Experience and its moral modes: Culture, human conditions, and disorder, A Kleinman

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Content: Experience and Its Moral Modes: Culture, Human Conditions, and Disorder ARTHUR KLEINMAN THE TANNER LECTURES ON HUMAN VALUES Delivered at Stanford University April 13-16, 1998
ARTHUR KLEINMAN is Maude and Lillian Presley Professor of Medical Anthropology and Chair of the Department of Social Medicine at Harvard Medical School. He is also Professor of Anthropology at Harvard University. He was educated at both Stanford and Harvard, and received his M.D. from Stanford in 1967. He is a fellow of the American Association for the Advancement of Science, the American Psychiatric Association, the American Academy of Arts and Sciences, and the Royal Anthropological Institute. H e has been a Guggenheim Fellow and fellow of the Center for Advanced Study in the Behavioral Science. He directed the World mental health Report. In addition to many published articles, he is the author of numerous books, including Writing at the Margin (1995) ; Rethinking Psychiatry (1998) ; Social Origins of Distress and Disease (1986) ; and Patients and Healers in the Context of Culture (1980), which was awarded the Wellcome Medal for Medical Anthropology by the Royal Anthropological Institute.
PROLOGUE TO THE LECTURES What I seek to accomplish here is to bring the perspectives of medical anthropology, cultural psychiatry, and social medicine to bear on moral theory. I will draw on my knowledge of these disciplines along with my field research and clinical work in Chinese society and in North America to examine moral issues concerned with our era's great transformation of suffering and medicine and social life more generally. I will describe the profound implications of the truly dangerous burden of social suffering. In response to these human tragedies, neither the cultural resources of the pro- grams of tradition nor those of the programs of modernity seem at all adequate. Indeed they all-too-regularly add to the sense and substance of disorder. Subjectivity itself is undergoing an epochal I am deeply grateful for the opportunity to present these ideas that the Tanner Lectures afforded. I wish to thank the three official commentators on these lectures, Allan Werthheimer, Hazel Markus, and especially Veena Das for their reflections and for the tonic of lively intellectual colloquy. I also wish to thank Sylvia Yanagisako, Carol Delaney, Barbara Koenig, David Spiegel, and other friends and interlocutors at Stanford, including those in the Program of Values and Society, for their responses. And I extend the appreciation to my colleagues Michael Herzfeld and Amartya Sen for their thoughts regarding various parts of the argument I have presented. I have also benefited from the responses of Robert Hefner, Charles Rosenberg, Stanley Tambiah, and Don Seeman. Without the acutely critical sensibility of Joan Kleinman and the assistance of Mathew McGuire and the tremendous effort of getting it all into (and out of) the computer by Joan Gillespie there would be no published version at all. I acknowledge Michael Oakshott's Experience and Its Modes (Cambridge and New York: Cambridge University Press, 1985 [1933]) as the source of the title of the lectures. I am not seeking to work out Oakshott's ideas here, but I find resonant these few: " `Experience' stands for the concrete whole which analysis divides into `experiencing' and `what is experienced' " (p. 9); "practical activity is a form of experience" (p. 249); "a specific world of experience is the world of value" (p. 285); and "the practical comprises all that we mean by a moral life" (p. 296). These ideas, of course, are derivative of European philosophy, especially phenomenology, over the last century, and together with certain Chinese formulations, the writings of William James, and contemporary anthropological theory are the intellectual streams that build up into the source of what I have tried to develop in these lectures. [ 357 ]
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change. It may represent a deep and most dangerous transformation. Once I have described what I take to be the fundamental challenge, I will then try to indicate a possible direction for human engagement with it. So daunting is my subject, so limited my skills, that I must beg your indulgence with my overreaching. I do so not to amuse you with a display of my pretensions, but because of a keen sense that there is in this subject so much that matters for all of us. The perspectives and research I will present deal with moral processes at the local level of lived experience. Hence I need to begin first with an ethnographic orientation to experience. Experience I will define, following many others, as the felt flow of interpersonal communication and engagements.1 Those lived engagements take place in a local world.2 Experience is thoroughly intersubjective.3 It involves practices, negotiations, con-
1 For an extended account of the theory of experience developed here, see Arthur Kleinman and Joan Kleinman, "Suffering and Its Professional Transformation: Toward an Ethnography of Interpersonal Experience," Culture, Medicine and Psychiatry 15, no. 3 (1991): 275-301; reprinted as chapter 5 in Arthur Kleinman, Writing at the Margin: Discourse between Anthropology and Medicine (Berkeley and Los Angeles: University of California Press, 1995), pp. 95-119. William James, in his Hibbert Lectures at Oxford in spring 1908, observed: "Reality, life, experi- ence, concreteness, immediacy, use what word you will . . . by reality here I mean where things happen" (Linda Simon, Genuine Reality: A Life of William James [New York: Harcourt Brace, 1998], p. 359). 2 The concept of local worlds is developed further in Arthur Kleinman, "Pain and Resistance: The Delegitimation and Relegitimation of Local Worlds," in Pain as Human Experience: A n Anthropological Perspective, ed. M. J. Good, P. Brodwin, B. Good, and A. Kleinman (Berkeley and Los Angeles: University of California Press, 1992); and for the Chinese setting in Arthur Kleinman and Joan Kleinman, "Moral Transformations of Health and Suffering in Chinese Society," in Morality and Health, ed. A. Brandt and P. Rozin (New York and London: Routledge, 1997), pp. 101-18. As used in this paper "local worlds" is meant to emphasize the fact that ethnographic descriptions focus on micro-contexts of experience in villages, urban neighborhoods, work settings, households, and networks of bounded relationships in communities where everyday life is enacted and transacted. 3 The idea of the intersubjectivity of experience can be found in the Western phenomenological and pragmatist traditions; see John Dewey, human nature and Conduct (New York: Modern Library, 1957 119221); William James, "The Consciousness of Self," in T h e Principles of Psychology (Cambridge: Harvard University Press, 1981); Alfred Schutz, T h e Phenomenology of the Social W o r l d (Evanston: Northwestern University Press, 1969); Max Scheler, Man's Place in Nature
[KLEINMAN] Experience and Its Moral Modes
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testations among others with whom we are connected. It is a
medium in which collective and subjective processes interfuse. W e
are born into the flow of palpable experience. Within its symbolic
meanings and social interactions our senses form into a patterned
sensibility, our movements meet resistance and find directions, and
our subjectivity emerges, takes shape, and reflexively shapes our
local
By local world I mean the ethnographer's village,
neighborhood, networks, family, and other institutions. Even in a
vast sea of globalization, in which we are more acutely aware that
local worlds have permeable boundaries, undergo frequent change,
and that their members may belong to several different networks at the same time -even with these qualifications the local perdures
as the grounds of social life.5 But I shall suggest that in local
worlds we can also speak of local biologies with particular moral-
(New York: Noonday Press, 1971 [1938]); among such French thinkers as H. Bergson, Les donnйes immйdiates de la conscience (Paris: Alcans, 1889) ; Pierre Bourdieu, T h e Practice of Theory: A n Introduction to the W o r k of Pierre Bourdieu (New York: Macmillan, 1990) ; Marc Auge, "Thйorie des pouvoirs et idйologie": Etude Cas en Cote-d 'Ivoire (Paris: Hermann, 1975); and among the Chinese social scientists who developed the movement to sinicize social science (e.g., K. K. Hwang: "Face and Favor: The Chinese Power Game," American Journal of Sociology 92, no. 4 (1987) : 944-74; Ambrose King, "Kuan-his and Network Building" Daedalus 120, no. 2 (1991): 63-84; K. S. Yang: "The Chinese People in Change," in his collected works on the Chinese People (Taipei: Kuei Kwan Book Co., 1987; in Chinese). In this paper, I elaborate the latter especially into a position that claims cross-cultural validity. 4 On the emergence of subjectivity in interpersonal relations, language, and other symbolic mediators, see George Herbert Mead, Mind, Self, and Society; From the Standpoint of a Social Behaviorist (Chicago: University of Chicago Press, 1972 [1934]); Alfred Schutz, T h e Phenomenology of the Social World (Evanston: Northwestern University Press, 1967) ; Yang: "The Chinese People in Change." 5 There is an extensive anthropological literature on the relation of the local and the global (see, for example, Ulf Hannerz, Transnational Connections: Culture, People, Places [New York: Routledge, 1996)). An unusual example is to be found in a collection of research studies of how McDonald's Restaurants have been a source of both globalization and indigenization in East Asia (see James L. Watson, ed., Golden Arches East: McDonald`s in East Asia [Stanford: Stanford University Press, 1997]). It is difficult to sum up this literature, but on the whole it would seem to suggest that globalization has led to transformations in cultural, economic, political, and psychological processes, yet there is still considerable evidence of the power of local social processes to resist or reshape these influences.
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bodily connections, connections that express and constitute the mundane and the supramundane.6 Experience is characterized by an orientation of overwhelming practicality.7 What so thoroughly absorbs the attention of participants in a local world is that certain things matter, matter greatly, even desperately8. What exactly is at stake, across local worlds and historical epochs, varies, sometimes extravagantly so.9 The
The idea of local biologies has been developed by both social and biological anthropologists. Whereas some mean by this term that biology is represented differently in local knowledge (see Atwood Gaines, ed., Ethnopsychiatry [Albany: State University of New York Press, 1992], as, for example, in the case of anatomy in the Chinese medical tradition vis-а-vis its representation in biomedicine; others convey the idea that biological processes defined and measured in biomedical terms are transformed by social processes (see Margaret Lock, Encounters with Aging: Mythologies of Menopause in Japan and North America [Berkeley and Los Angeles: University of California Press, 1993]). It is in this second sense that I use the term in this lecture. (See also Peter Ellison's "Reproductive Ecology and `Local Biologies,' " paper presented at the panel "The Body and the Cultural and Biological Divide," Annual Meeting, American Anthropological Association, Washington, D.C., 1996.) 7 See, for example, Dewey ( H u m a n Nature), James ("Consciousness of Self"), and Schutz (Phenomenology). Among anthropologists, the most convincing ethnographic presentations are those of Michael Jackson, Paths toward a Clearing: Radical Empiricism and Ethnographic Inquiry (Bloomington: University of Indiana Press, 1989); Unni Wikan, "Public Grace and Private Fears: Gaiety, Offense, and Sorcery in Northern Bali," Ethos 15 (1987) : 337-65; Veena Das, Critical Events: A n Anthropological Perspective on Contemporary lndia (Delhi: University Press, 1994) ; Renato Rosaldo, "Grief and a Headhunter's Rage: On the Cultural Force of Emotion, in Proceedings, American Ethnological Society, Washington D.C., 1983, pp. 178-95. See also Kirsten Hastrup and Peter Hervik, eds., Social Experience and Anthropological Knowledge (London and New York: Routledge, 1994). Robert Desjarlais, (Shelter Blues: Sanity and Selfhood among the Homeless (Philadelphia: University of Pennsylvania Press, 1997) provides a critical reflection on experience as an ethnographic category that is part of his study of the homeless mentally ill in Boston. That experience is characterized by overwhelming practicality does not diminish the importance of cosmologies, myths, rituals, or collective and individual theorizing in religious or secular contexts. It only clarifies that these crucial processes need to be seen as aspects of practical rationality and local practices. 8 Arthur Kleinman ("Everything That Really Matters: Social Suffering, Subjectivity, and the Remaking of Human Experience in a Disordering World," Harvard Theological Review 90, no. 3 [1992]: 315-16) develops this point and illustrates it with interview materials from North America and China. 9 The pertinent ethnographic and historical literature on cultural difference is by now simply immense. A few examples are Talal Asad, Genealogies of Religion: Discipline and Reasons of Power in Christianity and lslam (Baltimore: Johns Hopkins Press, 1993); John Bossy, Christianity in the West, 1400-1700 (Oxford: Ox-
[KLEINMAN] Experience and Its Moral Modes
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symbolic apparatuses of culture elaborate these meanings and con- strain how individuals remember and act upon them so that local worlds can be (and often are) greatly different cultural spaces." Even in the same world, there can be (and often are) conflicts ford University Press, 1985); Clifford Geertz, Local Knowledge and Further Essays in Interpretive Anthropology (New York: Basic Books, 1983); Catherine Lutz, Unnatural Emotions: Everyday Sentiments on a Micronesian Atoll and Their Challenge to Western Theory (Chicago: University of Chicago Press, 1988) ; Ganneth Obeyesekere, T h e Cult of the Goddess Pattini (Chicago: University of Chicago Press, 1985); Michelle Rosaldo, Knowledge and Passion: Ilongot Notions of Self and Social Life (Cambridge: Cambridge University Press, 1980); Bruno Snell, T h e Discovery of the Mind (in Greek Philosophy and Literature): T h e Greek Origins o f European Thought (Oxford: Blackwell, 1953) ; Unni Wikan, Managing Turbulent Hearts: A Balinese Formula f o r Living (Chicago: University of Chicago Press, 1990). See also Jean Delumeau, "Sin and Fear": The Emergence of a Western Guilt Culture in the Thirteenth-Eighteenth Centuries, trans. Eric Nicholson (New York: St. Martin's Press, 1990); Peter Gay, T h e Naked Heart (New York: Norton, 1995); Carlo Ginzburg, T h e Cheese and the Worms: T h e Cosmos of a SixteenthCentury Writer (New York: Penguin Books, 1982); Irving Hallowell, Culture and Experience (Philadelphia: University of Pennsylvania Press, 1967); Jackson (Paths); Fred Myers: Pintupi Country, Pintupi Self (Washington, D.C. : Smithsonian Institution Press, 1986); E. Schieffelin, T h e Sorrow of the Lonely and the Burning of the Dancers (New York: St. Martin's Press, 1976). 10 The concept of culture has been used in different ways and is hotly debated in the 1990s both within and without anthropology. Susan Wright ("The Politicization of Culture," Anthropology Today 14, no. 1 [1998]: 7-15), writing in the official publication of the Royal Anthropological Institute of Great Britain and Ireland, puts it: older views of culture emphasized its boundedness, defined characteristics, unchanging, shared, and homogenous elements, while newer views emphasize that culture is an active process of meaning making, is contested, involves individuals who are differently socially positioned, has local, national, and global connections, is not closed or coherent, and can be used hegemonically. The appropriations of the idea of "culture" in politics, commercial practices, and international development programs show that its uses are salient as its content. In this lecture, I draw upon elements of both newer and older definitions, as will soon become apparent to the reader; but at both local and global levels I use "culture" to mean symbolic apparatuses of meaning making, representation, and transmission. Culture is closely connected with political and economic processes and changes in relation to them; it is both shared and contested; it is differentially distributed across the divisions of class, ethnicity, religion, gender, and age cohort; it is realized in local worlds yet extends beyond them; and it contains coherences and incoherences. The idea of culture's appropriation as part of political and economic processes that are historically shaped and consequential for human futures is one I am particularly interested in and seek to develop in this lecture. Indeed, although treated as a strawman in the guise of "cultural relativism" in moral theory in the 1980s and earlier, in the 1990s culture has been taken up in moral debates, but more often in a manner that strips it of its economic, political, and historical aspects. (See Arthur Kleinman, "The Anthropology of Bioethics," chapter 3 in Writing at the Margin, pp. 41-67.)
