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Of pipes, persons, and patients
  1. G M Sayers
  1. Correspondence to:
 Dr G Sayers, Department of Geriatric and General Medicine, Northwick Park Hospital, Watford Road, Middlesex HA1 3UJ, UK;
 gwensayers{at}ic.ac.uk

Abstract

Michel Foucault’s analysis of Magritte’s painting, Ceci N’est Pas Une Pipe, and the later work, Les Deux Mystéres, serves as a template, that is broadened to consider different representations of persons and patients. Kant’s noumenal person is contrasted with phenomenal persons, and the well individual is contrasted with the patient. Patients may be considered as the subject or object of illness, and both versions are “imprisoned” within a psychological and social context that curtails freedom, threatens continuity of existence, and may question the nature of their personhood.

  • medical humanities
  • persons
  • patients
  • René Magritte
  • Michel Foucault

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WHAT IS A PIPE?

Ceci N’est Pas Une Pipe was painted by René Magritte in 1926. It is a picture of a pipe, under which he wrote the words: “This is not a pipe”. In 1966 he painted a second version, Les Deux Mystéres, in which the first version is framed and mounted on an easel, a completed work, while a second larger though identical pipe floats above the easel. Foucault examines the ambiguities apparent in these pictures.1

In the early work, we are invited to consider an easily recognisable pipe and a contradiction between the image and the text. At this level, however, the contradiction may be more apparent than real, as the image is a depiction of a pipe and not in itself a pipe.2 Nevertheless, a drawing of an object permits recognition of the object it represents. What is misleading is the inevitability of connecting the text to the drawing, as is caused by the meaning of the word “pipe” and the likeness of the image. However, considering the text apart from the drawing, it can be inferred that the sentence, “this is not a pipe”, is not in itself a pipe; and the word “this” set aside from the representation of the pipe, in itself is not a pipe.3

The later work is more puzzling. In this picture, “there are two pipes. Or rather, must we not say, two drawings of the same pipe?” Foucault compares the framed pipe with its stable coordinates, with the larger floating pipe and its ambiguous location, and suggests the “disproportionate floating pipe, (an) ideal pipe” is a fantasy of a pipe, or a “pipe dream”.4 He then reconsiders the apparent stability of the lower form. He recognises that the easel is not well supported by its feet that are bevelled and liable to collapse, with the prospect of its destruction. In this case the “pipe” could “break” and disappear. “While above, the larger pipe without measure or reference point will linger in its inaccessible balloon-like immobility”.5

This paper uses the paradox arising from the two representations of the same pipe, and the suggestion that one is “not a pipe”. The essence of the metaphor will be extended to include some aspects of persons and patients, whilst relating these different representations to the floating and framed pipe forms. The patients to be described all have life threatening illness and they are therefore not representative of all patients, as not all illnesses are life threatening, and not all patients are altered by illness.

Initially the focus will be on persons, as the Kantian conception of a person is presented as a state of being that cannot be realised by an individual, and hence analogous to the “pipe dream”.

WHAT IS A PERSON?

Kant proposed that a person is a rational agent who acts in accordance with his principles, and is not caused to act or influenced by anything outside of himself. As such, this agent is autonomous.6 Since the agent chooses his action, having had the freedom to choose otherwise, he acts freely,7 but acts on the basis that he would expect others to act similarly under similar circumstances.

Kant believed a person’s existence to have absolute value, and this he ascribed to man’s being something which is an end in itself. Hence he proposed that man must in all his actions, whether directed at himself or others, always be viewed as an end.

Although conceived as a paradigm of moral theory, the idea of an autonomous and self governing person, behaving freely and in accordance with what is right, and not wavering from the course of action prescribed by its rational will, has popular appeal. But when applied to life’s circumstances it falters for a number of reasons.

The phenomenal person is an individual who lives within a social fabric. The beliefs, values, and preferences of such a person are to a large extent a product of their culture and society; hence they will differ in different epochs, in different geographical areas, and in different individuals.

