Abstract: For Foucault, ‘modern medicine has fixed its own date of birth as being in the last years of the eighteenth century’. During this period, a paradigmatic turn has taken place in the history of medical thought regarding the classifications of the disease. With the discovery of pathological anatomy the focus of the classificatory technique has shifted from a source in the symptoms experienced by the living patient to a source in the organic lesions found in the corpse. Consequently, the lived experience of illness came to be seen as relatively insignificant; the real disease was to be located in the material body, the world of res extensa. The disease came to be seen as hidden inside the body and could be best uncovered by opening up the object-body, the Korper. Hence, the birth of pathological anatomy is marked by an irony: ‘That which hides and envelops, the curtain of night over truth, is, paradoxically, life; and death, on the contrary, opens up to the light of day the black coffer of the body’. Nineteenth century medicine, Foucault observes, was haunted by this gaze that ‘cadaverises life and rediscovers in the corpse the frail, broken nervure of life’.
What Foucault wanted to argue in The Birth of the Clinic is in the context of development of modern medicine life, disease and death formed a technical and conceptual trinity. The epistemological primacy of the corpse has provided us with a radically new perspective of death: ‘instead of being what it had so long been, the night in which life disappeared, in which even the disease becomes blurred, it is now endowed with that great power of elucidation that dominates and reveals both the space of organism and the time of the disease’. Crudely, death came to be providing a grasp on the truth of life and the nature of its illness. The present paper attempts to see this as a paradox associated with the very foundation of modern medicine, which is Cartesian in spirit. Seeking help from Drew Leder’s phenomenological studies on medicine, we try to expose how Cartesian notion of body constitutes the paradigm of western medicine. The said paradox, as we proceed to argue, provides with a platform to rethink modern medicine; a rethinking that has much to learn from Merleau Ponty’s concept of incarnate body.
Keywords: cadaverising, modern medicine, medical gaze, cartesian notion of body, incarnate body, Merleau Ponty, pathological anatomy, medicine knowledge
The present paper aims to address a fundamental paradox of modern medicine. The paradox is associated with the concept of death implied in the discourse of modern medicine. Death, which is supposed to be the symbol of failure and termination of the curative project, becomes, paradoxically, constituting the paradigm of modern medicine. Michel Foucault associates this with the moment of the discovery of pathological anatomy in the history of medicine with which death began to be looked at as endowed with greater power of explication. Foucault’s project in The Birth of the Clinic is that of ‘archeology’ determining the conditions of possibility of medical experience in modern times. However, we take this paradox to be providing a platform to rethink the philosophical presuppositions of modern medicine, especially with regard to the concept of body. There have been many attempts to rethink the conceptual foundation of western medicine mainly basing on the phenomenological paradigm of lived body, of which Drew Leder’s works need special attention. Obviously, Foucault does not explicitly subscribe to the notion of lived body; his view is often regarded as cultural constructionism where body is taken as always already a politically inscribed field. However, this paper attempts to see the relevance of Merleau Ponty’s notion of lived body particularly with an assumption that it supplies a strong support to the critical gesture of Foucault’s project. In the first part of the paper, we try to understand the implications of Foucault’s observation. Secondly, we focus our attention on Drew Leder’s phenomenological studies on medicine which attempt to expose how Cartesian notion of body constitutes the paradigm of western medicine. In the final section, an attempt is made to understand the significance of the notion of lived body, which puts pressure on both the machine-model and the constructionist model, for a rethinking with regard to the modern medicine.
