doi: 10.1111/nup.12067

Original article

Nursing and the new biology: towards a realist, anti-reductionist approach to nursing knowledge Stuart Nairn PhD MA RGN Lecturer, School of Health Sciences, University of Nottingham, Derby, UK

Abstract

As a system of knowledge, nursing has utilized a range of subjects and reconstituted them to reflect the thinking and practice of health care. Often drawn to a holistic model, nursing finds it difficult to resist the reductionist tendencies in biological and medical thinking. In this paper I will propose a relational approach to knowledge that is able to address this issue. The paper argues that biology is not characterized by one stable theory but is often a contentious topic and employs philosophically diverse models in its scientific research. Biology need not be seen as a reductionist science, but reductionism is nonetheless an important current within biological thinking. These reductionist currents can undermine nursing knowledge in four main ways. Firstly, that the conclusions drawn from reductionism go far beyond their data based on an approach that prioritizes biological explanations and eliminates others. Secondly, that the methods employed by biologists are sometimes weak, and the limitations are insufficiently acknowledged. Thirdly, that the assumptions that drive the research agenda are problematic, and finally that uncritical application of these ideas can be potentially disastrous for nursing practice. These issues are explored through an examination of the problems reductionism poses for the issue of gender, mental health, and altruism. I then propose an approach based on critical realism that adopts an anti-reductionist philosophy that utilizes the conceptual tools of emergence and a relational ontology. Keywords: nursing philosophy, positivism, altruism, biology, realism, mental health.

Introduction Correspondence: Dr Stuart Nairn, Lecturer, School of Health Sciences, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3DT, UK. Tel.: 01 332 724 946; e-mail: [email protected]

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The purpose of this paper is to explore the way that biological knowledge and, in particular, the neurosciences and genetics have affected nursing knowledge. More broadly I am concerned to develop an under-

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standing of nursing that adopts a relational approach to the notion of interdisciplinary knowledge. Furthermore, I am concerned that the holistic impulses of nursing are under threat from a type of reductionist thinking that undermines, not just nursing, but the health sciences more broadly. I would contend that nursing has a number of problems with identifying what it is as a clinical and academic discipline. Attempts to define a distinct body of knowledge have been tried with varying degrees of success. But what characterizes these discussions is the clinical reality in which nurses confront a variety of problems, ranging from biological dysfunction to psychological distress. Carper’s (1978) work is one influential example of an attempt by a nurse theorist to accommodate these different realities. Any attempt to make these different subjects work together is fraught with problems, and in this paper I will address the problem of the way that nursing knowledge both needs biology but should also be critical of the potential problems of reductionist biology. I will suggest in this essay that a multi-level approach, based upon a more explicit ontological framework, will provide a conceptually more productive way for nurses to engage with interdisciplinary knowledge. The focus will be on how biology can be utilized with an emphasis on a critical engagement with that knowledge. The concern I will raise is that there is a strand of biological thinking that conflates and reduces the upper levels of nursing knowledge, such as social interaction, into the biophysical domain, and this undermines, rather than enhances, nursing interventions. This paper will be structured in the following way. Firstly, I will examine the theoretical debates within biology and the problems of how to integrate genetic and neuroscientific knowledge into a coherent understanding of what it means to be human. Secondly, I will examine the problem of theory and method in relation to neuroscience. Thirdly, I will examine these two issues as they apply to the non-health–related issue of gender and the health-related issue of mental health and the influence of biological psychiatry. Fourthly, I will examine Haigh’s (2010) paper that adopts a biological focus on the nature of altruism and caring in nursing. I will conclude by arguing for a realist, anti-reductionist approach to knowledge that

incorporates the central ideas of emergence and a relational, non-conflationary approach.

The philosophy of biology A BBC news headline from their December 2013 website stated that ‘Men and women’s brains are “wired differently” ’ (BBC News, 2013). The article then went on to argue that men and women are better at some tasks than others, that women can multi-task while men are better at learning and performing single tasks. It is suggested that this is because men and women, as the headline states, are ‘wired differently’. However, while the headline suggested that this is a scientifically proven fact, the rest of the story is written with so many caveats about: overgeneralizations of neural connections with human behaviour; that there is no such thing as hard wiring; that brain networks change and that the causal relationship has not been proven, that the headline comes to appear little more than a rhetorical device to attract the reader’s attention. Trying to make complex science an attractive read is a continuous problem for journalists, but biological reductionism remains a problem and not just within popular texts (Tallis, 2011). There are signs that this is changing, particularly as the promises of genomic research, which reached its apotheosis in the human genome project, turned out to be inflated and in the view of Rose & Rose (2012) were largely driven by an academic and corporate desire to turn this knowledge into a profitable commodity. Nonetheless, reductionist thinking continues to be an influential way that biological knowledge is produced. An example of reductionist thinking can be found in Dawkins’s (2006) well-known text The Selfish Gene, which was originally published in 1976. The book is based on the idea of the biological body as a machine and that successful genes rely on a ruthless selfishness. The tension in this work is that for Dawkins, selfishness is pre-programmed into our machine-like body and that to be civilized we need to assert altruistic behaviour despite our biology. Eagleman (2011) has pursued the machine metaphor to the brain claiming that it largely runs on autopilot where the ‘I’ has very little control over what we perceive to be our own actions.

