Risk and Regulation at the Interface of Medicine and the Arts : Dangerous Currents [1 ed.] 9781443893473, 9781443898881

Citation preview

Risk and Regulation at the Interface of Medicine and the Arts

Risk and Regulation at the Interface of Medicine and the Arts: Dangerous Currents Edited by

Alan Bleakley, Larry Lynch and Gregg Whelan

Risk and Regulation at the Interface of Medicine and the Arts: Dangerous Currents Edited by Alan Bleakley, Larry Lynch and Gregg Whelan This book first published 2017 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2017 by Alan Bleakley, Larry Lynch, Gregg Whelan and contributors All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-4438-4813-1 ISBN (13): 978-1-4438-4813-8 This book is a result of a concerted drive to create dialogue between medicine and the arts, the performing arts in particular; and to restore the spirit of radical education to Dartington Hall. The 2015 Association for Medical Humanities (AMH) conference received generous financial support from Falmouth University and the Wellcome Trust.

Fig. I: ‘The biggest risk is not taking any risk ... In a world that’s changing really quickly, the only strategy that is guaranteed to fail is not taking risks’ —Mark Zuckerburg. ‘High Wire Man’ courtesy of Peter Rood 2012

TABLE OF CONTENTS

Acknowledgements ..................................................................................... x Introduction ................................................................................................. 1 The Dartington Effect Alan Bleakley Overview Chapter One ............................................................................................... 10 Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives Jennifer Patterson Part I: Selected Keynotes Chapter Two .............................................................................................. 26 The Chances Alphonso Lingis Chapter Three ............................................................................................ 32 False Truths A Conversation between David Cotterrell and Roger Kneebone Chapter Four .............................................................................................. 52 Arts-based Learning in Medical Education: The Risks Allan Peterkin and Suzy Willson Part II: Performances Chapter Five .............................................................................................. 68 It’s Good to Breathe In (This Devon Air) Martin O’Brien Caroline Wellbery ................................................................................ 74 How to See Pain Neville Chiavaroli ............................................................................... 81 Through the Champagne Glass, or, What Has Radical Arts to do With Medicine?

viii

Table of Contents

Chapter Six ................................................................................................ 85 Preface to Hardy Animal Laura Dannequin Lecture Demonstration ........................................................................ 88 Chapter Seven............................................................................................ 91 Titillation Emily Underwood-Lee Chapter Eight ............................................................................................. 98 The Hauntologies of Clinical and Artistic Practice Joanne ‘Bob’ Whalley and Lee Miller Part III: Histories Chapter Nine............................................................................................ 112 Norm and Deviations: Neoclassicism and Anatomical Illustration in Eighteenth and Nineteenth Century Britain Allister Neher Chapter Ten ............................................................................................. 129 Art as Resistance to Death Vassilka Nikolova Chapter Eleven ........................................................................................ 154 ‘Through Vast Realms of Air’: The Poetry of Francis St Vincent Morris Paul Dakin Part IV: For Some, Just Living is a Risk Chapter Twelve ....................................................................................... 166 Haiti’s Suffering Body: Medical Themes in Jacmel’s Kanaval Bridget MacDonald Chapter Thirteen ...................................................................................... 171 ‘Liminal Identities’ and Power Struggles: Reflections on the Regulation of Everyday Foodways at a Homeless Centre and the Use of Creative Participatory Research as a Tool of Empowerment and Resistance Julie Parsons and Clare Pettinger

Risk and Regulation at the Interface of Medicine and the Arts: Dangerous Currents

ix

Chapter Fourteen ..................................................................................... 190 Medical Humanities Generation Gap Sangeetha Saunder Chapter Fifteen ........................................................................................ 192 ‘Fowl Language’: A Medical-Humanities Conversation Andrew N. Williams and Nicola Scudamore Part V: Exhibition: At the Sharp End of Bluntness Chapter Sixteen ....................................................................................... 210 At the Sharp End of Bluntness Sue Bleakley, David Cotterrell, Ruwanthie De Chickera and Martin O’Brien Sue Bleakley ....................................................................................... 212 It’s in the Bag David Cotterrell and Ruwanthie de Chickera .................................... 214 Mirror: Hierarchy Martin O’Brien .................................................................................. 240 It’s Good to Breathe In (This Devon Air) Contributors ............................................................................................. 241

ACKNOWLEDGEMENTS

Alan Bleakley would like to thank his wife Sue, who contributed to the conference and to this book, for her support for his wild educational schemes; and his wider family just for being who they are. The editors owe thanks to Kerry Taylor, Falmouth University, for her tireless work towards making the AMH 2015 conference such a success, and for sculpting the final book manuscript. Falmouth University and the Wellcome Trust provided generous financial support for the conference. Thank you to the Wellcome Trust for continuing to promote the medical humanities in the UK through support of research, conferences and public engagement events.

INTRODUCTION THE DARTINGTON EFFECT ALAN BLEAKLEY

This book offers a selection of presentations from the 2015 Association for Medical Humanities (AMH) Annual Conference at Dartington Hall, Devon, UK, June 23-25: Dangerous Currents: Risk & Regulation at the Interface of Medicine & the Arts. The focus was on how performance art might inform medical practice. The conference organizers were Alan Bleakley and Larry Lynch. Alan Bleakley was President of AMH from 2013-2016. AMH is the longest established Association of its kind internationally; is registered as a learned society; has run annual conferences since 2002; and has a constitution, a vibrant membership, and a website (www.amh.ac.uk). AMH has been instrumental in shaping the culture of the medical humanities in the UK and influencing North American and Canadian organizations in the field. The Association has also lobbied funding bodies – the Wellcome Trust in particular – to provide significant funding both for centres of research and for individual projects within the UK. While annual conferences have focused on conversations between medicine and healthcare and the arts and humanities, these have tended to privilege medicine and the humanities over the arts, and have not given adequate space to performing arts. Alan Bleakley had run the AMH annual conference in both 2005 and 2010, giving a voice in particular to visual artists working with medical themes. For the 2015 conference, he wanted to focus upon the contributions of the performing arts to the medical humanities. A parallel exhibition was planned, running at the Dartington Hall Gallery, that is documented towards the close of this book. The conference included six plenary talks and performances, focusing on collaborations between artists and doctors; four performances; three films; and sixty paper presentations; plus the parallel exhibition referred to above. There were just over one hundred delegates.

2

Introduction

Dartington’s Legacy When I visit Dartington Hall, I salivate like Pavlov’s dogs. Actually, the reflex is metaphorical – more a flow of creative juices. Yet, on recent visits, I found this reflex was on the wane and it was easy to see why – Dartington was turning into a cosy National Trust treasure, its radical arts legacy withering on the vine. Dartington College had long since moved to Falmouth University, an organ transplant that has puddled rather than firmed up. Many of the nerve connections with Dartington’s radical spirit have been severed, as courses in the performing arts have become commodities in a labour market. The Dartington Gallery was morphing into a tasteless gift shop; and the Great Hall was hosting weddings and other functions, rather than ringing with intellectual debate, birthing the extraordinary and celebrating the non-functional. Dartington College alumni include the writer Deborah Levy, the saxophonist Mornington Lockett, the artist George Passmore (of Gilbert and George), and the composer Patrick Nunn. Alumni of Dartington Hall School (closed 30 years ago) include the painter Lucian Freud, the sociologist and educationalist Michael Young, the jazz saxophonist Dick Heckstall-Smith, the artist Breon O’Casey, the painter and musician Mark Fry, the literary editor Miriam Gross, the broadcaster Kirsty Lang, the jazz musician Lionel Grigson, and the epidemiologist and anthropologist Matthew Huxley, son of Aldous Huxley. The historian, social critic and novelist Theodore Roszak coined the term ‘counterculture’ to describe the San Francisco Height Ashbury hippie peace culture and its aftermath, a rapid transformation into an aggressive political movement aligned with black and feminist liberation. But countercultures are processional. Just a generation before hippies, the Beats smoked marijuana, studied Zen Buddhism and invented stream of consciousness writing. But wait, wasn’t that James Joyce who championed stream of consciousness in the 1920s; or maybe Laurence Sterne in 1757 with Tristram Shandy? And didn’t Aldous Huxley study Buddhism and the effects of mind-altering substances? Huxley gave talks at Dartington in the 1930s when it had got into its stride as a total educational experiment in living after the purchase of the estate by Dorothy and Leonard Elmhirst in 1925. The Elmhirsts established a centre for radical arts and crafts, sustainable living, the ecological imagination, and innovative Deweyean education culminating in a school run by its pupils in collaboration with often mildly eccentric but open-minded educators. The Elmhirsts too introduced non-Western values and spiritual perspectives to displace an

The Dartington Effect

3

entrenched Western colonialist mindset long before ‘post-colonial’ thinking informed contemporary cultural studies. So, the ‘counterculture’ is a processional effect, a recent edition of which was the annual ‘New Themes in Education’ conference series run at Dartington from 1984 to 1986, directed by the filmmaker and writer Mark Kidel. This is when I first came into contact with what has been called ‘the Dartington Effect’. The Dartington Effect is an infection, rippling out from a total living experiment shaped by radical experimentation in the arts. It stains the bland and ordinary, and bruises too-tender sensibilities. The ripple too is a sticky ghost that latches on to you, even as you enter the medieval courtyard - and makes you rash, or think and do interesting things on impulse, just to see the consequences. While the College and school were in full swing (the school closed after a scandal in 1987) the place seemed hugely energized, a focus of a new counterculture. The Dartington Effect was particularly evident in the New Themes in Education Conferences mentioned above, where I first encountered its fiercest flames, such as Michael Young, co-architect of the UK Welfare State and the National Health Service, and founder of the Open University. At the Dartington Education Conference the Tao of Physics (Fritjof Capra) was rehearsed; poets Peter Redgrove and Penelope Shuttle described how sex and poetry were interdependent; Arnold Keyserling, son of the philosopher Count Hermann von Keyserling, and exposed as a youth to the teachings of Gurdjieff and Ouspensky through face to face encounters in Paris, brought shamanic teachings; and the economist Borna Bebek drove from Zagreb to Dartington in a ramshackle sports car to deliver a mind-bending talk on how to read Plato; these, amongst a host of other inspiring events. Sandwiched between conferences were workshops such as that run by James Hillman on animals in dreams and myth. I gave talks here too and ran workshops with my partner Sue. We even gained a reputation for pushing the boundaries. I was proud that this happened at Dartington – that I had contributed some creative juice and poetic effect to its procession. I had such nourishing lasting memories of boundary-stretching events at Dartington that when the opportunity to run the 2015 Association for Medical Humanities conference came up, in my second year as President of that organization, I immediately booked Dartington Hall as the venue. Serendipitously, I had retired from my longstanding Professorial post at Peninsula Medical School and was working part time for Falmouth University as Professor of Medical Humanities. To add to the serendipities, I formed an alliance with Dr Larry Lynch, Director of the Academy of Music and Theatre Arts (The Performance Centre) at

4

Introduction

Falmouth, who had been a Dartington student and continued to study for his PhD there, and then worked at the College as director of art and performance. Larry too had noted Dartington Hall’s decline into the bland and was keen to spike the drink. Professor Gregg Whelan, a performance artist and academic who had recently joined the Falmouth faculty, joined the party. Gregg too was a Dartington graduate and his parents still live on the estate. Larry and Gregg recommended booking other Dartington alumni and ex-faculty as speakers and performers, such as Aaron Williamson and Martin O’Brien. The stage was set.

Dangerous Currents: Risk & Regulation at the Interface of Medicine & the Arts The 2015 AMH conference promoted dialogue between medicine, the arts and humanities with six particular emphases: 1. Social justice. 2. That artists would have a high profile at the conference and not play ‘handmaiden’ to medicine and doctors. 3. That within the arts, performance would have high profile. 4. That the tradition for radical art and innovation associated with Dartington would be upheld through the process and content of the conference. 5. That work presented should attempt to alter perceptions and practices in medicine and medical education. 6. That medical and healthcare practitioners attending the conference could see their work as a performance – scripted, staged, rolerelated and performed with frontstage and backstage elements. Medical students, after all, encounter simulated ‘actor patients’ in clinical skills settings as a prelude to ‘live’ clinical engagement. The weather was perfect, the setting glorious and the conference exceeded expectations in terms of intellectual and practical ferment, pushing the boundaries and setting high standards. There was fizz, collaboration, argument, consent, dissent and ferment. Flat spots were mostly experienced in the days after the conference, as a sense of loss. This book offers only a selection of the work presented at the conference – a slice of a very rich cake. It will have great sentimental value for those who participated in the conference, but it offers more than that. It is also a slice through some of the varied and interesting work that is currently being done under the umbrella terms of the ‘medical

The Dartington Effect

5

humanities’ and ‘health humanities’ – terms that cover the improvement of medical education through engagement with the arts and humanities, public engagement with medicine, the study of medicine as a discipline and culture, and the wider use of the arts as an accessible medium for therapy. Many prefer the descriptor ‘health humanities’ as a more inclusive term moving beyond just medical culture to embrace healthcare as a whole. It seems to me that what is currently the most interesting of the health humanities’ many foci is engagement with the intertwining of politics and aesthetics in medicine (Bleakley 2015). This has been highlighted by the recent (2016) series of junior doctors’ strikes in England. Junior doctors are simultaneously becoming politicized and interested in style of practice. A new generation of young doctors – almost certainly shaped by an emerging demographic of more women now practicing medicine than men – is embracing issues of social justice and patient-centredness; displaying resistance to unproductive and previously dominant norms of clinical practice such as paternalism, authority-led hierarchies, and institutional cynicism; and noting that medicine is successful not just because of what you do, but also how you do it (style of practice, including ethics, professional behaviour, and communication with both patients and colleagues in clinical team settings). Style of practice can be summarized as the aesthetics of medicine. Use the word ‘aesthetic’ in medicine and surgery and you risk being mocked – unless of course you are referring to aesthetic (i.e. plastic) surgery; yet, medicine is regularly described as an art as well as a science. Aesthetics at root means ‘sense impression’ and doctors must above all learn to use their senses in diagnosis. Medicine, like art, is grounded in the education of sensibility and this extends beyond using the senses for diagnostic reasons to the place of sensibility in forming therapeutic relationships with both patients in consultations and colleagues in clinical teams (Bleakley 2014). Yet ‘sensibility capital’ or what is valued about how one should sense – as Jacques Rancière describes the political dimension of aesthetics in culture – is rarely discussed in medical education. Medical students do not learn that sensibility capital is a form of power held by senior doctors and not readily distributed to medical or healthcare students, other healthcare practitioners such as nurses, and – above all – patients. Indeed, senior doctors often render medical students insensible in medical education where they resort to teaching by humiliation or fail to demonstrate the humanity and artistry of clinical practice. Artists can teach both medical

6

Introduction

students and doctors a thing or two about using the senses, but they are not even invited to the medical education party. This is true for most medical schools, but there are singular exceptions. In 2002, along with Dr Robert Marshall and Dr Rainer Brömer, I introduced a radical medical humanities curriculum to what was then Peninsula Medical School, a new school in the UK formed from an alliance between the Universities of Exeter and Plymouth. Artists and humanities scholars worked alongside clinicians and students to educate for sensibility and sensitivity, and the results were impressive. The underlying rationale was to redistribute sensibility capital across artists, humanities scholars, students, medical school faculty and patients, in a democratizing of medical education. This has served to produce sensibility in students to make them more interesting, innovative and caring practitioners who can tolerate ambiguity or uncertainty. Intolerance of ambiguity is the mark not only of the authoritarian individual but also of authority led cultures, and medicine historically is one of those cultures. The project of the democratization of medicine – helped by grounding medical education in the arts and humanities – is furthered by feminizing, as more women than men are now entering and working in medicine, as noted above; a move to patient-centred practice; and the establishment of collaborative clinical teams where hierarchies are flattened. Paradoxically, the riskiest thing that can happen to medicine is to democratize and feminize, yet these are the very processes that will make medical practice safer. The rise of the ‘critical’ medical humanities, and a broader ‘health humanities’, has challenged the traditional role of the artist and humanities scholar in medical education: as handmaiden to medicine. Rather, the arts and humanities – especially their more radical, politicized modes – have come to challenge medicine’s paternalism, autonomy and scientific persona in developing critical conversations with medicine. Medicine must democratize and teams must work collaboratively around patients where improved communication lowers patient risk in reducing medical error. The arts – such as drama, performance and literature – provide the media through which such democratization can be learned. How one acts into a role, or performs – just as how one looks and what one sees – are subject to power structures and those structures can be resisted and broken down, such that sensibility capital is redistributed fairly. Michel Foucault focused on the rise of regulation in modern western culture as surveillance, right down to the micro-surveillance of self by self (have you ever caught yourself blushing while alone and having a transgressive fantasy?) But post-Foucault, our obsession has been with

The Dartington Effect

7

risk rather than regulation. We now live in a ‘risk society’ in which the code of surveillance has been cracked and turned viral. Medicine has been described as a certain art of uncertainty, where risk is pervasive, but patient safety is the outward promise to the public and risk must be left in the shadows. How does medicine deal with this difficult relationship between risk and regulation in an age where, on the one hand patients are promised safer practice, but on the other, over-diagnoses and overmedication are soaking away much needed resources? The 2015 Association for Medical Humanities annual conference took as its theme critical conversations between medicine (including surgery, and encompassing healthcare) and the arts (including the humanities and the liberal social sciences) focused on issues of risk and regulation. Again, we live in a culture that, paradoxically, generates risk (especially in the economic sphere) at the same time as it generates more and more regulation. Our greatest risk is that of environmental degradation, yet we continue to make aggregate lifestyle choices that are creating irreversible environmental damage. Our lifestyles choices – junk food, lack of exercise, alcohol and recreational drugs – are so often at odds with maintaining ‘health’, while medicine’s resources are heavily biased towards curative intervention rather than prevention. Art, too, is, or should be, a risky business (Welchman 2008). I have nothing against art that pleases or salves, but surely the main role of the artist is to subvert, upset and challenge habit and convention to make us ‘think otherwise’. Art in critical conversation with medicine should make us think otherwise about descriptors such as ‘health’ and ‘wellbeing’. Nietzsche (and later Gilles Deleuze) described artists as ‘diagnosticians’ or ‘symptomatologists’ of the body of culture – setting out which symptoms emerge in a culture and how we might treat them. Our most pressing symptoms are environmental degradation, and poverty leading to health issues caused by the 1% phenomenon – that the richest 1% are making obscene amounts of money that do not help to raise quality of life for all because of lack of proper redistribution of wealth (Dorling 2014). The wide range of performances, drama, film, conversations and discussion of ideas presented at the conference (from delegates and invited artists, doctors and surgeons) debated Nietzsche’s notion as they address the conversation between risk and regulation across medicine and the arts. What follows is, again, a selection from that range of presentations.

8

Introduction

A note on content and style The editors have chosen to place emphasis on the eclecticism and variations in style of the contributions received. Papers came in a variety of sizes and forms – descriptive, rhetorical, reflective, rigorously critical, purposefully abrasive, conversational, illustrative, illustrated (or not), polemical, as commentaries on other’s work, and so forth. Rather than making authors adapt to a common framework, we have allowed for what Gilles Deleuze and Félix Guattari call ‘lines of flight’ – sudden, emergent, tangential expressions that find a form and trajectory and leave a trace: a firework display.

Works cited Bleakley, A. 2014. Patient-Centred Medicine in Transition: The Heart of the Matter. Dordrecht: Springer. —. 2015. Medical Humanities and Medical Education: How the Medical Humanities Can Shape Better Doctors. London: Routledge. Dorling, D. 2014. Inequality and the 1%. London: Verso. Welchman, J.C. (Ed.) 2008. The Aesthetics of Risk. California: jrp/ringier.

I would like to thank the Wellcome Trust and Falmouth University for their generous sponsorship of AMH 2015, and all members of the Association for Medical Humanities (AMH) for their continuing support.

OVERVIEW

CHAPTER ONE REFIGURING RISK IN MEDICINE AND HEALTHCARE: CRAFTING WILD NARRATIVES JENNIFER PATTERSON

Abstract Risk does not exist. It is an invention rather than a reality yet it arguably underpins Western societal structures. Etymologically ‘risk’ is a relatively recent word and one whose origins appear obscure. In Chinese medicine, its relationship to fear locates its influence in the kidneys, with adrenaline. Its various contemporary uses and meanings suggest a hybrid origin, a becoming that melds European commerce and Arabic belief systems with a sense of looking back upon Classical Graeco-Roman heroic identity, for conceptually it has been re-grounded in traditional and gendered Western practices. Its engendered aspects have led to its particular appearance in male-dominated narratives about bravery and adventures in pursuit of finance, treasures or goals. Possible Arabic origins identify something that is accorded by God rather than chance. In this century, Beck’s work on ‘Risk Society’ associates management of risk with Weber’s Western consumer materialism and Protestantism. The concept of risk has therefore become an instrument of economics and political and material social governance and yet, Janus-like, risk also constitutes a medium or process, a threshold locus for re-thinking or trialling - and potentially validating an emergent individual identity, sometimes successfully, sometimes with horrifying consequences. On the one hand risk, associated with scientific measures, can be ‘managed’ while chance, serendipity and opportunity are ‘wild’ options that are not ‘managed’ but fast acquiring marginal ecocredentials. In Chinese medicine, its relationship to fear locates risk in the kidneys, with adrenaline. It is therefore arguable that mainstream Western society itself operates from the kidney position, from fear of a future

Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives

11

intangible. Risk offers a means of transformation, a promise of value and ultimately a mediation of death or failure, but it equally avoids one of the huge realities of life - uncertainty. This paper explores some of the complex cultural and scientific framings of risk that seek to weight the dice, debating its use as purveyor or guarantor of safety in medical contexts.

Introduction Risk and normality have been thought into being as entities that imply a form of collective nominal solidarity for benchmarking and deviation. By implication they relate to measurement. Yet, neither risk nor normality exists in the ‘real’ world (the material world of everyday life). Both are particularly symbolic of Western ways of thinking, organizing and reforming the world from within particular and self-reinforcing constructions of knowledge. The medical philosopher, Georges Canguilhem (1991) pointed out in the 1930s that the ‘normal’ and the ‘pathological’ were not objective scientific descriptions but contaminated by political, technological and economic values. Risk is something that is inexistent. It is unknown, but has been scientifically and mathematically brought into being as a calculable (knowable) entity that can be employed as a means of ascertaining some sort of certainty in the face of uncertainty. There is an element of mathematical irony here, of a scientific need to capture the ineffable flux and the surplus of the real world. What is common to both risk and normality is that they comprise a method of gauging the inexistent through a system of containment by measuring and approximation, a movement from the outside in, a boundary making. Yet, life is beautifully uncertain and people are individual, so both measures again attempt to capture intangibles as finite, measureable and manageable. This reflects a Western cultural need to manage life, with normality pertaining to diagnosis and treatment of populations, while risk is more fundamentally about the fear of uncertainty (financially, in terms of interventions, or in the face of death). Yet its meaning holds a quality of serendipity, of potential luck. This paper explores concepts of risk and a selection of different arenas in which it is employed. It applies a range of postmodern methods drawn from deconstruction, discourse analysis, and reflexive modernity within a feminist framework to effect a reworking of risk.

12

Chapter One

Etymology and cultural connections Definitions of risk tend to focus on negative aspects such as hazard, danger or loss, especially in financial terms. The more widely accepted etymology of risk used in Western critical thinking is outlined in Ulrich Beck’s opening chapter to Risk Society (1992). Traditional etymological dictionaries locate risk as a word travelling into English from French, and into French from Italian where the word appears in Southern Italy during the Middle Ages, travelling with the spread of commerce through the French récif, risqué and risquer into English. Deeper roots show a Latin connection with nautical terms for cliffs and reefs signifying dangers, and with a Greek form meaning stone, root or ‘projection of firm land’. Homer describes the fig-tree root grasped by Odysseus that saved him from the Charybdis or whirlpool. In its modern sense, ‘risk’ returns us to the dangers encountered in Classical heroic epic. This Western socio-cultural genealogy of risk is visible across most academic disciplines, embedding mathematical and behavioural outcomebased probability frameworks associated with Modernity and founded on trading, capitalism, material culture and Protestantism. It is arguably embedded as a linguistic and structural genealogy rather than a topographical lineality. The Renaissance brought an influx of literature focusing on agency, and the development of exploration, trade and travel offering new horizons. Anthony Giddens (1999) associates this period with risk, new ventures and colonizing as opportunism, while this is the period in which Weber locates the origins of material culture as profit-worthy and pious, where Protestantism is linked with Capitalism. Beck and Giddens both describe ‘reflexive modernism’ as risk culture. Beck argues for reflexivity as an agent of change in facing environmental and human consequences of science and industrialization as constituent societal drivers. In so doing, he establishes a paradigm or world-view, an ethos and a collective identity for risk that are fundamentally Western and self-facing. Scott Lash and Brian Wynne (1992: 3-4) describe risk as “an intellectual and political web across which thread many strands of discourse relating to the slow crisis of modernity and the industrial society…[whose] dominant discourses for all they have taken on the trappings of liberal pluralism, remain firmly instrumental and reductionist”. The pragmatism of a reductionist view is inevitably seductive and an array of cross-disciplinary research evidences this as a particularly Western dialogue with uncertainty, and a methodology for containing, managing and governing through regulatory practices. In Philosophy of Risk, Chicken and Posner (1998: 11) offer a mathematical engineering

Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives

13

perspective, defining risk as “measure of the uncertainty about the ultimate consequences of a particular activity”. In the postmodern arena of outdoor and venture activities, risk is defined as “[a] real or apparent danger [whose] uncertain outcome… can be influenced” (Gilbertson et al, 2006). Associated with managing safety, risk is appropriated as a regulatory marketing tool, for example with children’s toys. Yet issues around risk involve perceptions and judgements, especially when stakes are high. Learning about taking risks is culturally perceived as a positive aspect of child development (Tovey, 2007). This goes beyond toys – for example where parental fear of ‘stranger danger’ has changed the way that children play today and remains the main barrier to children’s access to the outdoors, although reported incidents are sparse, where higher risks come from car accidents (Carver et al, 2008).

