CHRONI C CONDI TI ON AND NORMALI TY: TOW ARDS THE MOVEMENT
THAT BROADENS THE POW ER OF ACTI NG AND BEI NG HAPPY
1Solange Pir es Salom e de Souza2
Regina Apar ecida Gar cia de Lim a3
Souza SPS, Lim a RAG. Chr onic condit ion and nor m alit y : t ow ar ds t he m ov em ent t hat br oadens t he pow er of
act ing and being happy. Rev Lat ino- am Enfer m agem 2 0 0 7 j aneir o- fever eir o; 1 5 ( 1 ) : 1 5 6 - 6 4 .
This ar t icle is an epist em ological- t heor et ical st udy of t he healt h- disease pr ocess, w hose cent r al discussion
is t he fr ont ier bet w een healt h- disease and bet w een t he nor m al- abnor m al of t he per son in chr onic condit ion. I t
em phasizes t he im por t ance of t he subj ect ive dim ension, w it hout denying t he obj ect ive dim ension of t his pr ocess. I t show s t hat , w hen consider ing t he obj ect iv e aspect of t he healt h- disease pr ocess, t he definit ion of nor m alit y
is based on t he biological indicat or s gr ounded on st at ist ic par am et er s, w hich ar e applied as a r efer ence for all
indiv iduals. When consider ing t he subj ect iv e aspect of t he healt h- disease pr ocess, differ ent nor m alit ies appear ,
as people w it h chr onic condit ions deal w it h daily dem ands in differ ent w ay s, since t he w ay t hey lead t heir life
oscillat es bet w een ex pan sion an d in t r ospect ion . Th u s, h av in g a ch r on ic con dit ion an d bein g able, act iv e an d pow er ful in life m eans t o be aw ake, open and alw ay s m ov ing, cr eat ing new w ay s of being happy .
DESCRI PTORS: h ealt h - disease pr ocess; ch r on ic disease
CONDI CI ÓN CRÓNI CA Y NORMALI DAD: HACI A EL MOVI MI ENTO
QUE AMPLÍ A LA POTEN CI A DE ACTUAR Y DE SER FELI Z
Est e ar t ícu lo es u n est u dio t eór ico- epist em ológico del pr oceso de salu d- en f er m edad, cu y a discu sión
cent r al es la fr ont er a ent r e la salud- enfer m edad y la nor m alidad de la per sona en condición cr ónica. Dest aca
la im por t an cia de la dim en sión su bj et iv a sin n egar la dim en sión obj et iv a de est e pr oceso. Mu est r a qu e, al
con si d er ar el asp ect o ob j et i v o d el p r oceso sal u d - en f er m ed ad , l a d ef i n i ci ón d e l a n or m al i d ad se b asa en
indicador es biológicos calcados en par ám et r os est adíst icos, que se aplican com o r efer encia a t odos los individuos. Cu an d o se con sid er a el asp ect o su b j et iv o d el p r oceso salu d - en f er m ed ad , ap ar ecen d iv er sos n or m alid ad es,
pues la per sona con condición cr ónica lidia con los r equisit os diar ios de diver sas for m as, puest o que su m aner a
de llev ar la v ida oscila ent r e los m ov im ient os de ex pansión e int r ospección. Así, t ener una condición cr ónica y ser capaz, act iv a y pot en t e en la v ida sign if ica est ar despier t o, abier t o y siem pr e en m ov im ien t o, cr ean do
siem pr e n u ev as n or m as par a ser feliz.
DESCRI PTORES: pr oceso salu d- en f er m edad; en f er m edad cr ón ica
CONDI ÇÃO CRÔNI CA E NORMALI DADE: RUMO AO MOVI MENTO
QUE AMPLI A A POTÊN CI A DE AGI R E SER FELI Z
Esse ar t igo é um est udo t eór ico- epist em ológico do pr ocesso saúde- doença cuj a discussão cent r al é a front eira ent re a saúde- doença e ent re o norm al- anorm al da pessoa em condição crônica. Dest aca a im port ância
da dim ensão subj et iv a sem negar a dim ensão obj et iv a desse pr ocesso. Most r a que, ao consider ar o aspect o
obj et iv o do pr ocesso saúde- doença, a definição de nor m alidade baseia- se em indicador es biológicos calcados em parâm et ros est at íst icos, que são aplicados com o referência para t odos os indivíduos. Ao considerar o aspect o
subj et iv o do pr ocesso saúde- doença, sur gem difer ent es nor m alidades, pois a pessoa com condição cr ônica lida
de form as diferent es com as exigências cot idianas, vist o que seu m odo de andar a vida oscila ent re o m ovim ent o
de expansão e o m ovim ent o de int rospecção. Assim , t er um a condição crônica e ser capaz, at ivo e pot ent e na v ida significa est ar desper t o, aber t o e sem pr e em m ov im ent o, cr iando nov as nor m as par a ser feliz.
DESCRI TORES: pr ocesso saú de- doen ça; doen ça cr ôn ica
1 St udy ext ract ed from Doct oral Dissert at ion; 2 RN, PhD, Facult y, Mat o Grosso Federal University College of Nursing, e- m ail: solps@cpd.ufm t .br; 3 RN, PhD, Associat e
Professor, Universit y of São Paulo at Ribeirão Pret o College of Nursing, WHO Collaborat ing Cent re for Nursing Research Developm ent , em ail: lim are@eerp.usp.br
I NTRODUCTI ON
T
h e b a s i c c o n c e p t s g u i d i n g s c i e n t i f i c k n o w l ed g e p r o d u ct i o n i n h ea l t h w er e f o u n d ed o nposit ive science. The scient ific discourse, specialt y and
i n st i t u t i o n al o r g an i zat i o n o f h eal t h p r act i ces w er e
delim it ed on t he basis of obj ect ive disease inst ead of
healt h concept s ( 1). Merely using t he scient ific rat ionalit y
r ef er en ce f r am ew o r k t o u n d er st an d h eal t h en t ai l s
d i f f i cu l t i e s, w h i ch a r e m a n a g e d w i t h i n t h e l i m i t s
inherent t o t he reduct ion process charact erist ic of t he
scient ific const r uct ion( 1- 7).
