Now that
we have outlined Aristotle’s notion of health, we can investigate how his
political and ethical theory is structured primarily by that notion. The
metaphor of health in political talk involves the application of a few central
principles. Together these principles form the foundation of the
body/polis analogy. The polis is based on moral qualities, and “the
nature of moral qualities is such that they are destroyed by defect and by
excess. We see that the same thing happens in the case of strength and
health, to illustrate, as we must, the invisible by means of visible examples”[1]
Of course it follows that the craft of medicine is like the craft of politics,
and that the doctor is like the statesman.
There
are three key principles which authorize and structure the analogies of a
medical ethics and politics: a) the rule of telic privilege of the whole over
its parts, b) the rule of form over matter, and most importantly, c) the rule
of the mean.
a)
parts, wholes and composites
The
student of politics must obviously have some knowledge of the workings of the
soul, just as the man who is to heal eyes must know something about the whole
body. (Ethics, p.29)
Besides
the structural similarity of the living body to the polis, there exists an
existential relationship: the city-state is the whole and the person is the
part. The polis and the individual body are in contact with and have
effects on each other. If “man is by nature a political animal”[2],
then the healthy or sick human body cannot fail to shape the political order,
even as the regime shapes the health and sickness of the body. The polis
and the body are the same sort of thing: for like the body, “the city belongs
among composite things, and like other composite wholes is made of many parts”.
(Politics, p.86) Composites are relatively autonomous entities composed
of parts which function together for the whole. As we saw, they either
maintain an equilibrium among the elements of which they are composed or suffer
decomposition; both body and polis can be destroyed by strife at the level of
the elements which compose them. In living things, relatively homogeneous
materials are arranged into larger, more complicated wholes, always according
to a strict order. These wholes we can call “organs” (organon). An
organ is a specially functioning unit in which component parts are not
identical to each other but different in character; bones are different than
flesh, flesh different than sinew. The organ is a principle of unity of
structure and function. The hand as grasping, gesturing organ is coordinated
by the needs of the higher whole, the body itself: “‘..for Aristotle the
nature, form, or essence of the animal as a whole is primary and it is
this which determines the proportion of elements in the formation of
individual parts’”. (Tracy, fn. #26, p.170)
Similarly,
the polis is in turn composed of parts which are themselves individual
humans. It is faced with the challenge of integrating people who are very
different into social organs like households and assemblies- “the city is made
up not only of a number of human beings, but also of human beings differing in
kind. A city does not rise from persons who are similar” (Politics,
p.56). A polis is the coordination of dissimilar people into an
integrated set of social organs, a political organization: “The phenomena of
social organization are like a mimicry of vital organization in the sense that
Aristotle says that art imitates nature....Social organization is, above all,
the invention of organs”.[3]
There
are many different levels of part/whole/composite relations, both within the
body and within the city, an ascending pattern of organization and inclusion
into wholes. The body and the polis both stand out by reason of their
relative self-sufficiency (autarkous). (Politics, pp.56, 99) Yet,
they are not of different orders, but articulations along the same continuum of
“form and matter” relations. The self-sufficiency of the city is a
function of its composite nature. (Ibid, pp. 56-7) The distribution and
function of different parts in the whole is determined by a purpose or end
(telos). The telos is the final cause, the principle according to which
the activities of the parts are coordinated for the sake of the
whole. In other words, the whole is the final cause of the parts inasmuch
as they are organized. The value of a part is determined by its overall
contribution to the preservation of the totality: “one should look at the
virtue of the part in relation to the virtue of the whole”. (Politics,
p.54)
The
final cause is the principle which defines the organization of parts into a
whole, and it defines the telos of the arrangement at every level.
