Abstract
What is health? The answer to this question is by no means obvious. And yet in a way most of us know what it is like to be healthy, since this is the state in which we most often find ourselves in our normal life. Illness to most of us is an exception, a contrast to and interruption of our normal way of being in the world. Merely to experience something and to conceptualize it, however, certainly are two different things, although firmly connected. We can trace the theories of this connection at least as far back as Plato’s world of ideas explaining and supporting the world of appearance. The nature of the relation between experience and concept has, in the discipline of philosophy, been a constant source of debate and generated many different theories. This part of my work will take its starting point in one of the philosophical attempts to found a theory about the structure or eidos of experience — phenomenology.
‘Oder müssen gar Krankheit und Tod überhaupt — auch medizinisch — primär als existenziale Phänomene begriffen werden?’90
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Reference
Heidegger, Sein und Zeit (1986, p. 247).
As was made clear in Part 1, this study limits its scope to the Western tradition of medicine and health. I do certainly not, however, argue against the view that ancient Greek culture and philosophy were influenced by or built upon Egyptian and Mesopotamian culture, nor do I want to dispute the importance of Indian and Chinese healing practices and theories of health. The Hippocratic tradition (dating from c. 400 B.C.), however, (just like ancient Greek philosophy in general) seems to provide the starting point for a specifically Western cultural praxis and way of thinking. It also, as we have seen in the first part of this work, forms the starting point for a unique medical relationship with a certain structure of helping and healing.
rrely mainly on Petersson (1995) here. Specific references to all passages in Plato’s work in which the philosopher addresses these different concepts of health are found in this paper.
See the last two parts of Michel Foucault’s Histoire de la sexualit¨¦ (1984), ‘L’usage des plaisirs’ and ‘Le souci de soi’, for an examination of this theme.
Regarding the difference between Greek ethical thought and the non-cognitivist ethics characteristic of modern philosophical thinking, see Maclntyre (1985).
Here we seem to come close to the modern holistic health theories of, for instance, Ingmar Porn and Lennart Nordenfelt, which I will discuss later on. The main difference, however, is that the good life (eudaimonia) in ancient Greece was a normative and objective concept. The individual himself had no influence upon what was to be considered as a good life for him, as is the case in Porn’s and Nordenfelt’s theories.
The three most important articles by Boorse on health theory were published in the seventies (1975, 1976 and 1977). Boorse has recently defended his theory against the many different forms of critique it has given rise to in A Rebuttal on Health (1997).
Boorse writes in A Rebuttal on Health that he would today prefer the term ‘pathological condition’ to ‘disease’, in order to avoid misunderstandings (1997, p. 41 ff).
Boorse uses the term ‘state’ when he discusses diseases, although it would be more appropriate to call many diseases ‘processes’ (consider, for example, the various forms of cancer). The disease, in Boorse’s framework, causes an abnormal functioning (or more exactly the inability to function normally) of a part of the body. Sometimes, however, Boorse seems to allow the possibility of identifying the disease with the state of abnormal functioning itself (1977, p. 567). This possibility seems to arise from cases in which the cause of the abnormal functioning is not known, or in which the cause is known to be an external factor (such as pollution).
I will not discuss Boorse’s theory of mental health here separately, since it is in almost every sense similar to his theory of somatic health. The only difference lies in the possibility of the existence of other primary goals for the organism than survival and reproduction when psychological functions are taken into consideration in the theory (1976). Everything that the theories of psychology (and sociology) have to say about the normal functions of the individual should, however, in principle, be possible to express in the languages of chemistry and physics; there are no qualitative differences, and hence, the science of (neuro)physiology still seems to be the ultimate ground for Boorse’s philosophy of mental health.
As touched upon in Part 1 of this work, I will not consider the question whether science itself is value-laden, in the sense of depending on external constituting factors. It is not necessary for my argument to take a stand on the issue of the objectivity of science; the important thing is that there are other forms of knowledge in medicine than medical science. These other forms of knowledge, which I will try to explicate through the theories of phenomenology and hermeneutics, are based in clinical practice and focus upon the patient as a person and not exclusively as a biological organism. The degree to which science is a social construction or depends upon a preceding historical ‘episteme’ is consequently an issue that will not be dealt with here. I hope it has become obvious, from the first part of this work, however, that I do not proceed primarily from a theory of social construction, but from a phenomenological theory, based on the concept of lifeworld or being-in-the-world rather than on social relations of political power. The meaning-structures of the Western lifeworld are of course not historically static, but some basic strata are more reluctant to change than others. The caring, medical relationship which is the subject of this book is one example of this. The phenomenological structure of health, which I will try to outline later in this part, is another example. That science is an activity which proceeds from the basis of a cultural lifeworld and that it needs to be linked to this everyday world in order not to lose its meaningfulness, is however a phenomenological thesis which follows from my approach (Husserl 19766). But, on the other hand, it is also obvious that science during the last two centuries has, indeed, in many ways, changed the lifeworld in which we experience and seek help and remedy for illness.