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Essentially the‘I’ disappears into a‘vast,wet,chemicalelectrical network . . .The machinery is alien to us, and yet, somehow, it is us’ (Eagleman, 2011, p. 2). So racism is regarded as a natural and unpleasant part of our neural networks in tension with what is socially desirable (Eagleman, 2011, pp. 59–61) and the housing bubble can be explained by our instant-gratification circuits that apparently explains why the economic crisis occurred. This explanation for economic problems provides an apparently rational explanation for the irrational psychology of people’s brains. This can then be utilized as a defence of existing neo-liberal economic theory whose slippery and effective set of excuses for their own failures in predicting or managing the recent economic crisis in 2008 are usefully erased through biological determinism (Mirowski, 2013). The temptation to use biological ideas to explain everything, to reduce the complexity of the social world to some biological entity has a long history which at its worst has resulted in eugenics and racism (Pichot, 2009). However, biology does not have to be seen in this one-dimensional reductionist way. Alternative ways of examining biology are available within biology (Lewontin, 2001). For example, Rose (1997) in contrast to and in opposition to deterministic explanations argues that: it is in the nature of living systems to be radically indeterminate, to continually construct their-our-own futures, albeit in circumstances not of our own choosing.

(Rose, 1997, p. 7)

So for Rose, the indeterminacy is based on modifying the influence of microbiology so that other causal mechanisms are taken into account. By adopting a more explicitly ‘systems’ approach to how human beings operate that incorporates social, environmental, and cultural mechanisms, the genetic explanation, while not erased, is situated within a matrix of gene– organism–environment interactions. Tallis (2011) argues that while the brain is a necessary part of the explanation for consciousness and human behaviour, it is not a sufficient explanation. For Tallis, it is crucial that humans are not reduced to our materiality and that we are more than our physical existence. Our actions are not simply rooted in physical causes and that:

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the logic of the neuroscientist who conclude that the ‘self’, the ‘I’ – like free will – is unreal on the grounds that you can’t find it if you look into the brain; there is nothing in patterns of neural activity corresponding to anything like a self. We could of course, draw quite different conclusions: that the self does exist but it is not identical with patterns of neural activity. Only the prior assumption that neuroscience speaks the last word on what we are could force us to deny the existence of the self on the grounds that it cannot be detected by electrodes or scanners.

(Tallis, 2011, p. 58)

It is not my intention to adjudicate between these approaches. The problem of the mind/body is an intractable one resistant to firm conclusions, but it is important to recognize that biological reductionism and its willingness to make claims that go beyond their empirical data and that rests on reductionist assumptions about the priority of biology as a primary causative explanation are problematic. The negative consequences of this prioritization is that biology is used as an explanatory tool for subjects that go beyond its scientific remit and can result in overconfident conclusions. This overconfidence is reflected in the lack of critical thinking about the theoretical constructs employed in empirical research and can result in an uncritical acceptance of reductionist biology. I will explore these themes in more depth in sections 2, 3, and 4 of this paper, but this criticism should be understood in the broader context of biological knowledge. While reductionism remains a significant problem in the way that biology is presented and researched, there are significant and important alternatives within biology that allow for a more productive engagement with biological processes. Biology has now shifted towards a more multi-causal analysis and can be found in a number of different approaches including the evo-devo approach, niche construction theory, developmental systems theory, epigenetics, neuroplasticity, and a four-dimensional approach (Jablonka & Lamb, 2006; Laland et al., 2007; Allen & Williams, 2011; Bateson & Gluckman, 2011; May, 2011; and Griffiths & Stotz, 2013). The idea of neuroplasticity for example opens up the discussion about how much of the brain is internally fixed and how much flexibility the brain has, both in its own formation and its

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development and response to the external world. Again, I am not concerned to engage in any depth with these different theories but simply to argue that biology is an area of profound philosophical as well as scientific debate. So it can be argued that cultural influences are as important as underlying biology processes. This is not to suggest that reductionist approaches are without value. Griffiths & Stotz (2013) in their overview of genetic knowledge argue that a reductionist phase was a necessary precursor to a more systems approach. Understanding the microbiology of the gene is therefore seen as a necessary component of our understanding of how genes work but this was not a sufficient explanation. It becomes necessary to develop this knowledge to take account of the growing field of epigenetics which is as interested in why certain genetic processes are activated by what exists outside the gene as it is in the internal mechanism of genes. So biology should be regarded as an evolving subject area with competing theories about the nature of biological knowledge. Biology raises philosophical questions about morality, policy, and the truth claims of its scientific method. It is these issues that are important for the health sciences, and in examining these issues, I will suggest that nurses should be prepared to both draw upon this knowledge but in a way that critically engages with its limitations, especially when it adopts reductionist approaches that has the potential to undermine good nursing practice.

