Jan Hartman
Illness as evil and illness as good
It is bad to be ill. Illness is pain-a cardinal form of evil, together with weakness, sin, wrongdoing, and disgrace. Among all the forms of evil it is perhaps illness which most directly and urgently calls for action. This action-treatment-is good and as such it confers its own value upon everything that makes it possible. In the light of this understanding of good, illness itself acquires a secondary, indirect, yet nonetheless real value: in other words illness is also good. In the language of classical metaphysics, factors like this are referred to as “transcendental good”: a type of good inherent “by default” in even the most wretched constituents of our essentially good (as it is God's creation) world. I will not, however, attempt to claim these metaphysical heights. On the contrary, I will confine myself to a pragmatic methodological perspective.
My paper, as the title suggests, will be devoted to the ambiguity apparent in reactions to and opinions about illness. I will present an axiological dialectic whose dynamism provides grounds for the dynamism of the human practice of treating diseases. Similarly, stimulating ambiguities and dialectics are encountered in the area of crime and its prevention as well a.s in the complex relationship between individual egos and state institutions that enforce action orientated towards a common goal. In all these cases, an initial evil becomes a condition for the emergence of a highly developed product of culture, be it the science of medicine and health care, or the legal system, or democratic institutions.
I will not attempt to present a systematic analysis of the theoretical and practical problems in the area described in the title. All I would like to do is to show how the aforementioned axiological ambiguity comes to the fore in different, more or less theoretical notions of illness and treatment, as well as in popular beliefs. In order to accept those points of view which see “illness as good,” a departure from the classical concept of good is needed.
Namely, I am asking you to put aside that concept located at the crossroads of general metaphysics and practical philosophy and defined in the following way: good is whatever is the direct or indirect goal of action. in particular of human action. The concept of good that I have in mind is perhaps equally classical but. somehow mysteriously, competing with the former, namely: good in whatever contains, creates, or enhances an enriching meaning - which leads towards perfection.
There are numerous phrases that describe the decline from perfect health (to death) and accentuate different kinds and aspects of such a decline: some of them express the philosophy of the speaker as well as describing the illness.
Here is a list of some words and phrases that describe this decline, together with explanations of their meaning: I) “Pain”-bad, negative physical or psychological sensation; 2) “Weakness”-feebleness, lack of vital powers; 3) “Poor health”-a general condition of the body. being prone to disease; 4) “Ailment”-a slight but persistent malfunction of an organ or organs; 5) “Disease”-an impairment of normal physiological function, a pathological change: we refer to this situation by saying simply: “I am ill”; 6) “Hurt, injury, wound”-a sudden and serious malfunction, a break in the structure and violation of the integrity of the organs, even persistent damage to a part of the body; 7) “Disability”-a persistent handicap, malfunction or lack of an essential organ(s), seriously affecting one's everyday life; either inborn or resulting from a disease or accident; 8) “Monstrosity”-a marked structural deformity of an organ; 9) “Symptom”-any unusual sensation or change in bodily functions („something's happened to me”); 10) “Syndrome”-a theoretical medical notion describing a well-defined set of phenomena and processes conceived of as bad for an organism.
We have some of these bad things in mind when we utter the word “illness” or “disease” in various contexts. The relevant semantic field is further broadened by different beliefs and ideas of what really happens inside us when we are ill-in any of the above meanings. These beliefs and ideas can be quite simple, or can amount to entire medical theories, but all of them are grounded in general beliefs about what illness is in general and what its particular types consist in. This popular ideology and typology of illness seems to be worth analysing; not the least interesting is the fact that the categories of diseases are defined by certain “cardinal diseases” and “diseases as cultural symbols”: leprosy and syphilis, for instance.
1. The most primitive belief is, of course, the mythological idea of illness as “being possessed by evil forces.” The idea of mental disease as “possession by the devil” and of infectious disease as “bad air” both conform to this paradigm, as well as the explanation of illness as a punishment sent by God. These all are versions of the myth of disease as the intervention of an external super-human power, an intervention that is caused either by an infringement of a taboo, or as a result of sin. Illness in this sense is always accompanied by moral taint, a disgrace on the ill. Its symbols are the leper and the lunatic.
