The essence of care in health vulnerability : a Heideggerian construction

Objective: Refl ect on the essence of care in health vulnerability from the phenomenological perspective of Martin Heidegger. Method: Theoretical-refl exive study, anchored in three essential parts: 1) Care in Heidegger; 2) The essence of care in health vulnerability; And 3) Nursing care actions on health vulnerability. Results: Vulnerability must be recognized as an indelible trait of the human condition and has its constituents in the human being, co-presence and care. Caring is an interactive process that reveals itself in the relationship with the other. Respecting the integrity of the Being in vulnerability must be a priority in nursing care, through behaviors that privilege the Being. Conclusion: Understanding ontological care and its relation to vulnerability under Heidegger’s phenomenological view allowed us to uncover the facets of care in health vulnerability by adding to the nursing knowledge body a comprehensive and refl ective perspective. Descriptors: Health Vulnerability; Philosophy, Nursing; Hermeneutics; Comprehensive Health Care; Nursing Care. RESUMO Objetivo: Refl etir sobre a essência do cuidado na vulnerabilidade em saúde sob a perspectiva fenomenológica de Martin Heidegger. Método: Estudo teórico-refl exivo, ancorado em três partes essenciais: 1) O cuidado em Heidegger; 2) A essência do cuidado na vulnerabilidade em saúde; e 3) As ações do cuidar em enfermagem na vulnerabilidade em saúde. Resultados: A vulnerabilidade deve ser reconhecida como traço indelével da condição humana e tem seus constituintes na pessoa humana, co-presenças e cuidado. O cuidar é um processo interativo que se desvela na relação com o outro. Respeitar a integridade do Ser em vulnerabilidade deve ser prioridade no cuidar em enfermagem, por meio de comportamentos que privilegiem o Ser. Conclusão: Compreender ontologicamente o cuidado e a sua relação com a vulnerabilidade sob o olhar fenomenológico de Heidegger permitiu desvelar as facetas do cuidado na vulnerabilidade em saúde, agregando ao corpo de conhecimento da Enfermagem uma perspectiva compreensiva e refl exiva. Descritores: Vulnerabilidade em Saúde; Filosofi a em Enfermagem; Hermenêutica; Assistência Integral à Saúde; Cuidados de Enfermagem. RESUMEN Objetivo: Refl exionar sobre la esencia del cuidado en la vulnerabilidad de la salud bajo la perspectiva fenomenológica de Martin Heidegger. Método: Estudio teórico-refl exivo, basado en tres partes principales: 1) El cuidado de Heidegger; 2) La esencia del cuidado en la vulnerabilidad de la salud; e 3) Acciones del cuidar de la enfermería en la vulnerabilidad de la salud. Resultados: La vulnerabilidad debe ser reconocida como un trazo indeleble de la condición humana y tiene sus constituyentes en el propio ser humano, en las copresencias y en el cuidado. El cuidar es un proceso interactivo que se devela en la relación con el otro. Respetar la integridad del Ser en su vulnerabilidad debe tenerse como prioridad en el cuidar de la enfermería, mediante comportamientos que lo prioricen. Conclusión: Comprender ontológicamente el cuidado y su relación con la fragilidad bajo The essence of care in health vulnerability: a Heideggerian construction A essência do cuidado na vulnerabilidade em saúde: uma construção heideggeriana La esencia del cuidado en la vulnerabilidad de la salud: una construcción heideggeriana


