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Abstract
Modern hospitals have succeeded in saving humans from numerous diseases owing to the rapid development of medical technology. However, modern medical science, combined with advanced technology, has developed a strong tendency to view human beings as mere targets of restoration and repair, with modern hospitals characterised as spaces centred on technology-focused treatment. This results in a situation where human beings are reduced to objects and alienated. This study, integrating Heidegger’s concepts of dwelling and care, contends that ‘care’ is a vital concept in terms of the fundamental spatiality of hospitals and needs to be restored as the key guiding principle affecting hospital space. The loss of the caring spirit in the development of modern hospitals affects how hospitals are conceived, built and managed, as well as how human experiences within hospitals are dealt with or allowed for appropriately. This study offers critical reflection on how future planning of hospital spaces can be better conducted to ensure that human experiences, and the care needed to appropriately value such experiences, are adequately expressed, and the complexity of human existence is suitably considered.
- Medical humanities
- philosophy of medicine/health care
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Introduction
Modern hospitals go beyond being solely places to treat patients with diseases.1 As noted long ago in Buddhism, human suffering in relation to birth, aging, sickness and death is unavoidable.2 In modern society, hospitals have become essential and indispensable spaces for humans to go through each of these life phases. They are places where life can start to fall apart when one is diagnosed with an incurable disease, as well as places where one can experience the joy of being cured of a disease. As such, hospitals are key spaces closely related to the lives of modern people. However, despite being deeply associated with human survival, the need to treat diseases efficiently has led the modern large-scale hospital space to become a technical treatment-oriented space that focuses on diseases rather than on the patients with diseases. Every space in a hospital is regulated by the needs of technological medicine that focuses on a specific part of the body and assesses any related disease as precisely as possible.
Effectively controlling diseases and ensuring continuous patient monitoring are perceived as fundamental prerequisites for successful treatment. In pursuit of the efficient management of illnesses, hospitals have seamlessly embraced a form of surveillance and control system. Foucault (2003) coined the term ‘spatialization of disease’ to describe the connection between the rationalisation of a new view of disease, the classification of disease, and the emergence of clinical hospitals as institutionalised spaces. The spatialization of disease concept involves a tripartite process. Initially, in the first phase, there is a transition in the understanding of disease as something to be classified in terms of pathology. In the second phase, the disease is then re-interpreted in terms of the patient’s physical manifestations and undergoes a secondary spatialisation. Ultimately, in the third stage, the disease has its spatial presence expanded into the social sphere, primarily within the institutional space of the hospital. Through his investigation of the gaze, Foucault revealed how the spatial dynamics of the hospital enabled the development of processes of tracking, surveillance, control and mapping. The gaze of surveillance as understood by Foucault has evolved in relation to contemporary medical technology, allowing a more sophisticated diagnosis and exploration of diseases, and thereby prompting the pursuit of diverse therapeutic interventions in treating them. In this context, the patient’s significance becomes more pronounced as an entity embodying a specific ailment, rather than as an individual with a distinct identity. As technological advancements exert remarkable efforts in the remediation and eradication of diseases, a paradoxical outcome has become more apparent where technology, while used to intimately engage with diseases within the patient’s body, accentuates efficient spatial arrangement for disease management, thus relegating the patient to a state of marginalisation. The more state-of-the-art functions are installed, the more sophisticated and detailed the treatment of diseases becomes, with technological advancements further subdividing medicine into subdisciplines, creating new medical departments, and eventually playing a key role within these medical departments in the hospital space.
Foucault’s discourse prompts the recognition of hospitals as evolving into new electronic panopticons through medical knowledge dissemination via technology, while also acknowledging the growing dehumanisation of these spaces. In response, Foucault endeavoured to cultivate novel counterspaces that could resist this trajectory, aiming to generate new heterogeneous realms of resistance. Hence, his stance involved a dualistic approach that involved both breaking free from the power of modernisation when problem-solving and exiting from certain types of tangible spaces. Paradoxically, this call for de-spatialisation, aiming to transcend real spaces, seems to require a further removal from actual spaces, thus sidestepping fundamental reflection on the intrinsic spatial nature of hospitals. However, in contrast to this view, this study would contend that a foundational exploration of the inherent spatial nature of hospital environments should precede the creation of new alternative spaces. This approach necessitates recognising the vital importance of hospital spaces as significant realms for human existence within the present context of technology-driven healthcare, which would require an in-depth inquiry into the essential characteristics that hospital spaces, serving as pivotal arenas of human presence in this reality, should ideally embody.
However, existing research on hospital environments has largely focused on analysing the creation of therapeutic environments within hospitals, as well as the impact of these environments on patient satisfaction and healthcare staff productivity (Chaudhury, Mahmood, and Valente 2009; Rechel, Buchan, and McKee 2009; Siddiqui and Brotman 2015; Swan, Richardson, and Hutton 2003; Ulrich 2001). Research on the preference for more patient-friendly smart hospitals, which are becoming possible through advances in technology, has also been conducted (Garg 2021; Holzinger, Röcker, and Ziefle 2015). As most of these studies have only examined specific spaces within the hospital, such as patient wards, operating rooms and lobbies, it is difficult to fundamentally understand the relative context and significance of hospital spaces in relation to each other.
From a different perspective, in continental philosophy, research has focused on the experiences of patients suffering from specific diseases and illnesses. Wasson (2021) meticulously explored the intricate and uncomfortable emotions experienced by organ transplant recipients during the stages of pretransplant anticipation and post-transplant periods. That study revealed how patients, who must re-adjust to the extended life span brought about by post-transplant physiological changes, negotiated the differently experienced passage of time during pretransplant and post-transplant treatments to highlight how they established their own sense of temporality within this framework. Dalton (2021) applied Catherine Malabou’s perspective to explore the form of space that could accommodate the physical plasticity of patients with post-traumatic brain injury beyond the limitations of Foucault’s spatial concept that considers the patient’s body as being biopolitically restricted, claiming that such patients could be adequately accommodated. Bates (2019) viewed the hospital environment through the dichotomy of ‘good’ or ‘bad’ perspectives, using the experiences of two patients with cancer. She highlighted how disease recovery is intertwined with space and relationships.
