Still Life: An Introduction to Aesthetics and the Therapeutic Potential of Our Senses

Towards the tricky end of living until death actually comes, we often ignore the obvious. Our lives begin and end with our bodies. Our bodies are sensing creatures affected by time and limited by the laws of the universe.

Can we agree on this much? While we have our senses, we should pay attention to them. They guide us one way and another. The act of perception does not require memory nor much time to experience. We may — or may not — create meaning from what we feel; that is secondary gain. Meanwhile and immediately, we wish to simply feel alive.

There is a great reckoning happening within our healthcare system, down to our very notions of what constitutes health. Faced with poorer outcomes and at far greater expense compared with other developed nations, and now noting recent data telling us that medical error is the third leading cause of death, and asked to serve a meteorically rapidly aging service demographic living longer with a greater burden of disease, we are coming to terms with the benefits of our modern labors. It’s getting louder that something fundamental has to change. Our own former surgeon general himself, Vivek Murthy, called for happiness to be part of how we consider health. So, how do we measure happiness? How do we teach clinicians to be agents of meaning? Anatomy and physiology, as we currently understand them, don’t get us there. When considering meaning, mortality, contentment, peace, etc, we are beyond the mercies of medicine. And yet health is dramatically affected by these forces, as much as it is by gravity and atmosphere and electricity. What is more, medicine is asked to prescribe a therapeutic. What are we doctors to do? What is fair for us public to expect?

In clinic, I had the great pleasure of seeing a man and his wife with some frequency. He had leukemia, and she was his companion through it all. John did not suffer from symptoms except for minor fatigue and, in fact, had so much in stride. Pamela suffered more. She left the buoys of normalcy and her work as an artist and interior designer to accompany him through multiple series of treatments and to get ready for the creeping inevitability of his death. Already living well beyond the hematologist’s prognosis, John’s illness was not considered curable, and he’d exhausted all treatments but one. He kept doing well, and that was a bit of a problem. John was at peace, but poor Pamela had to prepare for his imminent death (“imminent” had been going on for two years at that point), soak up their precious life left together, and prepare for her life beyond, all in real time. She had to grieve while celebrating, and all the while she was cut off from the things that made up the rhythm of the life she’d built, namely her work and her art. This exhausting dance with the clock — and making meaning with it ticking away, with the end in and out and back in sight — is what we call existential distress. It’s the most vexing “symptom” we deal with in palliative care. And to add another layer of complexity, since she was not the one who was ill, hers was an existential distress by proxy.

The arrival of palliative care to the forefront of medicine and, increasingly, the healthcare system, heralds the arrival of subjectivity into our official notion of health. The squishy but undeniably poignant goals of quality of life and well-being at last have real purchase. But what is that stuff? The most frequently used validated metric for quality of life in healthcare is the McGill Quality of Life Index, which breaks it down into several domains including existential and spiritual. But this is very young research and there ain’t much of it — because these issues haven’t heretofore made the cut of science-driven, disease-centric medicine, and therefore practically no funding exists. But with these issues on the table now, clinicians get to — need to — deliver the relevancy of the humanities out of the closet and into the evolving liturgy of medicine. What is more, in this dawn of patient/human-centered care, the people actually doing the work of being ill get to weigh in. The lived experience has a shot at joining the laboratory for health research. This pivot away from focus on disease to focus on persons — the very human condition — represents the creative cross-disciplinary opportunity of the century.

