Medicine suffers from the problem of variability. In the 19th century, French experimental physiologist Claude Bernard argued that individual variability interferes with medical judgment. In his opinion, if we could prove that pathology is just a quantitative deviation from the norm, we would find the key to treating any person, no matter how different he is from the rest. In the end, if pathology is just a deviation, then not only the goal becomes clear, but also the method of therapeutic treatment itself: to return a sick person, organ, cell or system back to normal.
Many biomedical research continues to be based on this point of view; scientists regularly interfere with the work of organisms, cells, and gene networks to determine how these systems function "normally." Researchers are disrupting normal processes in living systems to set standards and find new treatments.
But what do we mean when we talk about normal physiology? As the philosopher Sarah Mogaddam-Taaheri wrote in 2011, if we look at abnormality not as a “broken normality”, but as a qualitatively different state, then it is difficult to understand how such interventions can restore the patient's health.
While researchers may overlook these subtleties, medical philosophers have been analyzing the nuances and trying to define the norm for years. One thought experiment invites us to consider options that are located at the edges of the spectrum and are not considered pathologies: green eyes, color blindness, very tall or very short stature, photographic memory, heightened taste. They can be contrasted with other conditions or variations: which cause inconvenience only in a certain environment (for example, the inability to recover from exposure to ultraviolet radiation); which are problematic only in some cultures or only at certain times (albinism or auditory hallucinations); which are so extreme that they interfere with the normal functioning of the whole organism (like Tay-Sachs disease).
But it is quite possible to live with different problems. For example, there are people who have high IQs and lead normal social lives despite hydrocephalus, a condition in which excess fluid in the ventricular system of the brain expands the skull and often causes serious damage. How can normality be a scientific concept when its spectrum is so wide? And after all, what is normality? Do we understand this word correctly? And how to comply with the norms?
The Czech philosopher Jiri Vaha in 1978 systematized various meanings of normality. “Normal” can mean frequent , that is, the most common among the population, for example, brown eyes in Mediterranean people or blue eyes in Scandinavians. “Normal” can mean average in a mathematical sense, such as average weight or height of a population - such data are often presented on graphs in the form of a bell-shaped curve; or typical , as can be said of a member of a group, population, or species. Sometimes "normal" means appropriate - no defects, deficiencies or irregularities, and sometimes - optimal in terms of peak fitness, this could include physical health or a keen mind. Or the word can be interpreted as ideal in the Platonic sense when it comes to perfect beauty or perfect body. And finally, there is our common daily use of the word, which most often falls somewhere between all these meanings and imagery, from "common" and "standard" to "expected" and "good."
In any case, the use of "norm" in a concrete sense can lead to serious consequences, especially if one considers that in the world it is the "normal" who have a privileged position. Some kind of deviation - from green eyes and voices in the head to life with hydrocephalus - will be abnormal in a given situation: uncommon, rare, atypical, potentially inappropriate, unfavorable, defective in something - and it is necessary from this state to return to the norm. However, it is rather controversial or just strange to consider such variations as pathology, especially if they are useful in some way.
Thanks to the realization of this simple fact, the ambiguity of the word "normal" in medicine has been preserved for centuries. In the 19th century, when Bernard defined illness as “abnormality,” the Belgian mathematician Adolphe Quetelet tried to study the human body using statistics to reveal patterns in individual differences. Since any parameter could become the object of such research, it seemed that everything could be explained in terms of averages; therefore, height, weight, blood pressure, heart rate, birth and death rates can all be represented as pretty curves.
In Quetelet's mind, these mean values began to take on a life of their own; they were no longer descriptions of parameters, but were seen as ideals to be measured against . Indeed, the now controversial Body Mass Index, which is often used to measure health, was originally called the Quetelet Index.
Quetelet believed that these indicators describe the homme moyen , or "average man" - the ideal person that nature could create; it stands at the very center of what probability theory calls the Gaussian distribution. While such a person does not have to exist in reality, mathematical values were considered as a real standard with which one can judge deviations from the norm, that is, about shortcomings. Consequently, "individuality became synonymous with error, and the average person appeared to be a real person." Together with Bernard's views, this approach was an important step towards the privileged position of normality that we see today.
In the 20th century, the French philosopher Georges Cangillem presented a more modern point of view: in pursuing the concept of normality, scientists of the 19th century did not take into account that the biology of evolution speaks of the variability of organisms. In Norm and Pathology (1943), Kangillem describes Charles Darwin's idea that organisms establish and maintain consistency, patterns of work and behavior in order to survive in changing circumstances. Kangil used the term “norm” to refer to various regulatory processes, from internal regulation of hormones to changes in diet, to remind us that no matter how unusual or far from the norm an individual seems to us, he can still be considered normal if his behavior guarantees survival. in a specific environment.
