing conclusions that are too broad to actually be meaningful.

My own dissertation asks how we can integrate a moral theological discourse into the already-interdisciplinary discourse about eating disorders, that is, anorexia nervosa and bulimia nervosa. Researchers have already acknowledged that eating disorders are physiological, biomedical, psychological, and sociological disorders; I argue that they are also moral disorders. So if you want to really know why people have eating disorders and what can be done about it, you need more that psychology, biomedicine, and sociology. You also need ethics, metaphysics, and yes, even theology.

Joss Whedon’s Dollhouse and Thomistic Anthropology

My husband and I are big Joss Whedon fans, probably because his shows (Buffy the Vampire Slayer, Angel, Firefly, and most recently Dollhouse), have such interesting philosophical and theological components. Joss Whedon’s new show Dollhouse is perhaps his most thoroughly philosophical.

The premise of the show is that the “Dollhouse” is a powerful, cutting edge organization that recruits young, beautiful individuals to be “dolls,” to have their brains wiped and memories erased so that they can be uploaded with different personalities to serve the needs of the Dollhouse clients. The leading scientist, the nerdy Topher, has designed a technology to quickly and practically effortlessly install the dolls’ brains with complete personalities, including memories, skills like rockclimbing and breaking into bank safes, and emotional connections with other people.

The most recent episode, starring, as always, Eliza Dushku as the evolving doll Echo, includes a new twist, as Topher figures out a way to change Echo on a glandular level in order to meet the demands of a distraught Dollhouse client who recently lost his wife in childbirth and can’t bond with his son. The man needs a mother for his son, and the Dollhouse provides. The opening scene shows Echo nuzzling an adorable baby as she breastfeeds him while her “husband” sleeps in the next room.

The client, Nate, quickly comes to recognize that the doll Echo is not his wife, and that hiring the Dollhouse to provide a mother for his son was a mistake. He calls the Dollhouse, demanding they remove her “or he’ll get rid of the baby,” while Echo surreptitiously listens at the door. Echo, fully installed with maternal instincts and lactating breasts, fears that her son is in danger, and desperately tries to escape.

She is almost successful. Echo is a remarkable doll in the show’s ongoing storyline, who is always sharp, smart, and talented, no matter what her personality, and always equipped with the best survival instincts. Her handler, Paul Ballard, ends up having to drag her screaming from a police station, while the father goes to recover his child. Even the standard calming line “Would you like a treatment,” fails to soothe the maternal Echo who fully believes that her child has been stolen from her.

When Topher goes to wipe the personality, returning Echo to the irenic “doll” state in which she walks around in pajamas and talks in naïve monotone, the story gets particularly interested. Echo’s maternal instinct doesn’t get wiped. When Topher asks her how she feels, Echo, half doll and half mother, punches Topher and makes for the exit, showing up at Nate’s house with the baby and a knife in hand, still fighting to keep her child.

When asked what went wrong, Topher responds:

“Maternal instinct is too strong for a normal wipe. I outplayed myself. . . Perhaps triggering lactation was a bridge too far.”

The father is eventually able to talk Echo down, explaining to her that he hired her to be a mother because he could not be a father, but that the real mother is a part of his son. Echo is not. In a poignant realization of what she is, a doll and not a mother, Echo hands over the baby. The next scene shows her in a playground, as Paul Ballard tentatively approaches.

Echo: I had a baby, now I don’t have him anymore. I feel sad. All of these things that happen to me, I feel them.
Paul: I know, Echo. I know you remember everything.
Echo: Not remember. Feel. I was married, I felt love. And pain, fear. It’s not pretend for me. They made me love my little boy, and then they took him away. They make it so real, every time, they make it so real. Why do they do that?. . .

Paul: If you want I can tell Topher what is going on with you and he can wipe you. You won’t have to feel sad anymore.
Echo: Feeling nothing would be worse. That would be like being asleep, like before. I’m awake now. I don’t want to go back to sleep.

What is so interesting about this episode from an EverydayThomist perspective is that Joss Whedon is implicitly endorsing an Aristotelian-Thomistic anthropology. For Aristotle and Aquinas, form subsists in matter. This means that the form of a person, their soul if you will, is not contained or trapped in the body, but is an integral, inseparable part of the body.

