The Concept of Normativity from Philosophy to Medicine: An Overview
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- Debru, C. Medicine Studies (2011) 3: 1. doi:10.1007/s12376-011-0056-6
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In this introductory paper, I try to give an overview of the concept of normativity in its philosophical history and its contemporary interpretations and uses in different fields. From philosophy of logic and mathematics to philosophy of language and mind, and to philosophy of medicine and care, normativity is found as a key concept pointing at the possibility of scientific and technical progress and improvement of human life in the interaction between the individual and his environment.
KeywordsPhilosophy of language and mindMoral philosophyNormativityMedical care
On some twentieth century philosophical ideas about normativity
The concept of normativity is a transdisciplinary concept which is found in every branch of philosophy and human sciences and pertains to every aspect of human life. However, the terms normative, normativity are rather recent. The term normativity seems to be an invention of twentieth century philosohy. In the nineteen thirties and forties, philosophers from very different backgrounds, including Edmund Husserl in Germany and Georges Canguilhem in France, developed the idea of normativity defined as the power of creating and changing norms. In his 1935 Vienna lecture, The crisis of European mankind and philosophy, and in the framework of his phenomenological reflections based on the philosophy of logic and mathematics, Husserl conceived normativity as the creation of a world of ideas put under the control of the norm of unconditional and objective truth. This world of ideas has the property of developing itself in infinity by the continuous creation of new ideas which become themselves the matter of further creations. Thus, the intentional life of individual persons and of communities is directed towards goals which are subjected to norms and go on in infinity. “ Mankind, considered in its soul, has never been and will never be accomplished. The spiritual goal of European mankind (…) is situated at the infinite : it is an infinite idea towards which the spiritual process as a whole seeks, if I may say so, to transcend itself. Not only consciousness in this process of becoming grasps this term as a telos in proportion to and within this development; but consciousness sets this term also in a practical way as a goal for the will, and erects it in a new form of development, put under the control of norms, of normative ideas ” (Husserl 1950, p. 236). Husserl puts the normative idea of mankind as a spiritual development in sharp contrast with a naturalistic and even “ zoological ” view of mankind. All aspects of cultural life are involved here, but mathematics as an infinite construction is the best example of human normativity defined as the continuous pursuit of objective and possibly unconditional truths (Husserl 1950, p. 240).
In the very different context of medical thinking Georges Canguilhem introduced the idea of a biological normativity in his 1943 MD thesis The normal and the pathological (Canguilhem 1972, p. 77). In a general sense, normativity may be defined as the power of establishing norms. From the particular standpoint of medicine, normativity was defined by Canguilhem as the organism’s power to create different and more or less stable ways of functioning according to various normal or pathological states. Canguilhems ideas were formed in the context of pathophysiology. They were confirmed by the reading of Goldstein’s neurological interpretations as exposed in his book The structure of the organism. Canguilhem was deeply in harmony with the medical theoretical thinking which was very much developed in Germany between the two world wars, and which could be characterized as a philosophical theory of the living being. In the true spirit of this holistic philosophy, Canguilhem wrote : “ life is polarity and as such unconscious position of value—in short, life is in fact a normative activity (…) In the full sense of the word, normative is what sets up norms. In this sense, we propose to speak of a biological normativity ” (Canguilhem 1972, p. 77). One of the consequences of this thesis for medicine defined as a technique rather than as a science is that “ physiology, rather than looking for objective definitions of the normal, should recognize life’s original normativity ” (Canguilhem 1972, p. 116). Being “ normal ”, for humans, is not a matter of fact, but an aspect of life’s original normativity. “ If one may speak of a normal man, as determined by the physiologist, this is because there exist normative men, men for whom it is normal to break norms and to establish new ones ” (Canguilhem 1972, p. 106). In the same vein, Canguilhem quoted Reiningers Wertphilosophie und Ethik : “ Unser Weltbild ist immer zugleich ein Wertbild ” (our view of the world is always at the same time a view of value) (Canguilhem 1972, p. 117). The science (and philosophy) of the living being should include the idea of the organism having not only a world view but mainly a world view which is fully value-laden. According to Canguilhem’s fundamental thesis, this matter of fact is indeed the case for normal physiology as well as for pathology. Pathological states are characterized by a remaining, although diminished, physiological normativity. The pathological is not the opposite of the normal; it keeps some normative character. Pathology does not mean necessarily a chaotic, catastrophic or irrational course. In pathological states, the organism tries to establish a new functional norm certainly different from the normal one but more or less viable. There is some kind of rationality in pathology, in the sense of a holistic concept of rationality. This philosophical thesis may apply to many fields of human experience, not only to medicine.
