Table Of ContentTHE MEANING OF ILLNESS
Philosophy and Medicine
VOLUME 42
Editors
H. Tristram Engelhardt, Jr., The Center for Ethics, Medicine and Public lssues, Baylor
College of Medicine, Houston, Texas
Stuart F. Spicker, School of Medicine, University of Connecticut Health Center,
Farmington, Connecticut
Editorial Board
George J. Agich, School of Medicine, Southern //Iinois University, Springfield,//Iinois
Edmund Erde, University of Medicine and Dentistry of New Jersey, Camden, New
Jersey
Patricia A. King, J.D., Georgetown University Law Center, Washington, D.C.
E. Haavi Morreim, Department of Human Values and Ethics, College of Medicine,
University ofTennessee, Memphis, Tennessee
Kevin W. Wildes, S.J., The Center for Ethics, Medicine and Public lssues, Baylor
College of Medicine, Houston, Texas
The titles published in this series are listed at the end of this volume.
THEMEANING
OFILLNESS
A Phenomenological Account of the
Different Perspectives of Physician and Patient
by
S. KAY TOOMBS
Department of Philosophy, Baylor University,
Waco, Texas, U.SA.
SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.
Toombs. S. Kay .• 1943-
The meaning of Illness a phenomenologlcal account of the
different perspectlves of physlclan and pat lent I by S. Kay Too.bs.
p. cm. -- (Phllosophy and medlclne ; v. 42)
Includes blbliographical referenees and Index.
ISBN 978-0-7923-2443-0 ISBN 978-94-011-2630-4 (eBook)
DOI 10.1007/978-94-011-2630-4
1. Slck--Psychology. 2. Physlclans--Psychology. 3. Medlelne and
psyehology. 4. Physlclan and patlent. 5. Pheno •• nologlcal
psychology. I. Title. I!. Serles.
[DNLM· 1. Disease--psychology. 2. Physlclan-Patlent Relatlons.
W3 PH609 v. 42 I \J 62 T672.1
R726.5.T655 1992
S10.69·S--dc20
DNLM/DLC
for Llbrary of Congress 91-46512
ISBN 978-0-7923-2443-0
Printed an acid-free paper
AH Rights Reserved
© 1992 Springer Science+Business Media Dordrecht
Originally published by Kluwer Academic Publishers in 1992
Softcover reprint ofthe hardcover Ist edition 1992
No part of the material protected by this copyright notice may be feproduced Of
utilized in any form Of by any means, electronic or mechanical,
including photocopying, recording or by any information storage and
retrieval system, without written permis sion from
the copyright owner.
For my father, Alan Brewis Bell
IN MEMORIAM
CONTENTS
ACKNOWLEDGMENTS ix
INTRODUCTION: A PHENOMENOLOGICAL APPROACH xi
CHAPTER ONE: THE SEPARATE WORLDS OF PHYSICIAN
AND PATIENT 1
1. Own World 1
2. Common World 8
3. Different Perspectives of Physician and Patient 10
4. Implications for Medical Practice 25
CHAPTER TWO: ILLNESS 31
1. Levels of Constitution of Meaning 31
2. The Patient's Apprehension of Illness 33
3. The Physician's Apprehension of the Patient's Illness 39
4. Implications for Medical Practice 42
CHAPTER THREE: THE BODY 51
1. The Lived Body 51
2. Body as Object 58
3. Lived Body in Illness 62
4. Body as Object in Illness 70
5. The Body-as-Scientific-Object 76
6. Implications for Medical Practice 81
CHAPTER FOUR: THE HEALING RELATIONSHIP 89
1. Illness-as-Lived 90
2. Empathic Understanding 98
3. Clinical Narrative 103
4. The Healing Relationship 110
NOTES 121
BIBLIOGRAPHY 149
INDEX 159
VII
ACKNOWLEDGMENTS
I should like to express my deep appreciation to the following individuals
who have provided assistance, inspiration and encouragement throughout
various stages of the development of this work.
Richard Zaner, Edmund Pellegrino, Eric Cassell and Richard Baron
fIrst convinced me that it was important to develop my ideas and to do so
in a philosophically rigorous fashion. In sharing their work and in
generously responding to my ideas, they provided the impetus for what
has become an intensely challenging and stimulating lifelong project. I
will always be grateful to them. In addition, Richard Zaner contributed
directly to this manuscript by reading it and providing invaluable
criticisms.
