Are we selfish b*stards driven by our own self interest?

Self interest as a human nature driver for happiness?

The drive of self-interest for material well-being has been seen to be a fundamental aspect of human nature, particularly since the Enlightenment (Persky 1995) as seen in the works of Adam Smith (1776) and John Stuart Mill (1836). Thomas Hobbes in Leviathan placed self interest on the throne of human motivation.

Yet, self interest has not been seen as the only drive for humanity. Alongside this drive is the ‘Will to Power’ associated with Friedrich Nietzsche, the ‘Pleasure Principle’ associated with Epicurus, Jeremy Bentham and with Sigmund Freud (Snyder, Lopez and Pedrotti 2007) and the ‘Will to Meaning’ associated with Frankl (1946/2006). Thus the quests for Power, Pleasure and Meaning are alternatives to economic self interest as drivers for human action. Erich Fromm and Manfred Max Neef have also discussed fundamental human needs which could be thought of as drivers for human action. Self interest for material gain does not feature anywhere near as prominent.

Miller (1999) argues that a different view of human agency acknowledges the power of other motives, such as public spiritedness ( Etzioni, 1988 ; Mansbridge, 1994 ), empathy (Batson, 1991 ; Kohn, 1990 ), commitment ( Sen, 1977 ), and justice ( Lerner, 1980 ; Tyler, Boeckmann, Smith, & Huo, 1997 ).

Yet given this, somewhat admittedly white, colonialist and patriarchal divergence of views on what motivates us in contemporary societies, it could be argued that hegemonic neoliberal imaginary (Hall 2011) especially in the United States and the United kingdom since the 1970’s, rests on the idea of the rational actor, the ‘free, possessive, individual’, using his economic self interest for ‘life liberty and the pursuit of happiness’. This is a concept understood in classical economics as ‘homo economicus’ – the rational actor in a market weighing up costs and benefits of consuming decisions according to price signals.  Neoliberalism may draw upon neoclassical economic theory and may draw upon theories of human behavior which suggest we are more motivated by rational action for self interest. It has also been used to justify the current economic order and also as an explanation for inequalities. Self Interest as expressed through ‘free’ markets is therefore not only an explanation but also a guiding imperative for policy or ‘ideology’. Adam Smith has particularly been appropriated to the cause alongside the later economists, Hayek and Friedman.

One aspect of rational self interest is that of “principal-agent” theory: agents will perform best under high-powered financial incentives to align their interests with those of the principal (a business school thesis – Layard 2009). For example employees and managers (agents) will work for the same goals of employers and shareholders (principals) and not in their own self interest, if the goals are aligned, e.g. profits are shared. However, Daniel Pink argues that above a certain level of material reward, what motivates us is Mastery, Autonomy and Purpose. Financial rewards start to become hindrances rather than benefits. Not that this insight affects the level of, and justification for, the ‘High Pay‘ of many ‘fat cat’ CEOs.

John Stuart Mill (1836) argued:

[Political economy] does not treat the whole of man’s nature as modified by the social state, nor of the whole conduct of man in society. It is concerned with him solely as a being who desires to possess wealth, and who is capable of judging the comparative efficacy of means for obtaining that end.

Similarly, Adam Smith (1776) wrote:

It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest.

Smith (1759) however does express in ‘The Theory of Moral Sentiments’ that self interest alone is not the sole motivator, men can act out of regard for others:

“How selfish soever man may be supposed, there are evidently some principles in his nature, which interest him in the fortunes of others, and render their happiness necessary to him, though he derives nothing from it, except the pleasure of seeing it. Of this kind is pity or compassion, the emotion we feel for the misery of others, when we either see it, or are made to conceive it in a very lively manner. That we often derive sorrow from the sorrows of others, is a matter of fact too obvious to require any instances to prove it; for this sentiment, like all the other original passions of human nature, is by no means confined to the virtuous or the humane, though they perhaps may feel it with the most exquisite sensibility. The greatest ruffian, the most hardened violator of the laws of society, is not altogether without it” .

This exposition of rational self interest demonstrates that Smith accepted that what makes us human is not only based on unrestrained self interest.

This is a point picked up by Becker (2007) who argues that moral leadership is exercised not solely based on rational self interest, that business decisions are not made only on the economic conditions of the market. The World Business Council for Sustainable Development (WBCSD) is also an example of business principles being enunciated which go beyond the simple search for maximum profit.

However, the theory of self interest allied to material reward remains strong as a description of ‘natural’ human behaviour. If it is ‘natural’ then human happiness is gained if self interest is given its head. Self interest as ‘human nature’ can be seen therefore as the major drive which should be harnessed both for prosperity and happiness. Graham Scambler, following on from Margaret Archer’s theory of ‘modes of reflexivity’, argues that we have entered an era where plutocrats and oligarchs have captured the levers of the State to rule as ‘Greedy Bastards’.

