The phenomenological ethics of K. E. Løgstrup – a resource for health care ethics and philosophy?

The phenomenological ethics of K. E. Løgstrup – a resource for health care ethics and philosophy?

Søren Holm BA MA MD PhD DrMedSciReader in Bioethics, Institute of Medicine, Law and Bioethics, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PT, UK, andProfessor of Medical Ethics, Centre for Medical Ethics, University of Oslo

Abstract This paper gives a presentation and critical assessment of the phenom-enological philosophy and ethics of the Danish theologian and philoso-pher K. E. Løgstrup (1905–1981). It is argued that although the ethicsof Løgstrup contain valuable insights, an uncritical appropriation as themain source for a health care ethics or a philosophy of caring, is prob-lematic. Løgstrup’s philosophy contains a number of internal problems,and does not adequately deal with some problems raised by work in themodern health care setting.

Keywords: health care ethics, ethics of care, closeness, phenomenology.

26 © Blackwell Science Ltd 2001 Nursing Philosophy, 2, pp. 26–33

Correspondence: e-mail: [email protected]

The phenomenological philosophy and ethics of theDanish theologian/philosopher K. E. Løgstrup isgaining popularity within nursing ethics (Lindahl &Sandman, 1998; Saveman et al., 1996), and at least oneauthor has even claimed that a thorough expositionof Løgstrup’s metaphysics and ontology is the onlyproper basis for nursing philosophy and nursing prac-tice (Martinsen, 1993). This application of Løgstrup’sethics was not one he himself envisaged. In his ownwork there is only one four page manuscript thatdeals with a problem in health care ethics, and it wasnot originally intended for publication (Løgstrup,1993a). The interest in Løgstrup started in the Scan-dinavian countries where his work can be readwithout translation, but it now seems to be spreadingto the USA where new translations of his main works have become available (Løgstrup, 1994, 1997).

Løgstrup’s ethics have also been discussed by thewell-known philosopher Alasdair MacIntyre, and bythe influential sociologist Zygmunt Bauman who seesLøgstrup as an important precursor of a postmodernunderstanding of ethics (Bauman (1993, 1996a, b),and this has further added to the interest in Løgstrupand his ideas.

It therefore seems an appropriate moment in timeto discuss (i) whether Løgstrup’s ethics is a promisingsource of new ideas in nursing ethics and health careethics in general, and (ii) how his ethical ideas can be applied to the dilemmas occurring in health care practice.

Such a discussion could also serve a furtherpurpose in pointing out that there is a large secondaryliterature on Løgstrup’s ideas in the Scandinavianlanguages. A literature that spans a range from thetotally dismissive (like a book entitled Løgstrup’s

Ethics – a Blind Alley in Moral Philosophy

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The Phenomenological Ethics of K. E. Løgstrup 27

© Blackwell Science Ltd 2001 Nursing Philosophy, 2, pp. 26–33

(Schaffalitzky de Muckadell, 1997) to the very posi-tive. Most of this literature is not – and probably willnever be – translated into English or any other non-Scandinavian language. This creates a problem for the non-Scandinavian philosopher interested inLøgstrup, because the lack of easy access to the sec-ondary literature can easily lead to an insufficientlynuanced reception of Løgstrup.

There is a general discussion in the philosophy of nursing about the way phenomenology andhermeneutics is used and misused. A main aspect ofthe critical side of this discussion is that the interpre-tations of phenomenologists like Husserl and Heidegger by nursing theorists often misunderstandthe basic concepts, and that the application of the philosophy therefore bears little resemblance to theoriginal (Paley, 1997, 1998). It is to be hoped that the same fate does not befall Løgstrup’s ethics.

