Handbook of Phenomenology and Medicine edited by S. Kay Toombs (Kluwer
Academic) As the fields of philosophy of medicine and
bioethics have developed in the United States, the philosophical perspective of
phenomenology has been largely ignored. Yet, the central conviction that informs
this volume is that phenomenology provides extraordinary insights into many of
the issues that are directly addressed within the world of medicine. Such issues
include: the nature of medicine itself; the distinction between immediate
experience and scientific conceptualization; the nature of the body -- and the
implications of embodiment in the realm of clinical practice; the meaning of
health, illness and disease; the problem of intersubjectivity -- particularly
with respect to achieving successful communication with another; the complexity
of decision-making in the clinical context (and in the realm of medical ethics);
the possibility of empathic understanding; the theory and method of clinical
practice; and the essential characteristics of the therapeutic relationship --
i.e. the relationship between the sick person and the one who professes to help.
Some of the authors who have contributed to this volume are philosophers, some
are engaged in other academic disciplines, and several are practicing healthcare
professionals. Their essays demonstrate that phenomenology can be an invaluable
practical tool, not only for those who are interested in the philosophy of
medicine, but for all healthcare professionals who are actively engaged in the
care of the sick.
From Editor's introduction: As the fields of philosophy of medicine and bioethics have developed in the United States, the philosophical perspective of phenomenology has been largely ignored. Yet, the central conviction that informs this volume is that phenomenology provides extraordinary insights into many of the issues that are directly addressed within the world of medicine. Such issues include: the nature of medicine itself; the distinction between immediate experience and scientific conceptualization; the nature of the body -- and the relationship between body, consciousness, world and self; the structure of emotion; the meaning of health, illness and disease; the problem of intersubjectivity particularly with respect to achieving successful communication with another; the complexity of decision‑making in the clinical context; the possibility of empathic understanding; the theory and method of clinical practice; and the essential characteristics of the therapeutic relationship -- i.e. the relationship between the sick person and the one who professes to help.
Although the interests and conceptions of phenomenology among particular phenomenologists differ in important ways', there are some commonalities that allow one to speak of "a phenomenological approach." The most important is derived from Edmund Husserl's injunction: "to the things themselves." That is, the phenomenologist is committed to setting aside his or her taken-for-granted presuppositions about the nature of objects or "reality" in an effort to begin with what is given in immediate experience, the phenomena as encountered, precisely as they are encountered. One of the primary aims of an explicitly phenomenological approach is to let what is given appear as pure phenomenon (the thing-as-meant) and to work to describe the invariant features of such phenomena.
A phenomenological approach thus involves a type of radical disengagement, a "distancing" from our immediate ongoing experience of everyday life in order to make explicit the nature of such experience and the essential intentional structures that determine the meaning of such experience. As such, phenomenology is an essentially reflective enterprise.
The common sense world itself (and our experiencing of it) becomes the focus of reflection. Our attention shifts from that of engagement in the world to a focused concern for the sense and strata of the very engagement itself. The task is to elucidate and render explicit the taken-for-granted assumptions of everyday life and, particularly, to bring to the fore one's consciousness of the world. In rendering explicit the intentional structures of consciousness, phenomenological reflection discloses the meaning of experience.
In order to describe phenomena as they are encountered, the phenomenologist attempts to effect a systematic neutrality. That is, in the phenomenological attitude "one places in abeyance one's taken-for-granted presuppositions about the nature of `reality,' one's commitments to certain habitual ways of interpreting the world". In particular, one sets aside any theoretical commitments derived from the natural sciences in order to describe what gives itself directly to consciousness. As Merleau-Ponty notes, this radical reflection does not deny the existence of the physical, social and cultural world. Rather, it reveals the "prejudices" and taken‑for‑granted presuppositions that are not explicitly recognized in our spontaneous, unreflective experience. Thus, the phenomenologist adopts a particular kind of attitude ("stance") towards inquiry and the objects of inquiry.