There is the body (including mind, relationships, and everything a body is and does) and there is time. Together they comprise the bulk of the subject matter of palliative care. You could say space and time, but the body is more specific and very much a space-occupying thing. The tricky and consequential fact is that a body is limited in time, and the human being in the body has the peculiar talent of knowing this fact, even when time seems in abundance. Every body dies, what can be an obnoxiously abstract fact until it isn’t. Between now and then, our choice seems to be to waste time pondering an uncertainly certain future state, or dumbly spend the stuff like it’s growing on trees. Can we be both aware and free? Meditation offers a technique to do so. But there’s a more fun way — and perhaps it’s the same way. And that is by way of the senses — the domain of aesthetics. There has long been an aesthetic component to medical care. The most renowned healing center in antiquity, for example, was the Sanctuary of Asklepios at Epidaurus — a vast complex in the Greek countryside comprising temples, shrines, statuary, baths, fountains, and one of the largest theaters in the classical world. In the early 1800s, Massachusetts General Hospital was designed in the Classical Revival style by Charles Bulfinch, who described it as: “spacious, ornamental to the town, and gratifying to the sight and feelings”. And, in the mid-nineteenth century, Florence Nightingale discussed numerous aesthetic aspects of healthcare in her famous book, Notes on Nursing, including the effects of music, laughter, artwork, flowers, nature, and other sensory experiences, on patients in her care. “People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by color, and light, we do know this, that they have an actual physical effect.” Nightingale was writing at a time before modern medicine, when patients were often as likely to be harmed by intervention as helped. At its best, medical care was simply that: the care of sick individuals, rather than the effective treatment of specific illnesses. With little or no understanding of the etiology of disease, pre-scientific medicine could be described as largely palliative in its response to patients’ symptoms, rather than to the pathology underlying their conditions. Medical intervention today is more effective in treating disease, but it has also been criticized for being “sterile” and dehumanizing — suggesting that therapeutic advances may have come at the expense of genuine caring for people who are suffering. In many ways, it is possible to see the field recently designated as the medical sub-specialty of Hospice & Palliative Medicine as a return to an earlier period of medical history due to its focus on care irrespective of any prospect of cure.

Note — to be encompassing of all allied health professions and inviting of relevant disciplines typically outside of healthcare, and to get at the style versus industry of care, instead of palliative medicine we’ll use the phrase palliative care.

The examples of Epidaurus and Massachusetts General and St. Christopher’s demonstrate that the intersection of medicine and aesthetics is not new, but, as Nightingale suggests, it is one that remains limited to vague associations with art and beauty, rather than being well understood. As a result, we would argue that aesthetic experience has been undervalued and underplayed, and, therefore, unable to achieve its full potential in the provision of care to patients. In this essay, concepts drawn from the histories of philosophy and medicine will provide a context in which to introduce a subject we call palliative aesthetics — defined provisionally as an investigation of the palliative potential of the aesthetic dimension.

I. AESTHETICS

Like many philosophical terms, “aesthetics” has roots in Ancient Greek. There was, however, no Ancient Greek word for “aesthetics”. Instead, it was invented in the 18th century in Germany, where it first appeared in the dissertation of a philosophy student named Alexander Gottlieb Baumgarten. Although he was writing about poetry, Baumgarten’s original conception of aesthetics differs significantly from the general understanding of the term today. Now practically synonymous with prettiness or attractiveness — notions notably absent from Baumgarten’s text — “aesthetics” started out much closer in meaning to its less-restrictive Greek root, aisthētikós — perceptive, from the verb: to perceive or apprehend by the senses… to feel… to see… to hear. In the final paragraphs of his dissertation, Baumgarten lays out an argument for expanding the traditional scope of philosophy beyond the limits of pure thought to include aísthēta — things perceived. In Baumgarten’s vision of philosophical inquiry, aesthetics provides a “perceptive” counterpoint to the rigid rationality of logic. The novelty of his proposal lies in the suggestion that philosophers concern themselves not solely with thought and reasoning, but give serious consideration to our capacity for feeling and perception as well. This simple yet bold proposition both gave a name to, and prepared the way for issues such as style, taste, beauty, art, and even the sublime, which would come to dominate the nascent field of philosophical aesthetics. Framing these modes of experience — thinking and feeling — helps us see new avenues for development towards the overall experience of being human and perceiving life.

