T Papadimos, A Marco
delivery of health care, ethics, philosophy medical, poverty, public health
T Papadimos, A Marco. Kierkegaard, Despair, Society, And The Medically Needy. The Internet Journal of Law, Healthcare and Ethics. 2004 Volume 3 Number 2.
Many Americans are underinsured or uninsured. These individuals certainly despair over their healthcare situation. Medically needy individuals may not be able to overcome the economic and social obstacles that bar fulfillment of their medical needs. These individuals may need help from society-at-large, but can the entity known as “society” actually despair over the plight of those who are medically needy and rise to meet the challenge of despair? A society that truly despairs over the plight of its medically needy will be more likely to make a true effort to assist them. Kierkegaard's work,
Does a society actually despair over the plight of those who are medically needy (the uninsured and underinsured)? If a society despairs, is it conscious or not? Do societies even recognize the plight of the medically needy? Forty three million Americans currently are medically uninsured, countless other millions are underinsured, and in 2003 another 3.1 million Americans fell below the poverty line . Søren Kierkegaard in his work
Kierkegaard claims this “sickness unto death” is despair, a “miserable condition that man as such does not know exists” . In this condition a person, while not understanding or realizing despair, wills “to be rid of oneself—this is the formula for all despair” . If despair cannot be recognized by man or by woman, then how can it be recognized by society? A society that cannot recognize despair, cannot act on despair, and, therefore, is incapacitated in appropriately responding to the despair of the medically needy (because society itself may be in despair and unable to act).
Kierkegaard's concept of despair illuminates the spiritual state of societies through pathos/passion and subjectivity (subjective truth). Kierkegaard teaches us that human pathos, or passion, is a precious commodity. He felt that turning thoughts into action was passion. Overcoming pain and suffering through pathos helps people through the bad times and, in its purest sense, to live and die for the right reasons and in the right way. Pathos is holy and divine to Kierkegaard:
“Why suffer what humans have suffered, the pain and the despair—what meaning can all of this have? For Kierkegaard there is no meaning unless passion, the emotions and will of humans, has a divine source. Passion is closely aligned with faith in Kierkegaard's thought. Faith as a passion is what drives humans to seek reality and truth in a transcendent world, even though everything we can know intellectually speaks against it. To live and die for a belief, to stake everything one has and is in the belief in something that has a higher meaning than anything else in the world—this is belief and passion at their highest” .
Pathos, at different times in different groups of individuals with the same political, social, or religious philosophy, leads to a critical mass which lends itself to action. The sincerity of a person's passion (and that of a society) is paramount.
The pathos/passion of individuals that leads to their organization and commitment to changing society comes from subjectivity. The subjective truth is what was important to Kierkegaard. This subjectivity is individual. A human's life experience is his/her very own and it belongs to no other human. Choices and the process of making those choices define a person, to themselves and to others. Subjectivity is a person's essence as a human being. It comes with the conscious recognition that one is a “self” and leads to the necessity of making meaningful decisions for the “self” . Subjectivity and pathos are complementary.
Kierkegaard suffered from melancholy and depression (i.e., death of his mother when he was young, a depressed father, a failed engagement, exclusion from elite Danish literary circles, and poor health in his mid-forties). This provided him with an exquisite grasp of despair leading to the articulation (through his lifetime of works) of a view/philosophy that has been very influential. For example, Kierkegaard heavily influenced Herbert Marcuse, who merged Freudian psychology with Marxist economics to demonstrate that people could be liberated from alienation and repression through social transformation that is characteristic of patriarchal capitalist societies . Also, Gyorgy Lukacs, who defended European communism as a method of overcoming the harmful effects of alienation, was a student of Kierkegaardian thought . Furthermore, in some of Kierkegaard's early fictional works, a narrative emerges about a young man in need of making meaningful choices in his life (especially in regard to the aesthetic and the sensual) can be found in popular books and movies, such as
What is Despair (in relation to a society)?
If society despairs, is it an “excellence or a defect”? Kierkegaard would agree that it is both. If a human society despairs, it is an indication that it is elevated over animal societies and demonstrates a deepness of spirit:
“If only the abstract idea of despair is considered, without the thought of someone in despair, it must be regarded as a surpassing excellence... Consequently, to be able to despair is an infinite advantage (over animals), and yet to be in despair is not only the worst misfortune and misery—no, it is ruination (a defect)” .