Although these studies highlight the patient’s perspective in relation to the rich meanings derived from the disease experience, the philosophical meaning of the hospital space where that experience most frequently occurs has not been considered. In addition, Malabou’s space, which appears to be an alternative to Foucault’s discourse, was also proposed while omitting the more basic question of what the fundamental spatiality of the hospital space is in which humans are treated. This study contends that a more appropriate approach would be to take the hospital itself as the primary factor and explore the meaning of the original existence of that space, and then explore in depth how human experience as a patient unfolds within such spatiality.
This study contends that the fundamental spatiality of hospitals lies in care, rather than as a technical therapeutic space, which can be demonstrated according to Heidegger’s concept of care. Caring encompasses the meaning of ‘cure’ in the sense of making someone better and improving their condition. While the concept of cure can be understood as being limited to the specialised actions of the medical staff within the hospital space, care is a more encompassing action that includes it. However, since modern times, the term ‘treatment’ has been used exclusively to denote the act of curing human illnesses, causing it to lose its original meaning. However, Heidegger considered care (Sorge) not only to be a medical practice at a phenomenal level but also to be a fundamental and overall structure of human existence (Heidegger 1962; Heidegger 1998; Heidegger 2010; Tomkins and Eatough 2013). Through this perspective, he opened a philosophical avenue to explore the intrinsic essence of healing, which could otherwise be eroded by over-reliance on technical treatments or confined to specific medical procedures. Moreover, this perspective extends to contemplating the fundamental nature of hospital environments.
Heidegger clearly grasped how existential space emerged through the act of zoning space in relation to the use of tools in the everyday world. For example, in the context of a healthcare space, healthcare practitioners use a variety of tools to work with ease and keep patient well-being in mind, contributing to an intuitive and existential spatial set-up. However, the space revealed in the context of using these tools can generate a primary insight that space is not a separate entity from humans but closely intertwined with them. Based on this insight, a fundamental question can arise as to how a hospital should be built, transcending the superficial concept of considering a hospital as a simple compartment for treatment, which draws on Heidegger’s architectural conceptual understanding regarding the meaning of dwelling.
His insight, which has practical implications, can be used to reveal the fundamental spatiality of the hospital, as this spatiality of care concept involves more than linguistic precision and, when linked to his concept of dwelling, can disclose hitherto unsuspected aspects of reality. This approach is useful in not only revealing the mode of existence of the hospital but also in understanding how the original spatiality of the hospital developed as an architectural space.
This study elucidates the fundamental spatiality of the hospital by reflecting on the reality of the hospital space in which modern technology-centred medicine was conceived. It offers theoretically informed discussion and presents considerations to relevant parties that may guide the development of hospital architecture.
Patient and public involvement
Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of our research.
The hospital as a technotherapeutic space
Spatialisation of disease
Diseases are treated in various hospital departments by professionals with specialised knowledge and insights that involve examining the body in great detail. In the early days of modern hospitals, only departments for internal medicine and surgery existed; gradually, new departments such as cardiology, urology, endocrinology, radiology, thoracic surgery, hepatobiliary and pancreatic surgery, were added. The hospital determines the appropriate department to treat patients depending on their symptoms and the affected part of the body or organ. Each medical department is a basic design element in the hospital space. One of the most important challenges in modern large-scale hospitals is determining how to deploy the various departments to treat a large number of patients efficiently.
However, based on Descartes’ mind–body dualism, certain assumptions continue to influence modern empirical medicine as well as the organisation and planning of hospital spaces. According to Descartes’ spatial theory, the nature of space is understood to have the properties of extension (res extensa, extended thing), involving length, width and depth. Res extensa is the remaining attribute after excluding the accidental elements of all objects and becomes the background for grasping objects and space within the same concept. This approach became the basis for viewing space as a measurable, homogeneous object and expressing it as a location with geometrical coordinates. In this context, space is reduced to a mathematical object that can be grasped objectively and manipulated. Considering an object and a space as having the same properties implies that the human body can be preferentially recognised as an objective entity occupying a specific space, similar to an object. Medical staff ask, ‘Where does it hurt?’ (Foucault 2003, xxi), and the patient answers, ‘It hurts here’. This reflects a spatial concept of a disease as something that exists somewhere in the body, with an implied linkage between the body, the disease and space, as revealed in the observation. Such questioning leads to a spatial reorganisation that prioritises symptoms and resulting diseases over patients, which is connected to the secondary spatialisation mentioned by Foucault. Here, the doctor’s gaze, or the technical gaze that replaces the doctor’s gaze, is the starting point and medium that allows the question ‘where’ to pinpoint the disease. The disease revealed here undergoes a third spatialisation in which it leaves the body and is reorganised into a social space, that is, a hospital-specific space. ‘If your eyes hurt, you should visit the department of ophthalmology’. If this perspective is projected into the hospital space, that is, if one assumes that a point on the X-axis in the relevant coordinate system is a disease in a specific area, the corresponding Y-axis becomes either a space in the hospital’s outpatient department or a space in a treatment room. Furthermore, each space in a specialised treatment unit becomes a location that determines where the diseased patient should be positioned in the hospital space, which can be considered another result of the spatialisation of disease. From this perspective, the hospital space is complete when it is equipped with diagnostic devices and treatment equipment. Occupying a space with a specific device or a human has a greater meaning than having a human existence within it. This results in a distorted view of the essential meaning of the hospital space that is otherwise inextricably linked to a human existence going through pain and treatment.
