Medicine, Health Care and Philosophy 2: 129140, 1999. 1999 Kluwer Academic Publishers. Printed in the Netherlands.

The art of perception: From the life world to the medical gaze and back again1
Christian Hick
Department of Medical History and Medical Ethics, Universitt zu Kln, Joseph-Stelzmann-Strae 9 / Gebude 29, D-50931 Kln, Germany (E-mail: Christian.Hick@uni-koeln.de)

Abstract. Perceptions are often merely regarded as the basic elements of knowledge. They have, however, a complex structure of their own and are far from being elementary. My paper will analyze two basic patterns of perception and some of the resulting medical implications. Most basically, all object perception is characterized by a mixture of knowledge and ignorance (Husserl). Perception essentially perceives with inner and outer horizons, brought about by the kinesthetic activity of the perceiving subject (Sartre). This rst layer of perceptual reality, the world of open perceptions, is the inescapable background for every rationality, every value, every existence (Merleau-Ponty). On an epistemological level a characteristic change of perceptual patterns in medicine was introduced by pathological anatomy (Foucault). The reference of medical perception to the dead body created the new possibility of absolute perception, allowing for more precise medical interventions, but at the same time coming into conict with the open structures of ordinary, non-scientic perception patterns in everyday life. On the basis of these distinctions, an analysis of the different perceptual patterns in medicine becomes possible. Such an analysis would be the task of a sub-eld in medical philosophy that could be called medical aesthetics having as its goal an art of perception understood as a technique of adequately applying different perceptual patterns in medical practice. Key words: life world, medical aesthetics, perception, phenomenology, theory of medicine

Ce nest pas cela, cela ne peut pas tre uniquement que cela E. Minkowski (1966)

Introduction: Perceptual differences I have not realized that the reality of my patient and my reality were not identical (Geisler, 1987, p. 9). The German internist Linus Geisler opens his book on the encounter of a patient and his doctor with this statement. At a rst glance, this introductory remark seems to be clear, and might even be regarded as a rather commonplace psychological truth. Upon further analysis, however, if one tries to understand what is really expressed in this phrase, things become less clear. How is it conceivable that two human beings do not share the same reality? In what sense is their reality, the world they live in, different? And if this is the case, how could these different realities be brought together?2

I think it would be a general consensus that there is no such thing as two separate worlds or realities in a strict physical sense. Nevertheless, Geislers statement seems to make sense and corresponds to a very common experience, not only in medical practice. By speaking of two or more different worlds or realities, one really means that there are different perceptions of this same world we live in. These different perceptions, however, sometimes seem to differ so much that there is not much common ground left. Quite obviously, all technical procedures, such as endoscopy or radiology, are perceived in a completely different way by the patient and by the physician who performs them. So an analysis of the structure of perception in medical practice could be helpful. I would like to call this eld of investigation medical aesthetics, aesthetics being understood in its etymological sense (asthesis

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= perception). This investigation should enable us to understand more fully how such a separation into different perceptual worlds is brought about and how this separation could be dealt with in medical practice. I will start my analysis at the most basic level with an introduction into the phenomenological research on the structure of ordinary object-perception given by Husserl in his Analysen zur passiven Synthesis. This phenomenological description of the characteristics of the perceived object can be complemented with a description of the perceiving subject laid out by Sartre in his Being and Nothingness (1943). After these rst insights into the strange and ambiguous world of perception, it will be possible to investigate the place of perception in the construction of our world, especially in relation to seemingly more objective scientic procedures. We will follow the arguments of MerleauPonty, who sees perceptual structures at the basis of every human activity. Perception at an epistemological level, as manifested in changes of the clinical view, will be considered along the lines of Foucaults investigation of the Birth of the Clinic. The aim of this study is to give some understanding of the ways in which perceptions structure reality in the interpersonal and the epistemological eld and to indicate where in medicine a sharpened attention to different perceptual patterns could be clinically useful.

in medical practice, that different perceptions create different worlds. (a) Perceived objects: The passive synthesis of perception Some of the nest dissections of basic levels of perception, which are paramount to all further discussions of perceptual experiences, are to be found in Husserls lectures of winter-semester 1925/1926, given under the somewhat deceiving title Grundprobleme der Logik and edited as Analysen zur passiven Synthesis (1966). The opening remark of the introduction of these analyses already indicates what will remain one of the main results of his investigations: Exterior perception is a constant pretension to perform something that, by its very nature, it cannot perform. (Husserl, 1966, p. 3).3 This sets up the ambiguous framework of perceptual operations. Considering our perceptions of objects in space, we realize that every object is given to our visual perception only by one of its sides. This spatial perspective is not an inborn aw, a weakness of human nature; it is the condition of possibility for perception itself. We may have a perception as clear and distinct as possible, for example, a perception of a table, but we will never perceive this table completely or adequately: it always will be presenting itself from one side, from a partial perspective. All spatial objects present themselves in this way, in perceptual shades (Abschattungen der Wahrnehmung), as Husserl calls it. It is impossible for exterior perception to give any perceived object in its totality, with all its perceptual shades at once (Husserl, 1966, p. 3). Every real-world perception is consciousness of one side that is given and, at the same time, consciousness of other sides that are missing (Husserl, 1966, p. 4). Perception is [. . . ] a mixture of real representation [. . . ] and empty indexing, referring to possible new perceptions [. . . ] By these references it calls out to us: There is more to see here, turn me around to all sides, run through me with your view, come near, open me up, divide me (Husserl, 1966, p. 5). All our perceptual experience has this strange double nature: surrounding a nucleus of real representation (the visible side of the table) there is an innite halo of emptiness, of invisibility. This indeterminate emptiness, however, is not nothing. It is an emptiness, that demands to be lled up, to be determined. Being a determinable indeterminacy (bestimmbare Unbestimmtheit), it asks for further perceptual efforts. The real, determined core in every perception is surrounded by these determinable empty horizons at its