Th r ou gh dept h , r edu ct ion an d n ar r ow in g of
t h i n k i n g , m o d er n sci en t i f i c r at i o n al i t y at t em p t s t o
explain r ealit y obj ect ively and pr ecisely. This r equir es
t r an slat in g ph en om en a in t o abst r act , calcu lable an d
dem onst r able schem es, so as t o find explanat ions t hat
cor r esponded t o unquest ionable t r ut hs, because t hey
ex pr essed univ er sal law s. The basic char act er ist ic of
m oder n science is t o t r ansfor m concr et e obj ect s int o
a g e n e r a l l a w , w i t h t h e h e l p o f m a t h e m a t i c
lan gu age( 1 , 6 ).
M o d e r n s c i e n c e e x p l a i n s h u m a n b o d y
exper iences t hr ough it s obj ect ivat ion m et hod and t he
r esu lt s of t h ese scien t ific st u dies can n ot be ign or ed
by pr ax is, alt h ou gh t h is does n ot h ide t h e lim it s of
g e n e r a l o b j e c t i v a t i o n ( 6 ). I n m o d e r n s c i e n t i f i c
d e v e l o p m e n t , r e p r e s e n t a t i o n s o f r e a l i t y w e r e
const r uct ed w hich st ar t ed t o be consider ed as t he t r ut h
an d t o ex er t p o w er o n o t h er t y p es o f k n o w l ed g e.
How ev er, scient ific rat ionalit y ignor ed a fundam ent al
aspect : t he lim it of concept s in r elat ion t o t he r eal,
p ar t icu lar ly in q u est ion s in h er en t t o h ealt h , m ain ly
w it h r esp ect t o t h e con cr et e ex p er ien ce of f eelin g
healt hy and get t ing ill( 1).
I n t he 17t h cent ur y, Descar t es concluded t he
ph ilosoph ical for m u lat ion t h at su st ain ed t h e bir t h of
m oder n science. Thr ough his ideas, t he or ganic v iew
m a d e r o o m f o r t h e r a t i o n a l i s t , m e c h a n i s t i c a n d
r ed u ct ion ist con cep t ion of t h e w or ld , in w h ich t h e
hum an body st ar t s t o be consider ed in a w ay sim ilar
t o a m achine( 3,8).
Descar t es’ philosophic const r uct ion pr oposed
t hat clear and dist inct ideas should not be m ixed w it h
t he senses em anat ed fr om t he body. He est ablished
t h e du alist ic r at ion alism t h at separ at es t h e t h in k in g
su b j ect ( r es cog it an s) f r om t h e ob j ect / n at u r e ( r es
e x t e n s a ) “ a s t w o o n t o l o g i c a l l y d i s t i n c t t y p e s o f
ph en om en a, con st it u t in g in t r an sit iv e epist em ological
f ields – t h at of ph ilosoph y an d r ef lex iv e k n ow ledge
on t he one hand, and science and obj ect ive r esear ch
on t he ot her ”( 9). Thus, Descar t es and Kant pr ov ided
t he base for t he t heor et ical fr am ew or k t hat sust ains
scient ific rat ionalit y and underst ands t he reason above
an d b ey on d n at u r e an d h en ce, sep ar at ed f r om t h e
w or ld it obser v es and m anipulat es( 3,7- 8).
Hence, m oder n scient ific r at ionalit y w as bor n
t oget her w it h nat ur al sciences and aim ed t o dom inat e
t h e p h e n o m e n a t h r o u g h t h e n a t u r a l i z a t i o n o f
explanat ions about all obj ect s it applies t o. Ther efor e,
t h r o u g h i t s m e t h o d , i t a t t e m p t e d t o cl a ssi f y t h e
phenom ena, get t o know t he causes and r egular it ies,
w it h a v iew t o discov er ing univ er sal law s t o be able
t o f o r e ca st , d o m i n a t e a n d i n t e r f e r e . I n t h e 1 9t h
cen t u r y, t h is r at ion alit y m odel w as ex t en ded t o t h e
t hen em erging social sciences ( 10) and w as consolidat ed
in m edicine, m ainly t hr ough t he exper im ent al m et hod
defin ed by Clau de Ber n ar d( 2 ).
Wit h a v iew t o t h eor et ical r ef lect ion s abou t
t he t hem e, t his art icle discusses t he norm alit y concept
p r esen t in t h e h ealt h - d isease p r ocess of p eop le in
chr onic condit ions. The cent r al t heor et ical discussion
is based on Geor ge Can gu ilh em ’s epist em ology an d
o n B a r u c S p i n o s a ’ s p h i l o s o p h y , a n d a l l o w s f o r
r ef l ect i o n s ab o u t t h e f r o n t i er b et w een h eal t h an d
disease and bet w een nor m al and abnor m al. To r each
t he obj ect ive, t he t ext w as or ganized as follow s: fir st ,
n o r m al i t y i s d i scu ssed as a q u an t i t at i v e v ar i at i o n
b et w een h ealt h an d d isease; n ex t , n or m alit y as a
qualit at ive differ ence bet w een healt h and disease and,
finally, t he differ ent nor m alit ies pr esent in t he life of
people in chr onic condit ions.
N ORM ALI TY: QUAN TI TATI VE VARI ATI ON
BETW EEN HEALTH AND I LLNESS
Au g u st Com t e an d Clau d e Ber n ar d ex er t ed
a st r ong influence on 19t h cent ur y philosophy, science
and lit er at ur e, as bot h of t hem “ sem ivolunt ar ily played
t h e r ole of f lag b ear er s”( 2 ) of t h e scien t if ic d og m a
en dor sed by biology an d m edicin e, w h ich iden t if ied
nor m al and pat hologic vit al signs as being of t he sam e
k in d, t h at is, pat h ologic ph en om en a as qu an t it at iv e
v ar iat ions of nor m al phenom ena( 2 ).
Com t e’s posit iv ism aim ed t o det er m in e t h e
law s of nor m alit y t hat w er e capable of suppor t ing a
scient ifically- based polit ical doct rine. According t o him ,
all societ ies have an essent ial and perm anent st ruct ure
t o be con sider ed as a disease w h ich polit ics sh ou ld
deal w it h , w it h a v iew t o r et u r n in g t o t h e pr ev iou s
st a t e i d ea l i zed a s n o r m a l , i n t h e sa m e w a y a s a
t r eat m ent . Claude Ber nar d believed t hat t he st udy of
liv e m at er ial p h en om en a t h r ou g h t h e ex p er im en t al
m et h od allow ed f or t h e ex p lan at ion of t h e r elat ion
bet w een ph y siological an d pat h ological ph en om en a,
r ed u cin g t h em t o a com m on m easu r e an d m ak in g
t hem hom ogeneous, j ust lik e gr oss m at t er( 2).
