Løgstrup’s thinking: a contribution to ethics in physiotherapy

ABSTRACT

Ethics is ever-present in all aspects of human interaction and, in any physiotherapy situation there is an inherent claim to act and care for the patient in the best possible way. The physiotherapy profession is provided with rules, guidelines and codes to support and ensure ethical professional conduct. In recent decades however, physiotherapy literature has emphasized how ethical agency is immersed in clinical reasoning in each particular situation, in the doing of physiotherapy. The Danish philosopher and theologian Knud E. Løgstrup offers a bottom-up approach to ethics, which may augment the philosophical underpinning of this development in ethical thinking. Løgstrup departs from the given pre-conditions of life; a point of departure where the ethical claim emerges from sensation in the concrete situations. This paper introduces Løgstrup’s situational ethics and its ontological framing, with four foci: how we can tune in to sensation and sense the ethical claim of the other; how human interdependence can be heard in what Løgstrup calls sovereign life utterances; relational responsibility and ethical norms; and the metaphorical importance of poetic understandings of the world. In four themes we reflect on how these ethical issues are at stake in physiotherapy practice with regards to: (1) uncertainty, tuned sensation and therapeutic attitude in physiotherapy; (2) sensuous, narrative and poetic meaning-making in physiotherapy; (3) physiotherapy and coming to oneself in new embodied experiences; and (4) ethical claims and codes of conduct in physiotherapy.

KEYWORDS:

• Physiotherapy
• ethics
• ethical demand
• K.E. Løgstrup

Introduction

Members of The World Confederation for Physical Therapy (WCPT) must follow the common norms of WCPT’s ethical rules and principles for professional physiotherapy practice. Since physiotherapy is practiced worldwide, in countries with diverse health issues, technological developments, socioeconomic structures, financial possibilities, and diverging cultural norms, values and beliefs, common principles and codes are expected to be integrated in line with national rules and laws. These common norms are revised regularly and adjusted to the consensus of a common standard. Up until 2000, ethical debates in physiotherapy were predominantly based on biomedical understandings and philosophical principles related to rational concepts of what ought to be done and how to conduct oneself as a professional. The concept of principlism (i.e. applying ethical principles to solve ethical dilemmas) was based on the notion of common moral norms. Thus, moral action implies the application of the bioethical principles of beneficence, non-maleficence, justice and autonomy. Since then, focus on ethical issues arising from specific physiotherapy situations has increased, linking ethical reasoning to clinical and narrative reasoning (Delany, Edwards, and Fryer, 2019; Delany, Edwards, Jensen, and Skinner, 2010; Greenfield, Delany, Mostrom, and Jensen, 2015; Greenfield and Jensen, 2010). In line with this development Edwards et al. (2004) argued that there is a dialectic nature of clinical reasoning which continues in ethical decision-making:

On the one hand, there is ethical decision-making as the application of normative or professional rules and principles to particular situations in a deductive or instrumental manner. Patient autonomy, justice, and not doing harm to patients are examples of such principles. On the other hand, there is a narrative (or communicative) approach to ethical decision-making where the experiential and contextual elements of a given situation (or narrative) guide decisions and actions, in turn, providing perspectives on these broader rules or principles of right and wrong (Edwards et al., 2004, p. 328).

Greenfield and Jensen (2010, 2012) underpinned the need for phenomenological understandings of patient’s experiences in ethical reasoning of patient-centered care. They underscored how a phenomenological attitude may enhance intersubjective understanding by mindfully, emotionally, and intellectually engaging with the patient’s subjective experiences and holding one’s own presuppositions in abeyance exploring this together with their patient. This proposal calls for a debate on the notion of professional attitudes and the power relations that exist within clinical situations. One might also argue that the increasing body of knowledge in physiotherapy, drawing increasingly upon humanistic and social science principles, in which the biomedical basis of understanding is challenged with perspectives from phenomenology, hermeneutics, narrative theory and social constructivism, in itself has ethical implications (Engelsrud, 1990; Natvik et al., 2019; Øberg, Normann, and Gallagher, 2015; Øien, 2010; Råheim and Håland, 2006; Sviland, 2014; Thornquist, 2006).

The increased focus on practice-based ethics has challenged the role of normative principles and codes of conduct, and raised discussions on a wide range of issues, such as informed consent, theoretical frameworks, moral agency, the ethics of the ‘other’, students and moral judgment, as well as ethical decision-making and professional identity (Delany, 2005; Drolet and Hudon, 2015; Edwards, Delany, Townsend, and Swisher, 2011; Edwards et al., 2012; Hudon, Drolet, and Williams-Jones, 2015; Linker, 2005; Praestegaard and Gard, 2013). A recent study by Delany, Edwards, and Fryer (2019) explored how individual therapists perceived, interpreted, and responded to ethical issues. The authors argued that in the very moment of the therapeutic situation, the therapist must take in the patient’s circumstances and integrate professional codes of conduct, ethical theory, and, in the given context, decide what to do, justified ethically and professionally. At the same time, the influence of personal values must be considered. At the intersection of all of this:

A diverse and complex ethical landscape where therapists encounter and grapple with ethical questions emerging from the impact of funding models and policies affecting clinical work, expanding boundaries and scope of practice and changing professional roles and relationships. Codes of conduct were described as foundational ethical knowledge but not always helpful for ‘in the moment’ ethical decision-making (Delany, Edwards, and Fryer, 2019, p. 663).

In this comprehensive study, rather than cognitive processes, ethical actions came across as relational, emotional, and context bound. Within a specific realm of work, sometimes involving situations of competing interests, the physiotherapist’s capacity to act ethically was related to the particular context where relationships and individual perspectives emerged in ethical stories.

