A Genealogia Da Moralidade Em Nietzsche

Nietzsche’s Genealogy of Morality and the changingboundaries of medicine, psychiatry and psychiatric andmental health nursing practice: a slave revolt?jpm_1584 700..705

F. C . B I L E Y r n p h d

Associate Professor, Bournemouth University, Bournemouth, UK

Keywords: medical and nursing

paternalism, Neitzche, philosophy

Correspondence:

F. C. Biley

R105

Royal London House

Bournemouth University

Christchurch Road

Bournemouth

BH1 3LT

UK

E-mail: [email protected]

Accepted for publication: 15 April 2010

doi: 10.1111/j.1365-2850.2010.01584.x

Accessible summary

• The boundaries of medical and psychiatric and mental health nursing practiceappear to be changing in recent years

• These changes include a move towards more inclusive health care practices thatrecognize common physical and mental corporeality

• This may suggest an inversion of the values that were previously held as good or bad

Abstract

The main constructions in Nietzsche’s On the Genealogy of Morality (1994) areemployed in order to explore the changes in mental health care that have been recentlytaking place. Characterized by boundaries that define the objectivity of scientificmethod, the biological stratum or the area of concern (disease and the disembodiedbeing) and the professional distance that is maintained in the healthcare encounter, thenoble morality of contemporary allopathic (Western) mental health care practiceappears to be being challenged, in an act of ressentiment, by the slave morality of society,inverting values and beliefs that have previously been held. Mental health care pater-nalism may be in the process of giving way to consumer sovereignty, patient participa-tion in decision making and the re-discovery of the embodied being at the centre of thehealthcare encounter. Nietzsche warns that the dominance of slave morality and theinversion of moral values (what was a quality that was held by the nobles and regardedas good) – that is, objectivity and mental health care paternalism – becomes bad; andwhat was a quality held by the slaves and regarded as bad – subjectivity – becomes good,may ultimately be detrimental to the advancement of society.

Introduction

People ‘originally praised unegoistic actions and calledthem good from the perspective of those for whom theywere done, that is, those for whom such actions wereuseful. Later people forgot how this praise began, andbecause unegoistic actions had, according to custom,always been praised as good, people then simply feltthem as good, as if they were something inherentlygood.’ (Nietzsche 1994)

In the book On the Genealogy of Morality, written byNietzsche and appearing as an English translation for thefirst time in 1967 as On the Genealogy of Morals, theauthor explored the subject of moral codes, the basis ofsurvivalist strategies, which he defined as falling into one oftwo categories. These are the moral codes of the nobility,which is characterized by qualities such as strength andassertiveness (good, or possessing the qualities of thenobles) and the moral codes of the slaves, characterizedby qualities and the subsequent emergent activity thatexpresses weakness, passivity and dependence (bad, orrather, lacking the qualities of the nobles). Tension betweenthese moralities creates a power struggle, and although

An earlier version of this paper was published in the InternationalJournal of Human Caring, 8: 2, 21–25; and it is re-published here withthe full permission of the Editor, Professor Zane Robinson Wolf.

Journal of Psychiatric and Mental Health Nursing, 2010, 17, 700–705

700 © 2010 Blackwell Publishing

noble morality once dominated, slave morality and theirpreviously identified qualities are now in ascendancy. Whatwas once bad now becomes good. Inspired by this purpose-fully over-simplified interpretation of Nietzsche’s position,which originally considered the rise of modern Christianmorality as a result of a slave revolt against earlier nobledominance, evidence is sought for the re-interpretation ofmodern allopathic (that is Western) medical, psychiatricand mental health nursing practice as a (power) struggleand an attempt to assert one set of codified behaviour overanother, or rather an inversion of what constitutes good orbad qualities. Specifically, in this instance, an investigationwill be constructed in order to establish whether thereappears to have been an attempt by the slaves (patients) toassert their ascribed qualities over the nobility (medicine,and in particular, psychiatry and subsequently psychiatricand mental health nursing).

Models, aims and goals of medicine,psychiatry and nursing

The practice of modern allopathic, Western medicine canbe interpreted in a number of different ways, with eachinterpretation generating its own definition. For example,Gunderman (1995) critically considers the adequacy of thedominant ‘reductive-isolation’ model of health and disease,which is characterized by:

quantification and measurement and aims to peerbeneath variability and subjectivity, and the infinitevariety of patient experiences to something universallydefinable measurable and objective (p. 676).

