Chapter Two
1. Three Problems of Normalization
In order to elaborate a critique of the normalization view, I will first focus on what I see as three interrelated problems inherent to it: quantification, abstraction, and exclusion. The next section will discuss these problems in relation to Christopher Boorse’s theory of disease, as he allows us to test Canguilhem’s insights against one of the most influential naturalist views.
In his central text, The Normal and the Pathological (1989), Canguilhem provides both a critique of certain concepts within the history of the life sciences as well as a novel way to rethink these concepts. By tracing the historical alterations that these scientific concepts have
undergone and by acknowledging the variability of biological norms he is able to uncover some problems inherent to what I am calling the normalization view. For example, the normalization view understands the abnormal in relation to an abstract statistical norm from which it deviates. However, this means that the normalization view runs into a problem precisely because it overlooks how the meaning of normality and pathology could be constructed from the organism’s23 non-indifferent relation to its environment. It also overlooks the historical conditions that allowed for abnormality to be considered as a mere deviation from a statistical species norm. Thus, the relation of normality and pathology to individuality and the environment has to be reconsidered. This admittedly abstract sketch of the normalization view and its problems could be made more concrete by considering the following questions: How did the statistical or quantitative view come about, what exactly does it amount to, and what are some examples of the recurring problems for such theories?
As was mentioned in the previous chapter regarding the genealogy of naturalism, the quantitative approach to disease was developed by various philosophers and scientists throughout the 19th Century who attempted to rethink the relation between physiology and pathology, e.g. Quetelet, Bernard, Fechner, Rautmann, Galton, and Pearson. I will further explore the implications of that genealogy here by discussing two historical factors that were important for the development and scientific popularity of the normalization view24. First, there was a general aim to make physiology a more rigorous (nomological) experimental science that would approach the achievements of the physical sciences. Posed in this way, individual variations and pathologies became regrettable irregularities or ‘errors of measurement’ whose underlying cause had to be explained so as to arrive at the supposed laws or regularities of physiology (Vácha 1985). Concomitantly, this understanding of ‘normality’ became possible through the rise of statistics in the 19th century (particularly Gauss’ normal distribution curve) and its importation into the life sciences by biologists and physiologists who sought to speak more objectively about human beings (Canguilhem 1989; Hacking 1990). It has been argued that from their inception these understandings of normality have been plagued by a possible conflation of facts with values: normality as not only the average, but also what is right or what
23 In this chapter, I will be using ‘individual’ and ‘organism’ interchangeably. In the next chapter, I will distinguish between these concepts so as to clarify that health and disease apply to individual organisms but not all biological individuals, e.g. populations.
24 To clarify, what I call the ‘quantitative’ view is a statistical view of disease. This view was modified in the 20th century to produce different naturalist views of disease, one of them being Boorse’s biostatistical account. It is my contention here that the ‘normalization’ view is at work in both: Boorse inherited it from the 19th century quantitative view. I partly established this genealogy in the previous chapter, and flesh it out further here.
ought to exist. Ian Hacking summarizes this view as follows: ‘The normal stands indifferently for what is typical, the unenthusiastic objective average, but it also stands for what has been, good health, and for what shall be, our chosen destiny’ (Hacking 1990, p. 169).
The basic idea behind the quantitative aspect of the normalization view, then, is that the statistical norm, as studied in physiology, takes precedence over the abnormalities and variations studied in pathology, entailing that the abnormal is merely a quantitatively determined lack or excess in relation to this norm. As mere quantitative deviations, or differences in degree, abnormalities can be derived or deduced from normality: they still refer to an underlying normal functioning, but with something added or lacking: ‘diseases are merely the effects of simple changes in intensity in the action of the stimulants which are indispensible for maintaining health’ (Canguilhem 1989, p. 48). Canguilhem challenges this by arguing that if there is no quality to quantitative variation25, then first, physiology has nothing new to learn from pathology, and second, biology and the life sciences more generally have nothing more to say concerning the nature of anomalies, sickness or death than physics or chemistry (1988a). If the difference between the normal and the pathological is merely quantitative, it becomes redundant and scientifically useless to distinguish between physiology and pathophysiology. By using the pathological to clarify the normal, the normalization view prevents the study of the pathological qua pathological.
