Table of Contents
Presented at ‘Theorizing the Body in Health and Medicine’, Maastricht University, Maastricht, Netherlands, 25-26 November 2015.
Not for citation.
This paper largely concerns grounding concepts that inform medical and social theories of impairment. It discusses impairment in relation to normal function, including its identification as deviation from normal health. It then draws upon phenomenological concepts to develop an alternate account of embodiment, as always already dependent upon relations with things outside itself. It posits that ’normal ability’ is consequently a socio-historical elaboration rather than an objectively existing state of affairs, and that the accompanying prioritisation of some modes of embodiment over others creates the phenomenon called disability. Finally, it outlines an alternative framework that eschews reference to transcendent norms for grounding in capacities and goals, however atypical, of embodied agents.
1.1. Medical and Social Theories of Disability and Impairment #
The meaning of disability is commonly take as settled. It is a personal problem occasioned by a dysfunctional body or property thereof. This ‘medical model’ broadly asserts the following (by degrees). (1) Identity obtains between disability and abnormal individual morphology. (2) This morphology fails to realise normal human function. (3) Disabilities directly cause negative outcomes or health decrements. (4) Consequently, disabilities warrant correction or rehabilitation, which the disabled person should aﬃrm.
Consider Christopher Boorse’s influential species typical function (Boorse 1977, 1997, 2014). Here, health equals conformity with species typical function. This is specified as statistically normal function or design of some ‘reference class’ (species members of similar age and sex). For Boorse, “the normal is the natural” (1977, 554): natural equals species typical design. Normalcy is an objective biological fact, verified statistically for a particular class. This ’empirical ideal’ grounds health judgements. Health is conformity with this ideal; disease deviates from it. Impairment, as deviation from normal function, is pathological, and so is essentially a reduction of health.
Theorists advancing a ‘social model of disability’ dispute that impairment is the preeminent cause of many limitations. Medical definitions do not merely report natural states of affairs, but also ascribe negative meanings to impairments, that acquire the status of “objective fact and common sense” (Kafer 2013: 5). They criticise the medical model for considering disability largely objective, knowable and constant, overlooking not only how properties change, but how experience thereof varies by culture or environment. Minimal attention is paid to other life-affecting circumstances. They suggest that the medical framework itself produces deleterious outcomes. Its pervasive influence may engender a “fallacy of composition… where a false conclusion is drawn about the whole person based on features of her constituent parts” (Smith 2009: 20–21). That disability is considered individual, a “personal tragedy” to be “treated, prevented or cured”, renders disabled people fundamentally unlike, even lesser than, a nondisabled majority (Oliver and Barnes 2012: 20). Removing disadvantage means overcoming disability through cure or personal fortitude. Social participation correlates to approximation of normalcy. Finally, where disability is considered the foremost or total cause of disadvantage, other causes are occluded and alternate responses precluded.
Social modellists reject that disability is immanent to the body. They disambiguate causes into two kinds—biological and social—with corresponding outcomes. Impairment describes mere objective morphological facts, and attendant limitations. Disability describes socially-instantiated discrimination flowing from negative evaluations about impairment; evaluations based in hierarchical divisions between normalcy and deviance whose origin is at least partially medical. Impairment becomes disability on meeting discrimination or an unsupportive environment. Impairment means one cannot walk. Disability occurs where buildings are inaccessible.
1.2. Some Problems of the Social Model #
The social model is laudable for disclosing aspects of disability not entailed by impairment. Yet certain aspects warrant criticism: chiefly, the impairment/disability distinction. This objectifies the body as a brute thing separate from and prior to social experience. First, this upholds persistent dualisms that render the body inert, atemporal and ahistorical: either a clump of inert stuff or mechanistically produced. It is reduced to what phenomenology calls an objective body (Merleau-Ponty 2012): “devoid of meaning, a dysfunctional, anatomical, corporeal mass obdurate in its resistance to signification and phenomenologically dead, without intentionality or agency” (Hughes and Paterson 1997, 329). Lived or agential aspects are transferred to separate social or mental domains.
