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Texto & Contexto - Enfermagem

Print version ISSN 0104-0707On-line version ISSN 1980-265X

Texto contexto - enferm. vol.28  Florianópolis  2019  Epub Apr 08, 2019

http://dx.doi.org/10.1590/1980-265x-tce-2017-0249 

REFLECTION

HUMAN CARE IN LIGHT OF MERLEAU-PONTY'S PHENOMENOLOGY

CUIDADO HUMANO A LA LUZ DE LA FENOMENOLOGÍA DE MERLEAU-PONTY

Patricia Anjos Lima de Carvalho1 
http://orcid.org/0000-0002-3247-5145

Sâmia de Carliris Barbosa Malhado1 
http://orcid.org/0000-0002-0651-1835

Tatiane Oliveira de Souza Constâncio1 
http://orcid.org/0000-0001-6811-1506

Ícaro José Santos Ribeiro1 
http://orcid.org/0000-0002-4389-7810

Rita Narriman Silva de Oliveira Boery1 
http://orcid.org/0000-0002-7823-9498

Edite Lago da Silva Sena1 
http://orcid.org/0000-0002-1236-8799

1Universidade Estadual do Sudoeste da Bahia, Programa de Pós-Graduação em Enfermagem e Saúde. Jequié, Bahia, Brasil.

ABSTRACT

Objective:

to reflect on Maurice Merleau-Ponty’s notion of intersubjectivity as a potential reference to researches and actions directed to human care.

Method:

a reflexive analysis addressing three thematic areas: intersubjectivity and the holistic care; intersubjectivity and interdisciplinarity within the context of care; and description of experiences related to the own body within the context of health care.

Results:

the discussion presents structuring elements of Merleau-Ponty’s notion of intersubjectivity, such as: dialogue, respect, bond, and language. On the other hand, it reveals ambiguities inherent in the connection of life and culture worlds, created in the intersubjectivity, resulting in different profiles of care, considering its potential to create interdisciplinarity and integrity within the context of health practices.

Conclusion:

intersubjectivity can contribute by making more creative and innovative the care with ourselves, the others, and the world.

DESCRIPTORS: Nursing; Nursing care; Public health; Philosophy, nursing; Integrality in health

RESUMEN

Objetivo:

reflexionar sobre la noción de intersubjetividad de Maurice Merleau-Ponty como un referencial posible para investigaciones y acciones dirigidas al cuidado humano.

Método:

análisis reflexivo, que desveló tres ejes temáticos: intersubjetividad y el cuidado integral; intersubjetividad e interdisciplinariedad en el contexto del cuidado; y la descripción de las vivencias del cuerpo propio en el contexto del cuidado en salud.

Resultados:

la discusión muestra elementos estructurantes de la noción Merleau-Pontyana de intersubjetividad, tales como: el diálogo, el respeto, el vínculo y el lenguaje. Por otro lado, revela ambigüedades inherentes al entrelazamiento del mundo de la vida y de la cultura, producidas en la intersubjetividad, que hace surgir diferentes perfiles de cuidado, teniendo en vista su potencial para producir interdisciplinariedad e integralidad en el contexto de las prácticas de salud.

Conclusión:

la intersubjetividad puede contribuir para que el cuidado de sí, del otro y del mundo ocurra de forma más creativa e innovadora.

DESCRIPTORES: Enfermería; Cuidados de enfermería; Salud pública; Filosofía en enfermería; Integralidad en salud

INTRODUCTION

Caring is the basis of human existence and exceeds the conception of a period to provide care, involving respect to the meaning of the experiences, open dialogues, and empathy, abilities and attitudes demonstrated in the relationship of individuals willing to take risks, potentiate encounters, and create independent life projects.1-2

Reflecting about care from a phenomenological perspective implies looking beyond technicality and acknowledging the potential of intersubjectivity to mobilize human dignity, considering the connection of several projects worldwide about human life.1

However, we note in the usual care that the biomedical model remains, both in education and performance of some healthcare practitioners, who are not able to hear and accept the user’s complaints. The rigidity of this model causes delays, hinders innovations in the health sector, and precludes the inclusion of new care strategies directed to implementation of interdisciplinarity and integrity.