In turning attention to the field of medicine as the focus of inquiry, a phenomenological approach is particularly helpful in the following ways: (1) phenomenology provides an explication of the fundamental and important distinction between the immediate pre-theoretical experiencing of the world of everyday life and the theoretical, scientific account of such experience. This distinction is particularly important in furthering our understanding of the relation between medical science and clinical practice, as well as in recognizing the differences between, say, the immediate experience of illness vs. the conceptualization of illness as a disease state, and the body-as-experienced vs. the body as the object of scientific inquiry; (2) phenomenology provides a method for engaging in the radical reflection on experience -- the phenomenological "reduction" or epoche. As noted above, the phenomenological "reduction" not only attempts to "bracket" (set aside) hitherto unquestioned assumptions, but simultaneously to clarify (and render explicit) the taken‑for‑granted presuppositions that "color" our experience. In the process phenomenology reveals the extent to which theoretical, social, cultural, and professional "habits of mind" influence our understandings and, interpretations of experienced phenomena -- in many instances circumscribing our "knowledge" about the phenomena themselves; (3) with its emphasis on firsthand or direct description phenomenology can provide a rigorous, detailed account of the manner in which we experience, and interpret, the world of everyday life in the context of medicine and medical practice. To give one example: in turning to "the things themselves," the phenomenologist focuses on the phenomenon of illness as it is immediately encountered or experienced (illness-as-lived). Such an analysis discloses certain invariant (or typical) features of the experience apart from the varieties of its concrete instantiations.
Understanding the phenomenon of illness in all its richness and complexity is of enormous practical value in the clinical context; (4) certain central themes of investigation in phenomenology are of particular relevance in thinking about issues related to medicine. Such themes include: the body, the nature of human being and existence ‑ Being-in-the-World; temporality; the constitution of meaning; the theory of intentionality; the structures of the Lifeworld -- Lebenswelt; the analysis of intersubjectivity, the turn to lived experience.
The essays in Section One illustrate the relevance of phenomenology in the domain of medicine. John Brough explores Husserl's phenomenology of time and temporal awareness, noting that "phenomenology seeks to disclose the fundamental temporal framework in which we experience the contents of our lives, whatever they may be." Brough explores some of the ways in which temporality pervades our experience in everyday life and then turns his attention to the phenomenon of time in the context of illness. He demonstrates that illness "provides a unique window on to the many levels of time that inform our lives," and that it also reveals "resources in our temporal being" that enable us to cope with the various disruptions that are a part of illness.
Patrick Heelan draws upon the phenomenological analysis of the Lifeworld (as found in the works of Husserl, Heidegger, Gadamer, and Merleau-Ponty) in order to provide a critique of the hypothetical-deductive account of modern science (the `received view') and to develop new themes about the way theory is related to praxis and how medical science is related to clinical practice. In particular, he aims to address the role of modern science in an important sector of the life-world, the world of medical practice. In noting the different roles of theory and practice, Heelan explores the "Janus-like" face of scientific theories and entities and the role of metaphor in scientific discourse and medical science. He shows how distortions in communication occur when the Janus-like face of a scientific fact goes unnoticed leading among other things -- to confusion in the public debate about "such contentious practices as abortion, cloning, disease prevention."
In discussing phenomenological method, Frances Waksler explicates two central features of the phenomenological approach that are "of particular significance for medical practitioners": the primacy of the subject's perspective and the suspension of belief (the phenomenological epoche). Waksler shows that the phenomenological method of inquiry provides a rigorous way to examine the activities of medical practice and theorizing, as well as illuminating alternative ways of thinking and acting within the domain of clinical medicine.
Fredrik Svenaeus focuses on the phenomena of health and illness noting, "The ultimate test of a phenomenology of illness must be the extent to which it does justice to the different forms of illness afflicting the individuals encountered each day by doctors, nurses and others working in the clinic." Drawing upon Heidegger's analysis of Dasein, Svenaeus argues that health can be understood as "homelike Being-in-the-World." Illness can, thus, be understood as a kind of "unhomelikeness" with a basic structure that can be identified. Recognizing this basic structure allows us to comprehend the particular ways in which individuals experience themselves as ill, as well as providing a vocabulary by means of which we can talk about different illnesses.
Per Sundstrom turns his attention to the phenomenon of disease. He examines the relationship between disease and illness, noting that in the clinical context most of the time the two go together, "disease/illness presenting itself as a mixed subjective/objective phenomenon, which is disturbing, disabling, or even calamitous to the individual patient, and ... recognizable by the medically trained professional as a deviation from normal functioning, or shape, of the body/organism." Sundstrom explores the pluridimensional meanings/conceptions of disease in this clinical sense, an exploration that is particularly important since "disease" is, in fact, the "phenomenological and conceptual center of practical‑clinical medicine."
Richard Zaner reflects on the astonishing developments in the newly emerging molecular medicine and asks (1) what do these developments mean with respect to the nature of medicine itself -- in particular, what are the implications of the shift from restorative medicine to a "new paradigm" that "is centrally concerned to conquer, replace and transcend nature," thereby altering the human condition itself? and (2) how are we to think about the self in light of the Genome Project? How is the self known and experienced? Is there a self at all? How exactly are we to understand the mystery of human being?
