The Clinical Encounter as a Prototypical Bakhtinian Act

ABSTRACT

The clinical encounter, as an inter-human relationship between the patient and their doctor, constitutes the arena where a clash between the worldviews of these agents can occur. Traditionally, the clinical encounter has been studied from an externalist perspective, extrinsic to the event itself, focusing on quantifiable outcomes. In his early texts, Bakhtin develops a philosophy of the act that remarkably suits the complexity of the clinical encounter. By combining elements of epistemology, gnoseology, axiology, and ontology in his architecture of a world constructed intersubjectively, Bakhtin provides us with an almost perfect model for studying the clinical encounter. Therefore, in this article, we argue that understanding the clinical encounter as a responsible Bakhtinian act brings new and interesting perspectives to the understanding of this peculiar event from within, while also paving the way for a more ethical and humane type of medicine.

KEYWORDS:
Responsible Act; Clinical Encounter; Bakhtin; Evidence-Based Medicine

RESUMO

O encontro clínico, como relação inter-humana entre o(a) paciente e seu médico(a), constitui-se na arena onde um embate entre as visões de mundo desses agentes pode se dar. Classicamente, estuda-se o encontro clínico a partir de uma perspectiva externalista, extrínseca ao evento em si, que visa desfechos quantificáveis. Bakhtin, em seus textos iniciais, elabora uma filosofia do ato que se ajusta de maneira notável à complexidade do encontro clínico. Ao unir elementos de epistemologia, gnosiologia, axiologia e ontologia em sua arquitetônica de um mundo construído intersubjetivamente, Bakhtin fornece-nos um modelo de estudo quase perfeito para o encontro clínico. Defenderemos nesse artigo, portanto, que a compreensão do encontro clínico tomado como ato bakhtiniano responsável traz novas e interessantes perspectivas para o entendimento desse peculiar evento a partir de dentro, além de abrir caminhos para um tipo de medicina mais ético e humano.

PALAVRAS-CHAVE:
Ato responsável; Encontro Clínico; Bakhtin; Medicina baseada em evidências

Introduction

The encounter between healthcare professionals and patients has been conceived as a dyadic encounter characterized by power asymmetries and the clash between scientific, rational, and authoritative knowledge and private relationships laden with personal values. However, as Carl May (2007, pp.29-30) asserts, late modernity brings forth a set of tensions between the production of individual identities and the production of facts about groups and populations, which, particularly in recent years, have been understood through disputes and negotiations within the epistemological framework of contemporary medical practice, namely evidence-based medicine (EBM). According to May, these tensions can be divided into two main groups:

Individualization: characterized by a progressive abandonment of medical paternalism and the objectification of the patient, in favor of a clinical practice centered on the sick individual, where the experiences and perspectives of their health problems are qualitatively related to and taken into account in decisions regarding disease management.

Aggregation: characterized by the mobilization of evidence about large populations of experimental subjects and carried out through the exercise of EBM, where quantitative knowledge is mobilized to guide disease management, which, in turn, is mediated by clinical guidelines and other practical conduct systems that structure the provision of healthcare.

The processing (production, publication, use, and criticism) of evidence, as well as EBM itself, have become central in debates about institutional relations, public policies, and even everyday medical practices, to the point where EBM has expanded beyond its initial scope and become a model of rationality for other areas (POMPILIO, 2006). In any case, it is within EBM and its vision of clinical practice that the arena for debate lies. When it officially emerged in 1992, the opening paragraph of the inaugural article was:

A new paradigm for medical practice is emerging. Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research. Evidence- based medicine requires new skills of the physician, including efficient literature searching and application of formal rules of evidence evaluating the clinical literature (Guyatt, 1992, p.2420).

The promise of a new medical rationality that would replace the previous one (based on individual experiences and also individualizing pathophysiological reasoning) was unable, despite shaking the foundations of old medicine, to eliminate the atavistic singularization ingrained in the analytical reasoning of physicians. The described opposition was established. Authority versus otherness. Indeed, on one side, individuality, the private, the clinical case, personal experience; and on the other, the collective of populations, the public, the impersonal, case studies, and the ever more colossal medical literature. All of this is at stake during the clinical encounter, whether it is between the physician and the patient or within the physician and the patient themselves. The voices that speak are the voices of culture (understood as science, philosophy, and aesthetics) and life.

In this article, we argue that Mikhail Bakhtin (1895-1975), particularly in the texts of his youth, namely “Art and Answerability” ([1919] 1990),¹ and Toward a Philosophy of the Act ([1920] 1993),² in which he outlines his prima philosophia, presents a consistent proposal addressed to this clinical impasse. By developing a theory centered on the concrete actions of individuals and the idea of responsible action, Bakhtin can propose an alternative ethical foundation for the identity and techno-scientific issues present in the clinical encounter. However, initially, we need to briefly examine the trajectory of medicine, from a divinatory discipline to the scientific power of today.

