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 scholarlyexchange/critique concerning spirituality in thenursing literature in Nursing Philosophy (Newsom,2008; Paley, 2008a, 2008b; Pesut, 2008a, 2008b) andelsewhere (Paley, 2007). Paley, of course the centralfigure in this discourse, is, with his reductionistapproach (Paley, 2008a), at his critical best inunabashedly deconstructing (he might not be takekindly to our use of this word) both the spiritualityliterature in nursing and the uncritical enthusiasmwith which it seems to be produced. In his response toPesut’s (2008a) critique, he gives those of us that dis-agree with him (or his reductionism) three options:

. . . ignore the paper altogether; provide some non-question-

begging 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. 138–139)

The paper cannot be ignored; it simply is too impor-tant for that. As for option two, we agree with Paley –it ain’t gonna happen. The third is interesting, but notfor the reason that Paley thinks. In this paper, we shallattempt to make two points. First, using Paley’s work,we note what might be a not insignificant contradic-tion: that a thinker who has spent so much time criti-cizing error suddenly, and conveniently, appears tocelebrate it. Second, the real achievement of Paley’s(spiritual) reductionism is to medicalize ‘existentialdistress’, and we are not sure this is such a good thingat all. Before we proceed, however, let us just say that

we think that Paley (2008b) is correct to ‘[cancel] thegratuitous assertions . . . in order to avoid futileexchanges with authors who might otherwise queueup to tell me that I am wrong’ (p. 138). Moreover, hisimplicit, and at times not so implicit, view that spiri-tuality has some direct connection to religion is onewe share. Finally, his subtle contention that more ofthe, shall we say, status quo research on spirituality innursing is likely to continue to turn up the same thing– i.e. more ‘gratuitous assertion’, is also something weagree with.

For over a decade, now John Paley has been one ofthe premier (critical) voices in the (theoretical)nursing literature (students rarely get out of ouradvanced theory classes without encountering him).In fact, spirituality is only the latest trouble spot thathas come under the hot lights of Paley’s criticalinterrogation; he has also done jobs on qualitativeresearch, particularly phenomenology (Paley, 1996,1998, 2000a, 2005a, 2005b), caring (Paley, 2001, 2002a,2002b), intuition and expertise (Paley, 1996, 2006a),Carper’s ‘ways of knowing’ (Paley et al., 2007) andmeaning (Paley, 2000b) among others. His modusoperandi seems to be, if we have read him correctly, tobegin a paper with a probative and heavy-handedcritique (which is almost always cogent and insight-ful), ridicule a few people along the way at times andend with ‘proper science’. Indeed, although his writingis 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 ofnurses who understand very well what scientificresearch is. But the discipline does not yet havestrength in depth, and rectifying this will, realistically,take a generation. Unfortunately, it will take muchlonger than that if slave morality opposition toscience continues . . .’ (p. 32). Clearly, he does not

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

Dialogue

137© 2009 The authors. Journal compilation © 2009 Blackwell Publishing Ltd Nursing Philosophy (2009), 10, pp. 137–141

think that this generation has come to pass, not in thespirituality literature at any rate – hence the need fora reductive approach to spirituality and, so called,spiritual care.

The value that proper science, or scientific method-ology, has for Paley appears to be its claim to accu-racy, or perhaps more correctly, its ability to detecterror. For example, ‘. . . embodied know-how, intu-ition and clinical experience are situated unequivo-cally in the context of discovery. They are certainlysources of belief, but they do not merit the status ofevidence because they fail to incorporate any proce-dure that is capable of identifying and eliminatingerror’ (Paley, 2006a, p. 84). ‘The possibility of illusionis permanently and systematically present. So theneed for a range of procedures capable of identifyingit, and then controlling for it, is ineradicable. Noamount of ontological bluster can make the “errorquestion” go away’ (Paley, 2005a, p. 202). ‘. . . in exalt-ing nursing’s alternative “patterns of knowing”, theliterature is celebrating the possibility of error’ (Paleyet al., 2007, p. 696). It might be argued then thatPaley adheres to an interventionalist science, asopposed say to something like Parse’s (1992) non-interventionalist, or perhaps more passive interven-tion, approach which by the way Paley (2006b)doesn’tthink much of. It is curious then that, all of a sudden,for the philosopher of accuracy, error turns out to bea good thing – positive illusion.

