John Quintner, retired rheumatologist, Melanie Galbraith, APA Pain physiotherapist, Horst Ruthrof, FICI, FAHA, Emeritus Professor in English and Philosophy at Murdoch University, Perth, Western Australia.
This article was originally prepared by Professor Ruthrof following a conversation (over wine) on Saturday 29th December 2018 with a view to appealing to the broad readership of Fibromyalgia Perplex. John and Melanie are responsible for the commentary and Milton Cohen kindly reviewed the article.
The relationship between clinicians and patients is not well described merely from the perspective of professional treatment or from the perspective of patient suffering. When the patient’s complaint is mainly that of unrelieved pain, the relationship can be fraught with difficulty.
To capture the complexity of such medical encounters, a more comprehensive approach could be achieved by choosing the path of intersubjectivity. The concept was introduced and elaborated in its modern form by the German philosopher Edmund Husserl [1859-1938] in his published writings and especially in his Nachlass (i) comprising his notes from 1905 to 1935, and resumed as a topic in its own right by his phenomenological successors, Cassirer, Scheler, Heidegger, Sartre, Merleau-Ponty, Levinas and others.
JQ/MG: Humans and their behaviour can only be understood as being within a social context or matrix. As Horst will show us, there are gradations in the different ways of being with others.
The relationship between patient and clinician can be regarded as a special case of intersubjectivity in which two subjects are interacting for the purpose of employing medical expertise in order to alleviate suffering.
According to Husserl there are four elements of intersubjectivity:
- Being-apart-from-one-another (Auseinandersein)
- Being-with-one-another (Miteinandersein)
- Being-within-one-another (Ineinandersein)
- Being-for-one-another (Füreinandersein)
In this article, we are drawing on the fundamental principles of intersubjectivity as defined in the phenomenological literature with the objective of offering a description of what typically occurs, and what should occur, in encounters between patients and clinicians.
Our description is guided by four principles mentioned above, which, according to Husserl, together provide the fundamental, minimal matrix of the kind of “being” that constitutes intersubjectivity. We use these principles as our main headings.
JQ/MG: When used in a restricted sense, intersubjectivity implies “shared” or “mutual understanding. But the force of Husserl’s concept is thereby lost. In his analysis, it is the possibility of being in the place where the other is – the possibility of exchanging places – the possibility of seeing the world from the point of view of the other, in this case, that of the person experiencing pain.
Importantly, Husserl views intersubjectivity only as the possibility of an understanding being reached, but not necessarily its accomplishment.
Like all human subjects, the medical professional and the patient can be regarded as singular subjects in a community of monads (ii) performing different social roles. As a consequence of our individual experiences, human beings do not doubt that they are separate entities in addition to interacting with others.
Monads can be thought of as indivisible entities, which are self-sufficient at a given moment in time, but in order to be self-sufficient, they have to interact with other monads, either by choice or by necessity.
Husserl speaks of the “uniqueness of existence” (Hua XV, p.374). To this extent, we are all beings-apart-from-one-another. As Husserl puts it, “The monads are absolutely separate; they have nothing real in common” (Hua XV, p. 377; my emphasis) and so exist as “mere beings-next-to-one-another” (Hua XV, p. 461).
Beyond this general sense of being monads, clinicians and patients share a special sense of separation. Such sentiments have many reasons. On the side of the patient, fear of being harshly judged and shyness can be barriers to mutual understanding, as can an impression of ‘false bonding’ in the case of a certain condescension in the bedside manner of clinicians or even outright arrogance
But even where good intentions prevail on both sides, clinicians and patients have different ‘horizons of expectations’. This phrase refers to the frameworks within which those of a particular generation in a culture come to understand, interpret, and evaluate. Each generation develops its distinctive horizons of expectations, which may not be readily understood by members of previous or succeeding generations.
JQ/MG: Although being in pain is a universal experience, individual interpretations of its meaning are many and varied. Frameworks used by clinicians to understand the pain of others include biomedical, bio-psycho-social, and socio-psycho-biological.
Clinicians are invested with institutional power, whereas patients are meant to be passive receivers of professional advice and treatment, no matter what specialized tasks they perform in their ordinary lives.
JQ/MG: This imbalance of power between healers and those to be healed has always been a source of tension, but has perhaps become less so now that an endless supply of information is readily available through electronic media. In other words, the “playing field” is now a more level one because there is an element of informed choice available to those wishing to self-manage their pain.
We could say, following French philosopher Michel Foucault (1926-1984) that the ‘enunciative modalities’ (iii) of the clinician and the patient are at considerable variance. The former speaks from a position of well-established and well-maintained institutional privilege; in comparison, the speaking position of patients is relegated to a minor function in medical discourse.
