Reflections of a Medical Ethicist
Kim Junhyuk / Yonsei University Professor and Medical Ethicist
The film opens with a bus arriving in a rural village, then cuts to an online lecture. The lecturer in the centre is nowhere to be seen. It's not a programme we're used to seeing, but it's exactly what we've become accustomed to in the post-COVID-19 era: live online meetings. The camera pans closer and closer to the lecturer's screen, which is filled with black, and we soon see a gigantic figure in a state of agony, somehow trying to read an essay on the novel Moby Dick. This is the opening scene of the film The Whale.
Charlie, a 272kg man who has endured a number of untreated health problems, learns that he is about to die and tries to reunite with his daughter, whom he has kept at arm's length. He abandoned his wife and eight-year-old daughter for a life with a man of the same sex, and their relationship has never been restored since. The daughter seems intent on hurting everyone around her, and even her mother has given up trying to help her. With only a few days left to live, Charlie is determined to leave her daughter with at least a small measure of confidence that she can have a good life.
The play of the same name has been adapted by director Darren Aronofsky, and the film, like the novel Moby Dick, wrestles with the question of fate and redemption. And the film achieves its ending so brilliantly. Since this is probably not the best place to revisit the film's meaning (or since others have already done so brilliantly), I'm going to read the film from a medical humanities perspective here. First and foremost, the object that the film is confronting will be understood here as the disease.
As you may recall, Moby Dick is a long musing by the protagonist, Ishmael, who is caught up in Captain Ehave's vendetta against Moby Dick and observes it. At the end of the novel, Ehave throws a harpoon at Moby Dick, who is caught in the line and killed. The novel is often read as depicting a confrontation between nature and man, fate and choice, or brute force and will. It's hard to deny the falsity of Ehave's passion as he cries out in his dreams that Moby Dick, who could care less about humanity, is the devil plotting against him. So what is the film about? What is the protagonist fighting against?
Firstly, his body. Unable to quench his mental hunger, the protagonist's binge eating has resulted in massive weight gain and cardiovascular problems, and Charlie's inability to control his body has led him to try to make some sort of statement about his existence in the face of his final approaching death.
Perhaps because it's based on a play, the entire film takes place inside Charlie's not-so-spacious house. But when Charlie is alone and having an existential crisis (i.e., seeing his life denied to him), the music dazzles the viewer as if it were an ocean of waves. And it is. The room in 'The Whale' is the Pequod on its way to hunt Moby Dick. And, of course, the closest thing we see to a "whale" in front of us is the giant body of Charlie that fills the screen. Charlie is fighting against his own body. It's a narrative we're all familiar with. We've all been there, battling our own bodies at one time or another: dieting, quitting smoking, getting sober, staying up at night with drooping eyelids. If you think of the whale in "The Whale" as a body, the film is simple. It's about a man binge eating and battling a cardiovascular disease that's trying to kill him.
But if you understand it that way, there's no point in watching this film, because there are so many stories of battles with the body in fiction, non-fiction, and film, and it's not like this film is particularly convincing in that regard. Plus, the main character doesn't really battle the body. Plus, I was sobbing at the end of this film. But if that's what this film is about, then I'm a weirdo.
Let's take a different approach. For this approach, we need a new concept of social disease.
The Whale won two Academy Awards for Brandon Fraser's performance as Charlie, and many overlapped the film with Fraser's own life, where he was abused by the film industry as a young, handsome actor, then divorced and raised a son on the autism spectrum.
What is social illness?
As we outlined last time, there is a problem with illnesses that have a social dimension, as opposed to illnesses that have a biological dimension or illnesses that have a personal, experiential dimension. On the one hand, there are cases where society exacerbates a disease or condition. The most common example in everyday life is the illness caused by overwork, and by extension, overwork death. In a social or professional environment that does not guarantee the individual sufficient rest and demands constant tension, a predisposition he has, whether genetic or otherwise, is aggravated and he dies of an acute heart attack. On the other hand, there is the phenomenon of disease manifesting itself differently in different population groups due to differences in social conditions. In general, many diseases are more prevalent and more severe in lower-income groups than in higher-income groups, and in slums than in richer areas. An easy example is tooth decay or gum disease. Obviously, tooth decay and gum disease are more prevalent in low-income communities and slums.