Although the practice-based ethical challenges debated in physiotherapy literature have increased considerably, there may still be a gap between this and the capacity to deal with unique ethical issues arising in clinical situations. To help bridge this gap, Delany, Edwards, Jensen, and Skinner (2010) proposed a model underlining a sense of moral agency in the specific context of physiotherapy. Focusing on skills, attitudes and actions, three steps are suggested as essential to support the intention to connect with people, systems, values and structures involved in the given situation: to listen actively, to think reflexively, and to reason critically.

As already mentioned, the value of phenomenology¹ has been underpinned within the debates of ethics and clinical reasoning in physiotherapy. Phenomenology is, however, a movement of multiple voices and, within physiotherapy literature Husserl² and Merleu-Ponty³ are frequently cited. How the phenomenological works of Knud Ejler Løgstrup (1905–1981) may contribute to enhancing ethics within physiotherapy has remained unexamined until now. Løgstrup is Denmark’s most famous philosopher next to Kierkegaard.⁴ Løgstrup belongs to the Danish philosophical tradition known as philosophy of life. Løgstrup’s philosophy involved extensive analysis of the works of Husserl and Heidegger,⁵ and he was also a critic of Kierkegaard and the Danish structuralist thinker Hjelmslev.⁶ Løgstrup’s phenomenology is first and foremost inspired by Hans Lipps,⁷ whose lectures he attended in Göttingen. His philosophy is claimed to account for two perspectives of human life; the existential human shaping of life (human utterances), and the ontological preconditions of life (life utterances) (Løgstrup, 1987, 2014).

Løgstrup’s most famous work was The Ethical Demand⁸ published in 1956. In it, Løgstrup presents an alternative understanding of interpersonal life, with a particular focus on inter-dependent trust. Løgstrup’s phenomenology of sensation was developed later, but it was implicit in his thinking already in 1956. His ethical perspectives emerge from a theological context. However, Løgstrup himself claimed that ethical, philosophical and ontological phenomena, which are universal, must be discussed in a universal manner (Løgstrup, 1987). This supports the possibility of reading his works as philosophy (Jensen, 2007), which we do in this paper. He was engaged in a wide range of issues such as education, ecology, arts and literature, and he participated actively in public debates. His philosophy is much referred to within healthcare research in Scandinavia. Although his ethics is not aimed at healthcare in particular, it has had a strong impact on the philosophy of care, and is well known in other fields of healthcare such as nursing (Martinsen, 2012).

A comprehensive critical review of Løgstrups philosophical perspective and its implications for healthcare is important,⁹ but beyond the scope of this article. Our concern here is to explore practice-based ethics through the spectacles of Løgstrup’s thinking, and to work in line with the hermeneutic tradition of making the interpretive perspective as explicit as possible. Our intention, with this paper, is to explore how Løgstrup’s ontologically situated ethics may provide philosophical underpinning to the ethical claim for clinical and narrative reasoning in physiotherapy. Since his ethics is relatively unknown beyond Scandinavian speaking countries, we first present an overview of his ideas before exploring how his ontological framing may be of use to physiotherapists.

Løgstrup’s ontologically situated ethics

Løgstrup’s ethics focuses on a radical privileging of intersubjective interdependence and its significance for ethical thinking and practice. The early focus in his philosophy was on anthropo-phenomenology and moved toward comso-phenomenology, but both aspects were present throughout his entire oeuvre (Jensen, 2007), and with regards to his philosophical ethics the differences between earlier and later writings are not fundamental (Holm, 2001).

He positioned his ethics as an alternative to the two dominant ethical traditions in Western philosophy: teleology and deontology.¹⁰ Løgstrup argued that while truly engaged in the other we do not need moral rules to guide our actions, but as we lose this engagement, such rules are necessary. We, therefore, need norms and codes to safeguard our flaws and egocentricity (Løgstrup, 2014).

Deviating from outcomes and duty-based ethics, Løgstrup suggested a third perspective; an ontologically situated ethics. Rather than discussing theoretical principles of ends and duties, his aim was to develop ethical understanding by departing from concrete life-experiences, trying to grasp, instead, phenomena that protect and support human life. Løgstrup’s ambition was to examine phenomena as close as possible to how they were available to us in our experiences; at the level of sensation (Løgstrup, 1987). It is on this level, he argued, that we may experience ethical claims, and he suggested that we are always subject to the ethical claims of the other, as they emerge in the situation.

Løgstrup was concerned about the extensive use of concepts, definitions and categories in philosophy and science of modernity, which tended to entangle and conceal important meanings. By making distinctions, he disentangled phenomena, uncovered differences, nuances, and interdependence in human experiences. In one example, Løgstrup discussed anger and rage as similar phenomena. The course they ran, however, was different. In anger, strength is mobilized to get a grip on oneself, whereas in the case of rage, one has simply lost such grip; one gets “beside oneself” through rage. This distinction illustrated the double meaning of bearing, as a way of carrying one’s body (posture); as a certain way of forming emotions (attitude); and how emotional expressions may be shaped in the dynamic regulation between emotional motion and bearing¹¹ (Løgstrup, 1987). Nuances, differences and interdependencies emerge in the process of describing phenomena distinctly. Whereas dialectic thinking, in the Hegelian way, refers to synthesizing thesis and antithesis, Løgstrup emphasized that dynamics existed, where opposites must not be synthesized. In order to understand nuanced emotional regulation and expressions, for example, we need to distinguish between the motions of emotions and emotional bearing/attitude, because they are different yet mutually interdependent. This is what Løgstrup called ‘thinking in unifying opposites’. Other examples of such unifying opposites are ‘sensation and understanding’ and ‘norm and spontaneity’ (Løgstrup, 1983, 2000, 2014).

A phenomenological understanding of sensation was implicit in Løgstrup’s ontologically situated ethics and four core issues are essential in understanding his perspective on ethics¹²: (1) ethical claim; (2) notion of what Løgstrup called sovereign life utterances; (3) existential shaping of expressions of impressions; and (4) poetic and ethical understanding of life (Pahuus, 2005). These four distinct features will be outlined, before we explore how they may be brought into physiotherapy thinking and practice.

