¹Jaiza Sousa Penha

²Mayane Cristina Pereira Marques

³Santana de Maria Alves de Sousa

⁴Helder Machado Passos

⁵Patricia Neyva da Costa Pinheiro

⁶Adriana Gomes Nogueira Ferreira

¹Discente do Programa de Pós-Graduação em Enfermagem da Universidade Federal do Maranhão. São Luís, Brasil. ORCID: https://orcid.org/0000-0001-9805-3802.

²Discente do Programa de Pós-Graduação em Enfermagem da Universidade Federal do Maranhão. São Luís, Brasil. ORCID: https://orcid.org/0000-0003-3341-0818.

³Professora permanente do Programa de Pós-Graduação em Enfermagem da Universidade Federal do Maranhão. São Luís, Brasil. ORCID: https://orcid.org/0000-0002-0973-0646.

⁴Professor permanente do Programa de Pós-Graduação em Enfermagem da Universidade Federal do Maranhão. São Luís, Brasil. ORCID: https://orcid.org/0000-0002-7064-0973.

⁵Professora permanente do Programa de Pós-Graduação em Enfermagem da Universidade Federal do Ceará. Fortaleza, Brasil. ORCID: https://orcid.org/0000-0001-7022-8391.

⁶Professora permanente do Programa de Pós-Graduação em Enfermagem da Universidade Federal do Maranhão. Imperatriz, Brasil. ORCID: https://orcid.org/0000-0002-7107-1151.

Corresponding author

Jaiza Sousa Penha

E-mail: jaiza.sousa@discente.ufma.br. Mailing address: Avenida dos Portugueses, nº 1966, Vila Bacanga, São Luís - MA (Departamento de Enfermagem da Universidade Federal do Maranhão). CEP: 65080-805. +55(98) 98719-3398.

ABSTRACT

Objective: To reflect on the integrality of health care from the perspective of Levinasian philosophical thought. Method: Reflective theoretical study based on the works “Otherwise than being or beyond essence”, “Totality and infinity” and “Ethics and infinity” by Emmanuel Lévinas. To discuss the concepts proposed by the author, non-systematic electronic searches were made on the subject as well as a critical reading of his works and of other scholars who investigated Levinasian ideas. Results: Integral health care proposes a broader view of the individual, respecting his uniqueness (otherness), desires, beliefs, considering his autonomy, through actions focused on his appreciation as a subject. For Levinás, ethics, the first philosophy, is born in the face-to-face relationship between the self and the other (professional-patient), in which the other is presented as a face, as absolute alterity, which demands care and responsibility. Conclusions: Levinasian thinking refers to a context in which the individual is at the center of the attention, as in integral care, which correctly and scientifically guides health work as a dialogic practice in which the other, as a patient, is co-responsible for the care. This reflection may motivate professionals and researchers to observe integrality in health from a philosophical perspective based on concepts defined by Emmanuel Lévinas.

Keywords: Integral Health Care. Nursing. Holistic Nursing. Philosophy. Integrality in health.

RESUMEN

Objetivo: Reflejar la integralidad del cuidado de la salud desde la perspectiva del pensamiento filosófico levinasiano. Método: Estudio teórico reflexivo a partir de las obras “Otra manera de estar más allá de la esencia”, “Totalidad e infinito” y “Ética e infinito” de Emmanuel Lévinas. Para discutir los conceptos propuestos por el autor, se realizaron búsquedas electrónicas no sistemáticas sobre el tema, una lectura crítica de sus obras y de otros estudiosos que investigaron las ideas levinasianas. Resultados: La integralidad del cuidado de la salud propone una mirada más amplia al individuo, respetando su singularidad (alteridad), deseos, creencias, considerando su autonomía, a través de acciones enfocadas a su valoración como sujeto. Para Levinás, la ética, la primera filosofía, nace en la relación cara a cara entre el yo y el otro (profesional-paciente), en el que este último se presenta como un rostro, como una alteridad absoluta, que requiere cuidados y responsabilidad. Conclusiones: El pensamiento levinasiano se refiere a un contexto en el que el individuo es el centro de la atención, así como en la atención integral, que orienta correcta y científicamente el trabajo en salud como una práctica dialógica en la que el otro, como paciente, es corresponsable del cuidado. Esta reflexión puede motivar a profesionales e investigadores a observar la integralidad en salud desde una perspectiva filosófica basada en conceptos definidos por Emmanuel Lévinas.

