Review of Care and Vulnerability by Kari Martinsen, a Norwegian Professor of Nursing Science.
A short stay in Sweden last year brought me into contact with the work of Kari Martinsen. Since her work is interesting for everyone working within the ethics of care, I would like to share my reading experience here. In her book, Martinsen advocates perceiving, a way of seeing of care givers that enables another way of being for patients in the hospital. The first is primarily a response to the objectifying gaze of care professionals, provoked by the growing influence of evidence based medicine. The second refers to the increasing importance of efficiency in healthcare, allowing little time for personal attention to the patient.
The central question of this book is whether hospitals invite people to dwell in their midst. Dwelling, a phenomenological concept, refers to a fundamental atmosphere of having a foothold in existence, that is, a sense of belonging, being safe, and feeling at home. According to Martinsen dwelling is under pressure in modern healthcare. She argues that dwelling is more than the satisfaction of patients’ needs and that it requires more of caregivers than merely execution protocols well. This issue is illuminated from various sides in four chapters. The chapters started as articles originally published in Norwegian.
The first chapter describes the hospital as a public house. A house as a place that is safe, warm and respectful. A place where you can be yourself. Just like at home, patients should dwell in the hospital. By dwelling patients may be experiencing impressions which are life sustaining in the midst of their pain and suffering. In today’s hospitals a tension exists between a house in which one may dwell and be safe, and a house which is focused on production and profit. The latter seems to prevail and sometimes even the rooms are almost literally taken away from patients for the sake of efficiency. This tension appears in my own research on elderly hospital patients in the form of a ‘wrong bed’. A term which is used for beds occupied by patients whereby the actual date of discharge has already passed. In the words of a patient in my research: ‘they want you to leave as soon as possible’. Obviously this patient has no experience of dwelling. According to Martinsen two different interpretations of life are at stake here. In the former, patients are seen has having dignity in themselves and the sick person and his surroundings must therefore stand at the centre of care. In the other, the functionalistic view is at stake. Here, the patient is reduced to his disease and a utilitarian, sorting mode of thought is central. In the latter, the fundamental tone is that of total control, in the former that of sparing. With sparing Martinsen means inducing belonging and being respectful so that illness (with its lack of order and structure) may be endured with dignity.
- In the second chapter the argument is made that to protect people’s vulnerability norms and rules are not enough. Something intermediary is needed. Nowadays, rules and protocols developed from clinical practice have become very important in the culture of hospitals. These rules and protocols, however, may never be absolute; they must always be judged or evaluated. Based on the thoughts of the Danish philosopher and theologian Knud Ejler Logsturp, Martinsen argues that human encounters in care must be sustained by mutual trust. Without this mutual trust, rules will not be credible. To relate in a trustful way to culture, norms and science, judgment is needed. Judgment requires both a commitment to and a distance from rules. Only within this distance can the other and his or her experiences appear and a zone of untouchability, instead of total control, be preserved. With untouchability she means boundaries not to be crossed. This allows the patient to show himself as he is, instead of being categorized beforehand by the care professional.
The following two chapters continue the reflection on Logstrup’s philosophy. The story of the Good Samaritan has a fundamental place in his work. The story shows different ways of seeing a person and emphasizes the importance of being seen in such a way that one becomes significant to the one who sees. Martinsen argues for seeing with the heart’s eye. To clarify what she means by this way of seeing she makes a distinction between perceiving and recording. Perceiving allows the other, who you may not know, to emerge as foreign and of your concern. Within perceiving there is a unity between the one who perceives and that which is perceived. In other words, perception puts two people in a common world. Allowing emotions is essential in perceiving and is in contrast to the contemporary propagated professional distance, which is reflected in the purely recording eye. In this way of seeing the nurse is withdrawn from the situation. He or she stands in an outside position and looks for similarities and general categories. The nurse and the patients do not belong to a common world and there is no interaction between them. When the patient is viewed in a recording way, everything is controlled by the nurse. The final outcome is classification instead of understanding. Martinsen advocates a person oriented professionalism in which both types of knowledge are taken into account.
The last article addresses evidence, which has been given a central place in health care. Martinsen draws attention to the fact that with evidence based medicine certain problems may be addressed, while others not. The dominance of evidence based medicine (EBM) may conceal issues that are also important in hospital care. She refers to philosophical questions and experiences which are of an existential nature. The Norwegian professor argues for complementary methods in health care research by which life-philosophical questions may be elucidated in other ways than those of the EBM approach. Drawing on the work of Paul Reicouer she states that the story may be such a method wherein a different kind of evidence matters. Both, life-philosophical ways of working and doing research, and EBM are needed. However, in contemporary hospital care, the former is often neglected in favour of scientific and technological research that offers concrete solutions to concrete problems. When it comes to elderly hospital patients the dominant discourse is that of frailty. Frailty refers to the physiological body, and involves as such an abstraction from immediate experiencing. Good care for the elderly, however, requires not only measuring objective parameters but also having insight into the reality faced by patients. Both are needed to enable the elderly to dwell in the hospital.
Care and vulnerability is an inspiring book and reflects a care ethical perspective. I believe some of Martinsen’s thoughts are notably enlightening for our work, such as her distinction between the perceiving and the recording eye. I, therefore, highly recommend this book.
Hanneke van der Meide, PhD student Tilburg University. Project ‘Vulnerable elderly in the hospital. A study into patient participation from a care ethical perspective’.