Professional Documents
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Project Muse 195102
Project Muse 195102
C. Barry Hoffmaster
Vulnerability does not mean much for our contemporary morality. It is antithetical to our emphasis
on individualism and rationality; it requires that we attend to the body and to our feelings. Yet only by
recognizing the depth and breadth of our vulnerability can we affirm our humanity.
V
ulnerability is one of those general notions stance, could be devastated by the unceasing jeers
we bandy about confidently but carelessly, and taunts of brutal schoolmates. A third meaning of
assuming that we know what it means and “vulnerable” is to be capable of being persuaded or
that it means the same thing for everybody. Were we tempted. A young woman burdened by university
challenged to explain it, though, we might admit to debt might be enticed, for example, to reply to an
some unclarity and puzzlement. What does vulnera- advertisement that offers substantial remuneration
bility actually mean? for egg donation. And a fourth meaning is to be li-
A dictionary provides multiple definitions. One able to increased penalties, as any bridge player
meaning of “vulnerable” is to be susceptible to some- whose team has won a game in a rubber knows. The
thing, a bad something naturally, such as disease or real meaning of vulnerability is richer than these
infection. People living in a war-torn country where sketchy definitions, however. To understand it, we
the water and sewer systems have been destroyed are, must appreciate what it means to live with vulnera-
for example, vulnerable to contracting malaria. A bility. People who are old, particularly those who re-
second meaning of “vulnerable” is to be capable of side in nursing homes or other long-term care facili-
being physically or emotionally wounded. A child ties, are vulnerable in many ways. What does vulner-
born with a physical or mental handicap, for in- ability mean for them?
To try to answer that question, I have to describe
the vulnerability of two people I know. The first is
Barry Hoffmaster, “What Does Vulnerability Mean?” Hastings Cen- my eighty-five-year-old father. As this is written, my
ter Report 36, no. 2 (2006): 38-45. father most likely is sleeping in a bed in a nursing
38 H A S T I N G S C E N T E R R E P O R T March-April 2006
home. Forty years ago my father he is transferred to a recliner and rented hospital bed, and she knew she
stopped playing basketball with me wheeled into the hall, he spends all did not have the size and the strength
and a friend of mine, went inside our his time in bed, so he gets bed sores. to get him into a wheelchair or to
house, lay down on our living room One sore on his ankle refused to heal turn him in bed. After he entered
couch, and had a heart attack. Two and exposed bone, necessitating what became a series of nursing
days later my mother threw open the surgery and a subsequent skin graft. homes, she visited him at least once a
back door of our house, rushed in Despite this intervention, the wound day, helped him eat, shaved him,
crying, and told me that my father persists. cleaned his dental plate, and took his
had had a stroke in the hospital. I did My father can also be wounded laundry home to wash. She was vigi-
not know what that meant at the emotionally. After one hospital stay lant in detecting lapses in his care and
time; it turned out that he did not he was transferred to a different nurs- aggressive in reporting those failings
have just any stroke, but what is aptly ing home, and when I went to see to anybody who could do something
and ominously called a “catastrophic” him there, I found him in a lineup of about them. She understood, intellec-
stroke. His entire right side was para- wheelchairs across from a nurses’ sta- tually at least, that there were many
lyzed. From then on, he could not tion. Even from a distance, I could other patients in the nursing homes
use his right arm and hand, and he see that his azure eyes were blazing. who required care, and that there
could walk only with a cane and a When I approached and he recog- were routines and schedules that had
brace. His speech was impaired, and nized me, he began waving his left to be followed. Yet her advocacy on
he always struggled—most often un- arm and talking, spewing sounds full behalf of my father was unstinting
successfully—to find the word he of fury but devoid of sense. I had and unsparing. As a result, she had
wanted and to complete the sentence rarely seen him angry, and through- tumultuous relationships with the
he had started. out my entire life I had never seen staff and the administrators, and she
Now, forty years later, ravaged by him that angry. He did not want to was undoubtedly regarded as a “diffi-
the misfortunes of stroke and old age, be there, but he was helpless. At last, cult” spouse.