In Aristotelian studies, this concept is pitted against a Platonic metaphysic and anthropology that sees the body and soul or the matter and form of a substance as two different opposing realities that are connected, but not necessarily so, in the human person. For Plato, the human person is primarily spirit. The matter, and this includes the entire sensitive appetite including the emotions, is unnecessary, transitory, and disruptive. Aristotle argued against such a dualistic anthropology that body and soul were what made a human being a person. Matter, including the emotions, is not disruptive but necessary. The human form cannot subsist without matter.

In Thomist studies, this concept is referred to as Aquinas’ hylomorphic anthropology, hyle meaning “matter” and morphe meaning “form.” The passions or emotions like love and fear which Dushku mentions in the above quote must be understood in light of this hylomorphism. The subject of the passions is not only the body, nor is it only the soul, but is rather the substance, the unification of the two. The passions are accidents which are predicated of the hylomorphic unity of the person who can only subsist as both body and soul.

Every passion, therefore, involves a psychosomatic change in the person. This means that every passion, properly understood, effects both the immaterial soul of the person and the material body. This is not a question of cause and effect, as it was for the neo-Platonist Descartes who assumed that the immaterial mind/soul of the person was affected by the passions emerging from the body. Rather, the psychosomatic movement of the passions is a unified event for Aquinas. One quippy way of putting this is that every act of love is also an act of knowledge, and every act of knowledge is also an act of love. The intellect and the passions, the soul and body, the form and matter, are always moving as a unified, hylomorphic unity.

A more Cartesian anthropology assumes that the mind is the controlling force of the person. In other words, Descarte’s cogito, ergo sum posits that the person is a subject who thinks, or a mind who happens to have a body. The body, and the emotions, are not essential to anthropology (although there is some debate about whether this is a caricature of Descartes. Another story for another blogpost).

What Joss Whedon gives us in Dollhouse is a challenge to this Cartesian metaphysics and anthropology. Topher assumes that the mind is the operating principle of the person—change the brain, change the person. Moreover, he assumes that the brain controls the body as he illustrates in this episode. With the proper changes to the brain, Echo goes from gun-fighting superwoman to lactating mama.

But the person, as “Instinct” cleverly points out, does not subsist just in the mind or the form of the person, but in the body itself. Echo does not just think as her infused personalities do, she also feels the way they do. And when Topher wipes her brain at the end of each mission, what he fails to recognize is that he cannot fully wipe each personality because each personality is somehow in Echo’s body, and specifically in her sensitive appetite which is still left with the somatic imprint of the psychosomatic emotional changes that each of her personalities experienced.

In contemporary Thomistic studies, this is becoming more of an important point, post-Grisez and Finnis who, along with the other neo-Thomists, assigned too much control to reason, and neglected the dynamism of the sensitive appetite in Aquinas’ philosophical anthropology. This mistake was based on a larger cultural assumption that the “mind over matter” mentality encapsulated what it meant to be a human being. More recently, we are rediscovering the importance of human matter in moral psychology. Joss Whedon’s “Instinct” perhaps unwittingly pointed that out. Another point for the Thomists.

Two Forms of Judgment: Judgment per modum cognitionis and per modum inclinationis

Aquinas distinguishes between two types of knowledge at the beginning of the Summa Theologiae that correspond to two modes of judging. The first is judgment by cognition (per modum cognitionis), the second is judgment by inclination (per modum inclinationis):

Since judgment appertains to wisdom, the twofold manner of judging produces a twofold wisdom. A man may judge in one way by inclination, as whoever has the habit of a virtue judges rightly of what concerns that virtue by his very inclination towards it. Hence it is the virtuous man, as we read, who is the measure and rule of human acts. In another way, by knowledge, just as a man learned in moral science might be able to judge rightly about virtuous acts, though he had not the virtue. The first manner of judging divine things belongs to that wisdom which is set down among the gifts of the Holy Ghost: “The spiritual man judges all things” (1 Corinthians 2:15). And Dionysius says (Div. Nom. ii): “Hierotheus is taught not by mere learning, but by experience of divine things.” The second manner of judging belongs to this doctrine which is acquired by study, though its principles are obtained by revelation (I, Q. 1, art. 6, ad. 3).

