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This research paper discusses the history of philosophical and emerging medical conceptions of the human body as part of a mind/body system, as a biological organism available to rational, scientiﬁc understanding, and subsequently as a focus for diverse perspectives recognizing and addressing the question of lived experiences of human difference. There are now multiple approaches to the human body in the ﬁeld of bioethics, including those continuing in the positivist tradition, where ethical questions are conceptualized in abstraction from the ﬂow of the medical quotidian, and those that perceive the ethical as embracing the matrix of a necessarily embodied experience unfolding between particular individuals. Issues of the social organization and social values informing medical decision-making and control in the different historical eras are also discussed.
The “human body” is a large subject, covering multiple disciplines, including the many philosophical standpoints, the clinical sciences, psychology, psychoanalysis, anthropology, history, literature, and sociology. The inventory of topics that fall within it is almost endless, including conceptions of the body, body and mind, body image disturbance, body modiﬁcation, commodiﬁcation of the body, cosmetic surgery, aging, cyborg bodies, enhancement, experience of illness, gender relations, gene therapy, plant and nonhuman animal bodies, obesity, organ donation and transplantation, pain, placebo effects, reproductive technologies, sexuality and sexual dysfunction, and suffering.
Because the subject is so large, it will not be possible in this research paper to cover all aspects of it. Instead, a few key topics will be presented, starting with a brief account of the history of concepts of the body in philosophy and medicine, together with some of the controversies they have generated. A few examples of contemporary debates will then be presented. The discussion will be conﬁned to Western concepts of the body and the Western medical tradition. Despite this limitation, it is important for readers to note that other cultural traditions have developed ways of understanding the body that are quite different from those presented here. To mention just one example to emphasize this point, Western medicine operates within a theoretical framework that differs in fundamental ways from Chinese medicine, which has an equally robust and ancient tradition. Whereas – as discussed below – the dominant paradigm in the West emphasizes mechanism and causality arising out of the operation of solid structures, in its Eastern counterpart, the body is conceived as a series of ﬂows and energies that interact in a dynamic and precarious equilibrium. The consequences of these discrepant perspectives are far-reaching, generating widely discrepant observational phenomena, diagnostic categories, therapeutic outcomes, and, not least, experiences of the body. It is important for the reader to bear in mind these caveats and limitations while reading this research paper.
Historical Aspects Of The Human Body In Western Philosophy And Medicine
Until relatively recently, discourses of the body in Western thought have been largely initiated and driven by medicine and the clinical sciences. Early philosophical thinkers showed little interest in developing formal theories of the body. This did not mean, however, that philosophy did not contribute profoundly to the formation of clinical and experimental medicine: on the contrary, the prevailing – and changing – philosophical tendencies were of decisive importance.
As pointed out by Grosz (1994), the ancient Greek philosophers displayed a profound aversion to the world of the body. For Plato, the very coinage of the word body (soma) was negative, having been introduced by Orphic priests who believed that humans were spiritual, non-corporeal beings trapped in bodies as if in dungeons (sema). A binary system was therefore thought to exist within which the “body” appeared at the negative pole, as mere nature, matter, formlessness, passivity, and mortality. All the qualities and attributes thus associated with the body, such as the senses, the feelings, and emotions, were deemed unreliable, merely subjective and irrational, and therefore not ﬁt for philosophical thinking. In this binary system the body cannot itself think but can rather only be the object of thought.
For much of the philosophical thinking in the West that has developed since the time of Plato, many of these elements have been retained, including the period up to and beyond the European Enlightenment of the eighteenth century, during which many other fundamental precepts were transformed. Philosophical and moral deliberations focused primarily on questions of the mind, person, self, and subjectivity. The soul, mind, and reason were considered to contain the pure and unchanging essence of the human. The body, by contrast, was thought to be base, changeable, temporal, and corrupt. Its appetites and inclinations were capable of inﬂuencing and limiting the expressions of the soul but could not determine its true destiny and nature, which lay elsewhere.
