Authors: Filip Maric & David Nicholls | Submitted: 14 May 2019
This article is currently under peer review.
Abstract
The fundamental role of ontology, epistemology, and ethics is widely recognised across the healthcare professions. Yet what is less known in physiotherapy is how ontology and epistemology potentially undermine the ethical intentions of our theories and practices. In this article, we draw on the work of 20th-century philosopher Emmanuel Levinas to highlight this problematic. Particularly Levinas’s ethical critique of ontology and the associated notion of thematisation enable us to highlight a violence that takes place in the philosophical foundations of physiotherapy. Using the overarching aims of physiotherapy, the theory and practice of diagnosis, and the notion and enforcing of professional identities as examples, we additionally show how this violence consequently pervades physiotherapy theory and practice. By exploring a range of critical and practical implications, we finally show how an application of Levinas’s critique of ontology additionally opens toward an otherwise physiotherapy grounded in a renewed understanding of self, other, and their relation. With this, we hope to highlight the core value and critical need for a deeper engagement with the work of Levinas in relation to all aspects of physiotherapy, and particularly its understanding and implementation of ethics that is so fundamental to its practice and a cornerstone of physiotherapy education.
Keywords: ethics, self, other, ontology, epistemology, positivism
Background
Described as one of the great Continental philosophers of the twentieth century, Emmanuel Levinas’s work has had a lasting influence well beyond the confines of philosophy. Levinas’s critique of ontology and his radical renewal of ethics has greatly inspired research in areas as diverse as social and political theory, theology, arts and design, legal theory, international relations, and pedagogy (Critchley, 2002). Increasing interest in Levinas’s ethics in healthcare theory and practice has also seen his writings explored in psychotherapy, medicine and nursing (Burcher, 2011; Clifton-Soderstrom, 2003; Naef, 2006; Nortvedt 2003, 2008; Surbone, 2005). Beyond a few very brief forays, however, Levinas’s work still remains largely underexplored in physiotherapy, which is perhaps surprising given the radical and fundamentally transformative potential that his critique of ontology and his otherwise ethics would have for physiotherapy theory and practice. This paper, therefore, sets out to introduce the reader to some of Levinas’s key ideas, most especially the concept of thematisation and the associated critique of ontology. From here we attempt to open a conversation about their critical and practical implications for physiotherapy.
The central importance of ethics and ethical relations in healthcare is widely recognised across the healthcare professions, including physiotherapy. An increasing body of research has sought to refine our understanding and responses to increasingly complex ethical challenges in clinical practice, research, and education (Dahl-Michelsen & Groven, 2017; Kulju, Suhonen, & Leino-Kilpi, 2013; Lillemoen & Pedersen, 2012; Murray & Holmes, 2009; Swisher, 2002). Consequently, professional guidelines are identifying ethics as ‘fundamental to the practice of physiotherapy’ and professional bodies around the world are looking to provide professionals with the knowledge and tools necessary to meet the ethical challenges they might face now and into the future (PBNZ, 2011, p. 4).
Similarly, ontology (the study of existence and being), and epistemology (the study of knowledge and its acquisition), are generally considered the foundations of all thought and scientific endeavour, with the ontological and epistemological foundations of positivism and biomedicine standing out in the world of healthcare, having dominated healthcare research and practice for the past centuries (Nicholls, 2018; Gibson & Martin, 2003; Grant & Giddings, 2002). As such, they have provided the philosophical foundations for modern-day evidence-based healthcare and physiotherapy, though recent years have seen a steady rise in the exploration of other philosophical paradigms and the divergent practices they can provide a foundation for (Gibson, Nicholls, Setchell, & Groven, 2018). What is less known in physiotherapy, however, is how ontology, epistemology and ethics relate to each other, and how fundamental they are for physiotherapy practices. Levinas’s work provides invaluable insights here then, allowing us to understand the relationship and application of ontology, epistemology and ethics better, and explore ways to apply these to the further development of physiotherapy theory and practice.
We begin this article with a brief overview of Levinas’s personal life and philosophical trajectory, and an exposition of his understanding and ethical critique of ontology and the associated notion of thematisation. This critique is then applied to the historical philosophical foundations of physiotherapy as the first and most fundamental locale in which the violence of thematisation takes place within physiotherapy, before showing how it plays out in three different areas of professional theory and practice: the overarching aims of physiotherapy, the theory and practice of diagnosis; and the notion and enforcing of professional identities. We conclude the article with a range of implications for physiotherapists looking to apply Levinas’s critique of ontology to theory, research, and practice. In line with these implications, this paper calls on physiotherapists and physiotherapy educators to carefully consider the unintended, yet inherent violence in approaching and relating to the other from a position of knowledge; and to consider whether their current theories and practices, and the ethics these are based on are perpetuating a ‘knowing’ of the other that is, in itself, unethical. The paper also calls on physiotherapy educators in two distinct, though philosophically overlapping ways: firstly, by urging them to consider the philosophical foundations and related ethics that they are passing on to future physiotherapists, and via these, also future healthcare beneficiaries; and secondly, to reconsider their education theories and practices from this perspective with their student’s as their primary ‘others’ in mind.
