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”.

 

 

 

 

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’.