Philosophy of Nursing: a New Visionfor Health Care

By J. M. Brencick and G. A. Webster, State Universityof New York Press, New York, 2000, ISBN0791443809, 247 pp., £15.50.

This latest contribution to the area of philosophy ofnursing attempts to provide a general approach tonursing practice that is also applicable to all areas ofhealth care work.

The strategy adopted in the book is to focus on therelationship between the general and the particular;or, in the authors’ terms, the universal and the par-ticular. The way they do this is to describe a specificnursing event and then to describe imaginary con-versations between a nurse and several philosophers,ancient and modern, who have developed positionson the question of the relationship between univer-sals and particulars. Thus dialogues are presentedwith Plato, Aristotle, Whitehead and several others(including Hildegard of Bingen described in the bookas a mystic). These dialogue parts of the book areexploited as opportunities to describe the generalpositions of the philosopher involved. For example, itis explained that for Plato universals are separablefrom their instances but for Aristotle they are not.More general positions on epistemology and ontol-ogy are also rehearsed. Kant’s division of reality intothe phenomenal and noumenal realms is explained,and so too is Whitehead’s ontology of ‘experiencingparticles’.

Following these imaginary dialogues with philoso-phers there is a sympathetic but critical discussion ofthe work of Jean Watson. Also, in the penultimatechapter the authors set out their own ‘philosophy ofnursing’.

It is not possible to do justice to their approach ina brief review such as this, but stated simply their view seems to come to this: caring is central tonursing. Caring involves interacting with persons at a spiritual level. This requires access to persons at a plane of reality that is distinct from the reality that is the object of scientific enquiry (they exploit Kant’s noumenal/phenomenal distinction to makethis claim).

Persons are properly conceived of as ‘communitiesof experiencing entities’ (p. 160). When an individualcomes to think they are becoming ill (‘coming downwith a cold’) this is because one or more of the ‘com-munities of experience’ that comprise that individualconveys this. In such a view of the person (one influ-enced by Whitehead as is stated in the book) all particles are claimed to ‘experience’ the world. Evennonconscious things experience the world in White-head’s sense. Brencick and Webster extend this totheir account of the person. Thus, presumably, thevarious bodily systems and subsystems that constitutethe individual all count as ‘communities of experi-ence’. Ill-health is understood as ‘disharmony’ in thecommunity of experiencing entities that constitutesthe ill person. When nursing a patient the respective‘communities’ that constitute the nurse and thepatient become closer and the possibility of caringemerges.

The spiritual flavour of the authors’ proposal isemphasized especially by them. When caring occursin the nurse–patient relationship this is said to involve‘the relationship between the community of personsand the Infinite One, [and] to the return of heaveninto earth . . .’ (p. 166). The spiritual plane of realityis also claimed to be a source of guidance in relationto moral matters (p. 165, p. 187).

So the aim of health care work is preserving orrestoring harmony in ‘communities of experience’.Also, in nursing caring is an especially important wayof achieving this aim. As noted, caring brings two distinct communities of experience (the nurse and the patient) closer.

I will close this review with a brief summary of whatseem to me to be the principal strengths and weak-nesses of the book.

With regard to strengths: the decision to focus onthe relationship between the general and the particu-lar seems a good one. This is clearly an area in whichmuch further work needs to be undertaken in philoso-phy of health care, because it seems that in order todo such work one needs knowledge of general rulesand scientific principles (e.g. relating to physiologyand chemistry), yet one needs to be sensitive to howthese apply in the case of each particular patient.Thusthe very term ‘patient’ is a general term fundamental

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to nursing (and of course ‘nursing’ is itself a generalterm), which is applicable to each particular patientthe nurse encounters. Yet, although all patients arethe same in that respect, they are all individuals andof course it does not follow that all patients are to betreated in the same way. This problem raises tensionsfundamental to health care work. For example nurseeducation seems to require the learning of general-izations, and the whole attempt to develop nursingtheory is an attempt to articulate generalizationsapplicable to nursing practice.

So it is unquestionably the case that the authorshave chosen a central arena to develop their own ‘philosophy’ of nursing and their ‘new vision forhealth care’.