Leadership and language Where today dictionary definitions of risk carry negative connotations of danger and harm, in management terms the opposite is true - a substantive body of work associates being ‘risk averse’ as signalling a lack of leadership associated with self-centred behaviour and organizational failure (Carmeli and Sheaffer, 2009). As a leadership behavioural characteristic, risk taking has been a 20th Century prerequisite for positive leadership behaviour and an effective measure of decision-making behaviour in both individual and organizational management (Sitkin and Pablo, 1992). Risk is portrayed as necessary for success, associated with superhuman behaviour, linked to a robotic, iterative decision-making process and viewed as something that can have beneficial, engineered outcomes. The heroic language of medicine, where interventions are enacted, as opposed to healthcare (Lupton, 1994), accompanies that of risk in this modality, as medicine succumbs to the lure of success through ‘strong’ leadership and managerialism. As an aspirational superhuman thinking machine, risk becomes identified with instrumentalism - productivity and usefulness. However, the risk society, as Beck has pointed out with some irony, is one “increasingly occupied with debating, preventing and managing risks that it itself has produced” (Beck, 2006: 332). Questions about an uncertain etymology based on a Eurocentric lens reveal that a wider diversity in thinking about the word ‘risk’ might offer space for creative expansion. In his detailed polemic on the etymology of the French word risque, Laurent Magne (2010) offers a discourse of potential roots that indicate the polyvalent complexity of the word. Etymologically, ‘risk’ refers as

14

Chapter One

much to human psycho-socio-cultural preoccupations as to its more common meaning as an economic evaluation frequently associated with probability in management and business. Yet the flip side of crisis or danger concealed and revealed by risk strategies presents opportunities and even serendipity, although these are two different things. Magne (2010) excavates these plural readings, locates the signifier (risk) within the concepts of the semantic development of a range of other words (the signified) and from a consciously Eurocentric and Western perspective presents different socio-cultural contexts for risk. He widens his remit to acknowledge this Western view and a lack of readings of an Arabic root in the literature, yet while he refutes Giddens’ (1990) and Weber’s (modernist projects) in favour of his semiological one, arguably they are compatible. Magne argues that the contested etymology and obscure origins of the word ‘risk’ have become so embedded in the modern capitalist project that its ancient origins have become obscured. He specifically deconstructs etymological roots presented by Bernstein (1996) as “hazardous rock in the sea”, to reconsider international commerce via Graeco-Byzantine and Arabic trading routes with Italy as the locus for the development of the idea of risk. He argues for an Arabic etymological origin as a signifier of ‘lot’, meaning that which Allah provides as a blessing in relation to material and spiritual wealth. In excess, this is to be shared, but it can also be at hand and be had through active participation (whether collected or earned as work). This is, as Magne (2010: 10) points out, is similar to the Ancient Greek world-view of ‘lot’ or destiny, an aspect of which is wishing to go against the Gods (hubris), a fate punishable by nemesis. Risk is inseparable from a cluster of concepts related to world order and social order located within an ideology of moderation. This has roots in both Arabic and Greek cultures, with notions of prosperity and good business being predestined by a divine origin, demonstrable also in the medieval Christian world. Magne aligns this with practices and interdictions on interest and money lending. His thesis then refutes the modernist project that locates the appearance of the word ‘risk’ in the emergence of capitalism in 16th Century Italy, becoming a simple expression of the everyday practicalities for things that may go out of control in business. From a Western viewpoint this is fundamentally problematic as it takes little account of the breadth of cultural changes developing within 14th to 16th Century Italian commerce, particularly in relation to banking, where promissory or provisory notes in exchange for delivery of goods was becoming more frequent and projected business into an uncertain future. Magne highlights that our view of ‘risk’ is then Eurocentric, a somewhat naïve position in

Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives

15

that it does not engage with the complexity of the machinery of Eurocentricity. Critically, Magne’s text does not consider the racist politics of othering and Beck’s call to consider this. Multiple meanings and origins are therefore embedded in the word ‘risk’. Indeed, current Western understanding of the concept of risk would appear to an extent to fuse these together, in a concept so powerful that it has even travelled back in time to repopulate more ancient situations, bringing together the idea of a ‘lot’ in life governed by the Gods. It is hard to ignore the fact that the word ‘risk’, irrespective of its etymology, signifies uncertainty and therefore the future. The concept of ‘lot’ is melded with aspects of individual heroism and encounters with danger, mediating attributes of personal leadership such as bravery or cowardice with rationalization. This offers a tool to support facing of risk or to justify risk aversion, distancing the danger and offering the illusion that risk can be managed. Risk, therefore can be contextualised within the move from beliefs in the power of the Gods/God as director of fate to that of the individual having an ability or potential to make his or her own way. It straddles a dynamics of choice and, with the 19th Century advent of institutionalized State powers over the individual, it straddles it again, giving birth to an entire science of how to measure and deal with uncertainty. However, risk management is also a regulatory governance methodology linked to a deeply embedded politics of self-actualization through reflexivity, specifically of the Western Modernity discussed by Habermas, Giddens and Beck. Risk measurement is therefore designed as a process of mediation, for encounters with frightening things, initially death, but by extension personal (professional and State) failures. It is also a means of quantifying, measuring and assessing things relating to the management of large numbers, complex situations, finances and aspects of governance in the Foucauldian sense of the institutional powers enacting the authority of the State over peoples (Foucault, 1988).

Health Peter Dahler-Larsen (2011) argues for the diagnostic abilities of reflexive modernity in ascertaining the problems in contemporary modern society. Out of perceived ‘risk’ arises historical governance of healthcare for an increasing citizen population in the latter part of the industrial revolution. Doctors are taught how to diagnose and treat within a biological model of what is normal, and a statistical model of what is uncertain.

Chapter One

16

Management of healthcare transitioned more firmly from the individual to the State during industrialization in the form of hospitals established via the Church and in some instances via Royal dispensation. For the governance of large peoples the corresponding increasing rule of correlations based on mathematical assessments in medicine has offered assurances with regard to welfare in terms of: -

diagnosis (basing diagnosis and professional education on a hierarchy of symptom frequency that of necessity eliminates the infrequent and unusual); treatment (what works for most people becoming protocol); medicine (an exact science of manufacturing, quantifying and prescribing) and; care (rationalized via time management).

In the biomedical paradigm the medium of illness acts to impersonalize an individual’s human body for the purpose of diagnosis and treatment. This intervention is subject to risk assessment and management, sometimes but not always shared with the individual. The system is itself, of course, heavily dependent on the good will and vocational professionalism of large numbers of people and the understanding that patients have that this is the case. The management of the system underestimates this trade in ‘care’ at its peril. A plethora of threads of networked external and internal consequences across medicine and healthcare form an interwoven risk ‘text’ and necessitate risk ‘assessment’ and ‘management’ of those consequences. The commercial activity of drug manufacture has for some time driven the increasing rule of scientific risk-based research in medicine based on mathematically designed trials that offered both manufacturers and prospective purchasers a ‘gold’ standard in respect of safety. This meant trading on an assurance that in large populations very few individuals might have adverse reactions, or a low risk correlation. In an era in Western countries where more and more medicines are consumed, there is an ageing population, and an increased rise in obesity, diabetes and autoimmune illness. It has become necessary to individualize and contextualize new ways of working with illness. Managing the risks associated with the chemical interactions of drugs that may take place in the body of a person who is taking a range of different medicines together, and one for which drugs research was unprepared, has become a new focus of the consequences of medical intervention. A rise in more individualized treatment, or patient-centred medicine, includes recognizing

Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives

17

patient expertise in their own conditions, part of the newly developing field of personalized medicine (Swan, 2009). A forerunner of this trend, rebutting traditional scientific and positivist risk methodologies, is the recognition of toxic waste activism. For Lupton (1993) the consequence of lifestyle choices (discussed below under food marketing) is one of two sorts of public health risk discourses, with hazardous societal by-products being the other. Localized disease clusters related to environmental hazards have evidenced non-traditional (lower class, female) lay expertise and established critiques that rebut and highlight the differences between public and scientific perceptions of risk (Brown, 1995:102). Indeed, localized contamination by toxic waste that correlates with cancers and other illnesses in clusters, despite the scientific risk evidence, has demonstrated that the model presents a particular perception dangerously far from lived lives and removed from notions of even domestic environmental justice. This is a powerful argument for epidemiology with a social justice focus through the elevation of public health concerns, but it also requires consideration of uncertainty and therefore of risk. The boundary of the inter-relation between public and private spheres is precisely the fertile space in which the Arts and Humanities operate and from where they offer expertise, demonstrating innovative ways of negotiating and engaging in communication. Another aspect of market-driven medical intervention requiring new forms of risk management is the overuse of antibiotics leading to the rise of antibiotic resistant germs. A rising incidence of autoimmune illnesses with a wide range of contributory factors, including environmental triggers, stress and diet, has led to the developing field of environmental medicine. Further, concerns and issues around food and diet demonstrate similarly problematic market-driven consequences influencing consumer behaviour and health - for example in the changing use of sugar in everyday foods, the demand-driven provision of unseasonal and unripened foods, as well as shelf-life and refrigeration-led genetic modifications (Nestle, 2002). Linked to this, as an issue of risk and related governance, are management proposals linking obesity, diet and poverty in the UK (Cummins and MacIntye, 2006). The digestive system - and its risk properties - is placed at the centre of individual and public health. Environmentally, in lay activist terms, the knowledge processes of the ‘slow’ movement demonstrates an additional and eco-centric view of international and local environmental risk perceptions in relation to food, and diet. Nowhere does this debate between the individual and the State become more critical than when it concerns life and death, and indeed to whom the

18

Chapter One

life of an individual belongs. This is clear, for example, in the euthanasia debate. It is also clear, from a different perspective, in consideration of risk during medical treatment, with potential consequences of litigation. The burden of responsibility is enacted as a transaction, and while the risk for the professional necessitates a sharing process prior to treatment, in reality it is only the professional and not the individual risk that can be shared, or the theoretical (and emotional) but not the practical. The irony is that the risk is not equal, and that in this evaluation, medical treatment and life are both afforded financial values. While what is a life worth is individual, globally incomparable, and profoundly inequitable, it is externalized, away from an individual. The technologies of modernity afford a dehumanizing cost basis to life, death and the area in between (damage). The role of risk in transactions crossing ethical divides is extremely complex. It is not straightforward in these real-life aspects, nor is it binary, but entangled and messy. Regulation is a political business. The growth of bureaucracy fits with the project of modernity in the Western world. Bureaucracy is a postcolonial and re-colonizing process that restricts and paralyses movement. Yet, the reflexive approach is an ancient one, originating in the healthy self-questioning practices of individual dialecticism. As a bureaucratic function, risk-driven management is metaphorically and literally stressful. Propelled by outcomes and facing the future it is driven by fear, again located in the kidneys in East Asian medicine. Adrenally responsive, it is always alert for things to go wrong. It is a watchful Janus-figure of the threshold, with one eye looking to the past and the other to an uncertain future societally programmed with a rapid, but limited, cognitive function. Whatever mathematics and cognitive psychology aim to assert, this is not a neutral figure: regulatory mechanisms aside, it can be creatively reconfigured to be plurally read and mis-read as a metaphor for social change.

Refiguring The dynamics of risk presented in mainstream social, historical and managerial contexts are overloaded with paternalist, Western governance in Foucauldian and feminist terms. Intrinsically linked to Western Classical heroism and laced with aspects of deadly danger, risk is presented as affordable in the sense that it offers a promise of individual success. This may come to nothing depending on the throw of the dice, or the will of the Gods, a sort of containment of events that sometimes involves a righting of wrongs done to individuals, and might today

Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives

19

comprise a natural order of things, as a form of moral discourse. It is interesting that in this particular model personal wit - a kind of street-wise sense relative to the immediate environment coupled with the ability to sense and seize opportunities - is more important than skills of integrity. In this Western representation of the heroic, skills are necessarily gendered male and recognizably human although extreme in scale. The hero’s environment is frequently a territory, being difficult, alien or dangerous, feminized as virgin, to be mapped or conquered. Bound up in metaphors of colonialism, this is also the space occupied by societal out-riders: the rogue, adventurer, pirate, financial wizard and potential law-breaker. Gender-testifying narratives of success are disseminated through narratives that permeate Western culture extending from Ancient Greek and Roman myth into philosophy, psychoanalysis and contemporary films and books (Patterson, 1993). The concept of the individual against the odds extends politically through the heroic to the individual risking all against the state. It is arguable that any notion of a singular heroic is completely misleading as the role creatively lends itself to being viewed as a ‘syndrome’ of gender-imposed traits of masculinity, even a multiple personality disorder in relation to changing cultural and historical environments and expectations (Nagy, 2013). Yet this is also one of the faces of leadership. One important general theme and counter theme is that the importance of community is inversely important in relation to the perceived threat to the protagonist. So, ultimately, the promise of risk is that of a re-cognition or re-thinking of the heroic; the creation or forging of individual identity and worth, a measuring against the odds that takes place through the medium of risk. The doctor, too, is archetypal hero as medicine follows the martial metaphors of ‘conquering’ and ‘eradicating’ disease. Ulrick Beck’s view of a second modernity is a self-reflexive one that raises issues of trust and credibility in relation to risk and the dominance of the institutions of science and technology (including medicine) as powerful creators and managers of knowledge about risk. Science and technology in this analogy become corporate bankers trading in a currency of risk in today’s ‘risk society’.

Risk and trust If risk originates in a shared understanding of the governance of a Western world-order as an active governance of uncertain futures, whether selfreflexive or not, then it is equally important to highlight the gendered origins implicit in all of these discourses and their deployment across

20

Chapter One

science, engineering, technology and medicine (STEM). STEM fields are traditionally and historically associated with invention and heroism with high status, engendered white, socially self-reproducing stereotypes. They are fields from which women have been until recently excluded and in which both women and minority ethics are persistently under represented with recognizable hermeneutic self-determining and out-moded characteristics (Smeding, 2012; Beede et al, 2011). These are the fields that drive the technologies of positivist risk mechanism as the means of managing or dialoguing with uncertainty. In any politics of equity, this raises further issues of trust, as risks are both regulated and generated by the practices of the institutions that create them. To benefit from these practices is to accept an internalizing of these risks and their regulation. In other words, risk is a confection that both reveals and hides the dangers it distances and conceals. It is a symptom of what is wrong with modernity, of societal illness. Within this framework, mistrust is compounded by the constraints of modernity around science and public knowledge, as a form of policing that is particularly evident around the borders and intersections between institutions and the public sphere, between research and practice, measured as benefits and losses, physical reactions and individual experiences. Yet, this is also where creativity and new ways of knowing are created. So risk and trust are highly polarized political activities that relate to social roles, and as such they incorporate and embed the politics of their origins. Carter (1995), in a discussion of HIV/AIDS, points out that neither Beck nor Giddens consider trust and reflexivity in relation to intimacy. Thinking in some detail about dialogues of othering, Carter considers how the construction of identity has a dependency on incomplete conceptualizing of self and other built on ideas of trust rooted in concepts that may fail, such as romantic heteronormative or feminized love as prophylaxis: “the linear association between risk avoidance and risk awareness is likely to be disrupted by complexities of the relationship between sex and identity” (Carter, 1995: 163). An ethics of care, such as that grounded in Carol Gilligan's (1982) work, emphasizes the relational nature of research and the emotional aspects of reason. The complex politics of relational positioning shaped by binary, rational logic underpins the pragmatic science of risk assessment outlined above. With woman traditionally othered in the process, Luce Irigaray (1993: 13) outlines her thoughts on what this means: Who or what the other is, I never know. But the other who is forever unknowable is the one who differs from me sexually. This feeling of

Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives

21

surprise, astonishment, and wonder in the face of the unknowable ought to be returned to its locus: that of sexual difference.

In consequence, therefore “jamming the theoretical machinery itself… suspending its pretension of a production of a [univocal] truth and a [univocal] meaning” (Irigaray, 1977, trans 1985: 78), wonder in the face of difference returns us to radical uncertainty – an authentic relational risk.

Conclusion The historical trajectory of the word ‘risk’ is, as I have demonstrated, associated with a wide range of social concepts and meanings whose current ‘line of flight’ may be celebration of difference that informs a critical feminist ethics. Risk might be seen as working at the boundaries with ‘found’ objects that are creatively reworked. Risk is also risqué, outside of society, without morals, a sort of pornography, a bawdy talk of science, as it were, a form of ‘cunt’ that is fragmentarily and differently lived and embodied. Face to face with the environmental implications of the way life is lived in the West and as a feminist critical theorist, I echo Haraway’s (1998) nervousness in using postmodern critical tools to face the real world - the disassembling and dissembling deconstruction of power within positivist science from a split position that can never experience so-called ‘objectivity’. The call for situated knowledges as forms of embodied practice supports constructing “knowledge of how meanings and bodies are made, not to deny how meanings and bodies get made but in order to build meanings and bodies that have a chance for life” (Haraway, 1998: 580). This presents me with consideration of metaphors, symptoms and translations as ways of unearthing and reworking shared and differentiated movements through echoes and soundings across those boundaries. As an herbalist, working with the earth in situ, permaculture offers a responsive mechanism based on ecological sustainability, a responsive ethical relational model where a greater diversity benefits the intervention taking place. Growing plants seems to me more of a responsive miracle than an “organic symbiosis” (Haraway, 1998: 581). It is dependent on external factors that can be mediated but not controlled; qualities of earth, air, sun and waters. In an ontology of air, as Irigaray has observed, and on another temporal threshold in a clinical setting, I share breath with an other as I listen, and also with the earth as I breathe. Risk faces both backwards and forwards in the present. Like Janus (the January after winter) it is a metaphor for a doorway that has the potential

22

Chapter One

to be a portal. Its textual representations are symptomatic of Western social illness that includes a fear of death and loss. Yet the threat of risk, as a powerful organizing force and incentive for particular collective adherence to regulations, enables refiguring or tracing of a different identity. Risk is a symbol of chance or opportunity, of the serendipity for a dialogue with life and death, and with not being able to control the world. It therefore offers a relational gift, a transcendent narrative potential. Moulded and refracted by social processes, from a feminist perspective risk embodies the potential disruption of binary identities and thought processes within Western societal fabric, affording a conversation with chance and the random. The Surrealist Paul Éluard (1929) wrote: “the earth is blue like an orange, never a mistake words do not lie”. The text holds relative truth. Rethinking the fragmented temporal multiplicity of risk – with its rhizomatic etymology - encourages creative encounters and ‘wild’ thinking.

Works Cited Beck, U. 1992. Risk Society: towards a new modernity. London: Sage —. 2006. ‘Living in the world risk society’ (A Hobhouse Memorial Public Lecture, LSE). Economy and Society. 2006; 35: 329-345. Beede, D.N., Julian, T.A., Langdon, D., McKittrick, G., Khan, B. & Doms, M.E. 2011. Women in STEM: A Gender Gap to Innovation. Economics and Statistics Administration Issue Brief No. 04-11. Available at: http://ssrn.com/abstract=1964782 or http://dx.doi.org/10.2139/ssrn.1964782 Last accessed: 16/07/16. Bernstein, P.L. 1996. Against the Gods: The remarkable Story of Risk. London: John Wiley & Sons. Open source: https://hal.archives-ouvertes.fr/file/index/docid/465954/filename/ Magne_Histoire_semantique_du_risque_et_de_ses_correlats.pdf Canguilhem, G. 1991. The Normal and the Pathological. New York, NY: Zone Books. Carmeli, A., & Sheaffer, Z. How Leadership Characteristics Affect Organizational Decline and Downsizing. Journal of Business Ethics. 2009; 86: 363-378. Carver, A., Timperio, A., & Crawford, D. Playing it safe: The influence of neighbourhood safety on children's physical activity—A review. Health and Place. 2008; 4: 217–27. Chicken, J.C., & Posner, T. 1998. The Philosophy of Risk. Brentford: Thomas Telford Ltd.

Refiguring Risk in Medicine and Healthcare: Crafting Wild Narratives

23

Cummins, S., & MacIntyre, S. Food environments and obesity— neighbourhood or nation? International Journal of Epidemiology. 2006; 35: 100-04. Dahler-Larsen, P. 2011. The Evaluation Society. Stanford, CA: Stanford University Press. Éluard, P. (1929). L'Amour la poésie. Paris: XXX. Foucault, M., Martin, L.H., Gutman, H., & Hutton, P.H. 1988. Technologies of the self: A seminar with Michel Foucault. Boston, MA: University of Massachusetts Press. Gilbertson, K., Bates, T., McLaughlin, T., & Ewart, A. 2006. Outdoor Education: Methods and Strategies. Champaign, Ill: Human Kinetics. Giddens, A. 1990. The consequences of Modernity. Stanford, CA: Stanford University Press. Gilligan, C. 1992. In a Different Voice. Boston, MA: Harvard University Press. Haraway, D. Situated Knowledges: The Science Question in Feminism and the Privilege of Partial Perspective. Feminist Studies. 1988; 14: 575-99. Irigaray, L. 1993. An Ethics of sexual difference. Ithaca, NY: Cornell University Press. —. 2009. Sharing the world. London: Continuum. Lash, S. Reflexive Modernization: The Aesthetic Dimension. Theory, Culture & Society. 1993; 10: 1-23. Lash, S., & Wynne, B. 1992. Introduction. In: U. Beck. Risk Society: towards a new modernity. London: Sage. Lupton, D. Risk as moral danger: the social and political functions of risk discourses in public health. International Journal of Health Services. 1993; 23: 425-35. Lupton, D. 1994, 2012 ed. Medicine as Culture: Illness, Disease and the Body. London: Sage. Magne, L. 2010. Histoire sémantique du risque et de ses corrélats : suivre le fil d’Ariane étymologique et historique d’un mot clé du management contemporain, 15ème Journées d’Histoire de la Comptabilité et du Management, Paris, Mars 2010. Nagy, G. 2013. The Ancient Greek Hero in 24 Hours. Cambridge, MA: Harvard University Press. Nestle, M. 2002. Food Politics. Berkeley and Los Angeles: University of California Press. Patterson, J. 1993. Reading States of Climax: Masculine Expression and the Language of Orgasm in the Writings of the Surrealist Philosopher and Poet, André Breton. In: J. Still, & M. Worton (eds.) Textuality and

24

Chapter One

Sexuality: Reading Theories and Practices. Manchester: Manchester University Press. Sitkin, S., & Pablo, A. Reconceptualizing the Determinants of Risk Behavior. Academic Management Review. 1992; 17: 19-38. Smeding, A. Women in Science, Technology, Engineering, and Mathematics (STEM): An Investigation of Their Implicit Gender Stereotypes and Stereotypes’ Connectedness to Math Performance. Sex Roles. 2012; 67: 617-29. Swan, M. Emerging Patient-Driven Health Care Models: An Examination of Health Social Networks, Consumer Personalized Medicine and Quantified Self-Tracking. International Journal of Environmental Research and Public Health. 2009; 6: 492-525. Tovey, H. 2007. Playing Outdoors: Spaces and Places, Risks and Challenges. Maidenhead: Open University Press. Weber, M. 1905. The Protestant Ethic and the Spirit of Capitalism. London: Unwin Hyman.

PART I: SELECTED KEYNOTES

CHAPTER TWO THE CHANCES ALPHONSO LINGIS

It had started to rain lightly in the Deer Park in Sarnath, where the Buddha had given his first sermon. I took shelter under the huge spreading Bodhi tree, which was grown from a cutting taken from a tree grown from a cutting taken from the Bodhi tree in Bodh Gaya, under which the Buddha attained enlightenment. Someone else had taken shelter there, a man of around 40, dressed in white kurta and dhoti with cream-colored scarf. His presence was very beautiful, composed and gracious, his voice resonant, and his body was physically beautiful too. He said he was an astrologer. I said I would like to hear about his work. He was consulted by people who are troubled, who find that they are unable to cope with their situation. He helps them get in touch with material reality and their bodies. He explains

The Chances

27

that our bodies are composed of oxygen, carbon, hydrogen, nitrogen, calcium, phosphorous, sulphur, potassium, sodium, chlorine, magnesium, silicon, iron, fluorine, zinc, rubidium, strontium, bromine, lead, copper, aluminum, cadmium, boron, barium, tin, iodine, manganese, nickel, gold, molybdenum, chromium, caesium, cobalt, uranium, beryllium, and radium. He recommended meals of varied and wholesome foods, dusted with ground precious stones - rubies and sapphires. He then prepared their chart, putting their birth and the cardinal events of their lives in the cosmic map of the most remote heavenly bodies. There is, he said, necessity, choice, and chance. There is today a rigorous discourse on determinism—the natural sciences, including anatomy, physiology, neurology. He said there is today a rational discourse on decision—ethics and politics. But in the West there is no longer a reputable discourse on chance. It only survives in the marginalized talk of gamblers and fortune-tellers. Each day we attend to the causalities that determine the physical wellbeing of our bodies and its safety, the causalities that determine the layout of possibilities and obstacles in our environment. We make decisions about the goals we want to pursue and the responsibilities we undertake for the welfare of our children and our community. But all the major events in our lives are due to chance—our birth, a teacher who captivated us and engaged us in mathematics or nursing, in music or football, the person we happened to meet and fell in love with, the job opportunity that abruptly opened, our child who was born or who was autistic or who died, the car crash that crippled us, the tumor that grew silently in our inner organs. Chance is the unpredictable, the incalculable, the incomprehensible, surprise, shock, good or bad luck. Chance is the bad luck we fear. Anxiety is the consciousness of risk. But chance also excites us, he said. It quickens the will. We hold on to a keen sense of chance in exhilaration and ecstasy. There is, he said, an element of chance and risk in every relation with another human being. We never really know what someone might think or might do. We can only trust him or her. When I think of the chance encounter of this woman with this man-out of the three billion men on the planet, of the chance that she pleased him and he her, and of the chance that they disrobed and copulated, and then of the infinitesimal chance that out of 200 million spermatozoa repeatedly ejected into her vagina this one met with and got absorbed into this ovum, I can only think that my existence was extremely improbable.

28

Chapter Two

Each gamete contributes 23 chromosomes. They could combine in more than 70 trillion different combinations. This particular combination that I am had but one chance out of 70 trillion to take place. Had any of these other combinations taken place, the child who would have been born would not have been me, but someone as different from me as a brother or a sister. Then we have to recognize that in my grandmother’s womb the chance that my father was who he is and not someone different was also one in 70 trillion. Likewise my mother is a staggeringly improbable chance combination, and likewise each of my ancestors. The more, now, that I study the world, with all the books and laboratories of physicists, chemists, biologists at my disposal, determining, for each event in the world, the conjuncture of disparate causes that brought it about, the less I see that my existence was anywhere programmed in the course of the natural world. Beneath me, behind me, there is nothing that programmed me, demanded me, required me. The causal determinisms that we track down in physics and chemistry explain why when we view the sun at the horizon the layers of atmosphere reflect light to us of varying wave-lengths, but do not explain why one sunset is more beautiful than another or why a sunset is beautiful, or make predictable that a sunset shall be beautiful. It is by chance that there is beauty in the world. That my facial features are refined or commonplace, that my hair is brown or blond are effects of chance. I find I have beauty, vivacity, brightness, flair, style, dash not through character management but by good luck. As I have the bad luck to be ugly, dull, lumbering, low vitality and low libido. As some people have the good fortune to have quick penetrating minds, there are also people who have a talent for happiness. In the workplace, in everyday situations, in the rain and the snow, they are not dulled and darkened by despondency and laugh a lot. Whereas others, equally endowed with health, self-confidence, intelligence, physical skills always seem to be in neutral, or even dull; they have to force themselves to feel happiness. By a stroke of bad luck some people have the genetic and biochemical predisposition to sociopathology. As there is physical bad luck, there is also moral bad luck. And there is moral good luck, as philosopher Bernard Williams argued. There are people who are spontaneously generous, people who impulsively leap to help a person in distress at risk to themselves, being brave by nature. People who easily resist peer pressure to go along with

The Chances

29

shabby and venal behavior. People who do not get overwhelmed with anxiety when a moral decision involves risk to themselves. Passions are distributed to humans by chance. The passion for truth, which drives great scientists--they say they found it in themselves, it was not really put in them by education. Likewise the passion for justice-awesome in Mohandas Gandhi and Martin Luther King and Ché Guevara. Anxiety and fear are the keen sense of risk, of bad luck, that fills our minds and also saturates our nervous sensibility and our musculature, our bodies. Statistics have been established for very premature infants, those born after 23 to 25 weeks of gestation. If they are given only palliative care, they will die. Of those who are given neonatal intensive care 62% survive; 38% die. 27% will survive without moderate to severe neurodevelopmental impairment. 38% will survive with moderate to severe neurodevelopmental impairment, such as cognitive impairment, cerebral palsy, autism, deafness or blindness, psychosis, bipolar disorder, and/or depression. 18% will survive with profound neurodevelopmental impairment. Parents may choose palliative care for their very premature infant, a care aimed at making their short lives as painless and peaceful as possible. The Netherlands has a national policy not to put infants born at less than 25 weeks gestation in intensive care. There is some risk that even with the most conscientious palliative care the infant will suffer. There is also uncertainty about how the parents will fare, visiting their infant doomed to die, and afterwards how they will deal with their decision. They will not have those allegedly consoling words ‘You have done everything you could,’ to resolve the doubts, misgivings, and desolate memories that may trouble them. Parents who choose intensive care know that their infant may be among the 38% who die in the neonatal intensive care unit. They hope that their infant will be among the 27% who survive without moderate to severe neurodevelopmental impairment. The statistics cannot determine the decision. How does one weigh a 27% chance of a healthy life against a 56% chance of death or profound impairment? They have to assess whether they can pay for neonatal intensive care and for the care of their child if he or she turns out to survive with severe neurodevelopmental impairment. They also assess their own mental and emotional strengths, and the activities that make their lives meaningful to them, which will have to give room to care for a possibly severely impaired child. They will have to

30

Chapter Two

think of the impact a severely impaired child will have on the time and resources they devote to their other children. They will consult the doctors who are caring for their infant and who have had impartial experience with very premature infants. It may be difficult to really understand what the doctor says: is he saying what he thinks the parents would do if they understood all factors involved? Is he taking account of how he thinks they would or could handle the decision and its consequences? Is he saying what he would do if he were the parent? In this situation with so many factors unknown, they will want to hear the experiences and thoughts of other parents who have put a very premature infant in neonatal intensive care. They will have to envision the circumstances and character of those other parents, and also assess the reasonings that led to their decision. Some parents may resolve the uncertainties by deciding on the basis of principles that they have decided are certain and now appeal to and reaffirm. Religious principles, for example. They thus deliver themselves from uncertainties and the risks of a decision that they may later regret. But finding themselves now in a situation where the risks in so important a decision are undecidable may lead them to question the decision they made in the past to take those principles as certain. In Ulan Bator you asked the only Mongol you knew, the desk clerk at the hotel (what slight knowledge!) and he told you where to find somebody who had a four-wheel drive. When they rent out a four-wheel vehicle it comes with the driver, though he speaks no English and you of course no Mongolian. But without a Mongol-speaking companion it would be impossible to use the vehicle: once outside the capital there are no paved or even graded roads and of course no road signs. The vehicle turned out to be a Russian make, 29 years old. The guy who had the car said the driver knew Mongolia from one end to the other and had friends everywhere. Of course he would say that. And of course if he knew the country and had friends everywhere, he could leave you anywhere with his cronies to cut your throat just to get your camera. Trust is taking what is not known as though it were known. In trust one adheres to something one sees only partially or unclearly or understands only vaguely or ambiguously. Trust makes contact with a singular individual, with the real individual, a power of initiative unto himself but also innately endowed with skills to hide what he does not know, to deceive, dominate, and trap others. One attaches to someone whose words or whose movements whose reasons or motives one does not see.

