Book Review: The Anticipatory Corpse: Medicine, Power, and the Care of the Dying

Jeffrey P. Bishop begins his ambitious critique with an invitation to friendship, calling us to listen to the hard things that follow “as if we were enjoying good food and wine in the comfort of a home” (xi). Over the next three hundred pages, he lays out a rigorous case for the way that death, rather than life, is at the center of medicine's ever-widening realm. From the cadaver, often the first “patient” encountered by medical students, to the abstractions of physiology, which suspend matter in a state between life and death, to the statistics employed to quantify and hone the efficiency of its interventions, medicine gathers its knowledge from and about the non-living. The knowledge is ordered toward gaining power over illness. But it is not over death, but rather over the way that we die, that this power is expressed. Power begets action: organ donation and the “uniform determination of death,” the intensive care unit and maintenance of death-that-is-not-yet-death; and most interestingly, according to Bishop, recent attempts to incorporate the social sciences and humanities into medicine. All of these, Bishop says emphatically, are constructed from the same type of knowledge and map out the same “biopolitical” territory. He holds them up for examination, acknowledging the great advances in health while mourning the loss of something essential at the heart of the call to heal. Indeed, Bishop has difficult things—even devastating ones—to say about the state of medicine. But his opening invitation is sincere. He offers, in the end, neither solution nor despair, but rather to share in hope: for what could renew a medicine so bent on gaining power at the boundary between life and death.

Bishop's analysis in The Anticipatory Corpse is built upon the work of Michel Foucault (1926–1984). Foucault, through much of his career, was concerned with investigations into structures of knowledge and power. He cites examples of how medicine went through a dramatic shift in the Enlightenment, leading to a dualism between will (understood as power), and matter (in this case, the matter of the body). Thinkers such as Bacon and Descartes, in their sciences, added to this dualism by rejecting two of Aristotle's four causes. Abandoning formal and final cause left only efficient and effective cause—and efficiency and effectiveness, Bishop says echoing Alasdair MacIntyre (1984), have become “the two great metaphysical and moral principles of modernity” (7). No longer concerned with purpose, or final cause, the science in which medicine is grounded looks instead to function—which can be normalized, generalized, and measured. Bishop writes,

The dead body thus acts as the epistemological foundation of knowledge because it is the stable ground against which the flux of life and disease can be known (56).

These philosophical moves liberated the powers of empiricism and efficient control, and are undeniably part of what makes modern medicine so capable of intervening in all of the marvelous ways that it does. But from physics is born a metaphysics, Bishop insists—a very particular way of envisioning the body, and the telos, “end” or “purpose,” of a human life. Bishop writes,

[M]edicine cannot help but see the body as an anticipatory corpse, precisely because its metaphysics is one that can recognize only cause and effect. It can recognize only nonliving matter playing itself out toward the final effect—the terminus—of all bodies; that is to say, the nonliving body plays itself out toward death (278).

This analysis has certain tangencies to the work of John Paul II, who emphasized at various points the unity of body and person (see, for example, Love and Responsibility, 1993, 23, and Theology of the Body, 2006, 8:4). In his introduction to John Paul II's Theology of the Body, Michael Waldstein (2006) draws from philosopher Hans Jonas to explain the effects of Enlightenment dualism: “Bacon did not anticipate this deep paradox of power derived from knowledge: that it leads indeed to some sort of domination over nature, but at the same time to a helpless subjugation under itself” (39). In his essay Waldstein quotes a passage from Familiaris Consortio (1981): “It is typical of rationalism to make a radical contrast in man between spirit and body, between body and spirit. But man is a person in the unity of his body and his spirit. The body can never be reduced to mere matter: it is a spiritualized body, just as Man's spirit is so closely united to the body that he can be described as an embodied spirit” (19). In the letter, the pope goes on to explain how Gaudium et Spes is a rejoinder to the modernism of Descartes and Bacon. In Evangelium Vitae (1995), John Paul II (1995) draws an even starker contrast, framing a modern struggle between a “culture of life” and a “culture of death.” And it is here that we rejoin the inquiry of The Anticipatory Corpse, for Bishop has things to say about the way that this “agonal struggle” plays itself out in modern politics. In order to approach this question, he turns first to the question of organ donation.

Three chapters are devoted to detailed discussions about the determination of brain death and the medical and political developments that led to the definitions that medicine uses today. Defining the precise point of transition was, and sometimes remains, remarkably difficult. Bishop devotes a chapter to the idea of finding the precise “location” of death—is it in the heart and lungs? The brain? Eventually, Bishop argues, it comes to be understood as not in the body at all, but instead is incorporated into the sovereign subject—the one who chooses.