With this difference also goes a decisive divide as to knowledge and truth claims (iv) on the part of clinicians and the subjective utterances of patients as laypersons. Perhaps the biggest barrier to intersubjective interaction between clinicians and patients is the necessary transformation of the patient’s subjective evidence of the pain experience into the objectivating process of medical diagnosis and treatment.
Part and parcel of traditional agenda setting in medical practice is to leave subjectivity behind in order to arrive at standard scientific solutions to the problem of curing or alleviating disease forms.
JQ/MG: “Objectivating” refers to a process of taking what is whole, complex, nuanced, and sophisticated and breaking it down into more fundamental parts. This is known as reductionism, an approach that has been extremely successful in medical science and practice but often unhelpful to many patients with persistent unexplained pain. The patient’s lived pain experience tends to be ignored in the clinician’s search for “objective” evidence of a disease or disease process.
Other reasons for the being-apart-from-one-another in the doctor-patient relationship include the existential situation of being forced together by illness rather than by voluntary decision-making, as well as the question of remuneration. The social roles of being paid and paying produce an opposition that intensifies rather than alleviates the disconnect between clinician and patient. What looms large here from the perspective of being-apart-from-one-another is the threat of the decentralisation (v) of the patient as a person.
At the same time, there is no escaping the fact that the clinician and the patient find themselves in a situation of having to interact with one another. In Husserl’s words, the “I has its peculiarity foremost in the You” (Hua XIII, p.247), such that “the existence of every monad is implicit in every one,” (Hua XV, p. 377) and “every monad stands in causality with other monads” (Hua XIV, p. 357).(vi)
What gives the medical profession its unique character is that here the relationship between individuals is always already premised on an asymmetrical form of social interaction between clinician and patient, between healer and person to be healed.
In this sense, the relationship between doctor and patient is a special case of Husserl’s being-with-one-another, understood as an indispensable component of communal life. What makes communities possible in the first place, according to phenomenology, is an agreement amongst individual subjects about the existence of a common world.
JQ/MG: For Husserl, intersubjectivity unreservedly presumes that the world as it presents itself to me is the same world as it presents itself to you, not because you can ‘read my mind’ but because I assume that if you were in my place you would see the world the way I see it (Duranti 2010). This theoretical possibility of “trading places” is in turn made possible by empathy.
But while from traditional empiricist perspectives (vii) the data of the objective world dictate the way human subjects cope with reality, following Husserl, phenomenology reverses the relationship of objectivity and intersubjectivity. It is not objectivity that produces intersubjective agreement. Rather, it is intersubjective agreement about reality (e.g. guided by standard explanations of the universe by scientists of each epoch) that produces the kind of objectivity that communities take for granted.
JQ/MG: The subjective is usually understood as that which pertains to the (individual) subject, consciousness or mind, while the objective is that which stands outside or independently of the (individual) subject. Husserl maintains that what is objective is nothing other than what is common to or has been acknowledged through the agreement of a community of subjects.
It is objectivity in this phenomenological sense that also guides medical experts and patients in their attitude to one another. That which is shared by doctor and patient is the common purpose of healing. And yet, the ways in which clinicians and patients contribute to this special form of being-with-one-another differ rather sharply.
Patients are asked to express their pain in a variety of ways, by pointing, tactile exploration, facial expression, making sounds of pain, and providing verbal descriptions. At this level, the interaction with the clinician consists of a process of transformation of patient subjectivity into the objectivity of professional diagnosis. To achieve this, the clinician employs the patient utterances for the purpose of extracting relevant information. Yet the successful identification of the cause of pain remains a fundamental problem. This is especially so in the case of a variety of chronic pain conditions, when determining this task escapes medical expertise.
But even in less complex healing situations, being-with-one-another reveals a stark asymmetry. The professional identification of the cause of pain produces a conversation in the mind of the clinician that is bound to differ from the subjectivity of patient utterances. To the degree to which clinicians are able to close the gap that exists between the two conversations they are able to assure their patients that they are in good hands. This requires not only a high degree of sensitivity to patients as persons, but also to the subtle differences of language. And since clinicians are the agenda setters of the healing process, it is their ethical duty to optimise interaction with patients in both these respects.(viii)
As to language, no matter how competent patients are linguistically, language (including body language) is the fundamental glue that makes communal life as being-with-one-another possible in the first place. In clinical encounters, patient utterances are typically conveyed in a narrativisation (ix) of their pain experience, the importance of which in clinical encounters has perhaps not been sufficiently recognised.
So far, the analysis has been to the exteriority (outward appearances) of clinician and patient interaction. What is still missing is by far the most significant aspect of being-with-one-another, termed “empathetic apperception” (x) by Husserl.
A communal life of separate individuals would not be possible, Husserl argues, if we were not able, at least to a certain degree, to read the minds of others and in so doing anticipate their wishes, intentions, worries, doubts, and hopes.
