APR-A-6
TREATING OTHERS HUMAN SCIENCES IN THEORY AND PRACTICE
Glenn W. Geelhoed
PhD Candidate in the Human Sciences
March 15, 2001
HOW CAN WE TREAT OTHERS?
Most theories of ethical behavior assume interaction among equals with principles of respect for autonomy without patronizing the recipient of services, especially when the relationship appears asymmetric. If one of the parties is empowered by authority or expertise and the other disadvantaged, there are additional burdens of caution in respect of conduct involving power imbalance, whether that authority is conferred by intentional systems—such as institutions of state, education, economic or moral/religious suasion—or by some biologic factors—such as age, strength, or the capability of the healer—the assumptions of a fundamental equality residing in the human personhood on each side of the interaction remain intact, generalized through Kantian principles or Golden Rules governing the care-giver, ruler, or authority figure over the disadvantaged, but equally autonomous human being helped or subjugated.
This may have seemed a self-evident principle despite nearly universal exceptions in its applications. At no time in the contentious eras of empires, or economic colonialism was symmetry self-evident to support the theory, and even less so today with the magnification of differences in political, economic and life/death/health power enhanced by technology and applied to help or hurt one side of the bipolar relationships. These disparities have become ever more exaggerated despite the curbs civilizations have placed upon excesses in mistreatment, and today there is a greater gulf between the treaters and treated in the complex of technology-assisted societies. When these economic and power disparities are within the borders of any given state, there may be codified rules set down by the society as formalized in a state or judicial entity or standards set by professional societies of practitioners. When the relationship occurs across lines of recognized states or rules promulgated by ethnic or religious common assumptions, the theory governing the practice of “treatment” becomes less clear and often exhibits sphere clashes in deontology.
A CASE IN POINT
I have been involved in the practice of health care for over a third of a century, and in the professional capacity of caring for the sick, I have had a special interest in populations that are further disadvantaged by poverty in surroundings of very meager resources in which subsistence itself is often difficult. While some of these destitute people (whom I might come to consider as “patients” in attempting to treat them) live within the same citizenship I share, most have been abroad. I further lead other people, students or other graduate health care givers, who join me in treating people across very large gulfs in economics, technology, religious, language, education, social and political boundaries. I have both practiced treatment, and sometimes reported the results of my observations in so doing on how treatment modified both the treater and treated.
At least one of these reports recently published has drawn a considerable storm of protest as to the methods and permission of treatment of a group I had represented as my intended beneficiaries in a medical aid project in Central Africa. After an initial acceptance with some enthusiasm for the intent and effect of the proposed health care intervention, a minority opinion was raised, not once, but on three consecutive peer reviews. The opinions of the demurring reviewers can be taken from the titles “Moral Maladaptation” and “Medical Imperialism” of editorial opinions, claiming higher authority, quoting Nuremberg Trial principles and international political processes in organizations with or without the imprimatur of the United Nations. These ethicists made the claim that another universally accepted form of “due process” was not followed or was unacceptably modified in the constraints of the conditions under which the treatments were conducted. It is true that the majority of the reviewers found the reports acceptable and some even thought the process described might explain elements of human species development and differentiation. The misunderstanding or misrepresentation of the “undertaking to treat” had given me pause, however, to re-consider by what right we might ever undertake to intervene in the circumstances of another, and endeavor to take it upon ourselves “to treat” when nearly all such treatment would involve quite different “others,” and a nearly inevitably wide gulf across which advocacy must function with imperfect information and limited understanding.
How might the Human Sciences help to illumine this controversy and prevent the theoretic paralysis that might otherwise lead to practice solipsism?
Practice patterns have evolved over time to describe, and then prescribe ethical behavior of those who treat others. These principles have been encoded in such supra-statal professional creeds as the Hippocratic oath, or a methodology known in anthropology as participant observation, or in Kantian ethics as treating all subjects as entities who are not means toward some end but an end in themselves with applications of any actions based in generalizable principles one might wish to have acted upon in one’s own treatment. This may be simplified in the Golden Rule. As generalizable as such a first principle might be, it might be caricatured in some extraordinary real-world circumstances: “I want to treat as I might wish to be treated, if only I were not sick and starving just now as you seem to be.”
The fundamental modification of the observed means that even the allegedly non-interventive practice of participant observation can come under considerable critical pressure for interference in the lives of those observed. The somewhat contrived controversy over the genetic research among the Yanomami Indians that has recently embroiled many institutions has resulted in the re-examination of similar questions of the ethics of anthropologists’ behavior in ethnography alone, if not in directly invasive actions into the lives of the communities under observation.
