Response to: ‘Edwards, Benner and Wrubel on caring’
Article first published online: 16 SEP 2002
Journal of Advanced Nursing
Volume 40, Issue 1, pages 45–47, October 2002
How to Cite
Benner, P. and Wrubel, J. (2002), Response to: ‘Edwards, Benner and Wrubel on caring’. Journal of Advanced Nursing, 40: 45–47. doi: 10.1046/j.1365-2648.2002.02384.x
- Issue published online: 16 SEP 2002
- Article first published online: 16 SEP 2002
by S. Horrocks (2002) Journal of Advanced Nursing 40, 36–41.
Horrocks' (Horrocks 2002) paper confuses our dialogue with Edwards' (Edwards 2001), and adds new misinterpretations of Heidegger that renderhis paper incoherent. Therefore we will let stand the Edwards, Benner and Wrubel dialogue (Benner & Wubel 2001), and take up our points of disagreements with Horrocks. We will follow the structural order of Horrocks' paper in our points of disagreement. We use brackets within quotes to reflect our interpretations.
Heidegger, a philosopher who believed in the primacy of practices and everyday comportment in the world, engaged in extensive dialogues with medical care (Boss et al. 1988) and often used examples from a carpenter's workshop. Horrocks departs from Heidegger's stance when he states:
…if one attempts to explain the ideas at the philosophical level (and in the case of Heidegger very complex ideas) is this appropriate for a general readership of nurses? If it is not appropriate then that means that there is the potential for nurse academics not to fully explain the philosophy that they are using (even if they understand it), and use the arguments at the nursing levelto obscure the arguments at the philosophical level. (p. 37)
Horrocks seems to think that discourse, in order to be ‘philosophical’, must stick to a technical specialized philosophical language, and that such a language is inappropriate for a general nurse readership. We disagree with these assumptions, and the patronizing tone in relation to nurses' capacities for understanding philosophical issues. Webelieve that everyday practical understandings can illuminate philosophy, and that philosophy translated and made relevant to practical concerns can become clearer and more relevant. We resist the elitist notion that philosophy should be left only to technical philosophical language and thus only accessible to philosophers who know how to read the technical ‘code’ words. We assert that because of the nature of meeting people in health and illness, where the impact of one's existentiell understandings of existence are often disclosed, nurses have enriched preontological understandings of being. The Primacy of Caring (Benner & Wrubel 1989) has been accessible to many nurses and phenomenologically-orientated philosophers.
When we wrote The Primacy of Caring there were fewer philosophical works in nursing. But that has changed over the past 13 years for example, with the coming of the Journal Nursing Philosophy, and many more philosophical works in nursing literature. For the past 21 years, nursing doctoral students at University of California, San Francisco have successfully taken courses in Heidegger, Kierkegaard, and Merleau-Ponty based on their interest and rich preontological understandings of world and embodiment as a result of their existentiell dwelling in the world of nursing. In our second edition of The Primacy of Caring (in progress) weare using nurses' increased interest and sophistication in philosophy to clarify the philosophical exploration of stress and coping related to health and illness.
Horrocks follows Edward's misconstrual of the subject matter of The Primacy of Caring as the caregiving of nurses. The focus of The Primacy of Caring is on the ontological structures of being human (existential and existentiell) as these are related to health, stress, coping and illness. This is not a trivial point. Our goal is to make the nature of human existence in the world visible in relation to the experience of stress (e.g. anxiety, depression, fear, foreboding) and other forms of challenge or breakdown in meanings and self-understandings in a person's world due to illness or injury. Ontological structures of care enable human beings to dwell in a world. Through being self-interpreting beings who have existentiell skills of dwelling in particular worlds, human beings have a preontological access to what it is to dwell in a world. To have a preontological understanding of worldliness requires something more and different than an ontic analysis (i.e. regional scientific analyses) of biology, caregiving, social structures, psychology or anthropology, for example. Emotions and skilful embodied comportment, background coping and significance are equi-primordial aspects of Dasein's way of being-in-the-world. Illness, injury and disability are forms of breakdown, and disease in the person's world, making the world accessible, or inaccessible in new ways (including the built world that may create disability). Recovery always entails recovering one's ability to re-enter and dwell in a familiar world. We use philosophical thinking to illumine the human experiences of stress and coping. While Edwards does refer to what nurses encounter and are concerned about in their caregiving (e.g. stress and coping), Horrocks does not. And both pass over the phenomena under discussion in our book: stress, coping and health as related to existential and existentiell structures of being in the world.