He constructed an ideal-typical sub-type of Archer’s ‘autonomous reflexive’ called the focused autonomous reflexive. Those who make up the ruling oligarchy, or the ‘greedy bastards’, are also ‘focused autonomous reflexives’. Scambler argues they have the following characteristics:

“TOTAL COMMITMENT:  The focused autonomous reflexive exhibits an overriding engagement with accumulating capital and personal wealth/income. Nothing less will suffice: that is, any deficit in commitment will result in absolute or relative failure. NIETZSCHIAN INSTINCT: Born of a Hobbesian notion of the natural human state, they betray a ruthless determination to cut whatever corners are necessary to gain an advantage over rivals. they are the ‘blond beasts’ of ‘noble morality’ whose values are constructed by themselves to serve their own interests. FUNDAMENTALIST IDEOLOGY: Commitment is not only total and Nietzschian but fundamentalist: it does not admit of compromise. It is an ideology – that is, a standpoint emerging from a coherent set of vested interests – that brooks no alternative. COGNITIVE INSURANCE: While cognitive dissonance is a state to which none of us is immune, they are  able to take out sufficient insurance to draw its sting. Thus accusations of greed and responsibility for others’ suffering are rarely internalized. Such epistemological and ontological security is the exception rather than the rule in this era of financial capitalism. TUNNEL VISION: A concomitant of a total, Nietzschian and fundamentalist commitment is the sidelining of other matters and a reflex and frequently gendered delegation of these to others. LIFEWORLD DETACHMENT: There is simply no time for the ordinary business of day-to-day decision-making. In this way focused autonomous reflexives rely on and reproduce structures not only of gender but of class, ethnicity, ageing and so on. Their Lifeworld detachment presupposes others’ non-detachment, i.e. other people service the every day requirements of life”. 

Graham Scambler’s typology requires empirical verification and is not meant to describe any one person in totality. Without studying the lives of the 0.01% and their ‘players’ (often to be found in the 1%), this cannot be verified. However, may we see indicators of their world views in their speeches and writings?

Societies have ‘myths’ – stories to explain phenomena and to bind the people together. Self Interest in free markets is an old story, an ‘anti-myth’, as it divides peoples based on negativity, rather than binds. It sorts a people into ‘winners and losers’, ‘top cornflakes‘, ‘skivers or strivers‘ and the ‘left behind‘. It is not based in the actuality of human experience or within philosophy over history, but has been imposed in the West as a guiding ideology especially since the Reagan-Thatcher Duopoly. The Autonomous Reflexives both in the political class and the corporate class of the 0.01%, have imposed  “there is no alternative” and ridden roughshod over other values and stories. Facts, evidence and reason have not worked against their neoliberalism to date. However we may be witnessing the challenge of Authoritarian Populism, which will either destroy or appropriate neoliberalism, as a new ‘anti-myth’. What we need now is a new story, to bridge this ‘myth gap’ (Evans 2017).

 

 

 

 

 

Becker, G. (2007) The Competitive edge of Moral leadership. International Management Review Vol 3 No. 1

Evans A (2017) The Myth Gap. What happens when evidence and reason aren’t enough. Eden Project Books.

Frankl V (2006) orig. 1946. Man’s search for meaning. Beacon Press. Boston.

Hall S (2011) THE NEO-LIBERAL REVOLUTION, Cultural Studies, 25:6, 705-728

Mill, J.S. (1836) On the Definition of Political Economy, and on the Method of Investigation Proper to It, London and Westminster Review, October.

Miller D (1999) The Norm of Self Interest. American Psychologist 54:12: 1053-1-6-

Layard, R (2009) Now is the time for a less selfish capitalism FT.com 11 March http://www.ft.com/cms/s/0/3f6e2d5c-0e76-11de-b099-0000779fd2ac.html#ixzz1AcXchHYm

Persky, J. (1995) Retrospectives: The Ethology of Homo Economicus. The Journal of Economic Perspectives, Vol. 9, No. 2. pp. 221-231

Snyder C, Lopez S and Pedrotti J (2007) Positive Psychology: The scientific and Practical Explorations of Human Strengths. Sage. London

Smith, A. (1759) Theory of Moral Sentiments. http://www.econlib.org/library/Smith/smMSCover.html  accessed 9th January 2011

Smith, A. (1776) On the Division of Labour. The Wealth of Nations, Books I-III. New York Penguin Classics, 1986, page 119.

Antonio Gramsci on intellectual thought – challenging nursing.

Antonio Gramsci on intellectual thought – challenging nursing.

 

 

Antonio Gramsci (1891-1937), leader of the Italian Communist party, was arrested and imprisoned by the fascist regime in 1926 and died in the Quisisana clinic in Rome in 1937, aged 47. His pre prison work and his ‘prison notebooks’ have hugely contributed to the examination and development of political philosophy and intellectual thought. Among the ideas he developed are the role of the intellectual in culture and politics and the concept of hegemony. The prosecutor at his trial was acutely aware of his intellectual abilities, and thus threat, and stated:

 

“We must prevent this brain from functioning for twenty years.”

 

(Buttigeig 2011 p16).

 

Gramsci found himself in a concrete prison not of his own choosing. Nurses find themselves in an abstract prison of the mind put there by their own reason, their lifeworld colonised by the systematic distorted communication of the strategic action of powerful others.

 

This is all a world away from the daily work of nursing, and so at first pass may appear of interest only to the likes of critical social scientists or historians of political thought. Reading Gramsci opens up a discussion on what being an intellectual might mean and of how power is exercised and maintained. Nurses going about their clinical work will not be vexed by such questions and it might be the case that academic nurses will not be either. That could be a mistake given the current context outlined by Streek (2016) of global challenges to social order which have current and future impacts on health and health care delivery.

