Illness as unhomelike being-in-the-world? Phenomenology and medical practice
Scientific medicine has been successful by ways of an ever more detailed understanding and mastering of bodily functions and dysfunctions. Biomedical research promises new triumphs, but discontent with medical practice is all around. Since several decades this has been acknowledged and discussed. The philosophical traditions of phenomenology and hermeneutics have been proposed as promising ways to approach medical practice, by ways of a richer understanding of the meaning structures of health and illness. In 2000, Swedish philosopher Fredrik Svenaeus published a book where he proposes that the phenomenological hermeneutics of Martin Heidegger and also the reflections on health and illness of Hans-Georg Gadamer offer important ways to approach the nature of medicine. In particular, Svenaeus argues that the goal of medicine is to promote and restore health, and that health ought to be seen as “homelike being-in-the-world”. Unhealth, illness, consequently should be understood as a situation where a person’s “being-in-the-world” in characterized by that lack of the rhythm, balance and “tune” of everyday living that characterizes not “being at home”. In this article, Svenaeus’ position is briefly outlined. Questions are raised whether “unhomelikeness” is to be seen as a metaphor, and, if so, if it is a fruitful such. Furthermore, I discuss whether or not a discourse on health and illness in these terms may be misleading in a situation where the ontological presuppositions of Heidegger are lost out of sight and the popular understanding of health psychology predominates. I also approach the question whether Svenaeus’ assumptions may inadvertently lead us to an unjustifiably broad understanding of the tasks of medicine. It is finally concluded that Svenaeus phenomenological and hermeneutical approach is both interesting and promising. There are, however, several questions that ought to be pursued further, and the step from philosophical analysis to everyday clinical discourse may be unexpectedly long and risky.
KeywordsHealth Illness Phenomenology Metaphor Understanding Home Limits of medicine
On a painting from the early nineteenth century, we see an emaciated man sitting in a hospital bed. Beside him, on a chair, is another man, well dressed, who bends towards him and lays his ear close to the side of the ill man’s chest. His concentration is intense. To the right in the painting we see a nurse and two other men in profile, who deeply interested follow what is going on. The artist’s name is Chartran and he has given his painting the name Laennec listening to a patient.
The quotation from Laennec epitomizes with striking precision what was to follow in clinical medicine as well as the central idea behind much of the triumphs of modern medicine. The strength of his vision pervades in our own time. When anthropologist Byron Good in the late 1980s interviews students at Harvard Medical School, one of the replies he gets is this:The constant goal of my studies and research has been the solution of the following three problems:
To describe the disease in the cadaver according to the altered states of the organs.
To recognize in the living body definite physical signs, as much as possible independent of the symptom.
To fight the disease by means which experience has found to be effective: … to place, through the process of diagnoses, internal organic lesions on the same basis as surgical disease (Faber 1923, p. 122).
Since at least three or four decades there have appeared second thoughts about this vision of the very nature of clinical medicine. A number of factors have contributed to this: a seemingly growing discontent with the quality of clinical encounters, wide-spread disillusionment among medical practitioners, the continuous appearance of syndromes that defy medical explanation and perhaps also a growing gap between popular expectations on medicine and the outcomes this same medicine is able to provide. This has not surprisingly led some critics to question some of the very corner-stones of scientific medicine, such as they were developed in the decades after Laennec. The role of medical technology has been called into question, as for example by Stanley Reiser who writes
You are not there just to talk with people and learn about their lives and nurture them. You are not there for that. You’re a professional and you’re trained in interpreting phenomenological descriptions of behavior into physiologic and pathophysiologic processes (Good 1990, p. 78).