I n 1877, Claude Ber nar d published t he r esult
of his experim ent al st udies and concluded t hat disease
r esult s fr om a dy sfunct ion, t hat is, fr om a v ar iat ion,
w h e t h e r u p w a r d o r d o w n w a r d , i n t h e o r g a n i sm ’ s
nor m al funct ioning. I n addit ion t o r esear ch by ot her
exper t s at t hat t im e, his st udy consider ed t hat disease
is not som et hing ex t er nal ent er ing t he body, but an
alt erat ion in physiological life it self, t hat is, “ it is not hing
m or e t h an t h e or g an ism ’s ow n r eact ion an d , m or e
precisely, t he grow t h in t issue irrit at ion, w hich w ill be
j u dged du r in g a cer t ain per iod as r espon sible f or a
m aj or it y or all of t he pat hological pr oblem s”( 11).
Thus, accor ding t o t his r efer ence fr am ew or k,
disease is any or ganic alt er at ion aw ay fr om w hat is
n o r m a l . I t s d e t e r m i n a t i o n r e q u i r e s t h e n e e d t o
m easur e or ganic funct ions, in or der t o define nor m al
v a l u e s w i t h a v i e w t o r e co g n i zi n g a l t e r a t i o n s a s
a b n o r m a l a n d , t h e r e f o r e , u n h e a l t h y. A l l o f t h i s
dem anded a quant it at ive under st anding, w hich im plied
a m et h od olog ical ch oice b ased on n at u r al scien ce,
w h ose classical p h y sics m od el en t ails t h e n eed t o
m easu r e v ar iat ion s( 1 1 ).
I n a st u d y f r om 1 8 7 8 , Past eu r sh ow ed t h e
ex ist ence of m icr oor ganism s and t heir im plicat ion in
t he t ransm ission of infect ious diseases. Disease st art ed
t o be conceived as a result of t he or ganism ’s invasion
b y ex t er n al ag en t s ( m icr oor g an ism s) t h at p r ov ok e
or gan and t issue dam age. Fr om t hen onw ar ds, each
in f ect iou s d isease st ar t ed t o h av e a sp ecif ic cau se
a n d t h e d i f f e r e n t r e s p o n s i b l e g e r m s w e r e
pr ogr essiv ely isolat ed an d cat alogu ed( 1 2 ).
Mi c r o b i a l t h e o r y c o n t a i n s a n o n t o l o g i c a l
represent at ion of t he disease, in w hich it is considered
as som et h in g en t er in g t h e or gan ism . How ev er, t h is
“ som et hing” st ar t s t o have a nat ur al and no longer a
m agical cau se, lik e w h at h appen ed in t h e pr im it iv e
con cep t ion . Resp ect in g t h e ap p r op r iat e d if f er en ces,
t h i s o n t o l o g i ca l r ep r esen t a t i o n w a s si m i l a r t o t h e
pr im it iv e disease concept ion and left lit t le leew ay for
i m a g i n a r y p o p u l a r i n t e r p r e t a t i o n s . Th i s w a s
r e sp o n si b l e f o r a co n si d e r a b l e p a r t o f m i cr o b i a l
t heory’s success ( 2,11). “ How ever, it is w hen w e feel t he
n eed t o t r an q u i l i ze o u r sel v es t h at an g u i sh p u t s a
co n st a n t w e i g h t o n o u r t h o u g h t s a n d , w h e n w e
delegat e t o t he m agical or posit ive t echnique t he t ask
of r est or ing t he or ganism affect ed by t he disease t o
t h e n or m , it is becau se w e do n ot ex pect an y t h in g
good fr om nat ur e in it self”( 2).
I n t h i s c o n t e x t , n a t u r e d i d n o t d i r e c t l y
int er fer e in t he healt h r eest ablishm ent pr ocess. This
w as subst ant ially differ ent from t he Greek concept ion,
in w hich nat ur e, bot h out side and inside t he hum an
being, w as seen in balance and har m ony. I f disr upt ed,
t his cr eat ed disease, seen as nat ur e’s effor t t o achieve
a n ew balan ce. Th e cu r e pr ocess ack n ow ledged t h e
ex ist en ce of cu r at iv e n at u r al f or ces in h er en t in liv e
o r g a n i sm s. Tr ea t m en t i n v o l v ed cr ea t i n g f a v o r a b l e
con d it ion s t o allow t h ese f or ces t o act in t h e cu r e
p r ocess. Th er ef or e, t h e Gr eek con cep t ion w as n ot
ont ological and localizing, like in t he case of m icrobial
t h eor y, bu t dy n am ic an d t ot alizin g ( 2 ). “ Nob od y can
cont est t he opt im ist ic char act er of infect ion t heor ies
in t er m s of t heir t her apeut ic ext ension. The discover y
of t ox in s an d t h e ack n ow led g em en t of t h e sp ecif ic
and individual gr ounds’ pat hogenic r ole dest r oyed t he
ad m ir ab le sim p licit y of a d oct r in e, w h ose scien t if ic
clot h in g d issim u lat ed t h e p er sist en ce of a r eact ion
t ow ards evil, w hich is as old as m an him self”( 2).
Al t h ou g h t h ey ex p l ai n d i f f er en t si t u at i on s,
s c i e n t i f i c a d v a n c e s c a n n o t h a n d l e t h e e n t i r e
com p lex it y in v olv ed in t h e h ealt h - d isease p r ocess.
I n t his per spect iv e, it is obser v ed t hat , by it self, t he
pr esence of bact er ia in an or ganism is not enough t o
char act er ize t heir bear er as ill. I t is concluded t hat ,
for people t o be consider ed ill, t he num ber of invading
m icr oor ganism s has t o exceed a r at e t hat is consider ed
n or m al( 1 2 ), ab ov e w h ich t h e or g an ic r eact ion is n o
longer phy siologic but becom es pat hologic, t hat is, a
d i sease.
Thus, t he nor m alit y concept w as st r engt hened
a s a f u n d a m e n t a l sci e n t i f i c p a r a m e t e r t o d e f i n e
h ealt h . Fr om t h is poin t on w ar ds, disease st ar t ed t o
b e u n d e r s t o o d i n t e r m s o f d e v i a t i o n s f r o m t h i s
nor m alit y, t hat is, people m ov ing aw ay fr om nor m al
lev els in any dir ect ion ar e consider ed ill( 12).