The phenomenological exploration of the body is of particular relevance for medicine. As Gallagher notes, "Perhaps the most general and most obvious fact about medicine is that it concerns the body. If one eliminates the body one eliminates the subject and object of medical science and practice." Yet, although the body is indeed the central concern of medicine, inquiries into the nature of the body in Western medical thought and practice are typically focused on the body as a type of mechanism -- the body-as-machine. The body is considered to be a particular type of material object, one that can be observed, scientifically analyzed, and understood exclusively in terms of its anatomical and physiological characteristics.
Phenomenologists such as Edmund Husserl (1989), Maurice MerleauPonty (1962), and Jean-Paul Sartre (1956) ‑ and, following them, Richard Zaner (1981, 1964); Drew Leder (1990); H.Tristram Engelhardt (1977, 1973); Erwin Straus (1963,1966); Stuart Spicker (1970); Hans Jonas (1966); Shaun Gallagher (1986); and S. Kay Toombs (1992a), to name a few -- have focused instead on the phenomenon of embodiment, i.e. the body as a living, embodying organism. In setting aside the mechanistic construal of the bodyas-machine, in order to explore the nature of the living, experiencing body, phenomenologists have distinguished the lived body from the objective physiological body. Behnke notes that this distinction is often expressed in the German words "Leib" and "Korper."
Leib is usually translated "lived body," sometimes "animate organism," "living body," or simply "Body," and is related to the phenomenological use of the French "corps propre." Korper is usually translated "physical body," sometimes "material body,"object body," or simply "body." ... Fundamental to the Body-body distinction is that the turn to the Body involves the turn to experiential evidence in contrast to the body as investigated by such natural sciences as anatomy and physiology.
Although it is not possible in the context of this introduction to give a full account of the phenomenological account of embodiment, certain key features of the lived body can be identified:
The lived body is not an object akin to other physical, animate objects in the world but, rather, the medium through which, and by means of which, I apprehend the world and interact with it.
In all its worldly involvements the lived body exhibits a bodily intentionality that reveals a dynamic relation between body/world -- that is, the lived body is an embodied consciousness that simultaneously engages, and is engaged in, the surrounding world. My embodying organism is always experienced as "in the midst of environing things, in this or that situation of action, positioned and positioning relative to some task at hand".
In this continuous body/world interaction, the lived body synthesizes the various senses and movements into a unity of experience.
The experiencing body ...is not a self-enclosed object, but an open, incomplete entity. This openness is evident in the arrangement of the senses: I have these multiple ways of encountering and exploring the world - listening with my ears, touching with my skin, seeing with my eyes, tasting with my tongue, smelling with my nose _ and all of these various powers or pathways continually open outward from the perceiving body, like different pathways diverging from a forest. Yet my experience of the world is not fragmented; I do not commonly experience the visible appearance of the world in any way separable from its audible aspect, or from the myriad textures that open themselves to my touch ....Thus my divergent senses meet up with each other in the surrounding world, converging and conuning filing in the things I perceive. We may think of the sensing body as a kind of open circuit that completes itself only in things, and in the world ...it is primarily through my engagement with what is not me that I effect the integration of my senses, and thereby experience my own unity and coherence.
Given this ongoing body/world interaction, illness is not simply a problem with the isolated physiological object‑body but, rather, a problem with the whole embodying organism/environment. The body/world relation reflects the fact that the lived body represents not just one's bodily being but one's contextual Being‑in‑the‑world. As the means by which one interacts with the world, the lived body makes possible the existential projects that are expressive of one's personhood. Consequently, the disruption of bodily capacities has a significance that far exceeds that of simple mechanical dysfunction.
The lived body is both intentional and orientational locus ‑ that is the lived body is the spatial and temporal center around which the rest of the world is grouped. My body has the central mode of givenness of "Here" whereas all other things (including my fellow human beings) are given as located "There" in relation to my body. Since surrounding space is intimately related to the positioning of the body (e.g. the designations of "near," "far," "high," "low," depend upon my bodily "Here") changes in bodily bearing (e.g. the loss of upright posture) and the disruption of bodily capacities inevitably disrupt the experience of surrounding space.
The body's "Here-ness," its "proximity," also means that I cannot physically distance myself from my body -- although I may separate myself from certain parts of it under certain circumstances. Thus, there is a symbiotic relationship between body and self. This symbiotic relationship with body can represent a source of threat in the event that the body malfunctions -- since whatever happens to my body also happens to me.