According to Aquinas, right judgment can be achieved either through the perfect use of reason or by way of inclination. Judgment per modum cognitionis is notional knowledge attained by rational study. In other places, he refers to this mode of judging as per studium et doctrinam, per modum rationis, and secundum perfectum usum rationis.

Judgement per modum inclinationis is not cognitive, and not a judgment which takes place through the cogitative power, but rather, judgment according to affection or desire, and thus a kind of affective knowledge. Elsewhere Aquinas writes,

Wisdom denotes a certain rectitude of judgment according to the Eternal Law. Now rectitude of judgment is twofold: first, on account of perfect use of reason, secondly, on account of a certain connaturality with the matter about which one has to judge. Thus, about matters of chastity, a man after inquiring with his reason forms a right judgment, if he has learnt the science of morals, while he who has the habit of chastity judges of such matters by a kind of connaturality (II-II, Q. 45, art. 2).

Aquinas is distinguishing the two different forms of judging, or assigning value to something, using the example of virtue. A person may judge a thing like chastity should or should not be desired because he or she has been taught and understands how such a thing should be considered moral or immoral. On the other hand, a person may judge rightly as to whether something should or should not be desired not through a cognitive decision, but rather on the basis of whether or not he or she actually desires the thing in question. In the case of the former, the intellect is clearly providing the basis of judgment through the cogitative power. In the case of the former, the affective inclination of the person provides the basis for the judgment. In this way, the virtuous person is the rule and measure of human actions. The virtuous person is inclined towards the object of virtue (inquantum ad illa inclinator) or through a certain connaturality with the object of virtue (per quondam connaturalitatem ad ipsa).

We might think of an example in eating. Some individuals need to mentally check themselves to ensure that they do not overeat. How much food this person should desire on any given occasion is a cognitive decision. This individual may desire to eat a second helping of a dish, but decide that this second helping would make him or her too full, and therefore decline. Others, however, just naturally desire the right quantity of food on a given occasion. This individual does not have to decide whether a second helping of a dish is appropriate—the individual simply acts on his or her desires.

We must be careful not to go too far in pitting these two forms of judgment against each other as opposites, but see them rather as corollaries. Affective knowledge and judgment per modum inclinationis is not a judgment made without knowledge, but is rather the synthesis of love and knowledge—a synthesis of cognitive and affective activity. If we understand the two modes of judgment in this way, as a single activity of knowing and loving, we may resolve the apparent tension in Aquinas between the passions and reason. Recall that Aquinas holds that the human person is a hylomorphic unity of body and soul, and that the sensitive appetite stands between these two in a unified activity of putting the whole human person substantially in relation to the world. Knowing and loving are distinct activities, but with the same principle of operation, which is the substantial unity of the human soul.

Moral knowledge, therefore, is not either purely rational knowledge or purely affective knowledge, but is rather a synthesis of both knowledge per modum cognitionis and knowledge per modum inclinationis.

The hylomorphic unity of the human person also explains how one particular power can overcome the other. If the soul’s full energies are employed in the act of cognition, of knowing, such cogitation can impede the affective movement of the soul. Aquinas says that the concentration of the intellect can actually overcome the sensitive appetite so that it no longer experiences certain sensible functions: “In the powers of the soul there is an overflow from the higher to the lower powers: and accordingly, the pleasure of contemplation, which is in the higher part, overflows so as to mitigate even that pain which is in the senses” (I-II, Q. 38, art. 4, ad. 3). More commonly, however, the soul’s activities get concentrated on affection and its accompanying form of judgment. In this way, a person under the influence of anger may judge a thing good that he would not so judge if not under the influence of that passion:

Now it is evident that according to a passion of the sensitive appetite man is changed to a certain disposition. Wherefore according as man is affected by a passion, something seems to him fitting, which does not seem so when he is not so affected: thus that seems good to a man when angered, which does not seem good when he is calm (I-II, Q. 9, art. 2).

What is important to note, however, is that the sensitive appetite seems to present the intellect with an object already laden with value. This challenges the view among some Thomists that the role of the sensitive appetite is only to obey reason.

Is Anger an Appropriate Response to Suffering?