II. KANTIAN AESTHETICS (A CRASH COURSE)

Two tools of their trade make dentists notoriously unpopular: needles and drills. Before they can get to work with the latter, we get stuck with the former. The purpose of this injection is to block the pain of the ensuing procedure; hence, it is called an “anesthetic” — literally: “without feeling”. The effects of anesthesia range from numbing a particular part of the body, to putting the patient to sleep completely; while its antonym — the aesthetic — has the potential to do just the opposite, that is: to wake us up. This “quickening” effect was described at the end of the 18th century by the philosopher Immanuel Kant in the Critique of Judgment — which remains one of the major texts in aesthetics today. A word on beauty: These days, we tend to assume beauty in the narrow sense, as in straight white teeth, or a particular body habitus found on magazine covers. Pretty. Light. Restrictive, and, most importantly, externally derived, objective. But, as Baumgarten set us up from the start, beauty is not so narrowly defined. From our point of view, beauty is a quality of wholeness. Hegel tells us that beauty is the “truth in sensuous form.” Something right in itself. In this way, beauty is synonymous with aesthetic, broadly defined. There is a nascent scientific field of study called, neuroaesthetics. This discipline seeks to understand how the brain experiences perception. One early finding is that there is no special area of the brain devoted to attractiveness. In fact, there is a singular anatomical zone that covers the gamut of types of perception, from repulsion to attraction. It is not as though some elite or lucky group of people have taste per se — aptitude for seeing “real” beauty — and others do not. Snobbery has been debunked. More importantly, taking in the material world has opened beyond something superficial or skin-deep. In this vein, Kant opens the Critique unexpectedly with the statement that it is impossible to know if something is beautiful simply by looking at it. Instead, he says, if we wish to investigate beauty, (in a philosophical sense), we must begin by looking within ourselves. It is in an object’s effect on the subject — our enjoyment of perceiving it — that the aesthetic domain is revealed. This revelation occurs, Kant says, in the “feeling of pleasure. And so, yes, beauty is in the eye of the beholder. It is an inborn birth right of being human, not an esoteric or bourgeois perk. This self-containment aspect has great and therapeutic significance, including playfulness. Kant explains that our pleasure in appreciating a mountain view, for example, arises from “the free play of our cognitive powers” — “free” because mountain-viewing is not governed by rules (nor associated with any particular thought at all, and therefore no frontal lobes required), and also because it is liberated from “the faculty of desire”. To desire something is to see in it some advantage for ourselves in possessing it, but when we enjoy looking at a mountain, we seek no such personal gain (apart from the opportunity to admire it for what it is in itself), while a logger or miner looking at the same mountain is likely to see it from the point-of-view of his interest in extracting its resources.

In contrast, Kant says our “taste for the beautiful is a disinterested and free of satisfaction”. Think: art for art’s sake, or being for its own sake. The pleasure we take in it “has a causality in itself” so that we want to remain in it “without a further aim.” Especially when wracked with pain and other obnoxious sensations, or when time is short, imagine the premium on such felt, fast freedom. Aesthetic as anxiolytic. Kant used the phrase, “purposiveness without purpose” to describe this useless but meaningful aesthetic state. It is very common for patients who are dealing with significant illness to feel cut off from their purpose, itself a strong life force. Their role in work or home life disrupted, their sense of self and connectivity to the world is threatened. Enter feeling a burden. In a 2011 study in California, this was the number one concern of people facing death. There is much to say about “feeling like a burden”, including a condemnation of our society’s disproportionate — and ultimately unrealistic — love affair with productivity. For our purposes here, suffice it to say that the aesthetic dimension offers a sweet counterpoint to our drive for purpose by way of output. Our “consideration of the beautiful” is something Kant says ‘[w]e linger over”, representing a moment of respite in the course of our daily lives — lives in which practically everything we do is done for the sake of something else, where every action we perform or person we interact with is a means to some other end. As an end in itself, our experience of the aesthetic halts that ceaseless striving — if only momentarily — in a perception that is complete in itself and free from desire. A meditation. In these moments, Kant says our “taste for the beautiful … preserves the mind in calm contemplation”. Yet, the effect of this contemplation is far from sedating. The word Kant uses to describe it is beleben: “quickened”, “animated”, “enlivened” — from leben: “to live”, “to be alive”.