Second, while disabling social responses to impairment are criticised, the category itself remains unaddressed. Social modellists claim that the medical model falsely overestimates limitations flowing from impairment properties, and rejoins that some, though not all, are spurious. This maintains, and also naturalises, the existing bifurcation into normal and abnormal embodiment. Impairment remains a problematic deviation outside the normal scope of embodiment. Interestingly, Boorse considers his work compatible with disability theory that admits impairment’s objective pathology, while well-known disability theorist Tom Shakespeare (2014) aﬃrms Boorse’s disease concept. For medicine and social model alike impairment equals natural abnormality. Relatedly, this impedes recognition that impairment’s provenance may itself be partially socio-historical and evaluative. This is apparent in contestations over definition: entities designated impairments vary by time and place. More profound still are Susan Wendell’s questions (1996), which inform what follows: how far must one walk to not be disabled? Do contextual variations not contribute?
2.1. Merleau-Ponty and Active Perception #
It bears consideration whether any strict division between normalcy and impairment is tenable, and whether the body is separate from social experience. Accordingly, I will outline a phenomenologically informed account of embodied subjectivity, before addressing the salience of what we might call ’technicity’. An enduring story about human experience supposes that perception and action serve knowledge; and, that objective body serves subjective mind, which is the locus of consciousness and knowledge. This is consistent with what Susan Hurley (2010) calls the ’traditional sandwich model’ of mind and body. The body inputs sensation; then the ‘heavy lifting’ occurs within the brain qua mind as this is organised into knowledge via representation; then finally, this is returned to the world as bodily action. Maurice Merleau-Ponty’s phenomenology rejects such definitive distinction between consciousness and embodiment. For him the body is no inert ventriloquist’s dummy requiring animation. It is an ‘organ’ of movement and connection, one’s very openness to the world. As embodied, as having a particular perceptual structure, and as immersed within the world, it necessarily and immediately has a perspective or comportment. Its world is prereflectively encountered as meaningful situations—where that meaning is structured by past and present interests—and as eliciting responses. Accordingly, the world appears not as Cartesian extensa wherein objects are disinterestedly arrayed and await meaning, but as already charged with sense. ‘Sense’ here connotes something like the French sens: at once meaning and direction. Likewise, the body is not typically experienced as an object, however intimate, but a power of acting towards situations. One does not have, but is, a body that is a “knot of living significations” (Merleau-Ponty 2012: 153). So, in familiar activity, body and world are not given as discrete terms—subject standing over against object—but as prereflective involvement in proximal activity. Knowledge serves activity. Indeed, perception is a kind of incipient action: to grasp the world is to prepare action in response to its solicitations. Consequently, the embodied self is not a substantive. Wherever encountered, it is always disposed, in motion, which is inauguration of sense.
2.2. Sociality and Technicity #
I have so far suggested that the body’s ’essence’ is to act towards situational possibilities, which concurrently inaugurates sense. This can be further developed. The human is traditionally considered bounded, self-identical and enduring, with determinate functions that exist in advance of activities. On one picture, to be human is to by the rational legislator of oneself: a conscious subject whose essence is not found it is body, who owns its body and uses it to realise its consciously-formulated ends (cf. with Hurley’s account above). Everything essential to the human is found in its mind; nothing outside that is essentially human. There is an essence of the human that transcends and endures through changes in its surroundings. Of course, we can propose a different ontology of the human and its embodiment: as something that exists or constitutes itself through its activities, and that is ‘always already enhanced’ through profound incorporation within such activity of extra-organismic materials. Various philosophers call this condition ‘originary technicity’. Technics here does not refer to specific technological objects, but to a constitutive relation of embodied activity with things outside it. And, technology captures the whole gamut of things that allow the development of an associated technique, and thereby modifies and extends what the human can do, and what it is. The human is what it is because of its technological relations. This implies that the human is constituted through creative engagement with things, and that its continued realisation likewise relies upon such relations.
Two interconnected phenomenological aspects are salient: one pragmatic, the other developmental. First, myriad prostheses, broadly construed, are incorporated within activities more usually limited to mind and body. For Merleau-Ponty (2012), the lived body does not terminate at the dermal boundary. He considers the nonsighted man whose integration of cane and bodily intentionality becomes sufficiently profound that the cane is incorporated within his perceptual integrity as he negotiates situational space. It is no longer an external mediating object, but one “sensitive zone” among multiple ‘organs’ that together give him his world (2012, 144). Likewise, experienced wheelchair-users traverse space using sensorimotor knowledge in which their chair is absorbed within this “global awareness of… posture in the inter-sensory world” (2012: 102).1 This is possible due to involvement within world-directed projects. Not only do thought and action overspill embodiment. They emerge from, and supervene upon, processual interactions between brain, body and world: they are enacted in “dynamic interactions between organisms and environments” (Protevi 2014: 127).
