EP. 93: BEING (IM)MORTAL
WITH TONY WYSS-CORAY, PHD
A neuroscientist discusses the possibilities of slowing down and even reversing age-related neurodegeneration and the philosophical and ethical implications of life-extension.
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Episode Summary
From ancient myths to science fiction, humans have long been fascinated by the idea of transcending the limits of our natural lifespan. But what does modern medicine say about the practical, actual possibilities of extending human life? Joining us to explore this tantalizing question is Tony Wyss-Coray, PhD, a neuroscientist and director of the Phil and Penny Knight Initiative for Brain Resilience at Stanford University. While his research focuses on age-related cognitive decline and Alzheimer's disease, his work has involved identifying the “biological age” of various organs and its implications on various diseases, and treating old animals with the blood of young animals to halt, and even reverse, aging of the body.
Over the course of our conversation, we not only discuss the mysterious mechanisms underlying neurodegeneration, but also venture beyond the lab to explore the philosophical and ethical dimensions of life extension. We ask: how does our understanding of aging affect our perception of self and identity? Is aging a disease to be treated? What are our social and moral obligations when it comes to prolonging life or enhancing brain function? Is immortality even desirable?
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Tony Wyss-Coray is the D.H. Chen Distinguished Professor of Neurology and Neurological Sciences and the Director of the Phil and Penny Knight Initiative for Brain Resilience at Stanford University. His lab studies brain aging and neurodegeneration with a focus on age-related cognitive decline and Alzheimer’s disease. The Wyss-Coray research team discovered that circulatory blood factors can modulate brain structure and function and factors from young organisms can rejuvenate old brains. Current studies focus on the molecular basis of the systemic communication with the brain by employing a combination of genetic, cell biology, and –omics approaches in killifish, mice, and humans. Wyss-Coray has presented his ideas at Global TED, the Tencent WE Summit, and the World Economic Forum, and he was voted Time Magazine’s “The Health Care 50” most influential people transforming health care in 2018. He co-founded Alkahest Inc. and several other companies targeting Alzheimer’s and neurodegeneration and has been the recipient of an NIH Director’s Pioneer Award, a Zenith Award from the Alzheimer’s Association, and a NOMIS Foundation Award.
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In this episode, you will hear about:
• 2:30 - How Dr. Wyss-Coray became drawn to neuroscience
• 4:45 - Defining neurodegeneration and aging
• 9:26 - The studies that led Dr. Wyss-Coray and his team to finding the gap between biological age and chronological age
• 21:06 - Is reversing the aging of an organism’s body a realistic goal?
• 28:31 - The possibilities and limits of treating neurodegenerative conditions
• 33:49 - Dr. Wyss-Coray’s groundbreaking work in treating old animals with the blood of young animals to reverse aging
• 38:51 - The philosophical and moral implications of life extension
• 48:57 - Dr. Wyss-Coray insight into the “secrets” behind some people’s longevity
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Medical anthropology provides a lens through which we can view the intricate tapestry of human health woven with the threads of cultural beliefs, social structures, and biological realities. It enriches our understanding of health, offering a more holistic view that respects the diversity of human experiences. Few have played a more significant role in creating this discipline, as psychiatrist Doctor Arthur Kleinman, whose early, extensive field work in Taiwan and China have shaped how we think about cross-cultural health care systems and their impacts on human suffering. Many of his books, including The Illness Narratives and Patients and Healers in the Context of Culture, have become seminal texts in medical anthropology. Doctor. Kleiman is also a moral philosopher whose writings have explored the frailty of our existence, and how uncertainty and crises sharpen our moral identities. Over the course of our conversation, we discussed Doctor Kleinman's bold explorations of human wellness across cultures, the search for meaning amid pain and suffering, the struggle to lead a moral life, and medical anthropology as a clarion call for a more nuanced and empathetic approach to health and healing.
Henry Bair: [00:02:20] Doctor Kleinman, thank you for taking the time to join us. It's an honor.
Dr. Arthur Kleinman: [00:02:24] Nice to be here.
Henry Bair: [00:02:26] You've had such a kaleidoscopic career, from psychiatry to medical anthropology to moral philosophy to ethics, and we're hoping to touch on all of those. But first, can you tell us your journey to medicine as a calling in the first place?
Dr. Arthur Kleinman: [00:02:40] Well, I guess it was the presence of absence. I did not come out of a family that had physicians in it. In a business, family, Wall Street and business. There was the romantic idea that medicine must be very different and that doctors must be pursuing a noble profession, and that idea was based purely on a romantic vision of what medicine could be. So it kind of struck me that was kind of nice to have the right values. And I always had the idea that I would do medicine, but I wasn't really interested in the biomedical sciences. Or any of the hard sciences. I was interested in, uh, history. In English literature. Comparative literature. In Asian studies. So when I was a Stanford undergraduate, much to the chagrin of my pre-medical advisors. I majored in history and just took the bare minimum of pre-medical courses that we get. We get me into medical school. But I was an excellent student and hence had no difficulty getting into medical school. And since I came from New York and had left New York to get as far away as possible from sort of a stultifying ethnic environment into a broader world, and that Stanford had given me, I stayed at Stanford for medical school.
