ethics - week 2 reading - boyd medical humanities

8/11/2019 Ethics - Week 2 Reading - Boyd Medical Humanities

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There is an objectivity about disease which

doctors are able to see, touch, measure, smell.

Diseases are valued as the central facts in the

medical view...Illness ... is a feeling, an experience of

unhealth which is entirely personal, interior to the

person of the patient. Often it accompanies

disease, but the disease may be undeclared, as in

the early stages of cancer or tuberculosis or

diabetes. Sometimes illness exists where no

disease can be found. Traditional medical educa-

tion has made the deafening silence of illness-in-

the-absence-of-disease unbearable to the clini-

cian. The patient can oVer the doctor nothing to

satisfy his senses...

Sickness... is the external and public mode of

unhealth. Sickness is a social role, a status, a

negotiated position in the world, a bargain struck

between the person henceforward called sick,and a society which is prepared to recognise and

sustain him. The security of this role depends on

a number of factors, not least the possession of

that much treasured gift, the disease. Sickness

based on illness alone is a most uncertain status.

But even the possession of disease does not guar-

antee equity in sickness. Those with a chronic dis-

ease are much less secure than those with an acute

one; those with a psychiatric disease than those

with a surgical one ... . Best is an acute physical

disease in a young man quickly determined by

recovery or deatheither will do, both are equally

regarded.2

Disease then, is the pathological process, devia-tion from a biological norm. Illness is the

patients experience of ill health, sometimes when

no disease can be found. Sickness is the role

negotiated with society. Marinker goes on to

observe that a sizeable minority of patients who

regularly consult general practitioners, particu-

larly for repeat prescriptions, suVer from none of

these modes of ill health. They appear, rather, to

be seeking to establish a healing relationship

with another who articulates societys willingness

and capability to help. So a patient, in the

sense of someone actively consulting a doctor

rather than just being on the books, does not nec-

essarily mean someone who has a disease, feels ill,

or is recognised to be sick; and of course there areother more mundane reasons, short of wanting to

establish a healing relationship, why a patient may

consult a doctorto be vaccinated before travel-

ling abroad for example. Most patients most of

the time however, probably can be classified as

having a disease, or feeling ill, or being recognised

as sick.

Popular and literary definitionsFor some patients, the last of these may be themost important. Recently I was handing out to a

class of medical students the General MedicalCouncils booklets on The Duties of a Doctor. Theuniversity janitor who was helping me unpackthem remarked: As far as Im concerned the

main duty of a doctor is to give me a sick note,otherwise I wont get sick pay. A week later, on atrain, I met a recently unemployed man who

recounted to me at some length how he hadcajoled his general practitioner into signing himoV for a few months longer, so that he could keep

on getting sick pay until he got to pensionable age.And according toHystories, by the American criticElaine Showalter,3 new ways of getting recognisedas sick are being found all the time. Modern cul-

ture is continually spawning hysterical

epidemicsin the pre-millennial years, ME, Gulfwar syndrome, recovered memory, multiple per-sonality syndrome, satanic abuse and alien abduc-tion. These, a sympathetic reviewer of the bookexplained, were examples of:

the conversion of emotional pain and conflictinto the camouflaged but culturally acceptablelanguage of body illness... . Typically, individualswho are unhappy or unfulfilled in their livesdevelop diVuse and evolving nervous complaintsand eventually seek help. A physician, or someother scientific authority figure, concocts aunified field theory providing a clear and coherentexplanation for the confusing symptoms, as wellas a new and a memorable name for the sydrome.

This explanation draws on contemporary diseasetheory, usually viral and immunological ideas. Anindividual case or two, often involving a well-known public personality, provides a popularparadigm for the new synthesis of symptoms. Abest selling novel ..., soon to become a majormotion picture, first advertises the syndrome to alarge audience. Magazine stories and televisiondocumentaries further publicise the symptoms.High-profile books for persons seeking infor-mation appear, as do patients autobiographies.Most recently, daily talk-shows, those agencies ofmass pop psychotherapy, unite suVerers andtherapists in order to dramatise their life storiesand to explain the meaning of their disorder formillions; in the process, participants cite enor-mous projected numbers of the aZicted andencourage others to come forward... . These areacutely communicable diseases... .4