In general, the concept of normality depends on the context. What is normal for one may be unacceptable for another; the same organism may be normal in one environment and abnormal in another. Just look at an innate difference in the ability to process lactose, or an acquired difference: for example, endurance athletes have a larger heart and a slower pulse. Such examples help to illustrate that normality varies among people and that differences and even abnormalities are not yet a sign of pathology.
Environmental relativity is everywhere. There are people with asymptomatic hypertension who, at high altitudes, begin to suffer from chest pain, nausea and shortness of breath. Different people have different abilities to recover from exposure to ultraviolet radiation: they range from minor skin damage to malignant tumors and cancer. There is dyslexia, which, according to some, should be considered harmful only where reading is an integral part of the culture. Even a certain environment is neither normal nor abnormal. Only the relationship between the individual and the environment determines the line between normal and abnormal variation.
Normality can be neither absolute nor universal. At the same time, according to Kangilem, this is not a reason to abandon the study of healthy and pathological phenomena from the point of view of biology. In doing so, we need to look at health and illness, given that within them there are psychological, behavioral and structural patterns, cause-effect relationships and biological norms. Speaking about norms, Kangilem proposes to divide them into “driving” and “repulsive”. Driving norms withstand various perturbations and adapt to changing requirements, they allow the body to overcome obstacles. An immune motive response involves the production of antibodies to fight off hostile bacteria and toxins.
Repulsive norms avoid perturbations and restrict the work of the organism; their fragility requires a strictly defined environment. The repulsive immune response to invaders from the outside includes inflammation, which can lead to hypersensitivity and extreme allergic reactions up to anaphylactic shock.
Cangillem's inductive approach contradicts the conclusions of 19th century scientists and the very concept of normality as an invariable quality, which is so prevalent today. Rather than starting with a rigid definition of normality, from which the concept of abnormality follows, Cangillem's method starts with physiology and then looks for theoretical justifications to explain what it saw.
This method initiated the research that medical philosophers now call naturalization . The answers to the questions should come from observing the manifestations of such qualities as endurance (maintaining constancy in the system despite changes), plasticity (moving between different levels of functionality), homeodynamics (compensation for signs of aging) and fragility (increased sensitivity to change). By means of these and other indicators, biology - not the idea of normality - determines what is characteristic of health and disease.
A systematic biological approach is also more applicable to a changing world in which species are in constant motion, and the organism and the environment must be synchronized. After all, systems can be stable or homeostatic or fragile only under certain external and internal conditions. You cannot talk about the stability of immunity, the gene network, or the whole organism, without specifying many biological variables and environmental parameters. Each system is unique and cannot be separated from the surrounding environment. This brings us to the question: when we talk about health, is health for whom? About what internal and external conditions?
The answers to these questions are critical to understanding health and treating disease. This approach can help to get rid of the very stigma of illness, since we assume that both health and illness are normal, they reflect different patterns and lifestyles. The disease does not contradict nature and does not signal the absence of norms - the norms are simply different . This does not mean that we should elevate illness: we should not see suffering as a blessing and a way to build character, just as we should not see mental illness as a path to enlightenment. On the contrary, as naturalization suggests, the fact that both health and illness are the norm does not mean that they are equal or indistinguishable.
Looking at our biology through the lens of naturalization provides a new perspective on healthy habits. Although the philosophy of Cangillem assumes that only a person himself is able to determine what is good for him, this does not mean that health is just a matter of subjective choice or that everyone has unlimited power in this matter: for example, I prefer X , and you prefer Y. therefore, for me, X is a healthy choice. Human health is individual due to the impact of its unique life history and behavior on the body and mind. So medicine needs to determine what is preferable for each person, depending on his own biology, environment and lifestyle.
All this assumes that medicine should not restore previous norms (which may not exist) after the disease and just time have completely changed the living system. Also, it should not force people to adapt to uniform standards and methods of treatment that are dictated by health authorities, since what is good for one can destroy another. Instead, new, personalized medicine must work with the individual to find a new way of working that takes into account their unique physiology and the capabilities and limitations of their particular environment. In many cases, changing the environment can be more effective than acting on the patient.
Never before has this view been more critical, given the concern that medical institutions are pathologizing normality by introducing a form of treatment that takes social and political values into account instead of the disease itself. Whether it's about the surge in popularity of Ritalin in schools or the ever-changing advice for a healthy diet, what we need most is a philosophy of medicine that is patient-centered and in the context of everyone's life.