The term "embodiment" refers both to the unity of body/consciousness and the fact that, since I am "embodied," my "own" body is always "with" me. For example, in reaching for the glass, I am in some sense aware that it is "my" arm that moves and that it is "my" body that effects the action. However, this relation with "my" "own" body is not a relation of "ownership" or "possession" --in the same way that I own, or possess, an automobile or a house.
One's experiential awareness of the body is limited in a variety of ways. Not only does the body's orientational locus make it impossible for me to apprehend all aspects of my body directly (e.g. I cannot walk around my body to view the back, nor can I directly view the interior of my body), but the body is "uncanny" in that it includes "events, processes and structures over which I have no control and of which I have no awareness".
In the experience of "uncanniness" the lived body is apprehended as in some sense "other than me". This sense of bodily alienation is particularly profound in the experience of bodily breakdown and malfunction ‑when the body is apprehended as a neurophysiological organism (a "hidden presence" that is necessarily beyond one's control).
As an embodied being I exhibit a certain corporeal style (bodily identity) -- way of walking, gesturing, and so forth --that is unique. This bodily comportment not only identifies the lived body as "mine", but also reflects the body as a social and cultural entity.
Perhaps the most obvious fact about the phenomenological concept of lived body is that it bears no resemblance to the notion of the "body" in medicine. As Zaner, Foucault and Leder point out, Western scientific medicine is " based, first and foremost, not upon the lived body, but upon the dead, or inanimate, body" -- a mechanistic and reductionistic understanding that has extensively shaped medical practice and theory. 2 Under the medically trained "gaze" of the healthcare professional, the body assumes the status of a scientific object, i.e. it is construed as an anatomical, neurophysiological organism and, more particularly, as a mass of cells, tissues, organs, and so forth, according to the categories of natural science. As a scientific object, a particular body is simply an exemplar of the human body (or of a Particular class of human bodies) and, as such, it may be viewed independently from the person whose body it is. Thus, the notion of body in medicine (often characterized as a "Cartesian" paradigm of body) effectively separates body/mind, body/world, and body/person.
Critics point out that, although the mechanistic/materialistic conception of body has "given rise to therapeutic triumphs" in modern medicine, it has also resulted in limitations and distortions in medical practice. For example, if health care practitioners focus their attention almost exclusively on the body/object as a malfunctioning anatomico‑physiological entity and ignore (or de‑emphasize) the patient's lived experience of bodily disturbance, then important factors of illness (such as interpretations, emotions, desires, worldly involvements, cultural background, and so forth) are ignored -- despite the fact that such factors play a crucial role in the course of disease and in therapeutic effectiveness.
Furthermore, in limiting the clinical "gaze" to the biological body and, in effect, abstracting the sick person from the body, this model disembodies and dehumanizes those seeking medical care. As Leder notes, "Patients often complain that they have been dealt with by their health‑care providers or institutions in a dehumanized fashion: as if they were but a disease entity, or a piece of meat to be prodded, punctured, and otherwise ignored."
The process of disembodiment is not only dehumanizing for the patient, but it also directly affects the quality of the clinical encounter by constraining the healthcare professional's ability: to communicate effectively with patients; to comprehend physical symptoms; to respond to the needs of the chronically and terminally ill and those whose disease is not easily correlated with demonstrated pathoanatomical or pathophysiological findings; to recognize and alleviate suffering; to grasp, and respond to, the experiential characteristics of illness; to comprehend the lived experience of disability; to understand the phenomenon of pain; to attend fully to the particular problems of the unique individual who is seeking help -- a task that both characterizes the traditional role of healer and that also morally grounds the profession of clinical medicine. As Pellegrino states,
It is the needs arising from the experience of illness in this person that provides the source of professional morality of those who profess to heal. Their moral obligations are rooted in the phenomenology of illness; since the experience of illness gives rise to expectations in the one who is ill. These expectations become promises each time the professional presents himself or herself to the person who is ill and offers to help. The promise of help shapes the nature of every healing ad and defines the requirements for successful healing -- even when cure is not possible. To heal is "lo make whole again" and that entails confronting and ameliorating the ways illness wounds the humanity of the one who is ill.
Furthermore, in the context of clinical medicine, ethical discussion and decision-making must necessarily address the existential predicament of the particular suffering individual who seeks help -- i.e. the person by whom, and for whom, a right and good decision must be made. Thus, clinical ethics must (among other things) explicitly attend to the unique life situation and lived body of the individual.
