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The following is an excerpt from my unpublished MA dissertation.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.
[xlviii] PS, §186, §191.
[xlix] Karl Marx, Early Writings, trans, Rodney Livingstone and Gregor Benton (London: Penguin), 277.