THE HERMENEUTICS OF MEDICINE AND THE PHENOMENOLOGY OF HEALTH INTERNATIONAL LIBRARY OF ETHICS, LAW, AND THE NEW MEDICINE Editors DAVID C. THOMASMA, Loyola University, Chicago, U.S.A. DAVID N. WEISSTUB, Universite de Montreal, Canada THOMASINE KIMBROUGH KUSHNER, University of California, Berkeley, U.S.A. Editorial Board SOLLY BENATAR, University of Cape Town, South Africa JURRIT BERGSMA, Rijksuniversiteit Utrecht, The Netherlands TERRY CARNEY, University ofS ydney, Australia UFFE JUUL JENSEN, Universitet Aarhus, Denmark GERRIT K. KIMSMA, Vrije Universiteit, Amsterdam, The Netherlands EVERT VAN LEEUWEN, Vrije Universiteit, Amsterdam, The Netherlands DAVID NOVAK, University of Toronto, Canada EDMUND D. PELLEGRINO, Georgetown University, Washington D.C., U.S.A. DOM RENZO PEGORARO, Fondazione Lanza and University of Padua, Italy ROBYN SHAPIRO, Medical College ofW isconsin, Milwaukee, U.S.A. VOLUMES The titles published in this series are listed at the end of this volume. THE HERMENEUTICS OF MEDICINE AND THE PHENOMENOLOGY OF HEALTH Steps Towards a Philosophy of Medical Practice by Fredrik Svenaeus Department of Health and Society, University of Linkoping, Sweden SPRINGER-SCIENCE+BUSINESS MEDIA, B.V. Library of Congress Cataloging-in-Publication Data Svenaeus, Fredrik. The hermeneutics of medicine and the phenomenology of health: steps towards a philosophy of medical practice / by Fredrik Svenaeus. p. cm. -- (International library of ethics, law, and the new medicine; 5) Includes index. ISBN 978-90-481-5632-0 ISBN 978-94-015-9458-5 (eBook) DOI 10.1007/978-94-015-9458-5 1. Medicine--Philosophy. 2. Medical ethics. 3. Hermeneutics. 1. Series. R723 .S845 2001 61O'.1--dc21 00-052051 ISBN 978-90-481-5632-0 Printed on acid-free paper All Rights Reserved © 2000 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 2000 Softcover reprint of the hardcover 1st edition 2000 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner. TABLE OF CONTENTS Preface VB Acknowledgements ix Introduction PART 1: THE CLINICAL ENCOUNTER 11 1.1 The Rise of a Western Tradition of Medicine 12 1.2 The Doctor-Patient Relationship in Pre-Modem Western Medicine 16 1.3 The Birth of Modem Medicine 22 1.4 Medical Technology 29 1.5 The Modem Medical Meeting - Success and Crisis 33 1.6 Research on the Clinical Encounter in the Twentieth Century 39 1.7 The Social and Cultural Background 44 1.8 Philosophy of Medicine 51 PART 2: THE PHENOMENOLOGY OF HEALTH AND ILLNESS 59 2.1 The Ancient Tradition 59 2.2 The Biostatistical Theory - Boorse 62 2.3 The Holistic Theory - Nordenfelt 68 2.4 Husserl's Phenomenology 75 2.5 The Phenomena of Health and Illness 78 2.6 Heidegger's Phenomenology 83 2.7 Health as Homelike Being-in-the-World 90 2.8 Homelikeness as the Rhythm of Life 94 2.9 Ability to Act and Attuned Understanding 100 2.10 The Lived Body and the Broken Tool 106 2.11 Health and Phenomenology - Medicine and Hermeneutics 114 PART 3: THE HERMENEUTICS OF MEDICINE 119 3.1 Explanation and Understanding 121 3.2 Hermeneutics - The Choice ofGadamer 130 3.3 Medicine and Hermeneutics 134 3.4 Ricoeur - Textuality and Narrativity in Medicine 140 3.5 The Medical Meeting - Interpretation Through Dialogue 146 3.6 Lifeworlds and Horizons in the Medical Meeting 153 3.7 The Goal of the Medical Meeting(s) 158 3.8 The Hermeneutics of Medicine - A Recapitulation and Discussion 163 3.9 Between Facts and Norms - Descriptive and Normative Analysis in the Philosophy of Medicine 166 3.10 Concluding Remarks and Future Projects - To Approach Medical Ethics from Attunement 173 Summary 177 References 183 Index of Names 193 Index of Subjects 197 PREFACE Fredrik Svenaeus' book is a delight to read. Not only does he exhibit keen under standing of a wide range of topics and figures in both medicine and philosophy, but he manages to bring them together in an innovative manner that convincingly dem onstrates how deeply these two significant fields can be and, in the end, must be mutually enlightening. Medicine, Svenaeus suggests, reveals deep but rarely explicit themes whose proper comprehension invites a careful phenomenological and her meneutical explication. Certain philosophical approaches, on the other hand - specifically, Heidegger's phenomenology and Gadamer's hermeneutics - are shown to have a hitherto unrealized potential for making sense of those themes long buried within Western medicine. What results from his 'reading' of those themes is a bold and important ontology and epistemology of medicine - from central concepts such as 'health' and 'illness', to what is mostly termed the 'physician-patient relation ship', to a constructive interpretation of the prominent 'methods' and 'goals' of medicine. As the author makes quite clear, moreover, it is medicine's own rich historical traditions that itself demonstrates the need for the kind of phenomenological approach he engages. The most prominent characteristics of that history, he rightly appreciates, are, first, that the fundamental point of medicine is the encounter or 'meeting' with patients; therefore, second, medicine must be understood as a spe cific kind of practice. While it is true