 

That context is variously called late modernity, post modernity, post industrial, disorganised, financial, rentier, or neoliberal capitalism. Wolfgang Streeck (2016) echoing Gramsci, suggests this context is actually a post-capitalist interregnum in which the old system is dying but a new social order cannot yet be born. Streeck calls the current order one of multi-morbidity, climate change being one of many frailties as we head towards social entropy, radical uncertainty and indeterminancy. Streeck argues that the current context is anchored in a variety of interconnected developments:

 

  1. Intensification of distributional (capital v labour) conflict due to declining growth.
  2. Rising social inequality.
  3. Vanishing macroeconomic manageability.
  4. Steadily increasing indebtedness (private and sovereign).
  5. Pumped up money supply (from quantitative easing).
  6. Possibility of another financial crisis as per 2008.
  7. The suspension of democracy.
  8. Slowdown of social progress.
  9. Rising Oligarchy and Plutocracy.
  10. Governments’ inability to limit the commodification of labour, money or nature.
  11. Omnipresence of corruption.
  12. Intensified competition in winner takes all markets.
  13. Unlimited opportunities for self enrichment (for the 1%).
  14. Erosion of public goods and infrastructure.
  15. The failure of the US to establish a stable global order.
  16. Public cynicism towards economics and politics.
  17. Rising populist nationalism and the spectre of fascism and isolationism in the US.
  18. Fracturing political blocs and alliances.
  19. Erosion of Democratic legitimacy and thus a democratic deficit.

 

 

To that:

 

  1. Health Inequalities.
  2. Potential Ecosystem collapse.
  3. Disruptive technologies: Automation, Artificial Intelligence and digitalisation.

 

 

Streeck seems to suggest that it is the very success of neoliberal capitalism, its defeat of social democracy and forces that would otherwise tame its destructive tendencies, that has paved the way for such developments that characterise its internal contradictions. There is nothing left to save capitalism from itself.

 

There are countervailing voices such as Joseph Norberg (on the possibility and actuality of progress), Daniel Ben-Ami (on growth based capitalism to solve ecological problems) and Stephen Pinker (on reducing levels of global violence) who paint more positive pictures. Add of course the voices of politicians who promise to ‘Make America Great Again’, to create “A country that works for everyone’ or establish ‘Russia as a Normal Great Power’ or to regain ‘primacy in South East Asia after a century of humiliation’. The picture now is one of complexity, tension, dynamics and unpredictability.

 

None of this bothers most UK nurses who work with individuals who are ill, distressed, living with long term conditions, or dying in hospital and at home. They are also involved in public health basing their approaches in general health management, health education and health promotion. Their training and education focuses on instrumental competency based knowledge and skill acquisition but it lacks critical enquiry into the context in which they work. Gramsci’s approach to intellectual enquiry could provide a blueprint for alternative or complementary critical nurse education that has to consider wider socio-political determinants of health, the sort of developments that Streeck outlines.

 

 

 

Gramsci’s thinking

 

We get an insight into how Gramsci’s brain functioned from a letter he wrote in 1929 to the wife of a comrade who also was in prison for ‘anti-fascist’ activity. The context is that of how to study while in prison. The prison referred to, of course, had concrete existence. However, if we consider that today nurses may imprison themselves within the conceptual walls of stultifying paradigms that block freedom of critical thought, for example biomedical empiricism, his thoughts on reflection and analysis might be useful. The letter predates Wright Mills’ 1959 chapter on intellectual craftsmanship, a reading of which shows some commonality in approach and is an alternative to the metrics used today in our research excellence framework assessments. One wonders if Gramsci was writing today, would he secure tenure in some contemporary Universities.

 

He wrote in the letter that one must abandon, in the prison context, the ‘scholastic mentality’ and banish the thought of pursuing a regular and in depth course of study. Along with Wright Mills who later wrote about avoiding empirical work if he could help it as it was merely about sorting out facts and disagreements about facts, this statement appears to be counter intuitive until one considers that a goal of intellectual life could be about criticality, understanding philosophy, self, culture, history, politics and society. Again put this way, many nurses may well eschew intellectual enquiry as irrelevant.

 

Gramsci urged language learning as rewarding, but more interestingly is his outlook on the relative paucity of texts in prison libraries. He argued that a political prisoner must extract “blood from stones” (Buttigeig 2011 p15). The paucity of books in prison was of course a function of the external constraints imposed by the regime. The ‘paucity of books’ available to students today may be a result not of external concrete constraints but of internal self imposed constraints as to what counts as proper reading for a degree in Nursing. Gramsci experienced a concrete prison of walls imposed by the fascist regime. We might experience a ‘prison of the mind’ constructed by dominant cultural ideas (hegemony) imposed by ourselves upon ourselves through the process of normative governmentality. Gramsci argued for ‘extracting blood from stones’, the stones being whatever he could get.

 

To get the most of the books available to him, often popular novels, Gramsci adopted the following viewpoint:

 

“Why is this always the most read and most published literature?”

“What needs does it satisfy?”

 

“What aspirations does it respond to?”

 

“What sentiments and views are represented in these awful books that have such broad appeal?”

 

For student nurses, these questions could be applied to many of the texts, for example the professional body’s literature, that they read to assist with the development of critical thinking. Critique could be emancipatory but in actuality reading ends up in uncritical acceptance. I’m not talking about appraising and critiquing research evidence or engaging in critical analysis of for example leadership theories in nursing. Criticality is lacking in the socio-political and power domain.

An example of the lack of such criticality is the almost universal acceptance of the UK’s Nursing and Midwifery Council’s revalidation process. The requirement is for nurses to renew their registration every three years by following the process outlined by the NMC. The surface reason for revalidation is that it ‘promotes greater professionalism among nurses and midwives and also improves the quality of care that patients receive by encouraging reflection on practice against the revised code’. If we apply Gramsci’s questions above to the texts on revalidation put out by the NMC, a possibility arises that we just might make alternative and critical analyses of just such banal statements in official publications.

