The British Society for the Philosophy of Science

The Normal and Pathological: The Concept of a Scientific Medicine

Author(s): Mary Tiles
Source: The British Journal for the Philosophy of Science, Vol. 44, No. 4 (Dec., 1993), pp. 729-
742
Published by: Oxford University Press on behalf of The British Society for the Philosophy of
Science
Stable URL: http://www.jstor.org/stable/688041
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Brit. J. Phil. Sci. 44 (I993), 729-742 Printed in Great Britain

The Normal and Pathological:

The Conceptof a ScientificMedicine
MARY TILES

ABSTRACT
In this paperit is suggestedthatCanguilhem'sexaminationof the historyof the
distinctionbetween the normal and the pathologicalcontains materialof
relevanceto current debates about the nature of medicine,in particular
concerningthe status of quantitativeindicatorsas indicatorsof the need for
medicalintervention. Hisargumentsagainsttheequationofhealthwithnormality
are presented,togetherwith his own suggesteddefinitionof health and the
implicationsof thisdefinitionforphysiologyandmedicine.

The concept of norm is an original concept which, in physiology more than

elsesNhere,cannot be reduced to an objective concept determinable by scientific
methods. Strictly speaking then, there is no biological science of the normal.
There is a science of biological situations callednormal. That science is
physiology.
Canguilhem ([1978], p. 138)

Thisis the provocativeconclusionwhichCanguilhemreachedat the endof his

doctoralthesis (publishedin 1943). When he returnedto the same topic
twenty years later (1963-6) this conclusionwas not substantiallyaltered,
although it was nuanced by the introductionof considerationof the
importanceofthe socialenvironmentofhumanbeings,ofthe socialconditions
forthe emergenceof modernmedicine,and the introductionof the conceptof
'error'into pathology.These additionscan be understoodas a reactionto
Foucault'swork The Birth of the Clinic,which appearedin l963 in a series
editedby Canguilhem.Indeedthere are many respectsin which Foucault's
work complementsCanguilhem's.Foucaultexaminedthe historicalperiod
(lateeighteenthandearlynineteenthcenturies)immediatelypriorto Canguil-
hem's startingpoint. WhereasFoucaultwas concernedwith the periodin
which the epistemologicalfieldof medicineis reformedand restructuredin
such a way that the distinctionbetween the normal and the pathological
comes to be central in the constitutionof the objectof scientificmedicine,
Canguilhemwas concernedwith the natureof the disciplinewhose objectis
constitutedin thisway. Themovetowarda self-consciously scientificmedicine
 Tiles
Mary
73o
health is
hand in hand with a shift in the conceptof health in which
goes
identifiedwith normality.As Foucault
primarily explains:
century
Generallyspeakingit mightbe saidthat up to the end of the eighteenth by
to normality; it did not begin
medicinerelatedmuch more to health than it had
of the organism and go on to seek where
analyzinga 'regular'functioning
backintonormal
deviated,whatit was disturbedby, andhow it couldbebrought
suppleness and fluidity,
workingorder;it referred,rather,to qualitiesof vigour,
the task of medicine to restore. Tothis
whichwerelostin illnessandwhichit was in
an important place to regimen and diet,
extentmedicalpracticecouldaccord
rule of life and nutrition that the subject imposed on himself.
short,to a whole
the possibilityof
Thisprivilegedrelationbetweenmedicineand healthinvolved
century medicine, on the other hand,
being one's own physician.Nineteenth
accordance with normality than with health; it formedits
was regulatedmorein
conceptsandprescribed its interventionsin relationto a standard functioning
of
andpurely
andorganicstructure,andphysiologicalknowledge oncemarginal
doctor was to become established at the very
theoreticalknowledgefor the and
medical reflection. . . when one spoke of the life of groups
center of all think
life, one did not
societies,of the lifeof the race,oreven of the psychological
medicalpolarityof
firstof the internalstructureofthe organizedbeing,butof the
the normaland the pathological. (Foucault [1963], p. 3 5)
very new, be of
Butwhy shouldthese historicaldiscussions,neitherof them
the present climate of debateabout
anygeneralconcernorinterest?Becausein
more generally, it is
medicinein particular,and science and technology not in
of claims to scientific status,
necessaryto raisethe questionofthe nature can
make the issues explicit. There
orderto discreditthem, but in orderto
medicines,nor a
neitherbe a sensibleresponseto the claimsof alternative
sensibledebate about the merits and disadvantages of high technology
institutionalized medical practiceis
medicineif the scientificityof current, and
simplytakenforgrantedin a dogmatic assertion, where the technological
with the scientifically progessive. A
the quantitativearealignedautomatically critical
rational, response requires a more
reasoned,andindeeda scientifically
be, requiredof a
andmoreconcretelybasedunderstandingof what is, or could
in recent years a return to placingmore
scientificmedicine.Therehas been,
we need to enquire about the conceptof
emphasison 'healthyliving' but
one'sdoctorthat
healthinvolvedhere.Withwhat authoritycan one be toldby
to reduce one's blood pressure, ought to go on a
one oughtto takemedication a prima-
fat-free,salt-freediet,eat oat bran,or whatever?Thereis, moreover,
and formations
facie groundfor thinkingthat there are here relationships medicine
which are not well understood.The conception of a scientific in
of practice founded
immediatelybringswith it the conceptionof a body Yet it is
theory,theorywhich is itselfthe productof basicscientific research.
and technology has, until
this relationshipwhich, like that betweenscience
becauseit was
recently,receivedlittleattentionfromphilosophersof science,
 TheNormaland the Pathological:ScientificMedicine 73I