This quantitative theory of disease also rests on the problem of abstraction whereby individuals are detached from their concrete circumstances by means of statistical analysis (Canguilhem 1989, p. 88). In order to determine pathological deviations, normality must first be established by abstracting from within individual (e.g. physiological fluctuations) and between individual (e.g. gender, geography, job differences, etc.) variations. The normalization view often assumes that there is an underlying type or essence to which all organisms can be identified, with such variations being only accidental quantitative deviations. However, Canguilhem points out that from the very conception of this view in the 19th century, Claude Bernard already had his reservations since ‘the use of averages erases the essentially oscillatory and rhythmic character of the functional biological phenomenon’ (1989, p. 151).
25 A certain reading of Canguilhem’s focus on the quality of disease should be avoided. Canguilhem does not simply prefer quality over quantity, as if appealing to something intractable for scientific investigation, as is often implied (e.g. Chimisso 2003; Roudinesco 2008). Instead, he argues that when dealing with living beings, quantitative changes always have a qualitative significance: quantification cannot erase quality, but neither does quality erase quantity: ‘The substitution of quantitative progression for qualitative contrast in no way annuls this opposition’
(Canguilhem 1989, p. 111; 1988a, p. 141).
Furthermore, this abstraction grounds the supposed epistemological and therapeutic priority given to normality, with normality either serving as the goal of knowledge or the goal of medical intervention in its attempt to restore nature’s order26. In an essay on Canguilhem, Paul Rabinow describes this view as follows:
Previously, medical training in France had privileged the normal; disease or malfunction was understood as the deviation from a fixed norm, which was taken to be a constant.
Medical practice was directed toward establishing scientifically these norms and, practice following theory, toward returning the patient to health, reestablishing the norm from which the patient had strayed’ (1994, p. 15f).
This reasoning is confronted with several problems. First, how do some variations result in disease in some individuals, whereas in others they pose no problem, as seen in the example of hydrocephalus or in multifactorially inherited diseases like cancer, hypertension or schizophrenia where environmental factors play a large role in how and whether the variation is expressed? Second, it seems obvious that there are variations that are not pathological even though they are deviations from this natural norm. Why is having green eyes not pathological if only 2% of humans have green eyes? Thirdly, even if variations and ‘oscillatory and rhythmic’
properties are acknowledged, any judgment that a trait or individual organism is ‘normal’
remains insufficient apart from the conditions in which it appears: behaviors, duration, previous state of the individual, environment, etc. As I will discuss below, it seems more accurate to argue that the normality of a trait, e.g. being able to read, digest lactose or even to run quickly, depends on the environment in which the organism develops and on its chosen or imposed demands. Statistical abstractions would thus seem to offer no means in themselves for distinguishing between normal and abnormal variation (Canguilhem 1989, p. 155).
Finally, the problem of abstraction as the basis of knowledge of normality leads to the problem of the exclusion of differences. If diseases are explained by their relation to what is statistically normal then insofar as they are different, they involve a contaminated or distorted normality: disease becomes an aberration which threatens our understanding of nature’s regularity. ‘From this perspective, the singular – that is, the divergence, the variation – appears to be a failure, a defect, an impurity’ (Canguilhem 2008, p. 123). In the aim to establish how
26 For Comte, ‘The identity of the normal and the pathological is asserted as a gain in knowledge of the normal’ and for Bernard ‘The identity of the normal and the pathological is asserted as a gain in remedying the pathological’
(Canguilhem 1989, pp. 43, 44; emphasis added). Canguilhem (1989, p. 45) points out that Nietzsche was also influenced by Bernard’s view that pathology illuminates normality.
nature’s lawful regularity creates ideal or normal organisms, variations are turned into unnatural, deficient or excessive deviations: as the normal is the index for what ought to exist, the abnormal becomes unnatural, what ought not to exist.
In all three instances, pathology is subordinated to physiology since disease is incapable of being a norm in itself apart from its relation to normality. Succinctly, it is because the abnormal is a quantitative deviation from a norm understood as an underlying essence that it can be considered unnatural. For the normalization view, then, the anomalous and the pathological are reduced to epistemological obstacles impeding the knowledge of normality, on the one hand, and to therapeutic obstacles to medicine’s supposed goal of re-establishing or maintaining physiological constants, on the other. Specifying these aspects can help to flesh out the genealogy of naturalism developed in the previous chapter.