1 The Secularization of Medicine

The art of the Hippocratics represented a radical change in the practice of medicine. New modes of thought left by the philosophy of the pre-Socratics emerged as an explanation for natural phenomena. The language of myths was no longer sufficient to explain the reality of the polis. Changes in the Greek man’s relationship with religion and their myths, as well as changes in the social and political world, provided the context for transformations in medicine. Thus, the iatriké techné accompanied the “secularization” of thought in the ancient Greek world. As Ferreira emphasizes:

The Hippocratic physicians, by distancing themselves from the miraculous medicine of the temples, were part of this secular current of thought (...); we have an expression of this in the well-known passage on epilepsy at the beginning of the medical treatise Sacred Disease: “Here is what there is to say about the so-called sacred disease: it does not seem to me in any way more divine or more sacred than other diseases, but it has the same nature and the same origin as them. People, due to their inexperience and astonishment, believed that its nature and cause were something divine because it is unlike other diseases” (Ferreira, 2019, p.19).³

A revolution of such magnitude needed to be controlled in some way. The need for a minimum uniformity of conduct (both in practice and behavior), as well as the establishment of a professional bond (previously determined by the religious connection of the Asclepiad clan, from which the Hippocratics sought to break free), demanded a new deontology. In this context, the Hippocratic Oath is still considered a landmark in the advent of ethics, particularly medical ethics. Medicine is, therefore, an inherently moral practice, which means that it is not possible to separate the questions “What is medicine?” and “What must medicine be?” It is for this reason that medicine can never be solely applied medical science. The evaluation of what should be done in medicine must be sought within the practice itself, in the analysis of its ontological structure (Svenaeus, 2020, p.54).

Medicine thus emerges as a practice rooted in morality, a scenario that persists even in the face of limited technical results obtained until the mid-18th century when the scientific discourse takes control, progressively yielding better results in medicine and allowing it to occupy increasingly important positions in the context of modern societies. To such an extent that authors like Michel Foucault can speak of the influence of “institutions of medical knowledge and power” and paraphrase Fichte by saying that we live under “open medical states” where the insertion of medical discourse knows no limits (Foucault, 2004, p.16).⁴

This state of affairs triggered a variety of reactions whose effects we still see today, ranging from anti-medicine movements like Ivan Illich’s “Medical Nemesis”5 (1975) and the cult of what is commonly referred to as “alternative medicine” (Louhiala, 2010), including branches of denialist and anti-science doctrines, to reactions from within the medical rationality itself, often conceived as processes of humanization, to cite just a few examples. In relation to the latter, several initiatives have been proposed with the aim of minimizing the alleged “mechanization” and impersonality with which healthcare professionals, especially doctors, began to treat those seeking their services, particularly from the 1970s onwards. However diffuse and unspecific the concept of humanization may be, since the human being is always the “target” of medical actions, there is often mention, on the one hand, of

the lived experience of healthcare professionals, who encounter the most eloquent examples of the causes and symptoms of dehumanization on a daily basis, and on the other hand, the frustration of patients, disillusioned by the inability of the scientific-technological apparatus to deliver what was promised to them. Not to mention the final “blow” in this context, dealt by the indifference or even disdain of the professionals who, in the face of technical failures, appear even more inept in the exercise of human virtues (Gallian, 2012, p.8).⁶

It is important to note here that the scientific turn that brought practical success to medicine was, after a latency period of a few decades (from the late 19th century until the end of World War II, i.e., a little over 50 years), translated as a progressive distancing of healthcare professionals from their patients. This process, which intensified with the incorporation of increasingly complex technologies, was conceived as the dehumanization of medical practices by a sector of society critical of these transformations. It was a profound revolution that generated counter-movements, in most of which attempts to improve medical care were consequently and coherently translated as projects of humanization.

2 The Opposition

The source of this reasoning is the somewhat naive idea that scientific thinking works with a type of theory of knowledge whose foundation is the subject-object relationship. Now, if doctors, in order to excel in a profession strongly based on scientific concepts, must become good scientists, it naturally follows that patients under their care will be objects of their studies and actions. Furthermore, science demands increasing specialization given the complexity of its objects, and medicine has not escaped this tendency (Srivastava, 2020). Fredrik Svenaeus (2000, p.37) is explicit in delimiting the problem: “These traits can be summarized in two key features: objectification (the reduction of the patient to a biological-physiological object) and specialization (the partitioning of this object between different medical specialities).” Ultimately, what we are seeking to understand are the changes that have occurred in the physician-patient relationship since the complete penetration of Galilean-based scientific discourse into medical practices. According to Svenaeus:

Ever since the advent of modern medicine around 1800, […], there has been resistance and reluctance to accept new scientific ideas and techniques. There was, from the beginning, a general fear that the scientific approach would ruin the art of medicine, the practical skills and wisdom of the experienced family doctor, who keeps close contact with his patients and knows the history of their personal problems as well as their somatic pathologies (Svenaeus, 2000, pp.39-40) (author’s italics).

