Forum: Featured Discussions: Among all Physicians, is there a Physician?

By Farr Curlin, Science of Virtues Scholar

               In his forthcoming book, A Case for Irony, philosopher Jonathan Lear explores Kierkegaard’s concept of irony to advance the virtue of ironic existence. Irony, as Kierkegaard used the term, arises from the fact that to be human is to put ourselves forward in our various social roles, e.g., as parents, students, worshipers, skeptics, scientists or clinicians. Lear notes that this putting ourselves forward implies a form of pretense. Humans literally pretend, and they pretend in terms of established social understandings and practices. For example, those who put themselves forward as physicians wear white coats and beepers, answer pages, ask questions of and touch patients in prescribed ways. They even depart from conventional norms in socially established ways. Some physicians forego the white coat, others the beeper, others even the physical exam. In all of these cases, the physician can give an account of what she is doing and why. Lear emphasizes that it is necessary and not to be caricatured that we put ourselves forward in these socially established ways.

Yet, in putting ourselves forward and giving an account of what we are doing, we are conscious that our account may be incomplete and that what we are doing may fall short. This consciousness establishes the structure of the ironic question, “Among all x, is there an x?” where x is any human practical identity. Consider the question, “Among all physicians, is there a physician?” What we might call the left-hand sense of physician is the social pretense. It includes all those who put themselves forward as physicians in socially established ways. What we might call the right-hand sense of physician is that toward which the pretense aims, but inevitably falls short. The right hand sense is what a physician (left hand sense) would be if her or she fully realized the practical identity toward which she aspires.

This concept of irony seems to have something to do with how we think about virtue with respect to any practical identity. Lear notes that although the structure of the ironic question is a tautology, we do not hear it that way. We recognize the ironic question as a genuine question, because we recognize that there is a potential gap between the left and right hand senses of all human identities and social roles. Although it would seem ridiculous to say, “That cat is really a cat,” it seems perfectly reasonable to say, “That physician is really a physician.” It seems reasonable because we know implicitly that among those who put themselves forward as physicians in the left hand sense, not all answer equally to the call of physician in the right hand sense. Virtuous physicians seem to answer the call better than most. We might say that virtuous physicians are those few, among all who put themselves forward as physicians, who are in fact physicians.

Ironic experience, Lear explains, happens in the first-person and involves two moments. With respect to medicine, the first moment happens when I become aware of a gap opening up between how I put myself forward as a physician and what I would be doing if I were to actually become the physician I am pretending to be. Irony’s second and paradigmatic moment involves what Lear calls “ironic uptake.” In this moment I am unsettled. I am shaken. I do not sense merely that I do not live up to the best socially established standards for medicine. Rather, I recognize that I do live up to the best socially established standards for medicine, and that is the problem.

Lear describes this second moment as uncanny: that which was familiar—being a physician—is rendered unfamiliar. I sense that all I have been taught about being a physician, and all of the practices available to me for living out that identity, fall radically short of what being a physician really requires. In this ironic moment, I am faced with new and radical questions: What is health? What does it mean to heal? Who are my patients? What am I seeking when I go about doing what I do as a physician? What is all of this accomplishing? Because of this second moment, Lear notes, Kierkegaard’s ironic observation that becoming human does not come easily “has less to do with the arduousness of a task than with the difficulty of getting the hang of it.”

In the same way, we might say that becoming a virtuous practitioner in any practical identity (including being human), does not come easily. It requires not only commitment to be living into the best socially available standards and practices for that identity. It also requires recognizing and responding well to irony—the experience of being arrested by a sense that all of the available social practices and norms for that identity fall radically short of what the identity actually requires. Those who possess the virtue of ironic existence will then detach from the current social pretense in order to engage in new social practices that more closely approximate the identity toward which those practices aim. In other words, the ironic physician will detach from the current social pretense of medicine in order to set out again in a quest to become the (virtuous) physician she is not yet.