ignore it. Rather than focusing on the person for whom a task
my father epitomizes what it is to be probably out of desperation, he was My mother remains in amazingly
vulnerable. He contracts multiple in- raging against a fate that he had en- good physical health, lives in a house
fections and diseases. He has recur- dured with patience, determination, by herself, drives a car, goes shopping,
ring urinary tract infections, each of and equanimity for half his life. cooks and cleans, pays the bills, and
which renders him weaker and push- As the days pass, though, he seems gardens. Only recently has she started
es him to an ever-lower plateau. He less and less capable of being emo- to have problems with her short-term
has some form of dementia on top of tionally wounded. And he no longer memory. How, then, could she be re-
the cognitive impairment caused by is capable of being persuaded or garded as vulnerable?
the stroke. His left hand shakes, so he tempted, even by food—perhaps the
might have Parkinson’s. In the nurs- last pleasure he had. Nor, although he ! ! !
ing home, he fell prey to van- and my mother were avid bridge
L
comycin-resistant enterococcus, players, is he any longer capable of et me approach that question
which put him in a private room. Be- playing a hand, let alone of winning a indirectly because I believe the
cause he cannot swallow, he is fed game. ways in which my mother is
through a peg-tube. When the tube is The second person is my eighty- vulnerable are, although not as palpa-
washed out, sometimes fluid builds four-year-old mother. For forty years ble as the ways in which my father is
up in his lungs, and he is transferred she has cared for my father. In addi- vulnerable, nevertheless regrettably
to the hospital to be treated for con- tion to all the usual spousal duties as- familiar. One of the articles I use
gestive heart failure. sumed by a woman of her time and when I teach bioethics discusses the
My father has been physically dev- background, she has attended to the plight of a hospitalized ninety-one-
astated. He can still be further details of his care and his extra needs, year-old man who is profoundly de-
wounded, however. Other than when even when he was still at home in a mented and, after a stay in the inten-
M
help and protect is abandoned to and y father’s and my mother’s
demonstrating the integrity of
at the mercy of strangers. She feels vulnerabilities are linked,
their marriage covenant. As she
guilty. She attributes my father’s loss of course. When my father
had cared for her husband at home
of the strength to walk and the ability was still at home, my mother could
for years, she now would mobilize
to swallow food and drink water to have injured her back trying to turn
all of the hospital’s resources in the
being in a nursing home. She excori- him in bed or help him sit up. When
service of her husband. Simply
ates staff—usually, but not always, to my father entered a nursing home,
40 H A S T I N G S C E N T E R R E P O R T March-April 2006
my mother was plagued by fears and tions. Paralysis and progressive weak- tising of drug companies, and by the
anxieties about how he was doing ness have rendered him immobile deeply rooted cultural injunction that
there and how he was being treated. and unable to eat or drink. Destruc- associates responsibility with action
As my father becomes progressively tion of tissues in his brain has im- rather than with acceptance, to cite
more withdrawn and silent, my paired his alertness, his perceptive- just a few factors. And some of those
mother loses even the partial interac- ness, and his comprehension. And causes are organizational or institu-
tion and the incomplete, uncertain the loss of physical and mental func- tional: the structures, staffing, and
communication she has had with tions has virtually eliminated his so- schedules of hospitals and nursing
him. She becomes more isolated, and cial functioning. His exchanges with homes, and the public and private
her worries magnify because her other people are limited, brief, and arrangements for providing and fund-
guesses about what he wants and how transitory. When vulnerability is the ing health care services.
he is feeling are even more specula- result of natural causes, there is little, Despite those differences, though,
tive. For a long time my mother has if any, difference between being “vul- there is a crucial similarity between
completed sentences for my father nerable” and being “at risk.” One the vulnerability of my father and the
and done things for him when he was could instead describe my father as at vulnerability of my mother. What
struggling. She has fewer opportuni- risk of having another urinary tract does not come out explicitly in the
ties for that now, but she has always infection, of getting aspiration pneu- dictionary definitions of “vulnerable,”
believed, quite sincerely, that she is monia, of developing bed sores. but what is most important about
helping him. And after years of help- My mother’s vulnerability is, in vulnerability, is what my father and
ing him in countless unremitting contrast, more limited and more se- my mother experience the most: the
ways, it is easy to understand why she lective. It derives primarily from loss of power that vulnerability im-
would want to make it a little easier blocked or impeded social function- poses and signifies, and the attendant
and quicker for herself. But the words ing. For that reason it is largely the re- loss of control that ensues. We fear
she spoke for him, the decisions she sult of human causes and human cre- vulnerability most immediately be-
made for him, and the things she did ations. Some of those causes are indi- cause of the particular harms we seek
for him made him even more vulner- vidual: the incapacity or unwilling- to avoid. But we fear vulnerability
able because they highlighted what he ness of individuals to provide the in- most profoundly because of the
could not do for himself. They also formation she needs or to provide it power we seek to retain.