Our basic theses are that (a) there is a significant, though inadvertent violence inherent in the historical, philosophical foundations of physiotherapy that is easily overlooked yet continuously enacted in its day-to-day theories and clinical practices; (b) that an application of Levinas’s critique of ontology and thematisation to physiotherapy theory and practice opens toward an otherwise physiotherapy that more accurately ‘captures the ethical core and central values of healthcare’ (Nortvedt, 2003, p. 25). Our hope is that this work highlights the critical need for a deeper engagement with the work of Emmanuel Levinas, particularly in relation to physiotherapy and its understanding and implementation of ethics that is so fundamental to its practice.
Emmanuel Levinas – a brief introduction
Born in 1906 in the Jewish community of Russian-occupied Kovno (now Kaunas, Lithuania), Levinas’s upbringing was steeped in both Jewish thought and the classical Russian literature. Reflecting on this time in several interviews, Levinas speaks of Judaism as that which ‘one breathed … in with the air’ on the one hand (Levinas & Anissimov, 2001, p. 84), and with reference to Russian literature, as that which led him to the philosophy of the other, ‘specifically Pushkin, Lermontov, and … above all Dostoyevsky’ (Levinas & Poirié, 2001, p. 28). Levinas found the novels of Dostoyevsky and Tolstoy ‘preoccupied with fundamental things … readable as a search for the meaning of life’ (Levinas & Poirié, 2001, p. 28).
Choosing ‘France on account of the prestige of the French’ and in France, ‘the city closest to Lithuania’ Levinas went on to study philosophy in Strasbourg in 1923 (Levinas & Poirié, 2001, p. 28). There, he read classical philosophical works from Plato and other Greek philosophers through to Descartes, but also modern philosophy with Henri Bergson as its most prominent luminary at the time. An academic year spent in Freiburg, Germany, during which he met and studied under the famous phenomenologists Edmund Husserl and Martin Heidegger, was, however, particularly significant to the development of his future method and thought.
Highly impressed by both of these thinkers, Levinas engaged deeply with both of their works, as is evident very early on in the publication of his doctorate thesis on The Theory of Intuition in Husserl’s Phenomenology in 1930 (Levinas, 1995). Though he played a major role in introducing Husserlian phenomenology to French philosophers like Sartre and others as a result of this publication, Levinas would later recount that the main import of Husserl to his own work was in providing ‘a method for philosophy’ that enabled one to ‘listen acutely for what is implicit’, to pay ‘special attention to what is allusive in thinking’ (Levinas & Malka, 2001, p. 94-95). Levinas argued that building on Husserl’s method of phenomenological reduction, and the general sentiment that phenomenology enabled one to get behind the appearance and to the very essence of phenomena, eventually enabled him to explore the limits of being and knowledge, and in this limit, ‘a forgotten experience from which it lives’ (Levinas, 1969, p. 28).
His relation to Heidegger would prove more difficult, though even more influential on Levinas’s thinking, as ‘Heidegger became Levinas’s most important philosophical rival, providing the philosophical resources, constraints, and pressure that eventually’ led to his famous exposition of ‘ethics as first philosophy’ (Fagenblat, 2018, p.3). To fully appreciate how Heidegger’s work became so crucial to the shaping of Levinas’s philosophy, it is necessary to consider Levinas’s experience of the Second World War. Levinas was profoundly shaken by Heidegger’s affiliation to National Socialism, his membership of the Nazi Party, and Heidegger’s public political commitment to its project expressed in his inaugural address following his election as the Rector of the University of Freiburg (Critchley, 2002, p.8). Levinas simply could not understand ‘how a philosopher as undeniably brilliant as Heidegger could have become a Nazi, for however short a time’ (Critchley, 2002, p.8).
