a critique of , , ,
The Laws of Form Applied to
Nursing And Medical Practice
Steven B. Hoath, M.D.
page 4
[the original paper is shown in Times font; comments are written in sans-serif Arial font]
The "flag" of the paper is located near the end. A good summary, this could also be a kind of manifesto for the extension of topology (a "boundary language") into all domains where treatment involves both technological and social/cultural/spiritual considerations. I'll quote the entire final part of the paper. It's excellent and provocative.
In logical terms, human beings are a care giving species. In fact, within the conceptual framework outlined in The Laws of Form, the basic perspectives of the primary care giving professions of nursing and medicine conform, without the slightest forcing, to fundamental structures of logic (Figures 2 and 4). Given this primacy of logical description, one would expect that the logical distinctions and operational models subsequently developed in Spencer-Brown's calculus of indications would be applicable to understanding the logical basis of other disciplines and human activities; e.g., the organization (or lack thereof) of current health care systems. Such logical models may be useful in medical law, for example, and have a heuristic value in differentiating the separate disciplines involved in patient care. Fiscal guidelines for reimbursement of health care professionals should reflect a balanced view of the differing logical models and perspectives as well as the complexity of the knowledge base required to execute a particular function. An unbalanced or systematic adherence to one perspective or the other is illogical and fiscally unsound.
Summary
Nursing and medicine represent two fundamentally different
perspectives on patient care. These perspectives correspond to
the initial equations in Spencer-Brown's primary algebra. In the
application of these perspectives particular attention is given
to the position of the boundary of the autopoietic system. In
the nursing perspective, this boundary is invariant and marks
the position of the patient as a biological entity. In common
parlance, the boundary of the nursing perspective is equivalent
to the topological surface of the individual, that is, at first
approximation, to the skin. This analysis supports the longstanding
efforts of nursing theorists to delineate a separate area of nursing
practice based on first principles [30,31].
In the medical perspective, the boundary of the autopoietic system
is less obvious in so far as it is distinguished from a set of
characteristics called the phenotype. The phenotype is
conceived as the result of physical interaction between the genome
and the environment. Such interaction occurs across not one but
two autopoietic boundaries. This form provides a model for mechanistically
linking specific cell types (secondary autopoietic systems) with
the observable characteristics of the organism (primary autopoietic
system). The outer limit of the medical perspective is the inner
limit of the nursing perspective.
In the application of these logical forms, the position of the
primary autopoietic boundary is critical to determining which
perspective is paramount in a specific care-giving situation.
Lack of attention to the importance of this boundary will result
in confusion. In addition, misunderstandings will arise if no
meaningful interpretation is attached to the void or the unmarked
state in the positional equation. In general, the void of the
calculus of indications is coterminous with the medium (pervasive
space of the Observer). Harmonious linkage between the biological
and social aspects of the individual (Figure 2) defines a state
of balance which is indistinguishable from the void. This state,
to use the apt phrase of Oliver Sacks, denotes "the usual
surface of health" [32]. Health, by this definition, is an
undistinguished state. We habituate to health and wellness. Disease
is distinguished from health. Without health, there is no disease.
In summary, it is hypothesized that differences in perspective
between nursing and medicine are fundamental but complementary.
These differences can be illustrated by reference to a formal
logical system such as Spencer-Brown's calculus of indications.
It is further hypothesized that focus on the role of the boundary
of an autopoietic system provides a means of linking these fundamentally
different but complementary perspectives. The boundary, thus,
provides a third element which is neither inside nor outside,
neither subject nor object, neither entirely holistic nor entirely
analytic. We need a new way of thinking about the boundaries of
autopoietic systems. A thinking which does not trivialize the
surface of things. Such thinking is required to develop collaborative
partnerships between nursing and medicine and to transcend each
discipline's singular point of view. The ability of health care
organizations to provide in depth patient centered care depends
upon such transcendence [33,34].
Footnote 1 is especially interesting:
This view of medicine and nursing has surprising resonances with philosophical thought. One of Heidegger's central categories, for example, is Cura or care [35]. According to Heidegger, Being (Dasein) is revealed when we become "authentic" and accept our world and "care" for all beings. The logic of the calculus of indications is consistent with this care focus. The fundamentally dual nature of the calculus, however, has it limits. Both medicine and nursing need to respect their logical limits and resist the temptation to overextend their appropriate purviews. There is a temptation, for example, to interconvert the two fundamental constants in the calculus of indications, the mark and the void. Since, the "void" is not given a specific form in the calculus, it can be both everything and nothing. Thus, it is a seemingly simple matter to equate the void with the mark (the Observer):
This is a simple way of portraying the ego (everything am I)
or existential nothingness (nothing am I).
Another construction derived from the Laws of Form, also seems
simple:
This is, in fact, the commonly held view of the process of
birth. That is, the mother containing a fetus, symbolized 
,
transitions through the mechanism of birth to yield the separate
entities of mother
and infant 
.
Neither of the above equations is allowable in the calculus
of indications. They are both illogical. The equations appear
to interrelate fundamental logical constants in a meaningful way.
Despite the persuasiveness and simplicity of their apparent constructions,
however, something is missing. A missing "third" element
is needed for proper signification of the boundary between the
constants [7]. What is ultimately needed for this signification
is a trinary not a binary logic [18].
Of course, this is the most brilliant part of the article, for me. The fact that a "self-evident" application of topology directly contradicts the calculus (in fact, it points to an inconsistency noted by Spencer-Brown himself) leads one to ask the question of whether a special "form" of the Laws of Form should be based on this very inconsistency. Its anomalous nature is the key. It points to other anomalous conditions, in culture, personal experience, etc., where the same "topology" - a contrast between our map accounts and our journal experience - applies.
Working backwards from the paper's conclusions might be profitable. Here are the guidelines that might be used:
- Keep the calculus "transparent" so that any theorems that are not self-evident are given some anecdotal or evidentiary basis.
- Use a common phenomenon that has a historical, cultural, and psychological basis. The flip of the boundary points both to a crucial joint in the calculus and to a crucial "moment" in therapy as well.
- Stake out domains at the biological level (immunology; gene therapy), holistic treatment, health-care strategy, and the psychology of health maintenance. Introduce these as potential "growth areas" that might benefit from topological investigation.
- Show how, although the implication is clearly that this topic is interdisciplinary, its application is consistent with current trends of disciplinary research and professional practice.
I'm looking forward to a critique of the critique and a few more rounds where we can negotiate our way from these excellent (but unpublished) insights to something quite astounding and convincing from multiple points of view.