Beyond cholesterol: is it possible a human medicine?

Dedicated to the memory of Edmundo Granda Ugalde (1946-2008)

Roberto Passos Nogueira [i]

I In the 1970s, a former Austrian-American priest, Ivan Illich, wrote a much celebrated book for its incisive criticism of medical technology and physicians which can often do more harm than good to their patients. In the last pages of The Medical Nemesis, Illich described health as a virtue, something that depends on the political assurance of personal autonomy and the responsibility to cultivate healthy habits. In his subsequent intellectual career in the 1990s, disappointed with the advancement of the pseudo-ethics of health promotion by modern states, Illich said that we should give up the associated notions of health and responsibility since they no longer can support any kind of virtue. Public polices aiming at health promotion have become so deeply committed to a self-imposed accountability, that there is no more a virtue to be pursued on behalf of health:
In the nineteenth and early twentieth century, then, health and responsibility were still believable ideals. Today they are elements of a lost past to which there is no return. Health and responsibility are normative concepts that no longer give any direction. When I try to structure my life according to such irrecoverable ideals, they become harmful - I make myself sick. In order to live decently today, I must decisively renounce health and responsibility. Renounce, I say, not ignore - I do not use the word to denote indifference. I must accept powerlessness, mourn that which is gone, and renounce the irrecoverable [ii].

According to Illich, in the place of the mandate for health as ones responsibility, we should defend a claim for certain essential liberties: the liberty to declare myself sick;
the liberty to refuse any and all medical treatment at any time; the liberty to take any drug or treatment of my own choosing; the liberty to be treated by the person of my choice, that is, by anyone in the community who feels called to the practice of healing, whether that person be an acupuncturist, a homeopathic physician, a neurosurgeon, an astrologer, a witch doctor, or someone else;

 the liberty to die without diagnosis.

In December 2002, accompanied by a group of friends and disciples in Bremen, Germany, Illich practiced the art of dying which he had preached for many years. And he did it without having received any medical diagnosis. II Policies supported by the modern state for health promotion have the nature of a moral imperative. They impose a mandatory personal responsibility that is never expected to be questioned as they are founded on the authority of biomedical science. Who feels obliged to eat low-cholesterol foods is not making a real choice, but only following the voice of scientific authority. One is unable to judge what says this voice - whether it's right or wrong and why. This moral imperative is obeyed since its explicit purpose is to avoid this or that dreaded disease, or because it promises health to all who submit themselves to a standardized way of living. Above all, it appears validated by the supreme good of our post-modern society, health. In his course on the Anormaux in the Collge de France, Michel Foucault [iii] traced the history of disease control in Middle Age from the exclusion model of leprosy to the inclusion model of plague. The latter does not endeavor keeping sick people away or isolated but tries to regulate the interaction between healthy and sick people in the towns. We can say that such techniques of intervention using social-medical rules were replaced in the twentieth century by the mentioned model of personal accountability concerning health risks. Myocardial infarction and AIDS prevention exemplify this model of pseudoautonomous normalization of health in everyday life. With the emergence of health as ones responsibility, what is required is not a passive submission to a set of rules, but a behavior that consciously avoids the risk factors identified by recent medical science findings. In this pseudo-autonomous model there is no room for trial and error or for a gradual learning dependent on freedom of choice. It is not expected that an individual will reach a wise middle point (meson) between extreme options that stand in his path to virtue, according to an Aristotelian moral paradigm. Nor is he to behave in obedience to rules he freely imposes on himself based on what is an evident rational duty, according to a Kantian moral paradigm.

Health nowadays became a moral obligation but at the same time it can be found as part of countless products for sale. The label no cholesterol is something equated with health. How is it possible that cholesterol has become synonymous with health? It is possible because in today's technological world health has nothing more to do with the condition of man in his existence in the world. Health is now understood as a set of substances, bodily conditions and behaviors that are assessed as risk factors. The ability to enjoy health depends on these physical and behavioral conditions, something that has been transformed into a personal responsibility. So, when someone finds a friend, no longer asks how you are or how's your health, but rather how's your cholesterol? The blood cholesterol content has become not a sign of a presumed health state but took the place of health itself, so that this question may receive the following response: my cholesterol was bad, but it is better now, I went through a tough diet. The idea of my health (what I feel and am) was replaced by the idea of my cholesterol, a substance that is inside myself and that I do not know what is, but before which I have responsibility. Indeed, few people know what cholesterol is and how it affects their physical sustenance and health. People generally ignore, too, that medical science differentiates the good cholesterol from the bad one so that a scientifically correct question should be this - how's your bad cholesterol? Further, we all know that scientific research can produce conflicting signals over time, as later tests disapprove earlier evidences. With the results of new research, hen eggs may be absolved as a source of harmful cholesterol, and salt as a hypertension inducing factor. The evidence of science is always provisional, and what was certified as being harmful to health can now be presented as positive. How can anyone have faith in science as a guide to his everyday behavior if the fickleness of its findings is the hallmark of the scientific spirit and this spirit can never be content with previously established facts? Nevertheless, health promotion policies cannot be relativist. Their aim is to prescribe the current evidence provided by the latest epidemiological and biomedical research.