For Foucault, ‘modern medicine has fixed its own date of birth as being in the last years of the eighteenth century’. In the eighteenth century, as he observes in The Birth of the Clinic: An Archaeology of Medical Perception, a crucial turn has taken place in the history of medicine. For the first time, medical knowledge took on a precision that had formerly belonged only to mathematics. The body became something that could be mapped in a rigorous manner. Disease became subject to new rules of classification; a new paradigm has emerged regarding the classifications of the disease. With the discovery of pathological anatomy, the focus of the classificatory technique has shifted from a source in the symptoms experienced by the living patient to a source in the organic lesions found in the corpse. Consequently, the lived experience of illness came to be seen as relatively insignificant; the real disease was to be located in the material body, the world of res extensa. The disease came to be seen as hidden inside the body and could be best uncovered by opening up the object-body, the Korper. Hence, the birth of pathological anatomy is marked by an irony: ‘That which hides and envelops, the curtain of night over truth, is, paradoxically, life; and death, on the contrary, opens up to the light of day the black coffer of the body’ (Foucault 166). Nineteenth century medicine, Foucault observes, was haunted by this gaze that ‘cadaverises life and rediscovers in the corpse the frail, broken nervure of life’.
In the discourse of modern medicine, life, disease and death formed what Foucault terms a ‘technical and conceptual trinity’. The continuity of the two age-old beliefs is shattered in this context. That is, the beliefs that placed the threat of disease in life and of the approaching presence of death in disease is broken down; in its place is articulated a different discursive space where the positions of the concepts of death, life and disease can be illustrated in a triangular way. Their relation is articulated in such a manner that the death represents the peak of the triangle; it is from the summit of death that one can see and analyze life and disease-organic dependencies and pathological sequences. Foucault elucidates further: ”Instead of being what it had so long been, the night in which life disappeared, in which even the disease becomes blurred, it is now endowed with that great power of elucidation that dominates and reveals both the space of organism and the time of the disease” (Foucault 144).
The privilege of the intemporality of death, Foucault says, is turned for the first time into a technical instrument that provides a grasp on the truth of life and the nature of its illness. Foucault’s point is that anatomical perception is a point of view ‘from death’. It could grasp life and disease, open up disease onto truth, only insofar as it invested death in its own gaze. ‘It is no longer that of a living eye, but the gaze of an eye that has seen death – a great white eye that unties the knot of life’, which bursts open ‘the wonders of genesis in the rigour of decomposition’(Foucault 144).
It goes without saying that dissection is not an idea invented in the eighteenth century. In a sense, it is as old as medical thought itself. Foucault’s attempt was to see its new relevance in the eighteenth century especially in the context of the discovery of pathological anatomy. Drew Leder, in his phenomenological studies on medicine, points out that the so called anatomical gaze, of looking at life from the point of view of death, is part and parcel of the Cartesian foundation of medical knowledge. He considers Descartes as the philosophical father of modern scientific medicine. The reason for this consideration is plain, that, the notion of body operative in modern medicine is Cartesian in spirit. Within the Cartesian dualistic framework body can be conceived only as dead and lived body is unthinkable, since life there can be looked at only as mechanical, modeled on the ‘lifeless’. Drew Leder points out that the notion of the dead body plays a threefold role within the project of Descartes. It helps to inspire his scientific investigations in a significant sense. Secondly, it is crucial to his investigative methodology. Thirdly, it constitutes the very foundation of his metaphysics. We shall here restrict ourselves to Drew Leder’s observation regarding the close link between Descartes’s metaphysics of body and his concept of life, that is, to the direct implications of the Cartesian notion of body for modern medicine.
As a matter of fact, medical knowledge, especially the idea of dissection was an important concern for Descartes. Drew Leder invites our attention to some of the instances from the life-history of Descartes showing his concern for the idea of dissection. Descartes engaged for years in the dissection of dead animals and animal parts with the clear intention of advancing his medical knowledge. At certain period of his life, as Drew Leder points out, (17-35) he paid almost daily visits to butcher shops, collecting materials for this purpose. In a letter written to Mersenne in 1639, it is stated that he spent much time on dissection during the last eleven years and he doubted whether there is any doctor who has made such detailed observations as he did.