An alternative approach, he suggested, is ‘the larger andmore complex reality of the patient as addressed by [an]ascendant interrelation’ view, ‘in which the organism hasan identity that transcends that material with which itis made’ (p. 676). Similarly, Tamm (1993) considered anumber of different religious, humanistic and transpersonalmodels of health, and biomedical, psychosomatic and exis-tential models of illness and disease. However, taking aslightly different perspective, in an interesting explorationof the main themes in Nietzsche’s On the Genealogy ofMorality (1994) as applied to caring, nursing and the res-sentiment of nursing’s attempt to escape from a state ofslave mentality/reality, Paley (2002) claims that the natureof medicine and the ‘medical model’ can be ‘defined by a setof boundaries . . .’ (p. 29). These boundaries, which alsoseem to define objectivity and ‘represent, and celebrate, thenoble’s [medicine’s] most prized characteristics, the quali-ties that make them what they are’ (p. 28), consist of the‘scientific method’, which defines the nature of legitimateevidence and perhaps therefore what constitutes knowl-edge and ‘truth’, the ‘biological stratum’, which ‘is a

boundary determining the proper field of enquiry’ (p. 29),and the ‘professional distance’, indicating the typicalnature and quality of the doctor-patient relationship. If thisdefinition of medicine, psychiatry, the medical model andmedical-model psychiatric and mental health nursing prac-tice can be accepted, then it can be seen to be characterizedas using evidence that has emerged through a process ofempirical analytical science (Rapport 2002), the ‘scientificmethod’. It has as its focus a concern the promotion ofhealth and the elimination of disease in human beings, the‘biological stratum’; and finally, maintains a ‘professionaldistance’ (and/or emotional detachment) in order to remain‘objective’. If this defines the nature of medicine and, bydefault, psychiatry and psychiatric and mental healthnursing, then their goals can be summarized in a clear andsimple statement that includes reference to all three bound-aries. It could be said to be aimed at the objective promo-tion health and elimination of physical and mental diseasein all human beings by the application of knowledge thathas emerged as result of the processes of empirical analyti-cal science. Superficially, for some this might form the basisof an acceptable and accurate definition of the goals ofmedicine and psychiatry. For many, it may reflect the actualactivity of the medical and nursing professions and thereality of its practice. However, adopting such a definitioncould have limited its effective practice and prompted themodern allopathic medicine critique and the actual and/orpotential alteration in the boundaries that, it will beargued, seem to be taking place. This definition of medi-cine, the medical model and medical-model psychiatric andmental health nursing can be reduced to one main theme,that is, the subject of objectivity.

Objectivity or subjectivity?

It has been claimed that the world view of contemporarymedicine is instrumental and scientific, objectifiable andknowable (Wiltshire 2003). Such a world view leads toscientific objectivism which fails to acknowledge the com-plexity of the human condition and recognize that medicine‘is not an exact science. Diagnosis and prognosis cannot bemade with absolute certitude’ (Lim 2002; p. 144). In anymedical encounter, both the psychiatrist/nurse and thepatient have at least one thing in common, that is that theyboth ‘possess’ a human body and mind, that they are‘embodied beings’ (p. 188). However, this:

is an object of knowledge in only one of them. Theconstruction of medicine seems designed to sever, orsuspend, recognition of this commonality

(Wiltshire 2003; p. 188)

Traditionally, science may be defined as ‘the construc-tion of generalizable statements about how the universe

Nietzsche, medicine and the slave revolt

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behaves’ (Greenhalgh 1999; p. 323), a view that fails torecognize ‘the uncertainty produced by the complexity ofthe human condition’ (Gillett 1994; p. 1125). In medicine,psychiatry and nursing, the practice and application ofpre-Kuhnian traditional science, that which promotes theidea of there being one single truth (Gillett 1994), is typi-fied by the rigorously defended evidence-based practicemovement, which applies statements of ‘truth’ (the correcttreatment) that have been ‘established by the empiricalobservation of populations in randomized trails and cohortstudies’ (Greenhalgh 1999; p. 324). Such an objective,reductive-isolation (Gunderman 1995) approach may havebeen fostered in psychiatry through its process of second-ary socialization or colonization, which is, as Habermas(1987; cited in Wiltshire 2003; p. 188) stated, ‘the shapingof the experiential world of our moral lives by instrumentalrationality, highly routinized procedures, and both techni-cal and technological management’ (p. 85). Pragmatically,such an approach is exemplified by a quote from a medicalstudent, who was being exposed, for the first time, to theprocess of cadaver dissection (Fig. 1), to the beginningprocess of objectification, of objectivity, to dealing with theother, another (something) that is not quite, but almost, adisembodied being.