With respect to interdisciplinarity, it has been a continuous and growing process in the health sector, in an attempt to overcome the fragmentation of human knowledge, in a search for a global view of the complex dimension of the health-disease process.3 In the last three decades, healthcare practitioners have abandoned the strictly biological view of health,4 acknowledging the complexity of knowledge and practices present in an healthcare model,5 which corroborates the thought that reinforcement of these practitioners’ actions is a challenge in the process to consolidate the holistic care. For this, we consider it is necessary, beginning in the universities, that the healthcare students have access to theories addressing care as an interdisciplinary topic.6

Accordingly, the study on care has evolved in the course of time and is considered as the essence of some professions, such as Nursing, for example. Therefore, it suggests a philosophical, ontological, and holistic reflection involved in caring that should go beyond empiricism, improving knowledge in the field of health through everyday human experiences.1,7

In this context, the admission in the doctoral program of the Programa de Pós-Graduação em Enfermagem e Saúde, Universidade Estadual do Sudoeste da Bahia, more specifically, the “Human Care, Integrity, and Interdisciplinarity” course gave us an opportunity to create a proposal of care based on the phenomenology of perception, with emphasis on Merleau-Ponty’s notion of intersubjectivity.8 The classroom discussions and new theoretical information showed us that every care happens as a relation, as an ambiguous movement involving transcendence of the continuous care-negligence-care resulting from interlacing the unreflective (negligence) with the reflective (care), which appears in intersubjectivity.

The contributions of phenomenology to science are countless and, with respect to health, has caught the attention of many authors, given the humanist and existentialist approach used to create knowledge, which has been created in view of the world experienced and the multiple dimensions involving care in the until now unexplored life experiences.9-11

Although Maurice Merleau-Ponty did not write about care in his works, the resumption of the perception of man as a I can, as a range of possibilities, is a new look at people, the contexts and the experiences of everyone involved in the care.

In this perspective, care should contribute to the creation of contexts of intersubjectivity and potentiate the capacity of the individuals involved in the process, so that the caregiver and the patient benefit from the interaction and ambiguity inherent in human life, which always offers a possibility to become another me,8-9when they “are involved in a relationship of getting close and pushing back, and in conversations and silence, and in the presence and absence”.11:472

In this article, we intended to reflect on Maurice Merleau-Ponty’s notion of intersubjectivity as a potential reference to researches and actions directed to human care. Therefore, we start from the following guiding question: how to reference Maurice Merleau-Ponty’s notion of intersubjectivity in researches and actions directed to human care?

Based on this question, the reflexive analysis allowed us to address three thematic areas, namely: Intersubjectivity and the holistic care; Intersubjectivity and interdisciplinarity within the context of care; and The description of experiences related to the own body within the context of health care.

Based on national healthcare researches, we present in the first area the relationship between intersubjectivity and holistic care, as it favors the humanized hearing, the receipt, and the creation of the caregiver-patient bond; in the second area; we included an international theory and considered intersubjectivity as an element to boost interdisciplinarity, and highlighted the importance to consider complex and less objective human dimensions to promote more horizontal and integrated health practices.

Finally, in the third area, we emphasize how the perception about men, the world, and things is established based on encounters and may contribute to give another meaning to the experiences of suffering and to promote health of all people involved in the care process. Thus, in addition to the national theories supporting the philosophical considerations to improve the researches in the healthcare field and, more specifically, in the nursing field, two Merleau-Ponty works supported this paper as well: Phenomenology of Perception8 and The Prose of the World,14 as foundations to point out the need for investment in researches and actions in the health field, with major focus on intersubjectivity.

REFLECTION

Intersubjectivity and the holistic care

Care, seen as an intersubjective experience, enables users of health service to experience the restorative capacity of the relationship with another individual and the world, which occurs as expressiveness, dynamism, and flexibility.2,6,9,12The individual who provides care, regardless of being a family member, a healthcare practitioner, or another type of caregiver, can update experiences, undo and redo perceptions about himself/herself, others, and things, and become another him/her, resulting in a greater openness to life and better health conditions.