So the reviewer, expounding Showalter, claims.People with ME and Gulf war veterans, bycontrast, understandably might contest this viewof what they are suVering from; and more

10 Disease, illness,sickness, health, healing and wholeness: exploring some elusive concepts

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scientific findings about the veterans health5 haveappeared since Hystories was published in 1997.Showalters argument nevertheless helps to illus-

trate Marinkers useful distinction betweendisease, illness and sickness. Whether or notsomeone is ill, is something the person concernedultimately must decide for him- or her-self. Butwhether that person has a disease or is sick issomething doctors and others may dispute.

Munchausens syndromeSome diseases, clearly, are less respectable thanothers. A classic example is Munchausenssyndrome, the diagnostic label applied to peoplewho repeatedly present themselves to hospitalswith convincing symptoms, often demanding andsometimes undergoing surgery which reveals noorganic disorder. People with Munchausens syn-

drome may seem reminiscent of Marinkers repeatprescription patients who seek a healing relation-ship with another who articulates societys willing-ness and capability to help. But their condition ismore likely to be dismissed as a bizarre form ofmalingering6 or the systematic practice of delib-erate and calculated simulation of disease so as toobtain attention, status and free accommodationand board.7 Most of them, it may be explained,are suVering from psychopathic personality orpersonality defect, a condition defined as beingcharacterised by impulsive, egocentric and anti-social behaviour, with a diYculty in formingnormal relationships, and a manner which iseither aggressive or charming or which alternates

between the two.8

That, it might be observed,makes them sound suspiciously like people whohave not had the opportunity or luck to end up assuccessful politicians or captains of industry.

People labelled with Munchausens syndromethen, may have succeeded in getting recognised asbeing sick, but not in the sense they intended. InMarinkers terms, their sickness has pretty lowstatus. It is doubtfully a disease, and as illness itsmeaning veers more towards the pre- thanpost-18th century usagewickedness, depravity,immorality. Such words, or the colloquial sick,sick, sick, are even more likely, of course, to beapplied to the perpetrators of Munchausensyndrome by proxypeople who abuse a child orfrail elderly relative by making them ill or

pretending that they are ill.

Philosophers questionsAre such people mad, or bad? How do you answersuch a question? To try to find a more helpful wayof framing it, let me move on to the purveyors ofconceptual clarity, the philosophers. To doctors,

Marinker suggests, disease is the most tangiblemode of unhealth. When they talk about disease,

they know what they mean. Philosophers are less

sure. R M Hare, for example, asks:

Why do attacks of viruses count as diseases, butnot the attacks of larger animals or of motor vehi-

cles? Is it just a question of size? Or of invisibility?I believe that doctors call the attacks of intestinaland other worms diseases, though there are also

more precise words like infestation. If I have atape or a guinea worm (which are quite large), doI have a disease? Does it make a diVerence if the

worm can be seen but its eggs cannot? Or does itmake a diVerence that the worm, although it caneventually be seen, is in some sense, while active,

inside the patient, whereas dogs and lorries, andalso lice and fleas, whose attacks are likewise notcalled diseases, are always outside the body? Does

a disease have to be somethinginme? And in whatsense of in? Some skin diseases such as scabiesare so called, although the organisms which causethem are on the surface of the skin, and do not

penetrate the body. They penetrate the skinindeed; but then so does the ichneumon maggot,and the body too. Is the diVerence between thesemaggots and the scabies mite merely one of size?Or of visibility?9

Well perhaps, Hare suggests, we just use the worddisease for conditions whose cause was notvisible before the invention of microscopes. But amore basic point, he adds, is that in order toidentify a condition as a disease we ... have tocommit ourselves to there being a cause, ascer-tainable in principle, of the same sort as the causesof diseases whose aetiology we do understand.What I take Hare to mean by this, is that whendoctors apply a diagnostic label like Mun-chausens syndrome, for example, they are com-mitting themselves to the hope that someday theywill be able to understandin medical terms(mentally ill or mad), rather than moral ones(bad)what makes these people act in the waythey do.

