The Face and the Person

I carry the plenum of proof, and everything else, in my face.

Walt Whitman, Leaves of Grass

The importance of the face in human interactions from the day we are born
cannot be overstated.

Infants, even if they are blind, communicate their feelings to
their parents in large part through facial expressions. For children and adults, so much of what we comprehend about people’s feelings
involves interpreting a glance, a smirk, or raised eyebrows. And there has been research suggesting that our own facial expressions can affect how we feel — what is called the “facial feedback hypothesis.”

I didn’t fully understand the importance of facial communication, though,
until I met patients with illnesses — such as

Parkinson’s Disease
 (PD),

depression
, and

schizophrenia
 — that drastically alter a person’s ability to express thoughts and feelings
through small movements of facial muscles. When meeting patients afflicted in this manner, I don’t know how
they receive my questions or explanations. I don’t know if they’re upset. I
can’t tell what they’re going to say next. The emotionless face, so empty
and devoid of character, can be frightening; a person
seemingly unaffected by emotion is capable of almost anything. Of course, these
patients experience emotions of all kinds. Their faces just don’t exhibit
them.

Leon Kass writes in Toward a More Natural Science about the
importance of emotions expressed through the face, for instance in blushing. This can help us to think about patients with
limited facial communication.

Blushing, like many facial expressions, “is not under our control.” Moreover, blushing is the “involuntary outward bodily manifestation of a very
complex psychophysical phenomenon.” Mental states induce blushing: shyness,
modesty, embarrassment, shame. Many of us blush when we’ve done something
wrong, know we’ve done something wrong, and are scolded for doing so. It is,
in certain respects, a public proclamation of shame. Similarly, the
furrowing of the brow, a smile, and a frown are also public manifestations of
mental states. All
this indicates that we are social beings and cognizant of those
around us. To wit, Kass argues that blushing requires a notion of the self,
a concern of how one appears to others, and an “awareness that one is on
display.”

The same is not always true about every facial expression, but
it is certainly applicable in most circumstances. When we laugh at someone
else’s joke, or cry when wronged in some way, we can do so alone. But more
frequently we do so in front of others and in response to others. In the
case of crying, we may try to be alone when we sob because we are concerned
about appearing fragile or weak. With smiling or laughing, we are
recognizing that someone else said something funny. These are social
reactions that require cognizance or acknowledgement of other human beings, and many of our facial expressions take place within the context of
social relationships. “The face,” Kass writes, “is not only the organ of
self-expression and self-presentation, the source of our voice and
transmitter of our moods; it also contains the chief organs for beholding
other selves.”

Because of the significance of the face in our social interactions, it is
“most highly regarded, both in the sense of most looked at and in
the sense of most esteemed.” Attention, wanted and unwanted, centers on the
face. Yes, some superficial aspects of ourselves can reveal much
beneath the surface: our deepest worries, fears, and joys. Such an
understanding ought to give us new appreciation for the kinds of
difficulties patients without facial expressions confront. They are
handicapped in their interactions with others. They inadvertently block a
vital mode of communication. They cannot indicate how they feel without
using words. As physicians we treat the symptomatic aspects of diseases
like Parkinson’s, but we cannot change someone’s face; even while patients
are on their PD medications, their facial deficits persist. It is one of
those debilitating aspects of illness that one can easily forget when thinking about people who suffer from these illnesses but that one cannot ignore when facing them in person.

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in
trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes
on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also
confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I
mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever
discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to
it.

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is
why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will
“make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted
something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was
having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the
elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health”
in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my
question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an
answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a
technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there
will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the
purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her
golf swing, or a family physician might administer amphetamine injections to people who want to
feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed,
doctors daily witness death and terminal illness. If we know CPR,
do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the
prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy
are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines
breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely
solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine,
is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the
Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism … composed of parts. It is a structure and not a
heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that
make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is
not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and
buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts
and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This
demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children
who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis
to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human
being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not
involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic
surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought
to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for
patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes,
“large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine
and we would be remiss if we didn’t study this purpose carefully. Without a purpose,
medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.

