Review (Rajala) – The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice

The article addresses physiotherapy’s ontological and epistemological underpinnings through Levinas’ critique of ontology, opening a dialogue for further Levinasian perspectives in physiotherapy and challenging some of the deep-seated assumptions of physiotherapy theory and practice. The greatest merit of the article is introducing Levinas’ thought into physiotherapy. While it is important to introduce thinkers who have not received much attention in physiotherapy before, it is not always a sufficient reason to do so without supporting argumentation. However, the article manages to demonstrate that Levinas has much to offer to philosophical and ethical writing in physiotherapy, which adds to physiotherapy knowledge and philosophical scholarship. There are a few things I would like to point out that would make the text more accessible, on the one hand, and philosophically more rigorous on the other. While I think the article is overall sound and well-thought, I would like push the authors further in their own practice of philosophy, which should be a fairly easy to accomplish. In what follows, I shall go through the article section by section.

Background

The authors offer a brief background on Levinas’ thinking in healthcare, which is helpful in contextualising this article in the wider healthcare scholarship. They also mention that “Beyond a few very brief forays … Levinas’s work still remains largely underexplored in physiotherapy …” It would be useful to offer refences to these works, however briefly they mention Levinas, in order to offer readers a glimpse into what might have been said and how Levinas has informed writing about physiotherapy. Offering references would highlight the importance of this article as perhaps the first lengthier exploration of Levinas’ thinking in physiotherapy context.

However, I would argue that the fact that Levinas has not been studied in physiotherapy is not surprising given how little physiotherapy research has utilised philosophy in its brief history in general. Therefore, rather than saying it is surprising that Levinas has not received much attention, I would express the importance of this work more explicitly here. Despite my disagreement, I do think the authors are on the right track when they express what the implications of Levinas’ thinking would be to physiotherapy. To say that it is surprising, however, is perhaps not the best way to express the importance of this article and might inadvertently give readers the impression that the philosophical body of literature on physiotherapy is larger than it really is. Philosophical physiotherapy research has barely moved beyond introducing philosophers and critical theorists to physiotherapy, and applying philosophical ideas to empirical research, but hopefully it is moving towards greater critical dialogue between critical perspectives. I wish to further point out that physiotherapy ethics in particular lags behind nursing and medicine in philosophical scholarship – both have a longer history of philosophical writing – and so far it has concentrated more on empirical perspectives and clinical practice, rather than theoretical and philosophical perspectives. In this context, then, it is hardly surprising that Levinas’s work (not to mention other notable Continental moral philosophers) is underexplored in physiotherapy, despite the potential contribution his thinking might have for the critical development of physiotherapy theory and practice.

In defining ontology, I would add that it is the study of the nature of existence and being, or the nature of reality. The reason why I would say this is that the authors go on to say that positivist ontology has dominated healthcare, which is correct, but positivist ontology has little to do with “being”: the characterisation of ontology as the study of being and existence is incompatible with positivism because the characterisation uses metaphysical language, which for positivism is nonsense. The difference between “nature of being” and “being” is that the former is something positivism might accept. However, the “nature” that positivism accepts is of course only one kind of nature of being that draws on objectivism and/or logical empiricism. I suggest the authors have a think about the characterisation of ontology to avoid the problem that some readers, who might be convinced by positivism, may reject the position advanced in this article tout court, because positivism rejects the latter expression “study of being” as metaphysics or crypto-mystical nonsense.

I would also like to problematise the use of “apply” and “application” in philosophy. Especially in Continental philosophy, it seems to me that what we do is rarely “application” in the proper sense of the word (join or combine with, to make use, attach to, relate to). Application – despite there being a whole branch of philosophy called “applied philosophy” – does not describe the practice of thinking through philosophy in physiotherapy: it does not do justice to the work in which the subject-writer-thinker engages when thinking physiotherapy practices/theories through a philosopher who has not said a word about physiotherapy. To my view, to apply something to something else glosses over the philosophical practice that happens in the “applying”, making it sound as simple and easy as plying one puzzle piece to fit with another resulting into an “application”. Rather than the result, what is important in critical philosophy is the process and practice.