The authors also deserve credit for their ambition.They attempt to carve out a new approach to healthcare work. It is one based upon an original ontologyof the person, and which involves commitment to alayer of reality beyond the scope of science; specifi-cally, a spiritual layer – that of the Infinite One, orGod. They explicate the concept of care by referenceto these two ontological theses (i.e. concerningpersons and God). Relatedly, they show that giventheir ontology of the person, health care work shouldbe ‘holistic’. Persons are ‘communities’, therefore it iswrongheaded to focus simply on one such community– e.g. one specific bodily system – at the neglect ofconsideration of how any interventions directed atthat system affect the whole ‘community’.

Some weaknesses – although the idea to focus onthe general and the particular is a sound one, it didnot seem to me that much progress is made in thebook in relation to explication of it. The authors staterepeatedly that individual persons and individualnursing events are composed of aspects that are bothsingular and universal, not much that is instructiveseems to be said beyond this. What is said seems toboil down to the point that the symptoms of illnesshave to be understood in the context of the patient’slife. This is a point made by others, e.g. Benner andWrubel (1989).

Furthermore, the positing of a realm of reality, aspiritual realm, or noumenal realm, seems ontologi-cally extravagant. The authors are clearly motivatedto do this by their spiritual views, but secular nurses

will not be persuaded that the positing of such a realmis necessary to make sense of the ideas of caring, ormorality. It can be claimed, plausibly, that a secularaccount of caring is indeed possible, e.g. in terms ofactions and appropriate mental states (specified innonspiritual terms).

The view that a spiritual realm can serve as a sourceof moral guidance will also trouble many secularnurses.What if such ‘guidance’ leads to a nurse takingdecisions about patient care that others find stronglyobjectionable? Is it sufficient for the nurse simply topoint to the source of her guidance? Clearly not.

The idea of persons as communities of experiencealso seems ontologically extravagant. The proposalthat all existing things are thereby experiencingthings adds an avoidable complication to the distinc-tion between things that merely exist and things thatboth exist and can experience things (in the usualsense of experience).

The appeal to holistic health care might also bechallenged. For example, suppose one has a splinter.One simply wants this removed. There seems no place for holistic care in such instances. Also, the idea of specialism seems defensible. It seems per-fectly legitimate to have health care professionalswho have specific areas of expertise, into the func-tioning of the nervous system for example. So theview that demonstrating the need for holistic carecalls specialism into question is open to objection.

The vision of nursing presented here, and in anumber of other USA texts on nursing is one thatmany UK nurses will find hard to recognize. Such avision is one in which nurses seem to have consider-able time to spend with patients and be prepared toinvest tremendous levels of emotional commitmentto them. For this reason many UK nurses may well besceptical about the ultimate value of the vision pre-sented in this book. Having said this, readers who aresympathetic to the work of figures such as Watson,Parse and Rogers are likely to find this book of veryconsiderable interest. It seems to me, ideas gesturedtowards in the works of these writers are expressedclearly in this book – perhaps more clearly than in theworks of those other writers.

Finally, in my opinion the book is an important con-tribution to philosophy of nursing. Some progress is

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made on examination of the relationship between thegeneral and the particular, although as stated above,this seems limited. Also, there are useful summariesof the views of many philosophers. The key chapterin the book, that in which the authors state their ownphilosophy of nursing, is a brave attempt to linknursing to a spiritual dimension of human existence.This attempt is interesting and warrants closescrutiny. But this reader, at least, did not find it persuasive.

Steven EdwardsUniversity of Wales Swansea

Practical Reason: On the Theory of Action

By Pierre Bourdieu. Polity Press, Cambridge, 1998,ISBN 0-7456-1625-9, (pb) 153 pp., £12.99.

Acts of Resistance:Against the New Myths of Our Time

By Pierre Bourdieu. Polity Press, 1998, ISBN 0-7456-2218-6, (pb) 108 pp., £9.99.

The Weight of the World: SocialSuffering in Contemporary Society

By Pierre Bourdieu. Polity Press, Cambridge, 1999,ISBN 0-7456-1593-7, (pb) 720 pp., £16.99.

Pascalian Meditations

By Pierre Bourdieu. Polity Press, Cambridge, 2000,ISBN 0-7456-2055-8, (pb) 320 pp., £12.99.