Th u s, sci en t i f i c st u d i es st a r t ed t o l o o k a t
healt h w hen it is r educed t o st andar ds t hat should be
r e st o r e d . H o w e v e r, d i se a se b e ca m e a p r i v i l e g e d
s c i e n t i f i c o b j e c t , b e c a u s e i t a t t e n d e d t o t h e
m et h od olog y in h er en t in m od er n scien ce. Th is w as
ph y sical- biological body t h at can be m easu r ed an d,
t h e r e f o r e , s c i e n t i f i c a l l y s t u d i e d , b a s e d o n a
fr agm ent at ion of t his body, w hich w as consider ed on
t he basis of m orphological and funct ional const ant s( 1).
I n t his cont ext , in t he developm ent of scient ific
rat ionalit y in healt h, t he focus cent ered on disease as
a deviat ion fr om nor m al. Then, t his nor m al becam e a
synonym of healt h and t he sick per son w as r elegat ed
t o t he back gr ound. This per son w as t hen consider ed
a s p a s s i v e , a s s o m e o n e w h o a w a i t s h e l p f r o m
som eon e w h o, in t h e n am e of k n ow ledge, at t em pt s
t o r eest ab lish t h e lost n or m alit y, w h et h er t h r ou g h
t r eat m ent s or nor m at ive pr escr ipt ions t o be follow ed.
Or igin ally, t h e t er m n or m com es fr om Lat in
and m eans squadr on, w hile t he t er m nor m al m eans
perpendicular. A norm is a rule t hat serves t o rect ify,
im p lem en t , st r aig h t en ( 2 ). Th u s, a n or m i s w h at i s
adopt ed as a base or m easur e t o car r y out or assess
som et hing; it is a pr inciple; r ule; m odel; st andar d( 13).
Hence, a norm is som et hing t hat exist s t o be follow ed.
Norm al is w hat or w ho follow s t he nor m . I n t his sam e
cont ext , st andardizat ion is t he act of effect of cr eat ing
and est ablishing norm s. Norm alizat ion, in t urn, is t he
r et u r n t o t h e n or m al st at e, t o n or m alit y. Abn or m al,
on t he count er par t , is w hat is out side t he nor m ; w hat
is against t he rules; w hat is irregular( 13), t hat is, w hat
o r w h o d o e s n o t f o l l o w t h e e st a b l i sh e d n o r m i s
con sid er ed ab n or m al.
The nor m can be seen as m eans used t o an
end, hence t ak ing t he for m of guidelines, r egulat ions
o r p r escr i p t i o n s( 1 2 ) t h at ar e set b y so m eo n e ( e. g .
healt h st aff ) and or ient ed t o an addr essee ( e. g. t he
sick per son) . Cust om s ar e nor m s, as t hey det er m ine
ce r t a i n st a n d a r d s o f co n d u ct t h a t , i n a w a y, p u t
pressure on individuals w it h a view t o t heir adj ust m ent
t o t hese st andar ds. The cust om cont r olled by a societ y
is a social norm , because it is a t ype of behavior t his
societ y r equ ir es, u n der pen alt y of pun ishin g any one
w ho does not behav e as desir ed( 12).
The concept s or iginat ed fr om t he w or d nor m al
ar e used in a w ide r ange of cont ex t s, alt hough t heir
m e a n i n g i s n o t a l w a y s p r e c i s e l y d e l i m i t e d o r
su g g e st e d . Th i s i s w h e r e d i f f i cu l t i e s t o d e f i n e a
sit uat ion as norm al com e up, as it is not alw ays clear
w h o o r w h a t d e t e r m i n e s a n o r m a n d o n w h a t
par am et er s t hese nor m s ar e based. I n t his cont ex t ,
t h e j u d g m en t t h a t d ef i n es a n o r m w i l l a l w a y s b e
subor dinat ed t o t he per son w ho est ablished it ( 2). “An
invest igat ion of st udies fr om m any ar eas leads t o t he
belief t hat t he use of t he t er m nor m alit y is guided by
consensus. An analysis of possible m eanings leads t o
d i f f e r e n t c o n c l u s i o n s , w h o s e c o m p a t i b i l i z a t i o n
som et im es r equ ir es con sider able effor t ”( 1 2 ).
I n cl i n i ca l p r a ct i ce , d i se a se i s co n si d e r e d
abnor m al, w hile healt h is consider ed nor m al. Nor m s
for count less clinical variables, such as w eight , height ,
p u l s e a n d b r e a t h i n g a r e s t a t i s t i c a l l y b a s e d a n d
c o n s i d e r e d i n t e r m s o f a v e r a g e , a n d t h e s e a r e
associat ed w it h “ cer t ain t oler ance int er v als, w hich in
t ur n char act er ize a nor m al v ar iat ion”( 12).
St at ist ical n or m alit y d oes n ot sat isf act or ily
at t end t o all cases in w hich healt hy per sons need t o
be dist inguished fr om t he ill. One of t he r easons for
t h i s d i f f i cu l t y i s t h e f act t h at cl i n i cal an d m ed i cal
pr act ice m ix m et r ic and non- m et r ic elem ent s. Hence,
t he applicat ion of st at ist ical nor m alit y in m edicine is
lim it ed( 12).
This lim it at ion is due t o t he st at ic and punct ual
ch ar act er of clin ical st at ist ical v ar iables, w h ich lose
t h e p er cep t ion of m ov em en t , r ed u cin g t h e h u m an
b ein g t o t h e “ b od y, t o t h e v isib le an d m easu r ab le,
ign or in g t h e m en t al, t h e dy n am ic, ex per ien ce, t h at
is, t he act ual condit ion of t hat body w it h r espect t o
lif e an d it s act iv it ies an d pr oj ect s. Th e body is n ot
only w hat one can see, and t he visible does not alw ays
allow for m easur ing”( 14).
I n v iew of t h is d iscu ssion ab ou t st at ist ical
n or m al i t y an d t h e n or m as a r u l e, “ n or m al i s t h e
per son w ho adj ust s t o t he nor m s. Whoev er at t em pt s
t o r each a goal an d f ollow s in st r u ct ion s, obey s t h e
r u les of a g am e an d d oes n ot m ak e an y f or b id d en
m ov es, w h o accom pan ies t h e r egu lat ion s is n or m al.
On t h e ot h er h an d , ab n or m al m ean s n ot f ollow in g
g u i d e l i n e s, m a k i n g i l l e g a l m o v e s, i g n o r i n g r u l e s,
f leein g f r om cu st om s, t u r n in g on e’s b ack on m or al
pr inciples”( 1 2 ).
