RECOGNITION IN AXEL HONNETH : CONTRIBUTIONS TO RESEARCH IN HEALTH CARE

Objective: to systematize the strengths and challenges of Axel Honneth’s Theory of Recognition, and to reflect on these as support for research in health care. Method: this is a reflection article which considers the potential of incorporating the category of recognition in the Honnethian proposition for research, understanding, exercising of practice and management of health care. Results: the process of recognition promotes the exploration and understanding of relations of power and respect, above all in terms of conflict which are ascribed to these. As a result, it indicates support for diagnoses and structuring nuclei for overcoming oppressive and unequal practices, with consequences for dealing with situations of insecurity, weaknesses in self-esteem and vulnerabilities in the interactions between the subjects, which are configured as contemporary challenges. Conclusion: in the scientific exploration of care, management and public policies in health, this theoretical framework can assist in the visibility of the context and in its critical knots, in order to promote autonomy and human dignity, which are relevant for the interpersonal relations in the processes of care, with fruitful contributions to the qualification of the health care. DESCRIPTORS: Health Care. Integrality in health. Social recognition. Research. Measurements, methods and theories. RECONHECIMENTO EM AXEL HONNETH: CONTRIBUIÇÕES À PESQUISA EM SAÚDE


INTRODUCTION
Scientific and biotechnological development, and their valuing in the routine of the health area, have recently been accompanied by a problematization of the techniques, and of positivism, for achieving intersubjectivity in the healthcare. 1 Among the effects, emphasis is placed on those relating to human rights and, as possibilities, disrespect and injustice. 2percussions on quality of life, fragmentation of the healthcare, unequal access to resources, iatrogeneses, and relational and communicational shortcomings are frequently revealed in health studies, and taken as challenges, 1,3 in particular regarding the involvement, participation and wellbeing of people over the entire course of the care. 4uch questions involve dimensions which demand a critical attitude, ethics and a perception of the practices' political meaning.The attitude tends to be more consistent when there is socio-philosophical support which promotes the scrutiny of interactional aspects limited to intersubjectivity, above all in terms of recognition, ethical and moral values, and justice.All these are connected to struggles of greater or lesser size which necessarily run through the health practices.
In seeking conceptual bases and theoretical frameworks which allow reflection and debate in this regard, it is particularly relevant to dwell on the issue of subjectivity in health actions.Thus, one can take intersubjectivity as the meeting between one or more subjects, characterizing the act of placing oneself before the other, which creates co-possibilities and sharings. 1Furthermore, intersubjectivity is a condition for realizing comprehensive health care, based in the autonomy of the subjects involved in the routine experiences of health and illness, and in the full exercising of their citizenship. 1In this regard, the present study indicates, as a premise, that the fecundity of Axel Honneth's Theory of Recognition [5][6] offers contributions for supporting the understanding and exercising of care as an emancipatory practice and, therefore, the interest in its dialog with the field of health in general, which may be extended to that of nursing in particular.
This theoretical framework has been explored in the area of health, 7 above all for discussing healthcare, 8-14 its policies 13 and the experiences of health workers. 15The above-mentioned studies make frequent reference to the issue of recognition and the process of self-realization, in constant transformation, which drives issues of autonomy, self-esteem and equality, with a view to the notion of democracy in contexts marked by inequalities. 5Self-realization refers to the concern and effort which mobilizes the subject to struggle for recognition, an element of connection between the individual dimension (personal self-realization and intersubjective relationships) and the social dimension (social support network and network of sociability). 6The research agendas raise concerns with the issue of social justice and intend, above all, to contribute to social changes in the clinical interventions and in the approaches to care and its management, with a view to the humanization and comprehensiveness of the health practices. 7n the line of these investigations, and seeking to add to them in the perspective of the conceptual densification of this theoretical contribution, the present article aims to systematize the strengths and challenges of Axel Honneth's Theory of Recognition and to reflect on them, as support for research in health.