III. “EVERYDAY” AESTHETICS

One of Kant’s goals in the Critique of Judgment was to isolate the aesthetic domain from all other modes of human experience. To him, the aesthetic — as something we attend to “disinterestedly” — is something necessarily set apart. For the American philosopher, John Dewey, however, just the opposite was the case. He takes the reader by surprise at the beginning of Art as Experience when he says it is one of life’s “ironic perversities” that the very works of art one might expect to be the proper subject of aesthetics, actually get in the way of understanding aesthetics properly. Similarly to the way Kant says we cannot know if something is beautiful simply by looking at it, Dewey believes that when we look at a work of art, it is not actually a work of art that we see. As the title of his book suggests, art, for Dewey, is not a particular object, but an experience, and, as experience, it is not limited to what we normally think of as “works of art”. Dewey criticizes Kant for walling off the aesthetic from the rest of life. Philosophy’s traditional approach to art, Dewey argues, leads aesthetics to an “ivory tower of ‘Beauty’ remote from all desire, action, and stir of emotion.” This segregation of the aesthetic “deeply affects the practice of living,” he says, “driving away esthetic perceptions that are necessary ingredients of happiness”. This would place aesthetics at the base of Maslow’s pyramid, upending the rarity and unessentialness typically reserved for art. We hope that anyone interested in cultivating an accessible and inclusive quality-of-life leap to Dewey. One needn’t care for art — a subset of aesthetics — but we all have aesthetic needs. Dewey is unusual in seeing the purpose of philosophical aesthetics not so much as defining agreeableness or providing a theory of art for intellects, but quite the opposite: in reconciling the aesthetic with everyday life. In his words: “recovering the continuity of esthetic experience with [the] normal processes of living.” As a result, almost anything, on Dewey’s terms, can be aesthetic — anything by which we are “carried forward, not merely … by a restless desire to arrive at the final solution, but by the pleasurable activity of the journey itself”. Ahhh, this is an effect we in palliative care long to foster but have lacked a framework for doing so. (On this note we will circle back to Pamela and John in a moment.) Unsurprisingly, Dewey draws examples from everyday life, rather than literature, museums, or the concert hall. He discusses the aesthetic value of popular music and films, gardening, sports, and even comic strips — anything, he says, “that intensifies the sense of immediate living”. Dewey describes this feeling as a “heightened vitality”, and says: “Only when the past ceases to trouble [us] and anticipations of the future are not perturbing is a being wholly united with his environment and therefore fully alive.” Dewey helps us get thought out of the way — not in an anti-intellectual way, but in service to direct experience. Many readers will know this prized effect as being in the moment. Presence. And those of us dealing with insidious senility or cognitive dysfunction might hear this as a miraculous inversion of an otherwise terrifyingly unsupported reality.

IV. DEFINING “DEATH”

We hope that readers already know that palliative care is not merely about dying, but instead about living well irrespective of time left. By way of the existential domain — a subset officially acknowledged by the field as one of the ways in which humans suffer — death continues to be a supremely organizing force, and its inevitability can teach of us a great deal about how to live while we can. Death also welcomes inductive reasoning into the development of quality-of-life (and of the field of palliative care). And finally, death gives us the constructs of time and preciousness and meaning — all the stuff of the existential domain. So what is death anyway? Surprisingly, perhaps, we still need to agree on a definition of this too. The medically and legally accepted determination of death in the U.S. states that an individual has died if and when he [or she] has sustained “irreversible cessation of circulatory and respiratory functions, or… all functions of the entire brain”. The Uniform Law Commission, a presidentially-appointed body meant to advise states on legal issues of universal concern, which proposed this wording, was quick to point out, however, that they were not attempting to provide a definition of death, but, rather, a “medical determination of biological death” — a significant distinction. When describing the experience of dying, modern hospice pioneer, Dame Cicely Saunders turned to poetry. In a paper on caring for patients with terminal cancer, she quotes a line from the Bengali poet, Rabindranath Tagore: “…life will take its leave in silence, drawing the last curtain over my eyes.” Tagore speaks of dying in terms of life rather than death, saying it departs silently in darkness, the senses spent. In fact, the poem begins with the loss of vision as a metaphor for death: “I know that the day will come when my sight of this earth shall be lost…” When Tagore writes about dying, like most patients, he is clearly not thinking of neurons and synapses or cardiopulmonary functioning (i.e. “biological death”). It is also clear that medicine (and the law) consider the body from the outside, quantifying data derived from its vital functions. To them, death occurs when these inputs drop to zero and the flow of data ceases. To Tagore, dying is also about inputs, but in reverse — the “inputs” we take into ourselves through experience, rather than the output of data into machines. His words above are not merely metaphor. In his terms, life departs with the senses — in silence and darkness — a loss he describes later in the same poem as the “end of my moments”. A moment, significantly, is not a specific unit of time, and therefore cannot be measured; it can only be experienced as moving forward (from the Latin momentum — movement). Objectively medically speaking, the moment of death is said to occur when our brains stop functioning and hearts cease to beat; but these are merely the external observations of a technician. Of much greater significance is the question: What does the failure of these organs mean to me? Answer: Only that, in death, my experiencing — my sense of being alive and myself — comes to an end. If we conceive of dying in this way — as the fading out of senses (“drawing the curtain over my eyes”) — then anything that enhances my sense of being alive while I still am, in this moment, has the potential to take on heightened significance. The premium on experience only goes up