Similarly, the soul is the final cause of the body. (On the Soul,
415b14, p. 46) As human beings we are especially defined by our
rationality, the full exercise of our higher soul. Ethical pathology
occurs in a life which has reversed priorities, which is lived for the sake of
the body-“a condition which is bad and unnatural”. (Politics,
p.40) It is the unbridled pursuit of pleasure which destroys regimes, and
the desire for pleasure is rooted in the dunamei of the elements. Matter
in its inherent violence is the principle of pathology.
b)
form and matter
The
term matter, or υλη, is associated with death, and is generally the root of
finitude, the limit of a thing’s possibilities. By virtue of its materiality,
the hylomorphic entity (be its body social or biological) is exposed to
accidents, epidemics or birth into monstrosity; “According to Aristotle, a
monster is an error of nature which was mistaken about matter”. (Canguilhem,
p.278) For Aristotle, knowledge is a relation between the general and the
specific. Actual entities, always made of matter, are knowable only
inasmuch as they can be subsumed under a general category; therefore, matter
radically limits knowledge. A decisive consequence of materiel embodiment
is that patients, as particular entities, are open to chance and always carry
the possibility of being otherwise than they actually are. For that
reason medicine cannot be an exact science (episteme) but is a skill, a τεχνη.
Medicine can have no “fixed dogma because the people to be treated are all
different. There is no ‘man’ as such”[4]
The singularity of the patient (Ethics, p.14) means that s/he is not strictly
knowable, for “Particulars must be perceived, whereas we have understanding in
so far as we get to know universals”. (A. Po., p. 43) Since “actions
belong among particulars” (Ethics, p.54), and politics concerns action,
the doctor and the statesman (again) both work under similar epistemological
limitations: “there are no fixed data in matters concerning action and
questions of what is beneficial any more than there are in matters of
health...the agent must consider on each occasion what the situation demands” (Ethics
,1104a1-10, p.35). The materiality of the hylomorph simultaneously limits
what can be known about it and what can be done for it; for the physical life
of the patient, like the social life of the polis, is an object of
deliberative, not exact, knowledge: “we deliberate about matters which are done
through our own agency, though not always in the same manner, e.g. about
questions of medicine..” (Ethics, 112b3-5 p.61)
For
example, because Aristotle’s account of particularity entails an emphasis on
practice, the concept of luck (τυχη) enters. “Luck and the consequences
of luck happen only to beings with capacity for good fortune and for the
conduct of life (praxis) generally. Hence luck must pertain to practical
affairs” (Physics 197b1-4, pp. 33-4) Luck is an articulation of
the individual’s exposure to the materiality of things, the world of the
incidental, the perverse, the pathological-it is no accident that Greek
physicians had to publicly defend medicine against the charge that “tyche
[luck] and not techne saves men” (Edelstein, p.107), for the physician,
although armed with knowledge, worked in a realm of chance:
In
medicine, anything can mean anything. Pains come from the most diverse
and contrary causes. (ch.42) Likewise, anything can constitute a
medication if only it changes the existing condition. (ch. 45) (Edelstein,
p.108)...incidental [factors] are indeterminate, since any individual may have
an infinite number of attributes. (Physics 196b28-9, p.32) Deliberation,
then, operates in matters that hold good as a general rule, but whose outcome
is unpredictable, and in cases in which an indeterminate element is involved. (Ethics
1112b2-4, p.61)
Medicine
and politics are both attempts to gain experiential, working knowledge of
matter and its combinations, in order to preserve organized composites.: “Moral excellence is concerned
with pleasure and pain...” (Ethics 1104b9, p.37) The human body,
as the seat of pleasure and pain, is also the inner limit of action, the ground
of our socioethical life. In the body, living matter comes into contact
with the traditions of a polis. Ethics is the response to our own body as
a desiring, acting being. The body, like ulh, is a principle of stubbornness
and imbalance. There is a materiel, biological parameter which limits the
possibilities of political life-the actual, medical life of the population, the
bodies whose desires must be governed and cared for. Bodies are volatile,
dynamic, always moving in and out of balance with their environment, seeking
equilibrium and forming new, pathological equilibriums: “No object is in a
constant relationship with pleasure.”[5]
The difficulty of imposing a form on matter is exactly parallel to that
of imposing a regime-and a regimen-on the living, desiring flesh of
people. And as the dunamei interact at the micro level, so desire acts at
the sociopolitical level, tearing apart and holding together larger wholes: “If
a regime is going to be preserved, all the parts of the city must wish it to
exist and continue on the same basis”. (Politics 1270b21-3, p.76)
Besides
the rule of ulh as principle of actualization and finitude, the form/matter
distinction carries a hierarchy: the matter is for the sake of the form,
