Re: Routledge international handbook of qualitative nursing research, p. 149. Discuss.

A nurse researcher who follows Ricoeur is always ready for the possibility that the narrative of a patient who has consented to take part in a study can take a life of its own. The textuality of a narrative overflows the intentionality of a subject, such that narrative is not simply an object of the consciousness of the narrator. If this is taken as a universal philosophical position, does this mean that there is always going to be a gap – or the staying away from ground as Ab-grund, to invoke Heidegger – between what a patient intends (means) to say and what is said? Does this mean that communication is not the best way to situate Dasein firmly in the Mitdasein (intersubjectivity) of its inevitable being-in-the-world? Ricoeur’s hermeneutics of the narrative thus makes Gadamer’s hermeneutic ideal of the fusion of horizons problematic in terms of its actual transparency in communicative Mitdasein. If narrative always slips beyond the grasp of Dasein, causing an abyss in being to appear here and there in the universal web of Mitdasein, then communication cannot be trusted as the site of clearing (Lichtung) in the understanding of being, which, Dasein, as an interpreting being, is constituted of. Instead of guaranteeing the truth of being in aletheia, narrative introduces its opposite, lethe, into play. Being becomes more like nothingness than being. 

Why should nurses read Heidegger? My argument is that Heidegger was the only hermeneutic philosopher who defined the meaning of Dasein as its being-toward-death (Sein zum Tode), which Dasein cannot be stripped of, because in being a being-in-the-world (In-der-Welt-sein), Dasein is mortal: as Heidegger quotes from Der Ackermann aus Böhmen in section 48 of Being and time, the moment we are born, we are already old enough to die. In Christianity, which is influenced metaphysically by Platonic eternalism, Christ, in his embodiment or being-in-the-world as Jesus of Galilee, had to go through, even as Son of God, death like any other human being – and his was slow and brutal in order to ascribe the divine meaning of Passion to his Dasein for the reflection and inspiration of Christians to this day.

For a nurse providing palliative care, the greatest challenge for both her and the dying patient is the existential possibility that death is meaningless. Every nurse understands that in the despair of meaninglessness, palliative care is reduced to the process of merely alleviating the physical sufferings of the dying patient until the arrival of death. But the nurse can see that dying in meaninglessness, the patient is already “broken” inside and is simply awaiting the obliteration of non-being. If meaninglessness is the universal order of things, then life is for the healthy and the physically endowed, and hedonism should become a norm for them, because pleasure is only possible in good health. Under such a horizon, the altruistic phenomenon of caring itself appears meaningless.

Reading Heidegger, the shallowness of hedonism will become obvious. The German philosopher uniquely defines Dasein as a being which, in its being, the meaning of being is its issue – its Sache des Denkens, that which makes its thoughtful inquiry or questioning possible at all. Beyond pain and pleasure is the existential lumen naturale of understanding of being, Seinsverständnis. It is the essence of being, which, for Dasein to be, is the truth of being. Understanding is openness to and freedom for meaning, and it can act as an antidote to the nihilism of meaninglessness. In fact meaninglessness is disclosed as inauthentic, as covering over of the truth of being. Nursing theory, then, becomes an endeavour to philosophically determine the understanding of being in the unique interpersonal Mitdasein shared by nurse and patient. The Sache des Denkens takes on an especially urgent character in the case of palliative care, so that the patient can die a good death.

Essentially speaking, Being and time demonstrates hermeneutically that the temporalised being of Dasein is being-toward-death (Sein zum Tode).

Alienation, which in German is Entfremdung, is to make oneself feel estranged about something – and that can include one’s very own Dasein, such that, to use a common psychological example, one is overcome by a feeling of strangeness when, looking at oneself in the mirror, what is there is the Stimmung of not feeling quite at home with oneself: what Heidegger vividly describes in section 40 of Being and time as das Unheimliche. Its standard translation is “the uncanny”. As the negation of familiarity, comfort and security, the uncanny thrusts Dasein into a confrontation with “the nothing”, das Nichts, which unsettles in its nothingness (Nichtigkeit). In these uncomfortable, if not distressing, moments, Dasein becomes clearly aware of a fundamental aspect of being, which is its staying away from ground as Ab-grund, exemplified in the primordial event of a being like Dasein clearing itself authentically in an uncanny gap in the uneven ecstasis of existential time. Geworfenheit,which belongs to Dasein‘s temporalisation (Zeitigung), becomes the free fall of Dasein into the absence of everyday understanding of itself and of existence, where time bends and ceases to become an even line of now-points (Jetztpunkte). The next moment in Dasein‘s existence is now filled with uncertainty, which is not just another “now” and is the condition of Dasein‘s Angst for its inescapable mode of being as being-in-the-world. In short, through the uncanny, Dasein enters the meaningful crisis of a deep attunement to the world, which the illusory protection of everyday “idle talk” (Gerede) in the inauthentic company of “the they” (das Man) shields Dasein from.

One of the central teachings of Being and time is the disclosedness (Erschloßenheit) of Dasein as being-toward-death (Sein zum Tode) in its being-in-the-world. The ultimate horizon of Dasein‘s temporal (and temporalised) existence is death. The uncanny unsettles in the form of Angst because in the final analysis, death comes into play. The fulfilment of Dasein‘s potentiality-of-being (Seinkönnen), i.e. fullness in its ending as indicated in the German word for perfection as Vollendung, becomes a vulnerable directionality (Ausrichtung) in the ecstases of time as Dasein‘s understanding of death coincides with its discovery, through the authenticity of its Angst, the abyssal nature of being, which Dasein, as being-toward-death, itself is.