V. NATURE AESTHETICS

Kant’s aesthetics is often thought of primarily as a philosophy of art, but, in the Critique of Judgment, he writes evocatively of the profound effects of our experience of nature — which, he says, “has spread beauty so extravagantly everywhere”. Someone who turns from the beauties of art to the beautiful in nature, he says, will “find here an ecstasy for his spirit … [and] we would consider this choice of his with esteem and presuppose in him a beautiful soul”. Philosophers, poets, musicians, and, more recently, environmental psychologists have told us that nature has the power to restore us: it allows us to “recharge”, and gives us a feeling of “new life”. Epidaurus is set in the midst of nature; Beethoven composed a “Pastorale” symphony that begins with an “awakening of cheerful feelings upon arriving in the countryside”, and the philosopher Jean-Jacques Rousseau wrote a book recounting the “reveries” he experienced walking in nature. Nature, according to Rousseau, provides a place “where the soul can … gather together its whole being, without needing to recall the past or encroach upon the future, where time is nothing to it, where the past lasts forever … with no other feeling of deprivation or enjoyment, pleasure or pain, desire or fear than simply that of our existence, a feeling that completely fills our soul; as long as this state lasts, the person who is in it can call himself happy … with a sufficient, perfect, and full happiness, which leaves in the soul no void needing to be filled. Such is the state I often found myself in on the Île de St-Pierre in my solitary reveries, whether I was lying in my boat as it drifted wherever the water took it, or sitting on the banks of the choppy lake, or elsewhere beside a beautiful river or stream gurgling over the stones. What does one enjoy in such a situation? Nothing external to the self, nothing but oneself and one’s own existence: as long as this state lasts, one is self sufficient… The feeling of existence stripped of all other affections is in itself a precious feeling of contentment and peace…” It is this “precious feeling” that we seek to awaken when, like Rousseau, we take a walk in a local park or a trip to the Grand Canyon. Psychologists argue that, more than simply providing a momentary diversion, “the natural environment plays an important role in human well-being.” Studies suggest that experiencing nature can help us to be more mindful — which is of particular interest in the context of palliative care because it “may facilitate well-being directly, by adding clarity and vividness to current experience and encouraging closer, moment-to-moment sensory contact with life”. Other research suggests that “nature connectedness” has positive effects on cognitive functioning, stress, anxiety, pain, and can even make us feel “more alive”

We know much about treating symptoms such as pain, nausea, breathlessness, anxiety, etc., but we know very little about how to treat crises of identity or meaning or the reckoning of time. Indeed it’s likely that many presentations of the former cluster are likely proxies or somatizations of the latter. Most medical remedies commonly used to treat symptoms are pharmacological, and most of these work by dulling. For existential distress these treatments may be exactly wrong. The real salve is fostering connection to the cosmos and rewarding the senses rather than muting them. A quick note on John and Pamela. Pamela loved beauty, in the big sense. One day in clinic, we hit on the idea of Pamela taking a moment every day to simply note whenever she happened on beauty. Some days it was a view, or old layers of plaster peeling off a wall, or a gorgeously hewn doorknob in her palm, or the sight of her grandchildren playing with John. This allowed Pamela a toe hold for delighting in her present life, with all of its complexities; a direct and uncomplicated sense of feeling well and being glad to be in the world, irrespective of all that she would otherwise wish to change but cannot. Aesthetic experiences helped her to be present — with or without purpose — and that can be a very difficult and high state to achieve. Meanwhile John is only happier for knowing his wife still knows how to feel well. And because she can experience beauty, she is beautiful. The prescription was for an aesthetic experience once daily as needed for existential distress. If we are serious about concepts such as quality of life, existential distress, wellness, whole-person care, human-centered care, and so on, then we need to reexamine our therapeutics. The wondrous news is that answers may be right under our noses — the simple sources of joy and engagement we all delight in but have yet to take seriously as medically relevant. The aesthetic is readily accessible, highly subjective (i.e. solely on the patient’s terms), and purely additive. It is the opposite of threatening. Living — including its endgame — after all is a sensuous experience. Isn’t it?

This article was originally published on findsatori.com