I will not here venture into any analysis whether Reiser is right or not in his rather dismal conclusions. What I want to do in this article is to take a closer look at one of the forms that the analysis of modern medicine and the critique of it has taken. This analysis is philosophical in the very deepest sense of the word. Phenomenology as a philosophical tradition was not very much heard of 30–40 years ago, at least not in the Anglo-Saxon world. Now it has inspired several influential attempts to understand the nature of medicine. In the US, philosophers Kay Toombs (Toombs 1993) and Richard (Zaner 1988) were among the first to present an analysis of the everyday realities of being ill and of the clinical encounter, inspired by phenomenology. Neurologist and author Oliver Sacks (Sacks 1984) as well as psychiatrist and anthropologist Arthur Kleinman (Kleinman 1998) also, albeit in a less philosophically sophisticated way, contributed to an understanding of medicine focusing on the illness experience and illness narrative—that is, exactly on what the Harvard medical student quoted above seemed to regard as some sort of epiphenomenon to the real thing, the disease process. This phenomenological approach hence focuses on the meaning of illness and on how illness intrudes and changes the life world of the ill person.
As the physician makes greater use of the technology of diagnosis, he perceives his patient more and more indirectly through a screen of machines and specialists; he also relinquishes his control over more and more of the diagnostic process. These circumstances tend to estrange him from his patient and from his own judgement (Reiser 1978, p. 1).
Explanation and understanding
It may at first seem that what is at stake here is best characterized by the distinction between understanding and explanation. The modern physician explains diseases with the help of models and methods from the sciences. Within this epistemology disease is a localized process in a tissue and it “produces” symptoms. The causal relation is best explained, and hence potentially also controlled, by ever more detailed scientific investigation. Using such explanations of bodily processes, diabetes became a treatable disorder, as well as hypothyreosis and myocardial infarction. There is, from this point of view, no reason not to continue the efforts to explain the natural phenomena of the body in health and illness—and this research with its clinical applications will finally do almost all the job we expect of them.
The emergence of a biomedical science that is focused on disease processes in cells and tissues has made possible the distinction between disease, as the scientifically defined aspect of being sick, and illness as the experiential, subjective counterpart of this. It is then possible to place disease in the realm of science where, allegedly, explanation is the goal—and illness in the world of human subjectivity, where we strive less for explanation than for understanding. However, the explanation/understanding-dichotomy is risky, since it tends to blur the fact that much scientific explanation is based on the understanding of processes—and much understanding of human subjectivity must involve explanation of human behavior. If, however, we use the notion of understanding as focusing on meaning and intentionality, it becomes obvious that investigating tissues involves fundamentally other forms of understanding than approaching the experiences of persons with serious chronic illnesses.
Disease processes are “located” in tissues and organs. Illness strikes towards human beings—towards their aspirations, their plans and hopes and desires. The ways individuals react when ill are almost endlessly varied and deeply affect how they want to, may and ought to be treated. Moreover, even if much of medicine’s efforts are directed towards medical interventions, diseases are not always detected to explain the symptoms. Illness at times seems to have a life of its own and the relation to the disease “behind” is often more than complex—sometimes there seems to be none at all. For these reasons and others, understanding is crucially needed for the clinical encounter to be meaningful and for medicine to reach the goal to promote or restore health. For these reasons, also, the tasks of the physician will remain dependent on two modes of understanding, two “epistemologies”—that of the human subject, associated to the uniquely personal life history—and that of nature, of the sciences (Toulmin 1993).
Explanation and understanding hence merge in the clinical encounter. The seemingly clear-cut distinction loses much of its meaning, given that any time a person seeks medical help or advice, what goes on must be understood at the same time in the light of the scientific medical knowledge–knowledge of the objectivized, depersonalized body—and within the meaning structures of everyday human experience, an experience which is changed, deranged and even deformed in illness. This is the basic insight from which we may conclude that there is an urgent need for a richer and more complex understanding of the illness experience, of how illness breaks into our everyday living. This, in turn, must be seen against the background of an understanding of our lived reality as healthy, of how human beings shape structures of meaning, coherence and intentionality in their lives.