Diametrically opposed to the Kantian notion of a person are individuals who are heteronomous in their behaviour. The behaviour of Oblonsky depicted by Tolstoy in Anna Karenina is illustrative of this:

Oblonsky never chose his tendencies and opinions any more than he chose the style of his hat or frock-coat. He always wore those that happened to be in fashion. Moving in a certain circle where a desire for some form of mental activity was part of maturity, he was obliged to hold views in the same way as he was obliged to wear a hat.

Benson described this type of behaviour as the Oblonsky syndrome.8

Oblonsky does not reflect on his preferences, nor can he defend them rationally, as he is influenced by prevailing opinion, and is caused to make his choices by factors outside of himself. In some ways his behaviour is commonplace, and he is similar to Ivan Ilych, about whom more will be said later.

People are individually different, and one can imagine them aligned along a spectrum, with the most autonomous at one end and the least autonomous at the other. It is as difficult to conceive of a purely autonomous person as it is to conceive of a purely heteronomous person. If the autonomous form were to be encountered in real life he or she might be labelled as “arrogantly self sufficient or a solipsist”, and their heteronomous counterpart could be described as “credulous, gullible, compliant, passive, submissive, overly dependent (or) servile”.9

Pursuing this further, the Kantian person chooses to act and is not impelled to act. This implies a freedom of choice that may not operate in daily life. A phenomenal person cannot always have such freedom of choice, as there are often constraints, both intrinsic and extrinsic, to the freedom of the agent. At the simplest level the person may not make the right choice, being unable to apprehend all of the options available. Alternatively the agent may recognise an action as being right but not possess the capabilities with which to effect the action, lack the opportunity to do so, or be swayed by external factors that compel a different course of action.

Finally, it is virtually impossible to interact with other human individuals on the basis that they are always regarded as ends, and never simply as a means for arbitrary use of another’s will. To the doctor, the patient may be regarded as a means to all sorts of ends, including the publication of research, earning a living, and establishing a reputation. To the patient the doctor may be “like a ferry-man: we need him for an hour and after that we forget he exists”.10

Thus the Kantian person is a philosophical ideal that may be likened to Magritte’s unbounded and unfettered pipe. The autonomy and freedom necessary for such a state of being is illusory, but such a representation might serve as a metaphysical standard to which an individual may aspire. In reality, it can be argued that no such person could exist, and that the phenomenal person in this sense is akin to Magritte’s framed pipe and hence could be comparatively designated as “not a person”.

But irrespective of the degree of autonomy and apparent freedom manifested by individuals in the course of their daily lives, they tend to feel secure in their continuing existence. This apparent security of person, and illusory sense of perpetuity or continuity of being, becomes threatened by serious illness. In this case the person may lose their prior sense of identity or being, as their status alters to that of a patient.

On this basis it will now be argued that the well self can be compared with the fantasy pipe while the patient self equates to the pipe that is “not a pipe”.

THIS IS NOT THE SAME PERSON

When a person becomes a patient a change occurs, both in the way the individual regards his or her self, and in the way in which others regard the person. Yet, there may be no externally visible signs of illness and so, analogously, there could, on the face of it, be two apparently identical representations of the individual; the prior well self and the current patient self.

Sartre said: “In life, a man commits himself, draws his own portrait and there is nothing but that portrait”. For Sartre, a person is what he makes himself to be. If he is a coward, he is so because of his actions and as such he is responsible for his cowardice.11 Illness, however, is not “drawn” by man, it is fortuitous, altering the portrait and causing the person to become a patient, and whereas the coward has the choice of relinquishing cowardice, the patient cannot choose not to be ill.