Basic structures of perception Classical conceptions dene perception as the result of central processing of lower sensual data. Sensory cells deliver input to higher neuronal structures, which in turn process these data into our perceptual experience: we internally process information coming from the outside. We own the perceived object, because it is, in its perceptual form, nothing but the result of our central processing. Implicitly, this approach tries to suggest that in our perception the outer object can, in principle, be given to us in an adequate way. While this psycho-physiological account certainly is one possible reading of the perceptual process, it is also a rather unilateral reading. The psycho-physiological theory of perception is not set up to explain the inner structures of perception itself. It only investigates the links from data to perceptions, presupposing an anterior separation between these two regions. What is more interesting though since the practical physician is most of the time a detective rather than a scientist is the reality of perception itself. The perceptual world, being the world we live in, merits an investigation in its own right, which has to start at the very basis with the structures of object-perception. This might permit a better understanding of the problem, so prominent

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exterior. Every perception is constituted by this strange alchemical mixture of two contrary elements. However, even what is perceived in all the splendor of direct core-perception (i.e., the top of this table at which I am looking directly), is not given to me in its totality. Even here, there is an inaudible call: Come closer and closer, look at me then, by changing your position, the position of your eyes etc., xing me, I will still give you new sights, ever new partial colorations etc., structures of the wood, unseen a while ago, seen before only in an indeterminate, general way (Husserl, 1966, p. 7). Even what we believe we perceive as real and as given in all its presence is, at the same time, the frame of new and deeper perceptions, of new determinations. Not only the external surroundings of a perception can be characterized as empty horizons: outer horizons. Even within the perceptual-core, inside the perceived top of this table at which I keep staring, there are perceptual horizons opening up: the inner horizons of perception. This inexhaustibility of perception has important consequences for scientic as well as everyday knowledge: there can never be entirely adequate knowledge of real world objects, not even by an innity of different perceptions, because perception itself is characterized not merely by its core content, but also by its innite horizons. At this point we can say that there is no such thing as a simple perception of an object by which the subject seizes, in a simple act, that which presents itself as a well-conned object. Yet such a simplied understanding of perception is, in positivistic interpretations, at the basis of science. Presumably, scientic undertakings are theoretical constructions based on observational facts. Husserl, however, reminds us of the complicated open structure of perception which we tend to forget in our natural predilection for clear-cut, well-conned scientic concepts: Every perception comes implicitly with a whole system of perceptions, every representation in it with a whole system of representations (Husserl, 1966, p. 11). These perceptual systems that form the smallest unit of perception are characterized by the double indeterminacy of their inner and outer horizons. No perceptual experience gives us an object in its rich entirety. Every perception is externally surrounded and internally undetermined by empty horizons indicating the possibility of a more adequate perception. Every representation comes with a plus ultra in its empty horizon (Husserl, 1966, p. 11).

This is, however, not the full story. As always, the full story takes the form of a paradox. Husserl started his investigation by stating that the perception of the outer world is a constant pretension to perform something that by its very nature it cannot perform. Perception is not only incomplete and open on all sides; it is also and at the same time pretending, and rightly pretending, to give us the object itself, the real and entire object (den leibhaftigen Gegenstand). In a peculiar way, every perception is a constant mixture of knowledge and ignorance, referring to possible new perceptions, that would transform this ignorance into knowledge (Husserl, 1966, p. 11). This perceptual mixture of the unknown and the known is the way, and the only way, in which objects are given to us. The perceptual movement, consisting in the kinesthetic union of movement and perception, is the continuous lling up of expecting intentions, referring to empty horizons. This perceptual movement creates the sense of any perceived object. This sense does not precede our perception of the object as a God-given or Platonic idea would; nor is the sense constructed in a purely intellectual way by a synthetic action of reason (Kant).4 This sense of the object, that which makes a table a table, is constituted by perception itself. It is simply the progress of perceptual knowledge (Kenntnisnahme) that occurs when we actually perceive the object. In other words, this sense has an evolutionary character. Sense is not given or cognitively constructed but progressively experienced and thus ever changing. However, given the ambiguity of perception pretending to give what it cannot give (the leibhaftige object which is itself always out of reach) we assimilate this progressively perceived sense of an object (its reality), with the object itself as perceived from a hypothetical absolute vantage point (its verity). This inborn tendency of perception does not feel at ease in an open world with internal and external horizons. It struggles hard to close these horizons by asserting: What I perceive now is the object itself in its entirety, the leibhaftige Gegenstand. It is important to note that this perceptual request for closed-up, well-dened objects is not an illegitimate tendency which should and can be eliminated. It is a necessary side of perception, the other side of which is characterized by the openness of its internal and external horizons (Husserl, 1966, p. 13). Even God could not overcome this ambiguity of perception when perceiving real world objects in space and time. All spatial objects can essentially be given only in this inadequate, mixed mode of knowledge and ignorance (Husserl, 1966, p. 19). There always remain spots of emptiness in perception crying out for fulllment (Husserl, 1966, p. 21).