Thus, nor m alizat ion em er ges fr om t he need
t o q u an t i t at i v el y d i f f er en t i at e b et w een h eal t h an d
d i s e a s e . Th e r e i s c o n s i d e r e d t o b e a c o n t i n u i t y
b e t w e e n h e a l t h a n d d i s e a s e , i n w h i c h d i f f e r e n t
q u a l i t i e s a r e n o l o n g e r s e e n b u t u n d e r s t o o d a s
g r a d u a t i o n s f r o m o n e t o a n o t h e r, t h a t i s , a s
physiological variat ions( 12). There is a need t o est ablish
nor m s in or der t o define w hat is nor m al and, hence,
healt hy and desirable, in cont rast w it h w hat flees from
t h is n or m al an d en t er s t h e space of t h e pat h ologic,
ill, abnor m al and, t her efor e, not desir able.
W i t h i n t h i s f o cu s, h ea l t h a n d d i sea se a r e
sim ilar t o life and deat h. Ther efor e, nor m alizat ion is
disease sit uat ion t hat flees from norm alit y, t here is a
need t o k now w hat should or should not be done t o
r eest ab lish h ealt h . Th is k n ow led g e, w h en acq u ir ed
t h r o u g h sci e n t i f i c m e t h o d s, h a s t h e a u t h o r i t y t o
prescribe norm s, as it is legit im ized as t r ue by m oder n
scien t if ic pr em ises.
N ORM ALI TY: QUALI TATI VE D I FFEREN CE
BETW EEN HEALTH AND I LLNESS
I n his doct or al disser t at ion defended in 1943,
Canguilhem br eak s w it h t his concept ion of healt h as
ad ap t at ion t o a p r ed ef in ed n or m an d sh ow s h ealt h
and disease as t he ex pr ession of differ ent st andar ds,
w h i c h a r e n o t o n l y l i m i t e d t o t h e a d a p t a t i o n
per spect ive. He opposes t he t hesis accor ding t o w hich
p a t h o l o g i c a l p h e n o m e n a a r e i d e n t i c a l t o t h e
c o r r e s p o n d i n g n o r m a l p h e n o m e n a , e x c e p t f o r
quant it at iv e v ar iat ions( 2 ).
Now ad ay s, v ar iou s au t h or s h av e look ed at
Ca n g u i l h e m ’ s w o r k , m a i n l y w i t h r e s p e c t t o h i s
concept ions about norm alit y and healt h, as t hese m ake
it possible t o ret hink t he concept ual bases of healt h on
t he basis of epist em ological prem ises ( 1,3- 5,7,15).
Al t h ou g h i n t h e f i el d of som at i c n osol og y,
Ca n g u i l h e m ’ s t h i n k i n g c o n s t i t u t e s a n i m p o r t a n t
ep ist em olog ical b ase f or n ew d ev elop in g collect iv e
healt h t heor ies, consider ing t he heur ist ic pot ent ial of
h is ideas abou t n or m alit y, ph ilosoph ic an d scien t if ic
healt h. Som e cr it icism against his st udies ev idences
t h a t h e su p p o se d l y r e d u ce d t h e h u m a n w o r l d t o
biological values. How ev er, a st r ong char act er ist ic of
h i s t h i n k i n g i s t h e co n si d e r a t i o n o f so ci o p o l i t i ca l
aspect s( 4 ).
Accor ding t o Canguilhem , hum an nor m s ar e
n ot det er m in ed as f u n ct ion s of an or gan ism t h at is
s e e n a s a m e c h a n i s m l i n k e d w i t h t h e p h y s i c a l
en v ir on m en t , b u t as act ion p ossib ilit ies in a social
si t u a t i o n . Th e h u m a n b o d y ’ s f o r m a n d f u n ct i o n s
ex pr ess socially adopt ed w ay s of liv ing. Hence, t hey
ar e not j ust t he ex pr ession of condit ions im posed on
life by t he env ir onm ent . Social and cult ur al cont ex t s
influence t he det er m inat ion of hum an or ganic nor m s,
d u e , a m o n g o t h e r f a ct o r s, t o t h e p sy ch o so m a t i c
relat ion. Canguilhem qualit at ively different iat es healt h
f r om disease an d est ablish es an or igin al dist in ct ion
bet w een nor m alit y and healt h, in w hich nor m alit y, as
a life nor m , com poses a br oad cat egor y t hat cov er s
healt h and disease as subcat egor ies( 2).
I n t h is per spect iv e, h ealt h an d disease ar e
locat ed in t he field of norm alit y, as bot h of t hem im ply
a cert ain life norm . Consequent ly, disease is no longer
t he opposit e of nor m al and becom es t he opposit e of
healt h. Abnorm al is no longer seen as t he absence of
norm alit y, because t here is no life w it hout life norm s,
as ev en t he m or bid st at e is a w ay of life. The point
disease and healt h hav e in com m on is t he pr esence
of a logic, of a char act er ist ic or ganizat ion, of a nor m
t h at w ill alw ay s b e p r esen t , ev en u n d er ab n or m al
con dit ion s. Th u s, abn or m alit y does n ot in dicat e t h e
ab sen ce of n or m s, b u t t h e p r esen ce of a d if f er en t
nor m t han w hat is expect ed ( 2).
Disease ent ails a cert ain degree of incapacit y
t o cr e a t e n e w n o r m s. H o w e v e r, i n g e n e r a l , t h i s
in capacit y is t em por ar y, as n ew n or m s ar e cr eat ed,
differ ent fr om ear lier ones, on t he basis of t he new
s i t u a t i o n i n s t a l l e d b y t h e d i s e a s e . A n d t h i s ,
independent ly of t he t ype of disease, becom es healt hy.
Due t o t he ir r ev er sibilit y of biologic nor m at iv it y, cur e
b e co m e s t h e ca p a ci t y t o cr e a t e n e w l i f e n o r m s,
s o m e t i m e s s u p e r i o r t o p r e v i o u s o n e s . “ Lu c i d
aw ar en ess o f t h e f act t h at cu r i n g d o es n o t m ean
r et ur ning [ t o t he pr ev ious st at e] helps t he pat ient in
his sear ch for a st at e m ar ked by a m inim um level of
r enouncem ent , r eleasing him fr om being fix ed in t he
pr ev ious st at e”( 2).
Th e i r r e v e r si b i l i t y o f b i o l o g i c n o r m a t i v i t y,
defended by Canguilhem , can be under st ood in a w ider
sense, consider ing social, m ent al and env ir onm ent al
issues ( 7). Not being a m achine, t he hum an being is
alw ay s t r an sf or m in g h im self, m at u r in g , ad v an cin g .