In reflecting on embodiment in the medical context, Shaun Gallagher focuses on, and extends, several of the concepts that informed Merleau-Ponty's analysis of the lived body. In particular, Gallagher makes a clear distinction between the concepts of body image and body schema noting that these concepts continue to play a role in medical research, explanation, and treatment, as well as in philosophical analyses of questions pertaining to cognition and personal identity. In the medical context, for example, the distinction between body image and body schema can be usefully employed in the systematic explanation of certain pathological conditions (including aplasic phantoms, unilateral neglect, deafferentia6on, and schizophrenia), as well as providing the basis for developing therapies that address disorders involving pathological distortions of body image. Gallagher also explores the manner in which these aspects of embodiment contribute to the sense of self and personal identity, as well as to the senses of agency and ownership.
Maureen Connolly turns her attention to the issue of gendered embodiment. In particular, she notes the incompatibility between biomedical and lived body approaches to the body -- noting specific ways in which the lived body is effectively "eliminated" in medicine. After providing a brief overview of feminist and phenomenological work on female embodiment, Connolly discusses how female embodiment is constructed in the context of clinical practice -- a construction that prohibits the healthcare practitioner from understanding (and responding to) the lived experience of illness and pain, that prevents effective communication, and that often results in differential (and sometimes dismissive) treatment for women. Connolly ends by suggesting concrete ways in which a "phenomenological sensibility" can inform praxis and provide an alternative way of approaching (and inhabiting) the clinical encounter.
Glen Mazis considers the significance of the "emotional body" in the context of serious illness and injury. Following Merleau-Ponty, he notes the constant interweaving of lived body and world -- an embodied engagement that is, at its heart, an emotional engagement. Mazis asks (1) in illness what are some of the emotional dimensions of a world that has at its center the "body uncanny", particularly since the only cultural response to one's predicament is the biomechanical colonization of the body, and (2) how can attention to the emotional dimension transform the practice of medicine (i.e. shift the emphasis from that of purely medical intervention to "healing" -- making whole -- an approach that specifically takes into account the emotional dimension of bodily being.)
Bruce Wilshire also explores the significance of the interweaving of body/world/community in the process of healing. Noting that we are already sensuously aware of our surroundings from the time we are in the womb particularly through the capacity to hear the sounds emanating from within our own bodies, our mother's body, and from the environing world Wilshire describes how Native American medicine calls upon this primal embodied connectedness to the world in order to arouse the "immunological and regenerative capacities of the body that bring about healing." In focusing on the phenomenon of auditory perception, Wilshire considers Rudolf Steiner's phenomenological analysis of the engaged body as hearer and music maker in order to grasp the role that music can play in the healing process. Wilshire notes that, as is the case with indigenous ways of regarding sickness, Steiner considers "disease as dis‑ease, lack of balance or flow." It seems that music is, thus, particularly well suited to restoring the sense of embodied equilibrium (a point that is illustrated concretely in Mazis' essay on the "emotional body" when he recounts Oliver Sacks' specific experience of regaining physical function through the power of music to "move" him.)
In turning to lived experience phenomenology provides concrete insights into what it is like, what it means, to experience illness and disability. An important avenue of such disclosure is the first‑person narrative of illness‑a form of story‑telling that has proliferated in recent years. Arthur Frank turns the "phenomenological gaze" to the illness narrative itself, in order to consider not so much what is disclosed about illness as lived experience but rather to analyze "how such narrative disclosures originate in an attitude of consciousness ... telling illness, comprising both speaking and hearing as reciprocal aspects of shared telling." In considering several illness narratives in light of Alfred Schutz's notion of "finite provinces of meaning," Frank demonstrates that "telling‑illness" is more than simply a consciousness of being ill. Rather it is an awareness of "living illness as a story in which one is both narrator and narrated, organizing consciousness and consciousness that is organized." Frank concludes by considering how the phenomenological analysis of "telling illness" raises important questions such as "How should one respond to the illness storyteller?" "What is the moral relationship between story‑teller and listener?" "What does the moral occasion of illness require of each one of us?"
Kay Toombs reflects on her own experience of neurological disease multiple sclerosis -- in order to illuminate the lived experience of bodily change (acquired disability). In particular, she considers the meaning of loss of mobility. In noting the dynamic relation between lived body and world, she describes, for example, the multiplicity of ways in which the experience of space and time change as one moves from the world of the "upright" to the world of the wheelchair user. Toombs also discusses the significance of loss of upright posture in terms of one's relationship with others, one's sense of self, the exercise (and perception) of autonomy, and the interrelationship between the emotions and bodily being. She suggests that understanding the lived experience of disability has important practical implications in the clinical context, as well as in the wider society.
