A psicoética da sindemia: o pático e o patológico

Acta Bioethica 2020; 26 (2): 147-153. DOI: http://dx.doi.org/10.4067/S1726-569X2020000200147 THE PSYCHOETHICS OF SYNDEMIC: THE PATHIC AND THE PATHOLOGICAL Fernando Lolas Stepke1 Abstract: After discussing the scope and implications of the expression “mental health” at both the individual and social levels, this paper emphasizes that suffering (a pathic condition) is not always pathological in medical terms, and should be taken into consideration when evaluating the responses to the syndemic (the synergistic outcome of many alterations of the social milieu) caused by Covid19. Against the background of the historical-anthropological dimensions of experience and expectation of societies, the dialogical underpinning of bioethical thinking is rephrased as a psychoethics that incorporates an evaluation of the responses affecting the public, the communicators, and authorities. This reinforces the need for an empirical situationism in moral deliberation and the demand for empirical axiology in which judgments are made after continuous contrasting values, principles, and norms with the actual behavior of people. Keywords: mental health, syndemic, psychoethics, covid-19 La psicoética de lo sindémico: lo pático y la patológico Resumen: Tras discutir el alvance y las implicaciones de la expresión “salud mental” tanto a nivel individual como social, este artículo destaca que el sufrimiento (como condición pática) no siempre es patológico en sentido médico y debería ser considerado al evaluar las respuestas a la sindemia (resultado sinérgico de muchas alteraciones en el medio social) causada por covid-19. Teniendo como trasfondo las dimensiones de experiencia y expectativa de las sociedades, el substrato dialógico del pensamiento bioético es refraseado como una psicoética que incorpora una evaluación de las respuestas que manifiesta el público, los comunicadores y las autoridades. Se refuerza la necesidad de un situacionismo empírico en la deliberación moral y la demanda de una axiología empírica en la cual los juicios se hagan después de contrastar continuamente valores, principios y normas con la conducta real de las personas. Palabras clave: salud mental, sindemia, psicoética, covid-19 A psicoética da sindemia: o pático e o patológico Resumo: Depois de discutir o âmbito e as implicações da expressão “saúde mental” tanto a níveis individual e social, esse artigo enfatiza que o sofrimento (uma condição pática) nem sempre é patológico em termos médicos e deve ser levado em consideração quando se avalia as respostas ao sindêmico (o desfecho sinérgico de muitas alterações do ambiente social) causado pela Covid19. Contra o pano de fundo das dimensões histórico-antropológicas da experiência e expectativa das sociedades, a sustentação dialógica do pensamento bioético é refraseado como uma psicoética que incorpora uma avaliação das respostas que afetam o público, os comunicadores e as autoridades. Isto reforça a necessidade de um situacionismo empírico na deliberação moral e a demanda para uma axiologia empírica na qual julgamentos são feitos depois de contrastar continuamente valores, princípios e normas com o comportamento real de pessoas. Palavras chave: saúde mental, sindêmico, psicoético, covid-19 1 Centro Interdisciplinario de Estudios en Bioética, Universidad de Chile. Universidad Central de Chile, Chile. ORCID: https://orcid. org/0000-0002-9684-2725 Correspondencia: flolas@uchile.cl 147 The psychoethics of syndemic: the pathic and the pathological - Fernando Lolas Stepke No health without mental health. Individuum and group Talking about mental health suggests that there can be many forms of health. Somatic symptoms or laboratory tests are, admittedly, insufficient for evaluating mental conditions. With its value undertones health is, as philosopher Gadamer(1) indicates, an enigma. It is a mysterious and ineffable feeling of completeness and inner disposition to cope with the difficulties of life. Health is “organic silence”. The body is acutely perceived when impairment, pain, or disability are manifest. Sometimes, mental conditions are not perceived as disease or sickness and self-perception does not help in defining or characterizing diseasestates. Galderisi et al.(2) propose a definition of “mental health” away from the eudemonistic position that only positive feelings count and objecting that wellbeing and happiness are essential for good mental health. This moral emphasis stems from one particular tradition- Western thinkingand does not consider variants in diverse cultural contexts. The definition proposed states: “mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society. Basic cognitive and social skills, ability to recognize, express and modulate one´s own emotions, as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium”(1:232). This definition explicitly recognizes that a healthy life is not life without difficulties but life with the ability to cope with them. Analogies can be established between the individual level and the group or community. The idea of a “sick society” merits consideration. Peace and harmony -essentially, silence- may be taken as indicators of wellness. Community health, however, is not the sum of individual states. It belongs to another conceptualization, as the pioneers of sociology indicated. 