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Rorty once described himself as a “postmodern bourgeois liberal” (1991a). He supported liberalism or, more correctly, liberal democracy, because he argued that such societies had the potential to improve their practices by reducing suffering through dialogue. Specifically, for Rorty, the potential benefit of living in a liberal. The identity of postmodern liberalism becomes distinct in its acute awareness of the dangers of an implicit or lurking teleology and its decisive resolution to avoid or ex- cise any such reliance. Rorty: A poeticized, or post-metaphysical, culture is one in which the imperative that is common to religion and metaphysics - to find an ahistorical, transcultural matrix for one's thinking, some- thing into which everything can fit, independent of one's time and place - has dried up and blown away.
Trans Am Clin Climatol Assoc. 2006; 117: 257–271.
PMID: 18528478
Abstract
Principlism, the predominate approach to bioethics, has no foundational principles. This absence of foundations reflects the general intellectual climate of postmodern relativism. Even America’s foremost public philosopher, Richard Rorty, whose pragmatism might suggest a philosophy of commonsense, seems to be swimming in the postmodern swamp. Alternatively, principlism’s architects, Beauchamp and Childress, suggest a constantly evolving reflective equilibrium with some basis in common morality as a workable framework for twenty-first century bioethics. The flaw in their approach is failure to conform to real doctors’ and patients’ experiences. Real doctors adopt a scientific paradigm that assumes an objective reality. Patients experience real suffering and seek effective cures, treatments, palliation and solace. The foundation of medical ethics should be that doctors altruistically respond to their patients’ suffering using scientifically acceptable modalities. Compassion, caring, and respect for human dignity are needed as guides in addition to justice, beneficence, nonmaleficence and respect for autonomy.
Introduction
Beneficence, nonmaleficence, justice and respect for autonomy, these four principles are widely accepted by the medical community to underlie medical ethics. Such has been the case since Beauchamp and Childress published the first edition of their classic text, Principles of Biomedical Ethics, in 1979 (1). Physicians who invoke the four principles presume that theirs is a deontological approach grounded in universal values. This is not at all the underlying method of the purveyors of “principlism,” however. Beauchamp and Childress refer to mid-level principles.
One might ask, then, what is the basis for using four principles to guide ethical decisions? Perhaps the two authors are seeking to escape what is, I think, the bane of useful decision-making in fields like medicine, fields that require real decisions affecting the lives of real people. I am referring to postmodern relativism, a philosophy that seems capable of undermining any meaningful basis for belief, yet incapable in moral philosophy of providing a workable substitute. Relativists have so effectively undermined the foundations of normative values that one philosopher said he could propose only a “thin” foundation for human morality, one that has few if any real applications, in contradistinction to a “thick” foundation that could actually guide doctors in rationing of scarce resources, addressing inequalities in access to care, use of human stem cells for research, assisted death and suicide, and similar real-life issues (2).
I think Beauchamp and Childress chart their particular course, built largely but far from exclusively on “mid-level”, some might consider free floating, principles precisely to escape from having a “thin” as opposed to a “thick” moral philosophy. They seek, if you will, an escape from relativism, but in a world where relativism seems to hold the philosophical trump cards. Before exploring their means of escape and its consequences, let me look at the relativists themselves, specifically, at Richard Rorty, father of neopragmatism, perhaps the least strident, most eloquent and convincing form of postmodern—though Rorty denies that categorization—antifoundationalism.
The Postmodern Reaction: Relativism, Neopragmatism and Antifoundationism
With devastating effects, postmodernism targeted a previously held confidence in human progress through science dubbed modernism (3). Foucault, Derrida, Lyotard and other Continental philosophers deconstructed well-accepted modern texts to unearth hidden power-laden cultural assumptions (4). Since these assumptions favored the traditionally privileged classes over those less privileged, such as women, minorities and third world citizens, postmodernism’s exposure of previously uncritically held assumptions is often applauded by intellectuals. Postmodernism threatens to founder, however, once science and mathematics are included among the “texts” being deconstructed into just so many culturally biased relative truths. By undermining all sources of “truth” as only texts to be deconstructed, these philosophers have been accused of ending up “aimlessly wandering about” (4). They produce nihilism. This should cause medical scientists especially to reject postmodern relativism: precisely because of all sciences, those pertaining to medicine remain most firmly within the intellectual sphere called modernism. This is a critical point to be appreciated by anyone undertaking to explicate medical ethics. I will return to it. For now, let me explore the ideas of Richard Rorty, who perhaps less subversively and with more supple intellectual force took up the antifoundationalist, antiessentialist cause against scientific modernism; that is, against believing that science addresses a real world about which it develops verifiable theories that progressively approach truth (5–7).
