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.