Notwithstanding his antipathy towards Heidegger’s position, the rise of Nazism during WWII was the more profoundly affecting experience. As Levinas himself would repeatedly state, his life and work were ‘dominated by the presentiment and the memory of the Nazi horror’ (Levinas, 1990, p. 291). Being incarcerated as a prisoner of war very early on, he found himself in a peculiar and somewhat paradoxical situation during this time. Recognised and segregated as a Jew, yet spared by his French uniform and the immunity it provided as a result of the Geneva convention, Levinas spent the war working, and even reading and writing philosophy in a prison camp virtually cut off from the outside world. It was only after being freed that Levinas learned of the full extent of the Nazi atrocities: ‘the horrors of the camps’; the killing of his entire family; and the murder of 6,000,000 fellow Jews and countless others (Levinas & Poirié, 2001, p. 42).
Much like for so many other philosophers and non-philosophers alike, the bigger question that posed itself after WWII then was ultimately how Nazism, and all of the atrocities that were enacted in its wake, were even ever possible. Levinas wrote in Totality and Infinity – his first major work, that, ‘Everyone will readily agree that it is of the highest importance to know whether we are not duped by morality’ (Levinas, 1969, p. 21). In other words, Levinas’s broader, central question became whether it was still possible and sensible to speak of ethics after its failure in WWII, ‘whether we can still believe in morality after Auschwitz’, and if so, how might this be possible (Bernstein, 2002, p. 254)?
It is in relation to this question that the full significance of Heidegger’s thought on Levinas’s work became clear, as it was Heidegger’s thought that ‘provided a way of understanding the deep philosophical roots of the weed that was Hitlerism’ (Fagenblat, 2018, p. 12). And although Levinas never entirely conflated Heideggerian philosophy with Hitlerism (Fagenblat, 2018), he still found in it philosophical access to ‘a crisis that is much more profound, and older’ (Levinas, 1989, p. 207). It is this crisis that Levinas ultimately turned his attention to his ‘critical questioning of Heidegger’s project of fundamental ontology’, asking whether there could be an otherwise fundamental philosophy that could provide the grounds for a different, ethical way of being (Critchley, 2002, p. 9). Due to the breadth of Levinas’s philosophical work and the diverse implications that can be drawn from his works we have restricted this article to Levinas’s critique of the philosophical foundations of a vast majority of Western philosophy which, in primary reference to Heidegger, he referred to as ontology. Further overviews of Levinas’s philosophical oeuvre can be found his own writings, as well as many other publications covering various aspects of his life (Bergo, 2007; Critchley & Bernasconi, 2002; Levinas, 1990; Levinas & Nemo, 1985; Malka, 2006; von Wolzogen, 2005). Of particular relevance here, however, is the development of Levinas’s critique of the violence of ontology.
Thematisation – the violence of ontology
Despite his affiliation with National Socialism, Martin Heidegger is widely recognised as one of the greats in the history of Western philosophy, whose work continues to exert wide influence in and outside of philosophy. His magnum opus – Being and Time – remains his most influential study, not least with Levinas, who held it in the highest regard, but also used it as the basis of his ongoing critique of phenomenology (Heidegger, 2008).
Following his primary interest in ontology, or the study of being, Heidegger wrote Being and Time as an attempt to uncover the fundamental nature of ‘being (Sein) by means of phenomenological analysis of human existence (Dasein)’ (Korab-Karpowicz, 2019). To Heidegger, this fundamental ground of existence is being itself. This is both in the sense of ‘being-there’ (Dasein), and in that being is always already ‘in’ the world. Critically, the primary way that the being is in-the-world begins is through consciousness, and, specifically, a consciousness of its self.
Levinas argued that consciousness is first and foremost ‘the presence of self to self’; the self coming into being through knowledge of itself (Levinas, 1987, p. 59). Levinas further stated that ‘existence and its disclosure are equivalent to the very production of being, since truth or disclosure is at the same time the work or the essential virtue of being’ (Levinas, 1969, p. 294). He thus concluded that ‘Being and Time essentially advanced the thesis that ‘Being is inseparable from the comprehension of Being’ (Levinas, 1987, p. 52) and it is thus that, ‘despite the novelty of his work, Heidegger rejoins and sums up the great Platonic tradition of Western philosophy’ that he attempts to leave (Critchley, 2002, p. 11).
To say that being is fundamental and that it coincides with consciousness is significant because it clarifies the terms that enable us to speak of Heidegger’s philosophy as a ‘fundamental ontology’ (Critchley, 2002, p. 9). At the same time, it allows us to recognise the inseparable connection between ontology and epistemology, being and knowledge. In recognising the connection between knowledge and being, Heidegger shows that knowing is the fundamental way in which being relates to the world. This critical point forms the centrepiece of Levinas’s critique of both Western philosophy and Heidegger’s ontology (Levinas, 1996, p. 1-10). Levinas argued that it is not only the primacy that Heidegger and others have given to being and its relationship to knowledge of the world that is problematic philosophically, but that both being and knowledge are also unethical and even violent.
