"Everything That Really Matters": Social Suffering, Subjectivity, and the Remaking of

Human Experience in a Disordering World

Author(s): Arthur Kleinman
Source: The Harvard Theological Review , Jul., 1997, Vol. 90, No. 3 (Jul., 1997), pp. 315-
335
Published by: Cambridge University Press on behalf of the Harvard Divinity School

Stable URL: https://www.jstor.org/stable/1509952

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"Everything That Really Matters":
Social Suffering, Subjectivity, and the
Remaking of Human Experience
in a Disordering World*

Arthur Kleinman
Harvard University

l TWhen William James launched into the Gifford Lectures of 1901, he

admitted to his Edinburgh audience a certain feeling of trepidation.
Those lectures, which he would later publish as The Varieties of Religious
Experience, evoked in James a sense of consternation because, as he re-
marked on the occasion, he was neither a theologian, nor a historian of
religion, nor an anthropologist. "Psychology is the only branch of learning
in which I am particularly versed," James pleaded.'
While admitting to the same feeling of alarm in addressing a subject that
seems at first so different from my own fields of expertise, I have this one,
and only this one, advantage over William James. Although we both trained
first in medicine, only later turning to psychology (in James's case) and
psychiatry (in mine), I happen also to be an anthropologist. And indeed it
will be through the engagement of anthropology with social medicine and

* This article is a revised version of the William James Lecture on the Varieties of Reli-

gious Experience presented at the Harvard Divinity School, March 1997.

'William James, The Varieties of Religious Experience (1902; reprinted Cambridge, M
Harvard University Press, 1985) 11-12.

HTR 90:3 (1997) 315-35

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316 HARVARD THEOLOGICAL REVIEW

cultural psychiatry that I will take up questions tha

pertinent to the varieties of religious experience. Tha
will soon expose inadequacies in my knowledge of th
hand that are much more serious than any my illustri
ancestor may have exhibited almost a century ago. N
magic of James's rhetorical style, which in the Variet
demonstration that to get at experience we need to r
gent readings that evoke the uncertainty, the exigency,
multiplicity of what is definingly human.

1 Formulation of the Problem

I wish, then, to address that point at which medical anthropology, and
particularly that brand of medical anthropology that I have called the an-
thropology of experience, converges with the study of religion. This par-
ticular point exists, in my opinion, in the experience of suffering.2 For the
choke, anguish, and often desperate hurt of suffering spark fundamental
questions about human conditions that are as central to medicine and to
anthropology as to religion. Those questions, moreover, become only sharper
through the transformative experiences of repair, remoralization, and regen-
eration. Serious illness, death and dying, grief, trauma, and healing, no
matter how great the differences in their cultural elaboration, are the com-
mon stuff of experience that summon inquiry in medical anthropology, as
well as in the study of religion.
Even as medical anthropologists have broadened their theoretical and
empirical framework to follow the blood trail of trauma from individual
episodes of distress and disease to such social disasters as civil conflicts,
structural violence, institutional racism, and the havoc of breakdown in
communities and even entire societies, the experience of suffering remains
their orienting subject. Anthropologists now configure suffering as much
more than the deep subjectivity of the afflicted person, the psychology of
the individual to which William James gave priority in his theory of the
twiceborn.3 That "moreness"-a term that James favored as a multilevel
signifier of whatever is subconscious, moral, and ultimately religious all at
the same moment-I shall use to examine suffering that includes the indi-
vidual level but also transcends it as cultural representation, as transpersonal

20n the ethnography of the experience of suffering, see Arthur Kleinman, Writing at the
Margin: Discourse Between Anthropology and Medicine (Berkeley: University of California
Press, 1996); Arthur Kleinman, Veena Das, and Margaret Lock, "Social Suffering," Daedalus
125 (1996) xi-xx; and Veena Das, Critical Events: An Anthropology of India (Delhi: Oxford
University Press, 1996).
3James, Varieties, 71-78.

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 ARTHUR KLEINMAN 317

experience, and as the embodiment of collective memor

one can speak of suffering as being social. Social suffer
subjectivity, its bodiliness as processes that connect the
cal, the political to the emotional, and the religious to
and the manner in which it (and with it the human experi
mation) is being remade in our disordering contempor
what I seek to conjure in this essay.
On the side of the study of religion, John Bowker h
sively that the question of suffering is always a centra
world's major religions, although handled in greatly di
Max Weber, whose intellectual legacy for our fields is incalculable,
theodicy-in its broadest sense, meaning-making in the face of history's
inevitable tragedies-was the modus operandi for the social science en-
gagement with suffering as a religious question.6 As the underpinning of
capitalism and the social order generally, Weber may actually have had in
mind sociodicy-the legitimation of society in the face of its failures-as
much as the justification of the cultural authority of divinity. Nevertheless,
his agenda for social analysis has oriented several generations of anthro-
pologists of religion, as well as of medicine.7 Those anthropologists have
taken as their framing orientation the concept of meaning (ultimate mean-
ing and the more prosaic varieties). The object of their inquiry is: how
people make, negotiate, and unmake meaning in the greatly divergent con-
texts of human conditions, including, and perhaps even especially, in con-
ditions of breakdown and disruption.
So dominant and abiding has this framework become that one wants to
speak almost of a tyranny of meaning that overvalues coherence and other
intellectualist priorities at the expense of everything else that the Jamesian
imagination (Henry, as much as William) held experience to comprise.8

4Ibid., 55, 67, 402-3; and John E. Smith, "Introduction," in James, Varieties, xlv.
5John Bowker, Problems of Suffering in Religions of the World (Cambridge: Cambridge
University Press, 1970).
6Max Weber, The Sociology of Religion (1922; reprinted Boston: Beacon, 1963) 138-50. On the
broader issue of Weber's view of meaning-making in the face of history's tragic course, see John
Patrick Diggins, Max Weber: Politics and the Spirit of Tragedy (New York: Basic Books, 1996).
70n the centrality of a Weberian approach to meaning in the anthropology of religion, see
Clifford Geertz "Religion as a Cultural System," in idem, ed., Interpretation of Cultures (New
York: Basic Books, 1973) 87-126. For its influence among medical anthropologists, see Arthur
Kleinman, Patients and Healers in the Context of Culture (Berkeley: University of California
Press, 1980) 71-118; and Byron Good, Medicine, Experience and Rationality (Cambridge:
Cambridge University Press, 1994).
8James, Varieties, 15, 59, 290, 402-3; for Henry James's view of experience, see his
discussion of consciousness in his preface to The Wings of the Dove (1902; reprinted New
York: Penguin, 1986) 35-51.

