I. EMBODIMENT IN THE PHENOMENOLOGICAL TRADITION

Philosophical and ethical issues are closely connected with medical and health professional self-understanding, knowledge, research, and practice. The human body occupies a central place in those contexts, but especially within medicine—certainly one of the sources for understanding the human body. In this entry, after a brief review of ideas about the body in the history of medicine, its place in philosophical thought since René Descartes is addressed. This history plays an important role in more recent philosophical reflections on human life, especially in writings directed to the experience of embodiment. After reviewing that history and the understanding of embodiment, some suggestions are made about the relationship between embodiment and the variety of ethical issues presented by medicine, biomedical research, and clinical practice. This discussion is unavoidably difficult, because both that history and the issues raised by efforts to explicate and understand embodiment are complex. Addressing those complexities, however briefly, will be helpful in delineating the specific concepts, terms, and methods used in the phenomenological tradition regarding embodiment.

From the earliest stirrings of human fetal life through old age, individuals are embodied. Whether their bodies are more or less healthy, or are sick, injured, compromised by congenital or genetic defects, or are such that they arouse social prejudice, individuals experience the surrounding world by means of a particular body. Being embodied, furthermore, means having a certain sexuality and thus experiencing the milieu in ways that both structure and are socially structured by that sexuality. Even slight reflection also shows that the human body has aesthetic, economic, political, and other dimensions specific to every cultural time: the body figures prominently in clothing styles, pornography, labor, torture, and the like. The experience of the body by oneself and others plays other important roles in broader terms: in the "body politic, " for instance, or in the manufacture of automobiles, or in contexts such as physical examinations in the military.

Underlying all of these, however, is a striking phenomenon: regardless of the state of health, skin coloration, sexuality, or sociopolitical usages, one body is uniquely singled out for a person's experience as "mine, " as that sole body through which anything else is experienced. While any full explication of embodiment must address each of these fascinating dimensions, the first question concerns that core sense of "mineness": How are we to understand that? It is to this that the present entry is devoted. First, however, an equally brief word is needed about the place of the body in medicine.

The Body in Medicine

Historically, physicians have sought to understand the body's structures (anatomy), functions (physiology), cellular makeup (biology, biochemistry), activating and regulatory mechanisms (neurology, immunology), the several organ systems and their connections (cardiac, pulmonary, renal, hepatic, etc.), and the variety of diseases, injuries, noxious environmental influences, and genetic and congenital conditions that govern the body's development and underlie personal life.

Even with this focus, however, historical medical views of the body have varied over time (Edelstein). For example, the "dogmatic" or "rational" view understood the human body as fundamentally causal in nature—events inside the body were thought to cause outer symptoms (a pathological understanding of the body and disease). By contrast, according to the "empiricist" and "skeptical" traditions, the body and the embodied person form an experiential, temporally developing "whole" in continuous and multiple interactions with the surrounding world (a holistic view). Physicians in later historical times who were convinced of the dogmatic, rational view literally looked inside the body—by dissection and vivisection—and understood its structures and functions. Those who held the empiricist view turned instead to history (the patient's history and the collective histories of other physicians) in treating diseases. These two basic, conflicting models have continued to have an important place in medical understanding (Leder; Zaner, 1988).

Although these views continue to be present in medicine, the rationalist tradition (emphasizing the body as a material, causally determined organic system) has been clearly dominant in more recent times. The first major steps in the historical development of a rationalist view of the human body were taken in the early fourteenth century by Mondino de' Luzzi and his student Guido da Vigevano (Singer). By far the most significant steps are found in the seminal work on anatomy by Andreas Vesalius (1514–1564) and later in the important discoveries in physiology by William Harvey (1578–1657), strongly endorsed by René Descartes and continued in the work of seventeenth- and eighteenth-century post-Cartesian physicians, such as Robert Boyle (1627–1691) and Friedrich Hoffmann (1660–1742) (King) and Jerome Gaub (1705–1780) (Rather).

