December 31, 2009

1. Kierkegaard and the Diamond Body

The local GreatBooks group recently discussed “The Knight of Faith,” an excerpt from Kierkegaard’s Fear and Trembling. Many people in the group were baffled by Kierkegaard; some of the most voluble members of the group were silent.

I was struck by how closely the essay followed the author’s life; much of it reflects Kierkegaard’s relationship with Regina Olsen. Kierkegaard frequently refers to Abraham and Isaac. As Abraham is prepared to sacrifice the beloved Isaac, Kierkegaard sacrificed the beloved Regina, breaking his engagement to Regina a day after they were engaged.

Kierkegaard says, “When the child is to be weaned, the mother blackens her breast.”1 Kierkegaard himself, after breaking his engagement to Regina, tried to wean her from him by making himself unattractive — blackening his breast. (He went to the theater every night, so that he would appear to be a social butterfly, a man-about-town, not someone who was deeply in love with Regina.)

When he describes “infinite resignation,” Kierkegaard speaks of “the pain of renouncing everything, the most precious thing in the world.”2 This is what Kierkegaard himself did: he renounced everything, even the most precious thing, Regina. One can renounce even life itself; Kierkegaard insists that one can “experience death before one actually dies.”3

But this isn’t pessimism or nihilism; by overcoming the fear of death, one can live more fully. Kierkegaard’s Knight of Faith “finds pleasure in everything, takes part in everything, and every time one sees him participating in something particular, he does it with an assiduousness that marks the worldly man who is attached to such things.”4 Nonetheless, the Knight of Faith isn’t a worldly man, and isn’t “attached to such things.”

Though he’s different, the Knight of Faith looks the same, he blends in; having passed through the infinite, he has returned to the finite. In this respect, Kierkegaard’s Knight is probably akin to the knights of other spiritual traditions. The Zen knight, for example, probably blends in, also the Muslim knight. According to a Muslim saint, “The true saint goes in and out among the people and eats and sleeps with them and buys and sells in the market and marries and takes part in social intercourse, and never forgets God for a single moment.”5 This sounds like a quotation from Kierkegaard.

The connection between Kierkegaard’s essay and Kierkegaard’s life becomes even more explicit when he discusses “a specific case.... A young lad falls in love with a princess, and this love is the entire substance of his life, and yet the relation is such that it cannot possibly be translated from ideality into reality.”6 So the young lad’s love for the princess would become “the expression of an eternal love, would assume a religious character, would be transfigured into a love of the eternal being.”7 Doubtless Kierkegaard’s love for Regina was “transfigured into a love of the eternal being.”

Kierkegaard understands “the deep secret that even in loving another person one ought to be sufficient to oneself.”8 Kierkegaard’s aim is self-sufficiency, maturity, personal growth. As Jung would say, one must have a certain detachment, while remaining active and involved. One shouldn’t be so attached to the beloved that one is “insufficient to oneself,” that one must have the beloved.

As I argued in a previous issue, Proust depicts the sickness of attachment, the failure to achieve self-sufficiency/detachment/resignation. Kierkegaard’s self-sufficient lover “is no longer finitely concerned about what the princess does.”9 Proust’s lover, who isn’t self-sufficient, is obsessed with what the beloved is doing when she’s out of his sight; he’s consumed with jealousy.

Nowadays, one often hears, “you can be whatever you want to be,” or “you can achieve anything, if you set your mind to it,” etc., etc. Kierkegaard rejects all this, or rather, he internalizes it. Instead of outer achievement, he speaks of inner achievement; instead of the external world, he speaks of the spiritual world: “Fools and young people,” Kierkegaard writes, “say that everything is possible for a human being. But that is a gross error. Spiritually speaking, everything is possible, but in the finite world there is much that is not possible.”

Kierkegaard focuses not on attaining external things, but rather on renouncing them, on being self-sufficient, on doing without. “In infinite resignation there is peace and rest.... Infinite resignation is that shirt mentioned in an old legend. The thread is spun with tears, bleached with tears; the shirt is sewn in tears — but then it also gives protection better than iron or steel.”10

Resignation should be freely chosen, not forced on one (not the result of “dira necessitas,”11 as Kierkegaard puts it). Kierkegaard wasn’t forced to forgo Regina, he chose to do so.

