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The Cry of the Flesh

Havi Carel

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The Cry of the Flesh

Havi Carel

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Über dieses Buch

What is illness? Is it a physiological dysfunction, a social label, or a way of experiencing the world? How do the physical, social, and emotional worlds of a person change when they become ill? Can there be well-being within illness?

In this remarkable and thought-provoking book, Havi Carel explores these questions by weaving together the personal story of her own illness with insights and reflections drawn from her work as a philosopher. Carel's fresh approach to illness raises some uncomfortable questions about how we all – whether healthcare professionals or not – view the ill, challenging us to become more thoughtful. Illness unravels the tension between the universality of illness and its intensely private, often lonely, nature. It offers a new way of looking at a matter that affects every one of us.

Revised and updated throughout, the third edition of this groundbreaking volume includes a new chapter on organ transplantation. Illness: The Cry of the Flesh will prove essential reading to those studying philosophy, medical ethics, and medical anthropology, as well as those in the healthcare and medical professions. It will also be of interest to individuals who live with illness, and their friends and families.

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The body in illness

It is Christmas 2004, the height of summer in the southern hemisphere, and I am in New Zealand. My friends and I are on holiday, touring the South Island for two weeks. Part of our trip is a three-day coastal walk in Kaikoura. We are walking towards the farm we are staying in on the eastern coast of the South Island. On the way, we see dolphins and seals and wood pigeons. The air is fresh and the scenery beautiful. I am eager to hit the trail and confident because I have been exercising a lot lately and feel fit and full of life. I have become a health freak, eating little fat, spending 45 minutes a day on the Stairmaster, and lifting weights. I bounce and walk forwards, happy, energetic, bursting with joy. We walk at a brisk pace, chatting and enjoying the views and the sunshine.
The terrain changes, and we are now walking uphill. Suddenly, things become difficult for me. I lag behind; I can no longer chat with my friends. I stop and pour out the water I am carrying. Perhaps I am carrying too much weight? I try to walk on, but something is slowing me down. I have to stop frequently to catch my breath. No matter how slowly I walk, I still have to stop. The trail that seemed so inviting and beautiful is now harsh and endless. Eventually, I lag almost an hour behind the group. My ever patient sister-in-law, Mona, notices I am struggling and slows down to my pace. She stops with me, pretending she wants to look at the views. I am worried: how could I be so unfit? Why isn’t my body responding to all the exercise? I thought I’d be leading the group, but instead I am soon labelled the slow one, the struggler.
In the months that follow, my husband and I invent a string of explanations for my breathlessness. Maybe my lungs are small? Perhaps I have asthma? Maybe I have a tiny chest infection? I return to the gym with greater ferocity and determination than before and sign up for an additional kick-boxing class. I don’t go to the doctor and will not do so until two years later, when my breathlessness has become so prominent and abnormal that these feeble excuses no longer seem reasonable. But the sense of uncertainty, the struggling, the inability to understand my own body’s responses have been constant companions to me since.
The betrayal of the body, and the increasing alienation from it that an ill person experiences, is the main focus of this chapter. So how is the experience of an ill body different from that of a healthy one? The phenomenological approach of Merleau-Ponty provides a fascinating account of this difference. It is Merleau-Ponty’s emphasis on perception and on the centrality of the body to human existence that I find particularly illuminating in relation to illness.
Merleau-Ponty sees the body and perception as the seat of personhood, or subjectivity. At root, a human being is a perceiving and experiencing organism, intimately inhabiting and immediately responding to her environment. To think of a human being is to think of a perceiving, feeling, and thinking animal, rooted within a meaningful context and interacting with things and people within its surroundings. By taking this approach, Merleau-Ponty responds to a previous, intellectualist (as he calls it) definition of the human being provided by the seventeenth-century French philosopher René Descartes (1596–1650). Descartes defined us as thinking, abstract souls who temporarily and contingently occupy a physical body. Descartes’s approach is known as “dualism” because it postulates two different substances: spatial or extending substances, such as physical objects, and thinking substances such as minds.
Merleau-Ponty’s aim was to correct this dualist view and, while avoiding the materialist reduction of mind to matter, to emphasize the inseparability of mind and body, of thinking and perceiving. His approach can be thought of as holistic with respect to the human being. We cannot divide a person into a mental and a physical part, because the two are inseparable. Any mental activity must have some physical action underlying it (for example, a neuron firing in the brain). It is impossible, from Merleau-Ponty’s view, to think of a purely mental action because mental activity, abstract as it may be, is always embodied. Additionally, for us to acquire abstract notions and concepts requires experience of the world. So, for example, our concept of the colour red arises from seeing red objects. The concepts arise from sensual, perceptual experience. If we take these two arguments together, we can see the grounds for Merleau-Ponty’s claim that there is no mind that is independent of the body in the strict sense.
Similarly, physical action cannot be seen as mechanical manipulation mysteriously governed from a distance by mental commands. The body is not a passive vehicle simply awaiting instructions from the mind. Nor is it a system of pulleys and levers (as seventeenth-century mechanistic philosophers thought) that only comes to life when infused with a soul. Rather, it is an active entity, capable of goal-oriented action and intelligent response to the environment. The separation between mind and body does not make sense. Moreover, the strict separation between an internal realm and an external world does not make sense when we think about how we actually experience our bodies and the world as a seamless unity.
Instead of artificially separating mind and body, Merleau-Ponty emphasized the centrality of the body and gave an account of how the subject inhabits it. This more organic and biological view of the human being as a human animal (which also has culture, sociality, and a meaning-endowed world) sees the body as the seat and sine qua non of human existence. To be is to have a body that constantly perceives the world through sight, touch, smell, and so on. As such, the body is situated and intends towards objects in its environment. Human existence takes place within the horizons opened up by perception.