The Chances

31

One’s mind surveys the certainties and the probabilities and the possibilities. Trust is a cut, a break, and a leap. It is an upsurge, a birth, and a commencement. It has its own momentum, and builds on itself. How one feels this force! Before these strangers in whom one's suspicious and anxious mind elaborates so many scheming motivations, abruptly one fixes on this one, at random, and, like a river released from a lock, one feels trust swelling one's mind and soul with force and light Trust is the strong surge of feeling that connects us with our fellows; it is the exhilarating leap that connects with another despite ignorance. Trust is impulsive and immediate. You do not decide to trust someone: you just trust him, or you do not. There he is, now, the driver, I at once extended my hand to his, and at once entrusted myself to this stranger who does not know a word of English. But he understands my hand and my smile and the buoyant steps with which I follow him to the vehicle. The leap of trust is exhilaration. There is nothing more exhilarating that trusting a stranger with whom you have no religion, ethnic, or moral community or language in common with him. Language was invented, Voltaire remarked, in order that men may conceal their thoughts. Whenever we contract with another human being, there is risk. And trust is everywhere--in the pacts and contracts, in institutions, in forms of discourse taken to be revealing or veridical, in the empirical sciences and in mathematical systems. Everywhere a human turns in the web of human activities, he touches upon solicitations to trust. The most electronically guarded, insured, paranoid individual is constantly asked to trust. To trust the veterinarian when he diagnoses the sick animal in our care is to trust his skill and thoroughness of observation, and his acquaintance with the relevant literature, and to trust therefore in turn the skill and thoroughness of observation of all those further veterinarians whose articles he has read. It is to trust the manufacturers of thermometers and biochemical used in diagnosis as well as in treatment. There is something vertiginous in every act of trust. The initial act of trust maintains itself only in extending itself, only in yet more acts of trust. Before submitting to surgery, we find out all we can about the knowledge, competence, and experience of the surgeon, but in the end we realize that he is capable of misjudgment in diagnosis, neglect of available research, lapse of skill, inattentiveness, or malice. In the end our decision is an act of trust.

CHAPTER THREE FALSE TRUTHS A CONVERSATION BETWEEN DAVID COTTERRELL AND ROGER KNEEBONE

David (installation artist) and Roger (surgeon, GP and engagement scientist) met at the AMH 2010 conference in Truro and have been collaborating ever since. This conversational enquiry five years later explored points of intersection between their different perspectives. Based on a transcript of their joint presentation at Dartington, the paper highlights how surgery (whether simulated or real) can provide a meeting place between art and medicine. In 2010, David gave a keynote presentation based on his experiences as an artist with a trauma team at Camp Bastion. To Roger, this resonated with his own experience as a trauma surgeon in Southern Africa in the 1980s, operating on patients who had been stabbed, shot and blown up. In 2015, they were invited back to the stage to present their understanding of the, unlikely, shared territory which had sustained their ongoing conversation during the past five years. The following article represents an edited extract of that public dialogue. ‘Roger’ represents Roger Kneebone and ‘David’ references David Cotterrell

Introduction Roger Five years ago in Cornwall, at this very conference, David and I were both giving keynote talks. To me it was fascinating to see how David, as a nonsurgeon, was seeing this world that to me had become completely familiar in one way and the way he showed it made it as completely unfamiliar in another… And so we started talking.

False Truths

33

I’d seen some pretty grisly things when I was doing trauma surgery. As I was working first of all in Soweto and Cape Town and then in Namibia in the war zone, I’d seen a few things blown off and mangled, and you’d seen a few things blown off and mangled during your time as a war artist observing a field hospital regiment in Afghanistan. I think the occurrences were similar but our experiences of those occurrences were very different, in a sense. So we started having conversations and these continued.

About, a year – something like that – later, I was doing one of these trauma scenarios at the Wellcome Collection. I had been invited to put on a sort of surgical day, and we had a series of enactments of an operation where the patient comes in, having been stabbed. He’s a simulated patient – an actor who’s been made up to look as if he’s been stabbed and he is being assessed by a consultant surgeon who deals with this kind of stuff all the time. In the simulation, the audience are allowed to stand around in a room, which is quite clearly not an operating theatre. It’s got one or two things that look a bit like an operating theatre, but it is not a surgical space. People have come in to a venue near Euston Station in London, into a museum and exhibition place, essentially. And so we were showing what happens when the surgeon examines this patient and then does an operation of the kind that I've shown you, and

34

Chapter Three

then people afterwards come along and they have a look and they have an opportunity to feel inside somebody’s tummy, which is something that not everybody’s had an opportunity to do. The audience and participants were very interested, but it was a kind of interest in the facts and the stuff that was going on. David was also there. I knew this – I’d invited him. I knew he’d been through all this stuff, so I imagined we’d have a good man-toman conversation afterwards about what it was like. But after a while, I started to notice that he was looking a bit green and crinkly and started to sway a bit. And I couldn’t understand it, so David, what was going on? David Yes. By that point I’d achieved a cold sweat and I was thinking that I might faint within the simulation. And, to be clear, I’d never fainted before. So I’d been through this tented field hospital and a kind of a rather nasty period. I’d later gone back to Afghanistan to see civilian hospitals and since seen operations in the UK. That whole time, I’d managed to stay on my feet. And then, I walked off the Euston Road into a kind of theatrical space in a museum. There was no pretence – there was no way you’re thinking, that I might have wandered into a hospital by mistake. Yet I found myself in the embarrassing situation of thinking that if I didn’t get a glass of water, everything was going to go black-and-white and I was going to collapse on the floor. We were trying to work out why this could happen and, you know, I was embarrassed because I thought I was a bit hardened to the whole thing, to be fair. It occurred to me that it actually reminded me of something very similar which happened in Camp Bastian. Although there I’d managed to grab a glass of water before anyone noticed that I was swaying. I think, what it was … was that somehow I had not been prepared for some sensory kind of trigger, which had happened in the simulated environment. I remembered that as part of my preparation for deployment before going to Afghanistan, a Paratroop doctor had sat me down in his kitchen somewhere in the southeast of England and took great pleasure in showing me the most horrific images he could find depicting battle injuries. If you happened to search for them – please never do – you get the most appalling collection of images. It’s not hard to find things that will shock. I thought he almost enjoyed feeling that he was, you know, toughening me up, ready for going out there. At the time I felt he’d probably done a good job. So when I arrived in Camp Bastion and I met my first patient I was expecting that this (whatever it was) would be minor compared to what I’d seen documented.

False Truths

35

Standing by the patient, something problematic happened in that I was told he would probably either be asleep or screaming, and had prepared myself for either possibility, Nobody had mentioned that he might actually be lucid and having a negotiating conversation with the doctor about which procedures he would be willing to have. Suddenly the X-ray apron became heavy and I realised that all of the images I’d seen on the internet and in The Guardian and Channel 4 news, and anywhere else that I thought responsible outlets might show me what war was about or medicine was about, had failed to provide any empathetic engagement to the reality. What they’d done was they’d illustrated somebody else’s world, but not challenged mine. And so then, the trigger may actually have been a human being talking, within a simulated similar scenario in the Welcome Collection. In the simulation I was seeing behavioural characteristics being absolutely accurately re-enacted, and experiencing something, which even in my own photographs, I’d managed to separate myself from.

36

Chapter Three

Intensifying the real Roger That raises interesting questions about what is happening with simulation, because – certainly in the educational world, there’s a sense that simulation is a bit of a poor substitute for the real thing, and you’re only doing things in simulation because for whatever reason you can't do them for real. But actually I think there’s a kind of intensification through simulation that in a sense makes some aspects of it more real than real. Shaping the experience and creating a particular focus that’s more vivid brings some things into view and keeps other things out of view. I suppose that’s partly what happens in the creation of a simulation. But it’s also about what everybody brings to that experience. To me there’s something you were showing that resonates with me within the operating theatre. I would leave a whole lot of parts of myself outside and give my undivided attention to working in a particular way. When I was outside the operating theatre, it would be in another kind of way. Then I would be talking to people and things. But getting the two muddled up in the same place is disorienting. So I started thinking about what simulation might be, about what is that process of distillation, of intensification. Does simulation offer anything more than could be offered if you had access to an originary world? Is simulation just a watered-down version of what you would get in an operating theatre, or does it do something different? I wondered how one might get that, in a way that’s possible to bring it away from an actual hospital. And so I came up with this idea of not thinking about what you can subtract - what you can get rid of from the real operating theatre - but thinking about what is quintessential to the experience of surgery. One of those things is to have an enclosure, a space, something that can separate inside from outside, even if that separation is notional and can be moved across by people watching. Nevertheless there is a marked-out space that says ‘this has a particular purpose as an operating theatre’.

False Truths

37

I worked with a couple of design engineers who spent a lot of time in the operating theatre, trying to identify and abstract what was critical and needed to be recreated. We came up with this idea of an inflatable space; an inflatable operating theatre that could pack down into the back of a car. We added one or two things that we felt were essential to have, such as an operating lamp. That’s really helpful, because as soon as you go into a space with an operating lamp, it tells you it’s an operating theatre.

38

Chapter Three

We realised that the focus of attention is the activity, the people working together. What happens around the outside is less important. So on the right of this image you have an anaesthetic machine. At the time, a couple of years ago, one of these cost about £80,000. They’re immensely heavy – full of stuff that only anaesthetists need. And I thought, well, if you don't really notice it, why have it? I thought maybe instead we could use a photograph of an anaesthetic machine – there it is on the left. It cost £80. It gives a sense of there not being an absence of something rather than being a specific presence of something. So we’re beginning to look at theatrical techniques. To me there’s something about recognising where the focus of attention normally is and thinking how you might want to place it differently. I began to see how powerful that is yet how under-recognised, certainly in the world of medical education – although of course second nature to anybody in performance. David Going back to my time in Afghanistan, what resonated for me was that I didn’t know how I was supposed to respond in an environment, which you find exotic, and where you probably won't have the critical analysis necessary to really understand what you’re looking at, at that time. So I tried to document everything. I took a thousand photographs, I wrote my first diary of my life, and I also took video cameras and things. When I came back I had this real problem - how do you compete with the objectivity of the image you’ve got? How do you compete with the power of genuine documentary material? Of course I’m still aware of this problem with Paratroopers’ documentation, and the fact that those things had also gone through the lens and onto the film or onto the digital sensor. They’d been real but they’d failed to impart anything in the sense of place. When I came back I was experimenting with ways in which I might be able to get a sense of what was important from this material, rather than simply accepting it for what it was. At one point there was a major incident call, which meant that the hospital could be overwhelmed. There were too many people dead or injured for the hospital to cope with. They warned us all, the people who’d been operating for 12 hours were woken up and told to operate again, the surgeons went for their cigarettes and patients started arriving one by one by helicopter. I wasn’t sure if I was emotionally strong enough to cope with it. So I set up a camera on a tripod in the corner of resus, to watch everything in case I had to bail out. As a last resort, if I couldn’t really handle it, the camera could become the observer.

False Truths

39

I was looked after very well by the nurses and doctors and they escorted me through. I ended up seeing what happened to patients from the moment they arrived off the helicopter to the point where they were dispatched back to Kandahar. I forgot about the camera and just left it running, set with a long depth of field so it recorded everything equally. About six months later I thought, okay I'll watch this. I looked through it, and what was extraordinary was that I realised the camera was seeing things that my eye did not. What was happening in this area of course was that we would watch the patients coming in. We spent ages waiting for things to happen – all laughing and joking and trying to look professional and calm and competent to each other so that we wouldn’t be seen as a risk to anyone else. Then the patient arrived, everybody naturally watched the casualty. At that point, for a moment, you see people in the background who actually dropped their guard and started showing what they really felt. It was an extraordinary thing because, as I was there, I just obscured all of the things that offered any kind of genuine narrative. And for me what was interesting was that the subjective approach to dealing with the footage offered a greater kind of glimpse of the objective truth and the fact that, actually, we were all terrified that we might embarrass ourselves by not living up to what was coming next.

At this point, if it was in focus, everybody would see paratroopers bringing in a body. But actually this guy in the background for me was more interesting, and the person taking notes. A very simple thing, but besides making me question the objectivity of the footage in a way that we all know – that is, reinforcing the idea that cameras aren’t really objective -

40

Chapter Three

perhaps it also revealed something of the challenge of our engagement with media. I realised that the way in which we read images is not necessarily representative of the way we experience reality.

Empathy through simulation Roger I think there are some interesting medical parallels here. I was thinking about this in terms of surgical textbooks. Up until about the 1970s, these used to have colour plates of operations done by medical artists. You’d see a particular part of an operation. It wouldn’t make much sense to you if you didn’t know the technicalities of the operation. They would show this part of the operation or that part. It seemed that they were showing the whole thing, but of course they weren’t. Then, for cost and all sorts of other reasons, the trend was to use photographs. And to me, although you would think that would give you far more information, it actually gave far less, because it just presented an undifferentiated snapshot of an individual person at an individual moment. It didn’t give a distillation of the essence of something that somebody was trying to show. And so there was something very interesting about what was lost through too much gain, through a sort of uncritical representation. It made me think in terms of simulation, of what we’re trying to do in terms of deciding what it is to be shown. I think this is a process that requires what my colleague Gunther Kress at UCL describes as semiotic work – the work that you have to do in making meaning out of something. Experience has to be mediated, to be translated, and that process of mediation and translation sits more comfortably with what artists and novelists do than what people involved in medicine think they’re doing.

False Truths

41

That made me start to think about what’s going on here with simulation. For those of you not in the world of medical education and medical simulation around surgery, if you want to go into an operating theatre and see what goes on, it’s really almost impossible to do. You can't just knock on the door and say “would you mind if I came and had a look?” For all sorts of very good reasons – confidentiality, infection control – it’s a closed space and so it should be. But if you want to get into a sophisticated simulation centre that represents an operating theatre, it’s almost as difficult to get in. The barriers are almost as high. If we look at the real environment and a simulation, which sets out to represent that real environment, those two are almost superimposed. So the real environment is there, the simulated environment is here, and the access and the activities are contained within a framework that exerts a sort of force field of repulsion. It says ‘if you’re not allowed to come in, then stay out’. I think that that’s how simulation is often seen, but I think maybe we can think about it differently. Instead of that close coupling between the simulated and the real within a fixed frame, we might think of a looser coupling within a permeable frame. That suggests new things we might be able to do with simulation that we couldn’t do if we see it as an exact reflection of something already there. At the moment I think people talking about simulation think about it as simulated reality. They don’t necessarily think that it’s in a frame at all and even if they do, they don’t particularly think about the frame. So I think it would be useful

42

Chapter Three

to spend a few minutes thinking about the frame. I've got a few examples that look at nibbling away at the edges of that frame and venturing into the area of risk and regulation and all those things that are that are difficult to deal with. David When you were speaking, it reminded me of an occurrence which happened about a year after I came back. I had a year to go back out there, to get my head straight and then finally I had to present something in the public realm. It was an exhibition about the ethics of war and medicine – these two things coexisting – but my part was about Afghanistan and revealing something about contemporary medicine within that landscape. I felt uncomfortable with that. The reason being that I recognised that although I’d been present, I hadn’t really seen Afghanistan and I hadn’t really understood medicine. Although I’d been there, my passport showed no evidence of entering the country. In some ways, I had not entered Afghanistan. I had simply entered and left the military via Brize Norton in Oxfordshire. I realised that while I was there, I was eating British food; I was living with British people; they were talking about Afghans as the others, apart from the translators. And what I was seeing - essentially, the only thing in which I had any real expertise - was a way of looking. I didn’t know anything about the history or the culture or what was beyond the wire and was free to superimpose my own assumptions. With medicine, although by the time I left, I knew about Asherman chest seals, combat tourniques and all sorts of things about catastrophic blood loss, I felt I actually knew very little. I was an amateur observer and any claim of authority would be misguided. So I tried to work out ‘what can I claim authority in?’ And I suppose what you can claim authority in is beginning to recognise that as consumers of information, of mediated views of other things, we need to begin to develop a critical understanding of the way in which we deceive ourselves or become complacent in believing that we are getting enough information to make a judgement.

False Truths

43

44

Chapter Three

Later, when I looked back at these photographs, the ones that weren’t too bloody, the ones that I could stare at for a while, were almost like souvenir postcodes of travelling by military. Images looking from a Chinook; views from Blackhawk helicopters; from Bunkers in Sangin; looking out across walls in Lash Kagar, and other places that I happened to be. But of course what was interesting was that none of them told me anything about Afghanistan or anywhere else. Of course if I say, they’re of Afghanistan, it would be interesting because it was an exotic idea. If I said it was Bermondsey, nobody would care quite as much but, actually, you could set up in Bermondsey and it would be just the same. In fact, you could take that frame and apply it to any view anywhere in the world and it would have given a very similar effect in terms of understanding what I’d seen – because, actually, I never really gazed beyond the frame. The frame, whether it was the window of a vehicle, the firing position within a Sangar, the hatch in an aircraft, conditioned everything. It gave meaning. So for a range of these images, I stripped away the image, and I've never shown any of this for any reason but I guess I viewed it as an interesting exercise. I took these silhouetted decontextualized frames and then superimposed them onto other images and footage.

This example is the Panjshir Valley, which is one of the most beautiful places on Earth. Unfortunately, it’s also the place that, at one point, was most heavily carpet-bombed on Earth at one point. The Russians bombed

False Truths

45

it, trying to attack the mujahedeen. The Taliban tried to kill the Northern Alliance there and it’s been basically subject to a lot of man-made disasters through that time. When I went there the war was over for the Panjshir Valley, at least temporarily, and I went hiking up into these hills to where in the Lake District you would describe as a scenic view. It happened that on top of this point I looked out and I felt more peaceful than I had done for many years. Strangers offered me tea, I got ’phone reception and rang home from an Afghan mobile and I had a strange and resonant experience of beauty. When I started applying these silhouettes to the footage, our perception of it rapidly changes. Each time a new frame is applied, the sense of danger or the sense of hostility or ownership or proximity to that landscape of course entirely changes. The landscape through it is much less important than the framework. And I suppose the question is how do you remain critical of the frame and the behaviour that we’re judging through it.

Fracturing the frame Roger I’ll describe an experience, which really made an impression on me, which started to challenge my ideas of a frame. This was at a conference for science communicators in London. We’d developed a heart attack simulation – quite a realistic one where simulated patients like the one I showed you at the Welcome collapsed with chest pain and was then rushed into hospital and there was a simulation of him undergoing one of those procedures where they feed a wiggly wire into the large artery in your groin under local anaesthetic, then dilate a narrow coronary artery in the heart. Then the patient gets better and goes home. We’d arranged to do this at the science communication conference. But the theme that year was ‘impact’, and so the conference organisers asked us if we would ‘fly our presentation below the radar’, as they put it, and not announce it in advance. So in the morning we set up our operating theatre, but the first part of the story was to happen at the end of a plenary session like this in the morning. So a man went up to the rostrum and said, ‘Look, I would just like to make an announcement, if I may, about a session that’s coming up ...’ And then he gave an extremely convincing impression of somebody collapsing to the floor with chest pain. Now, this must have taken perhaps ten or fifteen seconds before ambulance paramedics at the back of the room (who had come along as part of our group) moved in. Then I went up onto the rostrum and said ‘don’t worry, this isn’t a real heart attack, it’s a simulation. Come along

46

Chapter Three

and join us as we show you the rest of what happens to this patient when they then have treatment’. And then we went away and did that and some people came with us and saw what happened when the patient was treated and got better. But quite a lot of people didn’t. What actually happened was that an enormous groundswell of controversy and highly polarised views developed very quickly. People were talking to one another over coffee, they were tweeting, they were on Facebook, and there was an enormous controversy where some people would say: ‘This is completely unethical. I cannot imagine how anybody could allow this to happen. I felt my emotions had been trifled with; I felt betrayed’. Other people said: This is the most effective public engagement I have ever experienced. I had no what it would really feel like to see someone collapse, and now I know’. And I had no idea that this was going to happen, because I was showing what happens with wiggly wires when somebody has a treatment for a heart attack. Thinking about it afterwards, there were two completely different frames. My frame was that this would be an interesting public engagement event at a conference for professional science communicators, whose theme was impact. Having been invited by the organisers to put on an event just like this, that’s what we did. But from the audience’s point of view, this was somebody who appeared to collapse without warning with a heart attack, and it was a profoundly shocking experience. And I have to say that I think when people collapse in front of you with a heart attack it is a profoundly shocking experience and I think it's a legitimate area to explore. But it pointed out to me in spades the difference that different frames can make. So it started to make me think that simulation has all sorts of opportunities for trying out and taking risks. Sometimes those risks are not the risks that you expect, and sometimes those risks and that freedom from regulation also provides freedom from the reassurances that regulation can provide. And so there are all sorts of interesting blurrinesses, I think, on the edges of the frame. David I suppose this challenge resonated with me because I was desperately angry that people weren’t really moved by what they saw on the news when I came back. I was surprised that my family weren’t saying ‘I can't imagine how intense it was for you’. Because they’d only seen two press releases relating to the 77 people that had been wounded while I was there. The press releases where just for the two who had died. So it looked to

False Truths

47

those at home that not quite as much was going on. And of course the things that were digested through the TV that was concentrating on showing you Prince Harry firing machine guns in to the middle of nowhere and that kind of thing, but not really dealing with the unfamiliar and uncomfortable visions of violence. They were showing things which we’d already learned how to process. Things that we knew weren’t threatening. As an audience, we’ve passed the Lumière Brothers; we don't think the train’s going to burst through the screen and actually kind of run us over. We can watch documentation of war now with total safety at this side of the screen, and that concerned me. I thought we should be shocked by these things, and there must be some way.

About 11 days in, one of the people that I had seen very seriously injured was to be evacuated back to the UK. I got permission to travel with him to Kandahar to see part of what happens once somebody’s gone through their initial life-saving operation, they’re sedated and are transported back toward Birmingham and an ambiguous future of secondary operations and rehabilitation. In the middle of the night we travelled with the patient on a C130 Hercules out from Bastion. At Kandahar, we were met on the runway by a larger American transport plane carrying people who looked like us but were cleaner and slightly healthier. As the patient was transferred between the two cargo ramps, I felt that he moved symbolically from being an injured soldier, to being a seriously ill patient, and it felt

48

Chapter Three

like it was a very important transition. I photographed this extraordinary event by the light of Toyota pickup trucks and the resulting images became very important to me. The problem was, of course, that you could show those photographs, they might look quite beautiful and powerful, but they wouldn’t really tell you enough about why they meant something. Actually I came to realise that what was most important were the things you couldn't photograph. In some ways the camera selects for you what has enough light and actually what fits within the frame. And so we could be forgiven for just digesting information that actually fits, rather than changing the frame to fit the content. So when I came back I had a decision. I had footage from inside that aircraft and I wanted to show that. I wanted people to know what it felt like to be in a really cold environment, deafened by sound, seeing something that is a transformative moment in someone’s life, but I didn’t want to show footage that people could see simply as an illustration of an alien experience. So what we did was to build a room about six metres across, hemispherical, where you could see from the cockpit through to the ramp the whole environment of inside the aircraft. It ran for about 50 minutes, which was the length of the flight from Camp Bastian to Kandahar. At the beginning, the brightness of the ramp was down and the room was flooded with light. As it closed the environment was pitch black. The medics can be seen using torches to look after the intensive care patients. At the end of the 50 minutes, then the ramp goes down again allowing colour and light to return to our view.

False Truths

49

So you’re sitting in there, it looks quite spectacular and you’re expecting a narrative. You’ve got a few blue dancing lights and people’s finger torches. The sound of the aircraft was overpowering. We made it as loud as it could be without the pictures falling off the walls in the rest of the Wellcome Collection. It was at a level that might make you feel physically sick if you sat there for too long. And, actually, there was nothing going on. For the whole 45-minute flight, all you’re hearing is a deafening drone and you’re not seeing any conclusive evidence of anything happening … because nothing did. The point of it was that the disorientation, the lack of visual information, the lack of understanding was the resonant sensation that I wanted to recreate. I believed that the legacy of the sensorial experience that I was depicting, the thing which people remember as being momentous in their life, was actually tied to the lack of narrative, it was heightened through the anxiety and ambiguity of not knowing what was beyond the black fuselage or what was at the other end, in Birmingham. So we filmed this with five cameras, projected in the Wellcome. But of course I couldn’t take five cameras into an intensive care. Just to fly with the medical team, I had to pretend I was a member of the crew and nearly got kicked off because somebody thought I was a journalist. So we filmed it in the back of a trainer unit in England, which had never left the ground – it was actually a big shed. And only the instructor and I had ever been in Afghanistan. For everybody else there: it was the last day of training.

50

Chapter Three

But it was interesting because in the filmed simulation the behaviour was correct and the frame of the representation was unfamiliar. This meant that the audience had to engage with content, rather than digesting it as being something that was already understood. It meant that when soldiers came to look at the exhibition they thought I’d actually brought the dust back from Afghanistan and sprinkled it on the floor, because they believed they could taste it. Of course it had been hoovered earlier in the day; it was perfectly clean, but somehow the sensory trigger of the sound was enough for people to actually believe we’d filled in all of the sensory triggers and that we’d actually brought in the dust to ensure authenticity. And even though outside there was a sign clearly saying this is a film of a simulation of a medical evacuation, people were in there feeling sorry for the volunteers who were pretending to be casualties, and the invigilators were feeling an empathetic engagement with them.

Conclusion Roger I've been thinking for a while now about how and what to represent through simulation. This is one of Barbara Hepworth’s hospital pictures – she took them in the 1940s after spending a lot of time watching an orthopaedic surgeon who was operating on one of her triplets who had the bone infection osteomyelitis at the time. What’s fascinating to me about this picture is that it captures the essence of an operating theatre. But it was only after I'd been looking at it for quite a little while that I realised all the things aren’t there. There’s no patient and there are no instruments and there’s no actual operating taking place. Yet you’ve got a group of people focusing and concentrating intently. To me it’s all about intensity – intensity of people, intensity of experience, and intensity of intention.

False Truths

51

The point of this conversation for us is that subjective, fictional, manipulated responses to a subject can potentially offer a greater sense of truth than a direct representation – as a great artist from Sarajevo, Breda Beban, once said. The documentary framework has to be challenged not only in terms of content but also in terms of the media transmission. There are times when fiction, simulation and interpretation can offer a greater empathetic understanding than simply presenting the authentic documentation of extraordinary experiences beyond our own. I think, this core contention is the root of why Roger and I found that we had some shared interests and an enduring space for conversation.

