My Time in Medicine
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My Time in Medicine
ABSTRACT

Through this autobiographical reflection on a life in medicine and bioethics, the author discovers that time is a unifying theme in his work. From his early writing on the regulation of house staff work hours and his abandonment of essentialism and the development of clinical pragmatism as a method of moral problem-solving to his scholarship on end-of-life care and disorders of consciousness, time has been a central heuristic in an effort to bridge ethical theory and clinical practice.

Autobiographical essays can be an indulgence. Often self-congratulatory and low on self-reflection, they seldom serve a purpose other than to stoke nostalgia. So when given this opportunity to write about my life in medicine and bioethics, I decided I would take stock, and not simply celebrate whatever accomplishments I might have had. Rather, I would use this opportunity to look for themes that linked the decades together. My hope was that the process might assemble the mosaic that has been my life into a discernible pattern that could only be seen from a distance, and from the vantage of historical reflection. Maybe, [End Page 19] if I was lucky, past would be prologue, and I would learn something that might help me script the next few chapters in my story.

I must confess that I was surprised by what I have come up with, and hence my predictable, but intentionally deceptive, title. This essay in not about my life in medicine, but rather about how time, as a heuristic, has informed and organized my clinical work as a doctor and my more theoretical scholarship as a bioethicist. And like all things temporal, this realization has only become apparent in retrospect. As Kierkegaard (1843) wrote:

It is perfectly true, as philosophers say, that life must be understood backwards. But they forget the other proposition, that it must be lived forwards. And if one thinks over that proposition it becomes more and more evident that life can never really be understood in time simply because at no particular moment can I find the necessary resting-place from which to understand it—backwards.

(89)

I wrote what I thought was my first reflection on time and medicine for a talk I gave in Salerno back in 2010, when I was writing my book Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness (2015). I was reflecting on the case of Terry Wallis, who had emerged from the minimally conscious state. Having been thought vegetative for nearly two decades, he was now able to talk and communicate reliably. The problem was that he was stuck in time. A veritable Rip Van Winkle, he remained in 1984, the year of his injury. Time had stopped for him, even as it had moved on for the rest of us (Fins 2009).

Initially, this temporal lapse was a curiosity and presented practical challenges. Wallis thought his daughter, who resembled his ex-wife, was his wife. When he saw then-President George W. Bush giving a State of the Union address, he turned to his mother and asked, "What happened to Reagan?" (Fins 2015, 167). Wallis was living in what Augustine might have called "an eternal present," but ironically it was 1984. I was taken by Wallis's situation and the question of personal identity. Could one know who one was if one did not have a temporal sense of one's age or one's place in time. Yes, Wallis was Wallis, but he was temporally out of place (Fins 2015).

Bill Winslade described a similar case in his pioneering volume, Confronting Traumatic Brain Injury: Devastation, Hope and Healing (1998). The patient he profiled was "neither man, nor boy" (78–79). It struck me: could we truly have personal identity absent temporal contextualization? Heidegger (1927)—and mind you, I am not a big fan generally—did observe that der Sein exists in history and could not be ahistorical. And it turned out that such contextualization and placement in time had significant practical implications for my emerging work addressing the neuroethics of disorders of consciousness.

But one salient example. The authors of the...