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owing to differences of class, ethnicity, political faction, gender, and individuality.11 So that heterogeneity and complexity define most social spaces. Culture in the form of local knowledge and practices is as much about what is not shared as it is about what is shared. But that some things do matter, matter greatly -such as status, relationships, resources, ultimate meanings, one's being-inthe-world and one's being-unto-death and transcendence, among many other things -and that what matters has a collective as well as a personal significance is what provides experience everywhere with its moral mode. Experience is moral, as I define it, because it is the medium of engagement in everyday life in which things are at stake and in which ordinary people are deeply engaged stake-holders who have important things to lose, to gain, and to preserve. Among the things that order the course of the moral processes I will describe are dangers, dangers that are perceived to exist in the world and that represent serious threats to other things that are at stake as well. The dangers of social experience are multifarious. They occupy our attention because they can threaten our categories, our relationships, our projects, even our survival. In these lectures I will examine one type of danger: the sources, forms, and consequences of social suffering: a topic that I will develop at length later.l2 I select this subject for emphasis because,
11The ethnographic literature of the 1980s and 1990s is filled with examples of such differences from communities worldwide: e.g., James Clifford and George Marcus, Writing Culture: The Poetics and Politics of Ethnography (Berkeley: University of California Press, 1986) ; James Clifford, T h e Predicament of Culture: Twentieth -Century Ethnography, Literature and Art (Cambridge, Mass.: Harvard University Press, 1988) ; George Marcus and Michael Fisher, Anthropology as Cultural Critique: A n Experimental Moment in the Human Sciences (Chicago: University of Chicago Press 1986); Mary Steedly, Hanging without a Rope: Narrative Experience in Colonial and Postcolonial Karoland (Princeton: Princeton University Press, 1993); Anna Lowenhaupt Tsing, In the Realm of the Diamond Queen: Marginality in an Out -of -the -Way Place (Princeton: Princeton University Press, 1993). 1 2 See, for example, Arthur Kleinman, Veena Das, and Margaret Lock, eds., Social Suffering (Berkeley and Los Angeles: University of California Press, 1997). The Australian sociologist Bryan Turner, in a theoretical framing I only became aware of after writing these lectures, distinguishes between the "ontological fra-
[KLEINMAN] Experience and Its Moral Modes
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as we will see, it is so consequential for human conditions globally. This picture of social life may seem overly serious, even op- pressive. Joy and humor and imagination can lighten experience and describe the mundane (and supramundane) in ways that are just as crucial. But here, to counterbalance our society's famous romance with progress and sentimentality, I seek to emphasize suffering and danger. Seen in this light, moral processes differ in a fundamental way from ethical discourse. The latter is an abstract articulation and debate over codified values. It is conducted by elites, both global and local. Ethical discourse is usually principle-based, with metatheoretical commentary on the authorization and implication of those principles. (In bioethics, the chief principles are autonomy, beneficence, and justice; they in turn privilege informed consent and confidentiality.) Ethical discourse is reflective and intellectualist, emphasizing cognition (more precisely, in today's jargon, rational choice) over affect or behavior and coherence over the sense of incompleteness and unknowability and uncontrollability that is so prevalent in ordinary life. Or at least this is its canonical form in the Western tradition. In the Western tradition it often includes strong emphasis on individual rights, what has been called "autonomy unbounded," and a search for an acontextual objectivity: a view from nowhere.13 The result is a lack of emphasis, in medical ethics for instance, on solidarity with those who are disadvantaged and underserved in Euro-American communities and
gility" of ordinary men and women's being-unto-death, which human commonality he suggests is responsible for much of sociality, and the "social precariousness" that is the condition of societies. The latter, in turn, induces powerful responses from the state and its institutions that deepen precariousness. Medicalization, for example, is a response to ontological frailty and social precariousness that worsens the latter. Turner uses this approach to criticize much sociology as "ornamental" and to argue for a sharedness in experience that results from these elements of sociality as well as from the interpenetration of worlds and their hybridity (Bryan Turner, personal communication, University of Deakin, Melbourne, Australia, March 25, 1998). 13 This analysis of the anthropology of ethics draws upon an extended review in Arthur Kleinman, "The Anthropology of Bioethics," pp. 41-67.
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the poorest non-western societies.l4 Indigenous ethical discourses elsewhere do not always share these goals; and, as in the Chinese tradition, they may emphasize the right conduct of the ethically cultivated person -a character trait, albeit a cultural-psychological one -over principle-guided decisions. But they, like the canonical Western tradition, aim to be normative, to offer a "should" and a generalizable "must" about practices. Concern for respecting cul- tural difference has repeatedly pointed up the need for ethical dis- course to project local indigenous alternatives -which anthro- pologists call ethnoethical formulations -into global framings (and vice versa), but there is still great unclarity about how this is to be accomplished.15 14 This point is made by Renee Fox, "More Than Bioethics Alone: Critical Reflections on the Relationship between Medicine, Ethics and Social Science in the Education of Medical Students," First W. H. R. Rivers Distinguished Lecture in Social Medicine, Harvard Medical School, March 10, 1998. 15 Arthur Kleinman, "Bioethics." Certain moral theorists have been particularly sensitive to the issue of moral particularism and cultural differences: see, for example, Stuart Hampshire, Morality and Conflict (Cambridge, Mass.: Harvard University Press, 1983); as well as Amy Gutmann, "The Challenge of Multiculturalism in Political Ethics," Philosophy and Public Affairs 22 (1993) : 171-206. But Gutmann's piece is also an example of the way moral theorists construct ethical relativism as a strawman that is used to limit the seriousness of cultural difference for moral enquiry. A more impressive engagement of moral theory with cultural difference and cross-cultural disagreements concerning lived values is to be found in Michele Moody-Adams, Fieldwork in Familiar Places: Morality, Culture and Philosophy (Cambridge, Mass.: Harvard University Press, 1997). Moody-Adams remarks: "Although inhabitants of different cultures admittedly have different experiences, they can nonetheless contribute to a cross-cultural moral conversation." She also insists that "philosophy must give up its claims to moral objectivity or a special knowledge and must see itself and become part of everyday moral inquiry about `the life worth living and how human beings might attain it' " (p. 1 2 ) . Moody-Adams also notes that "moral philosophy always presupposes a kind of interpretive ethnography" (p. 169) and that "no philosophical interpretation of the structure of - - moral experience not even a systematic moral theory can solve moral problems, but it can influence the decisions and actions of human beings who contemplate the implications, principally by virtue of its tendency to encourage self-scrutiny" (p. 170). All of this sounds congenial for an anthropological approach to moral theory. Indeed, this anthropologically informed philosopher goes so far as to recommend "thick description" as a "suitable appreciation of the contexts and processes of moral inquiry, and of the means by which moral inquiry helps state the . . . claims and practices claimed to constitute morality" (p. 189). And yet while rejecting standard Anglo-American moral philosophy accounts, Moody-Adams castigates cultural relativism. Still, her notion of engaged moral inquiry as moral experience comes close to what I advocate in the last section of the lecture.
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In contrast to ethical discourse, moral experience is always about practical engagements in a particular local world, a social space that carries cultural, political, and economic specificity. It is about positioned views and practices: a view from somewhere and an action that becomes partisan. As local worlds become heavily infiltrated by globalization of the media, of political economy, and of folk and professional culture, so that the global discourse on ethics, for example, becomes hegemonic about such issues as human rights, under globalization moral experience is nonetheless still about the actualities of specific events and situated relationships. At the level of moral processes, accommodation and betrayal may seem to be different empirical options, but they are often made indistinguishable by ongoing compromises and nego- tiations. Local power relationships refract the force of economic and political pressure so that some persons are protected while others are more routinely and thoroughly exposed to the social violences that everywhere organize everyday life. Actions may not be coherent. Relations may be besotted. The sociologic of social roles and obligations and the exigency of situations and sheer personal cussedness may override choice, at least when it is modeled as an individual's rational decision making. The infrapolitics of interpersonal interactions may create conformity, confuse options, and encourage paralyzing perceptions of powerlessness. Irony, paradox, uncertainty, and change are the very stuff of moral experience. But like power, which thrusts particular people to the edge of social life and nullifies alternatives, these frustrating complexities are rarely taken up in ethical framings. Nor are the protagonists of ethical discourse and their ethical arguments understood as grounded in particular moral places and processes. But, of course, they are. And, to be sure, what is at stake in a local world may involve a moral economy of systematic injustice, bad faith, and even horror. Yes; from an ethnographic perspective what is at stake, what morally defines a local world, may be, when viewed in comparative perspective, corrupt, grotesque, even down-
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right inhuman.16 That is to say, the moral may be unethical, just as the ethical may be irrelevant to moral experience. For this reason, consideration of values in society requires both approaches as necessarily complementary. Contributors to ethical discourse are working harder, it now seems to me, to engage the descriptive ethnographies and social historical materials that make up moral processes, as can be seen in the development of situational and processual ethics, which clearly have tried to take concrete local problems into account. And, like most dichotomies concerning the social world, this one blurs when we consider the influence that ethical discourse (local and global) has in informing moral experience. Indeed, the incoherences and fragmentations that the hybridity, interpenetrations, and uncertainty of experience so regularly create are made more coherent and interpretable through ethical discourse. Social suffering, as we will soon see, emerges from the remakes local worlds that need more, not less, ethical deliberation. My point is not to disparage ethics on behalf of the moral processes of experience, but rather to contribute to a more inclusive and availing engagement across these related yet distinctive domains. Inclusiveness here must mean broadening the global discourse so that it considers other traditions beyond the canonical Western one and actively engages the local ethical discourse of participants in a local wor1d.l7 And, of course, nothing that I have said or will
16 Examples might include those described in Christopher Browning, Ordinary Men: Reserve Police Battalion 101 and the Final Solution in Poland (New York: HarperCollins, 1992); Primo Levy, Survival in Auschwitz (New York: Simon and Schuster, 1993); Rezak Hukanovic, The Tenth Circle of Hell: A Memoir of Life in the Death Camps o f Bosnia (New York: Basic Books, 1997) ; E. Valentine Daniel, Charred Lullabies: Chapters in an Anthropography of Violence (Princeton: Princeton University Press, 1997) ; Nancy Scheper-Hughes, Death without Weeping: The Violence o f Everyday Life in Brazil (Berkeley and Los Angeles: University of California Press, 1992). 17 For examples of what I have in mind with respect to engaging distinctive cultural traditions and local ethical discourses, see Kleinman and Kleinman, "Moral Transformations"; Kleinman, "Bioethics"; Veena Das, "Moral Orientations to Suffering," in Health and Social Change: A n International Perspective, ed. L. C. Chen,
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say about suffering and moral disorder is meant to deny that moral processes also involve remorse, regret, endurance, aspiration, courage, transcendence, and other responses that have an ethical and religious significance.18 An idea of "human nature" often underpins ethical discourse, and not just in the Western tradition, inasmuch as it naturalizes and universalizes ethical decision making. Behind the excruciating diversity of cultural contexts and the bewildering inexpediences of social situations, the claim can be made that human nature provides a universal basis for ethical standards and actions.l9 Jean de La Bruyиre, writing in the seventeenth century, ob- served: "In short, Men's souls and passions change not, they are yet the same still as they were. . . ." Denis Diderot, like the other Encyclopedists, claimed : "Human nature is the same everywhere; it determines everything that matters in human behavior; science is the best way to know human nature; science must therefore govern ethics and politics." And reflecting on human nature from a comparative cross-cultural perspective that capaciously encompasses both Brazilian aboriginal shamans and Parisian academic mandarins, Claude Lйvi-Strauss insists: "the outer differences conceal a basic unity." 20 In psychology, in economics, in medicine, A. Kleinman, and N. Ware (Cambridge, Mass.: Harvard University Press, 1994); Tala1 Asad, "On Torture, or Cruel, Inhuman, and Degrading Treatment," in Kleinman et al., Social Suffering, pp. 285-308; J. W. Bowker, Problems of Suffering in the Religions o f the World (Cambridge: Cambridge University Press, 1970) ; and Wei Ming Tu, ed., The Living Tree: T h e Changing Meaning of Being Chinese Today (Stanford: Stanford University Press, 1994). Kleinman, "Everything That Really Matters." 19 It is not my purpose here to comprehensively review the idea of human nature. It has, of course, an ancient provenance, even if Michel Foucault claimed that in its eighteenth-century form of human nature underwriting the rights of man it is a historically recent arrival. During the nineteenth century especially it got caught up with the ramifying cultural discourse on natural history, which increasingly lent to it a biological significance, as in the natural history of plants, animals, and diseases (see N. Jardine, J. Secord, E. Sparry, eds., Culture of Natural History [Cambridge and New York: Cambridge University Press, 1996]). 20 The quotations from La Bruyиre, Diderot, and Lйvi-Strauss are cited in Tzvetan Todorov, O n Human Diversity in French Thought (Cambridge, Mass.: Harvard University Press, 1993), pp. 3, 24, 61, respectively.
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and in other fields the idea of human nature is appropriated as an essentialized rationale for universals, including universal ethical standards. In a rather typical statement from bioethics, the physician-moral theorist Leon Kass writes that medical practice in its engagement with the existential questions of life and death, suffering, and solace "is a matter not only of mind and hand but also of the heart, not only of intellect and skill but also of char- acter. . . . It is rooted in our moral nature." 21 The cultural psy- chologist Richard Shweder and his colleagues, in a controversial essay whose conclusion many anthropologists are likely to contest, argue from a review of the cross-cultural record that moral concerns with autonomy, community, and divinity are rooted in human (or moral) nature.22 But Shweder et al. understand that "nature" not simply as a psychobiological universal, but rather as the coming together of "psychology, experience, and society" to create a pan-human moral orientation. Putative universals in cross-cultural perceptions of colors, preferences in life style, and other psychological processes have been used by sociobiologists to argue for a biological basis to human nature and even to claim an evolutionary source to ethical commitments. Thus, E. O. Wilson, the ever expansive entomologist, writing popularly about "the biological basis of morality," claims that "causal explanations of brain activity and evolution, while imperfect, already cover most facts known about behavior we term `moral.' " 23 Beyond the Western tradition, one can find uses of the idea of human nature in ways that are similar to these statements from the 21 Leon Kass, " `I Will Give No Deadly Drug': Why Doctors Must Not Kill," Bulletin of the American College of Surgeons 77, no. 3 (1992) : 6-17. 22 Richard Shweder, Nancy C. Much, Manamohan Mahapatra, and Lawrence Park, `` `The Big Three' of Morality (Autonomy, Community, Divinity) and the `Big Three' Explanations of Suffering," in A. Brandt and P. Rozin, eds., Morality and Health (New York: Routledge, 1997), pp. 101-18. 23 See E. O. Wilson, "The Biological Basis of Morality," Atlantic Monthly 28, no. 4 ( 1998) : 53-70. Wilson's polemical statement is based upon the idea of a biological basis of human nature, which itself is viewed as the product of gene-culture co-evolution. See also "From Ants to Ethics: A Biologist Dreams of Unity of Knowledge," N e w York Times, May 12, 1998, p. C1.