However, the problem of viewing despair from the societal level is two-fold. The first problem involves the “fragmentation” of despair. In other words, when we speak of society we are including all individuals, not the few or the many, and not a segment or fragment. An example of the “fragmentation” of society's despair is demonstrated by the war in Iraq, especially in its initial stages. There were groups that detested the involvement of the United States in that conflict, and there were groups that reveled in the possibility of war [8, 9]. One group despaired and one group did not. To be more Kierkegaardian about it: the former group despaired more than the latter group (if one were to consider that all people or groups have some level of despair). Such a fragmentation does not allow all of the members of a society to despair at the same time, nor to the same degree. While from an individual human's perspective despair is all or none (or at least none noticed by the individual), it is more difficult to apply such a concept to an entire society.
The second problem involves the expression of this “fragmentation” of society's despair. The collective energy of this despair may be expressed by government (local, state, and federal), large corporations or other institutions. Corporations may not be representative of society (but of stockholders) and yet they may express a will that can influence. The government may be made up of the people, by the people, and for the people, however, neither it nor large corporations function as a spirit, Christian or otherwise, as qualified by Kierkegaard. These large organizations, businesses or governments, may have goals and agendas, but they are not “spirit” and therefore cannot despair in a human sense. So how does a society demonstrate despair?
A society is language, tradition, wealth, poverty, culture, edifices, organizations, etc. A society is things, i.e., concepts (ideas, ideals) and structures (not only edifices, but laws and customs). It is true that people make up societies and are represented by their concepts and structures. Nonetheless, can these concepts and structures exhibit despair? Better yet, a more keen presentation of such an interrogative is, how does an observer of a particular society realize that the society under observation is in despair?
The observer can examine statistics as to crimes, birth rates, death rates, income levels, civil unrest, etc. However, a simple, basic question may be posed to reflect the ability of a society to despair or respond to despair, “do they take care of their own?” A society that despairs in “excellence” will care for those in need of health. A society whose despair is a “defect” is a society that despairs to be “rid of itself” and will allow increasing numbers of people to fall below the poverty line and not earnestly endeavor to provide health care for those in need.
The Universality of Despair
Kierkegaard states that “just as a physician might say that there very likely is not one single living human being who is completely healthy, so anyone who really knows mankind might say that there is not one single living human being who does not despair... ” . Ergo, there are no societies that are not in despair. Societies may seem healthy, vibrant, economically sound, and without despair, but “not being conscious of being in despair, is precisely a form of despair” .
Affluence may play a role in the despair of society. While public health indicators of a society may generally seem to be strong, or positive, there may be less affluent sectors of society that are not fairing well. Could it be that they are simply buried by the position of the more affluent? The affluent vote more and have the means to do more. Therefore, the more affluent members of a society may well decide social policy. They are informed daily by various media sources that those with less affluence have less access to health care. Nonetheless, is this affluent “fragment” conscious of despair? These individuals may lament their fellow citizens' misfortune (lack of medical access), but there may be no societal transition to action. Just as translational medicine attempts to unify cooperative research efforts between laboratory science and clinical science, society should translate the individual despair of the medically needy in an affluent society to action by large organizations, businesses, and government.
A society that indicates, through the actions (or inactions) of its institutions, “never to have sensed this indisposition (the despair of the medically needy) is precisely to be in despair” (unconscious form) . Such a society may be, or may become, reactive and regressive. A society that recognizes the ethical need of health care for all, and acts upon this recognition, may be a society in despair, but it is proactive and progressive (conscious form). It recognizes despair, a first step towards action. “Therefore, the common view that despair is a rarity is entirely wrong; on the contrary, it is universal” .
The Forms of Despair Applied to Societies
Societies are either aware of despair (conscious) or they are not (unconscious). Societies that are aware of despair and have resolved to translate the realization of this despair, in this case the plight of the medically needy, are conscious of their despair. Such societies attempt to provide health care for all,
“The ever increasing intensity of despair depends upon the degree of consciousness or is proportionate to its increase: the greater the degree of consciousness, the more intensive the despair” .