III In today biotechnological medicine, the human dimension of health and disease has been converted into what is the result of a quantitative assessment of the conditions of certain objects. As Heidegger tells us, it is a characteristic of modern natural science to take everything in the world as objects of observation and measurement. In medicine, the two conditions of the objects that are to be evaluated relate to the conceptual pair normality and abnormality. The patient is examined clinically to identify objects that may be normal or abnormal, according to standards established by medical sciences. Thus serum cholesterol is measured in order that the physician comes to know whether it is in the range of normal values. But the biochemical substances are just a class of objects that medicine evaluates as varying between the normal and the abnormal. There are many other objects that can be judged in the same line: the anatomical condition of the lung, the cellular composition of the liver, gradients of renal function, genetic traits, and so on. Medical diagnosis usually goes beyond the body constitution and extends into an appraisal of human behavior, i.e., into the field of psychiatry where one founds established parameters by which one judges whether a patient is having a mental disorder or not. The overall assessment that someone is healthy is always provisional, since it is impossible to examine for each patient all the objects likely to go through an abnormal change. This historically specific understanding of health and disease can be called object-determination. Here the expression objective determination is avoided because it would inevitably be understood in the sense that modern science gives their findings: something real, true. Let us see how it is defined an abnormal physiological condition, lymphocytopenia: Lymphocytopenia is the total lymphocyte count of <1000/L in adults or <3000/L in children <2 years (Merck Manual).

This condition is described in a sort of encrypted code but physicians are trained to memorize such standards and accordingly to interpret his patients test results. The object-determination of mental disorders for sure is something much more complex, since they are liable to larger variations of parameters. But this does nod avoid that groups of experts reach a consensus. For example, generalized anxiety disorder is so defined in the classification of the World Health Organization WHO (F41.1, ICD-10):
There must have been a period of at least 6 months with prominent tension, worry, and feelings of apprehension about everyday events and problems. At least four of the symptoms listed below must be present, at least one of which must be of items (1) to (4).

It follows a list of twenty-two symptoms divided into physical and mental types, such as symptoms involving chest and abdomen, difficulty breathing, feelings of shock, chest pain or discomfort, nausea or abdominal discomfort. By similar descriptions, all mental disorders are transformed into functional objects, so that they can be assessed and measured. It is important to keep in mind that object-determination is not an epistemological tendency particular to medical science. What happens is that we all exist under the rules of object-determination that are found in all theories and all practices of the natural sciences since the 18th century. Cartesian objectdetermination seems very familiar today: all that is experienced by man in the world are objects represented by the subject of knowledge in a right and secure way. What medicine and biopolitics have in view is not human health, but objecthealth. The aim of determining health and disease this way expresses a will to power in Nietzsches sense. One wants to get knowledge of something in order to better intervene through changes in abnormal objects, including human behavior. Summing up, health biopolitics express the will to power of science in the service of the state, and the will to power of the state in the service of science.

About this, Heidegger comments with great clarity and incisiveness, that from natural sciences we can see the human being only as an entity of nature.1[iii] For all these reasons, we ask ourselves here whether a human medicine is still possible. We do believe it is possible, but only in the future and only if we can move beyond todays object-oriented medicine, following the indications left by Heidegger's philosophical heritage. IV In seminars hold intermittently for almost ten years in the Swiss town of Zollikon, Heidegger interprets that health and disease are ontological phenomena that belong together. Disease is a privation of health, in the same sense as shadow is a privation of light. Disease is at once a loss and a disturbing of the freedom and the openness that characterize Dasein as beingin-the-world. We hardly can understand this because we live under the aegis of the metaphysical object-determination of health and disease. Historical concepts of health and disease depend on the philosophical response given to this question: what is the essential foundation of all beings? Heidegger identifies three historical responses to this question and each one departed from a fundamental ontological concept, as underlined below: 1. Physis, nature in Greek sense: what emerges and presents itself by itself (pre-Socratic thought, Plato and Aristotle); 2. Creature, everything created by God, and remaining in relationship to his Creator (Christian theology); 3. Object, something represented by the subject of knowledge in a right and secure way (Descartes and Kant, extending to modern philosophy and science). The studying of the history of the concepts of health and illness is usually never done in accordance with these three fundamental determinants. But it is easy to show, and in the following lines we will give a glimpse of it, that the concepts of health and disease are ontological bearers of these historical-philosophical determinations.