presumedto be straightforward. Tohave realizedthat it is not straightforward

is itself progress,but that does not mean that there is as yet any achieved
understanding.
The straightfowardpicture of the relationshipbetween basic scientific
knowledgeandthe practicebasedon it is thatthe basicsciencegivesobjective,
purely factual knowledgeof the general laws governinga specifickind of
phenomena.Practiceinvolves dealing with particularsituationsin which
thesekindsof phenomenaoccur.Thebasicgenerallaws can thenbe appliedto
the particularsituations(universalquantifierelimination)to providepredic-
tionsof what willhappenwhen givencombinationsof conditionsarerealized.
This gives rise to purelyfactualhypotheticalimperativesof the form'Ifyou
want to do X, then it can be doneby doingY or Z'.Hereit is assumedthat the
practicalgoalsare set independently; sciencehas nothingto say aboutwhich
goals should or should not be selected.In other words it is the functionof
science to establishthe facts, independentlyof all considerationof values.
Since courses of action are directedtoward ends dictatedby values, these
values must be suppliedby individualsor societies,and it follows that no
practicecan be whollyscientific-there can be no scienceof what oughtto be
done in relation to a given range of phenomena. How then could the
conceptionof a scientificmedicine,a practicewhose imperativesthemselves
have scientificstatus,ever arise?
However,a moment'shistoricalreflectionwill show that this is the wrong
question.The better questionwould be why haven't more questionsbeen
raised about the claims of medicineto scientificstatus, given the general
climateof divorcebetweenfactand value, theoryand practice?ForPlatoand
Aristotleit is quitenaturalto includemedicineas a sciencealongsideethics,
biology, and physics. In studying the good for man this must include his
physicalas well as his moralwell-being.But when teleologyis banishedfrom
science,the goodforman,whetherphysicalor moral,ceasesto be a legitimate
objectof scientificenquiry.Sciencecannot, or is not supposedto, consider
things as havingends,purposesor goals.It wouldseemthat health,physical
well-being, should go the way of virtue. That is has not is due to the
assumptionthat it is possibleto definephysicalhealth in purelyphysicalist,
physiologicaltermsvia the distinctionbetweenthe normalandthe pathologi-
cal (normalis healthy)withouta whiffof teleology,hencethe centralityof the
normal and the pathologicalin an examinationof the scientificstatus of
medicine.Canguilhemsays:
The ambition to make pathology, and consequently therapeutics, completely
scientific by making them derive from a previously established physiology would
make sense only if, first, the normal could be defined in a purely objective way, as
a fact, and second, all the diSerences between the normal state and the
pathological state could be expressed in quantitative terms, for only quantity can
take into account both homogeneity and variation. (Canguilhem [1978], p. 23)
732 Mary Tiles