2. Another classical view of illness, or at least of one of its essential types. is the idea of disequilibrium, of upsetting the balance of certain regulative components of the body-blood, phlegm, yellow bile. and black bile. for instance. A paradigmatic disease in this sense is sickness or intoxication. The notion of illness as a disequilibrium and disharmony turned out to be exceptionally fruitful for the science of medicine. It was this concept that enabled the change from treatment in the form of exorcism to treatment in the form of “detoxification” by applying a specially prepared substance: a remedy. This concept paved the way for modern pharmacology.
3. A medical topos of “bad blood” links the early modern concept of illness as an alchemical violation of homeostasis with the concept of illness as partial death: decay, rot, or gangrene. The prominent diseases here are “the vapours” and syphilis. Treatment consists mostly in “purification” of the body: surgical removal of decayed parts, amputations, cutting ulcers open, letting blood. >From the desire to remove all rotten bodily matter arose the most military of all medical disciplines-modern surgery. A sort of medical conservatism is also grounded in the same concept, namely, an approach that considers many diseases as relatively natural phenomena, similar to aging. and thus, unworthy of intensive treatment.
4. Yet another modern view of pathology-the mechanistic one-is symbolised by paralysis. Disease is a fault in the bodily mechanism-a malfunction. Something has “gotten stuck,” a cyclic process has been interrupted, a circuit has been cut, a vein has been blocked. The idea has proven to be extremely important for scientific medicine, since it emphasises the phenomena of conductivity, metabolism, and circulation. The search for a motor of the bodily mechanism directed the efforts of medicine toward studying the functions of the heart. This spiritual supremacy of cardiology is still prevalent in contemporary medicine-and certainly the fact that cardiac arrest is the most common cause of death is not the sole reason for it.
5. The most awesome disease of all-cancer-symbolises another type of illness: illness consisting in turning the vital powers of the body against itself (illness as a tumour, growth, monstrosity). In this category illness can be described as self-aggression, self-destruction, and anarchy in an organism. Neoplasms, acromegalies, and allergies-understood as auto-aggression of the body-are paradigm cases of diseases that support the idea that the ultimate cause of illness is the patient himself.
Having surveyed, though all too briefly, the morphology of the evil of illness, keeping in mind the whole network of various “had associations” aroused by the word “illness,” we are now in a position to recognise their mirror images in the concepts and ideas through which illness manifests itself as a non-evil, and indeed, as something positive and in a sense good. The existence of this positive reflex is inevitable for pragmatic reasons. Since illness is the necessary prerequisite for the existence of therapy and medicine. it must be tamed, accepted and explained by those who live with disease and those who live off it-by patients and doctors. Like every inevitable thing. illness must be presented as something meaningful and valuable in the broad perspective of the human condition.
All philosophical theories of illness, maybe except pessimistically existentialist philosophies, strive to discover a sense in illness. The Christian concept of illness is ambiguous in this respect. Learned Christianity, on the one hand. teaches that illness is a trial through which God “tests” our faith. Illness is, moreover, a memento mori-a figure of death, and a path to death. It therefore has a significant religious dimension; it is one of the ways to God. an opportunity for penance for the sinner, an opportunity for conversion for the infidel, and generally an opportunity for diverting thoughts from everyday mundane tasks to matters connected with salvation of the soul. On the other hand, however, popular Christianity tends to see illness mostly as something bad that God allows to exist-therefore it has to be borne, and accepted. Sometimes illness is even seen as God's just punishment, implying that whoever is ill must have deserved it.
The classical Greek concept of illness is most manifest in the stoic heritage. In this tradition, illness appears to be “insignificant.” The virtuous man ignores it, or, more precisely, accepts it as a fact of life towards which his attitude should be one of indifference. Illness does not encroach onto the sphere of his spiritual autonomy. Undergoing treatment is perhaps advisable, but only in so far as it is advisable to exploit all favourable opportunities -but without excessive effort to bring them about. From this point of view illness is not so much an evil as an obstruction.
Doctors of antiquity knew how to treat many diseases quite well, and scientific medicine existed in the late Middle Ages too (mostly thanks to Avicenna). but it was not until modern times that the idea of an active fight against disease came into being. We owe its birth to the modern spirit in philosophy. But not entirely and not everywhere. For the modern spirit in philosophy was far from homogeneous, and could be divided-provisionally-into two intellectual trends: a naturalist, positivist one and-in contradistinction-a spiritualist and romantic one. It was the former one-evolving from lAth-ccntury medical alchemy to positivisi somatism. symbolised by the cult of anatomy and vivisection, that inspired the search for active methods of remedial treatment. Illness was becoming more and more axio-logically neutral: a natural, though unwelcome, stale of an organism, as natural as all other diversions from norms which abound in nature. From this perspective health is a norm. whereas illness is an abnormality. On the other hand. romantic modernity is responsible for the “aesthete” concept of illness (we will come back to it later), as well as for the revival of spiritualist magical practices. These were dominant in the Renaissance, and today they resound in several-sometimes moving, despite their naivety-descriptions of efforts of a seriously ill person to regain health as if they were heroic battles with a cunning enemy who nevertheless can always be repelled with spiritual strength and an indestructible will to live.