Thus for Merleau-Ponty, the body is a body-subject, engaged in a “primordial dialogue” with the world. This dialogue is pre-reflective, absorbed engagement with the environment, which can be easily understood by thinking about everyday activities. For example, going for a walk is such a dialogue of the body with the environment: the legs propel the body forwards, the labyrinth in our ears keep us upright and balanced, the eyes provide visual information about the path ahead and any obstacles to be negotiated, and so on. This kind of dialogue with the environment requires the constant taking in of information and constant recalculation of route, speed, and muscular effort.
A second dialogue takes place between different body parts and types of information. This synthetic activity unifies the information coming from the eyes, legs, muscles, and so on to create a unified experience of walking. The whole time this complex interaction takes place, the walker could be avidly discussing Nietzsche, paying no conscious attention to her body. This does not make her disembodied and does not bring back Cartesian dualism. It simply shows that embodiment is a background condition for subjectivity. This holds true even if no attention is paid to the body. Whether playing tennis or working out a mathematical problem, both activities, and the whole spectrum in between, are possible only in virtue of having a body, existing as embodied in a world.
Many of our actions, particularly everyday routine actions, are pre-reflective: they are the product of habit rather than conscious reflection. A complex web of such habits makes up our behaviour. Our habits and ordinary ways of engaging with our environment create a familiar and meaningful world. Against this often implicit background, activity, reflection, and conscious thought take place. Normally, we pay attention to what is consciously preoccupying us at a given moment – for example, thinking about a philosophical problem, rather than about the cup of tea we are preparing. But Merleau-Ponty wants to focus on the significance and sophistication of this background and moreover to understand how it enables conscious thought to take place on top of it, as it were.
The body is the centre of his investigation. It is a unique kind of object for Merleau-Ponty. The body is, of course, a physical thing, an object that can be weighed, measured, and described using purely physical or naturalistic terms. But it is also the source of subjective feelings, perceptions and sensations, the seat of subjectivity, and consciousness. As such, the body is a subject-object, a unique being that can be experienced both from a third-person point of view (we see other people, measure their height, observe their eye colour) and from a first-person point of view (I feel myself sitting on the chair; I am thirsty; I stretch my arms and experience my muscles distending and releasing).
Merleau-Ponty uses the simple example (from Edmund Husserl’s Cartesian Meditations) of two hands touching each other. Each hand is both touching, active, sensing the other hand, and being touched, passive, being sensed by the other hand. It is this view of the body as being both an active touching subject and a passive touched object that reunites the mind and body, the first- and third-person points of view, and expresses most clearly the unique position of the body.
Merleau-Ponty develops the notion of bodily intentionality. Intentionality was originally conceived by Franz Brentano and Husserl as a relationship between mental phenomena and their objects. It is the relationship of being about something, or intending towards something. For example, if I wish to eat ice cream, ice cream is the intentional object of my desire.
Interestingly, only mental phenomena are intentional, or about something. Wishing for ice cream, or believing that my bicycle is in the shed, are examples of intentionality towards ice cream and bicycles. Every mental act such as believing, desiring, and so on must be about something, or, in other words, must have an object. Thoughts are about something, beliefs and desires are about something, but physical objects cannot be about anything. Physical objects are not mental phenomena and therefore lack intentionality. A shoe cannot, in principle, be about anything. This feature of “aboutness” is often regarded as the defining mark of the mental.
Merleau-Ponty took on board the idea of intentionality but refused to accept that only mental phenomena can have this property of intentionality or “aboutness”. He extended the notion of intentionality to include bodily intentionality. This is the body intending towards objects, directing itself at goals, and acting in a way that is “about” various aims and objects. For example, if I reach out to pick up a cup of tea, my hand intends towards the intentional object, the cup. The position of the hand, the direction of the movement, the arching of the fingers are all directed at, or intended towards, that cup.
An intentional arc, as Merleau-Ponty calls it, connects my body to the cup of tea. This intentional arc makes sense of a collection of disparate bodily movements, unifying them into a meaningful action: intending towards the cup of tea. In this sense, we could say that bodily intentionality is analogous to mental intentionality. Some philosophers make the stronger claim that bodily intentionality is primary to and the foundation of mental intentionality. They claim that there can be no mental intentionality without bodily orientation in a world: that mental intentionality is always underpinned by bodily intentionality.
What are the implications of this bodily intentionality? This notion contributes to our view of the body as an intelligent, planning, and goal-oriented entity. The body is not a passive material structure waiting for mental commands, but rather is actively engaged in meaningful and intelligent interaction with the environment. The body knows, so to speak, how to do many things, how to perform minute and complex actions, how to achieve goals from ice-skating to driving a car. Through its directedness, the body executes actions that are not merely random physical movements, but intentional, planned, goal-directed movements. Moreover, the movements only have meaning when understood as aimed at a goal. “For us the body is much more than an instrument or a means; it is our expression in the world, the visible form of our intentions” (Merleau-Ponty 1964: 5).
The body responds to the environment in an ongoing dialogue. Everything else depends on the body’s ability to perform, predict, and react appropriately to stimuli. Thus the body is the core of our existence and the basis for any interaction with the world. “The body is our general medium for having a world” (1962: 146). All our actions and goals have to be rethought in light of this new role accorded to the body or, more accurately, new recognition of the role that it was playing all along.