The overview for the article is very useful and it gives a clear picture of what is to come. The basic theses are also useful to have to guide readers. My only question is: why basic, why not just theses? I would also suggest a rephrasing of the final statement about the authors’ hope: “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. [my emphasis]” As the sentence stands, it might give the impression that there is not much engagement in Levinas’ work in general, and in particular in relation to physiotherapy. It would be clearer to narrow the scope down to physiotherapy, in order not to make overarching statements about the state of studying Levinas in general. The statement would also be more effective if it would be expressed as an argument (adding a because-clause): The authors’ hope is that the work highlights the critical need for a deeper engagement with Levinas in physiotherapy and its ethics that is fundamental to it, because … The reason why I think the statement would be more effective as an argument is that it would give a reason to keep reading further, a reason to care about what the authors are about to say. Granted, it is the most difficult thing to formulate why any work might be worthwhile, but it is important to try to convince those readers who are not already interested in philosophy (or Levinas): So what? Why does this matter? Why should readers care? The answers to these questions are often visible to those who know how to look, but they need to be made more explicit to those who do not (yet) have the tools to see them.

Emmanuel Levinas – a brief introduction

The introduction to Levinas offers useful information to help understand how and why he formulated his ethics the way he did. I suggest that the authors be more precise on Bergson. The sentence now reads as “he was the most prominent luminary of modern philosophy of the 1920s” on which I do not entirely agree.

I would also like to push the authors on their philosophical engagement with secondary literature, in which accuracy is of utmost importance. In quoting Fagenblat, it is not entirely clear that the pronoun in “his famous exposition of ‘ethics as first philosophy’” refers to Levinas, not Heidegger. In writing about Heidegger and how Levinas was shaken by his Nazi affiliation, the authors quote Critchley but it is not clear whether it is Critchley’s paraphrasing of Levinas or his interpretation on Levinas, or something else. The easiest way to solve this would be to assign authorship to Critchley: “Levinas simply could not understand, as Critchley explains, ‘how a philosopher as undeniably brilliant as Heidegger could have become a Nazi, for however short a time’.” The authors assign authorship well in the next paragraph: “As Levinas himself would repeatedly state, his life and work …” But again, in quoting Bernstein, “whether we can still believe in morality after Auschwitz” – I believe this is Bernstein’s voice, but it may easily turn into Levinas’ words in readers’ heads, which becomes problematic when this article is perhaps quoted somewhere else by someone who does not realise that we should always check every quotation from the original source, and never completely trust secondary sources. I would suggest engaging with assigning authorship to quotations more frequently (not all the time, but when there might be an ambiguity about who is speaking). It makes it easier to follow who says what if it is stated more clearly. I would also suggest that the authors think about when to quote and when to paraphrase: quotations are the bread and butter of close reading in philosophy, but often paraphrasing secondary sources might give more clarity. Generally, quotations in philosophy work best when they support the author’s argumentation – they should never be used to replace the author’s own writing.

Thematisation – the violence of ontology

In the first paragraph, I suggest putting the Heidegger reference after “Being and Time”, rather than at the end of the paragraph, in which the authors give their own argumentation rather than Heidegger’s. In the second paragraph, there is some repetition: the authors have described ontology above, so they can omit “or the study of being” here to avoid repetition in “uncover the nature on ‘being’ (Sein) …” I would also combine the first two paragraphs. I also suggest the authors avoid expressions such as “one of the greats” or “the great Continental philosopher”. The reason for avoiding such value statements is that, as authors in philosophy, we have a responsibility to the readers not to give them any fuel to make ad hominem judgements (we should criticise/admire/agree with the argumentation, not the person). The other reason is, of course, that we do not wish that readers simply take our word that a philosopher is worth reading just because they are widely recognised as “great” but rather argue for why they are worth reading.