INTRODUCTION
One of the fundamental tasks of the human condition is the act of caring, which is consolidated through the bond between the caregiver and the cared for.Caring incorporates different meanings, and can convey compassion, action, diligence and zeal.Sometimes it means placing oneself in the place of the other, that is, being with the other, as regards the special questions of the individual's life and their social relations (1) .In this perspective, care is embedded in the relations of the existence of the human being.
Care, in phenomenological thinking, names a mode of being that is active in all and any behavior, be it diligent or negligent behavior, fearful or assertive, attentive or inattentive, which will always be fulfilled as performance of care (2) .Thus, in order to understand the essence of care, we should look in a differentiated way at the presence and co-presences related to its existence.
Martin Heidegger, German philosopher of the twentieth century, stands out for his reflections on the Being, the presence, the cure and the nuances of care.Being is the way something becomes perceived, manifested, understood, and finally known to the human being in his or her existence.Healing, in turn, occupies the space of a double meaning, meaning "care" and "dedication" (3) .The philosopher expresses care as an act that occupies an ontological sense, proper to human nature.
Care is based on the essence of Being, giving meaning to existence and manifesting itself in different ways.Linked to care, emerges the principle of vulnerability, defined as the possibility of being injured, suffering any damage or health condition concern (4) .In the scientific literature, the term vulnerability is used repeatedly as synonymous with risk, susceptibility and fragility, being perceived and discussed as a negative condition.This concept limits their understanding and makes it difficult to operate in the context of health services with a view to promoting individual and collective well-being.
Vulnerability is one of the modes in which the presence may or may not present itself.Vulnerability presence is a manifestation of Being, which thus presents itself and in the relations of care established with the other co-presences in existence.
Differently from a superficial understanding, care and vulnerability are not present only in the field of health, but in the Being itself and in relationships, materializing in education, politics, economics.Thus, a holistic, multi, inter and transdisciplinary view of caring is necessary.
Under the phenomenological view, the nursing area manifests itself fundamentally through care and, in this sense, is privileged, because its proximity to the presence enables it to reach the Being, with the construction of bonds (2) .Caring for nursing consists of making transpersonal efforts from one human being to another in order to protect, promote and preserve humanity.It is also to help other people to gain knowledge, control and selfcare (5) .The actions of nursing assume, therefore, prominence in the caring relationship.
In order to contribute to the ontological construction of care in health vulnerability, we proposed this theoretical-reflexive study, which was anchored in three essential parts, interrelating them at the end of the article: 1) Care in Heidegger; 2) The essence of care in health vulnerability; And 3) Nursing care actions on health vulnerability.Martin Heidegger's work Being and Time (2005) was chosen as the theoretical framework for bringing the question of Being into its presuppositions.In it, the author chooses Man as the way to know Being.This understanding, associated to the comprehension that vulnerability is directly related to the human being and his/her existence, justifies the choice of Heideggerian phenomenology for the theoretical foundation of this study.
Thus, the objective was to reflect on the essence of care in health vulnerability under the phenomenological perspective of Martin Heidegger.

HEIDEGGER AND CARE
The human being is relative to the apprehension of the human being as Being-there (presence or Dasein), expressed from the understanding of the existence of the man as Being-in-the-world.It should be noted that presence is not synonymous with man or human, but a structural relation is conserved.Presence is the pure expression of Being (3) .Thus, the Being constructs in the presence of its existence, in the world in which it is inserted.
Co-presence is justified in the indispensable correlation of the human being with others (Being with or Mitsein), because there is never an isolated being or mode of being.Thus, the presence is always a co-presence, the world is always a shared world and living is always co-existence (3) .From this perspective, Being-there affirms itself as the Being-with in the relation that is established between the presence and co-presence, being of this relation that care arises.
Existence is used to denote the full richness of reciprocal relations between presences and co-presences.It is the Being itself with which the presence can behave and with which it will always be composed in some way: it is the pure expression of the Being.Thus, the presence always understands itself from its existence, or the possibility of being able to be or not itself (3) .
Being-there, as Being-in-the-world, finds the possibility of living in an inauthentic or authentic way.Inauthentic existence is characterized as an improper mode of Being, that is, it is a sphere of existence that follows without its own direction (3) .Inauthenticity is the existing Being who has not yet called upon itself the responsibility of assuming for itself its presence in the world (6) .la mirada fenomenológica de Heidegger permitió develar las facetas del cuidado en la vulnerabilidad de la salud, dándole una perspectiva comprensiva y reflexiva al cuerpo de conocimiento de la Enfermería.Descriptores: Vulnerabilidad en la Salud; Filosofía en Enfermería; Hermenéutica; Asistencia Integral de la Salud; Cuidados de Enfermería.
Authentic existence is a proper mode of Being, since it refers to the possibility of the Being-there to recognize itself as Being, freeing itself from anonymity and impersonality.In this possibility, anguish is one that can bring the presence back to the encounter of its totality as an Ontological-Being.Heidegger's anguish is not something paralyzing, but an opening to one's own existence.It is a possible resource for transcending the world and itself, making oneself out of the indifference of everyday life.Anguish is understood, therefore, as the movement for the rupture of what is set.
Carefulness, in the Heideggerian perspective, is understood as the totality of the ontological structure of Beingthere (6) .Care is at the first root of the human being, before any action, and all action is accompanied and imbued with care (7) .
Presence always occurs in an exercise that indicates and fulfills a radiating center of relationships.Therefore, the exercise of presence promotes relationships with two modes of being of existence: occupation (occupy from or with) and concern (solicitude, caring actively for someone who needs help).Occupation and concern are therefore constitutive of healing, so that to understand how busy-concerned healing means that, in this occupation and concern as a cure, the very Being who cares is in question (3) .Care is based on Being-there, giving meaning to existence, because it is a way of being in the world, in the relationship with oneself and with others.
The essence of Heidegger's care is expressed in authentic existence.It is active, assuming its responsibility, and manifests itself in its daily life through the possibility of openness to the world.Vulnerability presence is embedded in human beings as part of their existence.The condition of vulnerability calls for authentic care, in which the Being has the possibility of recognizing his anguish and transcending, to go beyond his own existence.

