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Peter Trnka “Subjectivity and Values in Medicine”

Trnka, Peter 2003. Subjectivity and Values in Medicine: The Case of Canguilhem. Journal of Medicine and Philosophy 28(4): 427-446.

Canguilhem focuses on normality and pathology as the founding concepts of modern clinical and research medicine. In search of the normal to which therapy is drawn, Canguilhem unfolds its normative meaning. Unfolding further, he discovers the nature of the normative in the value-orientation of a constructive, future directed activity, i.e.,subjectivity. Value-orientation, accordingly, is not a variable or an object but a constructing of fields for variables or objects. Value-orientation and the creative act of the subject thus coincide. Holding that subjectivity is a real, creative biological activity, as Canguilhem does, means thatnormalityandvalue-orientation, as concepts, are neither pure scientific descriptions nor mere human preferences. (428)

The danger of Canguilhem’s work is a biologization of norms that neglects culture. Canguilhem seizes upon the idea of value-orientation (normativité), making it the pivot of his conceptual structure, while Foucault evades the normative, as if it were ineluctably a concept of the human sciences, though presupposing it in his critique of the human sciences. (429)

Canguilhem offers three interpretations of normality conceived as the norm of medicine: (1) the statistical average or the standard, (2) what ought to be, and (3) the new. Thefirst two senses are more familiar than the third, though it is this latter option that Canguilhem defends. (429)

Irregularity, for Canguilhem, is the constitutive condition of rules. The regulative ideal, the norm, or the rule is derivative of an experience of obstacle. This could be an epistemic point: awareness of rules is contingent upon transgression. Canguilhem’s point is stronger, i.e., ontological. The existence of a rule is, accordingly, derivative of the experience of an obstacle. The subjective experience of impediment brings the rule into being: ‘‘this which I now feel as resisting me should not be.’’ (430)

To be alive presupposes some ability to distinguish between good and bad in the sense of what helps or hinders me. This minimal sense of the evaluative is subjective for Canguilhem, meaning that it must take root in the individual organism. (431)

[…] he distinguishes between two forms of life or two evaluative conceptions of adaptation and health. The first consists of propulsive values which attain a normal state (a constant or stable condition) only to exercise their normative function anew, and so depart from the previously achieved equilibrium in search of another. The second mode consists of repulsive values, which are not truly normative though they are stabilizing or normality-seeking; i.e., the being that strives entirely for equilibrium and is unwilling to give it up once it is attained relinquishes the process of generating values in favor of a permanent normality and by doing so turns pathological. The first mode is expressive, the second retentive or preservative. (431-432)

Canguilhem’s affirmation of propulsive norms completes our set of identifications by bringing creativity in line with the true meaning of normality. (432)

The WHO definition of health as complete well-being is broad and difficult to distinguish from economic prosperity, social comfort, political freedom, and moral satisfaction. And this is precisely its point: health may be a function of all the above factors and so an all-inclusive conception of health will necessarily blur the dividing line between the medical and the economic, social, political, philosophical, etc. (433)

The evolutionary point of view raises a number of ontological questions for the enterprise of defining health and disease: the wherein question (does health and/or disease reside in the cell, organ, individual or species?), the where question (does health and/or disease reside in a place or unit or in the relation between unit and environment?), and the when question (does health and/or disease exist now or in the next generation, etc.?). The‘when’question really folds together all three orientations, for the individual in relation to the species in an environment is the locus of transmission of traits, healthy or diseased, between the present and the future. Matters related to the temporal dimension of health are often ignored, perhaps because the issue is difficult or because of our hubris: we are prone to believe we can predict the future or shape it as we wish. (435-436)

The subjectivist view should not be confused with Canguilhem’s biological and ontological theory of subjectivity. Subjectivism, closely allied with individualism and cultural relativism, loosely resembles evolutionary theory in that individual preference, like genetic mutation, is the arbitraryelement decisive for the future. Suchinternalexplanations fail for the same reason: to conceive of evolution as driven by random mutability is anabstractionfrom a complex and co-implicatedfield of variables; to conceive of satisfaction as a ‘‘merely subjective’’, personal reaction is also an abstraction from the situation in which satisfaction functions as a real variable. In both the cases of genetic mutability and personal satisfaction, the internal moment only makes sense given afield in which it acts or is acted upon. (437)

[…] Canguilhem provides a biological and ontological account of value: living beings orient themselves to their environments (in part) by way of values. Living beings discriminate and accommodate based on an appreciation of the world or a system of values, be they implicit or explicit – this is, for Canguilhem, an actual attribute of the biological world. The creation of norms within the biological world is valuable not merely as novelty but as the variability which novelty signals or presupposes. Variability or the creative generation of norms is valuable and valued at least in part because of the difference such norms make in intensifying and extending life. (438)

[…] Canguilhem’s repulsive norms are associated with a mechanist or functionalist orientation to life: the belief that a norm may be secured to withstand variation is linked to a view of nature as inert and fundamentally repetitive. Propulsive norms, on the contrary, appeal to a generative conception of natural processes wherein variable, not static, repetition is the fundamental law; life is a‘‘vital force’’or biological being, not a mechanism or function. (438)

Teleological and mechanist views are fundamentally in error concerning the character of biological life. Mechanism and functionalism are inadequate characterizations from a biological point of view because they conceive of the environment as a fact, given or pre-constituted. In contrast, Canguilhem offers a fully biological, i.e., an ontological, view wherein the environment is itself partially constructed by the activity and needs of the organism. (439)

To value an individual feature involves the environment only as a given past or present condition, but not as an evolving, dynamic system. Canceling out errors through genetic manipulation assumes prior knowledge of the future shape of the conditions under which organisms will live. Such‘‘engineering’’ is neither impossible nor valueless, but the hubris of believing one can engineer the individual and their environment to perfection assumes the permanence of nature and reserves the creativity of science and reason for the subject. (441)

Whether we can in fact eliminate genetic ‘‘errors’’ is not Canguilhem’s main worry. The very possibility of naming a genetic feature an‘‘error’’ is the concern. For if an ‘‘error’’in the medical sense is neither a statistical anomaly nor a lesion, if it is not itself a dysfunction but a marker or harbinger of dysfunction, then how can the issue of values be removed from the judgement of error, and how may we, even in the rare case where a genetic marker has near certainty of phylogenetic expression as a defect, be sure about the environment in relation to which all such notions derive their meaning? (441)

Normality secured in total stability and local adaptation is the precursor of total pathology. Canguilhem brands such a nightmare, in which the very possibility of disease is thought to be eliminated, the ‘‘disease of the normal man’’ („la maladie de l’homme normal“): „the disturbance which arises in the course of time from the permanence of the normal state, from the incorruptible uniformity of the normal, the disease which arises from the deprivation of diseases, from an existence almost incompatible with disease.“ (1978, p. 178) (442)

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