m important forerunner to this modern theory of homeostasis was the work of Claude Bernard, who more than 80 years before Cannon founded the discipline of physiology and conceived of the normal physiological state as the preservation of a stable inner environment, which can be measured and assigned certain values. See Canguilhem (1991, pp. 260–261).
See von Wright (1971), especially Chapter 2: ‘Causality and Causal Explanation’.
See Jensen (1983). It might today. in the face of the development of recent biomedicine, be more accurate to speak of an informatic model in medicine than a machine model. The computer rather than the automobile seems to be the current model of the human body (Borck 1996). Boorse’s theory, in any case, is intended to apply to animals as well as to human beings. This in a way seems to be inevitable, since his concept of health is based on the organism and not on the person. I will elaborate on this theme in the next section when I discuss a holistic theory of health.
Boorse does allow for the possibility of supernormal functioning without disease: The unusual cardiovascular ability of a long-distance runner is not a disease’ (1977, p. 559).
Most of the problems I refer to here have already been highlighted by Nordenfelt in his On the Nature of Health: An Action Theoretic Approach (1987) ¡ª a work that I will discuss extensively in the next section ¡ª and before him by Canguilhem (1991 11966]). Other important critiques of Boorse are Engelhardt (1984) and Fulford (1989).
Canguilhem (1991 [19661) refutes in a convincing manner the biostatistical disease concept, which he shows to have been present in medicine ever since Claude Bernard and Auguste Comte. He also develops a view according to which health should be approached as an evaluative concept studied at the level of personal, clinical experience: In the final analysis, would it not be appropriate to say that the pathological can be distinguished as such, that is, as an alteration of the normal state, only at the level of organic totality, and when it concems man, at the level of conscious individual totality, where disease becomes a kind of evil?¡ The situation is such that if the physiological analysis of separated functions is known in the presence of pathological facts, this is due to previous clinical information, for clinical practice puts the physician in contact with complete and concrete individuals and not with organs and their functions’ (1991, pp. 87–88).
Etymological studies provide some support for developing a (w)holistic theory of health. The word ‘health’ originally seems to have meant ‘wholeness’ or ‘completeness’ (Klein 1966, p. 710). The same applies for the German ‘Gesundheit’ and the French ‘sant¨¦’ (Ritter and Gründer 1974, vol. 3, p. 560: von Wartburg 1964, pp. 184–186).
Boorse writes in A Rebuttal on Health that this was what he intended all the time, although he did not make it clear enough in the earlier articles (1997, p. 79).
The Latin word ‘persona’ originates from the classical theatre where it meant ‘mask’, ’role’ or ’character’. In the Christian tradition the concept of person was associated first with the Trinity and then with the human individual and his relationship to God. For this and later developments of the concept of person, see Horgby (1995) and Theunissen (1966).
There are exceptions, however. See, for instance, Singer (1993, p. 87).
The books by Nordenfelt I will proceed from in this section are On the Nature of Health: An Action-Theoretic Approach (1987. slightly rev. ed. 1995) and Quality of Life, Health and Happiness (1993). The most important forerunner to and source of inspiration for Nordenfelt is undoubtedly Canguilhem (1991 [1966]). For other attempts to formulate holistic theories of health, see Fulford (1989, 1993); Kass (1975); Pörn (1984, 1993); Seedhouse (1986); and Whitbeck (1981).
It could, of course, be said that it is, in fact, possible to fly even today given the right circumstances ¡ª the absence of gravity. The point of these examples is to highlight the fact that the abilities, actions and goals of a person need to be specified in terms of his environment. In the phenomenological context this will lead us to the concept of ‘lifeworld’ or ’being-in-the-world’.