But what does understand in medical termsmean in this context? Does it mean that doctorshope to find some causative agent in the patient,or in the patients environment? Or does it justmean that they are robustly rejecting Kants

demand that all the insane be turned over to thephilosophers and that the medical men stop mix-ing into the business of the human mind10 inthe vague hope that a therapeutic approach willeventually prove to be more eVective than a moralor legal one? And what are we to make of the factthat doctors have chosen to label Munchausenssyndrome by the name of a fictional liar, rather

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than by the name of the distinguished psychiatristwho first identified it, or by some medical termwhich suggests the direction in which they are

looking for an explanation? Applying the diseaselabel to this, and maybe some other conditions,sounds not very diVerent from what St Anselmcalled fides quaerens intellectum, faith seekingunderstandingalthough in this case the doc-tors sound rather less optimistic about finding acause than St Anselm was about proving theexistence of God.

At this point, of course, doctors might protestthat theorising around an example like Mun-chausens syndrome is more typical of philosophythan of more everyday medical practice, in whichmedical faith, seeking understanding, has repeat-edly found it. I think that response is fair.But to befair to philosophers too, let me add that Hare is

not arguing that disease is a kind of linguisticweapon wielded by doctors in order to get patientsto submit to them. His point rather is that theword disease has an evaluative character. Usingit can be justified, if patients and doctors evaluateit in the same wayif patients agree with theirdoctors that the disease is bad for them. But itbecomes problematic when this agreement isabsent. This suggests one reason then, why defini-tions of disease can be so elusive. To callsomething a disease is a value judgment, relativelyunproblematic in cases when it is widely shared,but more contentious when people disagree aboutit.

HealthWhen philosophers try to define health some ofthem reach a similar conclusion. R S Downie forexample, agrees that the World Health Organis-ation definition of healthas a state of completephysical, mental and social wellbeing, and notmerely the absence of disease or infirmityisoverambitious. Nevertheless, he argues, it is prob-ably aiming in the right direction.11 To try todefine health as simply the absence of disease orinfirmity leads you into diYculties: ill health cantbe defined simply in terms of disease, for example,because people can have a disease (especially onewith minor symptoms) without feeling ill, andthey can have unwanted symptoms (nausea, faint-ness, headaches and so on) when no disease or

disorder seems to be present. Nor is the fact that acondition is unwanted enough to describe it as illhealth: it may be the normal infirmity of old agefor example; and again a conditions abnormalityis not enough eithera disability or deformitymay be abnormal, but the person who has it maynot be unhealthy; and much the same may applyto someone who has had an injury. To say whether

or not physical ill health is present therefore, acomplex combination of abnormal, unwanted orincapacitating states of a biological system may

have to be taken into account. And things areeven more complicated when assessing mental illhealth. Abnormal states of mind may reflectminority, immoral or illegal desires which are notsick desires. On the other hand, a psychopath, forexample, may neither regard his state as un-wanted, nor experience it as incapacitating.

The problem, however, is not just that ill healthcan be diYcult to pin down. It is also that we nor-mally think of health as having a positive as well asa negative dimension. But here again things arecomplicated. A positive feeling of wellbeing, forexample, may not be enough. As Downie says: itwould be diYcult to make a case for viewing anacute schizophrenic state with mood elevation and

a blissful lack of insight as one of positive health.Nor is fitness suYcient: the kind of fitness soughtin athletic training, indeed, is sometimes detri-mental to physical health; and the desire to max-imise physical fitness as an end in itself maybecome an unhealthy obsession. Often, what isrequired is only a minimalist notion of fitness,age-related and geared to everyday activities.

True wellbeing, Downie goes on to suggest,requires (a) an essential reference to someconception of the good life for a human beingand (b) some conception of having a measure ofcontrol over ones life, including its social andpolitical dimensions. Those factors, as well as thecomplex negative side, have to be taken intoaccount when we ask what health means. But

even when we have taken all these factors intoaccount, we cannot quantify how healthy an indi-vidual is with any precision. That is not justbecause the sum is complex. It is also, Downieconcludes, agreeing with Hare, because the com-ponents include value judgments.