Irena Madjar considers what it is like to experience pain--particularly in the somewhat paradoxical context of clinical practice where the one whose aim is to relieve pain and suffering is also the one who is sometimes required to inflict pain. She notes that there are some essential qualities to the phenomenon of lived pain -- its embodied painfulness, its wounding nature, its socially mediated expression (acceptable ways of being with others when one is in pain) -- as well as some commonly held meanings with respect to the pain experience (for instance, in searching for the meaning of pain, many sufferers assume that pain is an inevitable consequence of illness, or that it is some kind of punishment or sign of failure). In focusing on the meaning of pain, Madjar draws attention to the inadequacy of biomedical descriptions and the need for healthcare professionals to move beyond standardized terms and numerical values in order to comprehend that lived pain is much more than simply "a pure sensation." "The key," she says, "is our attentiveness to the lived experience of the person in pain, and our willingness, individually and as members of health care teams, to work as much with as on our patients."
Although noting that the term "mental illness" is, in itself, problematic, Jo Ann Walton considers some of the elements that are central to the lived experience of those who are diagnosed with "mental illness" and who experience themselves as persons "with a mental illness." She discusses several phenomenological studies that have examined the experience of schizophrenia, postpartum depression, and anorexia nervosa. Such studies bring to light important features of the illness experience. For instance, in describing the ways in which the participants in her study of people with schizophrenia looked "both backward on their illness and forward toward the future," Walton finds a parallel with Heidegger's analysis of the temporal dimension of hope in everyday "normal" existence. Furthermore, so called "mental illnesses" are revealed to be particular ways of being-in-the-world (and not simply a disturbance of mental --as opposed to physical functioning).
The essays on clinical practice attest to the practical import of rigorously examining "the things themselves" in the context of the clinical encounter. Four of the authors are physicians, another has extensive experience in the field of nursing and patient care. Carl Edvard Rudebeck explores the role of bodily empathy in clinical communication. In distinguishing between the symptom and the symptom presentation, Rudebeck clarifies the meaning structure of the body in lived experience ‑ a meaning structure that he identifies as "the existential anatomy." Noting that the intentionality of bodily experience can be characterized along a continuum between outward intentionality (away from the body towards one's involvements in the world) and reflexive or inward intentionality (toward the body-as-nature), Rudebeck provides a descriptive account of the complex intentionalities of both symptoms, symptom presentations, and the communicated experience of the symptom. He notes that the first step in clinical diagnosis is grasping the patient's experience. "The richer, and more differentiated the doctor's perception of the symptom presentation ... the easier it is for the doctor to reach a valid judgment." In addition to providing an insightful and illuminating account of the symptom presentation, Rudebeck's analysis shows how the ground of lived experience provides the basis for a type of empathy that he calls "bodily empathy." Since doctor and patient share their "existential anatomies" in important ways, the doctor's own bodily experience can provide insights into presented symptoms. Rudebeck distinguishes several dimensions of bodily empathy and suggests ways in which these can be developed.
In his exquisite account of the "many faces of the clinic," Paul Komesaroff focuses on the irreducible "intricacy and complexity" of the encounter between patient and carer. In reflecting on his relationship with a patient Rebecca (whom he has known for about ten years), Komesaroff describes the heterogeneity that is typical of clinical discourse --the patient's story is "fluid, unpredictable and fecund" moving "seamlessly between different kinds of language." It cannot be reduced to the language of scientific medicine, nor does it come out as a single, coherent account. This variability of linguistic usage in the clinical dialogue is "not a purely technical matter: it is literally the means by which the patient reveals her `self" -- a "self' that is not a unified subject independent from social life or interpersonal experience, but rather one that is formed and generated in the relation between "self' and other (Levinas). The faceto-face confrontation with another thus has a particular ethical significance in that it is the "starting point for meaning, value and truth." In the clinical encounter, the patient herself is formed and presented in the clinical dialogue. Komesaroff considers what it means to be a partner in the clinical relationship -- where one is both called upon to witness, confront, and be responsive (and responsible) to the unique other who presents herself. He concludes, "the clinical encounter is inherently a moral relationship, but ... the conditions of morality here are very different from those presupposed in classical ethical theory."