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318 HARVARD THEOLOGICAL REVIEW

Sensory conditions of sounds, smells, tastes, feel, balan

complex and subtle sensibilities (moral and aesthetic),
agency and action also constitute everyday experienc
tions and social memories; fragmentary, contradictory, ch
and inexpressible, though they often are. The literary
sion against, and the popular culture's reaction to, the
century has challenged the dominion of meaning as in
or even inhuman.9 Primo Levi is not alone in finding t
ironically inhuman implication of personal experience
treme kinds of social suffering to be that human beings c
with and indeed justify anything.10 For many surviv
meaning out of the most extreme and dehumanizing cond
betray, or unmake the most basic values and moral int
than hypocrisy. It annuls the very project through which
or is illuminated by experience. No meaning can be m
mity of this defeat, as Holocaust scholar Lawrence Lan
intense feeling of alarm emerges from the monstrous cal
Accordingly, Elie Wiesel, Paul Celan, Primo Levi, Dan
survivor writers deny the possibility of theodicy.
Echoing the existentialist writers of four and five d
social theorists, like the Indian anthropologist Veena D
ter, her historian colleagues who are partisans of the
studies, argue that meaning-making needs to be criti
political tool that reworks experience so that it conforms
power.12 On the other hand, these social theorists and
fashioning meaning perhaps should be understood as
preoccupation, incongruent with the sheer exigency of su
destiny of the one-fifth of humankind existing under th
tions of extreme poverty. The desperately poor, Das sh
ling ethnography of political violence in India, have m
them by legal, medical, welfare, security, and religious

9Kleinman, Das, and Lock, "Social Suffering." Out of an enormous l

response to twentieth century havoc, see also Paul Fussel, The Great W
(New York: Oxford University Press, 1975); and Carolyn Forche, e
(New York: Norton, 1993).
'0Primo Ldvi, The Drowned and the Saved (New York: Summit,
"1Lawrence Langer, Holocaust Testimonies: The Ruins of Mem
University Press, 1991); idem, "The Alarmed Vision: Social Sufferi
ity," Daedalus 125 (1996) 47-66.
'2Das, Critical Events ; Gyanandra Pandey: "The Colonial Construction of 'Communal-
ism,"' in eadem, ed., Mirrors of Violence: Communities, Riots and Survivors in South Asia
(Delhi: Oxford University Press, 1990) 94-134.

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 ARTHUR KLEINMAN 319

purpose too often seems to serve the interests of the stat

let alone personal, concerns.
Survivors of the Bhopal disaster thus lose their vo
legal, medical, and still other professionals, whose cat
pain and suffering to the grievances of plaintiffs, the sy
or the ritual pleas of supplicants. This process of appro
collective authenticity of their own voices and denies
redefining their needs away from demand for basic refor
rights.13 The poorest poor, not only in India, but as one
telling ethnographies by anthropologists in Brazi
shantytowns, the killing fields of Sri Lanka and Mozam
rated inner-cityscapes in North America, often expre
lack the resources (symbolic and material) to control
what befalls them.14
Students of globalization describe a cacophony of ins
commercialized voyeurism, a prodigality of dismaying pic
global communication in a postmodern world of fragmen
unpredictability, bafflement, and dogged demand for the
deriving from constant change. The impossibility of e
real life constraints and contingencies of that which
operative for global "infotainment," such as one sees w
of current horrors from afar on the television's nightly
amoral virtual reality: suffering at a distance, and a sa
How can one assess meaning under these circumstance
Talal Asad, one of the more original anthropologists
analogizes the dominant cultural discourse of the glo
the amalgam of science, technology, political econom
procedure-to the role of Christianity as the determina
medieval period in the West.16 Both have created he
Christendom, Asad argues, deployed ultimate meanin

13Das, Critical Events; eadem, "Suffering and Moral Experience

Norman Ware, and Arthur Kleinman, eds., Health and Social Chang
vard University Press, 1994).
14See, for example, Paul Farmer, AIDS and Accusation (Berkeley: U
Press, 1992); Nancy Scheper-Hughes, Death Without Weeping (Berk
fornia Press, 1993); Phillip Bourgeois, In Search of Respect (Prince
Press, 1996); and Patricia Lawrence, "Violence, Suffering, Amman:
Lanka's Eastern War Zone," unpublished manuscript.
15Arthur Kleinman and Joan Kleinman, "The Appeal of Experie
ages: Cultural Appropriations of Suffering in Our Times," Daed
'6Talal Asad, Genealogies of Religion: Discipline and Reasons of
and Islam (Baltimore: Johns Hopkins University Press, 1993) 1-26