In the last post, I said that I was going to do a series of posts on some of the thoughts I have been having related to the “theodicy” issue, or the problem of evil and suffering in light of the belief that God is all-good and all-powerful. In this post, I am going to use as my starting point a quote from Harold Kushner, who I mentioned in the last post wrote a very famous book on theodicy called When Bad Things Happen to Good People. In his effort to explain God’s involvement in the suffering humans experience on this earth, Kushner writes,

We can recognize our anger at life’s unfairness, our instinctive compassion at seeing people suffer, as coming from God who teaches us to be angry at injustice and to feel compassion for the afflicted. Instead of feeling that we are opposed to God, we can feel that our indignation is God’s anger at unfairness working through us, that when we cry out, we are still on God’s side and God is still on ours (45).

In this post, I am going to expound on Kushner’s provocative idea about anger from a Thomistic framework in order to determine the moral and theological significance of anger, and whether Kushner is right is saying that suffering should prompt anger.

We tend to think of anger as vicious or harmful. Somebody may say, “I didn’t mean to do X, but I was blinded by anger,” or “anger is wrong; I want to be a more peaceful person.” Aquinas is aware that anger connotes sinfulness. There is good reason for this. In Matthew 5:22, for example, Jesus claims that one who is angry with his brother is liable to judgment. In his discussion of anger, Aquinas asks whether all anger is contrary to virtue, to which he answers a resounding no. Anger, which is a passion, can be aroused according to reason, which makes anger in some situations virtuous.

So how do we determine if anger is virtuous (according to the standards of reason) or not? Aquinas looks at the object of anger, or that to which the anger is directed. He identifies two objects to anger: one is the injury that the person suffers, and the other is vindication (vindicatio) that the person seeks. The vindicatio is the justice that one seeks to exact against an perceived injustice. It is the way of making an injustice right. The vindicatio is an evil under the aspect of good. Denying a person his freedom for a number of years in punishment for theft, for example, could be a vindicatio because it is an evil (imprisonment) that seeks to rectify an injustice (the theft), thus rendering the vindicatio itself a good.

If a person seeks a vindicatio against a person who does not deserve it, for example, the anger would be sinful. If a person seeks too great a vindicatio, such as when a person repays an injustice with a much greater injustice (beating a child for spilling milk), such anger would be sinful. So anger is virtuous if a truly unjust offense occurs and the response is proportionate to the injustice.

What about Matthew 5:22 that says that anyone who is angry against their brother is liable to judgment? In light of scripture, how can Aquinas still say that anger can be virtuous? One way which Matthew 5:22 has been explained is using the person/sin distinction. That is, it is wrong to be angry against a person, but okay to be angry against a sin. Because Jesus is referring to the former in his condemnation of anger, it does not contradict the thesis that anger can be virtuous. This is the explanation Augustine used, claiming that one is properly angered at the sin of one’s brother, not one’s brother himself. Thomas disagrees with this, claiming that if a person is unjust, it is fitting and proper to be angry towards that person, granted that one’s anger is proportionate and the vindicatio sought is just.

The reason is that anger is that, according to Aquinas, has a two-fold object—the injustice, and the rectification of that injustice. An injustice is when a person is not given their due. The order of the universe which is in natural things and in the human will reveals that there is justice in God. God orders things and orders that they be in right relationship, and this is what is meant by God’s justice. Kushner is right in identifying that when we recognize that things or people are not in right relationship, we are participating in God’s justice.

Anger, then, because it is concerned with justice, is properly determined by relationships. In order to determine if anger is appropriate, one must be in some relationship of justice, that is, a relationship that is ordered according to God’s standards. This requires a little explanation. I cannot be angry against an inanimate object, for example, because the inanimate object cannot do me an injustice. I may stub my toe on my desk, but my anger cannot rightfully be oriented towards the desk. Nor can I be angry at a hurricane or a virus for the same reason. I may be hurt by these things, but they cannot be the object of my anger because they did not commit an injustice against me. Anger, for Aquinas, is really properly directed at people.

