Spring 2010
Course: RLSOC 757
Tuesdays
4:00-6:30
MEDHM 700
ARLET 509
Illness of Body, Mind and Spirit
The focus
of this seminar is on
illness, that is, on the subjective aspect of sickness as experienced
by
patients, relatives, caretakers, physicians, etc. Reflection
on illness, however, requires
equal attention to the concept of disease. The
dialectical opposite of illness is disease, the
objectified aspect
of sickness and the target of scientific investigation.
The patient feels ill and the patient has a
disease. Nor can we ignore related
concepts like health, disability, malady, etc.
Required Reading:
Brody, Howard. Stories of Sickness. New York, NY: Oxford University Press,
2003. Ed. 2. ISBN 0-19-515140-2.
Caplan, Arthur L., McCarthey, James
J., Sisti, Dominic A.
editors. Health, Disease, and
Illness: Concepts in Medicine. Washington, D.C.: Georgetown
University
Press, 2004. ISBN 1-58901-014-0
Didion, Joan. The Year.of Magical Thinking. New
York, NY:
Alfred A. Knopf, 2005. ISBN
1-4000-4314-X.
Hunter, Kathryn Montgomery. Doctors’ Stories: The Narrative Structure
of
Medical Knowledge. Princeton, N. J.: Princeton
University
Press,
1991. ISBN 0-691-06888-7.
Styron, William. Darkness
Visible: A Memoir of Madness. New York:
Random House,
1990. ISBN 0-394-58888-6 (soft cover
acceptable).
Woolf, Virginia. On Being Ill. Ashfield, MA: Paris
Press, 2002. ISBN 1-930464-06-1.
For the
following, please refer to
the list of required readings. Three
books shall be read side by side. Our
first text is appropriately titled Health,
Disease, and Illness, by Caplan et al. This
is the most philosophical of all our texts,
carefully considering
what all these and related concepts meant in the past and mean in the
present,
and in the near future, the latter in the light of the “age of
genetics.” Clearly, one implication is
that these
concepts are historical and change in the course of time.
In general
pathology, the
classification of illness according to disease categories, is well
established
and time-proven.
A disease
category is characterized
by its:
- Symptoms
and signs (subjective complaints and objective observations) or
syndromes, i.e., clusters of symptoms and signs that occur together,
- Aetiology
or cause.
- Pathogenesis,
i.e., the way in which symptoms and signs come about as a result of the
cause.
These three
characteristics suffice
to diagnose an illness as being an instance of a specific disease
category. In actual practice this
disease concept is not as manageable as its simplicity might suggest. In mental illness it has mostly failed to
elucidate disease categories.
Presently
two concepts of disease prevail. The first concept, dating back to the 19th
century, holds that a disease is an (ontologically) real entity, that
exists in
always the same structure and characteristics. This
definition of disease limits it to purely
anatomical and functional
disturbances, leaving no room for any value judgment.
By extension, this also implies a value-free
science of health.
In the
beginning of the 20th
century, the philosopher and psychiatrist, Karl Jaspers, rejected the
notion of
disease entity on the ground of Kant’s philosophy.
Kant distinguished between the phenomenal
world, which can be known, and the nouminal world of
“things-in-itself,” which
can be approximated in our reflection, but cannot be known. This is the world of Ideas, like Mankind,
World, God, etc. For Jaspers, disease
entities
also represented Ideas, forever unknowable. Systems
of diseases (or nosology) for Jaspers became
categories or types,
approximating disease entities, but never fulfilling them.
Jaspers
makes a clear distinction
between category and type. A category
defines a demarcated area of reality. A
type is a mental construction, bringing structure to an area of reality
with
fluctuating boundaries. For example, a
case of illness belongs to a certain category, or it corresponds, more
or less,
to a type. In mental illness, we mostly
deal with types rather than categories.
This
introduces us to the second
concept of disease, much a product of the 20th century,
according to
which the concept is both descriptive and normative.
Diseases are constructed by a society and its
culture and reflect the values of this culture. This
is well unfolded and demonstrated in our second
text, Culture, Health, and Illness, by Helman,
a physician and medical anthropologist. If
anthropology is the theory of humankind, then
medical anthropology
studies the theories and practice of healing in diverse societies
throughout
history. A loose definition of a society
is a community of people, belonging together and held together by their
common
culture. There are many definitions of
culture, each describing certain characteristics of it.
My own definition of culture, inspired by
Claude Levi-Strauss, includes the language of society and adds to it
the sum
total of all non-verbal behavior. I am
quick to add that much of culture is unconscious and therefore not
accessible
to conscious manipulation.