A philosopher with common sense? When I first read Rorty, I thought he was a philosopher with common sense, a down home American pragmatist. He seemed like he might cut through the airy realms built by Continental philosophers to offer a method that corresponded to the way things really work in science and medicine. His neopragmatism seemed to say, truth is what proves useful, and how we determine “usefulness” is through the consensus of experts in an ongoing process of reflecting and deliberating on questions. Sounds just like science, doesn’t it? Don’t scientists accept or reject hypotheses by a consensus of experts’ opinions applied openly in processes like peer review and critiquing the reproducibility of results. But Rorty is no scientist; in fact, his own assessment of where he stands on ethics and other issues seems tied quite closely to his self-identity: This defines who he is but also limits his ability to escape from the quagmire of postmodern thinking. He’s too much of a postmodern thinker himself. Yet, Rorty identifies himself as a bourgeois liberal proponent of democratic values (8–10). Clearly, from his writings, he resides on the liberal arts side of the cultural divide. His affinity for democratic liberalism seems chiefly the basis for his vociferous disclaimer of being a relativist (8,11). When it comes to naming the persons most likely to influence pragmatic truths and progress, he calls them “strong poets.”
Taking Rorty to be the spokesperson for postmodern intellectualism, an insider but one with common sense, consider his ideas. This is what Beauchamp and Childress are up against in building a workable, that is to say useful and acceptable to practitioners, medical ethics.
His first and most influential book, Philosophy and the Mirror of Nature, starts from a different place than Continental philosophers like Foucault and Derrida; he starts by examining the so-called mind-body problem and examining the nature of knowledge (12). Rorty stakes a claim that one cannot distinguish between an external world that is real and what is added by the mind; therefore, knowledge must be “a matter of conversation and social practice” (11). The latter claim, though I think not necessarily the former, denies the most fundamental character of science: that our beliefs are constrained by what we know of the world. For Rorty, science like art, poetry, literary criticism, politics, and all other endeavors may be socially useful but has no claim on truth.
Rorty follows Thomas Kuhn’s historicist approach to science whereby Kuhn described scientific revolutions as a series of changing paradigms, one of which always replaced another (e.g., Einstein’s theory of relativity replaced Newtonian mechanics) when inconsistencies were noticed in the older, previously accepted paradigm and were shown to be better explained by the new paradigm (13,14). But, Kuhn did not believe that either paradigm was “closer” to the truth, because basic aspects of one are incommensurable with, hence falsify, the other. Assuming another paradigm will eventually replace and thereby falsify, for example, relativity, we must assume all paradigms ultimately are false; therefore, they do not lead closer to truth. Rorty applies this thinking to ever shifting intellectual fields like literature and politics, where one vocabulary replaces another according to—what? Fashion? Political correctness? Demographic and economic trends? So, how can Rorty deny being a postmodern relativist, embarked with all the other postmodern thinkers and writers on the same road to nihilism. He denies it by taking a historicist posture. Like Kuhn, he is willing to replace one paradigm with another, in this case bourgeois liberalism replaces fascism, communist totalitarianism, monarchism, and so forth, because we have tried the latter ways of doing things, and found we have more freedom and self-fulfillment under liberalism. We agree that liberalism is better. Rorty does not claim that liberalism is ultimately superior, just that we currently agree to prefer it.
This position leaves many unanswered questions. Some ground must exist for having knowledge and experiences, and for making observations; otherwise how could we “agree” on anything. It flies in the face of all experience to believe we are not constrained by an external world in some form. Finally, if there are no grounds beyond deliberation for choosing a free society over a totalitarian one; then, who are we to say ours is a better system compared to some fascists, for example, who may prefer living in a system where death camps are sanctioned by the state. Here, Rorty seems to have foundered. In a famous, and perhaps ill-advised statement, he admits he has nothing to say in the way of “you are acting against your nature,” if torturers come to the door to take away one of us (15). On the other hand, he consistently expresses his personal view that he opposes cruelty and humiliation.
I think in his mind we must oppose cruelty not because it is fundamental to our nature. We must oppose it because we ourselves are historically determined to be bourgeois liberals. I think this is an empirical observation reflecting Rorty’s particular circumstances. It is an observation that someone would make who lives in a world of academic freedom and fashion, of brilliant dinner table conversations, of passion for books and ideas. In this cloistered society, one can oppose any and all slights and humiliations. But, those of us who live in that world know that one may oppose them by joining the conversation, and not necessarily by having to do anything that requires making genuine sacrifices for the sake of alleviating the suffering of persons.
So, this is how it looks from Rorty’s relative perspective, that of a good man who lives the middleclass life of a tenured professor in an academic community. There are other worlds in which people live. What works in them may differ from Rorty’s experience.
The Wide Reflective Equilibrium
John Rawls, a Harvard philosopher, focused his work on social and political issues. A liberal, democratic thinker like Rorty—some might call him a welfare statist—Rawls applied the principle of justice, defined as fairness, to the social order. Fully aware of postmodern thinking, he needed a method to apply fairness that avoided the now discredited invoking of fundamental or universal theories. How can justice be the principle that guides society without being a fundamental human value?