AXEL HONNETH'S STRUGGLE FOR RECOGNITION
Critical Theory, a philosophical axis of the political-intellectual intervention which forms a basis for emancipation based on the logic of the ruling social organization has, as one of its contemporary representatives, the German philosopher and social scientist Axel Honneth.One of his most important works is The Struggle For Recognition The Moral Grammar of Social Conflicts, 6 which seeks to understand sociability in the tessitura of mutual recognition and its continuous normative reconstruction, based on moral conflicts.It emphasizes the construct of self-realization, understood as the concern and effort which mobilizes the subjects for struggles for intersubjective recognition, with impacts in the moral transformations of society and how this is organized. 6In this work, Honneth bases his views in Hegel, in a re-reading intermediated by the social psychology of Herbert Mead, and, in a certain way, gives continuity to the precursor ideas of Charles Taylor, who emphasized the centrality of the interaction with the other, and its consequences for the constitution of the self, and of personal selfrealization. 16onneth understands recognition as an intersubjective, dialogical and historical construction through which the subjects seek their realization in three essential domains: love, rights and social esteem from which arise, respectively, self-confidence, self-respect and self-esteem. 6In contrast with other theoreticians of recognition, 17 Honneth places particular attention upon conflicts in the social interactions -above all those which are effected as moral strength, promoting the seeking of recognition through political struggle.
This moral dimension of the conflicts confers visibility and consideration on the routine network of the relations, establishing a continuity between socially and historically constructed interactions and the personal cognitive and affective experiences, particularly when -and whenever -there occur experiences of disrespect, mobilizing feelings of injustice.:257 In the search for their autonomy and individuation, the subjects galvanize the domains of recognition with the intention of positive self-relation, and identity is linked to this process, deriving from the dialectics between individual and society, established in the continuity of the historicity of each subject and her collective.:259 As a result, social struggles can promote the subject's engagement in political action and, as a consequence, promote a self-relation which allows the subject to apply moral value to herself, which impacts on self-respect and transformation of her passivity in the face of the social processes.
The processes of self-relation which structure recognition are anchored in the domains of love, rights, and social esteem.:11 The sphere of rights involves the issue of dignity and relates to self-respect to the extent that it relates to people's participation in the public sphere, to their recognition (or not) of themselves as worthy of the same prerogatives and consideration as others. 169][20] In its positive expression, social esteem goes beyond the sphere of rights, overdetermining it, confirming, so to speak, the public proposal/ acceptance of new standards of moral and social normativeness, in which one legitimates the sphere itself of the rights.On the contrary, the experience of disrespect, in this plane, inhibits the strengths of emancipatory social reconstruction, degrading its carriers and putting social solidarity under stress.
The experiences of disrespect in each sphere (maltreatment and physical violence, denial of rights and social depreciation) affect dignity and impede or limit the subject's self-realization. 21However, they can have potential for promoting reflection, the result of moral indignation, 16 which has an emancipatory strength aiming for recognition.
Autonomy reflects the acquired set of skills generated and re-processed in the self-relation conducting life itself, established in a creative reflexive process, which is always incomplete and inexhaustible. 22In this process, the subjects extend the concession of rights which protect their personal autonomy. 6he approach proposed by Honneth "interprets autonomy in the light of the theory of intersubjectivity, considering the unconscious and language as constitutive strengths of individuation", 20:150 and highlights it, this being dependent on reflection, with the "ability to reflect on one's own impulses and motivations, and on the values of the environment, taking a position which can even deny these", 20:152 with a focus on the moral principles of the social context, a process which is linguistically mediated. 22For this, it indicates that the individual mobilizes the universal moral principles with affectivity and sensitivity to the particular characteristics of the situation. 22o the extent that they understand themselves based on the interactions, people see themselves as subjects under law and in their uniqueness in society, and develop a knowledge regarding the rights which belong to them. 20The conflict explains the appearance of the struggles, but also forms the societies and their individuals.Hence, the feelings of injustice and the experiences of disrespect simultaneously clarify the particular characteristics of the people and the social contexts in which they live.The struggle for recognition is a historical process which reassembles, reveals and produces moral progress, as it involves moral learning.
The intersubjective role of recognition for subjects' self-realization and the construction of their individual liberty, in conclusion, is revealed in the constituent relation between personal identity and societal praxis. 23Honneth believes in the emancipatory strength of the interaction based on the construct of recognition, emphasizing the importance of patterns of interaction which are more propitious for self-realization being perceived and constructed in resistance to interactive values and patterns which give rise to experiences of disrespect.