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320 HARVARD THEOLOGICAL REVIEW

pline, command, obedience, and control; the global policy

nity is one in which moral and religious meaning must op
in domestic, semiauthorized, or alternative spheres, driven
discourse by a technical rationality that makes theodicy b
Humiliation, states Asad, served the former regime
ating loving obedience as a virtue that, in turn, crea
appropriate to that particular time and place. Under t
gime, no one admires or uses humiliation, but rather
personality pathology. Biomedicine, for example, em
disenchanted rationality for which the question of ult
human) meaning lacks legitimacy. For biomedicine, dis
no purpose; illness experiences no teleology; and deat
Biomedicine's technological triumphs are its defining
fession also produces suffering, about which there is
meaning. Even bioethics, astonishingly, seems to gain
macy to operate in the high technology settings of th
care units by disavowing the broad contextual implica
man experiences of suffering in favor of a narrow t
professionally defined principles concerning individu
not without importance, these principles frequently overs
else that matters in the experience of families, patient
tioners. Talk regarding abstract principles of autonom
sent, for example, substitutes for understanding and engaging the
ethnographic contexts of end-of-life care or the unprecedented limits on
patient-doctor interactions under managed care.18
Thus the absolute primacy of concern with meaning-meaning that is
understood as a cognitive response to the challenge of coherence-would
seem to be dubious. When examined alone in this narrowly cognitivist
frame, meaning as a category provides an inadequate account of medical,
political, moral, or religious experience. It places greater value on "know-
ing the world," as William James put it, than on inhabiting, acting in, or
wrestling with the world. What other ways exist, however, for adequately
speaking of human experience and its changing conditions? To offer an
alternative, one needs to redefine suffering.

* Social Suffering: Cultural Representation, Transpersonal

Experience, and Embodied Subjectivity
Suffering, as I have said, is social. This is true in a number of senses:
(1) it is often a transpersonal engagement with pain and misery in social

7Kleinman, Writing at the Margin, 21-40.

'8Ibid., 41-67.

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 ARTHUR KLEINMAN 321

relationships, as in a family tragedy; (2) it is a societal

acts as a cultural model, a moral guide of and for exper
tional Chinese socialization of children to endure seriou
endurance as an end in itself; (3) it is also a professiona
organizes forms of suffering as bureaucratic categories a
nical intervention, such as the professional conversion of
into disease pathophysiology, or the making over of p
regulations into legitimate and illegal forms of welfare
last sense indicates, suffering is social, not only because
networks and bodies but also because social institutions
sistance to certain categories of sufferers (categories tha
constructed as authorized objects for giving help), while
treating them with bureaucratic indifference.19 Thereby so
through their policies and programs, frequently deepen
social suffering and become obstacles to their alleviation
ment policies of the International Monetary Fund and W
have deepened poverty in Africa, are a case in point.20
One way of perceiving suffering as cultural representatio
For example, the depiction of Christ, the man of sorrows, i
religious imagery of the Crucifixion both evokes path
cultural form.21 Michelangelo's Pieta realizes one of the W
prototypes of moral relationships, here cast as the sufferin
response to the sufferer. Bernini's Ecstasy of St. Teres
example of an arresting and influential cultural imagination
religious passion. More recent examples continue some of
but in new forms. When the cultural representation of suf
one can see in the images of social memory and cultural aut

19Kleinman, Das, and Lock, "Introduction," xi-xx; Michael Herzfel

tion of "Indifference": Exploring the Symbolic Roots of Western Bu
Berg, 1992).
20Paul Farmer, et al., Women, Poverty and AIDS (Monroe, ME: Co
1996).
2'For authoritative religious images of the Crucifixion, I refer to
Dictionary of Art (34 vols.; New York: Grove Dictionaries, 1996) 8.
cultural representations of the Crucifixion by Picasso and others that d
formation of the imagery of this icon of suffering in terms of abstract
ments in modern art appear in Terez Gerszi, Les Plus Beaux Dessins de
Belfond, 1988). Analytic accounts of changing depiction of the bodilines
include: Rosemary Coffey, "The Man of Sorrows of Giovanni Bellini"
of Wisconsin, 1987); and Sarah Beckwith, Christ's Body: Identity, Cult
Medieval Writings (London: Routledge, 1993); and Andrew Louth,
Catholic Christianity," in Sarah Coakley, ed., Religion and the Body (
University Press, 1997) 111-130.

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322 HARVARD THEOLOGICAL REVIEW

art, for example, do collective and subjective experien

If so, how? (See fig. 1.)

subjectivitY

Fig. 1: The transformation of "experience"-for example, suffering and

responses to it-is depicted here as the reciprocal influence of shifts in cultural
representation, social experience, and subjectivity which are shaped and
reshaped by epochal political, economic, and social structural transformations.

In her book The Suffering Self: Pain and Narrative Representation in the
Early Christian Era, Judith Perkins advances the idea that, in contrast to
the Stoic persona that was a key representation of the self for ancient
Romans (for whom suffering was no great virtue), second-century Christian
discourse fashioned a self that was centered around suffering, both as re-
ligious identification with divinity and as a political alternative.22
This discourse created a new paradigm for understanding suffering and
death, and, consequently, the experiential world. ... [T]hings that had
universally been thought bad and contemptible were suddenly seen as
valuable .... [T]his empowerment, together with the emphasis on the
resurrected body, display the subversive underpinnings of this discourse.23

The suffering body became the meeting place of the human and the
divine; healing became the material manifestation of Christian power. Chris-

22Judith Perkins, The Suffering Self: Pain and Narrative Representation in the Early Christian
Era (London: Routledge, 1995) 3, 11, 122-23, 131, 141.
23Ibid., 122-23.