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West. Thus, one reads in the Chinese philosophical tradition: "only those who are rash in their argument would say that human nature today isn't what it was in the past" or "the passions of a thousand men, of ten thousand men, are ever the same as the passions of any one man" (Xunzi, chapters 3, 5). Mencius, whose disagreement with Xunzi over whether human nature is inherently good or not is fundamental, nonetheless also remarks that all persons possess a number of qualities of human nature and that all must obey the same laws in moral life. Thus, it was characteristic of a major stream of the Chinese tradition to relate xing (physi- cal nature) with qing (emotions) and the moral order.24 Yet biology, once invoked as the source of that unifying human nature, appears to exert such a thin influence in the complexity of human affairs that most of the time it cannot be shown to be immediately consequential. The coarse-grained sentiments of the newborn and toddler may tell us a good deal about psychobiological physiology and its genetic bases, but the complex emotions of social life, such as remorse and regret, are the consequences of crisscrossing meanings, relationships, and subjectivities reworking biology to such an extent that the situation of adults is another case entirely. The front page of the New York Times of Tuesday, March 10, 1998, offers an impressive illustration of the immense disjuncture between the claims made for what is supposedly known about the biological bases of human nature and what is actually known about human conditions (Figure 1). The upper lefthand columns contain a picture of a flood in Elba, Alabama; the middle columns contain an article on a "gruesome" Serbian atrocity in Kosovo. The righthand column tells a tale about Trent Lott, the Republican leader of the U.S. Senate, who is trying to shift blame from Kenneth Starr, the Whitewater independent counsel, whose investigations of Monica Lewinsky's allegations 24 For a review of these arguments, see D. C. Lau, trans., Mencius Vol. 1 (xiii-xxvii). (Hong Kong: Chinese University Press, Hong Kong, 1970), as well Siu-Kit Wong, "Ching in Chinese literary criticism," Ph.D. dissertation, University College, Oxford, 1969.
FIGURE1. Front Page, New York Times, March 10, 1998.
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Lott had earlier decried as too slow, to President Bill Clinton, who Lott demands should now tell "the whole truth." Other stories on page one's layout include an account of political prisoners in Korea, an article on snow and bitter cold in the American Middle West and their effects on everyday life, the details of an antitrust case, and also plea bargaining in the killing of a baby by its teenage parents, as well as an essay on the challenges faced by bilingual education in America's increasingly diverse public schools. Taking up a small space in the lower left column, almost like the bottom line "sum" on a restaurant bill, is a headline about the current status of the human genome project that carries, in light of the other articles, the astonishing title "Mapping the Codes That Define Humans." The irony is extreme. D o political violence in the Balkans, the politics of a presidential scandal, natural disasters and their traumatic consequences, multiculturalism, American business, Korean prisons, and teenage pregnancy and infanticide receive their explanation from what the human genome project's proponents define as the genetic basis of human identity? I find the claim immodest and even ludicrous. Genes would seem to have precious little to do with the major political, economic, moral, and social issues discussed in the other stories, yet these issues are the very stuff of what it means to be "human." Viewed from the decidedly ordinary practices of everyday experience, human conditions certainly have a biology, but they have a history, a politics, an economics, and they reflect cultural and subjective differences. Indeed affective processes -understood in these social psychological terms -turn out to be even more con- sequential for moral processes than cognitive ones -a point made by the great Finnish anthropologist Edvard Westermarck, threequarters of a century ago. "moral values," wrote Westermarck, "are not abstract but relative to the emotions they express."25 25 Edvard Westermarck, Ethical Relativity (London: K. Paul Trench, Trubner and Co., 1932), p. 289.
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"The emotional constitution . . . does not present the same uni- formity as the human intellect," he opined after a review of a then large cross-cultural literature that today is too vast to review comprehensively. Affect and its biology, we might say in the way of an update, however, contribute more to difference than to sameness.26 In other words, moral processes are simultaneously social and subjective, or as I put it earlier, intersubjective, not natural. In place of a single "human nature," the moral modes of experience are more appropriately described by a large variety of "human conditions," particular conditions of social life and personal positioning that contain elements that are shared as well as many, many others that are quite distinctive. Psychobiology, once taken up in language, in symbolic codes, in narratives, in social relationships, and in collective and personal memories, does not specify a universal human nature, then, but rather local mind-body processes that are so open to the social world that human conditions are different, even greatly so, and change as local worlds and our places in them change.27 Biology is important, but in a rather different way than it is customarily invoked by those who appropriate it as the grounds for a universal human nature. My purpose here is to draw critical attention to the uses of the idea of "human nature" in ethics. There it often seems to be a means of begging difficult questions. (The Australian philosopher C. A. J. Coady is skeptical as to whether any authoritative testimony can be given at all about human nature.)28 It just as often seeks to authorize the idea of an autonomous naturalized realm of universals that can be objectively assessed independent of culture,
26 This is a rather large subject, which I have reviewed elsewhere, that would take too extensive a digression to develop here: see Arthur Kleinman, Rethinking Psychiatry (New York: Free Press, 1988). 27 Ellison, "Reproductive Ecology"; Lock, Encounters; Arthur Kleinman and Anne Becker, "Introduction," in "Sociosomatics": Psychosomatic Medicine (in press). 28 C. A. J. Coady, Testimony: A Philosophical Study (Oxford: Clarendon Press, 1992).
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politics, or economics.29 That asocial abstraction, which is so helpful to those who would restrict the idea of justice, for instance, to talk about the intentions of policy makers and the legal language of programs, rather than the unjust distribution of human problems and resources, is an impossibility when we use the socially grounded concept of actual "human conditions." Because I find that concern with ethical discourse far predominates over an orientation to moral experience in programs in values and society, and because my own professional positioning prepares me to do so, in these lectures I take my responsibility to develop the case for experience. One thing that a focus on experience entails is concern for change. For the ethnographer like the social historian, in order to specify a local world and its transformations, it is crucial to understand how moral experience changes under the interactions between cultural representations, collective processes, and subjectivity, interactions that are in turn shaped by large-scale changes in political economy, politics, and culture. Moral experience, then, possesses a genealogy just as it does a locality. Ours clearly is an era of the most pronounced transnational changes, changes that are remaking both the global and the local. The latest phase of finance capitalism has created unprecedented space and time compression, dissolved established value systems and social organizations, fostered the corporatization of professional work and the infiltration of technical rationality into all aspects of domestic lifeworlds, accelerated commodification of cultural processes, authorized entirely new aesthetics, and intensified "volatility" and "ephemerality" of style, products, technology, relationships, and lifestyles.30 As a result, local worlds have been dis-
29 O n the contested issue of objectivity and measurements of attitudes and values relating to an autonomous realm of nature, see the different positions of Amartya Sen and myself in Chen et al., Health and Social Changes. On the question of the cultural history of nature, see Jardine et al., Culture of Natural History. 30 The most impressive case for these effects is found in David Harvey, T h e Condition of Postmodernity (Cambridge: Blackwell, 1990). See also the chapters
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mantled, remade, marginalized, and brought under enormous
global, especially financial and marketing, influence. For example,
to understand the changing forms of suffering and responses to
them, both the three-sided set of local interactions among repre-
sentations, collective processes, and subjectivity and the influence
on it of the broader social forces I have described must be taken
into account. Out of those interactions, as we will soon see, suf-
fering mutates as do our responses to it.
Indeed, among the dangers that absorb the practical attention
of ordinary men and women toward social experience are the
varieties of human suffering. Social suffering has always been a
disquieting part of human conditions, but we are today -thanks to global media coverage -made more intensely and regularly
aware of the anguish and destruction of war, genocide, structural
violence, and the immense disparity of the life ways of the well-
to-do and the truly poor. You no longer need to be an expert in
public health or social development to know that disease and death
are unequally and unjustly distributed in communities, so that
those in extreme poverty-approximately 20 percent of the world's population -bear much higher rates of sickness, disability, and
premature death. That there are 200 million enslaved people in
the world -mostly children forced to work in awful sweatshops,
but also millions of young Asian, African, and Eastern European women sold into prostitution -as astonishing a figure as it is -
may not mean that much on a day-to-day basis in a North Ameri-
can suburb, but high rates of domestic violence, crime, substance
abuse, suicide, sexually transmitted diseases, and runaway adoles-
cents and broken families
There is also better understanding
on social and cultural change in Eric Hobsbawn, T h e Age of Extremes (New York: Vintage, 1994); as well as Saskia Sassen, T h e Global City (Princeton: Princeton University Press, 1991). Recent illustration of an extreme kind is given in a special issue of the New York Times Magazine (March 8, 1998) on "Business Class as a Way of Life." 31 Robert Desjarlais et al., eds. World Mental Health (New York and Oxford: Oxford University Press, 1995).
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that policies and programs aimed at controlling these problems can contribute to and even intensify the misery.32 And there is vague if widely held recognition that commercialism contributes to the sordidness. The frightening implications of a huge number of inner city youth (many of them African American and Hispanic) incarcerated in prisons is but one example, along with failed public housing, welfare, teenage pregnancy, drug enforcement, and immigrant and refugee programs, of the contemporary sensibility that social policies and programs are part of social suffering. Add to this the fear of downward social mobility, of ending up in a dead-end job without benefits, of being let go before a retirement pension becomes operative, of being uninsured or underinsured for health problems and injuries, of being unable to make a go of it as a single working mother or a retired widow, or for that matter as anyone marginal to the information technology that is the leading edge of economic opportunity, and the danger social suffering poses to ordinary human conditions, even in an era of selfpronounced material prosperity, becomes all too real. Among the varieties of suffering that will concern us, illness and injury are also important, because they are among the most frequent and widespread of contingent misfortunes. Read through a list of serious acute and chronic disorders from life-threatening infectious diseases to heart disease, cancers, diabetes, depression, emphysema, Parkinson's disease, stroke, dementia, and the hundreds of other common chronic illnesses from arthritis to psoriasis, add the threat of particular risk factors from moles to cholesterol levels, throw in the congenital and acquired disabilities and the fear of peculiar genetic vulnerability to diseases that cluster in families, add injury and trauma from vehicular collisions and from work and household accidents, and fear of impotence and of iatrogenesis, and also the stark reality of end-of-life care, and you have illustration enough from just this one realm of misfortune of why 32 Arthur Kleinman, Veena Das, and Margaret Lock, "Introduction," in Socia1 Sufferings.
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social experience -for all our use of euphemisms, statistical and metaphoric -carries a sense of danger; and perhaps also of why that sense is so troubling that it is routinely disguised and denied.33 Here then is the social terrain where I will lodge these lectures. W e stand in the thick of human experience, in the space of human problems, in the real-life local places where people live in the face of dangers, grave and minor, real and imagined. Here is where fear and aspiration, desire and obligation, mesh in the close encounters of ordinary men and women with pain and disaster and with the infrapolitics of power that apportion those threats unequally and distribute responses to them unfairly across the social fault lines in actual worlds.
LECTURE I. THE DANGER OF SOCIAL EXPERIENCE: SUFFERING IN LOCAL A N D GLOBAL PERSPECTIVES You grow up in our [American] society and you kind of get lulled into the view that you are protected, things are easy. You can take life easy. Then something happens, and . . . and you come to see just how dangerous things are. I've had it happen several times in my life so I should be prepared. But the only preparation is to be wary . . . all the time. That's why over time you stay very attentive to things at work, in the neighborhood, even in the family. Even in your body. I've been laid off after 20 years with one firm. I've been in a bad, bad car accident. I've experienced the death of a daughter to suicide related to drugs. And now my heart problem. The world is a dangerous place. Maybe even more dangerous than I'm willing to admit. -52-year -old unemployed executive from New York City with serious coronary artery disease My grandfather told it to my father during the Warlord Period. My father told it to me during the war with the Japa- 33 Arthur Kleinman, The Illness Narratives (New York: Basic Books, 1988).
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nese, And I told it to my son and daughter during the Cultural Revolution. H e understood it, but what could he do? H e was murdered. Even in these prosperous times I'm sure my daughter tells my granddaughter: be careful! Be very careful! Times change. History changes. The world is not the same. But social life is always very dangerous. -68-year -old Chinese intellectual from Beijing These two excerpts from research interviews in two very different social spaces are chosen to illustrate the emphasis I have given to the sheer practical relevance of ordinary experience and its orientation around an acute appreciation of local dangers. There is not much question in either instance about what matters and why what matters absorbs the concern of members of a local world. Nor can there be much question about why these dangers are threatening, and why social suffering is perceived as dangerous. This is not because these experiences are natural or universal in some banal sense, but because, given the finite number of ways of being human owing to the constraints of social life (including social psychobiological processes creating certain practical limits in human conditions), we are well aware of the social consequences of these experiences, even while at the same time we cannot be certain what their distinguishing cultural meanings and subjective feelings are like. The excerpts also illumine the intersubjectivity of experience. These dangers, along with the requirement for practical engagement with them, are faced by individuals in networks. They are both outside and inside the person, both social and subjective. Thus, they break down the sharp dichotomy between public and private spaces. Surely, there are public and private spaces at the level of the most macro- and most micro-processes. But much of lived experience in a local world occurs not in that realm of policy deliberation versus the deepest strata of innermost dreams and terrors, but rather in the mediating medium I described earlier as an intersubjective level of words, gestures, meanings, images, feel-
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ings, engagements with and amongst others, including others with whom we are in long-term, even intimate interactions as well as those who pass through our lives obliquely and infrequently, yet with real impact. Our felt experience of the flow of lived time and space is both part of the intersubjective stream of cultural practices and social engagements and part of our inner being. Symbolic forms - lan- guage, music, cultural images -belong to both the social world of values and the interior world of feelings. They link norms with emotions, creating mediating processes that I call sociosomatic.34 I have, at various times, used the image of a tidal stream to convey the interpenetration of the moral and the emotional, the social and the subjective. Experience, like a tidal stream, washes in among the feelings of inner life and rushes out among values, norms, and relationships. Moreover, as fresh water and salt water intermingle but also maintain their own forms in a tidal stream, so too do subjective and collective processes create a mediating world of intersubjectivity while still at times possessing their own characteristics. Social theorists have used different metaphors to capture this basic ethnographic and social historical understanding. Theorists have innovated new terms or revitalized old ones to express this mediating quality of human conditions. Traditional Chinese thought is not the only non-western tradition also to describe lived experience as intersubjective interaction-notably, renqing quanxi, social connections and their affective dynamics -but because thinkers in that tradition (like those in many other non-western traditions) were not steeped in mind-body dualism the dichotomy between body and society did not weigh as heavily on them as it has in the West. Therefore, thoroughgoing interpenetration between the world of values and the world of feelings was not a notion in a marginal intellectual stream but a canonical orientation in the Chinese tradition. That is to say, in traditional Chinese orientations society, body, and self are in constant relationship so that one 34 Kleinman and Becker, "Introduction."