Value judgments and metaphorsOne reason then, why definitions of disease andhealth are sometimes so frustratingly elusive is thepart played by value judgments in determiningwhat we mean by disease and health as well aswhat we mean by illness and sickness. In manycases this is not obvious, because most people, inour society at least, make the same or similar value

judgments about what these words mean andwhat are examples of what they mean. There is, asit were, a common core of ideas about whatdisease is or what health is. But beyond that com-mon core, judgments on whether a condition is adisease, or on what or who is healthy, begin todiverge, and our conceptions of disease and healthbegin to get fuzzy.




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Another way of understanding this, I think, hasto do with the important part played by metaphorin the development of thought and language.

When we want to talk about some new experienceor discovery for which our existing terminologyhas no adequate resources, a metaphora wordor words from some other area of experience, butused in a new waymay help us to say what wemean. Some thinkers, for example Nietzsche, andbefore him Shelley and Coleridge, have arguedthat all language develops by metaphorising andby metaphors becoming accepted as literal. Ourlanguage, they say, is littered with dead meta-phors; and this includes our scientific language.My own favourite example of the role played bycreative metaphorising in science is one which Ionce copied into a notebook from an article aboutthe brain in (I think) the Scientific American:

Axons sprout new endings when their neigh-bours become silent and the terminal branches ofdendritic arbors are constantly remodeled.

I find those metaphors drawn from arboricultureto neurophysiology, not only profoundly encour-aging, given my own aging brain, but alsopoetically inspired.

Health as a metaphorIn the case of disease,I have already indicated howmetaphorising seems to have been at work, in thedevelopment of this more specific term as aparticular instance of something causing dis-easeand making for lack of elbow room or freedom ofmovement. Health as a metaphor may be morecomplex. The word derives from an old Germanicroot meaning wholeness. But the most influentialexample, in the metaphorising process, of the ideaof wholeness, may have been that of the breedinganimal at the peak of its performance. If that isright, it may be part of the reason why, as theanthropologist Edmund Leach suggests, sub-liminally the general publics idea of good health isall mixed up with ideas about sexual vigour; andwhy, despite

the obvious discrepancy from reality, the modelof ideal good health which ordinary members ofthe public pick up, through the visual images ofthe Press and the TV screen, and from the verbalsuggestions of their doctors, is closely related tothe classical ideal of the youthful Greek athlete.12

A further point perhaps worth noting here, is thatonce metaphors get going, they can be hard tostop. Humans are highly imitative animals. Duringthe last general election for example, I noticed thehabit of using the word Look... as a punchyintroduction to a line of often oversimplified

argument, spread first among radio interviewersand then to politicians, including eventually TonyBlair. It was, I felt, a rather irritating habit. But

after a symposium I took part in soon after theelection, I realised that not only had one of theother speakers used Look... in the same way, butso had I. Our imitative or mimetic tendency then,may be one of the reasons why successfulmetaphors tend to proliferate so successfully.

Spiritual healthIn the case of health, we can see this happeningas the metaphor expands from bodily health, toinclude spiritual health (the Anglican prayerbooks phrase, there is no health in us), thenpolitical health (Shakespeares Hamlet refers tothe safety and health of the whole state), andfinally to ordinary usage today when we refer to

someone having a healthy or unhealthy attitudeand so forth.

Now none of this, perhaps, causes much troubleif we understand that these are metaphors whenwe use them to orientate our thought and action.In many cases moreover, expanding metaphorsusually only modify rather than radically alterthought or action already also oriented by otherpowerful metaphors. For example, to call anaccountant a company doctor doesnt excusehis doctoring the bookswhen an authority holdsan accountant accountable. But problemsmay arise when a metaphor expands in a spherewhere it is not challenged or complemented byother equally powerful metaphors which are alsoexpanding. In that case the metaphor in questionmay go on expanding its application almostindefinitely.