Solzhenitsyn captures a variety of ways that patients appear to themselves and others, in his book Cancer Ward. He describes the patients as “all looking like healthy people. Especially Proshka. His face glowed all over, as if he were in a holiday camp, not a hospital”.12 Yet the patients as a group are perceived to be somehow not quite real people. “How dumb they all were, how submissive, wooden almost!”13

Rusanov, a formerly decisive man is described as becoming indifferent. “His customary strength of will had been shaken. It was no longer he but the tumour that was in charge”.14

The category shift from person to patient is depicted by the description of Dontsava, a doctor, who becomes ill. She confers with a colleague as friends talk at a scientific meeting. “Yet having confessed to being ill was like having confessed to a crime: immediately they had lost the key to equality they once possessed. By her confession she had excluded herself from the noble estate of medical men and transferred herself to the tax-paying, dependent estate of patients”.15 She was crushed and had lost her former bearing.

Also shown, is the way in which a patient can cross the category gap. Oleg, a patient, helps a nurse analyse some data. He feels that by sitting at the nurse’s table he has changed his position, altering his status and so leaving “his other self, the one past help, one of the irremediables”, all behind him.16

A person, from early childhood, is aware of how different he or she is from others. Patients, however, acquire a group identity that may overpower and blur individual differences. Shortly after entering the cancer ward Rusanov experiences this. He felt the door to his past life had slammed behind him. He could not choose what to look at. “He had to look at the eight abject beings who were now his ‘equals’, eight sick men in faded, worn, pink-and-white pyjamas, patched and torn here and there and almost all the wrong size”.17 “In a matter of hours he had as good as lost all his personal status, reputation and plans for the future”.18 “He hardly recognised his own voice; it sounded so plaintive, so lacking in authority”.19

These examples illustrate how the patient self is diminished, and other than the well self, and hence can be equated with the representation of the pipe that is “not a pipe”.

THE PATIENT’S MATRIX

Foucault looked at the supporting framework of the pipe that is “not a pipe”, in order to see whether it reflected on the meaning of the script. He drew our attention to the mountings of the picture, and the unstable position of the easel, implying the prospect of its collapse with the consequent destruction of the picture.

Consider then, that the picture frame could be taken to represent the illness or the hospital, which entraps the patient, and the unstable mountings of the picture could represent the insecurity posed by the prospect of death.

Oleg had previously been a political prisoner in labour camps. He writes to friends comparing his experience as a patient with that as a captive. He asks them to guess where he is. The clues are the bars on the windows and “the rooms are full of bunks, and on each bunk lies a little man terrified out of his wits. During the day they pull you in, one by one, for talks with officials, ‘processing’, and for visits from relatives. Some times they come in and search the place. They take away personal belongings, so we have to hide them. We must fight for our right to go out and exercise. The most depressing thing is I have no fixed term. They don’t say a thing about when they are going to discharge me. What can a poor prisoner do? I put on my boots, fasten a woman’s dressing gown around me with my army belt, (leave the hospital grounds) and in five minutes I’m in the bazaar”.20

Vadim considers his diseased leg as being “in a trap, and with it his whole life”.21 Dontsava, the ill doctor, acknowledges that: “The moment she admitted the disease existed, she was crushed by it like a frog underfoot”.22 Rusanov thinks of his family “as now on the other side of his tumour. The tumour was growing like a wall behind him, and on his side of it he was alone”.23 “His tumour, deaf and indifferent, had moved in to shut off the whole world”.24

The perilous position of the picture, and the parallel dawning of the patient’s awareness of demise, is illustrated in the thoughts of Dontsava whilst undergoing investigations. “Her ties to life, which had seemed so strong and permanent, were loosening and breaking, all in the space of hours rather than days”.25 And Rusanov, whilst unable to sleep, imagined how “his whole happy life, so well thought out, so harmonious and useful, was now about to crack”.26

In other important ways patients may find themselves different from their well self. Normal life is characterised, for individuals, by the subjectivity of their experience. They are familiar with being the subject of their daily encounters as well as the subject of their own emotions. To a large extent they become the subjects of their illness. But patients, in some ways, may be treated as objects, dealt with by other people, at worst as inanimate beings, or at best as compliant recipients of care. They may become a part of the stage rather than participating as fellow actors.