made it impossible for him to do in a manner she can comprehend and Rollo May, a psychologist and psy-
more for himself, and, on occasion, retain. Some of those causes are cul- choanalyst who used to be read a lot
undoubtedly made it impossible for tural. My mother, like many people, but is not read much anymore, once
him to get what he really wanted. He has a deep and abiding belief in the said, “no human being can stand the
was aware of that, and he could be myths of medicine. She expects med- perpetually numbing experience of
frustrated and angered by that. It was icine to discover the cause of every his own powerlessness.”3 My father’s
obvious when he simply gave up. new illness, infection, ailment, and powerlessness extends almost as far as
There are also, of course, differ- complication, and she expects medi- it can. When I speak to my mother,
ences between my father’s and my cine to have a cure for every new she regularly tells me: “Your father’s
mother’s vulnerabilities. My father’s problem. Those expectations, as unre- not good. He hardly speaks, and all
vulnerability is largely the result of alistic as they are, are not entirely her he does is sleep.” In my view sleep is
natural causes and is much more own creation. They have been fos- one of his last blessings. My mother’s
comprehensive because of the exten- tered and encouraged by the scientifi- powerlessness, although less exten-
sive physical damage he has suffered. cally and technologically oriented, sive, is more agonizing because she is
Many functions of the tissues, organs, progress-preoccupied society she in- acutely aware of it. She appreciates
and systems of his body have been habits, by the cure and research mis- what my father has lost and how little
disrupted or destroyed, and harm to sions of the medical community and she now can do for him. She appreci-
those biological functions has cascad- the fund-raising organizations that ates what she has lost and what they
ed into his physical and mental func- support them, by the rampant adver- together have lost. She sees the lives
S
from fear and discomfort is to be- o what does vulnerability mean the myth, Inanna’s heroism is “hero-
come task-oriented. Rather than fo- for those who are vulnerable? ism as perseverance,” and he makes
cusing on the person for whom a task The philosopher Alfred North the connection to today: “The notion
is being performed, focus on the task Whitehead once said that human be- of fate that pervades Inanna’s heroism
itself. That strategy is alluring because ings have “a three-fold urge: (i) to seems increasingly intolerable to
it offers the reward of efficiency when live, (ii) to live well, and (iii) to live more individualistic notions of the
many tasks are accomplished and the better.”4 Vulnerability means loss to person.”5 Frank explains why:
reward of satisfaction when those all three: loss of opportunities to live
Campbell’s heroic model is more
tasks are accomplished well. But its better, loss of abilities to live well,
feminine than masculine, finding
greatest reward is distance from fear and, at its extreme, loss of living. My
its earliest paradigm in the journey
and discomfort. With that reward father’s stroke deprived my father and
of Inanna to the underworld.
comes a danger, however. The person my mother of opportunities to live
Inanna undertakes the journey,
lying in the bed can be depersonal- better and severely constrained their
suffers helplessly, is rescued by
ized and objectified. Cheerfulness, abilities to live well. Vulnerability can
helpers from the world she has left,
encouragement, and familiarity are, impair living well and can destroy the
and returns to sort out matters
of course, gifts to those for whom one good life. Ethics, from the time of
with those who did not contribute
is providing care, and they should not Plato and Aristotle, has been about
to her rescue. She wields no
be foregone. Yet they are brief and living well, about the good life.
weapons; her strength is her perse-
episodic, and their scheduled repeti- Shouldn’t ethics therefore be con-
verance. This trope of heroism as
tion might only expose their ultimate cerned about vulnerability, and if so,
perseverance is most useful to peo-
hollowness. They can be incorporated what does vulnerability mean for
ple who are ill and dying.6
into a routinized way of making it morality?
through a shift or a day, but they can- The sad answer to that question, Inanna is vulnerable because she suf-
not dispel the intractable realities of as of now, is “not much.” There are fers “helplessly” and because she de-
debilitation and dependence. When three reasons for this, I think. The pends on the help of others for her
those realities are pervasive, the only first is that vulnerability is antithetical rescue. She cannot do it on her own.
