Dialogue

Scientism and the medicalization of existential distress: a reply to John Paley

Clinton E. Betts* BSc BScN MEd RN and Andrea F. J. Smith-Betts BA BSW MEd RSW
*Assistant Professor, School of Nursing, McMaster University, Hamilton, Ontario, Doctoral Student, Faculty of Education,York University,Toronto, Ontario, Canada

We have read with great interest the recent scholarly exchange/critique concerning spirituality in the nursing literature in Nursing Philosophy (Newsom, 2008; Paley, 2008a, 2008b; Pesut, 2008a, 2008b) and elsewhere (Paley, 2007). Paley, of course the central gure in this discourse, is, with his reductionist approach (Paley, 2008a), at his critical best in unabashedly deconstructing (he might not be take kindly to our use of this word) both the spirituality literature in nursing and the uncritical enthusiasm with which it seems to be produced. In his response to Pesuts (2008a) critique, he gives those of us that disagree with him (or his reductionism) three options:
. . . ignore the paper altogether; provide some non-questionbegging reasons for thinking that the gratuitous assertions are true; or accept the naturalistic premise for the sake of argument, and evaluate the evidence from health psychology, social psychology, neuropsychology, and pharmacopsychology. (Paley, 2008b, pp. 138139)

The paper cannot be ignored; it simply is too important for that. As for option two, we agree with Paley it aint gonna happen. The third is interesting, but not for the reason that Paley thinks. In this paper, we shall attempt to make two points. First, using Paleys work, we note what might be a not insignicant contradiction: that a thinker who has spent so much time criticizing error suddenly, and conveniently, appears to celebrate it. Second, the real achievement of Paleys (spiritual) reductionism is to medicalize existential distress, and we are not sure this is such a good thing at all. Before we proceed, however, let us just say that
Correspondence: Clinton E. Betts, School of Nursing, Faculty of Health Sciences, 1200 Main Street West HSC-1V7, Hamilton, Ontario, Canada L8N 3Z5. Tel: +1 905 525 9140 ext. 22036; fax: +1 905 570 0667; e-mail: bettsc@mcmaster.ca

we think that Paley (2008b) is correct to [cancel] the gratuitous assertions . . . in order to avoid futile exchanges with authors who might otherwise queue up to tell me that I am wrong (p. 138). Moreover, his implicit, and at times not so implicit, view that spirituality has some direct connection to religion is one we share. Finally, his subtle contention that more of the, shall we say, status quo research on spirituality in nursing is likely to continue to turn up the same thing i.e. more gratuitous assertion, is also something we agree with. For over a decade, now John Paley has been one of the premier (critical) voices in the (theoretical) nursing literature (students rarely get out of our advanced theory classes without encountering him). In fact, spirituality is only the latest trouble spot that has come under the hot lights of Paleys critical interrogation; he has also done jobs on qualitative research, particularly phenomenology (Paley, 1996, 1998, 2000a, 2005a, 2005b), caring (Paley, 2001, 2002a, 2002b), intuition and expertise (Paley, 1996, 2006a), Carpers ways of knowing (Paley et al., 2007) and meaning (Paley, 2000b) among others. His modus operandi seems to be, if we have read him correctly, to begin a paper with a probative and heavy-handed critique (which is almost always cogent and insightful), ridicule a few people along the way at times and end with proper science. Indeed, although his writing is varied, his view seems to consistently be that . . . nursing must learn to do proper science (Paley, 2002a, p. 32). To this, he adds . . . there are plenty of nurses who understand very well what scientic research is. But the discipline does not yet have strength in depth, and rectifying this will, realistically, take a generation. Unfortunately, it will take much longer than that if slave morality opposition to science continues . . . (p. 32). Clearly, he does not