Dr. Arthur Kleinman: [00:04:20] But Stanford Medical School at that time at least, was a very different kind of medical school. It was a medical school that was dominated by pre-medical scientists. A number of whom had already one would win win the Nobel Prize. So they were very established scientists. But there were also strong in their belief that the problem with medicine was that doctors were not scientific enough. So I came out of medical school extremely well trained in sciences pertinent to medicine. But I came out of medical school almost incompetent in taking care of people with ordinary medical problems, almost none of which I had seen at the Stanford Hospital at that time. I had seen the most unusual immunological disorders, infectious diseases, very complex chronic disorders, but I had never seen a heart attack or a pulmonary embolus, which at that time was basic to what internal medicine training. And that's what I started out with. So when I went to the Yale New Haven Hospital in New Haven, I felt totally unprepared for the care that I was asked to give. And I wrote back to the dean of the medical school and said, you know, you did a great job for me as a scientist, I thank you for that. But I'm really not well prepared to take care of patients. And so it was a brutal internship of the kind that was the epitome of what is no longer allowed, but also what is seen as as sort of a crackpot way of training caregivers. I was on every 24 hours and off for 12 for an entire year.
Tyler Johnson: [00:06:14] A true residency, as it were.
Dr. Arthur Kleinman: [00:06:16] Yeah. And during that time, uh, for example, one of my co-interns at the Yale-New Haven got sick and I was on, on for five nights in a row of which by the end of that time, I was probably technically delirious because I'd only gotten about 2 or 3 hours of sleep any night. And if you had asked me what day it is, what time of the day, who's the president of the United States? I probably would have been technically delirious, unable to answer any of those questions. But there I was, taking care of very sick patients. So I knew there was something amiss in how we were training doctors.
Henry Bair: [00:07:00] Certainly. We've talked at length with various guests on this show about how the very way we train doctors may be exacerbating the crisis of burnout. I want to turn to your subsequent forays into medical anthropology, though. What is medical anthropology and what does this work mean to you? I understand this began when you joined the National Institutes of Health after your intern year. Can you tell us more about that?
Dr. Arthur Kleinman: [00:07:26] I went to the NIH and this was the Vietnam War. In fact, I entered the National Institute of Allergy and Infectious Diseases the same time that Tony Fauci entered NIAID That was in 1968. They, the NIH, sent me to Taiwan for a variety of reasons, including the fact that my wife was a China scholar and I spoke some Chinese and Taiwan sort of changed my perspective on things. I began to realize that the very way we thought about what medicine is, what it does, and what health care is about was incredibly skewed and not necessarily helpful or as helpful as it should be. So, for example, I noticed walking around Taibei at that time. That around the largest Buddhist shrine. It was sort of Buddhist, Confucian, Taoist combined. There were all the elements of a health care system. There were. Hospitals, clinics. Traditional Chinese medicine. Bonesetters. Herbalists. And if you looked at people coming there, you could see that they were defining the health care system by the way they walked through it, the choices they made and the like. And this didn't look at all like the health care system that the Ministry of Health at that time portrayed, which was hospitals, clinics, pharmacies, and that was it. The way people used it made no distinction between traditional medicine and biomedicine, between religious healing and secular healing, between untrained herbalists and highly trained internists. It was used in a certain way, and I wanted to find out why.
Dr. Arthur Kleinman: [00:09:25] That's really interesting. How do people decide how it's used? And I realized then that to do it properly, not only did I need a, a higher level of of Mandarin and some understanding of Taiwanese, but I, I needed to have a recognition and deep sense of what culture is about and how it how it works and how social structural factors like economic power, poverty, social class, how they had their influence on this. And so when I came back from the. Nih instead of going back to Yale to continue my training in internal medicine. I went to Harvard to study, uh, anthropology. And why anthropology? Because anthropology seemed to me the discipline that looked at how people live their lives. What their feelings and thoughts are and how their social world and their personal life intersect. And so I studied anthropology, and at the same time, I realized if I was going to combine medicine and social science, I had to find a discipline that would be receptive within medicine. So I went into psychiatry, actually with relatively little interest in mental illness and little experience with psychiatric care. But because it seemed to be the most open to bringing the social sciences and health together. But this is really a story of a bizarre turn of events, because over time, over the 50 years maybe that I've been doing this, psychiatry has become less and less open to the anthropology in internal medicine and infectious diseases, and all the things I was interested in have become more and more open to anthropology.
Dr. Arthur Kleinman: [00:11:23] And so that's been a kind of a of a paradox. But in all of this, what unified my thoughts was some very basic questions about what is medicine all about? And in 1974, while I was completing my residency in psychiatry at the Massachusetts General Hospital and studying anthropology at Harvard, I wrote a series of papers that were published for papers in that year. And they basically have been the central questions I've had for my whole career, which is, how do we understand the difference between the biomedical diagnosis of disease and the experience of illness that people have? Secondly, what is a health care system? What is it and how do you best describe it? Third, what is care? What is care all about? And caregiving. And fourth. Why is it that biomedicine and the kind of health care system we have in the United States seems to do such an inadequate job with care and caregiving? And those four questions have kept me going for half a century. So maybe the lesson someone could take listening to this is if you come up with the right questions, you won't exhaust yourself in looking for the for the answers. It's going to take you a long time to work things out.