CHAPTER FOUR ARTS-BASED LEARNING IN MEDICAL EDUCATION: THE RISKS SUZY WILLSON AND ALLAN PETERKIN

Allan I wanted to begin by saying that I have tried to be an artist AND a doctor for the last 25 years. (My father was a GP and suggested I should be a poet, not a doctor. Probably a first in any medical family!) I write fiction, poetry, cultural history and children’s books. What I love nowadays is that my vocation and avocation are now inter-woven into every aspect of my work and way of being. I have time to write. I lead a therapeutic writing group for men and women living with chronic illness. I practise narrativebased psychiatry. My colleagues and I work with medical students, junior doctors and learners from 11 different clinical disciplines. We incorporate arts-based teaching to foster the development of key attributes in young health professionals: reflective capacity, narrative competence, visual literacy, critical thinking and good self-care. We have the pleasure of using literary, visual and cinematic texts to help learners identify their own values, biases, assumptions and personal (and systemic) blind spots. They also help us look at ambiguity, moral distress and risk in compassionate, helpful, fleshed out ways. We create a safe, Winicottian space for play and thinking outside the box. No two teaching sessions are ever the same. Suzy Over the last 10 years I have developed the Performing Medicine programme, which works in medical schools and NHS Trusts across the UK. Like Allan, our work is “arts based”, drawing on techniques and ideas from the perfoming and visual arts, in particular, to support health professionals and medical students in developing skills and attributes central to healthcare. Our classes, workshops and programmes focus on

Arts-based Learning in Medical Education: The Risks

53

developing skills such as self-care; non-verbal communication; verbal communication – focusing on both language and metaphor, but also tone, pitch, and clarity of voice; teamwork; ways of seeing and appreciating difference. We create safe spaces in which these skills can be explored, practised and rehearsed, before being applied to clinical situations. Whilst we work with medical schools, hospitals and institutions, we are an external arts organisation – a theatre company – and our courses are delivered by a range of Associate Artists from a variety of disciplines – performance, fine art, dance, architecture. Allan Suzy and I have been asked to contemplate how physicians and artists perceive and work with/ through risk. Traditionally we’ve been taught to think that doctors and artists see risk in completely different ways. This may, of course, be based on unexamined cultural stereotypes. Personal attributes are of course key no matter what our professional practice is. Some of us thrive on adrenaline, others are risk aversive and crave routine. Some of us are extroverts rather than introverts. Table 1 summarizes the variables involved in personal risk management. One thought is that students who choose a medical career can usually count on financial security and social status in ways that most artists cannot. A medical life can be stressful and demanding but these socio-economic factors are definitely protective buffers. Risk taking Index Areas of risk Recreational Career Health Personal safety Social relationships

Impact of language in framing risks Table 1

Human factors Beliefs and values Personal vs greater good Fear vs pleasure Tolerance/ need for arousal Time limits Social norms Cost of risk Utility vs value Biological limits

54

Chapter Four

Once you hit medical school, your goal is to predict, manage and reduce risk for your patients and to avoid liability for your institution. The risk is also secondary – i.e., not yours. Your patient’s safety, wellbeing and recovery (or injury and demise) are what’s at stake. Table 2 summarizes some other differences which are really about how we learn, work and create meaning and hopefully a personal and shared aesthetic. These are very broad strokes and are not meant to stereotype. Many of us actually thrive within the liminal space between our brain hemispheres through our melding of medicine and art. Traditional medical training (in the absence of arts-based learning) is very left-brained: verbal, logical, reductive and requires an analysis of data (known and surmised) leading to action and intervention. Artists become good at waiting for inspiration, for meaning and knowledge to emerge. They often work with non-verbal content-images, bodily sensations and perceptions coming from all five senses. No good work emerges without improvisation, stretching boundaries, taking risks, making mistakes and provoking authority or at least challenging existing assumptions. Doctors look for what is categorical, common, shared, a.k.a. “diagnostic” and “prognostic” (predictable). When formulating a diagnosis, we’re repeatedly told to think of horses not zebras when we hear the thundering of hooves. In contrast, artists actually celebrate what is unique, peculiar, unpredictable and “storied”. Risk: differences or stereotypes? Artists Doctors Invite and thrive on risk Predict / manage / reduce risk Primary risk Secondary risk (i.e. to others) High financial risk Financial Security Works with: Symbols and stories Facts and diagnoses Provoking change Maintaining homeostasis Variable social status High social status Culture of improvisation Regulated culture Spontaneity Authoritarianism Table 2

Arts-based Learning in Medical Education: The Risks

55

Suzy In terms of training and education, it is true that the concept of risk-taking is central in the arts – students are encouraged to question, innovate, critique and explore. Stereotypes about artistic and scientific temperament are so entrenched in our culture it is difficult to move beyond them. Perhaps there are as many similarities as there are differences. In my experience of making theatre, there is a huge amount of recourse to analytical skills and logic. These stereotypes about artistic and clinical ways of thinking are busted all the time when we get to a front line delivery level. For example, I was in a discussion about project management with health professionals recently and someone said ‘it seems that in the arts you have fixed ways of doing things, but in healthcare we are much more flexible and ready to change’. At that moment I felt the world had turned upside down. But I suppose we have to accept that it is harder to see your own personal or systemic habits from the inside than from the outside. That is why interdisciplinary practice is so promising. Many people within educational establishment have pointed out risks to us both over the years - risks to medical students, to artists and to the medical profession.

Risks to medical students: Risk 1 – exposing vulnerability Allan Medical training is a form of acculturation and identity formation quite similar to the military - rigid and unforgiving. When we introduce artsbased teaching, we introduce new potential risks to our learners. They still have to master endless scientific content and learn new procedures (which carry the risk of real physical harm to another). We’re now asking them to think and feel laterally - to expose personal doubts and unpack learned privilege, beliefs, biases and values in front of their professors and peers. In the UK, your learners are much younger than ours in North America, who typically start medical school in their early to mid-twenties. Nonetheless, all of our learners still have developmental imperatives that can be impinged upon by the weight of their studies. They strive to be authentic, balanced, sexual, loving human beings who have a sense of purpose and pleasure in their work and personal lives. They repeatedly encounter aspects of human suffering and loss they have not yet experienced or even imagined. They fear not knowing something (when the mark of a good doctor as of a good artist is in fact a tolerance for ambiguity). Shaming, humiliation

56

Chapter Four

and building competitive attitudes amongst students are still employed by medical educators and students often feel silenced by abuses of power. They feel deeply for their patients but are encouraged to don a cloak of confidence and cultivate a - sometimes exaggerated - professional distance. This obligatory performance can represent an assault on developing an authentic self. What I’m saying is that the role of medical humanities educators is partly to respect the defense mechanisms of students while reminding them that there is so much more to discover! Suzy Yes – though we are seeking to challenge students, as Allan says, it is important not to alienate students either. This requires real sensitivity to individual contexts, and a clear framing to participants which makes clear the ways in which the arts based work is deeply relevant to clinical practice. Learning to manage feelings of vulnerability is important for health professionals and so developing skills to support this early on in medical training is important. Arts work can begin to help students develop a language in which emotions are both real and acceptable and not necessarily to be suppressed or denied. In our Performing Medicine programme we are looking at developing skills such as self-care, selfawareness, communication, teamwork to help students understand the context in which they are working and realize that they do not have to become a ‘professionally detached’ medical machine. We address the fact that the culture they are working within has not traditionally placed value on these areas but that medicine is changing rapidly and it is their generation who can bring about culture change - giving them confidence and inspiring them to help shape the profession they have chosen. In my experience, medical educators can sometimes be over protective of students almost as if they were vulnerable patients - worrying that arts work will be too challenging or will somehow make students feel too much. Sometimes this fear isn’t articulated in detail or with clarity – it is just a background suspicion of opening up a can of worms unnecessarily. I also find that sometimes the very different kinds of risk attached to a classroom environment or a ward environment are conflated. In a recent session at a London teaching hospital, one of the teachers said to me that during a typical teaching day she didn’t have time to go to the toilet. Apparently, this is a common problem among health workers, as the risks on an A&E ward, for instance, often seem too great to leave a patient in order to go to the toilet. I said to her - ‘but this is a teaching environment –

Arts-based Learning in Medical Education: The Risks

57

your students are not going to die if you go for a toilet break – they are not vulnerable patients’.

Risk 2 – Becoming “overly sensitive” rather than “professional” Suzy The fear of become over sensitive is deeply embedded institutional attitude within medicine that we can trace right back to the Enlightenment concept of the detached scientist. The main thrust of medical education is still a scientific one - how could anyone perform good science if they are letting their own desires, fears or emotions get in the way of their scientific decision making? But of course many elements of a medic’s daily life are not especially scientific – particularly in the patient/clinician encounter in which emotional alertness and sensitivity are sometimes critically important skills. We need to nurture subjectivity in our healthcare professionals – to deny it exists is both philosophically flawed and potentially very dangerous. Allan In my experience, medical students are taught to forget that they have or inhabit real human bodies themselves. They’re forced to ignore hunger, fatigue and other physical discomfort (even deferring bathroom breaks as Suzy mentions). They’re encouraged to develop a high level of emotional stoicism – all in the name of service - while they work on the “damaged” bodies of others. Some educators fear that this is a necessary split - so that students don’t become preoccupied by their own mortality and health risks. I strongly disagree with this view. Being aware of your unique physical presence and impact is vital to the doctor–patient relationship. Taking care of your body and psyche make you a more present, empathic healer who is actually less prone to burnout and to diminishing levels of empathy over time. Suzy Yes. There are times when ‘emotional stoicism’ is an important tool – in surgery, say – but it is only a tool, not a way of being. There is often a sense within a medical view that there are only two options – being either detached (and safe) or being sensitive and involved (and at risk of pain yourself). There is a need to first acknowledge these states and then explore the middle ground where you can be flexible, finding strength and

58

Chapter Four

openness. Arts can help with techniques to develop these attributes rather than leaving them to chance or expecting the student to work out their own coping strategies without any guidance. Developing the level of self-care and awareness required to meet the considerable emotional, physical and intellectual demands of the job requires discipline, practise and institutional support.

Risk 3 – Surveillance and monitoring Allan Because medical training is so hierarchical and authoritarian, our learners have a very healthy suspicion of those who hold power over them and decide their “pass/fail” futures. Most medical schools now require learners to submit personal reflections, portfolio entries and incident reports. Is this really another form of surveillance and “thought control”? They wonder how these can be fairly graded and judged, especially as they are encouraged to expose their subjective and emotional experiences of clinical and educational incidents. Many learn the game of submitting highly calculated (and not very authentic) narratives that meet a checklist of “learning objectives” rather than taking the risk of revealing too much. A critical story (in every sense of the word) cannot be untold. Suzy In terms of reflective portfolios, it is brilliant that these are now common in medical education; though I agree that they are often done badly and students don’t have enough guidance about how to make the exercise useful for them. This is interesting as it links to a view I have often come across within medical education that the learning outcomes of arts work are “beyond assessment”. While I understand that this may be an attempt to get away from a very assessment-driven system I also think that this approach undermines the fact that there are many rigorously tried and tested ways of assessment used with arts and humanities departments at universities across the world, reflective portfolios being one of them. In the arts, certainly in Drama, there is a very strong idea of taking responsibility for your own learning so if you were doing some kind of reflective portfolio there would be no point cheating or doing an inauthentic one because you won’t get to where you need to be. If you “cheat”, first, the quality of your work wouldn’t be good, and second, you are meant to be learning through writing the portfolio so you would simply not be learning. In order for it not being tokenistic these ideas need to be

Arts-based Learning in Medical Education: The Risks

59

built into the actual structure of the assessment within a medical education context, i.e. making sure these are actually marked with rigour and contribute to something along the way – connecting, for instance, your reflective portfolio with your OSCE results (if you really engage in an authentic reflection about how your practice is going then you will do better in your exams, or see where you need to do the work) or your experience with patients on the ward. These portfolios should not be a ‘confessional diary’ but a robust way of addressing your own learning needs and development.

Risk 4 – Offending students on religious, moral or aesthetic grounds Suzy Most of my work has taken place in London – a hugely culturally diverse city – and the student cohort at medical schools reflects this. Students need to be able to relate to people very different from themselves and feel confident about having conversations with patients about subjects that are not within their realm of personal experience. Within the Performing Medicine programme we do a lot of work around appreciating difference. Many artists are very comfortable talking about emotive issues around gender and sexuality or race. Sometimes there is a worry within medical schools that this work will be too challenging for students and to open conversations around race and sexuality may risk upsetting students or challenging their belief system. I would argue that this is absolutely why it is important to create safe spaces in which these conversations can take place – so that any assumptions students may have can be aired and moderated. So it is a risk, but it is better that these questions, misunderstandings and differences of perspective are encountered while the student is still training, when issues can be unpicked, debated and meditated on, rather than being encountered years later ‘on the job’ in a high pressure encounter with a patient. Allan Again, I would suggest that the humanities help students stretch their world-view so that they don’t impose unexamined beliefs and assumptions on their patients. We can invite them to identify and affirm personal values-they don’t have to relinquish them. They do have to respect the uniqueness, otherness and autonomy of their patients and also respect their own limitations.

60

Chapter Four

There is a whole neuro-cognitive psychology literature that demonstrates that reading literature increases empathy for all of us (not just clinicians) because we voluntarily enter the worlds of characters who are so different from ourselves as readers.

Risks to artists: Risk 1 – Instrumentalizing the arts Allan I worry about artists and humanities scholars not being treated fairly by their medical education colleagues. Johanna Shapiro has written about the medical humanities becoming “ornamental’ i.e., complementing rather than challenging or “resisting” curricular impositions. In the US, the medical humanities field is quite gendered – most faculty are female and also non-MDs (often PhDs in literature). Some of them have told me they don’t wish to be the “handmaidens” to a traditionally male enterprise. In the UK and Canada, doctors do more teaching but they may be “amateurs” in the true sense of the word. They love this approach to teaching and are passionate and engaged but may not have the rigorous, critical training to analyse what’s wrong with medicine. They may forget that their non-MD teachers need to be paid fairly (rather than donate their time) and to be engaged as equals in sometimes uncomfortable, “risky” discussions. Suzy There are many debates, as Allan says, about what the arts in medical education are or should be – ornamental or instrumental, and so on. The debate about instrumentalising the arts – the idea that it reduces the arts if they are used as useful tools to nurture specific skills, say, is very live in the UK at the moment and personally I think it is something of a red herring. Arts can be many things: entertainment, propaganda, therapy populist, elitist, shocking, reassuring, challenging, affirming. Artists choose to apply their learning and artistry in many different settings and to do this within an education setting is completely legitimate. I think embracing an idea of collaboration is more important to focus on. When medical schools work with artists and arts educators it is crucial that they are respected, valued and paid properly for their work. There needs to be a commitment to developing these areas of learning and new teaching methodologies at an institutional level if arts work is not to be seen as ‘ornamental’ or as a pet enthusiasm of one of the lecturers. It seems to me that collaboration across departments at universities can often help to instil mutual respect.

Arts-based Learning in Medical Education: The Risks

61

I understand that some artists or medical humanists may not want to collude with a system that they see as patriarchal – but for me what is the alternative? Radical change is unlikely to happen overnight. Perhaps the Buddhist idea of ‘skill in means’ is useful to conjure with here - an idea that you present teachings in such a way as to be understood by audiences with different levels and modes of comprehension. Multiple strategies need to be employed in order to change a complex system that has developed over hundreds of years. I believe that it is a good idea to employ arts methodologies to develop an area in the curriculum that already exists. This doesn’t need to be called instrumentalism it can be called collaboration. I work at a hospital where we are constantly thinking up ways that artists can support healthcare professionals to, for example, learn how to communicate more effectively with colleagues, have the confidence to raise concern, be more aware of how they are working with equipment, avoid restraint scenarios in mental health settings. Is this being a handmaiden to the medical model? Likewise, I vehemently defend the right of artists to make art for arts sake and, in fact, within the Performing Medicine programme we often discuss work that has been made in that way – the artists who made it might be surprised that they have ended up embedded within a medical curriculum. I think the arts work in very layered ways and often if you are ‘ticking one box’ there are many other learning outcomes and subtle changes that ripple out from that. It is important not to get paralyzed by the instrumentalist argument and to have confidence that change will inevitably happen just by doing the work itself. Change propagates change.

Risk 2 – Compromizing artistic integrity Suzy Allan mentioned medical teachers who are not trained in the arts but are passionate about working with the arts. Here, I think it is important that the courses developed are robust and would be taken seriously within an arts education context. The standard needs to be very high in order for this field to grow and gain respect. Sometimes, there is a risk that arts are romanticized by medical educators as necessarily ennobling or humanizing. I don’t believe this to be true. I have often been asked by clinicians - ‘can you do a few sessions with us so we can teach this ourselves’. This is undermining the artist who may have built up their experience over a 20 years career, even if they make it

62

Chapter Four

look effortless. If an artist suggested that they could be taught how to operate in an afternoon they wouldn’t be taken seriously. It is a matter of respect. Also, to suggest that this work should be taught by medical educators is missing one of the key benefits of working with artists in medical education – that by working with ‘outsiders’ it encourages an outward looking institution that values differing perspectives. Of course, much of this has to do with finance. Clearly, there needs to be a financial commitment from the institution to develop this work in order to maintain high standards. There is also a risk that artists working within health settings are censored or self-censor their own work. For example, a dancer might feel that he or she can’t talk about ‘energy’ or a performance artist won’t talk freely about, say, sexuality for fear that they will be ‘judged’ by medical students (who can be very unforgiving). Within Performing Medicine we have an artists’ training programme that supports artists to find an appropriate language to work in this context without compromizing their integrity. When we have guest artists coming in to talk there is always a facilitator there to support them and to help students to contextualise the work. For me, as an artist, there is also a broader issue about becoming institutionalized. There is a Catch 22 which I think is difficult to resolve: in order to be heard, to have credibility, you need to place yourself within institutions; yet the institutionalized artist is less able to see the kind of systemic problems that most need addressing. There is a danger that you are less able to take a risk or offer a controversial critique of what you find.

Risk 3 – Power differentials Allan I remember that when I was interviewed for my position as Head of the Program in Health, Arts and Humanities at the University of Toronto, the Chair of English sat on the interview committee. He asked me point blank: “I can see what this program will bring to medical educators and learners. What’s in it for us?” I have never forgotten that question. I took a deep breath and told him that we welcome the critical lens that scholars from other fields can bring to us - to challenge how we construct knowledge and provide care. We need thoughtful “medicine watchers” to render us accountable. We want to provide artists and humanities educators access to the real medical world-clinics, hospitals, operating theaters, nurseries, classrooms, patient waiting rooms. We want to create

Arts-based Learning in Medical Education: The Risks

63

opportunities to engage in dialogue with clinical providers. (How can you write about Lacan if you’ve never talked to a psychoanalyst?) Finally, I told him I would (over time) lobby for our medical school and Program to hire his graduates to build a robust community of engaged health humanities scholars at our university. That one question was a provocation - but it’s a good illustration of how the right question at the right time can open up your thinking. Suzy It is clear that over the coming years there will be huge challenges to our public health systems and big ethical questions in terms of genetics and the uses of new technologies. It seems to me that it is a far greater risk to our society NOT to involve multiple perspectives in finding solutions to these challenges and to leave them for the medical profession to deal with alone. The more dialogue and understanding we can create about these issues across disciplines, communities and cultures, within hospitals, universities, galleries, laboratories and on the street - the better.

Risks to medical schools: Risk 1 – Reallocation of precious resources (time/money) Allan Medical School Deans repeatedly remind us that they have no money and no time slots in the curriculum for new teaching. Happily, our medical school created a new Humanities lead position two years ago (along with other key theme leads like LGBT health, advocacy and aboriginal health) and I was pleased to be offered the position. I know what pressures there are in curricular design and implementation. I talked to our faculty about what was missing in current teaching. For example, we had no content on the growing field of narrative medicine. What I offered was a flexible, “curatorial model” - that I would help fill those identified gaps with lectures and seminars (and evaluate student response) provided I would be guaranteed a specific number of teaching hours in each of the four years moving forward. I offered to help find literary and other textual content for use in other teaching sessions. (We created a literary Companion Curriculum that matched poems/stories medical topics and lectures - see www.utmedhumanities.wordpress.com). I’ve written on this curatorial model (although I know the word “curate” is being used to death nowadays!) and have just published an article on how to do it in Medical Humanities (BMJ group).

64

Chapter Four

Suzy In Performing Medicine we have created a model that offers an alternative to creating medical humanities or arts ‘posts’ within medical schools, but could equally work alongside a lecturer in medical humanities. The medical schools or healthcare providers pay us (an external arts organisation) to deliver a programme of work that is developed in collaboration with medical educationalists and clinicians at the institution. We then employ a wide range of artists who deliver the programme directly. Working with artists and arts organizations requires a different way of thinking for higher education institutions and they need to be careful to properly credit and pay for the work, and also not to appropriate it. In terms of finding time within an already packed curriculum for this kind of work, it is helpful to collaborate on developing courses that already exist in the curriculum as well as developing new ones. It seems to me that there is an increasing willingness on the part of medical schools to embrace the arts and humanities. There is more and more pressure on them to develop capabilities in their students such as self-care and resilience and to address the need for a more compassionate healthcare system. It is becoming increasingly accepted that arts and humanities have a hugely important role to play.

Risk 2 – Culture clashes: provocation and critique Allan There will always be clashes and misunderstandings when artists and doctors engage in dialogue but we have a real opportunity to shape medical (and other clinical) education in ways that humanize both providers and patients. Unlike blunt criticism, arts-based critique is engaged, thoughtful and respectful as well as “risky” and provocative. If we model reflective capacity, creativity and critical thinking for learners, they can ask questions of themselves and others as part of lifelong learning and providing optimal care. Again, I would advise artists to stage their performances, exhibits, interventions and provocations based on the developmental level of their learners. We don’t want to overwhelm a first year student in his or her teens with a piece of performance art that simply unhinges them. We all use specific defense mechanisms at challenging points in our lives and these need to be recognized and respected. Medical training is stressful but we can find out how the arts affirm authenticity, assertiveness and new

Arts-based Learning in Medical Education: The Risks

65

ways of being for students. Find out about what they’re learning and how. What art-based learning has come before and how students evaluated it? (Artists are accountable too when they become educators). The process becomes iterative, organic, collaborative and accountable. Even in the face of “risk”!

Risk 3 – Poor student/faculty evaluations Suzy As Allan says – it is vital for artists need to find out what kind of work has already happened in this area – and in order to this there is a great necessity for a much broader and more rigorous evidence base – one that broadly contextualizes arts work in medical and healthcare education that draws on arts, medical education, history and philosophy of science. There is a risk that, in seeking to build an evidence base, the case for arts based methods is actually weakened. If over-simplistic evaluations that focus on using pre-existing measurement scales or generating quantitative data are relied upon (even if they do meet the desire for quantitative data from medical schools) then the actual, multiple impacts of the arts interventions are reduced – the complexity of the educational environment and the specifics of the arts based methods are not taken into account. Alternatively, if we say ‘we can’t evaluate this kind of work as what the arts and humanities do is intangible and internal’ – then we can’t make our case either. So, there is a need for robust programme evaluation that looks at a range of factors and the context in which the learning is happening, and uses a range of methods, so that you can meet both the needs of medical establishments and also the uniqueness of the arts intervention. Such an evaluation model would help us to articulate what it is that our healthcare practitioners should be learning and why, and explain how the arts and humanities can support this learning so well. Allan That’s right. Since we’re talking about risk, it’s important to add that many medical schools have not yet developed strengths in qualitative and narrative-based research. Numbers, scales and rubrics are easier to analyze and also carry the historical gravitas of the bio-medical model. They don’t capture professional and aesthetic processes or personal attributes very well. Creating new models of evaluation that assess for rigour, while capturing the story of what makes for a resilient, caring doctor with an

66

Chapter Four

attuned social conscience, will represent a much needed step outside the comfort zone. And maybe true collaboration between artists and doctors will start to mean being open to real transformation in the encounter – not being entrenched in one’s discipline, but being open to whatever comes. Definitely a risk worth taking.

PART II: PERFORMANCES

CHAPTER FIVE IT’S GOOD TO BREATHE IN (THIS DEVON AIR) MARTIN O’BRIEN

Martin O’Brien's work considers existence with a severe chronic illness within our contemporary situation. Martin suffers from cystic fibrosis and his practice uses physical endurance, disgust, long durations and pain based practices to address a politics of the sick queer body and examine what it means to be born with a life threatening disease, politically and philosophically. His work is an act of resistance to illness, an attempt at claiming agency and a celebration of his body.

It’s Good to Breathe In (This Devon Air)

69

70

Chapter Five

In It’s Good to Breathe In (This Devon Air) Martin O’Brien begins by using a scalpel to cut the shape of lungs onto his chest and performs physiotherapy, a treatment for cystic fibrosis designed to loosen mucus on the lungs. The image of the bleeding lungs carved onto his chest develops as the blood runs and covers his hands and body. His sick body is made visible by the physical inscription as he coughs and splutters his way through the performance. Martin then playfully uses the collected mucus, rubbing it on to his body and styling his hair with it. The performance celebrated the important history of radical arts practice on the old site of Dartington College of Arts, where Martin was once a student. The College no longer exists, having been re-located to Falmouth University in Cornwall. Martin’s performance also acted as a statement of resistance against the recent commercialising of the Dartington estate against the grain of its tradition as a radical education innovation. Martin’s performance was a new version of an ongoing piece called ‘Mucus Factory’. ‘Mucus Factory’, in Martin’s own words, is ‘a mixture of a durational physiotherapy session, a technique designed to clear the airways, and an artificial attempt to use mucus as a substance for vanity and pleasure’ (http://martinobrienperformance.weebly.com/performance.html). Martin appropriates physiotherapy - claimed as professional alliedmedical technique - as a performance, in self-treatment. In his own description (paraphrased): as a person living with cystic fibrosis, Martin uses physical endurance, disgust, long durations and pain based practices to address a politics of the sick queer body and examine what it means to be born with a life threatening disease, politically and philosophically. His work is an act of resistance not to illness per se but to the medical appropriation of his body in service of normative models of health. Through such work, he reclaims agency and celebrates his given body and being. In this work, Martin purposefully multiplies metaphors, through pun and double plays, such as ‘fluidity’ and ‘inscription’. The tangible fluid is coughed up mucus, abject matter used as hair gel or dangled into his mouth so that disgust and attraction are mischievously conjoined. The physiotherapy is less massage and more a paradoxical beating up, a selfimposed violence; but it is also an animal chest pounding, an act of agency and ownership of identity, a simultaneous boundary making and undoing, a territorial de-territorialising. The cutting of the shape of the lungs is another disguised act - as reclamation of the interior body, inscribing of identity, and a positive appropriation of the surgeon’s rights and rites. As somebody who lives with cystic fibrosis, where over-production of mucus is literally drowning the lungs and impacting and obstructing the

It’s Good to Breathe In (This Devon Air)

71

intestines, Martin draws on Lauren Berlant’s (2011) notion of ‘slow death’ to describe how his own endurance performances are inevitable and not contrived (O’Brien 2014). Endurance in art and endurance in life coincide. ‘Slow death’ seems to be the major metaphor that shapes his work. Medicine’s interest in impulse and heroism necessarily rejects the metaphor of ‘slow death’. Metaphors of ‘slow death’ or ‘suspended death’ do not interest modern medicine and this is what makes the work of artists like Martin so important. Such work celebrates what medicine denies, even as medicine and its allies such as physiotherapy work in good faith and wholeheartedly on behalf of the patient. Martin says: “I submit to medicine in order to survive – in order to endure longer”, but his endurance art is surely subverting medicine at the same time; perhaps not inverting, but multiplying up, the medical gaze (O’Brien 2014: 63). While the chronically ill body necessarily demands submission to regimes of regulation and maintenance, these can be subverted in acts of empowerment. Gianna Bouchard (2012: 94) suggests that “Live Art can erode and undermine the perceived creeping loss of agency over our bodies, reclaiming them from the dominant discourses of medicine and science”. Petra Kuppers (2007: 203) calls this the “reembodying of medically derived body knowledge”. This can be seen as a replacement of medicine’s dominant metaphors by those of artists; in Martin’s case, where he writes that “performance functions as a metaphor for illness experience” this can readily be reversed, where illness experience is a metaphor for performing death in life. Martin sums up his existence as “survival of the sickest” (http://martinobrienperformance.weebly.com), a replacement of both the Darwinian trope (survival of the fittest) and the ‘medicine as war’ master metaphor, in which those who suffer ‘illness’ are in healthy competition for the best re-statement of ‘quality of life’ indicators. This thoroughly subverts the direction of travel of all ‘health’ agencies such as the World Health Organisation whose stated aim is to ‘reduce risks’ to health and wellbeing. For example, the 2002 WHO Report is full of the rhetoric of combat against ill health and the creeping dangers of ‘risk’, seen as a ‘threat’ to humankind globally, where ‘These are dangerous times for the wellbeing of the world’. This is described as a ‘drama’ in which the key players are no longer the impoverished but the well off, gradually – in zombie terms – ‘eating their own flesh’ through excessive consumption of fatty foods, alcohol and frenetic lifestyles. A new order of governmental control is needed to bring some shape and order to this wild trajectory of self-imposed symptom. Desire must be curbed.

