Life – Interpretation and the Sense of Illness within the Human Condition: Medicine and Philosophy in a Dialogue (Analecta Husserliana)

LIFE INTERPRETATION AND THE SENSE OF ILLNESS WITHIN THE HUMAN CONDITION Medicine and Philosophy in a Dialogue

ANALECTA HUSSERLIANA THE YEARBOOK OF PHENOMENOLOGICAL RESEARCH VOLUME LXXII

Founder and Editor-in-Chief" ANNA- TERESA TYMIENIECKA The World Institute for Advanced Phenomenological Research and Learning Hanover, New Hampshire

For sequel volumes see the end of this volume.

LIFE INTERPRETATION AND THE SENSE OF ILLNESS WITHIN THE HUMAN CONDITION Medicine and Philosophy in a Dialogue

Edited by

ANNA-TERESA TYMIENIECKA The World Phenomenology Institute and

EVANDRO AGAZZI University of Genoa, Italy

Published under the auspices of The World Institute for Advanced Phenomenological Research and Learning A-T. Tyrnieniecka, President

KLUWER ACADEMIC PUBLISHERS DORDRECHT/BOSTON/LONDON

Library of Congress Cataloging-in-Publication Data is available.

ISBN 0-7923-6983-1

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TABLE OF CONTENTS

vli

ACKNOWLEDGEMENTS THE THEME / The Human Condition as a System of Reference for

the Medical Interpretation of Illness

IX

A-T. TYMIENIECKA AND A. AGAZZI / Editors' Introduction:

The Complex PhenomenO'1 of Illness

xi

A- T. TYMIENIECKA / Topical Introduction: Illness, Life, and

The Human Condition

xv SECTION I

INTERPRETING ILLNESS AND MEDICINE IN THE CONTEXT OF HUMAN LIFE: EXPERIENCE VS. OBJECTIVITY E. AGAZZI / Illness as Lived Experience and as the Object of

3

Medicine C. VIESCA / The Construction of Illness: A Context Problem J. WORRALL and J. WORRALL / Defining Disease: Much Ado

17

33

about Nothing? A. GRUNBAUM / Critique of Freud's Notion of Mental Illness

57

M. V. FIORENTINO / Cancer from the Medical and Existential

71

Points of View M. REICHLIN / The Experience of Illness and the Meaning

81

of Death SECTION II NEW CHALLENGES TO THE UNDERSTANDING OF MEDICINE: THE ETHICAL PARAMETERS. TOWARDS A NEW "MEDICAL HUMANISM"

The Role of Clinical Bioethics between Moral Principles and Concrete Situations

99

R. MORDACCI I Medicine as a Practice and the Ethics of Illness

117

P. CATTORINI / Application or Interpretation?

v

vi

TABLE OF CONTENTS

Sense or Nonsense of Illness in Ethics of the Body The Loss of the Sense of Illness: Euthanasia and the Right to Die J. LADRIERE / Is it Possible to Give Sense to Illness? L. CASSIERS / Towards a New Approach to Medical Humanism P. KEMP /

133

R. BARCARO /

147 153 181

SECTION III THE LIFE-TRANSCENDING PARAMETERS IN THE INTERPRETATION OF SUFFERING, DEATH AND HUMAN EXISTENCE: BUDDHISM, JUDAISM, CHRISTIANITY H. BARREAU /

The Meaning of Suffering in Buddhism and

Christianity

w.

The Christian Interpretation of Suffering La Maladie dans la Tradition Juive: Orthodoxie

PANNENBERG /

M. R. MACINA /

et Orthopraxie

La Souffrance de Job Le Sens de la Maladie: Une Perspective Spirituelle

J-M. VAN CANGH / E. BIANCHI /

Chretienne La Signification des Miracles de Jesus

195 203 213 235

J. DORE /

249 263

INDEX OF NAMES

279

ACKNOWLEDGEMENTS

This collection of studies, which fits squarely into our interdisciplinary LIFE program, stems from a joint conference of the International Academy of Science and the International Academy for Religious Studies that took place at the Scientific Institute San Raffaele in Milan, in May 1998. I express my thanks to Evandro Agazzi, president of the International Academy of Science for having entrusted us with these papers for publication. Mrs. Rosemary Lunardini, who has copy-edited this collection, as well as my assistant, Jeffrey Hurlburt, for his editorial help, merit my warmest thanks. A-T. T.

VII

THE THEME

THE HUMAN CONDITION AS A SYSTEM OF REFERENCE FOR THE MEDICAL INTERPRETATION OF ILLNESS

Both phenomenology of life and medicine, in its theory as well as practice, coincide in focusing directly on life. While medicine deals chiefly with mending ills and restoring good health to the human individual, phenomenology of life aims at discovering the articulations of life's progress, its focal points, its evolutionary phases, and its significance. Both meet squarely and fundamentally in the effort to understand human nature and the modalities of human existence. Their encounter is particularly intimate and significant - cooperative and complementary - when it comes to medicine's interpretation of illness, its symptoms, its causes, its prognosis, and its treatment, and when it comes to philosophy's discovery and pursuit of the rays of human life concerns, man's existential entanglements with other beings, our circumstantial sphere of interdependence, and the moral and spiritual valuation of life and its strivings. I maintain, in short, that through an expanded search for the understanding of illness, one that takes in the entire radius of human concerns, medicine can draw from its practice material evidence for philosophical! phenomenological theory. While prima facie the physician deals with a limited sector of a living body or psyche and the philosopher/phenomenologist deals with the concrete virtualities that life has brought about at this phase of its unfolding, that of the human condition, medical attention may not stop at the singular body or psyche, nor may philosophy limit itself to the investigation of the rudimentary factors of the creative virtualities of the Human Condition. Medicine sooner or later has to address the entire human situation of the suffering individual, even his or her spiritual horizon. And philosophy has to follow the unfolding of the creative virtualities up to their highest crystallizations in the moral and spiritual spheres that constitute human existence. We propose that conceiving the Human Condition as gathering all the strings by which the living human person is suspended within the unity-ofeverything-that-is-alive and as expanding that sphere into a specifically human spiritual sphere is borne out by medical efforts at interpreting adequately the innumerable variety of symptomatic presentations, prognostic IX

x

THE THEME

insight, and treatment requirements by prying deep into the patient's overt but also at first sight invisible motivations. As for philosophy, the forays into the fullness of human life that medicine at its best makes are the exemplification of its own inquiry into full-fledged human existence. Conversely, for medicine the philosophical conception of the Human Condition as the ground from which all the existential rays that subtend the personal universe spring forth and in which they gather, are sustained, and crystallize - its horizon - reveals itself to be a tacitly and spontaneously assumed system of interpretation of illness in its full medical context and, what is more, a satisfying aid in understanding and legitimating medicine. While in the preceding Analecta Husserliana volume devoted to medicine - Life: The Human Being between Life and Death, Vol. LXIV (2000) - we moved within the organic/communal spheres of medicine, this volume gathers inquiries into the cultural, existential, and spiritual spread of the human person. ANNA-TERESA TYMIENIECKA

EDITORS' INTRODUCTION

THE COMPLEX PHENOMENON OF ILLNESS

Illness is a very complex reality, and its complexity already consists in the fact that it is one of the most evident realities, but at the same time cannot be defined, so to speak, in itself, but only by means of some kind of negation and, more precisely, as the privation of a status that is "normal", or "positive". Therefore, illness is a typical example of a negative reality, and this fact already indicates the philosophical difficulty of accounting for its existence. Indeed, the concrete existence of illness is nothing less than an exemplification of the existence of evil, and such an existence has been, notoriously, one of the most challenging problems for philosophy during its whole history. Indeed the general attitude of Western philosophy has been that of equating being and good, with the consequence of interpreting evil as the expression of wrong judgment, in which humans, being unable to grasp the right position of the alleged "evil" in the ordered harmony of the "whole" of reality, attribute a negative ontological status to something that is in itself positive, if considered in the context of such a global totality. According to this view, evil could have only a moral meaning, being reducible to a "disorder" produced by human actions, that have the possibility of (partially) subverting the ontological order of reality. This view, already present in Plato, was strongly advocated by the Stoic school, and powerfully developed by the Christian philosophers, who were very soon confronted with the problem of the origin of evil. Already Saint Augustin had maintained that, since God is the creator of everything, every reality in itself is good, and the only evil is the expression of the "free choice" (liberum arbitrium), in virtue of which humans are able to orient their preference towards certain goods of low level, disregarding the goods of higher value. This doctrine was resumed and developed several times in the history of philosophy, and amounted to the negation of a proper ontological existence of evil: this was interpreted as a defectus essendi, that is, as a "limitation" that every created being inevitably shows with regard to the perfection of being. In other words, every reality is good in itself and within the limits of its particular finite nature. These philosophical and theological speculations, however, could not eliminate a fundamental evidence, of which illness is perhaps the most immediate example, the evidence that evil has a concrete presence in reality, xi

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EDITORS' INTRODUCTION

and not just as a consequence of bad human actions, but as a common feature of Nature. In fact illness does not affect only humans, but all kinds of living beings (plants and animals), and even non-living beings in an analogical sense (we often speak of maladies of metals, of monuments, of rocks, when we want to indicate certain spontaneous deteriorations of such entities). The philosophically interesting aspect of this fact is that the idea of illness makes an implicit but effective reference to an ought to be that is inscribed in the nature of any reality, and which we could call its normal state of existence and development, but at the same time it is recognized that this "normal" state is vulnerable, fragile, that it is an "ideal" rather than a concrete state of affairs, so that it is also "normal" that this state be altered and even destroyed. In other words, "generation and corruption" (to use the famous Aristotelian terminology) are not only the stages characterizing the normal and natural course. In such a way we become aware that evil is not just a "limitation" of being, but a real "wound" in being, that cannot be "explained away" by sophisticated arguments, but must be "accounted for" as satisfactorily as possible. Unfortunately a comprehension of illness cannot be attained by simply considering it as a kind of "cosmic destiny" (as it could appear from the above reflections). Its "reality" is testified to by the living experience of those who are affected by it, and this would be sufficient for recognizing its genuine reality, since the tact of being present in the actual experience of a subject is already a sufficient (though not a necessary) condition for affirming the reality of something. Here a phenomenological analysis helps us in understanding the deepest nature of illness, that cannot be equated with a simple experience of pain. A pain, even an acute one, is usually "localized", it does not affect our self-identity, it can make our normal operating difficult, but does not alter our attitude towards ourselves and our life, while illness, even a non serious one, has the effect of making us feel dependent on other people's help, of transforming our body into an obstacle, a hostile presence that blocks our projects, desires, intentions, an obscure threat to our survival or to our "quality of life". In such a situation we feel wounded "as a whole", it is our whole life that is affected, we have the impression of an adverse "destiny" that is hitting us and, if the illness becomes serious, complicated, feelings of fear and anguish begin to appear. In this situation the question that arises in the mind of the ill man is not a "causal explanation" of his or her state, by which the patient is affected, but can also concern the global sense of suffering, the global sense of her or his life, and the answers to such a questioning come from very different sources, according to the general spiritual framework the patent has at his or her disposal.

EDITORS' INTRODUCTION

xiii

In all cultures medicine has been conceived as a struggle against illness, and has been characterized by the ways of interpreting illness. Therefore, metaphysical and religious elements have always represented the intellectual background of medicine, along with more specific knowledge based on experience and rational elaborations of the same. Moreover the specific attention of medicine was concentrated on the affections of the body. With the creation of modern natural science, a new conceptual framework was elaborated for the interpretation of the functioning of the body, that also implied new interpretations of the malfunctioning of the same (that is, of illness). The objective and analytic spirit of the new science was applied to the interpretation and care of illness, such that alleged "subjective" dimensions of it were disregarded and considered as potentially misleading. This attitude has certainly permitted many concrete and unexpected advances in the diagnosis and therapy of many illnesses, but it has become more and more clear that this anonymous way of treating the illness rather than the patient has also produced several serious shortcomings. This is why a generalized preoccupation for the recovering of a global view of medicine, including a greater respect for the personal identity of the patient, a sensitivity for ethical issues, a consideration of non strictly physical dimensions of illness, are receiving increasing importance in the medical practice and the debates about the genuine status of medicine. The present volume aims at giving an overview of the different facets that must characterize a mature conception of illness, in which the achievements of the "scientific" medicine are fully recognized and, in a way, taken for granted (and, therefore, not explicitly treated), while the non-scientific aspects are explored. The indirect result should be a more mature consciousness susceptible of encouraging the trend towards a medicine better in keeping with its task of taking care of the patients in the global perception of their needs. EVANDRO AGAZZI

President - International Academy for Philosophy of Science ANNA-TERESA TYMIENIECKA

President - World Institute for Advanced Phenomenological Research and Learning

TOPICAL INTRODUCTION

ILLNESS, LIFE, AND THE HUMAN CONDITION

It belongs to our human existential tendencies to believe and expect that our life and the lives of our family and friends should and will unfold smoothly, with all their hurdles being satisfactorily overcome. But already at the birth of a living being there occurs the question of whether it is adequately outfitted for the exacting work of unfolding and establishing itself as an autonomous being in the world of life. And even assuming that it is in general so equipped, entering into the circumambient world with its specific environmental conditions puts the individualizing life in a particular context to be dealt with in the struggle for survival. This survival is not given as a matter of fact, a sheer gift of nature. It is contingent on the individual's endowment as much as on the circumambient situations and the skills the individual develops in coping with them. Human life is played out in the interaction of these three basic factors. Thus, disability, disease, and illness belong to the natural core of human life, to both its progress and its unavoidable decay. They hinder its advance, menace its natural path, signal its termination. They surge from within the individual life groundwork and its system of constructive operations, feeding upon and yet disrupting and destroying the individual's natural schema, even the very functions that maintain it. The human being, however, expecting the natural course of life to prevail, fights with all its powers and acumen to find the reasons for illness in order to prevent it and overwhelm it when it strikes. Though we know that illness, accident, disease, corrosion are a natural counterpart of life's constructive drive, and despite our knowing that we have to submit to and accept suffering when it comes, we protest as if it were unmerited and believe that it should be a passing thing. We see the evil as being inflicted by an unknown animus for mysterious reasons. Hence, humanity searches out the whys and wherefores of illness and disease in as many realms as are found in human existence empirical, physical, psychological, social, ethical, and supernaturally providential. We can see illness as a punishment for bad deeds and good health as recompense for a good life. Medicine enters into this situation and focuses directly on the bodily functioning of the human person and on the network of forces at play in his xv

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TOPICAL INTRODUCTION

lifeworld. In particular, contemporary medicine seems to identify illness directly with "causes" and "states" on the bodily and psychic planes, and maybe with factors in the extended societal realm. But illness cannot be identified exclusively with concrete pain and debility, nor is medicine to be shrunken to the effort to forestall death. Illness and well-being, suffering and contentment may be grounded in the aforementioned levels, but they belong to the entire existence of the individual, which transforms them. They find specific expression in his life experience and societal interaction. If we want to understand pain, suffering, illness, on the one hand, and well-being and the full enjoyment of existence, on the other, we must consult the full radius of the sphere of human life. I.

LIFE, HUMAN LIFE: BIRTH AND DEATH, THE TWO CONCRETE BOUNDS, ARE THEY FINAL?

1.

The Inner Sense ofLife: A Self-Motivating Passion

If we consider life within the concrete, cyclic outline of its inexorable course, we may well, as observing, reflecting, conscious beings who are, unlike other animals, aware in advance of this inevitable course, assume birth and death to be the bounds of life. This conscious estimation of the situation may even lead us to conceive of death as being the end of the individual life course, the end to all human projects and plans, and even as the "accomplishment" of the entire project of human existence. Going further, we might even assume that the whole of human life is oriented toward this point of accomplishment, that man is born to die, that our existence is existence toward death. However, here there emerges a sharp distinction between the natural, animal, concrete course of life - to which human life is also privy - and the specifically human existence in which we, unlike the other animals that follow it willy-nilly - are aware of the cycle of life. We unfold the virtualities of our consciousness and spirit precisely in the latter type of specific existence, in which we project ourselves ahead "statically," to use a term of Sartre's. Specifically human existence consists of this projection "ahead" of the entire conscious being, as rooted in life's groundwork. One could say, indeed, that within the vital dynamic network there is still a dynamism of the human spirit that synthesizes all within a passion for self-projected accomplishment. This zest, this inward striving carries us ever ahead of ourselves. It has no aim as such outside itself, yet it is not a "useless" or "empty" passion. Its fulfilment consists in the very enactment of its striving and not in the results. And yet there is a unique bond between

TOPICAL INTRODUCTION

XVII

the striving and the projects dynamically enacted - which crystallize the striving. Individualizing life is self-motivated. It does not refer to anything external for its "inner" reason. This passion bears the innermost sense of life. It is grounded in an autonomous life outfit. And yet, as has been pointed out above, it lies at the heart of nature-life, of the cosmic network of dynamic forces. Its autonomous nature is the outcome of their interplay and the system of life's existential sustenance. 2.

Suffering and Illness in the Human Condition

The unfolding of the self-individualizing design emerging from the naturelife context is contingent on the play of forces and virtualities in that context. We call this context in the particular situation of human life within the web of nature-life dynamisms the Human Creative Condition. Human life in its passional- or ekstatic - course (ekstatic because taking off from the natural ground) is contingent on the web within the Human Condition, is situated as well within the specific virtualities that this condition brings into the evolutionary constructivism of life. Let us now attempt to understand human pain and suffering, illness and death within the perspective of the Human Condition. 3.

The Human Condition

The emergence of the human type of individual life is not a sudden event. It involves a developmental expansion within the span of life. Hence the human individual has specific prerogatives as well as dependencies. We may define the human condition as a specific "station" in life's dynamically uninterrupted stream, a station because of all the investigated types, the human being alone invents rational networks of such relative stability that they outlast his or her own tum in the unfolding cycle of life. The Human Condition establishes the human living being in a most particular situation with respect to the total life expanse, the entire existential schema of living beingness. Simultaneously it gives the human being an outstanding position - a knot position - with respect to the spheres with which living being is suspended. Lastly, it gives to man a unique significance of life. The Human Condition is a station in life's dynamic stream due to the virtualities that the progress of life deposited as its foothold on life: the creative virtuality with its three absolutely novel valuative factors of sense, the aesthetic, intellective, and moral senses. In virtue of their employment the human living being devises new significant avenues for its self-

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individualizing process: the societal and cultural circuits of the spirit. On the wings of creative imagination, the living being is in a position to stepwise unfold a complete valuating and sense giving set of faculties orchestrated into a sovereign organization called "mind." The faculties of the mind process the data of the influx-outflow traffic that establishes and keeps the station afloat and in the network of the common world of life. The three factors of sense are the carriers and distributors of reason. The work and propensities of the three sense-giving/evaluating factors are indissociable since they complement each other in the projection of individualizing circuits, forging them within the inner networks of an "intimate zone" projected into a vast network of "outward" interlinkage with other living beings within a common world of life. With the emergence of these virtualities within the animal sphere of life, it is as a lid that had been put on animal capacities, keeping them subdued and confined to a half predelineated and half circumstantially conditioned situation in life were now lifted. The beings whom we call human now emerge endowed with the wings of imagination, which allows them to fly over the dull surface of existence toward universes of their own seeing, to select and so to plan their situations, their lives, their destiny. It is within this entire orbit of existence that human suffering, pain, and illness occur and call for full attention. Within this perspective we also find in an explicit way the reference system of life and ultimately of medical theory and practice. I We may begin by submitting that suffering and illness are not incidental to or an accident happening to the otherwise vital and prosperous course of an individual's life but are part and parcel of life, an inherent condition of its unfurling. We do consider well-being a natural matter of fact state, and we enjoy our life in that state thoroughly. Nevertheless we do not pay much heed to it. Pain, however, vibrates through all the chords of our beingness. The misery is permeating. Since this misery involves our entire functional system, to interpret pain and illness only symptomatically does not touch its essence. Only a holistic approach to illness may do so. II.

THE INDIVIDUAL COURSE OF LIFE

1.

The Perimeters ofExperience

Pain, illness, disease, accidents, etc. seem to refer - to focus - mainly on a concrete bodily or psychic function, and so the attention of the treating

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physician is on a specific function and its circuits as well as on the general condition of the patient's health. But in our direct experience pain and illness go much further. Excruciating pain focuses our entire organic system, as it were gathering it in one point of paramount significance. We are at the given moment forgetful of everything else, even dissociated from all else. The experience of excruciating pain sears through our entire beingness, all of which shrinks to the level of animal suffering. This vortex seems to draw in and envelop our innermost core so that we become separated from all personal, societal, and cultural concerns. This experience may seem to challenge the validity of such concerns, to lay bare the "real" existential core of human life. All else may be dismissed as being artificial and illusory. We may think that heretofore we have been wrapped up in a cocoon-like superstructure and that now the true core of human beingness is reclaiming us with full force. But this is not so. Pain may put all else in a secondary position outside of our immediate attention, but instead of dismissing them it merely suspends temporarily their claims on our attention. In fact pain and debility provoke a search into reasons and remedies that reaches into all the very real significant networks in which our experience is embedded. When investigated, the "real" existential core of the suffering human being, its nature, its coordinates, its dependencies and interdependencies, its reasons and effects, are found to stretch beyond the organic and vital to the psychological, interactive, societal, cultural, and intimately personal spiritual spheres. Beliefs, hopes, aspirations, foreboding remain. This "core" circumscribes a vast realm of existential experiences shared with others. In the very appreciation and treatment of illness there enter in issues of personal and moral significance. There is the person as the bearer of a moral status, his dignity and self-respect. Lastly there is the sufferer's participation in transnatural strivings redeeming life's misery in otherwordly aspirations. Are these streaks of the exercise of human existence that pain brings to light fulgerations having no head or tail? Are these but haphazard appearances behind which lay a fortuitous play of forces? With these questions we enter into the nature of individualizing life, which leads to our central study, that of the human condition.

2.

The Articulation of the Course of Life

Life is synonymous with self-individualization in existence. Life in its turbulent spontaneity does not proceed blindly or haphazardly as Bergson

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seems to have it. No matter at what cost, by trial and error, life proceeds by linking its energies, synergies, and forces into self-individualizing complexes that we distinguish as individual beings. Invoking Aristotelian intuition, we will characterize each being as projecting an "entelechial" design. I want to stress that the individualization of living beings - and only living beings manifest the characteristics of individualization - is a constructive progress that follows a design. This design is "entelechial" because it projects a line of articulation that the process follows from within. No external a priori factor, law, or direction fashions this constructive progress. Enriching this intuition is the Leibnizian idea of the monadic "individual substance." The entelechial design is seen to emerge together with the first motions toward life, toward the individualization of forces that had been lying there, if not idle, then nebulous, general, unattached, amorphous. Entelechy springs forth together with synergies that carry in themselves appropriately attached propensities - germinal virtualities - and come together in a knot initiating articulation. It emerges in virtue of this extraordinarily proportioned and measured articulation, which in turn occurs in virtue of the entelechial virtuality as if Iying-there-in-wait. The entelechial principle of design springs forth within the forge of generating life while carrying the ordering of the virtual articulations of the constructive line that processes operations; the functioning of organs, etc., then follow. The self-individualizing progress of beingness proceeds thus, moving on like a spiral of inward-outward directedness. Its constructive progress is dependent on the indispensable influx of "out!ride" substances, energies, synergies into its domain, a domain that emerges together with the advance made by the evolution of types of self-individualizing entities. Needless to say, this evolutionary progress or regress is also manifested in a twofold way: inward complexity and novel modalities of functioning, and outward novel interactive modalities and spread of interactive links and networks. Thus, we witness in this manifestation of life within the lifeworld a ladder along which less and more developed types of individualizing life are ranged, with the human being placed at its peak. CONCLUSION

Let us summarize our argument. In medicine we cannot avoid dealing sooner or later with the direct, personal concern of those afflicted with illness and disease as the poignant reality of the experience of pain and debility leads to questioning that goes beyond the immediate experience. Although that

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xxi

experience constitutes the core of the significance of illness and although medicine dealing with it directly is centered on the organic, physical, psychological realms of life with their dependencies in communal life, nevertheless the discourse of investigation inevitably extends into the network of transempirical dependencies. Searching the personal situations of suffering people brings out that although their symptoms manifest the organic, empirical realm of life, the imaginative, reflective, moral powers that reside in the animal frame raise them up from dull submission to animal destiny to a human situation reverberating with a uniquely personal significance of life. This network, on the strings of which specifically human existence is suspended, bears out that the person's motivational consistency may be identified with the sequential ordering of the course of individualizing life as it reaches the unique evolutionary phase of the Human Condition. It is through both networks, that of the ontopoietic individualization that gives the ordering of physiological processes its reference and that of the cultural, spiritual, and uniquely personal rays of self-identity, that pain, disease, disability and the medicine dealing with them are bound to find their sense and their appropriate remedies. ANNA-TERESA TYMIENIECKA

NOTES 1 Anna-Teresa Tymieniecka, "The Ontopoietic Design of Life and Medicine's Search for the Norm," Analecta Husserliana, Vol. LXIV, p. 13-36,2000.

SECTION I INTERPRETING ILLNESS AND MEDICINE IN THE CONTEXT OF HUMAN LIFE: EXPERIENCE VS. OBJECTIVITY

EVANDRO AGAZZI

ILLNESS AS LIVED EXPERIENCE AND AS THE OBJECT OF MEDICINE

ILLNESS: A COMPLEX REALITY

Illness presents a very large display of aspects and possible appreciations. It is an extremely complex "reality" and, for this reason, evaluating and treating it from a unique point of view, even that of medicine, turns out to be always reductive, and even arbitrary. Indeed we can say that at the very moment we attribute to medicine the specific task of being concerned with illness, the concept of medicine receives an unexpected semantic latitude, that is, the possibility of being understood according to quite different models, each one of them being related to the way illness is conceived (though, in a second moment, the "kind" of medicine adopted conveys a particular way of interpreting illness itself). What kind of "reality" is illness? In its fundamental sense it has the kind of reality of a human lived experience, that is, of an existential experience that totally envelops the subject who lives it and which, therefore, cannot be exhausted in any of the aspects that characterize it. For example, it is obvious that an illness usually implies a more or less significant level of suffering, or a more or less serious bodily injury, yet it cannot be correctly identified with either of them. Rather often a suffering, even an acute one, appears to us as an aggression striking us "from the outside", producing pain, but in the face of which we are able to keep our autonomy and capacity of reaction, as also happens in the case of many injuries occurring to our body. In the case of illness, on the contrary, even a not particularly serious one, we clearly perceive a global change in our way of being and living: we become unable to perform quite a lot of actions and functions that are absolutely trivial and elementary. We suddenly become dependent on other persons; our spatial and temporal borders are drastically reduced; we live in a palpable way a situation of impotence, limitation, and fragility; our capability of carrying out projects is greatly reduced; our body, that until that moment was one and the same thing with our self and remained "unperceived" and "silent", becomes something that stands in front of us as an external obstacle. In short, we feel that we are no longer ourselves. These general features are greatly magnified when illness increases persistence and seriousness, when it entails important and durable handicaps; and when the prospects for its duration, possibilities of 3 A.-I: Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 3-15. © 200 1 Kluwer Academic Publishers. Printed in the Netherlands.

4

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healing, degree of a possible recovery are uncertain. Our experience of illness becomes even more tragic when intense physical pain and the perspective of a fatal end accompany all of the above features. These features, and other similar things, are the reality of illness, and it would be very naive to maintain that they are simply the "subjective counterparts" of an objective situation that medicine is able to describe on the basis of scientific criteria. Nothing is more real than life, for one who lives it, and none can live one's life but in the first person, that is, as a subject. In this case, however, subjectivity is precisely the genuine mark of reality, and the sick person approaches the doctor (or some other person, or institution) with the aim of getting out of that personal lived experience which she does not accept. Hence, in the last analysis, it is medicine (be it scientific or not) that is measured and judged according to its capability of responding to the needs of the pathologic lived experience, and not vice versa. What has been said is not intended to shade "scientific" medicine but simply to recall the fact that it considers illness from an important, but partial, vision. For this very reason, medicine can and must be integrated with other visions capable of approaching this dramatic human experience according to other dimensions. I Precisely because it directly and deeply affects the existence of ourselves, and of other human beings who are more or less close to us, illness cannot avoid producing those questions of sense that the human being asks when the negative erupts into his existence. Such questions may be dictated, in the last analysis, by the desire of finding a means to expel such a negative (having understood its reasons and causes), but they inevitably have a broader range and, for this reason, often involve philosophical, cosmological, anthropological, and religious perspectives. Like all human lived experiences, illness is by no means an obvious thing: it must be, first of all, understood and explained, and in the second place a possible sense of it can be attempted. This seemingly simple proposal, however, opens the spectrum of different interpretations of illness (that is, the answers to the question, "What is illness?"), and of the explanations that can be provided for it. On the whole they depend on the conception of man that a given person, or a given culture, accepts. THE CLASSICAL NOTION OF HEALTH

What we have said becomes particularly clear if we consider how classical tradition conceived medical art. According to a terminology inaugurated by the Greek philosophers and continued at least until the Renaissance (which

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we will call "classical" or "pre-modem" for this reason), techne (in Greek), or ars (in Latin), which we normally translate as art, designated an efficacious activity grounded on a theoretical basis (that is, on a knowledge) capable of providing the reasons for its efficacy with respect to a specific goal. In the case of medicine such a goal was identified with health, and this concept had a global latitude, meaning a full and satisfactory human lived experience. Therefore, illness was defined through a negation, that is, as the "deprivation" of health, and, like all concepts defined by negation, had rather fuzzy borders, being open to different configurations depending on the kind of deprivation considered. In the modem perspective, on the contrary, the specific object of medicine becomes illness. Therefore, it is illness that must be characterized in a "positive" way (that is, in an exact and clearly identifiable way), while health becomes a rather fuzzy concept, being understood as the "absence of illness" in a necessarily general sense. Typical of the cultures that we shall call "traditional" in order to distinguish them from "modem" ones (and to which, therefore, also "classical" culture belongs) is the fact of conceiving human existence as embedded in a certain order, and health (understood in the global sense mentioned above) as consisting in an existential plenitude deriving from the congruence of the individual life with such an order that is at the same time universal and particular. Universality is expressed by the idea that the entire cosmos is an ordered whole, and such an ordering receives a sense that we can call "religious", since it is thought of as the manifestation of a divine presence understood in different ways. In certain cultures divinity is conceived as being transcendent, and order is interpreted as the consequence of a conscious and voluntary project of that divinity that (according to different modalities) has originated the universe and continues to govern it. In other cultures divinity has rather the characteristic of immanence, and the universe is conceived as a manifestation and almost as an unfolding of the divine. In both cases the principle of the ordering is metaphysical, that is, invisible, not perceivable through the senses, and is introduced with the aim of understanding and explaining whatever is shown by sense experience. It is fully consistent with such a world view to admit that reality as a whole contains forms, dimensions, entities of different kinds: material, immaterial, capable of mutual interactions both active and passive, according to a large display of modalities. Within this universal order are situated the particular orders of the single entities, each having its own ordered structure that is at the same time condition and warranty of its adequate subsistence and a contribution to the realization of the universal order.

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This situation also occurs in particular in the case of the human being and becomes even more accentuated in those views (and they are very numerous) in which man is conceived as a microcosmos, that is, as a complex reality in which are present and reflected all the elements, factors, and characteristics that enter the constitution of the universe. In the framework of such perspectives it appeared as perfectly rational to admit, for example, that an event or a practice of a religious kind could have consequences at the level of physical processes, of human actions and events (individual or collective), of the moral or mental spheres and, in particular, of people's states of health. In the same way a "disorder" of a moral kind could entail consequences of various kinds (including physical illness) in the life of a person, and this independently of considering such consequences as the punishment of a fault (indeed they could also affect innocent persons). All this happened because no real distinction (or at least no separation) existed between the natural and the supernatural, since that which (ml!ch later) has been designated as "supernatural" permeated the substance of the very "naturality", understood as the mundane physical reality. ILLNESS AND DESTINY

What we have said does not underestimate the fact that, in all cultures, illness is not equated with a pure and simple "adversity" that strikes an individual: it is specifically conceived as a "harm" that strikes man especially in his body, produces suffering, and can cause him death. As a consequence, a particular system of practices, and also a particular class of persons, are singled out as being specifically deputed to treat illnesses (and this is what enables us to determine the domain of "medicine" in each culture). Yet the considerations sketched above help us understand more exactly certain historical facts: for example, that, within many cultures, the priestly class was also (completely or in part) entrusted with the medical profession; that medical activities were performed by individuals who were believed to be endowed with magical powers; that a very strong causal link was put between pathological events and configurations of celestial bodies. It is too easy to laugh at all this as pure superstitious or irrational beliefs. As a matter of fact they constituted intrinsically consistent frameworks of intelligibility, according to which, first of all, the patient understood himself and his infirmity, and with reference to which medicine too looked for a rational justification of its practice. In particular, these frameworks are strongly bound to the lived experience of illness, a lived experience that does not accept to be inscribed in the scheme of chance, but in the very different scheme of destiny.

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Chance means, almost by definition, absence of reasons and sense: it is "blind" by antonomasia. Destiny, on the contrary, expresses the idea of a fixed track that has a certain sense, though this may remain concealed; still one can hope to decipher this sense and, at least in part, to render it favorable. Even independent of this possibility, however, the idea of destiny enables one to put illness within a framework that goes beyond illness itself, and in this going beyond may be inscribed also the confidence or the hope in a globally positive final outcome. This may be easier if destiny is thought of as an inscrutable divine design, for one may have confidence in the goodness of the divinity or in the possibility of acquiring her benevolence by means of rites or prayers. In the first case one can come to a positive acceptance of the seemingly adverse destiny or, in the second case, one can hope in some change of its course. This may happen in a different measure also if destiny is conceived as a kind of cosmic influence. In this case it is often conceived not so much as a strongly deterministic course of precise events, but rather as a lucky or unlucky "predisposition", so that, if this is known, it might be possible to realize certain conditions that could oppose the concretization of this predisposition (in case this is negative), or to take advantage of it (if it is positive). This, in particular, is the sense that astrology has received within medicine in almost all cultures: if it was believed, for example, that people born under a certain constellation had a propensity for a given kind of illness, it was possible to infer indications as to certain precautions that those people should adopt in order to avoid becoming victims of such illnesses. This appeared even more plausible as the cosmic influences were generally thought of not as mysterious direct actions but rather as energies specifically related with precise "elements" or "humours" that are present in nature as well as in the human organism (microcosmos). Therefore, the possibility was reasonably conceived of helping or opposing the cosmic influence by means of suitable procedures capable of controlling such elements or humours in the organism, and these procedures had precisely the meaning of therapeutic practices. THE HOLISTIC VIEW OF MEDICINE

The inscription of health and illness in a global perspective encompassing earth and heaven, cosmic influences, divine designs, and magic forces entailed an extremely holistic view of medicine, in which the concern of this art was not only "the whole" of the human organism, but also "the whole" of the universe, of the complex material and immaterial reality in which human life is situated. The reason why this perspective may be called "extremely"

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holistic is that it included many metaphysical conceptions that were needed in order to offer a sense for illness, by going beyond what is empirically ascertainable and by resorting to conceptions, beliefs, and practices offered by religion and magic. The holistic way of thinking, however, did not abandon medicine even when medicine became less metaphysically laden, that is, with the development of the "rationalistic" kind of medicine that was inaugurated in the West by the ancient Greek culture. When we qualify this medicine as rationalistic we want to stress that other medical perspectives were indeed "rational" (as we have tried to show), but they corresponded to a kind of rationality less rigorous than that inaugurated by Greek philosophers, which consisted in recognizing as knowledge only the results of empirical observation and strict logical argumentation. In the conceptual framework of this medicine it was still necessary to "go beyond" that which is immediately shown in sense experience (a condition that is unavoidable in any effort to understand and explain any kind of reality), but the "realities" admitted in this theoretical framework were more or less of the same "ontological kind" as the empirically observable realities (and in this sense they were "less metaphysical," as we have said). Indeed the "ordered whole" on which the attention of medicine concentrated was the human organism, the microcosmos, in which the four elements that constitute any material body (air, water, earth, and fire) are accompanied by the four fundamental humours (blood, phlegm, black bile and yellow bile), and completed by the four "qualities" characterizing them (warm, cold, humid, dry) that are related, in tum, to the four seasons. This quaternary scheme, whose first outline is due to Empedocles, and which is explicitly present already in the Hippocratean Corpus, had undergone various reshapings (which we shall not mention here), and had given rise in the history of Western medicine until the Renaissance, to anatomo-physiological theories about the localizations and paths of the humours, to diagnostic and therapeutic approaches, and to connections with astrological doctrines. What we want to stress, however, is that, according to this scheme, the health of the organism was conceived as a state of weighted balance among these various components (the krasis), while illness was interpreted as a breaking of the balance (that is, of the order) due to the prevailing or excess of one of these components over the others. The aim of therapy was that of helping the organism in recovering its balance, sometimes by intervening from the outside, sometimes by stimulating the internal energies.

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It is worth noting that this principle of the right measure, of avoiding excesses, that is the model of ancient ethics, of the classical idea of justice, of the classical ideal of wisdom, was also the leading model for medicine. But this is no pure coincidence: it rather reflects the fact that medicine did not lose sight (even in its technical peculiarities) of the global human lived experience. This is confirmed, for example, by the fact that Hippocratic medicine also gave ample attention to considerations of the patient's global condition of life (we would say, today, his quality of life), from his physicoclimatic environment, to his family context and his psychic well-being. This required from the physician, besides his technical competence, an irreprehensible human and moral conduct (let us think of the "Hippocratic oath"). What has been said regards the conceptual framework, the theoretical context of the medical art. In order for it to be really such, however, it had to be shown to be also an efficacious practice. This implied a large empirical component, consisting of accurate descriptions of symptoms, clinical courses, therapeutic outcomes, anatomical findings, collection and comparison of data, all things that are largely documented in the writings of the great medical personalities of antiquity, but also present in other cultures. For example: the priest-doctors of pre-Hispanic Mexico did not content themselves with healing their patients with rites and prayers, but received a long and rigorous formation that we would call "scientific" in a modern sense, that is, a technically specialized medical formation. MODERNITY AND THE MIND-BODY DUALISM

What changed with the rise of modem medicine (that is, the medicine whose developments started in the Renaissance)? Certainly much has changed, but not in a totally radical measure. If we maintained that the fundamental change consisted in the application to medicine of the discoveries of the new natural science, we would say something true, but it would still be a half truth (for, after all, traditional medicine also did not disregard the contributions offered by the natural science of its own time). The most decisive change regards the new conceptual framework (and more precisely the metaphysical framework) that characterizes modernity. This follows the quick deterioration of the theocentric perspective that had inspired the West during a millenium. This does not mean a refusal of "theism" and transcendence but, paradoxically enough, an exasperation of the transcendence of the divine that becomes rigidly separated from the world and confined to the domain of religion, to

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which one essentially accedes to through faith. At this moment the natural and the supernatural are conceived of as two separated orders of reality: the existence of God remains generally admitted, but he is reduced almost exclusively to the role of creator of the world and author of revelation, and the supernatural ceases to be a reference point for the understanding and the explanation of the physical world, as well as of the human world, which are interpreted iuxta propria principia. The not few thinkers who are still concerned with "saving" the legitimacy of a rational discourse on God and the spiritual dimensions of man estimate that this is possible by introducing a sharp ontological separation, inaugurated by the famous Cartesian distinction of the "two substances," the res cogitans (that is, the realm of spirit), and the res extensa (that is, the realm of matter, identified with everything that occupies space). Now substance, according to the way classical ontology had defined it, is anything that has in itself its autonomous existence: therefore, dividing reality into two kinds of substances amounted to conceiving of it as split into two orders of existence, completely autonomous and without interrelations. We have said that such a strategy had been introduced with the aim of "saving" the spiritual realities of God and man. But from what threat should they be saved? From the threat of materialism that was spreading on the impulsion of the cognitive successes of the new mechanistic science. This, in fact, was attaining more and more significant achievements by "reading" the world only on the grounds of concepts of matter and motion. It is true that this reading regarded only the physical world, but the pretension was already surfacing of extending it to the understanding of the whole of reality, and this would have meant the cultural elimination of any discourse on the supernatural. Therefore, here is the solution: the discourse of the new sciences concerns the physical world only, but beside it, and well separated from it, also exists the world of spirit. In this world science has no competence and, in turn, theology and metaphysics have no right to interfere in questions regarding the physical world. In such a way the reappearing of painful events such as the trial of Galileo were to be avoided, with the full autonomy of research granted to the new sciences, while a similar autonomy also secured theology and metaphysics. The advantages of this (provisional) intellectual peace, however, were paid for at a rather high price. Leaving aside the difficulties of a more general philosophical kind, it is enough, for the theme that interests us, to consider the price paid in the conception of man. This consisted in the breaking of the unity of the human being, a breaking that even amounted to a loss of its

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identity. Also in man, it was said, two separate substances coexist, the body and the spirit, without any philosophically justifiable correlation and interaction. The spirit will continue to be the subject matter of the traditional disciplines of a theological and metaphysical kind (feeling free to ignore the material dimension). The body will be the subject of study of the physical sciences, that is (in that historical moment), mechanics, and later the other natural sciences gradually developed. Interpreting the human body according to the conceptual framework of a certain science amounts essentially to conceiving of it as a machine and, in fact, it will be subsequently presented (as a whole, or in some of its parts) as a mechanical, chemical, thermal, electrical, cybernetic machine. But one could ask, What is the true man? Within the dualistic perspective any answer to this question will be arbitrary: depending on one's personal options, one will say that the true man is the spirit which happens to be joined to a material machine by chance; other people will say, on the contrary, that the true man is his body, of which the alleged spiritual dimensions are nothing but epiphenomena. As a matter of fact, neither the spirit nor the body are substances in a philosophically correct sense, for neither does a disincarnated spirit exist, nor a (human) body disjoint from all the psychic and spiritual lived experiences that accompany man's life. The true substance is man in his individual integrality, of which body and spirit are simply two areas in which it is possible to subdivide conceptually (but not concretely) his ways of existing. MEDICINE IN THE DUALISTIC VIEW

After the premises just outlined, it is easy to understand which way would fatally enter modern medicine. Having been traditionally concerned with the diseases of the body, and having now at its disposal the knowledge offered by the new physical sciences, medicine not only accommodated its theoretical frameworks to the interpretation of the body as a machine, but felt itself authorized (and almost methodologically obliged) to be concerned uniquely with the body, without indulging itself to accept references to the other "substance", and even considering as dangerous confusions all considerations overstepping a physicalistic way of treating the matters. In this way, almost at the borders of Galileo's work takes shape, for example, iatromechanics (that is, a theoretical conception of the organism and its functions as a system of mechanical parts and actions that gave rise to corresponding interpretations of illnesses, their causes and therapies). When

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such a perspective appeared too narrow, its corrections were not looked for in that dimension of man that physical science does not explore, but in a different natural science, and iatrochemistry became very influential (here the role of scientific reader in the reading of the organism and in the deduction of the corresponding corollaries of a medical kind passed over from mechanics to chemistry). Later other natural sciences offered similar services, when the necessity was perceived of broadening the theoretical frameworks of medicine. If medicine's concern is only the human body, and this is equated to a machine, illness is equated to a "damage" of the machine that must be "fixed" by first finding out the part that was damaged and then trying to repair it, or, if necessary, by replacing it. An additional breaking of the unity occurs in such a way: after the unity of the human individual, now it is the unity of his body that is lost. Not only is it overlooked that that which becomes ill is the human individual in his entirety (that is, that illness is in the first place a personal lived experience), but illness itself is considered as something affecting a determined part of his body, that is, a typically localized fact (this way of seeing is well in keeping with considering body essentially as a res extensa). Therefore a tendency that had appeared in medicine already at the beginning of the Renaissance receives a powerful impulsion, that is, the shifting of the attention on the pathologies of the single organs that was to be well supported soon by the developments of the observations in pathologic anatomy, and that is the root of a strongly specialized approach that has increasingly characterized Western medicine. (It is not accidental that even today illnesses are officially classified by reference to a certain organ or tissue: heart, liver, lungs, blood, skin, bones, and so on.) Also in this case we find an affinity with a mental attitude that is characteristic of modern science, that is, the adoption of the analytic way of thinking: while traditional thinking used to interpret and explain the functioning of the parts in light of the whole (the holistic point of view), the modern approach maintains that the properties and functioning of the whole are the result of the disposition and properties of its parts and are totally understandable and explainable as a function of these. It would be impossible to deny the great achievements attained in the different sciences and in medicine thanks to the adoption of the analytic method; yet the limits of this approach are rightly pointed out nowadays, as well as the real distortions it can produce. We cannot pay attention now to this important problem, but want to mention another fundamental issue.

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THE PHYSICALISTIC FRAMEWORK OF MODERN MEDICINE

We had the opportunity of saying above that the novelties of modern medicine with respect to traditional medicine are conspicuous, but not so radical as one could think at first sight. A feature is common to both. Modern medicine also does not ignore the existence of relationships and influences of the external environment on the human organism, with causal effects on the rise and course of pathologies; moreover, modern medicine is far from neglecting certain relations between the different parts of the organism. The difference only resides in the kind of interactions that are held to be really possible, or at least relevant, and this difference appears to be of a philosophical and, more precisely, of a metaphysical kind. For example, today we say that certain sites or climatic conditions are "healthy" or "unhealthy"; by this we admit that the external environment can have influences on the state of health of the organism, and also from the external environment come officially recognized pathogenic actions, such as aggressions from bacteria or viruses, the carcinogenic effects of certain chemical substances or of given radiations coming even from a great distance. With respect to the cosmic-environmental "influences" admitted by traditional medicines what changes is only the "typology" admitted: today medicine only recognizes influences entirely interpretable within the framework of causal actions of a physical kind, duly understandable on the ground of physical theories. That the spectrum of pathogenic influences might be broader, however, is tacitly admitted, for example, when it is recognized, on the basis of reliable statistical correlations, that gastroduodenal ulcer or heart infarct can be favoured by stress in life conditions. The rigorous physicalistic explanation of such causal actions of psychic states on organic illnesses is not clearly provided, and it is only vaguely claimed that it can be traced back, in principle, to certain alterations induced in the nervous system. Even the old idea that an individual may be "predisposed" to the occurrence of certain pathologies, even independently of certain precise external causal actions, is not banished from present medicine. Instead of attributing such a predisposing "constitution" to the influence of the constellations under which the individual was born (as did the old astrological theory), the concept of an inborn "constitution" is made precise through the theory of the inherited features inscribed in the genetic code of any single living being. The DNA provides the biochemical (that is, physicalistic) key for reading this ancient concept.

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EVANDRO AGAZZI MEDICINE AND THE RECOVERING OF THE INTEGRALITY OF THE HUMAN BEING

Once again, we do not want to suggest that the perspective of the physicalistic medicine is "wrong", but simply that it is onesided or partial: it concentrates on certain decisive aspects of illness but disregards the fact that illness, for the patient, is fundamentally a painful lived experience and that, owing to this fact, it is not perceived and interpreted the same way by the patient and the doctor. From many points of view this is unavoidable, but this does not justify the systematic ignorance of such a difference in perception; in particular, it does not justify the widespread conviction that the true face of illness is that which is presented by the "scientific" approach, while the other face is something that (in the very interest of the patient) it is better not to take into consideration. Nowadays we are becoming more and more aware that for a correct diagnosis and therapy it is important that two such images be compared and brought as near as possible (that is, that the doctor make a serious effort of "entering" the patient's point of view). It is not said, however, that the solution of this difficulty should be totally charged upon a greater commitment of the doctor. It relies, instead, on recovering the awareness of the unity of the human person, with the consequence (easy to affirm, but less easy to put in practice) that medicine has to heal the patient and not the illness, since the latter, far from being the concrete reality, becomes an abstraction when it is separated from the consideration of that person who is affected. This means that, in addition to medicine, other views must help the patient in challenging this existential impasse, helping him, first of all, overcome that kind of separation of himself from his own body that illness normally produces (when the body becomes an obstacle to his existential fullness); helping him in seeing illness as a manifestation of his finitude, without transforming it into an anguish, even when a total recovering of health is out of sight; helping him especially in giving some kind of positive sense to illness itself, bringing him to feel that illness does not strike the deepest levels of his personality, does not diminish his dignity: it can seriously reduce his possibilities of acting, but not those of thinking, of loving and of being loved, of desiring, of hoping, and even of encouraging other people through his example. All this is possible if we do not eliminate other dimensions of man that cannot be reduced to his physical dimension. The task of cultivating these dimensions concerns the whole culture of a given society, and especially philosophy and religion, literature, and the arts, in brief all that can help us to

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keep alive and give a value to those things that furnish an interior richness to our life and a non-nihilistic sense to our suffering and even to our death. Many experiences confront man with his fragility and finitude, but few of them make evident to him this situation: for this reason an illness that is lived well may reveal itself even as one of the most positive experiences of a whole existence (as many historical examples show). Department of Philosophy University of Genoa, Italy NOTES I This difference between the way illness is perceived and interpreted by the patient and the doctor has been the object of several studies. Among those deserving special mention, because of the pertinent use of concepts and approaches taken from phenomenology, is the volume of S. Kay Toombs, The Meaning of Illness. A Phenomenological Account of Different Perspectives of Physician and Patient (DordrechtIBoston/London: Kluwer, 1992).

CARLOS VIESCA

THE CONSTRUCTION OF ILLNESS: A CONTEXT PROBLEM

Starting in the 18th century, when Morgagni asserted the existent identity between organic lesion and cause of illness and opened a new era of medical knowledge (Morgagni, 1761), medicine and lesional pathology gradually became synonymous. In fact, medicine has directed most of its concerns to illness, towards its characteristics as an anatomical or physiological lesion, and then surgical therapeutics has won a choice place because of its capability to extirpate lesions. Lesional medicine constitutes the main column of modern medicine, and very actual research fields, like genetics, immunology, and biological psychiatry, don't move forward in a different way. But reality has proved to be bigger than the lesional world. There also exists the universe of medical sciences, which, from a biological point of view, opens the possibility of understanding not only illness but also health. There exists a universe of mental facts, of psychology and the relation between mind and body, of dualism, monism, and emergentism; studies about normality and the realm of healthy people as the object of biomedical considerations and actions; the world of medical anthropology, with its two dimensions, philosophical and sociocultural; the world of health, understanding it as a field by itself, including philosophical, anthropological, biological and medical approaches; the recently recovered ecological world view, inserting man once more into the natural environment, thinking about the existent relations between them and the results of their interactions; and the universe of social and cultural facts and creations, which is, without doubt, an everyday reality in human life. Finally, there is the world of history and the reality of man understood as a temporal conscience, burdened with the weight of the past and the future on his shoulders and sensitive to the importance of building an ever dissolving present, and conscious of the influence of existential facts on his health or illness. All of these fields of knowledge offer medical thinking unexpected landscapes, and define the necessity of developing not only new fields in medical science, but new philosophical ways of visualizing and understanding medical knowledge and its problems.

17 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 17-32. © 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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CARLOS VIESCA THE ACTUAL CONCEPT OF ILLNESS

We can now speak about illness. In the biological-Iesional thinking of the last century and a half, illness is described, seen, and conceived only as lesion first as an alteration of anatomical structure, later as a functional deviation. Macroscopic lesions are accessible to direct visual observation or to visualization by means of endoscopy, X-ray, or some other modern imaging technology; microscopic lesions, those infinitely minuscule deviations, are related by the lens of the microscope; and functional lesions are detected by applying the most complex and sophisticated technological resources. Always lesions. The sick person who is reduced to illness defined precisely as lesion is the result and, at same time, the manifestation of a contextualized relation that was inserted into and which emerged from the modern world. The question now is to comprehend the characteristics and define this contextual nature. Speaking about illness knowledge it's obvious that we intend to speak in scientific terms and that we propose to attain some means to facilitate the understanding of the essence and dynamics of illness. Then, if we focus our attention on the scientific conception and classification of illness, our objections are: Why is science elevated to a context category instead of put inside the context of modern thought and that of a physical and chemical world view? Why has biology been taken as a model for the medical sciences? what are their postulates and pretentions that permit us to make them a context rather than inserting them into a context? The process conducive to scientific formulations featuring modern medicine, shares with other sciences the belief in considering biological research postulates as essensially true, giving away any consideration about their temporality and restricted validity, limited by historical factors. Modern biomedical sciences pretend to be nontemporal and then their products are to be essentially true when methodologically correct. The first step was the configuration of modern biology, of a life science, or better, of a "living beings" science 200 years ago. The limits imposed by consideration of positive facts as the only way to attain a valid knowledge came a little bit later, in the middle of the 19th century. So, consignation of sensible data is now the only correct way to acquire new knowledge, always taking into account the strict formulation of hypothesis and theories and the inclusion of empirical and observable data. Modern science, as was said by the Italian scientist Valisnieri on the eve of the 18th century, proceeds by "putting brick over brick" in its everyday new construction. Its quality is defined by the fact that new bricks are substitutes for old ones and in this form the whole building is maintained, actualized, and

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operative. Medicine will be a scientific activity only in the measure that medical practice rests over objective knowledge proved by its subjection to the experimental method. We want to insist that the term "scientific" in reference to medicine is not essential but only a qualifier and it distinguishes only one medical system among many others. Indeed, in contemporary scientific medicine, it's possible to distinguish a conceptual basis, strictly scientific in nature, and a very ample series of practical activities, theoretically being applications of this precise knowledge but in reality being very distant from it and frequently falling into the field of almost empirical applications of more solid knowledge, or sometimes into that of mere medical craftsmanship (Noble 1986, 219). But it's precise to remember that general tendencies - or perhaps beliefs? - speak favorably about the gradual and continual transformation of art in science. For every scientist today, with more or less minimal modifications, the scientific foundation they are taught and, necessarily, that of our scientific medicine are absolutely indispensable. But, discussing these topics is not relevant for us, because the character of art imbued in medical practice is not our actual problem. We only comment on the existence of facts, enlightened by modern studies, that prove the cultural influence in constructing some illnesses, like menopausal syndrome or hypertension, recognized in western scientific medicine (Towsend, 1980,229). The point that we intend to make here is that there is a separation between modern western scientific medicine and any other medical system existing in other epochs and cultures, in other words, the medical systems which are historical and anthropological vestiges. This word is symptomatic of a very fine discriminatory procedure (Fabrega 1979, 167). From a modern western scientific point of view, each medical system excepting itself is condemned as empirical, nonscientific, or false. Western knowledge is science, and nonwestern thinking ways are empiricism which with difficulty can be considered as rational thought. But qualifying all medical knowledge or practice in terms of scientific thought, defining it according to contemporary experimental medical science, and after that considering as empirical any other type of medical knowledge, proceed to make a big division, keeping only as scientific that thinking produced by western modern medicine and leaving aside all the knowledge attested to by nonwestern medical systems and also by all previous western systems. The latter started with Hippocratic humoral medicine and concluded in the 18th and early 19th centuries, with Brownism, that of Broussais or Magendie's vitalism - in a word, every medical system registered in historical and anthropological sequences.