In the following, I want to approach and make some comments on one of the most interesting and promising attempts to perform such an analysis lately, namely Fredrik Svenaeus thesis from 1999, The Hermeneutics of Medicine and the Phenomenology of Health: Steps towards a Philosophy of Medical Practice. Svenaeus revised some sections of his book one year later, addressing some of the comments made to the first edition. I will follow his analysis in the Kluwer edition which appeared in 2000.
My point of departure is basically sympathising. I find Svenaeus’ analysis rich and in many ways illuminating. I do, however, also find several points worth further discussion and explication. This is especially the case with the central proposal that health should be thought of, seen as, and perhaps also spoken of, as “homelike being-in-the-world”. Consequently, illness is best seen as “unhomelike being-in-the-world”. In order to understand how Svenaeus argues for these concepts, so uncommon to ordinary language and everyday understanding, we must first take a look at how his analysis rests on the two philosophers Martin Heidegger and Hans-Georg Gadamer. I will then point to some problems that I think may arise if this phenomenological analysis becomes widely accepted, and also spills over into our everyday language. During my analysis, I will also make some comments on Wim Dekker’s proposal that an acceptance of the idea of health as “homelike being-in-the-world” is particularly relevant and promising in the area of palliative care (Dekkers 2009).
… the theories of phenomenology and hermeneutics are particularly suitable for this kind of analysis in the case of health and medicine, since they manage to explicate features that would otherwise remain hidden in an exclusively natural scientific approach to the subjects (Svenaeus 2000, p. 6).
This is a large claim and a demanding one. In order to spell it out, Svenaeus starts with a concentrated historical survey of how scientific medicine evolved until the present, and then analyses some suggestions for understanding health, including Boorse’s biostatistical theory (Boorse 1977) and Nordenfeldt’s holistic theory (Nordenfeldt 1995). There follows an introduction to phenomenology in general and to Heidegger’s phenomenology in particular, based on his work Being and Time from 1927. It is important in this connection to underline that only if the “fundamental ontology” of Heidegger is understood and accepted will the following analysis and suggestions concerning our understanding of health and illness be intelligible and meaningful. It is also worth noting that the language of Martin Heidegger poses great challenges to the person writing in English and who has to translate the German philosopher’s basic conceptual apparatus into another language. This is underlined by Svenaeus and it is a fact that not very much can be done about, except now and then pointing to difficulties that arise.
Svenaeus’ suggestion for a phenomenological analysis of health and illness is based on Martin Heidegger’s understanding of “being”, Dasein. Heidegger introduces the analysis of “attunement” in Part I, division I, section V. It must immediately be underlined that being is not to be seen as a psychological phenomenon and hence identified with certain feelings or thoughts. It is an ontological category and Heidegger’s ontology is directed towards the meaning-structures of everyday being. Being, Dasein, is the very precondition for any psychological phenomena at all to occur. Being is hence the very point of departure for this analysis and, if we follow Heidegger, we find ourselves thrown (geworfen) into this being which is characterized by three “existentials” (Existenzialen): Understanding (Verstehen), attunement (Befindlichkeit) and language (Rede). These aspects of being, roughly equivalent to thinking, feeling and talking, should together be seen as “a meaning pattern that binds human being and the being of the world together.” Svenaeus suggests that we add a fourth existential, the lived body, which is not very much dealt with by Heidegger. It is by living in and through these four intertwined aspects of being that we stretch out towards the world, intentionally, to understand it and to affect it in different way. This reaching out is what Heidegger calls “transcendence” and it is a fundamental aspect our “being-in-the-world”.
It is important to be aware of the intertwined nature of the existentials. “Every understanding has its mood. Every attunement has its understanding”, Svenaeus cites Heidegger from section four of Time and Being. If one existential is fundamentally affected, the others will change too—so that the whole of an individual’s meaning pattern is reshaped. Attunement in the form of moods colour our existence and our understanding of the world. Heidegger links certain moods to what he calls “authentic” understanding. If our understanding is “inauthentic” we risk falling into Verfallenheit, of identifying oneself as human with the things of the world. In anxiety, Angst, we become “authentic”, aware of our existence and reconnect to our being.