72

Chapter Five

This scenario is heaven-sent for students of Michel Foucault, whose life’s work was the exposure of forms of ‘governmentality’ either at the macro-level of big metaphors and big ideas such as the classification of knowledge, through to the micro-levels of self-imposed governance that we blindly call ‘conscience’. Martin’s work illustrates Foucault’s notion of aesthetic self-forming through resistance to normative discourse and associated metaphors. We can also make sense of Martin’s ontological positioning as ‘endurance zombie’ within a tradition stemming from Friedrich Nietzsche and re-worked by Foucault, valuing the transvaluation of all values. Nietzsche famously questions taken-for-granted moralities and asks if we can adopt a position of tolerance when faced with alien values. The zombie of course represents such values for most of us, and this is why the literalising of the metaphor in living, breathing endurance performance is challenging for the WHO ‘wellness’ mentality and mainstream medicine, as well as for the person on the street who accepts medicine without any critical interrogation or active sensibility. Foucault’s body of work systematically maps out the historical conditions of possibility under which once included citizens are now excluded through regimes that afford identities of ‘the mad’, ‘the prisoner’, ‘the sick (clinical patient)’ and the ‘sexually perverse’. Control of citizenry operates at gross (sovereign power) and fine (capillary power) levels. The State or Government includes and excludes through contested definitions and imposition of penalties; while ‘governmentality’ seeps down to the self as a capillary mechanism reaching into the finest aspects of life such as exercise, moral choice and sexual identity, even into ‘conscience’. Foucault surprises at every turn: classification is not a values-free expression of scientific logic but a political act of judgement and control over knowledge. The empty lazar houses once used by lepers afford convenient housing for moral irritants as towns and cities are cleansed of their village idiots, prostitutes, single mothers and beggars, who in turn are treated, or reformed by quasi-scientific re-classification. Institutions are built to scrutinise and ‘re-form’ the wayward in a drive to normalise and discipline. Irritated by seeing persons at home under the family’s terms, doctors invent a space and a set of techniques in which the patient can be reduced to symptom, managed and medicalised (the ‘clinic’). Finally, sex was never repressed during the Victorian era and is not ‘liberated’ now, but is represented and managed in differing ways such as the emergence of a ‘liberated’ confessional normative sexuality in modern times that still continues to marginalise many sexual practices and choices as perverse.

It’s Good to Breathe In (This Devon Air)

73

Martin O’Brien (2014) notes how biomedical science – seen through a Foucauldian lens – is a major instrument of disciplining and normalising the body, or ‘administering life’ in Foucault’s term. The production of ‘docile bodies’ through such bio-power again depends on the application of the major metaphors of the body as machine (inspection and regulation are passed off as regular maintenance), and medicine as war (the person must be suspended in order to clear a space for the battle with the toxic invader or mutant gene). In terms of chronic illness, as Martin notes, the ‘patient’ must be subjugated as a long-term regime of ‘care’ is introduced with regular inspections and moral censures (‘how many units of alcohol have you drunk this week?’, ‘have you taken your medication?’). Here, the default body is the healthy body that is well oiled, maintained, regularly inspected, and always ready for battle, and works within set limits of what is tolerated as normal sexual behaviour. This neatly bypasses the individual, unique, idiosyncratic and sensuous materiality of the body with its inner sense-impressions or acute sensibility. The individual’s sensibility is rendered insensible as sensibility capital fails to be distributed between doctor and patient, and is instead lodged with the doctor and the medical establishment sandwiched between its twin moralising metaphors of ‘medicine as war’ and ‘body as machine’. Martin’s performance was undoubtedly the highlight and main talking point of AMH 2015. Caroline Wellbery and Neville Chiavaroli wrote commentaries on his performance (below).

Works Cited Berlant, L. 2011. Cruel Optimism. Durham, NC: Duke University Press. Bouchard, G. Skin Deep: Female Flesh in UK Live Art since1999. Contemporary Theatre Review. 1999; 22: 94-105. Kuppers, P. 2007. Community Performance: An Introduction. London: Routledge. O’Brien M. Performing Chronic: Chronic illness and endurance art. Performance Research. 2012: 19: 54-63.

Alan Bleakley

74

Chapter Five

Caroline Wellbery: How to See Pain I became interested in the question of pain only from the margins of doctoring. As a doctor, I’ve of course always dealt with patients in pain. I’ve noticed such things as doctors developing a thick skin towards expressions of pain, and a certain cynicism about pain. I also recognized that patients are in pain in so many different ways, and that psychological pain amplifies physical pain, while our culture (at least in the US) with its zero tolerance of pain creates a great many conflicted feelings about pain, just as our prurientprudish culture gives rise to many conflicted feelings about sex. But this is not what I am talking about here. My everyday consort with patients’ pain never set off any epiphanies. Only the view from the margins—looking at phenomena of patients who are themselves at the margins of mainstream experience, has challenged me to reflect on what Carrie Stahl calls a “radical stance towards concepts of normalcy,” much as a traveller in a foreign place suddenly has, from the perspective of distance, illuminations about what is happening back in her own country. So this article has at its core pain, in this case pain as “exceed[ing the] individual body (in pain) and stretch[ing] to the level of the socially inflected pain of stigma”: this article concentrates on the provocative, public pain of S&M, as performed by such artists as Bob Flanagan and Martin O’Brien. As you may know, Bob Flanagan was an S&M artist with cystic fibrosis whose muse, Sheree Rose, helped ‘out’ his masochism and allowed him to combine publically his talents as a poet and performer with the exposition of his sexual proclivities. Martin O’Brien is an artist with CF much influenced by Flanagan. His performances display among other things endurance marathons of self-mutilation and extreme physical challenges. Pain is notoriously described as irreducible. It’s a common conception that the person who experiences it cannot communicate it—pain is expressed mythologically as an eternal present in its relentless, iterative and pre-linguistic immediacy, for example in the figures of Prometheus or Philoctetes. As Elaine Scarry writes in her seminal book, The Body in Pain: “the most crucial fact about pain is its presentness.” And actually, even today, there is a radicalized model of compassion that is based on this notion of inaccessibility, that we cannot know what another person is going through, and in consequence we need to relinquish our paternalistic claims on the patient. This is the core argument of Jane McNaughton’s (2009) treatise against empathy, in which she dismisses such anodyne reassurances as ‘I hear you,’ or ‘I know how you feel’ as phony and therefore medically and psychologically counterproductive.

It’s Good to Breathe In (This Devon Air)

75

But pain becomes a very different, visible and public matter from the margins I have been talking about. I first began thinking about this when I saw a sampling of Martin O’Brien’s self-mutilations and smearings at last year’s (2015) AMH conference at Dartington Hall. From the marginal vantage point of S&M as performance, pain is not private, and certainly not inarticulate. It is in relationship to an audience, it communicates. And I began to be very interested in what sort of communication this was, particularly as I realized--while observing the audience uncomfortably sipping champagne from cocktail flutes or even leaving the performance as blood and mucus flowed--that this communication wasn’t all that feelgood or funny or flattering. In fact as a communication, it was profoundly alienating. I began to explore this question of what O’Brien was trying to say, or rather do to us. I think that in both Flanagan’s and O’Brien’s work, survival and control are essential to the S&M experience. Both artists assert control by choosing to self-inflict pain, to counteract the reality of illness where their bodies arbitrarily ‘dish out’ a constant condition of helplessness. Both artists also needle the audience, provoking the audience to question its role as viewer or, I should say voyeur, by reminding us that our sense of control is an illusion. We too are mortal, the only difference being the degree of awareness we have about the fact that our body is sooner or later going to be a vulnerable wreck. That being said, I do not think that Flanagan’s and O’Brien’s performances can be lumped together, not least because Flanagan was more interested than O’Brien in winning over his audience (mostly via his charismatic personality). In fact, the extreme nature of Martin O’Brien’s self-mutilation forces us into an awareness of pain with a discomfiting immediacy. We watch O’Brien suffocate himself, or run a scalpel blade across his chest, or gag on nauseating-looking fluids his ‘assistant’ (Sheree Rose again) funnels down his gullet. In our disgust or empathically shared suffering or distress or whatever unsettled reaction these acts elicit, we are unable to take refuge in the conventions that protect us in our viewer role. Thus, the boundaries between bodies erode: we the audience cringe as mirror neurons are activated, and are thrust outside of anything resembling a comfort zone. Under the artist’s controlled pummeling, we experience our own loss of control. This role of performance as happening has been eloquently written about. In such boundary-blurring, confrontational performances, the audience is both a passive onlooker and a participant, with profoundly unsettling effect. As Falk Heinrich (2012) writes in a brilliantly formulated essay:

76

Chapter Five In the presence of flesh, the audience’s inclination to decipher and contextualize flesh as representation seems to cease. The presentation of flesh (and the audience’s perception of it) is recursive in that it points to itself trying to counteract the audience’s hermeneutical proclivity.

There is a push and pull of performance art that as they say ‘messes’ with the audience’s sense of normality and its natural inclination to “organize their proximity to pain” (Adam Hazlitt) through interpretive acts and thus to retain control of what is happening. Heinrich describes this dual role of passive observer and active interlocutor in somewhat convoluted artspeak: “Flesh and idea are intertwined when the body reflects on itself in the simultaneous act of perception and communication as seeing the seen and seeing seeing.” For the work of Flanagan and O’Brien, I interpret “seeing seeing” as a way of formulating the artist’s claim on the audience’s vulnerability. We cannot escape the glare of pain. I suppose I wrote up my mini-play (below) as a way to restore the viewer’s equilibrium. In my play, I give the muted audience a voice—or rather, more accurately, I give myself a voice. Of course, ‘my voice’ is embodied not only by the mother, but by the artist character as well. I try to give equal voice to the provocateur and the provocatee, although to the extent that I put explanatory words in the artist’s mouth, I am defanging his work. A mother, after all (and I am one) wants her child to inhabit normality and conventionality because that is her concept of survival. But the underside of survival is acceptance, which is why in this skit I formulate reconciliation with the son as ceding control to his vision and needs. Ultimately, the mother, as presaged by her showing up at her son’s performance in the first place, realizes that she has to join him where he is. But the oedipal and the artistic confrontations are not entirely parallel. To what extent acceptance serves that artist’s purposes is not at all clear. The audience may only be valuable to the artist as long as it resists. Normality readily sets in and makes the artist’s provocations less visible.

Works Cited Heinrich, F. Flesh as Communication – Body Art and Body Theory. Contemporary Aesthetics. Vol. 10. Available online: http://quod.lib.umich.edu/c/ca/7523862.0010.012?view=text;rgn=main Last accessed: 25 Sept 2016. Macnaughton, J. The dangerous practice of empathy. The Lancet. 2009; 373: 1940-1.

It’s Good to Breathe In (This Devon Air)

77

How to See Pain: Caroline Wellbery A mini-play based on the performances of the self-mutilating artist Martin O’Brien Son [Performs a pantomime of ritual cutting or smearing.] SLIDES OF O’BRIEN AND FLANAGAN'S PERFORMANCES PROJECTED IN BACKGROUND The mother is on the sidelines in her own sort of pain seeing this happening. Son catches sight of his mother: oh there you are--you came to my performance. Mother: Just to be clear: I came to rescue you from your performance. Son: No mother, just to be clear: it’s the performance that rescues me. Mother: What? How can you say that? You cut holes into your body! You suffocate yourself! You nail your foreskin to a board in public! How can you call that a rescue? Son: Remember when David died? He wasn’t even 16. I was only a kid at the time, but I knew I had what he had. That's when I realized this thing called cystic fibrosis would kill me. Mother: But you're 27 years old now. You've survived your cousin by more than a decade. You have a good life! Son: Do you have any idea how I've made it this far? Because I do performances. Because I lie there in public, hour after hour spitting gobs of mucus in my specimen cups and smearing myself with it! You know what the doctor said after my last show? ‘Your pulmonary function tests are better than ever! Amazing! What have you been doing?’ Mother: I don't understand. How does smearing yourself with blood and mucus help you survive? Son: Tell me, mother. When I stand here, what do you see?

78

Chapter Five

Mother: Why...I see you: my son. Son: No, I mean, describe what you see. Mother: I--you...I see a boy. Son: What kind of boy? Why a boy? Am I not a man? Mother: Well, you are too thin... Son: And pale? and stunted? Mother: you look normal to me. Really, completely normal. Son: Well, there you have it. Normal. But I'm not normal. Inside, I'm making thick mucus that mucks up my lungs. I cough and gasp for air. Inside, my blood carries a defective, invisible gene. The one you passed on to me, Mum. Invisible! So, that's what I do. I make my disease visible. [Puts on a rebreathing mask until he starts flailing. Mother tries to pull it off] Mother: Please, son, don't do this. I can't stand seeing you doing this to yourself. Son: And I can't stand the disease doing what it does. I can't let it have dominion over me! Don't you understand? Why do runners run marathons? Why do they run till they vomit? Why after they've broken a leg bone do they keep going? Answer me that. Mother: You're confusing me... Son: [approaches mother tenderly, then pushes her away] No, it's not for you to understand. You gave me death. Mother: That's so unfair. It's not my fault. Son: Would you have had me if you'd realized I'd be condemned to live like this? Mother: I don't know. [She runs her hands through her hair]

It’s Good to Breathe In (This Devon Air)

79

Son [steps forward to stroke her cheek, somewhat ironically] We all have our ways of expressing our pain...Do you remember those songs you used to sing to me? From your favourite musicals? Mother: ‘A spoonful of sugar makes the medicine go down’? Son: I had a happy childhood. Mother: Yes, you did. I think you did. Son: But it’s not sugar anymore. For the record: it never is. Mother: No, I suppose not. Especially when you’re living alone with three cats that hate each other … And you know, the doctor said my heart isn’t as strong as it used to be. Son: Oh, you’ll live forever…Do you hear that? Listen! [There is music coming from off-stage. Son turns towards it and perks up with delight. He starts singing. Gestures to the audience to sing with him, grabs his mother's hand and pulls her alongside him. Reluctant at first, she slowly yields to his invitation and eventually joins in. Mother and son face each other, letting go of their defenses through song] Supermasochistic Bob has Cystic Fibrosis He should've died young but he was too precocious How much longer he will live is anyone's prognosis Supermasochistic Bob is Cystic Fibrosis I'm dili-dili, I'm gonna die We’re dili-dili, we’re all gonna die When he was born the doctors said he had this bad disease That gave him awful stomachaches and made him cough and wheeze Any normal person would've buckled from the pain But SuperBob got twisted, now he's into whips and chains I'm dili-dili, I'm gonna die...

80

Chapter Five

You get the idea before I kill myself. I'm dili-dili, I'm gonna die Years have come and gone and Bob is still around He's tied up by his ankles and he's hanging upside down A lifetime of infection and his lungs all filled with phlegm The CF would've killed him if it weren't for S & M Son & mother: dili dili - we're all gonna die, we're all gonna die...

It’s Good to Breathe In (This Devon Air)

81

Neville Chiavaroli: Through the Champagne Glass, or, what has Radical Arts to do with Medicine? Has there been a more incongruous sight at a medical humanities conference? A crowd of delegates, holding their glasses of champagne duly supplied at the exhibition opening, congregate around a concrete courtyard at the back of the Dartington Hall estate, waiting and wondering who, or what, would emerge from under the white sheet covering the motionless human form lying on the ground. We bore witness to the following extraordinary performance. The human figure stirred, removed the white sheet from itself, and sat up. We watched as the semi-naked young man commenced rubbing some form of liquid over his torso, every now and then glancing up at the assembled crowd with a quizzical look. We stared as he picked up a scalpel and began incising the skin on his chest, and we grimaced as the blood started to slowly trickle down his body, and as it became clear that he was carving the shape of his lungs on his skin. Next, he lay on his back over a wedge-shaped mat, head down, and began slapping the front of his chest with his hands. His hands and chest became bloodier with each slap, until eventually he started coughing and spluttering, the unmistakable sound of phlegm rattling around his chest and throat. He sat bolt upright, and with a large intake of breath, coughed and spluttered and expectorated the mucous into one of the jars that had been prepared and placed beside the white sheet. He closed the lid on the jar, turned over onto all fours, placed the jar in his mouth and, holding it there with his teeth, crawled slowly across the cracked concrete to place the jar at the edge of his space, just a few centimetres from the feet of the closest delegates. He turned around, crawled back to his wedge and sheet, and performed the same actions again. Each time beating his chest until the mucous was shaken loose, each time carrying the jar with his teeth to be placed next to the other jars. When he had filled the final jar, the relief amongst the delegates was almost audible. But it was premature. Sitting on his heels, with the same quizzical half-smile he had given us at the beginning, he took one of the jars, twisted the lid open, held the jar upside down above his head, and waited – as we all waited, for an eternity it seemed – for the mucous to slowly creep down the inside of the jar, and stretch and finally fall into his open palm. Laying down the jar, he rubbed his hands together, and smeared the mucous through his hair. He then looked up at the assembled crowd of conference delegates, with a roguish smile and hair sticking out

82

Chapter Five

at odd angles, and waited patiently until we realised the show was over, and that we needed to clap. He then stood up, collected his things, and sauntered down the lane at the back of Dartington Hall, giving one final breezy wave before rounding the corner. We stood there for a several seconds, those of us who had stayed until the end, unsure of what we should do next, and for most of us I presume, what we should think. Sensibility had been a major theme of this conference. This performance had challenged our sensibility in one of the most confronting ways imaginable. One by one, people had turned away and walked to safer space, some bemused, some anguished. Those of us who stayed and watched, for the most part shuffled, squirmed, and suffered – yes, even if only vicariously – to the end. We walked back to the Great Hall for dinner mostly speechless, save for the odd throw-away line to save face and perhaps more importantly, to convince ourselves and our colleagues that to witness such a performance, to allow it to proceed unimpeded and unprotested through to the end, was an act of respect and honour rather than of voyeurism, diffidence or insensibility. But forget sensibility; what most of us wanted to know I suspect was what sense was there in what had just transpired? And what did it have to do with teaching or practicing as health professionals? These were the questions I was struggling with for the rest of the conference, and days and weeks later. And while the following attempt to interpret and construct a meaning for the performance may not be how the performer, Martin O’Brien – artist, academic, and sufferer of cystic fibrosis – intended it, it is a necessary act for this delegate, at least, who was simultaneously shocked, stimulated and discomfited by the performance. Gradually through the performance, and in the days after, I imagined the artist’s voice in my head: You, healers, educators, fellow humans, do you want to know what it means to live with my condition? A condition that must be managed every day but can never be cured. That will shorten my days but god knows (because the doctors don’t) by how much. Ok. Well here are my lungs. Bloodied, carved into my skin so you can see them more clearly than any medical imaging will ever reveal to you. Here is what I must do to live, every day, 4-5 times a day. Smack my chest. Loosen the deadly sputum. Cough and splutter it out. Do it again. Over and over and over again. Every day.

It’s Good to Breathe In (This Devon Air)

83

It hurts. It’s tedious. It’s a ritual that you’ve taught me to do. But you get to go home. This is what I do. Every day. And every day I fill these jars with this slimy, stringy, sticky stuff you call phlegm or mucous. It could kill me, yet it’s part of me. It looks like hair gel. Look, I’ll show you. You gotta have some fun sometimes… As a practicing physiotherapist, I treated many patients with ‘CF’. I knew the facts about the disease, and I was a competent practitioner. I helped regulate their lives with such rituals of treatment. I had learned to utilise my empathy to understand and feel with my patients. I believe I understood what it must be like to have to live with the disease. I realised after Martin’s performance that I truly had no idea. There can be no ‘knowing’ of the patient’s reality through factual knowledge, nor through the emotional imagination of empathy, and certainly not in the highly regulated environment of clinical practice. Not through words, texts, or even the blunt images of medical textbooks, or at least not through these means alone. Theories of performance talk about ‘epiphanic’ knowing, the ‘flash’ of understanding that can come from the combination of narrative and kinaesthetic elements in ‘irreducible experiences’ such as live performance (Kohn, 2011). This form of knowing is the missing ingredient in an empirical, positivist training which most of us believe serves us so well, from a clinical outcomes perspective. The experiential way of knowing that such performances offer is our most effective path to perspective, deep understanding, and revelation. What Martin and his fellow artists do is dangerous, clearly for them, but also for us as health practitioners. By breaking the rules and creating such risky situations, performance crashes through our regulated and desensitised perceptions of what it means to be a ‘healer’ and to be ‘healed’. They reveal the otherwise unreachable reality of our patients’ lives. And just as the pain and discomfort of daily self-percussion and mucous expectoration is necessary to hold the effects of disease at bay, so some moral pain and discomfort seems necessary for us as healers, to better understand the people we seek to heal, and embrace the humility the role demands of us. It’s a confronting message, one that jolts us out of our contented assumptions about what it means to be a competent practitioner, and a caring professional. While sipping on champagne, it is a particularly uncomfortable and unsettling message. But I am realising that that’s why we need the arts in health care and education.

84

Chapter Five

Work Cited Kohn, M. Performing medicine: the role of theatre in medical education. J Med Ethics; Med Humanit. 2011; 37: 3-4.

CHAPTER SIX PREFACE TO HARDY ANIMAL LAURA DANNEQUIN

It’s May 28th 2004 and I’m warming up behind the curtains of the main stage of the Lille Opera House. The thousand-seater auditorium is filling up rapidly. I’m twenty-two years old and I’m about to dance professionally for the first time. I’m totally inexperienced but somehow I’ve managed to land this job working with this world-renowned company, and I’ve been entrusted with a solo. My body is vibrating with excitement, and fear. And then before I know it the curtains rise and the show unfolds; then the audience is clapping and exhausted, we are bowing. I’ve come out unscathed – I’ve pulled it off. This marks the beginning of a thrilling ten years: profound and transformative learning, exhilarating successes followed

86

Chapter Six

by some deep disappointments, travels far and wide. At times I get trapped in jobs that don’t challenge me; but mostly I am soaring, inspired, at home. A decade on and I’m lying flat out on the front room rug of my Bristol flat, gently rocking from side to side as I attempt to relieve the terrifying, breath-stopping pain tearing across my back. The annular tears detected on the MRI scan have had ample time to heal and yet there I remain, in baffling pain, unable to move on or function in the world; trapped in a debilitating somatic straight jacket. Increasingly, my pain is adhering to a mysterious logic of her own: a crushing burn deep inside my spine one day, stabbing knives across my hips the next, then a deafening sting, or a raging hum…surprisingly absent one day, terrifyingly present the next. As I lie there passing the days, in hiding from the world, its trashed dreams and disappointments, I chance upon David Rakoff’s Stiff as a Board, Light as a Feather. Filmed three months before his death in August 2012, the nerves that once linked his arm to his torso have been severed to stop the excruciating pain caused by a tenacious sarcoma lodged behind his collar bone, and his limp arm is kept in place by his hand tucked deep inside his trouser pocket. Alone on stage, he talks about illness, and pain, the challenges of grating cheese, and taking dance class as a young man in New York. And then as he makes to exit the stage, he stops in his tracks and he dances. An exquisite, deeply moving dance. A dance full of joy and sadness, and possibility. And as I watch him I tell myself: you can do this. You can still dance. Perhaps not in the gravity-defying, risk-taking way you once had the privilege to. But still, you can try. So with great care – and fear – I began – barely noticeably – to dance – again. I danced lying on the floor, and I danced with words on the page, allowing the language to do the dancing I couldn’t – or didn’t dare to – and then bits of my body danced: my hands, my ankles, my eyes. I danced what I could. I leapt in my daydreams and I soared magnificently in my dreams, running freer and faster than I ever had in my waking life. And then the morning light gushing through the blinds would brutally remind me of what I had lost. The enormity of it. Most of us will live long enough to experience a decline in our ability. We will have time to prepare, to accept and adapt. My decline was violent and sudden and I experienced the loss of a huge part of my abilities as a biographical disruption* of tremendous proportions: it’s not only my physical abilities that have dramatically diminished but also my ability to participate, to be in and with. To go from enjoying great physical freedom to needing help with the simplest of tasks in the space of a few months, for no apparent reason, and with no sign of improvement, has been a deeply terrifying, isolating and destabilising shift.

Preface to Hardy Animal and Lecture Demonstration

87

So my attempt at dancing again – hesitant, stiff, unassured – started to allow me to begin to accept and surrender to this new body in order to make meaning of this baffling and debilitating condition. And to begin to grieve. To grieve a body that was once, not so long ago, so fluid, so graceful, so remarkable and exquisite in its abilities. As I go through this journey of discovery and improvements, setbacks and further improvements, I am discovering that I am far from alone: the British Pain Society estimates that almost ten million Britons suffer pain almost daily. That’s almost one in every seven of us. Despite significant advances in the field of pain research over the past twenty years, my experience has shown me that the complexities of pain mechanisms remain poorly understood and treatments inadequate, leaving me and an invisible army of patients at a complete loss as to how to move on from the pain state we find ourselves trapped in. As I reconfigure myself anew, I am finding solace in the idea that I am perhaps inhabiting a sort of dual or split body**: an archival body that is full of my experience and the somatic knowledge I acquired over the years, and a biological body I inhabit in the present, with its varying and complex pain symptoms. When I was pain-free and well, I felt that both of these bodies made one, or at least operated in harmony with each other. However when my biological body entered a negative loop of persistent pain and prematurely lost much of its ability, my rich archival body was not destroyed instantaneously: the neurological pathways that made being a dancer possible survived the disruption. So despite my biological body’s inability to execute feats of times past, another part of me still knows – really knows – what it feels like to dance fearlessly and to throw myself blindly into the air not too sure where or how I might land. As such, my internal daily experience is that of inhabiting two bodies that must now coexist in screeching discord. I am a few years into my chronic pain existence. I’ve gone through crashing lows, and come out the other side with renewed hope. My diagnosis stands at ‘non-specific low back pain’. After a recent intensely painful episode, I am renewing my commitment to practicing techniques that I feel might help reduce what I now understand to be a hypersensitivity to pain, or at least dampen the dread and anguish my itinerant pain symptoms can still provoke. Perhaps I am naïve but through trial and error, commitment and dedication, I believe that I can get better Hardy Animal is part of that process: it is a space for me to dance and stay alive despite the body’s shout to be still. It emerged as I began to realise that my archival body still haunted my present biological body and .

88

Chapter Six

that the chasm between these bodies afforded me a great creative potential. Hardy Animal is an attempt to make meaning from staring into this abyss Here’s to hoping… * term coined by sociologist Michael Bury. ** proposed by philosopher Havi Carel in her book Illness.

Lecture Demonstration

direct address to audience, off microphone, at lectern What I’ve learned through my chronic pain experience is that there are no simple straightforward truths that can single handedly make sense and meaning of it all. In my search for answers I have also found that the world really isn’t short of people willing to offer — and often sell — such solutions, theories and miracle cures: God’s will, past life, karma, a lesson from the Universe, repressed emotions, shock at birth or in the womb, genetic predisposition, I could go on… But the reality of it is — or my reality of it is — that chronic or persistent pain is a very complex and mysterious process that operates on a myriad of levels. I recently attended a lecture on neuropathic pain by a professor of molecular medicine at Bristol University. During the post lecture Q&A, his most common answer, by a long shot, was: ‘we simply don’t know’. Very broadly speaking there are two kinds of pain: the first one, acute pain, is a very useful kind of pain, because it’s pain that tells me when to remove my hand from the heat source that is burning it, or to stop running if I’ve just torn my hamstring; it thus acts as a safeguard to our bodies. Acute pain really, is an evolutionary necessity that keeps us alive and well. Individuals who suffer from congenital analgesia, an extremely rare disorder that results in a complete inability to feel pain, can find their life expectancy severely diminishes as their bodies are unable to warn them of even severe injury or illness.

Preface to Hardy Animal and Lecture Demonstration

89

The second type of pain, chronic or maladaptive pain, can be defined as continuous long-term pain of more than twelve weeks or, and this is the one I’m interested in, as pain that extends beyond the time that healing would have thought to have occurred after trauma or surgery. At the point when acute pain slips into chronic pain, what happens is that although the tissues that were initially injured have healed, pain messages keep getting fired via electric impulses along the nerve fibres, up the spinal cord and into the brain where the pain is perceived as very real. L. starts a ‘chorea hand dance’ during the paragraph above: at first nothing more than an involuntary nervous tick, then growing into a large uncontrolled hand movement that is increasingly attempting to distract her as it lands on her shoulder, her face … So the pain now being experienced is no longer being caused by damaged tissues but by the damaged pain mechanisms themselves, which in turn causes a cascade of changes in the central nervous system and in brain connectivity (with, for example, a loss of grey matter) so that one is now stuck in a loop of pain where fear and anger and shame and grief — and all sorts of other emotions — also start to play their part by amplifying these signals. It’s as if one was out at sea on a boat equipped with a shark warning system which, at completely random and unpredictable times, began sounding its alarm every time a small fish went by. Or at times something as tiny as a shrimp; heightened further by my emotional responses to the alarm. In essence, this alarm system is perceiving and warning me of threats when really there are none. So although at times incredibly difficult to accept when the pain is so raw — that surely there MUST be some serious physical damage that has just gone undetected — chronic pain really, is a disease affecting brain structure and function. I have also learnt that our pain mechanisms are adaptive: a research study was carried out using a test group of violinists and a test group of individuals who didn’t rely on their ability to use their hands much. Individuals in both groups had their fingers pricked with a needle after which the violinists consistently reported much greater levels of pain. This is one of many studies that shows us that pain mechanisms can become more sensitive in individuals who might, up to a point, benefit from the protection afforded by increased pain sensitisation.