In the modern age the thinker who had the greatest inﬂuence on how the body was to be understood was René Descartes (1596–1650). He argued that mind (res cogitans) and body (res extensa) should be thought of as mutually exclusive, self-subsistent, and ontologically distinct “substances,” neither of which requires the other to be or to be known. This familiar bifurcation of reality, which became known as “dualism,” raised the question of the nature of the relationship between the two parts. Descartes himself believed that mind and body “interacted.” The mind was not physically situated within the body but was rather intimately connected to it through an “intimate union.” This endowed the human body with genuine complexity that exceeded the simple “extended substance” that appeared to be implicit in his metaphysics.
In subsequent interpretations of Descartes, this subtlety was largely ignored, although the work of Blaise Pascal (1623–1662) was somewhat of an exception. He recognized the difﬁculty inherent in the idea of an “intimate union” of soul and body, posing directly the question of how the body could be known at all from this vantage point. Similarly, Benedict de Spinoza (1632–1677) recognized that the bifurcation created unresolvable problems for understanding the relationship between mind and body, claiming instead that what was therefore needed was a more universal, all-embracing “substance,” of which the speciﬁc substances of res cogitans and res extensa were no more than “attributes.” From this perspective, mind and body had to be recognized as interdependent. The body was a mirror of the soul, whereas mind was the idea of the body.
Throughout the history of medicine, within the limits of prevailing ideas and cultural beliefs – and indeed contributing to them – physicians have sought to understand the body’s structures, its functions and stimulatory and regulatory mechanisms, the nature of its constituent parts and the manner in which they are connected, and the range of pathological processes that could afﬂict it, including diseases, injuries, and noxious environmental inﬂuences. While the body was long considered to be subject to the vicissitudes of the soul and that body and the person inhabiting it were considered as a dynamic whole interacting in manifold ways with the surrounding world, the overall structure of the interaction was nevertheless thought, reductively, to be causal in nature.
In the rationalist tradition that came to dominate Western medicine, the internal events of the body as a bounded object were thought to generate visible outer phenomena, including symptoms, in the case of disease. The body was seen as a material, causally determined organic system available to visual interpretation. From the early fourteenth century, this view gave force to a developing elaboration of these causal relationships. This was exempliﬁed by Andreas Vesalius’ (1514–1564) work on anatomy and that of William Harvey (1578–1657) and Robert Boyle (1627–1691) in physiology. Morgagni (1682–1771), Leroux (1795–1870), Bichat (1771–1802), Broussais (1172–1838), Chaussier (1746–1828), Pinel (1745–1826), and many others helped elaborate the speciﬁc causal relationships, in part through the rapid expansion of the discipline of anatomy, which was premised on the novel assumption that what was observed at autopsy could be taken to explain clinical phenomena. In this work the body was progressively cleansed of the contaminating effects of the mind and soul. Disease became no more than the effects of “organic lesions” inside the body (Foucault 1973). These conclusions were applied to the formation of the discipline of clinical medicine by William Osler (1849–1919) and others, for whom the body was viewed explicitly as a complex system of physiologically interacting structures and mechanisms that needed to be distinguished radically from mental or psychological phenomena.
As Michel Foucault has shown, the concept of the body that ﬁnally took shape in medicine during this time reﬂected a process of historical development that overturned key preexisting assumptions (Foucault 1973). The composition of the new paradigm, according to which the body was seen as an arrangement of solid organs with deﬁned structures and physiological functions linked by speciﬁc causal relationships, was long and tortuous. A novel conception of corporeality was required that embraced simultaneously the dead (a carcass, or korper, as opposed to lieb) and the rationally decipherable. The result was a tightly constrained but nonetheless fecund system of ideas that generated multiple empirical projects and outcomes.
Despite its obvious strengths and successes, however, the new formation contained major lacunae and limitations, many of which proved to be linked to ethical problems. As in all systems of knowledge and belief, these remained largely invisible to the practitioners who labored in the medical and biological quotidian to ﬁll in the details of the grand architectonic plan. Recognition of these limits and the elaboration of responses to them became the basis of a subsequent set of philosophical developments that has contributed signiﬁcantly to the depth and complexity of contemporary bioethics.