THE ESSENCE OF CARE IN HEALTH VULNERABILITY
In the historical epistemological course of the field of epidemiology, the language of risk reached its discursive formalization, being apprehended as the mathematical expression, in which the rationality applied to representational quantitative risks and epidemiological vulnerabilities is evidenced.
The concept of risk indicates probabilities, while vulnerability exists as an indicator of inequity and social inequality.In this way, vulnerability predates risk and, in seeking to understand the mediations present in the health-disease process, promotes different possibilities for coping with them and related to people's daily lives (4) .
Vulnerability involves three interdependent fields: individual component or the understanding of personal behavior, social component or social context and programmatic or institutional component (8) .The interrelation among the dimensions described points to the need of broaden the understanding and interpretation of the constituents in order to clarify the understanding of vulnerability.
In order to move beyond the traditional approach to risk reduction strategies, vulnerability emerges as a concept of redirecting these actions to more contextual and social dimensions, the scenarios in which it materializes (8) .In general, vulnerability is described as situations of threat to human autonomy, as well as the process of being at risk for the development of diseases, harms or damages, resulting from a set of individual, collective and contextual aspects.However, it is inferred that this conception of vulnerability is limited, because it is restricted to negative consequences, evidencing man as passive.
Understanding vulnerability as an intrinsic condition to human existence generates the extension of this concept.Vulnerability must be recognized as an indelible trait of the human condition, in its irreducible finitude and fragility, as a permanent exposure to be wounded (1) .Reflecting on individual, social and programmatic dimensions (8) involving the individual and the community, also contributing to increasing levels of vulnerability, is to understand the essence of care in vulnerability presence.
The dissection of these dimensions allowed the meeting of their ontological correspondents in the Heideggerian phenomenology: human being, co-presence and care.It is observed that the phenomenological understanding of the elements assures their relational character and firm them as essential constituents of the vulnerability (Figure 1).Thus, when something interferes with some of these elements, causing imbalance, vulnerability emerges.
The essence of care in health vulnerability refers to modes of occupation and concern that sometimes take on deficient, inadequate forms such as variations, distortions, and exaggerations of the mode of concern (substitution, anticipation and consideration), or impersonal in occupation (Figure 2).
Concern is based on the ontological constitution of the presence as being-with and its positive modes refer to extreme possibilities.Substitution consists in withdrawing the "care" from the other and taking the place in the occupations, replacing it.In this concern, the other can become dependent and dominated.The concern that precedes the other in his existential possibility of being also subsists.This concern, in its essence, refers to healing itself, helping the other to become transparent and free to himself.Concern is guided by consideration, which expresses the commitment to go after, accepting the tensions, limits and differential characteristics of situations and modes of being (3) .

Human being
Co-presence The essence of care in health vulnerability: a Heideggerian construction Cestari VRF, et al.
is the human being, qualified in four dimensions: physical health, mental health, social health and spiritual health (1)(2) (Figure 3).
Occupation determines the presence of the presence in general (3) .In this form of healing, there is responsibility, but the perception of the other does not exist as an extension of one's presence, that is, occupation is given by obligation, and care is present in technique.The improper mode of occupation occurs when impersonality reigns.For Heidegger (3) , impersonality is an existential, belonging to the positive constitution of the presence.Impersonality removes the responsibility of each presence and prescribes the modes of being of everyday life.In this way, we stick to the medium of what is convenient.It is understood, therefore, that the nature of the impersonal resides in the mediumship.