Palabras clave: Atención Integral de Salud. Enfermería. Enfermería Holística. Filosofia. Integralidad em Salud.

RESUMO

Objetivo: Refletir a integralidade do cuidado em saúde sob a perspectiva do pensamento filosófico Levinasiano. Método: Estudo teórico reflexivo com base nas obras “Outro modo que ser para além da essência”, “Totalidade e infinito” e “Ética e infinito” de Emmanuel Lévinas. Para discutir os conceitos propostos pelo autor, foram feitas buscas eletrônicas não sistemáticas sobre o tema, leitura crítica de suas obras e de outros estudiosos que investigaram as ideias Levinasianas. Resultados: A integralidade do cuidado em saúde propõe um olhar ampliado sobre o indivíduo, respeitando a sua singularidade (alteridade), desejos, crenças, considerando sua autonomia, através de ações centradas na sua valorização enquanto sujeito. Para Levinás, a ética, a filosofia primeira, nasce na relação face a face entre o eu e o outro (profissional-paciente), em que este se apresenta como rosto, como alteridade absoluta, que exige cuidado e responsabilidade. Conclusões: O pensamento Levinasiano remete a um contexto em que o indivíduo está no centro da atenção, assim como no cuidado integral, que norteia correta e cientificamente o trabalho em saúde como uma prática dialógica em que o outro, enquanto paciente, é corresponsável no cuidado. Esta reflexão poderá motivar profissionais e pesquisadores a observarem a integralidade em saúde sob uma perspectiva filosófica a partir de conceitos definidos por Emmanuél Lévinas.

Palavras-chave: Assistência Integral à Saúde. Enfermagem. Enfermagem Holística. Filosofia. Integralidade em Saúde.

INTRODUCTION

The work developed by health teams, including nursing, especially in hospital institutions, has been characterized as segmented, mechanistic, centered on performing procedures and with supremacy in the use of technologies. Such fragmentation of care, with a biological focus and overvaluation of specialties, is the result of influences arising from the hegemonic Taylorist-Fordist work model^(1,2) .

This model, which is very present in the tertiary sector of the economy, in which the health sector is inserted, suffered consequences that predicted the logic of capital accumulation, intense use of technology, lack of interdisciplinary integration between professionals and alienation of work. These factors contributed to the characterization of the health service as artisanal, and the subject's satisfaction was not considered⁽³⁾.

Such conditions are contrary to the concept of integrality, as an organizer of care, and one of the principles of the Unified Health System (SUS), understood as an articulated and continuous set of preventive and curative actions, at all levels of complexity, individual or collective⁽⁴⁾. This provides for an expanded and holistic view of the individual, respecting uniqueness, desires and beliefs and considering autonomy. It implies actions for the promotion, prevention and recovery of diseases, focused on valuing the person who receives this care^(1,2).

In this sense, it is in the training of health workers that integrality must be encouraged and defended. In order for the idea of hospital-centered and biomedical care to be undone, higher education institutions and the teaching-learning process need to discuss integrality as a guiding principle of the SUS, a fundamental content to direct its professional actions⁽⁵⁾.

A study developed with Nursing students in order to know their perceptions about integrality identified weaknesses in the application of this principle in the academic development process. This reinforces the importance and challenge in the training of nurses and other professionals who need to be trained in view of the needs of individuals in actions to promote health and prevent diseases⁽⁶⁾.

Faced with this reality, it is possible to reflect on integrality and its characteristics from the perspective of the philosophy of Emmanuel Lévinas. For this philosopher, the other is presented as a face, that is, it is the representation of an absolute alterity, giving a new ethical meaning and valuing the human being. Lévinas considered ethics as a first philosophy, that is, ethics is before, below all and any philosophical or scientific rational thought. With this, we sought to answer the following research question: “How can the philosophical concepts proposed by Emmanuel Lévinas relate to the integrality of health care?”