A sequence of actions is several actions following in succession. The concept action-chain refers to the fact that an action can be thought of as doing x by doing y. The variables here do not refer to different actions in the sense of different events causally related, but rather to the same action under different descriptions. For example, 1 open the window by turning the handle by turning my hand. Any action, of which it can be said that there exists no description according to which the action is performed by doing something else, is called a basic action. Other actions are called generated actions. The basic action must still be described as an action; that is. it must be intentional ¡ª it must be a description of me or somebody else doing something, not of processes in my body that merely take place.
The replacement of ‘standard’ with ’accepted’ in On the Nature of Health (1995, rev, ed.) merely serves to underscore the fact that the circumstances must be specified by someone, and this determination can never be objective in the scientific sense. Someone has to accept the circumstances as standard; whether, in the case of health, it is to be the person whose health is being examined, some general consensus, or an expert team, has to be settled from case to case. There is no final answer on this issue in Nordenfelt’s theory (the same applies, as we shall see later, for what he calls ’vital goals’), and, indeed, this is, in his view, the inescapable (but not damning) consequence of the theory being normative.
Or more precisely: the second-order ability to realize vital goals given standard circumstances. Second-order ability is the ability to develop another ability given an adequate training program. I do not, for example, speak or understand Chinese, but given a (rather ambitious) training program, I can learn to do so. It is necessary to introduce the notion of second-order ability into the definition of health, since otherwise, people would automatically develop unhealth simply by moving to an unfamiliar culture with very different standard circumstances and vital goals (1987, pp. 49–50). This is not to say that what counts as standard and normal does not matter when we decide upon the matter of health. As we have already seen above, it is indeed crucial, and someone from a foreign culture deemed unhealthy by us might indeed be perfectly healthy given the vital goals and standard circumstances of his own culture
What we obviously cannot do is to define the basic needs in terms of necessary conditions that the individual must be able to fulfil in order to be healthy, since health is precisely that which we are trying to characterize in the explication of basic needs (Nordenfelt 1987, pp. 57–65).
Consider, for example, a person under very unfortunate circumstances living, let us say, in Somalia. This person may be able to realize his vital goals, in terms of physical and mental dispositions, but he is not given the opportunity and consequently is very unhappy. On the other hand the unhealthy person may be very happy, according to Nordenfelt’s definition, if he is given extremely favourable opportunities (for example mechanical aids and assistants) to attain the goals that, given standard circumstances, he would not be able to realize.
This is an important difference compared to the disease concept of Boorse, who identifies disease on purely scientific, and not on clinical grounds.
For a discussion of the relation between the concept of mental health and Nordenfelt’s theory, see Tengland (1998).
The authoritative guide to Husserl’s phenomenology, examining the genesis of his philosophy and its main themes, is Bernet et al. (1989; translated into English in 1993). Another valuable introduction to Husserl’s philosophy is Zaner (1970). My presentation of Husserl’s philosophy in this section is mainly built upon his Ideen zu einer reinen Phänomenologie and phänomenologischen Philosophie. Erstes Buch: Allgemeine Einführung in die refine Phänomenologie (I 976a [1913]). It is, of necessity, a very cursory introduction, omitting many of the main themes of Husserl’s philosophy, especially that which is generally referred to as the ‘genetic’ part of his phenomenology; that is, the constitution of the transcendental ego, which lives in the stream of acts of consciousness through the non-intentional processes of inner-time consciousness. The reason for leaving out this important part of Husserl’s philosophy is that I will turn to Heidegger instead of Husserl when it comes to laying out a phenomenological interpretation of health and thus will discuss the status of the self (ego, person) in the terms of Heidegger’s and not Husserl’s philosophy. I will return briefly to this theme in the next section.
See Zaner (1970) for this interpretation of the method of free fantasy variation in Husserl. It is interesting to note that this phenomenological ‘method’ bears many similarities to the conceptual analysis of Nordenfelt, who also, to a large extent, proceeds from imaginary examples. Perhaps free fantasy variation should really be considered the philosophical strategy, generally?
My chief sources of inspiration for these examples come from my study of clinical encounters at Ekholmen Primary Care Centre, and at the University Hospital in Linköping. I have also found information and stories about experiencing and living with illness, as well as meeting with the doctor, in many books. The accounts I have profited from the most are Fisher (1997); Guthrie and Guthrie (1997); Hardy (1978); Kantoff and McConnell (1996); Kleinman (1988); Richt (1992); and Senelick and Rossi (1994).