New entities in the hospital space: science and technology
Science and technology are a means to ensure objectivity and eliminate uncertainty when diagnosing and treating diseases. Roentgen’s discovery of X-rays in 1895 accelerated the tendency of empirical medicine to rely on technology (Tenner 1997). The use of state-of-the-art equipment, such as ECG devices and MRI, has reinforced a reductionist approach within medical science as a defining norm where the predominant focus is on diseased parts of the body and the subsequent effects (Helman 2007, 123). Modern medicine’s dependence on science and technology has increased as technology has advanced. Konner 1994, (22–47) has described modern hospitals as ‘temple[s] of science’, with some critical comment raised that machines have become physicians (Grouse 1983). Currently, technology comprises one of the three major elements of a hospital, together with patients and medical staff. Although of an inherently different character, technology is an indispensable component within the hospital space.
In a situation where technology has become a significant entity in the hospital space, an increasing proportion of medical staff need to learn how to use medical devices and analyse data obtained from these devices, rather than observe patients’ symptoms and prognoses. As the interaction between medical staff and various types of technology grows closer, the relationship between medical staff and patients becomes more distant and constrained. For instance, during a consultation with a patient, a doctor might not make eye contact but rather focus on a specific body part or the data sent by a medical device that appears on the computer screen.
Hospitals are also prioritising space for medical equipment, as technology becomes increasingly dominant in patient care. In this way, the hospital space, where the devices are placed and moved, is reduced to a functional tool for treatment. In a situation where the key focus of the hospital space could be expected to be on humans, it is paradoxical that technology dominates the hospital space. In the framework of a functional space distribution plan, it is reasonable to consider both humans and devices in abstract terms as entities occupying a certain area. However, within modern spatial theory, technology has developed from providing assistance to increase the efficiency of treatment, to becoming a dominating entity within the entire hospital space. Consequently, though it might appear that humans are the key elements within the hospital space, the use of technology has led to an inversion of the relationship between the human subject and a key object, namely, technology. Therefore, hospitals have become spaces centred on technology therapy.
Hillier’s (1996, 371) radical expression, ‘space is the machine’, implies that space is also an object that can be manipulated functionally and efficiently. In modern large-scale hospitals, patient admission, discharge and treatment processes are carried out efficiently, with similarities to a conveyor belt process. A new patient sheet is placed on the bed of a patient who has just been discharged, and another patient appears and lies down, which can create an impression that patients are interchangeable. As such, the requirements of technological efficiency encourage a particular standardised technology-suffused view of medicine and of hospital space, and of the human beings living in that space. While such hospitals have achieved considerable medical breakthroughs, such as overcoming previously incurable diseases and extending the life span of patients, and with their authority recognised throughout society, the problem of alienating humans as the subjects of treatment in a space occupied by advanced medical devices is an issue worthy of assessment and attention.
The essence of medical technology and its dangers as explored through the lens of Heidegger
As noted, technology not only brought about a change in the relationship between patients, doctors and devices, but also emerged as having an indispensable and dominant existence in the hospital space. Therefore, in order to reveal the fundamental spatiality of the hospital space, it is necessary to first pay attention to the essential properties of technology beyond the general understanding that technology is an efficient tool. Relevant reflection on this matter can be found in Heidegger’s thoughts on the dangers confronting a technology-driven era. Heidegger (2013) discussed the dangers of viewing technology as merely an instrument, through ontological reflection. Heidegger noted that technology no longer involves poiesis or instrumental reason. Although modern technology is praised as an all-purpose tool that has made life more convenient, Heidegger claimed that technology defines all entities to be useful only within the context of technology. Waterways become treasure troves of hydroelectric resources, while the land becomes primarily a place for human habitation or, beyond that, for property expansion and storage of underground resources. Heidegger defined this mode of existence for entities in a technology-driven society as involving a process of enframing. He presented a tragic diagnosis whereby both humans and nature will be reduced to a ‘standing reserve’ (Bestand) that can be used at any time within the production system driven by technology (Heidegger 2013, 12–21). Heidegger (2013, 18) proposed that clinical trials in hospitals were examples of how the requirements of technology determine how humans need to be manipulated.
Blood extracted from the human body has been used in various studies and experiments for treating incurable diseases. However, this development also shows that humans have become a ‘standing reserve’ (Heidegger 2013, 18) of material needed to survive. Research is continuously driven by the need to extend the use of medical devices as well as by pharmaceutical companies and hospital medical staff striving to invent more precise diagnostic devices and reagents. Such inventions, funded by pharmaceutical and medical device companies, are then used in further research or in experiments in hospitals to help overcome serious diseases, such as dementia and cancer. This creates a continuous cycle focused on technological development, with human life experiences increasingly modularised, as birth, ageing, sickness and death processes become enmeshed within technology. Advances in medical technology foster an approach that encourages precision in terms of breaking the body down into smaller units. As Heidegger (2013, 23) noted:
Because the essence of modern technology lies in Enframing, modern technology must employ exact physical science. Through its so doing, the deceptive illusion arises that modern technology is applied physical science.
According to Heidegger, technology transcends its role of treating patients and becomes an entity that reveals the hospital space as a technotherapeutic space dominated by technology. In this technotherapeutic space, technology generates an enclosed and hierarchical system, for which human beings become resources. Medicine that is based on enframing the instrumental rationality of technology, and hospitals that are permeated by such medicine, present several risk factors. An illusion is generated that all diseases can be conquered, which can act to dispel alternative ontological reflection. In addition, in fostering a view of humans as ontologically more machine-like, technology encourages a disregard of specific human qualities such as joy, anger, sorrow and pleasure (emotions). Therefore, the modern hospital space, in separating diseases from human beings, promotes a tendency to regard humans as primarily material, while ignoring the overall being of humans. Although technology in hospitals is intended to help cure or alleviate diseases in humans, it creates a contradictory situation that alienates humans. Answers to how this contradiction might be addressed can be found in Heidegger’s thinking.