The experience of becoming another or one I can begins based on the experience of their own body, and the body is the perception and the possibility to transcendence. Therefore, at each new experience, a past may be resumed and a perspective of the future may arise, carrying another me.8 As healthcare practitioners perceive the individuals as participants in the relationship, rather than objects of intervention, they can help to undo and remake identities, as well as their individual and shared stories.2 Hence, care should happen through intersubjectivity, leading to a committed and engaged position with others and to the creation of more autonomous life projects, both for caregivers and patients.2

Thus, the strategies favoring the creation of intersubjectivity contexts find total acceptance among the new conceptions of care, which is seen now as an element capable of changing life styles and the way people experience pain, based on co-responsibility for the shared health.2

The creation of subjectivities involves the relational, pragmatic, and reconstructive aspects of identities and implies overcoming the objectivist nature produced by the idea of permanence and “sameness” of the individual, which limits the advancement of health promotion practices, particularly those in which success would depend on his/her positioning as the subject of his/her own health.2 This idea corroborates the understanding that “in objective thinking there is no room for another individual and for a plurality of consciences”.8:468

In this regard, we notice that the caregiver-patient relationship and vice-versa favors the experience of transcendence, which occurs as the identification of an individual in continuous reconstruction, based on the presence of the other. Therefore, care always contributes to the construction of something creative and new and, as it is incomplete and unfinished, is constantly open to the joyful bond that is constructed and reconstructed in the intersubjectivity. Thus, care appears as a desired encounter between individuals, whose subjectivity is in constant reconstruction, resulting in existential success and promoting happiness.2

This form of encounter offers to the caregiving the opportunity to reveal himself/herself from his/her subjectivity, which can be influenced by the patient, the healthcare practitioner, the other family members, and/or other social actors, at the same time that encourages these people to get to know themselves and, in this sense, care, as an element inducing the relationship, corresponds to an authentic and creative knowledge that is created in each dialogical experience.9

Being open to dialogues and using language is also a possibility to experience a universe of resistance and alterity that may reveal the presence or absence (absence being understood as a feeling of failure that can be related to the non-adherence of the individuals to the proposals of the practitioners and our difficulty communicating them).2 In this sense, Merleau-Ponty’s notion that language is an ambiguous and spontaneous gesture, filling gaps, dissolving opacities, and demanding from the body attention to the entire existence, confirms that even the absences can show the facticity of men and the world.8

In this perspective, absences can also be seen from the point of view of caring, in which the individuals as existential territories move and produce life by giving a new meaning to, “in a movement in which the living act of someone entails the production of life in others”.13:29 Therefore, it is important to notice that the facticity of man can also appear in the absence, in the presence of someone or something that, when requesting sensitivity, solidarity, respect, compassion, harmony, creativity, art, and intuition, opens space for transformative experiences.10-11

Hence, this presence, in the form of dialogue, provides the practical success that involves reflection beyond the “how to”, moving to “why for” and “why” to take certain action, in order to create more live and offer more dignity in living, as well as individuals capable of discussing health, desires, and possibilities, and collectively establishing their projects of happiness.2,12

The creation of the individual in care practices happens as a real and intersubjective presence, which identity is undone and rebuild in the relationship with the other that, by imposing a type of resistance, entails new virtues in ourselves and lead us to the knowledge that there are countless possibilities to participate in the construction and reconstruction of identities and strengthen the transforming power of individuals and groups.2

In this sense, we realize that intersubjectivity favors the interconnection of feelings and contributes to the construction of personality, always as a resumption and overcoming the speech of others, that is, as a possibility to acquire new behaviors from the shared feelings. And we notice a feeling that never ceases to involve it, and “we can find before it the astonishment of the first witness of the first speech”,14:66 in other words, based on the caregiver-patient interaction, feelings can be transformed into new behaviors and so on.

