Breathlessness

CONTENT WARNING: This piece contains descriptions of police violence, torture, racism. 

How much air does it take to talk?
How much air does it take to breathe?
How much air does it take to live?

Kimberly Bain, a historian and social theorist of race, environmental and medical racism, and the Anthropocene writes^[1]:

Black breathlessness rings with clarity where it diagnoses the limitations of biomedicine, which has the extraordinary capacity to be so precise yet so powerless in addressing the inequity that makes up the very DNA of the United States—a settler colonial and imperial formation premised upon white supremacy. “I can’t breathe,” speaks with multiple valences. Breathlessness is a biomechanical phenomenon, but It is also psychological, as when policing and medical white coats conjure fear and demand compliance, and social, where it speaks to the ongoing oppression of communities of color. “I can’t breathe,” as I show in this piece, also reveals the limits of our capacity to reason.  

I’m digging into the cases of the four officers involved in George Floyd’s murder: Derek Chauvin, J. Alexander Kueng, Thomas Kiernan Lane, and Tou Thao. It’s about three years since May 25, 2020, when George Floyd lost his life, and most Americans seem to have moved on. I linger on “I can’t breathe” as a demand for action. What are the roles for biomedicine? If biomedicine is about keeping people breathing, “I can’t breathe” reveals the structural failure of biomedicine to intervene against systemic racism. How? And What can we as future providers do about it?

Biomechanical Breathlessness

Is it even possible to say “I can’t breathe?” Breathing and speaking both entail the moving of air across the vocal cords, but in different directions. If you can breathe, you can talk. Many also think the converse is true. If you can talk, you can breathe. The police arresting George Floyd certainly thought so, as transcripts of the police bodycam reveal. This is how they responded when George Floyd repeatedly told them “I can’t breathe:”

But is that true? 

For the authors of an Annals of Internal medicine (AIM) editorial^[4], titled “A Dangerous Myth: Does Speaking Imply Breathing?”, the answer is no^[5]. According to the self-styled “Pulmonary Critical Care Anti-Racism Working Group,” the idea that talking implies the ability to breathe is a myth:

The authors discuss how multiple first aid “training sources cite the inability to talk as a sign of choking.” “It is true that if you cannot move any air you cannot speak. However, the reverse is not true: You can move enough air to produce sound but not be able to breathe enough to sustain the gas exchange needed to prevent organ damage from hypoxemia^[7].”

If A, then B. That doesn’t mean if B, then A.

If one can breathe, then one can talk. But that doesn’t mean if one can talk, then one can breathe. 

400 mL, or just over a cup and a half of air, is necessary for life sustaining breath. “I can’t breathe” is 150 mL, or just under 2/3rds of a cup. The quantification of breath reduces breathlessness to an almost-comforting certainty. The numbers dispel the dangerous myth that if you can talk, you can breathe.

The authors of the editorial hoped that their review of “basic respiratory physiology” can dispel a widely-held myth that “is used to propagate injustice or violence.” When held by agents of state violence—the police—the myth of “if you can talk, you can breathe” exonerates the use of force by denying the existence of respiratory distress. The correction of such myths, the authors reasoned, could “prevent further deaths.” They ended their piece “advocating that all persons who describe respiratory distress receive immediate, serious attention and treatment.” 

Psychological Breathlessness

But breathlessness is not just a numerical problem. George Floyd repeatedly stated “I can’t breathe” before Chauvin even arrived on the scene. The State of Minnesota charged Derek Chauvin for 3rd degree murder and 2nd degree manslaughter on May 29th, 2020. I reproduce below the first four paragraphs from the Statement of Probable Cause submitted at the time by the plaintiff (the State of Minnesota) to the 4th Judicial District Court of the State of Minnesota:  

Keune and Lane were attempting to move George Floyd into the back seat of the car when he said. “I can’t choke, I can’t breathe Mr. Officer! Please! Please!^[9]” Struggling with his body half inside the police car, George Floyd told the police that he was claustrophobic and cannot breathe. This was moments before the widely circulated footage with Chauvin. How can biomedicine account for this breathlessness, one that is not about lung capacity?

