"To Normalize is to Impose a Requirement on an Existence." Why Health Professionals Should Think Twice Before Using the Term "Normal" With Patients

Abstract

The term “normal” is culturally ubiquitous and conceptually vague. Interestingly, it appears to be a descriptive-normative-hybrid which, unnoticedly, bridges the gap between the descriptive and the normative. People’s beliefs about normality are descriptive and prescriptive and depend on both an average and an ideal. Besides, the term has generally garnered popularity in medicine. However, if medicine heavily relies on the normal, then it should point out how it relates to the concept of health or to statistics, and what, after all, normal means. Most importantly, the normativity of the normal needs to be addressed. Since the apparently neutral label “normal” can exclude, stigmatize, and marginalize people who are defined in contrast to it as abnormal, health professionals should think twice before using the term with patients. The present critical perspective advocates against using the term “normal,” as long as no understanding of a person’s individual normality has been attained. It advocates for the right to autonomously determine one’s own normality. For health professionals I do not see worthwhile benefits of subscribing to the concept of (non-individual and normatively loaded) “normality” and imposing it on their patients. But I do see many risks.

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Bioethical Inquiry (2021) 18:389–394
https://doi.org/10.1007/s11673-021-10122-2
CRITICAL PERSPECTIVES
“To Normalize istoImpose aRequirement
onanExistence.” Why Health Professionals Should Think
Twice Before Using theTerm “Normal” With Patients
MichaelRost
Received: 7 December 2020 / Accepted: 24 April 2021 / Published online: 18 October 2021
© The Author(s) 2021, corrected publication 2021
of subscribing to the concept of (non-individual and
normatively loaded) “normality” and imposing it on
their patients. But I do see many risks.
Keywords Normality· Normal· Discrimination·
Is-Ought· Statistics· Normativity
“Normal” is a strange word. We use it constantly, like
our favourite mug, but our understanding of it remains
volatile, like the scent of the freshly brewed coffee in
our mug. In the following, I will critically discuss the
subject of normality with the aim to make people think
about the normal, its fallaciousness, and its dangers.
Abstract The term “normal” is culturally ubiqui-
tous and conceptually vague. Interestingly, it appears
to be a descriptive-normative-hybrid which, unno-
ticedly, bridges the gap between the descriptive and
the normative. People’s beliefs about normality are
descriptive and prescriptive and depend on both an
average and an ideal. Besides, the term has gener-
ally garnered popularity in medicine. However, if
medicine heavily relies on the normal, then it should
point out how it relates to the concept of health or to
statistics, and what, after all, normal means. Most
importantly, the normativity of the normal needs
to be addressed. Since the apparently neutral label
“normal” can exclude, stigmatize, and marginalize
people who are defined in contrast to it as abnormal,
health professionals should think twice before using
the term with patients. The present critical perspec-
tive advocates against using the term “normal,” as
long as no understanding of a person’s individual
normality has been attained. It advocates for the right
to autonomously determine one’s own normality. For
health professionals I do not see worthwhile benefits
M.Rost(*)
Institute forBiomedical Ethics, University ofBasel,
Switzerland, Bernoullistr. 28, 4056, Basel, Switzerland
e-mail: michael.rost@unibas.ch