Rawls proposed the wide reflective equilibrium (16). I think it important to point out that, in many ways, this is a pragmatic method. If pragmatism seeks to adopt what works; then, we have to ask, works for whom, and to achieve what goals or purposes. Thus, pragmatism becomes value-laden. The wide reflective equilibrium is a pragmatic method that answers these questions in the context of a democratic society. Notice, however, we have made certain assumptions: that society is democratic, and that we seek justice. He assumes that impartial judges in their considered judgments would agree that justice should be fairness. Rawls then suggests that we may reach consensus by applying our best intuitions and judgments to cases or issues using principles, rights and rules that we believe also apply. Revising this approach as often as necessary, our judgments, principles, rules and rights become consistent with and supportive of each other (16). This evolving process may develop new principles for achieving a just society over time. Rawls’ evolving reflective equilibrium sounds to me like a fairly accurate description of decision-making, definitely idealized, in twentieth century democratic welfare states. Faced with the argument that society is pluralistic and never reaches total consensus, Rawls modified his theory to be a converging equilibrium. Groups representing different belief-systems could agree to follow the democratic process so as pragmatically to create a functioning social order despite privately adhering to opposing viewpoints.
I began this essay by defining the problem for anyone proposing an approach to medical ethics to be escaping from postmodern relativism. Rawls’ was a social theory. In medicine, where decisions have concrete immediacy in affecting the lives of people, one can hardly depend on the shifting kaleidoscope of cultural relativism. The question is whether Beauchamp and Childress found a way out by adopting a Rawlsian reflective equilibrium?
Reflective Equilibrium as a Model for Medical Ethics
Richard Rorty Postmodern Bourgeois Liberalism
The wide reflective equilibrium as proposed by Rawls for social policy is a theoretical model that could serve medical ethics. It can encompass viewpoints ranging from those advocating a case-based approach to those who seek more generally applicable guiding norms. More than a set of competing vocabularies, the call for coherence by constant retesting with modification of moral beliefs based on cases allows for considerable consensus-building within an agreed framework. The framework proposed by Beauchamp and Childress consists of four semi-permanent mid-level principles. Their model recognizes that medical ethics is not a free-for-all. Considered judgments are developed by the stakeholders, who are trained ethicists; practicing physicians, other caregivers and their organized societies; governmental agencies; patient advocates; legal professionals; and representative voices from without the medical establishment. Arguably, the reflective equilibrium describes what exists in medical ethics. It does determine policy and opinion, and it is constantly evolving through the interaction of cases and issues with its stakeholders’ judgments.
Principles of Biomedical Ethics influences the actual reflective equilibrium by convincing stakeholders to adopt its four principles (1). These authors give precedence to the so-called mid-level principles that guide decisions while also incorporating rules, which are more specific applications derived from or compatible with principles (like “Do not lie to patients” or “Maintain patient-confidentiality”). Cases (like Tarasoff) reverberate through the system and modify how rules and principles are applied. Virtues like honesty and integrity ensure right application of rules and principles, and rights, officially or legally recognized, are also incorporated into the equilibrium, with which principles and rules must be compatible.
The Common Morality. Does anything fundamental within the evolving medical, social consensus justify choosing four mid-level principles? Beauchamp and Childress propose the common morality, shared moral norms, more basic than local customs. They are not grounded in any moral theory. One might say that the common morality is the basic human expression of right and wrong derived from our history and evolution as a species and society. Beauchamp and Childress believe that the common morality is always pluralistic, consisting of more than one principle; is pretheoretical but provides the basis for the moral convictions of all thoughtful and serious persons; and casts suspicion on any ethical theory inconsistent with it (1).
What is the Common Morality? Can we really agree on a common morality independently of societal mores? (see Table 1). Rorty goes no further than “avoiding cruelty,” and that with no justification beyond his personal, historically determined beliefs. Engelhardt says that secular morality has proved to be culturally diverse with no content-rich, commonly shared morality beyond “the very sparse requirement that one may not use persons without their authorization” (2). Yet, Beauchamp and Childress find a rich common morality, which they say is based on benevolence and justice, and contains strictures like “one must not lie,” “must not steal,” and “must not kill.” Among humans, in general, I think the rich common morality exists. We can say it is partly derived from our nature, partly derived from our families and small communities, partly from our civilizations. What brought about these? The human spirit? Random chance? Divine revelation? We are not now debating something’s characteristics or existence, we are debating its essence. This is very much like debating the nature of a thing-in-itself, apart from its primary and secondary qualities. Well, being one of the essences that we are trying to define, by definition we cannot know them. Whether the human nature that has a morality is in-itself a spirit or is purposeless energy changes nothing about the common morality as we know and experience it.
TABLE 1
•Richard Rorty (15): opposes cruelty and humiliation (personal belief) |
•Engelhardt (2): may not use persons without their authorization (moral reasoning) |
•John Rawls (16): justice as fairness (considered judgment) |
•Beauchamp and Childress (1): one must tell the truth, be loyal, not steal, not kill (common morality) |
*How various twentieth century philosophers have or might express their version(s) of moral foundations, and the basis for the moral beliefs expressed. Note: Beauchamp and Childress discuss various viewpoints on the common morality in their most recent edition (1), but the elements listed above arguably conform to its commonality across societies.
A Critique of Principlism
Principlism has dominated the teaching and practice of bioethics for twenty or more years. The wide reflective equilibrium is a robust model that in many ways conforms to real-world decision making. The model’s self-correcting and evolving features allow principles, rules, virtues and cases to continually realign so as to reinforce and support each other while addressing new trends and issues. Simultaneously, the common morality provides a semi-permanent foundation on which to rest the model. However, potentially serious flaws may undermine Beauchamp and Childress’ model of the reflective equilibrium and mid-level principles.