Theory and method In the first section of this paper, I have broadly suggested a philosophical problem with the theoretical assumptions underpinning biological reductionism. I am not suggesting that biology as a subject area is always reductionist or that methods associated with reductionism are never appropriate to the subject matter. However, the problem for nurses is that taking on any subject area without being aware of the internal disputes within those subjects can generate an uncritical acceptance of other subjects, which does not take account of the contentious and debatable nature of some of the conclusions. In this paper, I am

arguing that the central problem in engaging with biological knowledge is its reductionist tendencies and that part of this problem is reflected in – and an outcome of – the way that the brain has been scientifically studied. The neurosciences have based much of their research on technology such as functional magnetic resonance imaging (fMRI). Brain scanning has significantly helped in diagnosis of certain conditions such as brain tumours and identifying the crucial diagnostic distinction for stroke patients between a blood clot and haemorrhage as a causative agent. Scanning can also identify which areas of the brain are active and can go some way to helping us understand cerebral activity. However, the ability of the fMRI scanner to capture this activity (technically known as BOLD activity) is still developing: At its best, fMRI averages activity over about two seconds in a small block of brain tissue about 0.5 mm across. Although this block of tissue seems tiny, so complex is the brain that the tiny block contains some 5.5 million neurons, 22 kilometres of their dendrites, and up to 55 billion connections. Two seconds is a long time when neurons operate on a millisecond time scale, and as the cells use energy either to excite or inhibit their signalling partners, any change in blood flow might mean either excitation or inhibition.

(Rose & Rose,

2012, p. 254)

In short, the use of fMRI scanners should be premised on what they can and what they cannot do, and results based on these brain images should be treated with caution (Logothetis, 2008). Furthermore, the process of researching an individual in a technological environment is critically erased in the result. The context of research is put aside, and it is assumed that the way a person behaves when attached to an fMRI scanner is the same as when they operate in their everyday lives (Rose & Abi-Rached, 2013, pp. 76–7).As Rose & Rose (2012, p. 253) argue the fundamental problem with the neurosciences is that they are dominated by studies that exist at the level of abstract individuals given abstract tasks in laboratory conditions, rather than social beings existing in complex social environments. Much of this research is based on correlations which, as is well known, are not an account of causation and so researchers are often careful to use terms

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such as mental correlates. However, as Rose & Abi-Rached (2013, p. 54) argue, they are less cautious when reporting their results to the media. It should also be noted that neuroscience has been critiqued on its use of statistics and potential biases, largely as a result of inadequate sample sizes (see Button et al., 2013 and Fusar-Poli et al., 2014) while others have questioned the means that researchers have adopted in identifying what they term ‘puzzlingly high correlations’ (Vul et al., 2009). There are of course problems of method in all forms of research enquiry, but it is important to note that many of the issues that threaten a robust understanding of biological processes are partly one of the methods, and an understanding of these limitations should be taken into account when taking forward research findings. One of the central concerns of neuroscientists such as Tallis (2011) is that their subject area is overconfident in its presentation of the data and draws up fundamentally incorrect conclusions about the nature of what it means to be human and to have a self, and that even as the technological tools improve, that the theoretical problems of identifying causation within a theoretically reductionist model will simply incorporate new data into a pre-existing paradigm of positivist type thinking. These issues are pertinent to a range of issues, and I will explore them through two substantive areas of research: gender and mental health.

Gender and mental health The issue of sex and gender provides a useful example of how biological knowledge faces problems of methods but more fundamentally about how conclusions are drawn based on ideological assumptions (Jordan-Young, 2010 and Fausto-Sterling, 2012). Science of course is never value free, but it is incumbent upon scientist to be reflexive about those values and how they become embedded in the process of producing empirical data (Bourdieu, 2004). In Jordan-Young’s (2010) analysis of gender, it is very clear that such reflexivity is largely absent in brain organization theory that poses the question: does the brain create gender behaviour? On one level, the brain does operate differently between the sexes. So