Good (1994) exemplified the position of objectivedetachment in a study of medical students at Harvard andfound that they became isolated from the real world in apeer-reinforced denial of common (doctor-patient) corpo-reality (Wiltshire 2003), founded in an ever increasingconcern with learning about and understanding themechanical functioning of the body and an exclusion ofwhat was classed as irrelevant (non-biological) detail. Itcould be argued that the growing objectification and denialof a common corporeality that could be imposed bymedical and psychiatric and mental health nursing trainingleads to an inability to recognize humanity and the sacred-ness of the tasks with which graduates of medical and nursetraining eventually become involved. Could this be thedevelopment of clinical gaze, described as that which:

refrains from intervening: it is silent and gestureless.Observation leaves things as they are; there is nothinghidden to it in what is given. The correlative of obser-vation is never the invisible, but always the immediately

visible, once one has removed the obstacles erected toreason by theories and to the senses by the imagination

(Foucault 1975; p. 107).

If objectivity is the ultimate goal of ‘reductive-isolation’medical and psychiatric and mental health nursing practice,manifest as perceptions and statements of ‘truth’ arrived atthrough processes of empiric, rational science, disembodi-ment and the denial of a common corporeal reality, thenpractices emerge that do not maximize their potential.However, they could be seen to ‘represent, and celebrate,the nobles’ [medicine’s] most prized characteristics, thequalities that make them what they are’ (Paley 2002; p.28). Paley (2002) maintains that slaves’ (nurses’) reactionto this, a revengeful revolt against medical domination, hasbeen to invest heavily in the ressentiment of the develop-ment of an inversion of the objectifying medical model, the‘caring’ (meta)paradigm, in order to attack the ‘evil’ valuesof objectivity held by the nobles (medicine). According toPaley (2002):

To be ‘objective’ is a good thing . . . It is only when theslave revolt occurs that ‘objectivity’ . . . acquires a moralweighting. In the eyes of ressentiment, it is transformedinto something evil . . . repugnant, soulless, reprehen-sible (p. 28).

In a state of ressentiment, medical objectivity (practice)and the expression of nobility (Paley 2002; p. 31) becomespositivist (a pejorative term in this instance), reductionistand mechanistic (Paley 2002; p. 29).

Paley (2002) has constructed a very logical, coherentand compelling discussion of nursing’s response to medicaldomination. However, it may be considered to be flawed ina number of ways (Rapport 2002); not least because itappears to pay little, if any, attention to the sociologicalcontext in which the ‘slave revolt’ has taken place. Paley(2002) asserts that the caring slave revolt emerged from the‘burst of creativity’ (p. 33) that followed the expansion ofdoctoral programmes in nursing in 1970s USA. Psychiatricand mental health nursing, and for that matter medicineand psychiatry, cannot be easily separated from the con-textual and inextricably linked sociological soup of human-kind that ultimately dictates and must be held responsiblefor the nature of allopathic medical, psychiatric and healthcare practice. Although perhaps somewhat of an over-

Figure 1Carrie’s experiences of dissection (Levin2000)

‘We were told that our cadaver would be our first patient. I thought that was an interesting take on the situation. At first glance, my group's cadaver certainly didn't look human. Her skin had a plastic texture, her insides a muddy gray color rather than the brilliant reds and blues I naively expected from looking at the textbook atlases. She looked so small, frail, sexless even. But then I saw a blister on her toe. And on another cadaver, nail polish. So they were human, once. Still? I'm not sure. Iwish someone would talk to us and help us to deal with the confusion.’