Is the Reflective Equilibrium Outdated? Does an unspoken subtext run throughout Beauchamp and Childress’ description of the reflective equilibrium that if revealed would expose their thinking as being strongly influenced by a cultural assumption, namely, the assumption that we all are late twentieth century democratic liberals, that is to say, well intentioned, rational beings who can reach consensus leading toward the common good. You might say, the participants in Beauchamp and Childress’ ongoing reflections are those same academic conversationalists who inhabited the worlds of John Rawls and Richard Rorty. Autocad mep 2013 hangers wholesale. But, the twenty first century shows signs of a fractured equilibrium. Voices are raised. Polarization replaces consensus. Perhaps the center will not hold. To the extent that the wide reflective equilibrium no longer accurately describes our struggles as moral agents, the model could be obsolete.
Did Beauchamp and Childress Embrace a Contradiction? Beauchamp and Childress state that their principles are prima facie obligations. They distinguish prima facie from actual obligations because the latter guide actions when two or more prima facie principles conflict and must be weighed in the context of a particular situation. Thus, moral agents, guided by prima facie principles, reach actual conclusions in particular situations. Now, here lies the rub. Not only could this approach lead to pragmatism as opposed to principlism, but also Beauchamp and Childress assert that their four principles and common morality from which they are derived are normative, that is, they establish obligatory moral standards. However, if there is legitimate debate over what constitutes the common morality, and if the guiding principles of medical ethics are ultimately discovered by examining the history of medicine and societies; then, in fact, the content of common morality and the naming of mid-level ethical principles are empirically determined. They are therefore nonnormative. The inherent contradiction is that normative appeal is derived by empirically discovering nonnormative principles. So, it isn’t easy to derive a foundation for medical ethics from the common morality. Even if not contradictory, this effort becomes problematic because normative cannot be cleanly separated from nonnormative (that is, empirically discoverable) principles, any more than theory is easily separable from empirical observation, as Quine pointed out (17).
This raises the possibility that biomedical ethics should seek a more firm foundation than provided by reflective equilibrium.
Post-postmodernism, Truth Defined by a Pragmatically Determined Scientific Realism
Pragmatism Applied to Medical Science. Rorty believes that science should have no exalted position. But, there is a difference between science and fields like poetry, fiction-writing, painting, even philosophy. Science is about understanding the “external” world (Figure 1). These other fields are subjective, in the sense they are the imaginative creations of human beings. Postmodernists seized on a logical conundrum: all human experience being subjective by definition, we cannot truly experience the “external” world. So, how can we say that biomedical scientific observations are real? Are many scientific models not imaginative creations of the human mind? Do they correspond to an “objective” reality? Here, I am forced to fall back on a pragmatic definition of truth: Truth is what works. But then, works in what way? For whom? And why? How can we reach a consensus?
Scientific Realism: The product of successful scientific research is knowledge of largely theory-independent phenomenon (7). Painting: Professor Tulp’s Anatomy Lesson by Rembrandt van Rijn, 1606–1669, Mauritshuis Museum, The Hague.
Herein lies the distinction between science and other fields. In free-wheeling academia, a text can be deconstructed into any number of interpretations. Scientists pragmatically require their consensus to be based only on reproducibly observable phenomena. In particular, medical scientists have found that no other means for reaching consensus—clever arguments, religious authority, political correctness, wishful thinking, legislative action—works to treat disease. Does this prove that biomedical science is true. Scientific convention has it, being “true” is the only pragmatically workable criterion for reaching consensus. But are observations, for example of the circulatory system, true because they correspond in some way to external reality? Well, multiple interlocking pragmatically achieved successes support their truth. Likewise, their truth is coherent from these and other multiple interlocking perspectives. This may be as close as you can come logically to saying it corresponds to reality. I am saying their relational structures approximately correspond to reality irregardless of their indefinable natures, or essences. What about, then, the theory of reflective equilibrium, and Kuhn’s theory of scientific paradigms? Is our current way of conceiving reality on the level of human biology just one more paradigm waiting to be discarded?
Does the Reflective Equilibrium Acknowledge Scientific Reality? In the Kuhnian sense, biomedical science is normal science. There has been no paradigm shift since Vesalius (see Figure 2). As pointed out above, physicians are working on a level which to all intents and purposes constitutes a permanent framework. Realities constructed by theory and experience at this middle spaciotemporal level have remained unaltered by theories of relativity and quantum mechanics. So, herein lies physicians’ wide reflective equilibrium. Their consensus is that what happens to their patients is bound by a very real external world. It follows that their patients’ suffering is real. And, in fact, their compassion and caring are real. And, in this all encompassing realism (Figure 3), like all treatments, the physician’s compassionate caring and therapeutic use of self is also subject to the scientific method. Though genuine and not counterfeit, and ethically desirable, even compassion has observable outcomes, and so lies within the realm of accepted practice consistent with the physician’s unique role as the dispenser of science-based treatments.
The Sixteenth Century Paradigm: The scientific paradigm for biomedicine has not shifted since the sixteenth century but has expanded from gross anatomy to the molecular level. Illustration by Andeas Vesalius, 1514–1565, Library of the Faculty of Medicine, Paris.