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 ARTHUR KLEINMAN 323

tianity thereby is involved, this author claims, in a tran

jectivity. This new subjective self as sufferer took instituti
the organized collection of funds, administration of h
houses, and experiences of religious transformations, so th
of representation, self, and institutions became a vehicle of
Anthropologists of experience provide other sorts of em
confirm the relationship of changes in collective meanings
experience and in subjectivity to those in historical, pol
social structures.25 For example, William Christian, in his
of peasant visionaries in Ezkoiga in the Basque country
Franco 1930s, relates the visionary experience of sightin
saints (which attracted more than a million people to
Republic's anticlericalism and the growing political res
culminate in the Spanish Civil War.26 His description of th
of subjectivities via extraordinary experiences would hav
James, for it is quite in keeping with the Varieties' mag
"Mysticism."27 Christian, however, interprets this change
of sensibility and social context-a correlation of a const
kind rather than a presumedly natural psychosomatic kind
by comparing pictures of transformed subjectivity from C
pictures of Charcot's classical psychosomatic interpretation
rience as hysteria, which seeks to make sense of the psych
of isolated individuals who dissociate into postures of
acontextual confines of the clinic, without attending to
experience, as if it were a naturalized entity instead.28

* Somato-Moral Basis of Experience: Suffering

Transformation
The anthropology of experience understands the moral, the religious,
and the political to be embodied, evoked, realized, or actualized in somatic
processes like habitus, normal physiology, as well as in symptoms of pa-

24Ibid., 202.
25See books reviewed in Arthur Kleinman, "The New Wave of Ethnographies in Medical
Anthropology," in Writing at the Margin, 193-256.
26William A. Christian, Jr., Visionaries: The Spanish Republic and the Reign of Christ
(Berkeley: University of California Press, 1996); these visionaries saw the Civil War as the
beginning of the Apocalypse and the coming of the reign of Christ.
27James, Varieties, 301-39.
28Jean-Martin Charcot, Les Demoniaques dans l'Art (Paris: Adrien Delahaye et Emile
Lecrosnier, Editeurs, 1876-78); Desire Bourneville and Paul Regnard, Iconographie
Photographique de la Salpetriere (Service de M. Charcot) (Paris: Adrien Delahaye et Libraires,
Editeurs, 1876-1878).

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324 HARVARD THEOLOGICAL REVIEW

thology. Persons incorporate social memory in the bo

transform bodily processes. Moral categories are dire
tions, as are political affairs, much as the pathbreaking
of science and historian of medicine George Canquilhe
in society to enfold into normality in the body.29 Meanin
tant, to be sure, but it is the bridge that it creates betwe
bodily processes that is most consequential for human
Job, to take a biblical example, refers to his state of
Hebrew for "vexed."30 He is deeply vexed, shaken by
him, a power that threatens to break him, his body, and
The emphasis, according to Moshe Greenberg, is on t
outer force to inner state: religious, moral, and social
self reaction. This is different from the current psychog
Book of Job expresses inner state somatopsychically
cially), with an emphasis on the corporeal body as med
ety and individual. Emotion is one of the body's cond
floating independent state. In Job there is no differen
logical pain and physical pain. Bruno Snell's great boo
of the mind in ancient Greece expresses a similar poin
subjectivity deepened the dimensions of the self to craft
mode of self-awareness, which has occurred massively
centuries in the West, and with great intensity in the
least among educated urbanites in the non-Western wo
sociosomatic or moral-bodily relations was primary.32
In our own age of the dominance of the psychological, i
to read in William Styron's description of his life-threate
sive disorder that the experience of depression for h
pain,33much as Robert Burton described melancholia
Melancholy almost four centuries earlier.34 Without m

29George Canquilhem, The Normal and the Pathological (1966; repr.

30Moshe Greenberg, "Job," in Robert Alter and Frank Kermode, ed
to the Bible (Cambridge, MA: Harvard University Press, 1987) 283-
31Bruno Snell, The Discovery of the Mind: The Greek Origins of Eu
York: Harper, 1960) xi, 14, 16, 18-22, 65, 69.
32See, for example, Arthur Kleinman, Social Origins of Distress
nia, Depression and Pain in Modern China (New Haven: Yale Univer
mas J. Csordas, "Introduction," in idem, ed., Embodiment and Experien
University Press, 1994) 1-26; Robert A. LeVine, Culture, Behavio
York: Aldine, 1973); Robert I. Levy, Tahitians: Mind and Experienc
(Chicago: University of Chicago Press, 1973); and Charles Taylor, S
Making of Modern Identity (Cambridge, MA: Harvard University P
33William Styron, Darkness Visible: A Memoir of Madness (New Yor
34Robert Burton, The Anatomy of Melancholy (1621; reprinted New

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 ARTHUR KLEINMAN 325

Burton could speak of the spiritual and emotional aspec

as well as of the soul's physical sensation of it. In seven
teenth-century England, "depression" evolved as a term
rience of deprimere ("to press down") in both a mater
sense, and in the sense of a lowered or falling spirit,
sensibility of the soul's falling downward in the body.3
to emphasize is that this earlier cultural rhetoric linked
well as the invisible world of spirit, directly to the bod
subjective self as only one aspect of that interconnecte
it as a compound of physical, emotional, and spiritual
In research that my wife, Joan Kleinman, and I conducte
1978 through 1986 with survivors of China's immense
structive Cultural Revolution (1966-1976), we found th
been deeply wounded during this political maelstrom
vexed (Chinese fanzao) and complained primarily of bod
Somatic symptoms, complaints of dizziness, pain, and
their chief problems. While it was possible to argue on
whether the local diagnosis of neurasthenia or the glob
egory of depression was a more appropriate interpretation,
level there was an entirely different issue to consider. D
political expression of criticism of the Cultural Revolut
sion of the Chinese Communist Party itself) was unaccep
complaints of injured habitus were a form of collective me
wounds and recrimination. It was possible to express th
plaints and even for small groups of people to come tog
as a kind of shared trauma, even if there was a clear limit to their use as
political criticism and resistance. Here the subjective experience of pain
spread metaphorically from the physical body to the social body (namely,
the pain of damaged and damaging social relations). Similarly, the symp-
tom of dizziness established a metaphoric link between the dizzying effects
(personal and interpersonal) of a political campaign gone wild and vertigi-
nous. Exhaustion as lack of bodily vitality merged with the devitalization
of social institutions and networks, the exhaustion of social resources.37

35The definitions of "depress," "depressed," and "depression" in The Oxford English

Dictionary show the mix of material, energetic, and emotional senses. Stanley Jackson's mag-
isterial treatment (A History of Melancholia and Depression [New Haven: Yale University
Press, 1987]) illumines the interconnections between physical state (melancholy humor), emotional
and energetic condition (depression), and moral-spiritual condition (acedia).
36Arthur Kleinman and Joan Kleinman, "How Bodies Remember: Social Meaning and the
Bodily Experience of Criticism, Resistance and Delegitimation Following China's Cultural
Revolution," New Literary History 25 (1993) 707-23.
37Ibid.; Kleinman, Social Origins of Distress and Disease, 143-79.

