Ignaas Devisch

The illusion and the paradox of being autonomous, experiences from persons with spinal cord injury in their transition period from hospital to home

Purpose: To open a discourse on the concept of autonomy as a precursor for participation in individuals with Spinal Cord Injury (SCI) by exploring the experiences about their perceived autonomy in their transition period from hospital to home. Method: Based on the ‘grounded theory’ approach; in-depth, semi structured interviews were conducted with 11 SCI-patients. A theoretical sampling strategy was used and the data was analysed according to the constant comparative method. Results: To capture this complexity of autonomy, the results have been structured in themes with regard to the self of the patient and his independency. The analysis showed four different typologies of how autonomy is perceived; (1) the active agent, (2) the active follower, (3) the passive follower and (4) the passive victim. Conclusion: Rehabilitation professionals can help individuals in disconnecting their internalised ideal of independency to avoid the illusion of being autonomous and can gain insight in the patients’ typology and empower patients to avoid the paradox of being autonomous. If the ultimate goal of rehabilitation is participation; empowering the patient to achieve a ‘sense of agency’ instead of autonomy is the central goal for rehabilitation professionals. Empowerment and agency are key topics for the patient to gain mastery over his own life. Implications for Rehabilitation During the SCI rehabilitation process it is important to draw the clients’ attention to the difference between being independent and being autonomous. To enable the client with SCI in experiencing a sense of autonomy, it is recommended to reflect on his entire life-span. Embrace the socially embedded feature of autonomy; do not only focus on the individual but consider also his context. Empower clients in the way they want to be supported within their social context and make this clear and negotiable.

Progress in medicine: autonomy, oughtonomy and nudging

Rationale  In this article, I argue that we need a new perspective in the debate on autonomy in medicine, to understand many of the problems we face today – dilemmas that are situated at the intersection of autonomy and heteronomy, such as why well informed and autonomous people make unhealthy lifestyle choices. If people do not choose what they want, this is not simply caused by their lack of character or capability, but also by the fact that absolute autonomy is impossible; autonomous individuals are ‘contaminated’ by heteronymous aspects, by influences from ‘outside’. Consequently, there are many good reasons to question the widely accepted hierarchical opposition of autonomy (progress) versus heteronomy (paternalism) in medicine. In an earlier article an analysis is made of the neologism ‘oughtonomy’ to support the thesis that when it comes down to human existence, autonomy and heteronomy are intertwined, rather than being merely opposites. Methods  In this article, I reflect upon how social conditions might improve our ‘choice architecture’, what Thaler & Sunstein have called ‘nudging’: how to change individual health choices without being paternalistic? I explore the extent to which both oughtonomy and nudging are able to challenge the question of autonomy in todays medicine. Results and conclusions  Autonomy may and should be a shared target in todays medicine, but we should never forget that it is always intertwined with heteronomy. Starting from this perspective, progress in medicine demands far more than the increase of autonomy.

Oughtonomy in healthcare. A deconstructive reading of Kantian autonomy

For years now, autonomy has been discussed as one of the central values in health care. Understood as self-realization, it is opposed to paternalism which is conceived as an intolerable occurrence of heteronomy. Although different concepts have been developed to nuance this opposition, when it comes to health care discourse, heteronomy is still the enemy of autonomy. In our article, we defend the thesis that autonomy is only achievable as heteronomy. We are not arguing for an expansion of the meaning of autonomy, but are attempting to conduct an analysis which lays bare the ‘disrupting’ attendance of heteronomy within the principle of autonomy. Autonomy does not begin where heteronomy ends, but can only begin if heteronomy is already involved. To emphasize this, we prefer to elaborate a new concept: ‘oughtonomy’. This concept is inspired by Jacques Derrida’s distinction between ‘difference’ and ‘differance’. We will develop the concept of oughtonomy from a deconstructive reading of Kant’s idea of autonomy, inspired by philosophers such as Jacob Rogozinski, Jean-Luc Nancy and others. In addition to a first exploration of this concept, this article also discusses the possible consequences of oughtonomy for current debates concerning health care. Our quest for a new understanding of autonomy is motivated by the concern that, although the accent on autonomy as self-realization and independence has many advantages, we should also bear in mind the countless disadvantages.