The strategyrequiredis clearlyillustratedin Durkheim'sdiscussionof the

rules for distinguishingthe normalfrom the pathological.He takes it that
medicineis alreadyestablishedas a practicewhich is scientificin a way that
fewotherpracticesareandseeksto regainthe connectionbetweentheoryand
practiceat the level of socialand politicalaction.
Forsocieties,as for individuals,health is good and desirable;sickness,on the
otherhand,is badandmustbe avoided.Ifthereforewe findan objectivecriterion,
inherentin the fact themselves,to allow us to distinguishscientificallyhealth
fromsicknessin the variousordersof social phenomena,sciencewill be in a
positionto throw light on practicalmatterswhile remainingtrue to its own
method.(Durkheim[1895], p. 86)
Much of the credit for developing a methodology for experimental
physiologyand forthe visionof a medicinewhich is scientificin the modern
sense goes to ClaudeBernard.The basis for Bernard'sclaim that physiology
shouldbe genuinelyexperimentalwas his visionof a universaldeterminism.
Therearelaws governinglivingsystemswhichareidenticalin kindwith those
governingnon-livingsystems.Thesecan onlybe discoveredexperimentllyfor,
citingBacon,it is onlythroughexperimentthatwe can cometo a knowledgeof
those laws that increaseour masteryover nature.
The intellectualconquestof man consistsin diminishingindeterminismto the
extentthatwith the aidof experimentalmethodit wins groundfordeterminism.
Thisalonecan satisfyhis ambition,forit is by thismeansthathe extendsandwill
extendmoreand morehis powerover rlature.(Bernard[1865], p. 196)
Physiologymustthen be experimentalif it is to be the groundof technological
interventionin and mastery over the phenomenaof living organismsin
general and of human beings in particular.Moreover,this vision of an
experimentally basedmedicineis regardedas a finaldisplacementof all values
and all subjectivityfrommedicine.
. . . experimentalmedicineis not a new systemof medicine,but,on the contrary,
the negationof all systems.In effect,the advanceof experimentalmedicinewill
resultin the disappearancefromthat scienceof all individualviews, replacing
themby impersonalgeneraltheorieswhich will, as in othersciences,only be a
reasonedand regularco-cerdination of factsfurnishedby experience.(Bernard
[1865], p. 301)
It is this idea that both Foucaultand Canguilhemseek to undermine,the
ideathat medicineis scientificin the sensethat its object(bothin the senseof
goal and of objectof knowledge)is subjectto completelyfactual,objective,
determination.Both utilizethe history of medicineto demonstratethat its
objectiveis not a natural 'given'. Here I am focussing on Canguilhem's
argument'ssince these are designedto reflectdirectlyon to medicineas
currentlyconstitutedratherthan on the conditionsfor its emergence.The
interestofthe strategiesemployedbothbyFoucaultandCanguilhemliesin the
 TheNormaland the Pathological:ScientificMedicine 733
factthat theydo not seekto reinstatea rigidfact-valuedistinction.Theydo not
argue that medical practice,centered on health, cannot be scientifically
groundedbecauseof the value-ladennessof the conceptof health;i.e. they do
not arguethat the goal of medicalpracticeis set independentlyof the medical
sciencessuch as physiology,and could thus be alteredwithout affectingthe
content or the methodologyof those medical sciences. Rather, they are
concernedto revealthe ways in which thereare valuesintrinsicto and built
into the veryframeworkof the conceptionof medicalsciencesas linkedto the
possibilityof a scientificmedicine.ThusCanguilhem'sargumentsturn on an
insistenceon the specificityof the object(in the senseofobjectofknowledge)of
the life sciences, which rendersthese sciences distinctivein characterand
makes it impossiblewholly to assimilatethem, either methodologicallyor
epistemologically, to sciencessuch as physicsand chemistry.Thisis partof a
more generalstrategyto forcea reconceptualization of the scientificand to
move away from the positivistconceptionof science as wholly objective,
factual,purelydescriptive,etc. Thatmedicineis not scientificin the positivist
sense does not mean that it is discredited;it does mean that in so far as its
practiceshave been shapedby an imageof itselfas scientificin this sense it is
open to criticism,and it also means that its imperativescannot claim the
authorityof absolute,factualbacking;its claimsto authoritymustthemselves
be re-evaluated.
Canguilhem'sstated aim was to show the inadequacyof the principleof
pathologywhich assertsthat the morbidstate of a living being is a simple
quantitativevariation on the physiologicalphenomenawhich define the
normalstateof the corresponding function.An outlineof the issuehe wantsto
addressand the directionfromwhich he approachesis roughlyas follows.
Throughoutthe historyofthe variousspecifications ofthe conceptofdisease
thereruns a commonthread-disease is negativelyvalued;to be sickis to be
harmfulor undesirableor socially devaluedin some way. Positivevalues
attachto thingslikelife,longlife,the capacityforreproduction andforphysical
work, strength, resistance to fatigue, absence of pain, etc. From the
physiologicalpointof view what is desiredin healthis thus fairlyobviousand
this givesthe everydayconceptof physicaldiseasea relativelystablebasis.But