“What it Means for Society to Drastically Prolong Life” (panel two)

The second panel at today’s conference was called “Happily Ever After? What it Means for Society to Drastically Prolong Life.” The first speaker was Ted Fishman, author of the concisely-titled book Shock of Gray: The Aging of the World’s Population and How it Pits Young Against Old, Child Against Parent, Worker Against Boss, Company Against Rival, and Nation Against Nation. The title actually tells you a lot about his talk, which seemed remarkably level-headed and even-handed for this conference.
Fishman didn’t seem to have a dog in this fight, but just noted that life extension could play out a number of different ways, some rather good and others quite horrific. He worries in particular about social engineering projects, noting in particular that the Chinese went from encouraging families to have ten children under Mao to the notorious one-child policy. Fishman made this observation about global conflict: “If we think about the fight people are already willing to put up over the life they have, imagine if we were fighting to preserve much longer lives.” I haven’t read Fishman’s book, but after his brief talk, I’m very interested to do so.
Many of the conference speakers commented on how the population is aging at a staggering rate, with the fraction of the population over age 65 increasing from less than a tenth a few decades ago to the territory of a quarter or a third in the near future. Which reminds me of a perennial, basic problem for transhumanists and proponents of radical life extension: ostensibly, they should be celebrating this great gain in long life. Yet their ideology is, almost without exception, based upon a fetishization of youth and a loathing of old age. There’s a weird sense in which getting closer to their goal actually gets them further away. Which may be part of why today, at the greatest point for longevity in human history, we have a conference panel that refers to a “war on dying” and a “battle against aging.” As I’ve noted before, transhumanists paradoxically are only likely to feel more desperate and more martial as they get more of what they want. One wonders what they are liable to do as that sense of desperation increases.

Ted Fishman and Jason Furman.
Speaking next was Jason Furman, Deputy Assistant to the President for Economic Policy, and Deputy Director of the National Economic Council. He gave a wonky, mile-high analysis, and noted among other things that the Obama administration’s entire contingency plans for what we would do if the population started living to 150 or 200 consists entirely of Furman’s own thoughts on this in preparing for the conference over the last few days. I think I actually find this more reassuring than not.
Next up was S. Jay Olshansky, a demographer, frequent commentator on aging issues, and professor of epidemiology at UI-Chicago. Olshansky said that with life expectancy, you reach a point of diminishing returns: when you keep putting in the same amount of effort, you get less and less for it, which is why we’ve been stuck with life expectancy in the 75/80 range for a while. He noted that even if we completely cure cancer, we would only gain 3-3.5 years in life expectancy; for heart disease, 4 years; for both together, less than the combined 7 years.
Life extension should not be our goal, Olshansky argued; health extension should be. If we radically extend life, we may push into the region of life spans where we see types of ailments and degenerative diseases that are far worse than we’ve seen today. We may get to a point, that is, where the tradeoff is worse. But if we delay the aging mechanisms entirely, our situation could be much better: a three-year delay in the biological onset of aging would be the equivalent to curing cancer. And he thinks a seven-year delay is possible. Olshansky’s presentation seemed to be the most sensible, levelheaded, practical-minded one here — although I am skeptical about the notion that we will find horrible new degenerative diseases if we push up the life span, unless it’s well past the range that many people are already living now.
After Olshansky, Arizona State University professor Jason Robert (pronounced ro-BAIR) gave a weirdly rambling exposé of how he recently lost a hundred pounds, won $4,000 at a slot machine, and bought a sweet bike. (I’m not making this up. I have no idea what the connection to anything was, though he tried to explain it later.) Robert offered a whirlwind tour of the potential ethical issues related to radical life extension — changes in the social structure chiefly, changes in distributive justice, and changes in human flourishing. Unfortunately, he didn’t seem to have time enough to really go into any of these issues.
In his presentation, Robert divided the bioethics world into shiny-eyed bio-libertarians, naming Ron Bailey as an example, and set up quite a pair of straw men in Francis Fukuyama and Leon Kass as bio-Luddites who don’t like any technology. These are caricatures of all three men. But Robert offered these caricatures so he could set himself up as the reasonable moderate, offering a “liberal” approach, whereby people can get together to discuss different understandings of the good, and how those understandings should lead us to develop new technologies. Which is in fact just the idea behind Leon Kass’s approach (and, I think, is implicit in Fukuyama’s and Bailey’s expressions of their own ideas of the good).
The Q&A session following this panel was mostly unremarkable, except for one speech by Jay Olshansky. He said he was very disturbed by a conversation he was part of the evening before the conference — a conversation among the panelists over dinner last night. As Olshansky related it, talk of life extension and aging populations very quickly gave way to talk of health-care rationing and killing off the elderly to make way for the young. He didn’t name names, and nobody stepped up to confirm or refute what he said — in fact, it wasn’t mentioned again.
NIH director Francis Collins had to go testify on Capitol Hill, so the keynote presentation was canceled. So that’s all she wrote. For some alternate coverage, delivered with more of an air of neutrality and picking up on various details I missed, check out James Hughes’s post on the conference.