The mere conscious realization of the intensity of the despair of the medically needy makes such societies despair. This despair of those that “have not” causes despair in those that “have” and this acknowledgement creates a kinetic energy that causes the institutions of these societies, i.e., the government and large organizations, to respond. Though “spiritless” and secular the institutions in these societies respond as surrogate Kierkegaardian Christians.
Societies that are ignorant of the despair of the medically needy have a naiveté, almost an innocence, when it comes to acknowledging (or not) or recognizing (or not) despair. Kierkegaard further claims:
“Despair at its minimum is a state that—yes, one could be humanly tempted to almost say that in a kind of innocence it does not even know that it is in despair. There is the least despair when this kind of unconsciousness is greatest; it is almost a dialectical issue whether it is justifiable to call such a state despair” .
The latter, the unconscious form of despair, is the form that may be applicable to a society without health care safety nets of any kind. Such a society has “the despair that is ignorant of being in despair” . When it comes to those in medical need and society's despair may not rise to the level necessary to ensure that the despair of the medically needy will be acknowledged, accepted, and “despaired” (thus causing an action for resolution). This form of societal despair can be the most devastating, especially to the medically needy. This society's ignorance of its despair,
“Is simply a negativity further away from the truth and deliverance... Yet ignorance is so far from breaking the despair or changing despair to non-despairing that it can in fact be the most dangerous form of despair” .
In this case society and its institutions will never break through the ignorance and provide for those with a need. This unconscious form of despair, this ignorance, is best reflected in war-ravaged societies, i.e., civil war and those that are run by a tyrant, where fear causes society to quiet its collective voice and subdue its separate individualities. Recent experiences in the Balkans, the Sudan, and Iraq are vivid examples [12,13,14]. Of course, it is of great value to these societies when those with resources step into such a situation and help, despite the difficulties in doing so.
The U.S. Department of Health and Human Services recently published a report on national healthcare quality and disparity . The report found that disparities in healthcare occur throughout the United States and that high quality healthcare was not a “given”. The largest discrepancies occurred in preventive care and the report indicated improvement was possible. In the United States seriously ill persons who are not adequately insured may have no choice but to present themselves for care at a hospital, regardless of the financial consequences, to preserve their life. However, those with a “chronic”, smoldering process that are uninsured (or under-insured) may elect to forgo preventive care because of their inability to afford the cost. Many times the medical out-of-pocket expenses lead a family into poverty . In the USA out-of-pocket expenses that lead to impoverishment include older head of family, at least one member of the family in bad health, or the lack of health insurance. Surely American society despairs in not proceeding with the necessary changes, but it does not choose to make the requisite alterations.
In some societies “there is a rise in the consciousness of the self (societal awareness), and therefore a greater consciousness of what despair is and that one's state (society's) is despair. Here the despair is conscious of itself as an act; it does not come from the outside as a suffering under the pressure of externalities but comes directly from the self (of society)” . This is a society that comes closest to trying to “do the right thing” for the medically needy. Such a society nears virtue in regard to the medically needy and is conscious of the “infinite”. This society, “wants to enjoy the total satisfaction of making itself into itself, of developing itself, of being itself; it wants to have the honor of this poetic, masterly construction, the way it has understood itself” .
The social policies of most European democracies are representative of such an approach, although some of these governments may be overextended financially as to their ability to provide healthcare for all. A specific successful example would be Iceland, which has demonstrated the greatest longevity of a populace. Its national healthcare system has provided universal healthcare since shortly before World War I, giving Iceland one of the highest life expectancies in the world .
In Europe, specifically Germany, Austria, Great Britain and Denmark, structural reform strategies and financial incentives are under serious consideration because of the increasing budget burden of health care . These strategies include raising co-payments, premiums, and use of the U.S. model of diagnosis-related groups (DRGs). Also, there is a move in Europe toward more reliance on general practitioners, better coordination between community-based and hospital-based care, and better integration of the medical and social sectors. Nonetheless, Europe seems to continue to “defiantly” attempt to provide health care for all.
The argument here is not who provides the best care or the most funding. The standard is the intent to treat all people in need. In the Third World only the most meager care may be available (by Western standards), yet the goal is to help, as best as is possible, all of those in need. In other words, in this dialectic the “virtuous” intent of a society to give health care to all is the standard, not the concept of best/good care.