Something like this, I think,has happened in thecase of health, as a result of the declining vital-ity of religious metaphors in Western, or at leastEuropean, public discourse. Metaphorical idealssuch as healthy behaviour and mental health,propounded by doctors and others who areperceived to be objective and to have noideological axe to grind, have expanded to fill thevacuum as it were. The absence of any metaphorsmore convincing than therapeutic ones, thus mayhelp to explain why applying even such a label asMunchausens syndrome seems to many peoplethe best hope of understanding that morally

ambiguous condition. Similar reasons perhapsmay also help to explain why the language of eth-ics, again perceived as more objective than thatof religion, now plays an increasingly importantrole in Western public discourse. One diYcultyabout this perception of ethics however, is that itencourages the expectation that ethics should beable to deliver definitive answersjust as the

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public rhetoric of health encourages the expecta-tion that health is something that it ought to bepossible, not only to define, but also to achieve.

No health as suchA medical man, Sir William Jenner onceremarked13 needs three things. He must be hon-est, he must be dogmatic and he must be kind. Aphilosopher, by contrast, needs only the first ofthese. One of the most relentlessly honestphilosophers was Nietzsche. Let me quote some-thing he once wrote about health, to echo rathermore forcefully what I have been trying to say sofar:

there is no health as such, and all attempts todefine anything in that way have been miserablefailures. Even the determination of what healthmeans for your body depends on your goal, your

horizon, your energies, your drives, your errors,and above all on the ideals and phantasms of yoursoul. Thus there are innumerable healths of thebody; and ... the more we put aside the dogma ofthe equality of men, the more must the conceptof a normal health, along with a normal diet andthe normal course of an illness be abandoned byour physicians. Only then would the time havecome to reflect on the health and sicknesses of thesoul, and to find the peculiar virtue of each man inthe health of his soul: in one persons case thishealth could, of course, look like the opposite ofhealth in another person.14

Normal and normative

Nietzsche claims that we should abandon theconcept of a normal health. Let me use that, andhis reference to the soul, as a starting point forwhat I promised to say about science and religion.In this connection, a helpful contrast was drawnby the medical philosopher and historian GeorgesCanguilhem between two views of what is normal.On the one hand there is the view of disease ormalfunction as a deviation from a fixed normestablished by medical theory, to which normmedical practice seeks to return the patient. Onthe other there is the view of the organism as a liv-ing being that has no pre-established harmonywith its environment. The latter, Canguilhemargues, is the true view of normality. Beinghealthy, he writes:

means being not only normal in a given situationbut also normative in this and other eventual situ-ations. What characterises health is the possibilityof transcending the norm, which defines themomentary normal, the possibility of toleratinginfractions of the habitual norm and institutingnew norms in new situations.15

Perhaps a more colloquial way of putting whatCanguilhem says here is that health is not a mat-ter of getting back from illness, but getting over

and perhaps beyond it. Health, to quote Canguil-hem again:

is a feeling of assurance in life to which no limitis fixed. Valere, from which value derives, means tobe in good health in Latin. Health is a way oftackling existence as one feels that one is not onlypossessor or bearer but also, if necessary, creatorof value, establisher of vital norms.16

On this view then, to be healthy is not tocorrespond with some fixed norm, but to makethe most of ones life in whatever circumstancesone finds oneself, including those which in termsof some fixed norms may seem severely impairedor unhealthy. To be in good health, Canguilhem

writes, means being able to fall sick and recover.

The scientific pictureCanguilhem also, like Leach, comments on theseduction still exerted on our minds today by theimage of the athlete as the image of health,agreeing on its inappropriateness as an ideal forpractically all of the population. Why is this viewso seductive? Perhaps because we tend to assumethat a modern scientific or objective picture ofthe world, in which we ourselves figure as naturalphenomena, is the true view of the real world.In this scientific picture, it is diYcult not to seesomething like the image of the athlete as the idealof healthfor which all that comes before is apreparation, and all that follows a process ofdisintegration and decay.

But there is a serious problem about taking thisobjective scientific picture as the true view ofthe real world. The physicist Schrdinger put itas follows.17 The only way scientists can masterthe infinitely intricate problem of nature, is tosimplify it by removing part of the problem fromthe picture. The part that scientists remove isthemselves as conscious knowing subjects. Every-thing else, including the scientists own bodies aswell as those of other people, remains in the scien-tific picture, open to scientific investigation. Thisobjective picture is then taken for granted asthe real world around us; and because itincludes other people who are conscious knowing

subjects just as the scientist is, it is diYcult for thescientist to resist the conclusion that the truepicture of the real world must be an objec-tivepicture, which includes the conscious know-ing subject as another object. That conclusion,however, fails to fit all the facts. For, asSchrdinger says, this moderately satisfying [sci-entific] picture of the world has only been reached




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at the high price of taking ourselves out of the pic-ture, stepping back into the role of a non-concerned observer.