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326 HARVARD THEOLOGICAL REVIEW

Elsewhere I have shown that, in the Chinese tradition,

tions between moral categories, such as face (lianmian) an
quality of relationship (renqing quanxi), and emotional st
loss of face and absence of favor are really two sides of t
coin. These are not discrete phenomena inhabiting en
(inner and outer); rather, they are processes that cro
tween the personal and the transpersonal, the bodily and t
somatic interconnections indicate, moreover, that the
thoroughly dialectical. In that flow, cultural represen
relations, and embodied subjectivity interact so as to t
The idea of the spread of experience, like the shifti
wave-particle from social metaphor to corporeal sensib
can convey a notion of lived connection (or vital disco
erwise seemingly distinctive phenomenological domain
My purpose, then, is to call attention to a form of
that insists that experience is both within and without t
body-self, crossing back and forth as if that bound
Enculturation of persons into society accompanies the
their physiologies and their selves. When social ti
bereavement, so too are physiological ones. While I do
to review the neurological, endocrinological, immuno
cular processes that may contribute to the bodily med
rience, there is a fascinating and rapidly expanding liter
It demonstrates that biology is open to the social wo
that one may speak of local biologies or "cultural bi
In this medical-anthropological orientation, experie
of transpersonal engagements in a local world: a family,
borhood, a community. That flow of practices and f
Bergson, Merleau-Ponty, and many European phenom
it to be, a vital medium of socially constructed gest
communication, actions, reactions, engagements that
sonally and within the person.40 It is a tide that rises

38Idem, Writing at the Margin, 95-172.

39See Margaret Lock, Encounters with Aging: Mythologies of
North America (Berkeley: University of California Press, 1993); A
Becker, "Introduction," Psychosomatic Medicine: Special Issue on
publ. forthcoming. Anne Harrington, Professor of History of Scienc
will be editing a book series entitled "Cultural Neuroscience."
40Henri Bergson, Les donnes immediates de la conscience (Paris
Merleauu-Ponty, Phenomenology of Perception (London: Routledg
105, 405; Max Scheler, Man's Place in Nature (1928; reprinted New
Alfred Schultz, On Phenomenology and Social Relations (Chicag
Press, 1968).

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 ARTHUR KLEINMAN 327

washing in among the objects of inner experience, at o

back outwardly among the participants in the transpersona
bolic connections involve transductions between social states and emotional
states. Aesthetic conditions, such as response to music, point to similar trans-
ductions in moral conditions.41 Put more prosaically, in the disenchanted
language of social science and medical research there is a connection among
stressors, supports, coping reactions, and physiological processes, so that, for
instance, gender-related social losses and pressures transduce into the psy-
chobiology of clinical depression.42 As with demoralization and depression,
?so with remoralization and healing: societal transductions into physiology
underwrite powerful transformations of experience. The mediators of those
transductions appear to include smells, sounds, words, images, memories,
interactions, ritual performances, and music. Recent ethnographies illustrate
these body-self-society transductions in healing; other kinds of research are
beginning to shed light on how they create their effects.43
Experience (including its sociosomatic interconnections) is innately moral,
because it is in local worlds that the relational elements of social existence
in which people have the greatest stake are played out. These include su
vival, status, power, resistance, or loss. I do not mean to posit a banal id
of universals for the human condition. What is at stake undergoes grea
even extravagant, elaboration through the cultural apparatuses of langua
and aesthetics and across divergent social positions of gender, age cohor
political faction, class, and ethnicity. Yet the fact that some things rea
do matter, matter desperately, is what provides local worlds with the
immense power to absorb attention, orient interest, and direct action. More-
over, it is these local worlds that have the power to transform the
transpersonal and subjective poles of experience.44

41See, for example, William Flemming, Arts and Ideas (3d ed.; New York: Holt, Rinehart,
and Winston, 1958) 313, 342; Steven Feld and Aaron A. Fox, "Music and Language," Annual
Review of Anthropology 23 (1994) 25-54; Marina Roseman, Healing Seconds from the Ma-
laysian Rainforest: Temiar Music and Medicine (Berkeley: University of California Press,
1991); Haili You, "Defining Rhythm: Aspects of an Anthropology of Rhythm," Culture,
Medicine and Psychiatry 19 (1995) 361-84.
42George Brown and Tirrel Harris, Social Origins of Depression (New York: Free Press, 1978).
43See, for ethnographic examples, Thomas Csordas, The Sacred Self: A Cultural Phenom-
enology of Charismatic Healing (Berkeley: University of California Press, 1994); Robert
Desjarlais, Body and Emotions: The Aesthetics of Illness and Healing in the Nepal Himalayas
(Philadelphia: University of Pennsylvania Press, 1992); and Renate Devisch, Weaving the
Threads of Life: The Khita Gyn-ecolo-gical Healing Cult among the Yaka (Chicago: Univer-
sity of Chicago Press, 1993). For examples of studies of how healing is mediated, see Arthur
Kleinman and Anne Becker, "Introduction."
44For works that describe the moral orientations of local worlds, see the references in
Arthur Kleinman and Joan Kleinman, "Suffering and Its Professional Transformations," Cul-
ture, Medicine and Psychiatry 15 (1991) 275-301.

