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What Really Matters:Living a Moral Life Amidst

Uncertainty and Danger

Arthur Kleinman

OXFORD UNIVERSITY PREES

WHAT REALLY MATTERS

Harmensz van Rijn Rembrandt, The Return of the ProdigalSon, ��–��. Hermitage, St. Petersburg, Russia. Scala/ArtResource, NY

Also by Arthur Kleinman

Writing at the Margin:Discourse Between Anthropology and Medicine

Rethinking Psychiatry:From Cultural Category to Personal Experience

The Illness Narratives:Suffering, Healing and the Human Condition

Social Origins of Distress and Disease:Depression, Neurasthenia and Pain in Modern China

Patients and Healers in the Context of Culture:An Exploration of the Borderland Between Anthropology,

Medicine, and Psychiatry

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What Really MattersLiving a Moral Life

Amidst Uncertainty and Danger

Arthur Kleinman

2006

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Library of Congress Cataloging-in-Publication DataKleinman, Arthur.

What really matters : living a moral life amidstuncertainty and danger / Arthur Kleinman.

p. cm.Includes bibliographical references and index.

ISBN-13: 978-0-19-518098-5 ISBN-10: 0-19-518098-41. Conduct of life—Case studies. I. Title.

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Note to the Reader viii

Chapter 1 Introduction 1

Chapter 2 Winthrop Cohen 27

Chapter 3 Idi Bosquet-Remarque 46

Chapter 4 Yan Zhongshu 80

Chapter 5 Charles Kentworth Jamison 123

Chapter 6 Sally Williams 141

Chapter 7 Bill Burt/Simcha Adler 162

Chapter 8 W. H. R. Rivers 196

Chapter 9 Epilogue 217

Bibliographic Note 237Acknowledgments 247

Index 249

Contents

nformation contained in this book accurately conveys the spiritof my work as a physician and researcher, but, with the excep-

tion of the historical chapter on W. H. R. Rivers and my ownautobiographical details, all names, characteristics, and identi-fying details in the case histories have been changed. This ismeant to ensure confidentiality and protect the anonymity ofthe individuals, families, and institutions involved. When I havemade such changes, I have drawn on information from otherpatients and research subjects facing similar problems to makethe alteration valid in the light of the moral experiences of peopleI have treated and studied and lived among as a whole.

Note to the Reader

For Gabriel, Kendall, Allegra, and Clayton Arthur.

For Anne, Thomas, Peter, and Kelly.

For Joan.

For Marcia.

For Steven, Lee, Julie, and David.

For Laura.

For this family moving through ages and worlds . . .

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WHAT REALLY MATTERS

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Introduction

hat Really Matters chronicles stories of ordinary peopleand what matters most to them, in normal and extraor-

dinary times. It is a book about moral experience and howindividuals and groups come to grips with danger and un-certainty. We tend to think of dangers and uncertainties asanomalies in the continuum of life, or irruptions of unpre-dictable forces into a largely predictable world. I suggest thecontrary: that dangers and uncertainties are an inescapabledimension of life. In fact, as we shall come to understand,they make life matter. They define what it means to be hu-man. This is a book about people who, in the midst of suchchallenges, are trying to live a moral life.

The phrase “moral life” can be ambiguous because moralcan be used in two different senses. In its broader meaning,the word moral refers to values. Life, in this sense, is inevita-bly moral, because for each and every one of us, life is about

2 What Really Matters

the things that matter most to us. Just carrying on our exist-ence, negotiating important relations with others, doing workthat means something to us, and living in some particularlocal place where others are also passionately engaged in thesesame existential activities—all this is, by definition, moralexperience.

But this meaning of moral is not synonymous with good inan ethical sense. The moral experience that people share couldbe far from good, even malign. The values that we express andenact can be inhuman. Think of a local community that scape-goats or oppresses a minority, or one that supports slavery, childprostitution, violence toward women, or other abuses. Hereone’s moral experience could include complicity in terrible acts,just as ordinary men and women were caught up in perpetrat-ing the Shoah or racial slavery. Normal and shared moral ex-perience of this sort is so troubling precisely because what looksso wrong from the outside (or from the victim’s perspective)may not look that way from the inside, from the perspective ofcollaborators and perpetrators. That is why, in this first sense,what is moral needs to be understood as what is local, and thelocal needs to be understood to require ethical review (scru-tiny from the outside and from those on the inside who chal-lenge accepted local values).

In its more focused meaning, moral refers to our sense ofright and wrong. When we say we want to live a moral life,we mean one that embodies our own moral commitments.We can imagine a certain way of conducting our lives thatseems right: we can feel responsibility for others, and act onthose feelings; and we can respond to trouble and those introuble in a way that makes us feel we are doing good in the

Introduction 3

world. We expect that other people in very different localeswould agree that these acts are moral in this second sense,and even if we do not receive approbation from others, wefeel ashamed if we act in a way that goes against this coreimpulse to do the right thing.

Those who seek to live a moral life may develop an aware-ness that their moral environment, in the first sense, is wrong.They may respond with criticism, protest, and personal ef-forts to do the right thing, no matter how great the oddsagainst them being effective and how likely it is that theirchoices will have negative consequences for them. Many willnot rock the boat, and their interior, moral life will reflect theproblems with moral experience surrounding them. This ishow people come to collaborate publicly with unethical poli-cies, in spite of their private reservations, and later on de-velop feelings of guilt and misplaced loyalty, while others stayin denial for a lifetime. Of course, there are other people whoseem tone deaf to moral sensibility, who appear to be un-moved by feelings for other human beings. We shall see thatmoral life is closely connected to the idea of ethics, by whichwe mean we aspire to values that transcend the local and thatcan guide us in living a life.

Can we learn anything from the stories of people who havetried to live moral lives in very different settings, amidst par-ticular kinds of dangers and uncertainties, that can help usdo the same? Is it really feasible to try to live in a way thatruns against the grain of the moral environment that sur-rounds us? When there is real uncertainty about what to doand when the level of danger is high enough to threaten whatreally matters to us, what kinds of decisions do we make?

4 What Really Matters

Ordinary experience frequently thrusts people into troublingcirc*mstances and confounding conditions that threaten toundo our thin mastery over those deeper things that mattermost, such as our self-esteem, intimate relations, or religiousvalues. Divorce, the death of a loved one, injustice and dis-crimination, dead-end jobs, unemployment, accidents, chronicillness, artistic failure, alienation from faith community: any ofthese common calamities can break our grip on what we holddear, and destroy our sense that we are in control of our fate.

A surprising number of American families go into bank-ruptcy, about one in every seventy-five households this year,and a very large number just barely avoid it, constantly liv-ing on the edge of financial insecurity. A middle-aged execu-tive in New York has a heart attack and is unable to continueworking. His disability creates a new and dangerous finan-cial reality for his wife and young children and causes him toquestion the meaning of the life he has built. A young Bos-tonian loses her job as a software developer and cannot find anew one; her sense of self plummets, and she becomes de-pressed and suicidal. A struggling working-class AfricanAmerican family in New Orleans loses its beloved only sonin Iraq, and months later their third-generation family homeis destroyed by Hurricane Katrina. The boy’s father, a recov-ered alcoholic, refuses to seek a substitute for the rehabilita-tion program he has participated in for several years and goeson a binge of drinking. A liberal, professional Palestinian hus-band and wife, both educated in Paris, are shocked by thehorror of a brilliant daughter, a high school honor student,killing herself and others as a suicide bomber at an Israeli busstop and leaving behind a video in which she rejects secular

Introduction 5

values and commits herself to the fundamentalist religiousideal of jihad. These are but a few illustrations of the dangerand uncertainty that surround us and could strike us at anytime. Readers will doubtless be aware of others close to theirown lives. On an even larger scale, the evening news remindsus regularly of natural and man-made disasters that can over-turn life at a moment’s notice. Tsunamis, earthquakes, andhurricanes can destroy whole cities and kill or uproot hundredsof thousands of people. Failed or corrupt states in Africa orAsia, famine, or civil war visit misery on countless others. Ter-rorist attacks in New York, Madrid, London, or Jerusalem un-leash horror in the midst of the most prosperous cities. A rashof deaths from avian influenza raises the specter of pandemicdisease that could touch anywhere on the globe.

But immediate threats to a comfortable existence come at amuch more intimate level: within our own bodies. For all ofthe medical breakthroughs of the last fifty years, for example,most people are aware that many health problems are incur-able and that most of us will face the pain and limitations ofchronic conditions. Even a short list feels too threatening tothink about: diabetes, heart disease, ulcers, multiple varietiesof cancer, asthma, lupus, hepatitis, kidney failure, osteoporo-sis, Alzheimer’s. Not to mention that time itself saps our en-ergies, disfigures our bodies, and increasingly slows andmuddles our thought processes. And death, a silent hauntingof our days, waits for each of us.

Even in the absence of tragic events or disabling illness,people struggle steadily throughout their lives to hold on tothose things that matter most to them, things such as status,jobs, money, family ties, sexual intimacy, sense of order and

6 What Really Matters

self-control, health, life itself, and also religious commitments,political arrangements, and all sorts of culturally and person-ally specific agendas. This daily struggle can be fierce anddesperate because it is inevitably unequal. There is a power-ful, enervating anxiety created by the limits of our controlover our small worlds and even over our inner selves. This isthe existential fear that wakes us at 3 a.m. with night sweatsand a dreaded inner voice, that has us gnawing our lip, be-cause of the threats to what matters most to us.

WE EMPLOY A VARIETY of strategies to deal with the profoundsense of inadequacy and existential fear bred by the limits ofour control. There is outright denial with feigned nonchalance.There is, for those who can afford it, a comfortable boredomlaced with escapism: “Forget about life for a while.” There is,for a happy few, an irrepressible good humor. There is fatal-ism, as voiced by Harvey Deaton, a survivor of the terroristbombings in London on July 7, 2005, to the New York Times: “Ifyour number’s up, your number’s up.” And there is the hor-monal surge of youth, searching for physical challenges frombungee jumping to other extreme sports—substituting thefrisson of immediate but containable risk for the far grimmerreality of distant but uncontrollable perils.

Magical belief in technological supremacy over life itself isyet another classic American cultural coping response, as is fac-ing only problems that reach the crisis level one at a time. Andfinancial advisors, insurance salespeople, surgeons, psychologi-cal counselors, security experts, and many other professionalshave a vested interest in selling the comforting but fundamen-tally misleading notion of certainty about control over human

Introduction 7

affairs. “Risk management” is yet another society-wide myththat is punctured every time catastrophe—from hurricanes toepidemics—strikes us unprepared. These cultural responseswork by deluding us as to the nature of the human condition.

Given the manifest shakiness of our lives, what is surpris-ing is that we act, think, and write as if we were in control ofourselves and our world. It is our assiduous denial of exis-tential vulnerability and limits that is extraordinary in Ameri-can culture. Much of our society, of course, is founded on amyth of self-control (Jefferson’s perfectibility of man), mas-tery of the environment (taming the frontier), beneficence ofour social order (the city on the hill), and denial of humanlimits, including the ultimate one, death itself. Our pervasiveconsumer culture is founded on another myth of control—the belief that we can solve our problems through the prod-ucts that we purchase. Politics and the entertainment industrylikewise hold out the promise of easy solutions that minimizethe reality of danger and uncertainty. But although such cul-tural myopia may reach its extreme here, it is not just Ameri-can capitalism that underwrites denial. Socialist societies findit equally unacceptable to take too dismal a view of the hu-man condition and its possibilities. Even most mainstreamreligious traditions today have moved away from earlier vi-sions of the precariousness of the human condition to em-brace at least some aspect of the big lie. It is as if modernityitself were predicated on fostering this fiction, a falsehood atthe center of global culture.

YET IN TIME most of us are forced by the sheer recalcitrance ofthe world and the appreciating fragility of the body to face

8 What Really Matters

up to the size of the odds against us. We often camouflage itby humor and irony, which seek to keep the dark reality of itat a distance, and we muddle through clinging to the basiccommon sense that on any given day we are likely to make ithome safely. Of course, we need to do some amount of self-blinding just to function. If one had to review each day the“thousand natural shocks that flesh is heir to,” in Shakespeare’swords, one might never get out of bed. In that sense, denialof how chaotic and unstable life really is would seem neces-sary and healthy. Yet when the denial becomes so completethat we live under what amounts to a tyranny of not seeingand not speaking the existential truth, it becomes dangerousitself. This is what makes the closest and deepest experiencesof catastrophe, loss, and failure so terrifyingly unsettling. Wepuncture the bubble of illusion and cannot find our footing.We become disoriented because we see the world in so newand fierce a way.

This is not to say that our lives are nothing but a sequenceof defeats and miseries. Each of us knows triumphs from timeto time. Especially among those whose resources (financial,educational, and social capital, as well as health and emo-tional well-being) offer greater protection against the exigencyof threatening life events and the wearying pressures of ex-istence, aspiration and successes are realities. And especiallywhen we are young, life offers many joys and delights. Deepinvestment in family, work, friendships, creative opportuni-ties, and the building of futures makes it easy to forget thegrim burden of threat and loss. When we are young, we alsosimply don’t have enough of those crucial experiences of be-reavement, anxiety, and failure to teach us the bleaker side of

Introduction 9

existence. Neither heroes nor monsters appear in most lives.But over time most of us come to know at first hand the trialsthat make living such a serious business. Most victories suchas job promotion, financial success, and seeing a creativeproject realized are transient and limited in extent. Lives canbe rich with beauty and happiness—and in well-off countriesor neighborhoods many people enjoy both—yet as one agesostensible good fortune is often tempered, if not overbalanced,by disappointments, unfulfilled hopes, and the indignities ofa*ging. Beyond the immediacy of a joyous occasion, the peri-odic yet magical feeling of ebullience, and even long-termhappiness and the sheer distracting routine of one darn thingafter another lies what the great American psychologist andphilosopher William James called “genuine reality.” And it islife’s trials—bad luck, suffering, and even calamity—that teachus endurance and acceptance of genuine reality.

Today, our view of genuine reality is increasingly cloudedby professionals whose technical expertise often introduces asuperficial and soulless model of the person that denies moralsignificance. Perhaps the most devastating example for hu-man values is the process of medicalization through whichordinary unhappiness and normal bereavement have beentransformed into clinical depression, existential angst turnedinto anxiety disorders, and the moral consequences of politicalviolence recast as post-traumatic stress disorder. That is, suf-fering is redefined as mental illness and treated by professionalexperts, typically with medication. I believe that this dimin-ishes the person, thins out and hom*ogenizes the deeply richdiversity of human experience, and puts us in danger of beingmade over into something new and frightening: individuals

10 What Really Matters

who can channel all our desires into products available forour consumption, such as pharmaceuticals, but who no longerlive with a soul: a deep mixture of often contradictory emo-tions and values whose untidy uniqueness defines the exis-tential core of the individual as a human being. When thishappens, the furnishings of our interior are no longer the same;we are not the same people our grandparents were, and ourchildren will not be the kind of people we are. Several of thecases in this book reveal this disturbing trend. The fear seemsto be pervasive that if we admit what our condition is reallylike, we will fall apart, both as individuals and as a society.

But after three decades of doing psychiatry and anthropol-ogy, I don’t see any convincing evidence that facing up to ourhuman condition leads to paralysis and pathology. Quite theopposite, as the stories in this book illustrate: seeing the worldas dangerous and uncertain may lead to a kind of quiet lib-eration, preparing us for new ways of being ourselves, livingin the world, and making a difference in the lives of others.Surprisingly, confronting the deepest fears can mean givingthem up and asking critically why we ever allowed ourselvesto be so morally and emotionally shackled.

Many of the highest attainments of civilization have comefrom those who have had the courage to peer unflinchinglyinto the darkness of reality. Since the time of the ancientGreeks, the Western literary genre of tragedy has wrested re-markable wisdom from the encounter of human beings withthe fierce and unyielding way things are behind the façade ofconvention. Just to think of Antigone or Lear is to understandhow we have been enriched by this countervailing force.Rembrandt’s Prodigal Son, which appears on the cover of this

Introduction 11

book, is a beautiful painting, yet its beauty is saturated with asense of suffering and loss at the heart of life. Rembrandt’swork links the aesthetic tradition with religion as perhaps themost powerful means by which we build ethical meaning outof adversity and failure. This is also much of the substance ofthe Book of Job and the Gospels, as well as the texts and ritu-als of Buddhism, Hinduism, Confucianism, Taoism, Islam, andmany of the world’s folk religious traditions. They reveal thetruth about how easily our sense of comfort and order isshaken and how hard we have to struggle to maintain ouridentity and cultural worlds in the face of profound suffering.Yet it is in that struggle—as Antigone, Lear, and Rembrandt’sfigures so poignantly illustrate—that we find the meaning ofour humanity.

THIS UNBLINDED PERSPECTIVE on life is voiced by many people Ihave met in research and clinical settings over the years. Thus,one informant, who at the time was a fifty-two-year-old un-employed executive in New York City with serious coronaryartery disease, put it this way: “You grow up in [American]society and you kind of get lulled into the view that you areprotected, things are easy. You can take life easy. Then some-thing happens, and . . . you come to see just how dangerousthings are. I’ve had it happen several times in my life, so Ishould be prepared. But the only preparation is to be wary . . .all the time. That’s why over time you stay very attentive tothings at work, in the neighborhood, even in the family. Evenin your body. I’ve been laid off after twenty years with onefirm. I’ve been in a bad, bad car accident. I’ve experiencedthe death of a daughter to suicide related to drugs. And now

12 What Really Matters

my heart problems. The world is a dangerous place. Maybeeven more dangerous than I’m willing to admit.”

Another research interviewee, this time a sixty-eight-year-old Chinese intellectual in Beijing in the 1990s, reflecting onhis life experience in a very different cultural environment,told me: “My grandfather told it to my father during the war-lord period. My father told it to me during the war with theJapanese. And I told it to my son and daughter during theCultural Revolution. He understood it, but what could he do?He was murdered. Even in these prosperous times I’m suremy daughter tells my granddaughter: Be careful! Be very care-ful! Times change. History changes. The world is not the same.But social life is always very dangerous.”

Those who have lived through the sort of experience thesem*n speak of have felt life transmute into something new anddifferent, something not altogether understandable or desir-able; they have felt danger and uncertainty in their bones. Aseventy-five-year-old French academic, responding to a ques-tion about what he had learned by living through the Ger-man occupation of France, through the immediate postwarperiod with its cultural movements of existentialism and ab-stract expressionism, through the student protests and extremepolitical polarization of the late 1960s, then through the era ofunbridled commercialism and centrist political and culturalblowback of the 1980s and 1990s, with its anti-immigrant andantiglobalization populist movement, and finally through thenew time of Islamist terrorism, ruefully observed: “This is astrange world, Arthur! You cannot predict what is ahead. Ifeel, like many of my circle, more and more estranged by whatis happening. It is like I am watching one disaster after an-

Introduction 13

other unfold. This world of ours is a very dangerous place. Ifyou can lift your ideas beyond the ordinary and see the waythe world is and what we are and who we are becoming, youcannot honestly say to yourself . . . you understand what ishappening. It is . . . you feel alien, or rather the world feelsthat way. That way and frightening.”

“Oh, come now, it’s always been bad . . . if you look deepinto it,” interjected his wife of forty years, a painter and daugh-ter of Holocaust survivors. “Isn’t that so? So we just look awaylike the plowman in Auden’s Museé des Beaux Arts. If you lookunder the rug of civilization, where it’s dark and wicked, weare fierce and terrifying. You need to face that to discover thepossibility for creating something better,” she whispered.

These very different individuals from quite different soci-eties insist that modern culture contains a big lie. By failing toacknowledge the omnipresence of hazards, we maintain afalse image of who we are. And if we are misinformed aboutwho we are, then how can we prepare for where we areheaded and what lies ahead? I hold, as do the protagonists ofthese three vignettes, that if we can learn to face genuine real-ity, we can live better. That is the purpose of this book.

I do not mean to suggest that confronting genuine realitymeans seeing only the worst of experience. Joy, exuberance,and fulfillment are just as real as the darker and more peril-ous moments upon which I am focusing our concern. Loveand hope are not negated by loss and threat; if anything, theybecome better understood and more deeply cherished. It isthe sentimentality of Hollywood (and Bollywood) films withtheir happy endings that look truly misleading when placedagainst the truth of experience. The artists I spoke of earlier,

14 What Really Matters

who explore the depth of tragedy, show us just how preciousand hard-won are our real victories. Look again at Rem-brandt’s Prodigal Son: the reunion of the father and son is suf-fused by a glow of true joy, which is all the more radiantbecause of the years of pain plainly etched on the old man’sface. Living a life embraces positive and negative conditions,and indeed is a story of how they come together. Enlighten-ment about genuine reality should not demoralize us; it givesmeaning to our small triumphs and daily pleasures.

The fact that selves and world can be reworked in responseto hazard and insecurity, and that they are worth remaking,in spite of their limits, is what makes aspiration so important.To experience the limits of living and the inevitability of be-ing checked in everyday practice is not to be defeated or todespair in ethical, religious, or aesthetic ways. Ethical, reli-gious, and aesthetic work remakes the actual practices of or-dinary life, forging new synergies between values andemotions, so that individual and collective significance, tran-scendence, and the sense of ultimate order and control cometo animate who we are. It is precisely when an individual, afamily, or a community is threatened by catastrophe thatpeople turn to religion for explanation. They seek supportfor their deepest values, succor for the existential feelings ofloss and dread, and revival of hope. Religious rituals, andrelationships with coreligionists and religious leaders, do justthis. They revivify what really matters. Failure and catastro-phe empower religion; religion, in turn, empowers peoplefaced with adversity to overcome self-doubt and fear of fail-ing, and to act in the world. Is it surprising that the currentperiod of Christian reawakening and evangelical fervor in-

Introduction 15

tensified in the wake of September 11 and America’s globalwar on terrorism? There is also a downside to religious re-sponses to existential threats of catastrophe. We know thatsuicide bombers include many whose religious zeal in the faceof what they perceive to be a threat to Islamic values callsthem to their destructive acts, and dangerous religious pas-sions also motivate hatred and killing amongst Hindus, Bud-dhists, Christians, and Jews who mix fundamentalism withnationalism.

Culture expresses our sense that there is a special essenceto all that is human, and therefore that each of us is individu-ally exceptional. Consider the large-scale cultural processesin Europe and America that followed the devastation of theworld wars and the Shoah. Creative movements that unitedaesthetics and ethics went on to reframe human meaningsthrough modernism, existentialism, abstract expressionism,Holocaust literature, and other literary and artistic move-ments. These created new ways of making sense of our cha-otic and destructive world. They found value in people’sindividual lives at a time when a huge question mark hungover established cultural forms, calling into doubt their le-gitimacy and relevance. Even if the tone of the works wasbitter, the mode ironic, and the ethical stance one of an iso-lated person facing a dehumanized void, the very process ofcreating beauty and order out of pain and suffering reinvestedthe world with human meanings. In this sense, these artisticand ethical creations rebuilt the world. Even in our complexera, when cultural energies in secular society have come toemphasize salvation through the body and its desires, thereis a reimagining of who we are and where we are headed that

16 What Really Matters

revitalizes, once again, core existential values. You may findyour way in being reborn to another world under theevangelist’s tent; I may find mine in this world, planing thesea in my powerboat; we both may appreciate abstract paint-ings that resonate with our sensibility of what worlds arepossible. Yet in existential terms these are simply differentways of aspiring to and actually creating order out of disor-der and beauty out of jeopardy, new realities of meaning tosustain and recharge our hope in life.

For many, the most unsettling awareness of our times isthe threat of anonymity. When we consider the small and for-gettable quality of our private lives, we fear for the signifi-cance of our individual selves, our close connections, and ourlocal communities. Does it really matter that we were here atthis time? Will anyone remember us after we go? We fear anabsence of our presence. Once again, our sense of being spe-cial is expressed and affirmed by religious, ethical, and aes-thetic activities, which connect our private world to the largerone. That interior world is where we feel vitally alive and ourlives convincingly carry unique significance for loved ones,shared communities of faith or artistry, and, not least of all,ourselves. And that is how we prevent cynicism and nihilismthat would otherwise paralyze social commitments and indi-vidual initiative; that is how we nurture humor, optimism,and the common sense that we will somehow muddlethrough; that is how we preserve an enduring taste for life.Whether this cultural response is profound or shallow is lessimportant than that it renews our sensibility to life itself. Itallows us to savor our mundane existence. Instead of a graygrimness that arises when we coldly contemplate disen-

Introduction 17

chanted human ends and discover just how much we canendure, we can revel in the thrill of color and sound, the charmof taste, the exhilarating lightness of touch, the rightly ac-claimed mystery of love.

My point is that acknowledging the always unequalstruggle between where the world is taking us and where weaspire to go does not at all mean accepting a glum perspec-tive; rather, it involves developing a deeper and more fine-grained appreciation of what the moral experience ofcommunities and the moral life of the individual are about,and why both are so important. Within this broader moralcontext, we want to know what we can learn to help us live alife. For this reason, it is especially instructive to examine thegray zones where the separation between acts that sustain amoral life and inhuman ones that destroy it is thin, becausethese zones of the most troubling moral experience show justhow difficult it is to live.

In the course of our individual lives, moral and emotionalexperiences can change us so greatly that we are not the samepeople we were earlier: life, with all its transformations, hasrestyled us at the core. So, what is the core? Who are we? Weneed to get away from the idea of an unchanging human na-ture that resists all the myriad changes around us, like steelpiers holding up a bridge in deep, rough water. That imageholds for bridges but not for people. The countervailing imagethat arises in the mind is from the New England coast, wheremy family and I spend summers on the Gulf of Maine, abovea large tidal river about two miles from the Atlantic Ocean. Itis sometimes placid, sometimes very rough in these waters.Here the shoreline has a prima facie consistency, rocky ledges

18 What Really Matters

and rock-strewn beaches; if you are a serious boater, you haveto be cautious, no matter your knowledge of hazards wellmarked on charts and your GPS. Owing to the tidal condi-tions and occasional great storms, things that have a seemingpermanency—rocks, underwater obstacles, channel-markingbuoys—can shift, sometimes substantially enough for a lo-cal lobsterman with two decades’ experience of the water torun a thirty-two-foot lobster boat aground. If you regularlywatch the shore, you see that it is under almost constantchange, albeit within limits set by the local geology and hy-drology. So with the self, the soul. The limits are set by theprinciples and empirical reality of biology and psychology.The self is moored by the neurobiological hardwiring of rudesentiment and the rough genetic scaffolding of personality.But there also are moral and affective currents constantly atwork changing the self’s topography. Neurotransmitters cre-ate rough sensations of pain and anger. Remorse, regret, andother complexes of emotions and values are strongly influ-enced by interpersonal relations and meanings that contrib-ute to the building of the subtle and elaborated sensibilitiesthat constitute who we are. And culture, politics, and eco-nomics transform each of us—if not from day to day, thenfrom year to year as jobs change, careers transmute, fami-lies undergo growth and collapse, marriages rise or fall, andthe large historical forces that shape the destiny of nationsand influence entire populations roll over our lives, grind-ing, wearing away, shifting, breaking, making us let go andmove on.

Danger arises when our most deeply held values and emo-tions are threatened or lost. And people themselves become

Introduction 19

even more dangerous when they feel that these things are atserious risk. Then they are frequently prepared to do any-thing and everything to protect and defend what really mat-ters. In these moments of intense pressure, the self can bereshaped: the most placid and pacific person can become vio-lent, can participate in oppression or crimes against human-ity. Pogroms against Jews, from the Middle Ages up until thegreat Russian pogroms of the 1880s that drove hundreds ofthousands of Jews to emigrate to America, not infrequentlytook this character. Fear of social disorder and major politicalchange, laced with rumor, targeted a stigmatized “other” fordestruction. A deadly epidemic, some other public catastro-phe, and political dissension so threatened the local popula-tion and the central authorities that the Jews became a handyscapegoat. The Shoah—the genocide of European Jewry—canalso be seen in these terms: ordinary Germans accepted theNazis in order to stave off the Soviet menace and as part ofthe devil’s bargain tolerated the Nazis’ war against the Jews.

The willingness of ordinary Serbs and Croats to partici-pate in the mass killings of Bosnian Muslims also can be tracedback to the same social dynamic: a real danger threateningthe moral order—in this instance, the breakup of the nation-state into warring ethnoreligious groups—is associated di-rectly with the other group or indirectly blamed on them. Thisleads to the second-order, and often more deadly, danger ofthe threatened group either actively carrying out or passivelyacquiescing to the destruction of the people perceived as thesource of that threat. The existential message is chillingly clear:we will do all that needs to be done to protect our way of lifeand ourselves, and if we perceive a serious threat, we will

20 What Really Matters

engage in violence as a preemptive strategy or even a kind ofanticipatory revenge.

We can glimpse this social logic in the ways we Americanshave responded to the September 11 attacks on America withthe follow-on war on terrorism and the Iraq war. The top-pling of the Taliban and the destruction of al-Qaeda trainingcamps in Afghanistan made sense to many Americans, as didthe international hunt for terrorists and their sources of fund-ing. But the invasion of Iraq, its occupation, and the subse-quent deadly mix of insurgency and civil war there suggestthat we have gone too far and created just the kind of violentoverresponse that I have pointed to as a second-order andgreater danger. We seem to have a newfound certainty thatvengeance is right, no matter how many thousands must dieto avenge our national tragedy and affirm our national myththat we are making the world safer. We also have become sopreoccupied by our fears of internal insecurity and hiddenenemies that we have been willing to limit or actually abro-gate constitutional safeguards of the very rights we preach asmost sacred. Seen from this perspective, our quest for home-land security, our desire to mete out justice through vengeance,and our concern for global social control seem to matter moreto us than our commitments to rights, legal procedure, andeven the global democratization we proselytize so robustly.The last looks more and more like a fig leaf camouflagingthose fiercer commitments.

As we continue to pursue these policies, which manyAmericans view as morally justified, we are accused by mil-lions of Muslims of conducting a war on Islam, and by millionsof Europeans and Asians of making the world more danger-

Introduction 21

ous. Islamic communities provide moral support to youngMuslim men and women whom we call terrorists and theycall holy warriors and martyrs. Suicide bombers view theirown horrific actions as morally just, and so do members oftheir networks and communities. So here we have a contestbetween radically different moral justifications.

If we step beyond our own taken-for-granted commitmentsand those of our adversaries, it is clear that the moral visionand commitments of terrorists, including suicide bombers,are utterly unethical and antihuman. But it should be equallyapparent that our own lived values as outlined above, and asrepresented in how we behave in the world, are problematicas well. Neither moral position is acceptable. Both are peril-ous. To move beyond them we must advance an ethical ap-proach that seeks to transcend local commitments and yet atthe same time is locally applicable. To be effective at the col-lective level, such an ethical approach, I argue, must also workfor the individual who is seeking to build a life. That is one ofthe things I seek to explore in this book.

The chapters that follow set out stories of the struggles tolive a moral life of men and women I have encountered in myprofessional career as an anthropologist, psychiatrist, andChina scholar as well as through personal friendships. Likethe rest of us, these individuals have found themselves caughtin particular circ*mstances and in cultural conditions wherethe things that matter most to them have been challenged bywhat is at stake for others or for society. For example, a formerdecorated soldier, now decades into a successful legal career,looks back on the atrocities he committed in the Pacific warand sees indelible evidence not only of his own moral failings

22 What Really Matters

but of society’s hypocrisy in being unwilling to recognize thatwar is about turning ordinary men into killers. Once the trans-formation has occurred and violence is unleashed, societyturns its back on the moral life of the perpetrator. The centraltension between one person’s ethical aspirations and society’smoral reality extends for this angry middle-aged man into aconflict with his psychiatrist about what depression and itstreatment are about. Is tragedy a disease requiring an antide-pressant medication? Is a lifetime secret of having committeda terrible abuse a medical problem or a moral one? Are theremoral disorders and moral therapies? Are remorse, regret, andrepentance, not just symptom relief, the appropriate healingoutcome for facing up to moral failure?

A liberal Protestant minister who is barely able to controlhis own sexual impulses experiences the selling of sex in themedia and on the streets as an existential threat to moral re-sponsibility, his own and his adolescent parishioners’. Thefundamental conflict between religious aspiration and sexualreality (society’s and his own) is experienced first as the con-version of guilt into excruciating bodily pain and afterwardas the transfiguration of pain into the holy. His story will leadus through an exploration of living a life in the unchartedterritory between religion and medicine. And a Chinese phy-sician and intellectual confronts the political perils of theCultural Revolution as a direct threat to his ideals, his family,his career, and his own life. He comes to understand, in theradically different era of economic reform, that an ethos ofcompromise, acquiescence, and readiness to deceive and ex-ploit create a world in which living a moral life is intenselydifficult as well as risky.

Introduction 23

While the circ*mstances and conditions and outcomes di-verge, all of the protagonists in the chapters that follow arecaught up in moral experiences that define what it means tobe human, forcing them to confront who they are but alsoprovoking them to come to terms with who we all are, whatour shared humanity is all about—albeit with an intensitythat makes their life narratives arresting. I write these casesto illustrate how malleable moral life is, for individuals andgroups—and to show just how central jeopardy is to ourworlds and ourselves.

Can studying the experiences of a few individuals shapeour responses to the challenges we will have to face? Becausemany of the challenges I review seem unmasterable, what isthe implication for how we face them?

The answer is just that: we need to begin by surmountingour own denial and affirming our existential condition. Suchcrises and limits cannot be mastered, in the sense of conquered.They are to be understood and responded to as ethical, reli-gious, and aesthetic challenges. Getting a handle on what re-ally matters for us requires a self-critical stance toward ouremotions and values in which we try to step aside from (or,really, outside) our taken-for-granted world and sense of self.No easy thing, but it can be done. Seeing ourselves in thisway, we can ask the hard question: does what really mattersfor us contribute to an adequate or good life? If the answer isno, we obviously are in for a tough time of trying to remakeour commitments and realign them to those surrounding usin our local world. If the answer is yes, then we still need todiscover what the obstacles are to achieving an adequate life,and which (if any) of them can be surmounted. Even when

24 What Really Matters

the answer is that these barriers are the existential limits weface, the possibility is there to live creatively and morally. Evenunder threat to our core meanings, we can, for instance, firstdo no harm to ourselves and others. We have seen how first-order dangers, those forces outside ourselves that threatenwhat matters most to us, create second-order dangers, thethreat within ourselves that in defending what we value weviolate our humanity. Breaking this cascade can be a power-ful way to transform ourselves and even our worlds—forexample, by ending cycles of revenge, or by controlling an-ger turned inward into self-injury. By opening up a space ofcritical self-reflection on our world and ourselves, we canprevent ourselves and others from becoming worse peopleunder the pressure of changing conditions. We can protestand resist a dangerous moral ethos in our families, workplaces,and communities, and even if we are unsuccessful at chang-ing our local worlds, which is not unlikely, we can keep ourmoral practices in line with our sense of what is right. Andthat is indeed something worth struggling for, something thatcan transform others as well.

In several of this book’s stories, the lesson is that squarelyfacing failures in life is as important for our worlds and theothers in them as it is for our own self-esteem. We are mor-ally responsible for ensuring that others understand the so-cial injustice our worlds routinely create, including what wehave brought about through our own actions. And we arealso responsible for doing something about injustice.

In one story, we learn how AIDS transforms a mother andartist from a “taker” into a “giver,” and we thereby see howexistential crises caused by a health catastrophe can create a

Introduction 25

new moral life. In another of the book’s cases, we learn how aformerly quiet intellectual moves out of the library into thepublic world of others’ pain and suffering, so as to undo thevery moral conditions that made him famous, but which hehas come to understand are the cultural basis for political andmedical disaster. The lesson is not one of standard heroism—there is no victory—but a kind of negative heroism or anti-heroism that may not change the world but helps make clearto others what needs to change if the world is to be a lessunjust and desperate place. That antiheroism legitimates, atthe same time, alternative ways of living in the world thatoffer new and different personal answers to the question ofwhat an adequate life is. Heroic acts that change society arerare and more often than not meretricious fictions, whereasprotest and resistance as well as perturbing and disturbingthe status quo are, at best, the most ordinary people like uscan achieve.

THESE CHAPTERS point to a new way of conceiving of ethics.Ethics, a set of moral principles that aspire to universal appli-cation, must be seen in a context of moral experience, which isalways changing and usually uncertain, in order to provide amore adequate vision of values in society and how to respondto their clash and change. Taken alone, ethics, such as prin-ciples of virtue and justice, can be irrelevant to our localworlds, just as local moral experience, such as discriminationand oppression carried out in the interests of the dominantgroup, as in the American South in the era of segregation, canbe unethical, even downright evil—and can render peopleunable to criticize their own conditions. I examine efforts to

26 What Really Matters

unite the two, moral experience and ethics, in the stories ofactual individuals’ lives. Individuals’ efforts to live a morallife in the particular circ*mstances of moral experience canlead them to formulate ethical criticism of those circ*mstancesas well as to aspire ethically to values that go beyond the lo-cal reality and seek universal support. This new frameworkfor examining actual lives shows us who we are and who wecan be in response to some of the more disturbing value ques-tions of our era.

I include in these accounts an autobiographical chapterabout times in my life when I too faced the issues of moralimagination and responsibility highlighted in the other chap-ters. This effort at self-knowledge signifies that the authorcannot claim a position that is outside the local context of so-cietal changes and moral struggles. I too have my own storyto tell about moral experience and trying to live a life, as doeseach of you.

What we see in these stories, I believe, is not nearly so muchthe moments of intensive moral reflection that philosophersemphasize but rather what anthropologists and social histo-rians, biographers and psychotherapists so often describe: theinsecurity of moral life and the terrible inadequacy of ourusual fumbling efforts to change or fully comprehend whowe are and where our world is taking us. Yet, in the midst ofit all, we make a life. So how does that happen? How do wedeal with the world and build ourselves as moral agents? Thisis the existential core of each chapter that, I suggest, lies be-neath cultural difference, social diversity, and personaluniqueness. This is what matters most to me. This is the book’sclaim to truth.

Winthrop Cohen

inthrop Cohen represents for me the despairing ideathat society can impose on us a way of living that un-

leashes our anger and aggression in a thoroughly inhumanway. He also represents for me the inspiring idea that the or-dinary person over the course of his or her life can protestthat unethical imposition and can even insist on devoting alife to remorse, regret, and repentance. Winthrop Cohen holdsanother crucial significance for me. His case pointedly asks howordinary unhappiness and clinical depression differ. What doesit mean for us and our world when the soul’s tragedy is diag-nosed as a mental illness and treated medically?

I met him in a clinical consultation more than twenty-fiveyears ago. More accurately, I first met Mrs. Julia RichardsonCohen and her married daughter, Alexandra Frost—both tall,attractive, conservatively dressed, and worried. Winthrop had,at the last minute, backed out of accompanying them.

28 What Really Matters

“So what’s the problem?” I asked mother and daughter.“He won’t talk about it,” Mrs. Cohen told me. “Says he

can’t. But it is eating him up inside. I married a vibrant, won-derful man. Now he seems so sad, so hurt. It’s not right. He’sbeen so successful. We have everything anyone would want.So why does he seem so unhappy, so terribly unhappy?”

Mrs. Cohen’s daughter added, “He’s all closed up. We lovehim. He loves us. But we don’t talk. Because he can’t tell uswhat hurts so very much. But we’re afraid, afraid for him.”Then they both broke into sobs.

When they composed themselves, they told me they werequite sure Winthrop would come to see me, because he lovedthem and knew they were desperate for him to receive pro-fessional care. And indeed he did keep the next appointmentseveral days later.

A short, stocky, immaculately attired, sixtyish man with amilitary bearing—straight back, shoulders squared, sittingbolt upright at edge of his chair, hair in a brush cut, speechclipped, but otherwise expressionless—Winthrop Cohen madeno effort to contradict his wife and daughter.

“They’re probably right. I accept all the responsibility. It’smy fault.”

“What’s your fault?”“The way I am, I guess.”“What way is that?”“Ah, what to say, huh? Where to start?”He sighed—long, slow, and very deep. He looked down at

the floor. His face fell into a desperate sadness that made himlook greatly vulnerable. It was now clear why his wife anddaughter were so worried. He seemed on the verge of col-

Winthrop Cohen 29

lapsing. I waited. After what seemed like a two- or three-minute pause, he cleared his throat, bit his lip, and began.

“The war. It’s what happened to me in the war. I couldnever get over it. But I learned to live with it. Then all of asudden on my sixtieth birthday it became a terrible weight. Icouldn’t put it out of mind. I feel so very depressed about it.Sometimes I sit for hours, brooding over the past. What I saw,what I did. My daughter calls it depression. I don’t know whatit is. But whatever it is, it is bad.”

Winthrop Cohen had run away from home in a working-class section of lower Manhattan to join the Marines. The yearwas 1942. He was eighteen but looked older. After severalmonths in training camp, he was shipped out to the Pacifictheater. By the time the war ended, he had participated in theinvasion of four islands including Okinawa, been twice deco-rated for bravery, and sustained two wounds, both visuallyimpressive. One, a thin burn on the left side of his face, highacross the cheekbone, extended from under his eye almost tohis ear. It had turned lighter than the rest of his facial skin,which had a ruddy complexion, and had the effect of makinghim seem fierce and piratical, yet also aristocratic. The other,a long, deep, dark, dense scar on the outer surface of his rightarm from wrist to elbow, a shrapnel wound, made me thinkof the kind of work injury a construction worker might fallprey to. Those two contrasting images—elite and blue-collar—created my sense of what Winthrop was about.

He was demobilized in 1945, after which he returned toNew York, attended college on the GI Bill, received a scholar-ship to law school, and moved to the West Coast, where hejoined a large law firm. Over the years he had been very

30 What Really Matters

successful and was now a senior partner. His wife came fromthe wealthy Protestant business class of this southern Cali-fornia city. Over four decades, the Cohens had one child, en-joyed a happy family life, and became well-to-do, respectedmembers of the city’s elite.

Winthrop Cohen was the son of an unsuccessful small busi-nessman, a second-generation Jewish American who had gonefrom one failed business to another; his mother, a teacher andnonobservant Jew, had intentionally given him an aristocratic-and Protestant-sounding first name as a sign of her high as-pirations for his success.* Winthrop’s maternal grandfather,her father, had been successful as a builder of residential apart-ments, and Winthrop Cohen referred to himself as a “builder.”“My father was a failure. He couldn’t make a go of business,or family, or himself really. But I was like my grandfather. Iwas a builder, building a very successful career and a family.I’m proud of what I accomplished in this part of my life.”

About his three years in the Marines, Winthrop Cohen wasless proud, and he had been silent for four decades at thetime I met him. Neither to family nor friends nor for pur-poses of advancing his legal and business interests had hespoken of his wartime experience. He purposely avoided vet-erans’ organizations and the alumni gatherings of his Marineunit. When an article appeared in a local newspaper in the

*To me his name, with its contrast of Protestant upper class and Jewishlower middle class, and the contrast of his scars, one of which, as I’ve noted,looks like a scar from an elite duel and the other like a workingman’s injury,highlights the man’s dividedness, which helps explain what he was about.Over the years I came to think of him by his full name, Winthrop Cohen, ratherthan as just Winthrop. In this chapter I use his full name quite often in order toconvey this sense.

Winthrop Cohen 31

1950s listing winners of military decorations in the city, it car-ried Winthrop’s name but neither his picture nor his story; hehad refused to be interviewed. When sick a decade after thewar with complications of the hepatitis he had been infectedwith in the service, he explicitly rejected the suggestion ofgoing to the local veterans’ hospital. “I did all I could to put itall behind me. I froze it out. Even memories, whenever theypopped up, I pushed them away. Until now I was successful.I was aware of course that I had a hidden life, a part of methat discredited who I was, I mean had become, but I couldcontrol it, until now.”

What so thoroughly shook Winthrop Cohen were the memo-ries of beach landings, fighting in the jungle, and, most of all,killing. “I was made over into a killer. A proficient, remorselesskiller. I probably killed dozens of enemy soldiers. Most at adistance, but several very close up. One, I bashed his head inwith my rifle butt after he infiltrated our lines. He was a youngkid. I guess my own age. I just kept hitting him in the face withthat end of the rifle. I broke everything, his nose, his mouth,his eyes. He had knifed the guy in the next hole. I heard thescream. I came running. The kid froze. I could have shot him.But I wanted to really hurt him, so I destroyed him blow afterblow, till the rifle was covered in blood and gore. Then I satdown and retched. Another Jap (I hate the word now, but Iused [it] plenty then)—a fat sergeant—was wounded in thegut. He had been part of a machine gun crew that tore our unitto pieces. I just shot him. But that wasn’t enough. I was uncon-trollable, in a rage. I took my bayonet and . . . well, better notsay what I did, but it was bad. We mutilated them sometimes,and they did even worse things to our guys.

32 What Really Matters

“But these two murders aren’t the worst. You can under-stand them in a way and maybe even say things to justifythem. But I did something, something so awful, there is—there can be no justification, no explanation, nothing to makeit seem right. Nothing can exonerate me. This is the thing Ihave hidden all these years. The secret I have kept. The thingI did that can’t, can never be undone.

“He must have been a military doctor. We overran his po-sition. A small field hospital. There were guys on stretchers,almost dead. He raised his hands, dropping the stethoscopeat his feet. He had been bent over this stretcher, treating a guywith a lot of blood on his chest. He raised his hands and lookedat me. His eyes were fixed on me. He just watched me. I cansee him—so quiet, just waiting. Thoughtful, sensitive. Hedidn’t plead. He didn’t say anything. He didn’t move at all.He just looked at me. When I force myself to see it all overagain, he seems so human, so sympathetic. His face wasdrawn and sad, waiting. Oh, God! I shot him. I killed him. Heslid to the ground still looking at me. And I . . . I shot himagain and again.

“At that point, let’s face it, we weren’t taking prisoners.But saying that is no good. I could have taken him prisoner.It was me, Winthrop Cohen, not we or they, who killed him.In cold blood. Without any threat. There is no other wordfor it. I murdered him. I murdered a doctor while he tendedto his wounded men. Pure and simple. I killed an innocentman—no, I really think it is worse than that. I often think ofthat doctor. Who he was. What he did. What was he think-ing? He waited, but he knew, he seemed to know what Iwould do. He didn’t run or plead or fight. He just watched

Winthrop Cohen 33

me. I mean, in my dreams he watches me. He waits. He ac-cepts what I do.

“The more I think about him the more Christlike he becomes,from the sorrow in his eyes to the bullet wounds and blood. Imurdered a healer, a man of deep humanity. I’m sure of that.

“How could I? How could I do that?” Winthrop Cohen wept.His voice became strangled. He made no effort now to controlthe flow of feeling, which swept over him in great sobs.

I reached out to touch his arm. “I hear you. I understand.”But in fact I didn’t and couldn’t understand an experiencethat seemed to me as gruesome as anything I had heard. Weboth sat there in silence, stunned by the horrible remembrance;an image of the murdered Japanese doctor took over the room.There were no words to undo what Winthrop Cohen had doneor to make up for what he had gone through.

“There is no end to it, you know. No way to close it out. Ican’t go back and change what happened. I want to. But I cannever change what I did. I don’t accept the usual. . . . It’s war.Men do bad things, have to do awful things. Everything pureI believe in, I betrayed. I was raised to aspire to do the rightthings. My mother was a humanist. She taught me to lovebooks. She made me feel that we Jews were different, special.Because we were bound to God, we were bound to doinggood in the world. And look at me. I destroyed what I wasraised to value. How can I face myself?

“When we were on the troopship waiting to board the land-ing craft, my first time, a lot of us were scared, and try as wedid to hide it, it showed. We shivered, stuttered, vomited.Wet our pants. I knew I was scared. Then some fierce Marinemajor turned on us. He called us every name in the book, and

34 What Really Matters

then he bellowed, ‘Most of you sh*ts will die on this beach.Just be sure when you’re hit, you goddamn fall forward. Soyou don’t get in the way of the guys behind you.’ He meantit. His job was to take the beach and advance. You were noth-ing but his tools to do it. Expendable. That’s what no onecomprehends outside of battle. You killed and got killed.That’s the way you were trained. To be tough as hell, hard,truly hard, and that means inhuman, cruelly inhuman.

“That’s the other part of it. I was no aberration. I was nor-mal, supernormal. A hero. The hero taught to kill, and alongthe way to betray every decent value of peacetime society. Ifyou couldn’t do it, you were mocked until you did, or thrownaside, so some other poor SOB could do it. I mock myselfbecause I succeeded so well . . . because I can’t turn back orturn it off.”

Winthrop Cohen’s remorse and regret were accompaniedby almost all the cardinal symptoms of depression listed in theAmerican Psychiatric Association’s Diagnostic and StatisticalManual (which was in its third edition at that time): sadness,anhedonia (lack of pleasure), loss of sexual interest, sleep dis-turbance with early morning wakening, profound lack of en-ergy, difficulty concentrating, agitation, appetite loss with aten-pound weight loss, slowing down of all motor functions,and deep feelings of guilt, worthlessness, and hopelessness.As a young psychiatrist who had recently passed the clinicalexamination of the American Board of Neurology and Psychia-try, I knew that the appropriate treatment was to combine theright psychopharmacological drug with at least several monthsof weekly psychotherapy. That’s what I recommended andwhat Winthrop agreed to and complied with.