Henry Bair: [00:12:55] That's absolutely wonderful. Thank you so much for taking us through that journey. You know, a lot of it resonates with me. I grew up in Taiwan. I was born there. I only came to the US for college. So to hear your experiences in Taiwan, I feel connection to that. And I and I see what you mean. Even today, I think I would say health care in Taiwan today has moved a lot more closer to what it looks like in the US. At the same time, though, you know, like the largest academic medical center in my city of Taichung, the hospital is called China Medical University Hospital. There is the conventional Western medicine building. And then right across the street there is the Chinese Medicine department, and they are the faculty. There is on equal footing as like the Western medicine side. And patients will often go between clinics. Right. So you definitely see there's still elements of that, that social component that you talk about that you observed.
Dr. Arthur Kleinman: [00:13:50] So let me go a little further and give you a sense of then what is it that links those two times together? So what I found and became the basis of my first book, Patients and Healers in the context of culture, was that if you really want to understand what a health care system is. And how it relates to biomedicine. You have to enter the homes of people. Who are healthy or sick or managing some kind of treatment. And when you enter their homes, you discover a number of things. And this was research that I went back to do in Taiwan in 1975-76. First of all, you discover that most decisions about health, health care, illness experience are made in the context of the family. And a lot of those decisions have nothing whatsoever to do with what we call quote unquote medicine. That is, they never get to a doctor or a clinic or even a traditional medicine practitioner. They're taking care of in the context of family networks and communities. And that if you look at. What percentage of illness episodes so defined by patients actually get to biomedicine? Uh, you'll see they're under a quarter of those episodes. And although, um, severity plays a large role in this severity of symptoms, it's not the only determining factor by a long shot. And so therefore learning how people define, think about use a health care system really defines what the health care system is about. And today when people study health care systems, they really study them more. In light of that idea that I just talked about together with the sort of structures that public health management programs lay out, and I think that gives a more honest view of what health and health care are. And this requires you to understand a smaller role for medicine than we usually think of.
Henry Bair: [00:16:09] Can you further explain what this more limited role of medicine looks like?
Dr. Arthur Kleinman: [00:16:14] I'll give you an example. In 1995, I presented at the United Nations in New York City. The first World Mental Health Report, which had been done by a group that I led at Harvard. And at that time I knew that mental health was a big problem and we had identified a number of aspects of it. But that view of mental health was much smaller than what we have learned today, especially with Covid. Is the extent of mental health problems and the wide variety of approaches to mental health that constitute a kind of non-system but chaotic, incipient way of organizing different services. And so, for example, I also learned, you know, one of the good things about being at Harvard or at Stanford or any elite university is the quality of students that a faculty member gets. And I have had some amazing students, and one of them, Jim Kim, was the former head of the world Bank. And when Jim became head of the world Bank, he told me, let's do something on mental health. And we put we did a program in 2016, I think, called Out of the Shadows. And what it was was an attempt to present mental health, not to the ministers of health who constitute the audience of who, but to the ministers of finance around the world, because the ministers of finance are a thousand times more important than the ministers of health, and in fact the Minister of Health. If he calls the Minister of Finance of most societies, most countries will not get a return call the same day.
Dr. Arthur Kleinman: [00:18:04] Now, so in this program we showed, for example, if you look at depression, one of the commonest problems in mental health around the world. That about half of depressions that can be defined technically as depression do not require any kind of professional input. They respond to a variety of things. Exercise, diet, confiding relationships that are supportive emotionally. New relationships that pick up after losses. New forms of work and assistance that keep you going in the world. A sort of repair in your social life, as it were. That for half of depressions is all that's needed to remove those depressions and to get you to wellness and back to yourself. So if you think about that, then you wouldn't want any mental health experts, let alone psychiatrists, to be working on those half of depressions. Okay. Because so small is the mental health manpower resource in the world. You want to concentrate them. On what would technically be most advanced by their treatments, and that would be chronic refractory depressions that don't respond well to the kinds of interventions I mentioned, psychosis and its management, etc. there are a whole whole group of problems you'd want them to attend to. And so beginning from the perspective of the patient and family's voice, I think that's been my achievement, frankly, that I've opened a space for it to be heard and paid attention to. And that's what I conceive of as one of the really important contributions of the kind of work I do in medical anthropology and cultural psychiatry, opening that voice for the lived experience of people who are suffering. And listening to it, witnessing it, and then responding to it in a way that doesn't necessarily configure with the institutions we've built, many of which actually make things worse, but that ask questions, how can we do something better? I think that's been part of what I've tried to achieve.