In this sense, based on concepts established by Emmanuel Lévinas, this text aimed to reflect on the integrality of health care from the perspective of Levinasian philosophical thought, and can be an instrument for Nursing students and professionals, expanding their interpretations and understanding of the theme.

METHOD

Reflective theoretical study on the integrality of health care, as a principle of the SUS, relating it to some concepts defined by the philosopher Emmanuel Lévinas. To support this reflection, the works “Autrement qu`être ou au-delà de l`essence”⁷ (Otherwise than being or beyond essence), “Totalité et Infini”⁸ (Totality and infinity) and “Ethics and infinity” were used⁹. In addition, non-systematic electronic searches were carried out in December 2021 on the Google Scholar platform, using the terms “Emannuel Lévinas” and “health care”, in order to identify productions by other authors who investigated Levinasian ideas and that could be used in this reflection.

No time frames were established and articles and books dealing with the subject in English, Portuguese or Spanish, available in full, were included. Materials that did not present definitions that could be related to integrality in health were excluded.

RESULTS

Eight references were used to discuss and correlate the Levinasian concepts of alterity, responsibility, proximity, justice and reception and the integrality of health care, presented in the results and discussion of this reflective text.

Emmanuel Lévinas was born in Lithuania and had his work influenced by Husserl and Heidegger. He died in 1995. The philosopher presented great contributions with his works and established the ethical relationship from the other, being instituted through the “face to face”, the encounter between two people or more. This relationship is complex and permeated by alterity, that is, being available to the other, who is distinct, but deserves to be taken into account, respected and understood in the way he is, without indifference or suppression of his particularities^(8,10).

This other is represented by the face, by the first encounter, an original contact, in which the other is completely strange, different and infinitely transcendent, bringing his alterity and, with that, provoking moral demands on the self. It is in the condition of infinity that the other is protected from the totalizing intentions of the self.

In this sense, it is possible to establish a relationship between the concepts presented by the philosopher and integrality in health care. It is in this perspective that integrality foresees looking at the patient-other “as a complete being, without disconnecting him from his social, family, spiritual, environmental, political and historical dimensions^”(11:3), in a holistic way.

Thus, the patient-other is a complex being, which cannot be distanced from his broad context of life, and should not be analyzed only by the symptoms or the disease, as this is opposed to the criteria of integrality. For Lévinas, the face that represents the other inaugurates in the self the sense or an appeal of responsibility^(7,11,12). Before our rational and technical attitudes, the first truly human experience is moral, and it takes place in the order of sensitivity, face to face. Responsibility does not result from a rational calculation, but from an answer to an immediate question.

The very concept of the word care is related to this context of patient-other, in the sense of paying attention, thinking, showing interest, care and concern. The one who takes care starts to dedicate himself and care about the one who is cared for, being helpful, participating in his life, sufferings and joys. Thus, the attitude of caring with ethics causes restlessness, concern and responsibility.

It is understood, therefore, that the other who is in front of me (self) is a body, which presents sensitivity, which has a life and is sensitive to others and the environment. Another one that needs to be supported, cared for and protected. For all these reasons, it should not be treated as an object⁽⁸⁾. From this relationship, ethical responsibility is born, involved in care and respect, in which the self takes care of the other.

In this way, Lévinas contextualizes the meaning of proximity, which is established through welcoming the other, taking responsibility for him and remaining indifferent to the other’s alterity: “(...) welcoming the other is to put my freedom in question.”^(8:84). Therefore, it is necessary that the idea of proximity begins within the person who will provide health care, as well as in integral care, which requires professionals and managers to be available to take care and develop actions in a responsible, respectful and humanized way^(11,12). It is important to emphasize that proximity does not mean equality or fusion, nor the short distance in time and space, but the vulnerability of the self in the face of alterity^(7,13). The idea of proximity in Levinasian philosophy maintains the distances between the identity of the self and the alterity of the other.

