Homicidal ethics – on the use of trolley thought experiments and other such nonsense in health care ethics

There are five people standing on the train track. A train runs uncontrollably towards them. You can save these people. All you have to do is to pull the lever that directs the train to another track.

Here’s the twist: there’s someone standing on the other track too. This person is morbidly overweight and a smoker. Perhaps even a pensioner. What do you do? Do you let the train run over five people or do you pull the lever causing the death of one person?

But wait. There’s another twist. You could stop the train by pushing something heavy in front of it. A fat guy is conveniently standing next to you. Do you push the guy on the tracks to save the other people?

Would you change your mind if one of the five people on the first track was a brain surgeon? A millionaire who gives to charity? A child perhaps?

These trolley thought experiments are among the stupidest things human mind has ever spawned on earth. They are extremely dangerous simplifications. They are homicidal. Someone has to die. And you have only equally bad options to choose from. You have to weigh lives, conduct an “ethical” calculus, where the good of the many outweighs the good of the few. The criteria you are given are age, income, health, lifestyle, and so on. But even for Utilitarianism (and I’m not a fan) the trolley problem is a poor excuse.

Despite this, it is not unheard of that they are used as analogies for scarce resources in health care. The ethics of prioritization in health care fits all too well to the homicidal model of the trolley problem. The obvious example is organ donation. Would you kill a healthy prisoner if his/her organs could save five people?

Prioritization is something that health care workers face everyday. This is an undeniable fact. However, trolley problems offer a limited model for ethical decision-making. Although it might often be the reality of prioritization that only limited and equally bad options exist, why should the situation be simply accepted as given? Why should the complexity of moral life and the complexity of the human capacity for thinking be reduced to a game that is rigged from the start?

Trolley thought experiments and other such nonsense in health care ethics take moral distress – the resulting suffering from bad conscience of not being able to do one’s job as ethically as one would like to, often due to external (read: political and economic) circumstances – as a necessary evil. They claim, borrowing an argument from a paper at a bioethics conference I attended a while ago, that moral distress is necessary for the cultivation of the virtue of moral sensitivity.

To me this is unacceptable. The starting point for health care ethics ought not be to accept that things that are bad are also unchangeable. The starting point ought to be to resist whatever might stand in the way of moral practice. In other words, to use the trolley problem against itself, why the **** are the people forced to stand on the track in the first place?

On moral responsibility: Preventing people from dying due to cold homes?

Having born in a country (Finland) where winters are usually cold, I was sad to learn about winter deaths in Britain (for this short post I only use statistics from England). I recently wrote a column about this in Finnish for the journal of the Finnish Association of Physiotherapists.

Last winter, according to study conducted at my Alma mater UCL, saw the highest number of deaths due to low indoor temperatures in fifteen years. A total of 9000 people died which is a fifth of all winter deaths. Not because of last winter was colder than usual (it wasn’t). These excess deaths happen because of fuel poverty: people can’t afford to heat their homes.

The charity Age UK estimates that there are around 2.4 million households in fuel poverty, and 1.14 million old people live in fuel poverty in England alone. They estimate that the costs of fuel poverty to the NHS are around £1.36bn every year. The problem is obvious and so is the solution: let’s heat the homes.

In 2000, the government did agree a legally-binding objective to eradicate fuel poverty by 2016 (Warm Homes and Energy Conservation Act 2000). However, England saw an increase in fuel poverty between 2003-2010.

According to BBC Panorama, the government changed their definition for a fuel poor household: it used be those households that spend more than 10% of their income on heating their home. In 2013, three years before the target was to be met, the government changed how it measured fuel poverty in England to the Low Income High Costs (LIHC) indicator. Fuel poverty according to LIHC is based on whether keeping up a decent standard of indoor heat would leave the household below the poverty line. According to Panorama, about 13 million people would be classified as fuel poor if the old definition was still in place. When the new calculation tactic is used, the number of fuel poor people drops to around 5 million.

Clever.

Whether the old or the new definition is more accurate, people will still die. According to the National Institute for Health and Care Excellence (NICE), all health, public health and social care practitioners should be equipped to recognize vulnerable people to the health problems associated with a cold home such as older people (56% of deaths in cold homes are people aged 85 or older; 27% are between ages 75-84). People with poor immune system are also at risk: living in a cold home increases the risk of heart attack, strokes and respiratory infections.

The conclusion? The moral responsibility to clean up the mess of growing inequalities is left to the health care practitioners.

 

 

 

Reblogged: 30 days of September – Hegel’s Phenomenology of Spirit

Every year since 2014 the Critical Physiotherapy Network has run a month-long blogging campaign called 30 days of September. This year the purpose was to introduce books or texts that have been influential for CPN members. Here’s what I had to say, please visit this link.

We are now on day twelve and the introduced books have been interesting indeed, varying from the WHO’s International Classification of Functioning, Disability and Health (ICF) to Judith Butler’s Gender Trouble. My inspiring book was Hegel’s Phenomenology of Spirit which I first read for my MA dissertation on selfhood and dementia. I blogged about this earlier as a way to revisit my disseration because it will be something I return to in my – hopefully – next research project on dialectics, touch, affect and recognition.

Following up on Formula Comitis Archiatrorum – still not convinced

My previous blog post on Formula Comitis Archiatrorum has been by far the most popular on my site. It gets frequent visitors from all over the globe –  a fact that I was very surprised about but also very grateful for all the people who have shown interest in my little research. This is still a side project, one that I haven’t had too much time to return to, as it turns out its not even a footnote after all, but I’m very much intrigued by it. I have done some more research on it and I’d like to update some of the claims I made previously.

Most importantly, I’d like to return to the issue of what exactly is it? Is it a code and is it the first?

I still stand behind my main claims:

  1. There is no actual link between the Formula and our contemporary medical ethics codes.
  2. Other historical work in medical ethics has been more likely more influential, such as Percival’s Medical Ethics or even Hippocratic or Galenic medicine.
  3. Formula comitis archiatrorum is one example from the beginnings of Christianity but it doesn’t deserve any archetypal position as the first medical ethics code

In my previous post I wrote:

Nemec also mentions that the Formula was an oath. It is not clear, however, what the oath called Formula Comitis Archiatrorum really is. It is certainly not the same thing as the text documented by Cassiodorus. This document might however, as the normative claims in it show, contain something about the oath if it existed. Finding the answer to whether the oath existed and whether it is preserved in its entirety in Cassiodorus’ letter Formula Comitis Archiatrorum would require meticulous research through archives, whether any references are out there.

I think there is some unnecessary ambiguity here, one that arises from my own limited understanding the etymology of the word Formula back then. I’d like to clarify, after examining the issue further, that what the document Formula comitis archiatrorum is, is a letter of investiture – in Latin formula – a letter to appoint the Comes archiatrotrum, the count of the chief physicians, to the royal court to serve as the royal physician. So in this sense, by taking the position as the Comes archiatrorum, the one who is appointed would have committed to the norms in the document, so it can be considered as a written oath. But there is no evidence of any practices of swearing an oath that carries the name Formula comitis archiatrorum. Why? The evidence is quite simple: Formula does not mean ‘an oath’. This is not to say that there wasn’t an oath and it is not to say that it didn’t, if indeed there was one, contain the same normative claims but the possible sworn oath is certainly not the same thing as this document that is called Formula comitis archiatrorum. I explain this idea in more detail below.

When was it written? What is it not?

Formula comitis arhciatrorum is credited to Flavius Magnus Aurelius Cassiodorus, a statesman and writer. Like the dates of his birth and death, much of Cassiodorus’ personal life is unknown. One estimate is that he was born somewhere between 484 and 490, and died between 576 and 590.[1] Some knowledge about his life as a statesman, however, is preserved through his writings.

Cassiodorus served in the administration of king Theodoric the Great, one of the greatest barbarian kings, who ruled the Ostrogoths from 471 to 526 and an independent Gothic kingdom in Italy from 493 to 526. It can be deduced from Cassiodorus’ writings that he served as a quaestor from 507 to 511 and magister officiorum from 523 to 527.[1] After Theodoric’s reign Cassiodorus served most likely only briefly his successor, the ten-year-old king Athalaric and Theodoric’s only child Amalasuintha who was the queen regent. He returned to office around 533 when Athalaric appointed him praetorian prefect for Italy and then served during both Theodahad’s and Witiges’ brief and stormy reigns until late 530s.