While we are not in a position to experience the life of the mind of others, we are able by analogous empathetic projection to have a good guess at what they may be thinking.
JQ/MG: A considerable amount of time and effort have been expended in trying to arrive at a satisfactory definition of the experience we call “pain”. Yet, when someone tells us that they are experiencing pain we instantly have a pretty good idea of what they are talking about. We also know when our animal pets are likely to be experiencing pain by their behaviour. These are examples of “empathetic projection”.
The more familiar we are with another, the more successful such empathetic apperception will be. Nor, as recent research by Michael Tomasello has shown, is the human ability of “intention reading”, a capacity that is by no means the prerogative of adults. (Tomasello 2003) According to Tomasello, as early as in infancy humans are well equipped to probe the minds of those close to them. In other words, living with-one-another is also a living within-one-another (Hua XIV, pp. 268f.).
JQ/MG: Tomasello’s work is relevant to our understanding the way in which children acquire the ability to employ meaningful language by reading the minds of their parents and others close to them.
JQ/MG: Empathy is the primordial (fundamental) experience of participating in the actions and feeling of another being without becoming that other being. This experience comes out of our exposure to their bodies moving and acting in ways that we recognise as similar to the ways in which we would act under similar circumstances.
Husserl calls this form of intimate relation an “intentional within-one-another” (Hua XV, pp. 371f.) in the sense that our acts of consciousness, that is, intentionality, are not sealed off in individual minds. Rather, the monad “carries other monads intentionally in itself” (Hua XV, p. 17). So much so that “I include the will of the Other in my own, I serve him” (Hua XIV, p. 269) and that social acts are always “I-thou-acts” (Hua XV, 19).
JQ/MG: The German philosopher Martin Buber (1878-1965) famously wrote: “The primary word I–Thou can only be spoken with the whole being. The primary word I–It can never be spoken with the whole being.” In its relentless pursuit of reductionism, Medicine has tended to address the patient as being an “It”. But in a truly intersubjective encounter, clinicians must address those who are experiencing pain with their whole being.
In what sense, then, can we say that the transactions between patient and clinician are likewise a form of being-within-one-another? The question returns us to the difficult issue of sensitivity as an ethical burden on the part of the health professional.
Here, scientific objectivity is being challenged by the need to explore as far as is possible the intentional acts of patients, always respecting their idiosyncrasies, feelings, hopes, and fears. At the same time, it is in the interest of the patient to try to accommodate the doctor’s demand for information by way of active participation in the medical dialogue.
Ideally, then, “being-within-one-another” is a kind of “meeting of minds” between clinician and patient, a reciprocal process of empathetic apperception. Antagonisms have to be curtailed on both sides to allow for the emergence of mutual trust, a necessary condition of satisfactory treatment.
To achieve mutual trust is by no means a matter of health care routine. It requires the clinician’s will to enter the patient’s mind and a willingness on the part of patients to allow this to happen by revealing part of their innermost selves.
Looming large here are patient vulnerability and the health professional’s care in dealing with it. In such intersubjective, intentional interaction, the patient’s willing openness has to be met by the clinician’s readiness to expend empathetic, interpretive labour, employing techniques of creative prompting to encourage patient cooperation.
On both sides of the clinical encounter, then, openness, reciprocity, and spontaneity play central roles. Successful encounters of this kind offer the benefits of comfort for the patient and reassurance for the clinician.
As a consequence of the description of human acts of consciousness involved in such mutually interpretive situations, phenomenology has developed its own ethics, not as a system of stipulated values but rather as an awareness of ethical responsibility as an inevitable consequence of the complexities of being-within-one- another. Husserl called this ethical basis of intersubjectivity our being-for-one- another.
From infancy onwards, persons who are there for us surround us. Without them, we would simply not be able to exist. And in spite of all facts of human hostility and cruelty, Husserl’s “being-there-for-one-another” (Hua XIII, p. 483) remains an equally powerful facet of social reality. This, then, is the fourth indispensable component of human community formation.
We are by Husserl’s definition beings for one another. (Hua XV, p. 39) Husserl wrote of being-for-one-another as an “infinite, reciprocal ‘mirroring’”, long before brain science introduced the notion of “mirror neurons.” In phenomenology, the for-one- another is regarded as an “intentional implication” and “a potentiality of stages of empathetic apperception.” (Hua XV, p. 608)
JQ/MG: The discovery of so-called mirror nerve cells in the brains of monkeys has made it plausible to contemplate highly sophisticated “mirror”-like nerve cell systems that would enable us as human beings not only to mimic other persons, but also to anticipate (perhaps even to share in) their belief systems, attitudes, positive and negative emotions, perceptions and intended actions (Austin 2006).
Thus, Husserl derives intersubjective intentionality as necessary ground from his description of subjective acts of social cooperation. Subjectivity (the relationship with oneself), our inevitable epistemic starting point (xi), then is a consequence of sociality.