As we have seen above, Nordenfelt’s primary concept in conceptualizing health is, however, not lived experience, but ability. See Section 9 below for an analysis of the similarities and differences between Nordenfelt’s theory and my phenomenological approach to health.
In addition to ‘disease’ and ‘illness’ a third term, ‘sickness’, is often used in talking about health and its opposites. When contrasted to illness it is often used in the sense of a social role, a ‘sick-role’, ascribed to a person by other people, rather than being something experienced by the person himself. However, the term is also often used interchangeably with ‘illness’, especially in American English. To avoid confusion I will refrain from using the term ‘sickness’ in this work. If the term ‘sick’ is used in any of my examples it means ‘ill’ and nothing else. For an examination of the different meanings of the three terms, see the articles by Nordenfelt and Twaddle (1993).
See Drew Leder (1995) for a survey of the fragmentary but interesting attempts that have been made, mainly by Kay Toombs, Richard Zaner and Leder himself. I will return to these attempts later in this work. Psychiatrists and psychoanalysts inspired by the philosophy of Martin Heidegger have in a (at least partly) phenomenological manner developed theories of mental health and illness. Three well-known and influential examples are the theories of Ludwig Binswanger, Medard Boss, and Jacques Lacan. See Richardson (1993) and Spiegelberg (1972).
This is particularly obvious in some of the manuscripts which were not published until years after Ilusserl’s death. For a careful examination of this theme, see Zahavi (1994). The first and most important philosopher who developed a phenomenological theory based on the intentionality of the body was Maurice Merleau-Ponty. I will return to his work later in this part of my work. See also Zaner (1964) on the problems of the phenomenology of embodiment.
See Dreyfus (1991, p. 46 ff.).
Despite the difficulties indicated above, I do not want to claim here that it would be impossible to work out a theory of health working within the scaffold of Husserl’s phenomenology. Two interesting recent attempts to approach questions of normality and medicine on the basis of Husserlian phenomenology are Steinbock (1995) and Waldenfels (1998).
This presentation limits its scope to Heidegger’s early philosophy and first main work, Sein and Zeit from 1927: (1986, 16th ed.) The excellent new translation by Joan Stambaugh from 1996 has been a great help in transferring Heidegger’s vocabulary into English.
As indicated above, 1 (with Husserl and Heidegger) do not think that this gives rise to any sort of total cultural relativism; see Guignon (1991) for a good survey and formulation of the problem. To start with there will probably exist some meaning-strata that are common to all lifeworlds, and the objectivity of science as a certain activity striving towards the possibility of inter-subjective verification through empirical experiments might be such a stratum inherent in every current (Western) lifeworld. But that science is rooted in the lifeworld certainly means that, if science is left in a limbo, if it loses all connections to the lifeworld it was born in, it will lose its meaning for human beings. Science could then also become dangerous in its tendency to technologize the lifeworld; that is, not only cut its links to the lifeworld but also turn back on it and destroy its structures. Western medicine, to mention just one relevant example, would thus lose its character of a human meeting and end up as merely scientific investigation. This technologization of the world is a main theme of Heidegger’s late philosophy (1954b), and of many other German philosophers in this tradition such as Hans-Georg Gadamer and Jürgen Habermas.
In the lecture series from the twenties (see especially 1988) Heidegger does not hesitate to use the word ‘Leben’ in his philosophical analysis. See Krell (1992), especially Chapter 1 and 2. on this theme. The most powerful influence for Heidegger’s own ‘life philosophy’ was without doubt Wilhelm Dilthey. See Kisiel (1986–87).
This is Heidegger’s own famous example (1986, p. 84); one could think of countless others.
This model reminds us of the Aristotelian relation between logos and pathe, the two elements of the psyche which must be balanced in an adequate way in the virtuous (healthy) man. The book by Kisiel (1993) has shown the immense importance of Aristotle’s philosophy for Heidegger in the lecturing period of the twenties leading up to Sein and Zeit. Volpi (1996) has, in addition to this, shown how Heidegger’s philosophy is indeed pragmatic ¡ª that is, based in the active and not in the theoretical life (something that 1 stress in my own interpretation of Sein and Zeit) ¡ª but in a Greek rather than American sense.