After this brief glimpse into Cassiodorus’ public and personal life we can easily put to rest the misunderstanding that Formula comitis arhciatrorum was written or published in the 5th century.[2-11] It may have been in use during the early reign of Theodoric in the 5th century but without any other documentation other than Cassiodorus’ texts, it is difficult to know for sure in which century Formula was first in use. In addition to the fact that Cassiodorus was born towards the end of the 5th century, we know that he composed Formula comitis arhciatrorum along with numerous other letters and model letters for appointments (Lat. formulae) during his time as a quaestor but no later than the year 534.[1] What we do know is that in the late 530s, towards the end of his service as the praetorian prefect of Italy, he selected and edited 468 letters, proclamations, edicts, and formulae which he had written during his service and compiled them into 12 books called Variae. The most comprehensive English translation of the works is still Hodkin’s 1886 abridged edition[12] in which Formula comitis arhciatrorum is only translated partly.

The Variae is an early example of formulary collections of legal and chancery documents.[13] Cassiodorus’ motives for compiling it was, as he himself proclaims in the preface for Variae, to supply models for official eloquence for future administrators, to ensure the immortality of those praised in them, strengthen respect for laws, and to provide a mirror of his own character.[13,14] It is likely that Cassiodorus had also propagandistic motives.[1] For the contemporary reader the letters are an important source of the history of the Gothic rule in Italy, its political appointments, judicial decisions, administrative orders, and military commands. Most of the letters are written in the name of the kings but there are some that are written in Cassiodorus’ own person, which is why we can’t be sure whether the Formula had been in use in the 5th century in some form or whether it was indeed composed in the 6th century. Therefore they function also as a document of one statesman’s public career. Formula comitis arhciatrorum is one of the letters that Cassiodorus did not author in his own person.

According to Amory, the Variae remain a reliable source of Theodoric’s policy.[15] Any alteration and editing Cassiodorus made concerned only the probable elimination of personal names, dates, of protocol and eschatocol, and the possible addition of excurses on natural phenomenon.[1,15] It is difficult to say, however, that how much of the words can be directly attributed to the kings and how much Cassiodorus polished the kings thoughts. Perhaps, as O’Connell suggests, they are something in between being a direct reflection of the thoughts of the monarchs and a complete production of Cassiodorus.[1]

So is Formula comitis arhciatrorum a code of medical ethics? Or is it, as Jaroslav Nemec claims, also an oath?[16] (I still need to get my hands on Nemec’s source, Castiglioni A. A History of medicine. New York: Aronson 1975.) It is a short model letter, a form of investiture, written for the purpose of appointing the count of the chief physicians, or comes archiatrorum, to office. Although it contains some normative clauses on how physicians and the comes archiatrotum ought to behave, it is safe to assume that Formula comitis arhciatrorum is not, as it has been preserved for contemporary readers, a code of medical ethics. It is more likely that that is can be considered an oath in sense that the appointed comes archiatrorum, by accepting the appointment, committed to abide by the norms set in the letter. But there is nothing in the wording of the letter itself to indicate that it was a ceremonial oath that the comes architrorum would have sworn upon being appointed.

Is there any connection to contemporary medical ethics?

To support the argument that Formula comitis arhciatrorum is an archetype Timimi claims that it “it required that physicians widen and deepen their knowledge and originated our current concept of physician-to-physician engagement and consultation.”[10] Is this true either?

The whole Formula reproduces Hippocratic medical etiquette. This is not surprising given that Hippocratic medicine was the accepted practice in Cassiodorus’ Italy. Formula comitis arhciatrorum begins with a description medicine as the foremost respectable art. Then it is established that in such art there should be a foremost one, comes archiatrorum, to whom all those who take care of human health should report. Then six normative clauses follow: First, medicine should not be defined by case-based changing opinion but experience of the physician. Galen writes in a similar fashion in the 2nd century BCE where he argues for approaching signs of sickness logically, through science, and trough ethics. The second normative clause is the likely source for Timimi’s claim that Formula comitis archiatrorum required physicians to widen their knowledge. The Formula states that after their training physicians should have leisure for books, especially ancient ones, both within and outside medicine. Again, similar arguments can be found in Galen’s The best physician in also a philosopher.

The third clause is the likely source for Timimi’s second claim that our current concept of physician-to-physician engagement and consultation originated in Formula comitis archiatrorum. Physicians should, according to the Formula, desist from quarrels that injure patients. If agreement is not made they should seek advice from somebody who can be asked without envy, for a prudent man is willing to seek counsel. Hippocratic texts, De medico as well as the Oath, both discuss collegiality and seeking counsel.

The fourth normative clause asserts that physicians are consecrated by oaths. They should promise to their teachers to hate iniquity and love honesty. There is a similar pledge for loyalty to teachers, again, in the Oath.

The last two clauses concern the duty of healing and respecting human health and life. It sates that physicians are, fifthly, not allowed to fail in their duty and they must seek diligently what cures the sick and what strengthens the weak. Sixth and lastly, although mistakes may cause fault, a sin against the human health is the crime of homicide. The two last are clauses are similar to the Hippocratic idea of benevolence and the duties of physicians towards their art and their patients.

The formula ends with the honouring of the recipient with the title of comes archiatrorum to be a judge in the art of medicine, to cure the sick by eliminating conflicts among physicians. The visit of the comes archiatrorum should mean “health for the sick, relief for the weak, hope for the tired.” They should observe signs of sickness through their science and, finally, they are allowed to enter the palace and attend to the royal family.

So the argument about the archetype does not seem to hold true. There is nothing that really sets it apart that would earn it the special status it has been given in some articles. Rather than lifting one document among others, there is no one archetypal document from which our current ethics arises from. The way our conception of morality has evolved is rather attributable to religions and culture.

Conclusion

I have tried to make some clarifying points on this issue. I still hope to return to researching Formula Comitis Archiatrorum. I wish to clarify again that my intention is not undermine the document itself. The Variae, including Formula, are our most important documents for the history of Italy under Gothic rule.[13] Prioreschi argues that it is significant in the sense that it underlines the consideration in which medicine was held at Theodoric’s court, it contains important information about the way medicine was practiced and perceived, and it contains information about medical theory and therapy at that point of time and place.[17] Max Neuburger argues that Formula proves the existence of cultivated and organised medical practitioners in the 6th century Italy.[18] Whatever its significance, it is a part a wider historical context.[19-20]

References

1 O’Connell JJ. Cassiodorus. Berkeley: University of California Press 1979.

2 Aboujaoude E, Weiss Roberts L, Reicherter D. Introduction to ethics in clinical medicine. In: Weiss Roberts L, Reicherter D, eds. Professionalism and ethics in medicine. New York: Springer 2015:3–26.

3 Battacharya S, Stubblefield BG, Banerjee SK, et al. Ethics and moral principles in the practice of medicine. In: Battacharya N, Stubblefield GS, eds. Regenerative medicine. 2015:281–285.

4 Cantú-Quintanilla G, Alberú-Gómes J, Reyes-Acevedo R, et al. Conveniencia de un código para mejorar los estándares éticos en la Sociedad Mexicana de Trasplantes. Revista Mexicana de Trasplantes 2013;2: 97–100.

5 Freed JS. Legal and ethical issues in global health: a trip through the vagaries of truth and culture. In: Roth R, Frost EAM, Gevirtz C, eds. The role of anesthesiology in global health: a comprehensive guide. New York: Springer 2015:14–158.

6 Leigh H. Systems and ethicsl issues in CL psychiatry: hospital as a social sytem, sicj role and doctor role, ethical and legal issues. In: Leigh H, Streltzer J, eds. Handbook of consultation-liaison psychiatry. New York: Springer 2015:129–138.

7 Long NP, Huy NT, Trang NTH, et al. Scientific productivity on research in ethical issues over the past half century: a JoinPoint regression analysis. Trop Med Health 2014; 42: 121–126.

8 Motamedi MHK. Breaching medical ethics in research. Trauma Mon 2014;19: e17112.

9 Ramana KV, Kandi S, Bionpally PR. Ethics in medical education, practice, and research: an insight. Annals of Tropical medicine and Public Health 2013;6: 599–602.

10 Timimi FK. Medicine, morality and health care social media. BMC Med Aug 2012;10(83). doi:10.1186/1741-7015-10-83 (accessed Oct 2015).

11 Schwartz M. Ethical Challenges for the Nurse Caring for Neurologically Impaired Patients: A Case-Based Discussion. Journal of Hospice and Palliative Nursing 2015;17: 90–95.