Heideggerian philosophy proposes that the self and its self-consciousness precede knowledge of the other[1]: the other is always secondary to being and the self, and although Heidegger argued that the knowing ego ‘leave[s] a world that is intimate and familiar … and goes toward the stranger’, the other is only ever approached as a knowable entity, or object (Levinas, 1987, p. 47). As Critchley (2002) argues, ‘[P]articular beings are always already understood upon the horizon of Being’ (p. 11). Levinas argued that coming to know the other in this way carries an inherent violence because the self limits all otherness to the categories and capacities of the knowing ego. The other is never truly allowed to be other than the self, but is rather identified – made same-to-itself – according to the categories and capacities of the knowing ego; reduced and homogenised into the same through its knowing-movement (Filipovic, 2011, p. 61). In attempting to know the other, ‘the known is understood and so appropriated by knowledge, and as it were freed of its otherness’ (Levinas, 1989, p. 76), because ‘knowing amounts to grasping being out of nothing or reducing it to nothing, removing from it its alterity’ (Levinas, 1969, p. 44).
‘In ontology, the other is assimilated to the same like so much food and drink … ontology is the movement of comprehension, which takes possession of things through the activity of labor, where conceptual labor resembles manual labor. Ontology is like the movement of the hand, the organ for grasping and seizing, which takes hold of (prend) and comprehends (comprend) things in a manipulation of otherness … Levinas outlines and criticizes this digestive philosophy, where the knowing ego is what he calls ‘the melting pot’ of Being, transmuting all otherness into itself’ (Critchley, 2002, p. 16).
Levinas eventually refers to this movement as thematisation or totalisation, in reference to the way in which the other is approached and objectified as a ‘theme’, and assimilated into the encompassing totality of the self (Levinas, 1969, p. 59, 121; Zeillinger, 2009, p. 102). Whichever terms are used though, the full strength of Levinas’s ethical critique of ontology lies in the exposure of ontology as ‘a philosophy of power’, and critically, with its movement of thematisation, as a power so destructive it effectively undoes all otherness (Levinas, 1969, p. 46). Levinas uses powerful language to express the violence of thematisation, arguing that there is no underlying, philosophical difference between the conceptual and the corporeal annihilation of the other. Levinas argued that Western philosophy, embodied by the writings of Heidegger, ‘consists in neutralizing the existent in order to comprehend or grasp it. It is hence not a relation with the other as such but the reduction of the other to the same’; Thematisation involves a ‘suppression or possession of the other … “I think” comes down to “I can” — to an appropriation of what is, to an exploitation of reality. Ontology as first philosophy is a philosophy of power’ (Levinas, 1969, p. 45-46).
The case Levinas makes, then, is of grave importance to those who practice in the health arena, because his critique strikes at the heart of what it means to be a healthcare professional; what it means to understand the world the way we do; the way we engage with our clients and patients, communities and colleagues; the way we assess, diagnose and treat people; even the way we think about our purpose as a profession. Levinas challenges the entire philosophical basis upon which our Western healthcare system is based, arguing that it is both fundamentally unethical and violent.
The fundamental violence of physiotherapy
That Levinas’s critique of ontology challenges the basis of Western healthcare and exposes an easily unnoticed, but inherent violence in it is particularly evident in the philosophical foundations upon which contemporary physiotherapy practice is built. As a result of this grounding, however, this violence inevitably also pervades the profession’s most fundamental theoretical concepts and it’s clinical and professional practices. In this section, we therefore first turn our attention to the philosophical foundations of physiotherapy, as they are the primary locale in which this violence takes places, before showing how it plays out in three different areas of clinical and professional theory and practice: the overarching aims of physiotherapy, the theory and practice of diagnosis; and the notion and enforcing of professional identities.
The philosophical foundations of physiotherapy
The historical philosophical foundations of physiotherapy present the first and most fundamental field that Levinas’s critique of the violence and unethical basis of ontology and thematisation applies to within physiotherapy. As with nursing, midwifery, occupational therapy, and other orthodox health professions, the philosophical foundations of physiotherapy have had a longstanding affinity with biomedicine. This is, in part, because the medical profession established itself as the pre-eminent healthcare profession in the developed world after the middle of the nineteenth century. Biomedicine brought forward significant advances in the scientific method, and aggressively promoted positivism and Enlightenment principles of the primacy of the autonomous, self-determining and sovereign human (Nicholls, 2018).