What is the business for a philosopher in a butcher shop? Is it out of purely a non-philosophical concern that he engaged in the dissection of dead animals and animal parts? Leder says that Descartes extensive use of dissection implies that the dead body also plays a key role within his metaphysics of embodiment. Descartes models the living body first and foremost upon the lifeless. He challenged the tradition by arguing that the principle of animation is primarily mechanistic, that it is to be found in the body itself, not simply the soul. For medieval thinkers it is the soul that makes body animated and unless infused with soul body is just like a corpse. Descartes disagrees with this perspective and argues animation is the result of the body’s own mechanical processes. This is evident from his letter written to Henry More where he says life of the animals consists simply in ‘the heat of the heart’ and death is not the result of the soul’s departure from the body:
Death never comes to pass by the reason of the soul, but only because some one of the principal parts of the body decays: and we may judge that the body of a living man differs from that of a dead man just as does a watch or other automation (i.e, a machine that moves of itself), when it is wound up and contains in itself the corporeal principle of those principles for which it is designed along with all that is requisite for its action, from the same watch or other machine when it is broken and when the principle of its movement ceases to act.(333)
It is clear from the above that machine is Descartes’s model for understanding human body. Human body functions like a machine: life is nothing but a mechanical function of the body. As evident from his writings, Descartes was enthralled by the automatons of his day, which not merely perform diverse functions but even replicate the deeds of the living creatures, were in fact motivated by the mechanical forces. Drew Leder invites our attention to the concluding remark in the Treatise of Man where Descartes says ‘the fire which burns continually in our heart…is of no other nature than all those fires that occur in inanimate bodies’(20). This remark clearly implies the living body is not fundamentally different from the lifeless: ‘it is a kind of animated corpse, a functioning mechanism’ (Ibid.).
This image of human embodiment is an integral aspect of the Cartesian ontology which is fundamentally different from the Aristotelian one. In Aristotle’s hylemorphic account, body is ‘ensouled’ and the nature was understood as always already infused with soul seeking to realise certain aims. Descartes has replaced this vision of an ensouled nature with that of soul-less nature or nature as res extensa. This is a dead universe, where the notions of subjectivity and intention cannot be ascribed in any sense of the terms. The difference between these two is crucial for understanding the idea of technology including medical technology.
According to Drew Leder, the medieval world-view does not allow any space for technology in the sense in which the term is understood in the modern context. It is the mechanistic paradigm that facilitated the development of the tools. It involves a crucial shift in the very conception of knowledge: to know an object in mechanist terms is to comprehend by breaking it down into its constituent elements and analysing their interaction. The whole idea of knowledge implied in the mechanistic paradigm is summarised in Jonas’s observation, that is, “to know a thing means to know how it is and can be made and therefore means being able to repeat or vary or anticipate the process of making” (203-4). Obviously, this concept of knowledge implies a specific relation between the knower and the known where the former gains a power over the latter. As Drew Leder observes, (120) such was not the case with the final causes and substantial forms studied by the medieval. These were basically immutable, indivisible, God-given essences, to be contemplated, but not altered at will. The mechanist world-view allows the crucial shift from passive contemplation to the active manipulation which characterises the modern age.
The point of our discussion in the preceding sections was the paradox of modern medicine: the paradox of dead body constituting the paradigm of medical knowledge. The difference between Foucault’s and Drew Leder’s concerns is that Drew Leder takes the paradox to be providing a platform to explore an alternative model of medicine basing on the phenomenological insights. Our interest in this section is to rethink modern medicine in the light of this paradox and try to see the relevance of the phenomenological notion of lived body in this rethinking. The term ‘lived body’ derives from the German Leib. In German, the term Leib means living bodies. Husserl used the term Leib to refer to the body as it is lived by us contrasting it with the term Korper which designate inanimate or dead bodies. What we have seen in the previous section is that the Cartesian paradigm wipes out the essential difference between the Leib and the Korper. Within this paradigm, both the living body and the dead body are to be defined in terms of extension, the former being an instance of the general class of the extended substance. The phenomenological notion of the ‘lived body’ aims at problematising this mapping. It suggests that our body, the body as we live, has a unique structure of its own which resists to be captured by the Cartesian conceptual geography which is aimed to explain inorganic nature.