I am aware of the dangers involved in giving a very short presentation of parts of a very large philosophical work like Being and Time, based on a secondary source. What I want to do is to give an idea of how complex this thinking is and to which extent it demands a leap from familiar categories and patterns of understanding to another way of conceptualizing our most ordinary and well known experiences. Among these are of course health and illness and it is now time to turn the attention to Svenaeus’ analysis of health as “homelike being-in-the-world”.
In the same way as Husserl performed the phenomenological reduction in order to escape the “natural attitude” and focus upon intentionality itself as a constitution of objects, Heidegger tries to excavate the meaning-structures of human understanding, making the everyday understanding activities in the world possible (Svenaeus 2000, p. 89).
Health as “homelike being-in-the-world”
In health, the ever present threat of slipping into Unheimlichkeit, and hence to lose the homelike attunement, is held at distance. Svenaeus notes that the German word unheimlich has two meanings—“uncanny” and “unhomelike”, where probably uncanny is the most common understanding—and as so often in Heidegger’s writings it is very hard to capture this ambiguity when translated into English. (Svenaeus 2000, p. 93). Health, then, is when the attunement and mood of homelikeness “win over” unhomelikeness and thus permeate our being-in-the-world.
To be delivered to the world of intersubjective meaning—language, culture, history etc.—is to find oneself in the world (sich befinden), and this finding oneself appears in the form of an attuned understanding, in the form of finding oneself in a mood. Our attunement colours and determines our understanding of the world (Svenaeus 2000, p. 92).
But what does it then mean to be homelike? It is obviously not primarily what most persons probably would associate with health: feeling well, being fit, not having pain, not experiencing symptoms of unpleasant sorts. It may be all these things, of course, but they are rather what health made possible than health itself. Health is seldom experienced before it is threatened and lost. In a sense, one may even say that health is exactly this mode of being of “not-very-much-experiencing-how-I-feel”.
Svenaeus is here inspired by Gadamer, who may be seen as a follower of Heidegger, who in his The Enigma of Health, makes clear that “Health is not a state that one introspectively feels in oneself”, and describes health as “the rhythm of life”. (Gadamer 1996, pp. 113–114) This is probably counter-intuitive for most persons today, who are likely to identify health with a feeling. It may well be that contemporary tendencies to focus on health as “wellness” in a psychological sense may create obstacles for health in Svenaeus’ sense, rather than facilitate it.
When we are healthy, everything “flows”, the mood we find ourselves in does not make itself heard or seen (…) Health is a non-apparent attunement, a rythmic, balancing mood that supports our understanding in a homelike way without calling for our attention (Svenaeus 2000, p. 94).
Balance is also a crucial aspect of this healthy homelike being-in-the-world. The “moods of illness” are obtrusive, “colouring our whole existence and understanding”. (Svenaeus 2000, 95). Illness changes the healthy balance of being, that balance which makes direct attention to the world—transcendence-possible and unreflectedly there. Often, we do not notice it until it is gone. This may be why Gadamer talks about “the enigma of health”—being enigmatic exactly because it is so hard to capture, while still so obviously important for our understanding of ourselves in the world.
The increasing otherness of our body in illness hence strikes against our very selves. Our ordinary “homelike” lived reality, that manages to balance the otherness of the world, is not able to do so in illness. Our bodily existence is no longer homelike, in the sense of attuned, balanced, rhythmic and familiar.