It is true that with hindsight it is possible to discern a tacit recognition of the ethical perplexities of the developing conceptual model. For example, Rembrandt’s painting “The Anatomy Lesson of Dr. Nicolaes Tulp” (1631) can serve to illustrate the discomfort felt by many concerning the emerging foundational discourse of gross anatomy. In that painting, the semi-naked cadaver of a felon, Aris Kimt, lies partly dissected on a slab, surrounded by a group of doctors, their faces framed by white collars, their own bodies obscure in black robes or suits. As cultural semiotician Francis Barker has pointed out, the painting depicts not only the new way in which a dead man’s dissected body and the body depicted in the anatomical atlas mutually verify their truth and legibility; it also reﬂects critically on the social and philosophical transformations that were required to achieve this, including the system of hierarchy and oppositions that were needed and the shift in power to the learned bourgeois doctors (Barker 1984). Similar transformations, and the ethical discomforts associated with them, are depicted in other anatomical works: for example, the changing depictions and understanding of the sex and reproductive organs that reﬂected similar shifting ideologies and theoretical understandings.
Limits Of The Historical Models Of The Body And Ethical Critiques
The establishment of the almost complete hegemony of the rationalist model was an extraordinary departure from the preexisting history of medicine which, far from being dominated by a single perspective, had been characterized by a plethora of contending theories and practices. In fact, as Rembrandt’s painting intimated, the ascendency of a single model of the body was not purely a work of theory or philosophical debate: it was also an outcome of a power struggle for the control of the medical territory, which was rapidly becoming associated with social privilege and wealth. In other words, the conceptual structures of medicine were not independent of the social ones which were also in rapid transformation. The formal establishment of the medical profession signaled the triumph of a particular social group over rivals who were branded quacks and charlatans (Peterson 1978). This too in the later debates became an issue for ethical reﬂection. The defeated parties included – among others – female carers experienced in the areas of nursing, childbirth, and infant welfare. The establishment of a male-dominated hierarchy took place in relation to the application of the newly formed rationalistic and individualistic medical concepts to the understanding and control of every aspect of bodily function, especially those of women. More generally, women themselves were cast in negative terms, as on the side of nature, passivity, and materiality, standing against the irresistible force of reason, science, and technology (Grosz 1994).
The success of mechanism (with its view of bodily matter as passive) over vitalism in every aspect of bodily functioning (Cassirer 1950), of the dualistic, positivistic version of medicine, was a great victory, but it was won at a cost. Many other modalities of the body, including its inner experiences, the emotions, mind, sexuality, and suffering, were now excluded from its purview. It is true that the epistemological and discursive strategies of the European Enlightenment were more subtle and nuanced than the positivistic shadows that seized control of medicine on its behalf, just as it is also the case that Descartes’ actual views on the relationship between mind and body were more complex than the simplistic reformulations to which his work often gave rise (Zaner 1971). Nonetheless, the lacunae created by the newly emergent paradigm of the body only came fully and perspicuously into view many years later as the post-World War II cultural consensus dissipated along with the contemporaneous radical critical questioning of the project of the Enlightenment, of its dependence on racial and cultural exclusivity, and of social norms generally. From the point of view of ethics, this generated a new agenda for both medicine and society that required a radical broadening of the discourses of the body in which fundamental assumptions were renegotiated and new technical possibilities reevaluated.
As with the formation of the Enlightenment view of the body, this radical broadening of discourses within medicine only became possible on the basis of theoretical antecedents developed in the domain of philosophy. Here, a number of contributions were of key importance. Henri Bergson (1859–1941) argued that the human body, should be understood as the locus in the world of a person (Bergson 1970). The body, he claimed, is experienced as mine, as my center of action and experience, around which the ﬁeld of physical objects is spatially arranged. Spatiality and sensation only arise in speciﬁc contexts of action. The body is the means by which embodied persons engage with things, as well as contribute to the development of language and culture. Similarly, Max Scheler (1874–1928) reﬂected on the role of “lived bodiliness” (Leiblichkeit), which he distinguished from both the nature and “acts” of the “ego” and the “thing body” (Ko¨rper). For Scheler, as for Bergson, my body is experienced as mine and is the means by which I act in the ﬁeld of morality, objects, and social life.
It was, however, with Edmund Husserl (1859–1938) that the most fundamental shifts in thinking about –and in displacing – the very assumption of a body object were focused.