medicalscienceis not advancedby analysingthiseverydayconceptof disease.
Its task is to determinewhat are the underlyingvital phenomenawhich lead
men to call themselvessick,to determinetheirorigins,laws of evolutionand
the actionswhich modifythem.In specifyingthese phenomenathe everyday
value-ladenconceptsdisappear,but the vocabularyof disease is still used
because medical activity is essentiallylinked to patients and their value
judgementvia clinicalquestioningand therapeutics.A doctoris interestedin
diagnosisand cure,wherecuringis takento mean restoringa functionor an
organismto the normfromwhich it has deviated.Hederiveshis conceptionof
the normfromthreesources fromphysiology,as the scienceof normalman,
734 Mary Tiles
fromclinicalexperience,and fromthe representationof the norm which is
dominantin the societywithinwhichhe is working.Ofthesethree,physiology
is presumedto provide the ultimate court of scientific appeal. Modern
physiologyis presentedas a canonicalcollectionof functionalconstantsand
these are termednormalboth in so far as they designateaveragecharacter-
istics and because they enter into the normativeactivity of therapeutics.
Physiologicalconstantsarethus normalin botha descriptiveanda normative
sense. The question,as Canguilhemsees it, is whetherit is medicinewhich
convertsa purelydescriptivesense of norm derivedfromphysiologyinto a
biologicalideal and thus (as the straightforwardpositivistpicturerequires)
graftson this normativeelementby makingrestorationof normalfunctionits
goal.In thiscasemedicalvalueswouldbe superimposed on physiologyto yield
medicalpractice.Oris it that the normativeelementis alreadypresentin the
physiologicalconceptofthe normalso thatmedicinederivesfromphysiologya
conceptionof what should be its aim, as envisagedby Bernardand the
conceptionof a wholly scientificmedicine(medicalpractice)?In this case
physiologyis alreadydeliveringscientificallydeterminedmedical goals in
accordancewith the positivistideathat technologyshouldbe the application
of a science;physiologymust throw light on pathologyin orderto establish
and scientificallygroundtherapeutics;logicallywe can, on this view, only
progressfromexperimentalphysiologyto medicaltechnologyand practice.
Canguilhem'sargumentwillbe to the effectthatone cannothaveit bothways.
To the extent that physiologyconformsto the positivistidealof a science,it
cannot determinemedicalgoals and the debateabout what are appropriate
medicalgoals and appropriateprocedureswould have the status of ethical
disputes.To the extent that physiologydoes deliverguidelinesfor medical
practiceit does not conformto the positivistimage of sciencebut is able to
supply norms to medicalpracticeonly because medicalpracticehas itself
informedand directedthe developmentof physiologicalconceptions,so
leadingto the incorporationof a normativecomponentin the physiological
conceptionof the normal.
Slippageis possiblehere because of an ambiguityin the concept of the
normalbetweenthat which is usual and that which is as it ought to be. This
ambiguityextendsto physiologicallybasedmedicine,wherethe normalstate
designatesboththe habitualstateof the organsandtheirideal idealbecause
establishmentof the habitualstate is the ordinarytherapeuticaim. To make
his case Canguilhemneedsto arguethat therecan be no purelyscientific(in
the positivistsense) definitionof the normal which would bridgethe gap
betweentheoryandpracticewithoutrelyingon thisambiguity,i.e.a definition
of health as normalityis impossible.This requiresargumentboth against
definitionof the normal in terms of an ideal of physiologicalfunction
(attemptedby Bernard)and against definitionof the normal in statistical
terms.
 TheNormaland the Pathological:ScientificMedicine 735
The case against defining the normal in terms of ideal physiological
function,as suggestedby Bernard,can be illustratedby referenceto Bernard's
workon diabetes.In describingthis workCanguilhemshowshow physiologi-
cal understandingis gained, but from a perspectivewhich eliminatesthe
distinction between the normal and the pathologicalconceived as the
distinctionbetweenhealthand disease.Bernardshovvedthat the sugarfound
in an animal organismis producedby that organism,which impliesthat
blood sugar levels (glycemia)do not dependdirectlyon sugar intake. The
presenceof sugarin the urine(glycosuria)is then shown to be a consequence
of the rise of the bloodsugarlevel abovea certainquantitywhich servesas a
threshold.Urineis consideredas a productofrenalsecretion,andglycosuriaas
an excess of bloodsugar (glycemia)pouringover a threshold.The difference
responsibleforglycosuriais purelyquantitative;glucoseproductionandrenal
secretionarequalitativelythe same.In makingthis variationunderstandable
at the physiologicallevelit is explainedin termsofthe normal(law-goverened)
operationof physiologicalmechanisms.Butwhen glycosuriais regardedas a
major symptomof diabetes,the presenceof sugar in the urine makes it
qualitativelydiSerentfromnormalurine.
The problemwith the descentto purephysiologicalmechanismsis that it
leavesthe qualitativedifferencebetweennormaland pathologicalat the level
of illusory appearance.What Canguilhempoints out is that Bernard's