90

Chapter Six

This is part of what’s known as neuroplasticity or brain plasticity: our brain’s ability to reconfigure itself throughout our lives. An incredible feat really, until it reconfigures itself in a way that is deeply counterproductive, for reasons and through mechanisms that remain very poorly understood. As a dancer with chronic pain issues, all of this has huge implications. In practical terms what this means for chronic pain sufferers — or at least for myself — is that, in order to attempt to reverse this hypersensitivity, and hyper-arousal of the central nervous system, one must get into the habit of continuously distracting one's attention away from the pain messages — and from the associated fear that is shouting at me don’t do that, don’t pick this up, don’t have sex, don’t cycle up that hill, don’t bend that way, just walk off the fucking stage — and just keep going. Moment by moment. In time, this habit, alongside an array of other practices, should teach the central nervous system that moving is not dangerous and that warning me of non-existent threats is really not useful. It’s a process that requires extreme patience and tenacity and a sort of blind faith as really, there are no guarantees; it’s the hardest thing I’ve ever committed myself to but the best thing I’ve found so far. As for knowing how long this process might take, or how effective it might be, your guess is as good as mine. It's an exercise in convincing myself- over and over and over and over and over and over and over and over and over and over and over (...) again (‘chorea hand dance’ reluctantly recedes until her arm hangs at her side again) that pain does not equal harm. Tentatively - she begins to dance It's a completely counter intuitive exercise She dances (what she can) at first in silence then to Edwin Fischer’s recording of Bach’s Keyboard Concerto in F minor BWV1056: II. Largo Blackout

CHAPTER SEVEN TITILLATION EMILY UNDERWOOD-LEE

Titillation is a one-woman show made as a response to my experiences of trying to return to performance after my body has been radically altered by surgery and treatment following my diagnosis with breast cancer and the discovery of my BRCA1 gene variation. I have been left with a new body, a body that I do not know how to present on stage. In my earlier postcancer performance Patience (2008/9) I hide from an audience, disappear into the darkness, communicate only through language or am so confrontational that my body is blinding. Titillation is my attempt to place my cancer-marked body in the limelight; ‘the last time I took my clothes

92

Chapter Seven

off in a performance I frightened all the audience. I’ll try not to scare you too much today’. Cancer is the great threat, “the very names of such diseases are felt to have a magic power” (Sontag, 1978, p.7). Cancer shows us what we may become and what we can say with absolute certainty we will witness in at least some of the people we care about. Those who are cancer-marked are the ‘not-I’ that reminds us of the temporary nature of our health and the assuredness of our mortality, the threat of the other made manifest. The cancer-marked presents lack. Treatments often involve an amputation and lack is thus visibly inscribed on our bodies and the cancerous body is never able to meet up to the ego ideal of the whole, unified self. In the case of my own cancer I have undergone a double mastectomy and my concave chest and 24-inch scars visibly assert the authenticity of my experience, marking my truth on my body. The fetish stands in and distracts from lack, it makes us visible, it enables an audience to want to look at us: but the cancer marked body always asserts its otherness and is hence revealed to be lacking again. When layering the fetish over the marks of cancer we who bear the marks of cancer, are able to stand beside ourselves on stage, object for the scopic pleasure of others and deconstruction of that object in the same moment. Women who have had breast cancer and radical mastectomy are not supposed to be objects of desire. We are not supposed to be seen. The cultural and medical norm is that the mastectomised body is covered, hidden and associated with sadness. Current medical literature and practice advocate ‘breast-conserving surgery’ and immediate reconstruction or the wearing of prosthesis. “The emphasis upon wearing a prosthesis is a way of avoiding having women come to terms with their own pain and loss, and thereby, with their own strength” (Lorde, 1980, p.49). Titillation is my attempt to find my strength, to come to terms with my pain and loss, and to celebrate the breastless, desiring and desirable post-surgical body. I want to make visible the cancer-marked body, to place it centre stage and to shine a joyous spotlight on the scars.

Works Cited Lorde, M. 1980. The Cancer Journals. San Francisco, CA: Aunt Lute Books. Sontag, S. 1978. Illness as Metaphor. New York, NY: Farrar, Strauss & Giroux.

Titillation

93

Titillation Written and performed by Emily Underwood-Lee, choreographed by Kylie Ann Smith Verse 1 I enter from the rear of the space, dressed in my hospital gown. The stage is set with red slash curtains, microphone and chair. Centre stage is a pair of sparkling shoes. The room should be dimly lit. It feels sleazy, I am afraid and excited, keen to meet the people in the room, ready to look into their eyes, ready to notice the shape of their lips, my heart beats fast. Hello. Good evening. I’m so glad you are all here. I’m Emily, and I’m here to take care of all your needs. I can soothe, salve, stitch and dress. I can prod, poke and rub and I always ... Pause, blow on fingers, ... warm my hands. Most of all though I’m here to talk about breasts, Grasp my chest, great excitement, boobs, tits, fun bags, mammary glands, chesticles, lady pillows, melons, flesh bombs, jubblies, Bristols, norks, hooters, jugs, bazookas, baps, bangers and bosoms. Pause. I have a lot of medical experience; I’ve spent a lot of time in hospitals. But bearing in mind my lack of formal medical training it’s perhaps best if I leave your bodies alone, for now, and just share mine with you. Big smile. I am going to share the stories of my boobs and all we’ve been through together and apart. So settle back and make yourselves very, very comfortable. Music starts to play. I walk. Verse 2 On stage, seated, I smile and silently flirt. Now I am in control. I move to the microphone. I wanted to be a ballerina and I twirled and twirled. Turn finger I watched her leave for an evening at the theatre. She wore a bright electric blue dress and a blue clip in her hair that sparkled brighter than the sapphires pinned to her floor length black coat. Hand down left side of body I learnt that if you are young and beautiful and you offer tired, thirsty travellers ripe, juicy grapes they will do whatever you want, so long as you are dressed in green. Hips from side to side

94

Chapter Seven

I watched a woman wearing too much lace and spinning around and around. Circle hips I understood the power of the scent of skin warmed by the sun and flowers after a long sleep. Slowly raise arms over head I learnt that I would initiate the action sigh into microphone, drop hands but he would then take control and that large hands would make your waist feel tiny. Lift hands and then onto waist Beige iridescent lipstick. Pout, lick lips, pause I had my tiny waist and my fantastic tits and I seduced a rock star. Hands up to pointy breasts I thought I could conquer the world. This is how I learnt how to be a woman. Away from microphone. I am confessional, friendly, child-like. I will disarm you, charm you. I am not trying to seduce you (or am I?). Hello, I’m Emily, middle name Frances, a real grown up name. Lately I find I’ve been taking my clothes off a lot in public. The last time I took my clothes off in a performance I frightened all the audience. I’ll try not to scare you too much today. Back to the microphone. But I warn you now, I am gonna take my clothes off. Walk to centre stage. No known allergies. No known aspiration risks or airway blockages. Put on one shoe. All essential safety equipment ... Put on the other shoe. ... checked. Verse 3 So, as I said I’m here to talk about breasts, I’ve always thought my own breasts rather fabulous. Cup breasts and strike a pose. These aren’t them though, these are the fake ones. I’ll take them off later and show you. I lost the real ones. It’s not really like I misplaced them, Clasp chest – shocked face. Oh no – where could they be! I suppose they were more taken away than lost. They’ve gone anyhow. Verse 4 While I’m here I’d also like to talk a bit about Patrick Swayze. Most noted for his portrayal of Johnny Castle in ‘Dirty Dancing’ (that’s the one I love

Titillation

95

best) but he felt he gave his best work in his last project, the TV detective show ‘The Beast’. Anyone else a fan of Patrick? I’m with you, you and I both understand. It was Patrick who taught me the power of large masculine hands. Hands in the air, onto my waist, breathe in deeply to suck in my tummy and then breathe out slowly over microphone. 16 seconds of music, begin THE DANCE. Three years ago I heard that Patrick was ill, pancreatic cancer. Incurable. I started to dream that we would dance the last dance from ‘Dirty Dancing’ and we would do the lift! And it would be fabulous. I raise up my own body, it is only me but he is there too, I am him and I am me, we are one battered, post-cancerous body, reaching and holding, supporting and flying. Drop, walk to microphone, find someone, you are all Patrick now. I’ll make you a promise, this is my dance space and I’m going to dance for you later. Verse 5 Take the microphone to the chair. Sit down with legs spread and back to audience. Now I am frightened and frightening. I am dangerous. I am inside you. A little kiss, a little bite, creeping through you. My fingers will spread through your body. My tongues will lick from the inside out. I remember squirting cream, the hiss as it escapes from the can, the smell of sugar and aerosols. I will travel through your flesh, through your blood, I am carried through your veins. I’ll transform you one tiny cell at a time. Bending your body to my will. Turning you into exactly what I want you to be. Destroying you and breaking you. Making you ... just ... like ... me. Tap out a heart beat four times, the rhythm continues. Gugung, gugung, it’s a feeling, a heartbeat. I’ll never be sorry. Sit down on the edge of stage. Shut my eyes. Dream of the past, of parties, of dancing, of sunshine, and the feeling of long earrings scratching me as they are pressed into my neck. I have this dress, I don’t wear it often, it is black and it is satin and has a long flared out train at the back and stops on my knees at the front. And the neckline is like the one Anita Ekberg wears in the fountain in ‘La Dolce Vita’. It is slinky and sexy and beautiful. I would like to wear that

96

Chapter Seven

dress with long white gloves and my silver high heels. They are the shoes that I bought because they are the same as the ones Penny wears in ‘Dirty Dancing’. When I first watched the movie I wanted to be in her shoes, not metaphorically I didn’t want to have a botched abortion, I wanted to wear her actual silver stilettos. I had a big poster of Patrick over my bed when I was 14. Verse 6 Open my eyes. I look directly at you, Patrick. You know what’s coming next. I’m not going to let you go. I lick my finger, I move my hand down my throat, I touch my chest, I move my hand between my thighs and spread my legs. You are on your knees crawling towards me, enticing me, drawing me in to your body, your sweat, your strong hands, your hard chest, your open mouth. I stand over you, tower above you. I will lick your wounds. I will kiss away your tears. I will drink your sweat. I will caress you until the pain is gone. Verse 7 The heartbeat returns, I move back to the stage, I break the moment. Put the microphone down. Sit on the chair, shoes off. Informal, casual. A rest. I start to hear The Time of My Life begin to play. I watched you dance again and I knew new things. I watched you dance again and I knew it would all end in death. That perfect body would become frail and broken. That face would thin and crumble. Those cheeks would hollow. That belly would bloat. That chest would ooze fat and pus, stinking as it dripped into a bucket. I watched you dance again and I knew I couldn’t stop it. As the music fills my head I am transformed, no longer I, a quotation. I watched you dance again and I was scared. I was scared of everything. I was scared of what I saw, I was scared of what I did, of who I am, and most of all I was scared of walking out of this room and never feeling the rest of my whole life the way I feel when I'm with you. Verse 8 Stand up. Big smile. I am excited again. I’m going to do some dancing now. Take off my hospital gown to reveal another hospital gown and corset. Turn around to show the gown falling open, red net petticoats, red fishnets, ‘frou frou’ knickers.

Titillation

97

Music starts as my hospital gown falls to ground. THE DANCE, I remove the shoulders of my gown, my red silk bra, my breast prosthesis, I twirl, ridiculous and fantastic, repulsive and tempting, tassels fly, jelly breasts wrinkle, scars are revealed, glitter, glitter, glitter. I fling my arms wide and reveal my scars. I’m going to show, who is going to look? I got the first of my scars and lost my hair. I lost my left breast. The right one went as well. My ovaries were next on the list. This is how I forgot how to be a woman. Continue dancing. Patrick never got better and I don’t know if I will, but right now, I’m still here. I stand, topless and resplendent. I smile at the audience, look at their eyes, thank them with my pleasure. The light shines on my chest, revealing the brightness of my body.

CHAPTER EIGHT THE HAUNTOLOGIES OF CLINICAL AND ARTISTIC PRACTICE JOANNE ‘BOB’ WHALLEY AND LEE MIILER Abstract This is a paper intended for the ear as much as for the eye. It aims to open up a ludic space in which the body of the reader might begin to position itself alongside the embodied process of having ‘a practice’. The central concern of this writing is to interrogate interfaces of practice; to question what might be happening in the exchange between the practitioner and those on the receiving end of said practice. Whether it is the interface of audience / performer, or clinician / patient, we want to find space to value the uncertainty of the exchange. To this end, we position Derrida's concept of hauntology (see Spectres of Marx) as a possible critique of ontology, and offer the reader a consideration of how practitioner-researchers might find ways to secure what they don't know, by feeling around the edges of conspicuous knowledge. In this landscape of uncertainty, where the sclerotic nature of knowledge is challenged, we hope to remind ourselves of the value of the dialogic, the questioning and the unthought known (Martin Buber, 1958). By drawing upon Derridean hauntology, the knowingness of presence is replaced by 'discursive layers whose stratification allows long sequences to remain subjacent to ephemeral formations' (Derrida, 1994: 149). By shifting away from Alain Badiou’s position that to exist there must be consistency (Badiou, 2005), we seek to offer hauntologies of practice as valued opportunities where all the forgotten things, and all the mistakes made, can ghost the present moment. They serve as echoes of confusion and concern, and it is from these echoes that the elegiac and virtuosic might emerge. Fundamentally we want to offer the agentic possibility of failure, and the value of being seen in these moments of discomfort as strategic tools of expansion and growth.

The Hauntologies of Clinical and Artistic Practice

99

Ears cannot see, they are blind to the contingencies of spelling, and rely instead upon context to make sense of the narratives being offered to them. Practice is one of those words that hits the ear at just the right angle to afford a certain level of cognitive dissonance in its reception. Depending on the context, it can be either a noun or a verb, a having or a doing. In the context of performance practice, it is more often than not offered as a noun when it should be a verb; often people speak of ‘their practice’ when perhaps they would be better served to speak of the thing they are practicing; we tend to speak of that which we have mastered in those moments when its articulation strongly illustrates a faltering. When Thomas A. Schwandt positions ‘practices [as] local, contingent and contextual’ (Schwandt, 2005: 317), he is likely as not reminding his reader of this confusion, something that outside of North America, we could perhaps think of as the tectonic shift of consonants, the moving between the 's' and the 'c'. As academics who have worked in theatre departments for the past two decades, we are not sure at what point the 's' becomes a 'c'. Rehearsal is a process of doing something enough times that it will eventually shift out of the processual and into the landscape of 'product'; a difficult word to be sure, but one that will have to stand for the time being, partly because space is limited, but also because performing arts require a resistance of fixity, so that even when you have developed your 'product' you are constantly being encouraged to find ways to stay in the present moment. When performance studies scholar Peggy Phelan states that ‘[p]erformance cannot be saved, recorded, documented or otherwise participate in the circulation of representations of representations: once it does so, it becomes something other than performance’ (Phelan, 1993a: 146) she is also reminding the reader of the constant balance between the acquisition of skill, held against the stultifying effects of being too polished. Perhaps what is being struggled with here is the sense of possession, that mastery and achievement results in ownership, how something done becomes something owned. The shift to possession concerns us because of the implicit erasure of the body; the ‘doing’ of practice foregrounds the presence of the body, whereas the possession of practice runs the risk of ossification, overwriting the body that houses it, and crucially, the iterative process which allows for a continued relationship with training. To this end, this chapter will explore the potential of ghosting for both clinical and artistic practices. We would like to suggest that practice is intrinsically linked to bodies in space and place. Practice is what is done in a particular time and in relation to specific geographies. It is by beginning from here,

100

Chapter Eight

our own bodies in this place, the place where we currently sit/stand/lie, that we can articulate an understanding of there.

Interruption We recently returned from the fourth CARPA Colloquium held at the Theatre Academy in Helsinki. This biennial exploration of practice as research took as its theme performance and the non-human. One of the working parties offered the invented term ‘chairpomorphisation’ to describe the process at conferences which results in a human / non-human hybrid. The tightening of hip flexors, the rounding of lower back and shoulders, and the slow forgetting of lungs are all part of this hybrid, a creature that seems to forget its flesh, and runs the risk of its thought processes ossifying, turning to wood, metal and plastic, like the four legs it rests on. For now I would like to sidestep the unintentionally able-ist perspective from which this was offered, and instead focus upon the conceptual territory of being divorced from the body in the context of the conference. If I could ask those of you who are able to stand up, to temporarily (or perhaps permanently) move out of the orbit of your chair, lest you hybridise, and find a little room. You don’t need much. Now, it’s up to you if you want to keep your shoes on, or quietly slip them off, but whatever your preference, please step your feet hip distance apart. For those of you who remain in your chair, allow your attention to drift down to your sits bones. Slowly, with your attention in your sits bones or your feet, allow yourself to become aware of gravity, allow yourself to settle in, to ground yourself, to feel rooted. Now, work on the sensation of growing tall through the spine, feel the crown of the head floating away from the tailbone. Slide your shoulder blades down the back, letting them hug the back of the ribcage. Gently open up the front of the body, feeling as the sternum floats up towards the ceiling, offering your lungs the room to expand. Keeping this sense of expansiveness in the chest, very gently begin to fold forward, bending at the knee if your hamstrings require the space. If you are in a chair, slowly fold forward as you let your chest drift down towards your thighs. Everyone, encourage the neck to soften, finding space between the cervical vertebrae. Take a moment here. Breathe (5 long breaths). Slowly, roll up through the spine, vertebrae by vertebrae, the head coming up last. Let the shoulder blades slide down the back, open the chest and return to your breath.

The Hauntologies of Clinical and Artistic Practice

101

There is a whole range of strategies to articulate here and there; place and non-place (Augé), space and practiced place (de Certeau amongst many), smooth and striated space (Deleuze and Guattari), all different, but all trying to offer an articulation of two points and the moments in between. We would like to suggest that it is in this space between that the ghosts of practice lie. This chapter offers the reader an excavation, or perhaps an exorcism, of the gaps in between here and there, to explore what it is that happens in the moment of creative and clinical exchange. It speaks to 'the invisibles' of Della Fish (Fish, 2012), who describes elements, such as reflexive practices, as the unspoken and unnoticed of clinical practice. The rhetoric of ‘best-practice’ is littered with the ghosts of things we used to do, or expect others to do. We intend for this chapter to find space to consider what is forgotten, but still evident in the traces, and to ask what is at risk if we fail to listen to the echoes. Fundamentally, we are drawing upon the Derridean concept of hauntology, which comes from his 1993 work Spectres of Marx. Our background is in performance, a field littered with ghosts, not only the literal ghosts of Banquo and Old Hamlet, but as Herbert Blau reminds us in performance 'we are seeing what we saw before' (in Carlson, 2001: 1). It is strange working in a field for whom ghosts continue to have currency, when in broader contemporary culture there has been a clear shift away from such revenants. As Keith Thomas observes, there are no contemporary ghosts as people are no longer routinely 'carried off in the the prime of their life, leaving behind them a certain amount of social disturbance, which ghost-beliefs helps to dispel' (Thomas, 1984: 723). Instead death is anomalous, a shock to the social system. But the ghosts of hauntology are of a somewhat different order than the ghosts of Thomas. They are those things that haunt through replacement, or as Colin Davis offers, 'the priority of being and presence with the figure of the ghost as that which is neither present, nor absent, neither dead nor alive’ (Davis, 2005: 373). It is by valorizing that which stands in for the thing that it replaces (think of the ‘vintage’ filters in Instagram, a digitised patina of age and distance overlaying the most immediate and transnational sharing of the personal), that the hauntological exists. And while it absolutely applies to the digital, the dispersed, the postmodern, it might also be indicative of all arts practice. As Andrew Gallix observes: [w]hen you come to think of it, all forms of representation are ghostly. Works of art are haunted, not only by the ideal forms of which they are imperfect instantiations, but also by what escapes representation. See, for instance, Borges's longing to capture in verse the "other tiger, that which is not in verse". Or Maurice Blanchot, who outlines what could be described

102

Chapter Eight as a hauntological take on literature as "the eternal torment of our language, when its longing turns back toward what it always misses". Julian Wolfrey argues in Victorian Hauntings (2002) that "to tell a story is always to invoke ghosts, to open a space through which something other returns" so that "all stories are, more or less, ghost stories" and all fiction is, more or less, hauntological (Gallix, 2011: UP).

That which is captured, and that which escapes the frame; the fag-end framings of the fin-de-siècle, as we all hang on at the end of history, invoking that other Derridean trope, nostalgia - the ‘wound of wishing to return’ (Derrida, in Phelan, 1993b: 19). In this context, practice as a product, as the thing that we have falls through the fingers; the tighter we grip on to what we think we know, the more it eludes us. The evanescence of performance and the bodies implicated therein has been well explored by Phelan who observes that the ‘[p]erformance’s only life is in the present' (1993a: 146), reminding us that all we have is the present moment. The idea of presence, or rather of being present is something that the medical students with whom we have worked reflected upon. They spoke of struggling to find the space to breathe, of the cognitive process of learning to be responsible for the bodies of others’ pushing them away from their own embodiment. The idea of breath is so redolent of life, functioning as a cultural marker, so that it is positioned as a metaphor as much as it is a physical process. That these students, in their third and fourth years of training, felt so divorced from their own breath was deeply affecting to us. It highlighted the luxury of spending time with performance students and the hours we spend connecting to the breath and subsequently the body that generates it. In many performance and embodied practices, breath is the gateway through which the body is understood: b]reath is the flow of air between life and death. Breathing is an involuntary exercise that functions as the basis of all human activities, intellectual, artistic, emotional and physical. Breathing is the first autonomous individual action that brings life into being and the end of breathing is the definitive sign of disappearance (Nair, 2007: 7).

Once their inability to breathe had been offered as a point of concern, we asked who amongst them had witnessed the first breath taken by a body, and who had experienced the last breath given by a body. The question stuttered its way into the room, it seemed to struggle to find a place to land. It surprised them, confounded them, and they kept turning it over, like pebble in the palm. We talked about the uncertainty of Cheyne-Stokes

The Hauntologies of Clinical and Artistic Practice

103

and agonal respiration in the dying, prior to terminal apnoea, of being suspended between living and not, and what that meant for their bodies ‘holding’ that space. We wanted to talk to them about meditation, about the idea that the more you meditate, the more adept you become at it, the more you can hang in the space between breaths, how each one can flower into an eternity. We wanted to ask them how many lives might fit into that last expiration. But we didn’t. Instead, we talked about the possibilities of them being experts in flesh. We discussed a piece of performance art by Marina Abramoviü and Ulay called ‘Breathing in, Breathing out’ (1977), where the performers kneel face to face, pressing their mouths together, their noses blocked with cigarette filters. They breathe in each other’s breath, sharing the increasingly murky air, denying themselves external access to oxygen. The performance ends when one or both of them passes out.

Interruption Allow the eyes to slowly close, let the lids gently drift towards one another. Return to your breath. Take a moment to survey your body, let your attention track through and find any points of tension, shifting or adjusting to make yourself as comfortable as possible. Don’t ignore the small details; if parts of your body are asking for attention, they are not completely at ease. Listen in and shift accordingly. Return your attention to your breath. Inhale through your nose and be aware of the breath as it fills your lungs. Feel as your abdomen rises. Without pause, begin the exhalation, continuing to breathe through your nose while allowing the abdomen to fall naturally as the air leaves your lungs. Relax and allow the rhythmic nature of the breath to take over as inhalation and exhalation flow effortlessly into one another, like rolling waves gently washing against the shoreline. Soften the face, soften the front of the neck and throat, soften the chest, the tops of the shoulders, and the arms all the way down to the tips of your fingers. Relax the rib cage and the area around your heart. Notice as the abdomen softens with each rise and fall of the breath. Feel as the tops of the thighs soften, and allow your relaxed attention to flow all the way down to the tips of the toes. As your muscles begin to relax, the nerve impulses traveling to and from them decrease, and the brain can begin to calm down. Let this message of relaxation spread throughout the entire nervous system, and cultivate a sensation of relaxation, letting any tensions that have crept into your body and mind slowly release.

104

Chapter Eight

And we introduced them to Smith/Stewart’s Mouth to Mouth (1995) a repeated action enacted by the artists, Stephanie Smith and Edward Stewart, which sees Stewart fully submerged in a bath, releasing the air from his lungs into the water. We told them how Smith then bent over him, to fill his lungs with the air from her own. How he lies waiting until the tightness in his chest becomes too much and he has to breathe out again, the bubbles filling the water, and how she leans in once again offering him her breath. Smith is entirely responsible for him, and Stewart is utterly dependent on her - the responsibility of air. In his study Expressionism in Philosophy: Spinoza (1990), French philosopher Gilles Deleuze reaches around and explores the edges of Spinoza’s question: ‘What can a body do?’ When working with the medical students, we suggested that this is one of the performance artist’s job, to ask what the body can do, and in so doing invent and reframe the body each time afresh - to offer challenges to entrenched and normative views of the body. We would suggest here, just as we have suggested to those medical students, that this is also what they do, as doctors. In this dialogue between body and practitioner, whether performance or clinical, the conventional arrangements and understanding of the terrain is transformed and can enter the process of what Elin Diamond (1997: ii) calls ‘unmaking mimesis’. Diamond identifies the historical role of theatre and performance principally as mechanisms used to rehearse and reinforce essentialist configurations. In each body (patient/performer and those satellite: practitioners; family; audience) this unmaking can be experienced differently, because each body is different; each a contextually organism in need of specific and individual discourses and vocabularies, allowing for new ways of seeing within the ‘disciplinary system’ (Kershaw, 1999: 31), or as one medical student responded ‘testing the boundaries of ‘normal’’. For Diana Taylor, it is through the body that boundaries can be tested, not just the boundaries of the body, but the socio-cultural boundaries that hold the body in place: Western culture, wedded to the word, whether written or spoken, enables language to usurp epistemic and explanatory power. Performance studies allows us to take seriously other forms of cultural expression as both praxis and episteme. Performance traditions also serve to store and transmit knowledge. Performance studies, additionally, functions as a wedge in the institutional understanding and organization of knowledge’ (in Schechner 2002: 7).

This chapter becomes a site in which to consider if the field of medical humanities, like the field of performance studies before it, offers a ‘wedge’

The Hauntologies of Clinical and Artistic Practice

105

in the normative structuring of clinical approaches to the body, if there is a space for the radical in all practice? Or to extend it further, is all practice radical because it floats above, below, and beside language, and is that what is being offered by our invocation and application of hauntology? Perhaps the clinical form of resistance is not a wedge, but a poltergeist, a resistant memory that has forgotten it doesn’t have a form, but still insists on interrupting and playing before disappearing again. The hauntologies of practice are those moments where all forgotten things, all mistakes ghost the place you occupy in this moment. They are the echoes of confusion and concern that allow the virtuosic to emerge. Nicholas Till likens virtuosity to the 'ground, because you have to have this skill, the technique, and the know-how before you can do anything’ (Till, 2003: UP). To return again to Diamond and draw on her perspective of performance, which she positions as both a doing and a thing done (Diamond, 1996:1), practice is the thing that you do until it becomes the thing that you have. The hauntologic position of practice allows for the recognition of a reticulation, in that the thing you now have is ghosted by the things that you have done, encouraging practice to offer a level of fluidity while retaining the potential for unity, or as Derrida observes: [o]ne must also consider, to be sure, the singular involvement in the mobility of a highly differentiated, tactical and strategic context. But this should not prevent one from recognizing certain invariables beyond these limits. There is constancy, consistency and coherence here. There are discursive layers whose stratifications allows long sequences to remain subjacent to ephemeral formations (Derrida, 1994: 118).