[KLEINMAN] Experience and Its M o r a l Modes
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can speak of moral-somatic and moral-emotional processes: what I am calling today the moral modes of experience.35 That things actually at stake in the social world are interconnected with what is felt to be at stake in one's innermost being does not mean that what is involved is a process of social replication. The relationship between moral engagements and moral sentiments has been described as dialectical, open-ended, and indeterminante. As James Scott has shown, the inner transcript of a person may remain hidden because it resists the dominant public transcript in the infrapolitics of a village, where its open expression can injure that person, and we may extend his analysis to a social movement or a business organization.36 Personal obsession with a perceived threat may seem to have little to do with collective concerns; nonetheless, even an idiosyncratic fear may begin from collective suspicions and surely also may feedback to reinforce or call into question the authenticity of those public worries. What gives our local worlds their immense power to absorb our attention so as to direct our action, sometimes even away from personal interests, into collective projects and thereby force conformity or pressure one to contest and resist local conditions has to do with the character of danger at the core of interpersonal engagement that imparts a legitimate sense of threat to what is most at stake. W e fear that what we hold dearest could be seriously menaced, even lost entirely. Loss of a world, through forced uprooting or massive historical transition, produces a collective feeling akin to grief, a cultural bereavement. Feelings of menace can be a powerfully motivating force for violent actions, as when they are whipped up for political purposes into a frenzy of ethnic nationalist conflict. Feelings of menace occur also in the most deeply personal ways, as when we feel alienated from what was formerly
35 Kleinman and Kleinman, "Moral Transformations of Health and Suffering"; Kleinman and Kleinman, "Suffering." 36 James C. Scott, Domination and the Art o f Resistance (New Haven: Yale University Press, 1990).
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at stake for us and fear that we will float, disoriented, without a
clear stake in things. One may perceive such a fundamental divide
between personal and social orientations that one develops basic
distrust in one's local world. One fears being overcome by others,
forced to betray inner secrets of such vital significance that one
panics over being thoroughly lost or compromised without them.
Over time passionate commitment to a social cause later shown to
be unworthy or worse can yield a deep disquiet of misplaced loy-
alty. The absence of that sense of threat or betrayal can impart
a feeling of comfort with one's living condition, a sense of success
in having crossed over to safety. Joy may arise as much from that
sense of liberty as from its opposite: the resonant feeling of be-
longing to a community of shared faith and practice. Either way,
these are the moral-emotional dynamics of experience.
Ethnographers have also shown that trance and possession
states, rather than alienating members from their social groups,
as a form of personal pathology, frequently offer an authorized
channel for conveying personal problems, criticism, and accusa-
tion into collective space so that they are made more acceptable
and can be acted
Alternatively, this cultural psychology chan-
nel of what we now call dissociation can be seen to make available
to individuals a language and a voice that appropriate collective
fears as authenticated subjective realities. Hence we get two-way
traffic: the social world haunts the person with personified dan-
gers ; the individual animates a legitimate social strategy to express
individual doubt and desire collectively. Thus, authorized mythol-
ogy about demons, witches, and other forms of malign influence
(e.g., today perhaps early childhood traumas or the threat of en-
vironmental pollution) becomes verified states of personal being:
37 Among others, this point is illustrated in the ethnographic descriptions of trance and possession states by Janice Boddy, W o m b s and Alien Spirits: W o m e n , Men, and the Zar Cult in Northern Sudan (Madison: University of Wisconsin Press, 1989) ; I. M. Lewis, Ecstatic Religion: A n Anthropological Study of Spirit Possession and Shamanism (Hammondsworth: Penguin, 1971); Aihwa Ong, Spirits of Resistance and Capitalist Discipline: Factory W o m e n in Malaysia (Albany: State University of New York Press, 1987).
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cultural epistemology becomes local ontology.38 Multiple personalities, chronic fatigue, multiple chemical sensitivities may be our contemporary examples.39 The psychophysiological process of dissociation, then, like memory and emotion, connects a particular outward shape of the social world to particular inward forms of the body-self : in Bryan Turner's arresting terms, "ontological frailty" and "social precariousness" change in relation to each other and in relation to changing societal responses (see note 1 2 ) . I have said that to understand Historical Changes and cultural differences in this dynamic field of local experience we need to understand how cultural representations, collective processes, and subjectivity intersect and change under the impress of the largescale transformations in politics and economics that define an era or a place. I will illustrate this process of change and difference in modes of moral experience with respect to suffering and lay and professional responses to it. The early Christian era provides a serviceable example. Secondcentury Christian discourse fashioned a self that was centered around suffering. Suffering became a religious identification with divinity and a political alternative to the Stoic persona that was a key representation of the self for Romans (for whom suffering was not a virtue). As one historian of religion puts it: "Thus discourse created a new paradigm for understanding suffering and death, and, consequently, the experiential world. . . . Things that had universally been thought bad and contemptible were suddenly seen as valuable. . . . This empowerment, together with the em- phasis on the resurrected body, display the subversive underpinnings of this discourse."40
38 See Allan Young, T h e Harmony of Illusions (Princeton, N.J.: Princeton University Press, 1995); Ian Hacking, Rewriting the Soul: Multiple Personality and the Sciences o f Memory (Princeton: Princeton University Press, 1995). 39 Norma Ware and Arthur Kleinman, "Culture and Somatic Experience," Psychosomatic Medicine 54 (1992) : 546-60. 40 Judith Perkins, T h e Suffering Self: Pain and Narrative Representation in the Early Christian Era (London: Routledge, 199S), pp. 122- 23.
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This was no more and no less than a transformation in subjectivity. The new subjective self took institutional form around the organized collection of funds, administration of hospitals and poorhouses, and experiences of religious transformation. The entire cluster of representation, self, and institutions became a vehicle of political power. Historical studies of witch burning in the medieval period tell a story of a transformation in subjectivity as well. The circle of religious obsession with sin and with the role of the devil, moral fears about the threat of sexuality, the social marginality of certain groups of women, church politics, and the development of new religious institutions reveal a reorganization of cultural representations, collective processes, and personal memory and affect that created a terrifying form of interpersonal experience in European towns and villages that had dire consequences for many.41 By the turn of the Enlightenment not only was witch burning proscribed, but the experiential reality that featured and realized fear of witches, inquisitional practices, and the institutional support of civil authority had disappeared. Consider the possibility that the Nazi era in Germany, Stalin's era of terror in the Soviet Union, and Mao's Cultural Revolution in China as well, perhaps, as the Cambodian genocide and more recently Bosnia's ethnic cleansing might support similar analysis of the transformation of the political, moral, and subjective structure of experience.42 Are the dif-
41 Norman Davies, Europe: A History (Oxford and New York: Oxford University Press, 1996), pp. 566-67. 42This kind of argument is made, albeit in distinctive ways and with varying degrees of success, in such works as those of Browning, Ordinary Men; and Daniel Goldhagen, Hitler's Willing Executioners: Ordinary Germans and the Holocaust (New York: Knopf, 1996), on Nazi Germany and the Holocaust; and see David Apter and Tony Saich, Revolutionary Discourse in Mao's Republic (Cambridge, Mass.: Harvard University Press, 1994) ; and Wei-Ming Tu, "Destructive Will and Ideological Holocaust: Maoism as a Source of Social Suffering in China," in A. Kleinman et al., Social Suffering, on Maoist political violence; and Mark Danner, "Bosnia: `The Great Betrayal,' `I N e w York Review of Books, March 26, 1998, pp. 40-52, and his other pieces on Bosnia in the N Y R B , November 20, 1997, December 4, 1997, February 5, 1998, February 19, 1998, reviewing the major themes
[KLEINMAN] Experience and Its Moral Modes
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ferences in sense and sensibility in different eras simply an example of identifying key features in these changing structures ? Humiliation in the Middle Ages of Christian theological hegemony: was it a means of creating loving obedience as a virtue so as in turn to create subjects appropriate to that time and place, as the social anthropologist Tala1 Asad argues ?43 In the same historical period, we can also easily see that suffering was organized into something profoundly different than it is in Western Europe or North America today: namely, disdain for bodily pain and valuing of suffering of the self (or soul) as a salvational practice. In Colonial New England, Puritan modes of experiencing suffering emphasized discipline, prayer, and the positive virtues of self-negation, reflection, moral regeneration, and spiritual redemption. Suffering was a test of faith; a sign of impaired virtue; an occasion for salvation. Theology and moral practices and bodily sensibility were supported by the community's key institutions: church, school, workplace, family. In New England in the 1990s, where I live and work, the popular culture and leading social institutions support a fundamentally different mode of experience. Pain and suffering, especially chronic forms, are dealt with as if they were without positive value, a thoroughly bad thing. (Sotto voce, I explicitly exclude here the "no pain, no gain" mentality of our sports culture because it appropriates such a thin and limited and nontranscendent notion of suffering.) No one is expected anymore to merely endure pain and suffering. The methods for socializing children and the societal institutions that support moral meanings and practices do not reward endurance of misery or acceptance of the limits of repair and rescue. The salvific potential of suffering is at an all-time low. Even the experiential realities of old age and dying have been reorganized to emphasize that
of the leading works on Serbian atrocity in Bosnia. See also the chapters in Veena Das et al., eds., Violence and Subjectivity (Berkeley: University of California Press, in press); and Daniel, Charred Lullabies. 43 Asad, Genealogies of Religion.
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pain, disability, and the end of living can be so managed as to avoid or minimize suffering, which is seen as extraneous, no longer a necessary part of these terminal realities. When the pope, visiting Cuba for the first time in January 1998, uses the words of suffering of self, soul, and society, they seem almost anachronistic, quaintly out of keeping with the words used by the globalized media, especially those used to describe human adversities. The same commercial processes that sell suffering at a distance, a safe distance, deny that anyone need experience suffering up close - all one need do is buy something to relieve the pain.44 The mix of technology, legal procedure, and policy analysis that is the dominating global technical rationality of our times projects the idea that all forms of suffering are manageable, if in no other way then by insurance and forecasting.45 Perhaps this disguise is what Montesquieu had in mind when he observed "the truth would be a terrible one, and we should have to conceal it from ourselves." 46 Or perhaps what is truly ominous is that our political economy, via advertising, even commodifies this sobering self-reflection. This characterization of distinctive eras is necessarily crude ; community-based studies give a more nuanced understanding. Here the cross-cultural record of ethnography can be cited. In a study of AIDS and poverty in rural Haiti at the outset of the HIV pandemic, for example, Paul Farmer shows how both the local culture of blame and the global discourse of accusation that pointed a finger at Haitians as the supposed source of AIDS at the time led
44 Arthur Kleinman and Joan Kleinman, "The Appeal of Experience; the Dismay of Images: Cultural Appropriations of Suffering in Our Times," Daedulus 125, no. 1 (1996): 1-23; compare with Luc Boltanski, La souffrance а distance (Paris: Mйtailie, 1993); and with Pierre Bourdieu, La misиre du monde (Paris: Editions du Seuil, 1993). 45 Asad, "On Torture"; see also Nicholas Christakis, "The Self-fulfilling Prophecy in Medicine," paper presented W. H . R. Rivers Lecture, 1998, Harvard Medical School, forthcoming, for an account of risk, prognosis, and forecasting in medicine as well as risk and forecasting in society generally; for more on the latter, see Ulrick Beck, Risk Society: Towards a N e w Modernity (London: Sage Publications, 1992). 46 Cited in Todorov, O n Human Diversity, p. 365.
[KLEINMAN] Experience and Its Moral Modes
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to a figuring of the problem in which victims -usually poor rural women -were routinely accused and societal responses to their suffering both minimized their need and blunted their agency because of huge differences in political-economic power.47 Lawrence Cohen's field research in Benares, India, shows that dementia of the aged was earlier neither culturally marked as an experience of suffering nor understood by family members or professionals as a reason for medical (or religious) intervention?48 All that is changing, the teeming humanity of this rich ethnography reveals, as geriatrics emerges as a professional field in India and as the global media present lifestyle alternatives that lead to marketing innovations that change local attitudes to the elderly. The upshot is a socially constructed yet locally experienced epidemic of "dementia,'' Anne Becker's research in rural Fiji suggests that a consistent pattern of social support for women during and after pregnancy, quite different than in North America, makes the experience of postpartum depression virtually absent in Fiji.49 Here cultural representations and collective processes remake the psychobiology of subjective experience to prevent this form of suffering. Linda Green, exploring fear as a way of life among Mayan villagers during Guatemala's era of terror in the 1980s, observes that "memories of horror are experienced as bodily complaints by widows and others as a moral response, an emotional survival strategy, to the political repression they have experienced. . . ."50 The research that Joan Kleinman and I conducted in Hunan among survivors of China's vastly destructive Cultural Revolution showed how three common symptoms -dizziness, fatigue, pain -acted as
47 Paul Farmer, AlDS and Accusation: The Geography of Blame in Haiti (Berkeley: University of California Press, 1992). 48 Lawrence Cohen, No Aging in India (Berkeley: University of California Press, 1998). 49 Anne Becker, Body, Self and Society (Philadelphia: University of Pennsylvania Press, 1995). 50 Linda Green, "Fear as a Way of Life," Current Anthropology 9, no. 2 (1994) : 227-56.
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bodily metaphors of collective and subjective disorientation, exhaustion, and hurt in that exceptionally dangerous time.51 These symptom symbols authorized alternative history and disguised intersubjective remembering of political criticism and social resentment and moral recrimination. Many other ethnographic studies add support to the notion that distinctive cultural representations of suffering and processes of socializing people as sufferers (and as healers) constitute and express different collective and subjective experiences of suffering (or its opposite).52 Shigehisa Kuriyama notes, for example, that "tension" in earlier times in Western history was a "prized virtue, a quality to be sought and cultivated." 53 He goes on to comment on its altered meaning today, where "it almost invariably signals anxiety and alarm. Once upon a time, tenseness announced vigor and health, it declared the power of life; now it speaks of distress, and names a source of sickness." Kuriyama relates the change to both a professional and popular change in understanding what atmosphere is and how it relates to health and sickness. In earlier eras baro- metric pressure in the air was seen to correlate with vitality or its diminution in the body. Kuriyama associates the banishment of vitalism from science and medicine in the West and the use of tension and pressure as social metaphors to talk about "the demands of a competitive marketplace, the pace of modern life," and their health effects on the person with a change not only in dis- 51 Arthur Kleinman and Joan Kleinman, "How Bodies Remember," New Literary History 25 (1994), 707-23. 52 As Marshall Sahlins (Islands of History [Chicago: University of Chicago Press, 1985], p. xiv) configures social experience generally this "structure of conjuncture" involves "the practical realization of cultural categories in a specific historical context, as expressed in the interested action of the historic agents, including the microsociology of their interaction," creating a "relation between a happening and a structure (or structures) ." 53 Shigehisa Kuriyama, T h e Expression of the Body: T h e Divergence of Greek and Chinese Medicine (New York: Zone Books, in press). But clearly the crosscultural picture is a lot more complex. In Greece today, for example, Michael Herzfeld ( T h e Poetics of Manhood: Contest and Identity in a Cretan Mountain Village [Princeton: Princeton University Press, 19851) shows that tension is highly valued and cultivated.