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328 HARVARD THEOLOGICAL REVIEW

Having defined moral worlds and somato-moral proc

trate them with a few statements by people whom I h
rather different settings because of their experiences
remarks provide the title of this article: "Everything T
They also will begin, I hope, to suggest how the mor
I am building here may help us to get at religious exp
forms of moral and religious experience undergo thos
that define epochal shifts in social life.
When I think about those really bad times [the Cultura
the beatings, the real chaos, the destructiveness, I think o
matters ["really is important"]. Family, surviving, keeping
These are so much better times now. We live so much better. We all
do. But that time, that terrible time made it clear, completely clear
about everything that really matters. And now, I'm not so clear. Not
really clear. None of us are. Now what matters is money, things to
buy. Our experience is changing. We are all changing. Then I felt
really vexed, deeply troubled. Now, what do I feel? Can't be certain.
Nothing is clear anymore.

A sixty-year-old Chinese intellectual, 1995

Everything that really matters! Matters to me. Know what I mean? Liv-
ing, dying, going through it all, all those things you do, and need, and
love, and want, and feel. When she [wife of 38 years] died, when she
died I knew, just knew, I had to do what matters. No good suffering,
hurting. Get ready; do what you need to do. No good suffering. Feeling
sorry for yourself. Get over it. The rest, I thought, is meaningless ....
But now, three years later, I can't get the handle of it. Really I can't. I'm
not sure, not so sure what counts anymore. I'm floating. There isn't any
firm, really firm ground. It seems all to be shifting. Do I start over
again? Do I stay loyal to my memories? Do I? I feel lost. But I find my
friends are the same way. Everything seems to be changing. Not just us,
the world. What does matter? It just is terribly confusing.

A sixty-two-year-old American executive

Here I'm dying of metastatic cancer, and you ask me, 'Does your reli-
gious belief help?' It does really; it does help. But I think you don't
mean belief. Or I don't mean belief. Well, what is religion, really? Is it
going to church to pray to God to get better? Maybe, for some. But not
for me. For me, well. . . here, it's faith that something more really
matters, counts. Something bigger and beyond you. So death's got to
be seen against. . . against that; and then all of a sudden it looks
different, and feels very different. It is so depressing otherwise, when

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 ARTHUR KLEINMAN 329

you consider it from just you. It's a feeling thing. Y

and act differently. I'm here so sick and the disease
don't feel depressed. For that matter, I don't feel my
I'm better than usual in one way. I don't feel so unce
world is one where we are made to feel uncertain, to
thing. In some bizarre way, I don't feel that way now
changed, for me .... I'm even thinking maybe we liv
where religion or faith only really counts when you'
end. Then everything is clear. Otherwise it's pulling
Our world doesn't let you. . . doesn't let you. . . we
see, maybe can't see, what matters most of the time.

S. R., a sixty-three-year-old American

teacher in the terminal stages of lung

* The Transformations of Suffering: Mora

Medical Degenerations and Regenerations
"Everything that really matters"? This phrase, or
runs through these very different interviews almo
the first instance, I use these examples to illustrate
basis of social experience. What really matters ma
distinctive, but the realization that something reall
anchored locally, both in a transpersonal and in a su
human conditions, I am convinced, their moral edg
manness. As I shall try to show in the final sectio
sensibility that what is at stake is threatened by
political, economic, cultural-may also be character
ence. But I shall also attempt to describe how the pr
these contemporary interviews, individuals from two
ies, associate a certain kind of threat, a type that on
called the threat of the loss of the human, with the d
tions in moral experience evoked by the current ph
I now return to the case of S. R., the sixty-three-yea
from an East Coast, North American city who is in
metastatic lung cancer. From a purely technical perspe
ment outcome, he is about to become part of the still
deadliness of lung cancer, even in an era of powerf
tions. For the highly malignant tumor with which
year survival rates, even with surgery followed by radiation and
chemotherapy (all of which he had received), are very poor. Most patients

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330 HARVARD THEOLOGICAL REVIEW

don't live beyond five years, many don't reach this m

and-a-half years beyond diagnosis of the tumor.
Medically speaking, the treatments merely slowed
cancer. Because those treatments also caused significa
rash, intestinal problems, weakness) that S. R. foun
(and eventually, awful), it is not entirely certain wh
medical treatment contributed to the quality of his
problematic. In a broader perspective, however, hosp
nal weeks and months with nurses and doctors visiti
S. R. to die very much as he wished: at home, in th
members, and in sufficient control of pain and othe
symptoms that he remained clearheaded and able to do t
valued-reading, talking, observing nature-even into
of-life care for him was successful.
Not only did S. R. not feel depressed during this final period of his li
he felt, in at least one very important sense, "better than usual." In t
interview, he went on to say that terminality, confronting his own death,
him determine with greater clarity and certainty "what matters," and it di
that in an epoch and local setting that usually makes such clarity and
certainty unavailable. Rather than having felt defeat, demoralization,
despair as the end approached; he felt remoralized. This sense of mora
regeneration was so strong that in interviewing him just before he died
myself, caught it and felt uplifted by his spirit. I now relate it to the w
one feels, for example, after listening to the conclusion of Mahler's Th
Symphony or other musical works that stir the emotions and in their final
lift something deeply human within, leaving a sense of expansion, comp
tion, even joyousness. I associate similar feelings with prayer in the sy
gogue when I was a child and a believer. Doubtless others have more
recent familiarity with this lived experience of transfiguration. One must,
then, think of the outcome of illness in moral (or religious) terms, rather
than in medical terms alone.
For many patients with serious, chronic conditions, the lived experien
is one of endurance of severe hardship: suffering is a way of life and
transformations are usually not good. The claims made for high technolo
interventions and the growth of our scientific knowledge base-which i
deed have produced important successes-hide that reality, as do the fac
expectations that psychotherapy and psychopharmacology can relieve r
sidual pain and suffering. In this respect, the culture of biomedicine, which
does not value the core illness experience at the same level as the diagno
and treatment of disease pathology, conspires with the popular culture
treat death as the enemy. They have great difficulty coming to terms with

