Havi Carel

Phenomenology and its application in medicine

Phenomenology is a useful methodology for describing and ordering experience. As such, phenomenology can be specifically applied to the first person experience of illness in order to illuminate this experience and enable health care providers to enhance their understanding of it. However, this approach has been underutilized in the philosophy of medicine as well as in medical training and practice. This paper demonstrates the usefulness of phenomenology to clinical medicine. In order to describe the experience of illness, we need a phenomenological approach that gives the body a central role and acknowledges the primacy of perception. I present such a phenomenological method and show how it could usefully illuminate the experience of illness through a set of concepts taken from Merleau-Ponty. His distinction between the biological body and the body as lived, analysis of the habitual body, and the notions of motor intentionality and intentional arc are used to capture the experience of illness. I then discuss the applications this approach could have in medicine. These include narrowing the gap between objective assessments of well-being in illness and subjective experiences which are varied and diverse; developing a more attuned dialogue between physicians and patients based on a thick understanding of illness; developing research methods that are informed by phenomenology and thus go beyond existing qualitative methods; and providing medical staff with a concrete understanding of the impact of illness on the life-world of patients.

Phenomenology as a Resource for Patients

Patient support tools have drawn on a variety of disciplines, including psychotherapy, social psychology, and social care. One discipline that has not so far been used to support patients is philosophy. This paper proposes that a particular philosophical approach, phenomenology, could prove useful for patients, giving them tools to reflect on and expand their understanding of their illness. I present a framework for a resource that could help patients to philosophically examine their illness, its impact on their life, and its meaning. I explain the need for such a resource, provide philosophical grounding for it, and outline the epistemic and existential gains philosophy offers. Illness often begins as an intrusion on ones life but with time becomes a way of being. I argue that this transition impacts on core human features such as the experience of space and time, human abilities, and adaptability. It therefore requires philosophical analysis and response. The paper uses ideas from Husserl and Merleau-Ponty to present such a response in the form of a phenomenological toolkit for patients. The toolkit includes viewing illness as a form of phenomenological reduction, thematizing illness, and examining illness as altering the ill persons being in the world. I suggest that this toolkit could be offered to patients as a workshop, using phenomenological concepts, texts, and film clips to reflect on illness. I conclude by arguing that examining illness as a limit case of embodied existence deepens our understanding of phenomenology.

Epistemic Injustice and Illness

Abstract This article analyses the phenomenon of epistemic injustice within contemporary healthcare. We begin by detailing the persistent complaints patients make about their testimonial frustration and hermeneutical marginalization, and the negative impact this has on their care. We offer an epistemic analysis of this problem using Miranda Frickers account of epistemic injustice. We detail two types of epistemic injustice, testimonial and hermeneutical, and identify the negative stereotypes and structural features of modern healthcare practices that generate them. We claim that these stereotypes and structural features render ill persons especially vulnerable to these two types of epistemic injustice. We end by proposing five avenues for further work on epistemic injustice in healthcare.

Illness, phenomenology, and philosophical method.

In this article, I propose that illness is philosophically revealing and can be used to explore human experience. I suggest that illness is a limit case of embodied experience. By pushing embodied experience to its limit, illness sheds light on normal experience, revealing its ordinary and thus overlooked structure. Illness produces a distancing effect, which allows us to observe normal human behavior and cognition via their pathological counterpart. I suggest that these characteristics warrant illness a philosophical role that has not been articulated. Illness can be used as a philosophical tool for the study of normally tacit aspects of human existence. I argue that illness itself can be integral to philosophical method, insofar as it facilitates a distancing from everyday practices. This method relies on pathological or limit cases to illuminate normally overlooked aspects of human perception and action. I offer Merleau-Ponty’s analysis of the case of Schneider as an example of this method.