THE PATIENT AS THE SUBJECT OF ILLNESS

Ordinarily, patients would consider themselves to be the subject of their illness. It is their bodies that contain the disease and their minds that bear its effects.

If there are physical changes, these differences become apparent to the patient. Ivan Ilych recognised this when his brother in law paid a visit and looked at him. “That stare told (him) everything. Ivan Ilych locked the door and began to examine himself in the glass, first full face, then in profile. He took up a portrait of himself taken with his wife and compared it with what he saw in the glass. The change in him was immense”.27

Ilych, whilst trying to work, would become aware of his gnawing pain. “It drew his attention to itself not in order to make him take some action but only that he should look at It, look it straight in the face: look at it and without doing anything suffer inexpressibly”.28 His awareness of his illness altered his perception of his life. He considered the question of his own mortality. He had been taught the syllogism: “Caius is a man, men are mortal, therefore Caius is mortal”. This seemed correct as applied to Caius, but certainly not as applied to himself.29

In this context, Ilych could be said to have viewed himself as looking at a picture of himself with the subscript, “This is not Ilych”, as the viewer observes the pipe under which is written, “This is not a pipe”. How could he align the reality of his subjective experience of illness and the prospect of his own destruction, with his own (unreal, as he is a man) conception of his previously well self, and its apparent (for him) permanence?

As the subject of his illness Ilych felt alone. “He wept on account of his helplessness, his terrible loneliness, the cruelty of man, the cruelty of God, and the absence of God”.30 He “wanted to weep, wanted to be petted and cried over”. Instead he conversed with visitors as if he was well. “This falsity around him and within him did more than anything else to poison his last days”.31

As the subject of illness patients may lose the freedom to determine what happens to their lives. Oleg criticised his doctor. “No sooner does a patient come to you than you begin to do all his thinking for him. And once again I become like a grain of sand, just like I was in the camp. Once again nothing depends on me”.32

Rusanov realised that: “He was no longer a vital cog in a large, important mechanism. In fact he felt he had lost all power and significance”.33

In all of these instances, the patient feels altered and disempowered. The other, previously well, self floats in his consciousness like a taunting reminder of how he was prior to his illness.

THE PATIENT AS AN OBJECT OF ILLNESS

Patients may be experienced by others, and hence by themselves, as either belonging to a subcategory of person, or as otherwise different from their former self. The basis for this statement is best described by how patients may be treated by others.

Oleg is reluctant to have a blood test. His doctor chides him. “You ought to be ashamed of yourself! You’re a man aren’t you? She looked at him with that well-known feminine mockery that men cannot endure”.34 On a different occasion Oleg takes a doctor to task. “Can’t we get away from this tone of voice? You sound like a grown-up talking to a child. Why not talk as adult to adult?”35

Ilych, as subject of his illness, recognises that elevating his legs reduces his pain, but his wife and doctor talk of him as if there were no grounds for his behaviour, his subjective reality is dismissed. The wife of Ivan Ilych says to his doctor: “‘You see he doesn’t listen to me and doesn’t take his medicine at the proper time. And above all he lies in a position that is no doubt bad for him—with his legs up’. The doctor smiled with a contemptuous affability and said: ‘What’s to be done? These sick people do have foolish fancies of that kind, but we must forgive them’.”36

Historically, the practice of medicine has been based on clinical objectivity and detachment from the patient as a person. Writing of the evolution of academic medicine in eighteenth century France, in The Birth of the Clinic, Foucault positions the patient as the object of a clinical gaze; the type of gaze with which a botanist examines plants, or an astrologer the stars. The patient thus represents a passive recipient, rather than an active participant in the clinical encounter.