The word “Claustrophobia” last appeared in the 3rd edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, in the section of “simple phobia” to refer to “fear of closed spaces^[12].” In the latest edition, DSM-V-TR, the phrase “enclosed places” is found under the diagnostic category of “specific phobia,” as a phobic stimulus of a specific kind: “situational^[13].” It’s coded as F40.248.

I’m not sure what to make of the word “claustrophobia” disappearing from the DSM, but psychiatry gives us another lens through which to understand “I can’t breathe” beyond lung physiology. Several breathing related symptoms appear in the list of panic attack symptoms, which can be consequent to phobias, in the DSM:

Breathlessness, then, goes beyond lung capacity numbers. 

But this seems to fall outside of the police’s comprehension. They did not address Floyd’s 14 assertions that he was claustrophobic. 

Unlike the relationship between talking and breathing, “claustrophobia” did not warrant a response. To the police arresting George Floyd, there’s nothing to do for the claustrophobic breathlessness induced by the enclosed backseat of the car. To them, their job is just to put a body inside. “Sensations of shortness of breath” falls out of their scope of response, and “trembling or shaking” become understood as a sign of resistance. The juvenile retort, that because you aren’t listening to what I am saying, I am not going to listen to you either, underscores how the police construed George Floyd as an object. The content of what he said didn’t matter, let alone how he was feeling.  

This objectification goes beyond policing. Medicine, too, participates in it when it reduces “I can’t breathe” to a matter of lung capacity. To listen to George Floyd’s claustrophobia, to consider the psychological dimension, expands our ability to think beyond physiologic volume. One can imagine a parallel editorial in the American Journal of Psychiatry, one that similarly dispels some myth regarding breathing, panic, and claustrophobia. That article might address the importance of considering other causes of respiratory distress. Like the Annals of Internal Medicine piece, it might advocate for immediate, serious treatment for all persons experiencing phobia induced respiratory distress. At least, it would call for medical intervention before Chauvin even appeared on the scene.

Social Breathlessness

Both the lung capacity or phobia approach, however, leaves policing itself unquestioned. THe authors of the AIM article writes, “the persistent use of of malignant platitudes in the face of another person’s suffering is disturbing, At best, it represents the thoughtless use of heuristic shortcuts; at worst, it indicates deep gaps in empathy, toxic cognitive biases, or malicious intent.” Such framing puts the responsibility on individual police officers rather than the system of policing. Heuristic, empathy, bias, and intent are all individual attributes. We can certainly prosecute individuals who induce respiratory distress in another person, but what do when it is systemic police brutality that induces fear, when policing suffocates? What kinds of “attention and treatment” would be required? 

In the remainder of this piece, I discuss the limits of biomedical reasoning when it comes to addressing this social breathlessness. Where police violence is a foundational feature of the United States – emblemized by the slave catcher, the border police, and private security forces for schools and gated communities – is it even possible for biomedical practitioners to intervene? I highlight three structural features that incapacitates our ability to respond: emotionless objectivity, legal wordsmithing, and self-censorship. I explore each of these by critically contextualizing the AIM authors’ calls for action. In doing so, I contend that addressing breathlessness for patients at a social scale requires clinicians to wade into the discomfort of politics.

I. “According to our oath as clinicians, it is our responsibility to the public to aggressively correct such misconceptions to prevent further deaths^[18].”

There was a clinician on site. Genevieve Hansen, an off-duty firefighter and emergency medical technician, attempted to intervene^[19]. She was out for a walk on her day off when she “heard a woman yelling that they’re killing him.” When she arrived, George Floyd was already on the ground. She approached the scene, and her first words, as recorded by the bodycam, was “Is he talking now?” Along with another bystander, she told Chauvin to get off of George Floyd. When she approached, Chauvin said, “Don’t come over here.” She identified herself as a firefighter and asked for the police to check for a pulse. They couldn’t find one and ordered her to step back onto the sidewalk.

At the trial, the defense attorney asked Hansen if she would agree that her “demeanor got louder and more upset.”        