However, paradoxically, the literature that seeks to understand the phenomenon of the clinical encounter is relatively scarce. As we have stated elsewhere, in the clinical encounter,

characterized as the inter-human relationship between the patient (including any accompanying individuals) and their doctor, the state-of-the-art of biomedical science, ethical and moral values, and the socio-cultural environment within which it takes place are all at play. In such a way that its participants establish “a nexus of choices and priorities” that is highly particular (Pellegrino & Thomasma, 1981, pp.26-28) - a nexus whose decision-making horizon is guided by the telos of restoring a state of well-being inseparable from the current concept of health - revealing, hic et nunc, the very essence of medicine (Pompilio, 2016, p.53).⁷

In general, publications on the subject focus not on the clinical encounter itself, but on the effects that such an encounter would have in terms of hard outcomes such as patient satisfaction, autonomy, health, and treatment adherence.

As part of this movement to contain medical power, it is also important to note the simultaneous emergence of Bioethics as a discipline that is increasingly present in medical education. Edmund Pellegrino categorizes the evolution of Bioethics into three periods. Initially (1960-1972), there was a period called protobioethics, where the language of human values was juxtaposed with the perception of the dehumanization of medicine due to the growing power of science and technology. The focus was on education and how it was conducted, both theoretically and disciplinarily. The second period (1972-1985), known as true ethics or philosophical bioethics, starts from the premise that, given the increasingly complex dilemmas posed by the technologization of care, there is a need for formalizing the language and the responsible philosophical framework to deal with them. As Pellegrino says:

(...) the subjects of discourse centered on the theoretical substratum of bioethics - principlism, deontology, utilitarianism, virtue, casuistry, feminism, caring, narrative, or some combination of theories. (...) Clinical ethics appeared as an applied branch of bioethics, and more recently, social policy, organizational ethics, and methods of doing ethics have occupied philosophers (Pellegrino, 1999, p.82).

Finally, the third stage, labeled by Pellegrino as global bioethics (1985-present), involves expanding the scope beyond medical specialties to include disciplines such as law, religion, anthropology, economics, political science, psychology, among others. In general, the structuring of the bioethical movement within the framework of medical rationality fits into attempts to counter unrestrained scientism and to return to the foundations of medicine as an essentially ethical art since its inception.

3 Prototype of the Responsible Act: Bakhtin Speaks to Healthcare Professionals

Mikhail Bakhtin, whether due to the editorial confusion surrounding his publications in Brazil and abroad or his somewhat fragmented style, is virtually unknown to opinion leaders in the medical field, philosophers of medicine, academics, or practicing physicians in general. He is much more embraced in the field of Literature, especially as a philosopher of language. However, the main reason for this may be the relatively recent publication of his ideas regarding moral philosophy, particularly the essay Toward a Philosophy of the Act⁸ (hereafter referred to as TPA). Although written in the early 1920s, this work was only published in Russian in 1986 and translated into English in 1993. The English edition, organized by Michael Holquist, led to a provisional translation by Carlos Faraco and Cristovão Tezza, which is freely accessible. The “official” Brazilian edition was only published in 2010 (Boenavides, 2020). With all these difficulties, it is not surprising that the idea of a “first philosophy” based on an ontology of the act went unnoticed by the medical community. Here, we will attempt to draw a parallel between these ideas, based on TPA, in order to apply and understand the clinical encounter as a responsible act through a Bakhtinian lens. As a method, we will follow the order of argumentation in TPA, even though, as Adail Sobral (2019, p.29) says, the text “is dense and extremely dialogic, repetitive in the treatment of ideas.”⁹ For the Portuguese version of the article, we used the third edition of the Brazilian version, translated from Italian by Valdemir Miotello and Carlos Faraco (Bakhtin, 2020). For the English version, we will use the 1993 American edition organized by Vadim Liapunov e Michael Holquist (Bakhtin, 1993).¹⁰

The Two Worlds and the Delimitation of the Problem

Right from the start, Bakhtin clarifies the separation between the theoretical-discursive thinking and the unrepeatable experiences of historical reality:

The moment which discursive theoretical thinking (in the natural sciences and in philosophy), historical description-exposition, and aesthetic intuition have in common, and which is of particular importance for our inquiry, is this: all these activities establish a fundamental split between the content or sense of a given act/activity and the historical actuality of its being, the actual and once-occurrent experiencing of it (Bakhtin, 1993, pp.1-2).¹¹

This argument culminates in the conclusion that: “[…] two worlds confront each other, two worlds that have absolutely no communication with each other and are mutually impervious: the world of culture and the world of life” (Bakhtin, 1993, p.2).¹²

Bakhtin refers to the world of culture as the world that encompasses philosophy, natural sciences, and aesthetics. The world of life is the world in which we live and die, where we theorize (philosophy and sciences) and contemplate (aesthetics), where we consider the otherness of the other, and where responsible acts that give meaning to our existences occur. In the short yet powerful essay from 1919, “Art and Answerability” (Bakhtin, 1990, pp.1-3),¹³ which many commentators consider as part of the project developed in TPA, Bakhtin argues for the unification of the three fields of human culture - science, art, and life - in the “unity of an individual person.”¹⁴ The idea is that if we try to grasp an event through theoretical categories, historical knowledge, or even aesthetic intuition alone, we will find that such an event is indeterminable through these methodologies. In the first case (theoretical),

we cognize the abstract sense, but lose the once-occurrent fact of the actual historical accomplishment of the event; in the second case we grasp the historical fact, but lose the sense; in the third case we have both the being of the fact and the sense in it as the moment of its individuation, but we lose our own position in relation to it, our ought-to-be participation in it (Bakhtin, 1993, p.16).¹⁵