This other (patient-other), the foreigner, the different, so to speak, the beyond of being, is what allows the existence of this ethical relationship, making reception possible⁽¹⁴⁾. Therefore, it is in this context in which the other presents himself to the self with a perspective of responsibility.

Corroborating this concept, the National Humanization Policy points to the autonomy and protagonism of subjects, with integral health care, free from prejudice or privileges of any nature and broad social participation^(15,16). This reinforces the idea that, in the care setting, caring for the patient-other is to perceive him or her as alterity, as a singular other-subject, in which the self exhibits responsibility for the other⁽¹⁷⁾.

When we talk about integrality as a principle of the SUS, this is reiterated as one of the axes of Primary Health Care (PHC), which is the gateway to the health system, which must organize and direct the flow of care for patients within the care network, given that it raises assistance at all levels of complexity. In this way, PHC managers and professionals must place the individual at the center of attention, giving him priority, considering his uniqueness.

In this sense, the concept of justice was analyzed according to the thought of Lévinas. For the author, it is born from the moment when the self meets or perceives the other, as alterity, establishing a relationship of responsibility. Justice acquires the sense of justifying itself in the context of Levinasian ethics, justifying itself in the face of the demands of the other. At the same time, in health care, professionals need to evaluate their actions under the parameters of justice at all times. Thus, that patient-other should be prioritized, not only because of his severity, but in all existential aspects, also using technical and scientific knowledge and skills to take care of this alterity⁽¹⁸⁾.

“Justice was necessary, that is, comparison, coexistence, contemporaneity, meeting, order, thematization, the visibility of faces and, therefore, intentionality and intellect”^(7:158). It is with this perception of justice, characterized by the author, that health professionals must consider the other, as justice always has responsibility as its beginning and end.

With these considerations, for integral health care, in which the individual needs to be perceived in a holistic way, professionals, in the context in which they are inserted, need to reflect on actions from an ethical perspective, dealing with justice and humanization the alterities, adapting and personalizing their attitudes according to the needs of the patient-other.

In a mutual, dialogical relationship between the self and the other, it is understood that the first needs the second, given that it is who depends on the other for humanization, for the ability to take responsibility for this other⁽¹⁴⁾. Levinas also states that this is a non-symmetrical relationship, that is, one is responsible for the other without expecting reciprocity⁽⁹⁾. In this sense, in the professional-patient scenario, the professional self depends on the patient-other for its humanization. In short, it is he, the patient-other, who defines the action of the self-professional, insofar as he is the one who, with his demands, demands the action of the professional.

Thus, one of the objectives of the integrality of health care is the expanded look at the individual who needs care, in which the professional needs to welcome him, not under a biological approach, but in all aspects of life that involve him, the epiphany of the face defended by Lévinas, leads us to understand that it would be necessary to break with indifference, allowing oneself to know and understand the other.

However, health care is vertical, causing distance and distancing people, both in the relationship between professionals and between them and patients and family members. This compromises the quality of health care, which needs to be reorganized, especially with regard to the interpersonal relationships of the actors involved, representing a daily, gradual and collective challenge⁽¹⁹⁾.

According to Levinasian thinking, and in contrast to what are considered challenges for the integrality of health care, it is in the face of the other that his concerns and needs are exposed, in which the self cannot be oblivious to this, it cannot be insensitive to reality, being, therefore, ethical.

Emmanuel Lévinas’ “thou shalt not kill”⁽⁸⁾ means not exactly the literal definition of the expression, but not preventing the life and pleasures of the patient-other, his minimum needs for comfort, fulfillment, well-being, among other inherent needs to survival, including socio-historical-cultural aspects, without reducing it, as it appears in different forms: it is the orphan, the foreigner, the widow, the poor.

DISCUSSION

The integrality of health care, despite constituting one of the doctrinal principles of the SUS since 1990, is still a challenge for institutions and care professionals. Transforming fragmented, mechanized health work, with a biological approach, which emphasizes signs and symptoms, in a holistic view of the individual, considering culture, beliefs, life history, level of education and feelings, is part of the objectives of integral care.