Paley’s (2008a) spiritual naturalism rests on justthis – positive illusion. ‘I will be classifying all reli-gious and non-naturalistic beliefs as positive illusions;that is a special case of falsehood’ (p. 10). In otherwords, such beliefs are ‘optimistic but unequivocallyfalse beliefs’ (p. 11), in a word – error. For someonewho has expended so much intellectual energyarguing against the ‘celebration [of] the possibility oferror’, this is an unusual twist indeed. Of course it is afamiliar one. Indeed, it comes under the heading ofthe, now famous/infamous, God Delusion (Dawkins,2006), although positive illusion is thought to be moreproductive, by Paley, and to be sure that it is morepolite (than Dawkins).This is to say that, Paley, unlikeDawkins and others (e.g. Dennett, 2006; Wolpert,2007), does not wish to expunge such delusion (excuseus; positive illusion) but rather use it: (1) to explain

what ‘gratuitous assertion’ does not and (2) tointervene scientifically (i.e. clinically) in an effort toreduce ‘existential distress’, although there may be athird reason for its use that we will mention in amoment. He even goes so far as to suggest the possi-bility of using a form of shock treatment and drugs‘. . . it would in any case be premature to propose thatconsenting palliative care patients could benefit fromthe use of [a low-energy magnetic field],’ and ‘. . . it ispremature to talk about offering hallucinogenic drugsto palliative care patients who suffer from existentialdistress’ (Paley, 2008a, p. 13). Premature yes, but onegets the sense from Paley’s paper that, with only alittle scientific progress, the thought is both interestingand promising. In effect, Paley has medicalized ‘exis-tential distress’, and he has used error to do it. More-over, he now has an idea of how to treat it and in ourview he is dangerously close to a Brave New World.Given that ‘existential distress’ is a natural phenom-enon, after all Paley’s is a naturalist theory, do wereally need to add it to the innumerable other phe-nomena that have been scientized, medicalized anddiagnosticized (see Furedi, 2004; Conrad, 2007; Szasz,2007 and numerous others). Indeed, the subtitle ofConrad’s (2007) most recent book The Medicalization

of Society is On The Transformation of Human Con-

ditions into Treatable Disorders. See also the work ofCallahan (2003) and the research imperative. If ‘exis-tential distress’ is not a human condition (and prob-ably an ineluctably spiritual one) then we are not surewhat is. Moreover, in the context of religion and spiri-tuality, it gives Ilich’s (1975) ‘laicisation’ a whole newmeaning. Ever since Szasz’s (1974) The Myth of

Mental Illness (it was originally published as a paperin Szasz, 1960), a great effort has been expendedattempting to deal with the potential control andcolonization of human beings with diagnosis andtreatment by experts. Paley, in a single paper, seems tohave taken us right back there. Now, we do not meanto suggest at all that those with, or in, existential crisisbe 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 some-thing important to say, even with their ‘gratuitousassertion’. Let us now briefly outline three possible

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sticking points of Paley’s sudden warming to humanerror and his apparent medicalization of ‘existentialdistress’.