12 Hodgkin T. The letters of Cassiodorus: being a condensed translation of the Variae epistolae of Magnus Aurelius Cassiodorus Senator. London: Henry Frowde 1886

13 Mommsen T. Cassiodori Senatoris Variae. Berolini [Berlin]: Weidmann 1894.

14 Barnish SJB. Introduction. In: Cassiodorus. Variae. Liverpool: Liverpool University Press 1992.

15 Amory P. People and identity in the Ostrogothic Italy, 489–554. Cambridge: Cambridge University Press 1997.

16 Nemec J. Highlights in medicolegal relations. Bethesda: U.S. Dept. of Health, Education, and Welfare, Public Health Service, National Institutes of Health, National Library of Medicine 1976: 10–11.

17 Prioreschi P. A history of medicine. Vol. V – Medieval medicine. Omaha: Horatius Press 2003.

18 Neuburger M. Geschichte der Medizin: Erster teil. Stuttgart: Verlag von Ferdinand Enke 1911. Also in Hoops J. Reallexicon der Germanischen Altertumskunde. Berlin: Gruyter 1973: 443.

19 Amundsen DW. Visigothic medical legislation. Bulletin of the History of Medicine 45, issue 6 (1971): 553.

20 Kibre P. The faculty of medicine at Paris, charlatanism, and unlicensed medical practices in the later middle ages. Bulletin of the History of Medicine 27, issue 1 (1953): 1.

Theoretical bioethics as moral activism (?)

This is a draft of a paper that I gave at the Postgraduate Bioethics Conference, University of Bristol, UK, that was held between August 31 – September 1, 2016.


I

As empirical approaches are gaining a firmer foothold in bioethics, it is essential to reflect on the role philosophical theory might, or might not, hold in the future. If theoretical ethical reflection is still useful, what does a practical moral theory look like? In this paper I explore one possible way of understanding what practical moral theory means, what makes it particularly ‘moral’, and how we might think differently about its place in bioethical research.

II

I believe we can agree that we often have certain expectations for a practical moral theory: it needs to perhaps tell us something useful about the right way to live and the right thing to do, it needs to be directly applicable to real clinical situations, and it needs to give us clear guidance and concrete tools that help us to navigate the messy terrain of moral life. Criteria such as these arise from a mode of thinking that in continental philosophy and sociology is called instrumental reason. Instrumental reason understands the practicality of a moral theory as directly equivalent to some systematic tool, such as a set of universal rules and principles or some other framework that we can effectively – even cost-effectively – apply and utilise in bioethical problem-solving.

Instrumental reason is problematic, as theorists from Max Weber to the Frankfurt school have argued. We can find similar critiques also in ethics of care. One of the problems of instrumental reason is its tendency to reduce everything to mere utility. This reduction excludes everything that doesn’t fit its criteria, such as affectivity, complexity of moral life, etc. Despite the problems, it can also be thought to be useful: for example, when the best possible moral care may require more time and resources that are available, and if we can’t immediately change these material and ideological conditions that restrict moral action, then having easy and clear tools may be essential for the minimal standard of moral care.

However, despite this possible, although questionable advantage, we need to resist utility as the criterion of practicality. When the validity of a theory is measured against its immediate applicability, and it is thus reduced to a tool, instrumental reason disvalues theory and gives primacy to practice. This limits our understanding of what theory is and what it can do. To resist utility as the criterion means that instead of asking whether we can use this or that theory in practice – as if the theory would be an unchanging, ossified authority entirely external to us, and not a creation of human action – we could ask, for example, that can we learn something about ourselves and others, or about the society, by engaging with theory?

Simply by changing the question, I think we already take a step closer to a more practical theory. As the German critical theorist Theodor Adorno argues, when theoretical research resists this simple primacy of practice, or the principle of utility, it already (although paradoxically) contains a practical element. What this means is that when an idea is followed though ruthlessly to see where it leads, and the impatient demand of immediate application is disregarded, theory is taken to its full potential as a critique with practical, transformative potential.

III

Before I recast the meaning of a practical moral theory and argue for its continuing value in bioethics, I need to make my position clear: I’m not defending theory for theory’s sake. Neither do I think all theories are utterly unpractical merely because they are theories. Rather, for anything theoretical to prove its practicality, we need to expand our very understanding of what theory means.

First and foremost, theory doesn’t mean simply the list of theories that we find in many textbooks, such as the moral systems developed specifically for bioethics or the trinity of classical moral theories – virtue ethics, deontology, and utilitarianism. It is not the act of choosing and applying a methodology or a theoretical approach in our research either. Although these are all examples of ‘theories’, the idea of theory I’m trying to outline here includes the way we actively engage with these theories. If we expand the concept of theory further, it can also be taken to mean the way we practice thinking that uses theoretical elements.

This idea of theory can perhaps be better explained by contrasting the instrumental application of a theory against something that can be called the critical practice of a theory. By making this difference clear, I mean to say that theory can’t prove its practical worth if it is simply applied uncritically as some outside authority. It can prove its practical worth only through the practice of the theory; namely, through the idea of a theory as a form of practice.

Practicing a theory in bioethics can mean at least two things. Firstly, it refers to the critical, rigorous, and continuous engagement with the chosen theory in our research. In this sense, there can be no closed or finished philosophical systems, no ossified frameworks or tools, in this category of practical moral theory outlined in this paper. Rather, practicing a theory through critique keeps the theory fluid.

Secondly, and importantly, the practice of a theory requires that we think about its relevance to making better the actual material, ideological, historical, economic, political, and social conditions in which we do research and care for patients. This act of thinking is a form of practice, not merely because thinking itself is an active ‘doing’ but also because critiquing wrongs has a power to change the world, however minute or remote the changes may be at first.

For example, directing our critique towards the material and ideological conditions for morality allows us to stop accepting the world, with all its problems and obstacles for moral action, as given. In other words, we can stop accepting the role of theory as the external authority that helps us to make the best of the wrong conditions of moral life. Instead, the purpose of moral philosophy today is to point out the wrongs to start to make them right, even if we didn’t yet have a ready alternative to offer. This connection to the actual material and ideological conditions is also what makes a critique, or theory as a form of practice, as particularly moral. It could even be called moral or politico-moral activism.

In sum, by practical moral theory I don’t mean the moral theories themselves. It is rather the practice of continued critical thinking on the level of theory, directed towards theory, in relation to the actual material and ideological conditions we inhabit.

IV

In conclusion, the idea that theory can be a form of practice, challenges the way we think about theory’s place in bioethics. Theory becomes something that is not outside ourselves: it is rather our own action and our power of imaginative thinking. By rethinking the meaning of theory as internal instead of external, we assign a new task for it; one that shifts the moral agency from the external ethical tools and frameworks to the frontline professionals and researchers themselves. This task is to see (theorein, thea, theatro) and face the contradictions and discomforts of moral life, and create an awareness of them. Here lies the transformative potential of theory as a form of practice, of theory as moral activism.

On theory, practice and dichotomies

The relationship between theory and practice seems to be something I always return to. This blog post is based on my very first attempt to make sense of the topic; an essay I co-authored with my dear friend two years ago in Finnish. I have translated it into English for the purpose of sharing it but also as a way to go back, as it were, to where it started. This essay was written as a popular piece so the intention is not to offer a philosophically robust text but rather an accessible polemics about how to think about thinking and doing in physiotherapy. I also feel that what we wrote was an “inspirational piece” to some extent: the intention was to encourage critical thinking and thinking that is perhaps unconventional for the majority of practicing physiotherapists; one that challenges the prevailing scientific world view, established “truths” and formality of thinking.

The original Finnish version is published as: Rajala, Anna Ilona and Jenni Aittokallio. “Dikotomiat ajattelun kahleina. Mitä teorian ja käytännön erottelu merkitsee fysioterapeutin työssä.” Fysioterapia 61, no. 4 (2014): 27–31. Translation into English is mine.


 

Dichotomies shackle thinking

What does the division between theory and practice signify in physiotherapy?

