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Paper to be presented at 5th Central and Eastern European Conference on Phenomenology “Corporeity and affectivity”, in celebration of Merleau-Ponty’s 100th birthday Prague September 28th - October 2nd, 2008 The relevance of Merleau-Ponty's philosophy for the understanding of health and health science methodology by Karin Dahlberg, professor and Martina Summer Meranius, doctoral student School of Health Sciences Växjö University, Sweden The lifeworld – a phenomenal field Merleau-Ponty took seriously upon the oft-repeated idea and Husserlian motto in phenomenological philosophy to go to the things themselves. For him, and for phenomenology, things are things of experience. The idea of going to the things themselves means to do full justice to the lived experience, e.g. the everyday experience (Husserl, 1970; Merleau-Ponty, 1995). This idea includes the aim to approach the world as it is experienced in all its variety, without avoiding the complexities. Husserl’s lifeworld theory came into full blooming by Merleau-Ponty and became a lifeworld phenomenology. He expresses the idea of lifeworld as our being to the world, and the lifeworld is a world of perception. Accordingly, for Merleau-Ponty, the awareness and understanding of the lifeworld is a necessary condition for knowledge. In his famous preface he says that the lifeworld precedes knowledge. Perception is not a science of the world, it is not even an act, a deliberate taking up of position; it is the background from which all acts stand out, and is presupposed by them. (1995, x) It is clear, that for Merleau-Ponty we can never escape the lifeworld, the complex, qualitative and lived reality that is there for us whatever we do. We live in and through a “phenomenal field”, a phrase that suggests how the world we investigate has two faces: we judge the world in relation to our experience of it, and at the same time the world or an object of the world is present, even if we are not aware of it at the moment. It is there whether or 1 not we experience it. And it is present, as lifeworld, already when researchers or other professionals start to think and to carry out their work. The lifeworld is thus pre-scientific, pre-theoretical and pre-reflective. This is of crucial importance for the health sciences. The notions of the phenomenal field and lifeworld add something vital to this scientific arena, which for so many years has been dominated by medicine. The apt for mathematics and statistical measurements has urged medicine to divide and categorise the living human existence into separate entities such as body and soul, outer and inner, physical treatments and psychological ones. All the complexity of human suffering is neatly organised in diagnoses, mostly accompanied by drug prescriptions. This in combination with the technological approach of medicine has clearly divided the people in health care in two groups: the experts who are the professionals and the patients who are the passive receivers of care. In the health science research that is based in phenomenological ontology, epistemology and methodology we can see that the briefly described medical understanding of human existence and its health care consequences are neither true nor good. Human existence is much more complex, not least when people are ill, than any diagnosis can cover. In our project we interviewed old patients who are labelled “multi-morbidity” by medicine. In our preliminary results we have found that it is not the many diagnoses or the many illnesses and their inherent order that is their problem. The core of their suffering is their struggle not to let illness take over and dominating their everyday life. This struggle seems to be more sever due to the doctors’ approach. Our interviewees explain how doctors give them advices that are related to each diagnosis, with the results that their patients get contradictory advices. One example is a woman with heart problems as well as rheumatism. The cardiologist told her to rest but the rheumatologist said she had to be active. As a result she felt abandoned, her health situation became unsure and unsafe, and she didn’t know how to deal with her life when she felt tired and stiff. This leads us over to the next section. The lived body A main contribution by Merleau-Ponty to the lifeworld theory was his notions of the body as lived. In phenomenology we don’t have to deny that we are of biology, but without understanding that the body is lived, health sciences fall short. The lifeworld is for Merleau-Ponty the lived world. It is the world we have access to through our bodies. As he expresses it (1995), “I am to the world as 2 body”. Referring back to the woman we just heard of one can say that a tired and stiff body likely gives access to a tired and stiff life. It would be difficult to overstate the centrality of the subjective and lived body in Merleau-Ponty’s understanding of the human world. The human body can never be understood merely as an object that can be moved around the room in the same way as furniture and other things1. The body as lived is distinguishable from other objects in that we can turn away from the latter whereas we can never turn away from the body2. Instead, the body is constantly perceived and constantly perceiving. It is through the body and the bodily experiences that the surrounding world becomes meaningful for us. It is the body that gives us a world in the first place, being “our means of communication with it” (1995, p. 92). We can never free ourselves from this embodiment, never come away from or stand outside ourselves as subjective bodies, but constantly let the body root us in the world. The bodily connection is generally both meaningful and coherent. In Merleau-Ponty’s words, our body is “a nexus of living meanings” (p. 151). In short, the “body is our anchorage” (p. 144) in the world. As long as we live we have a world and the reason for that is the fact that we are subjective bodies. The lived body provides one with a home in the world and in its existence it emphasizes the mutuality between humans and the world. This mutuality is very concrete in the embrace (Smith, 2006). One can embrace another person, and “one can embrace an idea, a religion, some change, literature, a new way of living, and so on, and one can in turn be embraced by events and spaces that, for some, carry sacred value” (p. 2). MerleauPonty would have said that when you embrace the world, the world embraces you back. Through the embrace, and the touch, there is a sense of connection, with the world, with everything that is. As lived bodies and through our lifeworlds we belong to the world of “flesh”3, which means an ontological connectedness and mutuality. All of us, 1 “If my arm is resting on the table I should never think of saying that it is beside the ash-tray in the way in which the ash-tray is beside the telephone” (Merleau-Ponty, 1995, p. 98). 2 “To say that it [the body] is always near me, always there for me, is to say that it is never really in front of me, that I can not array it before my eyes, that it remains marginal to all my perceptions, that it is with me” (Merleau-Ponty, 1995, p. 90). 