In Greek Hippocratic medicine, disease was understood as a distorting changing of natural body constitution: disease arises and shows itself in a way that distorts nature. There was then no idea of what is an object or a subject. Under the influence of pre-Socratic philosophers and, later, of Aristotle, human disease was understood as a manifestation of physis. Nature is continually changing while it appears, disappears and reappears by itself. Disease comes up because of a harmful unbalanced composition of the body humors whose features correspond to the four natural elements (air, water, earth and fire). According to these concepts, humors involve a dynamics of flowing, mixing, retention and elimination in and out of the body. In turn, medieval Christian theology is marked by a distinction between natural health (still understood in a Greek way) and salvation as souls health. In the early centuries of the Church, with the work of Tertullian on baptism, healing of the soul came to be understood as salvation, in analogy to the healing of bodily ailments described in the gospels as part of Jesus preaching. If we do not have in mind this bond between healing and salvation, we may misunderstand an important chapter in the history of medicine, that is, the care of the sick provided by religious helpers and doctors in hospitals built and maintained by the Church since the Middle Age. To illustrate these brief remarks on the concept of health according to Christian theology, it is convenient to cite Thomas Aquinas Summa Theologica in which original sin is conceived in analogy with the disharmony of bodily diseases:

original sin is a habit. For it is an inordinate disposition, arising from the destruction of the harmony which was essential to original justice, even as bodily sickness is an inordinate disposition of the body, by reason of the destruction of that equilibrium which is essential to health

[iv].

Medieval theologians left untouched the Greek concept of bodily health and out of it created a double analogy with souls health. First, all of us are born under the dominance of original sin, as a sort of hereditary disease of the human species. Second, salvation is a sort of healing that restores souls harmony broken by original sin.

Much later, in the seventeenth century, the historical determination of all beings as objects was inaugurated brilliantly by Descartes. This philosopher provided the necessary ontological foundation for disease to be understood as an object, more specifically, an abnormal object. From the second half of the nineteenth century on, disease was studied by the method of anatomical and clinical medicine, inaugurated by Auenbrugger, Corvisart, Bichat and Laennec. The object-determination in medicine begins as early as 1770 when Auenbrugger discovers the foundations of the method of thorax percussion. He explains his method of patients physical exam by an evident objectification of man, comparing human thorax to a drum:
A healthy mans thorax resounds when it is finger beaten. The sound that the thorax emits is comparable to that which is usually obtained on the drums when they are covered by a cloth or other fabric made of coarse wool. [v]

The anatomical-clinical concept of disease is made victorious in the first half of the nineteenth century and in the next two centuries object-determination of health and disease develops to an extraordinary point in all fields of medicine. The Heideggerian understanding of Dasein's health, described briefly below, aims to establish a fundamental break with the empire of the objectdetermination of health, and, in general, to leave behind all metaphysical distinctions between subject and object. What is announced in a Heideggerian phenomenological medicine is the presupposition that is necessary to study human health from the understanding of what Dasein (or being-in-the-world) is. Dasein can never be understood as a sensible object, which is present here and now. Dasein consists essentially of the ability to apprehend and be concerned to every entity in the surrounding world, beginning with those that have the same mode of being (ours alike).The concept of Dasein can better be understood in its ontological dimension when we consider the essential possibilities of mans being open to everything that addresses him in timespace. In fact, nothing would prevent us translate Dasein by The Open, as suggested by Thomas Sheehan [vi]. This is anyway a better solution than the Being-There, a copy of the French tre-l, which Heidegger criticizes because Dasein does not designate a location in space, but the very opening given to human being.