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Western modern medicine, after the discovery of microbes and their pathogenic action, following the determination of some physical and chemical body functions, and after developing an amazing competence to control illnesses previously incurable, has made of the entire world a conquered territory. It has relegated every other medical system, like those developed in some tribal or primitive cultures, to the realm of fallacy, falsehood, and superstition, making of them only an accumulation of untrue beliefs. THE MULTIPLE CHARACTER OF TRUTH

So, the problem now acquires a new perspective, and we can ask if the resolution of some medical or health problem is determinant on possession of truth in terms of exclusivity. We can also ask if only a singular truth exists, and, if the response is positive, what are the arguments to be sure that this veritable truth is that of western scientific medicine? In other words we can reformulate the question asking if that truth is a discovered truth or an invented truth. Is it coming from nature or, contrarily, from human thought about nature? In any case, it is also valid to question the ontological status of illness and to express a fundamental doubt: Do medical sciences give us discoveries or merely interpretations? In these terms we propose to reconsider our concepts about medical science and medical knowledge and also to discuss the problem of context. It's evident that medical knowledge has sustained a close connection with those ideas. Two opposite thinkers, Hegel and Comte, included it in Philosophy for its role as the only true science and being, its goal fixed in the possibility to acquire true knowledge about reality. But our main problem comes from the undecipherable nature of reality and the impossibility to warrant the certainty about attained knowledge. In this term need we ask "Who defines reality?" and, if this reality is valid for everyone, opening then a fundamental doubt about the nature of reality as conceived by actual science, it is in absolute terms. These questions have not been posed frequently by medical thinkers because they believe in that reality defined by physico-chemical sciences. So the construction of modern medical knowledge is circular because it's developed from the same basis that constitutes its advancement possibilities, and demonstration of hypotheses is only possible if the defined a priori are sustained. This assertion seems heterodox and really is, because it puts in doubt the ultimate essence of natural sciences as derived from a true knowledge of reality and, moreover, the only true reality of knowledge. Medical science goes ahead, always returning back over itself, and this is,

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simultaneously, the secret key to its exploits and the clue to its weakness. It is convenient to insist that concepts construction is ideally developed, eliminating every subjective instance, leaving the sensorial supply to the observer and the store of data to the observed individual converted now into an object of knowledge. Eyes, ears, hypothesis by one side, data in the other, and beings bereft of their inner significance and constituted only by cells, neurons, hormones, proteins, antibodies, nucleic acids, etc., offered to the researcher senses and conjectural thinking. This operative limitation makes it easier to obtain a reduced but deeper knowledge, but also to give up integrative perspectives. It's possible to know little and almost insignificant details about a hypothetical, biological unit which only becomes human after a sophisticated reflection which is referential but never integrative. This kind of knowledge has been able to create its illnesses. We may take as an example the more or less 500 problems associated with gene alterations which have been individualized and constituted in illnesses lamentably characterized as syndromes. We said "lamentably", in this case because the syndromatic configuration leaves open a big hole in the certainty to prevent failings in expected discoveries, being possible now, or at least expected to be achievable in a short time. Syndromatic alterations may be related to altered or mutant genes or to differences in protein sequences identification. Clinically, these illnesses are not confined to western peoples, but in their genetic syndromes configuration are exclusive to western scientific and experimental medicine. It's obvious that this exclusivity comes from explanatory mechanisms and not from alterations description which is accessible to other medical systems and sometimes also to the general public. Explanation signifies construction and implies a reference to a biological and molecular universe and world view. These considerations permit us to discuss: 1) Differences between description and explanation in medical systems existing in unrelated contexts. 2) The nature of explanation and the registered peculiarities in their change or permanence inscribed in contextual differences and transitions. 3) Necessity to conceptualize a common denominator to a possible series of interpretative differences. THE INTERPRETATIVE NATURE OF MEDICINE

Medicine, like other sciences and scientific pratices, is essentially interpretative (E1kana 1981, 10). Generally, it starts from what is called by some

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authors a "thick description" of observational reality. It consists in individualizing and putting in hypothetical succession the most important elements adverted in that reality or, better, in that segment of reality which is studied; after that, it proceeds in describing and detaching them with the view to gradually attain access to complex levels, different in their integrity to the simple addition of their parts. (Geerz 1973) After description arrives explanation, and this is the precise moment when, with or without the presence of an explicit conscience, epistemological criteria arise. (Ryle 1971, 465) This observational practice is never unilineal. The history of medicine has witnessed over centuries the primordial observation and successive discoveries about multiple illnesses. Some have been endowed with fortunate names, over the course of time; others have disappeared after they expressed for a while local or at least limited criteria which cannot resist significant changes in basic concepts or sometimes in paradigms. I consider it convenient to stress that we can find two types of paradigmatic changes: those developed inside the affected culture and provoking important but always autodirected changes, and those originating from the outside, sometimes making plea, employing a universal imagery to the end of a particular historical development, sometimes to the absence of new possibilities at the interior of that culture, but always proceeding to a cultural continuity rupture. So all illnesses and diseases decribed in diverse epochs and cultures result from observations consigned in different modes. But, we can ask, "What is that observed and what is its defined nature? Are they dependent from the cultural context? Had they been developed through time? Do different observations take consideration of diversity in choice possibilities and develop it methodologically? To illustrate that, we may now consider some examples. In Japan it is frequent to find an illness called Taijin Kyofusho. It has been studied by physicians, psychiatrists, and anthropologists. This single illness has been deprived of its more intimate and significant traits when, searching for the possibility to include it in international illness classifications, researchers have presented it sometimes as an atypical anxiety neurosis (Russell, 1989, 391), sometimes as an obssessive-compulsive reaction, arriving at some exotic terms like "social phobia" (Marks 1969) or "anthrophobia". (Kato, 107) Japanese reality has been richer than the scientific, i.e. reductionist illness translation. Being conceived from inside Japanese social life, its most important traits are those related to thinking that some body characteristics of afflicted people are disruptive to other persons; someone believes that his "coup d'oeil" is awful, someone that it's his smell, or that the problem is

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implicit in his gestures or in the fact that his facial expressions are hideous. (Tanaka Matsurni, 1979, 231) A preoccupation to be agreeable to others is the central source of conflict and the distinctive illness trait. Individuality of symptoms or symptomatic complexes was never important. So preoccupation to be delicate and gentle is the central data and that which puts us in rapport with the extreme politeness intrinsic to social relationships that are transcendental to traditional Japanese culture. It is clear that without this reference it's not possible to make the necessary association of this particular illness with Japanese culture. This simple fact consideration permits us to affirm that Taijin Kyofuso is not simply a neurosis, instead, if you like, it isa very singular neurosis of and by Japanese people educated in their traditional culture or provided at least with a knowledge which permits a significant expression of it. Japanese physicians, excluding any necessity to know brain receptors and their relationships with these neurotic states, have been able to describe, individualize, and interpret, inside their own culture and according to their own societies exigencies, a significant illness. In this case, illness contruction doesn't derive from molecules but from social facts and reality. Taijin Kyofuso persistence will be tied to cultural links endurance more than to biological knowledge and will disappear only in direct relationship with a deep change in society affecting structures and beliefs basically related to the traditional Japanese world view. Similar considerations can be made about characteristic illnesses existent only at the interior of some specific cultures. One of them is amok, a mental disruption characterized by delirium and a compulsive running, with aggressive behavior leading to kill some people; this illness only takes form and explanation in the Malayan culture of head-hunters (Carr 1978, 269). The next example comes from western culture, but this time differences are due to historical development. Melancholy is a very complex nosological entity conceived 25 centuries ago by Greek thinkers. But the extraneous thing about it is that coming from distant times it appears incessantly with the most recent international illness classifications. Most amazing of its traits is its multiform polysemia. After Hippocratic four humours theory, in its final form as represented by Galen's interpretation five centuries later, melancholy, formed in the spleen, is correspondent with earth, with earth atoms in the Empedocles elemental theory, and is their representative inside the body. Excessive black bile configures the illness so denominated. Today, melancholy is only a mental alteration, but in its origins it covered a wide alteration group which was characterized by heaviness, slowness, hypochondrial flatulence, dry gangrene in extremities, a voluminous spleen, a

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blackish color in the skin. That melancholy figure which identifies it with mental troubles was defined from the start as a chronic illness accompanied by awful delirious dreams about death and disintegration, sadness, suicidal tendencies, a heavy impediment to think and to act (Hippocrates 1855,630, Saxl et al. 1989). Our question now is, "was melancholy discovered or invented?" The conceptual integrative trends study asserts the existence in nature of some coexisting observable features which were associated and related to a melancholic humor presence. Its origins can be traced to the 5th century B.c. to explain some dark facts in the then forming humoral theory (louanna, 1974, 136). It's possible to speak about discovery, but it will be better to qualify it as a reiterative assertion of a given reality, an interpretative invention. But, what do I mean by interpretative invention? Reality apprehension permits the proposition of some substances, structures, laws, variated systems and a descriptive image useful as a referential frame. The paradigmatic nature of this image will be reinforced after its proximity and correspondence with the world view accepted as valid in a specific epoch, culture, or society; in some other cases it will be judged and lived as revolutionary because of the presence of essential differences. The sole fact of a substance discovery, like melancholy in its due time, makes people consider its real existence and obliges them to the hypothesis chain of formulation-construction. It's interesting to remember that Hippocrates and his followers saw melancholic humor in blood, in secretions in diseased tissues, in somatical dynamics through 2,000 years. This substance's existence, impossible to prove today, nonexistent in the light of actual science, was the cornerstone of a scientific theory considered certain as a reality expression of existing things. Considering a long history, from black bile to modern depression, molecular theories don't exist only from a technological difference; the existence of technological possibilities enables the researcher to amplify his scope beyond the limits not only of microscopy but also of imagination, and incites him to work with invisible entities, like bacteriophages or prions, for example. But at last, the primordial difference resides in the way of looking at the phenomena and in the conjectural structure. Both Hippocratic and modern scientific thought proceeds by observing facts and extracting data from them, and only then begins their speculative activity; in that moment, they contrast their finds with a preconceived world view. It's evident that humoral theory was only possible in a nature specific conception, the notion of physis, a living, eternal, rational and ordinative nature, where melancholy, phlegm, blood, and bile were simultaneously discovered and

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invented and employed as bricks in building a science valid for the next 2,500 years. But, it's licit for us to doubt and make questions about the real concordance between man's intelligence and nature's intelligibility and, ask if there really exists also a transcendence, whatever it means, in which the entire theory takes its foundation or if it is only related to historical situations and cultural contexts intending to explain the universe. In any case, it is obvious that the theoretical constructions' immanent character and their essential provisionality which influence, in a positive or a negative way, weigh heavily over their cognitive characteristics. (Angel, 1987,465) Melancholy's history is a rich history plentiful in sense and meaning changes and also in significance of concepts. For example, after the 14th century, a belief was imposed about the association of melancholy with the intellectual man, with scholars who become crazy after too much study, or with demoniac posession or love madness, and then arose the concept that defines melancholy as a devil's favorite humor. Universal order has been changed, at least conceptually, and attention is directed to detect and describe signs of devilish presence, to find witches and sorcerers, and to identify dangerous melancholics, dangerous in the sense of altering or putting at risk the course of divine arrangements. In a single phrase melancholy was the balnearum demonium. One century later, genius and melancholy persisted closely related to scholars and artists and the fact is, by this only attribute, they were suspected by the Inquisition to be in commerce and communication with the devil. This particular fact was very important to define terms in the fight for human dignity. Illness and genius are two elements endowed with a disturbing proximity. All the while, being natural or diabolic, no one doubted melancholic humor's reality. Melancholy's and melancholic humor's epistemic level among European Renaissance physicians and scholars who intended the classical naturalism revival, never will be the same after diabolic intervention beliefs were accepted as a rational possibility. In other words, from the 14th and 15th centuries, religious doctrines' acceptance modified completely the cognitive order in putting it inside the supernatural realm and consequently deriving illness' construction among any other cultural compartments to a different world view which transmits to God all the ancient physis and parmenidian attributes and predicates. At this precise moment nosologic discourse becomes invested with a new symbology derived also from a different world view. At the time when priests and inquisitors were searching for signs disclosed by God's grace and were denouncing demoniac activity, physicians intended to demonstrate that melancholy was only an illness due to humoral alteration.

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In the 19th century, melancholy again lost its mystery at the moment when objective rational and secular thinking banished the devil from the medical world, and it then became an entity in the recent psychiatric classifications. It maintained its name and also its central reference to sadness; the romantic artist is a melancholic by definition, in the same way as suicidal people are, but it also appears that melancholy may be the object of medical treatment and reclusion. One more time taxonomy had changed its optics and symptoms consigned to define their presence and apparition order in a merely descriptive way, denoting the melancholic humor disappearance in the new objective reality world. This time melancholy becames only a reminiscence. In this sense melancholy's persistence in American classifications of the 1980s, under the form of involutive melancholy, is a vestige of its former self. Did there exist anytime a melancholic humor and an illness, melancholy, caused by its disproportion in the interior of the body? Or is it better to think about the existence of a peculiar world view which had permitted the humoral theory construction and with it the rational acceptance of the real existence of some illness as melancholy? SYNCHRONY, DIACHRONY AND ILLNESS KNOWLEDGE

Viewed in their conceptual reality mirror, humoral theory is the most fine expression of a supposed natural reality. This same assertion perhaps will be correct in the near future when applied to microbial or to biological molecular theories. Considering them from the angle of their development over time, all these theories lost some of their original pretentions in the moment when we considered their provisional nature directly due to the omission of a transcendent revelation. Under the light of history studying long time periods, the successive steps of discovery and invention, of description and interpretation of a subjacent reality can be considered as a process of manifestations including construction of illness characterization criteria. Hypothetically, if a Greek physician could have thought about a medical problem in biological-lesional terms, surely it would have been impossible for him to pose his questions in any different form than these proceeding from or providing him with congruent representations to his physiological thought. Contrarily, for a present day thinker, physical elements and humoral theories will be absolutely deprived of sense, and his questions surely will be proposed after chemical, microbial, inmunological or biological-molecular paradigms. Speaking in terms of truth, both paradigms, that of Greek science and that of actual knowledge, are equivalents in the measure from which

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everyone expresses the requirements and necessities of their own cognitive system. In this way, truth becomes validity. Considering temporal sequences, it will be important to remember the diachronic influence and the fact that those paradigms, humoral and biological-lesional are successive ones; that, historically, the second replaces the first after a lot of essays and incertitudes. We can think that this substitution has been made because the second paradigm is superior; but we can't fail to consider another fact related to the changes in social, cultural and cognitive contexts and, in this case, that illnesses individualized and defined after this paradigm change correspond to precisions rooted in the new contextualized paradigm. It's also convenient to recall that, in view of expressing validity judgments, it will be a prerequisite to the presence of an impartial observer, an observer less hypothetic than one frequently referred to in moral discussions, and necessarily a stranger to both explanatory systems. In parallel situations, but making an analysis of two contemporary cultures, it is evident that arbiters always will be unconsciously ethnocentric. A particular possibility has been realized by the survival of classical medicine concepts in the Arabian world, in the so-called Avicennian medicine. Effectively, in Islamic medicine schools today texts are studied which are written in the pure Avicenna tradition with or without recurrence to his Cannon. This is the best and the most integrative medical system developed in the tradition of Hippocrates and Galen. In Islamic hospitals, diagnostics and treatments are done in reference to bile, phlegm, blood and black bile's existence, and melancholy is not a mental illness without cultural roots but an absolutely valid concept. For Islamic physicians today it is a common opinion that they can diagnose and cure humoral illnesses, and, obviously, maintain the certainty of their real existence. In this case, modern technology will be incorporated and will be a relevant aid to an old medical system which is not convinced of the superiority of western medical explanatory systems and, evidently, doesn't leave a place to it. In this way, it's very impressive to observe the muslim Indian medical schools' efforts to establish and develop bridges between Unani medicine - as they call the Greco-Arabian system - and western medicine's new theories. (Tughlaqabad, 1993) We are witnesses of this opposition but also of the complementarity that is essential to both systems, and we are also witnesses to the daily use of Islamic medicine by many millions of human beings. Similar things can be expressed about ayurvedic and Chinese systems, corresponding each one of them to a particular world rooted view in myths,

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beliefs, and knowledge cultivated in these cultures through millennia (Unschuld 1988; Porkert 1974; Dash 1978; Jaggi 1981). I think this diversity problem needs to be introduced another time to our philosophical inquiries. It will be posed from an anthropological relativist perspective, giving priority to reality diversity problems and to explanatory systems, also manifold, and making evidence of different ways to perceive and conceive the same universe. The next step ought to be the transit from relativism to a pluralistic structured theory. It is actually imperative to study illness classificatory systems in their diversity and establish comparisons between them. It's also necessary to make precise the reality characteristics made evident and prioritized by every one of the studied systems, without discarding it and detaching their differences and concordances, in order to build a more comprehensive approach to systems. ONTOLOGICAL REALITY OF ILLNESSES AS A PROBLEM

Have illnesses existed by themselves? Do morbid species exist in nature? And, in this case, are they classifiable as plants and animals? The possibilities of affirmative responses permitted scholars in the 18th century to have hopes about feasible binarial classifications of illnesses, in the traces of the Linnaeus plant world. They intended to define gender and species and to constitute classificatory trees with trunks and branches representing illnesses, ordered according to internal relationships and being as far from the trunk as generations separate them from the original classificatory item. This was the idea of the works of nosographers like Boissier de Sauvages or Richerand, and a very fine example of that is the dermatose's tree proposed by Alibert in the early 19th century, schematizing the "real" descendance and filiation of skin diseases. But we have another substantial problem posed through illness formulations considering neither patient presence nor their participation in constructing the image of a particular illness. Then, does the essence of illness depend on the illness or on the patient suffering it? And, if this second possibility is preferred, can the essence of illness be displaced from the illness and the patient? And, do illness, diseases or affections, essences or accidents, in an ontological view, have an existence by themselves? Or what's their ontological state if we accept the postulates of postpopperian epistemology? All these questions deserve a detailed analysis, and I am sure we can obtain multiple elements for future reasoning and reflection.

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In the present state of knowledge and of epistemological thinking applied to medicine, I think it's not conceivable to consider illness as an abstract condition, especially without some consideration of the ill person's existence and significance. Actually, a simple platonic world applicable to the idea of illness, or, worse, to ideas of illnesses is not a viable nor sustainable concept, and the criteria supporting personified illnesses or morbid entities made autonomous in reason of some exotic essential existence don't deserve to be seriously discussed. SOME CONSIDERATIONS FROM THE THIRD EPISTEMIC WORLD

As concluding remarks I think it pertinent to expose some considerations about the relationship between illnesses and cultures in light of the previous reflections. In fact all the previous statements look for classificatory trends that facilitate for us the organization required to access another step of taxonomic reality. In this way we can ask: Which are the illnesses that fulfill the requirements prescribed for access to the species category? Is it licit to propose fevers or humoral alterations? Galenic cancros, or viral lymphomas? Magical fright or collagenosis? Spirit loss or genetical problems? I think that it is not a valid action to establish continual illnesses sequences, because working without considering cultural epistemological leaps bears us to compulsory grave internal contradictions. Instead, I propose to think about and analyze the discontinuity factors in illness series. I don't think that ethnocentric distinctions will lead in any way to a better or at least valid new philosophical or philosophical-anthropological comprehension of the illness problem. Every person, as a representative of a culture, is convinced, in a superficial or fanatic manner about the reality of his illness knowledge and concerns. Also, he will be sure about the superiority of his own concepts to those maintained and believed by other individuals pertaining to different cultures, without appreciating if the cultural discontinuity comes from different times, historical sources, or geographical spaces. It's not sufficient to consider contemporary civilizations and cultures as better than ancient ones, nor to take technological development as the sole valid superiority criterion. It will be necessary to question the landmarks and referential frames of this supposed superiority, and also its filiation from a "more real" reality unknown to any other culture and provided with a guarantee certificate.

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In nonwestern classificatory systems, illnesses are inserted in a different reality order, giving way to detaching diverse symptoms and signs in an order unrelated to that of modem scientific taxonomies. As an example we can consider bhuta deva illnesses, included as important items in old Indian, ayurvedic medicine, which are simultaneously illnesses caused by spirit possession and mental disturbances with evident behavior changes; in the same way it's possible to put as evidence, widows' disturbed comportment attributed by the same Indian medicine to evil spirits; or the Kyasanur forest disease, deadly in the same way as if produced by a virus - as we think - or by angry spirits provoked by an irreverent invasion of the jungle. All these three illnesses are due, in ayurvedic theory, to disturbances induced by spirit possession, but it's compulsory to observe, for a better uaderstanding, the social norms disrupted, its presentation manners or its intrinsic dynamism and consider the essential differences between them and medieval Christian demonic possession or djin possession characteristic of Islamic cultures or cihuateteo possession in prehispanic Mexican cultures. Another example: Pi in Chinese traditional medicine comports pains and contractures in muscles and tendons, but requires the appearance of climatical alterations, a peculiar heavenly body's distribution, a singular predispsition in human bodies, and a characteristic relationship between ying and yang conjunction. Those explanatory systems never will be reducible to chemical substance actions or biomolecular functions. Alterations of uric acid or those of some rheumatoid factor don't cover the total significance of gout before incorporation of other nonprecisely medical components in the scientific sense of the term. These concepts are valid only in the presence of a contextual agreement and coincidence sometimes with traditional unconscious beliefs, at other times with sophisticated knowledge. For example, just speaking about gout, coacihuiztli was for the Aztecs a different thing than gout to Spanish friars, although in dictionaries they translated as equivalents if not synonyms. Remembering a mythical serpent, Aztec physicians, called ticitl, referred to Quetzalcoatl, the feathered serpent god, signifying coacihuiztli the serpent illness, and the remedies were ascribed also to the same god or to the part of the universe corresponding to him. (Viesca 1997) Spanish friars understood gout as an illness related to excessive drinking and eating meats, and some of them knew, like their physicians, that the cause was humors attracted and accumulated in the joints (Lobera de Avila 1544), all these explanations being very different from metabolic alterations useful today. In terms of what is true, all of them are right or wrong depending on the contextual frame that explains them and the observer/researchers' referential knowledge. In other

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words, all of them are provisionally true, valid within the contextual limits imposed by space and time to their cultures. So, speaking in terms of human rationality, of provisional and relative rationally constructed world views, we must assume plurality as an essential fact and develop a complex thinking applied, in this case, to medical concepts as directed to understanding and classifying illnesses. Illnesses, as classified items, exist only in specific historical and cultural contexts and are always expressed in particular languages, in concrete situations wherein it's possible to recognize the confluence of cognitive factors, systems of cultural representations, mythical beliefs, identity and difference relationships, social relationship nets, all factors defining individual characteristics needed for the illness systems and particular illnesses construction. Obviously, this diverse, apparently incongruous, heap of data responds always to human necessities expressed through cultural filters. It is only in restating epistemological analysis based on consideration of conjunction and separation dynamics, of comparison and differentiation of unreductible peculiarities, of searching common traits and recognizing epistemological distances between concepts and conceptual systems, that we may propose an actual illness philosophy providing it with a scope valid for an immediate future, a future of globalization and tolerance, of individuality, annihilation and humanism, of reductionism and of expanded thinking. The main goal is to restore the human dimensions of illness. REFERENCES Angel, Ronald, "The Impact of Culture on the Cognitive Structure of Illness", Culture, Medicine and Psychiatry, II, 4 (1987): 465--494. Carr, John E., "Ethnobehaviorism and the Culture-Bound Syndromes: The Case of Amok", Culture. Medicine and Psychiatry, 2,3 (1978): 269-293. Dash, Bhagwan, Fundamentals ofAyurvedic Medicine, New Delhi, Bansal & Co., 1978. Elkana, Yehuda, "A Programatic Attempt at an Anthropology of Knowledge", in E. Mendelssohn and Y. Elkana, Sciences and Cultures, Dordrecht, D. Reidel, J981, p. 10. Fabrega, Horacio, "Elementary Systems of Medicine", Culture, Medicine and Psychiatry, 3,2 (1979): 167-197. Geerz, Clifford, "Thick Description: Towards an Interpretative Theory of Culture", in Geerz, c., The interpretation of Cultures, New York, Basic Books, 1973. Hippocrates, De la maladie sacrlie, 14, dans Ch. Daremberg, ed. Oeuvres choisies d'Hippocrate, Paris, Labe ed., 1855, p. 630. Jaggi, O. P. Ayurveda: Indian System ofMedicine, DelhilLucknow, Atma Ram & Sons, 1981. Jouanna, Jacques, Hippocrate et l'Ecole de Cnido, Paris, Les Belles Lettres, 1974, p. 136. Kato, M. "On the Problem of Anthrophobia in Japan", Seisin Pgaku, 16 (1054): 107-112 (in Japanese).

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Lobera de Avila, Luis, Libro de laas cuatro enfermedades cortesanas, Toledo, 1544. Marks, M. I., Fears and Phobias, New York, Academic Press, 1969. Tanaka Matsumi, Jonko, "Taijin Kyofusho Diagnostic. A Cultural Issue in Japanese Psychiatry", Culture. Medicine and Psychiatry, 3( 1979): 231-246. Morgagni, Giovanni Battista, De sedibus et causis morborum per anatomen indagatis libre quinque, Venetis, ex typog. Remondiniana, 1761. Noble, Mark, Drake-Holland, Angela J., "Discrepancies between Scientific Theory and Practice in Relation to Physiological Hypothesis", Theoretical Medicine, 7, 3 (1986): 219-231. Porkert, Manfred, The Theoretical Foundations of Chinese Medicine, Cambridge, Mass/London, England, MIT Press, 1974. Russell, John G., "Anxiety Disorders in Japan: A Review of the Japanese Literature on Shinkeishitsu and Taijinkyofuso", Culture. Medicine and Psychiatry, 13,4 (1989): 391-404. Ryle, J., "Thinking and Reflecting", in Ryle, J., Collected Works, Hutchinson, 1971, vol. II, pp.465-478. S/a Theories and Philosophies of Medicine, Tughlaqabad, New Delhi, Department of History of Medicine, 1973. Saxl, E, Klibansky, R., Panofsky, E. Sacurne ec la Melancholie, Paris, Gallimard, 1989. Towsend, John Marshal, "Menopausal Syndrome: Illness or Social Role. A Transcultural Analysis", Culture. Medicine and Psychiatry, 4,3 (1980): 229-248. Unschuld, Paul, Introductory Readings in Classical Chinese Medicine, DordrechtiBostonl London, Kluwer Academic Publishers, 1988. Viesca, Carlos, Ticiotl. La medicina de los anciguos mexicanos, Mexico, Departamento de Historia y Filosoffa de la Medicina, UNAM, 1997.

JENNIFER WORRALL & JOHN WORRALL

DEFINING DISEASE: MUCH ADO ABOUT NOTHING?'

1.

INTRODUCTION: CHARACTERISING "DISEASE-IN-GENERAL" A PROBLEM WORTH THINKING ABOUT?

Medical science, of course, tries hard to characterise more definitely and fully the symptoms and causes of particular conditions generally referred to as diseases. Equally obviously, clinicians are called upon all the time to make diagnoses - to decide, against the background provided for them by the present state of medical science, and on the basis of their perceptions of the signs and symptoms, whether or not someone under their care has a particular condition: lung cancer, diabetes mellitus, congestive heart failure, or whatever. There is often a good deal of uncertainty about such judgments. Doctors strive hard to become more skilled at making them, and some philosophers - employing techniques from decision theory and artificial intelligence - have tried to help them. The topic of this paper, however, is not judgments of this sort, but rather of a second sort that medics are also sometimes called upon to make. These are second-level or meta-level judgments of the following kind: having identified some definite set of signs and symptoms, and being, let's suppose, confident that they have diagnosed the correct condition, clinicians may then be called upon to decide whether or not that condition amounts to a genuine disease or illness. They often feel very uncomfortable about such judgments. Perhaps philosophers, with their expertise in conceptual matters, can provide significant help here by providing a clear-cut and defensible characterisation, not of any particular disease (that seems clearly a purely scientific issue), but of the class of diseases - of what might be called "disease-in-general." This idea has spawned an enormous literature indeed the problem of characterising what does and what does not count as a disease is often regarded as one of the defining problems of the philosophy of medicine (Boorse 1997, 100). This fact alone would tempt some present-day philosophers to regard the philosophy of medicine as an intellectual backwater: "conceptual analysis," • This paper was written for a conference in 1998. For reasons connected with the production of this book, it has not been possible for the authors to amend it to take into account the more recent literature.

33 A.-T. Tymieniecka and E. Agazzi (eds), Ana/ecta Husserliana LXXII, 33-55.

© 200 1 K/uwer Academic Publishers. Printed in the Netherlands.

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or the "explication" of concepts, although central to analytic philosophy for many decades, is, on the whole, no longer viewed with any great enthusiasm within contemporary philosophy. But, whatever one's reservations about conceptual analysis in general, there seem to be at least three reasons for regarding the analysis of disease as an exceptional case. The first is that, unlike many cases where conceptual analysis has been liberally indulged in, there appear to be urgent practical reasons why an analysis of the concept of disease is needed. In particular, and again unlike many other cases, the way in which what might be called "grey cases" are resolved by the analysis seems really to matter from a practical point of view. "Grey cases" here are conditions whose status as diseases (or not) is controversial or intuitively unclear ahead of systematic analysis. The idea of conceptual analysis is, of course, to use the clear-cut instances of the phenomenon (in this case lung cancer, pneumonia, and so on) and the clearcut non-instances to derive necessary and sufficient conditions for the target notion - in this case disease; those necessary and sufficient conditions will then be applied to decide the "grey cases." How grey cases are resolved is, as we shall see, crucial to a range of judicial, insurance, and social decisions. The second reason why even those most anxious to stress the limitations of conceptual analysis might be ready to grant the case of "disease" special status is this: as we shall see, many difficulties have been alleged to stand in the way of providing any purely descriptive, value-free account of disease. These difficulties have persuaded a clear majority of those writing on the problem to hold the normativist thesis - that "disease" is an ineliminably value-laden notion. Since medicine is the study of disease, this thesis, if correct, would seem prima facie to threaten the whole idea of medicine as a science or as firmly based on science. The third reason relates closely to the first two and concerns the status of mental illness or disease. There has been a great deal of discussion - much of it stemming from the work of Thomas Szasz - as to whether it is proper to talk of mental illness at all. This discussion (when clear at all) operates by taking a notion of disease-in-general derived from clear-cut and therefore invariably "physical" cases, and then comparing so-called mental disease or mental illness against the standard thus provided. We begin, then, by elaborating on these reasons for taking seriously the enterprise of characterising the general notion of "disease."

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THREE REASONS FOR SEEKING AN ANALYSIS OF THE NOTION OF DISEASE

(i)

Grey Cases Matter

Consider two patients attending a rheumatology clinic. Mr. A is 45 years old, married, with two children. He presents with difficulty in walking owing to a short right leg and stiff right hip resulting from septic arthritis of the right hip in childhood. He is already in receipt of invalidity benefit and mobility allowance and is now applying to be rehoused by the local authority on the grounds that he is, because of his illness, finding it increasingly difficult to negotiate the stairs in his house. Mr. B is 35 years old, single, and lives alone. He also presents difficulty in walking and gives a history of birth trauma. He exhibits a bizarre gait, but no abnormality in the musculoskeletal system can be found to account for this. He is not in receipt of invalidity benefit and is in fact in the process of lodging his second appeal against the state social security decision not to award him this benefit. He feels that he is suffering from an illness and wants his doctor to support this claim and hence to help him overturn this decision. However, neurological examination and investigation showed no abnormalities, and, in particular, no evidence of damage suggestive of birth trauma. This patient had, though, been referred to the psychiatric services several times in the past. Reports showed that he had been abused as a child and had spent his early life in a succession of foster homes. He had been bullied at school where he was an underachiever and found difficulty forming relationships both with his peers and teachers. He had held several menial jobs, each for no longer than a few weeks, and was now socially isolated. The clinician may well feel intuitively that Mr. B is no less deserving than Mr. A. However Mr. A's social benefits are secure, while Mr. B's appeal will definitely not be successful unless the doctor declares that he has a "genuine disease or illness." There is no scientific evidence of birth trauma being the cause of Mr. B's disability. Indeed there seems to be no doubt that his disability results, not from birth trauma or any other overt physical injury, but rather in some complicated and little understood way from the fact that he is a profound social misfit. Perhaps one should say that Mr. B is indeed ill, that he is suffering from a genuine disease by virtue of being a social misfit. But this judgment also seems fraught with danger: it recalls Soviet Russia's treatment of dissidents (misfits in the context of that society) as psychiatrically ill.

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The issue of whether or not some condition is "really" a disease in fact arises frequently in insurance and general social contexts. For example, in the 1970s a Manchester general practitioner prescribed the nicotine gum, Nicorette, to one of his patients and charged the prescription to the UK National Health Service on the grounds that it was treatment of a genuine disease, which he termed Tobacco Use Disorder. Norman Fowler, then Minister of Health, ruled against this on the grounds that smoking is not a disease but a "bad habit." Fowler argued that Nicorette is therefore not a drug under NHS definitions ("a substance that has a pharmacological effect in relation to the prevention or treatment of disease") and that therefore the NHS was under no obligation to pay for it. In the 1980s a dispute arose over whether or not stammering constitutes a disease or illness. Claims had been made to private health insurers in the UK for treatment for stammering; but these had been turned down on the grounds that stammering "is not a disease, because correctable by education or training." An eminent paediatrician, Noel Preston, argued, however, that: ... it is not normal to have any difficulty with enunciation and the flow of speech. This being the case, stuttering would be a deviation from the normal healthy state. The stutterer is not free from disease or dysfunction, and he does not enjoy all his parts functioning normally. Therefore stuttering is an illness. I

Finally, although the list could easily be greatly extended, a 1995 article in the UK Independent on Sunday newspaper raised the issue of whether or not developing wrinkles amounts to a disease and so again merits treatment under the NHS. Amongst comments quoted from medics involved were the following: The wrinkle is a serious disease. Do you know anyone who gets up every morning and worries about illness? But everybody worries regularly about wrinkles. (American dermatologist Albert Kligman) Wrinkles are not a normal part of the ageing process.... Just because wrinkling is not lifethreatening does not mean we should not treat it. Few dermatological conditions are going to kill you, but we still treat them. (Professor Christopher Griffiths, Manchester) It is hard to draw up rules to distinguish between what is medical and what is cosmetic. Some people would try and make you feel guilty for treating wrinkles, but I do not see what is wrong with it. It is only controversial in the context of rationing inside the NHS. (Andrew Griffiths, St. Thomas', London) I

Both of the above two cases are reported in Resnek (1987).

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The Law Courts, too, often take it to be crucial whether or not someone's condition at the time some crime was committed amounts to a genuine disease: indeed in jurisdictions that still include the barbarism of capital punishment, such a judgment can be, as everyone knows, quite literally a matter of life and death. This sort of question arises almost invariably in the case of putative mental diseases - a field where "grey" predominates. So it is not surprising that, within the medical profession, it has generally been psychiatrists who have been at the forefront in seeking to characterise the notion of disease. A leading example is R. G. Kendell, Professor of Psychiatry at Edinburgh, who perspicaciously remarked (Kendell 1975,444): Most doctors never give a moment's thought to the precise meaning of terms like illness and disease, nor do they need to. They simply treat the patients who consult them as best they can, diagnose individual diseases wherever they can, and try to relieve their patients' suffering even if they can't. ... But there are some situations in which this unthinking empiricism is inadequate. Psychiatrists are only too well aware of this, since they are often required to express opinions about the presence or absence of illness in the courts, and to defend these opinions to hardheaded lawyers....

So both insurance (including state insurance) and legal issues often raise questions of what is really a disease and, finally, it is easy to construct a long list of particular conditions whose status as genuine disease (or not) has been extensively and heatedly debated independently of any specific judicial or social-insurance consideration. This list includes alcoholism, homosexuality, PMT (pre-menstrual tension) and ME (myalgic encephalo-myelitis or, as some prefer, CFS - Chronic Fatigue Syndrome). The heatedness of such debates indicates that the issue of whether or not these particular conditions are really diseases carries a great deal of significance for many people. (ii)

Medical Science and the Normative View ofDisease

The second reason for even a sceptic about the value of conceptual analysis in general to take seriously the idea of "explicating" disease was, remember, this. Many attempts have been made to give such an explication in purely descriptive terms, and there are few who think that any such explication has proved adequate. Instead there is quite a strong consensus around the idea that, although a satisfactory way to demarcate disease from non-disease indeed exists, this demarcation ineliminably involves judgments of human value - conditions count as diseases only because we judge them to be of disvalue. But if "disease" is an ineliminably value-laden term, then it seems difficult to see how medicine, the study of disease, can be scientific. Of course

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everyone agrees that the practice of medicine involves any number of valuejudgments: which patients to treat, which to give priority to, when it is more humane to tum off the ventilator, and so on. But how can even the theory of medicine be scientific if what appears to be its very topic of study - disease has no purely descriptive characterisation? Moreover since the "we" who are doing the disvaluing may change - that is, since what is disvalued by a society at one time may not be disvalued by another society or by the same society at a later time - the line differentiating disease from non-disease, even amongst known conditions, may be society-dependent. And this again seems inconsistent with what we normally think of as a scientific subject matter. Certainly Christopher Boorse, whose characterisation of disease is widely regarded as the most sophisticated attempt at a "naturalistic" characterisation, sees the whole aim of his enterprise of developing a "value-free scientific disease concept" as that of providing a "bedrock requirement to block the subversion of medicine by political rhetoric or normative eccentricity." (1997, p.100) One of the normative eccentrics that Boorse may have had in mind (though he does not explicitly cite him) is Ian Kennedy. Kennedy wrote (Kennedy 1983 5-6): ... illness, a central concept of medicine, is not a mailer of objective scientific fact. Instead it is a term used to describe deviation from a notional norm. So a choice exists whether to call someone ill. The choice depends on the norm chosen and this is a mailer of social and political judgment.

Kennedy writes in terms of "illness" rather than disease. But since these are usually either regarded as equivalent or differentiated on the grounds that illness is a particular type of disease - one in which the patient suffers discomfort (disease can of course be, at least temporarily asymptomatic) - his claims clearly apply to disease too. Kennedy also goes on to make the following inference from the alleged normative nature of illness or disease: illness is a spurious scientific term and ... the doctor in purporting to determine its existence as an objective fact is [in fact] engaged in a series of moral, social and political choices ... (ibid., 10).

Or, as he puts it more succinctly if scarcely more plausibly: Each diagnosis of illness is an ethical decision. (Ibid., 17)

There are some fairly crude non sequiturs here, as we wilJ show later; but none the less, the possible role of values in the characterisation of disease

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and the effect of any such role on scientific method in medicine certainly forms a reason for seeking greater clarity concerning the notion.

(iii)

MentalIllness?

The third apparent reason for swallowing any qualms one may have about conceptual analysis in the case of disease, we mention only to lay aside as too large an issue (at any rate in terms of the amount of literature produced) to be dealt with here. This is the question of whether or not those who are presently characterised as mentally ill are really ill in the sense of suffering from a genuine disease. Szasz, of course, seems to take it that there is a clear-cut notion of disease to be derived from "physical" illnesses; and he goes on to argue that the so-called mental disorders do not satisfy that notion - psychiatrists are using the notion of illness, in talking about mental illness, in a purely "metaphorical" sense, largely motivated by evaluative judgments. A clarification of the notion of disease-in-general might, then, shed some light on this issue of mental disease in particular. 3.

SOME ATTEMPTED DEFINITIONS OF DISEASE AND THEIR PROBLEMS

The history of medicine exhibits definite "revolutionary" changes both in ideas about particular diseases and in general ideas about causative agents in disease. We here, however, are concerned solely with current conceptions. So what exactly is involved, according to current conceptions and theories, in someone's suffering from a disease? One major motive in characterising and investigating particular diseases has always been to explain suffering and incapacitation in the absence of overt physical injury. We might, therefore, try something like: • DEFINITION I: A disease is any clearly characterisable condition that involves suffering or some degree of incapacitation not produced by any overt physical injury. But Definition I is clearly inadequate. First, because, as is well known, a whole variety of diseases may be, at any rate for a long time, asymptomatic. This is true of many extremely severe diseases such as lung cancer: someone may have the disease and yet be neither suffering nor incapacitated. Indeed if he is unfortunate enough immediately to fall under a

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bus he may never actually suffer as a result of disease. But secondly and conversely, Definition I is inadequate because a person may well be suffering and incapacitated by conditions that would not normally be considered to fall under the concept of disease. Some people suffer great anxiety and mental anguish from, and may be socially incapacitated by, the fact that they are bald, short, "too thin," "too fat," have "too big" a nose, etc, etc. Nonetheless, none of these conditions presumably ought, on its own, to count as a disease. The case of asymptomatic disease shows the need for a more objective element in the definition: the lung cancer sufferer may be asymptomatic but the lesion shows up on X-ray. So let's try • DEFINITION 2 ("Disease as lesion"): Any process or state counts as a disease if it is produced by some definite structural or functional abnormality or abnormalities (not ones in tum caused by some "external" physical injury). Definition 2 - surely correctly - allows the possibility that someone may in fact be suffering from a disease even though no one can at present identify it. She may be exhibiting signs and symptoms that in fact result from some underlying lesion or abnormality, even though no one can at present identify that lesion or abnormality. (Otherwise we should have to say that no one suffered, for example, from Parkinson's disease until 80 years or so ago when the brain lesion that characterises it was discovered.) The definition also, of course, deals by construction with the counterexamples to Definition I supplied by asymptomatic diseases. The second type of counterexample still threatens, however. Someone's nose may be large enough to constitute a structural abnormality; his shortness may be abnormal and may obstruct various functions he might otherwise perform, but again neither large nose nor shortness per se is plausibly characterised as a disease. Perhaps the definition can avoid these counterexamples, but only by being made more explicit concerning what constitutes an "abnormality" (or, better, a disease-indicating abnormality): as it stands, Definition 2 simply wraps the enigma of "disease" in the mystery of "abnormality." What, then, is the relevant notion of abnormality? The most straightforward understanding would be as simply statistical abnormality. This leads to • DEFINITION 3: Any process counts as a disease if it is produced by or associated with some definite structural or functional characteristics or

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some definite structural or functional processes that are statistically abnormal. But it is again easy to produce what seem to be clear counterexamples both to the sufficiency and to the necessity of Definition 3. There is a whole range of statistically abnormal structurally and functionally definable states being abnormally intelligent or abnormally physically attractive - that, far from being characteristic of disease, are clear social assets. Moreover, the counterexamples to Definition 2 have not been met: both the large nose and the degree of shortness involved are notions of statistical abnormality which therefore would still satisfy Definition 3 but are not, so we agreed, happily characterisable as constituting diseases. Finally, there are some conditions that, far from being abnormal, are universal or near universal - for example, eventually developing some degree of osteoarthritis - and yet normally count as diseases. Or suppose, horrifyingly, that there were a nuclear war and that all of those "lucky" enough to survive suffered from what we used to call "radiation sickness." Since this condition would now be universal, it would no longer seem to count, by Definition 3, as a disease. Clearly "abnormality" needs to be understood in some more special way than merely statistical abnormality. This leads to a definition, which unlike the previous ones, has real advocates in the relatively recent literature. • DEFINITION 4: Any process counts as a disease if it is produced by or associated with some definite structural or functional characteristics or some definite structural or functional processes that are not only statistically abnormal but which also put X at a biological (evolutionary) disadvantage. So, for example, the psychiatrist J. G. Scadding explicity defined a disease as the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for their species in such a way as to place them at a biological disadvantage. (Scadding 1967)

That is, the genuinely pathological characteristic is to be distinguished from the merely abnormal by the fact that it puts its owner at some definite biological disadvantage. Being exceptionally clever or exceptionally attractive is not indicative of disease because not at all disadvantageous. Certainly having an abnormally large nose or being abnormally short may be

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disadvantageous in important respects, but presumably the suggestion is that the disadvantage is not "biological." But then we need to know precisely which disadvantages count as biological. Kendell, advocating and elaborating on Scadding's definition, claimed that being at a biological disadvantage here consists exclusively in suffering from "conditions which reduce fertility or shorten life." Whatever its merits as an account of "biological" disadvantage (it is not clear why biology has any interest in lengthening our lives beyond reproductive age), it is certainly easy to play the counterexample game with this explication too. The definition surely rules out as non-diseases various (statistically) abnormal conditions psoriasis is one example among many - that do not reduce fertility (at least physiologically speaking) or shorten life, but nonetheless (i) cause suffering, (ii) involve well-characterised lesions, and (iii) may be relieved by medical means. Since a condition with these characteristics would surely normally count as a disease, the definition seems to be in trouble. Also, women who choose to be sterilised would be, in conjunction with their doctors, deliberately inflicting a permanent disease on themselves. Moreover, in order to avoid refutation by minor conditions, such as the common cold, which again surely ought to count as, of course minor, diseases, the idea in the definition of "reducing fertility or shortening life" would need to be interpreted in highly attentuated, dispositional ways. Furthermore, it seems clear that there are diseases in which reproductive advantages outweigh disadvantages, at least in particular circumstances. Obvious examples are immunities conferred by some mild infectious diseases: in the middle of a smallpox epidemic, to be suffering from cowpox is enormously beneficial for one's reproductive and survival prospects and yet surely cowpox should count as a disease. Again, it would seem difficult to characterise asthma as a nondisease on the grounds that it saved lots of otherwise fit young men in 1914 from the front trenches, even though it thereby greatly lengthened their lives and increased their likely reproductive success. It is easy to see how one might start further to modify the definition in the attempt to deal with these counterexamples. Perhaps some ceteris paribus clause can deal with the cowpox/smallpox and asthma-in-times-of-war cases: asthma or cowpox does, ceteris paribus, (tend to?) reduce fertility or shorten life in "normal" circumstances. This, however, would in turn lead to great problems over what counts as a "normal circumstance." Perhaps the psoriasis counterexample can be warded off by understanding factors that might reduce fertility in a broad sense so as to include social and behavioural as well as "purely physical" ones. Psoriasis may reduce one's fertility not by affecting sperm production or ovulation but by making one less sexually attractive. But

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this move in turn threatens to let back in as diseases abnormal shortness and abnormally large noses. Moreover, as Kendell himself allows - since he favours the inclusive understanding of reproduced fertility - making this move implies that homosexuality, transsexuality and even choosing a life of devotional chastity, all count as diseases under the definition. Well, one of the frustrations of conceptual analysis is that one person's damning counterexample may be another's clear-cut positive instance; but surely the counterexample party would be in the strong majority in this case. Moreover, if the central problem is, as Kendell explicitly takes it to be, that of developing a characterisation of disease so as to be able to give clear and convincing answers to questions from "hard-headed lawyers," then it seems most unlikely that what the courts want to know if they ask an expert whether or not PMT, say, is "really a disease" is whether or not the condition tends to shorten life or reduce fertility. Partly in response to some of these difficulties, Christopher Boorse has developed a characterisation of disease that is widely regarded as the most sophisticated presently available within the "naturalist" approach (that is, the approach that insists that disease can be characterised without resort to considerations of value). Boorse's characterisation is, he declares, inspired by a notion of a "species design" and of diseases as deviations from that design. Indeed he describes his approach as "based on the Galenic view that 'Disease is contrary to Nature': you are diseased just in case you are not in the 'normal' healthy state - health is normal functioning, where normality is statistical and the functions biological. ..." Boorse's account is: • DEFINITION 5: A disease is a type of internal state which is ... an impairment of normal functional ability, Le. a reduction of one or more functional abilities below typical efficiency . .. (Boorse 1977, 567). This has been modified only slightly in his latest publication (Boorse 1997,8-9) to read • DEFINITION 5': A disease is a type of internal state which is either an impairment of normal functional ability, i.e. a reduction of one or more functional abilities below typical efficiency, or a limitation on functional ability caused by environmental agents. The additional clause here is intended to deal with apparent counterexamples to the original formulation produced by, amongst other things,

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diseases such as some degree of osteoarthritis or some degree of dental caries, which, far from being "atypical," are universal or nearly so. Boorse's definition has in turn been subject to a whole range of criticisms. These include the charges that it is (i) circular, (ii) subject to counterexamples both in excluding conditions that ought to count as diseases and especially in including many conditions which ought not so to count, (iii) based on bad biology, (iv) based on bad medicine, and (v) covertly value-laden. Boorse replies at length to all these charges (Boorse 1997). Obviously we cannot here carefully examine each of the criticisms, Boorse's responses, and explain exactly why, despite Boorse's rejoinders, at least some of the charges in all five categories stick. Instead we can only give, in the briefest and sketchiest terms, the main outlines of what we see as some of the chief problems. First, there are a series of interrelated conceptual problems: (i)

The Galenic view that Boorse endorses of diseases being "contrary to Nature" is surely incoherent, or at any rate inconsistent with current naturalistic, anti-teleological views. We are part of Nature (what else?) and everything that happens to us is part of Nature (what else?). Pathogens such as bacteria or viruses are parts of Nature too (what else?). How could anything that actually happens be contrary to Nature? (ii) Boorse clearly thinks of Darwinian theory as supplying the scientifically kosher counterparts for what would otherwise be the teleological aspects of his account - what he seems really to mean by "contrary to Nature," for example, is counteradaptive. But in fact many diseases, thought of as processes, may be examples of Darwinian adaptations. Elaborating his view, Boorse claims that, for example, "Common symptoms of acute illness such as fever, vomiting, and loss of appetite imply failures of such functions as temperature maintenance and digestion." In fact, however, as recent Darwinian approaches to medicine have emphasised, fever may very well be an adaptive beneficial response to infection - beneficial because it does more damage to the invading bacteria or viruses than to the host. Similarly diarrhoea and vomiting, far from implying failure of some function, may well in fact be examples of adaptive functioning - one way in which the host organism can efficiently expel large numbers of the invaders. (For a fascinating introduction to "Darwinian medicine" see Nesse and Williams 1994.) These Darwinian insights, by the way, underline the lesson (already absorbed in more enlightened medical quarters) that the standard medical approach to treating fever, diarrhoea and vomiting may sometimes be entirely misguided - prolonging the

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condition or endangering the patient, rather than alleviating the condition and helping the patient. (iii) Boorse's characterisation relies on defining the function of various organs and physiological structures. This is a notoriously difficult notion that has been the subject of endless analysis in philosophy of science. We agree with Schaffner (1993) that talk of functions is sanctioned only by what he calls a "vulgar" interpretation of Darwinian theory and that it relies on assumptions about the goal-directedness of natural processes that are unacceptably anthropomorphic.

Secondly, even laying aside these underlying conceptual problems, there are any number of apparent counterexamples to Boorse's definition, just as to the earlier ones. The clause about "limitation on functional ability caused by environmental agents" threatens, for example, to make being held in gaol count as a disease; while the first clause makes the account staggeringly allencompassing - all of us are diseased all the time. Indeed Boorse allows that it is hopeless to try to abstract one notion of disease from the confusion of ordinary and even expert common usage. There are, he thinks in the end, several disease notions. He is attempting to articulate the "pathological notion" of disease, but there may be other notions such as the clinical notion, perhaps the judicial notion, the notion for insurance purposes and so on. However, Boorse's account fails to capture even one notion adequately and if his analysis has no prospect of addressing the issues about the grey cases with which we began, then it is difficult to see it as of major interest: practising clinicians wanted a clear-cut notion of disease to enable them to give clear-cut answers to "hard-headed lawyers" and others, but Boorse admits that his own analysis, even if successful, would not meet this need. The net result of this investigation so far, we hold, is that the attempts to characterise disease-in-general as an entirely descriptive, "natural" category form a classic case of a Lakatosian degenerating research programme: none of the attempted definitions is adequate; each has been patched up to meet the difficulties of the earlier ones only to run into counterexamples and difficulties of its own; and this has led to a proliferation of separate diseaseconcepts which in turn meet counterexamples, are amended, and so on. This degeneration of the naturalist programme may explain the perhaps initially surprising popularity of the alternative "normative model" - the view that disease can only be characterised by invoking human values as well as descriptive matters of fact.

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The idea of the "normative model" is essentially to go back to Scadding's definition (Definition 3 above) but instead of following Kendell and Boorse in taking "abnormality" in a statistical and/or biological sense, to insist that the relevant notion of abnormality is an evaluative one. The relevant sense of abnormality is not in the natural condition or process itself, but rather in the eye of the beholder (or rather collective beholders). So, for example, Engelhardt's influential characterisation goes as follows: • DEFINITION 6: A disease is "the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for their species in a way that we judge to constitute a significant disadvantage. (Engelhardt 1983,25; emphasis supplied) Although this is not as sharply formulated as one might wish, the context makes it clear (i) that the "norm" referred to here is not statistical but rather some sort of evaluative ideal, and (ii) that judgments of significant disadvantage refer not to "our" perceptions of biological disadvantage but rather to our evaluations of conditions as generally undesirable. The main idea behind the account is, I take it, that we should not look to anything in the nature of the two conditions to place, say, normal pregnancy and lung cancer in two qualitatively different classes. Each is a natural process (what else?) subject to a distinctive etiology and producing a characteristic set of signs and symptoms: the reason we think of the lung cancer as a disease and pregnancy as not is simply that we (generally) evaluate the latter positively, the former negatively. These evaluations, on Engelhardt's account, tie in very closely with decisions about intervention. He writes: [E]valuation enters into the enterprise of medical explanation because accounts of disease are immediately focussed on controlling and eliminating circumstances judged to be a disvalue.... Choosing to call a set of phenomena a disease involves a commitment to medical intervention, the assignment of the sick role, and the enlistment in action of health professionals. To call alcoholism, homosexuality, presbyopia, or minor hookworm infestation diseases, involves judgments closely bound to value judgments. Granted there is a spectrum from broken limbs to color blindness along which interest in construing a constellation of phenomena as a disease varies. The pain and discomfort of either a broken limb or a schizophrenic break invite immediate medical aid, while issues of color blindness or dissocial behaviour lie at the other end of the spectrum. But all along the spectrum, the concept of disease is as much a mode of evaluating as explaining reality. (Engelhardt 198 i, 4~ 1)

But Engelhardt's definition too seems rather obviously to fail. Most of us would value the condition of extreme poverty, for example, much below the

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condition of having a mild cold - yet the latter is, in normal terms, the disease, not the former. Even if we rule this out ad hoc perhaps by claiming that extreme poverty is not a "physical" condition, the old counterexamples about extreme shortness and the like still strike. As does the fact that what surely ought to count as a minor disease may in some circumstances be valued very highly indeed. Here Boorse seems to be correct: As any short person knows, shortness may reduce a person's quality of life much more, in the long run [! !l, than a minor allergy or viral infection. It cannot be undesirability alone that makes a physical condition a disease. On the other hand, it is clear that diseases can be desirable under some circumstances. Cowpox could save a person's life in the midst of a smallpox epidemic; myopia would be advantageous if it meant avoiding the infantry. (Boorse 1977,544)

Moreover, although Engelhardt advertises historical changes in what is regarded as a disease as supporting his characterisation, and although he seems to have persuaded many other commentators, a little analysis shows that the opposite is true. Engelhardt's discussion of the "disease" of masturbation has been widely influential. He shows that indulgence in masturbation was widely regarded as a disease both in Europe and the USA from the 18th century and through the 19th. Many unfortunates, both male and female, were subject to horrifying "treatment" to eradicate the disease. Engelhardt claims that: The disease of masturbation is an eloquent example of the value-laden nature of science in general and of medicine in particular.

It is true that since the "we" who do the judging of significant disadvantage may have different social valuation frameworks at different times, Engelhardt's Definition 6 has the consequence that what counts as disease is society-relative. But this seems clearly to be a fault of the characterisation rather than a virtue. What we surely want to say is not simply that masturbation was a disease relative to 18th and 19th century Western notions but is not, relative to later 20th century notions; we want to say that people in the 18th and 19th centuries were wrong - not just wrong relative to our present conceptions, but plain wrong - to think of masturbation as a disease. Engelhardt's characterisation does not permit this judgment. Finally the tie-in with intervention on the normative model is clearly inaccurate. Engelhardt and other normativists claim that the evaluations implicit in differentiating disease from non-disease are reflected in clinicians' decisions to intervene or not: we intervene only to attempt to correct conditions we disvalue. This latter claim is no doubt in some sense correct, but it clearly shows again that this model has failed to capture any intuitively

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satisfying distinction. Doctors certainly act in many cases of apparent nondisease: for example in circumcision, in preventing pregnancy in healthy women, and so on. On the other hand there are many cases that surely seem to count as diseases - at both ends of the seriousness scale - where clinicians will often choose to make no intervention: in the case of minor diseases, such as the common cold, for example, and in the case of terminal disease. The normative model of disease seems hopeless, while the attempts to characterise disease naturalistically form a classic example of a degenerating research programme. In these circumstances, the smart move is invariably to return to the initial problem situation and think again about the whole enterprise. 4.

THERE IS NO SUCH THING AS DISEASE (THOUGH THERE ARE OF COURSE DISEASES)

It seemed like a good idea to try to characterise the idea of disease-in-general

(a) because the notion does seem to be obscurely used even in relatively expert "common usage" and (b) because it seemed important, for a variety of reasons, to try to clarify it. There is indeed no doubt that medical usage is confused and entrenchedly so: "disease," "illness," "injury," "disorder" are all used with at best rough and ready distinctions. This is reflected in the often quite marked differences, even within medically well-informed groups, about which conditions are or are not considered to constitute diseases. It is worth mentioning a couple of pieces of empirical research on the extent of this terminological inexactitude. The first is the study of Campbell, Scadding and Roberts (1979). This involved presenting a set of 38 conditions to four different groups of subjects (nonmedical academics; secondary school students; medical academics; and general practitioners) who were asked to state whether or not each of the conditions counted as a disease. Various precautions were taken to control for order effects and the like. Although medics in general tended to be readier to count conditions as diseases than lay people, a great diversity of opinion was uncovered in all groups, even the medical ones. Thus while almost everyone counted malaria, tuberculosis and lung cancer as diseases, some 38% of medical academics, for example, did not classify haemophilia as a disease and over 30% of the same group also failed to count cirrhosis of the liver amongst the diseases. There was a 50-50 split amongst medical academics over both schizophrenia and depression (in both cases many more general practitioners classified the condition as a disease).

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In the second empirical study, Stefan and McManus looked at how the readiness of medical students to count certain conditions as diseases evolves over time (1989). Fifth-year, third-year and first-year medical students were presented with a list of conditions and asked which ones were "definitely diseases." In general, fifth-year students were much readier to count conditions as diseases than those at earlier stages of their course: for example, while only 18% of first year students counted "gallstones" as definitely a disease, 58% of third year and 82% of fifth year students did so. There are clearly two different explanations for this great and shifting unclarity in usage. The first is that "disease" is indeed a real concept, a "natural kind," but the perception of this real concept even amongst experts is vague and confused. This confusion might then be reduced, or even perhaps eliminated, if the right characterisation of this concept could be found and articulated - hence the explicatory efforts of Scadding, Kendell, Boorse et al. The naturalist explicatory research programme may presently be degenerating, but it might be destined .to "stage a comeback" and perhaps even find the correct definition of disease. But a second explanation of the terminological variability is that it reflects the fact that there is no real distinction in nature between "disease" and "nondisease." It is not that there is ontologically a clear-cut distinction which is presently largely misperceived or only dimly apprehended, but rather that there is no clear-cut distinction to be perceived. (At any rate, there is no such clear-cut distinction that is independent of humans and their preferences.) It seems to us that - paradoxical (and indeed anti-scientific) as it might initially sound - it is the second explanation that is correct. Indeed it seems to us, once thought about clearly, obviously correct. "Disease" is not a natural kind; there is no distinction in nature between processes that count as disease and those that do not - or, rather, there is no reason to think that disease is a natural kind, no reason to think that there is such a natural distinction. This is a view that has in fact been argued in the literature before, though not always as clearly as might be liked, and its consequences have not been fully or clearly appreciated. (See, e.g., Hesslow 1993, and Resnek 1987.) Well, first, what is a "natural kind?" Or rather, since we can only know that from, so to speak, a god's eye view, what are the grounds of reasonable belief concerning what are and are not natural kinds? The only serious view is that we have good reason to think that a class of entities constitutes a natural kind if and only if that class is the extension of a monadic predicate in the best, most unified exposition of our present best relevant theory. Hence "electron" designates a natural kind; "witch" does not. The fact surely is that

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there is at present no scientifically successful theory of disease-in-general, nor is there any prospect of such a theory. On the other hand there are, plainly, plenty of scientifically successful theories of the etiology and course of lung cancer, pneumonia, tuberculosis, and many other particuLar diseases. (Or rather, as we should say in our Sunday best if our account is correct, "particular conditions which are often thought of as diseases.") Hence it is reasonable to think that "lung cancer" is a natural kind, but there is no reason to think "disease" is. (Of course there are other particular conditions such as schizophrenia concerning which the jury is still very much out.) Surely, when thought through clearly, the sensible view of the situation is something like this. What exists in nature, despite Boorse's unscientific "Galenic" view, is a disparate set of natural processes - what eLse? Sometimes certain processes are indeed differentiated from naturally analogous ones and called diseases on valuational grounds. This has been well illustrated by Peter Sedgwick (1983, 120-121): The blight that strikes at corn or at potatoes is a human invention, for if man wished to cultivate parasites (rather than potatoes or corn) there would be no 'blight', but simply the necessary foddering of the parasite-crop.... Outside the significances that man voluntarily attaches to certain conditions, there are no illnesses or diseases in nature. ... The fracture of the septuagenarian's femur has, within the world of nature, no more significance than the snapping of an autumn leaf from its twig; and the invasion of the human organism by choleragerms carries with it no more the stamp of 'illness' than does the souring of milk by other forms of bacteria.

Notice immediately, however, the elementary point that has nevertheless often been obscured: this does not of course mean that humans invent blight in the sense that they create the objective, causal processes involved. The same causal interaction between parasite and potato occurs whether we call that interaction "blight" or "parasite-foddering"; the fact that we differentiate the snap of the 70-year-old femur from the snap of the autumn leaf only in terms of human evaluations has of course no effect at all on the biology of the fracture and repair of either human bone or oak leaf. Notice also that it by no means follows from the fact that our distinctions between "diseases" and "non-diseases" are sometimes made on valuational grounds, that values are always involved. On the contrary there seems to be nothing systematic here. That is both (partly) why disease talk is so confused and why the so-called normative model of disease is just as prone to counterexample as other "models." Sometimes, for instance, it is treatability that seems to matter. Medics, for example, generally seem to prefer to talk of genetic disorders rather than disease, and this seems to be on the grounds

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that they can only be diagnosed, perhaps palliated, but not cured. Similarly the psychiatrists' distinction between mental illness and personality disorder seems to rest on the fact that medical means are (as yet) of no use in attempting to treat the latter. We do not then endorse the normative model, any more than we endorse the naturalistic one. Normativists have correctly identified some of the reasons why the attempt to characterise disease naturalistically fails; but the sensible conclusion from the points they have made and we have here elaborated is not that "disease" is a normative notion, but rather that there is no such thing as disease. The notion fails to find any joints in nature at which to carve. Medical science neither currently uses nor has any need for any such notion. But what, finally, of the reasons we gave to try to seduce you into taking the attempt to explicate the disease notion seriously? How do those considerations look, if we accept that there is no such thing as disease? 5.

NOR DOES IT MATTER THAT THERE IS NO SUCH THING AS DISEASE-IN-GENERAL

(i)

Grey Cases Reconsidered

When a medic is asked whether some condition is "really" a disease, she should be careful to ascertain whether she is being asked a question to which there is a real-world, descriptive, true-or-false answer. She might be being asked about descriptive, scientific issues in ways that use the word "disease," but these can always be paraphrased more accurately in ways that avoid the word. They are standard requests for further information about the condition - generally its causes or etiology. Suppose, for example, that a medic is asked: "Is ME a real disease?" This might be an "internal," scientific question; but if so, then it really amounts to asking whether or not there is a recurrent constellation of signs and symptoms with some underlying, if presently unknown, causal etiology (perhaps of a definite "physical" kind such as a viral infection) in the patients (or most of the patients) currently diagnosed as suffering from ME. A positive answer to this question, complete with a specification of the causal nexus involved, would not, however, distinguish ME from, say, the processes of achieving puberty or becoming pregnant, each of which is marked by a characteristic set of symptoms and signs and each of which has a precisely specifiable causal etiology, but neither of which would in itself surely count as a disease.

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If the medic, having answered this descriptive, scientific question or, as in this case, admitted present ignorance on it, is asked for more - say by the head of a University Board of Examiners looking to make due allowances for a candidate said to be suffering from ME - "yes, but does this causal process you have specified really amount to a disease?" - then she is being asked an evaluative, normative question rather than a descriptive, scientific one. Something like: "Does the student deserve our sympathy and a higher grade than his marks as they stand seem to merit?" She is being asked this normative question under the guise of an apparently descriptive, scientific one. The attempt by medics like Kendell to resolve the perplexities brought on by harassment by "hard-headed lawyers" by defining what a disease really is, though perfectly understandable, is, in fact, misguided -logically misguided. It - of course unknowingly - assumes that the normative, evaluative or prudential issues undoubtedly involved can be solved by some factual, descriptive decision. But once this assumption is articulated, then it stands as clear logical nonsense despite some philosophical attempts to blur the issue. The "is/ought fallacy" - or the claim to infer an "ought" from an "is" remains fallacious. Our position entails that what Kendell perspicaciously identified as the "unthinking empiricism" of most medics is entirely justified. Remember: "Most doctors never give a moment's thought to the precise meaning of terms like illness and disease, nor do they need to. They simply treat the patients who consult them as best they can, diagnose individual diseases wherever they can, and try to relieve their patients' suffering even if they can't." (Kendell 1971) Those medics who are called upon - having characterised a patient's condition to their own satisfaction, or having decided what they can or cannot do to help that patient - to state whether that condition "really" amounts to a "disease" or not, are being asked a non-scientific, nondescriptive question. If society has got itself in a muddle concerning issues of responsibility, then it is up to society to get itself out. It is simply a confusion to think that medics can sort out a moral muddle by making descriptive scientific distinctions. If we go back in this new frame of mind to some of the particular "grey cases" we considered earlier, it seems immediately obvious that what is really at issue are evaluative, political or normative matters - not scientific ones at all. In the case, for example, of tobacco use disorder, was Norman Fowler's motivation for denying that this is a disease scientific? Or was his motivation to save the NHS money (the justification if pressed being evaluative -

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smokers don't deserve NHS funds, because they ought themselves to have the "willpower" to stop without the rest of us paying for it)? In the wrinkles case, remember that one of the medics commented, It is hard to draw up rules to distinguish between what is medical and what is cosmetic. Some people would try and make you feel guilty for treating wrinkles, but I do not see what is wrong with it. It is only controversial in the context of rationing inside the NHS. (Andrew Griffiths, St Thomas' - our italics)

Or let's return to the rheumatology clinic and the cases of Mr. A and Mr. B. When we think about the matter coolly and logically, it seems clear that

what we have are two different causal processes, each leading to a certain kind of disability. A is supported and B is not, because society has deemed A deserving and B not. Calling A diseased or "genuinely disabled" and B not is indeed a moral judgment and should not be disguised as a scientific one. (ii)

Medical Science and the Normative View of Disease Reconsidered

If disease were a normative, evaluative notion, then it would seem that the idea of medicine as based firmly on science is under threat. How could medicine be scientific, if its central notion - that of disease - is shot through with values? The suggestion by the more radical normativists like Kennedy is that something like the following argument is sound:

(i) medicine is centrally concerned with disease; and (ii) disease is an evaluative notion; therefore, (iii) medicine is not a science but instead an exercise in applied ethics. But medicine is not concerned with Disease, but instead with diseases - or, again speaking "Sunday best," with particular conditions, such as lung cancer, congestive heart failure, and so on that are within its purview. Kennedy's position, quoted earlier, is based on a fairly crude non sequitur. Even if it were established that disease-in-general is a normative notion - that we call lung cancer a disease only because we disvalue it, it would of course hardly follow that "each diagnosis of [disease]" in this case lung cancer is "an ethical decision." Having chosen to distinguish the condition for whatever reason, valuational or not, the question of whether or not some unfortunate suffers from it is clearly an objective descriptive question independent of any evaluative norms.