“How do you feel?”: oscillating perspectives in the clinic

“The body is originally constituted in a double way: first, it is a physical thing, matter […] Secondly, I sense ‘on’ it and ‘in’ it: warmth on the back of the hand, coldness in the feet.” These words were written by Edmund Husserl, the 20th-century philosopher and founder of phenomenology, the philosophical study of human experience. For Husserl, this duality of experience is a unique feature of human existence. Humans are both physical matter, like kettles, trees, and rocks; but they are also capable of having conscious experience. On the one hand, we are physical objects; on the other hand, we are consciousness. What is the relevance of this dual existence to medicine? We consider the philosophical basis for this view and its potential importance to clinical consultations. In his Ideas II, Husserl uses the example of two hands touching each other in order to reveal the uniqueness of human existence. When the right hand is the active, touching one, it is at the same time touched by the left hand. If we consciously decide to reverse the roles and concentrate on the left hand as touching, we can still experience both dimensions: the active touching and the passive being touched. In order to be touched one has to be a thing among things, a physical object. Such an object is always open to the possibility of being touched. But in order to touch one needs to be able to sense the touching. One needs a consciousness that can perceive the touching. Our embodied consciousness contains both aspects. With this idea in place, let us now turn to the clinical situation, which can be seen as containing an objective and a subjective component. The physician is often construed as an objective observer, palpating, listening, looking and examining an object that is laid before her: the patient’s body. The patient is a subject, experiencing pain, discomfort, or relief. However, we would suggest that the situation is more complex. The patient’s view of her body might become objective, while the physician’s presence is often also subjective, because it perceives and senses as only subjects can. The physician’s approach is traditionally characterised as objective and active. She guides the patient’s telling of her story by structured questioning, aided by appropriate encouraging and empathic responses, to achieve the main task of the consultation, which may be to make a diagnosis, review treatment, or decide on further action. The development of a relationship with the patient is seen as facilitating these tasks, and involves the doctor knowing a lot about the patient’s life, and the patient very little of the doctor’s. When it comes to touching the patient in the course of a physical examination, the doctor’s stance is the same. Her hand becomes an instrument on which her whole sensory awareness is focussed in order to detect the slightest abnormality in the body beneath it: a lump that should not be there; a roughness where it should be smooth; dullness where it should be hollow. This concentration on the touching hand requires a kind of shutting out of the world to the extent of being unaware of the rest of the patient attached to that part being examined. Doctors have been criticised for this, but this is crucial to the practice of the examining art, like a musical performance in which the pianist is absorbed only in the music under her hands. But of course, unlike a pianist and her piano, doctors are made of the same stuff as their patients. Aware that being touched by cold hands may be uncomfortable, the doctor will try to warm them; conscious that rough hands are unpleasant, she will keep them supple with cream. Medical students are taught to watch the face of a patient they are examining, but in fact it is the touching hand that gets the message if there is a problem, because the body can touch back. The examining hand can sense even a slight quiver or tensing of muscles if it finds a painful area, even before the patient utters a word. This touching back not only gives information to the objective examiner, it transforms the doctor into an experiencing subject. So we can see that throughout the consultation the doctor oscillates between the position of an experiencing subject encountering another subject (“I must warm my hands so they are not cold to the touch”), to objective examining instrument (analysing the physical flesh under her hand), and back again. Let us now turn to the experience of the patient. When lying down on the examination bed the patient cannot help but feel like an object, a thing laid out for scrutiny. Anyone who submits herself to the gaze of the doctor may feel her body become a medical object. But at the same time, the patient is also thinking about the touch as it feels to the physician. Thoughts might include: am I clean enough; how does she feel about touching me there; does she think I am fat? The patient presents herself to the touch and judgment—real or imagined—that ensues. In this sense the patient recognises the limits of the physician’s objective stance. A further objectification takes place in the clinical setting. When entering the CT scanner, for example, some feel they are being converted into data points, sliced by the x-ray making its way down their torso. When a patient is shown ultrasound images of her own body, these images are unrecognisable to her as images of her body. Even if she feels curious about the images and the processes they capture, it is still hard for her to reconcile these objective images with her subjective feeling of her body. These experiences, especially when repeated, may lead to a sense of alienation from one’s body, and indeed to treating that body as an aberrant object over which one has little control. The patient is a subject, but a subject that is objectified. So how are we to think about the subjective and objective perspectives in the clinic and why is it important for clinicians to recognise these different ways of experiencing? Our suggestion is to try to move from viewing the physician’s perspective as objective and the patient’s perspective as subjective towards a greater appreciation of the oscillation from one position to the other. This oscillation does not denote an inconsistency. On the contrary: it marks the unique duality of the human body, which is capable of both subjective experiencing and of being experienced by others as an object. Recognising the oscillation as key to understanding human experience in its openness and vulnerability might serve as a step towards contesting the expectation that doctors should be purely objective in their clinical practice. Recognising this oscillation between subjective and objective, active and passive, roles can also introduce a second-person perspective that is available to the physician. This perspective, that of being there without pretending to stand in their patient’s shoes, avoids patronising assumptions and does not objectify the patient. We suggest that the second-person perspective (‘I can see that you are feeling bad’) may offer a way of improving communication in the clinic by emphasising the subjectivity of the physician—her normal exchange with another human being—despite her objective role. Emphasising the subjectivity of the clinician may make her more approachable to the patient, and enable the patient better to share her illness experience. By recognising each other’s subjectivity both physician and patient stand to gain. The physician gains a more natural mode of expression, and the patient has a feeling of being listened to by a fellow human being who neither purports to stand in her shoes, nor to be completely objective. Finally, this reconciliation may also create a shared world of meaning in another way. When the physician observes the patient objectively, she also sees the patient’s body as an instance of an anomaly or pathology. From this point of view the patient presents as a “case”. But from the patient’s subjective point of view, their illness is a way of being, a particular world they inhabit. By bringing closer the objective and subjective points of view and recognising the constant oscillation from one to the other, we may also bridge the gap between the view of illness as a pathology and illness as a way of being, and so reduce the distance between these two contrasting perspectives present in the clinic.

Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome

Chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) remains a controversial illness category. This paper surveys the state of knowledge and attitudes about this illness and proposes that epistemic concerns about the testimonial credibility of patients can be articulated using Miranda Frickers concept of epistemic injustice. While there is consensus within mainstream medical guidelines that there is no known cause of CFS/ME, there is continued debate about how best to conceive of CFS/ME, including disagreement about how to interpret clinical studies of treatments. Against this background, robust qualitative and quantitative research from a range of countries has found that many doctors (and medical students) display uncertainty about whether CFS/ME is real, which may result in delays in diagnosis and treatment for patients. Strikingly, qualitative research evinces that patients with CFS/ME often experience suspicion by healthcare professionals, and many patients vocally oppose the effectiveness, and the conceptualisation, of their illness as psychologically treatable. We address the intersection of these issues and healthcare ethics, and claim that this state of affairs can be explained as a case of epistemic injustice (2007). We find evidence that healthcare consultations are fora where patients with CFS/ME may be particularly vulnerable to epistemic injustice. We argue that the (often unintentional) marginalisation of many patients is a professional failure that may lead to further ethical and practical consequences both for progressive research into CFS/ME, and for ethical care and delivery of current treatments among individuals suffering from this debilitating illness.

Temporal Finitude and Finitude of Possibility: The Double Meaning of Death in Being and Time

Abstract The confusion surrounding Heidegger’s account of death in Being and Time has led to severe criticisms, some of which dismiss his analysis as incoherent and obtuse. I argue that Heidegger’s critics err by equating Heidegger’s concept of death with our ordinary concept. As I show, Heidegger’s concept of death is not the same as the ordinary meaning of the term, namely, the event that ends life. But nor does this concept merely denote the finitude of Dasein’s possibilities or the groundlessness of existence, as William Blattner and Hubert Dreyfus have suggested. Rather, I argue, the concept of death has to be understood both as temporal finitude and as finitude of possibility. I show how this reading addresses the criticisms directed at Heidegger’s death analysis as well as solving textual problems generated by more limited interpretations of the concept.

Epistemic injustice in psychiatry

It has been argued that those who suffer from medical conditions are more vulnerable to epistemic injustice (a harm done to a person in their capacity as an epistemic subject) than healthy people. This editorial claims that people with mental disorders are even more vulnerable to epistemic injustice than those with somatic illnesses. Two kinds of contributory factors are outlined, global and specific. Some suggestions are made to counteract the effects of these factors, for instance, we suggest that physicians should participate in groups where the subjective experience of patients is explored, and learn to become more aware of their own unconscious prejudices towards psychiatric patients.

Conspicuous, Obtrusive and Obstinate: A Phenomenology of the Ill Body

Phenomenology can be used to describe the experience of illness by focusing on first-person accounts of what it is like to suffer from a particular illness. By offering a phenomenological framework through which to study illness, this chapter illuminates the experience of illness. The framework consists of four themes that I bring together in order to offer such a phenomenological understanding of illness. The first is Toombs’ analysis of the essential features of illness. The second is Sartres three orders of the body. The third is the claim that the healthy body is transparent and illness is the loss of this transparency. Finally, using Heideggers tool analysis, I will suggest that illness is a breakdown of ‘bodily tools.’

The return of the erased: memory and forgetfulness in Eternal sunshine of the spotless mind (2004).

Eternal sunshine of the spotless mind is a film about remembering and forgetting loss. This essay reads the film as an examination of mourning and melancholia, which are distinct ways of remembering and forgetting both a love object and its loss. Freud distinguished mourning from its pathological counterpart, melancholia, claiming that there is a normal way to grieve, mourning, and its degeneration into an abnormal pattern, melancholia. The author aims to make two points: firstly, that both processes are characterized by ambivalence and identification and therefore have some commonalities; secondly, that there is a difference between the two processes that is less apparent than the ones discussed by Freud. This is the difference between remembering a good and a bad object. Following Klein the author argues that this is a crucial qualitative difference between mourning and melancholia. She concludes that a central issue in grieving is not forgetting but remembering well.