On the other hand, some things become ill because of social circumstances or factors. Society decides what is and isn't a problem, and when it manifests itself in an individual's body, it is labelled as a disease. Take eugenics, for example. As you may know, eugenics is the effort to enhance the genetic disposition of an entire population (usually the people of a country). Eugenics does this in two ways. There are other problems, but the biggest one is that society defines what constitutes "superior" and "inferior". When Nazi Germany decided that the blood of Jews and Gypsies was inferior, ethnicity became a social disease.
The same thing can be said about disability or genetic disease. A disability may make an individual's life uncomfortable. But are people with disabilities inferior to people without disabilities?
No. Nevertheless, when society identifies certain ethnicities, disabilities, or even languages or abilities as "inferior" and attributes them to individual problems, society makes these factors sick on unclear grounds. This is also a social disease. I will call this social illness "wu-huan" (憂患) because the Chinese character wu (患) means both trouble, illness, and calamity, and the Chinese character wu (憂) means illness, pain, and suffering. Social sickness refers to the suffering of the body and mind caused by problems beyond the individual level, by catastrophes, and we suffer because of them.
Harpooning a world of hate and exclusion
In 'The Whale', Charlie is ostensibly unable to control his appetite and is beyond the point of being described as morbidly obese. But why did he get there?
It's because a society that didn't tolerate his lover drove her to her death. His love could not save his lover. Because his relationship with his lover was considered an unacceptable illness. His life had become an illness.
Thus, the whale the film confronts is not Charlie's biological body. The Moby Dick of The Whale is a world that makes him an object of disgust and exclusion. Like Moby Dick in the original novel, the world is not interested in the individual. It doesn't deliberately try to kill him, it doesn't have a grudge against him or a spiteful plan to push him into a pit, but it's that indifference that kills us. Someone is drowned in the great waves of the world, and he is left alone. Our striving for life becomes futile in the face of that injustice, that impartiality that does not make the stronger suffer more, that does not protect the weaker. And so, even though we know that AHAB is an unbeatable opponent, we can't help but cheer him on when he strikes the harpoon of hate.
The film climaxes with Charlie and his daughter together picking up Ehave's harpoon and hurling it into the world (of course, there are no harpoon, no fight, or even a violent movement in the film). And we see through The Whale. The world will prevail. Small gestures by individuals can do little more than put a tiny dent in its enormity. But those scratches will one day bring down the world, the great whale. It's not easy to do anything about the enemies that surround us. From the distant 4-3 to the nearer Itaewon, from the broader Japan that defined Korean blood as inferior to the narrower practices surrounding genetic engineering, the world, in its indifference, robs the individual of his rights and suffocates him. But we know. As we hurl our seemingly futile harpoons, those bottles, Wu Hwan, will one day fall.
Reflections of a Posture Expert / Eam Taekyoung
Types of social stress
In addition to overwork, economic class, and social prejudice, factors that contribute to social stress include overly self-centred individuals and groups, competing groups, legislation and organisational cultures that do not reflect social change, and sudden changes in the social environment (since the mid-1990s (IMF crisis), South Korea has seen a sharp increase in suicide rates, finally overtaking Japan), The universal consciousness of groups that use the individual as a tool to achieve group goals, and the endless competition among various groups that stems from evolutionary humans not having the genetic systems to control over-satisfaction (surplus).
I believe that a more fundamental social stressor than the ones listed above is "postural deformity due to rapid sedentary socialisation". There are so many variables that affect posture that it is very difficult to approach analytically. In addition, the stress caused by sedentary posture is an underlying stress that everyone experiences, is universally recognised as an individual problem, and a direct causal relationship between posture and stress is not readily apparent. As a result, there is no group of people who have systematically and scientifically studied the relationship between posture and stress. However, I believe that posture is a very personal stress, but it is also a social stress because it is a stress that everyone experiences, and this stress is the underlying energy that fuels the universal aggression of modern people.
Stress in Paleolithic humans
Our bodies and minds have evolved to adapt to the hunter-gatherer lifestyle of the Paleolithic. A hunter-gatherer lifestyle means that most of our daily activities take place in the great outdoors, where we are exposed to considerable risk. You might encounter wild animals or venomous plants and animals.
So if you're faced with a situation that could threaten your life, you have two choices: fight or flight, and in both cases you need to be physically strong. So it's a very strong physical and mental tension. In the Paleolithic period, these highly stressful situations were common enough that they developed appropriate coping mechanisms. During this time, the ability to run was one of the most important means of survival, so it's likely that our bodies were optimised for running. However, modern humans still have this Paleolithic running optimised body. In the photo below, you can see that the centre of gravity of the head is at a tilt of about 12 degrees when looking straight ahead, and the average marathon runner's spine is also at a tilt of about 12 degrees.