This human prerogative of openness is what Heidegger calls the understanding of being. Consider everyday situations such as these: I walk into a restaurant, see an empty table, sit down and call the waiter (orientation in immediate spatial context); I drive home from my workplace (orientation in non-immediate space: to make present to oneself a place that is far away); I think of the tasks I have to accomplish tomorrow at my office (orientation in the temporal context). All these situations involve a kind of comportment that differs drastically from animals behavior in their environment. Dasein is concerned with all entities of the world not by means of a mind, as presupposed by a scientifically view, but as having a human body itself. To the continuous demands of the world, Dasein has multiple possibilities of responding, behaving freely in one way or another. The way Dasein comports itself is not caused by a definite fact, as happens with the animals, which depend on environmental stimuli. Based on linguistic ability, Dasein is requested by worldly beings and the answers given relate to motives to comport in one way or another, according to a decision. Man is moved in time-space by motives, which are reasons to act so and so, while animals move obeying to stimuli coming from the environment. This is possible because, thanks to the gift of language, man alone has the understanding of being - in other words, he knows what is this and that. No doubt, animals have a world too, but in a very limited way. We can only think of another health and another medicine, if we assume that man is not an animal among others (the rational animal), and that disease is not a natural object with biological or behavioral abnormal format. Disease must be understood as both privation and perturbation. It is these two philosophical determinations that are in need of recovery by a human medicine in order to characterize Dasein's being-ill. This could never be accomplished by a metaphysical return to Aristotles thought. If we comprehend what are the possibilities of Dasein in the time-space structure of quotidian world, as described by Heidegger in his classical work Being and Time, only then can we realize what the privative and the disturbing features of human being-ill are as compared to a diseased animal.

Dasein has a relationship of freedom with openness to the world. Freedom is what makes Dasein be open; it precedes and underlies opening. Therefore, one can say that Dasein is the Free-Open-Being. Only what is open can be closed to the world. Disease is at the same time a loss and a disturbing of Dasein's freedom and openness. Not only disease, but also drunkenness, mourning, and addiction to drugs are different modes of Dasein's existential closure that go along with a restriction of freedom. Being free and open characterizes man in his being at home in the world. Instead, disease emerges as a loss or deprivation of freedom and openness to the world. This can be expressed by a patient as follows - "Doctor, I would like to do what I used to do before, but I can no more; if I try, I cannot do it well, I feel bad and insecure and then I just give up". The relationship to the world is deficient on one hand, and troubled or distorted, on the other. In some mental illnesses such as schizophrenia, a distorted relationship with the world often takes the form of hallucination. We can analyze the condition of ill-being of Dasein's possibilities in two temporally distinct senses. There is a privation of world that makes itself manifest as a momentary disturbing of the space-time relationship to the world, as it happens in drunkenness. But there is also a durable disturbing of this relationship that comes with a great variety of serious diseases, from pneumonia to Alzheimers. But Dasein can not be conceived as something present that suffers privation and disturb. Only Dasein's possibilities are what can be shown to be in lack or disturbed. Who is seriously ill is also usually on bed. To be on bed indicates already a deprivation of world, an inability to move freely and adjust oneself to things and other persons. One of the existential meanings of disease is a restricted ability to adapt, to understand and to deal with quotidian tasks and everybody else. The phenomenological evil of disease is indicated by a double suffering: "no longer being able to do this or that" and "being confused, upset, and insecure". The assumption that we have adopted from Heidegger's thought is that mans being-ill is a negative image of what constitutes Dasein as being-in-the-world. Being healthy is being at home in everyday life, as this is an essential mode of temporal concern with the world. Being at home is at the same time being free

and opened to the relationship with people and things. Therefore, the statement "I'm fine" stands for "I'm home in the world", which is also a well-being with others, because Dasein is essentially being-with-others. V To complete these brief introductory notes on phenomenology of health and disease, we comment two decisive Heideggers lessons in Zollikon Seminars. The first one is about the human essential needing for help:
The human being is essentially in need of help he is always in danger of losing himself and of not coming to grips with himself. The entire question of the human beings capacity for being ill is connected with the imperfection of his unfolding essence. Each illness is a loss of freedom, a constriction of the possibility for living [vii].

The second one is about how to help man:

We do psychology, sociology, and psychotherapy in order to help the human being reach the goal of adjustment and freedom in the broadest sense. This is the joint concern of physicians and sociologists because all social and pathological disturbances of the individual human being are disturbances of adjustment and freedom. (..). Any adjustment [by the patient] is only possible and meaningful on the ground of existential being-with [Mitsein]. As to the physicians will-to-help [the patient]: One must pay attention to the fact that it always involves a way of existing and not the functioning of something. If one aims at the latter, then one does not add to [the understanding] of Dasein. But this is the goal

[viii].