Health care access is an ethical and economic conundrum that concerns all members of a society. All “conscious” societies despair for citizens that cannot access prompt and appropriate care. These “conscious” societies approach the dilemma in different ways with varying amounts and forms of funding, and all hope for a good result. Certainly individuals and families who do not have adequate health care despair. Those fortunate enough to have good access to health care may be concerned about those who do not. However, this concern seems to be a “lighter” form of despair in that, “I feel bad, but I am glad it is you and not me”. To provide healthcare access to an entire society is not an act of an individual, but an “intent to treat all” on an institutional or national level. An “intent” that is universal at the level of an individual wells up throughout an entire society and is reflected in governments, institutions and their policies. Unfortunately, such a decision is not founded upon philosophical or ethical debate, but is an economic and political decision. It should be a decision to be made by a society-at-large through a reflection of its despair in the looking glass of its institutions, organizations and government.
Kierkegaard's deep intellectual foray into the darkness of the despair of the individual can easily prompt the application of his forms of despair to societies and their abilities and/or desire to provide care to the medically needy.
Despair as sin applied to societies
Sin is a category that Kierkegaard emphasized applied to the individual alone and he probably would have resisted the extension of this notion to an entire community. Nonetheless, we will attempt to justify the extended application of this concept.
Kierkegaard begins Part Two A of
“Sin is: before God, or with the conception of God, in despair not to will to be oneself, or in despair to will to be oneself. Thus sin is intensified weakness or intensified defiance: sin is intensification of despair. The emphasis is on
Next, Kierkegaard delves into the Socratic definition of sin as ignorance, “If sin is ignorance, then it doesn't exist because sin is indeed consciousness” . If this is true, then according to Socrates, sin does not exist. Christianity adheres to the notion that pagans and natural men do not know what is sin. There is an assumption that only God can reveal what is sin . The Greeks, according to Christian thought, lacked the concept of will, or defiance. Kierkegaard points out that,
“The intellectuality of the Greeks was too happy, too naïve, too esthetic, too ironic, too witty—too sinful—to grasp that anyone could knowingly not do the good, or knowingly, knowing what is right, do wrong. The Greek mind posits an intellectual categorical imperative” .
He continues his commentary with the suggestion that it is tragic-comic to see all this knowledge and understanding that Socrates and the Greeks exhibited had no power over their lives, and “that their lives do not express in the remotest way what they have understood, but rather the opposite” . The Greeks actually understood quite well, as did Kierkegaard because he urges us not to go beyond Socrates, but to reexamine his teachings. If a person does the right thing, then he did not sin. If a person does not do what was right, then he did not understand what was right. If he had understood what was right, his understanding would have resulted in a prompt correction.
Since God must reveal to man what sin is, and having established the Christian stance (sin = despair) and the Socratic position (sin = ignorance), Kierkegaard states the following on behalf of the pagan and natural man:
“All right, I admit that I have not understood every thing in heaven and on earth. If there has to be a revelation, then let it teach us about heavenly things; but it is most unreasonable that there should be a revelation informing us what sin is. I do not pretend to be perfect, far from it; nevertheless, I do know and I am willing to admit how far from perfect I am. Should I, then not know what sin is? But Christianity replies: No, that is what you know least of all, how far from perfect you are and what sin is. Note that in this sense, looked at from the Christian view, sin is indeed ignorance; it is ignorance of what sin is” .
Thus, Kierkegaard has cleverly associated sin with ignorance and despair.
Can Kierkegaard's view of sin be applied to a society? We believe so. His view of the self involves the body (the finite, the temporal and the necessary) and the soul (the infinite, the eternal, and the possible) . He further states that, “ Such a derived, constituted relation is the human self, a relation which relates itself to its own self, and in relation to another” (this complicated thought may be a lampooning of G. F. W. Hegel's work, which had influenced Kierkegaard) . There are two relationships here, (1) the body and soul, and (2) between self and another. Kierkegaard envisioned self-hood in two forms, “the religious self, that is constituted by God, and another form of self-hood, the ethical self, which is constituted by commitment to humanity, or to a specific human being” .
If self-hood is a commitment to humanity, and the self's ignorance and/or despair can be considered sin (that is the ignorance and despair in regard to the medically needy—whether this is a sin before God can be argued exhaustively by all faiths), then it is possible to extrapolate sin to the many “selfs” of a community that are not committed to humanity and, thus, to society-at-large.