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In fact, however, we have argued that there is no such thing as disease-ingeneral. Kennedy's argument needs to be turned precisely on its head: (i)

medicine is (or should be) scientific - it attempts accurately to describe real processes in nature; and (ii) there is no general distinction in nature between processes that count as disease and those that do not; therefore, (iii) scientific medicine does not endorse a distinction between so-called "disease" conditions and non-diseases. Accepting that there is no such thing as disease does not threaten the role of science in medicine but on the contrary endorses it. As the historian of medicine, Lester King, has said: Biological science does not try to distinguish between health and disease. Biology is concerned with the interaction between living organisms and their environment. What we call health or disease is quite irrelevant. and All medical science studies facets of behavior under a wide variation in conditions. Many of these variations we call disease. But the grounds for calling them disease are not any essential part of the studies. Disease is an arbitrary designation. (1981,107,109)

The general situation concerning values and facts in medicine is surely quite simple. Of course values are often involved both in choosing which conditions to study and especially in complicated ways in the application of medical scientific knowledge - decisions about who to treat, about who to regard as able to work, and many others are undoubtedly value-laden. Nonetheless most diagnoses consist of some sort of no doubt partial and fallible identification of the causal process involved in producing some set of symptoms and signs. This is what medics are, or should be, experts in. They have also perforce become experts in excusing people from work and the like. They are generally - if only implicitly and uneasily - aware, however, that this issue and many others like it are evaluative ones in which they have no special expertise (except that, of course, garnered from experience). It can be argued that society off-loads too many of its important, evaluative issues onto doctors. By often phrasing the question in such cases in terms of whether someone is really ill, really has a disease, society is in effect, though perhaps confusedly rather than deliberately, salving its conscience by pretending that it is asking for objective, scientific medical advice.

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Medical Illness (Briefly) Reconsidered

As suggested earlier, the way that Szasz and others have argued that the whole notion of mental illness is a "myth" is by comparing so-called mental illnesses with a notional general characterisation of disease abstracted from uncontentious diseases in the physical domain. Again the literature on this topic is highly complex but the message of our paper for the debate seems plain: since there is no reason to think that any such adequate general characterisation of disease can be developed, this is not a sensible way in which to approach the issue of the status of mental conditions.

Whittington Hospital, London and London School ofEconomics REFERENCES Boorse, C. (1977): "Health as a Theoretical Concept," Philosophy ofScience, 44, 542-573. Boorse, C. (1997): "A Rebuttal on Health" in J. M. Humber and R. F. Almeder (eds): What is Disease? Totowa, New Jersey: Humana. Campbell, E. J. M., Scadding, 1. G. and Roberts, R. S. (1979): "The Concept of Disease," British Medical Journal, 2,757-762. Engelhardt, H. T., Jr (1975): "The Concepts of Health and Disease," in H. T. Engelhardt, Jr. and S. F. Spieker (eds): Evaluation and Explanation in the Biomedical Sciences. Dordrecht: Reidel. Hesslow, G. (1993) "Do We Need a Concept of Disease?" Theoretical Medicine, 14, 1-14. Kendell, R. E. (1975): "The Concept of Disease and Its Implications for Psychiatry," British Journal of Psychiatry 127, 305-15. Kennedy, I. (1983): The Umasking ofMedicine. London: Allen & Unwin. Nesse, R. M. and Williams, G. C. (1994): Evolution and Healing - the New Science of Darwinian Medicine. London: Weidenfeld and Nicholson. Resnek, L. (1987): The Nature of Disease. London: Routledge. Scadding, J. G. (1967): "Diagnosis: The Clinician and the Computer," Lancet, ii, 877-882. Schaffner, K. F. (1993): Discovery and Explanation in Biology and Medicine. Chicago: University of Chicago Press. Sedgwick, P. (1983) "Illness - Mental and Otherwise" in A. L. Caplan, H. T. Engelhardt, Jr. and J. J. McCartney (eds): Concepts ofHealth and Disease. Reading, Mass: Addison-Wesley. Stefan, M. D. and McManus, I. C. (1989): "The Concept of Disease: Its Evolution in Medical Students," Social Science and Medicine, 29, 791-792.

ADOLF GRUNBAUM

CRITIQUE OF FREUD'S NOTION OF MENTAL ILLNESS*

INTRODUCTION

The most basic ideas of psychoanalytic theory were initially enunciated in Josef Breuer's and Sigmund Freud's "Preliminary Communication" of 1893, which introduced their Studies in Hysteria. Three years later, Freud designated Breuer's method of clinical investigation of patients as "a new method of psycho-analysis."1 By now, the psychoanalytic enterprise has completed its first century. Thus, the time has come to take thorough critical stock of its past performance qua theory of human nature and therapy, as well as to have a look at its prospects. 2 THE "DYNAMIC" AND "COGNITIVE" SPECIES OF THE UNCONSCIOUS

Freud was the creator of the full-blown theory of psychoanalysis. But he was certainly not the first to postulate the existence of some kinds or other of unconscious mental processes. Over earlier centuries, a number of thinkers such as Plato, Gottfried Wilhelm Leibniz, and Hermann von Helmholtz - had done so in order to explain conscious thought and overt behavior for which they could find no other explanation. Indeed, Freud had additional precursors who anticipated some of his key ideas with impressive specificity.3 As he himself acknowledged,4 Arthur Schopenhauer and Friedrich Nietzsche had speculatively propounded major psychoanalytic doctrines that he himself claimed to have developed independently thereafter from his clinical observations of his patients. There are major differences between the unconscious processes hypothesized by current cognitive psychology, on the one hand, and the unconscious contents of the mind postulated by psychoanalytic psychology, on the other. s Freud's "dynamic" unconscious is the supposed repository of repressed, forbidden wishes of a sexual or aggressive nature, which recklessly seek immediate gratification without regard to the constraints of external reality, but whose reentry or initial entry into consciousness is prevented by the defensive operations of the ego. Indeed, according to Freud, we would not even have developed the skills needed to engage in cognitive activities if we did not rely on them to gratify our instinctual needs. 6

57 • This article is reprinted under a new title from the author's essay in the companion book to the 1998 Library of Congress Exhibition Sigmund Freud: Conflict and Culture. This book shared that title and was edited by M. Roth (New York: A. A. Knopf, 1998).

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However, the psychoanalyst Heinz Hartmann was driven, by facts of biological maturation discovered non-psychoanalytically and presumably already known to Freud, to acknowledge in his "ego psychology" that such functions as cognition, memory, and thought can develop autonomously by innate genetic programming, independently of instinctual drive gratification. 7 In the cognitive unconscious, there is great rationality in the ubiquitous computational and associative problem-solving processes required by memory, perception, judgment, and attention. By contrast, as Freud emphasized, the wish-content of the dynamic unconscious makes it operate in a highly illogical way. Furthermore, the dynamic unconscious acquires its content largely from the unwitting repression of ideas in the form they originally had in consciousness, whereas neither the expulsion of ideas and memories from consciousness nor the censorious denial of entry to them plays any role at all in the cognitive unconscious. 8 Freud reasoned that the use of his new technique of free association could lift the repressions of instinctual wishes, thereby bringing the repressed ideas back to consciousness unchanged. This Freudian technique calls on the patient to express freely, without omissions, any and all thoughts, feelings, wishes or whatever that come to mind apropos of any given idea. In the case of the cognitive unconscious, there is typically no such awareness of, say, the elaborate scanning or search process by which someone rapidly comes up with a half-forgotten name when asked for it. Some psychoanalysts have claimed the compatibility of the two species of unconscious within the same genus,9 yet Morris Eagle has articulated the extensive modifications required in the Freudian notion of the dynamic unconscious, if it is to be made compatible with the cognitive one. lO More importantly, some Freudian apologists have erroneously claimed support for the psychoanalytic unconscious from the cognitive one, II although the existence of the latter does not confer any credibility on the former. We must likewise beware of the bizarre argument recently put forward by the philosopher Thomas Nagel that the pervasive influence of Freudian ideas in Western culture vouches for the evidential probity of the psychoanalytic enterprise and for the validity of its doctrines. 12 Yet Freud's widespread cultural influence no more validates his tenets than Christian cultural hegemony warrants belief in the virgin birth of Jesus or in his resurrection. 13 Even Nagel's premise that Freudian theory has become part of the intellectual ethos and folklore of Western culture cannot be taken at face value. As Henri Ellenberger has stressed,14 the prevalence of vulgarized pseudo-Freudian concepts makes it difficult to determine reliably the extent to which genuine

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psychoanalytic hypotheses have actually become influential in our culture at large. For example, the purview of Freud's psychoanalytic motivational elucidation of slips or bungled actions ("parapraxes") was avowedly confined to lapses whose "motives [are] unknown to consciousness,"15 and which are thus thought to be prima facie psychologically unmotivated. Yet all psychologically motivated slips or bungled actions - even those whose promptings are both conscious and transparent - are commonly but incorrectly called "Freudian." Hence Freud disclaimed any credit for the explanations of those slips that are motivationally transparent. 16 CRITIQUE OF FREUDIAN AND POST-FREUDIAN PSYCHOANALYSIS

Let us now tum to my critique of the core of Freud's original psychoanalytic theory, and thereafter, to a verdict on whether my objections to this core are overcome by the two major post-Freudian sets of hypotheses called "selfpsychology" and "object relations theory." I have often been told by psychoanalysts that they no longer accept Freud's formulations, as if this disavowal vouches for the probity of one or another of the post-Freudian doctrines. Moreover, when Freud is not under attack by outside critics, these same revisionists continue to cite him very frequently with biblical deference. As Freud told us, "The theory of repression is the cornerstone on which the whole structure of psychoanalysis rests. It is the most essential part of it."17 The three principal branches of the theory of repression are sets of hypotheses pertaining to the unconscious causation and psychoanalytic treatment of psychopathology, the theory of dreams, and the previously mentioned theory of slips or parapraxes. In each of these three branches, the repression of mental contents is asserted to playa causally necessary role: it is deemed crucial to the production of neuroses and psychoses by unconscious sexual motives, to the formation of dreams by latent, forbidden infantile wishes, and to the generation of bungled actions by diverse hidden motives of displeasure (German: "Unlust"). In Freud's view, our neurotic symptoms, the manifest contents of our dreams, and the various sorts of slips we commit are each constructed as "compromises between the demands of a repressed impulse and the resistances of a censoring force in the ego."18 Therefore, Freud can be said to have offered a unifying "compromise-model" of neuroses, dreams, and parapraxes. And psychoanalysts have pointed to the explanatory virtue of such unification to claim validity for it, a claim that I shall challenge.

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But what, in the first place, is the motive or cause that initiates and sustains the operation of the unconscious mechanism of repression before it produces its own effects? Apparently, Freud assumed axiomatically that distressing mental states, such as forbidden wishes, trauma, painful memories, disgust, anxiety, anger, shame, hate, guilt, and sadness - all of which are displeasurable - typically actuate, and then fuel, forgetting to the point of repression. 19 Thus, repression presumably regulates pleasure and displeasure by defending our consciousness against various sorts of negative affect. As Freud put it dogmatically: "The tendency to forget what is disagreeable seems to me to be a quite universal one,"20 and "distressing memories succumb especially easily to motivated forgetting."21 Yet he was driven to concede, "one often enough finds it impossible, on the contrary, to get rid of distressing memories that pursue one, and to banish distressing affective impulses like remorse and the pangs of conscience." Furthermore, he acknowledged that "distressing things are particularly hard to forget."22 Thus, some painful mental states are vividly remembered while others are forgotten or even repressed. Yet Freud's account is vitiated by the fact that factors other than the degree of their painfulness determine whether they are remembered or forgotten. For example, personality dispositions or situational variables may in fact be causally relevant to memorial success or failure. Freud never came to grips adequately with the negative import of the phenomenon of obsessive recall of distressing experiences for his central tenet that negative affect drives repression. (Incidentally, the psychologist Thomas Gilovich at Cornell University is now doing valuable work on the sorts of conditions under which painful experiences are remembered, and on those kinds of other conditions under which they are forgotten). Another basic difficulty, which besets all three branches of the theory of repression alike, lies in the epistemological defects in Freud's "fundamental rule" of "free association." It is a cardinal thesis of his entire psychoanalytic enterprise that this method of free association has the twofold major capability of being both causally investigative and therapeutic. It can identify the unconscious causes of human thoughts and behavior, both abnormal and normal, and, by overcoming resistances and lifting repressions, it can remove the unconscious pathogens of neuroses, thereby providing therapy for an important class of mental disorders. We are told that by using his unique method to unlock the floodgates of the unconscious, Freud was able to show that neuroses, dreams, and slips are caused by repressed motives. For brevity, I shall use the legal term

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"probative" and will say that a supposed method for identifying causes correctly is "causally probative." And, using medical terminology, I shall speak of the causes of an illness as "the etiology" of that illness. Employing these locutions, I now ask: What was Freud's evidence that free association is causally probative for etiologic research in psychopathology? As he tells us very clearly,23 his argument for this investigative tribute to free association is essentially a therapeutic one going back to the "cathartic" method of treating hysteria, which had been pioneered by Freud's senior mentor Josef Breuer. In the cathartic method, the hypnotized patient is asked to retrieve the memory of a repressed trauma and to verbalize the previously suppressed emotion felt when he/she had the traumatic experience. Such an emotional release or "catharsis" becomes possible after the hypnotic recall of the trauma. What then was Freud's therapeutic argument that free association can uncover the causes or pathogens of psychopathology? Freud inferred the key therapeutic hypothesis that the remedial disappearance of the neurotic symptoms is not a placebo effect, but is causally attributable to the cathartic lifting of repressions by means of the method of free association. According to Breuer and Freud, in a placebo-cure, the patient's expectation of improvement ("suggestion") is responsible for the cure. Assuming, to the contrary, that the cathartic lifting of the patient's repressions is the operative therapeutic agent in getting rid of his/her neurotic symptoms, Freud 24 then drew two additional major theoretical inferences as follows: (i) the presumed cathartic removal of the neurosis by the associative lifting of repressions is good evidence for postulating that ongoing repressions, accompanied by affective suppressions, are causally necessary for the very existence of a neurosis. 25 After all, he reasoned, this postulate then permits the valid deduction of the stated key therapeutic hypothesis that the cathartic removal of the presumed pathogen of the neurosis would issue in its disappearance (cure); furthermore, he concluded (ii) if repressions accompanied by affective suppression are the essential causes of neurosis, the presumed unique ability of the method of free association to uncover them vouches for its capacity to identify the causes or pathogens of the neuroses. However, his therapeutic argument for the cogent etiologic probativeness of free associations fails multiply, no matter how revealing the associative contents may be in other respects in regard to the patient's psychological preoccupations or personality dispositions. In the first place, the durable therapeutic success on which the argument was predicated at the outset did not materialize, as Freud was driven to admit

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both early and very late in his career. 26 For example, contrary to Breuer's own report,27 his treatment of his famous first patient Anna O. was a complete therapeutic fiasco. 28 And Breuer knew it, when he sent a letter referring her for further treatment elsewhere. But even insofar as there was transitory therapeutic gain, Freud failed to rule out the stated rival hypothesis of placebo effect, which undermines his attribution of such gain to the insightful removal of repressions by free association: this ominous hypothesis of placebo effect asserts that treatment components other than insight into the patient's repressions - such as the mobilization of the patient's hope by the therapist - are responsible for any resulting improvement. 29 To rule out that rival hypothesis cogently, it would have been necessary to show that in a control group of similar patients whose repressions are not lifted, the treatment outcome was worse than in the psychoanalytically treated group. No such data have become available during the past century.30 Thus, the viability of the rival hypothesis of placebo effect rightly challenges Freud's insight-dynamics of therapeutic gain. Moreover, even if we grant the assumption that the neurosis is removable by cathartically lifting repressions, this outcome does not provide cogent support for postulating etiologically that repressions, accompanied by affective suppressions, are causally necessary for the existence of a neurosis. This lack of support for the crucial foundation of the entire theory of repression can be made apparent from the following analogous fact: the remedial action of aspirin for tension headaches does not lend any support to the outlandish etiologic hypothesis that a hematolytic aspirin deficiency is a causal sine qua non for having tension headaches. Yet if an aspirin deficiency in our blood were causally required for tension headaches, then it would follow validly that the removal of that deficiency by taking aspirin will issue in the removal of the tension headache. But that is just not good enough to warrant the inferred etiologic role of the aspirin deficit. Similarly, supposing that "repression accompanied by affective suppression" is causally necessary for neurosogenesis, then it follows validly that the cathartic removal of the repression will issue in the removal of the neurosis. But again, that is not enough to infer the pathogenic role of repression-cum-suppression. Thus it is unavailing to the purported etiologic probativeness of free associations that they may lift repressions, since Freud failed to show that the latter are actually pathogenic. The upshot is that Freud's stated therapeutic argument multiply forfeits its foundation. Furthermore, it is a red herring to claim, as some psychoanalysts have done in rebuttal, that this fundamental difficulty is overcome by Freud's subsequent theorizing.

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Yet, as we learn in Freud's opening pages on his method of dream interpretation, he extrapolated the role of free associations from being only a method of etiologic inquiry aimed at therapy, to serving likewise as an avenue for finding the purported unconscious causes of dreams. 3l In the same breath, he reports that when patients told him about their dreams while associating freely to their symptoms, he boldly, if not rashly, extrapolated his "compromise-model" from neurotic symptoms to manifest dream contents. In that model, both symptoms and manifest dream contents are regarded as "compromises between the demands of a repressed impulse and the resistances of a censoring force in the ego."32 A year later, Freud carried out the same twofold extrapolation to include sundry slips or bungled actions. What, in Freud's view, do free associations tell us about our dreams? Whatever their manifest content, they are purportedly always wish-fulfilling in two logically distinct ways: at least one usually unconscious infantile wish is required as the motivational cause of any and every dream,33 and the manifest content of the dream graphically displays, more or less disguisedly, the state of affairs desired by the wish. As Freud contends: "When the latent dream-thoughts that are revealed by the analysis [via free association] of a dream are examined, one of them is found to stand out from among the rest ... the isolated thought is found to be a wishful impulse.... This impulse is the actual constructor of the dream: it provides the energy for its production. . . ."34 Furthermore, Freud claimed that a preconscious universal wish-to-sleep explains why we dream at all, as distinct from why our dreams have the specific manifest contents they do. 35 Quite independently of Freud's unsuccessful therapeutic argument for the causal probativeness of the method of free association, he offered his psychoanalysis of his own 1895 "Specimen Irma Dream" as a separate, nontherapeutic argument for considering the method of free association to be a cogent means of identifying hypothesized hidden wishes as the motives of our dreams. In my detailed critique of that unjustly celebrated analysis of his IrmaDream,36 I have argued that Freud's account is regrettably no more than a piece of false advertising: it does not deliver at all the promised vindication of free association; it does nothing toward warranting his foolhardy dogmatic generalization that all dreams are wish-fulfillments in his stated twofold sense, and it does not even pretend that his alleged "Specimen Dream" is evidence for his compromise model of manifest-dream content. Nonetheless, Freud's analysis of his Irma Dream continues to be celebrated in the psychoanalytic literature as the paragon of dream interpretation. Moreover, his wish-fulfillment theory of dreaming was deeply flawed from the outset. As it now turns out, he did not heed a patent epistemological con-

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sequence of having abandoned his 1895 Project's neurological energy-model of wish-driven dreaming. By precisely that abandonment, he had forfeited his initial biological rationale for claiming that at least all "normal" dreams are wish-fulfilling, which left him without any kind of energy-based warrant for then universalizing the doctrine of wish-fulfillment to extend to any sort of dream. Yet, unencumbered by the total absence of any such warrant and of any other justification, the universalized doctrine, now formulated in psychological terms, rose like a phoenix from the ashes of Freud's defunct energy model. As I have argued elsewhere,3? his neuroenergetic argument for wish-driven dreaming was dead-in-the-water at birth. Once he had chained himself to the universal wish-monopoly of dreamproduction, his interpretations were constrained to reconcile wishcontravening dreams with the decreed universality of wish-fulfillment,38 Such reconciliation demanded imperatively that all other parts and details of his dream-theory be obligingly tailored to the tenability of his governing wishdogma. Yet Freud artfully obscured this contrived dynamic of theorizing, while begging the methodological question. Indeed, since there are innumerable distressing, prima facie wishcontravening dreams, Freud's idee fixe of universal wish-fulfillment dictated nothing less than the following three major artifactual doctrines of his dreamtheory. First there is the distinction between the conscious, manifest content of a dream - which is topically polymorphic - and the repressed, latent content, which Freud claimed to feature invariably a repressed, infantile wish. 39 The manifest content is allegedly just a fa\ade for the forbidden, latent wish-content: the former purportedly resulted, in the service of disguise, from the distortion of the forbidden wish by a process that Freud designated as the "dream work"; but this hypothesized distortion must not be confused with the familiar bizarreness of dreams. A second artifact of Freud's "wish-imperialism" was the related tenet that the manifest dream-content, no less than a neurotic symptom, is the product of a conflict and compromise between a repressed wish clamoring for expression - a so-called latent "dream-thought" - and the censorship exerted by a repressing ego. 40 Finally the insistence on the universality of wish-fulfillment in dreams also imposed a methodological exigency. As Clark Glymour has noted,41 Freud's method of dream interpretation by free association was antecedently constrained by his exigency to weave together the ensuing associations selectively so as to yield a wish-motive as standing out from the others. But Freud misrepresented this pre-ordained result as a straightforward empirical

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finding,42 unencumbered by prior theory-driven regimentation of the products of the patient's associations. Advocates of psychoanalysis have proclaimed it to be an explanatory virtue of their theory that its compromise-model gives a unifying account of such disparate phenomena as neuroses, dreams, and slips, and furthermore that the theory of repression also contributes to Freud's theory of psychosexual development. In fact, some philosophers of science have hailed explanatory unification as one of the great achievements and desiderata of the scientific enterprise. Yet, in other contexts, unification can be a vice rather than a virtue. For example, Thales of Miletus, though rightly seeking a rationalistic, rather than mythopoetic, picture of the world, taught that everything is made of water - a cosmic chemical unification. But a later chemist could have said to Thales, across the millennia: "There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy."43 As I have argued, the same moral applies to Freud's dubious psychopathologizing of normalcy; by unwarrantedly assuming the causal cogency of the method of free association, his compromise-model has generated a pseudo-unification of neurotic behavior with dreaming and the bungling of actions. The French philosopher Paul Ricoeur4" endeavored to parry quite different criticisms of psychoanalysis from philosophers of science during the 1950s and 1960s. 45 In concert with the other "hermeneutic" philosophers Karl Jaspers and Jiirgen Habermas, as well as with Ludwig Wittgenstein, Ricoeur retorted patronizingly that Freud himself had "scientistically" misunderstood his own theoretical achievement, such that the scientific failings of psychoanalysis were actually virtues. Mind you, scientism is a form of intellectual malfeasance. It is the supposed misguidedly utopian, intellectually imperialistic and exclusionary worship of the scientific way of knowing the world, and it is often linked as a whipping boy with what is untutoredly denigrated as "positivism." The hermeneuts offer their own reconstruction of psychoanalysis. But elsewhere I have contended that all of the misunderstandings and confusions with which they charge Freud are actually their own, not his. 46 Thus, they champion the muddled doctrine that Freud's theory of the unconscious "meaning" of symptoms, dreams, and slips is a contribution to semantics! Accordingly, Ricoeur speaks of Freud's supposed "semantics of desire." And the English psychoanalyst Anthony Storr stated misguidedly that "Freud was a genius whose expertise lay in semantics."47 But the Freudian meaning of a symptom is etiologic, unlike the semantic meaning of language.

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The etiologic meaning of a symptom is its latent motivational cause. No wonder that the methods of the herrneneuts have deplorably failed to spawn a single new clinically or explanatorily fruitful psychoanalytic hypothesis. Instead, their proposed reconstruction is just a negativistic ideological battle cry that leads nowhere. POST-FREUDIAN DEVELOPMENTS

What have been the contemporary post-Freudian developments insofar as they still qualify as psychoanalytic in content rather than just in name? Are they on firmer epistemological ground than Freud's original major hypotheses?48 The well-known clinical psychologist Morris Eagle has given a comprehensive and insightful negative answer to this question. 49 As he tells us: "In the last forty or fifty years there have been three major theoretical developments in psychoanalysis: ego psychology, object relations theory, and self-psychology. If contemporary psychoanalytic theory is anything, it is one of these three or some combination, integrative or otherwise, of the three."50 As we already had occasion to note, Heinz Hartmann's ego psychology departed from Freud's instinctual anchorage of the cognitive functions. More importantly, both Heinz Kohut's self-psychology, as well as the object relations theory of Otto Kernberg and the British school, fundamentally reject Freud's compromise model of psychopathology: indeed, self-psychology has repudiated virtually every one of Freud's major tenets. 51 Similarly, the object relations theorists deny that the etiology of pathology lies in Freudian (oedipal) conflicts and traumas involving sex and aggression, claiming instead that the quality of maternal care is the crucial factor. However, besides diverging from Freud, these two post-Freudian schools disagree with one another. But what about the evidential merits of the two post-Freudian developments that are usually designated as "contemporary psychoanalysis"? Do they remedy Freud's epistemological failings? Eagle argues that the verdict is clearly negative: "The different variants of so-called contemporary psychoanalytic theory ... are on no firmer epistemological ground than the central formulations and claims of Freudian theory.... There is no evidence that contemporary psychoanalytic theories have remedied the epistemological and methodological difficulties that are associated with Freudian theory."52 Since Jacques Lacan avowedly forsook the need to validate his doctrines by familiar canons of evidence, I shall not comment on them, except to

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mention his willful, irresponsible literary obscurity and notorious cruelty to patients,53 which he justified as satisfying their alleged masochistic needs. Finally, what are the prospects for the future of psychoanalysis in the 21st century? The noted psychoanalysts Jacob Arlow and Charles Brenner reached the following sanguine conclusion about both its past and its future: Psychoanalysis will continue to furnish the most comprehensive and illuminating insight into the human psyche. It will continue to stimulate research and understanding in many areas of human endeavor. In addition to being the best kind of treatment for many cases, it will remain, as it has been, the fundamental base for almost all methods that try to alleviate human mental suffering by psychological means. 54

By contrast, a dismal verdict is offered by the renowned American psychologist and psychoanalyst Paul E. Meehl. 55 Since one of my main criticisms of psychoanalysis figures in it, let me explain first that, apropos of my critiques of Freud's theories of obsessional neurosis (the Rat Man) and of transference, I had demonstrated the fallaciousness of inferring a causal connection between mental states from a thematic ("meaning") connection between them. 56 Meehl refers to the latter kind of shared thematic content as "the existence of a theme" and writes: His [Griinbaum's) core objection, the epistemological difficulty of inferring a causal influence from the existence of a theme (assuming the latter can be statistically demonstrated), is the biggest single methodological problem that we [psychoanalysts) face. If that problem cannot be solved, we will have another century in which psychoanalysis can be accepted or rejected, mostly as a matter of personal taste. Should that happen, I predict it will be slowly but surely abandoned, both as a mode of helping and as a theory of the mind [reference omitted).

Accordingly, in regard to the last 100 years, Arlow and Brenner's rosy partisan account is very largely ill-founded, if only because, as we saw, the lauded comprehensiveness of the core theory of repression is only a pseudounification. Among their glowingly optimistic statements about the future, only one is plausible: the expectation of a continuing heuristic role for psychoanalysis. Such a function does not require at all that its current theories be correct. As an example of the heuristic role, one need only think of the issues I raised in connection with Freud's dubious account of the relation of affect to forgetting and remembering, issues that range well beyond the concerns of psychoanalysis. In this vein, the Harvard psychoanalyst and schizophrenia researcher Philip Holzman observes: "This view of the heuristic role of psychoanalysis, even in the face of its poor science, is beginning to be

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appreciated only now."57 Holzman mentions three areas of inquiry as illustrations: 58 (i) the plasticity and reconstructive role of memory as against photographic reproducibility of the past, (ii) the general role of affect in cognition, and (iii) the relevance of temperament (e.g. shyness) in character development, as currently investigated by Jerome Kagan at Harvard. These are topics that will very probably be explored further in the years to come. University of Pittsburgh NOTES I All citations of Freud's writings in English are from the Standard Edition of the Complete Psychological Works of Sigmund Freud. trans. by J. Strachey. et al.. Hogarth Press. 1953-1974. 24 volumes. Each reference will use the abbreviation "S.E.... followed by the year of first appearance. volume number. and page(s). The present reference to Freud is S.E. 1896. 3: 151. 2 For further details. see Adolf Griinbaum. The Foundations of Psychoanalysis: A Philosophical Critique (University of California Press. 1984). There are German. Italian. Japanese. French. and Hungarian translations. See also Adolf Griinbaum. "Is Freud's Theory Well-Founded?" Behavioral and Brain Sciences 9 (1986). 266-281; Adolf Griinbaum. Validation in the Clinical Theory ofPsychoanalysis: A Study in the Philosophy of Psychoanalysis (International Universities Press. 1993); and Adolf Griinbaum. "One Hundred Years of Psychoanalytic Theory and Therapy: Retrospect and Prospect" in Mindscapes: Philosophy. Science. and the Mind. eds.• Martin Carrier and Peter Machamer (University of Pittsburgh Press and University of Konstanz Press. 1997). 340-343. 3 Marcel Zentner. Die Flucht Ins Vergessen: Die Anfiinge der Psychoanalyse Freud's bei Schopenhauer (Wissenschaftliche Buchgessellschaft. 1995). 248. 4 S.E. 1914. 14: 15-16. 5 Morris Eagle. "The Psychoanalytic and the Cognitive Unconscious" in Theories of the Unconscious and Theories ofthe Self, ed.• R. Stern (Analytic Press. 1987). 155-189. 6 S.E. 1900.5: 566-567. 7 Morris Eagle. "The Dynamics of Theory Change in Psychoanalysis" in Philosophical Problems of the Internal and External Worlds: Essays on the Philosophy of Adolf Griinbaum. eds.• J. Earman et al. (University of Pittsburgh Press and University of Konstanz Press. 1993), ch. 15,374-376. 8 Eagle, "The Dynamics of Theory Change in Psychoanalysis." 161-165. 9 Howard Shevrin et aI., "Event-Related Potential Indicators of the Dynamic Unconscious." Consciousness and Cognition I (1992). 340--341. 10 Eagle. "The Psychoanalytic and the Cognitive Unconscious." 166-186. II E.g.• Michael Basch. "Psychoanalysis, Science & Epistemology." The Bulletin of the [Chicagojlnstitutefor Psychoanalysis 4(2) (1994), I. 12 Thomas Nagel. "Freud's Permanent Revolution." New York Review of Books. 12 May 1994. 34-38. 13 Adolf Griinbaum, Letter-to-the-Editor. New York Review of Books, II August 1994,54-55. Contra Thomas Nagel's "Freud's Permanent Revolution."

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Henri Ellenberger, The Discovery of the Unconscious (Basic Books, 1970),547-549. S.E. 1901,6:239. 16 S.E. 1916, 15:47. 17 S.E. 1914, 14:16. 18 S.E. 1925,20:45; 1917, 16:301. 19 Helmut Thoma and Horst Kachele, Psychoanalytic Practice, vol. I (Springer-Verlag, 1987), 107-111. 20 S.E. 1901,6: 144. 21 S.E. 1901,6: 147. 22 S.E. 1916,15: 76-77. 23 S.E. 1900,5: 528; Griinbaum, Validation in the Clinical Theory of Psychoanalysis, 24-26. 24 Adolf Griinbaum, "One Hundred Years of Psychoanalytic Theory and 'Therapy: Retrospect and Prospect," 340-343. 25 S.E. 1893,2: 6-7. 26 S.E. 1925,20: 27; 1937,23,216-253. 27 S.E. 1895,2:34-35. 28 Henri Ellenberger, "The Story of Anna 0.: A Critical Review with New Data," J. Hist. Behav. Sci. 8, 1972, 267-279; and Mikkel Borch-Jacobsen, Remembering Anna 0.: 100 Years of Psychoanalytic Mystification (Routledge, 1996). 29 See Adolf Griinbaum, "The Placebo Concept in Medicine and Psychiatry" in Non-Specific Aspects of Treatment, eds. M. Shepherd and N. Sartorius, published for the World Health Organization, (Hans Huber Verlag, 1989),7-38. 30 H. Bachrach et al., "On the Efficacy of Psychoanalysis," Journal of the American Psychoanalytic Association 39, 1991, 871-916; S. Vaughan and S. Roose, ''The Analytic Process: Clinical and Research Definitions," International Journal of Psycho-Analysis 76, 1995, 343-356. 31 S.E. 1900,4: 100-101. 32 S.E. 1925,20: 44. 33 S.E. 1900,5:546,548-549,552-554,567-568,583-584. 34 S.E. 1925,20:44. 35 S.E. 1900, 4:234; 5:680. 36 Griibaum, The Foundations of Psychoanalysis, ch. 5. 37 Adolf Griinbaum, "A New Critique of Freud's 1895 Neurobiological Dream Theory" (forthcoming). 38 S.E. 1900,4: 134-135; 1925, 20:44. 39 S.E. 1900,5:553; 1925,20:44. 40 S.E. 1925,20: 45. 41 Clark Glymour, ''The Theory of Your Dreams" in Physics, Philosophy, and Psychoanalysis: Essays in Honor of Adolf Griinbaum, eds., Robert Cohen and Larry Laudan (D. Reidel, 1983), 57-71. 42 S.E. 1925,20:44. 43 Shakespeare, Hamlet, Act I, Scene V. 44 Paul Ricoeur, Freud and Philosophy (Yale University Press, 1970),358. 45 Barbara von Eckardt, "Adolf Griinbaum and Psychoanalytic Epistemology" in Beyond Freud: A Study ofModem Psychoanalytic Theorists, ed., J. Reppen (Analytic Press, 1985), 356-364. 46 Griinbaum, The Foundations of Psychoanalysis, 1-94; Adolf Griinbaum, " 'Meaning' Connections and Causal Connections in the Human Sciences: The Poverty of Hermeneutic Philosophy," Journal of the American Psychoanalytic Association 38, no. 3, 1990, 559-577; 14

15

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Griinbaum, Validation in the Clinical Theory of Psychoanalysis, ch. 4; and Griinbaum, "The Hermeneuti Versus the Scientific Conception of Psychoanalysis," in D. Aerts et al., (eds.) Einstein Meets Magritte: The White Book. (Kluwer, 1999),219-239. 47 Anthony Storr, "Human Understanding and Scientific Validation" in Open Peer Commentary, Behavioral & Brain Sciences 9, no. 2, June 1986,260. 48 Griinbaum, The Foundations of Psychoanalysis, ch. 7. 49 Eagle, "The Dynamics of Theory Change in Psychoanalysis," 373-408. 50 Eagle, "The Dynamics of Theory Change in Psychoanalysis," 374. 51 Eagle, "The Dynamics of Theory Change in Psychoanalysis," 388. 52 Eagle, "The Dynamics of Theory Change in Psychoanalysis," 404. 53 Andre Green, "Against Lacanism," Journal of European Psychoanalysis 2, 1995/1996, 169-185. 54 Jacob Arlow and Charles Brenner, "The Future of Psychoanalysis," Psychoanalytic Quarterly 57, 1988, 13. 55 Paul E. Meehl, "Commentary: Psychoanalysis as Science," Journal of the American Psychoanalytic Association 43, no. 4, 1995, 1021. 56 Griinbaum," 'Meaning' Connections and Causal Connections in the Human Sciences"; and Griinbaum, Validation in the Clinical Theory of Psychoanalysis, ch. 4. 57 Philip Holzman, "Hilgard on Psychoanalysis as Science," Psychological Science 5, no. 4, July 1994, 190. 58 Private communication.

MARIO V. FIORENTINO

CANCER FROM THE MEDICAL AND EXISTENTIAL POINTS OF VIEW

AN OVERVIEW OF THE PROBLEM

In the decade between 1920 and 1930 the life-span of the normal Italian population was about 50 years, and it gradually increased, reaching a mean of 70 years in the decade between 1980 and 1990 (1STAT report: Le Regioni in cifre, Rome 1990). Approximately the same trend has been found in all developed countries: for Benton R. Adkins et al. (Surgical Care for the Elderly. Williams and Wilkins, Baltimore, 1988) the probability of survival in the United States has reached 16 years for people of 65, and more than 10 for people of 70. This increasing longevity in the human species is due, at least partially, to reduced or delayed tumour-related mortality: around half of the known types of cancer are present nowadays in a completely curable phase, and more than another third can be effectively palliated, allowing for our patients to have several years of normal or nearly normal survival. The best achievements have occurred in some forms of less common tumours, like the lymphomas and germ cell tumours, but also breast cancer and small-cell lung-cancer, and most of the characteristic infantile cancers have increased chances for survival and cure. Many of our patients have been observing for years this improved course in their relatives and friends: but this favourable evolution has not yet changed the myth bound to the word cancer; and so it is with the prejudices of many doctors, who still too often adhere to the mentality of lay people. But Cancer, the word itself, for the man on the street still means "going straight to death with plenty of suffering". Concern about the risk of deteriorating the life-quality of the informed cancer patient has long been an alibi for non-communication. Sometimes patients are not so concerned since the start with their first signs and symptoms, but often they are, and they overtly show such concern: the doctor may be human, silent and involved in the patient's psychological suffering; but remaining silent however is not justified: let us see why. One author states: "In Total Care we need informed consent, informed choice and good communication between patient, family and medical staff. These are essential for improving the quality of life (QoL) of cancer patients" 71 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 71-79. © 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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(Deeken, 1995). Indeed an old-fashioned paternalism in information, apparently easier to manage, has become incongruous, while the awareness of the problem favours in patients the ability to cope with such difficulties. Now the Law, Moral, and Insurance rules, require a different approach, and the treatability of many cancer conditions has helped change this outlook. "Death must be met with dignity by a conscious person, who has been informed and has been a protagonist during the disease course", says Cattorini philosophically in his 1996 report. According to the opinion of this author, the QoL of the terminal patient is deteriorated by all ways of facing death different to the one that he proposes. Our personal experience is that the sensible doctor feels anxious and nearly frightened when preparing to speak the truth, but we at all times feel relieved after having spoken, because the reaction of the patient is usually human and constructive, beyond the negative expectations of relatives and friends. The reason for this is that sharing all information with the patients has favoured the patients' active participation in treatment planning: the informed patient generally hopes to be able to help modify the disease course and will share or even favour the active optimism of the therapeutic team. Santos in 1994 also affirmed: "The knowledge of the truth has commonly a positive effect on the doctor/patient relationships." Accordingly it may (and should) be a real effort in our daily practice to disclose information. At first, patients may be struck by what the doctor opens up, but just some hours or a couple of days later, inevitably they will reach a more serene approach. Doubts concerning diagnosis, the terror of the unknown, fear over the obscure words and the unpredictable nature of suffering, are transformed by this information into an active and constructive approach, and there is less space left for despair. In a loyal cooperation, the patient and doctor become allied in combating the disease. The aim of their battle cannot always be the victory (or cure). But "not-being-alone" makes a big difference: this condition is often referred to as "therapeutic alliance". Gupta in 1996 reported the example of a Hindu woman, living in a small country-town of India, where she was surrounded by a sweet and loving family, who was found to have a cancer: nobody spoke frankly to her in her native area, and she was sadly living this fear of the unspeakable and unknown. Then, for treatment, she was brought to a Canadian hospital, where all the diagnostic, prognostic and treatment programs were made clear by sensitive physicians and nurses. Not only did she adhere to the program and attain a more serene attitude, but when going back home she searched for people

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who had had similar diseases, and found some comfort in meeting them and speaking periodically with them. This example underlines the effects of having a correct decisional interview, as the patient obtained in Canada rather than in her own country. MODALITIES OF THE DECISIONAL INTERVIEW

Two capital problems occur in these cases in which information can be supplied at the start of specialized medical care: 1) it needs to be a package of news on the disease and on its possible treatment, and 2) it should be open to discussion plus adhesion or refusal by the patient, and to modifications of the treatment plans according to the patient's preference. Another point is who informs: a responsible physician should always communicate to the patient; but the general aspects of communication with the patient must involve all the sanitary team as described by E. Capovilla in 1992. Anyway it isn't a specific task of the diagnostic specialist, but of the treating team. Some contrasting opinions of patients have been reported on this subject (Liu, 1994) but a radiologist or a laboratory doctor cannot complete the communication work, with treatment proposals and prevision of subsequent outcomes. Insufficient communication and poor confidence affect both the patient's self-esteem, and the doctor's professional satisfaction in the treatment of cancer, according to Taylor (1984); Ramirez also underlined in 1995 the fact that for the physician, the absence of a nice communication and alliance with patients may be a cause for suffering from professional burnout syndrome. And a burned out physician sometimes abandons the profession, or performs it in a less effective and conscientious way. Another detail of importance is to whom we should communicate: indeed we should encourage the patient to share good news as well as bad news with the nearest relatives; a small number (lor 2) may be involved with doctors, so that subsequent information spreading may be "dosed". With married people, communication is always of great help, as underlined by Hilton as well as by Fitch in 1994, and by Pistrang in 1995. Which amount of information is to be considered correct? During the decisional interview only the essential must be told, avoiding the details on

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stage and sites of tumour spread. Only the most likely side effects of treatment should be initially presented. An exact (numerical) time-related prognosis should never be done, as it would often be unsure and nearly wrong. Special studies on the educational position of physicians towards patients and its psycho-physical effects have been deepened by Fawzy in a series of clinical studies, summarized in 1994: among these effects, an improvement of immunity, including anticancer immunity, has been found. Also the late side effects should be discussed before a decision is taken, and mainly in patients with a good prognosis. But not at the first approach: in this case we would risk a mix-up. Two brakes prevent the patient from understanding too large a number of data: one is lack of basic knowledge, and the other is his/her condition of concern and suffering. Both types of the above-cited braking increase in the case of enrollment into a clinical research study, as underlined by Byrne on the BMJ, early in 1988. Which conditions should be arranged for such a presentation interview? No rushing; proper premises; the patient in bed or seated; the doctor seated. Should it occur while the two actors (patient and physician) are hand-inhand? This varies from case to case. No intervening phone calls should interrupt the communication. And simple language should be used. The QoL issues can be usefully recalled during this initial interview (Fallowfield 1995). Indeed, the discussion of the future QoL interiorizes the fact that life is not at an end. When preparing a decisional interview, the doctor should remember that there are "times of reaction" in the patient's mind that cannot be overlooked, and also if individual variations exist. So one should arrange for one or more colloquia to be held in the proper surroundings, with quiet modalities as already recalled, and we should remember that the time required for the patient's adaptation to the news may be, and usually is, longer than the time required for our global communication: this is a good reason for communicating fractions ofthe truth in divided subsequent times. Contraindications: the relatives may describe the patients as "fragile, unprepared, frightened enough, over-anxious, pessimistic, too young, too old, too irresponsible", or say that s/he "bears too many responsibilities", or that s/he is affected with: ... arterial hypertension, atherosclerotic heart disease, diabetes. These are in their opinion all good reasons for not communicating, while one of the real motivations of relatives is rarely if ever presented: they fear that after the bad news, all the life of the family would be adapted to such sad novelties, and that every project or communication of joy, or good news

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should be restrained as upsetting and futile. Probably they don't confess even to themselves this motivation, but we know it is present at least in their deep unconscious. Most patients are nonetheless sensitive beings, and when kept out of open communication, are altogether aware that a fact that "cannot be pronounced" is happening, and death is impending, although it will occur within a non-predictable interval. Some precautions should however be taken: some preliminary information even in the modality of talks on the general medical progress, and the curability of some tumor types should be told before communicating; especially for patients who have previously suffered some similar sad experience in their family. One or two days before giving new information updates, the physician may suggest that "special diagnostic data qualifying for the preferable treatment are being collected", and this may justify some necessary delay in completing the full information. Let us now discuss the written information forms: they are not advisable, at least in the cases where they are not compulsory; written contracts are in use for bureaucratic issues or when mutual understanding and confidence are lacking. Signing a form does not ever guarantee understanding, especially for the elderly patients (Byrne, 1988), but it may only underline an existing lack of confidence and the possible inadequacy of human interaction. After the information forms, there are the consent forms: when these are requested by Health Authorities, the doctor should help everybody in clearly distinguishing his cooperation and friendly spirit from the "bureaucratic requirement". The consent form should always include three main sections: I) disease information, 2) proposed treatment (aim of the study, when appropriate; alternatives for the patient's choice, if consent is not given) 3) long term outcome with early and late likely side effects. Of course the colloquium preceding the signature of the form (or simply the initial colloquium, when no form is required) should stimulate positive feelings like hope, constructive cooperation, adhesion to the advice given, known as compliance; willingness of the doctor to "work" for human and physical help. Our public should not object that these positive feelings represent one only face of the problem, because the negative aspects are often

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well represented not only by the common feeling and myth regarding the malignant disease, but often also by propaganda from quack therapists, who try to always discredit official medicine: so we need to stand on the side that re-establishes an already broken equilibrium. If a patient is sent to us by the surgeon or another physician for a consultation procedure, we could start with: "Don't ask me now to give early conclusions; we will have time at the end of this interview to discuss everything". The patient at this point has the chance to say: "I already know it is cancer" or, "you will tell my relatives" or "remember, I do not want frightening news" or "we can discuss this with my family doctor". And if you do not get the first answer, but one of the latter ones, you know that the patient is not prepared to have direct frank communication. This does not mean you will never communicate, but simply that you need some intermediate passage, and to be very cautious: psychological preparation is certainly needed in these cases. In the last two decades, when the diagnosis was usually kept secret or denied by all others, contradiction could be necessary, but this was contributing to uncertainty and fear. If the first contact of our patient with medicine for a cancerous disease had previously occurred according to this old style, it may be important to find justifications for the previous deception and leave the impression of some harmony between colleagues. In the case of in-patients, a longer time is available for adaptation of the patient's mind to reality. But we would not suggest spending hours in explanations: the time, generally a few hours or one day left between short interviews allows him/her to meditate and process preliminary information, and may per se be effective in preparing patients to cope. But the physician should never make a statement that he might later reject: better to be a little reticent! Duration of the information or communicating process: information must continue after the decisional interview. Do not focus on tumor markers, but on the treatment's progress. Continuing the information can maintain a good doctor/patient relationship. Modem treatments aim at long-term results, and pass through short-term suffering: the side effects of extensive and mutilating surgery, of radical radiotherapy and of aggressive, eradicating chemotherapy represent a way of exchanging present fear and suffering for later success and well-being. These sufferings during the treatment period are chronologically associated with the impact of discovering cancer, and so they can heavily affect the existential condition of the patient: accordingly we must remember that they require proper medico-psychological support. But we should not forget that involving active and conscious participation of the patient in the battle for his/her health

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will often be able to reduce attention to the present condition and increase an active and hopeful position regarding the future outcome. Some hint is also needed for the case of tumour relapses: when the patient presents the first metastasis or a further one, great care must be given again to the communication: but when the diagnosis of relapse is certain, a clear even if brief - report must certainly be offered, together with a possibly new treatment plan: and if the correct procedure has been followed at the first presentation of that patient, it will be enough to follow a similar procedure. It may be different and difficult for us to take under our care a patient who has always been cheated by others in a previous relevant part of the disease course. According to Deeken (1955) a modality of "education to death" can be adopted in these cases, when hope for improvement and for a long survival cannot be credible. A "reference person" is needed during all the treatment period, to give confidence, reduce anxiety, and avoid pain underreporting (Lin 1995). The optimal "reference doctor" for cancer patients should be the medical oncologist. At the beginning, other specialists are often involved; but in the disease progress, hormone- or chemo-therapy will be needed: an already established contact with the medical oncologist will be of help in these conditions. The psycho-oncologist will advise doctors on the suitable moment for giving information, and suggest whether some of the given information has caused trouble or has been misunderstood. These are all important issues (Cassileth 1995). The social worker should also recognize the need for pain medication in terminal patients. (Glaichen 1995). The need for a special "coaching" of patients to express, and of nurses to elicit expression of the pain has been stressed (Wilkie 1995). "Information contributes to easing communication and psychological support to patients, by breaking down the isolation imposed by not having been informed of the situation" (Centeno 1994). For long-term survivors (at least in India), it was shown that many of the patients look back to the experience of disease and treatment, saying that "there is no substitute for an opportunity to talk and share experiences with other cancer survivors and their families" (Gupta 1995). So not only professionals, but also lay people and other ex-patients should be involved. WHAT HAPPENS IN CLINICAL RESEARCH

When the patient is faced with proposals to be enrolled into a clinical experiment, his/her ability to understand his/her own disease condition and the

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reasons for the proposed choice of treatment are generally diminished (Byrne 1988; Taylor 1984; Siminoff 1989). The common requirement of written information and consent forms, represents a further difficulty added to entering a trial of experimental medicine. When - on the opposite side - it is suggested to a patient that s/he might undergo a non-standard treatment (NST) or quackery, s/he tends to agree to this latter, rather than to enter into a randomized trial, despite any guarantee that this is medically and ethically correct. But even in terms of QoL, the NST results are often poor (Cassileth, 1995, Italy today). CLOSING REMARKS

Loyal communication improves quality of life because it: improves a good doctor-patient relationship; causes in patients a constructive optimism, in the form of the therapeutic alliance; removes the fear of the mythical mystery on the unmentionable disease, and may represent a sound basis for preparing patients to face the problems of treatment, and in the case of failure, a dignified death. REFERENCES AND SUGGESTED READING (*) (*) Bergsma J.: Doctors and patients. Strategies in long-term illness. Kluwer Acad. Pub\. pp.

228, 1997. Byrne D. J., Napier A. and Cuschieri A.: "How informed is signed consent?" Br Med J, 296, 839-840, 1988. Capovilla E. D., Martella S., Mariggio A., Girotto G. and Fiorentino M. Y.: "Implicazioni psicologiche in oncologia", in XV corso agg Oncol Med. form Mustacchi G. et aI, AIOM, pp. 131-140, Trieste 1992. Cassileth B. R.: "The aim of psychotherapeutic intervention in cancer patients". Support Care Cancer, 3(4):267-9, 1995. Cattorini P: La morte offesa. Espropriazione del morire ed etica della resistenza al male. EDB, Edizioni Dehoniane, Bologna 1996. Centeno Cortes c.: "Medicina paliativa: Necesidades psicosociales del enfermo oncologico en situacion terminal". Diss Abstr Int [C}, 55(2):493 1994. (*) Deeken A.: "Death education as a way to improve the quality of life of cancer patients after a relapse". Gan to Kagaku Ryoho; 22 Supp\. 1:22-5 1995. Djulbegovic B. and Sullivan D.: Decision making in oncology. Churchill Livingstone, 1996. Drago D. and Alessi c.: "L'informazione per il paziente oncologico: Ie opinioni e la pratica". Boll Ordine Medici. Padova, 6, 8-9,1995.

CANCER FROM THE MEDICAL AND EXISTENTIAL POINTS OF VIEW 79 Fallowfield L. J.: "Assessment of quality of life in breast cancer". Acta Oncol, 34(5):689-94 1995. Fawzy F. I., Kemney M. E., Fawzy N. W. et al: "A structured psychiatric intervention for cancer patients. n, Changes over time in immunological measures". Archives of Gene Psychiatry, 47,729-735,1990. (*) Fawzy F. 1. and Fawzy N. W.: "A structured psychoeducational intervention for cancer patients". General Hospital Psychiatry, 16, 145-192,1994. Fawzy F. I., Fawzy N. W., Arndt L. A. et al: "Critical review of psychosocial interventions in cancer care". Arch Gen Psychiatry, 52,100--113,1995. Fitch M. 1.: "How much should I say to whom?" J Palliat Care, 10(3):90--100 1994. Glaichen M.; Blum D.; Calder K.: "Cancer pain management and the role of social work: barriers and interventions". Health Soc Work, 20(3):200--6 1995. Gupta H.: "Cancer Sahyog". Meeting the challenge of cancer survivorship. [POS News Letter, pp. 9-12, December 1995. Hilton B. A.: "Family communication patterns in coping with early breast cancer". West J Nurs Res, 16(4):366--88; discussion 388-91 1994. Lin C. c., Ward S. E.: "Patient-related barriers to cancer pain management in Taiwan". Cancer Nurs, 18(1): 16--22 1995. (*) Liu S., Bassett L. W., Sayre J.: "Women's attitudes about receiving mammographic results directly from radiologists". Radiology, 193(3):783-61994. Pistrang N., Barker c.: "The partner relationship in psychological response to breast cancer". Soc Sci Med, 40(6):789-971995. Ramirez A. J., Graham J., Richards M. A. et al: "Burnout and psychiatric disorder among cancer clinicians". Br J Cancer; 71(6): 1263-9 1995. Santos Z. M., Santos G., Abrantes P.: "Comunicacao medico doente em oncologia". Acta Med Port, 7(6):361-51994. (*) Santosuosso A. and Tamburini M.: "Dire la verita al paziente; alcuni motivi psicologici e giuridici". Fed. Medica, 43, 7,503,1990. Siminoff L. A., Fetting J. H. and Abeloff M. D.: "Doctor patient communication about adjuvant therapy". J Clin Oncol, 7,1192-1200,1989. Surbonne A.: "Truth telling to the patient". JAMA, 268,13, 1661-1662, 1992. Taylor K. M., Margolese R. G., Soskolne C. L.: "Physicians' reasons for not entering patients in a randomized clinical trial of surgery for breast cancer". N Engl J Med, 310, 1363-1367, 1984. Von Korff et al: "The relationship between pain and depression". Br J Psych. Suppl: 101-108, 1996. (*) Wilkie D. J., Williams A. R., Grevstad P., Mekwa J., "Coaching persons with lung cancer to report sensory pain. Literature review and pilot study findings". Cancer Nurs, 18(1):7-15 1995.

MASSIMO REICHLIN

THE EXPERIENCE OF ILLNESS AND THE MEANING OF DEATH

1.

ILLNESS AND THE CONSCIOUSNESS OF DEATH

It is common sense to say of human beings that they die because they fall ill; and, as a matter of fact, virtually all deaths have an identifiable pathological event as their direct or remote determining cause. However, death is not merely a hypothetical event, rather it is our most certain possibility, inherent in human nature: human beings do not just happen to die, but necessarily do so. Therefore, it is clear that, on reflection, our ordinary assumption must be reversed: Morbidity is in fact parasitic on mortality, and it is because we shall eventually die that we also fall ill. We could also say that death is the illness of illnesses, the illness of those who are in good health. I The fragility of our bodily condition is such that health, as the complete absence of all disease, is but a regulative idea: As it is sometimes put, there are no healthy individuals, only yet undiagnosed patients. The thought of death is quite remote from our ordinary, prereflective consciousness, though the experience of illness may awaken it. Illness appears in the first instance as a mark of finitude, imposing a sudden stop in the ongoing flow of our lives. Clearly, in most cases what is being threatened is just our everyday life, namely, the various opportunities and comforts that generally constitute our pleasure and that, in a basic - though not exclusive - sense, make life worth living. The compression of possibilities experienced in relatively trivial diseases generally does not, by itself, suffice to cause an explicit confrontation with death; besides, this confrontation is made ever more difficult by the progress of medicine, which tends to conceal the essential link between illness and death. Since scientific medicine promises to heal all diseases, our immediate reaction to the event of illness is to delegate its management entirely to medicine, in the hope of restoring full health. However, in cases of severe diseases, and of course in lethal ones, what is being threatened is our very existence. Then, in the background of illness we can see death coming closer and beginning to concern us. We can thus say that, from a phenomenological viewpoint, the experience of illness paradigmatically anticipates the event of death: It is a memorial of our nature as human beings, provoking a relationship with our mortality.

81 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 81-95. © 2001 KluwerAcademic Publishers. Printed in the Netherlands.

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This is not to say, however, that illness is the original source of our consciousness of death. Just as the passing of time can be interpreted as a progressive decrease of possibilities only on the background of some previous notion of a finite set of possibilities,2 so the deprivation of some possibilities in illness does not by itself produce the thought of death, that is, of the deprivation of all possibilities. Should we not have previously had any notion of death, we could not but think of illness as a passing thinning of our possibilities to be eventually overcome by a full restoration of health. Contemporary phenomenologists rather refer the original constitution of death in consciousness to the experience of the other's death, particularly the death of a proximate other, a friend or relative. 3 This death is experienced as an announcement of my own death, or even as my partial death, since, in the relationship that linked our lives, my very identity was at stake. The sense of loss that I am now experiencing is not only a loss of the other, but in a true sense, a loss of myself, the lack of a part of me. In the words of Paul Ricoeur, "The other's death penetrates in me like a lesion in our common being."4 The other's death can appear as a sort of betrayal, because his not-being-there breaks the promise of community and proximity that tied us together; on the other hand, my beloved's death can also be accompanied by a sort of feeling of guilt, as if I should have died instead of her. 6 The end of all communication, the changing of the other's face into a wordless mask, anticipates my own silence at others' words, my inability to correspond to their call, i.e., my own death. In this view, death is a telling mark of our relationality as human beings as well. The reason why the other's death can be a loss for myself is that I cannot acquire my identity as an individual but through the recognition of another's look. Deprived of that look that sustained my consciousness, I experience that solitude, far from being the contrary of beingwith-others, is rather its privative experience. Consciousness of mortality, while being a decisive feature of our consciousness as humans, also marks the distinction of human death from the simple ending of an animal's life. In virtue of their anticipation of death, human beings are made inherently mortaI,7 so that death is not an event transforming them from outside but coming in some true sense from "inside"; in other words, mortality is not really distinguishable from finitude. Not all philosophers agree on this point: We can recall, for example, Sartre's explicit denial of such an equivalence. s However, while it is not contradictory to conceive of human beings as immortal and nonetheless finite, since finitude would constantly be manifested in our agency and in the failure to live up to our moral commitments, it is doubtful that in such a possible world moral

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commitments and moral action would still be what we are used to knowing in the present situation of mortality. As noted by Morin, it is plausible to say that an amortal man would no longer be a man. 9 In fact, our understanding of ourselves, including the ability to choose and act freely, is inherently determined by the notion of a finite set of possibilities and a finite lapse of time to realize them. This amounts to saying that our actual experience of finitude is so closely associated to our consciousness of death that any conception of the former needs to embody the notion of the latter. 10 Grounded on such an anticipation of death, the experience of illness is a reminder of this ever-present possibility. If the other's death provides us with the notion of our death, illness can further anticipate some "experience" of it, even though, strictly speaking, death is a nonphenomenon, a nonobject of which any experience is a priori excluded. While death cannot fall in the domain of our experience, the indirect notion of it we gain through the others' death nevertheless assures us that death concerns our own existence and indeed is the most certain of our certainties. Illness recalls to our consciousness this ever-present and ever-elusive object, enabling us to establish some form of relationship with it. 2.