First, who are the ones deciding that such beliefsare false – well we the experts who know? Thus, our

scientific accuracy determines that their beliefs arefalse and this time, rather than correcting error, we

(the experts) now see it as a good thing for them (thelayperson). Moreover, we are not to tell them ‘Thenaturalistic perspective theorizes spiritual belief as apositive illusion; but that does not imply that weshould refer to it in those (theoretical) terms duringcontact with the patient.This would be pointless, mas-sively insensitive, and probably (in view of the efficacyof positive illusions) counterproductive’ (Paley,2008b, p. 139). Neither are we to ‘[foist positive illu-sion] on unreceptive patients’ (p. 11), rather we waituntil such errors and falsehoods appear and then we‘subtly [encourage]’ (p. 11) them, or again with a littlescientific progress intervene with ‘low-intensity mag-netic fields’ and/or hallucinogenic drugs. Is it just us,or does this read like some kind of trickery, the per-petration of a fraud in the best interest of the patient?And could this arrogant expertism be any more pater-nalistic? And, by the way, what other truths that wehave, and falsehoods that they have, should we bekeeping from patients? Should we falsely diagnose,although we know better, in order to keep up thepatient’s spirits (pun intended), which is to say subtly

encourage positive illusion? Again we quote Paley(2005a) ‘The possibility of illusion is permanently andsystematically present. So the need for a range ofprocedures capable of identifying it, and then control-ling for it, is ineradicable. No amount of ontologicalbluster can make the “error question” go away’ (p.202) and ask: when and how we know what kinds oferror and illusion are good and what kinds must beidentified and controlled for.

Second, as we know, scientifically, that positive illu-sions happen, and do in fact represent an explanationof religion and spirituality, the next logical questionseems to be – why. The most common naturalisticanswer is that it evolved that way, presumably for apurpose. At any rate that’s Dawkins’s answer, butthere are others (Holmes, 1996; Montell, 2002; Azariet al., 2005; Dennett, 2006 and see Dow, 2006 for an

excellent overview of anthropological theories of theevolution of religion). We suspect that this would bePaley’s as well. ‘Lurking in the wings of this discus-sion, and offering it a considerable degree of support,is a network of ideas that we will have no time tobring on stage, in particular, accounts of the origins ofreligion provided by contemporary studies of thebrain, evolution, cognitive anthropology, and artificialintelligence’ (Paley, 2008a, p. 10). If then it is all, neu-rology, cognitive and social psychology, and of courseevolution 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 foran infinite regress towards an ‘unfathomablemystery’. Perhaps then, a naturalist explanation turnsout, despite its sophistication, avoidance of ‘gratuitousassertion’, convincing argument and that it is ‘clini-cally useful’ (p. 12), to be not so natural after all. Wedo admit that this is not an argument so much asassertion; we just hope it is not gratuitous.

Finally, one of the most important complaints aboutpositivism, excepting the epistemological one, wasthat ‘. . . most of the topics that have made philosophyinteresting were puritanically forbidden’ (Allen, 2002,p. 29) by it. Now we are not calling Paley a positivist(although he certainly is an analytic tradition thinkerno doubt, and a very good one), rather we suggest thatperhaps turning everything into proper science, asecular scientism that is very nearly theological itself(Turner, 2004; Roy, 2005), may well have the sameeffect – i.e. excluding what might be philosophicallyinteresting (and even clinically useful in the emergentsense) about spirituality and the human condition.Moreover, as Allen (2002) put, ‘The problem concernsthe place or value of science in the wider culture, whatscience does for or to culture, and to people whobelieve in its “truth” ’ (p. 27). Earlier we suggestedthat there might be a third reason for Paley’s use ofpositive illusions (in addition to explanation andpragmatic 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 Paleythe analytic thinker, just doesn’t like this irrational,religious rhetoric – ‘gratuitous assertion’. Thus, whenerror becomes convenient – well, it becomes conve-

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nient. Paley might not be an angry atheist likeDawkins, but he is an irritated one. However, he hasindeed provided a tidy explanation of religious andspiritual belief, perhaps a little too tidy. We admit thatit is attractive and alluring, but we also think it ismisguided and potentially dangerous. We end then,with Barrett’s (1962) view at the conclusion of hisbrilliant 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 . . . Nowa-

days, we accept in our public and political life the most

humanly unreasonable behaviour, provided it wears a ratio-

nal mask and speaks in officialese, which is the rhetoric of

rationality itself. (p. 270)

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