Contributions of the theory of recognition to healthcare

Abstract

Based on Axel Honneth, this theoretical study describes elements of the theory of recognition and its interfaces with user autonomy in healthcare, describing how the spheres of rights, love, and solidarity intersect with autonomy. From reflections on professional practice and the care offered, one concludes that the theory of recognition can serve as a framework that expands the understanding of healthcare situations, especially those in which elements of recognition are suppressed or impaired. Applying the theory to the field of healthcare opens interesting perspectives for understanding the value of rights, love, and solidarity in healthcare and the possible consequences of their non-observance.

Bioethics; Personal autonomy; Freedom; Critical theory

Resumo

Embasado em Axel Honneth, este estudo teórico descreve elementos da teoria do reconhecimento e suas interfaces com a autonomia de usuários(as) no cuidado em saúde, retratando as esferas do direito, do amor e da solidariedade em suas interfaces com a autonomia. A partir de considerações reflexivas sobre a prática profissional e o cuidado ofertado, conclui-se que a teoria do reconhecimento pode servir como estrutura que amplia a compreensão de situações do contexto de saúde, especialmente aquelas em que os elementos da esfera de reconhecimento são suprimidos ou prejudicados. A translação da teoria para o campo do cuidado de saúde abre perspectivas interessantes para compreender o valor do direito, do amor, da solidariedade na saúde e de possíveis consequências de sua inobservância.

Bioética; Autonomia pessoal; Liberdade; Teoria crítica

Resumen

Basado en Axel Honneth, este estudio teórico describe elementos de la teoría del reconocimiento y sus interfaces con la autonomía de los(las) usuarios(as) en el cuidado en salud, retratando las esferas del derecho, del amor y de la solidaridad en sus interfaces con la autonomía. Con base en las consideraciones reflexivas sobre la práctica profesional y el cuidado ofrecido, se concluye que la teoría del reconocimiento puede servir como un marco que amplíe la comprensión de las situaciones en el contexto sanitario, especialmente aquellas en las que los elementos de la esfera del reconocimiento están suprimidos o perjudicados. La traslación de la teoría al ámbito del cuidado de la salud abre interesantes perspectivas para comprender el valor del derecho, del amor, de la solidaridad en la salud, y las posibles consecuencias de su desconocimiento.

Bioética; Autonomía personal; Libertad; Teoría crítica

The term “bioethics,” a neologism attributed to Van Rensselaer Potter, has gained amplitude as a field of knowledge for being more strongly associated to the boundary issues of life and death. Today, bioethics has also been applied to research with human subjects, public health, and health policies, imparting a more ecological and social approach¹ .

As a multidisciplinary and transversal field of knowledge, Bioethics includes relevant reflections on the autonomy of citizens to decide about their health and their lives. When exercising choice, users should receive enough communicative content from health professionals to adequately decide among the available alternatives. But the accumulation of individual practical experiences is not always enough to operate in this field, which requires knowledge of appropriate theoretical references.

From the contemporary standpoint of the healthcare field, transdisciplinary perspectives should be added to the disciplinary ones in the best interest of each profession, especially of the system users. Theoretical references from medicine, nursing, the humanities and social sciences, and other disciplines can be coordinated in the interest of interdisciplinary dialogue. We conclude therefore that the contributions by German philosopher Axel Honneth can be valid for supporting autonomous decision by users, since his perspective discusses experiences of disrespect suffered by individuals led to make choices without having conditions for the proper exercise of this autonomy² .

Reflective analyses on the theory of recognition have been conducted to verify its effectiveness in offering a useful conceptual framework for understanding relationships, struggles, oppression, the needs of the oppressed, and conditions of injustice and inequality. The theory of recognition is also contrasted with diametrically opposed theories to further identify its explanatory and prescriptive possibilities³ , ⁴ . Honneth elaborated a critical theory in which the processes of social change must be explained in light of actions directed at restoring mutual recognition or, more specifically, improving it at a higher level.

The struggle for recognition can be the driving force for developing an ethical community ( Sittlichkeit ), whose process is reflected in the sphere of human consciousness and understood as the sequence of the following stages: the relationship of the individual with themself; the institutionalized relationships of subjects among themselves; and the reflexive relationships of socialized subjects with the world around them² . His perspective has conferred greater understanding of social struggles and conflicts, serving as a basis for the social sciences.

Within healthcare, daily life is permeated by situations and conditions that interfere with user’s exercise of autonomy, limiting the decision alternatives that impact the lives, relationships and activities of those involved. Notably, the hospital, with its classical disciplinary organization and its strongly structured routines and rules, may be a limiting environment for people’s autonomy, capable of triggering relevant issues for bioethical debates, especially shaping implications for the concept of recognition.

