Philosophical Context of Nursing

Introduction

It is often assumed that the primary task of healthcare is the restoration and maintenance of health, and that the moral importance of healthcare largely arises from this connection. Although inequalities exist in the distribution of other goods, the distribution of healthcare is thought to be special precisely because 'health' itself is in some sense special. How health needs are to be characterized is of central concern to the establishment of such distributive principles. But, a theory of health needs rests upon the assumption that there is, or could be, a general theory of health. Currently there is no consensus on a general theory of health and it seems increasingly unlikely that such a consensus is possible. (McDonald, 2004) Law and Widdows (Law & Widdows, 2007) claimed that the difficulty in reaching consensus on a general theory of health is because different parties have different needs for such a theory. As an example, he claimed that some theories are constructed merely from a theorist's perspective, others are constructed to provide useful definitions for the practice of medicine, and others are constructed in an effort to create global healthcare policy. Following is a presentation of the most prominent theories of health presented in the scholarly literature. These theories could be categorized in at least two ways: by their philosophical foundation and by the discipline from which they originate. There are three philosophical foundations upon which theories of health arise, they are naturalism, normativism, and a hybrid of the two. Naturalists seek definitions of health and disease that are based in scientific facts and theories and are value-free. Conversely, normativists believe that health and disease reflect value judgments as health is a state that is considered desirable and disease is considered a state to be avoided. Finally, hybrids seek to find a middle ground between the scientific facts of the naturalists and the value judgments of the normativists. This method of categorization sheds light upon the philosophical foundation of a theory of health, but does not provide insight into any social or political basis the theorist may experience as bias. Instead, these insights may be deciphered when categorizing the theories of health into the disciplines from which they were constructed often reflecting the author's need or desire for constructing such a theory. These disciplines include the fields of the philosophy of medicine, the biological science, nursing, and indigenous medicine. This is the categorization methodology that I have chosen. The following chapters include a presentation of these theories along with comments on their similarities and differences. Of all of these disciplines, the theories are constructed from within the field of nursing.

Significance

The significance of a theory is determined by evaluating how much the adjustment in beliefs alters our thinking in regard to the phenomenon of interest. In other words, does the theory eliminate our ignorance about the phenomenon? With regards to the concepts of health and disease, I concur with Catherine McDonald (2004) that, "currently there is no consensus on a general theory of health." Although it may seem of minimal significance to add yet another theory of health to the already existing 20 or so, this theory offers a new perspective. If this perspective of health being determined by the relationship between body, mind, and spirit is deemed to be valid, it could alter the course of healthcare. Although this may seem farfetched, one could extrapolate that if health is compromised when body, mind, and spirit are operating incoherently and/or independently a simple "realignment" to unified coherence may return the person to a healthy state. If this could be accomplished without requiring a diagnosis or costly interventions, this could significantly alter the basic principles of healthcare as we know it in Western medicine today.

Scope

The scope of a theory identifies "the range of different adjustment outcomes that the theory can explain" (Mithaug, 2000). The scope of The Emerging Theory of Health as Unified Coherence is limited because it only affects adjustment outcomes regarding health and healthcare. However, within that context, it is applicable to physical, mental, and spiritual health. Furthermore, health could be considered a requirement for "a good life." Therefore, although the scope may be limited, the relevance of that scope is vast.

Assumptions and Propositions

Theories are constructed through reviewing the possible reasons for the discrepancies, outlining assumptions, and developing testable propositions all concluding with the theory. The possible reasons have been presented, following are the assumptions and propositions