390 Bioethical Inquiry (2021) 18:389–394
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“You want towatch outfor[words] whose
influence isfelt everywhere, butwhose location
andoperation remain somehow invisible.”
(Stephens 2019, 278)
The term “normal” is culturally ubiquitous, but its
conceptual essence has not been fully unveiled (Ste-
phens 2019). If a concept is widely used among
both lay persons and health professionals, one might
expect a well-elaborated understanding of what it
means. Unsurprisingly, this assumption is not met in
the case of the normal, which is dynamic and con-
tingent on cultural and historical circumstances. To
make things even worse, multiple domain-specific
normalities coexist.
In times of crisis, typically an uptick in prevalence
of the term “normal” can be observed. Just compare
pre-pandemic and pandemic numbers or use Google-
Books-Ngram-Viewer to see the increase during and
especially after political crises. In these cases, the
term “normal” is mostly applied to social, political,
and economic conditions. This should not obscure
another field of application, namely persons and their
qualities.
The present opinion piece addresses this particular
field of application. As the coronavirus spreads, the
use of the term “normal”—primarily being applied
to social conditions, such as a return to normality as
indicated by an end of curfews—spreads as well, and
this risks to reinforce the acceptance of the concept
of normality, also when applied to persons. This is
unfortunate because, as will be shown later, the label
“normal” often stigmatizes, marginalizes, and some-
times even pathologizes persons who are not consid-
ered normal.
The normal “uses apower asold asAristotle
tobridge thefact/value distinction, whispering
inyour ear thatwhat isnormal isalsoright”
(Hacking 1990, 160)
Ethical analysis distinguishes between two types
of statements. Descriptive statements make factual
claims about how the world or a person is. Normative
statements make prescriptive claims about how the
world or a person ought to be. Normative conclusions
(e.g. how persons should behave, which qualities are
good) need to rest on at least one normative premise.
Of course, as with descriptive premises, the norma-
tive premise is always debatable, but the point is that
an ought (i.e. normative claim) cannot solely rest on
an is (descriptive claim).
Interestingly, the normal appears to be a descrip-
tive-normative-hybrid. It seems to unnoticedly bridge
the gap between the descriptive and the normative,
a gap which philosophers have been struggling with
for eons. In “The Normal and the Pathological,” Can-
guilhem articulates this convergence: “the concept
of normal is itself normative” (Canguilhem 1991,
241). Correspondingly, recent psychological research
evidences that “people actively combine statisti-
cal and prescriptive information [i.e. descriptive and
normative statements] ( … ) into an undifferentiated
notion of what is normal” (Bear and Knobe 2017,
25; Wysocki 2020). People’s beliefs about normal-
ity, thus, are descriptive (i.e. average, frequency) and
prescriptive (i.e. ideal, goodness) and extend beyond
a mere description of persons into the realm of moral
norms.
Yet, where does normality’s normative force come
from? Most of the time, normality is derived from
statistics (e.g. averages), which, by nature, represent
mere descriptive statements about the distribution of
measured qualities and which lack any intrinsic nor-
mative significance. For the normal distribution, nor-
mal refers to the situation where most of the sample
data clusters around a single value (the mean) with
observations far apart from this value being rare,
but it neither describes one part of a binary normal-
abnormal condition (Cryle and Stephens 2017) nor
defines some sort of statistical normativity. Here,
human qualities follow a normal distribution and
every manifestation is normal. In themselves, such
descriptive statements cannot be translated into nor-
mative claims. Statistics are immensely important
for science, but they are “detrimental when used as a
blunt instrument of measurement to legitimize labels
[e.g. normal] that differentially sort people into sub-
populations that augment social inequalities” (Mason
2015, 343). Alas, despite lacking a normative under-
pinning, the normal usually embraces a non-justified
ought, which comes along perfectly disguised as a
well-justified moral norm.

