The philosopher and psychoanalyst has set up the first research chair in philosophy at Hôtel-Dieu hospital in Paris. How is she applying that to rethink our care and our health? Interview.
Cynthia Fleury is a philosopher, psychoanalyst and professor at the American University of Paris. She is a member of the National Consultative Ethics Committee and the medical psychology unit of France’s SAMU emergency medical service. The many books she has written include Pretium doloris. L’accident comme souci de soi published by Pauvert and La fin du courage. La reconquête d’une vertu démocratique by Fayard.
IN VIVO Selon vous, notre société produit des individus qui ont le sentiment d’être remplaçables. Qu’entendez-vous par là? CYNTHIA FLEURY La question de la souffrance au travail, de l’obsolescence programmée qui structure littéralement le champ économique n’est pas nouvelle, mais elle s’accélère fortement depuis une trentaine d’années. La révolution néo-managériale s’est abattue à la fois sur les services publics et sur les entreprises. Elle pousse cette notion de remplaçabilité à son maximum: si vous n’acceptez pas des conditions inacceptables éthiquement, vous êtes précarisé, placardisé, remplacé voire licencié. Petit à petit, se construit un monde strictement marchand, tenu essentiellement par un jeu de multinationales et de processus qui cherchent à tout monétariser. Nous ne sommes pas du tout dans le domaine du complot mais dans une dynamique capitaliste extrême, extraordinairement dérégulée. Ceci avec l’aval des politiques, qui ont peut-être cru que c’était là une bonne manière de faire. Or, on est retourné quasiment à la crise de 1929 en termes de répartition des richesses sur cette planète. En tout cas aux Etats-Unis, où 1% de la population détient 2% de la richesse mondiale; ce n’est vraisemblablement problématique pour personne puisque ça continue. Tout cela me fait dire qu’il faut un nouveau terme, la remplaçabilité, pour qualifier ce processus de grande disqualification du sujet.
IV Quelles sont les conséquences de ce sentiment de remplaçabilité? En quoi est-ce que cela modifie le comportement des individus? CF On ne dit plus au sujet qu’il ne vaut rien, mais on lui fait comprendre qu’il est remplaçable au même titre qu’un produit. Ce processus balaie la singularité. Cela a plusieurs conséquences: la première, c’est une forme de découragement, de dépréciation, de mésestime de soi, voire de passage à l’acte contre soi-même. La deuxième, c’est le ressentiment qui conduit à des comportements psychotiques de base jusqu’à des passages à l’acte plus dangereux encore pour soi-même et autrui. Enfin, l’histoire nous a toujours montré que la traduction politique du ressentiment renvoie à plus de votes xénophobes, et de repli.
IV Cette idée de remplaçabilité grandissante des individus s’applique-t-elle au milieu hospitalier, aux professionnels comme aux patients? CF Comme différentes entreprises, l’hôpital a été bombardé par une révolution managériale basée sur la tarification à l’acte. Elément surréaliste quand on pense que le temps accordé au patient, la singularité d’un diagnostic constituent aussi une forme de soin. L’hôpital d’aujourd’hui est soumis à des procédures de rationalisation qui font que petit à petit les professionnels ne peuvent plus soigner convenablement.
“Humanities introduce the power of critical thinking within the hospital”
IV Should the price of care be factored into the value of the health professional/patient relationship? CF The relationship and the time needed to make a diagnosis, which also means not sending someone to have unnecessary X-rays or operations done. We’re in a period of highly advanced technical know-how, which prevents the clinical aspect of medical care from coming into play. But medicine without clinical care is just computer science. Technical know-how is a wonderful advantage if it’s based on caring about others, recognising the subject.
IV Is that why you set up a research chair in philosophy at the hospital? As a way of counter-balancing technical know-how and hyper-management? CF Relationships weakened by the management style that we’ve imported from the business world gives health professionals the feeling that they no longer know how to do their job. And the management technique of bullying is alive and well in hospitals too, like in that case where a professor threw himself out a window at the Georges Pompidou hospital in Paris.
IV Did he leave a letter, an explanation? CF Extensive correspondence revealed the exclusion he experienced, the constant humiliation, indifference, cynicism, scorn, false accusations and the feeling of being cut off from his responsibilities. It’s hardly a unique case. With the research chair, we wanted to look into how to “treat the hospital”, following in the footsteps of Tosquelles. A physician from a top school has also begun examining violence directed at medical students.