148 To qualify as an epidemic. the impact of adverse conditions on a population must be wide and unexpected in scope. Pandemic is the term reserved for cases covering many countries and regions. The term syndemic suggests a global, compound disorder with many synergistic elements, including viral or bacterial diseases, social disruption, economic and mental components which should be considered when setting priorities for concerted action(3). No single cause can be isolated. The notion of cause must be replaced by function(4). The result is a function of many factors, some of them unknown to the observers or not acknowledged by the official discourse. “Mental” is a way of talking, a particular language game, or narrative, that isolates certain experiences or situations. Mental wellbeing is, heuristically speaking, a device for better expression and control, not a substance or independent reality. The trend toward a reification of nosological entities derives from the medicalization of suffering and the classification of “diseases” justifying medical action. There is no health without mental health. Health is an integrated whole. It can be said that the expression “mental health” is a pleonasm, a rhetorical figure for emphasizing experience and expression (mentation and behavior). Levels of analysis Individual health is a personal construction. The ability to carry out intended tasks, satisfaction with life, access to goods and activities, number and quality of personal relations, among other factors, determine the perceived quality of individual life. This perception varies greatly due to fatigue, difficulties, environmental conditions. It is not stable; it shows variations without altering the perception that different states refer to the same individual identity. Ther are oscillations without losing continuity. Wellness and well-being are descriptive terms subject to changes. Social or community health is not simply the aggregate perception of individuals. It is based on a general level of satisfaction not properly represented by any member of the group. It is neither an average of measured conditions nor a statement shared by all persons. Public health, as the effort of organized communities and scientific discourse, Acta Bioethica 2020; 26 (2): 147-153. DOI: http://dx.doi.org/10.4067/S1726-569X2020000200147 depends on concerted action by the State and the market. Number of beds, mortality and morbidity rates, number of subjects vaccinated, incidence and prevalence of diseases, all these are indicators of how well public health institutions perform. However, results are not outcomes. All healthcare systems, irrespective of the political environment, enter periodic crises because demands increase by wish and need. Dissatisfaction with the performance of the systems is always present. In this sense, results are not outcomes; these include the final reception and evaluation by the stakeholders. While the personal effort may be relevant at the individual level, the conditions within a group depend on power exerted by some members over others, i.e. the authority of the State or the success of the private enterprise. Individual perception of wellness depends on the position of the person on the scale or ladder of decisional power. Those who control will feel that conditions are adequate while those dependent on others will feel that their capacity to control, make decisions and set priorities are limited and will consider that societal health is bad. These ideas are important for assessing mental health. It is essential to recognize that the very definition of a “group” is complex. Geographical, linguistic, and ethnic criteria are not always relevant; there are groups formed by affinities not dependent upon any of these factors, i.e., political ideology, migrant status, income, or other. It is doubtful that categories employed for assessing individual health are pertinent or essential for estimating social health. The orientation of classical thinking in medicine is geared towards evaluating macro dimensions using micro estimations. For analyzing the effects of disruptions due to a pandemic, and for ethical analysis, these serve as points of entry but need to be complemented by other considerations, including political policymaking and decisionmaking. Psycho-cultural value theories Data and insights from anthropological research must be used in bioethical discussions. The “Georgetown mantra” of principles (autonomy, beneficence, non-maleficence, justice) and their relative importance depends on the societal structure and its basic value orientations usually subsumed under the vague term “cultural difference”. General orientations of society, albeit unconscious, are critical for the very definition of terms such as autonomy and justice. Many misunderstandings arise when trying to “map” values from one cultural setting onto another. Societies can be characterized by