Assumptions

Human beings consist of three components: (a) A physical body, (b) A mind, and (c) A spirit. 2. The functions of these three components are: (a) The physical body allows for experiencing the world through the senses of sight, hearing, taste, touch, and smell; (b) The mind allows for processing the information gleaned from the senses; and (c) The spirit provides a conscience that allows for knowing right from wrong. 3. Metaphorically, we can refer to: (a) The physical body as "what we see [hear, taste, feel, or smell]"; (b) The mind as "what we think"; and (c) The spirit as "what we know to be true." 4. "Likeness" between what we see, what we think, and what we know to be true can be described as either coherent or incoherent. The terms coherent or coherence are used as in physics where they describe the relationship between two or more waves moving in a consistent direction and at a consistent frequency, even if they demonstrate differing amplitudes. Coherence is a dualistic concept with waves being either coherent or incoherent although they may exhibit differing levels of incoherence. When the three components of a human being are coherent, they exhibit consistency with one another. Conversely, when the three components are incoherent, they are in contradiction of one another. 5. "Collaboration" between the three components of human beings (body, mind, and spirit) can be described as unified or independent. They may form themselves into a single unit defined as unified or unity, or they may remain separated components within the whole defined as independent or independence. 6. The general concept of health status exists as a continuum with unequivocal health on one end and unequivocal disease on the other and neutrality in the center. 7. Because human beings consist of a body, a mind, and a spirit; both ends of the spectrum health and disease can be subdivided into physical, mental, and spiritual components.

Propositions

Utilizing the metaphor in Assumption #3, the relationship between any or all of the three components of a human being can be described in terms of: (a) their likeness, and (b) how they collaborate. First, likeness can be described as either coherent or incoherent. Secondly, the terms unity and independence describe how the three components of human beings collaborate. 2. Considering this two by two square of likeness and collaboration, four possibilities can exist. A human being's body, mind, and spirit can be: (a) coherent and unified, (b) coherent but independent, (c) incoherent but unified, (d) incoherent and independent. 3. The states of health and disease can be defined by how one's body, mind, and spirit relate in terms of likeness and collaboration. 4. Health is a state of coherence and unity of one's body, mind, and spirit. 5. Disease is a state of inconsistency and independence of one's body, mind, and spirit. 6. Health masquerading as disease is a state of coherence but independence of one's body, mind, and spirit. 7. Disease masquerading as health is a state of incoherence but unity of one's body, mind, and spirit. 8. Examining the subdivisions of health, one's degree of physical health can be defined as our ability to coexist or be at peace with incoherence and independence between what we see, what we think, and what we know to be true. 9. One's degree of mental health can be defined as our ability to understand or define in a way that one can live with incoherence and independence between what we see, what we think, and what we know to be true. 10. One's degree of spiritual health can be defined as our ability to make sound moral judgments when there is incoherence and independence between what we see, what we think, and what we know to be true

Literature Review

The highest degree of controversy played out in the literature among all of these theories is the ongoing debate between proponents of Boorse's Bio-Statistical Theory of Health and Nordenfelt's Theory of Health, including debate amongst the authors themselves. Although both take a teleological approach aiming to define the design and function of a human being; Boorse takes a naturalist view, while Nordenfelt takes a normativist view (Kovacs, 1998). Another striking difference between the various theories is the degree of holism each employs. The theories derived from the biological discipline suggest a narrow scope and a more reductionist / elementalist view, whereas those derived from the indigenous medicine and the nursing disciplines offer a more holistic view insisting on approaching the human being as an integrated body, mind, and spirit. Additionally, many, but not all, of the theories derived from a Western philosophy tend to focus on a more biological definition whereas the Eastern philosophical theories focus more on an energetic definition of human beings. The individual theories vary greatly and as McDonald (2004, p. 1) stated, "There is no consensus on a general theory of health." However, they all offer a definition of health and disease.