For Merleau-Ponty, lived body is the locus of intentionality. This is to say that it is essentially directed toward an experienced world and this directedness makes it different from the object-body. Moreover, in a significant sense, the lived body constitutes the phenomenal world, the world-as-experienced. We cannot grasp the world without reference to the bodily powers through which we engage them – our senses, motility, language, desires. Grasping the world is primarily a bodily engagement where our body makes the world sensible and thereby possible. The lived body, thus, is not just one item among other items in the world, but a way in which the world is disclosed. The being of the world is this disclosure, the way it is disclosed in our body.
To understand body as the locus of intentionality is not to go for a subjectivist characterisation. It is important that Merleau-Ponty, in his latter writings, deliberately avoided using his earlier expression, ‘body-subject’ to designate body as intending entity. While the body has a subjective role, it is also a body-object, an item in the world. Lived body is to be understood as a field where the subject-object duality evaporates. Merleau-Ponty, in his incomplete work The Visible and the Invisible, explains this point in a compressed but convincing manner. It is the eye that opens up the visible world. Though it is not visible for me and thus absent in vision, it takes its place within this world as a visible object of determinate colour and shape. Similarly, the lived body is absent in our engagement with the world but it makes the world present and it also takes place within the world. It is an ‘intertwining’, both perceiver and the perceived, intentional and the material. This existential situation, inherently ambiguous, is never captured in the Cartesian framework. More accurately, Cartesian scheme was an attempt to resolve the ambiguity of our embodiment by rigidly separating thinking from materiality.
To be the human is to be the site of an intentionality, to have an ambiguous being/becoming which is materially situated and enacted. In Cartesian dualism the physiology of the body is conceptualised without recourse to intentional terms. According to Drew Leder, this conceptualising, that is to understand that this body can be analyzed mechanistically is the great success of the so called Cartesian medicine. The paradigm of lived body calls for a re-transformation of thought concerning embodiment, which, according to Drew Leder, need not involve discarding the knowledge and techniques that Cartesian medicine has yielded. Rather, Cartesian medicine should be treated as one option, subsumed within a broader, holistic perspective (Ibid 128). But, however, Merleau-Ponty’s concept of body is not to be understood as merely suggesting an alternative paradigm of holistic medicine. It deeply problematises the whole discourse of modern medicine and presents a radically different ontology, ‘the ontology of flesh’, the core theme of which is ‘intertwining’.
Let us go little deep into the implications of the idea of intertwining. The point which is to be emphasised is that lived body as intertwining does not indicate the fact that body has a subjective role as against the notion of object-body. It actually suggests the idea of body as an indeterminate constancy, to use Carol Bigwood’s illuminating expression (98-113). Our human bodily being takes place within a natural-cultural situation. It is about to say that lived body is neither the result of biological determinants nor is it purely a culturally construct. To understand body as an indeterminate constancy is to acknowledge a kind of indeterminacy at the fundamental level of our bodily being. In The Visible and the Invisible, Merleau-Ponty says: “everything is cultural in us” (our Lebenswelt is ‘subjective’, our perception is cultural-historical) and “everything is natural in us” (even the cultural rests on the polymorphism of wild being) (1968: 253).
This idea is better represented in Merleau-Ponty’s notion of ‘flesh’ and ‘incarnate meaning’. To say that our body is fleshy is to suggest the image of a sentient body, contrasting it with that of an inflexibile matter. Body’s relation with the environment is primarily that of involvement, not of containment. We are sensibly attuned to, and synchronised with, our surroundings through a ‘latent knowledge’ that is present before any effort of our cognition. We engage the world in a precognitive level. It is not our cognitive categories that makes sentience possible but rather this ‘silent, precognitive, intimate bonding of our body’ with the environment. As living beings, we are not in full cognitive possession of determinate, sensed objects but are lost in the world, irretrievably absorbed in an indeterminate context of relations. We find ourselves in a ‘field constantly filled with fleeting plays of colours, noises, and tactile feelings that nonetheless usually emerge as meaningful, but by means of a communication with our surroundings that is more ancient than thought’(Bigwood 106).