To summarize: The “unhomelike being-in-the-world” is a fundamental rupture of that familiarity, flow, rythm and “tune” that characterize health. Health, then, is not to be primarily understood by ways of those psychological characteristics that now seem so tempting to apply: feeling well, being fit etc.—and neither alone as the absence of a biomedically definable deviance of bodily structure and/or function, that is of disease. Obviously, disease is often the cause of illness and “unhomelikeness”, but certainly not always—and it is not disease that calls a physician to act and to come to the rescue of a patient, but the suffering resulting from his unhomelikeness.
We may stop here to ask ourselves again whether Heidegger’s language, with its obvious poetic qualities, is superior to other discourses on health and unhealth. Is there perhaps more obscurity than needed in this understanding of health and illness? Is really health similar to home and is consequently unhealth unhomelike? Is this a metaphorical way of speaking, and if so—is it a good, fruitful metaphor?
Metaphor or not?
The purpose of bringing in the adjective “homelike” is obviously to direct the reader’s attention to and ílluminate the analysis of health and illness. By bringing in words—here “home” and “homelike”—that at first seem unrelated to health, a new and richer understanding may be won. This is what metaphors often do. Metaphors abound in language. As Dekkers notices, they offer a rich way to “…make a familiar thing look different and realize that two seemingly unrelated experiences have something in common”. (Dekkers 2009) The use of metaphors seems to be an indispensable way to help us reach a better understanding of persons, things, concepts and ideas. Science can do without metaphors just as little as poetry can.
But do we at all deal with a metaphor here? If a metaphor is defined as Lakoff and Jonsson do, as “understanding and experiencing one kind of thing in terms and concepts of another” (Lakoff and Johnson 1980) it seems no doubt that it is metaphorical to propose, for example, that “my health is my home”. Here, clearly, one kind of “thing”, health, is understood in terms of another, home. But this is not what is proposed by Svenaeus—it is that health is homelike.
It is worth reflecting on the notion of “entity” here. In the phenomenological understanding spelled out above, it is not home as entity that is compared with health as entity. It is being at home that is compared with being healthy. Health has, as a way of “being-in-the-world”, certain characteristics—and these are proposed to resemble, in certain illuminating ways, our “being-in-the-world” when we are home. Or “at home”?
(A metaphor is a) figure of speech that implies comparison between two unlike entities, as distinguished from simile, an explicit comparison signalled by the words “like” or “as.” The distinction is not simple. The metaphor makes a qualitative leap from a reasonable, perhaps prosaic comparison, to an identification or fusion of two objects, to make one new entity partaking of the characteristics of both.
Whether this is a metaphor or an analogy or a simile may not be very important. The thing to ask ourselves is if it is truly illuminating, fruitful, well found?
One way to answer this is to attempt to find a meaning of “being home” that is in line with the phenomenological analysis of what it means to be healthy. Which are those connecting threads that are supposed to be illuminating? Health is, as we have seen, by Svenaeus associated with a balance that makes it possible for the healthy person to transcend, to be in the world in an “attuned” way, permitting action in this world to flow freely and rythmically. This being is proposed to be “homelike”. Is the similarity with “home” the familiarity, the “everydayness” and the relative ease of action which we experience at home? At home there may well be all sorts of problems, and one may not even like one’s home (it may even be the site of repression and violence)—but at home we are basically “in tune” with the world. I know my home in detail, at least when it has become exactly “homelike”, I do not have to think much when I move around—I could even know my way in the dark. This lack of “friction” for my living and my intentions may perhaps be what is illuminating for health? Clearly, when we are not healthy any more, when illness is there, our lives do not have this rhythm and balance any more.
One may perhaps understand this also by thinking of home in terms of an extended self. The phenomenological analysis understands our being as fundamentally corporeal and Svenaeus suggests that this embodied being should be seen as an existential, as a fundamental requirement for Dasein. But our embodied being does maybe not have a definite outer limit where our skin ends, with the physical borders of our body. When we get deeply acquainted with a physical place and with the modes of living and understanding of this place, our embodiment extends to include this “topos”. If this is what we mean by home, this home becomes a part of me. In this sense, my home becomes my body and my body my home. If this is an illuminating way of understanding, it makes full sense to say that when I feel healthy, I am exactly in the situation where my being is homelike. And when I am unhealthy, this “home” is no longer a home.