“Responsibility to the public” doesn’t capture the difficulty of “advocacy,” especially against real police violence. What kinds of strength is required to “speak truth to power,” in the midst of violence? Not everyone occupies the same position of power from which to advocate. Hansen is a white woman, and as a firefighter, first responder kin. In a different context, Chauvin might’ve seen her as an ally. Yet her whiteness did not prevent her from being perceived as a threat, because she was advocating for a Black man. The defense lawyer’s cross examination attempted to make her out as emotional, and thus, not credible. The history of “hysteria” means that witnesses who are women are subject to this line of sexist reasoning. But this also goes beyond individual identity. Reliable witnesses, according to the customs of this country, are supposed to be impartial. Where we can’t peer inside someone’s head to see if they are biased, emotional displays become evidence of partiality. To be heard in court demands stifling one’s emotions. 

Moreover, voicing fails if there is no one to listen. Defense arguments for charges against the police always recourse to the idea of threats. Individual police officers are cast as powerless subjects beset by angry crowds, mobs, and criminals. This fear becomes the justification for the use of force. The fear also leads to an incapacity to hear. Certainly, the myth of if you can talk, then you can breathe, played a role in the use of deadly force. Yet dispelling this myth would not dispel police fear as a central justification for the use of force. Dispelling physiological myths also would not compel the police to listen. As evident from the bodycam transcript, Lane and Kueng tuned out George Floyd before Chauvin even arrived. For police to understand themselves as under a constant state of siege if for the police to be structurally incapable of hearing. What is the utility of advocacy when it falls on deaf ears? Even when people do listen, Hansen’s example shows that not every clinician is heard in the same way. Society’s listening practices are themselves biased, favoring the words of those deemed less emotional, thus more objective. Thus we get in a double bind with emotions: emotions are used to exculpate police violence; yet in the face of such violence, one is supposed to suppress emotions in order to be heard. It would take a lot more than biomedical truths to address these features of how emotions affect who society hears and does not hear. 

II. “The use of incorrect physiologic statements to justify the force leading to the deaths of Eric Garner and George Floyd is Unacceptable. As human beings, we emphasize that It does not take medical training to inherently understand the profound danger and inhumanity behind forcibly inducing respiratory distress in another person^[20].”

Do people inherently understand inhumanity? Is what’s unacceptable 1) the deaths of Eric Garner and George Floyd, 2) the use of force that led to their deaths, or 3) the use of myths to justify the use of force? If it’s only the last part, then we are faced with an uncomfortable possibility, that the use of force leading to the deaths of Eric and Garner and George Floyd could be acceptable with the right justification. The possibility of justification would also mean that there is nothing inherent to recognizing the inhumanity of certain acts. The field of biomedicine is premised upon doing no harm, but there are fields, for example the military, that are predicated upon forcibly stopping people from breathing.

These two paragraphs are taken from the so-called “torture memos,” a group of legal documents drafted by then Deputy Assistant Attorney General of the United States John Yoo and signed in August 2002 by Assistant Attorney General Jay S. Bybee. The memos were drafted in response to the CIA, who requested that the Attorney General’s office evaluate whether their “proposed conduct [in interrogating Guantánamo Bay detainees] would violate the prohibition against torture found at Section 2340A of title 18 of the Unite States Code.” The “proposed conduct” ranged from “walling” and “facial slap (insult slap)” to “insects placed in a confinement box” and infamously, waterboarding.

The subject of waterboarding feels as if they are drowning. Physiologically, waterboarding induces respiratory distress^[22]. The act is the intentional infliction of breathlessness.

The text of the memos do more than evoke an emotional response. They force us to acknowledge that there is no “inherent” understanding of what acts are human or inhumane. Indeed, “rule of law” means what matters is legal definition, not some presumably shared sense of morality. Whoever writes the definition controls exactly when, where, and how inducing respiratory distress can be perfectly legal in the United States.

Under U.S. law, torture is defined as “an act committed by a person under the color of law specifically intended to inflict severe physical or mental pain or suffering (other than pain or suffering incidental to lawful sanctions) upon another person within his custody or physical control)^[23].” Each word in this definition presents an opportunity to justify how waterboarding, or indeed any infliction of respiratory distress, would not violate this U.S. Statute. For example, one can appeal to an external scientific authority to declare that waterboarding does not inflict physical pain, and is thus not torture. When there is a range of expert opinion, one can either find a sympathetic expert or alter definitions. As we read in the memos, the introduction of a time duration criteria makes it possible to define torture away. If “prolonged” mental harm on the order of “months or years” is the requisite criteria for torture, then waterboarding cannot be torture because the emotional distress created by waterboarding only lasts minutes. 