Heidegger (2013, 39) noted that for humans and technology to find their essence, they must first find ‘the full breadth of the space proper to (their) essence’; it is impossible to solve fundamental problems without locating this essential space. Heidegger explains why it is necessary to discover the fundamental meaning of this essential space, in this case, the hospital space. Heidegger (2013, 28) quotes Friedrich Hölderlin, ‘But where danger is, grows/The saving power also’.3 This is intended to remind the reader of the fundamental question that needs to be posed. Here, danger refers to a situation in which the revealed hospital as a technotherapeutic space is only enframing through the treatment and elimination of diseases, with all possibility of reflection being blocked. As the essence of technology is enframing, the hospital, which is a technological treatment space, has also blocked all possibility of ‘unconcealment’. Escape from this situation not only requires moving out of it but also revealing the essence of the situation. The more hospitals treat humans as objects of disease treatment and elimination, the more technology raises a paradoxical question about the essential meaning of the hospital space.
From Heidegger’s theories, it is possible to realise that without ignoring or rejecting the present situation, the solution may lie in confronting the dangers or risks revealed in terms of the fundamental spatiality. This does not entail a radical claim to ignore the technological therapeutic space and return to some prescientific state. Rather, this means starting by facing the current situation in which space works to exclude human experience and then seeking to understand and restore the hospital’s essence as a space that can truly heal humans. Here, the historical starting point for finding the essential space of a hospital lies before the modern era because modern medicine continues to develop based on modern-era rationalism while condemning the medicine of the previous era as unscientific. Through reflection on the essence of the hospital space, it is possible to determine something of the fundamental spatiality that the current hospital has lost.
Care inherent in premodern hospitals
To explore the fundamental spatiality of hospitals, it is necessary to examine the premodern concept of hospitals. This is not to assert that hospitals of the past and of today are interchangeable, but that finding the essence of the hospital space can be approached by uncovering traces of more fundamental and universal aspects of hospitals that were ignored at the birth of modern hospitals.
In terms of etymology, ‘hospital’ appears to be derived from the Latin hospes, which refers to a host taking a guest into their house and taking care of that guest (Bassareo et al. 2020; Pevsner 1976; Selwyn 2010; Vescia 1998). Hospes was also used to refer to lodgings where travellers, such as pilgrims to the Holy Land in Jerusalem, stayed—hence the origin of the concept of a hospice as a medical facility in which those who were terminally ill with cancer were cared for (Garces-Foley 2006; McGilly and Haines 1995; Riva and Cesana 2013). It has also been claimed that hospital is derived from the Latin word hospitalitas, meaning welcoming and hospitality, or hospitium, meaning accommodation or shelter (Abomeh 2013; Yeo 2019) or that a hospital has a meaning similar to a hotel (Yeo 2019). These various meanings suggest that it refers to a place where people are cared for with sincerity.
Another word that indicates a hospital as being a place of care is nosocomium, which appears in the Edicts of Justinian (528–529 AD). In terms of etymology, the prefix nosos means disease and is associated with nosokomos (caregiver), nosokomia (a noun meaning to care) and nosokomein (to take care of) (Vandewalle 2004). Nosocomium is also mentioned in the context of Christian facilities for the poor.4 Hospitals were, therefore, places that prioritised not only the sick but also the poor, pregnant women, orphans and disabled people. This provides a clear image of the hospital as a place of care. It seems that religious facilities played an additional role alongside worship, namely, that of caring for patients as a kind of ‘pseudo hospital’. As hospitals were often associated with a religious facility, the spatial characteristics of these places were also intertwined with a religious character.
The temple of Asclepius, where temple medicine was practised in fifth century BC in Greek cities, was an early type of hospital (Edelstein and Edelstein 1998; Yeo 2017). The passage of the temple leading to the healing room was designed to incorporate the natural environment so that the sound of a spring could be heard, and natural light entered the space from an opening in the ceiling.5 Rather than being a segmented and closed space, it was designed to lead naturally to healing in harmony with the surroundings. At this location, patient healing could occur within a state of appropriate consciousness, exemplified in the use of dream therapy.
A key concept here was ‘incubation’ (Oberhelman 2013, 29), which is derived from the Latin incubatio and incubationem, meaning ‘to brood, rest, and dwell’ (Renberg 2017, 12; Online Etymology Dictionary 2021). While awaiting dream healing, for example, patients would stroll around the temple premises, breathing in fresh air and alternating between resting and exercising (Edelstein and Edelstein 1998, 248). The theatre, gymnasium and library situated around the temple were essential spaces for patients awaiting dream healing, designed with consideration for the interplay between the surrounding natural environment, the healing process and suitable activities.
Gesler (2003) highlighted that the reason the temple of Asclepius was able to maintain its reputation as a healing site was the favourable natural environment of Epidaurus in Greece, particularly its abundant water supply that could be used for healing purposes. Water was not only essential as potable fluid for patient healing but also held symbolic significance of purification, cleansing away the impurities of illness; hence, it was a crucial element in the ritual of cleansing (Gesler 2003, 25). Hippocrates also emphasised the importance of an environment conducive to caring for patients beyond the doctor’s expertise, especially one involving a pleasant climate and landscape and suitable water quality, indicating how important a healing environment was considered at that time (Hippocrates [n.d] 2011). This harmony in terms of dream healing, the architectural form of the temple, and the overall landscape of the healing space was core to ensuring a genuine healing space. Here, the value of the treatment environment is highlighted: namely, the space, rather than the treatment action. Thus, a closer inter-relationship is shown between care and space.