In the first paragraph, it would be more useful to mention how Nazism influenced or didn’t influence Heidegger’s work (e.g. his black notebooks?), rather than “despite his affiliation, his philosophy is influential.” For those unfamiliar with Heidegger, it might give the wrong impression about Heidegger and Heideggerians. If the authors have space, it would be more interesting to have the information about Heidegger’s controversial past in some more detail, rather than a reassurance that reading Heidegger is okay despite his affiliation: we cannot simply dismiss Heidegger because of what or who he was, but we can dismiss him based on what he thought and wrote.

The longer Critchley quotation towards the end of this section, I suggest that the authors introduce it. Structurally, now they have a quotation after another without any contextualisation or connecting the quotations to each other. It is always useful to ask: How does a quotation support the point I am trying to make? It might be useful to bring Critchley in e.g. “As Critchley explains …” or “Critchley offers a helpful clarification…” or something on these lines. The quotation, in any case, needs a reason for being there.

Towards the end of the section, the writing starts to fall apart a little. My suggestion for the whole section, which is heavily philosophical, is to think about how to make it more accessible: 1) simplify the use of punctuation, 2) shorten sentences and/or divide longer sentences into two or more, 3) make sure it is clear who is speaking, and 4) quote only when necessary and only when it supports what the authors are trying to say.

Finally, it would also be helpful to have a clearer explanation of what violence means in this article. The authors briefly say “there is no underlying, philosophical difference between the conceptual and corporeal annihilation of the other” which they could highlight more to help readers understand the kind of violence Levinas is writing about. I suspect that perhaps the majority of readers are not familiar with Levinas or the idea that violence can be more than physical and emotional (despite ethical violence and epistemological violence having been studied in healthcare). I think the authors could try to convince the readers more to accept that ontology can be violent, and that it is so inherently, and why and how Levinas argues this. Perhaps clearer signposting might help. Signposting and more explicit explanation of what is meant by violence might also help to read the sections that follow, because the authors are not always explicit about how or why the theories and practices below are violent.

The fundamental violence on physiotherapy

The authors showcase thinking through Levinas nicely in this section. I would again like to push on their writing, which is fine but with minor stylistic/structural tweaks can be better. For example, I suggest thinking about beginnings. The beginning sentence of this section is very long, and I imagine hard to follow if readers are new to Levinas. It would be more effective if the authors could clarify the beginning, perhaps adding signposting, but definitely shortening the opening sentence to invite readers to keep reading along. The most difficult thing to do in philosophical writing is to convey difficult thoughts in an accessible manner, without simplifying the thought beyond recognition. The easiest way to do so is to think about structure and keeping sentences (not the content) simple: a full stop gives the reader a pause to think about what has been said (vs. semicolons, elongated dashes, etc.) The writing in this section is generally much clearer than in the previous section.

The philosophical foundations of physiotherapy

The beginning sentence here is again structurally complex, perhaps it might help to switch the order around? As a quick side note, critique vs. criticism, there is a difference – just wanted to make sure the authors think about the use of the words (not saying they necessarily use them incorrectly). In saying that “Levinas’s work … goes much further than these in arguing that positivism leaves no room for difference…” – unfortunately, I haven’t read Levinas quite enough to be sure whether Levinas wrote explicitly about positivism? Here the authors state that Levinas is arguing this (“Levinas challenges the positivistic basis of physiotherapy…” vs. “we can challenge the positivistic basis of physiotherapy through Levinas’ work…). It would be clearer to say that, rather than Levinas challenging positivism in physiotherapy, it is the authors who challenge positivism in physiotherapy thinking through Levinas’ critique of ontology. I think this is what the authors are doing, but it is not always clearly expressed. I suggest making a clear distinction between what the authors are arguing through Levinas and what Levinas has argued. The subjectivity of the authors can and should show – this is one way to challenge covert positivism in our scientific writing.