THE ACTIONS OF CARING FOR NURSING IN HEALTH VULNERABILITY
Health work is centered on live-in-work, that is, human labor at the very moment is performed and determines the production of care.In this sense, there are three valises that involve the technological arsenal of health work: the instruments (hard technologies), the structured technical knowledge (light-hard technologies) and the relations between subjects that are materialized in actions (light technologies).It is essential that nurses understand and know the technologies used in the health work process, since nursing work contributes to the promotion, protection, maintenance and recovery of health or even to a dignified death.Thus, technologies liberate men from certain functions that can subjugate them (9) .We should understand that care occupies all spaces, being strongly implicated to the sense of Being, in co-existing (3) .
In nursing, care should be conceived as a way of living, of being, of expressing oneself.It is an ethical stance towards the world, a commitment to human dignity and its spirituality.In this way, it involves all behaviors and attitudes developed with competence to favor the potentialities of care subjects and maintain or improve the human condition in the process of living or dying (5) .It is perceived that the Being of care in the actions of nursing care Physical health is understood as the normal development of the individual, with balance between the organic components.Mental health implies orientation in time and space, absence of alienation, ability to balance themselves in different life situations, self-realization, openness to others and for oneself, freedom of thought, expression and creation.Social health is the adjustment of the individual in the social group, involving adequate housing, balance of economic factors, leisure, education and relationships.The spiritual health is revealed in the way of facing life.Belief in an absolute or transcendent Being is fundamental to overcoming obstacles (1)(2) .These four dimensions are associated in an intersubjective dynamic way, permeating the human being, endowed with perceptions, feelings, values and knowledge.
Nursing professionals deal with the human being in his or her existential condition all the time, who can, by the facticity of the world, be in a state of illness.In an authentic Heideggerian saying, the human being is not, in this condition, a sick Being, but it is a Being who is experiencing a situation of "being sick", which affects him in the various spheres of his being (3) .
In order to meet the needs of the human being, nursing values must be based on solidarity (which favors human life inserted in society), the value of truth (corresponds to the human desire to know the real), morality (it is presented by demanding an intention of love, being realized by means of good works and projecting itself in the world as a duty to be) and utility (it is what favors life).It is important to highlight that these values cooperate for the development and growth of all those involved in the care process (5,7) .
Care is involved in the actions of human beings integrally and incorporates human existence as a manifestation of sharing, exchange and reciprocity (5) .In this sense, health care is imbricated in the professional-patient relationship, in which caring for oneself should not be forgotten or underestimated, but understood in the uniqueness of the other.Caring for oneself is perceived as essential for the human being as soon as people become aware of their right to live and the way of life they have (2) .In caring for oneself, the Being inserts itself in an emancipatory and transforming process, becoming active in its existential trajectory.
Authentic care becomes essential in Nursing practice so that they are perceived as beings who care for other beings, with authentic concern, in a professional, therapeutic, scientific and human way, in order to achieve health and well-being of those who they care.In this way, they provide freedom and conditions to experience the very possibilities of Being (7) .
In order to ensure authentic care, nursing theories are firmly established as a strategy for identifying the work object, designing actions in a systematic way.Theories allow the creation of a space of own knowledge and represent an attempt to expand or renew knowledge, as a specific knowledge for nursing (10) .In the context of the knowledge network around health care and vulnerability, nursing theories can corroborate the construction of a health model consistent with authentic care, by guiding the actions and the critical reflection of the nurse.

Study limitations
One limitation to be considered in the elaboration of this reflexive study was the terminological confusion between vulnerability and risk, frequently used in national and international scientific literature.The close relationship between both concepts reduces the understanding of vulnerability, which goes against the evolution of Being.
Contributions to the area of nursing, health or public policy In the scope of care in health vulnerability, this study contributes to the apprehension of caring as an interactive process that reveals itself in the relationship with others.Respecting the integrity of the Being in vulnerability, regardless of their condition, should be a priority in nursing care, considering behaviors that privilege Being.

FINAL CONSIDERATIONS
Care is revealed in the relations of the existence of the people who care and are cared for, involving consideration and respect in the modes of being, of proceeding as essence and human existence.The phenomenological view of Martin Heidegger allowed us to unveil the facets of the Being of care in health vulnerability, adding to the body of knowledge of the Nursing area a comprehensive perspective.
The intimate relationship between human beings and vulnerability was verified, enabling the apprehension of the vulnerable Being as the Being of care, which requires authentic care to overcome barriers and reveal itself in its existence.To this end, nursing care must be imbued with expressive, competent, safe actions, aimed at promoting health and well-being, as well as favoring the potentialities of being cared for.
The condition of vulnerability in health should not assume more importance than the care itself.Authentic care enables the presence to assume its possibilities and choices, moving away or taking risks.It is opportune for us nurses to respect such choices, educating and stimulating the educational care of Being-there in the unveiling of their existence.