In this perspective, the relationship enables the communication between feeling and reflecting, revealing the co-existence with others, a generalization that invokes the transformation of personality, of the culture being. When we identify ourselves with a gratifying experience, the perceptive body promotes such a radical change to the point where we no longer know where and when it began, that is, at the same time that the universality of feeling mobilizes us for alterity, in order to establish new identifications as historical beings, it produces new coexistences and generalizations, as to promote bonds that guarantee the opening to new and endless transformations.

In Merleau-Ponty’s terms, we could say that this process happens because “[...] speaking and understanding do not presuppose only thought, but, in a more essential way and as a foundation of thought itself, the power to let yourself be demolished and reconstructed in another more current you, several possible others and, presumably, all”.14:42

The integrality of care, in an intersubjective perspective, suggests rupture with the traditional clinical practice, which operates predominantly in the individual settingand in the singular encounter, counteracting the actions proposed by the field of collective health, which collective nature ended up protecting the importance of the expanded clinical practice, which were against the ideas of many sanitarians.15 Thus, in order to achieve a humanized and well-grounded care, it is necessary to be in the patient’s shoes to have a vast theoretical base.

These strategies show us that we need to publicly declare the need to expand the clinical practice in the public healthcare services. If we fail to do so, whether involuntarily or by omission, we will continue to support the hegemonic proposal: the degradation of clinical practice, diagnostic and therapeutic techniques that end up being expensive, ineffective and sometimes even iatrogenic.15

Therefore, it is essential to expand the perceptive focus on care, which must be seen in the connection of the co-participant individuals, as contexts of intersubjectivity and possibility of becoming another. Thus, care favors the decision-making process directing and creating our history, as well as reveals the importance of investing in care practices directed to the creation of intersubjective contexts, which happen and show themselves through dialogue and their phenomenal capacity of revealing our ambiguities as something beneficial, enabling us to transform, transcend, undo, and rebuild the other.

Intersubjectivity and interdisciplinarity within the context of care

The individual is his/her body as a way of finding his/her place in the world, a field of action at his/her disposal, and a set of possibilities, which places him/her in a field of experiences. Intersubjectivity, on its turn, enables the emergence of new senses, which give the body not only an original experience but also an originating one.8,16

The individuals correlate with each other by different forms of insertion in the world, and the intersubjectivity announced implies coexistence. This implies correlations between individuals and worlds in a concrete way, considered in their global totalities as incarnated experiences, and not as physical-chemical apparatuses or a set of thoughts.8,16

In this sense, care, as a truly human practice, needs to be seen beyond a materialized body; and not only in a biological, reductionist, and curative point of view.6 Thus, the own body as a living experience may be inserted in the movement of attitude changes in care practices.17

In the field of these practices, the experience of the own body allows us to understand that interdisciplinarity happens through the relationship established between the individuals who, according to Merleau-Ponty’s thought: assume an equal, connected to feeling, to the unreflective; and a different one, related to the diversity of knowledge and socio-cultural functions undertaken throughout life.8

In this regard, by abandoning the perspective of the vertical knowledge, we adopt a position in favor of the dialogue and the construction of intersubjectivities that are so important to guarantee interdisciplinarity, which values free knowledge and respects the several disciplinary and socio-cultural knowledge shared horizontally in the relationships between service users, healthcare practitioners, and other caregivers, and their different existential contexts.

Thus, interdisciplinarity appears through intersubjectivity, based on the dialogue, when someone’s speech shakes us and our speech, by using answers and questions, and reaches their meanings. Intersubjectivity offers possibilities to invade one another, at the same time that the unreflective perception moves at free will, impossible to constitute, always constituent.