 

“Why is the NMC always the most read and most published literature on professional behaviour?” Because of its statutory position as the regulator to protect the public. Because Nurse educators use it as the basis for their teaching. Because the NMC has the power to discipline nurses…..

“What needs does it satisfy?” Neophyte nurses, especially, need guidance on professional behaviour and standards and don’t have the time, or resources or educational preparation to consider this in an in depth way. NMC guidance provides the generally widely accepted standard……

 

“What aspirations does it respond to?” To keep one’s registration and to bolster one’s subject position as ‘safe practitioner’

 

“What sentiments and views are represented in these awful books that have such broad appeal?” The sentiment of nursing as ‘character based moral work’, of nurses as ‘caregivers’, as self sacrificial angels who always cope……

 

The answers to the 4 questions of course are myriad and those above are merely some examples requiring further reflection, reflexivity and criticism.

 

The lack of critique of the NMC on revalidation illustrates ‘normative governmentality’, in that nurses and midwives, and perhaps more interestingly nursing academics, have internalised certain norms, values and assumptions that prevent them from seeing anything other than the official line. This could be an example of what Furedi (2006) refers to as philistinism underpinned by instrumentalism in higher education, in which academics become educational technocrats rather than what Gramsci refers to as organic intellectuals.

 

Intellectuals are those with broad reading, vision and a concern for public issues. Graham Scambler argues intellectuals are not only engaged in the public sphere but do so around an identifiable moral or political position. A question arises about the degree nurses and midwives are, or wish to be, engaged in moral and political questions, the degree to which they can engage in communicative action free from systematic distorted communication.

 

The questioning of texts exemplifies the Gramscian notion of critical enquiry and action and allows us to consider such questions as, for example, what counts as research in contemporary nursing faculties. The answer to that is political in that it frames what nurse academics study, write about and publish, and it frames what students of nursing count as valid knowledge. If we apply those questions to the published outputs of contemporary nursing scholarship what answers would we get? For example, does a high h index always indicate intellectual rigour or criticality? Given the wider determinants of health, which include the social, political and ecological, it could be suggested that health care professionals would be aided in their understanding of health and illness, and hence what to do about it, by critical enquiry that goes beyond accepted epistemologies.

 

Nursing students have been told to be critical thinkers and many University curricula claim to foster such thought. Texts are not to be accepted at face value, and that we should examine assumptions and viewpoints of writers. This should go beyond for example appraising research literature for methodological rigour. Should we also appraise the metaparadigms and epistemological assumptions of ‘acceptable’ and ‘REFable’ nursing research? Should we ask what degree does contemporary scholarship in nursing reflect the sort of intellectual enquiry that Gramsci and Wright Mills advocate? In a world increasingly characterised by forces that threaten to disrupt stability and global order in ways that could be catastrophic to human health, are we preparing nurses to face that?

 

Gramsci died far too soon, and ‘without honour in his own country’. Whether he considered his life a failure in that fascism still held power, nonetheless he provides a template for thinking, studying and critique in difficult circumstances. He had a vision, he was an intellectual, he had a political purpose. Whether academic nurses in the 21st century find this inspiring or irrelevant may depend on what vision we have for nursing praxis for the future.

 

 

 

Buttigeig J (2011) in Gramsci A (1975) Prison Notebooks. Volume 1 Ed. Einaudi G. Columbia University Press. New York.

 

Furedi F (2006) Where have all the intellectuals gone? Confronting 21st Century Philistinism. Continuum.

 

Gramsci A. (1975) Prison Notebooks. Vos 1-3. Edited Einaudi G. Columbia University Books New York.

 

Scambler G (2013) What is an intellectual? http://www.grahamscambler.com/what-is-an-intellectual-2/

 

Streeck W (2016) The post-capitalist interregnum: the old system is dying, but a new social order cannot yet be born. Juncture 23 (2): 68-77

The More Beautiful World Our Hearts Know is Possible. Part 2.

The More Beautiful World Our Hearts Know is Possible.  Part 2. 

 

Part 1 discussed Charles Eisenstein’s outline of what he called the ‘old story’ of the world, at times called the ‘Story of Separation’. This was traced to its origins in western thought evolving into a ‘mechanistic’ view of life. I suggested that although nurse education understands concepts such a holism, actual adult nursing practice may still be based on the ‘old story’ which includes biomedical reductionism within a neoliberal discourse of ‘efficiency, economy and effectiveness’.

May 12th is ‘International Nurses Day’ and is being celebrated on twitter. For an, albeit self-selected, sample of nurses, and what they value, the tweets may present a particular view of what nursing is about. As such it is ‘espoused theory’, i.e. it is what we say we value and do. Following the #IND2016 reveals the thread and expressed values. It cannot however provide much of a clue as to the personal world views of nurses, their ‘epistemologies’, their ‘ways of knowing’ (empirical?) or their ‘ontologies’, ‘the meaning of existence or being’  (duality?).

An epistemology is how you think knowledge can be attained, it is about the nature, source and limits of knowledge, for example through sensory experience (empiricism). A biomedical epistemology bases its knowledge on physiology and anatomy, what can be measured and predicted according to laws of biological science. The subjective experience of illness cannot be taken as ‘proper knowledge’ because it cannot be seen, measured or is open to scientific experimentation or enquiry. The epistemology underpinning many alternative therapies accepts knowledge from theories of chakra, or theories such as ‘like cures like’ and argues that this knowledge is just as valid as knowledge derived from scientific randomised controlled trials favoured by biomedicine.

