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The Meaning of Illness.

By S. Kay Toombs. Norwell, Mass.: Kluwer, 1992. 148 pp. $64.00.

As the myriad critics who love to hate it have pointed out, the World Health Organization's definition of health ("a state of complete physical, mental, and social well being") is unrealistically and perhaps insidiously broad. Not only is it difficult to know who according to this definition is healthy, but more importantly, this definition lends itself to the medicalization of life; it brings everything within the purview of medicine, including what was once thought to be within the purview of religion or education or law.

The going alternative, however, seems equally problematic. The biomedical model defines health as the absence of disease, where disease is a matter of the body alone. According to its critics, the biomedical model is far too narrow; health is never merely a matter of the body alone but always involves the whole self.

S. Kay Toombs's new book, The Meaning of Illness, brilliantly charts a course between the too broad WHO model and the too narrow biomedical one. Though Toombs's book may not represent a paradigm shift--she is indeed part of a tradition of thinkers critical of the biomedical model (Eric Cassell, Arthur Kleinman, Edmund Pellegrino, and others)--she enlarges their project by getting specific about how to bridge the gap between the physician's and patient's conceptions of health and illness. According to Toombs, physicians have to bridge that gap if they hope to treat their patients more effectively--in particular, their patients with chronic or incurable illness.

This book is a rarity. It not only analyzes the relationship between physician and patient and explores the meanings of health and illness in a subtle and substantive manner that will interest philosophers, but it also suggests how physicians can become better healers. Toombs's investigation of the goal of healing is for the most part astonishingly clear. I say "astonishingly" because this reader is astonished to find a clear explication of the thought of some of the twentieth century's most difficult and important philosophers. I say "for the most part" because the introduction and first chapter, which begin from an explication of the thought of the German philosopher Edmund Husserl, are at moments a little dry. But complaining that an explication of Husserl is a little dry is like complaining that sailing gets you a little wet.

Following Husserl, in the first of her four chapters Toombs distinguishes the "natural" attitude, which involves the immediate pretheoretical experiencing of the world of everyday life, from the "naturalistic" attitude, which involves an abstraction from immediate experiencing in favor of a theoretical, scientific account of such experiencing. Whereas the meaning of illness for the patient is constituted from her "natural" attitude, the meaning of illness for the physician is constituted from her "naturalistic" attitude. "Thus, when physician and patient talk about |illness' they are not discussing a shared |reality.'" One of Toombs's chief aims is to bridge this gap between what the patient means by illness and what the physician means. She undertakes to build this bridge not because she thinks that physicians act in bad faith, but because only when physicians better understand what illness means for patients will they become better healers.

Chapter two begins from Jean-Paul Sartre's understanding of how the patient and physician conceive of illness differently. Toombs argues that whereas for the patient, illness is first of all the prereflective experience of the body in pain, for the physician, it is first of all an example of a disease state, a pathoanatomical or pathophysiological fact. Her analysis, which is in part filled out with the details of her own experience as a sufferer of multiple sclerosis, becomes at this point more complicated. Though the patient's primary attitude toward her illness is pretheoretical, she is also able to conceive of her illness as a pathoanatomical or pathophysiological fact. And that conception, which entails, for example, an understanding of the consequences of the disease for the future, is an important source of anxiety and suffering. The patient's illness thus gives rise not only to pain that requires managing, but to suffering that requires interpretation.

Beginning primarily from the work of the French philosopher Maurice Merleau-Ponty, in the third chapter Toombs examines how the physician and patient conceive differently of the body. Though the reader can predict how she construes that difference, one couldn't predict the nuanced way in which she elaborates it. Though the patient's prereflective apprehension of her body is different in kind from the physician's reflective apprehension of it, the patient also experiences her body as an object: "My body is at once the most intimate yet alien presence."

When we are healthy, most of the time we are utterly unaware of the workings of our bodies. Yet there are certain situations "when the body suddenly appears in the field of consciousness." The experience of dragging one's body around when fatigued and having a limb fall asleep are examples of such negative situations; sport, dance, and sexual excitement are positive situations when "the lived body is recognized as essentially corporeal, as a physical material entity." Though this shared experience of the body-as-object does not put the physician in the shoes of the patient nor the patient in the physician's, this apprehension of the body-as-object provides the beginning of a bridge across the gap of their different apprehensions of illness.

Whereas the first three chapters explore the fundamental difference between the patient's lived experience and the physician's naturalistic account of that experience, the final chapter explores how, for the sake of healing, the physician can gain insight into the lived experience of illness. Toombs's thesis is that the physician is required to understand illness as a fundamental "loss of wholeness"; without this understanding, the physician cannot respond to the threat posed to the self by illness and so cannot heal the patient.

The first step toward that healing is that physicians simply attend to the loss of certainty, control, and freedom that illness brings. The next step has already been hinted at: the physician needs to use her own lived experience of the body-as-object as a point of mutual understanding. The third step is for physicians to begin paying attention not only to the medical history that reflects the "voice of medicine," but to the clinical narrative that reflects "the voice of the life-world." Since the patient's suffering is a function of her understanding of the meaning of her illness for her life, only when the physician also understands what the illness means for the patient can she hope to help restore the patient to wholeness.

I began with the claim that Toombs steers a middle path between the biomedical and WHO models of health. But isn't the language of "restoring the patient to wholeness" every bit as broad as the language of WHO? To answer that question, it is important to remember that patients with chronic and incurable illness are at the heart of Toombs's concern. It is precisely these patients who cannot be restored to "a state of complete physical, mental and social well being." Tending to the whole person--aspiring to re-integrate the sufferer into her web of responsibilities and relationships to the extent that is possible--is different from aspiring to establish in the person a state of complete well-being. Toombs's vision is more modest and less utopian than the WHO one.

In a word, Toombs claims that if medicine is to tend to the needs of that majority of patients who are chronically or incurably ill, it must base its practice on a different understanding of health and illness. If and when a medical school decides that its students ought to look beyond the goal of defeating diseases of the body to the goal of restoring the wholeness of the person, Toombs's book will be an excellent place for it to start. Meanwhile, those of us trying to conceptualize a middle path between the World Health Organization's too broad understanding of health and illness and the biomedical model's too narrow understanding will find much help in Toombs's rich and thoughtful book.

Erik Parens is associate for philosophical studies at The Hastings Center
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Author:Parens, Erik
Publication:The Hastings Center Report
Article Type:Book Review
Date:Nov 1, 1993
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