Tyler Johnson: [00:20:43] It's interesting because, you know, most people I think if you go to medical school, you learn a model of how to approach medicine, and then you learn a certain subspecialty category within that model, right? You learn how to be a cardiologist or how to be a psychiatrist, or how to be an orthopedist or whatever. And then you go and you repeat ad infinitum, the thing that that specialized skill set that you learned, you apply that skill set to a million different scenarios over the course of your career. Right? So what first strikes me is that you almost immediately sort of transitioned from, rather than using a skill set that you had received to approach a group of relatively similar problems in the way that you had been taught to do, you immediately went to this sort of, for lack of a better word, this kind of meta level, and said, well, yeah, but what about the entire system, the entire approach that we're using to medicine? Right. But then also in your career you have gone, I would argue, even a level I don't know if I want to call it higher, but but another level beyond, let's say that, which is to think and write not just about what is the system that we use to approach medicine or health care or caring or that. But actually you wrote a book called What Really Matters, right? So you have then gone to say, okay, even beyond just medical concerns, strictly understood what I mean, frankly, what is the purpose of life? Right.
Tyler Johnson: [00:22:12] Like the great question and I want to read it's a little bit of a lengthy paragraph from the introduction to that book, what really matters. So I'm going to do sort of three things here in sequence. I want to read a paragraph from the book. Then I'm going to play a short clip of music. And then I want to ask you to expound on a question that results from these two things. So. So the book chronicles the experiences of people trying to assert moral courage in the face of difficult circumstances. In effect. And so in the introduction, you begin to talk about the fact that we often speak colloquially as if difficult circumstances are somehow the exception to the rule, when in fact they really are the rule for most people most of the time. And then in the context of talking about that, you write, many of the highest attainments of civilization have come from those who have had the courage to peer unflinchingly into the darkness of reality. Since the time of the ancient Greeks, the Western literary genre of tragedy has wrestled remarkable wisdom from the encounter of human beings with the fierce and unyielding way things are behind the facade of convention.
Tyler Johnson: [00:23:24] Just to think of Antigone or Lear is to understand how we have been enriched by this countervailing force. Rembrandt's Prodigal Son, which appears on the cover of this book. And parenthetically, if you're listening, you can Google it. It's a beautiful painting and sort of dark hues is a beautiful painting, yet its beauty is saturated with a sense of suffering and loss at the heart of life. Rembrandt's work links the esthetic tradition with religion as perhaps the most powerful beings by which we build ethical meaning out of adversity and failure. This is also much of the substance of the Book of Job and the Gospels, as well as the texts and rituals of Buddhism, Hinduism, Confucianism, Taoism, Islam and many of the world's folk religious traditions. They revealed the truth about how easily our sense of comfort and order is shaken, and how hard we have to struggle to maintain our identity and cultural worlds in the face of profound suffering. Yet it is in that struggle, as Antigone, Lear and Rembrandt's figures so poignantly illustrate, that we find the meaning of our humanity. Now, with that still in our brains, I want to listen to about a moment of this. So this is a setting of O Nata Lux, written by Morten Lauridsen.
Tyler Johnson: [00:25:37] So I play that short clip of music because to my ears, and I'm no professional musician, but that music very much illustrates the point that you are making in the paragraph that I read, which is to say that it is piercingly, hauntingly beautiful, yet inescapably sad. It is profoundly it is just weighted down with sorrow. And, you know, on this podcast, if you look at this podcast, which is now going close to 100 hours of publicized conversations, if you look at the podcast writ large, in effect, we do this through the prism of medicine because Henry and I are both doctors. But really, the question that we are wrestling with is precisely the question that you wrestle with in that paragraph, which is, how are we to make meaning out of a life that is filled with suffering, or for that matter, out of a profession where in our best moments we are witness to the suffering of other people. And so I'm hoping that in the spirit of the paragraph that I read and the book that you wrote, that you can talk a little bit about what your decades of both professional and your own personal lived experience have taught you about that connection between a recognition, even in an embrace of the concrete reality of suffering, and then the quest to still find and build a life of meaning in the midst of that.
Dr. Arthur Kleinman: [00:27:06] Yeah, well, thank you for that. Now, that's not only just a beautiful and right on question, but it is really gets to the heart of things. Well, if you go back to my first attempt to write clinically. At the book level, at the level of a manuscript. It was my book, The Illness Narratives, which had some great success actually, within medicine, which was wonderful. And one of the things I'd begin the illness narratives with is a story that took place at the Stanford hospitals in my, I think, second or third year of medical school. I was on a surgical service where my job was to hold the hand of a seven year old girl who had been badly burned as she was sat in a whirlpool bath. And the tissues were slowly from the areas that were badly burned. Were twisted away by a resident and a fellow. And my job is the medical student just was sort of the holder and. And she went through agony and screamed and cried and was clearly was very painful opening these wounds. And frankly, I couldn't take it. After a couple of days I was holding her hand, but to what avail? And she would respond to nothing that I said so just out of me. I don't know where it came from. I blurred it out. Um. How do you tolerate this? How do you go through this each day? What is it like? And to my utter amazement, she stopped and she started telling me what the experience was like.