conceptionof a scientificmedicinegroundedin physiologycan seempossible
becausetherearealwaystwo waysof lookingat a physiologicalstate.(i)It can
be viewedas a simplesummaryof quantities,withoutconsideringquestionsof
biologicalvalue;the bodycan be consideredsimplyas a complexphysicaland
chemicalmechanism.Fromthis point of view there is a rsaturalcontinuity
betweenphysiologyandphysicsandchemistry.Butthe physicalandchemical
state of a mechanism cannot be called healthy, normal, diseased, or
pathological.'Normalandpathologicalhaveno meaningon a scalewherethe
biological object is reduced to colloidal equilibriaand ionized solutions'
(Canguilhem[1978], p. 59). (ii) Thephysiologicalstatecan be viewedas one
which has a qualitativevalueforthe livingorganism,in whichcase therewill
not be a continuitybetweennormaland pathologicalstates.
Because physiology stands at the cross-roadsof the laborcltoryand the clinic, two
points of view about biological phenomena are adopted there, but this does not
mean that they can be interchanged. The substitution of quantitative progres-
sion for qualitative contrast in no way annuls this opposition. It always remains
at the back of the mind of those who have chosen to adopt the theoretical and
metrical point of view. (Canguilhem [1978], p. 58)
To reduce the differencebetween a healthy man and a diabetic to a quantitative
difference of the amount of glucose within the body; to delegate the task of
distinguishing one who is diabetic from one who is not to a renal threshold
736 Mary Tiles
conceived simply as a quantitative diSerence of level, means obeying the spirit of
the physical sciences which, in buttressing phenomena with laws can explain
them only in terms of their reduction of a common measure. (ibid.,p. 58)
If physiologywere to living bodieswhat astronomy,dynamics,hydraulics,
hydrostatics,etc. are to inert ones then there would be no space left for
pathology.Thereis no pathologyof inertbodies.
Is a personto be treatedas sicksimplybecausehis bloodpressuredeviates
froma given norm,becausehis bloodsugarlevelsare abnormal,becausehis
cholesterollevelis too high, etc.?Is failureto conformto the normgroundfor
medicalintervention?Thesebecomepressingquestionswhen such tests are
used by insurancecompaniesfor the settIngof rates for life and medical
insurance.Howarephysiologicalnormsto be determined? Bernard'sviewwas
thatthe physiologically normalis to be definedin termsof an idealtyperealized
in preciseexperimentalconditionsand was throroughlyopposedto use of
statisticalnotions.Butthe notionof an idealtypeas the typenot merelyfrom
which explanationsstartbut at which tnedicalpracticeshouldaim already
importsvalues.Whatguaranteesthat a modeof functioning,deviationsfrom
which can be explainedby referenceto interferingfactors(the idealfunction
from an explanatorypoint of view), will coincidewith the ideal at which
medicalpracticeshouldaim?
The more promisingroute for one concernedto obtain a scientifically
respectabledefinitionof the normalis to incorporatea use of statisticsinto the
understandingof mechanismsandfunctionssuppliedby physiology.Canguil-
hem does not set his face against all use of statistical methods. He
acknowledgesthat in biologyit is necessary,in orderto representa species,to
givenormswhichareempiricallydeterminedaverages.Butthisdetermination
of the normal(typical)membersof a speciesby no meansentailsthat every
memberof the specieswhich deviatesfromthose normsis abnormal.All real
individualswill divergein somedegreeor otherfromthesenorms;it is in this
that theirindividualityconsistsand on which the possibilityof evolutionby
naturalselectiondepends.
This,however,does not rule out the possibilityof a reverseconnection-
that averagesmay be viewedas the expressionof norms.The human typ
the averageman might be determinedas being such that those who most
closelyresemblehim are most commonwherasthose who divergemost are
rare.Theproblemwith this suppositionis that the normsexpressedin human
averagesmaynotbe purelybiologicalnorms,butmaybe a reflectionofwaysof
life,themselvesan expressionof human values.
Ifit is true that the human body is in one sense a product of social activity, it is not
absurd to assume that the constancy of certain traits, revealed by an average,
depends on the conscious or unconscious fidelity to certain norms of life.
Consequently, in the human species, statistical frequency expresses not only
 TheNormaland the Pathological:ScientificMedicine 737
vital, but also social normativity. A human trait would not be normal because
frequent, but frequent because normal, that is, normative in one given kind of
life, taking these words 'kindof life' in the sense given to them by human
geographers. (Canguilhem [1978], p. 92)
Forexample,averagelife span, or post-natalmortalityfor infantsup to five
yearsdependson, amongstotherthings,the techniquesof collectivehygiene,
provisionof medicalfacilities,etc. which in turn reflectthe value attachedto
life by a given society.In this case the averagelife span is not a biologically
determinednorm.Theaverageexpressessocialnorms.Thisopensupthe space
of comparativeanatomyand physiologyalongsideconsiderationof regional
variationsin relationto environmental,social, and life-styledifferences.For