In modern times, the body was first proposed as a fundamentally causally determined organic system by Giovanni Battista Morgagni (1682–1771) and Xavier Bichat (1771–1802). Before this time, even though abundant autopsy reports had been published, such recorded data had not offered any correlation between clinical and anatomical findings (King). With Morgagni and Bichat, however, this changed profoundly. The introduction of the "clinicopathological correlation" radically altered medical understanding. For the first time, what was found at autopsy was taken as "explaining" clinical symptoms observed while the patient was alive. Now disease took on a highly specific form—the "organic lesion" found inside the body—and was no longer associated with a more or less loosely collected set of clinically observed symptoms or patient reports (King; Zaner, 1988). Because this "correlation" fundamentally changed the way physicians understood disease, it has been called a "revolution" (Laín Entralgo) comparable to what Copernicus effected in astronomy when he proposed that instead of thinking that the sun moves around the earth, we should perceive it to be the other way around.

The marriage of clinical medicine to biological science, definitively begun in the nineteenth century, was consummated through the work of neurologists such as John Hughlings Jackson (1834–1911) and clinicians such as William Osler (1849–1919), and the educational reforms recommended by Abraham Flexner (1866–1959) in the early twentieth century. Medical thinking then incorporated the idea that the body is a complex system of physiologically interacting structures and mechanisms governed by multiply interrelated controls seated in the neurological system. Some physicians, appreciating that this complex organism (or set of organ systems) serves as the embodied person's means of expression and action, advocated a type of "medical dualism" or "epiphenomenalism"—there must be a place for the "person, " whether thought of as a distinct entity or as a causal consequence of the body complex's functional stability across time.

The Body in Philosophy

While the history of philosophical and moral deliberations about human life is quite as sophisticated and colorful as medical history, the bulk of reflections have focused on mind (person, self, subjectivity, and related notions) (Zaner, 1980). With some notable exceptions, however, there has not been nearly as much reflection about body per se. In large part, a basically traditional view of these matters was assumed: that body and soul are distinct (or even separate) realities, and that what is essential in human life is to be found in the soul, not the body. The soul (mind, reason) is the pure and unchanging essence of the human; the body, on the other hand, is a baser sort of affair, belonging to the changeable, the temporal, and the corrupt. The soul, imprisoned within the corporeal, is subject to the body's peculiar "nature, " its appetites and inclinations, but has its true destiny and nature elsewhere—a destiny it must pursue by becoming freed from its worldly, bodily prison.

There have been exceptions to this view of the human body. René Descartes (1596–1650), for example, argued that mind (res cogitans ) and body (res extensa ) are to be understood as "substances": mutually exclusive, self-subsistent, and ontologically distinct entities, neither of which requires the other to be or to be known. This familiar bifurcation of reality (dualism), often said to be at the basis of modern medicine and modern thought more generally (Cassell, 1991; Eccles), led Descartes to the view that mind and body "interact" in some manner, although specifying that the form of this interaction proved to be inordinately difficult and highly problematic (Leder).

Hardly satisfied with that, and challenged by Princess Elizabeth (daughter of the exiled king of Bohemia, living at the time in Holland), Descartes's reflections on the body show a surprising turn—one that has not been well appreciated. The mind, he thought, is not "in" the body in the way a boatman is "in" a boat—contingently or accidentally. Rather, the mind is "intimately" connected to the body, an "intimate union" that led him to the view that the human body is intrinsically complex and not at all the simple "extended substance" posited in his metaphysics (Zaner, 1988). As Descartes remarked to Princess Elizabeth, neither mathematics nor metaphysics is capable of apprehending this union. It can be known only in "daily conversation" and in clinical encounters—one might say that the union is essentially a matter of concrete experience (Descartes, 1967; Descartes, 1973; Lindeboom).

To be sure, from his early work in anatomy, Descartes had learned that the cadaver does indeed seem to be little more than such "extension." But from his earnest attempts to provide medical diagnosis, he knew full well that while it is alive, the body is far more than merely a material entity extended in space. For example, writing of the "dropsical patient" in his Meditations (Descartes, 1955), he took pains to point out that there are in fact two "natures": the one subject to the laws of nature, the other with its own specific characteristics that must be understood in quite different ways than the other (Kennington). Indeed, Neils Stenos (1638–1686), a younger physician contemporary of Descartes who specialized in the brain, contended that nature in the first sense was merely heuristic, a "manner of speaking" (une pure dénomination is Descartes's phrase), and should not be taken literally (Lindeboom). This intrinsic complexity of the body—as cadaver and as embodying the mind— did not attract the attention of many philosophers (or, for that matter, physicians) (Zaner, 1988).