Dr. Arthur Kleinman: [00:28:56] And I realized that at that point that you could witness a person's pain and enter a realm which would be the realm that you're really talking about, a humanistic realm of suffering with the real intention of witnessing, of intensely listening. And someone could tell you what it was. And in telling you actually. Their experience was eased a bit because during that period of time she didn't cry out, she didn't scream. She allowed the doctors to tweeze away the tissue. And every day thereafter, for about a week, I just sat there and listened to her and she got to really squeeze my hand hard and and tell me, tell me what her feelings were. This. This was seven year old girl. And so I learned a great lesson from that, which was that she was telling me about some dimension of experience that I could relate to, even though I couldn't get it right in my mind. What is it like to be a seven year old with terrible burns over your body? But there was some domain we could enter that was the domain of our shared humanness. And that took me later in my career to ask the question, if we go beyond illness because illness is what we work with as doctors, what category does it fit into? And it fits into, in my view, the much larger category of suffering. And in that large category of suffering, there's both a sort of individual pain and suffering that people have. But also what I came to describe as the social suffering that not just groups go through, but that individuals share with groups.
Dr. Arthur Kleinman: [00:30:48] And so here I felt I was beginning to come to a subject that I've always been interested in, which was pain. And for the first time, it was a seven year old girl who was giving me a feeling about what pain is like. Now that ties directly to the way you introduced the subject. And let me show you why you don't have to look at it from the only from the Western tradition of that paragraph you read. But the Chinese tradition is a very effective way as well. So there's a Taoist tradition that's been written about by my colleague Michael Puett in a fine book called The Path. And in this Daoist tradition, the idea is that the world is filled with negative things. There are all these terrible things that can happen to you, from accidents to illness. You can lose your money. You can lose your family. You can lose your life. You have all these things. And also there are the bad things that come out of interpersonal relationships like revenge, hate, resentment, suspicion, stigma, and. In the Daoist tradition. The idea is that this mass of negativity around human beings ultimately means that any human enterprise will fail. We'll eventually have to fail. So you can set out a medical practice. You can go on a pilgrimage to find wisdom. You can engage in religious activities, you can be a teacher conveying wisdom, but ultimately you're going to fail.
Dr. Arthur Kleinman: [00:32:33] And because of the just the negativity of the world. But this tradition says something that's extremely close to the existential tradition and the image that Camus gave us of Sisyphus pushing a rock up a hill and then having it go back down, having to do it again. And that is the idea that the in the Daoist tradition that in spite of all that negativity, you must. Cultivate yourself and the world and act in the world to build something in the world. And I think that's kind of extraordinary that you recognize from the start that everything is going to fail. Everything will end in failure. And yet your responsibility, your human responsibility to be a human being, is to cultivate yourself and build and cultivate your world and build in your world that which is humanly important. And I think that speaks to what you're saying, that behind the facades that we have is a great set of sadness. Part of it relates to our own, to death, the fact that all of us will die. And that relationships will end, our own life will end, etc.. And part of this, of that experience is the recognition that of what might be called cultural violence. That the way we have built our cultures is to mis recognize. The steep reality. So that if you look at the Stanford Magazine or the Harvard Magazine, etc., it's all about success stories. Okay? The alumni have been successful who've done really important things.
Tyler Johnson: [00:34:27] That's because that's all we do at Stanford. There are no failures, actually. Of course, you might have forgotten since you left.
Dr. Arthur Kleinman: [00:34:33] Except if you if you go to the back of the Stanford Magazine, which is a good magazine, by the way, you read all the obituaries, it gives you a more sober view of experience than the gung ho, rah rah beginning part. Anyway, in what really matters when I tried to do was to take an anthropological view of life. So in the in the most stark anthropological view of life. We're alone in the world. And God did not create us, we created God. God's okay. What is surrounding us is the uncaring natural world that is a world of predator and prey. Of collaboration for certain things that produce practical ends. But that is a world in which human beings really are surrounded by geological time. By evolutionary time, all of which are non-responsive to the human issues we've just talked about, so that when you die from the anthropological standpoint, you are off in a cold, unfeeling world in which you just disappear. And people have to deal with that.
Henry Bair: [00:35:56] So what you just painted is a rather harsh, grim picture of our existence, yet it's clear from your writings that you nonetheless find hope in our struggle to persist. What have your experiences and observations taught you about where meaning can be found?
Dr. Arthur Kleinman: [00:36:11] There's not a society in the world... Big societies, small scale societies, in which care is not an important part of the society. So in spite of this objectively bleak reality. Care is an important part of what human beings do. And part of that care is quest for wisdom, for the art of living. Then has developed in many societies, but his attempts to develop a kind of wisdom that helps people to get through the world. To deal with loss and pain and to care for memories. That's what I wrote about in my book, The Soul of Care to care for memories, because so much of our life is about to caring for memories and all of that in my mind. That is what the stuff of literature and art and music is about. That is the stuff of the human core of our experience. So seen from the. Fact that where we can be seen as any other animal, we get the initial description I gave you, which is an incredibly bleak anthropological perspective. But then, seeing as what is special to our humanness, I think we get a much more availing sense of the importance of of the human. Okay, in spite of all the negative. Now, having done that. I use that to critique ethics, because I think that ethics has again misled us, blinded us to the world we live in. So in bioethics, in medical ethics more generally.