 

Ontology is the philosophical enquiry into the nature of being, becoming, existence and reality. A dualist ontology considers that there is a separation between the material existence of the human body and the external material world. It accepts that that mind and matter exist separately. Biomedicine adopts this understanding of the human body, that indeed the individual human body is a separate unit of existence from other human bodies, and indeed is separate from the whole of material existence. Therefore what happens to the individual affects only the individual, and what the individual does affects only their sphere of influence.

 

Student nurse education will be based on both these assumptions in the background. All of the work learning for example A and P and pharmacology are grounded in this world view. This holds for the majority of clinical skills learning. This holds true more for adult nursing than mental health and learning disabilities:

 

“Over the past few decades learning disability and mental health nurses…(are)… developing rapprochement with service users and a commitment to social models of care. In mental health care this can be seen in the development of recovery focussed care, while in learning disability Wolfensberger’s (1972) normalisation theory has had an equally radical impact. While adult nursing has also changed a great deal in the same time period, it has not undergone the seismic shifts in philosophy and approach to care that have taken place in these two disciplines. For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care.”  (Ion and Lauder 2015).

 

The context in which adult nurses work, and the nature of illness experienced by their patients, means that understanding health from the ‘new story’ view is perhaps idealistic for the majority of adult nurses.

The above descriptions of empiricist and dualist epistemology and ontology is what Eisenstein calls the ‘old story’. Thus, a brief outline of Eisenstein’s view of the ‘new story’ might provide a basis for some critical reflexivity. He variously calls it the ‘Story of Interbeing’, the ‘Age of Reunion’, the ‘Ecological Age’ or the ‘World of the Gift’.  Wendell Berry calls it the ‘world of love’ or ‘health as membership’.

This resonates with David Loy’s (1988) comment:

 

 “In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (David Loy 1988 p 302).

 

Loy contrasts Eastern non dualist philosophical traditions, with mainly Western dualism in that:

 “….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings” (p140).

 

This then is a non-dualist viewpoint in which ‘us’ includes the biosphere; we are indivisible as human beings from all life forms and all matter.

 

The principles of Eisenstein’s ‘new story’ are (p15):

  1. That my being partakes of your being and that of all beings. Our very existence is relational going beyond interdependence.
  2. What we do to another, we do to ourselves.
  3. Each of us has a unique and necessary gift to give to the world.
  4. The purpose of life is to express our gifts.
  5. That every act is significant and has an effect on the cosmos.
  6. We are fundamentally unseparated from each other, from all beings, and from the universe.
  7. Every person we encounter and every experience we have mirrors something in ourselves.
  8. Humanity is meant to join fully the tribe of all life on earth, offering our uniquely human gifts towards the well-being and development of the whole.
  9. Purpose, consciousness, and intelligence are innate properties of matter and the universe.

This view may be more applicable to one’s personal view than to clinical practice. It might be interesting to think what clinical practice might look like if we took these precepts seriously? The current design of hospitals and clinics, the clinical pathways we develop and the sort of practitioner we educate is based on the ‘old story’ of biomedicine, so we know what that looks like. It is our current world.  Could it be possible to redesign and to rethink?

This is philosophy, but Eisenstein argues this fits with what physics tells us about the world, it is more than ‘new age’ assertion and hope. There is a continuing divide however between the new paradigms of physics and biology and the Newtonian mechanistic world view of everyday experience. The one is the espoused theory – what scientists and philosophers say is so, and practical action – what we actually do and experience as adult nurses.

The issue goes beyond what clinical practice looks like and where it takes place. The ‘old story’ underpins our ecological, social and economic crises because it narrows the definition of what it is to be human, what reality is and thus what the possibilities are.

Yagelski (2011) calls this ‘the problem of the self’:

“My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”.

Student nurses in the Adult field in the UK are schooled, and experience, the ‘autonomous, thinking being’ separate from the natural, physical and social world. The political world is torn between Margaret Thatcher’s ‘no such thing as society, only individuals’ and a more social(ist) democracy. To date Thatcher’s view prevails as a core element of neoliberalism.

Adult nurses go to work within a mechanistic, empirical, patriarchal, separate, reductionist and biomedical context. This is a world in which the cause-effect relationship of the RCT is the gold standard for evidence. They will have a clear sense of boundaries between themselves and their patients and with other health professionals. The work context is similarly managed in a fragmentary way, units of work need to be measured and evaluated, processes clarified, evidence to be checked. Wendell Berry calls this the ‘world of efficiency’.

He also refers to the ‘world of love’, a world which Eisenstein might recognise as ‘Interbeing’.

However, this is a view that hospitals and industrialised medicine struggle to understand and thus cannot ‘heal’ or make ‘whole’. Berry accepts that the hospital does well at surgery and other procedures, treating the body and its parts as separate things.

 

Healing, however, meaning reconnecting and making whole, is alien to many medical practices. For example, any place of healing would emphasise and prioritise such things as rest and food. Whereas a hospital treats a body as a machine that needs fixing and that the rest it needs is a low priority. Both sleep and nutrition in acute hospitals continue to be topics addressed in the literature as not always delivered in the best way possible. The very design of hospitals seem antithetical to both.

 

Berry argues that rest, food and ecological health ought to be the basic principles of the art and science of healing, but currently healing is based on other principles: biomedicine technology and drugs. Berry criticises biomedical practices for making only tenuous links between healing, rest and food and no link at all between health and the soil:

 

Industrial medicine is as little interested in ecological health as is industrial agriculture” (p98).