Winthrop Cohen 35

Winthrop Cohen’s clinical depression responded to a shortcourse of antidepressant medication and psychodynamic psy-chotherapy focused on clarifying and interpreting his war-time trauma in the context of his biography and intimaterelations. After eight weeks, he no longer stared off into spaceor looked agitated or seriously depressed. He returned towork. His wife and daughter thanked me for treating this“breakdown.” But Winthrop Cohen never thanked me. To thecontrary, at our last meeting, he implied that I was part of thesocietal collusion to cover up the threatening implications ofwar experiences such as his.

“I can put it away again. I don’t feel the same pressure. Ican sleep, and eat, and fornicate again. But you know as wellas I do that what’s bothering me can’t be treated or cured. Jobsaid: ‘I will maintain my integrity. I will hold on to my righ-teousness.’ I did neither. I soiled myself as I was soiled. I lostmy humanity as those around me did the same. You don’thave any answers. Nor do I. Save to live with it. To realize Idid the worst is to understand how ordinary men do badthings. How ordinary Americans were so anti-Semitic at thattime. How ordinary Germans did what they did during theHolocaust. How all of us are capable of murder. In the midstof war when all hell breaks loose and you are empowered toact with impunity, you can do horror and be decorated for it.And you can dine out for decades telling war stories, storiesthat are untrue. Because who can face up to the reality of theevil we did? Only the patriotic memories last. The killing isforgotten. The suffering remembered, because it is legitimateto speak of it. What can’t be said—I mean in public—is whatI did. What does that tell you about the soul?”

36 What Really Matters

Winthrop Cohen asked me this question two decades ago.I wrote it down verbatim in my clinical notes. The commen-tary I added alongside Winthrop’s words in my notes is notworth repeating because it seems banal and disturbingly offthe mark. I must have felt my clinical prowess was threat-ened because I commented solely on the depression and itseffect, and what happened after treatment. I knew, of course,there was a larger, more telling ethical issue, but I turned awayfrom it.

Perhaps I was misled by Winthrop Cohen’s final word. Soul,after all, turns the force of his critique to the inner self as if itwere isolated from the world. But everything else he saidpoints to the world. What does that tell you about the world?It is just as damning and sounds in retrospect the right con-clusion. Job referred to his inner state with the Hebrew termka’as, “vexed.” That is the same meaning Chinese victims ofthe Cultural Revolution gave to their feeling state, which theynamed with the term fan zao—vexed in the sense of beingshaken by an outer force that powerfully agitates our innerstate. It reminds me of the inseparable tie between our selvesand our local worlds, emotion and value. And it reminds meof Winthrop Cohen, because he had been shaken by the bru-tal force of war and what he felt was a just response to whathe had done and what had been done to him.

Eight years ago I learned from a former colleague thatWinthrop Cohen had died of liver failure, the long-term con-sequence of the hepatitis he had contracted in the Pacific war.I went back to my clinical notes, something I do not routinelydo, because I was troubled by something unfinished, ethicalquestions I had never addressed. I tried to rethink the case in

Winthrop Cohen 37

the much wider context of twentieth-century American soci-ety. What had mattered to Winthrop Cohen was to moveahead, to succeed at a high level. His mother had set him onthe course of moving from the Jewish lower middle class, towhich their prospects had fallen, to the Protestant elite classthat then dominated American society. She did it with thename she gave to him, the stories she told him, and the highexpectation she held for him. The negative example of hisfather’s repeated failures was masked by the positive exampleof his grandfather’s achievement.

But Winthrop Cohen also embodied a religious ideal. Hebore the mark of a people that defined itself, in his words, asspecial in its relation to God, in its historical sense of the el-evated demands of its ethical culture, and in its stubbornstruggles to square religious values with real-life problemsthrough especially strong concern with suffering, healing, andmedicine. In the radically changed ethos of battle, WinthropCohen had succeeded brilliantly as a warrior—a success thatwould be matched by his secular career, which advanced fromone achievement to another. But as a human being, he hadfailed in his own mind in the most existential way. He hadkilled, and not just with professional competence but withsavage explosions of rage. And he had killed someone who,he said to me, even at the moment of being killed practicedthe very ethical values Winthrop Cohen associated with hisown religion. He called this military doctor “innocent,” “ahealer.” Of course we don’t really know if this was so. For allwe, and Winthrop, know, the Japanese medic may have par-ticipated in atrocities too. If he personally hadn’t done so, otherJapanese had. And of all America’s wars, the war Winthrop

38 What Really Matters

fought in seems to come closest to the justifications of a justwar. Even if we find this rationalization unappealing, WinthropCohen was fighting for his life. In the chaotic hell of battle hehad done what he had to do, I thought, trying even in myinterpretive strategy to protect this vulnerable former sol-dier who refused all artifice and counterargument. Wasn’this implacable self-criticism a vindication of his decency?But for Winthrop it was the existential reality of his moralimagination that counted. He had done what he could neveraccept. He had done more than betray his ideals; he haddone something so evil there was no atonement, only pun-ishment. He, a Jew on his way to success in the Christianworld, had killed a “Christlike” figure. He said that. Andmy thoughts now completed the charge: he had thereby en-acted a vicious myth that has been immensely destructiveover so many generations. His personal tragedy, I now toldmyself, was deepened by the embodiment of this terriblydangerous collective myth.

For Winthrop Cohen, what mattered most at the moment ofhis heroism and horror was killing and avoiding being killed.He proved to others and himself that he could do it. He re-membered, however, and he remembered with a vengeance.Even forty years after the event, he could put himself rightback into the fighting. His memory had the purpose of takingvengeance on himself. He could not forget or forgive himself.He had justice in mind. And so we have the telling, and notuncommon, paradox of a man with mental illness (depression)giving voice to powerfully disturbing insights about the dan-ger of ordinary life and the burden of moral responsibility thata normal man could neither think nor speak.

Winthrop Cohen 39

I wrote in the introduction that this is a book about ordi-nary people caught up in ordinary and extraordinary experi-ences that define the dangers and uncertainties of actual morallife. Twelve million Americans were in military service in theSecond World War. Only several million bore arms, and fewerstill were combat troops. Even so, Winthrop Cohen’s experi-ence of war was shared by many, many servicemen. Not neces-sarily the atrocities, but surely the killing and being killed arewhat combat was about. In this sense it was and still is theordinary moral experience of war. We have no idea how manyformer soldiers came to interrogate that life, but the novels,poems, and works of criticism in the postwar years indicatethat some did. Perhaps this is what makes Winthrop Cohen atleast somewhat extraordinary: his later life was obsessed byquestions of wartime guilt for actions he committed that in-creasingly seemed to him inhuman and ethically indefensible.

Extraordinary experiences—the end of life, emergencies,extreme social conditions—concentrate the focus of ordinarymen and women on what is most at stake for them and forthose around them. Just so, Winthrop Cohen came to see whatmattered most in warfare for him and for others. Proving him-self a warrior among warriors; channeling his fear and rageinto deadly acts that destroyed the enemy, even conspicuouslyso; doing all in his power to protect himself and the smallband of servicemen with whom he had bonded in a tight fight-ing unit—all were commonsense commitments and actionsthat he was trained to perform and did indeed carry out, par-ticipating in a shared moral world. This held true until thatmoment when he saw himself step beyond what he couldpersonally countenance even in the heat of battle. Then he

40 What Really Matters

began to question that moral world: its sources, its taken-for-granted commitments to do what it takes to succeed, and itsconsequences. Where did his moral responsibility lie? Whatwere the limits to what he (and by implication others) couldand would do? When was his moral imagination meant toclarify boundaries and protect against going too far? Howcould he deal with acts of atrocity when the extreme condi-tions had changed and he returned home once more to an-other local world, where radically different things matteredmost and where the actions he participated in ran directlycontrary to what was approved and valued?

I THOUGHT ONCE AGAIN about Winthrop Cohen in 2004 as I readof the atrocities committed by American soldiers and marinesin Iraq. And once again I felt haunted by his refusal to hidebehind conventional justifications that shift responsibilityfrom the perpetrator to leaders and on to society as a whole.No wonder we want (need) to forget what moral experience,especially under extreme conditions like war, is really about.To understand how our world can change so radically that manyof the things most at stake for us are altered fundamentally—such as life becoming cheap, decency and honor abandoned,anything becoming permissible in a gray zone that toleratescunning and brute force on behalf of survival—can be a dis-orienting experience. Such a troubling experience can alien-ate and depress us. We become alienated by the value gapbefore and after change, by the stark disparity between wordsand deeds, and by how once taken-for-granted local valuesbegin to look when we better understand what stands be-hind them, what they really mean. And we can become de-

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pressed when we realize that we are so dependent on localvalues at a particular time and place that we are vulnerable,to a degree not previously appreciated, to the danger of in-fluence and to our own readily misplaced loyalty. We alsolearn that it is not just dangerous local values that put us atrisk. Our own failures in imagining alternative realities, car-rying through with moral responsibilities, and preventingvengeful overreaction greatly compound the dangers we face.

To challenge local common sense and to go even furtherand question our own sensibility puts us at odds with theway the world is. It also has the potential to undermine oursense of self and seriously upset our emotional stability. Thisis what happened to Winthrop Cohen. He had first tried toforget what had taken place in his moral life. But over fortyyears he had come to critique his world and himself in themost basic terms. He became outraged by the disparity intruth between what we say we value at times when we areunder no serious threat and what we actually are capable ofdoing when we feel what really matters could be taken fromus. He thought of this divide as hypocrisy. It might make lifemore livable, but it also promoted actions that were franklyinhuman and unethical. Viewed in this perspective, ordinarylife looked deeply troubling because it disguised the cunningand connivance that made survival, security, and stabilitypossible. Winthrop alleged these things and more, in wordsboth direct and metaphoric.

Memories can (and do) kill, when they foster acts of re-venge. The words are in my psychotherapy notes, but I seemedto have missed almost completely their ethical resonance, sofixated was I on treating the depressive symptoms and what

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I then took to be their underlying cause in Winthrop Cohen’spsychopathology. As Winthrop’s symptoms improved, he wasnot focused on depression. He was bothered by a deeper con-cern that I suppose I was then unprepared to name and ad-dress. Moral experience, he implied, can lead a normal persontoward murder. Normality, not pathology, was the problem.Normality could be abusive; it was dangerous.

The atrocities at the American military prison at Abu Ghraibin Iraq occurred in a local world that condoned and encour-aged the humiliation of prisoners, assault on their culturalvalues, and the abuse of deadly force. Atrocities were perpe-trated in the name of intelligence gathering. This sad state ofaffairs became, among the group of military police guards,normal. Justification of a general kind was provided by mili-tary higher-ups. They wanted information on the growingIraqi insurgency and on specific terrorist threats to the UnitedStates. The alleged abuses—threatening young prisoners withattack dogs who on occasion were allowed to bite, forcingprisoners in groups into sexual positions, and perhaps evenbeating several prisoners to death—went one or more stepsbeyond what was prescribed in the military manual. But werethese practices, especially the nonlethal ones, that far outsidethe ballpark of police actions aimed at softening up prisonersfor interrogation? The attacks of 9/11, the war on terrorism,and fighting the increasingly deadly insurgency in Iraq werethe reasons given by Pentagon and other Bush administra-tion officials for aggressive interrogations. Backed by theseofficial justifications, and with growing feelings of fear andrevenge in response to attacks by insurgents and riots by pris-oners, prison guards participated in a moral milieu that cre-

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ated abuse as a routine. The moral scenario I have describedof actual dangers leading to overresponses that escalate dan-ger actually took place. I don’t mean to exculpate the abusiveguards. Their individual actions were unacceptable. Theywere responsible for the abuses. They went well beyond ac-ceptable rules of engagement and ethical limits, and did so,at least in several cases, for their own sad*stic pleasure. Thereis a difference between their actions and what Winthrop Cohendid in a life-threatening combat situation. And yet Winthropwarned that further abuses would happen, had to happen,because of the moral conditions established by war. When Ireread my notes and rediscovered Winthrop Cohen’s voiceof ethical alarm mixed in with my technical psychiatric ob-servations, I was appalled at my own failure to acknowledgethe value crisis and human tragedy that he had insisted werethe heart of the matter. How had I been so far off the mark?

My notes speculated about dissociation—the splitting ofcognition from affect, action from moral sensibility—whichwas coming back as a fad in psychiatry just then. The basicargument was that in situations of extreme threat, we sepa-rate thought from feeling so that we can flee, fight, or, if webecome victims, block out the brutal reality of assault, freez-ing it in a cut-off traumatic space outside of consciousnessand memory. It all seemed to fall into place. People are ableto repress traumatic memories for a certain amount of time.Eventually the memories resurface and cause anxiety, de-pression, and other mental problems. Trauma, once split offinto dissociated states, the theory stated, reemerges as post-traumatic stress disorder or other conditions. My original analy-sis of Winthrop’s problem is an example of the seduction of

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the professional by the analytic framework he is trained toapply. Allan Young, a leading medical anthropologist oftrauma, calls this seduction “the harmony of illusions.” Bythis Young means that the therapist applies an interpretiveframe of traumatic memories causing symptoms, a frame thatcomes to shape the therapist’s understanding of the patient’spost-traumatic experience. Once the condition is describedin terms of repressed or dissociated trauma, the refiguredexperience comes to seem a confirmation of the theory. In fact,it is all a huge tautology. That’s where I was, caught in a pro-fessional loop that left me deaf to Winthrop Cohen’s com-plaint: what was at stake for him was the soul and not thetrauma, the moral crisis and not the Oedipal conflict.

I’m certain Winthrop meant to leave me with a discomfort-ing feeling. He wanted me to feel what he felt: namely, thatwhat he was suffering was not disease but tragedy. He couldnot come to terms with the morality or normality of his ac-tions during the war, and he knew I couldn’t either. He hadbeen remade in a terrifying and devastating way, and yet thosevery qualities later in life spurred him toward critical self-reflection. As I have learned in research from those who havesuffered other forms of political violence, being vexed shakesone out of comforting illusions and can be contagious. It un-dermines confidence in justice and goodness while pressingone to create both in one’s life. It doesn’t necessarily respondto treatment. In place of healing it gives voice to pain andsuffering about the sometimes defeating reality of our lives: aseemingly despairing reality that, when we confront it, can onlybe lived through, we imagine, enduring the unmasterable. Itis exactly here where religion, ethics, and aesthetics remake

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meaning, creating hope. And seen in this way, there is some-thing uplifting about Winthrop Cohen’s ethical framing of hislife and times. There is hope in his moral courage, his grimfidelity to a damning reflection on self and world. There ishope in his implacable commitment to an unblinded acknowl-edgment of having participated in evil. There is hope in hisrefusal to abandon a language of remorse and regret, and inhis lived commitment to the impossibility and yet the unavoid-ability of repentance. And amidst great danger and huge un-certainty, hope is what makes the human condition livable.

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Idi Bosquet-Remarque

all, thin but muscular, her pale skin freckled by the sun,her brown-blond hair pulled back into a severe ponytail

setting off large, soft gray-green eyes, Ida Hélène Bosquet-Remarque, known as Idi, was a French American woman whofor over fifteen years, from 1980 to the late 1990s, worked as afield representative for several different international aid agen-cies and, later, European foundations, first and only brieflyin Southeast Asia and subsequently in sub-Saharan Africa.Idi was an expert in working with refugee and internally dis-placed women and children, and with the local bureaucrats,police, soldiers, religionists, and health and social welfareprofessionals who surround them. I narrate her story becauseIdi was a friend of two decades who represents for me ourfinest impulse to acknowledge the suffering of others and todevote our lives and careers to making a difference (practi-cally and ethically) in their lives, even if that difference must

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be limited and transient. I tell her story because of her re-markable moral responsibility for those in deep poverty anddesperate difficulties, and because of her willingness to dogood in the world almost anonymously, without seeking ca-reer advancement or public attention.

Her focus was humanitarian assistance. She worked in warzones, failed states, politically unstable border zones, andplaces afflicted with other, less clearly identifiable forms ofpolitical violence, such as structural violence in which thepolicies of the state and the global powers place the poorestat great risk for premature death from malnutrition, expo-sure to toxins, transmission of highly infectious diseases, andother sources of health inequality. Although she held an ad-vanced degree in sociology from the Sorbonne and anotherin international public policy from the University of London,Idi managed to eschew managerial or policy-level positionsin the central headquarters or regional offices of the NGOsthat have employed her.

Idi’s work took place in Africa at a time when that continent’ssocieties were undergoing tumultuous change. Under the op-pressive regime of structural adjustment policies insisted uponby the World Bank and International Monetary Fund as theirrequirement for poor countries to receive economic assistance,those recipient countries during the 1970s and 1980s were forcedto severely cut public spending for health services, social wel-fare, and education. These policies placed tremendous pres-sure on the poorest peasants and urban dwellers, whileaddicting their countries’ leaders to repeated cycles of heavyborrowing, near bankruptcy, retraction of the public sector,further debt, and further borrowing. The result, abetted by

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endemic corruption among the elite classes, was greater andgreater debt that weakened nation after nation. So when in-stances of sectarian and ethnic strife occurred, there was littleto hold societies together. The upshot was failing and failedstates, states that could not provide for vulnerable citizens orcarry out basic services. It was in this postcolonial contextthat ethnic and regional conflict began to tear apart Liberia,Sierra Leone, Congo, Rwanda, Somalia, Sudan, Angola, Mo-zambique, Côte d’Ivoire, and others. The Rwandan genocide,the repeated famines in the Horn of Africa, and the splinter-ing of the Congo were only the most extreme examples ofbreakdown. There were, of course, relative success stories,such as postapartheid South Africa. But even among the moresuccessful countries, during this period epidemics of AIDS,tuberculosis, and malaria spread out of control. Into this cha-otic situation, nongovernmental organizations (NGOs) suchas Oxfam, Save the Children, Doctors Without Borders, andhundreds of others brought humanitarian assistance frominternational donors. Especially active were internationalgovernmental organizations such as UNICEF; governmentalorganizations such as the Scandinavian, Canadian, and Brit-ish aid agencies; American foundations, including Ford,Rockefeller, and Carnegie; and religious-based humanitarianassistance and medical relief programs. In this swirl of activ-ity, some programs were truly effective, but many, many failedowing to corruption, mismanagement, cultural barriers, anda dismaying combination of donor politics and local politics.It became characteristic for programs to end after running foronly a few years as new projects captured the increasinglyshort attention span of the global donor community, before

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old ones had any chance of being evaluated or generalized.Still, many humanitarian assistance workers stayed on underdire circ*mstances and responded to crisis after crisis—famine,civil war, epidemics of newly emergent deadly infectious dis-eases such as Ebola and AIDS, mass migration of populationsout of war zones, trafficking in women and drugs, destruc-tion of environments and animal populations, and on andon. Idi was one of the thousands of foreign experts whoworked with NGOs in Africa to aid populations in crisis, re-spond to emergencies, and deal with the deep structural in-equalities that placed vulnerable people at great risk. Her skillwas in working closely with local people, doing what shecalled “field work.”

“You know what I mean, our equivalent of ethnography [theresearch method of social and cultural anthropologists].Mucking around in villages and market towns; learning thelocal dialect; living closer to how our clients do, or just a levelbetter than they do, to be honest. Identifying the most vulner-able and struggling to organize supplies, infrastructure, andsupport. Building latrines, protecting drinking water, puttingup tents, vaccinating infants and children. That’s what we doas well as triage medical cases—when there is someplace totriage them to. We also need to locate and recruit part-timestaff. Identify local people who can help out. Keep the policeand army calm. You name it, we do it. . . . Water. Now, that’sas big as food. Burials. Death is everywhere under these con-ditions. But then so are births. I could go on. I get an aw-fully good feeling out of getting things done under trulydifficult conditions when they have a human effect. Stay putfor a few years, then move on somewhere else. . . . Another

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list of problems, another community to learn, another order ofpossibilities. Friends, good friends to make and work with.”

I had known Idi since her college days in the mid-1970s. Iwas a research fellow at Harvard and in the process of mov-ing to the University of Washington, where I would go on tobuild a program in medical anthropology and cultural psy-chiatry until I returned to Harvard in 1982. Idi was a studentat an elite private liberal arts college in Massachusetts. Shehad heard of my research and asked me to be an informaladvisor for her field research and senior honors thesis, some-thing I have done often over the years. Over two decades Igot to know her quite well, and whenever she returned to theUnited States she stopped in to see me.

Idi had a nearly lifelong commitment to working withpeople in poverty and in extreme conditions. Her senior hon-ors thesis was a remarkably mature analysis of ethnographies,that is, firsthand descriptions of villages, neighborhoods, andnetworks by anthropologists who had learned the local lan-guage, lived for one or more years observing local affairs, andparticipated in family life, work, and religious and politicalactivities. Idi’s thesis centered on ethnographies of the poorand marginal in the world’s poorest societies. Most strikingwas the interest she devoted to the ethical implications ofanthropological research among the disadvantaged. Shebravely concluded, much against the prevailing wisdom ofthe time, that it was ethically unacceptable to study those indistress without first providing practical assistance to allevi-ate their suffering. At the time, many ethnographers had astheir goal “scientific description,” which put into practice anideal of formal and usually distant relations to informants as

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well as formal methods of gathering and analyzing data. Theybelieved that if you intervened in the life of your researchsubjects, it would bias the findings. So the idea, strange as itmay sound today, was to avoid being involved in practicalapplications such as health care and social service for the lo-cal community. She was equally suspicious of “witnessing”as an end in itself. She didn’t believe that simply recordingvoices of sufferers and analyzing their stories of distress couldbe an end in itself. You had to act, she insisted, to help people.And she was not alone in her beliefs; she pointed out that thegreat existentialist French writer Albert Camus similarly be-lieved that engagement—that is, being personally commit-ted to others and taking on real responsibility for joining themin resolving major problems in the messiness of local life—was as much about practical action as it was about empathyand solidarity. Idi was also somewhat suspicious of advocacyin research unless it translated solid findings into direct ac-tion. Here, Idi was criticizing social scientists who spoke onbehalf of indigenous people but who either had not carriedout systematic research, or, if they had, did not base their com-ments on new findings. She feared they would usurp the rightof local people to represent themselves, while adding noth-ing new to the analysis of what needed to be done.

Her thesis was based on a half year’s research in an EastAfrican setting, which gave her ample experience to developan informed opinion about each of these issues. I rememberalmost exactly a conversation I had with her, shortly after shereturned from her thesis research, about professional burn-out. Idi remarked mordantly, to my initial surprise, that jour-nalists and even social scientists were placing too much

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emphasis on the suffering of the expatriate staff of humani-tarian organizations. Because they spoke English, were ur-bane, and could connect quickly with foreign visitors, theirstories got told. For example, news reports about southernSudan’s periodic famines often centered on the foreign ex-perts themselves. They are asked what it’s like to work insuch a place and how they can do their work under such“primitive” conditions. Harassed African mothers, holdingdying children in their arms, whom they are trying to feed,only form the background. They are rendered silent by theforeign interviewers. The desperate mothers are good for aword or two, but otherwise they are left outside the conver-sation that goes on with the expatriate aid workers. To Idi’smind this led to an undervaluing of the suffering of the peoplethe foreign staff were there to assist. Idi belabored this point ina manner that seemed to me atypical for her. She criticized theEuropeans and Americans with whom she worked for theirtendency to live in their own world. They were protected fromthe conditions (the filth, the flies, the hovels) of the refugeesand internally displaced. They did not have to share thoseslightly better but still grindingly poor conditions (offices with-out glass in the windows, torn clothes, broken chairs and desks,an absence of writing or toilet paper) that made the lives oftheir local professional colleagues (African doctors, dentists,ministers, teachers) so difficult. Idi targeted what I knew to bereal issues, but her tone was, for a young woman who wascharacterologically sympathetic, uncharacteristically stridentand unsympathetic. This was a matter that really bothered her.

This critique was prelude to an even more troubling con-cern, one that Idi could see directly affected herself. Foreign

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aid workers and their affiliate NGOs received funding andrecognition for projects that they themselves initiated andcontrolled. But didn’t this setup, Idi wondered, contribute tothe problems of poverty and community inefficacy? Shouldn’tit be local workers, not foreigners, who took charge and heldthe principal responsibility for the failure or success of aproject? Shouldn’t it be those local workers who thereforereceived the credit? Because if local people running localprojects got the credit, then those projects might be much morelikely to be sustained.

Since the aid workers were mainly whites from rich coun-tries, there was among them a certain smell of neocolonial-ism, as well as self-serving careerism, by which she meantnot only as a professional but also, she put it mercilessly, as a“saint.” Hence for Idi there was a problem she referred to,mockingly, as “the last white hope.” Perhaps this is the post-colonial equivalent of the “white man’s burden” of the colo-nial era. For Idi, it referred to the not-so-hidden racism bywhich Euro-Americans saw themselves as Africa’s only hope.Any successful program, it was expected, had to be led bywhite people, preferably heroic figures such as AlbertSchweitzer. The humanitarian worker as hero, whether it wasthe product of the imagination of aid workers or of their West-ern audience, made her suspicious.

And yet Idi also could see that without foreign workersthere might be no program at all—not because of some faultof local workers (though she admitted they needed to raisetheir level of professionalism) but because they could not com-mand the financial and symbolic resources required to funda program with economic, social, and political capital. The

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irony of her thesis, Idi remarked lightly but tellingly, was thatshe had found an argument against hiring someone like her.Her first real field experience had, much as she relished thework, undone her future, Idi lightly laughed.

I once had the opportunity in 1989 to observe Idi in herprofessional capacity in an East African country known atthe time for its corrupt bureaucracy and its dismal results fromnumerous assistance programs. There I watched her put intopractice much of what she had previously written about. Shewas also, under these trying circ*mstances (scarce funds, lim-ited staff, political problems from organizing assistance forpoor women in a marginalized and illegal squatter settlement),rather impressively effective—meaning she did more than justsurvive against the odds and actually had organized a seri-ous program, small but with clear evidence of some success.The program provided food aid, clean water, latrines, low-level health services, and protection to migrant women andtheir children. I spoke with several of the desperate peopleshe assisted as well as with her local colleagues, and cameaway, after an admittedly brief evaluation, feeling that Idi haddone something unusual.

I remember one terribly thin African woman with whom Ispoke about Idi. She told me she was thirty-five, yet she lookedmuch, much older, with streaks of gray in her black hair. Herface was lined with two rows of tribal initiation scars on eachcheek. She wore a colorful green dress with a yellow ribbonaround her neck. She had several small children, who, de-spite their tattered clothes, looked reasonably healthy andlaughed loudly while they ran around outside the wood framebuilding they shared with other families near a pit latrine and

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protected water source. This woman said that she owed herfamily members’ lives and her own to Idi. She wept whenshe recalled: “We arrived with nothing, and people here triedto take advantage of us. This program saved us. And this pro-gram is Idi. We feel like she is one of us. She’s not like theother officials. They are cold and distant.” I was so taken bythe obvious heartfeltness of her expression I wrote it downand included it in a letter praising Idi’s efforts to a senior fig-ure in the organization Idi worked for at the time.

Idi and I walked around a shantytown housing thousandsof migrants. They illegally occupied the land and put upshacks of cardboard, cast-off metal, and sticks. The govern-ment had decided on a political strategy of ignorance. Thesepeople simply did not exist in any official way. So they re-quired neither piped water nor sewage disposal. Childrenplayed in the dirt streets, which were slick with raw sewageand littered with broken bottles. Idi told me that when it rainedthe streets became streams of mud and fecal matter—a placeof such contamination that recurrent diarrheal disease andskin ulcers were omnipresent. The infant mortality rate wasfive to ten times that of a nearby middle-class neighborhood.Standing around on the corners of dirt tracks with enormouspotholes, men and a few women with dazed expressions heldjars of home-distilled spirits. Alcoholism, Idi demonstratedwith specific family examples, worsened the grinding of eco-nomic wretchedness. Intoxication intensified domestic vio-lence, which in turn, Idi posited, led to depression, spasms ofrage, agitation, and suicide.

“Hopelessness,” she explained as I furiously scribblednotes, “is endemic here. What we are doing is helping the

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more active, effective women to organize community pro-grams to protect them and their kids, and to try to rehabili-tate the men.” We visited one family in a jerrybuilt shack. Theyoung wife and mother held an infant she was feeding, whiletwo older children played on the dirt floor. So poorly venti-lated was the shack that I had trouble breathing. The stenchof rotting food, garbage, and feces was strong, the heat fero-cious. Flies covered the walls. The children had thick green-ish mucus running from their nostrils, and one had a deep,rasping, productive cough. Idi spoke to the young mother inKiswahili. She told her about the community clinic wherepublic health nurses supported by Idi’s organization couldtreat the children without charge. The woman looked ex-hausted. Her husband was in the hospital with tuberculosis.She had no family or friends nearby to help her. She explainedto Idi shyly that because she was desperate she sold herselffor sex to various of the men who stood drunk or druggednear the shack. Idi cautioned her about STDs and HIV/AIDS,but it was clear the woman already knew about the risk. Shesimply could not demand safe sex from customers who re-fused to wear condoms. Idi was already organizing localnurses to develop a more substantial AIDS prevention project.She tried to enlist this woman, but the woman prevaricated.Idi later told me that there was a stigma associated with AIDSthat spread from infected people to local AIDS programs, andas a result, her clients were reluctant to join.

After we left the shack, Idi remarked that this program wasone of several new ones she was initiating. Idi seemed verytired. She turned to me and whispered that it was when shesaw what terribly poor young women like this one were up

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against that she began to despair whether it was possible todo anything useful.

I asked Idi how she did it. How could she find the stamina,perseverance, and commitment to respond to such over-whelming conditions? How in the midst of global epidemicsof substance abuse, related violence, HIV/AIDS and otherdiseases, and structural inequality could she succeed?

She responded with a twinkle in her eyes and a sly smile:“Don’t go and overestimate our success. Just keeping clientsalive and staff going is a kind of success. But how do we doit? What’s the alternative? Give up? Shut down? Run away?Once you rule those things out, you do the one thing left todo. . . . I focus on what needs to get done. Which in this casemeans not everything these poor women need, but at least afew of the more crucial things that help them survive andfight on. Which amounts to as much as the damn officialswill let drop through their grasping fingers. Look at the dis-trict officer [a local government administrator] here. He isn’ta bad guy at all, but he can’t even record the displaced be-cause then it would commit the government to actually offerreal services. He’s been told the government won’t do that,hence he proceeds as if the migrants and refugees don’t exist.As I said, he’s not a bad fellow. He is intelligent, has a degreefrom an American university, knows the kinds of things heshould be doing, but he is administratively bound. He can’tact. And if he did on his own cross the higher-ups, they’dnever let him have the resources. Worse still, he’s told to be agatekeeper to the state’s resources. And hey, he has to livetoo—poor soul. His salary is completely inadequate, so he isgoing to look for ways to put some public money aside for

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private purposes. He’s got to, for his wife and kids. He reallywould like to do something, but he can’t afford to. I call that aplus. He’s a potential ally. He just doesn’t know it. I’ve workedwith much worse. . . . I give him and those who aren’t asenlightened and well-meaning as he is the strong impressionthat I’m going to get these people who are sick, starving,scared, living on the street and in the shacks at least some ofthe things they need. . . . ‘Don’t lecture me about the regula-tions, which I already know and you know I know. Don’t hidebehind politically correct talk. . . . For God’s sake, listen tothese poor people; these women know what they need; theymay just have the answers. You know it’s not as difficult asyou make it seem; even under these pitiful conditions, youcan do good. I can be easy to work with. I won’t be in yourface. No threat. No problem. Hey, you can take the credit.You might even come out looking like a winner. If this pro-gram is going to succeed, if these desperate people are goingto succeed, you need to get something out of it too. I won’tstop you. But don’t, just don’t avoid me. Don’t brush me off.I can help you, but if necessary I can bring you trouble too. Sofriend, let’s get it done!’”

Tough words spoken with a hardheaded realization of theart of what is feasible. But the voice was soft and also carriedwith it the hope of what is possible. The professional exper-tise and personal conviction, both formidable, were carriedso lightly and with such good humor that the message wasnot an unattractive one.

Idi didn’t exclude herself from the searchlight of criticism.“You know, out here I feel I have at one moment or othermade every mistake. Yet in the end things work out. Oh, not

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everything, but more than you might imagine. More oftenI’m the problem, or my program is. I’ve even wondered para-doxically if you need to be a ‘problem’ to accomplish any-thing substantial. If we don’t break the business-as-usualroutine, we don’t get the attention of the power holders, andwithout their attention little can happen. But I’m not here tobe a culture broker. It’s too late for that kind of mediationbetween local and outside interests. We need to act. So I act asif I were a local player. Of course I’m not. But if I pretend tobe one, I sometimes can make things happen. Of course notalways for the best. And when you act like a local you hadbetter be prepared for the same rough treatment these womenexperience. I’ve had that happen too. What I mean is that youneed to act locally but keep some of the clout of an outsider. Inever get the balance exactly right. And I’ve blundered badlywith real consequences. But if you don’t risk it you becomelike so many of my peers, a stock player who can be manipu-lated. On the other hand, when I fall off the balance beam,which I do from time to time, there is a big noise and a bigmess. I did that with a needle exchange program that was, ah,a little ahead of its time and without the proper license, a pro-gram to protect battered wives that was, well, licensed but per-haps a little excessive in hiding women from their husbands.”Idi had learned from these and other misadventures that ne-gotiating with the local political leaders was crucial.

To be effective she fashioned a simple strategy: she oftentraveled with an entourage of migrants and locals who sawher as their spokesperson when dealing with the administra-tive apparatus of the state. Because of their support, state of-ficials could not dismiss her as a foreigner meddling in things

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she didn’t understand. The cachet (communication channelsand cash) of the institutions Idi represented gave her themeans to make things happen, including at higher levels ofthe local political economic system. In one instance I observed,this combination of local voices and external power createdassistance for several displaced families who were homeless,with the promise of more to come for a larger group of womenand children. In that case, Idi threatened a visiting social wel-fare official who worked in the ministry that if he didn’t par-ticipate in a meeting in the slum, which he had told her wasimpossible for him to do because his ministry did not recog-nize the existence of the slum, she would bring together theforeign representatives of the major NGOs and take them tosee his boss. In such a meeting, she promised, she would criti-cize him so that his job would be in jeopardy. But once thisofficial met with her clients, Idi stepped back and let themraise specific demands for better housing and financial assis-tance for their children. She had rehearsed these women; nowshe stood behind them. Once the meeting ended, she wentout of her way to be supportive and nice to the ministry offi-cial. Nonetheless, Idi recognized that her affiliation with asmall European NGO and her lack of wide recognition re-stricted her work and limited her successes.

“I don’t delude myself. I’m not the UN High Commissioner[for Refugees]. I’m not even the major local coordinator. Iknow I represent a relatively small organization with just afew programs of limited scale. At first it imposed a terriblesense of restriction that made me uneasy. How can I justifyhelping only a few? But now, years into it, I feel more at ease.It’s a more human scale. We know our clients. Invest in them.

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Follow them up. They mean something to us as real people.They are never just a number. I feel like nothing is perfect inthe world. You do what you can with what you have. WouldI like to do more? Of course. Can I live with the limits? Yes, Ican. Well, not when I see so many desperate faces. But yes,definitely yes, when I work with those people I can help. Mypolicy training tells me I got it all wrong. But my lived expe-rience in this place tells me I’m doing okay.”

The more I spoke to Idi the more she had to say about thistension between what was good from a programmatic per-spective and what was good from her own more complexlyhuman, on-the-ground experience.

“When I was a student it [the plans and strategies for run-ning a successful program] seemed clearer. Now things aregray most of the time. The more I get to know the people weassist the more complex they are. Few are simply victims.Some were also perpetrators . . . even in the same family. . . .You hear stories of betrayal. How often am I told not to trustor believe others. It can get awfully confused and paranoid.Corruption is an instance too. When I started out I could smellit like rot. Now I don’t recognize the odor so easily. Is thepoor DO [district officer] corrupt because he tries to makefinancial gain out of our programs so that his family can eatbetter? After all, the government assumes he can’t live on hissalary, which is meager, and that he will supplement ‘creatively.’If the sums are small, and it’s not outright theft, I tend not toget in a huff. It’s when you see the higher-ups squeeze andgrind people to live like the proverbial fat cats that I get reallyupset and blow the whistle. I have only the greatest disdainfor those robbers. Their greed is so destructive. Otherwise I

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have come to accept we all need to muddle through somehow,and muddling can be a very thin space from corruption.”

Idi reserved her most devastating criticisms for the higher-ups in several of the NGOs and international governmentalagencies with whom she has worked. “They can’t keep theirhands off micromanaging what we do in the field. They oftenhave little sense of what our on-the-ground problems areabout. They have usually formed their policy decisions evenbefore they talk with us and see the programs. They are un-comfortable in the extreme with our clients. Maybe they fearcatching some infectious disease. I know I sound satiric, butbelieve me, that’s how some of them really are. In New York,London, and Paris they dream up new objectives, rewrite ourcharge, spend money on nonsense. Every year we’ve got tohave a new theme to catch the attention of the media. Newbuzzwords. Everything is spun by these guys to make publicrelations pizzazz. I think they test them on politically correctspeech: how else to explain their sterilized jargon? I’ve had acouple try to mess with my programs. It made me very cynicalvery fast. And cynicism is the kiss of death in this business.Better to move on to some other posting than to wallow incynicism. I watched too many good people end up that way.I’m no romantic—you know that—but you’ve got to keep somekind of vision of what genuinely ought to be if you’re going towork in this profession. You don’t have to buy all the humanrights talk, so much is flummery. But you do have to commityourself to helping people in distress. And that requires somekind of belief in the prospect of a different kind of world.”

Idi enunciated these words with a light laugh and soft playof irony in her lively features, as if to undermine too defini-

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tive a critique of the humanitarian assistance community. Shehad come to be uncomfortable with taking too definitive astand on her field because she had increasingly come to see itin the more complexly human terms of real individuals strug-gling to save highly particular programs that are a mix of suc-cesses and failures. Still, the foundational commitment in herlife to the desperately poor came across with passion.

Idi was well read on the issue of women and develop-ment. She could cite facts and figures on women’s lives inthe developing world in regard to female infanticide, sexualabuse, genital mutilation, slavery, violence and trauma, aban-donment to poverty, lack of health equity, and witchcraftaccusations. The effects of patriarchy were starkly visible inher workaday world. Nonetheless, she was well balancedin discussing the subject. Most of the officials and technicalexperts with whom she worked were men, even thoughwomen were becoming more prominent. With these malecolleagues her easy elegance was visibly attractive, and Idiwas not unaware how useful this could be in her profes-sional work. Her personal life was private, off-limits to thosewho were not good friends. She did this to protect herselfand maintain clout within a man’s world. It provided her,she told me, with a certain mystery and charisma, whichwas crucial in her work. She had had several close malefriends, one of whom was a European journalist and anothera South Asian artist. Idi never expressed an interest in mar-riage or children. She had perhaps a dozen close femalefriends whom she referred to as her “international love andsupport network.” She often stayed with members of this“ILSN,” as she called it, when she took leave time abroad.

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Two were well-educated African women. They had becomeher closest friends.

Idi spoke with great fondness of her own family: a FrenchAmerican father who was an international investment banker,a French mother from a wealthy family in Burgundy who wasa medical researcher in Switzerland. A younger sister was aphysician with an international NGO in the Middle East, anda much younger brother was studying music at a French uni-versity. “My father’s parents were poor. They immigrated toAmerica after the war in 1946. They had family in New Yorkstate. There was also a political problem. My grandfatherwasn’t exactly an official of the Pétain government, but hehad done something; he was a collaborator, maybe not a realwar criminal, but from what I can figure out, something prettyclose to that. Anyhow, they had to leave.”

An East African colleague, himself a successful leader ofsmall community projects, who knew Idi and respected her,despite often being hard on foreign experts in Africa, con-fided: “Idi is special. You don’t see many like her. She fits inlocally. Or at least tries to. She lives, more or less, on the localeconomy. Doesn’t stay in fancy accommodations. She has lotsof friends among the people she works with. She doesn’t hangout after hours with expats. In fact, her best friends are twoAfrican women. Speaks Kiswahili, not fluently or even verywell, but bravely. She uses it. Listens and speaks with it. Peoplereally appreciate that. As a result, she learns a lot that otherrepresentatives of international NGOs just don’t get. Of courseshe is like a lot of people in humanitarian work: thoughtfuland sympathetic. Idi, however, is also incredibly astute po-litically and culturally. And best of all she is calm, selfless,

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and just very positive. Africa is not a basket case to her; Afri-cans are not ignorant or incapable. She knows colonial historyand postcolonial theory, better than I do. But like everythingelse she travels light. No posturing. She also possesses a kindof natural touch for collaborating with all kinds of people andinterests in order to [make] really bad situations less danger-ous for women and children, to protect them.”

And that’s how I saw Idi too. She had made an irrevocablecommitment to live among the poorest Africans as a friendand fellow member of the community, and to do all she couldto help them. She was motivated by a passion for social jus-tice and by an unwillingness to accept things as they are,which would have condemned these people to the most mis-erable social disparities. There were deep roots to this extraor-dinarily difficult but inspiring commitment. She kept alivethe image of her grandfather’s collaborationist past and workedagainst it. Everything she associated with him—collaborationwith evil, racism, failure of moral vision and responsibility—she sought to reverse in her own life. She drew on her family’sCatholicism, and especially liberation theology, for the prior-ity it gave to the suffering of the poor as the grounds for so-cial justice and personal salvation. She had read, in the originalFrench editions, the writings of the Parisian ethical theoristand Jewish theologian Emmanuel Lévinas. His ideas becameher ideas: namely, that ethics precedes everything else; thatethics itself requires face-to-face relations; that suffering isuseful only in the response of the other person to the personin pain, making empathy the central ethical act. Absent thisethical response to local people and their problems, policiesand programs were untethered to real lives and actual worlds.

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They would be unlikely to succeed either in human terms oras practical projects. Idi persisted in her work. She stayedwhen other foreign aid experts departed. She connected withpeople at a human level deeper than program protocols.

It was because of the stability of this picture of Idi Bosquet-Remarque over so many years that I grew so concerned atour last meeting in 1997. Idi telephoned from the airport inGeneva, Switzerland, to tell me she was on her way to Bostonto see friends and wanted to see me as well. This time, shesaid she needed my clinical advice. Those words surprisedme, because she had never before made such a request. Wemet in my office at Harvard for several hours, then had lunchtogether, and afterward walked slowly around Harvard Yard,back and forth on a chilly gray fall day with the trees in splen-did colors, before returning to my office.

Idi all of a sudden seemed a disturbingly different person.The twenty-two months in West and Central African warzones had taken an enormous toll. Both zones of violence werechaotic, shifting from week to week with different groupsfighting for unclear and changing reasons. Civilians were thetargets of brutal and deadly attacks. As a result, large groupswere in movement, attempting to escape the widespread de-struction. Idi had been assisting these uprooted groups ofhungry, frightened, and sick families.

Idi’s face was thinner and, most notably, her facial expres-sion had changed. Gone were the lively expression and ironicsmiles. Her face now looked immobile, the muscles taut, hergaze fixed in an expression of grim seriousness and hyperalertfocus. While Idi spoke, her eyes looked directly into mine,her own unblinking. The contrast between their soft warmth

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and the hardness of her expression was striking. That con-trast radiated a sensibility of disappointment, loss, and in-jury mixed with alarmed responsibility. The feeling I tookaway was that here was a woman who had seen too muchand been asked to do too much. Yet even now she seemed tobe steeling herself for things to get worse, creating an aura ofvulnerability that I had not ever before seen in Idi. She toldme that over the last two years she had gone through terrify-ing encounters that had left her feeling drained and pushedagainst the wall. Up until this point, whatever emotions offrustration and failure she had felt had been transient. Theywere quickly sublimated into amused irony and soft, self-effacing criticism. But Idi now spoke as if her former confi-dence had dispersed, and along with it her hopes about herwork and the world in general. She seemed bereft of her can-do optimism. In its place were grim emotions of loss, fear, anddemoralization. These feelings mirrored grim on-the-groundconditions. In Sierra Leone, civil conflict, which had been go-ing on since the early 1990s, seemed interminable. The mili-tary forces of the government competed with different rebelgroups as to who could do greater damage to villages andtowns. People were mutilated or killed, families broken apart,agricultural and market systems destroyed. Liberia was ineven worse condition: the society, not just the state, was bro-ken. In eastern Congo, the aftermath of the Rwandan geno-cide in 1994 sent large numbers of diverse groups into therainforest. There were distinct militias, uprooted civilians, andRwandan, Congolese, and other militaries. Their presencefurther destabilized this already highly decentralized region,so political control shifted frequently. Towns were occupied

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by one group of troops one month and then by another armedforce the next. Violence was everywhere.

My concern only intensified when Idi observed, “I think Inow have discovered how so many of my co-workers andpredecessors became numbed. How people burn out and getout. It’s pretty awful, really. Terrible, in fact. I was held atgunpoint not once but three times. I was repeatedly threat-ened. That’s happened before. But not like this time. This timeI thought I was going to be killed. I witnessed atrocities be-fore. But not so many. Or with such a feeling of inadequacy.Sometimes it felt like nothing could be done. One side is asincapable of stopping as the other. And indeed there are al-ways more than two sides. Everyone on the ground is complicit:the politicos, the militaries, the police, even the refugees. Oneminute you see a cute little kid, the next minute he holds anautomatic rifle to your head and you feel he could care lesswhether you live or die. Even the UN people and the NGOsseem near helpless. So many are demoralized. The killings,the mutilation, the cycles of revenge, cease-fire after cease-fire, all the broken promises, wasted money, failed programs. . . the whole thing is rotting away. It is hyperdangerous,hypercorrupt, hyperthreatening.”

Idi recounted fragments of her memories of the violenceand destruction. In one town in the Congo, she had estab-lished a program for displaced women and children. When anew military force entered the town, all the women and chil-dren were forced to leave at gunpoint. Several days later afew women returned and reported being beaten and raped.In another market town, all the money Idi had brought in topay for supplies and food was taken from her at gunpoint.

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On yet another occasion, she barely avoided being beaten byCongolese government troops who were enraged over theirlosses in a recent battle and blamed her NGO for providingsupport for the militia they were fighting. Although sheavoided being hurt, she had to resort to outright bribes tosurvive, leaving her with a profound sense of dismay.

“Never before have I had so much trouble controlling myreactions. I don’t know if I know how to go on. My inside isnumb and cold. I know I’m angry, very angry. But it’s not likebefore. No hot rage. It’s a cold, soul-freezing thing. Dead. Ifeel like part of me is dead. I feel my will is draining away. Afailure, a f*cking failure.”

Here Idi was referring to the forced discontinuation of sev-eral of the programs she had started. She felt she was unableto provide support or protection for displaced families in greatneed. The core work of her NGO had stopped, as had that ofthe other NGOs. It was just too dangerous. The failure of hermission made her feel she had failed, so complete was heridentification with her work.

Idi pursed her lips and stared at me. Her eyes grew moist.I felt as if she were staring straight through me. She seemedexhausted and lost. I sensed she might break down. I hur-riedly (too hurriedly) suggested she take time off. Get away, Itold her. Rethink this disaster and your role. Maybe do some-thing else for a while as you sort out your options.

Idi just continued to look at me, unblinking. Then she bither lip and wrinkled her nose into an expression of distaste.“No! I’m not going to run away. There are people, lots ofpeople dependent on me. My NGO has a lot at stake. I can’twalk away from that responsibility. I guess I’m talking to you

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about this stuff to find out what you can do when you feelnumb and defeated but know you must go on. I don’t knowwhat will happen. Maybe this is the beginning of the end.But I need you to listen. There are lots of us who feel this way.I’ve read about post-tramatic stress disorder (PTSD) and wehave all sorts of mental health people coming through. Someof the ones specializing in PTSD sound like used-car sales-men giving a pitch for a car that’s got problems. I’m not con-vinced. I don’t feel like I have an illness. This is, well, despair,I guess. I spent years learning what needs to be done to helppeople in desperate situations and how to do it. And here thesituation is so bad, I feel desperate. We all do. Nothing seemsto work. But that’s too black and white. It’s not exactly right.A few things look promising. Then conditions change, and . . .they don’t look so promising anymore. Right now nothingdoes. But I sense things could change.”

Idi was referring to a particular relief program she had beenasked by her home office to discontinue because of the sever-ity of the violence. She had disregarded the order and keptgoing. For a while the program had seemed to be stabilizing;then a new militia took over whose leaders simply shut heroperation down. There was such a back-and-forth in the con-flict, however, that there was a possibility one of the militiasshe had worked reasonably well with could soon regain con-trol of this area, and her program would be up and runningagain.

“It is just damn exhausting. You can only be frightened forso long before you begin to feel, f*ck it, let’s admit we don’tknow what to do. Nor does anyone else, it appears to me. Soit’s time not to wallow in misery, but to pull back, regroup,

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rethink, but not get out. We need help from people like you[here Idi meant my psychiatric role] to deal with the numb-ing, the demoralization. But I’m going back. Actually, it’s as-tonishing: a fair number of colleagues have gone through thisthing and gone back. But first I need to work out what I cando better. How to assist others. That’s what it’s about at heart.My life gains its meaning from this work. The people needme and I need them, I guess. Now I must do what job I can.To do that I need to find a way out of this . . . a road out of thisdesolation.”