Tuned sensation and the ethical claim

Phenomenologists have argued since the 19th century that human life cannot be isolated from its context. Edmund Husserl brought to the fore the notion that awareness is always awareness of something (intentionality), and Heidegger insisted that people were thrown into the world; always already being in the world (Birkelund, 2002). For his part, Løgstrup argued against the possibility of a neutral and detached position characteristic of modernism, positivism and the Enlightenment values underpinning Western science and medicine. He stated that we cannot understand human life separated from the time and place in which we exist, and humankind should not attempt to make the world an object of its control. Løgstrup suggested that we must acknowledge that human life is interwoven in the world through what he called ‘sensation’.

To understand Løgstrup’s philosophy, we need to distinguish between our contemporary neuroanatomical understandings of sensation and sensation as phenomenon. Løgstrup’s concern is with the latter, and how sensation always includes the phenomenon being sensed.¹³ He illustrated this idea with the example of someone looking at a boat at sea. If you look at a boat on the sea, Løgstrup argued, the phenomenon of seeing this boat encompasses both you as the seer and the boat itself. Even if the boat is kilometers away, in the seeing as phenomenon, the distance becomes irrelevant (Løgstrup, 1984). In this way, sensation make possible a kind of presence in the world without distance to it.

According to Løgstrup, we are ‘tuned in sensation’ by multitudes of impressions, that continually shape and refine our expressions. What we really mean when we speak of the human mind is this tuning in sensation, which acts like a soundboard. It is continually tuned as we encounter new situations, and in this attunement, we are brought closer to ourselves as we are tuned by new impressions and find our bearing in body and language. New tuned impressions challenge our embodied attitudes in order to understand ourselves better in the new context. The capacity to support and shape expressions of emotions emerging in new life situations depends on how we are able to adapt our attitude. Løgstrup argued that by being open to ourselves and our relationship to the world, we may ’come to ourselves’ in sensation and in the bearing of our emotions (Løgstrup, 1987).

Løgstrup argued that we have trustworthy access to the world in sensation, although tuned impressions do not always make immediate sense. We can never fully capture all and tuned impressions need clarification to make meaning. By clarification, Løgstrup means the process by which we become aware of meaning in the shifting motion between sensation and language, a meaning derived from, and close to, the impression in sensation. This is part of, but different from, interpretation and intellectual activity. When we express tuned impressions in words and language, a space is created where thoughts may move with freedom to reflect; a space where varieties of possible meanings may come to the fore (Løgstrup, 1976, 1984).

In Løgstrups philosophy, the ethical claim emerges in and from interwoven existence with others, which is grounded in tuned sensation. It is due to the continuous tuning in sensation that we can sense and clarify the claim. Implicit in the ethical claim, is a call to be received, in the sense that I am implicitly asking for the ambience and tone of my tuned speech to be acknowledged by the other. In all conversations and interactions, we always disclose something of ourselves. This carries the inherent risk that we may not be received and that my ‘self’ is ignored (Løgstrup, 2000). Therefore, vulnerability and interdependence are inherent in all human relations. It is in sensation that we can be moved by what is at stake for another person in a particular situation. Even the most subtle and fleeting moment can tune our impressions; a change in the other’s tone of voice, or an almost imperceptible shift in posture. The ethical claim could therefore be described as a tuned impression of somebody in need of assistance. Such tuned impressions move us toward action, and we are challenged to find our way to act.

Human interdependence and sovereign life utterances

The second feature of Løgstup’s ethics relates to phenomena that support life in its vulnerability, such as trust, hope, compassion, mercy and open speech, what he calls sovereign life utterances. These are not personal achievements, or qualities belonging to the individual, but rather given by life itself, pre-culturally. They emerge spontaneously, anonymously unfolding in the space between people, directing us in an outwardly orientation toward each other. Trust, for example, is preconditioned on mutual coexistence; it emerges as the other is receiving us. Exposed to one another in interdependence, trust comes forth. It is not volitional, but present in all relationships, whether we like it or not. In Løgstrup’s (2000) terms, sovereign life utterances act behind our back, and he upholds that we become ourselves when supported by sovereign life utterances.

However, life can be cruel and difficult, and there are many situations where trust may be abused and our ethical claim dismissed. Løgstrup (1994) argued that this is when we can really experience how fundamental trust is to human life. It is hard to live without the support of sovereign life utterances like trust, hope or mercy. Deprived of this existential assistance, a person may become trapped in what Løgstrup calls self-orbiting cognitive emotions. This is when we circle around our own reactions in compulsive introversion.

Open speech is one of the phenomena Løgstrup describes as a sovereign life utterance. Speaking out comes spontaneously when a person is moved by impression. A person must actively hold back in order not to confide or tell the truth. Løgstrup’s point of departure is that every person has a kind of private zone which nobody should intrude, and in social interaction we move in the tension between speaking out openheartedly and withholding ourselves. To prevent spontaneous open speech from turning into flippant chatter, thoughtless gossip, embarrassment or even offensiveness the sovereign life utterance of open speech needs to be counterbalanced by respect for this private space which Løgstrup calls the ‘zone of untouchability’.¹⁴ We need to respect this zone both in ourselves as well as in the other. The spontaneous tendency to speak openly needs to be kept in check, in order to respect and not violate this zone, however the zone of untouchability also needs open speech to prevent solitude and isolation. The two phenomena need each other. As different yet interdependent phenomena, open speech and respect for the zone of untouchability interact as unifying opposites, vitalizing life. The ethical challenge of therapeutic relationships like physiotherapy is sharpened with regards to this. It is the responsibility of the therapist to shape an openminded therapeutic space, yet at the same time prevent violation of vulnerable boundaries. The therapist must balance between an open, accepting and receptive attitude and at the same time sensitively restrain from infringing upon that which needs to be left alone. Thus, with this subtle dynamic in mind, respectfully making space for the patients need to speak freely and openly may be of indispensable value and, sometimes, crucial to the outcome of physiotherapy, particularly where patients are vulnerable, or have a fragile sense of self.

