The positivist ideal – subject-free science
The term subjectivity – understood as the counterpart to objectivity – resonates poorly with science. Methodological prescriptions therefore seek to eliminate the patient's and researcher's subjectivity. However, this elimination process may occasionally be only tenuously justified.
The researcher needs to avoid a subjective description of experience, but this does not mean that the researcher should avoid providing a description of subjective experience. Where the former description leads to misunderstanding, the latter gives rise to deep insight (6). Such insight into the subjective will be especially valuable in cases where adaptive systems contribute significantly to pathophysiological processes.
The prescription that researchers must avoid bringing their own subjectivity into the study can hardly be fully complied with. This was made evident during the Norwegian positivism debate in the 1950s and 60s.
The debate was started by Arne Næss's (1912–2009) doctoral thesis from 1936 (7). He wished to show that knowledge of the actions of others can be gained without assuming a knowledge model in which the researcher's subjectivity contributes to the knowledge outcome. For this purpose, he found it necessary to develop a method that could capture the reality – the 'positive' – of the observed person's behaviour, assuming that functional behaviour as perceived by a non-biased observer could lead to this goal.
Hans Skjervheim (1926–99) later challenged Næss's assumptions by showing that neither the researcher's, nor the observed person's subjectivity can be fully eliminated, and moreover that any attempt at such elimination would reduce the researcher's opportunity to obtain a correct understanding of human dispositions to act (8). Næss appears to have subsequently incorporated Skjervheim's objections (9).
In a medical context, Christopher Boorse has sought to revitalise the positivist ideal by highlighting that biological function may serve as a value-neutral demarcation criterion between health and illness – health is present when all bodily processes function normally, measured in terms of a healthy reference group matched for age and gender; illness means that these processes function less well than expected (10).
With regard to adaptive systems, this is an erroneous assumption. Adaptive systems surely develop from genetic structures that are constituted at the moment of conception, but their functional form is established only through the system's self-creating interaction with the environment. Health and illness may thus be realised in multiple ways – for example, monozygotic twins develop different adaptive systems, and as shown for the immune system, these differences may even increase over the course of life (11). Such differences reflect the changing realisation of subjectivity throughout life, and also profess that adaptive functionality should be regarded more as a relationship between the organism and its environment than as a property of the organism itself.
This kind of understanding implies that illness may occur as a result of changes in the environment as well as in the organism, and there may therefore be little relevance in equating illness with dysfunction, as advocated by Boorse. It is possible to have a fully functioning immune system and still develop cancer, allergies, autoimmune diseases and chronic infections.
Insufficient recognition of the pathophysiological influence of subjectivity may perhaps be the reason why certain complex diseases – including chronic fatigue syndrome – remain unexplained (12). In this syndrome, there are no biomarkers that can distinguish the ill from the healthy, and the diagnosis is therefore made on the basis of the patient's subjective experience of his or her bodily functioning.
This is the same subjectivity by which patients and controls are included in research studies. Subsequently, however, the researcher largely neglects the importance of subjectivity in favour of objective measurements of cellular, molecular and functional parameters, despite the fact that there is widespread agreement among researchers that the syndrome is associated with the function of adaptive systems and that 'basic research linked to infections, inflammation, immunology, neurology and genetics' ought to receive support (13).