In other words, such grasping becomes inevitably mechanical, which for Bakhtin means that it is an assimilation constituted by the interaction of elements that, despite contact and proximity, maintain the isolation of the two worlds, failing to constitute a unity of meaning. This occurs mainly because “the essential condition for this integration to occur is not found in science, art, or life taken individually or partially, but in the creation of a meaningful whole through the responsible action of the subject” (Sobral, 2020, p.26) ¹⁶ Bakhtin refers to this separation between worlds as a crisis of culture, and the proposed solution to this problem is his philosophy of the act as the “assumption of responsibility by the subject” (Sobral, 2020, p.26).¹⁷ Only the individual in their singularity can be this responsible being, and this will only occur in praxis, in everyday life. In other words, “the division created between two mutually impervious worlds can only be superseded in life when we cognize, choose, act, create, build worlds where life itself becomes the object of a given domain of culture” (Ponzio, 2015, p.128).¹⁸ Here, it is crucial to grasp the metaphor of construction.

The Bifronted Janus and the Two Truths

The question then becomes: how to describe the unity and singularity of a world that cannot be abstracted into theoretical systems without losing its meaning? Indeed, on one hand,

it is obvious that knowledge must necessarily be knowledge of the general, proceeding through concepts, through classifications, (...) in which the singular, in one way or another, reappears in the form of an individual identified by belonging to this or that set, to this or that genre (Ponzio, 2020, pp.16-17);¹⁹

on the other hand, it is also an eminently identity-based question, as it deals with

the recognition of the singular difference of each one, by the fact that the very social organization (...) operates on the basis of classifications, closures, attributions of belonging, resorting to the genre, to the universal as a condition of identification, differentiation, individuation” (Ponzio, 2020, pp.16-17).²⁰

Bakhtin responds that the world is not abstractly “systematic,” but concretely ‘architectonic” because we value, conjecture, and contemplate from our own space-time coordinates, from the unique place that each individual occupies, without the possibility of being replaced, without the ability to make excuses, as each individual is a participatory and responsible irradiating center. He frequently uses the word edinstvennji, meaning “singular, unique, unrepeatable, exceptional, incomparable, sui generis,” to describe this special moment linked to moral responsibility and the ethics of the act. On the other hand, “repeatable” and/or generalizable occurrences are also linked to a responsibility, albeit referred to as special and associated with theoretical honesty (in terms of intellectual coherence). Bakhtin takes advantage of the fact that the Russian language seems to be the only one among European languages to possess two terms to describe truth: istina and pravda. Istina incorporates the concept of absolute reality - what truly exists in contrast to what is imaginary or unreal. In the Russian language, the word istina marks the ontological aspect of this idea, signifying absolute self-identity and, therefore, accuracy, genuineness, and self-equality. Pravda is not only “truth” but can also be translated as “justice” and is never used to designate scientific truth. Pravda as the truth of an event, therefore, is inseparable from the concrete “who,” the real agent, nor from the concrete “where” that together specify knowledge. For this reason, it is not generalizable like istina; on the contrary, it is focal, unrepeatable, and unique.

For medicine, in particular, it may be opportune at this moment to introduce the distinction between body and organism. The individual cannot be merely reduced to a “purely biological entity, confined to the sphere of physiological needs, in which the body itself has been supplanted by the abstraction of the organism and its unity has been replaced by division into organs” (Ponzio, 2020, p.23).²¹ The body, our perspective on the world, the source of feelings and knowledge, cannot be reduced to the economy of organs except through a radical abstraction completely disconnected from living reality. In this sense, istina could be understood as a kind of “truth of the organism,” as it accounts for the objectification of its parts, the generalization of its processes, and the compartmentalization of its functioning, opening space not only for study and understanding but also for interventions, as it allows a certain distance from the agent. Pravda, on the other hand, whether related to the integrity of the individual or emphasizing their singular characteristics, is inseparable from a moral conception of the body and demands not only professional ethics but also Bioethics, essential for conducting research in the field. It is important to note that this conception of the individual as an organism has fundamental repercussions on the concept of health, which operationalizes not only public policies but also private consultations and underpins general healthcare practices. It is characteristic of the biostatistical theory of health, for example, to treat the body as an organism (Boorse, 1977) by stating that “health is the absence of disease,” and whether someone is sick or not, from this perspective, becomes a merely empirical observation typically expressed in terms derived from scientific (i.e., statistical, pathophysiological, or anatomopathological) vocabulary. Just from this perspective, it is already possible to circumscribe the confinement of actions taken within the scope of a language focused solely on translating technical aspects of a relationship that, as we said, is dyadic. Furthermore, based on this fragmentation, both physical and vernacular, it becomes difficult to locate the hierarchical level at which disease occurs because, at any moment, some cell or even segment of DNA will exhibit a defect, which, by empirical definition, characterizes disease. Such observations lead to bizarre conclusions, such as the notion that every organism must be sick²² to some extent.