 

SUMMARY

If practical knowledge is considered primary in physiotherapy, should theoretical knowledge be separated from practice once and for all? The purpose of this philosophical essay is to demonstrate that the idea of a division between theory and practice is false. It arises from a tendency to think in dualities; a tendency that has dominated Western thought and its attempts to explain the world around us. Our claim is that understanding the relationship between theory and practice can only emanate from the complex idea that they already contain one another. The reality is more complicated than dichotomies lead us to believe. So settling for dichotomies and other divided totalities, which structure our understanding in a restricted manner, is to undermine our very capacity to think. Instead of trying to model or depict the world through divided totalities, we ought to strive towards the very boundaries of our understanding; towards what lies beyond what we might consider as knowledge-certainty. It is the only way to open up possibilities to realise something new.

 

Introduction

Physiotherapy is strongly based on empirical things: on practice and on concrete physical action. This approach is also inseparably included in the origins of the word physiotherapy. The ancient Greek fysis (φύσις) refers both to nature’s transformative processes and to the concrete matter that constitutes nature. Therapeia (θεραπεία) refers to caring, serving and healing.

Practicality is no doubt an important part of professionalism and a source of pride in physiotherapy. The evidence base in physiotherapy is also based upon practice and systematic practical research. Its aim is to produce indisputable knowledge and practical tools for professional use. The need for this type of knowledge is undeniable: it makes physiotherapy more accurate, safe and effective. By doing so, it contributes to the appreciation and recognition of the profession.

What about theoretical knowledge that is based on, for example, ethics or philosophy? Do physiotherapists need such knowledge? If practicality is considered as the primary value of knowledge in physiotherapy, should theoretical knowledge be separated from physiotherapy practice once and for all?

The aim of this essay is to show that theory and practice are not as dissimilar as perhaps is often thought. The contraposition of the two arises from the duality that has characterised Western thinking for centuries. This worldview, we argue, restricts understanding and needs to be set under scrutiny.

Our claim is that understanding the nature of theory and practice can only arise from the idea that they always already contain something of one another.

Dichotomies are deeply rooted

People tend to think in dichotomies (image 1). Dichotomies are based on the idea that the two sides of a whole are fundamentally different, which means they are also separate. Thus neither one of the opposites can contain something of the other.

pic 1

Image 1. Some examples of dichotomies.

According to a dualistic worldview, upon which dichotomies are based, everything is strictly separated in two basic elements: immaterial and material. The relationship between theory and practice is also seen as such dichotomy where theory represents the immaterial and practice the material side of things.

Dichotomies do not always, however, mean that the opposites cannot interact with one another (image 2). For example, René Descartes (1596—1650) famously argues that the mind and body are different and separate elements. The mind is the I or the self who confirms its existence through its own ability to think and who moves the machine-like body. (1) Similarly to Descartes’ mind-body interaction, the interaction between the parts of a dichotomy is usually hierarchical: one of the parts dominates and guides the other but neither can contain something of the other.

pic 2

Image 2. The parts of a dichotomy are separate but form a whole, a totality. The whole is based on the thought that the parts interact with one another.

It is often difficult to notice the way dichotomies emerge in our everyday life because they are very deep-rooted. For example Lauri Rauhala [translator’s note: a Finnish psychologist whose theory of the unity between body, consciousness and situation is often used as an opposite to Descartes’ mind-body dualism in the Finnish health care context] also expresses quite explicitly that his theory is based on Descartes’ dualism. (2) Descartes’ mind-body dualism is not, however, entirely satisfactory for Rauhala. Instead, he argues, what constitutes a human being is the inseparable unity of body, consciousness and situation (3). This latter element, situation, transforms dualism into pluralism, but it does not change the fact that even pluralism separates the parts of a whole as fundamentally different elements.

A dualist might talk about the connection or severance between mind and body. A pluralist might talk about the interaction between mind, body and situation that constitute the human being as a whole. However, these expressions are based on the mind-body dichotomy. This dichotomy sees mind and body as different and separate. It is a dichotomy not even Rauhala was willing to deconstruct. (2)

The relationship between theory and practice is often described in this very same manner: theory and practice are fundamentally different and thus separate, sometimes even independent of each other. Theory is thought to guide practice and vice versa but they do not contain anything of one another (image 3).

pic 3

Image 3. Are theory and practice separate and different but interacting (A) or are they intertwined, inseparable, indistinguishable: could they somehow contain elements of one another (B)?

There is no pure theory and practice

The relationship between theory and practice can be understood in at least two ways. In general, empirical research—the evidence base—can be understood as theory and clinical work with patients or clients as practice. On the other hand, empirical research can be seen as a part of physiotherapy practice. In this case, philosophy, ethics or untested scientific hypotheses—everything that is literally theoretical as opposed to empirical—can be understood as theory. (See image 3)

In both instances the idea of a strict separation between theory and practice is false. Rather, they are constantly intertwined, interacting and sometimes indistinguishable so that they form the complex web of our everyday practices. Theodor Adorno argues that all theory, or all thinking that constitutes theory, is in itself already a form of practice as long as it concerns the world that we live in (4). This argument can be explained further: the significance of thinking becomes relevant when it is shared with others, as it then becomes something very concrete. As Peter L. Berger and Thomas Luckmann argue, our ability to express is something that objectifies thought. (5)

If thinking is itself an active doing, a practice, it is by a closer inspection practical rather than theoretical. Communication is the relevant practice in objectifying a theory, making thinking concrete. Communication can include all culture and social interaction that contains meanings: writing, dancing, visual arts, music, sign language, expressiveness of the body, and speaking. Because communication is also an active practice, the theory or thought that is shared becomes a part of that practice. Such practice, when it affects people, has a potential to change something in the concrete world we live in. Similarly, when we read or hear something theoretical that we were not familiar with, it has the potential to change the way we think and, by doing so, it then changes the way we act. This intertwined chain of theory and practice highlights the fact that it is very difficult to actually make a clear separation between the two.

Even if there exists something like a pure practice or pure theory, we can never reach an understanding about their pure forms. When we think we have reached something pure and immediate, it is already mediated though our own understanding, which is always coloured by everything we have learned and experienced previously. This means that behind every conscious action, there is always at least something theoretical upon which our understanding is formed.

 

Physiotherapy practice always contains theory

In order to further the understanding about theory and practice, it is necessary to understand objectivity and subjectivity. Objectivity refers here to the knowledge that is claimed to be true independent of the interpretation of human actors (subjects). Contrarily, subjectivity always refers to acting human beings.

Physiotherapy is guided, on the one hand, by methods that are based on objective research and, on the other, by subjective intuitions that arise from the interaction with the patient/client. Intuitions, although they are formed unconsciously, affect our actions. The objectivity of science and the subjectivity of intuition can be thought to represent two extremes. However, the one cannot be understood without the other.

It is not uncommon that in scientific research and methods pure objectivity is held in higher regard than subjectivity or everyday clinical practice. Scientific research, however, can never get rid of the human being as its interpreter and sharer. The action of human beings, as argued above, is always based on theoretical knowledge to some extent: understanding of language and meanings, current theories of human nature and consciousness, ethical principles, and so on. This subjective quality, as Adorno argues, is irreplaceable in sciences. It is the only way in which scientific abstractions, such as numbers, can be combined and interpreted as something understandable. (4) For example, the result 22 from Berg’s balance test becomes understandable only when the physiotherapist interprets the meaning of the number and its significance to the patient/client.

Subjectivity is thus an inseparable part of objective science: an object becomes something at all only when someone defines its meaning (6). This means that physiotherapy cannot be based solely on empirical research or mere everyday practice. It is also based on non-empirical theories with which both researchers and clinicians form, interpret and understand their perceptions.

Similarly, the subject cannot separate itself form the objective environment. Intuitions that are formed in interaction and that guide actions are not born in isolation within the subject. They arise from outside the subject; the subject interacting with the objective world.

 

Problems of dichotomies 

Dichotomies restrict thinking

The idea of the hierarchical relationship between the parts of a dichotomy highlights oppositions that are already wholly unnecessary. For example, hierarchies always make the possibility of a reciprocal learning process between researchers and clinicians more difficult.

The hierarchical theory-practice dichotomy can also signify instrumental thinking, where theory is used merely as a tool. According to such mode of thinking, ethics or philosophical theories are used only when convenient to achieve a goal. They are not thought to have any active, more permanent role in practice.

Dichotomies also simplify our understanding of the world. They become closed systems, readily given sets of concepts, which exclude every possibility to think otherwise.

 

The problem of closed systems

Dichotomies are defined positively, that is, through what they are or what they contain. The problem in maintaining such positively defined dichotomies is that it does not further understanding. Positive definitions are static and they prescribe every dichotomy as a finite system of meanings.