Slipping from ontology to psychology
One may ask oneself if the understanding of the expression “unhomelike being-in-world” is at all meaningful outside the realms of phenomenological analysis? An ontological analysis ad modum Heidegger is probably not what most people, or even most philosophers, are prepared to perform or capable of managing. Does this mean that this metaphor should be restricted to those probably rather few contexts where Heidegger’s phenomenology is known and understood?
This may not be so. The phenomenological analysis spelled out above may not be insurmountable for anyone to approach, if it is presented in ways that are understandable. Svenaeus has shown, in a “popularized” Swedish version of his book called, in translation, The Meaning of Illness (2003) that his analysis on the contrary seems to offer good chances for an understanding of such experiences of illness and affliction that almost all people have made. By all probability, the scientific description and understanding of disease is far more impenetrable for the person without special knowledge.
But there is more to be said about this. I have already noticed that the everyday understanding of health probably is “psychological”, in the sense that health tends to be identified with certain feelings and thoughts. Health and fitness is for most people today a “feel-good” thing. If we assume that it becomes fashionable and commonplace for health care professionals to talk about health as “homelike” it may not be the deep meaning structures of “being-at-home” that people associate to, but rather psychological states they are used to have at home. The very point of the metaphor/analogy/simile then seems to be lost. The psychological similarities between being healthy and being at home may or may not be there. As noted above, one may hate or dislike one’s home, and one may not feel good at all there. Health as homelike seems to give rise to totally wrong associations for such a person. Within the realms of phenomenological understanding, health is “homelike being-in-the-world” also for this person, but probably not from his own psychological point of view.
So when Dekkers in his article suggests that care givers in palliative care ought to think about the goals of their practice as their patients’ safe coming home or as a more homelike being of the terminally ill person, one may wonder if the richness of connotations that he points to will really remain. It seems more likely that the everyday meaning of “home”, as the physical place where the ill person lives and maybe has a family, will pervade and make the other interesting connotations that Dekkers points to very secondary and perhaps even unintelligible.
Using a word with such a strong everyday understanding as “home” and hoping for a broad metaphorical interpretation of it seems hazardous. Patients will not easily come to terms with physicians telling them that they will get this analgesic in order to make their being more homelike. This may seem an unlikely example, but my point is that there is and will remain a gap between the philosophical usefulness of the concept and its use in everyday clinical settings.
The limits of medicine
Any understanding of health, illness and disease must offer us a reasonably practicable and morally justifiable way of delimiting the tasks of medicine. The tendency of contemporary medicine to extend into ever new areas has been much commented and this may indeed be one of the reasons for the discontent and uncertainty about medicine’s role and task that was mentioned in the beginning of this article. It is, of course, also of urgent importance that the limits of medicine’s responsibility are not unjustifiably narrow.
We must, then, ask ourselves whether the understanding of health and illness proposed by Svenaeus makes it reasonably possible for us to rightly delimit the tasks of medicine. Does thinking about illness as “unhomelike being-in-the-world” help us in this respect? In other words, are all states of “unhomelike being-in-the-world” rightly cases for medical interventions? If, as Svenaeus proposes, the promotion and restoration of health is the goal of medicine, and if health ought to be seen as “homelike being-in-the-world”, then this will be the inevitable conclusion. But is unhomelikeness always equal to illness?
At closer look, it seems as if our attunement, our basic patterns of meaning, may be disrupted for several very different reasons. Being ill is, if we for the moment exclude psychiatric illness, associated to a change in bodily perceptions and is hence usually approached by bodily investigations. Disease often accompanies this, but as Svenaeus rightly notices, not always and the presence of disease is certainly “ not the only explanation why a person is ill, and it is definitely not the only illuminating thing we can say about ill persons” (Svenaeus 2000, pp. 115–116).