Merleau-Ponty’s point is that lived body has a way of ordering of its own even though it is primarily pre-rational and pre-linguistic in its engagements. Our sentient body is accustomed to life “which steals across the visual field and bind its parts together” (1945: 35). It is capable of seeing things unified. It is not an intellectual act of giving meaning and order to the chaotic world. It gathers the ‘meanings’ that the things have, and ‘see to it that they have meaning’. This is what Merleau-Ponty means by embodied perception. In other words, perception is a bodily act of capturing the sense of the world, the sense that belongs to the ‘sensible signs’ of the visual field and not to the intellect. It is this incarnate meaning that is neglected in the constructionist framework where body is treated as purely a cultural construct. The constructionist’s culturally inscribed body is, paradoxically, a disembodied body. As Carol Bigwood puts, it “lacks terrestrial weight and locatedness because, it has left out this aspect of the body’s incarnate situation” (103).
Merleau Ponty’s use of the expressions ‘sign’ and ‘sense’ need to be clarified further especially to have a better understanding of how do they differ from the structuralist/constructionist perspectives. The expression ‘sign’, for Merleau-Ponty, does not refer to the unity of signifier and the signified. Rather, it is to be understood in close relation to the notion of significance. The ‘signs’ presented to perception are no way detachable from their living significance. The incarnate sign does not refer to its signified but is ‘filled with its significance’. The signs in the visual field have immanent meanings or significances depending on the way they are disclosed in the lived body. In French, ‘meaning’ is sens, which means ‘sense’, ‘significance’ and ‘direction’. Merleau-Ponty makes use of these implications and attempts to broaden the meaning of ‘meaning’ to include nonlinguistic and noncognitive meanings.
In seeing the things as unified, body is motivated by its environment in a significant sense. But the ‘motives’ in the environment are not to be confused with objective causes; motivation is not of the nature of causal determination. They are not fully articulate and hence not fixed. It is not at all the case that body takes up and combines them in a fixed manner. They are, as Merleau-Ponty argues, a part of an ‘open situation’ and it is always uncertain whether the phenomenal meanings that they offer find their resonance in the body. Lived bodies, then, are not biologically fixed entities geared into and determined by an external, physical world. Body’s being is ‘fleshy’; there cannot be any solid body. Lived bodies are fluid movements toward a situation which is always open, wherein it must find its indeterminate supports.
Indeterminacy is the necessary aspect of our incarnate bodily situation. Every perception is accompanied by an unperceived horizon, a horizon of other things and dimensions of the thing that are not sensed and thus absent in perception. However, this absent background persists as a non-sensory presence. We ‘sense’ it, but this sensing is not physiological. Merleau-Ponty explains this point with the help of an instance of seeing a ship in the sand. When I open my eyes and suddenly see that there is a ship in the sand, my eyes focus themselves on the ship. The ship becomes thematised and the surroundings vanish into the background. My eyes ‘inhabit’ the boat, synthesising it as a unified thing. However, the ship that becomes the theme of my perception does not thereby become a completed object, transparent to consciousness. Bodily perception can never said to be complete and determinate, not only because it is spatially extended beyond its present focus, but also because it is temporal and must be persistently restated in us. Our living present is ragged between a past, the retentional aspect, that it takes up and a future, the protentional aspect that it projects. There is always an excess beyond what I experience at this moment because my incarnate existence happens within the indefinite horizons of space and time.