The German term Anerkennung can be translated as “recognition,” stricto sensu , something understood as respect, and not only “cognitive identification”⁵ . But more than its etymological information, there exists a theoretical framework that can put the term in perspective and help with useful reflections to the actions of healthcare professionals. While interdisciplinary teamwork has been discussed in light of the theory of recognition⁶ , as well as some of its contributions to health research³ , ⁷ , we need a more in-depth understanding of its theoretical interfaces with user autonomy.

Based on above, this study presents a reflective research question as a starting point for further examining the theoretical framework – What are the interfaces between the theory of recognition and user autonomy in healthcare? –, seeking to describe elements of the theory of recognition and their intersections with user autonomy in healthcare.

Method

This theoretical study, aligned with Axel Honneth’s theory of recognition, was construed by the following steps: selection of the central topic for reflection and discussion; screening of national and foreign publications on the topic and theoretical framework, with recognition among peers and with substantive constructs to enable discussions.

Subsequently, we decoded the assumptions and concepts of the aforementioned theory to produce argumentative lines that presented potential contributions to understanding situations linked to healthcare, concerning user autonomy. This decoding identified general characteristics of the assumptions and of the theory of recognition; elements of the sphere of recognition; adoption of recognition and autonomy as privileged topics in reflections on healthcare. We also noted the implications of antithesis elements against the recognition sphere of users-healthcare professionals relations.

Results and discussion

General characteristics of Honneth’s assumptions and theoretical thought

Based on Hegel’s writings, Axel Honneth asserts the idea that the struggle for recognition constitutes the moral grammar of social conflicts. The great philosophical advance of the theory of recognition is to bridge Hegel’s original idea with the immanence of George Herbert Mead’s social psychology, as it embraces the current societal intellectual scenario⁸ . Honneth’s writings allow us to interpret the Hegelian theory of intersubjectivity in a post-metaphysical theoretical framework, building the hypothesis that the experience of disrespect (non-recognition) represents the affective source of knowledge for social resistance and collective uprisings ⁹ .

In Honneth’s understanding, the morally motivated struggles of social groups and the collective attempt to establish, institutionally and culturally, expanded forms of reciprocal recognition accomplish the normatively managed transformation of societies² . For this reason, like Hegel, Honneth proposes a progressive typology of the spheres of recognition: love, rights, and solidarity.

The first sphere – love – allows the individual to develop self-confidence, which is essential for self-realization. Only the feeling of being recognized and approved confers self-confidence, enabling the individual to participate in social life. In the legal or rights sphere, the person must realize that a meaningful life is only possible with recognition of rights and duties² , which, in the outcome of successful recognition, is accompanied by progress in the socialization of individuals who recognize themselves with rights, autonomous, and as a social member of a legal community. And in the solidarity sphere, the subject is recognized as worthy of social esteem.

The concept of recognition as a privileged topic in healthcare

In the hospital setting, users’ autonomous decisions allow them to choose the best type of treatment and assistance required to meet their daily vital needs. The healthcare professionals’ duty is to respect users as subjects of rights, informing them broadly and clearly about their pathologies, health conditions, and treatment options, thus allowing them to determine and exercise their autonomy. Such principle, however, is not always easily translated into professional practice when faced with the systemic challenges of healthcare.

It is recommended, therefore, as a starting point for the theory of recognition to support healthcare practice, to accept as an assumption that respect for users should reflect the three spheres of recognition proposed by Honneth: rights, love, and solidarity. Ideally, these spheres would be the starting point for building healthcare, since, in the opposite situation, we verify three forms of disrespect: violation, disenfranchisement, and degradation, respectively. Once in the condition of citizen or user, the individual tends to resist these forms of non-recognition.

Humanization policies in the health care system in Brazil are concerned with educating users and citizens signatories to the right to health. Situations consisting of conditions such as disenfranchisement, violation of decision-making opportunities, and degradation of the human condition are, therefore, grounds for conflicts. Lack of recognition can occur in user-healthcare professional relations, leading to serious misunderstandings, such as those seen in the hospital routine and that sometimes reach mainstream media. Such conflicts supposedly interfere with achieving a higher level of quality of care and treatment¹⁰ .

It is thus crucial that the healthcare team decides on the treatment indicated to patients with their consent and active participation, based on the spheres of recognition, starting with that of rights, which can influence commitment to the patient and effective treatment. Elements such as honesty and guarantee of autonomy must be considered, including to support the decision making of the person under professional care.

Such observation is important because users, in everyday situations, run the risk of being suppressed from deciding on different therapies, being only informed about the particularities of the treatment chosen by the healthcare team, without active participation. Although in Brazilian society it is uncommon for users to claim a position of conflict when faced with suppression of the right to participate in healthcare choices, one must consider that, as responsible for ensuring the guarantee of principles, professionals must interact appropriately as not to deprive users of this participation.