Addressing the Cartesian idea of the "intimate union" of soul and body, Blaise Pascal (1623–1662) argued that one must be able to account for this intimacy. He noted with marked irony that if, like Descartes, one "composes all things of mind and body, " surely that mixture would be intelligible—especially to one who so composes all things. Yet not only do we not understand the body, and even less the mind; least of all do we know "how a body could be united to a mind. This is the consummation of [our] difficulties, and yet it is [our] very being" (Pascal, pp. 27–28).

Benedict de Spinoza (1632–1677) thought that Descartes's bifurcation created insuperable difficulties for understanding how the mind could possibly be connected to the body, much less "intimately" connected. Like others at the time, Spinoza's argument is couched in metaphysical terms: he argued that what Descartes termed "substance" (mind and body) could only be "attributes" of the one and only substance, reality itself. Mind and body are essential to one another; the way in which they are "united, " he concluded, then becomes comprehensible. The body is a mirror of the soul; mind, the idea of the body (Spinoza).

Understanding the body continued to preoccupy physicians but did not become a focal issue for philosophers until the early writings of Henri Bergson (1859–1941). Although he did not fully probe the matter, Bergson argued that the human body should be seen as the person's placement or locus in the world. What makes the body, a sui generis phenomenon, unlike any other worldly object is, he believed, that it is experienced as "mine, " as "my center" of action and experience. While it is physical, it is not simply that; it is the "center" of experience, and thus the field of physical objects is spatially organized around it. In addition, the human body and its perceptual capacities are in the service of action. The body is fundamentally an actional center. It is that by means of which the embodied person is able to engage in actions in and on the field of objects. Spatial location and the familiar sensory qualities are thus always experienced within specific contexts of action: for the perceiver, "things" are "menacing, " "helpful, " "handy, " "obstacles, " and so on (Bergson). Correlated to the body as the center of action, physical things are organized as "poles of action" appearing only within specific activities directed toward them, as Jean Piaget (1896–1980) later emphasized. Because of these characteristics, the human body is a critical factor in the development of language and culture.

In the early days of the twentieth century, Max Scheler (1874–1928) devoted serious reflection to the "lived body" (Leib ), in particular as regards the performance of "deeds" in moral conduct. Scheler's analysis suggests that both "ego" and the ego's "acts" are distinct from what he terms "lived bodiliness" (Leiblichkeit ). At the same, lived bodiliness must be sharply distinguished from the "thing body" (Körper ). Although Scheler does not mention it, this idea is a clear echo of the earlier Cartesian insight. The body that embodies the person ("my body") is uniquely singled out for, and experienced by, the person as "mine" (and in this sense is "intimately connected"). As the person's experiential "center, " it is that by means of which the person is, as it were, worlded: in the midst of objects, people, language, culture, and so on. These points, which had also impressed Bergson, came to be regarded as fundamental to embodiment, and are crucial for understanding subsequent discussions.

Edmund Husserl (1859–1938) grappled with this phenomenon throughout his career. Its primary feature, he contended, is the experiential relationship of consciousness to its own embodying organism (Husserl, 1952). Granted that this organism (Leibkörper ) is uniquely singled out (Husserl, 1956–1959), the problem of embodiment is to determine in what sense and in what ways it is actually experienced by the person as his or hers, since it is solely by means of that experience that it is at all possible for the person to experience worldly things (physical, biological, cultural).

What had so impressed and troubled Descartes—the "intimate union"—Husserl calls the experiential relationship to the "body-as-mine"; however, he did not appreciate Descartes's insight any more than had Bergson or Scheler. Descartes seems clearly to have recognized that while a person is alive, there is an "intimate union" between body and soul; yet how are we to understand this "union"—a connection that is all the more peculiar when death occurs and this "alive" body becomes a cadaver that seems no different in kind from any other material thing? Although apparently appreciating this puzzle, Descartes nevertheless obscured matters (as did many others after him) by trying to resolve the very different metaphysical question of the "mind–body" relation.