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These outlines of some basic structures of perception have one very important consequence: There are no such things as universal objects of perception, given conclusively and in the same way to all of us. Rather, the essences of objects, the reality of our world in time and space are outlined by the direction of our perceptual interests. These perceptual interests determine our perceptual movements. The resulting object reached by this interest-guided kinesthesia is always a relative object, deemed to be sufcient in particular circumstances. [The practical interest] designs a relative self. What is practically sufcient is considered to be the self (Husserl, 1966, p. 23). A house, says Husserl, can be given in an optimal way, as the house itself, after careful exploration, for both the buyer and the seller. But nevertheless, this house itself, as perceived in light of the practical interests of buying or selling, is not the house itself, as a physicist or a chemist might see it (Husserl, 1966, p. 24). The reality of a perceived object is determined by the interests guiding the perceptual movements, that give us a particular object. (b) The perceiving subject: The movement of perception In his analyses on passive synthesis, Husserl describes the constitution of perception from the vantage point of the perceived objects. If we look at the other side of this perceptual process, we will nd the perceiving subject at the origin of the ambiguity that is characteristic of the constitution of perceived objects. Perhaps one of the most down-to-earth descriptions of perceptual activity from the point of view of the perceiving subject can be found in an example from Jean-Paul Sartres 1943 book Being and Nothingness (Ltre et le nant). Sartre embarks on discovering the source from which the halo of nothingness, the empty horizons of perception, come into our perceptual world. True to the good professional standards of French existentialist writings, the animated halo of nothingness pops up in a Paris cafe. Imagine Les deux Magots, Boulevard St. Germain, on an lazy summer afternoon: I have rendezvous with Pierre at four oclock. I arrive half an hour late. Pierre is always on time; would he have been waiting for me? I look into the room, at the clients and I say: Hes not there (Sartre, 1943, p. 43).5 This negative statement is not the result of an abstract judgment. It stems from the perceptual experience I have of Pierre not being there. But how can I perceive

something that is not there? This is what Sartre tries to explain. Language already indicates that this negative perception is indeed a perceptual phenomenon and not an intellectual judgment: I immediately saw that he was not there (Sartre, 1943, p. 44). In this perception of an absence there is, as in every perception, the constitution of a foreground form emerging from a background plane, a core perception with its halo of internal and external horizons as Husserl had indicated. The movement of perception, guided by my perceptual interests, orchestrates these two very mobile elements of foreground and background: All depends on the direction of my attention. When I enter this caf to search for Pierre, a synthetic organization is made of all the objects in the caf, forming the background on which Pierre is given as having to appear. This organization of the caf into a background is a rst nantisation (Sartre, 1943, p. 44). The analyses of Husserl, which describe perception from the point of view of the perceived object, are complemented by the introduction of the perceiving subject. The open horizons of perception are constituted by a perceiving subject. The action of this subject is perceptual, not intellectual negation (nantisation). The subject actively organizes its perceptual eld by suppressing background information and by accentuating a foreground form, that in this case happens to be the absence of someone. This nantisation is given to my intuition, I am witness to the successive fading of all the objects I look at, in particular of the faces. They retain me for an instant (if it was Pierre?), and then they quickly decompose, precisely because they are not the face of Pierre (Sartre, 1943, p. 44). Thus it makes perfect sense to speak of the (perceptual) presence of what is (sensually) absent. Pierre as an absent person has effects on my actual perception of the caf in a much deeper way than if I would only think of him as not being there. His not-being-there structures the intuitive, pre-conscious, non-thetical operation of my perception. An intellectual judgment about another person not being there does not entail a similar reorganization of my perceptual world: Wellington and Paul Valry are not in this caf either, as Sartre points out. These absences, however, are pure abstract judgments, not primary perceptual experiences.

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It is by such perceptual magic, below the bright constructions of reason, that human subjects constitute their worlds, these worlds being different ways of organizing reality. But what is the moving force behind this perceptual shaping of reality? It is my waiting for Pierre and just for him: [. . . ] I was expecting to see Pierre and my expectation has brought about the absence of Pierre as a real event concerning this caf, it is an objective fact now, this absence, I have discovered it [. . . ] (Sartre, 1943, p. 44). The structuring of my perceptual world is neither an intellectual function nor a judgment on already existing objects. More radically, it is the interest-guided constitution of objects. The reality of perceptual worlds can hardly ever be changed by a purely intellectual discourse. It is not easily possible to persuade someone to make a change in his perceptual world. What constitutes her perceptual world has the character of inescapable objectivity, objectivity brought about not by rational judgments but by the deeper layer of perceptual experiences. To modify her reality, her way of perceiving would have to be modied. We will discuss the signicance of this phenomenon for health education and preventive medicine in the last part of this paper. (c) The priority of perception It is now clear that perception determines at a preconscious level the structure of our reality. This preconscious, reality-constituting power of perception has been studied most exhaustively by Merleau-Ponty (1945). He concludes that perception constitutes our most basic link to the world. For him, every other human attitude towards the world, be it science or rationality in general, is dependent on this fundamental perceptual basis. Our relation to the world is not that of a detached subject to an entirely given object. Every perception is, as Husserl already indicated, perception with horizons. The objects of the world are, originally, not known by us; before being known, they are present in our perceptual practice: The perceived world is the ever presupposed background for every rationality, every value, every existence (Merleau-Ponty, 1996, p. 43). The world of perceived objects cannot abstractly said to be true for every rational being. It is a world which is real for everyone who is in the same situation (Merleau-Ponty, 1996, p. 52). Under the possible world of truth, being a derivative, secondary layer, there is the world of reality, the world of perception.