THE CIVIL CONDITIONS OF DEATH

The present conditions of dying do not favor the appropriation of mortality as a transcendental condition. The denial of death has long been diagnosed by many as one of the main diseases of contemporary Western societies. I I The increase in the quality of life, the rise of opportunities for most people to live a wealthy life, and particularly the progress of medicine in protecting health and in successfully curing many diseases have favored the removal of our mortal condition from our ordinary consciousness and from the social practices of everyday life. Through a relatively quick cultural development, death has become the new, and perhaps the last, taboo of our societies. Since Gorer's famous article on the pornography of death, 12 it has become commonplace to institute an analogy between the role of death in our culture and that of sex in Victorian society. The pornography of death lies, in the first place, in its being the object of a systematic censorship. Death is not an issue about which there can be open talk in contemporary society; within the bounds of "civil" conversation, such talk generates discomfort and elusiveness. A second analogy with past attitudes to sex is that, notwithstanding such censorship, talk about death does have some kind of presence in contemporary discourse and is not simply excluded from any social commu-

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nication: This presence, however, is somehow "wild,"13 presenting its object in a distorted and indirect fashion. Death is in fact at stake, often playing a central role, in many movies or TV fictions; it is widely exhibited in the media; it is an essential element in most videogames. What is common in all these forms of the presence of death, is the typically "excessive" fashion in which it is presented. The death which is spoken of is always violent, unjust, tragic. It is shown in its spectacular elements and is usually presented as the outcome of a series of crimes and misdeeds. Two consequences follow: For one thing, in such stories of widespread violence in which any person or character has but a fungible part, death is trivialized by being entirely deprived of its existential import and by retaining a mere functional role in the development of a story. Even when, as in journals and TV news, true stories of real people dying are at stake, the frequency of such news and the impersonality of the account contribute to creating a sense of detachment from one's individual life. In this context, death is always perceived as concerning others; it is the argument of an "objective" communication in which there is no question of the listener's consciousness. In its turn this systematic removal of the existential dimensions of death has the effect of depriving this wild presence of death in public communication of its potential criticism against the censorship and denial we mentioned. Public discourse concerning death, in its spectacular and violent forms, does not thereby enable any discourse on death by human beings who acknowledge themselves as mortals, as beings who have to die. On the contrary, it could be maintained that stressing the existentially neutral, spectacularized, and objectified forms of death is part of the effort to deny death as a reality regarding our individual life. The individual's death is thus concealed under the "inauthentic" forms paradigmatically exemplified by the phrase "one dies." The role of medicine in reinforcing this process of removal is particularly effective. The technical attitude recommended as the only pertinent strategy against illness is just aimed at concealing its metaphoric value, by which it is expressive of the inherent fragility of the human condition, and thus of its mortality. The rationalist proposal to radically demythologize illness by depriving it of its metaphorical aspects,14 while important for its refutation of impertinent, metaphorical associations (such as that between illness and guilt), unduly removes the room for any existential meaning of illness and death. One of the undesired consequences of the denial of the connection between illness and mortality is the patient's alienation from his death. In fact, the social interdiction of discourse concerning death bars any commu-

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nication with the dying person and leads to an essentially infantilizing system of relationships with her. Since the rhetorical language of sympathy and compassion has become suspect and sometimes even embarrassing, caregivers and relatives lack any symbolic resources in order to voice their emotions in relation to the approaching death. Due to the present fast process of informalization,15 any standard form of communication or agency within this context is indeed associated with an unpleasant impression of falsity or hypocrisy. However, entrusting the task of finding adequate expressions of sympathy to the individual's creative expressiveness mostly results in the lack of all communication. The unbearableness of the thought of death, and the lack of a language in which to convey the emotions it generates, leads to the exclusion of the patient from the management of her disease. Particularly in the event of lethal disease, the patient is very often deprived of the truth concerning her health condition and, in most cases, not even informed of the imminence of her death. Commenting on this dispossession of death, characteristic of our age, Aries complained that, for many centuries, death has been a tragedy in which one played the part of the dying, whereas now it has become a comedy, in which the dying plays the part of one who is unaware of being close to death. 16 The inevitable outcome of these civil conditions is a private, somewhat clandestine death in which the more the dying avoids disturbing her caregivers and relatives, the more she preserves her human dignity. Discretion becomes the supreme virtue: What caregivers and relatives mostly expect from the dying is that she sustains the comedy, not troubling them with any direct talk of death and conforming herself to the request to die "pianissimo, almost on the tip of her toes."I? The social censorship of death is not restricted to the care of the mortally ill but also stretches to the aftermath of death. Another feature of our era, stressed by most "thanatologists," is in fact the social interdiction of mourning. What it was once obligatory to express publicly is now strongly prevented from being shown; the rituals, norms, and conventions that once rigorously commanded the performance of some actions and the refraining from others, have been replaced by a general prohibition to give any publicly appreciable expression to one's inner feelings of mourning and affliction. This social prohibition obviously does not do away with those feelings, but simply forces them within the individual, preventing their adverse effects on social communication. Suffering thus becomes essentially private and incommunicable even in the familiar context: Crying is possible only to oneself, secretly, "as if it were an analogue of masturbation."'8 Here again, what is

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most expected, as a matter of "decency" from the dead ones' relatives, is that they withhold any expression of emotion, not imposing on their neighors any participation in their sufferings. 19 It has been noted that this interdiction of mourning can have severe pathogenic effects on the individuals who, having lost their dear one, are not allowed to find relief in tears nor to elaborate their loss through the communication of such strong feelings and emotions. 2o 3.

A "NATURAL" DEATH?

Sociologist Werner Fuchs strongly objected to the theory of the removal of death in contemporary Western societies. 21 He interpreted these contentions as the expression of some cultural critics' disappointment in the domination of nature realized in our society. In his perspective, the sociological interpretation focusing on the denial of death is regressive in that it surreptitiously reintroduces a magic-archaic image of death, seen as the invariant feature of human nature, marking an insurmountable boundary to man's appropriation of nature. He denounced this use of death as the last weapon against modern industrial society, the last resource of irrationality against the enlightenment of science and of social organization. Rather, the present situation should be viewed as evidence of the emergence of a new paradigm, in which death is interpreted as a simple, natural fact, deprived of any magical or transcendent meaning. In fact, the images of death are not independent social variables, and natural death, as an individual's peaceful dying out, is the rational attitude most adequate to the secularized condition of contemporary Western society. One point made by Fuchs is doubtless true: that the thesis of the removal is not a purely descriptive one but has an implicit normative function. This can be a deficiency for descriptive sciences such as sociology or psychology, but it is not an argument against its truth. Moreover, we could concede that natural death, as intended by Fuchs, is consistent with the general features of secularized societies; however, from a philosophical viewpoint, it is important to stress the anthropological consequences of such a concept and the practices it inspires. This paradigm of "a natural death" is problematic because human death is in most cases unnatural and untimely. In fact, there is probably no individual's death of which it can be said that it came as a peaceful dying out, not having any pathological event as its proximate cause. This very fact challenges its alleged naturalness, since it can always be hypothesized that, in a future time, some therapeutic measures will be available to counterfeit such

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an event, so that it will be deprived of its lethal character. This also points to the inevitable social determination of the dying process: What is a sufficient cause of death today will be insufficient tomorrow, and what is sufficient in one place is at the same time insufficient in another. These simple facts deprive the concept of a "natural" death of much of its clarity and appeal. Moreover, death is for the most part unnatural from an existential point of view as well: It is only rarely that we see people dying peacefully, "tired of the years" like some biblical characters, having fully achieved their life plans and conscious of having lived "enough." It is much more common for death to come too soon, unwanted and untimely, when much is still desired and much is waiting to be achieved. The Enlightenment proposal to reduce death to a simple, natural fact does not seem feasible, because on one side it conceals the social determinants of death that often make it unjust; on the other, it forgets its untimeliness which makes it existentially intolerable. Certainly, as Fuchs maintains, death is not quite invariable and its images are not subtracted from social determination. However, the proposal of a natural death seems to forget that the anticipation of death is constitutive of the consciousness of ourselves. This "naturalization of death" leads to reducing it to a purely biological fact, entrusted to the competent management of medicine and devoid of existential meaning. We would rather contend that death is not natural in the biological sense, but instead belongs to the human condition: this amounts to saying that death inherently marks our being in the world, shaping our ways of acting, promising, hoping, and despairing, even though its conceptions, images, and metaphors are generated in historically and culturally determined fashions. This existential effort to make sense of human mortality, on the part of both the individual and of society, does not amount to a "hymn of praise to death," as feared by Fuchs, but to the recognition of an essential feature of the human condition. Such an effort is not the duty of medicine, nor can it be replaced by a merely technical management of death. 4.

THE ETHOS OF DEATH AND THE PHILOSOPHY OF DEATH

The observations developed in the previous paragraphs point to the necessity of recovering the event of death to the domain of civil communication, and of rethinking contemporary attitudes of denial and underestimation, if we are to set the conditions for the individual to responsibly confront death. It is necessary to rebuild something like an ethos of death, that is, a system of representation of death that helps human beings to accept their mortal nature. This

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does not imply resuscitating archaic images of death: There is no need to postulate magical entities or revive theological assumptions to stress the importance of death as a symbolic event in the lives of human beings and as one of the central events that shape associated forms of living for which systems of mores must account. Civil society, unlike political society, is based on a shared sense of living, that is, on a series of values and beliefs that are embedded and expressed in the practices that shape communal life. The function of these practices is to constitute points of reference in the formation of the individual conscience with particular reference to the central moments in human life. If left to itself, the individual's freedom is in fact devoid of any content and cannot generate sufficient reasons for acting: These must be provided by the images of the good life that are generated in the thread of basic human relationships and are differently worked out in any single historical context. Freedom is more plausibly defined as the consent given to some such ideal image of the human good, than as the generation of one in a fit of creative liberty. While subject to the individual's appropriation and criticism, these practices have an irreplaceable function in shaping the individuals' value commitments; a society entirely lacking in general assumptions regarding central features of human life, such as birth, sex, or death, and thus unable to help its members in the appropriation of such "natural" facts, could hardly exist as a society.22 An ethos of death allows individuals to give order and meaning to their emotions towards death through a free and open communication with others: This is not only a condition of psychological well-being, but also a condition of moral decision-making. Consenting to death and reconciling ourselves with our mortal nature presupposes that we can acknowledge some meaning of the life we lived: this, in turn, is only possible if we can be reassured by another that our life's narrative is not devoid of internal meaning and coherence, that what we achieved is not going to lose its value with our death, and maybe that others are willing to continue in the same way we did. 23 Any human being should be helped in dying well, since no one can make sense of her life nor consent to death if left alone. When a dying person becomes aware that her life has lost all value for her likes, that the good she realized will not be remembered, or even that her death will be a relief for some other, a good death is something she simply cannot realize by herself. Removing the censorship towards death does not involve the adoption of a consistent set of eschatological beliefs. Actually, it is even possible for religious beliefs in an afterlife to have a negative impact on our present life and on our ability to enjoy it. This can be the case when the belief in a future

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life causes detachment from the historical commitments of our present existence. In Plato's Phaedo, for instance, Socrates contends that wisdom consists in the meditation on death and that the philosopher does not regret to leave this life in order to be associated with God. In fact, this is what he wishes for himself, since to live is learning to die. This Socratic contention, and its many Christian parallels, can - though it need not - inspire attitudes of such a historical disengagement. Spinoza rightly contrasted this attitude by stressing that nothing is remoter from the wise man than to make his life a meditatio mortis, since wisdom refers essentially to life, to which the wise man devotes his meditation. Reconstructing an ethos of death does not involve any gloomy attitude, or constant meditation on death. A philosophy of death is rather a meditation on life and is meant to illuminate this life. To understand death as a transcendental feature of human nature is to acknowledge that death is a limit, or bound. This must be understood in its positive meaning as well. We commit ourselves to certain life plans because we know that our possibilities are finite and that our time has a measure that is ever in the process of growing thinner. With Heidegger, we could say that, by the anticipation of our most peculiar, unconditional, certain, and unsurpassable possibility, we are made free to embrace all other possibilities, understanding them in their relative value. 24 In this sense, Being-towards-Death is not a useless "thinking about death," but the condition of an attitude of authenticity towards life. Death can be tolerable only for one who has reconciled herself with it in the course of her life. Such a reconciliation with mortality seems indeed possible only for one who has devoted her life to a good that must not be presently possessed in order to motivate action and be appreciated as such: a good which is not disposable, but rather calls for the disposal of one's life. That is, one can accept death if she has spent her life for a cause that she acknowledges as greater than she is, the care of which she can entrust to someone else in the belief that her own life has not been in vain, as long as it has contributed to what others can continue to develop and appreciate, making of it a sense for their lives. In this view, mortality implies that human fulfillment cannot consist in the definitive possession of the good and that human existence finds its authenticity when it takes the form of a commitment to some cause that is acknowledged as greater than the individual's life, a cause that inherently cannot be fully realized nor possessed by the individual. Even though it cannot do away with the tragicalness of death, the commitment to such a cause can help make sense of it if other conditions are met. Prominent among

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these is a common ethos of death to enable both the dying and her relatives to objectify their emotions and to benefit from a shared participation in the event of death. In the absence of such conditions death can hardly be tolerable or peaceful. 25 5.

THE CONTROL OF DEATH

Over the last years bioethics has devoted much discussion to issues such as voluntary euthanasia, advance directives for treatment, and, generally, procedures of decision-making concerning medical treatment at the end of life. It is no surprise that a renewed effort to confront the reality of death comes from the domain of the biomedical sciences. Death is in fact largely medicalized, and medicine is the only accepted form of discourse on illness and dying. On the other hand, Fuchs has pointed to the technologicalization of medicine as one of the main factors impeding the emergence of the concept of a natural death. Claims of a right to die emerging from this debate, particularly in the Anglo-Saxon bioethical literature, can be interpreted as a reaction to the domination of technology, and to the denial of death that is expressed in the tendency to overtreat dying patients, and in refusing to accept the evidence of imminent death and of the final defeat of medicine in the fight against disease. The idea of rationality underlying this cultural trend can be assimilated to that inspiring the proposal of a natural death. Interestingly, "natural death" is also the slogan under which legislation promoting the introduction of advance directives for medical treatment was first enacted in the United States: It was the California 1976 Natural Death Act, then followed by analogous laws in all North American states. More recently, in many countries there have been proposals to pass legislation allowing the performance of voluntary active euthanasia, some of which have actually been enacted. It is now lawful for physicians to help consenting patients to die in the Netherlands and in the State of Oregon; an analogous law was also passed, but then repealed, in the Northern Territory of Australia. 26 Of course, the substantive discussion of these issues would imply a larger and more profound analysis than is possible here. We will confine ourselves to a few considerations on how recent proposals to recognize, and even constitutionalize, a right to die affect the civil conditions of dying that we have depicted. Is it true, as sometimes claimed, that the euthanasia movement is a powerful means to remove the civil censorship on death?

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The cultural and social trends culminating in these legislative initiatives clearly assume the individual's control over her own death as the central value to be promoted. It is the general contention of most bioethicists supporting voluntary euthanasia that a good death is equivalent to an autonomous death, and that self-determination is all that is needed in order to "humanize" contemporary conditions of dying. 27 Doubtless, the proponents of euthanasia and assisted suicide firmly assert the duty to disclose the truth to any individual patient, since this is considered highly promotive of autonomy; and it has been our contention that withholding the truth from patients is functional in the keeping of the civil censorship on death, and that it ends in the irredeemable solitude of the dying. However, the reasons grounding this common conclusion differ significantly: While in our perspective, truth-telling is the condition for the establishment of a personal relationship with the dying and for the possibility of a true communication and participation in the dying's predicament, the bioethical pro-euthanasia mainstream is rather satisfied with the assertion of the primacy of autonomy and with the fulfillment of the duty of disclosure, to allow the patient to make her own choice. Once the patient has been told the truth concerning her physical condition and has been given all the opportunities to implement her autonomy or self-determination - e.g., filling in a living will or requesting active euthanasia - everything has been done that could be done. This philosophy has nothing to say to the dying, except to remind her of the legal opportunities to do away with her life. In vain one would search in this procedural approach for any substantive reason to choose one or the other course of action, or for the recommendation for caregivers and relatives to promote the objectification of the patient's fears and hopes through an outspoken and participating communicative process. In other words, recent bioethical discussion on death concentrates on the removal of legal obstacles to the individual's choice, neglecting the broader and deeper demands of morality. As noted by Callahan, "The more publicly sanctioned our right to choose death, so it seems, the more buried, the more hidden, the meaning of death in our lives, and the more excluded from any common, public discourse. The more public becomes the espousal of choice, the more private the content and substance of that choice."28 Two preoccupations monopolize the bioethical approach to death: the implementation of autonomy and the avoidance of pain. Autonomy or selfdetermination is understood as synonymous with control over one's life and death: What is mostly feared is the event of a death happening outside the subject's control, with the dying in the full power of medical technology,

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unable to voice her preferences for treatment or for withholding/withdrawing disproportionate treatment. This concept of autonomy is based on an individualistic presupposition, according to which human dignity is inherently associated with the individual's independence from others, with her capacity to stand alone and to impose her will on matters concerning herself. Dependency is considered as the worst evil, and dying in a condition ·of dependency as involving an undignified death. In the light of the relational concept of the self we espoused, this concept of autonomy appears radically misguided. The appeal to such an individualistic stance actually seems to prejudice any opportunity to make sense of death and to die a peaceful death, since in the dying process it clearly appears that "the flight from dependency is a flight from humanity."29 The second preoccupation of the bioethical approach is pain relief. The absolutely central role played by this consideration in end-of-life discussion is due to the fact that, any other substantive feature being out of place, painless death is the only remaining image of a good death and analgesia the only substantive moral ideal of the bioethical approach to death. Of course, it cannot be denied that avoiding undue suffering is a pertinent therapeutic aim; but the obsession with pain control leads one to forget that an individual's life can be valuable even in the presence of pain. Presenting the management of pain as the central feature in terminal illness situations results in the misconception of the actual moral requirement, that is, in the first instance, to live with the disease and to confront death in consciousness and freedom, since the meaning of life can be threatened, but not destroyed, by pain or suffering. To conclude, as long as it restricts attention to autonomy and pain management, to the prejudice of any moral discourse on the individual's resources and agency in the face of illness and death, bioethical talk on death does not constitute an effective break in the civil censorship on death. Fashioned in the characteristic third-person style of normative reflection, it carefully avoids the existential questions posed by the mortal condition and does not confront the first-person problem of dying. This is, of course, consistent with the general theoretical approach of most recent moral philosophy, according to which there must be no question of the good life, but only less pretentious questions of well-being and individual preferences. Therefore, illness and death are not really confronted by such a reflection: That lethal disease and dying are conditions inherent in human nature, with which we must learn to live, is entirely neglected by the mainstream of contemporary bioethical debate, which is only preoccupied with finding ways to

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escape such conditions. But to escape these conditions is to escape the actual moral problems. Universita San Raffaele NOTES Cf. V. Jankelevitch, Penser la mort?, Editions Liana Levi, Paris 1994. This is the shortcoming of Max Scheler's classic analysis of death in his essay "Tod und Fortleben," in Schriften aus dem Nachlass Bd. 1 Zur Ethik und Erkenntnislehre, Bern 1957. 3 See especially P. L. Landsberg, Essai sur I'experience de la mort, Editions du Seuil, Paris 1951, that corrects Heidegger's analysis on this point. Significant anticipations of this phenomenological analysis of death can be found in the 4th book of Augustine's Confessions. 4 P. Ricoeur, "Vraie et fausse angoisse," in Histoire et verite, Paris 1955 (my translation from the original French). 5 The reproach of the dead is actually a common feature of mourning in many cultures. In this respect, Landsberg notes that only God is faithful, for only God never dies (Essai sur l'experience de la mort, p. 39). 6 This feature is emphasized by E. Levinas, La Mort et Ie temps, L'Herne, Paris 1992. 7 In this sense, Heidegger noted that, as soon as she is born, the human being is already old enough to die; he also contended that only humans die, while animals, lacking the consciousness of death, only perish. 8 Sartre separated mortality from finitude by stressing that, even if she were immortal, the Dasein would be finite, since in choosing herself as human, she makes herself finite by the very act of her freedom (L' Etre et Ie neant, Gallimard, Paris 1963, 4th part). 9 Morin discusses the myth of amortality in the last chapter of the first edition of his L'Homme et la mort, Buchet et Chastel, Paris 1951 (this chapter is the second-last in the second edition, Editions du Seuil, Paris 1970). 10 As a matter of fact, Sartre's denial of this identity is strictly dependent on his denial of every relationship of the pour-soi to his death. This analysis unduly underestimates the imaginative projection by which human consciousness can anticipate itself into future situations and events, and it ultimately degrades human dying to a mere process of decomposition, analogous to that affecting natural objects. This Epicurean thesis of total extraneity between life and death seems to also be shared by Wittgenstein who states frankly: "Death is not an event of life. Death is not lived." (Tractatus logico-philosophicus, London 1922,6.4311) 11 See, among others: H. Feifel (ed.), The Meaning of Death, McGraw-Hill, New York 1959; G. Gorer, Death, Grief and Mourning in Contemporary Britain, Doubleday, New York 1965; E. Becker, The Denial ofDeath, Free Press, New York 1973; Ph. Aries, Essai sur l'histoire de la mort en Occident, PUF, Paris 1977; N. Elias, Ueber die Einsamkeit der Sternbenden in unseren Tagen, Suhrkamp, Frankfurt 1982. 12 G. Gorer, "The Pornography of Death," The Encounter 5 (1955), Oct., 49-52. 13 This adjective is used by Aries to define, in general, our experience of death in modern society. This wildness is due to the removal of death from the cycle of communal life and its complete relegation to the domain of scientific technology. 14 Cf. S. Sontag, Illness as Metaphor, Farrar, Strauss and Giroux, New York 1978. 2

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See N. Elias, Ueber die Einsamkeit der Sternbenden in unseren Tagen. Ph. Aries, Essai sur I'historie de la mort en Occident. J7 See V. Jankelevitch, La mort, Flammarion, Paris 1966. 18 G. Gorer, "The Pornography of Death," The Encounter 5 (1955), Oct., 49-52. This feature is emphasized also by Elias, who notes that, at our stage of civilization, crying is allowed only for women; however, he wonders, for how long? (cf. N. Elias, Ueber die Einsamkeit der Sternbenden in unseren Tagen). 19 In his famous description of the everyday Being-towards-Death, Heidegger had already noticed that, in the tranquilizing perspective of the "one dies," the other's death is socially disturbing, and constitutes a lack of tact (Sein und Zeit [1927), Max Niemeyer, Tiibingen 1984, § 51). 20 This is not to say that the practice of mourning is a mere therapeutic device to confront the psychological uneasiness following the death of one's beloved, as many "thanatologists" seem to imply; the practice has an existential truth-value as well, as we hope to make clear in the following. 21 W. Fuchs, Todesbilder in der modernen Gesellschaft, Frankfurt a. M. 1969. 22 Particularly, it can be said that some recognized form of management and elaboration of mourning is the basis of all culture: "There is in fact no culture but when a certain domination of the irreversible flow of time is assured, which implies the performance of a multitude of techniques designed to palliate absence, and the absence par excellence is that of the dead, who does not disappear momentarily but absolutely and irreplaceably." (F. Dasture, La Mort. Essai sur lafinitude, Hatier, Paris 1994, p. 9; my translation from the original French). It was Vico who first noted that the social practices of wedding and of the burial of the dead lie at the very beginning of history and culture. 23 On the other hand, it can also be emphasized that, on the part of the society, the cultivation of its memories and the transmission of its values would not be possible without some way to commemorate the dead. Rituals of commemoration are a significant part of the effort to promote the assimilation of the good expressed in the dead person's life and to let it be fruitful for future generations. When a society loses the ability to celebrate its majors' dying in a way that retains their memory and example, it loses its capacity to think of itself historically and to project its future in the light of past events and experiences. 24 Cf. Sein und Zeit, § 53. 25 "Peaceful" is the death envisaged in Callahan's account, that recovers and modifies the "tame death" of ancient times described by Aries; according to Callahan, a peaceful death encompasses "a notion of the self that has, in some sustaining way, come to accept death.... It should also be a death marked by consciousness, by a self-awareness that one is dying, that the end has come but, even more pointedly, a death marked by self-possession.... Equally, it should again be a death in public, by which I mean a time when friends and family draw near ..." (D. Callahan, The Troubled Dream of Life. Living with Mortality, Simon & Schuster, New York 1993, p. 54. See also pp. 195-197). 26 On the Dutch Law, see European Commission, Euthanasia and Assisted Suicide in the Netherlands and in Europe. Methodology of the Ethical Debate, Office for Official Publications of the European Communities, Luxembourg 1996; on Oregon, see G. Annas, "Death by Prescription: the Oregon Initiative," New England Journal of Medicine 331 (1994), 1240-1243; on the Australian Law, see H. Kuhse, "Voluntary Euthanasia, Politics and the Law," Monash Bioethics Review 16 (1997) no. I, 1-4. 27 See, among others, P. Nowell-Smith, "In Favour of Voluntary Euthanasia," in R. Gillon (ed.), Principles of Health Care Ethics, Wiley & Sons, London 1993, pp. 753-762; M. Charlesworth, 15

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Bioethies in a Liberal Society, Cambridge University Press, Cambridge 1993; R. Dworkin, Life's Dominion. An Argument about Abortion, Euthanasia and Individual Freedom, Knopf, New York 1993. 28 D. Callahan, The Troubled Dream ofLife, p. 35. 29 Ibid., p. 127.

SECTION II NEW CHALLENGES TO THE UNDERSTANDING OF MEDICINE: THE ETHICAL PARAMETERS. TOWARDS A NEW "MEDICAL HUMANISM"

PAOLO CATTORINI

APPLICATION OR INTERPRETATION? The Role of Clinical Bioethics Between Moral Principles and Concrete Situations

1.

WHICH APPLICATION OF ETHICS?

Clinical bioethics is the ethics applied to the problems dealing with clinical cases, and therefore, the reflection made regarding the moral dilemmas which resuit ~hen we have to make a decision relating to the well-being of one or more patients. Regarding the contents (substantive ethics), the following questions serve as paradigms: "What is the best (in a moral sense) thing to do here and now for this patient?" or "What clinical decision best promotes the patient's good in this situation?" To understand the epistemological statute of this application we must at the outset define the terms in use. l First of all we adopt the definition of ethics as the rational justification of moral judgments. Everyone evaluates, expresses judgments on what is good or bad in particular circumstances, makes choices suitable for promoting what seems to be the prominent value or what is most just in certain conditions. Ethics corresponds to the attempt to account for what the moral agent has decided or put into practice. Such an attempt can be acted upon in different directions. A widespread manner of presenting the function of philosophical ethics consists of identifying this in work involving conceptual clarification, the work of making reasoning more coherent and consistent, and above all the foundation of appropriate criteria for motivating the practical decision. This foundation, as it proceeds, necessarily becomes more extensive and universal, and at the same time loses specification. In biomedical ethics this happens when we justify a therapeutic decision based on a behavioural rule, when we support the rule on the basis of principles, and finally when we anchor such principles to fundamental ethical theories. Utilitarianism, Kantianism, personalism, contractualism, and libertarianism - to name but a few examples - offer each one precisely an axiomatical framework from which one extracts the criteria for solving particular moral questions. It is maintained that the aspiration of philosophical ethics is to find the most simple, clear, comprehensive, complete, and coherent general theory in order to set up a background against which to solve the maximum number of specific dilemmas. The fecundity of

99 A.-T. Tymieniecka and E. Agazzi (eds). Analecta Husserliana LXXI!, 99-115. © 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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the theory would actually be verified based on its flexibility of application to specific cases. 2 So in search of a valid certainty we progress from cases to theory. Reciprocally we extract back from the theory applicable consequences relative to concrete cases: consequences which, if unsatisfactory to us, make us suspect the validity of the theory. This equilibrium or reflecting circle shows us immediately the complexity of applied ethics and, therefore, also the complexity of clinical bioethics. In fact, we must ask ourselves what type of application is in use. To begin to reply we could firstly recognize that the application is a richer activity than the mere syllogistic deduction, since this application is not to deduce from known premises, conclusions so logically convincing and sure as those premises. Rather it is a question of using a necessarily abstract principle with the purpose of creating order among complex realities which are, therefore, always richer than the initial principles. It is exactly for this reason that the validity of an ethical theory is verified (as previously acknowledged), based on the fecundity of its application to particular cases. This phenomenon is very different from what would happen if the deduction followed a syllogistic model. For these reasons we have maintained that in the application there is a "rebounding" of the rule from reality, into which it falls, to the theory from which it originates. 3 This "rebounding" is such that the deformation stamped or conveyed from reality to the rules may result in the modification of this same theory. Commenting on a text by SI. Thomas Aquinas (Summa Theal. I, II, q.94, a.4), a neoscholastic scholar stated: "Speculative knowledge is always related to necessary truths, whilst practical reason must apply more general precepts to particular cases which are always more complex than the types of conduct to which the universal precepts refer. Therefore, while in speculative knowledge there is an identical truth (est eadem veritas), in the universal precepts and conclusions (in the axioms and theorems) [...J in practical knowledge 'truth or practical rectitude is not the same in particular conclusions, but only in the more universal principles, and even when it is the same, it is not known equally to aiL''''

In our opinion the complexity of the ethical application has been misunderstood from the theoretical approach, which has opposed deontological and teleological positions, without using an adequate phenomenological reconstruction of the symbolic quality of the moral experience, a quality which, as we will demonstrate, can instead be more correctly defined from a hermeneutical approach. 2.

THE THEOLOGICAL DEBATE ON MORAL NORMS

The philosophical and theological debate on the statute of moral norms has shown in the last decades some of the limits of that type of deontological

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approach which claimed to deduce syllogistically from a general precept a

casuistic evaluation so analytical and rigorous as to be able to outline with absolute certainty the threshold between licit and illicit, based only on the material configuration of the gesture and not considering the interpretation of its significance. Such a syllogism was articulated according to a framework of the following type. 5 What man is (metaphysical starting-point) is observed and what he should be is deduced from this observation, concluding that a determined duty can never be transgressed. Or, in faith (theological startingpoint) is recognized the goodness of the divine order addressed to the moral agent, and norms are drawn from it by deduction which do not allow for exceptions. Within the limits of this paper we will not reconstruct the critical reflection on this type of schema, and we will limit ourselves to a classic exemplification relative to the limits of the negative norm which prohibits killing. If the order "do not kill" (understood materially and not symbolically) continues to be valued (as certain deontologists claim with certainty) also in situations where it is recognized as licit to take the unjust aggressor's life, one must realize that its meaning is anything but obvious and does not coincide with what common sense would literally intend. What is the nonobvious meaning of the veto against killing? A first hypothesis is that "do not kill" is actually equivalent to "do not kill the innocent," with which, however, there is the problem of meaning (objective? subjective?) of the notion of nocens (not innocent) and of the criterion with which to balance the level of the defense compared to that of the attack (saving how many lives justifies killing the aggressor?). A second hypothesis is that "do not kill" is equivalent to "do not kill, unless killing is the only way of saving a greater number of human lives." This is an assertion which connotes the original precept of a conditioned valency and of an evident utilitarian tone, so that the difficulty is raised of justifying the deduction of a norm which should be absolute (do not kill the innocent) through the specification of another wider one (do not kill) which would only be relative. A third hypothesis is that "killing" the aggressor is not, in some cases, exactly equivalent to killing but to saving a life by killing: in such a circumstance the action of killing would be included in the description of a wider positive act (of saving), which would comprise among its partially undesired aspects that of eliminating a life. It is intuitive, however, that in this way many forbidden acts (forbidden if described in isolation and externally) could be reabsorbed (through an opportune redescription of the act of which

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this is part) into a licit act which includes and justifies them. At this point what significance would it have to speak once again of an absoluteness of the prohibition? What has been said for the order "do not kill" is also valid for every other negative moral norm which is presumed always valid and without exceptions. Thus it is not true that it is never licit (from a Roman Catholic moral point of view) to use contraception and even to practice sterilization. It is legitimate to resort to sterilization if there is no other way of preventing a procreation which is the fruit of sexual activity which is unavoidablyin human and lacking in unitive meaning. So the veto can be reformulated thus: it is not licit to sterilize someone in order to render infertile the use of his genital sexuality, unless that use is not desired and not morally due (the case of the prevision of rape is most known and discussed), since it does not constitute a moral problem to deprive of procreative meaning an action already deprived of every unitive significance. 6

In the opinion of some contemporary theologians (and in our opinion) there is only one way to save the absolute character of the norm and at the same time its capacity to constructively apply to concrete situations: thus it must be recognized that the (substantive)? moral norm commands without exception if understood symbolically, as a prescription concerning first of all the human attitude towards another person. If, however, the norm is understood in a materialistic sense8 this must admit the exceptions raised by particular cases which are always more complex than the conduct externally described by the general precepts. The moral norm is, therefore, valid without exception if understood as a prescription of a practical personal attitude, an attitude which cannot be represented or ordered other than through acts ordered or forbidden determinedly. Understood thus, such a norm appears to be irreducible, as, however, ethical theses of the teleological type would want, to the precept of maximizing the so-called premoral goods (life, health, pleasures ...). The actual difficulties of consequentialist ethics, all centered on the evaluation of the consequences of an action, are shown particularly in the description of the expressive actions, wanted and carried out not primarily for the acquisition or production of results, but as the externalization of a personal disposition, that is, as the manifestation of a desire (for example, the desire which enlivens the sexual relationship) which the moral agent has recognized as deserving of approval (and to which lovers promise fidelity).9 3.

CLINICAL BIOETHICS AND HERMENEUTICS

Ethics seeks a rational justification of moral evaluations. However, to show the reasons why something is done or decided as right does not signify - as we

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have said - deducing the evaluation from a general maxim with an objective and impersonal procedure, such as for which the subject can estrange himself from the context, forget his own feelings, and behave as a rational decider engaged precisely in connecting a norm (which he recognizes once and for all) to a problem (which he describes from the exterior). In reality the more morally important the decision, the more integrally (and, therefore, the more emotionally) involved the subject feels, the more the subject is invited to discover who he really is and what he really wishes to be, the more the subject finds in the situation appropriate elements for understanding the sense of the general norms (which until then had guided him spontaneously). The concrete content of the decision (the imperatives "do not kill," "do not betray," "do not envy" applied to particular people) thus becomes a symbol of the total idea of good life, which attracts the subject's desire and, therefore, forces him to check integrally his own moral disposition. The interpretative work concerning the meaning of an action, work which practical reason must carry out in applying itself to the individual case, can be opportunely illuminated and exploited in philosophical terms, referring us to the kind of understanding required by the hermeneutical method. Having originated as a reading technique for religious and legal texts, 10 hermeneutics has been used to advantage in a philosophical context as a paradigm of an understanding which requires a "fusion of horizons"ll between the text and its interpreter, and which can only be accomplished if he who understands puts his suppositions into play, transposing himself into the world of the text, recognizing there a truth which concerns him and letting it act upon himself. By analogy, concerning the moral act, the hermeneutical perspective maintains that a human action can be understood and judged only inasmuch as the observer (or the moral agent himself) perceives and gathers meanings and intentions, allowing himself to become involved in a participatory fashion (and not as detached spectator) in the world of values, which the act expresses. 12 If an action has a moral meaning, this can in fact only happen in a human context. The meaning of an act (and thus also the meaning of illness), as also the meaning of a word or statement in a literary text or the meaning of a graphic mark in a picture, can be named only considering the history in which it is inscribed and to whose configuration the act contributes, and only accepting to be called and questioned by the truth which such an act witnesses and proclaims, provoking us to take a position. In other terms moral disapproval (or approval) of a particular action can be justified only if it includes the hermeneutics of the meaning of such an action and the consideration of the personal attitude of the agent. Obviously this leads to avoiding every naturalistic fallacy. In fact, no text when considered

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in a materialistic way (i.e. examined as a series of ink marks on a sheet of paper) has significance; in the same way, no biological explanation can provide understanding of the human sense of a gesture. To find a meaning and translate it into a linguistic product, the reader of a text and the interpreter of an action must put themselves on the intersubjective level on which human communication takes place. 13 Regarding clinical bioethics, the hermeneutical perspective includes as fundamental task that of relating the particular action (on which it is intended to formulate a judgment) to the concrete subject who lives that specific circumstance, a subject with his own unique tastes, preferences, behavioral styles, and individual wishes. The personal world of the sufferer must, therefore, be taken into consideration, the meaning of his words and gestures must be discerned; and the real intention, which links his actions, which often appear contradictory, has to be searched for. The patient seeks to 'make sense' of events and to do what is best; autonomy as lived out is not just the exercise of an arbitrary power of choice but an attempt to choose well in the context of one's life story, with its own plot, aims, and values. The health care provider [14] can playa crucial role in restoring autonomy by helping the ill person reconstruct meaning in the face of the threat posed by events. 15

Moreover, the caregiver and the patient together are interpreters of the illness and joint authors of the illness narrative. Tn particular, the caregiver, listening with the third ear, "attends not only to what is said but also to what is unspoken and to what is unspeakable, all the while conversing with the patient to test the fit of the patient's experience with similar experiences."16

Often the clinical bioethicist meets sick people who confide to him their difficulties in discerning the best solution to the moral dilemma they are faced with: to continue treatment or not, to reveal a diagnostic truth or not, to resort to interrupting pregnancy or not. Likewise it is not an infrequent experience to receive requests from patients whose liberty and competence in decisionmaking appear, at least initially, to be disturbed by personal psychological conflict and family pressure, disoriented by tempting but illusory market publicity, distorted by omnipotent and triumphalist representations of medicine, representations which unfortunately cause the immaturity of the individual growth to collude with corporate or commercial interests. In such cases the subject seems to be guided by an ambivalent intention and thus finds himself, more or less consciously, facing the task of making the most suitable choice for his own life, taking into consideration and evaluating his

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feelings, fantasies, and worries, in which confusedly he feels the presence of his own fragmented identity. Every psychotherapist knows that sterility can express a conflictual desire, an unwillingness to become a father or mother with which the conscience does not agree. Inability to have a child may cover incapacity to love a child. The unconscious has reasons that reason does not know [...j. For this reason when facing every request for induced fertility it would be better to delay the medical response of rushing into treatment and to leave space preliminarily in order to interpret the symptom. Freud defines somatic manifestations as 'organ language,' precisely to indicate the communicative intentionality and the meaningfulness of the sense. Of course greater self-knowledge is not sufficient to solve the problem of sterility (although sometimes one unexpectedly unblocks incomprehensible obstacles), but helps nevertheless to face it better. 17

In some clinical stories the suffering voice cannot be heard and has to be perceived, found, and understood even by the patient, who is in search of a meaning: [... j helping sick people to 'find their voice'. Once we concentrate on the voiced quality of conversation about moral matters, questions of interpretation necessarily arise. Such questions, raised in the context of illness, are fundamentally questions of meaning. The doctor is drawn into a dialogue with the patient and asked to help make livable sense of sickness or injury. This demanding moral work requires not only reasoning skills but reading skills as well. It requires imagination. Metaphor is the preferred language of imagination and one of the chief elements of moral life; it is the vehicle of empathy.18

Unfortunately, the practice of applied ethics today deals mostly with abstract theories of action, balancing-procedures among general principles, detached views from nowhere, and impersonal techniques of justifications. A rationalistic attitude undervalues what actually moves people to act, i.e. motives and passions: It treats the rational content of speech and argument without regard to the engaged concerns that incite both speech and action. It by and large ignores mores and customs, sentiments and attitudes, and the 'small morals' that are the bedrock of ordinary experience and the matrix of all interpersonal relations. It by and large ignores real moral agents and concrete moral situations, preferring the abstraction of the hypostasized 'rational decisionmaker' confronting the idealized problem needing to be solved. [... j Though originally intended to improve our deeds, the reigning practice of ethics, if truth be told, has, at best, improved our speech. 19

4.

THE CONTRIBUTION OF PSYCHOANALYSIS

Thus applying ethics to a clinical case does not signify merely showing the theoretical roots of a principle, rule, judgment or decision. It also always means realizing, interpreting, and questioning the wishes of the moral agent:

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the wish of a couple or single woman to have a child, the wish of a terminally ill patient to die, and so on. Moreover, this hermeneutical concern must not be dealt with by submitting a request (expressed by a sick person or someone using medical services) to the preliminary examination of an expert or learned committee. Instead, and firstly, it is a question of offering suitable conditions for the patient to discover the uniquely personal sense which he attributes to the request for medical assistance, and so in that way he may judge whether that sense is appropriate to his personal moral opinion, style, and values in which he believes most. In fact, in ethically meaningful choices there is never simply a request for technical assistance: while choosing to consult medical expertise the subject also always opens an inquiry and makes a decision about himself, about the sense of his life and personal identity. Therefore, it would be incorrect, on the part of medical professionals and institutions, to reduce the deep meaning of the request for treatment (which is also always a question concerning the sense of one's own existence) to the expression of a material need which technical knowledge should satisfy, registering and fulfilling in an impersonal, mechanical, and instantaneous manner what the sick person explicitly demands in a particular situation. Behind the symptom, behind the appeal to the doctor, and even behind the so-called flight into illness or behind the escape in recovery, there are often unconscious reasons which "reason" just does not know, which, nevertheless, can be revealed by interpreting the language the sick person uses to tell about his illness and by the hermeneutics of original symbols in which his vision of good, his image of the world, and his opposition to evil come together and are expressed. It is in these cases that the contribution offered by clinical bioethics could take advantage of the theoretical background and clinical skills cultivated by the psychoanalytical tradition. It may seem rather hasty to introduce here an approach which should merit a much deeper explanation relating above all to the epistemological statute of the psychoanalytical work. However, we wish to first express dissatisfaction at the complete and brutal separation, mainly presented as obvious, between ethics and psychoanalysis, a distinction which would run parallel to that between philosophy and science (a human science in this case) and which would lead to their essential incommunicability. Due to this bias, in fact, on the one hand clinical discoveries in psychoanalysis are relegated to a strict scope with its own esoteric validation criteria, so actual phenomena of conscience (in a psychological sense) would be authorized to be considered only by specialized experts skilled in a competence from which is prejudicially separated the interest in moral questions.

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On the other hand, reserved to philosophical speculation is the task of founding by self-referencing the doctrine of good, almost as if it were possible to define essential ethical categories - such as sense of duty, separating them from reports made in the psychological sphere - such as sense of guilt - and almost as if it were possible to immunize rationalistically the concept of norm, distancing it from any reference to passions, feelings, or inclinations. However, it has been pertinently affirmed that the moral problem concerns the psychological theory, as much as the psychological problem concerns the moral theory; in particular, an ethics, which would consider the question of good more from the view of conscience than law, must acknowledge in the phenomenology of instincts, drives, wishes, and conflicts demonstrated in psychoanalysis, the affective root of ethical growth and of moral self-representation of the agent. 20 Having quickly considered these premises, we should like to try to comment on the contribution, precisely in a moral sense that, in our opinion, psychoanalytical points of view could offer. As already mentioned, ethics provides rational justifications for evaluation. In psychoanalysis, unconscious reasons leading to a choice are acknowledged, categorized, and verified. It cannot be objected that this is only a preparatory moment and that once rendered conscious, such reasons become the type on which would be exercised - at least according to a widespread representation - philosophy in the sense of intellectual references to a universal theory. The reason which can be supplied, when the many figures of an unconscious desire are interpreted, has an intrinsic individual and characteristic feature which theory does not recognize. It is, for example, my attraction to something, my sense of loneliness, the recurring dislike I feel for a type of behavior, which motivate and justify the decision or action I take. Tastes, inclinations, emotions, all this universal fluid of passive experience (as in Latin affectus pati) is the affective substance in which the identity of the moral agent takes shape and justifies, or rather, supplies a particular reason for which he, and only he in that way opts or opted for a certain sequence of events. The discerning of affections, on which psychoanalysis is carried out, leads the subject in fact to recognize himself in emotions which appeared extraneous to him and to regain possession of himself morally, freely consenting to the practical disposition shown in such mental representations or rejecting it as something truly alien to himself, artificial or camouflaged. In general words, we would claim that the relationship between passion and reason is not between alternative terms (as rationalistic ethics maintains).

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On the one hand, reason has the task of giving a good shape to the passions (preventing, for example, the desire from becoming impoverished and humiliated). On the other hand, by only interpreting the desire that surprises, attracts, and drives the conscience, reason can determine the concrete and situational content of the moral norm. We can, therefore, conclude that both philosophical ethics and psychoanalytical work put forward reasons in support of a moral choice. The former exhibits the universal norm to follow and in some cases goes as far as to produce a very general idea of good life, which deserves putting into practice. The latter will unmask illusory needs and show symbols of good, in which the subject recognizes his own original identity and in the faithfulness to which he molds his own moral style. In clinical cases in which an ambiguous feeling is experienced (where the ambiguity regards precisely both the typology of the action to be performed and the identity itself of the subject and his real desire), the moral agent can take advantage of both argumentative competences when he questions himself on which alternative choice could be said to be good. Good as far as it is really his choice and defensible before all. For these reasons we believe that at least in some aspects psychoanalysis can also be defined as a hermeneutical practice that may contribute to the understanding and maturation of the value world of the subject. 5.

AESTHETICS IN ETHICS

Moral hermeneutics (an example of which can be represented - as we have claimed - by psychoanalysis) produces its own effects, positioned between moral experience and theoretical ethics. We would now like to outline a consideration concerning the specific type of justificatory argumentation that hermeneutics adopts, when it seeks to understand the sense of an action in the context of a life. Here we wish to underline the affinity of such an understanding with respect to the understanding of the sense of a word in a text (i.e., the task of literary or artistic criticism) and with respect to the creative activity with which a work of art is produced (the task of the artist). In this sphere a kind of interpretation and construction is in action, which in many cases will use reflecting judgments. In these reflecting judgments, which Kant saw in the aesthetic field,21 is given only the particular, and the universal is to be sought not in laws a priori of intellect, but in the reflection on objects for which a preconstituted law is lacking. It is a question of objects which demand universal recognition (beauty is something which pleases or

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tends to please universally), but whose value is to be found in the intrinsic quality of the work and not in relation to abstract criteria defined externally. Also in the moral sphere, judgments regarding objects are formulated with respect to which a general ethical norm exists, but it is widely undetermined and to be "filled," specified, and connoted through the specific norms that the particular situation, full as it is of values and latent senses, reveals to he who knows how to read and interpret it. So it happens when the moral agent interprets his own emotions to discern what he really wants and what is concealed behind the desire which attracts him. The subject does not simply ask himself, "What external limits must I respect whilst I realize my preferences? What prearranged norms direct my wish?" (as if he knew a priori the sense of his own wish and the significance of the norms which should direct it). Rather the subject asks himself, "What are my real preferences? What rule can help me to be faithful to my desire, not to impoverish it, to open it up to new revelations? What internal line of coherence binds my life, passions, and aspirations and can help me render my own life story original and not alien, or rather as one which is truly mine?" Operating in this way, the moral judgment does not limit itself to applying a rule but in fact contributes to shaping. Moreover, despite the contextual distinctiveness and uniqueness of the work, neither the artistic action nor the moral one can be understood as an arbitrary deed or a subjectivistic one. There is a stringent legality in artistic action for which, if it is true that a successful work is "fitting to itself' and nothing beyond itself, it is also true that artistic invention is guided by the same form which, if it succeeds, produces. The piece of work, we could say,22 acts even before existing, is formed and forming together, and does not reach being formed if it has not been forming. The piece of work, therefore, summons to itself the action of the artist, action which could remain inferior to the summoning if it does not follow faithfully the rigorous, internal legality which will constitute the beauty of the work. Such a law, which is produced with the work and together with it counts as a judging criterion of the artistic gesture, can be said therefore, to transcend the concrete action, since the artist does not invent it despotically but also discovers it, brings it to light, and obeys it. From this it is not difficult to demonstrate analogies relating to the moral action. Every authentic moral agent wants to do good for the sake of good, but this unconditionally desired good is symbolically represented and expressed in particular orders (injunctions or prohibitions): keep the promise, take care of the person, be just to the poor, do not lie. These orders lay a

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claim on the liberty of the subject, requiring him to assume an intentional disposition which is unreservedly good; therefore, these do not order exterior obedience of the rule but in fact propose themselves as pregnant with a moral sense which, once believed and desired, can permit interpretation of the meaning and shaping of the rule in concrete situations. Something happens, as if the good action summons to itself the moral agent and invites him to assume an authentic personal disposition and to make use of the norms like guidelines, helping to discover and shape the unique manner in which he has to do good here, now, and in front of all. CONCLUSIONS

Our attempt to look for a more convincing and fruitful way of applying ethics to histories of illness in the clinical context has led us to recognize and consider the contribution that might come from psychoanalysis (as a hermeneutical practice also dealing with the ethical symbols woven through the conscious enunciations and the emotional experience of the moral agent) and from the area of aesthetics or art criticism (as a creative or interpretive practice dealing with the shaping or discovering of the inherent norm and the individual truth, which have to be recognized or obeyed in the work of art). This attempt raises of course the question of the nature of bioethics itself, specifically of its interdisciplinarity and of the relationship between philosophy and other disciplines (humanities and particularly psychology). In this matter, a permanent tension has to be noticed inside bioethics, between disciplines of particularity (grounded in existential and experiential details) and disciplines of generality (as philosophical ethics, employing abstract concepts and reasoning).23 It is not only a question of distinguishing different intellectual domains but of acknowledging the unavoidable abstraction from the real moral experience perpetrated by different perspectives, if it is true that "[t]hose differences reflect the differences between cognition and affect."24 Well, if you deal with applied ethics, you cannot renounce them both. We endorse an "ecumenical" vision of bioethics, a vision that recognizes the philosophical central nature of bioethics without undermining the dialogue with the disciplines of particulars. But we are not sure that you can assign simply a descriptive task to these disciplines of particularity, taking for granted that the normative task of philosophical ethics can only be performed by intellectual explication and impersonal tools. We would rather maintain that applied ethics is quite different from theoretical knowledge, and that practical

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reason also makes use of rational forms of moral justification, which are - to use a famous distinction - more idiopathic than nomothetic and which are specifically devoted to the interpretation of the original meaning of an action seen as a text. In this hermeneutical effort, rational skills are used which are very close to those going into action in understanding and evaluating a picture, a romance, a dream, a parapraxis. We dare to say that these interpretive practices own a normative component and an ethical competence that may be perhaps unimportant for episteme, but are essential for the exercise of phronesis. The law which requires the consent of the "heart" (that is the personal core where affections, intelligence, and will come together) can be understood and approved only if one accepts preliminarily to question the ambiguous forms of human desire in which the identity of the agent is revealed and the key features of his original inclination towards good are disclosed. If this intrinsic legality is not considered and obeyed, the moral action is reduced to an impersonal and external faithfulness to the norm taken literally. If, however, we undertake to know, mention, and interpret the affections which surprise and fascinate us, then a virtuous, hermeneutical circle will be made; the vision of good which we believe in will be put to the test in its capacity to give meaning to human, spontaneous inclinations and, if so, will be represented in patterns of behavior able to motivate the total and specific growth of that subject; on the other hand, the aforementioned inclinations will have the opportunity to disclose their always ambiguous nature, revealing the passive ground of our unique moral world, opening up unexpected scenarios of action, and revealing the uniquely individual characteristics of will. Full Chair of Bioethics, Medical School ofVarese NOTES I The research used EA.R., University of Pavia, Contitato 6, financial years 1996 and 1997, on the subject: "L' assistenza sanitaria negIi enti di diritto pubblico: nuove questioni etiche e deontologiche." 2 On the relationships between theories, considered judgments and moral decisions, see Principles of Biomedical Ethics, by T. L. Beauchamp and J. E Childress, New York & Oxford, Oxford University Press, IV ed., 1994, in the pages concerning specification, generalization, reflecting equilibrium. T. L. Beauchamp, "Principles and 'Principlism'," in AA.VV., Le radici della bioetica, Milano, Vita e Pensiero, 1998,47-59, writes: "Principles, in the prima facie conception, should be understood less as norms that are applied and more as guidelines that are interpreted and made specific for policy and clinical decision making," p. 55. The 'specification' of the principles is defined (quoting Richardson and De Grazia): "The progressive filling in and

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development of the abstract content of principles, shedding their indeterminateness and thereby providing action-guiding content" (Beauchamp, 1998, p. 55). I personally agree with many of the criticisms of principlism expressed by hermeneutical ethics, for example by D. Leder, "Toward a Hermeneutical Bioethics," in A Matter of Principles? Ferment in U.S. Bioethics, edited by E. R. DuBose, R. Hamel and L. J. O'Connell, Valley Forge, Trinity Press International, 1994, 240-259. 3 P. Cattorini, "Considerazioni sull'identitil della bioetica," KOS, Feb. 1992, n. 77, 7-10. S. Vanni Rovighi,lstituzioni difilosofia, Brescia, La Scuola, 1982, p. 145. 5 We don't take into consideration here deontological positions like those of Kant, Ross, Rawls, but particularly those appealing to divine revelation or natural law or metaphysical anthropology. 6 G. Perico, "Stupro, aborto e anticoncezionali," La Civiltii Catrolica, 1993, III, 37-46; L. Ciccone, "Non uccidere," Questioni di morale della vitafisica, Milano, Ares, 1984,348-350. 7 With the term "substantive" we translate the concept of "materiale" referred to the so-called "norme generali materiali di azione," that is, ethical norms prescribing or forbidding concrete human actions (actions that may be described with sufficient precision) and expressed by synthetic (non-analytic) judgments. 8 That is separating such a norm from the intention which presides over such actions, from the context in which these actions are inscribed and therefore, from the situational and personal meaning which the norm has. Included in its symbolic valency, a commandment is always valid but it is not possible to deduce from it syllogistically judgments on concrete acts. G. Angelini writes on these themes in L'evidenza e lafede, Milano, Glossa, 1988 (p. 436): "The 'killing' in question in the commandment which prohibits it is certainly an act defined 'materially' but not defined 'materialistically,' that is, defined without considering intentional dispositions which preside over its accomplishment. When it is understood in such a 'materialistic' sense, ineluctibly it would go against the problem of the thousand exceptions, which even a commandment so undoubtedly fundamental must recognize (legitimate defense, war, capital punishment, etc.). 'To kill' is the name of a practical intention of man, of a way of relating to another man; and of a way of wanting which immediately appears bad." The concrete act of killing, therefore, represents symbolically a moral attitude of hostility, contempt, wish to debase and annihilate the other; an attitude which is also conveyed in other acts (externally lighter), such as in insults, scornful expressions, and affectations of superiority (see Angelini, 1988, p. 437). 9 A. Lattuada, L'etica normativa. Problemi metodologici, Vita e Pensiero, Milano 1985, p. 19. 10 See M. Ferraris, Storia dell'ermeneutica, Milano, Bompiani, 1988. In Encicl. del Novecento, Roma, 1977, v.II, under the heading "Ermeneutica," pp. 731-740. H. G. Gadamer places the meaning of ermeneuein in the oscillation between the translation and the practical indication, between communicating and requiring obedience. II The reference is to H. G. Gadamer, Veritii e metodo, Milano, Bompiani, 1983. In human sciences the single event does not simply serve to ratify a law which then, coming down again to the application domain, renders the anticipation possible. The ideal of Geisteswissenschajten, however, is to understand the phenomenon itself in its unique and historic concreteness, discovering how a particular individual or people has become what it is. 12 For the analogies between text and action see P. Ricoeur, Dal testo all'azione. Saggi di ermeneutica, Milano, Jaca Book, 1989. A hermeneutical perspective in the sphere of generative ethics is that of Bioetica della generazione, Torino, SEI, 1996, by P. Cattorini and M. Reichlin. 13 "[ ••• J The action can be treated as a text and tbe interpretation, through the motives, as a reading. Reconnecting an action to a composition of motives is like interpreting a text or part of a text depending on its context," writes P. Ricoeur in Se come un altro, Milano, Jaca Book,

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1993, p. 146. By the same author, see again Dal testo all'azione. Saggi di ermeneutica, in particular the chapter: "II modello del testo: l'azione sensata considerata come un testo," pp. 177-198. 14 And - we add - the clinical bioethicist as articulator of the perspectives of case participants, as facilitator of dialogue between parties, as recaller of contexts often obscured, as Socratic interlocutor (in Leder's words, 1994, p. 255). 15 D. Leder, 1994, p. 248. 16 R. A. Carson, "Interpretation," in W. T. Reich, Ed., Ene. Bioethics, New York, Simon & Schuster, 1995, p. 1285. "Contrary to the impression created by the stainless-steel apparatus and vital-sign monitors of rescue medicine, what is required of the caregiver in patient encounters is less often swift judgement and deft action than a discerning reading of the situation at hand. What does the ailment in question mean? Is the suffering to be relieved or endured, and in what measure? What can one reasonably expect to be the result of this or that intervention? Are there fates worse than death? Answers to such questions must be thought through and talked about person by person, case by case. In this process of reflection and conversation, defensible courses of action evolve" (p. 1287). 17 S. Vegetti Finzi, "Biotecnologie e nuovi scenari familiari. Una prospettiva psicoanalitica e femminista," Bioetica, n. I, 1994, 60-82. 18 R. A. Carson, "Medical Ethics as a Reflective Practice," in R. A. Carson and C. R. Burns, eds., Philosophy of Medicine and Bioethics, Dordrecht, Kluwer Acad. Pub!., 1997, 181-191. 19 L. R. Kass, "Practicing Ethics: Where's the Action?" Hastings Center Report, 20, I, Jan.-Feb. 1990,5-12. See also the comment by R. Hamel in Bull. Park Ridge Center, Sept. 1990,42--43. 20 G. Mazzocato, Patire e agire. L'insuperabiLe profiLo moraLe dell'Lo e Le aporie della teoria psicologica, Milano, Glossa, 1995. 21 The importance of the reflecting judgments for the political and moral thinking has been studied by E. Vollrath, Die Rekonstruktion der politischen UrteiLskraft, Stuttgart, Klett-Cotta, 1977 and E. Pleines, Praxis und Vernunft. Zum Begriff praktischer Urteitskraft, Wiirzburg & Amsterdam, K6nigshausen Neumann-Rodopi, 1983. Furthering the analogy between the ethical and aesthetical judgment would result in much to say concerning the quality of the hermeneutical work which constitutes the ethical judgment in the situation and which has led us to speak of the same clinical bioethics as an art critique (see P. Cattorini, Sotto scacco. Bioetica di fine vita, Napoli, Idelson-Liviana, 1993, pp. 169 ff). Just as the beautiful work of art, so the good action cannot be presumed and produced by simply applying general laws known a priori. The successful work of art itself supplies the criteria of judgment which should be given, since the artistic creativity (in Pareyson's words "formativita") has as its own law, the individual inherent rule of the piece of work. Let us call "formativitli" the character of doing which, while doing, invents the way of doing; pure "formativita" is the nature of art, since it is a forming just for a forming (and not forming for any other reason or function), so that in art the norm cannot be but the inherent norm of the individual artistic piece of work. For these concepts see L. Pareyson's Teoria dell'arte, Milano, Marzorati, 1965, according to which in art, together with the method of application, the rule or norm which should be applied is also invented. 22 See again Pareyson, 1965. 23 See E. D. Pellegrino, "Bioethics as an Interdisciplinary Enterprise: Where Does Ethics Fit in the Mosaic of Disciplines?" in R. A. Carson and C. R. Burns, Eds., Philosophy of Medicine and Bioethics, Dordrecht, Kluwer Acad. Pub!., 1997, 1-24. 24 See again Pellegrino, 1997, p. 6.