We agree with Horrocks when he points to the importance of the notion of ontological difference in Heidegger's thinking and acknowledge that it is indeed a complex idea, primarily because it goes against the traditional understandings of being in the Western tradition. Heidegger states:
If we reserve the term ‘ontology’ for that theoretical inquiry which is explicitly devoted to the being of beings, then what we have had in mind in speaking of Dasein's ‘being ontological’ is to be designated as something ‘preontological.’ It does not signify simply ‘being ontical’, however, but rather ‘being in such a way that one has an understanding of being.’ (Heidegger 1962) (p. 32).
Horrocks is correct to assert that Daseincannot be translated as human being. However, human being is ontico-ontological in that human beings are the kind of beings that allow other beings to show up or be disclosed. Horrocks is mistaken in his interpretation of Heidegger when he defines the existentiell as ontic:
But an inquiry about some particular Dasein's own existence is ontical [here Horrocks should have said existentiell, which is ontological and not ontical]. Heidegger develops a new set of categories to capture the underlying structure of human existence, which he calls ‘existentialia.’ This allows him to apply the distinction between the ontological and ontical to human existence, the ontological becomes ‘existential’ and the ontical becomes ‘existentiell. (p. 37)
Here Horrocks confuses the Heideggerian terms existential (ontological structures of world and Dasein as philosophers such as Heidegger lay them out) and existentiell structures of dwelling in particular worlds. For Heidegger, existential and existentiell structures are both ontological and not ontic (a regional scientific study of things in the natural world). Existentiell is ontological in that dwelling in particular worlds create the conditions of possibility for a preontological understanding of world. Existentiell is ontological but not thematized. Heidegger calls the shared cultural practices, habits, skills, and common understandings of what it is to be a particular kind of human being dwelling in a particular culture, a preontological understanding of being. Preontological experiences of practices form the ground for understanding the groundlessness of actual ontic interpretations of particular scientific disciplines. Dreyfus’ interpretation of Heidegger here may be clarifying:
Cultures and cultural institutions have existence as their way of being, and so does each of us. To exist is to take a stand on what is essential about one's being and to be defined by that stand. Thus Dasein is what, in its social activity, it interprets itself to be. Human beings do not already have some specific nature. It makes no sense to ask whether we are essentially rational animals, creatures of God, organisms with built-in needs, sexual beings, or complex computers. Human beings can interpret themselves in any of these ways and many more, and they can, in varying degrees, become any of these. But to be human is not to be essentially any of them. Human being is essentially simply self-interpreting… (p. 23)
…Now we will see that, precisely because Dasein's way of being makes facticity possible, it can never be defined by its facticity (Dreyfus 1991). (p. 25)
This is so despite the fact that some facticity is necessary to gain access to the world in a preontological way, and through this access we have the possibility of gaining an ontological understanding of being.
As an example of Heidegger's technical use of the terms existentiell andexistential, a person's self-understanding inrelation to existing in the world of ‘the disabled’ is existentiell and preontological. A nurse's understanding of the particular world of nursing is existientell and preontological. Whereas, a nurses' general psycho-social understandings of her patients' various roles and possible roles is ontic (neither existential nor existentiell, what Horrocks would term sociological and erroneously existentiell/ontic.). If a nurse thinker, or philosopher does ontology in order to better understand what it is to be Dasein in general [Heidegger's main project in Division One of Being and Time (1962)] then that kind of understanding is about what structures human worlds and is therefore ontological and existential. In Primacy of Caring we spent far more time on preontological understandings of dwelling in worlds (existentiell) because the general existential structures of human worlds show up in situations of disruptions to dwelling in a world…breakdowns in smooth functioning and everyday coping.
We drew on Heidegger's notion that there is more than the ‘pure intentionality’ (deliberative explicit intent), in the lived experience of comportment in a familiar world, though we do not ignore the central role of deliberative thought, especially in situations of learning and breakdown. It was Edward's reduction of intentionality to only deliberative ‘pure’ intentionality that we were problematizing. Primordial intentionality comes before deliberative intentionality which is derivative of primordial intentionality, i.e. everyday comportment and coping in the world. Primordial intentionality is central to Hedegger's understanding of preontological and ontological understanding (Heidegger 1982). We assert that our discussion of different forms of intentionality is central to Heidegger's understanding of Dasein and ontology.
Contrary to both Edwards' and Horrocks' assertion, Heidegger does not understand the ‘ontological’ as being ‘deeper’ but rather as being more general.