Physiotherapy followed biomedicine in adopting the idea of a single objective reality (Nicholls, 2009). This belief upheld a number of critical assumptions underpinning the scientific basis of physiotherapy theory and practice, including the belief that reality, phenomena, or objects exist separate and independent of subjective experience, or subjectivity. This view held that every object has a distinct nature, or essence of its own; which, thanks to its separate nature and existence, can be distinguished, observed, and identified through the rigorous application of scientific methods. Critically, other entities – including people, bodies, actions, intentions, values and beliefs – can be known by a knowledge-gaining and knowledge-bearing subject (Crotty, 1998; Grant & Giddings, 2002).
The belief in a single objective reality and the related fundamental assumptions of positivism have been extensively critiqued elsewhere (Giddings & Grant, 2007; Proietti et al., 2019). Although never before applied directly to physiotherapy, our contention is that Levinas challenges the positivistic basis of physiotherapy and both its ontological relation to reality in which the object-other is identified and approached as a knowable, or thematisable entity; and its belief that the practitioner is the knowing, doing ego; the expert that identifies, gains and defines knowledge about the other (Grant & Giddings, 2002, p. 14-15).
In recent years, other critiques of the positivism inherent in evidence-based biomedicine (and, by extension, physiotherapy) have emerged, not least from those advocating for person-centred care, holistic medicine, qualitative research, narrative-based medicine and the humanities (Clifton- Soderstrom, 2003; Gibson & Martin, 2003; Greenhalgh, Howick, & Maskrey, 2014; Holmes et al., 2006; Miles, Loughlin, & Polychronis, 2008; Shaw, 2012). Levinas’s work, however, goes much further than these in arguing that positivism leaves no room for difference: that Western philosophy upon which biomedicine is based, limits the (underlying) otherness of the other through an ‘imposition of scientific language on illness experiences which universalises persons into general categories before understanding’, or rather, without fully acknowledging ‘their specificity’ and unknowable otherness (Clifton- Soderstrom, 2003, p. 459).
Levinas’s critique directly targets positivism’s desire to manipulate reality, its desire to ‘explain, predict or control events’ (Critchley, 2002, p. 16). This, of course, relates directly to physiotherapy, with its interest in injury, rehabilitation, evidence-based decision-making, assessment and differential diagnosis, therapy and cure (Grant & Giddings, 2002, p. 14). Given that positivism is fundamental to physiotherapy, and that it lies at the ‘philosophical heart of all clinical trials, experimental and quasi-experimental designs, epidemiological surveys, single-incidence studies, tests of validity and reliability, and a plethora of other quantitative designs’, it follows that that continue to dominate and shape evidence-based physiotherapy (Nicholls, 2009, p. 528). At their core, all of the more specific epistemological tools employed by positivism and the scientific method – quantification, measurement, and experimentation, verification, etc. – exhibit adherence to the very same, fundamental ontological and epistemological foundation as does the arguably objective knowledge, truth, or evidence that is garnered through the application of these tools (Grant & Giddings, 2002, p. 13-14). In Levinassian language, the philosophical and scientific foundation of physiotherapy is ontological (Nicholls, 2009, p. 528). It should also be clear that this foundation is not merely theoretical. The epistemological tools of the scientific method employed in mainstream physiotherapy not only orientate subsequent practices but are themselves already epistemological practices that enact the same relation between the subject-self and object-other as the movement of ontology in which they are grounded. Positivist ontology and epistemology are always already practices in themselves – a specific kind of doing and relating that enacts a fundamental violence to the other who is purportedly in their care.
The aims of physiotherapy
Going beyond the purely epistemological, a growing number of researchers have already shown that the ontological underpinnings of positivism and the scientific method have shaped some of physiotherapy’s central theoretical concepts and professional practices. Most especially, positivism has been shown to underpin physiotherapy’s notions of the body, movement, function, normality, and therapeutic touch (Allen, 2007; Bähr, Nicholls & Holmes, 2012; Cott, Finch, & Gasner, 1995; Gibson, 2014; Gibson & Teachman, 2012; Jorgensen, 2000; Rosberg, 2000; Wikström- Grotell & Eriksson, 2012). Looking at physiotherapy through a Levinassian lens may allow us, therefore, to interrogate how the profession’s practices might be unethical, by dint of their pervasive positivism. It may help us see how this fundamental violence is implicit in everyday clinical and professional physiotherapy theory and practice, as for example in the case of the overarching aims of physiotherapy.