The work of Pierre Bourdieu has made little impactupon the discipline of nursing. Yet his work seems farmore salient for nursing than that of, say, Foucault,Habermas, Heidegger, and the motley gaggle of ‘post-modernists’ that are a growing feature of the morephilosophical reaches of nursing discourse. Bour-dieu’s work is very wide-ranging. He can legitimatelyclaim to be an anthropologist, sociologist, social the-orist, philosopher and empirical researcher. He is theauthor of over 30 books and of over 300 papers. ‘Atthe base of this work is both a philosophical perspec-

tive and practical methodology which have attemptedto establish an alternative to the extremes of post-modernist subjectivity and positivist objectivity. . . Bourdieu’s ideas offer an epistemological andmethodological third way’ (Grenfell & James, 1998,pp. 1–2). This chimes with my attempts to argue forrealism as a ‘third way’ in nursing (Wainwright, 1997;Wainwright, 1999). Bourdieu attempts – via his devel-opment and use of the concepts of capital, habitus and field – to sublate some of the classic dualisms that beset (and damage) social research (e.g. theobjective–subjective, agency–structure, idiographic–nomothetic, and theory–research antinomies). More-over, an analysis of the logic of practice is central to Bourdieu’s quest. His aim is ‘to make the mundaneexotic and the exotic mundane’ (Bourdieu & Wacquant, 1992, p. 68). This strikes me as a usefultouchstone with which to guide nursing (even social)research.

Practical reason elaborates the fundamental char-acteristics of his theoretical approach. Habitus isBourdieu’s key concept. ‘Habitus may be read as agun out of which the individual is shot, thereby deter-mining their social trajectory’ (May, 1996, p. 127).Habitus therefore tends to reproduce existing socialstructures; it is ‘durable but not eternal’ (Bourdieu &Wacquant, 1992, p. 133). Habitus, which reflects classposition, produces distinctive bodily forms that areendowed with differential social, cultural and eco-nomic value (e.g. diet and exercise). Habitus is essen-tially a processing of structure. Habitus is a rathervague and elastic concept.The reaction of some nurseacademics here would be to subject it to a ‘conceptanalysis’. Yet this is the opposite of what Bourdieurecommends. What matters to Bourdieu is how theconcept can be employed and made to work in hisempirical research. The very flexibility of habitus is therefore its strength and this has allowed Bour-dieu to produce a series of dazzling insights into dis-parate aspects of the social world (see Lane, 2000).For example, on the culture of distinction, academia,art, literature, education, the cultural practices ofFrench peasants and of Algerian ‘tribal life’, even onfootball!

A second key idea is that of capital. Here Bourdieusupplements the idea of economic capital with a

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variety of other capitals. Namely, symbolic capital(prestige, the recognition of economic or culturalcapital); cultural capital (legitimate knowledge andoccasionally also physical capital); and social capital(relations with ‘significant others’). Capital is there-fore a resource (a form of wealth) that yields power.How much a type of capital can be cashed out fordepends on a third key idea: that of the ‘field’. To givean autobiographical example: having a degree ingeography and being a qualified teacher counted fornothing when I worked as a clinical nurse in ICU, butthis cultural capital was crucial in my move into nurseeducation and research.

In Practical reason the reciprocal relationshipbetween the embodied structures of the habitus andthe objective structures of social fields are exempli-fied in a series of concrete analyses. These range fromdiscussions of the family as a site of social reproduc-tion through to reflections on political morality. Ithink a Bourdieusian perspective on clinical prac-tice would have profound ramifications for nursingresearch. To function as social beings we usuallysimply take our social world for granted. We do notthink about what we do because we do not have to.For Bourdieu practice is governed by a ‘logic of prac-tice’. Attempts to provide ‘theoretical logics’ of whatis a practical logic (like riding a bike) are thereforemisguided. Hence the practical logic of everydaylifestyles and health-related behaviours explains thegulf between peoples beliefs about health promotionand their inactions. Most behaviours are literally theembodied practices of a person’s habitus.