When the authors use “Western philosophy” I think they are using it in the sense that Levinas uses it, i.e. the ontological and epistemological assumptions thereof. However, when saying that biomedicine is based upon Western philosophy, without saying what is meant by Western philosophy, makes the sentence “that Western philosophy upon which biomedicine is based” possibly false (if Western philosophy spans from Ancient Greece to today). I would not go so far as to say that biomedicine is based upon Western philosophy, rather, it is based on the positivistic/objectivistic assumptions of post-Enlightenment philosophy. Perhaps the authors could frame “Western philosophy” in Levinas’ terms. In any case, they need to be more specific. In other words, the authors need to be careful of not conflating Western philosophy and positivism, because positivism is essentially what they are criticising, not the whole of Western philosophy (without further qualification). Finally, the final paragraph could be clearer. This is where the authors bring their argumentation to the fore, so they would have to make sure it is accessible. All in all, the argumentation in this section is sound, but I would like to see more explicit argumentation on violence. My suggestion is to work on the final paragraph to make sure, again, that the important message is accessible to a wider audience, not just those already interested in philosophical writing.

The aims of physiotherapy

I would use “has been argued” rather than “has been shown” to challenge (perhaps covertly popping up in our language) the positivistic or empiricist assumptions of physiotherapy research. In the second paragraph, I think the final sentence is the author’s argumentation, but there is a reference to WHO at the end (one can only wish WHO would argue about positivist assumptions). This section could again benefit from addressing violence explicitly: both “maximum movement” and “complete physical, mental and social well-being” and universalizing all bodies in a Procrustean manner via quantification and making bodies equivalent/exchangeable are exactly the kind of violence the authors have addressed, however, it would be helpful to state this to remind the reader (the one perhaps new to different concepts of violence) that these practices are fundamentally ontologically violent to otherness. Perhaps signposting might again help. Compared to the previous section on philosophical foundations, it is more difficult to draw out the point the authors are making in this section. It might be helpful to clarify what is it that the authors are arguing?

The theory and practice of diagnosis

The beginning of this section is better. The authors begin with explaining clearly what this section is about, which is very helpful. They address individual factors, such as individual goals, and that such factors serve to support the processes of establishing diagnosis based upon specialised labels. However, wouldn’t clients’ goals also often be the same or similar to professional’s goals? I would expand the discussion here, perhaps looking at the glossary definition of EBP by the WCPT that addresses client/patient characteristics, preferences, and situations. Or looking at something else, but I would argue that the case is stronger if the authors had an object of criticism here from which they draw their argument (which I think is valid, but could be supported better).

I suggest that when the authors quote, it is always beneficial trying to find the original source. When relying on secondary sources, we risk misquotation and taking quotes out of context. The Kierkegaard quotation, which seems to be a popular one, is also a tricky one. There is another version circulating: “If you name meyou negate me. By giving me a name, a labelyou negate all the other things I could possibly be.” I can only find quotations from Kierkegaard’s works that are close to this, but not this exact quote. Perhaps the quotation is paraphrasing Kierkegaard? In any case, it would solve the tricky situation to either indicate that the quote is attributed to Kierkegaard rather than what he has written, if it is not possible to find the actual primary source for the quotation. Or perhaps omit quotation marks, and use paraphrasing rather than quotation.

Professional identity

Again, better opening for the section. A clear statement and its easy to follow up.

Toward an otherwise physiotherapy

I would omit “Beyond its general value as a critical theory…” and simply begin with “The overarching implication…” The first part of the sentence is not relevant for the argument and it is fairly vague to have much relevance to the reader either. Writing critical theory ought to avoid giving “value” to anything simply because that something is a critical theory – this is surely not the intention here, but because the sentence is a bit vague, it gives too much room to build strawmen. Moreover, at this point of the article it should be clear that Levinas’ critique has value in general, therefore I don’t think the authors need to repeat it here (or, make it clearer in the first two sections). It is always more interesting to be more assertive rather than use general sentences, i.e. make each sentence count.