Husserl, the great founder of modern phenomenology, uncovered the experiential relationship of consciousness to the “lived body” (Leibko¨rper) with which it is inherently linked (Husserl 1983). The problem of embodiment was now concentrated on the modalities of experience, since this experience was now considered to be the sole means by which contact could be made between persons and things: being a body made it possible to have a world in the ﬁrst instance.
Husserl’s work opened up a broad array of possibilities as phenomenology moved in many directions. Gabriel Marcel, Jean-Paul Sartre, Martin Heidegger, and others took up the challenge thrown down by Husserl and developed the newly created discipline in idiosyncratic ways. However, it was the work of Maurice Merleau-Ponty who rigorously developed an understanding of the importance of the body in both cognitive and affective experiences (Merleau-Ponty 1945). In the wake of Freud, who posited that the mind develops in response to the needs of the body as it develops in infancy and early childhood, Merleau-Ponty’s contribution was to place the foundation of knowledge and subjectivity in corporeal existence. He argued that the positivistic sciences had lost touch with the life-world, that is, the lived reality that arises from and is structured by the fact of our “embodiment.” We are not pure minds who carry our bodies as unwanted burdens; being itself presupposes bodily life. In fact, in his later work, Merleau-Ponty went even further than this, recognizing the inherent limits of the ontological foundations of Western thought. In his mature writings, Merleau-Ponty presented the body – if it is still possible to use the term unproblematically – as inherently ambiguous, as the “intercorporeal ﬁeld” in which individualized bodies crystallize as discrete and intersubjectively engaged entities. This perspective has made it possible to recognize the importance of the doctor’s own corporeality in the clinical encounter: the doctor too is embodied (Komesaroff 2014a).
The Flourishing Of Contemporary Perspectives
The novel theoretical perspectives, directly or indirectly, stimulated the development of an
astonishing explosion of further reﬂections on medicine and the body and the ethical implications associated with their relationship. Whereas once the body and its associated phenomena were presented in the ofﬁcial discourses by a narrowly circumscribed theoretical model that testiﬁed to the triumph and power of rationality, from the mid-twentieth century, a new, postmodern sense of ferment and fecundity took over.
While space does not permit the full explication of this process, it is noted that it has included thinkers in the feminist tradition; in the areas of gay and queer studies; in disabilities, race, and cultural studies; and in philosophy itself, who have taken up these issues in relation to diverse phenomena including menstruation, pregnancy, menopause, gender and sexuality (Lingis 1984), physical and mental disabilities (Shildrick and Mykitiuk 2005; Toombs 1993), and colonialism, racism, and cultural difference (Fanon 1970). They have also included writers who have reﬂected on their own experiences of illness and the novel perspectives on the body generated by patient narratives (Frank 1995). All these thinkers have questioned the normative role of the medical ﬁeld and its patriarchal assumption or normalization of values associated with white European masculinity and thus the “othering” of most of the world’s bodies. Drawing on, among others, the rigorous work of Irigaray with her critique of sexually “indifferent” knowledges (Irigaray 1985) and of Butler with her critique of identities conceived legalistically as stable or essential (Butler 1990), they have challenged the medical ﬁeld to reassess the very terms of skin color, disability, femininity and masculinity, sexual ambiguity and ﬂuidity, longevity, weight, and others, in order to recognize the existence of a vast ﬁeld of different individuals and communities all embodied differently and living in different, heterogeneous worlds of value (Petersen 2007). It is here that the apparent certainties of the scientiﬁc body and of the doctor’s formation, capacities, and role have been most challenged.