features such as collectivism versus individualism, or materialist versus post (or non)materialist preferences. The decisional style accepted in a community may not be accepted in another. Simple moralizing of illuminated prophets is not helpful for decisionmaking unless interpreted in the context of the “cultural environment” and its symbolic texture. An analysis of “core values” is essential for an adequate appraisal of causes and effects of mental health disruption at the individual and group levels. Values may be defined as conscious goals concerning three universal requirements with which individuals and societies must cope: a) biological needs; b) coordinated (harmonic) social interactions; c) smooth functioning and permanence of institutions(5). Values are embedded in language games and represent “universals” of meaning that give sense and desirability to actions. The term justice, applied to a situation or action, provides an understanding of rational and reasonable outcomes satisfying the emotional concreteness required by participants in the social discourse. Ideals cannot be confused with the practical use of the principle justice, mediating between values and customs; it has an instrumental character. There are “levels of use” of terms, particularly those that are value-laden. At the first level, words are used in their commonsense denotations and connotations and not subject to profound analysis. Their effectiveness resides in the emotional undertones; problems associated with terms such as dignity, justice, right, indicate that the user is guided by aesthetic or emotional resonance rather than by cognitive or practical implications(6). The conflict between universal and local conceptions of value is solved differently in different settings. The distinction between “etic” (universal) 149 The psychoethics of syndemic: the pathic and the pathological - Fernando Lolas Stepke and “emic” (local) in anthropological studies must be bridged by adequate concepts of culture. It depends on how differences are approached, either by Verstehen (comprehension) or by Einfühlen (empathy), that is, hermeneutics based on the rational use of prejudices or emotional understanding. This resembles the distinction between nomothetic and idiographic approaches in science. Casuistry and situationism prevail when considering the specifics, principlism is oriented towards universalization. Psychological and social wellbeing is rooted in the fabric of a culture. Part of the state of wellbeing is not available for discursive elaboration. Everybody knows when life is good but few can conceptualize the reasons for the assessment. Besides, people tend to detect difficulties easier than wellbeing. As we noted, silence is the cornerstone of wellbeing. Pathic versus pathological. The constitution of well-being Suffering is inherent to the human condition(7). In every culture, there exists a quantum of difficulties that a normal person should endure. The symbolic universe of culture imposes norms and evaluates the responses to them according to socially established criteria for “appropriateness” or “normality”. Any disruption in the social sphere causes uneasiness, worries, anxiety, and fears. These different forms of suffering are “pathic” conditions. In a purely medical outlook, these turn into “pathological” states. However, impairments, disabilities, and handicaps are pathological only when the disruptions they produce are conceptualized by medical experts. Sometimes, the expert opinion does not adequately reflect the beliefs and expectations of persons and populations. Every culture is a web of meanings and expectations. The disruption is ever-present. What is pathological in a pathic condition is not the cause of dis-ease. It is the response supported by knowledge and compassion. The syndemic disruption manifests itself in all aspects of life. It changes personal relations, affects economic stability, disrupts political order, pro- 150 duces chaotic reactions, and resistance to expert measures. One of the problems associated with the emergency is that people´s suffering has many causes, including the threat of contagion, the imposed lockdown, the economic disruption, and political unrest. To prioritize which aspect should be dealt with in the first place is a moral dilemma. It involves consideration of values, norms, and principles. Each society or groups within a society place different emphasis on the importance of these factors and demand attention to issues such as structural inequalities, inequities, racism, poverty, hunger, access to medical care. This global crisis results in the synergistic effects of a constellation of causes and circumstances that can be described with the term “syndemics”(8). Experience and expectation It is helpful to use the anthropological and metahistorical notions of Erfahrungsraum (field of experience) and Erawartungshorizont (horizon of expectation), proposed by Reinhart Koselleck for the analysis of historical developments in societies(9). At any point in time, assessment of social or individual conditions depend on the experiential space, meaning actual