We talked for long time, or Idi did. I knew my job was tolisten, to give her space to say all the things she needed to getout. The theme of desolation—in the sense of wretched isola-tion, dejection, anguish, and despair—wove its way throughher words. She asked me if she was depressed in a clinicalsense. I said no, I didn’t think so. She asked me if I would stillrespect her if she couldn’t go on with her career. “Come on,”I remember saying, “I respect you more than just about any-one. It won’t change if you can’t go back to that horrendousplace. In fact, I don’t want you to go back. I’m afraid some-thing could happen. You could be seriously injured or killed.Please, you’ve done enough. Either wait until it is safer orleave for good now!”

Idi asked me what I thought was wrong with her. I told herI wasn’t going to give her a psychiatric diagnosis. “If you re-ally want to know, I think you are demoralized,” I told her.“Not in the sense of depression, but in that of a moral crisis.You feel the burden of responsibility for your programs andyet you don’t see clearly how you can carry out that respon-sibility. You don’t see a way forward for yourself and your

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programs, yet your work matters more than anything else toyou. And you have done more than could be asked of any-one, but it isn’t enough, is it? So what are you doing? Payingback your grandfather’s moral debts? Liberating your soulby washing the feet of the most despised? Getting ready forsainthood?” I tried to shock her into rethinking what she wasdoing. We went over and over the same ground. Then Idi gotup from the old Harvard chair next to my desk and reachedacross to me, kissing her fingers and placing them on my fore-head. “You don’t know any more than I do, do you? But I cansee the love in your eyes and hear the great concern for me inyour voice. That’s what I came for,” she said, and this time afaint smile spread slowly across her freckled cheeks. “I knowwho I am here. Maybe I am working out family guilt andliberating my soul. So what? I take your point: it is a moralcrisis. How to live a moral life? I once thought I knew. I don’tnow. I need to find my way again. Don’t worry about me.”These last words I didn’t write down. I didn’t need to. I canstill feel them inside me.

I walked out of William James Hall together with Idi,crossed Harvard Yard, and waited as she got into a taxi at thequeue in the square. Then she gave me a big, big smile, andthe taxi pulled away from the curb and turned west towardBrattle Street. My feelings were tumbling. I felt reassured andempty at the same time. Maybe desolation is contagious, Imused. Or maybe I just saw my moral exemplar disappear,and I need to rethink who I am. What does it mean to live amoral life? After all, what really matters? Out of that last en-counter with Idi and those unanswered questions came theimpetus for this book.

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And so, after a brief rest period with friends in western Mas-sachusetts, Idi Bosquet-Remarque—shaken but reanimated—went back into the conflagration. I followed her reimmersionthrough mutual friends. At first, she veered between losingpurpose and giving in and starting over anew with yet an-other action project. Finally, she steadied herself and rebuiltone of the programs she had initiated earlier, which had beenoverrun and temporarily abandoned. Along with her renewedsense of confidence and purpose, Idi’s passion and sense ofinjustice returned. She wrote me a note about her anger to-ward media figures who helicoptered in and out of dangerzones for hour-long photo opportunities without experienc-ing what she took to be the defining reality: the effort to existday by perilous day in the midst of chaos. She also describedher renewed admiration for those who could not helicopteraway—the displaced and the local populations, includinglocal experts. Despite the extreme hardships and uncertainty,they had to find ways to keep going and recover. She passeda message to me through a mutual friend that she had hadthe dubious pleasure of falsifying her college thesis’s theorythat aid workers didn’t have to experience the conditions lo-cal people did and hence lived a kind of morally false life thatwas unsustainable. It was bloody difficult to be a foreign ex-pert, and you were not protected emotionally, physically, ormorally from the great dangers around you. As in so muchelse of living, she explained, there was no single pattern.People experienced life and worked their way through eventsdifferently. Trauma was real and consequential, but no onecould say how it was some people remained strong while oth-ers crumbled, how some professionals stayed to face the

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struggle while others escaped, defeated. She had been wrong,she wanted me to know, to downplay in her thesis the impor-tance of burnout; but she was also wrong, she now held, notto have recognized multiple outcomes. She insisted that pro-fessionals, like laypersons, are not necessarily best viewed aspassive sufferers. Both are active agents who rework suffer-ing, like so much else in life, into their own lives, private andprofessional. What mattered most was commitment. If youhad it, you could stick it out; when you lost it, it was time toget out. I never had an opportunity to ask Idi to expand orclarify this point. So, like much in my life, it is a fragmentburied deep in me that periodically irritates and needs to bemassaged and thought through. Amidst great dangers andhuge uncertainties, Idi seemed to be telling me, she had foundwhat mattered most, and it was commitment to be there, forand with others who were in greatest need. Whatever its sourceor its consequences for her life, that commitment counted most;it was what she was, and what she felt she had to do.

Idi Bosquet-Remarque completed another year in Africa,returned to France, and moved to Switzerland to take up atemporary post with a European NGO. She was driving arented car on a mountain road in winter in the French Jurawhen her car skidded and she was killed. It was a shock to allwho knew her.

Later, when I told Idi’s relatives that I intended to tell herstory in a book I was writing, her mother and sister requestedthat I not reveal the family’s identity and that I also alter someof the details of her life to protect her and their anonymity.“That way,” her mother confided in our final telephone con-versation, “you will honor what she believed in. Not saints

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or heroes, but ordinary nameless people doing what they feelthey must do, even in extraordinary situations. As a family,we believe in this too.” Her sister offered a long lament thatended with this encomium: “She was so splendid . . . in herwork and her being. Everything she did carried with it beauty.She was beautiful in action—a kind of moral beauty. And youknow others sensed that, and it changed them. We’ve receivedsome wonderful letters from her friends and colleagues inAfrica and Asia. One was written by one of her very bestfriends, an African woman whom Idi visited from time to timeto refresh her spirit and just have fun. I’m holding that letterin my hands just now. It reads, ‘Will the programs shestruggled so hard to build and save last? Who knows? Maybenot. Did they make a huge difference in what is happeninghere? No, of course not. How can a single person hold back aflood? But did those programs make a difference for somepersons: yes, indeed, they did, they do. Will we miss her?Very much. Will she be remembered and will that memorymatter: Yes! Among my husband’s people there is the idea thatthe ancestral spirits can include outsiders, like foreigners, whocan become a powerful source of energy and efficacy in thelives of present and future generations. I feel Idi is one of themand that his relatives must propitiate her spirit via rituals. Ihave requested that and paid for the rites. So soon she shall behere again among us, helpful as usual, beautiful as usual, livelywe hope as ever, doing good in the world.’”

Idi was remarkable because she was so serious in her com-mitment to assist people in danger. Idi regarded her own des-peration as an accurate reflection of what most people on theground were experiencing: the personal trauma of a public

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crisis. She worked in countries where the state had failed.There was no organization of services. Public order unraveled.The processes that define a functioning economy—buying, sell-ing, traveling, farming, fishing—stopped. Going outside tocollect firewood or drinkable water was a life-threatening task.The complete absence of social control gave rise to impunityfor those who resolved feuds and rivalries with violence. Inthis setting there simply was no official presence—even a cor-rupt one—to negotiate with. Nothing that had broken gotfixed. Terror was everywhere. The UN system and NGOs,worried about the safety of their staff, pulled out field work-ers and abandoned programs. Chaos was everywhere, thickon the ground.

Another field worker for a humanitarian assistance initia-tive described living and working in such countries in thestarkest terms: “The saliva dries up in your mouth. Your heartis racing all the time. You imagine gangs of thugs and merce-naries coming after you. Your local staff melts away. Whocould blame them. But it leaves you terribly exposed. Yourheadquarters wants you out of there, now. But really it’s toolate to get away, and even if you could, you know that yourpresence—thin and insubstantial as it is—may be the onlything separating the people you are there to protect frommassacre. Try to run away from that one and think of whathappens to any sense of decency and professionalism thatguides your identity. It is the most godawful feeling. There isnothing, it seems, that you can do, but to leave is to maybemake things much, much worse.”

He went on to say that when the killing started in a refugeecamp in Sierra Leone where he was stationed, even this senti-

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ment gave way to sheer terror and an almost reflexlike re-sponse to save himself first. I asked him if he had stayed afterthat. He looked hard into my eyes, then tears formed in hisand he said no.

WHERE IS THE OUTRAGE, the demand for justice? Where is theimpulse to assist others? Where is the commitment to doinggood in the world? Idi’s story, sad as its ending is, is about alife devoted to another image of what the world is like orcould be like. As a college and medical school teacher, I havemet more than a few students who started out with Idi’s ori-entation. Over time most drop out as career and family con-cerns lead in entirely other directions. Yet some—a surprisingnumber, in fact—stay the course and build lives like Idi’s. Theyare vulnerable to the same moral experiences that so pro-foundly shook Idi. They rarely surface as moral exemplars(though a few, such as Paul Farmer and Jim Kim, do) becausethe media prefer a different kind of survivor and hero, a glam-orous figure who dramatically triumphs against the odds ina clear-cut success story that brings lasting results.

And yet generation after generation have made this moralcommitment, from the YMCA movement at the close of thenineteenth century through the Peace Corps volunteers start-ing in the 1960s and those today who work for internationalNGOs concerned with humanitarian assistance, medical aid,and human rights. These brave individuals take significantrisks and commit themselves to causes that make their livesmore difficult and volatile than they would be otherwise.Many experts in postcolonial studies believe that individualssuch as Idi and humanitarian assistance in general actually

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deepen the very problems they seek to address. The humani-tarian aid workers, either out of naivete or active collusion, itis claimed, camouflage the harsh consequences of the globalpolitical economy by suggesting that traditional values andforeign idealism will win out in the end. The focus is turnedaway from the political and economic processes that createsuch serious social problems as extreme poverty, systematiccorruption, and political violence, sidetracking questions ofland reform, improving access to education, providing effec-tive health care and public health services, and replacing thecronyism and corruption of patrimonial politics with repre-sentative government and a free and critical press. Concernwith the plight of particular individuals and families distractsfrom the proper focus on societal problems of inequality anddestitution. What is more, these critics of humanitarian assis-tance argue, the values imported by the agents of humanitar-ian aid may subvert the agency of local communities andreplace local moral experience with global commitments—such as the politically correct overemphasis on individual free-doms and the overvaluing of a culture of consumption—as away of fostering not just Western power but Western moralsuperiority. The foreign institutions set an agenda that worksfor their purpose but may not work for individual countries.Indeed, the expatriate agenda may deepen social problemsand make their alleviation more difficult. And expatriates maybe as corrupt and corrupting as local power brokers.

Idi was not unaware of the bite of these criticisms. She her-self referred to them and believed they were partially justi-fied. But only partially. It was the quality of the humancommitment to others in deep distress with full awareness of

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the moral complexities of that action that stood for her as thedefining act of solidarity and practical assistance. It is a mat-ter of what you see (or choose to see), she said, what you feel(or do not feel), what you end up doing (or find yourself notdoing), how you practice living and what demands you makeon where the world has (and can) take you. It is a matter, shewent on, of what you can say back to the world and do in re-sponse to the world. It was her unselfish, admittedly difficult-to-defend, but perhaps still not entirely impractical conviction,tempered by wariness about unintended outcomes, that theworld can be, must be changed. Her life demonstrated thatthis is what really mattered to Idi. And Idi herself matteredgreatly to the few people who knew her well, including me,because, in the words of her sister, of the moral beauty of thelife she envisaged and struggled to sustain.

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Yan Zhongshu

o survive in China you must reveal nothing to others. Orit could be used against you. Use only indirection and . . .

ambiguous language. Sometimes you even should block yourown thoughts, because you know at those terrible times youcan’t trust yourself. You might betray yourself and others.That’s why I’ve come to think the deepest part of the self isbest left unclear. Like mist and clouds in a Chinese landscapepainting, hide the private part behind your social persona. Letyour public self be like rice in a dinner: bland and inconspicu-ous, taking on the flavors of its surroundings while giving offno flavor of its own. Too strong a personal flavor and you mayentice others to jealousy or hatred. Some will want to take ad-vantage of what they know to get ahead and hurt you.

“You also need help from others so that no one can blameyou. Strong connections can protect you and may offer ameans of escape when you are trapped by circ*mstances. . . .

“

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But a wife, a child, a close friend can also betray you. In yourheart how can you be sure you won’t betray them too?”

The speaker was Dr. Yan Zhongshu, a slight, white-hairedretired physician seventy-six years of age who lives in Wash-ington, D.C., with his unmarried daughter, a researcher in asmall biotechnology firm. His two sons and their families stilllive in Beijing, the city where they and Dr. Yan himself wereborn and lived most of their lives. Dr. Yan has been in theUnited States for seven years but still does not feel entirelysafe. He remains fearful that his family is vulnerable to per-secution from the Chinese government should he say or dosomething that is perceived as against the Chinese Commu-nist Party. Hence he insists that I use anonymity when tellinghis story: “I don’t want my family’s safety to be damaged.”

I have known Dr. Yan for about a decade, beginning beforehe left China for the United States. We met at a medical con-ference, and we have had many talks, including formal inter-views, most of which centered on the development of themedical profession in China. Some took place in my office atHarvard; a few were in his own home. In the course of thesetalks I learned a great deal about his life. Yan Zhongshu’s storyis salient to this book because it illustrates how history andpolitics and economics shape our moral lives, and because italso discloses that individuals in the worst of times can resistdoing frightful things to others, even if the scope of that re-sistance is limited.

Dr. Yan continued: “I don’t believe what anyone tells meunless they relate it to the actual conditions they have livedthrough. I know. I have had ideals. I have sworn not to followbad models which I have seen all around me since childhood.

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Yet in a bad time, I too was complicit. I did what I had to inorder to survive.

“I imagine the situation has always been present to someextent in traditional Chinese society. Under Communism ithas reached its most intense and awful stage. This is the con-stant pressure everyone in China must feel. . . . No one therecan foretell what will happen next week, next month, or nextyear. For all we know policies could be entirely reversed. Therecould be another Cultural Revolution. You are shaking yourhead but you don’t know. Of course it is unlikely, but no onecan assure you—not with all the twists and turns we havetaken under Communism—that it can’t happen again. Andin a different sense it has happened right now. Our age ofmarket socialism is a cultural revolution of a different sort.What people believe in is reversed.

“You can attempt to read or control the future. But you can’t.Only the Party and your work unit [each large workplace—factories, hospitals, universities—was organized as a workunit, where work and daily life activities were controlled bythe all-powerful secretary of the local branch of the Commu-nist Party] and people with great power can do that. And whentimes change, that is when you get hurt.

“In the years I have lived in America I have gone back toChina three times. The reality of life, even with all the eco-nomic change, is the same. It may be a capitalistic marketeconomy, but they can still go after you. When they do, onlysecrecy, and protection by others in your network, and for-tune will determine what happens.”

Dr. Yan was born in Beijing in 1929 into a small but risingmerchant family, the youngest of five children including three

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sons. His grandfather and father built up an import-exportbusiness with branches in Shanghai, Tianjin, Guangzhou, andHong Kong. From the late 1920s until 1937, while China wasunder the rule of the Nationalists (the Kuomintang, or KMT),the business thrived. Yan Zhongshu’s grandfather first be-came a financial contributor to the KMT and later a KMTmember. KMT-controlled gangs helped the family businessto succeed. Dr. Yan observed sadly, “I don’t know all that wedid for the KMT, but I always suspected it was a lot and muchof it illegal.” After 1937, when the Japanese occupied Beijingand later still invaded other areas of China, including Shang-hai, the Yans began to develop a behind-the-scenes relation-ship as collaborators. (From 1937 to 1945 the Japanese foughtthe KMT and their rivals, the Communists, in a brutal warduring which the Japanese military occupied large parts ofChina and perhaps as many as twenty million Chinese werekilled. The Japanese installed Chinese puppet authorities andforced businessmen, professionals, and other classes of Chi-nese to collaborate. In response, many from the Chinese eliteclass escaped to distant regions still under KMT or Commu-nist control.) The Japanese authorities told Dr. Yan’s grandfa-ther and father that if they worked closely with the occupiersthey would become even wealthier, and threatened to ruintheir business if they did not. At the same time, KMT agentssecretly visited the Yans and warned them that if they contin-ued to collaborate openly with the Japanese they would bekilled. Under mounting pressure from both sides, the entirefamily slipped away in the cold gloom of an early winter morn-ing in 1940, and, led by KMT agents, made their way to Chong-ching, the damp, hilly, riverine city in the remote vastness of

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Sichuan in China’s southwest, where the KMT governmenthad retreated in 1937 to continue the war with the Japaneseinvaders. In Chongching, the Yans were contacted by Ameri-can advisors who eventually persuaded them to use theirnetwork of business agents to smuggle information out of andinto Japanese-occupied territory. In 1945, after Japan’s uncon-ditional surrender following the atomic bombing of Hiroshimaand Nagasaki, and with the surrender of all of Japan’s mili-tary forces in China, the Yans returned to Beijing (then re-stored to KMT control) and resumed their trading activities.But as the conflict between the KMT and the Communists,led by Mao Zedong, turned into civil war and it became ap-parent that the Communists would win, the Yans negotiatedwith secret agents of the Chinese Communist Party (CCP)and began to send money, goods, and information to them.At the same time they kept their KMT ties active. “One of myuncles actually joined the [Communist] Party, but two othersbelonged to the KMT. . . . This was fairly common. You cov-ered all the numbers on the gambling table with your bets. Iabhorred this quality in my family. No ideals. No constancy.Blow with the wind. All that matters is to protect your wealth.In my mind I became a resister to this self-serving mentality.It seemed to me then to represent all that was wrong with theChinese tradition.”

In 1949, the Yans remained in Beijing after the Communistvictory. At first they were warily optimistic about their pros-pects to survive and maintain their lifestyle under the newleadership, which reassured businessmen, professionals, andintellectuals that it would respect private property and otherrights. But they soon heard that the CCP had begun the mass

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killing of landlords, and the Yans themselves began to feelthe squeeze on their resources by CCP cadres. It very soonbecame clear that private property and businesses would betaken over by the state. In 1950, under the subterfuge of visit-ing their Guangzhou subsidiary to handle a business prob-lem, the entire family escaped to Hong Kong. Yan Zhongshuwas in medical school in Beijing at the time and decided,against the strongest family protest (“they tried to bribe meinto joining them and into feeling guilty that I was unfilial”),to complete his schooling and remain in China afterward. “Irejected my family. I wanted to contribute to the motherlandand work with all my might for values that were differentthan the commercial ones my family worshiped—values thatled my family to collaborate with whatever power was incontrol no matter what they thought of it.”

Dr. Yan told me that he believed Communist rule would begood for China because the new government would priori-tize responding to the huge economic disparities, extremepoverty, and political chaos that had created so much suffer-ing for the Chinese. “At first I felt good that I had made theright choice,” Dr. Yan observed. “My classmates and I weretruly enthusiastic about public policies that prioritized pub-lic health and social development. The government put an endto prostitution and with it the epidemic of STDs. They man-aged the drug abuse problem well too. Sale of female childrenwas ended, as was female infanticide. The great migration ofdestitute peasants to the cities could be stopped because socialorder was reestablished. We created one standard of health carefor everyone, at least in the cities. There was this great drop ininfant mortality because of mass vaccination and sanitation.

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The worst social health problems—TB, malaria, encephalitis,schistosomiasis—were coming under control. So were home-lessness and extreme poverty. If you were a medical studentwith a progressive viewpoint—even one whose class inter-ests seemed threatened—you had to be impressed. You know:the century had been China’s shame. We were backward andignorant; even India looked better. We were the sick man ofAsia, and all of a sudden we were becoming something newand stable and promising. We could stand up and face theworld and ourselves with pride.”

But by the mid-1950s Dr. Yan, like most of his classmatesand many other professionals, had second thoughts. Theybecame disenchanted with land reform and urban renewalbecause of the brutality of the Communists’ policy enforce-ment, which involved mass killings, forced expropriations,increasingly radical collectivization, and the imprisonmentof critics and even those supporters who were suspected ofnot being enthusiastic enough. The propaganda of class war-fare had hardened into repetitive abuse of people outside ofthe “red” sectors who now constituted a stigmatized “black”margin of class enemies: erstwhile businesspeople, home-owners, landowners, liberal intellectuals, and members of otherpolitical parties. Restrictions on living conditions tightened withrationing and reallocation of living space. Most irksome wasthe widening gap between the CCP’s ultraegalitarian rhetoricand the actual practices that preferentially benefited the newcadre class, who had their own schools and higher-qualitystores as well as special access to better housing. It seemed toDr. Yan and his circle of friends that the revolution had merelychanged membership in the elite class without doing away

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with it. Certainly, the takeover had not constructed an egali-tarian society, which the increasingly strident political rheto-ric claimed to be the aim of Communism.

In response to worsening political oppression, Dr. Yan sur-reptitiously made his way to Guangzhou, from where, as-sisted by his family’s old network of business connections,he was smuggled into Hong Kong. But once inside this bas-tion of the British empire’s capitalist policies, Dr. Yan did notat all feel liberated. Rather, he became ever more unhappy ashe experienced a colonized society that displayed many ofthe social and economic ills that he associated with Chinaunder the KMT.

“I felt the Chinese in Hong Kong were exploited. My fam-ily, who had collaborated with the KMT and the Americansand the CCP, and had tried to do the same with the Japanese,were doing what they were good at, getting along with occu-piers. There was no idealism at all, just the rush for money. Ifelt very uncomfortable, like I didn’t belong. I thought I feltbetter in China, as difficult as the situation there had become,because at least in China there was a shared sense of under-going hardship for some greater purpose, to build the nation.Socialism was oppressive to be sure, but it was for publichealth, social reform, accessible clinical care—all the rightthings. Capitalism stood for none of this, but rather seemedto thrive on greed, selfishness, and all the other bourgeoisevils I had been taught in medical school to condemn. Herethey all were. And my family was in the midst of it, pushingand shoving for money. I know it sounds foolish now, but atthat time I regarded them as the essence of all that was oldand ruinous in Chinese culture.”

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So, once again against the strenuous objections of his fam-ily members (“they almost locked me up”), Yan Zhongshureturned to China. The year was 1957. The terrible irony isthat this young, idealistic physician from a wealthy familyreturned to China at the very moment radical Maoism wasintensifying collectivization and the use of terror, like thatdeployed by Stalin in the Soviet Union two decades earlier,to control those perceived as unenthusiastic foot draggers,critics, dissenters, and outright enemies of the state. In theAnti-Rightist Campaign of 1957, which saw tens of thousandsof intellectuals, professionals, and people whose class back-ground made them suspect sent to labor camps or prisons,Maoist investigators interrogated Dr. Yan because of his bour-geois background and “overseas problem,” meaning that hehad family in Hong Kong. He came through the investiga-tion without being branded outright a rightist, which wouldhave meant years of stigma that would have put his life onhold, constant criticism, and perhaps time in a reeducation-through-labor camp (a euphemism for China’s gulag of re-mote concentration camps for political prisoners), but he wasunder a pall of suspicion, viewed as potentially unreliablebecause of his family’s involvement with the KMT and moveto Hong Kong. “Had I received the label of a counterrevolu-tionary, as did several of my classmates, it would have meantprison, maybe a labor camp, or even a bullet in the back ofthe neck. Being a rightist outright would also have been prettybad. Being a suspected sympathizer but not wearing a politi-cal cap, I was suspect and a target for criticism. I couldn’t jointhe Party or advance my career professionally, of course. Butafter going through criticism and reeducation meetings—lots

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of them—I was allowed to continue as a doctor, though de-moted from research to ordinary practice. That was okay withme. I enjoying seeing patients and was good at it. The reallyhard part was when my girlfriend was forced by her cadrefamily [cadres are local political officials] to renounce me. Thatmade me feel bitter at the time, but eventually I came to ac-cept this condition too as tolerable. I was after all only a littlerightist, and there were mitigating circ*mstances. In fact, theParty branch secretary in the work unit did a lot to protectme. I was a good clinician and a hard worker. The hospitalneeded me. I survived. Probably if I had been in my girl-friend’s situation, I would have done the same thing. I wasraised to compromise and collaborate to get by, and underCommunism I learned out of necessity how to do what I hadresisted in my own family.

“I think that’s what Communism had done to the Chinesepeople. Better than in ancient China under Confucian ideol-ogy, Communism forced people to learn how to accommodatethose in power. Chinese like me—especially those who livedthrough the political campaigns—learned how to get by. Youdo what you must do . . . even if you can’t stand what youdid. But we also learned to be skeptical, skeptical of any ide-ology, especially Communism but including Confucianism.It is really much more than skepticism. We feel alienated fromany standard of values. Only those that count at the momentto help you get through mean something. Take guanxi [con-nections traditionally based on either moral or pragmatic re-lations]. It’s become entirely functional, pragmatic. The samewith filial respect [filial reverence for parents and ancestorswas the core of Confucian values]. The sentiment is if they

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aren’t useful now, toss them away. It’s a corruption of whatthey once meant. This is the saddest and most unfortunatelegacy of Maoism. What these people have done to our tradi-tion and to us. ”

Stigmatized and restricted in opportunity to build the lifeand career he wanted, yet still “getting by,” Yan Zhongshuunexpectedly received another chance to leave China. Theyear was 1965, the year before the onset of the most violentand chaotic political campaign that radical Maoists unleashed,this time against the leadership and the state itself, which Maohad come to view as resisting his policy of continuous revo-lution and challenging his power. “My family somehow man-aged to bribe a group of high-level cadres in Guangzhouthrough their old business networks. How they accomplishedthis, I still don’t know, but they had the connections to do it. Imight have gotten out. Who knows? I was suspicious of asetup. The police did that sometimes. Later I discovered itwas the real thing, but by then the Cultural Revolution [1966–1976, a catastrophic, nationwide, political campaign that at-tacked individuals in the government, Party members,cadres in work units and particularly intellectuals who werelabeled enemies of the people and often exiled to impover-ished rural areas for political reeducation] had created neartotal chaos and it wasn’t possible to even dream any longerof getting away.”

In spite of the menacing atmosphere of the opening monthsof the Cultural Revolution, when Red Guards—radicalizedyouth—held public criticism sessions where political targetswere beaten or even killed, Yan Zhongshu still believed hecould contribute to build public health and health services

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for China and thereby “serve the people.” Dr. Yan told methat to give himself courage he added up all the positive as-pects of his situation, which even then seemed to him a pa-thetic way of trying to convince himself of his safety. At thetop of the list was his professional competence as an infec-tious-disease expert. Surely, he told himself, medical expertssuch as he were needed, and his career would protect himfrom ostracism and injury. His experience in the early 1960scontributed to his denial and blindness to what was to come.

“The campaigns against rightists had relaxed. I was able tomarry [a fellow physician in the same work unit with the samepolitical problem of coming from a wealthy background andhaving family overseas]. We had two sons and she was preg-nant again with our daughter. I was getting ahead in the hos-pital. It seemed to me things were getting better. What amiscalculation! I simply couldn’t face up to how bad thingswere and how dangerous they were going to become.”

In 1966 the Cultural Revolution quickly picked up speed,like a whirlwind, and Dr. Yan, his wife, and their childrenwere sucked into the devastation. “It was truly horrible. Worsethan I can convey. My wife was the target of a big characterposter.” These large posters placed in public spaces by radi-calized members of the work unit attacked other members andtargeted them for violent “struggle sessions,” big public eventsthat often involved everyone in the work unit. Either RedGuards from outside the unit or those radicalized work unitmembers who became Red Guards orchestrated these sessions,which were scripted to include denunciations by “the masses”of the politically targeted members, then forced self-criticism,followed by humiliation and beating of these “enemies of the

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people.” Colleagues and family members were often forcedto join in the criticism.

“She was beaten so badly one of her eyes was seriouslyinjured. The retina had a tear and no one could help her. They[the work unit’s Red Guards] kept her in the basem*nt of thehospital in a kind of prison for several months. When shewas released she had lost much of the vision in that eye andhad developed a psychiatric condition. She was fearful allthe time; even a noise frightened her so severely she didn’twant to leave our apartment. Then they sent her to a ruralarea in the northeast. It took me a month to discover whereshe was. Meanwhile I had three small kids. I asked my in-laws to take care of my youngest, our daughter. Then withmy two sons I went to a remote county in Gansu [in China’sfar west]. It was just as well, because life in China becamecompletely chaotic. You couldn’t get what you needed to carefor a family: food meant standing in long lines for hardly anychoices. There was no work. My clinical work stopped. Sodid my teaching and a research project I had started. A revo-lutionary committee of workers, students, and the militaryran our hospital. Doctors like me who had political problemsspent all their time in criticism sessions. No time to see pa-tients. They beat us up and turned nurses on doctors, doctorsagainst cadres, husbands against wives. It was truly a masspsychosis. Gansu was rough but in a different way.”

Dr. Yan lived in a small town in Gansu from 1966 to 1972.From 1972 to 1976 he lived and worked in a large city in Gansuat a general hospital. “I lived with my sons for six years in avery difficult place. A rundown county town with limited elec-tricity, insufficient and uneatable food in collective canteens.

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We were always hungry. But what was really bad was thatwe had to drink brackish water. My hair fell out. I developeda skin disease. My older son didn’t grow normally but seemedstunted. He was sick all the time. I was frightened he woulddie. Then when things got a little better in our living arrange-ments, I realized there was no schooling. So he learned aboutfixing tractors. That’s about all. He lost his education, as didmy second son, who even today seems cognitively slow. Some-how my daughter managed to come through all right in spiteof the fact my in-laws, who took care of her, had by then be-come street cleaners.

“I couldn’t stand my situation. The poverty was crippling.We had almost no equipment or drugs. Here I was a high-tech expert and I watched patients die from routine infec-tions because we couldn’t get antibiotics. I was an intellectualand there was nothing to read. No one to talk to about ideas.I felt like my mind was drying up. Periodically some cadrescame through to attack those of us who were under a politi-cal cloud. There was yelling and screaming. You were madeto feel terrible . . . frightened, agitated, lost. You couldn’t saywhere things were going. Some days the complete absence ofstimulation made you feel a quick death would be prefer-able. But slowly I gained the confidence of local leaders whor*ally appreciated my dedication to practice good medicinein such bad conditions. They sent us more to eat. We got aplace to live that was not so terrible. They protected me fromvisiting bands of Red Guards. What they couldn’t do waslessen my fear or desperation. I thought about suicide. Butwhat good would that be for my children—and wife? We weresurvivors, my family; somehow I felt I’d get through, but it

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was terrible. So bad that when I think about the dirt, the aw-ful and meager food, the dirty, sour water, I feel that old de-spair again like a numb, empty feeling, a terrible feeling Idon’t ever want to relive again. Ah, what a time!

“Meanwhile my wife’s mental condition continued to de-teriorate. I couldn’t get permission for her to join us in Gansuor for me or her parents to visit her in the northeast. I felt sofrustrated. I think it was that that made my hair begin to fallout and then turn white. In the fourth year of our separation,I received word that she had committed suicide. I never sawthe body or got the details. Was it true? Was she murdered?No one could find out. It was all so very inhuman. I becamevery bitter. I could be surly with my sons and with my pa-tients. I was filled with anger and grief. I was hopeless. Well,not exactly. If I had been hopeless, I would have agreed toremarry. ‘A true peasant wife,’ the leaders of the county hos-pital told me. I resisted and fortunately was able to avoid thator I would still be in Gansu.

“They needed my skills, and I knew that. But there was adanger to being effective. They wanted to keep me. [The localCCP leaders had complete control over Dr. Yan and his chil-dren.] Meanwhile, others were returning to their homes inBeijing, and I was still living in that hell. But I had made upmy mind. I would get away one day by whatever means; I’dget out. That was the only hope I had, and it kept me alive.”

Soon after the Cultural Revolution officially came to its endin 1976, Dr. Yan together with his sons returned to Beijing. Hehad been able to bribe several of the local cadres responsiblefor personnel to authorize his application for a transfer. Atthe same time his hospital’s leaders in Beijing were attempt-

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ing to resurrect their infectious-disease program. They invitedhim to return, and the local authorities complied. Beijing it-self was in difficult straits: warring political factions hadbrought work units to a standstill, schools and universitieshad stopped operating, and Dr. Yan’s hospital was in disre-pair. In 1978, with Deng Xiaoping’s declaration of a new eraof economic reform, Yan Zhongshu received news that he wasofficially rehabilitated. As a direct result, the director of thehospital promoted him to a senior post. This time his career—both as a clinician and a clinical teacher—flourished. Togetherwith younger colleagues who were quick to master the newlaboratory techniques, he undertook clinical research studiesthat have been published in China’s leading medical journalsand several times in European and American research reports.

“I tried to make up for all those wasted years. We all did.But it was too late for my sons to catch up educationally. Atfirst I considered this to be one more tragedy, but actually,since advancement was blocked for higher education, theywere encouraged by the new economic conditions to be amongthose who tried new things. They were ready as jobs openedin the private sector to take advantage of what for others wasa risky adventure.” In the early years of the economic reform,1978 to the mid-1980s, it was young people on the margins ofsociety, such as Dr. Yan’s sons—who did not work in the thenmore desirable, guaranteed jobs of the public sector and whodid not have the education to advance through the univer-sity system—who entered into the newly opened and quiteuncertain opportunities of the private sector. Called “jump-ing into the sea,” starting up or joining private companieswas risky, but out of this generation of entrepreneurs emerged

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the real vanguard of China’s extraordinary economic successin the past two decades. “They [his sons] started off workingin restaurants. Then they joined a shipping company. Even-tually they went back to their roots and found work in a newimport-export firm. Now they have support from their cous-ins in Hong Kong, and the business is successful, and theyhave moved up to managerial positions. They plan to startup a branch of the old family business, which already is oper-ating in different parts of China, sometimes with the childrenor grandchildren of those who were the original businessagents. They are doing well, and my grandchildren will re-ceive the education denied to them.

“My daughter followed a completely different path. Shedid well in school. By the time she was in senior middle schoolthe question of class background no longer mattered so muchfor admission to university. Staying in Beijing with her grand-parents, her education wasn’t disrupted to the extent of thosesent to rural areas, like my sons. She received a reasonablescience background at the university, and she graduated at atime when American universities were seeking out Ph.D. stu-dents in the sciences and engineering from China. Getting avisa proved to be no big problem because by then lots of Chi-nese were going to America. She got her Ph.D. in biology fromthe University of California and then did several postdocsat East Coast universities. One of her mentors went on tojoin a small biotechnology firm, and so she went too. She isa very hard worker, like me, and she is well paid. She chosenot to marry. I am still hopeful, but she says she isn’t inter-ested in marriage. I managed to come to America to live withher after I retired. My family in Hong Kong sent me money

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and asked me to retire in Hong Kong. I visited a few times,but eventually I thought it would be better for me to be withmy daughter. She looks like my wife and I want to help her,and she wants me to share her life. We don’t need to talkabout the past, but it’s with us all the time, like a sharedscent.”

Dr. Yan’s eyes teared; he shook his head, coughed, and wenton. His voice sounded soft and sad at first, but it quicklychanged, becoming hard and insistent.

“It makes me dizzy and weak to think of the past and allthat has happened. Today it seems like traditional ideas aboutthe cycles of history are coming true. China is more or lessback to where it was in the 1930s. My sons are doing what mygrandfather and father did. And the Communist Party is stillin command. But who could have imagined this during theCultural Revolution? It is a strange kind of progress. My gen-eration was blown apart. Lives ended. Careers were stopped.Families were destroyed. Look at what happened to my wife.Look at me. I got through it, somehow, but what a terriblewaste of years. So much misfortune! Ah! But this new time istroubling in its own way. So many of the problems of the 1930shave returned: drug abuse, prostitution, homelessness, un-employment, corruption. Corruption, I think, is the worstproblem. The whole country runs by corruption. . . . You wantto buy something, pay someone off first. You want the policeto do their job, you’ve got to pay them. Medicine was neverso corrupt. Probably because we had so little money earlier,and if you had it then, what would you buy? Now you needmoney all the time. Patients must give bribes to see a special-ist or to get surgery or the latest medicines.

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“I told you how I hated the way my family collaboratedwith this faction or that one. But really I now wonder, is thereany other way? We’ve all become like that. Communism ru-ined so much in China. Who can look at China now withoutfeeling regret? So much pain and injury to produce a societythat is crude, greedy, and empty of values. Everything is su-perficial and pragmatic. You scratch my back, then I scratchyours. If you don’t help me, I drop you and move on to culti-vate someone else. If he doesn’t help, I drop him too. Every-thing for sale. No more big lies because no one even believesin Communism. But capitalism looks dirty and disappoint-ing. It’s not the capitalism of the States but something wilder,rougher. There was a bitter joke in Beijing before Tiananmen.What’s the longest and most painful road to capitalism? Yes,you’ve got it . . . Communism. But nowadays the bitternesshas disappeared and so has the idealism. Where is Chinaheaded? What’s happening to the Chinese people? Nothingcould be worse than Maoism, but the current direction is de-structive too.”

Dr. Yan continued with a bitter smile: “Let me tell you astory. When the Cultural Revolution broke out, I had a closefriend in my clinical department. He and I graduated fromthe same medical school. He was the classmate I felt closestto. He had a very open personality. We had many good timestogether. He actually introduced me to my wife. I helped himadvance in the hospital. He was very ambitious. We spentour free time together. Once when we were drinking togetherwe swore an oath to be like blood brothers and protect eachother and our families. He came from a different background.His parents were ordinary workers. They were poor. So Xu

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Weiqing came from a red background. But he also had a po-litical problem. His uncle had been forced by the authoritiesto become a soldier in the KMT army. Eventually his unclebecame an officer and escaped to Taiwan, where he rose to ahigh rank. I knew this and other things about my friend, andhe knew just about all there was to know about me. We hadsworn to keep these secrets, and I trusted him. Then duringthe Cultural Revolution, there was a big struggle session inthe hospital. A lot of the senior doctors were attacked. Butafter a few weeks the criticisms began to include more juniorstaff. Then I became a target. I got criticized.” Dr. Yan wascriticized both for the old political issues of his class back-ground and his family in Hong Kong and because his scienceorientation was said to reflect too urban and elitist an ideo-logical orientation. “Weiqing was attacked for being my friend.He was told [by the unit’s Red Guards] to draw a clear linebetween us. And after being roughed up and threatened withbeing sent to some horrible place in the remote mountains,he ended up . . . hmm, denouncing me. That was bad enough.But he did more to hurt me. He revealed everything I hadtold him, which got me into such serious trouble that onlythe party secretary saved my life by moving me and the boysto Gansu. Otherwise I was done for.” Dr. Yan was close to theleaders of the hospital, including the party secretary, becausethey valued him as one of the best clinicians and also for hishigh scientific standards.

“I just couldn’t accept what Weiqing did. Lots of friendswere forced to turn on each other. Even married couples. Youhad to make a show of it or you were attacked. But friendsusually said the least they had to. Two of my other friends

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did just that. They joined the denunciations, but even thoughthey could have worsened the case against me and gotten meinto more serious trouble, they kept quiet about the moredangerous things they knew about me. Weiqing told every-thing. He even embellished the truth so that I looked reallybad. It was Weiqing who yelled first that I could never betrusted but was an enemy of the people who should be beatento death. He grabbed a stick and hit me with it. He reallymeant to injure me. I fell down bleeding. There were hun-dreds of people present. The Red Guards urged him on. Butmost of the work unit members were silent. I think Weiqingcould have killed me if he had been allowed to continue tohit me. My head was bleeding. My arm was numb. Then twosenior doctors who were still respected stepped forward atthe urging of the party secretary. They took the stick awayfrom him. They pushed me into a storage room. The partysecretary locked the door. I was covered in blood. My glasseswere broken. I could feel the blood trickle down the back ofmy neck where the skin was raw from the beating. Weiqinghit me so hard on the head I had a gash that required stitches.But I felt no pain. My heart was filled with sadness and grief.Later still anger flooded through me. I hated him for betray-ing me and nearly killing me—all to protect himself.

“Well, years later when I returned from Gansu, we were againin the same department. In fact, we shared an office. I couldn’tlook at him or speak to him. I detested him. I blamed Weiqingfor everything that had befallen me, even what happened tomy wife. Because he had accused her too. I felt a burning in mychest rising into my throat, just being around him. Under mybreath I cursed him: ‘You bastard, when I get the chance, I’ll

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get back at you!’ But never so that he or anyone else couldhear. I’d learned my lesson. Never trust anyone!

“Well, in 1982, I think it was, Weiqing finally came up tome and tried to apologize. He couldn’t justify what he haddone, of course, but he tried to make it sound ordinary, as ifeveryone did what he did. You remember, it was just after thetime of the literature of scars [a short period in which novels,short stories, and actual personal narratives of suffering dur-ing the Cultural Revolution were authorized by the Party].All sorts of personal accounts appeared condemning the ter-rible things that had taken place in the Cultural Revolution.After a year or so the authorities stopped it, because the criti-cism was getting out of control. But still a lot of people weretrying to come to terms with all that had happened. Severalfriends, for example, told me how sorry they were. How theytried to protect me but couldn’t. I didn’t believe them com-pletely, but I could understand their situation. Weiqing wasdifferent. He had told everything and almost killed me, andwhat he said to justify his actions was simply untrue. I saidnothing in return. He couldn’t look at me when he spoke. Hehad no face [that is, he had no moral standing]. I turned awayfrom him.

“About four years later, I had the chance I dreamed aboutto get revenge. The hospital had a connection with a ruralcommune in a very poor area of Henan [an impoverishedinterior province]. When they could, they provided us withfruits, and we sent them medicine. Under pressure from thegovernment to help rural areas, the leaders of our hospitaldecided to reopen a clinic in that commune that members ofour department had staffed during the Cultural Revolution.

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They badly needed a full-time clinical director who wouldmake a commitment of several years. It was a terrible posi-tion, a kind of exile. It would finish off the research career ofwhoever went there. It would also be a very difficult place tolive. No one wanted to go. Everyone looked for an excuse.The party secretary, who had at last been rehabilitated andreinstated after a terrible ordeal like mine, came to see me.He too had been criticized and beaten by Weiqing. He said tome that now was the time to get back at him. ‘We can killhim,’ he snarled, ‘by having him sent to that place. He hasasthma and will never survive there. When we have the bigmeeting to choose a head of the clinic, you propose Weiqing.Everyone will support you. That’s all you need to do. I’ll takecare of the rest, and we’ll get the bastard for good.’

“Now, Weiqing was an excellent physician and researcher.His career was really flourishing. He had big ambitions butwas somewhat thwarted by his past. People remembered hisactions in the Cultural Revolution—against me, against theparty secretary and others—no one trusted him. He had lotsof enemies among the senior staff, otherwise he would al-ready have been appointed department head. This was whatI had waited for, the opportunity to finish him off.

“The meeting took place at night. The hospital’s main au-ditorium was filled. There was a lot of excitement and anxi-ety. Everybody was scared of being sent to that remote clinic.The party secretary asked for nominations. He looked at me.I felt all my hatred focus on the words that would recom-mend Weiqing. I saw him squirm. He knew it was a setup.He knew I was going to get revenge. That the party secretarywould make it happen. He couldn’t look up. His eyes were

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fixed on the floor. You could see his body tremble. The partysecretary coughed. He looked at me as if to say, ‘Get on withit. What are you waiting for? Let’s get him out of the way.’Finally, out of frustration, he called my name: ‘Comrade Yanhas something to say.’

“I looked at Weiqing. I felt my face flush, my heart pound.I started sweating. Meanwhile, I could slowly recall the ter-rible day when Weiqing betrayed me and almost killed me.‘Comrade Secretary,’ I blurted, ‘it is too much for any of us tostay in that remote commune for years. It would be like go-ing back in time to the worst days of the Cultural Revolution.Comrade Deng Xiaoping says that a cat can be black or white.It doesn’t matter so long as it catches mice. Let us not sendanyone out there like I was sent to Gansu and you were sentto Xinjiang. No more vengeance. No more name-calling. Nomore destroying lives and careers. I recommend instead thatwe rotate the position every few months among the staff. I’mready to go for a month. So should everyone else.’

“I really can’t say how I said those words. I can’t remem-ber making a decision to say them. They just came out, likean explosion. But I wasn’t unhappy with what I said. Sur-prised, but not unhappy. No sooner did I finish speaking thandozens of staff members—senior and junior—yelled theirsupport. There was so much agreement that the party secre-tary could do nothing but agree too. There was an atmosphereof relief. At any rate, that became the policy. I became a smallhero. And the opportunity to get back at Weiqing disappearedlike that.”

Yan Zhongshu put his head back, resting it on the largearmchair in the study of the apartment in Washington, D.C.,

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he shared with his daughter. His face seemed to me calmer.He closed his eyes. I thought he had fallen asleep. But justthen he began to speak in a soft, slow manner. “Retrospec-tively it seems incredible, just like you say. But I think I’vecome to understand myself. I could never hurt anyone likeWeiqing hurt me. It must be constitutional. Even during theworst days of the Cultural Revolution, I couldn’t bring my-self to attack others. I made believe a few times. But my col-leagues knew I was only pretending. And many were thatway too. The ruthless ones were those sad cases who com-pletely lost themselves in the mass hysteria and were capableof doing the worst things. Some had great cruelty in theirhearts, but most were acting out of fear. They felt threatenedand fought to survive. That was a fairly sizeable group, butstill a minority . . . most of us just went through the routines.Weiqing was so very ambitious that he forgot about others.What I think is that he became terrified of what might hap-pen to him if he didn’t protect himself, and to do that heneeded to get rid of me. Actually, he told me as much afterthe big meeting at the hospital. He came to my apartment.There were tears in his eyes. He knocked his head on theground to thank me. He called himself names: coward, bas-tard, things like that. He told me he had felt trapped andneeded to protect himself. He would do anything he had todo to survive, no matter what. He sacrificed me to keep him-self alive. Then when he had betrayed the secrets I told him,he lost himself in a terrible rage, he said. He hated me forputting him in that position and he hated himself for what hewas doing. And he was afraid. Afraid I would turn on himand afraid that association with me would ruin his chances.

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Weiqing told me that at that moment he truly wanted to killme and would have if he wasn’t stopped.

“We never spoke again about that time. We worked togetherfor years. There was a superficial return to speaking terms.We joked together a few times and we even took a few mealstogether. But whenever I thought of my poor wife, or my sonsand me drinking that sickening brackish water, I felt ice inmy heart. I could not forgive him. I did not trust him. And soI would not be too friendly, despite all his efforts. That [in-stinct] proved right a few years later.”

From April 1989 to early June of that year, during China’s“democracy spring,” demonstrators in the enormous publicspace of Tiananmen Square demanded greater political free-dom for China and openly criticized the government and theParty. Over time the numbers grew from hundreds of stu-dents to thousands of Chinese of every class, background,and occupation. Entire work units marched under the ban-ners of democracy and freedom: universities, factories, news-papers. Citizen groups in different areas leading into and outof this central public space—before the Forbidden City (forhundreds of years home of China’s emperors), beside themausoleum holding Mao’s embalmed body, next to the GreatHall of the People, and only blocks from the gated commu-nity where China’s current rulers reside—blocked majorroads, preventing police and military units from entering.Smaller demonstrations took place in other Chinese cities. Thepolitical order was under assault. Leading government offi-cials met with student leaders of the protest, but were unableto restore order or control the situation, which looked to bespinning toward breakdown of the Communist dictatorship

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as was happening in Russia and Eastern Europe. During thissame period the press became more critical of the politicalsystem and books and films appeared (for example, River El-egy) that criticized not only Chinese Communism but the en-tire Chinese cultural tradition as being oppressive, corruptand anti–human rights.

Finally, the retired senior leader—Deng Xiaoping—togetherwith a powerful circle of colleagues, who were staunchly an-tireform and feared that the state would collapse if somethingwere not done to break the democracy movement, rallied themilitary and struck back, killing hundreds and perhaps thou-sands of students, workers, and other ordinary citizens whileclearing Tiananmen of its newly erected liberty statue and allother symbols of protest and change. Then there followed abrief but brutal period of repression as the Party sent authori-ties to identify, imprison, and in some cases execute leadersof the movement, a number of whom escaped Beijing for thecountryside or other cities, or even made their way to HongKong and the West. There would be no peaceful revolutionfrom below, no change of the political status quo in China.

Dr. Yan initially hesitated to participate in the demonstra-tions. He remembered back to the Hundred Flowers Cam-paign of the late 1950s when Mao invited criticism of thegovernment and the Party, but when it became too widespreadand serious, he instigated a campaign against the critics whohad let their ideas be publicly known. Cynics had said thatMao’s original intention had been to smoke out his critics andtarget them for repression. So Dr. Yan was wary as the de-mocracy movement accelerated into a full-scale assault onCommunist society. But near the end of May, as virtually the

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entire staff of his hospital took part in the demonstrations, hejoined a doctors’ march, one of whose leaders was his oldfriend the party secretary, who was now about to retire. Fol-lowing the June 4 massacre, a period of repression and re-crimination began. An investigation squad of police visitedthe hospital and interrogated activists, including the partysecretary. Somebody had denounced the work unit’s leadersas politically incorrect. Months later it emerged that XuWeiqing was the informer. Only modest trouble resulted fromthe investigation, but it did delay the party secretary’s retire-ment and may have cost him some of his benefits. Severalyears later the party secretary told Dr. Yan that he had learnedfrom his connections in the police that Xu Weiqing had beenan informer since the early days of the Cultural Revolution.He pointed out that had Dr. Yan acted at the right moment,Xu Weiqing would have been exiled and would not have beenable to continue to cause trouble. Dr. Yan responded with rageand criticized himself so passionately for being naive and stu-pid that the party secretary had to calm him down. “I will notbe fooled again,” Dr. Yan swore at the time. “But in fact I was,”he sighed to me, and continued: “And that’s how I began tounderstand more clearly what China is becoming.”

