Sunday, July 23, 2006

Arthur Kleinman Q&A

Originally appeared in the Boston Globe

By Harvey Blume

"AFTER ALL THESE YEARS of being a psychiatrist, and anthropologist, what have you learned that's useful for living?" That's the question Arthur Kleinman, a professor of anthropology at Harvard and a former chair of the department, challenged himself to address in his new, plainspoken, and engaging book, "What Really Matters: Living a Moral Life Amidst Uncertainty and Danger" (Oxford).

Kleinman, now 65 years old and still, despite the often somber tone of the book, hale and hearty, has had an influential career as a psychiatrist, teacher, researcher, and writer. His book "The Illness Narratives: Suffering, Healing and the Human Condition" (1988), now standard fare in medical curriculums, is a defining text of medical anthropology, a field that uses anthropological methods to study the social and cultural elements of disease.

In "The Illness Narratives" Kleinman insists that it isn't enough for physicians to master the relevant biology, especially when treating chronic illness. Chronic diseases, he wrote, "by definition cannot be cured," and to effect even "modest improvement," a doctor must appreciate the psychological and social components of the ailment. It is in part due to Kleinman's efforts that the idea of healing--alongside the more traditional notion of curing--has gained a foothold in the medical establishment.

The new book broadens the scope of Kleinman's earlier work by asking the same kinds of questions about human life as a whole that he had previously asked about illness per se. Given that most of us are bound to experience, "some kind of health catastrophe near the close of our lives, if not sooner," what, he asks, makes for a good life, a meaningful life? To find answers, Kleinman mines his own experience and that of eight other people--a disparate group that includes a New York City sanitation worker, an Israeli kibbutznik, and an English psychologist who treated soldiers shell-shocked during World War I. What he values in these cases is people's efforts to act ethically in the midst of suffering and adversity.

When I met with Kleinman in his office at Harvard's William James Hall, I opined that "What Really Matters" was obviously not written with the youth market in mind.

KLEINMAN: You have to be of a certain age, to travel through dark periods. I've spent my whole career working on suffering, so it's not that I'm unfamiliar with it. And I've had some diseases--asthma, for example, hypertension--but they never affected me the way my wife's neuro-degenerative disease, which has ruined her vision, affected me. The book was written during a stage of my life that was--that is--difficult.

IDEAS: The book is in some ways a critique of language, isn't it? You make a point of trying to clear the air of the medical language that obscures what you see as the basic realities of human life.

KLEINMAN: There are key psychiatric disorders like schizophrenia and depression, but I'm very concerned about people who have ordinary unhappiness, or have experienced a catastrophe, or just bad luck, and are renamed depressed or having an anxiety disorder. That's happening in a big way right now. I'm concerned about taking ordinary life, stripping it of its moral content, and making it over into a disease.

IDEAS: Are you still a practicing psychiatrist?

KLEINMAN: I stopped practicing about six years ago. But I had 25 years of practice and saw thousands of cases. I saw many people in psychotherapy and also used psychopharmacology. It's precisely because I believe in the seriousness of mental illness that I've been concerned about medicalization, remaking the normal into the abnormal.

IDEAS: Why is this happening?

KLEINMAN: There's a hyping not just of psychiatry, but all of medicine. This has come out of the medical-industrial complex, and the need to get medicine the resources and support it needs, for research, among other things. I'm all for medical research--but not the hyping. The other day I received a solicitation from a medical foundation, and was surprised by the first sentence, which said: "Imagine a world free of disease." That's inhuman! There can't be a world free of disease. Disease is part of what life is about.

By the time you get to be my age, in the middle of your seventh decade, you're going to realize that just about every family is going to deal with a social or health catastrophe. That's not something people have been prepared for. It's grim. But the grimness is made over by religion, aesthetics, ethics, into something that makes life meaningful.

IDEAS: One of the key figures in the book is Winthrop Cohen, a hero of World War II in the Pacific, who came to you in his 60s, some years ago, and was depressed. But didn't you, when you looked over your notes more recently, conclude that by calling him depressed you were missing something essential?

KLEINMAN: I missed the moral statement. Here was a decorated solder, who had, in his own words, been turned into a killer, committing several atrocities. The worst was that he'd killed an unarmed Japanese doctor who had been treating Japanese wounded. Think of how hard it is for a guy who's been treated as a hero to say, "I killed a doctor up close, who looked in my eyes, and made me feel I was a real killer." There are some things you can't say.

The rest of his life was an encounter with that atrocity, a constant attempt to deal with it, and finally, a kind of giving up. That produced a very severe clinical depression. But the clinical depression was in the context of the tragedy. And maybe the illness, the fact that he really did become depressed, allowed him to speak.

IDEAS: You stress the importance of ethics to meaningful life--the need to resist local norms, go against the flow. But whether you're writing about Winthrop Cohen, or a survivor of the Chinese Cultural Revolution, or a humanitarian worker in Africa, or telling your own story, what comes out is how hard it is be ethical, how many gray areas there are.

KLEINMAN: The best most of us, me included, can do, is less than heroic. Most of us are caught in situations in our work, in our institutions, maybe even in our families, where part of us is a collaborator. Periodically, we make a decision to stand up for something. How do we do that? I don't have the answers. I'm just saying that in looking at people over the course of my life I'm astonished to see that most of us try to build this ethical part of our lives.

DEAS: How important is guilt to ethical behavior?

KLEINMAN: It is important to the moral imagination. It makes us unpack ourselves, be critical of ourselves, and begin to step out of ourselves. It helps us imagine what it would be like to be in the other person's shoes.

IDEAS: Can you give me an example of ethical behavior from your own life?

KLEINMAN: I'll never forget this. I was sent by the NIH to a medical research unit in Taiwan during the Vietnam War. I was odd man out because I was from the NIH. The worst the captain who ran the place could do to me was send me back to Bethesda, Maryland. Navy doctors could be sent to the boonies in Vietnam with a Marine battalion. So no one ever spoke up, except for me.

We had a neurosurgeon who was comparing the Korean War to Vietnam, and said: "We've made incredible gains in neurosurgery. Today we can keep a soldier alive who's got half a brain." I remember him saying that, exactly. So I raised my hand and said, "Well, maybe preventive medicine would be better." Everyone looked at me. If I was a Navy physician, I wouldn't have said that.

Harvey Blume is a writer based in Cambridge.