example, a study of Brazzavillenatives revealed 66 per cent of them as
hypoglycemic,with 39 percent rangingfrom0 9 g to 0 75 g and 2 7 percent
below0 75 g. Thesearelevelswhichwouldbe consideredgrave,if not fatal,in
Europeans,yet arewithstoodby Africanblackswithoutapparentdisturbance
and withoutconvulsionsor coma.The causesforthe hypoglycemiacouldbe
found in their conditionsof life, chronic undernourishment,chronic and
polymorphous intestinalparasitismandmalaria.Thetoleranceofit couldthen
be seen as an adaptionto these living conditions.
It followsfromthe viewsjust outlinedthat a statisticallyobtainedaverage
cannotprovidethe doctorwitha criterionofwhetherthe individualbeforehim
is or is not in a normalor healthystate. 'Wecannot startfromit in orderto
dischargeourmedicaldutytowardthe individual.'Iftraditionis to bebelieved,
Napoleonhad a restingpulserateof 40 when in goodhealth,yet the average
for the healthy member of this species is around 70. The view which
Canguilhemhas been urgingis that the normalis neitheran averagenor the
reflectionof a law of normalfunctioning,but is a norm which is capableof
beingtransformed in the specificcontextofan individualmemberofthe species
andof his relationto the particularenvironmentin whichhe lives.Thismeans
that at the level of quantitativegeneralizationsthe boundarybetween the
normalandthe pathologicalwill necessarilybe imprecise,even thoughit will
be quiteprecisefor each individual.
ThusCanguilhemconcludesthat the conceptsofnormalandaverageareto
be regardedas distinctconcepts.Thisis the negativeclaim.Thepositivetheses
concerninghealth, physiology,and medicineare foundedin Canguilhem's
view that values enter into the very constitutionof the domain of the life
sciences, not as elementswhich are arbitrarilyor subjectivelyimposedon
them, but as inherentin the objectof study.
It is life itself and not medical judgement which makes the biological normal a
concept of value and not a concept of statistical reality. For the physician, life is
not an object, but rather a polarizedactivity, whose spontaneous effortof defense
and struggle against all that is of negative value is extended by medicine by
738 Mary Tiles
bringing to bear the relative but indispensablelight of human science.
(Canguilhem[1978], p. 73)
The basic fact on which Canguilhem insists is that there is no biological
indiSerence. It is the framework of a biology of natural selection itself which
introduces this valuation along with notions of adaptive value, selective
advantage, and so on. The whole basis of the theory of natural selection is that
the diSerences resulting from random variation are not all of equal survival
value. Here it is the polarity of life and death which is the source of the value.
This dynamic polarity of living beings finds expression in normative activity.
There are healthy biological norms and pathological ones and they are not the
same. The definition of health must thus be one which (a) makes sense at the
level of the individual and (b) is in full accord with the biological conception of
man as a living being. Health is that which confers survival value, i.e.
adaptability.It is also the feeling of being able to establish vital norms, of being
able to cope with challenges presented. It is the ideal from which the image of
the athlete derives its seductive power she is one who can transcend the
physiological limitation incorporated into the characterization of women,
establishing and living by a new set of physiological norms. She is thus seen as
an embodiment of biological normativity. (In this image the reality, the price
paid for athletic specialization, is absent.)
Healthis a marginoftoleranceofthe inconstanciesofthe environment. . . What
characterizeshealthis the possibilityof transcendingthe norm,which defines
the momentarynormal,the possibilityof toleratinginfractionsof the habitual
normand institutingnew normsin new situations.
Tobe in goodhealthmeansbeingableto fallsickandrecover,it is a biological
luxury.(Canguilhem[1978], pp. 115-16)
Disease is then characterized as a reduction in the margin of tolerance for
the inconstancies of the environment. Here it should be emphasized that the
environment includes the totality of conditions which may affect an organ-
ism's functions and in the case of human beings this includes the social
environment. The danger of diseases such as measles lies not in the threat
which they immediately pose to the healthy person, but in their potential for
reducing the person's abillty to face other diseases the concern over measles
is with the possibility of pneumonia and other complications. Similarly
diabetes is not so serious if it is just glycosuria-but coma and gangrene are
another matter. Hemophilia is not in itself life threatening, so long as
traumatism does not occur but in what range of conditions can that be
assured?
What, now, are the implications of this definition of health for physiology?
Canguilhem has clearly rejected Bernard's definition of physiology as the
science of normal functioning (i) because he has rejectedthe equation of health
with normality, (ii) because he has rejected the idea that there can be any
 TheNormaland the Pathological:ScientificMedicine 739