This perceptual reality is the milieu where real communication between two partners has its foundation. In its ambiguity it gives means to mutual understanding as well as grounds for differences. If we are, a friend and I, facing a landscape and if I try to show my friend something I can see, that he cant, we cannot explain this situation by saying that I see something in my world and that I would try by verbal messages to evoke an analogous perception in the world of my friend. There are no two worlds numerically distinct and only a language uniting us. There is, and I really feel it when I get impatient, a sort of exigency that what is seen by me should be seen by him. At the same time, however, the object itself that I see demands this communication, by the reections of the sun on it, by its colors, by its sensible evidence (Merleau-Ponty, 1996, p. 52). So our starting point, the observation of the patient and his doctor living in different worlds, has taken a more precise sense. There are not two worlds which are essentially different. There are two different perceptual experiences, creating different perceptual worlds. They do not merely differ in being different interpretations of the same objects, a difference that could easily be mediated by language alone. The difference is rooted deeper, in the layer of perceptual object-constitution. Different realities are thus different modes of perception, different perceptual choices. Emerging from this perceptual differences, however, there is at the same time an exigency of communication: perceptual differences not being intellectually xed, have an intrinsic tendency towards mutual enrichment by means of communication. Merleau-Ponty considers objections that could be formulated to what might be seen as an exaltation of perception. Some might object that all of MerleauPontys analyses on perception might well be true in the psychological frame of subjective experience. But by no means could perception be thought of as the foundation of our objective reality. The objective reality so the objection would continue can be revealed by science only, which gives us objective laws, valid irrespective subjective experiences. The world of objective scientic knowledge the physical world is prior to the ambiguous, ever changing world of perceptions. Perceptions are secondary, subjective phenomena. Against this classic, positivistic world-view, Merleau-Ponty defends his conception that all of our experience, all of our knowledge is basically structured as perception, with internal and external horizons, principally open to modications and never coming to rest in absolute objectivity. What we regard as objective knowledge is nothing but the preliminary

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result, the tentative closing of perceptual experiences. Merleau-Ponty argues that as early as 1947, studies in philosophy of science had demonstrated that every science always has the character of an innitely approximated knowledge, being an elucidation of the pre-scientic reality of perception. Hence, this explanation of the pre-scientic perceptual world will never come to a natural end (Merleau-Ponty, 1996, p. 56). Today, in light of additional studies in philosophy of science by such scholars as Kuhn (1979), Feyerabend (1995) and Laudan (1977), there is even more reason to believe that the rationality of science does not consist in providing us with a closed, objective view of the world. All sciences are dependent on a prescientic, pre-objective structure that is given to us in perceptual experiences; all are different explications of the same [perceptual] knowledge (Merleau-Ponty, 1996, p. 66). Moreover, perception is not just one (psychological) event in a closed world of entirely given objects but our principal point of contact with the world. The subject of perception cannot be separated or eliminated from perception without destroying the perceived world itself: It is out of the question to describe perception itself as one of the events happening in the world, because we never can efface this aperture we are from the tableau of the world, this aperture, by which the world comes into existence for someone, because perception is the aw of this great diamond (Merleau-Ponty, 1945, p. 240). If even the perception of spatial objects is never closed, the perception of other humans must a forteriori be even more lively and open, as it is the meeting of two perceiving subjects. And in this perception of the Other, of another person, we encounter the same ambiguous structure, characteristic of every perception: the Other we perceive is strictly speaking not just an other, a second ego; paradoxically, it is an alter ego. The other is not myself, yet he is, at the perceptual level, the same perceptual subject as I am. By a counter-example, Merleau-Ponty shows what would happen if there were no such underlying pre-objective perceptual stratum, but only intellectual judgments in our relation to the others. This counterexample is taken from Blaise Pascals examination of love. Pascal remarks that a man does not love a woman for her beauty, which can pass, nor for her reason, which she can lose. How then does he love her? Quite unexpectedly, Pascal concludes: One never loves another person; one only loves qualities (cit. by Merleau-Ponty, 1996, p. 70).