The re-reading of the theory of recognition proposed by Honneth² offers a comprehensive and original model for understanding social reality, a necessary text for disciplines in the field. When using this theory to clarify that the non-recognition of users as autonomous subjects highlights the struggle for human dignity, physical integrity, and the recognition of the value of diverse cultures and ways of life, we reach an opportunity for applying the theory to healthcare practice.

Importantly, regarding the principle of respect for autonomy, it is essential to require healthcare professionals to accept that users act freely in their decisions and actions, being limited only by the sphere of rights, which also calls for responsibility in dealing with professionals and other users. The spheres of recognition allow, in professional practice, to resize the interpretation of care in terms of moral grammar, related to the social context to which the user belongs. This includes all kinds of cultural values and how users experience them.

Moving on to reflections on the sphere of love, here recognition assumes the character of affective assent and encouragement, in which individuals express feelings of esteem. The intersubjective experience of love constitutes the psychic presupposition for developing all other self-respect attitudes² . Recognition is sought as an affirmation of autonomy, accompanied by dedication, when one speaks of recognition as a constitutive element of love: it is only this symbiotically nourished bond, which emerges through mutually desired demarcation, that produces the degree of basic individual self-confidence indispensable for autonomous participation in public life ¹¹ .

Self-confidence, self-esteem, and self-respect allow the individual to recognize and appropriate their autonomy, identifying their capacities in the other; but only to the extent to which every member of a society is in a position to esteem himself or herself, one can speak of a state of post-traditional social solidarity ¹² .

Moreover, the relationship of recognition is translated into respect for autonomy that health professionals must extend to the user. Here, communication should be understood as an orientation toward emancipation, that is, the ability to recognize in the other’s rationality the conditions that will enable a free choice. Supported by Habermas’s theory of communicative action, Honneth presents his theory as the construction of a rationality that communicates itself through the principle of freedom, constituting the engine of democratic societies under the rule of law.

Considering Honneth’s approach to freedom, the user must have, on the part of professionals, their recognition of freedom ensured. But for this to occur, their decisions must be based on rationality (autonomy), and not simply on their subjective desires (heteronomy). Despite being a contractual relationship, which implies rights and duties, respect for the patient’s autonomy cannot jeopardize or annul the beneficent purpose ( telos ) of the professional act² .

Conceptualizing a humanized health care comprises intersubjective elements, which include ambiguity. Consequently, one must constantly reflect on the conflicts between personal and professional choices in the sphere of health communication. Only then will it be possible for the healthcare team to identify, in the communication process, the weaknesses that potentially prevent recognizing the user as an autonomous subject. Health professionals must verify such weaknesses as a new understanding of care, which is also understood as an expansion of recognizing the other as an autonomous subject.

Family members and friends trying to interpret the patient’s free will, aware of their decisions, may install conflict in the relationship with healthcare professionals. If, on the one hand, the constant presence of family members and friends facilitates understanding and constitutes a relevant support network to healthcare; on the other, this same presence can threaten the patient’s free expression, becoming a high risk for their autonomy. Despite being an extremely complex issue, professional efforts to balance such components and improve relations among care practitioners are welcome.

Esteem, which takes place in the environment where the spheres of rights and love are respected, relates positively to constructing the sphere of solidarity, a striking element in the constitutional principles established in the social pact of the 1988 Brazilian Constitution. The sphere of solidarity, however, also includes the dimensions of particular realities, such as those of professional acts in the search to offer ethical and humanized care.

Implications of the manifestation of disrespect and considerations for healthcare professionals

The individual’s integrity is due to recognition. Whenever this premise is violated or deprived by denial or degradation, disrespect tends to manifest itself, as in cases of offence or debasement, which can potentially damage the individual’s identity. Deprivation of basic rights prevents the individual from taking ownership of their will. The disrespect experienced drives the subject to resistance and conflict, in a struggle for recognition. If the first form of disrespect comprises the experiences that undermine self-confidence and lead the person to social disrespect, the second encompasses debasement.

The particularities in the forms of disrespect in the sphere of legal recognition, namely, disenfranchisement, represent a limitation of personal autonomy and failure to consider the individual as a subject capable of forming moral judgment, since they are not granted moral responsibility as other members of society are. Experiencing disenfranchisement is measured not only by the degree of universalization, but also by the material scope of institutionally guaranteed rights² .