According to the World Confederation for Physical Therapy (WCPT), one of the foremost aims of physiotherapy is ‘to provide services that develop, maintain and restore people’s maximum movement and functional ability’ (WCPT, 2016). This aim is, in turn, heavily influenced by the World Health Organisation (WHO) definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’(WHO, 1948), and the WHO’s International Classification of Functioning, Disability & Health (ICF). The ICF, for its part, provides a tool for the comparison and measurement of ‘levels of health’, using ‘optimal health’ as its benchmark. Here, optimal health is posited as a ‘common metric … applicable to all people irrespective of health condition’ (WHO, 2002, p. 3). Clearly, identifying optimal health as ‘a state’ that can be ‘measured’ and universally applied to ‘all people’ resonates strongly with positivist ontological assumptions and resulting epistemological practices of assessment, calculation, measurement, surveying, quantifying, scaling and evaluating (WHO, 2002, p. 3).
More specifically, physiotherapy’s aim to provide ‘services that develop, maintain and restore people’s maximum movement and functional ability’ becomes additionally interesting if we reframe Levinas’s notion of otherness etymologically and therewith, interestingly, also in terms more familiar to physiotherapy (WCPT, 2016, emphasis added). Etymologically speaking, we could say that to reduce the other’s otherness, or, alterity, means to reduce the other’s ability to alter, to change and exceed the limits imposed by our knowledge and understanding. Precisely to be able to (be) alter, or change, however, also means to be mobile, or moveable, and finally, to able to move (Harper, 2019). With this in mind, the professions therapeutic aim seems curiously overlapping with the Levinassian admonition against any limitation of the other, any restriction of alterity. But even if this is the case, the overlap is lost entirely as soon as ‘maximum movement’ is identified, defined, and thus limited in terms of (objective) knowledge, especially if we additionally consider that physiotherapy theory and practice generally defines movement in rather limited terms of e.g. physical ranges of movement of specific joints. That this presents an intrinsic discord of the utmost importance to physiotherapy becomes particularly evident when looking at the theory and practice of diagnosis.
The theory and practice of diagnosis
The theory and practice of diagnosis provides a very clear example of the way that thematisation is enacted in physiotherapy practice if we consider that this ‘first act of violence occurs whenever I limit the other to a set of rational categories, be they racial, sexual, or otherwise’ (Beavers, 1999, p. 3). In the context of clinical practice, this means that thematisation happens in the process and application of diagnostic procedures, as they are applied to a client with presenting health problems. Standard approaches to practice mandate that clients are approached, observed, interviewed, and examined from the perspective of our professional knowledge, and diagnostic categories of mainstream healthcare are applied. Though putatively individual factors, such as client goals, are also considered, they largely only serve to support the process of establishing the client’s diagnosis according to specialised, epistemological, diagnostic labels such, as a lumbar sprain, rotator cuff tendinopathy, and plantar fasciitis.
The issue with these diagnostic labels from a Levinassian perspective is that they reduce and limit the other to the categories and capacities of the knowing and doing professional self. The act of diagnosis incapacitates and immobilises the other by restricting or even undoing the other’s ‘otherness’. This notion also resonates with the work of other preeminent philosophers, as for example, the work of Søren Kierkegaard who argued that ‘when you label me, you negate me’ (Kierkegaard in McManus, 2019). The label constrains the potential to be ‘other’ than the label to which they have been codified and categorises them so that they fit in with similarly labelled others. Thus, the act of diagnosis itself may be seen, paradoxically, as diametrically opposed to ‘the ethical foundation of medicine’ as much as the supposed aim of physiotherapy to maximise movement (Clifton-Soderstrom, 2003).
It should be noted that this is clearly not to say that this is an intended violence towards the other. But looking at diagnosis from a Levinassian perspective enables us to highlight that this violence nonetheless takes place and underlies our most basic professional assumptions, even if it easily goes unnoticed. And because this strikes at the heart of what it means to practice contemporary physiotherapy, we believe that to draw attention to it is of utmost importance for a profession whose stated aim is to ‘develop, maintain and restore people’s maximum movement and functional ability’ (WCPT, 2016). From a Levinassian perspective, physiotherapy may indeed be incapacitating and immobilising the other, rather than developing, maintaining, and restoring mobility.
Professional identity
As well as affecting our patients, thematisation also affects physiotherapy professionals and the construction of their professional identity. The notion that certain ‘personal and professional behaviours’ are another integral part of the professional’s identity coincides with the belief that the professional shares a set of values, practices and codes with her peers (WCPT, 2011a, p. 2). This ‘sameness’ is grounded in objectively identifiable, ontological knowledge and, in Levinassian terms, represents a similar thematisation to that which physiotherapists apply to their patients. The development of this sameness is a critical element built into a physiotherapist’s ongoing professional education. It is first defined in undergraduate education, as physiotherapy students ‘attain the knowledge, skills, and attributes described in the guidelines for physical therapist professional entry level education’ (WCPT, 2011b, p. 1). Continuing professional development further promotes the idea that the knowledge, skills, and attributes need to be practiced on an ongoing basis to be maintained, developed and enhanced. And regulatory authorities are deployed to ensure that practitioner’s personal ethics do not transgress their professional identities.