CARE IN HEALTH CARE AND THE PERSPECTIVE OF INTERSUBJECTIVE RECOGNITION
Honneth's Theory of the Struggle for Recognition, in giving centrality to intersubjectivity and to the reflexive and dialogical process for transforming social relations, 16 is shown to be interesting for throwing light upon certain challenges and critical areas in health practices and policies.
From the point of view of common knowledge, healthcare in general is seen as the application of a set of technical procedures undertaken with a view to achieving a specified end established a priori, based on scientific knowledge. 1However, reconstructivist approaches, supported in a hermeneutic perspective, emphasize that the entire use of knowledges and techniques in health care necessarily involves a relational dimension and that to be effected and legitimated as Care, in the most radical sense of the term, the interactions need to be actively directed towards the other, to that who requires the care.As a result, the intersubjective interactions rich and dynamic are necessary for comprehensive care, along with embracement, responsibilization and the expanding of horizons, which are capable of making both caregiver and receiver of care autonomous and creative subjects in the construction of the normative patterns of health, compatible with the personal values and needs, and socially satisfactory. 1,24In this regard, the Honnethian notions of affective openness to the other, respect for her rights and attention to her values and concerns appear to have a close dialogue with the normative horizon which guides the proposal of the Care.
It is necessary to be fairly cautious when one seeks to promote dialogue between conceptual frameworks constructed based in theoretical traditions, practical motivations and diverse planes of abstraction.The fact that the framework of the Care is defined not in the ambit of Political Philosophy, but is, rather, a more concrete plane of intervention, and strongly interwoven in technical and scientific knowledges, requires a series of conceptual mediations and reserves.It does not seem to us, however, to be erroneous to identify in the health actions the demonstration of the fecundity of the dialogue between Care and Recognition.
Firstly, if we think about the genesis of the health problems or conditions which cause the need for the health actions, we will already be able to perceive the affinities between the frameworks.Honneth himself bases his investigations on recognition in the plane of the affective interactions, which he terms as love, strongly based in the psychotherapeutic concepts and experiences of the pediatrician and psychoanalyst Donald Winnicott.Winnicott 25 not only valued aspects related to mutual recognition between mother and child in his theory of psychopathogenesis, but also gambled on interactive techniques which explore the affective dimension as a path for reconstruction of subjects' self-esteem and autonomy in the creation of their own therapeutic processes, expressed in concepts such as spaces, phenomena, transitional objects and holding. 25] The conceptual framework of vulnerability represents exactly this progressive gaining of awareness of the importance of relational aspects, in which the personal plane cannot be considered in isolation from the intersubjective interactions which extend to the social life and to the organization of the health institutions, in both the genesis and in the response to the care needs. 28It is this same framework which leads us to the importance of intersubjective recognition in the domain of the affections, so broadly developed by Winnicott, as a way of encouraging, in the other, the self-confidence and creativity to respond personally and socially to the situations of vulnerability. 291][32] The framework of vulnerability and that of recognition maintain normative affinities to the extent that one can even risk (re-)defining vulnerability as "the result of systematic violation of the conditions of reciprocal recognition between the subjects", 33:21-22 in a given sphere of everyday life.:22 In the plane of the interpersonal relations, Care is shown to be closely linked to the unique and intersubjective experiences, giving centrality to the quality of the meeting and the interaction, to the particular characteristics, and to the modes of relation with people.It involves stimulating, based on the intersubjectivity, the emergence of meanings, cultural peculiarities, experiences and concepts of justice and respect, issues which relate to quality and to difference, all present in the normative perspective of the theory developed by Honneth. 16he subjects construct themselves in the I-other relation, in a dialogical and always unfinished process, which directly or indirectly affects the collective. 16:121 It is no different in the interactions which occur in the field of health.The structural aspects of humanization and of comprehensiveness point exactly to the challenge of dealing with the oppressions which, consciously or not, voluntarily or not, produce disrespect, nonrecognition; whether in the provision of care or in management.Oppression contains the germ of the struggle and is guided by the normative principle of self-realization, which is related to ethics, which turns the conflicts experienced in the spaces of health into an opportunity for the reconstructive efforts of humanization and of comprehensiveness in the field of health.
In this way, the conceptual framework offered by Axel Honneth's Theory of Recognition is productive for understanding struggles based on the moral dimension circumscribed in the conflicts, 16,34 with attention given to the material, symbolic and legal dimensions.Health, as a right of the citizen, involves struggles for recognition, continuous democratic acts, dependent on intersubjectivity, at distinct levels and by/with distinct subjects, directed towards achieving conditions for human integrity.
