I feel very lucky and privileged to be a Physiotherapist. Physiotherapy, a profession that encompasses many dimensions such as clinical, educational, leadership, consultancy and research but most importantly, as a group of responsible people who engage and supports Others. It is with this in mind, at this most challenging time, that I reflect on my journey with my profession and how I value others.
I was very fortunate to meet Dr Filip Maric amongst a number of inspiring people including Joost van Wijchen, Laura Rathbone, Els Lamers, Ann Gates and Vincent Bastiaans at HAN University as part of an International week. It was a wonderful visit that both stimulated and challenged me. During many conversations, I was struck in particular with Filip’s area of interest of fundamental ethics, particularly from the viewpoint of Emmanuel Levinas and I would like to thank Filip for introducing me to this.
The ever-growing fountains of knowledge:
Physiotherapy, as a profession, has grown in its wealth of knowledge with an ever-expanding research base. An area of interest of mine is how to consider this wealth of knowledge and apply it, in the best way, for the individual person or group of people. Most of my focus is usually on individuals due to the nature of my job but I recognise that population health is of the utmost importance. For the purposes of this post, I would like to focus on the care of individuals.
The field of philosophy examines the assumptions, foundations, and implications of science, as well as the manner in which it progressively explains phenomena and predicts occurrences. I believe now, perhaps more than ever, that science and the humanities are both of equal importance within the context of growing knowledge and technological advancement. Kerry, Maddocks and Mumford (2008) made a very clear point on this over a decade ago.
How might we understand knowledge and unpack it?
I often refer to Aristotle who describes knowledge as episteme (knowledge as fact), techne (knowledge as craftsmanship) and phronesis (knowledge as wisdom; to do the right thing at the right time, in the right context). This can be unpacked further but it is clear that knowledge that is viewed in this way is complex and dynamic phenomenon.
If we look at knowledge as facts, it could be seen from the viewpoint of science. Science attempts to discern objective, concrete and universal knowledge, often through repeatable and measurable ways through the use of our senses. For science to be taken seriously, it has to rigorously test hypotheses, often through failure, in order to make advancement. However, the scientific lens may not unearth all of the areas that Aristotle refers to and it may assume that these universal laws are applicable in every context. This philosophical bias (Andersen, Anjum and Rocca, 2019) may, for good reason, emphasise carefully controlled studies over other methods to minimise contextual or confounding factors in order to establish a truth without bias but in doing this, possibly risk missing the very elements that may be of importance (Kerry, 2017).
Knowledge that is seen as craftsmanship or wisdom, by its very nature, is inherently value laden and embedded within a social context. As such, knowledge does not exist in its own vacuum and therefore, is not complete without a way in which it is applied in the real social world. In Physiotherapy practice, it makes sense to me that the ethical position on how we apply this knowledge is of prime importance. The judicious use of knowledge requires the application of its multiple sources to be grounded within an ethical framework in which it is delivered. Tonelli (2010) makes the compelling case that clinical research, pathophysiologic rationale and clinical experience are all required to make sound judgement in a casuistic way for the individual case. This multi-dimensional perspective of understanding knowledge, amongst many reasons, may be why knowledge translation is challenging. Added to this, the consequences of certain philosophical biases that are incorporated into practice underscore the ethical nature of Physiotherapy practice, thus calling forth the need for a deeper understanding of human beings embedded within their socio-cultural contexts within the complexities of health care.
To summarise, I believe that knowledge is complex, dynamic and context sensitive. Therefore, a number of viewpoints or lenses are useful in order to make sense and apply this knowledge. Knowledge from science and the humanities are both important in order to apply it in the real world. The application of this knowledge, therefore, must be grounded within an ethical framework that is coherent within its setting. In this case, within Physiotherapy, I argue for a humanistic framework which leads us to a philosophical perspective of Emmanual Levinas and the fundamental ethics surrounding Others.
Levinas and the Other:
Filip Maric and Dave Nicholls wrote a paper ‘The fundamental violence of Physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for Physiotherapy theory and practice’. The paper briefly introduces the background of Emmanual Levinas of which I will summarise below.
Levinas was born in 1906 in the Jewish community of Russian-occupied Kovno (now Kaunas, Lithuania). He went on to study philosophy in Strasbourg where he read classical philosophical works from Plato and Other Greek philosophers through to Descartes, but also modern philosophy. Subsequently, Levinas studied under the famous phenomenologists Edmund Husserl and Martin Heidegger, who were significantly influential in the development of his future method and thought. The influential tensions that Levinas experienced during the Second World War alongside Heidegger’s affiliation with the Nazi party strengthened his insight towards an alternative fundamental ethical way of being that contrasted with the phenomenological focus on the self.
Much broader, Levinas felt that much of Western philosophy tended to subvert the ethical relation to the other by placing persons within the unifying system of ontology (the nature of being), hence denying persons their right to be themselves or their otherness. The inherent tendency of a culture based in a philosophy that seeks to overtake a person’s otherness into the same as themselves is one of power, control, oppression and even tyranny. Levinas makes a phenomenological claim that an ethical relationship, which is founded upon respect for the other’s radical alterity (or difference), exists prior to the ontological relationship, which is based on knowledge and comprehension of the other.
Put in another way, one’s relation to the other is the foundation of human knowing, not the other way around.
When I encounter someone else, I experience a difference between the other and myself. This initial difference is the first moment in ethics, in the acknowledgement of another who obligates me. The foundational nature of the ethical relationship is one that may be neglected in Western philosophy and its branches. The influential work of Heidegger, for example, treats ethics as secondary to ontology (the nature of being) and epistemology (the nature of knowledge). Levinas suggests that it is the ethical perspective, in the experience of the other, that should be the norm, and that this creates the standard to which other Western philosophical perspectives are seen relative to.
