When is a disease not a disease? No quibbling academic riddle this, but a problem increasingly pressing upon medical practice and ethics alike. So many questions crowd in. Is it valid to talk of a person being ill without a disease, or having a disease without being sick? When and how do we draw dividing-lines between conditions, disabilities and abnormalities, on the one hand, and diseases, on the other? This can be a crucial issue when it comes to final authority in deciding the fate of severely-malformed babies. If, say, Down’s Syndrome is a disease, then, arguably, it’s the doctor’s dilemma; if not, not.
In any case, can the writ of ‘disease’ run beyond the organic? Thomas Szasz in particular has long contended that the very term ‘mental disease’ is a misnomer, fiction or, worse still, a fraud. In 1973, following a postal vote, the American Psychiatric Association removed homosexuality from its roster of mental illnesses: what clearer admission of hopeless confusion between disease and deviancy?
All these problems – of definition, demarcation and decision – we feel are special to medicine today. It is chastening, therefore, to be reminded that the questions underlying them were being analysed, with great perspicacity, by the French philosopher and historian of science, Georges Canguilhem, in a work written in 1943 and now gratifyingly back in print in an English translation. In a nutshell, The Normal and the Pathological is a sustained protest against what Canguilhem saw as medicine’s pernicious drive to reduce the notions of health and disease to an axis running from ‘normality’ to the ‘abnormal’. By such a device, the idea of disease was being both diluted and over-extended.
Canguilhem argues vigorously against this creeping scientism. Taking as read the statistical notion of normality derived from the ‘law of large numbers’, it makes no sense to equate the healthy individual with any such Queteletian homme moyen. Health is not a matter of approximations to the average, but of appropriate individual adaptation to environment. The right pulse-rate for an Indian yogi would not be healthy for an Olympic sprinter. The genetic ‘defect’ which produces sickle-cell anaemia in black people is adaptive in West Africa for conferring protective resistance against malaria.
Put another way, Canguilhem’s contention is that it is mystifying for medical authorities to treat ‘normality’ as a value-neutral descriptive notion. As its etymology indicates, ‘normal’ is a prescriptive term – is indeed normative. From this, it should be clear that, in using the terms ‘healthy’ or ‘sick’, we are not objectively recording natural facts as we might falling bodies, but rather imposing our own values on experience – which ultimately amounts to a bias in favour of life. The order of physics may be value-neutral: bio-medicine cannot be. We must, of course, strive to achieve stricter criteria for defining the sound and the pathological, but this has to do, not with fact-gathering and experimentation, but with conceptual clarification.
This is not to imply, however, that Canguilhem is a wishy-washy subjectivist. Far from it: his whole point is that we must reinforce the conceptual distinctions between the healthy body (seen as a goal) and disease understood, not as mere physiological aberrancy, but as a real presence. Here it’s intriguing to contrast Canguilhem’s confidence about microbes with the latest modern cultural constructivism of Bruno Latour’s The Pasteurisation of France. To deny the ontological status of disease is as obtuse as to deny the reality of evil, observed the Strasbourg philosopher, then in the thick of Hitler’s war.
This brings us back to the philosophical and political nub of Canguilhem’s enterprise. One of the cardinal aims of the progressive intelligentsia in 19th-century France was to render the study of knowledge, society and medicine properly scientific. Positivism in particular promised to reveal the hidden orderliness of existence, and to formulate the laws governing that order. What Auguste Comte did for sociology, Claude Bernard and his followers undertook for bio-medicine. Physiology would encompass all the laws of the living body. In consequence, the vulgar, Manichean vision of Life battling – to the death! – against Disease would be discredited as an obsolete survival from the theological stage of thinking and in its place a unifying physiology would emerge, which would translate diseases into pathology, while regarding the pathological as nothing but a deviation from the physiological standard.
This Bernardian, biometrical attempt to reconceptualise health and disease in terms of (perhaps even a quantifiable) order and disorder is rejected by Canguilhem as misguided in its application to medicine. More strennously still, he deprecates its being smuggled, under the guise of ‘social physics’, into the broader theorising of society. The use of diagnostic terms and statistical methods to measure social health is not only phoney – a version of the naturalistic fallacy – but ideologically suspect. Above all, as he argues in the concluding sections of this book, added in 1963, the importation into social praxis of spurious organic analogies has sanctioned the rise and empowerment of ‘normalisation’. The social-scientific gaze sets about ‘discovering’ what is natural, what is normal, from the universe of social facts, and then uses this ‘knowledge’ to reinforce these norms – by medicalising and penalising deviancy.
By the Sixties, Canguilhem could of course cite in his support his one-time student, Michel Foucault, whose work laid bare the ‘normalising’ role of the modern disciplines of medicine, pedagogy, penology and psychiatry. The insights and analytic strategies common to both will be instantly evident to all readers of The Normal and the Pathological (though Canguilhem’s prose, if often frustratingly grand, never aspires to Foucault’s neologistic esotericism). Not least, both are committed to visions of discourse – conceptual structures ruptured by discontinuities – of a kind utterly foreign to the positivist legacy.
Yet the differences between Canguilhem and Foucault are worth pondering too. Here, as throughout his writings, Canguilhem appears to retain a commitment to authentic medico-scientific truth, and its distinctiveness from its ideological perversions, which is alien to Foucault’s viewpoint. Rendering scientific positivism compatible with philosophical radicalism was, it seems, less of a problem to the teacher than it was to the student. Canguilhem’s apparent confidence that, with the achievement of a truly ontological science of disease (Pasteurian, not Bernardian), the scope for intellectual hanky-panky has been reduced, may sound alarmingly like Susan Sontag’s polarisation of science and metaphor in approaching the symbolism of diseases. And, perhaps because of this residual (if within his own terms somewhat problematic) faith in medico-science as progressive knowledge, Canguilhem’s work can’t be said to prefigure Foucault’s bleakness. Reason, science and philosophy retain their emancipatory promise.