The translation of the term ‘Befindlichkeit’ into English presents real difficulties. The choice of ‘state of mind’ in the first translation of Sein and Zeit by Macquarrie and Robinson was obviously faulty, since Heidegger’s aim is precisely to not get stuck in any psychology or philosophy of mind as opposed to body and world. Stambaugh’s ’attunement’, in the more recent translation, however, is also problematic, since it identities ‘Befindlichkeit’ with ’Stimmung’ and ’gestimmt sein’, which are also translated as ’attunement’ and ’being attuned’, respectively, in her idiom. ’Sich befinden’ literally means ’to find oneself’, and through tying this notion to (but not identifying it with) feeling and mood ¡ª ’gestimmt sein’ ¡ª Heidegger wants to indicate that the way in which we find ourselves in the world, as thrown into a situation together with others, is fundamentally to be thought of as a precognitive phenomenon. Befindlichkeit is therefore the link between Geworfenheit and Stimmung ¡ª to find oneself in the world is to find onself as being thrown into a mood.
See Held (1993); Pocai (1996); and Svenaeus (1997).
The final meaning of this transcending-returning structure in Sein and Zeit is attained through an analysis of time. Dasein ‘zeitigt sich’ ¡ª projects itself towards the future in a coming back to the possibilities which have been given to it through the past. In this way Heidegger tries to overcome a philosophy that is narrowed down to focusing upon the present as the mode through which the past and future acquire their meaning. Dasein’s way of being in time (or rather its way of being as time itself) is ‘outstanding’ (ek-statikon) in the past and future, which are therefore called ‘Ekstasen’. It is through this time-structure that Heidegger’s famous ’being-towards-death’ should be understood. Dasein is not only a projecting and coming back of itself through and towards its possibilities, but also a finite project. The certainty of death indeed belongs to the meaning of every human existence. But this certainty not only means that the future will not be forever, but also that Dasein is dying at every moment in the sense of a constant uncertainty of what the future will hold ¡ª every moment could be the last one (1986, p. 245).
Heidegger generally shuns the notion of ‘person’ and uses ‘self. The reason for this is that he thinks that the concept of person is caught up in an ‘ontic’ tradition, tied to theology, anthropology and psychology (1986, pp. 46–50). This, however, does not seem to be a convincing argument, since almost every concept which Heidegger uses in his fundamental ontology has an ‘ontic’ pre-history. This is certainly true of Selbst, see Taylor (1989). I will therefore in this study not follow Heidegger’s advice, but will rather use the term ‘person’ in a similar way to the phenomenological outline of ‘self. For an illuminating study of the phenomenological concept of self, which uses medicine and illness as clues, see Zaner (1981). See also Chapter 3 of a later work by him (1988) for a phenomenological approach to illness.
Nietzsche’s notion of a ‘große Gesundheit’ seems to be a forerunner to such interpretations (1973, pp. 15–17, 317–319). That is, ’the great health’ of Nietzsche could be understood as a form of authenticity ¡ª the mode of existence of the ’fitter’, stronger, braver individual or culture, which can endure and learn from pain and illness ¡ª rather than as health in the usual sense. On this subject see Krell (1996), Chapter 10, and Raymond (1999). The remarks by Nietzsche on Gesundheit der Seele in Die fröhliche Wissenschaft could also, however, be interpreted as promoting an individualistic, holistic health-concept: ’Es kommt auf dein Ziel, deinen Horizont, deine Kräfte, deine Antriebe, deine Irrthümer und namentlich auf die Ideale und Phantasmen deiner Seele an, um zu bestimmen, was selbst für deinen Leib Gesundheit zu bedeuten habe’ (1973, p. 105).
My phenomenological analysis of health does not strive towards changing the everyday meaning of the terms ‘health’ and ‘illness’. One alternative would of course be simply to accept the consequences of these imperfect homologies ¡ª between, on the one hand, authentic understanding and health and, on the other hand, inauthentic understanding and illness ¡ª and say that people we normally refer to as healthy are not ‘really healthy’, and that people we refer to as ill are sometimes indeed ‘very healthy’. This alternative is in line with the Nietzschean proposal I remarked upon above. My aim is rather to explicate by way of phenomenological analysis what we mean in everyday life by ‘healthy’ and ‘ill’. Of course, however, this analysis could also lead to a change in our view on individual cases.