 

This sentence makes no sense unless health is defined within a non-dualist, non-reductive ontology.

 

This disconnect between healing, health and medicine is illustrated by Berry by describing the experience of his brother’s heart attack. The debt to the hospital is acknowledged, as John his brother underwent a Coronary Artery Bypass graph. In the hospital the ‘world of love’ confronts the ‘world of efficiency’ – i.e. medical specialisation, machinery and procedures.

 

John came from the ‘world of love’ of family, friends, neighbours which the hospital struggled to deal with. This world of love seeks for full membership, it seeks to be joined. However the world of efficiency ignores this love as it must ‘reduce experience to computation, particularity to abstraction and mystery to a small comprehensibility’. In other words any experience that cannot be objectively measured and calculated is devalued and takes second place to the ‘real’ work of diagnosis, intervention and evaluation.  Hence the focus on vital signs, NEWS, blood gas analysis, blood tests (FBCs, U and Es), ECGs, urine output, X-rays and CT scans; the particularity of a patient’s pulse is abstracted to concepts such as hypovolaemia; the particularity of a real person is abstracted into a set pf physiological parameters transformed into documentation replete with risk scores and reduced into medical categories; the mystery of the pale, clammy patient, expressing chest pain has to be comprehended as myocardial infarction (or other diagnostic category that gives meaning).

 

Efficiency must ally itself to machinery – John was in the intensive care unit – to standardise, to provide numbers to predict and control. The efficient nurse will use all the tools that biomedical science gives to provide the best physical care. The effective nurse will use the appropriate biomedical tools and interventions which are evidenced based; the economic nurse will do so with the minimum of cost.

 

Love however cannot be standardised, is not a graph, a chart, anatomy, an explanation or a law:

 

“The world of love includes death, suffers it, and triumph over it. The world of efficiency is defeated by death; at death all its instruments and procedures stop. The world of love continues and of this grief is the proof” (p105).

 

The professional ‘field’ of adult acute care excludes the ‘amateur’, excludes the world of love. Descriptions from the professionals to the family that procedures were ‘normal’ failed to acknowledge that nothing about this was normal. Normality for them was biomedically defined, was what they have experienced with other patients. Lying in a hospital bed is pretty far from normal for everyone else.

 

The worlds of love and efficiency divided experience, however people can cross between. The amateur may not be able to cross into the world of efficiency. The machines and data are ‘a foreign land’, but the professional can cross into the world of love:

 

“During John’s stay…there were many moments in which doctors and nurses – especially nurses! – allowed or caused the professional relationship to become a meeting between two human beings” (p108).

 

Berry described on such moment. John’s wife Carol was waiting for news of the bypass operation, and as a nurse also knew the seriousness of the situation. Two nurses came to tell Carol that the operation had been a success and that during the procedure a balloon pump had been inserted into the aorta, a possibility that had never been mentioned.

 

Carol being unprepared for this news was disappointed and upset. The two nurses tried to reassure her by repeating what they had just said (professional and within the world of efficiency). Then there was a long moment when they just looked at Carol.

 

One of them then said “Do you need a hug?” Carol said “Yes”.

 

This brings us to a starting place, a starting place for healing and a crossing over into the world of love.

 

Many nurses today will understand this crossing over, many will intuit that the world of love is part of healing, of health as wholeness even while they work on the world of biomedical efficiency. This is a corrective to the isolationist, reductive and machine like process of ‘nursing’ care in some hospitals and care homes. However, at times we struggle to provide this ‘world of love’ as the Ombudsman report (2016) into the hospital discharge of older people testifies.

 

Eisenstein asks us to consider that separation causes distress and provides the wrong solutions. If we really believed and felt that the old person sitting alone in bedroom was us, would we want to change things?

I accept that I can’t do it. I can’t heal those around me. I’m stuck in the transition between the world of love and the world of efficiency. I am not able or willing to pay the heavy price to close the gap by myself.  I can make a difference, though, to some and Eisenstein argues that little differences can add up. What is my gift to the world? Having read Eisenstein , I have to admit it is not a question I’ve ever addressed. My sense of self is individual, is separate, is ‘dualist’ and yet I know it could be different? The new story is a vision of where I could be, it is not where I am.

I don’t think this is matter for individuals to provide an individual response to such issues as loneliness. It would be a ‘good thing’ of course if isolated lonely old people had visitors, and that the visitors themselves would benefit from that. However, that is the ‘old story’s’ solution. Many individuals do not have the time, energy, resources emotional and physical, the geography or the history to close the gaps. That is because our total system of care mirrors the social, economic and political systems that emphasise efficiency, effectiveness and economy and the sovereign individual. That is why our culture is increasingly turning to individual responsibility for health, education and welfare. Health and social care is framed within austerity budgetary constraints, we cannot think about anything other than the financial costs.

This means we cannot imagine or vision “a more beautiful world our hearts know is possible”.

 

 

 

 

Changing our mindset for health and sustainability.

Changing our mindset for health and sustainability.

 

“In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (David Loy 1988 p 302).

 

As I have previously suggested, health care professionals are becoming more alert to the issue of climate change and how this might affect the health of populations in the future. Climate change is only one aspect of sustainability, others of course relate to issues such as food production, distribution and security. The solutions put forward to address the myriad issues appear to be based in two different, but not necessarily mutually exclusive, approaches: 1) the technico-rational and 2) philosophical. If health care professionals are to put forward plans of action then they need to consider some of their philosophical and ideological assumptions that underpin those solutions.  I would suggest that a little more philosophical enquiry into the nature of society and our relationship to ‘nature’ just might prompt a rethink of our reliance on technical solutions.