The Memos have been severely criticized, especially in the legal sphere^[24]. They are not representative of the federal government’s stance (which changes), but rather reveal that we do not all share the same sense of justice. There are many ways through which one can “reason” through whether something constitutes “myth” or “legality.” Indeed, “reason” is what provides flexible cover. In rejecting Chauvin’s appeal in April 2022, the judge wrote that “‘the law only permits police officers to use reasonable force when effecting a lawful arrest … Chauvin crossed that line here when he used unreasonable force on Floyd.” This returns us to the earlier question of what the AIM editorial authors found unacceptable. Did they object to  the use of force in general, or did they simply reject the use of incorrect physiological statements to justify deadly force? The latter would imply the possibility of a correct physiological justification, just that there could be reasonable use of force. We then become entirely dependent on how we define what is reasonable, the wordplay of what constitutes how much air it takes to talk and how much air it takes to breathe.

III. “We hope that everyone will join us in advocating that all persons who describe respiratory distress receive immediate, serious attention and treatment^[25].”

Does it not seem impotent to conclude a piece on addressing systemic injustice by advocating for medical treatment? Is this the upper limit of what physician advocacy can look like, not to demand a stop to the forces that induce respiratory distress, but only to prescribe treatment when someone describes respiratory distress?

Put more generously, what is the clinician’s scope of responsibility? What can “clinicians” do, especially where non-clinicians cannot? Certainly, this includes a discussion about the physiology of talking and breathing. Presenting the “authoritative” voice and speaking for human physiology in ways that other people can’t is one way to influence the medico-legal discourse, but that influence is provisional. One can simply consult another expert witness with a more sympathetic opinion, and indeed, the editorial was published in the “Ideas and Opinions” section. Apparently, the demand for justice is not universal. It’s just an idea. 

There is a curious form of self-censorship. It’s as if demanding justice is unscientific, that there is a limit to what is sayable by clinicians. Even though police violence has oppressed communities of color and caused mental distress, the DSM makes no mention of it^[16].  The AIM editorial was written by an “anti-racism working group,” but the word “racism” or even “race” does not appear anywhere in the text. What accounts for these absences? Is it because racism seems too big of a concept to be captured by the kinds of measurement that we are comfortable with? Is it because the word is too political and medicine should be apolitical? Or, are we afraid of the enormity of what it would take to repair the harm? Maybe it’s professionalism, custom, or disciplinary divides, but is it too hard for clinicians to breathe the word “justice?”

Social theorist Gabriel O. Apata has described suffocation as “the characteristic feature as well as the weapon of contemporary racial injustice^[26].” If Black breathlessness is the condition of the United States today, then I suggest that “I can’t breathe” diagnoses a parallel phenomenon that enables this suffocation: biomedicine’s refusal to see how politics infuses everyday living. This refusal is not willful. Rather, it is a consequence of circumscribing professional roles, bodies of knowledge, and ways of thinking. The reduction of breathing to lung volume, the inability to listen to mental distress, the policing customs that imagine constant siege and demand impossible docility, the need to be emotionless to be heard as an expert, the clever wordsmithing that defines injustice away, the inability to say racism where it exists … Each of these is a suffocation, a professional inability to talk, let alone breathe. 

To focus only on George Floyd’s breathlessness is to lose sight of the surrounding bystanders, each holding their breath, powerless to stop the air from being choked out of Black Lives. 

Talking Against Breathlessness 

If A, then B. That doesn’t mean if B, then A.

It does however, mean If not B, then not A.

If one can’t talk, then one can’t breathe. 

If one can breathe, then one can talk.

So talk. The authors of A Dangerous Myth took an important step in speaking, breaking the breathlessness of the witness in their own way. But where there are limits to their intervention, we can exceed them. It would entail Abolition Medicine^[27], to “interrogate the upstream structures that enable downstream violence.” This effort would entail self-work, not just self-care. It would entail what anthropologist Deborah Thomas has described as witnessing 2.0,^[28] which asks us to – citing communication theorist Barbie Zelizer – “assum[e] responsibility for contemporary events.” 