Heidegger is unique in the history of modern philosophy in describing the phenomenon of thought, which makes humans unique and appropriate to be given the phenomenological designation of Dasein in Being and time, when there is every danger of reducing thought to reason while philosophers work against the background of the Enlightenment tradition that is handed down to them. In Being and time, Heidegger introduces the notion of Stimmung to encompass the complex activity of thought.

To understand the existence of self as being-in-the-world as Dasein and not as some transcendental ego that can be abstracted from the world, the question of empathy, which is a mode of being integral to nursing care, invites a hermeneutic approach. Dasein, being the fundamental mode of being in which its thrownness (Geworfenheit) is defined by its possibilities in a temporal world, discovers in empathy the possibilities of oneself in others. This in fact forms a uniquely existential argument against solipsism.

In the context of patient care, disease is both actuality and potentiality. While the patient’s Dasein is determined by disease – more profoundly in the case of life-threatening illness such as cancer -, the healthy, too, sees in the patient the possibility of being diseased, even in the same way such as being affilicted by cancer, in oneself. When looked closely enough, the other becomes a mirror for the self. Such reflection highlights the reflective quality of thought itself: the thinking of Dasein is none other than thinking in Mitsein: Dasein being-with-one-another. Hermeneutics, then, is the interpretation of this ontological facticity of self and other in Mitsein, which, in terms of understanding of being, can be called Mitdasein, which forms the horizon of empathy. This is an existential moment in its own right.

Thomas and Pollio argue in their book Listening to patients: a phenomenological approach to nursing theory and practice (2002) that the interpretive phenomenology of Heidegger and Gadamer concerns itself with universal essences and requires adaptation and modification in order to make it effective for nursing research and practice, which both look at concrete experiences and situations of patients. They mention that in K Caelli’s The changing face of phenomenological research: traditional and American phenomenology in nursing (Qualitative health research, 10(3), 2000, 366-377), at least 20 different kinds of phenomenology have arisen in American nursing research.

Ricoeur, in explicating the anti-foundationalism of hermeneutics, which rests on the phenomenological legacy of Husserl but is resolutely opposed to its idealism as a metaphysical nostalgia for the Hegelian absolute, places the philosophically informed work of hermeneutics in the immanence of the text, whereby the texuality of the text, or its being, is the being that exists beyond the subjectivity of the author, even the field of her comprehension (Ricoeur 1975, p. 91 and p. 94).

In the context of nursing theory, which has as its imperative the healing of the patient or the palliative care of the dying, what confronts the nurse is not only the texuality of her communication with the patient, but with the sheer immanence of the patient’s diseased condition itself. Without falling into the objectivism of pathophysiology, the hermeneutically trained nurse looks for the uncanny (unheimlich) belonging-together of Dasein and disease in the being-in-the-world of the patient as the starting point of interpretation. Hence, founded upon the existential projection of care (Sorge), nursing practice, when it takes on the reflexivity of thought in philosophy, has a unique Sache which differentiates itself from the academic hermeneutic practice in the humanities, which preoccupies itself almost exclusively with texts both ancient and modern.

In Being and time Heidegger sets out to elevate the traditional, metaphysical understanding of being as a universal to a higher level that lays the ground for his important insight of ontological difference: being is not just any being, nor is it simply “every possible determination existent in a being” (Heidegger, 1996, p. 38). The starting point of Heidegger’s fundamental ontology is that “being is not a genus of beings” (ibid.). Heidegger differentiates being (Sein) from beings (Seiende), even if the latter is in every instance appropriated by the former in the Ereignis of fundamental understanding. Being transcends beings – but Heidegger is careful not to repeat the metaphysical understanding of transcendens as koinon, but to ground it in what he calls the ecstatic-temporal unity of the hermeneutic horizon that allows us to think being beyond beings (ibid., marginal remark). Given that the hermeneutic circle is, methodologically speaking, the interpretative consequence of ontological difference, its circularity has a universal structure embedded in the nature of understanding. Understanding itself has the universality of transcendence in that every understanding has understanding of being (Seinsverständnis) as its ground.

The being of care (Sorge) in nursing is the patient – the sick as distinct from the healthy. Resonating with Heidegger’s fundamental ontology in method and in structure, a hermeneutic nursing theory is grounded not in the koinon of patient care, which is the brute fact of the sickness of patients, but in the specific being-with (Mitsein) of nurse and patient that allows for the universality of hermeneutic circle to be grounded through dialogue and communication, which necessarily involve understanding and interpretation. In existential terms, both nurse and patient are thrown (geworfen) together into a situation where there is an implicit understanding of healing or, in the case of terminal illness, palliative care. However, given that the patient is not an object but a person, i.e. a Dasein capable of uncovering the meaning of its being, the situation in nursing care is necessarily hermeneutic. What a hermeneutic nursing theory does is to make this ontological facticity explicit.

For Heidegger, experience places Dasein in a hermeneutic situation in that on the primordial level, it concerns itself with the understanding of being as the uncovering of the truth of being of Dasein, so that the meaning of being of Dasein can come within its horizon of comprehensibility. In contrast to the mood of French existentialism, the affliction of disease is not absurd, but has a meaning waiting to be interpreted and integrated into the whole or holon of the patient’s being. The suffering and possibly shortened life expectancy brought about by disease, whether acute or chronic, places the being of a patient in a situation where there is a sense of urgency in making sense of how to continue with life.