However, if we duly consider the perceptual experience we have of persons, it becomes evident that, on the contrary, we do love persons and not qualities, which are secondary abstractions by rational judgments, especially inappropriate in the lived interpersonal experience of love. Our lived, perceptual experience of love, founded in the pre-objective ground of perception, goes innitely further than can be reconstructed by rational consideration. The special character of love, in this example, documents the existence of a strong pre-conceptual layer of reality, of which the structures of perception outline the general form. Absolute perception We have been following investigations into the nature of perception and its internal structures. It is interesting to note now, that different forms of perception can also be found on an epistemological level. The work of Foucault, especially his study on the Birth of the Clinic (1963), shows how different modes of perception are linked to historically prevalent structures of scientic discourse. His analyses in the Birth of the clinic must be read not only as a reconstruction of some facts in a limited period of medical history.6 He wants to go beyond merely factual history of science by analyzing the changing possibility conditions of these facts, that is, the conditions under which changes in medical experience are at all possible. To this avail, Foucault analyzes the changes in medical perception patterns. The signicance of these structural changes in the way doctors looked at and perceived the patients and their illnesses in the period of Foucaults investigation (approx. 17701830) is apparent in a subtle modication of the way they start a conversation with their patient: No longer do they ask How are you? but rather Where does it hurt? (Foucault, 1993, p. xiv). The question thus arises how the collective change in the way medical reality is perceived, is followed by a subtle but decisive change in the way medical problems are tackled. Foucault distinguishes two different ways of looking at medical reality which are historically situated before and after the large-scale introduction of pathological anatomy into clinical medicine by Bichat. According to Foucaults reconstruction, the period preceding Bichat was characterized by a phenomenology of medical signs, a sharpened attention paid to what could be perceived on the patient himself, without the intervention of theoretical considerations. As Foucault shows on the example of Tissots Avis aux gens de lettres sur leur sant (1767), there was a veritable pathological hermeneutics of human illness,

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founded on a rich and colorful perceptual experience (Foucault, 1993, p. 12). So, in the early Paris clinic the medical view was still the epistemological incarnation of what we have described above on the level of object-perception as an open perception, with its inner and outer horizons, ideally perceived in the absence of any theoretical preconception of the object in question. The clinic followed the famous phrase of Corvisart: All theory always remains silent or vanishes at the patients bed (Corvisart, 1808, p. VII).7 Medical perception was understood as a contemplating look which does its best not to disturb what it is trying to observe. The early Paris clinic tried to perceive an illness in the way this illness presented itself by itself. The clinical perception was supposed to follow the lines of presentation chosen by the observed object. To reach this aim, the medical perception had to free itself of all intellectual and theoretical bounds: the concrete sensibility of perception became the essential way to gain access to the reality of an ill patient. Foucault has shown how this special mode of perception, this specic form of medical aesthetics in its etymological sense, gains an aesthetic dimension in the second sense also, as a normative prescription of artistic rules. Medical practice seemed to be proudly establishing itself as an artistic enterprise, as a virtuoso perception of the dazzling variations of illness: In medicine, everything or nearly everything depends on a quick look (coup doeil) or on a lucky instinct. Certainties are found more in the sensations of the artist itself than in the principles of art (Cabanis, 1819, p. 126).8 Everything changes in medical perception according to Foucault9 with the introduction of pathologic anatomy. Bichat, for the rst time, breaks up the aesthetic contemplation of the symptoms of illness and tries to penetrate under the surfaces of perceptual reality. Bichats work is directed at nding below the simple perceptual reality the verity of the pathological lesion. The medical perception gains a new dimension. It goes vertically from the manifest surfaces of the body to the hidden surfaces of tissues (Foucault, 1993, pp. 137149). This new way of medical perception, this pathological view, is no longer characterized by an open, ordinary perception (as dened by Husserl). The adventurous perception, going below the visible surface of the patient, is no longer a mundane, ambiguous perception. The medical perception, by choosing to follow the lines of pathological anatomy, becomes

absolute perception: regard absolu (Foucault). This contradiction in terms a perception being absolute marks, at least for a certain historical period, the end of a paradigm, the end of a world-view: the end of open perceptions in a medical context. The truth of an illness is but the unveiling of its pathological substrate, a truth that is only to be discovered post mortem. Death is the adequate dark light in this objective reign of absolute perception. The symptoms intra vitam are nothing but veils, opaque veils for the layperson, transparent veils for the skillful doctor: What conceals and envelops, the curtain of night hiding the truth, is, paradoxically the life. The death, on the contrary, opens up the black box of the body to the light of the day [. . . ] Medicine in the XIXth century has been haunted by this absolute eye, that turns life into a cadaver and nds again, in the cadaver, the fragile, broken veins of life (Foucault, 1993, p. 170). The pathological anatomy introduced by Bichat has been a decisive factor in the development of the modern view of the human body. It has overcome the insecure, ambiguous, ever-open world of free perceptual shades, by reference to stable post mortem facts: Without any doubt it will remain decisive for our culture, that the rst scientic discourse on the individual had to pass through this moment of death (Foucault, 1993, p. 200). Foucault ends with the rather gloomy conclusion that the modern, scientic study of the human individual has become possible only by rooting the verity of this science in the death of the same individual. The everopen world of ordinary perception with its undetermined horizons by its very structure impossible to exhaust has been replaced by an unambiguous law of discourse, made possible only by the unique and well determined factual truth of death.