Shaping expressions of impressions – moral norms and ethical practice

Løgstrup’s radical claim is that a person can never be involved with another person without holding something of this other person’s life in their hands (Løgstrup, 2000). It applies to us all, whether we are therapists or not. Løgstrup argued that it may not be easy to interpret this situation; to understand what is at stake for somebody other than ourselves, and how much actually is in our hands. The ethical claim is rarely explicit, and how to respond is usually uncertain. A specific response is not demanded. We are called to decide how we choose to act. How we respond will depend on our clarification and interpretation of the particular situation. We are left to ask what it is that we are sensing? What does this claim actually mean? What does the other person need? What is actually going to be helpful for the other? What is our role, responsibility, and possibility in this situation? When moved by ethical claims, Løgstrup argues, compassion is the driving force. If what compassion tells us to do is in conflict with our sense of professional obligation, however, we are faced with a moral dilemma. Løgstrup does not offer concrete guidance on how to act, but recognizes that, in difficult situations, we need support from culturally shaped norms, rules and regulations.

To acknowledge the tone of the other, whether this calls for little or much, puts the person at the mercy of another. The responsibility is universal to humans, and we are left to decide how much of the other person’s life we are prepared to hold in our hands. At times, the responsibility we hold feels light and easy, at other times it can be almost overwhelming. It may be a matter of simply offering an encouraging smile or a kind word. However, it may at times concern life-changing personal challenges. As Løgstrup claims, whether a person succeeds in life or not, may, at times, depend on another (Løgstrup, 2000).

Interdependence is always present, and still each and every one of us is fundamentally responsible for leading our own lives. We give shape and form to our actions with our own personal bearing, as we express emotions, attitudes, intentions or basic needs. Responding to ethical claims requires open-minded orientation toward unstated calls implicit in the situation, while shaping responses in tune with ourselves, in a manner for which we can be held responsible (Pahuus, 2005). Løgstrup emphasized that there is always this human and personal contribution, which reflects who a person is. In his philosophy, two basic elements can be identified. On one hand, there is the ethical claim, constituted by spontaneous and immediate impressions in sensation on a pre-cultural ontological level. On the other, there is the personal responsibility of an individual to shape his or her expressions and actions in adequate, sensible and ethical ways.

Importantly, Løgstrup argued that the ethical claim emerging from the situation of the other, is not a demand for fulfillment. It is not a request for passivity or an expression of a person’s willingness to hand over responsibility to another. On the contrary, the ethical claim opens a space for an uncertain, negotiated engagement. In such situations, rules, regulations, procedures and sociocultural norms can be of support, but they will always remain insufficient to the task in hand. Løgstrup does not define what is morally right or wrong. Rather, his concern is how we use norms in interaction. He reminds us that norms do not belong to anyone in particular, but that they emerge in the sociocultural space between people. We must, he insists, relate to norms with a certain distance and not use them to attempt to arrest, capture, or, to use Løgstrup’s own powerful metaphor, guillotine or execute the other (Løgstrup, 2000; Martinsen, 2012).

In one way or other there will be power involved in all relationships. In health professional practices there are economic constraints and social mandates imposing limits on what we can do to support others, and the relationship between patient and physiotherapist is asymmetrical with regards to responsibilities and needs. However, it is not so much the power imbalance that concerns Løgstrup, but rather how we use the position that we are in. The important matter is that with supremacy follows an additional ethical responsibility to use this position to care for the other and protect their vulnerability (Løgstrup, 2000). Professional education can provide paradigmatic ideas of the validity of knowledge and how we relate to time and space in the cultural shaping of clinical practices, guiding how we structure the direction of our attention, intentions and actions. At times, such guidance may be in conflict with the ethical claim inherent in a situation, challenging the role of the professionals with regards to their obligations, positions and capacities to act. Ethical action arises from compassion as spontaneous sovereign life utterance and, as such cannot be trained. What we may train, however, is a professional attitude of open-mindedness, culturing attentiveness to the tuned expressions of the other, and the capacity to tune in to the situation with tone, expressions and language that acknowledges the other’s experience (Martinsen, 2012). Ethical action, in response to the claim from the situation of the other, requires more than standard rules and guidelines for best practice. It calls for clinical reasoning with a flexible relationship to prevailing norms. To grasp what is at stake, and to be able to respond ethically in a situation requires knowledge, insight, understanding and reflection, but perhaps even more importantly, it requires attentive awareness.

Factual knowledge is indispensable in physiotherapy and healthcare, and the high demands for care calls for efficiency. However, preoccupation with productivity and generalized instrumental knowledge risks obscuring, disregarding, or devaluing ethical and foundational issues that arise in everyday clinical and social situations. In Løgstrup’s (2014) words; ‘Of course, factual knowledge is indispensable and is becoming ever more so, but this alone doesn’t do it, again and again; yes in all vital issues a residue is left which can be clarified only through a different apprehension than the professional’.

Tuned sensuous poetic understanding of life and ethical practices

A unilateral focus on instrumental factual knowledge may eclipse human vulnerability and ethical claims in concrete situations. Løgstrup argues that we are moved by expressive and semantic everyday language and that this poetic language holds the capacity to bring ethical and foundational issues like vulnerability, compassion and interdependence to the surface (Løgstrup, 1983, 2000, 2014; Martinsen, 2005; Pahuus, 2005). An example of poetic ways of describing and understanding experiences in physiotherapy follows later.

He argues that the open and sensuous dimensions of poetic understanding of life have the same foundation as those needed to grasp ethical issues. Both ethical and poetic understandings emerge from life experiences where people are intertwined with each other; vulnerable and interwoven in open sensation. Poetic understanding may expose existential meanings and make the enigmatic tangible, if only in flashes. Although poetic ways of understanding life are characterized by openness to new possibilities, such foundational experiences are prone to slips, or changes, as we try to name and describe them. In poetic writing, the kinship with embodied tones and gestures is in their rhythm and resonance, pictures and metaphors, and so remain ethereal and elusive, requiring constant presence and openness toward the other (Løgstrup, 2000).