Second, prosthetics are profoundly interwoven within the development of the human. For Joanna Zylinska (2010, 156) the human is “always already prosthetic, whereby relationality and dependence on ’the outside’ are the condition of emergence and existence in the world”. This reliance upon self-exteriorisation, composition and assemblage suggests a radical bodily openness. Humans do not merely interact with external things, while remaining essentially unchanged: in transforming technology, they are transformed. A fundamental aspect of human existence has been, and continues to be, meaningful and active negotiation of human-nonhuman boundaries. The history of hominisation is one of co-evolution with tools and prosthetics (Leroi-Gourhan 1993): “a long line of technical prostheses such as flint stones and other ‘memory devices’ that have played an active role in the very process of the constitution of the human” (Zylinska 2010: 157). This constitution remains essentially incomplete.
All bodies are mixed. The human—individual humans, and the human as an ’entity’—is not self-identical but produced through its associations. This has implications for biological-social relations. Recall the phenomenological insight that milieus are disclosed not only according to morphology, but also accumulated experience expressed as habit or comportment. So, worldly possibilities are disclosed as an indivisible compound with organismic and social aspects. There is no pure organism separate from social and technical relations, since comportment is enabled and acquired within a world of already meaningful, historically elaborating assemblages.
2.3. A Biosocial Account of Impairment #
I will now consider implications for impairment. This concerns its status as a supposedly natural dysfunction, rather than socially instantiated disability. My point is that impairment is no more natural than disability. Impairment arises due to the historically elaborated disvalue attached to atypical morphology.
First, contexts delimit in advance which activities are available, and thus which have been assigned value. While a certain body may be unable to realise activities in a given milieu, many purportedly spontaneous and natural objectives and situations are contingent outcomes of the aforementioned harmonisation of bodies and space, that has prioritised a delimited range of morphologies. This grants to typical bodies their apparently natural function. Yet since situations and activities are produced and contingent, so are associated functional norms. There is no essential human function that transcends contexts. Context-transcendent ability would imply some kind of originary, self-sufficient, complete human, as though in the state of nature. As Bernard Stiegler writes, this condition would represent “the absence of relation” (Stiegler 1998: 128). There is no universally valid—that is, ’normal’—mode, but normalised relations that prioritise certain modes.
Put differently, ‘ability’ is not preexistent but realised in situational activity.2 This makes occurrence not merely spatial but temporal. Disability and ability exist as they happen, according to the activity at hand and norms concerning valued activity. There is no ability or disability antecedent of situation, only enabling and disabling relations. ‘Ability’ is less a matter of innate features, and more of temporally-normalised relations between bodies and a world of ‘assistive devices’ that en-able them. The seeming complementarity between ’normal’ humans and environments is not spontaneous, but the outcome of activities, both historical and contemporary, that render the world thus according to a privileged corporeal ideal. Conversely, disability qua impairment is neither reducible to physical properties, nor inherent lack.3 It occurs where supports are absent, or ill-fitting for merely atypical bodies: where an orientated body encounters others with incongruent orientations, or spaces with inapt affordances. The ’normal body’ it is implicitly given at one pole of the body-world circuit, instantiated within milieus of various kinds. One attempts ’normal’ possibilities because these are habitually given as ‘what one does’, and because contexts advert to such affordances. So, environments solicit unrealisable possibilities: however effectively the non-visual person or wheelchair-user comports themselves, they inhabit an environment designed for motility other than theirs.
Though partially instantiated in architecture, cultural products, policy prescriptions, and so on, disability is relational: it is only activated to the extent that these encounter bodies. In this biosocial notion of humanity, categorisations are non-trivial, and affect distribution of resources for activity. Thus, some enjoy affordances while others are denied. It is not intrinsic to an atypical body that it cannot act in a milieu; a historically elaborated milieu only accommodates typical bodies. This does not deny that ability has degrees, only that it is specifiable independent of context and activity. And, it may be enacted differently—aided, or inhibited—by different environments.
3.1. The Problem of Limits: Impairment and The Human #
So, the development of the human has centrally involved production and negotiation of limits, including boundaries between itself and what lies outside it, where this outside has also involved anomalous embodiment. Some such limits are materially embedded: genetic endowments (prioritisation of certain genotypes during prenatal testing), or spatial organisation (inaccessible architecture). Others are epistemic: ways of seeing, thinking and acting incarnated as habit or “maintained in textual, technological, institutional procedures or cultural practices”. (Gallagher 2013: 7) They might be recognised as contingent and somewhat negotiable. While variable in extent—behaviour is more readily modified than morphology—none are truly transcendent, a priori categories. This does not make them arbitrary. They determine in advance what is thinkable or doable (Foucault 2012). This characteristic is not inherently negative, since limits are conditions of possibility: they also enable. Every action reckons within possibilities organised by contextual limits (and implicitly, those limits themselves) (Merleau-Ponty 2012).
