Abstract
Grief is a raw and painful emotion. It helps the living to mourn and bury those who have died and to sustain the memory of their personhood and deeds. But when persons die before their time, die as a result of injustice, or (as is often the case) die prematurely because of injustice, the grief of the living can motivate collective action and critical reflection. Paul Farmer knew the power of grief as a physician, medical anthropologist, and social justice advocate who committed his life to the service of those who are sick and impoverished in our world. He was able to harness his emotions into a moral commitment to making health care accessible for all human beings regardless of ability to pay, which culminated in his co-founding of the medical non-profit organization Partners in Health (PIH). Farmer showed the global public health establishment that it is possible and necessary to tell the truth about our world, as well as to transform the structure of that world so that it does not produce so much premature, unjust, and preventable death. Despite being a secular organization, PIH still articulates their commitment to global health equity in explicitly theological language, as a preferential option for the poor.
Following Farmer’s own premature death in 2022 at the age of 62, a group of theologians who had been profoundly influenced by his work ‘wrote as their grief was still fresh and raw’, channeling it into the production of this volume (p. xii). The contributors do not limit themselves to the hagiographical task of giving honor and recognition to Farmer’s prophetic Christian witness. The primary purpose of the book is academic, namely to ‘acknowledge and describe the influence and impact that his scholarly work and on-the-ground praxis have had on the field of theological ethics in general and on each of the contributors individually’, and they aim to uncover ‘important insights for the work of theological ethics going forward’ (p. 2). Whereas they intend to address other theologians as their primary audience, they also ‘articulate the critical—and indispensable—theological dimensions of his work and his practice of the moral life for those in the secular fields’ of medicine and public health as a secondary audience (p. 5). The eighteen contributors to the volume hail from four continents, and their areas of expertise span the breadth of the theological world, including both academic theology and pastoral/practical theology. Their essays are arranged thematically into four sections, each section being accompanied by a brief introduction to frame its content, as a way to call attention to the multiple dimensions of the mutual and reciprocal relationship between Farmer and theologians.
While space constraints do not permit me to review or even to mention all of the excellent essays, I would like to highlight those that I found most helpful (though other readers with concerns different from mine will perhaps find other essays more helpful). Jorge Ferrer offers an interpretation of Farmer’s way of life as that of an ‘organic intellectual’, a category borrowed from Antonio Gramsci which refers to the kind of scholar who is accountable to the academy as well as a particular oppressed social constituency (p. 90). Such a scholar is actively engaged in the social struggle to build a new and more just society, a commitment that does not decrease the need for academic analysis but, on the contrary, requires the scholar to treat this task with even greater seriousness. Ferrer’s proposal offers not only an apt interpretation of Farmer but also a sharp challenge to the theological ethicist, who may be tempted to lead the more comfortable and superficially progressive life of the ‘traditional intellectual’ who absents himself from the work of sustained social engagement (p. 91).
The existential and analytical questions explored in Ferrer’s essay are examined with more contextual specificity in the essays by Alison Lutz and Leo Guardado. Lutz, a former PIH colleague of Farmer, highlights the relatively privileged social positionalities of Western(ized) public health experts, which can shape cultural assumptions about the agency of impoverished people and reproduce social hierarchies. As an antidote to this kind of humanitarian paternalism, she asserts that ‘the oppressed must be protagonists of their own liberation’ (an insight originating with Gustavo Gutiérrez), and she suggests that ‘people who face the dual burdens of poverty and disease must be preferentially engaged to design the interventions aimed at helping them’ (pp. 95, 96). Farmer made a praxis of accompaniment central to the approach of PIH to ensure that the moral agency of all, especially those who are impoverished, would be engaged in the work of healthcare equity. Similarly, Lutz invites theological ethicists to consider the praxis with which we engage the communities to whom we are accountable, to determine whether we are disrupting or strengthening the very social hierarchies we officially claim to oppose.
Guardado asks similar ethical questions in the context of the relatively recent surge of interest among theologians in conducting ethnographic fieldwork, particularly through the model known as participatory action research (PAR). Given the historical entanglement of anthropology (and theology) with white colonial projects, Farmer used a qualitative methodology that was attentive to these power imbalances as he brought the voices and perspectives of impoverished people to the ears of the global public health establishment. Theological ethicists who are now turning toward PAR therefore ought to tread carefully and ‘ask about the why and wherefore of this methodological adjustment’ (p. 144). After all, no theologian can plausibly aspire to do such work while maintaining illusions of being morally objective, politically neutral, or otherwise non-implicated in structural violence. Farmer’s example invites theologians to relinquish control over the encounter ‘and instead to enter into a dialogue with the communities with whom [they] research to collaboratively discern what in fact would be a contribution to the community and its priorities, including political priorities’ (p. 150).