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think that this generation has come to pass, not in the spirituality literature at any rate hence the need for a reductive approach to spirituality and, so called, spiritual care. The value that proper science, or scientic methodology, has for Paley appears to be its claim to accuracy, or perhaps more correctly, its ability to detect error. For example, . . . embodied know-how, intuition and clinical experience are situated unequivocally in the context of discovery. They are certainly sources of belief, but they do not merit the status of evidence because they fail to incorporate any procedure that is capable of identifying and eliminating error (Paley, 2006a, p. 84). The possibility of illusion is permanently and systematically present. So the need for a range of procedures capable of identifying it, and then controlling for it, is ineradicable. No amount of ontological bluster can make the error question go away (Paley, 2005a, p. 202). . . . in exalting nursings alternative patterns of knowing, the literature is celebrating the possibility of error (Paley et al., 2007, p. 696). It might be argued then that Paley adheres to an interventionalist science, as opposed say to something like Parses (1992) noninterventionalist, or perhaps more passive intervention, approach which by the way Paley (2006b)doesnt think much of. It is curious then that, all of a sudden, for the philosopher of accuracy, error turns out to be a good thing positive illusion. Paleys (2008a) spiritual naturalism rests on just this positive illusion. I will be classifying all religious and non-naturalistic beliefs as positive illusions; that is a special case of falsehood (p. 10). In other words, such beliefs are optimistic but unequivocally false beliefs (p. 11), in a word error. For someone who has expended so much intellectual energy arguing against the celebration [of] the possibility of error, this is an unusual twist indeed. Of course it is a familiar one. Indeed, it comes under the heading of the, now famous/infamous, God Delusion (Dawkins, 2006), although positive illusion is thought to be more productive, by Paley, and to be sure that it is more polite (than Dawkins). This is to say that, Paley, unlike Dawkins and others (e.g. Dennett, 2006; Wolpert, 2007), does not wish to expunge such delusion (excuse us; positive illusion) but rather use it: (1) to explain

what gratuitous assertion does not and (2) to intervene scientically (i.e. clinically) in an effort to reduce existential distress, although there may be a third reason for its use that we will mention in a moment. He even goes so far as to suggest the possibility of using a form of shock treatment and drugs . . . it would in any case be premature to propose that consenting palliative care patients could benet from the use of [a low-energy magnetic eld], and . . . it is premature to talk about offering hallucinogenic drugs to palliative care patients who suffer from existential distress (Paley, 2008a, p. 13). Premature yes, but one gets the sense from Paleys paper that, with only a little scientic progress, the thought is both interesting and promising. In effect, Paley has medicalized existential distress, and he has used error to do it. Moreover, he now has an idea of how to treat it and in our view he is dangerously close to a Brave New World. Given that existential distress is a natural phenomenon, after all Paleys is a naturalist theory, do we really need to add it to the innumerable other phenomena that have been scientized, medicalized and diagnosticized (see Furedi, 2004; Conrad, 2007; Szasz, 2007 and numerous others). Indeed, the subtitle of Conrads (2007) most recent book The Medicalization of Society is On The Transformation of Human Conditions into Treatable Disorders. See also the work of Callahan (2003) and the research imperative. If existential distress is not a human condition (and probably an ineluctably spiritual one) then we are not sure what is. Moreover, in the context of religion and spirituality, it gives Ilichs (1975) laicisation a whole new meaning. Ever since Szaszs (1974) The Myth of Mental Illness (it was originally published as a paper in Szasz, 1960), a great effort has been expended attempting to deal with the potential control and colonization of human beings with diagnosis and treatment by experts. Paley, in a single paper, seems to have taken us right back there. Now, we do not mean to suggest at all that those with, or in, existential crisis be ignored. Rather, perhaps it is here, responsiveness, being with, non-judgement, connection, or as Pesut (2008a) puts it, a supportive spiritual presence (p. 136), that spiritual care advocates might have something important to say, even with their gratuitous assertion. Let us now briey outline three possible

