“You Are Going to Die”: Risky Truth-telling in the Contemporary American Hospital

As Mr. J’s nurse, I observed him over two months growing increasingly frail, agitated, and delirious—ultimately requiring chemical and physical restraint just to perform clinical care. Despite the clear signs of decline, Mr. J was not on hospice, nor designated DNAR; instead, he was full code, with his care directed toward recovery. What I was tasked with felt far from true care—it was participation in perpetuating a lie, not in honestly tending to his imminent death.

This paper examines two major challenges facing the Christian nurse as they work to care well for the dying patient, before proposing parrhesia, or courageous truth-telling, as a way for nurses to faithfully care for the dying. The first challenge, drawing from Sharon Kaufman’s ethnography …And a Time To Die, American medicine obfuscates death. Medicine operates on the “presupposition” “that its task is to preserve life as such and to reduce suffering as far as possible.” (Max Weber, Science as a Vocation [Philadelphia: University of Pennsylvania, 1917], 9; Kaufman, And a Time to Die, 21.) Driven by the purpose of maintaining life, medicine maintains death as a peripheral object— at least until it is unavoidable. Furthermore, the modern Western technological age has rendered death a choice. Life-sustaining interventions normalize and stabilize dying bodies; in order to die, one must choose to continue their technologized life no longer. This is a difficult proposition when we are all, to a certain degree, living the technologized life now. The medical system simply directs one to further indulge in this life and blurs the line between ordinary and extraordinary means. Modern technology is the fulfillment of medicine’s aim for life’s restoration and death’s forestalling, thereby obfuscating death’s reality and inevitability.

The second challenge, drawing from Foucault’s work on hierarchies’ ability to legitimate institutionally selected forms of knowledge and disqualify subjugated knowledges. Tracing the emergence of disease in eighteenth- and nineteenth-century France, Foucault found that a regime of truth and sets of practices created a hierarchy of knowledge, placing educated physicians at the top and the lay ill person at the bottom. This hierarchy legitimated physicians (so long as they aligned with medical knowledge) as truth-tellers while disqualifying the knowledge of the ill person as naïve. Hierarchy is often reinforced through institutional selection. Only on the condition that one goes to certain schools and takes certain tests may one contribute to the established knowledge.  Nurses sit somewhere in between the doctor and the patient. They have gone through more institutionally approved training than the patient but not as much as the physician. Compared to the physician, their knowledge is deemed naïve or “beneath the required level of cognition or scientificity” (Michel Foucault, Power/Knowledge, 82).  Should the nurse disagree with the physician, their knowledge is disqualified. Thus, the nurse faces the conundrum: why speak up and critique medicine’s obfuscation of death if no one will take me seriously?

Nursing’s traditional response to these challenges is patient advocacy, which is often understood as the nurse’s protecting and empowering the patient’s emergence of their true self. Due to the nurse’s advocacy, the patient can freely and authentically choose what aligns with their values. The failure of advocacy is that it assumes patients can be self-grounding, that if given protected fertile ground, patients can emerge as their true and authentic selves. No one, least of all critically ill patients, living in the hospital, often moving in and out of delirium, are single and self-secure. Contingent to human existence is an openness to others’ occupation of ourselves. This openness means, as Judith Butler notes, that “what I can ‘be,’ quite literally, is constrained in advance by a regime of truth that decides what will and will not be a recognizable form of being” (Judith Butler, Giving an Account of Oneself, 22.) Operating within medicine’s regime of truth, Patients’ very possibilities of subjectivity — what they can desire, choose, and understand as their own, the truth they can tell about their best interest, have already been preordained. Advocacy, in not recognizing this reality and denying the nurse the ability to critique, makes the patient all the more vulnerable to the hospital’s regime of truth, perpetuating medicine’s obscuring of death. 

Drawing from Foucault’s late lectures on parrhesia and Christian ascetism, an alternative response is proposed in the Nurse as Christian parrhesiastes. parrhesia is a direct and frank verbal act where the speaker, compelled by duty, risks personal consequences to express the truth for another’s benefit. Ascetic parrhesiastes achieved this by dying to themselves each day, accessing a truth grounded in the other world, which transcends the present world’s fears, conventions, and hierarchies. Guided by a commitment to this order, the nurse parrhesiast could thus act as a witness to a different way of being—one that faces death with openness and courage. In life and speech, the parrhesiast reflects the values of this eternal order, challenging the denial of death so embedded in medical institutions.
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The nurse parrhesiast lives this calling with humility and moral courage, consciously positioning themselves as a truth-teller within the constraints of a system that resists acknowledging mortality. Drawing on Foucault’s framing of parrhesia, this paper shows how nurses, by embracing parrhesia, might critique the regime of truth in hospitals that marginalizes nursing voices and sustains the illusion of indefinite life. With the ascetic’s resolve to die to themselves daily, the nurse parrhesiast bears witness to the finite nature of life and confronts the barriers to dying well. By encouraging both patients and fellow clinicians to accept mortality, the nurse parrhesiast can help restore honesty and compassion to the dying process, helping patients like Mr. J prepare for death.