Perhaps Bourdieu’s most influential book is Dis-

tinction (1984). This 600 page social science citationclassic has sold over 100,000 copies in France.More recently, The Weight of the World was also abestseller in France. The original publication of thisbook led to a wide-ranging debate on inequality, civicsolidarity and politics. This is a massive ethnographyof the social suffering that persists in Western soci-eties. The book documents the discriminations, ten-sions and conflicts in the everyday worlds of theunemployed, farmers, and factory and clericalworkers. The family, the school, declining estates, thework of the police and social workers are all grist tothis monumental work of social research. This book

gives voice to the silence of their despair. Any nursewith more than a passing interest in any one of theareas of inequal-ities, social exclusion, citizenship,social justice and critical social theory should readthis classic book.

Acts of Resistance is Bourdieu’s most explicitlypolitical work. The book is a sustained attack on themyths of neo-liberalism. The book charts the rise ofprivate enterprise and the corresponding decline ofpublic welfare. Bourdieu argues that flexible marketsand global competitiveness is increasing the misery ofswathes of ordinary people. All too often failure inschools is interpreted as individual, not class based,thereby maintaining class hierarchy. The middleclasses replicate their habitus while their workingclass counterparts attempt the much harder task oftransforming their habitus. Differences in habitusshape an unequal fight and so are instrumental in thereproduction of inequalities. ‘One is always surprisedto see how much people’s wills adjust to their pos-sibilities’ (Bourdieu, 2000, p. 216).

In contrast to the political polemics of Acts, Pas-

calian Meditations is Bourdieu’s most explicitly philosophical work. Bourdieu originally trained as aphilosopher. It has become something of a habit(us)for Bourdieu to read philosophy every day. LikeHabermas, he too was once a Heideggerian. It seemsthat a penchant for Heidegger is something that somegreat intellectuals grow out of. Pascalian Meditations

draws on the philosophers Wittgenstein, Austin,Dewey and Pierce in a critique of the nature of schol-arly reason.The book addresses grand themes: power,time, history, the universal, and the purpose of exis-tence. The book is a typically Bourdeausian mix ofdensely argued prose and bon mot. For example: ‘Itis not sufficient to change language or theory tochange reality . . . While it never does harm to pointout that gender, nation, or ethnicity or race are socialconstructs, it is naive, even dangerous, to suppose thatone only has to “deconstruct” these social artifacts,in a purely performative performance of resistance,in order to destroy them . . . One may . . . doubt the

reality of a resistance which ignores the resistance of

reality’ (Bourdieu, 2000, p. 108, my italics). I suspectBourdieu will test the intellectual mettle of many anurse academic!

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This set of recent books by Bourdieu may seem torepresent different facets of his outstanding intellect.However, the way in which Bourdieu fuses empiricaldata with both theoretical acumen and philosophicalinsight is a lesson for all of us in both the ‘science and art’ of doing social research. Reviews of Bour-dieu’s contribution as a social thinker range from full-some praise (‘this is the most original and cogentmodelling of the social world that we have’; Fowler,1997, p. 13) through to idolatry (‘not only the best,but . . . the only game in town’; Lash, 1993, p. 193).However, the best way to appraise Bourdieu’s workis simply to use it. But first you need to read it . . . sobuy these books!

References

Bourdieu P. (1984) Distinction: a Social Critique of theJudgement of Taste. Routledge, London.

Bourdieu P. & Wacquant L. (1992) An Invitation to Reflex-ive Sociology. Polity Press, Cambridge.

Fowler B. (1997) Pierre Bourdieu and Cultural Theory:Critical Investigations. Sage, Thousand Oaks, California.

Grenfell M. & James D. (eds.) (1998) Bourdieu and Educa-tion: Acts of Practical Theory. Falmer Press, London.

Lane J.F. (2000) Pierre Bourdieu: a Critical Introduction.Pluto Press, London.

Lash S. (1993) Pierre Bourdieu: cultural economy andsocial change. In: Bourdieu: Critical Perspectives(eds C. Calhoun, M. Postone & E. LiPuma), pp. 193–211.Polity Press, Cambridge.

May T. (1996) Situating Social Theory. Open UniversityPress, Milton Keynes.

Wainwright S.P. (1997) A new paradigm for nursing: thepotential of realism. Journal of Advanced Nursing, 26,1262–1271.

Wainwright S.P. (1999) Scientific Realism in Nursing. Papergiven at the third ‘Philosophy of Nursing’ conference,15–17 September 1999. Centre for Philosophy andHealth Care, University of Swansea, UK.