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course but in the experience of health and suffering. Like tension and pressure in the West in earlier centuries, qi (vital energy) in the Chinese cultural tradition, Kuriyama suggests, is a different sensibility that results from a particular cultural constitution of experience. Pressure, tension, and qi may be taken as examples of "local biology." The interaction of psychobiology, cultural discourse, and social institutions such as medicine and business elaborates a distinctive experiential world that includes different sensations, different sensibility, and differences in the common sense understanding of what they signify with respect to health and disease. Indeed, the result of such historical change is a particular cultural organization of body-self-society processes or in other words: a distinctive local biology. In keeping with the analysis advanced in this lecture, such a local biology could also be referred to as a moral biology, one in which the moral, the political, and the medical are inseparable. Anthropological studies in support of this point include notably Margaret Lock's demonstration of distinctive symptoms, meanings, and responses to menopause among Japanese and North American women.54 Other research demonstrates the local patterning of hormonal, cardiovascular, and immunological responses to distinctive social conditions.55 There is also intriguing evidence that in our own times in the West self-expression of the deepest kind has increasingly become a public performance that would have astonished our forebears. Many have been utterly amazed by ordinary people's overt reaction
54 Margaret Lock, Encounters with Aging: Mythologies of Menopause in Japan and North America (Berkeley: University of California Press, 1993). 55 Ellison, "Reproductive Ecology"; Kleinman and Becker, "Introduction"; see also list of references in Richard Wilkinson, Unhealthy Societies: T h e Afflictions of Inequality (New York and London: Routledge, 1996) ; as well as Anne Harrington, ed., T h e Placebo Effect (Cambridge, Mass.: Harvard University Press, 1997); and John Cacioppa and R. Peltt, eds., Social Psychophysiology (New York: Guilford, 1983), among many other relevant works that illustrate, for instance, the effect of bereavement on mortality; variation in mortality and morbidity with religious affiliation and religiosity; and variation in physiological parameters such as heart rates, blood pressure, or T-cell levels across sociodemographic groups.
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of deep emotionality in the public display of private grief that fol-
lowed the death of Princess Diana. But should we be so surprised ?
Clearly we have passed over into a new era: one in which the
highly proclaimed emotional continence of British society of the
past (itself something of a cultural stereotype) has given way to
its opposite. Not only does the inhibited and deeply private sensi-
bility that characterizes Henry James's paradigmatic depiction of
upper-middle-class Victorian Britons and Americans describe a dif-
ferent world, but that portrayal of the world in recent movies like
The Wings of the Dove makes it over into something much more
akin to the way we are
Our globalized age of talk shows,
sit coms, and glamour world photojournalism sponsors a different
subjectivity of self-disclosure, outed performances of arousal, vicar-
ious suffering, and perhaps also a thinning out and simplifying of
grief, shame, and other complex emotions, which, as one commen-
tator wondered, may be "now real only if we are seen having
them?":57 if "human nature" can be so malleable owing to chang-
ing times and circumstances you can appreciate why I question this
overused concept (and the ways it is employed) ; why I insist that
our subjectivities are not fixed any more than is our social circum-
stance or, as we will now see, our alleged moral compass.58
56 Henry James, in his "Preface" to the novel The Wings of the Dove (New York: Scribner and Sons, 1902), describes the sensibility of the character of his age in an extraordinary depiction of the subtlest, most indirect, and complex emotions that emphasizes privacy and continence and elaborate sensitivities that have little to do with the way they are portrayed in the recent film version as overt, singledimensional, and rather coarsely functional sentiments. 57 Adam Phillips, "Grief on Demand," New York Times, Sunday, September 7, 1997, p. E17. 58 Julia Raiskin, conducting an ethnography of a psychiatric telephone consultation service in Moscow in 1997, provides telling evidence of the way historical changes in subjectivity allow for people's selective memory and forgetting and therefore for renarratizing in 1997's Russia how experience was lived in the 1950s and 1960s in the Soviet Union. Here is an exchange between her and two Russian psychotherapists talking about the late Professor Andrei Snezhnevsky, who played a key role in the political abuse of Soviet psychiatry: Psychotherapist A: "I knew him, I was his graduate student. Yes, he loved his students, that is true. But he was one hell of a bastard. H e had these awful squinty eyes and if you disagreed with anything he said he would
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THE MORAL EPIDEMIOLOGY OF SOCIAL SUFFERING IN A DISORDERING AGE Suffering can be called "social" in several senses.59 Their combined significance is to give emphasis to the idea that social suffering can be an index of moral disorder; or put differently, in a disordering time we can speak of the moral epidemiology to which findings on social suffering contribute. First, in what ways can suffering -the experience of going through, enduring, or transcending pain and tribulation -be considered social? To begin with, experiences of diseases, dying, bereavement, trauma from
just throw this awful look in your direction. H e was not half bad a scientist either, he did a lot for the diagnosis of schizophrenia, but he went too far, with the sluggish [schizophrenia, a diagnosis used to label dissidents.]" Julia Raiskin: "What do you think about that as a diagnosis?" Psychotherapist A (pointing at Psychotherapist B ) : "She would know a lot about that. She was the head of a whole department at the KGB Hospital." Psychotherapist B: "It was not the KGB! It was many years ago. Ay, just forget it. Leave me alone." Psychotherapist A: "She was, she was. She will tell you all about sluggish." Psychotherapist B: "It was a diagnosis like any other. Some are really sluggish schizophrenics, their symptoms and all. Of course, it is a category like any other. Somewhere there must have been misdiagnosis." Psychotherapist A: "Somewhere, right there under your nose. I am sure you sent away a few yourself." Psychotheraist B: "For God's sake, just leave me alone. You have to agree that no reasonable person would have opened his mouth in those years. Anyway, do you really think it is better for someone to be sent to Siberia for life, or just to spend a few months in a hospital and then come out and live a normal life?" Psychotherapist A : "You call that a normal life? Your whole life you are on the same insane registry, and that means no work, no traveling abroad. You call scientists' street sweeping a life? I would rather go to Siberia." Psychotherapist B: "It's better than Siberia. I am going to do some work." (She walks out and heads for her cubicle.) (Julia Raiskin, chapter 3, Senior Honors Thesis, Department of Anthropology, Harvard University, 1998) One can see here the way memory and forgetting first suppress and then revivify former kinds of subjectivity and being-in-the-world (as professional collaborators in the police state) that now are neither acceptable nor experienced as real anymore. 59 Arthur Kleinman, Veena Das, and Margaret Lock: "Introduction," in Kleinman, Das, and Lock, Social Suffering.
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natural catastrophes, and violence are most often intersubjective. Think of Alzheimer's disease in an elderly woman, the mother of three adult children with families of their own. Their mother may have such devastating cognitive impairment that she can neither recognize them nor realize the degree of her own disability. Yet they are overcome by their hurt, loss, and frustration. Where is the experience of suffering ? Contrary to our pronounced Western ideological tendency to emphasize the tragedy of a single person, the locus of suffering in this instance and in many, many others is in the intersubjective space between the demented patient and her closest family members.60 In bereavement, in domestic violence with family breakdown, in business failure accompanied by unemployment, and in end-of-life care, it is clear that suffering itself is intersubjective. In that intersubjective space, suffering is taken up in engagement with what matters most. Indeed, what is most at stake may be suffering itself and responses to it. After thirty years of working with patients with chronic illness, their family caregivers, and the professionals who help them, I have come to the strong impression that most of the time cancer, heart disease, diabetes, asthma, depression, and most other chronic conditions evoke an interpersonal experience, a relational style of suffering.61
60 The powerful entailment of the Western tradition's emphasis on the individuality of suffering can lead even such a dialectical theorist as William James to focus solely on the sick person, made more compelling in his case by his recognition that illness, at least as constructed in the West (in this instance his disease), frequently isolates and self-absorbs the sick person to an inordinate degree. "I find myself in a cold, pinched, quaking state when I think of the probability of dying soon with all my music in me. My eyes are dry and hollow, my facial muscles won't contract, my throat quivers, my heart flutters, my breast and body feel as if stale and caked. . . . I have forgotten, really forgotten that mass of this world's joyous facts which in my healthful days filled me with exultation about life. . . . The increasing - pain and misery of more fully developed disease the disquiet, the final strangula- tion, etc., begin to haunt me, I fear them; and the more I fear them, the more I think about them. I am turned into a pent-in egoist, beyond a doubt, having in my spiritual make-up no rescuing resources adapted to such a situation" (cited in Simon, Genuine Reality, p. 296). But as James's own illness experience actually shows, his was as intersubjective an engagement with body and death as it is possible to imagine, with family and friends deeply involved. 6 1 Kleinman. T h e I llness Narratives
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But suffering is "social" in a second, and rather different, sense as well. That is to say, certain mental and social health problems have social roots. Illicit drug and alcohol abuse, related violence, sexually transmitted diseases, many neuropsychiatric disorders, and suicide are on the increase in many areas of the world, rich and poor alike.62 A leading hypothesis is that these conditions are more adequately configured as forms of social suffering that result from massive political, economic, and cultural changes of our era of triumphal global capitalism. This is surely the case with the spread of tobacco and alcohol use, and the health problems associated with such use, in low-income societies. It can also be seen in the statistical correlation of greater infant and maternal morality and child and adult morbidity with the widening gap between the richest 20 percent and poorest 20 percent of the population globally.63 All societies have a health gradient in which by far the greatest burden of disease and premature death is carried by their poorest members. The World Health Organization ( W H O ) calls poverty the greatest killer and maimer of people.64 But while poverty may be the most deadly social cause, it is not the only one. Race in America also correlates (even when poverty is statistically controlled) with worse health and health care outcomes. Hence social suffering is a marker of disadvantage, relative powerlessness, and devastating effects of social change, and in this sense is a moral indicator of cultural or societal disorder. Inasmuch as we are living through a pandemic of mental health and social health problems that is occurring at the very time, we are informed, that economies are growing faster than ever before and societies are becoming materially richer than before, and because that pandemic does not relent but perhaps even intensifies in "richer societies," it is not unreasonable to consider current global political economic and cultural transformations as disordering, a major cause of social 62 Desjarlais et al., World Mental Health. 63 Richard Wilkinson, Unhealthy Societies. 64 World Health Report, 1996 (Geneva, Switzerland: WHO, 1997)
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suffering, here understood as disordered moral experience in a disordering epoch.65 For example, as China, under economic reform and so-called market socialism, has moved from a terribly poor society to the world's most rapidly growing and, as measured by Purchasing Power Parity, the world's third largest economy, rates of alcoholism, illicit drug abuse, violence, suicide (330,000 deaths per year; 40 percent of suicides globally), depression, STDs (sexually transmitted diseases), AIDS, and family and community breakdown are all increasing (see fig. 2).66 Suffering carries yet another, equally troubling social meaning: namely, the way that health and problems such as drug abuse, violence, and the sedimentation of HIV/AIDS, STDs, tuberculosis, and related conditions among the members of the poorest strata of society are divided up and managed differently by the medical, welfare, legal, religious, and other institutions of contemporary society. The result of this division of labor is that institutional responses tend to fragment these problems into differentiated, smaller pieces that then become the subject of highly particularized technical policies and programs, increasingly ones that last for short periods and then are replaced by yet others that further rearrange and fracture these problems. The upshot sometimes can be effective policies and programs. But all too often there is another result altogether. Institutional practices make health and social problems more intractable and deepen both the sense and substance of misery. At the same time, narrow technical categories strip away the moral significance of these problems, and practitioners appropriate the authentic voices of sufferers for their own institutional ends. Let me use one of my own professions -psychiatry -as a sad but telling example. First, I want to make clear that I am not anti- 6 5 Desjarlais et al., World Mental Health. 66 Arthur Kleinman and Joan Kleinman, "Transformation of Everyday Social Experience in Chinese Communities," in Culture, Medicine and Psychiatry (in press) ; Sing Lee and Arthur Kleinman, "Epidemiology of Mental Illness in China," Harvard Review of Psychiatry 5 (1997) : 43­46
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FIGURE 2. CHINA'S MENTAL/SOCIAL HEALTH INDICES (1978-98) Rates over 20 years Alcohol Abuse Illicit Substances Depression STDs HIV/AIDS Violence Crime Gambling Displacement
psychiatry. There are many important contributions that psychiatrists and psychiatric institutions make, including providing more effective recognition, diagnosis, and treatment of mental illnesses than in the past.67 The knowledge base of psychiatry has grown substantially, and with it has come more effective and efficient mental health care for thousands. But psychiatry is in a unique position vis-а-vis other medical specialties; it is the only one for which its core disorders do not have biological markers.68 There is no x-ray or blood test to diagnose a case. Hence the diagnosis of depression, even schizophrenia, and postraumatic stress disorder is decided entirely on interview criteria, making it difficult or even impossible to delimit the borders of these disorders. Thus, when the WHO claims that there are more than 300 million people worldwide at this moment who suffer from depressive disorder, although we know the actual number is high, we do not know how valid this number is. Take the difference between normal bereavement and clinical depression (a pathological state). When I was trained to be a clinical psychiatrist, in the early 1970s, the official psychiatric diag- 67 See Arthur Kleinman, Rethinking Psychiatry (New York: Free Press, 1988). 6 8 Arthur Kleinman and Alex Cohen, "Mental Illness," in ENCARTA Encyclopedia (Redmond, Wash.: Microsoft, 1998).