It is impossible not to correlate such images with the conflicting worlds of doctors and patients. It is common for the doctor, due to the eloquence of scientific discourse, to try to bring the dialogue to the “world of culture” (scientific realm), which already constitutes a detachment from the concrete reality of the encounter. It is common for the doctor to evade the arduous ethical and moral responsibility of the act, taking refuge in the comfortable special responsibility and theoretical honesty of science and technology. As an old professor of medicine aptly summarized: “The doctor strives to obtain objective data about the patients’ illnesses, but they insist on telling the story of their suffering.”

If it is not possible to describe this “architectonic” structure composed of particular values and a space-time experienced by each individual from an objective standpoint (i.e., detached, abstract, purely cognitive), because that would simplify, impoverish, and mystify the encounter, “such understanding also cannot be based on empathy, which would also be a impoverishment to the extent that it reduces the relationship between two mutually external and non-interchangeable positions to a single view” (Petrilli, 2016). The interpretation-comprehension of the unique individual presupposes a standpoint that is external, “extralocalized,” exotopic, other, different, and at the same time not indifferent to the other, thus participatory and responsive to alterity (Petrilli, 2016).²³ For the Russian philosopher, the only way to unite the two worlds is through

the acts [which] actually proceed and are actually accomplished once and only once. //An act or our activity, of our actual experiencing, is like a two-faced Janus. It looks in two opposite directions: it looks at the objective unity of a domain of culture and at the never-repeatable uniqueness of actually lived and experienced life (Bakhtin, 1993, p.2).²⁴

In the clinical encounter, a prototypical Bakhtinian act, both worlds are at stake, that is, the “larger”²⁵ world of culture which encompasses, in our case, the biomedical science where all the theoretical patients, participants in clinical studies and trials exist, and the "smaller" world of the individual life of those two people who come together with a common objective. It is also interesting to note that Bakhtin explicitly states that “the irreproachable technical correctness of a performed act does not yet decide the matter of its moral value” (Bakhtin, 1993, p.4).²⁶ It is not enough to accurately diagnose or treat. Something more is required. However, he does not devalue scientific knowledge in any way but emphasizes that its function is complementary and derived in relation to the responsible presence of the subject in the act. This perception is subtle and precisely captures a serious problem that is relatively common in many medical services: protocol-driven and guideline-driven medicine. Again, it is not about devaluing the knowledge that provides protocols and therapeutic guidelines. They are extremely useful and true (istina). It is primarily about considering them insufficient in fully characterizing the ethical intersubjective procedure at play there. However, the strength of the Bakhtinian argument is not limited to this aspect alone.

The Disembodied Subject

In the continuation of the text, Bakhtin proceeds to criticize Kant, sensu lato, by stating that it is not possible to derive an ethics from a transcendental subject. Kant argues that the moment of judgment is the moment of activity of our reason because it is us who produce the categories of synthesis that enable knowledge. However, for Bakhtin, this transcendent element a priori “did not surmount their dissociation and mutual imperviousness, and hence one was compelled to think up a purely theoretical subiectum for this transcendent self-activity, a historically non-actual subiectum” (Bakhtin, 1993, p.6).²⁷ Such a phantasmatic subject “had to be embodied each time in some real, actual, thinking human being, in order to enter (along with the whole world immanent to him qua object of his cognition) into communion with the actual, historical event of Being as just a moment within it” (Bakhtin, 1993, p.6).²⁸ And he emphatically concludes: “[a]ll attempts to surmount […] the dualism of cognition and life, the dualism of thought and once-occurrent concrete actuality, are utterly hopeless” (Bakhtin, 1993, p.7).²⁹ If we take into account the discussion on Bioethics and the “theoretical” manner in which studies on the act of the clinical encounter are conducted, we will find troubling echoes in this forceful warning from Bakhtin. It is not possible to derive an ethics solely from theoretical foundations. The separation of worlds regarding responsible action is only achieved through the artificialization of this embodied subject. “The theoretical world is obtained through an essential and fundamental abstraction from the fact of my unique being from the moral sense of that fact - ‘as if I did not exist’” (Bakhtin, 1993, p.9).³⁰ This statement finds echoes in phenomenological assessments of the clinical encounter, such as those undertaken by Fredrik Svenaeus. Assessments that take into consideration the fact that the ethics of this peculiar encounter can only occur in praxis, in the flow of the encounter itself, to the point of questioning the possibility of the existence of a theory of Bioethics (Svenaeus, 2000, p.168).

