Abstract
This paper examines the meaning of space and its relationship to value. In this paper, I draw on Henri Lefebvre to suggest that our ethics produce and are produced by spaces. Space is not simply a passive material container or neutral geographic location. Space includes the ideas on which buildings are modeled, the ordering of objects and movement patterns within the space, and the symbolic meaning of the space and its objects. Although often unrecognized, space itself is value-laden, and its values are suggested as people interact within that space. By reflecting on the spaces of health care, we will see that we not only must attend to the quandaries caused by the delivery of health care in non-acute places, but also to the values that produce and are produced by spaces. These values influence our moral imagination and shape us as people.
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Notes
According to Lefebvre (1991), an ethics that is primarily situated in mental space resembles sentiments of math, science, and philosophy as influenced by Descartes’ division of the res cogitans and res extensia. Kant separated space from the empirical and historical world, denoting it an a priori that functions in the realm of consciousness and reinforcing Platonism over the Aristotelian importance of categories and teleology. For Kant, space is a cognitively understood condition for the possibility of pure reason, or of morality. “From a philosophy of space revised and corrected by mathematics,” Lefebvre writes, “the modern field of inquiry known as epistemology has inherited and adopted the notion that the status of space is that of a ‘mental thing’ or ‘mental place” (p. 3). Lefebvre argues that different logic has been developed in various mental spaces, and logical theories are then applied to the world in a way that appears untouched by ideology or experience. He writes, “In an inevitably circular manner, this mental space then becomes the locus of a ‘theoretical practice’ which is separated from social practice and which sets itself up as the axis, pivot or central reference point of Knowledge” (p. 6).
Many scholars, like Stonington, who have written about place are discussing what I understand as space. I distinguish place and space to highlight that space is not merely location.
Lefebvre writes, “In Hegelianism, ‘production’ has a cardinal role: first, the (absolute) Idea produces the world; next, nature produces the human being; and the human being in turn, by dint of struggle and labour, produces at once history, knowledge and self-consciousness” (p. 68).
For a helpful discussion of Lefebvre’s ideas, see Watkins (2005).
An interesting example of a values conflict embedded in the evolution of hospital space and design has to do with the movement from large open patient wards to small private rooms. Verderber and Fine (2000) offer an interesting account of this history. Critics of moving away from large wards and towards separate rooms, most notably Florence Nightingale, saw the open ward as allowing for higher quality nursing care. A debate intensified in the mid-twentieth century. A movement towards semi-private wards occurred first. Strategies of clustering groups of patients emerged, and patient preferences for private rooms gained recognition and persuasive power. Patients prioritized the value of privacy, whereas Nightingale and others prioritized the ease and quality of care.
Illustrating this point, Ahuja cites a 1932 speech by Kahn, who said that building a hospital “requires knowledge of industrial processes for after all the same principles underlying the proper functioning of a manufacturing plant apply to the planning of a hospital building… Every department must be so coordinated as to cause all to operate jointly with maximum efficiency and for the greatest good” (pp. 403–404). Ahuja summarizes, “The University of Michigan’s new hospital provided a striking endorsement of efficiency as an institutional value that, importantly, it was willing to promote publicly. Its design resonated with an industrial model and supported an operational approach that maximized in-hospital productivity” (p. 426).
There are many critiques of the hospital and the procedures of the ICU. One recent article that was published while I wrote this paper is “Efficient, Compassionate, and Fractured: Contemporary Care in the ICU.” I found this paper helpful and insightful. See Bishop et al. (2014).
The space of the home and health care delivery also collide in long term care facilities, such as the nursing home. Young (2005, pp. 155–170), for example, reflects on the way that nursing homes have failed to cultivate the spatial elements of home. In many cases, residents cannot develop habits of their own, control who enters their areas, arrange their belongings, or maintain objects that have acquired meaning throughout time. She emphasizes the way that the ordinary aspects of home support and enact personal identity. When people lack the opportunity to develop a space, including the arrangement of objects, the patterns of movement, and the meaning of objects and activities, the dominating space of health care precludes them from thriving in their own lived space. Spaces inevitably collide when the places of home and health care overlap; however, careful ethical reflection can improve the production of a home health care space, whether that occurs in a house, apartment, or communal facility.