Perceptual patterns in medicine: the art of perception I have tried to describe two archetypal perceptual patterns relevant to medicine: (1) The open, ordinary pattern of perception with its mixture of knowledge and ignorance, and (2) the closed, scientic way of perceiving reality, constituting absolute knowledge. This knowledge is absolute not in the sense that it cannot be modied at all, but in the sense that it can only be modied by perceptions of the same closed type, staying within the framework of scientic perceptual

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patterns, thus methodologically banning any ordinary perceptions from inltrating the scientic knowledgebase. Before exploring some of the specic implications for medicine contained in the recognition of these two fundamentally different perceptual patterns an exploration that concerns a special sub-eld of medical philosophy that I have called medical aesthetics we need to examine at a more general level the relations between these two major modes of perceiving medical reality. The analyses of Merleau-Ponty and much of the research in philosophy of science have shown that science is not the description of objective reality itself, but one possible description of reality, contingent upon the chosen method. Science is one possible secondary practice, based on the primary world of perception, this ever presupposed world of everyday life that Husserl has called the life world (Lebenswelt; Husserl 1962, p. 465). All human enterprises, medical or otherwise, have their common basis in this open perceptual reality of the life world. With the introduction of pathological anatomy, however, the perception patterns of medical practice closed up: perception became absolute perception, constituting an entirely given object. Both ways of looking at the medical reality have their advantages. The open clinical perception permits a more adequate rendering of the reality in which the patient lives, reminding us at the same time that every perception, and every science, can never be totally adequate to the inexhaustible reality. The absolute perception of pathological anatomy has permitted medicine to escape the spell of the innite possibilities of natural perception by reducing the innite perceptual investigation of a living body to a more nite form of research: a post mortem analysis under the unambiguous perceptual rule of dead structures. From the point of view of how exactly a knowledge renders concrete reality, open perception might be considered superior to science, as Merleau-Ponty argues in the discussion following the presentation of his paper on the priority of perception before the French society of philosophy (Merleau-Ponty, 1996, p. 91). MerleauPonty, however, rejects any hierarchical conception of different forms of human inquiry into the structures of reality, because this would presuppose a pre-established point of view on what should be the absolute goal of our inquiry. The different approaches of scientic and ordinary perception are best seen as concentric forms of investigation motivated by different goals and trying to elucidate different sectors of reality. Evidently, our modern practice of medicine is characterized foremost by the scientic form of medical research, committed to healing the living by know-

ledge gathered from analyzing the dead. Given its practical success, it would be evidently wrong to reject this form of medicine en bloc as being inhumane or reductionist.10 We can ask, however, whether scientic perception patterns can and must be complemented by perception patterns more adequate to the open life world of an ill patient. There are several areas, in clinical medicine as well as in theoretical medicine and medical ethics, where a distinction between open and closed perceptions can be helpful and a stepping back to open perception patterns could be indicated: (1) The problems medical science often encounters in preventive medicine may be related to an underestimation of the importance of ordinary perceptions constituting the life world. Medically known health hazards such as the consequences of tobacco or drug abuse, are notably absent from the perceptive worlds of those engaged in these forms of hazardous behavior. The hazards may be well known by the subjects but they are not perceived. What is objective truth in the life world of a human subject is not what science calls objective truth, but what is constituted by the interest-guided open perceptions of this subject (Sartre). These objective perceptual structures of a particular life world often are virtually immune to cognitively oriented interventions, as they are rooted in the lived experience of the person concerned. Consequently, health education programs should focus more on showing the consequences of hazardous behavior (e.g., by visualizing the lived experience of resulting illnesses, interviews with patients, etc.) and less on explaining the medical problems that might result. (2) In the area of medical diagnosis the signicance of open perception patterns is evident at two points. The rst point concerns the rather common problem that despite a sustained diagnostic follow-up, the patients complaints cannot be tted into any known diagnostic category. Such a deadlock often leads to even more intense and invasive diagnostic procedures. Yet it may be more effective to bracket for the time being the closed perceptions of medical science, returning instead to the primary perceptual stratum of the patients lived experience. By retaking the history of the patient, not so much his medical history but rather his illness narrative (Cassell, 1985), one can try to reestablish the perceptual ambiguity of ordinary perception and to look for any empty indexing (Husserl) emerging from the well known core of the patients problem. Trying to perceive what is absent, going back from the closed world of scientic evidence to the abyss of ignorance surrounding any

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real world perception, can be a heuristic tool for discovering what has, by its ambiguous nature, so far escaped the medical grip: There is more to see, turn me around! these exhortations not only apply to object perception but ever the more so to the perception of a patients medical problem. The second issue engendered by our reection on the nature of perception is a caveat concerning the consequences of diagnostic classications. Any classication of diseases must be seen as a mutilation of what is perceivable in the individual patient a loss of reality, which is especially problematic in the case of psychiatric illness (e.g., DSM-IV). The motivation for these and other classicatory efforts is understandable: to obtain clearcut disease-concepts that can be operated on with condence, seemingly permitting us to seize the verity of the disease in question. However, as Husserl has shown, the verity of an object is its sense as perceived from a hypothetical and absolute point of view. In the case of a patients illness, such a hypothetical and absolute point of view can never adequately render the specic sense a certain illness has for the individual patient. It may be more helpful for an understanding of the patient, to try to seize the reality of a disease, that is, the perceived sense of a disease, by trying to follow the perceptual lines according to which a patient structures the reality of his illness. It should be remembered that this exploration of the lived experience of a patients illness need not be less certain, less objective, than the traditional scientic approach by classication. Quite to the contrary: only ordinary perception can give us real certainty, as only this type of perception gives us the object itself (den leibhaftigen Gegenstand) and not a secondary abstraction. (3) By giving the open perceptions of lived experience more focus, mutual understanding in the patientphysician encounter can be enhanced. It has been suggested (Toombs, 1992; Welie, 1998) that on a purely scientic or procedural level, phenomena such as empathy, fellow-feeling or comprehension are difcult to understand. Toombs has shown convincingly that problems in patient-physician communication do not stem from different levels of knowledge but from a more profound difference in understanding (Toombs, 1992, p. xv). This difference in understanding is brought about, in our view, by a difference in perceiving: it is only with great difculty that the closed and absolute view of medical science can be linked back to the lived perception a patient has of his illness. Conversely, if the doctor is able to step back to