possibilities for meaningful action, and the horizon of expectations. Both aspects are closely related, except in times of disruption, when they dissociate. The future appears not predictable. Even if it looks positive, the lack of control that ensues makes it a source of stress. Change generates stress, for it involves unpredictability and lack of control. From a historical point of view, Koselleck contends that the time between 1750 and 1850, termed Sattelzeit, definitely changed European Weltanschauung (cosmovision), mostly due to the idea of progress. This dissociated experience from expectation. The future holds from then on another character, a new time (Neuzeit) conceptually different from before. Although much can be discussed in this idea, it is interesting to note that seminal works of the European mind appeared in that period. Most importantly, technologies and sciences were modified in a way that promised permanent perfection. For medicine, the end of the XVIIIth and the beginning of the XIXth century meant the change from Acta Bioethica 2020; 26 (2): 147-153. DOI: http://dx.doi.org/10.4067/S1726-569X2020000200147 a relatively ineffective praxis to the hope that the mysteries of the body and the human soul could be solved. That change was a lasting one, signaled by the idea of progress, technification of medicine, and medicalization of society. It is difficult to imagine the previous state of affairs when medicine and the medical profession could not claim success in the way contemporary “medical science” does. Between experience and expresión there can be a gap and public health is a matter of public trust on the reasonableness of the measures taken by authorities, and this in turn on how these measures are willingly accepted. The principle of vertical solidarity is an outgrowth of accepted leadership and governance. These two polar frames of mind allude to inner dispositions assumed to exist both at the individual and the group level. Experienced Erfahrungsraum may be biased if a person or a society is not well aware of the true possibilities according to a reality principle. That perception of the real world may change or modify the sense of accomplishment or self-assertion needed for initiating action and for selecting courses of action. The historical record shows that people behave in remarkably similar ways to health threats of a pandemic nature. Descriptions of pandemics in the past resemble what happens in the 21st century(10). During the Black Death of 1348-1349, populations reacted with fear, inclinations to enjoy life, discrimination against sick persons, and social unrest. The dominant intellectual resource was the Catholic Church, whose authority was damaged by the inability of the clergy to stop the pestilence or to protect people, given its alleged communication with God. Etiological considerations at the time were different from what is current to-day but despair, anxiety, fear, and resignation were the same(11). It may be true that there does not exist a permanent human nature and what we read in the reports from witnesses of those days can only analogically be compared with what happens today. But the reactions and emotions evoked by the written accounts may be assimilated to current descriptions of anxiety and depression. The behavioral dimension Irrespective of individual feelings or emotions, in times of crisis or turmoil, what counts at the societal level is the behavior of persons. Citizens may or may not agree with measures taken during a pandemic, but their behavior will determine the outcome. For instance, lockdown and quarantine are dispositions taken by health authorities to limit contagion and reduce social interactions. They may be accepted willingly or may b objected because these measures limit the liberties of persons. Sometimes, necessity or individual choice push persons to violate restrictions, stressing the syndemic character of the situation, that is, that the health hazard or risk is less important for some than other urgent activities. Compliance does not prevent frustration and anger. The ethical analysis of responses must consider the behavioral dimension since moral justification, although based on intentions, convictions, and emotions is reflected in actions and choices. As evidence from different societies shows, it is difficult to obtain adherence to restrictions for different reasons. Dangers and threats may appear remote or abstract. The need to establish contact with friends or relatives may prevail. A response to anxiety may be to enjoy life and ignore or deny consequences. Justification may vary but the point is that inner dispositions cannot be ascertained. The psycho-ethical response Different forms and expressions of anxiety Fear from contagion and anxiety from uncertainty is the most frequently encountered reactions to the current situation all over the world. Reliance on scientific facts is hampered by miscommunication, false information, conspiracy theories, and ignorance. Ignorance is present also in scientific circles, confronted with the new viral infection. When ignorance is universal, it cannot