Svenaeus has in his second edition somewhat expanded his original analysis of this crucial question. He is well aware of the risk that while all illness seems to be unhomelike ways of being-in-the-world it is not obvious that the opposite is the case. Being lost in the woods may, for example, exemplify a case of such unhomelikeness which we ought not to label an illness. This is, argues Svenaeus, due to the time aspect. We are usually lost for a short time. (Svenaeus 2000, p. 116) But is this really a sufficient explanation why we would not call this an illness? Say a person is lost in the woods for a couple of days and found—hungry, cold, thirsty and in despair. Has this person really been ill? Few would accept such a label. But I would without hesitation lift my phone, call my work and declare I am ill—only after half an hour in the morning with the unhomelikeness of a bad head-ache, a cough and fever. Why is this? It may, of course, be because I know from long experience that symptoms like those I have do go on for usually several days and hence are not very transient. But is this the only reason? Is it not also the case that it is something about the way that the common cold comes about, that distinguishes it from the certainly also very physically and mentally unhomelike experience of being lost several days in the woods?
Svenaeus notes this: “Stressing the time aspect of illness, while contrasting it to other forms of unhomelikeness, but it hardly answers all our questions.” (Svenaeus 2000, p. 116) It must also be remembered that “As we have seen, the parts of the meaning pattern that are hardest to replace and to reinterpret are the ones tied to our own embodiment. The lived body forms the centre of the self” (Svenaeus 2000, p. 117). My infection strikes primarily and very obviously at my embodiment, while the person lost for 2 days in the woods at least not primarily is affected in this way, though certainly after some time.
My point here is that it seems hard to deny that we do bring in considerations about what kind of “unhomelikeness”, which “symptoms”, the person experiences, and for which reasons it has appeared, when we decide whether to regard it as illness or not. Time span, as Svenaeus suggests, certainly comes into the picture, as well as the degree to which the self in its full “bodyliness” is affected. But also questions of assumed causality seem relevant. Where there is a causally defined bodily disturbance, unhomelikeness is immediately considered as illness (waking up with a common cold or having torn the Achilles tendon), but where there is not, the question of whether it ought to be looked upon as illness or not seems less clear cut (being lost in the woods for a longer time). It hence seems justified to say that whether “unhomelike being” is considered as illness or not is judged in relation to the circumstances under which it arose, how it “shows”, and the assumptions about its back-ground.
Svenaeus makes the important reminder that his analysis is exactly phenomenological, not semantic or logical. Such an analysis cannot be expected to draw a clear cut line between healthy and ill. Rather, health and illness, just as homelike and unhomelike being-in-the-world, must be seen as moving along a continuum. They are not mutually exclusive states. As Svenaeus formulates it, “Health and illness, on the phenomenological level, must be seen as graded phenomena, since both homelikeness and unhomelikeness are always present to some degree in our being-in-the-world”. The need for a sharp distinction between them that sometimes occurs in everyday contexts, usually has no counterpart in the phenomenological analysis.
Both somatic and psychiatric illnesses strike against our selves, but in different ways. In the former case our embodied being is changed in such a way that certain bodily functions on which our everyday living depends are disrupted. This accounts for the unhomelikeness of being somatically ill (again, a common cold may be a good example). In the case of mental illness, the unhomelikeness is not, at least not primarily, the result of changed and unpleasant bodily perceptions or loss of bodily function. Mental illness is, in its very essence, a change in the meaning structures of the self. The depressed person is ill, not in the sense of changed and obstructive bodily perceptions that make life more difficult and unhomelike, but in the sense that her whole way of being-in-the-world has undergone a gradual shift towards darkness, inertia, hopelessness and anxiety.