In the twelfth century in Christian areas, hospitals had the characteristic of being a Christian institution for the poor. In other words, they involved a more concrete space for care. Nam (2015, 195–239) claimed that the Pantokrator Xenon, built in Constantinople in 1136, could be regarded as the first modern hospital, particularly in the sense that surgery and outpatient treatment were also performed there. Xenodocion and xenon have their roots in Christian facilities for the poor that appeared before the fourth century (Nam 2015). Xenodocheion is derived from xenos, meaning ‘foreigner’, and decomai, meaning ‘to welcome’ (Nam 2015, 197). The name does not imply that it was a place of disease and treatment but rather that it was a place of hospitality and that strangers were welcomed. Through the term xenon, it can be seen that hospitality and care provided to everyone without exception, beyond simple treatment or for specific persons, were the essential elements that embraced the entire space.
Even in the Middle Ages in Europe, when sickness was considered a curse (Lee 2016, 239; Cunningham 2008, 30), the basic function of medical care involved allowing patients to return to their own community. Healing was linked to religious salvation. Religious facilities, such as religious houses and churches, were practical places where active intervention was performed for patients. Salvation and healing were not limited to religious rhetoric. Salvation derives from the Greek soteria, meaning liberation and freedom, salvatio in Latin, and Heiland in German. It is also connected to the related terms saos, salvus and heil, as well as healing in English (Tillich 1984). Salvation, healing and happiness are inextricably linked in that heil also means happiness in German. A space was clearly involved in which people were taken care of so that they could receive salvation from God.
Hospital care has been dismissed as being inferior where it cannot be scientifically objectified or clearly categorised. However, in terms of etymology, a hospital’s way of existence has been based on care, salvation and hospitality. Care has been a vital component of human life since the beginning of mankind. It cannot be limited to a specific act or method. According to Heidegger, care is closely related to essential meanings represented by specific types of dwelling and architecture. Therefore, Heidegger’s insight into care as an existential structure critical to human existence allows for informed reflection that extends beyond seeing the hospital as a technical and therapeutic space and reveals the fundamental spatiality of the hospital space through showing its link with an architecture associated with caring.
The fundamental spatiality of the hospital in terms of Heidegger’s theories on care and dwelling
Care in Heidegger and the fundamental spatiality of the hospital
Heidegger insightfully recognises the mode of being of Dasein, which is characterised by Sorge, that is, the possibility of a being who cares about one’s own existence and who attends to others. To provide an existential justification and explanation for Sorge, Heidegger invokes the Greek myth of ‘Cura’ regarding the personification of care (Heidegger 2010, 242; Reich 1995). In this context, Sorge is translated into English as ‘care for’ or ‘anxious for’, emphasising the affective dimension of the term, which connotes a certain mood. At the heart of Heideggerian care, which is based on this mood, there are two essential aspects: attending to one’s own concerns as well as those of others, and making choices for the sake of the future, explained in terms of their existential and ontological significance (Elley-Brown and Pringle 2021, 26). The original meaning of Sorge implies a way of relating to the world ‘as a primordial structural totality’ (Heidegger 2010, 238), where humans are constantly ‘thrown’ into a mode of care that involves concern for oneself, attending to others and solicitude. This primordial structural totality of human existence as Sorge entails a relational mode and ontological concept, embodying the fundamental essence of being-in-the-world.
Heidegger names the active practice of caring for others as Fursorge in German, which carries the connotation of solicitude and involves an intense mode of care and concern. This approach involves enclosing oneself within one’s own sphere of care and dependency through caring for others, thereby maximising one’s own dependence on others. This term encapsulates the idea of caring for and attending to others, reflecting the profound ways in which Heidegger conceives of the act of caring for others. Furthermore, this approach also entails creating conditions that enable others to enter into their own possibilities and take responsibility for their own existence. Assuming responsibility for one’s own existence entails living out one’s allotted time, which involves constantly forging ahead of oneself in anticipation of the future that lies ahead and making decisions that determine one’s own possibilities. In this sense, Sorge as care is not simply confined to a narrow understanding of actions but is rooted in temporality. It captures the idea that care is fundamentally attuned to the temporality of existence.
King (2001, 220) contends that, for Heidegger, care and temporality are mutually intertwined and understood as a connected unity of care, while temporality can only be approached and understood through care. In the tension between the ‘already’ and the ‘not yet (death-yet-to-come)’, one’s mode of existence in terms of Sorge, or as existential care, resonates with the past, present and future, as one chooses what is given. This mode of existence is embodied in Heidegger’s notion of care. Through the effects of temporality, care reveals that the spatiality of the hospital exists in relation to oneself. Time reveals itself as the means by which one’s ‘thrown’ existence projects itself, intertwining with the past, present and future, and where one assumes one’s own possibilities. Heidegger’s insight in relation to Sein-zum-Tode (being-toward-death) refers to a reflection on one’s whole self after realising that one is bound to die, after having been immersed in one’s daily life with one’s own being thrown into the world. Carel (2013) expounds on Heidegger’s insight into ‘being-toward-death’, which is not an explanation ‘of’ death. She emphasises the word ‘toward’ in this term in showing that the time that flows forward is a dimension that reveals the overall meaning of the mode of being of Dasein as involving a temporality that allows one to plan one’s life. She highlights that every moment of human life from birth to death contains meaningful content because death is only a final event, and all beings exist within unknown limits ‘moving toward the destination of death’. In this respect, insight may be gained in terms of one’s own authentic understanding even through the death of others. According to her interpretation, because the unwavering impossibility of death for human consciousness contrasts with the certainty of human finitude, proximity to experiencing death physically and closely can prompt renewal and finding purpose and meaning in life. Her interpretation suggests that a different approach to death and the space of death are possible, in which hospitals are not just places where termination ceremonies take place but also meaningful places to reconstruct the lives of existing individuals even amidst frequent deaths.