3 [W]hen I reflect on the essence of subjectivity, I find it bound up with that of the body and that of the world, this is because my existence as subjectivity is merely one with my existence as a body and with the existence of the world, and because the subject that I am, when taken concretely, is 3 all our experiences, all my thoughts, your thoughts “and the thoughts of others are caught up in the fabric of one sole being”, Merleau-Ponty (1968, p 110) states. Because we belong to the same world, Merleau-Ponty seems to suggest that we are in one way or another connected with everything and everyone. Our very own behaviour, our personal actions and our individual ways of being are all a result of our own personal room in the world, which can be described as one’s own entry to a common and shared world. This being, the flesh of the world, which underlies and sustains the differences represented by individual beings, is as a background very much present in what is and what happens, but at the same time it is “silent” and “invisible”. These ontological insights cannot be neglected if we want to understand how it is to be old and ill in some ways. These people, as we all, want to embrace the world and be embraced back, but their illnesses, and not least the treatments, alienate them from others’ vibrating world of existence. To be given this bunch of diagnoses tells the world that one is different and does not belong. The modern health care adds weight to the burden. One characteristic meaning of suffering in this context is to find oneself being reduced to a body-object. One example from our research can illustrate this: A woman with chronic heart failure has been advised not to lift her arms above the head level. However, once coming home from grocery shopping she wants to put her articles into the kitchen cupboards and fridge, and she cannot wait until the home care personnel shows up, for one thing she never knows for sure what time they come. What she does is that she lifts and carries and stows her things in to the right places – but without saying anything. She plays a game with the unknowing carers, covering up her real existence with a show-up. This is the worst part of her being ill, she says, it is worse than being ill in the first place. This acting is called noncompliance by medicine. In fact, it is her way to master her existence. In particular, the cheating is her response to the health care approach, which makes a split between her body as object and body as subject. It is her response to a form of health care that tries to separate her out from a living existence. Health science methodology This project is part of the research carried out at the Centre for Lifeworld Research, the School of Health Sciences at Växjö University, in the south of Sweden. Our research and research education is epistemologically built upon inseparable from this body and this world. The ontological world and body which we find at the core of the subject are not the world or body as idea, but on the one hand the world itself contracted into a comprehensive grasp, and on the other the body itself as a knowing-body. (1995, p. 408) 4 continental philosophy, and especially the phenomenology by Husserl, Heidegger, Gadamer, and – most important – the phenomenology of Merleau-Ponty. In such research approach we have found the guiding methodology that we need to be enough open for the lifeworlds of patients in health care, their suffering and their well-being. In particular, we have found substance in “the philosophy of the flesh” by Merleau-Ponty. The epistemology of his philosophy gives us to understand that it is never either or, but always both - and. He has clearly shown how all lived meanings and nuances are intertwined, and if we are to separate anything from anything else, we have to relate the one to the other by way of figure and background. The whole is always a gestalt: a gestalt that is momentarily stable, but that shifts over time and with place. To openly meet and illuminate lifeworld phenomena and their meanings we try to use different methods. In the project with people with several illnesses we have practised interviews. Inspired by Merleau-Ponty we want to give room for a corporeal field. The reciprocity of intercorporeal communication, or “carnal intersubjectivity”, as Merleau-Ponty (1987), also calls it, is not: … by a mind to a mind, but by a being who has body and language to a being who has body and language, each drawing the other by invisible threads like those who hold the marionettes – making the other speak, think, and become what he is but never would have been by himself. (p. 19) When we are open to phenomena and their wealth of meanings we see their particularity, what makes them unique. Seeing the unique requires an ease with complexity and in order to understand the world we have to pay attention to the actual, lived reality, and especially its internal dialectic and many-sidedness, its dimensions and layers. However, the phenomenological interest in particularity does not exclude an interest in generality, which is also a phenomenological idea. Particularity and generality, uniqueness and sameness, is a natural paradox within being and of the lifeworld, and consequently also of lifeworld research. As humans we are at once both unique and irreducible, and similar to others with whom we share consensus about the lifeworld. Uniqueness is irretrievably coupled with sameness; humans are at once both much more alike than different and, singularly, us. We share sameness insofar as we all exist as humans having lifeworlds, being part of the same world, the same “flesh”, but we are unique through our choices about how to live that existence and see meanings of it (cf. Merleau-Ponty, 1968, 1995; Sartre, 1998). In phenomenological research, we prefer generality in our results descriptions in the form of essences, i.e. structures of meaning. “Phenomenology is the study of essences”, Merleau-Ponty (1995, vii) says, 5 again in his famous preface to Phenomenology of perception. Essences belong to the world that is “already there” (ibid.); they belong “already” to the lifeworld and the everyday manner of which we live our lives, researchers or not. He further argues that matter is “pregnant” with its form … (Merleau-Ponty 1964a, p. 12). Consequently, essences are not something that we as researchers explicitly add to the research. They are there already, in the intentional relationship between the phenomena and us. Merleau-Ponty also teaches us that all essences are open, infinite and expandable and they are never completely explored and described. Meaning emerges in relation to “events” of the lifeworld, and when the lifeworld changes, meaning changes as well. In conclusion, we want to argue that thanks to phenomenology in general and Merleau-Ponty in particular health sciences can be an important complement to the science of medicine. His philosophically well grounded and thoroughly worked through ontology serves as a spotlight on the human existence when it is stricken by ill health. Accordingly, the phenomenological epistemology of Merleau-Ponty gives us the foundation necessary to build a strong methodology with which we can develop health sciences research that is understood as valid. 6