Psychiatric illness is perhaps the area of medicine where questions of delimitation have been most pressing. What is considered mentally sound or ill has far reaching consequences, for the person as well as for society at large. The struggle to reach definitions of mental illness which answer several different needs has been going on and will go on. Svenaeus does not deal very much with this, but on the pages just cited he makes some statements that offer interesting possibilities. One of the examples he deals with is the case of grief, and prolonged grief. To make a justifiable distinction between grief and depression is a classical challenge for the practitioner. Does the phenomenological analysis performed by Svenaeus in any way come to their help here?
What we have called somatic illness obviously does mental harm—if it means that persons are unhomelike, and what is this if not “mental”?—and is often best treated by medical means. Hence, Reznek’s definition, as I see it, offers no chance to distinguish between mental and somatic illness. Svenaeus seems to want to do that, when he notes that “Although self and world are always interconnected in a synthetic way through the being-in-the world of the self way, it is still possible to make a distinction between the person and the world he inhabits” (Svenaeus 2000, p. 117). Though the self is largely a bodily self, it also has “mental characteristics” and it is these that are primarily transformed in mental illness. To distinguish between a prolonged grief and a depression would, then, require a sensitive and thorough understanding of the extent to which these mental structures are affected, the reasons why, to which extent the person’s life patterns are affected and whether there is a process of healing or of accentuated symptoms going on. Both states, grief and depression, are unhomelike, but to different degrees, for (usually) different reasons and also with different prognosis.
Something is a (mental illness) if and only if it is an abnormal and involuntary process that does (mental) harm and should best be treated by medical means (Reznek 1991).
I have tried to point to some aspects of Fredrik Svenaeus’ phenomenological and hermeneutical understanding of health and illness that need further explication and development. But I have from the very beginning made clear that I believe that the phenomenological analysis of the illness experience offers rich possibilities to redress a lost balance and in a decisive way complement the predominantly scientific modes of understanding ill persons. One may say that phenomenology gives access to an epistemology within which certain of the riddles and enigmas of clinical everyday life are better understood and handled.
Sacks gradually recovers and “comes home” again, but it is striking to which extent his way of telling us this is in line with Svenaeus’ analysis of health and illness. It certainly makes much sense and it is clearly illuminating to view Sacks’ predicament as essentially “unhomelike”. For the final outcome and for the well-being of his patient, the surgeon, dr Swan, would have gained much from incorporating into, indeed amalgamated with, his technical skills an openness for and understanding of his ill colleague’s life world as ill. The surgeon’s incapacity in this case had no serious consequences, except (and this is of course nothing minor) the aggravation of Sacks’ worries and pain that his lack of interest caused. But in many other cases both right diagnosis and treatment, inevitably both dependent on the clinical dialogue and some degree of mutual understanding, will fail. Even if very few health care professionals will read either Martin Heidegger’s Time and Being or Fredrik Svenaeus’ thesis, it seems clear that the attempts to, in Svenaeus’ words, “excavate the meaning structures of illness” must continue and involve those who practice medicine, if medicine is to be truly human.
In particular, it no longer seemed a “home”. I couldn’t conceive it “housing” anything, let alone part of me. I had the feeling that it was either totally solid or empty—but, in either case, that it contained nothing at all. I looked at the rim of toneless flesh above the cast, and then thrust a hand down inside. The experience was inconceivably shocking and uncanny. The day before, when I had put my hand down and palpated the quadriceps, I had found it “horrible”—limp and pulpy, like a sort of soft inanimate jelly or cheese. But the horror was nothing to what I felt now. The day before, touching it, I had at least touched something; whereas today, impossibly, I touched nothing at all. The flesh beneath my fingers no longer seemed like flesh. It no longer seemed like material or matter. It no longer resembled anything. The more I gazed at it, and handled it, the less it was “there”, the more it became Nothing—and Nowhere. Unalive, unreal it was no part of me—no part of my body, or anything else. It didn’t go anywhere. It had no place in the world (Sacks 1984, p. 73).
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