Dr. Arthur Kleinman: [00:38:08] We were all trained really with the view of a predecessor of mine at Harvard, John Rawls, who wrote the great book A Theory of Justice. Rawls said. That because of all the differences in who we are, our background, our wealth, our knowledge, we should always begin ethical inquiry with a veil of ignorance, with a veil of ignorance, which we don't worry about the context and we don't worry about the past. We just start going forward and then ask questions that get at more ethical acts and the like. Okay, get at a more just world. But this is a total Hollywood esque vision of the world. In my view, that is unacceptable to anyone who's thinks deeply about social inequality, which every anthropologist does think deeply about. Because as my late student Paul Farmer put it, the great problem of the world is that some people are regarded as mattering less. It's that mattering less. It's that unequal playing field. It's the fact that we start in a totally unequal playing field. Which in my view has got to be the basis of ethics, especially medical ethics. That its context and history to begin with that are got to be taken into account. So if you're concerned with population ethics and public health, you've got to begin with that in order to address social and health inequalities and seek out social justice.
Henry Bair: [00:39:50] A lot of this discussion of ethics is fascinating. We're talking about it at the societal level, the philosophical level, so it can get a little bit abstract. How does this actually play out on a daily individual basis? And moreover, what do you do when your individual ethical values conflict with the values of the people or the environment around you?
Dr. Arthur Kleinman: [00:40:13] At the individual level. This presents an interesting dilemma. So individuals are not just sitting there as isolated individuals as American neo libertarianism and neo liberalism would have us believe. Individuals are part of groups. You're part of your work group, your family group, your community. Within those social groups, there are things that matter most. So a simple example. You may come to a clinic to join a clinic as a young doctor on the wall of the clinic. They say serve the people. Actually in China, after Mao, with Mao Zedong, all clinics had that serve the people. Okay. But actually, when you're in the clinic, you see the workings of neoliberalism, and every patient is a profit center. Okay? And you begin to say, well, there's a there's a difference. There's a gap between 'serve the people' and 'every patient is a profit center'. And you yourself may disagree with what is socially acceptable in that setting. In this instance, it's treating patients as if they were a source of income rather than caring for their illness. And then what do you do in that setting? Well, you could you could criticize it openly, though. Few people do this because we're all wise enough in personal interactions to know you get into a lot of trouble locally if you do that. So you keep it to yourself in what an old friend of mine, who's a great anthropologist, political scientist at Yale, Jim Scott, calls 'the hidden transcript'. The thing you only share with people who are close to you that in fact, you can't tolerate the values expressed in the actions of people around you.
Dr. Arthur Kleinman: [00:42:08] So how do you go beyond the local? That's the problem for every one of us, whether it's the family, whether it's the clinic, whether it's our local community. How do you go beyond the local? Because in the local, what matters most and therefore what is by definition for an anthropologist, what is moral since moral for an anthropologist is what locally matters most for people, okay may actually not be good. This leads you to some remarkable understandings. The Lancet Commission on the Holocaust is just releasing its report now. Okay. The Nazi doctors in this view, in this anthropological view. Were extremely moral. They were committed to an idea, to a feeling, to an action which was to kill the Jews. This wasn't just a random thought. This was a deep commitment. This was what was at stake for them to get rid of the Jews, to kill the Jews. That Jew hatred was at the core of what they were about and what they did. So we have to see that as the fact that the moral could be terrible. What we're committed to is what really matters. Doesn't have to be good. It could be terrible. That's what we call it in anthropology, the moral. And we search when we have a discrepancy. When we have a conflict with the moral, we search to go beyond the moral, and therefore we search for what we would call the ethical for that set of values and practices that go beyond the local and are the way we we see is the right way to to act in the world, the way we would like to see others as well as ourselves act in the world.
Dr. Arthur Kleinman: [00:44:02] But we have a problem when we do that. Just think about it for a minute, because this local, this personal aspiration. Which is, in my view, how the ethical begins this personal aspiration to go beyond the moral that what is locally at stake for people to find out what really would be important if we could sustain it over time and place to find what is good in the world, how to do good in the world, etc.. Where does the personal find support for that? It's always Partizan. It's going to be in a religious tradition. It's going to be in a tradition of secular humanism. It's going to be in a tradition of ethics. This is part of what is characteristically human. And this is what humanists, I think over generations, great literature, great art has recognized. This is the equivalent of your sadness. Hearing the painful voice of life is also seeing that our ethical aspirations, which are so remarkable in their ability to motivate us and move us that they are limited. By the structures we have built. Which invariably are partizan towards some position. So I think that I'm not unusual as a physician, having kind of this sort of trajectory of ideas. I think that any sensitive, thoughtful physician who spends time taking care of patients and goes through a lifetime in which medicine is the fulcrum of that, is going to come to ideas like this. They may not be the same anthropological ideas that I've raised, but they're a recognition that there's some discrepancy, some gap.