More recently, the idea of normativity arose much interest in the fields of moral philosophy, of epistemology (with the discussions on epistemic values), and of analytical philosophy of language. Indeed, the terms, normative and normativity, do apply to many different things, be it statements of any kind, from logic to law, to grammar and to language, and to any kind of rule including technological rules. But most importantly, normativity does not only designate the power of the rule which is going to be applied, but also and mainly the power of the human subject who formulates these rules, and applies them thanks to his personal authority, social status or whatever. The ability of the individual who creates a new order in his social environment may be thus described as “ normativity ”, and here medicine comes again into the picture.
Indeed, the medical meaning of normativity remains an essential part of the picture for two very special reasons : the increasing creation of social norms for medical practice and the increasing concern for the patient’s autonomy or rather personal normativity (a feature which is particularly desirable for patients in danger of loosing it due to severe neurodegenerative diseases for instance : how to allow these patients to express themselves and interact with their environment, so that they keep most of their normative power). In this paper, we will try to give an overview of the philosophical discussions on the nature and sources of human normativity, and to show their relevance for medical practice in the interaction between patients, health practitioners, and their human environment.
Some philosophical remarks on logic and mathematics
The paramount power of human normativity and its anthropological basis are best described in classics of XXth century philosophy and in more recent developments in analytical philosophy. I will make use of some commentaries on Wittgenstein by the philosopher Jacques Bouveresse in his book La force de la règle. Wittgenstein et l’invention de la nécessité. In order to understand what it is to follow a rule, the examples of grammatical and logical rules are basic. They allow to ask a particular question : does the ability to speak a given language rest upon an implicit knowledge of its grammatical rules, or does the ability to speak a language involve also a creative participation of the speaker? (Bouveresse 1987, p. 14). Indeed rules are not just a matter of external necessity, but rather a matter of choice and perhaps of conventions. Mathematics are the best example of a creative process based on rules and able to create new mental objects which may be used as new rules etc. Now we meet a question about the epistemological status of these rules. Are they similar to ordinary propositions in the logical sense, which are endowed with a truth value, or are they something else, constituting the frame for formulating meaningful sentences without being themselves either true or false? Are they just conventions, or are they endowed with a kind of necessity which is very likely not of a platonic, external, realistic kind but rather the result of an internal process of creating rules according to rules—a thesis which represents in its essence Wittgenstein’s grammatical, non conventionalist, conception of mathematics? (Bouveresse 1987, p. 23). According to Wittgenstein, there is no contradiction for a mathematical proposition to be a rule, not simply stipulated by convention, but generated according to other rules. There is rather a kind of circle, well defined by Quine who noticed that if logic must result from conventions, logic is necessary for the inference of logic from conventions. Indeed, some kind of logical rules of deduction are necessary there in order to build logic. How can we justify these rules of deduction? According to Wittgenstein, there is nothing like a preexisting meaning of a grammatical proposition which would force us to accept other grammatical propositions which are logically deducible from it. The new connections which we discover were not already present in any sense. They are the result of a construction which has to be performed and accepted at each step. The new connections are an additional determination of the meaning and an extension of the grammar, not simply an explanation of any concealed content. The meaning of a word is the rules of its uses; if we change the rules, the meaning is different. This is a constructivist view of logic and mathematics. In this view, we have to give an account of the relationship between meaning and use (Bouveresse 1987, p. 35–36).