Under this aspect, limits are necessary but transformable conditions. Under another, they seem fixed and insuperable. Such is the case when some state of affairs is naturalised as an enduring object, its constitutive processes elided. This occurs routinely with the human. Manifold reasons exist to question the universality of generic humanity with normal form and function. The human emerges relationally: its apparent harmony within the world is not, strictly speaking, spontaneous, but the product of co-evolving processes. However, only the outcomes of such activities are typically endorsed as real. Developmental processes are taken as secondary, or even ignored. This takes the product for producer: it places the ‘ideal human’ prior and external to the circumstances of its elaboration. Its purportedly determinate form and function become transcendent norms constraining bodies and modes of being within a grid of pre-given possibilities. Limit becomes a limitation upon variety, while the body’s fundamental and constitutive indetermination is obscured.
There are related implications for freedom and dependence. As I alluded to earlier, at least since modern thought, the human person has been considered an individual cognising agent, having certain essential attributes, and free—at least in principle—from constraint. Rational, individual autonomy is paramount among such attributes. The body, while partially determined, labours to realise this freedom (Esposito 2015). This becomes another norm transcending life (Campbell 2008). Thus, tool use by nondisabled people appears to merely extend a preexisting and indwelling freedom or ability. Prosthetic use by a putatively impaired person, however, is called assistive; here, the tools are thought to be the sources of freedom or ability, or to compensate for the absence of these capacities. This distinction is specious: it elides how ’nondisabled autonomy’ is likewise dependent upon, and enabled by, constitutive technological associations.
3.2. Limits on the Future #
Why this production of oppositional limits within the heterogeneity of bodies? Foucault famously cites rationalising Enlightenment goals of organised knowledge and administered bodies. Where bodily anomaly was hitherto comprehended through myth or religion, medicine now performs this role. However, he and others note that its relatively simple dichotomies have succumbed to more granular and mobile operations called biopolitics (Deleuze 1992; Esposito 2008; Foucault 1978). These practices address biological capacities and health conditions as political problems. They seek to “optimise, and multiply [life by] subjecting it to precise controls and comprehensive regulations”, by targeting perturbations in phenomena that manifest at the population level: “birth, and mortality… health, life expectancy” (Foucault 1978: 137, 139). The most salient aspect of these processes—processes that Catherine Mills calls a politicisation and “intensification of biological difference” (Mills 2011: 25)—is the aim to “improve life by eliminating accidents, the random element, and deficiencies” (Foucault 2005: 248). That is, biopolitics involves an attempt to master and control the human present, and especially future, by rendering these “regular, predictable, knowable” (Grosz 2004: 111). Keith Ansell-Pearson and Babette Babich both describe such goals as utopian. Instead of life “as it is, with all its trouble and mess” (Babich 2017, 123), these crave life extirpated of all suffering and adversity (Ansell-Pearson 1997). Imagining the possibility of a future purged of disorder, these seek to delimit its outlines in advance.
This is of utmost importance for anomalous embodiment, which affronts not merely by involving ‘hardship’, but due to its unpredictability and unboundedness. It appears to warrant normalisation by exceeding “predictable narratives” (Garland-Thomson 2012, 351). In one prevailing imagined future—called by Alison Kafer a ‘curative imaginary’—atypical bodies have no place: this “understanding of disability… not only expects intervention but also cannot imagine… anything other than intervention” (Kafer 2013: 27). This medicalised temporality cannot conceive a future not governed by present ideals of human perfection. Impairment rehabilitated or cured confirms progress; as un-cured, it either falls outside or impedes it. This is especially apparent in bioethical endorsement of practices like prenatal testing, which take as axiomatic that “we” want children who are “longer-lived, stronger, happier, smarter, fairer” (Harris 2010: 8). For methodologically individualist ethicists like John Harris, this involves prevention of inverse attributes, which for him include atypical properties. Thus these appear as failure to properly realise an ideal future. Such imagined futures do not merely reveal present ideals, but loop back in turn to condition the present. For example, the majority of women in developed countries choose abortion following a Down syndrome diagnosis (Mills 2014).