“The mind and the world jointly make up the mind and the world.” Aphorism attributed to the philosopher, Hilary Putnam, 1981 (20). Painting: First Operation Under Ether by Robert C. Hinckley. Harvard Medical School’s Countway Library.
Moral Implications. Knowing their patients are suffering, and knowing they know the best means to respond to that suffering, physicians are called—in the highest moral sense—to apply real science for the benefit of their patients (Table 2). Morality dictates they cannot employ alchemy, witch doctoring, exorcism or anything else but normal science. This moral purpose stares physicians in the face. It is in fact the foundation of medical ethics. It is defined by the very reason their patients seek a physician: “Apply your science to relieve my suffering.”
TABLE 2
•Real Disease |
•Real Suffering |
•Real Compassion |
•Real Treatment |
*How realism in one’s philosophical world-view translates to a moral mandate.
Medical ethics should not be based on an effort to skirt postmodernism by reaching a purely intellectual reflective equilibrium subject to argument and revision. Medical ethics is based on an overriding reality, the scientific reality that bounds the context within which medicine is practiced. This reality is only modifiable by new reproducible observations accepted as such by the scientific community. For hundreds of years, all such observation have extended but have not altered the conceived nature of biomedical reality. Arguments advanced by Rorty and all postmodernists are then judged irrelevant. Truth is defined by the brute reality of an empirically experienced world that inflicts suffering. Moral truth is the existential call to respond to that suffering. This is a rather humbling observation—a physician cannot rely on his poetic imagination, his encounter with an authentic self (18); he must subordinate himself to working humbly and compassionately within reality.
Summary, Deontology After All (See Figure 4)
Tentative schematic of how basing knowledge in scientific truth leads to an altruistic mandate for physicians founded on the reality of human suffering from disease, and on physicians’ relationships with patients. Patients seek science-based treatments. A reflective equilibrium influenced by the basic mandate works to guide the necessary ethical decision-making and includes principles in addition to Beauchamp and Childress’ four principles for dealing with increasingly complex twenty-first century problems.
- Patients and their suffering exist in a real world described by biomedical science.
- The fundamental moral principle of medical ethics is altruism. The physician is altruistically called upon to respond to patients’ suffering by applying science.
- This fundamental principle probably derives from our deepest human nature: our need to respond to someone else’s suffering.
- Beneficence, nonmaleficence, justice and respect for autonomy are mid-level principles that can be derived from physicians’ altruistic duty to respond to suffering. They are historically and experientially based guides that assist physicians in their efforts to respond to and relieve suffering.
- Altruistic response to suffering is an unwavering moral principle, but to derive from it a “thick” morality that actually guides decisions, one must apply principles pragmatically. As Dewey defined it, moral values arise from an appraisal or reflection on (potential) actions (19).
- The four mid-level principles do not optimally address all dilemmas or exhaust the need for principles. To proceed with compassion and caring are perhaps equally valid principles, strongly applicable to many twenty-first century ethical dilemmas faced by physicians.
- Certainly, the rules, case-precedents and virtues derived through working with mid-level principles are constantly, pragmatically being modified and made coherent.
DISCUSSION
Farrar: Williamsburg: Very interesting, Dr. Branch. I agree with everything you’ve said. However, I think, ethically, what you’ve talked about doesn’t solve the problem that we have in this country and the world. It seems to me that the main problem we have to decide is whether life belongs to us here on earth or to God.
Branch: I don’t think I can solve that problem.
Farrar: No, but I think that is the problem. I believe that, however we humans happened to be on this earth, we must make these decisions, rather than defer to some “higher power”. You realize, I am sure, that many people in this country believe that we should not be making these decisions.
Branch: I understand that, and I think that if we believe that we have to respond using a science-based approach to the suffering of human beings, that we can come into that belief out of either a position of faith or a position of agnosticism and humanism.
Czeisler: Boston: Very interesting presentation. The importance of getting someone’s consent before they participate in something made me think of a conversation and some of the results that I presented this morning. When I first presented them at our institution to all the different training program directors, there was about a half an hour conversation that ensued afterwards, that making mistakes in the middle of the night might be a very important part of training a physician, because the lessons that were learned from very serious mistakes resulting in adverse outcomes or even death were never forgotten by those trainees; and that was an essential part of their training experience. And as I listened to the discussion for about a half an hour, I was thinking about whether or not the extent to which the patients were involved in consenting to that process, and I just wanted your thoughts about—let’s say—if that were essential to training, how would you think that it should be approached?
Branch: I can’t totally agree with your premise that it is essential to training.
Czeisler: I’m not saying I agree with it myself. I’m just saying that this was the discussion that surprised me.
Branch: I think I would place the principle of treating the patient as an autonomous human being and getting their consent above the rate of learning of young trainees, and, frankly, I would have to believe that we could find better ways to teach them than to allow them to make mistakes. I think that mistakes are inevitable. I make mistakes, we all do. I also think there’s an ethical way to approach learning from the mistakes, that we are just now beginning to grapple with bringing them out in the open. Actually telling patients about them, and talking about them a lot more among ourselves.
