Hi all,

This week I thought we would touch on one of the more popular lines of thought that is frequently argued by my colleagues. That, is the notion that there are different “ways of knowing” in explaining phenomena. The idea that there are different ways of knowing things is not really new, and forms the basis of any philosophical and epistemological argument, but promoting the verb over the noun (a curiously North American pastime) and the principle that these ways are all equally valid as forms of explanation are more modern ideas, arising from the postmodern movement of the 1970’s.

My thoughts on this were triggered as a few weeks back when in a discussion I heard the trite comment that “…of course  science is only one way of knowing, there are really four different ways of knowing, empirical, ethical, personal and aesthetic.”  What surprised me was that the individual arguing this view made no attempt to justify the classification, but presented this as an established given, simply arguing that this illustrated established ways of knowing in nursing and why we should use a plurality of views in our thinking. So, what is the argument and theory behind this position?

This typology comes from the work of Barbara Carper (1978). Carper’s proposed  a typology of fundamental ways of knowing  that classifies the different sources from which knowledge and beliefs  can be derived. It was specifically applied to nursing knowledge and is seldom used outside of my profession but identified four “patterns of knowing:”

1. Empirical: Experiential knowledge from scientific inquiry, or other external sources, that can be empirically verified.
2. Ethical: Attitudes and knowledge derived from an ethical framework, including an awareness of moral questions and choices.
3. Personal: Knowledge and attitudes derived from personal self-understanding. “Personal knowledge is involved with the knowing, encountering and actualizing of the concrete, individual self.”
4. Aesthetic: knowledge derived from an appreciation of the nature and art of nursing. “An esthetic experience involves the [immediate] creation and/or appreciation of the situation” This involves  empathic knowledge, including imagining one’s self in the patient’s position, and creativity in the response.

This classification system was really a reaction against empirically derived knowledge, and “scientific” nursing, by emphasising that more personal attitudes and intuitive aspects of knowledge were important too. Well, that certainly sounds reasonable in terms of explaining personal human experience, but let us explore the justification for the typological division further.

Empirical knowledge is easy enough to explain (and also forms the basis for modern scientific argument). It arose in the early-to-mid-17th century  as a response to rationalism (espoused by René Descartes and Benedict de Spinoza). Whilst the rationalists held that knowledge is attained through the operations of the mind, empiricists (such as Francis Bacon, John Locke, George Berkley and David Hume)  argued that knowledge was based on experience and best attained through human perception of the world and phenomena through sensory experience. Isaac Newton was also a key early proponent. I.e. we know things because we have experience of them, or can demonstrate them to be true (or things that we can verify through  experience).

Now here lies the rub; the other three forms, whilst arguably all forms of knowledge generation, can’t be separated so easily and all resort to rationalism. All represent forms of artistic subjective interpretation, and all require us to adopt some form of relativistic thinking. Ethical knowledge, for example, requires us to make judgments on what is right or wrong. This of course varies with different cultures,  and as Roger pointed out in his earlier post, science has very little to say about what is right or wrong. We all possess knowledge of what we consider is right or wrong, but this really comes from our culture or personal beliefs. For example here in North America and in the UK we generally consider eating horse meat, or digging up our dead relatives for a party “wrong,” but in some cultures (such as in Madagascar) they have no problem with those things, and it is a normal part of their everyday cultural life. Hence, ethical knowledge is really a relative form of knowledge.

The same goes for personal knowledge (knowledge of self from personal self-experience). If I see the face of the Madonna in a grilled cheese sandwich and feel it is of religious significance and meaning to me personally, but no-one else sees it or feels that way, then that is my personal experience, and is relative to anyone else’s. Personal self-knowledge is largely subjective (by its very nature) and works as an explanation of the self-perception for the individual. So for explaining why we feel as we do, and react to things it has value. However, for everyday practical issues it is fairly useless in terms of being able to explain any other shared experience or phenomena.

The same also applies to aesthetic knowledge; knowledge of the  immediate or empathic knowing is based on intuitive and abductive reasoning processes, which we know are flawed processes in “truth preserving” rationale, (that is to say useless for any form of general application) and so once again these represent relative and personal ways of knowing. I would also argue empathy is hugely problematic for health professionals, as we are not our patients, and so trying to put ourselves in their position would seem very unwise, as it will reflect what we think we would feel if we were them; not what they actually feel. I also find aesthetic knowing particularly dubious, as I can’t really see how to separate it from personal knowing (apart from the temporal element of immediate appreciation). As there is no clearly identifiable demarcation of one from the other why use these categories to differentiate different forms of knowledge? Knowledge of self, and aesthetic knowledge seem inextricably intertwined.