Steven P. WainwrightResearch Fellow, Florence Nightingale School of Nursing and

Midwifery, King’s College London

Confessions of a Philosopher

By Bryan Magee, Phoenix Press, London, 1998,ISBN 0753804719, 496 pp. (paperback), £8.99.

Bryan Magee suggests that it is a mistake ‘for begin-ners to think they can get very far by themselves in

the study of philosophy’. So it is not surprising thatthere are many introductory philosophy texts, but inmy experience there is a problem in that most of them are not very helpful, and may even put offrather than encourage beginners. However ‘Confes-sions of a Philosopher’ takes an unusual approachwhich I found both engaging and successful, and thereare several reasons why this is so.

First of all Magee did not decide to become aphilosopher for academic reasons, but rather has beencaptivated by philosophical problems and ideas eversince his childhood, even before he recognized themas such. Second, he did not choose to follow a careeras a professional philosopher, but nevertheless hasbeen immersed in philosophy throughout his life,alongside a range of other interests, notably music,the theatre, politics and broadcasting. This leads himto describe himself as a commentator on philosophyrather than a player, both an insider and an outsider,who like an anthropologist can stand back from the philosophical scene, even when he is intimatelyinvolved with it. Third, he is a consummate commu-nicator having devised and presented several radioand television series about philosophy and philoso-phers. So his writing is readily accessible to the lay-man, as well as providing fascinating insights into thelives of many contemporary philosophers who havetaken part in these programmes. Finally, he originallygraduated from Oxford in history, and his ideas arealways presented within a broad historical per-spective, which helps the beginner to situate them.

All of this enables Magee to stand apart from thepresent context of British philosophy, which heargues is both parochial and deeply flawed. Duringmuch of the twentieth century, philosophy in Britainhas been in thrall to the analytic tradition and domi-nated by Oxford philosophers. Magee suggests theyare like art critics or musicologists rather than artistsor composers, and thus are like men who sit polish-ing their glasses without any concern for lookingthrough them at the world. He therefore goes on toclaim that what they do is not actually philosophy atall, because real philosophy must be concerned withquestions and problems about the world and in doingso must be creative and synthetic, not merely analytic.The prevailing characteristics of these so-called

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philosophers are he suggests a ‘clever shallow-ness – self-congratulatory, complacent, a combinationof self-assurance with blinkeredness’. Recently thistradition has been giving way to an interest in Continental Philosophy, but this comes off no morelightly than analytic philosophy because of whatMagee sees as its wordy emptiness and lack of rigour. Popper is the only recent philosopher whosework he admires wholeheartedly for having eschewedboth these fashionable traditions. Magee alsoexcludes moral problems from the realm of phi-losophy altogether, because he considers them to bepractical matters which are not amenable to logicalenquiry.

The appropriateness of this approach as an intro-duction to philosophy is not that the uninitiatedshould necessarily agree with Magee’s detailed con-clusions, but rather that he demonstrates the intellec-tual excitement of his own philosophical progress, andinvites readers to embark on a similar journey forthemselves. The inclusion then of much everydayautobiography is not just an entertaining addition, butpart of the message. What it shows is that at thedeepest level philosophy is inextricably part of one’slife, and one in which for Magee music and art arealso interwoven. To be a true philosopher one has to

have philosophical problems and be interested inphilosophical ideas. A few people, like Magee, areborn philosophers and remain so throughout theirlives. Philosophy captures them, rather than themchoosing to do philosophy. So philosophy is not some-thing anyone can decide to take up or drop at will,but rather something for which they need to have afeel. Most of us are inclined this way to some extentthough, and what this book does is to show by personal example how such intrinsic philosophicalinquisitiveness can be fostered and made enjoyable.

All this is a far cry from the dry systematic tech-nical approach usually adopted by professionalphilosophers. It suggests that philosophy is moreabout ways of seeing and understanding than an aca-demic discipline relating to a particular body ofknowledge. Hence Magee does not attempt toprovide a comprehensive guide to philosophy, but aninevitably partial perspective, which is both delight-fully readable and inspiring. I was sufficiently takenby this book to read it twice in the space of a fewmonths, and would thoroughly recommend it toanyone who wants to get a feel of how philosophyworks in the hands of an impassioned devotee.

David GreavesUniversity of Swansea