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 ARTHUR KLEINMAN 331

the limits of treatment and the reality of suffering as a w

death in our society is becoming more and more difficu
In the process that I am highlighting, transformation
gious (to beg the question of how they differ by hyphe
because the outcome is transcendence. Suffering itself i
experience. As Clifford Geertz famously put it: "as a reli
problem of suffering is, paradoxically, not how to avoid su
to suffer. .. ."45 In American society in the current er
repeatedly affirm that the highest value is still placed on t
tation of a good therapeutic outcome, of happy endings.4
endurance, and progression of suffering or decline are w
This too is a moral-religious condition, even if there is
The lived experience of "everything that really matter
ordinary. That is what the words of S. R. and the other
have quoted seem to mean. The bodiliness of moral cat
phoric spread of emotional processes through social relation
ology of socially constituted conversion from norms into n
Book of Jeremiah means when it quotes divinity as sayin
law into their inward parts"),47 these sociosomatic processes
society and the body-self, they can transform both poles o
Perhaps this says something more fundamental about s
tion, healing, or transcendence as bodily mediated tran
ence. Sociosomatic reactions, in this sense, are a source n
transformation but perhaps even more routinely of neg
one who visits the medical intensive care units and wa
hospital would find that a high percentage of the most seri
with cancer, heart disease, stroke, end-stage renal or liv
like would satisfy the technical criteria for major depre
they suffering from a psychiatric illness? The neurov
that may make one conclude so, can also result from the
diseases and the treatments they receive. What some inte
ness and depressed mood strikes me as the felt moral-em
of suffering at the end of life. That there is a moral-religi
the end of life is demonstrated not only by states of r
remoralization, but by demoralization and despair. Tho
core aspects of moral-religious phenomenology. Yet, incr
society denies this side of suffering, rendering it impossibl

45Geertz, "Religion as a Cultural System," 103.

46See, for example, Christopher Lasch, The Culture of Narcissism
1978) 3-33; and Philip Rieff, The Triumph of the Therapeutic (New
47Jer 31:33-34.

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332 HARVARD THEOLOGICAL REVIEW

cal rationality and technology of biomedicine, and by

and gratuitous optimism of Hollywood. The difficult
demoralization and the troubling uncertainty over wh
mood disorder or a moral state is the primal scene for m
and for considerations of assisted suicide. Perhaps n
margins of the dominant technical discourse that aut
ence in our times and the private, semiofficial, or alt
moral-religious life that presses up against that dominat
a more poignantly powerful example of the failure of
to terms with suffering per se as moral-religious exp

I'm ready to die; but they won't let me, it seems. It make
case: this disease can't be cured. I've had all the treatm
worked. Now its time to let me die on my terms. Oh,
convinced another try with yet some other treatment w
few more days or weeks. And my family is just as un
really what's the point. ... A psychiatrist told me I was
course, I am. Isn't that what suffering is supposed to
bring it all to a close. Do I have to go with a smile on m
seems to me ridiculous, and insulting.

A seventy-eight-year-old artist with leuke

hospital with fourth exacerbation in six m

Many Americans, together with increasing numbers of

fluent societies, seem to regard suffering as something t
that one can and should avoid, that is without any redeem
something to which society should respond primarily with
that defines our age. There is also the problem of the mi
abuses of suffering that I discussed earlier. This points t
moral orientation and social practice that is troubling
highlights a tragic consequence of history: our globalizin
and popular culture seem to have become a threat to
which I now will briefly turn as the conclusion to this e

* The Threat of the Loss of the Human in a Disordered and

Disordering Epoch
In the "Introduction" to his deeply pessimistic history of the world in the
twentieth century, the distinguished British historian Eric Hobsbawm offers
a devastating warning concerning the passing of the human in our times:
At the end of this century it has for the first time become possible to
see what a world may be like in which the past, including the past in
the present, has lost its role, in which the old maps and charts which

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 ARTHUR KLEINMAN 333

guided human beings, singly and collectively, through li

represent the landscape through which we move, the seas
sail. [It has become possible to envision a world] in whic
know where our journey is taking us, or even ought to tak

One can find similarly dire warnings and wildly dark

work of other humanists, social scientists, and culture c
French cultural historian Philippe Aries, in his magiste
history of death in the Western tradition, is yet one ot
rueful chorus when he sardonically concludes:
A small elite . . . propose not so much to "evacuate" death as to
humanize it. They acknowledge the necessity of death, but they want it
to be accepted and no longer shameful .... They propose to reconcile
death with happiness. Death must simply become the discreet but dig-
nified exit of a peaceful person from a helpful society that is not torn,
not even overly upset by the idea of a biological transition without
significance, without pain or suffering, and ultimately without fear.49

The threat of the loss of the human turns on the idea that if cultural
representation and collective experiences can transmogrify in a fundamen-
tal way in a time of enormous social change, then so too can subjectivity
be transformed.50 That transformation, this line of analysis so ominously
insists, can be of a kind to cancel, nullify, or evacuate the defining human
element in individuals-their moral, aesthetic, and religious experience. It
is a social reconstruction not so much of a category of the person as of a
life trajectory and of experiential existence. The threat could come from the
iron cage of technical rationality that Weber, for example, believed bureau-
cratic society would create to replace tradition, sentiment, and the ad hoc
with efficiency-based institutional controls. Or it might come from the de-
struction of empathy owing to a turn toward inhuman fundamentalisms, to
a blame-it-on-the-victim, narcissistic preoccupation with materialism, or to
commercialization of suffering. Another scenario for this prototypical hu-
man end game expects, as in Hobsbawm's bitter forecast, a loss of collec-
tive memory owing to the bloody havoc of this century that has dislodged
inner values from their traditional cultural moorings, while failing to re-
place them with cultural resources from the programs of modernity that