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Articles from Transactions of the American Clinical and Climatological Association are provided here courtesy of American Clinical and Climatological Association
Few terms in the contemporary critical lexicon have been as vociferously debated and as persistently unstable in meaning and use as postmodernism and its various avatars, such as postmodernity. In spite of this instability, postmodernity may be defined as a broad category designating the culture that historically extends from the late 1960s to the early twenty-first century, and that is economically determined by postindustrial capitalism. Postmodernism would refer, more narrowly, to the characteristic intellectual and aesthetic currents and practices of that era, reflected, for example, in certain philosophical ideas or works of literature and art.
The terms postmodernity and postmodernism also suggest a break, respectively, with modernity, determined economically by capitalism and culturally by humanism and the Enlightenment, and with Modernism, the literary and aesthetic movements of modernity in the late nineteenth and early-twentieth centuries. While the distinction between modernity and postmodernity can be made without much difficulty, the distinction between modernism and postmodernism is more complicated. Some early critics argued that postmodernism was not really 'post' at all, but simply 'late' modernism. It quickly became apparent, however, that, despite its continuities with modernism, postmodernism does represent a definitive break from its predecessor, as well asa broader overall phenomenon, which includes in particular postmodernist theory.
Arguably the single most crucial conceptual determinate of the postmodern era and of postmodernism, defining this break, is an uncontainable and irreducibly de-centered multiplicity of coexisting cognitive and cultural paradigms, without any one of them being uniquely dominant or central. This postmodern de-centering, however, is defined not by the absence of all centrality, but by multicentering as the emergence of many centers and claims upon one or another centrality, including by previously marginalized fields and groups. Multiculturalism and related trends may be best seen as reflections of this situation, whose cultural and political implications, however, have a much greater scope.
Conceptual Postmodernism and Postmodernist Theory
The roots of conceptual postmodernism may be found in the ideas of some of the major figures of modernity and modernism, ideas that set in motion profound challenges to and changes in our thinking about the world and in the status of knowledge itself. Friedrich Nietzsche, in particular, initiated a radical critique of the Enlightenment ideals of absolute truth, universal morality, and transhistorical values, which he replaced with a radically multicentered or, in his terms, perspectival understanding of human knowledge, morality, and culture. It is primarily through Nietzsche and related figures, such as Sigmund Freud and Martin Heidegger, that the genealogy of postmodernist thinking is connected to Poststructuralism, one of the most important conceptual revolutions of postmodernism. Several parallel scientific revolutions took place throughout twentieth-century science, especially in physics (relativity and quantum theory) and biology, and in literature and art, and these revolutions also contributed to postmodernist conceptuality and epistemology.
These changes culminated in the postmodern crisis of, in Jean-François Lyotard's terms, legitimation of knowledge. 'The postmodern condition' itself, responsible for this crisis, was famously defined by Lyotard as 'an incredulity toward metanarratives,' especially the 'grand narratives' that seek to provide a single, all-encompassing or teleological framework for understanding the world. Lyotard's key example is the Enlightenment grand narrative of the progress of civilization through reason and science. He, however, extends this critique to other grand narratives of modernity, including Hegelianism, Marxism, and Freudianism. The collapse of the grand narratives has left us with no hope of a single conceptual system or discourse through which we might attempt to understand the totality of the world. Instead we have a plurality of frequently incommensurable worlds and often mutually incompatible systems of language and thought through which to comprehend them.
Cultural and Political Postmodernism
The cultural formations and aesthetic movements of postmodernism are intricately bound up with both the ideas of conceptual postmodern ism and the economic, technological, and political transformations of postmodern ity. A dramatic example of this entanglement is the relationship between 'the disappearance of the real,' which is an epistemological conception, and media culture. Jean Baudrillard observed that by the late twentieth century, media technologies in their roles as technologies of reproduction and representation, had become so advanced that images or copies have become 'simulacra,' reproductions sufficiently powerful that they first obscure, then displace, and ultimately replace and function as 'the real.' This instability in the distinction between reality and representation is an abiding theme and hallmark of postmodern culture and art.
Postmodern technologies are also transforming other fundamental concepts and categories through which people understand the world and themselves. As postmodern bioengineering and genomic technologies erode the distinction between human and machine, humans and their conceptions of themselves are being reshaped and reimagined to an unprecedented degree. Technologies of transportation and communication are creating the 'spatialization of experience' and the concomitant disappearance of the temporal, which are linked to a postmodern subjectivity that is fragmented and contingent, an intersection of fluctuating 'positions.' This spatialization of experience and the loss of a sense of history accompanying it, Fredric Jameson argues, impair the ability of postmodern subjects to 'cognitively map' their positions in relation to the increasingly complex political and economic systems of global capitalism.
For Lyotard, postmodernity potentially offers a new and better ground for the practice of democracy and justice. He argues, against Jürgen Habermas, that de-centered postmodern heterogeneity makes obsolete the Enlightenment ideal of consensus, which all too frequently required the suppression of minority dissent. Postmodernity, with its heterogeneous interests and worldviews, allows previously oppressed or marginalized groups to make claims upon justice, and upon a position of centrality, even in the absence of majority consensus concerning such claims.