Finally, debasement expressed in degradation relates negatively to social value. One’s honor and dignity are relative to the measure of social esteem accorded to one’s way of self-actualization² . When people are degraded to conditions considered devalued or deficient, the possibility of assigning social value to their own capabilities gets nullified. Consequently, social esteem is lost, that is, the understanding of oneself as esteemed for one’s properties and capabilities² .

With the experience of degradation or debasement, in addition to social humiliation, individuals are threatened in their identity and, possibly, may be driven to fight for social recognition that has been unjustifiably denied. If social assent does not occur¹⁴ , ¹⁵ , negative emotional reactions such as anger, indignation, and sadness may ensue.

In Brazil, health is a conquered right that is aligned with the legal sphere. But when offered in degrading conditions, whether for users or professionals, it triggers mechanisms of social humiliation. In such conditions, people tend to react from passive acceptance to violent forms of action. In healthcare, suppression of the spheres of love and solidarity creates conditions of low recognition with degradation. Some social strata, however, are not always engaged in eliminating degradation, prioritizing rescuing the spheres of recognition, focusing on blaming other actors and disregarding the complex and systemic dimension of healthcare.

Also because of degradation, the feelings of individuals generally represent affective reactions to the success or failure of the practical intentions of those with whom they relate. One is oppressed by a feeling of lack of self-worth, for one’s own person is constitutively dependent on the recognition of others ¹⁶ . Consequently, the moral force within lived social reality that is responsible for development and progress in is a struggle for recognition ¹⁷ .

To minimize the risks inherent to disrespect, interactions between professionals and users cannot disregard the patients’ decisions whenever their clinical condition allow expressing them, becoming a “contractual relationship.” This implies observing the rights and duties for both parties, and ensuring the recognition of the patient’s dominion over their own life and freedom.

Health professions have built, via their regulatory frameworks, instruments that incorporate the spheres of recognition and limit their suppression. The Medical Code of Ethics¹⁸ prohibits physicians from suppressing the patient’s right to decide freely about themself or their well-being, a principle directly related to individual autonomy. The Code of Ethics for Nursing Professionals¹⁹ determines the duty of professionals to ensure that users have all the necessary information to make decisions.

In cases where health professionals neglect to respect user autonomy, one must consider the sanctions to which they are liable. Negligence, understood as omission, is the opposite of diligence, which means acting with love, care, and attention, avoiding failure. For both professions, such an infraction can reach the ethical, civil and criminal spheres.

Article 22 of Law 3,268/1957 lists the disciplinary sanctions for physicians in the following hierarchy, depending on the severity: confidential warning in a reserved notice; confidential censure in a reserved notice; public censure in an official publication; suspension of professional practice for up to 30 days; and termination of professional practice, approved by the federal council. For nursing professionals, the penalties contained in the Federal Council of Nursing (Cofen) Resolution 564/2017, Chapter IV – of infractions and penalties –, Article 108, can be, hierarchically, depending on severity: verbal warning, fine, censure, suspension of the right to professional practice (for up to 90 days) and termination – the latter, implemented by Cofen.

A careful examination of health professions’ regulations will result in the location of other duties and rights aligned with preserving elements concerning the spheres of recognition. This indicates that the theory of recognition corroborates the importance of a performance aimed at ensuring care, zeal, information, preservation of rights, and solidarity. It also runs the risk of suppressing elements that are relevant to the theory itself²⁰ .

Final considerations

As a theoretical framework capable of supporting healthcare action, the theory of recognition proposes relevant elements, considering that dilemmas and conflicts tend to emerge from conditions in which the spheres of rights, love, and solidarity are not observed. Claims for recognition thus, reflected in the exercise of autonomy and satisfaction of needs and aspirations, do not occur in isolation from the daily culture in which they are judged as legitimate. The moral grammar of social struggles integrates the process in which the bioethical prescriptions that guide self-respect and self-esteem are renewed, always thought of by the theory from the perspective of intersubjective socialization.

The translation of elements of the theory of recognition – especially expressed in the spheres of rights, love, and solidarity – and their relation with autonomy, when applied to healthcare, can serve as a reference for the communication practices within the therapeutic pact established between professionals and users. Importantly, recognition emerges as necessary to analyze the integrality of care; it is a professional and personal attitude of recognizing in the other an intentionality that is familiar to us.

In other words, only by perceiving the user as an individual similar to those who make up the healthcare team one can suppress the reification and change attitudes and care practices based on models that empty the human dimension from health system users. Like users, professionals are endowed with moral values that guide their own lives and health, and this recognition leads them to operate within the limits of the best ethical values of their profession.

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Publication Dates

• Publication in this collection
  18 Mar 2022
• Date of issue
  Oct-Dec 2021

History

• Received
  21 Jan 2020
• Reviewed
  27 Sept 2021
• Accepted
  23 Oct 2021