Physiotherapy and Fundamental Ethics

318 Pages·2017·1.05 MB·English

Physiotherapy and Fundamental Ethics
–
Questioning Self and Other in Theory and Practice

Filip Maric

A thesis submitted to Auckland University of Technology
in fulfillment of the requirements for the degree of
Doctor of Philosophy (PhD)

School of Clinical Sciences
Faculty of Health and Environmental Sciences

2017
Abstract
Physiotherapy and Fundamental Ethics engages the field of
physiotherapy through a critique of its contemporary foundations from
the perspective of the ethics philosophy of Emmannuel Levinas, in
order to develop novel approaches to physiotherapy practice.
Physiotherapy is a well-established healthcare profession, practiced in
healthcare systems around the world. Despite its success, modern
healthcare more generally faces a number of significant challenges,
including increasing financial burdens, an increasingly ageing and
chronically ill population, ongoing technological innovation, and
diminishing trust in conventional healthcare. Ways in which
physiotherapy could respond to these challenges and adapt to future
needs are being explored. One approach entails a thorough
reassessment of the profession’s status quo and its subsequent
development, drawing on hitherto unexamined philosophies,
methodologies, and practices. This study seeks to contribute to these
efforts by drawing on a range of traditions that have not yet been
introduced to the profession, but appear to hold great potential for its
critical reassessment and development.

Levinas’s fundamental ethics provides the theoretical framework for
this, beginning with its exposition of the ontological and
epistemological underpinnings of Western metaphysics and science as
implicating a violence against the other. This violence consists in
negating the other and any relation to otherness through a totalizing
movement, assimilating the other into the categories and capacities of
the knowing ego, its knowledge, and self. Consonant with researchers
who consider implications of Levinas’s work to other healthcare
professions, I argue that Levinassian ethics reveals the theories and
practices that shape contemporary physiotherapy as inadvertently
opposing its original therapeutic motives and aspirations. By arguing
that the other is characterised by a preceding and un-encompassable
infinity and exteriority, Levinas developed his contrasting conceptions of
fundamental ethics and the self-in-relation as otherwise than being.
These provide the theoretical grounds on which I develop a novel
understanding of the physiotherapist and physiotherapy practice. They
are developed around the key notions of passivity and accompaniment
drawn from Levinassian literature and further expanded throughout
this thesis.

Inasmuch as ethics as passivity and accompaniment questions the very
possibility of practice without doing violence, I draw on Pierre Hadot’s
approach to philosophy as a way of life, and the philosophies and
practices of predominantly Japanese lineages of Zen(-buddhism),
ii
Aikido and other martial arts, and the treatment approach, Shiatsu.
Building on their distinct emphases on physical practice and a
resonance between them that I elucidate, I argue that they provide
particularly fertile grounds for the development of otherwise
physiotherapy practices.

Autoethnography provides the methodological point of departure, as
this study sets out from my personal involvements in physiotherapy
and the Japanese philosophical, martial, and therapeutic traditions.
Autoethnography was adapted in this thesis through a critical
encounter with Levinas’s and Hadot’s work. This consolidated the
contrasting and conjunctural encounter of physiotherapy with
fundamental ethics and other philosophies and practices for
physiotherapy’s critique and development. Through this
methodological engagement with Levinas and Hadot, the research
offers a novel development of autoethnography to the fields of
qualitative research. Its broad reference-field further indicates
contributions that inflect across these fields, including other healthcare
professions underpinned by the same ontology and epistemology. The
primary aims of this study remain the development of a critical
perspective that expands on Levinas’s fundamental ethics, and the
development of novel approaches to physiotherapy on this basis.

iii
TABLE OF CONTENTS
Abstract ii
Attestation of authorship viii
Acknowledgements ix

CHAPTER ONE – PHYSIOTHERAPY AND FUNDAMENTAL ETHICS 1
Introduction 1
Background 9
Extant developments in contemporary physiotherapy 10
The philosophical and practical traditions informing this study 14
From fundamental ethics to physiotherapy 21
Methodological approach 24
Scope and Framework of the thesis 29
Fundamental ethics in practice 29
Beyond fundamental ethics 31
Goodness and the good 34
Positivism, biomedicine, physical therapy and physiotherapy 36
A Trojan Horse 38
Overview of the thesis 39
In summary 41

CHAPTER TWO – SELF AND OTHER IN THEORY AND PRACTICE 43
Introduction 43
Preparation 44
Philosophy, aims, and methodology 44
Questioning ourselves 47
Rules and tools on the research path 49
Objectivity: Beginning with the personal 50
A historical dimension 52
Relevance: Correlating personal and professional concerns 55
iv
Description 57
Mapping the field and its tools 58
A review of literature 60
Interpretation 68
A judgment of value 69
A judgment of adequacy 77
Comparison and critique 80
Comparison 83
Critique 84
Subjectivity & eclecticism 86
Practice 91
Dialogue 92
Methodological difficulties 94
Ethics and ethos 95
In summary 98