The main features of Løgstrup’s ethics

Løgstrup’s ethics was developed over a period ofabout 25 years from the early 1950s to the mid 1970s(Løgstrup died in 1981). During this period manychanges were made in the theoretical framework, andone large segment of the secondary literature is con-cerned with a discussion of (i) the correct periodiza-tion of Løgstrup’s thinking and writing, (ii) whetherthere are actually major differences between theearlier and later works, or whether the differences areonly minor, and (iii) whether the ethics should beunderstood as philosophical or whether it requires atheological underpinning (Andersen, 1989; Bjerg,1994; Hansen, 1998; Hauge, 1992; Jensen, 1994;Pahuus, 1993; Thomassen, 1992). In my presentationof Løgstrup’s ethics I will assume that the differencesbetween earlier and later writings are not funda-mental, and that it therefore makes sense to presenta single interpretation of the main features ofLøgstrup’s ethical ideas. I will also assume that whatLøgstrup presents is fundamentally a philosophicalethics, which does not require any further foundationin specific Christian/Lutheran theological concepts. Ibelieve that this second assumption is partly war-ranted by the philosophical claims Løgstrup himself

makes (Løgstrup, 1991, especially pages 122–132),and partly by the pragmatic consideration that if theethics is fundamentally theological and Christian,then its relevance in the modern secular health caresector may be rather limited.

Løgstrup was a phenomenologist, mainly inspiredby the German phenomenological philosophers.He made extensive studies of both Husserl and Heidegger, but his main inspiration came from thephysician and philosopher Hans Lipps with whom hestudied for 1 year in Göttingen (Lipps, 1977). In ashort autobiographical sketch Løgstrup writes:

Few heard him, nobody understood him. I went to every-

thing with him the year I was in Göttingen. [. . .] I

understood as much, that when I did not understand him,

it was because I thought in schemata, while he went to the

phenomenon, without prejudice and unimpressed by the tra-

dition. [. . .] But there is nobody I have learnt more from

than Hans Lipps. Maybe I am the only one, including in

Germany, who has learnt anything from him.1 (Løgstrup,

1993b, p. 159)

Løgstrup’s main philosophical opponent was Kant and his highly structured epistemology andethics, but he also put forward strong criticisms ofKierkegaard.

One of the things that Løgstrup learned from Lippsis the importance of concrete phenomenologicalanalysis, i.e. the idea that the task of phenomenologyis primarily to analyse everyday phenomena, and thatall higher level theories should be based in such con-crete analyses.

The basis of Løgstrup’s ethics is a concrete phe-nomenological analysis of what happens in themeeting between persons. According to Løgstrup it isa basic ontological fact about human existence thatwe are always already entangled or intertwined with,and in the life of, other human beings. This entangle-ment is not a contingent attribute of human existence,something that happens to us, but that could just aswell not happen. The entanglement of our lives isthere ontologically prior to our constitution as indi-vidual persons. Although we may be tempted to see

1 All quotes are translated from the original Danish by the

author.

28 Søren Holm


individuals as separate, because that is how we firstmeet them and identify them, a closer analysis willshow that any absolute separateness is an illusion.Just as each seemingly separate mushroom springsfrom a huge interconnecting mycelium,2 so humanindividuals only come into being already entangled inthe lives of others.To exist as a human being is alwaysto exist with others. The eremite can only be aneremite if there is a society around him. It thusbecomes very important to analyse the phenomenol-ogy of the entanglement and to understand its con-sequences. In order to understand Løgstrup in thisarea it is crucial to note that for him ethics is funda-mentally about thinking in first person terms.The firstquestion to be answered in ethics is not how we canevaluate moral agents or acts from a third personal,impartial perspective (Nagel’s The View from

Nowhere; Nagel, 1986), or even how we should evalu-ate our own acts after we have performed them. Thefirst and most important question of ethics is how I,the concrete person in the concrete situation shouldact now.

Løgstrup is very clear with regard to the conse-quences of the entanglement. Because we are entan-gled I always hold some part of the other person’s lifein my hand. Some part of the other person’s life isdependent on how I act in the situation.The mere factof entanglement thus creates an ethical demand onme to act in a way which takes care of that part of the life of the other that I hold in my hand. This partof Løgstrup’s ethics is thus in some ways similar to certain ideas in the ethics of Emanuel Levinas,although Løgstrup never did read Levinas and neverdid locate the origin of the ethical demand in somespecific body part (Hansen, 1998; Vetlesen, 1996). ForLøgstrup the ethical demand is unilateral and radical.It is not a question of reciprocity.