In light of this understanding, this study contends that hospitals can be seen as spaces where death, the contradiction of ‘the possibility of the impossibility of experience’, can be more closely felt. As an impossible experience, death would seem to entail being cut off and as having lost all possibilities; however, it summons each person as a possibility to take responsibility for their lives and start a new one. Hospitals are places where people can vividly experience that a human being can die only by looking back, for example, on the process from cancer diagnosis to surgery. When death approaches as a result of a disease, current ways of life abruptly cease to function adequately. Ultimately, humans have no choice but to face the underlying anxiety within themselves. Heidegger (1998) called this anxiety the fundamental attunement (Grundstimmung) that paves the way for one’s own life. This fundamental attunement does not come easily. Rather and paradoxically, one discovers one’s authentic self in an uncanny or unfamiliar feeling, which also affects one’s understanding of one’s self. This fundamental attunement reveals the place one is in as a new ‘there’. As revealed in the word Befindlichkeit or ‘situatedness’ in English, human self-understanding is tied to the space in which the relevant situation occurs. A hospital is a vivid field of life, where one may experience the collapse of all standards and beliefs previously held as death, considered a distant future event, approaches the present.
Ultimately, care, understood through temporality as the ontological structure of Dasein, is connected to the world as the site of one’s own existence, where one lives their life. Both being fully immersed in one’s daily life and caring for others with sincerity are ways of relating within the world as a space, advancing ahead of time, and being a part of the scene of one’s life. As such, Sorge, which carries existential meaning, goes beyond the partial meaning described in medical fields regarding care and treatment. Heidegger’s care is embodied fundamentally as the existential presence of being-in-the-world, beyond emotional dynamics, and concretised in the space of life. Hospitals comprise a world and the site where therapeutic actions take place routinely. However, Sorge reveals care to be an existential structure within the fundamental and ontological spatial dimension of the hospital. Heidegger’s care goes beyond specific actions and reveals the fundamental mode of existence in the hospital as a site of human existence.
Caring in a cherishing manner involves dwelling, and human existence entails space within the horizon of meaning. It refers to one’s existence in which one is enabled to take responsibility for one’s own unique possibilities and for planning one’s life anew. Hospitals can be seen as a temporary residence that protects and cares for individuals who are confined to the premises for a certain period of time, with the aim of helping them return to a healthy everyday life. In this context, hospitals must have a fundamental spatiality that protects human dignity. If the hospital space is considered as an independent object without considering its relationship with the humans staying within it, hospitals will become spaces where it is difficult to expect existential care for humans.
Hospitals need to recover their fundamental spatiality so that death can penetrate into life and human beings can plan their lives anew. In addition, spatiality considerations are essential in allowing humans to take care of themselves as well as others appropriately. Rather than being primarily technotherapeutic spaces, hospitals need to be places where existential care is manifested phenomenologically and where temporality becomes appropriately sensitive to spatiality.
The embodiment of care through dwelling
Heidegger challenged the metaphysical perception of space as separated from human life and understood that space is centred on human behaviour rather than simply being a dimension of perception. He called the resulting human behaviour in this context Besorge (Heidegger 1998, 100). He observed that a region (Gegend) is prepared by designating places for various tools needed for taking care, that is, for undertaking specific actions in daily life, and spaces are opened according to ‘the context of useful things’ (Bewandtnis-Zusammenhang) between the tools in this region (Heidegger 1962, 146, 1998, 145).
However, the technological therapeutic hospital (Gestell) treats not only patients but also medical professionals as resources. The patient, named and designated through quantification, along with the allocated space and designated medical personnel assigned accordingly, easily becomes a mere standing reserve (Bestand) within the Gestell space that constantly operates under the guise of maximising treatment efficiency. This perspective of reducing human healing space to a utilitarian and instrumental framework facilitates the easy management of space by fragmenting it to the maximum extent possible. In this context, examination rooms inside hospitals, which resemble the cold and dry atmosphere of hospital rooms filled with machines, not only inhibit human orientation by severing the relationship with the world, but also render people incapable of truly caring for themselves and dwelling in a space. It is perhaps natural that delirium can arise in older adult patients after surgery in extremely stressful situations, or that disorientation can occur in patients being treated in intensive care units.
The issue facing hospitals is that they are immersed in technological and therapeutic spatiality, with devices and corresponding spaces arranged only for convenience of use by medical staff. As a region, hospitals are open only to medical staff and are inevitably unfamiliar to patients. A space and world that is not open to patients is no longer natural to them, unlike former contexts where the area for healing was more familiar in terms of the natural environment and where the alignment of disease and treatment tools was less mysterious. The modern hospital is a technology-oriented space in which medical departments are continuously subdivided and devices are prioritised over the requirements of humans in terms of creating healing spaces. Tools transform the world into an object (res) that is useful, and space transitions into physical space. In such a space, the natural relationship and context between spaces and between spaces and humans are likely to be lost. The resulting space in which technology predominates fosters a sense of fragmentation and deprives one of the possibility of naturally connecting one’s self with the relevant space and context; thus, one loses the ability to understand one’s self (Casey 1997). Space becomes an object to be engaged with and learnt about in the same manner as other forms of knowledge and information.