However, the phenomenological for-one-another has three distinct meanings. One refers to “the other I” who is simply “there for me as the other human being” (Hua XIII, p. 475); the second meaning is the “for-one-another” that forms the basis of a “loving community” (Hua XIV, p. 175); while the third meaning is that of personal love, the “loving care for the other”, Husserl’s Fürsorge (Hua XIV, p. 175).
In ideal professional health care, all three senses of being-for-one-another will be found. Which should not be surprising since, after all, they are distilled from a description of general social intentionality (xii) of which health care appears to us as a necessary component.
JQ/MG: The third meaning – “loving care for the other” – can be problematic for contemporary health care, but much sought after by patients. It requires a close “fit” to occur between clinician and patient. Each is motivated by a genuine interest in discovering the uniqueness of the other. When the participants are suddenly aware that they have become as one (i.e. WE) the “possibility” of an intersubjective encounter has been “actualised” (made real). It can be described as an “Aha” moment.
In this context, Husserl envisages the possibility of a “naturalist anthropology” (Hua XIII, p. 481).
JQ/MG: In Husserl’s writing the concept of intersubjectivity includes all possible human relationships with the natural world. This includes other people. The totality of these experiences provides us with a broad spectrum of what we understand as the human condition (Duranti 2010).
Whatever the social origins of the ethical dimension of health care as an encounter between clinicians and patients, the fundamental principle of the for-one-another tends to be overshadowed by financial, technological, and managerial considerations, as well as the constraints of consultation time. As a result, patients often feel that they are minor parts (i.e. cogs) in intricate and inscrutable machinery rather than persons looked after by other human beings.
After Husserl’s path-breaking studies, other phenomenologists have pursued the description of intersubjectivity. Ernst Cassirer and Max Scheler added the point that empathy works not because we are able to pinpoint the minutiae of other minds, but rather as a basis for holistic judgments, whereby we take into account the overall personality of others, including the normativity (xiii) of their value systems.
While this requires special training, sensitivity, respect for others, and time, it suggests that encounters between clinicians and patients could greatly benefit from such a revision of the notion of empathy.
Jean-Paul Sartre foregrounded especially the conflictual side of intersubjectivity, Martin Heidegger elaborated the existential situation of human Dasein as thrownness (i.e. being thrown into the world), while Maurice Merleau-Ponty resumed Husserl’s distinction of the physical and the lived body and Emmanuel Levinas added significantly to the ethical dimension of our construction of the Other.
As Dan Zahavi (2008) argues in a recent paper, “Beyond Empathy: Phenomenological Approaches to Intersubjectivity”, our habitual constructions of others are viable social, intentional acts that involve a great deal more than the mere subjective projections of feelings as the term empathy (Einfühlung) might suggest.
JQ/MG: Caregiving has never been solely in the province of health care professionals. “Its instinctual roots are innate and universal. We find that even the most insular of human beings is impelled to reach out beyond the boundary of self to care for a pet cat, turtle or growing plant” (Austin 2006. p. 457). For this very reason we recommend to health professionals that when they engage with their patients experiencing pain they choose the path of intersubjectivity.
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(i) Nachlass (German) is the collection of written material left behind when a scholar dies.
(ii) Husserl used the term “monads” for individuals.
(iii) “Enunciative modalities” refers to the theoretical position from which a person is speaking. Questions can be raised, such as – “On whose authority and/or on what evidence do you make that statement?” These positions can change for any number of reasons, not the least being advances in scientific knowledge
(iv) A “truth claim” is another way of saying that a particular proposition is true.
(v) Decentralisation here means the transferring from patient to clinician of the decision-making power.
(vi) These thoughts recall the English poet John Donne (1572-1631) who famously wrote: “No man is an island, entire of itself; every man is a piece of the continent.”
(vii) Empiricism, a word derived from the Greek, means ‘experience’. Taking an empiricist perspective is seen as placing an undue reliance upon one’s experience by assuming that what humans see is actually there in the way we see it. Which would mean that all other creatures see the world wrongly.
(viii) These important matters were raised and discussed in a previous article. Available at: http://www.fmperplex.com/2016/02/08/381/
(ix) Narrativisation is the presentation or interpretation of the clinical problem by means of a story or narrative.
(x) Apperception refers to how you put new information into context. You get a perception of a chair through your eyes, but apperception is how your mind relates it to chairs you’ve seen before.
(xi) Our “epistemic starting point” refers to where we started out from in our quest to understand intersubjectivity.
(xii) Intentionality is the ability of our minds to be about, to represent, or to stand for, things, properties and states of affairs.
(xiii) Normativity is the phenomenon in human societies of designating some actions or outcomes as good or desirable or permissible and others as bad or undesirable or impermissible.