In this enquiry, we encounter an unexpected thing. Even in mathematics, which has the most precise and explicit rules, it seems that no anticipation can predict in advance a case which has not been previously encountered. Every application of a rule to a new case is in fact a new application. According to Wittgenstein commenting on the individuality of the numbers in his Philosophical Grammar, if a universal rule is given to me, I must know each time anew that this rule can be applied in this particular case. No act of prevision can spare me this act of intuition. Then indeed the form to which a rule is applied is at each step a new form (Bouveresse 1987, p. 36). The application is not a matter of an act of intuition, but of an act of decision. Similar remarks were made by the French mathematician Emile Borel, who asked the question, whether the kind of operation by which we go from one integer to its immediate successor is really the same at each time, or not. From a certain point of view, it is the same, and from another, it is not, since adding one to one in order to get two, and adding one to two in order to get three is not the same operation. Even in such a regular system as arithmetics, a new application involves at each time a decision regarding it. So that, what characterizes best mathematics is its normative character. Mathematics is not descriptive, it is rather prescriptive. Mathematics, in the Wittgensteinian sense, is normative in a way which has nothing to do with any truth of a logical norm. It creates a special kind of necessity, the necessity of a newly created fact, the factual necessity of our special way of doing things, which is ours and does not seem to be possibly of another kind. In other words, this necessity is an anthropological necessity, it depends on a fact of nature, which appears necessary because there is no other alternative – and moreover which appears necessary from within (it could appear as contingent rather than necessary from an external point of view). If we try to summarize the most significant results, from the standpoint of the idea of normativity, of this sketchy investigation in the field of the philosophy of mathematics, it appears that the idea that the recursive application of the same rule is at each step a new situation different from the previous ones, and that there is something unforeseeable in this application. This rather unexpected result seems to be of great relevance for any aspect of human thinking and action, including certainly the ones which are most remote from pure mathematics, like medicine.
The nature of normativity according to the analytical philosophy of language
Let us try to get now into another field of contemporary philosophical enquiry, the analytical philosophy of language, and ask the following questions : is there something irreducible in normative statements (statements of the “ ought to ” kind) compared with factual statements? Can we give an account of this difference by using the logical tools of analytical philosophy? This problem was dealt with by Ralph Wedgwood in a recent book on the nature of normativity. As an analytical philosopher, Wedgwood considers the existence of normative statements or judgments as a fact, which needs explanations, but refuses to propose any definition of the term “ normativity ” as such, perhaps fearing that defining concepts such as normativity would lead us into a kind of mystical realism. He defines his task as giving a theoretical account of the ordinary understanding of normative terms by analysing their truth conditions in a logical and semantic way. This task is very different from more naturalistic approaches of the normativity problem, which are more and more developed in natural sciences like cognitive neuroscience and psychology, which deal with the different problem of understanding how we as human beings create and possibly change norms, and not only follow them in our language.
From the standpoint of the analytical philosophy of language, normative thinking, normative knowledge, normative truths, normative judgments, normative intuitions, normative beliefs etc. are matters of fact—facts of discourse, language and thinking which bear on non existent realities. What is the semantic content of these very peculiar kinds of statements? Does the semantic explanation of normative statements need statements or concepts which are themselves non normative, or not? In other words, is normativity in language and thinking reducible or not reducible to factual properties? In case it would turn out to be irreducible, we would face a logical circle. Wedgwood’s own thesis, is that we can avoid this circle. Other philosophers, like John Mac Dowell, Ronald Dowrkin or Derek Parfit claim on the contrary, in their own “ quietist ” thesis, that it is impossible to give a non-circular explanation of normative discourse. Wedgwood relies on an argument of Saul Kripke regarding reference, in order to justify his own claim : “ I shall give an accont of what it is for a thought or a statement to be about what ought to be the case without making any use of (…) a notion of a thought’s or a statement’s being about what ought to be the case ” (Wedgwood 2007, p. 20). Only very general normative properties like truth, proof, belief, decision can be used in order to analyse normative statements exactly in the same way as any other kind of statements. Indeed, normativity can never be absent from statements of the sort “ Necessarily, if one is rational, if one judges ‘I ought to do this’, one also intends to do this ” . Necessity and rationality are normative properties, so that the project of an explanation of normativity in totally non normative terms makes no sense.
However, Wedgwood claims that particular normative statements of the form “ I ought to do this ” can be analysed without referring to any normative property of the same kind. As a philosopher of language, he notices that normative terms are extremely context-sensitive and express different concepts in different contexts (Wedgwood 2007, p. 23). Under such conditions, the philosophical theme of intentionality enters the discussion. Indeed, Wedgwood’s own theory of the nature of normativity, which he pictures as “ normative judgment internalism ” as opposed to externalism, stresses the subjective, first person dimension of normative judgment, whereas externalism stresses the external, objective source of normativity. According to Wedgwood’s internalist theory, there is an essential link between normative judgment and practical argumentation and motivation for action. Normative judgments or statements can be pictured as first-person judgments, with the qualification, that action is strongly context-dependent, and should be appropriate and reasonable. Normative judgments can be understood in terms of their regulative roles in practical reasoning. The concept of a right planning for action is introduced by Wedgwood under conditions, which do not allow any uncertainty. Under the specific conditions of certainty it is clear that the role of normative concepts or judgments can be easily described as commitment or obligation, which necessitates the realisation of the planned action. This is a rather ideal model, which should be totally different under conditions of uncertainty.