Concluding Remarks #
With all of this in mind, can there be any justified ethical assent towards biomedical strategies, given that these will most likely prolong normalisation, and implicitly endorse a biopolitical future? Arguably yes, so long as this is accompanied by conceptual work to disclose presuppositions and explore alternatives. I do not argue for or against particular procedures, but am concerned where certain outcomes seem obvious, or are taken for granted. I am sceptical of practices that proceed from abstract types rather than concrete embodiments; from individual autonomy rather than interdependence; and especially, claims based in restoration of full humanity. While not every mode of living is equivalent—some things are experienced as obstacles; bodies do incur restrictions—I reject ideal form or function for the absolute singularity of bodies, and multiple and diverse modes of living.
I finish with several gestures towards a more open account. First, anomaly has nothing essentially to do with health. Catherine Mills notes that for Georges Canguilhem, species typicality illicitly conflates two kinds of norm. Anomaly is synchronic, describing similitude and difference among diverse bodies. Its norms are statistical. Pathology is diachronic, describing temporal modification of life course: how conducive states of affairs are with subjective goals. Its norms are therapeutic and evaluative. Anomaly, as statistical deviation, is not abnormality qua pathology, which involves “direct and concrete feeling of suffering and impotence, the feeling of life gone wrong” (Canguilhem 1991: 129). For Canguilhem, health involves capacity to respond to milieus. Crucially, this is not relative to an absolute ideal—for him no such type exists—but previous states of that life. A bodily state can only be evaluated—can only be normal—relative to milieu and life trajectory. If anomaly does not perturb life activity, it is normal, not pathological, for that person. This might also comport with Merleau-Ponty’s ‘optimal grip’ (2012): an adequate relation to desired outcomes in some context. This norm of optimality could be considered as relative neither to other bodies nor an abstract ideal, but to realising conditions that, however atypical, avail of one’s ‘flourishing’. This can be fruitfully coupled with Anita Silvers differentiation between functional level and mode: “mode is the manner in which a functional outcome is achieved… level is the quantitative degree of the functional performance, such as speed or the strength” (Amundson 2000, 36). For ’normal function’ advocates it is better to approximate normal mode than to function well, precluding “anomalous but effectively adaptive alternative modes” (Silvers 1998: 104). However, if normal function is abandoned, high functional levels are realisable for “very atypical people” using “atypical modes of functioning” (Amundson 2000: 48).
Second, autonomy criteria require modification. Humans are constitutively conditional upon myriad prosthetics. Instead of a binary between normal bodies with (potentially) unlimited freedom of activity, and abnormal bodies whose activity is intrinsically limited, there are heterogeneous bodies within contexts that partially enable them. I reject dichotomisation between dependency and autonomy for a concept of enablement. This captures interrelation between each aspect of activity, addressing the role of context (enabled by) alongside realisation of action (enabled to). A simultaneously richer and more modest autonomy should relinquish the will to individual self-mastery, for a relational form that encompasses and affirms connections with other bodies and technologies.
Finally, there is the future. That humanity is malleable and emerges with situation does not dissolve it outright—it is a profound horizon for life—but implies that its outlines are not unchangeable. Burgeoning biotechnological developments will transform capacities in ways that overspill all extant humans, engendering new, yet-inconceivable, entanglements and enablements. There is no principled reason to differentiate between biotechnical, or medical and social, interventions. Rejection of a normalcy criterion means that proposed interventions need not replicate existing functions. They are only limited by what can be imagined. And, imagining different futures might also allow us to differently imagine, and create, the present.
Works Cited #
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Such insights are augmented by Bach-y-Rita’s study of prosthetic tactile-visual substitution system use by visually-impaired people. Visual stimuli from a head-mounted camera is referred to a vibrotactile activator array, producing a ’tactile image’ on the subject’s back. With time subjects report three-dimensional spatial experience of objects and object-relations, and can enact spontaneous spatial negotiation (including grasping), despite never having seen. See Bach-y-Rita et al (1969). ↩︎
No convenient opposite exists for impairment. I will discuss ‘ability’ in a fairly general sense. Hence I use disability and ability here in a loose sense of ‘(not) being able to do things’, where this is not caused by bodily properties but relations with milieus. ↩︎
For this reason, I consider impairment merely a medical term with limited applicability, and do not consider impairment qua objective abnormality part of the furniture of the universe. Henceforth I will use ‘anomalous embodiment’ to denote mere atypicality, and disability to describe limiting situations based in assumptions that impairments are objectively real. ↩︎