Theories of Health from the Philosophy of Medicine

A comparison of the theories of health derived from the philosophy of medicine discipline reveal several insights. The first being that although one might assume that four such theories derived from the same discipline might share a common worldview perspective, they do not. Although all do share the mental structure described by Gebser (1985), the theories from Boorse and Twaddle are mechanistic, whereas the theories from Nordenfelt and Mordacci are contextualistic to utilize Pepper's (1942) worldview terminology. Another difference is that the theories from Boorse and Twaddle are valuefree naturalist's views whereas Nordenfelt's and Mordacci's theories are value-laden normativist's views. Finally, this comparison demonstrates that the theories posited by Boorse and Twaddle are both mechanistic and naturalistic where human beings are viewed as machines and health and disease are viewed as value-free states. Furthermore, the theories posited by Nordenfelt and Mordacci are both contextualistic and normativist where the value associated with health and disease is considered to be determined based upon the environment, or context, in which that human being lives. This comparison demonstrates that the theories of health derived from the philosophy of medicine appear to lack consistency not only to Pepper's schema, but also in how they relate health and disease to the values imbedded within society.

Theories of Health from the Biological Sciences

One might expect all of the Theories of Health derived from the biological sciences to fall cleanly within what Pepper (1942) termed the organismic worldview where human beings are akin to an evolving organism. However, this is not the case. The WHO (World Health Organization, 1948) theory does fall within Pepper's organismic world view, however, it also supports a mechanistic worldview. Meanwhile, a close relative of the WHO theory, Bircher's theory, is organismic, but also supports elements of contextualism. Finally, Dubos' theory most closely supports the perspective of contextualism, but offers hints of organicism. Meanwhile, from Gebser's worldview perspective, all of the theories from the biological sciences are within Gebser's (1985) mental structure.

Theories of Health from the Nursing Discipline

Nurses are often called "the front line" of the healthcare community. They are the most accessible and closest allies of patients, especially in a hospital setting. Possibly because of this connection, the theories of health derived from the nursing discipline focus more heavily on the patient as a human being as opposed to the mere definitions of health and disease. Additionally, of all of the theories of health, those from the nursing discipline offer the greatest number of example of being placed in actual practice than any other. Theories derived from the this discipline include Martha Rogers' Theory of Unitary Human Beings (Rogers, 1987), Margaret Newman's Theory of Health as Expanding Consciousness (Newman, 2008), and Jean Watson's Theory of Human Caring (J. Watson & Foster, 2003). When Martha Rogers' Science of Unitary Human Beings was first published in 1970 (Rogers, 1987), it offered a new perspective to nursing theories in use at that time. Rogers' theory provides a framework for nursing that sharply diverges from the predominant medical model approach to the delivery of nursing care as a reductionist, mechanist and analytic process (Biley, 1990). Rogers' fresh perspective offered an alternative to traditional nursing theories considered more static and closed in their world views (Smith, 2003) and as a result has started to challenge many preconceived ideas about nursing (Biley, 1990). The basis of Rogers' revised theory is that both human beings and environments are irreducible, indivisible, single-wave, pan-dimensional energy fields. Rogers was specific in stating these human beings and their environments "are" energy fields as opposed to "they have" energy fields (Rogers, 1986). Furthermore, the energy fields of human beings and their environments are in constant interaction interpenetrating one another. Margaret Newman constructed her Theory of Health as Expanding Consciousness while both a student and colleague of Martha Rogers, author of the Theory of Unitary Human Beings (Rogers, 1970). Newman's theory stems from that of Rogers', but also incorporates components of David Bohm's Theory of Reality as Undivided Wholeness (Bohm, 1980). Newman's methodology was what Jarvis' (1999) entitled "theory from practice." As a nurse, Newman routinely cared for patients suffering from chronic disease and disabilities, which made it difficult for her to accept the commonly held definition of health as the absence of disease. If she had, she would have essentially been accepting that her patients were living without health and therefore possibly without hope. Her original theory took into account only those people suffering from disease or disabilities, however, she has since revised it to include all people including those that meet the conventional definition of health as an absence of disease (Newman, 1997). Jean Watson was one of the first theorists focused on the concept of "caring" as opposed to "curing." Watson constructed her Theory of Human Caring in an effort to add new meaning to the practice of nursing and increase the dignity associated with patient care (J. Watson, 1997). The theory was first introduced in Watson's (J. Watson, 1979) text entitled Nursing: The Philosophy and Science of Caring. The theory is based on 10 "carative factors," which Watson (1979) described as making up the "core of nursing. Watson developed her theory by importing concepts from other fields such as humanistic psychology, phenomenological philosophy, and existentialism (J. Watson, 1979, 1997). Watson posited that her theory provides an alterative worldview of nursing placing it within a more metaphysical context by establishing nursing as a carative process incorporating spiritual dimensions aiming to help individuals increase the harmony between their mind, body, and soul [i.e., health] (J. Watson, 1988). Although Watson's theory holds little in common with Rogers' or Newman's theories, they all emphasize the importance of the interaction between the patient and the nurse by either the nurse entering into the patient's experience, the patient entering into the nurse's experience, or both. The theories of health derived from the nursing discipline offer the first entre into Gebser's integral structure that is readily accessible within the Western world of healthcare. It is of interest to note that Newman pulled her expanded vision of Roger's theory back into the realm of the mental structure from Roger's integral structure theory. In terms of Pepper's worldview, most of the theories of health from the nursing discipline are within the organismic worldview