that medicine's centerpiece, so to speak, is the clinical event, Svenaeus argues that very few of those who have written about medi cine focus on the encounter, the meeting of doctor and patient, itself. What has in stead captured most attention are the results or outcomes of that meeting - health, compliance, satisfaction, autonomy. However interesting such matters are, and Svenaeus does not dispute this, the fact is that medicine has only rarely been appre hended in light of the ontological and most important epistemological themes which, more than anything else, reveal what medicine is. Svenaeus clearly appreciates as well how deeply contemporary medicine has been influenced by the close relationships it has developed over the past 100 years with the biomedical sciences. As he suggests, however, such sciences are themselves specific types of human activity that impact not only medicine but the everyday world as well. Not only must this influence be critically appreciated, but a fuller phenomenology of medicine, he appreciates, must include critical explications of the central orientations and concepts of the biomedical and natural sciences. Although he does not engage in the latter, beyond a number of intriguing suggestions arising from his central concern with medicine as a clinical practice, it is clear that he un derstands this wider thematic quite well. VII PREFACE V1l1 One of his more creative analyses is found in the way Svenaeus utilizes the key notions developed by Heidegger, especially in Sein und Zeit, to work his way through the major features of the clinical practice - that is, the medical encounter. It is in his quite fascinating 'reading' of Gadamer, however, that readers will be treated to perhaps the most innovative and intriguing features of this important book. After a careful critique of Ricoeur and other, more recent, discussions of hermeneutics, Svenaeus concludes that none prove entirely adequate or pertinent to the dimensions of clinical practice - whose major characteristic is not 'text', but rather dialogue. Suggesting how Gadamer's main notions are commensurate with Heidegger's on tology, Svenaeus then embarks on his own phenomenological explication of the clinical encounter - and here, as I've suggested, is his native air, the place he knows best and where his innovation and insight are clearest. To help make his case as clear and compelling as possible, it is evident that he understands what is needed: a 'praxical' discussion of actual clinical encounters. There are a number of clinical examples provided, each chosen because it illustrates some paradigmatic features of the clinical encounter, and in these discussions Svenaeus's wonderfully articulate 'feel' for actual clinical life is the clearest and most interesting. I first came to know Fredrik Svenaeus during his extended visit at our Center for Clinical and Research Ethics at Vanderbilt University Medical Center. His excite ment over what became available to him here was obvious, as was his quick intelli gence and, more, his completely natural sense for, and his ease in, clinical encoun ters. He was, if I may so express it, very much 'at home' - not unlike the way in which he assimilates Heidegger's key notions of the 'homelike' (and 'un-homelike') 'attunement' in order to understand the special aspects of meetings and encounters which present people as ill, injured, or compromised by social or genetic circum stances. This book is a pleasure to read, for it sheds important light on hitherto only rarely understood features of medicine as a clinical practice. Unusually articulate and well read in the important literatures of both fields, Svenaeus shows a sound knowledge both of medicine and phenomenology. His innovation and insights will doubtless make this book a standard against which future studies in the philosophy of medicine will be judged. Nashville, Tennessee, August 2000 Richard M. Zaner ACKNOWLEDGEMENTS This book is a slightly revised version of my doctoral dissertation which I finished and defended in Linkoping in April 1999. At the defence Wim Dekkers from the Catholic University ofNijmegen acted as opponent and I would like to thank him for the interesting and enjoyable dialogue which we enjoyed on this occasion. Wim per formed a critical and insightful reading of my work, and his comments were one of the main sources for the amendments which I have made since then, mainly in Part 2 of this book. I hope that this new edition will fmd its way to more readers than the original dissertation manuscript published by Linkoping University Press, and that the changes I have carried out make. my theses on medicine and hermeneutics clearer and more plausible. It seems to me that the course culminating in a doctoral dissertation is, in many ways, the entire, lengthy path wandered during the intellectual journey of one's life. The path is, of course, not meant to end there, but where did it -really begin? And who is responsible for the itinerary in question? If this work stems from me, then I am myself certainly made up by others. Thus, I will begin these acknowledgements by going