Therefore, in Merleau-Ponty’ words, the experience of becoming someone else occurs through intersubjectivity, which is created “when I listen, I do not understand the articulated auditory sounds, the speech is spoken within me; it questions me and I resonate it, it involves me and lives in me to the point where I no longer know what is mine, what is its. In both cases, I project myself in the other, I implant it in me, our communication resembles the fight of two athletes in the extremities of a single rope. [...] There is a double action in language, the one we play and the one we make the other play, representing it within ourselves”.14:41

Thus, language signals a type of generalization between me and the world, in which an insignificant distance is established, that is, in this relationship, “[...] The other and I are like two circles almost concentric and distinguished only by one light and mysterious difference”.14:168

This generalization of the body is established through the universality of feeling, which is well described in the following Merleau-Ponty’s reflection: “I look at the man motionless in his sleep and who suddenly awakens. He opens his eyes, gestures toward his hat located next to him, and takes it to protect himself from the sun. I am finally convinced that my sun is also his, that he sees and feels it as I do, and, finally, that we perceive the world together [...]. When the man wakes up beneath the sun and reaches for his hat, between the sun that burns me and makes my eyes blink and the gesture that relieves my fatigue, between this tired face there and the gesture of protection that seems to ask me, a bond is established without any decision from me”. 14:170-71

Thus, the world exists for everything that moves in and for it: it is a phenomenal field where everything is seen in profile One field does not exclude the other as consciousness does, on the contrary, it tends to expand as it establishes the path by which we are exposed to the world of coexistence, that is, it constitutes a possibility of becoming another me.8-9,13In this perspective, the phenomenal field reveals the phenomenon always in profile and provides the space for the transcendental experience that enables what was immanent and unreflective to finally exist, to become reflection, “[...] creative operation that participates in the facticity of the unreflective”.8:95

Therefore, we are increasingly approaching the interdisciplinarity in intersubjective care and, hence, supporting the promotion of health. It is in this direction that health studies3,7demonstrate collective to enhance human life quality and existential contexts. When we reflect on health from a perspective of connections of individual and shared dimensions, we can also analyze interdisciplinarity as a sharing of sensitive and unthinking worlds, beyond the horizontal approach to reflexive knowledge.

Description of experiences of the own body within the context of health care

The experience as healthcare practitioners from different areas, namely: psychology, nursing, physical education, physiotherapy, dentistry, medicine, and nutrition; but linked by the universality of feeling that resembles the interest in collective health, the area of connection of the graduate program to the Coordination for Improvement of Higher Education Personnel (CAPES), as with so many other feelings likely to emerge in the experience of the own body; made us realize the intersubjective experience as a potentiator of encounters and knowledge.

Pursuant to Merleau-Ponty’s view, the experience of the own body becomes possible for postgraduate students through intersubjectivity of language, “more evident as we deliver ourselves to it, less equivocal as we think less about it, rebellious to any direct possession”,14 which appears in the speech when we share knowledge and practices, meanings and reflections related to the forms of existing in the world.

In this context, we can illustrate the following experience lived by us in the intersubjective experience of thinking about care with the point of view of Merleau-Ponty’s phenomenology,8 in September 2010, when one of the authors of this article arrived at the type II Psychosocial Care Center (in Portuguese Centro de Atenção Psicossocial tipo II - Caps II), in the city of Jequié-BA, to teach a practical class in the Nursing undergraduate course.

On that day, everything seemed confused and tumultuous: the doctor did not show up; the coordinating nurse was absent to meet the secretary of health; the nursing technician alone distributed the routine medications to the users; the craftsman, in an attempt to welcome her and the students, began to sweep the room where the planned activity was supposed to happen; the users, during the dramatization of a scene of social mobilization, revealed how great their expectation was in relation to her presence as a representative of the University in the service.

This experience caused her to feel what, according to Merleau-Ponty, corresponds to the real experience of the other, something impersonal, related to the world of senses, which filled her and mobilized the decisive attitude to try to do something to help users of Caps II.

Thus, she called the students to go to the city council to request an open session aimed at discussing issues related to Care for people with mental suffering in the city of Jequié-BA. At first, they proposed October 10, considering that on this date the World Mental Health Day is celebrated, but the session was scheduled for October 27, 2010, a date more convenient for the councilors.

The dialogue with the councilors promoted excitement by the feeling of empathy with others, human beings, that, at the time, addressed the place of users of the Caps, and that, at that moment, still had not reached the spirit of citizenship. Embarrassed by the experience in the Caps and touched by it, it occurred to her to be the spokesperson for those users and to share with the legislators the feeling of indignation about the flaws of the local health management with respect to the inadequate operation of Caps.