It could be said that undergraduate education represents a time of self-development, but that this development is directed towards a pre-determined professional identity. Whether as a replacement for, or as an addition to, the development of self-being, it is desirable that a homogenous professional identity is clearly distinguishable from the heterogeneous personal selves for the thousands of people that become therapists. So while the WCPT’s definition of CPD implies that personal skills, knowledge, and behaviours are supplementary to professional ones, this supplementation ultimately affirms their distinction and the gradual exclusion of the personal from the professional (WCPT, 2011a).
This supplementary and subordinate relationship is evident in the kinds of reflective practice and supervision now being advocated for by professional bodies internationally. Supervision is aimed at ‘helping the development of a professional identity’ (PNZ, 2012, p. 1), while professional self-reflection is also directed at ‘improving or affirming their professional practice’ (PBNZ, 2011, p. 22). Supervision and self-reflection, therefore, consistently privilege the professional self over the personal self, even though, on the surface, they appear to be about the practitioner’s sense of self. As practices of identification, they are ultimately aimed at aligning physiotherapists with this professional group-identity, and in doing so they subordinate, assimilate, exclude, reduce, and even undo the unique and idiosyncratic otherness of the practitioner. Even though there are undeniably some variations amongst professionals, what remains as the broad, underpinning professional identity presents a restricted category that enacts that same violence that Levinas’s critique of ontology was directed at, and, through this lens, we find the irreconcilable tension at the heart of the profession’s aim to ‘develop, maintain and restore people’s maximum movement’ (WCPT, 2016).
Toward an otherwise physiotherapy
Even this brief review of the broad, overarching aims of physiotherapy, the theory and practice of diagnosis, and the way in which professional identity is developed highlights the extent to which contemporary physiotherapy remains grounded in a (positivist) ontology and epistemology. Building on Levinas’s critique of ontology, it underscores the extent to which physiotherapy may reproduce the fundamental violence of thematisation, and through this immobilise otherness, rather than liberating it. Though inadvertent, this violence is done to the supposed ‘beneficiaries’ of healthcare, and healthcare practitioners alike. Applying Levinas’s critique of ontology to physiotherapy thus implies a radical critique of the profession; in the original sense that thematisation lies at the ‘roots’ of physiotherapy.
One of the issues that this radical critique of physiotherapy raises is that it appears to leave the profession with little practices, if any, that are not fundamentally violent. If the knowledge with which physiotherapists identify themselves, and the practices that we develop, achieve colonisation and containment of the other, rather than mobilisation, what justification is there for physiotherapy practice? What implications, then, does Levinas’s critique of ontology and its violence of thematisation have for physiotherapy theory and practice?
In line with the growing body of work applying critical theory to physiotherapy research and practice, we believe that the principal benefit of the critical study of physiotherapy lies in exposing otherwise unnoticed and unreflected problems that pervade its theories and practices (Setchell, Nicholls, Wilson & Gibson, 2018). In the present case, this is the exposure of an inadvertent, primary act of violence, inherent, but as yet unseen, at the heart of contemporary physiotherapy practice. By highlighting that our professional theories and practices run counter to our therapeutic aspirations to ‘develop, maintain and restore people’s maximum movement and functional ability’, we hope to open the door to other ways to imagine physiotherapy that are coherent with this aim (WCPT, 2016).
Beyond its general value as a critical theory, the overarching implication of Levinas’s critique of ontology and thematisation lies in its call to interrupt our conventional ways of thinking and doing physiotherapy, in full recognition of the underlying harm they cause. This is clearly a profoundly disruptive call, given the fact that virtually all of our professional self-understanding and sense of agency has been built on thematising knowledge and practice. But even in this general sense, refraining from the fundamental violence enacted through our conscious knowing and doing constitutes an otherwise therapeutic practice in itself. Not that this is particularly heroic, given that it is, in our case, an iatrogenic violence. But, figuratively speaking, letting go of our knowing and doing frees the other from the constraining grip of the self-same, and thus re-liberates the other to her fundamental, unknowable otherness.