Steven Crowell is in large part responsible for providing me with the
intellectual tools to carry out my project. He nurtured my interest in
phenomenology and shared my excitement as I discovered new insights. I
could not have asked for a more responsive teacher.
H. Tristram Engelhardt, Jr. has not only provided helpful critical
comments but he has invariably caused me to reflect more deeply and to
discover new and interesting ideas. Our exchanges have been both
stimulating and rewarding.
Stuart Spicker has contributed greatly to the development of this
manuscript. His careful textual criticism has prompted me to refine the
work in important ways. While he is in no way responsible for what is
fInally said here, I warmly acknowledge his assistance.
One of the most rewarding aspects of this endeavor has been the
participation of the following individuals who have taken time out of their
busy lives to make comments and express ongoing support for my work.
Their encouragement has been a highly motivating factor throughout the
course of this project: Jerome Bruner, Jay Katz, Ian McWhinney, Michael
Schwartz, and Oliver Sacks. Special thanks are due to Charles Silberman
who has graciously put aside his own writing to read mine and to make
detailed and insightful suggestions. Furthermore, at those times when I
doubted my ability to complete the task, he assured me that the end result
would be worth the effort and he motivated me to continue.
ix
x ACKNOWLEDGMENTS
There is one person without whom this book would never have been
written. My husband, Dee Toombs, is the source of whatever strength I
have and the one constant in a life that is necessarily filled with uncer
tainty. His unwavering love and support gives me the freedom and the
courage to pursue those goals and projects I hold dear, and to continue to
do so in the face of progressive physical disability. In this way he keeps
me whole.
I would also like to thank Kluwer Academic Publishers for permission
to include material which was previously published in the following
articles: Toombs, S.K.: 1988, "Illness and the paradigm of lived body."
Theoretical Medicine 9 (June 1988): 201-26; Toombs, S.K.: 1987, "The
meaning of illness: A phenomenological approach to the patient
physician relationship." Journal of Medicine and Philosophy 12 (August
1987): 219-40; Toombs, S.K.: 1990, "The temporality of illness: Four
levels of experience." Theoretical Medicine 11,227-241.
INTRODUCTION
A PHENOMENOLOGICAL APPROACH
My interest in exploring the nature of the patient's and the physician's
understanding of illness has grown out of my own experience as a
multiple sclerosis patient. In discussing my illness with physicians, it has
often seemed to me that we have been somehow talking at cross purposes,
discussing different things, never quite reaching one another. This
inability to communicate does not, for the most part, result from inatten
tiveness or insensitivity but from a fundamental disagreement about the
nature of illness. Rather than representing a shared reality between us,
illness represents two quite distinct realities - the meaning of one being
significantly and distinctively different from the meaning of the other.
In this work I shall suggest that psychological phenomenology provides
the means to examine the nature of this fundamental disagreement
between physician and patient in a rigorous fashion.! In particular,
psychological phenomenology discloses the manner in which the
individual constitutes the meaning of his or her experience.
In providing a phenomenological description,2 the phenomenologist is
committed to the effort to begin with what is given in immediate ex
perience, to tum to the essential features of what presents itself as it
presents itself to consciousness, and thereby to clarify the constitutive
activity of consciousness and the sense-structure of experiencing.
One of the primary aims of an explicitly phenomenological approach is
to let what is given appear as pure phenomenon (the thing-as-meant) and
to work to describe the invariant features of such phenomena. As Edward
Casey (1976, pp. 8-9) notes "the phenomenologist's basic attitude is: no
matter how something came to be in the first place, what is of crucial
concern is the detailed description of the phenomenon as it now appears."
A phenomenological approach thus involves a type of radical disen
gagement, a "distancing" from our immediate ongoing experience of
everyday life in order to make explicit the nature of such experience and
the essential intentional structures which determine the meaning of such
experience.3 As such, phenomenology is an essentially reflective
enterprise. The common sense world itself (and our experiencing of it)
becomes the focus of our reflection. As Richard Zaner (1970, p. 51)
xi