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women have a part of their brain that induces ovulation (Vidal, 2012). In this domain, the brain has clear sex differences between men and women. However, on the level of human behaviour, cognition, sexuality, and so on the evidence is far less clear. Indeed, one writer characterizes neuroscience as neurosexist (Fine, 2010). In a detailed study by Jordan-Young (2010), a number of issues are raised about how brain organization theory works, which essentially argues that sex differentiation is not only about reproduction but also behaviour. If this is the case, then there are implications for how we treat and educate people and also what we can expect from men and women. For example, if women are intrinsically better at caring than men and men are better at math than women, then this becomes a biological explanation for occupational differences. However, Jordan-Young (2010) questions these types of findings (see also Vidal, 2012) on two levels. Firstly, that the limitations of the methods employed, which are essentially quasi-experimental, are not properly acknowledged, an issue I have already addressed in the previous section. Secondly, and more fundamentally, that the assumptions that are embedded in the research agenda generate the results that confirm those assumptions. In other words, the scientific agnosticism that is supposed to drive scientific research is undermined by what she refers to as assumption containers. Value assumptions are contained within the measurements that scientists employ. So measuring concepts such as masculinity, femininity, and homosexuality are central to the research agenda. However, as Jordan-Young (2010) points out the underlying concepts that have shaped the agenda of neuroscientific research on gender and sexual orientation is historically changeable and while the definition of these concepts has evolved, the empirical findings have been reported in such a way as to produce a linear and consistent support for fundamental brain-based differences between men and women: The general term feminine sexuality is used to gloss divergent – and in some cases diametrically opposed – concepts in

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the research. This level of departure from earlier definitions veers dangerously close to making brain organization literally unfalsifiable . . . because scientists have not noticed the changes and confronted them directly, they have both reinforced the notion that ‘masculine’ and ‘feminine’ sexuality are universal, timeless constructs and created the illusion of a seamless line of evidence supporting human sexuality as hardwired by hormones.

(Jordan-Young, 2010, p. 142)

Scientific research on homosexuality produces similar conceptual problems with Jordan-Young (2010, p. 168), arguing that the diverse definitions mean that one scientist’s homosexual is another’s heterosexual, and suggesting that the looseness of these definitions means that the results can be produced that reflect the scientist’s assumptions, a type of scientific gerrymandering that fundamentally undermines the research results. In short, the relationship between brain structure and behaviour remains an open question. That men and women often behave in ways that reflect established constructs of the ‘feminine’ and the ‘masculine’ can be accepted without making the assumption that these differences rest on a biological aetiology. More fundamentally, the research agenda is unable to answer the question, partly because of the complexity of the relationship and the intractable problem of the mind/body problem, and also because the assumptions that frame the research have a tendency to produce results to confirm rather than critically interrogate the evidence. Similar problems occur within the field of mental health. There is a long-standing tension within mental health over how far personal distress is biologically based (Pilgrim & Rogers, 1993 and Stone, 1998). If there is a biological basis, then it strengthens the case for diagnostic approaches to psychiatric care. It also has a tendency to decontextualize mental health problems and turn them into an individual rather than a social problem (Rose & Abi-Rached, 2013). Concerns have been raised about the efficacy of these biologically based approaches with their emphasis on medication. The evidence for the disease approach has been questioned, and an analysis of morbidity and mortality rates suggests serious problems with the disease model. For example, suicide rates among schizophrenics have increased substantially (Healy

et al., 2006), and deteriorating outcomes for other mental health problems have been noted for patients using psychotropic drugs and an increasing divergence noted between life expectancy of people with serious mental health problems and the rest of the population (Healy, 2009). Bentall (2009) has drawn upon evidence that suggests that many mental health patients have better recovery rates in developing countries with only limited mental services than in the developed world where patients are subjected to the full array of modern medicine. Concerns over the efficacy of mood stabilizers for bipolar disorder has also been noted (Harris et al., 2005), and this has developed into a call for a shift away from biological approaches (Barker & Buchanan-Barker, 2011 and Barker & Buchanan-Barker, 2012). The call for a new paradigm for mental health is based on a criticism of the existing paradigm that overemphasizes the biological at the expense of the psychosocial, removes people from their social context, and neglects discriminatory structures such as class, ethnicity, gender, and culture (British Psychological Society, 2013). In short, the focus on classification and diagnosis that largely emerges out of a biological route of causation sets up the boundaries and hence the assumptions that guide the research agenda and then reinforces those assumptions rather than critically examines them (Thomas et al., 2012). Thomas et al. (2012) argue that what matters in good mental health practice is the nature of the therapeutic relationship rather than the ‘science’ of psychiatry, and others have emphasized how the recovery model places the subjectively defined needs of the user at the centre of the therapeutic relationship rather than the objectifying gaze of the professionals (Bentall, 2009). At the centre of this debate is the uncertainty about the aetiology of mental distress. The call for a new paradigm (Thomas et al., 2012) situates its argument on this uncertainty and the conflicting nature of the evidence and proposes a more flexible and open approach to therapy. This approach relies less on medication, or even specific psychological methods such as cognitive behaviour therapy, but rather on the complex business of identifying what meanings the user attaches to their distress and what they consider