because the form is always the principle of a higher whole, a level of totality
higher in rank than the that of the wholes which comprise the units of
appropriated matter. The individual in the polis has been integrated into
a higher totality. The purpose of the polis is the good life of the
collectivity, and the regime coordinates the individuals to that end; those who
legislate and rule will ideally work for the common good. As long as they
are successful, the regime will continue, even spanning
generations. The regime is the form (ειδως) taken by a partnership:
Life’s
teleological process is not perfectly infallible...The existence of monsters
(De Generatione Animalium IV.10) shows that nature does make mistakes, which
can be explained in terms of matter’s resistance to form...The form of an
organism is expressed through a rough constant; it is what the organism appears
to be most of the time. Hence we can consider the form to be a norm,
compared to which the exceptional can be characterized as abnormal.[6]
The
polis is by nature (Politics 1253a1-3, p.37), but must be supplemented
by the tecnh of politics, just as the body also exists by nature, but must
attain perfection through the supplement of regimen (and the tecnh of
medicine). “...just as in the case of other craftsmen...material (ulh)
should be available that is suitable to work on...so too in the case of the
political expert and the legislator the proper material should be available in
a suitable condition”. (Politics 1325b39-1326a2, p.203) The regime
creates laws and therefore (by implication) a whole culture of practices; it
marks itself as form on the matter of the living human bodies in the polis:
“The splendid supple physique, the reckless realism and immoralism which
pertains to the Hellene was a necessity, not a ‘natural quality’. It was
produced, it was not there from the beginning...”[7]
A
regime can be identified throughout the flux of living generations who carry
the traditions: “it is looking to the regime above all that the city must be
said to be the same”. (Politics 1276b9-10, p.89) The traditions of
a polis encounter the living ulh of successive biological individuals, being
adjusted to or resisted by the nature of their various flesh. In the city
as in the patient, the ulh-the bodies of the people-is a principle of
illness. For it is ulh which is the source of the body’s desires, and
ulh is unlimited. The elements are, in the final analysis the source
of all desires; the desires of the body, like the volatility of the elements of
which it is composed, are a figure of disorder: “For the nature of desire is
without limit, and it is with a view to satisfying this that the many live”. (Politics
1267b2, p.69) The many (who correspond on the political level to “matter”)
suffer from endemic akolasia (self-indulgence); the “natural appetites” govern
their lives. The word akolasias is “literally the result of not being
punished” (from kolazein, ‘to punish’”-in the Loeb, p.184) The etymology
implies that punishment is a potential “cure”; after all, self-indulgence is a
mild disorder of the experience of pleasure:
An
index of our character is provided by..pleasure or pain...A man who abstains
from bodily pleasures and enjoys doing so is self-controlled; if he finds
abstinence troublesome, he is self-indulgent...[again,] virtue has to do with
pleasure and pain..This is further indicated by the fact that punishment is a
kind of medical treatment and it is the nature of the medical treatments to
take effect through the introduction of the opposite of the disease. (Ethics
1104b16-8, p.37)
If the
part/whole/composite relation allows structural characteristics and
hierarchical principles to be transferred from body to polis, then it is the
principle of telos which allows the city to be judged by a medical norm.
It is according to the end of a thing, what a thing is for, that the
integration of its parts can be called successful or not. In the polis
and in the body, “It does not accord with nature for the part to be preeminent
over the whole, but this is the result in the case of someone having such
superiority” [among equals]. (Politics 1288a26-7, p.116) For the
system which is improperly dominated works against nature, but only for a short
time, since by so doing it kills itself-as tyranny kills the city-state.
c)
the doctrine of the mean
“Too
much and too little food and drink destroys our health; the proportionate
amount, however, produces, increases and preserves it. The same applies
to self control, courage and the other virtues.” (Ethics 1104a17-20,
p.36) Health/sickness is a form taken by Aristotle’s normativity:
deviation from the mean into the extreme constitutes a pathological
condition. In the formation of the ethico-political subject (that is, the
subject who can produce acts which conform to right reason), Aristotle is
concerned with the mean in filling the “natural appetite”. (Ethics
1118b-1119a, pp.79-80) Self indulgence or licentiousness (akolasia)
consists in desiring the wrong things, or enjoying the right things more
frequently and intensely than they should be enjoyed, causing the body to
respond inappropriately to possible sources of pleasure as distributed in
social space. To be self-controlled is to desire rightly, to select an
appropriate frequency, intensity and form of pleasure. It is the doctrine
of the mean (to meson) which determines how we can desire and select objects
correctly.