To illustrate this point, Bishop takes a look at the cases of Terri Schiavo and Eluana Englaro. Both were at the center of debates about the continuation of life determined to be in a persistent vegetative state. Most relevant to Bishop's concerns, both cases were decided in the political spheres. He argues that both “socially conservative” and “socially liberal” viewpoints share a common boundary, and in so doing miss something of what is at stake in these decisions. In the liberal case, life is only protected when it has the possibility of being “the good life,” which requires, by extension, the ability to choose. Life outside of that state may be excluded from protections, and therefore opened up to a variety of abuses, from experimentation to death—increasingly so the more that liberalism blurs the line between killing and allowing to die. The conservative argument, on the other hand, doggedly defends the “bare life” of such individuals—at times, to the point of missing the vast tragedy inherent in what has been lost when the “good life” is no longer possible. Those who make such arguments also must contend with the ways that their struggle may codify requirements to preserve life that is dependent on technology, risking making life itself an “idol,” contrary to the views articulated by Pius XII and John Paul II that “life is a relative and intermediate good, not the highest good” (p. 123); that it must also be properly oriented to its good end, or telos. In both the liberal and conservative cases, life becomes circumscribed by in the power of the state.

[I]nherent in drawing a line between bare life and the good life is the creation of the political space that is a no-man's-land, where a person is neither dead nor alive, and also both dead and alive; we only await a sovereign decision (220).

This is one of the most challenging sections of the book, for it cuts not only against the tendency to be swept away by the technological and ideological dominance of medicine but also, at times, against those who resist that domination. He argues, looking to MacIntyre (1984), that one of the main reasons for the seemingly intractable debate is that modern society is impoverished of an entire moral category: that of a moral tragedy. Such tragedies, in which the protagonist is confronted with two rival but mutually exclusive actions, do not yield to a calculus of the “best option” given the potential consequences. Neither may they become a question of the priority of one moral appeal over another. Instead, the protagonist must own the fact that whatever he or she chooses, he or she will leave undone something that should be done. What is left, MacIntyre (1984) argues, is to act with virtue:

The tragic protagonist may behave heroically or unheroically, generously or ungenerously, gracefully or gracelessly, prudently or imprudently (MacIntyre, 1984, 224).

This virtue is measured as what is fitting and proper for the flourishing of the individual, for his or her oikos/home, for the greater community. And the protagonist must also mourn what is left undone. Both Bishop and MacIntyre (1984) point to our society's lost capacity to mourn: instead, modern victors throw their lot in with constituting powers, those sovereigns in control of life and death, which necessarily do violence to those under their control. Bishop writes,

We have lived so long within modern biopolitics that we can no longer conceive of oikos as anything but political … The resources of oikos are already lost to us, for the polis reaches right down to bare life (218–219).

The final chapters bring Bishop's thesis into its starkest resolve. Here, Bishop identifies various attempts to bring humanity and compassion back into a medicine so enamored with efficient control. He labels the new movement “biopsychosociospiritual medicine,” which in itself emphasizes the ad hoc nature of the various interventions, tacked on one after another, concatenated in a single and all-encompassing gesture.

Bishop is quick to affirm the genuine goods of some of these practices. But he also points to how, when institutionalized, they can become normative: forcing the variety and depth of human experience into stages of grief; turning religion into a coping mechanism that is useful so long as it produces constructive behaviors.

Are the dying not more expertly controlled with the psychologist, the social worker, the chaplain evaluating with their various tools of assessment, deploying their disciplinary expertises?

he asks (6–7). The trouble is at the root: that the metaphysics of medicine lacks its proper telos. The human is envisioned by medicine as only being concerned with cause and effect; the only good that medicine can provide, even with its psycho-socio-spiritual trappings, is to preserve some normal function isolated from the meaning of an individual life in the richness of context and community.

These discourses of meaning and comfort define and create in a self-reflexive manner. That is, as they define the “good death,” they also create it—manufacturing a death that necessarily involves medicine and all of the sciences under its command. Death is at the beginning of these sciences and is their inevitable terminus. And with this metaphysics, Bishop chillingly writes, the care of the dying inevitably becomes fatal. “Death becomes the means to cause comfort” (278), he says, for “Medicine cannot let the dying be” (284).

The book does not end with this gesture of despair, and there is a brief but invigorating phenomenological turn near its end. Bishop looks toward a new science, envisioning a medicine grounded in life, and humbled to the ultimate good of persons. He proposes, even, that theology might be what can save medicine: looking to communities that can re-integrate what has been torn asunder by the dualisms and reductions of modernity, that have preserved in enclaves at the periphery of biopolitics some of the saltiness of integrated life. Hope, too, comes in the encounter of person with person, the call of the suffering one and the response of the healer. The healer is only able to respond because he or she has always already been the recipient of another's answer to his or her own call.

In the suffering of the other, one is called into becoming—and thus into being—what the other needs. Both the other and the perceiver undergo a transformation of being (301).

And in their suffering, they create a new cycle: not from death unto death but rather from dependence unto gift.

Perhaps the best friends are those who we can count on to help us name things we cannot name ourselves. It will take such friendships to regain a sense of hospitality in the face of the challenges medicine faces today. Bishop does much to name the problems, and takes us even to the threshold of a possible solution. What medicine, and by extension, humanity, needs, Bishop says in his conclusion, are not prescriptions, but living traditions; not reformers, but saints.

The Anticipatory Corpse, the first book of physician, philosopher and educator, Bishop, is highly recommended to those who work in the disciplines of palliative care, end-of-life care, and at the intersection of faith and medical practice. It is an impressive demonstration of the way that faith can infuse philosophy and engage a culture. The book bears its weighty points with subtlety, and never becomes a polemic. It sure-footedly makes its way among the various domains of medicine, social sciences, and history, offering many insights along the way.