The point Schrdinger is making can bediYcult to grasp, or at least to hold on to, becausethe view that an objective picture is the truepicture of the real world seems like commonsense. It is reflected, for example, in what DavidChalmers, in The Conscious Mind,18 characterisesas Dont-have-a-clue materialismthe viewheld widely, but rarely in print which says Idont have a clue about consciousness. It seemsutterly mysterious to me. But it must be physical,as materialism must be true. The problem is thatall of us, before we begin to think critically aboutsuch questions, have come to experience the worldand other people as things out there, eitherinanimate or animate. So is not that, ultimately,

the true picture of us also? To deny it feelsunreasonableas unreasonable as it must oncehave felt to deny that the sun went round theearth. Yet just as science once destroyed that illu-sion, so too now, science itself is destroying themodern illusion that the truepicture of the realworld is an objective one which science, when ithas made all its discoveries, will eventuallyprovide.

InterplayThis message of course has been underlined bymodern physicss realisation that, as Schrdingerputs it, the object is aVected by our observation.You cannot obtain any knowledge about an objectwhile leaving it strictly isolated. Or as Heisenbergobserved:

Science no longer confronts nature as anobjective observer, but sees itself as an actor in thisinterplay between man and nature. The scientificmethod of analysing, explaining and classifyinghas become conscious of its limitations, whicharise out of the fact that by its intervention sciencealters and refashions the object of investigation.19

Science no longer confronts nature as anobjective observer, but sees itself as an actor in thisinterplay between man and nature. The problemabout conceiving health in terms of fixed normssuch as those of biochemistry, or the ideal of theathlete, is that it assumes that the objective

observers viewpoint is the true one, and discour-ages those who adopt it from seeing themselves asactors or agents, rather than patients who areacted upon. Daniel Dennett has remarked thathuman beings oZoad as much of their minds aspossible into the world.20 If we want to gain amore adequate understanding of the meaning ofhealth, along the lines Canguilhem suggests, we

may have to be prepared to oZoad rather less, andtake responsibility for rather more, of our minds.

That at least seems to be what science itself is

now telling us;and in that respect science providespart of the explanation of why definitions of healthare, and are likely to remain, elusive. If health is away of tackling existence in which one is notonly possessor or bearer but also, if necessary,creator of value, establisher of vital norms, thenwhat constitutes health in one person may well, asNietzsche said, look like the opposite of health inanother person.

Religious ideasThe final part of the explanation I want to suggestconcerns religion. A nave, albeit widely-heldview, is that religious ideas about the world havebeen disproved by science. What actually hap-

pened historically is more complex. Schrdingeragain provides a helpful explanation:

One of the aims, if not perhaps the main task ofreligious movements has always been to round oVthe ever unaccomplished understanding of theunsatisfactory and bewildering situation in whichman finds himself in the world; toclosethe discon-certing openness of the outlook gained fromexperience alone, in order to raise his confidencein life and strengthen his natural benevolence andsympathy towards his fellow creaturesinnateproperties, so I believe, but easily overpowered bypersonal mishaps and the pangs of misery.21

Religion, Schrdinger suggests, has always tried toround oV or close the disconcerting open-ness of human experience. In the past, it hasdone this, often very successfully, in terms of sci-entific or pre-scientific ideas which at the timeseemed plausible to everyone. When these ideaswere overtaken by new scientific explanationswhich seemed to fit the facts better, religion, beingmore conservative than science, was slow to givethem up; and this helped to create the impressionamong many people that it was only a matter oftime before science would explain everything. Butthis idea of science demonstrating a self-contained world to which God (or the religiousor transcendent dimension) is a gratuitousembellishment, Schrdinger points out, beginsto seem unrealistic when we grasp what he is say-

ing about the absence of the conscious knowingsubject from the scientific picture of the world. Ifscience were able to exclude the religious or tran-scendent dimension from reality (rather than justfrom the scientific picture of reality),it would be atthe cost of excluding the first-person humandimension also. But the idea that science can dothis, Schrdinger adds, springs not from people

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knowing too muchbut from people believingthat they know a great deal more than they do.