42 H A S T I N G S C E N T E R R E P O R T March-April 2006
Campbell’s interpretation of the myth least in the tradition of Western ana- constitution than rationality because,
makes sense of her suffering and gives lytic philosophy, are grounded in rea- while all human beings are vulnera-
it a moral point. That sense and that son, and the purer that reason can ble, not all human beings are rational
point are foreign to the ethos of indi- be—the more it can emulate the rea- or even possess the potential to be-
vidualism, though, and Frank right- son of logic and mathematics—the come rational. All human beings are
fully worries about how Inanna’s better it is. A paradigm of this strong- born into vulnerability and remain
struggle with her vulnerability is mis- ly rationalistic approach is Immanuel deeply vulnerable for some time, but
represented by that ethos: Kant’s classic work, Groundwork of the human beings who are born without
Metaphysic of Morals,8 which has certain portions of their brains or
I am troubled by what happens
shaped the course of moral philoso- with extreme mental impairments
when Campbell’s notion of the
phy ever since it appeared in 1785. never will become rational. Moreover,
heroic is transformed into self-help
Kant’s challenge in the Groundwork is our universal vulnerability resonates
prescriptions for a happy life; re-
to explain how imperatives—direc- with moral significance. For one
constructing the myth within a
tives that tell us what we ought to thing, it is our very vulnerability that
contemporary spiritual narrative
do—are possible and, in turn, how creates the need for morality. The
loses the heroic. Though Inanna
the supreme principle of morality, legal philosopher H.L.A. Hart links
increases her power and her divini-
which Kant calls the “Categorical Im- the fundamental moral and legal pro-
ty through her journey, she does
perative,” is possible. Kant’s answer is hibitions on killing and inflicting
not enter the underworld to have a
that a categorical imperative can exist harm to our common vulnerability.
personal growth experience. She
only if there is something that is an That people are “prone to, and nor-
goes because it is her fate to go.
“end in itself”—that is, is not valu- mally vulnerable to, bodily attack” is,
She is called to the underworld as
able as a means to something else but Hart says, a truism:
preparation to become the goddess
has intrinsic, unconditional value.
whom she can become only by [T]hings might have been, and
The only thing that has such intrin-
making that journey and incurring might one day be, otherwise.
other people.
such suffering. The cosmic order There are species of animals whose
sic, unconditional value, in Kant’s
requires her becoming and thus physical structure (including ex-
view, is rationality. Kant famously dis-
her journey. Neither the journey oskeletons or a carapace) renders
tinguishes nonrational beings, which
nor its aftermath makes her happy them virtually immune from at-
have “only a relative value as means
by most human standards. Inanna tack by other members of their
and are consequently called things,”
does increase in wisdom and species and animals who have no
from rational beings, which “are
stature, but this “growth” is neither organs enabling them to attack. If
called persons because their nature al-
personal nor linked to pleasure.7 men were to lose their vulnerabili-
ready marks them out as ends in
ty to each other there would vanish
Vulnerability means that one is con- themselves—that is, as something
one obvious reason for the most
trolled by, rather than in control of, which ought not to be used merely as
characteristic provision of law and
the world. Vulnerability marks the a means—and consequently imposes
morals: Thou shalt not kill.10
limits of individualism, but the ethos to that extent a limit on all arbitrary
of individualism doggedly refuses to treatment of them (and is an object of None of us is invincible; all of us are
acknowledge those limits and instead reverence).”9 In this tradition of vulnerable, in similar ways at the be-
construes vulnerability to fit its as- moral philosophy, rationality gives ginning of our lives and later in dif-
sumptions and goals. human beings their unique moral sta- ferent ways at different times in dif-
The second reason that vulnerabil- tus and their incomparable moral ferent circumstances. All of us, there-
ity doesn’t mean much to morality is worth. fore, need the protection—and legal
that vulnerability is missing from Human beings are rational, but enforcement—of morality.