Promoted to be deputy head of his clinical department in1991, Dr. Yan was responsible for overseeing clinical services.The 1990s were a difficult time for China’s hospitals, and Dr.Yan’s hospital was no exception. Costs of electricity, basicsupplies, medical equipment, and food increased rapidly, butthe government forced hospitals to charge patients the sameoutpatient registration fee and inpatient per diem as they hadearlier. At the same time, the Ministry of Health and its local

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urban equivalents reduced support for the salaries of hospi-tal staff, the procurement of drugs, and the maintenance ofolder buildings and the construction of new ones. The hospi-tal where Dr. Yan practiced was caught in a crunch. The hugemigration of rural workers to the city increased emergencyward and outpatient visits. Hospital staff were underpaid andoverworked.

In addition, the market economy changed the balance ofpower in the patient-doctor relationship and, indeed, the en-tire medical profession. An authoritarian Confucian modelthat gave primacy to doctors was transformed into a consumermodel that encouraged patients to request the latest and morecostly diagnostic tests and treatments. The hospital’s leaderspressed clinicians to pander to this desire for high technol-ogy, as they saw it as one of the only ways of meeting theirfinancial obligations. Thus doctors were encouraged to en-gage in bad clinical practices such as ordering tests that wereunnecessary, overpriced, and potentially dangerous. On thetreatment side, doctors were told to prescribe more drugs andto favor the most expensive ones. Much the same took placewith surgical interventions. Patients and families, exposed tothe media’s hyping of the marvels of biomedicine, were will-ing participants in what Dr. Yan regarded as systematic abuseof professional standards and a misuse of scarce resources.

The changing climate within medicine encouraged not onlyinefficiency and wastefulness but also mass corruption. Se-nior doctors with established reputations had such a largefollowing of patients that they would see new patients only ifthey received a suitable “gift,” usually a bundle of cash in apaper bag or envelope placed at the doctor’s side. Surgeons

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expected such gifts before and after operations. “Money be-came everything,” Dr. Yan lamented. “For the administrators,including the new party secretary, it was the measure of suc-cess. For doctors and nurses, it was necessary to live in thenew market economy. Before, there was little to buy, and youdidn’t need to pay for most things—rent, food, services wereeither part of what the work unit provided or were deductedfrom your salary. Now you need money to buy things, andyou are expected to pay for everything yourself. Buying thingsis what China is now about. It is like a complete reversal ofhow things were in the era of collectivization. Corruption iscompletely out of control, like before 1949. The drivers of theambulances demand bribes to bring a sick person to the hos-pital. The hospital porters expect a small tip to show familieswhere to go to register or visit a ward. The policemen at thegate won’t let cars enter let alone park without collecting alittle ‘gift.’ None of this is appropriate. Even the medical stu-dents and medical school teachers get involved. Our best stu-dents, the smartest and most ambitious, who formerly wouldhave gone into research and specialty practice, now prefer towork in the pharmaceutical industry. They sell drugs to thehospital’s doctors and give kickbacks to those doctors whoprescribe their drugs the most. The teachers expect moneyfor after-hours tutorials, and they make it clear that if youwant to pass exams, you better take these extra courses.”

Dr. Yan found himself becoming increasingly discouraged.“I couldn’t accept what was happening. People regarded meas a foolish idealist. I couldn’t believe we had spent all thoseyears emphasizing collective values and high standards onlyto sink into selfishness and corruption. It was completely

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demoralizing. And not just for me. My friends and colleaguesalso complained. We actually had believed the ideology: ‘servethe masses,’ ‘build the nation,’ ‘strive selflessly to assist com-rade workers and peasants.’ Now that it has all changed, itmakes the past seem false, a big lie.

“I used to be a consultant to a special ward at a hospital inthe late ’70s that was set aside for senior cadres. It had air-conditioning, the latest technology, high-class food, maid ser-vice, while the rest of the hospital’s wards were crumbling.But even though we knew there was inequality, we still be-lieved in the collectivist rhetoric, believed it made us supe-rior to capitalism. With the change in the economy in the 1990s,we became what we had been taught to criticize. This wasthe true ‘cultural revolution.’ At first it seemed great. We hadclothing that was much nicer, new places to eat, better livingconditions, opportunities to travel, even abroad. But over timeit has returned us to all the evils of the 1930s. Businessmentell us that China in the twenty-first century is like Americawas at the end of the nineteenth century, the ‘wild West.’ Youcan buy everything, even people. Everything is for sale.

“Now that I live with my daughter here in America, I real-ize China’s brand of capitalism is much cruder than America’s.People are materialistic and pragmatic and that’s it. Ameri-cans may take that for granted, but you have religion andspirituality. And there is a legal system and a moral code. InChina the situation is worse, much worse. Traditional cul-tural practices are empty and dying. There is no religion.Qigong is a search for that, but it is very thin and superficial.What can you expect from the one-child family and all thematerialism? There is so much selfishness. It is the time for

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people like Xu Weiqing. My time is over. But the time forscoundrels is now.”

Clearly Dr. Yan’s bitterness over the wasted years, the cul-tural hypocrisy, and continuing political oppression coloredhis view of breathtaking economic changes that have cata-pulted China from a poor country to the world’s third largesteconomy and an engine of growth for the global politicaleconomy. This has vastly altered the lifeways of ordinaryChinese, especially the 250 million Chinese who live in thecoastal cities and special economic zones, which have experi-enced such a huge economic transition. While there is stillplenty of criticism of the failure of political reform, Chineseinside and outside China have increasingly become robustlynationalistic and are viewing the period of economic reformas an era of unprecedented prosperity that has altered notonly material realities but the very meaning of what it is to beChinese. The fact that China will be hosting the OlympicGames in 2008 is seen by many as symbolic of this new era ofits international power and optimistic internal transforma-tion. So while he is not alone in his criticisms, Dr. Yan is con-siderably more negative about the new China than mostcommentators, inside and outside China, for whom bitter-ness over the radical Maoist past is being replaced by the sensethat China is entering an epoch of enormous possibility.

Dr. Yan’s career began to wind down in the early 1990swhen there was tremendous financial pressure on the hospi-tal. The new party secretary and new director of the hospitalheld a meeting with the senior physicians and told them thehospital faced financial ruin unless it found new ways of gen-erating money. Some of Dr. Yan’s colleagues suggested that

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they copy other, more famous hospitals, which were openingup clinics intended for rich overseas Chinese and other for-eigners. The approach would be to charge inflated amountsfor the latest high-tech diagnostic and therapeutic procedures.Dr. Yan and several of his friends, who were also senior phy-sicians, remonstrated that this was not the purpose of medi-cine or their hospital, which, though small and not wellknown, had always prided itself on its high clinical standards,rigorous clinical teaching, and applied research directed tohealth problems salient to the community. The party secre-tary, Tan Zhiwei, and the director of the hospital, Dr. WuZewen, who had formerly worked under Dr. Yan, led a cho-rus of responses. Dr. Yan, they stated, was a fine clinician anda dedicated teacher and researcher, but he and those whosupported his ideas were outdated. China had changed, andgreatly so. This was no longer the China of collectivization.This was a new China. The cautions were no long relevant.Did they want the hospital to go the way of other state enter-prises that failed to modernize? That way would lead to fis-cal crisis, breakdown of the organization, and loss of jobs andretirement benefits. It was good to hear the old ideals reaf-firmed, but they were, alas, the values of a time gone by. Dr.Yan noticed that Weiqing remained silent throughout the dis-cussion, which surprised him because Weiqing now headedone of the hospital’s major centers and therefore ought to haveshared Dr. Yan’s concerns and been on his side.

It turned out that Weiqing, Dr. Yan’s nemesis, was engagedin even more ambitious planning for re-creating the hospitalas an engine of profit making. Over the next several months,Weiqing together with Secretary Tan and Director Wu made

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public plans to develop property that belonged to the workunit but was a few blocks away into a shopping complexthat included restaurants, a hotel, stores, and commercialoffices. Indeed, they had already made the initial investmentsand had lined up a Hong Kong developer and high-levelgovernmental backing. The proposed shopping arcade wasparticularly difficult for Dr. Yan and his circle to accept be-cause it would replace a rehabilitation unit, a nursing home,and a hostel for the families of patients. The implications ofthese plans for Dr. Yan and his circle was that the futuredevelopment of the hospital would be toward highly com-mercial interests that would undermine the hospital’s pro-fessional values and academic traditions, remaking its ethosin a direction they could not accept. They complained, butto no avail. This time the administrators and their allies inthe city government warned them to mind their own busi-ness or suffer the consequences. Years later, Dr. Yan bitterlyobserved:

“We . . . capitulated. There was no alternative. All of a sud-den the operative issues were different. We had in fact be-come more or less irrelevant, as Director Wu had pointed out.But Mr. Tan was worse. A coarse, hard former military cadre,he shouted at us, if we got in the way he would crush us. Wecould forget about bonuses or improved retirement benefits.He even threatened to take away our housing. He was like athug. He knew little about patient care and had little interestin research. His background was in management in the mili-tary hospital system. For him our hospital’s research tradi-tion and its reputation for strong primary care programsmeant nothing. Only the high-tech sector made business sense

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to him. We could have been a factory for clothes or a depart-ment store as far as he was concerned.”

According to Dr. Yan, there was general suspicion that theHong Kong developers had paid off the hospital’s leaders.The rumors of corruption deepened when the hotel openedand it became clear that it was not only catering to legitimateguests but also attracting prostitutes and gamblers. “I don’tthink they were selling illicit drugs,” commented Dr. Yan withraised eyebrows, “but that was all they weren’t selling. I feltdemoralized, as did others. What could have been worse thanwatching the hospital’s investments foster STDs and for all Iknow HIV/AIDS? That was when I knew I had to get out. Ithought I had wasted my career. I became despondent. I onceeven thought of suicide. Oh, not seriously, but I did have thepassing idea that it would be one form of protest they wouldhave to take seriously.” Traditionally in China, the suicide of ahigh official as a moral protest had to be responded to by theemperor and had great cultural significance for ordinary people.

At this low point, Weiqing approached Dr. Yan and beganin a sympathetic voice by telling Dr. Yan that soon both ofthem would need to retire. Things were moving so fast inmedicine that their generation was outdated. What Chinaneeded anyway was not strong practitioners but strong re-searchers who would bring China up to speed on the hugedevelopment of biotechnology that was shaking medicineworldwide. Weiqing said there was potentially a huge amountof money to be made in biotechnology. Look at the UnitedStates, he said; everyone there was getting in on biotech. Prettysoon China would develop such companies, and it was pre-cisely the moment to form one of them. What the hospital

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needed to do was to spin off a private firm, attract a largeamount of capital from Hong Kong and Singapore, and hireresearchers, especially Chinese who were returned studentsfrom the United States or who could be lured back from theStates. They could cater to the problems of wealthy overseasChinese, Weiqing enthused, and develop new drugs for prob-lems such as impotence, baldness, infertility, depression, andobesity. They could apply for foreign grants for some of thework, and maybe global pharmaceutical companies could bejoint partners, he continued. Then Weiqing came to the point.What they needed was a front man, someone credible andwith a background that spanned research and clinical prac-tice. Someone who could speak before audiences, meet withinvestors, inspire researchers, and represent the company in-ternationally. Dr. Yan had good English, had contacts in HongKong through his family, was a scientist and a clinician, andwas the right age to run the company. As Dr. Yan recalled,Weiqing concluded, “Don’t worry—Tan, Wu and I will workbehind the scenes on the business side of things. You will onlyrepresent us. Lots of people here admire you even if you’renot that well known at the national level. But you will be inthe future. You could make a lot of money and become fa-mous too. Think about it.”

“Everything Weiqing said blackened my heart. I felt as if alarge stone sat cold and hard in my stomach,” Dr. Yan re-ported. After taking a few moments to calm his emotions, Dr.Yan accused Xu Weiqing of being a scoundrel, ready to doanything and everything to advance his own ambitions with-out a thought for others or for the best interests of the institu-tion they had worked in for decades. But even as he spoke

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the words, Dr. Yan knew he was defeated. Weiqing had ev-erything working in his favor. The time was ripe. The ideawas logical and attractive. The administrators were fully be-hind it. It would change the hospital completely, but whocould say it wouldn’t succeed? If it did, the economic condi-tion of everyone in the work unit might benefit. “I had to facethe truth. What he proposed did represent the future. What Istood for represented a past that perhaps could not be re-vived again. I stopped, not completing my thoughts. I hadnothing to say.” Dr. Yan said he was amazed at what Weiqingsaid next, not because of its content but because Weiqing wasso brazen. He called Dr. Yan blind, telling him that he hadnever figured out that in China you need first of all to findout which way the wind is blowing and go in that directionwithout hesitating and before others passed you by. “‘Do whatyou need to do to get ahead,’ Xu told me. ‘Before it wasultraleftism, so you ran left. Now it’s capitalism, so you runright. Even the police and army are into it in a big way. Standstill, and you lose out. Stand up and try to obstruct the forceof change and you are lost. The only thing that matters is toget ahead. I’m stuck with this lousy hospital. It was never bigenough or famous enough for my ambition. But still, it’s whatI have. Otherwise, I would have jumped into the sea long agoand become an entrepreneur. Now biotechnology plus theshopping plaza is all we have to get ahead. We need to be-come more capitalist than the capitalists, more crooked thanthe crooks. This society is run by thugs. You know it as wellas I do, but you never came to terms with what that meansfor our lives. I figured it out long ago. They screwed me andyou and everyone else. They made me do the things I’ve had

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to do to survive. Be hard, very hard. That’s what I’ve learnedover all these years.’

“Then,” Dr. Yan remarked, “he turned on me and said hewould be hard on me. He told me to get out, get out now, if Icouldn’t accept the offer. There would be no room for me.‘Go to your daughter in America,’ he shouted. I felt like slap-ping him in the face. But all my pent-up anger at Weiqingquickly dissipated. I felt numb all over. It was the end. Therereally was no more to say. I never spoke to him again, even atmy retirement party, just before I departed for America.

“Why did I leave, you ask? Well, Weiqing was right. It wastime to retire. I couldn’t do much for the hospital. I didn’twant to be a mere figurehead and used like a puppet. I hearthat Weiqing has started up the biotech firm and that he is thehead. Maybe that’s what he wanted all along. I feel like oneof the traditional scholars of ancient times. I’ve retreated to aremote place to be a recluse.” In Chinese history, when thescholar-bureaucrats who administered the country under theemperor lived through a period of dynastic change or othertimes of turmoil when they felt the moral context was unac-ceptable, they could try to refuse high office and administra-tive responsibilities by becoming recluses, feigning madness,or simply retiring. While this did not always save them, itwas taken as a sign of their criticism and protest against aparticular time and leadership. “Perhaps it’s my way of sur-viving. I can remember the past as if it were here right now,but I have no sense of what the future will be like. My feel-ings and values belong to the past. Even in the worst days Icould still sense that I knew what I should do. Now I’m veryunclear. What once was good is now bad; what once was bad

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is now good. And still we live on. Some days I feel dizzy, as ifI couldn’t find my place on the ground. It’s not the sameground. What matters now doesn’t appeal to me, and, hav-ing finally gotten out of China, it doesn’t have to appeal tome. America will never be my home either. But I’m with mydaughter and we have each other. My sons are doing well.The grandchildren might come to America someday. Whoknows, maybe we will someday return to China.”

Yan Zhongshu’s story is the story of modern China be-ginning in the 1930s. Huge societal transformations—wars,political revolution, social turmoil—overwhelmed Dr. Yan’shospital, his family, and his own personhood. What hap-pens to ordinary experience as politics and the economy re-fashion moral life is clear here to a degree not often visiblein societies where change is much slower and not nearly sodecisive, and where outcomes are more complex and multi-form. The close connection between emotion and values isalso clear in the instances of Dr. Yan’s narrative of angrybetrayal, loss of face, and terrified acquiescence to mass vio-lence. Dr. Yan’s experiences in a society that is politicallyoppressive and socially tumultuous, and which morally hasundergone an about-face in public values and even in pri-vate life, demonstrate how transient human conditions areand how mistaken it is to claim an essential human naturethat is beyond history and culture. How to live a moral lifeamidst such dangers and uncertainty is an unresolved butpressing question for Dr. Yan and for many other Chinese.Moral experience for them connects the public domain ofcontested meanings and power to the innermost world ofsensibility, and it does so in an unpredictable way, as Dr.

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Yan’s visceral inability to extract revenge from his nemesis,Dr. Xu, so dramatically illustrates.

How best to understand Dr. Yan, Dr. Xu, and their oppo-site reactions to the precarious political climate in which theywere both forced to live? Distinct patterns of action mark theirpersonalities like different signatures. Dr. Xu’s deep cynicismand sociopathic disregard for others and his willingness tosucceed at any cost, including persistent deceit and betrayal,all carried out without lasting remorse or regret, mark him asdangerously unethical. The fact that Dr. Yan also survivedwith entirely different behaviors undermines Dr. Xu’s self-exculpatory defense that in bad times you have to do badthings to survive. And yet Dr. Yan, for all his idealism andcriticism of collaboration, also recognizes that survival in thelocal worlds torn apart by radical Maoism required keepingthese critical self-reflections hidden. In his own way, Dr. Yanwas also a collaborator; he had to be to live in the most dan-gerous times. At the few points at which he overtly resistedthe vector of political force (resisting revenge and turningdown being a figurehead), it was possible to do so, and heknows that. Even his story, as framed for me, an interestedforeigner, is a kind of survival strategy, keeping his self-image(and mine of him) unsullied, agentic, and open to new anddifferent possibilities in a new and different world. Dr. Yan’smoral authority itself is based in framing his biography as amoral tale of resisting corruption and hypocrisy. He is alreadybringing an external ethics to bear on the radical shifts of lo-cal moral experience. There is no hero here. And while Dr. Xu’scommitment to do all that it takes to maximize his personaladvantage as what matters most comes to seem appalling, he

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is no monster either. His betrayals and the self-serving cyni-cism of his final speech may damn him for the reader, but it isactually Dr. Xu, not Dr. Yan, who saves the hospital, admit-tedly by distorting its mission, and who remains in Chinacontributing to its development and his survival. Rather thana stark story of good versus evil, Dr. Yan’s account speaks tothe gray zone of survival, the banality of moral compromiseleading to untoward outcomes, and the unmasterable featuresof moral life.

Dr. Yan becomes more accepting of his family’s modus viv-endi, collaboration, although it remains for him a disappoint-ing reality of Chinese society. He told me in one of our finalinterviews that his family and the thousands like them hadlittle choice, if they wished to survive and do well, but to tryto work with local authorities, even if those authorities abusedpolitical power. His regret came from his recognition of thedownside of this moral climate: collaboration with unethicalpolicies and corrupt practices, continued injustice and inequal-ity, and lost opportunity for reform. It is the irresoluble ten-sion between personal refusal to do the worst and collectivewillingness to collaborate with lesser evils if need be that dis-appoint him in the possibilities of leading a moral life. Andwith a sad and telling realism, he recognizes that it is Dr. Xu,not himself, who can create a viable future for his work unitin the China of today, a China whose current local worldsalienate him thoroughly (perhaps too thoroughly). For Dr. Yan,and for me, Xu’s victory is a despairing one. And yet his owndefeat—for that is how Dr. Yan sees it, as a defeat—signifiesfor me the survival of aspiration for something finer and bet-ter that remoralizes the world. Dr. Yan’s refusal to exile Xu at

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the hospital’s mass meeting breaks the cycle of revenge andserves as an uncanny but greatly important instance of moralimagination and responsibility. He would not go along withviolence even when he would benefit, and he found a way tocreate an unexpected and more promising outcome.

Moral experience has no ending. Ethical reframings, suchas the one I propose above, may be used to make it seem thatDr. Yan is the ultimate victor. But I prefer (and I think Dr. Yanhimself prefers) to place emphasis on the uncertainty andunfinished character of the struggle to master experience thatis unmasterable. Ordinary moral experience is rarely aboutvictories. No human story can use the word ultimate. Countno man happy until the end, goes the refrain of the ancientGreek chorus. I take this to mean that in fashioning a morallife we are always subject to limits to what we can control,outcomes we cannot predict, and deep dangers that are everpresent. It is not a matter of waiting until Yan Zhongshu andXu Weiqing are dead to judge their lives; rather, there is noultimate basis for comparison. Seen in that light, Dr. Yan looksmore antiheroic than anything else. It is, after all, his criticalself-reflection on the dangers of the world and the self thatopen a space, even if a tiny and an unstable one, for protest,resistance, and potential remaking. And that is where my ownethical positioning comes in. I share Dr. Yan’s concerns andcritiques, but as an outsider who has not had to exist over thelong term within China’s moral ethos, I am hesitant to judgeand advocate something I think is better. Perhaps what Dr.Yan’s narrative really tells us is how greatly difficult it is to bealive as a subject in the local world and at the very same timestand back from or otherwise apart from the local so that you

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can bring into it an extra- or supralocal perspective to evalu-ate local experience and offer an alternative ethical vision.And yet, as difficult as that balancing act is, that is what needsto happen. If there is to be an ethics that humanly matters,then it must be part of the moral-emotional-political messi-ness that is what local life is. Dr. Yan’s narrative, that is, showsus just how painfully difficult it is to step outside our practi-cal personal and societal responsibilities (our moral world),imagine some other, more availing ways to live, and put theminto practice. His story also shows us that coming to terms withthe dangers and uncertainties of our lives, however painfuland troubling it is to confront what matters, is the existentialresponsibility we owe our humanity to craft a moral life that isnot simply the mechanical reaction of a cog in the machine butreflects the human potential for self-knowledge and collec-tive refashioning of who we are and where we are headed.This is the ethical requirement of human experience—not easy,never fully accomplished, always caught up in the limits ofpolitics, social life, and our own genetically and psychologi-cally based passions, but, at the end, what moral life is for.

Charles Kentworth Jamison

have waited fifteen years to tell this story of pain and theholy; suffering, sex, and redemption; religion and medicine.

I met the man I will call Charles Kentworth Jamison, a minis-ter from a liberal Protestant denomination in the Pacific North-west, in a university hospital’s chronic pain clinic, where forseveral years I was an attending psychiatrist. Following anintensive evaluation, I saw him every few months for twoyears. After I moved east, we stayed in contact for six yearsvia telephone and letters, and he came to see me on one occa-sion for a lengthy follow-up interview. A large-bodied, tall(about six foot three), robust man, usually dressed in well-tailored and fashionable but informal attire, with an expres-sive face and head of thick, unruly white hair, ReverendJamison was in his sixties when we first met. He had beensuffering from severe episodes of pain in his head and neckfor at least two decades and had developed a characteristic

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movement, a kind of tic, that represented his pain. Every fewminutes his right hand would massage his neck and the backof his head, while he simultaneously turned them downwardand from right to left. The pain was constantly present at amodest level, but periodically—every week or two, it seemed—it would get much, much worse. At those times, Jamison tooksemieffective non-narcotic pain medication but refusedstronger narcotic analgesics, which would have quelled thepain altogether. In order to dampen the pain’s intensity toan endurable level, he would stop whatever he was doing,go into his bedroom, pull the shades closed, turn off all thelights, lie flat on the bed, and struggle to make his mind goblank and relax.

Unlike most pain patients I interviewed at the clinic,Jamison had not himself chosen to seek expert help. Instead,he had with great reluctance accepted the strong advice of hisdoctors and family, who had grown frustrated by his inabilityto control his chronic pain. Jamison’s reason for attending thepain clinic was not the only thing that distinguished him fromthe other patients. In the course of our first interview, Rever-end Jamison shocked me so thoroughly that the routine lineof questioning, which focused on the problems pain eithercreated or intensified in the patient’s life, and which I hadperfected in evaluating hundreds of pain patients, stoppedin its tracks.

He looked hard into my eyes and told me all my questionsabout the negative consequences of pain were entirely off base.As excruciating and debilitating as the pain occasionally was,Jamison saw it as a very good thing. No chronic pain patientI had interviewed had ever confessed to viewing his suffer-

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ing as beneficial. I blurted out, “Surely, given all that you’vebeen through, you’re joking?” He took a deep breath, strokedhis head and neck in the characteristic manner, and repliedwith firm emphasis: “It has caused me to suffer, really suffer.But I still affirm it has been a good, a very good thing.”

I asked him to explain what this remark could mean, andReverend Jamison launched into the following story. He hadgone into the ministry in an indirect way, after zigs and zagsin his life trajectory. A popular and handsome football hero inhigh school and college, he had many girlfriends and manysexual affairs during his adolescence and early adulthood.Sex became so urgent in his twenties, he remembers, that hemasturbat*d whenever he was alone while experiencing de-tailed sexual fantasies that turned on female sexual odors. Hebecame obsessed with these fantasies, so much so that he felthe could do nothing to limit or remove them. The fantasieswere so intense and his self-control so weak that he felt unableto subdue them and was, as a result, guilty and ashamed.

In his early thirties he met a remarkable young woman whosoon became his wife. Her life experience had been almostthe polar opposite of his. Although she was quite beautifuland had a wide circle of friends, she was a virgin and firmlyembraced a Protestant abstemiousness equally applied to sex,alcohol, gambling, and frivolity—all of which, except for gam-bling, were things that Reverend Jamison had delighted infor a decade while he worked as an assistant high school coachand began part-time graduate studies in religion.

At the outset of their marriage, he worked hard to restrainhis fantasies and behavior. Their relationship developed intoa deep and in his words “miraculous” commitment. As their

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relationship deepened so did their sexual relationship, becom-ing more active and mutually joyous. However, five yearsinto that marriage, for no apparent reason, Reverend Jamisonfound himself experiencing again sexual fantasies of the sameintensity as in his early adulthood. He was a graduate stu-dent at that time and was surrounded by young women, sohe found outlets for his powerful sexual desire. But each timehe committed adultery he felt intense guilt, profound unwor-thiness, and self-hatred. Around the same time, his wife be-came pregnant with the first of their three sons. During thatpregnancy’s final trimester, she became dangerously hyper-tensive. (Many women experience some elevation of theirblood pressure during pregnancy owing to fluid retention,hormonal surges, and the enlarging fetus pressing on majorblood vessels, but some develop very high blood pressure,which, if untreated, can produce stroke, heart attack, or otherserious complications.) Because the condition put the lives ofboth the unborn child and Jamison’s wife at risk, the obstetri-cian suggested terminating the pregnancy, an option theJamisons quickly rejected. Reverend Jamison told me that notlong after that discussion he found himself alone with a younggraduate student with whom he previously had had a briefsexual liaison. He was extremely excited: his heart pumping,his thoughts racing, the erotic fantasies vivid like a motionpicture in his mind. Then a powerful and unexpected emo-tion flooded his sensation. He described it as a sensibility ofthe holy, a physical feeling he associated with accompanyinghis parents to prayer sessions when he was a child. Duringthose acts of intense prayer, when he felt himself directly ad-dressing God, he had felt his heart and breathing speed up

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and a sensation of lightness and buoyancy come over his bodyas if he were floating in the air. Suddenly he would experi-ence a jerking of his neck and his head would snap up andbackward.

This time he felt the rapid heartbeat and breathing, experi-enced the lightness and sensation of floating in the air, andhis neck and head snapped back. He sensed that he was inthe presence of the divine. He felt first thrilled and then hu-miliated by the sinfulness of his thoughts. He asked God tohelp him to control these intrusive thoughts and help his wifeso that her hypertension would come under control so shecould give birth to a healthy baby. He parted from the youngwoman, explaining to her great surprise that he could nolonger carry on as before because he had been called by God.

Over the next few weeks all that he prayed for came to be.His wife’s blood pressure returned to near normal and hisown invasive erotic fantasies ceased. A few days before thebaby was born he came to the decision that he would followwhat he now interpreted as a call to the ministry, an epiphanythat had delivered not only a healthy son but also salvation.His wife was surprised and concerned by his determinationto become a minister. She was skeptical of “true believers”and what she derisively called “religious magic,” and saidshe had not pictured her husband and herself so involvedwith a church. Indeed, she considered herself a nondenomi-national Protestant who found religious meaning in personalrelations and nature, not institutions. Her husband reassuredher that what he had in mind was not a fundamentalist com-mitment but a doctrinally liberal yet personally disciplinedProtestantism.

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Over time, Jamison became a respected minister with asmall but active congregation. He practiced a kind of Protes-tantism that he associated with highly liberal positions onmatters of doctrine and ritual and especially social policy. Forexample, he advocated against the Vietnam War, for civilrights, for women’s rights including abortion rights, and forconsecration of women as clergy. He considered himselfuniquely skilled at pastoral counseling. “Whenever I had aparishioner or family with problems concerning sexuality,adultery, or for that matter violence and other family tensions,I felt my personal experience had prepared me to be empathic,supportive, and helpful in a practical way.” He said that hecould understand what combination of inner and outer forcesdrive people to do what seems irrational, as with the case ofadolescent turmoil and suicide. He was sought out by ado-lescents and youth in trouble and developed a local reputa-tion for drawing them back to religious commitments. Hiscareer flourished, as did his family life. Their second and thirdsons were born, and his relationships with his sons and hiswife became the central meaning of his life. His wife also be-gan to develop a part-time career as a real estate agent, whichover the years elevated their lifestyle.

A few years into his ministry, Jamison encountered anotherdecisive moment. A young woman who had worked in a pro-fessional escort service and as a nude dancer came to see him.She complained of experiencing elaborate erotic fantasies andsometimes acting on them. Reverend Jamison felt himself fal-tering for the first time in years. “It became clear pretty quicklyI wasn’t prepared to deal with this. It was way too seductive.On the one side I wanted to help this woman, and on the

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other side, I wanted to act it out with her. I began to feel outof control myself, and a hypocrite. You know, I’m counselingyoungsters who are pushed into sexual activity at an earlyage by our culture’s preoccupation with sex and youth, andon the other hand, I’m experiencing the same biological andpsychological urges they are, [and those urges were just] asuncontrollable. . . . I didn’t know what to do. One minute myhead was full of prayer, the next minute overrun with sex.And I was ready to do it with this poor woman. No, it wasworse than that. I called up escort services, then hung up thereceiver. I drove my car past X-rated clubs, and part of mewanted to dash in and see and do all kinds of things. I startedmasturbating again. I was about to dive off the deep end. Myown congregation was physically near to a couple of X-ratedmovie houses and bars with advertisem*nts for live nudedancing. It was a real bad area but one you drove through onthe way to shopping. Suppose my church members saw megoing into one of these places or were there themselves? Howwould I deal with it? I felt so torn between desire and guilt Icould have screamed. Then my wife had a business trip thattook her out of town for several weeks. That time was purehell for me. I felt like my body had become a battle zone forendlessly conflicting emotions. Terrible.”

Then, at a point at which Reverend Jamison felt he couldno longer control himself and was about to give into his over-whelming sexual fantasies, he experienced what he wouldlater call “divine intercession.” He woke up one morning, af-ter spending the night sleepless and sexually aroused, with astiffness in his neck and an ache in the back of his head. Overthe course of several days the sensation worsened into the

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pain he experiences today. At first he interpreted the pain lit-erally as God’s punishment. Later he took it to be God’s grace.Periodically, over the decades, especially at times when hefeels a return of fantasies and can (outside of intercourse withhis wife) smell sexual scents, the pain worsens into a strongerparoxysm. The intense pain both breaks the intrusiveness ofsexual fantasies and produces relief and a sense of control. Itfollows a trajectory of transformation from the unendurableto the endurable and then to the spiritually transporting. ForJamison, his pain increasingly fused with religious sensibil-ity, enabling him to identify with Jesus on the cross. It be-came a feeling of transcendence, as if he was moving throughsuffering to the sublime.

Pain, for Reverend Jamison, is salvational, converting aharmful and unwanted desire into a state of grace and re-demption. “You’ve got to see it my way,” he explains. “Thepain hurts a lot and periodically disables me, but much moreoften it empowers me. It has made me much more attuned tothe bodily representation of the spiritual and emotional stateof others. It has made me a better listener. But more than that,it makes such a powerful difference in my own life.

“I see religion in the body, in emotions, in personal andfamily struggles. And of course for me, it brings me closer toGod. I believe it is my struggle between evil and good, andgood wins. It is an experience of the holy born out of the flow-ers of evil. It teaches me that we are not helpless when pow-erful desire takes over. It makes me more aware and morecritical of how our own culture manipulates desire. It hasmade me a better minister, especially to youth and adoles-cents in trouble. I know what they are going through. I be-

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lieve religion can be right there with them in their experi-ences. I’ve learned, I guess, that for people like me the worldis not so much about moral choice. How could I make a ratio-nal choice in the face of overwhelming bodily feelings? Reli-gion is what makes moral life feasible in the face of suchpowerful cultural and biological currents. Religion makes thebody remember; pain can be a religious memory. That’s whyI can say, honestly say, my pain has been a source of good inmy life. Doctors don’t get it. The pain clinic didn’t. This is areligious, not a medical, thing.”

Jamison did not use his criticism of cultural and biologicalforces shaping experience to justify his own failings, aboutwhich he was equally critical. These forces were not scape-goats in his way of seeing life. His own failings were his re-sponsibility, he told me repeatedly. Yet these highly personalproblems, he also insisted, could not be controlled or rem-edied by individuals alone. The confluence of cultural mes-sages, biological impulses, and personal actions that was atthe root of addictions to substances and to sex, ReverendJamison said to me, required religious intervention. When hetalked about pain as a religious memory, he meant that painwas his ethical conscience and that it created in his sensibilitythe memory of God’s grace working in his life.

Jamison’s emphasis on the import of religion is not as ex-traordinary as it may seem. Of all the rich, technologically ad-vanced countries in the world, America has by far the highestpercentage of people who express a belief in God: more than90 percent of Americans are religious in this sense. In compari-son, in more secular European countries, rates of belief canfall below 65 percent. Also, about two-thirds of Americans

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state in surveys that God has been active in their lives. By thisthey mean that God has guided decisions and affected out-comes. This is a figure that dwarfs the statistics for Europe.Religion in America centers on personal faith and individualspiritual quest more than theological niceties (although cer-tain core Christian tenets such as the sanctity of life have beenpoliticized and clearly are taken very seriously indeed). Forexample, Americans define religion as the spiritual aspect ofthe self, whereas Europeans see religion more broadly in termsof theology, ritual, and the institution of the church itself. ForEuropean and Latin American Christians the social gospel ofjustice seems more alive and important than it is for U.S. Chris-tians, who have in recent decades turned away from socialjustice toward more individual cultural values such as per-sonal liberation and salvation. William James’s Varieties ofReligious Experience, which defines religion in psychologicalterms, remains popular a century after its original publica-tion. For James religion was a feature of mind and feeling,not institutions and rituals. Catholicism and Judaism havebeen Protestantized in America, with greater emphasis on thedeep personal roots of religiosity. Pastoral counseling, whichrelies on a secular quasi-Freudian approach, is an importantaspect in the training of American religionists. This is not thecase in many other societies. There priests and ministers coun-sel about issues of doctrine and religious practice; in theUnited States they may do so as well, but counseling is largelyunderstood to be a psychological education and treatment.

Thus, religion and psychology are closely related in Ameri-can society. And religion is also present in alternative andcomplementary medicine; acupuncture and herbalism, for

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example, are often practiced along with a language of spiri-tuality. Patients are encouraged to meditate and find theirspiritual center. Indeed, in an age of simply enormous tech-nological and scientific advances, religion now infiltratesnearly all aspects of American society, including medicine.Pain specialists have long recognized the role of religion as asource of psychosocial support in the clinical management ofchronic pain patients, but biomedicine, the legally definedmedical profession and its hospitals and research centers,which had a long history of professional hostility to religion,is newly welcoming to religious issues. Medical students arenow introduced to religious questions in courses on patient-doctor relations, and medical ethicists, psychiatrists, and pri-mary care physicians are expected to show genuine respectfor religious concerns. Today, there is a new rapprochementbetween religion and biomedical science, with researchersstudying how spiritual practices and religious rituals mayinfluence the hormonal system and with it immunological andneurological processes that have physiological effects on in-fection, pain, the placebo effect, and healing. Stress worksthrough this hormonal system to alter cardiovascular andmental states. Religious practices have been shown to limitor even reverse these effects. Harnessing the healing benefitsof religious practice is now a serious scientific undertaking inmedicine.

Religionists played a founding role in the development ofAmerican bioethics. Religious values are often of concern topatients and families and caregivers at the end of life and inother serious clinical scenarios. Reverend Jamison was in-volved in psychological counseling. He was deeply interested

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in the science of stress and how religious practice affectedstress responses, including his own. He worked with ethi-cists on clinical issues, including those around the end of life.And he was fascinated by religious healing. But I am espe-cially interested in the religious entanglement with moral ex-perience in his life, illness, and treatment.

Reverend Jamison’s everyday bodily experience, in hisperspective, becomes a personal battleground between goodand evil, desire and divinity. God’s grace, he believes, keepshim from succumbing to sexual impulses that earlier he actedon in ways that made him feel sinful. Pain mediates betweenhis intimate struggles and the holy. Pain is salvific, savinghim from the torments and humiliation of desires he can oth-erwise not control. Pain orders his experience, not only sig-naling what matters most but realizing it. And it prepares him,in his mind, for his ministry, which seeks out those who, likehimself, suffer from powerful psychological processes theycannot master.

I am most definitely not implying here that all physicalsuffering is the result of God’s will. I am reporting what Rev-erend Jamison said throughout the years I knew him. ForJamison, leading a moral life amidst danger and uncertaintythat matched his ethical aspirations meant living with painand finding God through that pain. Suffering had for himpositive ethical significance that transcended medical diag-nosis and treatment. Pain is part of moral life, he insisted,and it remade his way of living so that he could surmount thechief moral peril he faced.

Of course I have worked with other patients for whom re-ligion loomed on the other side of the pain equation, includ-

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ing ministers and their spouses whose pain was worsened bytheir ministries, including their extensive social obligations.For example, one rural minister’s spouse’s back pain intensi-fied when the large social obligations she had in their ruralcommunity made her feel trapped in a glass bowl where shecould not express herself. Many people who experience paindo not interpret their suffering in religious terms. I have satby the bedside of patients whose severe episodes of pain couldnot be controlled by prayer and who felt nothing at all in theway of religious transformation. Their moral worlds andbodily habitus were quite different from that of ReverendJamison. Several felt that God had abandoned them. Othersobserved that pain itself was the main danger in their lives.Several chronic pain patients told me that to control the se-verity of the symptoms, they had shut down their careers andfamily, and their way of living had been greatly impoverished.

Reverend Jamison refers to the body in pain as a source ofmemory. The body remembers the unsuccessful struggles tomaster unwanted experience, and the suffering body remem-bers God. Embodiment—namely, experiencing meaningthrough bodily process, such as pain—is a means of collec-tive as well as individual memory. As numerous researchershave noted, bodily practices such as a certain pattern of ges-tures, movements, body piercing, or physical complaints canrepresent cultural meanings and social position. In this case,embodiment unites emotions, values, and ritual. ReverendJamison’s bodily tic can be interpreted as the outward expres-sion of an internalized prayer, a ritual of remembrance, a reli-gious practice calling forth the presence of divinity. Theefficacy of his prayer is not found in the disappearance of his

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pain, as it so often is in healing rituals; rather, the pain itself,as it is made over into the sacred, is the source of his moraltriumph in sublimating unwanted sexual desires into religiousmeaning. Perhaps in this way, Reverend Jamison’s experiencecomes close to early Christian and medieval representationsof pain as sacred in itself, an aspect of the suffering self thatacts as a mediating bridge between the person and God. Thepoint has been made by historians of Christianity that earlyChristians valued a suffering self in contrast to Romanstoicism’s devaluing of suffering. For Christians, the suffer-ing self linked their experience of the world with Christ’s.Suffering itself was valued for this religious reason. Jamison’sillness narrative too is not about an easy or superficial heal-ing, or even healing at all.

Of course, there is also a more skeptical reading of thereverend’s tale. Some might read into it indiscipline, absenceof self-control, immature sexual desire, and the abuse of reli-gion as a merely utilitarian device to cover over a deeply prob-lematic ethical failing. This is not how I personally sawReverend Jamison nor continue to imagine his inner world,but I cannot contest an alternative perspective. Perhaps forsome Reverend Jamison is sinful, a self-deceiving preacher,unworthy of ministering to others with his own inner worldin such disarray. This core tension between different read-ings of Reverend Jamison’s story—pain as authenticity ver-sus pain as deception—reflects a deep current of uncertaintyand suspicion in human conditions of chronic pain. Is the painthat authorizes disability benefit claims real or is it a strategicploy (conscious or unconscious) to obtain financial support,among other benefits? This core conundrum in chronic pain

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care challenges a naive therapeutic understanding as a mis-representation of a deeper, more disturbing reality. Becausemoral experience involves strategic acts meant to alter theperspectives of others, our ethical reflections can be taken tobe disingenuous moves in games of power. We use pain forlocal purposes. Viewed this way, Reverend Jamison could beregarded as a sociopath, with religion merely camouflage forantisocial behavior.

As I have framed the issues in the preceding chapters, Rev-erend Jamison’s local world must be the starting point forunderstanding his pain experience. But then what? Do wefollow Emmanuel Lévinas’s insistence that face-to-face ac-knowledgment of his suffering is the basic ethical action?Lévinas holds that ethics always comes first, and ethics meansaffirming other persons and their suffering. But what if thissuffering is inauthentic? And if so, where does that leave hiscaregivers and family, who experienced such frustration? Sowhat should be the ethical response to Jamison’s perplexingmoral experience? Is the core ethical action one of criticizingthe reverend’s too comfortable and comforting dilemma fol-lowed by pressure to get him to give up his painful yet ac-commodating defense in favor of some less costly (to familyand health care providers) way of coming to terms with hisbiography and his passion? Is the change that is called fornot within his psyche but in his world—that is, in his rela-tionships with his wife, children, and parishioners? Or doesthe problem lie in the inadequacy of ethics itself to come toterms with Jamison’s unsettling emotional and moral turmoil?This range of questions might have helped me shape a thera-peutic response better than administration of yet another pain

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questionnaire or newly developed analgesic. In the care ofpatients with chronic pain and other chronic illnesses, pro-fessional and family caregivers need to address the ethicaland religious issues as much as the medical and psychologi-cal ones.

In the end, I guess I intuitively followed Lévinas’s model. Iaffirmed Reverend Jamison’s experience of pain as well ashis religious experience as real. And I dealt with his sexualfantasies not just as a psychological problem but as a moralone. But I wondered about the alternative. For as we shallencounter it in a later chapter’s description of the contribu-tions of W. H. R. Rivers, medical intervention turns not onlyon the relation between moral experience and emotions butalso on the politics of everyday life. It is the latter—the po-litical side of family and work experience—that seems leastdeveloped in my interpretation. What was religiously trans-formative for Reverend Jamison was pure frustration for hiswife, children, parishioners, and doctors. Was his the politicsof resistance against the conventional constraints of the every-day middle-class American world? Did his chronic pain ex-perience provide Reverend Jamison with sanction for hiscriticism of the dangerous effects of American society on ado-lescent and young adult sexual development and their han-dling of violent impulses? Did his religious response to hispain legitimate his countercultural therapeutic efforts on theirbehalf, including his insistence that what medical profession-als and increasingly laypersons regarded to be the individualpathologies of adolescents in turmoil requiring medical treat-ment was in fact conflict and contradiction in Americans’moral experience over sex and substances—cultural conflict

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and contradiction requiring ethical and ultimately religiousintervention? Did this apply to his own personal encounterwith chronic pain, pain that defeated his caregivers, includ-ing the medical system? Not having carried out an ethnogra-phy of Reverend Jamison’s local world, I can’t answer thesequestions with any conviction. But over the years, my encoun-ter with Reverend Jamison and many other patients whosechronic pain frustrated professional medical and familycaregivers has only intensified this line of inquiry. Painchanged their world. On superficial psychological and medi-cal reckoning these changes seemed entirely negative. Butapplying broader social interpretation, I have often wondered,as in the case of Winthrop Cohen, if bodily experience of pain,depression, exhaustion, and other chronic symptoms are notalternative forms of criticism and protest, and, in the case ofReverend Jamison, action meant to have societal effects mak-ing over local worlds into new moral conditions.

What I mean here is that once such symptoms have be-come chronic, for whatever biological or psychological rea-son, they can also come to express, say, the alienation that apatient feels from society, criticism of a spousal relationshipor that with a business supervisor or co-worker, or protestagainst financial and political realities more generally. Chronicpain is a major complaint for the American disability system,and because so many of those who receive disability benefitsare working-class or poor, that system is sometimes regardedas an indirect transfer of wealth in a society characterized byincreasing social and economic inequalities without manyother means of transferring resources. Thus, chronic pain, inthis regard, could also be viewed as a weapon of the weak, an

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action meant to improve economic and social conditions. AsI noted in Dr. Yan’s story, during the collective trauma ofChina’s Cultural Revolution many intellectuals and cadreswho became political targets developed symptoms of neur-asthenia. Three of these—headache, dizziness, and severe fa-tigue—seemed to express collective as well as personalfeelings of exhaustion with the political campaigns, disorien-tation in a society in which the leaders and even the valueswere being overturned, and pain from the trauma of publiccriticism. Under the repressive political regime of the People’sRepublic of China, this was one of the few ways to expressprotest and criticism. For Reverend Jamison pain was not justa complaint but a way of coping with the frustrations of acultural gap between actually lived moral values and ex-pressed ethical aspirations that he took to be a huge and dan-gerous hypocrisy, a hypocrisy that he recognized in himselfas well. And through his actions on behalf of troubled youth,Reverend Jamison could be viewed as acting on his own worldto reduce that gap between the real and the ideal out of areligious passion whose source seemed to be the pain of un-acceptable sexual desires. In that sense, we might imagineReverend Jamison going beyond criticism and protest ofAmerican culture to try to remake the psychocultural dynam-ics of youth inhabiting his world. Whether or not we agreewith this interpretation of pain, we can still appreciate thatfor Reverend Jamison there is an ethical project of transform-ing the self and the world.

Sally Williams

or those who are seriously sick and for those who care forthem, illness is quintessentially moral. Serious illness elicits

the deepest and most complex emotions: fear and demoral-ization, rage and humiliation, but also the awareness of pre-viously unrecognized values. Illness can, for some, make lifematter. A newly diagnosed cancer patient, for example, hashad to work through the anguish of uncertain diagnostic tests.There is also a limbo-like state in which emotions swirl be-tween expectations of polar opposites, normality and death,before she is told she definitely has cancer. During the trialsof treatment, denial can alternate with giving up. Along thetrajectory of cancer care, she concentrates her focus on com-pleting the treatment, but also on those people and thingsthat matter now. She may rediscover her religious connec-tions, revivify her marriage, find that neighbors really canhelp, sink into such despair that for the first time in her life

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she is willing to do psychotherapy, or reconnect with elderlyparents to talk through family burdens she never thought shecould voice. I have interviewed such patients, as well as manyothers who felt with a new limit placed on their days theywould do those things that brought beauty, happiness, andhope: travel, return to long-dormant artistic interests, read,learn a new sport, buy clothes, pray. If the cancer can’t becontrolled, this woman’s end-of-life days will turn on moralmeanings, from the way she seeks to die to the rituals andceremonies she wishes to memorialize her life and all thebusiness of ending life—wills, funeral arrangements, con-fession, final words—that few can imagine is truly final un-til we actually do it. Examining the cultural and personalnexus of illness is another way of understanding what re-ally matters.

Sally Williams is a fifty-four-year-old artist and owner of asmall art gallery in New York City. Tall, dark-haired, round-faced, her olive skin tanned and glowing, she looks a decadeyounger. Sally’s gaze is open and direct, and yet there is some-thing in her visage—“a shade of sadness, a blush of shame,”in John Greenleaf Whittier’s words—that gathers darknessand suggests things deeper and hidden, hurtful things. In heradulthood Sally has been many things—the daughter of adepressed, alcoholic father and a mother with advanced Alz-heimer’s dementia; a wife who has been separated from andreconnected with her husband, Daniel, a business consultantand environmentalist, and their three adult children; a talentedlandscape painter whose work has been displayed in galleriesand purchased by museums; a successful small-business ownerwith a thriving gallery; a member of a small, closely knit net-

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work of friends, most of whom are artists and writers; and,most tellingly, a recovered drug addict who two years beforeI first interviewed her was diagnosed with AIDS. I haveknown Sally’s husband for two decades out of a mutual in-terest in things Chinese; I got to know Sally slightly throughhim. After she found out about her diagnosis she asked me ifI would be interested in interviewing her because of my re-search with patients suffering chronic diseases. I had donesomething like this with patients with other disorders on sev-eral occasions. Sally and I have had eight interviews stretchedout over five years.