The indeterminacy that Merleau-Ponty talks about, points to the complexity of our incarnate natural-cultural situation. Obviously, it puts pressure both on the mechanistic and the constructionist models. The perspective that there can be no inflexible bodily structures and our bodies are not preset foundations does not imply that bodies are merely cultural constructions. Lived body is naturo-cultural that its dwelling in the world is to be understood as consisting of an intertwined web of relations with the cultural and the natural. So, there is a specific sense in Merleau-Ponty’s use of the term ‘natural’ as it does not indicate one of the poles in the nature/culture binary. It indicates our ‘nonpersonal’ perceptual existence that underlies and intertwines with our personal cultural and intellectual lives. It runs through us, independently of us, provides the possibility of phenomenal presence. Every perception takes place in this atmosphere of generality and is presented to us anonymously. Just as we are thrown into our mortal situation where we find ourselves ‘already born’ and ‘still alive’, so are we open into incarnate situations, modalities of existence already destined for a fleshy world. ‘Just as birth and death are nonpersonal horizons, so is there a nonpersonal body, systems of anonymous functions, blind adherences to beings that I am not the cause of and for which I am not responsible. I am connatural with the world through no effort on my part’ (Ibid 108).
This fresh model of body, as it is obvious from the above account, goes beyond nature/culture dichotomy which is actually a residue of the Cartesian dualism. Merleau-Ponty’s phenomenology of body is not an attempt to solve the body-mind problem; rather it attempts to dissolve it. Also, it is not merely the case that, in Merleau-Ponty’s formulation, culture and nature meets in the lived body; rather, the opposition between the notions of existence in nature and existence in culture gets blurred in lived body. We exist concurrently in cultural and natural ways that are fused together at the fundamental level of our embodiment. Nothing determines us from the outside or inside, precisely because we are not cut off from our surroundings. The inside/ outside dichotomy misrepresents our incarnate situation. We are not ‘within ourselves’ but from the very beginning thrown open to our surroundings in a semi-determinate but constant coition with things. In the last analysis, as Merleau-Ponty puts it, there is only this natural- cultural momentum of existence, this ‘unmotivated upsurge of being’ of which the body and the environment are only abstract moments (Ibid 109).
The suggestion of this paper is to see the relevance of this paradigm of embodiment for rethinking the conceptual foundation of the modern medicine. The paradox that Foucault points out provides us a platform for a rethinking but it needs to be supported with the idea of lived body. Foucault’s concept of body, if it is interpreted in a constructionist manner, lacks this dimension. It is doubtful whether Foucault’s thought actually fits into the constructionist model. There are moments in Foucault’s thinking where there is a strong resistance to the constructionist model and this is often interpreted as a disadvantage of his perspective. For example, Judith Butler (177-8) claims that Foucault appears to assume a materiality of the body prior to inscription. For Foucault, as for Nietzsche, cultural values emerge as the result of an inscription on the body, understood as a medium. In order for this inscription to signify, however, that medium must be fully transvaluated into a sublimated domain of values. The distinction between the inscribed body and a body prior to inscription, Butler argues, operates as essential to the task of Foucault’s genealogy. Occasionally, Foucault subscribes to a prediscursive multiplicity of bodily forces that break through the surface of the body to disrupt the regulating practices of cultural coherence imposed upon that body by a power regime. Butler finds this as a disadvantage, a remainder of foundationalism and the nature/culture dichotomy in Foucault’s own theory. But, is Foucault’s assumption of a prediscursive body, (if at all there is anything like that in Foucault), so naïve? Is this a foundationalist assumption? We prefer to answer these questions in the negative. There is another way to look at it that Foucault’s assumption moves close to Merleau-Ponty’s concept of body as indeterminate constancy, rather than foundationalism. By this Foucault’s archeological inquiry regarding medicine, psychiatry and so on could reassert its radical, critical gesture in a more significant manner.
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T. V. MADHU. He is an Associate Professor in Philosophy, University of Calicut. His areas of interest are contemporary continental philosophy, especially philosophy of body, self and the other. His publications include two books in Malayalam on neo-Marxist thought (DC books) and on the question of self (Kerala Sahitya akademy). He has also published more than ten research papers in various journals and volumes.