The status of knowledge is altered as societies enter what is known as the postindustrial age and cultures enter what is known as the postmodern age.… Postmodern knowledge … refines our sensitivity to differences and reinforces our ability to tolerate the incommensurable.
source: Jean-François Lyotard, The Postmodern Condition: A Report on Knowledge.
By contrast, Jameson defines postmodernism as 'the cultural logic of late capitalism,' for him an inherently unjust formation. The material structures of postmodern technologies, local and international politics, and global capitalism, he argues, ultimately determine our experience of postmodernityand the nature of postmodernist culture and art, and thus put justice in conflict with postmodernity.
Most current views of postmodernity and postmodernism may be positioned between these two visions, between the justice of the heterogeneous and the 'cultural logic' and unbridled power of global capitalism. If, however, one combines the views of Lyotard and Jameson, cultural postmodern ism embodies two competing and conflicting drives arising from capitalism and democracy defining postmodern ity. Globalization, in its positive and negative aspects, comes with postmodernity, and together they give rise to conceptual, cultural, and political postmodernism across the geopolitical landscape of both hemispheres.
Postmodernism in Literature and Art
In considering postmodernist aesthetic practices in parallel with the postmodern lack of political consensus, Lyotard invokes 'the lack of consensus of taste.' Instead these aesthetic practices are characterized by an affirmation of their multiplicity. None needs to be defined by any given form, however multiple or fragmented, as was the case in modernist aesthetics, and as would be demanded from art by the consensus of modernist taste. By contrast, postmodernist aesthetic practices may adopt any form, outlook, or agenda, new or old, and allow for other (than postmodernist) practices and alternative approaches. The postmodernist aesthetic is thus defined by the (political) sense of this multiplicity of practices.
Literature.
Continuing the narrative experiments of the modernists, the first generation of postmodernists, American and British writers of the 1960s and 1970s 'metafiction' (Kurt Vonnegut, John Barth, Thomas Pynchon, John Fowles, and Angela Carter), produced texts that simultaneously questioned and violated the conventions of traditional narrative. Similarly the postmodernist Language poets (Lyn Bernstein, Charles Hejinian, and Bob Perelman), inspired by the linguistic experiments of modernism and the new ideas of poststructuralism, deployed a fractured, systematically deranged language aimed at destabilizing the systems (intellectual, cultural, or political) constructed through language. The fragmentation, intertextuality, and discontinuity that characterize so much of experimental modernist and postmodernist literature find a kind of fulfillment in the inherently fragmented, intertextual, and discontinuous form of 'hypertext,' a computer-generated Web text with multiple branching links.
Another hallmark of postmodern literature, and of postmodern art in general, is the erosion of the boundaries between 'high,' elite, or serious art and 'low,' popular art, or entertainment. Decidedly serious literary works now make use of genres long thought to belong only to popular work. A related phenomenon is the development of numerous hybrid genres that erode the distinctions, for instance, between literature and journalism, literature and (auto)biography, and literature and history.
The emergence and proliferation of feminist, multiethnic, multicultural, and postcolonial literature since the 1970s is, however, the most dramatic and significant manifestation of the de-centering and de-marginalization defining both postmodernity and postmodernism. In the 1970s and 1980s, American and European literature underwent an immense transformation as writers who had traditionally been excluded from literary canons--women and ethnic and racial minorities--moved from the margins to the centers of the literary world. There are counterparts to this phenomenon in history and anthropology, which have seen a proliferation of histories from below and outside--histories of women, of children, of the working class. Postmodernism has gone from History with a capital H, to histories, small h.
Visual art.
With the institutionalization of 'high modernism' in the mid-twentieth century and the increasing commercial appropriation and commodification of artworks, the modernist ideal of an artistic avant-garde, standing apart from mainstream culture, became increasingly obsolete. Postmodernist art has been, since its beginnings in the movements of the 1960s--Pop art, Fluxus, and feminist art--art that was inherently political and simultaneously engaged with and critical of commercial mass culture. All these movements are linked to the development of multimedia performance art and conceptual art, a term that designates art that is neither painting nor sculpture, art of the mind rather than art of the eye. The logical extension of this definition (following Marcel Duchamp) is that nearly anything, properly 'framed' or designated as such, might be thought of as art. One of the most distinctive characteristics of postmodernist art is the dissolution of traditional categories of art and artworks, and the proliferation of new and hybrid forms that have broadened these categories to an unprecedented degree, even greater than encountered in literature.
The feminist art of the 1960s, 1970s, and 1980s challenged the institutionalized male bias and sexism of the art system in a wide-ranging critique that extended from the writing of art history and criticism, to museums and art galleries, to the predominance of the 'male gaze' and the objectification of women in visual media throughout history, to definitions of art that excluded such traditionally female forms as quilts and weaving.
No doubt the logic of the simulacrum, with its transformation of older realities into television images, does more than merely replicate the logic of late capitalism; it reinforces and intensifies it.
source: Fredric Jameson, Postmodernism, or, The Cultural Logic of Late Capitalism.