According to Heidegger, dwelling is made possible in what he calls the fourfold way (das Geviert), where the sky and earth meet, and mortals and divine things are brought together in one place (ort) (Heidegger 1971; Heidegger 2001). Furthermore, he asserts that the object (Ding), where the fourfold way converges, is not a passive entity created by humans for a specific purpose, but actively reveals the truth of existence (Heidegger 2001). Architecture is what makes such a fourfold way tangible and physically possible. Building on this insight, this study contends that dwelling becomes a poiesis, which is embodied in the act of caring and the making of buildings in order for humans to live on this earth and that, as a building, the hospital also embodies the meaning of a specific ‘thing’ and realises the mode of existence of Dasein, which exists authentically, reflecting the essence of being, through architecture. The place where the fourfold way converges and intertwines as one entity enables mortal beings, who face death within the finite nature of life, to care for each other and make dwelling possible. As Heidegger’s thinking in relation to bridges demonstrates, a bridge is not simply a means of transportation but is established as a place in itself. In the realm of the bridge, a path (Weg) and a place (Platz) are created, and space (Raum) is brought forth (Ahn 2018, 98). Just as the world is not contained within space, space as a clearing generates each individual place with its own essence in various locations. In other words, a building becomes a dynamic place with relational significance to the surrounding world, rather than a solitary entity.
Malpas, while exploring Heidegger’s later spatial thinking, underscores the importance of meaningful connections between humans and the fourfold way, as ultimately it is through this place that the identity of Dasein is determined (Malpas 2021; Malpas 2022). Bollnow’s (2011) insight into the relationship between space, connection and experience and how they determine the existence of Dasein supports the importance of connection to the surrounding world for fundamental dwelling.6 The implications of dwelling can be observed more concretely in the works of Norberg-Schultz, an architectural phenomenologist, who focuses on the vertical connection between heaven and earth in Heidegger’s notion of the fourfold way, and identifies the relationship between humans and space in architecture as involving elements of ‘existential space’ such as centre/place, direction/path and district/domain, thus revealing the meaning of existential dwelling (Norberg-Schulz 1974). Ultimately, this highlights the need for a hospital as a place to be connected to the surrounding world in a certain context, and that external and internal perspectives should be concretised through the interaction of spatial relationships rather than through physical distinctions. Rather than viewing a specific space in a segmented and quantitative manner, examining the three elements of existential space reveals that space can be interpreted in terms of contextual and qualitative aspects. These three elements include paths that reveal directionality from the centre, paths that narrow and expand into a specific area, and spaces that are both macroscopic and microscopic. As pointed out by Haddad, ‘qualitative place’ can be discovered through the concrete actions of humans, revealing its layered meanings (Haddad 2010). This point has particular relevance in relation to the implementation of Cassell’s ‘person-centered medicine’ (Cassell 2010), which seeks to comprehensively understand the relational aspects between patients and medical professionals, as human behaviour and experience are shaped through interactions with the contextual world around them.
The arrangement of devices is a representative phenomenon of technotherapeutic spatiality that emphasises only efficiency, which differs fundamentally from how hospitals would be if the care component, as discussed, were to feature more prominently. The fundamental mode of existence of ‘being-in’ stands significantly removed from the typical hospital environment. According to Mugerauer, dwelling entails not merely being confined to a space, but rather is associated with a feeling of being ‘at home’ in relation to one’s surroundings (Mugerauer 2008). While a hospital space cannot provide the comfortable and familiar feeling of a home, an atmosphere that generates excessive unfamiliarity and tension can disrupt the fundamental spatiality of the hospital as an ‘authentic dwelling’. The identity of a person can be aligned with a space (Bollnow 2011), whereas such alienating environments can interfere with this process. Human beings have no choice but to open themselves to others in the context of space. Such human actions and behaviour take place based on an interpretation of space, which implies that the hospital space involves more than an implementation of engineering technology.
Modern large-scale hospitals focus on designing buildings to facilitate efficient human traffic and the use of advanced medical equipment to treat as many patients in as little time as possible. If one looks at this reality only partially, it might seem adequate in terms of ensuring the right type of hospital architecture. However, a more informed viewpoint suggests that more work needs to be done to ensure that hospital spaces are able to deal appropriately with the existential needs of humans in multiple phases of life in terms of care. This may involve: ensuring effective and meaningful communication between patients and medical staff (Rentmeester 2018); helping patients during crises where it is difficult for them to take care of themselves in an unfamiliar hospital space, by allowing recovery within a more familiar human-centred world (Kong 2013); and encouraging a phenomenologically new perspective on illness as an ‘otherness’ and heterogeneous experience within a patient’s own temporality, rather than continuing to adopt a dichotomous approach that distinguishes between normality and abnormality (Svenaeus 2011). Although this hospital space is the closest space to death for many, it need not be a space where people seek to ignore death and make it invisible because they cannot own their own death. Rather, it could allow patients and medical staff to reconstruct their lives through the deaths of others and for a focus on the patient’s experience as a person suffering from a disease, with death as a life-transformative prospect (Bates 2019; Dalton 2021).
To achieve this, hospitals that serve human dwelling should not be limited to functional purposes alone, but rather be designed as spaces in which individuals care for themselves and others by engaging with the surrounding world, allowing them to develop a deep understanding of themselves and others. As hospitals tend to have a sterile and impersonal atmosphere, a thoughtful approach to hospital spaces is necessary to create an environment that is welcoming for both medical staff and patients. Moreover, hospital design should prioritise the experiences of patients, families and healthcare professionals, rather than relying solely on the leadership of a few in the design process.
Conclusions
Modern medical science has made remarkable advances in treating diseases and prolonging life. These advances have been embodied in areas devoted to the ‘spatialization of disease’ in hospitals. Spatialisation of diseases along with technology-oriented treatment has further accelerated the subdividing of disease processes and of pursuing specialisations accordingly. As Heidegger predicted, the more precision required by medical technology to improve the effectiveness of treatment, the more firmly hospitals become spaces centred on technology-based treatment that may even alienate humans.