the stratum of pre-conceptual open perception it is much easier to establish a web of shared reality between her and the patient. Ordinary, everyday perceptual patterns, with inner and outer horizons and a mixture of knowledge and ignorance, are by their ambiguous nature more open to mutual understanding, exchange and compromise, than xed, clear-cut scientic concepts. Rather than the absolute perceptions of medical science to which only the doctor has easy access, the perceptions of the life world which in principle can be shared by patient and doctor alike can facilitate a common basis for communication. This return to the life world would be reected by a change in medical questioning, back from where does it hurt? to the everyday question: How are you? (4) Liquefying frozen perceptual structures at the same time is one of the operational principles of psychotherapy. Many everyday problems or dissatisfactions (e.g., at work, with oneself, with a partner) are aggravated or maintained in an irresolvable state by progressively closing perceptual patterns. This becomes especially evident in failing interpersonal relations, where the other no longer is perceived by what he is doing (leaving his being unknown and unpredictable to some extent), but by what he is or rather: by what he is supposed to be. Perceptual exercises, trying to look beside petried structures, making an effort to overlook the evident, aiming at discovering the margins and horizons of the obvious, reactivating unlearned perceptive movements, may ultimately lead to the discovery of new sense, thereby providing a fresh starting point for reconsidering the problem at hand. (5) The recognition of different perceptual patterns is also relevant for medical education. The distinction between the two patterns outlined in this paper is especially important here, as the clinically useful capacity to switch from scientic to ordinary perception is teachable as any other medical skill. At the beginning of students medical education, this switch tends to happen spontaneously when students are equally concerned by the still mostly unfamiliar problem in medical science with which they are presented, as by the concrete illness experience of the patient exhibiting this problem: How might he manage to live with it? What is everyday life like for this patient? However, in the course of standard medical education, with its heavy emphasis on biomedical sciences, this capacity to switch perceptions tends to be progressively unlearned and to be replaced by the ever more unambigous, ever more knowledgeable

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absolute perception of scientic medicine. Clinical teaching thus should enlarge its focus to not only transmit clinical skills but also the capacity to step back from the medical world and to perceive the patients experience with the patients eyes. Tools to achieve this could be specically designed methods of history taking that complement the medically oriented standard history by introducing questions about the patients disease experience. (6) A consideration of the different modes of perception that are present in the medical eld can also aid in understanding the much discussed problem in medical theory whether medicine is best to be understood as an art or as an applied science. As Wiesing (1995) has shown by a historical analysis, this epistemological problem is grounded in the difculty of understanding the relation between the two, seemingly totally separated constitutive elements of medicine: knowledge and praxis. If knowledge is exclusively understood as scientic knowledge, the separation between this scientic knowledge and medical praxis appears to be absolute indeed. It would then be the task of an autonomous discipline (loc. cit. p. 323) quod omnes dicunt medical ethics? to re-adapt nonnormative scientic facts (medical knowledge) and normative rules of action (medical praxis). If, however, medical knowledge is acknowledged to be of a mixed type, stemming from ordinary as well as from scientic perceptions, the separation between this mixed medical knowledge and medical praxis becomes less pronounced. Mixed medical knowledge, containing not only closed scientic but also ordinary open perceptions, and thus integrating elements of ignorance, would by its ambiguous nature have more links to the equally ambiguous medical praxis. Moreover, as open perceptual knowledge is intimately linked to the kinesthetic praxis of perception by which it is constituted along the lines of perceptual interests, the distinction between knowledge and praxis becomes even less sharp. Hence, integrating open perceptions with their normative halo of perceptual interests into medical knowledge would, by changing the characteristics of this medical knowledge, aid in lessening the distance between knowledge and action in medicine. In this context, the task of medical ethics would be less difcult too: medical ethics would no longer have to link ex nihilo a norm-free, totally isolated sphere of scientic knowledge with the normative needs of medical praxis, but could start within a context, provided by the mixed knowledge base of medicine. The normative context of