Things can also be understood through negativity. Acknowledging the negative, what things are not or do not contain, or have not been defined as, is also significant. When thinking acknowledges something beyond positive definitions, the understanding of things remains more open-ended. This gives room for different points of view. Negative understanding has thus the tendency to avoid becoming a closed system (6).

Adorno argues that however dynamic a system might be conceived as, as long as it defines its contents positively, it becomes finite and static: closed systems are bound to be finished (6). When something is finished there is no more need to discover or progress. What is already found provides the necessary satisfaction and there is no need to question the foundations of whatever is considered as the truth at any time.

 

What can a closed system mean?

Let us further illuminate the problem of a closed system in physiotherapy by this following example.

Every divided totality—a whole that is constituted of parts—is formed in the same manner: the whole is first taken apart and then put back together. This is the case in both Descartes’ dualism and Rauhala’s pluralism. Interpreting these thinkers sets a challenge for physiotherapists who work with patients/clients whose experience of themselves is already shattered in pieces.

For example, Rauhala’s body-consciousness-situation division can be used to understand eating disorders: the condition of the physical body can be thought to get worse if the body image is interpreted pathologically by consciousness. This means that the connection between body and consciousness in disturbed. Eating disorders, its causes and effects, are also closely connected to the patient/client’s life or situation.

However valid this might sound, the truth is that no word composition (body-consciousness-situation, biopsychosocial, etc.) is ever enough to pick up the shatters and make the patient/client whole again (7). Instead, critical thinking that aims at developing our understanding is needed. Rauhala himself highlights this by writing that despite his popular tripartite representation, our understanding of what constitutes human beings is actually never complete (8).

 

Critical thinking – better understanding

What if there were other theories that could expand our understanding? According to Adorno, the conception of finite systems should be turned upside down and we should believe that there is always something else outside the system (6). Everyone benefits from such critical thinking: the least does is that it keeps every physiotherapist challenging their limits. A critical stance towards the foundation of our thinking, towards things and what we think we know about them, is healthy. For example, repeating some concept like a mantra (e.g. biopsychosociality) without considering its meaning, understanding and interpreting the world around us may become defined and restricted by this one concept in a narrow and blind manner.

Perhaps it is worthwhile to stop and think whether I, as a practical person, could benefit from theoretical thinking instead of rejecting it? Or, could I, as a theoretical person, benefit from practical things instead of rejecting them merely on the grounds of them being practical? Are there even people that are either purely theoretical or practical?

 

Leaning new by pushing boundaries

Settling for dichotomies or other divided totalities that define our understanding in a restricted manner is undermining our own potential and capacity to think. If we could ever define the nature of theory and practice once and for all, our drive for knowledge ends. There would be no more need for sciences, neither social nor natural sciences. We could repeat the same formulas without thinking or questioning our conduct, and never progress.

We can only make progress by continuing to question our established ways of thinking and doing. What do my conceptions of things restrict or enable? Do I exclude something by defining my patient/client’s functioning in some particular way? Is some way of thinking a mere tool for me? Can I do more to maintain good physiotherapy practices by offering individualised therapy instead of the ossified patterns I might be repeating?

It is difficult, sometimes even impossible to categorise knowledge without dichotomies. Human beings have always had the need to give things finite definitions. The finite nature of knowledge brings comfort.

While human beings seek something authentic they find models, examples, mathematical abstractions and simplifications instead (9). Admittedly, although such ways to represent things around us do not correspond to reality, the fact remains that models, examples, mathematical abstractions and simplifications are sometimes needed. Through them it is easier to begin to understand something and also learn or teach new. However, this is not something to settle for forever because the reality is more complicated than any dichotomy or model leads us to believe. The purpose is not to find the best model or depiction of the world but to strive toward the very boundaries of our understanding. By pushing boundaries we might realise something new.

 

Anna Ilona Rajala
MA, PT, PhD candidate

Jenni Aittokallio
PT (specialisation in psychomotor physiotherapy)

 

References

(1) Descartes R: A Discourse on the Method. Oxford University Press. 2006.

(2) Rauhala L: Tajunnan itsepuolustus. Yliopistopaino kustannus. 2006.

(3) Rauhala L: Henkinen ihminen. Gaudeamus. 2009.

(4) Adorno TW: Negative Dialectics. Routledge. 1990.

(5) Berger PL, Luckmann T: The Social Construction of Reality. Penguin. 1966.

(6) Adorno TW: Stichworte. Kritische Modelle 2. Suhrkamp. 1998.

(7) Laing RD: The Divided Self: Penguin Books. 1969.

(8) Puhakainen J: Persoonan puolustaja. Like. 2001.

(9) Horkheimer M: Critique of Instrumental Reason. Verso. 2012.

Finding the ‘body’ of Richard III

Here is what I wrote for the KiSSiT platform called Thinking Through Shakespeare in which researchers and Shakespeare enthusiasts can engage with Shakespeare and with the world through Shakespeare. ‘Twas a fun way to explore ‘medical Shakespeare’ and I shall surely return to Richard’s body and disability/deformity soon. Visit Kingston Shakespeare Seminar here for more intresesting posts and events!

Kingston Shakespeare Seminar

The remains of Richard III were found under a car park in Leicester in 2012. Since then researchers (often through popular media) have tried to reinstate Richard’s lost glory by busting Tudor myths trough scientific evidence. One of the myth busting methods, also seen in the documentary series on Channel 4, was to diagnose him backwards in history.

The mysteries whether George III, Ludwig II of Bavaria or Vaslav Nijinsky suffered from lead poisoning, schizophrenia or ‘madness’ intrigue us. I think many medical historians would agree, however, that making diagnosis backwards in time based on myths, tales and historical documents is always, if not dangerous at least highly problematic.

Richard's scoliosis was visible when his remains were found. This is due to ligaments rotting away slower than flesh which would have enabled earth to surround the bones as time passed and to preserve the position the body was buried in. Richard’s scoliosis was visible when his remains were found. This is due to ligaments rotting away slower than flesh which would have enabled earth to surround the bones as time passed and to roughly preserve the position of the spine while he was still alive.

Richard’s case is…

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The elusive Formula Comitis Archiatrorum – The first medical ethics code?

Check out also my follow-up on September 8 2016, where I re-examine some of the claims I made here on the Formula Comitis Archiatrorum. My original post is below.


While looking into the history of medicomoral principles and codes for my PhD thesis, or rather for one footnote in my thesis, I came across with reference to the Formula Comitis Archiatrorum (another link including other works here) which is said to be the first known code of medical ethics (Aboujaoude et al. 2014, 5; Battacharya et al. 2015Cantú-Quintanilla et al. 2013; De 2015; Freed 2015, 144; Leigh 2015, 134; Long et al. 2014; Motamedi 2014; Ramana et al. 2013Timimi 2012). Incidentally, or perhaps not, Wikipedia tells the same story as do numerous non-academic Internet sources.

The Formula is credited to Magnus Aurelius Cassiodorus, born c. 484-90 and died c. 577-90 CE. He was a statesman and writer serving in the administration of Theodoric the Great, the king of Ostrogoths. The Formula is referred to as the historical archetype of contemporary medical codes of conduct. As Timimi (2012) writes:

When we discuss medical morality and medical ethics, what we are really referring to is our core belief of what is the right medical action and what is the wrong medical action; in essence, the code by which we practice.The first historic archetype of this from which our current ethics have evolved was likely the Formula Comitis Archiatrorum […]

The claim that this text was the first known medical ethics code seems odd to me as there is little mention of it in any credible source on the history of medical ethics. I did a search about the Formula in couple of databases. There is very little research done on it at all apart from couple of articles (see Amundsen 1971; Kibre 1953), and no research on it as the so called first code of medical ethics. In fact, it took me some time to even find an English translation (reprinted in Plinio Prioreschi’s remarkably comprehensive book series, pp. 121 – 122). Could it be that such an important text – the first code of medical ethics – has been paid so little attention and that the research on it, as the first code of medical ethics, is non-existent? If the Formula is the first ever known code of medical ethics, what sets it apart from Hippocratic or Galenic texts, or al Ruhawi’s, ibn Sina’s, or ben Maimon’s texts which also describe/prescribe suitable conduct for physicians? To answer these questions I need to see whether the Formula truly is the first medical ethics code as has been claimed or whether these claims are merely based on an unfortunate case of limited source checking and repetition of false information.

Is it the ‘first’ and is it ‘a code’?