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G. Abba, Felicita, vita buona e virtu. Saggio di jilosojia morale, Roma. LAS. 1989 G. Angelini. in AA. VV.• L'evidenza e lafede. Milano. Glossa. 1988 J. D. Arras. "Principles and Particularity: The Role of Cases in Bioethics". Indiana Law Journal. 69.1994.983-1014 T. L. Beauchamp. "Principles and 'Principlism..•• in AA. VV.• Le radici della bioetica. Milano. Vita e Pensiero. 1998.47-59 T. L. Beauchamp and J. F. Childress. Principles of Biomedical Ethics, New York and Oxford. Oxford University Press. IV ed.• 1994 R. A. Carson. "Interpretive Bioethics: the Way of Discernment". Theoretical Medicine, II, 1990. 51-59 R. A. Carson. "Interpretation". in W. T. Reich, Ed., Ene. Bioethics. New York. Simon & Schuster, 1995 R. A. Carson. "Medical Ethics as a Reflective Practice". in R. A. Carson and C. R. Burns, eds., Philosophy of Medicine and Bioethics. Dordrecht, Kluwer Acad. Pub\., 1997.181-191 P. Cattorini. "Considerazioni sull'identita della bioetica", KOS. Feb. 1992, n. 77, 7-10 P. Cattorini. Sotto scacco. Bioetica dijine vita. Napoli. Idelson-Liviana. 1993 P. Cattorini and M. Reichlin. Bioetica della generazione. Torino. SEI. 1996 E. J. Cassell. "Life as a Work of Art". Hastings Center Report. Oct. 1984,34-37 T. S. Chambers, "The Bioethicist as Author: The Medical Case as Rhetorical Device", Literature and Medicine, 13, n. I. Spring 1994,60-78 L. Ciccone, "Non uccidere", Questioni di morale della vitajisica. Milano. Ares, 1984 D. De Grazia. "Moving Forward in Bioethical Theory: Theories, Cases, and Specified Principlism". Journal of Medicine and Philosophy. 17, 1992,511-539 M. Ferraris, Storia dell'ermeneutica. Milano. Bompiani, 1988 J. Finnis. Fundamentals of Ethics, Georgetown Univ. Press. 1983 H. G. Gadamer, Verita e metodo. Milano. Bompiani, 1983 J. M. Gustafson. "Moral Discourse about Medicine: a Variety of Forms", J. Med. Philos.• 15, 1990.125-142 R. Hamel, review of L. R. Kass. 1990. in Bull. Park Ridge Center, Sept. 1990, 42-43 L. R. Kass. "Practicing Ethics: Where's the Action?". Hastings Center Report. 20, I. Jan.-Feb. 1990.5-12 P. Kemp, "Per un'etica narrativa. Un ponte Ira J'etica e la riflessione narrativa in P. Ricoeur". Aquinas. 31. 1988.435-458 A. Lattuada, L'etica normativa. Problemi metodologici, Vita e Pensiero. Milano 1985 D. Leder, "Toward a Hermeneutical Bioethics", in E. R. DuBose. R. Hamel and L. J. O'Connell, eds .• A Matter of Principles? Ferment in U.S. Bioethics, Valley Forge. Trinity Press International, 1994 J. D. Lock. "Some Aspects of Medical Hermeneutics: the Role of Dialectic and Narrative", Theoretical Medicine, II, 1990.41-49 A. MacIntyre. After Virtue. A Study in Moral Theology, Notre Dame. Univ. Notre Dame Press. 1981; Dopo la virtu. Saggio di teoria morale, Milano, Feltrinelli. 1988 G. Mazzocato, Patire e agire. L'insuperabile profilo morale delflo e Ie aporie della teoria psicologica, Milano, Glossa, 1995 D. Mieth. "II significato dell' esperienza esistenziale dell'uomo", Concilium. 10, 1976,34-62

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M. Montello, "Medical Stories: Narrative and Phenomenological Approaches", in M. A. Grodin, Ed., Meta Medical Ethics, Kluwer Acad. Pub!., 1995,109-123 R. Mordacci, "II dibattito sui metodo nella bioetica anglosassone" ("Fenomenologia, ermeneutica e 'etica narrativa"'), in AA.VV., Introduzione allo studio della bioetica, Milano, Europa Scienze Umane, 1996, 107-112 R. Mordacci, SuI contributo delI'ermeneutica alIa bioetica, in AA.VV., Le radici della bioetica, Milano, Vita e Pensiero, 1998 L. Pareyson, Teoria dell'arte, Milano, Marzorati, 1965 E. D. Pellegrino, "Bioethics as an Interdisciplinary Enterprise: Where Does Ethics Fit in the Mosaic of Disciplines?", in R. A. Carson and C. R. Bums, eds., Philosophy of Medicine and Bioethics, Dordrecht, Kluwer Acad. Pub!., 1997, 1-24 G. Perico, "Stupro, aborto e anticoncezionali", La Civilta Cattolica, 1993, III, 37--46 A. Pessina, "L'ermeneutica filosofica come sfondo teorico della bioetica. Elementi per una valutazione", Medicina e Morale, 1996, 46, 43-70 H. S. Richardson, "Specifying Norms as a Way to Resolve Concrete Ethical Problems", Philosophy and Public Affairs, 19, 1990,279-310 P. Ricoeur, Della interpretazione. Saggio su Freud, Milano, II Saggiatore, 1966 P. Ricoeur, Dal testo alI'azione. Saggi di ermeneutica II, Milano, Jaca Book, 1989 P. Ricoeur, Filosojia della volonta. I. II volontario e l'involontario, Torino, Marietti, 1990 P. Ricoeur, Se come un altro, Milano, Jaca Book, 1993 D. C. Thomasma, "Clinical Ethics as Medical Hermeneutics", Theoretical Medicine, 1994, IS, 93-111 P. van Tongeren, "The Relation of Narrativity and Hermeneutics to an Adequate Practical Ethic", Ethical Perspectives, v. I, n. 2, June 1994, 57-69 S. Vanni Rovighi, Istituzioni di jilosojia, Brescia, La Scuola, 1982 S. Vegetti Finzi, "Biotecnologie e nuovi scenari familiari. Una prospettiva psicoanalitica e femminista", Bioetica, n. I, 1994,60-82 J. Verstraeten, "Narrativity and Hermeneutics in Applied Ethics" Ethical Perspectives, v. I, n. 2, June 1994,51-56 M. H. Waymack, "Narrative Ethics in the Clinical Setting", Making the Rounds, v. I, n. IS, April 8,1996,1--4 R. Zaner, Ethics and the Clinical Encounter, Englewood Cliffs, Prentice Hall, 1988

ROBERTO MORDACCI

MEDICINE AS A PRACTICE AND THE ETHICS OF ILLNESS

1.

A MORAL UNDERSTANDING OF MEDICINE

Current developments in the biomedical sciences are going to produce profound changes in the nature of medicine in the near future. One can recall the immense revolutionary power of molecular medicine in relation to the way diseases will be treated and prevented once the Human Genome Project is completed and treatments apply more and more extensively the knowledge thus obtained: not only will diseases with a genetic basis have a clear diagnosis, but other illnesses will benefit as well from treatment deriving from the use of recombinant DNA techniques. The present image of medicine as a mainly surgical and pharmacological enterprise will be profoundly modified by the increasing presence of a biotechnological drift, centered on cells and particularly on DNA. This change represents a dramatic shift in the ability to fight diseases, since in most cases we will be able to radically remove the cause of a disease (a gene) or to modify the genetic endowment so as to make an organism resistant to a specific disease. In the face of these changes, contemporary culture is called to rethink the nature and role of medicine, although such a reflection is needed anyway in order to offer a better interpretation of the relation between medicine and other forms of human activity. The basic question seems to be: What should we expect from medicine as a part of the human effort to relieve the condition of suffering and to enhance the prospects of a flourishing life? In other words, will molecular medicine improve our ability to cope with illness and suffering, and, in general, with the limits of the human condition, or will it exacerbate the sense of alienation that so many people feel today in hospitals and during the course of some medical treatments? The interpretation of medicine needed in such historical and cultural circumstances is not just an inquiry on its epistemological status, as if medicine could be defined only by the kind of knowledge it is based on. Neither a philosophy of medicine as a speculation on medicine, nor as a logic of medicine, nor as a philosophy of the medical science would serve our present cultural needs in this field.' In this sense, the growing evidence that both biomedical practice and research intrinsically raise moral as well as legal, political, social, and economic problems makes it clearer than ever that to II? A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 117-131. © 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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think of medicine as a science or simply a scientific activity, although a very complex one, is not only reductive but simply wrong. On the other hand, physicians still tend to consider themselves scientists, and the scientific foundations of their practice have been repeatedly stressed to gain public recognition and authority. Today we can see better that the modern and contemporary interpretation of medicine as a part of the scientific endeavour is less adequate than the ancient and medieval interpretation of it as an "art," although even this term does not cover the actual status of medicine nowadays. It cannot be a way out of this impasse to say that medicine is at the same time an art, a profession, a science, and a commodity. 2 What we rather need today is a comprehensive understanding of the nature of medicine that makes it possible to see immediately how the moral aspects of medical practice can be understood as inherent rather than juxtaposed to it. This means that the nature of medicine must be looked at from an explicitly moral point of view. Probably the best way to do this is to try to understand what kind of practice medicine is: that is, as a kind of human activity whose fabric is a texture of meanings expressed in the various actions that constitute it as a recognizable human endeavor. An interpretation moving along this line can open the space for an ethic of medicine that springs from inside it and is not imposed on it from the outside, e.g. from an ideology, a philosophy, or a religion; and yet, as we shall see, medicine is not an isolated practice but a part of the pervasive search for the good that constitutes human agency, and it therefore receives its sense in a strict dialectic with all the other practices human life is made of. An "internal" interpretation of the moral sense of medicine does not entail a separated, special morality disconnected from the rest of moral life. 2.

LINES OF A PHILOSOPHY OF MEDICINE

Philosophical interpretations of medical practice have already been developed by many influential scholars whose reflections clearly point in the direction suggested above. Probably the most thorough of these attempts is the philosophical interpretation of medicine offered by Pellegrino and Thomasma in A Philosophical Basis for Medical Practice. The line of the argument developed by these authors highlights the essential features of medicine as a practice, although with some ambiguities concerning the very use of the term "practice." My own contribution is an attempt at clarifying this point with a more precise definition of practice. The characterization given by Pellegrino and Thomasma starts with some insights

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deriving from a phenomenology of the clinical encounter. For these authors "a specifically medical event is formed by clinical interaction" and "the moral nature [of medicine] stems from the fact that patient and physician mutually enter into a healing relationship";3 the modes of this relationship (i.e. what is important in it - morally important and relevant for its definition) are the characteristic traits of responsibility, mutual trust, decision orientation, and the curative intention (what the authors call the "aetiology" of medicine). These traits represent, though rather synthetically, the result of a phenomenological consideration of the clinical encounter. They emerge as formal characteristics of the experience lived by the individual consciousness involved in the clinical relationship. Yet, at closer scrutiny this phenomenological analysis does not seem to be taken to its ultimate level. The experience behind the clinical encounter - that is, the experience of illness, the need for help (for a specific and competent kind of help) and the practical and verbal answers offered by the presence and the activity of the physician, the nurse, and the health-care system - is not exhausted by the formal and rather exterior modes of responsibility, trust, decision, and intention. The most basic feature of that encounter is the quality of the relationship that takes place during its course. In that relationship what is at stake is a whole universe of discourse, one in which illness is given an understandable and credible sense which patient and caregiver can possibly share, at least as a background to their practical exchange. An adequate understanding of the implications of the phenomenological analysis of the clinical encounter leads to the discovery of a deep and intrinsic connection between the technical activities and the scientific knowledge of medicine, on one side, and a simpler and more radical form of life on the other, a form which is at the basis of the human relationship with every other reality - it being a person or any other entity in the world. That original form of relationship is care, and medicine represents a specific and highly sophisticated determination of that form, in which medical care is the competent and scientifically based practice of caring for the ill. Although phenomenological approaches are not so common in the philosophy of medicine, phenomenology is certainly the most effective method and the closest to personal reality, in order to try to understand what medicine is for the conscience of human beings (phenomenology claims to be, if anything, a method for the conscience to bring to clarity the original nature and content of its experiences). Merely conceptual analysis would not serve the aim of rendering the essence of medicine, since such an inquiry should instead concern first of all those contents of the experience of the

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healing relationship relevant for the individual consciousness and not a formal definition derived from an abstract concept. What really is at stake in the medical practice is the symbolic exchange effected in and through the actions performed by physicians and patients, and recognized by the cultural context as having a specific meaning. Pellegrino and Thomasma argue that "medicine clearly is a domain of activity which is distinctive and distinguishable as science, art, and praxis. It comprises a set of legitimate philosophical issues and questions which derive from the unique nature of the clinical encounter."4 The characterization of medicine as "a distinct intermediate discipline, a tertium quid, between art and science but distinct from both of them [...] a habit of practical understanding refined and perfected by experience in dealing with patients," or as a "derived discipline, a third class of human enterprises that combines· theory and practice in a unique way,"5 is unsatisfactory. It would be quite strange to recognize that we have no single concept to describe, from a general point of view, the kind of human activity that medicine is. Being a third class of human activity would make of medicine an odd discipline, as if through centuries of history and dramatic mutations we were not able to recognize medicine as an activity with distinctive characters. On the other hand, it is also true that many other contemporary forms of activity could be said to occupy a middle ground between science and "art" in the general sense of a practical enterprise (the truth is that we cannot use the term "art" any more as the medievals did), but it is unclear what such a positioning means from an epistemological point of view. More fundamentally, such a characterization does not clarify how theory and practice interact in the domain of medicine: What is the role of scientific knowledge in an art? And is there any possible unity of vision between the points of view of the physician as scientist, healer (artist), and caregiver (acting practitioner)? How could we ever avoid the possible conflicts between these different perspectives? In fact, Pellegrino and Thomasma, after their analysis of the modes of the clinical encounter and of the forms of medicine, define the basic form of medicine as that of "a kind of craftsmanship of healing placed within an imbalanced relationship," a craftsmanship that "involves healing the body with the body."6 In this sense, one can say that the fundamental essence of medicine lies in its practical dimension, where theoretical knowledge serves a specific goal (that of healing) in the context of the clinical relationship. Yet, these authors do not explicitly endorse a definition of medicine in terms of practice, although the use of the term "craftsmanship" points in this direction and medicine is often spoken of or referred to as a practice (even the title of

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their book bears the expression "medical practice" rather than simply "medicine"). 3.

MEDICINE AS A PRACTICE

One might suggest that medicine could fall under the domain of what Aristotle called practical science,? but such a characterization would be difficult to handle under the contemporary, prevailing interpretation of what "science" means;8 furthermore, this characterization bears some ambiguity about the status of the discipline, since the latter is defined essentially as a "science," that is, a theoretical activity, although with a practical aim. This may be true of medical knowledge (and therefore of the biomedical sciences nowadays), but it is false as a description of medicine identified with medical practice. The mere existence of treatises of medical knowledge would not suffice to determine the existence of medicine; such formalized knowledge may not even be strictly necessary for an effective medical practice. On the other hand, there is no doubt that while Aristotle defined medical knowledge as practical science, he repeatedly ranked medical practice among the arts (technai), especially in examples and analogies. 9 Yet if we look at the definition of techne given in book VI of Nicomachean Ethics, we cannot avoid feeling a bit uneasy at applying such a definition to medicine (and not only to modem but to ancient medicine as well). Art is defined as "a state of capacity to make, involving a true course of reasoning" and "there is neither any art that is not such a state nor any such state that is not an art" (the given example is architecture);l0 moreover "the reasoned state of capacity to act is different from the reasoned state of capacity to make. Hence too they are not included one in the other; for neither is acting making nor is making acting." 11 There are some passages in which medicine is presented as analogous in some respect with "matters concerned with conduct and questions of what is good for US,"12 that is, with matters related to praxis rather than techne, but on the whole the characterization of medicine as an art (techne) remains quite clear in the Aristotelian text. Nonetheless, there are reasons to doubt that this Aristotelian characterization of medicine as an art really covers what we call medical practice. This kind of thought especially arises when we think of the supposed telos of the "medical art," that is health: to be short, it seems too reductive to think of the health of a person exclusively in terms of a product, the result of a "making" (poiesis). First, health is a multifaceted notion, and, although on the physical level of the concept it might seem appropriate to say that health is

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the result of, say, an appropriate medical treatment, we nonetheless know that in many instances a state of health means something more complex than that, i.e. a condition sometimes compatible with an impairment. Second, health is normally not the result of any medical treatment but a normal state of the individual who is threatened by illness and whom medicine tries to restore. So health is not, strictly speaking, a product of the medical art (as a house is the product of the making of architecture), but a result of the dynamic interaction between the natural processes and the healing operations of the physician. Third, longing for health is a far deeper desire than just the aspiration to physical well-being, as it appears from phenomenological description of the emotions and expectations of patients facing illness (no matter how serious).13 Fourth, health is a good that receives at least part of its meaning and content from the relationship between the healer and the healed, the caregiver and the cared for - a good that is partially constituted by the symbolic exchange of meanings which takes place in the clinical encounter. 14 Fifth, health is a relevant feature of the overall good of persons and therefore contributes, though in a complex way, to happiness, so that to be concerned with the health of persons means at the same time to be concerned with what is good for them; at least, it is always important when deciding about a medical treatment to see it in the light of the more general good of the patient. IS Finally, what seems often important in medical practice is not so much the goal of health but the act of healing or at least of caring, which is in some respect independent from the achievement of that goal. What a patient expects from a physician and a medical team is first of all to be cared for, with the hoped result to be healed; but the fact that a medical team may not be able to restore the patient's health does not deprive their actions of their quality of medical actions. Essentially, all that the medical staff does is an expression of the fundamental commitment of medicine, that of caring, even if the goal of health cannot be achieved. These considerations strongly suggest that medicine has much in common with the realm of praxis; even, we might say, since its aim is a feature of the good of the person and since that good is exchanged primarily in the context of an interpersonal relationship, the essential characterization of medical practice could be sketched in tenns recalling the Aristotelian notion of praxis rather than that of techne. It is, therefore, easy to see that these considerations do lead us to refer to a notion which has received much attention in the recent debate in moral philosophy, Le. the notion of practice.

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An alternative way to characterize medicine, then, might be to consider it as a practice using a vast domain of knowledge for the purpose of healing. A general definition of practice, although quite a complex and long one, is that given by Alasdair MacIntyre, designed in a loosely Aristotelian context. This definition runs as follows: Any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended. 16

To reduce complexity to a schematic list of properties, the basic features of this definition can be summarized as follows:

1. Coherence and complexity: A human activity constitutes a practice if it has some degree of complexity and internal coherence, i.e. if it is not just the result of spontaneous and incidental activity pursued without any meaningful intention or made up of a mere sequence of acts belonging to different and unrelated practices. According to MacIntyre's examples, bricklaying is not a social practice; architecture is. 2. Cooperation: A social practice implies the cooperation of various agents for a commonly shared goal. A completely solitary activity, carried out by an individual with no recognition or mandate by others, does not constitute a practice. 3. Internal goods: The performance of a particular practice is determined by the attempt to realize a determinate figure or form of the good, which cannot be realized otherwise. To use MacIntyre's example, playing chess can lead to prestige and money if one is a champion, but these are not goods intrinsic to playing chess; the internal values of playing chess can be achieved only in the very act of playing at the best level of excellence possible for the subject. The masters of a practice are those persons able to realize its internal goods at the highest levels (or even better, see below). The notion of internal goods is crucial for the definition of practice, as it permits one to distinguish a particular practice from any other and allows one to draw the important distinction between internal and external goods; the latter can be included in the practice, but they do not define its identity since they belong more appropriately to other forms of activity. 4. Standards of excellence: Any subject performing a practice can achieve its goods in a more or less adequate manner, but there are standards of

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excellence that define the minimal, socially accepted levels of correspondence between the performed activity and the achievement of its internal goods. Performing at the basic standard of excellence is required to enter the relevant circle of those performing a certain socially recognized practice, but it is implicitly assumed that anyone entering the field of that practice will try to improve his ability to achieve its internal goods. 5. Extension of human powers: The goods internal to a practice can always be realized better; thus, there is an open space for those who have acquired a special dominance over the virtues necessary to realize those goods, so that they may achieve them to an unprecedented degree in the history of that practice. Their enterprise can be counted as establishing a new frontier in the capabilities of man concerning that practice. It is perfectly clear, as Jeffrey Stout has also noted,17 that medicine is a social practice according to MacIntyre's definition. Medical care is a complex and coherent activity, which implies cooperation between various people pursuing a common general good through different individual tasks; this common general good can be said to be internal to medical practice in the sense that it cannot be achieved otherwise, so that any way of achieving that good (we will try to specify it below, but in general we can assume it is "caring") constitutes an example of medicine; there are standards of excellence, and below them nobody is publicly allowed to practice medicine; and the masters of the practice are those who extend its limits in realizing its internal goods. Although MacIntyre's definition uses the more general notion of good rather than that of goal, we might assume, in this context, that the senses of the two terms largely overlap: A goal (or a te/os in the Aristotelian sense) is the good pursued in a particular kind of action. There are goods that are not the result of an action - so that they do not constitute a goal for human action - but human agency is characterized by the tendency to achieve a goal which is understood as a good by the agent. In the following, we will rather take up the notion of goal, because it is more determinate and because the discussion concerning the nature of medicine usually occurs with reference to its presumed goals. In a more analytical style, Lennart Nordenfelt has defined medicine along similar lines, characterizing it as "the practice performed or supervised by physicians/psychiatrists in their professional activity of enhancing health by preventing or treating diseases, injuries or defects."18 It is clear that the center of this definition is still the patient-physician relationship, although in an indirect sense, since the focus here is on the activity of those who profess to

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heal (physicians/psychiatrists and those supervised by them). What matters is what those people do in the attempt to enhance health - a goal that includes prevention and treatment. Therefore, this seems a good definition, although problems persist with reference to the notion of health as an intrinsic goal of medical practice. 4.

INTERNAL AND EXTERNAL GOALS

Of course, in order to describe what kind of practice medicine is, it is necessary to in order identify at least one distinctive internal good, by virtue of which all the activities performed under the general label of medical practice are recognizable in a coherent manner. External goods are those goods which can be achieved or realized in the course of a particular practice, but are not peculiar to it. For example, medical practice usually brings money, power, and prestige to physicians, but these are external goods, not goods that are peculiar to and distinctive of medical practice (nor of any other practice). Before trying to specify the good internal to medical practice, a question must be answered concerning the nature of that good. Although the distinction between internal and external goods proposed by MacIntyre is, as Stout recognizes, "tolerably clear,"19 some may argue that there is no such thing as an internal good to be pursued as distinctive of a particular practice. Any social practice receives its goals (and therefore its goods) from the cultural context in which it is performed, and there is no "essential" goal or te/os that objectively defines a practice all around the world and in any human society. What we, in the industrialized West, call medicine is something quite different from what wizards and magic healers do in other cultures or even from what westerners used to do in ancient and medieval times. Therefore, so the argument goes, the distinction does not lead to the identification of any hard-core values of any practice; rather, an "internal" value has to be recognized, from a distance, as a value imposed on the practice by the surrounding culture; the variability of the goals that identify medicine in different times and places implies that those goals are not intrinsic but simply a social construction; one can say that "medicine is thus best thought of as an evolving fund of knowledge and a changing range of clinical practices that have no fixed essence."20 In particular, the key concepts of health and illness appear to be too strictly dependent on the cultural context to be used to define a practice throughout the world. The question concerning the nature of the goals defining a practice seems to be a crucial one, in particular for medical practice, since the ethics of

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medicine depends on which values are considered the proper ones for it as a practice, and those values depend on the goals defining medical practice. Anyway, I think that the alternative external-internal is misplaced. Any form of practice has internal values, but they are embodiments or practical examples of values that are always at the same time to a certain extent belonging to the general existence of human beings. A practice cannot be totally severed from the wider texture of human existence, for it is in our practices that we are trying to give reality to our hopes and our beliefs concerning the whole of our lives. Thus, there can be incompatibility between the particular telos of a practice and the general human search for the good only if we have already lost the original connection between them, that is, if we have separated the particular practice from the search for the good life as a whole. This comprehensive search constitutes the texture of the fabric in which the particular practices can have an intelligible sense; and this connection between the overall search for the human good and the goods internal to a practice constitute precisely its moral form, that is, its meaning as a part of the moral life of an individual or a society. There can be an excellence in purely technical terms, a skill of performance which realizes at a very high level the goods internal to a determinate practice, but it may well be the case that the person with such an ability loses sight of the place held by the values inherent to that practice with respect to other values that are more general or closer to the most relevant dimensions of human life. Any human practice aims at realizing goods that are modes of the overall notion of the good life, and there is no practice which can be said to be allencompassing as a way to realize the good life. It is for this reason that the traditional cardinal virtues can be traced in most human activities, since, as MacIntyre himself recognizes - at least for justice, courage, and honesty they are qualities that need to be cultivated for any kind of activity.21 Furthermore, we have good reasons to say that the goals of medicine are certainly subject to deep variations among cultures, but that they nonetheless make medical practice recognizable everywhere. It is not arbitrary to define a certain practice as belonging to (a form of) medicine, although the range and scope of what it entails is heavily dependent on the particularities of a specific culture. The basic feature of any of these activities is the attempt to care for an ill person, by any definition of illness and by any means one can make use of. Therefore, the sense of a practice can be said to be socially construed, but not on empty spaces. Medicine is a practical response to the challenge of illness in terms of a scientifically sound and technically developed form of

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care. This practical response takes a number of different forms depending on the way a particular culture in general considers the event of illness and the ways to face it from a moral and from a practical point of view. These meanings need not be reciprocally incompatible but can vary significantly while remaining under the general intention of caring in a competent manner. The concrete form of a competent act of caring is obviously dependent on the scientific development of a determinate culture or historical period; and, therefore, variation is nothing strange in this general characterization of medical practice. Furthermore, and finally, medicine aims at restoring or enhancing health, but at the same time it recognizes that this is not always possible and that it can assume the less ambitious aim of palliating or assisting. Modem medicine is more technical than practical, but the essence of the medical enterprise is still a practical one. We would not recognize as medicine a practice completely detached from the human effort to give meaning to illness and suffering, and yet the question of the determination of an understandable sense of illness is a larger goal than the one that defines medicine. Medicine is limited to a practical response, that of caring in a competent manner, i.e. using the best resources of scientific knowledge. The elaboration of a sense for illness, suffering, and the desire of health is not a goal of medicine, but physicians cannot practice medicine without appealing to a shared sense of illness and health, because the dimensions of illness and health cannot be reduced to the merely biological; their analogical complexity calls for a deeper awareness of this multilevel meaning. "The reality that counts is cultural reality, and the system used by the healer or doctor need be accurate only in terms of the culture in which it is being used, for it serves to explain illness."22 Thus we can define medicine as the practice of healing or rather the practice of competent care for the ill, because, whatever health and illness may mean, they will nonetheless identify a practical goal for all those involved in the situation of meeting human suffering and having at least the presumption to be able to heal. In this sense, it can be said that medicine is a form of caring that aims at curing, and that healing is its ultimate normative ideal but not a necessary result. Care, cure, healing, and health enhancement have their sense in the relationship of proximity with the suffering other; they represent the whole spectrum (at least care for the ill; at best heal or, even, enhance health) of the telos of a practice whose technical aspect has become prevalent in the contemporary age, obscuring its roots in the practice from which the technique

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can have a meaning. It is in the practice - that is, in the relationship, not in the technique per se - that the exchange of meanings takes place, that is, that care occurs. Medicine per se is not the skillful gesture of the surgeon (it could be an act of slaughter as well), but it is that act together with its sense as a moment of the caring relationship. Only within the horizon of the caring relationship does that gesture constitute a medical act. Every culture defines the contents of medical practice in ways partially different from those of other cultural worlds starting from different interpretations of the experiences of illness and health. These experiences, in particular that of illness, have traits that are originally common to all humans (they constitute the original core meaning inscribed in the experience of illness),23 but they can be construed in significantly diverging ways to the point that they give rise to quite different forms of practice as a competent response to illness. This does not mean that we cannot recognize medicine in the diversity of its historical forms, because we are authorized to call medicine any concrete form of caring relationship aimed at healing which uses the means and ways considered to be most adequate in a specific cultural context. Such a characterization implies an analogical concept of illness and health, which allows recognition of the persistence of identity through variation in the different concrete embodiments of the historical notions of illness, health, and medicine. 5.

RETHINKING THE ETHICS OF ILLNESS AND HEALTH

One of the necessary steps to rehabilitate the identity of medicine as a practice is the rethinking of the ethics of illness. Illness is, in fact, an event which calls the individual's conscience to a special challenge, that of defining his or her personal way of resisting illness. The ways of this resistance are elaborated by the subject on the basis of his or her cultural and moral resources, and they in turn contribute to the determination of the style of a certain culture with reference to the ultimate questions of moral life. Medical practice is inscribed in this movement, and it can significantly determine its direction; if, as our culture is presently doing, we deliver to the technological side of medicine all the mission of facing not only the material challenge of illness but also the challenge of its meaning for us as human beings, we implicitly endorse an understanding of illness as devoid of any sense apart from the pure idea of negative: in fact, as a purely technological enterprise, medicine cannot give any other meaning to fatal illness than that of "failure." Thus if medicine is seen as a technical answer to a technical problem, its only

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rule is efficiency; and yet, this path takes us away from any possibility of giving any sense to all the situations in which we cannot heal or cure but only care. The result is that this situation leaves the patient (who is declared incurable or terminal) completely alone. The main reason for the dissatisfaction of many people confronting medical practice lies in the absence of a perceived framework of meaning sustaining and animating the technical operations doctors and nurses perform at the bedside. The language and the gestures of contemporary medicine are not viewed as communicating an understandable sense of the condition of illness, in particular when the latter is chronic, degenerating or incurable. Medicine needs to be connected through a network of meanings to a wider perspective in the moral life, where competent care is a part of the larger effort to face the limits and promises of the human condition. The moral resources designed to give a sense to illness, suffering, and death, together with the practical answer of caring and the activity of the health-care professions, constitute what we might call the ethics of illness: not a set of norms but a framework of sense which is made present in the act of choosing to realize certain goods in the face of the challenge posed by illness. Another side of the problem is the question of enhancing, and this is an aspect we can just mention here. Today we are facing the challenge of finding a reasonably clear sense of what it means practically to promote or enhance health, since we are ever more capable of doing it. We might call this side of the problem the ethics of health, in the sense of a moral reflection concerning the potentialities of contemporary medicine. The bioethical discussion on this issue is still quite underdeveloped and it is strictly connected with the debate on the prospects of human gene therapy. A very general criterion in this area would be the notion of "human nature," if only this concept were not so despised by many contemporary philosophical perspectives. 24 Anyway, such a concept seems like one we cannot do without, as even the critics sometimes admit,25 and we should try at least to suggest some essential traits of human beings in order to have a normative guide. The widespread interpretation of the notion of human nature is that of a fixed reality whose boundaries constitute normative barriers against the attempt to modify the present existential conditions of human life. Needless to say, this is a rather materialistic (and indeed biologistic) understanding of human nature, even if, as it seems, it has been assumed and defended by many religious perspectives in the first place. A more dynamic understanding of human nature is nonetheless implied by those who recognize at least two essential traits of human beings: rationality and freedom. Usually these two

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traits also serve as normative guides, in the sense that, for example, detriment to the rational abilities or of the free will of an individual by means of any medical or technological intervention is considered unethical. Even an enhancing project, if it implies the risk of diminishing the functional ability of man as a rational and free agent, would be considered unacceptable in this perspective. I would add to these traits that of having (or rather being) a recognizably human body: Man is an embodied rationality and a culturally and historically situated freedom, or, in other words, man is a bodily self. For a human individual it is essential to have a body,26 in the sense that the personal characteristics of the body may change, even dramatically, but if I distort the human body or self, I am not enhancing health. Thus enhancing supposes that we consider the interrelation between faculties and powers. The harmony of the human being is an equilibrium which can be redesigned continuously (as we have been doing throughout history and not only in medicine). The problem is that very often we do not know enough to predict the outcome of an intervention in one or the other of the dimensions of human life, since every dimension is so strictly connected with any other that a small change in one part may bring to disruption a delicate balance in another. This warning calls not for inaction, but rather for prudence, that is, for the exercise of discernment in front of any single choice posed by the potentialities of introducing changes in the features of our present condition.

Universita San Raffaele Milan NOTES I For these forms of the philosophy of medicine see H. T. Engelhardt, K. W. Wildes, "Philosophy of Medicine," in W. T. Reich (ed.), Encyclopedia of Bioethics, Macmillan, New York 1995, pp. 1680-1684. 2 Cf. E. D. Pellegrino, D. C. Thomasma, A Philosophical Basis of Medical Practice, Oxford University Press, New York 1981, pp. 196-199. 3 Ibid., pp. 63-64. 4 Ibid., pp. 25. 5 Ibid., pp. 59,61. 6 Ibid., pp. 72, 73. 7 Cf. e.g. Aristotle, Metaphysics, A 98Ia-982a. The basic idea is that a practical science is a formalized (rigorous and objective) cognitive activity with a practical aim. 8 The modern and contemporary idea of science entails not only the idea of true knowledge of the causes, but it is intrinsically related to a specific method (the observational-experimental one)

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designed to obtain rigorous and objective information. The point is that such a method is not always applicable to practical knowledge and even less to practical activity. 9 Cf. e.g. Nicomachean Ethics, I, 1094a; I, 1097a; II, lI04a; V, 1138a; VI, 1138b; VI, 1141a; Vi, 1143b; VI, 1143b; VI, 1145a. 10 Nicomachean Ethics, VI, 1140a (trans. D. Ross). \I Ibidem. \2 Nicomachean Ethics II, 1I04a (trans. D. Ross): "Matters concerned with conduct and questions of wbat is good for us have no fixity, any more than matters of health. The general account being of this nature, the account of particular cases is yet more lacking in exactness; for they do not fall under any art or precept, but the agents themselves must in each case consider what is appropriate to the occasion, as happens also in the art of medicine or of navigation." 13 I tried to suggest some considerations in this direction in "The desire for health and the promises of medicine," Medicine. Health Care and Philosophy 1(1998): 21-30. 14 In a roughly similar way, Pellegrino and Thomasma suggest that health is a "relational good," cfr. For the Patient's Good, Oxford University Press, New York 1988. IS This is also suggested by the characterization of the patient's good offered by Pellegrino and Thomasma in their For the Patient's Good: The comprehensive notion includes the "biomedical good," the "best interest" of the patient, the "personal good," and the "ultimate good." \6 A. Macintyre, After Virtue, 2nd ed., Notre Dame University Press, Notre Dame 1984, p. 187. \7 J. Stout, Ethics after Babel: The Languages of Morals and Their Discontents, Beacon Press, Boston 1988, pp. 266ff. 18 L. Nordenfelt, "On medicine and other species of health enhancement," in L. Nordenfelt, P. Tengland (eds.), The Goals and Limits of Medicine, Almqvist & Wiksell International, Stockholm 1996, pp. 33--49. 19 Ibid., p. 268. 20 The Goals of Medicine, Special supplement, Hastings Center Report 26 (Nov.-Dec. 1996), p. S7. 2\ Cf. A. Macintyre, After Virtue, p. 191; cf. J. Stout, Ethics After Babel, p. 269. 22 J. P. Browder, R. Vance, "Healing," in W. T. Reich (ed.), Encyclopedia of Bioethics, pp. 1032-1038, p. 1034. 23 Cf. R. Mordacci, "Health as an analogical concept," Joumal of Medicine and Philosophy 20(1995):475--497. 24 Cf. e.g. K. Bayertz, GenEthik: Probleme der Technisierung menschlicher Forpjianzung, Rowohlt, Reinbek bei Hamburg 1987; If. ing. GenEthics. Technological Intervention in Human Revolution as a Philosophical Problem, Cambridge University Press, Cambridge (MA) 1994. 2S Cf. J. Harris, Wondenvoman and Superman: The Ethics of Human Biotechnology, Oxford University Press, Oxford 1992. 26 Maybe not this body, but a body recognizable as a human body.

PETER KEMP

SENSE OR NONSENSE OF ILLNESS IN ETHICS OF THE BODY

The aim of this paper is to explain the sense and nonsense of illness in the framework of bioethics understood as an ethics of the body. I.

SENSE AND NONSENSE OF ILLNESS

Let me begin with some definitions of health, illness, and curing. Health must be a well-balanced function of our body and all its parts, in their mutual relationship and in their relationships to the natural and social environment. This body is vulnerable, due to the fragility of the balance between organs and functions, and because of the relationship between the body and its environment, in particular, other people. Therefore health depends not only on organic life, but also on the psychological and social life of an individual and the group to which he or she belongs. Illness can be considered as a disturbance of the corporal and/or mental unity, by which this unity becomes fractured or wounded, and thereby highly vulnerable. This is the reason why people who are ill often feel isolated, needing help and assistance not only for their organic lives but also for their live as people and members of society. Indeed, much illness may have not only physical reasons but also, and perhaps more basically, social reasons, which is particularly true for mental disease. Therefore doctors and nurses often cannot know, by a simple examination of the sick body, to what extent the illness is rooted in social conflicts and discontent which the patient cannot overcome with mere medical help and intervention. In these cases they must know something about the life story of a patient if they are to be able to have some idea of how much they can do to restore the health of the patient. It follows that to cure is to restore the wounded mental and physical unity of life by reintegrating the sick person into his or her social and organic context. But if a particular disease of a particular person is incurable, then the task of the doctor and the nurse is to alleviate pain and suffering, and psychological aid may be needed more than medical drugs and procedures. Even in situations where there is very little to do medically, everyone involved can always accompany the dying person. 133 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 133-146.

© 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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1.

Nonsense oflllness

The question of whether illness makes sense must be considered in the light of these definitions. In all cases where a cure is possible and illness can be defeated, the disease can be experienced as a test or a proof of the will to recover and thereby in general of the will to live and the courage to be. But in cases where illness is fatal and terminal it is not so easy to answer the question: Can illness as disintegration and destruction of the healthy unity of a human being have any meaning? Does it make any sense that my life is going to be annihilated and my world destroyed? If we put the question in such terms, it is clear that there are two kinds of answers which cannot satisfy our questioning. We cannot be satisfied by an empirical and scientific answer. From an empirical point of view, illness simply happens every day for many people, and so it makes as much sense as any other empirical fact. An individual may fight against it, or at least prevent it from worsening. But the illness remains a fact belonging to natural processes in an objective representation of the world. According to this representation the subject itself who asks the above question makes no sense. It has meaning only for the human being as a question about itself. It follows that for this being the empirical answer makes no sense, since the questioning itself of subjective life has no meaning. A speculative answer cannot satisfy this questioning either. It says that illness belongs to a natural order, implying that all that appears and comes to existence must necessarily disappear in one way or another. Thus fatal illness is a totally normal and banal disintegration of the body as a living organism, by which this organism approaches its end and makes room for others. This speculative statement is just as true as the empirical statement about illness. But to the person who is terminally ill, and to all others involved in that person's life, these answers are superficial and external. The very sick person requires not an empirical or speculative answer, but an existential answer. Illness is nonsense, because it threatens all that has a meaning for the sick person: his or her life together with others. It threatens to lock him or her up in an isolation from others. To some human beings this threat is the most dreadful, for instance when the terminally ill person is a mother or father who feels deeply responsible for and towards her or his children. In such cases the illness is a nonsense which ruins the sense of life; it is an unacceptable evil and is inscrutable for the dying person and for everybody who makes an effort to accompany the sick person by suffering together with her or him.

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Sense ofIllness

However, paradoxically, this illness also makes sense. It has a meaning as (1) the threat against which the sick person mobilizes all available power and (2) as the beginning of an end to which he or she, finally, is obliged to consent. But it is not the nonsense that has found a sense. What still has meaning is the fight against death, the struggle for life, the courage to be, the will to live. In this struggle happiness is not excluded. Truly, illness causes suffering, and in our experience of suffering it means the disproportion between what I am able to do and what I want to do. A serious illness reduces a great deal of what I am able to do, but it does not necessarily prevent me from every happiness. Real and true happiness is not the satisfaction of all one's needs but a relationship between persons in mutual giving and receiving where it is not important what and how many things, if any, they can give each other. Thus, even the dying person who cannot give anything other than his or her presence (by a word, a gesture, a look) has the possibility of happiness. So deep suffering cannot hinder happiness. But pain - hard physical ache can do it. Strong pain obliges me to concentrate only on the evil in such a way that I cannot think of anything other than what I can do in order to escape it. This pain can consequently make me very selfish, and this egocentrism can destroy my relationship with others. Therefore, in this situation, the task of the other is to relieve the sick person in his or her struggle against pain. Pain can often be relieved by drugs, acupuncture, and other kinds of treatment, but also by the encouragement of the sick person. And it has to be reduced if communication is to be possible. However, pure suffering often cannot be removed or reduced, yet this removal is not indispensable for feeling happiness. To the sense of illness as adversary also belongs the story of the disease which is a part of the life story of the sick person. Therefore, it is important that the doctors, the nurses, and the relatives take an interest in this story and listen to what the patient tells about crucial events in his or her life. This story, whether it is directly told or not, is essential to the personal integrity of the patient. Integrity should not be imagined as a mysterious mark inculcated once and for all in the human being as part of its nature or substance. The integrity of a person means the untouchability of his or her most inner core. A human being is not untouchable in every sense, but the untouchable is the coherence of its life, its Lebenszusammenhang. This coherence can only be known by the story narrated about the person's life, by telling this story.

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Integrity can truly be hurt or violated by contempt or indifference; the untouchable can be touched by the refusal to recognize it as the identity created by telling the life story. This refusal touches precisely the heart of the human being, whose self-respect is constituted by respect for the coherence of its own life. A disease has a meaning as part of the life story in general, and when it has been discovered by the sick person long before it has been perceived by a doctor or a nurse, the sick person has already interpreted it in this coherence when he or she enters into the clinical encounter. The sick person has consequently had the opportunity to reflect not only on the nature of his or her illness - i.e. what kind of illness it is - but also on its role in his or her conception of life; possibilities of overcoming or of struggling against it; or simply finding an equilibrium between its evil and a good life despite this evil - a solution obtained, for instance, by some cancer patients. The doctor or the nurse does not respect the personal integrity of the patient if he or she does not give the patient some time for listening to the life story to which belongs the illness story. For the patient to say something about his or her own life story expresses the idea he or she forms of personal experiences, and of personal expectations rooted in these experiences. Finally, illness makes personal integrity more vulnerable than it is for a person in good health. As a mental and physical being, a person is always vulnerable. But the poor and the weak are, of course, more vulnerable than the rich and the strong. Therefore, the task of the doctor and the nurse is not only to cure the patient but also to show respect to the sick person and thereby encourage him or her through the suffering. It should not be forgotten that one cannot always cure, but one can always contribute to alleviating and consoling. The suffering may remain; nevertheless, it can be relieved by the recognition of the integrity and the vulnerability of the sick person - exactly what the goal of the struggle against illness can always be. Thus, although illness in itself is meaningless, this nonsense has meaning, nevertheless, as the enemy we have to fight against. The struggle against illness and death belongs to life itself and may even contribute to strengthening the community between mortal human beings who are obliged to fight together. II.

ETHICS OF THE BODYI

The task of the doctor towards the sick person to care for corporal life belongs to the tasks of modem ethics of the body, which prescribes concern

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for the integrity and vulnerability of the body. Such an ethics also has another name: bioethics. Bioethics is more than a biomedical ethics, since it intends to protect not only the human being but also the whole living world against manipulation of biotechnological interventions in the physical and mental life, both in medicine and elsewhere. Modern bioethics is born of the discovery of the necessity to limit biotechnological manipulations of life - bios. And bioethics found "biolaw" at the moment when society recognized that bioethics concerns social life and that it is necessary to claim legal limits to the use and the practice of biotechnologies. This putting the body in the focus of ethics has led to a change of ethics. Today we can speak about the bioethical turn, which means this change in the philosophical debate about ethics. First of all the bioethical turn refers to the change in the fundamental conceptions of the good life. From focusing on the protection of the possibilities for every human being to act and think freely, ethical considerations are increasingly concentrating on the protection of living organisms and their corporeal life from interventions that reduce them to objects for unrestrained manipulation and transformation, not least the interventions of modern biotechnology and biomedicine. This is a turn of ethics towards bioethics, presupposing a narrative vision about the dignity, the integrity, and the vulnerability of corporal life, and for these reasons claiming limits to the biotechnological and biomedical interventions in living beings. Secondly, and as a consequence of the turn of ethics towards bioethics, the bioethical turn implies a revolution of the relationship between ethics and law. During most of the 20th century leading legal philosophers have made a sharp distinction between ethics and law. This distinction has been linked to a long historical development in which ethics was reduced to concern for care and mercy in close relationships, whereas law was considered as a demand for maintaining a social order which was created by a powerful ruler who forced others to accept his order, or which was instituted for domination by rulers who entered into a contract ensuring mutual protection of everybody against everybody. In its most democratic form, this order was developed as a regulation of free actions so that everybody could be as free as possible without preventing others from being free. Thus the law became a system of protection of all against all. In this system ideas of caring for, and paying regard to, the most vulnerable individuals were not indispensable, since law could be considered the result of the instinct of self-preservation protecting the egoism of everybody against the egoism of everybody else. In this way the development of society as a bureaucratic machine of suppression became possible: Law

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became an instrument of necessary political domination which could not be held responsible by any ethical authority, and ethics was displaced to the private sphere.

1.

Protection of Corporal Life

Today, this separation of ethics and law according to which ethics is a private thing and law a political technology is challenged by the demands of legal regulations which arise from bioethics. These demands concern not only the adaptation of the freedom of each person to the freedom of all other persons, but also the protection of the living body, which should not only imply the corporeal life of autonomous individuals but also the life which is not yet, or not any more governed by a free reason comprehending the life of fetuses, children, senile and insane persons, and others. This recognition of the right of the most vulnerable and defenseless people to be taken care of - and to be concerned about their corporeality - inevitably brings up the question: Should there not be legal regulations which put limits to the human manipulations of the lives of animals? At the time when ethics was only concerned about the consideration for personal life in human community, and law was only aiming at protecting the autonomous individuals against each other, the question of an ethics of care concerning animals could not really be formulated. At present, however, we must not only include animals in ethical care and legal protection, but we must also go further and speak about a law which corresponds to an ethics for nature as a whole with which, by which, and in which we are living.

2.

Biolaw Presupposes Bioethics

At the time when ethics was merely understood as an ethics for the relationship between persons, and law was conceived as totally independent of ethics and only determined by the need for order in society, legislation could be considered only as an expression of power relationships. The legal power according to this view was given no other task than to maintain the domination reflected in the laws. For example, these laws fix the limits for interventions in the freedom of citizens and determine when they impose different virtues on citizens. But once ethics is extended to deal with the consideration of all living beings - from the human body to the whole living nature - and once there is legislation and/or legal practice which will decide limits for interventions in living beings, then law is no longer merely a super-

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structure to the given social establishment, but it is an expression of the consideration and the respect which people have for corporeality and nature in general. We can call this new tum of bioethics toward law a turn from bioethics to biolaw. Probably the term "biolaw" - as the term "bioethics" - is an American invention for the complexity of court decisions and/or legal rules concerning bioethical questions. But a few years ago some French lawyers began to use the corresponding French word "biodroit" to express the legal philosophical idea of social reactions to modern biological and biotechnological challenges to the legal system, the aim of which is to protect fundamental civil rights. Some of these lawyers were going so far that they saw biolaw as a legislative alternative to what they considered a more occasional regulation of medical science and biotechnologies recommended by ethical committees. Indeed, in the French debate about ethics, one does not speak very much about "bioethique," but prefers to speak about "ethique biomedicale" (biomedical ethics) as something which is expressed in biolaw and concretely in the three big biolegal laws adopted in the last reading by the Senate and the Parliament in 1994. I see no reason for adopting this disparity between bioethics and biolaw. On the contrary, we have to consider bioethics as a presupposition for biolaw. This biolaw has shown its necessity as a social regulation in trying to fix legal frames and valid law for the solution of conflicts provoked by bioethical cases and questions. 3.

The Fields of Biolaw

These questions come up in all fields where human beings are affected by medical science and medical technology. They apply to ethics on different levels, first of all, as professional ethics of the physician and the whole medical staff, i.e. the classical medical ethics for good medical practice. Moreover, they apply to the ethics which concerns the respect for the rights of the patient in the clinical encounter with the whole medical scientific team (physician, nurse, psychologist, social worker, chaplain, and perhaps others); they also apply to the ethics of research, which directly or indirectly involves human beings in experiments. And finally, they apply to the ethics concerning the limits to people's use of, or admittance to, modem biotechnology and biochemistry, whether they are ill or not - for example, in order to obtain an induced abortion, to receive treatment for infertility, to commit assisted suicide, or to obtain a cure of rejuvenation.

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In all these fields, conflicts will arise as to what is permitted and what is not. This also applies to all kinds of biotechnological interventions in the lives of animals and plants, i.e. in people's relations to the environment and to the biosphere in general. Here bioethics becomes an ethics of environment and an ethics of nature, which implies a biolaw as an environmental law, including legal regulations for the environment and for nature in general. But how can legal authorities make their judgments in order to solve bioethical conflicts? The answer is simple: They can refer to ideas about what is important for the realization of the good life of human beings as well as for all living beings.

4.

The History ofthe Body

Looking back on the European history of the concept of body since Plato and Aristotle, we can see that already the Greece of Antiquity was living in tension between two radically different ideas of the body: the Orphic-Platonic view according to which the body is the prison and the grave of the soul, and the Aristotelian view according to which the soul is the form and the end of the body. The Christian concept of the body had been characterized by the same tension since Paulus: The body was at the same time the temple of God and the flesh which causes the ruin of man. Later the Platonic accent can be found in Augustine, whereas the Aristotelian conception becomes fundamental for the idea of the body in Thomas Aquinas. The emergence of modern natural science, however, involves a revolution of the view of the body which first becomes an object of knowledge when one ventures to dissect dead bodies, and later even more so when one exposes the living body to experiments. This was the condition of a medical science much more effective than in earlier times. Yet the instrumental conception of the body was counterbalanced by philosophical considerations of Kant and later by the sensibility, taste, sympathy, and imaginative judgment of Romanticism. To Kant these considerations brought the idea of the ethical and aesthetic "common sense" by which we, as reasonable beings, reached our universal thinking and, as he said it, "put ourselves in thought in the place of everyone else." Despite this thinking, the technical conception of body and nature remained dominant, and after the Renaissance replaced the ancient search for some kind of harmony between man and cosmos. This has created the background for questions linked to the application of modern biotechnology and biomedicine and thereby created the need for bioethics and biolaw.

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Bioethics as Ethics ofthe Body

In our century the bioethical questions have been crucial when we consider race discrimination and its terrible consequence in the Nazis' contempt for the dignity of human beings. This was the result of the ideas of domination linked to a pure technical view of body and nature. To oppose this view there is a need for an ethics of the body which is built on the phenomenological concept of the body in our century (Edmund Husser!, Maurice Mer!eau-Ponty and others) which considers the origin of the human being in connection with the development of the whole living nature, but at the same time also insists on Kant's idea of the infinite value of the human being as an end in itself. This ethics of the body must be based on the vision of the good life which is characterized by ideas of dignity, integrity, and vulnerability, and which expresses our experience of what according to Kant - has no equivalent, i.e. what is irreplaceable. Then the condition is given for the clarification of concrete bioethical problems, especially concerning organ transplantations, genetic engineering, test-tube reproduction, experiments applied to the human being, euthanasia etc., and - in a broader perspective - experimentation on animals and interventions in living nature, i.e. in the lives of species and in the whole ecological cycle.

6.

Ethics of the Body as the Foundation for Biolaw

The ethics of the body also gives conditions for a biolaw which tries to include the idea of the irreplaceability of the living being in law-making, in the elaboration of legal argumentation, in the development of legal practice in court, and in their administration. The treatment - and the comprehension - of life, which transforms the living being into an object for interventions, makes possible the better life as well as the destruction of life. It permits a better life to the extent that it is the condition for hygiene and medical science. However, the objectification of life becomes destructive when one forgets the living and experienced body, which is known from inside by every conscious human being and thus reduces the corporeal life to a mere object for manipulation. A whole group of philosophers in the 20th century, not least phenomenologists such as Maurice Mer!eau-Ponty, Paul Ricreur, Michel Henry, and Emmanuel Levinas, have opposed this objectification and have tried to develop another understanding of the human being as participating in living nature. This effort has

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intensified the insight of the importance of the living and experienced body for personal identity, existence, and political community. And it has entailed a new idea of political reasoning, which is seen not only as an application of rational or technical principles, but also as an exercise of powerful judgment in relation to conceptions, evaluations, and standpoints which have their roots in corporeality and sensuality. The phenomenological concept of person, which combines corporal identity and vulnerability with existential integrity and dignity, must be the pivot both of a bioethics that reflects on the foundation of responsible decisions, and of a biolaw that expresses the social regulations of biotechnological and biochemical interventions in living beings. This ethics, moreover, must build on the faculty of the judgment that evaluates - in a hermeneutical circle - the ethical principles and relates them to concrete cases.

7.

Justice and Law

The turn of ethics towards bioethics throws new light on the general relationship between ethics and law. Since ethics can no more be limited to the relationship between persons but concerns all life, and since laws and rules protect the body, its genes, and in a certain sense the whole living world, the law must presuppose respect for body and nature. Biolaw becomes the occasion for abandoning the rationalistic prejudice which says that ethics and law have nothing to do with each other and that justice is a meaningless word. Talk of justice becomes full of meaning again, as does talk of the idea that expresses the good life on the level of society and links law to ethics. It follows that the idea of justice implying right actions, equality before the law, and equal access to the most important goods, as well as their fair distribution, is reintegrated in the understanding of the foundation of law. In this perspective, the practice of justice must not only be conceived as practice of "valid law," but must also be seen as care for the good life. However, law is not only determined by ethics or by a vision of a just society. Philosophy of law both in its "positivistic" and in its "realistic" version is right in claiming that the demand for a social order, which makes the condition for the settlement of conflicts of interest, is also decisive for the establishment of law. But if one considers politics as a pure dog-fight and thinks that power interests are the only motives for legislation and for legal practice, it becomes meaningless to express the claim of a legislation saying that limits to interventions in bodies and in all living beings must be maintained in order to respect integrity and irreplaceability. Therefore, in the

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age of bioethics we must recognize that law can be determined neither by pure ethics nor by pure politics of interests, but must exist in the field of tension between ethics and political power where dignity, integrity, and vulnerability can be respected. 8.

Legal Protection of the Body

Thus, the biolaw we see emerging on the basis of bioethics, in several countries, especially in Northern Europe and in the United States, expresses demands for protection of the body and corporeal life in biotechnology and medical technology. The most clear example of that is the passing of the three biolegal laws in France in 1994. These laws were established 10 years after the creation in that country of the National Ethics Council, the first of its kind in the world. The French laws in particular are remarkable, because they do not only proclaim the inviolability of the body (which among other things means a demand for the subject's informed consent to an intervention in his or her body), but also presuppose the body's "indisposability," i.e. that it is not at the disposal of the individual, which means that the body, its function and organs must not - even when its own body is at stake - be treated as an object of manipulation and, for instance, bought and sold. It does not follow, however, that biolaw should necessarily develop into a detailed legal complex like the French bioethical laws. Even in a common law system like that of the United States or Great Britain, biolegal decisions by courts or by administration authorities may be rooted in similar ideas of respect for the dignity, integrity, and vulnerability of the body. The validity of biolaw is, therefore, only dependent on whether or not it has its roots in bioethics, i.e. whether bioethics becomes decisive of what lawyers call "source of law." It does not depend on a hierarchical law system. 9.

Ethics as Source of Law

In the 20th century some movements in the philosophy of law - not least in legal positivism (Kelsen) and legal realism (Ross) - have tried to ignore ethics as a source of law. Hans Kelsen, who wanted to elaborate a pure theory of law, did not like the concept of "source of law." The basis of law according to him could only be the very fundamental (preconstitutional) law, saying that there must be a legal order in society. By using the term "source of law," however, one is easily brought to think of nonlegal sources of law as, for instance, moral and political principles. And since he considered such sources

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as unacceptable and definitely unthinkable, he refused to use the tenn "source of law" in his original "pure theory of law." Alf Ross was more "realistic" and admitted that one could speak about "sources of law" in order to explain "the ideology of the judge," in which the judge is influenced by an aggregate of factors in formulating the role on which he or she bases the decision. He designated himself as a legal realist and recognized that cultural factors, for instance ethical ideas, belonged to the "ideology of the judge" and influence his or her legal decisions. To a legal sociologist it is, therefore, meaningful to speak about ethics as a source of law. Nevertheless, he considered such a source of law as inferior to those sources of law which are constituted by legally authorized fonnulations (for example, in legislation) and by legal precedent. Moreover, he firmly rejected traditional ideas about justice as valid sources of law. To him justice had meaning only as the concept of the correct application of a general rule. He could not understand what he was to do with the idea of justice as the idea of the good life in society. Still, today we see that the person who applies the law (the judge, the administrator, etc.) must necessarily presuppose such an idea of justice when he or she resorts to bioethical ideas of the good life in order to make a fair decision in cases concerning limits to interventions on living beings. Here, for instance, the judge, the administrator in the state or in the community, cannot be satisfied with a narrow idea of justice as the correct application of the law. He or she also needs narrative ideas about what makes the application correct, i.e. ideas about the view of man, society, and nature by which one wants to detennine the social life. These should be ideas which are not only rooted in local and national traditions, but also in mankind's cruel and terrible experiences of violations of the dignity and integrity of vulnerable human beings. It follows that ethics must be the most important source of law to modem biolaw, i.e. ethics must be the most essential driving force of biolaw. 10.

Law Shapes Ethics

However, we shall not forget that it is not only ethics which determines biolaw. The influence also goes in the opposite direction. This is possible because law is not identical with ethics; the aim of law is more modest than the goal of ethics. Ethics intends to realize the good life entirely. Law is content with realizing social integration. Thus legal decisions and legislation may be more guided by the claim for social peace obtained by compromises than by the desire for justice. Legal

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decisions can be too mild or too hard for some of the implied parties, and laws enacted by parliament can even be clearly unjust to some of the persons concerned, without being legally invalid. These kinds of decisions may also occur in the field of biolaw. Therefore, bio1aw constitutes an autonomous narrative sphere. And legal decisions made out of pure pragmatical considerations - only in order to obtain peace or to introduce a compromise which to some extent satisfies all parties - exert influence on people's conception of what the good life is. For instance, the opinion in the United States was influenced by the verdict in New Jersey High Court in 1976 which permitted the parents of the unconscious Karen Quinlan to decide to stop the life-support system. Opinions were divided, but the court took a decision concerning what ethics should be in this case. Also the court's reference to abstract declarations of human rights as grounds for legal decisions, such as the Court of Human Rights in Strasbourg, can be a "legal shaping of ethics." And if the High Court in countries where it has the authority to do so, or a Constitutional Council, refers to the Constitution as a ground for criticism of a law passed in Parliament or as a limiting interpretation of it, then this will be a legal decision which will affect our ideas about both politics and ethics. Finally, legal decisions and legislation in the field of bioethics are not without importance for what is considered as good. The decisions of the legislative power in cases which Ronald Dworkin calls "hard cases," i.e. those concerning abortion, euthanasia (implying the question of the criteria of death), test-tube children etc., as well as in more "soft cases" such as that of "substitute mothers," have merely changed something in the ethical mind of many people. The same can be said about the legal decisions concerning these questions in many countries where legislation plays a more minor role in the legal order than does administrative and legal practice.

11.

Ethics Evaluates Law

That does not mean, however, that law has the final word. Laws can be considered as obsolete or erroneous. And by referring to ethics (called "the nature of the case" or "the reason") the court may realize that the time has come to break with former legal practice, just as legislation and administration can change law and rules in accordance with a deeper ethical insight. For instance, this might happen in many countries according to the rule of obligatory anonymity for donors in the field of human procreation when the "test tube children" have grown up and it is no longer only the voices of the

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social parents that are heard in the debate, but also these childrens' accusations against society for having had no courage to let the children - at least at a certain age - have the right to know the truth about their biological roots. After all, it is not law which judges ethics, but ethics which evaluates law. Thus the biolaw of our time and the legal politics it depends upon cannot do without a deep concern for bioethical questions. Bioethics leads to biolaw, but biolaw can never rise to a higher position than bioethics and work completely on its own terms. The right can never really be detached from the good. And in the long run law cannot keep its validity if it condemns or prevents the good life. Centre for Ethics and Law Copenhagen NOTE 1 This text is mostly an English revised version of the final chapter of the Danish book by Peter Kemp, Mette Lebech, and Jacob Rendtorff: Den bioetiske vending (The Bioethical Turn), Spektrum, Copenhagen, 1997.

REFERENCES Emmanuel Kant, Critique of Judgment, translated by J. H. Bernard, Hafner PresslMacmillan Publishing Co., New YorkILondon, 1951, 40. Hans Kelsen, Pure Theory of Law, translated from Reine Rechtlehre, second edition 1960, Peter Smith, Gloucester, Mass., and University of California Press, Berkeley and Los Angeles, 1967/1989,p.233. Alf Ross, On Law and Justice (1953), University of California Press, Berkeley and Los Angeles, 1974, p. 77.