Now, Løgstrup is not naive, despite the claim to thateffect by some of his critics.3 He realizes full well that

this ethical demand can be and often is rejected. Butwhat he points out is that when I reject the ethicaldemand that is created in the situation, it is not onlythe case that I reject to take care of the welfare of theconcrete other, I also show myself to be indifferent to the much more important question of whether ornot life as such should be supported or destroyed(Løgstrup, 1991).This second question is more impor-tant because the existence of (human) life as such ismore important than the existence of each of us indi-vidually, but it is not more basic to ethical thinking. Itjust allows us to add yet another feature to the ex post

facto negative assessment of a person who rejects theethical demand.

On the basis of his phenomenological analysisLøgstrup also claims that it is possible to identifysome basic, authentic modes of reaction to the otherperson whom I meet. In later writings Løgstrup callsthese modes of reaction ‘spontaneous manifestationsof life’ or ‘spontaneous utterances of life’,4 but theidea is clearly enunciated even in the early writings.Løgstrup never explicitly defines how many sponta-neous manifestations of life there are, but it is usuallyaccepted that there are three core spontaneous manifestations of life:

• trust,• the openness of speech,• compassion.

According to Løgstrup the spontaneous manifesta-tions of life are prereflective and spontaneous in thesense that they are the way we meet the other person,unless we actively reflect and decide to act differently.They are, furthermore, authentic in the sense thatthey are expressions of the basic ontological entan-glement of individual human beings.

I need to have reasons if I am to treat somebodywith suspicion, and even if I am in a situation whereI know I have to be suspicious and guard what I say,trust and the openness of speech are always there inthe background and may break through even againstmy manifest intentions to suppress them. Løgstrup2 This is my example and not Løgstrup’s.

3 Løgstrup’s colleague Johannes Sløk is said to have remarked

‘Løgstrup? – If somebody writes a Christmas card to him and

wishes him a merry Christmas and a happy New Year, he

believes that the other person really means it!’

4 The Danish term is ‘spontan livsytring’ but this creates some

translation problems because ‘ytring’ in Danish has connota-

tions of both verbal and nonverbal communication or activity.



uses an example from the experiences of his wifeduring the second world war, where Løgstrup had togo into hiding because of his involvement in theDanish resistance movement:

At four o’clock in the morning the door bell rings insistently.

When the woman comes down the secret state police is

standing outside demanding that she opens the door. When

they are inside they ask for her husband. They are told that

he is on a business trip and not at home. One of the two men,

ugly as sin, and evidently capable of all brutal acts, starts

searching the house, armed to the teeth. The other, who has

a pleasant character and is full of friendliness and approach-

ability at the same time converses with the woman and

ensures her that what is happening is inconsequential and

just routine. The woman acts pleasantly, perfectly without

nervousness. She knows full well that his charming dimini-

shing of the importance of what happens is only aimed at

loosening her tongue, so he cannot deceive her. She knows

that the least slip of the tongue will be used to forge weapons

against her husband and herself. But in spite of this – and

this is perhaps the strangest of it all – she continually has to

check the temptation to get on speaking terms with the

man, as if he could be turned from his destructive project

to human understanding and reason. All the time she has

to keep a cool head. Why? What is it that presents itself in

the temptation? It is the elementary and definitive strange-

ness of speech as a spontaneous manifestation of life, that is

its openness. To speak is to speak out. (Løgstrup, 1972,

p. 17)

It is slightly misleading that Løgstrup uses the term‘trust’ for the phenomenon he describes, because hisconcept is not co-extensive with the everyday conceptof trust.5 The phenomenon he is analysing is the basicelement of communication that as soon as we open acommunication with another we necessarily alsoopen at least part of ourselves to our interlocutor. Wecannot communicate without daring to move forward

to be met/accepted by the other. When we communi-cate we always deliver (part of) ourselves into thehands of the other, and it is this interdependence thatLøgstrup calls trust.