Insights such as Schrdingers have not been

lost on many more perceptive modern religiousthinkers, who see no necessary conflict betweenreligious and scientific ideas. One of the definingattitudes of science, Schrdinger points out, is thatin an honest search for knowledge you quiteoften have to abide by ignorance for an indefiniteperiod.22 But such an acknowledgement of igno-rance is also what is required by the Judaeo-Christian rejection of idolatrysuperstitiousmental pictures or preconceived notions whichinhibit open-minded attention to reality in all itsvarietyand this religious rejection of idolatry, ithas often been argued, was what opened the wayfor modern scientific enquiry. The scientific fidesquarens intellectum, moreover, has a strong family

resemblance to religious faith as described by twokey modern religious thinkersKierkegaard,when he remarked that not only the person whoexpects absolutely nothing does not have faith, butalso the person who expects something particularor who bases his expectancy on somethingparticular23; and Coleridge, when he wrote thatfaith may be defined as fidelity to our ownbeingso far as such being is not and cannotbecome an object of the senses; and hence ... tobeing generally, as far as the same is not the objectof the senses.24

Religious statements of this kind illustrate notonly the compatibility of science and religion, butalso that the idea of a healthy person as a creatorof value, establisher of vital norms can be

endorsed by religion. Coleridges famous descrip-tion of the imagination as a repetition in the finitemind of the eternal act of creation in the infinite IAM,25 for example, implies that religious knowl-edge of what it calls God is analogous not towhat is seen by an objective observer, but to whatis encountered by Heisenbergs actor in theinterplay. That this encounter is with reality, is inno way diminished by its taking place through thecreative human imagination.

Wholeness, healing and deathFor religion, the two remaining words I men-tioned at the outsetwholeness and healingareintimately related. Healing is understood by

religion not only as the natural process of tissueregeneration sometimes assisted by medicalmeans, but also as whatever process results in theexperience of greater wholeness of the humanspirit. Healing in the latter sense need not be reli-gious in form (nature, music or friendship as wellas religious rites may be agents of healing), noraccompanied by cures or miracles. These or

other signs of hope, when attested, may be seen astraces of a transcendent or encompassing whole-ness, in which human wholeness is grounded. But

wholeness is always imperfectly realised in thefragmentariness of human experience; and whilefor religion the encompassing wholeness is notreducible to a psychological projection, it isdiscovered most commonly in the mode ofexpectancy, both in the midst of life and in theface of death.

Religious expectancyReligious expectancy clearly is not something onwhich science can have much to say, exceptperhaps to discourage religion when it too rapidlyor rhetorically seeks to close the disconcertingopenness of experience by interpreting its ownexperience and expectancy in terms of some-

thing particularclinical trials to prove thepower of prayer or the validity of near-death expe-riences, for example. But whether or not religiousexperience and expectancy represent more thanpsychological reality, remains part of the discon-certing openness of human experience, which canbe closed or rounded oVno more conclusively byscientific experiment than by religious dogma.Such questions admit only answers given, not bydetached scientific or religious observers, but byor between conscious knowing subjects, the actorsin the interplay.

This disconcerting openness perhaps is what,finally, makes the meaning of health, healing andwholeness so elusive. If acknowledging opennessmeans suspending pre-judgment, for example onthe realism of expectancy in the face of death,these words may take on counterintuitive mean-ings:

A physically dependent patient who has come toterms with his past life and his approaching death,for example, may well feel, and thus (because noone else is better placed to judge) be nearer towholeness than ever before.26

Such a person may even, in this perspective, bedescribed as healthy.

Whether such counterintuitive meanings are enter-tained of course, depends on whether the viewpointof the conscious knowing subject is given at least asmuch weight as that of the clinical observer.Canguilhem sums up the results of much physi-ological, pathological and clinical observation asfollows.