 

The first, technico- rational, approach implicitly accepts dominant modes of thinking, which could be called ‘modernist’.  It is often based upon various philosophical traditions without explicitly critiquing them. These traditions, such as rationalism, empiricism and dualism, can be traced back to the Enlightenment and the dawn of western science. These ideas of course underpin much of modern capitalism which is another taken for granted economic model underpinned by philosophical assumptions about how the social world works.

 

A modern exponent of this is Daniel Ben Ami who, in ‘Ferraris for All’, argues that what is required is more economic development and growth, i.e. much, much more of the same, in order that humanity can better control nature and to come up with scientific and technical solutions to such issues as ocean acidification, climate change and soil erosion. Capitalism, rationalism, empiricism and dualism are implicit in this way of thinking. In short, this accepts the current economic growth based model and an understanding of how we relate to nature through extraction and development of natural resources for human use. The answer for sustainability and human health is improved technologies. I think there are flaws in this approach, one of which is that it relies too much on assuming what brought us success in the past, i.e. capitalism and technological development, will continue to do so in the future. That is to say it is based on inductive logic and its flaw; past patterns might predict the future but cannot guarantee it. As Nicolas Naseem Taleb reminded us, there might be a black swan to confound the ‘all swans are white’ logic.

 

David Loy’s comment leads us to the second approach, the philosophical, in that we might want to examine some of the assumptions that underpin the technico-rational, and especially ‘dualism’ – the separation between man and nature, mind and body. Loy contrasts Eastern non dualist philosophical traditions, with mainly Western dualism in that  “….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings” (p140). This then is a non dualist viewpoint in which ‘us’ includes the biosphere; we are indivisible as human beings from all life forms and all matter.

 

In Cartesian dualism, the Platonic tradition and the Judeo-Christian religious tradition, the self is separate from nature and is understood to be the source of awareness, meaning and value. This results in a devaluing of the physical world in which the human self is separate and superior.  The human ‘subject’ is separate from the natural ‘object’, and so what we do to ‘it’ is not part of ‘us’. Dumping toxins into the oceans is acceptable because the ocean is not part of us – it is a waste sink, we are doing something to a separate ‘it’. The human subject then becomes capable of confronting an objective world, a world which is there for our use.  The idea of human exceptualism (Catton and Dunlap 1978) – that man is special and apart from nature – takes root in this discourse.

 

This sentiment harks back to Francis Bacon, who argued in 1620 “The world is made for man, not man for the world”. In ‘The New Atlantis’ , Bacon thought that by and through the application of scientific and technological dominion over nature, men would usher in a new age of abundance and comfort.  This has echoes in Sigmund Freud’s (1927) assertion: ‘The principal task of civilization, its actual raison d’etre, is to defend us against nature’.

 

The call to have dominion over, to conquer, to harness, control or subjugate nature is predicated upon this idea of separateness from it. This control is thus predicated upon the self in opposition to nature which Yagelski (2011) calls  ‘the problem of the self ‘:  “My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”. Shabecoff (2001) suggested that concerns expressed in critiques by environmentalists of this dualist interpretation resulted in the ‘Heidelberg Appeal’ , a document signed by many scientists,  which reasserted that progress by man always involved harnessing nature to man’s needs.

However, we know that human health is inextricably bound with the physical and natural environment and what Charles Eisenstein calls ‘separation’, i.e. dualist thinking, results in practices that are injurious to us. In this regard Chivian and Bernstein (2010) argue the biodiversity is crucial to human health and I suggest that we might do better to consider ourselves part of nature not separate from it. Is it a philosophical step too far to consider that the clearing of Amazon rainforest is therefore as injurious to my health as contracting a virus?  Changing low energy light bulbs is a technical solution, perhaps I also need to change the way I think.

 

 

 

 

 

The More Beautiful World Our Hearts Know is Possible. Part 1

The More Beautiful World Our Hearts Know is Possible.   Charles Eisenstein (2013) North Atlantic Books. Berkeley.

 

This book should be required reading for all. Student nurses especially interested in health should read and discuss the implications. It will appeal to a wide range of people and is written in a very accessible style. This is not a book that would interest Donald Trump, Boris Johnson or the ‘Masters of the financial Universe.’ It would be too ‘fluffy’ for hard line leftists mired in economic determinism. It draws upon a re-emerging world view: a ‘systems view’, of life central to ecological and sustainability discourse. It has a long history; one crushed by the forces of colonialism, genocide, imperialism, extractive and other form of capitalism, patriarchy, Abrahamic religion and scientism. Its roots are to be found in the three social movements for social justice, indigenous rights and ecology.

A ‘Systems view of Life’ challenges the fragmentary, mechanistic, individualist view of life. Charles Eisenstein thinks, along with writers such as Fritjof Capra (the ‘rising culture’) and Paul Hawken (the ‘blessed unrest’) that we are in transition from one to the other. Stephen Sterling suggests that the sustainability transition cannot be made without adopting a ‘systems view’. Nurse education and practice has not fully caught up with the implications of such thinking.