For Løgstrup the spontaneous manifestations oflife is the basic level of ethical phenomena, but herealizes that an ethics that only contains the sponta-neous manifestations of life would be severely defi-cient, because the manifestations can easily bestrangled and exterminated. He therefore also dis-cusses the other side of ethics, the ethical norms thatstep in when the ethical demand does not call forwardthe spontaneous manifestations of life, or when it issuppressed by personal interests or other factors.These norms are formalizations of the spontaneousmanifestations of life, which tell us what to do, forexample in situations where there is conflict betweenthe spontaneous manifestation of life and our indi-vidual (egoistic) interests. But the norms are notprimary. Ethics is not a system of formalizable rules,and we do not decide what is ethically right by deduc-ing it from a system of rules or norms. The norms areonly replacements for the basic ethical phenomena,which we need when they fail. For Løgstrup thejudgement ‘I have borrowed a book from my friend.He trusts me, and therefore I ought to give it back’ ismore basic than the judgement ‘Promises ought to be kept’. The concrete situation is primary, and thegeneral rule secondary.

The relationship between concrete action andgeneral norms is notoriously difficult in Løgstrup. Onhis analysis norms have two possible functions. Theycan function as a criterion of right action, and theycan be a ‘surrogate motive’ or ‘replacement motive’for decent action when our own moral life fails andwe are unable to react directly to the ethical demand.A norm can, however, never be a primary reason toact. Løgstrup imagines a situation where I havepromised to help somebody if he needs it, and wherethe situation where he needs my help arises. Hewrites:

The natural would then be to honour the demand because

of the man, his case, the mutual and trusting relationship,

and the common life for which sake morality exists, all taken

together as one. Should one do it for the sake of the moral

5 The Danish term Løgstrup uses is ‘tillid’ which according to the

most comprehensive Danish-English dictionary can be trans-

lated as ‘confidence, trust, faith (in), reliance (in or on)’

(Vinterberg & Bodelsen, 1990). Løgstrup himself has never

given any guidance concerning the English translation of this

central term, but the problem referred to here caused by the use

of ‘trust’ also occurs in Danish with the original term ‘tillid’.

30 Søren Holm


rule that we all know and which says that one should keep

ones promises, then one would have to acknowledge that

one didn’t care about the man, his case, and our trusting rela-

tionship. Something must have made me indifferent in order

for the moral rule to individuate itself and present itself in

my consciousness. In other words, one would have to have

become indifferent to some of the demands and challenges

that directly flow from the relationship to other people, in

order for them to be replaced by the specific moral admon-

ishment to do ones duty. (Løgstrup, 1996, p. 41)

Løgstrup evidently does not reject the importanceof moral norms in certain circumstances, but he doesreject any suggestion that the formulation or under-standing of such general moral norms is the centralpart of ethics. Concrete action in response to theethical demand is central, norms only derivative andsecondary.

Criticisms of Løgstrup’s ethics

In the secondary literature on Løgstrup it is possibleto identify some distinct types or kinds of criticism.The first of these kinds is a criticism that mainlyreproduces the main areas of disagreement betweenanglo-american analytic philosophy and phenome-nology. According to this criticism Løgstrup’s ethicscan be rather summarily rejected because (i)Løgstrup commits the naturalistic fallacy, and (ii) hisphenomenological analysis cannot discover any basicconstituents of human existence (Schaffalitzky deMuckadell, 1997).The first of these charges is levelledagainst Løgstrup because he tries to say somethingabout how a person ought to act, based on claimsabout how the world is. The second charge is built onthe further claims that (i) Løgstrup’s phenomenologyof, for instance, trust as a spontaneous manifestationof life is problematic, because we can imagine counterinstances where distrust and suspicion seem to beprimary, and (ii) that the entanglement of human livesis a purely social and contingent fact that cannot formthe basis of ethics. I see no way of resolving this firsttype of criticism, because it primarily reproduces avery basic disagreement about the scope, validity andapplicability of phenomenological analysis. If onestarts with the premise that the style of ethics pre-

ferred in anglo-american analytic philosophy is theonly valid way of doing ethics, then one has answeredthe question of the value of Løgstrup’s approach,even before one has raised it.