Zollikoner Seminare (1994 [1987]). These seminars appear to be one of the very few places where Heidegger addresses not only health and illness, but also embodiment (Leiblichkeit). Heidegger, otherwise reluctant to discuss the specific activities of everydayness, is here forced to address these themes in the presentation of his philosophy. The encounter between the famous philosopher and the doctors offers very stimulating reading since Heidegger (even more than in his lecture courses) has to mobilize all his pedagogical skills in the face of the questions of the philosophically untrained audience. Boss writes in his introduction that: ‘diese Seminar-Situationen riefen die Phantasien wach, es würde erstmal ein Marsmensch einer Gruppe von Erdbewohnern begegnen and sich mit ihnen verständigen wollen’ (1994, p. xiv).
However, the two terms ‘mental’ and ‘psycho-somatic’ are rejected by Boss, who employs a Heideggerian vocabulary.
t is a widespread misunderstanding that Heidegger was an ‘existentialist’ like Sartre, who clearly built his theories on Sein and Zeit, but also changed Heidegger’s phenomenological hermeneutics into an ethics of authentic freedom. It is ironic that Boss, who wants to be a true Heidegger scholar and who often reproaches others for an anthropological reading of Heidegger’s philosophy, falls into the trap of existentialism himself when it comes to health.
It seems to me that the existential psychoanalysis of Ludwig Binswanger, despite its originality and fruitfulness for psychiatry, tends to make the same mistake; that is, health is understood as freedom, and illness is identified with the lack of such freedom. See Binswanger (1962, pp. 118–119). Guignon (1993)
Wohnen ¡ª ‘to dwell’ ¡ª is an important theme, particularly in Heidegger’s later works, although he never links the thoughts about being at home in the world to health; see, for instance, (1954a). See also L¨¦vinas (1961) for a phenomenological analysis of the home.
The double meaning of the German word ‘unheimlich’ ¡ª it means both ‘uncanny’ and ‘not at home’ or ‘unhomelike’ (‘unheimisch’) ¡ª cannot be translated directly into English. For the etymology of the word ‘unheimlich’ and the relation between the phenomenon of Unheimlichkeit and mental illness, see Freud (1919). See also Binswanger (1963), ‘The Case of Lola Voss’.
Erwin Straus’s idea of an I-Allon (I-other) relation as the basis of our being-in-the-world has been very helpful here in my reading of Heidegger. See Straus (1966a, 1969).
One also finds some support for balance being an important aspect of health in sociological studies focusing upon the everyday experience and understanding of being ill and healthy. The notion of being in a state of balance is often mentioned when one asks people about their thoughts on health. In addition to this, absence of diseases, well-being, and strength, are common denominators of health. Health is considered a sort of imperceptible harmony which is rarely explicitly noticed and thought about except when it is replaced by a feeling of disharmony ¡ª illness. See Tegern (1994).
This thought is inspired by Straus’s essay The Upright Posture (1966b), in which, however, the author also tries to give this phenomenon a moral significance which is absent in my analysis.
See Plügge (1962, p. 97).
The example is taken from Hardy (1978, pp. 232–233). It has however been slightly altered.
Pain would here not be restricted to a sensation in the body, but would consist in an atmosphere, a ‘pain-mood’ disrupting understanding. See Leder (1984–85). See also Heidegger (1989. pp. 118–119): ’Eine Magen “verstimmung” kann eine Verdüsterung fiber alle Dinge legen.’
This formulation might remind the reader of Aaron Antonovsky’s book Unravelling the Mystery of Health (1987). ‘Sense of coherence’ in Antonovsky’s theory is not, however, an attempt to characterize health, but a factor contributing to health. Antonovsky’s health concept seems to be similar to the biomedical one ¡ª that is, absence of disease. Antonovsky, a medical sociologist by profession, discovered that sense of coherence in one’s life seemed to be the most important factor for enduring (and surviving) situations of heavy stress without getting depressed or ill in some other sense.
For an interesting study of normal and pathological physiology from a phenomenological perspective, see Buytendijk (1974). The following remark by Buytendijk fits in nicely with my attempt at a phenomenological theory of illness: ‘Being ill is above all alienation from the world’ (p. 62, italics in original). 15611 is tempting here to extend this interpretation of health as a rhythmic balancing being-in-the-world to include the regular suffering of mild diseases ¡ª such as having a cold once or twice a year, from which one recovers without seeing the doctor or taking any drugs. The homelikeness of health would thus be viewed as a balancing which is sometimes lost, but which constantly seeks to re-establish itself. Recent
studies on the functioning of the immune system could be invoked to support such a theory. Canguilhem’s view upon health as a capacity to institute new biological norms in changing circumstances also seems to point in this direction (1991. pp. 196–197).