There is an imperfection in man, a "gap" in his existential foundation of freedom with openness. Man is always in danger of losing himself and distorting his concerning relationship with the world. He easily let himself be carried into closed ways of existence which are manifest in situations such as isolation, depression, gambling, compulsions or addictions of all kinds and mental illness. Such imperfection of mans essence is what previously Heidegger had characterized as mans finitude. It is an inner fault, a failure to live well, but it is what makes us humans, as underlined by Thomas Sheehan (ix). Not only the patient, but any normal person is in need of help, because, due to this failure of the original essence of the human being, every one of us faces ongoing difficulties of dealing with the pressing demands stemming from the world. In this sense, man is characterized as less adjusted to his environment than animals to theirs. It is not as a matter of biological incapacity for

adaptation, but an existential difficulty that has to do with the hardships of living with freedom and openness, in face of worlds continual claims for responses. In this sense, man is born stressed and has no escape to being stressed. Somewhere Heidegger says that stress is the burden that human being has to carry in order to be free. On the other hand, human freedom has no reason to be - it does not have a foundation. Heidegger says that human freedom is somehow suspended over an abyss (Abgrund, in German). It has no thinkable grounding, and this is reason of the failure of our ecstatic existence in spacetime. Man is always in danger of losing himself. Thus the essence of man is imperfect, and so is his health. But paradoxically this essential imperfection is what assures freedom to Dasein. Helping man to adjust does not mean to pursue a functioning as a useful intervention. Helping Dasein is just a let it be. We have to help Dasein stay connected in an open and free concerning with the world, or gradually recover this original kind of relationship. Help can only be meaningful to the extent that a person is left free to decide for an opened living. Concluding, helping the sick man cannot obey the traditional model of medical intervention, aimed at restoration of a given object. Nor can it conform to the model of psychoanalytic auscultation, which aims to achieve a cathartic apex. Healing takes place in the phenomenological sense when man overcomes a given form of closure. Healing is always a phenomenological pleasurable reopening. It is a reopening back to the affective condition of "empathy" with world entities, inspired by the vision of future possibilities of concern with others, with things and with oneself. Phenomenological medicine which springs from the thought of Heidegger is not a new version of psychoanalysis, in spite of the fact that the existential approach of "letting it be" makes it comparable to a psychoanalysis treatment, the only point of Freuds doctrine praised by Heidegger. One of the key differences is that phenomenological medicine is not concerned with psychical phenomena but with Daseins health phenomena as a whole. It is an integral medicine of man, that is, a medicine which envisages Dasein as the being that has world not with consciousness, but with the body, "to the last muscle fiber", as Heidegger said. In the future, there will be another medicine able to help

patients with schizophrenia and those who suffer from cancer or any other health problem that current medicine identifies as a physical or a mental ailment. Which therapeutic methods and practices will it use for this sake? This is not yet known, nor ought to be anticipated by ad hoc proposals that may easily resume the object-determinative ontology inherent in modern biotechnological medicine.

[i] Roberto Passos Nogueira is a physician, PhD in Social Medicine and researcher on socioeconomic and philosophical dimensions of health and medicine in Braslia, Brazil. E-mail address: rpassosnog@gmail.com. The English version of this paper was written by the author, August, 2011. [ii] See http://www.davidtinapple.com/illich/1990_health_responsibility.PDF [iii] Foucault, M. Abnormal, London: Picador, 2004 [iv] Summa Theologica, first part of the second part, question 82, Article 1. [v] Nouvelle Methode pour reconnaitre les maladies internes de la poitrine par la pecussion de cette cavit par Avenbrugger, Paris, 1808. See in Google book collection:

http://books.google.com/books?id=PGL5cUHixyQC&printsec=frontcover&dq=auenbru gger&ei=GVFeTtGPBs7aUKmMvLAF&cd=1#v=onepage&q&f=false
[vi] A Paradigm Shift in Heidegger Research, Continental Philosophy, Continental Philosophy Review, 34: 183202, 2001. [vii] Zollikon Seminars: Protocols Conversations Letters. Evanston:0 Northwestern University Press, 2001, Zollikon Seminars, p. 157 [viii] Zollikon Seminars, p. 154-157 [ix] KEHRE and EREIGNIS: A Prolegomenon to Introduction to Metaphysics. In: A Companion to Heideggers Introduction to Metaphysics, edited by Richard Polt and Gregory Fried. New Haven and London: Yale University Press, 2000