Ethics
trains the self as an appetitive, social entity, and ethical education
resembles a tecnh. In ethics, we must focus on the same primitive body
(soma) that is the object of medical craft. The body (as opposed to the
cell or tissue or gene) is the level at which Greek medical knowledge, and
Aristotle’s ethical knowledge, both occur. It is because the body is the
prime metaphor for the political collective that Greek medicine can form a
paradigm for political life:
Order
is the oldest concern of political philosophy, and if it is plausible to
compare the polis to an organism, then it is plausible to compare civil
disorder to an illness. The classical formulations which analogize a
political disorder to an illness....presuppose the classical medical (and
political) idea of balance.[8]
The
knowledge of how to be ethical is structured in a way roughly similar to the
knowledge of how to be healthy. The mean is the form taken in
ethical life by health; it specifies the proper arrangement called for by taxis
in terms of balance and proportion.. Within the bones, throughout the
body, in the relations among desires, in one’s political, public acts, and
throughout the polis; the mean appears as the principle of health-durability
and success in function-at each level.
3.
medicine
The Eudemian
Ethics makes the basic comparison explicit (1220a2-4): ‘Just as good
physical condition (euexia) consists of the separate excellences of the parts
of the body, so also of the excellence of the soul...’ (Tracy, p.229)
Greek
medicine was preventive medicine, oriented around the concept of regimen.
It was a medical art which aimed at maintaining the best possible level of
health, more than a set of techniques designed to cure sickness: “the question
of how a healthy man should live in order to remain healthy is just as
important a problem for medicine as the healing of the sick”. (Edelstein,
p.303) Preventive medicine and the lifestyle of the patient were the
dominant themes. The medical tradition on which Aristotle drew so heavily
in his work was grounded in an epistemology and a politics which led to the
dominance of regimen in practice:
medicine
related much more to health than to normality; it did not begin by analyzing a
‘regular’ functioning of the organism and go on to seek where it had
deviated...it referred, rather, to qualities of vigor, suppleness, and
fluidity, which were lost in illness and which it was the task of medicine to
restore. To this extent, medical practice could accord an important place
to regimen and diet, in short, to a whole rule of life and nutrition that the
subject imposed on himself. This privileged relation between medicine and
health involved the possibility of being one’s own physician.[9]
It is
here that we begin to see how virtue and health were so closely associated in
Aristotle’s thought: both are exeis created by regimen. The nature of
regimen entails an economic condition for the production of virtue and health
such that finally, the Nichomachean Ethics can only be addressed to an
aristocracy. Total health and full virtue, by reason of both their causal
interdependence and socioeconomic conditions, belong to those who rule from
merit. The dominant figure of health, the athlete, and the
dominant treatment, regimen, were appropriate to the such a class:
“...the man who wishes to live in accordance with the physician’s requirements
must have time at his disposal and be rich...Only the rich and independent,
therefore, can live in a completely healthy manner”. (Edelstein, p.305)
The political problem of the Ethics is that in the polis, the most
pleasurable items are most readily available to those in whom moderation
carries the highest stake-the rulers. “[The well-off] will be most
particularly in need of philosophy and moderation and [the virtue of] justice
to the extent that they are at leisure in the midst of an abundance of good
things..” (Politics 1334a32-4, p.222) The solution of the Politics
is the aristocratic distribution of physicians and regimen, spare time and
virtue: those who most required regimen were also those to whom it was most
available.
The
aristocratic regimen must negotiate the most intense of all pleasures and
pains; its subjects enjoy the greatest of pleasures, but they also endure the
worst possible pains-the wounds of war-for they must produce victory. As
the word “aristocrat” shares the same root as the name Ares, so the aristocratic
function hinges on the use of heavy arms in the defense of the polis. The
training of the aristocratic body and mind revolves around the political life,
which entails not only political conflict within the council but also physical
conflict with other cities and nations:
In the
model of the hoplite city-state the army does not constitute a specialized body
with its own particular techniques and its own form of organization and
command; nor does warfare represent a separate domain calling for different
abilities and rules of action from those of public life. There is no
professional army...and no categories of citizens specially devoted to the
profession of arms. Military organization is continuous with, and an extension
of, civic organization.[10]
To
maintain health, then, requires the application of tecnh, of medicine.