mixed knowledge is constituted by the integration of open perceptions which are always and inescapably impregnated by norms, corresponding to kinesthetic choices, constituting the life world of the ordinary patient and his doctor. (7) Finally, the case has been made that open perceptions, not abstract principles, are at the root of any ethical experience or behavior. It is by perceiving the Other, more precisely, by perceiving him not as an object, as in scientic perception, but by perceiving him perceiving, that we approach him as an alter ego. Here, the French philosopher Levinas takes up the analyses of Merleau-Ponty, trying to rethink ethics as rooted in the primary world of perception. For Levinas, ethics is not a system of normative rules and orders; ethics originally is optics (Levinas, 1971, p. 8) and founded in the preconceptual stratum of an open perception of the Others face. For medical ethics it becomes thus important to regain access to this primary, ethical vision of the patients face, often buried under the scrutinizing examination of this patient as a medical object. Such an authentic ethical perception of the Other is attained, as Levinas indicates, when I am face to face with the patient, looking at him but yet not realizing the color of his eyes (Levinas, 1982, p. 79). These preliminary analyses show, that there are many levels at which it might be useful to supplement scientic perception in medicine by open perceptual patterns, more biased towards a recognition of the ambiguous details in personal and interpersonal life. The recognition of these two modes of perception may permit a more fruitful access to empirical as well as conceptual problems in medicine. An art of perception could be seen as a technique for adequately dealing with different perceptual patterns in medicine. It would consist, above all, in the art of changing perceptions, of acknowledging differences in perceptual patterns and of choosing the most adequate pattern for any given situation. Medical practice must incorporate both modes of perception we have identied: the absolute perception of science as well as the open perception of ordinary life. To gain a view as complete as possible of a medical problem we need to obtain a stereoscopic view on the reality of the patient, which in turn demands mastery of these two perceptual modes. This is particularly difcult given the fact that the perceptual modes to be fused into one stereoscopic vision of medical reality are rather divergent. Fortunately, a complete fusion is not always necessary: At a perceptual level double-images are not to be feared as they are a more adequate rendering of the inexhaustible, richly differentiated perspective structure of reality.

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Notes
1. Revised version of a paper presented at the XIth Annual Conference of the European Society for Philosophy of Medicine and Health Care, Padua, August 2123, 1997. I am indebted to M. Dornberg (Freiburg), S. Grtzel (Mainz) and U. Wiesing (Tbingen) for their comments on earlier drafts. 2. For a detailed discussion of this question from the phenomenological point of view see K. Toombs (1992). For Toombs, illness as lived and the disease state as diagnosed by the physician must be conceived as being situated in two separate worlds: [. . . ] When physician and patient talk about illness they are not discussing a shared reality (Toombs, 1992, p. XV). What ultimately enables a communication between these two worlds is the fact that the physician may set aside her medical knowledge on the functioning of the organism, by focussing instead on the lived experience of her own body, especially in instances where she encounters bodily limitations or resistances. This experience of the uncanniness of her own body provides an opportunity for the physician to understand the illness experience of her patient. We will follow a slightly different approach than Toombs to shed light on this problem of shared reality in medicine, by focussing not on the bodily experience as a whole, but on one privileged manifestation of our embodiment, i.e., perception. 3. My translation. 4. The investigations of perceptual patterns, e.g., by Husserl or Merleau-Ponty, operate on a more basic level than the only seemingly similar analyses of cognition prevalent in the framework of radical constructivism, that explicitly link themselves to a peculiar interpretation of Kants view on reality and its representation. (Schmidt, 1987, p. 7). Even more misleading seems to be Maturanas approach trying to understand cognition as a particular form of autopoiesis in biological systems, not hesitating to identify his concept of cognition with the Cartesian cogito without trying to differentiate cognition from perception (Maturana, 1987, p. 89). These radically intellectualistic theories of radical constructivism unfortunately seem to miss the stratum where non-intellectual construction i.e., constitution of a world actually operates: on the pre-conscious level of kinesthetic activity. 5. My translation. 6. For the aim of this study, it is less important, whether Foucault gives an entirely adequate or comprehensive view of the conceptual changes in medical history, i.e., whether his reconstruction is historically correct. It even seems to be very probable that Foucaults analyses in the Birth of the clinic only offer a preliminary and incomplete yet stimulating rst sketch of the hesitations, surrounding the development of the modern medical view. In this sense, Hess is rightly asking whether this modern medical view can in fact be understood as being mainly characterized by the perceptive patterns of pathological anatomy, as Foucault sometimes seems to suggest (Hess, 1993, p. 12). However, what still makes Foucaults analyses so important is his methodical focus on medical perception patterns (on an epistemological level) and on the inuence

7.

8. 9. 10.

of changes in these patterns on medical practice. So the historical shift from semiotic to diagnostic medicine which Hess describes in his study mainly on the level of intellectual history (Hess, 1993, p. 18), can also be rendered in terms of differences in perceptual patterns: the modern medical regard historically develops from a scrutinizing view on prognostical signs (semiotics), passing by the contemplation of diseases as entes sui generis (naturhistorische Methode) to end with the penetrating etiological inspection of scientic medicine, focusing on what is perceivable by the methods of physiological and pathological investigation (Hess, 1993, pp. 291299). So the link between a shift in perceptual patterns specic to different medical methods and the changes in the way a doctor perceives his patient becomes even more obvious and it must indeed be asked, what consequences this concentration of the medical regard on disease (Hess, 1993, p. 300) has had for the relationship between a doctor and his patient. Cit. by Foucault, 1993, p. 107. This is the idealizing selfinterpretation of Corvisart. From a modern point of view it is clear that there can be no such thing as an autonomous praxis that could banish any theory. Likewise, there can be no theory independent from the practical procedures (e.g., quantitative measurements) that establish its basis. In seemingly refusing any theory the praxis merely chooses to adopt a different theory. Cit. by Foucault, 1993, p. 122. Cf. note 6. Foucault emphasizes that his study was not aiming at judging the different forms of medical practice it uncovers. (Foucault, 1993, p. XV). Nevertheless, his conclusion is obviously skeptical on the subject of a life science founded on structural analyses of dead bodies.

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