The Ill Body

Having seen how central the body is to any notion of agency or subjectivity and to achieving any goal, we can now ask what happens when the body loses some of its capacities and becomes unable to engage freely with its environment. In illness and, more pointedly, in some cases of chronic illness and disability, we find a need to rethink the body’s ability to engage with the world, its ability to provide movement, freedom, and creativity as it did before.
So how should we think about illness? If we go back to Merleau-Ponty’s view of the body as both object and subject, the ambiguity of the body, as he calls it, we can see an important dimension of bodily experience exposed in illness. This is the difference between the biological and the lived body. The biological body is the physical or material body – the body as object. This body can become diseased. The lived body is the first-person experience of the biological body. It is the body as lived by the person. This body experiences illness. Normally, in the smooth everyday experience of a healthy body, the two bodies are aligned, harmonious. There is accord between the objective state of the biological body and the subjective experience of it.
In other words, the healthy body is transparent, taken for granted. We do not stop to consider any of its functions and processes because as long as everything is going smoothly, these are part of the bodily background that enable more interesting things to take place. So while digestion, fluid balance, and muscular performance are going well, we do not experience them consciously. They silently and invisibly enable us to compose symphonies, have coffee with friends, and daydream while walking the dog.
It is only when something goes wrong with the body that we begin to notice it. Our attention is drawn to the malfunctioning body part, and, suddenly, it becomes the focus of our attention, rather than the invisible background for our activities. The harmony between the biological and the lived body is disrupted, and the difference between the two becomes noticeable.
We can also think about the body using the analogy of an instrument or a tool. Take a pen, for example. We normally use a pen to perform a task, say, to write a letter. While using the pen, we do not notice it. It is inconspicuous, a means to an end. Our attention is focused on the end – writing the letter – while the means are relegated to the background. But when the pen fails to write, the car refuses to start, the milk bottle is empty, they suddenly become the centre of attention. They cease to be an invisible background enabling some project and become stubborn saboteurs.
This inconspicuousness characterizes tools and even more so for our bodies. Whereas we can throw out the useless pen and grab another, our bodies stand in a very different relation to us. Our bodies cannot be replaced, thrown out, or even repaired as readily as we would like them to be. My head with a headache remains attached to me and becomes increasingly conspicuous, increasingly disabling. It is precisely because our bodies are not tools that their dysfunction is so intimately linked to our well-being. Whereas my malfunctioning car can be sold and a new one bought, my body is me. This is an essential feature of our embodied existence that is brought out by illness. Illness is an abrupt, violent way of revealing the intimately bodily nature of our being.
Another reason the difference between the biological and the lived body emerges in illness is that the lived body is in large part habitual. It is used to performing certain tasks at a certain speed, in a certain way. Think of the way you do something that you do routinely: shave, play tennis, chop vegetables, sew, play the piano. These actions can be performed expertly, efficiently, and smoothly because they have become habitual. Our bodies learned to perform them, and with each repetition, the habit is reinforced, incorporated further into our bodily repertoire. We may perform some actions with little or no attention. Again, the actions are harnessed to the goal of the activity: getting to work, cooking a meal, ironing a shirt. It is only when we watch a novice, say, a child learning to ride a bicycle, that we appreciate the difficulty of the activity and the level of expertise our bodies have acquired.
Our everyday activities rely on the interplay between the body as it is experienced now and the habitual body. The habitual body provides the framework, the expertise, while the body as it is experienced now provides instant feedback from the environment, different sensations, feelings of satisfaction, and so on. Our expert bodies are the product of many years of habituation and practice. The practice can be conscious and structured, as in taking dance lessons or driving instruction, or unstructured and spontaneous, as in children’s play.
This acquired expertise, the effortless ease with which we perform habitual tasks, relies on two things. One is the continuity of the experiencing subject. The same person who learned to play the piano as a child is now playing Mozart’s Fantasy in D Minor. Memory and continuity are essential for maintaining personal identity over time. The second is that the actual capacities of the biological body remain intact. These physical capacities underlie any attempt to rehearse or master new skills. A common example would be that of an adult attempting some childhood feat, such as a somersault or back dive that she perform...