There is more to show that the claim made of the Formula as the first code of medical ethics is false than that it is true. Firstly, the Formula is simply not the first code of medical ethics (“firstly” because there’s more to come in case I fail to convince). By a closer inspection on the use of sources in the articles that hold that the Formula is the first known medical ethics code, either there are none or the reference is one and the same: Jaroslav Nemec’s Highlights in Medicolegal Relations. Nemec writes (pages 10-11, with my italics):

Theodoric (454-526), King of the Ostrogoths and conqueror of Italy, renewed the ancient Roman institution of comes archiatrorum [the count of the chief physicians] and prescribed the wording of the oath which persons appointed to that position were supposed to take. The oath, called then Formula comitis archiatrorum, was inspired apparently by Theodoric’s “magister officiorum,” Flavius Magnus Aurelius Cassiodorus, and it is considered the earliest known code of medical ethics from the beginnings of Christianity.

It is clear here that Nemec does not claim that the Formula is the first medical ethics code. It is rather the earliest known code for physicians from the beginnings of Christianity which is a very different matter. This claim makes much more sense and places the Formula in a more credible relation to Hellenic, Hellenistic, Roman, and Medieval medical writings.

Secondly, one argument to support the claim that Formula was the first known code of medical ethics would be that it has a distinctive formulation, values, or principles which resemble contemporary ethical codes more than any other medical ethics text in antiquity or medieval period. This argument does not seem to hold true. There is nothing that really sets it apart from other similar texts that would earn it the special status it has been given in some articles. Moreover, there is nothing in it that proves it as an archetype of contemporary codes of conduct.

It is a short text; a model letter (Lat. formula), a form of investiture, written for the Comes archiatrorum. Cassiodorus did not write it in his own person. It begins by a description of medicine as the foremost respectable art. Then it moves on to state that in such art there should be a foremost one, Comes archiatrorum, to whom all those who take care of human health should report. Then a few normative claims are made:

– Medicine should not be defined by case-based changing opinion but experience of the physician
– After their training physicians should have leisure for books, especially ancient ones, both within and outside medicine
– Physicians should desist from quarrels that injure patients; if agreement is not made they should seek advice from somebody who can be asked without envy for a prudent man is willing to seek counsel
– Physicians are consecrated by oaths: they should promise to their teachers to hate iniquity and love honesty
– Physicians are not allowed to fail in their duty and they must consider souls; they should therefore seek diligently what cures the sick and what strengthens the weak
– Although mistakes may cause fault, a sin against the human health is the crime of homicide

After this the recipient is honoured with the title of Comes archiatrorum to be a judge in the art of medicine, to cure the sick by eliminating conflicts among physicians. The visit of the Comes archiatrorum should mean “health for the sick, relief for the weak, hope for the tired.” They should observe signs of sickness through their science and, finally, they are allowed to enter the palace and attend to the royal family.

My third point to undermine the claimed status of the Formula as the first code is that there are other texts written roughly at the same period that resemble ethical codes more, e.g. De Medicis et Aegrotis (Concerning Physicians and Sick Persons) in Lex Wisigothorum, Book XI, Title I (see Appendix A), written perhaps even earlier than Formula, c. 504 CE. All of this is not to say that Formula Comitis Archiatrorum is not an important document. As Prioreschi argues (2003, 120), it is significant in the sense that it underlines the consideration in which medicine was held at Theodoric’s court, it contains important information about the way medicine was practiced and perceived, and it contains information about medical theory and therapy at that point of time and place. My point is, rather, that the reason why it deserves a special mention instead of some other text should be seriously questioned: despite its possible significance, its position as a distinctive medical ethics milestone seems now more and more arbitrary.

Nemec also mentions that the Formula was an oath. It is not clear, however, what the oath called Formula Comitis Archiatrorum really is. It is certainly not the same thing as the text documented by Cassiodorus. This document might however, as the normative claims in it show, contain something about the oath if it existed. Finding the answer to whether the oath existed and whether it is preserved in its entirety in Cassiodorus’ letter Formula Comitis Archiatrorum would require meticulous research through archives, whether any references are out there.

The value of finding ‘the first’

I can only conclude that the claim about Formula Comitis Archiatrorum as the first medical ethics code, the archetype for contemporary ones, is not backed by any research. It might be among the first Christian medical ethics codes but there is nothing to show that it is any more significant than others.

The claim is based on an unfortunate poor use of sources and limited source checking, i.e. a total lack of critical reading. The problem perhaps is the need to establish ‘the fathers of’ and ‘the first originals’ as if this would establish the validity of any introductory remark on the history of medical ethics. As if finding ‘the first’ had value in itself. And once ‘the first’ has been found, there is no longer need to question its validity: it is the original, this is where it started, end of story. And when ‘the first’ is safely mentioned, it shows that some research has happened. Moreover, I seriously question the value of such ‘information’ in the first place. Rather than seeking for ‘facts’, classifying and categorising them, ticking the box ‘history of ethics’ done, and attempting to construct a linear timeline of so called important milestones, wouldn’t it be more interesting to discuss the text itself and its implications for contemporary medical morality?

References

Amundsen, D. W. “Visigothic medical legislation.” Bulletin of the History of Medicine 45, issue 6 (1971): 553-569.

Kibre, P. “The faculty of medicine at Paris, charlatanism, and unlicensed medical practices in the later middle ages.” Bulletin of the History of Medicine 27, issue 1 (1953): 1-20.

Thoughts on Hegel and Dementia

Revisiting Hegel and dementia

The question whether selfhood[i] is something that is lost or preserved in dementia had intrigued me ever since I took on this topic in MA dissertation at University College London back in 2013. This post is to revisit the ideas I had back then. The background for the selfhood debate is, in a nutshell, as follows: some believe that the ultimate consequence of dementia is a total deprivation of the self[ii] while others believe that the self is preserved trough recognition in the caring relationship and through embodiment.[iii] The former position is, for me at least, counterintuitive. The thought that dementia leads to a total loss of self has moral bearing: it can lead to a disregard of the people with the disease. The latter converges with my experience as a clinician. However, a proper balance between the social view of recognition and the accounts that emphasise the importance of the body or, in other words between idealism and materialism, is yet to be articulated.

My attempt at balancing was to interpret the selfhood debate through a materialist reading of G. W. F. Hegel—something I think I would succeed better now if I were to attempt it again. The idea that selfhood depends on recognition owes to the philosophical and sociological traditions influenced Hegel, a major figure in German idealist thought that flourished between the 1770s and 1840s. In his Phenomenology of Spirit, Hegel argues that a subject must enter the social world of others and in order to become conscious of itself, it needs to direct its affirmative action towards the material world and gain the recognition of others. I approached selfhood and dementia in this dialectics with an understanding of both idealism and materialism: recognition emerges from within our consciousness and the significance of action grounds the worth of people with dementia to the concrete, material world. This suggested synthesis between the social views of self and the approaches emphasising embodiment in previous research has not, as far as I am aware, been done before through Hegelian dialectics.

The following is an excerpt from my unpublished MA dissertation. When (or if) referring to this text please use the following details: Rajala, Anna Ilona. “Ethics of Dementia: Hegelian Dialectics and the Problem of Selfhood.” MA diss., University College London, 2013.

Dementia through Hegel’s dialectics

Hegel describes the Phenomenology of Spirit as the “detailed history of the education of consciousness itself.”[iv] This refers to his theory of the dialectical movement[v] of consciousness, the experience as Erfahrung, through which we come to learn about the world and ourselves. This movement is thus inherent in all our knowledge: we do not merely passively perceive things as they exist immediately but actively create meanings for objects as they appear to us mediated through our senses and our prior knowledge. This indicates that our knowledge about the people with dementia also arises from the dialectical movement within our consciousness in relation to the immediate world, rather than from purely grasping something objectively true about them.[vi] The dialectical movement starts from a simple certainty of sensing something indeterminate that is reflected back to consciousness as perception then understood through concepts finally becoming something determinate. This last stage can only come to be when the subject enters the social world and becomes conscious of itself through its desire for action and the recognition of others. This idea is presented in the notoriously perplexing and intense chapter about lordship and bondage, where the “decisive step … to recognition”[vii] is taken. Before I delve into this, however, I need to demonstrate how Hegel arrives at the point where two subjects begin to struggle for recognition in order to explain the dialectical process. Then, I examine how Hegel’s dialectics can be understood in the context of dementia.