ROSANGELA BARCARO

THE LOSS OF THE SENSE OF ILLNESS: EUTHANASIA AND THE RIGHT TO DIE

The interpretation and sense of illness are strictly related to our cultural development, historical situation, and beliefs. Scientific discoveries and medical progress over the centuries have led to changes in the concept of illness, changes that affected the interpretation people gave (and give) to illness. It is possible to understand illness in two different, complementary ways: illness as a consequence of an alteration of physical or psychological parameters, a discrepancy from a given standard of numerical values which is set as the equivalent of health; and illness as a judgment expressed by an individual human being on his physical, psychological and emotional conditions. Medicine and psychoanalysis now understand many causes of such alteration and judgment, but the sphere of moral meaning is far from a materialistic comprehension of the phenomenon called illness. A spiritual approach to illness and suffering exists. In some cases this approach accompanies the understanding of pathological situations and is typical of religious beliefs, as often happens in Christianity. From a Christian point of view, illness and suffering have a common source: They originate from original sin and are consequences of the fall of Adam and Eve. I Physical pain is not as bad as moral pain. Physical pain in itself is not endowed with meaning; it is merely "shameful." Its meaning comes from our hope to gain eternal life beyond our human existence. In this way pain and suffering prepare people (who endure their suffering) for the salvation they seek from God and for the salvation awaiting them. The interpretation of illness, pain, and suffering has continued to change throughout the centuries. In our contemporary understanding of human life, illness and suffering are often thought of as a temporary accident that can be overcome by applying the right techniques or means. The suffering human being loses importance in the face of the technocratic power of physicians. Illness and suffering are often considered little more than a technological and scientific challenge. The consequences of the secularization of culture experienced nowadays are affecting the way of understanding the human being, the human person. According to a widespread point of view, a genuine person is endowed with 147 A.-T. Tymieniecka and E. Agazzi (eds), Analeeta Husserliana LXXII, 147-152. © 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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specific functions (conscience, rationality, physical capability and so on) and the loss or reduction of some function implies a reduction in the value of an individual as a person. Pain and illness might impose a very wide spectrum of limitations on a person. They are obstacles to the development and existence of people, and the individual feels the need to use every means to avoid, control, and remove them, even if the final solution would be voluntary death - suicide or euthanasia. THE EUTHANASIA DEBATE

The bioethical and biomedical debate on the practice of euthanasia and assisted suicide arose in the 1970s in controversial clinical situations. The most widely discussed cases involved bedridden hospital patients, who were unconscious and without any hope of recovery, living in a persistent vegetative state and being medically treated to inhibit a progressive dying process. Their living conditions gave rise to questions about the sense of continuing bodily life when biographical (conscious) life has ceased. Many courts (sometimes even the U.S. Supreme Court and the House of Lords in Great Britain) were asked to intervene to settle disagreements which had arisen between hospitals, patients, and/or their families; these disputes centered on the topic of foregoing life-sustaining treatments, such as artificial nutrition and hydration or pulmonary ventilation, in order to let these subjects die naturally. The intervention of judicial power gradually overshadowed moral and philosophical debate, and legal matters began to prevail. The legal discussion has focused, in particular, on statements drawn from particular decisions, such as those from the milestone Quinlan and Cruzan cases in the U.S.A. In these judicial rulings, involving patients in a persistent vegetative state who were artificially fed and ventilated, the U.S. Supreme Court expressed a positive opinion on abating life-sustaining treatments in order to let these patients die naturally. The public at large and supporters of voluntary euthanasia and assisted suicide saw the U.S. Supreme Court verdicts as an acknowledgement of an individual "right to die." Where the Supreme Court spoke of the right to die a natural death, pro-euthanasia movements saw a right for every human being, sound of mind, to ask for a lethal injection to end his/her life. This has led to a heated public debate. Despite the emphasis on juridical aspects, the philosophical spectrum of the bioethical debate on this subject is very wide and is growing fast. Where there are no moral objections against

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removing pain and suffering (by almost any means possible) because they are pointless, the situation of a terminally ill patient asking for a hastened death process or for a sudden and medically induced death provokes considerable philosophical discussion. The core of the argument in favor of euthanasia and assisted suicide is the concept of death with dignity. In many cases, terminally ill patients die alone in hospital, in pain and suffering. For these patients there is no hope of recovery; palliative therapy has not been applied or has failed; and their pain is untreatable. In the face of this situation, patient movements and associations are asking for timely, dignified, and humane death brought about with medical assistance. This is the so-called right to die. A FEW NOTES ON THE "RIGHT TO DIE"

The actual meaning of the expression "right to die" is very ambiguous. There is no universal consensus as to its meaning. The strength of the debate on this topic may well be a direct result of scholars' failure to provide a single, clear interpretation of the very sense of this term. There are basically two ways of understanding such a right: a moral understanding and another that emphasises the legal meaning of the expression. In the former case, people are entitled to do or have something on moral grounds without any legal enforcement. In the latter case, having a right simply means that someone has a right to do or have something by law. L. R. Kass's article, "Is There a Right to Die?" is very helpful in distinguishing these hidden meanings and clearing up confusion. Kass analyzes four meanings for the debated expression: 1) the right to refuse medical treatment and hospitalization; 2) the right to assisted suicide; 3) the right to die with dignity; 4) the right to choose the time and manner of one's death. The author pays particular attention to the right to refuse medical treatment and the right to receive medical assistance in dying. Kass criticizes the use of the principle of autonomy, created by scholars who attempt to establish it as the basis for a legal right to die (and to be killed). He states that: 1) the right to die cannot be established on the basis of the principle of autonomy, because that would impose an obligation on someone else and thereby restrict hislher autonomy; 2) the patient's autonomy cannot be the grounds for someone else's right to kill and the patient's own right to be killed; 3) "a right to an assisted death (a right against interference) can at most approve assisted suicide and euthanasia for the mentally competent and alert" (Kass, 39); 4) "if autonomy and dignity lie in the free exercise of will

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and choice, it is at least paradoxical to say that our autonomy licenses an act that puts our autonomy permanently out of business." At the end of his paper, Kass analyzes excerpts from the Cruzan ruling. "Right to die" movements, in this author's opinion, misunderstood what the judges established about the possible existence of a right to die. The judges - unanimously - stated that only a right to refuse medical treatment exists, on the basis of the 14th Amendment. Moreover, they spoke about a "liberty interest" for Nancy Cruzan, a patient in persistent vegetative state, because they found that - in those conditions - dying by withdrawing artificial nutrition and hydration was in Nancy's interest, since she could never have recovered. It is clear that there is no agreement and a lot of confusion and misunderstanding about the meaning of the expression "right to die" among proeuthanasia movements and scholars themselves. The bias fluctuates between its interpretation as a right to refuse unwanted medical treatment, or as a right to obtain active assistance to die. Some justices of the U.S. Supreme Court argued that a right to die by hastening death exists, because it is impossible to distinguish clearly between withdrawing medical treatment and physicianassisted suicide. Some others distinguish between these two different rights. In general, it is a fairly common position that a law which guarantees a right to be killed cannot exist, and that should it exist, a traditional, constitutional analysis would forbid killing. Actually, in many circumstances the interests of the State are stronger than those of the individual and conflict with a right to die, since protecting social minorities (dying people, the elderly, and so forth) is a State interest. CONCLUSION

Statements which identify assisted suicide with the withdrawal of medical treatment are wrong, because these are two clearly distinct acts. Assisted suicide is performed through explicit suggestion and medical prescription in order to bring about the death of a competent patient; the withdrawal of a therapy is the result of a clinical evaluation of a patient's conditions and possibility of recovery. If a patient is in a persistent vegetative state and receives artificial nutrition and hydration, and there is no hope of recovery, withdrawing medical treatment is not assisting the patient to die but discontinuing a useless medical procedure. The final verdict on the whole matter is very confused, but it is interesting to note that while philosophers and courts are debating the existence and foundation of a right to die, in the Netherlands voluntary active euthanasia

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was decriminalized in 1993. A physician can help hislher patient die as long as some clinical conditions are met - a hopeless pathological situation, persistent and untreatable pain and suffering, and the patient's request to die. Since 1991 many attempts have been made to regulate physician-assisted suicide (the Washington, California, and Oregon referenda, for example). In November 1997 a new referendum in Oregon gave rise to the Death With Dignity Act: A terminally ill, adult patient may ask for a medical prescription of deadly drugs, in order to bring about death; medical support is strictly limited to prescribing drugs and any active aid is forbidden by law. The right to die debate is largely grounded on misunderstandings; the idea that active voluntary euthanasia and physician-assisted suicide are warranties protecting human dignity is wrong. Patients, particularly terminally ill ones, are fragile and might be manipulated by families or physicians; in many cases they do not understand their clinical conditions or the therapies they are undergoing. They ask for death because they are alone, in pain, or depressed. What they are looking for is help and assistance, not necessarily an end to their lives. Many studies by scholars engaged in hospice activities have shown that a dignified death is a consequence of appropriate medical and palliative treatment, psychological counselling for patients and their families, and global care of the suffering human being when treatment is no longer possible. Euthanasia and physician-assisted suicide are the easy way to death, not the right way to cope with a humane death. Many scholars see establishing a legal right to die as a correct approach to end-of-life issues. In their view, it is sufficient to modify laws against murder and to establish safeguards for patients and dying people against the influences of family and physicians. They forget other legal and sociological aspects: first of all, the consequence of assigning a negative role to the State by establishing a right to protect private interests in killing someone, a role which might restrict the individual liberty of people who refuse mercy killing. In this way, the controversial role of physicians in bringing about their patients' death arises. At the moment there is no clear prospect of a generally accepted approach on the matter, either from a philosophical or a juridical point of view. The debate is open. C.N.R.

Centro Studi Filosofia Contemporanea Genova, Italy

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In the volume in which this essay appears, an analysis of the meaning of suffering is developed in the paper by H. Barreau, The Meaning ofSuffering in Buddhism and Christianity.

REFERENCES R. Barcaro, 1996. "A proposito del diritto di morire." Bioetica, 4: 499-510. P. Becchi, 1995. "La volonta del malato e la deontologia del medico: due punti di vista in conflitto sull'eutanasia." Bioetica, 3: 85-92. R. J. Blendon, U. S. Szalay, R. A. Knox, 1992. "Should Physicians Aid Their Patients in Dying? The Public Perspective." Journal ofAmerican Medical Association, 267: 2658-2662. D. W. Brock, 1992. "Voluntary Active Euthanasia." Hastings Center Report, 22: 10-22. F. D' Agostino, 1993. "Bioetica e diritto." Medicina e Morale, 4: 675-690. T. R. Fried et al., 1993. "Limits of Patients' Autonomy: Physician Attitudes and Practices Regarding Life-sustaining Treatment and Euthanasia." Archives of Internal Medicine, 153: 722-728. E. G. Jones, 1995. "Hospice and Palliative Care;" in F. A. Huser (ed.), Palliative Care and Euthanasia, Edinburgh, Campion Press: 10-16. y. Kamisar, 1993. "Are Laws against Assisted Suicide Unconstitutional?" Hastings Center Report, 23(3): 32-41. L. R. Kass, 1993. "Is There a Right to Die?" Hastings Center Report, 23(1): 34-43. F. G. Miller et ai, 1994. "Regulating Physician-Assisted Death." The New England Journal of Medicine, 331: 119-123. F. G. Miller, J. C. Fletcher, 1993. "The Case for Legalized Euthanasia." Perspectives in Biology and Medicine, 36: 159-176. W. Pannenberg, 1998. "II significato cristiano del dolore." KOS. Rivista di medicina, cultura e scienze umane, 152: 42-45 T. E. Quill et al., 1992. "Proposed Clinical Criteria for Physician-assisted Suicide." The New England Journal ofMedicine, 327: 1380-1384. R. S. Shapiro et aI., 1994. "Willingness to Perform Euthanasia: A Survey of Physician Attitude." Archives of Internal Medicine, 154:575-584. J. D. Velleman, 1992. "Against the Right to Die." The Journal of Medicine and Philosophy, 17: 665-681. S. M. Wolf, 1995. "Constitutional Controversy Over Physician-assisted Suicide and Euthanasia." Newsletter by The Center for Biomedical Ethics, University of Minnesota.

JEAN LADRIERE

IS IT POSSIBLE TO GIVE SENSE TO ILLNESS?

The lectures which have already been presented have analysed from different points of view - medical, psychosocial, phenomenological, existential - the concept of illness, and some of them have examined in a precise way certain particularly important categories of illness. The question which we must now take into consideration is the question of the sense of illness. More precisely, we have to question its sense from the point of view of its possibility. This suggests immediately a progression in three steps: a) What does it mean "to give a sense?" b) What can we think about the possibility of giving a sense to illness? c) What sense could be actually given to illness? 1.

TO GIVE A SENSE

The expression "to give a sense" can be used in a neutral way, without particular precision about the modality of the sense which is at stake. We shall then simply have to examine what sense is, as opposed to nonsense. But we can take into consideration, in a more precise way, not sense in general, but a sense which could be considered as endowed with positivity, as opposed to a sense which, on the contrary, would be qualified negatively. Or again, we could take into consideration a sense endowed with a constructive force, as opposed to a sense charged with a destructive potential. Let us first examine sense simply as opposed to nonsense. It will be useful in order to undertake that examination to begin with the case of language, which is exemplary. Any sequence of terms, borrowed from a given language, does not constitute a meaningful sentence. One of the tasks of the analysis of language is to determine what the conditions are which must be met by a sequence of terms in order to constitute a meaningful sentence. Some of those conditions are of a syntactic order, others are of a semantic order, and still others of a pragmatic order. In order to be susceptible to carrying a meaning, a sequence of terms must constitute, as it is said, a well-formed sentence. "The sea inevitably" is not a well-formed sentence: that sequence of terms lacks a predicative term, in such a way that it provides only a germ of meaning, not a complete meaning. "Caesar is a prime number" is a wellformed sentence, but devoid of meaning, because it violates a semantic 153 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 153-179.

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condition which imposes a predicate to be applicable only to a term of the same semantic category. And finally, the famous example of Austin, "The cat is on the mat but I don't believe it," is a semantically normal sentence but is devoid of meaning because it contains a pragmatic contradiction: the second part of that sentence denies the belief which is implied by the assertion of the first part of the sentence. But given that the conditions of meaning are fulfilled, we have to examine how the meaning of a sentence is actually formed. According to a purely analytic conception of semantics, the meaning of a sentence is quite simply the result of combining the meanings of the terms which compose it, those meanings being supposed to be well fixed, independently of the sentence contexts in which they can occur. But actually a lexical term, nominative or predicative, acquires its meaning in and by the contexts, purely linguistic or practical, in which it is used. Thus a predicate which expresses a property called "ostensive," as the color predicates, acquires its meaning, initially, by the displaying of objects possessing the property concerned. In the case of the more abstract predicates, the meaning is constructed by the mechanism of the interanimation of sentences, as Quine explains. If, in a sentence like "X is red," supposedly already understood, X is replaced by Y, the new sentence will be understood according to the model of the first one. In general, we could say that the initial meaning of a predicate is given by an application field. But that field is always susceptible to being extended. Moreover, the initial meaning can be enriched by setting up relations between the predicate in question and other predicates in appropriate sentences. In the same way, the initial meaning of a nominal term is given by the displaying of its correlate or by characterizing properties, again in the context of appropriate sentences. And that meaning can be enriched by taking into consideration supplementary properties. Wittgenstein had expressed that dependence with respect to the context by saying, in the Tractatus: "Only the proposition has a meaning; and it is only in the context of a proposition that a noun has a meaning."l That can be generalized for every kind of term. But as a given term can occur in ever new propositions and as every term can thus be connected to other terms, without a priori limitation, thanks to those propositional contexts in which it can occur, the terms of a language constitute networks which are always susceptible to being more and more extended. And we are thus directly led from the propositional holism of Wittgenstein to the general semantic holism of Quine, according to which the meaning of an expression, term or proposition, derives from the whole of the language. But a language, in the measure in

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which it is effectively used, is a living reality, and as soon as new propositional contexts appear, the meanings of the terms are modified and new semantic possibilities appear. To be sure, it is possible to associate a meaning with a term, considered in a state of isolation, as is the case in dictionaries. But this amounts then only to retaining a kind of semantic schema, which is like a diagrammatic summary in which, in principle, all the uses which have been made of the given term in a given epoch are recapitulated. And a dictionary often gives examples of use by means of typical sentences, in order to explain the meaning of a term. But there we have to do with a meaning which is just very partially fixed. It is rather a kind of semantic function, which expresses a meaning potentiality rather than an already determined meaning. When a given term is used in a new sentence, the meaning potential which is associated with it interacts with the potentials of the other terms of the sentence, and the meaning of that sentence emerges from such interaction. Thanks to that emergence, the meaning potentials become determined meanings. And when a term is extracted from the sentence in which it occurred, the meaning which it had received there is added to its meaning potential, making it thus available with that supplementary semantic charge for further uses. But the contexts are not only of a linguistic nature; in the real use of a language, they are situations of interlocution in which many elements other than linguistic data intervene. Pragmatics has precisely introduced in the analysis of language the dimension of contexts in a generalized sense, by leaning upon the devices which language itself provides the speakers in order to anchor, so to speak, their discourses in the practical contexts in which they interact with each other. Those devices are the index terms, or clutch terms according to the terminology of Jakobson - such as the pronouns and the adverbs of time and place which enable the speaker to situate himself with respect to his interlocutors and to their surroundings; and the verbs which express the speech acts by which the speaker specifies why he utters such and such a sentence. The general form of an utterance is of the type "F p," where F represents a speech act of a certain kind and where p is a descriptive proposition. The action of the operator F on the proposition determines the modality according to which, in the proposition, the predicate is attributed to the subject. A proposition such as "The sea is blue" does not have exactly the same scope when it is formulated under the modality of a categorical assertion as when it is formulated under the modality of a conjecture. Thus the proposition, considered in isolation, presents a meaning potential rather

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than a fully determined meaning. And when it is taken under the action of a pragmatic operator of the type "I believe that," "I wonder if," "I warn you about," and so on, its potential is transformed into a completely determined meaning. As Wittgenstein says, "The proposition shows its meaning,"2 it does not describe it from outside. It displays a certain articulation between the terms which it is made of. Thus a descriptive proposition such as "S is P" shows, by its structure, the belonging of the object designated by S to the applicability field of the predicate P. It shows that belonging. But in the effective use of a language, it shows it to concrete speakers. And what each speaker understands effectively depends upon the way he understands the terms. But if he understands them, it is thanks to the familiarity he has acquired with language. What a term means for him is the sum of all the circumstances in which he has encountered or used that term. Even an elementary predicate as a color predicate does not have exactly the same meaning for every speaker. And for a given speaker the meaning of a term varies from one occurrence to another one, even if only very slightly and if he can recognise among all those occurrences sufficient analogies to perceive the meaning in question as relatively stable. The fully concrete meaning which is attached to a term for a given speaker thus depends upon all his personal history. The pragmatic point of view necessarily introduces into the functioning of language, the dimension of individual historicity, which opens for every user of a language a proper perspective on that language. The meaning of an expression does not scatter however, for all that, into a multitude of singular meanings. The devices of language ensure the possibility of exchange and of mutual understanding, to the extent, precisely, to which they present the meanings in an objective form, recognizable by all the users of the spoken language. What is thus presented by means of the acoustic or graphic signs which communicate a sentence, supposedly meaningful, is not a rigid meaning, absolutely identical for all the speakers, but a scheme of articulation on the basis of which every speaker can elaborate the fully concrete and determined meaning which that sentence will have for him. We could thus distinguish two modalities of meaning: the objective, non-contextualized meaning, which constitutes the invariant core, recognizable (in principle) by all the users, and the pragmatic, completely contextualized meaning, which constitutes the interpretation, proper to each speaker, of the objective meaning. The relation between those two modalities of meaning can be described according to the model of the relation between a function and its values: the objective meaning is a functional scheme

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which, when applied to a determined context, becomes the pragmatic meaning of the given expression for the one who is situated in that context. But how does a concrete speaker recognize thus the pragmatic meaning, from the point of view which he occupies, of such and such a sentence? As already indicated, he takes support from the structure of the sentence which is presented to him, but at the same time he makes an appeal, implicitly, to all the occurrences of the different terms of that sentence in his own linguistic history. He then inserts the meaning potential of each of those terms in the structure presented by the sentence, thereby endowing the meanings of those terms with the supplementary nuance conferred on them by the new context in which they are thus used. In every new sentence, heard or pronounced, a genesis of meaning is going on. By reviving thus the anterior stages of that genesis, the speaker reassumes a part of his own history and thereby the whole of that history itself, as a background to the emergence of the pragmatic meanings. If, in a new occurrence, a term can take the pragmatic meaning which that occurrence confers to it, it is in the measure where that occurrence is in a certain continuity with all those which preceded it, and where, moreover, it is compatible not only with the situation in which it takes place - that is to say with the other propositions which are exchanged at that moment in the interlocutive context - but also with all the cultural baggage of the speaker and, finally, with all his history. In other words, what makes the pragmatic meaning of an expression is the way in which the objective meaning refracted in it inscribes itself in a history. And the condition of possibility of sense is the possibility of that inscription - inscriptibility. All this can be generalized. The analysis of language gives us to understand what is meant by a sentence such as "That proposition has that sense." By analogy it helps us to understand also what is meant by sentences like "That situation, that conduct, that event has that sense." But we must examine more closely what inscription is. It is neither a simple recollection, nor a remaking of actions which have been performed in the past, nor a story, nor a report which would tell what has happened at such and such a moment. But it is a constitutive moment which comes and takes place in a history which is building itself up. A situation which would be experienced but which would remain as a foreign body, incapable of being assimilated, would be, as experienced, inscribed in a life under a, so to speak, negative modality, as non-integrable; and it would be thus lived as nonsense. But to the extent in which it would have effectively affected a life, it would make sense of it, although in a paradoxical manner: its sense would be made

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of its nonsense. The history in which there is inscription is a quite original "becoming," which is not the same as in a living being, in a biological sense, but of a being for whom, precisely, there is the possibility of an experience of sense and of a partaking between what is sensed and what is devoid of sense. It will be appropriate to introduce here, in order to characterize what makes the human being a being of sense, the term existence, not in the meaning of existentia or of esse, but in the meaning which has been given to it by phenomenology, as expressing the modality of being proper to the human, existing being. Heidegger gives us a very clear indication about that, in paragraph 9 of Sein und Zeit: "We shall reserve existence [Existenz] in order to designate the determination of being which is convenient only for the being-there [Dasein]. The 'essence' of the being-there resides in its existence."3 That term has the advantage of evoking in a rather concrete way the proper character of a being who subsists in the mode of projecting himself out of himself, of being in some way ahead of himself. Correlatively, Heidegger uses the term Existentials [Existenzialien] in order to designate "the being characters of the being-there [die Seinscharaktere des Daseins]," which "determine themselves from existentiality [Existenzialiteit]."4 Now existence is able to resonate with what is somehow or other affecting it. It is the resounding of a situation in it (which could be the presentation of a sentence in a context of interlocution) which is for it the sense of that situation. Two properties are implied here: on the one hand, the capacity of being affected; and on the other hand, the capacity of existence to grasp what affects it according to its sense. The capacity of being affected is what constitutes the originary constitutive passivity of existence. Heidegger designates it by the term Befindlichkeit, for which the translation "feeling of the situation" has been proposed. We have to do there with a constituting element of the ontological structure of the human being, with what Heidegger calls an "existential," in the meaning which has just been referred to. The concrete manifestation in the "phenomenon" (what appears) of that ontological property is constituted by the affective dispositions of the type of mood, what Heidegger calls the Stimmungen. He has himself explained that he has translated by Stimmung the Greek term pathos, which goes back to the verb paschein, which means to suffer, to bear, to endure, to be afflicted. Befindlichkeit is the pathic dimension of existence, which has been brilliantly analyzed by Michele Gennart in a doctoral thesis, not yet published, which is situated in the line of phenomenological psychology. 5

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Heidegger, in Sein und Zeit, detects in the Befindlichkeit three essential determinations: the revelation of the Geworfenheit, the "being-thrown-away" expression which has been translated by dereliction,6 the revelation of the being-in-the-world as totality; and the revelation of the possibility of encounter. Geworfenheit is "the facticity of the fact which compels man to be responsible for his own being."7 "By the feeling of the situation, the beingthere is always already brought in front of himself, he has always already sensed himself, not because he would perceive himself as a subsisting being but because, in his mood, he feels himself as situated."8 On the other hand, "the mood has always already revealed the being-at-the-world in its totality and alone makes it possible to turn toward anything."9 We find here the second character of the Befindlichkeit, which reveals it as "an existential fundamental mode of the openness of the being-there, [which comprises] simultaneously the revelation of the world, the revelation of coexistence and the revelation of existence, as this one is itself essentially being-at-the-world."10 Finally, the third character, "the feeling of the situation implies existentially an orientation toward the world, which reveals this one, and from which the encounter of a being capable of concerning us becomes possible."ll But, while being marked by that originary affectability, existence possesses the capacity of grasping what affects it according to its sense, that is to say precisely as being thus affected. To grasp the sense of a sentence or of a situation is to understand it. The active capacity which is evoked here is the capacity of understanding, which for Heidegger is a second existential, because it is for him not a psychological property but an ontological character, codetermining the being of the human existing being. Understanding is primordially self-understanding. Existence is, so to speak, accompanied by a light which makes it accessible for itself. And it understands itself by seizing itself according to its possibilities, because, as existence, it is essentially open to an unceasing happening in which it projects itself in the mode of possibility. "By understanding [Verstehen]," writes Heidegger, "the being-there projects his being by aiming at his possibilities."12 If understanding refers back essentially to possibilities, it is because it "has in itself the existential structure of what we call the project. Understanding projects the being of the being-there as originally toward that in view of what he is, as toward his meaningfulness, that is to say toward the worldliness of his world."13 But if existence has those capacities, we must wonder how, in the course of its unfolding, the sense is effectively appearing. As already suggested about linguistic meanings, existence is living itself, according to a modality of

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presence to itself and to the world which belongs to historicity. What comes with its encounter presents itself there in its present, but that presentation mobilizes in itself all of the past and opens some possibilities in the field of the future. Understanding, in which existence seizes the sense while seizing itself in its being-affected, retakes in itself what flows thus back from the past and what announces itself in the dimension of the project. For example, in the case of a sentence, the linguistic structure is there, in its present factuality, but inside it all the language history of the hearer is resounding, so to speak, and in that history the hearer receives an access to all that it implies. The pragmatic sense of the sentence is the resounding of all those harmonics, coming from the past and from the future, in the present of existence, such as it is affected by what is giving itself to be heard. If, in general, the concrete sense of a situation is its repercussion in a life, to grasp the sense for the existing being, or to understand the situation, is to understand its own life, as being thus affected, and is in some way to become thus the sense which arises in it, and which, while arising, is, at that moment, the very passage of the life which it is affecting. But the sense is not a pure datum, which we should only have to record, as if we had to do with the presence of a thing. It is constructed. In that construction, there is, to be sure, a part which is given and which is related to the fundamental passivity of existence. But there is also a work of elaboration, which mobilizes the past and evokes the future. That work can, in principle, be pursued indefinitely, but inevitably it must give way, at a certain moment, to a conclusive stand. That begs the intervention of an act of decision, which adds in some way to what is lacking in the available elements of appreciation, in order to ensure, finally, the formation of a definite sense. There are situations where this process of determination of the sense comes to an end almost immediately. But there are also cases where existence remains perplexed for a long time, the situation being loaded with ambiguities and seemingly not sufficiently determined to be able to show its sense clearly. We could think, for example, of the work of deciphering an obscure text, where different hypotheses are evoked and put to the test and where the sense which discloses itself finally is nevertheless only conjectural. In any case the grasping of the sense is always of the order of an interpretation. Every situation, besides existence itself, is analogous to a text which delivers its sense only parsimoniously. The criterion by which the interpretation hypotheses are judged is essentially a criterion of coherence; the best interpretation is the one which agrees in the best way not only with the text as a whole, but also with all the context to which it belongs, and

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finally with all the knowledge of the interpreter and thereby with his very existence. It happens that we have to do not with a relatively opaque situation, the interpretation of which remains invincibly uncertain, but with a situation in some way polyvalent, which authorizes diverse readings, equally acceptable from the point of view of the coherence criterion. But it happens also, in a case of that kind, that those different interpretations are not situated at the same level of meaningfulness but are organized in different levels, revealing thus an arrangement in superposed strata, where the most immediately apparent interpretations are only necessary, but not sufficient (mditions for the more profound interpretations, and where these reveal the L. vth of those. In a case of that type, the work of construction of the sense becomes a kind of archaeology, which tries to reconstitute the process of internal et~qcturation of the sense by which this one has been so distributed in succes: ~trata, the configuration of which, such as it is reconstructed by th mterpreter, reproduces the genesis. The descent from the "apparent sense" toward the "profound sense" performs again, in sum, in reverse direction, a process of self-constitution which is always in progress. The construction of the sense is thus a kind of deconstruction which is at the same time, to tell the truth, a reconstruction. But this one is never final, because it is in debate with the possible, which is never exhausted. The procedure can be stopped by a decision, and that is what happens most frequently, in any case in daily practice, but decision does not definitively close the access to the possible. Life itself remains so, in some way available for its own understanding. Meanings are determined in a more or less stable way, decisions are made, paths are opened, other ones are closed. But the work of interpretation can always be resumed, every situation can be submitted to a reinterpretation, the life of sense is always relaunched. If existence can understand itself in each of its moments as the resounding in that moment of what comes and affects it in its originary passivity, and thus as the sense for itself of what comes at its encounter in that moment, it is because, as already recalled, it is fundamentally an understanding of itself in its whole, a seizing of itself in totality. And it has that self-understanding inasmuch as it is a natural light for itself. Now if it is thus present to itself as understanding itself, it is because it is constitutively open to a horizon of illumination. It is light for itself inasmuch as it is exposed to the light which comes to it from that horizon which philosophical tradition calls "being." The possibility of sense is thus given in the relationship between existence and being. That relationship is an interval which cannot be marked off by finite

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measurements. If a situation can have a sense for existence, it does so inasmuch as it inscribes itself in that relationship, as a moment which integrates itself thus by this very fact in the unfolding of existence. That inscription in existence is possible inasmuch as existence itself inscribes itself in being. We must come now to the examination of sense as positively qualified. In the idea of sense there is not only a cognitive dimension, but also a dimension of value. Now there is value only if there is a criterion, with the aid of which it is possible to recognize the presence or the absence of value. If we can say that sense, in itself, is inscription into existence, it is with respect to existence that sense can be judged as to its value. Now from the point of view of that relation, a sense can be recognized as bearing a positive determination or, on the contrary, as introducing into existence a destructive principle. Existence indeed is not simply a pure dynamism, an unceasing thrust, a vital self-assertion; it contains in its very constitution a directional aspect, an orientation, and it is inhabited by an internal normativity, determined by that orientation, according to which the events and the situations which are affecting it can be judged by themselves or by external witnesses. The sense of an event or of a situation can be said to be positive when it looks to the future, when it keeps the sheaf of possibilities intact, or, according to a more demanding criterion, when it contributes effectively to lead existence toward its accomplishment, this being understood as satisfaction of the desire to be or according to the concept of the blessed life. If a determined sense can be recognized as positive, according to the terms of that general indication, we still have to know more precisely what type of accomplishment it favors. In particular, we shall have to distinguish the type of sense which is situated in the perspective of a self-realization of existence and the type of sense which is situated in the perspective of an encounter. In the first case, accomplishment will have to be interpreted as a kind of reconciliation of existence with itself, of a reunification of its powers surmounting definitively its dispersion. In the second case, accomplishment will have to be interpreted as going outside oneself, abandonment of oneself to an alterity in the hands of which existence puts itself totally, while entrusting to it the destiny of its own being. To those two forms of accomplishment correspond two forms of positivity. It will be perhaps possible to judge one of those forms to be more authentic than the other one, according to the criterion of directionality, by comparing them from the point of view of their conformity to the intrinsic orientation of existence. Such a judgment will depend, finally, on the question of knowing whether, by itself, according to its internal nor-

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mativity, existence is essentially the process of its self-constitution, or whether it is the expectation of an occurrence which it cannot, by any means, provoke by itself. Everything depends on the question of knowing whether existence is fundamentally correlated to an immanent teleological principle or whether it is correlated to an order of events which radically includes the dimension of alterity. In any case, it will be possible to say of the sense of an event or of a situation that it is negative if it constitutes an obstacle to the accomplishment of existence, this one being conceived as self-realisation or as the event of an encounter. All that can count as sense contributes, directly or indirectly, in a positive or in a negative way, to the accomplishment of existence. But we must distinguish between local sense and global sense. It is always in a particular moment of the unfolding of an existence that a sense is formed. But this one may concern the very particularity of that moment or existence as such in its totality. To be sure, it is always existence which, locally or globally, is at stake, but it can be affected, precisely, according to such and such a determination which it gives to itself, or which happens to it, or in the radical bringing into play of itself, deciding on the whole of its destiny. The question of the existential qualification of sense, of what determines it as positive or not and according to what measure, is particularly decisive when several interpretations are equally acceptable and when the determination of sense belongs finally to a commitment of the will. In such a situation, existence is called to give its qualification to itself, by making election of such and such a sense. In the process of the constitution of sense, it is then the moment of construction which obtains absolute priority with respect to the moment of reception of something given. But a willed sense is not for all that an arbitrary sense. Because what is willed is judged by the internal normativity of existence. By willing this or that sense, the will is ratifying what is in itself the exigency of its authentic accomplishment or, on the contrary, what contradicts it and by that very fact then contradicts itself. Therefore, the construction of sense, in its most radical import, is a process which brings into playa destiny. 2.

THE POSSIBILITY OF GIVING A SENSE TO ILLNESS

The question which we must answer concerns the possibility of recognizing a sense in a situation which is of the type of an event, even when it has to do with an illness of great length: illness occurs in an existence, according to a possibility inscribed in its constitution, to be sure, but nevertheless always as

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a circumstance which surprises and more or less deeply modifies the course of a life. It is clear on the other hand that the intention underlying the question is to ask if it is possible to give to illness a sense which could be judged as positive. It is, of course, possible to answer immediately in a positive way to the question by taking into account the testimony of persons, known personally or indirectly, who are living or have lived the misfortune of illness and who succeed or have succeeded in integrating it into the totality of their existence by giving it, implicitly or explicitly, a positive sense. But the question is to know what has made their experience possible. Now if we raise such a question, it is because illness, by itself, is a kind of challenge to the possibility of giving sense. It strikes a blow to the body and thereby to existence itself, it thwarts its unfolding, in some cases in a very serious and irreversible manner. By attacking the integrity of the body, it makes difficult and sometimes impossible the initiatives which underlie the work of interpretation and thereby the very process of the construction of sense is more or less radically jeopardized. As already said, the sense is not simply given, and a minimum of vital energy is necessary in order to transform truly the moment of pure affection into a positive inscription in existence. It could be pointed out, however, that this situation does not prevent the recognizing of a sense which could be qualified as minimal. Illness generates a kind of contraction of existence, first, in a visible way, by limiting more or less drastically the mobility of the patient and, consequently, by reducing in proportion the spatial field which is accessible to him, but also, more profoundly, in an existential meaning, by contracting more or less severely the field of the possible and thereby blocking more or less decisively the fundamental dynamism of existence. There is, in that situation, a possibility of sense which proposes itself as the most immediately evident. It is the possibility of a sense which could be called "purely descriptive": the sense of illness would be simply the recognition of what it is in an evident way in its pure factuality, namely an obstacle to the accomplishment of existence. But this is precisely what confers to a sense a negative qualification. The question concerns the possibility of a sense which could be qualified positively. It could also be pointed out that illness, although directly affecting an existence, has visible aspects and that, therefore, two points of view are possible, that of the patient himself or that of the witness. It could be argued that the witness, seeing the situation from outside and being affected only very indirectly by the illness, besides as far as he is actually affected

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through the sympathy that he can feel for the patient, is in a better position than this latter to construct the possible positive sense of the illness. He will be able to suggest to the sick person an interpretation which will possibly help him to positively live his illness. But what the witness can do, at best, is to explain to himself and possibly then to the sick person how, as a witness, he believes himself able to understand the situation. We cannot forget that the sense which is brought into question here is the resounding of an eventlike situation in an existence. Being existential, it cannot be constituted as sense apart from the existence which is affected. Somebody can explain to another person how he is living an event. Nobody else will be able to really live that event in his place. If a reflexive language can speak of illness, it is only in the dimension where it can propose concepts able to evoke what is lived according to its proper signifying potential, without reducing it to what a story in objective form could say. It does not substitute itself for what is lived, it can only shed light on its conditions of possibility. If the construction of a sense cannot be achieved for an existence but in the very situation which affects it, the possibility of that construction must be given in the very circumstances which constitute the situation. Now, from the point of view of existence, the first character of illness is that it affects the existing being in his body, be it locally, as in the case of an organic lesion, or globally, as in the case of a mental illness, which disorganizes functions of a high level of integration but is based in any case upon an organic support. It therefore brings necessarily into play the relation of existence with the body in which it is living itself. The possibility of giving a sense, if it exists, must be found in that circumstance. In order to see what can be thought about that possibility we must examine the relation of the existing being with his body. What appears immediately is that the body has a very strange status, which does not lend itself to a univocal interpretation. From a certain point of view, the body is a living organism which belongs to the long chain of living beings, which has its place in the chart of evolution, from which the constitution and the functioning can be studied by the methods of scientific analysis, on which it is possible to act efficaciously on the basis of the knowledge which can be acquired about it. The body, contemplated in that way, is the object-body. It is the body such as it is viewed by science, such as it is viewed also, at least partly, by scientific medicine. Partly only, because medicine, even the most objective kind, cannot put between brackets the other signification of the body. The object-body is essentially the body such as it can be seen from outside, by a glance capable of neutralizing its existential signification. But the existing being himself can, in some measure, adopt that objectifying

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attitude with respect to his proper body or, more easily perhaps, with respect to certain parts of his proper body. He cannot, however, really suspend the indissoluble link which attaches him to his body, in such a way that, in his case, we have to do only with a pseudo-objectification. Be that as it may, the object-body is but an abstraction, possible only from an attitude of thought which succeeds in seeing the body in what makes of it a fragment of the cosmic reality. We could say that the object-body is the cosmic body. This is evidently not without consequences, as this amounts to evidence of the human reality belonging to the cosmic reality. What is remarkable, from an existential point of view, is that such an abstraction can take on a practical aspect, as is the case in an evident and necessary way in medical practice. Now, if this is so, it is because the real body lends itself to that abstraction and even, in some measure, provokes and calls it. Inhabited by existence, and not being able to detach itself really from it except by death, the body has, nevertheless, a kind of autonomy which enables it precisely to lend itself to objectifying practices. But we must well recognize that, even in the realm of pure thought, that objectification is never total: as human body, the object-body is never completely object, although it can be considered as such. The body is primordially what it truly is inasmuch as it is lived. The object-body is constituted by a partial detachment from the lived body. The German language uses two distinct words to speak of the body: "Korper" and "Leib." The first one designates the objectified body, the second one corresponds to the expression "lived body." This expression aims not at the body as living being, but at the body as support of existence, at the effectivity of that fundamental feature of existence by which it is essentially being-in-the-world, openness to the cosmos, to others, to the cultural field. Our body, writes Merleau-Ponty, "is eminently an expressive space," but it is "not only an expressive space among all the others. That is only the constituted body. It is the origin of all the others, the very movement of expression, what projects outside the significations, by giving them a place, what makes them begin to exist as things, under our hands, under our eyes. [...J Our body is our general means of having a world." 14 The lived body is not an instrument nor a kind of opposite reality which we could apprehend at a distance. It is in no way for us an "elsewhere." It is what gives us a place, what gives us an anchor in space and time and thereby also in a tradition and in a historical and cultural field. More exactly, it is itself exactly that place which is for us unobjectifiable because it is the very condition of any possibility of localization, the generalized center of per-

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spective from which our perceptive space is organized around us, beings and things are distributed, the possible ways of exploration of the world are outlined, in short from which opens that universal field in which our life, at each instant, can unfold. To be sure, we can, in thought, represent our situation and see ourselves as from outside of where we are. But it is thanks to an imaginary operation of displacement in which, putting ourselves in the place of another, we are seeing ourselves as the other of that other. But it is then the place where that witness is located, which becomes, in that thought representation, the center of perspective. But if the lived body is, as a place, openness to the world, it is so only not inasmuch as we perceive that environment whose borders are at the infinite and where we have our dwelling place; it is also how it understands that environment as a field of action, and as it understands itself correlatively as the power of intervention, capable of modifying it and of inscribing it in its own projects. The lived body is the perceiving body and acting body, from itself, not however as a sovereign power, but in a constant interaction with a world which proposes to it its possibilities and through which it itself has the mission of transforming the latent signification into existentially relevant signification. While being that function which receives, so to speak, existence in a determined place, by opening around it the space of its unfolding, the body is also what enables existence to constitute itself as a self, in other terms, what confers to it its selfhood. As self, existence is a dynamic relationship with itself, perseverance in its being, and self-position in the unity of its powers. Now those three aspects of selfhood find their support in the mode of temporalization of the body proper. Stretched in some way between what it is and what it was, it is threatened by a kind of internal scission which would put it outside of itself, and thus fall into the dispersion and the disintegration of its being. Now it lives as the constant conjuration of that threat. Its temporality is not made of an irremediable separation between present and past, but of an unceasing resumption of what is no more in the effectivity of what is. It is thus a continuous reunification of its being with itself; that process is by itself a dynamic relationship of the lived body with itself, by virtue of which it subsists in being and is unceasingly reunited with itself. Merleau-Ponty compares in a very suggestive way the unity of the lived body with the unity of a work of art: "A novel, a poem, a picture, a musical piece are individuals, that is to say beings where it is impossible to distinguish the expression from what is expressed, the sense of which is accessible only by a direct contact, and which radiates their significations without leaving their temporal and spatial place. It is in this sense that our body is comparable to

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the work of art. It is a knot of living significations and not the law of a certain number of covariant terms."15 It is in that mode of relation with oneself, proper to the lived body, that existence finds the effectiveness of its selfhood. But if this is so, it is because, as Merleau-Ponty writes, "I am not in front of my body, I am in my body, or rather I am my body."16 It is by the body that existence receives the powers in which the mode of being which it is actualizes itself. It is by the body also that it is made fragile and vulnerable. If Befindlichkeit is authentically an "existential," as Heidegger explains, the "pathic" dimension of existence is prior with respect to the concrete modalities of its manifestation. And it is to that dimension that we must relate the pathic aspects of bodility, even if those are immediately present to experience, before any reflection. The possibility of illness is inscribed in the pathic dimension of existence, as one of its concrete modalities. And as such, it makes partly manifest the signification of that dimension. Partly only, because Befindlichkeit is, in a very general sense, capacity of being affected. And suffering, which is the lived aspect of illness, is only, we could say, the acute, perhaps paroxystic form of that capacity. It could even be said, in a literal sense, that it is the properly pathological form thereof. But if illness can be related to the pathic dimension of existence, it must be recognized that it belongs by itself, as possibility, to the very constitution of the being of the human reality. This does not imply, however, that it is a necessary manifestation of that constitution. It is, on the contrary, properly speaking, an accident; it is an event which happens and which surprises. It is even that contingency which characterizes it perhaps primordially. It is also by contingency that Spinoza defined passivity in his Ethics. We read in Proposition II of the fourth part: "We are passive (patimur) in the extent to which we are a part of Nature which cannot be conceived by itself, without the other parts." I? That proposition is justified by the following explanation: "We are said to be passive when something whereof we are only a partial cause [...], that is to say [...] something which cannot be deduced from our sole nature, is born in us." In other words, we are passive when a state which does not derive in a necessary way from our essence takes place in us. The fact, however, that the possibility of a contingent occurrence such as illness belongs to our constitution, induces us to wonder if that possibility itself is not contingent. We could insert here a theological note about the effects of original sin. In the normal state, in which we are in the world without restriction, the body does not make itself felt as such; it is our very presence to the things and to others, it is our glance over reality, our action in the universe of the

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practices, the surge of our life; it is ourselves, it is our existence. In illness that immediate and happy relation of existence with the body is transformed. The body is no longer that spontaneity which adjusts itself without reluctance to our intentions, it becomes unavailable, it withdraws, so to speak, into its singularity - it puts itself outside the flow of existence, it introduces an alterity in the midst of our presence to ourselves, it makes itself a stranger. But at the same time it weighs on existence, it imposes on it the opacity of an irretrievable contingency, and as an insisting and claiming materiality, it occupies all the fields of consciousness by the suffering in which it is trapped and by the helplessness which overwhelms it. At the same time, as it withdraws in its alienation, it does not cease to be the support of existence and thereby to adhere to it, but in the mode of a kind of monopolizing which mobilizes existence for its own ends and confines it in a present which seems henceforth cut off from its horizons. That experience of the alteration and of the alienation of the body reaches its most intense and afflicting form as the experience of suffering, which adds to the feeling of powerlessness before adverse events, that sort of despair which the existing being is experiencing when, overwhelmed by the pain and aspiring to be delivered of it, he is obliged to recognize that it adheres invincibly to his existence and that it is, in some way, its very being. Buytendijk has described in an impressive way that experience of the pain which is lasting, which undermines from inside all that makes the coherence and the creativity of a life, which reduces this one to a state of generalized powerlessness and is increased by the feeling that it is without reason: "Why to be thus handed over to pain, why that powerlessness, that destruction of all freedom, even the freedom of the thought, of the feeling, of the will? Why that perplexity? That questioning, spurred by the pain, has the character of a protestation. The pain is twice as painful, because it is at the same time a tormenting mystery."18 The existing being, in illness, experiences himself as a prisoner of his body, inasmuch as he is subjected to its constraint, as if it were the effect of a force coming from elsewhere. But he continues to inhabit that body as his body, to find in it the anchorage of his existence and the support of his being-in-theworld. The sick body secedes, it becomes unavailable, it puts itself at a distance from itself, into one word it objectifies itself. It does not metamorphose for all that, into an object-body. Its objectification is not like an exterior glance, it is immanent to the very process of becoming sick. We don't have to deal with a real objectification here, which would break the adherence of the body to existence. The lived body remains lived body in the sickness; the

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transformation which this one induces does not throw the lived body into an object-body, it introduces a modification of the lived body and thereby of the concrete modality according to which existence gives itself its effectivity. The sick body is always adhering to the movement of existence, it is always the place in which the self receives a determined location and becomes assured of its selfhood. And as such it is always open to a world. But that world is a contracted, narrowed world, offering to the self only a restricted field of possibilities and opposing to the dynamic of the project the powerlessness of the body, which is not only organic, or simply physical, but existential. In that powerlessness, existence itself is affected in its willingness to be. But if the suffering body, although limiting and hindering, is always a lived body, it is now up to this suffering body to be the support of existence. That support is limited, and we could even say it is making its sickness its own and thus limiting itself. That self-limitation is its way of giving itself a world and thus living as a lived body. It is by making itself self-limiting that it is able to continue being a lived body. And it is thus inasmuch as it is selflimiting that it continues to be the support of existence. The limitation imposed by the sickness can thus be understood in two ways: as a kind of radical locking of existence, which prevents it from unfolding as existence, thus introducing into it an essential contradiction; or as the endeavour of the lived body to assume the alterity of the sickness, in the very name of the conatus which is at the heart of existence. The first interpretation, which is the more spontaneous, because it brings to the fore the pathic character of illness, gives illness a sense which must be qualified as negative. On the contrary, the second interpretation, without explicitly giving a sense of positive value to illness, safeguards its possibility. According to that second interpretation, existence is not engulfed in the pathic dimension of the body; it retains an energy which enables it to maintain existence, and thus openness, promise and invention of self, despite the restriction which affects it. It remains an existence while assuming what happens to it, while transforming a fate into a destiny, while integrating in the willing of itself what threatened to be but an external determinism. Such behavior is an integrating, overcoming, movement of transcendence. But if the body, as lived body, is the effectivity of existence, we must recognize that this movement of transcendence is not an operation of pure thought, or of pure will, that it is already in the suffering body itself. The self-limitation is precisely that by which the body, assuming its condition, is asserting that it is more than its condition; it is transcendence. That transcendence, immanent to the lived body, is a condition of the possibility of interpreting illness in a positive way.

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It is, however, still just a partial condition, which provides the necessary energy for such an interpretation. But this one demands still another condition, which already concerns the content of the interpretation. lllness affects existence at a certain moment of its becoming and it extends over a certain period of time. But whatever that period may be, it affects existence in its totality. It can be through such or such an organ, but what affects that organ resounds on the body as a whole, thus generating a general ill-being. There are also states, like the feverish states, where the body directly experiences in itself as a totality the aggression which it suffers. Thereby existence itself and the relation which it sustains with itself, the way in which it experiences itself are called into question. A possible positive sense must thus be able to envelop existence in its totality. Two possibilities appear here. The interpretation of the situation can bring into play the relation of existence with itself, in a kind of purely immanent, thus non-objectifying reflexivity. Such an interpretation must end up in reducing existence to its pure immanence and thus in closing it radically on itself. But that would amount to stopping the movement of transcendence, to negating the existential dynamic, to taking existence out of its world, in short to conferring to the situation a sense which would be in the most radical meaning of the term a negative sense. The other possibility consists in inscribing existence, in the most resolute and fully assuming manner, to a larger context and in interpreting the situation from the point of view of that more encompassing perspective. But that widening of perspective cannot be produced by a simple decree of the will. An access must be secured for existence, to a dimension which exceeds its familiar world, from existence itself. And to ensure that, the interpretation must be able to lean on the hidden presence, in the immanence of existence, of such a dimension, and in this one existence must be put a relation with an alterity, as already inhabited by it. The construction of a positive sense according to this second possibility demands an act of recognition, discovering in the implicit, by a reflexive movement, a belonging which was not yet conscious of itself but which can become self-conscious, and an act of ratifying assumption which belongs to the will. The construction of the sense, in its most decisive moment, is indeed of the order of willing. 3.

THE DETERMINATION OF A SENSE

How could we conceive the effective constitution of an appropriate sense of illness, that is to say of an interpretation directly relative to existence in totality, as affected by illness? In accordance with what is asked of it, such an

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interpretation cannot be simply applied from outside to the situation. It must find support upon a dimension already present in the implicit, and show how it can be explicitly assumed. Two possibilities are present here. We could think of a dimension which belongs to the constitution of existence or of a dimension which is of an existential order, which, somehow or other, has befallen existence. Let us first examine the case of a constitutive dimension. Existence has its worldly effectivity, it is "in the world," as supported by a living body which, as living, is inserted into a network of relations, cosmic and biological, and which thereby participates in the great cycles of nature and of life and is situated in a history of life. That history is also recapitulated in it, in this sense that we find again, in the hypercomplex system which it constitutes, micro-systems which have been constituted at different moments in the evolution of living beings. While assuming its body in the spontaneous unfolding of its being, the existing being assumes its biological conditions such as they are determined by the history of life and by the present situation of its cosmic environment. Now illness can be conceived as a dysfunctioning of the organic system, corresponding to a possibility which belongs to those conditions. The genetic replication is a mechanism of great precision and great reliability, but the very nature of the materials which are used exposes them to chance mutations, resulting from purely physical factors, and those mutations can generate grave consequences. In certain respects, mutability can thus be considered as a serious defect of the system. But on the other hand it appears that it plays a very important role in evolution. An absolutely stable system would be without doubt more safe, but its fecundity would be nil. A mutation is an accident, the possibility of which belongs to the constitution of the system, and that accident is potentially harmful. But it is the result of the flexibility of the system, which introduces diversification and novelty. The potential danger of mutability can be considered as the price to pay in order to ensure flexibility. Seen in that perspective, the sense of illness could simply be that it is, as a possibility always present, a consequence of the biological conditions imposed by bodility. And it could in some way be justified in the measure to which it would be possible to recognize it as the counterpart to the complexity of a system whose extraordinary performances are partially compensated by a relative fragility. A sick person could give a sense to his state by becoming aware of that conditioning. Even if it is supposed that this consideration could be sufficient to constitute a really positive sense, it remains that illness, considered in that way, is an accident. It can be understood. But is it really possible to assume

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it? For the one who is subjected to illness, whatever its possible biological explanation, it is a hardship and it is lived as a suffering. And in this hardship existence itself is submitted to affliction. Why that affliction for the one who is living it? Seen from the scientific point of view, illness is contemplated in its character of generality, as a process of a certain type capable of affecting any individual. Seen from the point of view of the sick person, it is a quite singular reality. He himself is concerned, in his irreducible selfhood, which cannot be shared. The true question which his sickness is raising for him is precisely the question of that singularity: why am I, so to speak, put aside in that hardship, as if a secret fate condemned me to it? And why under this form now, why that implacability, when no apparent necessity can explain it? But it is possible to prolong the endeavour to find a sense in the biological conditions by pointing out that complexity, a counterpart to fragility, is not simply a datum but that it has a highly positive value, in so far as it makes possible a life which is no longer simply biological; more precisely, complexity makes possible the assumption of the biological bases of the properly human life in that ontological modality which is designated by the concept of existence. Now the process of complexification which ends up in that possibility is itself inscribed in the immense dynamic of evolution. The sick person who is questioning about the "why?" of his state can be led thereby to understand his proper life from the point of view of that becoming, to consider himself, in his individuality, as a link in a process of cosmic nature which must obey a hidden necessity. The hardship which befalls him itself depends upon that necessity. Even if he is unable to disentangle its precise forms, he can at least grasp it globally and feel himself invited to inscribe himself deliberately in it, ratifying so by his own will the hidden law of the world. That attitude is the expression of a wisdom which puts itself in harmony with fate. It is, however, not a form of resignation, because it is grounded in a feeling of participation in a grandiose genesis. It is an integrating overcoming of the situation inasmuch as this one is limiting and even disintegrating, and integration is a unity which is underway in forming itself and which is more encompassing than the unity of a particular life. That reinforcement of the argument which invokes the preparation in the "biosphere" of the emergence of the "noosphere" - in the terms of Father Teilhard de Chardin - meets the same objection as its first formulation. The evolutive process, whatever its scale and intrinsic meaning, is an anonymous process with respect to which the individual is only the local and ephemeral

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bearer of an advent which transcends absolutely the limits of his minuscule contribution. From the point of view of the universal life, the individual is without a proper value. Now it is as an individual that the human being is suffering; it is in his selfuood that illness affects him. A positive interpretation must be able to rejoin the singularity of the existing being and to give an account of what befalls him, in a life which is his own, not the life of the cosmos or even of the "noosphere." Now what makes it singular as such is what happens to him, as the unexpected and novel. This leads us to the idea of a dimension which is of an existential order. An event is an episode which marks a breaking in a becoming, and at the same time constitutes an advent. As occurring in a process already under way, it takes place in a history, and as introducing a break in it, it inscribes in it a singularity. Thereby, it also confers to the history to which it belongs the character which makes it authentically historical: the singularity of what is of the order of an an event is what is the most proper to historicity. But the dimension of an event can intervene in two forms, (1) in the form of visible episodes, of what happens under an empirically observable appearance and is in principle accessible to all through the testimony of those who have experienced it, or (2) in the form of what is proper to the event as such, that is to say of that character which we are induced to recognise in certain visible features inasmuch as they cannot be related to a law of constitution. There are, in human reality, some possibilities which reveal themselves as very fundamental, so much so that they seem to belong to its constitution, or to its essence, and which, nevertheless, by reason of their contingent character and strangeness, cannot be considered as essence properties and appear as it were as a surplus with respect to the originary constitution of existence. Those possibilities, when they manifest themselves, are represented perceptibly by events in the first sense. But what is proper to an event as such is not in the order of what is visible. It is like a concealed constitution, which has this strange character of being real only in the form of an intervention. In other words it has a character of historicity. But its historicity is not the kind of historicity proper to visible events. It has, nevertheless, a relation with this one; inasmuch as the possibility of concrete events manifests itself perceptibly, the historicity proper to an event as such determines the historicity of what is visible without, however, showing itself as such in it. What is visible from it in the manifestation is made of only the signs or symptoms of a fundamental disposition which remains concealed. Inasmuch as the historicity of the pseudo-constitution, of what is proper to an event as such, determines the historicity of what is visible, the history which properly belongs to it can be

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called an arch-history: entrenched in the continuous occurring of a pure event, it is readable in the signs which it gives of itself in the world of experience. Illness, having the character of an accident, of the "pathic" in the sense of Spinoza, can be understood precisely as a sign which harks back to that concealed historicity of an arch-history, to dispositions which do not derive from the constitution of human reality but which nevertheless impose on it, in the form of events, conditions which it cannot evade. Those conditions are not only the biological properties whose constraint, in accordance with bodility, has an effect upon existence; they are more radically ontological conditions which, as such, affect existence from inside itself. What expresses at best the essential of those conditions is the idea of misfortune. There is, in the concrete status of the human being, an inescapable dimension of misfortune, which is weighing on his existence at the same time implacably and unexplainably and which manifests itself through all the figures of the tragic, all the forms of failure, of suffering and of tearing, and singularly through the hardship of illness and the destruction of the integrity of the body. Misfortune affects the human being in his singularity; it is of the order of an event, but in each one it affects all the others; it is a condition eminently shared. The sense given to illness could reside in that sharing. In illness the common condition is directly and sensitively suffered, and in that experience illness could be lived as the sign of that condition, and thus as the sign of a universal solidarity which makes of everyone, for himself and for all the others, a companion of misfortune, making his way with all the others in the same despondency, in hac lacrimarum valle. The feeling in which that solidarity is lived cannot be other than compassion, in the most literal meaning: the suffering-with. When the condition of misfortune becomes evident, in its abrupt character, as ineluctable and impassable, it only remains to cry for oneself, for all the human beings, for mankind as such. But there is a kind of consolation in the consciousness of not being alone, in the thought that others are more severely affected and that we happen to be all sharing in a same fate. Compassion points each one toward the part which he has in the misfortune of all; it is at the same time universal and singular, universally singular. It mediates a concrete relationship between the self of the one who is suffering and the self of each one of the others. In this sense the hardship of illness is universalizing, but it is through this feeling. Now what that feeling gives one to feel is that, in the suffering of existence and in particular in the suffering of illness, there is an adverse power which adheres to the human condition without however being its essence, as if an alien intention

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had partially taken possession of it. But the presence of what is thus manifesting itself, in all the signs of it which are given, is sensed only in an enigmatic way, in enigmate. It is what characterizes, even as such, an event of an arch-history. But that nonmanifest historicity is itself radically reinterpreted, in the context of the Christian faith, as taken up again in another historicity, more authentically and manifestly belonging to the event order, which could be called the "christic historicity." Unlike the arch-historicity of the misfortune, which is an adherent to the ontological status of existence and appears as almost confused with it, the christic historicity is immediately manifested in a visible historicity, the historicity of the life and death of the historical Christ. But it is however, still not entirely revealed as a sign, the prediction of Christ, his miracles, his very person are the signs of the presence among us of the new historicity which He is instituting. That reinterpretation of the arch-historicity of misfortune is not a destruction but an assumption that the christic event takes over, in itself, the kind of event belonging to the unfortunate condition of the human being. That resumption, which transvalues its sense, is a constitutive element, a preliminary condition, of the realization of the salvation in Jesus Christ, the essential condition which also commands and makes possible the first one, being the openness of existence to the christic mystery. From the point of view of that new historicity, illness is reinterpreted, in any case in its aspect of suffering and in its destructive character, as a consequence of an order of events which is of a properly spiritual nature, which is thus wholly independent of the conditions of the cosmogenesis, namely, the occurring of evil. Now, in his redeeming action, the christic historicity directly attacks that source of misfortune. Christ faces the mystery of evil by inscribing and assuming it in his very existence and by living it until death, and does that at the same time in his visible and earthly reality, in the event of his Passion, and in the invisible reality of the interior mystery of His person. The sense of illness, in that perspective, can be that it is by itself effective participation, directly experienced, in that transforming process which is at the heart of the christic historicity. It is itself a visible figure of the mystery of evil, but it is such already inasmuch as, in Christo, that mystery in it is reassumed in the redeeming act. This gives all its meaning, at the same time anthropological and theological, to the famous prayer of Pascal,"In order to ask God for the good use of illness," which was probably composed by him in 1654, eight years before his death, and which was published after his

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death, in Cologne, in 1666. 19 Three essential moments only will be retained here. The singular force of that text is that it has the form of a prayer, not of a theological commentary; that in it the person of Pascal comes into play, in front of God, in a radical way; that it thus has an eminently existential scope. It says, therefore, that the sense of illness, which he is himself suffering, is in the very act by which he is living it. In a first moment, illness is interpreted as the occasion of a conversion. Only an occasion, because it is certainly not illness which can produce a conversion: "I am asking and I am seeking God himself; I am addressing you alone, my God, in order to obtain you.... You could create my soul: you alone can create it anew. You alone could form your image in it: you alone can re-form it, and imprint again in it your obliterated portrait, that is to say Jesus Christ my Saviour, who is your image and the character of your substance"20 But illness, which is a gift of God, puts us in a frame of mind in which we are brought back to ourselves and made able to will our conversion and ask for grace for it: "Even the disgraces which befall your chosen ones are the effects of your mercy."21 The effect of illness is first, from a purely existential point of view, to deprive existence of its self-possession by tearing it away from all its attachments and by reducing it to a state of powerlessness where it is put in the presence of itself, as pure existence, apprehending itself only in its conatus, in that effort toward being which is at the root of desire. Thus a state of passivity is created in the soul and makes it receptive. In that state it discovers itself as desire for God and it asks for the grace of conversion, by which alone that desire can be granted: "May I consider myself in that sickness as in a kind of death, separated from the world, devoid of all the objects of my attachments, alone in your presence, in order to implore your mercy for the conversion of my heart."22 In a second moment what is brought to the fore is the dimension of suffering in illness, inasmuch as it affects the body. In a move of great mystical audacity, Pascal calls on the love of God for his sufferings, using as an excuse the fact that his pains "have some resemblance" to the sufferings of Christ: "0 God, who so loves the bodies who are suffering that you have chosen for yourself the body which has been the most overwhelmed by sufferings among all those that have ever existed in the world! Find my body agreeable, not for itself, nor for all that it contains, because everything in it deserves your wrath, but for the pains which it is enduring, which alone can be worthy of your love. Do love my sufferings, Lord, and may my pains invite you to visit me."23

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With that direct reference to the sufferings of Christ, the prayer opens explicitly the existence of Pascal to the christic horizon. And thereby it directly prepares the third moment, strongly inspired by Saint Paul, where we have no more to do with the "resemblance" to the sufferings of Christ only, but where an appeal is made to a real substitution, by identification, of Christ himself to the Christian Pascal, thus giving to illness that fullness of christic sense which is implied in the participation in the mystical Body of Christ. In the last section of the prayer, Pascal addresses Christ in these terms: "As nothing is agreeable to God unless offered by you, do unite your will to mine and my pains to those which you have suffered. Make mine become yours. Unite me with you, fill me with you and with your Holy Spirit. Do enter my heart and my soul, in order to bear there my sufferings, and do continue enduring within me what you still have to suffer of your Passion, which you complete in your members until the perfect consummation of your Body; in order that, being full of you, it would no longer be me who would live and suffer, but it would be you who would live and suffer in me, a my Saviour."24 In the interpretation of Pascal, which is perfectly consonant with the teaching of Saint Paul,25 the idea of compassion, which has been introduced above in the perspective of the arch-historicity of misfortune, is transformed and made effective in the mystical idea of the participation in the Passion of Christ. Now in his Passion, Christ faces evil and destroys its empire. The mystery of misfortune reveals itself then as the effect in the visible reality of the mystery of evil. And the struggle against illness can be understood as a form of the struggle against evil. Continuing through the centuries, in the expectation of what is announced in the vision of Saint John: "He will wipe all tears from their eyes and death will be no more; there will be no more bereavement, nor screams, nor grief, because the first things will have disappeared."26 Universite Catholique de Louvain Louvain-la-Neuve, Belgium NOTES Ludwig WiUgenstein, Tractatus logico-philosophicus, 3.3. Ibid., 4.022. 3 Martin Heidegger, Sein und Zeit, Erste Halfte, sechste unveranderte Auflage (1st publication 1927), Tiibingen, Neomarius Verlag, 1949, p. 42. The translations which are given here are inspired by the French translation of Rudolf Biihm and Alphonse De Waelhens, L'etre et Ie temps, Paris, Gallimard, 1964. For the text quoted here, see p. 62 of that translation. I

2

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Ibid., p. 44. (French transl., p. 65.) Michele Gennart, Corporeite et presence. Pour une phenomenologie de la dimension pathique du delire et de [,hollucination, These de doctorat, Universite Catholique de Louvain, Faculte des Sciences Philosophiques, 1994, 576 p. 6 Cfr. Sein und Zeit, op. cit., § 29, pp. 134-140. (French trans\., pp. 168-175.) 7 Ibid., p. 135. (French transl., p. 169.) 8 Ibid., p. 135. (French transl., p. 169.) 9 Ibid., p. 137. (French transl., p. 171.) 10 Ibid., p. 137. (French transl., p. 171.) II Ibid., pp. 137-138. (French transl., p. 172.) 12 Ibid., p. 148. (French transl., p. 184.) 13 Ibid., p. 145. (French transl., p. 181.) 14 Maurice Merleau-Ponty, Phenomenologie de la perception (Bib1iotheque des Idees), Paris, Gallimard, 1945, p. 171. 15 Ibid., p. 177. 16 Ibid., p. 175. 17 Spinoza, Ethics [1677], Fourth part, "About human servitude or about the forces of feelings," Proposition II. (Quoted here according to the French version published in the "Bibliotheque de la Pleiade": Oeuvres completes, Paris, Gallimard, 1954, p. 493.) 18 FJJ. Buytendijk, Uber den Schmerz. Translated from Dutch by H. Plessner, Bern, Hans Huber, 1948. Quoted by Michele Gennart, op. cit. (footnote 5), p. 225. 19 Blaise Pascal, "Priere pour demander Ii Dieu Ie bon usage des maladies," in L'Oeuvre de Pascal (Bibliotheque de la Pleiade), Paris, Gallimard, 1950. 20 L'Oeuvre de Pascal, op. cit., pp. 330-331. 21 Ibid., p. 328. 22 Ibid., p. 330. 4

5

23

Ibid. p. 334.