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to be ‘success’ rather than a disease model based on cure. It is therefore the nature of the relationship that matters rather than a technical approach that relies on assumptions about the brain-based nature of mental health. In both the example of gender and mental health I have suggested that the theoretical assumptions of the research agenda has promoted particular ways of looking at the world and has systematically framed the types of data collected and the way it has been interpreted. In other words, the science is theory driven, and the empirical data are collected more to confirm the theory than critically evaluate it and partly confirms the arguments of Kuhn (1970) and Feyerabend (2010) that theory matters more than method in scientific practice, even when the researchers appear to be empirically driven as in the assumption containers described by Jordan-Young (2010). I will now look at a specific example of a nursing theorist attempting to accommodate biological knowledge into nursing theory. The problem I will suggest is that when biology is used as an all-encompassing explanation or prioritized in a reductionist manner, then knowledge about how to care for patients and organize health care is weakened.

Altruism and the politics of health Let me start this section with following quote: Nursing altruism is programmed to ensure the survival of the meme rather than to act in the best interests of patients. Certainly patients reap benefits of this selfish altruism, but that can be argued to be a side effect rather than the result. (Haigh, 2010)

Haigh’s paper is an attempt to apply the principles of biological evolutionary theory to the nurse–patient relationship and attempts to re-frame our understanding of nursing altruism. Haigh relies upon Dawkins’s (2006) concept of the meme. To simplify a complex concept, the essence of a meme is that it is the cultural equivalent of genes in that a unit of culture is replicated in the social world, be it a catchy tune, a recent fashion through to behaviours such as altruism. This process of replication is not the same as genes, but the correspondence between the two is

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heavily emphasized in much of the literature. In Haigh’s paper, genes and memes are presented as the same where it is emphasized that memes are the cultural equivalent of the way that ‘physical and biological characteristics spread and replicate themselves via DNA’ (Haigh, 2010, p. 1402). This involves a conceptual leap from the way people are observed to behave and the theoretical construct of memes and their supposed basis in biological processes. So Haigh argues that because many applicants to nursing programmes emphasize that they want to do good and that many nurses acknowledge that job satisfaction is partly based on the emotional rewards of caregiving, that this shows that they are not really being altruistic or even caring, but are simply reproducing an altruistic meme. Furthermore, this meme is essentially selfish because it ensures the reproduction of a meme that is little more than a means of boosting one’s self-esteem and reproduces a collective group mentality within nursing that has very little to do with patient care and is primarily about establishing the status of the nursing group. Essentially, altruism is reconstituted as selfishness. We are only altruistic so that people can admire us and give nurses public respect. Delivering good care to patients, when it happens, is little more than a superficial side effect of selfish motivations. Perhaps the most obvious point to make about this argument is that while altruism is seen as a problem to be conceptually unpacked through memes, the concept of selfishness is not. As selfishness apparently conforms to the idea of the selfish gene, selfish behaviour does not require close attention but altruism is a ‘problem’ precisely because it does not fit into our supposed biological base. So altruism has to be reconstituted as selfish, but it is unclear why this is the case. Many of the arguments about human aggression are based on similar arguments (see Fuentes, 2008), and Haigh ignores the growing number of theories I outlined in part one that suggest a more complex relationship in the way that biology works both internally and externally. As Douglas (2006, p. 160) points out, causation is not a one-way process from genes to behaviour but a two-way process. There is a socio-cultural route to human behaviour as well as a biological one. Culture, it should be

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emphasized, is not made up of discrete units as the theory of memes suggests, but a complex set of beliefs and meanings that are often ambiguous, contradictory, and endlessly overlapping. Studying one supposedly discrete element such as altruism and ignoring the social and historical contexts in which altruist and selfish behaviour occurs is a fundamentally reductive and impoverished way of examining human behaviour. Essentially, Haigh’s argument is based on theoretical assumptions and presented as being based on empirical scientific evidence that I would argue it does not (see Rose, 1997 and Tallis, 2011). An antireductionist approach that draws out the relationship would I suggest be a more productive way of addressing the problem. I will outline what this might look like in the final section of this paper. However, more fundamental than this is the way that Haigh makes her biological arguments work in the nurse–patient relationship. Haigh uses the prisoner’s dilemma model and applies it to the nurse– patient encounter and uses a pain management scenario.The prisoner’s dilemma looks at the way that two prisoners might behave and attain reduced sentences by betraying another colleague. It is essentially a game of logic that tries to assess human behaviour logically by working out how much one can trust another. So it assesses whether selfishness or cooperative behaviour works. Whatever one might think of this model, its use by Haigh produces a highly artificial and thinned out view of the nurse/patient interaction. Haigh suggests that this dilemma is useful in understanding how a nurse might deliver pain relief to a patient with a history of drug abuse. This raises the question of whether the analgesia is being given on the basis of pain relief or to meet the addictive needs of the patient. This is clearly a complex problem, but for Haigh the question is about whether the nurse ‘wins’ or ‘loses’ or the patient ‘wins’ or ‘loses’ or whether they can both ‘win’ or ‘lose’. The idea that the nurse/patient relationship is simply one of winning and losing, that there is some sort of competitive game in which each side is trying to maximize their ability to win or lose is certainly a strange way of characterizing this relationship. Apparently, the nursing meme will ensure that nurses will ‘always