In the beginning of the dialectical movement, the subject is only abstractly aware of itself as “this particular I.”[viii] All living beings, subjects, exist in this way and thus an individual with dementia is also a particular I with an awareness of self as a sentient being.[ix] The subject, Hegel argues, becomes first certain of sensing this, here, now—something not yet named that exists immediately for consciousness. This is “the essential point for sense-knowledge”[x]and the initial stimulus of simple immediacy. It has nothing yet to do with imagining, thinking or even perceiving the many qualities the object may have and the subject merely “apprehends” what it immediately senses and does not yet “comprehend” it.[xi] Rather, “the thing is, and it is, merely because it is.”[xii] However, this immediacy of the relationship between the subject and the object turns out to be impossible at the very moment of grasping the indeterminate because both, once they enter into a relationship, are necessarily mediated through one another: the subject is certain about sensing something through the object and the object is sensed only through the subject.[xiii] In other words, the dialectical movement of consciousness begins with a passing moment of sense-certainty of the immediate, which becomes mediated at once it is sensed. Because of this mediation, Hegel argues, we cannot know the objects in their immediacy. Rather, they are constituted in our consciousness—they exist for us—although they also continue to exist without our knowledge about them.[xiv] Thus the world of objects proves to be a mode of relation between our consciousness and objects.[xv]

The mediation also proves, as Hegel writes, that the truth about the objects is not the immediate grasping but rather the mediated perception,[xvi] which occurs only after the sense-certainty is reflected back from the object to the subject, who then becomes able to point out the object for the first time, or to perceive it. At once the perception is again reflected back to the object, which has now changed from being the immediate this, here, now into a determinate something by the act of perception.[xvii] The subject must now progress from perceiving the unified object, which its consciousness has constituted by excluding and including differentiated and determinate properties, to thoughts.[xviii] At this stage the subject still merely apprehends the objects that exist for it in a subjective world of appearances governed by the laws of nature.[xix] The objects can only become determinate through active comprehension, or conceptual thinking, which is possible only when the subject steps out of its subjective world to the world of others and becomes self-conscious.[xx]

This next stage, although it is easy to think that people with dementia remain in a subjective world of their own, does not mark their exclusion for two reasons. Firstly, people with diminished cognitive and intellectual capacities still have many capabilities by which they constitute their knowledge of the world and continue to create, express, and have meaning as Pia C. Kontos and Stephan Millett have shown (see note iii). Despite the disease and although the brains of people with dementia might interpret sensory input differently compared to a brain that functions within ‘accepted normality’, people with dementia can comprehend actively and think conceptually because there is nothing in their minds, as Hegel would argue, that has not come from our shared world through Erfahrung, the dialectical lived experience of consciousness.[xxi] This indicates that existence itself is necessarily social, not subjective, and thus the idea of a wholly subjective world of an individual with dementia is impossible. Indeed, even hallucinations, delusions, and nonsensical communication arise initially from the real world and thus have meaning for everyone occupying it. People with dementia, as Ashworth and Ashworth argue, are still conscious actors with thoughts and communication, and all of it should be interpreted as meaning something even if it was nonsensical for us.[xxii] Secondly, people with dementia continue to direct their action towards the material world as long as they continue to occupy a space in it—after all, being is also active and not passive—and thus their action has significance for their very existence. As Hegel asserts, a subject as consciousness comes into existence and arrives at conceptual thoughts with determinate content, as opposed to pure thoughts, through formative work. Through it, it also realises its independence and existence in its own right.[xxiii] Action is thus essentially what makes people with dementia subjects deserving of recognition in the first place.

In order to direct its action and move from being a particular but undifferentiated I to being self-conscious, a subject must take a stance Hegel calls desire. Human subjects, including people with lower cognitive abilities, must satisfy desires and necessarily, by these acts, be reflected via the object of desire towards the material world.[xxiv] In the pre-self-conscious level, Hegel argues, desire is also essential for the subject in realising that it is actually a living being. In order to realise this, its object of desire must be another living being like itself[xxv] because by reflecting itself to the other living being, it can realise that it is an independent living consciousness, namely, like the other but separate from it. Thus to become self-conscious is to find satisfaction of desire in another self-consciousness.[xxvi] This signifies that as long as people with dementia continue to satisfy desire through action towards others—ability that is arguably lost only when they cease to exist—it should be interpreted as a meaningful attempt to become assured of one’s existence, singularity, and living features. In addition, we can learn about ourselves only through the interaction with others, which indicates the importance of interpersonal relationship between living beings despite lowered cognitive abilities. As Hegel writes, each of us mediate ourselves with ourselves but only through a mediation through the other[xxvii] and in order to become self-conscious, each needs to find itself as a subject and an object at the same time.[xxviii] Thus, to become self-conscious is to exist for another self-consciousness,[xxix] which signifies the necessary sociality of selfhood and the need to be recognised by others in order to recognise oneself. Hegel writes: a self-conscious subject “exists in and for itself when, and by the fact that, it so exists for another; that is, it exists only in being acknowledged.”[xxx] Finally, the subject “leaves behind it the colourful show of the sensuous here-and-now and the nightlike void of the supersensible beyond, and steps out into the spiritual daylight of the present.”[xxxi]

The differentiation from the other and becoming truly certain of oneself and one’s independence, Hegel argues, requires not only the reflection back from the other but also its sublation.[xxxii] Once a subject is faced with another, he writes, it is forced out of its subjective world to find itself as another subject. It then loses itself in the face of its own newly found otherness because it first sees only its own self in the other and not yet the other.[xxxiii] It must overcome this otherness by reflecting back into itself from it and sublating it. Mutual recognition can occur after this reflection only if both of the subjects let each other, as Hegel writes, go free.[xxxiv] However, in the context of dementia mutual recognition is prevented by our own fear of dependency, frailty, insanity, and death. As Kitwood argues, we turn people with dementia into a “different species” as a way to deal with the anxiety and fear it causes.[xxxv] We sublate their otherness as we simultaneously have to accept their likeness to ourselves, for we cannot destroy them completely or else we end up without recognition ourselves as we too depend on others—indeed, in a relationship with an individual with dementia we depend on that individual—to become recognised as self-conscious subjects.

The mutual dependency of the recognition of the other is realised after the subjects have sublated each other and found out that they are conscious living individuals separate from everything else and certain only of themselves. As Hegel explains, the subjects first consider finding their own selves more essential than recognising the other but then they realise that they actually dependent on each other for recognition, through which they can prove their worth to themselves and to the other and rid themselves of uncertainty once and for all.[xxxvi] Thus they must enter into a struggle for recognition, “a life and death struggle,”[xxxvii] in which one subject ends up in a dominating position and the other submits. Hegel calls these dominating and submitting positions lordship and bondage.[xxxviii]

In the struggle for recognition, Hegel argues, both subjects act upon each other in order to prove themselves. They seek the death, the negation of consciousness, of each other by leaving them without recognition in order to preserve their own certainty or else be negated by the other. They must stake their own lives if they are to come on top of the struggle and to elevate their self-certainty to truth.[xxxix] The one, who staked one’s life and survived the struggle by sublating the other, gains initial independent existence and domination of the relationship. It has become the lord and the other has become the bondsman, who remains dependent and exists only for the satisfaction of the lord’s desire to consume.[xl] Although it seems that the lord is able to gain the recognition of the bondsman, it gains it by coercion. Thus, it is not enough to assure the lord after all because it needs to gain recognition from another independent subject.[xli] In the end, Hegel argues, it is then the servile consciousness who, through fear of death, desire and formative action towards the material world in order to serve the lord, becomes aware of its true existence as an independent being capable of conceptual thoughts that arise from within its own consciousness. For Hegel, the truth about self-consciousness and independence lies in the servile consciousness.[xlii] The lord takes a passive stance towards the material world by consuming the things the bondsman forms. Thus it realises that it is not independent after all and it is forced back into itself unable to step out in the social world.[xliii]

The struggle and the following allegorical positions of lordship and bondage are not stable and fixed.[xliv] This is exemplified in a study by Granheim et al. that use the lordship/bondage dialectics as a metaphor from the care provider’s perspective to examine the interaction between professional carers and people with dementia diagnosis accompanied by behavioural disturbances. They argue that care the providers and patients alike are in a continuum of struggle for recognition as both strive to be the one who defines the relationship, which now and again culminates at unequal situation where both in turn dominate while the other submits. For the care providers, on the one hand, domination means gaining control over the disturbing behaviour of one patient for the benefit of all others in close proximity but at the expense of the disturbing individual’s freedom. On the other hand, submitting means focusing on the individual but failing to perceive the collective’s needs.[xlv]