Then the concepts of intentionality and first-person viewpoint come necessarily into the picture. The slogan “ the intentional is normative ” has been much discussed by philosophers recently. From the previous analyses it is clear that normativity represents a special form of intentionality, which has to do with practical judgment, disposition, and commitment for action. Does intentionality in general and essentially involve some form of normativity? Many philosophers, including Husserl and more recently Davidson, defended already this idea. According to Wedgwood, “ intentional facts are partially constituted by normative facts ” (Wedgwood 2007, p.159). The reason why this seems to be the case is that all intentional states or properties involve two elements : “ (i) a content, which is composed out of concepts, and (ii) a mental relation or attitude (such as belief, desire, hope, fear, and so on) towards that concept ” (Wedgwood 2007, p. 161). For instance, believing can be pictured in two ways. The belief is right if and only if its content is true, and second, the belief is rational (under certain circumstances) only if these circumstances determine its probability so that its content is true (Wedgwood 2007, p. 162). The normative element of the intentional is found in the relationship between the intentional conceptual content and the intentional attitude regarding this particular concept. With his theory of “ normative judgment internalism ”, Wedgwood wants to avoid to different dangers : the danger of a total reduction of the normative to natural properties (naturalism), and the danger of a purely metaphysical and mysterious picture of human normativity.
Some empirical studies on the sources of human normativity
However, internalism leaves some room for an explanation of normativity in naturalistic, psychological and even neurobiological terms, as we may observe more and more frequently in some research programmes and reports which are worth mentioning. It is rather striking to notice that in the naturalistic approach of normativity in developmental cognitive psychology (dealing with young children) normativity is considered as a power as well as as a fact. The description of normativity as a fact which is found in language and whose logical and analytical properties can be looked for (with the not entirely unexpected result that normativity involves intentionality and rationality)—this description is not enough. How can these normative rules be created, how can they be perceived and accepted? These questions were investigated by researchers at the Max Planck Institute for evolutionary anthropology in Leipzig. The children who participated in the study were two and three years old. These children can understand the rules of a game and follow them. Moreover, they can notice situations in which the rules are not followed and they can protest. A “ normative awareness ” is found in very young children (Rakoczy,et al. 2008, p. 875–881). Similar empirical studies can be found on the inhibition of violence among children, showing the existence of normative behaviors. In a recent book, the neurobiologist Jean-Pierre Changeux tries to show how factual knowledge about the human brain may be useful for the scientific understanding of the sources of norms and values and for the practical development of normative behavior in society. Examples of empirical studies on normative behaviors and moral emotions include the inhibition of violence in children, and the distinction between social conventions and moral imperatives. The study of children raised in different cultures and in different social conventions shows that after the age of three, children judge as acceptable not to follow religious rules, but they consider as unacceptable the transgression of essential moral rules (Changeux 2009, p. 97). However, and not surprisingly, the question of the sources of human normativity was dealt with mainly in moral philosophy, as we shall see.
Moral philosophy on the sources of human normativity
In her book The sources of normativity, Christine Korsgaard wrote : “ It is the most striking fact about human life that we have values. We think of ways that things would be better, more perfect, and so of course different than they are; and of ways that we ourselves could be better, more perfect, and so of course different, than we are. Why should this be so? Where do we get these ideas that outstrip the world of experience and seem to call it into question, to render judgment on it, to say that it does not measure up, that it is not what it ought to be? Clearly we do not get them from experience, at least not by any simple route. And it is puzzling too that these ideas of a world different from our own call out to us, telling us that things should be like them rather than the way they are, and that we should make them so » (Korsgaard 1996, p. 1). According to Korsgaard, “ the fact of value is a mystery ”, a mystery which is in need of a philosophical enquiry. Four kinds of solutions were proposed by philosophers : (i) realism—norms and value are real things (Plato, Aristotle); (ii) voluntarism—there is no right or wrong in a state of nature, norms and values are imposed on us by an authority, obligation derives from the command of someone who has legitimate authority over the moral agent (Hobbes); (iii) norms and values are discovered by an internal reflection—theory of the “ reflective endorsement ”, meaning personal approval (Hume); (iv) the content of norms and values is potentially universal, it is found by an autonomous act of free will—the laws of morality are the laws of the agent’s own will and its claims are the ones he is prepared to make on himself (Korsgaard 1996, p. 19). Kant and contemporary kantians like John Rawls are representatives of this trend—Kant’s formal universalism is well known.