Critique of Theoreticism

According to Bakhtin, under the term theoreticism, all forms in which the ability to understand the responsible, singular, and unique act is forced to its limits are encompassed, or in his words, “the various attempts to bring theoretical cognition into communication with once-occurrent life conceived in biological, economic, [medical, we would say], and other categories, i.e., all attempts at pragmatism in all its varieties” (Bakhtin, 1993, p.12).³¹ Converting one theory into another is futile. The only way to achieve such integration, as mentioned above, is to start from the act itself, not from its theoretical transcription, as it is the act that truly unfolds in existence. According to Bakhtin, “theoretical reason in its entirety is only a moment of practical reason, i.e., the reason of the unique subiectum’s moral orientation within the event of once-occurrent Being” (Bakhtin, 1993, p.13) (autor’s italics).³² This line of reasoning deals a fatal blow to the ways in which the clinical encounter has been studied since then. The inescapable conclusion is that we have not studied it correctly, that is, from within the event itself, which is disturbing. Further in the work, when highlighting the impossibility of total empathy (something highly valued in medical practice), ³³ Bakhtin writes: “Even if I know a given person thoroughly, and I also know myself, I still have to grasp the truth of our interrelationship, the truth of the unitary and unique event which links us and in which we are participants” (Bakhtin, 1993, p.17).³⁴ This stance is opposed to the one found in the world of technology, namely, a world which “knows its own immanent laws, and it submits to that law in its impetuous and unrestrained development, in spite of the fact that it has long evaded the task of understanding the cultural purpose of that development” (Bakhtin, 1993, p.7),³⁵ here in clear alignment with Heidegger regarding the autonomy of technology. Bakhtin asserts that “[h]aving acknowledged once the value of scientific truth in all the deeds or achievements of scientific thinking, I am henceforth subjected to its immanent law: the one who says a must also say b and c, and thus all the way to the end of the alphabet” (Bakhtin, 1993, p.35) (author’s italics).³⁶ He further insists that “[t]he closer one moves to theoretical unity (constancy in respect of content or recurrent identicalness), the poorer and more universal is the actual uniqueness; the whole matter is reduced to the unity of content, and the ultimate unity proves to be an empty and self-identical possible content” (Bakhtin, 1993, p.39).³⁷ Now, this aligns perfectly with the moral alienation of the physician from scientific evidence. The German philosopher Hans-Georg Gadamer, a student of Heidegger, addressed this issue in a series of essays on medicine and its practices, collected in an interesting anthology under the title “The Enigma of Health.”³⁸ Gadamer’s question concerns the problems related to the real possibility of science fully and satisfactorily grounding social life on rational (or, in Bakhtinian terms, cultural) bases. His answer points in the direction of a paradox that is difficult to resolve: “the more strongly the sphere of application becomes rationalized, the more does proper exercise of judgement along with practical experience int the proper sense of the term fail to take place,” (Gadamer, 1996, p.17)³⁹ or, in other words, the more intensively the area of application is rationalized, the more the exercise of judgment itself is lacking, and with it, practical experience in its true sense. For Gadamer, the rational capacity for judgment is closer to Kant’s concept of judgment, and by rationalization, he understands the linking of conduct to a theoretical framework, which in the case of medicine would be biomedical science. In clinical practice, practical decision-making confronts these two types of knowledge because it is very difficult to know whether applying a general rule to a specific case is correct and at the same time just. This results in an irreducible tension in any decision-making process involving structured knowledge. However, there are practical spheres of behavior in which this difficulty does not culminate in a critical conflict. This is precisely the case with technical expertise, that is, technology and its applications. In this sense, when scientific knowledge is directed towards doing (know-how vs. knowledge), the tension of practical decision-making is minimized because the existing conflict between one choice and another is rationalized by science, that is, it is scientifically justified, even if it is not exactly the case at hand. Bakhtin and Gadamer approach the same subject from different perspectives. The latter focuses on epistemology, while the former focuses on ethics. However, Gadamer recognized and explored this hybrid constitution of medicine and its contemporary modus operandi. Bakhtin, despite not using medicine as an example, employs the language of ethics, which not only aligns perfectly with Gadamer's discourse but also makes complete sense from a medical standpoint.

The Cure

The position we occupy is unique, and it is from there that the infinite world of possible knowledge must be accessed. However,

instead of bringing all theoretical (possible) knowledge [poznanie] of the world into communion with our actual life-from-within as answerable cognition, we attempt to bring our actual life into communion with a possible, theoretical context, either by identifying as essential only the universal moments in our actual life, of by understanding our actual life in the sense of its being a small scrap of the space and time of the large spatial and temporal whole, or by giving it a symbolic interpretation (Bakhtin, 1993, pp.50-1).⁴⁰

It can be inferred here that we are authorized to play any role, doctor, nurse, patient, etc., as long as we do not strip ourselves of our responsibility and do not abandon the singularity that characterizes us because

[i]n order to root the deed, the personal participation of once-occurrent being and a once-occurrent object must be in the foreground, for even if you are a representative of a large whole, you are a representative first and foremost personally. And that large whole itself is composed not of universal of general moments, but concretely individual moments (Bakhtin, 1993, p.53).⁴¹

It is the role of the medical professional to adjust the vectors of this knowledge and presence. The attitudes and behaviors of professionals should not be shaped by scientific articles, guidelines, or evidence. These serve as empty generalizations and artificial categorizations. To root the act, the clinical encounter, personal, untransferable, and unrepeatable participation in it is necessary.