Reflecting Ferrer’s recognition that the socially engaged theologian will treat the intellectual task with more seriousness, not less, due to their practical and existential commitments, Therese Lysaught and Suzanne Mulligan employ a high level of analytical and methodological rigor in their sharp critiques of dominant economic ideologies and structures as well as the cultural assumptions that normalize and reinforce them. Lysaught argues in her essay that neoliberal economics has shaped not only global health but also, in more subtle ways, the fields of bioethics, theology, and theological ethics, enlisting them as part of the ideological apparatus for the reigning economic order. Following a brief overview of the gradual implementation of neoliberalism in societies across the globe, including its effects on healthcare access, healthcare delivery, and clinical care, she turns to the bioethical field itself, asking whether it is ‘simply a coincidence that the dominant conceptual framework for bioethics emerged in 1980—at the moment that neoliberalism became the dominant global economic (and eventually social) ideology’ (p. 165). This is no mere rhetorical question, given that the principle of autonomy (and the unstated yet operative principle of utility) maps easily onto a neoliberal anthropology of the free, rational, individual chooser seeking to maximize preferences. This family resemblance ‘is not accidental’ (p. 167). If this observation about bioethics is accurate, then theological ethicists ought to consider whether it is also true of our own discipline in some measure—potential examples of the coopting of theology by neoliberalism abound, and Lysaught lists them. To conclude this profoundly unsettling analysis, she proposes that Farmer and PIH offer to theology a reorientation toward ‘an alternative anthropology … of self-gift’ capable of motivating resistance to neoliberal institutional policies as well as deeply internalized neoliberal concepts and assumptions (p. 179).
Mulligan specifies even further the dehumanizing consequences of the reigning neoliberal economic paradigm by focusing on the vulnerability and agency of women, who comprise a majority of the world’s impoverished people and sick people according to UN statistics. Farmer carefully accounted in his methodology for the fact that women, particularly poor women of color, are more vulnerable to structural violence than men, due to several intersecting axes of oppression. Mulligan therefore proposes, echoing Lutz, that ‘attentiveness to women’s stories must form the basis of strategies aimed at dismantling the violent structures that continue to oppress and marginalize the world’s poor’ (p. 187). She also clarifies that Farmer ‘saw the need to create a space for women’s voices to emerge, not just because this will accelerate more effective health care and human rights outcomes, but because he recognized the importance of women’s agency in se’ (p. 194). It is intrinsically valuable, not instrumentally valuable, to empower women’s agency. On the basis of this insight, Mulligan observes that a lack of sustained theological reflection on the cultural biases of misogyny and sexism, which conspire to thwart women’s exercise of agency, contributes to ‘a serious gap in Catholic teaching on social sin’, which is clearly reflected in official magisterial teachings on marriage and family (p. 196).
Finally, Stan Chu Ilo continues to use the same intersectional method of analysis employed by Mulligan and Farmer in his own essay. In dialogue with Farmer’s final book, Fevers, Feuds, and Diamonds, Ilo asks uncomfortable questions about how racist and colonialist assumptions continue to structure global health interventions on the African continent. Building on Farmer’s observation that the 2013–2015 Ebola pandemic in West Africa was exacerbated by the dominant ‘control-over-care paradigm’ recommended by global public health authorities, Ilo identifies ‘racism, colonial medicine, and a concatenation of factors like religion, economies of scale, and past history’ as the primary social determinants of health in the ‘clinical deserts’ of West Africa, which jointly ensure that ‘Ebola is only a deadly disease if you live in Africa’ (pp. 289, 283, 280, 282). In effect, he exposes ‘global health’ as a neo-colonialist ruse, whose main concern is to prevent disease outbreaks, which are artificially manufactured through the destruction and neglect of healthcare infrastructure in the colonized nation, from spreading to the colonizer’s home nation (thus the lack of concern for prevention and treatment). In response to the fact that the Church has usually been ineffective as an advocate for dismantling the structural violence of colonial medicine in Africa, Ilo proposes ‘a biosocial ethics of holistic health as an ethical framework’, by which he means an approach that values the health of all, especially that of the most poor and vulnerable; develops health policy on the basis of broad participation from faith-based organizations, governments, and local communities; and ensures procedurally that the priorities are ‘set by the Africans themselves, rather than by external forces and external interests’ (pp. 299–300).
My overall response to this volume is deep gratitude for the work of each of the contributors and the three editors in particular. They have turned a great tragedy—the premature death of a man who worked tirelessly himself to prevent premature deaths—into a beautiful, socially relevant, and genuinely useful academic resource. It will surely hold theological ethicists accountable to continue the work of healthcare justice and advocacy in their own research and practical commitments. The prophetic tone is often—and appropriately—challenging toward the reader. Moreover, there is a remarkable degree of thematic and methodological continuity throughout the volume, such that the many contributions genuinely do hang together as parts of a single, coherent whole. I plan to assign several of the essays in my undergraduate bioethics course and to cite them in my own research, both of which are facilitated by the open-access format available on the Journal of Moral Theology website. My evaluative assessment of the scholarship itself is that it meets a very high standard. It would have been tempting for the contributors to an edited volume written under such circumstances to indulge in gratuitous hagiography at the expense of academic rigor, but they have kept the former activity to an appropriate amount, and the interdisciplinarity represented by the authors provided fertile ground for producing the kind of geographically broad and historically deep analysis that would have pleased Farmer himself.