Stress in the modern world
The universal stress that modern humans experience is much different than that of Paleolithic humans.
First, the most common stress in modern humans seems to be physical stress from the bending moments of the spine. This stress seems to be a constant, not a variable, that is unavoidable for anyone who spends time sitting. Since most of us lead sedentary lifestyles, our muscles must be tense to support the bending moments caused by our downward-facing posture.
However, the low level of tension in these muscles makes it very difficult to recognise the problem, and postural deformities continue to build up over a person's entire life. So slowly and steadily, their impact seems to grow, making it natural for almost everyone to have one or two ailments in the second half of life.
Secondly, whereas Paleolithic humans lived a life with an approximate 50:50 relationship with nature and the people around them, modern humans seem to live a life with an approximate 50:50 relationship with nature and the people around them. In general, modern people have become less connected to animals and nature and more connected to themselves and the people around them.
In the Paleolithic era, there was always a powerful threat of life and death in the great outdoors, and the stress caused by that was very powerful, so the stress caused by relationships with other people was probably relatively weak and not continuous (?). However, modern society has conquered all of the stressors caused by nature, so it can be seen that stress caused by internal problems and relationships with others has become important.
This means that Paleolithic humans had a strong stress response that was honed by the threats they faced from the great outdoors, so the stress of interpersonal relationships would have been manageable. However, for us modern humans, it is quite possible that the stress of our current lives, of which the stress of our relationships with others is a part, is the most powerful stress we experience.
To summarise. We modern humans still have systems that are well suited to managing the characteristics of the Paleolithic human body and mind, but Paleolithic humans were generally exposed to strong but short-lived stresses, and modern humans are generally exposed to weak but long-lived stresses. In other words, while Paleolithic humans lived lives characterised by "powerful but short-lived stress", modern humans generally live lives characterised by "psychologically powerful and very long-lived stress", which is weaker in absolute stress intensity compared to Paleolithic humans. Unfortunately, humans have not evolved adequate coping mechanisms to deal with this kind of 'sustained low-intensity stress' in the distant past.
The paradox here is that the safer society becomes, the more intense the psychological stress people experience. This may explain why our society is becoming safer, but younger people are finding life more challenging.
The Butterfly Effect of Sedentary Socialisation
Stress in the modern world is mainly caused by mild but persistent stresses (such as prolonged sitting with a downward gaze and emotional labour), and modern people are increasingly exposed to the effects of these stresses due to the progress of digital socialisation. Sitting for long periods of time with a downward gaze seems to be the main cause of mild but persistent stress in modern people, and the secondary cause of increasing aggression and depression.
Nowadays, people in general, whether young, middle-aged or elderly, are spending less time playing sports and more time in sedentary activities such as studying, playing games and using smartphones, so the amount of time spent in a slouched position continues to increase.
Slouching can lead to unrecognised micro-pain, which shifts brain activity from the 'pain circuitry' to the 'emotional processing circuitry', which can lead to an increase in violent tendencies. According to Dr Srinivas Pillay of Harvard University, mild low back pain is the second most common cause of disability in the United States, and more than 80 per cent of Americans will experience it in their lifetime. He also notes that when pain persists, the associated brain activity shifts from "pain" circuits to circuits that process emotions, and that emotions such as anxiety often stem from chronic back pain, making it much more difficult to regulate.
* Mechanisms of appetite in sustained low-intensity stress:
- Paleolithic: turbo mode (hunting, running) --> sympathetic nerve activation (heart, lungs, eyes) --> high energy expenditure --> energy replenishment through appetite.
- Modern: Stress mode --> Sympathetic nerve activation (activation of heart, lungs, eye function) --> Energy expenditure is not high --> Energy replenishment through appetite --> Obesity
* Disease-causing mechanisms of continuous low-intensity stress: Continuous stress --> depression --> dysautonomia --> decreased breathing rate --> poor circulation --> poor blood supply to some areas of the body and decreased physical activity --> calcification of unused muscles --> postural deformity and accelerated deterioration of body parts --> disease occurs in normally weak areas.
* Transition mechanism of persistent low-intensity stress to aggression: mild but persistent physical/mental stress --> low-intensity pain --> stimulation of pain circuitry --> stimulation of emotional circuitry --> transformation of perceptions of difference into feelings of intolerance --> accumulation --> manifestation in aggressive behaviour.