The doctor is required not primarily to cure the sick, but to maintain and
enhance health. The implication is that as human beings, it is part of
our nature that we live best through tecnh, that we must supplement our own
nature through regimen in order to be fully human. After all, the polis
itself is completely natural-and completely cultural. And it is the polis
which allows us to live as humans by allowing us to work on and recreate
ourselves. Health depends on “a creative way of life”[11];
ethics is “an art of living-as medicine is in the full sense of the word.”
(Canguilhem, p. 87)
Since
it is based on a preventive medicine, Aristotle’s nosology and etiology of
political disorder can lead to few prescriptions in the face of a failed
sociopolitical order. However, he can describe optimal conditions for the
outset or founding of the political system. In the case of a failure,
“the error arises at the beginning, and the beginning is said to be ‘half of
the whole’, so that even a small error there is comparable to any made
throughout the other parts”. (Politics 1303b27-9, p. 153) This
emphasis on origins follows logically from the organic model of political life;
“to recognize an ill (kakon) as it arises in the beginning belongs not to an
ordinary person but rather to a man expert in politics”. (Politics
1308a32-4, p. 163) Where, then, does social illness start?
A
reversibility exists in the way that the sickness and health of the polis and
the sickness and health of the bodies which it governs mutually influence each
other. If the city fails to see that food, water and waste are properly
distributed, the actual bodies of those who live in stricken districts will
grow ill. The city provides a new space for disease: “Infectious
bacterial and viral diseases that pass directly from human to human with no
intermediate host are therefore the diseases of civilization par excellence:
the peculiar hallmark and epidemiological burden of cities and of countryside
in contact with cities.”[12]
The sickness and health of the community is distributed (in part) by the
regime, but the sickness and health of the population in turn determines the
character of the regime. The medical life of the population can totally
transform the political character of a city. The concern with sickness
can in fact become the main concern of a community, creating the regimented,
obsessed regime of the quarantine-during an outbreak of plague in the 17th
century:
First,
a strict spatial partitioning: the closing of the town and its outerlying
districts, a prohibition to leave on pain of death...the division of the town
into distinct quarters, each governed by an intendant. Each street is
placed under the authority of a syndic, who keeps it under surveillance; if he
leaves the street, he will be condemned to death. On the appointed day,
everyone is ordered to stay indoors: it is forbidden to leave on pain of
death...Only the intendants, syndics and guards will move about the
streets...It is a segmented, immobile, frozen space. Each individual is
fixed in his place. And, if he moves, he does so at the risk of his life,
contagion or punishment.[13]
[1].
Aristotle, Ethics 1004a 12-5 Martin
Ostwald, trans. Macmillan, 1962 p.36
[2].
Aristotle, Politics C. Lord, trans.
Chicago, pubs. 1984 p.37
[3].
Georges Canguilhem The Normal and the
Pathological Carolyn R. Fawcett, trans. Urzone, 1989 p.253
[4].
Ludwig Edelstein Ancient Medicine C.
Lilian Temkin, trans. Johns Hopkins, 1967 p.108
[5].
Roland Barthes The Pleasure of the
Text Richard Miller, trans. Noonday, 1973 p.37
[6].
Canguilhem, Ideology and Rationality in
the History of the Life Sciences Arthur Goldhammer, trans. M.I.T., 1988
p.129
[7].
Nietzsche Twlight of the Idols R.J.
Hollingdale, trans. Penguin 1977 p.108
[8].
Susan SontagIllness as Metaphor
Doubleday, 1989 p.76
[9].
Foucault, Birth of the Clinic Alan
Sheridan, trans. Vintage, 1975 p.35
[10].
Jean-Pierre Vernant, Myth and Society in
Ancient Greece J. Lloyd, trans. Harvester 1980 p.36
[11].
Rene Dubos The Dreams of Reason Columbia,
1961, p.96
[12].
W. McNeill Plagues and Peoples
Doubleday, 1976 p.45
[13].
M.F., Discipline and Punish Alan
Sheridan, trans. Vintage, 1979 pp.195