“win” the nurse/patient game’ (Haigh, 2010, p. 1407). Haigh’s use of scare inverted commas when using the terms win and lose does suggest that Haigh is conscious of how these terms might be interpreted, but no exploration is offered. Reconstituting this relationship into a game with winners and losers only makes sense if one accepts the premise that some entity called memes is somehow a cultural reflection of our genetic make-up which then programmes us to see every interaction with patients as a competitive game which we as nurses need to win and then delude ourselves into thinking we are somehow being altruistic. Each step of this argument is fundamentally flawed and relies on a reductionist approach that conflates complex social interactions within one strand of biological thinking. The meanings we have about the world cannot be sliced up into manageable components that then reflect some preconceived idea about human biology. As Tsuda (2011) has argued, meanings are generated from the narratives of those who are a part of that culture and any anthropological study of societies meaning systems must start with how people interpret and make sense of their culture. These meaning are not a stable aggregated set of facts that can be mechanically identified into some discreet entity but rather a set of ideas and values that are in a state of constant discussion and debate. It is not that these ideas cannot be examined with an eye to the scientific method, but memes adds nothing to already existing sociological concepts that attempt to understand the complex meanings of culture and how society reproduces and changes existing cultural beliefs and which can be understood as cultural systems rather than as an epiphenomena of biology. For example, Archer (1996) has produced a complex theory that incorporates an understanding of culture as a system, but one that is dynamically related to the reflexive self (Archer, 2010) and not a biologically determined self or pre-programmed nonself (Eagleman, 2011), whereas Bourdieu (1990) has developed a sophisticated theory about how culture is reproduced through the notion of habitus. These social and cultural theories provide a more robust approach to the idea of culture that recognizes the openness of social life, its essential indeterminacy

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which is based on human reflexivity rather than a biologically deterministic approach to cultural meanings. Altruism, like any other human attribute, is highly contextual, and understanding such behaviour requires an understanding of many influences and cannot be reduced to an artificial construct like a meme, which gives an apparent scientific basis to social behaviour. A concept like altruism can be presented in a way that reduces human behaviour to a thinned out, automated, and unreflective process. However, not only is this a questionable description of human behaviour; it also depends upon only one way of utilizing biological knowledge, and there are other more useful ways of exploring the biological that do not pursue a reductionist agenda. In the final section, I will try and provide a provisional way of looking at some of these issues that is based on a relational ontology rather than on reductionist and conflationary thinking, whether that comes from biology or any other subject that attempts to prioritize its own domain of study. My purpose is to find a way for a nursing approach to knowledge that can utilize biological knowledge that is not deterministically reductionist. Such an approach acknowledges the multiple causative mechanisms at work in the world and how biology is as much a product of the upper levels of that world as it is of the micro world.

Realism and biology In the history of the philosophy of science, it was often the subject of physics that was regarded as the root of scientific knowledge. Carnap stated that because physical language is ‘the basic language of Science the whole of Science becomes Physics’ (Carnap, [1934] 2011, p. 97). He concluded that: ‘the statements and words’ and ‘the facts and objects’: of the various branches of Science are fundamentally the same kind. For all branches are part of the unified Science, of Physics.