When Sally first discovered she was infected, in 1997, shewas completely straightforward and open about her disease:“I wanted my children, each of them, to know my AIDS sta-tus, and my friends too.” Sally reports it wasn’t easy tellingthem, or her husband, but when she finished she felt “liber-ated.” It was particularly hard “to explain all that I did fortwo truly miserable, horrific years, after the separation frommy husband Daniel, a decade ago. I became a dope addict,about as low as you can get, doing anything for a fix. That’swhen I got infected, though I didn’t know it until two yearsago, when I developed chronic diarrhea and exhaustion.”

Sally looked back over the eight years between when shegot clean and when she discovered she had AIDS: “You see, Ihad spent those years building myself back up again. I madea good place in the world. I became a successful artist and aneffective businesswoman. I made the gallery into somethingspecial, and then that bad time came back in the worst way tohaunt me, to hurt me. AIDS. I felt ashamed all over again. Ihad stayed clean. But I wasn’t clean of infection. I learned I

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had AIDS at what was turning out to be the very best time ofmy life.”

Sally continued: “I wish I could say I’ve managed well.I’ve had big ups and downs since learning I was infected.Two of my kids, my boys, at first turned away from me. Theyhad had enough and were in denial. Now they are support-ive and loving. My daughter, Jennifer, God bless her, in spiteof all she has to do in graduate school, was there, completelythere for me. Most remarkable of all, my husband returned.He came back in my life, back to help. Isn’t that crazy! Al-most a decade before, he walked out, away from me. He foundsomeone else. I fell apart totally. When I was doing drugs, Iactually tried to burn him, to make him pay. . . . Then aftertwo years at rock bottom I rebuilt my life. On my own andstarting at the bottom, I succeeded . . . in my art, in my busi-ness, and in my . . . well, in the art of living. So then I getseriously sick with this terrible disease and he comes back. Adifferent man, a different me, and a different, a very differentrelationship. He is . . . well, great. We still don’t live together,yet we might as well. He is always here with me. He wants totake care of me, and he does. He takes care of me. We aredeeply, fully in love again.”

Sally’s marriage is not the only aspect of her life that hasstabilized. She has experienced two serious opportunistic in-fections that could have killed her. “They knocked me to myknees. Terrible! I was completely out of it; thought I was onthe way out.” But now she takes twenty pills each day and issymptom-free, looking healthy and flourishing. “It is incred-ible, how these pills make this disease a chronic conditionyou can live with. Imagine if I had AIDS at the outset of the

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epidemic with nothing to stop the progression . . . dyingslowly, day by day, in pain, with diapers, nothing but skinand bones, demented, vomiting, sh*tting, and with so muchignorance and stigma like a dark halo encasing me.”

Previously a reticent, self-involved, deeply private woman,Sally astonishes herself by her newfound outspokenness andactivism on behalf of AIDS and drug abuse programs. Sally isexplicit about this change in her personhood: “Somethingsnapped. Something gave way . . . some deep hesitance. I feela new Sally Williams. Less, much less self-absorbed; more,much more out there . . . saying what needs to be said. I’vegot no time now for indirection. I speak up, speak out, andit’s not about me. I kinda lose my sense of self in some muchlarger, more important world out there.”

This appealing image of becoming absorbed in somethinglarger, something in which you lose the self, recurs throughoutour talks. Sally is convinced that enlisting in the AIDS and drugabuse movements is a positive transformation in who she is.She overcomes a formerly compelling privacy and moves be-yond an inhibiting selfishness toward action in the world, ac-tion on behalf of others. The sense of inner resistance givingway so that she can do things means that whatever held incheck her ability to engage with others also limited her ownartistic and business talents. Traveling inward inhibited her;traveling outward into the larger world is liberating. She expe-riences creativity and happiness, in spite of her serious sick-ness, and she does so by losing the self, and its inhibitingpreoccupations, in doing things that matter to her now.

“I feel an inner pressure to make my ideas known and todo something about them. Act on them.” Without trying to

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excuse or defend herself, Sally refers to her pre-drug-abuseand pre-AIDS persona as a “taker.” She explains: “I was soselfish that, looking back, I realize I was caught up in what Icould get out of people, even the family. I was not a giver. Itook and I expected more. I simply didn’t concentrate [on]what I could do for others. Not a good way to be, but I’ve gotto be honest, that’s the way I was.”

Despite her previous self-absorption, Sally feels that she’s“different now. I really am. I see beyond, well beyond me. Iguess I realize that when I die, and who knows how soon thatwill be, I’ll . . . well, I’ll be taken up in the immensity of theuniverse. What remains won’t be me, but what I’ve done forothers. This damn disease, and actually also the drug abuse, ismy great teacher. Life is about doing for others—family, friends,the world, I guess. I’ve got no time for my inner demons.They’re not important enough. I’m not important enough. I’mhere to get on with it, get on with the big things that count, thatcount for me and, more importantly, for others. . . .

“I know now that we are in the middle of a great plague, aworld epidemic like the Black Death in the Middle Ages, andwe are mostly oblivious to it. Actually there are two epidem-ics, deadly ones: AIDS and drug abuse. And they go together,as I know from a hard, hard experience. But because theseepidemics are primarily with the poor, with people of colorwho are made to count for less, we don’t do what needs to bedone. We don’t pour in the resources. We just let this fire burnslowly, consuming those who matter less, until it touches onthe world we know, the comfortable, privileged world. . . .Well, I know what these things are, from the inside. Theychanged my life. I want people to wake up.

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“Life is one helluva serious business. It hurts you; it cankill you. I was raised like so many people in the U.S., with anentirely false sense of comfort and security. I know! I fell rightout of the middle class to the lowest. I sold my body for a fix.I needed drugs so bad I allowed myself to live in filth in abasem*nt with other dope fiends. I shared needles withdrugged-out people I hardly knew. We used dirty syringes,dirty water. We were animals. We acted like that because wecouldn’t control our need, our desire for drugs.”

Not unlike Reverend Jamison, Sally Williams contends thereare two sources of her tragedy. She acknowledges her own self-ishness as the cause of her self-destructive actions. Yet that fail-ure to feel anything beyond the self as truly valuable sheattributes to more than an isolated character flaw. Her selfish-ness, she argues, is powerfully conditioned by hyperindividual-ism, narcissism, blindness to the unjust human conditionssurrounding us, and deafness to the call from our local worldto do something to remedy and repair those inhuman condi-tions. These are dangerous cultural forces of our time and placethat translate into self-destructive (which also means world-destructive) behavior. That is what makes her ashamed of herpast, and that is also what makes her feel that, while her past isbehind her, she must respond to the call for responsible action.

“Been there, done that!” she concluded emphatically. Shecontinued bitterly: “Oh, I can’t even think about it withoutwanting to cry, to scream. How did I do it? How did I getthere? You want to know what I think? I don’t mean to offeran excuse, just understand what happened.

“I must have been eleven or twelve when my father startedabusing me. It was never sexual. But when he was flat-out

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drunk—like a couple of times each month—he could be verymean and violent. He punched my mother, made her cry. Heslapped me and my brother. Rarely he threw us around, likerag dolls. One night he was a monster, the next day he criedand begged our forgiveness. Most often, he acted, we all acted,like nothing was happening. We weren’t supposed to talkabout it. No, that’s not strong enough: we couldn’t, not a word,talk about it. It was like there were two worlds. One up, oneupside down. And you couldn’t say anything. . . . Well, itmade everything seem false, a great pretense of normalitycovering over a real hell. It was the silence, the secret thatcame to be the worst part. It eroded all the good, the love, therelationships. It felt dirty and wrong, completely so. It forcedme to be suspicious of everything, of everyone. I didn’t be-lieve anything that sounded good. I couldn’t conceive of ac-tions that could be good. It was like rot warping the structureof our lives as a family and my life.” Sally identifies feelingsof inexpressible rage, shame, and fear with this formative timein her life. These are the “inner demons” that she associateswith being “a taker,” being trapped in isolating cycles of hesi-tancy, self-absorption, and alienation.

“I think it kept going inside me, years and years afterward.Most of the time I guess I was okay. Popular. Attractive.Happy, even. Then periodically I would fall into a dark, darkplace. I was angry and depressed. Hopeless is not too strong aword. Then, after a spell, I’d climb out of it, back up into myother persona. A few episodes in my marriage, then my hus-band had enough. He left me when he finally couldn’t take itany longer. And that was when . . . oh, God! . . . that waswhen I . . . I really, totally, absolutely lost it. First I started

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drinking—a bottle of wine, then stronger things. . . . I knew Iwas in free fall, like Alice falling into Wonderland, only I wasin hell, Dante’s circles, falling from one down to the next, until,well, until I . . . I hit the bottom.”

She continued with a mixture of anger and sad vulnerabil-ity: “I lost control. I lost my identity. I even lost my sense oftime and place. I OD’d a couple of times. I got an abscess inmy thigh from shooting up with dirty water. Pus oozing outof a hot and swollen mass—painful and ugly. An apt meta-phor for my life. I also was hospitalized with hepatitis A. Iwas suicidal. The more I force myself to think on it, the moreI reckon I was thoroughly depressed, all the time. I tried tokill myself twice, once with an OD, the other time with poi-son. Now it all looks so distant, like another country. Onlyevery time I revisit it, I feel an equal mixture of horror andshame.”

Sally told me on several occasions that the depression andsuicide attempts represent an alienated, destructive self thathad lost its moorings in her world. As she spun out of thatworld into its predatory margins of drug abuse, prostitution,and the degradations of utter poverty, it was as if she hadentered another local world—a “hell” of emotional, economic,and moral inversion, “another country” that now feels horri-fying and shameful.

I asked Sally how she got out of it.“That I really truly don’t know. I only know one day I liter-

ally pulled myself off the floor. Said that’s enough. No more!No more abuse . . . [of] my body, me. I entered a detox pro-gram, and I came out clean. One of the less than 10 percentthat make it.” (Fewer than 10 percent of heroin addicts who

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enter rehabilitation programs complete those programs andstay clean.)

Soon after she got out of rehab, Sally started painting again.She knew that she had the training and the talent, but shealso knew she had to work hard and long at it, something shehad never done. “I poured myself into the work. I spent allday absorbed in painting. I woke in the middle of the nightand felt a pressure to paint. At first, my work was simply rawenergy, emotional hurt, exposed, but after a while it got moremature. I could work things through, difficult things, hor-rible things. My landscapes got darker, rougher . . . lots ofclotted space, dense, viscous space. The colors seemed to comeout of some hidden place in me.

“Earlier, when I was painting I never felt like I was a seriousartist. I had friends who were, yet it wasn’t there for me. I mean,the passion and the need were there, but not the . . . the comingtogether of inner vision, feeling, and execution. I mean formand sensibility, imagination and experience. Earlier on, I didn’tget it, I didn’t realize what it was that wasn’t happening, onlythat I seemed to be pretending. I couldn’t find, locate the placeI wanted to be. It was a great frustration.

“And come to think about it, I felt frustrated with my friendsand family too. I mean with how I was with them. With myartist and writer friends, I was a good listener. I supportedthem. But I really didn’t hear what they were struggling todo. I was all on the surface. The ones I admired, why, theywere at another level. They seemed to know what mattered,and I was completely unsure. That’s what I mean when I sayI didn’t get it. Kinda the same with Daniel and the children. Iloved them fiercely, but I didn’t know [how] to show it. I was

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too self-centered. It was all about me and my feelings of un-certainty. No, I think inauthenticity is the right word. I wasn’tsure who I was. I wanted to be different with them but I wasall encased in myself. Clotted . . .

“After I got back on my feet something happened. I felt thisgreat sense of responsibility, but it wasn’t to self-actualize; itwas more creating a new way of relating to my friends andfamily and my work. I was just as serious about them all.That’s why the combination of my own art and running thegallery seemed right. I also watched the constraints, or reallyrestraints, that had tied me up in knots, give way, and some-thing new come forward. I felt . . . well, different. More ableto be open. More in need of being direct. More willing to riskwhat it takes to bring all the crazy aspects of my world to-gether. I earlier lacked . . . the strength of conviction to beopenly critical. I hadn’t been able to act on things, to changethem. I let others do the advocacy. I stayed away, I shied awayfrom . . . from, well, power, from influencing others.

“I also had a couple of good breaks with my art. No, I madethose breaks. I made sure I got reviewed, noticed. It was thrill-ing and life-affirming to be praised. I realized I had the powerto be praised. Nothing like that happened before. I mademoney. I used it to buy this small place and fill it with paint-ings from people I [had] known for a long time, people likeme. Not big reputations, no famous names. Just damn finepainters. And this place was a success too . . . unbelievable,really. So I had made it back. And it was on my own, on myown terms. That mattered a lot. I had done it. I was doing it.

“Then I found out I had AIDS. Wow, that was a big one!Like I had been hit in the face, pushed against a wall, smashed.

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Amazingly, this time no falling down, no giving up. I guess Iknew, really knew from the worst experience, what couldhappen if I let myself fall down. I had been through all that.No more! No, I just couldn’t go through it—the loss and theshame—again. I had to work this thing through. Stand up toit. Face who I was and what was happening, what had hap-pened to me.

“By then my mother had dementia. Was lost in it. Shecouldn’t even recognize me at first. It was so sad. But I satwith her and gently told her about the AIDS. I don’t think sheunderstood much. Yet talking to her made me see things muchmore clearly. The whole picture. I went on for hours and hours.She would smile at me like I was talking about how to makea pie or how things were in the houses we had lived in. Shewasn’t there cognitively. Emotionally somehow she seemedto know. She seemed to bless me. . . .

“My father was drinking as usual, but from a bad drunkhe has become a sad drunk. He falls asleep. He spins stories.He lets himself show the hurt and despair. I talked to himtoo. And he kissed me and said he would stick by me, justlike I had stuck by him.

“My sons. What can I say? They, like my husband, had beenbadly burned when I was on drugs. They couldn’t handlebad news. Charlie, the oldest, he told me I got what I de-served. He shouted at me. Cursed me. Then he cried. I cried.And he held me tight and told me he was ashamed of himselffor how he reacted, not me. He was great from there on. Willwas different. He was very quiet. Said almost nothing. Didn’tcall me back. Didn’t return the calls. Dropped out of my lifefor at least a few months. But then he and his wife, Annie,

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came around, really came around too. They came over withfood, with treats. We have had some great times.”

Sally is most regretful about her relationship to her sons.She carries considerable guilt about her parenting, first be-cause she believes she failed to give them all the emotionaland practical support they needed when they were young,and second, because during the years of drug abuse she liter-ally dropped out of their lives. Initially when she reappearedshe caused even greater pain by exposing them to the desper-ate life she had “fallen into.” Much of her time now is de-voted to them and especially to her grandchildren. “I need tobe there for them; I know that. That’s probably at the top ofmy priorities, and it’s turned out to be wonderful.”

Sally’s daughter’s reaction to the news was quite differentfrom that of her brothers. “Jennifer was great, right from thestart. She is a hefty teddy bear of a woman with a big heart.Always was. She held me and helped me. Moved in. Took over.Put school on hold. I think she pulled me through that firstweek so quickly, so well the rest became easier, much easier.She called [Sally’s husband] Daniel. Told him he had to be there,be of use. He came right away. He was practical as usual butseemed distant. He told me how much I had hurt him when Iwas on drugs, begging for money, shaming him in front offriends. He couldn’t trust me then, still wasn’t sure he couldnow. Well, it took maybe a month, and then, miracle of miracles,we were back together. Better than before. We knew what wehad now. The other day we went to a cemetery we always ad-mired for its beautiful trees and seaside setting. We bought aplot. Not in a negative, this-is-the-end way. But in a happy,almost giddy, this-is-the-right-thing-to-do, do-now way.

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“And my friends have been great too. I knew I had a realcircle of friends. Strangely, I had never called on them. WhenI was doing drugs, I was too ashamed to ask for help. When Istarted up again, it was me who was doing for them. Theselast few years, my friends . . . have really been there for me. Inthe hospital. In the gallery, helping out run the place. Pro-moting my work. Even helping with the family. Ask Daniel.”

Daniel reported that in the two years after she was diag-nosed Sally would occasionally explode with rage over hercondition. At one time, she kicked a hole in the plasterboardin the bedroom. Another time she smashed a dish on thekitchen tiles. These dramatic outbursts didn’t last long. Theypunctuated much longer periods of gentleness, compassion,and calm. Daniel observed that Sally had long had difficultyhandling anger and fear, but that for the most part the AIDSyears were better in this regard. In my experience, such erup-tions of anger are not uncommon among patients with life-threatening disorders, and also among their caregivers. Sallyclearly had held rage in check during the years of physicalabuse by her father, and a psychodynamic formulation of hersubstance abuse, depression, and suicide attempts would haveample evidence for emphasizing anger toward close othersand herself. But I did not find anger as crucial an issue for heras the movement from self to world.

“So AIDS has been devastating, no question: a reality checkof the most basic kind,” Sally observed. “Yet it’s also beenabout something else. In some inexplicable but transportingway, AIDS has taken me to a different place: a place of truth,deep truth, and kindness—love, really.”

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Sally donates a significant percentage of her earnings to in-ternational AIDS treatment and prevention activities as well asto drug treatment programs. She has traveled to Uganda, SouthAfrica, Thailand, and Brazil to visit AIDS and drug abuse pro-grams. She has attended international AIDS conferences andcontributed to a global lobbying effort aimed at convincing themajor pharmaceutical companies to allow sophisticated AIDSdrugs to be made available as low-cost generic medications forpoor people in the developing world. Sally has written a short,unpublished memoir of her drug abuse and AIDS experiencethat she has shared with close friends and family. It is unsenti-mental and unsparing in its self-criticism.

In her memoir there is much of the sensitive descriptionthat one would expect from an artist whose painterly eye picksup on subtle detail and shadings in the rich context of herlife. But there is also a single compelling theme that infusesthe memoir with a hard-earned philosophy of life. We becomewho we are, Sally insists, because of the way we engage withthe very real dangers in the world. Life-threatening diseasessuch as AIDS can bring into focus what really matters andcan pressure sufferers to create certain changes, not just in-side but in the outside world too. In Sally’s case such changetook place in her subjective self, in her art, in her circle offamily and friends, and in the world of policies and programsconcerned with drugs and AIDS.

I HAVE HAD MANY clinical and research interviews with AIDSpatients as well as with many others suffering from othergrave health conditions. Eighteen years ago I published The

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Illness Narratives, a collection of individual portraits of realpeople living with severe chronic diseases—cancer, heart dis-ease, depression, diabetes, chronic pain. From my experience,I know that Sally Williams’s story is not representative. Muchmore commonplace are loss, desperation, and failure cascad-ing into bitterness, isolation, and withdrawal. The disablingconsequences of the disease pathology and the responsive-ness or resistance to treatment are influential here, yet whatis most important is the patients’ subjective self, the qualityof their relationships, and the moral life they imagine thatcan be fashioned out of pain and adversity.

There is not any single overdetermined meaning to disease;rather, the experience of serious illness offers a means of un-derstanding in a particularly deep and powerful way whatpersonal and collective moral experience is about. It is, to besure, always various and contradictory, and yet it also illus-trates the core existential insight that the things most at stakeare clarified, for us and others, by the dangers we encounter.Those dangers, moreover, can and often do remake whatmatters most, so that what matters and who we are is notwhat was before, but instead becomes something new anddifferent.

In a state of siege, Sally redefined her life and her world.Sally’s optimistic story demonstrates that experiences of life’svery real dangers not only are about injury and limitation butalso hold the potential of creative and inspiring change. Cre-ative because they open new realities; inspiring because, inthe face of pain and death, these experiences change intimateothers, offering the possibility that their moral life can also bedifferent. In Sally’s case, her experience with disease led her

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to open her eyes to the greater world out there, and to hear itscall for us to respond to what really matters to others.

Middle-class American society often tries to blind itself tothe problems of crime, violence, drug abuse, and AIDS andattributes these problems to those who have fallen out of thecircle of wealth, happiness, and hope. Sally’s own fall fromgrace made her deeply suspicious of gates, walls, and sepa-rate worlds, domestic or public. She insists that AIDS anddrug abuse, and also poverty and violence and stigma, mustbe seen as part of all of our worlds. Only this way can weovercome silence and denial and get on with the struggle todeal effectively with human misery and its sources. In herview, there is no place to hide. There can be no completelysecure domain, safe from the dangers that beset most people.

Serious disease can do that to people. It can open eyes, breakdown doors, encourage active engagement with real threatsand their societal causes. That it most frequently doesn’t havethis result but rather further shuts off individuals into the not-so-splendid isolation of pain and the inefficacy of self-absorbedmisery doesn’t invalidate the possibility for repair and rebuild-ing of self and world; it simply reveals how difficult it is tobring these things about. The line between hope and despairis vanishingly thin. Moral experience, especially the moralexperience of suffering, holds the potential for remaking ourlives and those of others.

I know Sally Williams somewhat better than the interviewmaterial may suggest. I have watched her operate in herworld. I have spoken with her husband, her daughter, andseveral close friends. These others confirm the conclusions Ihave drawn. Jennifer went so far as to say that coming to

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terms with AIDS had made her mother a stronger, more sym-pathetic, and emotionally and aesthetically more cultivatedperson. A mutual friend drew out an even stronger lesson.“Sally was like a lot of us, pretty self-absorbed, quite selfishabout her work. Ambition can be greedy and blind. Now sheis a different person altogether. Maybe it’s her success as anartist. Maybe it’s AIDS. Whatever it is, she is a better friend,and it is simply wonderful to see how active she is for AIDSissues, for her art, and her friends. Maybe the best is howclear she thinks and speaks about what’s going on with ourlives and our world. She says what needs to be said.”

But the most powerful testimony came from her husband,Daniel. When I asked for his reflection on his wife’s situation,Daniel Williams dropped his head, walked a few paces away,and stepped back toward me, shaking his head and pursinghis lips.

“I’m not sure what to say. I’ve loved her for a long time,even when we were apart. When she fell apart . . . wow, shefell apart! I don’t know the half of it. Don’t want to know. Itwas terrible, and not just for her, for all of us too. I was angryand frustrated and had no idea what to do. The kids, maybesave Jennifer, who always tried to pull Sally out of it, musthave been where I was . . . lost.

“I had to cut her off, or she would have ruined me too.That all changed when she came out, came back. I still couldn’tdeal with it, so I kept my distance. But I heard, I watched . . .she came back great. She made it. Better than before. By thenI wanted to see her again, but I didn’t know how to do it. Iwas feeling guilty. I had dropped her completely. She neededme and . . . and I wasn’t there. When she had all those suc-

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cesses, I felt . . . well, I felt I didn’t do anything to help. Icouldn’t just call and say, ‘Here I am again.’ But when Jentold me about the AIDS, I ran, literally ran to Sally. I wantedto be needed; I wanted a second chance. I knew I could help.. . . When I got to her . . .” Daniel broke down. When he wasable to pull himself together, he continued, “When I got toher, she was great . . . real. Everything came out. Everythinggot said. I’m so impressed by how she has handled this. Whoshe is. What she has become. Nothing hidden, left unsaid. It’sall out in the open.

“I think you could say,” her husband went on, “we expectedthe emotional maturity, the making over of pain into art. Idon’t mean it was destined, but that it was inside her charac-ter, ready to come out. But not the advocacy. She has becomepolitical, savvy in a political action way. Where did that comefrom? Never saw it in her before. She wasn’t a joiner of groups,a leader of groups. Quite the opposite. Sally has always beenrestrained. That’s her beauty. But now you also get the advo-cacy, and . . . lobbying. Yeah, real lobbying. That still amazesme. That was always my side of things. But not now. I’m inthe background. Oh, I help raising funds, but she is out front.Sally calls politicians like she was doing it all her life. Yet someway the whole thing fits. She is a whole person. She hasn’tlost the artistic side. Hell, no; it’s even stronger. But she cando it all. Do more things. Look at how she looks. She looksso much younger. And healthy. . . . When you think, it’s in-credible. She has actually done better, much better withAIDS. I know it sounds crazy. But I’m not exaggerating. Thiswonderful woman has come completely alive. She’s mak-ing the most of every day. This is her best hour, and it’s not

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a frenzy or escape. She’s become more fully herself. Andshe is doing things, useful things, beautiful things, strongthings, good things. She’s doing it all . . . and I’m, we’re sovery proud of her.”

TWO YEARS AFTER I FINISHED recording this interview, SallyWilliams suffered a stroke. The stroke left her left arm andleg weak, so she now drags her foot and can’t use her lefthand effectively. She is also noticeably slower in speaking.She expresses sadness and frustration, yet she keeps work-ing, and with the help of Daniel and her friends the galleryremains open.

It was initially dispiriting to watch this once greatly vitalwoman slowed and diminished. Sally doesn’t paint muchnow. She no longer can give speeches or work the telephonefor her causes. Her energy is measured in small doses. Hervision is affected, and sometimes when she is speaking to youher eyes seem focused beyond you. She stumbles, has troublegetting up from a chair or placing herself on a couch. Sheneeds assistance. Daniel and Jennifer are usually with her,helping her navigate.

And yet even this devastating neurological condition is nota final defeat. Her sensibility is alive to color and form. Sheoften sings songs from her past. She is still tremendously in-terested in her friends and family members and wants to knowwhat they are up to. She still has a presence in conversations.You can see that she is fighting her serious functional limita-tions to accomplish what she can. After speaking with her,despite her slowed speech and difficulty finding the rightwords, you come away struck that this remarkable woman is

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doing all she can to make her much smaller world lively andsignificant. She is not demoralized, not depressed.

Sally’s sad story is not completely without a happy end-ing. Daniel, chin thrust forward and fighting back tears, con-cluded: “We have been through a lot. It isn’t easy. We are doingall we can. It’s what you have to go through in living. You dowhat you must do. Sally tries. She tries, and she’s doing whatshe can. All she can. Being with her through this, I have beenmade better. So have the kids, so has Sally.”

We are all at high risk for experiencing some kind of healthcatastrophe near the close of our lives, if not sooner. We allwill be faced with catastrophic outcomes that we can neitherreverse nor do much to ameliorate. These catastrophes wemust endure, suffer through, live with. Stroke, heart failure,end-stage kidney or liver or respiratory disease, dementia,and the complications of chronic illnesses from diabetes toAIDS all define the final months or years of life. They consti-tute the terminal danger that defines the end of life, and withit the moral condition of human ends.

None of us, certainly not I, can be a neutral observer of howour friends, family members, and we ourselves come to theend. Neither of my professional backgrounds as anthropolo-gist or psychiatrist prepares me with the technical terms andprofessional theories to deal with this core human condition.The messy mix of emotion, relations, and values that we allinevitably find ourselves in is the human condition. So I willcall Sally’s struggle authentic, brave, admirable, because thoseare the words in my everyday world that speak to her condi-tion, our condition. That is how I see her as a moral exemplarof how I want to face health catastrophe in my own life.

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Bill Burt / Simcha Adler

n the preceding chapters I have suggested that it is insuffi-cient to express value positions without clarifying their emo-

tional, social, and political context. So an acquaintance ofmine—a good-natured physician from an old Yankee familyin Boston—asserts in a dry, soft voice that fiscal responsibil-ity is what matters most. He tells me it matters more thansocial justice, more than family love, more than the Episcopa-lian Church, of which his family has been members for gen-erations. When I have questioned why this value is so central,this otherwise mild-mannered, cautious, usually tolerant, andotherwise amusing middle-aged man fulminates, stammers,and eventually, when he is thoroughly frustrated with me,shouts, “It just is, that’s why!” What he doesn’t say is whatmatters so much he can’t say it without breaking down intears. His father spent down the family fortune and died with-out leaving a life insurance policy, so his wife had great diffi-

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culty raising their three children and, as a result, my acquain-tance could not attend the private school he had hoped toenter or enjoy the social life that his wealthy cousins experi-enced. He had always felt like “a poor relation,” he once toldme. His own life has been lived almost in exact counterpointto what he calls his father’s failure. He is extremely respon-sible, but especially so in matters of money. If you remove theexpressed value—fiscal responsibility is what counts—fromthis disturbing circle of meaning, you neither understand thevalue nor the man who proclaims it. This is as true for me asfor those whose stories I have narrated. Hence this chapter turnsto autobiography in order to describe my own condition—subjectivity, local world, moral experience—and to suggesthow it may influence the interpretations I am offering. I willbegin by narrating an interlocking set of images, emotionallyloaded memories that seem to me to authentically expresswho I am and what has been at stake for me.

IT IS LATE AFTERNOON on a Friday in winter 1997, gray, wet, andcold. I’m in Washington, D.C., as part of a small internationalmeeting on global health that includes both experts and rep-resentatives of several funding agencies. We are sharply de-bating the development of HIV/AIDS prevention trials inAfrica. The issue at the moment is the absence of treatmentfor African AIDS patients. I have something to say on thispoint, but it is a distinctly minority position in this meeting. Iwant to say that for the most fundamental ethical reasons andbecause prevention is unlikely to be effective without it, treat-ment must be provided for these patients. This is a positionthat the representatives of the donor agencies were not then

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favoring. I am reluctant to express my position because I amnot an AIDS expert; rather, I have come to the meeting as anexpert in global mental health problems to seek funding forpoor African, Asian, and Latin American sufferers of seriousdepression and psychosis, and for those who are addicted tosubstances or suicidal. Perhaps if I antagonize the donors now,I will later on lose their support for mental health care. I thinkof my East African colleagues who practice medicine withAIDS patients without treatments that are widely availablein North America and Western Europe. Seen from the per-spective of what goes on in their practice, it seems difficult tospeak of the very real economic constraints (echoed by justabout everyone in the room) without at the same time pressinghome the ethical implication of the humanitarian tragedy offacing patients without effective drugs being available. It is ethi-cally unacceptable not to make these drugs, at the time in wideuse in rich countries, also available in Africa, I want to say. Noone else says it. Indeed, the consensus in the room is troubling:only prevention, not treatment, is possible in Africa. And thisis stated again and again as firmest conviction. The time is run-ning down. I feel a palpable inner tension: should I speak outon the AIDS matter, possibly alienating the major players whenI turn to my primary concern, or hold my fire and wait for amore favorable situation to bring up a decidedly less popularissue for which I’m the only spokesperson present?

I feel my predicament in my chest: a tightening and, no-ticeable to an asthmatic, early signs of labored breathing. Atthe time, the tension seems more in the realm of emotionsand interpersonal relations than in that of morality. But whyisn’t it a matter of morals? After all, two serious things—each

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saturated with value—are at stake for me, pulling in differ-ent directions. The experience that tests my agency turns on aconflict between what is at stake for the group and what mat-ters most to me.

In the end, I do speak up about the imperative of provid-ing the latest treatment for AIDS patients in sub-Saharan Af-rica, no matter how difficult the problem of cost. It has thenegative effect I feared. I am quickly criticized for being im-practical and, worse yet, for distracting attention from theall-important prevention issues. And the experts and fundersseem more resistant to entertain large-scale support for glo-bal mental health initiatives when my time comes to speakfor that agenda. I have made a strategic error, as one of myfriends in the room later whispers to me. But I felt unable tocontain myself, as if a deep core of fire were exploding out ofme. There is a paradox here. In the guise of talking about theethics of AIDS treatment, it is the ethics (and emotions) of myown position in the meeting that matters more at the time.And it is the passion and commitment of the others presentin the room that signals that an ethical dispute, not just a tech-nical one, is occurring. Looking back after eight years, it isquite clear that a major transformation has taken place inpopular and professional values concerning what to do aboutAIDS in Africa. (In fact, so far has the pendulum swung thatsome AIDS experts fear prevention is being downgraded asmost experts and policy makers get on the treatment band-wagon.) Yet, as almost always happens in my reckoning, theethics of actual experience goes unvoiced.

From an anthropological perspective, ethics as interper-sonal experience is crucial because values are rooted in our

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social conditions. Standard medical ethics holds that casescan be parsed into questions of patient, family, and healthcare professional choice where rational decisions can be madeonce the relevant ethical principles have been identified andtheir implications for the case at hand discussed; moral expe-rience more or less disappears under the heavy weight of ethi-cal principles such as patient autonomy and confidentiality.Stories of real lives are trumped by philosophizing about jus-tice, virtue, and ethical choice in the abstract. For example, inthe case of end-of-life care, decisions are made about dyingwith dignity, limiting or withholding treatment or assistingsuicide, and addressing religious questions of ultimate mean-ing by searching for the right combination of ethical principlesdespite the fact that so little is known about the person and hisor her life situation that the case is usually experientially flatand thin, the real issue being the principle-based analysis. Froma psychiatric point of view, the situation I just recounted is trou-bling because it is precisely those concrete details of a life and aworld that need to be taken into account to understand whothis person is, what she or he wants, and what is appropriatefor doctors and nurses to do. These same emotional and moraldetails are as important for understanding what the moral is-sues in the Washington meeting were for me as are the con-cerns for justice and equity with which I premised mydiscomfort with what was then the consensus about AIDS inAfrica. Those details lead from story to story, so that a life un-folds around the value questions, and this becomes the humancontext for understanding what really matters to people. Theseare stories that enable my own life to unfold around the valuequestions that I take to define who I am.

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I REMEMBER BEING A BUSY INTERN on the internal medicine serviceat the Yale–New Haven Hospital. The year is 1967. The civilrights movement and the anti-Vietnam War campaign are in-tensifying. America is on the point of exploding into a culturalrevolution. I’m working twenty-four out of each thirty-sixhours. I’m exhausted and impatient to see my condition (andthat of the country) change. A teenager with a rare and poorlyunderstood liver disease dies in the hospital. I’m the internresponsible for this patient’s care. While the boy’s body is stillin the hospital bed, a senior professor of world renown ap-pears on the scene. Dr. A, as I shall call him, is locally infa-mous for his single-minded pursuit of knowledge and for hisfierce personality, which often leads to his being brutally over-bearing toward the medical residents and nurses (thehospital’s “lowerarchy” as it is put among us). He bluntlyorders me to immediately ask the family (whom he has nevermet before and who are now grieving in the waiting room)for permission for an autopsy. His objective is that the liverbe removed expeditiously so that it can be studied microscopi-cally and chemically. Feeling that it is unacceptably insensi-tive to ask them at this trying moment, I suggest we wait untilthe family has had a chance to see the body and at least beginto vent their feelings. Waving my objection aside with a smileand rolling eyes, Dr. A brutally informs the family that for thesake of science there needs to be an autopsy performed im-mediately, before their son’s liver begins to rot. Anger andrage erupt. The parents and siblings say no, in unison, andproceed to lay into my senior teacher for his boorish manner.Silently agreeing, I watch with foreboding as he rushes backto me. Grabbing me by the lapels of my white coat, he pushes

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me around the corner of the ward and up against the wall. Ina commanding voice, his hands shaking with anger, he or-ders me to take the three biopsy needles that nestle in hislaboratory coat pocket. He will distract the family; I am torun into the hospital room, lock the door, and take multiplebiopsies of the dead boy’s liver. I demur. He snarls. I weaklysuggest we ask the parents again for their permission. Heexplodes into a coarse diatribe laced equally with impreca-tions and with not-so-indirect threats to my career. We faceeach other with open dislike. I murmur no. “Kleinman,” heseethes, “you just do it, goddamn you. Do you hear me? Whothe hell do you think you are? This is crucial to research. Weneed to learn what is going on in his liver. You do it, now!” Igrab the needles he holds out to me, and dash into the room.I pull back the sheet, looking at the body—white, cold, slightlystiffening—but avoiding the face. Then, blocking out of mymind all the contrary feelings, I quickly jab the biopsy needlesinto the liver, through the hairless skin, under the taut ribcage, which now becomes discolored at the three puncturepoints. I stuff the needles, with their liver cores, deep into mypockets and run from the room. I rush past the family, whoare still passionately berating the professor. I am too anguishedto look or speak to them, even though I know them far betterthan he does.

I never again spoke to this implacable expert. Even whenhe slapped me on the shoulder in passing at the next weeklyclinicopathology conference and ostentatiously praised mefor what I had done, I lowered my head and squirmed, hu-miliated by the coerced deed. Later I felt equally ashamedthat I did not bring the issue up at the conference before my

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fellow residents and other professors. But it seemed com-pletely outside the ethos of our training, and an irrelevanceto the science talk of the meeting. Medical ethics talk, as sur-prising as it may sound, had no presence there or anywhereelse in our daily clinical work in 1967. Ironically, the livedvalues of that world—the local moral milieu—excluded ex-plicit concern with ethics.

This episode probably occupied altogether less than an hourof my professional life of thirty-six years, yet it moves insideme still, like a deep flow of hot lava. This episode bothers memost in that I did something that I knew at the time was un-ethical; that what I did was coerced out of me in a culturalethos where this was normal experience; and that I was un-able to express my revulsion or any criticism but had to “eatthe bitterness,” as Chinese put it. The emotional and moralresponses can’t be separated from each other. They were therein my sensibility, three decades later at the global health meet-ing, when the micropolitics of the interactions with powerfulothers added a third side to my experience.

I have had many occasions subsequently to recognize myethical failure and to observe how it makes me more vigilantand quick to respond to what is at stake in my life and in theevents around me. I recognize now that what is at stake forme is the anguished sense I have of my own constrainedmorality. I see how limited I am in living the kind of life Ibelieve in because of what is outside in my world and by whatis inside me. And the fact that I know this alarms me, becauseI can allow a partial truth to stand before and obscure thewhole truth; because I can be complicit with unethical actsand fail to protest them; and because I can deny what matters

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most to me and thereby deny who I am. I feel a burning sen-sation in my face and a tightening in my chest even while Iwrite these words because I am ashamed of these failures. Yetthis troubling sensibility has also at times spurred me to dowhat I felt to be the right thing. Shame can be a decisive moralemotion.

I tell this story because so much depends on understand-ing moral issues in this way: as an inseparable connection ofmoral tensions, bodily emotional states, political contingen-cies, and the particular institutional or professional issue athand in the dramas and mundaneness of genuine experience.Think of Charles Jamison’s bodily reactions to his own self-perceived immorality and his criticism of American culturalvalues as another source of his crisis. Winthrop Cohen’s de-pression also illustrates that crucial nexus with his remorseand regret, and insistence that the military and society moregenerally were as responsible for his atrocity as he was. Orconsider Dr. Yan’s moment of truth, when he turned awayfrom vengeance after the great trauma of the Cultural Revo-lution in China, only to experience defeat once again by thechanging political, institutional, and moral reality. I have wit-nessed many such occasions like the one recounted from myown life, when in the course of living we comply with or failto resist pressure that we sense is wrong because the atmo-sphere of the setting we are in and the players surroundingus expect us to conform and because, truth told, we too wantto get on with what is at hand. And I have observed the op-posite as well, as in Dr. Yan’s dramatic refusal to participatein vengeance, when the embodiment of earlier moral experi-ence together with the politics of the moment erupt in an in-

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expedient voice that challenges taken-for-granted assump-tions about what is acceptable action. I’m certain my responseat the small global health gathering is one such example.

WHY HAVE I FELT CALLED to address this subject? That questionstrikes me as worth examining with respect to my own back-ground in order to clarify what is at stake for me as the au-thor of this work. I had always been absorbed by experience,the local, everyday variety. As a child in Brooklyn in the 1940s,I watched with wonder the comings and goings, acute ten-sions, and chronic intrigues of a complex multigenerational,well-to-do Jewish family. Against the sweeping backgroundof vivid stories of the Great Depression and World War II,heroic and terrible, these domestic tragicomedies were ofan entirely different order. They were small-scale and self-contained, as if reflecting another reality that, even if framedby great external events, was not by any means insignificant;my family drama possessed its own structure and charm anddanger.

I became an intense listener. And I heard many stories, sometrue, some I recognized even then as not so true. To my naivemind, though, they were all of an order with the biblical taleswe struggled to translate in late-afternoon Hebrew schoolclasses and with the children’s classic adventure books I es-caped to on weekends, only the family sagas were more ab-sorbing. They were closer and more complex moral lessonsabout real-life experience, where the interaction between indi-vidual propensities and what seemed at the time like familialdestiny could be seen to work through acts of impetuosity,brute endurance, and a host of inveterate failings, from bitter

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resentment to blind, grasping self-aggrandizement, so as toshape character and careers. These pathways were somehowsimultaneously novel and stereotyped. They could be dis-cerned in the actual faces, body language, and fine peculiari-ties of relationships of these family members and friends whosat in front of me in the heavy Victorian parlor, lighted harshwhite in winter and with a golden glow in summer, like thestage of a small but lively theater.

I was not a disinterested spectator, of course. Quite theopposite. There were multiple familial subplots unfoldingalong with one master drama, and either I was part of themor they held some significance for me. My small segment ofthe family—my maternal grandparents, mother, brother,stepfather, and one particularly close aunt, uncle, and twocousins—was in the middle of what felt viscerally like a terri-bly slow, only occasionally painful, but inexorable and dan-gerous slide. Financially, my grandfather had made severalinvestment decisions in the late 1940s that would prove di-sastrous. At the very moment when the suburbs were beingbuilt, he chose to invest in real estate in the downtowns ofseveral small cities in upstate New York and in New Jersey. Ittook about a decade for this enormous error to play out. Theproperties he had purchased lost most of their value as theinner-city settings they were in quite literally disintegrated.At the same time, a square block of prime Manhattan realestate that he had purchased as a kind of insurance policywas taken away from him by the city under the rule of emi-nent domain, supposedly in order to build a school (whichnever was built). As the family’s financial condition changed,so did its relationships. My grandfather seemed to lose faith

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in his four daughters and sons-in-law as successors to hisbusiness interests, and more or less gave up in investing inthe future of his other business ventures: a major soap com-pany and a small mortgage business, in particular. Latent ten-sions exploded into open crisis. One aunt and uncle, who hadalmost as much wealth as my grandfather, broke away, to-gether with their three children, from what had been a tightfamily circle. Another aunt died of posthepatitis cirrhosis, andher husband, who was having an adulterous affair with herbest friend, and son went into a kind of exile.

My aunt Rose and uncle Paul and my mother and stepfa-ther did not change their expectation of inheriting consider-able wealth, but their relationships began to show the strainof their growing sense of panic that the small family worldthey had known and taken for granted for decades was chang-ing ominously. I could myself see—and it was regularly pointedout to me by my grandparents, who performed like a Greekchorus—that these larger-than-life parents, aunt, and uncle,though robust and engaged in near-constant activities, wereunable to prevent a gathering darkness and overall decline.As their inefficacy or wastefulness worked its way towardthe denouement, I felt like the proverbial novice who pos-sesses the dispiriting insight that there was a pressing needto do something, but it could not be matched by what thenovice had to offer.

Not least of the forces indicating a strong tide within mul-tiple stories was the fact that as a child I lived with two fam-ily names. At P.S. 161 on Crown Street, my primary school, Iwas Arthur Spier (pronounced Spear). At the Brooklyn Jew-ish Center, my Hebrew school, I was Arthur Kleinman. Spier

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was the name of my biological father, whom my mother haddivorced when I was one year old. I never met him, which Ihave come to accept as part of who I am, after years of anger,regret, and mourning. Kleinman was the name of my stepfa-ther, who adopted me when I was twelve. (Legal notificationwas buried in New York’s Irish Echo newspaper—not a placemy German Jewish father would be expected to notice it.)The 1940s were an age greatly different from the present onewhen it comes to divorce and adoption. These subjects werestigmatized to the point of being taboo. Nothing was explic-itly explained to me, yet over time I came to understand thatthere was a secret, and that it held real significance for me. Ibecame an undercover detective of clues, working out whatmy dual identity could signify. There was something therethat mattered so greatly that it tremendously concentratedmy interest in conversations and stories. That my biologicalfather never surfaced in my life and that the story itself wasnever fully clarified became a wound that required healing;it was a hidden compass, secretly orienting my responses. Itheightened my sensibility to danger and led to early recogni-tion that memory and history were not the same thing andboth could be treacherous. It educated me in the insistent sensethat I needed to see things broadly, beyond my world ofwrenching affect and fog-bound remembrances, so as not tomiss anything hidden that was potentially important; whileat the same time I was aware that that parochial world pos-sessed one overwhelming yet mysterious absence of presence:my real father. My grandmother whispered to me that he wasthe king of Bensonhurst, a wealthy real estate developer, but

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she would say no more. My mother said nothing, but when Ipressed her (which I hesitated to do until I was in my teensbecause she seemed so terribly vulnerable on this one sub-ject), she also whispered but gave an entirely different storyabout a much older husband, an autocrat dominated by hismother, involved with a real estate scandal that was in the news-papers for weeks, a partner who was a well-known judge com-mitting suicide, a criminal case taking shape, and her desperateneed to get away. I didn’t learn more until I was in my thirties,after my stepfather died, and I begged my mother to tell meeverything. Her love for me and mine for her had been so cen-tral that I had forgone truth for our tie to each other. But I hadas a result a powerful need for others to enter into my life asfather figures, moral mentors. It also gave me “a hunger forpeople,” what Franz Kafka said “a born doctor does.”

In these human dramas or stories, it wasn’t the play ofwords and the cadence of telling or the power of metaphorthat held my attention so completely, but rather what theyhad to say about real life and how they lifted me into the flowof actual experience, tossed with events and alive with char-acters but with the tide moving powerfully in a set direction.After hearing these tales repeated I could close my eyes andstep into them, because they were about my family and itscircle, and in truth I was already on the inside, part of thelives and the world that were concentrated by serious hap-penings into revealing with astonishing clarity their transfig-uring logic: a destiny of progressive decline in family fortuneand the growing certainty that I would never know who myfather was and what, if anything, I meant to him.

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I WAS TWENTY-ONE. It was the summer before I entered StanfordMedical School, and I had just finished my undergraduatestudies at Stanford, where I concentrated in history. My par-ents requested that I return for these three months to NewYork. I found a job with the New York sewer system, a kindof physical-labor “internship” usually taken at that time, likethe roadside construction crew jobs of holding the stop/gosign, by high school and college students. I knew academicstudies and weekend athletics. I had the romantic idea that Ishould also experience what it was like to work as a “com-mon laborer.” I did this, I now believe, largely to cross myparents and grandparents, who had what I regarded as a typi-cally biased Jewish business-class view of manual workers asbrutal, unthinking, and un-Jewish. A rebel since choosing toattend a distant West Coast university, I had incorporated aMarxist critique of capitalist society; I was ready to side withthe working class. Besides, the job paid well enough that Icould save money, so when I returned to medical school Iwould be able to live with friends in an apartment in PaloAlto, a chance to break free of dorms. After four years I hadhad enough of dorms. I had never done real physical laborfor pay—working as a waiter and athletic counselor in sum-mer camp hardly seemed to justify that muscular term. And Ihad never been anywhere near the inside of sewers.

The first day on the job the stench of the sewer paralyzedme: I couldn’t orient myself in the dark, dirty subterraneanworld, and I was overpowered by the odor of feces, urine,and all the other “unclean” things that run into the sewer sys-tem. The slime and the pest-infested shadows, the foul airand the putrid odor made me retch, then search for the lad-

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der to get out into fresh air. Only hours into the job I wasready to call it quits. I could not imagine how I could descendevery workday for twelve weeks into the terrible stench anddarkness.

Then, as I stood still at the bottom of the ladder in the midstof it all, fighting panic and a rising suspicion that I wasn’ttough enough, one of the three co-workers on that initial foray,Bill Burt, a heavyset, white-haired Irishman with a cherubicface always set in an ironic smile accompanied by a constantpatter of jokes, laughter, one-line quotations, and bits of song,grabbed me by the shoulder with his great ham of a hand,keeping me from bolting but also almost knocking me intothe repulsive stream of sewage. “You’ll be okay, kid. After aweek you won’t even smell it; a week after that you won’thesitate to eat a snack while poking around in all the sh*t.And after that you’ll feel you’re missing something whenyou’re away from it.”

Boisterous and piratical, like Stevenson’s Long John Silver,Bill winked at me, ostentatiously pulled a Hershey bar out ofhis pocket, and broke it in half, offering me one part while hedevoured the other. Then, as I gagged and waved away hisoffering and continued to gasp for breath, he initiated me inthe local betting pool, the numbers game. Could I guess howmany condoms would float by in the flowing muck in a fifteen-minute period? Each day all the workers waged a nickel, adime, a quarter, or a few bucks to pick the right number, whichwas ascertained as an average across different districts.Enough could be made to pay for a dinner for two, he re-marked, raising his bushy eyebrows approvingly. In spite ofmy unsettled state, I couldn’t help but laugh and bet a nickel

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on a figure Bill told me was so outrageously high that it hadnever, in his thirty years in the sewers, been observed. Thatsame day, he duly sent me to the utility truck to fetch a left-handed wrench. I could hear Bill and the others roar in laugh-ter as I earnestly went about the impossible quest of determiningwhich wrench was left-handed. When I finally gave up andreturned to inquire innocently what were the distinguishingfeatures of such a wrench, the laughter, if anything, wasgreater still. When Bill told me the punch line—there ain’tany such thing—his voice was warm and sympathetic. “Nevermind,” he said, “a couple of weeks and you’ll be a master ofsewer work.”