In noting that modern medicine and its institutions are "strictly divided along dualistic mind/body lines" even though "the evidence accumulates that all illness is a function of the human organism as a whole, at all levels, from the molecular to the cognitive and affective, and that the organism's environment, both social and physical, is an important influence on healing," Ian McWhinney traces the evolution of clinical method in Western medicine from its roots in Greek antiquity to the present. He proposes that the "modern clinical method" ‑ with its dominance on abstraction and the devaluation of experience -- be transcended by "the patient‑centered clinical method," a method that enjoins the clinician to focus explicitly on the patient's lived experience. After describing the patient-centered method in detail, McWhinney concludes, "The new method should not only restore the Hippocratic ideal of friendship between doctor and patient, but also make possible a medicine which can see illness as an expression of a person with a moral nature, an inner life, a unique life story: a medicine that can heal by a therapy of the word and a therapy of the body."
Patricia Benner focuses on the phenomenon of care both in terms of its ontological structure in the human lifeworld of concerns and possibilities (i.e. what is it about our Being‑in‑the‑world that is the ground for care or concern?), as well as in terms of particular caring practices that are related to specific lifeworlds and contexts (such as clinical medicine). She illustrates how an understanding of the ontological dimension of care enables us to reflect on (and develop) care0giving practices that are optimally responsive in terms of meeting the needs of the one who seeks care.
In reflecting on the phenomenon of suffering and its relationship to pain, Eric Cassell states, "The path, stretching from the physiological response evoked by a physical stimulus to the disintegration of the person experienced as suffering, is important to understand not only for itself but also as an exemplar of mind‑body interactions." He demonstrates that, while there is a distinction between pain and suffering, it is a mistake to assume that the experience of pain itself is a purely physical sensation detached from the meanings, predictions, interpretations and behaviors associated with it (all of which are a function of the person experiencing the pain). Thus, pain is "subjective in the sense of experienced by the subject -- the person ... [and] ... in the sense of expressive of the subject -- the person." Pain progresses to suffering when the injury to the patient broadens to the extent that the integrity of the person is threatened. Cassell notes that, like pain, suffering is personal and individual. It can come from "any physical, social, or emotional process that leads to a loss of integrity of the person." Unless suffering is directly addressed, it may continue even if the pain or other physical or social processes are controlled. In explicating the complexity of pain and suffering, Cassell shows that "the involvement of persons in their own illness and manifestations of disease can be traced from the earliest symptoms to the ultimate personal injury, suffering. It follows that there can be no true appreciation of sickness and its treatment without an understanding of persons."
Mark Bliton considers the relevance of phenomenological method in the context of his engagement in clinical ethics consultation. He notes the complexity of decision‑making in the clinical setting where "not only are there apparent differences among personal beliefs, professional opinions, and responsibilities, whose meanings may not be reducible to some common theme, but the meanings of physiological factors, let alone moral ones ... are embedded in complex webs of cultural and social relationships." Thus, responsible ethical inquiry must "always be guided by careful attention to the moral relationships and understanding of the individuals actually making the decisions and living with their choices." Bliton illustrates by relating his experience of talking with more than 150 pregnant women (and partners) about their decisions to undergo open‑uterine fetal surgery. From these conversations he identifies a number of themes that pervade such moral deliberations. These include: the manner in which the experience of pregnancy is influenced by prenatal ultrasound imaging (and, particularly, the ways in which ultrasound shapes the perceived moral status of the fetus); the impact of uncertainty on the process of moral deliberation; the ways in which the meanings of disability influence the decision "to do" something; and the role of religious language and faith in decision‑making. Bliton's findings raise important issues not only for the particular context of open‑uterine fetal surgery but in terms of ethical deliberations about the status of the fetus, considerations about what it means to say that an individual "freely" chooses a certain course of action, and in terms of defining the nature of clinical ethics.
Mackenzie critiques prevailing conceptions of autonomy that are widely held in mainstream bioethics. In particular, she questions "maximal choice" conceptions of bodily autonomy which include "the view that an agent's bodily autonomy is always enhanced by maximizing the range of bodily options available to her; and the view that any expansion of a person's bodily capacities, or of her instrumental control over her bodily processes ... enhances her bodily autonomy." Mackenzie suggests that the phenomenological notion of embodiment offers an alternative view of bodily autonomy that explicitly recognizes the "complex relationships among the biological, social and individual dimensions of embodiment," as well as the intimate connection between body and selfhood. Following Ricoeur, Mackenzie identifies two different senses of "belonging" with respect to the body ("selfhood" and "ownership") -- a distinction that "helps explain why the notion of bodily ownership misunderstands the sense in which a person's body belongs to her." She proposes a concept of bodily autonomy that takes into account whether or not a person has an "integrated bodily perspective" (a notion that explicitly recognizes that the person is an embodied agent whose body is constitutive of selfhood), and whether or not the person has the capacity for normative critical reflection.