The understanding, therefore, is that overcoming inequality and forms of oppression present in the relation can be diagnosed and receive visibility through the use of a conceptual basis which pro-motes the expansion of understanding of the situations experienced by the subjects in the process of caring for themselves and for the other.Making use in studies in health -of the lens of recognition, in the Honnethian proposal, means focusing on conflicts and disrespects based on the uniqueness of the social, historical and cultural context which contains them, as well as the violations in the domains of recognition.As a result, there is a favoring of social diagnoses articulating them with the presence or not of struggle for recognition, for changes effected within the system itself.In the path of transformation, the struggle is a consequence of the 'extent' of the injustice felt.This is a process caused by situations and practices perceived as disrespectful and restricting, and its occurrence depends on the cultural horizon of socialization, as it is in this that morality is processed. 6Therefore, the moral expectations linked to healthcare and its management may be favored in terms of revelation, based in the routine of its realization.
The moral experiences "retain the social patterns of recognition regarding which a subject can know herself to be respected in her sociocultural environment", 6:258 whether it is this who produces and/or who receives the care.The domination will indicate dimensions of conflicts, as well as the extent to which the struggle is being sought or blocked, a reflex of the cultural reading of the oppression.In health, there seems to be a naturalized understanding that the prescription and correction of the variances are the central and only paths, which comprise the issues and are extremely important challenges for the health area.The use of recognition for considering the care, its management and the guidelines of the health policies may come to place this understanding under stress and indicate critical diagnoses of oppression and injustices.Extending these revelations in the scientific evidence may come to find semantics in the disrespect and promote social transformations.

CONCLUSION
The theoretical contribution of Axel Honneth's Theory of Recognition provides a conceptual framework for understanding intersubjective relations and social struggles, as well as to consider oppressions and oppressed groups, their needs, inequalities and injustices, in different scenarios and cultural contexts.
In this approach, there are dense and appropriate constructs for understanding and discussion regarding disrespect and its consequences, with pos-sibilities for examining peoples' emancipation, with particular attention to the constructs of self-relation and self-realization and their domains.
In the field of health, in the search for effective comprehensive and humanized care, it seems to be fruitful to bet on intersubjective recognition as a conceptual resource for grasping the needs of people and communities and responding to them, as well as adding criticism to the meetings which we health professionals produce, with a view to achieving more worthy, humane and comprehensive practices, with consideration for emancipatory self-realization.
In this regard, and by way of conclusion, we emphasize, amongst the strengths of Axel Honneth's Theory of Recognition for contributing to health research, the following: 1.The possibility of defining objects of investigation which move between the plane of the individual uniqueness and that of what is shared collectively, without loss of the social dimension which articulates these, as the relational character of the category of recognition always relates to the plane of intersubjectively constructed experiences, values and normativities, identities and actions of the subjects.This is of great value for research in health in general, and in nursing in particular, to the extent that a significant part of the knowledge produces the needs to consider the social determination of the health-illness-care processes, at the same time as it aims to instruct practices which, to a large extent, concern individuals.
2. The dialogue that this conceptual framework establishes between the plane of rights and the struggles for emancipation, which is in line with the values which guide the proposals of comprehensive and humanized care and of reducing vulnerabilities in the health field, strengthening the identification of the dialogue (between rights and emancipation), or the lack of this, as a research object in ethical and politically responsible health.
3. The fecundity of the category "disrespect", the opposite of recognition, as an indicator of situations in which the subject's integrity as a human being is, in some way, threatened, which has direct implications for illness and, therefore, enormous heuristic value for studies geared towards the promotion, protection and recuperation of people's health.
The challenges for incorporating this framework into our research practices are major.These are related, above all, to the as-yet poor familiarity of researchers in the health field with the production of contemporary sociology and political philosophy; to the complexity of the theoretical-methodological articulation of constructs which are based on fairly distinct epistemologies; and, as in any process of reconstructing practices, the difficulty of overcoming the conservative tendencies which lead us even unconsciously to reiterate and legitimate concepts and practices which are already institutionally and culturally embedded in our routine.With the present study, our intention is to contribute so that these challenges may be seen not as obstacles, but as encouragement for our best energies and reconstructive skills.