Even if one, like Boorse, tries to solve this problem by specifying different levels of normal functioning for different ages, one cannot deny that some of the causes of these lower levels of functioning would indeed normally be called diseases. Nordenfelt would try to solve the problem of a decreased ability to realize vital goals in life by saying that the vital goals change throughout life (1987, p. 113). This is indeed true, but many other things in addition to abilities and vital goals change throughout life, and the phenomenological theory is meant to be better suited to give an explication of these changing circumstances, which are of importance for a discussion of health.
For a phenomenological study of the genesis of the self, see Part 2 of Zaner (1981). I have not found it necessary to include such an analysis in this work, although I think Heidegger’s phenomenology in combination with the theories of other phenomenologists such as Richard Zaner and Paul Ricoeur ¡ª in the case of the latter see especially Oneself as Another (1992) ¡ª offer great possibilities.
n the Zollikoner Seminare Heidegger talks about the possibility of releasing (auslösen) moods through electric shocks (1994. p. 244). The method, however, does not produce (bewirken) moods ¡ª this is impossible since moods are not objects or states that can be produced, but meaning-patterns of existence. The mood is only correlated to a brain state: ‘Die Gestimmtheit wird nur ausgelöst. Je einer Gestimmtheit ist ein bestimmter Gehirnzustand zugeordnet. Der Gehirnvorgang ist jedoch nie hin-reichend für das Verstehen einer Gestimmtheit, nicht hin-und zu-reichend sogar im wörtlichsten Sinne, weil er nie in die Stimmung als solche hineinreichen kann.’ We will return to these issues in the first section of Part 3, which discusses explanation and understanding in medicine.
The example is taken from Senelick and Rossi (1994, p. 70) and is continued in the next part of this work.
This of course presupposes that the comatose person is really unconscious and not merely sleeping. Dreams are clearly examples of a form of existence having attunement and understanding.
We will soon return to Merleau-Ponty in discussing the lived body. This, however, might be the proper place for an urgent question that might already have entered the reader’s mind in my presentation of Nordenfelt’s theory: What about children (infants) and animals? Are they all deemed unhealthy by the holistic and the phenomenological theories? Nordenfelt tries to solve the dilemma that infants are not able to realize vital goals by introducing the notion of ‘standard adult support’ (1987, p. 104). The phenomenological answer would be similar, since infants are not immediately but only gradually thrown into the intersubjective meaning-patterns of being-in-the-world. This process certainly demands support and teaching ¡ª consider language use, for instance. The transcendence and coherence one demands for a child to be healthy would therefore gradually increase. It is important to remember that I do not identify illness with a total lack of transcendence. This indeed would only be the case when a human being is dead or in a coma. Illness is a defective transcendence, a partial breakdown in the meaning-patterns of worldliness of Dasein. Now, what about animals? Do they have vital goals? Do they have worldliness? Heidegger’s answer would be something like, no, or, if so, only in a reduced sense. In the lecture course from 192930, Grundbegriffe der Metaphysik: Welt ¡ª Endlichkeit ¡ª Einsamkeit (1983), he compares the being-inthe-world of human beings and animals. Do they both have Dasein ¡ª that is, openness to the world as a meaning-pattern? Heidegger writes that human beings are at the same time part of the world ¡ª as bodies ¡ª and have world ¡ª they are weltbildend. Animals are part of the world and weltarm ¡ª ‘world-poor’. They are not, however, in the manner of a stone, weltlos (1983. pp. 261–264). Does this ‘world-poorness’ indicate that we could ascribe health in the phenomenological sense to higher animals in the same way as to infants? I do not have any definite answer to this question. The main reason for Heidegger to deny animals worldliness in any full sense is their lack of language. But do not some animals speak (dolphins, chimpanzees)? And do not many animals live in intersubjective moods as well as individualized suffering (illness)? See Krell (1992) for an interesting discussion of many of these themes. See also Buytendijk (1958).
See here again the excellent book by Leder (1990a), which particularly tries to investigate the forgotten field of lived somatic functions.
lnteresting borderline cases here are the types of mental illnesses which seem to lack attunement altogether: persons suffering from alexithymia and some psychopaths, for instance. If one does not have any feelings at all, how can one then suffer from an attunement of homelessness? But in many such cases, what the subject lacks is empathy rather than feelings, and this does not mean a total lack of attunement, although it certainly means a very defective one. See Svenaeus (1999a).