ontologicalgroundingforthe notionof normalfunctioningat the level of the

biological type the level at which physiology, as a science dealing in
generalization,wouldhave to work,(iii)becausehe rejectsthe equationof the
pathologicalwith the abnormal.On his account of disease it involves the
institutionofnew functionalnormswhichareprecariousin relationto change
in environmentalconditions. Once again the fundamentalpoint is that
physiologymust be seen as a biologicalscience, a science which has living
beingsas its objectof study.
Thelawsofphysicsandchemistrydonot varyaccordingto healthordisease.But
betweenits
to failto admitthat froma biologicalpointof view, lifediSerentiates
states means condemningoneselfto be even unable to distinguishfood from
excrement.Certainlya livingbeings excrementcan be foodfor anotherliving
beingbut not for him. Whatdistinguishesfoodfromexcrementis no physico-
chemical reality but a biological value. Likewise,what distinguishesthe
physiologicalfrom the pathologicalis not a physico-chemicalreality but a
biologicalvalue. (Canguilhem[19 78], p. 130)

Of what, then, is physiologythe science?The answer suggestedis that

physiologyis the science of stabilizedmodes of life, where modes of life are
dividedinto two fundamentalkinds:

(1) those whose stabilitywill not preventthem frombeing alteredand re-

established the normal(normative)mode of life (normallyfunctioning
immunesystem immunity);
(2) those whose stability is tenuously clung to because disruption is
threatening the pathological(non-normative)modeof life,even though
the stabilityexpressesa kind of normalityso long as the being is alive
(pathologicallyfunctioningimmunesystem allergy).

It is not the jobof physiologyto lookforan objectivedefinitionof the normal,

but ratherto recognizethe normativecharacterof life.Theroleof physiology
wouldthen be to determineexactlythe contentof the normsto which lifehas
succeededin fixingitselfwithoutprejudicingthe possibilityor impossibilityof
eventuallycorrectingthesenorms.In so faras physiologyworksto determine
the constantsandinvariantswhichdefinethe phenomenaoflifeanddoesso by
scientificmethods,it is a sciencein everysense.In so faras it looksforthe vital
significanceof theseconstants,it goes beyondwhat is undertakenin sciences
such as physicsand chemistry.Forto take this step involvesconsideringlife
not as timelessand unchangingbut as constitutedby a polarizedmovement.
The bio-chemistand the bio-physiciststudy matterfroma differentpoint of
view than the chemistandthe physicist.Moreoverthe biologicalpointof view
adoptedby the physiologistis the pointofview of a livingbeing.Thecategories
of health and diseaseare introducedinto human consciousnessbecausethey
 Mary Tiles
74o
arelivingbeings;thisconsciousnessis an expressionof
theirexperienceoftheir
own biologicalpolarity.

The fact is that the physiologist's scientific

activity, however separate and
autonomous he may conceive it to be in his laboratory,
maintains a more or less
close, but unquestionable relationship with medical
activity . . . The categories of
health and disease are biologically technical and
subjective, not biologically
scientificand objective.Livingbeings preferhealth to
disease . . . The physiologist
is often a physician, always a living man, and
this is why the physiologist
includes in his basic concepts the fact that if the living
being's functions assume
modes all equally explicable by the scientist, they are
not for this reaon the same
for the living being himself. (Canguilhem [1978],
p. 132)