It is to the embodiment phenomenon that Gabriel Marcel's analysis of the fundamental opacity (the elemental "feeling" or, as he termed it, Urgefühl ) at the heart of personal life—my body qua mine—is addressed (Marcel, 1940). It is here, too, that Maurice Merleau-Ponty locates the essential ambiguity intrinsic to the body itself (Merleau-Ponty). So "intimate" is this "union, " both Marcel and Merleau-Ponty point out, that one is tempted to say, with Jean-Paul Sartre, "I am my body." "My body qua mine" is thus the paradigm of "belonging" or "having": the sense in which things belong to a person is ultimately derived from the ways in which the "own" body is experienced as belonging to the person. The latter is the condition for the former (Marcel, 1935). This existential source of "belonging" becomes apparent especially in instances where mental disturbances occur and the sense of "mineness" becomes severely compromised or remains seriously undeveloped (Bosch). A central issue then emerges: By virtue of what is this one animate organism uniquely singled out to exist in my experience as that whereby everything else in the world is experienced? Which specific processes are there without which this organism would cease to be experienced by me as mine, or which give it its sense as mine (Straus, 1958)?

The problem is exceedingly complex and subtle, and is by no means settled (Zaner, 1971, 1980). It is one of those regions where philosophy and medicine can productively learn from one another. Within philosophy, however, there seems at least some agreement that the animate organism becomes and remains an embodying organism solely to the extent that (1) it is not just a physical body but a genuinely animate organism, the sole "object" within which the person's own fields of sensation (that whereon sensations occur) belong; (2) it is the only object "in" which the person immediately "rules and governs, " within and from each of its "organs" and the total organism itself; (3) it is that whereby the person's "I can" (walk, perceive, move, grasp, and the like) is most immediately realized and enacted; (4) it is that "by means of which" the person perceives and otherwise experiences the field of worldly objects (things, people, language, etc.) and thus is the person's access to the world and the focus of the world's (objects, people) actions on the person; and (5) it is not only that whereby the person experiences other things, but it is itself experienced by the person (in health and sickness, and these in specific individual ways)—that is, the person's embodying organism is reflexively related to itself (Husserl, 1956, 1959).

The Body in Medicine and Philosophy

It should of course be recognized that, given the uniqueness of each embodiment, individuals experience their bodies (and, correlatively, the surrounding world) in different ways, depending on initial biological endowments, native and cultivated abilities, activities that are available and/or encouraged, and others. Thus, a boy who from birth has been unable to walk experiences "I can" in quite different ways from a boy who has that ability. If the latter has an accident that renders him unable to walk, moreover, his inability is experienced quite differently from that of the former— indeed, while the one undergoes a "loss, " the other may not, except perhaps in the indirect way of realizing that while others can walk, he has never been able to. One who is born blind experiences the surrounding world quite differently from one who goes blind due to an accident—while neither experiences a "visual world, " the one has "to get used" to the absence of visual space while the other has never experienced anything else. Even in cases where an individual may from birth lack several bodily capabilities (such as Helen Keller), or loses them through illness or injury, the features suggested above still hold: the embodying organism is that whereby one experiences sensations, which most immediately embody wishes and movements, by means of which one perceives (in whatever ways), and through which other things are experienced. Moreover, there are many other meanings the human body acquires—social, political, economic, and others—that a more complete explication of embodiment must address—bodily abilities, stances, comportments, and movements (Buytendijk) that have their sense and place within the spheres of nature, culture, and history.

Embodiment is thus fundamentally connected with various levels and modalities of bodily actions, attitudes, stances, and movements (Buytendijk), personal striving or willing, and perceptual awareness of things (including the body itself). Wishing, desiring, noticing, attending, and the like are or can be actualized (embodied, enacted) by means of corporeal movements (kinesthetic flow patterns correlated with muscle activations) that are functionally correlated with the several perceptual fields and what appears in them (turning one's head and looking at …). Only to that extent can one sensibly say that this organism is "uniquely singled out" from the field of worldly objects as "mine." Involved in embodiment are processes of sensory "feeling"—coenesthetic (of inner body, e.g., of hunger), kinesthetic (of body motion), proprioceptive (of body stance or posture)—and elementary strivings (reaching, squinting, locomotion, etc.). Together, these contribute not only to the sensing of "this" organism as "belonging to me" but also to the forming of the surrounding field of objects as correlated to bodily feelings and movements, positions, and actions.