(Carnap, [1934] 2011, p. 101)

The early logical positivists were preoccupied with this idea of the unity of science based on the physical nature and empirically verifiable nature of scientific statements (Reisch, 2005). One of the consequences

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of this is that the early positivists were concerned to establish the priority of the physical and the reductionist nature of scientific knowledge. So while other subjects such as chemistry, biology, psychology, and sociology all have their own language, they are in principle only fully explicable through their physical roots. One of the effects of this was to prioritize physics. According to Horkheimer (1947/2013), the consequence of this epistemic prioritization results in a reductionist approach that gives the idea of human truth the character of a non-human objectivity that hypostasizes knowledge into a spurious nontheoretical science. Therefore, science needs to go beyond method to be truly scientific, so as to understand the human, social processes involved in the production of ‘facts’. Therefore, the empirical is at best a starting point for science and not its end point. Positivism, despite the historical complexity and sometimes radical political implications of its theories (Reisch, 2005), has the effect of neutralizing a truly critical approach to scientific knowledge. Biological reductionism has, with the rise of molecular biology, developed a preoccupation with explaining the human at the genetic and neural level, in what has been described as neurogenetic determinism (Rose, 1997) that in some respects has reimagined these earlier debates on the nature of scientific knowledge. The reductionist notion of a ‘unity of science’ employed by the early positivists has been re-written with a new type of biological reductionism. In short, the reductionist tendencies of positivism continue to undermine the idea of science, and some biologists and neuroscientists seem to have been particularly prone to this way of thinking. This has been referred to by some as neuromania (Tallis, 2011 and Legrenzi & Umiltà, 2011) whereby neuroscientific explanations have become used to explain everything from personal relationships to the workings of the global financial system. The idea then emerges whereby complex ethical and moral questions are addressed by brain images and empirical correlations that assumes causation rather than examines it. In a sense, it is a way of substituting the exploration of moral and ethical questions with a ‘scientific’ answer and this has happened:

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through a positioning of intuitions and emotions at the very core of moral judgements, in opposition to rationalist views. (Meloni, 2013, p. 86)

While this may provide some insights into nonrational explanations for human behaviour, Meloni (2013) argues that the result is to explain morality purely as an automatic bodily process and as a consequence erases rather than interacts with sociocultural understandings. The application of biological explanations has been employed by nurses in the area of ethics (Stanley et al., 2007), and Paley (2008) utilized biology to critique the discourse of spirituality. While I share his criticism of the attempt to inculcate a religious dimension into an essential component of the self, I do not accept his use of biological arguments to critique them. Our experiences cannot be reduced to biology, but they are an essential part of those experiences. What this means is that while the biophysical can exist without the social the opposite is not the case (Carolan, 2005). This is a relational approach to knowledge that asserts that while the social is dependent on the natural world for its existence, it is not reducible to it. So if I walk in to a cathedral my body may react in a particular way that I may describe as spiritual, aesthetic, alienating, indifferent, or whatever. To have those experiences requires my physical body but also depends on how I react, and this also depends on my own reflexivity, my cultural experiences, and the broader belief systems that I occupy in this particular socio-historical moment. Reductionism essentially rests on the argument that the lower levels of the world, the micro rather than the macro, have the ability to explain why events take place. To put it in the language of critical realism (Bhaskar, 2008; Clark et al., 2008 and Nairn, 2012), reductionism ascribes causal powers to the lower levels and eliminates them from upper levels, hence the way that altruism is explained purely from the perspective of the activities of genes. It entails arguing that only the micro really matters in terms of causation. All the contradictory and complex behaviours associated with the nurse–patient relationship, with gender behaviour or mental health, are then explained at the lower level of the human organism

rather than the whole person and its socio-historical circumstances. The most effective type of research seems to explain causation within its own domain of the real. For example, the immobilization of a limb to aid recovery can result in altered neural pathways that privilege the limb that is being used and may possibly affect the recovery of the injured limb. However, the idea of mirror neurons that it is suggested are an explanation for humans’ ability to interact is more problematic as it entails a jump from the neural level to the socio-cultural level and is unable to identify the route of causation (Tallis, 2011). What Tallis argues is that while the neural level is necessary for our understanding of human behaviour, it is not a sufficient explanation. Critical realism suggests that reality is stratified between different domains of the real (Elder-Vass, 2010). So the academic structure of knowledge partly reflects the ontological reality of the world. So biologist look at biology, psychologists the mind, and sociologists the social. Within these different topics, there are further extensive levels of the real. In biology, for example, there is the cellular, the organism, the environment, and doubtless many more between them. What is key however is that upper levels are emergent from the lower levels and cannot exist without them but in the process of their emergence develop causal powers of their own: The value of the concept of emergence lies in its potential to explain how an entity can have a causal impact on the world in its own right: a causal impact that is not just the sum of the impacts of its parts would have if they were not organised into this kind of whole.

(Elder-Vass, 2010, p. 5)

What this means is that causation is not restricted to the lower levels, the genetic for example, but also to the upper levels. Causation is also downwards, from the whole to the parts (Ellis, 2012). For example, the placebo effect relies upon biological processes responding to external contexts, and it is the meaning systems of the culture that produce the biological changes. This also helps to explain the effects of neuroplasticity whereby the adult brain is no longer seen as a fixed entity but is capable of change and adaptation to environmental stimuli. Top-down causation

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therefore changes the lower levels, and neurons do not operate independently of context (Ellis, 2009). Therefore, causation is ultimately multiple rather than mono-causal and not reliant on the parts to explain the whole. However, emergence does accept that without the parts, the whole could not exist but that the parts may be able to exist without the whole. As Wimsatt puts it: An emergent property is – roughly – a system property which is dependent upon the mode of organization of the system’s parts.