Dr. Arthur Kleinman: [00:46:00] Between the ways that we conceive of the world and the way the world really is. And I think that I don't think there's a field better poised than medicine to give that insight to people. And that's it was based on this that I wrote the book, The Soul of Care. This and the fact that I had lost my wife with early onset Alzheimer's disease and had cared for her for ten years. And I wanted to get at this action, this aspiration for the good, this trying to figure out how do we place ourselves in this world of structures that are not us, but where we're trying to realize something that goes beyond the local? I think that that's where care is lodged. This comes out of being a caregiver and someone who does care that we feel inevitably poorly served. Why the structures around us? And we see the struggle. To make sense of our world and the recognition, ultimately that mystery, uncertainty mixed with danger and threat. And make it very difficult at the end to know what is wisdom and what is not. But nonetheless, having said that, that quest for wisdom in esthetics, in religion, in art, in the sphere of ethics, I think that is what we're all caught up in. And so writing about that, I think, was simply giving voice to what I had sensed and learned and heard from my patients and my colleagues and my teachers. And it fit in with a with what is the human tradition which we all are part of.
Henry Bair: [00:47:51] So having said all of that, how does this aspirational view of the human endeavor shape your approach to medicine?
Dr. Arthur Kleinman: [00:47:59] For me, medicine is not just good to practice. It's good to think, okay. And I think anything that I have contributed has actually come out of this feeling that medicine has given me that you're surrounded with an inadequacy of understanding, do a better job. And so, you know, there's the old story. You hear the story about a the story of a player of the glass harmonica who is the first person on their instrument. To be invited by the Israeli Philharmonic to play at the Israeli Philharmonic may not be the world's greatest orchestra, but it has the most attentive audience. And in the first 4 or 5 rows, you have people with the scores out on their lap looking at it while the soloist is playing. So this guy in the glass harmonica practices and practices launches into the Bach Preludes, and at the end, there's a standing ovation and a small voice in the back of the room cries out, play it again! And the harmonica says, oh, I'm so pleased with this response. I will play one of the preludes again, and he plays the prelude again. Standing ovation, small voice in the back of the room. Play it again! To which he responds, Ladies and gentlemen, I'm so delighted with the way you respond. I'm just too exhausted. I can't play it again. And from the back of the room comes the voice. You play it again until you get it right. Okay. And so I feel, you know, that's basically. What I've been trying to do. I've been trying in different spheres, whether it's in the sphere of clinical practice and the sphere of the health care system, in the larger sphere of social suffering, in the world, of the uncertainties and inequities of moral experience that I'm trying to get this right. And so and what is it I'm trying to get right? And I think it comes back to the earlier story I told about the human. It's the fact that. It's our humanity. What is our humanity about? What is it trying to do? Where does it come from? What does it do? And I think that's where I've got myself lodged with this enormous sense of mystery and total inadequacy on my part. But. You know you do. What's there to do? And this is what I've seen for me, is there to do.
Tyler Johnson: [00:50:35] So two things in response to to some things that you were just talking about. You know, the first one is that you, you sort of mentioned and you talk about in the same introduction to the book that I was reading from earlier, you talk about this issue that we for just to keep terms clear, I'm going to do something that you don't do, but I'm going to talk about small m morality and big M morality. Right. With small m morality being sort of the virtues that you grow up around that you assume are, you know, sort of what, what make good and bad. And then big morality being what you actually if you can try to independently reflect and sort of, you know, access your own conscience and your own moral compass, things that you may come to that are outside of your initial cultural context or that you know, that are, that you truly believe after studying and thought and whatever are normative in some kind of universal sense. And part of what I hear you saying a moment ago is that the real frustration comes when you've now spent a lifetime trying to say, well, okay, let's let's become independent from all of our cultural contexts and all of our, you know, all of the whatever religious and political and societal and, and career wise and whatever constraints and figure out. But what is the true, universally normative big M morality, right, or what we would sometimes call the big G good, but that even when you try to do that, you're always constrained, right? You you have always read the books you've read and heard, the people you've heard and been taught by the people you've been taught by and whatever. And so there is no way to be completely independent.
Dr. Arthur Kleinman: [00:52:04] And so on the one hand, I totally I mean, that's just true, right? I agree with that. None of us is omniscient. But on the other hand, and you sort of alluded to this, but I just think it's really important to articulate this really forcefully, at least in my view, is the fact that even though none of us can ever become, you know, at least as presently constituted, omniscient in a way that allows us to have some sort of, you know, complete hold on what true big M morality is. It is precisely the idea that that big morality exists, that there is such a thing as the good as right and wrong, that the struggle towards trying to find that, however inadequate we are, however endless it is, however, limited the results. The struggle still matters, right? Because otherwise it's easy to slip into this kind of endless narcissistic relativism where you just kind of throw up your hands and say, well, but you know, who cares? Everybody's values are as good as everybody else's, and you might as well just get a lot of money and live on a yacht in the Bahamas. Right? I mean, so it's important to say that I at least, you know, I'm just speaking for myself. But but as a person who reflects on these things a lot and who's, you know, utterly aware of my own limitations in trying to discover any sort of ultimate answer to them, I think that the recognition that the struggle still matters, even if the results are inadequate, is really important.