back to my own beginnings. I would like to thank my mother, my father and my sister. Among many other things, my mother gave birth to me, which, I have heard, was a far from pleasant ex perience. My father introduced me into the art of philosophical thinking and dia logue, which, I hope, was more enjoyable. My sister, finally, has been there ever since the beginning offering me a kind of reversed mirror image of what is important in life. We are very much alike and yet so different. It is not easy to find good teachers and supervisors as one makes one's way for ward through the philosophical scrub. Good pathfmders are indispensable in this ter rain. Alexander Orlowski introduced me to phenomenology and hermeneutics, and during the first half of the 1990s, I had the opportunity to take part in the meetings of the phenomenology seminar at the Department of Philosophy at Stockholm Univer sity led by him. Although my visits to the seminar, due to lack of time, have become less frequent during the last years, it has certainly been crucial for my knowledge and image of continental philosophy, and I am indebted to its members for offering me this opportunity, rare in the Swedish philosophical community, otherwise so one sidedly dominated by analytical philosophy. In this connection I would also like to thank the members of our private, nameless, nomadic philosophical seminar, which convened evenings during many years to read and discuss different masters of suspi cion over a cup of tea. The academic year 1992-93 I was awarded a scholarship by DAAD, which made it possible for me to spend two semesters at the Free University in Berlin. This year ix x ACKNOWLEDGEMENTS was crucial for my orientation in the German philosophical tradition, and I would particularly like to mention the excellent seminars led by Milan Prucha and Michael Theunissen, which opened my eyes to many new perspectives. During that year I also met David Fopp and Ludger Hagedorn with whom I had many stimulating philosophical discussions. These friendships have proved lasting and our discus sions, renewed during my visits to Germany and theirs to Sweden, inexhaustible. In the context of this book I would especially like to thank David, who has scrupulously read every part of it and provided very helpful as well as sharp criticism. In 1994 I was accepted as a graduate student at the Department of Health and Society, University of Linkoping. Tema Hiilsa och samhiille has ever since then been my second home, and I would like to thank, not only the professors and graduate students, but also the administrative staff, for creating such a relaxed and effective environment for pursuing good research. The librarians at the now sadly closed Tema Library should here also be remembered. They and their colleagues at the Royal Library in Stockholm, of which I have also made extensive use, have offered valuable help in finding books and articles, not obscure perhaps, but still hard to get hold of in this country. Although I have chosen to organize these acknowledgements chronologically in stead of hierarchically I cannot resist to single out one person as the most significant when it comes to the writing of this book. It is of course customary to recognize one's supervisor as the first person to thank, but Lennart Nordenfelt not only had the courage to accept me as his student, although my field of philosophy was not his speciality, but also to let me cultivate phenomenology and hermeneutics within the philosophy of health and medicine in my own way. He has always supported me and believed in the value of what I am doing, and his critique of my manuscript at differ ent stages has been very productive. Lennart has not only been a good pathfinder in the philosophy of medicine and health, but has also taught it to me in the manner of sharpening my own machete, rather than borrowing his. For being given the oppor tunity, ability and responsibility of pruning the underbrush into my very own garden I am greatly indebted to him. Another significant intellectual partner in the work on this book has been Nils Uddenberg at the Institute for Futures Studies in Stockholm. We have met at differ ent stages of the development of this work to discuss drafts and ideas, and these con versations have meant a great deal for the present form and contents of this study. Our dialogue has, however, not only been helpful in the process of creating argu ments, but also immensely stimulating and encouraging in itself, simply an excellent example of the joy of doing philosophy together. My Vergil in the world of clinical medicine has been Mikael Thyberg from the University Hospital of Linkoping. I would like to thank him for his administrative as well as intellectual labours in initiating me into the basics of modem medicine. I would also like to thank Lars Perers, head of Ekholmen Primary Care Centre, for allowing me to follow and study him and his colleagues in their daily clinical work. The interdisciplinary world of Tema has offered a number of seminar series which have given me the chance to learn, think about, and discuss different aspects