Does Levinas think there is a way out of ontological violence? Perhaps the authors might think about making it clear that in Levinas’ terms there is no way out of the fundamental violence in order not to give the impression to the readers that the problem is somehow solvable (I don’t think he thinks there is a reconciliation based upon his critique of Hegel, but I might be wrong)? Then they could go on to argue what to do with the fact that ontology is fundamentally violent to otherness.

“… in full recognition of the underlying harm they cause.” It would be clearer the authors you used “violence” throughout, not to confuse readers. Using “harm” here might make people think that physiotherapy is doing only physical harm. My other worry is the question whether we can refrain from conscious knowing and doing? I think that problematising our knowing and doing is possible but refraining – at the moment at least – isn’t possible beyond a suspended utopian possibility of not doing fundamental violence to otherness. What would a refraining from conscious doing and knowing look like? If we think in Levinasian terms, I don’t think there is a reconciliation in sight (again, I might be wrong, but I don’t think Levinas agrees with Hegel)? However, I agree that seeking to challenge our knowing and doing does constitute an otherwise practice.

The sentence “Not that this is particularly heroic, given that it is, in our case, an iatrogenic violence.” I can see what the authors are getting at here, but I do not think “heroism” is a goal for critical practice. The authors introduce here yet another form of violence, iatrogenic violence, which may be confusing because iatrogenic violence is surely more than epistemic, ontological, and ethical violence? Perhaps the whole sentence could be omitted, or the meaning clarified. The final sentence also raises some questions: “letting go of our knowing and doing frees the other from the constraining grip of the self-same, and thus liberates the other to her fundamental, unknowable otherness.” This is difficult to grasp with the knowledge of Levinas provided in the beginning. It might be helpful to think about the audience, hopefully some of these questions help to clarify the passage: Can we simply let go of our knowing and doing? Does Levinas think such freedom can be attained? What does Levinas mean when he says the Other is unknowable? Why is it figurative?

Diagnostic practice doesn’t have to be labelling in physiotherapy, if we think about functional “diagnosing”, which can be more like “detective work” critically evaluating all sorts of obstacles and enabling factors (including social, political, economic, ethical, physical, discriminating, and other such aspects), rather than biomedical labelling. However, even a biomedical diagnosis might help the person who is worried about their health: giving a name to the “problem” might empower the person. I think there is more to the problematic than thinking diagnoses in terms of labels, perhaps the authors might address this a bit more?

I’m not sure we have to choose between “traditional” and “otherwise” physiotherapy. Perhaps again thinking about some questions might help clarify the argumentation and convincing the reader: Are traditional and otherwise physiotherapy necessarily incompatible? Is it about “letting go” of our identity or critically “altering” it? Can we get rid of an identity that we have once internalised, or do we change the identity? Can we unlearn it completely? When we define the self, the other, their relationship, physiotherapy, and physiotherapists, is defining practice not ontological violence? Compared to defining, is understanding violent? I think these questions address choice of words. I suggest thinking about precision in choosing words to avoid question begging.

A few final comments

There are a few typos and missing words that can be easily handled in the final proof reading. Are semicolons in lists necessary? In general, I wish to see more precision in choosing words and using quotes. It would also be helpful to explain violence more before going into the physiotherapy-specific topics. It might also be helpful to think about the section “Toward and otherwise physiotherapy” – bringing in primary sources on Levinas to see what he says about whether it is possible or not to not being violent might help with rigour. Some more signposting and clarifying, shortening sentences. Overall, this article has a lot of merit and I recommend its publication, all it needs is a round of thoughtful editing to make it more accessible and more rigorous.

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