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nostic criteria in our country taught that normal bereavement lasted for one year. After thirteen months (to avoid misdiagnosis because of anniversary reactions), a bereaved person could be diagnosed as depressed. Inasmuch as the symptoms of bereavement and depression are the same, only the time criterion can determine when the diagnosis is appropriate. Today DSM-IV, the official diagnostic system of the American Psychiatric Association, lists two months as the normal course of bereavement. Slightly more than eight weeks following the death of a spouse, a parent, or a child, a grieving family member is diagnosable as a case of depressive disorder. In fact, the cross-cultural data on bereavement are so thin that it is really not known in a scholarly sense what the course of bereavement is, and how it may vary by age, gender, or culture. Because around 2 million people die each year in our own country, the number of bereaved is quite high. That means that so is the number of potential patients. Does political economy play a role in the institutional conversion of the bereaved into patients? Almost certainly it does. But this is not the only problematic side to this story. What effect does an antidepressant have on the experience of bereavement? What does it mean to the sufferers, to their family members, and to society to convert a moral problem (grief) into a medical one (depression) ? Does changing how we categorize normal bereavement influence the subjective and interpersonal experience of grieving ? Anthropologists and historians of science have described how the idea of "normality" has been expanded from medicine to infiltrate almost every area of society.69 The infiltration has been attributed to the modern nation state and its institutional forms of social control. Now, for example, there is as I mentioned "normal" bereavement and pathological bereavement. This is a process of remaking social
69 Margaret Lock, "Displacing Suffering: The Reconstruction of Death in North America and Japan," Daedalus 125, no. 1 (1996): 207-44; see also George Canquilham, T h e Normal and the Pathological, trans. Carolyn Faucett and Robert Cohen (New York: Zone, 1989); and Ian Hacking, T h e Taming of Chance (Cambridge: Cambridge University Press, 1990), p. 160.
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experience that is called "medicalization." What are the negative
effects of medicalization? Victims may be turned into patients, as
when victims of political violence are labeled as cases of post-
traumatic stress disorder. While this may lead to financial benefits
and services, what is the moral, political, and health significance
of this transformation in social experience? I don't think we know.
When we call a dying patient who is receiving end-of-life-care
for metastic breast or prostate cancer "depressed," we end up in
the same situation. Most patients with end-stage cancers and also
terminal heart disease, liver failure, renal failure, and stroke can
make the technical interview-based criteria for clinical depression,
because their often serious appetite, sleep, and energy disturbances
as well as their pain, agitation, and sadness are produced by their
end-of-life medical conditions and also by the treatments they re-
ceive and by the tribulations of coming to terms with death and
crafting a way to die. But these are the same symptoms as those
of depressive disease. There is no scientific means to separate the
two. It would be grotesque to label all these patients as mentally
ill with depressive disorder: an extreme example of the institu-
tional transformation of suffering into disease. And yet this is in-
creasingly happening. The momentum seems to be inexorable.
Here then is another illustration of social suffering, one in which
professionals and institutions transform the recalcitrance of a
moral problem into the corrigibility of a medical one. Programs
that manage welfare, legal, and religious responses to social suf-
fering tell much the same story. Not only does social power break
persons and bodies in the causation of disease, but it remakes
people into the objects of institutional
Structural vio-
lence and welfare policy, and the cycle of political violence, forced
uprooting, search for refuge, and management of trauma, are tell-
ing instances. Sometimes this transformation is helpful, at other
times it is not. But either way it reveals the inseparability of the
moral, the medical, and the political.
70 Kleinman, Das, and Lock, "Introduction."
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Ethical discourse can play a potentially useful role of reflexive awareness of how an institution and its members come to understand the way societal values and professional commitments influence their functioning. But it is equally crucial to focus on moral processes so that we can come to see how the subjects of institutional practices (as well as the practitioners) are caught up in the very transpersonal processes of social experience that create, sustain, and appropriate suffering. A small but telling example from California is Anne Fadiman's arresting account of how a Hmong family with an epileptic child in Merced, whose loving attention to a seriously ill daughter is quite extraordinary, is made over into child abusers whose child is forcibly removed by this state's governmental agencies not because her physicians are incompetent or unfeeling, but precisely because their high standards of professionalism lead to dedication but also to inflexibility. These cultural standards of practice will not allow them to share control of the treatment, not to grant respect to another cultural reality.71 The prolific book reviewer and social critic Ian Buruma defines another sense in which social suffering holds salience for our times.72 Analyzing the social uses of suffering in the cases of the commercialization of Anne Frank's diary, and in the preoccupation of American Jews with the Holocaust as a uniquely defining religious as well as Cultural event, and in the constant rehearsals of victimization in Serbian national identity that so frequently justify horrific brutality to outsiders, and in the insistent claims by some in the Chinese American community that the Japanese Army's "rape" of Nanking in the 1930s is another "holocaust" to be treated on the same level as the Nazi extermination of European Jewry. Buruma concludes ruefully that ethnic, racial, and
7 1 Anne Fadiman, T h e Spirit Catches Y o u and Y o u Fall Down (New Y o r k : Farrar, Straus and Giroux, 1997). 7 2 Ian Buruma, "The Afterlife of Anne Frank," N e w York Review of Books 45, no. 3 (February 19, 1998) : 4-8.
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national overidentification with suffering (including competition over whose people's suffering is greater) is a powerful collective appropriation that can have dangerous consequences in creating cycles of vengeance, distorting sentimentality, a sense of moral superiority, and failure to come to terms with changed times with new problems and opportunities.73 Buruma's criticisms can be all too readily waved away as a kind of backlash from the unaffected, but he identifies a disturbing tendency. Social suffering, then, points to the intersection of the great cultural and political economic forces of our epoch with human conditions, such that normality and disorder are being recast into new forms of social experience -forms that have as much to tell us about the moral transformation in local worlds and globally in our time as they do about our engagement with and responses to those transformations. Perhaps no other aspect of that transformation is deeper and more dangerous than the changes in subjectivity that affect suffering and our responses to it. I turn now to that difficult and potentially ominous question.
A DEEP AND MOST DANGEROUS TRANSFORMATION I earlier adverted to the changes in subjectivity that in combination with changing cultural representations and collective processes characterize the modes of moral experience of a particular time and place. But what sort of transformation in subjectivity animates and constrains moral experience in our own era in this society ?
7 3 W. S. DiPiero writes in the N e w York Times Book Review (March 8, 1998, p. 4) "a sour whiff of suffering as privilege rises from their [memoirs of suffering] pages, and I feel as though I'm expected to envy or even covet such privilege." Seamus Heaney in his play The Cure at Troy, based on Sophocles' Philoctetes, writes of "the swank of victimhood . . . the wounded one whose identity has become dependent on the wound. . . ." However, the identification by African Americans of slavery and its long-term effects with "time on the cross,'' suffering as an explicitly Christian religious experience, seems to suggest how powerful suffering can be as a source of social movements and change. It is also a reminder of the locality for the coming together of religious, political, ethnic, and individual identity in particular worlds of pain that to outsiders may carry a very different signification.
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Adam Smith in his Theory of M o r a l Sentiments reckoned that pity and compassion were part of human nature.74 They were the primary source of our fellow feeling for the misery of others. As Smith put it with a characteristic balance of jaundiced eye and one big economic reason for expectant faith, "How selfish soever man may be supposed, there are evidently some principles in his nature, which interest him in the fortune of others. . . ." Smith went on to argue that human nature assured that people were the bearers of a much stronger feeling of tenderness toward children than filial piety toward parents -a point whose reversal in the Confucian tradition doesn't lend confidence to our reception of his claim to natural and universal standards. In our own era, the distinguished Canadian moral theorist Charles Taylor writes that "we should treat our deepest moral instincts, our ineradicable sense that human life is to be respected, as our mode of access to the world in which ontological claims are discernible and can be rationally argued about and sifted." 75 Taylor goes on to observe that the modern situation in the West is such that while many con- temporaries concur that "some ground in human nature . . . makes human beings fit objects of respect" (pp. 10-11), that respect has come to be formulated in terms of human rights. As a result, the autonomy of the individual is fundamental to the Western moral outlook, and great importance is given to avoiding and relieving suffering and affirming ordinary life. In this way, questions of personal identity (read subjectivity) and questions of moral action interfuse. "We are," writes Taylor with characteristic concision, "selves only in that certain issues matter for us" (p. 34). And he points to the social space of ordinary life and moral questions that hold considerable resonance with the definition I offered at the outset of experience (p. 35, for example). And yet, for Taylor the
74 Adam Smith, Theory o f Moral Sentiments (Indianapolis: Liberty Classics, 1983 [1759], P. 9. 7 5 Charles Taylor, The Sources of the Self (Cambridge, Mass.: Harvard University Press, 1989), p. 8.
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idea of human nature, despite the social space of moral action and the fact that we come to our identity through historically situated narrative forms, remains crucial. W e have, he avers, an inner "craving which is ineradicable from human life. We have to be rightly placed in relation to the good" (p. 44; emphasis mine). But we have already seen that the case for a single, universal human nature is unconvincing at best. At worst it is a means of begging a greatly troubling question: namely, if there is no fixed and final human nature, then what guarantees, in different times and places, moral responses and responsivity to those in misery and to social suffering more generally ? Here I wish to argue that anthropologically speaking there is no guarantee. Indeed, I believe we are now undergoing, thanks to an unprecedented infiltration of globalization into every nook and cranny of local worlds, a deep and a most dangerous transformation in subjectivity; and such a transformation in personhood, affect, and sensibility, as Taylor suggests, must mean a transforma- tion as well in moral processes -perhaps not on the order of some of the earlier horrors I recounted, yet ominous nonetheless. What evidence is there to support so dismaying an assertion? Elsewhere Joan Kleinman and I have written of the commercial appropriation of images and voices of suffering as infotainment on the nightly news to gain audience share.76 The arresting artistry of photojournalism and the ubiquitous real-time video recorder are making over witnessing into voyeurism. W e are no longer merely titillated by appalling images of brutality, trauma, and carnage. Now we need to see them in order to feel that stories have been authenticated. But these images, to be effective, must be
76 Arthur Kleinman and Joan Kleinman, "The Appeal of Experience, the Dismay of Images: Cultural Appropriations of Suffering in Our Times," Daedalus 125, no. 1 (1996): 1-24; on the subject of the uses of images, see also Martin Jay, Downcast Eyes: The Denigration of Vision in Twentieth-Century Thought (Berkeley: University of California Press, 1993) ; and David Michael Levin, Modernity and the Hegemony of Vision (Berkeley: University of California Press, 1993).
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of suffering at a distance, usually a great distance.77 There is nothing we need do (or in fact can do) in these circumstances. So that both the suffering and our responses to it become gratuitous. Sometimes, as when images involve sexual imagery, there seems to come to pass a stunning conversion of empathy into desire, a transformation that the extraordinary photographic artistry of our age clearly aims to achieve. And so powerful are T V images that they may seem more real than lived experience, so that images provide the occasion for exhibition of moral-emotional responses of a kind previously kept private, as in the outpouring of grief for Princess Diana. Does such a transformation in cultural representation and collective response, under the immense pressure of commercial power, also bespeak a transformation in moral-emotional processes themselves? Are empathy and compassion being thinned out by the sheer enormity of exposure to wounds and horrors? Does the absence of a close connection that demands action mean that we are seeing a dissociation of sensibility and responsivity, of feeling and obligation to be there, to do something, to be engaged? Or put in terms of the argument of this lecture, are those very expectations to be understood as specific to a particular societal configuration of the political, the economic, the psychological, and the moral ? Let me illustrate what I have in mind with a brief tale of something that happened to me last summer. Midnight in an old apartment block. I am drawn by sounds to an open window. It faces onto an interior courtyard. Dried leaves stick to its panes. The heavy midsummer's air fills with sobs, with crying, with the long loud wails of a single female voice. "Dead! D o you want me dead? Is that i t ? Do you want to take everything away from me? Everything in me? Do you? Do you? You go on upward. And what about me? About me? I'm left
77 Boltanski, L a souffrance. Consider also the idea of a proper distance for emotional response in Thomas Scheff, Catharsis in Healing, Ritual and Drama (Berkeley and Los Angeles: University of California Press, 1979).
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behind, damn you, like an old coat . . , Left behind? Left alone! Left to die! Left to die! Ayeh . . . Ayeh . . . Ayeh!" Deep, distressing moans follow. The distraught voice stops me completely with its pain. The wrench of loss sounds absolute. I can feel the ache of breathing broken by sobs reverberate in my own chest! The clutching sensation makes me, an asthmatic, gasp for air. Framed by so muted and minimal a response from a thin male voice, it keeps me still, listening in the darkness, long after an upstairs window snaps shut and all sounds cease. The end of a marriage? The close of a long affair? The tone color of the domestic threnody -dark, ominous, filled with bitter hurt- makes me think it will end as a court case. So much passionate energy overflows that for a few menacing moments I even worry about the risk for suicide; but there is neither direct threat nor action. Nonetheless the thought stays in mind, as it would for a psychiatrist, faint but still present, an indistinct remainder of the danger of words. I am a sojourner in a foreign city, staying in the apartment of others, who are on vacation far away. I know no one here. There is no sensible reason for me to be so engaged with the aftereffects of the commotion. There are no faces, no stories I can affix to the disembodied voices to give them personal shape; no history known to me can bring the event into a context of significance. Yet, inside, hours afterward, I can still feel the anguished pain. Here before me was a riveting instance of break-up and loss; an experience about which I knew nothing and could do nothing, but still I was held by its sheer intensity, its insistent force, which caused the sounds to echo down the corridors of memory, drawing taut the filaments of sympathy. But still, the anonymity of the occasion leaves an aftertaste of lingering disquiet. I am but the spectator of a transitory event. One that has for me neither a beginning nor an ending. Nothing is required of me. There is freedom to listen in or not, but no responsibility, no obligation to be engaged. Now this can happen to
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anyone at anytime. But suppose we are repeatedly experiencing such anonymous suffering. Owing to the global changes in communication, travel, entertainment, and the like, suppose we are recreating the world so that we are awash in exposures to suffering that are primarily gratuitous. What then does it do to us ? Does it eventually lead us to tune out, close off, and disregard? Does it alter the moral response to suffering? Musing in the early morning quiet, I think back to a TV news program I saw some months before. Film flickers across my memory of wounded refugees dying in the bush in a Zaire that no longer exists. One of the wounded, a teenage boy, speaking very quietly, almost inaudibly, his ebony face an immobile mask of resignation, recounts the horrors his family has experienced on the long, long journey. The commentator mentions the uncertainty of whether this victim was also, earlier, a victimizer. The film clip ends on this point of uncertainty, a fragment of pain followed immediately by an advertisement for beer. Healthy, playfully happy, eroticized white bodies frolic at the beach. The juxtaposition of real agony and commercialized joy, black and white, is shocking. Is there a message here? Is it that experiences come and go, some die, some have fun, it's all a matter of switching channels? Is it a commentary on the lack of moral engagement? Nothing need matter to the viewer, save self-interest. Am I worrying over a sign of some fundamental rupture in what I had been educated to believe to be the existential order of things? Has there been, imperceptibly, a seismic shift in the self and in moral sensibility? So that the rock-certain claim about the Judeo-Christian tradition of the late European ethicist Emmanuel Levinas, that moral practice begins with the empathic suffering of the witness in engagement, in solidarity with the sufferer, no longer holds, because we have changed in some basic way?78 If this is our new condition, what would be the implications of such a change in 78 Emmanuel Levinas, "Useless Suffering, In The Provocation of Levinas, ed. R. Beraconi and D. Wood (London and New York: Routledge, 1988).