That day—the longest one in my life save for the first dayof my hospital internship—our supervisor (Bill called him theAppalling Boss), Harold Wilson, took me aside and in hispinched, high-pitched Yankee voice warned me, in so false afashion that even I (the tyro) could detect the cloying dishon-esty, that I should be very careful working with Bill. He’dteach me bad habits, Harold complained. He’d turn every-thing into a joke, slack off and cover up for it more shrewdlythan Brer Rabbit, cut corners, and show me what it was liketo just put in time. His finger against his nose, Harold whis-pered that he would take it upon himself to educate me right.The first lesson was to observe what he would himself dothat very day after work. “You warm up a little soup. You putit in any old jar, and you bring it to elderly widows in theneighborhood. I’ve got two on my block. You do that, son,and you will not only be a good person, but one day one ofthose old gals will leave you some money after they pass on.That’s building for the future. That’s how you can make some

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money in life!” he intoned with such seriousness that helooked like he could strangle his neighbors if they failed tocomply. That was Harold, Bill would say, shaking his head:stingy, calculating, duplicitous, self-righteous, and danger-ously earnest.

Much of the workday Bill organized so we could avoidHarold and thwart his hectoring, self-serving directions.Harold would send us on a mission to fix a broken meter,locate a sewer break, or deal with a backed-up pipe with anoverly serious admonition to do it slowly, by the book, and ina way that would avoid problems. Avoiding problems, he toldus, was the ticket to success. Don’t make waves. If it was be-yond our skills, we should call for help and then it wouldn’tbe our responsibility. Punt it to some other group if we could.Let them f*ck up, not us. We should report problems, notfailures—it was better never to have tried to fix anything thanto get caught screwing up. “I don’t want problems on mywatch,” he lectured us.

We spent hours in the utility vehicle with the two-way ra-dio turned off so that Harold couldn’t reach us, resting be-tween jobs that we completed with lightning speed buteffectively. (Bill would later report to Harold that we were inthe sewer system, so we turned the radio off to save its bat-tery.) When emergencies were announced—when our radiowas on, that is—we were usually the first to respond, drivingHarold into a fury (“Goddamn it, let others do it. Supposesomething goes wrong. We get blamed,” he would fulminate).

Bill guided me through the difficulties and occasional dan-gers of the work. We never did anything by the book, mostlyto save time and do it right, as he would say, but also to annoy

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Harold, who was a stickler for working through the detailsso that we could slow things down and avoid new jobs. Wedid things Burt’s way, as it was known among our co-workers,meaning doing routine maintenance quickly but to a high stan-dard so that we could respond rapidly to crises, making adull routine more exciting and “doing some good in theworld.” It also meant more time to schmooze and less timeexposed to noxious fumes and raw sewage. Bill twice savedme when I slipped on the slick catwalks bordering the riverof waste that had swollen into torrents when the runoff fromsummer squalls found its way into the sewer system. One ofthose times I was hanging on to a railing with one hand, myother holding a heavy hammer, while my feet flailed in thespace above the flow. Bill pulled me to my feet, admonishingme, “Don’t do that—it’ll mess your hair.” He taught me howto open and close huge valves that regularly got stuck, howto accurately reset ancient meters that were nearly impossibleto read even with the flashlight shining directly on them; howto unclog a blocked pipe—a messy business; how to repairan electrical wire; how to quickly evaluate what was wrongwith one of the enormous pumps and consult with the on-call engineer to come up with a long-term fix instead of theproverbial chewing gum and duct tape; and how to thinkcoolly under pressure, like the time we seemed trapped in asmallish space with foul air, unable to get the sewer coveropened, and three of our team panicked and ran in the wrongdirection. Bill became deadly serious that time. “Don’t everdo that, son, don’t ever panic. Stay cool and think hard,” hewarned me as he worked out a way to signal our distress andposition so others could get us out.

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He was proud of my education. Some days he brought innewspaper articles he clipped, usually ones about misman-agement, waste, or corruption in the city. When I got into ashouting match with Harold about discrimination towardblacks (Harold had told me they would never work on histeam while he was boss and that I was “one of those nigg*r-loving Jews”), Bill used his humor to bring it to an end beforeHarold actually fired me, which he had threatened to do.When I got into a fistfight after being called a “soft Jew boy”by one of the rougher workers, Bill grabbed the man’s arm ashe reached for a wrench. He then pushed me to the side andthreatened my adversary with the same wrench. Later thatday Bill pressured me to apologize to my enemy and buy hima carton of cigarettes “before he finds a way—and he will,believe me—to really hurt you.” I watched in concern as Billbroke up a fight between four teenagers with chains and batson one of the more violent streets in our area. Others werelooking on, but only Bill stepped forward and with his quickpatter and jokes and the lie that the police were already ontheir way got the combatants to disperse. Bill also respondedto a dog attack and drove a snarling German shepherd awayfrom an elderly man, to whom we ended up, against the regu-lations, giving a ride to his apartment house, for which Haroldberated us daily for a week (“If you are going to be good Sa-maritans, do it on your time, in your car, and make sure hepays you for it!”). Bill shrugged off this pitiless remark andtold me, “We’re here to do good in this world. We’re onlylittle people, but when you can, you do what you can.”

But most of the time, sitting in the truck or back at the base,Bill would take out his corncob pipe and tell me stories. I

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learned how he had come to resign himself to a job that oth-ers dismissed as beneath them, which in his joking mannerBill admitted was literally true. But humor and constant chat-ter couldn’t disguise the disappointment and humiliation inhis eyes when he talked about growing up dirt poor inBrooklyn’s notorious Pig Town slum, dropping out of schoolin the eighth grade, learning about life by running errandsfor the Mafia on the waterfront, marrying a girl he didn’t loveafter she became pregnant, carrying on in a dreadful familyrelationship decade after decade with two daughters who al-ways sided with his sour wife and were as unfaithful as shehad been, and coming to terms with work aspirations thathad spiraled downward to “just marking time.” Bill had twoyears to go until he could take early retirement on a smallpension. It was crucial to him that he hang on so that he re-ceived that pension, which meant tolerating Harold and put-ting up with the petty corruption Harold and others organizedas the everyday work routine. Workers bribed their way outof the worst jobs, pilfered supplies for their own purposes aslong as it wasn’t blatantly obvious, even spent work hourson second jobs (as long as Harold was paid off). Bill wouldn’tor couldn’t participate in this network of corruption, in partbecause after so many years he couldn’t afford to get caughtand lose his pension, and in part because it would degrade areputation that had been built on opposing values. “Maybe,probably, I’m a jerk for not being on the take,” he told meeach time we witnessed a particularly egregious example, suchas the time Harold traded new meters we had been sent fromthe supply depot for old ones and pocketed the difference.(“It doesn’t matter, you know,” the Appalling Boss intoned

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when we caught him. “Who can tell the difference anyway inthis muck? And they all do it, all the way up the line, don’tyou forget it!”) Bill once told me he was occasionally temptedto steal something for his boat, his one great pleasure in lifeand his hope for the future, but thought better of it when herealized how it would diminish his self-esteem, which wasbuilt on what our co-workers and even I thought of him.

The boat was everything to him. He had bought it from asalvage company, which had raised it from its watery grave,giving it a second life. Lazarus seemed just the right name. Hehad bought it for “peanuts” but had spent “real dollars, lotsof ’em,” fixing Lazarus up and keeping her afloat. We wentfishing in Long Island Sound for bluefish with a couple of hisbuddies, and with such a decrepit wooden hull and ineffec-tive rebuilt engine it was surprising the boat ran at all. ButBill beamed at the helm in the tiny cabin and promised methat someday he would get a more powerful bilge pump sowe wouldn’t have to bail the bilge water by hand. During thehours of trawling, Bill asked me to tell him about my life, andslowly, painfully, I told him about the secret history of mytwo names and absent father, about the humiliation that hadcaused, and about the academic successes that never seemedable to fulfill my vaulting ambitions, whose tyranny I couldneither withstand nor understand. To say he became a fatherfigure is to say what we both came to implicitly understand,though never could say openly, as the summer wound downand the time approached for my return to California.

My last day on the job, I took him to lunch and bought hima shrimp salad sandwich and vanilla milk shake, followed,over his protests, by blueberry pie. We lingered in the small

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snack shop with its sad oil painting of the Maine coast and itsgrimy counter and broken stools. We tried to joke about ourtime together, but it was a bust. (“You never would have madeit in the sewers—no street smarts and too little ambition,” hecracked. I retorted, “If I’m not there to do full-time bailing,the Lazarus will sink so fast you won’t be able to tell yourbuddies those fish stories to keep ’em from wising up to howcome there ain’t no fish.”) There were no words when I saidgoodbye at the end of the workday. Harold gave me a present,whose provenence, in spite of everything I had seen, stillamazed me; it was one of our own logbooks, already par-tially used but with the incriminating pages torn out, nowcrudely wrapped in used Christmas paper. It was to take notes,he said, in my anatomy course. And the Appalling Boss alsooffered some parting advice: “If you can cheat, Arthur, it ain’ta bad idea, but I hope you learned here how not to get caught.”Then Bill simply stood up, his huge hand on my shoulder,and pleaded, “Go, go quickly, son, before you make an oldpirate cry. Go, do good in this miserable world.”

The story doesn’t end here. I had a difficult first semesterin medical school. I thought seriously about dropping out.Two of my friends who were finishing bachelor’s degree pro-grams asked me to join them on a trip to Hawaii. I was temptedbut uncertain. I wrote Bill a long, convoluted, sentimentaliz-ing letter about the importance of what I had learned fromhim. I told him my friends had in mind getting jobs as con-struction workers and living on the beach. I explained thatmed school was demanding too much time, and I felt cut offfrom “real life.” Maybe I should just chuck it and become aworker and writer like John Steinbeck. What I had learned

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from my summer’s job was that I could do things, practicalthings, I had neither known or valued before, and that I couldbe happy with very little so long as I could have friendshipslike the one we shared. I went on and on in this tendentious,maudlin vein, I now shudder to remember.

Two weeks later, I found a letter from Bill Burt in my cam-pus mailbox. Bill had addressed it to A. Climen. The letteritself was painfully printed with a sloping line and sloppyend to each sentence and many spelling errors, words crossedout, and an almost complete absence of grammar. Bill hadclearly been worked up by the fact that I was contemplatingleaving med school. “Don’t be stupid,” he wrote, in essence.“Do you want to do donkey labor like me the rest of yourlife? Don’t blow your chance. This may be the only good oneyou get. Do you want to live like I do: paycheck to paycheck,never able to afford things, caught up in the petty dishonestyof Harold and his ilk, unable to stand up and condemn therottenness of work because you are too dependent on surviv-ing to want to threaten the only adult job you have had andprobably now the only one you could get? Do you want adead marriage, awful, unfaithful kids, the bitter feeling thatyou deserved better? Don’t mistake what you felt over threemonths for how you would feel after thirty years. Don’t be ajerk and mess up. If you drop out of school, you can forgetabout sympathy from me. I will consider that you learnednothing. Poor working stiffs like me don’t have no power.We are little people. No one need take account of us, but lotsof bad folks prey on us. We get eaten up by big people. Andworse still, we do it to ourselves because of resentment. Kid,if you give up on becoming a doctor, I’ll come there and break

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your legs! You don’t need to write back until you have anM.D. after your name.” That is more or less the way I remem-ber it—the words of a mentor admonishing me to recognizetwo different worlds and to enact the one I had preparedmyself for.

BILL’S LETTER FIGURED IMPORTANTLY in another episode with a newmentor, a new presence, the following summer. Having some-how survived the first year of med school, and buoyed byBill Burt’s letter, I had borrowed money from my parents andgrandparents and headed off to Europe to find the aestheticand intellectual inspiration that had eluded me during theacademic year. It was my first trip to Europe. I spent much ofthe summer in German university towns, where I could getby with my two years of college German and my small bud-get. I had a rich set of experiences, primarily with Germanstudents. I was relaxed, happy, and feeling better about thechoice of medicine as a career. Israel wasn’t even in my mindas a place to visit.

I have already described in The Illness Narratives how, nearthe end of summer, I crossed over the Rhine into France andentered a small town near Colmar. I checked into a tiny hoteland went for a stroll along the banks of a weed-filled canal. Asquall blew in from the east, and as the rain rushed down Idashed for a distant copse of tall trees. I got to the trees withso much momentum that it was only at the last instance thatI realized I was about to crash into the gate of a cemetery. Thegate, with a Star of David at the top, flew open as my bodystruck its iron bars, and then the gate rebounded toward astone monument with the names of the members of the Ruben

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family chiseled into the stone. You could make out from thedates of birth who were the grandparents and who the smallgrandchildren. They had all died on the same day in the early1940s. That seemed odd. Then I spied more memorial stones,more graves, more of the same date of death. It must havebeen a natural catastrophe, I reflected, perplexed, as I stoodin the open with rain pouring over my unprotected head. Therain stopped and I walked slowly back into town. But some-thing dark and foreboding moved in me, rising and strainingin my thoughts. I entered the hotel to find a different womanat the reception desk. I had no French at that time; so in astrong German voice I asked the receptionist what had hap-pened to the Ruben family and all the other families in theJewish cemetery. Why had they all died the same day? Look-ing back, it was an extraordinary scene. For the French recep-tionist, who had never seen me before, here was a youngGerman student (seemingly even down to the blond hair andblue eyes) asking in blunt, unqualified words about the Ger-man invasion of Alsace and the Holocaust (the word had notcome into vogue then) as if he had never heard of the SecondWorld War. Not surprisingly, she exploded in an angry voice,reminding me that it was after all my people, Germans, whohad invaded and occupied France and made war on the Jews.

I stood and stared at her. I apologized for angering her,told her I was the American who had checked in earlier, nota German, and quickly walked outside. I walked up anddown the streets in agitation. The happy bubble of my sum-mer burst into a chaos of dark feelings. I had again learneda fundamental truth about deep currents of history andmemory underneath surface realities. I was shaken by my

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willful disregard of the war, the genocide of my people, thecollective avoidance (which was widespread then and inwhich I so readily participated) of what had happened lessthan two decades before. And yet the way I absorbed thisterrible truth was as if I were a German. The French recep-tionist had dealt with me as if I were one of the perpetrators.I experienced the two meanings—victim and perpetrator—simultaneously.

The shock carried over into the next day, and so I decidedto explore the world about which I had been blind. I flew toTel Aviv. The sense of interfused personal and collective cri-sis only deepened when in Haifa I contracted pneumonia.Put on antibiotics and referred to a youth hostel in the desertto recuperate, I spent most of a week coughing my way aroundthe Negev. Finally I got on the bus to Jerusalem for a final fewdays before flying back to New York. On the bus, I took outBill Burt’s now dog-eared letter and read it over several times.Each time I felt thankful for the gift of his semiliterate prose.

“Important?” The tall, wiry, deeply tanned Israeli in theseat next to me smiled into my uncertain stare. “You’ve beenreading that letter over and over again. It must be important,”he repeated affably.

I looked at him. He wore tan shorts, hiking boots, a wornshort-sleeved shirt, and the kind of white cap I had seen mem-bers of kibbutzim wear when they worked in the fields. Hisbrown hair was cut short, and he wore a pair of wire-rimmedsunglasses, which he removed as he introduced himself. SimchaAdler was in his late thirties. He spoke American English, hav-ing taken a master’s degree in agronomy at Michigan StateUniversity. He was now the leader of a new kibbutz in the desert

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made up of English-speaking young men and women who hadrecently made aliya (immigrated) to Israel from the UnitedStates, United Kingdom, Canada, and Australia.

“Want to visit us?” he asked, looking intensely into my eyes.“Wish I could,” I responded equally warmly, “but I’ve run

out of time for summer travel. I need to get back home tostart my second year in medical school.”

“You really should visit,” Simcha gently admonished me.“I’m not just inviting you. You were meant to be with us. Imean, even though I don’t know you, I have this strong feel-ing that you should become a member of our group.”

“How can you say that?” I answered, smiling. “You don’tknow me. What are you, some kind of recruiter?”

“You could say that,” he laughed. “Yes, definitely, that’swhat I am, a recruiter; in fact, your recruiter.”

“Are you putting me on?” I said with exaggerated seri-ousness.

“I’ve never been more serious,” he replied the same way.We both laughed and shook hands.Simcha asked me about myself. I was bursting with self-

reflections and emotional turmoil. I had had no one to sharethe tormenting jumble of feelings and ideas with, even as theydeepened and became more acute over the previous week ofdesert solitude. Simcha was so encouraging, so enabling, suchan intensely empathic listener that it all came out in one pow-erful torrent of words, images, sensibilities, stories stitched to-gether by the golden thread of a young man’s self-fashioning.My quest for finding personal meaning was hopelessly en-tangled with collective questions of class, ethnic, religious, aes-thetic, and national identity. Through it all, Simcha looked

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directly into my eyes, smiling softly, not making any move-ment, and yet somehow he suggested that he understood.We were almost in Jerusalem when I slowed down and thenstopped, drained by the passionate prodigality of words andfeelings. Simcha said nothing. We sat in silence as the after-noon sun turned the stone of walls and buildings into goldenhues whose intensity gave the sense that trumpets weresounding. Then the enchantment burst as the bus turned intothe bustling, grimy city streets.

We walked from the bus stop toward the walled city. In1962 this was the line of demarcation between Israeli and Jor-danian troops who had faced off in armed confrontation, withmost of the ancient city in Arab hands, since the 1948 war ofindependence. Simcha told me the history of how the Jewishparamilitary force had lost the Temple Mount. He gave me asketch of where things now stood militarily. We retraced oursteps and found a tiny café. Simcha ordered roll-up sand-wiches of lamb, tomatoes, and onions together with cups ofsteaming tea.

“You want to know my story?” he asked so softly I couldbarely hear, his handsome head tipped backward. “I am asurvivor,” he almost whispered. “I was born in Russia, likeyour mother’s grandparents. My family—all of them—werekilled. I am the only one who got out. I came here as a kid.I’m now almost forty years old. So many things happened. Ifought in the war of independence. Went to university, stud-ied in the States, returned. I wanted to be a farmer. It was thereturn-to-the-soil movement and also a love of the out-of-doors. An agronomist, I had plenty of occasion to visit differ-ent sites. I found a place in the desert. It’s very beautiful. Six

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years ago I brought together a group of young men andwomen who wanted to build, not just a place but themselves.We have a very special group. We share, we work, we singand dance, and we get ready to fight. Because we are in astate of war. And small fights are happening all the time. Weare border guards, and some of us are in an elite paratrooperunit. And me, well, like I said, I’m the recruiter. I travel aroundand find people, our kind of people. That’s why I sat next toyou on the bus. You looked . . . well, like one of us.”

Simcha smiled at me, but his eyes had lost their intensity. Heseemed sad, wistful. “We will be attacked. There will be waragain. Jews will come from all over the world to fight along-side us. It is your heritage to be here with us. To live and maybeto die with us. To help build this land. To defend it. To standup and defend the remnant, the survivors. I won’t say it is yourresponsibility, because it is something holier that that. I am themessenger, but the call I bring comes from our people, livingand dead. I call you on their behalf, on your behalf.

“Listen to me, listen carefully, Asher Michail,” Simcha con-tinued, using my Hebrew name. “What you hear is all thatmatters now. Your life, your striving can only be realized tothe extent you find yourself as one of us. We need you andyou too need us. So, can I recruit you?” This time the wordswere said gravely.

I really didn’t need to think about it, and I surprised my-self with the suddenness and finality of my words. “I can’tjoin you. You mistake me, though I am not put out by themistake. Don’t misinterpret me. I’m American—a JewishAmerican, sure, but an American. I believe in the diaspora,not the homeland. I can’t stomach exclusivity. That would

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exclude Bill Burt and most of the other people, the other non-Jews, who have been significant in my life. If Israel’s verysurvival were threatened, I might very well come back as acomrade in arms. But I couldn’t stay here with you. I’m notfrom here. What’s clear now to me is I don’t belong. I’mdiasporic. I’m more sympathetic to the conversos than to thetrue believers. I hear you about the remnant. I feel the obliga-tion. I’m complicit in the willful ignorance and denial. I willnot fail to remember again. I am not the same person I was. Ihear the screams of the victims.

“But when the French receptionist reacted to me as if I werea German, a perpetrator, I felt horror. Not all were monsters.Most must have been complicit. The horror was that I couldempathize my way into being complicit, or at least makingno waves of protest. Maybe I have too much imagination.”

I had more to say, but Simcha cut me off.“Okay, you’re not one of us, but you yourself said when

war comes you are one with us. Don’t forget that! I’m not look-ing for bodies—I want the spirit. Do you hear me, Asher?”

“I hear you,” I said very slowly, my eyes fixed uncertainlyon Simcha, who was now once again smiling at me.

“You are something of a recruiter yourself,” he laughed.“We will miss you. My instinct was right. Whoever you are,whatever you become, you have heard the call. You said nothis time. I should be annoyed. But I’m not at all. I heard whatyou said. Who knows, maybe the diaspora too can haunt aperson, forcing you to . . . well, let’s just say, recruit. Go inpeace, my brother.”

I have never regretted this turn of events. As the Israeli-Palestinian conflict deepened, I could see the truly danger-

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ous contribution of ethnic and religious nationalism to intrac-table political violence. The antiheroic stance of mutual self-critical reflection looked to be the only promising wayforward. Heroism, in the classic mode, only perpetuated trag-edy. There were too many recruiters on both sides. As W. H.R. Rivers, whom we will read about in the next chapter, liber-ated himself to understand, moral mentoring can intensifydanger unless it enables individuals (and collectivities) tobreak out of local dialects of moral experience that under-write violence by mobilizing inhuman responses to threats towhat we mistakenly hold to be most at stake. Moral responsi-bility is not itself enough; it must be balanced with criticalimagination. Over the years I’ve never felt I have had thatbalance, far from it, but I can now at least affirm the necessityof the unequal struggle to somehow find it.

Maybe it’s not a surprise that my diasporic identificationhas weakened over the decades. I married outside the faith,and my wife and I raised our children in a broad coalition ofvalues: Chinese, American Protestant, Jewish. I remain deeplysuspicious of ethnic and religious exclusivity. Our friendshipnetwork is a global one. This is also true of the network ofstudents I have mentored. Together with my family they rep-resent the closest and most important circle of intimate oth-ers. Since many postdoctoral fellows, Ph.D. students, M.A.students, medical students, and undergraduates have workedwith me over thirty years, I should know something aboutacademic mentoring. What I have learned is that mentoringturns on dealing openly with the complexities of moral expe-rience. Encouraging self-critical reflection, but not dominat-ing it, matters. So does the explicit recognition that we are

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here to do good in a practical way in the world as part of ourmoral self-fashioning. To accomplish that, we need to riskopenness to being changed by others. Being serious aboutresearch and teaching means offering evidence that one pos-sesses an intellectual project that really matters to oneself andto others. A mentor draws a young scholar or clinician to-ward the subject in a kind of apprenticeship, the final stage ofwhich requires that the apprentice move beyond the mentorinto an intellectual, emotional, and moral space of his or herown. This is not easy to achieve, and it is threatening to both,but it must happen.

At any rate, this is the context of emotion, meaning, andrelationship that makes up my local world and my subjectiveself. Out of this nexus emerge the core themes of this book:the centrality of experience; the powerful influence of cul-ture, politics, and economics that can make us complicit inemotional and moral untruth; the way danger and our re-sponses to it make and unmake existential realities; the call ofthe world for responsibility and imagination and practical ac-tion on behalf of others in need; and the aspiring defeats anddespairing victories—the quality of antiheroic everydayness—that make life unmasterable yet open to hope, unexpectedtransformation, beauty, and critical ethical reflection.

The balance between the elegiac and the promising keepschanging. Four shining grandchildren and an enabling fam-ily have carried me through rough times, on one side; on theother are the bravery and sheer struggle that Joan, my wife offorty years and research collaborator, has demonstrated dayby day as she lives with a fierce and unrelenting neuro-degenerative disorder that has ruined her vision, compro-

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mised her memory, stolen her independence, and shaken ourbonds. No time is easy; no life is as simple a progression as anacademic vita outlines. The only certainty is the uncertaincourse of aging and health and the inevitability of catastro-phe. I could not have written this book in an earlier time, andhad I tried to do so, the balance would have been far differ-ent, as would the understanding of danger. The existential isalways our mode of being human, but what is foundationalto living differs developmentally as it does situationally. Wego on, and on, and on, arriving and departing from new sta-tions, and neither the journey nor we ourselves are quite thesame. Each age and station develops a different answer to thequestions of who we are and where we are headed.

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W. H. R. Rivers

now turn to a historical case: W. H. R. Rivers, an anthro-pologist and psychiatrist in Cambridge, England, who was

influential in the first two decades of the twentieth century. Ido so for two reasons. First, Rivers’s story is a strong illustra-tion of this book’s contention that moral experience is a keyto understanding persons and their worlds. And second, Riv-ers himself formulated a critique and practice of reworkingmoral experience as the basis for changing people and theirworlds through education, research, psychotherapy, and poli-tics. And this became central to his own moral life. The storyof W. H. R. Rivers summarizes the issues illustrated in theearlier chapters, but it also offers a larger social historical ex-ploration of why the existential question of who we are inlight of where our world is headed is so necessary.

“At Cambridge you knock and enter. The room was beau-tiful, with its brown paneled walls, but nothing else was. It

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was in an awful muddle, with books and papers and oddsand ends of anthropological trophies all over the place. . . .Then Rivers came out of his inner study, and somehow atonce the room came alive, and the things in it were right afterall. There he was, rather tall, trim, quick and light in his move-ments, in navy blue. You got a swift impression of straight,broad shoulders and a jutting chin, and at once of a tremen-dously alert mind. He shook hands, told me to sit down, satdown himself, said that no doubt I knew what I wanted andhow to get it, took off his spectacles and swept his handacross his eyes with perhaps the most familiar of his ges-tures, and waited. . . . He was like a man suddenly comeback from somewhere into a world which on the whole hedid not like very much. Tea came up from the College Kitchen. . . somehow it came out that I had read a little anthropol-ogy, and even that I had heard of Cross-Cousin Marriageand Classificatory System. Rivers’ stammer disappeared. Thetable was cleared of a book or two. For a brief time we poredover complicated diagrams of relationships. Only for a shorttime: the History was urgent, and out I came again, suddenlyto realize that I had been treated, not as an undergraduate,but as an equal.

“That was Rivers’ way, then and later. It was a great part ofhis power over men, especially young men.”

This is the reminiscence of the English psychologist andfounder of memory research, Frederic Bartlett, in RichardSlobodin’s book on Rivers. Remembering Rivers as a pres-ence at St. John’s College, Cambridge, in 1909, Bartlett con-tinued: “His power did not lie in what he said and wrote . . .but in himself.”

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“I had said good-bye to Rivers. Shutting the door of hisroom for the last time. I left behind someone who had helpedand understood me more than anyone I had ever known,”wrote Siegfried Sassoon, the celebrated antiwar poet who hadbeen Rivers’s patient at Craiglockhart Military Hospital in1917. In Sherston’s Progress, Sassoon went on to describe a visitRivers made to him after Sassoon had returned to the trenchwarfare in France, been wounded, and was evacuated to aLondon hospital.

“And then, unexpected and unannounced, Rivers came inand closed the door behind him. Quiet and alert, purposefuland unhesitating, he seemed to empty the room of everythingthat had needed exorcising. . . . My futile demon fled me—forhis presence was a refutation of wrong-headedness. I knewthen that I had been very lonely while I was at the War; Iknew that I had a lot to learn, and that he was the only manwho could help me. . . . Without a word he sat down by thebed; and his smile was benediction enough for all I’d beenthrough. ‘Oh, Rivers, I’ve had such a funny time since I sawyou last!’ I exclaimed. And I understood that this was whatI’d been waiting for.”

Another sketch of Rivers comes from A. C. Haddon, whoinitiated and oversaw anthropological studies at Cambridgeand was Rivers’s colleague and friend for three decades.Haddon wrote in Rivers’s obituary in 1922, “He regarded allhuman conditions as the appropriate study of psychology andethnology [a nineteenth- and early-twentieth-century term foranthropology’s comparative cross-cultural approach]. This isillustrated by his last phase when friends in London, know-ing his interest in labour conditions, invited him to stand as

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Labour Candidate for Parliament for the University of Lon-don. He agreed to do so as he felt that his special knowledgemight be of use under the present critical conditions; it wasnot political influence that attracted him, but merely a desireto give his best to his fellow men; to quote his own words: ‘Toone whose life has been passed in scientific research and edu-cation the prospect of entering practical politics can be no lightmatter. But the times are so ominous, the outlook both forour own country and the world so bleak, that if others think Ican be of service in political life I cannot refuse.’”

Near the end of her engrossing 1992 novel Regeneration,which features Rivers as its central character, Pat Barker, inan inspired creative act, “embellishes” an extraordinarily tell-ing story that Rivers reports to his great friend and collabora-tor Henry Head as “the experience of having your life changedby a quite trivial incident.” Barker has Rivers remember backto his days as an ethnographer of Melanesian society whenhe was traveling on the mission boat Southern Cross. A groupof Melanesian islanders, recent converts, are on board, andso Rivers goes through his usual field method of gaining in-formation about kinship and economic exchange. He asksthe islanders what they would do with a guinea. “Would youshare it, and if so who would you share it with? It gets theirattention because to them it’s a lot of money. . . . Anyway, atthe end of this—we were all sitting cross-legged on the deck,miles from anywhere—they decided they’d turn the tableson me, and ask me the same questions.” So they get Rivers tosay what he would do with a guinea. Who would he share itwith? He responded that because he was unmarried he wouldnot share it with anybody. “They were incredulous. How could

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anybody live like that? And so it went on, question after ques-tion. And it was one of those situations, you know, where oneperson starts laughing and everybody joins in and in the endthe laughter just feeds off itself. They were rolling round thedecks by the time I’d finished. And suddenly I realized thatanything I told them would have got the same response. Icould’ve talked about sex, repression, guilt, fear—the wholesorry caboodle—and it would’ve got exactly the same re-sponse. They wouldn’t’ve felt a twinge of disgust or disap-proval or . . . sympathy or anything, because it would all havebeen too bizarre. And I suddenly saw that their reactions tomy society were neither more nor less valid than mine totheirs. And do you know that was a moment of the most amaz-ing freedom. I lay back and I closed my eyes and I felt as if aton weight had been lifted.”

“Sexual freedom?” asks Head.“That too. But it was, it was more than that. It was . . . the

Great White God de-throned, I suppose. Because we did, wequite unselfconsciously assumed we were the measure of allthings. That was how we approached them. And suddenly Isaw not only that we weren’t the measure of all things, butthat there was no measure.”

W. H. R. RIVERS (1864–1922), as these excerpts attest, was a mostremarkable figure. Researcher, teacher, therapist, politician—he was a polymath, and a distinguished one, who at the timeof his premature death at age fifty-eight was a fellow of St.John’s College, Cambridge, a member of the Royal Society,winner of its highly prestigious Royal Medal, and, at one timeor another, president of Britain’s leading societies of psychol-

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ogy, anthropology, and folklore. Haddon hailed him in hisday as “the best field ethnologist there ever has been. He wasalso in the first rank as a psychologist.” Not least, for ourpurposes, he was greatly valued for his huge productivity asa scholar, his intellectual seriousness and breadth, and, per-haps most of all, for the sensitivity and generative quality inhis friendships, teaching, and therapy. Rivers had a specialinfluence on others, as the preceding examples attest, an in-fluence that members of his circle identified as moral due tothe enabling quality of his way of engaging others and thesense of responsibility that he brought to (and expected from)those relationships. Pat Barker’s Regeneration rescued Riversfrom relative obscurity, turning him into both witness andhero of Victorian and Edwardian times. Even though Riverscame from and participated in British imperial culture, heturned himself into a critic of nationalism, colonialism, andthe class system, which brought such devastation in the GreatWar. And he attempted to reform his world. Beginning as ahesitant, self-effacing, even reclusive scholar, he remade him-self as a public intellectual who took on the major social is-sues that challenged his times. His life story reaches acrossthe eight decades to our era, signifying a different moral ageand the transformation of both our outer and inner worlds.Yet I retell Rivers’s story principally because he was an exem-plar of remaking moral experience by living a moral life.

Born in 1864 into the slightly shabby gentility of the Victo-rian English upper middle class—his father was a rural par-son in Surrey who had become known for his approach tothe treatment of stammering, a trait his son suffered fromthroughout his life—Rivers was educated first in medicine,

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with advanced training in neurology and psychiatry. But heabandoned the clinical side of medicine early on for a researchcareer in physiology—then the leading basic medical science,which was shaping the methods and subject matter of fieldsas seemingly different as psychology, zoology, and surgery.

Rivers was invited to Cambridge in the early 1890s to de-velop experimental psychology, and he maintained an activeinterest in psychology throughout his career. A. C. Haddon,another former physiologist, asked Rivers to join him andothers on an expedition to the Torres Strait (north of Austra-lia, near New Guinea) to study social, biological, and histori-cal aspects of the local peoples who lived on the islands thereand specifically to oversee the expedition’s psychological test-ing of the native population. In less than a year of fieldwork,Rivers transformed himself into an anthropologist. He devel-oped interests in kinship studies and other aspects of socialorganization. He introduced more systematic field researchmethods and went on to conduct intensive individual field-work, producing early ethnographies of Melanesian societyand of the Todas, a hill tribe in south India. Indeed, he mightbe regarded as the first modern ethnographer. His researchreports established a new standard for ethnographies and areoccasionally still read in anthropology courses.

Whatever Rivers’s scholarship delved into, he worked atwith enormous energy, fierce absorption, and huge produc-tivity. Yet while carrying on a busy, full-time career as an an-thropologist, Rivers also continued his physiological research,studying fatigue and, most famously, collaborating with Headon an experiment on peripheral nerves that became one of

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the sources of his reputation in medicine, because it set out anew theory of how nerves regrow after being severed.

In World War I, Rivers returned to clinical medicine as hisvoluntary contribution to the war effort. His extraordinarytalent as a master psychotherapist emerged in the context oftreating shell-shocked officers, who were being diagnosedwith psychiatric categories such as anxiety neurosis, neuras-thenia (a then popular medical term for fatigue and relatedpsychosomatic symptoms), or to a lesser extent hysteria. Hismost notable patient was Sassoon, a decorated soldier whowas placed into treatment in 1917 after sending an open, pub-lished letter to Parliament protesting the war. A poet, Sassoonhad not sought out a medical remedy but rather saw his actas public protest. His friend and fellow literary figure RobertGraves, who suffered from war-related neurasthenia, arrangedfor Sassoon’s hospitalization in place of a court-martial. Riv-ers, as we have seen, had a great effect on Sassoon, who ide-alized him as his “personal Savior.” But the quasi-religiousrelationship also protected Sassoon from delving too deeplyinto the “tortured inward self” of inexpressible hom*osexualdesire that Sassoon and his friend T. E. Lawrence (“Lawrenceof Arabia”) recognized they shared. Rivers actualized a kindof protective psychotherapy, a talk therapy that avoided ex-posing deep wounds and aimed instead to enable Sassoonand others to gently and slowly rebuild shattered emotionsand heal broken self-images. As much for himself as forSassoon, who exerted an equally powerful effect on Rivers,Rivers created a self-exploration that placed the treacherouswaters of sexuality off-limits.

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As a military officer, Captain Rivers was obliged to eithercertify his patients as disabled and unfit for service or returnthem to the carnage of trench warfare in France. It was “theage of massacre,” as Eric Hobsbawm calls it in The Age of Ex-tremes: “One quarter of the Oxford and Cambridge studentsunder the age of 25 who served in the British Army in 1914were killed.” Trench warfare along the Western front involvedmillions of men who “faced each other across the sandbaggedparapets of the trenches under which they lived like, and with,rats and lice. . . . Days, even weeks of unceasing artillerybombardment—what a German writer later called ‘hurricanesof steel’—were to ‘soften up’ the enemy and drive him un-derground, until at the right moment waves of men climbedover the parapet, usually protected by coils and webs of barbedwire, into ‘no-man’s land,’ a chaos of waterlogged shell-craters, ruined tree-stumps, mud and abandoned corpses, toadvance into the machine-guns that mowed them down.”

Not surprisingly, men broke down under the immensestress. The term shell-shocked was popularly applied; it con-veyed the erroneous but culturally legitimizing idea thatphysical trauma, such as concussion, from bombardment withhigh-explosive munitions was responsible for the symptoms.Those symptoms seemed to fall into two different orders ofthings: paralysis, mutism, psychological deafness, and othermotor and sensory disturbances, primarily among the working-class enlisted ranks, and tics, stuttering, agitation, panic, night-mares, sleep disturbance, amnesia, and other symptoms thenbelieved to be more cognitively sophisticated and emotionallyrich, principally in officers, most of whom at the beginning ofthe war came from the upper middle class and aristocracy.

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Today, shell shock would, with other symptoms such as de-pression and flashbacks, be diagnosed as post-traumatic stressdisorder, by which psychiatrists and psychologists wouldunderstand the condition to have a psychological origin withbiological and social risk factors. But the very presence of cer-tain symptoms has changed over the decades, so the conceptof hysterical conversion has lost its cultural salience and al-most disappeared, and certain diagnoses such as neurasthe-nia are no longer used.

It was not lost on patients or physicians in Rivers’s daythat the symptoms served the highly practical purpose of re-moving the soldier from the extreme danger of the war zone.The diagnoses were stigmatized, and sufferers were popu-larly regarded as either malingerers, cowards, or madmen.To Rivers’s great credit, he argued strongly that these disor-ders were based not on physical head trauma but on psycho-logical trauma and that this did not make them any lesslegitimate forms of pathology deserving humane care andtechnically competent treatment interventions. Rivers’s dis-tinguished scientific career brought greater acceptance of theneuroses of warfare, as he sometimes referred to them, butthere was still considerable skepticism among military pro-fessionals, including medical officers. Ben Shephard, a Britishhistorian of military psychiatry who has written a definitivereview of war neuroses, describes two warring schools of mili-tary physicians: the “hard” school played down psychologicalissues for fear it would lead to huge numbers of men seekingthis means of escape, and the “soft” school, which includedRivers, sought to describe, legitimate, and heal the seriousand widespread emotional trauma of warfare.

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Rivers entered the Great War, as he himself noted, with con-ventional ideas of bravery, loyalty, and steadfastness servingnationalistic ambitions. But unlike the vast majority of his coun-trymen, Rivers’s ethnographic experiences had made him criti-cal of colonial and missionary policies, which he heldresponsible for depopulating whole societies, among other badthings. In Melanesia, he criticized missionaries and colonialgovernment administrators for undermining natives’ religiousceremonies and attacking their core values, thereby demoral-izing local populations, whose faith in the future dwindled andwith it their commitment to social and biological reproduction.He moved toward a relativist position in the early years of thetwentieth century, when, as the quote from Barker’s novel sug-gests, he turned away from invidious cross-cultural compari-sons and argued for the crucial influence of local contexts onpeople’s lifeways. He explicitly rejected the racialist science ofhis day. Rivers’s views were not conventional, but on the otherhand, he did not oppose the war, at least not until its immensehuman cost as well as his medical experience and relations withSassoon and other patients changed his mind. By the end ofthe war, however, Rivers had convinced himself that his loyal-ties had been grievously misplaced. He recognized Sassoon’srole in his own “regeneration.”

Rivers returned to St. John’s at the war’s close to continuehis anthropological studies. He would transform himselfa*gain, this time as a public intellectual, comfortable with awide network of influential acquaintances, planning the fu-ture development of his several professional fields from po-sitions of leadership, outspoken on current affairs, delvinginto working-class issues and socialist connections, and rec-

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ognized by his friends as more confident, happier, and morecomplete in himself. Again, Rivers drew upon his reserves ofenergy to carry out a prodigious amount of academic work.He died in the midst of the political campaign, running as theLabour candidate for the University of London’s seat in Par-liament. One evening, while alone in his college rooms, hesuffered the terrific abdominal pain of a strangulated bowel.The long loose loops of intestine kink, cutting off the bloodsupply to a section of bowel, which then dies, spewing itsfecal contents into the abdominal cavity and spreading infec-tion through the blood, resulting in sepsis, shock, and death.He was unable to summon help. By the morning it was toolate to do anything medically.

WHEN I BEGAN STUDYING medicine and anthropology, I viewedRivers as a failed predecessor who had worked separately inmedicine and in anthropology without building a bridge (nowcalled medical anthropology) between these different domainsof knowledge and practice—domains that had grown so farapart by my own student days in medicine at Stanford in theearly 1960s that I was told that they had nothing to do witheach other.

The descriptions of Rivers at the outset of this chapter evokethe issues that frame this book: experience, its moral modes,and where their changing forms and meanings are taking us.It is W. H. R. Rivers as an exemplar of moral experience andits vicissitudes that will guide our further exploration of hislife and work.

Rivers got at living a moral life via the relationship betweenpsychological symptoms and human values. A point Rivers

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repeatedly emphasized in his writings on psychopathology—he had to repeat himself and do so loudly in an age whenFreudianism was becoming the fashion, among the elite atleast—is that sexuality is only one of the sources of inner con-flict creating neurosis, and not necessarily the most funda-mental one. A more fundamental source for Rivers—howcould he have avoided it during the Great War, when he hadhis most sustained clinical encounters?—is the instinct of react-ing to life-threatening danger with efforts at self-preservation.The army officers Rivers treated were, he believed, experienc-ing neurotic symptoms because of conflicts between inner feel-ings, largely unconscious, of self-preservation and societal andmilitary values that required them to be brave and steadfast inthe trenches, where they could neither flee nor fight but had topassively persevere under shelling that appeared to kill sol-diers randomly and over which they could exert no control atall—a terrifying reality. Seen this way, the conflicting moralworlds of his officer patients—their homes, schools, and themilitary combat conditions they endured—were the source oftheir illnesses. Theirs were moral disorders.

What little Rivers had to say about his own interiority takespsychodynamics in a different direction, from sexuality tomorality. Rivers tells about his relation to Sassoon in his analy-sis of his “Pacifist Dream” in his book Conflict and Dream.Sassoon, here called B., had recommended Rivers read Bar-busse’s Le Feu, a critical work that promoted his thinking inan antiwar direction.

“During the analysis [of B.] I remember quite clearly thatwhen I was reading the [English] Review I had thought of thesituation that would arise if my task of converting a patient

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from his ‘pacifist errors’ to the conventional attitude shouldhave as its result my own conversion to his point of view. Myattitude throughout the war had been clearly in favor of fight-ing until Germany recognized defeat. . . . Though my mani-fest attitude was definitely in favor of war to the finish, I hadno doubt about the existence of a very keen desire that thewar should end as soon as possible for the egoistic motivethat I might get back to my proper studies, which had beeninterrupted by the war. I have no doubt that this egoisticmotive was always active beneath the surface. I was awarethat if I had been acting solely on my own immediate inter-ests I should have wished the war to come to an end at once,regardless of future consequences. There was thus the groundsfor a definite conflict in my mind between a ‘pacifist’ ten-dency dictated by my own interests on the one hand, and, onthe other, opinions based partly on reasoned motives, partlyon conventional adherence to the views of the majority, infavor of a fight to the finish. The article in the English Reviewmay be assumed to have reinforced the egoistic side of theconflict by providing the rational support that, owing to thesupposed economic ruin of Germany, peace by negotiationhad become possible. The conversation with B. must also haveserved to stimulate the conflict, though it is not easy to saywhich side of the conflict would have been strengthened.”

Rivers concluded, “So long as I was an officer of theR.A.M.C. [Royal Army Medical Corps], and of this my uni-form was the obvious symbol, my discussions with B. on hisattitudes towards the war were prejudiced by my sense that Iwas not a free agent in discussing the matter, but that therewas the danger that my attitude might be influenced by my

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official position. As a scientific student whose only objectshould be the attainment of what I supposed to be truth, itwas definitely unpleasant to me to suspect that the opinionswhich I was uttering might be influenced by the needs of myposition, and I was fully aware of an element of constraint inmy relations with B. on this account. So long as I was in uni-form I was not a free agent, and though no one can be a freeagent during a war, it was a definite element in my situationat the time that my official position might be influencing thegenuineness of the views I was expressing in my conversa-tions with B.”

Therapy, like fieldwork, involved entering the local worldof the patient and getting him to return in memory to thehorrors of that other, most dreadful world of experiencingonce again the faces of battle. Rivers drew on moral experi-ence to affect his patients. By making them face what wasreally at stake—their survival and also their fears of disgracingthemselves in the ultimate test of manliness at the frontlines—Rivers moved them toward a liberating self-awareness, in-cluding recognition of the untenable position in which societyhad placed them. His ethnographically informed method en-abled them to see what was at stake and why it was so con-flicted, even if it did nothing to keep them out of harm’s way.Rivers called his psychotherapeutic approach—appropriatelyenough, in the sense I have given it, though ironically from theperspective of depth psychology—autognosis (self-knowledge).As his own conflicted story indicates, Rivers was coming tothe transformative recognition that self-knowledge must beabout not only one’s psychological state but also one’s socialand political position. Rivers came to see, long before Foucault

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and postmodernism, that power and knowledge were insepa-rable. Seeing emotion in moral terms required a psycho-therapy that emphasized the surface and protected the patientfrom losing himself in depths of the self that obscured theconnections to the moral and political.

I believe this is the reason why so many of Rivers’s friendstook his uncompromising commitment to the scientificmethod, and above all his uncanny ability to identify whatwas at stake and influence others to engage it through theforce of his own commitment to a certain kind of mutual self-knowledge, as evidence that he was in touch with the rootsof their moral experience. In other words, Rivers’s therapeu-tic powers and his interpersonal influence grew out of hisethnographic practice in the field, in the ward, and perhapseven in the senior common room, a practice that started ashierarchical and one-sided (in his early days with the TorresStrait expedition team) but ended up as a mutual explorationof knowledge about the world, authenticity of the self, andcommitments to practical living.

Analyzing his own dreams, in Conflict and Dream Riversobserved “the desire for change and novelty, which is one ofthe strongest elements in my mental make-up.” We see thisin his response to the call to Cambridge, the reinvention ofthe erstwhile experimental psychologist as an anthropologistduring the Torres Strait expedition, and the leap back intoclinical medicine in the war with its subsequent journey fromconventional patriotism to incipient dissidence. Rivers hadlived through his own mutations and believed in their im-portance in his life and in the lives of others. But he under-stood as well that such change, if it was to have a transfiguring

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potential, needed to grow out of people’s knowledge of theirworlds and how their selves operated (or were operated on)in those worlds. That knowledge was not just any knowledge,but knowledge about the particular tensions and conflicts inmoral experience.

The relationship between the moral and the medical spheresof existence could not, Rivers believed, be lodged solely inthe individuation of the person. That dominant framing inpsychotherapy left out larger societal forces—politics, eco-nomics, social class, culture—that powerfully constrained thelocal worlds of patients and therapists. It was the relation-ship between the moral, the medical, and the political spheresof everyday life that explained the sources of pathology andenabled or blocked the possibilities for therapeutic transfor-mation. But engaging this broader nexus of causality andchange led to more than just increasing the potential for indi-vidual transformation. It made social change possible as asource of prevention, repair, and remaking of a local world.This was the possibility Rivers actualized in his final, and in-complete, reinvention as a political player. It is the abidingchallenge to the fields of which he had become an esteemedancestor, even if not directly influential: medical anthropol-ogy and social medicine. And as I have tried to demonstratein my interpretation of the worlds of experience of the pro-tagonists of the earlier chapters, this framework for relatingsubjectivity and social experience is still a crucial one fortheory and practice.

THERE IS A POLITICS OF MORAL PRACTICE in psychotherapy. Anyresponse to victims of political violence—say, in Iraq, Afghani-

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stan, Colombia, or Congo—by diagnosing them as patients withpost-traumatic stress disorder (PTSD) and treating them forthe pathological effects of memory but failing to bring into thetreatment program the politics of violence and trauma and thequestion of how to live a moral life under those dangerousconditions is an inadequate one. The act of reconstructing thetrauma of political violence as only an individual problem ofemotion and memory places its causes and consequences be-yond the focus of intervention. Seen in this light, Rivers didnot mistake what the issues were in his psychotherapy or hispolitics. Ultimately, one had to remake a world, and that re-quired remaking the self as moral and political agent.

Rivers flourished in a prewar and wartime era that em-phasized an explicitly moralizing cultural idiom, one sharedby his friends, colleagues, and students, most of whom werein positions of power and authority. The cultural messagesconcerning how one should behave and the ways of socializ-ing young people into adult roles turned on themes of cour-age, loyalty, endurance, steadfastness, manliness, doing theright and decent thing by others, shouldering responsibility,and so on. These moralistic terms not only characterized thatage’s culture but established the values to guide emotions,sense of self, and what I have called moral experience. Thismoralizing and moralistic world enabled Rivers to exert hisstrong personal influence over others. He became a master atexpressing this language and using it to advance his career.And, as we have seen, he was extraordinarily successful inhis time, and received high honors and academic position.But Rivers began to understand that his era’s norms and nor-mality were dangerous, and greatly so. Unlike many of his

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contemporaries, Rivers came to see how the very personhoodof soldiers, workingmen, and their leaders embodied valuesand emotional reactions that fueled the fires of war andthrough the political manipulation of patriotism created anunprecedented catastrophe. He also came to realize that thedestructiveness of British imperialism, racism, and class-basedsocial life grew out of the same cultural ethos of dangerousmoral commitments. Thus, he concluded, men (and it was apatriarchal and paternalistic world of men he had in mind)had to be remade to remove the incendiary moral bridge be-tween power and destruction. Different models of how to livein the world were needed that challenged the establishedmoral culture before it proved too late.