In the
introduction we designated
illness as the dialectical opposite of disease, and as its subjective
aspect. We shall now attempt to describe
the range of experiences that a sick person may undergo, using the work
of H. Faber
and Karl Jaspers as our guides:
a)
Feeling
ill, i.e., feelings of
discomfort, impotence, and danger.
b)
“Awareness
of illness” because we
have correctly interpreted our predicament or because the doctor told
us so.
c)
“Disease
insight,” according to
Jaspers’ definition, implies knowing the nature of the disease, its
symptoms,
and its severity, to the extent that a lay person of the same culture
can know
this. This definition underscores that
now the patient has an intellectual or cognitive knowledge of the
disease.
d)
In the
final step the patient
learns to own the disease and struggles with coming to terms with his
predicament. Of course, this stage only
occurs in chronic diseases, disabilities, and ultimately fatal
conditions.
This is a
place for discussing the
difference between physical and mental illness, a topic which is
addressed by
various authors in Caplan’s anthology, some of which conclude that
mental illness
is a myth, or is of a different order from physical disease. Common linguistic usage seems to encourage
this view of mental illness. After all,
while we speak easily of physical disease, we rarely use the term
mental
disease. The official classifications of
diseases use exclusively the terms mental illness or mental disorder. Is this tantamount to saying that mental
disease is only an illness, a subjective experience of lack of well
being, missing
any objective substrate? Is this the
source of the discrimination against and the lack of understanding of
the
mentally ill throughout the history of mankind? Our
questions are of course rhetorical.
Fortunately,
we now have the
concepts to clearly delineate the differences between physical and
mental disease. Starting with our
definition of disease, we
observe that for most mental diseases we know the symptoms and signs,
but we do
not know either the aetiology or pathogenesis. It
begins to dawn more and more, that many mental
diseases have a
sizeable genetic component in their aetiology, but thus far the
pathogenesis
remains obscure. A classification of
mental diseases on the basis of symptomatology alone is indeed not more
than a
typology, as Jaspers understood so well, a typology which has to change
when
psychiatry grows up and discovers the true aetiology and pathogenesis
of mental
disease. Do not take me wrong. When this happens, Jaspers will still insist
that nosology, whether it concerns physical or mental disease, is at
best a
system of categories and never a system of disease entities.
Turning now
to the subjective
aspect of physical and mental illness, we are able to discern equally
vast
differences. The first and central one
concerns the awareness of illness, which sooner or later develops in
physical
disease, and is totally absent in mental disease. The
mental patient is not aware of being ill,
although he may be subject to terrifying experiences of persecution, of
collapse
of the world, etc. Or he may think he
has a body illness and visit his doctor, or suffers intense feelings of
guilt,
moving him to seek spiritual help. Feeling
persecuted will make him turn to the police
or lawyers.
The second
difference deals with
disease insight, which is also absent in mental illness.
Yet, because this feature has a cognitive
dimension, the patient may learn to develop disease insight in course
of time.
Within the boundaries of his cognitive abilities, the patient may even
learn to
own his disease and come to terms with it. Obviously,
this requires years of psychotherapeutic
work, often not
within the financial reach of the sufferer.
Our third
text by Kathryn, M.
Hunter, a professor in English literature, undertakes the study of “the
interaction between physicians teaching and learning to take care of
patients,
sometimes both at once.”
Her
study
is also anthropological, but she chooses to investigate “the
white-coated
tribe”
in
action, accompanying them on rounds and participating in case
conferences and
grand rounds. As a by-product, she
learned about the physician-patient relationship. She
observed that the heart of medicine is
not science, but the telling of stories by the patient, augmented by
the
findings of physical examination, laboratory data, visualization
studies, etc.
which together constitute the physician’s story. The
physician’s work thereby becomes
analogous to literary interpretation of narratives, in which the plot
is
represented by the diagnosis.
Of course,
there is a link between
the patient’s story, the physician’s story (case history) and the
writings of
patients’ and physicians who reported their experiences of illness in
self or
intimates. This subgenre of
autobiography or biography is known as pathography, and Kathryn Hunter
ends her
book with a discussion of the importance of a vast knowledge of case
histories
and pathographies for the practicing physician. It
is out of this intertextuality that the
physician’s interpretive
powers spring.
The
remaining books will be
discussed in the assigned sessions. Two
of the books, by Styron and Frank, are true pathographies.
Whether Pouncey’s book, announced as a novel
and dealing with old age, counts as a pathography, shall be decided, I
hope, in
our class discussions. Robert Coles is a
child psychiatrist and psychoanalyst and his book, a jewel on his
crown, will
guide us in spiritual reflection.
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