Underlying causes of ageing
The paper, 'Summary of the Copenhagen Conference on Ageing 2022', states that
"Genomic instability, telomere attrition, epigenetic changes, mitochondrial dysfunction, loss of proteins, deregulated nutrient sensing, cellular senescence, stem cell depletion, and altered cell-to-cell communication were the 10 hallmarks of aging proposed by López-Otín and colleagues in 2013. The proposal of these features of aging has been instrumental in guiding and driving research into the biology of aging. Nearly a decade of in-depth exploration of aging research has led to the formulation of new features of aging, including autophagic damage, microbiome perturbation, altered mechanical properties, junctional dysregulation, and inflammation. The convergence of 'old' and 'new' features of aging provides a more comprehensive explanation of aging and age-related diseases, which can shed light on the study of interventions and treatments to achieve a healthy, happy and productive life for the elderly."
A key consideration in research into the causes of chronic diseases is that modern humans, as well as those of the past, are still born with bodies built for running, but have rapidly become sedentary through the Industrial Revolution, the internet and the popularisation of smartphones, and yet the medical community seems to have failed to include this as a consideration at all.
I believe that the genomic instability, telomere attrition, epigenetic changes, mitochondrial dysfunction, loss of proteins, deregulated nutrient sensing, cellular senescence, stem cell depletion and altered cell-to-cell communication, autophagy damage, microbiome disruption, altered mechanical properties, junctional dysregulation and inflammation that have been identified as causes of aging are all directly or indirectly related to the problems caused by living in a sedentary society with a body fit for running.
Due to a sedentary lifestyle, "progressive postural modifications" and (or) "constant tension in some muscles" appear to contribute to decreased autophagy, neurodegeneration, immune ageing, decreased cell motility, decreased cell-to-cell communication, cell stiffness, and loss of elasticity. 'Progressive modification of posture' leads to gradual atrophy or crushing of blood vessels, nerve and lymphatic vessels. 'Constant tension in some muscles' can lead to progressive atrophy of cellular metabolism. This 'gradual' change can be seen as ageing.
The reason why chronic oxidative stress in immortal cell lines leads to telomere shortening, impaired growth, and genomic instability, while acute stress has little effect, is that our stress management mechanisms are well-established to deal with "high-intensity, short-term stress," but virtually nonexistent for "low-intensity, sustained stress," in order to respond well to attacks from threatening animals. This is because modern humans still have bodies that have evolved to cope with frequent exposure to life-threatening predators in the Paleolithic era.
Mitochondria are responsible for converting food into energy that the cell can ultimately use. The emergence of mitochondrial transplantation as a new treatment for dementia and the correlation between aerobic exercise and mitochondrial volume seem to offer a new interpretation of the causes and remedies of dementia. It is worth noting that the cause and solution of dementia can be interpreted as follows.
Dementia is a degenerative disease. As a result of the Industrial Revolution, physical activity, such as running and walking, has declined in relation to the sudden increase in life expectancy since the 1950s. In addition, people generally lose muscle mass after about 40 years of age, which leads to a generalised and intensified slouching posture, especially with the head protruding forward, after about 50 years of age. This makes it easier for the blood vessels that pass through the neck area to become compressed or constantly stiff. This leads to a deterioration in the quantity and quality of blood supply to the brain. It"s a degenerative condition.
To prevent dementia, the most important thing is to avoid forward bending of the neck in the average daily posture. Next, it"s important to reduce activities that require the brain to constantly focus on something, as fatigue builds up when the amount of breathing is low compared to the energy used. Breathing is one of the reasons why writers have a shorter lifespan than people in other professions, which can be very stressful.
Conclusion
As a posture expert, I believe that many of the physical and mental illnesses, ageing, depression, social aggression, etc. of modern society are all derived from "posture-induced social stress," which is caused by the rapid transformation of global society into a sedentary society. Therefore, it seems that medical scientists need to study and analyse the fact that we modern humans still have a body that has evolved to suit the Paleolithic way of life [a way of life based on hunter-gatherer life, involving activity (body), stress and food], but live in a significantly different modern environment, as the first and most fundamental factor to consider. The current focus on the micro-world of genes and the like is very worrying. We should not lose sight of the fact that our bodies are integrated, networked, mega-variable functions.
If we don't do enough to address the common postural stresses of modern life, it's increasingly likely that I or my family members will take over the role of Charlie from The Whale in real life.
When the film ended, I thought of the poet Arthur Rimbaud. Perhaps Charlie is the reincarnation of Rimbaud...
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