The paternalistic assumption that we, older, perhaps, at least more knowledgeable if not wiser heads know what is best for not just individuals, but whole populations, underlies quite a number of actions taken in public health, with even some recent authors alleging that there has been a failure of trust in not taking the imperatives of social engineering far enough. Autonomy is one principle, but an outright ban on smoking or the casual use of alcohol might be a far more effective “treatment” of a population than the individual damage repair after the fact of abuse of any such agents. There must be some constraints on the side of both goods and rights, and the freedom to pursue what happiness each can seek in some activities may lead to what could be called “other” victimless crimes.” Self-infliction, however, quite frequently burdens the society at large—and the caregivers in particular—for which they might have a self-interest as well as altruistic opinions on the restraint of personal freedoms to pursue certain excesses. The full circle is turned when we might exercise such care of an individual or population that we permit them to do nothing at all lest they expose their lives to any danger from experiencing life’s vagaries, while being constrained by such respect for the autonomy of others as to be unable to take any action in treatment for any at any time. The reductio ad absurdum would be that we should not even be acquainted with the “other”, since just observing them and knowing they exist might be interference in their autonomy, and ignorance of their existence would further relieve us of any obligation to intervene in their welfare. Surely, the Human Sciences must have a role in steering us out of such a theoretic impasse for a practical resolution of how to represent, respect and relieve others and assist them in rehabilitation for empowerment in self-actualization.
The subaltern may speak, but not usually through one of their number being lifted up above the mass becoming a neo-colonialist speaking for the voiceless masses through amplified positions in the colonizers’ world. Advocacy must recognize otherness, and acknowledge that it is never possible to perfectly represent despair from comfortable agencies within the developed world. I have run into a problem with advocacy becoming agency, transforming quickly to ownership in perpetuity of a human problem, with a guarantee of failure in treatment in order to keep the problem and agency budget growing. If advocacy means representing the downtrodden, there should be a rapid transition to work the advocate out of a job rather than enshrine it in perpetuity as a goad to the conscience and purses of the comfortable. Chauffeured limousines of aid agency advocates have the look of self-interest above representation---doing very well by doing good. Advocacy is better tolerated if the representation is over against the interests of the society—and over the advocate’s own; that does not mean that the sincere are always effective, but the inverse is hypocritical.
It is not simplistic to say that the way to treat the inequities of post-colonialism is to get beyond it. Institutionalization of a second-class status is re-inflicting the injury and again enshrining dependency in perpetuity. The goal of good treatment is not to create compliant patients, but to produce empowered healthy healers. A successful treatment may be a threat to the agency, but not to the person who is treating. Agency ought to be a self-limited condition extinguished by its success.
Perhaps, but that equality is not very apparent now, however far we stand from that creation. And, the inequities in resources, capabilities, richness of life-world and experience grows ever more disparate, since it is difficult to cultivate some of the finer expressions of the Human Sciences while engaged in a desperate struggle for subsistence. It takes a certain consumer surplus of capital, of energy, of leisure to dedicate a higher proportion of our attention and effort to the non-vegetative functions of staying alive, and in many human populations, one hundred percent is not enough to insure that basic fact of life. It is easy, when surrounded by the misery of such “inhumanity”, (if one stays, without fleeing to much more comfortable surroundings) to get a “glow in the dark” opinion about one’s own humanitarian instincts. It often seems it is easier to share in the miseries of the world as a short-termer knowing that one can go back, retreating into the comforts of excess, and cultivate the finer arts and sciences which are luxuries not easily afforded by the destitute. While there is nothing particularly ennobling about abject poverty, it is often surprising what “gifts from the poor” may be learned in listening to the destitute who have been stripped of many of the distractions of excess things and remarkably focused on the fundamentals of adaptation for survival.
Many of the resources of these resourceful people are a spiritual strength that keeps them indomitable under crushing circumstances, creating a human science of their own out of the hardscrabble life at the margin. It is hardly to be romanticized since it is not often pretty or sentimental. They have not been treated well by circumstances, most often outside their control, but they remain subjects, and not objects, and create an art, and a culture. After openly acknowledging the wide inequalities that exist among men, that allows me to come to them even if they cannot come to me, there is a self-interest in our interaction that each side realizes. We may each try initially to exploit each other as representatives of some other world for an advantage in our own. They may seek to work their way into my confidence for medical or economic advantage as special adoptees. The advantage for me now added to those pre-existing reasons for such adventure excursions into the unknown may now include representing them through actualizing such shared experience to report in a dissertation for whatever advantage that may be outside their world. These secondary gains aside, from each end of our interaction, acknowledged and then superceded, there evolves a special understanding across language, culture, economics and the boundaries of our respective life-worlds. This understanding may seem to be its own reward on either side, beyond the immediacy and busyness of the preemptory demands of their having a special-purpose friend or my having “ field informants.”
If there is a key of some sort in understanding the “other” it is probably not to be derived by some data determined by the kind of measurements I have carried out, however instructive these may have been in illumining a few micro-analytic glimpses into the survival adaptations which may keep these people functioning when I, or others, might not, by simply giving up in the face of such want as to drive to despair. It may be from the bilateral sharing of some understanding of what human qualities we may communicate through whatever different means we have each learned—through song, or art, or bushcraft appreciation of the world about them that I may have studied, but they know from an existential perspective.