But it needs to be emphasized that there is quite another dimension to embodiment. Although surprisingly little attention has been devoted to it, it turns out to be quite essential. However tempting it is to say "I am my body" (when, for example, someone strikes me in the face, I say "Don't hit me!"), many cases in psychopathology literature (Binswanger), and situations in daily life, suggest that matters are more complicated. The relation between self and its embodying organism seems as much a matter of "otherness" as of "mineness." However intimate and profound the relation between the person and the person's body, it is equally true that a person experiences his or her body as strange and alien, in ways that can be understood (Leder).

I am my body; but in another sense I am not my body, or not simply that. This otherness is so profound that we inevitably feel forced to qualify the "am": it is not identity, equality, or inclusion. It is "mine, " but this means that the person is in a way distanced from it, for otherwise there would be no sense to "belonging"; it would not be characterizable in any sense as "mine." So close is the union that a person's experience of his or her "own" body can be psychologically unnerving (its happy obedience that the person notices for the first time, or its hateful refusal to obey his or her wish to do something) (Binswanger). So intimate is it that the person has moments of genuinely feeling "at home" with it. Yet so other is it that there are times when the person treats the body as a mere thing that is other, obsessively stuffing it with food or otherwise mistreating it; or when it is encountered as "having a life of its own" to which the person must willy-nilly attend: like it or not, "my" hair grows and must be trimmed for certain purposes, "my" hands cleaned, "my" bowels moved, "my" cold cured, and so on (Zaner, 1980; Leder).

The person finds himself or herself embodied by an animate organism whose peculiar connections to the person (and the person to it) give embodiment its uniquely uncanny character. Nothing is so much "me-myself, " yet nothing seems so strange; so deeply familiar (Who else could "I" be?) yet so oddly alien (Who, indeed, am "I"?). This experience is not indicative of an inability to make up one's mind but, rather, suggests the peculiarity of embodiment. What seems distinctive is this "mineness/otherness" (the most familiar yet the most alien) dialectic that is the core of human body-as-experienced (Engelhardt; Zaner, 1980).

In these terms, to speak of embodiment is to speak of something that "I" am and not something that can be placed over against me (ob-jectum ) as an object. As embodied, "I" am in a clear sense a fundamental puzzle to myself— precisely what Pascal had appreciated with remarkable insight. What is expressed by "the problem of the body" is precisely the person's "being as embodied, " that is, the fundamental sense of being human in the first place. The "self-body" (or "mind-body") problem is, therefore, a matter of experience: It is enacted at every moment in the ongoing life of the person. These considerations make it easier to appreciate that the human body is essentially expressive. It is that by means of which the person enacts and expresses feelings, desires, strivings, and so on (albeit in culturally and historically different manners) (Merleau-Ponty, 1945). This expressiveness signifies that embodiment is valorized, that is, deeply textured with a sense of worth (whether positive or negative, as the case may be). After all, what happens to it happens to me: the person, as that which "rules and governs, " is at the same time subject to its conditions. What happens to the person's body, in still different terms, matters to the person whose body it is: The embodying organism lies at the root of the moral sense of inviolability of personhood— of the "privacy, " "integrity, " "consent, " "respect, " and "confidentiality" that play such profound roles in research ethics, bioethics, and clinical ethics. Nor does the fact that people can and do dissemble and deceive themselves and others—as in cases of factitious illness when a person is thought to "fake" symptoms (Ford)—belie the body's expressivity. Indeed, these are themselves expressive phenomena, however difficult it may be to discover and to interpret them (Hauerwas and Burrell).