Her feelings at the moment, in the light of the Merleau-Ponty’ thought, were characterized as an experience of coexistence with the other, an universal experience, which expressed itself as generality. It was not a personal feeling, but a shared one that had both a feeling of equal (unthinking) and different (reflected). For the author, “(...) the speech is not satisfied by designating thoughts as a number, in the street, designates the house of my friend Paul - but really metamorphoses into them as they metamorphose into it (...)”.14:148

In this sense, “the speech of the other not only awakens in me thoughts already formed but also drags me into a movement of thought that I could not have reached by myself, and finally opens me to strange meanings”.14:150 The author continues “therefore, it is important for me to admit that I live not only my own ideas but that, in the exercise of speech, I become the one I Iisten to”, and furthermore, “I need to finally understand how speech can carry a meaning.”14:150

The experience described happened as a phenomenon that made the participants find their thoughts in the speech of the other, as it happens with all humans, and, in this particular study, with the healthcare practitioners. By authentically and innovatively reflecting, they show the power of speech in the context of healthcare practices.

CONCLUSION

From the own body, we can understand the world of culture (reflections) that distinguishes us, to some extent and historically, from the another; interlacing with the sensitive world, which brings us together, in a constant experiential and ambiguous movement between what is offered by the dimension of the unit learned and the dimension of the generality of feeling, or between what is offered by the reflective dimension and the unthinking dimension.

Thus, in the intersubjectivity created in the encounter of individuals, in the connection of the reflective and the sensitive, practitioners, users, and other caregivers become co-participants of a care capable of addressing multiple aspects of individual and shared influences, giving new meanings to experiences, and developing skills for everyone involved. Hence, the intersubjective coexistence promotes a humanized, interdisciplinary, and holistic care.

These connections show the inter-corporeal generality found in the encounter of individuals, in their coexistence and in intersubjectivity; there are moments of creation of new life, affective, and reflexive meanings in the relationship me-others-world, boosting, therefore, care contexts closer to life quality and health, for practitioners, users, and/or other caregivers.

When we look at the clinical practices extended with Merleau-Ponty’s point of view, we perceive care as an inter-corporeal experience, which arises in the movement between the unreflective (feeling) and the reflexive (reason), and shows both integrality and interdisciplinarity as principles to be achieved through intersubjectivity, created in the encounter between individuals.

Thus, care involves a bio-psychosocial understanding and appears as an ambiguous movement, divided in different profiles and in a care-negligence-care relationship and vice versa. In this dynamic and ambiguous relationship, even the phenomenon of caring can be revealed both under the unreflective dimension, and under the reflective dimension; as it happens with negligence. The understanding of these constant and ambiguous relationships can favor an approach of caring for the other, for oneself, and for the world, as it considers the intersubjectivity essential to the construction of interdisciplinarity and integrity so important to improve human care. In this sense, the reference presented may support researches and strengthen the actions of nursing care and of other practitioners working in health services.

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Received: March 31, 2017; Accepted: August 22, 2017

CORRESPONDENCE AUTHOR: Patrícia Anjos Lima de Carvalho patricia.anjos3@gmail.com

CONTRIBUTION OF AUTHORITY Study design: Carvalho PAL, Malhado SCB, Constâncio TOS, Ribeiro IJS. Data analysis and interpretation: Carvalho PAL, Malhado SCB, Constâncio TOS, Ribeiro IJS. Discussion of the results: Carvalho PAL, Malhado SCB, Constâncio TOS, Ribeiro IJS. Writing and / or critical review of content: Carvalho PAL, Malhado SCB, Constâncio TOS, Ribeiro IJS, Boery RNSO, Sena ELS. Review and final approval of the final version: Carvalho PAL, Malhado SCB, Constâncio TOS, Ribeiro IJS, Boery RNSO, Sena ELS.

CONFLICT OF INTEREST No any conflict of interest.

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