When faced with ethical claims, we are challenged by the need to make sense of the vulnerability of the other. Thus, how we are prepared to act, and the shape and form we give this action, reflects and constitutes our personality. What a person chooses to do, demonstrates who he or she is. There may be a tension between the ethical claim emanating from the other, and our own personal and existential desire to act. We may experience the claim and, at the same time sense limitations in our ability to respond adequately. Løgstrup concedes that the distance provided by reasoned thinking may help us to clarify the meaning of such opposing forces and claims, whereas poetics may evoke the immediate experience of them (Løgstrup, 2000). Løgstrup argued that poetic understanding illuminates and brings us closer to the ethical tensions that exist in all embodied relationships, whereas approaches underpinned by objectivity and detachment draw us away.

Løgstrup’s ethics and ethics in physiotherapy

Interaction in physiotherapy is deeply grounded in sensation. From this perspective, the role of the therapist is to be open and attentive to the ethical claim that is ever present. If we allow tuned impressions to direct our attention, intentions and actions, we will be called to reflect both on what we do, and what that doing does. What we may learn from Løgstrup is that there are life supporting phenomena, such as trust, hope, compassion, mercy and open speech, that will support ethical conduct in clinical practice if we are truly engaged in the other. If this is the case, the therapeutic attitude must be of the utmost importance. When thinking with Løgstrup’s philosophy, we are challenged to shift our focus from sensation as a physiological phenomenon to a much more profound act of ‘sensing’.

Ethical reasoning involves professional decision-making and attentive listening to the patient’s need to express themselves. However, patients are often unable to express what is needed, it is the responsibility of the physiotherapist to sense, hear, clarify and interpret what is called for. There is a foundational vulnerability for the patient and therapist in the therapeutic situation, where physical touch is embedded in sensuous intertwining. Such situations offer significant opportunities for a practice tuned into what is at stake for the patient. This kind of ethically attuned practice depends on the capacity of therapist to shape the therapeutic space so that trust and sovereign life utterances may emerge from, act upon, and support the therapeutic process.

We will explore how Løgstrup’s ontologically situated ethics in relation to clinical practice in physiotherapy under the following 4 subheadings: (1) Uncertainty, tuned sensation and therapeutic attitude in physiotherapy; (2) Sensuous, narrative and poetic meaning-making in physiotherapy; (3) Physiotherapy and coming to oneself in new embodied experiences; and finally (4) Ethical claims and codes of conduct in physiotherapy.

Uncertainty, tuned sensation and therapeutic attitude in physiotherapy

When codes of conduct are “described as foundational ethical knowledge but not always helpful for ‘in the moment’ ethical decision-making” (Delany, Edwards, and Fryer, 2019), the inherent uncertainties of ethics in clinical practice come to the fore. Uncertainty has long been known to be a characteristic feature of healthcare practice (Law, 2002), and Greenhalgh (2013) recently pinpointed such uncertainties. There is uncertainty about how complete, accurate and relevant research-based evidence can be, with its potential benefits and harms. There may be uncertainty about the patient’s life-experience and what is best for a particular patient in given circumstances. There may also be uncertainties when multi-professional collaborative work is involved. Ahlsen, Mengshoel, Bondevik, and Engebretsen (2017) have explored how uncertainty unfolds in clinical reasoning within physiotherapy, showing how changeable and unstable clinical encounters can be. Rajala (2018) has argued for an ethics of the actual and, in particular, in physiotherapy, as a moral practice involving ”bodies that encounter, interact with and touch each other, move and are moved physically, psychologically, socially, culturally, biopolitically and emotionally”. The connection between uncertainty and ethics has been underscored by Gibson (2018) in arguing for an ethics of openness that can help the physiotherapist develop increased senstivity and embrace doubt. Gibson (2018) also underscored that boundaries between the self and other are always blurred.

Løgstrup’s lays out how boundaries are blurred in sensation. Following his thinking, as a physiotherapist, I am moved in sensation by the patient, and the patient is equally moved by me. In physiotherapy this can be represented in very concrete situations. When palpating a muscle, for example, the physiotherapist senses the tension of the patient. Simultaneously the patient is moved by the impression of the physiotherapist’s touch, posture and attitude, tone of voice and interest in listening. All of this may tune the situation and have effect on the patient’s sense of feeling safe, which in turn may cause alertness and mobilize muscular tension. Thus, palpation is not just a technique for the therapist to assess muscle tension. The patient senses the therapist as well as themselves in a potent relational way. Løgstrup goes further, however, arguing that in all human relationships we always hold something of the other person’s life in our hands. How much of the other person’s life we hold will vary from situation to situation. Because of this inherent responsibility, there is always a power relation, where the person doing the holding carries more responsibility than the person being held. Løgstrup suggests that acknowledging the tone of the other, whether it calls for little or much, is fundamental to ethical practice. Although the ethical claim emerging from the situation of the other calls for fulfillment, he does emphasize, that fulfilling it may not be possible or necessarily the right thing to do.

In physiotherapy, the therapist is responsible for holding and the patient is held, although not without responsibility. Because of the intimate physical nature of physiotherapy practice, physiotherapists are at perpetual risk of encroaching on the patient’s zone of untouchability. The vulnerability of the therapist may also be challenged in such encounters, but the power asymmetry inherent in this kind of relationship needs the most thoughtful and sensitive care. Ethical claims may be misread or ignored by either party, but the patient who is in need of help is particularly at risk. The therapist may have the advantage of social capital, authority and specialized knowledge, and so, because of this, they bear much of the responsibility for shaping and defining the situation. To interpret the needs of the other requires tuned sensation. But to judge how much responsibility is in the hands of the therapist in a given situation will always be uncertain. And what is more, because embodied boundaries are blurred, an openness toward the other always needs to be balanced by respect for the zone of untouchability. There is a particular risk of overstepping dynamic and contextual ethical boundaries inherent in the embodied interaction of physiotherapy. But, following Løgstrup, it is by being alert and open in sensation that physiotherapists may perceive when and where to stop.