Each aspect of biomedical breathlessness that I’ve identified here is an opportunity to address Bain’s Black Breathlessness. Insist on hearing the subjective despite the seduction of numerical simplicity. Lean in to emotions where it directs our moral compass. Assume responsibility when words are shaped to limit liability. Call out injustice, especially when silenced by respectability and our internalized sense of “decorum.” Jump into the political fray, because breathlessness compels us to. 

Alex Chen is a CDY5 at the Perelman School of Medicine

Art by Santiago Lopez, an MS1 at the Perelman School of Medicine

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^[1] Bain, Kimberly. 2020. “Didn’t Need, To Know.” Literature and Medicine 38 (2): 239–41. https://doi.org/10.1353/lm.2020.0016.

^[2] State of Minnesota v. Thomas Kiernan Lane. 27-CR-20-12951. Exhibit 2. Axon_Body_3_Video_2020-05-25_2008. p. 15

^[3] Ibid. p. 16

^[4] Law, Anica C., Gary E. Weissman, and Theodore J. Iwashyna. 2020. “A Dangerous Myth: Does Speaking Imply Breathing?” Annals of Internal Medicine 173 (9): 754–55. https://doi.org/10.7326/M20-4186.

^[5] https://globalnews.ca/news/7160881/george-floyd-death-talking/

The Associated Press, AMY FORLITI. “Medical experts: Floyd’s speech didn’t mean he could breathe.” Telegraph Herald (Dubuque, IA), July 10, 2020: 8. NewsBank: Access World News – Historical and Current. https://infoweb-newsbank-com.proxy.library.upenn.edu/apps/news/document-view?p=WORLDNEWS&docref=news/17C24C52CBA71FB0.

^[6] Law. Et al.

^[7] Ibid.

^[8] Statement of Probable Cause in Complaint submitted by the State of Minnesota to the 4th Judicial District Court of the State of Minnesota, charging Derek Chauvin for 3rd degree murder and 2nd degree manslaughter on May 29th, 2020.

^[9] Exhibit 2. P. 12.

^[10] Exhibit 2. P. 7.

^[11] Ibid. p. 7 – 8.

^[12] Janet B. W. ; Fi Spitzer, Robert L. ; Gibbon. 1980. DSM-III. Diagnostic and Statistical Manual of Mental Disorders (Third Edition). 3rd edition. American Psychiatric Press. P. 229.

^[13] Association, American Psychiatric. 2022. Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-Tr. 5th edition. Washington, DC: Amer Psychiatric Pub Inc. p. 224-225.

^[14] Association, American Psychiatric. 2022. Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-Tr. 5th edition. Washington, DC: Amer Psychiatric Pub Inc. p. 235-236.

^[15] Exhibit 2. P.2.

^[16] Police only appears as patients (e.g. suffering from PTSD), as part of delusions (in psychotic disorders), and as “authority figures” who don’t understand tic disorders.

^[17] Law. Et al.

^[18] Ibid.

^[19] http://www.cnn.com/TRANSCRIPTS/2103/30/sitroom.01.html

^[20] Laws. Et al.

^[21] “Interrogation of al Qaeda Operative.” Memorandum for John Rizzo Acting General Counsel of the Central Intelligence Agency. August 1, 2002.

^[22] Bierens, Joost J. L. M., Philippe Lunetta, Mike Tipton, and David S. Warner. 2016. “Physiology Of Drowning: A Review.” Physiology 31 (2): 147–66. https://doi.org/10.1152/physiol.00002.2015.

^[23] 18 USC § 2340(1)

^[24] https://www.whitehouse.senate.gov/news/op-eds/how-justice-erred-on-waterboarding

^[25] Laws. Et. al.

^[26] Apata, Gabriel O. 2020. “‘I Can’t Breathe’: The Suffocating Nature of Racism.” Theory, Culture & Society 37 (7–8): 241–54. https://doi.org/10.1177/0263276420957718.

^[27] Iwai Y, Khan ZH, DasGupta S. Abolition medicine. Lancet. 2020;396(10245):158-159. doi:10.1016/S0140-6736(20)31566-X

^[28] Thomas, Deborah A. 2019. Political Life in the Wake of the Plantation: Sovereignty, Witnessing, Repair. Durham: Duke University Press.