This value character of the embodying organism also helps elucidate more fully why the continuing discussions of many bioethical issues—pregnancy, prenatal diagnosis, abortion, psychosurgery, withdrawal of life support, euthanasia— are so highly charged and deeply personal. On the other hand, the profound moral feelings evoked by certain medical practices (surgery, chemotherapy) and much biomedical experimentation (in particular the Human Genome Project) are understandable, as they are in effect ways of intervening or intruding into that most intimate and integral of spheres: the embodied person. The person is embodied, enacts himself or herself through that specific animate organism that is his or her own, and is thus expressive of that very person. Bodily schemata, attitudes, movements, actions, and perceptual abilities are all value modalities by which one enacts and expresses one's character, personality, habits, goals, moral beliefs—in short, by which the person is alive as such.

To view medical practice and biomedical research from the perspective of embodiment is to appreciate them as planned or potential interventions into the sphere of personal intimacy, whether this sphere be initial (as in infancy) or more developed. Whether or not such interventions are mainly directed to the body (medicine, surgery) or to the person's mental life or status (psychiatry, psychotherapy), they all unavoidably affect the individual. The person's life as a whole is necessarily affected by surgery no less than by psychotropic medication. Psyche and soma are inextricably bound together as constituents of an integral, contextual whole (Zaner, 1980). The expressive and valuative character of this whole, the embodied person, helps to explain why every medical intervention falls within the moral order. Recognizing this, of course, does not of itself settle any of the ethical issues present in research or clinical situations: when it is morally permissible to withdraw life support, for instance, or whether it is right to restrict a retarded person's ability to procreate. However any such issues may eventually be settled, the point here is that medicine is an inherently moral enterprise, in no small way due to the nature of embodiment and the interventional character of medicine (Cassell, 1973, 1991).

Clearly, the effort to settle the specific ethical issues associated with medical practice and biomedical research requires that the fundamentally ethical nature of any intervention be explicitly recognized and appreciated (Zaner, 1988). It can also be appreciated that the ethical issues associated with the medical profession (medical ethics) can be distinguished from those that arise in research (biomedical ethics) as well as from those that occur in clinical settings (clinical ethics). Each set of issues poses important and distinctive problems.

While embodiment has a place in each of these disciplines, perhaps it is more important in clinical ethics deliberations. Because embodiment is essentially individual, the tasks of identifying, discussing, and (one hopes) settling moral issues that arise in clinical situations require that the specific circumstances of each individual situation be determined. Personal integrity and respect for the unique person are not concerns somehow imported into clinical situations from the outside; they are, on the contrary, intrinsic to the very nature of biomedical research and clinical practice. It might be added that in problematic cases (interventions for an unconscious or incompetent patient, for instance), the decision to intervene in ways that do not or cannot include the patient's own perspective nevertheless requires other ethical grounds, and thus must be subject to critical ethical assessment. Other problematic situations—involving mental retardation, disabled infants, and so on—do not escape the necessity to respect the patient, though they do require special ways of taking it into account (e.g., consulting family or surrogate) along with the ethical issues involved in decision making (identifying and respecting the moral frameworks of each decision maker).

Medical and other health issues are not only inherently within the moral order but also context-specific. No bioethical or clinical ethics issue can be settled in the abstract. Every medical practice, no matter how apparently trivial, is value-laden to begin with, which means that it either explicitly or (most often) implicitly expresses some vision of what is, or is thought to be, morally good. The primary issue for ethics in clinical situations is to help primary decision makers make explicit what each believes to be most worthwhile, of greatest value, as this is found in ongoing clinical or research situations. Only subsequently does it become possible to make informed judgments about the particular context-specific practices and issues facing people in clinical or research contexts (Zaner, 1988).

How one can come to such truly informed judgments is an obvious problem, but it is not within the scope of this entry. It is, one hopes, enough to have delineated the philosophical and ethical dimensions of the human body— in particular, the phenomenon of embodiment, its expressive and value character, and consequently the ethical nature of medicine and biomedical research. What remains to be done is also clear: not only to find appropriate ways to incorporate these philosophical and ethical considerations into the teaching and practices of the health professions and the research community, but also to study the important aesthetic, political, sexual, and other dimensions of the body in social life more broadly.

richard m. zaner (1995)

SEE ALSO: Biology, Philosophy of; Feminism; Gender Identity; Human Dignity; Human Nature; Life; Women, Historical and Cross-Cultural Perspectives; and other Body subentries

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