“Indeed, the objectifying thematization inherent to the Western logos as ontology does not do justice to the way in which the Other exists. The only adequate response to the face is my being devoted to the Other. If I reduce the Other to an interesting topic for my observation or reflection, I am blind to the claim that is constitutive of the Other’s coming to the fore.” (Peperzak, 1997, p. 34)
Simply put, the implicit use of objectification that is dominant in Western philosophical reasoning does not do justice to others. Rather, in Western philosophy, if we attempt to reduce others to our observations or reflections of ones-self then we are at risk of causing potential harm to others.
What implications might this have for Physiotherapy?
Although I have not read around a large amount of Levinas’ work that would place me anywhere near as an expert, the reading that I have done has resonated. Levinas’ work calls forward the need to embrace diversity, cultural and social differences. It engenders a mind-set change to hesitate and consider others first and foremost.
In clinical practice this elevates communication and interpersonal skills as a priority because it is through our embodied way of understanding others that we seek to appreciate and comprehend through sense-making, on an equal footing, with others. We, as clinicians may have knowledge of the body, of physiology, of anatomy or whatever, but first and foremost we are people making sense of each other with the acknowledgement that, in our difference, we are both human beings with different sources of knowledge and experiences. In all cases, my patients are far wiser than I am, in many ways, but certainly in regard to themselves. This nurtures a sense of epistemic humility, for example, I could have a huge amount of knowledge and understanding around the latest randomised controlled trials, systematic reviews, narrative review and qualitative papers surrounding a condition like low back pain, but unless I am able to engage and understand others and placing themselves first within the clinical encounter, the sense-making process of each other will be lost. The inter-subjectivity, or sense making process, using body communication, language and insight to the other uplifts the therapeutic encounter. A genuine curiousness of the other places them truly at the centre of comprehension that comes before all considerations of being or knowledge of the condition that the other person presents with. Carl Rogers, the American Psychologist, embodies this perspective in his book, ‘On becoming a person’, wonderfully:
“…I find that the more acceptance and liking I feel toward this individual, the more I will be creating a relationship which he can use. By acceptance I mean a warm regard for him as a person of unconditional self-worth-of value no matter what his condition, his behaviour, or his feelings. It means a respect and liking for him as a separate person, a willingness for him to possess his own feelings in his own way. It means an acceptance of and regard for his attitudes of the moment, no matter how negative or positive, no matter how much they may contradict other attitudes he has held in the past. This acceptance of each fluctuating aspect of this other person makes it for him a relationship of warmth and safety, and the safety of being led and prized as a person seems a highly important element in a helping relationship.” (Rogers, 1961, p. 85)
Levinas and the face to face encounter
Levinas felt that the human face was of fundamental significance in encountering others. The face is not considered as a physical or aesthetic object. Rather, the first, usual unreflective encounter with the face, is as the living presence of another person and, therefore, as something experienced socially and ethically. The face looks towards others, which both at the same time overwhelms and resists the existential experience of the human encounter. If one refuses the existence of the another’s face, it causes an overflowing experience that calls to the other in a fundamentally moral way.
Levinas insists that science, technology and other theoretical systems of knowledge cannot function independently. Human existence does not form the basis of knowing in and of itself. Rather, ‘‘…it is the epiphany of the Other’s face and speech rupturing the homogeneity of my universe and breaking its totality’’ (Peperzak, 1997, p. 12).
Modern technology, however, has allowed novel forms of interaction that have permitted clinicians to see others at distance. During the current Covid-19 crisis, the use of video consultations has transformed the usual clinical encounter. By seeing the other, in their own environment and communicating as if one where with them has been a revelation. Those, like myself, now find the telephonic clinical encounter distancing, devoid and stale in comparison. One can truly see that the healthcare encounter has forever been changed as a result. The new telehealth system of care will bring both excitement and scepticism resulting in both revolution and disruption. Only time will tell how the future landscape of Physiotherapy care will end up. Either way, how the profession evolves through considered conversation with others both within and outside of Physiotherapy will determine its own future success. Educational institutes will have to adapt as well, once again, highlighting the importance of person-centred communication and ethical considerations causing us to hesitate on our own traditional practice and hubris.
The recent months have indeed caused me to seriously reflect on the Physiotherapy profession and perhaps, if you have managed to get this far, I hope this blog has created a space for you to reflect. Once again, I would like to thank everyone that attended the HAN International learning week that triggered my thoughts. If there was any time to consider others, I think the time is now. Please, continue to be kind to yourself and more importantly, others.
References
Kerry R, Maddocks M & Mumford S (2008) Philosophy of science and physiotherapy: An insight into practice. Physiotherapy Theory and Practice. 24:6, 397-407.
Laplane et al (2019) Why science needs Philosophy. PNAS 116 (10) 3948–3952.
Andersen, Anjum and Rocca (2019) Philosophy of Biology: Philosophical bias is the one bias that science cannot avoid. eLife; 8: e44929.
Kerry, R (2017) Expanding our perspectives on research in musculoskeletal science and practice. Musculoskeletal Science and Practice. 32. 10.1016/j.msksp.2017.10.004.
Tonelli, M.R. (2010), The challenge of evidence in clinical medicine. Journal of Evaluation in Clinical Practice. 16: 384-389.
Maric F and Nichollls D (2019) The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice. Open Physio Journal.
Peperzak, A (1997) Beyond – The Philosophy of Emmanuel Levinas. Illinois: Northwestern University Press.
Rogers C (1961) On Becoming a Person: A Therapist’s View of Psychotherapy. Boston: Houghton Mifflin.