Being mondaine : Jean-Luc Nancy's Enumerations of the World

In one of his latest books, La pensée dérobée (2001), Jean-Luc Nancy continues writing about the major themes of his work up until now: community, sense, being as being with, or singular plural being. These themes come together in a witnessing of the world “as such”: that is to say,the world here and now in which we are living in common. The sense of the world is nothing but this being-in-common. This makes Nancy a thinker of “globalization”, albeit in a very specific way, one concerned with the way in which we are “world”. One way to argue this is to consider the way in which Nancys workis larded with enumerations. Very often he “recites” our singular plural being by giving lists of the diversity of “things”. This is also the case for a few of the texts in La pensée dérobée. In trying to catch an echo of these “recitals”, I want to review the theme world in Nancys oeuvre and ask the question if and how Nancy thinks of our global coexistence nowadays. A part of this text was presented at the 4th annual conference of The Society for European Philosophy at the Manchester Metropolitan University (11–13 September 2001).

A trembling voice in the desert: Jean‐Luc Nancy's rethinking of the space of the political

Abstract This essay explores Jean‐Luc Nancys rethinking of political space in terms of an ontological ‘being‐with’. It elucidates how Nancys thinking of community emerges out of the French philosophers reworking of Heideggers crucial notion of Mitsein. For Nancy, although Heidegger argues that Dasein is always already also Mitsein, Mitsein is nonetheless also occluded by the priority accorded to Dasein. The consequences for the way in which community or the space of the political is configured are profound since traditional conceptions of the subject of community thus remain unreconstructed. Nancy however does reconstruct community by emphasising that the primal ontological conditions of community are not conceived as the One, the Other or the We, but as the ‘with’, ‘relationality’, and the ‘between’. The question of being (Seinsfrage) thereby becomes the question of being‐with (Mitseinsfrage).

Lifestyle: bioethics at a critical juncture

More than ever, the way we live our lives has become subject to our own decisionmaking. Our whole way of living, in particular what we do to our body, has become the expression of personal lifestyle choices. Because we can make changes to our body according to our own individual preferences, every aspect of our life begins to be seen as the result of individual and voluntary decisions. The comparison with advertising is pertinent here: we should no longer accept the way we are but can choose from a variety of options. Go to any supermarket and look around: innumerable products are promoted because of their healthy ingredients, whether to lower our cholesterol or heighten our natural resistance. And, of course, we buy what is on offer. Consequently, there are increasing discussions in healthcare and bioethics journals and forums about lifestyle and the autonomy of the individual. Lifestyle is at the center of current debate about how biotechnology or drugs can help people adjust their rapidly changing lifestyles. It is also an issue in debates on the ethics of current health policy and health insurance: private insurance companies are increasingly promoting the values of mass sports, fitness, and a healthy way of living. In many countries, the pursuit of a healthy lifestyle has or is expected to become a criterion in the allocation of healthcare services. One of the crucial questions is what could be the consequences of this evolution for healthcare policy for individuals and for society in general? If we consider individuals as autonomous and regard the way they live as largely a matter of their own free choice, would it then not be ‘‘logical’’ to hold patients personally responsible for making (un)healthy lifestyle choices, when they try to obtain insurance or enter healthcare facilities? And if the individuals are unwilling to change their risky behavior, could they then also be denied healthcare services? In short, the discussion about lifestyle also concerns responsibility and the amount of control that others should be allowed to exercise over an individual’s choice for a particular way of living. Critics of paternalism talk about control and tyranny, whereas defenders point out the importance of public interest. In this article, we will take a step back from current approaches to lifestyle and concentrate on the history of this concept. To do this, we use a method derived from the work of the French philosopher Michel Foucault, the genealogical method. A genealogical analysis aims to unravel the previous turns and shifts of meaning of the central concepts of a given system of thought in order to understand what is going on today.

Philosophy of Sport in Belgium and the Netherlands; History and Characteristics

For a few decades now, philosophy of sport has been an acknowledged area of philosophy. Several journals exist, and organizations and conferences are organized to discuss the numerous topics. Philosophy of sport is a lively discipline that debates a wide range of topics, including practical ethical questions such as doping and enhancement and questions regarding sport practices in society, as well as more abstract questions regarding internal values of sport, and the nature of sport itself. Although internationally oriented, sport philosophical debates do sometimes differ from country to country, from region to region, depending on local embedding of issues and favorite sports. In the Low Countries—Belgium and the Netherlands—some specific themes have dominated the discussions, sometimes with far-reaching consequences for sport. It was, for instance, the arrest of the Belgian football player Bosman (in 1995), which set the world of football upside down. The Netherlands and Belgium have many commonalities. As good neighbors, both Belgians and the Dutch are fond of cycling and football (“soccer” for North Americans). The Dutch are an acclaimed football nation ever since the 70’s and, being a “country of water,” have a long, dominating, and culturally important, tradition in skating, as well as swimming and sailing. In this paper, we sketch the outlines of the development and debate in sport philosophy in the Low Countries over the last two decades: what is at stake, what are the main topics and publications and what is currently dominating the landscape of philosophy of sport? Since the Netherlands have a more active philosophy of sport community than Belgium, and since the former has more inspired the latter than the other way around, the recent history of philosophy of sport in the Netherlands makes up the bulk of this paper. The developments in Belgium will be described in general terms. We will conclude with an attempt to pin down the specific contribution of philosophy of sport in the Netherlands and Belgium to the international forum.