Additionally, if anger is to be justified, the right rectification must be sought. A child who commits a grievous fault–perhaps he hits one of his siblings–has committed an injustice which the parents, due to their relationship of justice with the child, have a responsibility to rectify. Perhaps they will ground the child, or require some sort of positive compensation to the assaulted sibling. However, the sibling who has been harmed is not in a relationship that allows him to seek the necessary vindicatio. It would be inappropriate for the sibling to ground his own sibling or to hit his sibling back. It would also not be appropriate for a stranger to punish the pugilistic sibling. Nor would it be appropriate if a child was the victim of an injustice committed by a parent to seek vindicatio. If a child is hit by a parent, the appropriate response is to appeal to a higher authority, like the police. In short, in order to seek a vindicatio, one has to be in the right position of seeking justice.

This is why we frown on vigilantes, or civilians who go out to seek vindicatios against injustices that are going unpunished. Because such civilians are not in the proper relationship of justice to the people whom they are punishing, they are actually committing an injustice in their actions in seeking a vindicatio that is not theirs to seek. Their anger is not virtuous, because the vindicatio sought is not virtuous.

Reasonable anger (and hence, virtuous anger) according to Aquinas is (1) prompted by an occasion of injustice, (2) directed at the perpetrator of injustice, and (3) seeks a just vindicatio to restore the injustice. If anger meets these three requirements, Aquinas would say it is virtuous.

So how does this play out regarding the theodicy question as Kushner sees it? First of all, the object of anger must be an actual injustice, not just something that makes us unhappy. Aquinas would not say it is virtuous to be angry if you, for example, get diagnosed with a terminal illness. This is not an injustice that should rightfully prompt anger. Moreover, there is no committer of an injustice towards which one can direct their anger. A more proper response would be sorrow at the fact that one is experiencing an evil, but not an injustice. But it would be proper to experience anger at a news story relating how somebody has been raped or murdered, or to be angered when you hear about the violence in the Middle East or Zimbabwe. Here, we do have an injustice, and perpetrator, which can be the object of our anger.

Second, the anger must be directed at the right person. If I read about what is going on in Zimbabwe and get angry at Robert Mugabe, my anger may be justified. If I read about Zimbabwe and get angry at black people, my anger is definitely not. Similarly, if I get angry at God when I hear about Mugabe’s egregious offenses against his people, my anger is not targeted at the right person. Such anger, according to Aquinas would not be justified.

Lastly, the vindicatio sought must in itself be just. If I decide that I am going to go assassinate Mugabe to stop his injustices, the unjust vindicatio thus renders my anger unjust. A more just vindicatio might be writing to the UN or raising awareness in this country by writing letters to the newspaper or marching in DC, or praying to God for the Zimbabweans who are suffering.

Kushner is right that we should feel compassion and sorrow for those who suffer. But I am not quite sure that an appropriate response to suffering is anger. Anger connotes that an injustice is being done that one can do something about. Sickness, death, and natural disasters are indeed evils, but they are not injustices. Such tragedies may be handled in an unjust way. Hurricane Katrina, for example, was not itself an injustice, but the subsequent way it was dealt with in many ways was.

This is not to say that Aquinas thinks we should remain Stoic in the face of suffering. He acknowledges that the passion of sorrow, which is the apprehension of some pain or evil, is a appropriate. When one is faced with a pain or evil, it may be appropriate to weep, to seek to remove or alleviate the harm, or even, as is the case with Job, demand answers from God. But for Aquinas, and I think he is right, it is not an injustice to experience pain, nor does God owe us any answers. The proper response to suffering, I would argue against Kushner, is not anger, but rather sorrow. The situations that concern Kushner, the death of a child for example, do not arouse God’s anger because no injustice is being done. God’s universe is still in order, even if we suffer.

But this is not the final word for Aquinas against Kushner, which will be the subject of another post on the issue. Aquinas, as a Christian, has not only a God that gets angry at injustice, as Kushner does, but also, a God who through the incarnation, is capable of suffering with, or feeling compassion and sorrow with his creation. And through the resurrection, Aquinas has a God who not only suffers with his creation, but has also ultimately defeated suffering in the grand eschatological scheme. Thus, for Aquinas, suffering should prompt not only anger if an injustice is done, or sorrow if no injustice is done, but should also prompt us to reflect on the God who loved us so much, that he suffers with us, and is himself ultimately the remedy to our sorrow.

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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