By allowing the hauntologic in to practice, the virtuosic is not demonised as a fixed set of predetermined tropes, but recognised as both certain and contingent. Without wishing to tip headlong into a consideration of nonhumanism and object-oriented materialism, there is a helpful connection to be had here; that being the recognition that an object has to be inconsistent in order to exist, which is a significant shift away from Badiou’s position that to exist there must be consistency. It is this recognition of inconsistency that allows a hauntological approach to practice to have value. It is through inconsistency that the practitioner might discover agency. Academic Peter Davey articulated concerns that a blame culture in the NHS prevented medical practitioners learning from their mistakes (Davey, 2013: UP). Davey, a specialist in improving quality in clinical practices at University of Dundee, felt that the systems for monitoring patient safety were not working effectively. In response he trialled a pilot study in which trainee doctors and medical students were actively

106

Chapter Eight

supported in recording adverse incidents and encouraged to discuss them with their senior colleagues. Recent training programmes within the NHS have seen airline pilot Matt Lindley similarly explore the value of error reporting in risk-based industries (in Hammond, 2015). The agentic possibility of failure is, of course, radically different in performance than in clinical contexts, but there remains potential value in the conversation across contexts. What can be learnt from a practice that is built upon failure, by a practice for which failure might result in catastrophic outcomes for the patient? What gives us pause about this line of questioning is the assumed transactional nature of the implied exchange; instead of the intrinsic worth of arts practice, the conversation becomes governed by the extrinsic. The application of an artistic approach to practice, in that it offers the potential to absorb failure, or at least allow failure to be valued as a valid pedagogic and self-evaluative strategy, might offer critical insights into developmental processes, but it reinforces an unhelpful perspective which positions arts as valid dependent only upon their use-value. Arts practice, in this context, becomes that which can be strip-mined and applied to clinical practice, with one model serving the other. Not only does this set up an unhelpful hierarchy, it positions failure as curative; the thing we do till we learn how to stop doing it. Our concern here is that both sets of practices then position failure as a thing to go through, but ultimately master; returning again to an ossification of practice in which this plus this leads to that. Perhaps this is a part of a larger problem surfaced by Schwandt, who believes that higher education struggles to successfully ‘frame teaching, learning and inquiry in the professional practice fields’ (2005: 313). The presence of ‘doing’ within graduate and postgraduate teaching serves to highlight the fundamental schisms in the academy surrounding knowledge creation. Knowledge becomes something that is fixed, and, well, knowable. Perhaps this is why we want to move away from an ontological understanding of practice, and towards a hauntological approach. As Powell and Stephenson-Shaffer suggest ‘hauntology functions as a critique of ontology as we have understood it. Hauntology does not surpass ontology; it reimagines it’ (2009: 1). Thus, a practitioner's knowing can remain both fixed and contingent, allowing in all of the moments of unknowing, reminding us that not only was there a time when we did not 'know', but there will likely be a time in the future where what seemed certain, shifts. What we are moving towards are the gaps in our practice, those lacunae into which our knowledge slips, and we find ourselves on uncertain ground. Although Till positioned virtuosity as the ground upon

The Hauntologies of Clinical and Artistic Practice

107

which practice must be based, the hauntologic reminds us of the fissures, and encourages us to welcome them. For Nancy Stark-Smith, dancer and founding participant of contact improvisation, this uncertain ground is rich with potential: Where you are when you don't know where you are is one of the most precious spots offered by improvisation. It is a place from which more directions are possible than anywhere else. I call this place the Gap [...] Being in a gap is like being in a fall before you touch the bottom. You're suspended - in time as well as place (Stark-Smith, 1987: 3).

As we move towards a conclusion, we have one other small observation to offer; when writing down the shift between s/c of practic(s)e, it is hard not to be reminded of Roland Barthes’s S/Z in which he offered the terms ‘lisible’ and ‘scriptible’, words which when translated into English become 'readerly' and 'writerly' (Barthes, 1974). Between these two terms is a potential gap to interrogate, where the active participant in a text and the passive recipient of a text might be unseated; where the audience can have the agency to engage and disengage from moment to moment. Practice, or specifically the hauntologies of practice, allows space for just such a resistance. Practice is resistant precisely because of its hauntology, it carries with it the mistakes, the uncertainties, and the uncomfortable moments of exposure. Perhaps then, practice can offer a gentle critique of the virtuosic, not because performance artists or medical students are hobbyists or dilettantes in any way, but rather because its hauntological profile is built upon a raw terrain, with fissures and gaps that cannot be navigated, only plunged into.

Works Cited Abramoviü, M, Ulay. 1977. ‘Breathing In, Breathing Out’, performance action, first performed at Studenski Kulturni Centar, Belgrade. Augé, M. 1995. Non Places: An Anthology of Super-modernity. London: Verso. Badiou, A. 2005. Being and Event. London: Continuum. Barthes, R. 1974. S/Z. Oxford: Blackwell Publishing. Buber, M. 2000[1958]. I, And Thou. London: Scribner Classics. Carlson, M. 2001. The Haunted Stage: The Theatre as Memory Machine. Ann Arbor: University of Michigan Press. de Certeau, M. 1988 [1984]. The Practice of Everyday Life. London: The University of California Press.

108

Chapter Eight

Davis, C. État Presént: Hauntology, Spectres and Phantoms. French Studies. 2005; 59: 373-379. Diamond, E. 1997. Unmaking Mimesis: Essays on Feminism and Theatre. Oxford: Routledge. Diamond, E. (Ed.) 1996. Performance and Cultural Politics. London: Routledge. Davey, P. 2013. ‘Tayside pilot study offers potential to improve the quality of patient care nationally’, 9 May, press release, University of Dundee. Available online: http://app.dundee.ac.uk/pressreleases/2013/may13/patientcare.htm Last accessed: 21 Oct 2016. Deleuze, G. 1992[1968]. Expressionism in Philosophy: Spinoza. New York: Zone Books. Deleuze, G, Guattari, F. 1988. A Thousand Plateaus: Capitalism and Schizophrenia. London: The Athlone Press. Derrida, J. 1994. Spectres of Marx: The State of Debt, the Work of Mourning, and the New International. New York: Routledge. Fish, D. 2012. From Strands to The Invisibles: from a technical to a moral mode of reflective practice. In: Using Occupational Therapy Theory in Practice. G. Boniface, A. Seymour (eds.) Oxford: Blackwell Publishing, pp. 38-48. Gallix, A. 2011. Hauntology: A not-so-new critical manifestation. The Guardian, Books blog, 17 June, unpaginated. Available at: http://www.theguardian.com/books/booksblog/2011/jun/17/hauntology -critical Last accessed: 21 Oct 2016. Hammond, C. 2015. ‘From The Cockpit to the Operating Theatre’, presented by Claudia Hammond, BBC Radio 4, Fri 19 June, 11am, 28 minutes. Kershaw, B. 1999. The Radical in Performance: Between Brecht And Baudrillard. London: Routledge. Phelan, P. 1993a. Unmarked: The Politics of Performance. London: Routledge. —. 1993b. Reciting the Citation of Others; or, A Second Introduction. In: L. Hart, P. Phelan. (Eds.) Acting Out: Feminist Performances. Ann Arbor, MI: The University of Michigan Press, pp. 13-31. Powell, BP, Shaffer, TS. On the Haunting of Performance Studies. Liminalities: A Journal of Performance Studies. 2009; 5: 1-19. Available online: http://liminalities.net/5-1/hauntology.pdf Last accessed 21 Oct 2016. Schechner, R. 2002. Performance Studies: An Introduction. London: Routledge.

The Hauntologies of Clinical and Artistic Practice

109

Schwandt, T. On Modeling Our Understanding of the Practice Fields. Pedagogy, Culture and Society. 2005; 13: 313-332. Smith / Stewart. 1995. ‘Mouth to Mouth’, video piece, single black and white security monitor installation and amplified sound, looped. Sreenath, N. 2007. Restoration of Breath: Consciousness and Performance. Amsterdam and New York: Rodopi. Stark-Smith, N. Taking No For an Answer. Improvisation issue, Contact Quarterly. 1987; 12: 3. Thomas, K. 1984[1971]. Religion and the Decline of Magic: Studies in Popular Beliefs in Sixteenth- and Seventeeth-Century England. London: Penguin. Till, N. 2003. 'It's good for you, the virtue of virtuosity', presented at Virtuosity and Performance Mastery symposium, Middlesex University, 31 May - 1 June 2003. Available at: http://www.sfmelrose.org.uk/e-pai-2003-04/nicktill/ Last accessed: 21 Oct 2016.

PART III: HISTORIES

CHAPTER NINE NORM AND DEVIATIONS: NEOCLASSICISM AND ANATOMICAL ILLUSTRATION IN EIGHTEENTH AND NINETEENTH CENTURY BRITAIN ALLISTER NEHER

This essay is about the conflicts and accommodations that characterised the relationship between British anatomical illustration and neoclassicism.1 In the late eighteenth and early nineteenth centuries neoclassicism was the most influential artistic doctrine in the visual arts in Western Europe, which facilitated its migration to non-artistic contexts, such as anatomical illustration. The relation between the two, though, is a problematic one. By its very nature neoclassicism seems to be at odds with anatomical illustration. Neoclassical aesthetics shifts the act of depiction towards idealisation, simplification and the suppression of individualising characteristics. Anatomical illustration does not typically follow this approach; indeed, it usually needs to take one opposed to it. Consequently, this widely accepted approach to anatomical illustration found itself negotiating a conflict with its guiding artistic ideas at the most fundamental epistemological level — the level of accurate visual description. One might think that this would be a good reason to seek artistic guidance elsewhere, but neoclassicism was also the doctrine most closely associated with cultural refinement and intellectual sophistication in the mind of the educated public, and this was an association gentlemen anatomists found difficult to put aside, given their tarnished reputation in the era of grave robbing and the Anatomy Act of 1832.

1

I am using ‘neoclassicism’ with a lowercase ‘n’ because I do not want to refer only to the art movement identified as ‘Neoclassicism’ but to the more general use of neoclassical aesthetics in art and illustration in this period.

Norm and Deviations

113

In this era neoclassicism was a regulating force in decisions about how the body should be depicted, but anatomical illustration was not 'Art', and standardised conventions for representing the body's interior had not yet been settled upon. So, anatomists and artists had greater latitude to experiment with how artistic styles could be shaped to fit their purposes. This paper will discuss the strategies that four prominent artists and anatomists adopted in their struggles to resolve the dictates of aesthetics with the requirements of naturalistic depiction. In each case, the demands of one side or the other in this potential conflict were mitigated to accord with the creator’s purposes. The four cases considered are representative of the tensions that shaped anatomical illustration in this period.

General tenets of neoclassicism One way of understanding neoclassicism as a style is to see it through its rejection of Rococo aesthetics. It was common to view Rococo art as corrupted, an indulgence in luxury for an aristocracy that trivialised art. Neoclassical artists thought its subjects were often frivolous, hedonistic and licentious. Jean-Honoré Fragonard’s ‘The Swing’ (c. 1767, oil on canvas, Wallace Collection) is a well-known work that provides a clear example of this evaluation. Neoclassicism rejected as well the sensuousness of Rococo art itself: the visual charm, grace, and atmospheric and textural effects of its paintings seemed to mark it as a luxury object for the idle wealthy. Instead, neoclassical artists and theorists called for an art of moral significance that was rational and substantial. Diderot said that the artist must be a philosopher and a man of integrity. Winckelmann told painters to dip their brush in intellect. To find appropriately elevated subjects many artists turned to the stories of classical Greece and Rome. Jacques-Louis David often did, and his 'Death of Socrates' (1787, oil on canvas, Metropolitan Museum of Art, New York) provides a notable example of art guided by these ideals. Gone are the flickering highlights and atmospheric effects of Fragonard. Pastel colours and feathery contours give way to sombre hues aligned with primary colours and clearly demarcated forms. With neoclassicism's edifying and noble themes comes a cleaner and purer linear style, which was thought to offer a more rational understanding of form and a more powerful vehicle for content. The artist's role changed from a purveyor of luxury goods to a public educator who revealed higher truths. Neo-classicism is typically thought of as pursuing ideal forms and it is usually assumed that it found them in Classical art, especially the sculpture of Ancient Greece. This is true as a general characterisation, but the goal

114

Chapter Nine

was not for artists to copy Classical art; rather, they were to imitate its approach to depicting nature's forms. Ideals were to be found in the study of nature through a rigorous process of reflection that extracts the ideal from the diversity of individuals and their distinguishing differences. Here is how Henry Fuseli, the Swiss/English artist and Professor of Painting at The Royal Academy in London, put it: By nature I understand the general and permanent principles of visible objects, not disfigured by accident, or distempered by disease, not modified by fashion or local habits. Nature is a collective idea, and, though its essence exists in each individual of the species, can never in its perfection inhabit a single object. (In Knowles 1831).

Fuseli's formulation helps advance our discussion because of the way in which it is philosophically noncommittal. Neoclassicism is often associated with a Platonic conception of the ideal. In Plato's theory of knowledge, as it is set out in the Republic, the ideal is an abstract general idea that embodies the essence of a class of objects, what Plato calls a 'Form.' For example, all circles share a common essence, a common ‘Form,’ but every actual circle is imperfect because it falls short of the ideal in some way. The ideal contains the truth about circularity and actual circles are just imperfect instantiations of it. A theory of knowledge of this nature commits one to the existence of abstract general ideas as real things that inhabit a higher realm separate from the world of ordinary objects. Such a doctrine is fundamentally at odds with the tenets of British empiricism, the dominant theory of knowledge in the era we are considering. Empiricists, such as John Locke, the principal philosophical figure of the period, argue that all knowledge is ultimately derived from the senses. In the end, general ideas are nothing but abstractions created by reflecting on the properties shared by a group of individual objects - they are not a special kind of ideal object. We should note that Fuseli's statement on the ideal in nature is formulated in a way that it could be compatible with either a Platonic or empiricist approach, though the latter would be more common among his fellow British art theorists. Clearly, a Platonic approach would not be the best one for anatomical illustration because by the nineteenth century science is meant to be descriptive, not normative. An empiricist approach would appear to be a better fit and we can see how neoclassicism might have come to be taken as a suitable style for anatomical illustration. After all, anatomists also saw themselves as rational and rigorous explorers of nature and they too sought the universal truths behind nature's varieties and accidents. Even so, the fit is

Norm and Deviations

115

problematic, as will become clear when we turn to William Cheselden's (1733) Osteographia, or the Anatomy of the Bones.

William Cheselden William Cheselden (1688-1752) was a prominent anatomist and surgeon and a close friend of the famous English painter and art theorist Jonathan Richardson (1667-1745). They shared substantial common ground and complemented each other's interests. Most importantly, Cheselden had a cultivated understanding of the visual arts and Richardson had a broad interest in natural philosophy. They were both involved in the Saint Martin's Lane Academy, the precursor to the Royal Academy of Arts in London, which suggests that Cheselden was more than an artistic amateur. Cheselden's artistic judgment is on display in the engravings for his book on the skeleton, Osteographia, which is often praised as one of the most beautiful anatomical works in the Western tradition. I would like to consider Osteographia in relation to some of Richardson's central art theoretical doctrines, especially those in his ‘An Essay on the Theory of Painting’. Richardson's Essay was an English addition to continental art theory and it followed the basic structures and themes of continental treatises on the visual arts. Significantly, Richardson did not appeal to continental philosophers but used Locke's (1969) An Essay Concerning Human Understanding for his philosophical foundation. In putting forward a British art theory, Richardson also attempted to elevate important British genres, such as portraiture, that were not as highly regarded on the continent. Central to Richardson’s elevation of portraiture was his newly created aesthetic category 'Grace and Greatness,' which is related to the neoclassical ideal of improving natural appearances. Richardson (1715) gives the artist the ability to rationally make an inductive determination about what is ideal: A Painter must Raise his Ideas beyond what he sees, and form a Model of Perfection in his Own Mind which is not to be found in reality; but yet such a one as is Probable, and Rational. Particularly with respect to Mankind.

Richardson often cites Raphael as the artist who excelled at achieving this type of ideal, which is not unusual because theorists with neoclassical inclinations often enlisted Raphael for this role. Richardson himself never seems to tire of praising the Raphael cartoons in the Victoria and Albert Museum in London and exhorting British artists to seek guidance from

116

Chapter Nine

them. They are, he maintains, the greatest compositions Raphael produced, lifting London over Rome as the safe keeper of artistic excellence. When we turn to the engravings of Osteographia we can see the influence of Richardson's neoclassical doctrines immediately in the models Cheselden chose for his figures.

Figure 09.1: Cheselden, Osteographia, plate xxxv. Reproduced with the permission of the Osler Library of the History of Medicine, McGill University.

Norm and Deviations

117

The skeleton has been put in the pose of the Apollo Belvedere, which was a touchstone for Richardson and for neoclassical aesthetics from mideighteenth century to mid-nineteenth century.2 The engraving itself certainly has the grace and beauty of a Raphael drawing, but it is not a 'model of perfection' in Richardson's sense. Indeed, for Cheselden the anatomist it could not be. The explanation for why it could not be lies in the image on the title page of Osteographia. There we find a picture of Cheselden's students drawing the torso of a skeleton with the aid of a camera obscura. As far as I know, Cheselden was the first anatomist to use a camera obscura in the production of his images. He used it as a means of assuring accurate depiction, and of convincing the viewer that his images presented the unmediated visual truth. In that way it served as a rhetorical guarantee of the accuracy of his illustrations. I have seen the original drawings done in the camera obscura for Osteographia, which are in the collection of the Royal Academy of Arts in London, and it is clear that the parts of the skeleton were copied with meticulous care, warts and all.3 They are not in any way 'models of perfection.' Cheselden's purpose is to present the truth, not to create an image of the ideal. Nevertheless, in Cheselden's world the regulative power of neoclassicism over images is so strong that when he turns to deciding upon the compositions for the final versions he cannot entirely escape its influence. As an anatomist, he adopts a strategy commonly used for representing parts of the body, i.e., the individualising details of a particular specimen are played down in favour of creating a generalised one, but in Cheselden's case the generalisation becomes a kind of perfected example — one suitable for the Apollo Belvedere, for instance — though it is not an ideal in Richardson's sense.4 In the end, Cheselden’s singular images are the product of a complex set of negotiations between his scientific aims and the reigning aesthetic doctrine and dominant epistemology of the era.

John Flaxman John Flaxman (1775-1826) is likely Britain’s most famous neoclassical artist. He is best known for his sculptures, though his illustrations for The Iliad, The Odyssey and Dante's Divine Comedy are also well known to those with an interest in the history of British art. Although Flaxman was 2

Apollo Belvedere, Vatican Museums, c. 120-140 CE, marble copy, after bronze original c. 350-325 BCE. 3 The Royal College of the Arts, Library, Cab. B/ Box 14, 03/6826. 4 Ibid.

118

Chapter Nine

for the most part self-educated he became the RA’s first professor of sculpture. His Lectures on Sculpture delivered at the Royal Academy of Arts demonstrate his extensive knowledge of the history of art and his familiarity with the intricacies of the debates in art theory of his era.5 If we take Flaxman’s Pastoral Apollo as a representative example of his art, we can see quite clearly that it exemplifies the neoclassical ideals set out at the beginning of this paper.6 As is usually the case in neoclassical representations of the human figure, the anatomy is correct but anatomical divisions and distinctive anatomical features have been subdued and moved towards idealisation in a figure whose beauty depends upon the elegance and clarity of its forms. Typical of Flaxman's works, it is a subtly balanced composition that embodies the Greek spirit of rhythmical design. There is no doubt that it bears a family resemblance to the Apollo Belvedere. Flaxman's drawings possess an even greater purity of form and linear simplicity. He is indisputably an artist of line — it is his means of thought, which is apparent in the rational, well-defined linear explorations of his subjects. It is not surprising, then, that when he turns his attention to anatomical illustration these qualities are carried over to the new task. On his death, Flaxman left 13 original anatomical drawings, to these William Robertson added two others and wrote a text to turn Flaxman’s collection into a treatise on the anatomy of the bones and muscles. The title of the book, Anatomical Studies of the Bones and Muscles, for the use of Artists from drawings by the late John Flaxman, makes clear who the intended audience is.7 The messy realities of dissection have been reformulated through the refined elegance of Flaxman's neoclassicism style. Line is the sole artistic element used to delineate anatomical structures.8 In the engraving reproduced here, beautifully fluid lines travel almost the entire length of the leg. They reveal its parts and their volume through remarkably subtle variations in line weight and contour, but Flaxman's concern is with the general forms of the body, not the particular details of an anatomical specimen. Clearly the book could not have served as an instructional work for medical students, and of course it was not intended to. Artists need to understand anatomy to the extent that it helps them create plausible idealised bodies. Unlike Cheselden, Flaxman did not have to reconcile the competing demands of science and art. When it came to 5

John Flaxman 1829. John Flaxman, Pastoral Apollo, marble, 1824, Petworth House, United Kingdom. 7 Flaxman J. (1833). Anatomical Studies of the Bones and Muscles for the Use of Artists. London: M. A. Nattali. 8 Flaxman’s original drawings are in the collection of the Royal Academy of Arts. 6

Norm and Deviations

119

Figure 09.2: John Flaxman, leg, Anatomical Studies of the Bones and Muscles, for the use of Artists from drawings by the late John Flaxman. Reproduced with the permission of the Osler Library of the History of Medicine, McGill University.

120

Chapter Nine

representing the body neoclassical aesthetics fully regulated his creations and anatomy had a claim on art only to the extent that it did not undermine its aims.

Robert Knox Robert Knox (1791-1862) is an anatomist whose views on art at first glance seem similar to Flaxman's. Knox is famous for his role in the Burke and Hare scandal as the anatomist to whom they sold the bodies of their murdered victims. At the time he was one of Europe's most highly acclaimed anatomists and the courses at his private anatomy school in Surgeons’ Square in Edinburgh were in such high demand that he had to offer them twice a day. Of course, after Burke and Hare his career declined precipitously. Incrementally he was removed from all of his positions and the flood of students clamouring to study with him was gradually reduced to a trickle. Disgraced and in financial difficulty he took to translating French medical books into English and giving lecture tours in the provinces. The dramatic end to his international career did though give him more time to devote to another great passion — the fine arts — that he had nourished throughout his adult life. Knox wrote two books that he hoped would make a contribution to the artistic debates of the day: Great Artists and Great Anatomists and A Manual of Artistic Anatomy.9 At first glance, Knox's views on art seem similar to Flaxman's, but the question of the relation of anatomy to art had a wider scope for him. Generally speaking, it was an important matter of debate in most European countries, though in Britain it attracted more attention. The lives of art students and anatomy students in London overlapped in many ways. In an era before photography, medical students had to become accomplished draughtsmen so that they could record specimens and convey their observations. Very often they gained those skills through courses at The Royal Academy of Arts. Correspondingly, art students required a thorough understanding of anatomy in order to convincingly depict the human body in action. An anatomy course for artists was available at The Royal Academy (William Hunter gave the first series of lectures in 1768) but many artists wanted a deeper understanding and decided to follow courses in dissection at private 9

Knox R. (1852). A Manual of Artistic Anatomy: for the use of Sculptors, Painters and Amateurs. London: Henry Renshaw. Knox R. (1852). Great Artists and Great Anatomists; a Biographical and Philosophical Study. London: John van Voorst.

Norm and Deviations

121

anatomy schools, which were flourishing in London in this period. So they shuttled back and forth between each other's institutions, working side by side, while living in the same areas of London and going to the same coffee houses, pubs and restaurants.10 This interdependent life led to considerable cross-disciplinary expertise. For instance, the artist Benjamin Robert Haydon spent so much time at Sir Charles Bell's anatomy school that he could have run dissection courses for artists, while Bell became such a well-informed and adept artist that he wrote a book — The Anatomy and Philosophy of Expression as Connected with the Fine Arts — that was highly valued by Haydon and his friends.11 The attention that Knox gave to the subject of the relation of anatomy to art was, then, a matter of considerable interest to the British art world in general. At the heart of Knox's argument was the question of how artists learned anatomy and how that affected their depictions of people: The author of this inquiry had long been convinced of the unsoundness of the views of West, Bell, Haydon, and the Anatomical school of artists generally, wherever they may be. He did not question the utility of a knowledge of anatomy to the artist, but he questioned altogether the present mode of instruction, which in his view leads to a total misdirection of the artist’s studies.

Knox's biggest dispute with Haydon and like-minded artists was that they placed too much emphasis on dissection. Too many art students were spending too much time at Bell's Great Windmill Street School of Anatomy. Studying dead bodies had overtaken observing live ones. “The result has been the mistaking of the dead for the living,” Knox tells us.12 “It is the almost total absence of that life-like surface, which alone distinguishes the living from the dead.”13 Knox's point is an important one. It could well be true that if too much time is taken away from drawing live subjects, and invested instead in dissection, an artist's ability to create vital, convincing figures could be compromised. Ultimately, Knox takes the position that all the artist really needs is a foundational course in anatomy and time to closely study the movement of the superficial muscles beneath the surface of the skin. 10

For an extended discussion see Anne Carol Darlington, The Royal Academy of Art and Its Anatomical Teachings (University of London, Ph.D. Thesis, 1990). 11 Bell C. (1844, 3rd ed.) The Anatomy and Philosophy of Expression as Connected with the Fine Arts. London: Murray. 12 Knox, Great Anatomists and Great Artists, 142. 13 Ibid.

122

Chapter Nine

Knox's focus on the surface of the human body brings us to an important but surprising aspect of his approach to art and illustration. In both of his books there is a strong inner/outer dichotomy between the "beautiful forms" of the body's surface and its "hideous interior." The following sentence is representative: "But even when a student, I felt amazed at the application of the term beautiful to these internal shapes; shapes without form or colour, frightful, hideous, shocking to behold."14 Passages such as this are common and prominent in Knox's writings about art, which is surprising for an anatomist. Why does Knox feel such revulsion? The reason, apparently, is that there is a close connection to death: The instant the interior shows itself through the exterior, however trifling the indication may be, it marks not so much the approach of age as a tendency to dissolution. It is this that rivets the attention of the observer . . . the most dreaded of all human events.15

Art is about beauty and the noble characteristics of the mind, not dissolution and decay. Thus, “the exterior belongs to art, the interior to science and philosophy.”16 At this point in my research it is not possible to determine if Knox actually believed the interior shapes of the body are "frightful, hideous, shocking to behold," and that they are an intolerable reminder of mortality, or if he believed that this was what he had to say about this subject in a book on art intended for the general, educated public. Perhaps he even believed that such a display of Victorian sensibility might rehabilitate his public image - how could a sensitive and refined gentleman be a butchering anatomist and an associate of grave robbers and murderers? Regardless of the reason for his surprising language, it is clear from Knox's discussions of art that he believes very strongly indications of the interior structures of the body should be eliminated from artistic depictions. The protrusions of bones, tendons or anything else should not be evident anywhere in a painting or a statue. Like other neoclassicists, Knox held that modern artists should find their models in the sculptures of ancient Greece and Rome and in the paintings of the masters of the High Renaissance, especially, of course, Raphael. As a neoclassicist he found beauty in the delineation of forms through elegant lines, but his demand that the shapes of the "hideous interior" not protrude and mar the beautiful exterior forms of the body led him to a vision of art that was even more severe than Flaxman's, as we can see in figure 3. 14

Knox, Manual of Artistic Anatomy, 140. Ibid., 86. 16 Ibid., 77. 15

Norm and Deviations

123

Figure 09.3: The Outline of the Niobe, drawing of a Roman copy of the lateHellenistic sculpture. Drawing not attributed. From A Manual of Artistic Anatomy, 98. Reproduced with the permission of the Osler Library of the History of Medicine, McGill University.

124

Chapter Nine

It is a drawing of the head of the Niobe, which we can clearly see is more idealised and spare in its naturalistic details than the original statue. The anatomical illustrations that Knox includes in A Manual of Artistic Anatomy are also spare, linear and include only as much detail as is necessary to help the artist understand the mechanism beneath the surface. Once again naturalism in art is made subservient to a neoclassical vision of ideal beauty. Anatomical illustrations, however, are not to be governed by such a strict aesthetic doctrine, unless they are in a book on anatomy for artists. It must be that Knox exempts anatomical illustration from this regulating regime because he admires John Bell's illustrations, and nothing could be further from ideal beauty than them.

John Bell and Sir Charles Bell John Bell (1763-1820) and Sir Charles Bell (1774-1842) were brothers. They were raised and educated in Edinburgh and they both went on to make significant contributions to medicine. John Bell was an important anatomist and one of the most celebrated surgeons of his era. He is typically described as the founder of modern surgical anatomy. Charles Bell was also a renowned anatomist and surgeon but he is best remembered for his discoveries in neurology, especially for distinguishing the sensory from the motor nerves. He was knighted in 1833. John Bell became a Fellow of the College of Surgeons in Edinburgh in 1787 and in the same year began giving lectures on surgical anatomy at Surgeons' Hall. In 1788 the College of Surgeons gave him permission to build his own school in Surgeons' Square. From there he led a very successful career as a teacher up until 1800, when he turned his energies entirely to surgery. Charles Bell received his medical degree in 1798 and afterwards took his surgical training with his brother John. They worked together until 1804 when Charles moved to London to pursue private practice. Charles eventually took over the Great Windmill Street School of Anatomy in London, which had been founded by William Hunter, and ran it from 1812 to 1825. In this era he also played a significant role in establishing the Middlesex Hospital Medical School and in 1824 he became professor of Anatomy and Surgery at the Royal College of Surgeons in London. As mentioned earlier, it was during Charles Bell's time as director that the Great Windmill Street school became popular with artists who wanted to deepen their knowledge of anatomy.