Applying this to the more specific examples we have explored here, draws out how Levinas’s radical critique of ontology provides a gateway to the development of truly otherwise philosophical foundations for our profession. In relation to the aims of physiotherapy, for example, Levinas’s critique of ontology provides further support to the movement towards a more person-centred approach to physiotherapy (Kidd, Bond, & Bell, 2011, p. 155). Here, ‘patient’s needs and perspectives’ are incorporated into physiotherapy in a way that is ‘complementary to the traditional diagnostic and procedural hypothetico-deductive reasoning’ (Cruz, Caeiro and Pereira, 2013, p. 6). This is achieved by ‘listening attentively to the actual words that are spoken’ as part of the pathway ‘leading to diagnosis and treatment’ (Burcher, 2011, p. 13). But note that Levinas also provides us with tools to see when healthcare innovations appear to release patients from the traditional bondage of thematisation, whilst all the time thematising them anew. Listening attentively, may well be an important effect of Levinas’s critique of interventional practice, but not if it is merely a proxy for a new and different thematisation (Armstrong, 1999). If we are to truly relate to ‘patients in a manner that respects their alterity and otherness’ (Clifton-Soderstrom, 2013, p. 458), practice will need to stay ‘open to the full speech and discourse of the other’ as suggested by Adam (2016) in a resonant discussion of Lacanian psychoanalysis (p. 118).
More than merely listening more, however, Levinas’s critique of ontology urges us to hesitate far more rigorously (Ronell & Dufourmantelle, 2011). Somewhat paradoxically, this rigour consists in making this hesitation: refraining from the fundamental violence of ontology enacted in our knowing and doing, and making this a continuous practice. Hesitation here, then, is the ongoing effort implied in the idea of ‘staying open to the full speech and discourse of the other’ (Translated from Adam, 2006, p. 119, emphasis added). Applied to the practice of diagnosis, this would consist of continuously refraining ‘from representing and offering a closed knowledge’ to the client and then implementing it as the basis of practice (Translated from Adam, 2006, p. 119). The focus of practice would thus not be on identifying a definite, specific pathology and treating only this according to a set of professionally coherent standards, but would shift towards an acknowledgment, rehabilitation, or mobilisation of the unencompassable otherness of the other. It would not just be about providing a ‘provisional diagnosis’, but in possibly not applying a diagnostic label at all, not closing a category (ACC, 2019).
By urging us to let go of our prior professional identity, Levinas’s critique of ontology also supports current developments in reviewing and promoting diversity in physiotherapy (Andrion, 2017; Ross & Setchell, 2019). It specifically does so by adding sensitivity and strength to the call for a physiotherapy theory and practice that is based on a full acknowledgment, respect, and preservation of the fundamental alterity and otherness of the other person, whether this be another physiotherapy practitioner or client (Clifton-Soderstrom, 2013, p. 458; Critchley, 2002, p. 26).
Even more far-reaching, however, letting go of our professional identity is the necessary first step that opens towards a fundamental redefinition of the self, other, and their relation. Refraining from professional identification necessitates a reassessment of what we think of as the professional self; of how we define what a physiotherapist is; and consequently, what physiotherapy is. This is also where the full strength and benefit of Levinas’s work for physiotherapy actually lies, not only in providing an astute critique of the self, other, and their relation, but also in providing an alternate vision of these that is not grounded in being, knowledge and doing. Such a redefinition of self, other, and their relation is ultimately what a truly ‘otherwise’ fundamental philosophy for physiotherapy hinges upon.
Conclusion
Drawing on Levinas’s critique of ontology highlights how pervasive the fundamental violence of thematisation in physiotherapy theory and practice, from its positivist, biomedical philosophical and scientific foundations, through our professional self-understanding and agency, and even our most common day-to-day practices. This radical questioning of the professional has concrete implications for physiotherapy theory, practice, and education. It supports contemporary advances in person-centred healthcare by highlighting the need to acknowledge and preserve their individual specificity in theory and practice at all times. But even more so, it calls for a fundamental renewal of our understanding of our professional self, the others in our care, and our relation to them that is not based on ontology, epistemology, and the concomitant violence of thematisation. This is also of critical import to physiotherapy education insofar as it is there that professional agency and a first sense and understanding of a professional self are initially developed and can therefore be transformed in the most lasting manner. Building on his critique of ontology, the central focus of Levinas’s work was on describing a different, ethical relation between self and other. It is consequently of twofold interest to physiotherapy theory and practice, both in the critical sense laid out in the present article, as well as in its potential for the development of a robust philosophical foundation for an otherwise physiotherapy in the future.
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[1] Though the exact definition of the ‘same’ and ‘other’ are extensively debated and highly complex in both Levinas’s and Heidegger’s work, it should be sufficient here to understand the Same as the ego, or the thinking, doing self of consciousness, whereas the Other refers to anything that is not the self, be it another person, an animal, a system, an idea or a thing (Critchley, 2002, p. 15-17).