The second type of criticism accepts Løgstrup’sbasic phenomenological project as valid, but raisesspecific criticisms about some of his analyses and con-clusions. One of the more basic of these criticismsraises the question of why only positive manifesta-tions are included in the spontaneous manifestationsof life (Hansen, 1998). Doesn’t everyday experi-ence tell us that, for instance, anger or indignation are equally spontaneous and phenomenologicallyprimary as trust or compassion? Løgstrup doesanalyse a second negative type of manifestations oflife that he calls ‘circulating manifestations of life’ or‘circulating thoughtfeelings’, because they are not primarily directed against the other, but take placewithin the mind of the person him- or herself.Løgstrup, for instance, mentions hatred, and the wayhatred once it has emerged starts feeding itself andbecomes more and more embittered. But anger does not seem to have the characteristics of a ‘circu-lating manifestation of life’, so there must be someother reason to exclude it from the spontaneous manifestations of life. Here it seems that Løgstrup’sanswer is, that for some manifestation of life to be anethically basic manifestation of life it has to serve life, and not to serve the destruction of life, but thisdoes seem to add a further basic feature to moralitywhich cannot be found by pure phenomenologicalanalysis. It looks more like a remnant of a natural law idea.

Another possible criticism is that, whereasLøgstrup’s ethics is strong on the phenomenologicalanalysis of moral phenomena, and strong on the foun-dations of ethics, it is weak when it comes to concreteaction guidance. It is arguably exactly when the spon-taneous manifestations of life fail and I don’t knowhow to act towards the other, that I need an ethicalframework that can help me to act in the right way.It may well be that I shouldn’t expect to be able tofind an ethical framework that can always tell me howto act (there may be for instance true moral dilem-mas), but it does seem to be a positive feature of anethical framework that it is action-guiding in a wide



range of cases. The best we can hope for fromLøgstrup’s ethics in this regard is probably that it canpoint us towards an understanding of what kind ofpersons we ought to aim to become, if we want to bethe kind of persons who act rightly. Part of this under-standing of the ethical person would be an under-standing of how such a person could ensure that hisor her understanding of the situation and the otherperson was correct.

I have here implied that the lack of concrete specifiable action guidance is a potential problem for Løgstrup’s ethics, but it is of course exactly thesame feature that makes the ethics attractive for postmodern thinkers, because it makes it very fluidand context-sensitive. In this context it is, however,important to note that Løgstrup argues stronglyagainst moral relativism at the most basic level where we make the fundamental distinction betweengood and evil. The concrete morality of societies maydiffer but the fundamental distinction between goodand evil, between taking care of the other and livingat his expense, is valid for all societies (Løgstrup,1996).

Løgstrup and health care ethics

One of the reasons that Løgstrup’s ethics has becomepopular in nursing ethics is that his spontaneous mani-festations of life seem to fit well with a certain pictureof the ideal nurse as a person who spontaneouslyshows caring behaviour, and with certain ideas aboutwhat distinguishes the profession of nursing from theprofession of medicine. This fit may well be moreimaginary than real, but even if we accept it, it imme-diately points us to a major problem in the applica-tion of Løgstrup’s ethics in health care. As discussedabove it may show us an ideal picture of how weought to be as people, but it does not tell us how wecan attain this ideal state. Just as Løgstrup’s ethics isshort on action guidance, it is short on concrete guid-ance on how a person is to develop the kind of ‘innerlife’ that will bring forth the appropriate appreciationof situations and the appropriate spontaneous mani-festations of life. Here it is not sufficient to say that itis a characteristic of the expert nurse (Martinsen,1993), because it is empirically fairly evident that

many experienced nurses do not possess this charac-teristic, and unless we can show why they haven’tdeveloped it, and come up with suggestions abouthow nursing education and nursing practice should beorganized to remedy this defect, the ideal picture isrelatively worthless. Part of the function of a healthcare ethics is to be a basis for education in the healthcare professions, in order to ‘produce’ professionalsof a high ethical standard. It is therefore not sufficientto have an ethical framework that informs us aboutthe final product, the expert ethical professional,unless the framework also contains resources thatenable us to develop methods to ‘manufacture’ thisproduct.

In the possible wider application of Løgstrup’sethics in health care ethics a number of further questions occur, occasioned by specific features of the meeting between the health care professional and the patient. As we shall see these questions callinto doubt the value of an application of Løgstrup’sideas.