IV Does that violence occur only in hospitals? CF This violence is not specific to hospitals. It is typical of all of our organisations. But it’s more problematic at hospitals, a place where care is given. We are basically confronted with the madness of evaluation or profitability analysis, which is the polar opposite of health care and time given to others. These days, hospitals set profitability and budget targets. The point of the research chair is to bring the role of humanities back, to guide medical care and introduce the power of critical thinking within the hospital. We are working to develop a more holistic, existential, organisational and policy-based approach to health care. Hospitals need to gain more meaningful insight into the point of health care, because the main partner in fundamental changes at work in medicine—such as the shift towards outpatient care and extended life expectancy (and therefore educational therapy)—is the patient.
IV Do you believe that we should develop a different relationship with the patient? CF Patients now want a more equal relationship with health professionals. For a long time they were treated like children, denigrated and considered passive. When patients explain that they are objectified, belittled, and no one listens to them, we should not discredit what they’re telling us. Fortunately, many physicians and other health care providers recognise the patient’s expertise and contribution to their care. Narrative medicine is being increasingly incorporated into both teaching and practice.
IV Can philosophy realistically bring something to the development of medicine, considering its time frame is so much longer? CF Philosophy reminds us that the tool should not run the show. The tool is a creation, and we have to continuously re-examine what we’re using it for. Philosophy is not “lagging behind” science. It asks science to question itself and not to separate its development from critical analysis. It also calls on science to establish new rights, for example in reciprocal agreements between those who, as in the case of personalised medicine, donate their genomes and those who are responsible for figuring out how those personal data should be protected and shared.
IV In the world of health care, time for reflexivity is very limited. Do doctors attend your classes? Do they take the time to do that? How do you get them to come? Is it required? CF Yes, they come. But it’s just beginning to be integrated. The research chair is too recent to draw any conclusions about their attendance. The classes are open to anyone, and no one is required to come. Of course with all the partners of the research chair, we eventually want humanities to be more strongly integrated into medical teaching, in both initial and professional education, and hospital practices.
IV What percentage do these humanities courses represent in the medical education programme? CF For now, not enough. That will take time. But we’ve observed a generational phenomenon. Young people are more aware of the need to think differently about what medicine is becoming. Some on the rear lines told us that a research chair in philosophy is a luxury. There’s no money for that. It’s not a priority. We insist that it’s not a luxury, that it’s really necessary to protect care, health and recovery. If we’re not concerned with humanity, caring for patients becomes mere repair work. What mechanics do. The purpose of setting up this research chair in philosophy was to make an important contribution to helping reinvent the hospital. It’s very important not to let genetic and computer science believe that they alone can define its future.
IV You highlight the importance of the individuation
process to guarantee a form of humanity in patient care. But the historical definition of professionalism for health care providers is to leave emotions out, to be a function before being an individual. How do you resolve that tension? CF Individuation is about decentring. It’s not about getting emotional. Knowing thyself in no way means egocentric introspection. Who can provide care for someone else if they haven’t recognised the border that makes the other both subject and “person in need”? Individuals are not all-powerful. They are blatantly finite. They are only a border, a line beyond which is fantasy and before which is disappointment. So looking towards others helps them not to sink into the mirror of their soul. The other name for individuation is devotion, personal involvement. Humans are merely the individuation they attempt. If they don’t try enough, they lose access to their own humanity. Our work is to define criteria for professionalism that is in line with this individuation process and adapted to the modern world. The right distance also implies the right amount of closeness.
IV Do you think hospitals are at risk of dehumanisation? CF Humans and humanity are not the same thing. They’re very different. Humans are humans. Humanity is what we learn to build together. Humanity is assimilated with an enhanced form of humans, who can acknowledge their deadly impulses and create and build with others. All humans must take part in protecting humanity. It’s a drop in a huge ocean. Given the place the hospital holds in society, its role and the tensions that play out there every day, we must not give up. ⁄
(The Irreplaceables) by Cynthia Fleury, NRF, Gallimard, 2015.
The “5 à 7” at the FBM
On 1 December, the
Faculty of Biology and Medicine will launch its “5 à 7”, a programme of events organised to discuss the department’s key strategic focuses. The speakers at this first event—Béatrice Schaad, head of communication at the Lausanne University Hospital, and the philosopher Cynthia Fleury—will analyse the place of humans in the hospital.
At the César-Roux
Auditorium, 5:00 p.m