Hence, t his nor m at iv e ir r ev er sibilit y r esult s fr om t he
com plex it y of each being’s ex per iences ( 1 6 ).
T h u s , w h i l e h e a l t h i s c h a r a c t e r i z e d b y
op en in g t o m od if icat ion s an d b y t h e est ab lish m en t
of new nor m s, disease cor r esponds t o t he t em por ar y
or definit iv e im possibilit y of changes and unr est r ict ed
com pliance w it h nor m s. Mor eov er, healt h im plies t he
p o ssi b i l i t y o f g e t t i n g i l l , t h e t e m p o r a r y st a t e o f
d isease an d t h e cap acit y t o leav e t h e p at h olog ical
st at e ( 2).
Th i s e n t i r e t h e o r e t i c a l c o n s t r u c t i o n b y
Ca n g u i l h e m l e a d s t o t h e p r o p o sa l t o r e f o r m u l a t e
h eal t h p r act i ce, i n w h i ch t r eat m en t an d d i ag n o si s
sh ou ld p r iv ileg e ob ser v at ion an d t h e sick p er son ’s
p er sp ect iv e. Disease est ab lish es a n ew w ay of lif e
w h ich t r eat m en t n eeds t o r espect , an d t h e pr im ar y
g o a l s h o u l d n o t b e t h e r e t u r n t o a p r e v i o u s l y
Th e u n d e r st a n d i n g o f h e a l t h a n d d i se a se
should not rem ain rest rict ed t o biological and st at ist ical
cr it er ia only, but expanded by a per spect ive in w hich
t h e n o r m s t h a t d e f i n e h e a l t h a n d i l l n e s s a r e i n
accordance w it h t he w ays life is led, w hich each hum an
b e i n g i s i m m e r s e d i n , w i t h g r e a t e r o r l e s s e r
t ransform at ive capacit y. I f, on t he one hand, t he healt h
concept is r elat ed t o or ganic funct ions, on t he ot her,
it should also r elat e t o t he subj ect ive body( 3).
Thus, life doe snot k now indiffer ence, it is a
d y n a m i c p o l a r i t y i n w h i c h m o v e m e n t a n d
t r ansfor m at ion ar e closely r elat ed, am ong ot her s, t o
h e a l t h - d i se a se , t o i n d i v i d u a l - e n v i r o n m e n t , t o t h e
nor m al- abnor m al, and in w hich nor m at iv e capacit y is
som et im es m an if est ed m or e op en an d d y n am ically
an d som et im es m or e r est r ict edly( 2 ).
Th e dy n am ic polar it y w it h t h e en v ir on m en t
is w hat defines a liv ing being. I n t he case of hum an
beings, t he environm ent is not only physical, but also
social, cult ur al, am ong ot her s. Hence, t his is about a
p olar ized act iv it y, w h ose ex t r em es ar e h ealt h an d
illn ess; an d at t h e sam e t im e a n or m at iv e act iv it y,
w hich indicat es one of t he poles as w ant ed and t he
ot her as unw ant ed. This dy nam ic polar it y is differ ent
in each h u m an b ein g an d t h is d if f er en ce b ecom es
f u n d a m e n t a l a c c o r d i n g t o e a c h b e i n g ’ s s e t o f
capacit ies or pow er s t o cope w it h t he aggr essions he
is ex posed t o( 3).
Polar it y – h ealt h - disease, n or m al- abn or m al,
in sp ir at ion - ex p ir at ion , sleep - aler t , lif e- d eat h , is n ot
a n a b so l u t e e x p e r i e n ce t h a t b e l o n g s t o d i f f e r e n t
cat egor ies. I n st ead, it com poses on e an d t h e sam e
realit y, t hat is, part s of a w hole, in const ant int eract ion,
highly int erdependent , in w hich one pole cannot exist
w it hout t he ot her. This unit y, const it ut ed by opposit e
poles, does not em er ge fr om a st at ic ident it y, but as
a dynam ic int er act ion bet w een t w o ext r em es. Denying
t h e ex ist en ce an d f igh t in g again st on e of t h e poles
m eans fight ing against t he Whole( 17).
I n t h e Gr eek v iew , b ein g in t eg r ally m ean s
being healt hy, being com plet e. Dist ur bing t he w hole
a r o u s e s t h e p r e s e n c e o f o u r c o r p o r a l i t y i n o u r
c o n s c i e n c e . Th i s w e n t b y u n n o t i c e d b e f o r e t h e
d i st u r b an ce. On ce h i s w el l - b ei n g i s d i st u r b ed , t h e
hum an being t urns t ow ar ds him self and it is only t hen
t hat he per ceives t hat , befor e being dist ur bed, he w as
aw ak e, open and r ecept iv e( 6).
Disease cr eat es an in t r ospect ion m ov em en t
t hat leads us back t o our int er ior w or ld and m akes us
per ceiv e, feel and see our selves. Consequent ly, t o a
cer t ain ext ent , t his int r ospect ion m ovem ent dist ances
us fr om t he ext er nal w or ld. When looking at t he st at e
o f w e l l - b e i n g b e f o r e t h e d i s e a s e a p p e a r e d , t h e
f o l l o w i n g d o u b t em er g es: “ w h a t i s i t t h a t r ev o l t s
against t his st at e, t his dist urbance t hat , w hen w e feel
bad, leads t o dist ancing fr om ever yt hing t hat happens
on t he out side?”( 6).
This quest ion w as r einfor ced by t he Ger m an
poet Rain er Mar ia Rilk e w h o, w h en con f r on t ed w it h
a n i n c u r a b l e d i s e a s e t h a t c a u s e d s t r o n g p a i n ,
com plained t hat t he pain obliged him t o r em ain locked
up inside him self, inside t he pain, w it hout m anaging
t o part icipat e in t he place he w as in ( 6). I n ot her w or ds,
t h e p a i n en t a i l ed t h e i n t r o sp ect i o n m o v em en t b y
isolat ing t he pet fr om t he ex t er nal w or ld and closing
him in inside his int er ior w or ld.
Cu r r e n t m e d i c a l s c i e n c e h a s a n a l m o s t
vir t uous capacit y t o elim inat e pain, t ur ning m any pains
and diseases t r ansit or y. The abilit y t o suppr ess pain
h as r em ov ed it f r om it s p lace in t h e h u m an v alu e
scale, as pain t en ds t o t r an sf or m w h en t h er e is n o
h o p e o f d i sa p p e a r i n g o r w h e n i t s su p p r e ssi o n i s
cert ain( 6). I f people ar e able t o quest ion t heir disease,
it w ill alw ay s h av e som et h in g t o com m u n icat e t h at
can help t hem .
