Jamie Smith, a practicing nurse, brings a critical posthuman approach to ‘person-centre care’- urging us to question the assumptions that underly the widely employed framework.
As a nurse, privilege is made perceptible to me through contemporary healthcare practices such as person-centered care (PCC). PCC is built on assumptions of individual autonomy, choice, and self-determination, which are rooted in Western liberal ideals that prioritise individualism and self-sufficiency (Braidotti 2013; Wynter 2003). These ideals are associated with white European culture (Braidotti 2013) and have been used to justify the oppression of non-western European bodies (Jackson 2020; Benjamin 2020). I argue that person-centred care, as it is currently conceptualised, perpetuates and reinforces white euro-centric values and marginalises those who do not fit into this framework (Smith, Willis, and Hopkins-Walsh 2022).
Being a critic of person-centered care, or a proponent of posthumanism in nursing, can be tricky, especially when you’re a privileged, cis-gendered white person. Who am I to decide who gets to be ‘human’? As a white, queer, newly middle class, nurse-academic living in Germany, I’ve learned that my perspective is limited by the fact that the normative establishment has never had trouble considering people like me ‘human’. Who am I to debate what ‘human’ is? This is especially so since there continues to be atrocities committed against minority populations (based on race, religion, sexuality, nationality and immigration status) involving questions of personhood (Canty et al. 2023; Smith, Willis, and Hopkins-Walsh 2022).
Speaking with folks engaged in black scholarship has taught me that questioning the category of ‘human’ can cause alarm bells to go off. When I talk to people who come from crip theory, they also remind me that many people want to be considered human before they start to think about being (critically) ‘posthuman’. These conversations have cautioned me to be less cavalier with how I critique PCC. I am not here to define, redefine, or undo what it means have ‘human’ status. Instead, I’m trying to figure out if there are ways to cede any of the power with which my privilege restricts other people’s humanity. My entry point into critiquing person-centered care is to make the whiteness of the system perceptible and to understand that all knowledge(s) are situated.
Person-centered care has become the standard approach in healthcare. It aims to prioritise the needs, values, and preferences of the individual patient over the needs of the healthcare system.
Many of the ideas underpinning the development of PCC are well intended, such as the desire to include people in their own health care (McCormack and McCance 2010). However, the PCC approach also emerged within the context of a neo-liberal and neo-colonial healthcare system (Tieu et al. 2022) and developed without paying attention to the assumptions underlying the category of ‘person’ it refers to (Smith, Willis, and Hopkins-Walsh 2022; Bellacasa 2017). The ‘person’ is a rational, able-bodied and self-sufficient entity- something I do not believe exists.
PCC operates by assuming a level of individual autonomy and self-determination- it asks people to make decisions about their own care, advising the caregiver on what is best for them. Such an assumption of autonomy is predicated on a cartesian mind/body split; where the mind has the ability to make decisions over the earthly body. The mind/body split- an ideal of European enlightenment- assumes that the mind is a fixed, rational entity (Braidotti, 2013). By contrast, a range of posthuman thinkers (Braidotti (2013), Haraway (1988), Jackson (2020) and Wynter (1989)) contend that the body and mind should not be seen as separate entities, but rather as interconnected and interdependent. They argue that the capacities of both the body and mind are shaped by their material, social, and cultural contexts, which constantly transform their relationship to each other and the world.
The needs of an individual will always be situated within their context, and in the context of healthcare, including the socio-materiality of a situation. PCC begins to come undone when the ‘person’ is framed as a rational agent of their care, rather than care being something that is produced as part of environmental, material and affective contingencies. The last time you were unwell or saw a doctor– was your ‘rational mind’ thinking, feeling or behaving in a way that facilitated the making of rational decisions? I don’t think so.
Imagine a nurse coming on shift and being assigned three patients to care for that day; each of those patients has needs, desires and intentions– as do the nurses and the healthcare team. The nurse will prioritise these needs throughout the day and indeed some of them may not be met. Imagine these three fictional reasons for patient admission:
- Loose stools
- Chest infection
- Awaiting care package
The nurse sets out to promote the well-being of all the patients. The patient with a chest infection develops chest pain. The nurse responds appropriately, prioritising their care and preventing the potential of their condition worsening. At the same time the family of the person awaiting a care package wants updating on the status of their discharge and the patient with loose stools requires assistance with their hygiene needs. The nurse must prioritise and deprioritise care – leaving the question, do those patients who are deprioritised receive PCC? Some patients feel that others are (justifiably) the focus of care. The nurse is caring in a patient centred way, however, always in relation to the material and contextual developments of the environment. The patient or person in PCC exist in relation to other people.
In simple terms, PCC overlays a framework of a static and rational decision making, onto a very earthly process of living, ageing and dying.
In addition to its emphasis on cognitive rationality, PCC presumes we are all always individuals and independent- and this makes it fundamentally ableist. In offering the idea that people are always contingent on their context, posthumanism shows us that no-one is self-sufficient. As Wynter (1989) states: self-determination does not equate self-sufficiency. We as human, animal, plant, or any other thing, are contingent on each other to exist. Deleuze and Guattari (1988) elaborate on this by diffracting the concept of individual to the concept of the individual – a multiplicity of interconnected parts and processes, rather than a singular, autonomous entity.
Person-centered care as a health approach does not fully embrace the contingent characteristics of either the person, or of decision making. Some people’s reliance on others is framed and categorised as disabled or less able. I believe that agency is never solely located within the individual, but is instead distributed across networks of social, political, and material relations. In this way, person-centered care should be a collaborative and relational practice that acknowledges and respects the complex, intersectional identities of those receiving care. If we re-frame all people (and things) as reliant on each other then we are all disabled in some way.
So, what for person-centered care? Well, I want it to be messy, I want to muddy the waters. By this I mean we need to get away from the sanitized version of the rational and individualized patient in healthcare. We are all located in messy, untidy and dirty interdependent coordinates. Health and care are murky, emotional, embodied, embedded, subjective, and relational. The cis-white, heterosexual, male, European perspective is baked into the system and has sanitized diversity of experience and materiality – care has been commodified but it is not a commodity.
About the author
Jamie Smith works as a nurse, lecturer and research associate at Charité Universitätsmedizin Berlin
and The University of Edinburgh. He studied psychology as an undergraduate, before training
as a nurse and earning his Master’s degrees in both Nursing and Sociology. His PhD at the
University of Edinburgh explored nursing and institutional power using critical posthuman theory. He can be found on Twitter @Mrhornesmith.
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