The concept of resignation is much the same in Kierkegaard, Proust, and Jung. Kierkegaard is a passionate Christian, but much of his thinking can be translated into non-Christian terms, psychological terms. For Kierkegaard, resignation means self-sufficiency, accepting oneself as one is, accepting oneself whether or not the outer goal is achieved: “Only in infinite resignation,” Kierkegaard writes, “do I become conscious of my eternal validity.”12 This idea of “validity” (self-acceptance) can be easily translated into non-Christian terms.

Kierkegaard also mentions the opposite of self-acceptance, namely, self-contempt. He says “self-disdain [is] still more dreadful than being too proud.”13 Again, this concept can be carried over into a non-Christian environment. Elsewhere, Kierkegaard says that, for a melancholic like himself, it is important to give up self-hatred, and learn self-love.14

Though Abraham was prepared to sacrifice Isaac, he was given Isaac back. Likewise, Kierkegaard’s Knight of Faith, having renounced everything, is given everything back by virtue of the absurd. But this strange phrase “by virtue of the absurd” is never explained or paraphrased; perhaps one must read Fear and Trembling in its entirety in order to make sense of this phrase.

2. Nietzsche and the Death of God

After Kierkegaard, the GreatBooks group discussed Nietzsche — a little, one-and-a-half-page piece called “The Madman” (section 125 of The Gay Science). Everybody joined the discussion. Nietzsche’s poetic language was provocative, not baffling. This piece contains the famous phrase “God is dead,” which reappears in Nietzsche’s next book, Thus Spoke Zarathustra. “God is dead” isn’t Nietzsche’s most important contribution to philosophy, though it may be his most famous saying. “God is dead” was Schopenhauer’s contribution (though Schopenhauer didn’t use that phrase). “God is dead and therefore morality is dead” — this might be the essence of Nietzsche. Or better yet, “God is dead and therefore morality is dead, and therefore genocide will occur.”

One might say that human history consists of a series of gods — god concepts, god images — and that each of these gods has eventually died — that is, each of these gods has eventually ceased to meet the spiritual needs, the psychological situation, the intellectual demands of the society that spawned it. Gods change and evolve because man changes — the human mind changes. Perhaps Nietzsche was right when he said that the god of his society is dead — the god of Christianity, Judaism, and Islam. Perhaps a new god image is taking shape in our time — less anthropomorphic, less rational, less fond of writing books.

Where do gods come from? Does man create gods? I would say that man doesn’t create gods any more than he creates his arms, his legs, or his dreams. Gods arise within man, as a work of art might arise within man. “Does this mean that gods don’t really exist, they’re fictions, they’re ‘all in the mind’?” They exist as the mind exists, as archetypes exist; we can’t say that they don’t exist just because they can’t be seen, touched, and measured.

Some people in the GreatBooks group said that gods are the expression of our fears. It seems to me, though, that this is another negative, reductionist view of the subject. Imagine that you’re having a bitter quarrel with your neighbor. You dream of presenting him with a bushel of apples. The next morning, you do what the dream suggests, and the quarrel is ended. The dream is the voice of God, or the voice of the unconscious (pick your term). It’s not the expression of fear, it’s the expression of wisdom.

3. Fifteen Minutes of Fame

A couple months ago, when I was promoting my new book, Realms of Gold, I mentioned it to a local newspaper, the Seekonk Star. Recently they interviewed me (through e-mail), and ran a front-page article about my work. Here’s the unabridged version of the interview:

StarFirst off, have you lived your entire life in Seekonk and how old are you now?
HammondI’ve lived in Seekonk for ten years. I’m 48.
StarI saw on your website that you were first drawn to history at the age of 15, especially Greek culture. What was it about Greek culture that caught and kept your interest?
HammondI was interested in Western civilization in a broad sense, and that begins with the ancient Greeks. One might say that the Acropolis was the high point of Western civilization — often imitated since, but never equaled.
StarYou also say on your website that you led a “Stoic Life.” What does that mean?
HammondWhen I was about 16, I tried living by various philosophies, including the Stoic philosophy. The Stoics were the opposite of the Epicureans; the Stoics didn’t seek pleasure. So a Stoic life is one that emphasizes what you should do, rather than what you feel like doing.
StarWhy do you think colleges focus more on vocation than education in humanities? What type of impact does this have?
HammondOur society is a working society. It may be the first society in history that doesn’t have a leisure class. So colleges prepare people to work, rather than preparing them to use their leisure time. At one time, it was considered disgraceful to work. Now we’ve gone to the other extreme, and we consider it disgraceful not to work.
StarWhy did you decide to start writing, both your first book and your latest work?
HammondThe people I admired were philosophers like Nietzsche. In my eyes, such people were covered with glory. So naturally I tried to be like them. I couldn’t imagine why anyone would want to be anything else. So for me, writing a book wasn’t a decision, it was something that just happens, like breathing.
StarWhat can people expect from the new book... for those who read your first work, how do the two differ and are there any similarities between the two?
HammondMy first book (Conversations With Great Thinkers) is an original philosophical work, while my second book (Realms of Gold: A Sketch of Western Literature) tries to guide the reader through a study of Western literature. My first book is about ideas, my second book is about books. Both books cover a lot of ground, both books deal with civilization in a broad sense, both books give the reader my thoughts, my opinions.
StarIs there any type of impact you hope to have on your reader, or is your work intended to apply differently to each reader?
HammondThe first book tries to persuade the reader that certain ideas are valid, certain theories are true. The second book tries to make the Western classics approachable, easy, fun. When I gave a copy of the second book to a Seekonk librarian, Sharon Clarke, she said it made her want to read so many books that she wasn’t sure where to start!
StarWhy do you think there isn’t more attention paid to philosophy today on a widespread basis?
HammondThere isn’t much attention paid to The Great Philosophers — Aristotle, Spinoza, Kant, etc. But this doesn’t surprise me, I’m not interested in those philosophers myself. They’re difficult to read, and they don’t speak to our time. But there is interest in Thoreau, Alan Watts, Joseph Campbell, Jung, etc. There was even some talk about starting a discussion group in Providence that would be devoted entirely to Jung. Joseph Campbell’s interview with Bill Moyers is one of the most popular PBS shows. I met someone in Seekonk who listens to Alan Watts while driving. I met someone on a lake in Maine who was following Thoreau’s route on his own canoe trip. I’ve participated in more than 100 discussions of philosophy and literature in the Seekonk area — some at the East Providence library, some at Books on the Square in Providence, some elsewhere. So philosophy is not dead yet. It will last as long as man lasts.

4. Atul Gawande on American Health-Care

In a recent issue, I mentioned a popular writer on medicine, Atul Gawande. According to David Brooks, one of Gawande’s pieces in the New Yorker, “The Cost Conundrum,” was the most influential essay of 2009.15

Gawande writes in a lucid, readable way; he reminds me of another New Yorker star, Malcolm Gladwell. Gawande tackles serious questions in a serious way, and doesn’t seem to have any bias or pre-conceived opinion. It isn’t surprising that he’s popular.

Gawande argues that health-care spending is out-of-control because doctors are greedy, and because the current system allows them to be greedy. If I have a pain in my chest, I call my doctor on the phone. He, or his assistants, could respond in various ways:

  • Talk to me on the phone, ask me some questions, tell me to call again in the morning. Cost: zero.
  • Ask me to come to the office for an exam. Cost: $300.
  • Put me through a battery of tests. Cost: $5,000.

Gawande argues that the current system gives doctors an incentive to choose the higher-cost approaches; doctors earn more if they provide more services. Doctors are paid for quantity, not quality. In some cases, doctors are the owners, or part-owners, of the testing equipment, the hospital, etc. Gawande recommends setting up “accountable-care organizations” that pay doctors a salary, and don’t reward doctors for providing more services. He insists that more services doesn’t mean better care; he points out that some services are risky, and may do more harm than good.

Gawande examines a Texas town, McAllen, which has high medical costs. He says that McAllen has a medical culture that sees medicine as a business, and sees patients as sources of profit. Doctors are businessmen, investors; some of them ask for kick-backs in exchange for referrals. Gawande says that a town’s medical culture can be shaped by a few leaders.

About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.

Gawande mentions “anchor stores,” which set the tone for a mall, and “anchor tenants,” which set the tone for an industry. He argues that the “anchor tenants” in the McAllen medical world set a tone of greed.

One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores. “Medicine has become a pig trough here,” he muttered. Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.

Fifteen years ago, I noticed something similar in my neighborhood. I encountered a dentist who recommended expensive procedures, procedures that other dentists didn’t recommend. Not satisfied to be a dentist, he was also a businessmen, an investor, a real-estate speculator. My wife and I suspected fraud, and switched to a different dentist.