The first question is raised by the fact that themeeting between the health care professional and thepatient is exactly that, a meeting between a profes-sional and a patient. This implies that already beforethe meeting the roles and powers of each of thepersons is defined to some extent, and it creates spe-cific expectations about the structure, process andoutcome of the meeting. In the modern health caresetting it is also very rare that the health care profes-sional is able to act totally independently. The deliv-ery of health care usually takes place within a highlycomplex social structure, where each individualhealth care professional has to co-ordinate his or heractions with the actions of other health care profes-sionals, and has to act within confines laid down bythe organization. These structural features of modernhealth care create a major problem for an applicationof Løgstrup’s ethics in this area, because they makeit very important that both patients and health careprofessionals can form stable expectations concern-ing how other parts of the system, including otherhealth care professionals, will act in specific situations.The patients must, for instance, be able to expect thatthey will receive the same care and treatment (or atleast the same quality of care and treatment), no

32 Søren Holm


matter which doctor or nurse they meet.6 In thehealth care team each individual health care profes-sional must also be able to predict how the othermembers of the team will act, because otherwise itbecomes impossible to predict what consequences hisor her own acts will have, and therefore impossible topredict whether they will help the patient or not. Thisis simply a consequence of the fact that in modernhealth care no single professional has total controlover the treatment and care of a given patient. Somehealth care systems may try to perpetuate an illusionof total personal control and responsibility, but this isvery rarely more than an illusion. The problem thatnow occurs for Løgstrup’s ethics is, that if all healthcare professionals follow this ethic, then their actionswill no longer be predictable in the necessary manner.The good ethical person is not rule or norm boundbut responds to the concrete situation, and thisimplies a degree of unpredictability, which will createproblems in a complex social system where manyagents have to work in a co-ordinated way to reach acommon goal. Thus if each acts as he or she ought todo according to Løgstrup, this may have negative con-sequences for the achievement of the common goalof health care. What we need in a health care ethicssuitable for modern health care is, thus, not only ananswer to Løgstrup’s question ‘How should I act?’ butalso an answer to the question ‘How should we act?’,where the ‘we’ must be specified relative to the con-crete social organization of health care.

There are several ways to get around this problem,but all of them seem to require a basic modificationof Løgstrup’s ideas. One possibility would be to givesocially negotiated norms a greater place, but thisseems to contradict the primacy of the spontaneousmanifestations of life. Another possibility would be to allow agents to take account of the whole socialsetting in a very explicit way in their meeting with thepatient, but this seems to contradict the primacy ofthe ethical demand created in the specific meeting.

The last consideration leads on to a secondproblem that occurs because Løgstrup’s ethics, like anumber of other phenomenologically based ethicalframeworks, is primarily concerned with the meetingbetween me and the Other, but this leaves out of con-sideration the Third, i.e. any third person to whom Imay hold obligations or duties. By focusing so intentlyon the concrete interaction between the people whowe actually meet, Løgstrup’s ethics gets into difficul-ties in dealing with the wider circle of people who areaffected by our acts. In health care this for instancemakes it difficult to say something about resourceallocation and priority setting. On one possible inter-pretation the ethical demand is only created in theconcrete meeting, and my responsibility is only torespond to this demand in the appropriate way (i.e.by the appropriate spontaneous manifestation oflife). On this interpretation any thoughts about widerconsequences would actually be wrong, because theywould tend to inhibit the spontaneous manifestationsof life. An acceptance of this interpretation ofLøgstrup would, however, make his ethics ratherunattractive for health care, because it would inter

alia entail an obligation to disregard any resourceimplications of clinical decisions.

Attempts have been made to extend the ethics ofLevinas and Løgstrup to encompass a wider sphereof ethical concern (Nortvedt, 1996), but theseattempts are in themselves problematic because theyat the same time want to defend the ethical impor-tance of closeness and balance the ethical demand ofthose who are close against the interests of all thoseboth close and distant who are affected by my actions.As long as this problem has not been solved con-vincingly, Løgstrup’s ethics can at most be an ethicsfor a part of the health care field.

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The phenomenological ethics of K. E. Løgstrup – a resource for health care ethics and philosophy?