A large proportion of the knowledge base in physiotherapy is rooted in the biomedical paradigm, although the complexity of clinical reasoning is increasingly becoming more acknowledged (Ahlsen, Mengshoel, Bondevik, and Engebretsen, 2017). Contemporary demands for research-based practice is considered essential to promote conscientious and systematic clinical decision-making, and thus improve the quality of health services. How to combine clinical experience, scientific evidence and patient values, and how this can eliminate uncertainty remains unclear (Engebretsen et al., 2015). Løgstrup argued that professional practices require more than mere factual knowledge. We need support from a different way of apprehending what is at stake in situations where people are vulnerable and dependent on each other. The growing acknowledge-ment of narrative reasoning in physiotherapy literature could be underpinned by Løgstrup’s emphasis upon the potent capacity of poetic understanding. In everyday language, with its allegories and vivid metaphors, we may grasp what is at stake for a person on a sensuous, emotional and ethical level. Løgstrup’s ethics encourage the physiotherapist to treat each patient as a unique person and, each encounter as a moment pregnant with possibilities. An ontologically situated ethics emphasizes deliberate, thoughtful practice (Bolton and Delderfield, 2017; Delany, Edwards, and Fryer, 2019; Delany, Edwards, Jensen, and Skinner, 2010; Edwards et al., 2004; Greenfield and Jensen, 2010; Trede and McEwen, 2016), and challenges us to resist routine, implementation of practice mandates. It amplifies rather than reduces the complexity of therapeutic encounters and emphasizes the particular over the general; individuates rather than synthesizes; and encourages us to remain open, rather than defining and closed. If we follow Løgstrup’s line of thought, we need to base clinical physiotherapy practice in ethical and narrative reasoning supported by reflective application of general knowledge and, moral norms and codes, adapted to the patient in his/her/their context.

Sensuous, narrative and poetic meaning-making in physiotherapy

To listen actively, to think reflexively and to reason critically, are the three steps in the model for physiotherapy ethics suggested by Delany, Edwards, Jensen, and Skinner (2010). This offers helpful structure by which practitioners may approach clinical situations, in line with a phenomenological attitude using reflective and/or narrative reasoning. Also, Gibson (2018) and Trede and McEwen (2016) argued that both patients’ and clinicians’ narratives will underscore ethical subjectivities and may stimulate professional reflection and learning. What Løgstrup’s philosophy adds is how all of this is embedded in sensation; in the ethical claim inherent to the situation. It is the receiving aspect of the situation which is so deeply explored by Løgstrup. Patients’ illness stories are saturated with tuned sensation, and in clinical situations the physiotherapist and patient are interwoven in sensation. How we interpret the patient’s experience as it is expressed in this context, depends on how we make space for the patient to clarify tuned sensation and the language we have available as a narrative resource. To think in categories and through linear logic is less helpful when trying to sense and explore coherence in a patient’s life experiences. Everyday language is tuned by and saturated with tuned sensation. Rather than by categories and definitions of unambiguous concepts, it is in the tuned everyday language of the patient that meaning and understanding emerges.

Løgstrup argued that poetic and ethical understandings of life originate from the same sensuous source, and thus have the capacity to bring to the fore essential meaning. A patient’s experience¹⁵ may illustrate this (Sviland, Martinsen, and Råheim, 2014). For five years, Joanna had suffered a lot of pain and her balance had been very poor after a whiplash injury. For one and a half year the main focus had been on postural adjustments and grounding exercises in the context of Norwegian Psychomotor Physiotherapy. During this therapy she often experienced concrete sensations emerging within her body. While describing these sensations to her therapist, they became clearer as metaphors with meaning to her life situation. One example was when she sensed something black and hard like ebony inside, as a kind of seed. She had been embarrassed about this, but one day the black substance descended down her feet into the earth, and it transformed into a sense of strength and power. Her strength became grounded and activated, she said. The sense of the seed had been very clear, but the deeply felt sensation of strength growing within her didn’t become clear until she discovered how it was connected to her legs. Muscular changes in movement, respiration and postural pattern opened for this anchoring sensation. Her physiotherapist did not categorize Joanna’s sensuous experiences as bizarre or psychotic body-sensations. On the contrary she had made space for poetic meaning-making, where Joanna could express, in her own words, ideas that were saturated with sensuous and narrative imagination. She could portray her specific experiences in a poetic way. This gave vivid and potent meaning, and this new experience of power helped Joanna to take care of herself in an encounter with somebody who used to control and dominate her. Grounded through her feet she stood up for herself and trusted her own judgments. With the rooted seed and growing inner strength, Joanna’s experience of who she was had changed.

Physiotherapy and coming to oneself in new embodied experiences

In physiotherapy, mutually entwined inter-connectedness in sensation is deeply grounded in embodied tactile and emotional engagement, which is taking place during therapy. As already illustrated in the case of palpation the patients sense the therapist as well as themselves and thus boundaries between the self and the other is at stake. Gibson (2018) also underscored that this shared vulnarability is related to the notion of ’becoming’, rather than the notion of ’being’ of idealist philosophies and that this is relevant to physiotherapy.

Joanna, in the example above, had painstakingly worked to regain her balance after her neck injury. To sense her feet and the bearing structure of her body had been crucial. When aided by the therapist she could sense the possibilities, but during everyday life she kept losing it. It had been a long process of shifts and swings, but in the long run these experiences could be described as a process where she was coming to herself again and again in the sensation of finding her bearing in a more functional posture. Sensing her feet on the ground and a better balance had also given her new understanding of herself and her own strength. Her sensation of rootedness through her bodily bearing structures had changed during a long process of physiotherapy with new sensuous experiences and meaning making in interaction with her therapist. The encounter with a person from the past was a moment of revelation to Joanna; a ground-breaking existential moment of coming to herself where she had acted in a new way. Here body seemed to have become more supportive of her action and narration in tune with herself as a person (Sviland, Martinsen, and Råheim, 2014).