Notably, some effort has been made to proactively address the way that telemedicine will shape the patient-physician relationship. Mercy Health, for example, has noted that in leveraging new technology, there must be an emphasis on remaining true to the patient-physician relationship (Hale et al. 2015).
The production of spaces of non-acute health care delivery is always colliding with other spaces, including ICU spaces. Lefebvre is critical of what he calls abstract space. Abstract space is real space, but it tends towards homogenization. When space is abstract, people tend to downplay or erase distinction, particularity, and difference, leading to a kind of spatial interchangeability and homogeneity that overlooks the non-neutrality of space and fails to account for the interplay between the perceptive and conceptive, the real and the ideal.
On this point, Lefebvre is critical of what he calls abstract space. Abstract space is real space, but it tends towards homogenization. When space is abstract, people tend to downplay or erase distinction, particularity, and difference, leading to a kind of spatial interchangeability and homogeneity that overlooks the non-neutrality of space and fails to account for the interplay between the perceptive and conceptive, the real and the ideal.
References
Ahuja, N. K. (2012). Fordism in the hospital: Albert Kahn and the design of old main, 1917–25. Journal of the History of Medicine and Allied Sciences, 67(3), 398–427.
Bishop, J. P. (2011). The anticipatory corpse: Medicine, power, and the care of the dying. Notre Dame: University of Notre Dame Press.
Bishop, J. P., Perry, J. E., & Hine, A. (2014). Efficient, compassionate, and fractured: Contemporary care in the ICU. Hastings Center Report, 44(4), 35–43.
Borowitz, S. M., & Wyatt, J. C. (1998). The origin, content, and workload of e-mail consultations. JAMA, 280(15), 1321–1324.
Carpman, J. R., & Grant, M. A. (2001). Design that cares: Planning health facilities for patients and visitors (2nd ed.). San Francisco: Wiley.
Collignon, A. (2008). Strategies for accommodating obese patients in an acute care setting. Washington, DC: American Institute of Architects: Academy Journal.
Glaser, J. (1989). Hospital ethics committees: One of many centers of responsibility. Theoretical Medicine, 10(4), 275–288. doi:10.1007/BF00489649.
Gula, R. M. (1989). Reason informed by faith: Foundations of catholic morality. Mahwah: Paulist Press.
Hale, T., & Moore R. (2015). Mercy Virtual connects with a new model of care. Health Progress, 96(1), 13–17.
Lefebvre, H. (1991). The production of space (Donald Nicholson-Smith Trans.). Oxford: Blackwell.
Massey, D. (1992). Politics and space/time. New Left Review, 65–84.
Merrifield, A. (2000). Henri Lefebvre: A socialist in space. In M. Crang & N. Thrift (Eds.), Thinking space. London: Routledge.
Niesen, J. (2004). Lighting design for healthcare facilities: A common-sense approach. Washington, DC: American Institute of Architects: Academy Journal.
Pitt, A. (2015). Connected care is essential to telemedicine’s success. Health Progress, 96(1), 5–12.
Spielberg, A. R. (1998). On call and online: Sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA, 280(15), 1353–1359.
Stonington, S. D. (2012). On ethical locations: The good death in Thailand, where ethics sit in places. Social Science and Medicine, 75(5), 836–844.
Verderber, S., & Fine, David J. (2000). Healthcare architecture in an era of radical transformation. New Haven: Yale University Press.
Watkins, C. (2005). Representations of space, spatial practices and spaces of representation: An application of Lefebvre’s spatial triad. Culture and Organization, 11(3), 209–220.
Whittaker, S, and Johnny Cox. Use Catholic tradition to guide telehealth. Health Progress, 96(1), 51–55.
Young, I. M. (2005). On female body experience: “Throwing like a girl” and other essays. Oxford: Oxford University Press.
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Barina, R. New Places and Ethical Spaces: Philosophical Considerations for Health Care Ethics Outside of the Hospital. HEC Forum 27, 93–106 (2015). https://doi.org/10.1007/s10730-015-9277-5
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DOI: https://doi.org/10.1007/s10730-015-9277-5