be deemed guilty. However, the search for culprits in catastrophic situations seems to be a permanent feature of societies. Authorities, spiritual leaders, some groups within society, deities, or fate can be targets for aggression triggered by helplessness and hopelessness. In turn, when these sources of discomfort either do not respond or are unavailable, a state of despair ensues, resignation appears, and -given the 151 The psychoethics of syndemic: the pathic and the pathological - Fernando Lolas Stepke presence of other symptoms and complaints- give rise to characteristic states of depression. People react to distress in many different forms. Responses vary according to culture, social support, personality features, and intensity of stressors. There appears sometimes denial, which serves a protective function. The sense of invulnerability that pervades the public discourse has in denial a Good expresión. When arising from a public authority it may be excused as the attempt to avoid panic and provide tranquility. When the stressor lasts more than expected, however, denial is not the best coping mechanism and may be replaced by represión or alternative behaviors that may seem irrelevant or useless, depending upon the aims and consequences of actions. The social unrest that characterizes many societies finds its roots in conditions previous to the pandemic outbreak. All societies show some degree of perceived or real inequality, which is structural, and the reactions to discontent rang from not obeying indications to attacking authorities or political systems. It is characteristic of current situations that in many countries the forces of order are criticized when trying to impose or implement regulations. Dialogues tend to be tense, misunderstandings arise, and irrelevant concerns replace meaningful actions. People tend to believe that minor changes in legislation, replacement of persons in office, or allocation of resources may lessen the real anxieties being experienced. The aggressive mechanism may or may not be adaptative. Traditionally, those in power tend to distract attention maintaining the status quo and justify violence based on this rationale. Those who have less power, or strive at attaining power, justify violence on the principle of justice or compensation. The result is polarization within societies, explained at the sociological level but neglecting the individual states of anxiety that result in aggressive thoughts and behaviors. Other responses to anxiety and personal suffering are also observable. A feeling of closeness and proximity may ensue, with altruistic behaviors and desire to help others. This is expected from 152 those people engaged in activities that presuppose compassion and vocation to help, heavily demanded in times of stress. Examples of volunteers who engage in empathic behaviors or who enlist themselves in activities of social relevance appear and are widely informed. These different responses, aggression, despair, depression, philanthropy, are framed in different contextualizations. Unavoidably, description, and analysis are mixed with moral considerations and quick approval or rejection. The rational and reasonable decisionmaking is replaced by the use of labels belonging to the moral discourse. The psychoethics of syndemic crises Discussions on the causes and effects of a crisis may center on a normative or a descriptive position. We witness the appearance of “experts” who make recommendations, provide unwanted advice, or propagate fake news. As indicated(12), between a pure deontological and a pure teleological position regarding values and ethics, we need to anchor deliberation on a careful appraisal of concrete conditions of living, in the right context, and for the appropriate people. This amounts to advocating a reformulation of ethical discourses according to contexts without denying that certain universal principles can – or could- be discerned in almost all societies. This empirical situationism is all the more necessary in cases where situations change and the dynamics of threats are difficult to predict. The situation all over the world shows that people do not react as experts indicate or anticípate. This is a clear indication that moral judgments cannot be easily passed and needs a constant revisión and confirmation with empirical fact. A “grounded theory” of the ethical dialogical environment is demanded. This amounts to considering not only the presumed rational abilities or emotional empathy of authorities and the public but also to an analysis of underlying pathic states expressed in communications, social manifestations, and technical discourse. When these pathic states are transformed into pathological conditions, the imperative is to resort to a dialogue between empirical medicine, moral conviction, and public outcome. Acta Bioethica 2020; 26 (2): 147-153. DOI: http://dx.doi.org/10.4067/S1726-569X2020000200147 References Gadamer HG. Über die Verborgenheit der Gesundheit. Frankfurt a.M.: Suhrkamp; 1993. Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. 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