The medical gaze was an artist’s gaze, seeking the smallest details on the face of the person to be painted. Doctors were looking for signs differentiating diseases, and showing impending death or the possibility of recovery. The patient represented the space in which the disease was housed: “an external fact”.37 The disease to be discovered was of paramount importance. “If one wishes to know the illness from which he is suffering, one must subtract the individual with his particular qualities”.38

Foucault distinguishes between the patient as an individual, who happens to be suffering from a disease, and the patient as an object of study, where “what is present is the disease itself, in the body that is appropriate to it, which is not that of the patient, but that of its truth. It is ‘the different diseases that serve as the text’: the patient is only that through which the text can be read”.39

A dichotomy arose between the hospital in which the poor were treated, and the clinic, in which the doctors were trained. On the one hand the patient was requiring treatment of which he was the subject, but whilst being treated he was also portrayed as the object of the clinical gaze. “Indeed, a relative object, since what was being deciphered in him was seen as contributing to a better knowledge of others”.40

In many ways Foucault’s accounts appear contemporary. Patients are referred to as diabetics or epileptics; as if they are the diseases. They form a source of “teaching material” and what is learnt from their illnesses is used to treat others. Doctors may talk of them, rather than to them.

A patient recounted his own more recent experiences is these terms: “A major problem was that the patient in pre NHS days was never told what was being done to him. He was an object to be talked about but never with. Doctors would discuss the condition of a patient across the two sides of the bed as if it was empty. The patient and his fears were, it seemed, ignored”.41

The doctor may still perceive the patient as a representation of a person, or object. Diseases express themselves similarly no matter in whom they are lodged, and in order to learn the skills necessary for the practice of medicine it is not always necessary to have patients. Resuscitation techniques may be learnt using a life size rubber doll, with the understanding that such an effigy can be used as a patient substitute, in demonstrating where the defibrillator paddles are placed, and how the airway is secured. Similarly actors may be enlisted when teaching students communication skills. The move from effigy or actor, to patient, and the move from patient to patient, suggests that objects, or surrogates, or patients, may be equally interchangeable when practising medicine.

The arguments supporting the patient self as “not a person,” when compared with the well self, are sustainable within the paradoxical context presented. However, a final scenario remains to be explored. This is one in which the individual transcends the illness and obtains an insight that may transform his or her existence. It will be proposed that, under such circumstances, the patient may become a person approximating the ideal as envisaged by Kant.

THE PATIENT AS A PERSON

So far, the well person has been considered to represent the “real” person and the ill person has been considered to represent a state of being designated as “not a person”. For Ilych, however, his suffering caused him to enter into dialogue with his pain. In so doing he explored his prior life, that he had previously thought was quite proper, and this introspection raised these issues for him. “Maybe I did not live as I ought to have done”.42 And: “What if my whole life has really been wrong?”43

It occurred to him, that his acceptance of what was considered good by the most highly placed people might have been wrong, and that “all his social and official interests might have been false”.43 He read from the mere presence of his wife: “All you have lived for and still live for is falsehood and deception, hiding life and death from you”.44 Perhaps at this point Ilych became an authentic person, rather than a representation of a person, or “not a person”.

The individual cannot separate himself from his patient self as they occupy the same physical form. He can, however, compare his present self with his former self, and in the case of Ilych find his previous self to have been undesirable or inauthentic. The selves are coexistent, but in Ilych they battle for dominance. Ilych tries to escape into his former self by continuing his work as a judge. This he manages to do successfully until It emerges, gnawing at him and forcing him to attend.

By asking of It, and hence of himself, why he is being made to suffer in this way, he concludes that his life had not been as it ought to have been. As a dying patient he perceives the life he led as a non-autonomous person, and the life he should have led as an autonomous person. In a way Illych is comparing himself with the Kantian ideal.

Although Magritte provided us with two pipes over which to muse, he did not assure us that the larger floating pipe is a pipe, simply that the smaller framed pipe is “not a pipe”. What he presented is a representation of an object alongside a different representation of the same object.

This paper has depicted versions of persons and versions of patients. The reality of the perception of the versions ultimately will depend on the interpretation of the observer or the observed, rather than the signifier (words) or the signified (object).

Acknowledgments

I am very grateful to Martyn Evans for his encouragement and detailed comments on a previous draft of this paper.

REFERENCES

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