Michael Brannigan suggests that the work of Husserl and Merleau-Ponty can provide insight into a variety of issues in medical ethics -- including the issue of how best to decide whether or not to provide nutrition and hydration via nasogastric feeding to particular individuals. In bringing a phenomenological perspective to bear on the case of Claire Conroy, Brannigan critiques the prevailing distinction between "ordinary" and "extraordinary" treatment and considers how Merleau-Ponty's ontology of the body might have specifically informed the decisions made on Ms. Conroy's behalf. In particular, he is concerned to show that what is "morally obligatory" with respect to treatment decisions "rests upon a phenomenological understanding, one that considers treatment in terms of the entire context" of the particular individual who will be the recipient of such medical intervention.
Max van Manen considers what it means to engage in phenomenological research in the domain of public and professional practice. Noting that phenomenological inquiry involves the taking up of a particular attitude or style of thinking (i.e. "an attitude of reflective attentiveness to what it is that makes life intelligible and meaningful to us"), van Manen both outlines "how some of the methodological features of the phenomenological reduction are engaged by methods inventively borrowed from the broader field of the social and human sciences, from the humanities, and from other practical contexts," and demonstrates how phenomenological research can deal with practical topics in the domain of medicine. Since understanding the meaning of illness is of crucial significance in the care of patients, van Marten illustrates how one might engage in a research study focused on a certain aspect of Alzheimer's dementia. How, for example, can one understand the profound forgetfulness or memory loss in Alzheimer's patients? Beginning with experiential accounts of the ordinary experience of forgetting someone's name and including lived experience descriptions from Alzheimer's patients, van Marten briefly describes the reflective process of phenomenological analysis and writing. He points out that, even in this brief account, "some aspects of the meaning of name forgetting readily suggest themselves" ‑ for instance, the way in which memory is inextricably tied to selfhood. Thus, the tragedy of forgetting in Alzheimers is that the disease "slowly seems to rob a person of his or her selfhood." It is vital for practitioners to gain such knowledge of the experiential (or pathic) dimensions of Alzheimer's disease, since clinical decisions always relate to the suffering individual in the context of his or her particular life situation (as is the case with all illnesses). Furthermore, "implicitly or explicitly professional practices are shaped on the basis of how one conceives the inner life and the effects of Alzheimers on the nature of selfhood of the patients suffering from it." Phenomenological research is, therefore, an important resource for those engaged in the practice of clinical medicine since professional practice needs to be "not only pragmatic and effective, but also philosophic and reflective so that one can act and interact with competence and tact, and with human understanding."
Christina Papadimitriou discusses her phenomenological research practices as a fieldworker studying the phenomenon of physical disability. In particular, she is concerned to identify theoretical and conceptual biases in the study of disability that both limit our understanding of the lived experience of disability, and that cause us to "see" persons with disabilities as radically Other than we are. Papadimitriou describes her use of two phenomenological practices (bracketing and empathic listening) that have been particularly helpful in assisting her both to understand, and communicate with, her disabled informants. She ends by suggesting that, rather than seeing the "normal" and "pathological" as separate, we can understand them as "varieties situated along a continuum of modes of being-in-theworld." Disabled embodiment may thus be conceived as a form of human diversity ‑ "difference" as opposed to "disability" ‑ a conception that has important social and political implications.
The essays in this volume demonstrate that the philosophical perspective of phenomenology is an extraordinarily fruitful approach for examining theoretical and practical issues in the domain of medicine, clinical practice, and medical ethics. Clinical medicine is necessarily at the intersection of science and humanity. It is a human science that has, at its center, the suffering embodied human being who seeks help and the professional who responds (is responsive) to the call for assistance. As a discipline, medical ethics is also primarily concerned with issues that relate to (or have implications for) the care of the sick person. In eschewing abstraction in favor of a commitment to focus on "the things themselves," and in emphasizing the importance of clarifying the meaning and structure of the lifeworld and existence, phenomenology is thus particularly well suited for engaging in philosophical reflections that pertain to medicine.
Moreover, in providing the means to examine phenomena in
all their richness and complexity, the philosophical perspective of
phenomenology can powerfully illuminate and clarify theoretical and practical
issues in a variety of disciplines. Some of the authors who have contributed to
this volume are academic philosophers, some are engaged in other academic
disciplines, and several are practicing healthcare professionals. However, all
have found phenomenology particularly insightful in their work. Their essays
(and experience) attest to the fact that phenomenology is an invaluable
practical tool for those working in the field of clinical medicine, for those
engaged in clinical practice, and for all who are interested in the philosophy
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