So Rivers began to reject the very cultural values that hadmade him influential. He sought to assist Sassoon and otherofficers to rebuild their lives in a new, more enabling directionnot by telling them what they should do, in the authoritarianmode he now regarded as the cultural root of society’s prob-lems, but through a new form of ethnographic psychotherapythat encouraged them to come to terms with the cultural, po-litical, and moral forces that had made them who they are andthat had placed them in such a desperate situation.

Rivers is an epitome of what Tony Judt, the historian andsocial commentator on Europe, refers to as the burden of moralresponsibility. Judt wrote about how that burden connected thelives and actions of committed French political intellectuals—Léon Blum, Albert Camus, and Raymond Aron—to their times.Rivers offers another example of how the burden of moralresponsibility can be handled in such a way that changes in

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the person can have wider effects in the lives of others and oncrucial issues in the world.

Flaubert’s expression “No monsters and no heroes!” is usedby the scholar of comparative literature Victor Brombert todistinguish a kind of negative hero or antihero, “a perturberand a disturber” of the way things are. Brombert writes in InPraise of Antiheroes that “the negative hero, more keenly per-haps than the traditional hero, challenges our assumptions,raising anew the question of how we see, or wish to see our-selves.” Primo Levi, the Holocaust survivor and author, isone of Brombert’s exemplars, principally because Levi chal-lenged the sharp separation between good and evil, and inits place wrote about the gray zones of life where ordinarymen and women end up doing terrible things. For Levi thegray zone was a local cultural world where the moral normsand normality of everyday living, not just pathology, createdhorror and desolation. I have used this idea of the antihero todescribe several of the protagonists of earlier chapters.

W. H. R. Rivers could have been used by Brombert as yetanother negative hero or antihero. Rivers died before his po-litical career went anywhere. His works, while influential inhis time, were not transformative for anthropology or medi-cine over the long run and have largely been forgotten. Heperturbed and disturbed the moral ethos of his day not as arevolutionary but squarely from the center of the establish-ment. He liberated himself from the very cultural values thathad made him and his career. In living a life, Rivers showed,we need first to be aware of the dangers that are part of nor-mal, moral commitments. Then we need to craft a life that

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opens a wider space for others to build their own moral ca-reers, where they have alternatives to established norms andways of being normal. And that, in turn, makes it more fea-sible for us to bring emotions and values together in a moresubjectively enabling way. The direction of transformation isfrom our investment in others in our world to what mattersmost to us in our inner self.

Epilogue

arratives can haunt. What haunts our memories is morethan images and words, but the actual world of experi-

ence that stands behind them. The self-harassed man I callWinthrop Cohen was haunted by what he did as a soldier inthe Second World War. For over four decades he could nottransform the undermining memory from a secret narrativeof atrocity to a public confession of remorse and regret. Andhe haunted me with his terrifying testimony of murdering anunarmed Japanese military doctor who was caring for awounded soldier. He punished himself thereafter with un-wanted elaborations of the dreadful deed in dreams and fan-tasies. There were moments in our therapy where I was trulydisturbed by the uncanny feeling that the ghost of the deaddoctor was with us in my office, a silent witness, rememberedas a face, arms rising, and a crumpled bullet-ridden body, asWinthrop Cohen took the scene apart and put it together again,

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and in so doing took himself apart and remembered who hewas, refusing any mask, telling and retelling the murder asboth originating event and timeless present, a deed that couldnot be gotten over or passed through. Winthrop Cohen re-lived his past each day with astonishment, grief, and horror.

Winthrop Cohen insisted that I must not explain away thehaunting scene, mask who he was, or justify what he did.Instead, I had to step into it and relive it with him, and not asdistancing pathology, but up close in the choke and sting ofnormal moral experience. It would take me decades to freemyself from the self-protection of professional explanation tohear what he was saying. This is also what life is, he impor-tuned. Don’t say it is inexplicable but technically solvable.See it for what it is and feel ashamed for who we are.

Still, Winthrop Cohen’s demand for absolute authenticity,his lifelong loyalty to the despairing deed, and his unwilling-ness to protect himself or me from its ethical haunting is whatI mean by aspiration in defeat. Just as Idi and Bill Burt aspiredin the midst of occupational defeats for a better level of humanexistence and Sally Williams turned her own experience of drugabuse and AIDS into advocacy and activism in order to do somegood in the world, Winthrop’s penance through depression wasmeant to do more than flagellate himself as punishment.He was acknowledging something inherent in human con-ditions and protesting. Winthrop meant for both of us—all ofus, really—to feel remorse and regret to such a discomfortingextent that we would have to change who we were and whatwe did or charged others to do in times of war.

Winthrop Cohen, like the Reverend Charles Jamison, in-sisted there is a divided world and a divided self. The world

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of actual moral experience (what we are capable of doing)and the world of idealized ethical reflection (what we are so-cialized to aspire to or to not do) are separated for him by anunbridgeable chasm between what can be said and what mustnot be spoken. In the former, the space of ethical deliberation,we address justice, for example, while operating in an unjustworld, and in the latter, the space of everyday moral experi-ence, we go about doing what we have to do to get on withthe practical tasks of living, and in so doing end up practic-ing injustice. Danger, fear, and power characterize actualmoral experience. They too infrequently are acknowledgedand addressed as simply crucial in the world of ethics.

The self, for Winthrop Cohen, is similarly divided. In hisdualistic model, a critical, reflective consciousness vies witha passionate practical agency. The reflective self offers rea-soned justifications for our actions. Yet those actions—whatwe actually do in living—are as much based in passion andwillfulness as in reasoned choice. The thoughtful justificationsare often excuses, made up after the fact, for things that wedo that explode from within like surges of uncontrollable an-ger. The passion-laden, practical self is caught up in what Ihave called our local moral worlds, what William James calledgenuine reality. The reflective self is caught up in ethical de-liberation and aspiration.

For Winthrop Cohen the actual worlds of moral experienceand the practical, practicing self are filled with pain, anger,uncertainty, and disappointment. Of course, he would readilyadmit, they are also places of exuberance, ambition, andstruggle. The ethical world and the reflective self, for him,are comforting and comfortable islands of optimism, hope,

220 What Really Matters

and certainty. That’s the way the world is, the way we are;look upon it and despair, admonishes Winthrop Cohen. Andin his unappeasing criticism, we can almost hear the tone ofOld Testament prophets railing against the too easy accep-tance of the reality of evil and the hypocrisy of holding self-justifying ideals that we know are not intended to practicallyaddress that evil.

I find this bifurcated vision, which seemingly matches theidea of actual moral experience and imagined ethical aspira-tion that I have introduced in the case studies, deeply dis-turbing, as it is meant to be, yet also misguided. For there isspace for critical self-examination, responsible action, andmoral transformation in the divided world and in the dividedself. Idi’s story and the narratives of Dr. Yan, Sally Williams,and W. H. R. Rivers illustrate the bridging of real world, ac-tual self, and ethical space. Ethical imagination and responsi-bility can, indeed must, be grounded in the turbulent watersof moral experience. Even in the most desolate and isolatingmoral landscape there is a place for criticism, protest, andpractical efforts for change. And yet, in spite of its dualism,Winthrop Cohen’s unsparing vision is an antidote to the easylies of nationalistic sentimentality and commercial propa-ganda that would have us believe in a cultural scenario of anabsolute divide between polar opposites: good guys and badguys, heroes and monsters. The capacity to divide world andself may make life more bearable, because we can have ourcake and eat it too: we can recognize the moral and politicaldangers in living and claim that we stand apart from them ina space of our own idealized intention. This way there is norequirement for moral responsibility or for ethical reflection

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to confront limits, failures, overreactions, and other practicaldangers in ordinary moral experience. It misrecognizes whatis most troubling in experience.

What really matters to us is simultaneously what is mostoptimistic and what is most ominous. Winthrop Cohen changedhimself, and he changed me. His protest had the potential(albeit limited) to change others and even his world. That theworld has not changed that much is illustrated by atrocitiescommitted in the Abu Ghraib prison during the second Iraqwar. That the world can still be changed is illustrated by thepublic uproar, political condemnation, and legal responses tothat most recent abuse. Learning to value the defeated aspi-rations of antiheroes and to see their potential for remakingmoral imagination and responsibility is one way that we cantransform what is most dangerous in what matters most tous into something better for us and for our world.

I see Yan Zhongshu, at the very moment when revenge onhis still dangerous nemesis was at hand, inexplicably turningaway to create an entirely different and frankly better moralreality. What does that tell us about experience? There was andis no victory for Dr. Yan; in fact, his eventual departure fromthe hospital and exile from China amount to a species of de-feat. Yet within that story of disappointment, betrayal, and loss,there is something else that cannot be defined only as defeat.There is self-critique, protest of the local moral world and itsdangers, and the potential for transformation. Failure, seen thisway, is not entirely negative; it even can be creative.

Of course Yan Zhongshu’s presentation of self was meant toimpress me, and it did. Speaking in the safer context of theUnited States to an American China scholar already identified

222 What Really Matters

as interested and supportive of the moral resistance of intellec-tuals to political violence, Yan knew what kind of spin to hisstory I would find laudable. Assuming the moral high groundis a conversational strategy that Chinese employ when build-ing a network of connections, and Dr. Yan was drawing meinto his network. I can’t be sure there weren’t aspects of hisexperience that reflected other values, ones he could or wouldnot openly express. Yet he himself claimed to be both victimand collaborator. He talked of things he had to do to survivethat he deeply regretted. He impressed on me that over thecourse of his life he came to the dismaying understanding thathis family’s history of collaboration with those in power, resis-tance against which had motivated him to stay and work inChina, was not only the norm but quite possibly all that couldbe done in bad times. No hero, no victory, no self-serving mythhere, in this dark vision of our lives. Change under these po-litically oppressive circ*mstances would be of necessity infre-quent, limited, and not for the best.

In Reverend Jamison, the possibility for transformationshifts from the local world to the self, and in a peculiarlyAmerican way through the self to God. Here the body is thesite of a decisive struggle in which emotion and spiritualitytransfigure shame into salvation, pain into “a good, a verygood thing.” Imre Kertész, the 2002 Nobel prize winner forliterature, himself a Hungarian survivor of the Holocaust,writes in Kaddish for an Unborn Child that “on account of thepain I live some sort of truth.” What truth that might be forReverend Jamison surely has something to do with his des-perate need for self-control, which in turn opens a strangepossibility for religious conversion and hope.

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Still, his victory over unacceptable sexual impulse is tran-sitory, an alarming triumph that has to be won anew eachday. There is another sense in which this embodied ritual offorgetting and sublimating unwanted sexual feelings intosufferable pain is a kind of despair in overcoming. ReverendJamison once told me that what made it all powerfully con-vincing for him was that each time he was not sure that itwould be effective, that transcendence would occur.

In several of his books, Victory and Lord Jim, for example,Joseph Conrad features a protagonist who when first facedwith a life crisis requiring effective action in the world failsutterly to master the existential challenge. Later on, after liv-ing a life circ*mscribed by this core failure, the hero is pre-sented with another crisis requiring a decisive deed, and,facing down the fear of repeated failure, he triumphs in sucha way that both he and the world are changed. I once felt thatthis kind of heroic action could explain how certain individu-als so successfully tackled serious illness experience that inplace of expected disablement they seemed to have miracu-lously achieved what I then called a supernormality. I wouldnow argue with that earlier conclusion; I am more suspiciousof the orchestration of heroic images.

An antiheroic interpretation seems a better fit with Jami-son’s case. What for Reverend Jamison is “a good, a very goodthing” is for the vast majority of chronic pain patients need-less suffering. The omnipresent advertisem*nts for medica-tions tell us that we need not endure any discomfortwhatsoever. With the sole exception of “no pain, no gain” inthe discourse of sport, pain in our society is a thoroughly badthing.

224 What Really Matters

But this is not how it was perceived and responded to inearlier historical eras or in greatly different cross-cultural set-tings. The local worlds of Europe beginning in the first centu-ries of the Christian era witnessed a deep, massive culturalrevaluation of pain and suffering, a culture in which theseexperiences were religiously valued and even individuallysought after. Pain and suffering created a new and specialchannel of communication with the holy, a means of achiev-ing salvation.

Reverend Jamison’s understanding of his own predicamentby itself is unable to prevent the fierce demands of intrudingsexual feelings. And his understanding is much more psycho-logically elaborated than the prayerful reflections of early Chris-tian saints on their own pain and suffering. Nonetheless, hisinsistence on the salvific quality of his pain would have re-ceived considerable cultural support in that earlier era. In thissense, Reverend Jamison is an anachronism whose moral ex-perience is at odds with his age, calling into question what re-ligion means as much as what pain means in America. HadReverend Jamison experienced his pain as God’s punishment,he would be just as anachronistic and just as at odds with ourtimes. Pain in twenty-first-century America is supposed to benot sacred and salvific but secular and pharmaceutical.

Sally Williams’s story turns on the transforming potentialof serious illness. For many, such transformation does not leadto good ends. Exhausted and diminished, patients often suc-cumb to fear, loneliness, and desperation. And yet for SallyWilliams and not a few others I have known, chronic illnesscan inspire hope and creative acts of remaking one’s self andone’s network. A new Sally Williams emerged from awful

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experiences of AIDS and drug abuse, and so did alteration infamily relations, friendships, work as an artist, and her rela-tionship to the public world of crises and policies. Sally’smovement from doing for self to doing for others does notresult in a melodramatic movie ending of health and happi-ness. Something more authentic to our uncertain and un-masterable human condition and to the long littleness, asFrances Cornford put it, and anonymity of living in mass so-ciety emerges from her story. There is in Sally Williams a quietand never fully achieved nobility of failure.

In her painting too, Sally faced up to the fear that artistsand writers need to overcome: namely, that there is some au-thentic thing in them that must be aesthetically expressed butthat they have not succeeded in realizing in their works.W. H. Auden expressed the cold terror of this feeling in hispoem “Thanksgiving for a Habitat”:

God may reduce youon Judgment Dayto tears of shame,reciting by heartthe poems you wouldhave written, hadyour life been good.

W. H. R. Rivers brings us back from aesthetic to moral dan-ger. Rivers succeeds in his multisided career in a political andmoral climate of colonialism, racism, and jingoistic national-ism. His impressive influence on students, colleagues, andpatients, as we have seen, owed a great deal to the virtues of

226 What Really Matters

a moralistic and moralizing age, virtues that he himself em-bodied. Rivers’s experience as ethnographer and military psy-chiatrist led him first to question this moral climate and laterto criticize it as a destructive force that contributed to the deepcultural and psychological basis for the horrors of the GreatWar. His ethnographic method of intensive engagement withsubjects’ worlds, his psychotherapeutic strategy of helpinghis patients achieve a critical awareness so that they couldrevitalize their moral imagination and responsibility, and hispolitical campaign of social reform aimed to undo the moraldanger and to reconstruct moral experience in a more hu-manly promising direction.

I see Rivers struggling to de-moralize his times, to unmakewhat was seriously at stake in cultural norms and in inneremotional normality. Rivers understood that norms in thesocial world could come into the body. Cultural values couldguide our gestures, our posture, and even our emotions andour sense of who we are in the direction of what the groupregarded as good and desirable. Thereby, we become normaland moral human beings—normal and moral in the eyes of aparticular group or society, that is. For Rivers, this normaliz-ing or moralizing process could create truly dangerous pat-terns of personal actions, if the things that mattered most tothe group and society were themselves dangerous. HenceBritish army officers in the trenches in France and Belgiumexperienced the normalization of trauma as courage (and thereciprocal pathologization of fear and loss as cowardice). Theyeither perpetuated the futile slaughter or broke down. Eitherway, normalization could maim and kill. Norms and normal-ity, Rivers concluded, had to be refashioned. The moral had

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to be remade. Psychotherapy and political action could re-moralize the world and the person by transforming what wasmost at stake to serve the interests of peace and well-being.Re-moralization could break the vicious cycle of escalatingdanger so as to prevent the misuses and abuses of moral ex-perience. Rivers never got to put a political action programinto play, and he didn’t live long enough to see the long-termoutcome of his psychotherapeutic approach, so my interpre-tation runs well beyond the findings. It is enough to say thatfor Rivers moral critique and imagination and responsibilitywere the grounds for social reform and remaking the self, andthe one required the other.

This book is concerned with how the large scale disorga-nized and disorganizing historical forces of politics and politi-cal economy transform our moral life. That transformationresults from the interaction between three very different kindsof things: cultural meanings, social experience, and subjectiv-ity (inner emotions and sense of self), as shown in the figure onthe following page.

Large scale changes in political economy and politicalpower, as are taking place right now in our highly globalizedworld, change the cultural meanings we take for granted andthe collective experience we are socialized into, and with themthe self also changes, so that what we believe, how we acttogether, and who we are as individuals also becomes some-thing new. And that change extends to how we regard our-selves and others. The result is that suffering, well-being, andthe ethical practices that respond to human problems are con-stantly changing as local worlds change and as do we, thepeople in them, become something new and different. I drew

228 What Really Matters

upon this new framework to make sense of life in our times.If we are truly interested in national security, we ought to bequite concerned right now about what we and our world arebecoming; about the quality of our (and others’) moral expe-rience and ethical vision.

And yet at the same moment one must be aware of otherglobal transformations such as the enormous flows of infor-mation (including ideas and values) over the Internet and TVon an almost minute-by-minute basis that enable people tobe more critical of human conditions, empower them to re-sist threatening changes, and encourage their imagination ofnew and different moral realities. This two-sided moral qual-ity of our current era—the one ominous, the other hopeful—is crucial to understand where our world is taking us andwhere we may be taking our world.

CHANGES IN POLITICAL ECONOMY, POLITICS, AND GLOBAL CULTURE

local culturalrepresentations

social experience

subjectivity

The remaking of moral life

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A troubling yet sobering follow-up on Idi’s quietly effec-tive but low-visibility career arose several years after her un-timely death. I was attending a conference where I met twopeople (a European anthropologist and an American expertin humanitarian assistance) who had each worked in one ofthe countries in which Idi had served. Neither could remem-ber her, and the European anthropologist may not have mether. The American at first got her confused with anotherwoman. When I corrected his mistaken impression, heshrugged and with a wistful air remarked that there were many,many people like Idi who deserved to be better known andwhose contributions in the aggregate made a difference, butwhose individuality, while seemingly vivid and indelible, wasinevitably lost amid the blur of faces in the slew of humani-tarian assistance programs that started, ended, and were re-invented over time. He went on, in a distancing philosophicalmood, to opine that all individuals in the field had to ask them-selves repeatedly whether it really mattered that they hadcome or if it would have made any difference if they had not.Lost in his own reverie now, he asked, did it even make adifference in their own lives that they had been in this placeat this time with this project?

I remember walking away from that encounter shaken, feel-ing both disappointment and bitterness. I determined then tostop procrastinating and write about Idi. But in so doing, Ihave watched my own remembrances undergo a metamor-phosis from a heroic genre to an antiheroic one. It was fitting,I came to see, given the view of moral experience that hadincreasingly come to inhabit my thoughts, for Idi to have beenmistakenly identified, forgotten, or never met. After all, Idi

230 What Really Matters

was not the star of a movie, with all the celebratory, larger-than-life, dramatic qualities that role carries. As an ordinaryperson, she was, I had come to accept with regret, forgettable.She had achieved neither fame nor fortune; her circle of ac-quaintances, though lively and intense, remained small. Af-ter she departed Africa, a new generation of foreign expertshad started new projects in shifting situations with differentclients and partners. None of them had written or read thehistory of her work. And yet for me, perhaps because ratherthan in spite of these limitations, Idi will always representwhat is genuine and best in us.

Saying as much makes me realize I am overstepping mywarrant as witness and recorder of moral experience, as I didwhen I applauded a diminished Sally Williams’s transforma-tion through suffering from a “taker” into a “giver.” I ammoving from description to prescription, from the moral tothe ethical, and that is probably unavoidable. What do theseaccounts tell us about how we should live?

First we need to get right what matters most to us. It doesn’thurt to try to peek beneath the layers of family, self, and set-ting and find the strands that connect to our present commit-ments. Hence, Idi was not unaware of the impetus for herparents’ commitment to progressive politics, liberation the-ology, and works of reparation and restitution: her grand-father’s collaboration with the Nazis and the selfish greedand hauteur of her mother’s large haute bourgeois family.She also was not blind to the same influence on her careerand life. Sally Williams realized her readiness not to be silentbut to advocate for AIDS and drug abuse programs was in-tensified by her early experiences of a secret, unspeakable

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world of family violence, alcoholism, and depression. In BillBurt and Simcha Adler, and in later mentors, I came to see theabsence of presence of my own father, and the pressing needfor father figures in my own self-building. And this led to afurther recognition of why I so urgently needed to be a men-tor and healer to others, and perhaps also to why I initiallysearched for moral heroes.

This same process of autognosis, to use Rivers’s term forbecoming acutely self-aware of the forces that are shaping usand the directions toward which they are moving us, enablesus to see how the bundle of contradictions, incompatibilities,mindless routine, and the bewildering inexpediency of onedamn thing following another and of countless, cross-cuttingpersonal projects resisting realization of our plans preventsus from examining too hard and too critically the deep existen-tial structure of our lives. It just may not be possible to act inthe world and at the same time admit fully the dangers aroundus and the limits to coping, and to accept our end not just insuffering and death but in the smallness, ill-suitedness, andforgettable quality to our lives and work. That is what makesmoral experience so difficult and disappointingly human.

Eventually, we need to ask the question few of us ever wantto address directly: what should really matter? In this book Iam making the case for facing up to our existential conditionas what really matters. Underneath the huge varieties of cul-tural meanings, social experiences, and subjectivity, there is ashared condition of being human that centers on experiencesof loss, threat, and uncertainty. That is ground zero in our morallives. Yet my career as a psychiatrist and anthropologist con-vinces me that there can be no single thing that matters most

232 What Really Matters

for each of us or for all of us. The differences, as these chap-ters show, can be striking. But as troubling and uncertain as itis to come to terms with what matters in the actual conditionsof our worlds and our lives, I have come to believe that this isthe way to be authentic and useful in crafting a life.

In his short story “The Middle Years,” Henry James putswords in the mouth of a dying writer who is being tended toby a young physician who himself harbors a secret desire tobe a writer. The writer means to mentor the doctor (both ashealer and artist) by conveying a single truth about life andcareer: “ We work in the dark—we do what we can—we givewhat we have. Our doubt is our passion and passion is ourtask.” We are passionately anxious about doubt, I take it, be-cause it threatens to undermine self-control, undo competence,and, in the sense of this book, dislocate and distort those as-pects of moral experience that are most enabling while giv-ing expression to others that can be truly dangerous. Doubtin itself—a feeling of uncertainty and a need to call thingsinto question—is also what we must be passionate about be-cause we must interrogate our moral life. Passion is our taskbecause competence and even engagement without passionwould never lead to the kind of commitment Idi made, or toDr. Yan’s transfiguration of vengeance into healing, or to anyexpression of our deepest sense of who we are and what weare about that ran against the grain of convention and confor-mity. Passion is absolutely required in the unequal struggleto master human experience, or else we would succumb tocomforting self-illusions and the merely mechanical require-ments of social life and ultimately to demoralization. A pas-sion for doubting is a requirement of a moral life because we

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need to bring an aspiration for ethics to bear on moral experi-ence, and ethical enquiry and action are impelled when doubtis our passion and passion is our task. In yet another sense—namely, when passion means to afflict with suffering—HenryJames’s penetrating words resonate with our responsibilityto take seriously the existential limits of our human condi-tion. But it is just as important to understand that passionplays off joy, irony, and humor, which also are crucial quali-ties in getting through life.

How, then, to live? What to do? Those huge questions arefoundational to ethics, religion, and political theory. They arenot ones that I am prepared to answer with a specific pre-scription for living. I barely am able to muddle through; Ihave no such prescription. No one does, I contend. Still, whata lifetime of being with others in the messiness of moral ex-perience has taught me is that simplistic distinctions betweenthe objective and the subjective, the absolute and the relative,the right and the wrong, are no help and may even get us intodeeper trouble. Nor is it at all sufficient to take up a positionin which complexity, uncertainty, and undecidability negatethe vexing questions themselves, covering over our ownweaknesses and self-serving willingness to comply as longas we are comfortable and protected, as long as the futurebrings clean bathrooms and an air control system. That wayleads to a hollowing out of passion and purpose, to cynicismand nihilism, and ultimately disables us and denies us thecapability to change ourselves and our world.

Commitment to others, struggling to bring some good intoour close-up worlds even while acknowledging that our cop-ing skills are barely adequate, being passionate about projects

�� What Really Matters

that build the self and others, being serious about critical en-gagement steeped in self-reflection and aimed to rework or stopmoral processes that intensify danger, mobilizing aspiration indefeat and finding the courage and endurance even whenexperiencing the hollowness of victories not to completelydespair—those are the kinds of things that, no matter their triteand conventional ring, still feel authentic and useful. The au-thentic and useful, especially in a time when commercial pro-paganda and the politically meretricious are so ubiquitous, arestill something, as are kindness and decency—insisting, asEmmanuel Lévinas did, that the ethical precedes the episte-

mological, that acknowledgmentand affirmation of the other pre-cedes inquiry and enables areadiness for unexpected trans-formations, which do occur andcan be revitalizing if seized holdof and properly directed. Wemust see moral experience forwhat it is: all that we have and allthat we will ever have that definesour humanity and makes us andour worlds real.

I have long found arresting apainting of Pablo Picasso’s titled“The Head of a Medical Student”.The painting is of a face in theform of an African mask with oneeye open, and the other closed.Medical students learn to open

Pablo Picasso © ARS, NY. Head of aMedical Student, (Study for Les De-moiselles d’Avignon) 1907. CongerGoodyear Fund, Museum of ModernArt, USA. Digital Image © The Mu-seum of Modern Art / Licensed bySCALA / Art Resource, NY

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one eye to the pain and suffering of patients and the world,but also to close the other eye—to protect their own vulner-ability to pain and suffering, to protect their belief that theycan do good and change the world for the better, to protecttheir own self-interests such as career building and economicgain. I would generalize the provocative poignancy of thispicture to how we live our lives. One of our eyes is open tothe dangers of the world and the uncertainty of our humancondition; the other is closed, so that we do not see or feelthese things, so that we can get on with our lives. But per-haps one eye is closed so that we can see, feel and do some-thing of value. One eye, perhaps, sees the possibilities andhopefulness of who we are and where we are headed, whilethe other is shut tight with fear over the storms and preci-pices that lie ahead. Or, perhaps like all things human, it isabout something else altogether, something else that matteredto Picasso, because when I look at others of his paintings thatfeature faces formed as African masks, one eye often seemsclosed—a perturbing matter of style or a disturbing matter ofexistential insight?

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Bibliographic Note

o make this book accessible for the educated general reader, whosetime for reading is limited and who almost surely doesn’t want to getbogged down in excessive detail, I have written it without the schol-

arly scaffolding of footnotes and academic references to the research litera-ture. But both because I am myself, as a researcher and teacher, somewhatuneasy about this absence and because there may be readers whose inter-ests are piqued sufficiently to want to read further into this perspective onmoral experience, I am setting out a short list of relevant works that formthe research and theoretical basis for the positions I have advanced.

On the question of moral experience, the literature in philosophy,phenomenology, and social theory is large. I summarize key works—e.g.,those by John Dewey, William James, Michael Oakshott, and many oth-ers—in the Tanner Lectures I delivered at Stanford University in 1998,where I also show how medical anthropology, social medicine, and cul-tural psychiatry offer research that underpins the theory I advance. SeeArthur Kleinman, “Experience and Its Moral Modes: Culture, Human Con-ditions, and Disorder,” in G. B. Peterson, ed., The Tanner Lectures on Hu-man Values (Salt Lake City: University of Utah Press, 1999), 20:357–420.(This scholarly essay also can be downloaded from the Web atwww.tannerlectures.utah.edu.) A shorter version with more of a globalhealth policy thrust can be found in Arthur Kleinman, “Ethics and Experi-ence: An Anthropological Approach to Health Equity,” in Sudhir Anand,

www.tannerlectures.utah.edu

238 Bibliographic Note

Fabienne Peter, and Amartya Sen, eds., Public Health, Ethics and Equity,269–82 (Oxford: Oxford University Press, 2004).

Contributions to the anthropological approach to moral experience,including works that deal with social aspects of moral life, are Talal Asad,Genealogies of Religion: Discipline and Reasons of Power in Christianity andIslam (Baltimore, MD: Johns Hopkins University Press, 1993); Jono Biehl,Vita: Life in a Zone of Abandonment (Berkeley: University of California Press,2005); Pierre Bourdieu, The Logic of Practice (Stanford: Stanford UniversityPress, 1990); Pierre Bourdieu, ed., La Misère du Monde (Paris: Editions duSeuil, 1993); Georges Canguilhem, The Normal and the Pathological (NewYork: Zone Books, 1991); Rebecca S. Chopp, The Praxis of Suffering: An In-terpretation of Liberation and Political Theologies (Maryknoll, NY: Orbis Books,1986); Lawrence Cohen, No Aging in India (Berkeley: University of Califor-nia Press, 1992); Thomas Csordas, ed., Embodiment and Experience: The Ex-istential Ground of Culture and Self (Cambridge: Cambridge University Press,1994); Veena Das, “Moral Orientations to Suffering,” in L. C. Chen, A.Kleinman, and N. Ware, eds., Health and Social Change: An InternationalPerspective (Cambridge, MA: Harvard University Press, 1994); Veena Daset al., eds., Remaking a World (Berkeley: University of California Press, 2001);John Dewey, Human Nature and Conduct (New York: Modern Library, 1957[1922]); Paul Farmer, AIDS and Accusation: The Geography of Blame in Haiti(Berkeley: University of California Press, 1992); Ludwig Fleck, Genesis andDevelopment of a Scientific Fact (Chicago: University of Chicago Press, 1979);Michel Foucault, The Birth of the Clinic (New York: Vintage, 1973); CliffordGeertz, Local Knowledge (New York: Basic Books, 1987); Jonathan Glover,Humanity: A Moral History of the Twentieth Century (London: Jonathan Cape,1999); Byron Good, Medicine, Rationality and Experience (Cambridge: Cam-bridge University Press, 1994); Mary Jo DelVecchio Good et al., eds., Painas Human Experience (Berkeley: University of California Press, 1992); JohnGrey, False Down: The Delusions of Global Capitalism (London: Granta Books,1998); Michael Jackson, ed., Things as They Are: Introduction to Phenomeno-logical Anthropology (Bloomington: Indiana University Press, 1996); Mar-tin Jay, Songs of Experience: Modern American and European Variations on aUniversal Theme (Berkeley: University of California Press, 2005); JamesKellenberger, Relationship Morality (University Park: Pennsylvania StateUniversity Press, 1995); Arthur Kleinman, The Illness Narratives (New York:Basic Books, 1988); Arthur Kleinman, Rethinking Psychiatry (New York: FreePress, 1988); Arthur Kleinman, Veena Das, and Margaret Lock, eds., SocialSuffering (Berkeley: University of California Press, 1997); George Lakoffand Mark Johnson, Philosophy in the Flesh: The Embodied Mind and its Chal-lenge to Western Thought (New York: Basic Books, 1999); Roger Lancaster,Life Is Hard: Machismo, Danger and the Intimacy of Power in Nicaragua (Ber-

Bibliographic Note 239

keley: University of California Press, 1992); Margaret Lock, Encounters withAging (Berkeley: University of California Press, 1993); Margaret Lock, TwiceDead (Berkeley: University of California Press, 2003); Michel Moody-Adams, Fieldwork in Familiar Places (Cambridge, MA: Harvard UniversityPress, 1997); Tanya Luhrmann, Of Two Minds: The Growing Disorder inAmerican Psychiatry (New York: Knopf, 2000); Adriana Petryna, Life Ex-posed (Princeton: Princeton University Press, 2002); Nancy Scheper-Hughes,Death Without Weeping: The Violence of Everyday Life in Brazil (Berkeley:University of California Press, 1992).

On anthropological approaches to global health, see Robert Desjarlaiset al., World Mental Health (Oxford: Oxford University Press, 1995); PaulFarmer, Pathologies of Power (Berkeley: University of California Press, 2003);Paul Farmer, Margaret Connors, and Janie Simmons, eds., Women, Povertyand AIDS: Sex, Drugs and Structural Violence (Monroe, ME: Common Cour-age Press, 1996); Jim Yong Kim et al., eds., Dying for Growth (Monroe, ME:Common Courage Press, 2000).

Readers interested in getting further into moral experience in present-day Chinese society (as covered in Chapter 4) can consult, among manyrelevant works, Jasper Becker, Hungry Ghosts: Mao’s Secret Famine (NewYork: Free Press, 1996); Jung Chang, Wild Swans: Three Daughters of China(New York: Simon and Schuster, 1991); Jung Chang and Jon Halliday, Mao:The Unknown Story (New York: Knopf, 2005); Xiaotong Fei, From the Soil:The Foundations of Chinese Society (Berkeley: University of California Press,1992); Jicai Feng, Ten Years of Madness: Oral Histories of China’s Cultural Revo-lution (San Francisco: China Books and Periodicals, 1996); Jun Jing, TheTemple of Memories: History, Power and Morality in a Chinese Village (Stanford:Stanford University Press, 1996); Erik Mueggler, The Age of Wild Ghosts:Memory, Violence and Place in Southwest China (Berkeley: University of Cali-fornia Press, 2001); Elizabeth Perry and Mark Selden, eds., Chinese Society,2nd ed. (New York: Routledge, 2003); Orville Schell, Mandate of Heaven(New York: Simon and Schuster, 1994); Anne F. Thurston, Enemies of thePeople (New York: Alfred Knopf, 1987); Yunxiang Yan, The Flow of Gifts:Reciprocity and Social Networks in a Chinese Village (Stanford: Stanford Uni-versity Press, 1996); Yunxiang Yan, Private Life under Socialism: Love, Inti-macy, and Family Change in a Chinese Village, 1949–1999 (Stanford: StanfordUniversity Press, 2003).

For those whose interest in W. H. R. Rivers has been awakened, there isa small but interesting literature (both scholarly and fictional) about himand a much larger body of works about the tumultuous period in whichhe lived, including works on psychiatric syndromes associated with theGreat War: Peter Barham, Forgotten Lunatics of the Great War (New Haven:Yale University Press, 2004); Pat Barker, Regeneration (New York: Dutton,

240 Bibliographic Note

1992); Pat Barker, The Eye in the Door (New York: Dutton, 1994); Pat Barker,The Ghost Road (New York: Dutton, 1995); Joanna Bourke, An Intimate His-tory of Killing: Face to Face Killing in 20th Century Warfare (New York: BasicBooks, 1999); Henry Head, “William Halse Rivers Rivers, 1864–1922,” Pro-ceedings of the Royal Society of London, series B, 95 (1923): xliii–xlvii; A. C.Haddon, F. C. Bartlett, and Ethel S. Fegan, “Obituary. Williams Halse Riv-ers Rivers,” Man 22 (1922): 97–104; Anita Herle and Sandra Rouse, eds.,Cambridge and the Torres Strait: Centenary Essays on the 1898 AnthropologicalExpedition (Cambridge: Cambridge University Press, 1998); Eric Hobs-bawm, The Age of Extremes: A History of the World, 1914–1991 (New York:Pantheon, 1994); Ian Langham, The Building of British Social Anthropology:W. H. R. Rivers and His Cambridge Disciples in the Development of KinshipStudies, 1898–1931 (Dordrecht, Holland: D. Reidel, 1981); Eric Leed, NoMan’s Land: Combat and Identity in World War I (Cambridge and New York:Cambridge University Press, 1979); Paul Moeyes, Siegfried Sassoon: ScorchedGlory: A Critical Study (New York: St. Martin’s Press, 1997); W. H. R. Rivers,Instinct and the Unconscious, 2nd edition (Cambridge: Cambridge Univer-sity Press, 1924 [1920]); W. H. R. Rivers, “The Psychological Factor,” in W.H. R. Rivers, ed., Essays on the Depopulation of Melanesia (Cambridge: Cam-bridge University Press, 1922); W. H. R. Rivers, Conflict and Dream (NewYork: Harcourt, Brace, 1923); W. H. R. Rivers, Psychology and Ethnology (NewYork: Harcourt, Brace, 1926); Siegfried Sassoon, Sherston’s Progress (London:Faber and Faber, 1936); Ben Shephard, A War of Nerves: Soldiers and Psychia-trists in the Twentieth Century (Cambridge, MA: Harvard University Press,2001); Richard Slobodin, W. H. R. Rivers: Pioneer Anthropologist, Psychiatristof the Ghost Road (Gloucestershire, UK: Sutton, 1997 [1978]); George Stock-ing Jr., Malinowski, Rivers, Benedict and Others: Essays on Culture and Personal-ity (Madison: University of Wisconsin Press, 1986); Allan Young, The Harmonyof Illusions (Princeton: Princeton University Press, 1995).

On medical and psychiatric diagnoses that went into and out of fash-ion in the late nineteenth and early twentieth centuries, see GeorgeFrederick Drinka, The Birth of Neurosis: Myth, Malady, and the Victorians(New York: Simon and Schuster, 1984); Marijke Gijswijt-Hofstra and RoyPorter, eds., Cultures of Neurasthenia: From Beard to the First World War(Amsterdam: Rodopi, 2001); F. G. Gosling, Before Freud: Neurasthenia andthe American Medical Community (Urbana: University of Illinois Press, 1988);Mark S. Micale, Approaching Hysteria (Princeton: Princeton University Press,1994); Edward Shorter, From Paralysis to Fatigue: A History of PsychosomaticIllness in the Modern Era (New York: Free Press, 1993).

On late-nineteenth- and early-twentieth-century attempts to create newforms of psychotherapy, see Henri Ellenberger, Discovery of the Unconscious(New York: Basic Books, 1981); Marcel Gauchet and Gladys Swain, Mad-

Bibliographic Note 241

ness and Democracy: The Modern Psychiatric Universe, trans. Catherine Por-ter (Princeton: Princeton University Press, 1999).

The subject of medical ethics has become a huge one, with everythingfrom textbooks and research monographs to specialized journals. A fewbooks pertinent to What Really Matters include Sudhir Anand, Fabienne Pe-ter, and Amartya Sen, eds., Public Health, Ethics and Equity (Oxford: OxfordUniversity Press, 2004); Judith Andre, Bioethics as Practice (Chapel Hill: Uni-versity of North Carolina Press, 2002); Charles L. Bosk, Forgive and Remem-ber: Managing Medical Failure (Chicago: University of Chicago Press, 1981);Allan Brandt and Paul Rozin, eds., Morality and Health (New York: Routledge,1997); John Broome, Weighing Lives (Oxford: Oxford University Press, 2004);Allen Buchanan, Dan Brock, Norman Daniels, and Daniel Wikler, FromChance to Choice: Genetics and Justice (Cambridge: Cambridge University Press,2000); Daniel Callahan, The Troubled Life (Washington, DC: GeorgetownUniversity Press, 2000); John D. Caputo, Against Ethics (Bloomington: Indi-ana University Press, 1993); Deen K. Chatterjee, Ethics of Assistance: Moralityand the Distant Needy (Cambridge: Cambridge University Press, 2004); DavidDeGrazia, Human Identity and Bioethics (Cambridge: Cambridge UniversityPress, 2005); Arthur Kleinman, Allan Brandt, and Renée Fox, eds., “Bioeth-ics and Beyond,” special issue of Daedalus, volume 128, number 4, fall 1999;Thomas W. Pogge, ed., Global Justice (London: Blackwell, 2001); MarthaNussbaum and Amartya Sen, eds., The Quality of Life (Oxford: Oxford Uni-versity Press, 1993); Peter Singer, Rethinking Life and Death: The Collapse ofOur Traditional Ethics (New York: St. Martin’s Press, 1994).

For the most recent illustration of the medicalization of ordinary un-happiness and existential angst into mental disorders, see Ronald C.Kessler, Patricia Bergland, et al., “Lifetime Prevalence and Age-of-OnsetDistribution of DSM-IV Disorders in the National Comorbidity SurveyReplication,” Archives of General Psychiatry 62 (2005): 593–602 (this influ-ential epidemiological study claims that about half of all Americans willexperience mental illness sometime in their lifetime); David Healy, TheAnti-Depressant Era (Cambridge: Harvard University Press, 1997). For aclassic statement in social theory, see Renée C. Fox, “The Medicalizationand Demedicalization of American Society,” in Essays in Medical Sociology,465–83 (New York: John Wiley, 1979).

On the works and life of Albert Camus, see The Stranger (New York:Knopf, 1988 [1942]); The Plague (New York: Knopf, 1948 [1947]); The Fall(New York: Knopf, 1991 [1956]), The First Man (New York: Random House,1996 [1994]); Herbert Lottmann, Albert Camus: A Biography (Corte Madera,CA: Gingko Press, 1979).

On the works and life of Primo Levi, see Survival in Auschwitz (NewYork: Touchstone, 1996 [1958]); Drowned and the Saved (New York: Simon

242 Bibliographic Note

and Schuster, 1988 [1986]); Carole Angier, The Double Bond: Primo Levi, aBiography (New York: Farrar, Straus and Giroux, 2003).

On the works and life of Emmanuel Lévinas, see his Totality and Infin-ity, trans. Alphonso Lingis (Pittsburgh: Duquesne University Press, 1969);Otherwise than Being: Or Beyond Essence, trans. Alphonso Lingis (Pittsburgh:Duquesne University Press, 1998); Entre Nous, trans. Michael B. Smith (NewYork: Columbia University Press, 2000), especially “Useless Suffering”;Time and the Other, trans. Richard A. Cohen (Pittsburgh: Duquesne Uni-versity Press, 1987). See also Robert Bernasconi and David Wood, eds.,The Provocation of Lévinas: Rethinking the Other (London: Routledge, 1998);and John Llewelyn, Emmanuel Lévinas: The Genealogy of Ethics (London:Routledge, 1995).

On William James’s use of the idea of “genuine reality,” see Linda Simon,Genuine Reality: A Life of William James (New York: Harcourt Brace and Co.,1998). See also William James, Varieties of Religious Experience (Cambridge:Harvard University Press, 1985 [1902]); William Joseph Gavin, William Jamesand the Reinstatement of the Vague (Philadelphia: Temple University Press,1992); Gerald E. Myers, Williams James: His Life and Thought (New Haven:Yale University Press, 1986).

On mentoring and its perils, see Harold Bloom, The Anxiety of Influence(Oxford: Oxford University Press, 1975); Takeo Doi, Understanding Amae:The Japanese Concept of Need-Love (Kent: Global Oriental, 2005).

On the complexities of authenticity, see Alexander Nehamas, Virtues ofAuthenticity (Princeton: Princeton University Press, 1998); Charles Taylor,The Ethics of Authenticity (Cambridge: Harvard University Press, 1991);Lionel Trilling, Sincerity and Authenticity (Cambridge: Harvard UniversityPress, 1972).

On witnessing and testimony, see C. A. J. Coady, Testimony: A Philo-sophical Study (Oxford: Clarendon Press, 1992); Veena Das, “Wittgensteinand Anthropology,” Annual Review of Anthropology 27 (1998): 171–95;Shoshana Felman and Dori Laub, Testimony: Crises of Witnessing in Litera-ture, Psychoanalysis and History (London: Routledge, 1992); Lawrence L.Langer, Holocaust Testimonies: The Ruins of Memory (New Haven: Yale Uni-versity Press, 1991).

On moral responsibility in the lives of public intellectuals, see TonyJudt, The Burden of Responsibility: Blum, Camus, Aron, and the French Twenti-eth Century (Chicago: University of Chicago Press, 1998).

On antiheroism, see Victor Brombert, In Praise of Antiheroes: Figures andThemes in Modern European Literature, 1830–1980 (Chicago: University ofChicago Press, 1999); Stanley Hoffman, “Passion and Compassion: TheGlory of Albert Camus,” World Policy Journal, winter 1995, 85–90.

Bibliographic Note 243

On the history of extreme social dangers that result from the overreac-tion of people to perceived threats to what is culturally at stake, see IanKershaw, Hitler, 2 vols. (New York: Norton, 1999–2000); CatherineMerridale, Night of Stone: Death and Memory in Russia (London: GrantaBooks, 2000); R. I. Moore, “The Inquisitor’s Nightmare,” Times LiterarySupplement, February 9, 2001, 10–11.

On pain, see Good et al., eds., Pain as Human Experience; Kleinman, TheIllness Narratives; Kleinman et al., eds., Social Suffering; Roselyne Rey, TheHistory of Pain (Cambridge, MA: Harvard University Press, 1993); ElaineScarry, The Body in Pain: The Making and Unmaking of the World (New Yorkand Oxford: Oxford University Press, 1985); Susan Sontag, Regarding thePain of Others (New York: Farrar, Straus and Giroux, 2002).

On the lived experience of AIDS, see Jono Biehl, Vita: Life in a Zone ofAbandonment (Berkeley: University of California Press, 2005); Farmer, AIDSand Accusation; Farmer, Connors, and Simmons, eds., Women, Poverty andAIDS; Salmaan Keshavjee et al., “Medicine Betrayed: Hemophilia Patientsand HIV in the US,” Social Science and Medicine 53 (2001): 1081–94; PaulMonette, Borrowed Time: An AIDS Memoir (New York: Harcourt BraceJovanovich, 1988); Abraham Verghese, My Own Country: A Doctor’s Story(New York: Vintage, 1994); George Whitmore, Someone Was Here: Profilesin the AIDS Epidemic (New York: New American Library, 1988).

On religion, medicine, and subjectivity, see William James, The Varietiesof Religious Experience (Cambridge, MA: Harvard University Press, 1985[1902]); Georges Bernanos, The Diary of a Country Priest (New York: Carrolland Graf, 1937); Linda Barnes et al., eds., Religion and Healing in America(New York: Oxford University Press, 2005); John Bowker, Problems of Suf-fering in Religions of the World (Cambridge: Cambridge University Press,1970); Thomas Csordas, The Sacred Self (Berkeley: University of CaliforniaPress, 1994); John R. Hinnells and Roy Porter, eds., Religion, Health andSuffering (London: Kegan Paul International, 1999); C. S. Lewis, The Prob-lem of Pain (New York: Collier Books, 1962); Judith Perkins, The SufferingSelf: Pain and Narrative Representation in the Early Christian Era (London:Routledge, 1995); Wayne Proudfoot, Religious Experience (Berkeley: Uni-versity of California Press, 1985); Dorothee Soelle, Suffering (Philadelphia:Fortress Press, 1984).

On critiques of humanitarian assistance and development projects, seeMark Duffield, Global Governance and the New Wars (New York: Zed Books,2001); Arturo Escobar, Encountering Development: The Making and Unmak-ing of the Third World (Princeton, NJ: Princeton University Press, 1995);James Ferguson, The Anti-Politics Machine: “Development,” Depoliticization,and Bureaucratic Power in Lesotho (Minneapolis: University of Minnesota Press,1994); Mariella Pandolfi, “Contract of Mutual (In)Difference: Governance

244 Bibliographic Note

and Humanitarian Apparatus in Contemporary Albania and Kosovo,”Indiana Journal of Global Legal Studies 10, 1 (2003):369–81; “Une souverainetémouvante et supracoloniale. L’industrie humanitaire dans les Balkans,”Multitudes 3 (2000): 97–105; Samantha Power, A Problem from Hell: Americaand the Age of Genocide (New York: Perennial, 2003).

On failed and failing states in Africa, see Philip Gourevitch, We Wish toInform You That Tomorrow We Will Be Killed with Our Families (New York:Picador 1999); William Reno, Warlord Politics in African States (Boulder,CO: Lynne Rienner, 1998); Paul Richards, Fighting for the Rainforest: War,Youth, and Resources in Sierra Leone (Portsmouth, NH: Heinemann, 1996);M. Turshen and C. Twagiramariya, eds., What Women Do in Wartime (Lon-don: Zed Books, 1998); Carolyn Nordstrom, Shadows of War (Berkeley:University of California Press, 2004).

Of biographies that richly describe cultural contexts of moral experienceand the struggles of remarkable individuals to lead moral lives, see MyriamAnissimov, Primo Levi: Tragedy of an Optimist, trans. Steve Cox (Woodstock,NY: Overlook Press, 1999); W. Jackson Bate, Samuel Johnson (New York:Harcourt Brace Jovanovich, 1975); Ronald W. Clark, Freud: The Man and theCause (New York: Random House, 1980); Bernard Crick, George Orwell: ALife (Boston: Little, Brown and Co., 1980); Tracy Kidder, Mountains beyondMountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World(New York: Random House, 2004); Olivier Todd, Albert Camus: A Life, trans.Benjamin Ivry (New York: Alfred A. Knopf, 1997).