According to Løgstrup (2000) interdependence is foundational to all human life, we are each other’s worlds, and becoming oneself is never static. Rather, it is an ongoing process of finding our bearing in body and language, as new sensuous impressions continuously tune our sense of self. New tuned impressions in new situations may challenge previously held attitudes toward ourselves and call us to change. This ’coming to oneself’ as existential embodied anchoring has been explored in some narrative studies recently (Sviland, Martinsen, and Råheim, 2014, 2018; Sviland, Råheim, and Martinsen, 2012).

Ethical claims and codes of conduct in physiotherapy

To be considered a serious profession, and reduce the risk of malpractice in physiotherapy, common norms and codes are necessary. However, ethical debates in recent physiotherapy literature clearly pinpoint that the complexity of professional practice requires more than normative codes to support physiotherapists in their interaction with patients during therapy and care. The challenge of clinical practice, lies in the tension between the need for the physiotherapist to remain at all times receptive to the ethical claim of the other, while, at the same time, finding their own bearing in the situation, where their interpretation of implicit responsibilities are accommodated. This involves responding to the ethical claim to help and, at the same time, support the other person’s struggle to find their bearing. Thus, the physiotherapy encounter will always involve, at least to some degree, a patient’s existential becoming and who it is possible to be and become.

A situation described by a physiotherapy student may illustrate how tension between receptiveness to the ethical claim of the patient and codes of conduct may be embedded in a physiotherapsits interpretation of the implicit responsibilities in a situation (Riise, 2016). The student had been responsible for the physical rehabilitation of an elderly woman who had been referred for a stay at the rehabilitation center due to concerns about her ability to cope by herself at home. The patient and the therapist worked well together, and the therapy and training had been uncomplicated. When the student assessed the patient to be ready for discharge a home-visit was arranged. The student assessed the situation to be satisfactory, and she was ready to leave the house when she saw that the woman had prepared lunch for two. The student was bewildered, she had been taught not to accept gifts from patients, but there was something in the situation which made her feel that it would be wrong not to accept. While they were eating, a heart-breaking story unfolded. The woman talked of being traumatized by the sexual abuse she experienced as a child; a series of humiliating encounters with the health system; and the resent death of the only person who had supported her. In Løgstrup’s thinking, we might say that the student had been moved by tuned impressions and expressions in sensation during the home-visit. This tuning in sensation had alerted her to the need to accede to the patient’s offer of food. Perhaps she sensed that something important was at stake? Uncertain about how to relate to the common codes of conduct and norms, she decided to relate to them in a flexible way and accepted the offer of lunch. The tuned expressions of the patient’s story clearly showed that this woman was struggling to find her bearing. Moved by these impressions, the student changed the assessment of this patient’s possibility to cope on her own, and the course of the approach to a prolonged rehabilitation was changed.

Practitioners may feel inadequate and torn between loyalty to the patient on the one hand, and rules and mandates on the other. To follow the rules may undermine a sense of professional integrity, if professional interpretation and judgment in particular situations are downplayed. Instrumentally applying guidelines of best practices may actually reduce a sense of responsibility for the situation. A situated ethics therefore demands that we listen to others, but also to ourselves; to ask what are our limits and boundaries, tolerances, tendencies and loyalties.

Løgstrup’s ontologically based understanding of a situation insists that we, as human beings, cannot escape from uncertainty by overly regulating our approaches. He argued that this cannot eliminate risk and vulnerability. When applied to physiotherapy, this means that physiotherapists need to be mindful of the socially mandated power their role encompasses, and how to use this to help the patient in the best possible way. In situations where the application of codes of conduct are justified, physiotherapists need to be attentive to how this is done, so that the patient, is not “guillotined” by the physiotherapists as a kind of moral authority with the right to judge, decide, define, label or categorize the other person. If culturally shaped norms are to guide us in given situations, we must interpret and adjust them accordingly, so that there is space for the patient to find his/her bearing.

Common codes of conduct and spontaneously emerging ethical claims act as unifying opposites according to Løgstrup. Codes of conduct may aid us in situations where we are out on a limb, for instance, if we are overwhelmed by our own emotions. On the other hand, sensing what is at stake for the patient may save us from oversimplifying complexity and allow us to tolerate uncertainty. Løgstrup underscores the spontaneous ethical claim of immediate impressions in sensation, and the personal responsibility that each person has to shape expressions in adequate, sensible, and ethical ways that are foundational to all human life. Whether physiotherapists choose to integrate these basic assumptions in the theoretical underpinning of physiotherapy or not, they will always be undercurrents in the clinical situation.

Ethics is at the heart of the professionals’ desire to do good, to help people, and to be of value to others. It involves the practice and teaching of physiotherapy, the increasingly complex world of healthcare practice and, its systems and structures within which the professionals perform. Some have argued that Løgstrup’s work does not function well within the wider sphere of ethical concerns of today’s inordinately complex and expensive healthcare system (Holm, 2001), where expectations for rapid, efficient and effective remedies, represent major challenges for health professionals, which can put ethical agency under pressure. Løgstrup acknowledged the profound role of culturally shaped norms and social circumstances at an ontological level, but he did not analyze organizational and social structures. His perspective cannot encompass all aspects of ethical issues relevant to physiotherapy. However, when Løgstrup places sensation at the heart of ethical practice in the specific context of the moment of interpersonal relationships, he offers a lens through which we may view some aspects of the close interaction between patient and physiotherapist, in a wide range of clinical practices. His thinking resists generalization of very complex and contingent ethical questions emerging in clinical practice, where spontaneous aspects interacts dynamically with norms while clinicians wrestle with difficult situations and ethical dilemmas. We suggest that his approach to ethics may contribute to the ongoing discourse of ethics in physiotherapy, emphasizing how ethical issues arise in concrete situations.