Although Hegel’s dialectics can be used in this way to illustrate the struggle between people with dementia and others, it is more powerful in explaining the ethical interaction in the relationship because, as Hegel argues, the relationship between the lord and the bondsman is shaped by the action of the dialectical movement of consciousness, which we all share in the sense that every action is also the action of the other.[xlvi] In other words, one subject cannot act upon another without causing a re-action in it that again causes a reaction in the first subject. In this sense, according to Hegel, every action in a relationship is brought about by both of the subjects.[xlvii]

This indicates that people with dementia who are acted upon and capable of action—this refers to any kind of action, may it be concrete, within consciousness, sensible, nonsensical, or merely the act of being—are subjects in such ethical interactions because their action has an impact on the rest of world and our action has an impact on them. Simply because of this dialectics they are to be considered as subjects worthy of dignity and respect. Without the acknowledgement of it, however, people with dementia will not gain the recognition they deserve and need. As Hegel explains, the relationship will remain unequal unless the subjects realise that their own action towards the other is also action towards oneself and that mutual recognition is only possible when “each in its own self through its own action, and again through the action of the other” achieves recognition and self-consciousness.[xlviii]

It is then only by striving towards the moments of mutual recognition of selfhood and moral worth that a relationship between individuals with dementia and their carers can truly flourish. Through meaningful relationships, the individual with dementia can still be considered as a member of our shared world and, as Marx writes, act as “the mediator between you and the species, thus … be acknowledged by you as the complement of your own being, as an essential part of yourself … to be confirmed both in your thoughts and your love.”[xlix]

Notes and references

[i] Some prefer to use the word personhood to refer to the individual consciousness, the subject, the ‘I’ or the ego. However, the Latin persona has legal connotations so the debate about personhood also pertains to legal agency. To avoid the confusion that I do not write here about the legal status of an individual with dementia, I shall use the word selfhood to refer to the psychological or phenomenological notion of a person.

[ii] Daniel H. J. Davis, “Dementia: Sociological and Philosophical Constructions,” Social Science & Medicine 58 (2004): 375. See also Donna Cohen and Carl Eisdorfer, The Loss of Self: A Family Resource for the Care of Alzheimer’s disease and Related Disorders (New York: W. W. Norton Company, 2001), 22; Marie A. Mills and Janet M. Walker, “Memory, Mood and Dementia: A Case Study,” Journal of Aging studies 8 (1994): 18.

[iii] See Tom Kitwood Tom and Kathleen Bredin, “Towards a Theory of Dementia Care: Personhood and Well-being,” Ageing and Society 12 (1992): 269—287; Pia C. Kontos ““The Painterly Hand”: Embodied Consciousness and Alzheimer’s disease,” Journal of Aging Studies 17 (2003): 151—170; Stephan Millet “Self and Embodiment: A Bio-phenomenological Approach to Dementia,” Dementia 10 (2011): 509—522; Steven R. Sabat and Rom Harré, “The Construction and Deconstruction of Self in Alzheimer’s disease,” Ageing and Society 12 (1992): 443—461.

[iv] Phenomenology of Spirit (henceforth PS), §78. This also indicates the vastness of Hegel’s project and the impossibility to be exhaustive in this exposition.

[v] Hegel’s dialectics is not as simple as the usual schematic representation of thesis-antithesis-synthesis may lead us to believe. Rather, it is a process of constant movement of consciousness, the dialectical experience between subjects and objects. See Theodor Adorno, Hegel: Three Studies (Cambridge, Massachusetts: The MIT Press, 1993), 75. See also PS, §50—51.

[vi] This idealism in Hegel, stemming from Kant, positions itself against the immediate experience of sheer empirical materialism.

[vii] Axel Honneth, “From Desire to Recognition,” in Hegel’s Phenomenology of Spirit: A Critical Guide, eds. Dean Moyar and Michael Quante (Cambridge: Cambridge University Press, 2008), 77.

[viii] PS, §91. This awareness is analogical to Sabat and Harré’s self as personal singularity but for Hegel it is necessarily social.

[ix] A certain level of self-awareness can remain through later stages of dementia. See Marie A. Mills and Janet M. Walker, “Memory, Mood and Dementia: A Case Study,”Journal of Aging studies 8 (1994): 17—27; Steven R. Sabat, “Surviving Manifestations of Selfhood in Alzheimer’s disease: A Case Study,” Dementia 25 (2002): 25—36; Steven R. Sabat and M. Collins, “Intact Social, Cognitive Ability, and Selfhood: A Case Study of Alzheimer’s disease,” American Journal of Alzheimer’s disease 14 (1999): 11—19; Jeff A. Small, Kathy Geldart, Gloria Gutman, and Mary Ann Clarke Scott, “The Discourse of Self in Dementia,” Ageing and Society 18 (1998): 291—316; Ruth M.Tappen, Christine Williams, Sarah Fishman and Theris Tuohy, “Persistence of Self in Advanced Alzheimer’s disease,” Image: The Journal of Nursing Scholarship 31 (1999): 121—125.

[x] PS, §91.

[xi] PS, §90—91.

[xii] PS, §91.

[xiii] PS, §92.

[xiv] PS, §92—93, §101, §110.

[xv] PS, §166; Honneth, “From Desire to Recognition,” 78.

[xvi] PS, §112.

[xvii] PS, §107.

[xviii] PS, §113, §121.

[xix] PS, §146, §150.

[xx] PS, §164.

[xxi] PS, §36.

[xxii] Ann Ashworth and Peter Ashworth, “The Lifeworld as Phenomenon and as Research Heuristic, Exemplified by a Study of the Lifeworld of a Person Suffering Alzheimer’s disease,” Journal of Phenomenological Psychology 34 (2003): 183—186.

[xxiii] PS, §196—197.

[xxiv] Honneth, “From Desire to Recognition,” 78—79, 82.

[xxv] PS, §168.

[xxvi] PS, §175.

[xxvii] PS, §184. Compare to the necessary mediation of subjects and objects above.

[xxviii] PS, §174.

[xxix] PS, §177; Peter Osborne, The Politics of Time. Modernity and Avant-Garde (London: Verso, 1995), 74.

[xxx] PS, §178.

[xxxi]PS, §177. Here the subject has become sure of itself as an authoritative source of its knowledge that it actively constitutes for itself. Thus, it has arrived at an epistemological standpoint characterized by Kant in his transcendental philosophy. See Honneth, “From Desire to Recognition,” 78.

[xxxii] The original German word Aufhebung means roughly to preserve and change/cancel simultaneously.

[xxxiii] PS, §179—180.

[xxxiv] PS, §181.

[xxxv] Tom Kitwood, Dementia Reconsidered. The Person Comes First (Maidenhead: Open University Press, 1997), 14.

[xxxvi] PS, §185.

[xxxvii] The meaning of life and death are not concrete for Hegel. Rather, life refers to the process of becoming a self-certain, recognised, self-conscious subject. Peter Osborne explains that life is rather the category “which matches the reflective transition from consciousness to self-consciousness on the side of the object.” Osborne, The Politics of Time, 75.

[xxxviii] This passage in the Phenomenology, as Peter Osborne notes, is not to be read as historical realism but should rather be understood as a conceptual model of the structure of self-consciousness as such, although embellished by an illustrative social content of lordship and serfdom. According to Osborne, the lord and the bondsman are first and foremost typifications of power relations inherent in the structure of recognition that signify the necessary social character of all self-consciousness. Ibid. 72.

[xxxix] PS, §187—188.

[xl] PS, §188—189.

[xli] PS, §192.

[xlii] PS, §192—193.

[xliii] PS, §193—197.

[xliv] Osborne, The Politics of Time, 73.

[xlv] Granheim et al., “Balancing Between Contradictions: The Meaning of Interaction Between People Suffering from Dementia and “Behavioural Disturbances”, International Journal of Aging and Human Development 60 (2005): 153—154. This study does not however provide a deeper understanding of Hegel’s philosophy.

[xlvi] PS, §182.

[xlvii] Ibid.

[xlviii] PS, §186, §191.

[xlix] Karl Marx, Early Writings, trans, Rodney Livingstone and Gregor Benton (London: Penguin), 277.