Theories of Health from Indigenous Medicine

Like the other theories of health derived from the indigenous medicine discipline, Whare Tapa Wha is consistent with Gebser's description of the integral structure. It could be argued that this theory is even more consistent than that of Chinese Medicine or Ayurveda with it's inclusion of physical, mental, spiritual, social, extended awareness, and support. Again, like the other theories of health derived from the indigenous medicine discipline, Whare Tapa Wha views human beings as organisms within the organicist's worldview.

Worldview Perspectives of Existing Theories of Health

Of all of the theories of health examined, those derived from the indigenous medicine discipline are most closely aligned with one another. They all represent Gebser's (1985) integral structure and Pepper's (1942) organismic worldview. The only other category of theories that is similar is that of the nursing discipline where two of the three examined represent an integral structure and all represent an organismic worldview. It is of interest to note that of the four disciplines examined, the practitioners within the indigenous medicine and nursing disciplines often develop the closest and most intimate relationships with their patients as compared to the philosophy of medicine and biological science disciplines. One could ask whether there is some relationship between this closeness with their patients and their more holistic, energetic, and spiritual perspectives regarding their patients as human beings. Future study of this possible relationship might provide valuable insight into the field of healthcare and more specifically practitioner-patient relations. A detailed comparison of the theories of health derived from the philosophy of medicine discipline demonstrates that all share the mental structure described by Gebser (1985); however, they differ in Pepper's (1942) schema. The theories from Boorse and Twaddle are mechanistic, whereas the theories from Nordenfelt and Mordacci are contextualistic to utilize Pepper's (1942) worldview terminology. Another striking difference in the theories is their placement of value judgments on the states of health and disease. Boorse and Twaddle present a naturalist's, or value-free view, whereas Nordenfelt's and Mordacci's theories present the value-laden view of normativists. Another revelation from the comparison is that both Boorse and Twaddle not only present a naturalist's view, both are also mechanistic from Pepper's (1942) perspective. Conversely, both Nordenfelt and Mordacci present a normativist's view, and both are contextualistic. This comparison demonstrates that the theories of health derived from the philosophy of medicine appear to lack consistency not only in Pepper's schema, but also in how they relate health and disease to the values imbedded within society. In a more detailed comparison, the theories of health derived from the biological sciences do not fall cleanly within what Pepper (1942) termed the organismic worldview as one might expect. The WHO (World Health Organization, 1948) theory does follow Pepper's organismic worldview, however, it also supports a mechanistic worldview. Meanwhile, Bircher's theory, a child to the WHO theory, is organismic, but also supports elements of contextualism. Finally, Dubos' theory presents a contextualist's perspective, but offers hints of organicism. Meanwhile, from Gebser's worldview perspective, all of the theories from the biological sciences are within Gebser's (1985) mental structure. It is with the theories of health derived from the nursing discipline that we see the initial entree into Gebser's integral structure within the Western medicine system. Both Newman's and Watson's theories fall clearly within Gebser's (1985) integral structure, but Roger's theory is in the mental structure. In terms of another comparison, all of the theories investigated follow Pepper's (1942) organismic worldview. Finally, it is within the category of theories of health derived from the indigenous medicine discipline that we see all of the theories examined demonstrating Gebser's (1985) integral structure. These theories also present a consistent view of human beings as organisms that places them in Pepper's (1942) organicist's worldview