F. C. Biley


simplification, it could be suggested, for example, that theexpansion of doctoral programmes in nursing in 1970sUSA occurred for some reason. That reason may have beenbecause of dissatisfaction with the values and subsequentactions held by practitioners of allopathic medicine (andincluded in this is the practice of medical model dominatedpsychiatric and mental health nursing) in the general popu-lation. If, to expand Paley’s (2002) argument, members ofthe general population are considered to be the slaves inrevolt against medical and psychiatric domination, ratherthan nurses, a different picture might emerge. For example,the emergence of the caring or humanizing (Todres et al.2006) (meta)paradigm becomes one manifestation of therevolt rather than the revolt itself. Such an assertionrequires the search for, and identification of, the revoltitself, or at least the creative act that represents the revolt.If, for the sake of the argument in this instance, it isassumed that it is the general population that can bedefined as the slaves under the control (to some extent thisinvolves acknowledging, accepting and responding to themoral characteristics) of the nobility, then this search needsto centre, at least in the first instance, on the relationshipbetween the slaves and the nobility and the alteration ofboundaries and any objective practice.

Over 20 years ago one author claimed that the nature ofmedicine and psychiatry has changed considerably over thepast 50 years as a result of powerful social forces (Starr1982), a view that has been expressed elsewhere (Cantor2001, Berger 2002, Chin 2002). Although some advanceshave been made as a result of the development of, say,medical technology and social policy, commentators haveidentified that not all these changes have been positive.They have gone as far as to say that medicine is ‘a majorthreat to health’ (Illich 1976), with considerable adverseeffects and ‘the perception that conventional treatments aretoo harsh’ (Furnham & Forey 1994), and that the ‘focus onindividualism persist to the detriment of a social under-standing of mental health’ (Pilgrim & Ramon 2009). Inwhat could be called the beginning of an inversion of moralvalues, medicine has, according to Illich (1976), destroyedan individual’s inherent capacity to deal with death, painand suffering and he identified solutions to this thatincluded a need for a health care system that, amongother things, paid attention to patient autonomy (self-determination) and promoted self-care. While there hasbeen a reluctance to accept such criticism in some quarters,elsewhere there is a growing recognition of the limits ofevidence-based medicine, that ‘threaten[s] the art of medi-cine’ and ‘perpetuate[s] medical paternalism’ (Parker 2002;p. 273; emphasis added). Others have called for doctors toparticipate in the de-medicalization of medicine (Moynihan& Smith 2002) or run the risk of becoming its ‘most

prominent victims’ (Leibovici & Lievre 2002; cited inMoynihan & Smith 2002). However, this discourse doesnot define any boundaries that might have changed, or arein the process of changing. As it has been previouslyidentified, objectivity is the ultimate goal of ‘reductive-isolation’ medical practice, manifest as perceptions andstatements of ‘truth’ arrived at through processes ofempiric, rational science, disembodiment and the denial ofa common corporeal reality. These practices do not reallyidentify and adequately respond to the nature of concern ofmedicine, psychiatry and psychiatric and mental healthnursing, that is practices that are able to respond appro-priately and positively to the human condition.

Societies now demand, at least to some extent, that therecipients of mental health care are recognized as embodiedbeings, with a physical and mental corporeality that is incommon with practitioners of mental health care andwhere the material accompanies ‘the affective and the sym-bolic’ (Wiltshire 2003; p. 191). This is manifest in anumber of different ways, not least in the ressentiment-based demand being made by society that individuals aregiven the opportunity to participate in decision makingabout their treatment and care. Such an assertion supportsthe view that the boundaries of mental health care may bein the process of changing.

Wiltshire (2003) has maintained that ‘the pursuit ofautonomy for the patient often in practice results in theaugmentation rather than diminishment of medical [andpsychiatric] power’ (pp. 191–192). However, this perspec-tive only survives scrutiny if it is accepted that it is mentalhealth care that is driving the pursuit of patient autonomy.If patient autonomy is being pursued by patients, and/orthose in need of mental health care, as an act of ressenti-ment, that is a slave revolt against noble morality, thenmedical, psychiatric and psychiatric and mental healthnursing power, at least within the patient encounter, will bediminished.