Bioethical Inquiry (2021) 18:389–394 391
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“Normality isaterm which recurs withdisturbing
frequency inthewritings ofpsychologists,
psychiatrists, psychoanalysts, sociologists”
(Eysenck 1953, 177)
The term “normal” has generally garnered popularity
in medicine. A brief look at the occurrences within
the major classification systems not only reveals its
importance but also provides first hints as to where
the normal unfolds its normative power (Table 1).
While personalized medicine’s focus on individual
characteristics of patients might one day erode the
significance of normality in medicine (Chadwick
2017), today, undoubtedly, the normal is a major
diagnostic category in medicine. However, these
diagnostic classification systems no longer consider
the entirety of manifestations of human qualities as
normal. Instead, limits to normality are set and cut
off from both tails of a distribution which is math-
ematically infinite. Apparently, medicine “reserves
the right to confer labels of normality and abnormal-
ity, but to what extent are these terms objective and
purely descriptive?” (Mason 2015, 345)
Roughly, health has been conceptualized as an
“objective notion,” determined by empirically observ-
able symptoms (e.g. value-free biomedical model,
corresponding to some sort of statistical normality)
or as an “subjective notion,” socially and normatively
constructed (e.g. value-laden sociopolitical model,
corresponding to some sort of normative normal-
ity). Irrespective of this genuine contestability of
the concept of health and the underlying notions of
normality, if medicine heavily relies on the normal,
then it should point out how the normal relates to the
concept of health or to statistics, and what, after all,
normal means. Reflection on the normal should be
incorporated in classification systems and in medical
curricula. The normal should be an object of critique.
Its determination should not be left to the diagnos-
ing health professional. Most importantly, the nor-
mativity of the normal needs to be addressed. How-
ever, normality in medicine is currently not clearly
defined in the medical literature (Chadwick 2017;
Catita, Águas, and Morgado 2020). Only if medicine
achieves a shared operational conceptualization of
normality and the source of normality’s normativity
is expounded, the term “normal” could be used that
widely in medicine.
“This unassuming word can have asignificant
effect onthelives ofthose defined incontrast toit
asabnormal, pathological, ordeviant.”
(Cryle andStephens 2017, 2)
Normality, once established, is rarely made explicit
but still powerfully permeates our daily lives. Any
person-related reference to normality, simultaneously,
qualifies abnormality. Facing this ineluctable truth, an
individual might experience fear of denormalization,
which often results in marginalization and stigmati-
zation, and, hence, has strong incentives to adhere to
the normal. In fact, any form of normality entails con-
formity pressure. “Normal” is no neutral label. On the
contrary, it is—in its negative form: the abnormal—
being used in a variety of discourses as a metonym for
social exclusion. The normal and abnormal are power-
ful tools in the hands of those who construe its essence.
Table 1 Frequenciesa and examples of the term “normal” within classification systems
a Author’s own counting;
b In comparison, within DSM-I 19 instances (1x/7.6 pages);
c Classification of Mental and Behavioural Disorders—Clinical descriptions and diagnostic guidelines.
Frequency Examples
DSM-Vb366 instances
1x/2.7 pages
“normal life variation,” “abnormalities of emotional or cognitive processing,” “normal fluency of
speech,” “normal developmental variations,” “normal sexual desire,” “normal pattern of learning
academic skills,” “abnormal social approach,” “normal level of intellectual functioning,” “abnormal-
ity of emotional processing”
ICD-10c259 instances
1x/1.0 pages
“abnormalities of behaviour,” “normal social inhibitions,” “abnormal moodstates,” “normal fam-
ilyrelationships,” “normal sense of (fe)maleness,” “normal children”
ICD-11 1445 instances
1x/1.2 pages
“abnormal social behaviour,” “normal personality characteristics,” “normal delivery,” “normal range of
life experiences,” “normal skin,” “normal grief,”, “normal speech,” “normal menopause”