Ibid., pp. 336-337. Cfr. Col. I; 24, "I complete in my flesh what is lacking in the hardships of Christ for his Body, which is the Church," and Gal. 2; 20, "It is no more me who is living but Christ who is living in me." 26 Apocalypse, 21: 4.

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TOWARDS A NEW APPROACH TO MEDICAL HUMANISM

The title of this talk may be rather confusing. The term medical humanism appears to refer to some sort of wisdom or a particular vision of humanity and of its meaning that a doctor acquires through his daily encounters with patients. That is not in fact what I have to say. Instead, I would like to show how medical progress is slowly but surely changing the objectives of a wide range of medical activities and how as a result the medical world is asking not only itself but also the prevailing culture that underpins medicine some very new questions to which it has no answers. The purpose of medicine is to deal with the failures of humanity that result from the fact that human beings are betrayed by their own bodies. The stance that medicine has always adopted is one of resistance and struggle in the face of such failures. It has for centuries contented itself with this die-hard attitude, and its powerlessness was such that sickness and death quite naturally appeared to dictate not only the essential meaning but also the limitations of medical action. Doctors strove to sustain life in the face of death. Traditionally, the role of medicine was simple and clear-cut: to cure sicknesses and to stave off death or, failing this, to assuage suffering. The efficiency of modem medicine is challenging these straightforward objectives by adding new responsibilities that doctors have never had to take on before. Modem medicine is able to treat pain, but it can also deal with mental suffering. Now, however, medicine is expected to relieve the malaise associated with all types of frustration and perhaps the malaise of the want that characterizes all human desire. Medicine can maintain lives in a vegetative state almost indefinitely and is finding itself faced with the problem of having to define what forms of life are still human and what forms are not. Finally, given the efficiency of hormones, surgery, and (in the future) genetic engineering, medicine is now expected to fashion the body to suit the image generated by human desire, while it wonders where the limits of this desire may lie. There are three new, indeed very recent, issues that I would like to consider.

181 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXll, 181-192. © 200 I Kluwer Academic Publishers. Printed in the Netherlands.

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PAIN, SUFFERING AND FRUSTRATION

Even if, in principle, it has always been the mission of doctors to offer relief when they could not cure patients, for centuries the medical profession attached precious little importance to this task. First and foremost, this was because they were powerless. After all, their pharmacopoeia contained few if any antalgics and no anaesthetics other than alcohol. With no scientific understanding of diseases, they effected very few cures. They were, therefore, obliged to fall back on the power of self-healing which is inherent to living nature. In the words of Ambroise Pare, "I bandaged him and God cured him." The doctor thus endeavoured to give the patient support and strength to help him fight against the illness. Needless to say, he preferred those patients who didn't succumb to complaining and dejection. To make matters worse, as we are reminded by D. Le Breton, I "even though commonly used medicines sometimes offered relief, they also brought a certain amount of pain.... Barbers would cut abscesses with a razor . Patients were treated with cauterisation for wounds, bites or stings . Caustic substances were applied to haemorrhoids, verrucas and cankers." All these forms of treatment - which were often dreadful to endure - culminated in surgery, which of course was carried out without any anaesthetic. Doctors could therefore not afford to pity the patient or be excessively compassionate. Being soft on patients could compromise the healing process. To treat the patient, the doctor had to be vigorous and not hesitate to cause the patient some suffering. Traditionally, doctors were thus on the side of those who encouraged resistance to pain. Their attitude was then in line with contemporary culture. Every human being would throughout his life be exposed to a thousand forms of pain, large and small: headache, stomachache, toothache, traumatic pain, and chronic pain. Education was there to extol the virtue of having the moral courage and fortitude to carryon living and working despite pain. Doctors encouraged people to manifest the same courage in the face of illness. We can in this context better understand the words exclaimed by Velpeau at a meeting of the Science Academy in February 1847: "Is the question as to whether the patient suffers more or less of any interest to the Science Academy?,,2 This attitude is no doubt one of the reasons why doctors were opposed to the use of analgesics and anaesthetics when these appeared during the 19th century. Surgeons were for a long time (in fact, right up until the end of the 19th century) reluctant to use anaesthetics that allowed surgery to be carried out under narcosis. The same is true of analgesics. It is true that many of the first analgesics, and particularly morphine, could cause addiction. However, this

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fear does not explain the fact that until 30 or 40 years ago most doctors were reticent about using morphine to treat cancer-related pain in patients who did not have long to live and therefore had no risk of addiction. In a recent article, Father P. Verspieren showed that this cannot be explained, or cannot only be explained, by doctors being contaminated by the religious view of suffering. 3 Indeed, the reality was that there was a pervasive medical culture which felt that the patient ought to be strong and endure the pain. One hangover from this attitude is the fact that even now, teaching the specific treatment of pain and palliative care is not compulsory in many of our medical faculties. Nonetheless, society has evolved and the traditional attitude of doctors toward pain has had to change. Most people nowadays put faith in the benefits of science and technology, even though the wisdom of their trust is doubted in some quarters. For the last 200 years, science has given the West tremendous wealth for the benefit of the general public. The vast majority of our citizens do not have to endure cold or hunger. The major diseases that formerly decimated families and made death an ever-present threat from early childhood on, have been all but eradicated. Nonaddictive analgesics are to be found nowadays in the family first-aid cabinet. Who could doubt the efficacy of science to rid humanity of its evils and even to make man happy, particularly as the great ideologies that advocated a humanitarian ideal by having everyone follow the dictates of a social plan have proved their failure through the resulting massacres and human misery? The outcome of these ideals has shown that the sacrifices they call for are in vain. What remains is the tried and tested ideal of the consumer society bolstered by the efficacy of science. This development has profoundly changed the meaning of pain and even of suffering. In previous ages, pain and suffering were regarded as inevitable and had to be accepted as part and parcel of life. Le Breton cites Pascal, who puts it quite clearly: "It is good to make the most of evil, since it is so common, whereas good is so rare."4 The ability to withstand pain and suffering, it was thought, forges the character and puts the seal on man's strength and dignity. Nowadays, however, this conviction is losing ground. Mental pain and suffering have become an object of scandal - meaningless phenomena that science and medicine must eliminate. At the same time, most modern philosophical thought defines pain and suffering as unthinkable, something to which it is impossible to attach any meaning, as shown by J. Poree,5 and M. Baum. 6 Meanwhile, the traditional religious exegesis of suffering has come to be viewed with a great deal of suspicion as something that smacks of dolorism and even of masochism.

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Medicine has now been assigned this new task of eliminating pain. By and large, it has been successful in eliminating pain from most people's everyday lives. Furthermore, the efficacy of medicine has enabled it to reach out and discover or rediscover the phenomenon of mental suffering. This type of suffering not only accompanies pain with its aura of confusion, anguish, and, in some cases, despair, but nowadays it has become clearer than at any time in the past that certain types of moral suffering engender physical pain. Medicine has, therefore, taken on the challenge of combating mental suffering. It has discovered psychotropic drugs that can attenuate certain manifest mental illnesses such as psychosis, depression, and pathological fear. However, by extension, doctors have discovered that in many cases modem drugs can relieve the ordinary anxieties and sadness that come with everyday life. TranquiIIizers are being prescribed for children who are afraid to go to school and for adults who are reluctant to go to the dentist. People find it easier to cope with the stress of everyday life and even with life's disappointments and failures if they take antidepressant drugs. And when, at the end of the patient's life, this "therapeutic" arsenal proves insufficient in the face of death, doctors are increasingly being asked to carry out euthanasia, which is, after all, the next step in the logic according to which pain and suffering are unthinkable and even a source of indignity for man. This strange situation is causing some confusion among doctors. Until the present, it has been the doctor's task to offer psychological support to patients facing existential suffering. Now, however, biochemistry provides the answer. The doctor is thus confronted with a new dilemma concerning the nature of the psyche: Is it merely the result of the interplay of neurotransmitters, or, alternatively, does it have its own consistency and inherent nature? In more practical terms, doctors are asked what is the role of suffering in human life: Can they thus assuage everyday (i.e. nonpathological) existential suffering without destroying some of the essential human dimensions of humanity? However, on the one hand the doctor is expected to offer relief by chemical means, while on the other hand he is accused of encouraging people to consume excessive amounts of tranquillizers. He should therefore draw a distinction between "normal" existential suffering (that calls for the kind of psychological comfort that any human being should provide in such cases) and "pathological" suffering caused by the insufficiency of neurotransmitters. This may be going a bit far, but we may ask, as was emblazoned recently in the press, whether there is a "happiness pill" or a "serenity pill" that can eliminate all forms of suffering and existential malaise from everyone's life. But what kind of human beings would this produce? Will the malaise

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associated with the want that constitutes every human desire one day be eased by psychotropes without removing the desire?? The modern medical profession lacks the clear guidelines needed to provide answers to these questions. Doctors are not trained to engage in philosophical reflection - they are scientists. In addition, they come face-toface with more or less urgent or distressing individual cases of which the seriousness is difficult to evaluate. The "ambient consumption" culture offers doctors no guidelines or directives other than the imperative need to provide relief. However, what forms of suffering should they relieve, and how far should they go? The doctors' answers to these dilemmas are currently limited only by the relative insufficiency of the psychotropic drugs at their disposal and not by any philosophical conception of man. They have no way of knowing whether these limits are still valid. In this way, medicine poses for the philosopher a new dilemma: Not only does the philosopher have to attach meaning to suffering, but he must also say whether - and to what extent - suffering is part and parcel of the essence of humanity. 2.

THE PROBLEM OF VEGETATIVE LIFE

Thanks to the progress of modern medicine, more and more often doctors are able to prolong the basic vegetative dimensions of human life, more or less without any detectable mental or relational life. Chronic vegetative comas resulting from serious brain lesions are a case in point. However, the problem has a broader dimension: It is in fact possible to keep an increasing number of persons suffering from chronic senile dementia alive for several months and even for several years, apparently without any intellectual or affective life. It is possible to keep children alive who are so severely affected that they have no hope of any kind of education. To make matters worse, by resuscitating premature babies weighing 500 or 600 grams, many of whom will suffer major cerebral insufficiency, doctors are themselves engendering the situations which then leave them struggling with the question of the meaning and limitations of the concept of the "human being." These medically sustained, vegetative lives pose a challenge to doctors as to what constitutes the evidence of human life and this prompts them to decide to carry out euthanasia on people who have gone beyond this line and lost the human element of their humanity. This issue is in a way connected to the question, albeit in a totally different field, of the status (human or otherwise) of embryos, which is being challenged by the practices of IVFIET

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and, more particularly, by the experiments carried out on embryos. What constitutes human life? As long as medicine concerned itself only with striving against all odds to save human lives in a society where death was lurking everywhere, this hardly ever became an issue. When conscious and relational life was lost, death almost always came quickly. Modem technologies have opened up a whole new range of issues. In their search for some kind of answer, doctors come across evidence to show that it can be arbitrary or the result of a more or less explicit cultural convention. Scientific thought can provide some pointers on which to base our considerations, and some additional ideas will come from philosophical or religious thought. To this we might add the economic constraints imposed by the ideals of the consumer society. However, these ideas often point in opposing directions, and the doctor is left confused and looking for a way out of the arbitrariness that his scientific training prompts him to reject as unacceptable. 3.

THE DESIRED BODY

The technical/scientific progress achieved by medicine throws up a third series of new issues. Doctors are increasingly being called upon to take an active part (in an area that goes beyond pathology) in modifying the "natural" functioning of the human body. One of the first evident interventions in this field was hormonal contraception, which is now accepted as commonplace. However, things are now going much further. Lesbian couples or women who want to have a child without sexual intercourse are requesting artificial insemination. Other women are asking doctors to carry out insemination using frozen embryos after the death of their husbands. On a more mundane level, doctors are being asked to carry out surgical or hormone treatment to make various changes to the body for aesthetic reasons or even for sex changes. Other people ask doctors to choose the sex of their children. In the future, sterile couples will be asking doctors to help them become fertile through cloning, which would produce a child who is the "twin" of one of its parents. Some time in the future, and probably not very far off, gene therapy will help doctors prevent a whole range of serious illnesses. However, where should we draw the line between serious afflictions and slight - or simply "unpleasant" - anomalies, not to mention the possibility of an attempt to carry out state-sponsored eugenics, which always threatens to raise its head for economic reasons. What criteria can be used to answer these questions? The doctor's scientific training does not provide him with satisfactory answers because

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these dilemmas concern human desire, its symbolic dimension and its fundamental absence of limits. Modern medicine defines illnesses in terms of the biochemical disorders that they cause. In contrast, for doctors, good health means basically that all the chemical and physical parameters of the body are normal. This type of association already raises a problem, of course, when it comes to dealing with the psychosomatic disorders resulting from the contradiction between the desiring and symbolic vision of the body in the patient and this measurable biochemical definition of normality used by doctors. Without reference to pathology, how can we apply these biochemical criteria to the requests of which we have just cited a few examples? What answer can we give to those who wish to remodel their bodies or their children's bodies according to the fantasy generated by their desires? In this case, as in the context outlined above, the problem is where to draw the line between what is human and what is not. In times gone by, this question was answered by the "harsh reality of life," that is, the limits imposed by the nature of the body, and in particular the limits resulting from the miserable failure of medical science. Nowadays, it would appear that this "harsh reality of life" can be manipulated by technology and has become so pliable in the hands of scientists that doctors are once again left in utter confusion. In certain cases, they can see that the request is unrealistic because it masks underlying subconscious desires that will not be satisfied anyway. At other times, they are concerned because they feel that future parents want to predetermine too many of their child's characteristics, whereby the child appears to be ineluctably destined to fulfil the desire of its parents without any possibility of freedom. However, it is rare to find doctors whose relational training allows them to manage this intuition while respecting the genuine interests of the patient, his family and his progeny. Doctors' lack of psychological training is compounded in such situations by their lack of philosophical training. Even when they are well trained, how will they define the limits of the frustrations that may be necessary to preserve what is basically human? 4.

ARE THERE ANY ANSWERS?

The medical control of pain naturally leads to the medical control of suffering and conjures up the dream that one day it will be possible to control the malaise that comes with all forms of frustration, and even the want inherent in human desire. The ability to maintain vegetative life without any form of apparent mental life throws up the question of what is essentially human in

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human life. The possibilities of honnone therapies and surgery, and more particularly the foreseeable possibilities of genetic engineering, leave doctors faced with the problem of dealing with the boundless fantasies generated by the desires of human beings with regard to their bodies and their children's bodies. Doctors have been struggling with these three new issues for the last few decades. However, it is not only doctors who are challenged by these issues, but the entire cultural framework of society which faces the daunting task of offering us a new definition of man and the meaning of his existence. When left to themselves, doctors resign themselves to confusion. The practical answers they offer on the ground are chaotic and vary from one case to another, from one hospital to another and from one country to another. Practically everywhere, an antenatal diagnosis of mongolism results in a therapeutic abortion, but few people would kill a mongol child once he is born (as recommended nonetheless by P. Singer).8 Although many people would accept passive euthanasia, not so many people actually carry out active euthanasia. Some clinics agree to artificially inseminate lesbians, while others refuse. There are countless practical examples of such doubts and contradictions. In an effort to come to grips with the problem, more and more ethics committees are being set up. On such committees, doctors work with philosophers, psychologists, sociologists and other experts. This in itself is a recognition that the decisions involved extend beyond medicine and in fact embrace the entire prevailing culture. Certainly, the reflection process is clearer and the values and the principles adopted for decision-making are more clearly defined. However, in spite of all this, there is no consensus. Some, of course, adopt utilitarian positions. They advocate as their primordial criterion what is in the best interest of the patient, while subordinating this concept to the notion of the common good. However, we have yet to define "what is in the best interest of the patient." Too often, his interest is assessed mainly in tenns of the absence of suffering and even of subjective frustration, while the common good basically comes down to a question of consumption based on economic considerations. Although these criteria are useful on a case-by-case basis, they do not offer any solution to the philosophical problem of understanding what is basically human, or for that matter to the question of whether it is necessary to limit human desire to remain human. Others seek to resolve this question of what is human at a symbolic level and advocate freedom and the autonomy of man as his basic underlying value and the source of his dignity. To this end, they use the Declaration of Human

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Rights as inspiration. The doctor must therefore accede to any request that expresses and reinforces this autonomy, provided it is not harmful to others. Apart from the risk that this may lead to a form of individualism to the point where a person may ignore his essential link with society, having adopted this position it is difficult to protect people who appear to have lost their autonomy, for example, those who are mentally deficient or suffering from severe dementia. There are others - in the experimental field - who advocate acceptance of any type of experimentation that does not involve obvious risks. They extol the ethical value of scientific progress as something necessary to assuage the evils that afflict humanity. They believe that if any adverse effects appear, the experimental scientific method will identify them and enable us to correct them. In general, this position does not offer any solution to the suffering of those who, meanwhile, fall victim to such adverse effects. In addition, this approach often differs little from the clinically objective scientistic vision of man that ignores his symbolic dimension. It offers no solution to the problem of the limits of desire. Finally, it is easily contaminated by powerful economic interests. Some attempt to answer these new questions based on their religious - i.e. Christian - convictions. In their view life is a gift from God, and as God's desire is expressed through natural laws, they are opposed to all forms of euthanasia, manipulation of embryos, and insemination outside sexual intercourse and even to all forms of biochemical contraception. This concept is unconvincing to those who do not share the Christian faith. It is therefore difficult to expect this concept to serve as the inspiration for the laws of a largely pluralistic society, all the more as, even in the Christian world, these views are not unanimously embraced. Despite its basic fragility, this position does offer a challenge to all as it evokes the possibility of a transcendent dimension of man. By putting God - or Natural Law - in the equation, it points to the fact that "man is more than human." In this regard, it has much in common with the idea expressed by certain lay philosophers who also seek the transcendent dimension of man (e.g. Luc Ferry).9 If in fact we succeeded in developing this transcendence in a convincing manner, we would perhaps discover a new definition of humanity, its limitations, and the ethical rules to be observed. Meanwhile, other nonreligious thinkers have more in common with the clinical viewpoint and endeavour to give human suffering some meaning. For example, B. Vergely goes back to the Stoics and develops a similar philosophy.1O He sets out to describe an attitude that is neither a cry of des-

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peration nor a mere revolt. Perhaps like some who appear to experience this, we can "endure" life with patience, that astonishing blend of wisdom and sensitivity, that "great friend of the mystery and beauty of things." And when pain gets the upper hand, when our inner thoughts, that "presence with oneself' is lost, Vergely evokes the presence of other people that "breaks down the wall that separates everyone from himself."I! 5.

AN ETHICAL APPROACH FOR THE WEAK

In this rather cacophonous chorus of viewpoints, each of which offers not only its own strong arguments but also too many weaknesses, I would be tempted to champion views along the lines of the philosophy of Levinas inasmuch as he based his ethics on the responsibility of every man vis-a-vis other human beings. However, my approach is less philosophical than his and more rooted than his in my experience of psychology and psychiatry. Very briefly, my views might be expressed as follows. In my opinion, we must start out from the postulate that all human lives are of equal value and of equal dignity (which is a postulate that appears not only in the Declaration of Human Rights but also in the Christian religion); and that this dignity is first and foremost based on the fact that human beings have a consciousness that allows them to think about themselves and to think of others. It is within the framework of this consciousness of oneself that humans can affirm their belief in their freedom, stake a claim on their own autonomy, and express the feeling of their own dignity. However, I do not see freedom or dignity as internal properties that naturally exist in human beings. My experience suggests that conscience, freedom, autonomy, and dignity are cultural creations of a symbolic type that everyone receives through the consent, respect, and even the affection, of other people and that they have a responsibility to grant in tum to others. The primordial task of ethics is, therefore, to encourage everything that appears conducive to the creation and preservation of the sense of freedom and dignity in each human being. While appreciating the advantage to be gained in affirming general principles, such as the intangible nature of every human life or the radical autonomy of every human being, I attach more importance to the actual human relationships through which these principles come into play than to their rational enunciation. Accordingly, I feel it is more correct to associate the dignity of a person directly with the extent of solidarity offered by his fellow humans than with his own capacity for autonomy. Similarly, I do not interpret the taboo of murder only in the

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"negative" sense of a prohibition, but equally and more especially in the positive sense of the outcome that such a prohibition seeks to achieve: the duty of solidarity among humans. They are duty bound to wish life for each other and to seek the autonomy and dignity of their fellow man and to help each other to achieve these aims under good conditions. This is the very basis of the social contract and of the "dignity" of man. In practice, any ethical approach must therefore concern itself with this sense of solidarity. Of course, this may mean that we must give priority to the most fragile, that is, those whose situation is considered as inferior and whose dignity and autonomy are therefore under threat (whether the inferiority is the result of cultural or socio-economic factors or the result of illness). Whenever a culture - instead of excluding people - increases the number of people to whom it grants recognition of a level of human dignity equal to that granted to all, it achieves ethical progress, and vice versa. This happens when a slave acquires the same dignity as the master, the poor man the same dignity as the rich man, and ... the man who is sick the same dignity as the man who is healthy. This position is obviously arbitrary and idealistic. After all, human beings do not spontaneously feel equal. However, unlike positions that are in principle rational, it offers an ethical ideal which has no doubt not been achieved but which everyone can cling to and contribute towards in his dayto-day decisions. In my view, the first advantage of this ethical approach based on concern for other people lies in the fact that it restores a social link between human beings. It does not set them apart as individual entities whose autonomy is limited as it runs up against the rights of other people. It creates a social link that is both affective and positive since autonomy and dignity are received from the other person. Although we can easily recognize the legitimate right of everyone to aspire to his or her own happiness, one person's happiness is linked to the other person's desire to live and be happy. The ultimate value of human life is therefore to be found in its relational and thus symbolic dimension, without excluding the body, which is the basis for affectivity, a tendency sometimes observed in more rational positions. In the same line of thought, in my view the problem of the limitation to be imposed on the fantasies generated by desire, without, however, detracting from such fantasies, is well on the way to being solved through altruism. The rather Promethean hubris of those who set no limit on their control of the body or of the world is always likely to end in excessive individualism. The danger is that this attitude instrumentalizes certain other human beings -

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either they obstruct their striving after control or it becomes necessary to use them to achieve this end. Altruism forbids any such action, because ideally no human beings can be left behind by progress. On the contrary, it is through everyone's cooperation that it must - or should - define its breakthroughs and its limitations. Finally, this preoccupation with "concern for other people" appears to me to be "clinically" useful and enlightening when it comes to resolving exceptional cases (which is always a difficult task). It affords patients, their entourage, and their caregivers a climate of mutual trust within the framework of solidarity that creates a platform for consensus. For the sake of completeness, I should really illustrate these affirmations using examples drawn from actual situations. Also, I should no doubt go into more detail on the philosophical reflections on this issue. I would like to complete this work with the help of everyone's ideas and comments. Brussels. Belgium NOTES David Le Breton. Anthropologie de la Douleur, Paris: Metailie. 1995, pp. 163-164. Op. cit. p. 162. J P. Patrick Verspieren, S.1., "Les Discours sur la souffrance dans Ie Catholicisme," Laennec, Paris, March 1996, pp. 7-11. 4 Le Breton, op. cit. p. 161. 5 Jerome Poree, "Mal, souffrance, douleur," Dictionnaire d'ethique et de philosophie morale. Under the dir. ofM. Canto-Sperber. Paris: PUF, 1996, pp. 904-911. 6 Mylene Baum, "Peut-on repondre a la souffrance d'un point de vue medical?" Review of the Societe Balint Beige, 59, December 1997. 7 D. Le Breton, op. cit. 8 Peter Singer, Questions d'ethique pratique, Paris: Bayard Editions, 1997. 9 Luc Ferry, L'Homme-Dieu ou ie Sens de ia vie, Paris: Grasset, 1996. 10 Bertrand Vergely, La Souffrance. Recherche du sens perdu, Paris: Gallimard, FoliolEssai, 1997. II Andre Meury, "Le Monde des Poches." November 8, 1997. Recension of the work by B. Vergely. I

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SECTION III THE LIFE-TRANSCENDING PARAMETERS IN THE INTERPRETATION OF SUFFERING, DEATH, AND HUMAN EXISTENCE: BUDDHISM, JUDAISM, CHRISTIANITY

HERVE BARREAU

THE MEANING OF SUFFERING IN BUDDHISM AND CHRISTIANITY

Any attempt to carry out a brief comparison between the meanings attributed to suffering in Buddhism and in Christianity would appear to be a well-nigh impossible task. Indeed, the only manner in which such an undertaking would be possible, would be to consider Buddhism and Christianity as two spiritual disciplines rather than in any way as established religions which have given birth to traditions which differ slightly from one another, even though they are based on the same source. In this study we shall be considering these spiritual disciplines solely in respect to their source and - at the risk of oversimplifying - we shall be looking at their points of convergence, and their points of divergence. Both aspects may further our understanding of today's spiritual context and of the choice offered between these two spiritual disciplines. I.

POINTS OF CONVERGENCE

We may observe three points of comparison between the two, all of them embodied in the very nature of their spiritual message - in which suffering plays an essential part - which shall become ever clearer. First of all, Buddhism and Christianity both have what one might call a spiritual approach to suffering. They refuse to limit moral suffering to physical pain, despite the links that may exist between them. They believe, moreover, that it is easier to relieve or even eliminate such pain than to heal moral suffering. And, above all, they refuse to concede that the same methods that succeed in eliminating physical pain are equally successful in eliminating moral suffering. Here they would appear to be at variance with modern Western thinking which encourages us to believe that by setting up measures for health care and social welfare, backed up by a forceful policy, it is possible to overcome both suffering and pain despite the distinction maintained between them. This explains the persecution suffered by these spiritual families at the hands of political regimes armed with such beliefs. These regimes bring into play an important element of the materialism that is aimed at governing our civilization: For the latter, all that is required is to find the right technique which, if appropriately applied with sufficient means, 195 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXll, 195-201. © 200 1 Kluwer Academic Publishers. Printed in the Netherlands.

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should succeed in dispensing with all the negative aspects of our existence. Buddhism and Christianity are opposed to this materialism and denounce its overweening and - ultimately - damaging arrogance that is destroying mankind. They attach greater importance to the person who suffers, who, in each case, is seen as a single individual whose personal load of suffering cannot be unburdened by other individuals or by any other community - even though we are required to help carry such a load by manifesting charity or compassion. Nothing is further in keeping with these spiritual families than the setting up of hospitals in which all forms of suffering - both physical pain and moral suffering and the intertwining of the two can be healed or, at least, alleviated. Why is it impossible to do away with the sufferings of this world by coercive means? In essence, it is due to the fact that, for both Buddhism and Christianity, the cause of suffering is extremely obscure and yet highly meaningful at the same time. This constitutes a fundamental state of disorder that takes its origin from moral misdeeds that tend to accumulate and proportionally increase the true causes of suffering. Yet there is no way of forestalling moral misdeeds in others by force; the only way of doing so would be by committing an extremely serious moral misdeed oneself, namely by preventing a human being with a mind of his own, from exercising his spiritual autonomy. This explains the precepts of nonviolence and religious freedom. On this latter point, it would appear that Buddhism and Christianity are in accord. Moral evil is a hole to be climbed out of that all people carry within themselves. We can and must help others climb back up this slope, but it is a task that nobody can be spared. Regarding the latter, Buddhism shares with the Hindus the concept of karma, which designates the deed and its immanent consequences which call for retribution, and which is linked to the doctrine of transmigration and reincarnation. l Here we find individual lines of karmic responsibility, even if, strictly speaking, no independent self actually exists. Christianity, for its part, lays down the doctrine of the original sin whose effects are made to be felt on each moral agent - even the most innocent - since each moral agent has difficulty, according to the accepted doctrine, in making the demands of love and moral law prevail over his own self-centred interests and given that such prevalence calls for a conversion of the heart which is always personal and always to be recommenced. In both cases, the burden of evil and suffering is linked to human existence which pays for misdeeds committed at a time far removed from the agent who suffers the consequences. The third element of convergence between Buddhism and Christianity is apparent in their common refusal to succumb to moral evil and the ensuing

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suffering. In this respect, Buddhism and Christianity stand in opposition to traditional wisdom (Stoic and Spinozist, in particular) that tends to refuse the dignity of suffering, which they see as nothing other than an opportunity to renew their adherence to the universal cosmic order: Amor fati. Moral evil and suffering truly exist for Buddhism and Christianity, yet it is something from which one can free oneself and all mankind. That is precisely the program offered in the "four noble truths" that constitute the basis of Buddhism as preached by Gautama himself in his sermon at Benares, to initiate his teaching. 2 The first two truths relate to suffering that is universal (although not specifically made distinct from pain or dhuka, it would clearly appear that this term covers both concepts, expressing the inevitable misery of the human condition) and to the cause of suffering, namely the desire or thirst for existence. The last two truths relate to the cessation of suffering, namely nirvana or extinction of all desires, and the path leading to such cessation, which comes down to the practice of moral ethics and meditation. In Christianity, redemption and salvation are presented in a different light. We shall be examining this difference later, when studying the points of divergence between the two. However, it is important to point out beforehand that redemption and suffering also constitute an important - and even essential - aspect of the Christian message in terms of "good news." This can be illustrated in two teachings of this message: firstly, in the moral sayings of the Beatitudes which, while they admittedly acknowledge the existence of suffering on this earth, do not call for its abolition and even proclaim its necessity for the Master's disciples, but nevertheless set forward an argument for accepting and transforming such suffering through the promise of entry into the Kingdom of God for all those who patiently endure their suffering; and, secondly, the proclaiming of the total suppression of all suffering in this fUlly established Kingdom, when God will at last wipe away all tears from the eyes of his faithful. 3 In a word, this is redemption in two stages - the second being held over until after the resurrection of the dead. 2.

POINTS OF DIVERGENCE

In the message itself, relating to liberation from suffering, we have thus already observed the major points of divergence. These relate to the manner in which mankind can be delivered from suffering. They may also be observed from three different points of view which, as we shall see, are once again closely related to one another. It should first be noted that although Buddhism stems from the teachings of the Buddha - which are in no manner brought into question by any of the

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various forms of Buddhism - this does not, nevertheless, confer upon the Buddha the role of Mediator as understood in Christianity. Certainly, Buddha revealed the path to salvation, which he himself had discovered, yet he never claimed to play the central role in bringing about that salvation. Such is not the case in Christianity. Jesus is the Son of God, the Lord who brings to an end the divine revelation presented in Judaism by declaring himself to be the long-suffering Servant who the prophet Isaiah (chapter 53) had announced would atone for the iniquities of his people through his painful devotion. Following the resurrection of Christ, this people coextends to encompass the whole of mankind. Christianity thus constitutes the proclaiming of a salvation that has already taken place, as embodied by the resurrection of Christ. Believers must thus first accept this redemption by becoming aware that it concerns themselves, because of their astounding failings in the face of ordeals, both at the time of Christ and still today. Such is the faith that is required of those who wish to enter the Kingdom of God. And this faith must be accompanied by a predisposition to suffer ordeals that, on the one hand are inevitable in any human existence on earth and that furthermore, appear to be particularly linked to those leading a Christian existence since, subsequent to Christ,4 these people are called upon to bear the cross. Paul the Apostle, the author of the epistle to the Hebrews, Peter the Apostle, and the author of the epistles of John all bear witness to this fundamental teaching that cannot be brought into question without modifying Christianity. As a result of the existence of this Mediator, Christianity acknowledges the special role to be played by the Church - comprised of Christian believers - that this Mediator founded. For this Church is entrusted with the sacraments of the new life brought by Christ, particularly Baptism and the Eucharist. In Buddhism, the community of followers (the Sangha) also has a role to play; it is by way of this community that a monk is ordained and guided over a period of 10 years. The monk is also entrusted with the mission of educating laymen. Nevertheless, the major role is left to the follower who has to personally work on himself. He is able to attain deliverance by way of his own asceticism, in accordance with the paths he is instructed to follow. In Buddhism, there is a doctrine, or rather a Law (dharma), yet no definitive cult or heresy; there are only schisms that arise out of different interpretations of the doctrine, based on the experience of a spiritual leader. This leads us to the third difference, which this time relates to the very nature of salvation - the desired end to all suffering, which represents in fact nothing more than a negative aspect. The Buddha has always refused to clearly define what nirvana amounts to, and modern Buddhism makes

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reference to "vacuity" as being the ultimate reality into which the state referred to as nirvana immerses itself and which can only be attained fleetingly during life on earth. Christianity has a quite different approach, since the Mediator who carries the word of God, is also God himself. Salvation consists in taking part in heavenly life, as of this world, namely by way of the believer substituting his own life - which finds itself laid bare yet uplifted at the same time - with a heavenly one: "Eternal life is that they might know thee the only true God, and Jesus Christ whom thou hast sent" (John, 17, 3) is what Jesus himself is reported to have said in his prayer after the final paschal meal partaken of with his disciples. In a similar manner, Paul affirms that "he has been crucified with Christ," and that "it is no longer he who lives but Christ who lives in him" (Galatians, 2, 19-20). Thus nothing prevents the essence of salvation - which is given and not taken by force - from being attained and retained in the course of life on earth. Nevertheless, Christian salvation, as we have already observed, does not do away with suffering which remains linked to earthly life until the final return of Christ. This explains why - in the same speech in which he describes the essence of Christian salvation - Jesus is reported to have said, according to John, just before the preceding declaration: "In the world ye shall have tribulation: but be of good cheer; I have overcome the world" (John, 16, 33). Considering the manner in which Jesus conquered the world, it does not promise to be an easy victory. The same teaching emerges from what are termed the synoptic Gospels. In answer to the disciples who ask him what reward awaits those who have left all in order to follow him and spread the Gospel of salvation, Jesus admittedly promises them a hundredfold of what they have left behind, yet with persecutions, and "in the world to come etemallife" (Mark, 10,30). This suffering - which Paul affirms to rejoice in, since, in this way, he complements Christ's passion for his body, which is the Church5 - is never truly absent from the life of a Christian, and particularly an Apostle. It is that suffering which appears to be beyond all comprehension to today's materialistic world, yet it is not impossible for it to appear highly meaningful to a persecuted Buddhist who remains steadfast, in spite of all the efforts deployed in order to weaken his resolve. Christianity has provided the martyr with unequalled strength; many non-Christians who have drawn inspiration from it have perhaps come close to the deep meaning of Christ's sacrifice, which for Christians themselves remains an act of faith rather than one of intuitive understanding. Whatever the case may be, Jesus is the very symbol of the spiritual victory gained by self-sacrifice, and it would appear that he himself was committed to such being the case (John, 12,32).

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CONCLUSION

This brief comparison that we have endeavoured to carry out with regard to the theme of suffering in Buddhism and Christianity demonstrates that each puts forward two different solutions to the problem of human suffering. The former favors, in its solution, a monastic existence which is supposed to lead to deliverance from all spiritual oppression, enlightenment attained by meditation that surpasses the limits of individuality and extinguishes desire that is the cause of all suffering. The latter, by contrast, contents itself with acknowledging the virtues of a monastic existence that it did not invent and which it contents itself with welcoming into its churches for those who feel a calling for it. For the deliverance offered by Christianity does not reside in the relinquishing of all worldly goods and pleasures - although, in some respects, such is also required of its followers - but in the faith in the Saviour's love and in the answer to such love which takes the form of obedience to divine will as manifested to each individual. The existence of the Mediator and the example he sets for his disciples in order to enable them to imitate him are thus at the heart of the difference that exists between these two spiritual disciplines. Nevertheless, in view of the numerous similarities between the approaches led by these two disciplines with regard to human suffering and misery, it is not surprising that a certain number of Westerners, who no longer perceive what the Christian message holds for them today, are turning towards Buddhism, which offers them what they see as being a form of asceticism that more appropriately corresponds to their quest. On the other hand, many Orientals - fully aware of the profundity of Buddhism, yet equally aware of the difficulty of drawing a lesson from it that is adapted to all individuals and is sufficiently clear, particularly with regard to the realm of metaphysics - are turning towards Christianity. As long as, on both sides, the quest is an authentic one, this should not be interpreted, it would seem, as proof of syncretism but rather of a demand for spiritual authenticity, which is a sign of hope in the face of the utter moral confusion into which our planetary civilization is plunging. Strasbourg NOTES I

2

J. Brosse, Le Bouddha, Paris: Pygmalion, pp. 89-96. Ibid., pp. 43-47.

MEANING OF SUFFERING IN BUDDHISM AND CHRISTIANITY 3 4

5

Book of Revelation, 21, 4. Luke, 9, 23-26 (in panicular). Colossians, I, 24.

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THE CHRISTIAN INTERPRETATION OF SUFFERING

The point of view of the Christian faith in perceiving the various sufferings of human beings is determined by hope for a future that will overcome all suffering definitively. Thus in the Book of Revelations the future of the kingdom of God, the new Jerusalem, is described not only as the place of God's dwelling with human beings, but it also says: "He will wipe away every tear from their eyes, and death shall be no more, neither shall there be mourning nor crying nor pain anymore, for the former things have passed away" (Rev. 21, 4). Christian hope here reasserts promises from the Old Testament in a generalized way, beyond the limits of the people of the old covenant. Almost literally the word from Revelations alludes to Is. 25, 8: "He will swallow up death forever, and the Lord God will wipe away tears from all faces...." In the Revelation of John this is combined with Is. 35, 10: " ... Sorrow and sighing shall flee way" and also Is. 65, 19 about the new Jerusalem of God's saving future: "No more shall be heard in it the sound of weeping and the cry of distress." The background of this hope is the fact that suffering in its various forms characterizes the present lives of human beings everywhere, the lives of most people during most of their earthly existence. Suffering accompanies not only sickness or accident, but also occurs in hunger or poverty, the lack of progeny, and the loss of close relatives and friends. Often our sufferings are caused by what others do to us in times of war and by violence or injustice, by calumny, scorn, derision, or neglect. Wherever the integrity of our life, in its physical or psychological aspects, is violated, we suffer. Integrity of life means wholeness, and anything that infringes upon such wholeness causes more or less suffering. By contrast, healing means the restoration of the wholeness of our lives, without regard to the damage that has been done to us, and the complete wholeness of life means salvation. Sometimes the concepts of well-being and salvation have been distinguished to the effect that earthly well-being is considered quite different from spiritual salvation, which belongs to the realm of religion. I consider a separation between wellbeing and salvation to be wrong, for it is the wholeness of human life that is at stake in well-being as well as in salvation. This should be evident from the original meaning of the word salvation. The separation of salvation in the religious sense from other aspects of wholeness, integrity, and health serves 203 A.- T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXII, 203-211. © 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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only the secular tendency to treat the religious dimension of human life as a matter of only private interest rather to acknowledge the fact that religion is concerned with the wholeness of human life in all its dimensions. There is also always a religious aspect to suffering. In the psalms of Israel the sick person is considered to be left alone by God: "0 Lord, why dost thou cast me off? Why dost thou hide thy face from me?" (Ps. 88, 14). The sick person is close to death like those "who lie in the grave, like those whom thou dost remember no more, for they are cut off from thy hand" (88, 5). Therefore such a person cries out to God, the source of life, because his or her soul is "saturated with suffering" and close to the realm of the dead (88, 3). In other forms of suffering the situation is similar, in cases of injustice, calumny, and persecution by enemies. In these cases also the complaint is addressed to God, beseeching him for his help: "With thy faithful help rescue me from sinking in the mire; let me be delivered from my enemies and from the deep waters" (Ps, 69, 14). "Do not hide thy face from thy servant; for I am in distress, make haste to answer me" (69, 17). In summary it may be said: The deepest core of all suffering, according to the Psalms, is to be abandoned by God. Sickness, injustice, violence, slander are overwhelming evils to the person who is abandoned by God, and God's presence can save him or her from all of them. In the midst of such suffering the person praying in the Psalms considers himself or herself to be secure with God: "Whom do I have in heaven but thee? And there is nothing upon earth that I desire besides thee. My flesh and my heart may fail, but God is the strength of my heart and my portion forever" (Ps. 73, 25f). While God's presence is the assurance of salvation and life to the sufferer who turns to God, the one who turns from God is abandoned to death, because "those who are far from Thee shall perish" (Ps. 73, 27). To tum away from God and from his presence already entails death as the inevitable consequence, because God is the source of life. In the clear logic of this conviction the faith of Israel did not allow itself to be shaken even by the experience of the apparent fortune of the wicked and ungodly. We shall return to this point. The reason for this stubborn persistence of the Jewish faithful is, in any event, that in opposition to many contrary experiences, one insisted upon the conviction that turning away from God in sin must finally end in suffering and death, because God alone is the origin of life. In consequence of this principle the conclusion suggested itself that sickness, suffering, and death is to be regarded as the outcome of the human behaviour of turning away from God. Similarity, death and everything that brings people close to death was considered a consequence of sin. It was in this way that even Job

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interpreted his sufferings, although he was not conscious of any sin (Job 8, 29ff.). Sin ends in death, Paul says (Rom. 6, 16.23). Sin deceives the human person by promising a fuller life, and precisely by such foolish hopes it delivers him or her to death (Rom. 7, II). Probably Paul was thinking here of the biblical story of the first human beings in paradise, where we are told how the serpent seduced Eve into eating the forbidden fruit. God had strictly prohibited his human creatures from eating the fruits of the tree in the center of the garden, because the first human beings would die of its fruits. The serpent persuaded Eve however: "You will not die," but "God knows that when you eat of it your eyes will be open and you will be like God, knowing good and evil" (Gen. 3, 5). That means that human beings will be empowered to know everything and judge everything, and God in his envy does not allow that. Thus the desire for the fullness of life becomes the occasion to violate the divine precept. But the desire that turns against God and his command is sin. It means to turn away from God. Therefore the desire deceives the human person. It arouses the illusion of the fullness of life, but in reality delivers the person to death. In this way Paul described the connection leading from sin to death in Rom. 7, II. If in general, death occurs as a consequence of sin, which turns a person away from God, and sickness and suffering according to the witness of the Psalms put the human person close to death, does it not follow that suffering in its various forms is always a consequence of sin? According to the story of the origin of sin in paradise, this applies at least to the pain of women in childbearing and giving birth, and the same applies to the pains of labor in working the fields (Gen. 3, 16ff.). But does it apply correspondingly to all sufferings that people have to bear? In the book of Job this opinion certainly occurs in the words of Job himself (9, 29), although he is quite sure of his innocence (9, 21). The book of Job as a whole, however, interprets Job's sufferings from quite a different point of view, which is to say as a test of his faithfulness to God. Furthermore, there are many human sufferings that do not occur as an immediate consequence of people's behavior. They originate in the hostility of others. That is not only evident from the lamentations in the psalms, but already from the story of Cain and Abel, that follows immediately after the expulsion of their parents from paradise (Gen. 4). Individual experience is far from confirming unequivocally the thesis that there is a correspondence between what people do and what occurs to them. Good conduct is not always rewarded by happiness, and crimes do not always lead to the disaster of the criminal. Consequently the question arises: How can God permit things like that to happen? How is

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innocent suffering and the comfort of the ungodly to be reconciled with belief in the righteousness and justice of God? This is the problem of theodicy, of justifying God in view of the overwhelming experience of apparently unprovoked evil and suffering in the world he created. This problem accompanies monotheism like a shadow. This is true already of the philosophical monotheism of classical antiquity and even more so of the Jewish and Christian belief in one almighty and loving God as creator of the world. Monotheism cannot get rid of the responsibility for the evil occurring in the world by laying the blame upon some other agency than God. Certainly the abuse of the creature's freedom may be responsible for at least the moral evil in the world, but God always remains the maker of the creature, including his or her freedom, and he should have been able to forsee such abuse. How could a wise and benign creator, who is also almighty, admit so much wickedness and evil into his creation, which becomes the cause of so much suffering in his creatures? That is the strongest argument of atheists to this day. They only need to point to the general condition of this world to substantiate their claim that this world cannot have been created by a loving and also almighty God. The old people of Israel were never tempted to accept such a conclusion, great as their sufferings were in consequence of the physical and moral evils in the world. Their God may have receded into obscurity, when his righteousness was no longer noticeable in the course of events. But such experiences did not induce them to doubt his existence. He remained the only one of whom it could be hoped, that finally evil and suffering would be overcome. Thus people would acquiesce in adoring the superiority of God in his power and wisdom beyond human comprehension. Or one looked fora meaning in the sufferings of the righteous ones, like the book of Job did, in terms of testing their faithfulness and their obedience to God. In addition there was the evident motivation of anger and hatred of the wicked in their relations with the righteous ones, as the psalms lamented. This motive could also combine with that of God's testing of the faithfulness of his faithful servants, especially with regard to the suffering of the prophets and later in the interpretation of the passion of Jesus. The prophet suffers because his message is not accepted, but met with hostility. He also suffers because of God, like the example of Jeremiah shows, when God does not fulfill the menacing words of the prophet and thus compromises his authority. In a different way, the passion of Jesus was a consequence of his proclamation, because his message of the imminent presence of the kingdom implied the claim that God's salvation is presently active

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already through Jesus' own person. This could be heard as an impudent presumption and even as blasphemy, and the enmity against him it aroused became the cause of his suffering and death. Jesus nevertheless kept to his divine mission. The epistle to the Hebrews comments: "He learned obedience through what he sufferetf' (Hb. 5, 8), obedience to God his father, who sent him into the confrontation with his enemies that was to end in his death on the cross. Paul also wrote in his letter to the Philippians (2, 8) of Jesus, that he became obedient to God to the point of his death, even the death on the cross. The passion of Jesus, like that of the prophets, has been correctly characterized as "professional suffering," a suffering that had to be endured as a consequence of his mission that he had accepted from God. This was the particularity of Jesus' suffering, as distinct from all our sufferings from sickness or accidents. The apostles, however, participated in the sufferings of Christ when they delivered the gospel of Christ to the world and met the hostility of the world like Jesus himself did with his proclamation. Thus Paul said that "the sufferings of Christ came upon us" abundantly (2 Cor. I, 5), which is to say upon himself and upon those who cooperated with him. But in those sufferings he also discerned the guarantee of their future participation in Jesus' resurrection and in his new life. By sharing in the sufferings of Christ and in his death. Paul was hopeful to "attain the resurrection from the dead" also (Phil. 3, 10ff.). Paul could say the same for all Christians who are one with Christ through their baptism and who are exposed to the enmity of the world because of their profession of Christ (Rom. 6, 5). With regard to the prospect of the life to come, however, he said: "The sufferings of this present time are not worth comparing with the glory that is to be revealed to us" (Rom. 8, 18). From the point of view of the death of Christ then, all suffering, not only the professional suffering ofthe apostles, is seen in a new perspective. For the fate of death is universal. It concerns every human person. If the death of a person can be anticipated sacramentally through baptism and be united to the death of Christ, then each person can obtain the hope through baptisfrJ of a life beyond death, a life that has become apparent with Jesus already. This knowledge strengthens the baptized person to be patient in suffering (2 Cor. 1,6). Paul could even write that suffering itself causes patience (Rom. 5, 3), at least to those who are connected to Christ through faith. Thus the Old Testament exhortation to patience in awaiting the help of God and the fulfillment of his promises is combined with a new reason, because the new life that overcomes death has already become apparent in Jesus Christ. The

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more fervent Christians can be called upon to look at the example of patience in suffering that was provided by the prophets (lac. 5, 10). The hope for future participation in a new life for all those who now share the sufferings of Jesus Christ (Rom. 8, 17), could be extended by Paul to embrace all of creation. In the Epistle to the Romans he writes: "... the creation waits with eager longing for the revealing ofthe sons of God," which is to say that a new life out of the resurrection of the dead will become apparent in the Christians. For "the creation was subjected to futility, not of its own will but by the will of him who subjected it in hope, because the creation itself will be set free from its bondage to decay and obtain the glorious liberty of the children of God" (Rom. 8, 19-21). The "eager longing" of all of creation is an expression of its suffering under "the bondage of decay." Therefore, Paul says "that the whole creation has been groaning in travail together unto now" (8, 22). The picture of a woman laboring in order to give birth to a new life is related to the birth of new life out of the resurrection of the dead. Paul's conviction that all creation will participate in this liberation from the dominion of death is to be understood in the light of the prophetic promise of a new heaven and a new earth to come (Is. 65, 17; 66, 22). But who was it who subjected, as Paul said, creation to the fate of perishableness, to the dominion of death? Many exegetes thought this to be an allusion to the story of Adam's fall from paradise, which subjected not only his posterity but all of creation to the yoke of death. B~t it seems difficult to say of Adam that he actively subjected creation to death, and certainly he could not have done so "in hope." Therefore other exegetes who prefer to relate the somewhat obscure phrase "the will of him who subjected it in hope," to the creator himself, may be correct. This interpretation also corresponds to what the apostle says in the first letter to the Corinthians, where he wrote: "What is sown is perishable, what is raised is imperishable.... The first man was from the earth, a man of dust; the second man is from heaven" (1. Cor. 15, 42b and 47). Perishableness thus characterizes the life of the first creation. Imperishable life was obtained first by Jesus Christ, the second Adam. In this passage there is no reference to a paradise in the beginning of human history and to a fall that became the cause of death in the world. Rather it is said that the first man was created by God as a perishable being, and likewise we read in the epistle to the Romans that the entire creation was subjected to perishableness by God but "in hope," which is to say, with a view towards a future new imperishable life that was to be initiated for humanity - and apparently with a view to all of creation - in the resurrection of Jesus Christ.

THE CHRISTIAN INTERPRETATION OF SUFFERING

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h~w~~~~~~~~~~~~~~~

death is caused by sin, equivalent, as it were, to the "wages" that are paid by sin to her servants (Rom. 6, 23)? Paul remained in the line of Israel's conviction that sin separates from God, who is the origin of life, and consequently sin ends up in death, making such separation definitive. But in Paul's words this connection between sin and death is put into a more comprehensive framework, when he speaks of the perishableness of God's creatures as a consequence of an arrangement by the creator himself. These considerations have to contribute something decisive to the interpretation of suffering. For suffering and perishableness belong together. Therefore Paul says of all of creation that the creatures "groan" together with human beings under the yoke of perishableness (Rom. 8, 22). All creatures long eagerly, as we human beings do,for a life that is no longer subjected to the dominion of death and therefore no longer perishable. That is the wholeness, the abundance of life that all creatures strive to attain and preserve. But this wholeness of life, salvation, is "not yet" obtained. That is the root of suffering in this perishable form of life. The definitive integrity of our life is not yet achieved, and when we try to gain it for ourselves, we get involved in conflicts with others and become involved in new suffering for ourselves. To suffer from perishableness is the basic form of suffering. It is made concrete in all the special forms of suffering by sickness, injury, the denial of fulfillment. Suffering, then, is not only a consequence of sin but is also due to the fact that we lack the wholeness of life. Certainly such suffering gets intensified through sin when we try to be like God and yet must fail in this enterprise, Still, human beings try that again and again at the expense of others, and thus make them suffer. But suffering is already connected with the perishableness of our life, and that perishableness is ordained by God himself, because as finite beings we can obtain an independent existence of our own only under conditions of time. Our destination certainly transcends this perishable life. It points towards participation of our independent, created existence in God's eternal life. Therefore the complaint expressing the feeling of our suffering is no offense against God. It gives expression to our destination beyond the fragmentary form of this perishable life. From such a perspective it is possible to understand how Jesus in his Sermon on the Mount could praise those who complain of their sufferings: "Blessed are those who mourn, for they shall be comforted" (Mt. 5,4). Not only are those who are reviled and persecuted on behalf of their confession to Christ blessed, but also all those who suffer because they long for the future of

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salvation that can be brought about by God alone. Therefore, they are open for Jesus' proclamation of the imminent future of God's kingdom. Jesus' proclamation of woe, however, is directed to the rich and saturated, because they think they have obtained satisfaction already in this life and are no longer in need of the future salvation of God. When suffering is considered in itself to be damaging and crippling our life, it is meaningless and in many cases disgraceful. But it receives a significance when it becomes the occasion of longing for the future salvation that transcends this perishable existence. The meaning of suffering is in the salvation that God will bring about. In conclusion, this lecture will be illustrated by the story from the Gospel of John telling of the healing of the man born blind (9, 1-7). It begins with the question by the disciples who were shocked by the misery of this man and asked Jesus whether his suffering was produced by his own sin or by the sin of his parents. The question certainly indicates the compassionate revulsion of the disciples in view of such misery. It demands an explanation of how such suffering is to be reconciled with the righteousness of God. The customary explanation, however, was that suffering is the consequence of sin. Each person has to bear the consequences of his or her own conduct. But in a case like this, when somebody is blind from birth, such an explanation seems impossible. After all, he cannot have sinned even before his birth. Therefore, the disciples asked whether perhaps the sins of his parents were responsible for his suffering. But Jesus rejected the question and together with it this entire interpretation of suffering, in his answer: "Neither did he sin, nor did his parents, but the words of God are meant to be manifest in him" (9, 3), and immediately afterwards this happened through the act of healing. In this as in all other healings, Jesus brought about an anticipation of the future salvation, the eternal life, that God preordained for his human creatures. The meaning of suffering, Jesus' answer says, is to prepare human beings for the salvation God has preordained for them. The story indicates furthermore that it is not sufficient to comfort those who suffer by pointing their attention towards this future, but that the power of that future must become manifest with them even now, and that occurs in the act of healing that the person born blind experiences. It is remarkable how Jesus includes the disciples in his argument for his healing action: "We must work the works of him who sent me, while it is day" (9, 4). We are not supposed just to watch Jesus with astonishment, but to become active like himself. Another remarkable detail in this story is the double meaning in the result of Jesus' "therapy": The man born blind becomes able not only to see the things of this world, but also to see and

THE CHRISTIAN INTERPRETATION OF SUFFERING

211

recognize Jesus the Christ, while the healthy people who consider themselves normal in their ability to see, do not want to see Him. lnstitutfiir FundamentaLtheoLogic und Okumene Munich

MENAHEM R. MACINA

LA MALADIE DANS LA TRADITION JUIVE

Orthodoxie et Orthopraxie INTRODUCTION

Passer en revue les conceptions de la maladie qui s'expriment dans la tradition juive est une entreprise risquee et qui - j'en ai fait maintes fois I' experience - expose Ie theologien de service qui a accepte d'en traiter ex cathedra aux tirs de barrage de ceux-Ia meme, specialistes d'autres disciplines, qui l'ont prie de Ie faire. Je prends donc ce risque, non sans vous demander de faire preuve de cette disposition favorable du creur et de cette humilite de l'esprit, sans lesquelles l'ecoute de l'autre n'est que politesse formelle, ou concession momentanee de parole de la part d'un interlocuteur qui n'a un instant endigue Ie fleuve de ses certitudes que pour les deverser ensuite sur I' imprudent que vous etes, des qu'il estimera que vous avez epuise vos chances de Ie convaincre. A l'instar de son collegue chretien, et peut-etre avec plus de rigueur, Ie theologien juif est confronte a un dilemme. D'une part, conscient de I'auguste dignite de l'etre humain, cree a l'image de Dieu, mais aussi de sa faiblesse et des difficultes de sa condition incarnee, il voudrait passionnement parler de Lui a ses semblables, leur dire ce qu'il attend d'eux, en termes que chacun et chacune puissent comprendre et accepter. Par ailleurs, s'il n'est pas lui-meme devoye ou demagogue, il sait que ce Dieu, dont il s' efforce d' exposer les voies et les exigences, agit et s' exprime souvent de manihe tellement deconcertante, a vue humaine, que Ie simple enonce de ses actions et de ses paroles, telles qu'elles sont relatees dans les Ecritures, risque de scandaliser les esprits les mieux disposes. Dieu ne dit-il pas Lui-meme (Ex. 20, 5): Je suis un Dieu jaloux qui punis la faute des peres sur les enfants, les petits-enfants etles arrierepetits-enfants pour ceux qui me ha"issent.

Ou encore: (Dt 32, 35)

A moi la vengeance et la retribution, pour Ie temps oil leur pied tn!buchera ... Contrairement a une opinion tres repandue, il ne s'agit pas la de conceptions heterotestamentaires «totalement etrangeres a l'Evangile d'amour 213 A.-T. Tymieniecka and E. Agazzi (eds), Analecta Husserliana LXXll, 213-233. © 2001 Kluwer Academic Publishers. Printed in the Netherlands.

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de Jesus-Christ». En temoignent des passages neotestamentaires tels que ceux-ci: [C'est Jesus qui est cense parler, en faisant allusion au jugement eschatologiquel: Quant 11 mes ennemis, ceux qui n'ont pas voulu que je regne sur eux, amenez-Ies ici, et egorgez-Ies en ma presence. (Le. 19,27).' Quand Ie Fils de l'homme viendra dans sa gloire, escorte de tous ses anges, alors il prendra place sur son trone de gloire.... Alors il dira encore 11 ceux de gauche: Allez loin de moi, maudits, dans lefeu eternel qui a ele prepare pour Ie diable el ses anges . .. (Mt. 25, 31-33; 41).