Life tries to win against death in all the senses ofthe verb to win, foremost in the sense of winningin gambling. Life gambles against growingentropy.27




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But what if entropy grows too great, and lifes lastthrow seems lost? Should the subject in whom lifehas grown conscious recognise that this time the

odds are stacked too heavily against him? Or do alllifes attempts to win against death hint to himthat a deeper game, with higher stakes, is afoot?Religious arguments underdetermine any conclu-sive answer to this question. But so too doarguments which reduce first-person experienceto third-person psychological, sociological or evo-lutionary explanations, or reduce the experiencedmystery of being a conscious subject to a set ofeventually solvable scientific problems aboutthe property of consciousness. The disconcertingopenness of experience raises a question markagainst the conventional assumption that expect-ancy in the face of death is no longer availabletocritical thought. Might not a more critical stance

be to admit ignorance without denying admissionto hope? It is diYcult to see why that should notremain at least an open question; and as long as itdoes, the meaning of health, healing and whole-ness seems likely to remain elusive.

Kenneth M Boyd is Senior Lecturer in Medical Eth-ics, Edinburgh University Medical School andResearch Director, Institute of Medical Ethics.

References1 Brown L, ed. The new shorter English dictionary. Oxford:Claren-

don Press, 1993.2 Marinker M. Why make people patients? Journal of Medical

Ethics 1975:I:81-4.3 Showalter E.Hystories. London: Picador, 1997.

4 Micale MS. Strange signs of the times. Times LiterarySupplement1997 May 16: 6-7.

5 Unwin C, Blatchley N, Coker W, Ferry S, Hotopf M,Hull L, etal. Health of UK servicemen who served in the Persian Gulf

War. Lancet1999;353:169-78.6 Walton J, Barondess JA, Lock L, eds. The Oxford medical

companion. Oxford: Oxford University Press, 1994: 611.7 Youngson RM. Collins dictionary of medicine. Glasgow: Harper-

Collins, 1992: 406.8 See reference 6: 816.9 Hare RM. Health.Journal of Medical Ethics 1986;12:172-81.

10 Tillich P. The meaning of health. Richmond, California: NorthAtlantic Books 1981: 43. See also: Kant I. Anthropology from a

pragmatic point of v iew. [Translated by MJ Gregor.] The Hague:Martinus NijhoV, 1974: 82-83.

11 Downie RS, Fyfe C, Tannahill A.Health promotion: models andvalues. Oxford: Oxford University Press, 1992.

12 Leach E. Societys expectations of health. Journal of MedicalEthics 1975;1:85-9.

13 Treves F. The elephant man, and other reminiscences. London:Cassell 1923: 201.

14 Nietzsche F. The gay science. [Translated by W Kaufmann.]New York: Vintage Books, 1974: book III, section 120.

15 Canguilhem G. The normal and the pathological. New York:Zone Books, 1991: 196f.

16 See reference 15: 201.17 Schrdinger E.What is life? Cambridge: Cambridge University

Press 1967: 118f.18 Chalmers DJ.The conscious mind. Oxford: Oxford University

Press, 1996: 162.19 Heisenberg W. The physicists conception of nature. London:

Hutchinson, 1958: 29.20 Dennett DC. Our minds chief asset. Times Literary Supplement

1997 May 16: 5.21 Schrdinger E. Nature and the Greeks. Cambridge: Cambridge

University Press 1996:6.22 See reference 21: 8.23 Kierkegaard S. Eighteen upbuilding discourses.[Translated by HV

Hong and EH Hong.] Princeton: Princeton University Press1990: 27.

24 Coleridge ST. Essay on faith. In: Aids to reflection. London: GBell & Sons, 1913: 341.

25 Coleridge ST. Biographia literaria. London: Bell & Daldy, 1870:144.

26 Boyd KM. Health care ethics, health and disease. In: Gillon R,ed. Principles of health care ethics. Chichester: John Wiley & Sons1994: 812.

27 See reference 15: 236.

Boyd 17



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doi: 10.1136/mh.26.1.9

2000 26: 9-17Med HumanitiesKenneth M Boydwholeness: exploring some elusive conceptsDisease, illness, sickness, health, healing and

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