CHAPTER THREE – PRACTICE AND PASSIVITY 100
Introduction 100
The foundations of contemporary physiotherapy 101
The aim of physiotherapy 103
The ethics of physiotherapy 107
Reorienting physiotherapy practice 112
Professional practice 112
Physiotherapy as a way of life 118
Practices of passivity 124
Letting go of practice 127
Letting go of knowledge 132
Letting go of intention 132
Letting go of self 135
The practices of passivity 138
v
The therapist as passivity 139
In summary 146

CHAPTER FOUR – PASSIVITY AND ACCOMPANIMENT 148
Introduction 148
Beyond passivity 149
The fundamental relation 156
Distance and causation 157
Capacity and causation 163
Proximity and causation: Toward subjectivity 169
The self in relation 173
Existing professionally 174
Existing physically 180
Existing therapeutically 184
In summary 191

CHAPTER FIVE – PASSIVITY AND ACCOMPANIMENT AS 193
PHYSICAL THERAPIES
Introduction 193
Beyond structure 195
Passivity in practice 201
Mobilisation and rehabilitation 201
Anamnesis 203
Physical needs 215
Accompaniment in practice 218
Activities of daily life 219
Beyond everyday practices 223
Contact 226
The practice of physical therapy 231
In summary 239
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CHAPTER SIX – PHYSIOTHERAPY IN PRACTICE 241
Introduction 241
Passivity and accompaniment in physiotherapy 244
Ehtics in physical therapy 244
Physical therapy in practice 252
Subjection to all and everything: Approaching physiotherapy 262
Beyond physiotherapy 264
Passivity and accompaniment in autoethnography 268
Ethics in autoethnography 268
Autoethnography as physical therapy 272
Overview of findings 277
In conclusion 282

References 285

vii
Attestation of Authorship

I hereby declare that this submission is my own work and that, to the best
of my knowledge and belief, it contains no material previously published or
written by another person (except where explicitly defined in the
acknowledgements), nor material which to a substantial extent has been
submitted for the award of any other degree or diploma of a university or
other institution of higher learning.

Filip Maric

09 May 2017

viii
Acknowledgements
I would first like to acknowledge and thank my supervisors Mark
Jackson and David Nicholls. I am deeply indebted to you for your hard
work and for believing and sticking with me even through the toughest
of times. Your enthusiasm, generosity, and exemplary expertise are
inspiring to say the least. I hope that you are content with this thesis
and find it to repay you for your guidance and patience in bringing me
to the conclusion of this project.
Acknowledgement and thanks are also due to the staff at
Auckland University of Technology (AUT) for the guidance, resources
and financial support provided throughout the course of this study.
To my entire family, young and old, near and far, both alive and
breathing, and those alive in memory only. If it was not for your
unwavering love and support, I would neither be who, where, or what I
am, nor would it have been possible for me to embark on the journey of
this project. I hope that this thesis goes some way to make your
incessant encouragement and trust in me worthwhile, and in the best of
cases, helps build a better future for our young ones, for being of service
to them is the only thing that can justify the time and effort that have
gone into this thesis.
There are more people that I need to thank than I can possibly
include and do justice in this brief comment, from friends, colleagues,
teachers, co-practitioners, sponsors and others from the fellowships, to
personal and professional advisors, and many more. I cannot wait to get
back together and spend time with you all.
There is no way I could have done this if it was not for all of your
generosity. To give you far more of my company and support than I
have been able to during the course of this study is the least I could do
now, though I hope this thesis makes a beginning in the right direction.
ix
Chapter One
Physiotherapy and Fundamental Ethics

For the little humanity that adorns the earth, a relaxation of
essence to the second degree is needed, in the just war waged
against war to tremble or shudder at every instant because of
this very justice. This weakness is needed. This relaxation of
virility without cowardice is needed for the little cruelty our
hands repudiate. That is the meaning that should be suggested
by the formulas repeated in this book concerning the passivity
more passive still than any passivity (Levinas, 1998b, p. 185).

Introduction
This study engages the field of physiotherapy through a critique of its
theories and practices of self and other from the perspective of
fundamental ethics, and the development of novel approaches to its
thinking and practice on this otherwise foundation. This twofold
engagement takes places through a comparative critique of
contemporary physiotherapy with a range of philosophical, practical,
and therapeutic traditions that have not as yet been introduced to the
profession but appear to hold great potential for its further
development. Most prominently, Emmanuel Levinas’s fundamental
ethics provides the theoretical framework for this critique and
development of physiotherapy in its foundations. Pierre Hadot’s
approach to philosophy as a way of life, as well as my research into and
practice of Zen (-buddhism), Aikido and a range of other,
predominantly Japanese, martial arts, and Shiatsu (a Japanese manual
therapeutic approach) augment the critical perspective drawn from
1