Final Considerations

In this article, we have sought to develop the idea that the clinical encounter, as the canonical core of medicine, consists (or should consist, most of the time) of a peculiar event, as described by Mikhail Bakhtin in his work Toward a Philosophy of the Act.⁴² The proposal would be to recognize the singular participation of the subject, of their non-alibi, as a way to reaffirm them as “actively responsible” for their actions in the unrepeatable realization of the moment - an almost Heraclitean moment - of this event. Bakhtin uses the concept of a valuing center to describe the horizon of meaning that emanates from oneself, constituting values and significance, from which all temporality and spatiality equally arise, determining the world as “a stable and concrete architectural whole.” Such a valuing center does not necessarily conflict with the universal historical component (in our case, medical science) or with the values of a potential interlocutor (the patient) because they are distinct valuing centers. Nor is there a risk of relativism because, according to Bakhtin, pure and eternal truth (istina) is only realized as an incarnated moment in what he calls the existing-event. For him, all the extratemporal validity of the theoretical world of truth (istina) is only founded on the real historicity of the existing-event. It is merely a moment of it, subsequently transforming into a very special truth (pravda), situated, contextualized, and constructed. “However, the common contraposition of eternal truth and our pernicious temporality has a non-theoretical meaning” (Bakhtin, 1993, p.11) (author’s italics).⁴³ A certain axiological flavor, according to Bakhtin, in which we tend to attribute positive value to eternal truth and negative tonality to our ephemeral temporality. This is quite characteristic of medicine in general, and the clinical encounter in particular. However, it must be emphasized that such “penitent” thinking develops only within the architectural framework of the existing-event where the fateful act takes place. It does not exist outside of it, and that is what asserts its secondary and non-primordial existence. The responsible act precedes such judgments, not the other way around. The following quote seems to brilliantly summarize the assumption of the clinical encounter as a prototypical Bakhtinian act:

From within, the performed act sees more than just a unitary context; it also sees a unique, concrete context, an ultimate context, into which it refers both its own sense and its own factuality, and within which it attempts to actualize answerably the unique truth [pravda] of both the fact and the sense in their concrete unity. To see that, it is of course necessary to take the performed act not as a fact contemplated from outside or thought of theoretically, but to take it from within, in its answerability (Bakhtin, 1993, p.28) (author’s italics).⁴⁴

Research Data and Other Materials Availability

The contents underlying the research text are included in the manuscript.