Norm and Deviations

125

In their pre-university educations John and Charles received substantial artistic training. Their mother valued the visual arts and made sure they had good artists for tutors. During one period David Allan filled that role: Allan, the painter, was a man very dear to me in my early boyhood. There was sunshine the afternoon he came to see me. He was quite a man to a boy's humour. He was wont at all times to salute me, 'Ha! brother Brush. Let's see what you have been doing!' To him I am very principally indebted for my pleasure in drawing. . . He gave me his very beautiful studies from the Antique, and from Raphael's Cartoons, to copy, and was very good natured in his praise. 17

Without doubt, David Allen instilled in Bell a love of the art of Antiquity and the High Renaissance for these periods became the touchstones and standards for his thinking about art theory, as is evident in The Anatomy and Philosophy of Expression. They also shaped his anatomical illustrations. The clearest example is his book A Series of Engravings Explaining the Course of the Nerves, an early publication and one of the first that he produced without his brother John's collaboration.18 In Plate 1 we see what seems to be a successful fusion of neoclassical aesthetics and descriptive anatomy. Bell appears to have overcome the inherent conflict between idealisation and scientific truth. Clearly, the head has been taken from the Apollo Belvedere, yet the nerves of the face and eye seem to have been captured with unmediated realism. Once we read the text accompanying the plate, though, it becomes clear that this is not so: “This figure is not to be considered as an accurate representation of those intricate Nerves, which take their course through the bones of the face, but merely as a plan, which gives a simple arrangement of the first seven Nerves of the Cranium.”19 The nerves have been fashioned into a pleasing pattern consonant with the design of the sculpture's head. In presenting his research Bell accepted the regulative stylistic constraints of neoclassicism because his intention was only to provide a generalised plan of the facial nerves and this did not create a noticeable conflict between the descriptive and the ideal. All the same, though, there was a conflict, and it was resolved by shaping the factual to fit the aesthetic. Charles’s brother John would take a greater risk and overcome the conflict with a dramatic solution. 17

Bell C. (1870). Letters of Sir Charles Bell. London: Murray, 17. Bell C. (1803). A Series of Engravings Explaining the Course of the Nerves. London: T. N. Longman and O. Rees. 19 Sir Charles Bell, A Series of Engravings, 3. 18

126

Chapter Nine

As well as being a groundbreaking anatomist and surgeon, John Bell was an accomplished musician, draughtsman and writer. He read extensively and also managed to sustain an active social life. He had a passion for the visual arts and a profound understanding of them. They were the only artistic domain that he wrote about in-depth. As for his aesthetics, they were resolutely neoclassical.

Figure 09.4: John Bell, Second Book, Plate Fourth, Engravings, Explaining the Anatomy of the Bones, Muscles and Joints. Reproduced with the permission of the Osler Library of the History of Medicine, McGill University.

John Bell's great work on art and aesthetics is his two-volumes Observations on Italy, which he wrote during the last three years of his life. Bell visited Italy to aid his declining health and to study the great works of Italian art and test his artistic ideas against them. Bell's views on art are complex and it would require a lengthy discussion to state his ideas properly. I will only review a few that bear directly on the main topic. Apart from an emphasis of line and form, British neoclassicism looked for beauty in proportionality and the inter-relation of visual elements into a harmonious whole. Drama and action were to be restrained and the subject chosen should, as John Bell put it: “promote reflection, form the judgment and correct the taste”; it “must elevate the mind and be productive of

Norm and Deviations

127

general utility.”20 Like Knox, he argues that clear indications of anatomical structures are not acceptable in depictions of the human figure. He is not as strict as Knox, however, and does not suggest that artists should create ideals that verge on abstraction. The artist should know his anatomy and know it well, but he should not make a display of it and it should never supersede the creation of beauty. Who would expect, then, that a person who possesses such a refined artistic sensibility would produce anatomical illustrations that look like the following one? What could explain the extraordinary disparity between what he says about art and this illustration? Bell’s reply is set out in the Preface to Engravings, Explaining the Anatomy of the Bones, Muscles and Joints: “Even in the first invention of our best anatomical figures, we see a continual struggle between the anatomist and the painter; one striving for elegance of form, the other insisting on accuracy of representation.”21 Artists can make anatomical illustrations and they can make them artistically, but they are not making 'Art'. The fundamental aims are different, and that difference is more than an opposition between accuracy of representation and elegance of form. Anatomical illustrations are divorced from the ultimate ends of art, which, we recall, are to promote reflection, shape judgment, correct taste, elevate the mind and promote the greater good. Does striving for “accuracy of representation,” however, have to result in illustrations that are this bleak? Yes, Bell insists, they have been created to convey the greatest possible truth to nature and present it in the most useful possible way. The student must see what he will face in the dissection room. The harsh truth will help him understand anatomy better than the stylised beauty of neoclassical compositions. Bell is also determined to put an end to the tradition of the obliging or selfanatomising corpse, with its “puerilities” and “monstrous compounds” prancing around half anatomised. Perhaps Bell is right, but his illustrations seem to be about more than these issues. Why are they so grim and desolate? Does visual truth require the ‘mood’ that engulfs these illustrations? Why are they so dark? Their darkness, in fact, works against their purpose. In a medium such as engraving the artist only has the alternation of light and dark to record details of form and texture, and the 20

Bell J. (1825. 1st ed.) Observations on Italy, edited by Rosine Bell. Edinburgh: William Blackwood, xiv. Bell died before a final version could be prepared for publication. His wife, Rosine Bell, edited his notes and brought the present version to press. 21 Bell J. (1794). Engravings, Explaining the Anatomy of the Bones, Muscles and Joints. Edinburgh: printed by John Paterson, for Bell and Bradfute, vi.

128

Chapter Nine

greater the range of tonalities the greater the capacity to depict the properties of objects. Bell, however, has turned away from a balanced scale of tonalities and put greater emphasis on the stark contrast of light and dark, with darkness as the prominent tonality. Even the hatching in the engraving is needlessly dark. It almost obscures the information about the muscles that he wants to illustrate. The hatching lines themselves are also important to the creation of the unsettling effect produced by these images. Rather than using a rational and uniform system of cross-hatching to create alternations of light and dark and fashion three-dimensional volumes, Bell’s cross-hatching is often inconsistent and unpredictable. There are combinations of broken and erratic lines in dynamic explosions. Sometimes they serve no apparent representational purpose, as in the background shading behind the figure and under the table. They do contribute, though, to the unstable and abject atmosphere that characterises his images. It would be difficult to imagine a style more opposed to neoclassicism. Why Bell created such illustrations is a long story bound up with his view of life as an embodied, finite being, and that topic cannot be covered here. In relation to the topic of this essay, he represents the most dramatic resolution of the tension between neoclassicism and anatomy. Rather than accommodating or capitulating to the demands of aesthetics, as Cheselden, Flaxman and Knox did, Bell severs the relation between anatomy and art. It was a powerful gesture that helped shape the course of British anatomical illustration by diminishing the claims of art on medicine’s vision of the body.

Works Cited Cheselden, W. 1733. Osteographia, or the Anatomy of the Bones. London: W. Bowyer. Flaxman, J. 1829. Lectures on Sculpture. London: John Murray. Knowles, J. (Ed.) 1831. Henry Fuseli, The Life and Writings of Henry Fuseli, vol. II. London: Henry Colburn and Richard Bentley, Lecture VII, 313. Locke, J. 1969. An Essay Concerning Human Understanding, abridged and edited by A. S. Pringles-Pattison. Oxford: Oxford University Press. Richardson, J. 1715. An Essay on the Theory of Painting. London: Printed by W. Bowyer, for John Churchill at the Black-Swan in Pater-nosterRow.

CHAPTER TEN ART AS RESISTANCE TO DEATH VASSILKA NIKOLOVA

Plague The essential link between art and death is coded in the image of the Greek god Apollo and has existed since ancient times. One derivation of the name Apollo (Greek ਝʌȩȜȜȦȞ) is ‘terminator’ or ‘destroyer’, associated with the Greek verb ਕʌȩȜȜȣȝȚ (apollymi) – to cause disaster, to kill, to devastate, and to blight. Yet Apollo is the recognized god of arts, medicine and purification.1 As with everything in the Greek culture, the essence of this god reveals the principle of dichotomy at work – one and the same image reflects good and evil, light and dark. In his light side Apollo is the god of arts, and in his darker side the bringer of plague and divine retribution. This is why we have his image represented in art both with a silver bow (symbolic of his power to send epidemics and an object which is widely used in Christian art as a symbol of plague), or a lyre (symbolic of his ability in music and arts, leader of the chorus of the nine Muses) (figures 10.1 and 10.2). Except in pictorial art, we have this image revealed in poetry and in drama. Homer described the pestilence rained down by Apollo's arrows upon the Greeks warring at Troy (Iliad 1.47-53, trs. Lattimore 1951): He came as night comes down and knelt then apart and opposite the ships and let go an arrow. Terrible was the clash that rose from the bow of silver. First he went after the mules and the circling hounds, then let go a tearing arrow against the men themselves and struck them. The corpse fires burned everywhere and did not stop burning. Nine days up and down the host ranged the god’s arrows…

1

Plato in Cratylus connects the name to ਕʌȩȜȣıȚȢ (apolousis) – purification.

130

Chapter Ten

Figures 10.1 and 10.2: The two faces of Apollo – with bow and lyre

The playwright Aeschylus (trs. Smyth 1926) speaks of "the evils with which the god smote the Persians" (Persians 514): “What I say is true, yet much remains untold of the ills launched by Heaven upon the Persians”. Sophocles (Sophocles ed. Jebb 1887) himself sets the stage for the tragedy of the king Oedipus with the words (Oedipus Tyrannus, 25-28): "A blight has fallen on the fruitful blossoms of the land, the herds among the pastures, the barren pangs of women. And the flaming god, the malign plague, has swooped upon us, and ravages the town”. The counterpart of Oedipus, the Sphinx, whose image is a symbol of evil throughout the ages (Nikolova 1994), is first of all considered also to be an embodiment of plague: For whom have the gods and divinities that share their altar and the thronging assembly of men ever admired so much as they honored Oidipous then, when he removed that deadly, man-seizing plague [the Sphinx] from our land. (Aeschylus Seven Against Thebes, trs. Smyth 1926, 773 ff).

The image of the Sphinx (figure 10.3) is suggestive of the idea from ancient times - and flowering in the Renaissance - that disease is associated with the female principle as embodiment of evil. Later images of the plague in art support this. Where the plague is a god-sent punishment to the people, there is also its resolution in the image of the god Hermes and his caduceus, which has become a symbol of medicine. Pausanias related a local myth from the Boeotian polis of Tanagra that credited the god with saving the people in a time of plague by carrying a ram on his shoulders (figure 10.4) as he made the circuit of Tanagra’s walls: “There are sanctuaries of Hermes Kriophoros … They account … that Hermes averted a pestilence from the city by carrying

Art as Resistance to Death

131

Figure 10.3: Oedipus and the Sphinx by Francois-Xavier Fabre (1766-1837)

Figures 10.4 and 10.5: Hermes Kriophoros by Calamis; Christ the Good Shepherd

132

Chapter Ten

a ram round the walls; to commemorate this Calamis made an image of Hermes carrying a ram upon his shoulders …”. This myth provides an explanation of a cult practice aiming at reverting of miasma (the ritual pollution that brings disease according to the ancient beliefs). Reflections of Hermes Kriophoros may be detected in the image of the Good Shepherd Christ (figure 10.5), as in many Christian paintings and pictures Christ is depicted as averter of the arrows of plague. This is how, since antiquity, death was opposed by sublime hope. The most famous depiction of the plague in antiquity is the one by Thucydides in his History of the Peloponnesian War where he describes the epidemic (the plague in Athens, 429-427 BC) in a poetic way: people dying in the city while the fields outside are laid to waste. In Thucydides' History we are confronted with powerful literary resonances between the conditions at Athens and the mythology and legends of Troy and Thebes (Oedipus). This confirms that the dramatic effect of the epidemic was not lost among ancient authors. A lot of articles and books have been written discussing the nature of the epidemics – suggestions vary that it was a plague, typhus or small pox. Yet, for the literature and art this had no importance – in art it was generally accepted as a plague symbolizing the evil sent from gods for punishment of people. The Athenians were rendered hopeless: When people caught the plague, they gave up their resistance. The once loyal, deeply spiritual, lively and obedient Athenians were now unreligious, selfish … . The gods were no longer praised, and the laws were rarely ever followed ... . People gave up restraint and hope. The Athens before the plague and the Athens after the epidemic are complete contrasts. This just shows how one thing can effect humans' lives and attitudes (Berry 2014).

Yet, in the words of Carl Gustav Jung: “anxiety is just the first step to art”. The dramatic effect of suffering was captured in many pictures made by authors in later periods. Thucydides combined poetic description and Hippocratic (figure 10.6) trimmings - the vocabulary used by Thucydides to describe signs and symptoms differs from Hippocratic terms, but the dramatic description is based on formulae and phrases from Aphorisms and Airs, Waters, Places spread in the text.

Art as Resistance to Death

133

Figure 10.6: Hippocrates ordering plague clothes to be burnt, 17th century engraving

The artistic suggestion of Thucydides’ description had its influence in later poetic works. There can be no doubt that Lucretius recognized the power of Thucydides' description of the dual plague: of war and pestilence – in his De Rerum Natura he gave the epidemic a great prominence and copied its description exactly in a poetic rhythm. And in the Noric2 cattle plague of Virgil's Georgics (book 3) many see another imitation of Thucydides' description of the epidemic at Athens (West 1979). Indeed, some believe 2

Noricum is the Latin name for a Celtic kingdom, including parts of modern Austria and Slovenia.

134

Chapter Ten

that Virgil wholly invented the Noric cattle plague for the dramatic and poetic effect he so much admired in Lucretius and in Thucydides. In his mythical “plague at Aegina” (Met. 7: 523-613), Ovid also used elements borrowed not only from Thucydides' Athenian description, but from Virgil's cattle plague as well. These works of the Roman period have inspired a great deal of artistic works in later Europe (figure 10.6). After a millennium with no reported plague, the next one came with a number of major plague epidemics. The Byzantine historian Procopius first reported the epidemic in 541 that started from the port of Pelusium in Egypt3 and was transmitted by ships with grain reaching Constantinople in 542, spreading into Europe and Asia. Known as the ‘plague of Justinian’, this is the first known epidemic on record, and marks the first properly recorded pattern of bubonic plague. In a passage closely modelled on Thucydides, Procopius noted that because there was no room to bury the dead, bodies were left stacked in the open. He recorded the devastation in the countryside and the ruthless response by the hard-pressed Justinian: When pestilence swept through the whole known world and notably the Roman Empire, wiping out most of the farming community and of necessity leaving a trail of desolation in its wake, Justinian showed no mercy towards the ruined freeholders. Even then, he did not refrain from demanding the annual tax, not only the amount at which he assessed each individual, but also the amount for which his deceased neighbours were liable.

Because of the plague, tax revenues declined due to the massive number of deaths and the disruption of agriculture and trade. This brought change in the legislation in order to provide for development of the state and funding of new cultural projects - Justinian put significant funds towards the construction of great churches, such as Hagia Sophia, and spent huge amounts of money for wars against the Vandals. The most devastating pandemic in human history happened during the 14th century, coming along the caravan routes of the Silk Road and peaking in Europe in the years 1346-53. The disease hit Caucasus and Crimea (Caffa)4 by 1346, Constantinople by 1347, Alexandria in the autumn of 1347, and Cyprus and Sicily in the same year. In the winter of 3 Procopius, Anekdota, 23.20f. The famous Secret History (Apókryphe Istoría, Latin: Historia Arcana) was discovered centuries later in the Vatican Library and published by Niccolò Alamanni in 1623 at Lyons. Its existence was already known from the Suda, which referred to it as the Anekdota ("unpublished writings"). 4 Ancient Greek Theodosia, today a town in Crimea called Feodosia.

Art as Resistance to Death

135

1348, galleys from Caffa reached Genoa and Venice, but it was the outbreak in Pisa that was the entry point to northern Italy and the plague spread northwest across Europe, striking France (Marseilles was hit by January of 1348, Paris in spring 1348), followed by the Low Countries in the same year, and Spain, Portugal and England by June 1348. After that, the plague turned and spread eastwards through Germany and Scandinavia from 1348–50, Eastern Europe by 1350, and finally to Russia in 1351. The most popular word for the plague was pestis, which was later on used in the Yersinia pestis, the bacterium that causes the plague.5 Another Latin name was lues, known also from the work of Lucretius. Writers contemporary to the plague referred to the event as the ‘Great Mortality’ or the ‘Great Plague’. The name ‘Black Death’ (atra mors) was derived from Homeric Greek6 and adopted in classical Latin - in fact, it was a poetic image of death as dark and terrible. The descriptor Mors Nigra (Black Death) was used for a first time in 1350 by Simon de Covino (or Couvin), a Belgian astronomer, who wrote the poem De judicio Solis in convivio Saturni (‘On the judgment of the Sun at a feast of Saturn’) in which he attributed the plague to a conjunction of Jupiter and Saturn. In fact, it was a couple of years earlier when, on commission of the Pope in 1348, a group of learned men of the medical faculty at Paris concluded that the disaster was a result of a conjunction of Saturn, Jupiter, and Mars in the 40th degree of Aquarius at 1:00 p.m. on March 20, 1345. The doctors of the time, being unable to understand the origin of disease, also considered the plague a divine punishment (figure 10.7).

5

Formerly called Pasteurella Pestis, Yersinia pestis was discovered in 1894 by Alexandre Yersin, a Swiss/ French physician. 6 In Homer's Odyssey, Scylla's mouth is said to contain rows of teeth "full of black death" (ʌȜİȓȠȚ ȝȑȜĮȞȠȢ șĮȞȐIJȠȚȠ). The Latin word ater means ‘black’ having the overtones of ‘gloomy, sad, dismal, unlucky’ and exactly like the Homeric description, it is not used specifically about epidemics or plague.

136

Chapter Ten

Figure 10.7: Doctors looking for the reason of the disease

The Black Death had strong religious implications. On one side, the idea of the plague as a heavenly punishment turned people to more humble behaviour, making them more spiritual. On the other side, the Church could not save people from the disease, leading many Europeans to question their beliefs. However, it was far easier for people to lose faith and to point at the shortcomings or responsibilities of others. Specific groups were singled out for persecution and the Jews quickly became the primary scapegoats for the 14th century plague (figure 10.8). This group was accused of conspiring to spread the plague, since Jews were often merchants, and merchants carried the infected rats.

Art as Resistance to Death

137

Figure 10.8: Burning of Jews in a pit, The Nuremberg Chronicle

At the time when the plague spread around Europe, the continent was coming out from the so-called ‘Dark Ages’, trying to wipe out the unpleasant memories and move on to a more enlightened era. Barbarians no longer ravaged, and without the constant fear of invasion, art and architecture found fertile ground to grow. Medieval painters were not simply anonymous craftsmen, but well respected professionals. They were held in high esteem and often interacted with clergy and wealthy patrons. The arrival of Black Death opened a new era of painting. Artists were tormented by the constant menace of death, causing them to look for answers in scriptures and the Church. Paintings overflowed with tortured souls, death, dying, fire and brimstone (figure 10.9).

138

Chapter Ten

Figure 10.9: Death strangling the ill

Yet, the art of the period was also imbued with the dual mood of the situation. Drawings were both full of death and destruction and also very much human and religiously faithful. Literal plague paintings were less common, but there was a profusion of symbolic portrayals with victims of the plague shown as wounded and dying under a shower of arrows from a heavenly executioner (figure 10.10) (Burgess 1976, 422-8; Crawfurd 1914: 135-50; Polzer 1982: 111). The ancient concepts were revived in a new context with Christian imagery full of symbolism that was the same as in ancient times. The disease took the image of a woman as an embodiment of evil and the arrows of Apollo – the god with the silver bow - retained their message of epidemic death.

Art as Resistance to Death

139

Figure 10.10: Fresco in the former Abbey of Saint-André-de-Lavaudieu, France, 14th century, depicting the plague personified as a woman who "carries arrows that strike those around her, often in the neck and armpits—in other words, places where the buboes commonly appeared" (Mormando 2007).

140

Chapter Ten

Speaking about the symbol of arrows, that is how the Christian St. Sebastian came to be identified with the plague (figure 10.11) - in the role of a patron interceding for potential or actual victims. Sebastian became associated with the plague as early as the 7th century - a mosaic in the church of San Pietro in Vincoli in Rome shows the Saint with the following inscription: “To Saint Sebastian, martyr, dispeller of the pestilence”. By the time that the disease was reintroduced into Europe in 1347, the cult of Sebastian was widespread in Italy and elsewhere on the continent (Mollaret and Brossolet 1965: 76- 79). At the end of the 14th century there were innumerable representations of Saint Sebastian and the Black Death. There were churches and chapels dedicated to him and many of these were festooned with effigies of the Saint. A typical example is the chapel that still stands in Lansvillard, France. This chapel has seventeen frescoes tracing the life of the Saint, two of which are directly concerned with Sebastian's role during the plague.

Figures 10.11 and 10.12: St. Sebastian by Andrea Mantegna (1431-1506) - note the cloud and the hidden figure of a rider in it.

Mantegna’s St Sebastian shows a cloud with a hidden figure of a rider. A similar motif of the plague as a rider is seen in the famous woodcut from Dürer's series of illustrations for ‘The Apocalypse - the Four Horsemen’ (figure 10.12) presents a dramatically distilled version of the passage from the Book of Revelation (6:1–8), where the first rider represents the plague with the ancient symbol of a bow:

Art as Resistance to Death

141

And I saw, and behold, a white horse, and its rider had a bow; and a crown was given to him, and he went out conquering and to conquer. … When he opened the fourth seal, I heard the voice of the fourth living creature say, 'Come!' And I saw, and behold, a pale horse, and its rider's name was Death, and Hades followed him; and they were given great power over a fourth of the earth; to kill with sword and with famine and with pestilence and by wild beasts of the earth.

Figure 10.13: The Horsemen of the Apocalypse - from left to right, Death, Famine, War and Plague

142

Chapter Ten

Obvious cultural influences were seen not only in the art but also in the literature of this period. In 14th century Europe artistic and literary expression took on a dark humour and tone in order to cope with the tragedy. One of the most famous names, the Italian poet Boccaccio, set his Decameron in the plague year, 1348: How many valiant men, how many fair ladies, breakfast with their kinfolk and the same night supped with their ancestors in the next world! The condition of the people was pitiable to behold. They sickened by the thousands daily, and died unattended and without help. Many died in the open street, others dying in their houses, made it known by the stench of their rotting bodies. Consecrated churchyards did not suffice for the burial of the vast multitude of bodies, which were heaped by the hundreds in vast trenches, like goods in a ship’s hold and covered with a little earth.

This collection of vulgar tales was a predecessor to Chaucer’s Canterbury Tales. Boccaccio and Chaucer both mocked the hopelessness of those who had nothing to lose. But nowhere has the mood of the times been better reflected than in the letters and poetry of the prototypical humanist Petrarch, who remained preoccupied with the plague and its social consequences until the end of his days. In a moving verse he measures his personal loss against the devastating effects of plague on society, as a whole: Alas what lies before me? Whither now Am I to be whirled away by the force of fate? Time rushes onward for the perishing world And round about I see the hosts of the dying, The young and the old; nor is there anywhere In all the world a refuge, or a harbor Where there is hope of safety. Funerals Where'er I turn my frightened eyes, appall; The temples groan with coffins, and the proud And humble lie alike in lack of honor The end of life presses upon my mind, And I recall the dear ones I have lost, Their cherished words, their faces, vanished now, The consecrated ground is all too small To hold the instant multitude of graves. (See Wilkins 1961: 7980).

Smaller outbreaks of the plague continued for about 200 more years.7 Subsequent outbreaks, though severe, marked its retreat from most of Europe. The most general outbreaks in England ended with the Great Plague of London in 1665. 7

The Second Pandemic was particularly widespread in the following years: 1360– 63; 1374; 1400; 1438–39; 1456–57; 1464–66; 1481–85; 1500–03; 1518–31; 1544– 48; 1563–66; 1573–88; 1596–99; 1602–11; 1623–40; 1644–54; and 1664–67.

Art as Resistance to Death

143

Figure 10.14: The Dance of Death

Inspired by the Black Death, The Dance of Death (figure 10.14) or Danse Macabre, an allegory of the universality of death, became a common painting motif in the late medieval period. In the ‘Dance of Death’ style of Renaissance art skeletons mingle and dance among the living in daily scenes - such mingling depicted the intensity of the Black Death's journey across Europe. The Latin phrase Memento mori (“Remember that you will die”) became the leitmotif of the art - because of the Black Death, Renaissance art began to explore the nature of mortality and became reminder of the attitude to live a life worthy of favourable divine judgment. The historical imprint the plague left on Renaissance art is undeniable. The Black Death had a lot of consequences including cultural, religious and economic. These changes contributed to conditions favourable to the decline of feudalism, the end of the Middle Ages and the emergence of the Renaissance: with the extreme loss of life there was an overabundance of goods, a decrease in their price, a surplus of jobs and consequently a rise in wages. The standard of living actually increased. Also, the need for paid workers resulted in movement away from feudalism and the development

144

Chapter Ten

of a working class. All of these events paved the way for the coming Renaissance. The effect of the Black Death on Renaissance art is largely philosophical, symbolic and intangible and the plague's influence on art is profound because of the overall impact of the epidemics on many artists and their work. Artists gained subject matter to depict emotionally transparent representations of suffering, infection symptoms and philosophical beliefs about death. Symbols were used to convey beliefs about death - skulls, arrows, horsemen, decaying bodies and the hourglass are present in many of the works created during the bubonic plague's devastating presence. The Black Death's effect on European society urged artists to blend realism with communication about events. The art of these centuries abounds in images of death, yet it is also full of joy. The Europeans of the 16th and 17th centuries created incredible treasures of civilization. Far from being driven to despair by pestilence, they were spurred on to assert the glory of life.

Plague and syphilis At the end of 15th c. a new plague spread like wildfire - or, at least, wild behaviour! At the beginning there was not even a name for it. Everyone called it ‘the plague’. In the medical books of the period were used the words pestis and lues, but in order to distinguish the new epidemics from the Black Death, people started to attach adjectives derived from the name of the country which their own one disliked the most (and this, of course, is witnessed by the medical treatises). The English called the disease the French plague, the French called it the Neapolitan or Italian plague, the Italians and the Dutch called it the Spanish plague, the Portugese called it the Castilian plague, the Russians called it the Polish disease and the Polish called it the Russian disease, the Turks called it the Christian disease and the Persians called it the Turkish disease (Vassilka 1992). Whatever its origin, there can be no question that by the close of the 15th century a severe pandemic stalked Europe - from its most populated cities to most remote villages. To stop the insulting practice of political adjectives, one of the greatest scholars of the time - Girolamo Fracastoro (Hieronymus Fracastorius), a true Renaissance man,8 decided to give the disease a name and to attribute 8

Professor at the famous University of Bologna, he was an astronomer, geographer, botanist, mathematician, philosopher, and physician.

Art as Resistance to Death

145

the fault for it to the ancient Greeks (they were all dead, after all, and could not be offended!). In 1530 he published the poem Syphilis Sive Morbus Gallicus (‘Syphilis or the French Disease’) from which the name of the disease was later derived. Written in Latin, his poem describes a mythical young shepherd named Syphilus, or Sifilo, who rejected and, hence, insulted Apollo – the Sun god, and, as we know, the creator of epidemics.9 In response, Apollo struck Syphilus down with the terrible disease. No one knows where Fracastorius came up with this name for the unfortunate shepherd but some have hypothesized that he borrowed it from Ovid’s Metamorphoses, which features a character named Sipylus,10 while others believe Fracastorius was influenced by Virgil’s Aeneid. Yet, the best explanation could give us the etymology of the word itself, suggesting that the shepherd got the disease from the pigs he was caring about and his affection to them was the real reason to reject the sensitive god. In fact, sy+philis comes from the Greek ȈȊ(Ȉ) (pig) + ĭǿȁǿȈ (