Dr. Arthur Kleinman: [00:53:37] Yeah, I'd put it. I'd put it, you know, differently than what you say. So I think if you if you stay on the level of knowledge, you're going to end up in one of three places, either on the yacht paying attention to nothing but your own self-interest. Insane. The second way or third, um, a kind of, um, minimalist in your understanding of what you could do in the world and doing some good things, but in a very minimal way. My view is this aspiration for the moral to go beyond the local is not about knowledge. It's about practice. It's about practice. And that's what saves us in this world. And what I think comes out of the Daoist tradition that I talked about, or existentialism is the actual doing. It's the doing, not the thinking, okay. It's the doing. That's what care is.
Dr. Arthur Kleinman: [00:54:33] Care is not about thinking about care. It's doing. It's being out there with people. Medicine is privileged in its classical structure. By its close connection with care, it is distinctly limited today by the distance being built in by our health care systems that keep doctors from care. And indeed, that's my view of what burnout is. I think burnout is classical Marxist alienation. It's the doctor being alienated. From what he or she wants to do in the world, which was to is to give care by the systems that tie your hands behind your back when you're in the clinic or on the ward. Okay. Yeah.
Tyler Johnson: [00:55:19] You know, I wanted to insert one thing that... This has been on my mind through so much of what you've said. One person who I think, uh, embodies the best of kind of the, the medical, the care ethic that you're alluding to, but who is not a doctor is Bryan Stevenson, the founder of the Equal Justice Initiative. I know Bryan precisely for that reason. I want to read this from Bryan Stevenson. So this is in the context of Just Mercy, his book about working for inmates on death row. This is on a night when he's been working and working and working to get this person exonerated and is working right up until the moment when the person is actually executed. So Bryan Stevenson, as it were, fails in his efforts and then has to be there as the man is executed. So he comes home from that night and then, you know, sort of falls apart in his office. And then he writes this in retrospect, the name of the person who was executed is Jimmy Dill. For the context of the quote.
Tyler Johnson: [00:56:10] We are all broken by something. We have all hurt someone and have been hurt. We all share the condition of brokenness, even if our brokenness is not equivalent. I desperately wanted mercy for Jimmy Dill and would have done anything to create justice for him, but I couldn't pretend that his struggle was disconnected from my own. The ways in which I have been hurt and have hurt others are different from the ways Jimmy Dill suffered and caused suffering, but our shared brokenness connected us. Paul Farmer, the renowned physician who has spent his life trying to cure the world's sickest and poorest people, once quoted me something that the writer Thomas Merton said we are bodies of broken bones. I guess I'd always known, but never fully considered that being broken is what makes us human. We all have our reasons. Sometimes we're fractured by the choices we make. Sometimes we're shattered by things we would never have chosen. But our brokenness is also the source of our common humanity, the basis for our shared search for comfort, meaning, and healing. Our shared vulnerability and imperfection nurtures and sustains our capacity for compassion. We have a choice. We can embrace our humanness, which means embracing our broken natures and the compassion that remains our best hope for healing. Or we can deny our brokenness, forswear compassion, and as a result, deny our own humanity.
Dr. Arthur Kleinman: [00:57:40] Yeah. Now, Bryan and Paul were friends, and they were once at an airport together. And after spending time they departed. And in leaving Bryan said to Paul, you keep going. And Paul said to Bryan, you keep going. And Bryan said, no, you keep going. And Paul said, no, you keep going. And they went on like that for about five minutes. Okay. And the gist of that, in my view, is the doing, it's the doing of it. It's the giving of care, not the talking about it, not the writing about it. It's the actual hands on with care. And that's where you really find yourself. In my view, you don't find yourself with the pop American psychology of going deep into the self, and somehow theirs is an authentic self that you realize, no, you find yourself by being out there doing with others, among others. That's where you find the brokenness. And actually the person who stated the brokenness best is Leonard Cohen, the songwriter who talked about the brokenness that lets the light in, okay, that the brokenness lets the light in. I think that it's being out in that world, in that in that world of broken people, ourselves included with it. But doing something, doing something which is the human act. And I believe what that something is ultimately is care that it all comes down to care and caring. But I think it's medicine has this immense advantage that that's what we're supposed to be doing. We're supposed to be out there. Someone appears before you. They're injured, they're hurt. You have the skills to do something. You do it. Okay. That's the doing is the most human of what we are.
Henry Bair: [00:59:32] You know, conceiving of medicine as a distillation of our aspiration for meaning is as powerful a vindication of the sanctity of this calling as any I've heard. So with that, we want to thank you, Doctor Kleinman, for taking the time to come on the show and share your stories with us.
Dr. Arthur Kleinman: [00:59:49] It was great to speak to you guys. If you get a chance, take a look at my book, The Soul of Care, which lays a lot of this out. All the best.
Henry Bair: [01:00:01] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [01:00:20] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [01:00:34] I'm Henry Bair
Tyler Johnson: [01:00:35] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