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• 1
  BAKHTIN, M. Art and Answerability. Early Philosophical Essays by M. M. Bakhtin. Translated by Vadim Liapunov. Austin: University of Texas Press, 1990.
• 2
  BAKHTIN, M. M. Toward a Philosophy of the Act. Translation & notes by Vadim Liapunov. Edited by Vadim Liapunov & Michael Holquist. Austin: University of Texas Press, 1993.
• 3
  Original in Portuguese: “Os médicos hipocráticos, ao se distanciarem da medicina miraculosa dos templos, fizeram parte desta corrente de pensamento laico (...); temos uma expressão disto na conhecida passagem sobre a epilepsia, logo no início do tratado médico A Doença Sagrada: ‘Eis aqui o que há acerca da doença dita sagrada: não me parece ser de forma alguma mais divina nem mais sagrada do que as outras, mas tem a mesma natureza que as outras enfermidades e a mesma origem. Os homens, por causa da inexperiência e da admiração, acreditaram que sua natureza e sua motivação fosse algo divino, porque ela em nada se parece com as outras doenças.’”
• 4
  FOUCAULT, M. The Crisis of Medicine or the Crisis of Anti-Medicine? Translated by Edgar C. Knowlton, Jr. et alii. Foucault Studies, n.1, pp.5-19, 2004. Available at: https://rauli.cbs.dk/index.php/foucault-studies/article/view/562. Accessed on 07.19.2023.
• 5
  Original in Portuguese: “Nêmese Médica.”
• 6
  Original in Portuguese: “experiência vivida pelos profissionais da saúde, que se encontram, cotidianamente, com os exemplos mais eloquentes das causas e sintomas da desumanização; por outro, da frustração dos doentes, desiludidos diante da incapacidade do aparato científico-tecnológico de lhes entregar o que prometeram. Sem esquecer, aliás, a ‘estocada’ final neste contexto, desferida pela indiferença ou mesmo desprezo humano por parte dos profissionais que, na falência dos recursos técnicos, apresentam-se ainda mais ineptos no exercício das virtudes humanas.”
• 7
  Original in Portuguese: a nexus whose decision-making horizon is guided by the telos of restoring a state of well-being inseparable from the current concept of health - revealing, hic et nunc, the very essence of medicine.
• 8
  For reference, see footnote 2.
• 9
  Original in Portuguese: “é denso e extremamente dialogado, repetitivo no tratamento de ideias.”
• 10
  For reference, see footnote 2.
• 11
  For reference, see footnote 2.
• 12
  For reference, see footnote 2.
• 13
  For reference, see footnote 1.
• 14
  For reference, see footnote 1.
• 15
  For reference, see footnote 2.
• 16
  Original in Portuguese: “a condição essencial para [que] essa integração [ocorra] não está na ciência, na arte ou na vida tomadas isoladamente, ou de modo parcial, mas na criação de um todo de sentido mediante o agir responsável do sujeito.”
• 17
  Original in Portuguese: “assunção de responsabilidade pelo sujeito.”
• 18
  Original in Portuguese: “[A] divisão criada entre dois mundos mutuamente impermeáveis só pode ser superada na vida quando conhecemos, escolhemos, agimos, criamos, construímos mundos onde a própria vida se torna objeto de um determinado domínio da cultura.”
• 19
  In Portuguese: “resulta óbvio que o conhecimento deva ser necessariamente conhecimento do geral, procedendo por conceitos, por classificações, (...) nos quais o singular, de um modo ou de outro, reaparece sob a forma de indivíduo identificado pelo pertencimento a este ou àquele conjunto, a este ou àquele gênero;”
• 20
  In Portuguese: “reconhecimento da diferença singular de cada um, pelo fato de que a organização social mesma (...) funciona sobre a base de classificações, de fechamentos, de atribuições de pertencimento, recorre ao gênero, ao universal como condição da identificação, da diferenciação, da individuação.”
• 21
  In Portuguese: “entidade puramente biológica, confinado à esfera das necessidades fisiológicas e no qual o [seu] corpo mesmo tenha sido suplantado pela abstração do organismo e a sua unidade tenha sido substituída pela divisão em órgãos.”
• 22
  Here it is impossible not to remember Hofrat Behrens, the court counselor and chief physician of the Berghof sanatorium in Thomas Mann's The Magic Mountain. For him, everyone was a potential tuberculosis patient. The figure of Behrens represents the doctor captivated by the science of the time, which, however, still yielded very poor results.
• 23
  In a highly literary passage of TPA, Bakhtin explains that total empathy is impossible because “[i]f I actually lost myself in the other (instead of two participants there would be one - an impoverishment of Being), i.e., if I ceased to be unique, then this moment of my not-being could never become a moment of my consciousness” (For reference, see footnote 1).
• 24
  For reference, see footnote 1.
• 25
  In the context of criticizing psychologism as a theoretical approach to the same subject, Bakhtin states that “[...] we turn the great theoretical world (the world as the object of all the sciences, of all theoretical cognition) into a moment of the small theoretical world (of psychic being as the object of psychological cognition)” (Bakhtin, 1993, p.11 - For reference, see foonote 1). He further elaborates, saying, “The subiectum of the first is the world qua whole, while the subiectum of the second is a fortuitous single subiectum” (Bakhtin, 1993, p.50 - For reference, see foonote 1).
• 26
  For reference, see foonote 2.
• 27
  For reference, see footnote 2.
• 28
  For reference, see footnote 2.
• 29
  For reference, see footnote 2.
• 30
  For reference, see footnote 2.
• 31
  For reference, see footnote 2.
• 32
  For reference, see footnote 1.
• 33
  With honorable exceptions, see for example Balint, 1972, Fenstein, 1967, Szasz & Hollender, 1956, as well as Mishler, 1984, through the narrative approach.
• 34
  For reference, see footnote 2.
• 35
  For reference, see footnote 2.
• 36
  For reference, see footnote 2.
• 37
  For reference, see footnote 2.
• 38
  GADAMER HG. The Enigma of Health: The Art of Healing in a Scientific Age. Stanford University Press, 1996. Particularly, chapter I. Theory, Technology, Praxis, p.1-30.
• 39
  For reference, see footnote 38.
• 40
  For reference, see footnote 2.
• 41
  For reference, see footnote 2.
• 42
  For reference, see footnote 2.
• 43
  For reference, see footnote 1.
• 44
  For reference, see footnote 2.

Review I

About the reviewer SCIMAGO INSTITUTIONS RANKINGS

Review I

The article “The Clinical Encounter as a Prototypical Bakhtinian Act” presents a multidisciplinary approach that effectively connects the field of healthcare (medicine) with discursive studies. Through an original reflection on medical practice based on Bakhtinian philosophy, the article contributes to both healthcare and language studies. With a title that is very well-aligned with its content, the text successfully achieves its purpose by delving into the complexity of the clinical encounter through the understanding of this interaction as an answerable Bakhtinian act. The discussion offers new and intriguing perspectives on this event, opening a door for more ethical and compassionate considerations toward medical practice. Moreover, the article is well-written, clear, coherent, and grammatically correct, appropriate for scientific work. Considering the statements above, I repute this article RECOMMENDED for publication, with only a few minor adjustments indicated throughout the text. APPROVED

• peer review recommendation: accept

History

• Peer review received
  15 May 2023

Publication Dates

• Publication in this collection
  18 Sept 2023
• Date of issue
  Jul-Sep 2023

History

• Received
  14 Apr 2023
• Accepted
  21 July 2023