392 Bioethical Inquiry (2021) 18:389–394
“Normal” is a generic replacement term that,
mediated through persisting related beliefs, discrimi-
nates against certain—often historically excluded—
groups in various mutually constitutive discourses.
These discourses are interconnected and, therefore,
discrimination at the intersections can be amplified
(Crenshaw 1989). Intersectional groups can experi-
ence unique forms of overlapping discriminations
due to multiple categorizations as abnormal. In this
vein, the category of the abnormal can be understood
as the nucleus of various forms of discrimination. It
marks the area of densest overlap of discrimination
fields. This is why the malleable normal is so dan-
gerous. It feeds and, hence, spans many (medical)
discourses and does not exclusively unfold its power
in one separate field but across various fields. Many
normalities exist and they bolster one another.
This is illustrated by the following few findings on
the normative and exclusionary operation of normal-
ity that are related to medicine. The normal implicitly
determines social judgements about the acceptabil-
ity of certain kinds of biological variation (Amund-
son 2000). The bodily integrity of intersex people is
threatened by the idea of normal sexes (i.e. binary)
and by characterizing intersexed bodies as abnormal
(Reis 2009). The idea of normal abilities imposes
normative assumptions on persons with physical
disabilities (Davis 1995). Equating psychological
normality and mental disorders gives rise to ques-
tionable diagnostic labels (Bartlett 2011). The idea
of a normal body brings about oppressive narratives
about physically impaired people (Thomson 1997)
and abets gendered norms about bodily appearance
and bodily normalcy (Liebelt 2019; Kittay 2006).
The construct of normal infant growth is used to
force assimilation of indigenous people into the
nation-state (Butt 1999). The myth of a normal brain
leads to a pathologization and (dis)qualification of
individual human brains as abnormal and ultimately
disregards the notion of neurodiversity (Armstrong
2015).
Given these effects of the normal, shouldn’t we
allow only one form of normality, that is each per-
son’s individual normality? With respect to health,
Goldstein outlined that “disease can be determined
only by means of a norm which permits taking the
entire concrete individuality into consideration,
a norm which takes the individual himself as the
measure; in other words, as an individual, personal
norm” (Goldstein 1939, 433). Applying his health-
related rationale to the determination of normality,
ultimately, helped people to be who they are and
to do what they value doing. In contrast, imposing
(non-individual) normality on them unduly inter-
feres with their flourishing. Related to this, it has to
be realized that the term “normal” either refers to all
human qualities and, therefore, applying it to persons
becomes meaningless or it exclusively refers to a sub-
set of human qualities and, thereby, excludes some
from being normal (Fig.1).
“The benign andsterile-sounding word ‘normal’
hasbecome one ofthemost powerful ideological
tools ofthetwentieth [and twenty-first] century”
(Hacking 1990, 169)
I am advocating against using the term “normal”
with persons, particularly in medicine, as long as
no understanding of their individual normality
has been attained. I am advocating for the right to
autonomously determine one’s own normality. No
one should be subject to an imposition of normality.
In short, normality should be determined intra- not
inter-individually, internally not externally. Lacking
an understanding of a person’s individual normality
and still applying the term to the individual means to
“impose a requirement on an existence” (Canguilhem
1991, 239). This is likely to cause harm on the part
of the individual and violates the bioethical principle
of primum-non-nocere. Refraining from using the
term “normal” in the medical setting also means to
undermine normatively loaded normality at a societal
level. Without justificatory grounds it tells us what to
do and what to be and, thereby, perpetuates systems
of power, privilege, and inequality. These systems
require efforts to preserve them, mainly on the part
of the privileged and powerful. Taking away the(ir)
normal helps to dismantle their hegemony.
Although historians studying normality are
“unpersuaded (…) that the concept of normal relies
on logical coherence, and that exposing its contradic-
tions will fatally undermine its functionality” (Cryle
and Stephens 2017, 9), you can still emphatically ask
yourself, what would be lost, if you simply stopped
using the term “normal” when referring to persons,
refrained from using the term with patients? Can’t
you always replace the term with a more accurate
one? Do you really need it?
Regarding patient care, medical ethics frequently
invokes a risk-benefit evaluation. To conclude, a
patient, without any doubt, is free to define its own

Bioethical Inquiry (2021) 18:389–394 393
normality, but for health professionals I do not see
worthwhile benefits of subscribing to the concept of
(non-individual and normatively loaded) “normal-
ity” and imposing it on their patients. But I do see
many risks. Medicine’s persistent recourse to normal-
ity not only—in many instances—fails to honour the
paradigm of rigorous science, it also—more impor-
tantly—fails to honour the lived experiences of those
systematically excluded by the social, cultural, and
medical authority of the normal.
Funding Open Access funding provided by Universität
Basel (Universitätsbibliothek Basel).
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Note. This figure neither claims to be exhaustive nor perfectly systematic but aims to preliminarily capture
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Fig. 1 The normal in various discourses

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