Much of nurse education is founded on the old view; and thus we learn to reduce the human body to its constitutive parts (reductionism), that the most important knowledge is anatomy, physiology, biology, that health is about disease processes, specific aetiology, cure (biomedicine), that the focus of diagnosis is the individual apart from their social and ecological context, and we can understand illness and health in a cause and effect manner.  There are of course exceptions to this overly simplistic description yet it is probably the case that when in clinical practice the focus is on acquiring skills, knowledge and attitudes to undertake a certain role. This is done with the implicit acceptance of a fragmentary, mechanistic worldview. Up to a point that is as it should be. However, if nurses in their personal as well as their professional lives are to join in creating that transition then they need to be critically reflexive (challenging ourselves, our own thoughts, our own sense of self) and critically reflective:

In ‘An Invitation to Social Construction’ (2009) Kenneth Gergen introduces this concept with the following explanation:

‘Critical reflectivity is the attempt to place one’s premises into question, to suspend the ‘obvious’, to listen to alternative framings of reality and to grapple with the comparative outcomes of multiple standpoints…this means an unrelenting concern with the blinding potential of the ‘taken for granted’…we must be prepared to doubt everything we have accepted as real, true, right, necessary or essential’.

Eisenstein poses some key questions to assist with this process (p4):

  1. Who am I?
  2. Why do things happen?
  3. What is the purpose of life?
  4. What is human nature?
  5. What is sacred?
  6. Who are we as people?
  7. Where did we come from and where are we going?

 

These questions may come across as a bit ‘new agey’ but are of course questions scientists and philosophers have asked. They are not questions often found explicitly in nurse education.

The following answers to those questions have been the dominant discourse leading to our fragmented, reductionist and dualist paradigm. Eisenstein calls this the ‘Story of the World’, while Capra and Luisi (2014) outline its origins in western philosophy, locating it with the giants of science and philosophy: Newton, Descartes, Hobbes, Locke and Mill to name just a few. A passing note: they are all white men. Much of today’s science, including some medical practice, and philosophy has moved on, but has not yet reached into our emerging worldview as practical activity in the social, economic and political worlds dominated still by the neoliberal imaginary in the Anglo-American world view, and by other various forms of materialist capitalism elsewhere (e.g. Russia, China, India).

 

  1. Who are you? The liberal humanist self of the sovereign individual; a separate individual among other separate individuals in a material universe that is separate from you. There are clear boundaries between us and the material world. You are ‘skin encapsulated ego’. You are a ‘flesh robot’ programmed by genes to maximise your reproductive self- interest. Your mind is a separate ‘bubble of psychology’, separate from other minds and materiality. A ‘soul encased in flesh’ or a mass of particles operating according to the laws of physics. A separate biological, anatomical, physiological you.
  2. Why do things happen? The impersonal forces of physics (gravity, light, mass) act upon all particles including you. All phenomena are a result of mathematically determined interactions. There is no purpose, intelligence or design behind it all. There are only impersonal forces and masses. This is life, the sum of the interaction of force and mass.
  3. What is the purpose of life? There is only cause. The universe is blind and dead, inanimate and uncaring about your existence. There is nothing that can ‘care’. Life exists and reproduces itself. Thought is only electromechanical impulses; love is a ’hormonal cascade’. Life is based on the self interest of the reproducing unit, its self interest is in conflict with the self interest of other units, everything that is not self is either indifferent or hostile. Dog eat dog, survival of the fittest.
  4. What is human nature? As we live in a hostile universe of competing individuals and impersonal forces, we have to protect ourselves and this means exercising control. Anything that assists with control: money, power, status, security, information, is valuable and must be acquired. We are at heart ruthless maximisers of self interest. Economically we are utility maximising rational actors, ‘homo economicus’.
  5. What is sacred? As the ruthless pursuit of self interest is anti-social we must aspire to ‘higher things’. This means controlling the desires of the flesh, engaging in self denial and self discipline. We must ‘ascend’ into the spiritual realm if religious, or into the realm of reason, principles and ethics, if secular.
  6. Who are we as people? Anthropocentric: The apex of evolution, the highest form of life, a special kind of animal. We are unique created in the image of God (if religious) or unique in having a rational mind (if scientific). We alone possess consciousness, we alone can design the world.
  7. Where have we come from and where are we going? We started out as naked, ignorant animals barely able to survive in a hostile environment; lives were ‘nasty, brutish and short’. Our brains enabled the transition to be the lords and possessors of nature, having ‘dominion over all we survey’, our destiny is to free ourselves from work, from disease, even from death itself.

 

These answers are the ‘old story’ that are still somehow the, albeit torn, fabric of much of our reality. The answers are changing, the old is emerging into the new but the transition is not complete. The new story has no coherent programme, no powerful political party, no country, no organising principles. It does have a movement however. This movement is not to be found in the mass media, filled as it is with mass culture. The movement is not to be found in the palaces, the parliaments or in presidential residences. The movement does not have a giant multi-national corporation, trade agreement or is backed by a military-industrial complex. It faces the forces of the old story, of capital flows, of religious fundamentalism and of scientism. It is not an ‘it’.

 

As you read this, consider your own world view and answer for yourself the above questions. In addition reflect on what this means for nursing practice. To what degree are we still in the old story in actual practice? Put aside the espoused theory of ‘holistic practice’ and look for what the ‘theory in action’ is. Are there clinical areas which heavily depend on individualising, separating, fragmenting, reducing human experiences to biomedical and scientific processes? Are you able to discern what assumptions and values underpin the daily work?

 

Finally, consider the issue of care and support for older people: what assumptions, values and interests are at play here? Have we separated the old from the rest of us? Do we feel their pain? Have we created a system that integrates and values their existence? What priorities drive the whole system of care? A clue is that in the UK’s parliament, the needs of older people for care and support is seen as a huge ‘commercial opportunity’.