“ Ther e ar e w ays of being ill, accor ding t o t he
w ay s of t h e illn ess. Som e diseases ar e v isit s: t h ey
ar r ive w it hout w ar ning, dist ur b t he peace of t he hom e
a n d g o a w a y. Th a t i s t h e ca se o f a b r o k e n l e g ,
appendicit is, a cold, m easles. Once t he right t im e has
passed, t he disease picks up it s bag and leaves. And
ev er y t hing r et ur ns t o how it alw ay s has been. Ot her
d i s e a s e s h a v e c o m e t o s t a y. A n d i t i s n o u s e
com plaining. I f t hey hav e com e t o st ay, w e need t o
d o w i t h t h e m w h a t w e w o u l d d o i f a n y o n e
per m an en t ly m ov ed in t o ou r h ou se: ar r an ge t h in gs
in t he best possible w ay so as t o avoid j oint life fr om
b ein g p ain f u l. Wh o k n ow s on e m ay ev en g et som e
benefit out of t he sit uat ion? [ ...] Hence, if you m ake
friends w it h your disease, it w ill give you free lessons
about how t o live w iser ”( 18).
CH R O N I C CO N D I T I O N : P R ESEN CE O F
DI FFERENT NORMALI TI ES
Peop le w it h ch r on ic con d it ion s st ar t t o liv e
w it h t hem and it is expect ed t hat t hey w ill at t em pt t o
accept t hem . And t hat is not easy, as t he disease, in
w ell- being. Lear ning t o accept t he disease oft en m eans
accept ing w hat is giv en, w hat is lim it ed and painful,
bu t ou r h u m an side con sist s in alw ay s k eepin g t h e
fu t u r e open an d allow in g for n ew possibilit ies ( 6 ). I n
t h is p er sp ect iv e, n or m alizat ion is p er ceiv ed as t h e
possibilit y of ch an ge, of t r an sf or m at ion , of cr eat in g
n or m s d er iv in g f r om n ew h ealt h lev els est ab lish ed
on t he basis of t he disease( 2).
“ Som et im es, I t hink about w het her w e do not
n eed t o r edefin e t h e concept s of h ealt h and illn ess,
so as t o see t hem in t er m s of t he or ganism ’s capacit y
t o cr eat e a new or ganizat ion and or der, adequat e t o
it s special and m odified disposit ion and t o it s need,
m or e t h an in t er m s of a r igidly def in ed ‘n or m ’. Th e
d i s e a s e i m p l i e s a c o n t r a c t i o n o f l i f e , b u t t h e s e
con t r act ion s d o n ot n eed t o occu r. I t seem s t o m e
t hat alm ost all of m y pat ient s seek life – and not only
in spit e of t heir condit ions, but because of t hem and
even w it h t heir help”( 19).
I n t h is con t ex t , h ealt h an d d isease h av e a
r h y t h m t h at ch ar act er i zes t h em as p o l es t h at ar e
com plem en t ar y an d belon g t o lif e. Th u s, disease is
no longer j ust relat ed t o w hat is lim it ed, t o deat h, t o
pain, t o suffer ing, t o t he absence of m ovem ent s, as it
st ar t s t o be under st ood as a par t of t he m ov em ent s
o f l i f e. Heal t h as a p r o cess i m p l i es act i v i t i es an d
changes t hat even include t em por ar y disease phases.
Ch r on ic con dit ion s ar e ch ar act er ized by t h e
f act t h at t h ey ar e n ot t em p or ar y, as t h ey b ecom e
p ar t , w h et h er f or a lon g or in d et er m in at e t im e, of
people’s lives. How ever, t his does not m ean t hat t hese
p er son s alw ay s f eel ill, sin ce an ot h er ch ar act er ist ic
o f ch r o n i c co n d i t i o n s r e f e r s t o e x a ce r b a t i o n a n d
r em i ssi o n p h a ses. I n a n ex a cer b a t i o n p er i o d , t h e
f a m i l y n e e d s t o g e t c l o s e r t o t h e s i c k p e r s o n s ,
c h a r a c t e r i z i n g a c e n t r i p e t a l p r o c e s s , t h a t i s , a
m o v em en t o f f am i l y i n t r o sp ect i o n ; i n a r em i ssi o n
per iod, on t h e ot h er h an d, gr eat er au t on om y n eeds
t o b e p r o m o t e d f o r t h e p a t i e n t , ch a r a ct e r i zi n g a
cent r ifugal or ex pansion m ov em ent( 2 0 ).
D u r i n g t h ese ex p a n si o n a n d i n t r o sp ect i o n
m o v e m e n t s , t h a t i s , d e a l i n g s o m e t i m e s m o r e
int ensely w it h t he int er nal w or ld and at ot her t im es
m o r e i n t en sel y w i t h t h e ex t er n al w o r l d , p eo p l e i n
chronic condit ions feel m ore at ease or m ore rest rict ed
in t heir ow n norm s and in t hose ruling t heir peers.
Healt h has a nor m at iv e plast icit y t hat is not
r est r i ct ed t o an av er ag e o r t o an i d eal , i m p o si n g
st andar ds of conduct fr om t he t op dow nw ar ds, fr om
t he out side t o t he inside or from t he universal t o t he
s i n g u l a r( 2 ). B e i n g h e a l t h y m e a n s b e i n g a b l e t o
incor por at e nor m s t hat differ fr om t hose r uling unt il
t hen, and even pat hological nor m s, w it hout losing t he
abilit y t o act . Thus, people can be ill – et ym ologically
speaking not firm – and cont inue able and healt hy in
sev er al ot h er aspect s of lif e. People can lie ou t side
t he aver age of cult ur al ideals of healt h, but m ay st ill
be able, act iv e and happy( 16).
Being able, act iv e and pot ent in life, despit e
being obliged t o liv e w it h a chr onic condit ion, m eans
being aw ake, open and alw ays m oving. I t also m eans
b ei n g ab l e t o d eal w i t h ch al l en g es b y ov er com i n g
adv er se condit ions, in t he at t em pt not t o r est r ict t he
w ay of leading one’s life t o t he lim it at ions of chr onic
con dit ion s. Th er efor e, t h er e is a n eed t o seek w ay s
of m ax im izing coping abilit ies, t hat is, each per son’s
pot ency( 2- 3, 6,16).