Final summary

The intention of this article was to explore how Løgstrup’s ontologically situated ethics may provide philosophical underpinning to the ethical claim for clinical and narrative reasoning in

physiotherapy. We have argued that Løgstrup’s perspectives on ethics may help physiotherapist to explicate some of the ethical challenges related to 4 aspects of this clinical practice. The first aspect is related to how ethical demands arise from the uncertainty implicit in physiotherapeutic processes and require an open therapeutic attitude where the therapist is persistently attentive to tuned sensation of the patent’s situation and the therapeutic context. The second aspect of exploration is how new meaning may emerge for patients during physiotherapy when the therapeutic space is open for the patient’s narratives and clarification of new sensuous impressions, in a poetic language. The third aspect relates to how these new embodied experiences during physiotherapy may offer new possible ways of coming to oneself and thus have existential meaning. The fourth aspect explores the dynamic between ethical claims arising in complex therapy situations and how we may relate to and be supported by the codes of conduct in physiotherapy in a spacious way. Through this exploration we suggest that Løgstrup’s ontologically situated ethics may provide philosophical underpinning to the ongoing development of the theoretical basis for ethics in physiotherapy and that this brings to the fore an ethical claim for clinical and narrative reasoning in physiotherapy.

Declaration of interest

The authors report no conflict of interest.

Notes

1. Phenomenology emerged from Edmund Husserl’s philosophy. It was expanded on by a wide range of other philosophers, thus developing into a multifaceted movement, which opposes the idea that research can provide objective knowledge about the structures of human experience and consciousness. It is concerned with how the world is experienced by the subject, attempting to bridge the gap between the objective and the subjective and thus grasp essential aspects of everyday human life situated in the world.

2. Edmund Husserl (1859–1938), a German philosopher who established the school of phenomenology. The majority of his work was published in Husserliana post humt. In Die Krisis der europäischen Wissenschaften und die transzendentale Phänomenologie (1936–1937) Husserl introduces the notion of lifeworld as the natural mode of human experience of the world, prior to the alienation deriving from European science of modernity.

3. Maurice Merleu-Ponty (1908–1961), a French phenomenological philosopher, strongly influenced by Husserl. He emphasized the body as the primary site of knowing the world, expressed in one of his main works Phenomenology of Perception (1945). His thinking moved toward the ontology of “the flesh of the world”, in his last published essay Eye and Mind (1961, translation to English 1964) and his incomplete works The Visible and Invisible (1964).

4. Søren Kierkegaard (1813–1851), a Danish philosopher considered to be the precursor to existentialism. His writing was extensive: Bind 1–28 og K1–28, København, 1997–2013. The Concept of Irony (Om Begrebet Ironi med stadigt Hensyn til Socrates), Either/Or (Enten – Eller) and Fear and Trembling (Frygt og Bæven are some of his works thought to be especially significant.

5. Martin Heidegger (1889–1976), a German philosopher most famous for his contributions to phenomenology, hermeneutics, and existentialism, and his best known book is Sein und Zeit/Being and Time (1927).

6. Louis Hjelmslev (1899–1965), a Danish linguist who he founded the Cercle Linguistique de Copenhague. From the semiotic theory of Ferdinand de Saussure he developed a structural theory of language.

7. Hans Lipps (1889–1941), a German philosopher and medical doctor. He was a student of Husserl. Løgstrup thought his philosophy had connotations to Ludwig Wittgenstein’s works.

8. Some of Løgstrup’s work is available in English translation in: Løgstrup K. (1997) The Ethical Demand, Notre Dame, Indiana University of Notre Dame Press. Løgstrup K. (1995) Metaphysics, Milwaukee: Marquette University Press. However, to explain Løgstrup’s thinking in English is challenging because his agenda was to avoid standardized concepts. He used everyday language in a creative way, with the intention to describe phenomena on a sensuous/experiential level, which was essential in his phenomenological philosophy. By using common words in novel contexts, he attempted to exceed preconceptions eclipsing more profound understanding. For this article to reflect Løgstrup’s phenomenology a more standardized English language would be misleading.

9. There is an ongoing debate where authors like J. Paley has criticized the use of phenomenological philosophy within nursing research. Among others, S. Holm, P. Nordtvedt and C. Schaffalitzky de Muckadell have raised critique against the use of Løgstrups ethics in particular.

10. The teleological tradition of ethics is concerned with good outcomes, intentions and consequences of action. Utilitarianism, is a version of teleological ethics, where an action is seen as good when its outcome results in the greatest possible pleasure for the smallest amount of suffering. The deontological tradition refers to what is right, emphasis is therefore on the duty to act according to universal moral rules of what is truly good (Løgstrup, 2014).

11. It can be argued that this interdependent dynamic between emotions and emotional attitude is embedded in the muscular functions of motion and posture and thus may be relevant to certain areas of physiotherapy (Sviland, Martinsen, and Råheim, 2007).

12. The structure of this presentation follows Mogens Pahuus, a reputed interpreter and former student of Løgstrup.

13. This has connotations to Merleau-Ponty’s later work on the ‘flesh’. There is, however, no evidence suggesting that Løgstrup was acquainted with Merleau-Ponty’s work. Merleau-Ponty begins from the notion of perception and works his way toward sensation (Madison, 1981). Løgstrup, on the other hand, comes to sensation via ethics.

14. Løgstrup develops the term ‘urørlihetssonen’ in Symbol og system (Løgstrup, 1982).

15. Joanna shared this story with other patients in a focus group interview about their experience with Norwegian Psychomotor Physiotherapy. A more in-depth analysis can be found in Sviland, Martinsen, and Råheim (2014).