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 vi 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