I also have some concerns that arguing that the way that nurses generate knowledge is somehow fundamentally different from the way other people “know” things is rather an unproductive activity. Suggesting nurses “know” things differently from everyone else, would seem rather a self-defeating argument; so what? I would suggest more usefully, we could consider the following as a simple classification of ways of knowing if we wish to establish the principle that knowledge has individual and subjective components:

1) Empirical Knowledge: a posteriori knowledge derived from experience

2) Intellectual Knowledge; a priori knowledge derived from;

• Individual cognitive processes
• Group socio-cultural processes

The terms a priori (“prior to”) and a posteriori (“posterior to”) have long been used to distinguish types of knowledge, justifications or arguments. A priori knowledge or justification is that independent of experience (for example ‘all swans are birds’); a posteriori knowledge or justification is dependent on experience or empirical evidence (for example ‘some swans are black’). There are many points of view on these two types of assertion, and their relationship is one of the oldest problems in modern philosophy. A priori can also refer to an argument made without a logical basis that is without evidence or analysis. Kant’s view of a priori (expressed in his Critique of Pure Reason in 1781) was that it described the underlying mental processes prior to experience. For example, he saw time and space as a priori constructs created by the mind.Kant proposed that whilst we could know particular facts about the world only via sensory experience, their form depended upon “a priori” reasoning, which was a mental construction. He also supported the priority of mind over matter (or physical experience) and this forms the basis for much postmodern thinking.

Aside from that, I would argue if we wish to adopt Carper’s classification, then logically we have to support as many different categories of  “knowing” as we can imagine. My point here is, the arguments used to support Carper’s classification can be equally well used to underpin other creative classifications. So in the spirit of Borge’s fictitious Chinese Celestial Emporium of Benevolent Knowledge (1942) I give you (cue the fanfare) my typology of “Ways of Knowing:”

1. Empirical Knowing; knowledge derived from empirical sources,
2. Blessed Knowing; knowledge revealed in sacred ancient texts,
3. Fabulous Knowing; knowledge derived from fabulous conceptions,
4. Fanciful Knowing; knowledge derived from dreaming,
5. Luneful Knowing; knowledge derived from states of madness,
6. Arcane Knowing; Knowledge of things beyond comprehension,
7. Spooky Knowing; knowledge derived from magic,
8. Lupine Knowing; knowledge derived from werwolves,
9. Satellite Knowing; knowledge of things that, from a great height look like flies, and lastly of course,
10. Other Knowing; knowing from other than the above.

That should cover it, so please feel free to disseminate and use my typology widely (but please don’t forget to cite your source here on the Real Science blog)!

Lastly, where does this leave us in regard to evidence-based practice (EBP)? Well, in terms of understanding patients (and societies) preferences and the personal acceptability of therapeutic interventions these sort of typologies might seem useful enough. For example, in a paper exploring myths surrounding Evidence-based practice by Professor Hugh McKenna et al. in 1999 the authors cited Carper’s typology as a rationale for  knowledge informing the patient’s choices of therapeutic intervention. Certainly, non-emprical forms of evidence and knowledge are an important part of EBP (EBP includes consideration of acceptability to the patient as a form of evidence). An informed and competent patient can refuse any treatment on the basis of their personal beliefs and preferences, and a nurse should select the best interventions based on this as part of the EBP process. Nevertheless, apart from identifying that people have highly individual knowledge and beliefs that affects their decisions (who would have thought), Carper’s typology is of little practical value in understanding health decisions, as it can be equally well supplanted by any other typology. At the end of the day this leaves us with a lot of arbitrary intellectual nonsense. Amazingly enough, I find this bunk it is still taught as sage wisdom in many PhD nursing programs with no attempt (from what I have seen) to critique it as an alternative or heterodoxical viewpoint.

In considering the merits of Carper’s typology today, maybe we should also consider the 1970’s was the decade of other “bright” ideas such as the Ford Pinto (arguably the worst car ever manufactured), wide lapels, and the heyday of the kipper tie. Maybe it’s time this rather archaic classification of “ways of knowing” should go the same way as them.

As always opinions, critique, vehement disagreement, dissent and argument welcome as commentary.

Bernie

References

Borges J.L. (1942) John Wilkins’ analytical language. In Weinberger E. et al. (Ed.). The total library: Non-fiction 1922–86 (2001) 229–232. London, Penguin Books.

Carper B.A. (1978), “Fundamental Patterns of Knowing in Nursing”, Advances in Nursing Science 1(1), 13–24

Kant, E. (1996). Critique of pure reason (W. Pluhar Trans.). Indianapolis: Hackett.

McKenna H, Cutliffe J, McKenna P (1999) Evidence-based practice: demolishing some myths. Nursing Standard. 14, 16, 39-42.

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