A la lumiere de cet aper~u, forcement sommaire, il est facile d'entrevoir que les reponses de I'Ecriture et de la tradition juive au dramatique probleme de la souffrance humaine, en general, et a celui de la maladie, en particulier, risquent d' etre tout aussi derangeantes, voire scandaleuses pour Ie croyant moyen. Je procederai, ci-apres, a un inventaire sommaire des conceptions relatives a la maladie, telles qu' elles s' expriment dans les ecrits bibliques canoniques (I), dans Ie Nouveau Testament (II), et dans la litterature rabbinique des premiers siecles (III), en les illustrant par des textes de reference, choisis parmi ceux qui font autorite tant pour Ie judai'sme que pour Ie christianisme. Entin, dans la demiere Partie de cette etude (IV), je brosserai, a grands traits, un panorama des opinions et des croyances des penseurs juifs orthodoxes, du Moyen Age a l'epoque modeme, et des comportements qu'ils preconisent face a la maladie et aux souffrances qui en decoulent. Tenant compte du fait que, sauf exception, je m' adresse a un public non verse dans les sciences juives, j' ai choisi de donner a mon expose un caractere plus descriptif que speculatif. I.

LA MALADIE DANS LA PREMIERE ALLIANCE

Plus de trois cents versets du Premier Testament parlent de la maladie, soit pour en faire etat, soit pour relater des faits de guerison, generalement miraculeuse. Pour les ecrivains sacres, la maladie vient de Dieu, elle est la consequence du peche, et e1le sert d'instrument de chatiment. Plus surprenant: Dieu lui-meme se fait Ie medecin des malades et exige qu'on ait recours a lui pour etre gueri. Entin, Ie devoir de visiter des malades n'est pas oublie. I.

Passages scripturaires mentionnant des guerisons divines

lis abondent. En voici un florilege:

LA MALADIE DANS LA TRADITION JUIVE

215

• Nb 12, 13: [A propos de Myriam, devenue lepreuse en raison de sa medisance a l'egard de MOlsel: MOise implora Ie Seigneur: '0 Dieu, dit-il, daigne la guerir, je t' en prie!' • Dt 32, 39: C' est moi [Dieu) qui fais mourir et qui fais vivre; quand j' ai frappe, c' est moi qui gueris et personne ne delivre de rna main.

L'Ecriture nous rapporte la guerison de Naaman, courtisan du rai de Damas, qui etait lepreux (cf. 2 R. 5). En 2 R. 20 (= Is. 38, 5), Isa'ie guerit Ezechias d'une maladie martelle et lui ajoute quinze annees de vie. Dans Ie livre de Tobie, non canonique mais connu de la tradition juive, c'est I' Ange Raphael lui-meme (dont Ie nom signifie precisement 'Dieu a gueri') qui delivre Tobie de sa cecite. Pour Ie livre de Job (5, 18), c'est Dieu "qui blesse, puis panse la plaie, qui meurtrit, puis guerit de sa main."

2.

La maladie comme chatiment ou consequence du peche

Au moins une cinquantaine de passages scripturaires font etat de ceUe conception. En voici un bref f1oriU:ge. • Lv 26, 15-16: "Si vous rejetez mes lois ... Je vous assujettirai au trembLement, ainsi qu'ii La consomption et ii La fievre qui usent Les yeux et epuisent Le souffle." • Nb 12, 9-10: La colere du Seigneur s'enflamma contre eux [Aaron et Myriam, qui avaient jalouse et critique MOise). n partit et la nuee quitta la Tente. Voila que Myriam etait devenue iepreuse, blanche comme neige. • Dt 28, 21-22. 27.35: Le Seigneur attachera a toi la peste . .. Le Seigneur te frappera de consomption, defievre, d'inj/ammation, defievre chaude, de secheresse, de rouille et de nielJe ... Le Seigneur te frappera d' uLceres d'Egypte, de bubons, de croutes, de pLaques rouges dont tu ne pourras guerir. Le Seigneur te frappera de mauvais uLceres aux genoux et aux jambes et tu n'en pourras guerir, de la plante des pieds au sommet de la tete.

• 2 S 12, 15: Le Seigneur frappa l'enfant que la femme d'Urie avait donne a David, et iL tomba gravement maLade. ·2 R 5, 27: [en punition de I'avarice de Gehazi, serviteur d'Elisee. ce demier lui annonce:) "Ia Lepre de Naaman s'attachera a toi et a ta posterite pour toujours ... Gehazi s'eloigna de lui bLanc de Lepre comme la neige." • 2 R 15,5: Le Seigneur frappa Ie roi et il fut afflige de la Lepre jusqu'au jour de sa mort ... • 2 Ch 16, 19-20: Ozias, tenant dans ses mains l'encensoir a parfum, s'emporta. Mais alors qu'il et s'emportait contre les pretres, La Lepre bourgeonna sur son front, en presence des pretres tous les pretres se tournerent vers lui et lui virent La Lepre au front. lis l'expulserent en hiite . car Le Seigneur l' avait frappe.

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• Za 14, 12: Et voici la plaie dont Le Seigneur frappera tous les peuples qui auront combattu contre Jerusalem: iI fera pourrir leur chair alors qu'ils se tiendront debout, leurs yeux pourriront dans leurs orbites et leur langue pourrira dans leur bouche. • Ps 38, 2--9: "En moi tes tleches ont penetre, sur moi ta main s'est abattue, Tien d'intact en ma chair sous ta colere, rien de sain dans mes os ii cause de rnafaute. Mes offenses me depassent la ti~te, comme un poids trop pesant pour moi; mes plaies sont puanteur et pourriture 11 cause de rna folie ..." • Ps 41, 3: I'ai dit: "Pitie pour moi, Seigneur! gU/!ris-moi, car j'ai peche contre toi!" (refa'ah nafshi ki-hat'ati lakllJ • Ps 89, 33: "Je visiterai avec des verges leur peche, et par des pestes [= nega'iml leurs iniquites." • Ps 103,3: "Lui qui pardonne toutes tes offenses, qui te guerit de lOute maladie." • 2 M 9,4-6: Mais Le Seigneur qui voit tout, Ie Dieu d'lsrael, Ie frappa d'une plaie incurable et invincible. A peine avait-il acheve sa phrase qu'une douleur d'entrailles sans remede Ie saisit et que des souffrances aigues Ie IOrturaient au-dedans. ...

3.

Passages scripturaires presentant La maLadie comme une oeuvre redemptrice

II est une dimension de la maladie, que I' on peut appeler "vicariante", et qui,

a elle seule, necessiterait une etude particuliere, qu'il n'a pas ete possible de

realiser dans Ie cadre de la presente enquete. Elle repose sur un passage d'Isai'e, que Ie christianisme considere comme une prophetie de la mission redemptrice de Jesus (cf. Mt. 8, 17), mais qui, convenablement analyse a la lumiere de la tradition rabbinique, contribuerait certainement a une meilleure comprehension theologique du mystere de la souffrance. On notera, dans ce texte, la recurrence de la notion de "maladie", qui ne semble pas devoir etre prise au sens metaphorique. Et pourtant, il s'agit d'un innocent. • Is 53, 2--12: Comme un surgeon il a grandi devant lui, comme une racine en terre aride; sans beaute ni eclat pour attirer nos regards, et sans apparence qui nous elit seduits; objet de mepris, abandonne des hommes, homme de douleurs [rnakllovotl, familier de la rna/adie, comme quelqu'un devant qui on se voile la face, meprise, nous n'en faisions aucun cas. Or ce sont nos maladies [TM: !lalayenu; Sept.: hamartias] qu'il portait et nos souffrances [maklloveinul qu'il supportait. Et nous, nous Ie considerions comme puni, frappe par Dieu et humilie. Mais lui, il a ete victime lou: 'blesse' = mel!olal] 11 cause de nos iniquites [mipesha'eiituJ, ecrase 11 cause de nosfautes [me 'awonotei'nul. La correction qui nous rend la paix est sur lui, et par sa b/essure nous sommes gueris [nirpa 'lanul ... LE SEtGNEUR a voulu I' ecraser par 1a maladie. ...

LA MALAD IE DANS LA TRADITION JUIVE

4.

217

Le recours a dieu dans La maladie

Les Psaumes celebrent a l' envi les actes de guerison - physique autant que spirituelle - que Dieu accomplit, Ie plus souvent pour exaucer les prieres des souffrants: • Ps 30, 3:

"SEIGNEUR

mon Dieu, vers toi j'ai erie, tu m'as gueri."

• Ps 41, 2-34: Heureux celui qui discerne (maskil) Ie pauvre et Ie faible ... LE SEIGNEUR Ie garde ... LE SEIGNEUR Ie soutient sur son lit de douleur, tu refais tout entiere la couche oil il languit. • Ps 146,8:

LE SEIGNEUR

rend la vue aux aveugles,

LE SEIGNEUR

redresse les courbes. ...

Pour Ie Siracide: ·38,2: C'est du Tres-Haut que vienlla guerison, comme un cadeau qu'on re~oildu roi.

Le meme livre conseille: • Si 38, 9: "Mon fils, quand lu es malade ne Ie revolle pas, mais prie Ie Seigneur el il te guerira."

Ou encore: • 38, 14: A leur lour en effel, ils prieronl Ie Seigneur qu'il leur accorde la faveur d'un soulagement ella guerison pour te sauver la vie.

Plus insolite est la conception de Dieu comme guerisseur plus efficace que les medecins: • 2 Ch 16, 12: Asa eul les pieds malades, d'une maladie Ires grave, dans la lrente-neuvieme annee de son regne; meme alors, il n'eut pas recours dans sa maladie au SEIGNEUR mais aux medecins.

5.

Devoir de rendre visite aux malades, de les soigner et de prier pour eux

Generalement consideree comme l' apanage du christianisme, cette attitude etait deja pronee par Ie Premier Testament, meme si c'est a contrario comme en Ezechiel, ainsi qu'en temoignent ces deux citations: • 2 R 8, 29: Ochozias, fils de Joram, roi de Juda, descendil 11 Yiznjel pour visiler Joram, fils d' Achab, parce qu'il elait souffranl [selon LXX; TM: 'malade']. • Ez 34, 4: Vous n 'avez pas fortitie les brebis chelives, soigne celie qui ttait rnalade, panse celie qui tlail blessee.

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A en croire ce passage d'un Psaume, Ie juif pieux prie meme pour ses ennemis: • Ps 35, 13-14: "Moi, pendant leurs maladies, vetu d'un sac, je m'humiliais par Ie jeune, ma priere revenant dans mon sein, comme pour un ami. pour un frere, j'allais ~a et la; comme en deuil d'une mere, assombri,je me courbais."

6.

Synthese

On sait que, pour I'homme moderne et a fortiori pour Ie chercheur et Ie penseur eclaires, il n' est pas question de prendre au pied de la lettre les passages scripturaires evoques. Vne teHe lecture leur apparait comme «fondamentaliste» et temoignant d'un retour scandaleux a une «mentalite prelogique». II reste que ces textes posent de vraies questions tant aux exegetes qu'aux theologiens. Car, a supposer meme qu'ils ne soient que Ie reflet des conceptions irrationneHes et mythiques propres aux cultures du Proche-Orient ancien, Ie fait que de teHes conceptions aient trouve place dans le canon des Ecritures juives et se retrouvent dans celui du Nouveau Testament temoigne de leur appartenance aun fonds venerable de croyances orthodoxes, sur lequel s'est edifiee une orthopraxie juive dont on peut dire qu' eHe est passee, pour l' essentiel, dans la Tradition chretienne posterieure. A eHe seule, cette constatation oblige les specialistes - juifs et chretiens des disciplines concemees a un effort d'explicitation qui ne se limite pas a eluder les problemes poses par ces textes difficiles, en les mettant arbitrairement au rang des vieilles superstitions vehiculees par un judaisme ancien depourvu de nos connaissances scientifiques modemes, qui attribuait a des puissances celestes ou demoniaques les phenomenes hostiles de la nature et acceptait sans critique, au nom de la theodicee, leur incidence sur l'integrite physique et psychique de l'individu. II.

LA MALADIE DANS LA NOUVELLE ALLIANCE

Deux faits massifs se degagent de la lecture du Nouveau Testament: l) la conception - conforme a celIe du Premier Testament - selon laquelle la maladie est Ie salaire du peche; 2) la liaison entre la predication du Royaume et la multiplication des miracles de guerison, comme si l'integrite physique etait une preuve et une consequence incontestables de l'avenement de la nouvelle ere inauguree par l'irruption du Royaume de Dieu dans Ie monde. En outre, comme c'est Ie cas dans I' Ancien Testament, Ie devoir d'accueillir et de soigner les malades est souligne.

LA MALADIE DANS LA TRADITION JUIVE

1.

219

Passages neotestamentaires presentant La maLadie comme une consequence ou un chatiment du peche

Une lecture rapide du passage qui suit semble contredire la conception heterotestamentaire selon laquelle la maladie est une consequence ou un chatiment du peche: • In 9, 1-3; 6-7.34: En passant, il vit un homme aveugle de naissance. Ses disciples lui demanderent: "Rabbi, qui a peche,lui ou ses parents, pour qu'il soit ne aveugle?" Jesus repondit: "Ni lui ni ses parents n'ont peche, mais c'est alin que soient manifestres en lui les oeuvres de Dieu."2

La quasi totalite des theologiens et exegetes chretiens ont deduit de ce texte que, sur ce point comme sur beaucoup d'autres, la Revelation neotestamentaire etait en «rupture» avec la tradition du judai'sme ancien, 3 et que Ie refus, exprime par Jesus, de lier la maladie au peche, constituait un «progres theologique indeniable» par rapport a une conception juive consideree comme «prelogique», ou «archalque». Pourtant, d'autres textes neotestamentaires s'inscrivent en faux contre cette conclusion hative. Voici les plus significatifs: • In 5, 2-14: II y avait Iii un homme qui etait infirme depuis 38 ans. Jesus, Ie voyant etendu et apprenant qu'il etait dans cet etat depuis longtemps deja, lui dit: "Veux-tu guerir?" L'inlirme lui repondit: "Seigneur, je n' ai personne pour me jeter dans la piscine, quand I' eau vient iI etre agitee; et, Ie temps que j'y ailIe, un autre descend avant moi." Jesus lui dit: "Leve-toi, prends ton grabat et marche." Et aussitot l' homme fut gueri. ... Apres cela, Jesus Ie rencontra dans Ie Temple et lui dit: "Te voila gueri; ne peche plus, de peur qu'il ne t'arrive pire encore." • 1 Co 11, 27-30: Ainsi donc, quiconque mange Ie pain ou boit de la coupe du Seigneur indignement aura iI repondre du corps et du sang du Seigneur. Que chacun donc s'eprouve soimeme, et qu'ainsi il mange de ce pain et boive de celte coupe; car celui qui mange et boit, mange et boit sa propre condamnation, s'il ne discerne Ie Corps. Voila pourquoi il y a parmi vous beaucoup de malades et d'injirmes, et que bon nombre sont morts." • Ac 13,11: [Paul s'adresse iI Elymas Ie magicien] "Voici a present que la main du Seigneur est sur toi. Tu vas devenir aveugle et pour un temps tu ne verras plus Ie solei!." A I'instant meme, obscurite et tenebres s'abaltirent sur lui, et il tournait de tous cotes, cherchant quelqu'un pour Ie conduire. • Jc 5,15-16: La priere de la foi sauvera Ie patient et Ie Seigneur Ie relevera, et les pechis qu 'il a commis lui seront remis. Confessez donc vos pechis les uns aux autres et priez les uns pour les autres, afin que vous soyez gueris' • Ap 16, 2: Et Ie premier lange] s'en alia repandre sa coupe sur la terre; alors, ce fut un ulcere mauvais et pernicieux sur les gens qui portaient la marque de la Bete et se prosternaient devant son image.

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• Ac 18, 6: Voila pourquoi, en un seul jour, des plaies vont fondre sur elle [Babylone]: peste, deuil et famine.

2.

Guerison des malades et annonce du Royaume dans la Nouvelle Alliance

Les passages qui mentionnent et decrivent les guerisons operees par Jesus et ses disciples sont trop nombreux (plus de 180) pour etre tous cites ici. Je me limiterai a ceux qui presentent cette mission de guerison en liaison directe avec I'annonce du Royaume. • Mt 4, 23: II parcourait toute la Galilee, enseignant dans leurs synagogues, proclamant la Bonne Nouvelle du Royaume et guerissant toute maladie et toute langueur parmi Ie peuple. • Mt 9, 35: Jesus parcourait toutes les villes et les villages, enseignant dans leurs synagogues, proclamant la Bonne Nouvelle du Royaume et gwJrissant toute maladie et toute langueur. • Mt 11, 2-6: "Es-tu celui qui doit venir ou devons-nous en attendre un autre?" - Jesus leur repondit: "Allez rapporter a Jean ce que vous entendez et voyez: les aveugles voient et les boiteux marchent, les lepreux sont gueris et les sourds entendent, les morts ressuscitent et la Bonne Nouvelle est annoncee aux pauvres. ... "

• Lc 4, 18: "L'Esprit du Seigneur est sur moi, parce qu'il m'a consacre par I'onction, pour porter la bonne nouvelle aux pauvres. II m'a envoye annoncer aux captifs la delivrance et aux aveugles Ie retour a la vue...." • Lc 9, 2: Et illes envoya proclamer Ie Royaume de Dieu et faire des guerisons. • Lc 9, 6: lis passaient de village en village, annon,ant la Bonne Nouvelle et faisant partout des guerisons. • Lc 9, 11: Mais les foules, ayant compris, partirent a sa suite. II leur fit bon accueil, leur parla du Royaume de Dieu et rendit la sante aceux qui avaient besoin de guerison.

• Lc 10,8-9: "Et en toute ville oil vous entrez et oil I'on vous accueille, mangez ce qu'on vous sert; guerissez ses malades et dites aux gens: Le Royaume de Dieu est tout proche de vous."

3.

Accueil et soin des malades

Entin, la Nouvelle Alliance n'oublie pas de preconiser une attitude de compassion et de charite envers les malades. En temoignent les textes suivants: • Mt 25, 34-40: Alors Ie Roi dira a ceux de droite: "Venez, les benis de mon Pere, recevez en heritage Ie Royaume qui vous a ete prepare depuis la fondation du monde. Car j'ai eu faim et vous m' avez donne a manger ... j'etais un etranger et vous m' avez accueilli, nu et vous m' avez

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vetu, malade et vous m'avez visitti. . .." Alors les justes lui repondront: "Seigneur, quand nous est-il arrive de te voir affame et de te nourrir ... nu et de te vetir, malade ou prisonnier et de te visiter?" Et Ie Roi leur fera cette reponse: "En verite je vous Ie dis, dans la mesure oil vous I'avez fait 11 I'un de ces plus petits de mes freres, c'est 11 moi que vous I'avez fait." • Lc 10,30.33.34: Jesus reprit: "Un homme descendait de Jerusalem a Jericho, et il tomba aux mains de brigands qui, apres I' avoir depouille et roue de coups, s' en allerent, Ie laissant a demi mort. ... Un Samaritain, qui etait en voyage, arriva pres de lui, Ie vit et fut pris de pitie. II s'approcha, banda ses plaies, y versant de l'huile et du vin, puis Ie chargea sur sa propre monture, Ie mena 11 l'h6tellerie et prit soin de lui." • Ac 16,3: Le ge61ier les prit avec lui 11 I'heure meme, en pleine nuit, lava leurs plaies et sur-Iechamp re~utIe bapteme, lui et tous les siens.

4.

Synthese

Les remarques exprimees dans la synthese de notre Premiere Partie valent pour la presente. En effet, il n' est pas rare de lire, dans des ouvrages chretiens, des considerations qui font litiere de certains passages, genants pour nos conceptions rationalisantes de modernes, appartenant au fonds scripturaire evoque ci-dessus. Je ne voudrais ni m'immiscer dans un domaine qui n'est pas Ie mien, ni porter des jugements sur une problematique ressortissant a des conceptions chretiennes qui ont peut-etre une part de bien-fonde. Toutefois, je ne pense pas que soit digne de specialistes l' attitude, presentee comme «humaniste et soucieuse d'etre pen;ue par nos contemporains», qui consiste a se debarrasser des problemes theologiques et ethiques que posent des conceptions neotestamentaires du type de celles qui sont rapportees ci-dessus, en les reputant «irrationnelles», au motif qu'elles appartiennent au «vieux fonds mythique de la mentalite prelogique des civilisations anciennes», et qu'on peut en trouver I'origine dans les anciennes litteratures non bibliques. A mon avis, les vrais problemes auxquels il conviendrait de s'attaquer - et qui ne sont, MIas! que trop rarement traites - sont precisement celui de la presence massive, dans les livres saints de presque toutes les religions primitives, de ces motifs - trop vite qualifies de mythologiques et d'irrationnels -, et celui de leur presence dans les ecrits fondateurs de la foi chretienne. III.

LA MALADIE DANS LA LITTERATURE RABBINIQUE

Nous allons examiner maintenant quelques conceptions rabbiniques afferentes a la problematique de la maladie, en ayant soin de verifier, pour

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chacune d'entre elles, son enracinement biblique et, le cas echeant, la presence, dans Ie Nouveau Testament, de themes identiques ou analogues. 1.

La Maladie et les souffrances comme «salaire» du peche: une

doctrine essentiellement rabbinique?

Sur base d'une comprehension inadequate des textes rabbiniques, certains auteurs chretiens, peu rompus a la dialectique propre aces derniers, repondent generalement a cette question par l'affirmative. Nous allons voir que, meme si certains textes talmudiques semblent accrediter cette conception, les choses ne sont pas aussi simples. II faut tenir compte tout d'abord de la conception a contrario des anciens rabbins, selon laquelle l'absence d'epreuves et de souffrances ici bas n'est pas forcement un signe de benediction. Cette condition apparemment privilegiee est souvent interpretee par eux comme un signe de reprobation divine. En effet, toujours selon les rabbins, il vaut mieux souffrir ici-bas que risquer de perdre sa part de la felicite dans Ie monde a venir. Et, de toute maniere, la souffrance rachete les peches. Voici deux textes pour illustrer ce point: • Midrash Sifre'i, parashah et/ylnnan, pisqa 7: L'homme doit aussi davantage se rejouir des souffranees [yissurin] que de ce qui lui arrive de bon. Car si I'homme est dans la felicite toute sa vie, ses peehes ne sont pas pardonnes. Et par quoi sera-t-il pardonne? - Par les souffranees. • TB Sanhedrin 101 a-b: Rabba, fils de Bar Hana a dit: quand Rabbi Eliezer est tombe malade, ses disciples sont entres pour lui rendre visite. II leur a dit: une forte colere regne sur Ie monde. lis On! eclate en larrnes, tandis que Rabbi Aqiba seul riail. Pourquoi ris-tu, lui On! demande les autres. Et pourquoi pleurez-vous? leur a-t-il demande. lis [=They] lui ont repondu: Est-il possible qu'un 'livre de la Torah' [Rabbi Eliezer] soit dans la souffranee et que nous ne pleurions pas? [Reponse] C' est justement pour cela que je ris. Tan! que je ne vois chez mon maitre ni Ie yin toumer, ni Ie lin se deteriorer, ni I'huile repandre une mauvaise odeur, ni Ie miel ferrnenter, je me dis: peut·etre - Dieu I'en garde - mon maItre a-toil refu iei-bas toute sa part du monde ii venir. Maintenant que je vois mon maitre dans la souffrance, je me rejouis [parce que je sais qu'it aura sa part du monde 11 venir].

Cette conception - j'ai pu Ie constater en maintes occasions - semble etrange, voire arbitraire, a beaucoup de chretiens. C'est leur droit. Mais avant de se hater de l'imputer au seul judalsme talmudique, ils devront s'interroger sur Ie pourquoi de la presence du meme theme dans les textes neotestamentaires suivants, malgre les tentatives exegetiques les plus acrobatiques pour en nier I' evidence. • Lc 16, 19-35: II y avait un homme riche qui se revetait de pourpre et de lin fin et faisait chaque jour brillante chere. Et un pauvre, nomme Lazare, gisait pres de son portail, tout couvert

LA MALADIE DANS LA TRADITION JUIVE

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d'ulceres. n aurait bien voulu se rassasier de ce qui tombait de la table du riche.... Bien plus, les chiens eux-memes venaient lecher ses ulceres. Or il advint que Ie pauvre mourut et fut emporte par les anges dans Ie sein d' Abraham. Le riche aussi mourut, et on I'ensevelit. Dans I' Hades, en proie 11 des tortures, i1leve les yeux et voit de loin Abraham, et Lazare en son sein. Alors il s'ecria: "Pere Abraham, aie pitie de moi et envoie Lazare tremper dans I'eau Ie bout de son doigt pour me rafraichir la langue, car je suis tourmente dans cette flamme." Mais Abraham dit: "Mon enfant, souviens-toi que tu as ret;u tes biens pendant ta vie, et Lazare pareillement ses mau.x; maintenant ici il est console, et toi, tu es tourmente. .. ."

• Lc 6, 21.24-25: "Heureux, vous qui avez faim maintenant, car vous serez rassasies. Heureux, vous qui pleurez maintenant, car vous rirez. [... J Mais malheur 11 vous, les riches! car vous avez votre consolation. Malheur 11 vous, qui etes repus maintenant! car vous aurez faim. Malheur, vous qui riez maintenant! car vous connaitrez Ie deuil et les larmes."

Entin on trouve un echo de cette conception dans un Pseudepigraphe fortes connotations eschatologiques: 5

a

• Apocalypse de Baruch, XLVIII, 50: "... de meme que pendant un bref laps de temps, dans ce monde qui passe et ou vous vivez, vous avez endure des peines nombreuses, ainsi dans Ie monde qui n'a pas de fin, vous recevrez une grande lumiere."

Texte qui ne manque pas de paralleles neotestamentaires, dont ces deux passages auxquels on se limitera: Mt 5, 5: Heureux les affliges, car ils seront consoles. Rm 8, 18: J' estime en effet que les souffrances du temps present ne sont pas 11 comparer 11 la gloire qui doit se reveler en nous.

2.

Toute souffrance ne procede pas obligatoirement du peche

II est temps de faire justice de I' idee qu' en judalsme, la conception dominante est que les maladies sont toujours causees par Ie peche. A cet egard, Ie texte talmudique de reference est Ie suivant: • TB Shabbat fin 55a - 55 b: Rav Ami 6 a dit ... il n'y a pas de mort sans faute comme il est ecrit (Ez 18,20): "Celui qui a peche, c'est lui qui mouITa! Un fils ne portera pas la faute de son pere ni un pere la faute de son fils: au juste sera imputee sa justice et au mechant sa mechancete." II n'y a pas de souffrances [yissurinJ sans pecM, comme il est ecrit (Ps 89, 33): "Ie visiterai avec - On objecte: MOIse et Aaron des verges leur pecM, avec des plaies [nega' imJ leur iniquite" n'ont-ils pas pratique toute la Torah? Pourtant, ils sont morts [ J D'ou nous pouvons deduire qu'il y a une mort sans faute, et des souffrances sans pecht? L'objection faite 11 Rav Ami est restee sans reponse.

II serait trop long d' entrer ici dans les meandres des discussions halachiques qui rendent l'intelligence de ce passage impossible au profane. J'en ai tronque plusieurs developments, dont la comprehension suppose la

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connaissance des mecanismes de l' analyse textuelle du Talmud et de ses procedes d' exegese. II reste que cette discussion n' est pas sans faiblesse et que sa conclusion n' est pas rigoureuse. En particulier, comme I' ont fait remarquer des commentateurs ulterieurs (ba'aler hatossafot), I'objection apporte bien une preuve contradictoire au sujet de la mort, mais pas au sujet des souffrances. On a la nette impression que Ie debat est oriente de maniere a conforter l' opinion des Sages, selon laquelle on ne peut etablir une relation de causalite mecanique entre maladie et peche. 3.

La maladie comme punition dans Ie Talmud

Outre sa presence dans l'Ecriture sous forme d'une lepre infligee a Myriam pour sanctionner sa medisance (Nb. 12, 10), ce motif figure egalement dans les parties aggadiques du Talmud et dans les Midrashim. Ie me limiterai ici aux maladies punitives infligees par Dieu au prophete Elisee. La premiere eut lieu a la suite de la malediction qu'Elisee pronon (l Co 1,22-23). Tout est resume, la, dans la Croix de Jesus et dans la parole de I'Evangile qui I' annonce. II faudrait enfin enregistrer chez Jean la relativisation du merveilleux que traduit bien son choix de presenter comme des «signes» (semei'a), adresses a la foi, les sept "actions de puissance" de Jesus qu'il retient et met a son compte. Ce qui a ete dit au titre des principes d'interpretation que nous fournissent ces trois elements que je viens de relever, suffit a indiquer, dans ses grandes lignes, la voie d'une juste interpretation des miracles de Jesus. Certes, en meme temps que comme prophete, Jesus s'est manifeste et a ete reconnu, au cours de sa vie et de son ministere publics, comme thaumaturge et comme exorciste. II a toutefois ete systematiquement en garde contre toute tentative de Ie reduire lui-meme a la figure d'un specialiste du miraculeux et du merveilleux, tant en paroles qu'en actes. II faut dire de lui qu'il est thaumaturge et plus que thaumaturge, ou guerisseur et plus que guerisseur, comme on dit de lui qu'il est prophete et plus que prophete. Et c'est par rapport a ce "plus" qu'il faut comprendre sa figure de guerisseur thaumaturgique, comme c'est par rapport a ce "plus" qu'il faut comprendre, par ailleurs, sa mission de prophete. II est Ie propre Fils de Dieu venu parmi nous pour temoigner a ee monde et en ee monde, qu'il est promis a un destin qui depasse ce monde, bien qu'il se joue pour ce monde et en ce monde. Un destin qui est partage de la vie de Dieu a jamais, qui passe donc par un processus pascal qui est a la fois de mort et de resumection, et conduit ainsi au Salut.

LA SIGNIFICATION DES MIRACLES DE JESUS V.

275

LES ENSEIGNEMENTS MAJEURS, POUR NOUS, DES MIRACLES DE JESUS

Que Jesus ait accompli des miracles de guerison et d'exorcisme auxquels on peut reconnaitre Ie sens que nous avons dit, comporte pour nous quelques enseignements que je propose, pour finir, de degager en deux temps: - un eclairage sur la condition humaine, - quelques indications sur la maladie et la guerison. 1.

Un Eclairage sur La condition humaine

a. Premier enseignement: L'existence humaine est corporelle. A s'en rapporter aux comportements de Jesus (qui viennent confirmer ses enseignements), la foi chretienne ne considere pas Ie corps comme un vetement, ou comme un instrument temporaire, d'un essentiel de l'homme qui serait son interiorite, conscience ou "arne". Jesus va vers les malades, les infirmes, les handicapes, et nous avons note avec queUe frequence et queUe regularite il Ie fait. II vient au secours des corps souffrants, et pas seulement d'etres qu'affecte une misere morale ou un deficit spirituel. Illes traite avec attention et bonte avant de les guerir. Jamais on n'a l'impression qu'il s'attache a leur corps comme a un moyen pour acceder a leur arne, qu'il voudrait conquerir par Ie biais de ce qu'il ferait, en vertu de sa puissance, pour soulager leur souffrance physique. La place faite et l'importance accordee aux miracles de guerison dans la narration evangelique, sont a elles seules l'attestation evidente de la place essentielle que la foi chretienne fait, et a toujours a faire, a la corporalite de l'homme et donc a tout ce qui l'affecte. Celui que nous confessons comme Ie Verbe de Dieu s'est occupe des maladies et des miseres des hommes, et dans la proportion que nous avons vue. C'est donc que Dieu attache un prix, en son Christ, a la dimension corporeUe, et essentieUement corporelIe, de nos vies. b. En cette dimension corporelIe de son etre comme en toutes les autres, l' homme apparaft comme iJ. La fois remis iJ. Lui-meme et confie aux autres. II est significatif qu'aucun des beneficiaires de miracles n'est dispense d'avoir a se prendre en charge lui-meme, a conduire sa vie, a se responsabiliser par rapport a l'existence qui l'attend aussi au-deLiJ. de sa guerison. La plupart des recits de miracles s'achevent sur des consignes que Jesus donne acelui qu'il a gueri pour la poursuite de l'existence qu'il s'est vu restituer. Dans cette existence qui est devant lui, il ne sera pourtant pas seu!, car tout homme est

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invite a se preoccuper de son semblable dans Ie besoin, a visiter Ie malade et Ie prisonnier, a prendre soin du voyageur blesse au bord du chemin ou du pauvre couvert d'ulceres et laisse a la rue. Autrement dit, selon Jesus, il n'y a pas seuLement les miracles pour soulager maladies et miseres humaines! Dieu ne se sert pas, pour les soulager, que des miracles de son Christ. 11 veut se servir aussi de nos propres mains. Je ne vois pas ce que nous gagnerions a disproportionner Ie miraculeux-merveilleux, et en consequence a sous-estimer Ie caritatif et Ie misericordieux. Guerir la maladie est aussi affaire de responsabilite personnelle et de service mutuel. c. Enfin La condition humaine est a considerer comme Logee a La jois a l'echelle du temps et a celle de L'eschatoLogie. Certes, Jesus a soulage des miseres et des epreuves corporelles et spirituelles en ce monde. Et l'on peut deja en tirer les enseignements que je viens de relever. Mais d'une part il n'a pas gueri tous les Iepreux et tous les boiteux, tous les paralytiques et tous les epileptiques qui existaient en Israel a son epoque! Et par ailleurs, quand bien meme il l' aurait fait en son propre temps, resterait Ie probleme de tous les autres lieux de la terre et de toutes les autres epoques de I'histoire.... C'est que Ie centre de sa mission n'est pas reductible a une ceuvre de guerisseur. 11 s'agit d'une mission de Redempteur, et c'est ce que veulent precisement signifier, pour leur part, ses miracles de guerison. Y compris comme corporelle, l'existence humaine n'est pas reductible a ce qui s'en montre dans les temps et les lieux du monde; elle est promise a la resurrection de la chair et a la vie etemelle. Voila ce que je retiens comme une premiere serie d"'enseignements". Ils portent donc sur la condition humainc en general. Je passe maintenant a des enseignements - plus precisement: a des indications - sur la maladie et sur la guerison. 2.

Quelques indications sur La maLadie et La guerison

a. Premiere chose a dire a cet egard: par ses attitudes et son comportement de guerisseur, Jesus manifeste que ce qui compte, c'est La personne maLade et non pas sa maLadie. Que chaque malade est unique et doit donc etre consiclere et traite comme tel: voila ce que Jesus fait apparaitre. Mais il ajoute et manifeste aussi qu'il doit etre traite ainsi selon la totalite de son etre, c'esta-dire comme un etre qui n' est pas seulement en attente de guerison, mais en recherche de sens: comme un etre a la fois capable de priere et coupable de peche, a la fois dispose a une foi et mu par un desir et une esperance.

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277

Tel est "I'etre-malade" que Jesus nous invite a considerer lorsque nous pretendons nous occuper de maladies et de malades. En tenons-nous assez compte, nous autres, queUe que soit notre specialite, quand nous analysons conceptuellement et pretendons traiter ou gerer pratiquement ce que nous appelons, globalement, "Ia maladie"? b. Deuxieme point: Jesus ne se preoccupe pas seuLement de La maLadie, mais de La souffrance - ce qui est bien autre chose -, et de la souffrance sous toutes ses formes. Jamais Jesus ne la valorise comme teIle, dans une perspective ou doloriste ou expiatoire. A I' egard des malades et des souffrants, son intention se resume a ceci: les rencontrer et dialoguer avec eux, manifester de la compassion pour leur etat, et leur apporter soulagement et guerison. II y a la un enseignement puissant, dont on pourrait trouver une illustration saisissante dans la parabole du Bon Samaritain, a la condition de ne jamais oublier que celui qui manifeste une teUe attitude a I' egard de la souffrance des hommes n'est pas seulement Ie meilleur d'entre nous, mais Dieu meme, venu en cet homme pour se montrer, tout compte fait, plus humain que n'importe lequel des humains. c. Une troisieme indication sera pour souligner que Les miracles de Jesus n'apportent pas seuLement La guerison, mais Le saLut. A travers les miracles, malgre tout bien Iimites en nombre si I'on se place a l'echelle de I'humanite, que Jesus a accomplis, se signifie Ie fait que Ie Dieu qui, en lui, s'est approche de nous, offre a tout homme de ce monde une resurrection des morts et une vie eternelle ou toute maladie sera vaincue, toute mort engloutie et toute larme effacee. d. Enfin il est notable que si Jesus peut oeuvrer ainsi et ouvrir aux hommes une vie et une esperance qui ne sont pas seulement pour ce temps du monde mais valent pour "maintenant et toujours", c'est qu'il n'est pas qu'un thaumaturge eminent, mais bien Ie propre Fils de Dieu fait homme. Cela signifie qu'il ne sauve pas en restant a distance de ceux qu'il veut secourir. Tout au contraire, son action pour eux suppose qu'il a "quitte son ciel", afin de se faire, "sur la terre", tout proche d'eux, pour devenir l'un d'eux, prenant sa part de leurs souffrances et partageant meme leur mort - et pour etre ainsi capable de vaincre sur leur propre terrain maladies et souffrance, desesperances et mort. Le~on pour nous: Guerir ne va pas sans partage. Traiter une maladie suppose que, d'une maniere ou de l'autre, on "s'arrange" pour etre avec Ie malade et "de son cote". Les maladies des hommes ne relevent pas seulement du diagnostic et du traitement, de bistouris et de medicaments. Elles relevent

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aussi, et meme d'abord, de la presence et de l'attention au malade, de la cordialite et de la proximite a son egard - en un mot: de l'amour pour lui. Strasbourg NOTE BIBLIOGRAPHlQUE Apres avoir accepte de donner cette conference, Ie Professeur Dr. J. Dore est devenu Archeveque de Strasbourg. S'il a pu reprendre et mettre en forme pour la presente edition I'essentiel de son expose oral, il ne lui a pas ete possible, dans les delais impartis, d'en mettre au point tout l'appareiIlage bibliographique. II suggere ici plusieurs ouvrages qui, I' ayant lui-meme eclaire dans son etude, pourront etre precieux pour Ie lecteur qui voudrait documenter ou poursuivre la recherche sur les differents points abordes: R. Bultmann, "A propos du probleme du miracle", in Foi et comprehension, I, 1933 (tr. fro Paris 1970),pp.24G-257. A. Duprez, Jesus et les dieux gw!risseurs, Paris 1970. A. George, "Paroles de Jesus sur ses miracles", in Jesus aux origines de la christologie, Leuven 1975, pp. 283-301. X. Leon-Dufour, in "Groupe d'Entrevemes", Signes et paraboles, Paris 1977. C. Perrot, Jesus et l'histoire, coil. "Jesus et Jesus-Christ", Desclee, Paris 1979. X. Leon-Dufour, "Miracle", in Catholicisme IX, 1982, col. 252-269. J. M. Van Cangh, "Miracles de rabbins et miracles de Jesus", in Revue TMologique de Louvain 15 (1984), pp. 28-53. R. Latourelle, Miracles de Jesus et tMologie des miracles, Montreal 1986. C. Perrot, J. L. Souletie, X. Thevenot, Les miracles, Paris 1995. H. Jaschke, Jesus Ie Guerisseur (tr. fr.), Paris 1997.

INDEX OF NAMES

-A-

Centeno, C. 77 Comte,A. 20 Cruzan, N. 148, 150

Abel 205 Abraham 223, 226 Adam 208 Aeschylus 248n Alibert 28 Angel, R. 25 Angelini, G. 112,259 Rabbi Aqiba 222, 225 St. Thomas Aquinas 100, 140 Aries, P. 85, 93n Aristotle 121, 131n, 140 Arlow, J. 67 Asclepios 226 St. Augustine xi, 140,256 Avicenna 27 Avila, L. de 30

-DDasture, F. 94n Deeken, A. 72, 77 ben Dossa, H. 268 Dworkin, R. 145

-EEagle, M. 58, 66 Elias, N. 94n Rabbi Eliezer 222, 225, 230 Elihu 235-238, 242 Eliphaz 244-245 Elisha 224 Elkana, Y. 21 Ellenberger, H. 58-59 Empedocles 8, 23 Engelhardt, H. 46-47 Eve 205 Ezechias 215

-B-

Barreau, H. 152n Baum,M. 183 Beauchamp, T. III n-112n Benton, A. 71 Bergson, H. xix-xx Boorse,C. 33,38,43-45,47,49-50 Brenner, C. 67 Breuer, J. 57,61-62 Broussais, F. 19 Buytendijk, F. 169 Byrne, D. 74-75,78

-FFabrega, H. 19 Fallowfield, L. 74 Fawzy, F. 74 Fitch, M. 73 Fowler, N. 35-36,52-53 Freud, S. 57-70, 105 Fuchs,VV. 86-87,90

-C-

Cain 205 Callahan, D. 91,94n Campbell, E. 48 Capovilla, E. 73 Carr, J. 23 Carson, R. 113n Cassileth, B. 77-87 Cattorini, P. 72

-GGadamer, H. 112n Galen 23,27 Galileo 10--11 GautamaBuddha 197-199 Geertz, C. 22 Gennar!, M. 158

279

280

INDEX OF NAMES

Gilovich, T. 60 Girard, R. 243,245-246, 248n Glaichen, M. 77 Glymour, C. 64 God 10,25, 93n, 177, 189, 197-199, 203-211,213-217,219-221,224-228, 231-232, 233n, 235-243, 247, 250, 252-254,256-258,260,263,267-275, 277 Gorer, G. 83 Griffiths, A. 36, 53 Griffiths, C. 36 Gupta, H. 72-77 Gutierrez, G. 243

-H-

Haberrnas, J. 65 Hartmann, H. 58, 66 Hegel, G. 20 Heidegger, M. 89, 93n-94n, 158-159, 168 Helmholtz, H. von 57 Hennezel, M. de 250 Henry, M. 141 Hilton, B. 73 Hippocrates 24, 27 Holzman, P. 67-68 Honi 268 Husserl, E. 141 -1-

ben Isaac, E. 230 Isaiah 198, 215

-JSt. James 229 Jaspers, K. 65 Jeremiah 206 Jesus Christ 58, 176-178, 198-200, 206-211,214,216,219-220,244,246, 250-254,257-260,263-278 Job 205,235-248,258 St. John 178 Jonas 270 Josephus, F. 267 Jouanna, J. 24 Jung, C. 235

-KKagan, J. 68 Kant, I. 108, 140-141 Kass, L. 149-150 Kato, M. 22 Kelsen, H. 143 Kendell, R. 37,41-43,45,49,52 Kennedy, I. 38, 53-54 Kernberg, O. 66 King, L. 54 Klibansky, R. 24 Kligman, A. 36 Kohut, H. 66 Kubler-Ross, E. 237-238

-LLacan, J. 66-67 Landsberg, P. 93n Lazarus 222-223,233n Le Breton, D. 182 Leder, D. 113n Leibniz, W. 57 Leveque, J. 235 Levinas,E. 93n,141 Lin, C. 77 Linnaeus, C. 28 Liu, S. 73 St.Luke 266,273-274

-MMagendie, F. 19 Maimonides, M. 229 Manasseh 225 St. Mark 271, 273 Marks, M. 22 Matsumi, T. 23 St. Matthew 253, 266, 273 McIntyre, A. 123-126 McManus, I. 48-49 Meehl, P. 67 Merleau-Ponty, M. 141, 166-168 Messiah 227 Morgagni, G. 17 Morin, E. 83, 93n Moses 215 Myriam 215

281

INDEX OF NAMES

-N-

Naaman 215 Nagel, T. 58 Nesse, R. 44 Nietzsche, F. 57 Noble,M. 19 Nordenfelt, L. 124

--0Oedipus

245

-P-

Panofsky, E. 24 Pareyson,L. 113n Pari, A. 182 Pascal, B. 176--178, 183, 256 SI. Paul 178,198-199,205,207-209, 252,274 Pellegrino, E. Il8, 120, I3 I n Perrot, C. 266, 269 St. Peter 198 Pistrang, N. 73 Plato xi, 57, 89, 140,249 Pleines, E. I I3n Poree,J. 183 Preston, N. 36

Quine, W. 154 Quinlan, K. 145, 148

-R-

Ramirez, A. 73 Angel Raphael 215 Ricoeur, P. 65,82, 112n, 141,249 Roberts, R. 48 Ross, A: 143-144 Russell, J. 22 Ryle, J. 22

-S-

Saadia Gaon 228-229 Sartre, J.-P. 82,93n Satan 235,238,240-241,270 Saxl, F. 24

Scadding, J. 41,45,48-49 Scheler, M. 93n Schopenhauer,A. 57 Schuchardt, E. 250 Sedgwick, P. 50 Siminoff, L. 78 Singer, P. 188 Socrates 89 Soloveitchik, J. 233n Spinoza, B. 89, 168 Stefan, M. 48-49 Storr, A. 65 Stout, J. 124--125 Szasz, T. 34,39,55

-TTaylor, K. 73, 78 Teilhard de Chardin, P. 17 Thales of Miletus 65 Thomasma, D. 118,120, l3ln Toombs, S. 15 Towsend, J. 19

-VVanier, J. 255 Velpeau, A. 182 Vergely, B. 189-190 Verrneylen, J. 235, 238-239, 245 Verspieren, P. 183 Cardinal Veuillot 249 Vico, G. 94n Vogels, W. 235, 237 Vollrath, E. 113n

-WWilkie, D. 77 Williams, G. 44 Wittgenstein, L. 65, 93n, 154, 156

-YYehudah he Hasid

Zucker, D.

233n

229

-z-

Analecta Husserliana The Yearbook of Phenomenological Research Editor-in-Chief

Anna-Teresa Tymieniecka The World Institute for Advanced Phenomenological Research and Learning, Belmont, Massachusetts, U.S.A. 1.

Tymieniecka, A-T. (ed.), Volume 1 ofAnalecta Husserliana. 1971 ISBN 90-277-0171-7

2.

Tymieniecka, A-T. (ed.), The Later Husserl and the Idea of Phenomenology. Idealism - Realism, Historicity and Nature. 1972 ISBN 90-277-0223-3

3.

Tymieniecka, A-T. (ed.), The Phenomenological Realism ofthe Possible Worlds. The "A Priori', Activity and Passivity of Consciousness, Phenomenology and Nature. 1974 ISBN 90-277-0426-0

4.

Tymieniecka, A-T. (ed.), Ingardeniana. A Spectrum of Specialised Studies Establishing the Field of Research. 1976 ISBN 90-277-0628-X

5.

Tymieniecka, A-T. (ed.), The Crisis of Culture. Steps to Reopen the Phenomenological Investigation of Man. 1976 ISBN 90-277-0632-8

6.

Tymieniecka, A-T. (ed.), The Selfand the Other. The Irreducible Element in Man, Part 1. 1977 ISBN 90-277-0759-6

7.

Tymieniecka, A-T. (ed.), The Human Being in Action. The Irreducible Element in Man, Part II. 1978 ISBN 90-277-0884-3

8.

Nitta, Y. and Hirotaka Tatematsu (eds.), Japanese Phenomenology. Phenomenology as the Trans-cultural Philosophical Approach. 1979 ISBN 90-277-0924-6

9.

Tymieniecka, A-T. (ed.), The Teleologies in Husserlian Phenomenology. The Irreducible Element in Man, Part III. 1979 ISBN 90-277-0981-5

10.

Wojtyla, K., The Acting Person. Translated from Polish by A. Potocki. 1979 ISBN Hb 90-277-0969-6; Pb 90-277-0985-8

II.

Ales Bello, A. (ed.), The Great Chain ofBeing and Italian Phenomenology. 1981 ISBN 90-277-1071-6

12.

Tymieniecka, A-T. (ed.), The Philosophical Reflection of Man in Literature. Selected Papers from Several Conferences held by the International Society for Phenomenology and Literature in Cambridge, Massachusetts. Includes the essay by A-T. Tymieniecka, Poetica Nova. 1982 ISBN 90-277-1312-X

13.

Kaelin, E. E, The Unhappy Consciousness. The Poetic Plight of Samuel Beckett. An Inquiry at the Intersection of Phenomenology and literature. 1981 ISBN 90-277-1313-8

14.

Tymieniecka, A-T. (ed.), The Phenomenology of Man and of the Human Condition. Individualisation of Nature and the Human Being. (Part I:) Plotting the Territory for Interdisciplinary Communication. 1983 Part II see below under Volume 21. ISBN 90-277-1447-9

Analecta Husserliana 15.

Tymieniecka, A-T. and Calvin O. Schrag (eds.), Fourulations ofMorality, Human Rights, and the Human Sciences. Phenomenology in a Foundational Dialogue with Human Sciences. 1983 ISBN 90-277-1453-3

16.

Tymieniecka, A-T. (ed.), Soul and Body in Husserlian Phenomenology. Man and Nature. 1983 ISBN 90-277-1518-1

17.

Tymieniecka, A-T. (ed.), Phenomenology ofLife in a Dialogue Between Chinese ISBN 90-277-1620-X and Occidental Philosophy. 1984

18.

Tymieniecka, A-T. (ed.), The Existential Coordinates of the Human Condition: ISBN 90-277- 1702-8 Poetic - Epic - Tragic. The Literary Genre. 1984

19.

Tymieniecka, A-T. (ed.), Poetics of the Elements in the Human Condition. (Part I:) The Sea. From Elemental Stirrings to Symbolic Inspiration, Language, and Life-Significance in Literary Interpretation and Theory. 1985 For Part 2 and 3 see below under Volumes 23 and 28. ISBN 90-277-1906-3

20.

Tymieniecka, A-T. (ed.), The Moral Sense in the Communal Significance of Life. Investigations in Phenomenological Praxeology: Psychiatric Therapeutics, Medical Ethics and Social Praxis within the Life- and Communal World. 1986 ISBN 90-277-2085-1

21.

Tymieniecka, A-T. (ed.), The Phenomenology of Man and of the Human Condition. Part II: The Meeting Point Between Occidental and Oriental Philosophies. 1986 ISBN 90-277-2185-8

22.

Tymieniecka, A-T. (ed.), Morality within the Life- and Social World. Interdisciplinary Phenomenology of the Authentic Life in the "Moral Sense'. 1987 Sequel to Volumes 15 and 20. ISBN 90-277-2411-3

23.

Tymieniecka, A-T. (ed.), Poetics of the Elements in the Human Condition. Part 2: The Airy Elements in Poetic Imagination. Breath, Breeze, Wind, Tempest, Thunder, Snow, Flame, Fire, Volcano ... 1988 ISBN 90-277-2569-1

24.

Tymieniecka, A-T., Logos and Life. Book I: Creative Experience and the Critique of Reason. 1988 ISBN Hb 90-277-2539-X; Pb 90-277-2540-3

25.

Tymieniecka, A-T., Logos and Life. Book II: The Three Movements of the Soul. 1988 ISBN Hb 90-277-2556-X; Pb 90-277-2557-8

26.

Kaelin, E. F. and Calvin O. Schrag (eds.), American Phenomenology. Origins and Developments. 1989 ISBN 90-277-2690-6

27.

Tymieniecka, A-T. (ed.), Man within his Life-World. Contributions to Phenomenology by Scholars from East-Central Europe. 1989 ISBN 90-277-2767-8

28.

Tymieniecka, A-T. (ed.), The Elemental Passions of the Soul. Poetics of the Elements in the Human Condition, Part 3. 1990 ISBN 0-7923-0180-3

29.

Tymieniecka, A-T. (ed.), Man's Self-Interpretation-in-Existence. Phenomenology and Philosophy of Life. - Introducing the Spanish Perspective. 1990 ISBN 0-7923-0324-5

30.

Rudnick, H. H. (ed.), Ingardeniana II. New Studies in the Philosophy of Roman Ingarden. With a New International Ingarden Bibliography. 1990 ISBN 0-7923-0627-9

Analecta Husserliana 31.

32.

33.

34.

35.

36.

37.

38. 39. 40.

41. 42.

43. 44. 45. 46.

Tymieniecka, A-T. (ed.), The Moral Sense and Its Foundational Significance: Self, Person, Historicity, Community. Phenomenological Praxeology and Psychiatry. 1990 ISBN 0-7923-0678-3 Kronegger, M. (ed.), Phenomenology and Aesthetics. Approaches to Comparative Literature and Other Arts. Homages to A-T. Tyrnieniecka. 1991 ISBN 0-7923-0738-0 Tyrnieniecka, A-T. (ed.), Ingardeniana lll. Roman Ingarden's Aesthetics in a New Key and the Independent Approaches of Others: The Performing Arts, the Fine Arts, and Literature. 1991 Sequel to Volumes 4 and 30 ISBN 0-7923-1014-4 Tyrnieniecka, A-T. (ed.), The Turning Points of the New Phenomenological Era. Husserl Research - Drawing upon the Full Extent of His Development. 1991 ISBN 0-7923-1134-5 Tyrnieniecka, A-T. (ed.), Husser/ian Phenomenology in a New Key. Intersubjectivity, Ethos, the Societal Sphere, Human Encounter, Pathos. 1991 ISBN 0-7923-1146-9 Tymieniecka, A-T. (ed.), Husserl's Legacy in Phenomenological Philosophies. New Approaches to Reason, Language, Hermeneutics, the Human Condition. 1991 ISBN 0-7923-1178-7 Tyrnieniecka, A-T. (ed.), New Queries in Aesthetics and Metaphysics. Time, Historicity, Art, Culture, Metaphysics, the Transnatural. 1991 ISBN 0-7923-1195-7 Tyrnieniecka, A-T. (ed.), The Elemental Dialectic of Light and Darkness. The Passions of the Soul in the Onto-Poiesis of Life. 1992 ISBN 0-7923-1601-0 Tyrnieniecka, A-T. (ed.), Reason, Life, Culture, Part I. Phenomenology in the Baltics. 1993 ISBN 0-7923-1902-8 Tyrnieniecka, A-T. (ed.), Manifestations of Reason: Life, Historicity, Culture. Reason, Life, Culture, Part II. Phenomenology in the Adriatic Countries. 1993 ISBN 0-7923-2215-0 Tyrnieniecka, A-T. (ed.), Allegory Revisited. Ideals of Mankind. 1994 ISBN 0-7923-2312-2 Kronegger, M. and Tyrnieniecka, A-T. (eds.),Allegory Old and New. In Literature, the Fine Arts, Music and Theatre, and Its Continuity in Culture. 1994 ISBN 0-7923-2348-3 Tyrnieniecka, A-T. (ed.): From the Sacred to the Divine. A New Phenomenological Approach. 1994 ISBN 0-7923-2690-3 Tyrnieniecka, A-T. (ed.): The Elemental Passion for Place in the Ontopoiesis of Life. Passions of the Soul in the Imaginatio Creatrix. 1995 ISBN 0-7923-2749-7 Zhai, Z.: The Radical Choice and Moral Theory. Through Communicative Argumentation to Phenomenological Subjectivity. 1994 ISBN 0-7923-2891-4 Tyrnieniecka, A-T. (ed.): The Logic of the Living Present. Experience, Ordering, Onto-Poiesis of Culture. 1995 ISBN 0-7923-2930-9

Analecta Husserliana 47.

48. 49. 50. 51. 52.

53.

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56. 57. 58. 59.

60.

61. 62.

Tymieniecka, A-T. (ed.): Heaven, Earth, and In-Between in the Harmony ofLife. Phenomenology in the Continuing Oriental/Occidental Dialogue. 1995 ISBN 0-7923-3373-X Tymieniecka, A-T. (ed.): Life. In the Glory of its Radiating Manifestations. 25th ISBN 0-7923-3825-1 Anniversary Publication. Book I. 1996 Kronegger, M. and Tymieniecka, A-T. (eds.): Life. The Human Questfor an Ideal. 25th Anniversary Publication. Book II. 1996 ISBN 0-7923-3826-X Tymieniecka, A-T. (ed.): Life. Phenomenology of Life as the Starting Point of Philosophy. 25th Anniversary Publication. Book III. 1997 ISBN 0-7923-4126-0 Tymieniecka, A-T. (ed.): Passion for Place. Part II. Between the Vital Spacing ISBN 0-7923-4146-5 and the Creative Horizons of Fulfilment. 1997 Tymieniecka, A-T. (ed.): Phenomenology of Life and the Human Creative Condition. Laying Down the Cornerstones of the Field. Book I. 1997 ISBN 0-7923-4445-6 Tymieniecka, A-T. (ed.): The Reincarnating Mind, or the Ontopoietic Outburst in Creative Virtualities. Harrnonisations and Attunement in Cognition, the Fine Arts, Literature. Phenomenology of Life and the Human Creative Condition. Book II. 1997 ISBN 0-7923-4461-8 Tymieniecka, A-T. (ed.): Ontopoietic Expansion in Human Self-Interpretationin-Existence. The I and the Other in their Creative Spacing of the Societal Circuits of Life. Phenomenology of Life and the Creative Condition. Book III. 1997 ISBN 0-7923-4462-6 Tymieniecka, A-T. (ed.): Creative Virtualities in Human Self-Interpretation-inCulture. Phenomenology of Life and the Human Creative Condition. Book IV. 1997 ISBN 0-7923-4545-2 Tymieniecka, A-T. (ed.): Enjoyment. From Laughter to Delight in Philosophy, Literature, the Fine Arts and Aesthetics. 1998 ISBN 0-7923-4677-7 Kronegger M. and Tymieniecka, A-T. (eds.): Life. Differentiation and Harmony... Vegetal, Animal, Human. 1998 ISBN 0-7923-4887-7 Tymieniecka, A-T. and Matsuba, S. (eds.): Immersing in the Concrete. Maurice ISBN 0-7923-5093-6 MerJeau-Ponty in the Japanese Perspective. 1998 Tymieniecka, A-T. (ed.): Life - Scientific Philosophy/Phenomenology ofLife and the Sciences ofLife. Ontopoiesis of Life and the Human Creative Condition. 1998 ISBN 0-7923-5141-X Tymieniecka, A-T. (eds.): Life - The Outburst of Life in the Human Sphere. Scientific Philosophy / Phenomenology of Life and the Sciences of Life. Book II. 1998 ISBN 0-7923-5142-8 Tymieniecka, A-T. (ed.): The Aesthetic Discourse of the Arts. Breaking the Barriers. 2000 ISBN 0-7923-6006-0 Tymieniecka, A-T. (ed.): Creative Mimesis of Emotion. From Sorrow to Elation; Elegiac Virtuosity in Literature. 2000 ISBN 0-7923-6007-9

Analecta Husserliana 63.

Kronegger, M. (ed).: The Orchestration of The Arts - A Creative Symbiosis of Existential Powers. The Vibrating Interplay of Sound, Color, Image, Gesture, Movement, Rhythm, Fragrance, Word, Touch. 2000 ISBN 0-7923-6008-7

64.

Tymieniecka, A-T. and Z. Zalewski (eds.): Life - The Human Being Between Life and Death. A Dialogue Between Medicine and Philosophy, Recurrent Issues and New Approaches. 2000 ISBN 0-7923-5962-3 Kronegger, M. and Tyrnieniecka, A-T. (eds.): The Aesthetics of Enchantment in ISBN 0-7923-6183-0 the Fine Arts. 2000 Tyrnieniecka, A-T. (ed.): The Origins ofLife, Volume I: The Primogenital Matrix of Life and Its Context. 2000 ISBN 0-7923-6246-2; Set ISBN 0-7923-6446-5 Tymieniecka, A-T. (ed.): The Origins of Life, Volume II: The Origins of the Existential Sharing-in-Life. 2000 ISBN 0-7923-6276-4; Set ISBN 0-7923-6446-5 Tymieniecka, A-T. (ed.): PAIDEIA. Philosophy / Phenomenology of Life InspirISBN 0-7923-6319-1 ing Education of our Times. 2000

65. 66. 67.

68. 69.

Tyrnieniecka, A-T. (ed.): The Poetry ofLife in Literature. 2000 ISBN 0-7923-6408-2

70.

Tyrnieniecka, A-T. (ed.): Impetus and Equipoise in the Life-Strategies ofReason. Logos and Life, volume 4. 2000 ISBN 0-7923-6731-6; HB 0-7923-6730-8 Tyrnieniecka, A-T. (ed.): Passions of the Earth in Human Existence, Creativity, ISBN 0-7923-6675-1 and Literature. 2001

71. 72.

Tyrnieniecka, A-T. and E. Agazzi (eds.): Life - Interpretation and the Sense of Illness within the Human Condition. Medicine and Philosophy in a Dialogue. 2001 ISBN Hb 0-7923-6983-1; Pb 0-7923-6984-X

73.

Tyrnieniecka, A-T. (ed.): Life - The Play ofLife on the Stage ofthe World in Fine ISBN 0-7923-7032-5 Arts, Stage-Play, and Literature. 2001

Kluwer Academic Publishers - Dordrecht / Boston / London