Au t h or s in t h e h ealt h ar ea( 7 , 1 4 , 1 6 , 2 1 - 2 2 ) h av e
looked at Bar uc Spinosa, a philosopher cont em por ar y
w it h Descar t es w ho opposed t he Car t esian v iew and
p r esen t ed a co n cep t i o n o f t h e h u m a n b ei n g a s a
som at op sy ch ic u n it com p osed of m u lt ip licit ies an d ,
t her efor e, w it hout dissociat ion bet w een body and soul.
Spinosa pr oposed a concept of healt h r elat ed
t o e a ch p e r so n ’ s p o w e r t o t h i n k a n d a ct . Th u s,
affect ions, t hat is, t he im pressions hum an beings feel
w hen t hey have cont act w it h t he w or ld, cr eat e affect s
t h at in f lu en ce t h eir w ay of seein g an d bein g in t h e
w o r l d , o f t h i n k i n g , k n o w i n g a n d v a l u i n g t h i n g s.
Accor ding t o t his aut hor, k now ledge, in t he sense of
w isdom , incr eases hum an beings’ pow er t o t hink and
a ct , m a k i n g t h e m m o r e a ct i v e a n d cr e a t i v e a n d ,
t her efor e, healt hier( 2 3 ).
“ Not k n ow in g ou r in t er n al cau ses dist an ces
u s f r om ou r sp on t an eou s im p u lse t o p er sist in ou r
ex ist en ce, f r om t h e in t r in sic m ov em en t t ow ar d s u s
( co n a t u s) , a n d p u t s u s i n a v u l n e r a b l e p o si t i o n ,
su bm it t ed t o ex t er n al cau ses, decr easin g ou r pow er
t o act an d m ak in g u s passiv e. Act iv it y is r elat ed t o
pot ency. Passiv it y, t hen, leads us t o ser v it ude w hen,
w i t h o u t k n o w l e d g e a b o u t o u r s e l v e s , w e d o n o t
p e r c e i v e t h a t i n t e r n a l c a u s e s w e r e r e p l a c e d b y
ex t er nal ones. Failing t o r ecognize our dom inat or in
t h e e x t e r n a l p o w e r t u r n s u s r e f u g e e s o f a n o t h e r
per son, slaves w it hout know ing it . This w ay, w e w ould
be r eact ing alienat ed fr om our selves, passive, w it hout
using our act ive and cr eat ive abilit y, w hich decr eases
o u r p o w e r a n d i n d u ce s u s t o a v i ci o u s ci r cl e o f
d ep en d en ce, of t en d ep en d en ce on w h o or w h at is
I n t h is sen se, t h e ch r on ic con d it ion af f ect s
our conat us, t hat is, our desir e, our effor t t o per sist
in being and our pow er t o act and t hink, and st ar t t o
ex er t ef f ect s on ou r ow n du r at ion , on pleasu r e an d
pain, on j oy and sadness. These effect s t ake t he for m
of au g m en t at iv e p ow er s ( ex p an sion , j oy, op en in g ,
f r eed o m ) o r d i m i n u t i v e ser v i t u d es ( i n t r o sp ect i o n ,
sadn ess, closu r e, im pr ison m en t )( 2 1 ).
A liber at ing pr ocess is cr eat ed in t he int er ior
of t he passions t hat increases t he force of conat us t o
t he ext ent t hat sadness m oves away and j oy get s closer.
The j oy and desire t his gives rise t o prepare t he hum an
being for act ivit y, decr easing t heir passivit y( 21).
Ther e is no cont r adict ion bet w een Spinoza’s
philosophy and nor m s, except w hen t hey ar e im posed,
w h et h er as v alu es or as av er ag es. How ev er, t h ese
nor m s ar e not cont r adict or y w hen t hey ar e est ablished
b y m en an d w om en in t h eir ow n in t er est , b ecau se
t h e y c o n s i d e r t h a t c o m p l y i n g w i t h t h e s e n o r m s
g u a r a n t e e s, o r e v e n e x p a n d s t h e i r p o w e r s ( t h e i r
possibilit ies) of realizing happiness. I t should be asked
for every norm w het her it incr eases or decr eases t he
ap p et it e f or lif e. All h u m an b ein g s h av e con d it ion s
t hat st r engt hen t heir ow n healt h ( incr ease t he for ce
of t heir pow er ) . Healt h pr ofessionals ar e r esponsible
for helping t hese people t o t ake hold of t heir pow er s
an d act in g as f acilit at or s of t h e sear ch f or w h at is
r eally necessar y t o be happy( 21).
I t is not enough j ust t o know t he r easons w hy
a cer t ain nor m ex ist s. Fir st , t her e is a need t o seek
sel f - k n o w l ed g e, a n d t h en ch o o se t o a ccep t t h ese
nor m s and aggr egat e t hem t o one’s exist ence, w it hout
cr eat ing r equir em ent s t hat cannot be ex per ienced in
a p o t e n t a n d h e a l t h y w a y( 1 4 ). Th u s , t h e m o r e
know ledge hum an beings have about t he causes t hat
af f ect t h em , t h e g r eat er t h eir p ossib ilit ies of b ein g
a ct i v e a n d f r e e t o w a r d s t h e i r o w n l i f e . Th e l e ss
k n ow ledge t h ey h av e, on t h e ot h er h an d, t h e m or e
t hey w ill be subj ect t o coincidence, w it hout perceiving
t he t r ue dim ension of t heir ser v it ude.
FI NAL CONSI DERATI ONS
Th is ar t icle discu ssed t h e n or m alit y pr esen t
in t he healt h- disease pr ocess of people w it h chr onic
d iseases. Healt h p r of ession als n eed t o ex p an d t h e
r esear ch an d d iscu ssion s ab ou t w h at is con sid er ed
as nor m alit y. I f it is under st ood as st at ic and unique,
t his can im pair people w ho do not fit int o est ablished
s t a n d a r d s . W i t h o u t d e n y i n g t h e i m p o r t a n c e o f
scien t if ic k n ow led g e an d h ealt h p r act ice, ill p eop le
sh ou ld m ain t ain t h eir au t on om y, an d t h is w ill on ly
b e p o ssi b l e i f t h ey a r e g r a n t ed t h e co n d i t i o n s t o
choose and be cr eat iv e. Only people w ho under st and
w h at is goin g on in t h eir ow n body can m ak e t r u ly
f r e e c h o i c e s , p e o p l e w h o f o l l o w s t a n d a r d s n o t
b e c a u s e t h e y w e r e i m p o s e d , b u t b e c a u s e t h e y
u n d er st an d t h em an d k n ow t h at t h ey ex p an d t h eir
possibilit ies of bein g h appy.
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