Philosophies, or rather ideologies, of illness influenced not only general concepts of medicine, but also the practical attitudes of doctors as well. A conservative doctor with Christian or classical attitudes is by no means quick to opt for active and aggressive treatment. Illness for him is a natural state and most diseases, as he is always ready to remind us, are self-curable. Moreover, every age has its diseases, and the biological clock cannot be out-maneuvered. When the time comes for dying, for arteriosclerosis, a stroke, or cancer, the patient should be allowed to die quietly. Intensive treatment is only justified in cases where minor diseases turn into serious ones, or when a dangerous disease occurs “unjustly”-the patient is too young and “too healthy” for it. It should be said that such traditionalists among doctors are rather rare today. The active type is dominating-and not only because modern ethics demands that the doctor do everything possible for the patient, but also due to the fact that in a contemporary free-market society, doctors -like everyone else (including philosophers!)-tend to sell their services as broadly as possible. An active doctor, thus, treats you even when you are as fit as a fiddle; for example, he/she may recommend prophylactic treatment, or a diet and a healthy way of life; or he/she may prescribe vitamins, cosmetics, and Prozac (if you happen to live in the US). If you feel just a bit under the weather-and have made the mistake of telling him/her about it-he/she will come up with the most sophisticated treatment. Nobody is allowed to be ill in his/her presence-let alone die. In the world of active medicine, the boundaries between illness and health, prevention and therapy, serious disease and hypochondria, have been obliterated. This is perhaps why “allergy” seems to be the favourite of contemporary medicine.
As we have seen, in the complex history of medical beliefs and ideas. illness was looked upon not only as a definite evil but also as a manifestation of the natural (and supernatural) order of things, as something irrelevant and trivial but also as something significant and important. Human activities oriented towards the tight against diseases were. and still are. being amplified by the forces inherent in tensions between various ideas, concepts, beliefs. and opinions connected with diseases and treating them. It is not worth talking too much about the fact that it is bad to be ill. It seems, however. worthwhile to point to another extreme in the whole range of opinions that have ever occurred in the philosophy of illness. This is the “aesthete” approach that has already been mentioned, the idea that illness has certain specific inherent moral and aesthetic values.
The aesthetics of illness is grounded in a prima facie justified belief that the socio-psychological type of an individual is partially determined by his/her physical appearance: the way he or she looks, his/her age. the condition of the body. The unique personal quality of an individual is thus often co-determined by certain flaws, imperfections, and disabilities. It is hard to be a noble Nestor without being aged: a justified user of a walking stick must suffer from at least a slight impediment of movement, etc. The Romantic movement valued the aesthetic aspect of illness to an extent that provoked some to pretend to be ill (e.g., by using pale powders) and even to engender it artificially (e.g., by drinking acetic acid). Romantic ideals emphasized connections between the hapless life of an artist and the content and quality of his creation. A persistent and unbearable disease often figured prominently among the necessary calamities of a respectable artist. Thus illness was perceived as both a manifestation of and the reason for the artist's sublime sensitivity. Moreover, it guaranteed the truth of his creation. Great “patients” in the history of culture include Marcus Aurelius, Pascal, Nietzsche, and Proust. Among diseases allegedly connected with high spiritual values, tuberculosis and various heart problems can be mentioned, along with-even more significantly-all diseases perceived as specific to upper social classes, such as haemophilia, migraine, and anemia. The commoners, who were also not incapable of appreciating the value of illness, had to content themselves with illnesses which had “socially initiating” value and symbolised transition to the next class in a hierarchy defined by age (generation). Such “illness of age” included first the diseases of childhood, then diseases of middle-age-going bald and putting on weight (if we may count these as quasi-diseases), and finally diseases of old age.
There can be no doubt that a world without diseases would not be a human world: neither would a world without senility and dying. This is ultimately why doctors will always remain suspect individuals who tend to intervene in the natural order of things in this “best of all possible worlds.”