The example has been constructed mainly with the help of Kantoff and McConnell (1996).
Merleau-Ponty (1962) offers an analysis of the meaning-structures of perception performed mainly with the aid of different defects. It is also noteworthy here that to return to health from severe illness generally seems to provide people with new ideas and feelings about the structure and meaning of life.
Many philosophers, like Sartre for instance, reproached him for this exclusion. To deem Heidegger an idealist on these grounds would, however, clearly be wrong, since his phenomenology is intended to transcend both naive realism and idealism (1986, pp. 207–208). Merleau-Ponty’s Ph¨¦nom¨¦nologie de la perception from 1945, a work highly dependent not only upon Husserl’s phenomenology, but also upon the analysis of worldliness in Sein und Zeit, makes up for this shortcoming of Heidegger by focusing upon the role of the lived, phenomenal body in perceptional activity. Interestingly enough, the Zollikoner Seminare provides evidence that Heidegger was aware of this shortcoming already when he wrote Sein und Zeit and that the body as lived ¡ª Leib ¡ª forms a more important part of Dasein’s being-in-the-world than is evident from the book: ‘Sartres Vorwurf kann ich nur mit der Feststellung begegnen, daß das Leibliche das Schwierigste ist und daß ich damals eben noch nicht mehr zu sagen wußte’ (1994, p. 292). It is highly likely that Heidegger’s analysis of the body in the Zollikoner Seminare was inspired by a reading of Merleau-Ponty, though he is never mentioned there.
As Straus has pointed out the original meaning of the Greek organon is indeed tool (1966b, p. 150).
Some philosophers before me have suggested the broken tool example in Heidegger as a promising way to a phenomenology of illness. They have, however, never actually carried out the analysis. See Leder (1990a, pp. 19, 33, 83–84), Rawlinson (1982, p. 75), and Toombs (1992b, p. 136 ff.).
The phenomenology of pain is without doubt the best explored area of the phenomenology of illness. A classic case is Buytendijk (1962). I would also like to mention the excellent book by Elaine Scarry, The Body in Pain (1985), which explores the effects of torture as severe damage to the person’s being-inthe-world. Language, for example, as a way of inhabiting the world, is destroyed through pain.
This fourfold structure of worldliness would be a parallel (and indeed an alternative) to Heidegger’s later notion of das Geviert of gods, human beings, sky and earth, constituting the ‘dwelling’ (Wohnen) in the world, see (1954a). The fourfold existential structure would, in the same way as das Geviert, include nature (the earth meaning nature ¡ª animals and plants) in the form of Leib, an aspect of existence which is all too absent in Sein and Zeit. It would also, however, be centred around Da-sein, rather than Sein. Human beings would accordingly occupy the centre of the structure and not just one of its nodes.
This quotation inevitably provokes thoughts about the era of organ transplantation which was still in its infancy when Heidegger said this in 1972. There still remain important limits, however, regarding which organs it is possible to store in the ‘tool-box’ and for how long. Nevertheless, given the emergence of cyberspace and artificial organs, the difference between hand and hammer certainly seems even more diffuse today than in Heidegger’s time.
For a study of the stigmatizing effects of illness and handicap, see the classic book by Goffman (1974). See also Toombs (1992a, 19926).
n the phenomenology of the lived brain see Leder (1990a, p. 111 ff.).
Nordenfelt too must in his theory come to the conclusion that the handicapped person is unhealthy since he does not have the ability to realize vital goals given standard circumstances (1987, p. 128). The handicapped need the assistance of aids, which make the circumstances nonstandard. This might seem counterintuitive since most handicapped people would consider themselves healthy.
For future possibilities see Guthrie and Guthrie (1997), Chapter 15.
As I pointed out in Section 2, however, Boorse himself, particularly in his latest work (1997), considers such a goal and image of clinical practice far too narrow.
See here again the works by Kisiel (1993) and Volpi (1996) regarding Heidegger’s readings of Aristotle.
The books of Oliver Sacks, for instance (1984, 1985), give (without providing any phenomenological theory of health) a fascinating account of the insights phenomenological descriptions of ill persons can provide for medicine.
On the subject of lived time and the illness experience, see Toombs (1990).
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Svenaeus, F. (2000). The Phenomenology of Health and Illness. In: The Hermeneutics of Medicine and the Phenomenology of Health. International Library of Ethics, Law, and the New Medicine, vol 5. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9458-5_3
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