A Growing Acceptance of Holism in Healthcare

Although reductionism has been at the basis of current schools of thought in the Western healthcare system for the past century, holism is slowing gaining acceptance again among both patients and healthcare providers through the use of what the NIH (2007) terms Complementary and Alternative Medicine (CAM). The category of CAM includes many modalities that range from the more well known (e.g. homeopathy, naturopathy, acupuncture, Chinese medicine, chiropractic, etc.) to more esoteric (e.g. absent healing, bioenergy therapy, directed prayer, faith healing, laying-on of hands, magnetic healing, occult medicine, psychic surgery, shamanic healing, spiritual healing). From the patient's perspective, three fourths of the world's population depends on these modalities for their healthcare needs (Cardena, et al., 2000). In the United States, a 1993 study demonstrated that two out of three U.S. patients had sought out, and in fact been treated, with some form of CAM as it has been defined by the U.S. NIH (D. M. Eisenberg, et al., 1993). Five years later, Eisenberg et al. (1998) conducted a follow-up study, which demonstrated that "alternative medicine use and expenditures increased substantially between 1990 and 1997." During this time, the "probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (p = 0.002); there was no significant change in disclosure rates [to physicians]; the percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change" (D. Eisenberg, et al., 1998). However, the most striking results of the survey were the extrapolations to the U.S. population. Findings demonstrated that upon extrapolation the "47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all U.S. primary care physicians" (D. Eisenberg, et al., 1998). In terms of expenditures, "out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all U.S. physician services" (D. Eisenberg, et al, 1998). Although more recent statistics are not readily available, the growing popularity of CAM can be witnessed by visiting any popular bookstore to see the number of best seller publications by CAM advocates such as Deepak Chopra, Andrew Weil, Christine Northrup, Jon Kabat-Zinn, Candace Pert, Bruce Lipton and others. From the healthcare provider's perspective, CAM and its holistic basis, is also seen as growing in popularity as more and more clinical studies demonstrate its effectiveness. Peer-reviewed journals such as The Journal of the American Medical Association, The Journal of Behavioral Medicine, The Clinical Journal of Pain, The Journal of Advanced Nursing, Sociology of Health and Illness, and The Rheumatic Disease Clinics of North America, and The American Journal of Public Health have published articles attesting to the effectiveness of CAM techniques in a variety of outcomes studies including those that have documented a reduction in hospital stay days, reduced critical care scores, and reduced recovery time, as well as providing increasing general measures of well-being.

Conclusion

These different directions seemed disparate at times, but there always seemed to be some thin thread on continuity. Whether the material be from scientific publications, literature, historical accounts, medical journals, philosophy texts, religious doctrines, or spiritual texts; there always seemed to be a loose connection. Concatenated theories may be among the most difficult to construct due to these loose connections. They may also be among the most difficult to follow as the theorist weaves the connections together in hopes of constructing a theory that is simple and understandable. I found the literature on theories of health most helpful in aiding me in constructing such a theory. In reviewing these theories hailing from disciplines including the philosophy of medicine, the biological sciences, nursing, and indigenous medicine, I found that my emerging theory does not neatly fit in any one of these categories. It was constructed utilizing Jarvis (1999) perspective of the practitioner researcher, Mithaug's (2000) four-step strategy for theory construction, and intuition as a methodology. Although my personal background is in the realm of the biological sciences, along my career path, I have learned about holism and taken a more esoteric approach than practitioners training in Western medicine - one that is more in tune with the fields of nursing and indigenous medicine. Therefore, just as I seem to live "in the spaces between the spaces," so does my theory.

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