Authors have expressed concern with the simple rejec-tion of medical and psychiatric paternalism. Such pater-nalism is one form of doctor–patient or nurse–patientrelationship that is characterized by objectivity, pays littleor no attention to patient preferences, where the doctor ornurse acts as a guardian (Emanuel & Emanuel 1992) and‘where the patient passively acquiesces to professionalauthority by agreeing to the doctor’s [nurse’s] choice oftreatment’ (Charles et al. 1999b; p. 781). Such an approachwill severely limit the potential of patient participation inmedical, psychiatric and psychiatric and mental healthnursing decision making. Emanuel & Emanuel (1992)suggested that alternatives, such as the informative, inter-pretative and in particular, the deliberative model ofdoctor–patient (nurse–patient) relationship, where the



doctor (nurse), acting as a friend or teacher, enters intodialogue with the patient in order to illicit and agree valuesneed to be considered, an idea that has been mirroredelsewhere (Quill & Brody 1996, Chin 2002). Similarly,Berger (2002) argues that paternalism, which is moreacceptably re-titled ‘moral authority’ needs to be employedto complement ‘sapiental authority’ (which arises fromcompetent action) and ‘charismatic-empathic authority’(acting as a friend) in the care of those with chronic dis-eases. Charles et al. (1999b) identified that restricted timeand funding were barriers to the promotion of patientparticipation in decision making, but that different models,from a range of paternalistic, informed, shared and inter-mediate options, can be employed according to circum-stance, arguing, for instance, that:

In cases where both the patient and doctor [nurse] preferthis [paternalistic] approach, it can be argued that theyhave entered a form of partnership . . .

(p. 781).

Conclusion

Whatever the model of patient participation in decisionmaking, as it can be seen from this brief excursion into themedical and psychiatric literature (and there is of course awealth of further material and evidence that could havebeen employed to explore the subject in more depth), thesubject is certainly on the medical and nursing agenda,although it seems to be being treated cautiously. Theboundaries of medical, psychiatric and psychiatric andmental health nursing practice appear to be changing fromobjectivity and medical, psychiatric and nursing paternal-ism towards more inclusive, humanizing and life-world led(Todres et al. 2006), health care practice that recognizescommon physical and mental corporeality. But does thisrepresent a slave revolt, a ressentiment, and inversion ofthose values that were regarded as good, or bad?

Nietzsche’s previously unmentioned Priests, who are theleaders of the slave revolt, are those who are intelligent butotherwise lack the characteristics of the nobles. In thisinstance, it could be said that they are like medical doctors,psychiatrists and psychiatric and mental health nurses, butthey are not. The Priest, or Priests, are responsible for therevolt, for guiding the herd to the new morality. If it issociety that is changing the boundaries of medicine andpsychiatry then those in society who could be regarded asprogenitor Priests could be those involved in the serviceuser, consumer, human, feminist, black and equal rightsmovements (see for example Charles et al. 1999a) and theemergent ‘notion of consumer sovereignty in healthcare’(Charles et al. 1999b). Names might include, but only forthe sake of illustration, Martin Luther King, the Dalai

Lama, Dworkin, Malcolm X and John F. Kennedy.Nietzsche himself may not have taken an exception to suchan assertion, as he stated (from within the context of hisown conceptualization, which was, of course, very differentto the one stated here) that slave morality was in itsascendancy and that the major source of the revolt wasegalitarian democratic socialism.

However, just at the point when all loose ends should besatisfyingly brought together in order to neatly concludesuch philosophical/hypothetical meanderings, there is onefinal interjection that potentially threatens to subvert thetentative assertions that have been made so far, or at leastdemands further attention than can be given here. A claimhas been made that the Priests of the new (slave) moralityare driving consumer sovereignty in healthcare, thesearch for alternatives to objective practice and the re-embodiment of the health care encounter; and that theboundaries of medical practice are changing. Nietzsche(1994) warned, however, that ultimately the dominance ofslave morality is a threat to the advancement of man andthat noble morality, in either a pre-existing or new form,needs to be rejuvenated or newly (re-)constructed. It istempting, but dangerous (as the suggestion cannot beexpanded according to the orthodox requirements ofacademic rigour) and a little too ambitious at this point,to try to suggest solutions to this emerging dilemma andto predict the future of medical, psychiatric and psychiatricand mental health nursing objectivity, but Wiltshire’s(2003) assertion that the future of medicine, psychiatry,nursing and medical morality could be in the professionadopting some of the moral principles and practice of whatmight be considered to be real psychiatric and mentalhealth nursing (as defined by, for example, Brimblecombeet al. 2007) might seem to be a tantalizing potential. Sucha solution would satisfy those who demand consumer sov-ereignty, re-instate the embodied being at the centre of thehealthcare encounter, and offer a re-inversion of thosequalities that were once regarded as good (or bad) andsubsequent noble re-domination.

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A Genealogia Da Moralidade Em Nietzsche

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