moral philosophy, our intellectual en- human beings also have bodies, and For another thing, we cannot un-
deavor to understand and enhance because they have bodies, they are derstand the persons we are, and thus
morality, because moral philosophy vulnerable. In fact, vulnerability is an how to live well, without recognizing
ignores the body. Moral theories, at even more basic feature of our human vulnerability as an ineluctable feature
T
he third reason vulnerabili- suspicion is that it was because father has coped for four decades
ty doesn’t figure in our un- they expressed feelings. Rollo May has depended, in large measure, on
derstanding of morality is says that although care goes be- my mother. His plight reflects, as
that, like vulnerability, feelings yond feeling, it begins with feeling: MacIntyre observes, a general truth
have no place in rationalistic con- “It is a feeling denoting a relation- about the human condition: “It is
ceptions of moral philosophy and ship of concern, when the other’s most often to others that we owe
morality. Nevertheless, vulnerabili- existence matters to you; a rela- our survival, let alone our flourish-
ty engages our feelings as much as, tionship of dedication, taking the ing, as we encounter bodily illness
if not more than, our reason. My ultimate form of being willing to and injury, inadequate nutrition,
father taught me that. During my get delight in or, in ultimate terms, mental defect and disturbance, and
family’s last visit to see my father to suffer for, the other.”14 I think human aggression and neglect.”17
and mother, I spent a lot of time in that in complimenting my shirt Vulnerability is a source of our
my father’s room watching him my father was telling me that I concern for others, but it also is a
sleep. Sometimes he was sleeping mattered to him, and that in com- source of our interest in and re-
when I arrived and sleeping when I plimenting the fish bowl he was liance on others. Our common
left; I would come back later, and telling me that he was happy that vulnerability bonds us and binds
he still would be sleeping. But he mattered to us.15 And I think he us to other people. The demented,
44 H A S T I N G S C E N T E R R E P O R T March-April 2006
helpless individual lying in a bed Arthur Frank for his detailed, acute as- 8. I. Kant, Groundwork of the Metaphysic
sessments of several versions of this of Morals, tr. H.J. Paton (New York: Harper
might still be capable of feeling, but, & Row, 1964).
paper, his wealth of knowledge, and his
perhaps more important, that person encouragement. And I thank the Hast- 9. Ibid., 96 (pages 428 and 65 in the edi-
is capable of making us feel. We can ings Center Report’s anonymous referees tion issued by the Royal Prussian Academy
feel compassion for that person’s loss- for their perceptive comments and crit- in Berlin and in the second edition, respec-
es and that person’s suffering. We also tively).
icisms.
can feel our common humanity—our 10. H.L.A. Hart, The Concept of Law
(New York: Oxford University Press, 1961),
own fragility and our own dependen- References
190 (emphasis in original).
cy. If we do, we truly can care for that 1. J.J. Fins, M.D. Bacchetta, and F.F. 11. A. MacIntyre, Dependent Rational
person and for ourselves. That is what Miller, “Clinical Pragmatism: A Method of Animals (Chicago, Ill.: Open Court, 1999),
vulnerability means for us. Moral Problem Solving,” in Pragmatic x.
Bioethics, ed. Glenn McGee (Nashville, 12. Ibid., 4.
Acknowledgments
Tenn.: Vanderbilt University Press, 1999),
13. Ibid., 1.
30-44. The précis of the case is taken from
The first draft of this paper was writ- 32-39. 14. May, Love and Will, at 303.
ten for a conference on “Vulnerability 2. Ibid., 37-38. 15. Richard Zaner makes this point
in Later Life: Challenges and Possibili- about people who are dying: “Some . . . are
3. R. May, Love and Will (New York: Dell
haunted by whether or not their lives made
ties for Supporting Persons ‘At Risk,’” Publishing Co., 1969), 14.
any difference, whether they mattered. Oth-
the 20th Annual McMaster Summer 4. A.N. Whitehead, The Function of Rea- ers want especially to let us know they care
Institute on Gerontology, organized by son (Boston, Mass.: Beacon Press, 1929), 8. for us, that we who remain alive matter to
the McMaster Centre for Gerontologi- 5. A.W. Frank, “Narratives of Spirituality them, that our lives have been worthy.”
cal Studies, Hamilton, Ontario, and and Religion in End-of-Life Care,” in Nar- R.M. Zaner, Troubled Voices (Cleveland,
held on June 2, 2003. I thank the orga- rative Research in Health and Illness, ed. B. Oh.: The Pilgrim Press, 1993), 144.
nizers for the invitation to speak and Hurwitz, T. Greenhaigh, and V. Skultans 16. May, Love and Will, at 303 (emphasis
the participants for their helpful ques- (London, UK: Blackwell Publishing and in original).
tions and supportive comments. I BMJ Books, 2004), 141.
17. MacIntyre, Dependent Rational Ani-
thank Sylvie Lamer and Kathryn Desai 6. Ibid., 140-41. mals, at 1. See also Zaner, Troubled Voices, at
for reading drafts of this paper and for 7. Ibid., 141. 145.
their valuable suggestions. I thank