Excerpt from the edited book Philosophy of Nursing: Five Questions (2014) in which 'five open-ended questions are addressed by 24 key figures engaged in philosophical questions in nursing'.
Below is part of my response to the question:
What, in your view, are the most interesting, important or pressing problems in contemporary philosophy of nursing?
[...] The most pressing philosophical
problems for me are the same ones that troubled Laing more than fifty years
earlier; that is to say, the existential problems arising from the study of our own being-in-the-world or, to use
Laing’s term, man in relation to other men.
Laing’s starting point was the
extreme case of the schizophrenic patient who does not appear to experience
himself as a person, and whose distorted self-image is generally reinforced by
medical professionals. Laing famously observed that he had great difficulty in
observing the textbook signs and symptoms of psychosis when interviewing
patients. His first thought was that that this was due to a deficiency on his
part; that he was not clever or observant enough to spot what other psychiatrists
appeared to see. His second thought was that perhaps they had got it wrong, before arriving at the realisation that the
doctor and the patient form a single existential subject-object Gestalt. That
is to say, the ‘reality’ of the clinical situation is jointly constructed by
the doctor and the patient; each perceives the other from their own frame of
reference and each responds to the other according to how they imagine that the
other is perceiving them (think, perhaps, of Sartre’s example in Being and Nothingness of the peeping Tom
who suddenly switches from observer to observed as he realises that he himself
is being watched). The trick is at all times to consider the possibility of the
other as a thinking, feeling, autonomous subject and to recognise that the
other will often respond to me as nothing more than an object in their own
perceptual field.
Laing’s project, which he
articulated in the terms and language of existential phenomenology, was to move
beyond the traditional ‘objective’ doctor-patient relationship towards a
subjective hermeneutic understanding from the patient’s point of view. Whilst afull hermeneutic understanding is
rarely if ever possible, Laing argued that we must nevertheless resist the
temptation to assess, judge and respond to the other according to our own
medico-bio-scientific categories. The least we can do is to reach out and
attempt a person-to-person existential grasp of the lived experience of the
other in the form of a therapeutic relationship. Whilst there are psychological
and sociological aspects to this undertaking, it is at heart a philosophical
venture, and it seems likely that Laing was influenced here by Sartre’s notion
of the transcendent ego; that is, the argument that the ‘I’ or ego is, in his
own words, situated ‘outside in the world;
it is a being in the world, like the ego of another’. This supposition to some
extent circumnavigates the ‘other minds’ problem and opens up the possibility
of authentic and largely unmediated contact between myself and others ‘out
there’ in the world. We might say, then, that the most fundamental and pressing
philosophical problem in the field of nursing is the question of otherness; of
attempting to understand and engage with our patients and colleagues. Whilst
Laing explored this problem specifically within the relationship between the
psychotic patient and the psychiatrist, I would suggest that it has a wider
relevance that extends to the nurse-patient relationship in general (that is,
not only in psychiatric nursing), indeed, that it is fundamental to the practice of nursing.
The importance of an existential
hermeneutic understanding of the other was, for me, brought into sharp relief
by the recent and very shocking case in the UK of a 22 year-old man who died
from dehydration whilst being treated in hospital. This example can be added to
a growing list of cases neglect and failure to care, mostly by nurses but
sometimes also by other health care professionals. Increasingly, the response
from the general public and from patient groups is that nurse education has
become too academic and nurses too highly qualified, resulting in a lack of
common sense and basic compassionate care at the bedside. Sartre’s work,
however, suggests the opposite. His position is that the ‘natural attitude’
(the common-sense view) is of other minds, other Egos, as largely inaccessible
to our own consciousness and hence unknowable (and even, perhaps,
unverifiable). We tend most of the time to view others merely as objects in our
perceptual field, and when we do view them as autonomous subjects, it is rarely
from a position of empathic understanding. As Laing pointed out, our failure to
understand the life-worlds of others is largely due to our experience of them
as fundamentally separate and removed from our own experiences. In the example
cited earlier, the agitated and aggressive behaviour exhibited by the
dehydrated patient was wrongly interpreted because no attempt was made to
understand the world from his perspective. The remedy for this gross lack of
imagination is not less education but more. Compassion cannot be taught, but
the knowledge and understanding necessary for its recognition and expression
most certainly can. The application of
common sense is not the solution but part of the problem.
For me, the practice of nursing is
fundamentally concerned with the development of caring human relationships, and
this requires a deep philosophical understanding of the nature of our own being qua being and that of our patients.
All other problems in contemporary philosophy of nursing, including matters of
ethical conduct and questions about the nature of nursing knowledge, are
secondary to this fundamental ontological concern and, I would suggest, can
only fully be addressed within the context of what Laing referred to as the
existential-phenomenological science of persons. Put another way, we must first
establish the principles of an authentic and respectful patient-nurse
relationship before we can even begin to formulate questions about what it is possible
and desirable to know and how we should behave in the context of that
relationship.
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