In addition, integrality provides assistance for the individual and the community, including disease prevention actions, from primary care to secondary and tertiary levels in the health system. Considering that Nursing professionals have the autonomy to act in all these levels of care, it is necessary to reflect on the integral care that must be developed, under a philosophical view.

Thus, holistic nursing directs practices towards the physical, social, emotional, economic and spiritual needs of the other, in the face of the process of coping with illness and the effect on the ability to self-care. Therefore, as recommended by Florence Nightingale, a precursor of world nursing, responsibility, compassion, commitment and critical thinking are expected in the being and acting of nurses⁽²⁰⁾.

It is observed that the philosophy of Emmanuel Lévinas can be related to integrality, when he highlights ethics as a first philosophy and reaffirms that it is born immediately after the contact between the self and the other, in the face to face, in which life takes on the truly human sense. This other presents itself as a face, as an absolute, transcendent alterity, an immediate reality that demands a notion of responsibility, justice, acceptance, proximity. Proximity that is not the absence of distances, but the non-indifference to the presence of the other who looks at me⁽⁷⁾. The preservation of the relationship between a subjectivity and alterity requires separation. There is a relationship only insofar as the terms of that relationship remain separate.

The patient-other is seen as a unique person, from the moment the other speaks and exposes himself to the self in an attempt to be understood, the self can no longer be absent, insensitive, he cannot help but feel responsible. The face of the other will always be an incognito presentation and, therefore, demanding from the self-professional an attitude of openness to the reception, sometimes having to get rid of the protocols and dynamics established for the treatment. In this sense, it is understood that, in care, the professional is available for the novelty of the other's face. Therefore, according to Lévinas' ethical dimension, health professionals must assume responsibility for the other, attending to his calls (needs) and assuming care⁽²¹⁾.

The objective of integrality is to achieve health care based on the needs of the subject to be cared for, on the knowledge of the professionals involved in the action and also the others, who work in the management and structuring of health services, with an expanded focus human beings and their needs^(1,22).

On the other hand, studies show that health care in Brazil is still inadequate in this sense, with professional practices that prioritize the clinic, overvaluing biological, impersonal aspects, giving up the needs that the individual presents, making him dissatisfied and insecure⁽²³⁾. A good example is the willingness and time of health professionals to listen to patients in consultations and procedures.

Therefore, it is necessary that changes occur in the way of producing care, in order to avoid the emphasis on specializations and centered on the professional as the holder of knowledge, aiming to cover the demand of the other and his family, which permeates Nursing, which seeks to promote horizontal and interdisciplinary care, and not vertical and bureaucratic practices that emphasize the production of services and tasks⁽¹⁾.

It is in the encounter between nurse and patient in which the professional self is faced with his prerogatives and limits, knowledge and skills necessary for decision-making, in face of the rights of the other, which presents a real need, whether it is a disease or a doubt to be clarified by those who offer assistance⁽²⁴⁾.

Therefore, for Levinas, taking care of the other requires great responsibility, which the nurse cannot escape, and cannot be insensitive to the call of the other who needs to be fully taken care of, which is a moral duty of the profession. Thus, the practice of these professionals will always have the human person in all his dimensions⁽²⁵⁾.

CONCLUSIONS

Levinasian thinking leads to a context in which the individual, the one who cries out for care, is at the center of attention, not being seen as a disease or an object, correctly and scientifically guiding health work, considering integral care as a dialogic practice in which the other, as a patient, has co-responsibility for his own health. Therefore, the challenge of integral care, in addition to users and their families, involves professionals and managers.

In this way, this reflection can support the development of other research in the area of Nursing, corroborating and sustaining the scientificity of its practical actions, as a profession and discipline, provoking and instigating professionals and researchers to observe integral health care from an adaptable philosophical perspective to the concepts of alterity, justice, responsibility and the self-other relationship, defined by Emmanuel Lévinas.

The study's limitation was the difficulty in finding publications in the area of Nursing that contextualized the integrality of health care from the author's philosophical basis, while this reinforces the relevance of this manuscript for the advancement of knowledge in the area, proposing further investigations on the subject.

The present work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.

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Submission: 2022-01-25

Approval: 2022-04-29