48Eric Hobsbawm, The Age of Extremes: A History of the World, 1914-1991 (New York:
Pantheon, 1994) 16.
49Phillippe Aries, The Hour of Our Death (New York: Alfred Knopf, 1981) 614.
50I am grateful to Gerald Bruns, Professor of the Humanities at Notre Dame University, for
suggesting the term "threat of the loss of the human," which is the theme of the Roger Allan
Moore Lecture that he will deliver at the Harvard Medical School in the spring semester
of 1998. Also relevant to this essay is Bruns's article, "Loose Talk about Religion from Wil-
liam James," Critical Inquiry 11:2 (1984) 299-316 .

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334 HARVARD THEOLOGICAL REVIEW

offer hope of a new or renewed means of authoriz

stones in this genre are the apocalyptic visions of
bodian genocide, the Stalinist terror, and the more re
breakdown in Afghanistan, Rwanda, and the form
places of enormous destruction that call into question
moral and religious foundations of humanity. Her
the desperate, even cynical feeling that maybe not
way. There is a perspective alive in the humanities
even contributes to this nihilistic conclusion.
Some have claimed that the escalatory rhetoric of loss of the human i
part of millenarian dismay, a contagious sensibility of human decline tha
is simply out of keeping with actual human affairs and conditions. Th
economists of the World Bank, for instance, insist that things have neve
been better in material terms.51
This fear of the loss of the human, although it has picked up intensity
in the 1990s, has been around for a very long time. Discernible also in
earlier periods of vast societal change is the fear that fundamental huma
values and the subjectivity of humanity itself could develop in an inhuma
direction.52 Nor is this fear culture-bound to the West, although it seems to
find its most intense and consistent voice there.
Fear of the loss of the human seems to correlate with an awareness of
changing forms of social experience and inner life that are the consequenc
of vast historical, political-economic, and cultural transformations. Thes
major transformations periodically sweep through localities, regions, or, i
the current interdependent world, the entire globe. This recognition is a
apprehension that the existential itself is not fixed, that human nature
malleable, and perhaps to so great a degree that the term itself is invalid
Human beings are no longer the same persons in sensibility or other as
pects of body-self that their ancestors were, or that their descendants wi
be. More than just dress, diet, and cultural meanings change.
Collective experience, as well as subjectivity, are distinctive in differen
eras and different places.53 Today one senses a fundamental change. Th

51Investing in Health (World Development Report; Washington, DC: World Bank, 1993)
52For a representative sampling of the literature, see Jean Delumeau, Sin and Fear: The
Emergence of a Western Guilt Culture, 13th-18th Centuries (1983; reprinted New York: S
Martin's, 1990); Andrew Delbanco, The Death of Satan: How Americans Have Lost the Sen
of Evil (New York: Farrar, Strauss, and Giroux, 1995); Peter Gay, The Naked Heart: The
Bourgeois Experience, Victoria to Freud (New York: Norton, 1995); Christopher Lasch, Th
True and Only Heaven: Progress and Its Critics (New York: Norton, 1991); and Keith Tho-
mas, Religion and the Decline of Magic (New York: Scribners, 1971).
53The literature suggesting this point as it relates to suffering comes from a number o
directions, as I have illustrated above. Other examples include Rebecca Lester, "Embodied
Voices: Women's Food Asceticism and the Negotiation of Identity," Ethos 23 (1995) 187

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 ARTHUR KLEINMAN 335

tendency is to fear that this change is so great that it will

at stake for humanity, so that entirely different matt
world of our children's children, while today's world w
lost that this age will be able to lament with Montaig
ruefully in the Essays that the world he was born into
What makes this fear especially powerful at present
effects of advanced capitalism which, like some univer
to many to dissolve all that really matters. There is a part
this fear. Another part, however, rejects its essentializin
in its place, would conclude: substantial transformation
really matters"-in the sense that I have discussed it her
of what is at stake in local worlds-is always the point o
change in social experience. Whether one likes it or not,
shape and direction, or can adjust or not to its speed a
today is such a time of change. One can feel and react
personal relationships, in work, in sensibility, and no
ward parts." This provides the grounds to engage soci
rethink policy, programs, and moral initiatives for its reli

222; Margaret R. Miles, "Voyeurism and Visual Images of Violence,"

tury 101 (March 21-28, 1984) 303-4; Christopher McKevitt, "To Suf
The Concept of Suffering in the Cult of Padre Pio da Pietrelcino," Jou
Studies 1 (1991) 54-67; and Douglas Hollan and Jane Wellenkamp, Co
fering: Culture and Experience in Toroja (New York: Columbia Un
For a provocative discussion of changes in collective experience and
place dramatically in events of political violence, see Stanley J. Tamb
Ethnonationalist Conflicts and Collective Violence in South Asia (Be
California Press, 1996).
54Michael de Montaigne, The Complete Essays (1948; reprinted Stan
versity Press, 1992) 773.
55Consider the following instances of policy-oriented analyses that
as a platform upon which to erect different scaffoldings for organizin
cies: Robert Desjarlais, et al., eds., World Mental Health: Problems a
Income Countries (New York: Oxford University Press, 1995); Wi
Suffering Seriously: The Importance of Collective Human Rights (A
1996); and Timothy Lytton, "Responsibility for Human Suffering:
tion, and the Frontiers of Tort Law," Cornell Law Review 78 (1993) 4

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