Other strains of postmodernist art (from the 1980s to the early twenty-first century), which one might call 'the art of simulacra,' focus on the prevalence of the image (particularly the media image), technologies of reproduction, and strategies of appropriation of already existing works. It encompasses the work of a broad range of artists and movements, from the video and performance art of Nam June Paik, Laurie Anderson, andBruce Nauman, to the photography of Cindy Sherman and the graphic art of Barbara Kruger.
Architecture.
While reflecting many general aspects of postmodernism, the phenomenon and concept of postmodernist architecture have a particular specificity and complexity, in part because the term postmodernist architecture was given a specific meaning very early in the postmodern period. What characterizes postmodernist architecture most, however, is its diversity in spirit and in style, and the ways it defines itself, in each movement and project, in relation to this diversity.
For some, the quintessential expression of postmodernist architecture is the shopping mall, an enclosed city in which spatial disorientation seems to have been a deliberate, structural intention. Elsewhere this disorientation also takes on a temporal, historical form, as architects combine disparate elements from previous architectural eras and styles in the same building, an incongruous mixing that initially gave rise to the term postmodernist architecture. Philip Johnson's AT&T headquarters in New York City, an austere, International-style skyscraper sporting a baroque Chippendale pediment, would be a postmodernist building in this earlier sense. For some architects, postmodernism was defined by the abandonment of modernist utopianism and a validation of vernacular architecture, as in Robert Venturi's celebration of the 'decorated shed' of commercial architecture. New computer-assisted design and computer-assisted manufacturing (CAD/CAM) technologies and high-tech materials have made it possible to break from the traditional architectural forms and create more free-form and sculptural edifices, such as Frank Gehry's Guggenheim Museum in Bilbao, Spain.
Music and dance.
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Although not as widespread or influential as other art forms, postmodern music and dance have nevertheless developed many of the key traits of postmodernism, sometimes in their most radical aspects, both building upon and working against such modernist figures as Arnold Schönberg, Igor Stravinsky, and Pierre Boulez in music, and George Balanchine, Martha Graham, and Merce Cunningham in dance. Radically experimental postmodernist composers such as Karlheinz Stockhausen, Iannis Xenakis, and György Ligeti have gone beyond modernism in dislocating the classical harmonies and replacing them with ever more complex, nearly unmusical, sounds and noises.
The same formal experimentation can often be found in postmodernist dance. Postmodernist dance is, however, particularly characterized by the collapse of boundaries between 'high' dance (classical ballet and modern dance) and 'popular' dance (jazz dance, folk and tribal dance, ballroom dancing, break and line dancing, and Broadway musical choreography), as choreographers fused their various styles and movements. Among the most prominent representatives of the postmodern dance scene are Bill T. Jones, Twyla Tharp, and Mark Morris. Some choreographers have gone even farther afield, incorporating movements from the martial arts, sports, acrobatics, mime, games, and even the mundane physical activities of everyday life. These trends are found in postmodernist (classical) music as well, from the usage of elements of jazz and rock and roll to the incorporation of street or elevator noises.
Dance, however, became quite literally more a part of the world, as choreographers developed architecturally inspired, site-specific works. At the same time, dance increasingly became a part of the broader forms of performance art and multimedia art, as choreography was linked to political concerns and combined with video, text, and other media. One might say that the choreography of postmodern dance is the choreography of postmodernism itself, its aesthetics and its politics, including its politics of aesthetics defined by the lack of a single consensus of taste.
See alsoModernism ; Structuralism and Poststructuralism .
bibliography
Amiran, Eyal, and John Unsworth, eds. Essays in Postmodern Culture.New York: Oxford University Press, 1993.
Baudrillard, Jean. Jean Baudrillard: Selected Writings. Edited by Mark Poster. Stanford, Calif.: Stanford University Press, 1988. A defining treatment of the problematic of reality and representation in postmodernity.
Geyh, Paula, Fred G. Leebron, and Andrew Levy, eds. Postmodern American Fiction: A Norton Anthology.New York: W. W. Norton, 1998.
Harvey, David. The Condition of Postmodernity: An Enquiry into the Origins of Cultural Change. Oxford and Cambridge, Mass.: Blackwell, 1989. A comprehensive and authoritative study of modern and postmodern spatiality.
Huyssen, Andreas. After the Great Divide: Modernism, Mass Culture, Postmodernism. Bloomington: Indiana University Press, 1986. An important treatment of the relations between elite and mass culture in modernism and postmodernism.
Jameson, Fredric. Postmodernism, or, the Cultural Logic of Late Capitalism. Durham, N.C.: Duke University Press, 1991. The most influential Marxist treatment of postmodernism.
Rorty Postmodern Bourgeois Liberalism Pdf Merger
Latour, Bruno. We Have Never Been Modern. Translated by Catherine Porter. Cambridge, Mass.: Harvard University Press, 1993. An important assessment of the state of culture after postmodernity.
Lyotard, Jean-Francois. The Postmodern Condition: A Report on Knowledge. Translated by Geoff Bennington, and Brian Massumi. Vol. 10 of Theory and History of Literature.Minneapolis: University of Minnesota Press, 1984. A seminal study defining the problematic of postmodernity.
Phillips, Lisa. The American Century: Art and Culture 1950–2000. New York: Whitney Museum of American Art in association with W. W. Norton, 1999.
PaulaE.Geyh