This phenomenon of the emergence of the modern hospital space prompts reflection on what spatiality fundamentally involves, which Heidegger considered to be integrally linked to the human fate of being (Seinsgeschick). Reflection and exploration of the hospital space had occurred prior to the emergence of the modern hospital space, which modern medicine has ignored, but which suggests that the fundamental spatiality of the hospital must be critically linked to care.
Care goes beyond the act of treatment. Heidegger’s use of Sorge provides insight concerning the meaning of care in an ontological dimension related to space. Prior to the current focus on disease repair and removal, the first priority of hospitals was to serve as places of care where human existence most dramatically unfolded.
Dasein, the being of ‘situatedness’, involves experiences of anxiety, to which there must be a fundamental attunement in the hospital. However, human experiences and perceptions in the technotherapeutic space of current hospitals cannot express the authentic self and one is prevented from living as an existential person in the current ‘uncanny and unfamiliar’ space, which risks encouraging humans to instrumentalise themselves. Despite limited awareness that the hospital space is dominated by technology used for treatment, spatial planning should be based on ensuring a fundamental way of existence for humans in which authentic spatiality lies in care.
Care is connected to dwelling and takes on a concreteness that can be built into architecture. Dasein involves being-there, in which the relationship between dwelling and caring becomes clear. However, in the current focus on constructing hospital buildings, the richer implications of dwelling have been lost. The hospital space, while being a space shared with others, should be designed such that technology, that is, the tool, fits the context of use, and that the tool has a subsidiary role in the work of providing care and in making dwelling a concrete reality. Prior to any practical engagement, care should be considered as integral to the fundamental spatiality of the hospital, and reflection that promotes such understanding needs to be prioritised within an appropriately configured hospital dwelling space. Above all, as a hospital is a space where death is particularly real, it needs to be a space where the possibilities of a new life can be grasped through encountering one’s true self in the face of death, which paradoxically means that life confronting death reveals new life unfolding in this hospital space.
This study has some limitations. First, as a theoretical and philosophical discussion, it lacks findings derived from empirical research. Heidegger’s thought has been applied to the hospital space as a critical point of view that calls for reflection on the ontological foundations of modern science. Critical research is not possible until the perspective put forward in this study has been presented and considered, as well as different approaches for testing and advancing various hypotheses that may be developed in relation to it. Although reflections on the fundamental spatiality of the hospital have been offered, it is not appropriate at this stage to suggest concrete and immediate solutions. Nevertheless, this study is meaningful in that through ontological reflection on the technical treatment-oriented hospital space that has become specialised, subdivided and functionally biased, it was able to reveal the essential meaning of the hospital space. Using Heidegger’s insights on dwelling and care in relation to a fundamental way of human life, it was possible to identify a particular view of care as critical to both theoretical reflection on hospitals and on how hospitals might be better constructed. Subsequent follow-up research should involve case studies related to current hospitals and integrate architectural phenomenological theories based on Heidegger’s concept of dwelling into the analysis. Architectural phenomenological perspectives can help guide phenomenological studies more precisely and aid in addressing previous research limitations.
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Acknowledgments
The author expresses her heartfelt gratitude to Professor Lee, Jong-Kwan, whose unwavering inspiration, encouragement, and guidance breathed life into her dissertation. The author would also like to thank her husband for his support and advice throughout the difficult times as well as her mother, who always prayed wholeheartedly for hermy daughter and who has been, her guiding light and unwavering source of support. Above all, The author thanks her savior Jesus for bestowing upon her all of her intellect and creative abilities. This paper is a supplement and summary of a part of Hye Youn Park’s doctoral thesis, “From the technological and therapeutic space to authentic care space: Perspective of phenomenology of architecture,” which was completed in 2021.
Notes
1. Helman (2007) noted that the role of a hospital can be viewed in various ways, such as being a refuge, a factory, a business, a temple, a university, a prison or a city.
2. The four noble truths form the foundation of all Buddhist thought, particularly ethical thought. In terms of the first truth, Buddhism claims that suffering pervades every aspect of human life, which includes physical suffering—birth, ageing, sickness and death—as well as mental suffering (Garfield 2021).
3. Heidegger (2013, 28) clarified the meaning of saving power or to save (retten): ‘to save’ does not simply preserve the nature of an entity, but rather means active work that allows it to be revealed in its original form. Here, essence does not simply mean the universal and essential elements of a species but rather a mode of existence in which these elements are governed and managed, as occurs, for example, in the state or family. Therefore, hospitals are not limited to the normative concept of ‘a place to heal diseases’; rather, revealing the way of existence of the hospital space involves actively elucidating the essence of the hospital space.
4. In the Edicts of Justinian promulgated between 528 and 529, nosocomium, brephotrophia and gerontocomia appear together. A brephotrophia is an orphanage for infants and a gerontocomia is a facility for caring for older adults. These facilities are always referred to as a hostel hospital (xenon), a poor hospital (ptochotrophia) or an orphanage (orphnotrophia) after the Act of Anthemios in 472, where xenon, a hostel hospital, can be seen as nosocomium. Although the functions and characteristics of these facilities are not clearly distinguishable, it provides a glimpse into the relationship between the hospital and the church in Eastern Roman society at a time when Christian culture had substantially taken root in the fifth century (Nam 2015, 222–30).
5. The temple of Asclepius appeared to be focused on setting up a healing environment (Compton 1998; Kim 2009).
6. Bollnow refers to such space, which is contrasted with mathematical space, as ‘experienced space (erlebter raum)’ (Bollnow 2011, 61–62).
Bibliography
Footnotes
Contributors HYP was responsible for: study conception and design, data collection, analysis and interpretation of results, and manuscript preparation.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.