Horrocks misinterprets Heidegger and our work when he states:
Thus inquiring into the underlying existential ontological structure of Dasein is logically prior to inquiring into the existentiell ontic (sic) nurse or academic because it carries an awareness of being which is the preontological understanding of being, which is, nevertheless implicit. But because it is situated in the ontical [existentiell would be the correct term here, not ontical since ontic only relates to the scientific understanding or study of entities] in other words the existentiell [unthematized ontology] it is at this point that there are a lot of complaints that, even though Heidegger says that he is analysing being, he is instead doing philosophical anthropology. (p. 38)
These complaints would be justified if Heidegger held this position, but he does not. Inquiring into the underlying existential ontological structure of Dasein is not, according to Heidegger, logically prior to inquiring into the ontic structures. Inquiring into the existentiell ontological structures and examining everyday comportment and existence is however, phenomenologically prior to making the existential ontological structures of Dasein explicit. This passage makes it clear why Horrocks misunderstands Heidegger, our work, and the dialogue with Edwards. How could he possibly be thinking in Heideggerianterms when he states? ‘Dasein predominantly understands itself in an ontical way.’ An ‘ontical way’ would be an objectified, scientific way, and while academicians may think of themselves in this way much of the time, most people do not.
Horrocks misunderstanding of Heidegger continues when he states:
While the existentiell understanding is a competence for projecting towards some particular end, the underlying existential understanding is a competence for projection in general. (p. 38)
But Heidegger would claim, and rightly so, that human beings in their everyday comportment or existence would not know how to project themselves ‘in general’. In everyday comportment and existence (existentiell) we can gain a preontological grasp of our ungrounded position in the world. The requirement for a preontological understanding of being is existence in a world (existentiell) and this unthematized ontological understanding creates the conditions of possibility for making the ontological difference explicit. This should be clear to Horrocks when he quotes Heidgegger:
‘Dasein always understands itself factically in definite existentiell possibilities’ (Heidegger, 1980, p. 360).
What Horrocks mistakenly calls ‘world-developing’ we call world-defining, as ontological existence is to be thrown into an already developed world.
Horrocks never comes to terms with primordial intentionality described by Heidegger (Heidegger 1982, Heidegger 1962) and continues to use ‘intentionality’ as ‘conceptual’, or deliberate thought, while we are drawing attention to Heidegger's idea that primordial intentionality comes with existing or dwelling in a world, an ontological existentiell, not thematized, and certainly not ontic.
We are trying to be true to the aspects of Heidegger's work we have drawn on, but we do not claim to agree with all of Heidegger's work, nor to work exclusively from it. Our project was to articulate how ontological structures of care constitute human existence…human worlds, and we assert that enhanced understanding of the ontological structures that constitute the possibilities of dwelling in a world are essential to understanding wholeness and integrity, and stress and coping related to breakdown in a human world due to illness, disability or injury. Ontic caring practices must respond to a preontological understanding of human existence (unwittingly or not). An understanding of a person's particular lifeworld concerns [and not just objectified facts about their mental and physical condition] is required in order to have one's caring practices respond to the concerns of the one being cared for. Cartesian medicine has de-worlded the person and amassed amazing success in curing infectious diseases and effecting surgical cures. But it has been less successful in dealing with the necessary structures of care related to dwelling in particular worlds essential to well-being and recovery. This is particularly evident in the areasofhealth promotion and illness prevention, and in the care of the chronically ill.
In pointing to ontological structures of care that constitute dwelling in human worlds we point to temporality, situatedness, disclosive spaces or clearings, and the roles of embodiment and emotions in existentiell dwelling. We claimed that caring strategies (ontic) as they are taught in nursing school often follow the ethos of Heidegger's term ‘authentic care’, care that responds to the person's particular world:
Everyday Being-with-one-another maintains itself between the two extremes of positive solicitude – that which leaps in and dominates, and that which leaps forth and liberates. It brings numerous mixed forms to maturity…and along with our understanding of it. Thus in concernful solicitude the Other is proximally disclosed (Heidegger 1962, p. 159).
As nurses learn to dwell in the nursing world and take up caring practices as world disclosing, then dwelling in those caring practices becomes ontological existentiell. We conclude that the translation of ontological notions of being human that we articulated in The Primacy of Caring did make sense to nurses who work with patients who experience extreme forms of break down or dwell in well-functioning worlds. Temporality, situatedness, and the horizons of one's world are altered by illness, disability and injury. Nurses have direct experience with these phenomena in caring for the ill. We believe that this work illuminates the philosophy of Heidegger, Merleau-Ponty, Kierkegaard, by giving examples of existentiell ontological structures in relation to human experiences of stress and coping related to health and illness.
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