The literary works cited in this book with reference to moral experi-ence are W. H. Auden, Collected Poems (New York: Vintage International,1991 [1976]); Joseph Conrad, Lord Jim (New York: Penguin, 1988); JosephConrad, Victory (New York: Penguin, 1996); Frances Cornford, “Youth,” inPoems (Cambridge: Bowes and Bowes, 1910); Henry James, “The MiddleYears,” in The Turn of the Screw and the Aspern Papers (New York: Penguin,1986); Franz Kafka in a letter to Max Brod describing Robert Klopstock,dated February 1, 1921, in Leo A. Lensing, “Franz Would Be with Us Here,”Times Literary Supplement, February 28, 2003, 13–15; Imre Kertész, Kaddishfor an Unborn Child, trans. Christopher Wilson and Katharina Wilson(Evanston, IL: Northwestern University Press, 1997 [1990]); Philip Larkin,Collected Poems (New York: Farrar, Straus and Giroux, 2004); John GreenleafWhittier, “Barbara Frietchie,” in Complete Poetical Works of John GreenleafWhittier (Boston: Houghton Mifflin, 1895).

Books are not the only, or even the main, source of knowledge aboutmoral experience; films offer some of the most deeply arresting illustra-tions (as do plays and opera). In the hauntingly powerful Brazilian filmclassic Central Station (1998, Walter Salles Jr.), for example, Doña Dora, aworking-class retired teacher who now lives by writing letters for illiter-

Bibliographic Note 245

ate travelers passing through Rio’s central train station—letters that shecynically either fails to mail or actually tears up—is so concerned with thelimited income she realizes to support a lifestyle that frustrates her thatshe seeks to sell an orphan to operators of a ring that trades in children.Forced by a friend to confront the evil of what she has done, she frees theboy and accompanies him on a picaresque quest to find his absent father.In traveling by bus, pilgrims’ van, and foot from Rio to Brazil’s impover-ished northeast, Doña Dora first loses her money, then her commitment,then the boy himself, only to undergo a religious and moral transforma-tion that will take her and the boy to reunion with his adult brothers andthen send her back, as a new, remoralized person, on the bus to Rio. I findthis film illustrative of some of the key ideas in this book, for example,local worlds of suffering; the dangers of social experience, including ourown participation in dangerous acts; the defeats and limits of everydaylife; the possibilities of moral-emotional transformation for self and oth-ers; the place of moral responsibility and imagination in our lives; and thedivided sense that where the world is taking us is both ominous andhopeful—the former requiring protest and resistance on our part, the lat-ter readiness for change. I’m sure readers have their own list of such films.Others in my list include Hiroshima Mon Amour (1959, Alain Resnais); Float-ing in the Air Followed by the Wind (1976, Gunther Pfaff); The Blue Kite (1993,Zhuangzhuang Tian); The Wall (1998, Alain Berliner); All About My Mother(1999, Pedro Almodóvar); It’s My Life (2001, Brian Tilley); From the OtherSide (2002, Chantal Akerman); Beijing Bicycle (2002, Xiaoshuai Wang); ThePianist (2002, Roman Polanski); Three Rooms of Melancholia (2005, PirjoHonkasalo).

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Acknowledgments

his book has been many (too many) years in the making. I initiallywrote several detailed historical and philosophical chapters meant toframe the life stories included here. I later decided those chapters were

too academic for the book I wanted and needed to write, and so I putthem aside. Nonetheless, I fear they were a burden to the final year of lifeof Joan Gillespie, my devoted friend and longtime assistant. For this I amregretful, but for the rare privilege of working with her, I will always bedeeply grateful.

My current assistant, Marilyn Goodrich, picked up the threads andpieces and typed the entire manuscript into the computer, including mul-tiple revisions and edits. I thank her wholeheartedly for her skilled workand warm and responsive personal style. I also acknowledge the contri-butions of several graduate student research assistants: Erin Fitz-Henry,Jesse Grayman, and especially Pete Benson, as well as assistance fromCris Paul.

The chapter on W. H. R. Rivers benefited greatly from some days spentin the Master’s Lodge at Trinity College, Cambridge, England. For thatopportunity I thank my colleague Amartya Sen, then master of the col-lege. At Cambridge, the reference librarians at the University Library weregood enough to help me access the relevant materials in the A. C. HaddonCollection on Rivers’s life and intellectual career. I also benefited fromdiscussions in Cambridge with Anita Herle and Sir Martin Roth.

248 Acknowledgments

I have presented earlier versions of the introduction and epilogue aswell as the chapter on Rivers in a number of seminars: the Friday MorningResearch Seminar in Medical Anthropology at Harvard; the Faculty Col-loquium of the Department of Social Medicine, Harvard Medical School;the History of Psychoanalysis Dinner Seminar at Harvard’s Faculty Club;Amherst College, Dickinson College, Williams College, the University ofCalifornia at Berkeley, Stanford, Princeton, Columbia, the University ofCalifornia at Davis, the University of California at Los Angeles, Case West-ern Reserve, Johns Hopkins, the State University of New York DownstateMedical Center, Mt. Sinai Medical School, University of Manchester, Uni-versity College London, and the Chinese University of Hong Kong, amongother venues. I acknowledge with great thanks the importance of the re-sponses of members of these audiences to the working out of the ideas inthis book. I must acknowledge the assistance of a large group of colleaguesand friends whose names are simply too numerous to list. They must eachknow how much I have learned from their responses to this work, andhow much I value their support.

I had forgotten how difficult it is for an academic, and a highly special-ized one at that, to write for a wide audience, projecting complex ideasand findings into the space of educated conversations. Tim Bartlett, KateHamill, and Peter Ginna have been extraordinary in facilitating clear anddirect prose and an accessible message.

It is said that when he broke down psychologically in the midst of hisstudies of the workings of human societies, the great German sociologistMax Weber was asked why he spent so much time and put in such effortat understanding troubling human conditions. His answer supposedly wasthat he wanted to see how much he could endure. This project has been atest of my own endurance. Perhaps it has even been more than I couldendure. That I didn’t break down (though I came close) must be due to thegreat love and assistance I have received from my family, to whom I dedi-cate What Really Matters.

Index

Abu Ghraib prison, 42, 221abuse: child, 147; in prison, 42–43. See also

drug abuseaction and advocacy, 51activism, 145–46, 155, 157, 159addiction: drug, 143, 144; sexual, 131Adler, Simcha, 188–92, 231adolescents and sex, 138, 140. See also

children; youthadoption as taboo, 174adultery, 126advice, seeking, 66–72advocacy, 159; and action, 51aesthetics and ethics, 15Africa: AIDS in, 164–65, 166; aid work in,

48–49, 52, 65; change in, 47–48;Congo, 67, 68–69; literature on, 244;research in, 51; success in, 54–58, 60–61, 66; war zones in, 66; white peoplein, 53. See also Bosquet-Remarque, Idi

Age of Extremes (Hobsbawm), 204aging, 5, 8–9agreement, 103. See also collaborationAIDS: activism on, 145–46; in Africa, 164–

65, 166; as chronic condition, 144;diagnosis of, 143–44; discovery, 151–52; epidemic of, 146; literature on,243; living with, 158–61; preventionof, 150, 155, 163, 164; programs for,56; as reality check, 154; risk of, 56

alcoholism, 4, 55

alienation, from values, 89ambition, 112, 115, 116, 194America: capitalism in, 110; cultural

revolution in, 167; denial of problemsin, 157; expatriate aid workers from,52; pain in, 224; religion in, 131–33;response to terrorism in, 20–21

American Board of Neurology andPsychiatry, 34

American Psychiatric Association, 34anachronism of moral experience, 224ancestral spirits, 75anger, 154; of betrayal, 100; doctor’s, 167–

68; toward media, 73anguish, 168, 169anonymity, 16, 74anthropology, 165; literature in, 238–39;

and medicine, 207antiheroism, 25, 193, 215; literature on,

242–43. See also heroismAnti-Rightist Campaign of 1957,

Chinese, 88anti-Semitism, 35. See also Jewsapology, 101apprenticeship, 194. See also mentoringartist, 142, 150–51, 155, 225. See also

Williams, Sueaspiration, 33, 140; in defeat, 218; of

ordinary life, 14; survival of, 120assumption, 171, 200atomic bombing, 84

250 Index

atrocity: as normal, 42–43; in war, 40, 217;witnessing, 68

attack: capable of, 104; September 11terrorist, 20; on values, 206

attention, holding, 175Auden, W. H., 225authenticity, 225, 234; literature on, 242;

of pain, 136–37authoritarianism, 214autobiography, 26, 163. See also

Kleinman, Arthurautognosis (self-knowledge), 208–11, 231autopsy, permission for, 167–68avoidance of problems, 179

Baker, Pat, 206balance: of elegiac and promising, 194–

95; of locals and foreigners, 59–60; ofresponsibility and imagination, 193

bankruptcy, 4Barbusse, Henri, 208Barker, Pat, 199, 201Bartlett, Frederic, 197begging forgiveness, 148betrayal, 61, 80–81; anger of, 100; of

friend, 104; and misplaced loyalty,206. See also revenge

betting, 177bioethics, 133. See also ethicsbiological father, 174–75biology of impulses, 131biomedicine and religion, 133biopsy, coerced, 168–69biotechnology, 114, 116bitterness, 111bizarre, the, 200blame, 100boat, pleasure from, 183body: memory, pain, and, 135; in

struggle, 222Bosquet-Remarque, Idi, 46–79; and

change in Africa, 47–48; commitmentof, 46, 65, 74–75, 77–79; criticism ofaid work, 51–53, 62–63, 77–78; deathof, 74; education of, 47, 50;ethnographic work of, 49–50; familyof, 64; renewed purpose of, 73; safetyof, 76–77; seeking advice, 66–72;success of, 54–58, 60–61, 66; workwith migrants, 55–57, 59

bravery, 29breakdown, 35bribery, 69, 94, 97, 108–9, 182Britain, culture of, 201, 214British Army, 204Brombert, Victor, 215brooding, 29

brutality, 86burden of moral responsibility, 71, 214burnout, 68, 74Burt, Bill, 177–86, 188, 218, 231;

correspondence of, 185–86, 188;joking manner of, 177–78; stories toldby, 181–84; work habits of, 179–81

Burt, Idi, 218, 219, 229–30Bush administration, 42business agents, 84

calamity, 4Cambridge, England, 196–97, 202Camus, Albert, 51; literature on, 241cancer patient, 141–42capable: of attack, 104; of change, 233capitalism, 82, 87; in America and China,

110; and Communism, 98career: advancing, 213; of aid workers,

53; changes in, 89, 90; destroying,102–3; doctor’s, 99, 107–10, 111–17,121; of moral experience, 216;multisided, 225; politics and valuesof, 215; promotion in, 107; protectionof, 91–92, 93, 94–95, 99; threat to, 168;waste of, 114; winding down, 111. Seealso job

caregiver, issues facing, 138catastrophes, 7; health, 161Catholicism, 65, 132cemetery, Jewish, 186–87Central Station (film), 245certainty: of control, 6–7; in selling, 6; of

uncertainty, 195. See also danger anduncertainty

challenge: in Africa, 47–48; to commonsense, 41; of humanity, 23; to moralculture, 214

change, 12; belief in, 62; capable of, 233;career, 89, 90, 111, 213; in China, 110–11, 118–22; and consistency, 17–18;creating, 155–56; crisis and, 233; cyclesof, 97; desire for, 211–12; large scale,227–28; in moral context, 116–18;moral experience and, 196; opennessto, 194; and pain, 139; and protest, 221;from remorse, 218; social, 212; invalues, 40–41; of views on war, 206,208–10; and what really matters, 41,89, 118, 155–56. See also transformation

chaos, 90–91, 93; political, 85; ofwartime, 204

children: abuse of, 147; in Africa, 54–55;hope for, 94–97. See also family; youths

China: Communism in, 81–82, 83–84, 85–87, 89, 97–98, 105–6; criticism andprotest in, 140; economics in, 95–96,110–11; enemies in, 90–94, 97–102;

Index 251

ethics and reform, 110–11, 118–22;intellectual in, 12, 36; literature on,239; modern, 118; political control in,105–6; suicide in, 114; survival in, 80–82, 221–22; war with Japan, 83–84. Seealso Cultural Revolution, Chinese;Yan Zhongshu

Christianity, 132, 136, 224Christ Jesus, 130, 136chronic disease, 143–44, 156chronic pain, 123, 124, 135–39civil war (China), 84class, 37; British system of, 201; and drug

abuse, 147; issues of, 86, 89; inwartime, 204; and work, 176

coercion, 168–69Cohen, Julia Richardson, 27–28Cohen, Winthrop, 27–45, 139, 170, 217–19,

220–21; killing in war, 31–34, 35, 37,38–39; in Marines, 29, 30, 33; moralexperience of war, 38–43; psychiatrictreatment of, 27–28, 34–35, 36, 42, 43–44; religion and ethics of, 36–38, 41, 45

collaboration, 2, 65, 222; and ethics, 3;family’s, 83, 85, 87, 89–90, 98, 120; outof necessity, 89; for survival, 119, 120

collective level: of moral experience, 21, 156collective myth, 38collectivism, 88; end of, 112; reversal of,

109–10collusion, societal, 35colonialism, 53, 87, 206combat, 39, 43. See also warcommitment: to aid work, 49, 53, 65, 74–

75, 77–79; and devotion, 21, 77;global, 78; impetus for, 230; inmarriage, 125–26; moral, 77, 214; andmoral justification, 20–21; passion of,232; to scientific method, 211; inwartime, 39–40; as what reallymatters, 74, 75. See also responsibility

common sense, 8, 41Communism, Chinese, 81–82, 83–84, 85–

87, 89, 97–98, 105–6; and capitalism, 98community, moral experience of, 17complicity, 68, 192; in untruth, 194compromise, 89, 120conflict: of emotions, 129; of motives, 209;

of values, 165, 182, 208–9Conflict and Dream (River), 208, 211conformity, 170confrontation, armed, 190. See also warConfucianism, 89Congo, 67, 68–69Conrad, Joseph, 223consistency and change, 17–18consumer culture, 7, 78context: moral, 116–18; of society, 37; for

understanding, 166control: certainty of, 6–7; of chronic pain,

135; of desire for drugs, 147; limit of,6; of political order, 105–6, 119; social,20, 76; of thoughts, 127

coping, limits to, 231core of human nature, 17Cornford, Frances, 225correspondence, 185–86, 188corruption, 61–62, 97, 114; on the job, 182;

mass, 108–9; and money, 97cost of success, 119counseling: pastoral, 128–29, 132;

psychological, 133courage, 90; to face reality, 10co-workers, 177, 181–86, 188Craiglockhart Military Hospital, 198creativity, 15, 155–56crisis, life, 72, 223criticism, 220; of culture, 36, 138, 140;

ethical, 26; of government, 105–6; ofhumanitarian assistance, 62–63, 77–78; pain as form of, 139; political, 90–92; of reform, 111; self, 38, 58, 107,155; of self and world, 36; target of, 88

cruelty, 104cultural environment, 12cultural revolution: in America, 167;

economic change of, 110Cultural Revolution (China), 82, 86, 97,

104, 110, 140; enemies in, 90–94, 97–102; perils of, 22; vexation of, 36. Seealso Yan Zhongshu

culture: British, 201; challenge to, 214;and change, 18; of consumption, 7, 78;criticism of, 138, 140; and desire, 130–31; of human essence, 15; literatureon, 244; and moralistic terms, 213;myth of control in, 7; of pain andsuffering, 224; values of, 214, 226

cynicism, 62

danger and uncertainty: admitting, 231;and certainty of uncertainty, 195;coming to terms with, 122; engagingwith, 155–56; escalating, 43; feeling,12–13; to humanity, 24; in life, 1; life-threatening, 208; moral and political,220–21; normality of, 213, 215–16; andpain, 134–35; preparation for, 11–13;of second order, 19–20; seeing, 235;terminal, 161; and values, 18; andwhat really matters, 226

death, 36, 74, 142, 161, 166, 207–8; infantmortality, 55; suicide, 4, 93, 114, 149.See also killing

Deaton, Harvey, 6debt, international, 48

252 Index

decency, 76deception, 136defeat, 116; aspiration in, 218; and

victory, 9, 120, 221–23. See also failure;success

delusion, 7demarcation, line of, 190dementia, 152democracy, demand for, 105–7demoralization, 68, 71, 110, 114, 232Deng Xiaoping, 95, 106denial, 6, 7, 8; of moral, 9; overcoming,

157; surmounting, 23; of what reallymatters, 169–70

denunciations, 91, 99–100, 107depopulation, 206depression, 22, 29, 71; of drug addict, 149;

and ethics, 36; as punishment, 218;symptoms and treatment of, 34–35;treating, 41–42; vs. unhappiness, 27

desire: for change, 211–12; and culture,130–31; for drugs, 147; for killing, 105;sexual, 125, 129, 130–31, 136, 140

desolation, 71despair, 27, 70, 157destruction, 147; and power, 214developing world, gender in, 63development: commercial, 113; literature

on, 243–44devotion, 27, 77. See also commitmentDiagnostic and Statistical Manual

(American Psychiatric Association), 34diagnostic tests, uncertainty of, 141diaspora, 191–92, 193differences in values, 84–85, 88, 89dire circ*mstances: of humanitarian

assistance, 48–49, 52disability, 4, 136disadvantaged, study of, 50disappointment, 67disasters, news of, 5discrimination, 181disease: chronic, 143–44, 156; moral

experience from, 157; as teacher, 146.See also pain; and individual conditions

disenchantment, 86disgrace, 210distinctions, simplistic, 233distress, signaling, 180divine intercession, 129. See also Goddivorce, 174. See also marriagedoctor: anger of, 167–68, 205; military,

32–33, 37. See also physician; YanZhongshu, Dr.

doing for others, 146doubt, passion about, 232–33drama, family, 171–75dreams, 33

drug abuse, 143–50; activism on, 145–46;and addiction, 143, 144, 149–50; andclass, 147; epidemic of, 146; hell of,149; rehabilitation from, 149–50;support for prevention andtreatment, 155

drugs: for AIDS, 164; prescribed, 109. Seealso pharmaceutical industry

economic assistance, 47. Seehumanitarian assistance

economy: of AIDS treatment, 164; andchange, 18; global political, 78;market, 82; money exchange in, 199;political, 109–9, 110, 227; reform of,95–96; success of national, 96

education, 29, 140, 176; about money,178–80; and employment, 47; inethnography, 50; of family members,93, 95, 96; of government worker, 57;and mentoring, 186, 193–94, 232, 242;pride in, 181; quitting, 184;reeducation, 88

egalitarianism, 86emergencies, responding to, 179–80emotions: conflicting, 129; elicited by

illness, 141; sensibility of, 169–70;stability of, 41; trauma of, 205; andvalues, 118

empathy, 65empowerment, 130; of information, 228;

and religion, 14–15end-of-life, 36, 74, 142, 161, 207–8; care

at, 166ends and means, 51endurance, 16–17enemies, 31, 39, 90–94, 97–102, 102English Review, 208–9environment: cultural, 12; of moral life, 3.

See also cultureepiphany, 127escapism, 6estrangement, 12–13ethics, 11; and aesthetics, 15; aspirations

of, 140; in China, 110–11, 118–22; anddepression, 36; development ofbioethics, 133; disingenuous, 137; ofempathy, 65; failure of, 136, 169; limitof, 43; literature in, 242; medical, 133,166–70; and moral life, 25–26, 121–22,219–21; question of, 136–40, 165;reflective, 219–21; and religion, 36–38,41, 45; and survival, 119–21;transformation of, 140; and values, 3,140, 165–66; of wartime experience, 41

ethnic nationalism, 193ethnography, 49–50, 202, 226ethnology, 198, 199

Index 253

Europe, 186; expatriate aid workers from,52; pain in, 224; religion in, 131–32.See also individual countries

everyday life, politics of, 138evil, 38, 220; condemning, 87; vs. good,

130–31, 215evolution of experience and vision, 121–22exclusivity, 191–92, 193execution of movement leaders, 106exhaustion, 70exile, 102existentialism, 6, 8, 10, 194–95, 235;

experience of, 2, 23–24, 38, 122, 196, 231expatriate aid workers, 52expectation, 37experience, knowing from, 152exploitation, 87extraordinary, the, 39eyes, open and closed, 234–35

failure, 30, 37; ethical, 169; of ethics, 136;feeling of, 69; moral, 21–22; nobilityof, 225; in parenting, 153; to protect,169; responsibility for, 131; of states,48; in unrecognized values, 131;victory, defeat and, 9, 116, 120, 218,221–23. See also success

fame, 115family: adoption and divorce in, 174; in

Africa, 54–56; of aid workers, 64, 74;artist’s, 142, 143, 144; changes in, 118;in China, 81–82, 83–84, 85–87, 89, 97–98, 105–6; collaboration of, 83, 85, 87,89–90, 98, 120; drama in, 171–75;education of, 93, 95, 96; fiscalresponsibility of, 162–63; guilt of, 72,158; jobs for, 95; living with, 96–97;loss of member of, 4; one-child, 110;political attack on, 91–92; relocationof, 92–93; response of, 144, 152–53,154, 157–58; safety of, 81; seekingautopsy permission from, 167–68;survival of, 93–94; through roughtimes, 194; value differences in, 82–85,88, 89; violence in, 148; as what reallymatters, 128, 153

fantasy, sexual, 125–26, 127–30, 138Farmer, Paul, 77fatalism, 4, 6father, biological, 174–75father figure, 63, 175, 183, 231fault, 28fear: of anonymity, 16; of danger and

uncertainty, 12–13; of disgrace, 210; offailure, 69; of government, 81; ofhuman condition, 10; preoccupationwith, 20; of revolution, 92; self-protection out of, 104; of terrorism, 42

feasibility, 58Le Feu (Barbusse), 208fighting: breaking up, 181; for life, 38films: bibliographic note on, 244–45;

sentimentality of, 13finances: family, 172–73; hospital, 111–14,

116; insecurity of, 4fiscal responsibility: as what really

matters, 162–63Flaubert, Gustave, 215foreigners and locals, 52–53, 59–60forgetting, 35; of war experiences, 40–41.

See also memoryforgiveness: begging, 148; withholding,

105foundation, 195free agent, 209–10freedom, 105, 200French academic, 12. See also Bosquet-

Remarque, IdiFreudianism, 208friend: beating of, 100; betrayal of, 104;

response of, 154, 157–58; temptationfrom, 185–86

Frost, Alexandra, 27–28frustration, 150, 245fundamentalism, 15funding: for aid work, 53; seeking, 163–64future vs. past, 116–17

gangs, 83gender in developing world, 63genocide, 67. See also Holocaustgenuine reality, 9, 13–14, 219Germany, 209giver vs. taker, 146, 148global donor community, 48global health: international meeting on,

163–66; literature in, 237, 239globalization, 78, 227–28God, relationship with, 125–30, 131–32,

135–36good, 2; pain and suffering as, 124–25,

223; vs. evil, 130–31, 215good life, 23government, 105; African, 55, 57–59; aid

organizations of, 48; Chinese, 81;criticism of, 89

grace, God’s, 130, 131Graves, Robert, 203gray zones of life, 215Great War, 206, 208; literature on, 239–40Great White God, 200grieving, 167group vs. individual, 165guilt: about parenting, 153; family, 72,

158; sexual, 126, 129; wartime, 39

254 Index

Haddon, A. C., 198, 201, 202hardship, for a purpose, 87hatred, 102, 104haunting memories, 217–18Head, Henry, 199, 202“Head of a Medical Student, The”

(Picasso), 234healing, 136; and religion, 133, 134health: global, 163–66; problems of, 5;

risks to, 161. See also illness; andindividual conditions

Health, Chinese Ministry of, 107health care, 85–86. See also hospital;

medicinehelp, 80; reluctance to seek, 124heritage, Jewish, 191heroism, 34, 77, 223, 229; antiheroism or

negative, 25, 193, 215; of humanitarianworkers, 53; literature on, 242–43

hidden life, 31history: cycles of, 97; and memory, 174,

187HIV/AIDS, 163Hobsbawm, Eric, 204Holocaust, 19, 35, 187. See also Jewsholy, the, 123, 126, 130. See also religionhome, loss of, 4homeland, Jewish, 191homelessness, 86hom*osexuality, 203hope, 55, 94–97, 148, 157hospital, 94, 107–8, 110; doctor-family

dispute in, 167–68; financial pressureon, 111–14, 116; as prison, 92; survivalof, 120. See also medicine

human condition, 10, 161; core of, 17;transient, 118. See also humanity

humanitarian assistance, 47, 48–49; aidworkers, 53, 73, 75; commitment to,46–47, 53, 65, 74–75, 77–79; criticismof, 62–63, 77–78; dire circ*mstancesof, 48; discontinuation of, 69–70;funding for, 53; literature on, 243–44;programs for, 52, 229; responsibilityfor, 67, 69; tragedy of, 164. See alsoBosquet-Remarque, Idi; NGOs

humanity: challenges of, 23; culture of,15; danger to, 24; and inhumanity, 1,34, 147; loss of, 35; moral experienceas, 234; moral life as defining, 234;struggle for, 11

humiliation, 168; of political enemies,91–92

humor, 6, 177–78Hundred Flowers Campaign (China), 106hunger, 93hypocrisy, 41, 220hysteria, 104

idealism, 81, 98, 109ideal vs. real, 140, 166identity, dual, 174. See also selfideology, 110; skepticism of, 89ignorance, political strategy of, 55illness, 224; emotions elicited by, 141;

moral source of, 208. See also pain; andindividual conditions

Illness Narratives, The (Kleinman), 156, 186illusions, 8; harmony of, 44imagination: critical, 193; of moral life,

38; in wartime, 40–41impulse: biology of, 131; sexual, 134, 223inadequacy, 26, 68inauthenticity, 151India, 202individual: advantage as what matters

most, 119; and family, 171; as moraland political agent, 213; moral life of,17, 156; personal life and:professionalism, 63; andprofessionalism, 63; public, 80; andsociety, 21–22, 37; threat to, 5;transformation of, 17–18, 145; valueof, 15; vs. group, 165. See also self

inequalities, and transfer of resources, 139infant mortality rate, 55influence, 151, 201, 206, 211, 213, 225information: empowerment of, 228;

smuggling of, 84informer, 107inhumanity, 1, 34, 147. See also humanityinner demons, 146In Praise of Antiheroes (Brombert), 215insecurity, 26inspiration, 27, 156insurgency, 42. See also warintellectual: absence of stimulation for,

93; in China, 12, 36; public, 206intensity of problem, 124international aid. See humanitarian

assistanceinternational governmental

organizations, 48. See also NGOsInternational Monetary Fund, 47interrogation of prisoners, 42intimate threats, 5investigation, 107investment, financial, 172–73Iraq, 20, 40, 42, 221Islam, 20–21Israel, 186, 188–89, 190, 192

James, Henry, 132, 233–34James, William, 9, 219, 242Jamison, Reverend Charles Kentworth,

123–40, 147, 170, 218, 222–24; andethical questions, 136–40; pain and

Index 255

religion of, 123–24, 126, 130–31, 132–37, 224; relationship with God, 125–30, 131–32, 135–36; sexual life of,125–26, 127, 129–30, 136, 138

Japan, 37, 83–84Jesus Christ, 130, 136Jews and Judaism, 132; cemetery for,

186–87; and Holocaust, 19, 35, 187;and Israel, 186–92; pogrom andShoah for, 2, 19

jihad, 5job: corruption on, 182; loss of, 4;

opportunity for, 95–96; retirementfrom, 114, 117, 182. See also career

Job (Bible), 35, 36joking, 6, 177–78Jordan, 190journalists, 51Judt, Tony, 214justice, 38, 132, 219justification, 20–21, 32, 42, 101, 219–20;

for war, 37–40

Kaddish for an Unborn Child (Kertész), 222Kertész, Imre, 222kibbutz, 188killing, 34; desire for, 105; of landlords,

85; random, 208; in war, 31–34, 35, 37,38–39, 204; as what really matters, 38.See also murder

Kim, Jim, 77Kleinman, Arthur, 156, 163–95; on AIDS

in Africa, 163–65, 166; on balance,194–95; with co-workers, 177, 181–86,188; education of, 176, 178–79, 181;family of, 171–75; in Israel, 186–92; asmanual worker, 176–81; on medicalethics, 167–70; on mentoring, 193–94

knowledge: about moral life, 212; fromexperience, 152; of self, 208–11; ofwhat really matters, 150

Kuomintang, (KMT, China), 83–84

labor camps, 88landlords, killing of, 85Lawrence, T. E., 203Levi, Primo, 215, 242Lévinas, Emmanuel, 65, 137, 138, 234, 242liberation: from fears, 10; of soul, 72Liberia, 67life: crisis of, 223; as moral, 1;

prescription for, 230, 233lifestyle, maintaining, 84life-threatening danger, 208limit: of control of existential fear, 6; of

coping, 231; sensibility to, 160; set byillness, 142; of success, 60–61, 66

listening, 171, 189

living conditions: with family, 96–97;restrictions on, 86

local and foreign workers, 52–53local level, 21, 25; assistance at, 49, 51;

ethical vision at, 121–22; influence of,206; moral at, 2; of moral world, 219;research at, 51

locals and foreigners, 52–53, 59–60London, 198Lord Jim (Conrad), 223loss: of family member, home or job, 4; of

humanity, 35; of optimism, 67love, 154loyalty, misplaced, 206. See betrayal

magical belief, 6maintaining lifestyle, 84manliness in wartime, 210manual work, 176–81Maoism, 88, 90, 98, 119Mao Zedong, 84, 106Marines, life in, 29, 30, 33market economy, 82, 108–9, 110marriage, 144, 148, 174; commitment in,

25–26. See also familymass psychosis, 92masturbation, 125, 129materialism, 110matters. See what really mattersmeaning: from work, 71–72means and ends, 51measure of things, 200media: anger toward, 73; on heros, 77medication, 9, 124. See also drugsmedicine: and anthropology, 207; and

biotechnology, 114, 116; ethics of, 133,166, 169; issues facing caregiver, 138;literature in, 240–41, 243; permissionfor autopsy, 167–68; profession of, 81,108–9; and religion, 22, 132–33; inwartime, 211. See also hospital; YanZhongshu

Melanesia, 199, 206memory, 31, 210, 213; embodiment of, 135;

fostering revenge, 41; haunting, 217–18; and history, 174, 187; and pain, 131;remembering, 35, 75, 196–200;repression of, 43; of vengeance, 38

men, in developing world, 63. See alsofather

mental health, 94; and suffering, 9;tautology in, 44. See also psychiatry

mentoring, 186, 193–94, 232; literature on,242. See also education

“Middle Years, The” (James), 232migrants: and hospital services, 108;

working with, 55–57, 59

256 Index

military, 67, 68–69, 70; background in,113; doctor in, 32–33, 37; officer in,204–6, 208–10; service in, 29, 30, 33, 39

militias, 67ministry, 125, 127–28, 130; and pain,

134–35misery, 157mocking, 34modernization, 112. See also changemoney, 87, 114; and corruption, 97;

education about, 178–79; exchange of,199; and poverty, 47, 50, 85–86, 93,182; as success, 108–9

monster, 215. See also antiheroismmoral high ground, 222moral life: of aid workers, 73;

anachronism of, 224; career of, 216;choice in, 131; climate of, 120;commitment to, 77, 214–15;complexity of, 79; constrained, 169;constraint of, 169; in contested publicdomain, 118, 120; context of, 116–18;crisis of, 72; danger to order of, 19; asdefining humanity, 234; environmentof, 3; and ethics, 25–26, 121–22, 219–21; exemplar of, 207; failing of, 21–22;high ground of, 222; imagination of,38; of individual and community, 17;insecurity of, 26; justifications of, 21;knowledge about, 212; literature on,244; meaning of, 1–3, 72; andmoralistic terms, 213; politics of, 212–13; and power, 137; prescription for,230, 233; reconstructing, 226–27; andreligion, 134; remaking of, 156–57,201; and responsibility for, 38, 47, 193,220, 242; reworking, 196; superiorityof, 78; transformation of, 227–28;understanding issues of, 169–70;values and ethical aspirations, 140; ofwar, 38–43; as what really matters, 1–2; in worst of times, 81. See alsoresponsibility

motives, conflict of, 209murder, 32–33; haunting of, 217–18. See

also killingMuslims, 20–21mutilation, 31myth: collective, 38; of control, 7

nationalism, 15; ethnic and religious, 193national security, 228national shame, 86necessity, 89neocolonialism, 53. See also colonialismnetwork: of business agents, 84; for

protection, 82; support, 63

neuroses: sexual, 208; of shell shock, 203,204–5. See also psychiatry

New York Times, 6nexus of values, 193, 194nobility of failure, 225NGOs (nongovernmental organizations),

48, 77; discontinuation of programsof, 69; limits of, 60–61; safety of staffof, 76. See also humanitarianassistance

normal, 34, 226; atrocity as, 42–43; dangerand uncertainty as, 213, 215–16, 223;perspectives on, 2

novelty, 211

obligations, social, 135. See alsoresponsibility

official position, 210Olympic Games (2008), 111one-child family, 110openness to change, 194opposites, 182, 220oppression, political, 87optimism, 221; loss of, 67order, public, 76. See also controlordinary life, 4; remaking of, 14ordinary people, 35, 39, 75, 230; stories

of, 1others: in community, 17; co-workers as,

177, 181–86, 188; doing for, 146;friends as, 100, 104, 154, 157–58, 185–86; in group, 165; in network, 63, 82,84; responsibility for, 47; in society,21–22. See also family; world

overreaction, literature on, 243

pacifism, 208–9pain: in America, 224; authenticity of,

136–37; as bad, 223; chronic, 123, 124,135–39; as form of criticism andprotest, 139; as good, 124–25, 223; andissues facing caregivers, 138;literature on, 243; and memory, 131;and religion, 123–24, 126, 130–31,132–37; of social obligations, 135; andsuffering, 224, 234–35; and truth, 222;as what really matters, 134

Palestinian-Israeli conflict, 192panic, 180passion, 219; about doubt, 232–33past vs. future, 116–17paternalism, 214patient-doctor relationship, 108. See also

medicinepatriarchy, 63. See also fatherpatriotism, 214Peace Corps, 77Pentagon, 42

Index 257

perpetrator vs. victim, 2, 61, 188, 192, 222personal advantage, 119. See also

individual; selfpharmaceutical industry, 9, 109, 115, 164phenomenology, literature in, 237philosophy, literature in, 237physical response: to erotic fantasy, 126–

27; to sexual desire, 129; to suffering,134; to tension, 164

physician, 32–33, 37, 167–68; military,205. See also Yan Zhongshu

Picasso, Pablo, 234–35plague, 146pleasure from boat, 183pogrom, 19policy, public, 85–86political prisoners, 88politics, 227; of career, 215; and change,

18; climate of, 119; criticism of, 90–92,111; danger and uncertainty of, 220–21; of economy, 78, 227; entering, 199,206; of everyday life, 138; ofignorance, 55; of moral experience,212–13; oppression in, 87–88; order in,67, 83, 85, 105–6; reform of, 111; ofrevolution, 91–92; violence in, 193,212–13

position, official, 210post-traumatic stress disorder (PTSD),

43–44, 70, 205, 213poverty, 85–86, 182; crippling, 93; risks

from, 47; study of, 50power, 151; and destruction, 214; games

of, 137; and knowledge, 211; of self,197; Western, 78

prayer, 126, 127, 135–36predictability, 1pregnancy, 126–27preoccupation, 145; with fear, 20; with

sex, 129prescription for life, 230, 233preservation, of self, 208pressure, 35; under communism, 82; in

war, 83pretending, 104, 150pride, 30, 181prison, 32, 88; abuses in, 42–43; hospital

as, 92private property, 84–85private sector, 95problem: avoiding, 179; being, 59;

intensity of, 124; medical or moral, 22Prodigal Son (Rembrandt), ii, 10, 14professionalism, 53–54, 76, 81, 91, 108–9;

and personal life, 63; and tautology ofmental health, 44

propaganda, 86

protection: of career, 91–92, 93, 94–95, 99;network for, 82; self, 104; ofvulnerability, 234–35

protest: and change, 221; criticism asform of, 139–40; failure to, 169

Protestantism, 123, 125, 127–28, 132psychiatry, 27–28, 34–35, 36, 42, 43–44,

166; literature on, 239–40psychology, 132, 133, 205, 207psychosis, mass, 92psychotherapy, 210–14, 226, 227;

ethnographic, 214; literature in, 240–41; protective, 203

public relations, 62public sector, 95, 118–20punishment, 38, 224; depression as, 218;

God’s, 130purpose: and ambition, 112, 115, 116, 194;

greater, 87; renewed, 73. See also whatreally matters

qigong, 110questioning, 41, 232–33

racism, 2, 53, 181rage, 31, 37, 154rationality, 209rationalization, 38rationing, 86reactions, validity of, 200reality: courage to face, 10; existential, 38;

genuine, 9, 13–14, 219reality check, AIDS as, 154real vs. ideal, 140, 166rebellion, 176recrimination, 107recruiting, 189, 191–93reeducation, 88. See also educationreflective consciousness, 219reform. See changeregeneration, 206Regeneration, (Barker), 199, 210rehabilitation from drug abuse, 149–50reimagining, 15–16rejection of culture values, 214relationship. See commitmentrelief: atmosphere of, 103religion, 123–40; in America and Europe,

131–33; in China, 110; andempowerment, 14–15; and ethics, 36–38, 41, 45; and humanitarianassistance, 48; literature on, 243; andmedicine, 22, 132–33; and moralexperience, 134; and nationalism, 193;and pain, 123–24, 126, 130–31, 132–37,224; and psychology, 132, 133; andsexual life, 22, 125, 136, 140; on

258 Index

religion (continued )suffering, 11; transformation through,138; and values, 14–15, 37, 133. Seealso Jamison, Reverend CharlesKentworth

Rembrandt, 10, 14remembering, 35, 75, 196–200. See also

memoryremorse, 218renunciation, 89repression of democracy movement,

105–7reputation, 203; on the job, 182; mass,

108–9research, ethics of, 50–51resistance, 81, 84; to action, 145resources: access to, 57; transfer of, 139response of family and friends, 143–44,

151–53, 154, 157, 200responsibility, 28, 67; for aid work, 67, 69;

burden of, 38, 71, 214; existential, 122;for failure, 131; fiscal, 162–63; moral,38, 47, 193, 220, 242; in wartime, 40–41

restriction on living conditions, 86retirement, 114, 117, 182revealing nothing, 80revenge and vengeance, 20, 101–3, 119;

breaking cycle of, 121; fostered bymemories, 41; for terrorism, 42

Review, English, 208–9revolution: and class, 86; fear of, 92;

suicide in: 93; survival in, 104. See alsoCultural Revolution, Chinese

right and wrong, 2–3, 33rights, respect for, 84risk: of AIDS, 56; of health catastrophes,

161; management of, 7; from poverty,47. See also danger and uncertainty

Rivers, W. H. R., 138, 193, 196–216, 211,220, 225–27; literature on, 239–40; asmilitary officer, 204–6, 208–10; onmoral experience, 207, 212–16; aspsychotherapist, 210–14; reminiscenceon, 196–200; as scholar, 200–203

rough times, 194Royal Army Medical Corp, 209rules of war, 42–43Rwanda, 67

sadism, 43sadness, 28safety, 90; of aid staff, 76–77; of family, 81St. John’s College, Cambridge, 197, 206Salles, Walter Jr., 245salvation, 224Sassoon, Siegfried, 198, 203, 206, 208, 214scandal, family, 175scholar, 200–203

school, dropping out of, 184. See alsoeducation

Schweitzer, Albert, 53science, 51, 211. See also individual

disciplinesSecond World War, 39secrets, 99–100security, 20; national, 228seduction, sexual, 128seeing danger, uncertainty, and value, 235self: control of, 7; criticism of, 36, 38, 58,

107, 155; destructive action toward,147; divided, 219; esteem for, 183;interest of, 209; knowledge of, 208–11,231; preservation of, 208; protectionof, 104; public, 80; sense of, 41, 110,145–47; and world, 36, 154, 157. Seealso individual

sensibility, 3; emotional and moral, 169–70; to functional limitations, 160; ofthe holy, 126; questioning, 41;religious, 130; renewal of, 16

sentimentality of films, 13September 11 attacks, 20service, 91, 146; military, 29, 30, 33, 39sewage, 55sex and sexuality, 203, 223, 224; addiction

to, 131; adultery in, 126; desire in, 125,129, 130–31, 136, 140; fantasy of, 125–26, 127–30, 138; impulses of, 134, 223;masturbation in, 125, 129; andneurosis, 208; and religion, 20, 125,136, 140; risk in, 56; of youths, 129,138, 140

Shakespeare, William, 8shame, 170; of AIDS, 143; in coerced

deed, 168; national, 86; for who weare, 218; of world, 39–40

sharing of story, 181–84, 189–90. See alsostory

shell shock, 203, 204–5Shephard, Ben, 205Sherston’s Progress (Sassoon), 198Shoah, Jewish, 2, 19shoreline, image of, 17Sierra Leone, 67significance, unique, 16silence, 28, 30; about family violence, 148;

from oppression, 87; overcoming, 157;of repression, 43, 105–7

sinfulness of thought, 127skepticism, 89Slobodin, Richard, 197, 200smuggling of information, 84social change, 212. See also changesocial control, 20; absence of, 76social experience: and subjectivity, 212socialism, 82, 87

Index 259

socialization, 213social justice, 38, 132, 219social obligations, pain of, 135social scientists, 51social theory, literature in, 237society: context of, 37; individual and,

21–22soldiers, experience of, 39. See also warsoul, 10, 35–36; liberating, 72Spier, Arthur (Arthur Kleinman), 173spirituality, 132–33stability of emotions, 41stake in survival, 210standards: of official position, 210;

professional, 108–9; in wartime, 42–43Stanford University, 207state failure, 47. See also governmentstigma, 88; of diagnosis, 205stimulation, absence of, 93story: continued through

correspondence, 184–86, 188;existential core of, 26; of facingfailures, 24; family, 171–75; learningfrom, 3; of liberation, 10; of medicalethics, 167–69; of moral experience as,196; of ordinary people, 1; of pain andthe holy, 123, 131–36; of real lives, 166;of reminiscence, 196–200; sharing of,181–84, 189–90; of struggle, 21; ofsuffering, 101; of survival, 190–91

strategy: on limits of control, 6; forsurvival: 119–20

stress and religion, 133, 134struggle: body in, 222; good vs. evil, 130–

31, 215; with human condition, 161; forhumanity, 11; story of, 21; uncertainand unfinished, 121; unequal, 17; forwhat really matters, 5–6

stupidity, 107, 185subjectivity: literature on, 243; and social

experience, 212success, 8, 30, 38; in Africa, 54–58, 60–61,

66; after addiction, 143–44; at anycost, 119; of artist, 151; avoidingproblems as, 179; confirmation of,157–61; confirming, 157–61;economic, 96; limiting, 60–61, 66;money as, 108–9; as what reallymatters, 37. See also failure

suffering, 9, 11; acknowledgment ofothers’, 46; of aid workers, 52; asgood, 124–25, 223; of local people, 51;as mental illness, 9; and pain, 224,234–35; physical, 134; reworking of,74; story of, 101; value of, 136. See alsopain

suicide, 4, 149; attempts of, 149; in China,114; in revolution, 93

superficiality, 105superiority, 78supernormality, 223support network, 63survival, 57; of aspiration, 120; and

ethics, 119–21; of family, 93–94; inmoral context, 117; by revealingnothing, 80; in revolution, 104; atstake, 210; story of, 190–91; inwartime, 40

taboo, divorce and adoption as, 174taker vs. giver, 146, 148Tan Zhiwei, 112, 113tautology, 44teaching, 140, 180. See also education;

mentoringtechnology, 108; belief in, 6temptation, 185–86tension: physical, 164; of pregnancy, 126terrorism, 15, 20–21, 42, 88testimony, literature on, 242“Thanksgiving for a Habitat” (Auden),

225therapy, 210; psychotherapy, 203, 210–14,

226, 227, 240–41thoughts, control of, 127threat, 19; to career, 102–3, 114, 168; at

intimate level, 5; to what reallymatters, 4

Tiananmen Square demonstrations, 105times, worst of, 81Todas hill tribe, India, 202tolerance, 89Torres Strait expedition, 211tragedy, 22, 43, 164transfer of resources, 139transformation, 201, 206; ethical, 140; of

moral life, 227–28; personal, 145;portrayed in film, 245; potential for,221–22, 224; religious, 138; of self, 17–18, 145; therapeutic, 212; of world, 24.See also change

transience, 118trauma, 35, 73, 75; psychological, 205;

and PTSD, 43–44triumph, 8. See also failure; successtrust, 80, 99–100, 102, 153truth: disparity in, 41; and pain, 222;

partial, 169

uncertainty: certainty of, 195; ofdiagnostic tests, 141; struggle of, 121.See also danger and uncertainty

understanding: context of, 166; moralissues, 170; self, 104

unhappiness vs. depression, 27, 103United Nations, safety of staff of, 76

260 Index

University of London, 199untruth, 194. See also truthusefulness, 234

validity of reactions, 200values, 89; alienation from, 89; and

aspirations, 140; attacking, 206;betrayal of, 33–34; of career, 215;change of, 40–41; conflict of, 165, 208;crisis of, 43; of cultural, 226; anddanger, 18; and emotion, 118; andethics, 3, 140, 165–66; familydifferences in, 82–85, 88, 89; of fiscalresponsibility, 162; of individual, 15;local, 2; as moral, 1–2; and moralisticterms, 213; nexus of, 193, 194;opposing, 182; and psychologicalsymptoms, 207; rejection of, 214;religious, 14–15, 37, 133; seeing, 235;of suffering, 136; unrecognized, 141

Varieties of Religious Experience (James), 132vengeance and revenge, 20, 41–42, 101–3,

119, 121; of memory, 38veterans, war, 30–31vexation, 36victim vs. perpetrator, 2, 61, 188, 192, 222victory and defeat, 9, 120, 218, 221–23. See

also failure; successVictory (Conrad), 223violence: in Africa, 68; family, 148;

political, 193, 212–13; of war zones, 66visa, 96vulnerability, 67; to pain and suffering,

234–35

war/wartime: accepted rules in, 42–43;atrocity in, 217; change of view on,206, 208–10; Chinese civil, 84;Chinese-Japanese, 83–84; contributionto, 203; dissociation from experiencesof, 44–45; in France, 198, 204; Iraqi, 20,40, 42, 221; Israeli, 190–91;justification for, 37–38; killing in, 31–34, 35, 37, 38–39; leaders in, 214;medicine in, 211; moral conditions in,38–43; neurosis of, 203, 204–5;veterans of, 30–31; vexation of, 36;weight of, 29; what matters in, 39;zones in Africa, 66

Western power, 78what really matters: about humanitarian

assistance, 229; appeal of, 118; inchanging times, 41; changing worldas, 79; commitment as, 74, 75; contextfor understanding, 166; and creatingchange, 155–56; dangerous thing as,

226; denial of, 169–70; doing forothers as, 146; existential condition as,231; family as, 128, 153; fiscalresponsibility as, 162; getting right,230; illness determining, 141–42;killing as, 38; as moral, 1; not knowing,150; optimistic and ominous as, 221; toothers, 157; pain as, 134; personaladvantage as, 119; question of, 72;reworking of moral experience as, 196;struggle for, 5–6; success as, 37; threatto, 4; in wartime, 39

white people in Africa, 53Whittier, John Greenleaf, 142who we are, shame for, 218willfulness, 219Williams, Sally, 142–61, 218, 220, 224–25,

230; as activist, 145–46, 155, 157, 159;background of, 142, 147–48; drugabuse and rehabilitation, 143, 149–50,155; living with AIDS, 154–56, 158–61;response of family and friends, 143–44, 151–53, 154, 157

Wilson, Harold, 178–81, 182witnessing, 51; of atrocity, 68; literature

on, 242women, in developing world, 63work: and class, 176–77; manual, 176–81;

meaning from, 71; as rehabilitation,150

world: changing, 24, 40–41, 79, 213;criticism of, 36; divided, 218–19, 220;ethical, 218–20; and self, 36, 154, 157;shared, 39–40. See also global

World Bank, 47worst of times, 81wrong vs. right, 2–3, 33

Xu Weiqing, 98–103, 104–4, 107, 112, 114–17, 121; survival of, 119–20

Yale-New Haven Hospital, 167Yan Zhongshu, Dr., 81–122, 140, 170, 220,

221; betrayal and revenge of, 98–104,119; career of, 99, 107–10, 111–17, 121;and Communism, 81–82, 83–84, 85–87, 89, 97–98, 105–6; on ethics andreforms in China, 110–11, 118–22;family of, 81–85, 88–94, 98, 118; hopesfor his children, 94–97

YMCA movement, 77Young, Allen, 44youths, 8; jobs for, 95–96; and sex, 129,

138, 140; socialization of, 213

Zewen, Dr., 112, 113

Contents
Note to the Reader
Chapter 1 Introduction
Chapter 2 Winthrop Cohen
Chapter 3 Idi Bosquet-Remarque
Chapter 4 Yan Zhongshu
Chapter 5 Charles Kentworth Jamison
Chapter 6 Sally Williams
Chapter 7 Bill Burt/Simcha Adler
Chapter 8 W. H. R. Rivers
Chapter 9 Epilogue
Bibliographic Note
Acknowledgments
Index