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subjectivity, in who we are, when writ large as a transition in society's collective sensibility and behavior ? Can a disordering time such as ours break Western societal traditions of human engagement and substitute in their place something more sinister, more destabilizing for our future, as has happened in the past and is still happening around the world ? Here you have the question at the heart of this exploration. W e live in a time of immense transformations in financial systems, in trade, in communication, in technology, in transportation, in global culture-transformations that in turn are reshaping societal structures such as the city and the workplace and the home as well as creating new lifestyles and perhaps even new forms of behavior. The unsettling compression in time and space and the fragmentation of cultural practices and confusion of virtual and lived reali- ties that characterize this age -are they also altering the collective and personal poles of everyday experience? If there is reason, as I believe there is, to justify such a query, what significance does a potential change in the ordinary existential roots of experience - the way we feel and act -hold for our understanding of moral questions and practices? Either human nature is malleable to a degree we have never imagined and we are participating right now in a sea change in its elements, or our era, like other momentous times of epochal change before it, is ushering in another form of subjectivity altogether, a new type of personhood. Suppose this were the case. Several objections to this train of thought can be lodged, of course. Globalization also carries with it greater attention to international relations, greater familiarity with other cultures, and arguably more respect for differences (e.g., in ethnicity and gender). And one can point almost endlessly as well to evidence that all of human history has its share of misery, in response to which not only has empathy been tested but, at crucial points, it has failed. Forgetting and denial have made the moral effects of such failure tolerable, allowing ordinary men and women to live
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through bad times while not feeling such despair that they have given up or experiencing such hypocrisy that they have annulled projects of tradition and modernity of those who follow them. Global social change is indeed complex, multisided, and likely to have several (perhaps contradictory) effects. The alteration in collective and individual experience that I have identified may be offset by other changes. Nonetheless, for all that, the transformation of moral and emotional processes seems real enough and consequential. That it is flanked by other changes with potentially different effects makes the story told in these pages both more complexly human and more interesting. It is reflections like this one that in past eras and in other societies have led concerned people to wonder aloud whether such changes can be fundamental enough to cause the loss of the human.79 There is a sense today that this fear of the loss of the human is not entirely romantic or unwarranted. Like some universal solvent the disordering effects of advanced capitalism appear to be dissolving much that really matters to ordinary men and women globally. Is this merely an essentializing millenarian dismay? Is it the kind of apperception of danger to what is at stake that I characterized earlier as itself a spur of desperate and inhuman acts? Or is it our enormous preoccupation with, say, the threat of alien invasions that is itself a sign of our recognition of the alien lineaments of our time and even a self-reflexive sensibility that we are ourselves becoming alien ? So much depends on maintaining the fiction that nothing has changed all that much. That at base we can change political economy, political practices, technology, social institutions, and cultural forms, and yet ourselves remain the same. Because that is the way
79 I am indebted to Gerald Bruns for this idea; but I accept responsibility for the way I use it here, which differs in a fundamental way from Bruns's sense that there may be a useful effect of widening and remaking what is meant by the "human" within a moral community. See his Roger Allan Moore Lecture, "On Ceasing to Be Human," Department of Social Medicine, Harvard Medical School, April 23, 1998.
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things seem to have been and will be. But things clearly are not the same. What if it isn't just material things like information and entertainment technologies that are different, but relationships and sensibilities and all the other dense package of moral-emotional things that constitute and express subjectivity, intersubjectivity, experience? I realize I may not have convinced you that there is a widening gap between the witnessing of disaster and the feeling of an obligation to respond. I simply don't have the space needed to review the various sorts of data that would be necessary to better substantiate my case. In any event, nothing but the years to come will show if this be prescience or alarmism. Rather, I want to spend the second of my lectures to address the chief implication of this analysis for scholarship, for practice, and for policy. My purpose here is not to level a moral indictment of our times, not to conjure up prudishly the tawdriness, the squalor, or the horrors that would make for a fin-de-siиcle call for moral rejuvenation. Actually, there are many positive sides to our epoch-in technology, in social policy, in legal procedure, in respect for cultural, gender, and other difference, and even in other domains where self-reflective awareness is ramifying -that do at times make me feel cautiously optimistic about other aspects of our future.80 No, rather I seek to press home the point about a transformation in experience and its moral modes in order to figure out what that transformation specifically may mean for practices, policies, and programs concerned with social suffering.
80 See, for example, Alan Wolfe, One Nation after All (New York: Viking, 1998).
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LECTURE II. THE MORAL, THE POLITICAL, A N D THE MEDICAL: ETHNOGRAPHIC AND CLINICAL APPROACHES TO HUMAN ENGAGEMENT
Images in the popular media are not the only materials I can present to make a case for a moral mutation in experience. Take my own field of medicine, and the patient-practitioner-family relationship that is so central to health care. The managed care revolu- tion that we are living through today -a transformative part of transnational political economic developments -in its unprece- dented search for efficiency (and profits) has altered this core clinical relationship almost beyond recognition and raised a serious question as to whether the core skills of doctoring can be preserved. (Of course, managed care has also done certain useful things like reduce unnecessary medical costs and improve regulation of practice standards.) A typical scenario in managed primary care is that a physician has between twelve and fifteen minutes to see a seriously ill patient on a follow-up visit for a complicated chronic condition such as diabetes, cancer, heart disease, or clinical depression. During that time the clinician needs to check the results of blood tests and other lab values, read the x-rays (or the radiologist's report), take a history of symptoms, current functioning, and response to new treatments, perform a physical examination and write prescriptions, and plan the further course of care (including rearranging a regimen of diet, exercise, and lifestyle, making referrals, discussing disability assessment, and the like) . There is such a compression of time that there is hardly time to accomplish these tasks. There is literally no time to do what that clinician has been trained to do to provide quality care: namely, solicit the patient's illness narrative, engage the emotional, family, and work issues that together constitute the social course of the disorder and the response to treatment, and communicate sensitively about the prognosis and next phase of care. Engagement with issues of cultural, religious, gender, and other sources of dif-
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ference in clinical case management that requires additional time and effort is almost certain to be short-changed. The practitioner, that is to say, cannot adequately deal with the patient's suffering. The upshot, as we are now becoming aware, is frustration, anger, and a deep sense of disaffection on behalf of patients, family members, and practitioners. That is what these voices mean to convey: They rush me in for a visit. There is hardly time to talk about what is happening. No one asks anymore how I am feeling. And then I am rushed out. I don't get a chance to tell all that has happened. Or even to ask about what is coming next. I am very angry and very disappointed. What good does it do? -65-year -old man with worsening diabetes and associated kidney, visual, and metabolic problems You would think I was irrelevant to my disease from the way I get treated. Nobody asks me about my ideas. When I make a suggestion, it's taken as if it came from left field. It makes me angry, and it makes me want to do something, anything really to show them that I am part of this. Sometimes I purposefully miss an appointment or don't comply with the treatment- as silly and futile as it is. I'm sore because I want to have my opinion respected, taken into account. -39-year -old college teacher with a chronic intestinal condition I'm just so angry at them. They don't listen. I want to shake them by the scruff of the neck and tell 'em: Here, don't you disregard me. What can you d o ? They make me so angry sometimes that I want to stop coming , Sometimes I don't show up. But it only makes things worse for me. -64-year -old mechanic with chronic liver disease My mother is 93. She doesn't hear well. She needs someone to speak with her who can slowly explain what her dizziness is about and why it is so difficult to control. But the doctors and nurses don't even seem to have the time to speak to me so that I can explain to her what's happening. It's very frustrating. How can they use the word "quality" to describe the care she gets ? But there is no alternative. -55-year -old woman who is a real estate agent
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I was so scared that they would not give my dad all he requires. They might write him off. Another 80-year-old. Time to pull the plug. I read the papers. I know what doctors are doing to keep costs down, and to ration care. If you don't push 'em, you don't get what you should. Well, I pushed 'em for Dad. I simply don't trust people in the hospital. I watch what they are doing and I speak up. -40-year -old African -American lawyer whose 81-year -old father was in a teaching hospital with stroke and heart disease Something very deep and very bad has happened, is happening to medicine. There is so little time, and so little emphasis on spending time with patients, talking to them, asking about their problems, explaining what needs to be done, responding to their fears and wants. It's all a new language: cost, efficiency, management talk. This isn't the language of clinical practice I was trained in. I feel frustrated and very, very alienated. I'm beginning to think it is not for me. I need to get out of it. -60-year -old primary care physician in a managed care practice in a Health Maintenance Organization (HMO) W e all know medicine is going through a revolution. But you like to believe -have to believe -that the change off sets only the nonclinical aspect of care. But that's preposterous. So we can't even tell ourselves lies we can believe in. My institution doesn't seem to value any longer those things I was trained to believe are central to good care: a close trusting relationship with your patients, good communicative skills, enough time to talk things over with patients who are going through bad times with their diseases, attention to what bothers them. That is not only the "soft" side of care. You need to do these things because they really are essential. And if you don't, don't do them I mean, then what kind of doctor are you ? What kind of care are you giving? It's really a moral issue. The managed care institution with all its paraphernalia has become more important than the patient. The relationship should be called "patient-doctor-managed care provider," because we spent most of our time on the management issues. I think that is a dangerous slide in the moral content of doctoring. -48-year -old primary care physician in a large HMO
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Sometimes I feel like a hypocrite. I am standing up before a room of medical students and teaching them things about communication and psychosocial skills in doctoring, and acting as if they have the time to do these things once they get into practice. They don't; they won't! They can't take the time, and they will not get the support they need from practice managers to do the things they know how to do and know they should do. So there we are. That is medical education today. Wouldn't you call that a pedagogic crisis? But for a medical educator it is also a moral crisis. What to d o ? 57-year -old medical educator at a leading American medical school
Of course, I have selected these excerpts from interviews to make my point. They are a biased sample. Some of the same complaints have been leveled against medical practice for a long time, well before the current era of managed care and the corporatization of medicine. The problems may be intensifying, yet they have been around for decades. But I could provide many, many more complaints in support of the overall theme. The engagement with patient and families' experiences of suffering appears to many to be thinning out and even disappearing under the managerial pressure of Health Care Financing and delivery "reform." The change is a change in the clinical relationship (and in self-identity of the health professional from healer to businessperson, technician, or bureaucrat), but over time it also shapes expectations and practices so that the intersubjective experience of clinical care is changing. (Is self-identity of the patient also transmuting from sufferer to consumer and co-payer and commodified object of technological and managerial manipulation ? ) That change is a transformation in the moral processes of illness experience and doctoring. In the social transformation of American medicine today, several things are happening in concert. The human engagement with pain and suffering is being reformulated, as part of a century-long institutional transition, into purely technical issues that are man-
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aged by technology and technical rationality. Thus, the ethos of end-of-life care is being converted from a religious and moral one into a psychiatric question of using psychotropic medication to treat clinical depression. At the same time, the political-economic transformations of health care financing and delivery are compressing time to a minimum that is consistent with the greatest efficiency and profits. In that squeeze moral processes in the patientfamily-doctor relationship either are left unaddressed or are converted into their technological equivalent, professional ethical discourse, which itself has become a subspecialty of biomedicine (to wit: bioethics), and subject to some of the same pressures of time and efficiency. Hence the curiously disquieting image of the clinical bioethicist, beeper in hand, responding to emergency pages to render definitive ethical judgments immediately so that business can get under way expeditiously. In either case, there is in practice a revaluation of values. But the revaluation is not out of keeping with cultural and political processes in the Western tradition - not at all. Thus, mind-body dualism, with its supporting ideas of the body as a machine and rejection of matter (physical stuff) encompassing spirit, points the way toward the transformation of medical care into industrial models such as the servicing of automobiles or the training of airline pilots in safe practices. And this moral transformation of meanings and experience works hand in glove with the political-economic transformation of medicine into more highly institutionalized systems in which the proletarianization of professionals and the commoditization of health and health care are tied up with greater bureaucratic efficiency and control.81 The deep connections between the moral, the political, and the medical are particularly visible in the management of pain, par-
81 In this sense of the triumph of managerial and institutional rationality as a source of "efficiency," we are watching the working out of the Weberian forecast for society as a whole within medicine, perhaps the last major holdout from the dominance of technical rationality and institutional control (see John Patrick Diggins, M a x Weber-Politics and the Spirit of Tragedy [New York: Basic Books, 1996], pp. 12-16, 99-101, 106-9).
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ticularly chronic pain. Elaine Scarry has tellingly put it for our Western tradition: "So, for the person in pain, so incontestably and unnegotiably present is it that `having pain' may come to be thought of as the most vibrant example of what it is to `have certainty,' while for the other person it is so elusive that `hearing about pain' may exist as the primary model of what it is `to have doubt.' Thus pain comes unsharably into our midst as at once that which cannot be denied and that which cannot be confirmed." 82 The problem of pain is posed as a cognitive one: a truth that cannot be denied and cannot be confirmed. It is established as the kind of issue that requires legal procedure. No wonder so many chronic pain patients complain that medical care has failed them because they feel they are treated without respect for their suffering and without trust, as if they were deliberately deceiving their caregivers. Ask physician pain experts and you all-too-often see the mirror-image: complete distrust of patients' complaints.83 Surely, there is another way to proceed here. The value commitment of engagement with the person in pain that holds for practitioner or family caregiver in various formulations of ethics and the moral requirement of such engagement in many local worlds of medicine are not the same as the rational technical detection of truth or deception. Acknowledgment of the words and feelings of the other in pain is what is called for.84 Failure to acknowledge the other's condition is a moral (and cultural) failure, no matter what is the cognitive issue at hand. Ethical discourse about the principle of beneficence is not what I have in mind; but rather a reform in local moral processes and in the application of ethical formulations for those circumstances.
82 Elaine Scarry, The Body i n Pain (New York: Oxford University Press, 1985), p. 4. 83 See, for example, Marian Osterweis, Arthur Kleinman, and David Mechanic, eds., Pain and Disability (Washington, D.C.: American Academy Press, 1987). 84 See the way this point is made by Stanley Cavell, "Comments on Veena Das," Daedalus 125, no. 1 (1996): 93-98.