The client-centred approach as experienced by male neurological rehabilitation clients in occupational therapy. A qualitative study based on a grounded theory tradition

Abstract Purpose To explore the perspectives of male clients in a neurological rehabilitation setting with regard to the occupational therapy they have received and the client-centred approach. Method This study involved a qualitative research design based on the grounded theory tradition. Individual in-depth interviews were used to collect data. Data were analysed using a constant comparative method. Seven male participants from an inpatient neurological setting were included using a theoretical sampling technique. Results Three themes emerged to describe the approach of the therapists to client-centred practice: (a) a shared biomedical focus as the start of the rehabilitation process, (b) the un-simultaneous shift from a biomedical towards a psycho-social focus and (c) formal versus informal nature of gathering client information. Conclusion A client-centred approach entails a shift from the therapist focussing on recovery from the short-term neurological issues towards the long-term consequences of the disease. According to the client, this shift in reasoning must occur at a specific and highly subjective moment during the rehabilitation process. Identifying this moment could strengthen the client-centred approach. Implications for Rehabilitation Client-centred practice entails a shift from recovering the short-term neurological issues towards the long-term psycho-social consequences of the disease. To be effective in client-centred practice, the clients expect from the professional to be an authority with regard to biomedical issues and to be partner with regard to psycho-social issues. Client-centred practice is most likely to be successful when client is susceptible to discuss his psycho-social issues and finding this moment is a challenge for the professional. Using formal methods for goal setting do not necessarily cover all the information needed for a client-centred therapy programme. Rather, using informal methods could lead to a more valid image of the client.

Foucault at the bedside: a critical analysis of empowering a healthy lifestyle

Since quite a few years, philosophy is heading towards the bedside of the patient: the practice of philosophy has stepped out of its ivory tower, it seems, to deal with empirical or practical questions. Apart from the advantages, we should keep in mind the importance of a critical analysis of medical or clinical practice as such. If ethics partakes the clinical stage, it runs the risk only to discuss the how question and to forget the more fundamental what or why questions: what are we doing exactly and why is it good for? Starting from the principle of the empowerment of the patient, we will demonstrate how the discourse on empowerment in health care seems to forget a profound reflection upon this principle as such. By rehearsing some basics from the governmentality theory of Michel Foucault and the actualization of it by Nicolas Rose, we will argue how philosophical investigation in medical-ethical evolutions such as empowerment of the patient is still needed to understand what is really going on in todays clinical practice.

Accessible health care for Roma: a gypsy's tale a qualitative in-depth study of access to health care for Roma in Ghent.

BackgroundIn general, vulnerable populations experience more problems in accessing health care. This also applies to the Roma-population. In the City of Ghent, Belgium, a relativly large group of Roma resides more or less permanently. The aim of this study is to explore the barriers this population encounters in their search for care.MethodsIn this qualitative study using in-depth interviews the barriers to health care for the Roma in Ghent are explored. We interviewed 12 Roma and 13 professionals (volunteers, health care providers,…) who had regular contact with the Roma-population in Ghent. For both groups purposive sampling was used to achieve maximal variation regarding gender, age, nationality and legal status.ResultsThe Roma-population in Ghent encounters various barriers in their search for care. Financial constraints, not being able to reach health care and having problems to get through the complexity of the system are some of the most critical problems. Another important finding is the crucial role of trust between patient and care provider in the care-giving process.ConclusionRoma share several barriers with other minority groups, such as: financial constraints, mobility issues and not knowing the language. However, more distinctive for this group is the lack of trust in care providers and health care in general. As a result, restraint and lack of communication form serious barriers for both patient and provider in their interaction. In order to ensure equitable access for Roma, more emphasis should be on establishing a relationship of mutual respect and understanding.