These four basic philosophical solutions are answers given to a very special question, which Korsgaard defines as the “ normative question ”, which may be posed in the following way : “ Ethical standards are normative. They do not merely describe a way in which we in fact regulate our conduct. They make claims on us; they command, oblige, recommend, or guide. (…) And it is the force of these normative claims – the right of these concepts to give laws to us—that we want to understand ” (Korsgaard 1996, p. 8–9). “ When we seek a philosophical foundation for morality, we are not merely looking for an explanation of moral practices. We are asking what justifies the claims that morality makes on us. This is what I am calling the normative question. Most moral philosophers have aspired to give an account of morality which will answer the normative question. But the issue of how normativity can be established has seldom been directly or separately addressed, as a topic of its own right ” (Korsgaard 1996, p. 10). Where could we find, then, the answer to the normative question? According to Korsgaard, the answer “ must appeal, in a deep way, to our sense of who we are, to our sense of our identity ” (Korsgaard 1996, p. 17). If we go back into ourselves, in difficult situations, we should be able to find an answer. Korsgaard’s own answer to the normative question is eventually Kantian (and some hints to Kantianism are found also in Wedgwood’s discussion)—with the qualification that the content of formal universalism is given by reflective endorsement. “ The reflective structure of human consciousness requires that you identify yourself with some law or principle which will govern your choices. It requires you to be a law to yourself. And that is the source of normativity. So the argument shows just what Kant said that it did : that our autonomy is the source of obligation ” (Korsgaard 1996, p. 103–104). In the end, and as a possible consequence of this mixture of Kantianism and reflective endorsement, we are lead to conclude that all four philosophical theories of the sources of normativity are true, they are all parts of the overall picture of human normativity (Korsgaard 1996, p. 165).1
Normativity versus autonomy. Medical implications
The concept of autonomy is a philosophical concept which underwent a change of meaning from the collective and political to the more individual level. Christian Wolff used this term in 1757 in his book on moral and political philosophy in the sense of the independance or self-determination of a state. Although Jean-Jacques Rousseau did not use the term, he is considered as responsible for the introduction of the idea of autonomy in the sense of obeying a law which the individual prescribes for himself. This move towards moral philosophy is even stronger in Kant’s work. Autonomy in the Kantian sense means self-rule of the will which discovers in itself universal laws. Much more recently, the idea of autonomy was introduced in medical ethics, in much more pragmatic discussions regarding health care and health economy. The idea of autonomy was meant as the ability of the patient to sustain him or herself, to rely on him or herself rather than on the others. The concept of normativity, as we did see, has quite a different background. As a matter of fact, it involves the collective horizon of mankind, the essential relationship between individuals. It means the ability of the individual even in diminished conditions to establish new norms for himself and for the others. Stephen Hawking is an extreme case, since he keeps his normative, creative power, his ability as a man not only to rule himself (or at least his mind), but to communicate with the others and to enrich their lives.
It is worth introducing here the concept of health as a dynamical concept. It has been stressed many times that recovery does not mean a full return to the previous health state, because the organism’s whole functionality has changed. The idea of normativity is in harmony with this dynamical concept of health. In the case of severe chronic, degenerative or genetical diseases, for which there is no cure, normativity has a much more serious and interesting content—a dynamical content, obviously. Let us go to clinics to illustrate this point. Between two bouts of multiple sclerosis, the patient may have the time to adjust to his or her pathology, thus showing his or her remaining normativity. The Freireich disease is a neurodegenerative disease of the motor command. There is no cure, and no hope. Handicapped students suffering from this disease may keep however an extremely strong desire for work, recognition, scientific contribution, and interaction with the others. Patients suffering of amyotrophic lateral sclerosis, a degenerative disease of the spinal chord motoneurones, ending in a paralysis of the respiratory muscles, may see their lives improved by technical devices which allow them to communicate with their environment even in a still creative way, showing an incredibly rich human experience, keeping their normativity, in the sense of their ability to contribute to the human experience of their immediate environment, in spite of having lost most of their autonomy (Le Forestier, in this volume). The same is true for very elderly people, suffering from the syndrom of frailty, of diminished physiological functions making them more sensitive to unexpected external perturbations. Their autonomy is reduced, their normativity may be even enhanced, depending on the quality of their interaction with their human environment.
Normativity is a philosophical term which describes very well almost every aspect of human experience. The new awareness of human normativity may be useful to improve many social and technical aspects of medical practice and care.
Ibid., p. 165.