There are agencies with agenda to supply “vertical care programs”, some of which may literally involve some stuff pushed out of the back of an aircraft over some such population. “Aid utilization” means the expenditure of certain funds budgeted and a smooth outflow of resources, whatever their effect might be. Analyzing the overall results in the human population so treated beyond the “aid uptake” measures that are the end of the “evaluation” process might get some sets of micro-analytic numbers by which success can be declared, given the specific target and the brackets set out in advance for achievement of what would be called a measurable success. But, it would be unlikely that an aid project would be stopped, given the feedback that the humanitarian results were a decrease in the welfare of the population so treated. This is called a “pipeline problem”, that there is an interruption of the outflow of funds in aid utilization. I have encountered multiple projects, which should have been interrupted on the basis of a decrease in the well being of the people treated, but they would not be, since the aid project was a benefit program to the donors. Examples of such “treatments to the first world donors” might be farm surplus transshipment programs that are price support benefit programs to Iowa farmers; infant formula donations that were a gift to Swiss Nestle; or the preposterous donation of an MRI scanner in a Mozambican Hospital without Band-Aids, bed sheets or penicillin—a gift from the German government to Siemens.
HOW
WOULD THE OTHER TREAT HIM OR HERSELF,
AND HOW MIGHT HE OR SHE TREAT
US AS THE OTHER?
I am quite literally an “ET” falling from another planet into the cultures I visit. How am I treated? I am a resource to be exploited, to be “conned,” to be co-opted, ingratiated—in other words, exactly as I might treat them. After we have had a lot more experience of each other, we each find that the rather direct and primitive approach is ineffective—since we have both around “others” before, and we must try a bit more sophisticated approach through bargaining, barter, and arrive at some sort of mutualism in a symbiotic relationship, recognizing that they are the local experts and I am in their territory. They recognize that I must have the edge on resources, since, after all, I got there from half a world away, and seem to have some sort of outside world support system, in which they would like to share.
What would they want for themselves? They would like to have just a little of the advantage that I apparently have had, since, if only they had, then they too, could be like me—since I seem to be empowered, and capable enough to take care of most of my problems and some of theirs as well. And how well might they do if this were an opportunity given to them? If the entire gross national product of the USA, the largest economy the world has ever seen, were dropped as a donation into Africa, it would disappear without a ripple visible a generation hence. If they had had just half the opportunities I have had, of course, they would their own voice, and not become like me, but a better they. They would not need advocacy, except for opportunity. That choice to be able to develop much more of their full human potential is perhaps the most common of the human links that makes for understanding despite wide inequalities among others.
Ashcroft, Bill, Gareth Griffiths, and Helen Tiffin. The Empire Writes Back:
Theory and Practice in Post-Colonial Literatures. 1989
Bhabha, Homi Conrad, Joseph. Heart of Darkness.
Crosby, Aldred. Ecological Imperialism: The Biological Expansion of Europe 900--1900.
1986
Fukiyama, Francis. The End of History. 1990
Fukiyama, Francis. The Great Disruption: Human Nature and the Reconstitution
of Social Order. 1999
Geelhoed, Glenn W, “On the Profession of Medicine,” Michigan Medicine 319, March,
1967.
Geelhoed, Glenn W. Out of Assa: Heart of the Congo. Three Hawks Publishing
Company, Alexandria, VA, 2000.
Geelhoed, Glenn W. “Mind the Gap” British Journal of Surgery, 1990
Geelhoed, Glenn W. “Wanted: World-Class Surgeons”, Bulletin of the American
College of Surgeons, Sept. 1998
Geelhoed, Glenn W. “Metabolic Maladaptation: Individual and Social Consequences
of Medical Intervention in Correcting Endemic Hypothyroidism” Nutrition 15:
908, No. 11/12 Nov/Dec, 1999
Geelhoed, Glenn W. “An Author’s Editorial: Health Care Advocacy in World Health”
Nutrition Vol. 15: 940, No.11/12 Nov/Dec, 1999
Levi-Strauss, Claude. The Scope of Anthropology. Original (in French) and translation
by Sherry Ortner Paul and Robert A. Paul, Jonathan Cafe: London, 1967
Levi-Strauss, Claude. Tristes Tropiques. Original (in French) and translation
by John and Doreen Weightman, Atheneum, New York, 1974
Munson, Ronald. Intervention and Reflection: Basic Issues in Medical Ethics.
Wadsworth Publishing Company, Inc. Belmont, California, 1979
Rothman, David “The Shame of Medical Research” New York Review of Books, November
30, 2000
Said, Edward. Orientalism. 1978
Said, Edward. Culture and Imperialism. 1993
Sapolsky, Robert M. “Requiem for an Overachiever: In the Fast Lane of Africa,
the Good Guys Finish Dead,” The Sciences 15, Jan/Feb 1997
Spivak, Gayatri, “Can the Subaltern Speak?”
Tierney, Patrick, Darkness in Eldorado, 2000
Wilson, Edward O. Consilience. 1998