Gawande mentions several successful examples of “accountable-care organizations.” One is the Mayo Clinic in Rochester, Minnesota.

The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked [the C.E.O.] how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs....

Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, [the C.E.O.] says that the Florida site has become, in some respects, the most efficient one in the system.

Gawande emphasizes moral factors. The system worked as long as doctors practiced in an ethical way, it broke down when greed overpowered ethical constraints. I’m reminded of the neo-conservative theories that trace social phenomena to moral factors. One neocon, James Q. Wilson, said “At root, in almost every area of public concern, we are seeking to induce persons to act virtuously, whether as schoolchildren, applicants to public assistance, would-be lawbreakers, or voters and public officials.”16 Gawande describes how we’ve failed to induce doctors to act virtuously, we’ve failed to induce doctors to consider only the health of the patient.

In a recent issue of the New Yorker, Gawande discusses the health-care bill that’s now working its way through Congress. The title of his piece is “Testing, Testing: The health-care bill has no master plan for curbing costs. Is that a bad thing?”17 Gawande argues that it’s okay to have “no master plan for curbing costs.” What’s important is testing lots of little plans, pilot programs, and he thinks the health-care bill does a good job of this:

To figure out how to transform medical communities, with all their diversity and complexity, is going to involve trial and error. And this will require pilot programs — a lot of them. Pick up the Senate health-care bill — yes, all 2,074 pages — and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

As in his earlier article, he advocates “Accountable Care Organizations” rather than the current fee-for-service approach. He says that some of the pilot programs,

try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention — so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.

Gawande compares the attempt to reform health care with the attempt, made a century ago, to reform American agriculture. He says that American agriculture became efficient, productive, a world leader, as a result of government-sponsored pilot programs. He cites an agricultural historian named Roy V. Scott, author of The Reluctant Farmer.

For industrializing nations in the first half of the twentieth century, food was the fundamental problem. The desire for a once-and-for-all fix led Communist governments to take over and run vast “scientific” farms and collectives. We know what that led to: widespread famines and tens of millions of deaths.

The United States did not seek a grand solution. Private farms remained, along with the considerable advantages of individual initiative. Still, government was enlisted to help millions of farmers change the way they worked. The approach succeeded almost shockingly well. The resulting abundance of goods in our grocery stores and the leaps in our standard of living became the greatest argument for America around the world.

Gawande scoffs at the anti-government attitude of Reagan and others. But he isn’t completely in agreement with Democrats, especially on the issue of malpractice reform:

[The health-care bill] contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan. That’s a crucial lesson of our agricultural experience.

Gawande not only praises government programs from a century ago, he also praises the government’s role in agriculture today. In short, he’s convinced that the federal government has a crucial role to play — in health care and in agriculture.

© L. James Hammond 2009
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Footnotes
1. p. 293 The excerpt is probably from a GreatBooks anthology, and page numbers refer to this anthology. The anthology, in turn, was made from an edition of Fear and Trembling that was published by Princeton Univ. Press, 1983, pages 9-14 and 35-53. back
2. p. 299 back
3. p. 304 back
4. p. 297, 298 back
5. Grunebaum, Gustave E. von, Medieval Islam: A Study in Cultural Orientation, IV, 5 back
6. p. 300 back
7. p. 302 back
8. p. 303 back
9. p. 303 back
10. p. 304 On page 307, Kierkegaard says, “Through resignation I renounce everything. I make this movement all by myself, and if I do not make it, it is because I am too cowardly and soft and devoid of enthusiasm and do not feel the significance of the high dignity assigned to every human being, to be his own censor, which is far more exalted than to be the censor general of the whole Roman republic.” back
11. p. 304 back
12. p. 305 back
13. p. 304 Didn’t Nietzsche say that the ultimate art is the art of self-love? back
14. “As a man of sanguine humor is required to hate himself, so perhaps it is required of me that I should love myself and renounce the melancholy hatred of myself which in a melancholy man can be almost a pleasure.”(Kierkegaard, by Walter Lowrie, V, 3) back
15. “The Cost Conundrum: What a Texas town can teach us about health care,” June 1, 2009 back
16. Quoted in David Brooks, “The Bloody Crossroads,” New York Times, 9/7/09 back
17. December 14, 2009 back