In a further development of these tendencies, some thinkers have extended the critical reﬂection on Western science to question the bounds of what it means to be human and the nature and basis of our relations with the nonhuman – the plant, animal, and object-worlds. One example of this is the work of animal rights activists such as Peter Singer and Tom Regan. Another is the writing of the feminist author Donna Haraway, who proposed the concept of “cyborg” to encompass what she claims is a new category of body-selves hybridized with technologies, machines, and nonhuman materials, including people living with pacemakers, transplanted organs, genetic material, test-tube wombs, and so on (Haraway 1991). From Haraway’s point of view, science has rendered obsolete fundamental binary oppositions previously taken for granted: between organisms and machines, humans and animals, living and nonliving, and the natural and the artiﬁcial. Instead, “we are all chimeras, theorized and fabricated hybrids of machine and organism” (Haraway 1991). Here it is important to note also the work of the contemporary philosopher Gilles Deleuze who, inﬂuenced by Nietzsche and Spinoza, and along with colleague F. Guattari, has posited what he calls a “body without organs” (Deleuze and Guattari 1977): “a discontinuous, nontotalizable series of processes, organs, ﬂows, energies, corporeal substances and incorporeal events, speeds and durations” (Grosz 1994). In what is a major, afﬁrmative reconceptualization and ontology, the body for Deleuze is not a thing but is “understood more in terms of what it can do… the linkages it establishes.. .the machinic connections it forms with other bodies… how it can proliferate its capacities” (Grosz 1994). This philosophical perspective opens vital new possibilities for medical thinking and practices.
One ﬁnal inﬂuential current of thought will be mentioned here, also arising from Michel Foucault. In his study of the economic and social processes that developed with the modern nation state after the eighteenth century, Foucault claimed to discern the formation of novel “disciplinary regimes,” which he argued were part of the distinctive cultural context of modernity (Foucault 1977). Human physical vitality had become subject to forms of social control that no longer depended on large-scale mind or system based structures but instead were part of the inherent micro-constitutions of bodies themselves. In the new regime of “biopower,” in which medicine plays a key role, he argued that human forces are subject to the operation of numerous, diverse techniques for achieving the subjugation of bodies and the surveillance and control of populations. According to this view, the basic biological features of the human species – what used to distinguish its conditions of embodiment and expressivity – were now, inherently and fatally, the objects of political strategy, including through the design, discoursing, and implementation of health policy and programs.
Currently, the ﬁeld of health care, insofar as it concerns bodily life with its joys and suffering, illness, and well-being, is becoming newly rationalized in the context of globalization and economic rationalism. The corporatization of hospitals and other medical organizations based as they are on a primacy of ﬁnancial values are ushering a new quantiﬁcation of the body and a newly instrumental, rather than ethical, context of decision-making (Komesaroff 2014b).
The long, vivid, and eventful history of the modern Western body has generated a vast and rich array of ethical questions, concerns, and ongoing controversies. In the contemporary era, the body – which had once seemed philosophically straightforward – is now characterized by, and infused with, ambiguity. At the very least, the embodied self is now recognized to be at once social and personal, public and private, formal and intimate, male and female, human and nonhuman, and free and yet subject to profound, often deeply hidden, disciplinary forces. The very concept of “the body” has even been declared to be problematic, a development that has obvious, deep implications for medicine and medical ethics.
In this context a substantial part of the agenda of modern bioethics can be seen to overlap the problematic of the body. Some of the issues are obvious, while others are more subtle and complex. Debates about the social constitution of medicine and the contemporary forms of the clinical encounter, with its multiple dimensions of meaning and pathos; the regimes of public health as they are applied to bodies that are old and young, male and female, fat and thin, abled and disabled, and healthy and diseased; the implications of technologies, including organ donation, artiﬁcial organs, gene therapies, and novel surgical and pharmacological interventions in the functioning of the brain or in physical capacity; and the intersections of the body with the machines of culture and the market, commodiﬁcation, normalization, stigmatization, liberation, and control, in all these areas and more, contemporary bioethics engages with, and is fertilized by, the fecund and ﬂourishing disciplines that have been opened up by the modern discourses of the body.
Even if one branch of bioethics continues to adhere to the positivist tradition where ethical questions are conceptualized in abstraction from lived experience and the ﬂow of medical relationships, another incorporates the unrelenting and remorseless questioning of the biological and clinical sciences that was generated by the breakup of the old Cartesian-based Enlightenment consensus. Fuelled by intellectual and experiential resources supplied by phenomenology, feminism, postmodernism, post-colonialism, and the manifold social movements concerned with the rights of gay people, the disabled, women, and people with diverse cultural, racial, and biological backgrounds, this questioning has demonstrated that there is no – or at least, there is no longer – one single, lived body. Instead, there are many kinds of bodies, body-selves, and embodied experiences; therefore, since body and world are co-constitutive, there are many different worlds of knowledge, cognition, and feeling.
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