This bringsus to the relationbetweenphysiologyand

thathumanbeingsareconsciousof andseekto medicine.The fact
understandandcuretheirown
diseasesis seen as introducingan epistemological
andconceptualstructurefor
medicine which renders it distinct from sciences such
as physics and
chemistry,andeven otherbranchesof biology,forherethe
patient,or man as
potentialpatient,is bothsubjectandobjectof study.In this
case to allowthat
thenotionofdiseasemustultimatelybe tiedbackto the
valuejudgmentsofthe
sickman is not to introducea whollyillegitimate
subjectivity,forit is the sick
personwho is alsothe objectofknowledgeso thathis values
areinternalto the
objectof studyand so formpartof the objectdomain.
We think that medicine exists as the art of life
because the living human being
himself calls certain dreaded states or behaviors
pathological (hence requiring
avoidance or correction) . . . We think that in doing this the
living human being,
in a more or less lucid way, extends a
spontaneous effort, peculiar to life, to
struggle against that which obstructs its preservation and
development taken as
norms... the fact that a living man reacts to a lesion,
infection, functional
anarchy by means of disease, expresses the
fundamental fact that life is not
indiSerent to the conditions in which it is possible, that
life is a polarity and
thereby even an unconscious position of value; in short,
life is in fact a normative
activity. (Canguilhem [1978], p. 70)

In
otherwords,the expressionofdiseaseby a patientandits
negativevaluation
havesimultaneouslya subjectiveand an objective
status; the negative
valuation is not introducedonly in the patient'sverbalizationor
in his or the
doctor'sconceptualization of his statebut is presentin the stateviewedas the
state
of a livingbeingwhichis beingexpressedthroughhis
not behavior.Thisdoes
mean that the patienthas an objectivelycorrector
privilegedview of the
natureof his diseaseor even that humanconceptualization
are
vital norms.It is simplyviewingverbalizationsand determineswhat
part
of behaviorexpressiveof andpromptedby the disruption conceptualizations as
of vitalnorms.It
does
mean,however,thatthe businessofthe definitionofdisease
shouldnot be
 TheNormaland the Pathological:ScientificMedicine 74I

handedoverto anatomyandphysiology,rather,clinicalpractice,medicaland
surgical practice should have a continuing input into physiology and
pathology.Medicalpracticecannotbe groundedin an independentlyderived
bodyof basicscience.The conflictbetweenphysiologicallyand anatomically
baseddefinitionsofdiseaseandthosederivedfromthe experienceofthe patient
is itselfto be explainedby referenceto clinicalpractice.Thedoctormaybe able
to see a patientin someonewho doesnot feelhimselfto be one on the basisof
accumulatedexperiencederivedfromthose who have in the past presented
themselvesas patientsand the resultsof diagnostictechniquesperformedon
them.(An illustrationof the way in which clinicalandbasicresearchinteract
in the productionof physiologicalknowledgeis providedin Star [1986].)
Tosummarize:the healthystatecannotbe equatedwith the normalstate.A
personis healthyin so far as she is normativerelativeto fluctuationsin her
environment.Cureis the regainingof stabilizedphysicalnormsandis moreor
less effectivedependingon the robustnessor fragilityof the stabilization.But
no cure returnsthe systemto biologicalinnocence;curesalwaysinvolvethe
institutionof new normsof life,sometimessuperiorto the old ones.
Thisemphasison healthas opposedto normalityis of interestin the context
of morerecentdebatesconcerningthe characterof medicine,wherea positive
conceptof healthhas once againcome to be pushedinto the foreground.The
problemis that it has re-emergedin two very disparateforms:as an ill-
articulatedand highly subjectiveconcept,ill adaptedfor dialoguewith, let
aloneforincorporationinto the frameworkof, a medicinewhich sees itselfas
scientific;the other presentingitself as scientific,coming with quantitative
tests and physiologicalexplanationsderivedfrom statisticaldefinitionsof
normality.Wheremedicalcare is financedby privateinsurance,preventive
medicineis aimedat gettingthe majorityof the populationto conformto the
normsof those who have in the pastbeen statisticallygood risksformedical
insurancecompanies.
Canguilhem,on the otherhand,presentsa rigorouslyarticulatedconceptof
health,one which is groundedbackinto the generalframeworkof biological
science and which incorporatesthe gains which have been derivedfrom
advancesin our understandingof thebinternalstructures,mechanismsand
functions of living organisms.There is doubtlessmuch here that can be
criticizedbut,it seemsto me, it doesat leastprovidea startingpointforserious
discussiUon as welI as a model for what is requiredof a critiqueof scientific
medicinemountedwith the aim of reconnectingthe psychological,subjective
awarenessof disease with its medicalunderstanding,and of resistingthe
downgradingof clinical judgment of individualsin favor of quantitative,
technicallysophisticatedtests processedin largebatches.
Departmentof Philosophy
Universityof Hawaii at Manoa
742 Mary Tiles

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