(Wimsatt, 2008, p. 100)

Wimsatt (2008) sees this as a way of linking emergence with reductionism. Nonetheless, the essence of emergence is that while a new emergent entity is dependent on its parts, it develops causal effects that are relatively autonomous from the parts. What this means is that consciousness and indeed ideas like reflexivity can be seen as dependent on a neurophysiological base without reducing the mental to biological processes (Rose, 1997; Elder-Vass, 2010; Tallis, 2011). From a nursing perspective, this means that we can adopt a relational approach to interdisciplinary knowledge rather than reductionist approaches or arguments that rest on the prioritization of holism. It is the relation between different types of knowledge that matters, and the scientific and nursing endeavour should therefore be directed to exploring these complex relationships. This also means that we should avoid conflationary thinking. Reductionism essentially conflates the social with the biological and explains the social through the biological.There is also an opposite type of conflationary thinking perhaps most strongly characterized by Foucault, who described the construction of medical and psychiatric categories as discourses that constituted the subjects rather than developing as a response to them (Foucault, 1971, 1973). In other words, the biological is reduced to the cultural discourses of enlightenment thinking. From a critical realist position, therefore, it is necessary to maintain the ontological distinction between different levels of the real so that they can be examined as distinct entities that can then be explored within a relational, emergent, and anti-reductionist way. Conflating ontological levels creates conceptual confusion and opens the way to reductionist thinking.

© 2014 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 261–273

Risjord (2010) has suggested that nurses adopt a standpoint epistemology to knowledge based upon nurses’ practical interaction with nursing problems, which he describes as a bottom-up approach and a way of engaging with interdisciplinary knowledge without losing the distinctiveness of the nursing knowledge base. In some ways this makes sense and if I might take certain liberties with Risjord’s account it might be argued that while nurses are not expert biologist, psychologist, or sociologists, they are expert in utilizing those knowledges in managing nursing problems in a way that the biologist, psychologist, or sociologists would not. I think this would be a useful way of exploring the basis of nursing knowledge but such knowledge would need to be situated within an ontological appreciation of the different levels of the real that nurses deal with. Holistic care for example may be useful as a political assertion of how to manage the multiple issues affecting a patients’ well-being, but their interventions on that patient reflect the ontological status of these problems that inter-relate with each other and are not the same. Managing a biological problem may be enough in one circumstance, a psychosocial in another, but most will entail an understanding of how they interact with each other and that causation will often be multiple and complex.

Conclusion In Pichot’s (2009) book on the legacy of Charles Darwin, he expresses a preference for the work of the biologist Louis Pasteur over Darwin on the basis that Pasteur stayed within the technical issues raised by biological problems, of how bacteria works and how to manage the spread of infection. He did not stray into translating this knowledge into some socio-political analogy of how society should work. Darwin and his followers were less circumspect. Pichot (2009) argues that the consequences were that the valuable knowledge gained about evolutionary processes was then inappropriately translated into political ideologies including eugenics.The central argument of this paper is that conflationary and reductionist thinking remains a risk within nursing knowledge as it uses the methods and explanatory frameworks from one domain and then transposes them into another domain.

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The point I wish to make and the basis of this paper is to argue that while reductionist biology is highly problematic for nursing practice and theory, we do not need to equate biology with reductionism. If we explore biological processes as one element in a person’s health that inter-relates, in non-conflationary ways, with other causal mechanisms from other domains of the real, then nursing knowledge can develop in a way that more closely reflects the ontological reality of the multiple levels that make up the experience and real world of illness. As Risjord (2010) suggests, nursing knowledge should be based on the types of problems that nurses confront and draw upon diverse knowledge from different subject areas. However, this does not mean that we uncritically accept whatever comes our way. Biology is not a settled subject simply carrying out Kuhnian puzzle solving experiments but a diverse and philosophically contentious topic that contain diverse views on the nature of the human body. Problems of method remain difficult and are sometimes overlooked in the urge to produce discreet results. These issues are pertinent because of the influence they have on issues like gender and mental health. The translation of some biological theories and knowledge into areas such as altruism are potentially disastrous for nursing practice and a philosophically based science based on a relational, anti-reductionist approach offers, I would argue, a better way forward. In short, when arguments about human behaviour, the social, and the cultural rely on the translation of biological knowledge, it is appropriate for us to raise a sceptical eyebrow and critically interrogate the basis of such claims.

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