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Take the Confucian approach to suffering, as a telling alternative. Mencius remarked, "For every man there are things he cannot bear. T o extend this to what he can bear is benevolence (or humaneness) '' (VIIB: 31). Wei-Ming Tu has shown that this implies, on the moral level, engagement with others' pain and suffering.85 It is the extension of the moral-emotional capacity of the person to engage the other that is the issue. That exercise of human capability begins with acknowledgment and includes embodying the experience of the other's pain as compassion and responsiveness. The Jewish and Christian religious traditions in the West also contain a central commitment to the idea that the suffering other is to be engaged with compassion, so that, as Levinas puts it, the suffering of the witness on behalf of the sufferer provides the moral usefulness of the latter's plight.86 "For Levinas," as Gerald Bruns so tellingly puts it, "the face-to-face [relation] is an ethical [in our terms `moral'], not a cognitive relation; it is ethical precisely be- cause non-cognitive. . . . `The face [of the other] speaks to me and thereby invites me to a relation incommensurate with a power exercised.' . . . This incommeasurable relation is that of the ethical claim."87 Levinas insists that there is no human nature; every human being (and every human relation) is unique and refractory to categorization.88 Tala1 Asad, an influential anthropologist of religion, argues that the hegemonic global ideology of the present time -namely, an amalgam of technology, the technical rationality of policy deci- sion making, and legal procedure -drives such religious and ethi- 85 See Wei-Ming Tu, "A Religiophilosophical Perspective on Pain," in Pain and Society, ed H. W. Kosterlitz and L. Y. Terenius, Dahlen Conference, 1980 (Weinheim: Verlag Chemie Gmbh, 1982), pp. 63-78. 86 Levinas, "Useless Suffering." 87 Bruns, "On Ceasing to Be Human." 88 Bruns (ibid.) cites Stanley Cavell's The Claim of Reason (New York and London: Oxford University Press, 1979), p. 397, as a further development of this position on the primacy of moral engagement with others: "Being human is the power to grant being human. Something about flesh and blood elicits this grant from us, and something about flesh and blood can also repel it."
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cal framings of suffering as well as their consequences in moral processes out of the mainstream and onto the sidelines.89 This analysis is in keeping with Max Weber's argument that institutional forms in society would come to occupy a central place because they would be the strongest source of rational technical control and its efficiencies. The result would mean that religion, tradition, sentiment, and the ad hoc would be deprived of a central place in public discourse and in social process, in favor of the hegemonic rational technical discourse.90 In both visions, intersubjective moral processes in human relationships would lose their centrality, or rather would be reframed as cognitive questions for bureaucratic adjudication. This would seem to be an accurate portrayal of what is happening in the health care domain, and perhaps this reframing is happening even more generally in everyday social life. But if this is the reason why the current coming together of the medical, the moral, and the political is creating a problem for moral experience, then what alternatives are there that would sponsor a different and more humane approach to clinical practice, and more generally in human interactions? In this lecture, I seek to address the questions by employing an anthropological understanding of ethnography (and of clinical work as a kind of ethnographic application) as a model for moral engagement.91 CONCLUSION: MORAL ENGAGEMENT -ETHNOGRAPHY AS A HUMAN PRACTICE Ethnography is an engagement with others that brings the ethnographer into the ordinary, everyday space of moral processes in a local world. As part of the anthropological program, ethnographic description and interpretation is called "experience near" ; it precedes from the general to the particular, and only after privi-
89 Asad, Genealogies of Religion. 90 Denis Wrong, "Oversocialited Conceptions of Man in Modern Sociology," in his Skeptical Sociology (New York: Columbia University Press, 1976), p. 247. 91 Arthur Kleinman, chapter 1 5 in T h e Illness Narratives.
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leging the local does it extend back to a general framework that enables comparisons. The ethnographer, no matter how successful she is in participant observation, is always an outsider. She will come to understand local categories and even perhaps to feel the weight of local obligations, and she will almost certainly at some point get caught up in the give and take of daily life, but, for all that, she is not so fully absorbed by what is most at stake for local stake-holders that their world of experience becomes hers as well. She is aware (often acutely so) of that difference, that separation. (This even becomes true for the indigenous ethnographer.) Indeed, the ethnographer feels the pull of ties that bind her elsewhere, to her own network and to the world of scholarly discourse. That creates a defining marginality, and perhaps is one reason why many anthropologists end up studying marginal persons and groups. Even her involvement with global processes differs from that of those around her. And it is this positioning that makes ethnography, despite certain limitations in reliability of its findings, an interesting approach for moral theory -one that also holds potential significance for practice and policy. What is special about ethnography, then, is the practice it realizes, not the qualities of the ethnographer. With respect to the subject at hand, the ethnographer can claim no special human virtues, and history shows that all sorts of people have taken up the practice with varying results. What they do share usually is the burden of the almost impossible requirement of participating in local moral processes yet also being outside them. This form of insider-outsider engagement with a world of social experience has led to ethnographers being described, especially in earlier eras, at worse, as double agents or, in a somewhat nicer expression, professional strangers. It is not easy on the ethnographer, or on her informants and friends. But it confers, in this instance, one large advantage. The ethnographer's angle of exposure places her so uncomfortably between distinctive moral worlds and local and global ethical discourses and, what is more, creates such a destabi-
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lizing tension between them that she is forced to become, even at times it seems from published accounts against her will, selfreflexively critical of her own positioning and the commitments and problems it leads to as well as attentive to the new and unexpected possibilities that can (and so often do in real life) emerge. The situation is clearest with respect to moral processes, which, as I have described them here, could be said to be the actual stuff (the subject matter) of ethnographic enquiry, even if many ethnographers have used other names or categories to deal with them. The ethnographer's very marginality, as professionally discomfiting and personally burdensome as it often becomes, enables a comparison of the moral processes she comes to understand (withstand?) in her fieldwork with the moral processes that she is usually so taken up with in her own world that she (like most of the rest of us) takes them for granted to such an extent that they operate behind her back. There are probably other forms of engagement that give somewhat similar access to the moral modes of different worlds of experience -psychotherapy, social history, comparative religion, cross-cultural medicine, certain forms of literary criticism come to mind (not to mention the experience of immigrants) -all of which either share the comparative method or create the opportunity for destabilizing comparative engagement with experience of equal depth. But for the purpose of this analysis I will focus on ethnography. Besides the critical self-reflection on different cultural processes that it realizes in actual interpersonal engagements, ethnography more or less demands that the ethnographer take both indigenous ethical discourse and global ethical discourse into account simultaneously, and also that she examine how both are rooted in particular forms of moral experience. That ethnographers often find ways to avoid the responsibility must be one of the arresting ironies of scholarship. The disciplined professional skill with which the ethnographer tries to get things right from the native point of view means that ethnographic description can at best establish eth-
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noethical categories and describe how they are deployed in indige- nous ethical discourse and relate to global framings. Were most ethnographers better prepared in ethical discourse, they would be in an almost ideal place to project the local into the global (and vice versa). This is the scholarly contribution that ethnographers could make to moral theory. Because ethnography, at least as I describe it here, is not merely a social science methodology, and a demanding one, but also an intrinsic part of social and cultural anthropology, if moral theorists decide they wish to participate in this approach they need training in anthropology. Ten years ago, in The Illness Narratives, I suggested that clini- cal work can be modeled on ethnography.92 I went on to describe how clinicians can undertake a mini-ethnography of the illness experience and interpretation of illness narratives as both collective and individual to the benefit of care. In particular, I sought to emphasize the ethnographer's willingness to listen to others, to solicit and attend to their stories, and her skill in getting at what matters to people going about all the things that make up everyday life. I thought that this disciplined yet open-ended engagement could be a model for caregiving. But because of what I have already said about the dire effects of the managerial transformation of health care services on clinical practice I have no illusion that this is feasible under the current regime of the corporatization 92 Ibid. In recent years the call for ethnography in bioethics has become louder and voiced by many. See, for example, Barry Hoffmaster, "Can Ethnography Save the Life of Medical Ethics?" Social Science and Medicine 35, no. 1 2 (1992) : 1421­ 32; and multiple authors writing in Raymond DeVries and Janardan Sabede, eds. Bioethical Society: Constructing the Ethical Enterprise (Upper Saddle River, N.J.: Prentice Hall, 1998). But as Renee Fox and Raymond DeVries, writing in the same volume, point out, this new fashion has raised so much enthusiasm that the point is often missed that ethnographic study is a scholarly discipline requiring rigorous training and disciplined application (p. 275). In a recent workshop on "Ethics, Medicine, and Social Science," Harvard Medical. School, March 12, 1998, the same resonant interest in ethnography within bioethics and same caution were raised. Here I am less interested in the example of ethnography as a research method based in social theory and anthropological training than I am in the sensibility that ethnography requires of (and creates for) the ethnographer in the actual practice of doing fieldwork. (But see note 95 for a brief reflection on ethnography's contributions to scholarship.)
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of medicine. Nonetheless, ethnography still seems to me appropriate for educating medical students about illness as experience and for the practice of medical ethicists. And there are now available several impressive models of what this practice entails.93 Ethnography as ethical practice in health and medicine, then, is a growing concern that deserves another lecture all to itself. Not the least of its potential contributions is that it makes unavoidable the moral requirements of doctoring, which are so readily distorted by analytic preoccupation with business practices and technical efficiencies. In the complex, changing, diverse, and divisive local worlds of our era, the uneasy, divided sensibility that ethnography brings of being both within and without the flow of experience is not inappropriate modus vivendi. The ethnographer's self-reflective criticism of her own positioning and its limitations, her hesitancy to prescribe interventions, at least until their human consequences can be better understood, her newly emergent readiness to make a commitment not just to study others, but to engage them and to witness their problems so as to be of use (based as it would be in her acutely dismaying understanding of the failure of earlier generations of fieldworkers to do so), and her willingness to compare local processes and nonlocal discourse so that they can come into relation with each other are not irrelevant to the thrust of argument in this lecture. Nothing about ethnography is anything like a panacea or proven preventative. Yet, in the absence of any ultimate guarantee of compassion and willingness to acknowledge and respond to the suffering of others, the epistemological scruples, the ontological uncertainties, and the moral sensibilities (and predicaments) of the ethnographer offer themselves up as one means (limited and unpredictable though it be) of sustaining empathy and engagement that deserves serious consideration. That is to say, the ethnographer is "called" into the stories and lives of others by
93 The "Ethics, Medicine and Social Science" workshop featured the ethnographic contributions of Veena Das, Barbara Koenig, Charles Bosk, Renee Fox, Nicholas Christakis, Mary-Jo Delvecchio Good, and Alexander Capron, among others.
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the moral process of engaged listening, the commitment to witnessing, and that call to take account of what is at stake for people becomes an instructive aspect of the ethnographer's sensibility. Were this sensibility to be encouraged among ordinary men and women as a mode of moral experience (and ethical reflection), would there be the possibility of a countervailing social process in our globalized times? Could it broaden the horizon of moral imagination so as to encourage engagement with the marginal and solidarity with the afflicted? The expectation of what could be achieved would, of course, need to be quite limited, in keeping with the modesty of an anthropological intervention that amounts to rather little when put up against the driving force of political-economic, technological, and social-institutional change in our disordering epoch, or the equally dangerous political and religious and ethnic-nationalist fundamentalisms that have intensified in order to resist such transformation. The only thing perhaps to recommend it is that it is the only thing I can think of that emerges from (and seems valid within) my own circumstances. Some of us have argued for such an ethnographic moment in policy and programs directed at social suffering.94 The obstacles to the realization of that moment are formidable, because the language of policy is so powerfully controlled by economics and decision analysis and legal procedure that it is difficult to pry open even a small space for ethnography. Nonetheless, efforts are underway to try to produce a change. What I am now suggesting is that the ethnographic approach be developed more generally as a means of teaching about moral processes and examining their practical implications.95 How this might be accomplished in a society
94 See Kleinman, Das, and Lock, "Introduction"; and Desjarlais et al., World Mental Health. 95 That brings us, at the close, to scholarship. Ethnography is, in a certain way, a backward-looking methodology, more nineteenth than twenty-first century. It emphasizes face-to-face engagements, including both indirect participant observation and direct interviews, with a relatively small number of informants. It takes time, a good deal of time: months and years, not days or weeks. It tacks back and forth
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such as ours goes far enough beyond the limits of this lecture to suggest that it would be most prudent to break off here with merely the barest outline of this modest proposal. Yet I do think that it may well be in the sphere of applied moral theory that ethnog- raphy, pace the usual fear among ethicists about its encouragement of cultural relativism, could well hold most promise. Such a seem- ing irony would be quite in keeping with the deeply human roots and consequences of ethnographic engagement. Without relin- quishing my own tendency to see the future in Weberian terms as the propensity of unfolding into newer and deeper historical tragedies, I am willing to propose ethnographic sensibility as a way of living with the challenges that the next millennium has already between description and interpretation based on social theory. Thus, it proceeds from the general to the minutely particular, and then it struggles to go back toward the general, which it tends to recast in light of the findings. It requires the capaciousness of the book-length monograph to work out its findings and establish their significance. Thus, it seriously goes against the grain of space-time compression. It - is inefficient. It is not oriented toward reliability the verification of observa- tions -nearly as much as it is toward validity -the verification of the concepts that stand behind and shape those observations. It is curious in that it is an approach that combines humanistic and social science methodologies, not at all inappropriate for an academic discipline, anthropology, that crosses the three great intellectual divides of the academy: natural science, social science, humanities. It is not a compelling way of providing causality, but it does lend itself to lay. ing out the social dynamics of ordinary experience and offering a comparative analy. sis as well. Indeed, it seems ready made to describe and interpret and compare moral processes. Because it can be combined with quantitative social science techniques and with physiological measurement, it has the potential (all too infrequently realized in practice, to be sure) to relate the moral to the medical, the political, and the economic. A methodology that can encompass narratives as well as numbers has a certain advantage in interdisciplinary enterprises. In an era that is witnessing the hegemony of analyses based in economic, molecular biological, and engineering framings of research questions, ethnography has a certain utility to get at the human aspects of a wide range of subjects. Although it includes formal methods for getting at things like kinship relations, indigenous categories, linguistic data, and the like, ethnography relies as much on the ethnographer as a calibrated instrument of evaluation as on questionnaires, structured and semistructured interview guides, content analysis of narratives, historical archives, economic data, and psychological tests. Perhaps there is no better use of ethnography than when the researcher is a disciplined observed and interpreter in the engagement with moral issues. For this reason ethnography is a highly appropriate methodology for scholarship in the relation of moral theory to everyday experience of moral processes, for bringing together in the same context moral and ethical materials. This is also why it is appropriate as a method for evaluating the moral processes and social consequences of policies and programs.
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brought us that at least clarifies the magnitude and form of that threatening future. Of course, such a change in sensibility will amount to too little too late unless it helps to usher in new political and economic policies to address the social roots of social suff ering.96
96 For a cautionary discussion of why any engagement with ethical issues concerning social suffering must contain explicit engagement with political-economic issues, especially as regards the developing world and the poor in the technologically advanced world, see Solomon Benatar, "Just Health Care beyond Individualism: Challenges for North American Bioethics," Cambridge Quarterly of Healthcare Ethics 6 (1992): 317-415; Solomon Benatar, "World Health Report 1996: Some Millennial Challenges." Journal of the Royal College of Physicians of London 31, no. 4 (1997): 456-57 and Paul Farmer et al., eds., Women, Poverty and AIDS (Boston: Common Courage Press, 1996). Readers will doubless note that I cut the conclusion short without providing a fully developed theoretical summary. I do this intentionally. I plan to provide that summary in the book that I am now preparing. That book extends these two lectures into a more fully developed theory of how moral processes and ethnical discourse can be related. It does so by setting out an anthropological method for medical ethics and an ethnographic grounds for advancing human rights that also privileges the way both are realized in local worlds.

A Kleinman

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