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sticking points of Paleys sudden warming to human error and his apparent medicalization of existential distress. First, who are the ones deciding that such beliefs are false well we the experts who know? Thus, our scientic accuracy determines that their beliefs are false and this time, rather than correcting error, we (the experts) now see it as a good thing for them (the layperson). Moreover, we are not to tell them The naturalistic perspective theorizes spiritual belief as a positive illusion; but that does not imply that we should refer to it in those (theoretical) terms during contact with the patient. This would be pointless, massively insensitive, and probably (in view of the efcacy of positive illusions) counterproductive (Paley, 2008b, p. 139). Neither are we to [foist positive illusion] on unreceptive patients (p. 11), rather we wait until such errors and falsehoods appear and then we subtly [encourage] (p. 11) them, or again with a little scientic progress intervene with low-intensity magnetic elds and/or hallucinogenic drugs. Is it just us, or does this read like some kind of trickery, the perpetration of a fraud in the best interest of the patient? And could this arrogant expertism be any more paternalistic? And, by the way, what other truths that we have, and falsehoods that they have, should we be keeping from patients? Should we falsely diagnose, although we know better, in order to keep up the patients spirits (pun intended), which is to say subtly encourage positive illusion? Again we quote Paley (2005a) The possibility of illusion is permanently and systematically present. So the need for a range of procedures capable of identifying it, and then controlling for it, is ineradicable. No amount of ontological bluster can make the error question go away (p. 202) and ask: when and how we know what kinds of error and illusion are good and what kinds must be identied and controlled for. Second, as we know, scientically, that positive illusions happen, and do in fact represent an explanation of religion and spirituality, the next logical question seems to be why. The most common naturalistic answer is that it evolved that way, presumably for a purpose. At any rate thats Dawkinss answer, but there are others (Holmes, 1996; Montell, 2002; Azari et al., 2005; Dennett, 2006 and see Dow, 2006 for an

excellent overview of anthropological theories of the evolution of religion). We suspect that this would be Paleys as well. Lurking in the wings of this discussion, and offering it a considerable degree of support, is a network of ideas that we will have no time to bring on stage, in particular, accounts of the origins of religion provided by contemporary studies of the brain, evolution, cognitive anthropology, and articial intelligence (Paley, 2008a, p. 10). If then it is all, neurology, cognitive and social psychology, and of course evolution all the way down, the next question is, again, why then why after that, and why after that. This might well seem like a pernickety way to put it, but the point is that one clearly sees the potential for an innite regress towards an unfathomable mystery. Perhaps then, a naturalist explanation turns out, despite its sophistication, avoidance of gratuitous assertion, convincing argument and that it is clinically useful (p. 12), to be not so natural after all. We do admit that this is not an argument so much as assertion; we just hope it is not gratuitous. Finally, one of the most important complaints about positivism, excepting the epistemological one, was that . . . most of the topics that have made philosophy interesting were puritanically forbidden (Allen, 2002, p. 29) by it. Now we are not calling Paley a positivist (although he certainly is an analytic tradition thinker no doubt, and a very good one), rather we suggest that perhaps turning everything into proper science, a secular scientism that is very nearly theological itself (Turner, 2004; Roy, 2005), may well have the same effect i.e. excluding what might be philosophically interesting (and even clinically useful in the emergent sense) about spirituality and the human condition. Moreover, as Allen (2002) put,The problem concerns the place or value of science in the wider culture, what science does for or to culture, and to people who believe in its truth (p. 27). Earlier we suggested that there might be a third reason for Paleys use of positive illusions (in addition to explanation and pragmatic utility). Could it be that Paley the atheist (see Paley, 2008b, p. 138 for the outright admission), along with Paley the scientist, and we might add Paley the analytic thinker, just doesnt like this irrational, religious rhetoric gratuitous assertion. Thus, when error becomes convenient well, it becomes conve-

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nient. Paley might not be an angry atheist like Dawkins, but he is an irritated one. However, he has indeed provided a tidy explanation of religious and spiritual belief, perhaps a little too tidy. We admit that it is attractive and alluring, but we also think it is misguided and potentially dangerous. We end then, with Barretts (1962) view at the conclusion of his brilliant study of existentialism, Irrational Man:
To be rational is not the same as to be reasonable. In my time I have heard the most hair-raising and crazy things from very rational men, advanced in a perfectly rational way . . . Nowadays, we accept in our public and political life the most humanly unreasonable behaviour, provided it wears a rational mask and speaks in ofcialese, which is the rhetoric of rationality itself. (p. 270)

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