Having associated the concept of sin with society we would like to address Kierkegaard's concept of the “continuance of sin” in Part Two B of
“In the deepest sense, the state of sin is the sin; the particular sins are not the continuance of sin but the expression for the continuance of sin; in the specific new sin the impetus of sin merely becomes more perceptible to the eye” .
In the closing paragraph of this section (in fact, it is the closing paragraph of
An Acknowledgement that Society Despairs and the Demonstration of a Response
An argument has been made that societies can despair, i.e., its institutions, etc. However, some may say the above arguments were only clever twists on Kierkegaard's thoughts. On the contrary, there is evidence that institutions do despair. The Montefiore Medical Center (teaching hospital of the Albert Einstein College of Medicine) and the Urban Research Institute of the Johns Hopkins University have acknowledged that their institutions are situated in the midst of two of the largest urban concentrations of health risk and that an implicit social contract exists between their institutions and the community that requires a response [22, 23]. Stephen Foreman, Chief Executive Officer of the Montefiore Medical Center insists that there has been a call for institutional social responsibility of Academic Health Centers (AHCs) for more than fifty years that has gone unheeded [24, 25].
Foreman's healthcare system has put together broad community outreach programs that go beyond his institution's traditional mission of patient care, teaching, and research. His institution has improved the health of the underserved populations that are within reach of Montefiore's healthcare system. Montefiore Medical Center efforts have dated back over several decades. Their efforts have been successful by expanding the primary care network, creating a children's hospital and care network ($150,000,000), integrating health information technology ($125,000,000), use of managed care systems, enforcement of ethical allocation of resources, building teaching and research into their network, and preserving community vitality by creating a community development project dedicated to revitalizing the area immediately surrounding the medical center. This was an intensive, costly, but successful effort.
Johns Hopkins University is another AHC that is situated in the midst of a poor neighborhood (East Baltimore, MD). The establishment of an institute for urban health was a response by Johns Hopkins University to “improve the health and well-being of the residents of East Baltimore and to promote evidence-based interventions to solve urban health problems nation-wide” .
In Baltimore Johns Hopkins University had to deal with issues of mistrust in the community. It is a world-renowned institution in midst of some of the worst urban health conditions in the country. The President's Council on Urban Health studied two broad categories, (1) diverse oriented groups studying substance abuse, violence, cardiopulmonary disease, and sexually transmitted diseases, and (2) community-action task groups that studied communication, the environment, family, maternal-child issues, revitalization, information technology, the elderly, and governance. The council found thirteen major obstacles to improving the health of East Baltimore including, but not limited to poverty, crime, a lack of education, a lack of health insurance, and a mistrust of the university. These findings led to a sustained and focused effort by the university through the Johns Hopkins Urban Health Institute to improve healthcare access to the nearby medically needy populations.
In the aforementioned circumstances institutions understanding despair were spurred to action (thereby showing that they did despair). Presented here are demonstrations that show Kierkegaard's thoughts on despair can be applied to institutions, thus indicating that institutions that know and understand despair can alleviate it and produce healthcare access to those most in need of it.
At a time of budget shortfalls, rising heath care costs, and an aging population (in the West) societies must look inward and decide if they have the necessary will to overcome economic and political obstacles and muster a “conscious” attempt to bring adequate health care to all of their citizens. Some societies are limited by economics in their intent to treat their citizenry, but there are societies that allow the blind eye of “unconscious” despair to limit their field of vision even though they have the means of addressing the problem of medical need. The problem is not just sheer economics, but has been the lack of the ability of a society to engage in deep introspection and understanding. Kierkegaard's thoughts on individual despair may be “complex and idiosyncratic” , but those who till the fields where medical need meets medical practice feel Kierkegaard's view of despair, through pathos and subjectivity, is equally compelling on the societal level.
There is recent evidence certain institutions in American society, specifically AHCs in areas that have substantial urban working poor, have accepted the challenge that societal despair in regard to healthcare exists, that it is a serious problem, and that an effective response can be mounted. The evidence is growing in regard to the applicability and relevance of Kierkegaard's view of despair as it pertains to the health of the working urban poor and the ability of society to respond.